Medical education has a significant role in reducing the health inequities and physician shortages in sub-Saharan Africa (SSA). There has been an expansion in medical education in SSA since the early 1900s, with >168 med...Medical education has a significant role in reducing the health inequities and physician shortages in sub-Saharan Africa (SSA). There has been an expansion in medical education in SSA since the early 1900s, with >168 medical schools in the region. This expansion, has, however, been fraught with a myriad of challenges, chief amongst which include massive emigration of medical doctors, poor funding of healthcare and education, and adoption of traditional Western medical curriculum. Emigration creates significant shortages of clinicians and medical faculty, putting extra pressure and strain on the remaining clinicians and faculty, and driving even more emigration. Poor funding translates to poor remuneration, which is the greatest 'push factor' for emigration. Poor remuneration, service conditions and welfare, drive industrial/strike actions in medical schools, prolonging duration of medical training and graduation from medical schools. Western-style medical education can also be a 'push factor' factor for emigration upon graduation. To address the widening inequities in access to and quality of healthcare and physician shortages in SSA, private sector investment in medical education must be encouraged, as well as improved funding of healthcare and education by national governments, and the adoption of community-based medical education and problem-based learning with medical curricula that are tailored to local needs and peculiarities. This review article discusses the challenges and prospects of medical education in SSA using PAMO University of Medical Sciences, the first private medical university in Nigeria, as a case-study.
AIMS: This study investigates the association between PIWI-interacting RNA-63049 (piRNA-63049) and the risk of post-menopausal osteoporosis in a Chinese population. It explores piRNA-63049's role in modulating the Wnt si...AIMS: This study investigates the association between PIWI-interacting RNA-63049 (piRNA-63049) and the risk of post-menopausal osteoporosis in a Chinese population. It explores piRNA-63049's role in modulating the Wnt signaling pathway, which is crucial for bone health, particularly in the context of estrogen deficiency-induced osteoporosis. METHODS: We enrolled 216 participants divided into three groups: healthy control participants as the osteoporosis(-)fracture(-) group, osteoporosis patients without fractures as the osteoporosis(+)fracture(-) group, and osteoporosis patients with fractures as the osteoporosis(+)fracture(+) group. T-scores at both spine and hip were compared. The expression of piRNA-63049 and its impact on the Wnt/β-catenin signaling pathway were examined using polymerase chain reaction analysis and luciferase assays. RESULTS: Compared with other candidate piRNAs, piRNA-63049 exhibited significantly higher expression levels in patients with osteoporosis, while being highest in osteoporosis patients with fractures. T-scores of the osteoporosis(+)fracture(+) were also the lowest among all groups, which indicated worse bone health compared with the osteoporosis(+)fracture(-) group. Luciferase assays confirmed the molecular interactions between piRNA-63049 and the Wnt2b mRNA and β-catenin mRNA, both being crucial components of the Wnt signaling pathway. Overexpression of piRNA-63049 resulted in the downregulation of several key genes involved in bone metabolism, further elucidating its critical role in osteogenesis and bone health. Moreover, key genes of bone metabolism including LRP5, LRP6, OCN, OPN, and ALP were also regulated by the overexpression of piRNA-63049. CONCLUSION: Our study suggested that the dysregulation of piRNA-63049 is associated with the increased risk of post-menopausal osteoporosis and fractures in the Chinese population by modulating the Wnt/β-catenin signaling pathway. Key messages What is already known on this topic: Post-menopausal osteoporosis was recognized for its significant bone loss and increased fracture risk, largely due to estrogen deficiency disrupting bone remodeling. The Wnt signaling pathway was identified as a key regulator in bone metabolism, with its dysregulation linked to osteoporosis. However, the specific role of piRNA-63049 was not well understood, which requested further research into its regulatory functions and its connection to osteoporosis in the Chinese population. What this study adds: This study reveals that piRNA-63049 is significantly upregulated in post-menopausal osteoporosis patients, particularly in those with fractures, and demonstrates a direct molecular interaction between piRNA-63049 and the Wnt/β-catenin signaling pathway. How this study might affect research, practice, or policy: The study's findings have implications for developing targeted therapies for osteoporosis, as piRNA-63049's dysregulation may contribute to the pathogenesis of osteoporosis by negatively affecting bone metabolism genes. This could lead to new treatment strategies and improved clinical practices for managing post-menopausal osteoporosis.
