Open access

Mitral Valve-in-Ring Approach for High-Risk Pannus-Related Mitral Stenosis (2025)

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Type of publication:

Journal article

Author(s):

*Yera, Hassan O; Azam, Ziyad; *Azam, Najeeb M.

Citation:

Cureus. 17(10):e94204, 2025 Oct.

Abstract:

A male patient under follow-up for degenerative mitral regurgitation, treated with a Physio annuloplasty ring two decades earlier, developed progressive shortness of breath and fluid overload, corresponding to New York Heart Association (NYHA) class III/IV. A transoesophageal echocardiogram revealed significant mitral stenosis, with a mean gradient of 11.8 mmHg due to pannus formation around the annuloplasty ring. Surgical repair posed a mortality risk of 25%-35% because of the combined risks of redo surgery, reduced left ventricular systolic function and chronic kidney disease. A transcatheter mitral valve-in-ring (TMViR) procedure was the only feasible option. A 29 mm Sapien 3 valve (Edwards Lifesciences, Irvine, CA) was successfully implanted within the mitral ring. Four months following the procedure, the patient reported significant symptom relief and an improved quality of life (QOL), with a shift to NYHA class I/II. Follow-up echocardiography demonstrated a stable valve position, a mean gradient of 4 mmHg and mild mitral regurgitation. This case highlights TMViR as a viable option for high-risk patients with pannus-related mitral stenosis.

DOI: 10.7759/cureus.94204

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Missed on X-ray, Found on CT: A Retrospective Study on the Diagnostic Yield and Clinical Consequences of Occult Posterior Malleolus Fractures in Tibial Shaft Fractures (2025)

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Type of publication:

Journal article

Author(s):

Kanesan, Hariprasath; Choudhary, Zain; Singal, Sachin; *Kanesan, Mahesh; Hang-Kin Nam, Ronald; Radhamony, Niranj Ganeshan; Hamadto, Mohamed.

Citation:

Cureus. 17(10):e94260, 2025 Oct.

Abstract:

Background Posterior malleolus fractures (PMFs) are common in distal tibial shaft fractures yet are frequently occult on plain radiographs. Accurate preoperative characterization on CT may improve surgical planning and functional recovery. Methods We conducted a retrospective cohort study of consecutive adults (>=18 years) with mid- or distal tibial shaft fractures treated at a major trauma center (January 2022-December 2024). Demographics, imaging, fracture characteristics, management, and outcomes were abstracted. PMF detection was compared across radiography, CT, and intraoperative findings. Predictors of a posterior malleolus (PM) fragment being missed on radiography were evaluated with multivariable logistic regression. Among operatively treated cases, the effect of fixation strategy on postoperative full weight-bearing (FWB) was analyzed with a logistic model including fixation, PM status, and their interaction; pairwise, covariate-adjusted contrasts (emmeans with Tukey correction) compared strategies. An exploratory random forest provided permutation-importance rankings. Findings PMFs were present in 147/387 fractures (38.0%), more often in women (60.5%), closed injuries (76.9%), and distal fractures (98.0%). Radiography identified 116/147 PMFs (78.9%), and CT 120/147 (81.6%); 29/147 (19.7%) fragments were missed on radiographs but detected on CT or intraoperatively. Missed fragments were most frequent in undisplaced and intermediate-sized (33-50%) fragments; CT identified all posteromedial and >50% fragments. In adjusted analyses, fracture morphology was the principal correlate of radiographic omission: oblique patterns were less likely to be missed (adjusted odds ratio 0.18, 95% CI 0.04-0.60), whereas other demographic and injury variables were not significant. Among operatively managed fractures, intramedullary nailing was associated with the highest likelihood of achieving FWB and was statistically superior to plate and external fixation in pairwise, covariate-adjusted comparisons; the relative ranking of fixation methods did not differ by PM involvement. Neither PMF location (posteromedial, posterolateral, or undisplaced) nor fragment size independently predicted FWB, infection, or mal-/non-union. Conclusions Approximately two in five distal tibial shaft fractures harbour a PM fragment, and nearly one in five PMFs are occult on initial radiographs, particularly when undisplaced or of intermediate size. CT modestly increases detection and ensures complete characterisation of posteromedial and large fragments, supporting a low threshold for pre-operative CT in distal tibial fractures.

