Category: 3. Business

Introduction

Plasmacytoma is a rare neoplastic disorder caused by the abnormal monoclonal proliferation of mature B cells, accounting for approximately 10% of all hematological tumors.¹ Plasmacytomas are clinically and pathologically classified into three types: multiple myeloma (MM), solitary bone plasmacytoma (SBP), and solitary extramedullary plasmacytoma (SEP).² SEP is an extremely rare soft tissue mass composed of monoclonal plasma cells, accounting for 3–4% of all plasmacytomas. Nearly 80% of SEPs are located in the head and neck, particularly in the upper respiratory tract, followed by the gastrointestinal tract. SEPs rarely occur in the lungs, thyroid, breasts, testes, skin, or at other sites.³ Due to its rarity, SEP in the sternoclavicular joint has not been thoroughly studied. In this case report, we describe a 62-year-old male patient who presented with sternoclavicular joint pain and swelling. After excluding infectious and rheumatologic disorders, the patient was ultimately diagnosed with SEP.

Case Report

A 62-year-old male patient presented with progressively worsening pain and swelling in the left sternoclavicular joint for two months without any apparent cause. The patient visited the orthopedic department and was diagnosed with “sternoclavicular joint inflammation”. He received oral and topical analgesics as well as intravenous anti-inflammatory infusions, but his condition did not improve. Additionally, he experienced pain in the left neck and shoulder areas and had limited mobility. He underwent chest magnetic resonance imaging (MRI) with diffusion-weighted imaging (DWI) in the orthopedic department, which led to his admission for treatment at the rheumatology department of the same hospital. After admission, the patient experienced pain and swelling in the sternoclavicular joint as well as pain in the left neck and shoulder with limited mobility. The patient had hypertension for more than 20 years and was currently not receiving antihypertensive treatment. He reported that his blood pressure was well-controlled. He also had diabetes for over 15 years and was currently taking empagliflozin for glycemic control with satisfactory results.

The patient’s temperature was 36.8 °C, respiratory rate was 20 breaths/min, pulse rate was 84 beats/min, and blood pressure was 96/52 mmHg. His general condition was fair, and there was no enlargement of the superficial lymph nodes throughout the body. He was conscious, and physical examination of the heart, lungs, and abdomen revealed no positive signs. He exhibited redness and swelling of the left sternoclavicular joint, accompanied by significant tenderness and increased skin temperature. He also experienced pain in the left neck and shoulder and had limited mobility. There was no swelling or tenderness in the other joints and no rashes on the palms or soles of his feet.

Laboratory tests revealed a complete blood count, inflammatory markers, biochemical profile, thyroid function, and partial hematological parameters (Table 1). The patient tested positive for hepatitis B virus e antibody and core antibody but negative for anti-thyroglobulin antibody, anti-thyroid peroxidase antibody, HBV DNA, tuberculosis infection T-cell assay (T-SPOT.TB), hepatitis C virus antibody, anti-Treponema pallidum antibody, HIV antigen/antibody, and HLA-B27. Coagulation function, antinuclear antibody profile, tumor markers, anti-neutrophil cytoplasmic antibodies (ANCA), rheumatoid immunological markers, anti-cardiolipin antibodies, immunoglobulins, and complements were all within normal limits. No monoclonal immunoglobulins were detected in serum or urine samples.

Table 1 Laboratory Results of First Admission

A chest MRI T2-weighted imaging (T2WI) sequence showed abnormal signals at the sternal end of the left clavicle, with adjacent soft tissue edema (Figure 1). Ultrasonography of the sternoclavicular joint indicated bilateral sternoclavicular joint inflammation with irregular bone cortices. Whole-body bone ECT showed no typical signs of bone metastasis. Pelvic CT scan without contrast showed no evidence of sacroiliitis. Based on the patient’s negative HLA-B27 status, ankylosing spondylitis (AS) was tentatively excluded.

Figure 1 Chest MRI T2WI sequence showed abnormal signals at the sternal end of the left clavicle with adjacent soft tissue edema.

Blood Next-Generation Sequencing (NGS) indicated the presence of Pseudomonas, with a sequence count of 599151 and a relative abundance of 99.97%. It also identified the Pseudomonas aeruginosa complex with a sequence count of 598213 and a confidence level of 99%. Soft tissue culture and drug sensitivity tests of the sternoclavicular joint revealed the presence of Pseudomonas aeruginosa (50%) and Proteus mirabilis (50%), both of which were sensitive to meropenem. The results of the Brucella antibody test were negative.

The patient successively received pain-relief treatment with non-steroid anti-inflammatory drugs such as etoricoxib tablets, and tramadol sustained-release tablets. The patient also received a single intramuscular injection of 1 mL of compound betamethasone and an intravenous infusion of 40 mg methylprednisolone once daily for three days. Based on the result of culture, infection was considered, and the patient was administered oral linezolid tablets (0.6 g twice daily for two days) and an intravenous infusion of meropenem (0.5 g trice daily for three days, followed by 1 g trice daily for eight days) for anti-infection treatment. Despite therapeutic interventions, the patient’s joint pain persisted with unremarkable changes in inflammatory markers (Table 2), necessitating further diagnostic workup.

Table 2 Laboratory Results Before Transfer to Hematology Department

As malignancy could not be excluded, a biopsy of the left sternoclavicular joint was performed. Pathological examination revealed an abundant infiltration of plasma cells and neutrophils within the fibrous tissue, with some plasma cells exhibiting atypia and light-chain restriction. Plasmacytoma remains a diagnostic consideration, prompting the recommendation for repeat extensive biopsies to confirm the diagnosis. The patient was subsequently transferred to the Hematology Department for further management.

The patient underwent positron emission tomography (PET)-CT in the hematology department. The results indicated swelling of the soft tissue around the left sternoclavicular joint, roughness of the joint surface, and increased fluorodeoxyglucose metabolism. Reactive hyperplasia of the lymph nodes in the mediastinum, pulmonary hilum, and porta hepatis was considered. The increased uptake in some parts of the colon, rectum, and small intestine is thought to be due to inflammation or physiological reasons. No other significant abnormalities were detected (Figure 2).

Figure 2 PET-CT indicates soft tissue swelling around the left sternoclavicular joint with increased FDG uptake.

The bone marrow routine test showed that plasma cells accounted for 4%, with some morphological changes. The number of megakaryocytes increased slightly and some showed hyperfunctioning with platelet production. Flow cytometry analysis did not reveal any significant abnormalities. A bone marrow biopsy indicated active bone marrow proliferation (Figure 3).

Figure 3 Bone marrow routine examination indicates that plasma cells account for 4%.