AIM: This meta-analysis aimed to assess syndecan-1 as a biomarker reflecting endothelial glycocalyx injury in sepsis, investigate its correlation with disease severity, organ complications and clinical prognosis, and cla...AIM: This meta-analysis aimed to assess syndecan-1 as a biomarker reflecting endothelial glycocalyx injury in sepsis, investigate its correlation with disease severity, organ complications and clinical prognosis, and clarifies its complementary value relative to conventional sepsis biomarkers. DESIGN: A systematic review and meta-analysis conducted in accordance with PRISMA guidelines. Data analysis was performed using Review Manager 5.3, with standardized mean differences (SMD) and 95% confidence intervals (CI) calculated. Subgroup analyses were stratified by sepsis definitions (Sepsis 1.0/2.0 vs. 3.0), and sensitivity analyses were performed by excluding studies with serious or critical ROBINS-I bias. PATIENTS: A total of 29 studies involving 4985 participants (3902 with sepsis) were included. MAIN OUTCOME MEASURES: Circulating syndecan-1 levels in sepsis patients versus non-sepsis controls, survivors versus non-survivors, and patients with septic shock, acute kidney injury (AKI) and disseminated intravascular coagulation (DIC). RESULTS: Syndecan-1 levels were significantly higher in sepsis patients than non-sepsis [SMD = 1.16, 95% CI (0.86, 1.47), p < 0.00001]. Non-survivors had significantly elevated levels compared with survivors, and higher levels were also observed in patients with septic shock, AKI and DIC (all p < 0.00001). Subgroup analyses yielded consistent findings across different sepsis definitions, and sensitivity analyses excluding 9 high-bias studies confirmed the robustness of the results. CONCLUSION: Elevated syndecan-1 indicates endothelial glycocalyx disruption in sepsis, and is closely linked to worse prognosis, septic shock and organ dysfunction. As a complementary biomarker to lactate, procalcitonin and C-reactive protein, it improves multi-domain sepsis risk stratification and supports individualized resuscitation and endothelial-protective intervention research. Key messages What is already known on this topic? Syndecan-1 is a marker of endothelial glycocalyx degradation and has been linked to sepsis severity. However, its precise association with prognosis and complications remains unclear, and its clinical value relative to traditional sepsis biomarkers (lactate/PCT/CRP) has not been systematically clarified, necessitating a meta-analysis to quantify its clinical relevance and complementary role. What this study adds This study confirms that syndecan-1 levels are significantly elevated in sepsis, especially in severe cases, non-survivors, and patients with AKI or DIC, validating its role as a specific biomarker of sepsis-associated endothelial glycocalyx injury. Importantly, it clarifies that syndecan-1 is not a replacement for traditional biomarkers but a complementary indicator that captures the endotheliopathy domain unmeasured by lactate/PCT/CRP. Its lack of specificity for sepsis limits its utility as a standalone diagnostic biomarker, but it provides incremental prognostic value for risk stratification. How this study might affect research, practice, or policy Syndecan-1 may serve as a prognostic marker for endothelial dysfunction in sepsis and a stratification tool for identifying patients at high risk of capillary leak and fluid resuscitation-related adverse outcomes. It should be used alongside other biomarkers to inform personalized resuscitation strategies. This meta-analysis provides the most comprehensive quantitative evidence to date for the integration of "glycocalyx-friendly" management into future sepsis research and clinical guidelines, and guides the design of forthcoming trials targeting endothelial barrier protection.
