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This is the case of a 77-year-old female patient with Alzheimer's disease, complicated by partial complex seizures. Levetiracetam was administered, which provoked hemolytic anemia. An extensive laboratory evaluation was suggestive of a non-immune etiology. Subsequent discontinuation of levetiracetam resulted in improvement of hemoglobin. Pancytopenia has been reported with the use of levetiracetam, but not isolated anemia. With this case report, we want to increase awareness of a potentially serious adverse reaction provoked by levetiracetam, a preferred anticonvulsive drug in the geriatric population.

Background: Major depressive disorder (MDD) is increasingly viewed as a disorder of impaired neural plasticity, yet the mechanisms underlying diverse antidepressant classes - glutamatergic (e.g., ketamine), monoaminergic (e.g., selective serotonin reuptake inhibitors (SSRIs)), and GABAergic (e.g., neurosteroids) - remain incompletely integrated. The objective of this study was to extend a pruning-plasticity model of depression and directly compare, from an identical severely pruned baseline state, the efficacy, stress resilience, durability, and relapse vulnerability of three mechanistically distinct interventions: ketamine-like targeted synaptogenesis, SSRI-like gradual refinement of existing connectivity, and neurosteroid-like tonic inhibition. Computational models offer a controlled means to compare these pathways, but prior work has typically examined single mechanisms.

Methods: We extended a pruning-plasticity model of depression by applying 95% magnitude-based synaptic elimination to overparameterized feed-forward networks trained on a four-class Gaussian classification task. From identical pruned states, three interventions were tested: ketamine-like gradient-guided regrowth (50% reinstatement) with consolidation; SSRI-like prolonged low-learning-rate training with gradual internal noise reduction; and neurosteroid-like global tonic inhibition (30% damping plus tanh activations) with brief consolidation. Outcomes included baseline accuracy, resilience to graded internal activation noise (up to σ = 2.5) plus input perturbation, and relapse vulnerability after an additional 40% pruning.

Results: All treatments restored near-ceiling performance on unchallenged inputs. Ketamine-like synaptogenesis uniquely reduced sparsity (to ~47%) and conferred superior stress resilience (extreme noise accuracy 84.5%) with near-zero relapse drop (-0.2%). SSRI-like refinement improved combined stress accuracy to 83.5% but showed limited extreme noise tolerance (44.0%) and substantial relapse vulnerability (10.8% drop). Neurosteroid-like inhibition achieved rapid combined stress recovery (97.5%) while active, but was state-dependent (decline upon removal) with poor extreme noise buffering (42.5%) and moderate relapse drop (4.1%).

Conclusions: These simulations demonstrate that antidepressants operate through mechanistically distinct routes-structural rebuilding (ketamine), gradual optimization of existing connectivity (SSRIs), or reversible dynamic stabilization (neurosteroids)-yielding trade-offs in onset speed, durability, and stress resilience. The findings support a multifaceted plasticity framework for depression and provide computational rationale for mechanism-based treatment selection and combination strategies.

Visceral leishmaniasis is a potentially life-threatening systemic parasitic infection caused by protozoa of the genus Leishmania and transmitted by sandflies. Although uncommon in Portugal, it should be considered in the differential diagnosis of prolonged fever associated with pancytopenia and hepatosplenomegaly, even in immunocompetent individuals. We report a case of a previously healthy young adult who initially presented to an urgent Family Medicine consultation in primary care, where pancytopenia was identified and prompted timely referral to secondary care. Diagnosis was confirmed by the detection of Leishmania amastigotes in bone marrow aspirate during haematological investigation. Treatment with liposomal amphotericin B resulted in complete clinical and laboratory recovery. This case highlights the importance of careful primary care assessment, recognition of red flags, and effective coordination between primary and secondary care in non-endemic settings.

Background and objective: This preliminary study aimed to evaluate the effectiveness of a novel, clinically feasible low-intensity pulsed ultrasound (LIPUS) protocol in accelerating functional orthodontic treatment using removable appliances.

Methods: Five patients (mean age: 11.10 ± 0.41 years) diagnosed with Class II Division 1 malocclusion underwent functional orthodontic treatment supplemented with the LIPUS, US PRO 2000™ 2nd Edition device (Current Solutions, Austin, Texas, United States). Ultrasound stimulation was applied twice weekly during the first month, once every two weeks during the second month, and once every three weeks thereafter until completion of active treatment. The primary outcomes assessed were the duration of active treatment and dentoskeletal changes.

