Search

Abstract Nuclear receptors (NRs) function as crucial transcription factors in orchestrating essential functions within the realms of development, host defense, and homeostasis of body. NRs have garnered increased attention due to their potential as therapeutic targets, with drugs directed at NRs demonstrating significant efficacy in impeding chronic disease progression. Consequently, these pharmacological agents hold promise for the treatment and management of various diseases. Accumulating evidence emphasizes the regulatory role of exosome-derived microRNAs (miRNAs) in chronic inflammation, disease progression, and therapy resistance, primarily by modulating transcription factors, particularly NRs. By exploiting inflammatory pathways such as protein kinase B (Akt)/mammalian target of rapamycin (mTOR), nuclear factor kappa-B (NF-κB), signal transducer and activator of transcription 3 (STAT3), and Wnt/β-catenin signaling, exosomes and NRs play a pivotal role in the panorama of development, physiology, and pathology. The internalization of exosomes modulates NRs and initiates diverse autocrine or paracrine signaling cascades, influencing various processes in recipient cells such as survival, proliferation, differentiation, metabolism, and cellular defense mechanisms. This comprehensive review meticulously examines the involvement of exosome-mediated NR regulation in the pathogenesis of chronic ailments, including atherosclerosis, cancer, diabetes, liver diseases, and respiratory conditions. Additionally, it elucidates the molecular intricacies of exosome-mediated communication between host and recipient cells via NRs, leading to immunomodulation. Furthermore, it outlines the implications of exosome-modulated NR pathways in the prophylaxis of chronic inflammation, delineates current limitations, and provides insights into future perspectives. This review also presents existing evidence on the role of exosomes and their components in the emergence of therapeutic resistance.

Abstract Background Most patients starting chronic in-center hemodialysis (HD) receive conventional hemodialysis (CHD) with three sessions per week targeting specific biochemical clearance. Observational studies suggest that patients with residual kidney function can safely be treated with incremental prescriptions of HD, starting with less frequent sessions and later adjusting to thrice-weekly HD. This trial aims to show objectively that clinically matched incremental HD (CMIHD) is non-inferior to CHD in eligible patients. Methods An unblinded, parallel-group, randomized controlled trial will be conducted across diverse healthcare systems and dialysis organizations in the USA. Adult patients initiating chronic hemodialysis (HD) at participating centers will be screened. Eligibility criteria include receipt of fewer than 18 treatments of HD and residual kidney function defined as kidney urea clearance ≥3.5 mL/min/1.73 m2 and urine output ≥500 mL/24 h. The 1:1 randomization, stratified by site and dialysis vascular access type, assigns patients to either CMIHD (intervention group) or CHD (control group). The CMIHD group will be treated with twice-weekly HD and adjuvant pharmacologic therapy (i.e., oral loop diuretics, sodium bicarbonate, and potassium binders). The CHD group will receive thrice-weekly HD according to usual care. Throughout the study, patients undergo timed urine collection and fill out questionnaires. CMIHD will progress to thrice-weekly HD based on clinical manifestations or changes in residual kidney function. Caregivers of enrolled patients are invited to complete semi-annual questionnaires. The primary outcome is a composite of patients’ all-cause death, hospitalizations, or emergency department visits at 2 years. Secondary outcomes include patient- and caregiver-reported outcomes. We aim to enroll 350 patients, which provides ≥85% power to detect an incidence rate ratio (IRR) of 0.9 between CMIHD and CHD with an IRR non-inferiority of 1.20 (α = 0.025, one-tailed test, 20% dropout rate, average of 2.06 years of HD per patient participant), and 150 caregiver participants (of enrolled patients). Discussion Our proposal challenges the status quo of HD care delivery. Our overarching hypothesis posits that CMIHD is non-inferior to CHD. If successful, the results will positively impact one of the highest-burdened patient populations and their caregivers. Trial registration Clinicaltrials.gov NCT05828823. Registered on 25 April 2023.

Abstract Neuroendocrine neoplasms (NENs) are highly heterogeneous and potentially malignant tumors arising from secretory cells of the neuroendocrine system. Gastroenteropancreatic neuroendocrine neoplasms (GEP-NENs) are the most common subtype of NENs. Historically, GEP-NENs have been regarded as infrequent and slow-growing malignancies; however, recent data have demonstrated that the worldwide prevalence and incidence of GEP-NENs have increased exponentially over the last three decades. In addition, an increasing number of studies have proven that GEP-NENs result in a limited life expectancy. These findings suggested that the natural biology of GEP-NENs is more aggressive than commonly assumed. Therefore, there is an urgent need for advanced researches focusing on the diagnosis and management of patients with GEP-NENs. In this review, we have summarized the limitations and recent advancements in our comprehension of the epidemiology, clinical presentations, pathology, molecular biology, diagnosis, and treatment of GEP-NETs to identify factors contributing to delays in diagnosis and timely treatment of these patients.

Introduction: Self-esteem is a comprehensive personal evaluation of an individual's worth that involves a person's perception of self, it functions as a defense mechanism that individuals possess to safeguard themselves from psychological harm. This study aims to assess the prevalence of self-esteem and its associated factors among people living with physical disability. Methods: A cross-sectional study was conducted among people living with a physical disability residing inside Kathmandu Valley from August to November 2022 after acquiring ethical approval from institutional review committee of CiST College (Reference number: IRC/161/078/079). A total of 215 samples were taken for the study. A face-to-face interview technique was applied for data collection consisting of the Rosenberg self-esteem scale. Bivariate analysis applying a Chi-squared test and multivariable logistic regression was carried out to identify the factors associated with self-esteem at 95% CI and 5% level of significance (p-value

Introduction: With the increasing geriatric population, the demand of the geriatric care has been increasing worldwide. Numerous comorbidities like hypertension, COPD, diabetes mellitus, arthritis, are seen commonly in the older population of Nepal, affecting their quality of life. Assessing functional status of individual using Basic Activities of Daily Living and Instrumental Activities of Daily Life scoring is beneficial in predicting the mortality and morbidity among the group. This study hence focuses on determining the comorbidities and functional status of older population. Methods: This descriptive cross-sectional study was conducted from February 2024 to May 2024 in tertiary care hospital at Kathmandu among population of age group above 60 years, after taking ethical approval from Institutional Review Committee (Reference number: 19012024/04). A total of 423 individuals were taken for the study. Data collection for socio-demographic information, comorbidities, functional assessment via Katz and Lawton scale was done and analysed using IBM SPSS. Results: Among the total 423 participants visiting the outpatient department, 188 (44.44%) were males and 235 (55.56%) were females. Basic Activity of Daily Living using Katz scoring, suggested that 377 (89.13%; 95% CI: 85.76%-91.93%)) were independent. Using Lawton scoring for the assessment of Instrumental Activities of Daily Living, it was seen that 170 (40.19%; 95% CI: 35.48%-45.03%) were independent. There were 184 (43.50%) individual with comorbidities. Conclusions: Most of the patients were independent in Basic Activities of Daily Living as per Katz Index of independence and almost half were independent in Instrumental Activities of Daily Living as per Lawton-Brody scale.

