United States

Background 

Misdiagnosis of mild traumatic brain injury (mTBI) (concussion) in emergency departments (EDs) is underscored by historical controversy around the appropriate usage of traumatic intracranial injury diagnoses (S06 ICD-10 codes) intended for mTBI and head injury, unspecified codes (S09.9). The lack of consensus diagnostic criteria for mTBI has made the identification of this patient population challenging. Reducing variability in diagnosis is essential to advance research initiatives and align clinical recommendations across patient settings. We found that ED providers were divided in their preferences for selecting between these diagnoses, potentially impacting patient education about brain injury symptoms and clinical management. In this study, we sought to characterize patient and clinical factors that predict provider diagnosis. Additionally, we explored the effect of diagnosis on day 1 symptoms, patient education, and return to ED/hospital within 30 days. 



Methods 

We analyzed 1348 prospectively identified adults diagnosed with traumatic intracranial injury head injury, unspecified across 7 EDs from September 24, 2024, to May 25, 2025. We used logistic regression to identify demographic, injury, and clinical predictors of provider diagnosis and associations between diagnosis and day 1 symptom burden, provision of educational handouts, and 30-day readmission. 



Results 

Diagnosis of intracranial injury was independently predicted by younger age (p&lt;0.001), higher level of care (p = 0.017), presentation &gt;24 hours post-injury (p&lt;0.001), and patient trauma activation on admission (p = 0.015). Patients diagnosed with mTBI had a mean symptom burden (Rivermead Questionnaire total score) of 22.6 (SD = 16.3), significantly higher than those diagnosed with head injury (M = 10.9, SD = 12.5; p&lt;0.001). Patients diagnosed with mTBI were more likely to receive an educational handout at discharge (Est [SE] = 0.54 [0.13], p&lt;0.001). Return to EDs/hospitals within 30 days was not predicted by provider diagnosis. 



Conclusion 

Understanding which factors influence provider diagnosis is invaluable to successful efforts to improve the recognition and management of mTBI in EDs. We report that, albeit to a lesser extent, patients diagnosed with head injury commonly report mTBI symptoms and receive educational materials. Interestingly, these educational materials describe common signs and symptoms of mTBI during recovery. ED provider diagnosis of head injury might not be driven by a lack of recognition of possible mTBI. Shifting towards a diagnosis consistent with intracranial injury may facilitate more consistent and accurate dispersal of educational resources. Clarifying influences on provider preference will aid in developing interventions to unify diagnostic practices across clinical and research settings.

AMA Research Challenge 2025 

Characterizing Emergency Department Provider Decision to Diagnose Traumatic Brain Injury Versus Head Injury

The 45th Annual Meeting of the Cognitive Science Society will take place in Sydney, Australia as a modified hybrid conference. Presentations from the main-session room will be live-streamed every day for all events. This will include all invited talks and award sessions. Recordings of all CogSci 2023 sessions will be made available for on-demand viewing after the conference.<br>
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CogSci 2023

The 45th Annual Meeting of the Cognitive Science Society presents the latest research across cognitive science and highlights the theme of Cognition in Context.

Background 

Misdiagnosis of mild traumatic brain injury (mTBI) (concussion) in emergency departments (EDs) is underscored by historical controversy around the appropriate usage of traumatic intracranial injury diagnoses (S06 ICD-10 codes) intended for mTBI and head injury, unspecified codes (S09.9). The lack of consensus diagnostic criteria for mTBI has made the identification of this patient population challenging. Reducing variability in diagnosis is essential to advance research initiatives and align clinical recommendations across patient settings. We found that ED providers were divided in their preferences for selecting between these diagnoses, potentially impacting patient education about brain injury symptoms and clinical management. In this study, we sought to characterize patient and clinical factors that predict provider diagnosis. Additionally, we explored the effect of diagnosis on day 1 symptoms, patient education, and return to ED/hospital within 30 days. 



