Kasabach-Merritt phenomenon (KMP) is a rare condition associated with vascular tumors such as kaposiform hemangioendothelioma and tufted angioma; it can be life-threatening due to its consumptive coagulopathy. Thrombocytopenia and hypofibrinogenemia are characteristic of KMP, and anemia and raised d-dimer levels can also be detected. Here, we report a 7-month-old Cambodian with the condition. The infant was admitted to the National Pediatric Hospital in Phnom Penh because of a mass on the right side of the neck that had been progressively enlarging. The patient had severe thrombocytopenia (8,000/µL), anemia (Hb 7.6g/dL) and reduced fibrinogen level (1.5g/L). CT scan suggested and histopathology of the lesion confirmed a diagnosis of kaposiform hemangioendothelioma. Kasabach-Merritt phenomenon was diagnosed, and the infant was treated with platelets and fresh frozen plasma infusions, prednisolone (2mg/kg/day) and propranolol (2.5mg/kg/day). After eight weeks of therapy, platelets raised to 102,000/µL. The infant developed Cushing’s syndrome after 6 months of treatment, and prednisolone was scaled down to a maintenance dose of 0.5mg/kg/day. Fibrinogen levels went back to normal (2.14g/L) after seventeen months of treatment, and the tumor shrunk significantly. This case report shows that a combination of prednisolone and propranolol was effective for the treatment of KMP and kaposiform hemangioendothelioma. Timely recognition and treatment of Kasabach-Merritt phenomenon is essential.

Importance:Rapid digitalization of health care and a dearth of digital health education for medical students and junior physicians worldwide means there is an imperative for more training in this dynamic and evolving field. Objective:To develop an evidence-informed, consensus-guided, adaptable digital health competencies framework for the design and development of digital health curricula in medical institutions globally. Evidence Review:A core group was assembled to oversee the development of the Digital Health Competencies in Medical Education (DECODE) framework. First, an initial list was created based on findings from a scoping review and expert consultations. A multidisciplinary and geographically diverse panel of 211 experts from 79 countries and territories was convened for a 2-round, modified Delphi survey conducted between December 2022 and July 2023, with an a priori consensus level of 70%. The framework structure, wordings, and learning outcomes with marginal percentage of agreement were discussed and determined in a consensus meeting organized on September 8, 2023, and subsequent postmeeting qualitative feedback. In total, 211 experts participated in round 1, 149 participated in round 2, 12 participated in the consensus meeting, and 58 participated in postmeeting feedback. Findings:The DECODE framework uses 3 main terminologies: domain, competency, and learning outcome. Competencies were grouped into 4 domains: professionalism in digital health, patient and population digital health, health information systems, and health data science. Each competency is accompanied by a set of learning outcomes that are either mandatory or discretionary. The final framework comprises 4 domains, 19 competencies, and 33 mandatory and 145 discretionary learning outcomes, with descriptions for each domain and competency. Six highlighted areas of considerations for medical educators are the variations in nomenclature, the distinctiveness of digital health, the concept of digital health literacy, curriculum space and implementation, the inclusion of discretionary learning outcomes, and socioeconomic inequities in digital health education. Conclusions and Relevance:This evidence-informed and consensus-guided framework will play an important role in enabling medical institutions to better prepare future physicians for the ongoing digital transformation in health care. Medical schools are encouraged to adopt and adapt this framework to align with their needs, resources, and circumstances.