PURPOSE OF THE STUDY: Charisma is a relational construct that may shape communication, leadership behavior, and team dynamics in healthcare settings. It remains unclear whether charisma profiles differ across residents'...PURPOSE OF THE STUDY: Charisma is a relational construct that may shape communication, leadership behavior, and team dynamics in healthcare settings. It remains unclear whether charisma profiles differ across residents' intended medical specialties. STUDY DESIGN: This study examined the association between intended specialty choice and charisma profiles among Japanese postgraduate residents using a cross-sectional, nationwide, web-based survey conducted between 18 January and 31 March 2024 after a national in-training examination. Of the 9179 postgraduate year one and two residents invited, 5808 (63.3%) were included in the analysis. Charisma was assessed using a modified General Charisma Inventory with binary items. The primary outcome was the total modified inventory score and its association with the intended specialty was estimated using multivariate linear regression adjusted for age, sex, and hospital type (including university hospital affiliation). RESULTS: Among participants, aspirations for surgical-oriented specialties were associated with higher total charisma scores compared with internal medicine (Surgery: β = 0.26, P < .001; Neurosurgery: β = 0.37, P = .001). In contrast, aspirations for diagnostic specialties were associated with lower total charisma scores (Radiology: β = -0.25, P = .022; Pathology: β = -0.48, P = .011). Male sex (β = 0.20, P < .001) and university hospital affiliation (β = 0.14, P = .008) were also independently associated with higher total charisma scores. CONCLUSIONS: Charisma profiles among Japanese residents varied according to their intended specialty, consistent with a potential person-environment fit mechanism in early career preferences. Sex and institutional affiliation were also independently associated with charisma scores, suggesting socio-cultural and environmental influences. These findings can inform leadership development and career support strategies for residency training. Key messages • What is already known on this topic - charisma is a relational construct that can influence communication, leadership behavior, and team dynamics in healthcare settings. • What this study adds - in a nationwide cross-sectional web survey of 5808 residents, surgically oriented specialties were associated with higher total charisma scores, whereas diagnostic specialties were associated with lower scores (vs. internal medicine). Male sex and university hospital affiliations were independently associated with higher scores. • How this study might affect research, practice, or policy - charisma profiles may differ according to the intended specialty, person-environment fit, leadership development, and career support strategies in residency training.
BACKGROUND: The purpose of patient monitoring is to identify when immediate assessment to prevent morbidity and death is needed. AIM: To determine the optimal description of level of consciousness, using death within 24 ...BACKGROUND: The purpose of patient monitoring is to identify when immediate assessment to prevent morbidity and death is needed. AIM: To determine the optimal description of level of consciousness, using death within 24 h as a surrogate marker for when a patient needs to be assessed immediately. METHODS: Observational non-interventional study: the level of consciousness of acutely ill medical patients to a low resource Ugandan hospital was assessed daily using a modified version of the Richmond Agitation and Sedation Scale. RESULTS: 2579 daily observations (3.4 per admission) were performed on 757 patients; while in hospital 43 (5.7%) patients died, 42 of whom died within 24 h of their last observation. The inability to answer questions using speech had the highest uncorrected odds ratio for 24 h mortality (OR 14.4, 95% CI 7.2-29.3), the highest odds ratio when corrected for age and sex (OR 12.3, 95% CI 6.1-24.8), and highest Youden number (0.545). CONCLUSION: The inability to answer questions using speech was the level of consciousness assessment that best predicted 24 h mortality. As it is simple and unambiguous, it may help in the efficient identification of patients who need an immediate full clinical assessment. Key messages What is already known on this topic: Level of consciousness is frequently assessed by the AVPU score (Alert, responds to Verbal stimulus, responds to Painful stimulus and Unresponsive). However, AVPU has low rates of inter-rater agreement, and nurses may not agree on how to distinguish between "Alert" and "Voice." Moreover, there are few reports of its ability to accurately identify patients who need to be seen immediately. What this study adds: This study found the ability to answer questions using speech was the consciousness level within the AVPU or the Richmond Agitation and Sedation Scale that best predicted death within 24-hours and, hence, the need to be seen immediately. How this study might affect research, practice, and policy: More research is needed to determine the monitoring variables that most efficiently bring time-dependent treatments to patients while they are still effective. The inability to answer questions promises to be a rapid, easy, unambiguous and efficient method of identifying patients with a reduced level of consciousness who need immediate attention.
