A person in their twenties, assigned male at birth and diagnosed with gender incongruence, underwent gender-affirming surgery (GAS) after starting hormone therapy. Orchiectomy, penectomy, labiaplasty and vaginoplasty were planned. The preoperative evaluation revealed no contraindications to general anesthesia. Induction was performed with sevoflurane, propofol, fentanyl, remifentanil, and rocuronium. Cefazolin was administered as a prophylactic antibiotic. After bilateral orchiectomy, the patient developed rapidly worsening urticaria, wheezing, decreased oxygen saturation and hypotension. Anaphylaxis was diagnosed, and emergency treatment stabilized respiratory and circulatory function. Because the cause was unknown, the operation was paused. The patient was moved to the intensive care unit. Symptoms resolved within hours and the patient was discharged on the second postoperative day. Subsequent allergy testing, including prick and intradermal tests for anesthetics and antibiotics, revealed a positive intradermal response to remifentanil, which identified it as the cause. After detailed counseling, the patient and their family strongly wished to complete GAS, and reoperation was performed without remifentanil. The postoperative course was uneventful.

Major earthquakes may alter dermatological needs through physical injury, disruption of living conditions, and psychological stress. We investigated dermatological needs after the 2026 Kumamoto earthquake. This retrospective observational study included patients from eight severely affected municipalities who visited our dermatology clinic during the first 10 clinic days after the earthquake and a subsequent 12-clinic-days period. Outpatient attendance and selected dermatologic conditions were compared with those during the corresponding periods in 2025. During the first 10 clinic days, the number of patients from the eight municipalities decreased from 1670 in 2025 to 1030 in 2026 (38.3% reduction). Forty patients presented with earthquake-related traumatic injuries, and 19 presented with burns. Acute urticaria (2.5% vs. 1.3%, p = 0.021), herpes zoster (1.7% vs. 0.5%, p = 0.001), and exacerbations of atopic dermatitis (3.1% vs. 0.9%, p < 0.001) were significantly more frequent in 2026 than in 2025, whereas herpes simplex showed no significant difference. These findings indicate that the post-earthquake dermatologic needs include not only traumatic injuries and burns but also stress-related dermatoses, thus highlighting the potential role of dermatologists in multidisciplinary disaster medical care.

Montelukast is a selective cysteinyl leukotriene receptor 1 antagonist with an established, though nuanced, role in the management of asthma and allergic rhinitis. By inhibiting leukotriene-mediated signaling, montelukast targets a pathway involved in bronchoconstriction, mucus secretion, vascular permeability, eosinophil recruitment, cytokine release, and airway remodeling. Available evidence indicates that montelukast may reduce several markers of allergic inflammation, including fractional exhaled nitric oxide, peripheral and tissue eosinophilia, eosinophil-derived mediators, adhesion molecules, selected cytokines, and markers related to airway remodeling. These effects are most consistently demonstrated in asthma and allergic rhinitis, while evidence in chronic urticaria, atopic dermatitis, and other inflammatory conditions remains limited or exploratory. Montelukast's once-daily oral administration and age-adjusted pediatric formulations make it a practical option in selected children, particularly when inhaled therapy is difficult or adherence is problematic. However, montelukast should not be regarded as a direct substitute for corticosteroid-based anti-inflammatory therapy. Current evidence and guideline positioning support its use mainly as an add-on controller, or an alternative when more efficacious treatment is contraindicated. The benefit-risk balance is further shaped by concerns regarding neuropsychiatric adverse events, especially in children, although evidence remains heterogeneous. Current data show no increased risk of severe, diagnostically coded neuropsychiatric events, yet milder sleep-related and behavioral symptoms are consistently reported, so that caution and active monitoring remain warranted. Overall, montelukast remains a biologically plausible and clinically useful therapy, but its value depends on appropriate patient selection and realistic expectations of its anti-inflammatory potential.

Hereditary angioedema is a bradykinin-mediated genetic disorder increasingly controlled with effective long-term prophylaxis. In a phase 3 trial, a single dose of lonvoguran ziclumeran, an in vivo CRISPR-Cas9 therapy targeting KLKB1, significantly reduced attack rates. This approach represents a highly promising therapeutic strategy for HAE. However, it also raises important questions that require further investigation.

Hereditary angioedema (HAE) attacks are recurrent, debilitating, and potentially life-threatening. Across the clinical program, garadacimab long-term prophylaxis demonstrated early onset and durable, sustained protection against HAE attacks and clinically meaningful improvements in health-related quality of life (HRQoL). HAE treatment goals include total disease control (attack-free) and normalization of life. Predicting treatment effect may aid shared decision-making and choice of long-term prophylaxis. Here, we report an attack-free probability model predicting garadacimab treatment effect beyond available Phase 3 clinical data and explore the relationship between HRQoL and attack-free duration. A generalized mixed-effect Poisson model was developed and validated with data from the garadacimab pivotal Phase 3 (VANGUARD) and Phase 3 open-label extension studies. Efficacy variables, including attack-free probabilities, were predicted for simulated populations of garadacimab-treated patients and assessed for goodness of fit. Analysis of covariance was used to assess the relationship between Angioedema Quality of Life questionnaire scores and attack-free duration. Model-predicted efficacy variables adequately reflected observed clinical data with high goodness of fit (Nakagawa-Schielzeth conditional R[2]: 74.3%). Following a 1-month attack-free period after garadacimab initiation, patients had a 60% cumulative probability of remaining attack-free up to Month 25 and 49% up to 5 years. HRQoL improved with increasing duration of attack-free periods, reaching minimal to no impairment after 6 months. This attack-free probability model suggests long-term effects of garadacimab over a 5-year treatment period. Patients treated with garadacimab have the potential to live attack-free for long periods of time, with substantial HRQoL improvements.

This cross-sectional observational study was conducted at the Department of Immunology, Armed Forces Institute of Pathology/ CMH / NUMS, Rawalpindi, Pakistan, from September 2021 to December 2024. It aimed to identify the frequency of common presentations, triggers, and prodromes of hereditary angioedema (HAE) in the Pakistani population. Fifty HAE cases were screened using a specially designed questionnaire. The most common symptom was abdominal pain (92%), followed by swelling of hands and feet (66%), eyelids (60%), lips (58%), face (56%), laryngeal oedema (56%), and genital swelling (28%). Common triggers included food (42%), stress (42%), infection/fever (34%), trauma/surgery (22%), and fatigue (20%). The most frequent prodrome was discomfort at the site of swelling (64%), followed by tingling (36%), nausea (22%), asthenia (16%), fatigue (16%), and rash (4%). HAE is underdiagnosed in Pakistan due to limited awareness and diagnostic facilities. Recognising its clinical features is essential for early diagnosis, management, and improved outcomes. Key Words: Clinical features, C1 esterase, C4 levels, Hereditary angioedema, Prodromes, Triggers.