Methods 

We analyzed 1348 prospectively identified adults diagnosed with traumatic intracranial injury head injury, unspecified across 7 EDs from September 24, 2024, to May 25, 2025. We used logistic regression to identify demographic, injury, and clinical predictors of provider diagnosis and associations between diagnosis and day 1 symptom burden, provision of educational handouts, and 30-day readmission. 



Results 

Diagnosis of intracranial injury was independently predicted by younger age (p<0.001), higher level of care (p = 0.017), presentation >24 hours post-injury (p<0.001), and patient trauma activation on admission (p = 0.015). Patients diagnosed with mTBI had a mean symptom burden (Rivermead Questionnaire total score) of 22.6 (SD = 16.3), significantly higher than those diagnosed with head injury (M = 10.9, SD = 12.5; p<0.001). Patients diagnosed with mTBI were more likely to receive an educational handout at discharge (Est [SE] = 0.54 [0.13], p<0.001). Return to EDs/hospitals within 30 days was not predicted by provider diagnosis. 



Conclusion 

Understanding which factors influence provider diagnosis is invaluable to successful efforts to improve the recognition and management of mTBI in EDs. We report that, albeit to a lesser extent, patients diagnosed with head injury commonly report mTBI symptoms and receive educational materials. Interestingly, these educational materials describe common signs and symptoms of mTBI during recovery. ED provider diagnosis of head injury might not be driven by a lack of recognition of possible mTBI. Shifting towards a diagnosis consistent with intracranial injury may facilitate more consistent and accurate dispersal of educational resources. Clarifying influences on provider preference will aid in developing interventions to unify diagnostic practices across clinical and research settings.

poster

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Background
Cardiovascular disease remains the leading cause of death worldwide despite significant progress in prevention and treatment. Recently, abnormalities in coronary microcirculation have been observed in patients across the spectrum of cardiovascular diseases. Coronary microvascular dysfunction (CMD) is a heterogeneous condition characterized by increased coronary microvascular resistance and impaired vasodilation. CMD worsens clinical outcomes in leading causes of cardiac mortality such as myocardial ischemia, coronary artery disease, and heart failure, but the mechanism of CMD progression is poorly understood. Two-dimensional culture models of cardiac disease states are limited in applicability to in vivo disease owing to the complex three-dimensional microenvironment of cardiac tissue. Cardiac organoids derived from induced pluripotent stem cells (iPSCs) or primary human cells present an opportunity to better recapitulate the complexity of native myocardium; however, efforts to develop a vascularized, perfusable cardiac spheroid system to study cardiomyocyte-endothelial interactions have thus far been unsuccessful. The objective of this research is to establish a 3D model of vascularized and perfusable myocardium in order to interrogate the onset and progression of CMD.

Methods
Tri-lineage cardiac spheroids were developed by aggregating human fibroblasts, endothelial cells transfected with a flow-responsive GFP reporter (KLF2-GFP), and hiPSC-derived cardiomyocytes. A perfusable microvascular niche (MVN) was fabricated by injecting an endothelial and fibroblast-laden fibrin hydrogel into a precast microfluidic chamber. Addition of cardiac spheroids into the hydrogel was termed cardiac spheroids with microvascular network (CS-MVN). The CS-MVN system was cultured for 7 days, after which spheroid morphology, vessel perfusability, and internal hypoxia were assessed by confocal imaging. Vascularization was confirmed by video microscopy and beat-rate analysis during perfusion of the CS-MVN system with isoproterenol.

Results
Microscopy of CS-MVNs demonstrate lumenized, perfusable vessels within cardiac spheroids that anastomose with the surrounding microvascular network. Functionally, a microvascular network causes a significantly lower hypoxic burden in the spheroid interior, and vessels in close proximity to the spheroid are less permeable. The CS-MVN system exhibits an immediate chronotropic response to perfused isoproterenol versus a delayed, diffusion-governed response in spheroids seeded in fibrin gels with no microvasculature. 

