Hypersensitivity reactions after cyanoacrylate-adhesive closure of incompetent saphenous veins can range from mild and self-limiting to more severe. In the mild form, they can present as phlebitis-like reactions that are transient and resolve with antihistamines and oral corticosteroids. Although severe reactions are still rare, they have been described several times in the literature before. We describe the case of a foreign body reaction after cyanoacrylate-adhesive closure of a great saphenous vein leading to glue extrusion requiring surgical excision. Consideration of individual patient and anatomic factors is important when deciding on the appropriate method for varicose vein ablation.

Extensive oncologic resection in the maxillofacial region frequently results in functional deficits that compromise oral competence and patient quality of life. The present clinical report describes a patient who underwent commando surgery with partial maxillectomy and reconstruction using a pectoralis major myocutaneous flap following treatment for squamous cell carcinoma. The patient presented with an extensive facial defect, inadequate mouth closure, persistent salivary drooling, tissue exposure and discomfort during routine activities. A custom facial shield prosthesis was fabricated to provide passive external support and protect the reconstructed tissues. A lightweight clear acrylic prosthesis was designed to conform to the postoperative facial contours. Following insertion, the prosthesis provided passive coverage and support of the reconstructed tissues, with satisfactory clinical adaptation and patient-reported acceptance. Because comfort and salivary leakage were assessed only descriptively, these observations were not treated as objective functional outcomes. The primary clinically supported role of the prosthesis was protection of reconstructed tissues during postoperative healing when definitive correction was not feasible.

Herpes simplex virus 1 (HSV-1) establishes life-long latency in peripheral neurons following neuroinvasion, yet the early determinants governing latency versus productive infection remain poorly understood. Available in vitro models bypass the physiological route of infection by directly infecting neuronal cell bodies under antiviral suppression. Here, we established a compartmented axonal infection model that recapitulates HSV-1 neuroinvasion and latency establishment without pharmacological inhibitors. Using primary superior cervical ganglion (SCG) neurons, we demonstrated that low-dose axonal infection consistently establishes latency, whereas higher axonal doses or direct somatic infection led to productive replication. Latently infected neurons exhibit accumulation of the latency-associated transcript (LAT) and can be efficiently reactivated by UV-inactivated virus or VP16 expression. Remarkably, productive infection can be induced during low-dose axonal infection by simultaneous exposure of neuronal cell bodies, but not axons, to replication-deficient virions, implicating tegument delivery in soma overrides latency establishment. Conversely, excess replication-incompetent particles in axons suppress productive outcomes and subsequent reactivations, suggesting competition for retrograde transport. Together, these findings identify axonal entry and transport as critical regulatory checkpoints in HSV-1 latency establishment and suggest that interference with retrograde trafficking may represent a strategy to limit neuroinvasion and life-long reactivations.

Beta-blockers are the cornerstone of first-line therapy for symptomatic obstructive hypertrophic cardiomyopathy (oHCM), whereas mavacamten has recently emerged as an effective disease-specific treatment targeting the underlying hypercontractile state. However, the optimal management of concomitant beta-blocker therapy following mavacamten initiation remains uncertain. Available evidence indicates that beta-blockers do not diminish the favorable effects of mavacamten on left ventricular outflow tract obstruction or symptom relief but may attenuate improvements in exercise capacity due to chronotropic limitation. This work reviews the current evidence regarding beta-blocker use during mavacamten therapy and discusses the pathophysiological mechanisms underlying this interaction. Based on the available data, we propose a practical, physiology-guided approach in which continuation of beta-blockers is reserved for patients with specific clinical indications, including atrial fibrillation requiring rate control, myocardial ischemia, or increased ventricular arrhythmic risk, while cautious dose reduction or withdrawal may be considered in selected patients with persistent chronotropic incompetence after effective relief of obstruction. Prospective studies are needed to define the optimal strategy for integrating beta-blockers with cardiac myosin inhibition in oHCM.

IntroductionThe National Health Service (NHS) in England performs more than 35,000 varicose veins procedures annually to treat superficial venous incompetence (SVI). Around 1 in 10 patients experience significant pain in the first post-procedural week, which frequently affects quality of life (QoL). This feasibility study aimed to assess the effectiveness of routinely prescribed non-steroidal anti-inflammatory drugs (NSAIDs) for pain management following treatment for SVI, and to examine the feasibility of conducting a randomised controlled trial (RCT).MethodsEligible patients undergoing endovenous thermal ablation (EVTA) and/or concomitant phlebectomy for SVI were enrolled. Patients in the intervention group were prescribed Ibuprofen three times daily for five days following treatment. A 1:1 propensity score matched cohort using the nearest neighbour method with a calliper of 0.2 was derived from participants enrolled in a previous trial. Feasibility outcomes included the eligibility rate, recruitment rate, study completion rate, diary completion rate, and intervention adherence rate. Clinical outcomes included daily post-procedural visual analogue scale (VAS) pain scores recorded over seven days and NSAID-related adverse effects documented in patient pain diaries.ResultsOf the 56 patients assessed for study participation, the eligibility rate was 88% (n = 49) and the recruitment rate was 73% (n-36). The study completion rate was 69% (n-25). The diary completion rate was 50% (n = 18). The intervention adherence rate was 6-% (n = 15). There were no statistically significant differences in median pain scores between the two groups. No major NSAID-related adverse effects were reported.ConclusionRoutine post-procedural NSAID use was not associated with a statistically significant reduction in pain following EVTA and phlebectomy for SVI. However, this study demonstrated the feasibility of conducting an adequately powered RCT of NSAIDs for pain management following treatment for SVI and generated data to inform the design of such a trial.

