Search Results (3,546)

Background/Objectives: Free flap microsurgical reconstruction is the gold standard for complex oncological head and neck defects. Despite high success rates, flap failure carries significant morbidity and oncological implications. This study aimed to identify preoperative, analytical, and intraoperative predictors of free flap non-viability in a prospective series of head and neck oncological reconstructions. Methods: A prospective observational cohort study included 98 consecutive patients undergoing microsurgical free flap reconstruction at a single tertiary centre (January 2022–December 2025). Categorical variables were analysed with Fisher’s exact test and odds ratios (OR) with 95% confidence intervals (CI); continuous variables were analysed using the Mann–Whitney U test and rank-biserial correlation (r). Multivariate logistic regression was performed for variables with p < 0.20 in univariate analysis. Results: Free flap survival was 88.8% (87/98). On univariate analysis, intraoperative vasospasm (9.2% vs. 72.7%; p < 0.001) and prolonged arterial anastomosis time (median 25 vs. 45 min; p = 0.012) showed the strongest associations with flap failure. A negative O’Brien patency test (p = 0.012) and greater number of transfused red blood cell units (p = 0.033) were also significant. No preoperative variable was significantly associated with flap outcome. On multivariate analysis, vasospasm remained the sole independent predictor of viability (p = 0.014), with arterial anastomosis time showing a persistent trend (p = 0.079). Conclusions: Intraoperative vasospasm was the principal independent determinant of flap viability, while prolonged arterial anastomosis time showed a consistent univariate association and a non-significant multivariable trend. Given the small number of flap failures (n = 11), these findings, together with the proposed intraoperative time thresholds, should be regarded as preliminary and hypothesis-generating pending external validation. These findings underscore the primacy of intraoperative technical and vascular factors and may guide surgical training and perioperative management protocols. Full article

Background: Fusobacterium necrophorum is an anaerobic Gram-negative organism classically associated with severe head and neck infections and Lemierre syndrome. Central nervous system involvement is uncommon but may be rapidly progressive and fatal, particularly when associated with sinusitis, intracranial empyema, cerebritis, or brain abscess. Case presentation: We report the case of a previously healthy 18-year-old male who presented after four days of high fever up to 41.5 °C, severe holocranial headache, vomiting, and acute hyperactive delirium. On admission, he had meningismus, markedly elevated inflammatory markers, and concomitant Influenza A infection. The initial cranial computer tomography showed a left frontal hypodense lesion with hemorrhagic transformation and perfusion deficit. The cranial magnetic resonance tomography demonstrated left frontopolar cerebritis, intracranial empyema along the falx and tentorium, intraspinal extension, and extensive bilateral frontal, maxillary, and ethmoidal sinusitis, suggesting sinogenic intracranial spread. The patient underwent emergency bilateral pansinus surgery, placement of an external ventricular drain, left hemicraniectomy with evacuation of empyema, repeat evacuation of subdural empyema and frontal abscess drainage, and posterior fossa decompression with C1 laminectomy. Fusobacterium necrophorum was detected in anaerobic blood cultures and the operative intracranial samples. Despite aggressive interdisciplinary management, the patient developed septic multiorgan failure and died on hospital day 4. Conclusions: This case illustrates a rare but potentially fatal sinogenic Fusobacterium necrophorum infection of the central nervous system in a young adult. By providing a detailed report, we intend to increase awareness of this rare yet fatal clinical presentation. Full article

