Clinics and Practice

16 pages, 298 KB

Open AccessEditor’s ChoiceReview

Acute Aortic Syndrome: From Risk Factors to Hospital Burden and Healthcare Resource Utilization

by Cosmin Marian Banceu, Diana Mariana Banceu, Marius Mihai Harpa, Daiana Cristutiu, Mihai Calinescu and Horatiu Suciu

Clin. Pract. 2026, 16(7), 121; https://doi.org/10.3390/clinpract16070121 - 27 Jun 2026

Viewed by 609

Abstract

Acute aortic syndrome (AAS) comprises acute aortic dissection, intramural haematoma, penetrating atherosclerotic ulcer, and limited intimal tear, conditions that require rapid recognition because mortality and resource use are strongly influenced by time to diagnosis, anatomical extent, malperfusion, and the need for emergency surgical [...] Read more.

Acute aortic syndrome (AAS) comprises acute aortic dissection, intramural haematoma, penetrating atherosclerotic ulcer, and limited intimal tear, conditions that require rapid recognition because mortality and resource use are strongly influenced by time to diagnosis, anatomical extent, malperfusion, and the need for emergency surgical or endovascular intervention. This revised narrative review synthesizes contemporary evidence on clinical, genetic, environmental, and health-system determinants of prolonged hospitalisation, intensive care unit (ICU) utilisation, bed occupancy, and costs in patients with AAS. Beyond summarising established risk factors, the review adds a resource-oriented framework that links hypertension, advanced age, female sex, smoking-related comorbidity, hereditary aortopathies, haemodynamic instability, malperfusion, delayed diagnosis, operative complexity, and postoperative complications to measurable downstream outcomes such as ICU length of stay, total hospital length of stay, reoperation, readmission, and longitudinal imaging surveillance. We searched PubMed/MEDLINE, Scopus, Web of Science, and Google Scholar for relevant studies, registries, guideline documents, and cost analyses published between January 2000 and May 2026, with particular emphasis on studies from the last five years. The review was not designed as a meta-analysis; therefore, effect estimates are interpreted according to study design and generalisability. AAS imposes a disproportionate burden on hospital systems because high-risk patients often require advanced imaging, prolonged haemodynamic monitoring, complex open or endovascular repair, ICU care, and lifelong follow-up. Earlier diagnosis, structured risk stratification, targeted genetic evaluation, aggressive control of modifiable risk factors, and system-level pathways such as dedicated aortic networks may shorten hospital stay and reduce avoidable costs. Full article

21 pages, 2554 KB

Open AccessEditor’s ChoiceReview

Prevention of Gastrointestinal Bleeding in Patients Receiving Direct Oral Anticoagulants: A Narrative Review and Practical Framework for Prescribers

by Nicoleta Dubei, Larisa Anghel, Laura-Cătălina Benchea, Radu Andy Sascău, Cristina Prisacariu, Mircea Ovanez Balasanian, Bogdan-Sorin Tudurachi, Bianca-Ștefania Profire and Cristian Stătescu

Clin. Pract. 2026, 16(7), 120; https://doi.org/10.3390/clinpract16070120 - 26 Jun 2026

Viewed by 773

Abstract

Background/Objectives: As population aging increases the prevalence of atrial fibrillation (AF), the use of direct oral anticoagulants (DOACs) has expanded for thromboembolism prevention. Although DOACs offer advantages over vitamin K antagonists (VKAs), gastrointestinal bleeding (GIB) remains the most common extracranial adverse event. [...] Read more.

Background/Objectives: As population aging increases the prevalence of atrial fibrillation (AF), the use of direct oral anticoagulants (DOACs) has expanded for thromboembolism prevention. Although DOACs offer advantages over vitamin K antagonists (VKAs), gastrointestinal bleeding (GIB) remains the most common extracranial adverse event. Current guidelines address global bleeding risk but provide limited guidance on site-specific gastrointestinal risk assessment and prevention. This narrative review aims to summarize current evidence on the mechanisms, etiologies, and risk factors for DOAC-associated gastrointestinal bleeding and to propose a pragmatic, risk-based framework to support clinicians in individualized bleeding prevention. Methods: A narrative review of studies published between 2004 and 2025 was conducted, including randomized clinical trials, real-world evidence, meta-analyses, and major society guidelines. Evidence addressing DOAC safety profiles, gastrointestinal bleeding etiologies, patient-level risk factors, medication interactions, and preventive strategies was analyzed. Results: Gastrointestinal bleeding in patients treated with DOAC is strongly influenced by underlying gastrointestinal pathology, comorbid conditions, and concomitant medications. Established risk factors include prior gastrointestinal hemorrhage, Helicobacter pylori infection, gastrointestinal malignancy, diverticulosis, and angiodysplasia, as well as the use of nonsteroidal anti-inflammatory drugs (NSAIDs), antiplatelet therapy, or selective serotonin reuptake inhibitors (SSRIs). DOACs differ in gastrointestinal safety: apixaban consistently demonstrates the most favorable profile, whereas rivaroxaban and high-dose dabigatran show higher GIB rates. Preventive strategies such as H. pylori testing and eradication, proton pump inhibitor use in high-risk individuals, avoidance of NSAIDs and unnecessary antiplatelet therapy, and individualized DOAC selection may help reduce bleeding risk. Conclusions: Gastrointestinal bleeding risk in patients receiving DOAC therapy should be assessed using a site-specific and dynamic approach. A structured strategy integrating baseline risk evaluation, correction of modifiable factors, tailored anticoagulant selection, and risk-adapted follow-up may improve the safety of anticoagulation. The proposed framework may provide a pragmatic approach to individualized bleeding risk mitigation while preserving the benefits of DOAC therapy; however, prospective validation is required before its routine implementation can be recommended. Full article

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9 pages, 1145 KB

Open AccessEditor’s ChoiceArticle

Ultrasound-Guided Intra-Articular Infiltration of Hyaluronic Acid, Lidocaine, and Methylprednisolone in Patients with Temporomandibular Disorders (TMD): A Preliminary Pilot Case Series

by Giuseppe Messina, Francesco Mantia, Pietro Cataldo and Angelo Iovane

Clin. Pract. 2026, 16(6), 111; https://doi.org/10.3390/clinpract16060111 - 12 Jun 2026

Viewed by 870

Abstract

Background/Objectives: This preliminary pilot case series aims to evaluate the feasibility and temporal evolution of pain and function following an ultrasound-guided infiltration technique with hyaluronic acid and methylprednisolone in a specific patient population with Temporomandibular Disorders (TMD) characterized by MRI-confirmed retrodiscal tissue hyperemia. [...] Read more.

Background/Objectives: This preliminary pilot case series aims to evaluate the feasibility and temporal evolution of pain and function following an ultrasound-guided infiltration technique with hyaluronic acid and methylprednisolone in a specific patient population with Temporomandibular Disorders (TMD) characterized by MRI-confirmed retrodiscal tissue hyperemia. Given the absence of a control group, this study represents a preliminary exploration of a clinical approach utilizing individualized interocclusal devices during infiltration. Methods: Twenty-eight patients (16 females, 12 males) with TMD and MRI evidence of retrodiscal tissue hyperemia were enrolled in this prospective, uncontrolled study. A unique protocol was employed, utilizing individualized interocclusal devices to optimize joint space access during bilateral ultrasound-guided infiltration of a mixture containing low-molecular-weight hyaluronic acid, lidocaine, and methylprednisolone acetate. Pain intensity (VAS 0–100 mm) and associated symptoms (tinnitus, vertigo, headache, joint clicking) were assessed at baseline and at 30, 60, and 90 days’ follow-up. Results: A statistically significant temporal reduction in pain was observed at all follow-up points (p < 0.001), with the mean VAS score decreasing from 70.5 ± 11.4 mm at baseline to 43.0 ± 11.1 mm at 90 days. Joint clicking disappeared in 80% of patients immediately after treatment. Conclusions: The ultrasound-guided infiltration technique, combined with personalized interocclusal support, demonstrated preliminary feasibility and short-term temporal improvement in pain and joint clicking in this specific patient cohort. Due to the lack of a control group and the multimodal nature of the intervention, these findings should be considered preliminary and do not allow for causal inferences regarding the efficacy of individual components. Full article

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13 pages, 979 KB

Open AccessEditor’s ChoiceArticle

Factors Associated with Long COVID in the Pediatric Population: A Retrospective Case–Control Study

by Ioana Maria Otilia Lică, Iulia Florentina Țincu, Anca Cristina Drăgănescu and Doina Anca Pleșca

Clin. Pract. 2026, 16(6), 105; https://doi.org/10.3390/clinpract16060105 - 31 May 2026

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Abstract

Background: Long COVID in children is increasingly recognized, yet its clinical predictors and objective biological correlates remain insufficiently characterized. Objectives: The objective was to compare clinical, demographic, and laboratory characteristics between children with and without long COVID and to identify associated variables. Methods: [...] Read more.

Background: Long COVID in children is increasingly recognized, yet its clinical predictors and objective biological correlates remain insufficiently characterized. Objectives: The objective was to compare clinical, demographic, and laboratory characteristics between children with and without long COVID and to identify associated variables. Methods: We conducted a retrospective observational case–control study at the “Dr. Victor Gomoiu” Children’s Clinical Hospital, including pediatric patients with confirmed SARS-CoV-2 infection. Cases were defined as children with symptoms persisting ≥12 weeks after acute infection, while controls had no persistent symptoms at ≥12 weeks. Results: Eighty-nine children with long COVID and 88 matched controls were included. Children with long COVID were significantly older (1.79 ± 0.90 vs. 1.14 ± 0.80 years, p < 0.001) and more frequently from urban areas (86.5% vs. 69.3%, p = 0.0099). Lymphocyte, monocyte, and basophil counts were significantly lower in the Long COVID group, while D-dimer, ferritin, serum iron, urea, and creatinine levels were significantly higher. A multivariate predictive model demonstrated excellent discrimination (AUC = 0.94), with optimal sensitivity (84.3%) and specificity (89.8%) at a probability threshold of 0.48. Conclusions: Long COVID in children was associated with identifiable clinicobiological features. An exploratory composite model showed good discrimination but requires external validation. Full article

(This article belongs to the Topic Advances in Chronic Disease Management)

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12 pages, 240 KB

Open AccessEditor’s ChoiceArticle

Clinical Characteristics, Risk Score Distribution, and Hospitalization Status in Emergency Department Patients with Acute Chest Pain: A Single-Center Retrospective Four-Year Study

by Gabriela-Florentina Țapoș, Dan Iliescu, Mihaela Cristina Negru, Florin Borcan, Silvia Luca, Simina Crișan and Constantin Tudor Luca

Clin. Pract. 2026, 16(6), 103; https://doi.org/10.3390/clinpract16060103 - 29 May 2026

Viewed by 1039

Abstract

Background/Objectives: Cardiovascular diseases are a major cause of morbidity and mortality worldwide. Acute chest pain is a frequent reason for emergency department presentation and requires structured evaluation to identify life-threatening conditions. This study evaluated clinical characteristics, cardiovascular risk profile, risk stratification patterns, and [...] Read more.

Background/Objectives: Cardiovascular diseases are a major cause of morbidity and mortality worldwide. Acute chest pain is a frequent reason for emergency department presentation and requires structured evaluation to identify life-threatening conditions. This study evaluated clinical characteristics, cardiovascular risk profile, risk stratification patterns, and hospitalization status in adults with acute chest pain. Methods: We conducted a retrospective study using registry data from Arad County Clinical Emergency Hospital between January 2021 and December 2024. Adult patients with documented acute chest pain were included according to predefined criteria. Demographics, comorbidities, clinical presentation, troponin values, hospitalization status, and HEART, and EDACS categories were extracted when available. The Marburg Heart Score was also assessed as an exploratory complementary score. Statistical analysis used descriptive statistics, contingency tables, and chi-square testing, with available-case analysis. Results: Overall, 2070 patients were included. Most patients were aged 35–54 or 55–69 years. Hypertension and diabetes mellitus were the most common comorbidities, and pressure-like chest pain predominated. In unadjusted analyses, HEART and EDACS categories were significantly associated with hospitalization status across all study years. Score categories were significantly associated with hospitalization status across all study years. Age was consistently associated with cardiovascular comorbidity burden and higher-risk score categories. Conclusions: Structured risk stratification scores were associated with hospitalization status, while age was associated with cardiovascular risk burden. Full article

22 pages, 4604 KB

Open AccessEditor’s ChoiceReview

Artificial Intelligence in Rare Diseases: Workflow-Integrated Precision Kidney Care

by Charat Thongprayoon, Francesco Pesce and Wisit Cheungpasitporn

Clin. Pract. 2026, 16(6), 101; https://doi.org/10.3390/clinpract16060101 - 27 May 2026

Viewed by 1749

Abstract

Rare diseases affect over 300 million individuals worldwide yet remain underdiagnosed and poorly characterized due to fragmented data, small cohorts, and phenotypic heterogeneity. Advances in artificial intelligence (AI) are enabling integration of genomics, imaging, electronic health records, and patient-generated data to support diagnosis, [...] Read more.

Rare diseases affect over 300 million individuals worldwide yet remain underdiagnosed and poorly characterized due to fragmented data, small cohorts, and phenotypic heterogeneity. Advances in artificial intelligence (AI) are enabling integration of genomics, imaging, electronic health records, and patient-generated data to support diagnosis, phenotyping, prognosis, and therapeutic discovery. In kidney care, these capabilities are reflected in tools for genomic variant prioritization, AI-assisted histopathology, and integrated risk stratification models for rare and complex kidney diseases. This review synthesizes current AI applications across the rare disease continuum and proposes a clinically grounded framework to distinguish exploratory models from systems that are methodologically robust and operationally deployable. We highlight advances that address data sparsity and heterogeneity, alongside persistent challenges in validation, generalizability, equity, and workflow integration. Finally, we outline future directions, including federated learning, digital twins, and AI-driven clinical decision agents, as pathways toward precision-guided, workflow-integrated rare disease care. Full article

(This article belongs to the Topic Artificial Intelligence in Public Health: Current Trends and Future Possibilities, 3rd Edition)

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12 pages, 602 KB

Open AccessEditor’s ChoiceArticle

Non-Invasive Monitoring of Hemodialysis Patients: Challenges and Benefits in the Real World

by Orsolya Sáfár, Viktor Horváth, Árpád Kézdi, Péter Kevei and Ákos Géza Pethő

Clin. Pract. 2026, 16(6), 98; https://doi.org/10.3390/clinpract16060098 - 22 May 2026

Viewed by 1111

Abstract

Background: Cardiovascular complications are the leading cause of death in patients with end-stage renal disease (ESRD). Hemodialysis involves rapid electrolyte shifts and sudden fluid removal, which can affect ventricular repolarization and trigger arrhythmias in patients with ESRD. To enhance patient care, it [...] Read more.

