Medicina, Volume 61, Issue 9 (September 2025) – 220 articles

Background and Objectives: Lymph node management in cutaneous melanoma has undergone a paradigm shift, transitioning from routine complete lymph node dissection (CLND) to a more selective, individualized approach. This narrative review explores the historical evolution, current evidence and clinical guidelines surrounding lymphadenectomy for a patient with Stage III of melanoma. Materials and Methods: A comprehensive literature search was conducted across PubMed, Scopus and Web of Science, focusing on randomized controlled trials, meta-analyses and updated international guidelines published in the past 15 years. Results: Traditional surgical approaches favored radical lymphadenectomy for regional disease control. However, pivotal trials such as the Multicenter Selective Lymphadenectomy Trial II (MSLT-II) and German Dermatologic Cooperative Oncology Group Selective Lymphadenectomy Trial (DeCOG-SLT) demonstrated no survival advantage from immediate CLND following a positive sentinel lymph node biopsy (SLNB), underscoring increased surgical morbidity. Consequently, guidelines from Associazione Italiana di Oncologia Medica (AIOM), the European Society for Medical Oncology (ESMO), and the National Comprehensive Cancer Network (NCCN) now endorse SLNB as the standard for nodal staging, reserving CLND for select high-risk cases. Conclusions: The role of lymphadenectomy in melanoma is increasingly becoming selective, shaped by tumor burden, nodal involvement and response to systemic therapy. SLNB remains central to staging and treatment planning, while CLND is no longer routine. Continued clinical trials and integration with immunotherapy will further refine surgical strategies in melanoma care. Full article

Background and Objectives: Remimazolam is a recently introduced benzodiazepine that has been increasingly adopted as an alternative to propofol. Although several trials have compared remimazolam with propofol, these studies have primarily focused on induction-related hypotension in non-gynecologic settings. To the best of our knowledge, both intraoperative hypertension and hypotension have not been systematically evaluated throughout the full anesthetic course in the specific physiologic context of robot-assisted laparoscopic gynecologic surgery performed in the steep Trendelenburg position with pneumoperitoneum. Materials and Methods: In this retrospective study, propensity score matching was performed to minimize selection bias. The demographic data of 694 patients, along with the incidence of intraoperative hypertension and hypotension, were collected through a review of medical records. Results: A total of 694 patients met the selection criteria, all of whom underwent total intravenous anesthesia (TIVA) using either remimazolam (n = 321) or propofol (n = 373). After propensity score matching, 317 pairs were analyzed. The incidence of intraoperative hypertension was higher in the remimazolam group (66.2% vs. 52.1%; p < 0.001), whereas hypotension was more frequent in the propofol group (12.0% vs. 5.4%; p = 0.003). Conclusions: TIVA with remimazolam was associated with a higher incidence of intraoperative hypertension compared to propofol, whereas propofol was more likely to cause hypotension in patients undergoing laparoscopic gynecologic surgery. Full article

Background and Objectives: In vitro evaluation of macro and microscopic features of five resorbable barrier membranes used for Guided Bone Regeneration (GBR) in oral hard tissue surgery. Materials and Methods: Five different resorbable barrier membranes were analyzed by optical microscopy and scanning electron microscopy (SEM). For each sample, surface appearance, the presence and size of ridges and depressions, number of layers, and the inner structure were recorded. Each membrane was cut into 1 × 1 cm squares to determine mass, density and thickness. In addition, an EDX microanalysis was performed. Results: Under optical microscopy, all membranes appeared rough, with ridges and depressions. In cross-section, only Sample 2 presented true stratification. On SEM, most membranes showed a three-dimensional collagen fiber architecture. Sample 3, a sheet of collagenated equine bone, differed accordingly. EDX spectra showed broadly overlapping elemental composition, characterized by N, O and C. The mass depends on the composition: bone-containing membranes weighed more; those composed predominantly of collagen weighed less. Conclusions: Pore size, surface density and roughness, and the type of cross-linking can influence cell interaction and may lead to different regenerative scenarios, potentially improving the quality and timing of tissue regeneration. Membrane selection should be dictated by the clinical scenario, prioritizing properties most advantageous for the defect. Full article

Background and Objectives: The impact of peripheral below-the-knee (BTK) fractional flow reserve (FFR) on long-term clinical outcomes remains unknown. Materials and Methods: We enrolled 40 patients with severe BTK lesions (Rutherford 4–6). FFR (using 40 mg papaverin) and skin perfusion toe pressure (SPTP) by laser Doppler were measured during the index procedure. The primary outcomes were major adverse limb events (MALEs) (defined as reintervention on the index arterial segment or amputation of the index limb) and death during follow-up. Results: The median follow-up was 7 [IQR 4–8] years. After the index procedure, FFR increased significantly (p < 0.001) and post-revascularization SPTP was significantly higher in the FFR ≥ 0.80 group (p = 0.022). Multivariable regressions showed no association between change in FFR (absolute or percentage) and the risk of death (p = 0.39, p = 0.28) or MALEs (p = 0.83, p = 0.29), but both pre- and post-revascularization FFR values could predict MALEs at follow-up (p = 0.018, p = 0.012). Lower SPTP was also associated with the risk of MALEs (p = 0.027). SPTP > 97.8 mmHg was 100% specific for FFR ≥ 0.80. Conclusions: While there is no association between change in FFR and the risk of death or MALEs, lower FFR values either before or after revascularization were associated with higher long-term risk of MALEs. Moreover, a lower SPTP was associated with a higher risk of MALEs. Aiming for approximately 100 mmHg in SPTP represents a non-invasive surrogate of FFR ≥ 0.80. Larger studies are needed to validate the impact of post-revascularization FFR-SPTP-adjacent values on clinical outcomes. Full article