Background/Objectives: Diabetes mellitus is a chronic metabolic disorder characterized by impaired regulation of blood glucose due to defects in insulin secretion, insulin action, or both. Physiological and lifestyle factors vary among individuals. General medicine is not applicable to all patients. In this scenario, personalized medicine for each individual becomes costly. Effective management of continuous glucose levels with accurate insulin dosage is challenging. To overcome this, a digital twin (DT)-based insulin dosage simulator with an individual’s metabolic system is proposed in this work. Methods: Various machine learning techniques, mathematical models of physiology, and risk assessment using probability are used to predict the dynamics of patient-specific glucose–insulin. Parameters such as carbohydrate intake, sleep patterns, medications, and physical activity were incorporated into this model to capture real-world variations in daily life. For glucose–insulin interactions, the Bergman Minimal Model (BMM) is used; for time-of-day variability, a circadian insulin sensitivity model is used; and for predicting metabolic risks, Bayesian risk estimation (BRE) is used, which includes hyperglycemia risk. To enhance transparency and interpret model predictions, explainable artificial intelligence (XAI) methods are employed. Results: The simulation results showed improved glucose prediction accuracy, enhanced detection of hypoglycemia risk, and optimized insulin dosing strategies compared with traditional approaches. Conclusions: Overall, the proposed digital twin model offers a scalable solution using the latest techniques A “Prescriptive Analytical Framework” is provided using the BMM and BRE for personalized diabetes management and decision support for clinicians. Full article

Background: During the coronavirus disease 2019 (COVID-19) pandemic, changes in healthcare organisation may have affected the management of patients with chronic conditions, such as those with type 2 diabetes (T2D), who require close monitoring. Although there are studies that have analysed the access and management of patients with T2D in primary care (PC) during the pandemic, there is no synthesis of the results that inform us about the care provided and their effect. The aim of this study is to summarise the existing evidence on the care provided in PC settings to patients with T2D during the COVID-19 pandemic, as well as their follow-up care and outcomes, in order to understand the impact of the pandemic on their management. Methods: A scoping review was conducted according to the approach described by Arksey and O’Malley. Structured search strategies were developed for each of the selected databases (PubMed, EMBASE and Web of Science). We included articles published in English and Spanish up to 24 March 2026 on access to care for patients with T2D in PC during the pandemic. Two independent reviewers screened titles and abstracts to select studies related to the population, intervention, and outcomes of interest. In cases of disagreement, a third reviewer resolved the discrepancy. One of the reviewers extracted data and summarised them. Results: After duplicate removal, 535 records were identified, with 116 articles screened in full text and 26 included. Most studies were conducted in Europe and North America using retrospective designs and electronic health records. During the pandemic period, face-to-face visits and routine screenings generally declined, while telemedicine expanded and may have partially mitigated disruptions in patient contact, although inequalities in access were reported. Disease monitoring and complication screening also declined in several settings. Clinical outcomes such as HbA1c and blood pressure (BP) showed heterogeneous trends, with some studies reporting deterioration and others reporting stability. Some studies also highlighted increased adverse events and greater attention to mental health during care. Conclusions: Although telemedicine helped maintain patient follow-up, it could not fully replace face-to-face assessments and was implemented alongside some gaps in clinical monitoring, patient safety, and health equity. These findings underscore the need to maintain structured chronic disease management and to develop safe and inclusive telehealth models. Full article

Introduction: COPD-OSA overlap syndrome (OVS) is defined by the coexistence of chronic obstructive pulmonary disease and obstructive sleep apnea syndrome in the same patient; it affects 28.3% of patients evaluated for either condition and is associated with significantly higher mortality compared to either pathology in isolation. Current therapeutic approaches, involving PAP therapy and bronchodilation, treat this syndrome as a homogeneous entity and ignore the biological heterogeneity of this patient population. Objectives: This review proposes a systematic framework for the endotypic classification of biological interactions between COPD and OSA, integrating current literature on the pathophysiological mechanisms underlying the OVS, clinically accessible biomarkers, and emerging therapies. Methods: A narrative review based on available literature, focusing on studies published between 2010 and 2026 identified via searches in PubMed, PMC, and Dove Medical Press using the terms: COPD-OSA overlap syndrome, endotype, precision medicine, phenotype, biomarker, dupilumab, and incretin-based therapies. Results: Four clinical phenotypes (obese-metabolic, emphysematous, bronchitic-hypoxemic, and hypercapnic) and three molecular endotypes (Th2/eosinophilic, neutrophilic/oxidative, and metabolic-adipokine) are proposed, each with distinct pathophysiological mechanisms and specific therapeutic implications. The interaction between the two conditions generates a unique, pronounced hypoxemic profile. We propose the “double-hit hypoxemia” model as a conceptual framework characterized by amplified systemic inflammation and increased cardiovascular risk compared to either pathology in isolation. This proposed model has not yet been prospectively validated. Dupilumab (approved for an inflammatory phenotype in COPD patients characterized by eosinophil counts ≥ 300 cells/μL) represents a promising option, though currently unsupported in the OVS population, that could nonetheless be relevant to the Th2/eosinophilic endotype of this syndrome and tirzepatide (which reduced the AHI by up to 23.8 events/hour versus placebo in the SURMOUNT-OSA trial, conducted in patients with obesity and moderate-to-severe OSA, rather than in patients with confirmed OVS) could represent a promising therapy for the metabolic-adipokine endotype of obese patients with OVS. A minimal biomarker panel, comprising blood eosinophils, FeNO, daytime PaCO₂, BMI, and T90, allows for a practical approach to identifying the dominant endotype. Conclusions: Endotyping of OVS may provide a framework for moving beyond a uniform therapeutic approach toward more individualized management based on the dominant underlying biological mechanism. Randomized clinical trials focusing on endotypic stratification and OVS cohorts remain research priorities. Full article