Conclusion
We have, for the first time, established a cardiac spheroid featuring complete vascularization and perfusability, enabling advanced in vitro modeling of the cardiac microenvironment and function. Its modular nature will allow interrogation of parameters such as perfused factors, electrophysiology, fluid shear rates, and spatial differences in gene expression when modeling CMD in vitro.

Bioengineering a Perfusable Cardiac Spheroid System to Model the Vascularized Myocardium

Abstract Title
Altered Mucin Expression Detected in the Pathogenesis of Necrotizing Enterocolitis
Background
Necrotizing enterocolitis (NEC) is a devastating gastrointestinal disease affecting premature infants, marked by severe intestinal inflammation, mucosal necrosis, and high mortality. The intestinal mucosal barrier, maintained in part by goblet cell–secreted mucins, plays a critical role in host defense and microbial containment. Disruption of this barrier has been implicated in NEC pathogenesis, yet the specific role of mucin subtype expression and goblet cell dynamics in human NEC tissue remains incompletely understood. We hypothesize that NEC is associated with both a quantitative reduction in goblet cells and qualitative alterations in mucin expression patterns.
Method
Human intestinal samples from confirmed NEC cases and matched controls were obtained from histological sections. Samples and regions with clear epithelium and intact mucosa were assessed. Goblet cell mucin composition was visualized using Alcian Blue/Periodic Acid-Schiff (AB/PAS) staining, which differentially stains acidic (cyan), neutral (magenta), and mixed (dark blue) mucins. Using ImageJ, high-resolution images were analyzed to quantify goblet cells per crypt and classify their mucin phenotype. Data were compiled in a quantitative spreadsheet and the total number of each goblet cell mucin type were compared to identify trends for future investigation.
Results
Quantitative analysis demonstrates a consistent downward trend in total goblet cell density in NEC samples compared to controls. Overall, there was a ~21.6% decrease in total goblet cell count. Notably, the most pronounced decline was in neutral mucin- producing goblet cells in NEC tissue, which exhibited ~81.8% decrease in NEC tissue. Mixed and acidic mucin-producing goblet cells showed smaller reductions of ~18.8% and ~13.5%, respectively, in NEC samples compared to controls. These findings suggest a selective alteration in mucin subtype expression. Mucin composition, particularly the dramatic loss of neutral mucins, may play a role in weakening the protective mucus layer, thus contributing to epithelial vulnerability and disease progression in NEC.
Conclusion
Our study provides evidence that NEC is associated with both quantitative and qualitative changes in goblet cell populations and mucin subtype expression. The selective depletion of neutral mucin-secreting goblet cells may compromise the integrity of the mucosal barrier, facilitating inflammation and microbial translocation. Ongoing analysis will incorporate additional samples and statistical modeling to confirm the significance of these trends. Future directions include expanding the sample size and assessing correlations with clinical outcomes. These findings emphasize the importance of mucin biology in NEC pathogenesis and may inform future therapeutic strategies aimed at restoring mucosal protection in at-risk infants.

Altered Mucin Expression Detected in the Pathogenesis of Necrotizing Enterocolitis

Abstract Title
E-Cigarette Use Impairs Innate and Adaptive Immune Responses, Delaying Pulmonary Repair
Authors: Ivan Marrufo1, Armando Marrufo2, Ferrah Kheradmand2
1 University of North Texas Health Sciences Center
2 Department of Medicine-Pulmonary, Critical Care, & Sleep Medicine, Baylor College of Medicine

Background
E-cigarettes are marketed as safer alternatives to traditional cigarettes and are widely used by adults and young adults. However, heated aerosolized components—particularly propylene glycol (PG), vegetable glycerol (VG), and vitamin E acetate (VEA)—have been linked to e-cigarette or vaping-associated lung injury (EVALI). Since 2020, over 2,800 cases and 68 deaths have been reported. VEA, detected in bronchoalveolar lavage fluid of EVALI patients, may increase susceptibility to viral infections and disrupt both innate and adaptive pulmonary immune responses. Therefore, we hypothesize that VEA toxin within e-cigarette liquid alters both the innate and adaptive pulmonary immune function.