Background and Objectives: The evaluation of the haemostatic mechanism in premature neonates remains particularly challenging, due to their immature haemostatic system, the influence of inflammation and the variety of clinical factors. This prospective study aimed at (a) assessing the haemostatic profile of clinically stable preterm neonates by Rotational Thromboelastometry [ROTEM; (EXTEM, INTEM, FIBTEM assays)], (b) establishing reference ranges, and (c) investigating potential differences in comparison to healthy term neonates. We also evaluated the impact of clinical and perinatal factors on the haemostatic status of this vulnerable population. Materials and Methods: 69 premature neonates with no underlying morbidity and 226 healthy term neonates were the study subjects. In term neonates, blood was collected on the 2nd-3rd day of life, if sampling was required for any other reason (hyperbilirubinemia, ABO blood group incompatibility screening, maternal thyroid antibodies, or insufficient prenatal care), whereas in premature neonates, blood was collected between the 4nd-10th day after stabilisation. The parameters measured for each ROTEM assay included Clotting Time (CT), Clot Formation Time (CFT), Alpha angle (α, degrees), Clot Amplitude at 5 and 10 min (A5, A10), Maximal Clot Firmness (MCF), and Lysis Index at 30, 45 and 60 min (Li30, Li45, and Li60 respectively). Results: The data analysis demonstrated a prothrombotic profile in preterm neonates, characterized by increased values of A5, A10, (MCF), and α-angle, and shortened CT and CFT across all assays (EXTEM, INTEM, FIBTEM), when compared to term neonates. A statistically significant inverse correlation was observed between gestational age and clot lysis parameters (INTEM Li45, Li60). Additionally, hematocrit levels were negatively correlated with clot amplitude and kinetics of clot development, while platelet count was positively associated with clot firmness parameters (A5, A10, MCF) and α-angle. Mode of delivery and the presence of gestational diabetes did not significantly affect ROTEM assay values. Preterm neonates with a history of respiratory distress syndrome (RDS) exhibited a more pronounced hypercoagulable profile compared to those without RDS, as reflected by the enhanced clot strength and reduced CT, findings that may be attributed to postnatal pulmonary inflammation and its systemic effects on coagulation. Conclusions: This study introduces for the first time reference values for the parameters of ROTEM assays (EXTEM, INTEM, FIBTEM) in clinically stable preterm neonates—a highly vulnerable patient group with a distinct need for accurate and individualized monitoring of their haemostatic status. The combined assessment of these assays enhances diagnostic precision, and offers a more comprehensive evaluation of neonatal haemostasis. By defining reference ranges in whole blood, this work provides novel data that support the integration of ROTEM into clinical transfusion algorithms. Full article

Background: Orthodontic auxiliaries can create plaque-retentive niches that inflame adjacent soft tissues. We compared bacterial colonization on molar bands, Nance buttons, and acrylic plates and assessed associated periodontal and palatal tissue responses in adolescents. Methods: In a cross-sectional study (n = 128; 10–17 years), clinical indices (Plaque Index, Gingival Index, bleeding on probing, probing depth) were recorded at device-influenced teeth. Palatal fibromucosa under palate-contacting devices was graded 0–3 (0 = none, 1 = mild/diffuse, 2 = moderate/confluent, 3 = marked with papillary hyperemia). Swabs from device surfaces, adjacent enamel, and palatal mucosa were cultured for total aerobic counts (log₁₀ CFU/cm²); Streptococcus mutans burden was quantified by qPCR (log₁₀ copies/mL). Group differences and adjusted associations were analyzed. Results: Palate-contacting devices harbored greater palatal biofilm and presented higher soft-tissue inflammation than bands. In adjusted models, device type (Nance, acrylic) remained associated with higher Gingival Index independent of measured behaviors and wear duration. Palatal colonization tracked closely with palatal erythema, supporting a local dose–response at the palatal interface. Conclusions: Appliance design is associated with distinct colonization patterns and soft-tissue responses; palate-covering acrylic components warrant device-specific hygiene and routine palatal inspection. Selecting designs with better cleansability and reinforcing plate-specific cleaning may mitigate palatal inflammation during treatment. Full article

Background and Objectives: Laparoscopic surgery has evolved with the integration of robotic systems, offering enhanced precision and ergonomic benefits. However, conventional robotic systems often lack haptic feedback and are associated with high cost. The Saroa surgical system is a compact, pneumatically driven robot that integrates real-time haptic feedback, potentially addressing the limitations associated with conventional robotic systems. This preliminary study reports the first clinical use of the Saroa system in gynecologic surgery, aiming to assess its feasibility, safety, and usability in robot-assisted hysterectomy. Materials and Methods: Five patients underwent robot-assisted total laparoscopic hysterectomy using the Saroa surgical system. The clinical outcomes, setup and console times, estimated blood loss, and subjective surgeon evaluation were recorded. Results: All surgeries were successfully completed without any intraoperative complications or the need for conversion to conventional surgery. The median setup time was 12 min, the console time was 211 min, and the median blood loss was 80 mL. Surgeons subjectively noted that the system’s real-time haptic feedback substantially improved precision during vaginal cuff tissue manipulation, based on their tactile sensation and real-time force display, thereby reducing the perceived risk of traction-related tissue injuries. Conclusions: This study represents the first clinical application of the Saroa surgical system in gynecologic surgery. The findings suggest that the system is feasible and safe for robot-assisted hysterectomy. Despite limitations such as small sample size and the absence of objective force data, the favorable surgeon-reported experience highlights the potential value of haptic feedback in improving surgical performance. These results support further investigation through larger, controlled studies and quantitative performance evaluation. Full article