Background: Cardiovascular complications are the leading cause of death in patients with end-stage renal disease (ESRD). Hemodialysis involves rapid electrolyte shifts and sudden fluid removal, which can affect ventricular repolarization and trigger arrhythmias in patients with ESRD. To enhance patient care, it is crucial to regularly assess cardiac function using noninvasive and painless methods, such as Holter electrocardiography (ECG) and routine cardiac ultrasound. These evaluations may inform improved prevention strategies to reduce the risk of elevated cardiovascular mortality rates. Methods: In total, 40 patients with ESRD on chronic hemodialysis (HD) were approached, and only 18 were enrolled from September 2024 to July 2025. Detailed medical information was provided, and written informed consent was obtained from the patient. The median duration of Holter ECG recording was 84.65 h, and cardiac ultrasound examinations were conducted. Blood gas samples were collected hourly during the second dialysis session. Results: Surprisingly, one-third of the patients opted to withdraw their consent for this painless investigation. No significant differences were observed in the QT and QTc intervals between the dialysis and non-dialysis days (p = 0.184 and p = 0.446, respectively). However, a significant increase was observed during the first 3 h of dialysis when analyzing the intradialytic period. Conclusion: Some patients showed clinically significant changes in QT and QTc intervals during treatment, which could not be confirmed statistically. Although we did not formulate a hypothesis, it is essential to recognize that patient compliance significantly influences the cardiovascular outcomes of individuals undergoing hemodialysis. Full article

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22 pages, 1336 KB

Open AccessEditor’s ChoiceSystematic Review

Effectiveness and Safety of Hormonal Treatments in Children with Growth Disorders: A Systematic Review of Clinical Evidence

by Isidro Miguel Martín Pérez and Sebastián Eustaquio Martín Pérez

Clin. Pract. 2026, 16(5), 96; https://doi.org/10.3390/clinpract16050096 - 20 May 2026

Viewed by 1547

Abstract

Background: Growth disorders, including central precocious puberty and delayed puberty, can significantly affect linear growth, skeletal maturation, metabolic regulation, and psychosocial development during childhood and adolescence. This systematic review synthesizes the current evidence regarding the effectiveness and safety of hormone-based therapies used [...] Read more.

Background: Growth disorders, including central precocious puberty and delayed puberty, can significantly affect linear growth, skeletal maturation, metabolic regulation, and psychosocial development during childhood and adolescence. This systematic review synthesizes the current evidence regarding the effectiveness and safety of hormone-based therapies used in children with disorders of pubertal maturation. Methods: A PRISMA-guided systematic search was carried out between January 2016 and March 2026 in different databases, such as MEDLINE (PubMed), EMBASE, CENTRAL, Scopus, Web of Science, CINAHL, LILACS and OpenGrey; the protocol was previously registered in the PROSPERO database (CRD420251068048). Non-randomized, randomized controlled trials and observational research including participants aged 0–18 years receiving hormone therapies were eligible. Risk of bias was assessed using validated, design-specific tools. Results: Twenty studies involving 21,812 participants were included. GnRHa therapy improved final adult height (+3.5 to +4.5 cm) and reduced bone age advancement (−0.6 to −1.3 years) in children with central precocious puberty. rhGH therapy increased growth velocity (+3.0 to +5.0 cm/year) and height SDS (+0.3 to +0.9), particularly in idiopathic short stature and Prader–Willi syndrome. Combined GnRHa plus rhGH therapy showed greater short-term growth benefits than GnRHa alone. Both therapies showed favorable safety profiles, with predominantly mild adverse events and discontinuation rates below 2%. However, the evidence was limited by substantial heterogeneity and moderate-to-serious risk of bias. Conclusions: GnRHa and rhGH therapies are generally effective and safe for improving growth and pubertal outcomes in pediatric endocrine disorders. However, further long-term studies are needed to clarify their metabolic and psychosocial effects in adulthood. Nevertheless, these conclusions should be interpreted with caution due to the study’s moderate-to-serious risk of bias and heterogeneity. Full article

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15 pages, 1467 KB

Open AccessEditor’s ChoiceReview

A Clinical Decision Support System for Post-Surgical Cardiovascular Remote Monitoring

by Charalampia Pylarinou, Francesk Mulita, Efstratios Koletsis, Vasileios Leivaditis, Elias Liolis, Lefteris Gortzis and Dimosthenis Mavrilas

Clin. Pract. 2026, 16(5), 93; https://doi.org/10.3390/clinpract16050093 - 15 May 2026

Cited by 2 | Viewed by 701

Abstract

Background: Post-surgical cardiovascular monitoring places a heavy information burden on clinical teams, requiring the rapid synthesis of patient history, intraoperative data, monitoring streams, and surgical outcome evidence. Existing clinical decision support systems handle this integration poorly, and most offer little visibility into their [...] Read more.

Background: Post-surgical cardiovascular monitoring places a heavy information burden on clinical teams, requiring the rapid synthesis of patient history, intraoperative data, monitoring streams, and surgical outcome evidence. Existing clinical decision support systems handle this integration poorly, and most offer little visibility into their reasoning. We present a Retrieval-Augmented Generation (RAG) architecture designed specifically for this domain, with a focus on evidence traceability and practical workflow integration. Methods: We describe a three-layer RAG architecture comprising a retrieval layer that creates 768-dimensional representations of clinical scenarios; an augmentation layer using a stacking ensemble (Random Forest and XGBoost base learners with a logistic-regression meta-learner) to integrate patient-specific data with retrieved evidence and produce calibrated probability estimates; and a generative layer using a fine-tuned BERT classifier together with Gemini 2.5 Pro to synthesise actionable clinical recommendations. Components were prototyped on publicly available, de-identified data from MIMIC-III and the MIMIC-III-Ext-PPG benchmark to verify pipeline integrity. Proposed Evaluation Framework: This paper presents a system architecture rather than a clinically validated implementation. We outline a structured evaluation framework to assess the technical performance and clinical applicability of the RAG architecture, encompassing the technical validation of system components, expert assessment of clinical workflow integration potential, and analysis of interpretability features essential for healthcare deployment. Specific technical targets include retrieval precision >90% for relevant evidence, query response time <3 s, and a clinical appropriateness rating of >85% from expert review. Conclusions: We describe a RAG architecture for post-surgical cardiovascular monitoring in which every recommendation is linked to retrievable source documents, making the reasoning visible and challengeable. A structured evaluation framework is proposed to guide the system towards clinical validation. Full article

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12 pages, 496 KB

Open AccessEditor’s ChoiceSystematic Review

An Update on Umbilical Cord Abnormalities and Associated Thrombosis: A Systematic Review

by Marco La Verde, Eleonora Braca, Antonio Cerillo, Maria Fatigati, Pasquale De Franciscis, Davide Pisani, Mario Fordellone, Mariavictoria De Simone, Carlo Pietro Campobasso and Alessandro Feola

Clin. Pract. 2026, 16(5), 92; https://doi.org/10.3390/clinpract16050092 - 14 May 2026

Viewed by 1429

Abstract

Background and objective: Umbilical cord abnormalities (UCAs) such as hypercoiling, velamentous or marginal cord insertion, or reduced Wharton’s jelly are associated with umbilical thrombosis. UCAs increase the risk of vascular obstruction and impaired fetal blood flow, resulting in hypoxia or stillbirth. We [...] Read more.

Background and objective: Umbilical cord abnormalities (UCAs) such as hypercoiling, velamentous or marginal cord insertion, or reduced Wharton’s jelly are associated with umbilical thrombosis. UCAs increase the risk of vascular obstruction and impaired fetal blood flow, resulting in hypoxia or stillbirth. We examined the association between the UCAs and the umbilical cord thrombosis. Methods: According to PRISMA, five electronic databases (PubMed, Scopus, Embase, Cochrane Library, and Clinicaltrial.gov) were screened. Only studies that analyzed umbilical cord insertion abnormalities and abnormalities of the umbilical cord associated with thrombosis were included in this systematic review. Studies without thrombosis were excluded (PROSPERO ID: CRD420251087525). Results: Only 12 articles out of 1105 screened records satisfied the inclusion criteria, comprising 3 retrospective cohort studies, 3 case series and 6 case reports. The publication years ranged from 1983 to 2025. A total of 126 cases of umbilical vascular thromboembolism (UVTE) were identified, among which 84 cases of UCAs represented by 16 cases of stricture, 14 cases of hypercoiling, 16 cases of too-short cords (≤40 cm), 11 cases of too-long cords (≥70 cm), 5 cases of velamentous or furcate cord insertions, 12 cases of nuchal cord insertions, 13 cases of funistisis, 11 cases of true knots, and 3 cases of Wharton jelly abnormalities. Conclusions: UCAs, including true knots, abnormal coiling, and furcate or velamentous cord insertion, were highly associated with UVTE. Future studies should involve developing standardized criteria for the diagnosis and reporting of UCAs. Full article

(This article belongs to the Section Reproductive Medicine and Women’s Health)

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16 pages, 1116 KB

Open AccessEditor’s ChoiceArticle

Development of a Core Set of Nursing-Sensitive Patient Outcomes in Intensive Care Units: A Delphi Consensus Study

by Luciano Cellura, Anna Maria Grugnetti, Stefano Gabriele Scaglia, Attilio Quaini, Silvia Natoli and Giuseppina Grugnetti

Clin. Pract. 2026, 16(5), 89; https://doi.org/10.3390/clinpract16050089 - 30 Apr 2026

Viewed by 970

Abstract

Introduction/Aim: Nursing care constitutes a fundamental determinant of patient outcomes in intensive care units (ICUs); however, the absence of standardised nursing-sensitive indicators constrains the objective evaluation of care quality within this setting. The present study aimed to develop an evidence-informed core set [...] Read more.

Introduction/Aim: Nursing care constitutes a fundamental determinant of patient outcomes in intensive care units (ICUs); however, the absence of standardised nursing-sensitive indicators constrains the objective evaluation of care quality within this setting. The present study aimed to develop an evidence-informed core set of nursing-sensitive patient outcomes (NSPOs) specific to intensive care nursing. Methods: A Delphi consensus study was conducted between September 2023 and February 2025 at the IRCCS Policlinico San Matteo Foundation, Pavia, Italy. The process comprised a preliminary scoping review, followed by two iterative Delphi rounds and a final consensus meeting aimed at refining conceptual domains without modifying item ratings. Thirty-eight ICU nurses evaluated 35 evidence-based NSPOs using a five-point Likert scale. Consensus was defined a priori as ≥75% agreement (scores 4–5), with a minimum response rate of ≥80%. Reliability was assessed using a two-way random-effects Intraclass Correlation Coefficient (ICC). Results: Fifteen NSPOs achieved the predefined consensus threshold and demonstrated moderate-to-excellent reliability (ICC = 0.65–0.85). The validated core set was organised into four domains—safety, clinical, functional, and perceptual—reflecting both preventive–technical and holistic dimensions of ICU nursing care. Conclusions: This study produced the first ICU-specific evidence-based NSPO core set in Italy, providing a measurable and reproducible framework to support systematic outcome monitoring, and quality improvement in critical care practice. Full article

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16 pages, 473 KB

Open AccessEditor’s ChoiceArticle

Efficacy and Safety of Glycerol Lidocaine Ear Drops in the Non-Antibiotic Treatment of Otitis Externa Symptoms—An Observational Study

by Maria Sobol, Ewelina Sielska-Badurek, Mariusz Cięciara, Artur Wrzosek, Justyna Tomaszewska and Beata Roman

Clin. Pract. 2026, 16(5), 90; https://doi.org/10.3390/clinpract16050090 - 30 Apr 2026

Viewed by 1630

Abstract

Purpose: The aim of this study was to investigate the safety and efficacy, as well as relief of symptoms after regular use, of 0.5% lidocaine hydrochloride solution in anhydrous glycerol (Auridol) in the form of ear drops, in patients with symptoms of [...] Read more.

Purpose: The aim of this study was to investigate the safety and efficacy, as well as relief of symptoms after regular use, of 0.5% lidocaine hydrochloride solution in anhydrous glycerol (Auridol) in the form of ear drops, in patients with symptoms of otitis externa (OE) in a real-world setting. Methods: This real-world pre–post study included 64 subjects aged 1 to 69 years with symptoms as follow: swelling, pain due to regular exposure to water or caused by frequent use of detergents, pain due to prolonged wearing of earphones, or earwax clogging the external auditory canal. In each subject, following an otoscopic examination and interview given by an ENT, the Auridol treatment was initiated. The product was administered as two drops into the affected ear up to three times daily in patients with symptoms of OE. During each visit, physical and functional symptom were evaluated. In addition, the efficacy of using the product was assessment using a VAS scale. At the end of the study, subjects rated the product according to a Likert scale. Results: A statistically significant reduction in perceived pain was observed at t = 30′ as well as t = 3 days after application. For physical symptoms assessed by an ENT, a statistically significant difference was observed between consecutive scores for two of the assessed parameters (redness and swelling.) The product was rated very highly by the subjects. Conclusions: The results suggest that a combination of anhydrous glycerol and 0.5% of lidocaine in the form of ear drops has a positive effect in the treatment of symptoms of OE. Full article

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12 pages, 1794 KB

Open AccessEditor’s ChoiceCase Report

Steroid Refractory and Plasma Exchange Partially Responsive Longitudinally Extensive Transverse Myelitis Due to Tumor Necrosis Factor-Alpha (Etanercept): A Case Report

by Jelena Stojsavljevic, Rafael R. Perez, Emilia Petcu, Celestine Odenigbo, Cristian Madrid, Igor Dumic and Charles W. Nordstrom

Clin. Pract. 2026, 16(5), 86; https://doi.org/10.3390/clinpract16050086 - 29 Apr 2026

Cited by 1 | Viewed by 1185

Abstract

Background: Acute transverse myelitis (ATM) is an inflammatory disorder of the spinal cord with heterogeneous etiologies, including autoimmune, infectious, paraneoplastic, and drug-induced causes. Tumor necrosis factor-alpha (TNF-α) inhibitors have been infrequently associated with inflammatory central nervous system events, including transverse myelitis. TNF-inhibitor-associated myelitis [...] Read more.

Background: Acute transverse myelitis (ATM) is an inflammatory disorder of the spinal cord with heterogeneous etiologies, including autoimmune, infectious, paraneoplastic, and drug-induced causes. Tumor necrosis factor-alpha (TNF-α) inhibitors have been infrequently associated with inflammatory central nervous system events, including transverse myelitis. TNF-inhibitor-associated myelitis typically presents with short-segment lesions, a normal brain MRI, and partial responsiveness to corticosteroids. Longitudinally extensive transverse myelitis (LETM) and steroid-refractory cases are uncommon. Case Presentation: A 39-year-old woman with psoriatic arthritis treated with etanercept for two years presented with subacute progressive bilateral lower-extremity sensory loss and weakness. MRI revealed a T2 hyperintense spinal cord lesion extending from T11 to L1 with gadolinium enhancement, consistent with transverse myelitis, while brain MRI was normal. Cerebrospinal fluid analysis showed lymphocytic pleocytosis, elevated protein, oligoclonal bands, and increased kappa free light chains. Extensive infectious, metabolic, paraneoplastic, and autoimmune testing, including aquaporin-4 and MOG antibodies, was negative. Despite high-dose intravenous corticosteroids and the discontinuation of etanercept, the patient experienced clinical worsening with lesion expansion, meeting criteria for LETM, and developed urinary retention. She subsequently underwent plasma exchange, resulting in radiologic improvement and moderate clinical recovery. Conclusions: This case highlights an atypical presentation of TNF-inhibitor-associated myelitis characterized by a biphasic course, longitudinally extensive spinal cord involvement, steroid refractoriness, and responsiveness to plasma exchange. These features suggest either an unusually severe TNF-inhibitor-related inflammatory phenotype or a TNF-inhibitor-triggered antibody-mediated demyelinating process. Reports of TNF-inhibitor-associated myelitis evolving into longitudinally extensive, steroid-refractory disease remain limited, and this presentation may broaden the recognized clinical spectrum of TNF-α-related CNS inflammatory events. Close neurologic follow-up and heightened awareness of severe CNS complications associated with TNF-α inhibitors are warranted. Full article

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13 pages, 285 KB

Open AccessEditor’s ChoiceArticle

Efficacy of Combining Kegel Exercises with EMS-Based Pelvic Floor Muscle Electrostimulation in Postmenopausal Women with Involuntary Urinary Leakage

by Lucian Șerbănescu, Sebastian Mirea, Paris Ionescu, Ionuț Iorga, Traian-Virgiliu Surdu, Vadym Rotar, Stere Popescu, Elena Mocanu, Luana Alexandrescu, Cosmin Nișcoveanu and Radu-Andrei Baz

Clin. Pract. 2026, 16(5), 85; https://doi.org/10.3390/clinpract16050085 - 29 Apr 2026

Viewed by 1680

Abstract

Background/Objectives: Urinary incontinence (UI) is a frequent condition in postmenopausal women and is associated with a substantial negative impact on quality of life. Conservative management can include pelvic floor muscle training (PFMT) and high-intensity focused electromagnetic stimulation (HIFEM); however, data regarding the potential [...] Read more.

