Iron Deficiency Anemia and Migraine: A Literature Review of the Prevalence, Pathophysiology, and Therapeutic Potential.

This literature review explores the association between iron deficiency anemia and migraines, examining their prevalence, underlying pathophysiology, and therapeutic potential of iron supplementation in managing migraine symptoms. A systematic search across major academic databases, including PubMed, Google Scholar, ScienceDirect, and Science.gov, identified relevant peer-reviewed studies that focus on the link between iron deficiency anemia and migraines. The review highlights a higher prevalence of iron deficiency anemia among migraine sufferers, particularly women, with several studies indicating a significant inverse relationship between serum ferritin levels and migraine severity. The findings suggest that low iron levels may exacerbate migraine symptoms, and iron supplementation has been shown to reduce the frequency and intensity of migraines, especially in patients with confirmed iron deficiency anemia. The review also discusses the unique susceptibility of women, particularly those of reproductive age, to both iron deficiency anemia and migraines, emphasizing the importance of gender-specific approaches in treatment. Moreover, the potential impact of iron deficiency on neurovascular function and its contribution to migraine pathogenesis is explored, reinforcing the need for comprehensive management strategies that include nutritional interventions. While iron supplementation appears to be a promising therapeutic option, further research is required to fully understand its long-term effects and to refine treatment protocols to avoid the risks associated with iron overload. This review underscores the significance of addressing nutritional deficiencies as part of a holistic approach to migraine management, offering insights into potential avenues for improving patient outcomes.

Endovascular Management of Non-Cirrhotic Acute Portomesenteric Venous Thrombosis.

Acute portomesenteric venous thrombosis (PVT) is a rare but potentially life-threatening condition in individuals without cirrhosis. Initial management typically involves anticoagulation therapy, but the optimal approach to interventional treatment remains a topic of ongoing research. This article explores both traditional and emerging endovascular techniques, providing an overview of the existing evidence supporting their use. Additionally, it delves into the significance of acute PVT in the context of contemporary pathologies, notably COVID-19 infection, vaccine-induced immune thrombotic thrombocytopenia, and liver transplantation.

Periodic health evaluation in Para athletes: a position statement based on expert consensus.

Para athletes present a broad range of sports-related injuries and illnesses, frequently encountering barriers when accessing healthcare services. The periodic health evaluation (PHE) is a valuable tool for continuously monitoring athletes' health, screening for health conditions, assisting in the surveillance of health problems by establishing baseline information and identifying barriers to athlete's performance. This position statement aims to guide sports healthcare providers in the PHE for Para athletes across key impairment categories: intellectual, musculoskeletal, neurological and vision. A panel of 15 international experts, including epidemiologists, physiotherapists, optometrists and physicians with expertise in Para athlete health, convened via videoconferences to discuss the position statement's purpose, methods and themes. They formed working groups to address clinical, cardiorespiratory, neuromusculoskeletal, nutritional status, mental and sleep health, concussion and female Para athlete health assessment considerations. The PHE's effectiveness lies in its comprehensive approach. Health history review can provide insights into factors impacting Para athlete health, inform physical assessments and help healthcare providers understand each athlete's needs. During the PHE, considerations should encompass the specific requirements of the sport modality and the impairment itself. These evaluations can help mitigate the common tendency of Para athletes to under-report health issues. They also enable early interventions tailored to the athlete's health history. Moreover, the PHE serves as an opportunity to educate Para athletes on preventive strategies that can be integrated into their training routines, enhancing their performance and overall health. This position statement can potentially enhance clinical translation into practice and improve the healthcare quality for Para athletes.

Evaluation of daily supplementation of fertitonex on different semen parameters in idiopathic male infertility: a randomized double blind placebo controlled cross over study.

PURPOSE: The study aimed to evaluate the effect of fertitonex containing L-carnitine L-tartrate together with other micronutrients on different semen parameters in idiopathic male infertility as well as male reproductive hormones. METHODS: 100 randomized infertile patients were recruited from July 2023 to February 2024. They were randomized into two groups. Group (A) received fertitonex twice daily for the first 3 months. Group (B) received placebo twice daily for the first 3 months. Crossover was done after 1 month wash-out period for additional 3 months. RESULTS: Group (A) who started fertitonex first showed significant improvement in sperms concentration and motility and progressive motility as well as significant reduction in abnormal forms after 3 months from beginning the study (p < 0.001, p < 0.001, p < 0.001, p < 0.001, respectively). Interestingly, these improvements continued for additional 3 months after placebo intake (p < 0.001, p 0.005, p < 0.001, p < 0.001, respectively). Group (B) who started placebo first showed significant improvement in sperms concentration and motility and progressive motility as well as significant reduction in abnormal forms after 6 months from beginning the study (p < 0.001, p < 0.001, p < 0.001, p < 0.001, respectively). LH level was significantly higher among group (A) compared to group (B) at baseline and 3 months and 6 months (p value 0.02, 0.032. 0.024, respectively). CONCLUSION: We finally concluded that fertitonex is an effective, tolerable and safe drug that can be used for treating idiopathic male infertility.