Background and Objectives: Male infertility is a growing public health concern, with up to 50% of cases lacking a clearly identifiable cause. This study aimed to assess the epidemiological characteristics of male infertility in Lithuania and evaluate the clinical utility of oxidative stress assessment using the MiOXSYS system. Materials and Methods: A two-stage retrospective study was conducted between 2019 and 2023 at one of the largest fertility centers in Lithuania. The first stage involved an epidemiological analysis of 718 men who met the inclusion criteria. In the second stage, 261 men underwent oxidation-reduction potential (ORP) testing using the MiOXSYS system. Semen parameters were evaluated according to World Health Organization (WHO) 2010 guidelines. ROC curve analysis was used to assess the diagnostic value of ORP. Results: Male infertility was identified as the sole factor in 20.1% of couples, while unexplained infertility accounted for 24.4% of all cases. Among normozoospermic men, 48.5% exhibited elevated ORP levels (>1.34 mV/10⁶ sperm/mL). ROC analysis demonstrated moderate diagnostic accuracy of ORP (AUC = 0.634; sensitivity: 75.3%; specificity: 51.5%). The inclusion of ORP testing reduced the proportion of unexplained cases and supported their reclassification under the Male Oxidative Stress Infertility (MOSI) framework. Conclusions: This study provides novel epidemiological data on male infertility in Lithuania and highlights the potential of ORP testing as a supplementary diagnostic tool. Systematic evaluation of oxidative stress may help better identify cases previously labeled as unexplained and enable more personalized treatment strategies. Full article

Background and Objectives: Coronary atherosclerosis remains a leading cause of global morbidity and mortality. Chronic systemic inflammation has emerged as a key factor in atherosclerosis development. Tooth loss—often the final consequence of periodontitis—has been proposed as a potential clinical marker of systemic inflammation and cardiovascular risk. Objective: This narrative review synthesizes the available literature on the relationship between tooth loss and coronary artery disease (CAD) severity, exploring biological mechanisms, key epidemiological findings, and clinical implications. Materials and Methods: We reviewed observational studies, meta-analyses, and clinical reports assessing whether tooth loss is predictive of CAD severity and adverse outcomes. Results: A consistent association is reported between tooth loss and increased coronary involvement. Proposed mechanisms include periodontal inflammation, dysbiosis, systemic inflammatory responses, and translocation of oral bacteria. However, confounders such as smoking, diabetes, and socioeconomic status complicate causality. Conclusions: Tooth loss may serve as a simple, non-invasive clinical indicator of systemic inflammation and CAD severity. Incorporating oral health evaluation into cardiovascular risk assessment could enhance early detection and prevention strategies. Further longitudinal and interventional studies are required to establish causality and inform clinical guidelines. Full article

Background and Objectives: The severe systemic response to urinary tract infections known as urosepsis is associated with significant morbidity and mortality rates. The neutrophil-to-lymphocyte ratio (NLR) and the platelet-to-lymphocyte ratio (PLR) are simple blood tests that could be useful in predicting the outcome of sepsis. Materials and Methods: A prospective observational study was conducted at a tertiary care hospital, where our team studied 223 patients with urosepsis. The patients underwent Sepsis-3 criteria-based urosepsis and septic shock stratification followed by survivor and non-survivor classification. Clinical scores (Sequential Organ Failure Assessment-SOFA, National Early Warning Score-NEWS), laboratory markers (NLR, PLR, PCT-procalcitonin), and patient outcomes were then analysed. Results: An admission NLR ≥ 13 was a strong predictor of septic shock (adjusted Odds Ratio (OR) 2.10, 95% Confidence Interval (CI) 1.25–3.54) and in-hospital mortality (adjusted OR 2.45, 95% CI 1.40–4.28). While the prognostic value of the PLR remained moderate, the NLR demonstrated superior predictive power. As easily measurable biomarkers, the NLR and PLR provide valuable information to help clinicians identify at-risk patients during the early stages of urosepsis. Conclusions: The NLR is an independent predictor with high predictive value for both septic shock and mortality, performing as well as established clinical scores. The combination of these parameters with clinical assessments could lead to better early decisions and improved outcomes for patients with urosepsis. Full article

Background and Objectives: Oral squamous cell carcinoma (OSCC) is characterized by a high propensity for cervical lymph node metastasis, which remains a strong predictor of patient outcome. Despite advances in management, the prognosis for OSCC has not significantly improved, and the identification of reliable predictors for occult lymph node metastasis (OLNM) in clinically node-negative (cN0) patients is crucial for optimizing treatment strategies. Lymphovascular density (LVD) immunohistochemically assessed by podoplanin (D2-40) has been proposed as a potential biomarker for regional metastasis, but its prognostic value remains controversial. This study aimed to evaluate the prognostic significance of intratumoral (ILVD) and peritumoral lymphovascular density (PLVD) for OLNM in OSCC. Materials and Methods: A retrospective analysis was conducted on 43 cN0 patients with primary OSCC who underwent surgical resection and elective neck dissection (END) at a tertiary care cancer center. LVD was assessed by immunohistochemical staining for podoplanin (D2-40) in both intratumoral and peritumoral regions. Clinicopathological data were collected and statistically analyzed. Results: In observed cohort peritumoral LVD was significantly higher than intratumoral LVD. PLVD was also significantly higher in early-stage tumors (pT1/pT2) compared to advanced stages (pT3/pT4). Higher ILVD was significantly associated with the presence of OLNM. Neither ILVD nor PLVD demonstrated a statistically significant influence on overall survival, although a trend toward poorer outcomes was observed in patients with higher ILVD. Conclusions: ILVD was significantly associated with occult nodal metastasis, whereas PLVD was not. However, neither LVD parameter independently predicted overall survival. Results suggest that ILVD may serve as a useful marker for identifying cN0 OSCC patients at higher risk for occult metastasis. Full article