Brain lesions are known to affect cognition, emotions, and behavior, and have been implicated in cases of violence, particularly when involving neural circuits responsible for impulse control, emotional regulation, and judgment. While tumors, traumatic brain injuries, vascular abnormalities, and other types of brain lesions have been associated with psychiatric and behavioral disturbances, cerebral arteriovenous malformations (AVMs) have rarely been linked to psychosis and not with homicidal violence. We present the case of a 14-year-old boy with a large inoperable left parieto-occipital arteriovenous malformation extending into the temporal lobe who developed progressive neuropsychiatric symptoms culminating in psychosis and an explosive and fatal knife attack on neighbors. His developmental course was remarkable for early speech delay, attention deficit hyperactivity disorder (ADHD), oppositional behaviors, emotional dysregulation, severe headaches, and eventual psychotic decompensation characterized by paranoid delusions, disorganized thinking, and behavioral disinhibition. Prior to the homicidal event, neuroimaging showed progression of his AVM with cerebral edema, and John developed a Psychotic Disorder due to a Medical Condition (AVM). After arrest, he was found incompetent to stand trial and eventually placed in a state psychiatric facility. In contrast, his twin brother, raised in the same environment, was developmentally typical and psychiatrically healthy. How brain lesions can contribute to violent acts is a complex topic given the multifactorial origins of aggression. This case report, using a developmental approach, illustrates the connection between focal brain pathology, a cerebral AVM, and homicidal violence in a teenage boy. Treatment approaches, rehabilitation efforts, and legal implications are considered.

ObjectivesIncompetent perforating veins (IPVs) are important contributors to chronic venous disease (CVD), yet their clinical significance remains incompletely understood. This study aimed to evaluate the clinical and ultrasonographic characteristics associated with IPVs in patients undergoing endovenous treatment for varicose veins.MethodsA retrospective analysis was conducted on 192 limbs treated between 2021 and 2025. Limbs were categorized into IPV-positive and IPV-negative groups based on duplex ultrasonography. Clinical severity was assessed using the Clinical-Etiological-Anatomical-Pathophysiological (CEAP) classification. Multivariable logistic regression and receiver operating characteristic (ROC) analysis were performed to identify predictors of IPV presence.ResultsAmong 192 limbs, IPVs were identified in 102 (53.1%). Multivariable analysis identified saphenofemoral junction (SFJ) diameter as an independent predictor of IPV (Odds Ratio [OR]: 1.26; 95% CI: 1.08-1.49; p = 0.005). ROC analysis revealed an optimal cutoff for SFJ diameter of 7.75 mm for predicting IPV (Area Under the Curve [AUC]: 0.646; sensitivity 65.0%, specificity 65.2%). CEAP classification was numerically higher in the IPV-positive group (3.11 vs 2.86), although the difference was not statistically significant (p = 0.379).ConclusionSFJ diameter was independently associated with IPV presence and may serve as a practical ultrasonographic marker for identifying perforator incompetence in patients with varicose veins. Standardized duplex ultrasonography, including assessment of SFJ diameter, may facilitate objective treatment planning.

BackgroundThe role of incompetent perforating veins (IPVs) in varicose veins is controversial. There are different views on the mechanism of "incompetence" and, hence, the importance of IPVs. Those following CHIVA and "haemodynamic surgery" principles suggest higher velocities in the deep veins cause blood to flow inwards due to the Venturi effect. The senior author of this case has previously proposed that increased pressure by muscle activity forces blood out of any IPV, a phenomenon called "active" reflux. This case report appears to show active reflux in an isolated IPV using infrared thermography.MethodsA 34-year-old lady presented with a tender lower leg varicose vein due to an isolated IPV. She was placed supine and still for 10 minutes, then performed 10 plantar- and dorsi-flexions. Next, she stood up and stood still for 10 minutes. Her leg was monitored throughout using an infra-red camera (IFC).ResultsImmediately on lying, the IFC showed the vein, indicating blood flowing out of the IPV from the warm deep compartment into the colder superficial compartment (passive/diastolic or gravitational reflux). Over 10 minutes, the signal reduced significantly, suggesting no more blood was being pumped out through the IPV. During 10 plantar- and dorsi-flexions, the signal returned strongly, indicating blood being pumped out of the IPV once again. On standing, the signal was strong initially, but after 10 min of standing still, the signal had faded, indicating a lack of passive (gravitational) reflux in the IPV.ConclusionThis case suggests that reflux through this IPV is due to muscle activity and not by passive reflux due to gravity. This could explain why IPVs can cause fasciocutaneous damage and/or varicose veins in the lower limb. If correct, failure to identify and treat IPVs during varicose vein surgery would mean that the procedure would be inadequate.

Television medical dramas have long perpetuated a cultural hierarchy among medical specialties, and pathology has been a consistent target. From overtly comedic portrayals of incompetent physicians reassigned to the morgue to subtler character constructions that equate interest in pathology with professional disengagement, these narratives encode and broadcast the assumption that pathology is a lesser specialty - a destination for those who lack the commitment or endurance demanded by "real" clinical medicine. This piece examines the most recent iteration of this trope in the television series The Pitt, in which a medical student's stated interest in pathology is narratively tethered to her willingness to leave the emergency department on time, and contextualizes it within a broader pattern spanning Scrubs, The Good Doctor, Grey's Anatomy, House, and the forensic pathology subgenre. Drawing on workforce data, recruitment literature, and the documented scope of pathology and laboratory medicine - which underpins an estimated 60-70% of all clinical decisions - this article argues that the pathology trope is not merely a harmless fictional convention but an active contributor to the specialty's recruitment crisis, public invisibility, and cultural devaluation. At a time when the United States faces a projected deficit of more than 5000 pathologists by 2030, the cultural signals embedded in prestige television carry measurable consequences for the diagnostic infrastructure of modern medicine.