Gold open access

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

Posted on by

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

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

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)

Posted on by

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

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

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

Posted on by

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)

Posted on by

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

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

A Joint Venture: Advancing Health Equity for Underserved Communities Through Integrated Dermatology-Rheumatology Clinics (2025)

Posted on by

Type of publication:

Journal article

Author(s):

*Canteenwala, Zal; Thevathasan, Joseph; Baho, Heli George; Amin, Kunal; *Jain, Dimple; Amarasena, Roshan

Citation:

Cureus 17(10): e94590. doi:10.7759/cureus.94590

Abstract:

Background
Patients with immune-mediated disease often need both dermatology and rheumatology input. Separate appointments can increase travel and delay decisions, particularly in rural settings. We evaluated a monthly combined clinic in a rural UK catchment.

Methods
We conducted a prospective service evaluation (April-October 2022) of a consultant-led, co-located dermatology-rheumatology clinic. Forty-nine consecutive adult attendees completed an anonymous post-visit questionnaire on perceived usefulness, satisfaction, avoided appointments, travel costs, and prior time off work; free-text responses were thematically analysed by two reviewers. We report proportions with exact Clopper-Pearson 95% confidence intervals (CIs), with denominators varying due to item non-response.

Results
We analysed 49 questionnaires. All respondents viewed the joint appointment as a good idea (49/49; 100.0%; 95% CI 92.7-100.0), and all were satisfied (47/47; 100.0%; 95% CI 92.5-100.0). The clinic avoided an additional appointment for 44/46 (95.7%; 95% CI 85.2-99.5) and reduced out-of-pocket travel costs for 39/40 (97.5%; 95% CI 86.8-99.9). Among employed respondents, 19/36 (52.8%; 95% CI 35.5-69.6) reported previously needing time off work for separate specialty visits.

Conclusions
In a rural, cross-trust NHS setting, a combined dermatology-rheumatology clinic was feasible and associated with high patient-reported usefulness and satisfaction, fewer duplicate visits, and lower travel costs. Findings support continued provision and motivate comparative and economic evaluations using routine utilisation and cost data.

DOI: 10.7759/cureus.94590

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

Bronchiolitis Obliterans in an Adult Male After Admission With Panton-Valentine Leucocidin Staphylococcal Pneumonia (2025)

Posted on by

Type of publication:

Journal article

Author(s):

*Nadeem, Sabha; *Sargent, Georgina; *Wood, Gordon; *Ahmad, Nawaid.

Citation:

Cureus. 17(9):e91611, 2025 Sep.

Abstract:

A middle-aged man with no smoking or respiratory history presented with shortness of breath and facial swelling due to influenza. His condition deteriorated rapidly, and he required intensive care admission and intubation. He was found to have Panton-Valentine leucocidin (PVL) Staphylococcal pneumonia, with bilateral pneumothorax and subcutaneous emphysema. He responded well to antibiotics and chest drainage and was subsequently discharged. His follow-up radiology initially showed almost complete resolution. However, over the course of five years, he had multiple GP attendances and hospital admissions for recurrent infections with continued breathlessness on exertion. A follow-up CT suggested features of bronchiolitis obliterans (BO), which has not been previously recognised as associated with PVL Staphylococcal infections. Specialist teams have suggested active observation with consideration of transplantation in the event of deterioration. This case demonstrates that BO can be seen with previously unrecognised infectious aetiology and should be considered in any patient with appropriate symptomatology following a severe respiratory infection.

DOI: 10.7759/cureus.91611

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

CT coronary angiography in the lipid clinic: a pilot study and lipidologist survey (2025)

Posted on by

Type of publication:

Journal article

Author(s):

Graby, John; Sellek, James; Khavandi, Ali; Thompson, Dylan; Loughborough, Will W; Hudson, Benjamin J; Avades, Tony; Mbagaya, Wycliffe; Luva, Ahai; *Capps, Nigel; Shirodaria, Cheerag; Bayly, Graham; Antoniades, Charalambos; Downie, Paul F; Rodrigues, Jonathan C L.

