Justin Riley Lam

Aims: Structural heart disease is often underdiagnosed, and echocardiography is limited by access and referral thresholds. Artificial intelligence electrocardiography (AI-ECG) may identify echocardiographically defined structural heart disease. EchoNext-Mini is a released AI-ECG model, accompanied by a benchmark dataset, that detects a composite structural heart disease outcome and component conditions from 12-lead electrocardiogram waveforms together with age, sex, and electrocardiographic measurements. We assessed its transportability and recalibration. Methods and results: We linked electrocardiograms from MIMIC-IV to subsequent transthoracic echocardiograms, including adults whose electrocardiogram preceded an eligible echocardiogram within one year, one per patient. Labels were mapped to structured echocardiographic fields using original thresholds where available, harmonized definitions otherwise. The released model was applied without retraining to this cohort and its benchmark test set, then assessed for discrimination, calibration, recalibration, subgroups, and label sensitivity. Among 45 878 patients, structural heart disease prevalence was 47.2%. Composite area under the receiver operating characteristic curve was 0.790 (95% confidence interval, 0.786 to 0.794), against 0.820 on the benchmark test set. Component values ranged from 0.679 for left ventricular wall thickness to 0.837 for right ventricular dysfunction. The composite was near-calibrated (slope, 0.93), whereas all component probabilities overestimated risk in both settings. A shift derived from the released training prevalences, requiring no local outcome data, largely corrected it. Conclusion: EchoNext-Mini transported to MIMIC-IV with composite discrimination within the published external-validation range. Component probabilities behaved as ranking scores rather than absolute risks, a property of the released model rather than the validation setting, and require adjustment before use as risk estimates.

Introduction: Patients with rheumatoid arthritis (RA) have higher risk for pneumonia, interstitial lung disease (ILD) and pulmonary fibrosis (PF). However, the association between an ICD-10-coded pneumonia event (CPE) and the incidence of ILD or PF in the RA population remains unclear. Methods: We conducted a retrospective cohort study using the TriNetX database. Patients with ICD-10 for RA aged 50 or older who had a CPE within one year of RA diagnosis (CPE cohort, n = 4553) were matched 1:1 by propensity score for key factors, including demographics, comorbidities (i.e., COPD), and medication use (DMARDs, corticosteroids) to RA patients without a CPE (Control cohort, n = 4553). Cox proportional hazard models assessed the incidence of a composite ILD outcome, PF, and secondary complications over a 4-year follow-up after the index event defined as 1-year after RA diagnosis for both cohorts. Results: The CPE cohort showed an increased risk for all outcomes. Patients with CPE had a 2.48-fold increased risk for PF (HR = 2.48; 95% CI, 1.78–3.45; p < 0.01) and a 2.87-fold increased risk for the composite ILD outcome (HR = 2.87; 95% CI, 2.18–3.80; p < 0.01). The risk of rheumatoid lung disease was 4.15 times higher (HR = 4.15; 95% CI, 2.30–7.50; p < 0.01). Furthermore, the CPE group had a higher risk for all-cause mortality (HR = 1.82; 95% CI, 1.58–2.09; p < 0.01). Conclusions: The CPE within one year of RA diagnosis is associated with an increase in subsequent ILD-coded outcomes. While this retrospective design cannot establish causality, an unspecified pneumonia code in early RA may represent an early clinical manifestation of unrecognized ILD, serving as a high-risk marker that warrants pulmonary surveillance.