Severe adverse reactions induced by non-ionic contrast media remain an uncommon complication in veterinary medicine. This report describes the clinical manifestations and sequential computed tomography alterations indicative of acute shock captured during 2 min and 4 min delayed phases in a 10-year-old, castrated male Maltese dog. The patient, previously diagnosed with a cutaneous mast cell tumor on the lip exhibiting incomplete histopathological margins, underwent CT for metastatic evaluation. The patient had no clinical evidence of systemic disease, and no anesthetic adverse events were observed during past patellar luxation surgery. However, the 2 min delayed CT scan revealed suspected hepatic congestion, vascular collapse, marked esophageal wall edema, and intense intestinal mucosal contrast enhancement. Subsequently, the 4 min delayed CT scan demonstrated diffuse contrast medium stagnation within the cardiac chambers and renal parenchyma, accompanied by the absence of the renal excretory phase. During anesthetic recovery, severe hypotension and respiratory failure emerged, suggesting the development of hypersensitivity. Following immediate intervention with cardiopulmonary resuscitation, epinephrine, and dexamethasone, the patient temporarily exhibited facial edema, hematochezia, diarrhea, and transient ataxia. However, dobutamine administration successfully restored systemic blood pressure and tissue perfusion, returning the patient to a normal clinical status. Consequently, this case highlights potential pathophysiological mechanisms, key CT findings, and emergency management considerations for contrast-induced hypersensitivity. Notably, sequential CT imaging documented evolving shock-related changes before the onset of overt clinical deterioration, suggesting that these findings may represent early imaging indicators of contrast-induced hypersensitivity. Full article

Background/Objectives: Sepsis may cause hemostatic disturbances. Viscoelastic hemostatic assays, such as rotational thromboelastometry (ROTEM), may reveal functional hemostatic changes not captured by conventional tests. The study aimed to analyze ROTEM parameters in sepsis-induced coagulopathy (SIC) and overt disseminated intravascular coagulation (DIC). Methods: A retrospective cohort analysis of adult ICU patients with sepsis or septic shock (May 2023–August 2026) who had ROTEM testing (minimum EXTEM and FIBTEM) performed was conducted. Clinical scores (SOFA, ISTH SIC, ISTH overt DIC), conventional coagulation tests, inflammatory biomarkers, and full ROTEM panels (INTEM, EXTEM, FIBTEM, APTEM) were retrived. Group comparisons used Kruskal–Wallis and pairwise Wilcoxon tests; associations with ICU mortality were assessed by multivariable logistic regression adjusted for age, sex, and SOFA. Results: Of 167 patients, 40 (23.9%) met ISTH SIC criteria, 24 (14.4%) met overt DIC criteria, and 103 (61.7%) had no SIC/DIC. Patients with SIC or DIC demonstrated slower clot propagation, lower early clot amplitudes and maximal clot firmness, and lower fibrinolytic activity compared to septic patients without coagulopathy. The only ROTEM parameter that differed between SIC and overt DIC was platelet contribution to clot strength, which was lower in DIC compared with the SIC subgroup. In multivariable logistic regression sensitivity analysis, with no SOFA score included as a covariate, no pre-specified ROTEM parameter was associated with ICU mortality after adjustment for age and sex in the current cohort. The coagulopathy subgroup itself was not an independent predictor of ICU death after adjustment. Conclusions: Rotational thromboelastometry shows distinct features in patients with SIC and sepsis-induced overt DIC compared with patients without coagulopathy. In the current cohort, the only ROTEM parameter that distinguished overt DIC from SIC was PLT contribution to clot strength. No ROTEM parameter was associated with short-term mortality in the presented cohort. Full article