Background and Objectives: Hepatic steatosis is associated with an increased risk of liver-related morbidity and mortality. Although numerous studies have reported associations between depression, obesity, metabolic syndrome, and cardiovascular disease, the relationship between depression and hepatic steatosis has not yet been fully elucidated. Moreover, obesity is a shared risk factor for hepatic steatosis and depression; however, few studies have adequately adjusted for obesity as a potential confounder. In this study, we investigated the association between depression and hepatic steatosis stratified by obese and non-obese status. Materials and Methods: This study used data from the Korean National Health and Nutrition Examination Survey, conducted by the Korean Ministry of Health and Welfare between 2010 and 2019, which was a cross-sectional and nationally representative study of non-institutionalized civilians using a stratified, multistage, clustered probability sampling design. Multivariate logistic regression analyses were conducted to evaluate the association between depression and hepatic steatosis in the groups stratified by obese status. Results: Of 80,861 participants, data from 45,307 were included in the analysis. The prevalence of non-obese and obese hepatic steatosis was 3.1% and 19.3%, respectively, and the prevalence of diagnosed depression was 4.6%. Individuals with hepatic steatosis showed less favorable metabolic profiles, including higher rates of diabetes and elevated liver enzyme levels. Those with depression were older, predominantly female, and had lower socioeconomic status. After fully adjusting for confounding factors, multivariate logistic regression analysis showed that non-obese hepatic steatosis was significantly associated with an increased risk of depression, and obese hepatic steatosis was significantly associated with suicidal ideation and attempts. Conclusions: This study suggests a significant association between depression and hepatic steatosis with and without obese status. Given the significant impact of hepatic steatosis on depression outcomes, healthcare providers should screen patients with hepatic steatosis for depression and provide appropriate treatment as needed. Full article

Background and Objectives: Early allograft dysfunction (EAD), defined as suboptimal initial graft function following liver transplantation (LT), is a serious complication associated with increased post-LT morbidity and mortality. This study aimed to evaluate the impact of EAD on clinical outcomes and to identify associated risk factors. Materials and Methods: Ninety-three patients who underwent LT between July 2015 and August 2024 were retrospectively analyzed. EAD was defined by the presence of one or more of the following criteria: total bilirubin ≥ 10 mg/dL or international normalized ratio ≥ 1.6 on postoperative day 7, and alanine or aspartate aminotransferase levels > 2000 IU/L within the first 7 days. Results: EAD occurred in 20 patients (21.5%). Patients with EAD exhibited significantly lower graft survival (p < 0.01) and patient survival (p = 0.03) compared with those without EAD. EAD was an in-dependent risk factor for both graft survival (p = 0.021) and patient survival (p = 0.027). Acute liver failure (odds ratio [OR], 6.228; 95% confidence interval [CI], 1.179–32.906; p = 0.031), donor age (OR, 1.051; 95% CI, 1.008–1.096; p = 0.020), and warm ischemic time (OR, 1.048; 95% CI, 1.001–1.098; p = 0.046) were identified as significant predictors of EAD development. Conclusions: EAD adversely affects both graft and patient survival following LT. Recipient clinical status, donor age, and intraoperative conditions should be carefully considered to minimize the risk of EAD. Full article

Background/Objectives: Childhood obesity is associated with early metabolic complications, particularly insulin resistance (IR), which significantly elevates the long-term risk for type 2 diabetes and cardiovascular disease. Standard measures such as BMI may inadequately capture metabolic risk, particularly in children with atypical phenotypes such as TOFI (Thin Outside, Fat Inside). This study aimed to evaluate the prevalence and predictors of IR in a pediatric population with overweight and obesity, using both conventional biomarkers and bioelectrical impedance analysis (BIA). We also examined the predictive value of lipid ratios and fasting glucose and applied Principal Component Analysis (PCA) to identify underlying body composition dimensions. Methods: A retrospective cohort of 210 children aged 1–18 years, assessed in a tertiary pediatric endocrinology center in Romania, was analyzed. Clinical data included anthropometric measures, fasting laboratory results, and body composition parameters obtained via Tanita PRO DC430 MA BIA. Insulin resistance was defined as HOMA-IR > 2. ROC analysis assessed the predictive performance of triglyceride-to-HDL (Tg/HDL) ratio, fasting glucose, and BIA metrics. PCA was applied to BIA variables to explore dimensional structure. Results: Insulin resistance was present in 54.8% of the cohort. It was significantly associated with higher age, pubertal status, ALT, LDL-cholesterol, triglycerides, and BIA-derived fat-free mass (FFM), TBW, and PMM. ROC analyses showed moderate predictive power for Tg/HDL (AUROC = 0.645) and triglycerides (AUROC = 0.656) in identifying IR. BIA metrics had comparable discriminatory performance (AUROC~0.61). PCA reduced eight BIA parameters into two components: a fat-free mass axis (TBW, FFM, PMM, WATERM) and an adiposity axis (BMI, FATP, FATM, WATERP). Conclusions: This study highlights the high burden of insulin resistance among children with excess weight and supports the integration of BIA and composite biomarkers into early screening protocols. PCA-derived components may improve metabolic phenotyping in pediatric obesity. Full article