Because of insufficient tissue in the initial biopsy specimen, a repeat biopsy (left sternoclavicular joint biopsy) was performed on August 28, 2024. The pathological findings revealed fibrous tissue with scattered lymphocytes and plasma cell infiltration. Neoplastic lesions could not be excluded, and excisional biopsy was recommended for a definitive diagnosis; therefore, the patient was transferred to thoracic surgery for thoracoscopic thymectomy and mediastinal lesion resection. During the surgery, significant adhesions were observed in the left pleural cavity. A solid mass measuring 4×5 cm with a nodular appearance was found at the sternoclavicular joint of the left pleura. Hypertrophy of the left thymus was observed. Pathological examination of the mediastinal mass and thymus revealed fibro-fatty tissue with focal infiltration of a few plasma cells and light chain restriction. Plasma cell-derived tumors cannot be ruled out. Immunohistochemistry revealed CD56 (-), CD138 (+), CD38 (+), and Kappa ISH (++), indicating light chain restriction, and Lambda ISH (+).

Based on the histopathological findings, routine bone marrow tests, immunohistochemistry (IHC), PET-CT, and other diagnostic evaluations, the patient met the diagnostic criteria for SEP.⁴ Following local radiotherapy, pain in the left sternoclavicular joint was significantly alleviated after treatment completion. After nine months of follow-up, the patient’s joint pain has completely resolved. Laboratory findings were unremarkable (Table 3), and a repeat chest CT showed no evidence of local recurrence or disease progression.The timeline of the case was illustrated in Figure 4.

Table 3 Laboratory Results at Nine-months Follow-up

Figure 4 Timeline of the case report.

Discussion

Plasma cell neoplasms are malignant neoplasms characterized by monoclonal proliferation of terminally differentiated mature B cells that secrete clonal immunoglobulins with light chain restriction. They can manifest as Solitary Plasmacytoma (SP) or Multiple Myeloma (MM).⁵ SP was divided into SBP and SEP. Most plasma cells are located in the bone marrow; in rare cases, they can migrate to soft tissues with the help of adhesion molecules.⁶ This mechanism results in an extremely low incidence of SEP. SEP is rarer than SBP, accounting for approximately 30% of all SP cases. SEP is more common in males, with a median diagnostic age of 55–60 years and an incidence rate of 0.063–0.1 per 100,000 person-years.⁷ Pain is the most common initial symptom of SEP and is mostly caused by compression exerted by a local mass on the affected organ.⁸ Swelling may appear after or coexist with pain, varying in degree depending on the size of the tumor. Pain and swelling may restrict the mobility of the surrounding joints. When a tumor compresses the surrounding blood vessels and nerves, it may cause local skin redness, numbness, sensory loss, and other symptoms. SEP in the sternoclavicular joint is extremely rare, and specialized studies or case reports on this condition are relatively scarce.

Due to the rarity of SEP, the diagnostic process for this patient was extremely challenging. The patient presented with swelling and pain in the sternoclavicular joint, redness of the skin, pain, restricted movement in the left neck and shoulder, and decreased appetite, without systemic symptoms such as fever or chest tightness. Given that the symptoms were localized to the sternoclavicular joint area and inflammatory markers—such as ESR, CRP, PCT, and interleukin-6—were significantly elevated, the initial consideration was a rheumatologic or infectious disease. After admission, comprehensive laboratory and imaging examinations were conducted, including complete blood cell analysis, inflammatory marker testing, whole-body bone ECT, PET-CT, and local biopsy. Notably, NGS testing suggested an infection with Pseudomonas aeruginosa, and cultures of the soft tissue around the sternoclavicular joint also isolated Pseudomonas aeruginosa and Proteus mirabilis. Based on these results, the initial diagnosis was sternoclavicular arthritis. Antimicrobial (antibiotic) and anti-inflammatory treatments (nonsteroidal anti-inflammatory drugs, centrally acting analgesics, and corticosteroids) were initiated. However, despite various treatment regimens, the patient’s clinical symptoms did not improve significantly and the therapeutic effect was poor. This prompted us to reevaluate the accuracy of the initial diagnosis. Considering the patient’s poor response to conventional treatment, we highly suspected that the etiology might not be a simple infectious or inflammatory lesion but rather another underlying pathological mechanism. Therefore, we focused on the local lesions and performed multiple biopsies. However, due to the insufficient number of pathological specimens obtained, a definitive diagnosis could not be made. Finally, we decided to surgically excise the lesion to obtain sufficient tissue samples for a detailed pathological examination. The excised mass was pathologically analyzed and ultimately diagnosed as SEP.

In clinical practice, sternoclavicular joint SEP are highly prone to misdiagnosis and missed diagnosis because of their rarity and nonspecific clinical manifestations. It often needs to be differentiated from rheumatological diseases, infections, and tumors. The patient in this case presented with swelling and pain in the sternoclavicular joint as the initial symptoms and was first seen in the rheumatology department. Spondyloarthritis (SpA) and SAPHO syndrome were initially considered. SpA includes ankylosing spondylitis (AS), psoriatic arthritis (PsA), reactive arthritis (ReA), and inflammatory bowel disease-associated spondyloarthritis (IBD-SpA). AS is a chronic inflammatory disease that primarily affects the spine and pelvis.⁹ ReA is sterile arthritis that occurs after a specific infection. PsA is a chronic inflammatory joint disease associated with psoriasis. In addition to joint manifestations, IBD-SpA also presents with clinical symptoms of inflammatory bowel disease, such as abdominal pain, diarrhea, bloody stools, and mucous stools. All the above SpA conditions responded well to anti-inflammatory and analgesic drugs. SAPHO is a rare autoinflammatory disease characterized by skin and osteoarticular manifestations.¹⁰ A retrospective study proposed that anterior chest pain was present in more than 70% of patients with SAPHO.¹¹ The revised SAPHO diagnostic criteria in 2003 state that isolated or multifocal sterile osteitis/hyperostosis in adults, including the anterior chest wall, meets this criterion and that SAPHO can be diagnosed by excluding malignant bone and joint tumors and infections.¹² Hormone therapy can significantly improve the symptoms of SAPHO. However, in this case, the patient did not respond to hormone therapy, indicating a questionable diagnosis. In terms of infection, although laboratory tests suggested inflammation, the inflammatory markers did not improve with broad-spectrum antibiotics (linezolid tablets and meropenem injections), and the pain in the sternoclavicular joint remained unrelieved, suggesting a low likelihood of infection. Despite multidisciplinary collaboration involving hematology and thoracic surgery, malignancy still needs to be highly vigilant, including primary bone tumors, bone metastasis of tumors, and lymphoma.Since multiple local biopsies and immunohistochemistry failed to provide a definitive diagnosis, the final diagnosis of SEP was confirmed by thoracoscopic lesion excision and biopsy. This case highlights the complexity of diagnosing SEP, emphasizing the need to be highly vigilant for the possibility of rare tumors when conventional treatments fail, and the importance of clarifying the diagnosis through collaboration among multiple clinical disciplines and repeat biopsy.