Background: Osteoporosis is common in dialysis patients, yet treatment options are limited due to safety concerns in advanced kidney disease. Denosumab, with non-renal clearance, has been increasingly used, but its cardiovascular safety remains uncertain. Methods: We conducted a retrospective cohort study using the TriNetX Global Collaborative Network, encompassing data from 139 health care organizations. Adults older than or equal to 50 years with osteoporosis and end-stage renal disease on dialysis treated with either denosumab or oral bisphosphonates were included. Propensity score matching (1:1) balanced demographics, comorbidities, medications, and laboratory variables. The primary outcome was major adverse cardiovascular events (MACE: myocardial infarction, stroke, and heart failure). Secondary outcomes included hypocalcemia, fractures, and all-cause mortality. Cox proportional hazards models estimated hazard ratios (HRs). Results: After matching, 2112 patients (1056 per group) were analyzed (mean age: 73.9 y, 63.1% female). Denosumab was associated with increased risk of MACE (32.3% vs. 24.1%; HR: 1.690, 95% CI: 1.301-2.194; p p <0.001). Fracture incidence and all-cause mortality were not significantly different between groups. Sensitivity analyses and subgroup evaluations confirmed the robustness of these findings. Conclusions: In dialysis-dependent patients with osteoporosis, denosumab may be associated with increased cardiovascular and electrolyte-related risks compared with bisphosphonates, without clear evidence of superior fracture protection. These findings highlight the need for careful risk-benefit assessment when prescribing denosumab and underscore the importance of future prospective studies to clarify its safety and efficacy in this high-risk population.

Background: Cardiac resynchronization therapy (CRT) has demonstrated survival and symptom benefits in patients with heart failure with reduced ejection fraction (HFrEF). However, the comparative effectiveness of CRT with a defibrillator (CRT-D) versus pacemaker-only (CRT-P) remains uncertain in octogenarians, who are underrepresented in clinical trials. Objective: To assess long-term mortality and hospitalization outcomes associated with CRT-D versus CRT-P in octogenarians with HFrEF and left bundle branch block (LBBB), using real-world propensity-matched data. Methods: We identified 1,240 patients aged ≥80 years with HFrEF (LVEF ≤35%) and LBBB who underwent device implantation. After 1:1 propensity score matching across 65 clinical variables, 772 patients (386 CRT-D, 386 CRT-P) were included in the primary analysis. The primary endpoint was all-cause mortality over 3 years. Secondary endpoints included timepoint-specific mortality and all-cause hospitalization burden. Prespecified subgroup analyses were performed by ejection fraction (EF ≤25%, 26–35%) and by sex within each CRT modality. Results: Three-year mortality did not differ significantly between CRT-D and CRT-P (37.2% vs 39.1%; HR 1.026, 95% CI 0.814–1.293; p = 0.829). Mortality at 30 days, 90 days, and 1 year was numerically lower in CRT-D but not statistically significant. CRT-D recipients experienced fewer hospitalizations (mean 4.05 vs 5.36; p = 0.032). In EF-stratified subgroups, mortality was modestly lower with CRT-D (risk difference –3.8% in EF ≤25%; –2.1% in EF 26–35%), though not significant. Among CRT-D recipients, females had lower mortality than males (20.0% vs 29.5%; HR 0.637, 95% CI 0.353–1.149). Conclusions: In this real-world cohort of octogenarians with HFrEF, CRT-D did not improve survival over CRT-P but was associated with reduced hospitalization burden. These findings highlight the importance of phenotype-guided device selection, informed by arrhythmic risk, comorbid burden, and patient-centered goals of care.

Emerging evidence suggests a significant association between monocytes and the pathophysiology and prognosis of idiopathic pulmonary fibrosis (IPF). This review aims to systematically evaluate current knowledge regarding blood monocyte counts and their relationship with the etiology, progression, and prognosis of IPF. We conducted a systematic search in the PubMed database for articles published through 17 February 2025, using the MeSH terms “lung diseases, interstitial” and “monocytes,” which yielded 314 results. After filtering for full-text articles in English (n = 242), we included only studies focusing on blood monocyte counts with clinical implications in IPF. Articles relating to other cell types or non-IPF lung diseases were excluded. Our systematic search identified 12 relevant articles. Monocytes play an essential role in regulating inflammatory responses and resolution across multiple diseases, with established but incompletely understood contributions to lung fibrosis development in IPF. Correlations have been demonstrated between elevated blood monocyte counts and the following: (1) the presence and progression of interstitial lung abnormalities, (2) the progression from an indeterminate usual interstitial pneumonia (UIP) pattern on CT scans to definitive IPF, and (3) worse lung function parameters, an increased risk of acute exacerbations, and reduced overall survival in IPF patients. Monocytes serve as critical orchestrators throughout IPF’s natural history—from early interstitial changes to disease progression and acute exacerbations. Targeting monocyte recruitment pathways and reprogramming their differentiation represents a promising therapeutic approach, while circulating monocyte counts offer potential as accessible biomarkers for disease progression and treatment response. Future research should characterize stage-specific monocyte phenotypes to enable precision-targeted interventions.