Introduction: Echocardiography is an indispensable tool for the diagnosis and management of cardiac patients. It is important to know the spectrum of cardiac abnormalities detected by echocardiography for the proper management of patients. The aim of this study was to evaluate the echocardiographic diagnosis of patients at a multispecialty tertiary care hospital and find out the prevalence of various cardiac diseases diagnosed via echocardiography. Methods: This was a retrospective cross sectional study carried out at the Echocardiography lab of National Academy of Health Sciences. Records of all patients who had done Echocardiography from February 2024 to April 2024 were analyzed. Ethical approval was obtained from Institutional Review Committee (Reference Number:1231/2080/81). Results: Out of 3593 cases, there were 1750 (48.71%) female and 1843 (51.29%) male. Normal echocardiographic study was seen in 1184 (32.95%). Mean age was 56.13±17.38 years. Left ventricle diastolic dysfunction was seen among 1428 (39.74%), followed by tricuspid regurgitation 1026 (28.55%) and pulmonary hypertension 497 (13.83%). Other findings were, left ventricular hypertrophy 204 (5.67%), Left ventricular systolic dysfunction 165 (4.59%), rheumatic heart disease 102 (2.83%) and, congenital heart disease was the lowest documented finding, seen in 30 (0.83%). Conclusions: Most common diseases diagnosed by echocardiography in our study were, diastolic dysfunction, tricuspid regurgitation and pulmonary hypertension.

Introduction: Poor sleep quality is a global public health issue particularly more prevalent in medical professionals and students. Despite various health and occupational risks, research is still lacking regarding the quality of sleep and its irelated factors among medical professionals and students in our region. Therefore, our study aimed to estimate the prevalence of poor sleep quality in this population. Methods: This observational, cross-sectional study was conducted among medical professionals and students of Devdaha Medical College from December 2023 to June 2024 after ethical approval from the Institutional Review Board. Data regarding sleep quality and excessive daytime sleepiness were collected using the Pittsburg Sleep Quality Index (PQSI) and Epworth Sleepiness Scale with pre-made questionnaires in Google Forms. Results: Among 395 participants, 260 (65.83%) were in the age group 20-25 years and 200 (50.63%) were nursing students. The prevalence of poor sleep quality was 146 (36.96%; 95% CI: 32.19%-42.93%) and the global mean score of PSQI was calculated to be 5.12. Out of the total participants, 255 (64.55%) had excessive daytime sleepiness, 84 (21.26%) participants had one or more sleep problems out of which, snoring was in 40 (10.12%) participants. Conclusions: About one-third of the study population poor sleep quality and day time sleepiness was reported in more than half of the respondents.

Key Clinical Message MDMA and cocaine can result in acute onset rhabdomyolysis. However, delayed onset rhabdomyolysis and its pathophysiology is of concern Early therapeutic intervention improves prognosis. Such cases should be promptly referred and managed in centers equipped with critical care and renal replacement therapy.

Background: The shoulder pain etiology is diverse and many disorders present with similar symptoms and signs. Magnetic Resonance Imaging (MRI) provides good multiplanar delineation even without contrast and absence of radiation hazards. Aim and Objectives: To evaluate the role of MRI in diagnosing causes of shoulder pain and their limitations and pitfalls, if any. Material and Methods: Adescriptive cross-sectional study was undertaken in a tertiary care centre from January 2023 to December 2023 with study population of 100 patients referred to the Department of Radiology at our institute with complaints of shoulder pain. Results: Most patients in the study in our study were in the age group of 41-60 years (44%) with mean age of patients being 45.34 ± 16.10 years. In the present study, most patients were male (72%) and common pathologies observed were joint effusion (64%), rotator cuff tear (50%), tendinopathy (46%), degenerative diseases (42%), and bursitis (34%). Hill Sachs's lesion was observed in 20% of patients, while Bankart's was in 24%. A malignant tumor was present in only one patient. Conclusion: MRI showed high sensitivity and specificity for detecting rotator cuff pathologies. It is also highly sensitive for shoulder injuries arising from soft tissues particularly in cases without known trauma. These findings underscore the clinical relevance of MRI in managing shoulder pain, emphasizing its potential to enhance patient outcomes and optimize treatment strategies.

Abstract Background Atopic dermatitis (AD) is a biphasic type of skin inflammation characterized by a predominance of type-2 (TH2) and type-1 (TH1) helper T cell-biased immune responses at the acute and persistent chronic phases, respectively. The present study was aimed to evaluate the efficacy of Artemisia dubia folium extract (ADFE) on AD-like skin lesions through developing a murine model for acute and chronic stages of AD. To induce acute phase AD, the dorsal skin of BALB/c mice was sensitized twice a week with 1% 2, 4-dinitrochlorobenzene (DNCB), followed by challenge (twice) in the following week with 0.2% DNCB. To induce persistent chronic AD, some mice were challenged twice a week for 4 more weeks. After the second challenge, the dorsal skin was exposed to 3% ADFE (five times per week) for 2 weeks (acute phase) or 4 weeks (persistent chronic phase). Results The paradigm of TH2 or TH1 predominance at the acute and chronic phase, respectively, was observed in this mouse model. During the acute phase, we observed an increased IL-4/IFN-γ ratio in splenic culture supernatants, an increased IgG1/IgG2a ratio in serum, and elevated serum IgE levels; however, the skew toward TH2 responses was diminished during the chronic stage. Compared with vehicle controls, ADFE reduced the IL-4/IFN-γ and IgG1/IgG2a ratios in acute AD, but both ratios increased during the chronic stage. Conclusions Our results suggest that ADFE concomitantly suppresses the TH2 predominant response in acute AD, as well as the TH1 predominant response in chronic AD. Thus, ADFE is a candidate therapeutic for AD.

