An 8-year-old girl with chronic immune thrombocytopenic purpura treated with eltrombopag presented with lactic acidosis and severe hyperammonemic encephalopathy necessitating hemofiltration. Genetic metabolic disorders associated with hyperammonemia were excluded. Despite standard dosing, supratherapeutic plasma levels of eltrombopag were found, suggesting an adverse drug effect due to drug accumulation. Awareness of hyperammonemia as adverse reaction to eltrombopag is warranted. Close monitoring of transaminases is required in children and therapeutic drug monitoring could aid in tailoring effective treatment doses for children to mitigate risk in populations that are more susceptible to complications.

Compound muscle action potential (CMAP) recording provides an objective electrophysiological assessment of facial nerve function after injury. In rodent models, vibrissal CMAPs serve as quantitative surrogates of facial nerve integrity; however, practical descriptions of CMAP recording setups using widely available systems remain limited. In this study, we detail a practical and reproducible method for recording vibrissal CMAPs following direct stimulation of the facial nerve trunk in rats, using a BIOPAC-based system. CMAPs were recorded before and after unilateral facial nerve crush injury, followed by transection and epineural repair. Direct nerve trunk stimulation reliably elicited stable CMAP waveforms and supramaximal stimulation produced consistent responses suitable for longitudinal assessment. Baseline CMAP amplitudes were comparable to previously reported values. After facial nerve injury, CMAPs on the injured side were absent at 1 week, reappeared at 2 weeks, and increased further by 4 weeks. Because absolute CMAP amplitudes varied across recording sessions despite intact contralateral nerves, functional recovery was evaluated using left/right amplitude ratios. Single-peak CMAP amplitude was used to minimize waveform variability and stimulus-related artifacts. This method provides a straightforward and accessible approach for the electrophysiological assessment of facial nerve injury and recovery in experimental rodent models.

Congenital divided nevus of the eyelids is a rare form of melanocytic nevus which involves contiguous portions of the upper and lower eyelid margins unilaterally, hence the term ‘kissing nevus’. While usually present at birth, these nevi may also appear later in life. When the mass enlarges, it may cause cosmetic issues to the patient, as well as functional problems such as mechanical ptosis, ectropion, and epiphora.

We report three cases of congenital divided nevus of the eyelids, all presenting with unilateral upper and lower hyperpigmented lid masses since birth. The first case had an upper lid mass measuring 11 mm x 19 mm, and a lower lid mass measuring 55 mm x 47 mm, with both masses extending into the palpebral conjunctiva, and causing severe ptosis and corneal neovascularization due to chronic irritation. The second case presented with hyperpigmented masses at the lateral third of the right upper eyelid measuring 8 mm x 17 mm and of the lower eyelid measuring 9 mm x 15 mm on the lower lid with lashes growing through the masses. There was extension of the mass into the palpebral conjunctiva. The third case presented with a 23 x 18 mm hyperpigmented, well-circumscribed, verrucated mass at the medial half of the upper eyelid crossing the eyelid margin, and a 15 x 13 mm lesion at the medial third of the lower lid with the same characteristics, with small crusty lesions and clotted blood. All three patients underwent excision biopsy with lid reconstruction using full thickness skin grafts from the supraclavicular area. Six months postoperatively, the first case underwent a repeat full thickness skin graft due to graft contraction, and also received two sessions of fractional carbon dioxide (CO2 ) laser, two sessions of intralesional triamcinolone injections, and silicone gel application with further improvement of graft healing and scarring. The second case also underwent two sessions of intralesional steroid injection for scar management. During follow-up, which spanned 13 months for the first case, 10 months for the second case, and two months for the third case, improved functional and cosmetic outcomes were observed.

This case series highlights the outcomes of the most common surgical technique done for congenital divided nevi of the eyelids. Congenital divided nevi are usually diagnosed clinically and malignant degeneration is rare, hence lid reconstruction may be done without frozen section. The cases in the series were treated due to cosmetic and functional purposes, hence the importance of continuous post-operative follow-up to monitor for graft dehiscence, scar development, recurrence of the mass, malignant degeneration, and development of lid malposition. Additional procedures for scar management, such as CO2 laser and intralesional steroid injections, may be necessary to further enhance outcomes in complex cases. All three cases in this series exhibited improved functional and cosmetic outcomes post-operatively, with significant reduction in ptosis and scarring. Longterm follow-up revealed satisfactory recovery with minimal complications, with no recurrence nor malignant degeneration.

