International Journal of Medical Students (IJMS)
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The Intersection of Rheumatology and Cardiology: Cardiac Disease in Rheumatic Disorders within Palestinian patients between 2022-2024, A Retrospective Cohort Study
Full text linkBackground: Rheumatologic and cardiovascular conditions are major causes of morbidity and mortality. Recent research has shown a close association between them. As cardiac manifestations in the Palestinian population remain uncharacterized, the current study aims to investigate the proportion of cardiac manifestations in rheumatologic disease patients from Palestine and to determine the factors associated with these manifestations.
Methods: A retrospective cohort was conducted on rheumatology patients, at Al-Makassed Hospital from 2022 to 2024. Data was collected from electronic records for 296 patients. Cardiovascular manifestations were recognized through echocardiography and consultation reports. Analysis using SPSS version 26 was performed to determine the association between patients\u27 characteristics and the cardiac manifestations.
Data included demographics (age, gender), previous chronic diseases; especially regarding rheumatologic condition; age at diagnosis; cardiac manifestations; imaging reports, laboratory information, lipid profile, comorbidities and risk factors.
Results: Of the 296 patients, 71.6% were females, with an average age of 49.2 ± 15.5 years. The most common rheumatic diseases were seronegative spondyloarthropathy (25.1%), rheumatoid arthritis (RA) (18.1%), and systemic lupus erythematosus (SLE) (11.1%). The proportion of clinically recognized cardiac disease was 17.9%; whereas 16.6 percent of participants had obesity and 9.8 percent had an addiction to cigarettes. Among comorbidities other than rheumatologic diseases, hypertension (30.4%) and diabetes mellitus (19.9%) were the most common. Cardiac disease was significantly associated with older age, diabetes mellitus, hypertension, coronary artery disease, positive troponin, and positive CK-MB (p < 0.05). Meanwhile, no significant associations with gender, specific rheumatic conditions, or lipid profile were observed.
Conclusion: This is the first research from Palestine that studies cardiac involvement and its burden on rheumatology patients. The study identified seronegative spondyloarthropathy, rheumatoid arthritis, and systemic lupus erythematosus as the predominant rheumatological diseases, with an average age of diagnosis at 45 years. Hypertension, diabetes, and cardiac disease were commonly observed comorbidities. This population exhibits a heightened risk of subclinical myocardial injury with increasing age.
Integrated cardio-rheumatology care is advocated to support screening, risk assessment, and management of these patients; as systemic inflammation, seropositivity, and long disease duration play a dominant role in cardiovascular risk, especially in populations with low proportion of traditional risk factors (e.g.: smoking). This underscores the importance of integrating inflammatory markers and serologic status into CVD risk assessment tools for rheumatology patients. Furthermore, given the potential for subclinical myocardial injury, incorporating biomarkers such as CK-MB and troponin into routine monitoring may enable earlier detection of cardiac involvement. Future research in regional populations should aim to refine screening protocols—potentially including periodic echocardiography, carotid ultrasound, and biomarker testing— and guide preventive interventions.
There’s also a need for studies examining the effects of disease-modifying treatments on cardiovascular disease outcomes in patients with at-risk rheumatic diseases, studies employing early intervention techniques of anti-atherosclerotic drugs such as aspirin, statins, and angiotensin converting enzyme inhibitors in patients with diseases such as SLE and RA. And large-scale, population-based research is needed to specify the prevalence and patterns of cardiovascular manifestations in regional population.
Impact of War on Burnout among Medical Students at Al-Neelain University in Sudan, 2024
Full text linkBackground: Burnout, characterized by emotional exhaustion, depersonalization, and a reduced sense of personal accomplishment, is relatively frequent among medical students due to the demanding nature of medical education. In conflict zones, such as Sudan, the challenges are exacerbated by war, which disrupts training and increases psychological stress. Despite its potential long-term consequences on individuals and healthcare systems, burnout among medical students in these settings remains underexplored.
Aim: This study aimed to assess the prevalence of burnout among medical students at Al-Neelain University in Sudan, with a focus on the impact of war on burnout levels. Additionally, it evaluated the students\u27 coping mechanisms and resilience in overcoming the challenges posed by conflict and academic disruptions.
