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Hiatal herniations involving the transverse colon are a rare condition. This case study explores the hiatal herniation of the transverse colon as a complication of an esophagectomy through the prosection findings of a 91-year-old male anatomical donor ("donor") who had a documented esophagectomy procedure due to esophageal adenocarcinoma. A thorough dissection of the abdomen and thorax confirmed that a large portion of the esophagus was removed during an esophagectomy, and the remaining cervical portion was reconnected to the stomach in the posterior mediastinum of the thoracic cavity. A type IV hiatal hernia involving the transverse colon and greater omentum was also noted. This study aims to evaluate the donor's noted esophageal hiatal herniations and how surrounding atypical anatomy may be correlated with the history of a completed esophagectomy., Competing Interests: Human subjects: Consent for treatment and open access publication was obtained or waived by all participants in this study. Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work., (Copyright © 2024, Cummings et al.)

Herpes simplex virus type 1 (HSV-1) can cause a range of infections, including orolabial herpes and, in rare cases, tracheobronchitis, especially in immunocompromised patients. Inflammation from such infections might increase the risk of postintubation tracheal rupture, a serious complication characterized by subcutaneous and mediastinal emphysema and pneumothorax. This case report presents a rare instance of tracheal rupture following intubation in a patient with HSV-1 tracheitis. A 70-year-old woman with diabetes mellitus presented to the hospital with altered mental status after drinking a bottle of Coke. She was diagnosed with diabetic ketoacidosis, and multifocal pneumonia which were treated with insulin, antibiotics, and supportive care. She was also intubated for airway protection. After a few days of treatment, her mental status and medical condition improved warranting extubation. Post-extubation, she developed stridor that did not respond to medical treatment. In concerns for airway compromise, an attempt of re-intubation was complicated with hypoxemia, subcutaneous face and chest emphysema, pneumoperitoneum, and bilateral pneumothoraces leading to cardiopulmonary arrest. Cardiopulmonary resuscitation was started, and return of spontaneous circulation was achieved after one minute. She was eventually intubated with a smaller endotracheal tube, and bilateral chest tubes were placed. Bronchoscopy revealed tracheal injury and whitish growth around the endotracheal tube. A biopsy of the latter growth was consistent with HSV-1 infection, prompting antiviral therapy. The patient ultimately recovered and was discharged after tracheostomy placement. This case represents a rare instance of iatrogenic tracheal injury associated with HSV-1 tracheitis. Diagnosis of tracheal injury hinges on clinical suspicion and is confirmed through radiologic imaging and bronchoscopy. Treatment varies based on injury severity, with our patient's level II injury managed conservatively with antiviral therapy and tracheostomy, resulting in a favorable outcome., Competing Interests: Human subjects: All authors have confirmed that this study did not involve human participants or tissue. Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work., (Copyright © 2024, Haddaden et al.)

Introduction: Cardiovascular diseases (CVDs) such as hypertension, ischemic heart disease, and stroke are highly prevalent and have a significant impact on quality of life and the healthcare economy. This study aimed to evaluate adherence to medication regimens in CVD patients., Materials and Methods: A cross-sectional descriptive study of 203 patients was conducted using a semi-structured questionnaire which included an eight item Morisky Medication Adherence Scale (MMAS-8) to assess medication compliance., Results: The survey included 203 patients, 164 (81%) males and 39 (19%) females. Overall, 156 (76.8%) had medical insurance, while only 47 (23.2%) were not medically insured. In total, 161 patients (79.3%) adhered to the medical regimen., Conclusion: Most participants adhered to their treatment regimen in the present study. However, inadequate knowledge regarding side effects and abrupt discontinuation of medications without physician consultation was reported to a high degree. These findings highlight the areas for improvement in healthcare to improve medication adherence rates., Competing Interests: Human subjects: Consent was obtained or waived by all participants in this study. Institutional Ethics Committee of Vydehi Institute of Medical Sciences and Research Centre issued approval #VIEC/2017/APP/068. Animal subjects: All authors have confirmed that this study did not involve animal subjects or tissue. Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work., (Copyright © 2024, Agarwal et al.)

A gastrointestinal stromal tumor is a rare gastrointestinal tumor of mesenchymal origin. We present a rare case of a 32-year-old male patient with a history of iron deficiency anemia who presented with nocturnal cramping abdominal pain, nausea, non-bloody vomiting, loss of appetite, and weight loss. The patient had no significant family history of cancer. Prior imaging showed gastric distension with chronic inflammatory changes, but a scheduled esophagogastroduodenoscopy (EGD) was not done due to loss of follow-up. On admission, the patient was tachycardic with anemia. An abdominal CT scan showed new areas of gastric wall thickening with edematous wall thickening at the gastric cardia. An EGD revealed deep gastric ulcers with elevated edges with central necrosis, raising concerns for malignancy. A biopsy of the gastric cardia confirmed a high-grade stromal tumor with the aid of a DOG1 test; the gastric cardia was KIT-positive in immunohistochemical testing but negative for Helicobacter pylori. The tumor was staged at pT3N0. He was treated with surgical resection with negative margins and imatinib therapy. Postoperative surveillance showed no evidence of malignancy and the patient experienced a positive response to treatment with stable hemoglobin levels and significant weight gain., Competing Interests: Human subjects: Consent was obtained or waived by all participants in this study. Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work., (Copyright © 2024, Karki et al.)