Methods
Mice were exposed to either air, PG/VG, or VEA for 2 weeks, followed by an 8-week recovery. Lung immune cells were analyzed by flow cytometry. Single-cell suspensions were stained with antibodies to identify macrophage and T cell subpopulations.

Results
The results demonstrate that after a 2-week exposure to VEA, there was a significant increase in the total lung macrophage population compared to air-exposed controls. Lung macrophages were categorized into alveolar macrophages, resident cells native to the lungs, and monocyte-derived macrophages, originating from circulating monocytes and functioning in tissue repair and inflammation. Within the total macrophage population, VEA exposure led to a significant increase in monocyte-derived (CD11b⁺) and intermediate (CD11b⁺SiglecF⁺) macrophages, with a trend toward increased alveolar macrophages (SiglecF⁺). Following a 2-week exposure and an 8-week recovery period, VEA-exposed mice showed sustained increases in monocyte-derived (CD11b⁺) and intermediate (CD11b⁺SiglecF⁺) macrophage populations, alongside a decreasing trend in alveolar (SiglecF⁺) macrophages. Among adaptive immune cells, total T-lymphocytes were significantly increased after the 2-week exposure and 8-week recovery. Specifically, there was a significant increase in CD8⁺ T cells and a significant decrease in CD4⁺ T cells in VEA-exposed mice. Within the CD4⁺ T cell subset, pro-inflammatory Th1 cells were significantly decreased following VEA exposure and recovery.

Conclusion 
An increase in CD8⁺ T cells and a decrease in CD4⁺ T cells may contribute to heightened susceptibility to viral infections. Furthermore, the observed decrease in alveolar macrophages—alongside an increase in monocyte-derived and intermediate macrophage populations following a 2-week VEA exposure and 8-week recovery—may reflect a compensatory replacement mechanism driven by alveolar macrophage death.




E-Cigarette Use Impairs Innate and Adaptive Immune Responses, Delaying Pulmonary Repair


Background
Renal cell carcinoma (RCC) can invade the renal vein or inferior vena cava, forming a tumor thrombus associated with worse prognosis. However, the molecular drivers underlying tumor thrombus extension remain poorly understood. We aimed to identify gene expression differences between RCC tumors with thrombus extension (RITE) and those without (non-RITE) to uncover molecular mechanisms and biomarkers associated with tumor invasiveness.

Methods
We analyzed bulk RNA-seq profiles from 721 RCC tumor samples spanning 45,408 genes, collected at nephrectomy from three cohorts: Rodriguez (U.S., n = 71), Wang (China, n = 174), and TCGA-KIRC (n = 477). Differential expression analysis was conducted using PyDESeq2 on RITE (n = 96) versus non-RITE (n = 66) tumors, using thresholds of adjusted p < 0.05 and |log₂FC| ≥ 1. Functional enrichment was performed using Enrichr and g:Profiler, and prognostic relevance assessed via GEPIA (TCGA-KIRC).

Results
A total of 6,317 differentially expressed genes (DEGs) were identified. Among the top upregulated transcripts was lncRNA CERS6-AS1, previously implicated in tumor progression in other cancers. Notably, TCGA-KIRC survival analysis revealed that high expression of CERS6-AS1 was associated with significantly worse overall survival (HR = 1.8, log-rank p = 0.00037). Pathway enrichment of other RITE-associated DEGs showed upregulation of genes involved in chylomicron assembly and lipid metabolism, including APOA4, MTTP, APOC3, and APOE. Additional enrichment was observed in pathways related to the acute inflammatory response and oxidative phosphorylation.