Methods: A cross-sectional study was conducted among 259 medical students at Al-Neelain University, selected using a stratified sampling technique. Data were collected through an online, close-ended questionnaire comprising three sections: sociodemographic and training-related questions, a burnout assessment using the Maslach Burnout Inventory-Student Survey (MBI-SS), and an evaluation of resilience using the Brief Resilient Coping Scale (BRCS). The data collected were analyzed using Microsoft Excel and the Statistical Package for the Social Sciences (SPSS).
Results: Of the total of 259 medical students at Al-Neelain University, the prevalence of burnout using the two-dimensional definition was 18.5%, while 8.1% met the criteria for three-dimensional burnout. High emotional exhaustion and cynicism were observed in 31.7% and 32.8% of students, respectively, whereas 30.1% had low academic efficacy. Burnout was significantly associated with poor academic performance, inadequate social support, and limited internet access (p < 0.001). The Brief Resilient Coping Scale (BRCS) showed that only 19.3% of students had high resilience coping, while 45.9% had low resilience coping. Resilience showed a statistically significant moderate positive correlation with academic efficacy (r = 0.487, p < 0.001) and a weak negative correlation with cynicism (r = -0.226, p < 0.001). While burnout had a limited direct impact on clinical training for fifth-year students, conflict-related disruptions, such as reduced access to hospitals and inconsistent mentorship, posed significant challenges to their educational experiences.
Conclusion: Medical students at Al-Neelain University exhibited an alarming prevalence of burnout, compounded by academic and conflict-related challenges. It demonstrated the urgent need for interventions to reduce burnout, enhance resilience, and improve resource access, which are essential to support students\u27 well-being and ensure training continuity, especially in conflict zones like Sudan.
Table 1. Prevalence of Burnout, sub-scales, levels among medical students at Al-Neelain University (n=259).
Frequency (n)
Percent (%)
Emotional Exhaustion (High)
82
31.70%
Cynicism (High)
85
32.80%
Amyloidosis – A Rare Complication of Long-Evolving Rheumatoid Arthritis. A Case Report
Full text linkBackground: Amyloidosis consists of a diverse spectrum of medical conditions, defined by the accumulation of fibrillar proteins in a beta-sheet configuration in different tissues. Reactive amyloidosis (AA), previously known as secondary amyloidosis, can appear as a complication of chronic inflammatory diseases, such as rheumatoid arthritis. In present times, the use of biological therapies has decreased its prevalence, but it remains a considerable threat for patients, as its main target is the kidney, with progression towards renal failure. Light chain amyloidosis (AL) is a primary form of the disease, involving plasma cell clones in the bone marrow, and has been reported in patients with rheumatoid arthritis, constituting an important differential diagnosis. Herein, we present the case of AA amyloidosis in a patient with a long evolution of rheumatoid arthritis, highlighting its diagnostic difficulties.
The Case: A 55-year-old woman presented to our clinic with mild arthritic pain in the hands, fatigue and hyperpigmentation on the dorsal side of her forearms, associated with itching. Rheumatoid arthritis is present in her medical history, having been diagnosed 15 years prior. Her medication included Metotrexate for three years, interrupted due to digestive intolerance, followed by Sulfasalazine to the current presentation. Physical exam highlighted obesity, the skin lesions on the forearms and a positive Gaenslen sign bilaterally. Biologically, an important inflammatory syndrome was discovered, alongside a very high rheumatoid factor (FR). These have been persisting for a number of years, prompting several past investigations to identify its cause. A serum protein electrophoresis with immunofixation was negative for monoclonal bands, but serum light chains kappa and lambda were slightly elevated. Histopathological analysis of a biopsy from abdominal fat revealed apple-green birefringence in polarized light with Congo red staining, leading to the diagnosis of amyloidosis. Infection and cancer were ruled out after extensive investigations. Taking into account the lack of renal manifestations, the relatively poorly controlled rheumatoid arthritis and the very slight elevation of serum light chains, this was interpreted as reactive amyloidosis. Treatment was promptly switched to Leflunomide and the patient will be evaluated for treatment with anti-TNF biological therapies.
Conclusion: Amyloidosis can constitute a life-threatening complication to long-evolving chronic inflammatory diseases, such as rheumatoid arthritis. As no therapies that target amyloidosis specifically are available as of yet, management involves strict control of the underlying inflammatory condition, making early detection critical. This case highlights the diagnostic challenge this rare complication poses, as AL amyloidosis might also be considered, and the importance of controlling rheumatoid arthritis both clinically and biologically, in order to prevent its development.
