Background: Tonsillitis is an acute inflammation of the tonsils, frequently observed in children and adolescents. It presents with symptoms such as sore throat, fever, cervical lymphadenopathy, and tonsillar exudates, caused by viral pathogens (e.g., rhinovirus, adenovirus, influenza) and bacteria, notably group A beta-hemolytic Streptococcus pyogenes. Objective: To identify and evaluate the risk factors associated with tonsillitis in patients aged 4 to 18 years admitted to tertiary care hospitals in Peshawar during 2023–2024. Materials and Methods: A case-control study was conducted at the tertiary care hospitals in Peshawar: Khyber Teaching Hospital (KTH) and Hayatabad Medical Complex (HMC) in patients aged 4 to 18 years during 2023–2024, including 52 cases (patients diagnosed with tonsillitis) and 99 controls (patients without tonsillitis), using a 1:2 ratio. Participants were selected through convenience sampling, and data were collected using a structured questionnaire. IRB/ERC approval was not required as participation was fully voluntary, with implied consent through completion of anonymous questionnaires. Results: The study found that frequent consumption of spicy and sour foods, exposure to polluted environments, and a history of recurrent throat infections were significantly associated with an increased risk of developing tonsillitis. These results align with findings from previous studies conducted in regions with similar environmental and dietary patterns. Conclusion: This concludes that environmental factors, dietary habits, and a history of throat infections are major contributors to tonsillitis among children and adolescents. Focusing on pollution control, improved hygiene, and dietary awareness are recommended to reduce the burden of tonsillitis in the region.
Background: Social media now consumes over 3.5 hours of the average 16–24-year-old's day—the very cohort filling the world's medical schools. Even before clinical practice begins, 44.2% of medical students globally meet burnout criteria, rising to 88% in certain systems. Trapped between unrelenting academic demands and an attention-engineered digital ecosystem, students turn to social media for escape, only to resurface burdened by guilt — and scroll again. We conceptualized this self-perpetuating dynamic as the "Guilt Loop": a closed affective circuit in which guilt is not a passive byproduct but the active mechanism bridging problematic social media use (PSU) to Fear of Missing Out (FoMO). This architecture has remained unmapped, particularly in low- and middle-income medical-training contexts. Methods: A STROBE-compliant, national cross-sectional survey was conducted among medical students from public and private institutions across Pakistan (July–August 2025) via an anonymous online questionnaire. The instrument captured sociodemographics, usage patterns, and three validated scales: the Bergen Social Media Addiction Scale (BSMAS), the Education- and Social-Related FoMO Scales, and a custom-developed Academic Guilt Scale operationalizing the Guilt Loop construct. Reverse-coded items minimized acquiescence bias. Data were analyzed in IBM SPSS v28 using descriptive statistics, multivariable linear regression, and a mediation–moderation model, with significance set at p ≤ 0.05. Results Among 1,023 enrolled students, 53.5% were male and 77.9% attended public-sector institutions. Social media exposure was substantial: 75.9% reported ≥3 hours of daily use, and 34.6% exceeded five hours. Mean scores across all three psychological domains were elevated (BSMAS: 16.23 ± 5.37; total FoMO: 32.94 ± 9.50; Guilt: 19.24 ± 4.52), with strong positive intercorrelations (r = 0.54–0.58; all p < 0.001), consistent with a shared affective process. Mediation analysis supported the Guilt Loop: PSU exerted a significant direct effect on FoMO (β = 0.986, p < 0.001), which was attenuated by 37.3% upon guilt entry as mediator (β = 0.618, p < 0.001), confirming significant partial mediation. The mediating pathway was invariant across sex (moderation p = 0.721); however, the affective burden was not. Despite equivalent BSMAS scores, female students reported significantly higher FoMO (33.65 vs. 32.31; p = 0.024) and markedly higher guilt (20.03 vs. 18.55; p < 0.001), indicating a disproportionate affective cost at equivalent levels of use. Multivariable regression identified daily usage duration (β up to 1.95, p < 0.001), academic standing, and female gender (β = 0.99, p < 0.001) as independent predictors of guilt; BSMAS (β = 0.63) and Guilt (β = 0.83), not demographics, emerged as the sole significant predictors of FoMO. Conclusion: Guilt partially mediates the PSU–FoMO pathway, supporting the proposed Guilt Loop in medical students. These findings highlight the need for future longitudinal studies to establish directionality and inform targeted digital-wellbeing interventions in medical education.
Background: Pediatric ophthalmology faces ongoing workforce shortages, reimbursement concerns, geographic disparities in care access, and increasing advocacy demands.1,2 This study aimed to assess pediatric ophthalmologists’ perspectives regarding workforce challenges, telemedicine utilization, advocacy priorities, financial concerns, and social determinants of health impacting pediatric eye care delivery. Methods: An anonymous Likert-scale-based survey was distributed through the American Association for Pediatric Ophthalmology and Strabismus (AAPOS) online member discussion board using a REDCap survey link. Eligible participants included practicing pediatric ophthalmologists, pediatric ophthalmology fellows, and physicians retired within the past 10 years. Descriptive statistics and comparative analyses were performed in R statistical software. Responses were stratified by years since completion of pediatric ophthalmology fellowship training (fellow, <5 years, 6–10 years, 11–15 years, and >15 years). Fisher’s exact tests were used for categorical comparisons, and statistical significance was defined as p < 0.05. Results: A total of 67 respondents completed the survey; 64% identified as female, 34% as male, and 2% preferred not to disclose. Most participants (n=47, 71%) agreed that telemedicine improves access to pediatric ophthalmology care amid ongoing workforce shortages, including 52 respondents (76%) who agreed that retinopathy of prematurity can be adequately screened using telemedicine-based approaches. Nearly all respondents (n=63, 94%) reported that compensation concerns influence residents’ decisions not to pursue pediatric ophthalmology, and 66 respondents (98%) agreed that current reimbursement structures inadequately reflect the workload associated with the subspecialty. Lack of time was the most identified barrier to advocacy involvement. Frequently selected advocacy priorities included expanding insurance coverage and increasing public awareness of childhood eye disease. 60 (90%) agreed that social determinants of health significantly impact pediatric ophthalmic outcomes. Comparative analyses stratified by years since fellowship training demonstrated a significant difference in concern regarding reductions in pediatric ophthalmology research funding opportunities (p = 0.028). Among the 60 respondents who agreed this was a concern, 46 (77%) had completed formal fellowship training more than 10 years prior. Conclusion: Respondents broadly supported telemedicine as a strategy to improve access to pediatric ophthalmology care amid ongoing workforce shortages, including for retinopathy of prematurity screening. Financial considerations emerged as a major perceived barrier to recruitment into pediatric ophthalmology, with nearly all participants reporting that current reimbursement structures inadequately reflect the specialty’s workload and demands. More senior pediatric ophthalmologists expressed significantly greater concern regarding declining research funding opportunities, potentially reflecting generational differences in perspectives on the long-term implications of sustained research support within the field.
