Mohammad T. Abuawwad

Obstructive sleep apnea (OSA) affects about one billion individuals globally, posing a significant public health burden. While continuous positive airway pressure (CPAP) remains the first-line treatment, its effectiveness is often limited by poor adherence due to discomfort. This has led to growing interest in alternative therapies, notably hypoglossal nerve stimulation (HGNS), which offers a promising option for patients with moderate to severe OSA who are intolerant to CPAP. HGNS delivers electrical stimulation to the hypoglossal nerve to maintain upper airway patency during sleep and is particularly effective in patients with a body mass index (BMI) ≤32 kg/m2 and favorable airway anatomy. This chapter summarizes current evidence from our comprehensive systematic review and meta-analysis of 30 clinical studies involving over 800 adults. The three main HGNS systems—Apnex, Inspire, and ImThera—were evaluated. HGNS consistently reduced objective measures such as the apnea-hypopnea index (AHI) and oxygen desaturation index (ODI), while significantly improving subjective outcomes including the Epworth Sleepiness Scale (ESS) and Functional Outcomes of Sleep Questionnaire (FOSQ). Among the devices, Inspire has shown the most favorable efficacy and safety profile. HGNS was generally well tolerated, with low rates of serious adverse events and high patient satisfaction. It represents a viable alternative therapy for carefully selected OSA patients.

Background Libman–Sacks endocarditis (LSE) is a rare, nonbacterial form of endocarditis. Despite its significance, LSE remains under-studied. To address this, we aim to provide a comprehensive synthesis of clinical characteristics, diagnostic approaches, management, and outcomes, thereby clarifying patterns that can guide clinical practice and future research. Methods A systematic literature search was conducted in PubMed, Scopus, and Google Scholar from database inception through 25 August 2025 to identify published case reports and case series of Libman-Sacks endocarditis in adult patients with systemic lupus erythematosus. Retrieved records underwent title/abstract screening followed by full-text review. Eligible studies were subjected to standardized data extraction. A descriptive synthesis was performed, and methodological quality was appraised independently by two reviewers using the Joanna Briggs Institute (JBI) critical appraisal tools appropriate to the included report design. Disagreements were resolved through discussion. Results Forty-four cases from published reports were included. The mean age of included patients was 36 ± 12 years, and most patients were female (n = 36, 81.8%). The most frequently reported symptom was dyspnea and shortness of breath, reported in 26 (59.1%) patients. Neurological symptoms were also common (n = 17, 38.6%). Twenty-two patients (50.0%) had an established diagnosis of systemic lupus erythematosus before presentation. Antiphospholipid antibody positivity was the most commonly reported laboratory feature (n = 21, 47.7%), followed by antinuclear antibody positivity in 19 (43.2%) patients and anti-double-stranded DNA positivity in 16 (36.4%). Transesophageal echocardiography was performed in 33 (75.0%) cases and transthoracic echocardiography in 32 (72.7%). The mitral valve was involved in 37 patients (84.1%) when cases with combined mitral-aortic involvement were included; 34 patients had isolated mitral involvement, and 3 had double-valve involvement. Medical therapy alone was reported in 20 (45.5%) cases, surgical management alone in 13 (29.5%), and combined medical and surgical treatment in 11 (25.0%) cases. Most patients recovered (n = 34, 77.3%), whereas 5 (11.4%) died. Conclusion Libman-Sacks endocarditis is an uncommon but clinically important manifestation of systemic lupus erythematosus. In published case-based reports, mitral valve involvement appears to predominate, and common presentations include dyspnea, neurological symptoms, and thromboembolic complications such as stroke. Echocardiography remains central to diagnosis. Current evidence is limited to case-level literature, and management remains individualized, with some patients treated medically and others requiring surgical valve intervention.

Systematic reviews are used in medical research to synthesize evidence by collecting evidence from available literature without overlooking important sources or pieces. Several guidelines are available for the methodological implementation of a systematic review; however, none of them include case reports or case series as a potential source of information that could be pooled and analyzed. Although case reports may be criticized as an evidence source, they are important for documenting certain types of evidence such as rare conditions, adverse events, or novel emergent diseases. In this article, we attempt to set the foundation for a guideline on the systematic review of cases, and we suggest a step-by-step guide for investigators to employ for systematically reviewing case reports. We also dissect the application of this methodology in the available literature and review a case study of a systematic review of case reports. Generally, case reports can be synthesized into a systematic review, providing evidence on matters that may be hard to investigate using other methodologies, but concerns regarding quality and level of evidence remain present.

Background Superior mesenteric artery syndrome (SMAS) is a challenging condition that requires a high index of suspicion to be accurately diagnosed and managed promptly without affecting patients’ quality of life (QoL). Aim We aimed to assess the QoL of patients diagnosed with SMAS who had Laparoscopic duodenojejunostomy (LDJ) performed at Al-Basheer Governmental Hospital in Jordan. Methods This study is a retrospective case series of all patients diagnosed with SMAS who underwent LDJ between January 2022 and May 2024. Results Twenty patients with persistent symptoms were included. Their clinical presentation, radiological, and surgical data were analysed. We used the Short-Form Health Survey (SF-36) to obtain a measure to evaluate patients' physical and mental health after 12 months of follow-up. A simple linear regression model was used to investigate the predicted association between age, BMI, Aortomesenteric Angle, and Distance and the improvement in QoL. The mean age of our patients was 24 ± 6 years while the average weight at presentation was 45 ± 3 kg. The aortomesenteric angle averaged around 10 ± 3 degrees at presentation, and the aortomesenteric distance was at an average of 5 ± 1 mm. The pre-operative QoL scores averaged 41 ± 5 for females, and 43 ± 5 for males. Post-operatively the average BMI improved to 19.6 ± 0.5 kg/m². Using the linear regression analysis a statistically significant relation was found between BMI and the improved QoL (p = 0.043). Conclusion We demonstrated how such a rare condition can greatly affect patients’ QoL and emphasised the importance of comprehensive nutritional management as part of the therapeutic strategy for SMAS. We plan to implement a distinctive framework for the continuous stream of patients to further study and understand the features of SMAS and its effects on patients’ QoL. Graphical abstract

