Open access

Mortality from tibial shaft fractures in the elderly (MTFE)-a multicentre study of management outcomes (2025)

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Type of publication:

Journal article

Author(s):

Azhar M.S.; Selim A.; Daoub A.; Farhan-Alanie M.M.; Shah R.

Citation:

Injury. 56(12) (no pagination), 2025. Article Number: 112806. Date of Publication: 01 Dec 2025.

Abstract:

Introduction The mortality rate for tibial shaft fractures in the elderly is comparable to that of hip fractures, yet there is considerable variation in their management. Operative treatment allows for earlier weight-bearing and reduces potential complications of prolonged immobilization; however, it carries risks for this comorbid cohort. The main objective of this study was to assess the difference in 1-year mortality between operative and non-operative management. Methods A multicentre study was conducted across six trusts in England, including eight acute hospitals: three major trauma centres and five district general hospitals (DGHs). Data were collected retrospectively, covering a 5-year period from January 2017 to December 2021. The study included all patients aged 65 and over with diaphyseal tibial fractures (AO42). Patients with non-acute (>3 weeks), periprosthetic, pathological, or multiple lower limb fractures were excluded. Results A total of 171 patients were identified, comprising 38 % males and 62 % females. Of these, 59.6 % were managed operatively, while 40.4 % were managed non-operatively. The median length of stay was similar between groups (8 days non-operative vs. 8.5 days operative, p = 0.87). Non-union (21.7 % vs. 6.3 %, p < 0.001) and malunion rates (27.7 % vs. 4.6 %, p = 0.001) were significantly higher in the non-operative group. One-year mortality was also higher in the non-operative group (38.3 % vs. 12.1 %, p < 0.001). Univariate and multivariate analyses showed an odds ratio of 4.5 and 4.7 for one-year mortality with non-operative treatment, with p -values of <0.001 and 0.005, respectively. Conclusion This study demonstrated that non-operatively treated tibial shaft fractures in the elderly are associated with significantly higher rates of non-union, malunion, and 1-year mortality. Therefore, we recommend an expedited multi-disciplinary approach to managing these patients, including surgical treatment and unrestricted weight bearing where possible, to optimize outcomes. Level of Evidence Level III.

DOI: 10.1016/j.injury.2025.112806

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The spiked helmet sign in severe sepsis: an unusual electrocardiographic finding in a critically ill patient (2025)

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Type of publication:

Journal article

Author(s):

Manea, Hashim; Alhatemi, Ahmed Qasim Mohammed; Al-Ghuraibawi, Mohammedbaqer Ali; *Alhumairi, Ghaith Asaad; Al-Shammari, Ali Saad; Al-Ibraheem, Abdullah Muataz Taha; Ahmad, Ibrar; Abdulammer, Hussein Safaa.

Citation:

Oxford Medical Case Reports. 2025(11):omaf232, 2025 Nov.

Abstract:

Background: The 'spiked helmet' sign is a rare electrocardiographic (ECG) phenomenon characterized by transient ST-segment elevations mimicking an acute coronary syndrome, typically seen in critically ill patients. While often associated with severe physiological stress, its presence in sepsis is particularly uncommon.

Case Presentation: A 68-year-old male with a history of hypertension and diabetes mellitus presented to the emergency department with fever, altered mental status, and hypotension. Initial workup revealed severe sepsis secondary to pneumonia. His ECG showed pronounced ST-segment elevations in leads II, III, and aVF, with a distinctive 'spiked helmet' pattern. Troponin levels were mildly elevated, raising concerns for concurrent myocardial ischemia. However, the patient denied chest pain, and further cardiac evaluation, including echocardiography, showed no evidence of ischemia or infarction. Intensive care management included broad-spectrum antibiotics, intravenous fluids, and vasopressors. Despite the severity of his illness, the patient's condition gradually improved, and repeat ECGs showed resolution of the ST-segment elevations. The 'spiked helmet' sign was attributed to severe sepsis-induced autonomic dysfunction rather than primary cardiac pathology.

Conclusion: This case highlights the importance of recognizing the 'spiked helmet' sign as a marker of severe stress in critically ill patients, which may mimic myocardial ischemia on ECG. Prompt differentiation between this sign and true ischemia is crucial to avoid unnecessary interventions and focus on managing the underlying critical illness.

DOI: 10.1093/omcr/omaf232

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Bridging Communication Gaps to Enhance Patient Safety: A Quality Improvement (QI) Project on the Role of Abbreviations, Their Risks, and Pathways to Change (2025)

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Type of publication:

Journal article

Author(s):

*Talha, Saarah; *Smith, Ben; *Khan, Ayesha; Gaddoura, Zaina.

Citation:

Cureus. 17(10):e95843, 2025 Oct.

