Maduraflavacins A-E, Unusual Phenyl Polyene Metabolites Produced by a Rare Marine-Derived Actinomadura sp.

Phenyl polyenes comprise a small family of bacterial natural products with broad and potent bioactivities, primarily found in actinobacteria. Here we report the discovery of five new phenyl polyene metabolites, maduraflavacins A-E (1-5), from a rare, marine-derived actinobacteria strain Actinomadura glauciflava NA03286. The structures of these natural products were determined by NMR spectroscopy, HRESIMS, LC-MS/MS, and chemical derivatization. All of these new maduraflavacins feature methyl substitutions at the polyene side chain, and maduraflavacins A-C (1-3) possessed a 1-N-ß-d-glucosamine-(3 → 1)-O-ß-d-glucopyranosyl-(3 → 1)-O-ß-d-glucopyranosyl-(6 → 1)-O-ß-d-glucopyranoside tetrasaccharide moiety via an amido linkage with a phenyl polyene skeleton. Compounds 1 and 2 showed weak antibacterial activities against the Gram-positive bacteria Staphylococcus aureus Sau 16339 and Micrococcus luteus, respectively.

Acupuncture Provides Short-Term Functional Improvements and Pain Relief for Patients After Knee Replacement Surgery: A Systematic Review and Meta-analysis.

The impact of acupuncture on knee function and pain intensity following knee replacement remains controversial. Therefore, we categorized the postsurgery recovery period into 3 phases: short-term (≤2 weeks), intermediate-term (2 weeks-3 months), and long-term (>3 months), and then assessed the effectiveness of acupuncture in improving function and alleviating pain at different stages following knee replacement. This meta-analysis included randomized controlled trials that compared acupuncture intervention with either no treatment or a sham group after knee replacement. Six databases were searched from inception to December 31, 2023, including PubMed, Embase, Cochrane Central Register of Controlled Trials, Web of Science, and 2 Chinese databases (Chinese National Knowledge Infrastructure and WanFang Data). A total of 23 studies comprising 1,464 participants were included. Significant improvement of active range of motion was observed on day 7 and week 2 after operation. Lower pain intensity at rest was noted in patients receiving acupuncture in short-term periods after operation (12 hours, day 1, day 2, day 5, and week 2). A reduction in pain intensity during movement with acupuncture was observed on postoperative day 1 and day 7. Auricular acupuncture did not show not significant effectiveness in improving range of motion and pain intensity. For conventional acupuncture, the combination of distal and local point selection was found to be the most effective. Early application of acupuncture, in conjunction with physical therapy, starting before postoperative day 1 or day 2, was recommended. Further high-quality researches are warranted to validate the findings in this meta-analysis. PERSPECTIVE: This article demonstrates that acupuncture has short-term effects (≤2 weeks) on improving active range of motion and reducing pain during rest and during movement following knee replacement surgery. The findings support the early application of acupuncture in hospital settings after knee replacement. REGISTRATION ID: The study was registered on PROSPERO (CRD42024503479).

Adaptive formation control for obstacle avoidance of USVs with asymmetric input saturation.

Due to the complex maritime navigation environment, Unmanned Surface Vessels (USVs) are influenced by unknown nonlinear dynamics arising from external disturbances and internal uncertainties. Achieving effective formation control while maintaining obstacle avoidance performance presents significant challenges. This article proposes a Neural Networks (NNs) adaptive formation Artificial Potential Field (APF) obstacle avoidance control method for multiple USVs. By employing online updates of Radial Basis Function (RBF) NNs technology, the unknown nonlinear dynamics are approximated, thus addressing complex nonlinear dynamics problems. In scenarios involving multiple USVs navigating under high wind and wave conditions, collisions with obstacles frequently occur. To tackle this issue, a leader-follower control strategy is designed that effectively addresses risk assessment and obstacle avoidance under such challenging conditions. Additionally, to account for saturation constraints or potential faults in the controller inputs commonly encountered in engineering applications, it implements an asymmetric auxiliary control system. Furthermore, the Lyapunov stability theorem is utilized to ensure the stability of both the formation control and obstacle avoidance algorithms for multiple USVs. Finally, the effectiveness of the proposed algorithm is validated through simulations.

The Beneficial Effects of Lacticaseibacillus paracasei subsp. paracasei DSM 27449 in a Letrozole-Induced Polycystic Ovary Syndrome Rat Model.

