Archives of The Medicine and Case Reports

Synergistic Impact of Dual Hereditary Protein C and S Deficiency Exacerbated by Acute Pan-Sinusitis in Recurrent Cerebral Venous Sinus Thrombosis: A Case Report

2026-03-11T01:26:52+00:00

Cerebral venous sinus thrombosis is a rare neurovascular emergency characterized by thrombotic occlusion of the dural venous sinuses. While various prothrombotic states predispose individuals to this condition, the concurrent presentation of dual hereditary Protein C and Protein S deficiency is exceptionally uncommon. This dual coagulopathy severely impairs natural anticoagulant mechanisms. We report the case of a 49-year-old male presenting with severe postural dizziness, vertigo, and bilateral lower extremity paresthesia. The patient had a history of a previous cerebral venous sinus thrombosis diagnosed in September 2023, for which he was receiving warfarin. Due to historically variable international normalized ratio levels and new symptoms, a comprehensive re-evaluation was initiated. Neuroimaging confirmed acute extension of the thrombosis involving the superior sagittal, left transverse, and left sigmoid sinuses, alongside an incidental finding of acute pan-sinusitis. To eliminate the confounding effect of warfarin on thrombophilia screening, the patient was bridged to low-molecular-weight heparin for fourteen days prior to testing. Subsequent functional assays confirmed profound deficiencies in Protein C (26 IU/dL) and Protein S (13 IU/dL). Management involved treating the regional pan-sinusitis and a strategic pharmacological transition to rivaroxaban (20 mg daily), resulting in complete clinical stabilization. In conclusion, this case underscores the necessity of rigorous methodological timing in thrombophilia testing and highlights regional inflammation as a potent acute trigger in genetically susceptible individuals. It further demonstrates the long-term viability of direct oral anticoagulants in complex dual inherited coagulopathies.

Incremental Prognostic Value of Systemic Immune-Inflammation Index Over GRACE and TIMI Scores in Acute Coronary Syndrome: A Meta-Analytical Approach

2026-03-16T05:04:59+00:00

Current risk stratification in acute coronary syndrome relies heavily on the Global Registry of Acute Coronary Events (GRACE) and Thrombolysis in Myocardial Infarction (TIMI) scores. These models insufficiently account for systemic inflammatory burden. The Systemic Immune-Inflammation Index has emerged as a promising hematological biomarker to address this gap. A systematic literature search and quantitative meta-analysis were conducted following PRISMA guidelines. Six clinical studies focusing on the Systemic Immune-Inflammation Index and GRACE/TIMI scores in acute atherosclerotic conditions were included. Data were pooled utilizing a random-effects model to calculate the Standardized Mean Difference of index levels between high-risk and low-risk patient cohorts. The pooled meta-analysis demonstrated significantly elevated Systemic Immune-Inflammation Index levels in patients who subsequently experienced Major Adverse Cardiovascular Events compared to those who did not, yielding an overall Standardized Mean Difference of 1.12 (95 percent confidence interval: 0.99 to 1.25, p less than 0.001). Qualitative synthesis revealed that integrating this index into the GRACE and TIMI models yielded significant improvements in the Area Under the Curve, Net Reclassification Improvement, and Integrated Discrimination Improvement metrics. In conclusion, the addition of the Systemic Immune-Inflammation Index to conventional scoring systems significantly improves prognostic accuracy and risk reclassification for patients presenting with acute coronary syndrome. It serves as an accessible biomarker capturing residual inflammatory risk undetected by standard clinical models.