Conclusion
RITE tumors display distinct transcriptomic signatures characterized by lipid metabolic reprogramming, immune pathway activation, and elevated expression of CERS6-AS1, a marker of poor prognosis. These insights advance our understanding of tumor thrombus biology and may inform prognostic biomarker discovery and therapeutic targeting in RCC, laying the groundwork for future translational studies.

Decoding RITE Biology: Differential Gene Expression in Renal Cell Carcinoma With and Without Venous Extension

Background
Metastatic paraganglioma (mPGL) is a rare and aggressive neuroendocrine tumor that
arises outside the adrenal gland and often resists standard treatments like
chemotherapy and surgery. These conventional options typically show limited
effectiveness and carry significant side effects. However, recent advancements in
precision medicine, such as Peptide Receptor Radionuclide Therapy (PRRT),
immunotherapy, and molecular profiling, have revolutionized therapeutic approaches. PRRT, particularly with 177Lu-DOTATATE, has demonstrated promising results in
targeting somatostatin receptor-positive tumors, improving progression-free survival, and enhancing patients' quality of life. Additionally, immune checkpoint inhibitors (e.g., pembrolizumab, nivolumab) and targeted therapies (e.g., sunitinib, cabozantinib) are
being explored, with emerging evidence suggesting their potential in specific genetic
subsets.Advances in genetic profiling, including next-generation sequencing, allow for
risk stratification and personalized therapy based on mutations such as SDHB, SDHD, and VHL.Minimally invasive techniques like embolization and thermal ablation are also
gaining traction for palliative control. While traditional chemotherapy remains an option, combining it with targeted agents like sunitinib or cabozantinib offers new
potential.However, more research is needed to compare the efficacy and safety of these
novel approaches. Objective: This study evaluates emerging therapies for metastatic paraganglioma,
including PRRT, immunotherapy, and molecular-targeted agents, to assess their clinical
efficacy and safety. We analyze the role of PRRT in tumor control, investigate
checkpoint inhibitors, and explore how genetic profiling (SDHB mutations) informs
treatment selection. Additionally, we examine combination approaches and minimally
invasive techniques to optimize therapeutic strategies for this high-risk population. Methods
A systematic review was conducted per PRISMA guidelines using PubMed, Cochrane, and ScienceDirect (2014–2024). Controlled keywords identified studies on mPGL
outcomes related to PRRT, targeted therapy, and immunotherapy. Experts were
consulted, and reference lists reviewed. Studies were screened, quality assessed, and thematically synthesized. Results
From an initial pool of 54,365 studies, 120 met the inclusion criteria. PRRT showed
favorable tumor control and tolerability in patients with high somatostatin receptor
expression. Targeted therapies were particularly effective in cases with SDHB
mutations. Immunotherapies demonstrated promise in PD-L1-positive tumors. Personalized and combination therapies yielded better outcomes, though small sample
sizes and variability between studies limited broad conclusions. Conclusion
Emerging therapies, especially PRRT, immunotherapy, and molecular-targeted
treatments, are reshaping the management of metastatic paraganglioma. Genetic
profiling supports a more personalized approach. While current findings are promising,
further large-scale studies are needed to confirm long-term benefits and refine
treatment strategies.

Redefining the Treatment Paradigm: Systematic Review of Novel Therapies in Metastatic Paraganglioma