This study evaluates the efficacy and safety of the combined microneedling (CMNT) with minoxidil versus minoxidil monotherapy for the treatment of androgenetic alopecia (AGA), with a focus on the impact of microneedling parameters on treatment outcomes. We conducted a systematic review and meta-analysis (PROSPERO: CRD42024594487) of randomized controlled trials (RCTs) comparing CMNT versus minoxidil alone for AGA, following PRISMA guidelines. A comprehensive search across six databases was performed up to September 8, 2024. We identified 12 RCTs involving 631 AGA patients, with a total of 11 RCTs included in the meta-analyses. CMNT significantly improved hair count compared to minoxidil monotherapy (SMD 1.32, 95% CI 0.73–1.92, p < 0.01), with substantial heterogeneity (I² = 88%, p < 0.01). Subgroup analyses indicated no significant effect of microneedling (MN) depth (≤ 1 mm vs. >1 mm), duration (≤ 12 weeks vs. >12 weeks), or technique(device) (electrodynamic vs. rolling) on hair count outcomes. Additionally, A meta-analysis of six RCTs demonstrated a significant improvement in hair diameter with CMNT (SMD 0.34, 95% CI 0.11–0.58; p < 0.01), with no observed heterogeneity (I² = 0%). Investigators and patient’s self-assessment scores were also improved. Adverse events were more frequent with CMNT (74 vs. 59 events), however they were generally considered mild or self-limiting. CMNT significantly enhances hair count and diameter in AGA patients with mild adverse events. MN parameters including depth, duration, and technique variations did not significantly affect hair count outcome, suggesting microneedling as a promising adjunctive AGA treatment.

Background and Aims: Chronic kidney disease (CKD) patients undergoing peritoneal dialysis (PD) are susceptible to complications, including iron overload, which can significantly impact their prognosis and overall health. This scoping review aimed to study the prevalence and implications of iron overload in CKD patients undergoing PD.Methods: A comprehensive search was conducted across five databases, leading to the selection of 18 papers for in‐depth analysis. These studies collectively involved 381 PD patients, 60.3% were males.Results: No consensus was reached regarding the exact diagnostic cutoff for iron overload. The investigations revealed four main aspects: (1) Seven papers identified various factors contributing to iron overload, emphasizing the role of different iron supplements and magnetic resonance imaging's capability to diagnose iron accumulation in organs; (2) Iron overload in young patients was found to hinder growth; (3) Six studies highlighted the adverse effects of iron overload, with cardiac issues being the most significant; (4) Three studies demonstrated the efficacy of iron‐chelating agents, Deferoxamine and Deferasirox, in treating iron overload patients undergoing PD. Overall, the estimated prevalence of liver iron overload in CKD patients on PD ranges from approximately 10% to 28.6%, which is far lower than the prevalence of 75% elegantly shown in HD patients.Conclusion: While iron overload was a significant concern for CKD patients undergoing PD in the past, it is less common in the current era due to advancements in treatments, such as erythropoiesis‐stimulating agents. Treatment with specific chelation agents has proven beneficial, but there is also a risk of adverse effects, necessitating meticulous monitoring and timely intervention.

Background: To describe Purtscher’s and Purtscher-like retinopathy clinical features, etiologies, management options, and visual outcomes. Methods: Our protocol was registered on PROSPERO [registration number: CRD42023406843]. Seven online databases were searched: PubMed, Scopus, Medline, ScienceDirect, CENTRAL, clinicaltrials.gov, and Google Scholar. Original articles were included if they reported at least one subject diagnosed with Purtscher’s or Purtscher-like retinopathy. The primary outcome is to describe the clinical features of Purtscher and Purtscher-like retinopathies, including etiologies, results of related investigations, management lines, and visual outcomes. All analyses were conducted with the use of Statistical Package for Social Sciences (SPSS) version 27 (IBM SPSS Corp, SPSS Statistics ver. 26, USA) and Cochrane’s RevMan software. The methodological quality of included studies was assessed using the NIH quality assessment tools. Results: A total of 114 articles were included, describing 168 cases of Purtscher’s and Purtscher-like retinopathy. Patients were evenly distributed between males (50.89%) and females (49.11%). Average age of patients was 34.62 years old. Trauma was the leading cause of retinopathy, being reported in 39.88% of our patients, followed by systemic lupus erythematosus (SLE) (13.1%) and acute pancreatitis (11.9%). Bilateral symptoms were reported in 57.7% of patients with centrally blurred vision being the most complained symptom (OS: 34.32% and OD: 18%). 75% of patients elicited bilateral retinal findings. Cotton-wool spots were of highest prevalence (58%). Purtscher flecken was seen in 53% of patients. Macular edema was seen in 13% of patients. Overall, patients had a favorable prognosis (53%). Conclusion: Purtscher’s and Purtscher-like retinopathies are rare sight-threatening retinopathies that develop most commonly following trauma or other systemic diseases as SLE and acute pancreatitis. Little data is available regarding these conditions, and available data is of low quality. Patients develop bilateral disease in approximately 50% of cases, and several retinal findings are observed, with no specific tendency. Most observed signs are cotton-wool spots in around 55% of patients and Purtscher flecken in 51% of patients. Patients spontaneously recovered, although data is not conclusive. No clear prognostic value of etiological factors is identified, and further research is required in this regard.