In cases with atypical clinical manifestations, the diagnosis of solitary extramedullary plasmacytoma (SEP) requires a comprehensive assessment that integrates results from multiple disciplines, including laboratory tests, imaging, and pathology. Laboratory tests offer advantages such as being noninvasive, rapid, widely applicable, and allowing for dynamic monitoring; however, they have limited specificity and cannot localize the lesion. Only a minority of patients with SEP have detectable monoclonal immunoglobulins in their blood or urine; in this case, neither was found in the patient’s serum or urine. Imaging techniques, including ultrasound, CT, MRI, bone ECT, and PET-CT, can identify the location and extent of the lesion but lack specificity for a definitive diagnosis. Among these, PET/CT, with its high sensitivity and specificity, can suggest the possibility of malignancy through increased metabolic activity and is used to assess treatment efficacy and identify minimal residual disease, making it valuable for the diagnosis and treatment of SEP. After imaging identifies the lesion site, a tissue sample is obtained via fine-needle aspiration or surgical biopsy for pathological examination. The definitive diagnosis of SEP relies on histopathological biopsy, wherein both histological and immunohistochemical findings must demonstrate a homogeneous infiltration of monoclonal plasma cells within a solitary lesion. These cells typically exhibit positive expression for CD138 and/or CD38.¹³

The prognosis of SEP is closely linked to early diagnosis and timely intervention. Large primary tumor size and lymph node metastasis have been established as adverse prognostic factors.¹⁴ As SEP is a radiosensitive tumor, radiotherapy is often recommended as the primary treatment modality.¹⁵ However, comprehensive treatment strategies should be tailored according to individual tumor characteristics, including surgical resection, radiotherapy, and systemic chemotherapy. In this case, the presence of mild bone marrow plasmacytosis (4%) and lack of CD56 expression may increase the risk of progression to multiple myeloma (MM). The optimal management strategy for SEP remains an area of ongoing research.¹⁶ For high-risk SEP patients without lymph node involvement, we recommend an individualized treatment approach. A sequential regimen combining radiotherapy and surgery may achieve better local control.¹⁷

Most progressions from SEP to MM occur within the first five years after diagnosis. We acknowledge that this study has limitations inherent to a single-case report with short-term follow-up, and the current conclusions regarding treatment efficacy and prognosis are preliminary. Therefore, the patient requires long-term close monitoring, including serial serum and urine electrophoresis with immunofixation, as well as serum free light chain analysis. Additionally, detection of high-risk cytogenetic abnormalities via interphase fluorescence in situ hybridization (FISH) in clonal plasma cells may facilitate early identification of MM¹⁸ and should be incorporated into follow-up assessments.Given the rarity of SEP, there is an urgent need for large-scale, well-designed prospective studies to further clarify optimal diagnostic and therapeutic strategies.

Conclusion

Swelling and pain in sternoclavicular joints are commonly associated with rheumatic, infectious, and neoplastic disorders. SEP is extremely rare and poses significant challenges for its early diagnosis. A definitive diagnosis requires the integration of histopathological features, systemic lesion evaluation, and assessment of bone marrow involvement. Timely pathological confirmation is crucial, and an excisional biopsy may be necessary to obtain adequate tissue for a definitive diagnosis. The current follow-up period for this case remains relatively short, and we will continue close monitoring to track the disease course for any progression or changes.

Data Sharing Statement

The datasets used or analyzed during the current study are available from the corresponding author on reasonable request.

Ethical Approval and Consent to Participate

Written informed consent was obtained from the patient for the publication of all the images and data included in this article. The study was conducted in accordance with the Declaration of Helsinki (as revised in 2013). Ethical review and approval were not required to publish the case details in accordance with the institutional requirements.

Consent to Publish

The patient provided informed consent to publish their case details and any accompanying images.

Acknowledgments

All of us thank the patient for consent to the publication of the case.

Funding

No funding was received for this study.

Disclosure

The authors report no conflicts of interest in this work.

References

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Introduction

Nursing education is a crucial component of the health-care system that aims to produce competent, skilled, and compassionate nurses who can effectively contribute to patient care and address the diverse health-care needs of the population. In Uganda, nursing education system typically follows a structured curriculum designed to impart theoretical knowledge, practical skills, and ethical values essential to nursing practice.¹ The programs are governed by regulatory bodies such as the Uganda Nurses and Midwives Council (UNMC) as well as the Ugandan National Council for Higher Education, which set standards and guidelines for nursing education institutions.² Nursing training programs often include a combination of theoretical classroom learning and hands-on clinical training.³ Practical training and clinical rotation in various health-care settings are crucial components of nursing education in Uganda.⁴ Its curriculum outlines various teaching pedagogies, such as lectures or didactic teaching, simulation-based learning, case-based learning/case studies, and problem-based learning (PBL), aimed at providing comprehensive learning experiences for aspiring nurses.^5–7 It places a strong emphasis on developing essential skills, such as critical thinking, patient assessment, clinical decision-making, therapeutic communication, and evidence-based practice.^8,9 These skills are vital for nurses to deliver high-quality care and make informed clinical decisions in nursing practice. Musiime¹⁰ reported that the traditional (lecture) method is the most used teaching method in Ugandan universities, while case-based learning (CBL) is the most effective teaching method in enhancing student performance, with a prediction potential of 71.1% compared to lecturing, concluding that student performance is a reflection of skills that emerge from the instruction. Globally, studies revealed use of CBL pedagogy is limited in Africa. McLean¹¹ reported use of CBL based on global review articles; 54.9% for North America, Europe (25.4%), Asia (15.5%), South America (2.8%) and Africa (1%). Tsekhmister¹² in meta-analysis on worldwide use of CBL to other teaching methods for professional student teaching revealed selected studies conducted in USA, 33%; China, 24%; Germany and Saudi Arabia 9% while no studies were found in Africa.

Case-based learning (CBL) is a student- or learner-centered pedagogy that introduces students to real-life scenarios. It engages students in discussions of patients or clients’ cases, integrated with clinical presentations and health or illness conditions.¹³ CBL plays a significant role in enhancing critical thinking skills in clinical decision-making in nursing education by providing practical and immersive learning experience.¹⁴ CBL presents authentic scenarios and mirroring situations encountered in clinical practice. Students engaged in realistic patient situations, applied theoretical knowledge and decision-making to solve problems. The effectiveness of CBL allows students to gain professional knowledge to become competent in clinical decision-making and the provision of qualitative care to improve patient care outcomes. CBL serves as a bridge between theoretical knowledge and practical applications in real-life cases,¹⁵ offering students the opportunity to engage in actual clinical cases in a controlled educational environment. Like many others globally, Uganda’s health-care system demands nurses that swiftly analyze complex situations, make informed decisions, and provide effective patient care.¹⁶ CBL enables student to apply their theoretical knowledge to simulated or authentic patient cases, thereby enhancing their understanding of complex concepts.