Background: Despite advances in obstetrics in the United States, postpartum healthcare remains a leading cause of maternal hospital readmission, morbidity, and death (such as postpartum sepsis and venous thromboembolism). Differences in access to healthcare, socioeconomic status, and underlying medical conditions all contribute. Understanding how these factors are linked to maternal risk is essential for improving prevention and healthcare delivery. Aim: This study aims to understand the causal effect of geographic access to a level III obstetric hospital on postpartum complication patterns in the United States, using causal machine learning and publicly available health data. Method: We harvested data from 2,054 US counties across 37 states (2017-2019) using the Maternal Health Equity Linked dataset. With this, we analyzed the drive time to the nearest level III obstetric hospital, population size, the reporting accuracy of postpartum complication-related health reports, and the demographic profile (race composition, CDC Social Vulnerability Index) of a single county and its neighbors. GraphSAGE was used for explaining similarities in healthcare between counties (regional patterns), and DoubleML was used for ruling out confounding factors. Performance was assessed using leave-state-out cross-validation; area under the receiver operating characteristic (AUROC) for GraphSAGE and 95% confidence intervals were recorded for the DoubleML coefficients. Results: The median drive time to a level III obstetric hospital was 67.5 minutes, with 34.9% meeting maternity-desert criteria (inadequate access to sufficient care). GraphSAGE identified high-burden counties with an AUROC of 0.815 (95% CI: 0.785–0.844). The causal analysis showed that after accounting for social vulnerability and demographic factors, doubling a county's drive time to Level III obstetric care led to a 2.8% increase in the inpatient puerperal-complication rate (95% CI: 1.2-4.4%, p = 0.001), robust to excluding Level III host counties. This risk was amplified in rural counties (+6.4%, 95% CI: 2.0-10.9%, p = 0.004). Conclusion: Drive time to the nearest level III obstetric facility has a measurable causal effect on county-level postpartum complication rates. AI-based modeling delineated key geographic and social patterns associated with maternal health outcomes, helping to understand disparities in postpartum healthcare access. Future studies can incorporate patient-level clinical data, such as maternal comorbidities, to personalize postpartum healthcare access (e.g., targeted follow-up and telehealth).
Background: The rapidly expanding prevalence of AI in patient care and treatment planning reflects its transformative potential in improving healthcare outcomes and efficiency. AI applications in radiology can aid in accuracy of diagnosis and alleviating physician workload. However, one barrier to integration of AI is its financial burden due to subscription-based software costs, ongoing updates, and hardware requirements. A potential way to offset these costs is the adoption of local, on-device machine learning workflows, implemented through accessible development environments such as Apple’s Xcode in combination with Create ML and the Core ML framework. Methods: This project evaluated the accuracy of a Core ML–based image classification model for detecting brain tumors on MRI images and assessed the feasibility of leveraging the Xcode development environment to train machine learning (ML) image classification models with Create ML. Utilizing de-identified, publicly available brain MRI datasets, a supervised image classification model developed using Apple’s Create ML Image Classifier was trained to differentiate between glioma, meningioma, pituitary tumors, and healthy brain images. Standardization of images was done using Create ML Image Feature Print v2, which automatically scaled each image to 360 x 360 pixels. A total of 7,023 images were in the dataset with 5,970 (85%) images utilized for training and 1,053 (15%) images used for testing. Results: After 21 training iterations, the classifier achieved 93% accuracy on the test images, with precisions of 96% for healthy, 95% for pituitary tumor, 93% for glioma, and 87% for meningioma. Conclusion: The model demonstrates consistently higher performance across all categories, with slightly lower scores for glioma and meningioma. As shown by our CoreML model achieving 93% accuracy in identifying brain MRI tumor subtypes, utilizing the Xcode development environment and CoreML is a viable and promising way for future development of effective and cost-efficient diagnostic radiology tools for brain tumor detection.