Citation:

The International Journal of Cardiovascular Imaging. 2025 Oct 09. [epub ahead of print]

Abstract:

Guidelines recommend considering coronary calcium score (CCS) in asymptomatic patients to aid risk stratification. However, calcification occurs late in atherosclerosis. Coronary CT angiography (CCTA) can detect non-calcific plaque and inflammation before calcification develops, but impact on clinical management is not well documented. We compare coronary artery disease (CAD) detection and grading between CCS and CCTA, impact on management, and explore CCTA-derived inflammation biomarker (pericoronary fat attenuation index [FAI]) in the lipid clinic. Exploratory analysis of a prospectively maintained database of lipid clinic patients with CCS and CCTA (2018-2020). CCS grade was compared with CCTA stenosis, presence of high-risk plaque (HRP) and FAI-score analysis. UK Consultant Lipidologists completed an anonymised survey, documenting lipid target and management after sequential unblinding of CCS and CCTA data. In 45 asymptomatic patients (49% female, mean age 55 +/- 9), CCTA re-classified CAD presence in 22% (p = 0.002) and severity in 62% (p = 0.005) vs. CCS. HRP was observed in 20% (9/45), including 56% with CCS <= 100. Median LDL target with clinical vignette was 101 mg/dL (IQR 77-120), reducing to 89 mg/dL (77-120) after CCS, and 77 mg/dL (70-116) after CCTA unblinding. CCS altered LDL target in 12%, and CCTA a further 19% (chi2 57.0, p < 0.005). High FAI-score was demonstrated in 20%, including 22% of those with CCS <= 100 and 75% of those with <= mild CAD on CCTA. CCTA increased CAD prevalence and re-classified severity versus CCS, altering hypothetical management. High FAI-scores were observed across CCS and CCTA severity grades, including patients with no overt CAD.

DOI: 10.1007/s10554-025-03526-3

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

Postoperative Outcomes of the Desarda Technique Versus Lichtenstein Mesh Repair for Inguinal Hernias: A Systematic Review and Meta-Analysis (2025)

Posted on by

Type of publication:

Journal article

Author(s):

*Saeed, Jahanzaib; Jamal, Zohaib; Siddiqui, Asher; Muawaz, Muhammad; Saeed, Talha; *Jain, Rajesh K.

Citation:

Cureus. 17(9):e91388, 2025 Sep.

Abstract:

Inguinal hernias represent a prevalent surgical condition worldwide and constitute a significant proportion of elective general surgical procedures. While the Lichtenstein mesh repair has become the standard technique due to its tension-free approach, it is associated with several mesh-related complications, including chronic postoperative pain, seroma, scrotal edema, and foreign body sensation. To overcome these limitations, the Desarda technique was developed as a tissue-based, mesh-free alternative that reinforces the posterior wall of the inguinal canal using a strip of the external oblique aponeurosis. This systematic review compares postoperative complications between the Lichtenstein mesh repair and Desarda techniques to inform best practices in inguinal hernia repair. This systematic review was conducted according to the Cochrane Handbook for Systematic Reviews of Interventions and reported in line with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. A comprehensive search was performed across PubMed, Cochrane Library, Excerpta Medica database (EMBASE), Emcare, Medical Literature Analysis and Retrieval System Online (MEDLINE), and Ovid, without language or date restrictions. Randomized controlled trials (RCTs) comparing Desarda and Lichtenstein mesh repair for primary inguinal hernia in adults were included. Data on postoperative complications were independently extracted by two reviewers. Risk of bias was assessed using the Risk of Bias 2 (ROB 2) tool (The Cochrane Collaboration, London, United Kingdom). Statistical analysis was performed using RevMan 5.4 (The Cochrane Collaboration, 2020), with risk ratios (RR) and 95% confidence intervals (CI) calculated for binary outcomes. Heterogeneity was assessed using the chi-square and I2 statistics. A total of 23 RCTs were included, comprising 2,425 patients, 1,201 of whom underwent the Desarda repair and 1,233 who underwent Lichtenstein mesh repair. The Desarda technique was associated with significantly lower rates of scrotal edema (RR = 0.52, 95% CI: 0.34-0.78, p = 0.002), seroma formation (RR = 0.68, 95% CI: 0.47-0.99, p = 0.04), foreign body sensation (RR = 0.61, 95% CI: 0.42-0.88, p = 0.009), and chronic postoperative pain (RR = 0.26, 95% CI: 0.15-0.45, p < 0.00001). While the Desarda group also showed lower rates of recurrence, wound infection, wound hematoma, and loss of sensation, these differences were not statistically significant and should be interpreted with caution. The findings suggest that the Desarda technique may be preferable to the Lichtenstein mesh repair for primary inguinal hernia, as it is associated with significantly lower rates of chronic postoperative pain, seroma, scrotal edema, and foreign body sensation. Although other complications, such as loss of sensation, recurrence, wound infection, and hematoma, were also less frequent with the Desarda technique, these differences were not statistically significant. Overall, the outcomes were largely comparable.

DOI: 10.7759/cureus.91388

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

A Systematic Review of Long-Term Use of Proton Pump Inhibitors (PPIs) in Older Adults on Polypharmacy: Do PPIs Deplete Nutrients? (2025)

Posted on by

Type of publication:

Systematic Review

Author(s):

Shahid, Muhammad Salman; Ahmed, Nouman; Kamal, Zeeshan; Nathaniel, Laibah; Singla, Bhavna; Singla, Shivam; Kumawat, Sunita; Batool, Munaza; *Ekomwereren, Osatohanmwen; Anika, Nabila N; Sahil, Muhammad.