Polycystic ovary syndrome (PCOS) is a prevalent endocrine disorder affecting women of reproductive age globally. Emerging evidence suggests that the dysregulation of microRNAs (miRNAs) and gut dysbiosis are linked to the development of PCOS. In this study, the effects of Lacticaseibacillus paracasei subsp. paracasei DSM 27449 (DSM 27449) were investigated in a rat model of PCOS induced by letrozole. The administration of DSM 27449 resulted in improved ovarian function, reduced cystic follicles, and lower serum testosterone levels. Alterations in miRNA expressions and increased levels of the pro-apoptotic protein Bax in ovarian tissues were observed in PCOS-like rats. Notably, the administration of DSM 27449 restored the expression of miRNAs, including miR-30a-5p, miR-93-5p, and miR-223-3p, leading to enhanced ovarian function through the downregulation of Bax expressions in ovarian tissues. Additionally, 16S rRNA sequencing showed changes in the gut microbiome composition after letrozole induction. The strong correlation between specific bacterial genera and PCOS-related parameters suggested that the modulation of the gut microbiome by DSM 27449 was associated with the improvement of PCOS symptoms. These findings demonstrate the beneficial effects of DSM 27449 in ameliorating PCOS symptoms in letrozole-induced PCOS-like rats, suggesting that DSM 27449 may serve as a beneficial dietary supplement with the therapeutic potential for alleviating PCOS.

Obesity-induced chronic low-grade inflammation in adipose tissue: A pathway to Alzheimer's disease.

Alzheimer's disease (AD) is a leading cause of cognitive impairment worldwide. Overweight and obesity are strongly associated with comorbidities, such as hypertension, diabetes, and insulin resistance (IR), which contribute substantially to the development of AD and subsequent morbidity and mortality. Adipose tissue (AT) is a highly dynamic organ composed of a diverse array of cell types, which can be classified based on their anatomic localization or cellular composition. The expansion and remodeling of AT in the context of obesity involves immunometabolic and functional shifts steered by the intertwined actions of multiple immune cells and cytokine signaling within AT, which contribute to the development of metabolic disorders, IR, and systemic markers of chronic low-grade inflammation. Chronic low-grade inflammation, a prolonged, low-dose stimulation by specific immunogens that can progress from localized sites and affect multiple organs throughout the body, leads to neurodystrophy, increased apoptosis, and disruption of homeostasis, manifesting as brain atrophy and AD-related pathology. In this review, we sought to elucidate the mechanisms by which AT contributes to the onset and progression of AD in obesity through the mediation of chronic low-grade inflammation, particularly focusing on the roles of adipokines and AT-resident immune cells.

Clinical study of neutrophil-to-lymphocyte ratio and platelet-to-lymphocyte ratio in hypertriglyceridemia-induced acute pancreatitis and acute biliary pancreatitis with persistent organ failure.

BACKGROUND: The neutrophil-to-lymphocyte ratio (NLR) and platelet-to-lymphocyte ratio (PLR) are novel inflammatory indicators that can be used to predict the severity and prognosis of various diseases. We categorize acute pancreatitis by etiology into acute biliary pancreatitis (ABP) and hypertriglyceridemia-induced acute pancreatitis (HTGP). AIM: To investigate the clinical significance of NLR and PLR in assessing persistent organ failure (POF) in HTGP and ABP. METHODS: A total of 1450 patients diagnosed with acute pancreatitis (AP) for the first time at Shanxi Bethune Hospital between January 2012 and January 2023 were enrolled. The patients were categorized into two groups according to the etiology of AP: ABP in 530 patients and HTGP in 241 patients. We collected and compared the clinical data of the patients, including NLR, PLR, and AP prognostic scoring systems, within 48 h of hospital admission. RESULTS: The NLR (9.1 vs 6.9, P < 0.001) and PLR (203.1 vs 160.5, P < 0.001) were significantly higher in the ABP group than in the HTGP group. In the HTGP group, both NLR and PLR were significantly increased in patients with severe AP and those with a SOFA score ≥ 3. Likewise, in the ABP group, NLR and PLR were significantly elevated in patients with severe AP, modified computed tomography severity index score ≥ 4, Japanese Severity Score ≥ 3, and modified Marshall score ≥ 2. Moreover, NLR and PLR showed predictive value for the development of POF in both the ABP and HTGP groups. CONCLUSION: NLR and PLR vary between ABP and HTGP, are strongly associated with AP prognostic scoring systems, and have predictive potential for the occurrence of POF in both ABP and HTGP.