Abstract:

Introduction Effective communication within the multidisciplinary team (MDT) is critical to safe patient care. Whilst electronic health records have improved legibility, the widespread use of non-standardised abbreviations continues to cause misinterpretation, risking delays, errors, and compromised patient safety. Abbreviations are often used for efficiency, yet their meanings vary between specialties, creating barriers for rotating staff, cross-disciplinary colleagues, and patients reviewing discharge summaries. Quality improvement project We conducted a closed-loop quality improvement (QI) project structured around the SQUIRE 2.0 guidelines for QI initiatives. The project took place in a UK district general hospital to assess and improve understanding of commonly used ear, nose, and throat (ENT) specialty abbreviations. Eighty-two common abbreviations were identified and used in a written expansion test. In cycle one (n = 45), mean accuracy was 24.3%, with no participant exceeding 77%. Following targeted interventions (educational seminars and a printed reference guide displayed in shared spaces), a second assessment cycle was conducted with a new cohort. Post-teaching scores improved by a relative 40% to a mean of 35% (range 24%-52%). Mann-Whitney U testing confirmed statistical significance (p < 0.05). Implications and discussion Findings revealed a substantial baseline knowledge gap, highlighting a safety risk. Low-cost, high-visibility measures, such as reference posters and induction-based teaching, improved comprehension and could be readily adopted in other departments. However, residual gaps suggest the need for upstream interventions, including integration of documentation clarity training into medical education and continued departmental reinforcement. Conclusion Clinicians' baseline abbreviation comprehension was poor, but targeted education significantly improved understanding. Whilst no participant achieved complete proficiency, results show that simple, resource-light strategies can enhance communication clarity and support safer care. Broader adoption, alongside curricular change, offers a sustainable path to reducing abbreviation-related risks.

DOI: 10.7759/cureus.95843

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Hologenomic analysis of rectal mucus sampling for detection of adenomatous polyps and colorectal cancer (2025)

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Type of publication:

Journal article

Author(s):

Tock, Andrew J; Patel, Kamrun S; Morales-Walker, Emma; Zhang, Linglan; Orthodoxou, Chris; MacRitchie, Alasdair D; Njoroge, Stephen; Olaniru, Oladapo E; Mozolowski, Guy; Mendes, Ines; Baker, Dave J; Siew, Malvin; Humphrey, Hannah N; Walker-Davies, Eleanor T; McDermott, Frank; Spencer, Sue; Bird, Susan; Savva, Katerina-Vanessa; Cunningham, Christopher; Rottenburg, Hannah; Sisodia, Heena; Battersby, Nick J; *Jones, Gareth A R; *Lacy-Colson, Jon; Baggaley, Alice E; Peters, Christopher J; Dodd, Andrew; Kang, Kiran; Hamon, Chris; Crespillo-Casado, Ana; Law, Erica; Sands, Megan; Lywood, Hugo; Page, Andrew J; Daniels, Ian; Wise, Daniel.

Citation:

Nature communications . 16(1):10876, 2025 Dec 04.

Abstract:

Colorectal cancer (CRC) is the fourth most common cancer and the third leading cause of cancer-related mortality worldwide, with incidence rising among younger populations. The significant clinical and economic burden highlights the need for minimally invasive technologies capable of detecting pre-malignant and early-stage disease. Although liquid biopsy approaches have advanced, they have not achieved sufficient performance for clinical adoption when compared with colonoscopy, the current diagnostic gold standard. CRC is a mucosal pathology, yet current diagnostic methods have not leveraged mucosal biology. Here we demonstrate the clinical utility of rectal mucus specimens, collected using a minimally invasive device in an outpatient setting, without bowel preparation. Through a hologenomic approach integrating host and microbial genomics, we identify genetic and epigenetic aberrations and perturbations in microbial communities that drive the detection of adenomatous polyps and CRC in rectal mucus. Hologenomic integration enables superior stratification of CRC by disease site and stage compared with single-omics methods. In summary, we demonstrate the clinical utility of rectal mucus sampling combined with hologenomic analysis as a translatable prospective tool for diagnostic application.

DOI: 10.1038/s41467-025-66006-1

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Clinical and Functional Outcomes Following Intra-articular Platelet-Rich Plasma Injection for Knee Osteoarthritis: A Prospective Cohort Study (2025)

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Type of publication:

Journal article

Author(s):

*Murugesan, Thivagar; Mohankumar, Mahesh; Guna Surya, Pedapati Ssk Vijaya.

Citation:

Cureus. 17(10):e95297, 2025 Oct.

