Introduction: Accurate preoperative localization is essential for the surgical management of primary hyperparathyroidism (PHPT). Although ultrasound, technetium-99m sestamibi scintigraphy, and 4D-CT provide high localization rates, a subset of patients have non-localizing or discordant imaging. Selective parathyroid venous sampling (PVS) is an invasive adjunct that measures regional parathyroid hormone (PTH) gradients to aid localization in challenging cases. We present a threepatient case series demonstrating the utility of PVS in diagnostically complex PHPT. Cases: We retrospectively reviewed three female patients (ages 44–63) with biochemically confirmed PHPT who underwent selective PVS following negative or discordant imaging. Venous sampling was performed via femoral access with catheterization of bilateral internal jugular, brachiocephalic, and bilateral thyroidal veins. PTH levels were measured at each site and compared to peripheral levels to identify regional gradients. Surgical findings, intraoperative parathyroid hormone monitoring (IOPTH), histopathology, and postoperative biochemical outcomes were recorded. All patients had non-localizing or discordant preoperative imaging (USG, sestamibi, 4D-CT). PVS identified significant PTH gradients, guiding focused parathyroidectomy. IOPTH monitoring confirmed successful excision in all operated patients. Histopathology confirmed parathyroid adenoma in two cases; in the third case, the parathyroid tissue was identified within the thyroid gland. Postoperative PTH levels suppressed (range 0.79–1.48 pg/mL) in keeping with successful parathyroidectomy. Conclusion PVS effectively lateralized disease in imaging-negative PHPT and directly guided surgical management. When conventional imaging fails, PVS combined with intraoperative PTH monitoring enables targeted surgery and favorable biochemical outcomes.
Humans

Introduction: Hemorrhagic suprarenal masses presenting with hypertensive emergency pose a significant diagnostic challenge, particularly when biochemical and radiological findings are inconclusive. The clinical presentation may mimic catecholamine-secreting tumors, necessitating consideration of a broad differential diagnosis, including pheochromocytoma, adrenocortical carcinoma, retroperitoneal hemorrhage, and hematological-related extramedullary lesions. Accurate diagnosis is essential, as management strategies differ significantly. Case: We report a 48-year-old male smoker with no known prior medical illness who presented with sudden left-sided chest pain radiating to the epigastrium, associated with vomiting. On arrival, he was markedly hypertensive (207/131 mmHg). He reported a 1-year history of paroxysmal palpitations, headaches, migraines, and intermittent diaphoresis. Computed tomography angiography excluded aortic dissection but demonstrated a left retroperitoneal hemorrhage with non-visualization of the adrenal gland, suggestive of adrenal or tumor-related hemorrhage. He was initially managed empirically as a pheochromocytoma while undergoing biochemical evaluation; however, urinary metanephrines were only mildly elevated. Repeat imaging demonstrated interval enlargement of a non-enhancing suprarenal mass, raising concern for tumor-related hemorrhage. Subsequent ultrasonography, however, favored a liquefied hematoma, and percutaneous drainage yielded 750 mL of sanguineous fluid, resulting in marked clinical improvement. Notably, an elevated hematocrit prompted further evaluation for erythrocytosis. Subsequent testing confirmed JAK2 mutation-positive polycythemia rubra vera, providing a unifying explanation for both the erythrocytosis and spontaneous adrenal hemorrhage. The patient was commenced on hydroxyurea and referred for hematology follow-up. Conclusion Adrenal hemorrhage may closely mimic pheochromocytoma in hypertensive emergencies. A systematic, multidisciplinary approach integrating clinical, biochemical, and imaging findings is essential to avoid misdiagnosis and guide appropriate management, particularly in patients with underlying hematological disorders.
Hypertensive Crisis ; Pheochromocytoma ; Polycythemia Vera ; Hematoma