Background/Objectives: Urinary incontinence (UI) is a frequent condition in postmenopausal women and is associated with a substantial negative impact on quality of life. Conservative management can include pelvic floor muscle training (PFMT) and high-intensity focused electromagnetic stimulation (HIFEM); however, data regarding the potential benefit of combining these modalities remain limited. This study aimed to evaluate whether the addition of a structured Kegel exercise program to EMSELLA-based electromagnetic stimulation is associated with enhanced clinical outcomes in postmenopausal women with urinary incontinence. Methods: This prospective comparative study included 99 postmenopausal women with stress, urgency, or mixed urinary incontinence and an International Consultation on Incontinence Questionnaire–Urinary Incontinence Short Form (ICIQ-UI SF) score ≥ 6. Participants received either EMSELLA therapy alone (Group A, n = 49) or EMSELLA combined with a standardized Kegel exercise program (Group B, n = 50) over a three-month period. Symptom severity was assessed at baseline and at three months using the ICIQ-UI SF. Between-group comparisons were performed using analysis of covariance, adjusting for baseline scores. Results: Both therapeutic approaches were associated with clinically meaningful improvement in urinary incontinence symptoms. After adjustment for baseline severity, lower follow-up ICIQ-UI SF scores, greater mean symptom reduction, and higher response rates were observed in the combined-therapy group. Across all menopausal-duration subgroups, outcomes consistently favored the association of EMSELLA therapy with Kegel exercises. No treatment-related adverse events were reported. Conclusions: The association of EMSELLA electromagnetic stimulation with a structured Kegel exercise program was associated with greater symptom improvement than electromagnetic stimulation alone, suggesting an additive therapeutic effect of voluntary pelvic floor muscle training. This combined conservative approach was well tolerated and may represent a useful management strategy for postmenopausal urinary incontinence. Full article

10 pages, 1022 KB

Open AccessEditor’s ChoiceCase Report

Clinical Significance of Serum Protein Electrophoresis in Rapid Progression of Multiple Myeloma: A Case Report

by Silvia Iannelli, Melania Scarcella, Antonella Cusano, Federica Feleppa, Ylenia Pancione, Luigi Michele Pavone and Pasquale Cocchiaro

Clin. Pract. 2026, 16(4), 81; https://doi.org/10.3390/clinpract16040081 - 21 Apr 2026

Viewed by 1791

Abstract

Background/Objectives: Serum protein electrophoresis (SPE) is a widely used laboratory test for the detection and monitoring of monoclonal gammopathies, including multiple myeloma (MM). Although SPE is usually recommended in the presence of specific clinical or laboratory abnormalities, monoclonal gammopathies may occasionally develop [...] Read more.

Background/Objectives: Serum protein electrophoresis (SPE) is a widely used laboratory test for the detection and monitoring of monoclonal gammopathies, including multiple myeloma (MM). Although SPE is usually recommended in the presence of specific clinical or laboratory abnormalities, monoclonal gammopathies may occasionally develop rapidly and without typical symptoms. This case report aims to emphasize the diagnostic value of SPE in identifying an unexpected and fast-evolving monoclonal gammopathy. Methods: We report the clinical and laboratory eight-month follow-up of a 58-year-old male who initially underwent SPE for unrelated clinical conditions. Serial SPE analyses were performed using capillary zone electrophoresis. When abnormalities emerged, immunotyping and serum free light chain (FLC) assays were conducted. The diagnostic workup was completed with bone marrow aspiration, flow cytometry, and imaging studies according to current international diagnostic criteria. Results: The initial SPE (November 2023) showed a normal protein profile. After eight months, follow-up SPE revealed a prominent monoclonal spike in the gamma region (2.9 g/dL), associated with increased total serum proteins (91 g/L; range 64–82 g/L), elevated IgA levels (20.0 g/L; range 0.4–3.5 g/L), and a markedly abnormal κ/λ FLC ratio (54.00; range 0.31–1.56). Bone marrow analysis demonstrated >18% plasma cell infiltration, confirming the diagnosis of IgA-κ MM. The patient underwent standard therapy followed by autologous stem cell transplantation, achieving disease remission. Conclusions: This case highlights that clinically relevant monoclonal gammopathies may arise rapidly in the absence of classical diagnostic features. Routine SPE represents a cost-effective and accessible screening tool that can identify subtle protein abnormalities, prompting the timely use of more specific and invasive diagnostic procedures for aggressive plasma cell disorders. Full article

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10 pages, 208 KB

Open AccessEditor’s ChoiceStudy Protocol

Assessment of Physical Activity During Radiation Therapy for Lung Cancer: Study Protocol of the APART-LUNG Study

by Dirk Rades, Maria Karolin Streubel, Laura Doehring, Stefan Janssen, Sabine Bohnet, Christian F. Schulz, Hanne Falk Grauslund and Charlotte Kristiansen

Clin. Pract. 2026, 16(4), 80; https://doi.org/10.3390/clinpract16040080 - 20 Apr 2026

Cited by 1 | Viewed by 689

Abstract

Background/Objectives: Radiation therapy is a common treatment modality for non-small-cell and small-cell lung cancer that can be associated with considerable side effects, mainly reactions of healthy tissues in the radiation field. Radiation therapy may lead to significant fatigue, which can potentially be [...] Read more.

Background/Objectives: Radiation therapy is a common treatment modality for non-small-cell and small-cell lung cancer that can be associated with considerable side effects, mainly reactions of healthy tissues in the radiation field. Radiation therapy may lead to significant fatigue, which can potentially be mitigated by maintaining or increasing physical activity during treatment. Since achieving this goal may be a challenge for patients, they may benefit from a mobile application reminding them daily to perform a predefined number of steps. Such a reminder app will be investigated prospectively in a phase 2 trial. The current APART-LUNG study (NCT07380815) is a mandatory study for designing the prospective trial. Methods: The main objective of the APART-LUNG (exploratory non-interventional) study is to report patterns of physical activity during radiation therapy for lung cancer patients and generate hypotheses based on our findings. Our primary endpoint is the within-patient difference in weekly average steps per wear hour of the smartphone (week 5 minus week 1 of radiation therapy), and our secondary aim is to estimate differences in operational measures (wear time of the smartphone) between week 5 and week 1. The sample size of approximately 20 patients (full analysis set) allows us to detect a moderate-to-large standardized within-patient difference and is driven by feasibility and the intent to obtain preliminary estimates of effect size and variability. The results of the APART-LUNG study will be very important for appropriately designing a phase 2 trial. Full article

(This article belongs to the Special Issue Exercise and Sports for Chronic Diseases)

10 pages, 449 KB

Open AccessEditor’s ChoiceSystematic Review

Systematic Review: The Impact of COVID-19 Vaccination on Myocarditis Risk and Recovery

by Yibo Liu, Christopher Khatchadourian, Luke Sanders, Quincy Eweroke, Cyvannah Warner-McCutcheon, Jackson Lewis, Joaquin Santos and Vishwanath Venketaraman

Clin. Pract. 2026, 16(4), 77; https://doi.org/10.3390/clinpract16040077 - 17 Apr 2026

Viewed by 14953

Abstract

Background: Myocarditis is an uncommon but recognized adverse event following mRNA COVID-19 vaccination, with risk varying by age, sex, dose number, and vaccine product. Clarifying the magnitude of risk, clinical course, and recovery—relative to myocarditis following SARS-CoV-2 infection—is essential for risk–benefit assessment and [...] Read more.

Background: Myocarditis is an uncommon but recognized adverse event following mRNA COVID-19 vaccination, with risk varying by age, sex, dose number, and vaccine product. Clarifying the magnitude of risk, clinical course, and recovery—relative to myocarditis following SARS-CoV-2 infection—is essential for risk–benefit assessment and public health guidance. Methods: We performed a systematic PubMed and Embase search (January 2020–December 2024) and synthesized cohort, registry, and surveillance data on myocarditis incidence and outcomes following mRNA COVID-19 vaccination. Outcomes included incidence, observed-to-expected (OE) or incidence rate (IRRs) ratios, hospitalization, and short-term recovery. Study selection followed PRISMA 2020 systematic review guidelines. Results: Myocarditis following mRNA COVID-19 vaccination was identified as a rare adverse event, most commonly occurring after the second dose and in younger male individuals. Across multiple cohort and registry-based studies, cases were generally mild and self-limited, with most patients recovering without complication. In contrast, myocarditis following SARS-CoV-2 infection was consistently associated with more severe outcomes, including higher rates of hospitalization and mortality. Conclusions: Vaccine-associated myocarditis is rare, typically mild, and self-limited, with excellent short-term recovery; vaccinated individuals also exhibit lower odds of in-hospital death and intubation. In contrast, infection-associated myocarditis is more frequent and severe. Overall, the benefit–risk profile of mRNA vaccination remains strongly favorable. Full article

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18 pages, 1816 KB

Open AccessEditor’s ChoiceSystematic Review

Neuromuscular Characteristics Associated with Knee Instability in Osteoarthritis and After Total Knee Replacement: A Systematic Review and Meta-Analysis

by Ariane P. Lallès, Luisa Cedin and Markus A. Wimmer

Clin. Pract. 2026, 16(4), 74; https://doi.org/10.3390/clinpract16040074 - 14 Apr 2026

Viewed by 1306

Abstract

Background/Objectives: Knee joint instability is frequently reported in individuals with knee osteoarthritis (OA) and may persist after total knee replacement (TKR), where it represents a leading cause of revision. However, neuromuscular factors associated with knee instability remain poorly understood. This systematic review [...] Read more.

Background/Objectives: Knee joint instability is frequently reported in individuals with knee osteoarthritis (OA) and may persist after total knee replacement (TKR), where it represents a leading cause of revision. However, neuromuscular factors associated with knee instability remain poorly understood. This systematic review and meta-analysis aimed to compare neuromuscular characteristics between individuals with stable and unstable knees in OA and TKR populations. Methods: PubMed, CENTRAL, Scopus, and EMBASE were searched from inception to 10 January 2025. Studies comparing neuromuscular outcomes between stable and unstable knees were included. Neuromuscular parameters included: muscle strength, muscle power, muscle activation pattern, and joint stiffness. Where appropriate, pooled standardized mean differences (SMD) were calculated using random-effects models. Certainty of evidence was evaluated using the GRADE approach. Results: Nineteen studies (16 OA, 3 TKR; n = 7369 participants) were included, with eleven studies eligible for meta-analysis. OA individuals with unstable knees demonstrated significantly lower limb muscle strength compared with stable counterparts (SMD = −0.49, 95% CI −0.81 to −0.16, p = 0.003). Muscle co-contraction did not differ significantly between groups (SMD = 0.12, 95% CI −0.70 to 0.94, p = 0.77). The overall certainty of evidence was rated as very low. Conclusions: Knee instability in OA populations is associated with reduced lower limb muscle strength, although evidence quality is limited and findings regarding neuromuscular control strategies remain inconclusive. Evidence in TKR populations is scarce. Future studies should investigate muscle activation patterns and dynamic joint stabilization during functional tasks to clarify the neuromuscular mechanisms underlying knee instability. Full article

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15 pages, 901 KB

Open AccessEditor’s ChoiceReview

Efficacy and Safety of Platelet-Rich Plasma in Knee Osteoarthritis: Umbrella Meta-Analysis Based on Clinical Evidence, Methodological Quality and Therapeutic Positioning

by María Ángeles Ventura-García, Tesifón Parrón-Carreño, David Lozano-Paniagua, Bruno José Nievas-Soriano, Antonio Fernando Murillo-Cancho, Elena María Gázquez-Aguilera and Delia Cristobal-Cañadas

Clin. Pract. 2026, 16(4), 75; https://doi.org/10.3390/clinpract16040075 - 14 Apr 2026

Viewed by 1557

Abstract

Background/Objectives: Despite being a standard biological therapy for knee osteoarthritis, inconsistent results across studies—due to varied protocols—have obscured the clinical standing of platelet-rich plasma. This meta-analysis evaluates the efficacy and safety of PRP for pain, function, and adverse events, and examines the [...] Read more.

Background/Objectives: Despite being a standard biological therapy for knee osteoarthritis, inconsistent results across studies—due to varied protocols—have obscured the clinical standing of platelet-rich plasma. This meta-analysis evaluates the efficacy and safety of PRP for pain, function, and adverse events, and examines the potential benefits of combining it with hyaluronic acid. Methods: An umbrella review was conducted following the PRIOR (Preferred Reporting Items for Umbrella Reviews) and PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) recommendations. Meta-analyses evaluating PRP in knee osteoarthritis were included. Quantitative estimates of pain, function, and safety were extracted. Random-effects models were applied when possible. Methodological quality was assessed using AMSTAR 2, and study overlaps were assessed using the CCA method. Publication bias was analyzed using a funnel plot. Results: The meta-analyses included consistently showed the superiority of PRP over hyaluronic acid and placebo in reducing pain and improving function. Pooled estimates indicated clinically relevant improvements, especially in mild-to-moderate osteoarthritis. The combination of PRP and hyaluronic acid demonstrated superior functional recovery and a potential reduction in adverse events compared to PRP monotherapy. The overall safety profile was favorable. Conclusions: PRP is an effective and safe therapy for knee osteoarthritis, with consistent evidence of superiority over conventional intra-articular treatments. Combined PRP and HA administration suggests superior clinical efficacy compared to monotherapy. Standardization of protocols and appropriate patient selection will be key in future clinical guidelines. Full article

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14 pages, 885 KB

Open AccessEditor’s ChoiceArticle

Real-World Distributions and Concordance of C-Reactive Protein and Erythrocyte Sedimentation Rate Across Rheumatic Diseases

by Claudiu C. Popescu, Luminița Enache, Carmen Ștențel, Corina Mogoșan and Cătălin Codreanu

Clin. Pract. 2026, 16(4), 72; https://doi.org/10.3390/clinpract16040072 - 13 Apr 2026

Viewed by 862

Abstract

Objective: The objective of this study was to characterize real-world distributions of C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) across major rheumatic diagnoses and to quantify concordance/discordance patterns and combined CRP-ESR inflammatory phenotypes. Methods: We retrospectively extracted all CRP and [...] Read more.