Abstract:

Background and objective Knee osteoarthritis (OA), a common degenerative joint disease, often leads to chronic pain and disability, particularly in middle-aged individuals. With growing interest in regenerative therapies, platelet-rich plasma (PRP) has emerged as a potential biological treatment due to its anti-inflammatory and reparative properties. This study aimed to evaluate the clinical and functional outcomes following intra-articular PRP injections in patients with early-stage knee OA. Methodology A prospective clinical trial was conducted at a tertiary care center involving 113 patients diagnosed with Kellgren-Lawrence grade 1 or 2 knee osteoarthritis. Each participant received a single intra-articular PRP injection and was followed for 24 weeks. Pain and functional outcomes were assessed using the visual analog scale (VAS) and the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC)-CRD at baseline, and at six, 12, and 24 weeks post-injection. Results At every follow-up, both VAS and WOMAC scores demonstrated significant reductions (p < 0.001). Patients with grade 1 OA showed greater improvement compared to those with grade 2 at all time points. While VAS scores decreased from 5.87 to 2.85, the
average WOMAC score fell from 32.81 at baseline to 24.89 after 24 weeks. Better results were strongly connected with younger age and lower radiographic grade. Conclusions Our results align with existing research supporting the effectiveness of PRP in managing early osteoarthritis. The treatment showed consistent symptom relief, particularly in younger patients and those with lower radiographic grades. Over a six-month period, intra-articular PRP injections offered significant pain reduction and functional improvement in early-stage knee OA, establishing it as a safe and effective therapy.

DOI: 10.7759/cureus.95297

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Systemic Therapies for Moderate-to-Severe Atopic Dermatitis in Children and Adolescents: A Systematic Review (2025)

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Type of publication:

Systematic Review

Author(s):

Hamza Osman, Sahar Khalil; *Mohamed Ahmed, Malaz Awad; Idrees, Hoda; Mohammad Ali, Aziza Mohammad Hassan; Ahmed Taha, Aisha Hassan; Musa Shaikhelsafi, Fatima Hassan; Mirghani Hamour, Afrah Mohamed.

Citation:

Cureus. 17(10):e94907, 2025 Oct.

Abstract:

Moderate-to-severe atopic dermatitis (AD) in children and adolescents imposes a significant burden, often requiring systemic therapy. With the recent development of targeted biologics and Janus kinase (JAK) inhibitors, the treatment landscape has evolved rapidly. This systematic review aims to critically evaluate the efficacy and safety of these advanced systemic therapies in the pediatric population. A systematic search of PubMed/MEDLINE, Scopus, Web of Science, and ClinicalTrials.gov was conducted for randomized controlled trials (RCTs) published from 2020 onwards, yielding 250 records. Thirteen studies involving over 3,500 pediatric patients were included. Studies evaluating biologics or JAK inhibitors in children and adolescents (0-18 years) with moderate-to-severe AD were included. The Cochrane Risk of Bias 2 (ROB 2) tool was used for quality assessment. A narrative synthesis was performed due to clinical heterogeneity. Dupilumab and tralokinumab (biologics) demonstrated significant efficacy, with Eczema Area and Severity Index 75 (EASI-75) response rates of 43.3% at week 16 and sustained improvements in disease severity (SCORAD, IGA) and pruritus. The JAK inhibitors, abrocitinib and upadacitinib, showed rapid and high-magnitude efficacy, with EASI-75 and Validated Investigator Global Assessment (vIGA-AD) response rates frequently exceeding 70-90% by weeks 12-16 and providing rapid itch relief. Dupilumab's safety profile was favorable, with mostly mild-to-moderate adverse events (e.g., conjunctivitis). JAK inhibitors were associated with acne, nausea (abrocitinib), and herpes infections, necessitating routine monitoring. The overall risk of bias was low across most studies. Advanced systemic therapies are highly effective for moderate-to-severe pediatric AD. Biologics offer a well-established safety profile, while JAK inhibitors provide superior and faster efficacy, particularly for itch, but require careful safety monitoring. Treatment choice should be individualized based on disease severity, preference, and risk profile.

DOI: 10.7759/cureus.94907

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Atezolizumab-Induced Thyroiditis and Immune Checkpoint Inhibitor (ICI)-Type 1 Diabetes Mellitus: Diagnostic and Therapeutic Challenges in ICI-Associated Endocrinopathies (2025)

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Type of publication:

Journal article

Author(s):

*Al-Rubaye, Rafal; *Nadeem, Sabha; Soliman, Ahmed Abdulkader Zaki Ali.

Citation:

Cureus. 17(10):e94593, 2025 Oct.

Abstract:

The rapid evolution and increased application of immune checkpoint inhibitors (ICIs) in the oncology setting have introduced novel diagnostic and therapeutic challenges, particularly in the setting of endocrine immune-related adverse events (irAEs). Thyroid dysfunction is among the most common of these, while ICI-type 1 diabetes mellitus is uncommon and can present abruptly with life-threatening complications. A 76-year-old man with extensive-stage small-cell lung cancer being treated with atezolizumab developed new-onset diabetes, which manifested as diabetic ketoacidosis in connection with immunotherapy-induced thyroiditis. Metabolic instability in this patient was compounded by the inappropriate initiation of thyroid hormone replacement during the thyrotoxic phase of the thyroiditis as a result of misinterpretation of his thyroid function tests (TFTs). The unique clinical course of this patient illustrates the broad and unpredictable spectrum of ICI-related endocrinopathies and highlights the importance of prudent interpretation of TFTs, early recognition of ICI-induced type 1 diabetes mellitus, and close multidisciplinary management of irAEs.

DOI: 10.7759/cureus.94593

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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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