Medical education has been extensively debated and repeatedly modified in Western countries since the 1910 Flexner Report recommended a transformation of U.S.A. medical schools. It is debatable whether the changes have ultimately been beneficial to those countries; however, a pressing issue is whether medical education is as effective as it should be in low-and middle-income countries (LMICs), where most doctors are 'produced'. It is mandatory that medical education is at a sufficient level in all medical schools of all countries; is that the case at the present time?In this Opinion article, I will briefly examine the main aspects which need serious attention and urgent improvement.Are medical schools in practice (on paper, they may be) a lively and creative environment for teaching, innovation, and patient care? Most are not; they do not have the funds, staff and overall conditions to do so. Their so-called tripartite mission (research, teaching, patient care) is untenable in most low-and middle-income countries, as physicians cannot do well in all three. Most of the universities are unable to start any research project unless they obtain large grants, and faculty members involved in these efforts have no or very little time to spend with students. In addition, clinical faculty mainly focus on training residents rather than undergraduates.The inalienable, paramount mission of a medical school must be to form competent and compassionate doctors. Herbert Fred provided twenty years ago an excellent description of the increasingly overlooked importance of history taking and clinical skills for any clinician, and advocated for American students' clinical experience to take place largely in real-world settings, supervised by experienced, compassionate, common-sense practitioners (1). This continues to be extremely important for medical students in LMICs.For a medical school to fulfil its mission, it is fundamental to attract the brightest and most compassionate doctors. How to succeed in this? Doctors should work in adequately staffed primary care clinics or university hospitals, have adequate time for bedside and small group teaching, and earn salaries comparable to those of physicians who devote most of their time to private practice. Medical schools in LMICs cannot continue to rely largely on part-time or even casual doctors, as this unacceptably lowers the quality and consistency of student teaching.In September 1978, in Almaty (then Alma Ata), the World Health Organisation (WHO) defined primary health care as essential (2); management of complex chronic diseases, early diagnosis and disease prevention were considered of paramount importance.However, too much emphasis has since been put on tertiary, highly specialized care; disease prevention, primary care and the fundamental value of patient-doctor relationships are, de facto, overlooked, even though much emphasized theoretically. It is essential that they are given the importance that they still have, and must also have in the future, for medicine to continue to contribute to societal wellbeing. Therefore, the undergraduate medical curriculum must truly focus on primary care rather than on highly specialized tertiary hospital care.Simulation-based training has been hugely promoted in medical education in the current millennium; notwithstanding its much-emphasized benefits, the high costs, need for specialized equipment and facilities, and faculty training remain important barriers (3). It is essential that simulation equipment ensures realism of the experience by reflecting the often limited resources in the clinical environment in LMICs. In any case, clinical experiences on real patients must also be guaranteed, and increased; the traditional apprenticeship model (students learning through direct patient care under proper supervision of experienced clinicians) should be strongly pursued rather than increasingly disregarded. Professor Greenhalgh stated almost ten years ago that ''we need to challenge the colonisation of medical education by the unreal: the simulated patient, the silicone body part, the standardised scenario, the objective and structured (but entirely fictitious) clinical examinations'', and that ''the inexorable retreat of medical education from the messy, non-standardisable reality of illness and suffering'' should be stopped (4).Her words should be seriously considered even nowadays.Self-interest, family and/or friend pressure, and socioeconomic status influence the students' choice of medicine worldwide (5-7). In the past, medicine was chosen because young people wished to help, earn a high salary and be respected by others; presently, not only a high salary but also flexible working hours are essential for millennial students (8), and the idea of working long hours for inadequate public sector salaries is unacceptable. In Indonesia, for instance, medical students prefer jobs with a positive work-life balance' in addition, they would like to have jobs where more technology and more procedural protocols are used, teamwork is involved, and cases are not too complicated (9). Primary care is not an interesting career option for most of them (9). It is mandatory to consider the above reality to find ways to increase interest in primary care during undergraduate studies, and it is also compulsory to enormously improve working conditions in the public health sector in LMICs (10).A career in medicine is not for all. Medical schools should utilize a combination of tools to select their students, including academic performance measures (where the fact that scores at fee-paying private schools are higher than those at state or public schools should be considered), cognitive skills tests, semi-structured or multiple mini-interviews.Assessment of personal qualities must be an essential component of the admission process (11), as failures in professionalism are often linked to earlier problematic behaviors by students (12). Still practiced, direct entrance of high school graduates into medical schools, based exclusively on their performances in few basic subjects (13), must be abandoned in all countries.Due consideration must be given to the knowledge of English, which has been for decades the international language of medicine ( 14) and a fundamental international