Results: The mean duration of active treatment was 170.80 ± 19.76 days. Significant sagittal skeletal improvements were observed, including forward mandibular repositioning, reflected by an increase in the SNB angle "the Sella-Nasion plane to Point B angle" (mean difference (MD) = +1.32°), accompanied by a slight reduction in the SNA angle "the Sella-Nasion plane to Point A angle" (MD = -0.54°), a decrease in the ANB angle "the difference between SNA and SNB angles" (MD = -1.98°), an increase in the SNPog angle "the Sella-Nasion plane to Point Pog angle" (MD = +0.94°) further confirmed anterior mandibular displacement. Vertical skeletal parameters remained largely stable, with no evidence of adverse vertical effects. Dentoalveolar changes included controlled retroclination of the maxillary incisors, proclination of the mandibular incisors, and clinically relevant reductions in overjet (MD = -4.38 mm) and overbite (MD = -1.06 mm).

Conclusions: The modified LIPUS protocol produced favorable skeletal and dentoalveolar effects while maintaining vertical stability, suggesting it may represent a practical alternative to conventional daily ultrasound application during functional orthodontic treatment.

Introduction Patients with inflammatory bowel disease (IBD), particularly those receiving biologic therapies, are at increased risk of infections due to immunosuppression. Vaccinations play a vital role in reducing this risk, yet adherence to immunisation schedules remains suboptimal. This audit aimed to assess vaccination coverage among IBD patients on biologic therapies at Our Lady's Hospital, Navan, Ireland, and to identify areas for improvement. Aim and objectives The primary aim was to evaluate adherence to recommended immunisation schedules for IBD patients on biologics. Specific objectives were to assess uptake of vaccines including tetanus, diphtheria, and pertussis (Tdap), meningococcal, measles, mumps, and rubella (MMR), severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), influenza, herpes zoster, human papillomavirus (HPV), hepatitis B virus (HBV), hepatitis A virus (HAV), and varicella-zoster virus (VZV), to identify gaps in coverage, and to propose interventions to improve adherence. Methods A retrospective review of 24 patients with IBD receiving regular biologic infusions at the hospital's day ward was conducted. Data collected included demographics, type of IBD, biologic therapy details, and vaccination status. The assessment was based on the European Crohn's and Colitis Organisation (ECCO)-aligned immunisation recommendations. Immunity to VZV was accepted based on documented infection history or serological confirmation. Results Among the 24 patients reviewed, 14 had ulcerative colitis and 10 had Crohn's disease. Sixteen were male and eight female. Twenty patients were on infliximab and four on vedolizumab. Vaccination coverage was generally low: Tdap (5/11, 45.5%), meningococcal (1/4, 25%), MMR (1/2, 50%), SARS-CoV-2 (0/4, 0%), influenza (1/10, 10%), HPV (1/3 eligible females, 33.3%), HBV (2/15, 13.3%), and HAV (0/4, 0%). All six patients with VZV data showed immunity. No documentation was available for herpes zoster vaccination. Conclusion The audit revealed significant gaps in adherence to vaccination guidelines among IBD patients receiving biologics. These findings highlight the need for systematic interventions to improve vaccine uptake, such as routine immunisation status reviews during clinic visits, improved documentation practices, patient education on vaccine safety and necessity, and stronger collaboration between gastroenterologists and primary care providers. Educational materials should be provided during clinic or infusion appointments to address vaccine hesitancy and misinformation. Implementing these changes could reduce the burden of vaccine-preventable diseases in this vulnerable population.