BACKGROUND: Up to 10% of hospitalized patients in Europe carry a penicillin allergy label, yet most are inaccurate. Mislabelling drives inappropriate broad-spectrum antibiotic use, increased resistance, prolonged admissi...BACKGROUND: Up to 10% of hospitalized patients in Europe carry a penicillin allergy label, yet most are inaccurate. Mislabelling drives inappropriate broad-spectrum antibiotic use, increased resistance, prolonged admissions, and higher costs. Whilst local and national studies suggest that de-labelling is cost-saving, there has been no EU-wide analysis accounting for cross-country differences in antimicrobial resistance (AMR), costs, and equity. METHODS: We conducted a distributional cost-effectiveness analysis (DCEA) comparing Uniform versus Targeted rollout of penicillin allergy de-labelling across all 27 EU member states. Population data were sourced from Eurostat (2025) and AMR indices from ECDC EARS-Net (2023). Conservative estimates of prevalence, de-labelling effectiveness, QALY gains, and cost savings were drawn from published literature. Outcomes included incremental QALYs, costs, net health benefit (NHB), equity-weighted NHB (ENHB), and equally distributed equivalent (EDE) QALYs. Probabilistic sensitivity analysis (n = 1000) assessed robustness. RESULTS: Both strategies were dominant (health-gaining and cost-saving). Uniform rollout yielded 331 318 QALYs and €1.44 billion in savings, whilst Targeted delivered 355 561 QALYs and €1.54 billion, an incremental gain of 24 243 QALYs and €105 million. Benefits correlated strongly with AMR burden (r = 0.839). Country-level analysis revealed 2.1-fold variation in equity benefits, with the highest gains in Southern and Eastern European countries. CONCLUSIONS: Penicillin allergy de-labelling is a cost-saving, equity-promoting strategy across the EU. Targeted rollout offers superior efficiency and fairness, particularly in high-AMR countries, and should be prioritized for implementation. Key messages What is already known on this topic: Penicillin allergy labels are common but mostly inaccurate, leading to broader-spectrum antibiotic use, higher costs, and increased antimicrobial resistance. De-labelling is known to be clinically safe and cost-saving in local and national studies. EU-wide evidence incorporating equity and antimicrobial resistance burden has been lacking. What this study adds: This study provides the first EU-wide distributional cost-effectiveness analysis of penicillin allergy de-labelling. Both Uniform and Targeted rollout strategies are cost-saving and health-improving across all EU member states. Targeted implementation yields additional efficiency and equity gains, especially in high-AMR countries. How this study might affect research, practice or policy: Penicillin allergy de-labelling should be prioritized as a core EU antimicrobial stewardship strategy. Targeted rollout can maximize health gains and equity in high-burden settings. These results support EU-level investment and coordinated implementation of de-labelling programmes.