educational tool; weakness in English has long been recognized as a hindrance to medical students' communication and information handling skills (15). Considering the difficulty of medical studies, it is important to seriously consider the inclusion of English proficiency among the pre-requisites for admission rather than eventually providing English lessons during undergraduate medical studies. The emphasized need to favor access to medical schools of students from disadvantaged communities/background must not cause relaxation of necessary tools; what is mandatory is to truly favor their access to good primary and secondary schools.West-inspired theories such as student-centered approach and problem-based learning (PBL) are theoretically attractive but cannot be easily applied and could even be detrimental in other settings. For instance, if there are insufficient numbers of faculty members and facilitators and/or a faculty is made exclusively or almost exclusively of casual lecturers, PBL cannot be applied or, if tentatively applied, will be a failure.Importantly, in most countries in Asia, Africa, Latin America and the Mediterranean, where collectivistic societies strongly avoid uncertainty, and hierarchical cultural backgrounds prevail, lecturers are expected to make learning decisions for their students (16). Even in Japan, the implementation of PBL is problematic, due especially to the high burden placed on faculties, and is therefore avoided in many medical schools (17). As for assessment, in Asia neither students nor lecturers are ready for more dialogical and formative assessment (16). In fact, students place importance on getting certified achievements in (largely multiple-choice, question-based) summative assessments, rather than on selfdirected activities or peer-review (17). Hence, studies comparing outcomes of different teaching methodologies and assessment types are needed in LMICs. It is also very Academic integrity must be absolutely safeguarded in medical school exams. Is this the case? Unfortunately, it is not. Dishonesty is quite common among undergraduate medical students during online assessments (198,2019), and cheating is frequent also in theses (210). This behavior, if known to the general public, would be considered totally unacceptable; in contrast, students and lecturers have low expectations of each other's behavior (221). Medical schools should be much more seriously held accountable to produce competent doctors for the countries where they are located and for the world at large.Since 1998, the World Federation for Medical Education (WFME) has developed global standards for quality improvement, which have been accepted and tentatively applied in many countries. However, nearly 80% of medical colleges in India (the country with the largest number of medical colleges in the world) do not meet even the minimum criteria established by the regulator National Medical Commission; faculty absenteeism, inadequate and poor infrastructure, poor student-teacher relationship are major issues (232). In addition, increasing commercialisation and privatisation of medical education, unabated corruption, relaxation of basic requirements for establishing new medical schools, flawed entrance selection processes are huge challenges (243). The situation is not dissimilar in other countries. Does accreditation solve all problems and guarantee that competent doctors come out of every medical school? It does not, but the lack of it tends to guarantee the opposite.This is an extremely important issue. The students' clinical training must happen in conducive environments where there is proper attention to/care of the students. All medical schools must ensure this, and it is essential that clinicians in primary care clinics and hospitals are linked with medical schools through agreements that guarantee due attention to teaching and student supervision. Each medical school must have a budget and pay clinicians for their contribution. Ministries of health must ensure that the staffing of hospitals and clinics where medical students rotate is sufficient to make adequate clinical training possible, and that the salaries paid for their clinical activity are such that the clinicians do not spend most of their time in private practice, even when officially not allowed. All the above requires a shift of mindset that is anyway necessary if medical education is considered in real terms as important as it must be.LMICs' investment in medical education should not be in vain. A study involving 959 fifthand sixth-year students in six government owned medical schools in Ethiopia in 2015 indicated that only 70.1% wanted to practice in clinical care settings (254). This situation is not uncommon; clinicians who have even specialized in different fields in Western countries end up doing only administrative work in the ministries of health, hospitals or medical schools in LMICs, and their clinical expertise is lost. As for those who choose to work clinically, it is important that each ministry of health carefully plans the number of doctors needed in primary care and in the various specialties, and that a strong cooperation is in place with all medical schools in the country. The lack of a sufficient number of doctors in primary care (even more so in rural areas)(254) and in specialties which are considered less remunerative is an unsolved issue that needs strong attention and innovative approaches.I have briefly examined the huge problems and deficiencies of medical education in many LMICs; some of them are common alsoeven to Western countries, even though largely ignored. Obviously, not all medical schools in all LMICs are affected by the outlined problems and deficiencies, and some schools are actually preparing their students for medical practice very well. However, iIt is imperative to try and hugely improve all medical schools, and it is up to governments to ensure that clinicians educated in any medical school of their nations are competent, knowledgeable, compassionate and able to take care of the whole population. It is also important for everybody to consider that healthcare must not be a business but rather a fundamental right for every human being in any country; medical schools should prepare clinicians who will keep this in mind.