DOI: 10.7759/cureus.94260

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A Diagnostic Challenge: Sclerosed Hepatic Haemangioma Mimicking Malignancy (2025)

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Type of publication:

Journal article

Author(s):

*Lakhani, Umar A.

Citation:

Cureus. 17(10):e94449, 2025 Oct.

Abstract:

A 75-year-old lady presented to Accident and Emergency (A&E) with acute worsening shortness of breath and new palpitations. On assessment, she was found to have fast atrial fibrillation, signs of heart failure, and bilateral peripheral oedema. Investigations revealed pulmonary embolism and an incidental hepatic lesion on CT imaging, suspicious for malignancy. Multidisciplinary discussion led to liver biopsy, which confirmed a benign sclerosed haemangioma. The patient was managed conservatively for cardiac and thromboembolic complications. This case highlights the difficulty in differentiating sclerosed haemangiomas from malignant liver lesions on imaging alone and underscores the importance of biopsy and multidisciplinary decision-making in elderly patients with comorbidities. Learning points include diagnostic vigilance, safe management of anticoagulation, and avoidance of unnecessary surgery.

DOI: 10.7759/cureus.94449

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Long-Term Outcomes of Coronary Artery Aneurysms in Children With Kawasaki Disease: A Systematic Review (2025)

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Type of publication:

Systematic Review

Author(s):

Shafy, Shoaib Syed Mohammed; Salavarria, Karla Andrea Calderon; Saleh, Sara; *Cuino, Ingrid; Nadeem, Sadaf; Perez, Rebeca Cristina Romero; Shetty, Arushi; Adhikari, Kedar; Khatter, Tanya; Arasada, Chinmayee; Moussa, Naji; Mbaekwe, Eziamaka; Horsaengchai, Panchanit; Ali, Ramsha.

Citation:

Cureus. 17(10):e94418, 2025 Oct.

Abstract:

Kawasaki disease (KD) is a systemic inflammation of the blood vessels seen in children. It is the leading cause of acquired heart disease. Coronary artery aneurysm (CAA) is the most concerning complication, associated with long-term morbidity and mortality. This systematic review examined long-term outcomes of CAAs in KD, with emphasis on regression, complications, and the role of medical and surgical interventions. A total of 21 studies involving 10,922 patients were reviewed. The incidence of CAAs ranged from 3%-27%, mostly affecting infants under 6 months. Small and moderate aneurysms regressed in the majority of cases (>80%), whereas giant aneurysms were less likely to regress. Complications included thrombosis, myocardial infarction, major adverse cardiac events, and cardiac death. Early treatment with intravenous immunoglobulin (IVIG) enhanced the likelihood of regression. Aneurysms in the left anterior descending artery were less likely to regress, suggesting an anatomical influence. Coronary artery bypass grafting was the most common surgical intervention. Early and aggressive management with IVIG, with escalation to steroids or biologics when required, remains the preferred approach. Surgical intervention is sought for giant or persistent aneurysms. These findings emphasize the importance of timely diagnosis, risk stratification, and the establishment of standardized guidelines to optimize long-term care and surveillance of patients with KD.

DOI: 10.7759/cureus.94418

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Accuracy and Timeliness of Prehospital Global Triage System Protocols in Mass Disasters: A Systematic Review of Systematic Reviews (2025)

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Type of publication:

Systematic Review

Author(s):

Shaltout, Amr Essam; Elfatih Elbadri, Mohammed; Kaur, Kiranjot; Alsharif, Mohammed M; Alkhazendar, Aliaa H; *Hassouba, Omar Nasr; Ahmad, Muhammad Nabeel; Osman, Mazin; Zahid, Areeba; Banjamin, Shaun.

Citation:

Cureus. 17(9):e92796, 2025 Sep.