Introduction: The Triglycerides-Glucose Index (TyG), as a cost-effective and novel biomarker for insulin resistance, plays a pivotal role in the pathogenesis of heart disease. This study aims to assess the TyG’s capacity to predict cardiovascular risk. To investigate the correlation between the TyG and the 10-year risk of heart disease determined by the Framingham Risk Score (FRS). Materials and methods: A comprehensive study of 3,832 Indonesian participants (aged 19-65, Male 3,415). TyG Index threshold determined by ROC curve analyses. Its relationship with cardiovascular risk was assessed using the chi-square test and bivariate correlation analysis. Results: 3,832 participants (1,647 with high TyG≥8.7795, mean age 38.86). There was a significant association between TyG Index and FRS (P=0.02, sensitivity 0.53 specificity 0.57 PR 1.537). TyG-BMI and FRS (P<0.001, sensitivity 0.63, specificity 0.55, PR 2.18). METS-IR (P<0.001, sensitivity 0.59, specificity 0.55, PR 1.862), treadmill exercise test and FRS (P<0.025, sensitivity 0.07, specificity 0.96, PR 2). Bivariate correlation analysis between FRS and TyG, TyG BMI, METS-IR, SBP, heart rate, weight, waist circumference, and fasting blood glucose (P<0.001). In subgroup analyses, there was no significant correlation between TyG Index and FRS in the diabetes and hypertension groups (P=0.360, P=0.344). Conclusion: This study shows a strong connection between the Triglycerides-Glucose Index and an elevated 10-year cardiovascular disease risk as determined by Framingham Risk Score. The effectiveness of The TyG Index in predicting cardiovascular risk is affected by hypertension and diabetes.

Background: s/Aims: The role of surgery for pancreatic ductal adenocarcinoma (PDAC) with synchronous liver metastases remains controversial. Previous studies assessing the outcomes of combined surgery for primary PDAC and liver metastases have been limited by the inconsistent application of neoadjuvant chemotherapy (NAC). Methods: We identified patients with PDAC and fewer than three liver metastases who received at least six months of NAC and underwent simultaneous pancreas and liver resection between January 2018 and March 2023 at a single institution. Additionally, we queried the National Cancer Database (NCDB) from 2010 to 2019 to identify patients with synchronous metastatic PDAC to the liver who received NAC before simultaneous resection, serving as a comparison group. Results: Ten patients met the inclusion criteria for the institutional case series, with seven ultimately undergoing simultaneous resection. Among 224 patients in the NCDB who underwent simultaneous pancreas and liver resection, 70 patients (31.2%) received NAC.After a median follow-up of 59 months in the institutional cohort, five patients experienced recurrence, resulting in a median disease-free survival of four months (95% confidence interval [CI] 3, not reached). After controlling for confounding factors in the NCDB cohort, the administration of NAC was associated with improved survival (hazard ratio: 0.44, 95% CI 0.29–0.65, p < 0.001) compared to those who underwent upfront surgery. Conclusions Neoadjuvant therapy followed by simultaneous liver and pancreas resection for metastatic PDAC is safe and feasible, and it may provide a survival benefit in carefully selected patient populations.

Cushing’s syndrome is associated with a spectrum of systemic complications, including under-recognised effects on the musculoskeletal system. We present a case of a 37-year-old male with recurrent Cushing’s Disease who developed progressive lumbar radiculopathy secondary to severe Degenerative Disc Disease. Despite bilateral adrenalectomy, the patient exhibited persistent hypercortisolaemia and classical Cushingoid features. Imaging confirmed L4 disc herniation with nerve root compression. A multidisciplinary team initiated endocrine therapy and performed a successful minimally invasive lumbar discectomy, resulting in clinically documented neurological improvement during the immediate postoperative period. Chronic cortisol excess may disrupt spinal biomechanics and accelerate spinal degeneration through presumed bone demineralisation, muscle atrophy, altered fat distribution, and direct degradation of disc tissue. This case highlights the importance of early endocrine evaluation in patients with atypical or rapidly progressive spinal degeneration. Recognition and management of hypercortisolaemia are essential for surgical planning, optimising outcomes, and preventing recurrent spinal compromise.

Objective: : Posterior endoscopic cervical foraminotomy (PECF) is a minimally invasive surgical technique for treating cervical radiculopathy. Traditionally, PECF is performed under general anesthesia in the prone position, but concerns over anesthesia-related complications have led to the exploration of local anesthesia in the lateral decubitus position as an alternative. This study aims to compare the clinical outcomes, safety, and efficacy of PECF performed under local anesthesia in the lateral decubitus position versus general anesthesia in the prone position. Methods: : We conducted a retrospective analysis of 13 patients who underwent PECF under local anesthesia in the lateral decubitus position. The outcomes were compared with data from 357 patients across eight studies who underwent PECF under general anesthesia in the prone position. Outcomes measures included Visual analog scale (VAS) pain scores, Oswestry disability index (ODI), length of stay (LOS), minimally clinically important difference (MCID), and complications. Results: : Patients in the local anesthesia group demonstrated significant reductions in neck pain (VAS-N : 4.93±1.32 to 1.49±0.52, p<0.001) and arm pain (VAS-A : 8.69±0.75 to 1.85±1.46, p<0.001), achieving a mean pain reduction of 78.8%. These improvements were comparable to the general anesthesia group (VAS-N : 4.80 to 1.28; VAS-A : 6.71 to 1.23). Functional outcomes improved significantly in both groups, with ODI scores improving from 54.76% to 9.82% locally and from 39.92% to 9.62% in the general group. Although LOS was slightly longer for the local anesthesia group (5.85±3.20 vs. 4.81±2.17 days, p=0.18), post-procedure monitoring time was significantly shorter (3.2 vs. 7.4 hours, p<0.001). The local anesthesia group reported zero complications (0%; 95% confidence interval [CI], 0–22.8%) compared to an 8.68% complication rate (95% CI, 5.8–11.6%) in the general anesthesia cohort (p=0.612). Conclusion : PECF under local anesthesia in the lateral decubitus position provides comparably effective pain relief and functional improvement comparable to general anesthesia, though the difference in complication rates was not statistically significant and requires larger studies for confirmation. This technique may be particularly advantageous for patients at higher risk for anesthesia-related complications. Further research is warranted to validate these findings in larger, prospective studies.