Minimally Invasive Therapies for Knee Osteoarthritis.

Knee osteoarthritis (KOA) is a musculoskeletal disorder characterized by articular cartilage degeneration and chronic inflammation, affecting one in five people over 40 years old. The purpose of this study was to provide an overview of traditional and novel minimally invasive treatment options and role of artificial intelligence (AI) to streamline the diagnostic process of KOA. This literature review provides insights into the mechanisms of action, efficacy, complications, technical approaches, and recommendations to intra-articular injections (corticosteroids, hyaluronic acid, and plate rich plasma), genicular artery embolization (GAE), and genicular nerve ablation (GNA). Overall, there is mixed evidence to support the efficacy of the intra-articular injections that were covered in this study with varying degrees of supported recommendations through formal medical societies. While GAE and GNA are more novel therapeutic options, preliminary evidence supports their efficacy as a potential minimally invasive therapy for patients with moderate to severe KOA. Furthermore, there is evidentiary support for the use of AI to assist clinicians in the diagnosis and potential selection of treatment options for patients with KOA. In conclusion, there are many exciting advancements within the diagnostic and treatment space of KOA.

The #HOPE4LIVER Single-Arm Pivotal Trial for Histotripsy of Primary and Metastatic Liver Tumors.

Background Histotripsy is a nonthermal, nonionizing, noninvasive, focused US technique that relies on cavitation for mechanical tissue breakdown at the focal point. Preclinical data have shown its safety and technical success in the ablation of liver tumors. Purpose To evaluate the safety and technical success of histotripsy in destroying primary or metastatic liver tumors. Materials and Methods The parallel United States and European Union and England #HOPE4LIVER trials were prospective, multicenter, single-arm studies. Eligible patients were recruited at 14 sites in Europe and the United States from January 2021 to July 2022. Up to three tumors smaller than 3 cm in size could be treated. CT or MRI and clinic visits were performed at 1 week or less preprocedure, at index-procedure, 36 hours or less postprocedure, and 30 days postprocedure. There were co-primary end points of technical success of tumor treatment and absence of procedure-related major complications within 30 days, with performance goals of greater than 70% and less than 25%, respectively. A two-sided 95% Wilson score CI was derived for each end point. Results Forty-four participants (21 from the United States, 23 from the European Union or England; 22 female participants, 22 male participants; mean age, 64 years ± 12 [SD]) with 49 tumors were enrolled and treated. Eighteen participants (41%) had hepatocellular carcinoma and 26 (59%) had non-hepatocellular carcinoma liver metastases. The maximum pretreatment tumor diameter was 1.5 cm ± 0.6 and the maximum post-histotripsy treatment zone diameter was 3.6 cm ± 1.4. Technical success was observed in 42 of 44 treated tumors (95%; 95% CI: 84, 100) and procedure-related major complications were reported in three of 44 participants (7%; 95% CI: 2, 18), both meeting the performance goal. Conclusion The #HOPE4LIVER trials met the co-primary end-point performance goals for technical success and the absence of procedure-related major complications, supporting early clinical adoption. Clinical trial registration nos. NCT04572633, NCT04573881 Published under a CC BY 4.0 license. Supplemental material is available for this article. See also the editorial by Nezami and Georgiades in this issue.

Percutaneous Thrombectomy Using a Computer-Assisted Aspiration Device for Deep Vein Thrombosis.