Shaylen Foley,1 Danya E Keene,1 Roman Shrestha,2– 4 Shan-Estelle Brown,5 Kamal Gautam,2 Ryan A Sutherland,3 Francesca Maviglia,3 Rumana Saifi,4 Jeffrey A Wickersham3,4 1Department of Social and Behavioral Sciences, Yale School of Public Health, Yale University, New Haven, CT, USA; 2Department of Allied Health Sciences, University of Connecticut, Storrs, CT, USA; 3Section of Infectious Diseases, Department of Internal Medicine, Yale School of Medicine, Yale University, New Haven, CT, USA; 4Centre of Excellence for Research in AIDS (CERiA), Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia; 5Department of Anthropology, Rollins College, Winter Park, FL, USACorrespondence: Shaylen Foley, 135 College Street, Suite 323, New Haven, CT, 06510, USA, Tel +419 343-4606, Email shaysf@gmail.comIntroduction: Pre-exposure prophylaxis (PrEP) is an effective method for prevention of HIV transmission. Female sex workers (FSW) in Malaysia are at substantially increased risk of acquiring HIV compared to the general female population, yet little is known about this population’s current HIV prevention practices or acceptance of PrEP. This study aims to inform the culturally relevant implementation of PrEP through the qualitative exploration of (1) the potential need for PrEP in this population and (2) the factors that determine FSW willingness to use oral PrEP.Methods: In-depth, semi-structured interviews (n = 30) were conducted with FSW in English, Malay, or Tamil. Transcribed and translated interviews were analyzed using a grounded theory approach.Results: FSW express positive interest in PrEP but prefer it as a supplement to condoms, not a replacement. Perceived challenges to PrEP use include cost, adherence, and side effects.Conclusion: The findings suggest that in combination with condom use, PrEP may be an acceptable method of HIV prevention. Effective PrEP rollout may also include condom promotion using a peer-driven model, cost subsidies, and sex work harm reduction and empowerment components.Keywords: sex work, HIV, pre-exposure prophylaxis, Malaysia

Background: Hepatosplenomegaly is the simultaneous enlargement of liver and spleen. Its causes are enteric fever, hepatitis, scrub typhus, acute liver failure and leukemia and so on. The aim of this study was to determine the prevalence of organomegaly in the form of hepatosplenomegaly, hepatomegaly and isolated splenomegaly in admitted children along with various clinical features and diagnoses associated with them. Methods: A hospital based prospective descriptive cross-sectional study was done from 1st January 2020 to 30th June 2021. Children of one month to fourteen years with hepatomegaly, splenomegaly or hepatosplenomegaly were enrolled in the study. Results: A total of 72 children were enrolled in the study. Among them 65.2% had hepatomegaly, 30.55% had hepatosplenomegaly and 4.16% had splenomegaly. The prevalences of hepatomegaly, hepatosplenomegaly and splenomegaly were 6.46%, 3.02% and 0.41% respectively. Both hepatomegaly and hepatosplenomegaly were common between children of one month to five years with a prevalence of 3.71% and 1.37% respectively. Fever was the most common presenting symptom in both hepatomegaly and hepatosplenomegaly. Infection was the most common cause of organomegaly. Enteric fever was the most common cause of hepatomegaly, whereas scrub typhus was the most common cause of hepatosplenomegaly. Cases of isolated splenomegaly were rare. Conclusion: Hepatosplenomegaly, hepatomegaly are frequently encountered in children. These are mostly due to systemic illnesses owing to infection. Splenomegaly usually occurs simultaneously with hepatomegaly however isolated splenomegaly can occur in few cases. Proper history, physical examinations and investigations are of paramount importance for timely management of the patients.

Background: Ectoparasites are organisms that live in the skin for varying lengths of time and can cause disease. These infestations are highly prevalent in poor and underdeveloped areas. There is a paucity of studies regarding their prevalence in rural areas like the upper Karnali region of Nepal. We conducted a hospital-based study to know the burden of these infestations in the area. Methods: A hospital-based descriptive study was done from March 2023 to February 2024. Data were collected from medical records of the dermatology outpatient department (OPD) and all the clinically diagnosed cases of ectoparasitic infestation were studied. Data were presented as frequency and percentage; seasonal pattern of the diseases was also reported. Results: A total of 6,698 patients attended dermatology OPD during the study period, among whom 1340 had ectoparasitic infestations, resulting in a proportion of 20.01% in this group. Two infestations were found, namely, scabies and pediculosis capitis, with a proportion of 18.36% and 1.65%, respectively. Females represented almost half of the patients with ectoparasitic infestations (49.63%), but about 98% with pediculosis. Ectoparasitic infestation was most common in children aged 0–9 years, i.e., 31.31% and pediculosis was most common in children of 10–19 years (31.81%). Ectoparasitic infestations (41.94%), both scabies (41.7%) and pediculosis (44.55%) were most common during the monsoon season. Conclusion: The ectoparasitic infestations were common the patients presenting to the hospital. Scabies was the most common ectoparasitic infestation and a major public health problem.

Background: Hepatosplenomegaly is the simultaneous enlargement of liver and spleen. Its causes are enteric fever, hepatitis, scrub typhus, acute liver failure and leukemia and so on. The aim of this study was to determine the prevalence of organomegaly in the form of hepatosplenomegaly, hepatomegaly and isolated splenomegaly in admitted children along with various clinical features and diagnoses associated with them. Methods: A hospital based prospective descriptive cross-sectional study was done from 1st January 2020 to 30th June 2021. Children of one month to fourteen years with hepatomegaly, splenomegaly or hepatosplenomegaly were enrolled in the study. Results: A total of 72 children were enrolled in the study. Among them 65.2% had hepatomegaly, 30.55% had hepatosplenomegaly and 4.16% had splenomegaly. The prevalences of hepatomegaly, hepatosplenomegaly and splenomegaly were 6.46%, 3.02% and 0.41% respectively. Both hepatomegaly and hepatosplenomegaly were common between children of one month to five years with a prevalence of 3.71% and 1.37% respectively. Fever was the most common presenting symptom in both hepatomegaly and hepatosplenomegaly. Infection was the most common cause of organomegaly. Enteric fever was the most common cause of hepatomegaly, whereas scrub typhus was the most common cause of hepatosplenomegaly. Cases of isolated splenomegaly were rare. Conclusion: Hepatosplenomegaly, hepatomegaly are frequently encountered in children. These are mostly due to systemic illnesses owing to infection. Splenomegaly usually occurs simultaneously with hepatomegaly however isolated splenomegaly can occur in few cases. Proper history, physical examinations and investigations are of paramount importance for timely management of the patients.