BACKGROUND: The choice of the fourth drug in anti-tubercular therapy for adults with tuberculous meningitis (TBM) remains uncertain. This trial compared the effectiveness and safety of ethambutol (ETM) versus streptomyci...BACKGROUND: The choice of the fourth drug in anti-tubercular therapy for adults with tuberculous meningitis (TBM) remains uncertain. This trial compared the effectiveness and safety of ethambutol (ETM) versus streptomycin (STM) during the intensive phase. METHODS: This is an investigator-initiated, single-center, open-label, randomized controlled trial conducted during October 2020-June 2025. The study was stopped early because of slow recruitment. Patients were randomized to receive either STM (15 mg/kg intramuscular daily; ~90 injections) with isoniazid (H) 5 mg/kg (~300 mg/d), rifampicin (R) 10 mg/kg (~600 mg/d), and pyrazinamide (Z) 25 mg/kg (~1500 mg/d), or ETM (15 mg/kg orally daily) with HRZ for 6 months, followed by RH for 12 months in both arms. Primary outcome was mortality at 6 months. Secondary outcomes included in-hospital mortality and neurologic disability at 3 and 6 months. The disability was assessed using the modified Rankin Scale (mRS) as good (mRS ≤ 2) or poor (mRS > 2). Adverse events were noted. RESULTS: Of 131 patients screened, 49 were excluded. The results therefore are based on 82 patients. The two arms were matched for baseline characteristics. At 6 months, 26 patients had died: 12/42 (28.6%) in the STM arm and 14/40 (35%) in the ETM arm (hazard ratio: 0.78; 95% confidence interval: 0.36-1.70; P = 0.54). In intention-to-treat analysis, there were no differences in in-hospital mortality and disability at 3 and 6 months. Two patients each developed ototoxicity and vision loss in the STM and the ETM arm, respectively. CONCLUSIONS: In adults with TBM, there was no difference in mortality or disability at 6 months between ETM and STM arms, but the study may lack statistical power to detect a difference.The trial was registered in the Clinical Trials Registry of India, CTRI/2020/07/026423 (registered on: 7 July 2020). Key messages What is already known on this topic: The choice of the fourth drug in anti-tubercular therapy (ATT) for adults with tuberculous meningitis (TBM) remains uncertain. Despite extensive use, direct comparisons of ethambutol (ETM) versus streptomycin (STM) in TBM through randomized controlled trials are lacking. What this study adds: In adults with TBM, there was no difference in mortality or disability at 6 months between ETM- or STM-based ATT regimens during the intensive phase. How this study might affect research, practice, or policy: The safety profile of both drugs was comparable; hence, the choice of fourth drug may instead be guided by safety and feasibility.
Although they comprise only a small proportion of the medical take, patients who decide to self-discharge against medical advice pose a significant management challenge. They are often from a vulnerable patient populatio...Although they comprise only a small proportion of the medical take, patients who decide to self-discharge against medical advice pose a significant management challenge. They are often from a vulnerable patient population, and the challenges of providing adequate care are not insignificant. This short paper highlights the difficulties and explores possible responses.
Şen A, Yaman M, Durgun HM
… +6 more, Ülgüt ŞG, Belek S, Günel BT, Orak M, Gündüz E, Güloğlu C
Postgrad Med J
· 2026 Mar · PMID 41910233
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BACKGROUND: Electrical injuries can lead to extensive tissue damage, particularly rhabdomyolysis, a severe clinical condition resulting from skeletal muscle breakdown. The McMahon score is a validated prognostic model us...BACKGROUND: Electrical injuries can lead to extensive tissue damage, particularly rhabdomyolysis, a severe clinical condition resulting from skeletal muscle breakdown. The McMahon score is a validated prognostic model used to predict acute kidney injury (AKI) and in-hospital mortality in rhabdomyolysis. However, its performance in cases specifically induced by electrocution remains unclear. METHODS: This retrospective observational study evaluated 173 adult patients admitted with electrocution-induced rhabdomyolysis between January 2019 and December 2023. Clinical and laboratory data, including McMahon scores calculated at admission, were extracted from medical records. Patients were categorized based on survival status, and statistical analyses assessed the relationship between McMahon scores and clinical outcomes, particularly mortality and AKI risk. RESULTS: The mean age was 29.4 ± 17.5 years; 80.9% were male. The median McMahon score was 3.0. In-hospital mortality was 3.5%. Patients who died had significantly higher McMahon scores (mean 7.4 vs. 3.4, P < .001). Receiver Operating Characteristic analysis revealed a strong predictive value for the McMahon score in mortality (area under the curve: 0.936; 95% confidence intervals: 0.876-0.997). A cut-off score of ≥6 yielded 83.3% sensitivity and 89.2% specificity. Mortality probability exceeded 90% when the score was ≥10. McMahon score was positively correlated with AKI risk percentage (r = 0.998, P < .001). CONCLUSIONS: The McMahon score is a robust prognostic tool for predicting in-hospital mortality in electrocution-induced rhabdomyolysis. A score ≥ 6 indicates increased risk, while lower scores are associated with favorable outcomes. These findings support the use of McMahon scoring for early risk stratification in emergency settings for electrically injured patients.