Background/Objectives: Patients aged ≥ 65 years undergoing colorectal cancer surgery are at increased risk of postoperative complications and mortality due to advanced age, comorbidity burden, frailty, and reduced physiological reserve. The aim of this study was to evaluate perioperative predictors associated with early in-hospital mortality in patients aged ≥ 65 years undergoing colorectal cancer surgery. Methods: This single-center retrospective cohort study included 438 patients aged ≥ 65 years who underwent colorectal cancer surgery at a tertiary referral center between January 2017 and December 2018. Demographic characteristics, comorbidities, American Society of Anesthesiologists (ASA) classification, surgical urgency, perioperative laboratory parameters, and transfusion requirements were analyzed. The primary endpoint was early in-hospital mortality. Survival analysis was performed using Kaplan–Meier curves and Cox proportional hazards regression analysis. Results: The overall in-hospital mortality rate was 9.4% (41/438). Emergency surgery was associated with significantly reduced in-hospital survival compared with elective procedures (log-rank p < 0.001). Non-survivors more frequently presented with emergency surgical indications, higher ASA scores, greater comorbidity burden, anemia, nutritional impairment, elevated inflammatory markers, renal dysfunction, and increased transfusion requirements. In univariate Cox regression analysis, emergency surgery, ASA score ≥ 3, elevated creatinine, leukocyte count, and C-reactive protein levels, lower hemoglobin, albumin and total protein levels, and red blood cell transfusion were significantly associated with mortality. In multivariate analysis, elevated creatinine (HR 1.004, p = 0.030), leukocyte count (HR 1.064, p = 0.004), C-reactive protein (HR 1.009, p < 0.001), and lower hemoglobin concentration (HR 0.938, p < 0.001) remained independent predictors of in-hospital mortality. Conclusions: Early in-hospital mortality after colorectal cancer surgery in patients aged ≥ 65 years is associated with systemic inflammation, anemia, and renal dysfunction. Routinely available clinical and laboratory parameters may assist in identifying high-risk patients and improving perioperative risk assessment and postoperative management. Full article

Background/Objectives: Women with polyendocrine metabolic ovarian syndrome (PMOS) are known to be at higher risk of developing metabolic-related disorders. Here, we conducted a retrospective observational study to compare physical and laboratory findings associated with PMOS across different generations. Methods: We analyzed 470 medical records from 155 patients with PMOS from December 2002 to March 2023. Demographic, metabolic, and hormonal data were extracted and compared among age groups: <30, 30s, and ≥40 years. Results: The 30s group had significantly higher total cholesterol and glycated hemoglobin levels than the <30 group, while the ≥40 group had significantly higher diastolic blood pressure than both the <30 and 30s groups. The ≥40 group had significantly higher follicle-stimulating hormone and lower testosterone levels than both the <30 and 30s groups. Dehydroepiandrosterone sulfate levels and ovarian volume also differed significantly among the three groups, with both parameters decreasing with age. No significant differences in fasting glucose, fasting insulin, or homeostatic model assessment for insulin resistance were observed among the three groups. In multivariable linear mixed-effects models including age, BMI, and PMOS diagnostic criteria, BMI was independently associated with a broader range of metabolic parameters than age, whereas age was independently associated with follicle-stimulating hormone, testosterone, dehydroepiandrosterone sulfate, and ovarian volume. Conclusions: The present findings suggest that metabolic risk factors may emerge from a relatively young age in women with PMOS, with BMI showing broader associations with metabolic parameters than age. These observations support current recommendations for long-term metabolic monitoring and lifestyle management in women with PMOS. Full article