Potential profiling of self-management skills in older co-morbid patients.

BACKGROUND: Under the general trend of global aging, geriatric comorbidity is increasingly common, which may have some impact on the quality of life of the older people. Self-management can effectively improve patient compliance, subjective initiative, and improve patient quality of life. However, the present situation of self-management in different old people is different. Therefore, this study classifies older co-morbid patients through potential profiling analysis, understands the category characteristics of self-management level of older co-morbid patients, and discusses the influencing factors of self-management level of different categories of older co-morbid patients, which can provide reference for personalized intervention programs for different comorbidity characteristics of elderly people in the future.  METHOD: Through a cross-sectional study, 616 cases of older co-morbid patients in three districts of Zhengzhou City, Henan Province, were selected as survey subjects by using the whole cluster sampling method. The General Information Questionnaire, Chronic Disease Self-Management Scale, Health Literacy Scale, Electronic Health Literacy Scale, Collaborative Social Support Scale, and Health Empowerment Scale were used to conduct the survey. RESULTS: The result of LPA shows that the self-management characteristics of older co-morbid patients should be classified into 3 categories: good self-management (19.4%), medium self-management(27.9%), and low self-management (52.7%). The results of multivariate logistic regression analyses show that literacy, religiosity, health literacy, e-health literacy, appreciative social support, and health empowerment are influential factors for self-management among older co-morbid patients (p < 0.05). CONCLUSION: There is obvious heterogeneity in the self-management level of older co-morbid patients. It is recommended that healthcare professionals give targeted interventions for their weaknesses according to the self-management characteristics of different categories of patients in order to enhance the self-management level of this population and improve their quality of life.

Enhanced removal of lead and zinc by a 3D aluminium sulphate-functionalised graphene aerogel as an effective adsorption system.

The discharge of heavy metals into the environment has adversely affected the aquatic ecosystem due to their toxic and non-biodegradable nature. In this research, a three-dimensional graphene oxide/carboxymethylcellulose/aluminium sulphate (GOCAS) aerogel was synthesised and evaluated as a novel means for lead and zinc removal. The GOCAS aerogel was prepared via ice-templating of graphene oxide with carboxymethylcellulose and aluminium sulphate as the crosslinking and functionalisation additives. Characterisation of the aerogel by various analytical techniques confirmed the successful integration of the chemical additives. The hydroxyl and sulphate groups in the aerogel were found to participate in the adsorption of both metals. The equilibrium of lead adsorption was found to correlate well to the Freundlich isotherm, while zinc adsorption fitted closely the Langmuir isotherm. The kinetic adsorption behaviour of both metals was best described as pseudo-second-order. The interactive influences of concentration, temperature, contact time and adsorbent dose on the metal removal were explored by a central composite design, and the optimum adsorption capacity for lead was determined to be 138.7 mg/g at a GOCAS dose of 20 mg, initial concentration of 100 mg/L, temperature of 50 °C and contact time of 45 min. The optimum adsorption capacity for zinc was 52.69 mg/g at 30 mg, 65 mg/L, 45 °C and 40 min. Furthermore, regeneration studies with hydrochloric acid eluant were successfully conducted for up to four adsorption-desorption cycles. Overall, this work demonstrates that GOCAS aerogel is a viable nanosorbent for the adsorption of lead and zinc from water systems.

Relationship between thrombus vWF and NETs with clinical severity and peripheral blood immunocytes' indicators in patients with acute ischemic stroke.