Introduction: Primary adrenal lymphoma (PAL) is a rare extranodal lymphoma, accounting for less than 1% of cases. It often presents with non-specific constitutional symptoms and features of adrenal insufficiency. The absence of pathognomonic findings frequently leads to delayed diagnosis, by which time the disease is often advanced, contributing to poor prognosis. Case: A 59-year-old male with type 2 diabetes mellitus and previously treated pulmonary tuberculosis presented with 1 month of lethargy, anorexia, weight loss, and abdominal pain. He was cachectic but hemodynamically stable (BP 120/81 mmHg; glucose 5.1 mmol/L), with otherwise unremarkable systemic examination. Laboratory evaluation revealed hyponatremia (120 mmol/L), hyperkalemia (6.0 mmol/L), and severe hypercalcemia (4.4 mmol/L). A short Synacthen test confirmed adrenal insufficiency. Computed tomography demonstrated marked bilateral adrenal enlargement with bulky masses (8.9 × 8.7 × 8.7 cm right; 9.9 × 7.6 × 10.2 cm left), suggestive of malignant infiltration. Adrenal protocol imaging revealed indeterminate lesions with attenuation >40 Hounsfield Unit and relative washout <40%. Ultrasound-guided biopsy of the right adrenal gland was performed. The patient was discharged on hydrocortisone replacement with plans for early follow-up. One week later, he presented again in adrenal crisis with severe hypoglycemia (1.1 mmol/L) and cardiovascular collapse. Despite resuscitative efforts, he succumbed. Histopathology subsequently confirmed diffuse large B-cell lymphoma, activated B-cell subtype, consistent with PAL. Conclusion This case highlights the diagnostic pitfalls of PAL, particularly when constitutional symptoms mimic chronic infections such as tuberculosis. It underscores the need for high clinical suspicion in patients with bilateral adrenal masses and adrenal insufficiency. Early recognition, adequate steroid replacement including mineralocorticoid therapy, and prompt tissue diagnosis are critical to prevent rapid deterioration and improve outcomes.
Lymphoma

BACKGROUND: Spinal cord injury (SCI) survivors often experience constipation, which contributes to a reduced sense of well-being and a lower quality of life. Acupressure offers a non-pharmacological and non-invasive alternative therapy for treating constipation. OBJECTIVE: This study examined the effects of home-based acupressure on constipation and subjective well-being among SCI survivors. DESIGN, SETTING, PARTICIPANTS AND INTERVENTIONS: This randomized controlled trial randomly assigned 80 adults from Hong Kong with SCI to two study groups. Using a video demonstration filmed by a registered traditional Chinese medicine practitioner, the intervention group performed home-based acupressure (self-administered or caregiver-assisted) twice daily, 15 min/session, for 10 consecutive days. The control group performed manual light touching of the abdomen with the same frequency and duration as the intervention group. Both groups received defecation education through a structured booklet. MAIN OUTCOMES MEASURES: The primary outcome was constipation severity. Secondary outcomes included bowel habits, psychological well-being, and quality of life. Focus group interviews were conducted after the intervention to collect subjective feedback from participants. RESULTS: Significant group-by-time interaction effects on constipation severity (P = 0.005) and quality of life (P = 0.001) revealed that home-based acupressure produced better results than the control. These treatment effects persisted at the one-month follow-up and continued to have a large effect size (Cohen's d > 0.8). Compared to the control group, the acupressure group also had improvements in anxiety (Cohen's d = 0.69) and depression (Cohen's d = 0.72) at the end of the intervention period. Three qualitative categories were identified from the focus group interviews: improvements in bowel function and management; reduced psychological distress following relief from constipation; and acceptability of home-based acupressure. CONCLUSION: Acupressure effectively relieves constipation, enhances psychological well-being, and improves quality of life in people with SCI. These data provide novel evidence supporting the use of home-based acupressure as an acceptable and effective therapy for treating constipation after SCI. TRIAL REGISTRATION ClinicalTrials.gov (NCT05558657). Please cite this article as: Li MQ, Li Y, Lam W, Yeung WF, Ho YS, Li JY, Sun TC, Yuen S, Hu YL, Yorke J. Home-based acupressure for managing constipation and subjective well-being in spinal cord injury survivors: A randomized controlled trial. J Integr Med. 2025; 23(6):660-669.
Humans ; Acupressure/methods* ; Constipation/psychology* ; Male ; Female ; Spinal Cord Injuries/complications* ; Middle Aged ; Adult ; Quality of Life ; Aged