Pancytopenia is a decrease in the number of cells in all peripheral blood cell lines and has been associated with anemias, cancers, chemotherapy, infections, and nutritional deficiencies. However, pancytopenia concurrent with encephalopathy is rare and not well-studied. We present a case of pancytopenia concurrent with metabolic encephalopathy. An 81-year-old female patient presented to the emergency department for two weeks of increased fatigue and hypersomnolence. The patient had trouble staying awake during the initial physical exam, and her laboratory results were significant for pancytopenia, hypercreatinemia, hypernatremia, hypermagnesemia, and alkalemia. She was admitted to the floor, diagnosed with metabolic encephalopathy and acute kidney injury, and treated with medication withholding, fluid resuscitation, and electrolyte repletion. She also received a comprehensive workup for pancytopenia, iron replacement, and red blood cell transfusion therapy. After her metabolic encephalopathy was resolved, she was discharged with plans to follow up with hematology/oncology for stable but unresolved pancytopenia. We hypothesize that the patient's metabolic encephalopathy was likely due to acute kidney injury-induced uremia or dehydration. We further hypothesize that parvovirus B19 and myelodysplastic syndrome are possible etiologies for pancytopenia. Our case highlights the importance of closely monitoring patients taking Sodium-glucose co-transporter-2 (SGLT-2) inhibitors and loop diuretics for dehydration and subsequent organ failure., Competing Interests: Human subjects: Consent was obtained or waived by all participants in this study. Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work., (Copyright © 2024, Zou et al.)

Idiopathic orbital inflammatory disease (IOID) is a rare and poorly understood condition characterized by inflammation of the orbital tissues without an identifiable cause. This disorder can lead to symptoms such as proptosis, pain, and visual disturbances. We present the case of an eight-year-old female diagnosed with IOID who was admitted to the hospital with worsening right eye redness, proptosis, and pain. Her clinical course included significant right eye lagophthalmos, exposure keratopathy, and a corneal ulcer. Management involved a multidisciplinary approach with consultations from ophthalmology and rheumatology, treatment with corticosteroids, and supportive care. This case underscores the importance of early recognition and a comprehensive management strategy to improve outcomes for patients with IOID., Competing Interests: Human subjects: Consent was obtained or waived by all participants in this study. Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work., (Copyright © 2024, Elashmawy et al.)

Inhaled amyl nitrites, once used to alleviate chest pain, are more commonly now being used for their euphoric effects. The recreational use of inhaled nitrites can lead to methemoglobinemia, a life-threatening condition that hinders the utilization of oxygen in the body. In 2021, 2.2 million people aged 12 or older used inhalants in the past year. Methemoglobinemia has favorable outcomes with treatment. We present the case of a 43-year-old man, with a medical history of type 2 diabetes mellitus and hypertension presenting with bluish discoloration of the fingers that progressed to his tongue and lips. He disclosed using a recreational inhalant called "Rush" before coming in. Vital signs showed low oxygen saturation on room air, and further investigation revealed elevated methemoglobin levels on the venous blood gas. Methylene blue was used for treatment, with complete resolution of the patient's symptoms and the only side effect of green urine. The patient was later discharged home in a stable condition. History taking is a crucial part of managing methemoglobinemia, as presentation to the clinical setting could vary. Our case presents the milder version of the disease with quick complete recovery after appropriate treatment. It demonstrates inhalant abuse in a less common age group. The case also demonstrates a common side effect of methylene blue that is often forgotten., Competing Interests: Human subjects: Consent was obtained or waived by all participants in this study. Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work., (Copyright © 2024, Alkhateeb et al.)

Introduction: With the urgent need for clinicians capable of responding to the opioid crisis, an interprofessional education (IPE) pilot curriculum was launched to assess trainee self-efficacy in managing chronic pain and mental health conditions, and attitudes toward interprofessional practice among resident physicians, family nurse practitioners (FNP), and physician assistant (PA) students., Methods: This study involved the implementation of a pilot curriculum consisting of five interactive IPE sessions. All invited trainees across two academic institutions were asked to complete the assessments. Self-efficacy in managing chronic pain and mental health was measured at baseline and following IPE training using a researcher-developed tool, while attitudes toward interprofessional practice were measured with the Attitudes Toward Health Care Teams scale. Resident physicians were compared to FNP/PA students to examine differences between groups and within groups over time., Results: The final analysis involved 25 trainees who attended at least one IPE training session and completed pre-session and post-session surveys. The total pre-session survey and post-session survey response rate was 37.5% (n=36). Self-efficacy in chronic pain management improved among the resident physician (mean=3.85 ±0.40) and FNP/PA groups (mean=3.84±0.46) (p=0.05 and p=0.001), respectively. Self-efficacy in mental health management was not significantly improved among resident physicians (mean=3.41±0.49, p=0.48), but improved among FNP/PA students (mean=3.46±0.31, p<0.001). There was no difference in attitudes toward interprofessional practice., Conclusion: While IPE training did not result in attitudinal changes toward interprofessional practice, it shows potential for improving self-efficacy in managing chronic pain and mental health, particularly among FNP/PA trainees. This study was limited by a small sample size of trainees included in the final analysis., Competing Interests: Human subjects: Consent was obtained or waived by all participants in this study. Office of Research Compliance, Central Michigan University issued approval waiver for submission: 923801-2. Animal subjects: All authors have confirmed that this study did not involve animal subjects or tissue. Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: This project was made possible through a Picker Gold GME Challenge grant from The Arnold P. Gold Foundation (Grant ID# CH-17-002). The funder had no role in the design, implementation, results, or conclusions of this curricular study. Financial relationships: Elizabeth Cleek, PsyD declare(s) employment from The Arnold P. Gold Foundation. Dr. Cleek is Senior VP and Chief Operating Officer at the Arnold P. Gold Foundation and declares no conflicts of interest. Dr. Cleek served as a collaborator on this project at the request of the Principal Investigator/Project Manager, Juliette Perzhinsky, MD, based on Dr. Cleek's expertise in medical education. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work., (Copyright © 2024, Perzhinsky et al.)