Background: Clozapine is classed as an atypical antipsychotic and is used mainly in treatment-resistant schizophrenia. It is associated with multiple serious adverse effects which require medical monitoring. The cardiotoxic and hematologic toxicities of this drug are well recognized and monitored, however, the renal adverse events are less extensively monitored, primarily being represented by smaller observational studies or case reports. This study aimed to identify and analyze reporting patterns of renal adverse events associated with clozapine, in addition to assessing for potential disproportionality signals using data from the United States Food and Drug Administration Adverse Event Reporting System (FAERS) database. Methods: This study analyzed data from the United States Food and Drug Administration Adverse Event Reporting System (FAERS) through January 1989 to December 2025. The drug analyzed in the study was clozapine. Renal adverse events were identified using the Medical Dictionary for Regulatory Activities (MedDRA) preferred terms “Acute Kidney Injury,” “Renal Injury,” “Renal Failure,” “Renal Impairment,” “Renal Disorder,” “Chronic Kidney Disease,” “End stage renal disease,” “Nephropathy,” “Nephrolithiasis,” “Tubulointerstitial Nephritis,” and “Nephritis.” The disproportionality analysis was performed using reporting odds ratio (ROR) and proportional reporting ratio (PRR) with 95% confidence intervals, using all other drugs in the FAERS database as the control group. Results: Among the renal adverse events which were evaluated, acute kidney injury was the most frequently reported event involving clozapine, totaling 928 reported cases. Other reported events included renal failure (576 cases), renal impairment (377 cases), chronic kidney disease (203 cases), tubulointerstitial nephritis (147 cases), renal disorder (141 cases), and nephropathy (38 cases). The disproportionality analysis was unable to identify statistically significant signals for the majority of evaluated renal adverse events. Acute kidney injury demonstrated a ROR of approximately 0.99, while renal impairment demonstrated a ROR of 0.92. Additionally, chronic kidney disease, renal disorder, nephropathy, and renal failure did not exhibit evidence of disproportionate reporting comparative to the overall FAERS database. The highest disproportionality estimates among the evaluated renal adverse events were demonstrated by tubulointerstitial nephritis, with a ROR of approximately 1.6 and nephritis with a ROR of 1.28, despite having the lowest case count (28) among the included terms. No statistically notable signal was identified based on the study criteria. Conclusion: This FAERS pharmacovigilance study detected multiple reports of renal adverse events involving the use of clozapine within the database. Acute kidney injury represented the most frequently reported event. However, the disproportionality analysis could not identify a statistically significant safety signal for the renal adverse events assessed. Tubulointerstitial nephritis and nephritis demonstrated the highest disproportionality estimates with no signal, which may further necessitate an investigation in future studies. The importance of continued clinical awareness and renal monitoring in patients receiving clozapine is emphasized by the findings in this study. Additional observational studies to further evaluate potential renal adverse effects associated with this medication are also recommended, due to limitations of the database such as lacking denominator data or data quality inaccuracies from potential masking effects, underreporting and double entries.
Background Cardiovascular disease remains the leading cause of mortality worldwide, with cardiovascular risk factors increasingly appearing during young adulthood. Elevated blood pressure among university students frequently remains undetected due to limited preventive screening. Early identification of modifiable cardiovascular risk factors may support timely intervention and reduce long-term cardiovascular disease burden.This study aimed to assess the prevalence of abnormal blood pressure and associated lifestyle-related cardiovascular risk factors among university students participating in a preventive cardiovascular screening initiative. Methods A cross-sectional observational study was conducted during a university-based cardiovascular awareness initiative among students. Participants from all academic years (1st–6th year) were recruited through voluntary pre-registration. All screening activities were performed under direct cardiologist supervision. Collected variables included demographics, blood pressure measurements, body mass index (BMI), smoking status, physical activity, sleep duration, stress level, and relevant medical history. Blood pressure categories were classified according to the American Heart Association (AHA) hypertension criteria. 12-lead electrocardiography(ECG) was performed in participants who were identified as higher risk during clinical assessment. Descriptive statistical analysis was performed to evaluate cardiovascular risk profiles within the study population. Results A total of 89 university students participated in the screening (mean age 20.4 ± 1.7 years; 51.7% female). Abnormal blood pressure patterns were identified in 30.3% of participants, including elevated blood pressure in 16.9%, Stage 1 hypertension in 7.9%, and Stage 2 hypertension in 5.6%. Mean systolic and diastolic blood pressures were 120.8 mmHg and 78.7 mmHg, respectively. Regarding BMI distribution, 29.2% of participants were overweight or obese, while sleep deprivation (<6 hours/day) was reported in 49.4%. Additional cardiovascular risk factors included low or insufficient physical activity in 61.8% of participants, high or very high perceived stress in 14.6%, and active smoking in 5.6%. ECG was performed in 25.8% of participants based on clinical risk assessment, leading to identification of one previously undiagnosed Left Bundle Branch Block (LBBB) in an asymptomatic student requiring cardiology referral. Overall, specialist referrals were issued in 5.6% of cases following cardiovascular assessment. Conclusion We found a substantial burden of previously unrecognised cardiovascular risk factors and abnormal blood pressure patterns among apparently healthy university students despite their young age. The coexistence of elevated blood pressure, overweight status, sleep deprivation, and reduced physical activity underscores the growing importance of early cardiovascular prevention in young adults. The incidental finding of clinically significant electrocardiographic abnormalities further highlights the value of structured cardiovascular screening initiatives in university populations. Screening programs at universities may serve as effective strategies for early detection, awareness, and lifestyle-focused intervention to mitigate future cardiovascular risk.
Background Carbapenem-resistant Enterobacterales (CRE) are an emerging global public health threat associated with multidrug resistance, prolonged hospitalization, increased healthcare costs, and elevated mortality. Early identification of carbapenemase mechanisms is essential for effective antimicrobial therapy, infection-control practices, and antimicrobial stewardship. Differentiation between metallo-β-lactamase (MBL) and serine β-lactamase (SBL) producers is clinically important because SBL-producing isolates may respond to ceftazidime-avibactam, whereas MBL-producing isolates often require combination therapy with ceftazidime-avibactam and aztreonam. Modified carbapenem inactivation method (mCIM) and EDTA-carbapenem inactivation method (eCIM) are economical phenotypic assays that can reliably detect and differentiate carbapenemase-producing Enterobacterales. This study aimed to incorporate mCIM and eCIM into surveillance protocols for characterization of CRE isolates and rationalization of antibiotic therapy. Methods This retrospective cross-sectional study included 45 archived multidrug-resistant Enterobacterales isolates resistant to carbapenems, obtained from urine, blood, exudates, tissue, wound swabs, and sterile body fluids. Isolates were revived and identified using standard biochemical tests. Carbapenemase production was screened using mCIM and differentiated into metallo-β-lactamase (MBL) and serine β-lactamase (SBL) producers using eCIM according to CLSI 2023 guidelines. Real-time PCR was performed for detection of blaNDM-1, blaOXA-48, blaKPC, blaIMP, and blaVIM genes. Results Among the 45 isolates studied, Klebsiella pneumoniae (62%) and Escherichia coli (34%) were the predominant organisms. Phenotypic testing showed 36 (80%) isolates as MBL producers, 5 (11%) as SBL producers, and 4 (9%) negative for carbapenemase production. RT-PCR detected blaNDM-1 in 36 isolates and blaOXA-48 in 5 isolates, while blaKPC, blaIMP, and blaVIM were not detected. Co-expression of blaNDM-1 and blaOXA-48 was observed in 22 isolates. Most isolates demonstrated high resistance to β-lactams and fluoroquinolones, while tigecycline and minocycline retained comparatively better activity. Majority of patients recovered, with an overall mortality rate of 13%.