Long-acting antiretroviral therapy (LA-ART) represents an important advancement in HIV care as it has considerably reduced the frequency of dosing and therefore improved adherence [...]

Patients with systemic autoimmune diseases have increased susceptibility to infections, including tuberculosis, partly due to immunosuppressive treatment. We describe a case of extrapulmonary tuberculosis (tuberculous osteomyelitis of the right foot) occurring a few months after a diagnosis and apparently successful treatment of abdominal TB in a Kazakh patient with mixed connective tissue disease. Abdominal tuberculosis had occurred while the patient was on high doses of corticosteroids, whereas bone tuberculosis was diagnosed when glucocorticoid doses had been reduced. The diagnosis of tuberculous osteomyelitis was unfortunately made months after the disease manifested. Screening for latent tuberculosis should be mandatory before starting immunosuppressive treatment in patients with autoimmune diseases, especially in countries with a considerable tuberculosis burden, and tuberculosis should be high in the list of possible etiologies of multiple clinical manifestations in these patients. Пациенты с системными аутоиммунными заболеваниями имеют повышенную восприимчивость к инфекциям, включая туберкулез, отчасти из-за иммуносупрессивной терапии. Мы описываем случай внелегочного туберкулеза (туберкулезный остеомиелит правой стопы), возникший через несколько месяцев после постановки диагноза и, по-видимому, успешного лечения абдоминального туберкулеза у казахского пациента со смешанным заболеванием соединительной ткани. Абдоминальный туберкулез возник, когда пациент принимал высокие дозы кортикостероидов, тогда как костный туберкулез был диагностирован, когда дозы глюкокортикоидов были снижены. К сожалению, диагноз туберкулезного остеомиелита был поставлен через несколько месяцев после манифестации заболевания. Скрининг на латентный туберкулез должен быть обязательным перед началом иммуносупрессивной терапии у пациентов с аутоиммунными заболеваниями, особенно в странах со значительным бременем туберкулеза, и туберкулез должен быть одним из первых в списке возможных этиологий множественных клинических проявлений у этих пациентов. Жүйелікаутоиммундыауруларыбаремделушілердеішінараиммуносупрессивтіемгебайланыстытуберкулездіқоса, жұқпалыаурулардыңқаупіжоғары. Біздәнекертінініңараласауруыменауыратынқазақстандықнауқастаабдоминальдытуберкулездиагнозықойылғанжәнесәттіемделгенненкейінбірнешеайданкейінпайдаболғанөкпедентыстуберкулез (оңаяқтыңтуберкулездікостеомиелиті) жағдайынсипаттаймыз. Құрсаққуысыныңтуберкулезінауқаскортикостероидтардыңжоғарыдозаларынқабылдағанкездедамыған, алсүйектуберкулезіглюкокортикоидтардыңдозасыназайтқандаанықталған. Өкінішкеорай, туберкулездіостеомиелитдиагнозыаурубасталғаннанкейінбірнешеайданкейінқойылды. Аутоиммундыауруларыбаремделушілерде, әсіресетуберкулездіңайтарлықтайауыртпалығыбарелдердеиммуносупрессивтітерапияныбастамасбұрынжасырынтуберкулезгескринингміндеттіболуыкерек, алтуберкулезосынауқастардағыкөптегенклиникалықкөріністерүшінықтималэтиологиялартізіміндежоғарыболуыкерек.