Individuals with Philadelphia chromosome-negative myeloproliferative neoplasms (MPNs) such as polycythemia vera and essential thrombocythemia (ET) demonstrate an increased thrombotic risk associated with JAK2 mutations. Physicians must take heed when treating these patients, to mitigate this pro-thrombotic state as much as possible. Failure to do so, or exacerbating the state, can lead to dire consequences. We present the case of a 27-year-old female with a history of ulcerative colitis (UC) and ET, currently taking estrogen-containing oral contraceptive pills (OCPs). She presented to the emergency department with rapid weight gain, jaundice, nausea, and diarrhea and was found to have obstructive jaundice and thrombotic burden that extended into the portal, mesenteric, splenic, and hepatic veins. On the second attempt, a successful transjugular intrahepatic portosystemic shunt procedure was performed, resulting in improved venous flow. This case underscores the importance of cautious medication use, especially OCPs, in patients with hypercoagulable states due to JAK2 mutations, for example, the V617F mutation in JAK2. It emphasizes the need for vigilant monitoring, individualized management, and a multidisciplinary approach to mitigate thrombotic complications. Increased awareness and continued research are crucial for optimizing treatment strategies for patients with MPNs and associated genetic mutations., Competing Interests: Human subjects: Consent was obtained or waived by all participants in this study. Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work., (Copyright © 2024, Karns et al.)

Intussusception is the invagination of one segment of the bowel into the adjacent bowel segment leading to obstruction, intestinal ischemia and, in severe cases, peritonitis and perforation. While the condition is more common in children, adult intussusception does occur and is often attributed to malignancy. In this case report, we discuss an adult man who presented for weight loss and intermittent abdominal pain and was ultimately found to have ileocecal intussusception on CT imaging. A colonoscopy with cold biopsy was performed and pathology reports displayed a well-differentiated neuroendocrine tumor lead point; a rare event with only a few cases reported. Ultimately, the patient was taken to the operating room, and an ileocecectomy was performed with primary anastomosis. Prompt diagnosis and management are crucial in adult intussusception as a missed event can lead to tumor progression, bowel ischemia, bleeding and necrosis., Competing Interests: Human subjects: Consent was obtained or waived by all participants in this study. Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work., (Copyright © 2024, Hasalliu et al.)

Male breast cancer is a rare disease, and it is important to have a high index of suspicion in patients presenting with breast symptoms, such as a breast mass or nipple discharge. Most male patients who are diagnosed with breast cancer present with breast complaints and/or a strong family history of cancer. Here, we will present a 47-year-old male patient who was diagnosed with bilateral ductal carcinoma in situ during a routine gynecomastia surgery after massive weight loss. This case demonstrates the importance of sending breast tissue specimens for pathology, especially in a male patient., Competing Interests: Human subjects: Consent was obtained or waived by all participants in this study. Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work., (Copyright © 2024, Toomey et al.)

Esophageal perforation, a rare and serious condition, has seen a reduction in mortality from 30% to 15% over the last three decades due to advancements such as gastrointestinal stents, minimally invasive surgeries, and improved interventional radiology techniques. This review analyzes management strategies for esophageal perforation based on 14 English-language articles published from 2009 to 2024, primarily utilizing surveys and national database analyses. The management of esophageal perforation is complex, with challenges in diagnosis and treatment strategy. Despite surgery being the traditional treatment, the role of less invasive methods is growing. Effective management of esophageal perforation involves advanced imaging for diagnosis, hemodynamic stabilization, and a multidisciplinary approach to treatment, including surgical and non-surgical interventions. The evidence for different treatment outcomes remains limited, highlighting the need for comprehensive care involving thoracic surgery, interventional radiology, gastroenterology, and critical care in an intensive care unit setting., Competing Interests: Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work., (Copyright © 2024, Shaqran et al.)