Introduction: Rotator cuff (RC) injury is the leading cause of shoulder pain and disability. Arthroscopic RC repair has grown in popularity, with usage rising from 60% in 2007 to 83% in 2016. Studies suggest women report more pain and worse functional outcomes than men post-surgery, but research on sex-based differences beyond these factors is limited. This study examines differences in emergency department (ED) visits, complications, and 2-year reoperation rates following arthroscopic repair of atraumatic, complete RC tears.
Methods: The TriNetX Diamond Network, a global health research database, was queried using International Classification of Disease-10 and Current Procedural Terminology codes between January 2010 and April 2018. Patients diagnosed with complete RC tear who underwent arthroscopic shoulder surgery with complete RC repair were included. Patients with prior RC tears or arthroscopic shoulder surgery were excluded. Male and female cohorts were propensity-matched for age and three comorbidities within 1 year of RC repair. Rates of ED visits at 5 and 14 days postoperatively, complications at 1-month postoperatively, and repeat arthroscopy and arthroplasty at 1-year and 2-years postoperatively were analyzed.
Results: Of 108,852 patients identified (55.0% male), 48,208 females were 1:1 propensity-matched to males. Females had significantly higher rates of ED visits compared to males within 14 days postoperatively (2.69% vs 2.49%; P=0.045). Males had significantly higher rates of infection at 1-month postoperatively (0.14% vs 0.07%, P=0.001). Within 2 years postoperatively, females had higher rates of conversion to shoulder arthroplasty (1.03% vs 0.62%, P<0.0001), but similar rates of overall secondary shoulder surgeries (7.49% vs 7.71%, P=0.198). 
Conclusions: In this large, matched cohort study, female patients had higher rates of early ED visits and conversion to arthroplasty within 2 years, while males experienced more infections within 1 month. However, overall complication rates were low for both cohorts.

Sex-Based Differences in Postoperative Outcomes for Patients Undergoing Primary Arthroscopic Rotator Cuff Repair: A Propensity Matched Analysis

Abstract Title
Advancing Academic Insights and Clinical Outcomes: The Role of Resmetirom in MASH Therapy

Background
Metabolic dysfunction associated steatohepatitis (MASH, formerly NASH) is a leading cause of liver transplantation and is linked to increased cardiovascular mortality. Until recently, no medications were approved for this prevalent condition. Resmetirom is a liver-targeted, selective thyroid hormone receptor-β agonist that enhances hepatic fat metabolism and reduces lipotoxicity. In 2024, it became the first FDA-approved therapy for MASH with fibrosis (F2–F3 stages), based on its ability to significantly improve MASH histological activity and fibrosis endpoints. This review aims to synthesize current evidence on resmetirom’s efficacy and safety in MASH therapy.

Methods
A comprehensive search of PubMed from year 2015 to 2025 was conducted for clinical studies evaluating resmetirom in MASH. Seven relevant publications, including phase 2 and 3 Clinical and Randomized controlled trials, were identified. Data on histological outcomes, metabolic effects, and adverse events were extracted and qualitatively reviewed.

Results
Across the selected studies, resmetirom demonstrated consistent therapeutic benefits. A pivotal 36-week phase II trial showed resmetirom significantly reduced hepatic fat content by 30% relative to placebo (p<0.0001). Treated patients also experienced improvements in liver histology, with a trend toward NASH resolution. In a large phase III trial (MAESTRO-NASH), resmetirom 80 mg and 100 mg achieved NASH resolution (approximately 26-30% of patients) at nearly triple the rate of placebo (10%), and more patients had ≥1 stage fibrosis improvement versus placebo (24-26% vs 14%). Resmetirom therapy additionally led to beneficial reductions in LDL cholesterol (-14% to -16%) and liver enzyme levels in patients. The drug was generally well-tolerated; rates of serious adverse events did not differ from placebo. Mild gastrointestinal side effects (primarily transient diarrhea and nausea) were more frequent with resmetirom (risk ratio: 1.7-1.8 vs placebo), but no other significant safety concerns emerged.

Conclusion
Resmetirom meaningfully advances MASH treatment by promoting histological resolution of steatohepatitis and regression of fibrosis, while also improving lipid and liver profiles. It’s favorable efficacy risk profile, as evidenced by multiple trials, supports resmetirom’s pivotal role as the first pharmacotherapy for MASH. Ongoing studies and post-approval observations will further clarify its long-term impact on clinical outcomes and inform optimal integration into MASH management.