Objectives: Osteoblast is known to regulate hematopoiesis according to preclinical studies but the causal rela tionship in human remains uncertain. We aimed to evaluate causal relationships of bone mineral density (BMD) with blood cell traits using genetic data. Methods: Summary statistics from the largest available genome-wide association study were retrieved for total body BMD (TBBMD), lumbar spine BMD (LSBMD), femoral neck BMD (FNBMD) and 29 blood cell traits including red blood cell, white blood cell and platelet-related traits. Using two-sample Mendelian randomization (MR) approach, inverse-variance weighted method was adopted as main univariable MR analysis. Multivariable MR (MVMR) analysis was conducted to evaluate whether the casual effect is independent of confounders. Results: BMD was positively associated with reticulocyte-related traits, including high light scatter reticulocyte count and percentage, immature reticulocyte fraction, reticulocyte count and percentage, with causal effect estimate (beta) ranging from 0.023 to 0.064. Conversely, inverse association of BMD with hematocrit, hemo globin, and red blood cell count was observed, with beta ranging from − 0.038 to − 0.019. The association remained significant in MVMR analysis after adjustment for confounders. For white blood cells, BMD was inversely associated with neutrophil count (beta: 0.029 to − 0.019) and white blood cell count (beta: 0.024 to − 0.02). Results across TBBMD, LSBMD, and FNBMD were consistent. Conclusions This study suggested bone metabolism had a causal effect on hematopoietic system in humans. Its causal effect on red blood cell traits was independent of confounders. Further studies on how improving bone health can reduce risk of hematological disorders are warranted.

BACKGROUND:This study aimed to evaluate the discriminatory performance of 11 vital sign-based early warning scores(EWSs)and three shock indices in early sepsis prediction in the emergency department(ED). METHODS:We performed a retrospective study on consecutive adult patients with an infection over 3 months in a public ED in Hong Kong.The primary outcome was sepsis(Sepsis-3 definition)within 48 h of ED presentation.Using c-statistics and the DeLong test,we compared 11 EWSs,including the National Early Warning Score 2(NEWS2),Modified Early Warning Score,and Worthing Physiological Scoring System(WPS),etc.,and three shock indices(the shock index[SI],modified shock index[MSI],and diastolic shock index[DSI]),with Systemic Inflammatory Response Syndrome(SIRS)and quick Sequential Organ Failure Assessment(qSOFA)in predicting the primary outcome,intensive care unit admission,and mortality at different time points. RESULTS:We analyzed 601 patients,of whom 166(27.6%)developed sepsis.NEWS2 had the highest point estimate(area under the receiver operating characteristic curve[AUROC]0.75,95%CI 0.70-0.79)and was significantly better than SIRS,qSOFA,other EWSs and shock indices,except WPS,at predicting the primary outcome.However,the pooled sensitivity and specificity of NEWS2≥5 for the prediction of sepsis were 0.45(95%CI 0.37-0.52)and 0.88(95%CI 0.85-0.91),respectively.The discriminatory performance of all EWSs and shock indices declined when used to predict mortality at a more remote time point. CONCLUSION:NEWS2 compared favorably with other EWSs and shock indices in early sepsis prediction but its low sensitivity at the usual cut-off point requires further modification for sepsis screening.