Abstract:

This systematic review evaluated the accuracy and timeliness of global prehospital triage systems in mass disasters, following Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) 2020
guidelines. A comprehensive search of PubMed/MEDLINE, Embase, Scopus, and Cochrane Library up to June 2025 identified 344 records, of which four studies met eligibility criteria after screening and full-text assessment. Included studies analyzed conventional systems such as Simple Triage and Rapid Treatment (START), JumpSTART, Sort, Assess, Lifesaving Interventions, Treatment/Transport (SALT), and Modified Physiological Triage Tool (MPTT), as well as artificial intelligence (AI)-assisted approaches and diagnostic adjuncts like portable ultrasound. Sample sizes ranged from targeted reviews of 30-60 studies (systematic and evidence-based reviews) to practical evaluations of triage innovations involving prehospital and emergency responders. Data extraction captured accuracy, timeliness, and resource allocation, while risk of bias was assessed using the A Measurement Tool to Assess Systematic Reviews version 2 (AMSTAR-2) and the Scale for the Assessment of Narrative Review Articles (SANRA), with ratings ranging from low to moderate. Results demonstrated that traditional systems such as START and SALT provide rapid categorization but remain prone to over- and under-triage depending on responder training and situational factors. AI-driven models and portable diagnostic technologies significantly improved decision speed, diagnostic precision, and prioritization of life-saving interventions, reducing delays in critical care. Overall, while no single algorithm proved universally superior, integration of training, simulation-based preparedness, and emerging AI-supported tools was consistently associated with improved triage performance in chaotic, resource-limited disaster environments.

DOI: 10.7759/cureus.92796

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Microvascular Outcomes of Glucagon-Like Peptide-1 (GLP-1) Receptor Agonists in Type 2 Diabetes: A Systematic Review of Retinopathy and Nephropathy Evidence (2025)

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Type of publication:

Systematic Review

Author(s):

Arif, Atia; Lama, Sanu; Singla, Bhavna; Singla, Shivam; Kumawat, Sunita; Tharwani, Anusha; Usman, Muhammad; Khalid, Hamna; Kanukollu, Venkata Madusudana Rao; *Ekomwereren, Osatohanmwen; Khan, Shabir.

Citation:

Cureus. 17(9):e92976, 2025 Sep.

Abstract:

This systematic review evaluated randomized controlled trials examining the effects of glucagon-like peptide-1 (GLP-1) receptor agonists on microvascular outcomes in type 2 diabetes, focusing on diabetic retinopathy and nephropathy. Four eligible RCTs, enrolling over 27,000 patients with follow-up periods ranging from 32 weeks to 5.4 years, were included. GLP-1 receptor agonists consistently demonstrated renal protective effects, primarily driven by reductions in new or worsening nephropathy and acroalbuminuria, with more modest and inconsistent effects on estimated glomerular filtration rate (eGFR) decline. In contrast, their impact on retinopathy remained inconclusive. A transient signal of worsening retinopathy has been reported in the context of rapid glycemic improvement; however, across large outcome trials, effects on retinopathy have been inconsistent and remain inconclusive. Overall, the evidence for retinopathy risk is limited by small event numbers, heterogeneity in assessments, and exploratory analyses. The certainty of renal benefit was strengthened by rigorous trial designs and low risk of bias, whereas retinopathy outcomes were generally secondary and less robust. These findings suggest that GLP-1 receptor agonists can be prioritized for patients at high renal risk, but careful monitoring of individuals with pre-existing retinopathy remains warranted

DOI: 10.7759/cureus.92976

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Heparin-Induced Thrombocytopenia Following Tinzaparin Administration: A Case Report (2025)

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Type of publication:

Journal article

Author(s):

*Khallaf, Laila; *Katarki, Praveenkumar; *Ahmad, Nawaid; *Govindagowda, Thimmegowda.

Citation:

Cureus. 17(9):e93248, 2025 Sep.

