Annals of Medicine and Surgery最新文献

Breast cancer, as the most frequently diagnosed malignancy in women, continues to challenge clinicians due to its heterogeneity and variable clinical outcomes. As traditional diagnostic and prognostic markers often fall short in fully capturing disease dynamics, there is growing interest in the role of hematological biomarkers, particularly platelet indices, as accessible and cost-effective tools in cancer management. Recent evidence suggests that thrombopoiesis is not merely a bystander process but actively contributes to tumorigenesis through complex interactions with cancer cells and the tumor microenvironment. Platelets influence breast cancer progression by promoting angiogenesis, shielding circulating tumor cells from immune clearance, and facilitating metastasis. These tumor-promoting functions are reflected in measurable changes in platelet indices, such as platelet count, mean platelet volume, platelet distribution width, and plateletcrit. Abnormal values of these indices have been associated with advanced tumor stage, lymph node involvement, and reduced survival, highlighting their potential as biomarkers for disease monitoring and prognostication. Nevertheless, with further validation and integration into multimodal diagnostic frameworks, platelet-based biomarkers may enhance precision in breast cancer risk stratification and treatment planning. This review underscores the need for continued investigation into the interplay between thrombopoiesis and tumorigenesis and the translational potential of platelet indices in breast cancer care.

Background: Tuberculous pleural effusion (TPE) is a significant global health problem, particularly in high-prevalence regions such as India. Early diagnosis is crucial for effective treatment of this condition. Medical thoracoscopy offers a superior diagnostic yield compared with traditional methods. This study aimed to evaluate various thoracoscopic appearances in TPE, their diagnostic utility, and their correlation with microbiological and histopathological findings.

Materials and methods: This hospital-based prospective observational cross-sectional study was conducted at a tertiary care teaching hospital in eastern India, from 2023 to 2024. One hundred and twenty-one patients with suspected TPE underwent thoracoscopy, and the findings were classified into 11 categories. Pleural biopsies were examined, and the data were analyzed.

Results: One hundred and three patients were confirmed to have TPE. The most common thoracoscopic findings were easily peelable pleura and adhesions. Significant associations (P<0.05) were found between thoracoscopic findings of pustules and positive Cartridge-Based Nucleic Acid Amplification Test results, as well as between easily peelable pleura, multiple variable-sized nodules, and positive mycobacterial culture. Pustules, sago grain nodules, and a few discrete nodules were the most specific findings, with a high positive predictive value. Normal-looking pleura were also observed in TPE. Easily peelable and hard-to-peel pleura were novel findings in our study.

Conclusion: Medical thoracoscopy is a valuable diagnostic tool for TPE exhibiting various gross pleural appearances, and targeted biopsy of various lesions increases the yield of microbiological and histopathological analyses. Findings such as pustules, sago grain nodules, and a few discrete nodules are highly specific for TPE, allowing for the early initiation of antitubercular therapy even before microbiological confirmation.

Pharmacogenomics is now an essential part of precision medicine, as it describes how genetic differences at the individual level influence drug responses. Its combination enables a transition from trial-and-error prescriptions to predictive, genotype-directed treatment, thereby enhancing the safety and accuracy of treatment. Rapid genomic testing, AI-driven prediction of drug-gene interactions, and clinical decision-support systems have advanced, increasing their uptake in psychiatry, cardiology, and oncology. New methods, such as polygenic pharmacogenomic scoring and population-specific genomic maps, are even more personalized. Together, these advances make pharmacogenomics a central figure with the potential to shape the future of personalized, effective, and innovative healthcare.

Background: Cryptogenic stroke (CS) accounts for a substantial proportion of ischemic strokes, with atrial fibrillation (AF) often identified as the underlying cause. In countries with low-resource settings like Pakistan, limited access to extended cardiac monitoring delays AF detection, increasing the risk of recurrent stroke.

Objective: To determine the incidence and predictors of recurrent ischemic stroke in patients initially diagnosed with CS and later diagnosed with AF at a tertiary care hospital in Pakistan.

