Trinity School of Medicine

Background: Transcatheter mitral valve intervention, including repair (e.g., edge-to-edge repair) and replacement, is now a cornerstone of treatment for severe mitral regurgitation (MR) in high-risk patients, providing a less invasive alternative to surgical treatment. The purpose of this systematic review is to assess the efficacy and safety of different antithrombotic strategies to prevent thromboembolic events and bleeding complications after transcatheter mitral valve repair (TMVR). Methods: According to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, a systematic literature search on PubMed, Embase, Web of Science, Scopus, and Cochrane Library was conducted from January 2015 to January 2025. Eligible studies included adult patients who underwent transcatheter mitral valve intervention (including repair and replacement procedures) and compared different antithrombotic regimens, including direct oral anticoagulants (DOACs), vitamin K antagonists (VKAs), and antiplatelet therapies. Two reviewers independently extracted data and assessed quality. The studies were too heterogeneous, so a narrative synthesis was performed. Results: Fifteen studies involving 20,956 patients were included. DOACs were associated with a lower risk of major bleeding compared to VKAs [hazard ratio (HR): 0.21, p = 0.02, in one large study], with similar rates of stroke. Mortality was lower with DOACs in several analyses (e.g., HR: 0.67). Triple therapy and dual antiplatelet therapy (DAPT) were associated with increased bleeding risk without providing additional thromboembolic protection. Discussion: DOACs have a safer profile in post-TMVR patients, with reduced bleeding risk and lower mortality compared with VKAs. Triple therapy and DAPT should only be used in high-risk patients with specific indications due to their greater risk of bleeding. Optimizing outcomes requires a tailored approach to antithrombotic therapy, considering patient factors and procedural considerations. Definitive standards may still demand further investigation, such as multicenter randomized controlled trials evaluating antithrombotic treatments after TMVR.

The systematic review and meta-analysis explored the effects of aerobic exercise on cognition and sleep quality in individuals with insomnia. The research was important to identify effectiveness of mild, brisk, moderate and aerobic exercise among adults diagnosed with insomnia. The researchers searched multiple databases using PubMed, Cochrane, EBSCO, PsycINFO, Medline, and ScienceDirect to identify relevant journal articles. The keywords used for various search combinations were “insomnia,” “sleep,” “cognition,” “REM sleep,” and “aerobic exercise,” with the use of the Boolean operator “AND” and “OR” with terms associated with “quality of sleep.” Studies included qualitative and quantitative studies using the eligibility criteria as outlined in the PRISMA. registries.The research analyzed exercise in a routine for a person with insomnia improves their sleep quality and has a beneficial impact on their cognition. An interesting finding showed that daily aerobic exercise had a significant impact on enhancing the quality of sleep. A compelling finding revealed that sleep efficiency resulted in improved sleep latency which resulted in a decreased timeframe for falling asleep. An interesting finding was that sleep hygiene education was effective in improving the quality of sleep and mood among adults. An expected outcome was that age may play an important role in managing insomnia. An unexpected finding was that increased aerobic activity levels more than 150 minutes per week may benefit persons with insomnia. Though further research is needed to broaden knowledge about exercise on cognition and sleep quality, this systematic review contributes to the body of literature.

Early-career neurosurgeon training has not yet fully recovered from the decrease in operative exposure that began during the early COVID era. Elective case cancellations, redeployment, and limited staff access to operating rooms reduced the chances of graduated responsibility across a variety of settings and widened existing gaps in the global workforce. Much of this was addressed by numerous programs that reinforced the application of simulation using inexpensive models and virtual environments, helping keep skills developing in the absence of practical experience. It was reported that simulator hours and trainee confidence improved, although practical surgery was needed to consolidate them. Online instruction, video-conferencing dissections, and organized mentoring also assisted learning, particularly in areas where training facilities are not evenly distributed. New interest in digital tools and early uses of artificial intelligence were indicative of a larger project to create flexible training systems. Developing a systematic roadmap that brings together case-log surveillance, simulation, video assessment, stratified mentorship, and partners in networks can help stabilize and modernize early career neurosurgical education.