The Prognostic Superiority of Early ΔNLR Variations in Predicting In-Hospital Mortality among Emergency and Ward Patients with COVID-19: A Systematic Review and Meta-Analysis

2026-03-17T04:21:26+00:00

The neutrophil-to-lymphocyte ratio is an established biomarker reflecting systemic inflammation and immune dysregulation. However, single baseline measurements upon hospital admission often fail to capture the highly dynamic immunological trajectory of patients infected with the severe acute respiratory syndrome coronavirus 2. This study aimed to evaluate the prognostic superiority of early variations in the neutrophil-to-lymphocyte ratio, defined as ΔNLR, compared to static baseline measurements for predicting in-hospital mortality among patients admitted to the emergency department and general medical wards. A systematic review and meta-analysis were strictly conducted according to PRISMA guidelines. Data were meticulously extracted from ten selected observational cohort studies. The primary outcome assessed was in-hospital mortality. Standardized mean differences and 95 percent confidence intervals were calculated utilizing a DerSimonian-Laird random-effects model to appropriately account for anticipated clinical heterogeneity. The comprehensive meta-analysis integrated data from 4582 patients across ten independent studies. Both the baseline neutrophil-to-lymphocyte ratio and the early ΔNLR were significantly elevated in non-survivors compared to survivors. However, the early variation in the ratio, measured precisely at 24 to 48 hours post-admission, demonstrated a significantly higher predictive value for in-hospital mortality. The pooled standardized mean difference for baseline measurements between non-survivors and survivors was 0.82 (95 percent confidence interval: 0.61 to 1.03, p less than 0.001). In stark contrast, the pooled standardized mean difference for the early ΔNLR was 1.34 (95 percent confidence interval: 1.05 to 1.63, p less than 0.001), indicating a substantially stronger effect size and superior prognostic discrimination. In conclusion, early dynamic variations in the neutrophil-to-lymphocyte ratio offer superior prognostic value compared to static baseline measurements for predicting fatal outcomes in COVID-19 patients. Integrating kinetic monitoring into emergency and ward triage protocols can significantly optimize early risk stratification.

Re-evaluating Immediate, Adjuvant, and Salvage Intravesical Chemotherapy in Non-Muscle-Invasive Bladder Cancer: A Systematic Review and Meta-Analysis of Gemcitabine Non-Inferiority to Mitomycin C

2026-03-26T01:21:46+00:00

Non-muscle-invasive bladder cancer demonstrates a uniquely high propensity for recurrence following initial transurethral resection of bladder tumor. A single, immediate post-operative instillation of chemotherapy became the established standard to mitigate this risk. Mitomycin C historically functioned as the agent of choice; however, frequent drug shortages and significant local toxicity profiles necessitated the rigorous evaluation of viable alternatives. Gemcitabine, a pyrimidine nucleoside analogue, emerged as a promising candidate. This study aimed to evaluate the comparative efficacy and safety of gemcitabine versus mitomycin C across immediate post-operative, adjuvant, and salvage clinical settings. A systematic review and meta-analysis were conducted in accordance with PRISMA guidelines. The analysis utilized data from seven key comparative trials evaluating gemcitabine versus mitomycin C. A highly specific search strategy isolated direct head-to-head comparative studies. Data extraction focused exclusively on recurrence rates, time to recurrence, and adverse events. Pooled Odds Ratios and Standardized Mean Differences were calculated using a DerSimonian-Laird random-effects model. Sensitivity analyses isolating randomized controlled trials and excluding upper tract urothelial carcinoma data were explicitly performed. Five primary studies provided head-to-head comparative data for recurrence, comprising 405 patients. Two additional studies evaluated sequential salvage therapy. Adjuvant gemcitabine regimens demonstrated a significant reduction in recurrence compared to mitomycin C (Odds Ratio 0.38, 95 percent Confidence Interval 0.19 to 0.75). In strictly immediate single-dose settings, mitomycin C demonstrated a trend toward superior recurrence prevention over gemcitabine (Odds Ratio 1.65). Toxicity analysis heavily favored gemcitabine, showing a significantly lower incidence of chemical cystitis (Odds Ratio 0.22). Sequential salvage therapy yielded a 30 percent to 37 percent long-term recurrence-free survival. In conclusion, gemcitabine demonstrated non-inferiority to Mitomycin C regarding overall oncological safety and exhibited a markedly superior tolerability profile. Mitomycin C retained a marginal advantage in the strict immediate post-operative window due to its potent cell-cycle-independent action. However, Gemcitabine's efficacy in adjuvant settings and favorable side-effect profile established it as a highly rational alternative.