Citation:

Cureus. 17(8):e90888, 2025 Aug.

Abstract:

Proton pump inhibitors (PPIs) are widely prescribed in older adults, often beyond recommended durations, raising concerns about nutrient depletion. This systematic review examined the impact of long-term PPI use (>=6 months) on micronutrient status in older adults receiving polypharmacy. A comprehensive search of PubMed, Scopus, Web of Science, and Cochrane Central Register of Controlled Trials (CENTRAL) identified five eligible studies, including 693 participants. Results showed a 12-18% reduction in serum vitamin B12 over 12 months of PPI use. Calcium and parathyroid hormone levels declined significantly in a 12-month cohort, while bone turnover markers increased despite stable bone mineral density. Findings for magnesium were inconsistent, with results ranging from no change after 12 months to pharmacokinetic alterations without systemic depletion. Overall, the evidence consistently supports an association between prolonged PPI therapy and reductions in vitamin B12 and calcium, with conflicting results for magnesium. These deficiencies may contribute to cognitive decline, bone fragility, and increased fall risk in older adults. Routine nutritional monitoring, targeted supplementation, and deprescribing where appropriate should be considered to mitigate these risks, while further large-scale trials are needed in frail geriatric populations.

DOI: 10.7759/cureus.90888

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

Patient-Reported Importance of Functional Benefit in Geographic Atrophy (2025)

Posted on by

Type of publication:

Journal article

Author(s):

Dinah, Christiana; Enoch, Jamie; Ghulakhszian, Arevik; Sekhon, Mandeep; Salvatore, Serena; DeSalvo, Gabriella; Kumar, Praveen; Banerjee, Sanjiv; *Nayak, Devaki; Amoaku, Winfried; Shiew, Marianne; Osoba, Olayinka; Crabb, David P; Taylor, Deanna J.

Citation:

JAMA Ophthalmology. 2025 Sep 25. [epub ahead of print]

Abstract:

Importance: Intravitreal complement inhibitors injections (IVCIs) slowed progression of geographic atrophy (GA) lesions in several registration phase 3 trials although without benefit for prespecified secondary functional vision outcomes. Patient acceptability of these therapies needs further exploration.

Objective: To quantify the acceptability of IVCI therapy to United Kingdom patients with GA, assuming vision outcome benefits are expected.

Design, Setting, and Participants: This cross-sectional study took place at 9 geographically dispersed UK National Health Service centers from April 2023 to April 2024 among 153 participants with treatment-naive GA in at least 1 eye.

Exposures: GA in at least 1 eye.

Main Outcomes and Measures: Main outcomes were (1) acceptability of IVCI therapy based on completion of validated acceptability questionnaire. Participants were provided with a treatment information leaflet coproduced by a patients with lived experience of GA to inform them about the risks and benefits of IVCI for GA, assuming there were vision outcome benefits to this treatment and (2) response to the EuroQol 5-dimension with a vision bolt-on questionnaire to assess general health and vision-related quality of life. Spearman rank correlations and chi2 tests were used to explore associations between acceptability levels and specific ocular and sociodemographic characteristics.

Results: A total of 153 participants were recruited (93 [60%] women; mean [SD] age, 82 [7]), 57 (38%) of whom had bilateral foveal involvement. Median (IQR) visual acuity with habitual correction in the better-seeing eye and in eyes where neither eye was better or worse was logMAR, 0.30 (0.14-0.54; approximate Snellen equivalent, 20/40) and 0.47 (0.14-0.84; approximate Snellen equivalent, 20/63), respectively. Among the 153 participants, 81 (53%; 95% CI, 45-61) reported IVCIs were very much or extremely acceptable under the theoretical scenarios provided. The proportion finding IVCIs acceptable rose to 82% (95% CI, 76-88) when including those who rated prospective treatment as moderately acceptable. Belief in the perceived effectiveness of the treatment (rho, 0.52; 95% CI, 0.40-0.63; P < .001) and confidence in their ability to attend the eye clinic regularly (rho, 0.51; 95% CI, 0.38-0.62; P < .001) correlated with overall acceptability.

Conclusions and Relevance: IVCI therapy for GA may be acceptable to most UK patients with GA under the assumption that there are vision outcome benefits to this treatment. While current treatments do not result in vision outcome benefits, perceived effectiveness by patients was associated with acceptability, emphasizing the desire to quantify vision functional benefit concomitant with anatomical slowing of progression.

DOI: 10.1001/jamaophthalmol.2025.3264

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