Mounier-Kuhn syndrome (MKS), or tracheobronchomegaly, is a rare disorder characterized by dilation of the trachea and main bronchi due to atrophy of elastic and smooth muscle fibers. It is associated with recurrent respiratory infections, bronchiectasis, and airway collapse. Although radiological diagnosis is well established, clinical recognition remains delayed in many cases due to the disease's rarity and nonspecific presentation. We present a 56-year-old male with a known history of MKS who presented with pleuritic chest pain, productive cough, and constitutional symptoms. Computed tomography (CT) scans of the chest showed significant tracheobronchomegaly with posterior tracheal diverticulum and cystic bronchiectasis. Laboratory evaluation was unremarkable, and infectious and autoimmune workups were negative. The patient was treated conservatively with pulmonary hygiene, bronchodilators, and symptom-targeted therapy, leading to gradual improvement. This case dives into a noninfectious symptomatic flare of MKS, expanding the clinical understanding of its complications. We explore the pathophysiology of pleuritic pain in this setting and review diagnostic delays, bronchiectasis-related morbidity, and therapeutic strategies. Advances in interventional pulmonology, including airway stenting and tracheobronchoplasty, offer promising outcomes in selected patients. Early identification, structured imaging assessment, and a multidisciplinary approach are key in managing this complex syndrome.

Checkpoint inhibitor pneumonitis (CIP) is a serious immune-related adverse event. Patients with interstitial lung disease (ILD) or chronic obstructive pulmonary disease (COPD) may be at increased risk, but data comparing these populations is limited. We aimed to evaluate differences in CIP incidence, onset, recurrence, and outcomes among patients with ILD, COPD, and those without pre-existing lung disease. We conducted a retrospective cohort study using the TriNetX Research Network, identifying patients who received immune checkpoint inhibitors (ICIs) between January 2017 and January 2023. Patients were stratified into ILD, COPD, and control groups. CIP was identified using ICD codes. Propensity score matching (1:1:1) was used to adjust for baseline characteristics. Outcomes included CIP incidence, time to onset, recurrence, hospitalisation, and mortality. Among 184,000+ ICI recipients, 3147 had ILD, 8657 had COPD, and 47,031 had no known lung disease. After matching (n = 3147/group), CIP incidence was highest in ILD patients (4.6%) compared to COPD (1.9%) and controls (1.5%) (p < 0.001). Time to CIP onset was similar across groups. ILD patients with CIP had higher recurrence (16.4% vs. 9.1% and 8.3%) and higher all-cause hospitalisation (61% vs. 40% and 39%) compared to COPD and control groups. All-cause mortality was also higher in the ILD-CIP group (41.1%). ILD significantly increases the risk of developing CIP and worsens associated outcomes, including recurrence and mortality. These findings support closer surveillance and risk stratification in ICI-treated patients with underlying ILD.

Objective:To synthesize recent advancements in metastatic spinal cord compression (MSCC) treatment, evaluating their efficacy in improving neurological function, pain relief, survival, and quality of life.Background:MSCC is an oncologic emergency caused by the progression of cancer to the spine and is prevalent in approximately 3–5% of all cancer patients, with a relatively higher incidence of breast, prostate, and lung cancers. MSCC can lead to irreversible paralysis due to loss of vital sensory and motor functions, thus requiring an immediate diagnosis and treatment.Methods:A systematic PubMed search identified studies published over the past 5 years focusing on advancements in MSCC treatment. Applying the PICO criteria, 132 articles were retrieved, of which 38 met the inclusion criteria after rigorous screening.Result:Effective care of MSCC includes high-dose corticosteroids, surgery, and radiation therapy. Advancements such as robot-assisted and minimally invasive surgeries enhance surgical outcomes. Emerging technologies, including deep learning models for early detection and automated MRI analysis, improve diagnostic accuracy. Personalized medicine techniques, such as next-generation sequencing, enable the development of customized therapies tailored to individual tumor characteristics. Innovations such as bioengineered implants provide better imaging compatibility and reduce radiation scattering. Proton therapy delivers targeted radiation with minimal harm to adjacent tissues.Conclusion:Prompt, multimodal treatment is necessary, including corticosteroids, surgery, and radiation therapy to reduce symptoms and enhance patient outcomes. Despite advancements, challenges such as delayed diagnosis and limited access to specialized treatments persist. Precision medicine, artificial intelligence–based diagnostics, and easier access to clinical trials should be the main areas of future development. Preventing irreparable neurological impairments and improving patient quality of life requires a focus on palliative care and early intervention. Integrating innovative therapies with comprehensive supportive care in a patient-centered study is essential for enhancing neurological function, pain control, and overall quality of life.