Background: Ectoparasites are organisms that live in the skin for varying lengths of time and can cause disease. These infestations are highly prevalent in poor and underdeveloped areas. There is a paucity of studies regarding their prevalence in rural areas like the upper Karnali region of Nepal. We conducted a hospital-based study to know the burden of these infestations in the area. Methods: A hospital-based descriptive study was done from March 2023 to February 2024. Data were collected from medical records of the dermatology outpatient department (OPD) and all the clinically diagnosed cases of ectoparasitic infestation were studied. Data were presented as frequency and percentage; seasonal pattern of the diseases was also reported. Results: A total of 6,698 patients attended dermatology OPD during the study period, among whom 1340 had ectoparasitic infestations, resulting in a proportion of 20.01% in this group. Two infestations were found, namely, scabies and pediculosis capitis, with a proportion of 18.36% and 1.65%, respectively. Females represented almost half of the patients with ectoparasitic infestations (49.63%), but about 98% with pediculosis. Ectoparasitic infestation was most common in children aged 0–9 years, i.e., 31.31% and pediculosis was most common in children of 10–19 years (31.81%). Ectoparasitic infestations (41.94%), both scabies (41.7%) and pediculosis (44.55%) were most common during the monsoon season. Conclusion: The ectoparasitic infestations were common the patients presenting to the hospital. Scabies was the most common ectoparasitic infestation and a major public health problem.

Key Clinical Message Chronic ketamine use can lead to sphincter of oddi dysfunction (SOD), causing various hepatobiliary complications. Recognizing substance abuse history is vital for early detection. Timely intervention can prevent irreversible liver and pancreas damage. Abstract Ketamine is commonly abused as a recreational drug worldwide due to its ability to induce euphoria‐like effects. Ketamine abuse is associated with many hepatobiliary side effects ranging from cholestasis to biliary sepsis and death. Here we present a case of a young 29‐year female with upper abdominal pain due to SOD resulting from chronic use of ketamine. SOD can result in obstruction or dysfunction of the bile and pancreatic ducts. Ketamine induces SOD by activation of the muscarinic receptors in the sphincter of oddi. Detail history of substance abuse is crucial for early identification of ketamine‐induced SOD. Early identification and treatment of this rare condition can prevent permanent injury to the liver and pancreas.

Key Clinical Message Immune checkpoint inhibitors can rarely lead to occurrence of myositis, myocarditis, and myasthenia gravis (MG). Early recognition and multidisciplinary management are crucial for optimal outcomes. Vigilance for overlapping toxicities is essential in patients receiving combination immunotherapy. Abstract The use of immune checkpoint inhibitors (ICIs) has revolutionized cancer treatment, but it is associated with immune‐related adverse events (IRAEs) affecting various organ systems. The simultaneous occurrence of MG, myocarditis, and myositis highlights the complex nature of IRAEs. Early recognition and comprehensive multidisciplinary management are crucial for optimal patient outcomes. We present a unique case report of a 76‐year‐old male patient with advanced melanoma who developed concurrent myositis, myocarditis, and MG while receiving combination immunotherapy with Nivolumab and Ipilimumab. This case underscores the significance of recognizing and addressing the “Terrible Triad” of IRAEs in patients receiving ICIs. Healthcare providers should maintain a high index of suspicion for overlapping toxicities and promptly initiate appropriate interventions.

Key Clinical Message Patients of Bullous Pemphigoid with predominant lymphocytic inflammatory infiltrate on histopathology have a severe form of the disease requiring high doses of steroids along with an adjuvant immunosuppressant. Thus, the histopathological evaluation would predict the severity of Bullous Pemphigoid, especially in countries where ELISA and immunofluorescence are not readily available.

Subarachnoid hemorrhage is a neurological emergency in which arterial blood accumulates in the subarachnoid space with cerebral aneurysmal rupture being the most common cause. Subarachnoid hemorrhage is often misdiagnosed in the emergency department and mortality rates range from 8% to 67%. It may be the manifestation of the chronicity of the migraine. The difference in severity or quality compared to previous headaches, and other symptoms, particularly neck stiffness, but also seizure, syncope, focal neurological deficit, and vomiting are the key factors differentiating subarachnoid hemorrhage from the migraine. We report a case of a 37-year-old female with a previous history of migraines who presented with acute onset of excruciating headaches in the occiput associated with nausea, vomiting, and photophobia in whom a non-contrast computed tomography scan of the head showed hyper-densities involving the bilateral cerebral cortical sulcus and Sylvian fissure and the cerebral angiography showed a complex aneurysm in anterior communicating artery.

Introduction: Condyle of mandible plays crucial role in functioning of jaw. Untimely and inadequate treatment leads to deformity of face along with range of complications. The purpose of this study was to assess outcomes of open reduction and internal fixation of mandibular condyle fractures in terms of mouth opening, facial nerve function and occlusion. Methods: This was a prospective observational study conducted at Chitwan Medical College. Thirty-two patients of mandibular condyle fracture were treated by open reduction and internal fixation via retromandibular approach and evaluated for mouth opening, facial nerve function, and occlusion on 2nd day, 10th day and 25th day postoperatively. All collected data were entered on SPSS version 21 and analyzed using descriptive statistical methods. The results were presented as graphs and tables. Results: Of 32 patients, 7 patients show abnormal occlusion while 25 patients show normal occlusion. A gradual improvement in mouth opening and facial nerve function was also seen on 25th day. Conclusion: Open reduction and internal fixation gives superior clinical outcomes in terms of mouth opening, facial nerve function and occlusion. It also allows good anatomical repositioning and early function. Keywords: Facial nerve function, Mouth opening, Occlusion, Open reduction internal fixation Layman summary: The mandible is largest and strongest bone of face. However, it is also most common facial bone that is fractured. Condyle of the mandible is highly prevalent site of mandibular fracture. The fracture of mandible is managed by open or closed reduction. Both of the methods have their own merits and demerits. In this study, we planned to assess the outcomes of open reduction and internal fixation of mandibular condyle fractures at a tertiary care center of Nepal. We found that ORIF has a good clinical outcome in mandibular fracture in terms of mouth opening, facial nerve function and occlusion.