Background: Medical students worldwide increasingly rely on AI tools such as ChatGPT, Gemini and Claude for daily study and heavier use has been linked to higher anxiety and depression. Most studies frame AI as either helpful or harmful and overlook students who recognise that AI is weakening their reasoning and confidence yet still depend on it. This gap is clinically important because these students will soon make independent decisions for patients. Aim: To examine the association between AI-assisted learning dependency and psychological distress in Georgian and Indian medical students and to identify students who recognise AI-related cognitive harm yet continue depending on it. Methods: An anonymous web-based cross-sectional survey of medical students aged ≥18 years in Georgia and India was conducted via institutional and student networks using purposive snowball sampling. The 63-question instrument first captured demographic details including country, age, gender, training stage and workload. AI-use behaviour was then assessed through eight questions on frequency, daily duration, preferred tool, purpose and late-night use, plus a 10-question AI-Assisted Learning Dependency Scale developed for this study to capture behavioural and emotional reliance. Thirteen further questions probed students' perceptions of AI's effect on academic confidence, attention, independent clinical reasoning and verification of medical content with six more on sleep and screen-related symptoms. Psychological distress was grounded using the validated Depression Anxiety and Stress Scale (DASS-21), interpreted with established severity bands. Analyses comprised descriptive statistics, Pearson correlations between dependency and each distress subscale, and tertile-stratified comparison. Participation was voluntary with electronic informed consent and no personal identifiers collected. Results: A total of 104 medical students from Georgia and India participated; AI use was near-universal (98.1%). The AI-Assisted Learning Dependency Scale showed good internal reliability (Cronbach α = 0.837). Psychological distress was strikingly high: more than seven in ten met criteria for moderate or worse anxiety, and more than half for depression. Higher dependency was significantly correlated with each distress subscale (r = 0.27–0.32, all p ≤ 0.005), with a graded pattern: the most dependent students showed 50% higher mean depression and 56% higher mean anxiety than the least dependent. The most telling finding was the co-existence of perceived benefit and harm: while most students felt AI improved their understanding and confidence, half acknowledged it weakened their independent clinical reasoning and reduced their problem-solving effort, and only 41.3% verified AI-generated medical content. Almost one in three (30.8%) endorsed both benefit and harm, and this self-aware group carried the heaviest distress burden. Conclusion: In Georgian and Indian medical students, AI-assisted learning dependency was significantly and progressively associated with greater psychological distress. A substantial group recognised that AI was weakening their own reasoning and confidence yet continued to depend on it, and carried the heaviest distress burden. With fewer than half routinely verifying AI-generated medical information, these findings raise a clear concern: future physicians whose confidence is borrowed from AI may struggle to make safe independent decisions in clinical practice. Embedding structured AI-literacy training and protected independent-reasoning practice into early medical education should be considered a priority.
Background Uterine artery embolisation (UAE) is an established minimally invasive treatment for symptomatic uterine fibroids, offering uterine preservation and shorter recovery compared to surgery. Ongoing evaluation of real-world outcomes remains important to inform patient counselling and clinical decision-making. This study aimed to evaluate clinical outcomes following UAE for symptomatic uterine fibroids, focusing on complications, reintervention rates, and symptom improvement. Methods A retrospective single-centre cohort study was conducted at a tertiary maternity hospital, including women of reproductive age who underwent UAE for symptomatic fibroids between November 2021 and December 2024. Data were extracted from electronic medical records. Primary outcomes were peri-procedural complications, classified using the modified Society of Interventional Radiology classification system for complications, and reintervention rates. Secondary outcomes included clinician-documented improvement in menstrual symptoms. Descriptive statistics were used, with exploratory comparisons between baseline characteristics and complications. Results A total of 114 patients were included (mean age 45.5 ± 5.9 years). The mean largest fibroid diameter was 9.2 ± 3.5 cm. Menorrhagia was the most common presenting symptom (79.5%). Median follow-up was 119 days (IQR 2–334). Complications were reported in 18/112 patients (17%); including pain (n=4), post-embolization syndrome (n=3), fibroid expulsion (n=3), and infection and one case of sepsis (n=3). Rare complications included one case of small bowel obstruction and fistula formation, respectively. Reintervention occurred in 6/114 patients (5.3%) during follow-up. Among patients with available data (n=59), menstrual symptom improvement was documented in 44 (74.6%), while 15 (25.4%) had persistent symptoms. No significant associations were observed between complication occurrence and fibroid size, number, or patient age (all p>0.05). Conclusion UAE demonstrated a favourable short-term safety profile, with low complication and reintervention occurrences and meaningful symptom improvement. These findings support UAE as an effective minimally invasive treatment for symptomatic fibroids. However, interpretation is limited by missing data, short and variable follow-up, and lack of standardised symptom assessment.