Background: Antiretroviral triple therapy has considerably reduced morbidity and mortality in people living with HIV and is the standard-of-care treatment. However, it is lifelong and linked to long-term side effects and adherence problems. Methods: Here, we report long-term virological and immunological outcome in 12 virally suppressed people on short-cycle therapy with bictegravir/emtricitabine/tenofovir alafenamide administered five days a week (Monday to Friday). Results: All patients, after a long term follow-up, were virally suppressed Conclusions: In the wait for new long-acting antiretroviral drugs and new antiretroviral formulations, short-cycle therapy has proven to be a safe and effective alternative to the standard daily antiretroviral regimen for individuals living with HIV who are virologically suppressed.

The use of long-acting antiretroviral regimens will not be suitable for all people living with HIV for various reasons (previous virological failure with drugs of the same class, side effects, logistic difficulties, and costs). We think that short-cycle therapies could represent a feasible and valuable option for antiretroviral treatment optimization in selected individuals. So here we review clinical evidence about efficacy of short-cycle therapy in suppressed HIV-infected patients.

Background In this priority-setting exercise, we sought to identify leading research priorities needed for strengthening future pandemic preparedness and response across countries. Methods The International Society of Global Health (ISoGH) used the Child Health and Nutrition Research Initiative (CHNRI) method to identify research priorities for future pandemic preparedness. Eighty experts in global health, translational and clinical research identified 163 research ideas, of which 42 experts then scored based on five pre-defined criteria. We calculated intermediate criterion-specific scores and overall research priority scores from the mean of individual scores for each research idea. We used a bootstrap (n = 1000) to compute the 95% confidence intervals. Results Key priorities included strengthening health systems, rapid vaccine and treatment production, improving international cooperation, and enhancing surveillance efficiency. Other priorities included learning from the coronavirus disease 2019 (COVID-19) pandemic, managing supply chains, identifying planning gaps, and promoting equitable interventions. We compared this CHNRI-based outcome with the 14 research priorities generated and ranked by ChatGPT, encountering both striking similarities and clear differences. Conclusions Priority setting processes based on human crowdsourcing - such as the CHNRI method - and the output provided by ChatGPT are both valuable, as they complement and strengthen each other. The priorities identified by ChatGPT were more grounded in theory, while those identified by CHNRI were guided by recent practical experiences. Addressing these priorities, along with improvements in health planning, equitable community-based interventions, and the capacity of primary health care, is vital for better pandemic preparedness and response in many settings.

Hepatitis B virus (HBV) infection is endemic in Ghana and chronic kidney disease patients on haemodialysis are a high-risk group for HBV infection. We determined the prevalence of overt and occult HBV infection among haemodialysis patients at the Korle Bu Teaching Hospital in Ghana. 104 consenting End Stage Renal Disease patients on long-term haemodialysis were recruited for the study and their socio-demographic, clinical and laboratory information were obtained using structured questionnaire. All the participants were tested for the hepatitis B surface antigen (HBsAg). The HBsAg-negative participants were re-tested for hepatitis B surface antibody (HBsAb), hepatitis B core antibody (HBcAb) and HBV DNA using chemiluminescence and Roche COBAS Ampli-Prep/TaqMan analyser and real-time polymerase chain reaction. Eight (7.7%) of the total participants were positive for HBsAg. Among the 96 HBsAg-negative participants, 12.5% (12) were HBcAb-positive, 7.3% (7) had detectable HBV DNA (mean = 98.7±53.5 IU/mL) and 40.6% (39) were positive for HBsAb. Five out of the 7 HBV DNA-positive participants were males and only one participant was negative for HBcAb. Seventy-three out of the 96 HBsAg-negative participants were vaccinated and 37 of these vaccinated individuals had significant HBsAb titres (mean = 423.21± 380.72 IU/mL). Our data demonstrated that the prevalence of overt and occult HBV infection among the haemodialysis (HD) patients was 7.7% and 7.3%, respectively, and only 50.7% of those who showed proof of vaccination were protected from HBV infection.