Frederic Le Play (1829) introduced CBLinto social science during a statistical study of his family budget.¹⁷ In 1870, Professor Christopher Columbus Langdell at Harvard University School of Law developed a case study method based on the cognitive influence of inductive experimentation to create learning methods which was legally adopted by the USA as a teaching method.¹⁸ CBL was first used in the medical field in 1912 by Dr James Lorrain Smith when teaching pathology at Edinburgh University.¹¹ In the 1990s, CBL was used synonymously with case-based reasoning, which Kolodner (1993) explained as reasoning based on remembering past experiences, and is widely used in psychiatric diagnoses as well as medical education.¹⁹

CBL refers to the use of clinical cases to facilitate students’ teaching and learning. Obeagu et al²⁰ Gasim et al²¹ noted that the aim of CBL is to nurture students to prepare for medical practice using real clinical cases. It joins theory with practice by applying theoretical knowledge to cases using an inquiry-based learning method. CBL as a pedagogy is a two-directional active student-centered method that encourages communication, collaboration, critical thinking, and creativity among learners with the teacher as a facilitator.²² Collaboration helps medical students develop the spirit of teamwork, which is paramount in interprofessional team services in health-care delivery in a clinical setting. Techniques of CBL delivery include live presentations, computer/web-based, diverse modalities, live plus web, live plus book, live simulator, live/self-learning, and paper presentations. The evaluation methods for case-based learning includes surveys, tests, and tests plus survey.¹¹ CBL encourages critical thinking by presenting authentic, multifaceted situations that require analysis, evaluation, and problem-solving Obeagu et al.²⁰ Student nurses are prompted to assess data, identify patterns, consider various perspectives, and make informed decisions, thereby fostering critical thinking skills in clinical decision-making.

Critical thinking is a central competency in nursing education and practice, enabling students to engage in sound clinical reasoning and make evidence-based decisions that enhance patient outcomes. This process involves synthesizing knowledge from various sources to formulate appropriate interventions.²³ It equips students with the problem-solving skills to identify issues, evaluate alternatives, and implement solutions in a timely and efficient manner. Nurses with strong critical thinking skills are better equipped to recognize subtle changes in a patient’s condition, anticipate potential complications, and take proactive measures to ensure patient safety, which is crucial for preventing medical errors and providing high-quality care.²⁴ Nurses use critical thinking to appraise research findings, scientific evidence, and best practices analytically to integrate this evidence into their clinical decision-making processes, ensuring that patient care is based on the most current and reliable information available.²⁵ In nursing students it is the ability to apply higher-order reasoning skills in clinical decision-making. It involves purposeful, reflective judgment through which students analyze patient situations, infer possible outcomes, evaluate evidence, and justify nursing interventions. In this study, critical thinking is operationalized using the California Critical Thinking Skills Test (CCTST), a standardized tool with a 34-point total score that assesses performance across key subscales such as analysis, evaluation, inference, deductive, and inductive reasoning using multiple choice tests questionnaire. Higher scores reflect stronger critical thinking abilities, while lower scores indicate limited reasoning capacity. This study is guided by Facione’s Delphi Report on Critical Thinking,²⁶ which provides a comprehensive framework derived from expert consensus in philosophy, education, and psychology. Facione conceptualizes critical thinking as a combination of cognitive skills (interpretation, analysis, inference, evaluation, explanation, and self-regulation) and dispositional attributes that reflects traits such as inquisitiveness, open-mindedness, systematicity, truth-seeking, and confidence in reasoning indicating it is multidimensional in nursing.²⁶ This framework is particularly relevant in nursing education because clinical decision-making demands both cognitive reasoning skills and professional dispositions that support safe, patient-centered care. The study aimed to investigate the impact of case-based learning as a pedagogical tool for enhancing critical thinking skills in clinical decision-making among student nurses at Kampala International University (KIU).

Materials and Methods

Study Design

Study adopted a descriptive design to collect data from 37 Bachelor of Nursing (BN) science students in the fourth academic year of their program to achieve the research objective. The entire population of 37 students was sampled, 28 consented and participated in the study.

Sampling Technique

Criterion purposive sampling was used, which depends on the researcher’s judgment based on students predetermined criteria, to identify and select participants who can provide relevant answers to research questions for CBL topic “anemia in pregnancy”.

Inclusion Criteria

KIU BN science students in their fourth year who have studied related courses such as reproductive health, midwifery, and participated in CBL session specifically on “anemia in pregnancy”.

Exclusion Criteria

Nursing students of KIU who did not consent to participate in CBL pedagogy and those below the academic year because of non-exposure to interrelated courses on the topic of teaching intervention.

Case-based Learning Topic

The focus was on “anemia in pregnancy” as the core clinical case in classroom teaching of one CBL session for 3 h. The participants were exposed for the first time to CBL pedagogy as well as instruction topic in their training period because the study context use mostly lecturing and other methods not CBL.

Study Procedure

Implementation of CBL in classroom involve case presentations in progressive case disclosure to mimic real-life scenarios. Group work where students are divided into small groups to encourage teamwork, discussion and presentation. The teacher acts as a facilitator, guiding discussion with probing questions instead of lecturing. In this study, CBL pedagogy was implemented using Framework for Teaching (FFT) 3rd edition by Charlotte Danielson group and lesson plan structured by researchers focusing on the topic “Anemia in Pregnancy.” The four domains of FFT comprising of planning/preparation, learning environment, learning experience and principled teaching was adopted and pedagogical activities in each domains were adapted as step-by-step approach for this study (see Table 1).

Table 1 Framework for Teaching for Implementation of Case-based Learning (CBL)

Instrument for Data Collection

The instrument for data collection was California Critical Thinking Skills Test (CCTST) questionnaire. CCTST subscales of analysis, evaluation, inference, deductive reasoning, and inductive reasoning was adopted and adapted by developing the test items in each of the five subscales from “anemia in pregnancy”. CCTST total scores range from 0 to 34. The subscale scores range were analysis (0–9), evaluation (0–14), inference (0–11), deductive reasoning (0–16), and inductive reasoning (0–14). The sum of the scores of the analyses, evaluation, and inference was the total CCTST score. The inductive and deductive scales join the analysis, inference, and evaluation scales. The validity and reliability of this instrument were based on the Delphi Expert Consensus Report.²⁶ The Pearson correlation coefficient (r =0.68) was calculated using the test–retest method with five student nurses to test the reliability of the test items for the data collection instrument. It was administered individually to participants for 50 min in the classroom after the CBL session.

Data Analysis Method

The collected data were analyzed using percentage, distributive statistics and analysis of variance (ANOVA), with significance set at P <0.05. In addition, a qualitative interpretation of the California Critical Thinking Skill Test Scale Scores was presented with the following measures: not manifest (0–7), weak (8–12), moderate (13–18), strong (19–23), and superior (24–34). The data are presented in the tables and figures.