Background and Objectives: Sarcopenic obesity (SO), characterized by the coexistence of excess adiposity and reduced muscle mass/function, is associated with adverse outcomes in older adults. Oxidative stress has been implicated in the pathogenesis of both obesity and sarcopenia. This study aimed to evaluate the association between thiol/disulfide homeostasis (TDH), ischemia-modified albumin (IMA), and SO in obese older adults. Materials and Methods: In this cross-sectional study, 132 obese individuals aged ≥65 years were enrolled from a geriatrics outpatient clinic. SO was defined based on the ESPEN/EASO criteria, incorporating anthropometric, body composition, and muscle function measures. Serum native and total thiol levels, disulfide concentrations, and IMA were assessed. Logistic regression identified independent predictors of SO, and ROC analysis evaluated the discriminatory power of oxidative parameters. Results: SO was present in 15.2% (n = 20) of participants. Patients with SO exhibited significantly lower native (p = 0.003) and total thiol levels (p < 0.001), and higher disulfide/native thiol (p = 0.009) and disulfide/total thiol ratios (p = 0.009). IMA levels were slightly elevated in SO but not significantly different (p = 0.13). In multivariable regression, age and disulfide/native thiol ratio were independent predictors of SO (OR = 5.71, p = 0.041). ROC analysis showed that disulfide/native thiol ratio had moderate predictive accuracy (AUC = 0.684, p = 0.008), with a cut-off > 6.63 yielding 92.86% specificity. Conclusions: Older adults with SO exhibit disrupted redox balance, as evidenced by altered TDH parameters. The disulfide/native thiol ratio may serve as a useful oxidative biomarker for identifying SO. These findings highlight the potential role of oxidative stress in SO and warrant further research into targeted antioxidant strategies. Full article

Background and Objectives: Padel is becoming an increasingly popular sport, yet epidemiological data on sport-related musculoskeletal injury in Portuguese practitioners are limited. This study aimed to provide a comprehensive epidemiological analysis of Padel practitioners in Portugal to fill this gap. Materials and Methods: A nationwide self-reported questionnaire was administered to Portuguese Padel practitioners. The questionnaire covered sociodemographic, occupational, and health-related items. Results: Overall, 69.2% of respondents reported at least one lifetime Padel injury (mean 2.1 ± 1.2 injuries per injured athlete). Estimated injury incidence was 3.4 ± 4.7 injuries per 1000 h of exposure for the total sample (6.1 ± 4.9 per 1000 h among injured athletes). Tendinous (35.6%) and muscular (26.1%) injuries predominated. Most affected anatomical sites were the elbow (18.0%), ankle (16.6%), knee (12.5%), and shoulder (10.5%). Injuries most frequently occurred during training (32.9%) and were commonly attributed to fatigue/overload (24.1%). Reported severity was commonly moderate to severe (most frequent absences: 3–4 weeks and 1–3 months); physiotherapy was the principal management approach. Multivariable analyses identified several associations of practical relevance: higher body mass index was linked to greater overall injury risk (and specifically neck injuries); female sex was associated with higher odds of muscular injuries; years of Padel experience and equipment characteristics (e.g., number of overgrips) showed site-specific associations; and instructor supervision correlated with greater warm-up adherence and lower odds of elbow injury. Playing surface also influenced risk patterns. Conclusions: Portuguese Padel practitioners in this study experience a substantial burden of predominantly tendinous and muscular injuries concentrated at the elbow and lower limb. Athlete factors, exposure, surface, equipment, and supervision represent modifiable targets for multidisciplinary prevention and rehabilitation strategies. Full article

Background and Objectives: Gynecological conditions requiring surgical intervention have a profound impact on women’s physical, psychological, and social well-being. Minimally invasive procedures are increasingly preferred due to their benefits in reducing recovery time and improving patient outcomes. This study aimed to assess the changes in quality of life (QoL) among women undergoing surgical treatments for gynecological diseases. Materials and Methods: A cross-sectional study was conducted among 150 women hospitalized at the Minimally Invasive Pelvic Surgery Center. The participants completed two surveys: one prior to surgery and the other one month postoperatively. A self-developed questionnaire was used, tailored to the clinical and psychosocial context of the study population. Statistical analyses included the Wilcoxon signed-rank test for paired comparisons and the Chi-square test for categorical variables. A significance level of p < 0.05 was applied. Results: After surgery, 92% of women reported improved daily functioning, and 90% experienced a better overall quality of life. The average level of limitations decreased significantly from 40% to 16% (z = 11.24, p < 0.001). Higher BMI was associated with greater limitations both before and after surgery (r = 0.31 and r = 0.24, respectively; both p < 0.001). Conclusions: Women with uterine fibroids showed less improvement in several QoL domains compared to those with other conditions. Psychological factors, such as anxiety and long-term distress, play an important role in both pre- and postoperative well-being. Optimizing postoperative quality of life requires consideration of both the surgical method and individual psychosocial circumstances. Full article

Background and Objectives: Despite the advances in the treatment, severe burns with total burn surface area ≥ 20% are still a major cause of mortality worldwide. Pan-immune inflammation value (PIV) is a novel and promising biomarker to predict prognosis and mortality in various diseases. The aim of this study was to evaluate the utility of PIV to predict in-hospital mortality of patients with severe burn. Materials and Methods: This retrospective cross-sectional study included ≥18 years old patients with severe burn who were admitted to hospital within 12–24 h after the burn injury between January 2007 and August 2024. The demographics, clinical and laboratory characteristics of patients were recorded from electronic hospital records. Pan-immune inflammation value was calculated as neutrophil counts x monocyte count x platelet counts divided by lymphocyte counts. The receiver operating characteristic (ROC) analysis was conducted to determine the predictive value of PIV for mortality. Results: A total of 100 patients (median age 41 (26.3–55) years; 79% male) were included in the study of whom 23 were non-survivors. The PIV was significantly higher in non-survivors when compared to survivors (p = 0.009). The ideal cut-off of PIV was 1185, with a sensitivity of 69.6% and a specificity of 66.2%. The multivariate analysis showed that high PIV along with inhalation injury, and the need for surgery were predictors of in-hospital mortality. Conclusions: This study is the first to demonstrate that the novel, comprehensive index, PIV, is a reliable immuno-inflammatory marker predicting in-hospital mortality in patients with severe burn. Full article