Advancing Academic Insights and Clinical Outcomes: The Role of Resmetirom in MASH Therapy

A Rare Case of Microscopic Polyangiitis with Copositivity for ANA and Anti-dsDNA Antibodies

Background
Microscopic Polyangiitis (MPA) is a rare, small-vessel autoimmune vasculitis primarily affecting the kidneys and lungs. It is associated with anti-myeloperoxidase (MPO) antineutrophil cytoplasmic antibodies (ANCAs) and characterized by pauci-immune necrotizing glomerulonephritis. Diagnosis is confirmed with renal biopsy, revealing crescentic glomerulonephritis without immune complex deposition. Treatment involves high-dose glucocorticoids and either cyclophosphamide or rituximab, followed by maintenance therapy with azathioprine or mycophenolate mofetil. Plasmapheresis may be considered in severe cases. Early diagnosis and appropriate treatment are crucial for improving patient outcomes.

Case Presentation
We present a 74-year-old woman with a history of hypertension, stroke, carotid artery disease, and hypothyroidism, admitted for acute kidney injury (AKI) with a serum creatinine increase from 1.04 mg/dL to 8.5 mg/dL, elevated blood urea nitrogen, and metabolic acidosis. Initial laboratory findings indicated leukocytosis, anemia, and reactive thrombocytosis. Serology revealed positive antinuclear antibodies (ANA) and anti-dsDNA, suggesting systemic lupus erythematosus (SLE), but previous tests demonstrated elevated MPO antibodies, raising suspicion for ANCA-associated vasculitis (AAV). A CT-guided renal biopsy demonstrated necrotizing crescentic glomerulonephritis with no immune complex deposition, consistent with MPA. The patient was treated with high-dose intravenous methylprednisolone, followed by a tapering oral regimen, and underwent seven sessions of plasmapheresis. Despite intervention, she required chronic hemodialysis. She was discharged with a tunneled internal jugular catheter for thrice-weekly hemodialysis and planned outpatient rituximab therapy for MPA.

Discussion
This case underscores the diagnostic complexity of AAV, particularly when serological markers overlap with those of SLE. The patient's presentation with rapidly progressive glomerulonephritis, elevated anti-MPO antibodies, and pauci-immune necrotizing crescentic glomerulonephritis on biopsy strongly supports a diagnosis of MPA. However, the concurrent presence of ANA and anti-dsDNA antibodies, typically associated with SLE, complicates the clinical picture. Renal biopsy findings of necrotizing crescentic glomerulonephritis and the absence of immune complex deposition on immunofluorescence further favor MPA over lupus nephritis. Patients with AAV who test positive for ANA and anti-dsDNA often exhibit severe renal damage, including higher serum creatinine levels and lower estimated glomerular filtration rates. This case highlights the importance of renal biopsy in distinguishing between MPA and SLE, as overlapping serological markers can lead to misdiagnosis. Early and accurate diagnosis is crucial, as the management for these conditions differ significantly. In patients with AAV and concurrent lupus markers, treatment regimens may need to be intensified, and close monitoring is essential to address the increased risk of renal failure and other complications.

A Rare Case of Microscopic Polyangiitis with Copositivity for ANA and Anti-dsDNA Antibodies

Background: Emergency contraception (EC) is critical for preventing unintended pregnancies following unprotected or inadequately protected sexual intercourse. While oral levonorgestrel (LNG) pills are the standard FDA-approved EC method, the levonorgestrel intrauterine device (LNG-IUD) is emerging as an alternative, offering both immediate EC and long-term contraception benefits. This study evaluates the efficacy of LNG-IUD compared to oral-LNG for EC. The objective is to conduct a systematic review and meta-analysis of studies evaluating the efficacy of the levonorgestrel intrauterine device for emergency contraception, comparing its efficacy in preventing pregnancy with that of oral levonorgestrel.