Coronavirus disease (COVID-19) has been associated with a diverse range of extrapulmonary manifestations since its global outbreak in 2019. One of its rare complications is Guillain-Barre Syndrome (GBS), a post-infectious neurological disorder that manifests with a characteristic ascending limb paralysis. Here, we describe the atypical case of a 42-year-old African American male who developed bilateral facial paralysis within five weeks of testing positive for COVID-19. Initial diagnostic imaging and blood studies were negative for acute pathology. Albuminocytological dissociation found in a subsequent analysis of the patient's cerebrospinal fluid and his appropriate therapeutic response to intravenous immunoglobulin (IVIg) indicated GBS as the most likely diagnosis., Competing Interests: Human subjects: Consent was obtained or waived by all participants in this study. Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work., (Copyright © 2024, Taftaf et al.)

Management of acute coronary syndrome (ACS), cerebrovascular accident (CVA), and pulmonary embolism (PE) necessitates prompt intervention, as delayed treatment may lead to severe consequences. Each of these conditions presents significant challenges and carries a high risk of morbidity and mortality. We present the case of an 86-year-old female with a history of stage 4 urothelial carcinoma metastasized to the lungs, who presented to the emergency department (ED) with acute ischemic stroke (AIS), ST-segment elevation myocardial infarction (STEMI), and bilateral PE. We propose the term "multi-organ thromboembolic crisis" (MOTEC) to streamline the communication and management approach for patients experiencing critical thromboembolic events affecting multiple organ systems., Competing Interests: Human subjects: Consent was obtained or waived by all participants in this study. Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work., (Copyright © 2024, Gunaga et al.)

Researchers used the TikTok platform to investigate the quality of select TikTok educational content regarding gastroesophageal reflux disease (GERD). One hundred TikTok videos that fit the inclusion criteria were analyzed using DISCERN, a tool that evaluates the quality of consumer health information on the internet. There was no substantial difference in DISCERN scores between physicians and non-physician content creators. Nevertheless, both groups consistently scored low (<3) in areas such as providing sources of information, indicating the publication date of their sources, discussing treatment risks, and outlining potential consequences if no treatment is pursued., Competing Interests: Human subjects: Consent was obtained or waived by all participants in this study. Animal subjects: All authors have confirmed that this study did not involve animal subjects or tissue. Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work., (Copyright © 2024, Rehman et al.)

Introduction Tranexamic acid (TXA) administration perioperatively has demonstrated efficacy in reducing postoperative drops in hemoglobin levels and the need for transfusions among patients with peritrochanteric hip fractures. This study aims to perform a retrospective analysis to assess the impact on hemoglobin levels by comparing patients with fragility hip fractures who received TXA in the ED, in addition to the standard perioperative TXA dose, with those who did not receive TXA in the ED. Methods This study retrospectively reviewed 64 patient records from May 2020 to May 2021 at a Level II trauma center that were classified into two groups: patients who received one gram (g) of TXA in the ED, within five hours of injury (new protocol), or patients who received no TXA in the ED (old protocol). The primary outcomes of the study were hemoglobin and adverse events. An independent t-test was performed on continuous variables. A chi-square test was used to analyze noncontinuous variables. Statistical Product and Service Solutions (SPSS, version 25; IBM SPSS Statistics for Windows, Armonk, NY) was used for analysis. Statistical significance was set at a p value < 0.05. Results We measured the difference between hemoglobin on the day of surgery or day zero and on arrival in the ED, which was not statistically significant between the two protocols (p value = 0.322). The difference between hemoglobin levels on postoperative day one and on arrival in the ED was also not statistically significant (p = 0.339). Adverse events were lower in the new protocol but not statistically significant between the two protocols (p = 0.178). Conclusion Our study showed improved outcomes in postoperative hemoglobin with early administration of TXA in the ED. This is demonstrated by continuous higher postoperative hemoglobin in the new protocol group without an increase in adverse events. While the data did not achieve statistical significance, we believe there is clinical benefit in the early administration of TXA in the ED, a finding that continues to be explored and supported in the literature., Competing Interests: Human subjects: Consent was obtained or waived by all participants in this study. McLaren Healthcare System Ethics Committee issued approval SARC Protocol 202110-02. Animal subjects: All authors have confirmed that this study did not involve animal subjects or tissue. Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work., (Copyright © 2024, Doka et al.)