OBJECTIVE: To investigate the association between von Willebrand factor (vWF) and neutrophil extracellular traps (NETs) in thrombus with clinical severity and peripheral blood immunocytes' indicators in patients with early-stage acute ischemic stroke (AIS). METHODS: A retrospective study was conducted using the clinical data of 66 patients with AIS who underwent endovascular mechanical thrombectomy and had their thrombus samples collected. The concentrations of vWF and NETs in the thrombus samples were quantitatively assessed. Peripheral blood samples taken in the early stages of the disease were analyzed for total white blood cell counts (WBC), ratios of neutrophils (NEU%), lymphocytes (LYM%), eosinophils (EOS%), and monocytes (MONO%). The severity of clinical symptoms in these patients was evaluated using the modified Rankin Scale (mRS), Essen Stroke Risk Score (ESRS), Barthel Index (BI), and National Institute of Health Stroke Scale (NIHSS). RESULTS: Higher vWF levels in thrombus were associated with lower NIHSS scores, while higher NETs levels were associated with higher initial NIHSS scores. In the early stages of AIS, WBC count and vWF levels were negatively correlated, as well as NEU%. LYM% was positively correlated with vWF level; however, it was negatively correlated with NETs. EOS% was positively correlated with vWF levels. CONCLUSION: In the early stages of AIS, a higher peripheral WBC count and NEU%, combined with decreased EOS% and LYM%, were significantly correlated with a lower vWF level in the thrombus, potentially indicating more severe symptoms. Consequently, the timely administration of vWF-targeted medications is recommended for such patients. Reduced LYM% is indicative of elevated NETs levels and correlated with more severe clinical symptoms. Therefore, the prompt initiation of NETs-targeted medication is warranted for these patients.

How abiotic stresses trigger sugar signaling to modulate leaf senescence?

Plants have evolved the adaptive capacity to mitigate the negative effect of external adversities at chemical, molecular, cellular, and physiological levels. This capacity is conferred by triggering the coordinated action of internal regulatory factors, in which sugars play an essential role in the regulating chloroplast degradation and leaf senescence under various stresses. In this review, we summarize the recent findings on the senescent-associated changes in carbohydrate metabolism and its relation to chlorophyl degradation, oxidative damage, photosynthesis inhibition, programmed cell death (PCD), and sink-source relation as affected by abiotic stresses. The action of sugar signaling in regulating the initiation and progression of leaf senescence under abiotic stresses involves interactions with various plant hormones, reactive oxygen species (ROS) burst, and protein kinases. This discussion aims to elucidate the complex regulatory network and molecular mechanisms that underline sugar-induced leaf senescence in response to various abiotic stresses. The imperative role of sugar signaling in regulating plant stress responses potentially enables the production of crop plants with modified sugar metabolism. This, in turn, may facilitate the engineering of plants with improved stress responses, optimal life span and higher yield achievement.

Association between Serum Lactate Dehydrogenase Level and 30-day Mortality in Patients with Intracranial Hemorrhage with Acute Leukemia in the Induction Phase: A Cohort Study.

Objectives This study aimed to identify the association between lactate dehydrogenase (LDH) levels and 30-day mortality in patients with intracranial hemorrhage (ICH) with acute leukemia during the induction phase. Methods This cohort study included patients with acute leukemia with ICH during induction. We evaluated serum LDH levels upon admission. Multivariable Cox regression analyzed the LDH 30-day mortality association. Interaction and stratified analyses based on factors like age, sex, albumin, white blood cell count, hemoglobin level, and platelet count were conducted. Results We selected 91 patients diagnosed with acute leukemia and ICH. The overall 30-day mortality rate was 61.5%, with 56 of the 91 patients succumbing. Among those with LDH levels ≥ 570 U/L, the mortality rate was 74.4% (32 out of 43), which was higher than the 50% mortality rate of the LDH < 570 U/L group (24 out of 48) ( p = 0.017). In our multivariate regression models, the hazard ratios and their corresponding 95% confidence intervals for Log2 and twice the upper limit of normal LDH were 1.27 (1.01, 1.58) and 2.2 (1.05, 4.58), respectively. Interaction analysis revealed no significant interactive effect on the relationship between LDH levels and 30-day mortality. Conclusions Serum LDH level was associated with 30-day mortality, especially in patients with LDH ≥ 570 U/L.

(Z, Z, Z)-3,6,9-Nonadecadiene, a potential inhibitor of sex pheromone of Grey Tea Geometrid (Lepidoptera: Geometridae): electroantennogram test, wind tunnel, and in silico study.