Abstract:

Heparin-induced thrombocytopenia (HIT), a severe immune-mediated reaction, presents a significant diagnostic challenge, particularly with atypical symptoms like syncope or when induced by low-molecular-weight heparin (LMWH). This report describes the case of a 77-year-old male who developed severe thrombocytopenia following tinzaparin administration for bridging therapy after an elective endovascular aneurysm repair (EVAR). The patient presented to the emergency department with syncope, an uncommon manifestation of HIT. Initial investigations revealed isolated thrombocytopenia, and a high clinical suspicion based on a 4Ts score of 6 prompted the immediate discontinuation of tinzaparin and initiation of fondaparinux. The diagnosis was subsequently confirmed by a positive HIT antibody screening test. The patient's platelet counts improved in a few days, and he was successfully transitioned to warfarin without complications. This case highlights the critical importance of maintaining a high index of suspicion for HIT in any patient exposed to Heparin products, including LMWH, who develops thrombocytopenia, even when the clinical presentation is atypical. Early recognition and prompt management with alternative anticoagulants are essential to prevent life-threatening thromboembolic complications.

DOI: 10.7759/cureus.93248

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Comparative Diagnostic Accuracy of Clinical Assessment, Computed Tomography (CT), and Magnetic Resonance Imaging With Magnetic Resonance Cholangiopancreatography (MRI/MRCP) in Evaluating Common Bile Duct Stones (2025)

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Type of publication:

Journal article

Author(s):

*Al-Dulaimi, Mina; *Ibraheem, Mustafa; *Abdulkareem, Mustafa; Al-Dujaili, Aaisha; Abdulkareem, Ameer.

Citation:

Cureus. 17(10):e94572, 2025 Oct.

Abstract:

PURPOSE: To determine the most effective method for diagnosing common bile duct (CBD) stones, this research retrospectively compares the diagnostic accuracy of initial clinical evaluation, computed tomography (CT), and magnetic resonance imaging with magnetic resonance cholangiopancreatography (MRI/MRCP). The goal is to identify the optimal non-invasive strategy to guide patient management and prevent unnecessary invasive procedures such as endoscopic retrograde cholangiopancreatography (ERCP). An accurate diagnosis of choledocholithiasis is essential for proper patient care.

MATERIALS AND METHODS: This single-center, retrospective analysis involved 691 adult patients who were under evaluation for suspected choledocholithiasis. The effectiveness of clinical assessment, multidetector CT, and MRI/MRCP was measured against definitive diagnoses obtained from surgical or procedural findings. For each diagnostic method, the study calculated sensitivity, specificity, accuracy, and the area under the receiver operating characteristic curve (AUC).

RESULTS: CBD stones were present in 311 of the 691 patients, a prevalence of 45%. MRI/MRCP was the most effective diagnostic tool, with a sensitivity of 92.7%, a specificity of 91.9%, and an accuracy of 92.3%. In comparison, CT scans yielded a sensitivity of 73.2%, a specificity of 82.9%, and an accuracy of 78.3%. Clinical assessment resulted in a sensitivity of 71.1%, a specificity of 87.1%, and an accuracy of 80%. The AUC for MRI/MRCP (0.95) was markedly higher than that for both CT (0.83; p<0.001) and clinical assessment (0.81; p<0.001). There was no significant difference in the diagnostic performance between CT and clinical assessment (p=0.45).

CONCLUSION: For the non-invasive identification of CBD stones, MRI/MRCP provides superior diagnostic accuracy compared to both CT and clinical evaluation. It is recommended as the top imaging choice for patients with suspected choledocholithiasis.

DOI: 10.7759/cureus.94572

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Accuracy and Timeliness of Prehospital Global Triage System Protocols in Mass Disasters (2025)

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Type of publication:

Journal article

Author(s):

Shaltout, Amr Essam; Elfatih Elbadri, Mohammed; Kaur, Kiranjot; Alsharif, Mohammed M; Alkhazendar, Aliaa H; *Hassouba, Omar Nasr; Ahmad, Muhammad Nabeel; Osman, Mazin; Zahid, Areeba; Banjamin, Shaun.

Citation:

Cureus. 17(9):e92796, 2025 Sep.