The availability of long-acting cabotegravir and rilpivirine injection combination requires some changes in service delivery of outpatient HIV clinics; it is therefore important for clinicians to know the potential number of people living with HIV (PLWH) who are interested in a long-acting antiretroviral treatment. We aimed to determine in an outpatient clinic the number of PLWH, on dolutegravir/rilpivirine, accepting a switch to an injectable long-acting antiretroviral treatment, and the reasons underlying this choice. In our single-center study, in this subset of HIV-infected patients, the main cause for refusal of a long-acting injectable regimen was the need for the administration to be done in hospital, as required in Italy, suggesting that current regulations about this aspect must be changed.

Introduction. Kasabach-Merritt phenomenon (KMP) is a rare condition associated with vascular tumors such as kaposiform hemangioendothelioma and tufted angioma; it can be life threatening, due to its consumptive coagulopathy. Thrombocytopenia and hypofibrinogenemia are characteristic of KMP, and anemia and raised d-dimer levels can also be detected. Here, we report a 7-month-old Cambodian with the condition. Case Presentation. The infant was admitted to the National Pediatric Hospital in Phnom Penh because of a mass on the right side of the neck that had been progressively enlarging. The patient had severe thrombocytopenia (8,000/µL), anemia (Hb 7.6g/dL) and reduced fibrinogen level (1.5g/L). CT scan and histology of the lesion confirmed a diagnosis of hemangioma. Kasabach-Merritt phenomenon was diagnosed, and the infant was treated with platelets and fresh frozen plasma infusions, prednisolone (2mg/kg/day) and propranolol (2.5mg/kg/day). After eight weeks of therapy, platelets raised to 102,000/µL. The infant developed Cushing’s syndrome after 6 months of treatment and prednisolone was scaled down to a maintenance dose of 0.5mg/kg/day. Fibrinogen levels went back to normal (2.14g/L) after seventeen months of treatment, and the tumor shrinked significantly. Conclusion. This case report shows that a combination of prednisolone and propranolol has been effective for KMP and kaposiform hemangioendothelioma. Timely recognition and treatment of Kasabach-Merritt phenomenon’s are essenti

Abstract Background and Aims Liver fibrosis leading to chronic liver disease (CLD) is a major cause of morbidity, mortality and health‐care expenditure worldwide. The “gold standard” for diagnosis and staging of liver fibrosis is histological analysis of liver tissue obtained by liver biopsy, an invasive procedure. Therefore, there is the need to identify noninvasive and inexpensive markers for diagnosis and staging of liver fibrosis. This study aimed at evaluating the correlation of hyaluronic acid (HA) and 25‐hydroxyvitamin D (25‐OH vitamin D) serum levels as markers of fibrosis with histologically staged and graded liver biopsies obtained from CLD patients. Methods This was a case‐control study involving 40 CLD patients requiring liver biopsies and 40 controls. Liver biopsies were staged to determine the degree of fibrosis. Serum levels of 25‐OH vitamin D and HA were determined using ELISA. Statistical analyses were performed to determine differences in HA and 25‐OH vitamin D levels between controls and patients as well as to correlate the biomarkers with the stages of fibrosis. Results CLD patients showed significant (p < 0.001) increase in the levels of AST, ALT, GGT, compared to the controls. Patients also had significantly (p < 0.001) lower serum 25‐OH vitamin D and higher HA (p < 0.001) levels compared to the controls. Additionally, 25‐OH vitamin D levels of the CLD patients were significantly different across the stages of liver fibrosis likewise serum HA levels. Furthermore, 25‐OH vitamin D levels inversely correlated with the severity of liver fibrosis. A significant negative correlation (r = −0.33, p < 0.05) between CLD patients' HA and 25‐OH vitamin D were found. Conclusion CLD patients had significantly reduced serum 25‐OH vitamin D and higher HA. Both markers correlated with the degree of liver fibrosis. These findings have major clinical translatable implication in the use of vitamin D supplementation in the management of CLD in Ghana.