Sex pheromone analogs have high structural similarity to sex pheromone components. They also play a role in studying many agricultural pests. In our study, (Z, Z, Z)-3,6,9-nonadecadiene (Z3Z6Z9-19:Hy) was successfully synthesized, which is an analogue to 1 of 2 sex pheromone components of Ectropis grisescens Warren (Z, Z, Z)-3,6,9-octadecatriene (Z3Z6Z9-18:Hy), and it showed potential inhibition in experiments. In the electroantennogram test, Z3Z6Z9-19:Hy showed a dose-dependent response, and only measured half the response of Z3Z9-6,7-epo-18:Hy. However, the compound significantly reduced positive response of E. grisescens males by up to 70% in the Y-tube olfactometer. Furthermore, in the wind tunnel, it significantly inhibited all types of behavioral responses. The percentage of moths contacting the pheromone odor source was reduced even at the lowest dose tested. In silico study afterward, molecular docking results showed affinity between Z3Z6Z9-19:Hy and sensory neuron membrane protein 1. Our study revealed the potential of Z3Z6Z9-19:Hy as a sex pheromone inhibitor, which would provide new tools for monitoring and mating disruption of E. grisescens.

Prevalence and network analysis of internet addiction, depression and their associations with sleep quality among commercial airline pilots: A national survey in China.

OBJECTIVE: Airline pilots are members of a unique occupational group that is often confronted with sleep routine disruptions, yet relatively few studies have examined their mental health status. This study assessed the prevalence and network structure of internet addiction, depression and sleep quality problems in commercial airline pilots. METHOD: A total of 7055 airline pilots were included in analyses. Internet addiction and depression were measured with the Internet Addiction Test (IAT) and 9-item Patient Health Questionnaire (PHQ-9), respectively. Sleep quality was evaluated using the Pittsburgh Sleep Quality Index (PSQI). The network model was constructed based on an Ising model and its association with sleep quality was evaluated using a flow procedure. RESULTS: Internet addiction, depression and sleep quality were common among airline pilots. The prevalence of internet addiction was 8.0 % (95 % CI: 7.3-8.6 %), while the rates of depression and poor sleep quality were 23.3 % (95 % CI: 22.3-24.2 %) and 33.0 % (95 % CI: 31.9-34.1 %), respectively. In the depression and internet addiction network model, "Fatigue" (PHQ4; Expected Influence (EI): 2.04) and "Depressed/moody/nervous only while being offline" (IAT20; EI: 1.76) were most central symptoms while "Fatigue" (PHQ4; Bridge EI: 1.30) was also the most important bridge symptom. The flow network model of sleep quality with internet addiction and depression showed that "Appetite" (PHQ5) had the strongest positive association with poor sleep quality. CONCLUSION: Internet addiction, depression and sleep quality were common among airline pilots and warrant regular screening and timely treatment. Strategies to improve sleep hygiene may be useful in preventing onsets or exacerbations in depression and internet addiction among airline pilots.

Effectiveness of blended happy age education program (B-HAEP) on active aging promotion among pre-disable community dwelling older adults in Pakistan.

BACKGROUND: Addressing aging related functional declines in older adults has become a top priority for countries around the world. The aim of this study was to investigate the effectiveness of a blended happy age education program in promoting active aging among community-based pre-disable older adults. METHODS: We conducted a two-arm trial study in Khyber Pakhtunkhwa, Pakistan. Participants were randomly assigned into two groups using a computer-generated random sequence of 150 participants. RESULTS: Blended Happy Age Education Program (BHAEP) reduced time for 3 m walk (Estimated mean 19.5 ± 3.4 to 13.7 ± 1.3, effect size ηp² = 0.98, (P < 0.001). The current level of happiness improved in B-HAEP group from 4.7 ± 1.05 scores to 7.8 ± 1.6, P < 0.001, effect size (ηp² = 0.540). Healthy lifestyle significantly improved (P < 0.001, ηp² = 0.4). CONCLUSIONS: B-HAEP can be an effective intervention strategy to promote active aging in older adults with risk for immobility.

Mental health status among children and adolescents in one-child and multichild families: a meta-analysis of comparative studies.