Objective: The objective of this study was to characterize real-world distributions of C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) across major rheumatic diagnoses and to quantify concordance/discordance patterns and combined CRP-ESR inflammatory phenotypes. Methods: We retrospectively extracted all CRP and ESR tests performed in a tertiary university rheumatology hospital (January 2018–December 2023), including ICD-10-coded diagnoses. Analyses were conducted at the measurement level and patient level (medians across repeated tests). CRP and ESR were expressed as raw values and multiples of ULN and categorized into severity strata. CRP and ESR datasets were merged by patient identifier and calendar date to define same-day pairs; paired analyses used Spearman correlations and ULN-based phenotype classes. Sensitivity analyses tested alternative pairing windows, first-pair-only analyses, phenotype persistence rules, and tertile/quartile discordance definitions. Results: Among 16,921 patients with ≥1 CRP and 17,126 with ≥1 ESR, CRP was more disease-discriminative and only negligibly age-related, whereas ESR increased modestly with age and showed marked sex shifts across severity categories. Inflammatory burden was highest in gout and rheumatoid arthritis, intermediate in psoriatic arthritis and ankylosing spondylitis, and lower in connective tissue diseases (systemic lupus erythematosus, mixed connective tissue disease, Sjogren’s disease, systemic sclerosis, and dermato/polymyositis) and osteoarthritis; CRP distributions were more strongly right-tailed than ESR. Merging yielded 44,427 same-day CRP-ESR pairs from 16,824 patients (99.1% match). CRP and ESR were moderately correlated at measurement and patient levels, yet discordance was common: 27.3% of pairs showed isolated elevation of a single marker. Conclusions: In routine rheumatology care, CRP and ESR provide complementary information. CRP-ESR dissociation is frequent, persists at the patient level, and follows diagnosis-dependent phenotype patterns. Full article

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23 pages, 1422 KB

Open AccessEditor’s ChoiceReview

Serotonin–Norepinephrine Reuptake Inhibitors in Fibromyalgia Management: An Integrative Literature Review of Clinical Evidence

by Isabella Oliveira do Lago, Bruna Moura Medina Diniz, Daniela Vieira Buchaim and Rogerio Leone Buchaim

Clin. Pract. 2026, 16(4), 68; https://doi.org/10.3390/clinpract16040068 - 28 Mar 2026

Cited by 1 | Viewed by 3085

Abstract

Fibromyalgia (FM) is a chronic pain syndrome characterized by central sensitization and impaired pain modulation, involving dysfunctional descending inhibitory pathways and altered nociceptive processing. These processes contribute to persistent musculoskeletal pain, difficulties with sleep, feelings of depression, and ongoing fatigue. Serotonin and norepinephrine [...] Read more.

Fibromyalgia (FM) is a chronic pain syndrome characterized by central sensitization and impaired pain modulation, involving dysfunctional descending inhibitory pathways and altered nociceptive processing. These processes contribute to persistent musculoskeletal pain, difficulties with sleep, feelings of depression, and ongoing fatigue. Serotonin and norepinephrine are key mediators of pain control, and evidence indicates that dual reuptake inhibition provides superior analgesia compared to single-pathway approaches. Accordingly, serotonin–norepinephrine reuptake inhibitors (SNRIs), including milnacipran and duloxetine, approved for FM treatment, show favorable efficacy and tolerability compared with tricyclic antidepressants. This integrative literature review aimed to evaluate the impact of SNRIs on musculoskeletal pain, fatigue, depression, and quality of life in patients with FM by analyzing randomized clinical trials (RCTs), identified via PubMed/MEDLINE searches (2015–2025) in English/Portuguese using descriptors: “Fibromyalgia”, “Serotonin and Norepinephrine Reuptake Inhibitors”, “Duloxetine” and “Milnacipran”. From 195 records screened, 18 studies met inclusion criteria (9.2% inclusion rate); duloxetine evaluated in 16 studies (88.9%), milnacipran in 2 (11.1%); SNRIs demonstrated superior efficacy vs. placebo: pain reduction 30–40%, fatigue improvement 25%, quality of life enhancement 20%. SNRIs were overall more effective than placebo but did not achieve high levels of analgesia, underscoring the need for further research on long-term efficacy and comparisons with combination pharmacological and non-pharmacological therapies. SNRIs significantly alleviate musculoskeletal pain (30–50% of patients), fatigue, depression symptoms, and improve quality of life in FM versus placebo. Duloxetine showed superior efficacy for pain/depression; milnacipran excelled in sleep quality. Long-term studies and combination therapies warrant further investigation. Full article

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20 pages, 2455 KB

Open AccessEditor’s ChoiceArticle

Pre-Injury Adversity, Functional Recovery, and Salivary microRNA Changes After a Dual-Task Exercise in Asians and Pacific Islanders with Mild Traumatic Brain Injury: A Feasibility Study

by Hyunhwa Lee, Haehyun Lee, Jinyoung Park and Jessica Gill

Clin. Pract. 2026, 16(4), 65; https://doi.org/10.3390/clinpract16040065 - 25 Mar 2026

Viewed by 654

Abstract

Background: Mild traumatic brain injury (mTBI) is frequently associated with persistent cognitive and psychosocial symptoms, yet biological correlates of recovery remain poorly understood, particularly among Asian and Pacific Islander (API) populations. Pre-injury psychosocial adversity may further shape post-injury recovery trajectories. This pilot study [...] Read more.

Background: Mild traumatic brain injury (mTBI) is frequently associated with persistent cognitive and psychosocial symptoms, yet biological correlates of recovery remain poorly understood, particularly among Asian and Pacific Islander (API) populations. Pre-injury psychosocial adversity may further shape post-injury recovery trajectories. This pilot study examined associations between participation in a 2-week, home-based, dual-task cognitive–walking intervention (Daily Brain Exercise; DBE) and changes in cognitive, psychological, and salivary microRNA (miRNAs) measures among APIs with and without a self-reported history of mTBI. Methods: API participants completed remote cognitive testing (CNS Vital Signs), psychosocial assessments (Neuro-QoL), and saliva collection before and after DBE participation. Salivary RNA was purified, and miRNA expression was profiled using nCounter^® Human v3 miRNA Expression Panels (NanoString). Differential expression analyses were conducted using ROSALIND^® platform (OnRamp Bioinformatics, San Diego, CA, USA), a cloud-based bioinformatics analysis system, to calculate fold changes and p-values. Pre-injury psychosocial adversity was assessed via the Trauma History Screen and examined descriptively as a contextual modifier of functional outcomes. Results: Twenty-one APIs (mean age 22.9 years; 76.7% female) were enrolled, including 14 individuals with a self-reported history of mTBI (mean 4.64 years post-injury; 50% with multiple injuries). Following DBE participation, increases in cognitive flexibility and executive function scores were observed in both mTBI and control groups. Additional increases in psychomotor speed, processing speed, sleep disturbance, and depressive symptoms were observed descriptively within the mTBI group. Subgroup analyses suggested variability in pre–post patterns across combinations of mTBI history and pre-injury psychosocial adversity. Exploratory miRNA analyses identified seven miRNAs that were differentially expressed in the mTBI group following DBE (unadjusted p < 0.005), including hsa-miR-7-5p, previously reported in association with neurodevelopmental and neurological pathways. Conclusions: In this pilot, feasibility-focused study, participation in a brief, home-based, dual-task intervention was associated with descriptive changes in selected cognitive and psychosocial measures among APIs, particularly those with a history of mTBI and pre-injury adversity. The observed subgroup patterns warrant confirmation in adequately powered, controlled studies. Exploratory changes in salivary miRNAs co-occurred with functional improvements, thus generating a hypothesis for a future investigation. Full article

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23 pages, 2513 KB

Open AccessEditor’s ChoiceReview

Triple Latency as a Driver of Chronic Inflammation: An Integrative View of HSV, EBV, and CMV Persistence in Immunocompetent Hosts

by Maria E. Ramos-Nino

Clin. Pract. 2026, 16(4), 64; https://doi.org/10.3390/clinpract16040064 - 24 Mar 2026

Cited by 1 | Viewed by 1560

Abstract

Background: Herpes simplex virus (HSV), Epstein–Barr virus (EBV), and cytomegalovirus (CMV) establish lifelong latency in sensory neurons, lymphoid tissue, and myeloid–endothelial cells, respectively. A substantial proportion of adults worldwide are infected with all three viruses and may experience concurrent herpesvirus latency, yet they [...] Read more.

Background: Herpes simplex virus (HSV), Epstein–Barr virus (EBV), and cytomegalovirus (CMV) establish lifelong latency in sensory neurons, lymphoid tissue, and myeloid–endothelial cells, respectively. A substantial proportion of adults worldwide are infected with all three viruses and may experience concurrent herpesvirus latency, yet they have largely been studied independently. This review examined whether latent and intermittently reactivating herpesviruses share overlapping inflammatory signatures and whether their combined presence contributes to chronic inflammatory burden. Methods: A narrative integrative review was conducted using MEDLINE, Embase, and Google Scholar (inception–October 2025). Evidence from thirty-one cohort studies and mechanistic investigations spanning virology, immunology, neurology, and clinical medicine was synthesized. Results: Herpesvirus reactivation rates ranged from 23% in general Intensive Care Unit (ICU) populations to 85% in severe COVID-19. Concurrent reactivation of multiple viruses occurred in 34–63% of critically ill patients and was associated with worse clinical outcomes. Notably, simultaneous CMV and EBV reactivation independently predicted mortality (adjusted hazard ratio, 3.17; 95% CI, 1.41–7.13). Across infections, overlapping inflammatory biomarkers, including IL-6, TNF-α, CRP, and PGE₂, were consistently elevated, reflecting convergent activation of IFN and NF-κB signaling pathways. Mechanistic studies suggest cross-compartment immune priming, where CMV-driven T-cell exhaustion facilitates EBV reactivation, and viral cytokine signaling enhances HSV-associated neuroinflammation. Conclusions: HSV, EBV, and CMV triple latency may represent an underrecognized contributor to chronic inflammation in immunocompetent hosts. Understanding this multi-virus inflammatory network may inform mechanistic research, biomarker-guided risk stratification, and therapeutic strategies targeting convergent inflammatory pathways. Prospective interventional studies incorporating concurrent multi-virus monitoring are needed to clarify causal relationships. Full article

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21 pages, 1501 KB

Open AccessEditor’s ChoiceReview

Case-Based Perspectives on the Management of Genitourinary Syndrome of Menopause

by Jissy Cyriac and Richa Sood

Clin. Pract. 2026, 16(3), 60; https://doi.org/10.3390/clinpract16030060 - 12 Mar 2026

Cited by 1 | Viewed by 2964

Abstract

Background and Objectives: Genitourinary syndrome of menopause (GSM), previously known as vulvovaginal atrophy, is a chronic, progressive hypoestrogenic condition affecting vulvovaginal, urinary and sexual health in women. Common symptoms include vaginal dryness, itching, dyspareunia, urinary urgency and recurrent urinary tract infections (UTIs). Despite [...] Read more.

Background and Objectives: Genitourinary syndrome of menopause (GSM), previously known as vulvovaginal atrophy, is a chronic, progressive hypoestrogenic condition affecting vulvovaginal, urinary and sexual health in women. Common symptoms include vaginal dryness, itching, dyspareunia, urinary urgency and recurrent urinary tract infections (UTIs). Despite the high prevalence, GSM is underdiagnosed and undertreated, thereby negatively impacting women’s quality of life. To illustrate the practical aspects of GSM diagnosis and provide evidence-based management, we present a case-based narrative review synthesizing recently published, high-quality evidence. Materials and Methods: Evidence was drawn from multiple sources through targeted searches of databases, and included the 2025 AUA/SUFU/AUGS guideline (AUA), the 2024 NICE network meta-analyses (NICE), a 2025 systematic review/meta-analysis in breast-cancer survivors, the 2020 Menopause Society GSM Position Statement, the 2018 NAMS/ISSWSH breast cancer consensus, several primary source citations and other high quality peer-reviewed publications. Results: Five illustrative composite case vignettes of GSM are presented to highlight the evaluation strategy and evidence-supported treatment choices. Nonhormonal options are the first line treatments for mild GSM symptoms, either with or without the addition of vaginal estrogen therapy. For moderate to severe GSM, low-dose vaginal estrogen, vaginal DHEA, and ospemifene are all effective FDA-approved options. In breast cancer survivors, individualized decisions with oncology input are warranted. Maximal caution and a shared decision-making approach is required for women using Aromatase Inhibitors (AIs) for breast cancer risk reduction when choosing treatments for GSM. Conclusions: Treating GSM improves vaginal, sexual and urinary outcomes and quality of life of women. Clinicians need to proactively screen for GSM and offer evidence-based treatment options. The treatment decisions in breast cancer survivors are nuanced, requiring a shared-decision approach. Full article

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19 pages, 1774 KB

Open AccessEditor’s ChoiceSystematic Review

Assessment of Cognitive Emotion Regulation in Gambling Disorder: A Systematic Review of the Literature

by Ioana Ioniță, Mădălina Iuliana Mușat, Bogdan Cătălin and Adela Magdalena Ciobanu

Clin. Pract. 2026, 16(3), 56; https://doi.org/10.3390/clinpract16030056 - 5 Mar 2026

Cited by 3 | Viewed by 1483

Abstract

Background/Objectives: Gambling disorder (GD) is a behavioral addiction characterized by persistent and repetitive gambling behaviors that cause significant psychological distress and functional impairment. Increasing evidence indicates that difficulties in emotion regulation are a key factor in the development and persistence of GD. This [...] Read more.

Background/Objectives: Gambling disorder (GD) is a behavioral addiction characterized by persistent and repetitive gambling behaviors that cause significant psychological distress and functional impairment. Increasing evidence indicates that difficulties in emotion regulation are a key factor in the development and persistence of GD. This systematic review aimed to summarize and critically evaluate the existing literature on the relationship between emotion regulation strategies and gambling disorder, with a specific focus on studies using the Emotion Regulation Questionnaire (ERQ) and the Cognitive Emotion Regulation Questionnaire (CERQ). Methods: The review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA 2020) guidelines. Systematic searches were performed in PubMed and Scopus databases for studies published between 25 October 2015 and 25 October 2025. The methodological quality and risk of bias of the included studies were evaluated using the Joanna Briggs Institute (JBI) Critical Appraisal Checklist and JBI Checklist for Randomized Controlled Trials. Data extraction and synthesis were performed manually by two independent reviewers. Eligible studies included adult participants (≥18 years) diagnosed with gambling disorder or pathological gambling and using the ERQ or CERQ to assess emotion regulation. Results: Nine studies met the inclusion criteria, comprising a total of 607 patients with GD. Across studies, individuals with GD consistently showed reduced cognitive reappraisal, greater expressive suppression, and higher use of maladaptive cognitive strategies such as rumination, catastrophizing, and self-blame. All studies identified impulsivity, emotion dysregulation, alexithymia, or gambling-related cognitive distortions as significant predictors of gambling severity. Neuroimaging evidence from one study further revealed altered activation of frontal regions during negative emotion regulation. Conclusions: This review highlights the central role of emotion regulation in GD. However, the limited available ERQ/CERQ studies in GD were mostly cross-sectional, limiting causal inferences. Second, samples were predominantly male, reducing generalizability to women. Finally, only one study used neurobiological measures, hindering integration of self-report and neural data. These findings emphasize the importance of integrating emotion regulation-based interventions within therapeutic programs for gambling disorder, with ERQ and CERQ being useful tools to assess the pathology. Full article

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18 pages, 405 KB

Open AccessEditor’s ChoiceArticle

Factors Associated with Quality of Life Among Patients with Cardiac Pacemakers Assessed by Two Scales

by Eirini Stavrou, Georgios Vasilopoulos, Dionyssios Leftheriotis, Panagiota Flevari and Maria Polikandrioti

Clin. Pract. 2026, 16(3), 53; https://doi.org/10.3390/clinpract16030053 - 28 Feb 2026

Cited by 1 | Viewed by 1092

Abstract

Background/Objectives: Permanent cardiac pacemakers (PPMs) are small electronic implanted devices that regulate cardiac rhythm. Measurement of quality of life (QoL) serves as a powerful tool for gaining in-depth insights into pacing therapy and ultimately guiding patient-centered management strategies. The aim of the [...] Read more.