Distal vaginal agenesis (DVA) is a rare form of female genital tract malformation that presents as cryptomenorrhea. It results from the failure of the urogenital sinus to form the caudal portion of the vagina. Through a thorough history, physical examination and appropriate imaging studies, an accurate diagnosis is integral in selecting the correct intervention for the patient. This is a case of distal vaginal agenesis in a 10-year-old nulligravid, who presented with fecal retention from an abdominopelvic mass. The patient had no bowel movement for four days, and abdominal enlargement. On inspection, there was a 12.0cm x 10.0cm palpable abdominal mass. Inspection of the external genitalia, the introitus appeared concave, with no appreciable introital opening. On digital rectal examination, an anterior bulge was palpated 0.5 cm from the anal verge. A pull-through vaginoplasty was performed with an unremarkable post-operative course. The patient was discharged with a patent vagina and resolution of her gastrointestinal symptoms. On follow-up, the patient had monthly menstruation after surgery with no recurrence of her gastrointestinal symptoms.

Background:Medical laboratory diagnostic services play a critical role in the diagnosis,treatment,and manage-ment of diseases,forming the cornerstone of effective healthcare systems.Despite the crucial role of laboratory services,the quality and accessibility of medical laboratory services in sub-Saharan Africa(SSA)face signifi-cant challenges.Global health development aid has been pivotal in supporting SSA laboratory services.This study aimed to examine global health development aid initiatives that have successfully enhanced the quality of medical laboratory services and the challenges and barriers to effectively improving medical laboratory services through global health development aid in SSA.Methods:We used a narrative review study design.We searched PubMed,Web of Science and Scopus for articles published in the last 15 years.These three databases are generally considered premier databases for peer-reviewed articles in global health,public health,health systems,and biomedical sciences.The inclusion criteria for this review included research studies,reports,and grey literature.Only articles published in English from 2010 on-ward were considered.The analysis followed a qualitative approach,emphasizing thematic synthesis and critical interpretation.Results:Forty articles were included in this study.Of these,18 were primary research studies,11 were reports,7 were commentaries,and 4 were reviews.Five sub-themes from the successful global health development aid initiative themes were capacity building and training programs,infrastructure development,partnership models,policy advocacy and regulatory support,quality control and standardization of laboratory services.The sub-themes from the challenges and barrier theme were insufficient funding and resource allocation,human resource constraints,inadequate infrastructure and equipment,and political and institutional barriers.This review re-vealed that several factors,including financial sustainability,human resource capacity,institutional support,resilience,and effective monitoring systems,shape the sustainability of improvements in medical laboratory services in SSA.Conclusion:Achieving long-term sustainability requires strategies that ensure financial self-sufficiency,foster a skilled and stable workforce,and integrate laboratory services into national health frameworks.

Background:Work engagement(WE)is critical to quality primary healthcare delivery.However,limited research has explored its levels and determinants among healthcare professionals in low-and middle-income countries.This study assessed the levels and correlates of work engagement among physician assistants(PAs)in Ghana.Methods:A cross-sectional study was conducted among 439 PAs from October to December 2024.Participants were recruited via emails,social media platforms,and posters featuring study links and scannable questionnaire codes.WE was measured using the validated Utrecht Work Engagement Scale questionnaire.Results:Overall,WE levels were average,with similar trends across the three subdomains.In the bootstrapped multivariate linear regression model,anxiety was negatively associated with WE(β=-0.49,95％confidence interval[CI]:-0.77 to-0.21).Conversely,working in an urban area(β=0.36,95％CI:0.05 to 0.67),holding the rank of PA/Senior PA(β=0.27,95％CI:0.03 to 0.52),reporting good self-rated health(β=0.54,95％CI:0.19 to 0.88),and working at health centers(β=0.86,95％CI:0.22 to 1.50)were positively associated with WE levels.Conclusion:WE levels are average in the study sample,highlighting the need for strategic interventions to improve and sustain the healthcare workforce's motivation and performance.Addressing workplace stressors,enhancing professional development opportunities,and fostering supportive work environments could improve engagement among PAs and healthcare professionals in general.Strengthening WE is essential for ensuring resilient quality primary healthcare systems and achieving the goals of universal health coverage.