Background and objective Butter coffee drinks, mainly a form of a saturated fat diet, are widely accepted as a "healthy energy-boosting drink", especially in the young and healthy military population. The objective of our study was to determine the effects of medium-chain triglyceride (MCT) oil and butter on lipid profile, especially apolipoprotein B (ApoB), low-density lipoprotein (LDL)-cholesterol (LDL-C), high-density lipoprotein (HDL)-cholesterol (HDL-C), and other risk factors for coronary heart disease, such as BMI, BP, fasting blood glucose, HbA1c, and high-sensitivity C-reactive protein (hs-CRP) levels in healthy adults. Materials and methods We conducted a prospective study of 60 subjects who were randomized to one of the two following regimens: (1) coffee or (2) coffee with butter plus MCT oil combination. The primary outcome was the effect on ApoB. Secondary outcomes were as follows: non-HDL-C, LDL-C, triglycerides, BP, waist circumference, fasting blood glucose, and HbA1c. These parameters were evaluated at the baseline and after 12 weeks. The Mann-Whitney U test was utilized for analysis of the results. Results While 60 subjects were recruited for the study, only 41 completed it, meeting the minimum required sample size (17 per group) necessary to achieve the desired effect size: 21 males (nine in the control group and 12 in the experimental group) and 20 females (10 in each group). Anthropometric measures were similar between the two groups at baseline, and so were age and BMI (average age: 33.00 ± 5.84 years among controls and 30.86 ± 6.14 years in the experimental group; BMI: 27.35 ± 4.63 kg/m 2  vs. 25.74 ± 2.70 kg/m 2 ). The pulse rate was 69.35 ± 10.98 in the control vs. 70.68 ± 10.32 bpm in the experimental group. The waist size was also similar in both groups. Baseline lab findings were as follows: ApoB: 89.85 ± 17.52 (control), 81.60 ± 12.84 mg/dL (experimental); hs-CRP: 0.18 ± 0.27 (control), 0.17 ± 0.27 mg/L (experimental); LDL-C 113.65 ±23.71 (control), 106.50 ± 18.99 mg/dL (experimental); HDL-C 57.35 ± 14.63 (control), 62.41 ± 16.15 mg/dL (experimental); and triglycerides: 76.00 ± 31.30 (control), 56.77 ± 14.77 mg/dL (experimental), and these values were similar. The values after 12 weeks of intervention were as follows: BMI: 27.37 ± 5.24 (control), 26.36 ± 3.55 (experimental); pulse rate: 78.88 ± 14.00 (control), 74.20 ± 11.90 bpm (experimental); ApoB 87.1 ± 17.38 (control), 85.7 ±20.59 mg/dL (experimental); hs-CRP 0.26 ± 0.22 (control), 0.15 ± 0.14 mg/L (experimental); LDL-C 111.59 ± 20.35 (control), 114.10 ± 26.99 mg/dL (experimental); HDL-C 57.71 ± 12.93 (control), 64.85 ± 13.32 mg/dL (experimental); and triglycerides: 74.71 ± 25.39 (control), 60.80 ± 15.77 mg/dL (experimental). Conclusion At a significance level of 5%, there was no difference between the two groups, either at the baseline or at 12 weeks of intervention. Based on our findings, adding MCT oil and butter to coffee may be safe. However, further studies with larger sample sizes and longer duration are needed to validate our findings., Competing Interests: Human subjects: Consent was obtained or waived by all participants in this study. Walter Reed National Military Medical Center IRB issued approval 404482. Animal subjects: All authors have confirmed that this study did not involve animal subjects or tissue. Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work., (Copyright © 2024, Hoang et al.)

Dermatofibrosarcoma protuberans (DFSP) is a rare, slow-growing, malignant tumor in the dermis and subcutaneous fat diagnosed by pathological and immunohistochemical examinations. This case report provides the dermatological findings of a 73-year-old woman with DFSP who presented to a primary care clinic with a longstanding nodular lesion on her left upper thigh. Dermatological examination showed a solitary, skin-colored violaceous/hyperpigmented nodule on the superior anteromedial portion of the left thigh. A punch biopsy revealed spindle cell proliferation, and diffuse CD34 positivity, confirming the diagnosis of DFSP. A dermatology referral was placed for further management and complete surgical excision. Patient underwent wide local excision (WLE) and has no recurrence to date. Unfortunately, DFSP is commonly misdiagnosed before skin biopsy which delays treatment. This case is significant because DFSP is not often diagnosed accurately outside the dermatology specialty and serves as a reminder to practitioners to use biopsies during the diagnostic process of skin findings to prevent the delay in management., Competing Interests: Human subjects: Consent was obtained or waived by all participants in this study. Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work., (Copyright © 2024, Guerra et al.)

Lipoblastomas are benign neoplasms that arise from embryonal adipocytes. They predominantly impact the pediatric population, with most cases occurring in the first few years of life. These tumors typically present as a soft, palpable, painless mass and tend to involve the mesenchymal tissues of the extremities and trunk. Intraabdominal involvement and intraabdominal complications secondary to lipoblastoma are incredibly rare. Here, we present the case of a nine-year-old female who presented to the emergency department (ED) with one week of intermittent lower abdominal pain. The CT abdomen/pelvis demonstrated a well-circumscribed hypodense omental mass measuring 10.1 cm x 4.7 cm x 13.4 cm with minimal mass effect or bowel displacement. At that time, the patient's abdomen was soft without tenderness, distention, or rigidity. Her initial laboratory studies and vital signs were within normal limits. She was evaluated by pediatric surgery, who, given her clinical stability, planned for an anticipated elective resection. Thirteen days after her initial ED visit, the patient returned to the ED with nausea, vomiting, and diffuse abdominal pain. Repeat CT abdomen/pelvis revealed shifting of the omental mass from the left hemi-abdomen to the right hemi-abdomen with associated mesenteric 'swirl sign' and dilated loops of small bowel consistent with small bowel obstruction. Given the patient's CT findings and signs of peritonitis on a physical exam, she was emergently taken to the operating room, where the mass along with 20 cm of small bowel intimately associated with the mass was resected. The proximal end of the involved bowel was found to be twisted and necrotic, consistent with volvulus. A specimen was sent for cytogenetics and found to be positive for FLAG1, ultimately revealing a diagnosis of lipoblastoma. The majority of lipoblastoma development is underpinned by gene rearrangements in the zinc-finger transcription factor PLAG1. Although benign, these tumors can exhibit rapid proliferation and have high recurrence rates. Patients should be monitored long-term with ultrasound (US) or MRI following surgery to assess for recurrence., Competing Interests: Human subjects: Consent was obtained or waived by all participants in this study. Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work., (Copyright © 2024, Gingell et al.)