Telemedicine is increasingly transforming pediatric cardiology by expanding access to specialized care, supporting early diagnosis, and improving longitudinal monitoring of children with cardiovascular disease. This narrative review summarizes current applications of digital health in pediatric cardiology, with emphasis on congenital heart disease, pediatric hypertension, and arrhythmia management. Tele-echocardiography represents one of the most established telehealth tools, enabling remote interpretation of fetal, neonatal, and pediatric echocardiographic images and improving referral appropriateness, particularly in peripheral or resource-limited settings. In infants with complex congenital heart disease, especially those with single-ventricle physiology during the interstage period, home monitoring programs using mobile applications, pulse oximeters, digital scales, and structured caregiver reporting may facilitate early recognition of clinical deterioration and reduce avoidable transfers. In non-congenital cardiovascular disease, home blood pressure monitoring can improve diagnostic accuracy by reducing white-coat effects and supporting repeated measurements in real-life settings. Smartphone-enabled electrocardiographic devices and wearable technologies may enhance detection of intermittent arrhythmias and strengthen outpatient management. Despite these advantages, challenges remain, including data fragmentation, limited pediatric validation of consumer devices, interoperability issues, privacy concerns, and socioeconomic disparities in technology access. Properly integrated telemedicine may promote more timely, equitable, and patient-centered pediatric cardiovascular care. Full article

Aims: International diabetes guidelines recommend inpatient glycaemic management protocols for bolus enteral feeding in people with diabetes to improve clinical outcomes. This study aims to evaluate before and after hospital-wide implementation of an inpatient bolus enteral feeding protocol: (1) the incidence of hyperglycaemia (>13.9 mmol/L) and hypoglycaemia (<4.0 mmol/L), (2) medication prescribing practices and capillary blood glucose monitoring and (3) health care professionals’ knowledge and confidence levels. Methods: We implemented an inpatient glycaemic management protocol for bolus enteral feeding developed by a multidisciplinary team of diabetes nurse educators and endocrinologists and approved by the institutional medical board in July 2024. This before-and-after quality improvement study was conducted over 3 months across eight inpatient wards. Adult inpatients were consecutively enrolled if they met the inclusion criteria: (1) a documented diagnosis of diabetes mellitus, (2) receiving bolus enteral feeding and (3) treatment with glucose-lowering medication. Patients listed as critically ill were excluded. Nurses working in the pilot wards were also recruited. Before implementing the protocol, diabetes nurse educators trained inpatient nurses on understanding and executing the protocol for administering capillary blood glucose monitoring and medications for patients with diabetes on enteral feeding. Nurses’ pre- and post-knowledge levels and perceived confidence were assessed using a structured questionnaire. Electronic medical records were reviewed to evaluate the incidence rates of hypoglycaemia and hyperglycaemia before and during the 3 months following protocol implementation. We also assessed adherence to protocol-recommended capillary blood glucose monitoring frequencies based on the diabetes medication regimen. Results: A total of 31 patients were observed during the 6-week baseline period and 28 patients following protocol implementation. A total of 192 clinical care episodes were audited, comprising 78 in the pre-intervention phase and 114 in the post-intervention phase. The incidence of hyperglycaemia decreased from 43.6% to 10.5%, while hypoglycaemia decreased from 3.8% to 2.6%. After adjusting for protocol adoption rates, protocol implementation was associated with significantly lower odds of hyperglycaemia (odds ratio [OR] 0.22, 95% CI [0.07, 0.65], p = 0.006). A significant increase in appropriate nursing practices was observed post-intervention (p < 0.001). Adoption of the protocol by nurses decreased the odds of hyperglycaemia by 70% (p = 0.014). Nurses’ knowledge scores improved significantly from baseline to 3 months post-implementation (p < 0.001). Conclusions: Implementation of a standardised inpatient glycaemic management protocol for PWD receiving bolus enteral feeding was associated with reduced rates of hyperglycaemia and hypoglycaemia. Larger-scale studies are warranted to evaluate the effectiveness and sustainability of wider implementation in improving clinical outcomes. Full article