Background and Objectives: Hematological diseases can cause lasting physical and social impairments. Illness perception and emotional functioning, influenced by stigmatization and optimism, may shape these outcomes, yet their combined effects on health-related quality of life remain underexplored. This study investigates their direct and indirect links with physical and social functioning. Materials and Methods: Ninety-six hematology patients completed the EORTC QoL Scale, the Brief Illness Perception Questionnaire, the Stigma Scale for Chronic Illness, and the Revised Life Orientation Test. Analyses were performed using SPSS 25.0 software using descriptive statistics, correlations and path analysis. Results: The results indicated that more negative illness perception indirectly affected physical functioning through role (β = 0.38, p < 0.01) and cognitive functioning (β = 0.21, p < 0.05). Emotional functioning indirectly influenced social functioning via illness perception (β = −0.23, p < 0.05) and stigmatization (β = −0.34, p < 0.01), moderated by optimism. Additionally, illness perception directly predicted physical functioning (β = −0.21, p < 0.05), while emotional functioning directly predicted social functioning (β = −0.37, p < 0.01).; Conclusions: Illness perception and emotional functioning play a crucial role in shaping physical and social functioning among hematology patients. Optimism moderates these relationships, suggesting that supportive care efforts should target not only improving patients’ perceptions and emotional well-being but also fostering optimism to enhance overall health-related quality of life. Full article

Background and Objectives: Atrial fibrillation (AF) in critically ill patients (CIP) is associated with worse outcomes and increased mortality in the intensive care unit (ICU). Rhythm control strategies are often unfeasible due to underlying comorbidities, making rate control the preferred initial approach. However, conventional beta-blockers may worsen hemodynamics through negative inotropic effects and peripheral vasodilation. Landiolol, an ultra-short-acting adrenoreceptor antagonist, may offer an alternative due to its high β₁-cardioselectivity and minimal blood pressure (BP) impact. This study evaluated the efficacy and feasibility of landiolol in hemodynamically unstable CIP with tachyarrhythmia, used as add-on therapy after failure of standard treatments. Materials and Methods: Ten CIP, admitted for non-postoperative reasons, were prospectively enrolled for landiolol treatment (L-group) in the ICU of Ulm University Heart Center between July and December 2017. The control group contained 41 patients who had received standard therapy without landiolol (NL-group). The primary composite endpoint was defined as heart rate (HR) reduction while maintaining mean arterial pressure (MAP) above 65 mmHg. Results: The most frequent reason for ICU admission was hemodynamic instability related to tachyarrhythmia in patients with cardiogenic or septic shock. At therapy initiation, all patients exhibited a compromised hemodynamic status, with a median MAP of 68.0 (IQR 60.0–80.0) mmHg and a median HR of 160.0 (IQR 144.0–176.0) bpm. After a three-hour observation period, no significant differences in BP values were observed between the groups. The primary composite endpoint was achieved at comparable rates in both groups (p = 0.525). However, patients in the L-group achieved a greater reduction in HR compared to those in the NL-group (25.3% vs. 21.9%, p < 0.001). Conclusions: Landiolol achieved more effective HR control than standard therapy without adversely affecting BP stability. These findings suggest that landiolol may be a feasible and effective option for HR control in ICU CIP. Full article

Background and Objectives: Robotic-assisted partial nephrectomy (RAPN) is a preferred minimally invasive option for renal tumours, but its use in highly complex cases (RENAL score ≥ 9) remains underexplored. Only four Asian countries, India, China, South Korea, and Japan, have published studies on RAPN for complex kidney tumours, highlighting limited evidence. The aim of this study is to assess the perioperative, functional, and oncological effects of RAPN for complex renal tumours at a single tertiary centre in Malaysia. Materials and Methods: Patient demographics, tumour characteristics, perioperative parameters, and postoperative results were collected through a retrospective review that was conducted on 35 patients who had undergone RAPN between January 2023 and June 2024. The outcomes were analyzed using descriptive statistics, correlation analysis, and comparative tests between surgical approaches (transperitoneal vs. retroperitoneal). Results: Of the 35 patients, all had high-complexity tumours. RAPN achieved a “trifecta” outcome in 88.6% of patients. Significantly lower intraoperative blood loss is associated with the retroperitoneal approach in comparison with the transperitoneal approach, whereas other perioperative parameters, which include warm ischaemia time, did not show any significant differences. No positive surgical margins were observed, and no local recurrences or port-site metastases were detected during a mean follow-up of 11.31 ± 5.78 months. Postoperative changes in renal function were negligible, with a mean creatinine change of 5.69 ± 20.39 µmol/L. Conclusions: RAPN is a safe and effective option for complex renal tumours, offering excellent functional and oncological outcomes. The choice between transperitoneal and retroperitoneal approaches should be tailored to tumour characteristics for optimal surgical outcomes. This single-centre Malaysian study contributes to the limited Southeast Asian literature on RAPN for complex renal tumours. Full article