Background/Objectives: Permanent cardiac pacemakers (PPMs) are small electronic implanted devices that regulate cardiac rhythm. Measurement of quality of life (QoL) serves as a powerful tool for gaining in-depth insights into pacing therapy and ultimately guiding patient-centered management strategies. The aim of the present study was to evaluate factors affecting QoL among PPM patients by applying the two generic questionnaires: SF-36 and EQ-5D-5L. Materials and Methods: A total of 120 patients with PPM were enrolled. QoL data were collected through interviews using the 36-Item Short Form Health Survey (SF-36) and the Euro QoL 5-Dimensions 5-Levels Health Questionnaire (EQ-5D-5L). Patients’ characteristics were also recorded. Results: The majority of participants were male (54.2%), retired (83.3%) residents in urban areas (75.5%), had a DDD pacemaker (82.5%), had rate response programmed on (77.5%), and had comorbidities (83.3%). Regarding QoL measured by SF-36, the Physical Component Summary Score (PCS) was significantly associated with programming rate response in their pacemaker (p = 0.046), comorbidities (p = 0.047), and the NYHA functional class (p = 0.047). The Mental Component Summary Score (MCS) was significantly associated with sex (p = 0.034), place of residence (p = 0.003), NYHA functional class (p = 0.001), and patients’ level of information about the device (p = 0.039). Patients’ QoL, as measured by the EQ-5D-5L, was significantly associated with sex (p = 0.001), age (p = 0.019), occupation (p = 0.040), pacing mode (p = 0.034), comorbidities (p = 0.019), NYHA functional class (p = 0.047), and level of information about the device (p = 0.005). Conclusions: NYHA functional class, comorbidities, and level of information as reported by patients were the factors associated with QoL, as shown by the two scales. All three factors guide a personalized care plan since NYHA class shows the burden of disease, comorbidities add to the complexity, and patient information determines the effectiveness of management. Full article

23 pages, 934 KB

Open AccessEditor’s ChoiceSystematic Review

Fall Prevention Interventions and Fracture Risk in Community-Dwelling Older Adults: A Systematic Review and Meta-Analysis

by Yazan Jumah Alalwani, Munira Abdullah Aldossari, Layan Adeeb Alzahrani, Nouf Ibrahim Alhatlani, Sarah Musaad Albarrak, Waleed Khalid Moosa, Raghad Ali Aloufi, Ibtisam Heji AlBader, Sadeem Khalid Almulhim, Nurah Jamel Alnbi, Leen Awad Alkahtani, Fatimah Mohammed Alsayoud, Ahmed Y. Azzam and Ghada Fouad Al Yousif

Clin. Pract. 2026, 16(3), 52; https://doi.org/10.3390/clinpract16030052 - 28 Feb 2026

Viewed by 1856

Abstract

Introduction: Falls and subsequent fractures represent a major public health concern among older adults. While fall prevention interventions have demonstrated efficacy in reducing falls, their impact on fracture outcomes remains unclear. Methods: We conducted a systematic review and meta-analysis following PRISMA 2020 guidelines. [...] Read more.

Introduction: Falls and subsequent fractures represent a major public health concern among older adults. While fall prevention interventions have demonstrated efficacy in reducing falls, their impact on fracture outcomes remains unclear. Methods: We conducted a systematic review and meta-analysis following PRISMA 2020 guidelines. We searched multiple databases up to 7 June 2025 for studies investigating fall prevention interventions and fracture outcomes in community-dwelling older adults. A primary outcome was hip fractures; secondary outcomes included any fractures, falls, and serious fall injuries. Risk ratios (RRs) with 95% confidence intervals (CIs) were calculated, using random-effects meta-analysis where appropriate. Results: Seventeen studies were included, spanning over 25,000 participants. Interventions included exercise programs, multifactorial approaches, medication optimization, and vitamin D supplementation. For hip fractures, only two randomized controlled trials (RCTs) reported extractable outcome data (12,489 participants; 132 events); both showed non-significant reductions favoring intervention (RR 0.80–0.87), precluding pooled meta-analysis. For any fractures, five studies (18,519 participants; 1343 events) demonstrated no significant effect (RR 0.91, 95% CI 0.72–1.14; p-value = 0.40) with significant heterogeneity (I² = 65%). Fall prevention interventions significantly reduced falls across 14 studies. GRADE assessment indicated very low certainty for both hip fractures and any fractures due to limited studies, inconsistency, and imprecision. Conclusions: Current evidence suggests fall prevention interventions may reduce hip fractures but do not significantly prevent fractures overall. Despite consistent fall reduction, the translation to fracture prevention remains uncertain, highlighting the need for integrated interventions targeting both fall risk and bone health. Full article

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17 pages, 266 KB

Open AccessEditor’s ChoiceArticle

Redefining Beauty: Knowledge, Attitudes, and Behaviours Toward Aesthetic Medicine and Cosmetic Surgery in Urban Adults

by Fabiana Di Duca, Giancarlo Biondi, Elvira De Rosa, Alessandro Venuta, Salvatore Di Sarno, Alfonso Nardo, Bartolomeo Ferrante, Giovanni Mazzei, Stefano Scippa, Immacolata Russo, Maria Triassi and Paolo Montuori

Clin. Pract. 2026, 16(3), 47; https://doi.org/10.3390/clinpract16030047 - 26 Feb 2026

Viewed by 2023

Abstract

Background: In recent years, aesthetic medicine and cosmetic surgery have seen significant growth, reflecting changing sociocultural views on beauty and self-care; however, public knowledge and awareness of associated risks remain inconsistent. This study aimed to assess knowledge, attitudes, and behaviours toward aesthetic medicine [...] Read more.

Background: In recent years, aesthetic medicine and cosmetic surgery have seen significant growth, reflecting changing sociocultural views on beauty and self-care; however, public knowledge and awareness of associated risks remain inconsistent. This study aimed to assess knowledge, attitudes, and behaviours toward aesthetic medicine and cosmetic surgery in a large metropolitan population in Southern Italy using the Knowledge–Attitude–Practice (KAP) framework. Methods: A cross-sectional survey was conducted between June 2021 and January 2022 among 1079 adults aged 18–72 years residing in the metropolitan area of Naples. A structured questionnaire collected socio-demographic data and assessed knowledge, attitudes, and behaviours related to surgical and non-surgical aesthetic procedures. Descriptive statistics and multiple linear regression analyses were performed to identify predictors of knowledge, attitudes, and behaviours. Results: Overall, 66.8% of participants reported having undergone general beauty treatments, while 9.8% declared the use of cosmetic medicine procedures. A total of 5.1% had undergone botulinum toxin treatments, 11% reported filler injections, and 9.8% had experienced plastic surgery. A majority had strong knowledge, especially on non-surgical procedures, but there were gaps in their knowledge on side effects, regulations, age limits, and qualifications. Most viewed appearance as important, though with critical views of excessive aesthetic treatments and claimed limited social media influence. Female sex and parental status were positively associated with aesthetic behaviours, while attitudes emerged as the strongest predictor of engagement. Conclusions: Aesthetic practices are widely accepted within this urban population, yet important informational deficiencies persist. Targeted educational interventions based on the KAP framework are warranted to enhance health literacy, promote safe decision-making, and foster realistic expectations regarding aesthetic medicine and cosmetic surgery. Full article

19 pages, 6201 KB

Open AccessEditor’s ChoiceArticle

Transcranial Doppler Pulsatility Index and MRI Findings in Meningoencephalitis: A Pilot Observational Retrospective Cohort Study in Critically Ill Patients

by Maria Grazia Bocci, Giulia Capecchi, Antonio Lesci, Dorotea Rubino, Ilaria Caravella, Giorgia Taloni, Valerio Sabatini, Candido Porcelli, Giulia Valeria Stazi, Gabriele Garotto, Elena Mattiucci, Emanuele Nicastri, Tommaso Ascoli Bartoli, Gaetano Maffongelli, Emiliano Cingolani, Fabrizio Albarello, Giulia Anello, Paolo Campioni, Stefania Ianniello and Daniele Guerino Biasucci

Clin. Pract. 2026, 16(2), 41; https://doi.org/10.3390/clinpract16020041 - 14 Feb 2026

Viewed by 1017

Abstract

Background: Meningoencephalitis is a complex inflammatory condition of the CNS that can result in significant morbidity and mortality in critically ill adults. Accurate and timely neuromonitoring is essential for guiding management and improving outcomes. This study aimed to descriptively evaluate the prognostic value [...] Read more.

Background: Meningoencephalitis is a complex inflammatory condition of the CNS that can result in significant morbidity and mortality in critically ill adults. Accurate and timely neuromonitoring is essential for guiding management and improving outcomes. This study aimed to descriptively evaluate the prognostic value of early TCCD monitoring, particularly the pulsatility index, and its integration with conventional and perfusion MRI in patients with meningoencephalitis. Methods: We present an observational, retrospective, cohort study involving ten adult patients (median age 56 years, IQR 45.5–68.5; mean 55.9, range 35–76) with neurological syndromes caused by suspected or confirmed infectious meningoencephalitis. Etiologies included bacterial meningitis/meningoencephalitis (50%), viral meningoencephalitis (10%), neurotoxoplasmosis (10%), progressive multifocal leukoencephalopathy (10%), and undetermined origin (20%). Patients underwent TCCD and MRI within 24 h. In five cases, standard MRI sequences were acquired, while in the remaining five, perfusion imaging was performed using Arterial Spin Labelling (ASL). A favorable outcome was defined as survival with neurological recovery (Glasgow Outcome Scale > 5) at ICU discharge. Results: TCCD-derived PI provided valuable information on cerebral hemodynamics. PI values ≤ 1.25 were associated with favorable clinical outcomes and symmetrical MRI findings. Conversely, PI > 1.25 correlated with poor prognosis and often preceded MRI-detectable structural damage. When combined with ASL, PI mirrored the detected perfusion asymmetries and was associated with poor prognosis in fatal cases. Conclusions: Bedside TCCD can offer real-time assessment of cerebrovascular dynamics and, when integrated with conventional and ASL MRI, could enhance the understanding of pathophysiological processes in meningoencephalitis, supporting timely and informed decisions in neurocritical care. Full article

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19 pages, 1515 KB

Open AccessEditor’s ChoiceArticle

Longitudinal Changes in Depression, Anxiety and Stress Symptoms Among Hemodialysis Patients

by Adriana-Luciana Luca, Felicia Militaru, Mădălina Iuliana Mușat, Ion Udriștoiu and Eugen Moța

Clin. Pract. 2026, 16(2), 37; https://doi.org/10.3390/clinpract16020037 - 8 Feb 2026

Cited by 4 | Viewed by 1279

Abstract

Background/Objectives: Chronic kidney disease (CKD) progresses with the gradual and irreversible loss of renal function. In Romania, given the increasing number of patients undergoing hemodialysis (HD), the prevalence of psychiatric symptoms and disorders in this population has become particularly significant. Although important [...] Read more.

Background/Objectives: Chronic kidney disease (CKD) progresses with the gradual and irreversible loss of renal function. In Romania, given the increasing number of patients undergoing hemodialysis (HD), the prevalence of psychiatric symptoms and disorders in this population has become particularly significant. Although important advances have been made in the management of psychiatric conditions in HD patients, their mental health remains relatively poor. The aim of this study was to observe the severity temporal trends of depression, anxiety and stress symptoms and correlations among HD patients. Methods: A total of 173 patients, underwent a detailed anamnesis, with emphasis dialysis duration, comorbidities and a complex psychiatric evaluation, followed by the application of the Socio-economic Scale (SES-3); Mini Mental State Examination (MMSE); and the Depression, Anxiety and Stress Scale 21R (DASS-21R). The dialysis performance (spKt/V) and Charlson Comorbidity (CCI) indices were provided by DIAVERUM Nephrology and Dialysis Center in Craiova. Results: The severity of depression and anxiety symptoms significantly increased over six months, 0.248 ± 1.432 vs. 0.453 ± 1.488 (p < 0.0001; r_rb = 0.296) for depression, and −0.090 ± 1.004 vs. 0.089 ± 1.047 (p < 0.0001; r_rb = 0.252) for anxiety; while stress-like symptoms remained stable 0.080 ± 1.318 vs. 0.164 ± 1.357 (p = 0.0661; r_rb = 0.123), despite improvements in dialysis adequacy (spKt/V). Depression scores were moderately correlated with anxiety and weakly correlated with stress and spKt/V. Anxiety results were moderately correlated with stress, while both anxiety and stress showed negligible correlations with spKt/V. Clinical variables assessed showed moderate predictive value for psychological outcomes in this cohort. Conclusions: Our study confirms the temporal trend of severity of mental symptoms and their persistence among HD patients, highlighting the urge to integrate mental health screening and intervention programs and a multidisciplinary team adapted for each case. Full article

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17 pages, 830 KB

Open AccessEditor’s ChoiceArticle

Age at Menarche and Risk of Hypertensive Disorders of Pregnancy: A Retrospective Cohort Study

by Erick Ordoñez-Villordo, Monica Alethia Cureño-Díaz, Erika Gómez-Zamora, Miguel Trujillo-Martínez, Ricardo Castrejón-Salgado, Fani Villa-Rivas, Rocío Castillo-Díaz, Nadia Velázquez-Hernández, Juan Carlos Fernando Sánchez-Velázquez, Ximena Solis-Gómez and José Ángel Hernández-Mariano

Clin. Pract. 2026, 16(2), 32; https://doi.org/10.3390/clinpract16020032 - 29 Jan 2026

Cited by 2 | Viewed by 1611

Abstract

Background/Objectives: Hypertensive disorders of pregnancy (HDP) remain a major contributor to maternal morbidity and mortality worldwide, yet early-life reproductive factors such as age at menarche have been insufficiently explored in relation to HDP. Therefore, we aimed to evaluate the association between age [...] Read more.