Background/Objectives: Congenital chylous ascites is a rare neonatal condition characterized by the accumulation of lymphatic fluid within the peritoneal cavity. The disorder can be difficult to manage, as many infants show limited response to standard conservative strategies such as dietary modification and supportive care. Currently, no universally accepted therapeutic guidelines exist. We report the successful use of propranolol in the management of refractory congenital chylous ascites. Methods: Clinical data were collected from a 35-week preterm male infant who had prenatal ultrasound evidence of fetal ascites from the 28th week of gestation. Postnatal management initially included fasting, total parenteral nutrition, and from day 9 of life, continuous infusion of octreotide. Due to the persistent ascites, oral propranolol was added to the therapy on the 31st day of life. Current literature was reviewed to compare our findings with those available. Results: Following the addition of propranolol to ongoing octreotide therapy, the infant demonstrated gradual clinical improvement with decreased abdominal distension and reduction of ascitic fluid; as propranolol and octreotide were administered concurrently for approximately 30 days, a causal effect could not be isolated to propranolol alone. Oral propranolol was administered at 0.5 mg/kg every 6 h (2 mg/kg/day total), with heart rate, blood pressure, and glucose monitored throughout treatment; no propranolol-related adverse events (bradycardia, hypotension, bronchospasm, hypoglycemia, or feeding intolerance) occurred. Ultrasonographic resolution of ascites was achieved by day 48, the peritoneal drainage catheter having already been removed on day 34; propranolol was subsequently tapered and discontinued by day 68, and the patient was discharged in stable condition on day 93, with no recurrence on serial ultrasound over the 45 days from resolution to discharge. A narrative review of the literature identified nine infants with lymphatic disorders successfully treated with propranolol. Conclusions: This case suggests a possible temporal association between propranolol administration and clinical improvement in a neonate with congenital chylous ascites refractory to conventional management; no propranolol-related adverse events were observed during treatment. Given the rarity of this condition and the absence of standardized treatment guidelines, further studies—potentially through multicenter registries or prospective case series—are warranted to establish optimal dosing strategies, evaluate long-term outcomes, and clarify the role of propranolol in this setting. Full article

Background: Hypertensive emergencies are severe clinical conditions characterized by sudden elevation of blood pressure accompanied by acute target organ damage, including cardiovascular, cerebrovascular, renal, and retinal complications. Although blood pressure elevation is the defining feature, accumulating evidence indicates that activation of the renin–angiotensin–aldosterone system (RAAS) may play a central role in the molecular and cellular mechanisms underlying vascular injury. This review critically examines the current evidence regarding the involvement of the RAAS in the pathophysiology of hypertensive emergencies, highlighting its contribution to endothelial dysfunction, oxidative stress, inflammation, microvascular damage, and target organ injury, as well as its therapeutic implications and future research perspectives. Methods: A comprehensive narrative review of the literature was conducted using narrative reviews, systematic reviews, meta-analyses, experimental, translational, and clinical studies published in major biomedical databases, with particular emphasis on recent evidence addressing RAAS signaling, hypertensive emergencies, target organ damage, and emerging therapeutic approaches. Current international guidelines and landmark studies were also considered to provide an updated overview of the diseases. Results: Available evidence indicates that excessive activation of the classical ACE/angiotensin II/AT1 receptor axis contributes to acute vasoconstriction, endothelial dysfunction, reactive oxygen species generation, inflammatory activation, impaired vascular autoregulation, and microvascular injury, thereby promoting acute damage to the brain, heart, kidneys, retina, and large arteries. Conversely, the counter-regulatory ACE2/angiotensin-(1–7)/Mas receptor axis exerts protective vascular effects, although its role in hypertensive emergencies is unclear. Current therapies primarily focus on controlled blood pressure reduction, whereas the potential benefits of targeted RAAS modulation during the acute phase remain uncertain. Conclusions: The RAAS may play an important role in the pathophysiological processes underlying hypertensive emergencies, extending beyond its classical function of blood pressure regulation. However, direct human evidence remains limited and heterogeneous, warranting caution in interpreting these findings. A deeper understanding of the interactions between RAAS activation, vascular dysfunction, and target organ injury could help identify potential biomarkers and therapeutic targets, ultimately contributing to improved management and prognosis in patients with hypertensive emergencies. Full article