Introduction: Children are at greatest risk for severe illness from Respiratory Syncytial Virus (RSV). The aim of the study was to find out the knowledge of RSV, practice and knowledge about vaccination during pregnancy and the willingness to accept vaccines against RSV during pregnancy in the future among mothers needs to be understood which would add up information for stakeholder and policy makers. Methods: A preformed Performa was used for face-to-face interview was conducted among 340 pregnant women who visited the Antenatal clinic from 15-Oct-2023 to 30-Nov-2023 in their second and third trimester. Socio-demographic characteristics, knowledge and the attitude concerning antenatal vaccination affecting the acceptance of RSV vaccine were evaluated from the interview. Results: The mean age was 28.4 years, with 310 (91.18%) already having at least one child. Six (1.76%) participants had previously heard about RSV, and 325 (95.59%) were aware of the problem caused by RSV after they were briefly explained about it in their local language. A total of 246 (72.35%) of the mothers expressed willingness to be vaccinated themselves rather than vaccinating their children if such an option existed. Only 2 (0.59%) participants were familiar with nasal vaccines, and only 18 (5.29%) believed in such vaccines being effective. Despite this, almost all participants 339 (99.71%) in the study demonstrated willingness to receive additional antenatal vaccines if approved for use in future. Conclusions: The study showed a limited understanding of RSV in children among pregnant women in Nepal. However, they are aware of the impact of bronchiolitis and expressed a strong willingness to undergo maternal vaccination against RSV.

Legionella spp. is an underreported cause of Community Acquired pneumonia that affects significant population specially in urban areas and its prevalence is on an increasing trend. The routine practice of testing for urinary antigen of Legionella in all suspected cases of pneumonia is prevalent is resource rich western countries. Although several studies have shown no distinct advantage of performing routine urinary antigen testing, this practice continues to be preferred by clinicians. In this viewpoint, we have discussed the advantages and disadvantages of urinary antigen testing, its relevance in current practice and its impact on clinical outcomes.

Abstract Background Uterine leiomyosarcomas (uLMS) are aggressive tumours with poor prognosis and limited treatment options. Although immune checkpoint blockade (ICB) has proven effective in some ‘challenging‐to‐treat’ cancers, clinical trials showed that uLMS do not respond to ICB. Emerging evidence suggests that aberrant PI3K/mTOR signalling can drive resistance to ICB. We therefore explored the relevance of the PI3K/mTOR pathway for ICB treatment in uLMS and explored pharmacological inhibition of this pathway to sensitise these tumours to ICB. Methods We performed an integrated multiomics analysis based on TCGA data to explore the correlation between PI3K/mTOR dysregulation and immune infiltration in 101 LMS. We assessed response to PI3K/mTOR inhibitors in immunodeficient and humanized uLMS patient‐derived xenografts (PDXs) by evaluating tumour microenvironment modulation using multiplex immunofluorescence. We explored response to single‐agent and a combination of PI3K/mTOR inhibitors with PD‐1 blockade in humanized uLMS PDXs. We mapped intratumoural dynamics using single‐cell RNA/TCR sequencing of serially collected biopsies. Results PI3K/mTOR over‐activation (pS6high) associated with lymphocyte depletion and wound healing immune landscapes in (u)LMS, suggesting it contributes to immune evasion. In contrast, PI3K/mTOR inhibition induced profound tumour microenvironment remodelling in an ICB‐resistant humanized uLMS PDX model, fostering adaptive anti‐tumour immune responses. Indeed, PI3K/mTOR inhibition induced macrophage repolarisation towards an anti‐tumourigenic phenotype and increased antigen presentation on dendritic and tumour cells, but also promoted infiltration of PD‐1+ T cells displaying an exhausted phenotype. When combined with anti‐PD‐1, PI3K/mTOR inhibition led to partial or complete tumour responses, whereas no response to single‐agent anti‐PD‐1 was observed. Combination therapy reinvigorated exhausted T cells and induced clonal hyper‐expansion of a cytotoxic CD8+ T‐cell population supported by a CD4+ Th1 niche. Conclusions Our findings indicate that aberrant PI3K/mTOR pathway activation contributes to immune escape in uLMS and provides a rationale for combining PI3K/mTOR inhibition with ICB for the treatment of this patient population.

Tuberous sclerosis is an uncommon neurocutaneous syndrome characterized by hamartomatous growths with unpredictable progression. Diagnosing and managing neonatal tuberous sclerosis can be challenging. We report a rare case of a 30-day-old male born out of a non-consanguineous marriage who presented with poor suckling and persistent abnormal body movement, required prolonged intensive care, and was diagnosed with tuberous sclerosis with multisystem involvement.

Visual loss following a spine surgery in a prone position is a disastrous and irreversible complication. Moreover, the recommended treatment for such visual loss is lacking and the outcome is not so satisfactory. A 38-year-old gentleman developed profound right sided visual loss after an uneventful cervical spine surgery in a prone position that lasted approximately two and half hours. Immediate ophthalmic consultation was done and the case was diagnosed as right-sided central retinal artery occlusion. Despite the initiation of vasodilatation, anticoagulation, and adequate fluid infusion, satisfactory improvement was not achieved. Extensive review of pertinent literature highlighted limited efficacy of treatments for postoperative visual loss after prone spinal surgery, further emphasizing the importance of preventive measures as the cornerstone in such procedures.

Visual loss following a spine surgery in a prone position is a disastrous and irreversible complication. Moreover, the recommended treatment for such visual loss is lacking and the outcome is not so satisfactory. A 38-year-old gentleman developed profound right sided visual loss after an uneventful cervical spine surgery in a prone position that lasted approximately two and half hours. Immediate ophthalmic consultation was done and the case was diagnosed as right-sided central retinal artery occlusion. Despite the initiation of vasodilatation, anticoagulation, and adequate fluid infusion, satisfactory improvement was not achieved. Extensive review of pertinent literature highlighted limited efficacy of treatments for postoperative visual loss after prone spinal surgery, further emphasizing the importance of preventive measures as the cornerstone in such procedures.

Key Clinical Message Chylothorax is a rare entity associated with morbidity. Surgical thoracic duct ligation (TDL) by thoracoscopic approach is the recommended choice for persistent chylothorax. However, thoracoscopy is not feasible in case of previous pleurodesis. We describe a successful laparoscopic transhiatal en‐mass TDL in a 61‐year‐old lady for persistent spontaneous chylothorax after failed optimal conservative management and three sessions of pleurodesis. The study shows that laparoscopic transhiatal thoracic duct ligation is an effective alternative in a case where thoracoscopy is not feasible due to various reasons.

