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Background Central sleep apnea (CSA) is a recognized complication of opioid use, yet its occurrence in individuals using subtherapeutic and/or inconsistent doses of buprenorphine-naloxone remain underreported. This case highlights the development of severe CSA in a patient with opioid use disorder despite only partial adherence to a subtherapeutic maintenance dose of buprenorphine-naloxone. Additionally, our case report demonstrates the efficacy during the ASV titration study and subsequent intolerance to ASV and full face/ hybrid mask in treating coexisting CSA and obstructive sleep apnea (OSA) and discusses phrenic nerve stimulation (PNS) as an alternative therapy in cases of ASV non-compliance. Case presentation A 43-year-old male with a history of opioid use disorder was inconsistently using a self-reduced subtherapeutic maintenance dose of buprenorphine-naloxone of 2 mg/0.5 mg daily when he presented with excessive daytime sleepiness and witnessed apneas. The diagnostic portion of the split-night polysomnogram (PSG) revealed severe OSA with an obstructive AHI of 44.1 events/hour of sleep and severe CSA with a central apnea index of 67.6 events/hour of sleep, with approximately 60% of all events being central events. Standard therapies, including CPAP and BPAP, failed to control either his central or obstructive sleep apnea. While ASV achieved optimal resolution of both OSA and CSA during the ASV titration study, the patient later developed intolerance to both the ASV pressure settings and the mask interface despite adjustment of the pressure settings and switching from full face mask to hybrid mask respectively. This led to poor adherence, recurrence of symptoms, and eventual consideration for PNS as an alternative treatment approach. Conclusions Our case highlights the risk of CSA in patients who are using subtherapeutic or inconsistent doses of buprenorphine-naloxone. It also highlights that ASV can be highly effective in managing opioid-related CSA, but intolerance to pressure or mask interface may limit long-term use. In such cases, PNS represents a promising alternative. Clinicians should maintain a high index of suspicion for CSA in patients with opioid use disorder, regardless of buprenorphine-naloxone dose or adherence pattern.

Introduction: The incidence of brucellosis in Armenia in 2010 was twice as high as in other countries of the Caucasian region and has almost doubled over the last three decades. This study aimed to investigate factors associated with acute or chronic forms of presentation of human brucellosis. Methodology: Retrospective study using data from medical records of 455 patients hospitalized for the first time at the Nork Republican Infectious Disease Referral Hospital in Yerevan, Armenia between the years 2006 and 2016. We undertook descriptive analysis of cases, compared acute and chronic cases, and identified factors associated with acute and chronic cases using regression. Results: The majority of brucellosis cases had acute case presentation (73.0%), were males (70.3%), between the ages of 20-60 years (66.2%) and unemployed (89.9%). About two-thirds of cases reported a history of consumption of raw unpasteurized milk. The multivariate analysis revealed that factors associated with the form of brucellosis were age, symptom duration preadmission, fever, antibody titer, and hospitalization outcomes. Conclusion: This study revealed that brucellosis is unevenly distributed across different age groups, as well as regions of Armenia. Affected individuals did not seek medical attention after the onset of the symptoms for about 2 months. Therefore, the targeted educational campaigns could be of crucial importance to prevent the disease in humans, contribute to its early diagnosis and treatment.

Prior models of well-being have focused on resolving issues at different levels within a single institution. Changes over time in medicine have resulted in massive turnover and reduced clinical hours that portray a deficit-oriented system. As developments to improve purpose and professional satisfaction emerge, the Texas Medical Association Committee on Physician Health and Wellness (PHW) is committed to providing the vehicle for a statewide collaboration and illuminating the path forward. To describe the existing health and wellness resources in Texas academic medical centers and understand the gaps in resources and strategies for addressing the health and wellness needs in the medical workforce, and in student and trainee populations. Various methods were utilized to gather information regarding health and wellness resources at Texas academic medical centers. A survey was administered to guide a Think Tank discussion during a PHW Exchange, and to assess resources at Texas academic medical centers. Institutional representatives from all Texas learning health systems were eligible to participate in a poster session to share promising practices regarding health and wellness resources, tools, and strategies. Survey responses indicated a need for enhancing wellness program components such as scheduled activities promoting health and wellness, peer support networks, and health and wellness facilities in academic medical centers. Answers collected during the Think Tank discussion identified steps needed to cultivate a culture of wellness and strategies to improve and encourage wellness. The Texas Medical Association Committee on Physician Health and Wellness and PHW Exchange provided a forum to share best practices and identify gaps therein, and has served as a nidus for the formation of a statewide collaboration for which institutional leaders of academic medical centers have affirmed the need to achieve the best result.