Vancomycin, a bacterial cell wall inhibitor, can cause nephrotoxicity, typically presenting as acute tubular necrosis (ATN) but, in rare cases, can lead to acute interstitial nephritis (AIN). Risk factors include high doses, prolonged use, other nephrotoxic drugs and pre-existing kidney impairment. This case describes a man in his 70s with multiple comorbidities who developed AIN after 9 days of vancomycin therapy for a methicillin-resistant Staphylococcus aureus infection from infective endocarditis. His serum creatinine rose from 1.2 to 5.5 mg/dL, correlating with a supratherapeutic vancomycin level (40 mcg/mL). Despite stopping vancomycin, his renal function continued to worsen, leading to a diagnosis of AIN confirmed by renal biopsy. Despite high-dose corticosteroids, haemodialysis was required to stabilise renal function, emphasising the importance of early monitoring of vancomycin levels to mitigate nephrotoxicity risks.

TITLE: Perceived Clinical Readiness of Senior Medical Students as Outcomes 0f Online Clerkship in the Philippines: New Normal in Medical Education INTRODUCTION: COVID-19 formed new challenges to the medical institutions; it resulted in the transition from the usual face-to-face classes and direct clerkship training within the hospital to a new remote learning with online lectures and virtual clinical experience. Given the new online interactive setting, problems were raised given the limited patient care and interaction as well as restricted bedside teaching opportunities and its impact on how medical students can acquire and hone their clinical skills. OBJECTIVE: To determine the perceived clinical readiness of the medical clerks in the new normal setting in the Philippines. METHODOLOGY: Convenience sampling was used to gather respondents who were asked to answer an online survey questionnaire. The questions pertained to: academic training profile, clinical skills, patient management, communication, understanding clinical guidelines, and personal development. After analyzing the data, the scales of readiness from these subjects were gathered. RESULTS: The medical clerks in the Philippines perceived that they were ready with regards to understanding clinical guidelines, communication, personal development, and patient management. They were moderately ready in the different clinical skills in the departments of Family and Community Medicine, Internal Medicine, Pediatrics, Surgery and Obstetrics and Gynecology with some specific skills in Surgery and Obstetrics and Gynecology being perceived as less ready than the rest. CONCLUSION: The impact of the pandemic has disrupted the student’s confidence and readiness. This shows that online clerkship in this time of pandemic may have provided learning to a certain degree but it is not enough to replace what face-to-face training could offer.

TITLE: Antimitotic Activity of Samanea saman Leaf Extract in the In Vitro Development of Tripneustes gratilla Embryo INTRODUCTION: Commercially available anticancer drugs are expensive and may have side effects. This led the researchers to look into alternative plant sources. One of these is acacia or S. saman . OBJECTIVE: To determine whether S. saman leaf extract possesses antimitotic activity on T. gratilla embryos using vincristine sulfate as positive control. METHODOLOGY: S. saman leaves were extracted using hexane, CCl ₄ , CHCl ₃ , and water. T. gratilla embryos were fertilized in vitro. The fractions, vincristine sulfate, and DMSO in filtered sea water were added with the fertilized embryos in petri dishes. Samples were taken at 15 minutes after fertilization and every 30 minutes thereafter until the negative control reached a 32-cell stage. Fifty cells and their mean cell stage was evaluated per treatment. One-way ANOVA and Tukey tests were performed. RESULTS: Significant differences were seen starting at 75 minutes post fertilization up until the 165 ^th minute using One-way ANOVA. The Tukey test showed that all aqueous and CCl ₄ as well as hexane (200, 400, 800 ppm) extracts had no significant difference compared to vincristine sulfate; while all CHCl ₃ , hexane (100 ppm), and CCl ₄ (100 ppm) extracts showed a significant difference compared to vincristine CONCLUSION: The aqueous, hexane, and carbon tetrachloride extracts possess potential antimitotic activity on T. gratilla embryos. Thus, it is a potential alternative to vincristine sulfate as an antimitotic agent.