Methods: A retrospective cohort study was conducted at tertiary care Hospital, from January 2018 to December 2023. Adult patients with CS and a subsequent diagnosis of AF within 12 months were included. Data on demographics, diagnostic modality, echocardiography, anticoagulation adherence, and outcomes were collected. Cox regression was used to identify independent predictors of recurrent stroke.

Results: Out of 406 patients with CS, 109 (26.8%) were later diagnosed with AF. Recurrent ischemic stroke occurred in 32 patients (29.4%) over a median follow-up of 13.8 months. Only 11 of the recurrent cases (34.4%) were on anticoagulation therapy at the time of recurrence. Multivariate analysis identified age >65 years (HR: 2.21; 95% CI: 1.18-4.14), delayed AF detection beyond 6 months (HR: 2.58; 95% CI: 1.36-4.91), non-adherence to anticoagulation (HR: 3.44; 95% CI: 1.88-6.27), and left atrial enlargement (HR: 2.03; 95% CI: 1.15-3.57) as independent predictors of recurrence. Mortality (18.8%) and functional disability (mRS >3 in 59.3%) were significantly higher in the recurrence group.

Conclusion: Delayed AF detection and poor anticoagulation adherence significantly increase the risk of recurrent stroke in CS-AF patients. Prolonged cardiac monitoring and improved access to anticoagulants, particularly NOACs, are essential to reduce recurrent stroke burden in low-resource settings.

Pediatric leukemia, primarily comprising acute lymphoblastic leukemia (ALL) and acute myeloid leukemia, represents approximately 30% of childhood cancers worldwide. Over the past decade, advances in molecular and genetic profiling, including next-generation sequencing and minimal residual disease monitoring, have refined risk stratification and enabled individualized treatment strategies. Integrating these approaches into clinical practice has improved survival rates, particularly for high-risk patients, by guiding therapy intensity and informing targeted interventions. Targeted therapies, such as tyrosine kinase inhibitors for Philadelphia chromosome-positive ALL, Chimeric Antigen Receptor T cell therapy for relapsed or refractory cases, and monoclonal antibodies like blinatumomab and inotuzumab ozogamicin, have transformed treatment outcomes while reducing chemotherapy-related toxicity. Despite these advances, challenges remain, including the development of therapy resistance (e.g., BCR-ABL1 and FLT3 mutations) and long-term adverse effects such as cardiotoxicity and secondary malignancies. This narrative review summarizes recent innovations in risk assessment and targeted therapies, highlights current challenges, and discusses future directions to optimize personalized pediatric leukemia care.

Early-career neurosurgeon training has not yet fully recovered from the decrease in operative exposure that began during the early COVID era. Elective case cancellations, redeployment, and limited staff access to operating rooms reduced the chances of graduated responsibility across a variety of settings and widened existing gaps in the global workforce. Much of this was addressed by numerous programs that reinforced the application of simulation using inexpensive models and virtual environments, helping keep skills developing in the absence of practical experience. It was reported that simulator hours and trainee confidence improved, although practical surgery was needed to consolidate them. Online instruction, video-conferencing dissections, and organized mentoring also assisted learning, particularly in areas where training facilities are not evenly distributed. New interest in digital tools and early uses of artificial intelligence were indicative of a larger project to create flexible training systems. Developing a systematic roadmap that brings together case-log surveillance, simulation, video assessment, stratified mentorship, and partners in networks can help stabilize and modernize early career neurosurgical education.

Background: Mpox (formerly monkeypox) has emerged as a significant public health challenge in sub-Saharan Africa. The recent confirmation of Mpox cases in the Moyale region of Ethiopia highlights the urgent need for robust surveillance and response mechanisms in the Horn of Africa.

Policy gaps: While Ethiopia has a strong history of epidemic control, specific gaps remain in diagnostic capacity for orthopoxviruses in remote border regions, and there is a need to adapt current strategies to resource-limited settings.