Key Clinical Message Clinicians in tuberculosis and dengue endemic regions should have heightened vigilance for drug‐induced liver injury (DILI) overlapping with active infections, enabling prompt recognition and life‐saving conservative management. Abstract Severe dengue and drug‐induced liver injury (DILI) are significant independent risk factors for acute liver failure. The co‐occurrence of these conditions significantly complicates clinical management. Here, we describe the case of a 21‐year‐old Nepali female who developed acute liver failure during antitubercular therapy (ATT). The patient, presenting with fever and nausea after 3 weeks of ATT, subsequently received a diagnosis of severe dengue. Laboratory evidence indicated markedly elevated transaminases (AST 4335 U/L, ALT 1958 U/L), total bilirubin (72 μmol/L), and INR (>5). Prompt discontinuation of first‐line ATT, initiation of a modified ATT regimen, and N‐acetylcysteine (NAC) infusion facilitated the patient's recovery after a week of intensive care. This case underscores the potential for synergistic hepatotoxicity in regions where multiple endemic illnesses coincide. Early recognition of DILI, cessation of offending agents, and comprehensive intensive care are crucial interventions. While the definitive efficacy of NAC remains under investigation, its timely administration in these complex cases warrants exploration for its potential lifesaving benefits.

Abstract Tumor endothelial cells (TECs) actively repress inflammatory responses and maintain an immune‐excluded tumor phenotype. However, the molecular mechanisms that sustain TEC‐mediated immunosuppression remain largely elusive. Here, we show that autophagy ablation in TECs boosts antitumor immunity by supporting infiltration and effector function of T‐cells, thereby restricting melanoma growth. In melanoma‐bearing mice, loss of TEC autophagy leads to the transcriptional expression of an immunostimulatory/inflammatory TEC phenotype driven by heightened NF‐kB and STING signaling. In line, single‐cell transcriptomic datasets from melanoma patients disclose an enriched InflammatoryHigh/AutophagyLow TEC phenotype in correlation with clinical responses to immunotherapy, and responders exhibit an increased presence of inflamed vessels interfacing with infiltrating CD8+ T‐cells. Mechanistically, STING‐dependent immunity in TECs is not critical for the immunomodulatory effects of autophagy ablation, since NF‐kB‐driven inflammation remains functional in STING/ATG5 double knockout TECs. Hence, our study identifies autophagy as a principal tumor vascular anti‐inflammatory mechanism dampening melanoma antitumor immunity.

Abstract Glioblastoma (GBM) remains the most malignant primary brain tumor, with a median survival rarely exceeding 2 years. Tumor heterogeneity and an immunosuppressive microenvironment are key factors contributing to the poor response rates of current therapeutic approaches. GBM‐associated macrophages (GAMs) often exhibit immunosuppressive features that promote tumor progression. However, their dynamic interactions with GBM tumor cells remain poorly understood. Here, we used patient‐derived GBM stem cell cultures and combined single‐cell RNA sequencing of GAM‐GBM co‐cultures and real‐time in vivo monitoring of GAM‐GBM interactions in orthotopic zebrafish xenograft models to provide insight into the cellular, molecular, and spatial heterogeneity. Our analyses revealed substantial heterogeneity across GBM patients in GBM‐induced GAM polarization and the ability to attract and activate GAMs—features that correlated with patient survival. Differential gene expression analysis, immunohistochemistry on original tumor samples, and knock‐out experiments in zebrafish subsequently identified LGALS1 as a primary regulator of immunosuppression. Overall, our work highlights that GAM‐GBM interactions can be studied in a clinically relevant way using co‐cultures and avatar models, while offering new opportunities to identify promising immune‐modulating targets.

Abstract Background Mental wellbeing encompasses life satisfaction, social connectedness, agency and resilience. In adolescence, mental wellbeing reduces sexual health risk behaviours, substance use and violence; improves educational outcomes; and protects mental health in adulthood. Mental health promotion seeks to improve mental wellbeing and can include activities to engage participants in sport. However, few high-quality trials of mental health promotion interventions have been conducted with adolescents, especially in low- and middle-income countries. We sought to address this gap by testing SMART (Sports-based Mental heAlth pRomotion for adolescenTs) in a pilot cluster-randomised controlled trial (cRCT) in Bardiya, Nepal. Methods The objectives of the trial are to assess the acceptability and feasibility of SMART, test trial procedures, explore outcome distributions in intervention and control clusters and calculate the total annual cost of the intervention and unit cost per adolescent. The trial design is a parallel-group, two-arm superiority pilot cRCT with a 1:1 allocation ratio and two cross-sectional census surveys with adolescents aged 12–19, one pre-intervention (baseline) and one post-intervention (endline). The study area is four communities of approximately 1000 population (166 adolescents per community). Each community represents one cluster. SMART comprises twice weekly football, martial arts and dance coaching, open to all adolescents in the community, led by local sports coaches who have received psychosocial training. Sports melas (festivals) and theatre performances will raise community awareness about SMART, mental health and the benefits of sport. Adolescents in control clusters will participate in sport as usual. In baseline and endline surveys, we will measure mental wellbeing, self-esteem, self-efficacy, emotion regulation, social support, depression, anxiety and functional impairment. Using observation checklists, unstructured observation and attendance registers from coaching sessions, and minutes of meetings between coaches and supervisors, we will assess intervention fidelity, exposure and reach. In focus group discussions and interviews with coaches, teachers, caregivers and adolescents, we will explore intervention acceptability and mechanisms of change. Intervention costs will be captured from monthly project accounts, timesheets and discussions with staff members. Discussion Findings will identify elements of the intervention and trial procedures requiring revision prior to a full cRCT to evaluate the effectiveness of SMART. Trial registration ISRCTN, ISRCTN15973986 , registered on 6 September 2022; ClinicalTrials.gov, NCT05394311 , registered 27 May 2022.

Abstract Background An increased focus on quality and patient safety has led to the evolution of hospitalists. The number of hospitalists covering ward and outpatient care is on the rise in Japan. However, it is unclear what roles hospital workers themselves consider important in their practice. Therefore, this study investigated what hospitalists and non-hospitalist generalists in Japan consider important for the practice of their specialty. Methods This was an observational study that included Japanese hospitalists (1) currently working in a general medicine (GM) or general internal medicine department and (2) working at a hospital. Using originally developed questionnaire items, we surveyed the items important to hospitalists and non-hospitalist generalists. Results There were 971 participants (733 hospitalists, 238 non-hospitalist) in the study. The response rate was 26.1%. Both hospitalists and non-hospitalists ranked evidence-based medicine as the most important for their practice. In addition, hospitalists ranked diagnostic reasoning and inpatient medical management as the second and third most important roles for their practice, while non-hospitalists ranked inpatient medical management and elderly care as second and third. Conclusions This is the first study investigating the roles Japanese hospitalists consider important and comparing those to that of non-hospitalist generalists. Many of the items that hospitalists considered important were those that hospitalists in Japan are working on within and outside academic societies. We found that diagnostic medicine and quality and safety are areas that are likely to see further evolution as hospitalists specifically emphasized on them. In the future, we expect to see suggestions and research for further enhancing the items that hospital workers value and emphasise upon.

