Recurrent syncope and behavioral changes in the older population may suggest several disease entities associated with aging. Hypoglycemia is an often-missed potentially correctable underlying cause that should also be considered in the differential diagnosis. We present a case of a 62-year-old Filipino female who presented with recurrent syncopal attacks, behavioral changes and unintentional weight gain, associated with endogenous hyperinsulinemic hypoglycemia with no pancreatic mass seen on abdominal CT scan. A pancreatic head tumor was visualized through endoscopic ultrasound. Surgical removal of the mass resulted in resolution of her symptoms and restoration of her physical and functional wellbeing. This case is being reported to highlight that surgery cured her of the disease and she remains asymptomatic and well 13 years after her surgery.

Avulsion fractures at the femoral origin of the medial head of the gastrocnemius are exceptionally rare, particularly in skeletally immature patients, and may be overlooked when evaluating acute posterior knee pain. A previously healthy 13-year-old boy developed acute posteromedial left knee pain and felt a sudden pop while running. He could bear weight with difficulty and held the knee in slight flexion because terminal extension was painful. Examination showed focal posteromedial tenderness, preserved motion with pain at full extension, and an intact distal neurovascular status. Plain radiographs demonstrated a small osseous fragment posterior to the distal femur. Magnetic resonance imaging (MRI) identified a 1.2 × 0.5 cm minimally displaced, partially corticated fragment arising from the femoral origin of the medial head of the gastrocnemius, with no associated ligamentous, meniscal, or musculotendinous injury. The patient was managed with a long-leg cast at 30° of knee flexion for six weeks, followed by six weeks of supervised range-of-motion, stretching, and strengthening exercises. He regained painless full range of motion, normal strength on clinical examination, and a stable knee, and subsequently returned to sports without reported pain or functional limitation. At two-year clinical follow-up, he remained asymptomatic without instability or treatment-related complications. This case adds to the limited pediatric literature on this uncommon injury and highlights the role of MRI in characterizing the lesion and excluding associated injuries. Because no follow-up imaging was obtained, the outcome represents clinical recovery rather than radiographically confirmed osseous union.

In horizontal semicircular canal benign paroxysmal positional vertigo (HSC-BPPV) due to canalolithiasis, biphasic nystagmus is typically observed in the affected ear down or in both ear-down positions during the supine head-roll test. This report describes a case of HSC-BPPV with biphasic nystagmus observed only in the healthy ear-down position. A 59-year-old male had a one-day history of rotational vertigo when turning to the right. The supine positional nystagmus test produced left-beating horizontal nystagmus in the face-up position. In the left-ear-down position, there was biphasic nystagmus (i.e., left-beating horizontal nystagmus followed by right-beating horizontal nystagmus). In the right-ear-down position, there was right-beating horizontal nystagmus. The first-phase nystagmus observed in the left-ear-down position was stronger than the right-beating nystagmus in the right-ear-down position. The patient was initially diagnosed with left-sided HSC-BPPV (canalolithiasis), and the Lempert roll maneuver was performed. Re-examination the following day revealed findings consistent with right-sided HSC-BPPV (cupulolithiasis). Biphasic nystagmus can occur with the presumed healthy ear-down during the supine head-roll test. Misidentification of the affected side in HSC-BPPV (canalolithiasis) may lead to an inappropriate therapeutic maneuver and suboptimal treatment. In the present case, the affected side was initially misidentified, and persistent direction-changing apogeotropic nystagmus consistent with HSC-BPPV (cupulolithiasis) was observed after the maneuver. Although the mechanism underlying this change remains speculative and is based on a single case, clinicians should recognize that biphasic nystagmus during the head-roll test does not necessarily identify the affected ear. Careful interpretation of all positional nystagmus findings is warranted before performing a therapeutic maneuver.