PURPOSE: To demonstrate the safety and effectiveness of a computer-assisted large-bore thrombectomy (CA-LBT) device in aspiration thrombectomy for treatment of deep vein thrombosis (DVT). MATERIALS AND METHODS: A single-institution retrospective review was performed to include 16 consecutive patients (median age, 51.1 years; range, 19-77 years; 5 men and 11 women) who underwent percutaneous thrombectomy using a 16-F CA-LBT device (Lightning Flash Aspiration System; Penumbra, Alameda, California) for DVT (12 iliofemoral occlusions with or without caval extension [75.0%], 3 axillosubclavian occlusions [18.8%], and 1 caval occlusion [6.3%]) between January 2023 and August 2023. RESULTS: Thrombectomy was performed via the popliteal (n = 10, 62.5%), femoral (n = 3, 18.8%), saphenous (n = 1, 6.3%), brachial (n = 1, 6.3%), and femoral and brachial (n = 1, 6.3%) veins, with a median fluoroscopy time of 17 minutes (range, 7.2-61 minutes) and contrast agent volume of 110 mL (range, 30-175 mL). Restoration of anterograde flow was achieved in all cases (100%, 16/16). Thirteen patients (81.2%) received venoplasty after thrombectomy for residual stenosis. Stents were placed in 7 patients (43.8%). With a median clinical follow-up of 77 days (range, 3-278 days), symptom improvement was achieved among 13 of 15 patients (86.7%) who initially presented with DVT-associated symptoms. Of 14 patients with imaging follow-up, patency was confirmed in 12 (85.7%). Of the 2 patients (14.3%) with complete thrombosis on follow-up imaging, one patient was successfully treated with repeated thrombectomy using CA-LBT technology and the other was treated with systemic anticoagulation. CONCLUSIONS: Aspiration thrombectomy with this 16-F CA-LBT device is a feasible option for treatment of proximal or large-volume DVT.

Genicular Artery Embolization, Radiofrequency Ablation, and Corticosteroid Therapy for Knee Osteoarthritis: A Cost-Effectiveness Analysis Using Randomized Clinical Trial Data.

Background: Many patients with symptomatic knee osteoarthritis (KOA) are refractory to traditional nonsurgical treatments such as intraarticular corticosteroid (CS) injection but are not yet eligible for or decline surgery. Genicular artery embolization (GAE) and radiofrequency ablation (RFA) are emerging adjunctive or alternative minimally invasive treatments. Objective: To perform a cost-effectiveness analysis (CEA) comparing CS, GAE, and RFA, for treatment of symptomatic KOA using a Markov model based on a de novo network meta-analysis (NMA) of randomized control trials. Methods: CEA was conducted to compare GAE and RFA to CS using a Markov cohort state-transition model from a U.S. Medicare payer's perspective over a 4-year time horizon. The model incorporated each treatment's success and attrition rates, costs, and utility benefit. Utility benefit values were derived at short-term (0.5-3 months) and long-term (6-12 months) posttreatment follow-up from NMA of published RCTs using an outcome of improved knee pain and/or function. Analyses were conducted at a willingness-to-pay threshold of $100,000 per quality-adjusted life year (QALY). Sensitivity analyses were performed, including when simulating various cost setting scenarios (i.e., office vs hospital outpatient treatment). Results: RFA demonstrated larger treatment effect than GAE, more pronounced at short-term [standardized mean difference (SMD), -1.6688, 95% CI [-2.7806; -0.5571], p=.003] than long-term (SMD -0.3822, 95% CI [-1.9743; 1.2100], p=.64) follow-up. Across cost setting scenarios, incremental cost-effectiveness ratios relative to CS were $561-1563/QALY for GAE versus $76-429/QALY for RFA (not counting scenarios in which RFA was dominated by CS). GAE demonstrated higher cost-effectiveness probability compared to RFA (41.6-54.8% vs. 18.4-29.2%, respectively). GAE was more cost-effective than RFA when the GAE clinical success rate and post-GAE utility value exceeded 32.1-51.0% and 0.562-0.617, respectively, and when the GAE quarterly attrition rate was less than 8.8-17.4%. RFA was more cost-effective when baseline pre-treatment utility values exceeded 0.695-0.713. Neither GAE costs nor RFA costs were sensitive parameters. Conclusion: Across scenarios, GAE was consistently the most likely cost-effective treatment option compared to RFA and CS, although clinical success rates, attrition rates, and utility values impact its cost-effectiveness. Clinical Impact: GAE is likely to be more cost-effective than RFA or CS for treatment of symptomatic KOA.

Socioeconomic disparities and their effect on medical student academic attainment sudanese universities.