A biosynthetic gene cluster for the bioactive fungal sesterterpenoids variecolin ( 1) and variecolactone ( 2) was identified in Aspergillus aculeatus ATCC 16872. Heterologous production of 1 and 2 was achieved in Aspergillus oryzae by expressing the sesterterpene synthase VrcA and the cytochrome P450 VrcB. Intriguingly, the replacement of VrcB with homologous P450s from other fungal terpenoid pathways yielded three new variecolin analogues ( 5- 7). Analysis of the compounds' anticancer activity in vitro and in vivo revealed that although 5 and 1 had comparable activities, 5 was associated with significantly reduced toxic side effects in cancer-bearing mice, indicating its potentially broader therapeutic window. Our study describes the first tests of variecolin and its analogues in animals and demonstrates the utility of synthetic biology for creating molecules with improved biological activities.

BACKGROUND:This study aimed to evaluate the discriminatory performance of 11 vital sign-based early warning scores(EWSs)and three shock indices in early sepsis prediction in the emergency department(ED). METHODS:We performed a retrospective study on consecutive adult patients with an infection over 3 months in a public ED in Hong Kong.The primary outcome was sepsis(Sepsis-3 definition)within 48 h of ED presentation.Using c-statistics and the DeLong test,we compared 11 EWSs,including the National Early Warning Score 2(NEWS2),Modified Early Warning Score,and Worthing Physiological Scoring System(WPS),etc.,and three shock indices(the shock index[SI],modified shock index[MSI],and diastolic shock index[DSI]),with Systemic Inflammatory Response Syndrome(SIRS)and quick Sequential Organ Failure Assessment(qSOFA)in predicting the primary outcome,intensive care unit admission,and mortality at different time points. RESULTS:We analyzed 601 patients,of whom 166(27.6%)developed sepsis.NEWS2 had the highest point estimate(area under the receiver operating characteristic curve[AUROC]0.75,95%CI 0.70-0.79)and was significantly better than SIRS,qSOFA,other EWSs and shock indices,except WPS,at predicting the primary outcome.However,the pooled sensitivity and specificity of NEWS2≥5 for the prediction of sepsis were 0.45(95%CI 0.37-0.52)and 0.88(95%CI 0.85-0.91),respectively.The discriminatory performance of all EWSs and shock indices declined when used to predict mortality at a more remote time point. CONCLUSION:NEWS2 compared favorably with other EWSs and shock indices in early sepsis prediction but its low sensitivity at the usual cut-off point requires further modification for sepsis screening.

BACKGROUND:This study aimed to evaluate the discriminatory performance of 11 vital sign-based early warning scores(EWSs)and three shock indices in early sepsis prediction in the emergency department(ED). METHODS:We performed a retrospective study on consecutive adult patients with an infection over 3 months in a public ED in Hong Kong.The primary outcome was sepsis(Sepsis-3 definition)within 48 h of ED presentation.Using c-statistics and the DeLong test,we compared 11 EWSs,including the National Early Warning Score 2(NEWS2),Modified Early Warning Score,and Worthing Physiological Scoring System(WPS),etc.,and three shock indices(the shock index[SI],modified shock index[MSI],and diastolic shock index[DSI]),with Systemic Inflammatory Response Syndrome(SIRS)and quick Sequential Organ Failure Assessment(qSOFA)in predicting the primary outcome,intensive care unit admission,and mortality at different time points. RESULTS:We analyzed 601 patients,of whom 166(27.6%)developed sepsis.NEWS2 had the highest point estimate(area under the receiver operating characteristic curve[AUROC]0.75,95%CI 0.70-0.79)and was significantly better than SIRS,qSOFA,other EWSs and shock indices,except WPS,at predicting the primary outcome.However,the pooled sensitivity and specificity of NEWS2≥5 for the prediction of sepsis were 0.45(95%CI 0.37-0.52)and 0.88(95%CI 0.85-0.91),respectively.The discriminatory performance of all EWSs and shock indices declined when used to predict mortality at a more remote time point. CONCLUSION:NEWS2 compared favorably with other EWSs and shock indices in early sepsis prediction but its low sensitivity at the usual cut-off point requires further modification for sepsis screening.