Parameters
Unit
Value
Reference values
C-reactive protein
mg/dL
8.37
< 0,5
Rheumatoid Factor
UI/mL
140.2
< 14
Erythrocyte sedimentation rate
mm/h
67
< 30
Serum light chain lambda
mg/L
28.4
5.71 - 26.3
Serum light chain kappa
mg/L
34.62
3.3 – 19.4
Table 1: Laboratory Results at First Day of Hospitalization
The Lupus You Didn\u27t See Coming: Secondary Evans Syndrome with Fulminant Autoimmune Myocarditis in a Young Woman
Full text linkBackground: Some cases in medicine feel like a thriller, where every test, every symptom, and every intervention builds suspense. We present a young woman whose illness unfolded like a high-stakes medical drama: chest pain, cardiogenic shock, hemolysis, and mystery antibodies all converging in a race against time.
The Case: A 25-year-old female arrived at the emergency room with seven days of dragging left-sided chest pain radiating to the neck, back, and arms, accompanied by shortness of breath (NYHA II–III), palpitations, sweating, orthopnea, and facial puffiness. One day prior, she developed black stools and non-bilious vomiting. On arrival, she was in cardiogenic shock, requiring noradrenaline infusion.
ECG revealed ST-elevation in aVR with global ST-depression, and echocardiography demonstrated global hypokinesia with moderate left ventricular dysfunction. Labs were dramatic: hemoglobin 6 g/dL, highly elevated troponin I, deranged liver function tests, unconjugated hyperbilirubinemia, positive direct Coombs test, and low complement levels (C3 and C4).
Immediate management included intravenous steroids, multiple blood transfusions, and plasma exchange. Serology revealed strong anti-histone antibody positivity with a completely negative ANA profile (anti-dsDNA, anti-Sm, anti-RNP). Coronary angiography was normal, confirming myocarditis as the source of troponin elevation. Ultrasound showed hepatosplenomegaly, and history uncovered a recent mismatched blood transfusion, complicating the hemolytic picture.
Through rapid multidisciplinary coordination including critical care, cardiology, hematology, rheumatology, and nephrology, the patient stabilized, hemoglobin improved, and she was discharged on a carefully tailored immunosuppressive regimen.
Conclusion:This case is a diagnostic rollercoaster. Anti-histone positivity initially suggested drug-induced lupus, yet hypocomplementemia, secondary Evans syndrome, and fulminant myocarditis pointed toward an atypical or early-onset SLE. The presentation mimicked acute coronary syndrome, adding urgency and tension. It underscores that anti-histone antibodies should never be interpreted in isolation, and highlights the importance of integrating clinical, serological, and imaging data in complex autoimmune syndromes.
Some patients turn the ER into a thriller. Fulminant autoimmune disorders can masquerade as common emergencies, putting lives at immediate risk. Early recognition, rapid multidisciplinary intervention, and careful interpretation of serology are the keys to survival and successful outcomes. This is an incredibly rare presentation of anti-histone positive lupus, with ours being the second reported case in literature
Polypharmacy and Outcomes in Elderly Patients with Heart Failure: A Meta-Analysis
Full text linkBackground: Polypharmacy, commonly defined as the use of five or more medications, is highly prevalent among elderly patients with heart failure. While guideline-directed therapy improves survival, excessive or inappropriate medication use may increase mortality, hospitalization, and treatment burden.
Aim: This study aimed to evaluate the association between polypharmacy and clinical outcomes in elderly patients with heart failure, including mortality, hospitalization, and quality of life.
Methods: We conducted a systematic literature search in PubMed, Cochrane, and Scopus to identify observational studies assessing the impact of polypharmacy (defined as ≥5 medications) on elderly patients (≥65 years) with heart failure. Search strategies combined keywords (e.g., "heart failure", "polypharmacy") and subject headings (e.g., MeSH). The initial search yielded a total of 1,082 records. Studies were excluded if they were narrative reviews, case reports, or did not report quantitative outcomes of interest, such as mortality or hospitalization rates. After removing duplicates, titles and abstracts were screened based on predefined inclusion criteria. Following a full-text review of potentially eligible articles, 38 studies were included in the final systematic review, representing a pooled population of >250,000 participants. Of these, 11 studies provided sufficient quantitative data as Hazard Ratios with 95% Confidence Intervals and were included in the final meta-analysis for mortality and hospitalization. Findings from the remaining studies were synthesized narratively. Two reviewers independently screened, extracted data, and assessed study quality. A random-effects model was used to pool hazard ratios (HRs) and 95% confidence intervals (CIs). Statistical heterogeneity was assessed using the I2 statistic. Subgroup analyses were performed by medication type (heart failure–specific vs. non-cardiovascular), setting (community vs. hospital), and frailty status.