Background Retained epidural catheter is an extremely uncommon complication of epidural anaesthesia. Catheter breakage is usually due to shearing forces on withdrawal leading to fragmentation and retention in epidural space. Fragment migration has also been described in some cases, prompting consideration for early spinal exploration and removal, particularly where surgical expertise is readily available. We described our experience with a case of retained epidural catheter that was successfully managed with immediate spine exploration and retrieval. The Case 63 year old male admitted for elective urethroplasty for a short segment bulbar urethral stricture. He had no previous surgical exposure or significant medical comorbidities. Vital signs were stable and preoperative investigations were within normal limits. Epidural anesthesia was selected. The L4–L5 interspace was identified and accessed, and an epidural catheter was introduced. However, difficulty in delivering anaesthetic agents raised suspicion of catheter kinking, necessitating removal. During withdrawal, the catheter broke off, leaving approximately 5cm within the epidural space. The patient was informed and counseled regarding further management options. After initial urethroplasty, he underwent L5 laminectomy and successful retrieval of the catheter fragment under general anaesthesia with C-arm fluoroscopic guidance. There was no adverse event postoperatively, and the patient had no neurological deficits. He was discharged 5 days post-op and remained asymptomatic in subsequent follow ups. Conclusion Retention of the catheter in the epidural space is rare. Early spinal exploration and retrieval can be a safe and effective management option when the appropriate expertise and facilities are available.
Background: Hemoptysis refers to the expectoration of blood from the respiratory tract. Its etiology varies by region, cystic fibrosis is the most common cause in the developed world while tuberculosis predominates in endemic regions. Depending on severity, it can be managed medically, surgically, or through endovascular embolization procedures. Massive hemoptysis, defined variably as 200-1000mL of blood per 24 hours or any bleeding with airway compromise has a high mortality rate of 50%-70% without intervention. Bronchial arteries are the main source of bleeding, and bronchial artery embolization (BAE) is a minimally invasive and effective treatment option. The most common embolic agent for BAE remains polyvinyl alcohol (PVA) particles, although N-butyl-2-cyanoacrylate (NBCA) offers advantages including rapid and complete occlusion and adjustable polymerization rates via adjustable glue-to-contrast ratios. Methods: A single center retrospective study was conducted using data obtained from medical records and the Picture Archiving and Communication System (PACS), comprising 210 patients treated for hemoptysis via BAE using NBCA from 2014 to 2022. Patients included underwent appropriate preprocedural workup and BAE via a standard procedure. Preprocedural imaging included CT thoracic angiography to identify underlying lung pathology, bleeder vessels, and pseudoaneurysms. All patients underwent BAE using a digital subtraction angiography unit and a standard procedure with femoral access using a 5F sheath. Selective catheterization of target vessels was achieved using a 5F angiographic catheter followed by coaxial microcatheter insertion for distal embolization to avoid non-target spread. The agent used was 15% NBCA mixture (1:7 glue-to-lipiodol ratio) with the endpoint being complete stasis. The outcomes measured were technical success- catheterization and embolization of culprit vessels, immediate success- no fresh hemoptysis within 24 hours, recurrence at 3 and 6 months, and complications as per Society of Interventional Radiology (SIR) guidelines. Results: The patient group comprised 154 male and 56 female patients with a mean age of 48 years. Tuberculosis was the most common etiology. Hemoptysis was categorized as mild (n=42), moderate (n=132), or severe (n=36). A total of 693 vessels were treated- 606 bronchial arteries and 87 non-bronchial systemic collaterals, making an average of 3.3 arteries embolized per patient. Technical success was achieved in all cases (100%) with immediate clinical success seen in 208 patients (99%). Two patients succumbed to progressive pulmonary disease within three days. At 6 months, 180 patients were evaluated with 22 lost to follow-up. Hemoptysis recurrence rates were 12.6% (n=23) at 3 months and 10.8 (n=20) at 6 months. Minor complications were observed in 33.8% (n=71) with self limiting chest pain being the most common. Other minor complications were dysphagia and puncture site hematoma, which also resolved with conservative management. No major complications or procedure related mortality were noted. Conclusion: BAE with NBCA is a safe, effective, and affordable treatment method for hemoptysis. It demonstrates high immediate clinical success, low recurrence rates and low complication risk. These results are consistent with existing literature and suggest NBCA as a suitable alternative to PVA particles depending on operator experience.
Background: Gynecological cancers (GCs) account for one-third of newly diagnosed cancers in women and 15.77% of female cancer-related deaths worldwide, with Eastern Africa bearing the highest incidence and mortality rates globally. Global GC incidence is expected to increase by 49.61% and mortality by 77.23% by 2050, with Eastern Africa facing an even more devastating rise of 164.6% and 172.3% respectively. In Rwanda, cervical cancer accounts for 22.6% of all female cancers with over 600 annual deaths, yet data on the full spectrum of GCs remain critically limited, hindering resource allocation and national cancer control planning. This study aimed to determine the frequency and distribution of GC types, analyse patients' demographic and clinical characteristics, and describe disease staging, presenting symptoms, treatment modalities, and short-term outcomes at Rwanda Military Teaching Hospital (RMTH). Methods: A retrospective cross-sectional census study was conducted of all 504 patients diagnosed with or referred to RMTH with GCs between January 2023 and December 2024. Sociodemographic, clinical, histopathological, staging, treatment, and outcome data were extracted from medical records. Descriptive statistics, chi-square tests, and multivariable logistic regression were applied to identify predictors of late-stage presentation (International Federation of Gynecology and Obstetrics stages III–IV; p < 0.05). Results: Cervical cancer dominated the cohort (80.4%), followed by corpus uteri (6.9%), ovarian (5.4%), vulvar (4.6%), and vaginal cancers (1.8%). Demographically, most patients were middle-aged (53.4% aged 46–65 years), grand multiparous (65.6%), and almost exclusively insured through community-based schemes (93.8%), predominantly from the Eastern Province (31.5%). Unexpectedly, human immunodeficiency virus (HIV) co-infection was documented in 43.4% of tested patients, approximately 15 times Rwanda's general adult prevalence, being highest in vulvar (68.8%) and cervical (41.7%) cancers. An alarming 67.7% presented with advanced-stage disease, far exceeding the 20–30% reported in high-income settings, with vaginal discharge (52.5%), post-menopausal bleeding (47.3%), and pelvic pain (32.1%) as the commonest presenting symptoms. Chemoradiotherapy was the predominant treatment modality (66.9%), with significant geographic variation (p=0.001). Interestingly, province of residence was the sole independent predictor of late-stage presentation; Eastern Province women faced nearly fourfold higher odds of advanced disease versus Western Province (odds ratio 3.98, 95% confidence interval 1.38–11.46, p=0.010), while age, parity, and HIV status showed no independent association. Median referral-to-treatment interval was 143 days, with 76.6% experiencing prolonged delays, and follow-up data were absent for 79.2% of patients. Conclusion: GCs in Rwanda were characterised by cervical cancer dominance, near-universal late-stage presentation, disproportionate HIV co-infection, and geography-driven inequities in care access. Eastern Province residency emerged as the principal structural determinant of late diagnosis, contributing actionable evidence supporting Rwanda's 90-70-90 elimination targets through decentralisation of services and integration of cervical cancer care into HIV platforms. Future prospective studies with robust follow-up registries are essential to quantify survival outcomes and evaluate ongoing interventions.