It can be difficult to delineate the cause of urticarial eruptions, and in chronic cases, it can be a challenging condition to effectively treat. Several forms of urticarial eruptions are well documented and established. Our review focuses on a form of urticaria that is less commonly reported: adrenergic urticaria. In this review, we aim to consolidate the literature in the hopes that this urticarial subtype is considered in urticarial differentials, as well as highlight potential gaps in the research and future directions in treatment options., Competing Interests: Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: Dr. Francisca Kartono, DO, has disclosed her roles as a researcher for CP3 with the National Psoriasis Foundation, as well as her affiliations with Biofrontera and Alma Laser., (Copyright © 2024, Slater et al.)

Systemic lupus erythematosus (SLE) is an autoimmune condition more commonly observed in women of childbearing age. The most commonly reported initial presentations were fatigue, arthritis, and skin manifestations. However, due to the involvement of a variety of organs, diagnosis remains a challenge for physicians. Our patient is a 48-year-old lady who presented with severe bilateral lower extremity edema with non-resolving right lower lobe pneumonia and ipsilateral exudative pleural effusion. Her leg swelling was not responding to diuretics, and her pneumonia was not improving following a course of antibiotics. This unusual presentation prompted an autoimmune workup, which later revealed a diagnosis of SLE with class 5 lupus nephritis. Pleuritis, exudative pleural effusion, and lupus nephritis have been associated with autoimmune disorders in the literature, but this is an uncommon initial presentation in SLE without other clinical manifestations. Our case report highlights the challenges in the diagnosis of an atypical case of SLE and the need to maintain high clinical suspicion for SLE, especially in female patients with multiorgan involvement., Competing Interests: Human subjects: Consent was obtained or waived by all participants in this study. Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work., (Copyright © 2024, Khine et al.)

Legionella pneumonia is a severe form of pneumonia caused by the bacterium Legionella pneumophila . It often presents with atypical symptoms and can lead to complications such as rhabdomyolysis and acute kidney injury (AKI). Here, we report a case of Legionella pneumonia-induced rhabdomyolysis and AKI in a 32-year-old male. Laboratory investigations revealed elevated creatinine kinase levels and acute kidney injury. Further investigation confirmed Legionella pneumonia. The patient was promptly treated with appropriate antibiotics and supportive care, resulting in clinical improvement and resolution of rhabdomyolysis and AKI. This case underscores the importance of considering Legionella pneumonia as a potential cause of rhabdomyolysis and AKI, especially in patients with atypical pneumonia presentations., Competing Interests: Human subjects: Consent was obtained or waived by all participants in this study. Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work., (Copyright © 2024, Mada et al.)

Ensuring access to proper eye health services is not only a fundamental human right but also crucial for preserving an individual's quality of life, preventing blindness, and promoting overall well-being. This is especially true in low-income countries like Sub-Saharan Africa (SSA) where recognizing the intricate relationship between access to healthcare and social determinants of health (SDOH ) is crucial to addressing health disparities. The goal of this study was to elucidate and highlight not only the barriers millions face in obtaining eye care but also pave the way for interventions and policies aimed at creating equitable access across diverse populations. To do this, a scoping review was conducted across the Cumulated Index to Nursing and Allied Health Literature (CINAHL), Embase, and PubMed databases for studies meeting the search terms and inclusion criteria. The results show that intervention strategies that increase vision care must extend beyond the healthcare sector to address the multifaceted challenges. Collaborating with stakeholders involved in addressing broader livelihood issues, such as food security, education, and SDOH, becomes imperative to ensure comprehensive and sustainable improvements in vision care accessibility in SSA., Competing Interests: Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work., (Copyright © 2024, Gai et al.)

This case report explores the complexities involved in the diagnosis and management of asymptomatic mitral regurgitation (MR) in a 64-year-old male presenting with an incidental systolic murmur. Torrential MR with flail mitral valve (MV) segments was identified through comprehensive imaging and clinical evaluation, including echocardiography and catheterization. The discussion highlights the nuances of surgical timing, emphasizing the importance of tailored approaches based on left ventricular (LV) function and dilation. This report sheds light on the evolving landscape of managing asymptomatic MR, underscoring the need for balancing surveillance with proactive intervention to optimize patient outcomes., Competing Interests: Human subjects: Consent was obtained or waived by all participants in this study. Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work., (Copyright © 2024, Saeed et al.)