Results: Polypharmacy was present in >70% of elderly patients with heart failure, with hyper-polypharmacy affecting 20–30%. Our pooled analysis, visualized in the accompanying forest plot (Figure 1), demonstrated increased all-cause mortality with polypharmacy (HR 1.38, 95% CI 1.25–1.60) and greater risk with hyper-polypharmacy (HR 2.29, 95% CI 1.80–2.70). Hospitalization risk was also elevated (HR 1.22, 95% CI 1.05–1.41; P=0.009), particularly when non-cardiovascular medications predominated. In contrast, studies examining guideline-directed medical therapy (GDMT) showed that appropriate polypharmacy could mitigate risk and improve survival, especially in HFpEF and HFmrEF populations. Quality of life outcomes were inconsistent, with most studies reporting no significant association; modest improvements were observed when inappropriate medications were discontinued. Frailty amplified risks of mortality and functional decline.
Conclusion: Polypharmacy in elderly heart failure patients is associated with higher mortality and hospitalization, particularly in the presence of frailty or inappropriate prescribing. However, polypharmacy driven by GDMT may confer survival benefits, underscoring the importance of medication appropriateness. Targeted deprescribing interventions and phenotype-specific management may reduce harm and improve outcomes in this vulnerable population
Opportunities for Climate-Sensitive Work in the Health Sector - Kenya and Germany in Focus
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Background: Healthcare systems around the world are facing unprecedented challenges as concerns about climate change and its widespread effects intensify. The healthcare sector has two big problems: it is very vulnerable to the health effects of climate change and yet it contributes significantly to greenhouse gas emissions. Therefore, transitioning to climate-sensitive healthcare is a top concern for the whole world. However, implementation differs significantly across various economic and geographical contexts. This study aimed to identify and compare opportunities for climate-sensitive work in the health sectors of Kenya and Germany.
Methods: The study employed a qualitative approach, using a combination of field observations and expert interviews between July and September 2025. Data was collected over four-week periods at Kenyatta National Hospital (KNH) in Nairobi, Kenya, and Charité – Universitätsmedizin in Berlin, Germany. Methods included structured field observations across six key categories (energy, mobility, nutrition, supply chains, waste management, and digitalization) and in-depth, semi-structured expert interviews with medical students and hospital staff. Interview transcripts and observational notes were analyzed using thematic analysis.
Results: KNH demonstrated inherent low-carbon practices like passive cooling, local food sourcing with minimal packaging, and high reuse of materials including food waste. It however, faced systemic barriers including heavy reliance on fossil fuels, budget constraints, and inadequate waste recycling. Charité utilized energy-efficient infrastructure and efficient public transport but struggled with high food waste from individual packaging and perceived inefficiencies in waste sorting. Both institutions were making efforts towards digitalization especially in patient records. A significant knowledge-attitude-practice gap was identified; healthcare professionals and students in both countries expressed strong interest but reported a lack of formal education on climate-health interlinkages.
Conclusion: High-income healthcare systems can learn resource-efficient practices from low-income settings. Health care sectors in low and middle-income countries can adopt technological advancements from the former. Overcoming shared barriers such as educational gaps is crucial. These findings underscore the critical need for tailored interventions, cross-context learning, and integrating planetary health education into the core of medical training and hospital management
Genetically Confirmed Schwartz–Jampel Syndrome: An Ultra-Rare Case of Congenital Myotonia with Osteochondrodysplasia from India
Full text linkBackground: Schwartz–Jampel syndrome is a rare autosomal recessive disorder caused by mutations in the HSPG2 gene, leading to perlecan deficiency. Perlecan is a heparan sulfate proteoglycan critical for cartilage integrity, basement membrane stability, and neuromuscular transmission. The disorder manifests with skeletal dysplasia and persistent myotonia, while cognition and lifespan are usually preserved. Only about 150 cases have been reported worldwide. We report a four year old child with severe osteochondrodysplasia and generalized myotonia, highlighting the therapeutic benefit of botulinum toxin A in managing both blepharospasm and perioral myotonia.