Long-Term Renal Outcomes and Safety Profile of Non-Steroidal Mineralocorticoid Receptor Antagonists in Non-Diabetic Chronic Kidney Disease: A Retrospective Cohort Study

2026-04-02T05:43:12+00:00

Non-steroidal mineralocorticoid receptor antagonists, specifically finerenone, have demonstrated profound cardiorenal protective effects in diabetic kidney disease. However, their efficacy and safety in non-diabetic chronic kidney disease remain inadequately characterized, particularly within Southeast Asian populations experiencing high rates of hypertensive nephrosclerosis. A retrospective cohort study was conducted at a tertiary hospital in Makassar, Indonesia, evaluating 148 adult patients with non-diabetic chronic kidney disease (stages 3-4) who received finerenone between January 2022 and December 2024. Clinical data, including urinary albumin-to-creatinine ratio (UACR), estimated glomerular filtration rate (eGFR), and serum potassium, were analyzed using generalized and piecewise linear mixed-effects models over 24 months. The cohort (N=148) demonstrated a significant reduction in median UACR from a baseline of 845 mg/g to 460 mg/g at 24 months (p < 0.001). Following an initial hemodynamic eGFR dip in the first six months, the chronic annualized slope of decline stabilized at -2.2 mL/min/1.73 m² per year (95% CI: -2.8 to -1.6). Mild hyperkalemia occurred in 16.2% of patients, and moderate-to-severe hyperkalemia in 4.1%. Concomitant sodium-glucose cotransporter-2 inhibitor (SGLT2i) use was associated with a lower risk of incident hyperkalemia (OR 0.45, 95% CI 0.22-0.89). In conclusion, in this real-world observational cohort, adding finerenone to standard care in non-diabetic CKD patients was associated with significant reductions in UACR and an attenuation of eGFR decline over 24 months, alongside a manageable safety profile. These findings warrant further investigation in large, randomized trials.

Inverse Association between Platelet-to-Lymphocyte Ratio and Clinical Severity in Pediatric Dengue Infection: A Retrospective Cross-Sectional Analysis at Wangaya Hospital, Indonesia

2026-04-06T08:30:50+00:00

Dengue heavily burdens endemic regions. Early prediction of disease progression in pediatric populations is critical for optimizing outcomes. This study evaluates the Platelet-to-Lymphocyte Ratio (PLR), an emerging inflammatory marker, as a correlative biomarker of clinical severity in pediatric dengue. A retrospective cross-sectional analysis included 139 pediatric patients with confirmed dengue at Wangaya Regional General Hospital, Denpasar, Indonesia. Patients were classified using 2009 World Health Organization criteria into Dengue Fever (DF), Dengue with Warning Signs (DWS), and Severe Dengue (SD). Hematological parameters were obtained strictly during the critical transition phase. Statistical analyses included Kruskal-Wallis tests, Spearman correlation, Receiver Operating Characteristic (ROC) curve analysis, and Ordinal Logistic Regression. The cohort, primarily school-aged children (92.1%), presented with 11.5% DF, 73.4% DWS, and 15.1% SD. A statistically significant, weak-to-moderate inverse correlation existed between the admission PLR and clinical severity (r = -0.293, p < 0.001). The median admission PLR declined progressively from 78.1 in DF, to 59.8 in DWS and further to 24.3 in SD. ROC analysis discriminating Severe Dengue yielded an Area Under the Curve of 0.685. Regression confirmed the PLR as an independent, modest correlative factor when adjusting for age, sex, and fever onset day. In conclusion, a statistically significant, weak-to-moderate inverse association exists between admission PLR and pediatric dengue severity. While offering accessible pathophysiological insights, its moderate diagnostic accuracy limits its use as an isolated triage tool. The PLR may assist early risk stratification in resource-limited settings when utilized alongside standard clinical assessments.