Results

Figure 1 shows the overall CCTST scores. It was observed that very few 2 (7.1%) participants had a strong score, while majority 26 (92.9%) had a superior CCTST score. From Table 2, participants CCTST total score reported mean value of 27.39, mode 27, median 27, and standard deviation (SD) 2.65. Sub-scale analysis mean score: 5.79, mode 6, median 6, and SD 0.9. Evaluation sub-scale graded mean score of 3.96, mode 4, median 4, and SD 0.5. Inference sub-scale recorded 5.64 mean score and 5, 6, 1.01for mode, median, and SD, respectively. For deductive reasoning, mean score was 5.54, mode and median 6 each and SD 1.24. Inductive reasoning had mean score of 6.46, mode and median 7 each, and SD 0.68. Table 3 presented CCTST sub-scales presented using ANOVA, results indicated that CBL method was a statistically significant factor influencing participants’ scores in analysis (P =0.016), evaluation (P = 0.007), and deductive reasoning (P = 0.025). However, it did not have a statistically significant effect on the inference (P =0.932) or inductive reasoning (P =0.670) subscale scores in this study.

Table 2 Descriptive Statistics of CCTST Total and Subscale Scores

Table 3 Impact of Case-based Learning on Critical Thinking in Clinical Decision-making for California Critical Thinking Skill Test (CCTST) Sub-scale Scores

Figure 1 Qualitative Interpretation of California Critical Thinking Skill Test Overall Scores.

Discussion

This study showed that CBL has an excellent impact on student nurses’ critical thinking in clinical decision-making. Very few 2 (7.1%) participants had a strong score, the majority 26 (92.9%) had a superior overall CCTST score. The finding of the study were supported by Makoni²⁷ which revealed 98 (78.4%) student nurses and midwives were ranked in grade level 3 and 4 which is acceptable CCTST scale score and 27 (21.6%) of the respondents were graded level 1 and 2 which is very poor in the critical thinking skill test scale. In addition, Obeagu and Tukur²⁸ reported 13 (46.4%) of participants were proficient/safe (level 3), 12 (42.9%) had moderate/developing (level 2) while 3 (10.7%) scaled minimal/unsafe (level 1) in pretest scores. Posttest scores revealed 13 (46.4%) respondents at excellent point (level 4), 13 (46.4%) were proficient/safe (level 3) and 2 (7.1%) had moderate/developing (level 2) in Performance-Based Development System Model (PBDSM) on levels of critical thinking in clinical decision-making of student nurses using CBL.

In addition, participants CCTST total score reported mean value of 27.39, sub-scale analysis mean score 5.79, evaluation 3.96, inference 5.64, deductive reasoning 5.54, and inductive reasoning 6.46 as their mean score values. The above findings indicated that CBL enhances student nurses’ critical thinking in clinical decision-making which is in line with the work of Obeagu and Tukur,²⁸ the authors documented mean scores of 11.75 in pretest and 16.10 out of total score of 20 on student nurses critical thinking in clinical decision making of using CBL. Mostafa et al²⁹ reported that students’ critical thinking skills in clinical decision-making had mean scores of 14 for lecturing and 17 for CBL in partial support of this study findings.

Furthermore, the CBL method of teaching showed a significant factor for CCTST score for the participants; analysis (0.016), evaluation (0.007), and deductive reasoning (0.025); and not a statistically significant factor for their inference (0.932) and inductive reasoning (0.670). There was no study to discuss this findings. However, CBL is a more effective method for educating student nurses to enhance their critical thinking in clinical decision-making in nursing education.

Conclusion

It was observed that CBL, as a teaching pedagogy, has an excellent impact on KIU student nurses’ critical thinking in clinical decision-making, especially analysis, evaluation, and deductive reasoning. However, CBL has little impact on KIU student nurses’ inference and inductive reasoning, advocating the use of more than one student-centered teaching pedagogy to transfer adequate knowledge in the curriculum to student nurses. In addition, this shows the need to strengthen clinical teaching for student nurses to enhance their clinical management skills and bridge the gap in clinical practice among nurses.

Ethical Considerations

Ethical approval was obtained from the Kampala International University Research Ethics Committee (REC number KIU-2024-424), and permission was obtained from students who provided informed consent to participate in this study. The researcher ensured that the rights, dignity, and well-being of the participants were respected by implementing ethical principles of confidentiality, autonomy, justice, and informed consent.

Disclosure

The authors report no conflicts of interest in this work.

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European listings are showing signs of a revival as a string of companies launch or prepare initial public offerings, giving hope to the region’s capital markets after a prolonged slowdown.

This week, security services company Verisure raised €3.2bn in the biggest European listing for three years, while prosthetics company Ottobock raised €700mn in Germany’s largest IPO this year.

Swedish digital bank Noba, German automotive company Aumovio, skin laser seller The Beauty Tech Group and classifieds business Swiss Marketplace Group have all listed in Europe in the past few weeks. 

Several more flotations are being planned, including an IPO of €10bn German auto marketplace Mobile.de in Frankfurt, and London listings for tinned food company Princes Group and specialist UK lender Shawbrook.

Company executives and their advisers say geopolitical and economic worries — including market jitters sparked by US tariffs — have eased somewhat, creating a more favourable environment for listings after several IPOs were put on hold.

Stock markets are also trading at record highs, giving further encouragement for companies to list.

“We’re breaking the deadlock,” said Richard Cormack, head of Emea equity capital markets at Goldman Sachs, adding that there was a “good-sized cohort of transactions . . . It feels like now we’re at the proper start of a cycle.”

Martin Thorneycroft, global co-head of equity capital markets at Morgan Stanley, said Verisure’s blockbuster listing “will give a big boost to the large-cap, high-quality assets in the pipeline”.

European stock exchanges have been struggling to attract new listings: there have been 76 so far this year, the lowest level since 2009, according to Dealogic data.

Private equity firms have held on to companies for longer, rather than bringing them to the market, in the face of subdued demand, while some businesses, such as Swedish fintech Klarna, have chosen to list in the US, lured by higher valuations and deeper capital markets. 

The lack of listings has triggered European policymakers to try to encourage more domestic investment in homegrown businesses and incentivise founders to list businesses in the region. 

Companies listing on Sweden’s Nasdaq stock exchange have raised the most so far this year, at $6.7bn, according to Dealogic, while $1.2bn has been raised on the Frankfurt stock exchange, and the same amount on the Swiss SIX venue.

“It’s encouraging that activity is broadening beyond markets with strong domestic bases like Switzerland and Scandinavia”, said Stephane Gruffat, Deutsche Bank’s global head of equity capital markets syndicate. “We’re now seeing renewed demand in the UK, Germany and Spain — including [from] retail investors.”

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EU ships could face having to travel more slowly and use more fuel than their Asian competitors because of Brussels’ failure to authorise an innovative paint for ship hulls that prevents barnacles becoming stuck by making them hyperactive.

Medetomidine has long been allowed for human and veterinary use as a sedative, but scientists in Sweden discovered it has the opposite effect on barnacles, which become temporarily excited when they come into contact with the substance and so cannot settle on a surface.