Cyanobacterial Harmful Algal Blooms (CyanoHABs) occur when colonies of photosynthetic bacteria called cyanobacteria grow out of control, usually in warm, nutrient-rich, slow-moving waters. They are becoming increasingly prevalent around the world and release harmful toxins called cyanotoxins into bodies of water, which negatively affect human and ecological health. One such cyanotoxin is microcystin, with microcystin-leucine arginine (MC-LR) being the most widespread. Exposure to MC-LR inhibits serine and threonine protein phosphatase 1 and 2A in humans, causing a myriad of health problems. Fortunately, certain naturally occurring bacteria may be able to degrade MC-LR and reverse its effects. Mice were separated into five experimental groups based on three types of pre-treatments (control drinking water/vehicle, probiotic-supplemented drinking water, and heat-inactivated probiotic-supplemented drinking water) as well as two types of exposures (microcystin-LR and water/vehicle). RNA was extracted from kidneys for sequencing because MC-LR exacerbates kidney disease. Gene expression data were analyzed with 3 Pod Reports, an R package that produces a three-part report consisting of Gene Set Enrichment Analysis (GSEA), EnrichR, and integrative LINCS (iLINCS). MC-LR exposure was associated with upregulated cellular respiration and metabolism pathways and downregulated transcription pathways. Probiotic pre-treatment combined with MC-LR exposure was associated with upregulated lipoprotein particle pathways and downregulated respiration and ribosome pathways. Overall, the probiotic mixture corrected the transcriptional profile resulting from MC-LR exposure. Future high yield pathways that could be targeted for therapeutic benefit include VEGFR inhibitors and increased expression of renal kidney indicator genes such as EGFR.

Cyanobacterial Harmful Algal Blooms (CyanoHABs) occur when colonies of photosynthetic bacteria called cyanobacteria grow out of control, usually in warm, nutrient-rich, slow-moving waters. They are becoming increasingly prevalent around the world and release harmful toxins called cyanotoxins into bodies of water, which negatively affect human and ecological health. One such cyanotoxin is microcystin, with microcystin-leucine arginine (MC-LR) being the most widespread. Exposure to MC-LR inhibits serine and threonine protein phosphatase 1 and 2A in humans, causing a myriad of health problems. Fortunately, certain naturally occurring bacteria may be able to degrade MC-LR and reverse its effects. Mice were separated into five experimental groups based on three types of pre-treatments (control drinking water/vehicle, probiotic-supplemented drinking water, and heat-inactivated probiotic-supplemented drinking water) as well as two types of exposures (microcystin-LR and water/vehicle). RNA was extracted from kidneys for sequencing because MC-LR exacerbates kidney disease. Gene expression data were analyzed with 3 Pod Reports, an R package that produces a three-part report consisting of Gene Set Enrichment Analysis (GSEA), EnrichR, and integrative LINCS (iLINCS). MC-LR exposure was associated with upregulated cellular respiration and metabolism pathways and downregulated transcription pathways. Probiotic pre-treatment combined with MC-LR exposure was associated with upregulated lipoprotein particle pathways and downregulated respiration and ribosome pathways. Overall, the probiotic mixture corrected the transcriptional profile resulting from MC-LR exposure. Future high yield pathways that could be targeted for therapeutic benefit include VEGFR inhibitors and increased expression of renal kidney indicator genes such as EGFR.

Amniotic band syndrome (ABS) is a group of rare congenital abnormalities caused by wrapping of parts of the foetus by fibrous amniotic bands during intrauterine life. It can be seen in infants without any known genetic mutations. Band formation most frequently affects the distal segments, including the hand. Here, we report a case of a neonate who presented with multiple congenital abnormalities and clinical features that suggest the Amniotic Band Syndrome. It was delivered by a 17-year-old female patient at 28 weeks period of gestation, who had a medical abortion.

Cyclopia is the most extreme form of holoprosencephaly. It is characterized by the failure of the embryonic prosencephalon to properly divide the orbits of the eye into two cavities which results in babies with a single or partially divided eye in a single orbit. We report a case of a 28 years old primigravida who came for medical termination at 25 weeks of gestation and delivered a 600 grams dead female fetus with cyclopia, fetal proboscis, and neurocutaneous marker. Its incompatibility with life makes early diagnosis using ultrasonography and fetal magnetic resonance imaging essential in early management and essential counseling to parents.

Key Clinical Message Dolutegravir, the most recent antiretroviral drug with high efficacy, good tolerability, infrequent drug–drug interactions, and a favorable safety profile has not been reported in current literature as a cause of acquired sideroblastic anemia. Here, we present a 35‐year‐old male patient who was diagnosed with acquired sideroblastic anemia to Dolutegravir therapy.

Public policies often aim to improve welfare, economic injustice and reduce inequality, particularly in the social protection, labour, health and education sectors. While these policies frequently operate in silos, the education sphere can operate as a cross-sectoral link. Schools represent a unique locus, with globally hundreds of millions of children attending class every day. A high-profile policy example is school feeding, with over 400 million students worldwide receiving meals in schools. The benefits of harmonising interventions across sectors with a common delivery platform include economies of scale. Moreover, economic evaluation frameworks commonly used to assess policies rarely account for impact across sectors besides their primary intent. For example, school meals are often evaluated for their impact on nutrition, but they also have educational benefits, including increasing attendance and learning and incorporating smallholder farmers into corporate value chains. To address these gaps, we propose the introduction of a comprehensive value-for-money framework for investments toward school systems that acknowledges the return to a common delivery platform—schools—and the multisectoral returns (eg, education, health and nutrition, labour, social protection) emerging from the rollout of school-based programmes. Directly building on benefit-cost analysis methods, this framework could help identify interventions that yield the highest gains in human capital per budget expenditure, with direct implications for finance ministries. Given the detrimental impact of COVID-19 on schoolchildren and human capital, it is urgent to build back stronger and more sustainable welfare systems.