Background Giant cell tumor of bone (GCT) is a rare primary bone tumor, which can metastasize and undergo malignant transformation. The standard treatment of GCT is surgery. In patients with unresectable or metastatic disease, additional therapeutic options are available. These include blocking of the receptor activator of NF-kappa B ligand (RANKL) signaling pathway, which plays a role in the pathogenesis of GCT of bone, via the anti-RANKL monoclonal antibody denosumab. Case Presentation Herein we report on a female teenager who presented in a very poor clinical condition (cachexia, diplopia, strabismus, dysphonia with palsy of cranial nerves V, VI, VIII, IX, X, XI and XII) due to progressive disease, after incomplete resection and adjuvant radiotherapy, of a GCT which affected the cervical spine (C1 and C2) as well as the skull base; and who had an impressive clinical response to denosumab therapy. To the best of our knowledge, this is the youngest patient ever reported with a skull base tumor treated with denosumab. Conclusion In situations when surgery can be postponed and local aggressiveness of the tumor does not urge for acute surgical intervention, upfront use of denosumab in order to reduce the tumor size might be considered. Principally, the goal of denosumab therapy is to reduce tumor size as much as possible, with the ultimate goal to make local surgery (or as in our case re-surgery) amenable. However, improvement in quality of life, as demonstrated in our patient, is also an important aspect of such targeted therapies.

Hodgkin lymphoma (HL) accounts for roughly 10% of all lymphomas and 0.6% of all malignant tumours analysed worldwide yearly. Data regarding HL in developing world are exceptionally constrained. The main objective of this research is to investigate the incidence patterns of HL within the Republic of Armenia and to portray disease distribution according to age and sex. There is a very strict evidence on the frequency of HL in Armenia. The results of our research find out that the frequency of HL in Armenia has not changed altogether over the past 15 years and is comparable to that detailed from the USA and Europe.

Chemotherapy-induced thrombocytopenia (CIT) is a significant complication of cancer therapy. Data on the optimal management approaches of this morbidity in children and young adults are still limited. The aim of the study is to estimate the frequency and severity of CIT and associated clinically significant bleeding in children and young adults with solid tumours and haematologic malignancies. For this retrospective, hospital-based study, children (0-18 y) and young adults (19-40 y) with different types of solid tumours and haematologic malignancies who received chemotherapy at the Muratsan Hospital Complex of Yerevan State Medical University were identified from the patients' database and included in the study (overall 122 patients). Thrombocytopenia was defined as a decrease of platelet count below <100 × 10 /L. For assessing bleeding, WHO scale had been used. Overall, the whole group of patients received 430 chemotherapy cycles. During 131 (31.6%) chemotherapy cycles, patients developed CIT. The study revealed a statistically significant inversely proportional correlation between the age and the severity of CIT. Another important finding of the study was that the patients, who previously were exposed to radiation therapy, were more likely to develop CIT, than those who have not received radiation therapy (68% and 28.7%, = 0.001). From 430 cycles of chemotherapy, 31 (7.2%) cycles reported to have bleeding events. Our study showed that clinically significant thrombocytopenia and bleeding are quite rare among children and young adults. Younger age and previous exposure to radiation therapy are positively correlated with the severity of thrombocytopenia. Larger studies are needed to investigate these findings.