Background and Objectives: Performance of robot-assisted total knee arthroplasty (TKA) procedures has continued to increase in popularity. However, tourniquet use is necessary for longer periods of time in robot-assisted TKA than conventional manual TKA because the robot-assisted procedure requires an additional registration process. The use of tourniquets for long periods increases the risk of hidden blood loss and ischemic soft tissue injury in the lower extremity. The purpose of this study was to compare the value of performing robot-assisted TKA without the use of a tourniquet to that of performing this surgery with the use of a tourniquet. Parameters we assessed were blood loss, degree of postoperative thigh and knee pain, and occurrence of early post-operative complications. Materials and Methods: Data from 100 consecutive patients who underwent primary unilateral robot-assisted TKA between July 2024 and July 2025 were included in this study’s analyses. Patients were divided into three groups chronologically. The first 29 patients comprised group 1, the early tourniquet group; the next 30 patients were assigned to group 2, the no tourniquet group; and group 3 was the late tourniquet group and comprised the remaining 41 subjects. However, because allocation was chronological rather than randomized, the outcomes of later groups may partly reflect the surgeon’s accumulated experience (learning curve), which should be considered when interpreting the results. The primary outcome measure was estimated blood loss (EBL). The secondary outcome measures included transfusion rate, visual analog scale (VAS) pain scores for the knee and thigh on the third postoperative day, readmission rate due to surgical complications, superficial and deep infection rate, length of operation, and length of tourniquet use. Results: Group 2 participants, the no tourniquet participants, experienced significantly greater EBL on postoperative days (PODs) 1, 2, and 3 compared to the subjects assigned to groups 1 and 3 (p = 0.003, p < 0.001, and p = 0.005, respectively). However, there were no significant differences in transfusion rates (p = 0.290) among the 3 groups. VAS scores for knee and thigh pain were also not significantly different among the three groups (all p-values > 0.05). Three patients in group 1 (10.3%), one patient in group 2 (3.3%), and one patient in group 3 (2.4%) were readmitted for complications related to wound healing (p = 0.289). Additionally, two patients in group 1 developed superficial wound infections from which the causative bacteria were cultured. No infections were observed in the other groups (p = 0.082), however. Two patients in group 1 and two patients in group 2 experienced symptomatic deep vein thrombosis (DVT) (p = 0.235). No group 3 patients experienced DVT, and only one patient in group 2 was confirmed with DVT using an enhanced CT scan (p = 0.308). Group 3 patients had shorter lengths of surgery (p < 0.001) than group 1 and 2 patients and had shorter periods of tourniquet use (p = 0.034) than group 1 patients. Conclusions: Tourniquet non-use in robot-assisted TKA surgeries was associated with greater EBL in acute postoperative periods, but this finding was not accompanied by any change in transfusion rate. Tourniquet non-use was not clinically beneficial for reducing immediate postoperative thigh and knee pain or reducing the prevalence of early post-operative complications. Tourniquet use in robot-assisted TKA may be beneficial because of the advantages its use provides in maintaining a clear surgical field and in facilitating the cementing process. Full article

Stroke is a leading cause of disability and the second cause of death in adults. Moreover, the incidence of stroke is continuously rising. Acute reperfusion therapies (ARTs) have revolutionized stroke medicine and have altered the natural course of acute ischemic stroke. However, these treatments are ultimately offered to only a minority of acute ischemic stroke (AIS) patients, primarily due to delays in presentation. The use of advanced imaging has partially increased eligibility for ART; nevertheless, a large proportion of AIS patients remain untreated. In addition, many stroke centers lack readily available advanced imaging, sometimes lacking even computed tomography angiography. In these settings, several recent studies have sought to simplify the imaging prerequisites and criteria for the administration of ARTs. In this review, we discuss the possible treatment options for AIS patients presenting in different time points, according to type of imaging availability and mechanical thrombectomy availability. Our aim is to provide evidence-based recommendations, but also to analyze emerging data supporting the individualized, off-label use of ART without the aid of advanced imaging. Full article

Background and Objectives: The clinical significance of gastrointestinal (GI) tract wall thickening incidentally detected on abdominal imaging remains unclear. This study aimed to examine the relationship between GI tract wall thickening seen in imaging and what is found during endoscopy, as well as to explore how hemoglobin, C-reactive protein (CRP), and albumin levels can help predict the presence of malignancy. Materials and Methods: In this retrospectively designed study, 209 patients were included who were found to have GI tract wall thickening on radiological imaging and underwent endoscopy within 90 days. Endoscopic findings and laboratory data were recorded. Patients were compared based on the presence or absence of malignancy, and a receiver operating characteristic analysis was performed. Results: Malignancy was detected in 8.5% and 10.9% of the upper and lower GI tract cases, respectively. In patients with upper GI tract malignancy, hemoglobin levels were significantly lower and CRP levels were higher (p < 0.001 and p = 0.015, respectively). Similarly, in lower GI tract malignancy, hemoglobin levels were lower (p = 0.033), whereas CRP did not show a significant difference (p = 0.115). Cut-off values were determined as 11.8 g/dL for hemoglobin and 40.75 g/L for albumin, and both were found to have high negative predictive values. Conclusions: GI tract wall thickening detected radiologically is clinically significant and should be further investigated endoscopically. Certain biochemical parameters may aid in ruling out malignancy; however, endoscopy remains essential for definitive diagnosis. Full article