Abstract Background Hypothesizing that soccer‐associated public health campaigns influence men more than women, we investigated the characteristics and motivations of participants who received rubella antibody testing at a Japanese professional football league event. Methods This was a survey‐based cross sectional study, comparing the characteristics and motivations between men and women regarding rubella antibody testing. Results Free and convenient testing was the biggest behavioral influencer, but the information provided by healthcare professionals and athletes also played a strong motivating role. Men reported more influence from celebrity athletes than women. Conclusions Public health attention raised by celebrity athletes may facilitate rubella awareness among male spectators.

Malignant atrophic papulosis sometimes known as Degos’ disease is an idiopathic, uncommon condition with fewer than 200 occurrences documented. It is a chronic thrombo-obliterative vasculopathy characterised by papular skin lesions with a core porcelain-white atrophy and a surrounding telangiectatic border. We report a 15-year-old male patient with a recurrent history of hollow viscus perforation, which was managed on all the occasions with exploratory laparotomy and primary perforation repair. Additionally, the patient had a five month history of numerous, non-itchy, atrophic papules with a core porcelain-like area and hyperkeratotic margins, characteristic of Degos' disease. The only basis for diagnosis is the distinctive skin lesions with biopsy. Along with systemic lupus erythematosus and other connective tissue diseases, tuberculosis must also be taken into account while assessing the clinical presentation of malignant atrophic papulosis. There is currently no known treatment for malignant atrophic papulosis that has been effective.

This article unfolds the journey of a 28-year-old junior doctor entangled in the throes of a pernicious anemia diagnosis during her travels abroad, a scenario exacerbated by the grip of a COVID-19 lockdown. Adrift without medical insurance and distant from her family, she found herself under the care of a compassionate on-call resident, emphasizing the crucial role of kindness and compassion in her predicament. Her treatment regimen encompassed a series of CBC tests meticulously tracking cobalamin and ferritin levels, complemented by extensive examinations for iron deficiency and a regimen of vital vitamin B12 injections, all carried out under vigilant scrutiny to ensure the eventual normalization of her lab findings—a process spanning over a week. As the medical landscape continues to grapple with the COVID-19 pandemic, stories like hers underscore the vital need for empathy and understanding within the healthcare sphere. In these challenging times, compassion emerged as a lifeline, bridging the gap between distress and recovery. This narrative serves as a poignant reminder that amidst the complexity of medical science, it is often the simplest acts of kindness that can make all the difference. In the face of an ongoing shift towards policy-centric healthcare, the article advocates a return to a patient-centric approach, one where kindness becomes an integral element of treatment, alleviating anxiety, reducing uncertainty, and promoting overall well-being. It prompts readers to reflect on the profound impact of compassion and empathy in medicine, sparking a dialogue on how fostering a more humane and inclusive healthcare system ultimately benefits us all. Experience Framework This article is associated with the Patient, Family & Community Engagement lens of The Beryl Institute Experience Framework (https://theberylinstitute.org/experience-framework/). Access other PXJ articles related to this lens. Access other resources related to this lens.

Key Clinical Message Skin involvement in systemic lupus erythematosus (SLE) is common. Bullous lesions in SLE patients are usually due to other autoimmune conditions or rarely, due to lupus itself. Bullous SLE is rare blistering disorder characterized by subepidermal blisters. We, hereby, present a case of bullous SLE in a 24‐year‐old female who responded well to systemic glucocorticoids, mycophenolate mofetil, and dapsone.

Introduction: Hypovitaminosis D is a global public health problem affecting approximately one billion people, with a particularly high prevalence in South Asia. Several hospital-based studies from Nepal show a high prevalence of hypovitaminosis D. However, large-scale community-based studies are lacking. The aim of the study was to find out the prevalence of hypovitaminosis D among blood samples of patients presenting to the Department of Biochemistry of a tertiary care centre. Methods: A descriptive cross-sectional study was conducted among blood samples of patients presenting to the Department of Biochemistry of a tertiary care centre from 3 November 2022 to 30 April 2023 after obtaining ethical approval from the Institutional Review Committee (Reference number: 136/22). Patients of all age groups and genders who were sent for the evaluation of Vitamin D at the laboratory were included. A convenience sampling technique was used. The point estimate was calculated at a 95% Confidence Interval. Results: Out of 376 patients, hypovitaminosis was seen in 274 (72.87%) (68.38-77.36, 95% Confidence Interval). Vitamin D insufficiency was present in 252 (91.97%) and vitamin D deficiency was present in 22 (8.03%) participants. Conclusions: The prevalence of hypovitaminosis D was found to be higher than other studies done in similar settings.

Key Clinical Message Primary retroperitoneal masses have numerous differential diagnoses, many of which are rare entities. These can be neoplastic or nonneoplastic. Among the rare conditions are solitary fibrous tumors, which can either be benign or malignant. It is a mesenchymal, spindle‐cell tumor, reported first in 1931 as a pleural tumor by Klemperer et al. A 20‐year‐old lady, with abdominal pain for 6 months, was diagnosed with a retroperitoneal mass on the left lower abdomen on USG which was confirmed by an MRI scan of the abdomen. The patient underwent laparoscopy‐assisted excision of the mass. The final histopathological reports and immunohistochemistry reports revealed a solitary fibrous tumor. Solitary fibrous tumors (SFTs) are rare tumors in the retroperitoneum. In our search, fewer than a hundred cases have been reported. It has a characteristic “patternless pattern” in a microscopic study. Adverse outcomes of SFTs are associated with atypical features in histology, such as nuclear pleomorphism, necrosis, increased cellularity, and mitoses >4/10 HPF and size more than 10 cm. The standard of care is surgical excision with clear margins. Open surgeries have been done traditionally; we present a case where we performed the excision laparoscopically.

Key Clinical Message Granulomatosis with polyangiitis (GPA), formerly known as Wegener's granulomatosis, is a necrotizing vasculitis characterized by small‐to‐medium‐sized vessel involvement and the presence of antineutrophil cytoplasmic antibodies (ANCA). We present a case of a 26‐year‐old Asian woman who was transferred to our center from a nearby hospital, where she presented with shortness of breath, tested positive for COVID‐19, and was being managed for COVID‐19 pneumonia. She also had hemoptysis, skin lesions, and left foot numbness. Serological markers and VATS‐guided lung biopsy confirmed the diagnosis. Treatment with methylprednisolone and rituximab led to stabilization, despite complications of subcutaneous emphysema and lower extremity neuropathic symptoms. Early recognition and appropriate management of GPA are crucial for optimal outcomes.