The Case: A male neonate, born full term to consanguineous parents, was referred on day one of life with suspected skeletal dysplasia. Birth weight was 3.0 kg (−0 to +1 SD), with macrocephaly (>+2 SD) and short length (<−3 SD). Dysmorphic features included a narrow thorax, bent femora and tibiae, retrognathia, long philtrum, and ichthyosis. Infantogram revealed rhizomesomelia with irregular metaphyses of long bones.
At four years, he presented with gross motor delay due to sustained skeletal muscle contractions, failure to thrive, and gait difficulty. Anthropometry remained <−3 SD for height, weight, and head circumference. Examination showed generalized myotonia of facial and skeletal muscles, pursed lips, micrognathia, thoracic kyphosis, hip abduction deformities, and hypertrophied muscles. Neurological assessment revealed hypertonia with areflexia, while speech and cognition were preserved. The differential diagnosis includes muscular dystrophies, skeletal dysplasias, myotonic disorders, congenital myopathies, and cramp–stiffness syndromes such as stiff person syndrome and Isaac’s syndrome. However, the coexistence of osteochondrodysplasia with persistent myotonia, supported by whole exome sequencing which revealed a homozygous likely pathogenic variant in the HSPG2 gene (c.5014+2T>C), confirmed the diagnosis. Parental carrier testing showed that both parents were heterozygous carriers of the mutation.
Management included carbamazepine and regular physiotherapy, which provided partial benefit. To address disabling blepharospasm and perioral myotonia that impaired feeding, botulinum toxin A injections were administered to the orbicularis oculi and orbicularis oris. This improved both vision and feeding ability, demonstrating an effective extension of botulinum toxin use in this condition. Parents were counseled regarding malignant hyperthermia risk with anesthesia and advised genetic counseling for future pregnancies.
Conclusion: Schwartz–Jampel syndrome should be suspected when skeletal dysplasia coexists with generalized myotonia, particularly in children of consanguineous unions. Supportive management includes physiotherapy and anticonvulsants, and botulinum toxin A, though primarily used for blepharospasm, can also enhance feeding through perioral muscle relaxation. Prognosis is generally favorable, as symptoms stabilize after adolescence and cognition remains intact. However, morbidity arises from progressive contractures and skeletal dysplasia, speech and feeding difficulties from facial and oropharyngeal myotonia, restrictive lung disease due to a narrow thorax, and the psychosocial burden of visible deformities with reduced mobility. Early recognition, multidisciplinary care, and family counseling, including genetic counseling for future pregnancies, are essential to optimize outcomes in this rare disorder
Effects of Blood Pressure Variability and Its Association With Dementia and Cognitive Impairment: A Systematic Review
Full text linkBackground: This systematic review aimed to assess the relationship between blood pressure, cognitive function, and the potential for dementia in individuals with hypertension or at risk of developing hypertension.
Methods: The review adhered strictly to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. A comprehensive search was conducted in databases, including PubMed, Research Gate, Google Scholar, and Science Direct. The inclusion criteria required studies that examined the association between blood pressure variability and the occurrence or progression of dementia and cognitive impairment. Two independent reviewers evaluated each study\u27s quality and potential bias using study-specific tools before inclusion.
Results: There were 17 studies, including four systematic reviews and meta-analyses, four randomized controlled trials, and nine observational studies, with 16,985,492 participants. The findings indicated that late-life blood pressure had a stronger association with cognitive function than midlife blood pressure. Hypertension was linked to an increased risk of all-cause dementia, Alzheimer\u27s disease, and vascular dementia. Anti-hypertensive medications could reduce the risk of dementia or cognitive impairment, although the specific type of medication did not significantly affect overall cognitive performance. A significant limitation of this review was the heterogeneity in diagnostic criteria, cognitive assessment tools, and imaging techniques used among the studies, which limited direct comparisons and conclusive findings.
Conclusion: Blood pressure variability emerged as a potential predictor for cognitive impairment. Implementing strategies to reduce blood pressure variability may help mitigate the risk of dementia and improve cognitive outcomes in vulnerable populations