PURPOSE OF REVIEW: Controversy remains about the difference in mental health status among children and adolescents between one-child and multichild families in China. Thus, we conducted a meta-analysis of studies comparing mental health status between both groups and explored their potential moderating factors. RECENT FINDINGS: Totally, 113 eligible studies encompassing 237 899 participants (one-child families: 83 125; multichild families: 154 774) were included. The pooled SMD of SCL-90 total score was -0.115 [95% confidence interval (95% CI): -0.152; -0.078; I2  = 86.9%]. Specifically, children and adolescents from one-child families exhibited lower scores in terms of somatization (SMD = -0.056; 95% CI: -0.087; -0.026), obsessive-compulsive symptoms (SMD = -0.116; 95% CI: -0.154; -0.079), interpersonal sensitivity (SMD = -0.140; 95% CI: -0.171; -0.109), depression (SMD = -0.123; 95% CI: -0.159; -0.088); anxiety (SMD = -0.121; 95% CI: -0.151; -0.092); phobic anxiety (SMD = -0.124; 95% CI: -0.166; -0.081); paranoid ideation (SMD = -0.040; 95% CI: -0.070; -0.009); and psychoticism (SMD = -0.119; 95% CI: -0.148; -0.089). Study publication year was significantly associated with differences in mental health status between both groups ( P  = 0.015). SUMMARY: Children and adolescents from one-child families had better mental health status compared to those from multichild families in China. Future studies should investigate the underlying factors contributing to such mental health differences, and the potential interventions that could address these mental health problems.

MCNP simulation and experimental study in situ low-grade copper analysis based on PGNAA.

A prompt gamma neutron activation analysis (PGNAA) facility utilizing 252Cf source has been developed for in situ analysis of copper samples. Monte Carlo simulation is employed to determine optimal sizes for neutron moderator, gamma-ray shielding material, and thermal neutron absorber. Subsequently, based on the parameters optimized by MCNP, the PGNAA facility was constructed. Five sets of experimental samples containing low-grade copper concentration of 0 %, 0.5 %, 1 %, 1.5 % and 2 % are measured with the PGNAA facility. The results show that the minimum detectable concentration of copper is 0.218 %. The maximum relative deviation of copper is 8.53 %.

P450-Modified Multicyclic Cyclophane-Containing Ribosomally Synthesized and Post-Translationally Modified Peptides.

Cyclic peptides with cyclophane linkers are an attractive compound type owing to the fine-tuned rigid three-dimensional structures and unusual biophysical features. Cytochrome P450 enzymes are capable of catalyzing not only the C-C and C-O oxidative coupling reactions found in vancomycin and other nonribosomal peptides (NRPs), but they also exhibit novel catalytic activities to generate cyclic ribosomally synthesized and post-translationally modified peptides (RiPPs) through cyclophane linkage. To discover more P450-modified multicyclic RiPPs, we set out to find cryptic and unknown P450-modified RiPP biosynthetic gene clusters (BGCs) through genome mining. Synergized bioinformatic analysis reveals that P450-modified RiPP BGCs are broadly distributed in bacteria and can be classified into 11 classes. Focusing on two classes of P450-modified RiPP BGCs where precursor peptides contain multiple conserved aromatic amino acid residues, we characterized 11 novel P450-modified multicyclic RiPPs with different cyclophane linkers through heterologous expression. Further mutation of the key ring-forming residues and combinatorial biosynthesis study revealed the order of bond formation and the specificity of P450s. This study reveals the functional diversity of P450 enzymes involved in the cyclophane-containing RiPPs and indicates that P450 enzymes are promising tools for rapidly obtaining structurally diverse cyclic peptide derivatives.

A Case Report of Multidisciplinary Diagnosis and Treatment of a Patient with Tuberous Sclerosis Complex and Multi-Organ Involvement / 罕见病研究

Tuberous sclerosis complex(TSC)is a rare genetic disease that can lead to benign dysplasia in multiple organs such as the skin, brain, eyes, oral cavity, heart, lungs, kidneys, liver, and bones. Its main symptoms include epilepsy, intellectual disabilities, skin depigmentation, and facial angiofibromas, whilst incidence is approximately 1 in 10 000 to 1 in 6000 newborns. This case presents a middle-aged woman who initially manifested with epilepsy and nodular depigmentation. Later, she developed a lower abdominal mass, elevated creatinine, and severe anemia. Based on clinical features and whole exome sequencing, the primary diagnosis was confirmed as TSC. Laboratory and imaging examinations revealed that the lower abdominal mass originated from the uterus. CT-guided biopsy pathology and surgical pathology suggested a combination of leiomyoma and abscess. With the involvement of multiple organs and various complications beyond the main diagnosis, the diagnostic and therapeutic process for this patient highlights the importance of rigorous clinical thinking and multidisciplinary collaboration in the diagnosis and treatment of rare and challenging diseases.