Cervical cancer continues to be one of the major causes of cancer-related mortalities among women worldwide, with a considerable share of this burden affecting developing countries like Pakistan. The addition of the HPV vaccine to the national immunization program of Pakistan had been a crucial leap toward the prevention of cervical cancer. Nevertheless, challenges that threaten the success of such a program are conspicuous. The most important ones are discussed in the letter, including the widespread dissemination of misinformation via social media on unfounded grounds, such as infertility resulting from the vaccine; deep-seated cultural taboos relating to sexual health; and an inert attitude of the government without a focused strategic communication. Mass psychogenic reactions, similar to the Tando Bago incident, further exacerbated the situation, along with disruptions in logistics due to natural calamities like floods. With this in mind, there is an imperative need for a multidimensional, proactive approach to ensure the long-term success of the HPV vaccination campaign. This should be in the form of public awareness campaigns adapted to culturally reorient attitudes, engagement of local community leaders and health providers, intensive vaccinator training, and incorporation of the vaccine into larger adolescent and reproductive health strategies. Public trust should be earned, equity assured, and, above all, the dramatic public health gains of the HPV vaccination assured through concerted efforts by government, civil society, and international partners.

ABSTRACTObstructive jaundice in pregnancy, though rare, can result from hormone‐induced biliary stasis and gallstone formation. Prompt recognition and timely surgical intervention, such as cholecystectomy and bile duct exploration, are critical to preventing maternal and fetal complications. This case highlights the need for vigilance in managing biliary disorders during pregnancy.

Hamayal et al found a significant correlation between metformin exposure and poor sleep quality in patients with diabetes, highlighting a significant clinical issue. However, the study’s validity, reproducibility, and generalizability are limited by methodological limitations. Causal inference is not possible due to the cross-sectional and single-center design, convenience sampling, and selection bias. The use of a self-report instrument, such as the Pittsburgh Sleep Quality Index, increases measurement and recollection bias and risks false classification of sleep disturbance. The relationship between metformin exposure and sleep quality is prone to residual confounding by diabetes duration, glycemic control, comorbidity burden, medication use, depressive symptoms, and socioeconomic factors. Reverse causality is also possible, as disrupted sleep may aggravate glycemic indices. Future research should adopt a prospective, multicentric design, objective measures of sleep, standardized definitions of case and outcome, and examine putative mechanisms involving antidiabetic interventions and sleep physiology.

Background:Burkitt lymphoma is a highly aggressive B-cell non-Hodgkin lymphoma closely associated with Epstein-Barr virus (EBV) infection and driven by MYC oncogene overexpression. It presents in three clinical forms: endemic, sporadic, and immunodeficiency-associated. Endemic Burkitt lymphoma, prevalent in Africa, typically involves jaw tumors; sporadic cases commonly present with abdominal masses; and immunodeficiency-associated cases occur in patients with HIV or other forms of immune compromise. A major clinical challenge is the development of severe metabolic complications, including lactic acidosis and hypoglycemia, resulting from rapid tumor proliferation and increased metabolic demands, particularly through enhanced glycolysis (the Warburg effect). These complications are often resistant to conventional supportive therapies and become life-threatening without urgent intervention.Purpose:To emphasize the clinical significance of early recognition and management of metabolic complications in Burkitt lymphoma and to examine the role of chemotherapy, particularly rituximab-based regimens, in improving patient outcomes.Methods:We conducted a comprehensive literature search across PubMed, Cochrane Library, and Google Scholar databases through September 2024 using keywords related to rituximab complications in Burkitt lymphoma. Studies were screened according to predefined criteria, focusing on lactic acidosis and hypoglycemia. Only English-language clinical trials, randomized controlled trials, and reviews were included. We excluded articles that did not include Burkitt lymphoma patients or address associated metabolic challenges and treatment-related toxicities.Conclusion:Early diagnosis and prompt chemotherapy initiation are critical for managing tumor burden and associated metabolic derangements in Burkitt lymphoma. While rituximab has significantly improved treatment outcomes, it must be used judiciously to minimize severe adverse effects. Timely intervention is particularly crucial in immunocompromised patients, where disease progression and treatment toxicity may be more severe.