With immune checkpoint inhibitors becoming the mainstay of systemic therapy in both metastatic and early-stage settings across many cancer types, the management of immune-related adverse events has emerged as a central priority of modern oncological supportive care. These toxicities can substantially impair the quality of life of cancer patients, including those who achieve long-term survival. Consequently, there is a pressing need to develop reliable predictive biomarkers to better tailor immune checkpoint inhibitor treatment and optimize patient selection. This review summarizes several of the most promising predictive biomarkers currently under investigation, including genetic factors; peripheral blood parameters and their ratios; autoantibodies; cytokines and chemokines; cytomegalovirus serostatus; gut microbiome characteristics; body composition metrics; molecular imaging features; and tumour- and patient-related factors such as cancer type, gender, and physical activity. Because single biomarkers have limited predictive value, multi-omics prediction models and composite immune-cell scores are increasingly demonstrating greater potential. However, none of these candidate biomarkers have yet undergone sufficient validation to support their incorporation into routine clinical practice. Full article

Post-hemorrhagic hydrocephalus (PHH) is a serious neurological sequela of severe intraventricular hemorrhage (IVH) in premature infants and remains one of the leading indications for ventriculoperitoneal (VP) shunt placement. Evaluating possible VP shunt-related complications can be challenging because clinical manifestations are often nonspecific, neuroimaging may initially appear unchanged, and microbiological cultures may remain negative. We report the case of a 19-month-old male born at 28 weeks’ gestation who developed Grade IV germinal matrix/intraventricular hemorrhage with bilateral intraparenchymal extension, early periventricular cystic leukomalacia, and post-hemorrhagic communicating hydrocephalus requiring multiple cerebrospinal fluid diversion procedures culminating in long-term VP shunt dependence. His medical history was notable for recurrent neonatal meningitis, secondary epilepsy with previous episodes of status epilepticus, secondary adrenal insufficiency, and severe global developmental delay. He presented with fever, recurrent coffee-ground vomiting, abdominal distension, progressive lethargy, reduced responsiveness, and localized erythematous swelling over the cranial VP shunt reservoir, raising concern for possible shunt-related pathology. During hospitalization, he deteriorated with status epilepticus and respiratory failure, with clinical concern for increased intracranial pressure, requiring admission to the Pediatric Intensive Care Unit (PICU). Laboratory investigations demonstrated leukocytosis, elevated C-reactive protein, cerebrospinal fluid pleocytosis, markedly elevated CSF protein, and CSF glucose of 2.0 mmol/L, for which a paired serum glucose value was unavailable, while repeated blood, urine, wound, and CSF cultures remained negative. Initial computed tomography (CT) demonstrated no significant interval change in the chronic hydrocephalus despite progressive neurological deterioration; however, serial neuroimaging later revealed progressive bilateral extra-axial fluid collections with radiological features suggestive of an evolving subacute subdural hemorrhage. The patient was managed with empirical broad-spectrum intravenous antibiotics, aggressive seizure control, stress-dose corticosteroids, respiratory support, and continuous multidisciplinary monitoring. His neurological and respiratory status subsequently improved, and he returned to his pre-admission neurological baseline before discharge with planned further evaluation at a tertiary pediatric neurosurgical center. This case highlights the diagnostic uncertainty surrounding acute neurological deterioration in a child with shunt-dependent PHH. VP shunt-related infection or malfunction remained important but unconfirmed diagnostic considerations, alongside competing or potentially overlapping contributors including status epilepticus, evolving extra-axial collections, respiratory infection, and endocrine or metabolic decompensation. No single etiology was definitively established. The case emphasizes the importance of serial neurological assessment, consideration of alternative diagnoses, repeat neuroimaging, and multidisciplinary evaluation when initial investigations do not establish the cause of deterioration. Full article