BACKGROUND: Socioeconomic status (SES) is a social classification factor that takes into account income, parental education and occupation. SES has been shown to play an important role in shaping students' academic performance, including in medical schools, but there still remains significant variation in findings around SES and academic achievement worldwide. We aim to assess and explore socioeconomic disparities and their effects on medical school performance at Sudanese public and private universities. OBJECTIVES: The objective of our study was to assess the effects of age, sex, living conditions, parental education and income level on the academic achievement of medical students from universities in Sudan. METHODS: This cross-sectional study was conducted among undergraduate medical students at ten public universities in Sudan between September and December 2023. Participants were included if they were older than 18 years and were studying in their 2nd year or older. The data were collected using an online questionnaire with open- and closed-ended questions measuring age, living conditions, parental income level and education. A convenience sampling method was used to recruit participants from universities. The data were analyzed using SPSS v28.0.0, and a p value less than 0.05 was used to indicate statistical significance. RESULTS: We received 832 responses, 516 (62%) from females and 307 (36.9%) from males. The median age was 23 years. Most students lived with their families (61.1%), followed by student housing (28.2%). This study revealed age (p = .024) (95% Cl: 0.025- 0.023) andhigh family income (p = .019) (95% Cl: 0.018- 0.02) are associated with academic achievement in the long term, as demonstrated through cumulative grade point average (cGPA). CONCLUSION: The findings underscore the importance of targeted support systems to bridge the socioeconomic gaps that exist among medical students, allowing all students to thrive academically regardless of their background. CLINICAL TRIAL NUMBER: None.

Kupffer cells dictate hepatic responses to the atherogenic dyslipidemic insult.

Apolipoprotein-B (APOB)-containing lipoproteins cause atherosclerosis. Whether the vasculature is the initially responding site or if atherogenic dyslipidemia affects other organs simultaneously is unknown. Here we show that the liver responds to a dyslipidemic insult based on inducible models of familial hypercholesterolemia and APOB tracing. An acute transition to atherogenic APOB lipoprotein levels resulted in uptake by Kupffer cells and rapid accumulation of triglycerides and cholesterol in the liver. Bulk and single-cell RNA sequencing revealed a Kupffer-cell-specific transcriptional program that was not activated by a high-fat diet alone or detected in standard liver function or pathological assays, even in the presence of fulminant atherosclerosis. Depletion of Kupffer cells altered the dynamic of plasma and liver lipid concentrations, indicating that these liver macrophages help restrain and buffer atherogenic lipoproteins while simultaneously secreting atherosclerosis-modulating factors into plasma. Our results place Kupffer cells as key sentinels in organizing systemic responses to lipoproteins at the initiation of atherosclerosis.

Genicular Artery Embolization: Embolic Material and Imaging Review.

Osteoarthritis (OA) of the knee is a degenerative condition impacting numerous individuals globally. Genicular artery embolization (GAE) has emerged as an effective minimally invasive therapy for managing medically refractory OA-related pain in patients who are not eligible for surgery. This intervention works by disrupting the inflammatory and neoangiogenic pathways that contribute to pain. The efficacy of GAE has been demonstrated in various clinical trials, yielding promising results. This review aims to explore recent advancements in the embolic materials used during GAE, examining their properties and potential benefits. Additionally, it will describe the use of pre-, intra-, and postprocedural imaging-particularly magnetic resonance imaging and other modalities-to optimize GAE outcomes.

Disease modifying treatment guidelines for multiple sclerosis in the United Arab Emirates.

The newly constituted National Multiple Sclerosis (MS) Society (NMSS)of the United Arab Emirates (UAE), set up a scientific committee to create a MS disease modifying treatment (DMT) guideline for UAE. The committee considered several unique features of the MS community in UAE including large number of expatriate population, wide variations in health insurance coverage, physician and patient preferences for DMT. The overall goal of the treatment guideline is to facilitate the most appropriate DMT to the widest number of patients. To this end it has adapted recommendations from various health systems and regulatory authorities into a pragmatic amalgamation of best practices from across the world. Importantly where data is unavailable or controversial, a common sense approach is taken rather than leave physicians and patients in limbo. The committee classifies MS into subcategories and suggests appropriate treatment choices. It recommends treatment of RIS and CIS with poor prognostic factors. It largely equates the efficacy and safety of DMT with similar mechanisms of action or drug classes e.g. ocrelizumab is similar to rituximab. It allows early switching of treatment for unambiguous disease activity and those with progression independent of relapses. Autologous hematopoietic stem cell transplantation can be offered to patients who fail one high efficacy DMT. Pragmatic guidance on switching and stopping DMT, DMT choices in pregnancy, lactation and pediatric MS have been included. It is expected that these guidelines will be updated periodically as new data becomes available.