People with chronic obstructive pulmonary disease (COPD) who have type 2/eosinophilic inflammation may remain at high exacerbation risk despite optimized triple inhaled therapy. Seven monoclonal antibodies targeting four pathways, namely, interleukin (IL)-4/13, IL-5/IL-5 receptor α (IL-5Rα), IL-33/suppression of tumorigenicity 2 (ST2), and thymic stromal lymphopoietin (TSLP), have now been tested in COPD, and previous COPD-biologics network meta-analyses provided cross-agent rankings and certainty assessments but predated the 2025-26 pivotal and alarmin-trial wave and did not include the complete seven-agent, three-pathway evidence set. We aimed to compare and rank biologics targeting type 2 and epithelial-alarmin pathways for moderate/severe COPD exacerbations. We conducted a systematic review and random-effects network meta-analysis of placebo-controlled randomized controlled trials (RCTs) of eligible biologics in adults with COPD, prospectively registered in the International Prospective Register of Systematic Reviews (PROSPERO; CRD420261448694) and reported according to the PRISMA 2020 statement and its extension for network meta-analysis (PRISMA-NMA). MEDLINE via PubMed, CENTRAL, Europe PMC, ClinicalTrials.gov, the WHO International Clinical Trials Registry Platform (WHO ICTRP), and Google Scholar were searched to 12 July 2026. Two independent reviewers screened records, with disagreements resolved by adjudication and quality control. Risk of bias was assessed using Cochrane Risk of Bias 2 (RoB 2). The primary outcome was the annualized rate of moderate/severe exacerbations, expressed as a rate ratio (RR) with 95% confidence interval (CI) versus placebo and analysed with frequentist netmeta (placebo-anchored, star network), with Bayesian sensitivity analyses and P-score ranking; certainty was assessed using Grading of Recommendations Assessment, Development and Evaluation (GRADE) via Confidence in Network Meta-Analysis (CINeMA). Of 2,719 records identified and 2,321 screened, 15 trial nodes were included; the primary maintenance exacerbation network comprised nine RCTs (placebo plus four agents: dupilumab, mepolizumab, benralizumab, astegolimab). All four agents reduced moderate/severe exacerbations versus placebo, three significantly. Dupilumab had the largest estimated relative reduction and highest P-score (RR: 0.68, 95% CI: 0.59-0.79; P-score: 0.9947), followed by astegolimab (RR: 0.85, 95% CI: 0.75-0.96; P-score: 0.5766), mepolizumab (RR: 0.88, 95% CI: 0.79-0.97; P-score: 0.4708) and benralizumab (RR: 0.88, 95% CI: 0.77-1.01; P-score: 0.4471). Heterogeneity was low (I² = 9.68%). Dupilumab was favored over each other agent in indirect comparisons via the common placebo; the astegolimab/mepolizumab/benralizumab cluster did not differ significantly. Dupilumab remained first across all sensitivity analyses and all three analytic engines, but the complete ranking was not stable. GRADE-CINeMA certainty was moderate for dupilumab and low for the other three agents. Across completed COPD biologic RCTs, dupilumab (in an eosinophil-enriched population) is the most effective agent for reducing moderate/severe exacerbations; astegolimab, mepolizumab, and benralizumab produce smaller, similar reductions of uncertain relative order. The evidence is limited by a star-shaped network (no head-to-head trials; transitivity untestable) and by mixing of eosinophil populations across trials.

VIPoma is a rare pancreatic neuroendocrine tumor characterized by the overproduction of vasoactive intestinal peptide (VIP), typically manifesting as watery diarrhea, hypokalaemia and metabolic acidosis. Its presentation can be atypical, complicating diagnosis. We report the case of a 30-year-old male who initially presented with obstructive jaundice and fatigue, with imaging revealing a pancreatic head mass and liver metastases. Histopathological analysis confirmed a lowgrade pancreatic neuroendocrine tumor. The clinical course was complicated by portal vein thrombosis and metastatic spread. Six months later, the patient developed persistent, refractory watery diarrhea with associated hypokalaemia. Elevated serum VIP levels and Gallium-68 DOTATATE positron-emission tomography and computed tomography (PET-CT) supported the diagnosis of VIPoma. Symptom resolution was achieved with subcutaneous octreotide, followed by transition to monthly long-acting release (LAR) octreotide. Approximately 60% of VIPoma cases are metastatic at the time of diagnosis, as demonstrated in this patient. The case highlighted the diagnostic challenges of VIPoma in the presence of atypical symptoms such as jaundice and absence of initial diarrhea. It also underscores the need for close multidisciplinary collaboration to determine the best course of action and to optimize patient outcomes.