Lambert-Eaton myasthenic syndrome (LEMS) is an autoimmune neuromuscular disorder caused by pathogenic autoantibodies directed against voltage-gated calcium channels present on the presynaptic nerve terminal. For LEMS patients refractory to initial symptomatic treatment with amifampridine, immunomodulatory therapy with intravenous immunoglobulin (IVIG) is often utilized. However, in the authors' review of literature, the utility of subcutaneous immunoglobulin (SCIG) in the treatment of LEMS has been scarcely reported. Here, we present a unique case of non-paraneoplastic LEMS managed with SCIG with excellent clinical response and improvement on electromyography. SCIG therapy may be a reasonable alternative for patients with LEMS who do not tolerate the intravenous formulation., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2024, Park et al.)

Sickle cell disease (SCD) is marked by episodic vaso-occlusive crisis (VOC). Recurrent VOC creates a pro-inflammatory state that induces phenotypic alterations in innate immune cells. Monocytes are of particular interest to VOC pathophysiology because they are especially malleable to inflammatory signaling. Indeed, inflammatory disease states such as chronic obstructive pulmonary disease (COPD), obesity and atherosclerosis are known to influence monocyte development and alter monocyte subpopulations. In this study, we describe SCD monocyte subsets by performing immunophenotypic flow cytometric, enzymatic, and morphologic analysis on peripheral blood. Herein, we add to the growing body of evidence suggesting aberrant monocyte populations underpin VOC pathophysiology. We found that SCD monocytes possess an immature phenotype as demonstrated by 1) decreased CD4 positivity (p < .01), 2) low α-naphthyl butyrate esterase (ANBE) expression, and 3) naïve morphologic features. We additionally found an increase in CD14 + CD16 - CD4 - monocytes (p < .01), a subset associated with the impaired immune response of post-trauma patients. Interestingly, we also found a large proportion of CD14 + CD4 - HLA-DR - monocytes which, under normal circumstances, are exclusively found in neonates (p < .01). Finally, we report an increase in nonclassical monocytes (CD14 dim CD16 + ), a subset recently shown to have a critical role in prevention and recovery from VOC., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2024, Gingell et al.)

Background This study addresses the participation gap in scholarly activities among internal medicine residents. While the Accreditation Council for Graduate Medical Education emphasizes the importance of these activities, the variability in their definition and support across residency programs presents a challenge. This study investigates these discrepancies and aims to identify the specific barriers and benefits residents perceive in scholarly writing, especially in case report writing, and to propose effective educational interventions. Methodology A voluntary online survey, pre- and post-educational intervention, was conducted among residents at Sparrow Hospital, Michigan State University. The intervention comprised a two-hour session focusing on case report writing, presentation skills, scientific literature searches, and research project engagement. Responses were obtained on a five-point Likert scale, and the data were analyzed as respective frequencies and percentages. Results Of 45 residents, 23 completed the pre-survey. With a response rate of 51% from the internal medicine residents, the post-intervention data revealed considerable improvement in the residents' understanding and appreciation of scholarly activities. There was a marked enhancement in their skills related to scientific literature search and in recognizing the benefits of scholarly engagement. Additionally, the intervention successfully increased their confidence in presenting scholarly work, networking, and identifying relevant venues for their research. Conclusions The study highlights the challenges residents face in scholarly activities, such as lack of training and mentorship. It suggests that focused workshops and mentorship can significantly enhance residents' research skills and confidence., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2024, Rayamajhi et al.)

Purpose: Humeral shaft fractures are common orthopedic injuries, representing 1-5% of all fractures. There is conflicting literature regarding the superiority of operative versus nonoperative treatment of these fractures. The purpose of this study was to examine functional outcomes and time to radiographic union in humeral shaft fractures with the hypothesis that both would be improved in patients treated operatively relative to those treated nonoperatively., Methods: This retrospective cohort study examined patients with humeral shaft fractures treated at a single large healthcare system between 2010 and 2020. A chart and radiograph review were performed to collect information on demographics, fracture, treatment, and outcome information. These measures were compared between patients treated operatively and nonoperatively., Results: Five hundred seventeen adult patients meeting inclusion criteria were identified; 233 were treated nonoperatively, and 284 were treated operatively. The mean patient age was 50.2 years in those who underwent surgery relative to 59.9 years in those treated without surgery (P<0.001). Operatively-treated patients had significantly faster time to radiographic union at a median of 113 days compared to a median of 161 days in nonoperatively-treated patients (P=0.001). The operative group was made weight-bearing as tolerated significantly faster than the nonoperative group (84 days versus 98 days, respectively, P=0.002). No statistically significant difference was seen between the two treatment groups in rates of complications or range of motion at the time of radiographic union. However, patients who underwent surgery were found to be up to two times more likely to achieve full shoulder forward elevation by the time of their final follow-up than those treated without surgery (P=0.011)., Conclusion: Patients with humeral shaft fractures treated operatively have faster time to union, earlier weight bearing, and no change in the rate of complications compared to patients treated nonoperatively., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2024, James et al.)