Fifteen-Year Trend in Inferior Vena Cava Filter Utilization before and after U.S. Food and Drug Administration Communications: Data from the National Inpatient Sample 2005-2019.

The purpose of this study was to evaluate the contemporary trends in inferior vena cava (IVC) filter utilization in the inpatient setting following the U.S. Food and Drug Administration (FDA) safety communications and compare those trends in relation to incidence of hospital admissions involving venous thromboembolism (VTE). The National Inpatient Sample was queried between 2005 and 2019. There was an increasing trend in the utilization of IVC filters between 2005 and 2010 (P < .01). Following the FDA communication in 2010, this reversed to a decreasing trend (P < .001), which persisted following the second FDA communication in 2014, although there was no significant change in the rate of decline (P = .67). Throughout the study period, the proportion of IVC filters placed in patients with VTE increased from 70.8% to 82.2%.

Studying the accessibility of healthcare services for cancer patients in Khartoum state amid the COVID-19 pandemic.

Objectives: This study aims to assess cancer patients' accessibility to healthcare services and perceived barriers during the COVID-19 pandemic in Khartoum state, aiming to explore the consequent impact on cancer patients. It also aims to determine the coping strategies used by patients to overcome these barriers. Study design: This is a retrospective analytical cross-sectional study. Methods: Data were collected from August 2020 to March 2021, with a sample size of 316 cancer patients. Systemic random sampling and SPSS version 25 were utilized for data collection and analysis. Results: The study found that 55.7 % of the surveyed cancer patients had experienced disruptions in accessing essential cancer healthcare services during the lockdown. The study identified the most common cancers as breast (19.7 %), gastrointestinal (19 %), and ovarian (11 %). Notable barriers included governmental travel restrictions (51.6 %), outpatient service closures (41.8 %), and high costs (27.8 %). Additionally, delayed treatment was directly associated with a 33.3 % fatality rate among the participants. Conclusions: This study highlights the considerable negative impact of the COVID-19 lockdown on cancer care in Sudan. Recommendations include a focus on telemedicine as an alternative form of patient consultation, the expansion of health insurance schemes to encompass cancer treatments, and strengthening healthcare infrastructure to facilitate cancer care during crises.

Meta-analysis of transjugular intrahepatic portosystemic shunt creation with or without intravascular ultrasound guidance.

OBJECTIVE: To conduct a meta-analysis to assess the efficacy of intravascular ultrasound (IVUS) during transjugular intrahepatic portosystemic shunt (TIPS) creation. METHODS: MEDLINE and Embase databases were queried until July 2022 for comparative studies reporting procedure metrics for TIPS creation with or without IVUS guidance. Meta-analysis was performed with random-effects modelling for total procedural time, time to portal venous access, fluoroscopy time, iodinated contrast volume use, air kerma, dose area product, and number of needle passes. Intraoperative procedure-related complications were also reviewed. RESULTS: Of 95 unique records initially identified, 6 were eligible for inclusion. A total of 194 and 240 patients underwent TIPS with and without IVUS guidance. Pooled analyses indicated that IVUS guidance was associated with reduced total procedure time (SMD -0.76 [95% CI -1.02, -0.50] P < .001), time to portal venous access (SMD -0.41 [95% CI -0.67, -0.15] P = .002), fluoroscopy time (SMD, -0.54 [95% CI -1.02, -0.07]; P = .002), contrast volume use (SMD, -0.89 [95% CI -1.16, -0.63]; P < .001), air kerma (SMD, -0.75 [95% CI -1.11, -0.38]; P < .001) and dose area product (SMD, -0.98 [95% CI -1.77, -0.20]; P = .013). A total of 4.2 and 7.8 needle passes were required in the IVUS and non-IVUS group, respectively (SMD, -0.60 [95% CI -1.42, 0.21]; P = .134). Pooled complication rates were 15.2% (12/79) and 21.4% (28/131), respectively. CONCLUSION: IVUS guidance during TIPS creation improves procedural metrics including procedural time, contrast usage, and radiation exposure. ADVANCES IN KNOWLEDGE: (1) The use of IVUS during TIPS is associated with shorter procedural time, lower contrast usage, and radiation exposure. (2)The use of IVUS is not associated with higher complication rates.