While each barnacle is small, a build-up of the crustaceans can vastly increase a ship’s drag in the water, increasing fuel consumption and carbon emissions.

I-tech, the start-up that patented the medetomidine biocide with 40mn krone ($4.3mn) of support from the Swedish government, estimates that if 10 per cent of a hull is covered with barnacles, fuel consumption increases by 40 per cent if the same speed is maintained.

Anti-fouling paints are also an important means of stopping invasive species travelling between continents. But although the EU itself has also funded I-tech, it has not approved its paint for use 16 years after the company first applied.

Magnus Jönsson, chief executive of I-tech, said the paint was “a non-lethal way of stopping the barnacles settling on the surface”.

I-tech applied for authorisation to the European Commission in 2009 for consideration under its biocidal products regulation. While medetomidine itself has received temporary approval, long bureaucratic processes and checks on the safety of the substance have meant it has not been approved for use in any biocide products.

The European Chemicals Agency last year recommended that the temporary approval of medetomidine be ended because it is “persistent, toxic, and identified as an endocrine disrupter”. Its opinion was largely based on a Norwegian study, which I-tech argues is flawed.

Member states are due to vote on its ongoing authorisation in the coming months, allowing the commission to take a decision early next year.

Despite the lack of approval for its products, I-tech has received €670,000 of funding from the EU and €1.3mn in conditional loans from the Swedish Energy Agency to scale up.

More than 90 per cent of its sales are made outside Europe. It has gained market share of about 50 per cent in Japan and South Korea, as well as a foothold in China, where it competes with traditional antifouling paints.

“Anti-fouling remains a serious challenge for international shipping . . . We need more antifouling options available on the European market and we should really welcome new products like this,” said a Norwegian shipping representative, who asked not to be named.

The commissions said it would “consider all elements and information, including from stakeholders, when making its decision” on the substance’s authorisation.

Two major reports on the EU’s waning economic competitiveness issued last year pointed to a failure to scale up domestic start-ups. The European Commission has vowed to improve the regulatory framework for start-ups and small businesses, and to simplify legislation for industry.

I-tech argues its product could help European ships cut emissions in line with the bloc’s ambitious climate goals. It says covering a ship’s hull with its antifouling paint can reduce carbon emissions by 15 per cent.

Didier Leroy, technical and regulatory affairs director at CEPE, the industry body for paint, printing ink and artists’ colours, said the EU had “such severe chemical legislation that they discourage investment and innovation”.

“If there is no more sufficiently efficient antifouling paint on the EU market then ships will not dry-dock any more for repair and maintenance and this will be done outside the EU,” he said, adding that this would harm other parts of the EU economy.

When Mark Constantine, 73, started cosmetics brand Lush, he was still recovering from bankruptcy, despite the triumphant sale of his first venture to The Body Shop for £9mn in 1991.

Yet Lush, launched in 1995, is now a global group, renowned for its bath bombs, operating more than 850 shops worldwide with an annual turnover in 2024 of £703mn, according to the company’s latest accounts. 

Constantine, the chief executive, and his wife Mo still own more than 50 per cent of the company, and are estimated to be worth £249mn, according to the latest Sunday Times Beauty Rich List — all the more remarkable for a man who was homeless in his teens.

His obsession with cosmetics was cemented as a young hairdresser. He started mixing shampoos in the 1970s alongside a small team, and pitched them to The Body Shop founder, the late Anita Roddick, who had just opened her second branch. She gave him his big break and their partnership over the coming decade laid the foundations for what would later become Lush.

Having vowed never to retire, Constantine still works from the same building in Poole, Dorset, where he launched Lush 30 years ago alongside his co-founders. “We’ve got more ideas now than we ever know what to do with,” he says. The self-proclaimed “hippy soapmaker” is also a notable philanthropist. 

Where did your business career begin? You didn’t start Lush until you were in your forties
I was still in my early twenties, making products in my bedroom, when The Body Shop started accepting my ideas. It was quite a power trip. It was a hell of an opportunity and I was so fortunate.

I learned a lot from Anita over the 15 years we worked together. She was dynamic and epitomised charisma. But we would argue constantly. If you didn’t argue back, Anita would think you hadn’t made much of an effort. Once she called me “unprofessional”, and I told her I’d prefer she called me a “wanker”. Five minutes later, a bunch of flowers arrived, with a note that just said — “Wanker”. That was the way we did business.

We were partners until 1991, when she bought the rights to our formulas for £9mn.

But I blew it all on my next company, Cosmetics To Go, within a few years. It was a mail order catalogue of beauty products (the non-compete agreement meant we could only sell via mail order). With Cosmetics To Go, we lost £1 every time we sent out an order, which was a problem because we were really popular. The one consolation was that all the products and inventions in that catalogue were ones that Anita had rejected, such as the bath bombs.

How did you recover from bankruptcy in January 1994?
I was quite ashamed of myself. I’d never felt so alone after going bankrupt. When I met the bankruptcy receiver and put my hand out to shake his, he wouldn’t take it. There was definitely shame. I would go through the back door of the shop because I just couldn’t face going through the front. I wanted to stay at home with a bag over my head.

I then had to figure out how I would turn things around. We had three mortgages, including our family home, a factory, and the Poole store/office, and three kids to support. I’d already had to sell another house in Swanage, Dorset, at a 50 per cent loss. That sale left us with £43,000 in cash. That was all we had left by the mid-1990s. So I used that money to start Lush. 

Did you or your wife hesitate about putting money into another business after the bankruptcy?
Well, no one was going to employ me. I was unemployable. I hadn’t — and haven’t — been employed full-time by anyone else since 1973.

I do remember I had to persuade Mo and my other business partner, Liz Weir, that perhaps we should put what was left into something new. I don’t know what exactly my wife thought about me betting on another business. But we’d been together a long time, so I think she just knew what I was like. I’m just really into the game. We both are. 

Saying that, my seven-year-old son at the time did corner me one day and asked: “Do you think you ought to get a proper job?” I had to explain to him that I thought I could market my skills better than in a “proper job”.

How do you feel about your wealth after your success with Lush?
I’m never very comfortable when the Sunday Times Rich List comes out, mainly because you never actually have the money. Everyone assumes you have all that cash, and you don’t — it’s the asset. I still live in the same house we bought 40 years ago.

Ultimately, wealth gives you a great opportunity to do a whole lot of things for others. That’s what I’m proud of. I was really touched by the kindness I experienced when I was homeless, living in a tent in a forest after being kicked out of the family home at 16. People invited me for dinner and let me stay. That’s always stuck with me.

What are your views on the government’s tax policy?
In general, I think wealthy people obsess too much about tax. They do all sorts of things that mess up their lives because it’ll save them some money. It just complicates your life to get caught up in moving, such as non-doms or sailing around in big yachts to avoid tax days.