Background/Objectives: Hypertensive disorders of pregnancy (HDP) remain a major contributor to maternal morbidity and mortality worldwide, yet early-life reproductive factors such as age at menarche have been insufficiently explored in relation to HDP. Therefore, we aimed to evaluate the association between age at menarche and the risk of HDP in a cohort of Mexican pregnant women. Methods: We conducted a retrospective cohort study among 1344 women with singleton pregnancies receiving care at a tertiary hospital in Mexico City in 2024. Age at menarche was categorized as <12, 12–14, and >14 years. HDP diagnoses were extracted from clinical records. Poisson regression with robust variance was used to estimate adjusted risk ratios (RRs). Sensitivity analyses included alternative menarche categorizations and restricted cubic spline models. Counterfactual mediation analyses assessed indirect effects through reconstructed prepregnancy BMI and gestational diabetes. Results: Both early (<12 years) and late (>14 years) menarche were associated with higher HDP risk than the 12–14-year reference (adjusted RR = 1.81; 95% CI 1.42–2.30, and 1.74; 95% CI 1.27–2.38, respectively). Spline models confirmed a U-shaped association. Mediation analyses indicated that prepregnancy BMI did not meaningfully mediate the association for either early or late menarche (<5% mediated). Gestational diabetes explained a modest proportion of the association for early menarche (≈14%), but not for late menarche. Conclusions: Age at menarche showed a robust U-shaped association with HDP, mostly independent of adiposity and gestational diabetes, within the limits of the available measurements. Incorporating pubertal timing into routine reproductive history taking may enhance contextual risk assessment for HDP. Full article

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16 pages, 1096 KB

Open AccessEditor’s ChoiceArticle

Elevated Serum LPS in Newly Diagnosed Hashimoto’s Thyroiditis: A Case–Control Study in Bulgaria

by Desislav Tomov, Boryana Levterova, Valentina Mihailova, Dimitar Troev, Zlatina Tomova, Yordanka Uzunova and Maria Orbetzova

Clin. Pract. 2026, 16(2), 26; https://doi.org/10.3390/clinpract16020026 - 26 Jan 2026

Viewed by 1584

Abstract

Background: Hashimoto’s thyroiditis (HT) is a prevalent autoimmune disorder, often diagnosed late due to its asymptomatic or nonspecific presentation. Emerging evidence suggests that gut-derived lipopolysaccharides (LPS) may contribute to autoimmune activation. Objective: The primary objective of this study was to assess circulating [...] Read more.

Background: Hashimoto’s thyroiditis (HT) is a prevalent autoimmune disorder, often diagnosed late due to its asymptomatic or nonspecific presentation. Emerging evidence suggests that gut-derived lipopolysaccharides (LPS) may contribute to autoimmune activation. Objective: The primary objective of this study was to assess circulating LPS concentrations and dietary patterns in patients with Hashimoto’s thyroiditis compared to healthy controls. Methods: A hospital-based case–control study was conducted involving 105 HT patients and 25 healthy controls. Serum LPS concentrations, thyroid hormone profiles, and autoantibody levels were assessed. Dietary patterns were evaluated using the validated KomPAN questionnaire. Results: HT patients exhibited significantly higher serum LPS levels, particularly those with elevated anti-TPO and TRAB antibodies. A positive correlation was found between LPS and the fT3/fT4 ratio (r = 0.247, p = 0.006), and a negative correlation with fT4 (r = −0.314, p < 0.001). Dietary analysis revealed lower Pro-Healthy Diet Index scores in HT patients (3.94 vs. 5.34, p = 0.001), with increased consumption of processed foods and reduced intake of whole grains and oats. Conclusions: Elevated levels of lipopolysaccharides (LPS) and unhealthy dietary patterns may play a role in the development of thyroid autoimmunity. Taken together, these observations are consistent with a multifactorial model that potentially involves gut barrier dysfunction, endotoxemia, and nutritional factors in HT pathogenesis. Full article

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17 pages, 1794 KB

Open AccessEditor’s ChoiceArticle

Sedation Strategies for Awake Carotid Endarterectomy: An Exploratory Retrospective Study Comparing Dexmedetomidine and Remifentanil

by Rosanna Carmela De Rosa and Antonio Romanelli

Clin. Pract. 2026, 16(2), 23; https://doi.org/10.3390/clinpract16020023 - 23 Jan 2026

Viewed by 1569

Abstract

Background: Awake carotid endarterectomy (CEA) under local anesthesia demands an optimal sedation strategy that ensures patient comfort while preserving the ability for real-time neurological assessment. Dexmedetomidine (DEX) and remifentanil (REMI) are widely used agents, but direct comparisons in this setting remain scarce. Methods: [...] Read more.

Background: Awake carotid endarterectomy (CEA) under local anesthesia demands an optimal sedation strategy that ensures patient comfort while preserving the ability for real-time neurological assessment. Dexmedetomidine (DEX) and remifentanil (REMI) are widely used agents, but direct comparisons in this setting remain scarce. Methods: Exploratory, retrospective, single-center study of awake CEA (March–July 2019). DEX or REMI infusions were titrated to a Richmond Agitation–Sedation Scale (RASS) of −1 to −2. Outcomes were sedation failure (RASS ≥ +2 despite maximum infusion rate), bradycardia, hypotension, and neurologic events. Statistical analyses used χ² test (categorical variables) and Student’s t-test or Mann–Whitney test (continuous variables). Associations were assessed with Firth’s logistic regression (univariable and bivariate models), reporting odds ratios (OR) with 95% confidence intervals (CI_95%). Trends in the Bispectral Index (BIS), hemodynamic, and respiratory parameters were assessed using two-way repeated-measures Analysis of Variance (ANOVA). A p-value < 0.05 was considered significant. Results: Fifty-two patients were included (DEX = 25; REMI = 27). DEX group showed more frequent sedation failure (32.0% vs. 3.7%; p = 0.020), bradycardia (36.0% vs. 3.7%; p = 0.009), and hypotension (28.0% vs. 0%; p = 0.011). DEX was associated with increased risk in sedation failure (OR 8.58, CI_95% 1.70–85.81), bradycardia (OR 10.17, CI_95% 2.05–101.21), and hypotension (OR 22.30, CI_95% 2.46–2959.60); the direction of associations remained consistent in bivariate models adjusted for baseline confounders. ANOVA showed group-by-time interactions for BIS, heart rate, mean arterial pressure, and end-tidal CO₂. No intraoperative complications or adverse outcomes were observed. Conclusions: In this retrospective cohort of awake CEA, DEX was associated with higher rates of sedation failure and hemodynamic adverse events compared with REMI, without an apparent impact on procedural success. Given non-random allocation and baseline imbalances, these findings are hypothesis-generating and warrant confirmation in larger, robust, and prospective studies. Full article

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10 pages, 193 KB

Open AccessEditor’s ChoiceReview

Attention to Elderspeak: A Call for Dignity-Affirming Communication in Advanced Nursing Care

by Takahiko Nagamine

Clin. Pract. 2026, 16(1), 21; https://doi.org/10.3390/clinpract16010021 - 22 Jan 2026

Cited by 5 | Viewed by 1916

Abstract

Elderspeak is a form of communication overaccommodation directed toward older adults, characterized by simplified language and an elevated pitch. While typically well-intentioned, it is rooted in ageist stereotypes and linked to negative health outcomes. A literature search was conducted in PubMed, CINAHL, and [...] Read more.

Elderspeak is a form of communication overaccommodation directed toward older adults, characterized by simplified language and an elevated pitch. While typically well-intentioned, it is rooted in ageist stereotypes and linked to negative health outcomes. A literature search was conducted in PubMed, CINAHL, and PsycINFO (2018–2025), yielding 24 key articles focusing on acute and surgical settings. The purpose of this narrative review is to synthesize current evidence on Elderspeak within acute care hospitals and propose a research framework and intervention strategies. Elderspeak is a key determinant of resistiveness to care (RTC), particularly in acute settings where it is triggered by functional impairment. Exposure increases patient distress and negatively impacts vital signs and cooperation with medical interventions. Inconsistent measurement is being addressed through standardized schemes like the Iowa Coding Scheme for Elderspeak (ICodE). This paper proposes that future research must employ mixed-methods, longitudinal designs to capture the impact of Elderspeak on long-term outcomes. Drawing on the ICodE, we propose a qualitative self-reflection tool for clinicians to enhance awareness in high-stakes acute settings. Eliminating Elderspeak is a foundational necessity for patient safety and dignity-affirming care in advanced nursing. Full article

(This article belongs to the Special Issue Advances in Clinical Nursing: Integrating Advanced Surgical and Medical Nursing for Enhanced Patient Outcomes)

16 pages, 259 KB

Open AccessEditor’s ChoiceArticle

Fatigue Among Caregivers of Hospitalized Patients

by Eleni Maria Mitrou, Lamprini Avramopoulou, Dimitrios Alefragkis, Athanasia Tsami and Maria Polikandrioti

Clin. Pract. 2026, 16(1), 22; https://doi.org/10.3390/clinpract16010022 - 22 Jan 2026

Cited by 1 | Viewed by 1273

Abstract

Introduction: Caregiving has been an emerging public health priority mainly due to the rapid pace of population aging, increase in chronic diseases and shortages of health professionals. In clinical settings, caregivers have a crucial role by providing support to patients. Consequently, they [...] Read more.

Introduction: Caregiving has been an emerging public health priority mainly due to the rapid pace of population aging, increase in chronic diseases and shortages of health professionals. In clinical settings, caregivers have a crucial role by providing support to patients. Consequently, they may experience physical and emotional burden mainly attributed to environmental, personal or family stressors. The aim of this study was to evaluate fatigue and the associated factors among caregivers of hospitalized patients in medical-surgical wards. Methods and Material: In the present study caregivers of hospitalized patients in medical and surgical wards were enrolled. Collection of data was performed with the following: a. Fatigue Assessment Scale (FAS), b. Zung Self-Rating Anxiety Scale (SAS) and c. Athens Insomnia Scale (AIS), which included patients’ characteristics. In this cross-sectional study, participants were selected using the method of convenience sampling. Results: Of the 142 participants, the majority were spouses (64.8%), female (64.8%) and over 60 years old (53.6%). The mean FAS score was 25.9 ± 9.3, the mean SAS was 38.1 ± 9.0, and the mean AIS score was 7.6 ± 4.7, indicating moderate, moderate to low and moderate levels of fatigue, anxiety and insomnia, respectively. Moreover, fatigue showed a positive linear correlation with both anxiety (Spearman’s rho = 0.713) and insomnia (Spearman’s rho = 0.671). The factors found to be statistically significantly associated with caregivers’ fatigue were the following: gender (p = 0.001), length of hospitalization (p = 0.013), experience of environmental stressors (p = 0.045), experience of financial stressors (p = 0.001), and unfamiliarity with the provision of care (p = 0.001). Conclusions: Provided that caregivers’ involvement in care not only enhances patient well-being but also supports clinical teams, it is widely comprehended that addressing their needs should be emphasized. Full article

(This article belongs to the Special Issue Advances in Clinical Nursing: Integrating Advanced Surgical and Medical Nursing for Enhanced Patient Outcomes)

7 pages, 227 KB

Open AccessEditor’s ChoiceCase Report

A Hypersexuality Subset Behavior Induced by Aripiprazole Overdose in an Antipsychotic Naïve Patient: A Case Report and Review of the Literature

by Tiziano Serfilippi, Silvia Piccirillo, Alessandra Preziuso, Valentina Terenzi, Francesca Romagnoli, Marella Tarini, Vincenzo Lariccia, Agnese Secondo and Simona Magi

Clin. Pract. 2026, 16(1), 19; https://doi.org/10.3390/clinpract16010019 - 20 Jan 2026

Cited by 1 | Viewed by 3569

Abstract

Background: Aripiprazole is an atypical antipsychotic that acts as a partial agonist on the dopamine receptor D2 while also displaying agonistic activity on the 5-HT1A and antagonistic activity on the 5-HT2A receptors. As a partial agonist, aripiprazole stabilizes the activity of the [...] Read more.

Background: Aripiprazole is an atypical antipsychotic that acts as a partial agonist on the dopamine receptor D2 while also displaying agonistic activity on the 5-HT1A and antagonistic activity on the 5-HT2A receptors. As a partial agonist, aripiprazole stabilizes the activity of the D2 receptor, preventing overactivation. Case presentation: Within our deprescribing activity, we came across the case of a 30-year-old antipsychotic-naïve patient treated with the depot formulation of aripiprazole for bipolar disorder and acute mania, possibly developing hypersexuality due to an overdose that impacted negatively and heavily on his personal life. Results: The patient developed a peculiar subset of hypersexuality, changing his sexual orientation. Of interest, one month after discontinuing aripiprazole and switching to paliperidone, all the sexual-related symptoms and impulse control disorders resolved. Conclusions: We suggest stronger communication among the clinical teams involved in the patient’s care and screening patients for impulse control disorder prior to the administration of aripiprazole and monitoring them during treatment. Full article

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30 pages, 1851 KB

Open AccessEditor’s ChoiceReview

Telehealth for Sexual and Reproductive Healthcare: Evidence Map of Effectiveness, Patient and Provider Experiences and Preferences, and Patient Engagement Strategies

by Romil R. Parikh, Nishka U. Shetty, Chinar Singhal, Prachi Patel, Priyanka Manghani, Ashwin A. Pillai, Luz Angela Chocontá-Piraquive and Mary E. Butler

Clin. Pract. 2026, 16(1), 14; https://doi.org/10.3390/clinpract16010014 - 9 Jan 2026

Cited by 1 | Viewed by 3060

Abstract

Objective: The aim of this study was to systematically map evidence to inform best practices for sexual and reproductive healthcare delivered via telehealth (TeleSRH) in United States-based Title X-funded clinics. Methods: We searched three databases (2017–2025) for studies evaluating effectiveness, harms, patient and [...] Read more.

Objective: The aim of this study was to systematically map evidence to inform best practices for sexual and reproductive healthcare delivered via telehealth (TeleSRH) in United States-based Title X-funded clinics. Methods: We searched three databases (2017–2025) for studies evaluating effectiveness, harms, patient and provider experiences, barriers/facilitators, and engagement strategies encompassing TeleSRH for sexually transmitted infections (STIs), contraceptive care/family planning (CC/FP), and sexual wellness, in countries with a human development index of ≥0.8. Results: From 5963 references and 436 articles, we included 142 eligible publications. TeleSRH use declined since the COVID-19 pandemic’s peak but remains higher than pre-pandemic. Evidence comes mostly from poor-quality studies. TeleSRH increases access and adherence to STI prevention (e.g., pre-exposure prophylaxis for HIV). Tele-follow-up may safely facilitate HIV care continuity. For CC/FP, TeleSRH is comparable to in-person care for patient satisfaction and uptake; patients are less likely to select long-acting reversible contraception but post-initiation tele-follow-up may increase its continuation rates. Vasectomy completion rates may be similar between pre-procedural counseling via telehealth versus in-person. TeleSRH’s potential benefits might include reduced travel time, wait times, no-show rates, and clinic human resource burden (via tele-triaging) and increased preventative screening rates for STIs and non-communicable diseases, prescription refill rates, ability to receive confidential care in preferred settings, and rural/marginalized community outreach. Implementation challenges span technological and capital constraints, provider availability, staff capability building, restrictive policies, language incompatibility, and patient mistrust. Supplementing synchronous TeleSRH with asynchronous communication (e.g., mobile application) may improve continued patient engagement. Conclusions: Preventive, diagnostic, and therapeutic TeleSRH can be effective, with high patient acceptability; however, effectiveness and adoption hinge on contextual factors outlined in this review. Full article

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16 pages, 3571 KB

Open AccessEditor’s ChoiceSystematic Review

A Systematic Review of Personality Disorders in Patients with Gambling Disorder

by Ioana Ioniță, Mădălina Iuliana Mușat, Bogdan Cătălin, Constantin Alexandru Ciobanu and Adela Magdalena Ciobanu

Clin. Pract. 2026, 16(1), 15; https://doi.org/10.3390/clinpract16010015 - 9 Jan 2026

Cited by 1 | Viewed by 2357

Abstract

Background/Objectives: Gambling disorder (GD) is characterized by a high prevalence of co-occurring psychiatric disorders, including personality disorders (PDs), which may negatively influence clinical presentation, treatment outcomes, and relapse rates. The aim of this systematic review was to synthesize recent evidence regarding the association [...] Read more.