Background Chronic diseases are emerging as a growing concern in Saudi Arabia, contributing to increased morbidity, mortality, healthcare costs, and reduced health-related quality of life (HRQoL). HRQoL is influenced by disease and treatment and is commonly assessed using the EuroQol five-dimensions five-levels (EQ-5D-5L) instrument. Assessing HRQoL helps in identifying areas that can be improved, ultimately leading to enhanced patient care and outcomes. Objective The study aims to evaluate the HRQoL among patients with chronic diseases and to assess the association of sociodemographic, clinical, lifestyle, and disease-related factors with HRQoL in Jeddah, Saudi Arabia. Methods A cross-sectional, multicenter study was conducted. Data were obtained using either interview-administered or self-administered questionnaires. The first section included patients' specific variables, while the second section consisted of the EQ-5D instrument. Results The study included 503 participants. The mean age of the participants was 44.3±13.8 years. The mean EQ-5D index score was 0.84±0.23, and the mean EQ-visual analogue scale (EQ-VAS) score was 77.22±20.60, indicating a generally good level of HRQoL at the population level. A strong relationship was observed between increasing chronic disease burden (multimorbidity) and poorer HRQoL across the overall sample, whereas the mean disease duration was not significantly related to HRQoL. Conclusion Patients with chronic diseases in Jeddah reported moderate to good HRQoL, the overall mean EQ-5D index score was 0.84±0.23, and the mean EQ-VAS score was 77.22±20.60. More than half of the participants experienced impaired health, especially in pain and psychological well-being. Multimorbidity was the most significant cause of impaired HRQoL, whereas the disease duration was not significantly related to HRQoL.

Chronic obstructive pulmonary disease (COPD) is a condition that inevitably leads to airflow limitation. COPD is among the leading causes of increased mortality and morbidity worldwide. A non-invasive and non-pharmacological approach is rehabilitation training, where the patient follows an active program to stimulate the limb and respiratory muscles. Training involves a constant increase in workloads throughout the rehabilitation process. A fundamental concept absent from the literature is that of including training sessions with reduced loads and periods of "unloading" intensity within the rehabilitation program. Without adequate recovery and rest between sessions, the patient may lack the resources necessary to tackle a subsequent demanding rehabilitation session. This situation could lead to the onset of overtraining syndrome (OTS), where the patient experiences an unexplained decline in performance. The article reviews the muscular adaptation of COPD patients and the planned rehabilitation and emphasizes the concept that clinicians should structure the rehabilitation training program not in a linear fashion (constantly increasing loads), but in a wave-like fashion (scheduling some sessions with decreased loads). This organization could benefit the patient's performance, reducing the risk of OTS.

Foreign body (FB) ingestion is common in children below six years of age. Most FBs are passed spontaneously through the gastrointestinal tract. However, multiple magnetic ingestion increases the risk of intestinal obstruction and perforation via magnetic attraction through bowel walls. We report a case of a four-year-old boy who came with a delayed presentation of multiple magnet ingestion over a year before presentation to the emergency department. The diagnosis was overlooked in the first presentation by the primary health care doctor, and the FBs in the X-ray were interpreted as being an artifact. This case underscores the need for increased clinician awareness of having a high index of suspicion of FB ingestion in pediatric cases presenting with prolonged vague abdominal pain and to be vigilant upon reviewing radiological images.

Drug reaction with eosinophilia and systemic symptoms (DRESS), also known as drug-induced hypersensitivity syndrome (DIHS), is a severe, multiorgan, delayed hypersensitivity reaction with significant morbidity. Diagnosis is often delayed due to its mimicry of other conditions. We present the case of a 69-year-old Hispanic male with hypertension and stage two chronic kidney disease who developed trigeminal neuralgia and was started on carbamazepine. Approximately seven weeks later, he presented with a generalized rash, angioedema, and mucosal swelling, initially attributed to his concurrent lisinopril therapy. Despite discontinuation of lisinopril and treatment with corticosteroids and antihistamines, his condition progressed with new systemic symptoms, including paresthesia, dysgeusia, polydipsia, polyuria, and weight loss. The progression of symptoms despite this intervention was the pivotal diagnostic clue. Hospital admission revealed marked eosinophilia (8.9 percent), mild transaminitis, and a diffuse erythrodermic rash involving more than 90 percent of his body surface area. A diagnosis of probable DRESS syndrome (RegiSCAR score six) secondary to carbamazepine was made. Immediate discontinuation of carbamazepine and initiation of intravenous corticosteroids led to rapid clinical and laboratory improvement. He was discharged on a prolonged oral steroid taper with complete resolution at follow-up. This case underscores the critical importance of considering DRESS in any patient with a rash and systemic symptoms occurring two to eight weeks after initiation of a high-risk drug, even in the presence of other potential culprits. It highlights that clinical progression despite withdrawal of one suspected agent should prompt urgent re-evaluation for an alternative etiology, such as DRESS.