Lots of people who read the FT will disagree with me but, personally, I believe in paying tax. I don’t like it — I do think it’s important, though.

Saying that, my opinion on tax policy from a business point of view is that you should concentrate on growth. Businesses can get distracted by worrying about tax instead of growth.

Family businesses are the backbone of this country. They don’t generate news though, so politicians don’t understand them. The government thinks business is just The City, which is basically the betting house.

But we just have to live with the government’s decisions on tax. I’m not going to move to Switzerland or anything because of tax. I’m just hoping to live long enough to see the next government come in.

Will you leave the business to your children?
My children have worked their butts off in this business for 20 years. So yes, I would like to leave it to them. Do I want to leave them a huge tax bill? Not particularly. But the plan is for our three children to inherit our shares.

I love spoiling people, including my kids. And family businesses, by their nature, involve some kind of nepotism. But at the same time, the kids are building skills and going through all the tough stuff you have to go through. 

What’s your philosophy on business today?
The reality is that entrepreneurs aren’t balanced people. I’ve had to manage my mental health my whole life, including panic attacks and anxiety. 

But I don’t like the image of business that TV portrays, such as The Apprentice or Dragons’ Den. I don’t like programmes where the jeopardy makes people cry. I don’t like the idea of needing to make a pitch in three minutes. Business can be done in beautiful ways — politely and kindly. That’s why I co-wrote The Poetry Business School. Poetry can teach you so much. 

I now see a business coach each week. We’ll talk about weak spots, such as how my judgment of men isn’t so good. I’ve turned a blind eye to some people I shouldn’t have. On the flip side, I think working with women is a secret weapon. As soon as you listen to them, that’s when you start getting successful.

Fundamentally, I believe in capitalism, but motivation should be shared around. At Lush, we’re partly family-owned and partly staff-owned [all external investors were later bought out]. That feels better than one or two people, then selling and taking all the money.

We’ve also given away £100mn in charitable giving over the past three decades. Yes, profit is still more important than policy, but not by much.

KARACHI – Gold prices in Pakistan massively decreased after hitting record high in local market on Saturday, September 11, 2025.

According to the Saraffa Association, the opening price of 24-karat gold per tola stood at 420,178 while the rate for 10 grams stood at Rs360,597.

Gold is a valuable commodity widely traded in global markets. Known for its rarity and durability, gold has been used for centuries as a store of value and hedge against inflation. It is traded in various forms, including physical bullion, futures contracts, and exchange-traded funds (ETFs).

Investors often turn to gold during economic uncertainty, as it tends to retain value when other assets decline. Major trading centers include London, New York, and Shanghai. Gold prices are influenced by factors like interest rates, currency strength, and geopolitical events, making it a crucial component of diversified investment portfolios.

In international market, the gold price also remained stable and now stood at historic high of $3,995 per ounce.

Today Gold Rate in Pakistan

City	Gold Price	Silver Rate
Karachi	420,178	Rs5,100
Lahore	420,178	Rs5,100
Islamabad	420,178	Rs5,100
Peshawar	420,178	Rs5,100
Quetta	420,178	Rs5,100
Sialkot	425,178	Rs5,100
Hyderabad	420,178	Rs5,100
Faisalabad	420,178	Rs5,100

Meanwhile, the rates of per tola and ten gram  recorded an increase and stood at Rs5,100 and Rs4,372 respectively.

Market experts attribute the ongoing volatility to uncertain trends in global bullion trading and the fluctuating value of the Pakistani rupee against the US dollar.

A decade after Volkswagen sent shockwaves through the automobile industry by admitting it had cheated on emissions tests, 13 of the world’s biggest carmakers are gearing up to defend a multibillion pound lawsuit over whether they all deceived regulators about harmful gases produced by diesel vehicles.

Hundreds of thousands of motorists in the UK are suing manufacturers including Mercedes-Benz, Ford, Peugeot/Citroën, Renault and Nissan over claims they installed “defeat devices” to manipulate tests for nitrogen oxide emissions. The claimants are hoping for thousands of pounds each in compensation.

The lawsuit, which barring a last-minute settlement will go to trial next week at the High Court in London, is among the most aggressive attempts in the world to widen liability for “dieselgate” beyond Volkswagen. It will be one of the largest collective actions in English legal history.

The Germany-based carmaker admitted in 2015 to installing software in 11mn vehicles worldwide to make them appear more environmentally friendly than they were. The dieselgate scandal has since cost VW more than €30bn and four of its former executives have received jail terms.

VW is not one of the “lead defendants” in the first part of the case beginning on Monday — although it is part of a larger group of defendants that could be affected by the eventual ruling.

Among the claimants is Adam Kamenetzky, who bought a Mercedes-Benz diesel car in 2018. While he had some scepticism given the earlier admissions by VW, the 45-year-old in south west London said he went ahead with the purchase, reassured by its emissions figures.

But he began having suspicions after encountering several technical issues including problems with its nitrogen oxide sensors. Though the sensors were repaired for free after he made a complaint, he said the value of the vehicle has dropped due to the unpopularity of diesel.

“I wanted to see justice,” said Kamenetzky, who joined a claimant committee that represents motorists to raise public awareness.

A defeat for the carmakers would once again shake trust in the auto industry, just as it is trying to draw a line under the dieselgate scandal.

While some manufacturers other than VW have reached settlements over allegations of diesel emissions manipulation in the US, they have mainly done so without admitting liability. All the manufacturers deny the claims against them in the London court case.

The scale of the claims in part reflects a boom in diesel car sales in the UK after tax breaks introduced by former Labour chancellor Gordon Brown favoured vehicles with lower carbon dioxide emissions.

But the sales surge came to an abrupt end after the 2015 emissions scandal brought to the fore concerns about nitrogen oxides, which are linked to health conditions including asthma, and can form smog.

From a peak share of 51 per cent of the UK’s new car market in 2012, diesel vehicles now account for only 3 per cent last year, according to the Society of Motor Manufacturers and Traders, a trade body. New sales of these cars are to be banned from 2030.

A total of 1.6mn vehicle owners have brought claims against the 13 carmakers, though those against only five of the companies — covering 846,500 claimants — are going to trial next week.

The lawsuit epitomises a new breed of mass claims in the UK, financed in part by hedge funds and other specialist litigation funders.

“Law firms and funders have invested hugely in this case,” said David Greene, head of commercial disputes and class actions at law firm Edwin Coe, who is not involved in the case. “If it were to be lost, I think that would be quite a blow.”

The court selected the five carmakers as “lead defendants” in an attempt to narrow what one defendant lawyer in the highly complex case said would otherwise be “unmanageable” litigation. The findings on law by the presiding judge, Mrs Justice Sara Cockerill, will establish precedent to apply to the other manufacturers.

Various other carmakers have long faced allegations around the world that they cheated on emissions tests, albeit not on the scale of VW.