Abstract:

This systematic review evaluated the accuracy and timeliness of global prehospital triage systems in mass disasters, following Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) 2020
guidelines. A comprehensive search of PubMed/MEDLINE, Embase, Scopus, and Cochrane Library up to June 2025 identified 344 records, of which four studies met eligibility criteria after screening and full-text assessment. Included studies analyzed conventional systems such as Simple Triage and Rapid Treatment (START), JumpSTART, Sort, Assess, Lifesaving Interventions, Treatment/Transport (SALT), and Modified Physiological Triage Tool (MPTT), as well as artificial intelligence (AI)-assisted approaches and diagnostic adjuncts like portable ultrasound. Sample sizes ranged from targeted reviews of 30-60 studies (systematic and evidence-based reviews) to practical evaluations of triage innovations involving prehospital and emergency responders. Data extraction captured accuracy, timeliness, and resource allocation, while risk of bias was assessed using the A Measurement Tool to Assess Systematic Reviews version 2 (AMSTAR-2) and the Scale for the Assessment of Narrative Review Articles (SANRA), with ratings ranging from low to moderate. Results demonstrated that traditional systems such as START and SALT provide rapid categorization but remain prone to over- and under-triage depending on responder training and situational factors. AI-driven models and portable diagnostic technologies significantly improved decision speed, diagnostic precision, and prioritization of life-saving interventions, reducing delays in critical care. Overall, while no single algorithm proved universally superior, integration of training, simulation-based preparedness, and emerging AI-supported tools was consistently associated with improved triage performance in chaotic, resource-limited disaster environments.

DOI: 10.7759/cureus.92796

Link to full-text [open access - no password required]

STONE Score as a Triage Tool to Guide Computed Tomography of the Kidneys, Ureters, and Bladder (CT-KUB) Requests in Suspected Renal Colic: A Quality Improvement Initiative (2025)

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Type of publication:

Journal article

Author(s):

*Hassouba, Omar Nasr; Abdullah Omar, Abdulaziz Alsamani; Awan, Manahil; Ahmad, Shahzad; Taha, Mawada; Venkatachalapathi, Sharmila; Abouelsadat, Mohamed K; Mercy, Albina; Sahnon, Abdelrahman Sahnon Abaker; Shafique, Usama; *Herman, Dodi I.

Citation:

Cureus. 17(9):e92080, 2025 Sep.

Abstract:

Introduction Urolithiasis is a frequent cause of emergency department (ED) visits, with computed tomography (CT) being the gold standard for diagnosis. Excessive imaging increases radiation exposure and healthcare costs. The STONE score is a validated clinical prediction tool, designed to estimate the probability of ureteric stones and reduce unnecessary imaging. Objective The main objective of this study is to evaluate the diagnostic accuracy of the STONE score in patients presenting with flank pain. Methodology This is a cross-sectional retrospective review conducted at the Shrewsbury and Telford Hospital NHS Trust (SATH), Shrewsbury, England, over a four-month period from April 1, 2023, to July 31, 2023. This quality improvement initiative reviewed 81 eligible ED patients who underwent computed tomography of the kidneys, ureters, and bladder (CT-KUB) for suspected ureteric stones. Demographic, clinical, laboratory, and imaging data were collected. STONE scores were calculated for all patients. Diagnostic performance was assessed using receiver operating characteristic (ROC) curve analysis. Results The mean age was 38.5 +/- 16.1 years; 35 (43.2%) were male. Ureteric stones were confirmed in 15/19 (78.9%) high-risk, 9/45 (20%) moderate-risk, and 0/17 (0%) low-risk patients. The STONE score yielded an area under the curve (AUC) of 0.879, with a sensitivity of 91.7% and a specificity of 66.7%. Alternative diagnoses included gallbladder stones, appendicitis, cystitis, diverticulitis, hydronephrosis, renal angiomyolipoma, polycystic kidney disease (PCKD), pyelonephritis, and small bowel obstruction (SBO). Conclusion The STONE score demonstrates good diagnostic accuracy, particularly in high-risk patients, and may help reduce unnecessary CT imaging and radiation exposure in the ED.

DOI: 10.7759/cureus.92080

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