Gürbüz H, Yaman M, Güvelioğlu AM
… +2 more, Kurt BB, Büyükaslan H
Postgrad Med J
· 2026 Mar · PMID 41910226
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BACKGROUND: Burn injuries are among the leading causes of trauma-related morbidity and mortality, particularly in low-resource and conflict-affected regions. This study aimed to evaluate the demographic and clinical fact...BACKGROUND: Burn injuries are among the leading causes of trauma-related morbidity and mortality, particularly in low-resource and conflict-affected regions. This study aimed to evaluate the demographic and clinical factors associated with short-term outcomes among burn patients treated in a war zone hospital in Northern Syria. METHODS: This retrospective observational study included patients hospitalized for burn injuries between 15 April 2023 and 15 April 2024 at Çobanbey Hospital Burn Center. Demographic data, burn etiology, total body surface area (TBSA), burn degree, and clinical outcomes were extracted. Patients with incomplete records were excluded. Univariate and multivariate logistic regression analyses were performed to identify mortality predictors. Receiver Operating Characteristic (ROC) analysis was used to determine the predictive value of TBSA for mortality. RESULTS: A total of 522 patients were analyzed; 57.9% were male, and 53.3% were children under 10 years. Scald burns (53.6%) and second-degree burns (56.1%) were most common. Mortality was significantly associated with older age, chemical burns, TBSA >30%, third-degree burns, multi-region involvement, and intensive care unit admission. Multivariate analysis identified age, TBSA, and multi-zone burns as independent predictors of mortality. ROC analysis showed high predictive value of TBSA for mortality (area under the curve [AUC]: 0.941, P < .001). CONCLUSION: Age, burn severity, and extent (TBSA) are major predictors of mortality in burn patients, particularly in conflict-affected regions.
Su Z, Zhang R, Kaburu FM
… +7 more, McDonnell D, Cheshmehzangi A, Šegalo S, Ahmad J, Nie JB, da Veiga CP, Xiang YT
Postgrad Med J
· 2026 Mar · PMID 41904655
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Wars erode human dignity and global solidarity. Take famine-the worst form of death by starvation en masse-for example. Famine is particularly telling and chilling, as in the modern era, the (almost) famine in Gaza and S...Wars erode human dignity and global solidarity. Take famine-the worst form of death by starvation en masse-for example. Famine is particularly telling and chilling, as in the modern era, the (almost) famine in Gaza and Sudan is predominantly human-made. In addition to acute consequences like deaths, famine also causes long-term damage to people's physical health and psychological well-being, from their susceptibility to cardiovascular diseases, trauma, and suicidality. A growing body of research also indicates that, largely due to high-definition and high-fidelity media coverage of wars with high definition and fidelity, people living in non-war zones can also face prolonged, yet often overlooked, mental health challenges. While the global health community shoulders the majority of the short- and long-term burden of care and cure in armed conflicts, we often have little power to hold warring parties responsible, not least because politicians' careers are often term-based if not short-lived. Using the famine in Gaza and Sudan as examples, this paper sheds light on the imperative of holding warring parties accountable-in care and cash-for the damage they exert on lives and livelihoods worldwide. Wars might be inevitable (almost), famine, and disregard for human dignity and despair are not. Key messages What is already known on this topic? War drives famine, disease outbreaks, psychological trauma, and health system collapse, disproportionately affecting women and children. Starvation has been used as a weapon of war, despite its prohibition under international humanitarian law. What this study adds Emphasizes the need to quantify the full health and economic costs of war, particularly in settings such as Gaza and Sudan experiencing famine and health system collapse. Proposes a Global Conflict Accountability Mechanism to hold warring parties financially responsible for health impacts. Advocates for the formal inclusion of global health professionals in diplomacy and peacebuilding. How this study might affect research, practice, or policy Encourages research on the long-term health and economic consequences of war, including mental health and chronic disease. Supports integrating global health actors into conflict-sensitive humanitarian planning and peace processes to improve equitable access to care.