In the US, Daimler, since renamed Mercedes-Benz, settled outstanding cases for roughly $2.2bn in 2020. Fiat Chrysler, now part of Stellantis, has paid out about $800mn in 2019 to resolve civil claims and another $300mn in 2022 in criminal penalties.

Carmakers have also faced litigation in Europe. Diesel emissions cases are pending in the Netherlands, Portugal and Germany. 

Yet the lawsuit in England and Wales would be one of the most consequential in Europe.

“We certainly accept that VW was an extreme example” of cheating on tests, said Martyn Day, co-founder of Leigh Day, the lead claimant solicitor firm on the case. “But we expect the judge to find that there were defeat devices in each of the vehicles.”

The value of the lawsuit has not yet been formally quantified, though claimant lawyers have said compensation could come to several thousands of pounds per vehicle owner — amounting to a total bill to the car industry running into billions.

The first part of the trial, to be heard over 10 weeks, will examine whether the manufacturers installed defeat devices, contrary to the law.

Even if liability is established, another trial would need to go ahead before the size of any payouts can be determined. The industry would be likely to contest the degree to which the misleading of regulators about emissions necessarily translates into financial losses for car owners.

Next week’s trial will even feature sample vehicles — 20 in total, across the five defendant manufacturers. Examiners at various testing centres across England have assessed how nitrogen oxide emissions compare during different conditions.

The tests that regulators originally conducted were carried out under particular conditions — at set inclines and driving speeds, for instance. The claimants argue that the “defeat devices” were designed to reduce emissions under these circumstances.

In court documents, claimant lawyers contend the manufacturers programmed the vehicles to detect when they were being examined. Nitrogen oxide emissions were “materially higher” during normal vehicle operation than the levels recorded in official tests, they maintain.

VW is among the wider group of defendants in the case, despite having earlier reached a £193mn settlement in the UK in 2022.

The settlement covered a different engine and concluded with no admission of liability. In relation to the latest case, VW said it “continues to hold the view that these claims are not justified, regrets that they have been made, and intends to defend them robustly”.

Lawyers for other carmakers are expected to argue in court that the claimants are seeking erroneously to associate the rest of the industry with the VW dieselgate scandal.

Carmakers are set to argue that the claimants have misunderstood the vehicles’ emission control systems and that their case is fundamentally flawed.

Mercedes-Benz, which is facing the largest number of claims in the case, said it has voluntarily been carrying out software updates on certain types of its diesel vehicles to reduce nitrogen oxide emissions.

“We continue to take steps to mitigate the impact of vehicle emissions and to further climate protection and air quality,” it said.

The German group has also said it would “vigorously defend” itself against the claims which it believed were without merit.

Ford, Nissan, Renault and Stellantis, the European group behind Peugeot and Citroën, also said their vehicles and engines were all compliant with applicable standards, and that they would defend the claims.

But Kamenetzky said he was “kind of stuck with” his Mercedes-Benz, given the decline in diesel car values.

“I’m needing the payout — to be able to purchase a car that actually does have sufficient technology to be clean.”

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First Brands Group’s chief executive may step down from the bankrupt car parts maker as lenders push for his removal in the face of mounting losses on billions of dollars in debt, according to people familiar with the matter.

A spokesperson for Patrick James said the First Brands founder was considering “relinquishing his role” atop the embattled group in response to questions from the Financial Times.

“Patrick James has always put the interests of First Brands Group ahead of his own and is evaluating his best path forward to help maximise value for its customers, suppliers, employees and lenders,” the spokesperson said.

The potential departure of James would cap a tumultuous few weeks for the low-profile executive, whose company has borrowed from some of the biggest institutions on Wall Street to finance a breakneck acquisition spree.

Its swift collapse has prompted an inquiry from the US Department of Justice, the Financial Times reported earlier this week. Federal prosecutors are in the early stage of looking into alleged financial irregularities.

James could be pushed out in the coming days, one of the people noted. The company is at the mercy of its lenders to fund its operations through bankruptcy.

Creditors have agreed to lend $1.1bn to stabilise the company’s business through bankruptcy, capital that is contingent on First Brands hitting milestones. Advisers to the company estimate it will burn through more than $900mn between its filing for Chapter 11 bankruptcy protection in September and late December.

James’ brother, Edward, stepped down from his senior role at the company, the people said.

Charles Moore, an executive from turnaround advisory firm Alvarez & Marsal, took the reins as chief restructuring officer as part of the bankruptcy. Stakeholders kept Patrick James in place for his co-operation during what has been a chaotic sprint to file for bankruptcy protection and keep the business operating, the people said.

A First Brands representative declined to comment. Alvarez did not respond to a request for comment.

Michael Baker, who served as First Brands’ chief corporate strategy officer, has also stepped down, said people familiar with the matter. His LinkedIn profile shows his work in the position ended in September. Baker joined First Brands in 2021 from law firm Paul Hastings, where he had served as a partner for a decade.

First Brands’ rapid downfall alongside the collapse of subprime car lender Tricolor at the start of the month has raised concerns of significant losses for some of the best-known players on Wall Street, as well as the potential for a wider fallout across debt markets.

The company, which makes Michelin-branded windshield wipers in Europe and Carter fuel pumps in the US, has amassed nearly $12bn of debt and off-balance sheet financing. Its roughly $5.5bn of term loans is now quoted at cents on the dollar, with an implied loss of more than $4bn.

The company was also a heavy user of off-balance sheet financing, selling customer invoices at a discount to funds owned by units of the investment bank Jefferies, Swiss bank UBS and Katsumi Global, a financing company owned by Japan’s Mitsui & Co and Norinchukin Bank.

One of its lenders earlier this week claimed as much as $2.3bn has “simply vanished”, and First Brands’ advisers said they are unable to locate the related collateral.

Meanwhile, BlackRock and Morgan Stanley have sought to redeem their stakes in a Jefferies fund that extended $715mn in credit to First Brands’ customers, said people familiar with the matter. The redemption requests were reported earlier by Bloomberg.

Morgan Stanley, BlackRock and Jefferies declined to comment.

In the 2000s, James, 61, acquired industrial businesses, including Columbus Component Group, an Indiana-based car parts manufacturing business. After several of these companies experienced financial difficulties during the 2008 financial crisis, James and other companies linked to him were sued by two lenders alleging fraudulent conduct had exacerbated their losses. James denied the allegations and the cases were dismissed after they ended in settlement.

James established Crowne Group, which in 2014 acquired Michigan-based Trico Products, a manufacturer of windscreen wipers. The combined group then pursued further debt-funded acquisitions, rebranding as First Brands Group.

Edward James played a key role in raising First Brands’ invoice and inventory financing, according to several specialists in the area who said they met with him to negotiate loans.

First Brands described Edward James as having held various roles at the company including in “finance, accounting and working capital solutions”, in a 2023 filing with the Securities and Exchange Commission.

Additional reporting by Sujeet Indap, Kate Duguid and Joshua Franklin in New York