Methods: A systematic review and meta-analysis were conducted following PRISMA 2020 guidelines. PubMed, Scopus, and Medline were searched up to December 16, 2024, using keywords related to postcoital contraception, levonorgestrel, and intrauterine devices. Five studies from two countries, totaling 920 participants, met the population, intervention, comparison, outcome, and settings (PICOS) criteria focusing on women of reproductive age using LNG-IUD or oral LND as EC. Risk of bias was assessed using the mixed methods appraisal tool (MMAT), and a random-effects model was applied due to significant heterogeneity.

Results: The LNG-IUD, when indirectly compared to oral LNG for EC, demonstrated a natural log of the odds risk ratio (ORR) of –0.51 (95% CI: -3.86-2.83, p=0.77), suggesting a lower risk of pregnancy with the LNG-IUD. However, the wide confidence interval and lack of statistical significance, as reflected by the high p value, likely results from limited studies available for this dataset.

Conclusion: This review found no statistically significant difference in efficacy between LNG-IUD and oral-LNG for emergency contraception, likely due to wide confidence intervals and limited data, supporting LNG-IUD as an alternative. LNG-IUD offers comparable efficacy to other EC options and the added benefit of long-term contraception, underscoring the importance of additional direct studies to expand emergency contraception options for women. Significance: The findings suggest that LNG-IUD could be a promising alternative to oral LNG for emergency contraception, offering both immediate and long-term contraceptive benefits. Expanding access to LNG-IUDs for EC could provide women with more options and flexibility in reproductive health management, emphasizing the need for further research to validate its efficacy and inform clinical practice.

Comparing the Efficacy of Levonorgestrel Intrauterine Device and Oral Levonorgestrel for Emergency Contraception: A Systematic Review and Meta Analysis

Effective endotracheal intubation requires both adequate glottic visualization and the physical maneuverability necessary to advance the endotracheal tube (ETT) into the trachea. In patients with anatomical limitations such as reduced oral aperture or thyromental distance, conventional laryngoscopy techniques may be rendered ineffective despite optimal visualization. This case report describes a strategic modification of standard video laryngoscopy (VL) technique to facilitate successful intubation in a patient with unanticipated difficult airway anatomy.
Case Presentation
A young, otherwise healthy female patient, approximately 5’2” tall with no significant past medical history, presented for elective outpatient carpal tunnel release under general anesthesia. Preoperative airway assessment revealed a Mallampati Class III score and reduced thyromental distance, though the airway was not formally flagged as difficult. Following standard preoxygenation, the patient was induced with intravenous anesthetics and paralyzed using rocuronium. Bag-mask ventilation was performed without difficulty. Initial intubation was attempted using a size 3 video laryngoscope (Glidescope) and a 6.5 mm cuffed ETT. A Cormack-Lehane Grade I view of the vocal cords was obtained. However, due to the patient’s small oral aperture, the ETT could not be adequately manipulated into position using conventional post-blade insertion technique. The approach was revised: the ETT was inserted first into the right buccal space while the mouth was maintained open via manual scissoring by an assistant. The VL blade was then inserted at midline, and the ETT was rotated 90 degrees to align with the airway. The tube entered the video field smoothly and was advanced through the vocal cords under direct visualization. Capnography and auscultation confirmed correct placement. A size 3 laryngeal mask airway (LMA) was prepared as a backup but not required.

The intubation was completed without hypoxia, trauma, or hemodynamic instability. The revised sequence allowed for controlled advancement of the ETT despite anatomic limitations. This approach preserved glottic visualization while accommodating mechanical challenges posed by limited oral aperture.
Discussion/Conclusion
In patients with small oral apertures and reduced thyromental distance, reversing the conventional sequence of VL—advancing the ETT prior to blade insertion—may offer a safe and effective alternative technique. When performed under appropriate conditions with adequate preparation and visualization, this method can serve as a valuable adjunct in the management of unanticipated difficult airways.


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