Background: Cardiovascular diseases (CVDs) are the leading cause of death worldwide and are considered silent killers that threaten different age groups. The stressful lifestyle of resident physicians might make them vulnerable to CVDs. Since 2021, Egypt has recently reported more frequent sudden deaths of junior physicians after long shifts. Many factors can be associated with this prevalence, such as diabetes mellitus, increased blood pressure, or a sedentary lifestyle. Therefore, this study aimed to estimate the risk of developing heart attack and stroke within 10 years among resident physicians in Egypt with the goal of informing health policymakers to improve the healthcare systems for Egyptian physicians., Methods: This cross-sectional study was conducted at six university teaching hospitals around Egypt: Cairo, Al-Azhar, Zagazig, Menoufia, South Valley, and Sohag. Data were collected on the ground using a questionnaire developed from a validated tool, the QRISK3 calculator, developed by the National Health Service, and used to measure the development of CVDs and stroke over the next 10 years., Results: Four hundred twenty-eight resident physicians filled out the study questionnaire, including 224 (52.3%) females. The mean age of the participants was 28.22 years (±2.54). The study revealed that 258 (60.3%), with a median (IQR) = 0.2% (0.1%-0.5%), of the resident physicians are at high risk of having a heart attack or stroke within 10 years. Migraine symptoms (n=65, 15.2%) and angina or heart attack in a first-degree relative (n=26, 6.1%) were the most reported risk factors. The risk was variable among the six university hospitals, with a significant P-value <0.001, where Menoufia University hospitals ranked first, followed by Zagazig University hospitals. However, the percentage of each specialty differs from others. The highest risk was among anesthesiology and ICU residents (n=18, 78.3%), followed by surgery residents (n=44, 62.9%)., Conclusion: About 258 (60.3%) of the resident physicians are at risk of having a heart attack or stroke within 10 years. There is an urgent need to increase resident physicians' awareness about their heart attack and stroke risks and for health policymakers to ensure a better lifestyle and friendly training environment for resident physicians in Egypt., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2024, Ramadan et al.)

Background and objective During the coronavirus disease 2019 (COVID-19) pandemic, many elective orthopedic surgeries, including anterior cruciate ligament reconstruction (ACLR), were temporarily postponed. The purpose of this study was to compare the outcomes of ACLR in patients who underwent surgery during the COVID-19 pandemic with those in a cohort treated before the pandemic. Materials and methods This retrospective review compared patients who underwent primary ACLR during two periods: March to June 2020 (the pandemic group) and January to December 2018 (the pre-pandemic group). Matched cohorts (1:1) were created using propensity matching. Time from injury-to-first visit, injury-to-surgery, and first visit-to-surgery were calculated. Subjective and objective outcomes, minimal clinically important difference (MCID) achievement, and complication rates were recorded for up to two years postoperatively. Statistical analysis included 𝛘2 or Fisher's exact tests for categorical data, and t- or Wilcoxon signed-rank tests for continuous data with significance set at P  < 0.05. Results The pandemic and pre-pandemic groups consisted of 33 and 217 patients, respectively. Matched cohorts consisted of 33 patients each. The time from injury-to-surgery and the first visit-to-surgery was prolonged in the pandemic group. When unmatched, visual analog scale (VAS) scores at three months postoperatively and Patient-Reported Outcomes Measurement Information System (PROMIS)-pain interference (PI) at six months postoperatively and at the final follow-up were higher in the pandemic group. When matched, PROMIS-PI at six months postoperatively was higher in the pandemic group, and VAS scores at one year postoperatively were higher in the pre-pandemic group. MCID achievement and complication rates did not significantly differ between the groups. Conclusions ACLR procedures were significantly delayed in the early months of the COVID-19 pandemic. While patients treated before and during the pandemic experienced varying pain levels during recovery, their functional outcomes, MCID achievement, and complication rates did not differ significantly., Competing Interests: The authors have declared financial relationships, which are detailed in the next section., (Copyright © 2024, Wolterink et al.)

Introduction: Lung cancer remains the leading cause of cancer-related mortality in the United States, with cigarette smoking recognized as the most important modifiable risk factor. The distinct smoking rates and occupational landscape in the Upper Peninsula of Michigan underscore the necessity of investigating the multifactorial influences on the prevalence and distribution of lung and bronchus cancer within this population., Methods: This study, conducted from January 2012 to December 2022, included 1035 patients diagnosed with lung or bronchus tumors who were first seen and/or received the first course of treatment at Upper Peninsula Health Systems (UPHS) - Marquette, the largest hospital system in the Upper Peninsula of Michigan and one of only two radiation oncology treatment centers in the Upper Peninsula., Results: This study demonstrated that the histologic trend of lung and bronchus cancers in a sample of 1035 patients in the Upper Peninsula of Michigan closely resembles that of national averages. Participants with a lifetime history of smoking made up 943 (91.1%) cases of patients diagnosed with lung or bronchus cancers in this study. Lifetime non-smokers only made up 53 (5.1%) cases of patients diagnosed with lung or bronchus cancers. The median age at diagnosis of participants in this study was 70 years., Conclusion: Our study provides significant insights into the histologic distribution of lung and bronchus cancers within the Upper Peninsula of Michigan, addressing a notable gap in the current literature for this rural and medically underserved population. The histologic distribution of lung and bronchus cancers in this region aligns with national trends. Furthermore, the distinct rates of cigarette smoking in the Upper Peninsula emphasize the critical role of smoking cessation efforts in reducing the burden of lung and bronchus cancers in this region., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2024, Burton et al.)