ImportanceImpedance monitoring is a critical component of cochlear implant (CI) surgery, yet the lack of comprehensive longitudinal data limits the development of evidence-based postoperative monitoring guidelines, potentially compromising patient outcomes.ObjectiveTo track impedance trends over 10 years post-implantation, evaluate the effects of electrode design on impedance dynamics, and examine the influence of patient age on impedance behavior.DesignRetrospective cohort study.SettingTertiary medical center.ParticipantsA total of 554 ears underwent cochlear implantation between June 2006 and December 2014; each ear received 1 electrode array from 1 of 6 electrode types.Exposure or InterventionLongitudinal impedance data were analyzed across apical, medial, and basal electrode contacts at 7 time points.Main Outcome MeasuresImpedance trajectories varied by age group, electrode design, and cochlear region, with persistent changes observed up to 10 years.ResultsImpedance increased markedly from intraoperative to first activation in most arrays, although a significant decrease in apical contacts was observed in CI512 adults (P = .0008). Apical and medial contacts generally stabilized or declined thereafter. In contrast, basal electrodes exhibited more heterogeneous patterns, including increases during 12 to 60 months of follow-up and decreases during 60 to 120 months. Compared to PM arrays, LW electrodes showed higher apical impedances, medial impedances that were mostly comparable and time-dependent, and persistently lower basal impedances than CI512. Among LW arrays, CI422 consistently demonstrated the highest impedance, whereas the MED-EL electrode series, Flexsoft exhibited the highest impedance. Overall impedances were higher in early childhood recipients, while adults tended to show higher values in the basal region.ConclusionThis study provides the first decade-long characterization of impedance changes, revealing dynamic variations in electrode impedance across different designs and age groups of cochlear implant recipients.RelevanceThis study highlights the need for long-term monitoring and offering practical guidance for individualized programming and electrode design.

The largemouth bass (Micropterus salmoides [Lacepède, 1802]) is a commercially important aquaculture species, but its production is severely threatened by largemouth bass virus (LMBV), necessitating the development of effective antiviral strategies. Chlorogenic acid (CGA), a natural polyphenol compound, exhibits broad biological activities, but its effect on LMBV infection remains unclear. This study evaluated the effects of CGA on LMBV infection using both in vitro and in vivo experiments. Using LMBV-permissive fathead minnow (FHM) cells as an established in vitro infection model, we found that CGA reduced the transcription and protein expression of the LMBV major capsid protein (MCP). CGA treatment reduced the transcript levels of inflammation-related genes IL-1β, IL-6, IL-8 and TNF-α, both pre and post viral infection. CGA increased the expression of antioxidant-related genes such as Nrf2, SOD, CAT and GPx while decreasing Keap-1 expression. Western blot analysis further confirmed that CGA suppressed the phosphorylation of JNK, ERK and p38. In vivo, largemouth bass were fed diets supplemented with 0 (NC), 200 (L200), 400 (L400) and 600 (L600) mg/kg CGA for 8 weeks. CGA treatment improved growth performance, decreased hepatic MDA levels and increased antioxidant enzyme activity, including CAT, SOD and GPx. The CGA-supplemented groups exhibited lower transcript levels of pro-inflammatory cytokines TNF-α and IL-1β, alongside elevated expression of anti-inflammatory cytokines IL-10 and TGF-β, compared to the NC group. CGA supplementation notably elevated the mRNA expression levels of Nrf2, CAT, SOD and GPx while reducing the mRNA expression level of Keap-1. Dietary CGA supplementation significantly improved survival rates in LMBV-challenged largemouth bass and inhibited LMBV-MCP transcription in the liver, spleen and head kidney. In summary, CGA demonstrates notable anti-LMBV activity in both in vitro and in vivo settings. These effects were accompanied by changes in Mitogen-Activated Protein Kinase (MAPK)-associated proteins and inflammatory- and antioxidant-related responses. Therefore, CGA represents a promising candidate for development as a dietary supplement to control LMBV infection.