Background- Advanced unresectable hepatocellular carcinoma (uHCC) is associated with poor prognosis and limited treatment options. Combination therapy with lenvatinib, a multikinase inhibitor, and pembrolizumab, an immune checkpoint inhibitor, has demonstrated promising antitumor activity in recent studies. However, variability in liver function status and prior systemic therapy exposure continues to influence clinical outcomes. This review evaluates the efficacy and safety profile of lenvatinib–pembrolizumab therapy in advanced uHCC. Objective- To assess the clinical efficacy, safety, and prognostic factors associated with lenvatinib plus pembrolizumab therapy in patients with advanced unresectable hepatocellular carcinoma. Methodology- A literature review was conducted using published clinical trials and real-world studies evaluating lenvatinib combined with pembrolizumab in advanced uHCC. Key outcomes analyzed included disease control rate (DCR), progression-free survival (PFS), overall survival (OS), and treatment-related adverse effects. Prognostic variables such as Child–Pugh classification, Albumin-Bilirubin (ALBI) score, and prior systemic therapy exposure were additionally reviewed. Result- Reviewed studies demonstrated favourable efficacy and acceptable tolerability of lenvatinib–pembrolizumab therapy in advanced uHCC. In a prospective cohort involving 71 patients, 81.7% were categorized as Barcelona Clinic Liver Cancer (BCLC) stage C. Disease control rates exceeded 80% in first-line settings and approached 70% in previously treated patients. Median progression-free survival was approximately 9 months. Liver function, assessed using ALBI scores, remained relatively stable during treatment. Common adverse effects included hypertension, fatigue, and hepatic dysfunction, while severe toxicities were infrequent. Conclusion- Current evidence supports lenvatinib combined with pembrolizumab as an effective and generally well-tolerated therapeutic strategy in advanced unresectable hepatocellular carcinoma. Treatment outcomes appear to be influenced by baseline liver function and prior immunotherapy exposure. Larger prospective randomized studies are required to further validate long-term efficacy and safety outcomes.
Background IgG4-related sclerosing cholangitis (IgG4-SC) is a fibroinflammatory condition that frequently mimics pancreatobiliary malignancies, contributing to its significant underdiagnosis. Critical knowledge gaps persist regarding safe diagnostic pathways when tissue biopsy is contraindicated, pharmacogenetic risk stratification for thiopurine therapy, and evidence-based rituximab maintenance strategies for high-risk phenotypes. This case addresses these gaps by validating multimodal diagnosis using the 2020 Revised Comprehensive Diagnostic (RCD) criteria in an anticoagulated patient, demonstrating the value of proactive TPMT metabolite monitoring, and providing preliminary evidence that intensified rituximab maintenance may reduce relapse in high-risk IgG4-SC. Case Description A 72-year-old male with a mechanical aortic valve requiring lifelong anticoagulation presented with obstructive jaundice and a pancreatic uncinate mass demonstrating superior mesenteric artery encasement, initially raising high suspicion for unresectable pancreatic adenocarcinoma. EUS-FNA was non-diagnostic due to intraprocedural bleeding despite warfarin bridging. Biliary brushings confirmed inflammatory changes without atypia, and CA19-9 was normal. Serum IgG4 was markedly elevated at 8.5 g/L (6.3× the upper limit of normal), carrying 100% specificity for IgG4-SC. Complete radiological resolution of the uncinate mass and pancreatic inflammation following corticosteroid initiation confirmed a diagnosis of Type 4 IgG4-SC with associated Type 1 autoimmune pancreatitis, per RCD criteria. Clinical relapse occurred during the corticosteroid taper, requiring repeat biliary stenting and re-induction therapy. Azathioprine was introduced as a steroid-sparing agent; however, TPMT metabolite monitoring revealed unfavorable shunting toward toxic 6-thioguanine nucleotide accumulation, prompting transition to rituximab (1000 mg IV, days 1 and 15). Following a 15-day delay in a scheduled maintenance infusion, the patient presented with acute cholangitis. Given his high-risk profile (Type 4 disease, baseline IgG4 >270 mg/dL), maintenance was intensified to five-month cycles. He remains in remission under close surveillance with longitudinal B-cell subset monitoring. Conclusion This case demonstrates that definitive IgG4-SC diagnosis can be safely established through convergent multimodal evidence when tissue biopsy is contraindicated, validating the real-world utility of the RCD framework. Proactive TPMT metabolite monitoring prevented life-threatening myelotoxicity and guided personalized immunosuppression. Most significantly, this case provides preliminary evidence that high-risk anatomical phenotypes warrant proactive rituximab maintenance intensification rather than reactive management, to preserve biliary integrity and prevent irreversible fibroinflammatory damage.