Background/Objectives: Gambling disorder (GD) is characterized by a high prevalence of co-occurring psychiatric disorders, including personality disorders (PDs), which may negatively influence clinical presentation, treatment outcomes, and relapse rates. The aim of this systematic review was to synthesize recent evidence regarding the association between GD and formally diagnosed PD and/or diagnostically anchored PD symptomatology, and to describe the main personality dimension most frequently reported in affected individuals. Methods: A systematic search was conducted in the PubMed and Dialnet databases for articles published between 30 November 2015 and 30 November 2025, according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA 2020) guidelines. PubMed was selected as the primary database because it is the most comprehensive source for peer-reviewed biomedical and psychiatric research, while Dialnet was included to complement PubMed by ensuring coverage of peer-reviewed psychiatric and psychological research published in other Romance-language journals, which are often underrepresented in international databases. The methodological quality and risk of bias of the included studies were evaluated using the Joanna Briggs Institute (JBI) Critical Appraisal Checklist for cross-sectional studies and the Newcastle–Ottawa Scale (NOS) for observational studies. Data extraction and synthesis were performed manually by two independent reviewers. Eight studies, predominantly cross-sectional in nature, assessing exclusively formally diagnosed personality disorders in adult individuals (≥18 years) diagnosed with GD were included. Results: Eight studies met the inclusion criteria, including a total of 4607 patients with GD. Across studies, personality pathology was highly prevalent among individuals with GD, with antisocial and borderline personality disorders most consistently reported. Elevated levels of impulsivity, emotional dysregulation, and narcissistic traits were frequently observed and were additionally associated with greater gambling severity, earlier onset, and poorer clinical outcomes. Antisocial personality symptoms were strongly linked to high-risk gambling subtypes, while obsessive–compulsive personality traits showed a more heterogeneous relationship with gambling severity. Conclusions: These results underscore the importance of personality assessment in individuals with GD and highlight the need for longitudinal studies using standardized diagnostic frameworks to inform tailored prevention and treatment strategies. Full article

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27 pages, 865 KB

Open AccessEditor’s ChoiceArticle

by George M. Pamboris, Spyridon Plakias, Charalambos Papacharalambous, Kyriakos Pavlou, Andrew Smythe, Anna Christakou and Eleftherios Paraskevopoulos

Clin. Pract. 2026, 16(1), 11; https://doi.org/10.3390/clinpract16010011 - 4 Jan 2026

Viewed by 2090

Abstract

Background: Rotator cuff-related shoulder pain (RCRSP) is a prevalent musculoskeletal disorder treated by physiotherapists. Although international guidelines support active, exercise-based management, little is known about current physiotherapy practices in Cyprus. Aim: To investigate physiotherapy management practices for RCRSP in Cyprus, assess adherence to [...] Read more.

Background: Rotator cuff-related shoulder pain (RCRSP) is a prevalent musculoskeletal disorder treated by physiotherapists. Although international guidelines support active, exercise-based management, little is known about current physiotherapy practices in Cyprus. Aim: To investigate physiotherapy management practices for RCRSP in Cyprus, assess adherence to recommended clinical guidelines, and compare findings with practices in other countries. Methods: A cross-sectional online survey was conducted among Cypriot physiotherapists between June and July 2024. An English case vignette-based questionnaire, adapted from validated international surveys, examined demographics, clinical reasoning, treatment preferences, and guideline adherence. Descriptive statistics summarised responses; chi-square tests and logistic regression identified associations between demographics and clinical decisions. Content analysis was performed on open-ended responses. Results: A total of 143 physiotherapists completed the survey. Most adhered to guideline-recommended care, with 99.3% (n = 142/143) prescribing exercise and 100% (n = 143/143) providing patient education. Conservative management was preferred, with 64.3% (n = 91/143) not recommending imaging, 72.0% (n = 103/143) not recommending injections, and 73.4% (n = 104/143) not recommending surgical referrals. Significant associations were found between special interest in shoulder conditions and recommendations for surgery (χ² = 4.937, p = 0.026) and injections (χ² = 9.143, p = 0.002). Physiotherapists recommending surgery were nearly seven times more likely to suggest MRI (Exp(B) = 6.944, p < 0.001). Conclusions: Cypriot physiotherapists predominantly use exercise and education for the management of RCRSP, aligning closely with international recommendations. Conservative strategies were favoured, with limited use of imaging, injections, and surgical referrals. However, variation in clinical decision-making, particularly regarding referrals and imaging, indicates partial adherence to best practice and highlights opportunities for enhanced guideline implementation and targeted clinical training. Full article

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25 pages, 1413 KB

Open AccessEditor’s ChoiceArticle

Early Trajectories of Suicidality in Adolescents and Young Adults: A Retrospective Study from a Community Mental Health Facility in Northern Italy

by Miriam Olivola, Serena Chiara Civardi, Silvia Carnevali, Roberta Anniverno, Federico Durbano and Bernardo Maria Dell’Osso

Clin. Pract. 2026, 16(1), 12; https://doi.org/10.3390/clinpract16010012 - 4 Jan 2026

Viewed by 1261

Abstract

Background/Objectives: Suicide is the second leading cause of death among adolescents and young adults. Those suffering from psychiatric illnesses are at particular risk. Our study, conducted at an outpatient mental health facility in Northern Italy, aimed at delineating demographic and psychopathological features [...] Read more.

Background/Objectives: Suicide is the second leading cause of death among adolescents and young adults. Those suffering from psychiatric illnesses are at particular risk. Our study, conducted at an outpatient mental health facility in Northern Italy, aimed at delineating demographic and psychopathological features of youths aged 16–29 who attempted suicide and were referred to our community-based outpatient service. Methods: We identified 63 subjects, most of whom suffered from personality disorders, mood disorders, and schizophrenia spectrum disorders. Analysis of variance and post hoc pairwise comparisons were performed. Results: Inferential analysis yielded significant results in terms of age at index suicide attempt across diagnostic groups. Patients with personality disorders attempted suicide at a younger age (M = 18.70) compared to those with schizophrenia spectrum disorders (M = 23.64; η² = 0.32). Conclusions: Our findings highlighted the period of transition from adolescence to adulthood as a stress on the need of preventive approaches towards suicidality in young people in both clinical and non-clinical settings. Moreover, the difference of age at index suicide attempt across different diagnostic groups stresses the need for tailored clinical interventions based on the specific psychopathological trajectories and natural histories of the diseases. Full article

(This article belongs to the Special Issue Innovations in Youth Psychiatry and Psychology: Challenges and Advances)

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16 pages, 1636 KB

Open AccessEditor’s ChoiceArticle

A Digital Twin Strategy Combined with a Monte Carlo Simulation Framework to Predict Outcomes in Patients with Unusual-Site Venous Thrombosis Treated with Direct Oral Anticoagulants Versus Vitamin K Antagonists Using Data from Real-World Populations

by Anabel Franco-Moreno, Luis Escobar-Curbelo, Juan Torres-Macho, Nuria Muñoz-Rivas, Cristina Lucía Ancos-Aracil, Ana Martínez de la Casa-Muñoz, Ana Bustamante-Fermosel, Paz Arranz-García and Miguel Ángel Casado-Suela

Clin. Pract. 2025, 15(12), 237; https://doi.org/10.3390/clinpract15120237 - 17 Dec 2025

Cited by 1 | Viewed by 1004

Abstract

Background/Objectives: Unusual-site venous thrombosis (USVT) lacks robust evidence guiding anticoagulant selection between vitamin K antagonists (VKAs) and direct oral anticoagulants (DOACs). This study aimed to evaluate recanalization, recurrence, and major bleeding outcomes in real-world USVT patients and to replicate these findings through a [...] Read more.

Background/Objectives: Unusual-site venous thrombosis (USVT) lacks robust evidence guiding anticoagulant selection between vitamin K antagonists (VKAs) and direct oral anticoagulants (DOACs). This study aimed to evaluate recanalization, recurrence, and major bleeding outcomes in real-world USVT patients and to replicate these findings through a validated digital twin model with Monte Carlo simulation. Methods: We conducted a retrospective study of 90 USVT patients (72% VKAs, 28% DOACs). A conditional generative adversarial network was used to generate digital twins matched on age, sex, thrombosis site, and malignancy. Logistic regression was applied to estimate treatment-specific outcome probabilities for recanalization, recurrence, and major bleeding. A nested stochastic simulation framework simulated 500 iterations across clinical scenarios, including increased DOAC use, cancer prevalence, cerebral vein thrombosis proportion, and optimized VKA control. Results: The mean age was 67.5 years, and 54.4% were female. 61.1% of splanchnic vein thrombosis, 36.7% of upper extremity deep vein thrombosis, and 2.2% of cerebral vein thrombosis were included. In the real cohort, complete recanalization occurred in 40.0% of patients with DOACs and 36.0% with VKAs. Recurrence was 8.0% with DOACs and 7.7% with VKAs, and major bleeding occurred in 8.0% and 10.8% of cases, respectively. All-cause mortality was 20% in DOAC-treated patients and 60% in those receiving VKAs. Digital Twin-based predictions replicated these results (recanalization 40.3% versus 38.0%; recurrence 10.9% versus 8.6%; bleeding 7.6% versus 9.1%). Simulated scenarios preserved the directionality effect, with the most significant differences observed in high-cerebral vein thrombosis and cancer-enriched patients. Conclusions: DOACs showed comparable efficacy and slightly lower bleeding risk than VKAs in USVT. Digital twin and Monte Carlo modeling provided robust, reproducible simulations of treatment effects under varying clinical conditions. Separating empirical and simulation-based findings, the digital twin supported the internal consistency of real-world observations and demonstrated the potential of in silico modeling as a complementary tool in rare thrombotic diseases. Full article

(This article belongs to the Special Issue Advances in Thromboembolism: Precision Prevention and Clinical Management)

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17 pages, 524 KB

Open AccessEditor’s ChoiceReview

Hyponatraemia After Hip and Knee Replacement: Incidence, Risk Factors, Clinical Consequences and Management in the Era of Enhanced Recovery

by Lauren Thornley, James Craig, Thomas W. Wainwright and Robert G. Middleton

Clin. Pract. 2025, 15(12), 236; https://doi.org/10.3390/clinpract15120236 - 16 Dec 2025

Viewed by 1877

Abstract

Introduction: Total hip replacements and total knee replacements are among the most frequently performed operations worldwide, and the demand for such procedures is ever-growing. It is essential to focus on preventable medical complications that can arise from these procedures, specifically postoperative hyponatraemia. Postoperative [...] Read more.

Introduction: Total hip replacements and total knee replacements are among the most frequently performed operations worldwide, and the demand for such procedures is ever-growing. It is essential to focus on preventable medical complications that can arise from these procedures, specifically postoperative hyponatraemia. Postoperative hyponatraemia has an incidence of 20–40% in total hip and knee replacement patient cohorts. Even mild postoperative hyponatraemia is clinically relevant, as it is associated with cognitive impairment and gait disturbance and may undermine the aims of enhanced recovery protocols. Severe postoperative hyponatraemia can lead to seizures, coma, intensive care admission, and death. Although uncommon, the high volume of patients treated in busy orthopaedic centres means such cases will inevitably be encountered. This narrative review summarises the current evidence on incidence, risk factors and consequences of postoperative hyponatraemia in total hip and knee replacement populations. Methods: A literature review was performed through the EBSCO and PubMed databases to identify relevant studies. Key search terms included were “hyponatraemia”, “total hip replacement”, and “total knee replacement”. Results: The incidence of postoperative hyponatraemia is largely between 20% and 40%; however, there are some outliers to this. Multiple risk factors have been identified through observational studies, including age, preoperative hyponatraemia, female sex and certain medications, which signal a need for a risk stratification strategy that can assist in preoperative assessment and the early identification of patients at higher risk of developing postoperative hyponatraemia. Evidence is scarce regarding interventional studies for the prevention and management of postoperative hyponatraemia, despite multiple studies highlighting the issue. Conclusion: Future work should focus on testable, quality improvement interventions, such as automatic sodium checks on postoperative day one, weight-based oral fluid protocols, oral salt supplementation, and escalation pathways for high-risk patients. Incorporating these into enhanced recovery frameworks has the potential not only to optimise safe early discharge for the majority but also to prevent rare but significant complications. Full article

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11 pages, 2172 KB

Open AccessEditor’s ChoiceArticle

Urine Cytological Diagnostics: Possibilities and Limitations—A 25-Year Review and Overview at Hannover Medical School

by Soudah Bisharah, Mieke Raap and Mahmoud Abbas

Clin. Pract. 2025, 15(12), 234; https://doi.org/10.3390/clinpract15120234 - 12 Dec 2025

Cited by 1 | Viewed by 1716

Abstract

Background: Urine cytology is a highly effective, straightforward, and cost-efficient diagnostic tool for identifying neoplastic and non-neoplastic changes in the bladder, ureter, and renal pelvis. The aim of this study is to demonstrate the high sensitivity and specificity of urine cytology in detecting [...] Read more.

Background: Urine cytology is a highly effective, straightforward, and cost-efficient diagnostic tool for identifying neoplastic and non-neoplastic changes in the bladder, ureter, and renal pelvis. The aim of this study is to demonstrate the high sensitivity and specificity of urine cytology in detecting a wide range of urothelial lesions, including metastatic involvement. Material and Methods: Urine cytology was performed on 9639 cases between 2000 and 2025. The samples, collected from patients, were processed at the Institute of Pathology. Cytological slides were prepared using cytocentrifugation and stained with May–Grünwald–Giemsa (MGG) and Papanicolaou stains. The cytological findings were classified according to WHO, 2004 compared with histological specimens. Additionally, selected cases underwent immunohistochemical and molecular analyses. All samples were anonymized and retrospectively analyzed following the guidelines and regulations of the local ethics committee. Results: Of the total cases, 7051 were classified as benign, 1269 as malignant, and 88 as normal findings. Insufficient material was obtained in 336 cases. No complications were reported during sample collection or processing. The concordance with histological findings for neoplastic lesions was over 96%, with a false-negative rate of 1.84%. The diagnostic methods demonstrated a sensitivity of 90.7% and a specificity of 96.64%. Among the 6956 cases analyzed, 3139 were women (45.13%) and 3817 were men (54.87%). Conclusions: The diagnostic value of urine cytology in representative material is relatively high in assessing both the presence or absence of malignancy and, when applicable, the tumor grade. This large 25-year single-center review demonstrates that urine cytology retains high sensitivity and specificity for the detection of urothelial malignancy, particularly high-grade disease. However, the atypical category remains a major diagnostic challenge and contributes substantially to false-positive results. Full article

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11 pages, 203 KB

Open AccessEditor’s ChoiceArticle

Teaching Prescribing in the PharmD Curriculum: A Qualitative Analysis

by Rachel E. Barenie, Devin Scott, David Rhys Axon and Alina Cernasev

Clin. Pract. 2025, 15(12), 232; https://doi.org/10.3390/clinpract15120232 - 9 Dec 2025

Viewed by 816

Abstract

Background: The scope of practice for pharmacists in the United States (US) is expanding rapidly, with the majority of states allowing pharmacists to prescribe to some degree. Doctor of Pharmacy (PharmD) programs are required to include medication prescribing effective 1 July 2025, ensuring [...] Read more.