The oral candidacy exam represents a key milestone in physics graduate programs, often signifying the transition from coursework to independent research. As a high-stakes and intellectually demanding assessment, it presents both academic and emotional challenges for students. Despite its significance, limited research has explored these exams from the perspective of graduate students themselves. My dissertation contributes to the growing body of literature on oral candidacy exams through a qualitative phenomenological study that centers physics graduate student experiences. The purpose of this research is to investigate the challenges that physics graduate students face as they navigate this exam and to understand the sources of support that assist them during the process. I developed a conceptual framework for examining physics graduate student perspectives on assessment, illustrating its application through coding and analysis of interview data. Using open coding, I identified major themes related to students’ experiences. Our findings show that peer support was mentioned and praised the most. Advisors were mentioned as very helpful. Participants generally felt confident that professors would help them if asked, however most of them had not actually reached out for help. Some participants mentioned that departments were helpful with administrative issues. The preparation stage and the oral candidacy exam itself were often described as vague and stressful. Many participants reported not receiving official feedback after the exam. Some participants felt that the exam outcome depended on the committee. There was inconsistency in the type of questions asked—some participants were asked research-related questions, while others were asked many core course questions. Participants valued the opportunity to focus on and develop their research during the process. Some participants mentioned that the candidacy exam is a good way to test students’ research abilities, although the goal of the exam wasn’t clear for some students.

The Armenian Highlands, a tectonically active segment of the Arabia‐Eurasia collision zone, exhibit widespread Quaternary volcanism, rapid uplift, and intense seismicity. However, the lithospheric processes driving these phenomena remain poorly understood. We present the first P‐ and S‐wave body‐wave tomography model of Armenia's crust and uppermost mantle, derived from regional earthquakes recorded by both permanent and temporary seismic networks. Our model reveals that beneath the Armenian Highlands, the crust is underlain by a pronounced low‐velocity anomaly in the uppermost mantle (∼40 km depth), indicative of asthenospheric upwelling and melt generation. This anomaly spatially correlates with monogenetic volcanic fields (e.g., Gegham and Syunik), supporting magma ascent through thermally weakened conduits. The lithosphere adheres to a “crème brûlée” rheological model, characterized by a seismogenic brittle layer (10–25 km depth, marked by high‐velocity anomalies) atop a ductile lower crust and uppermost mantle (with negative Vp and Vs anomalies). Beneath the Gegham Plateau, a thinner brittle high‐velocity layer coincides with elevated seismicity at 10–20 km depth, suggesting magmatically induced earthquakes rather than purely tectonic strain release. Collectively, this work establishes a framework for understanding collision‐related magmatism in comparable orogens.

Background. Interactions between alcohol, infection, and surgery and their effect on differentiation and functionality of T helper cells are not yet completely understood. We hypothesized that alcohol and surgery disturb differentiation of T helper cells and contribute to an impaired immune response. Methods. Mice were treated with alcohol for two weeks. Saline treatment served as control. Clinical performance and weight were assessed. On day 14, a median laparotomy was performed and animals were challenged with Klebsiella pneumoniae intranasally. Bacterial load was determined in lungs and blood. T helper cell subpopulations and the released cytokines were assessed in lungs, spleens, and plasma. Key transcription factors of T cell differentiation were evaluated. Results. Alcohol significantly impaired clinical appearance and body weight of animals with postsurgical infection (p<0.05). Bacterial load was significantly higher after alcohol treatment (p<0.05). T helper cell subsets and released cytokine levels were significantly altered in lung, but not in spleen. Expression of transcription factors of T helper cell lineage commitment did not translate into different counts of T helper cells. Conclusions. Alcohol and surgery lead to significant cellular and functional modulations of T helper cells during postsurgical infection. These effects may contribute to an impaired immune response after surgery.

Assembly of the mitotic spindle is essential for proper chromosome segregation during mitosis. Maintenance of spindle poles requires precise regulation of kinesin- and dynein-generated forces, and improper regulation of these forces disrupts pole integrity leading to pole fragmentation. The formation and function of the mitotic spindle are regulated by many proteins, including Aurora A kinase and the motor proteins Kif2a and Eg5. Here, we characterize a surprising role for the RhoA GTPase-activating protein, p190RhoGAP, in regulating the mitotic spindle. We show that cells depleted of p190RhoGAP arrest for long periods in mitosis during which cells go through multiple transitions between having bipolar and multipolar spindles. Most of the p190RhoGAP-depleted cells finally achieve a stable bipolar attachment and proceed through anaphase. The multipolar spindle phenotype can be rescued by low doses of an Eg5 inhibitor. Moreover, we show that p190RhoGAP-depleted multipolar cells localize Aurora A to all the poles, but the kinase is only activated at the two centriolar poles. Overall, our data identify an unappreciated connection between p190RhoGAP and the proteins that control spindle poles including Aurora A kinase and Eg5 that is required to prevent or correct spindle pole fragmentation.