Recommendations: This editorial advocates for integrating Mpox detection into Ethiopia's existing Polio and Measles surveillance networks to maximize cost-effectiveness. We recommend targeted vaccination strategies for high-risk healthcare workers rather than broad mandates, implementing community-based surveillance through Health Extension Workers, and ensuring ethical risk communication to prevent stigma.

Conclusion: Immediate coordination between the Ethiopian Ministry of Health, Africa CDC, and WHO is required to contain the spread and prevent a broader regional outbreak.

Introduction and importance: Perioperative management of granulosa cell tumors (GCTs) becomes significantly more complex in patients with neuromuscular conditions such as myasthenia gravis (MG). Herein, we describe a case of surgically managed stage I GCT in a woman with MG and hypothyroidism. This case is unique because the patient developed postoperative cardiac instability attributed to abrupt estrogen withdrawal after oophorectomy, which resolved rapidly with estrogen replacement.

Case presentation: A 38-year-old woman (gravida 0, para 0), married for 8 years, and who is a known case of MG and hypothyroidism presented to our center with a 2-week history of dull lower abdominal pain, intensifying during menstruation. The MRI raised a suspicion of malignancy after which the patient was taken for comprehensive staging surgery in which abdominal hysterectomy and bilateral salpingo-oophorectomy were performed. On post-op day 3, she developed palpitations, chest discomfort, progressive fatigue, and drowsiness. The patient was successfully managed with oral estradiol and discharged on post-op day 9.

Clinical discussion: From a gynecologic oncologic perspective, comprehensive surgical staging remains the standard of care for apparent early-stage AGCT. In our case, the patient's co-morbid MG added significant complexity to the perioperative planning. The cardiac arrhythmia developed as a result of sudden withdrawal of estrogen due to oophorectomy was successfully managed with oral estradiol, and the patient was successfully discharged.

Conclusion: Prompt recognition of post-oophorectomy hormonal withdrawal and judicious use of estrogen therapy may be essential in mitigating postoperative complications in hormone-sensitive tumors like AGCTs.

Background: Acute heart failure (AHF) remains a major cause of morbidity and mortality, especially in hospitalized patients. Inotropic agents like dobutamine have long been used for hemodynamic support, yet concerns over adverse effects such as arrhythmias and increased myocardial oxygen consumption limit their safety. Levosimendan, a calcium sensitizer with vasodilatory properties, offers a potential alternative. This meta-analysis was conducted to evaluate the comparative safety and efficacy of levosimendan versus dobutamine in patients with AHF.

Method: A systematic review and meta-analysis was conducted following PRISMA and AMSTAR 2 guidelines. Major databases including PubMed, Cochrane, Embase, and ScienceDirect were searched up to July 2025 without any language restrictions. Sixteen studies including 15 randomized controlled trials and 1 cohort study were evaluated for this study. Outcomes were pooled using a random effects model. Meta-regression was performed to assess the influence of baseline covariates.

Result: In the pooled analysis of 16 studies, levosimendan showed a statistically significant reduction in mortality (RR: 0.59; P = 0.0009) compared to dobutamine. While systolic blood pressure and diastolic blood pressure remained comparable, levosimendan led to a marked reduction in pulmonary capillary wedge pressure and improved cardiac index, left ventricular ejection fraction, and mixed venous oxygen saturation. B-type natriuretic peptide and IL-6 levels also declined significantly in the levosimendan group. Adverse events such as hypotension and atrial fibrillation were slightly more frequent with levosimendan, while tachycardia and ischemic events were more common with dobutamine. Overall adverse event rates were similar.

Conclusion: Levosimendan demonstrates favorable effects on mortality and key hemodynamic parameters in patients with AHF, especially those on β-blockers or with impaired left ventricular function. Although certain adverse effects like hypotension were more frequent, the overall safety profile remained comparable to dobutamine. These findings suggest levosimendan as a safer and more effective alternative in selected high-risk heart failure populations.