Introduction: Contemporary medical education demands educational approaches capable of adapting to the individual needs of students, something still limited by traditional teaching models. In this context, educational interventions based on Artificial Intelligence, including intelligent tutors, adaptive platforms, virtual patients, language models, and chatbots, have emerged as promising strategies to personalize learning paths, increase the availability of formative feedback, and reduce the extrinsic cognitive load associated with conventional instructional methods. Despite this potential, the magnitude of the benefit provided by these technologies, when compared to traditional or non-AI-based pedagogical strategies, still lacked robust and quantitative systematic evaluation. The objective of this study was to evaluate and quantify the impact of AI-mediated educational interventions on the academic performance and learning of medical students in relation to non-AI-based methods. Methods: A systematic review with meta-analysis was conducted according to the PRISMA 2020 guidelines. Searches were conducted in the PubMed, LILACS, and SciELO databases and included studies published between 2015 and 2025, in Portuguese, English, and Spanish. Eligible studies were experimental or quasi-experimental studies involving undergraduate medical students that implemented an AI-based educational intervention, presented a comparator group, and reported objective learning outcomes or academic performance. The methodological quality assessment used the RoB 2 and ROBINS-I tools. Quantitative synthesis was conducted using a random-effects model, with effect size estimation using Hedges' g. Results: The search identified 231 records, of which 81 studies were included in the qualitative synthesis and 10 randomized clinical trials comprised the meta-analysis. Educational interventions based on Artificial Intelligence have demonstrated a positive and significant impact on the learning of medical students. AI-based strategies showed superiority over traditional methods, with a robust effect size (g = 1.07; 95% CI: 0.90–1.24; I² = 48%). This effect size corresponds to a high educational impact, indicating substantial superiority of AI-based interventions. The greatest benefits occurred among pre-clinical students and in interventions using adaptive platforms, while chatbots and virtual patients also promoted relevant gains in clinical reasoning, communication, OSCE performance, and knowledge acquisition. Meta-regression indicated that students with lower baseline performance showed proportionally greater gains, suggesting an equalizing effect of AI, and that systems with complex and adaptive feedback were associated with better academic results. However, moderate heterogeneity was observed among the studies, especially regarding the types of intervention and methods of outcome assessment. Conclusion: Educational interventions based on Artificial Intelligence promote consistent and significant improvement in academic performance and learning outcomes of medical students. These effects are more pronounced when technologies are integrated into structured pedagogical models, anchored in adaptive feedback and aligned with curricular objectives. AI is configured as a high-value complementary tool, without replacing teachers or face-to-face clinical experiences, but enhancing the personalization of learning, reducing cognitive load, strengthening self-efficacy, and promoting educational equity. Its curricular incorporation must occur with teacher supervision, critical digital literacy, and attention to the ethical and responsible use of these technologies.
Background: Developing countries like Sudan face severe limitations in accessing primary healthcare. Since April 2023, an armed conflict has broken out in Sudan. This ongoing crisis has severely compromised healthcare access, especially for internally displaced persons, but the barriers influencing their healthcare-seeking behavior remain poorly understood. This study aimed to examine the accessibility of healthcare services, types of medical care sought, and barriers influencing healthcare-seeking behavior among internally displaced persons in Sudan in 2025, and to identify social, economic, and geographical factors affecting their healthcare decisions. Methods: A descriptive cross-sectional study was conducted among 944 internally displaced persons from Sudan, using convenience sampling, between September and October 2025. Data were gathered using an online structured self-administered questionnaire collecting data on sociodemographic characteristics; healthcare accessibility using the nearest health facility scale; health status; and barriers to healthcare-seeking behavior to evaluate accessibility, types of care sought, and barriers influencing healthcare-seeking behavior among internally displaced persons during armed conflict in Sudan. Data were analyzed using descriptive statistics, the Kruskal–Wallis test, and multivariable logistic regression, with adjusted odds ratios and 95% confidence intervals reported at p < 0.05. Results: Among 944 participants, approximately half (52.3%) lived within 2 km of a health facility, with a mean travel time of 21.5 minutes, and 57.6% reached care by walking. Clinics were the most commonly reported nearest facilities (48.9%), followed by hospitals (33.8%). The main challenges in accessing care included lack of specific services (28.3%) and long waiting times (16.7%), with financial barriers constituting a key barrier to access (62.5%). Multiple barrier variables emerged as the strongest predictors of reported challenges at health facilities, including access barriers (χ² = 75.51, p < .001), perceived discrimination (χ² = 56.95, p < .001), and barriers related to patient (χ² = 45.32, p < .001) and healthcare providers (χ² = 56.00, p < .001). Interestingly, higher income was associated with increased reporting of challenges (OR = 1.78, 95% CI [1.13, 2.80], p = 0.012). Conclusion: This study demonstrates that a significant proportion of internally displaced persons experienced difficulties accessing healthcare, largely due to financial, provider-related, and service provision barriers. Addressing these barriers is essential to improve equitable access to health services.