Background: The scope of practice for pharmacists in the United States (US) is expanding rapidly, with the majority of states allowing pharmacists to prescribe to some degree. Doctor of Pharmacy (PharmD) programs are required to include medication prescribing effective 1 July 2025, ensuring program alignment with modern pharmacy practice. Objective: This study aimed to characterize student pharmacists’ beliefs about education on prescribing in the US PharmD program. Methods: Focus group discussions (FGDs) were conducted with student pharmacists enrolled in the PharmD curriculum at two different universities in the US. The conceptualization and data collection, guided by Self-Determination Theory, occurred over three months during the 2024 Fall semester. Data analysis was performed using thematic analysis, and themes were identified through inductive and deductive coding. Results: Twenty-two student pharmacists participated in three FGDs. Thematic analysis revealed two major themes: (1) essential role of didactic education in the prescribing process and (2) enhancing student preparedness to prescribe through experiential training. These themes uncover student pharmacists’ beliefs that prescribing education is vitally important to the didactic and experiential curriculum, highlighting the need to take a comprehensive approach to incorporate these topics into the PharmD program. Conclusions: Teaching medication prescribing in the PharmD didactic curriculum using a state’s scope of practice as a framework for its delivery, with reinforcement in their experiential training, to ensure pharmacy students are practice-ready, may be a preferred approach for delivery. This area remains ripe for further study to determine an evidence-based approach to teaching medication prescribing to pharmacy students. Full article

12 pages, 253 KB

Open AccessEditor’s ChoiceArticle

Cultural Biases and Clinical Variation

by Óscar Gasulla, Antonio Sarría-Santamera, Ferran A. Mazaira-Font, Cielo García-Montero, Oscar Fraile-Martinez, Diego Cantalapiedra, Manuel F. Carrillo-Rodríguez, Belen Gómez-Valcárcel, Miguel Á. Ortega, Melchor Álvarez-Mon and Angel Asúnsolo

Clin. Pract. 2025, 15(12), 229; https://doi.org/10.3390/clinpract15120229 - 5 Dec 2025

Viewed by 836

Abstract

Background: This study investigates the possible role of cultural biases in clinical variation. Methods: An observational, analytical, and retrospective cohort design, using a Spanish primary care database, was used, on which a cross-sectional analysis was performed. Diseases were classified into the [...] Read more.

Background: This study investigates the possible role of cultural biases in clinical variation. Methods: An observational, analytical, and retrospective cohort design, using a Spanish primary care database, was used, on which a cross-sectional analysis was performed. Diseases were classified into the following: generic conditions with established protocols (control group), specialist-diagnosed diseases, women’s diseases, and psychiatric diseases. Diagnostic incidence was calculated across 25 geographical clusters, and variability was measured using the coefficient of variation (CV). To test systematic differences, multivariate linear regression models were adjusted for socio-demographics and healthcare system proxies. Results: The final sample for analysis consisted of 617,222 women aged 15 to 65, with a mean age of 43. The results did not reveal significant variability between generic and specialized diseases, but women’s and psychiatric diseases showed consistently higher CVs in all models (p < 0.05), indicating that approximately 20% to 30% of the clinical variation observed in these groups was unexplained. Conclusions: Although we cannot establish causality, these findings may suggest that cultural taboos and gender biases likely contribute to unjustified clinical variation, highlighting cultural bias as a plausible explanatory factor. Full article

15 pages, 2624 KB

Open AccessEditor’s ChoiceArticle

Ultrasound Assessment of the Tibial Nerve at the Retromalleolar Level: Influence of Anthropometric Characteristics and Clinical Implications

by María Benimeli-Fenollar, Cecili Macián-Romero, Lucía Carbonell-José, María José Chiva-Miralles, José Maria Montiel-Company, José Manuel Almerich-Silla, Rosa Cibrian and Vicent Tomás-Martínez

Clin. Pract. 2025, 15(12), 227; https://doi.org/10.3390/clinpract15120227 - 3 Dec 2025

Cited by 1 | Viewed by 813

Abstract

Background: Clinical procedures involving the tibial nerve (TN) are complex procedures due to its deep anatomical position and the variability of its course in the retromalleolar region. Few studies have described the ultrasound characteristics of the TN in vivo. This study aims to [...] Read more.

Background: Clinical procedures involving the tibial nerve (TN) are complex procedures due to its deep anatomical position and the variability of its course in the retromalleolar region. Few studies have described the ultrasound characteristics of the TN in vivo. This study aims to describe the ultrasound position of the TN and its relationship with the posterior tibial artery (PTA) at the retromalleolar level, evaluating the influence of sex, weight, height, and body mass index (BMI). Methods: A cross-sectional ultrasound study was performed on 100 volunteers. Anthropometric variables were recorded. Ultrasound measurements included the TN perimeter, distance from the medial malleolus to the TN center, depth, and spatial relationship with the PTA. Statistical analyses included Student’s t-test, ANOVA, Chi-square test, and Pearson’s correlation coefficient, with a significance level of p < 0.05. Results: The mean distance from the TN to the medial malleolus was 2.17 cm, and its mean depth was 0.91 cm. The most common anatomical pattern was Type I (TN posterior to the PTA) (60%). Sex influenced TN position, with men showing greater distances from the medial malleolus to the TN center (2.42 vs. 1.99 cm) and women showing greater depth from the skin surface to the upper edge of the tibial nerve perimeter (0.94 vs. 0.86 cm). Weight (p = 0.004), height (p < 0.001), and ankle circumference (p = 0.006) correlated significantly with TN location, whereas BMI did not (p = 0.253). Conclusion: These findings provide clinically relevant reference data that may improve the precision and safety of different tibial nerve procedures. Full article

(This article belongs to the Topic The Use of New Technologies, Artificial Intelligence and Digital Twin in Health and Clinical Practice)

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17 pages, 502 KB

Open AccessEditor’s ChoiceArticle

Systemic and Oral Factors Relating to Stress in Later Life: A Study Using the Japanese National Statistics Database

by Kanako Seino, Akira Komatsuzaki, Kanako Mitomi, Mio Susuga, Sachie Ono, Yukika Enoki, Asami Iguchi, Hiromi Fujita and Naru Komatsuzaki

Clin. Pract. 2025, 15(12), 226; https://doi.org/10.3390/clinpract15120226 - 1 Dec 2025

Cited by 1 | Viewed by 1030

Abstract

Background: The psychosomatic effects of stress are risk factors for a range of dental and systemic diseases. This study used the massive Japanese national statistics database to clarify the association of psychological stress with subjective symptoms and conditions requiring hospital visits. Methods [...] Read more.

Background: The psychosomatic effects of stress are risk factors for a range of dental and systemic diseases. This study used the massive Japanese national statistics database to clarify the association of psychological stress with subjective symptoms and conditions requiring hospital visits. Methods: Anonymized data from 93,690 respondents of the 2019 Japanese survey were provided for this study. From these data, those of 29,777 respondents aged 40–89 years were classified into stress groups based on their responses to the Kessler Psychological Distress Scale (K6). The response rates for symptoms and diseases were compared and analyzed using contingency tables and binomial logistic regression. Results: The items with the largest odds ratios in the univariate analysis were depression/other mental disease (7.60), followed by irritability (6.86) and health perception QOL (6.31). Among those with subjective symptoms, the proportion in the high-stress group was higher (15.1%), with a univariate odds ratio of 3.17. The results of the binomial logistic regression analysis, with subjective QOL as the dependent variable, were as follows: The explanatory variables with the highest adjusted odds ratios were stress group classification (3.14), followed by feeling physically tired (2.44) and sleep satisfaction (2.22). The stress group was associated with subjective symptoms, such as irritability and depression/other mental diseases, as well as with social factors, such as household structure and work hours. These results suggest the existence of specific symptoms, diseases, and environmental factors associated with high stress. Conclusions: The results suggest that stress may have a substantial impact on quality of life in later life. Therefore, healthcare measures for older adults should focus on the symptoms and diseases that tend to be associated with stress to mitigate their effects. Full article

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9 pages, 214 KB

Open AccessEditor’s ChoiceBrief Report

Sjogren Disease and Nephrolithiasis: A Case Series and Review of the Literature

by Ben Schroeder, Chokkalingam Siva and Chen-Chung Steven Liu

Clin. Pract. 2025, 15(12), 225; https://doi.org/10.3390/clinpract15120225 - 28 Nov 2025

Viewed by 2270

Abstract

Background: Primary Sjogren Disease (pSD) is a chronic autoimmune disease characterized by a classic triad of keratoconjunctivitis sicca, xerostomia, and polyarthritis. The primary pathological feature of pSD is lymphoplasmacytic infiltration in glandular epithelial tissue, often affecting the salivary and lacrimal glands, leading to [...] Read more.

Background: Primary Sjogren Disease (pSD) is a chronic autoimmune disease characterized by a classic triad of keratoconjunctivitis sicca, xerostomia, and polyarthritis. The primary pathological feature of pSD is lymphoplasmacytic infiltration in glandular epithelial tissue, often affecting the salivary and lacrimal glands, leading to classic sicca symptoms (ocular and oral dryness). Sjogren Disease (SD) can be categorized as “primary” when occurring independently or “secondary” when accompanying another autoimmune connective tissue disorder such as rheumatoid arthritis, systemic lupus erythematosus, or systemic sclerosis. Additionally, systemic disease is common in pSD and can manifest with kidney dysfunction resulting in nephrolithiasis and distal renal tubular acidosis (dRTA). Methods: This report details a case series drawing patients from the literature as well as patients from our institution which serves to demonstrate key points in clinical hallmarks. We utilize a literature search with key words Sjogren Disease, nephrolithiasis, renal tubular acidosis, and nephrocalcinosis in addition to pSD patients with concomitant nephrolithiasis at our institution to characterize clinical and serologic findings as well as treatment modalities. Results: We find well demonstrated clinical hallmarks such as female predominance and presence of dRTA amongst the cohort of pSD patients. We also find that further research on pSD serologies could prove beneficial in risk stratifying those most likely to develop renal disease and nephrolithiasis. Furthermore, we review signs, symptoms, pathophysiology, and management of SD with added emphasis on associated renal disease including nephrolithiasis and dRTA. Conclusion: Overall, pSD associated renal disease remains an area of ongoing research and further study on patient serologies may aid clinicians in better serving and surveilling patients at risk of systemic involvement. Full article

9 pages, 1390 KB

Open AccessEditor’s ChoiceCase Report

A Case of Extensive Airway Necrosis Following Esophagectomy Successfully Treated with Airway Stenting

by Tatsuki Tsuruga, Hajime Fujimoto, Esteban C. Gabazza, Masaki Ohi, Masahide Oki and Tetsu Kobayashi

Clin. Pract. 2025, 15(12), 223; https://doi.org/10.3390/clinpract15120223 - 27 Nov 2025

Viewed by 989

Abstract

Background: Airway stenting is an alternative therapy for patients with complicated esophagectomy. Case presentation: A 60-year-old man with clinical stage IIIA esophageal cancer underwent neoadjuvant chemotherapy followed by robot-assisted subtotal esophagectomy with cervical esophagogastrostomy and jejunostomy. During surgery, both bronchial arteries were ligated [...] Read more.

Background: Airway stenting is an alternative therapy for patients with complicated esophagectomy. Case presentation: A 60-year-old man with clinical stage IIIA esophageal cancer underwent neoadjuvant chemotherapy followed by robot-assisted subtotal esophagectomy with cervical esophagogastrostomy and jejunostomy. During surgery, both bronchial arteries were ligated to facilitate esophageal mobilization. Bronchoscopy on the first postoperative day showed no abnormalities; however, by the second postoperative day, the patient developed pneumonia and septic shock, requiring mechanical ventilation. On the fifth postoperative day, bronchoscopy revealed extensive epithelial injury extending from the trachea to both main bronchi, indicating ischemic airway damage. He was diagnosed with airway necrosis and referred to our respiratory department. Serial bronchoscopic examinations and suctioning of the sloughed epithelium were performed, and a tracheostomy enabled weaning from mechanical ventilation. By the twenty-fourth postoperative day, bronchoscopy revealed the accumulation of large, hardened secretions within the trachea, carina, and both main bronchi, resulting in airway narrowing and a high risk of asphyxiation. A silicone Y-shaped airway stent was inserted to maintain patency. Following stent placement, airway secretions progressively decreased, and the patient was discharged on the sixty-third postoperative day. The stent was removed six months later, with no recurrence of airway or respiratory complications. Conclusion: This case illustrates a rare but severe complication of extensive airway necrosis, likely caused by intraoperative bronchial artery ligation and dissection of the tracheal membranous portion. Although preservation of the bronchial arteries and meticulous surgical technique are essential preventive strategies, such complications may be unavoidable. In cases of extensive airway necrosis, airway stenting can serve as an effective therapeutic option to prevent obstruction and support recovery. Full article

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23 pages, 648 KB

Open AccessEditor’s ChoiceSystematic Review

The Effectiveness and Safety of Stem Cell-Based Tissue Engineering in the Regeneration of Periodontal Bone Lesions: A Systematic Review

by Marouan Fanid, Ana Sofia Vinhas, Cátia Reis, Marta Relvas, Rosana Costa and Cristina Cabral

Clin. Pract. 2025, 15(12), 222; https://doi.org/10.3390/clinpract15120222 - 26 Nov 2025

Cited by 1 | Viewed by 2895

Abstract

Background/Objectives: Periodontal diseases are highly prevalent worldwide, causing progressive destruction of the alveolar bone and eventual tooth loss when not treated. Despite advances in conventional periodontal therapies, complete tissue regeneration remains limited. This review aims to evaluate the efficacy, safety, and clinical relevance [...] Read more.

Background/Objectives: Periodontal diseases are highly prevalent worldwide, causing progressive destruction of the alveolar bone and eventual tooth loss when not treated. Despite advances in conventional periodontal therapies, complete tissue regeneration remains limited. This review aims to evaluate the efficacy, safety, and clinical relevance of stem cell-based tissue engineering approaches for regeneration of periodontal bone lesions. Methods: Following PRISMA guidelines, a systematic search was conducted across multiple databases, resulting in the inclusion of 17 studies in humans that met predefined PICO criteria. The study protocol was registered on PROSPERO (CRD420251229271). These studies assessed various stem cell sources, including dental and bone marrow-derived cells among others, both on their own and in combination with scaffolds or growth factors. Results: Most studies reported favorable outcomes in terms of clinical attachment gain, radiographic bone fill, probing depth reduction, and implant stability. No major adverse effects were noted, indicating good safety. However, results varied based on cell type, culture protocols, and defect characteristics. Conclusions: Stem cell therapy shows strong potential for periodontal regeneration, with outcomes that may potentially surpass those of conventional methods in selected cases. Further standardization, cost reduction, and long-term clinical trials are essential to confirm these findings and support their integration into daily dental practice. Full article

(This article belongs to the Special Issue New Trends, Materials, and Technologies and Consolidating Best Practices in Dentistry, 2nd Edition)

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