Background: Vasoplegic syndrome occurs in up to 25% of patients after cardiac surgery with cardiopulmonary bypass (CPB) and carries mortality >25% due to nitric oxide-mediated vasodilation and catecholamine resistance. Methylene blue (MB) inhibits guanylate cyclase and is used as rescue therapy, but evidence is limited to small studies. We conducted a systematic review and meta-analysis to evaluate the efficacy of methylene blue in treatment of cardiac surgery associated vasoplegia syndrome Methods: We searched PubMed from inception to January 2026 for studies comparing intravenous methylene blue versus control in adults with post-cardiopulmonary resuscitation vasoplegia. Primary outcome was 30-day mortality. Secondary outcomes were vasopressor duration, ICU length of stay, and mean arterial pressure at 6 hours post-CPB. Risk of bias was assessed using RoB 2 and Newcastle-Ottawa Scale. Data were pooled using random-effects models. Certainty of evidence was assessed using GRADE. Results: Four studies with 472 patients (2 RCTs, 2 observational) met inclusion criteria. MB significantly reduced 30-day mortality (OR 0.40, 95% CI 0.26 to 0.63; I² = 0%; moderate certainty), corresponding to 145 fewer deaths per 1,000 patients. MB also reduced vasopressor duration by 17.2 hours (95% CI -24.8 to -9.6; I² = 42%; low certainty), ICU LOS by 1.7 days (95% CI -2.8 to -0.6; I² = 58%; low certainty), and increased MAP at 6h by 15.0 mmHg (95% CI 9.0 to 21.0; I² = 15%; low certainty). Mortality benefit was consistent for prophylactic and therapeutic administration. Conclusions: In cardiac surgery-associated vasoplegic syndrome, methylene blue reduces 30-day mortality with moderate certainty and improves hemodynamic and resource utilization outcomes with low certainty. These findings support MB as rescue therapy while awaiting large RCTs to define optimal timing and dosing
Background: Gambling disorder is a behavioral addiction associated with significant psychological, social, and public health consequences. Patients frequently present with psychiatric comorbidities, impulsivity, emotional dysregulation, relapse, and suicidal behavior, contributing to poorer clinical outcomes and chronic progression of the disorder. Gambling-related problems are often underrecognized until severe psychosocial impairment develops. Better understanding of psychopathological characteristics, motivational factors, and predictors of relapse and suicidality may improve early identification and treatment of high-risk individuals. Methods: This retrospective observational study included patients diagnosed with gambling disorder treated at the Clinic for Psychiatry, University Clinical Center of Vojvodina, between January 2020 and December 2025. After inclusion and exclusion criteria were applied, 101 patients were analyzed. Data from electronic medical records included sociodemographic characteristics, psychiatric comorbidities, impulsivity, suicidal behavior, relapse, treatment compliance, psychotherapy recommendations, and motivational factors for gambling. Statistical analyses included chi-square test, Fisher’s exact test, odds ratio (OR), and Cramer’s V coefficient, with p < 0.05 considered significant. Results: The sample was predominantly male (96%), with a mean age of 36.8 ± 10.08 years, indicating that gambling disorder mainly affected the working-age population. Psychiatric comorbidities were present in 76.2% of patients, most commonly substance use and mood disorders, while impulsivity was identified in 49.5%. Suicidality was recorded in 40.6% of patients, emphasizing the considerable psychiatric burden associated with gambling disorder. The most common motivational factors for gambling were excitement and entertainment, followed by escape from problems and financial difficulties, suggesting the importance of both reward-seeking behavior and maladaptive coping mechanisms. A strong association was observed between elements of the suicidal continuum and suicide attempts (p < 0.001; OR = 174.2). Suicide attempts were not recorded among patients without suicidal ideation or planning. Regular follow-up visits were associated with lower rates of suicide attempts (p = 0.007; V = 0.47) and relapse (p = 0.036; V = 0.436). Impulsivity was significantly associated with legal problems (p = 0.02; OR = 8.5). Patients referred to supportive psychotherapy showed fewer suicide attempts, although significance was lost after continuity correction. Conclusion: Gambling disorder represents a complex psychiatric condition strongly associated with comorbid psychopathology, impulsivity, relapse, and suicidality. The findings of this study emphasize the importance of comprehensive psychiatric assessment and early recognition of suicidal thoughts and behaviors in patients with gambling disorder. Continuous therapeutic follow-up and long-term treatment engagement were associated with lower rates of relapse and suicide attempts, highlighting their protective role in clinical outcomes. Individualized multidisciplinary treatment approaches, including psychotherapy and monitoring of high-risk patients, may contribute to improved prognosis and more effective prevention of adverse psychosocial and psychiatric consequences. Key Words: Gambling Disorder; Comorbidity; Impulsive Behavior; Suicidal Ideation; Patient Compliance
Background: Empathy is a cornerstone of effective medical care, associated with improved patient outcomes, satisfaction, and physician well-being. Despite its importance, studies demonstrate that empathy declines during medical training, including in the preclinical years. Narrative Medicine (NM), which cultivates narrative competence—the ability to recognize, interpret, and be moved by patients’ stories—has been shown to support empathy, reflection, and professional identity formation. However, most NM interventions occur over extended periods, posing challenges for integration into time-constrained medical curricula. This mixed-methods study evaluates whether brief Narrative Medicine workshops can enhance empathy in first-year medical students and explores their feasibility for curricular implementation. Methods: First-year medical students participated in optional 60-minute Narrative Medicine workshops, co-facilitated by an experienced Narrative Medicine practitioner and a physician faculty member. Sessions included an overview of Narrative Medicine, close reading of a poem or short story, prompted reflective writing, and group discussion. Empathy was measured pre- and post-workshop using the Jefferson Scale of Empathy–Medical Student Version (JSE-S) and analyzed using the Wilcoxon signed-rank test. Semi-structured interviews were conducted to explore student experiences and perspectives; transcripts were analyzed using inductive thematic analysis with iterative codebook development. Results: JSE-S empathy scores increased significantly following workshop participation (n=27, p=0.001). Qualitative analysis (n=10) identified themes of workshops facilitating perspective-taking and empathy development, reconnecting students with their sense of purpose in medicine, and cultivating peer connection and community, along with a strong desire for curricular integration. Conclusion: Narrative Medicine workshops were associated with increased empathy among first-year medical students and represent a feasible, promising approach to fostering humanistic development in medical education. Larger, longitudinal studies are warranted to evaluate the durability of these effects.