Background and Objectives: Tibial tuberosity avulsion fractures are rare injuries in pediatric athletes, with limited data on the potential role of an elevated body mass index (BMI) as a risk factor. Previous studies have primarily focused on age, sex, and sport type, but the association between BMI and these injuries remains underexplored. Tibial tuberosity avulsion fractures are rare injuries predominantly affecting adolescent boys during sports activities involving strong quadriceps contractions. This pilot study aimed to analyze the epidemiological and anthropometric characteristics of patients with these fractures, including the distribution of injury mechanisms and the fracture types, to test whether the prevalence of overweight/obesity among cases exceeded national population benchmarks, and to describe the associated clinical outcomes. Materials and Methods: A retrospective analysis was conducted on medical records and radiographs of patients under the age of 18 treated between 2017 and 2024. The data collected included demographic and anthropometric characteristics, injury mechanisms, fracture classification, treatment methods, complications, and outcomes. The patients were categorized as normal weight (<85th percentile) or overweight/obese (≥85th percentile). The primary outcome was whether the prevalence of overweight/obesity among the cases exceeded national pediatric benchmarks. Formal sample size and power analyses were performed to guide future research. Results: Twenty-one patients met the inclusion criteria, with a mean age of 13.7 years; 95.2% were male. Soccer was the most common injury mechanism (52.4%), followed by athletics and running. The predominant fracture type was Ogden IVb (38.1%). Overweight/obesity was present in 52.4% of the patients, significantly higher than the national benchmarks. An open reduction and internal fixation was performed in 90.5% of the cases, with a mean follow-up of 14.6 months (range: 6–36). Complications occurred in 14.3% overall, all within the overweight/obese group (27.3%). Conclusions: This pilot retrospective study suggests a potential link between an elevated BMI and tibial tuberosity avulsion fractures, with overweight/obesity being significantly more prevalent in affected patients than in the general pediatric population. These exploratory findings warrant confirmation in larger, adequately powered studies, and emphasize the importance of weight management and tailored sports activities as potential preventive strategies. An early diagnosis, timely surgical intervention, and adequate rehabilitation are critical for achieving optimal functional recovery. Full article

Background and Objectives: This systematic review and meta-analysis aimed to analyze the available body of published peer-reviewed randomized controlled trials (RCTs) on the effects of concurrent training (CT) on biomarkers, morphological variables, and physical performance in people with sarcopenic obesity. Materials and Methods: Using six databases—PubMed, Medline, CINAHL Complete, Scopus, Cochrane Library, and Web of Science—a comprehensive literature search was conducted through July 2025. The GRADE, TESTEX, Rob 2, and PRISMA tools were used to assess the methodological quality and certainty. The protocol was registered in PROSPERO (CRD420251052935). Results: Out of 669 records, 8 RCTs with a total of 453 participants (68.9 ± 11.1 years) were included. Fifteen overall and three subgroup meta-analyses revealed significant improvements (p < 0.05) in insulin-like growth factor-1 (ES = 1.01, 95% CI = 0.26 to 1.75, p = 0.008) and leptin (ES = 2.54, 95% CI = 0.07 to 5.01, p = 0.04) levels; significant decreases (p < 0.05) in body mass index (ES = 0.54, 95% CI = 0.12 to 0.97, p = 0.01), waist circumference (ES = 1.80, 95% CI = 0.32 to 2.12, p = 0.008), and body fat (BF, ES = 1.31, 95% CI = 0.53 to 2.09, p = 0.001); and significantly increased (p < 0.05) appendicular skeletal muscle mass/weight (ES = 0.42, 95% CI = 0.14 to 0.71, p = 0.004), walking speed (ES = 1.80, 95% CI = 1.05 to 2.55, p = 0.000), and knee extension (ES = 0.76, 95% CI = 0.09 to 1.42, p = 0.02). However, no significant improvements (p > 0.05) were observed in IL-6, CRP, total cholesterol, triglycerides, trunk fat, BF mass, and MIHS. On the other hand, an important result in the meta-regression revealed that weeks of training can predict decreases in BF (R² = 0.32; p = 0.02). Conclusions: CT has been associated with significant clinical improvements in biomarkers related to increased muscle mass and decreased BF percentage. Full article

Background and Objectives: Normothermic ex situ heart preservation maintains donor heart viability by sustaining physiological conditions and reducing ischemic damage. However, the ideal perfusion pressure remains uncertain. This study aims to identify the optimal perfusion pressure to enhance graft preservation in rat heart transplantation. Materials and Methods: We utilized 20 male Sprague-Dawley rats (400–500 g). Donor hearts underwent normothermic preservation for 2 h using a Langendorff apparatus primed with 12 mL of solution at a consistent 3 mL/min flow. After preservation, hearts were transplanted heterotopically into the recipient’s abdomen. We defined successful preservation by observing a QRS complex in electrocardiographic monitoring for 3 h post-transplantation. Histological assessments for myocardial integrity occurred after 4 h of reperfusion. We analyzed statistical differences between successful and unsuccessful preservation groups. Results: Electrocardiograms indicated preservation failure in 8 of the 20 donor hearts due to the absence of a QRS complex. We observed no significant differences in ischemic duration between groups. At 120 min, although serum lactate and potassium concentrations increased in the unsuccessful group, the differences were not statistically significant. Higher initial perfusion pressures (>65 mmHg) at a constant flow rate resulted in elevated lactate and potassium concentrations post-preservation, indicating suboptimal outcomes. Histologically, hematoxylin and eosin staining showed better myocardial preservation in successful hearts, while TUNEL assays demonstrated increased apoptosis in unsuccessful hearts. All hearts increased in weight after preservation, but significant increases occurred only in unsuccessful cases. Conclusions: Higher initial perfusion pressures (>65 mmHg) negatively affect heart preservation outcomes, resulting in elevated serum lactate and potassium levels, increased heart weight, and greater histological damage. Maintaining optimal perfusion pressures is essential to preserve myocardial integrity and functional viability during normothermic ex situ heart preservation. Full article

Background and Objectives: Thoracic epidural analgesia (TEA) is considered the gold standard for postoperative pain control following major abdominal surgery. Bilateral rectus sheath block (RSB) is a promising alternative regional technique. This study aimed to compare the efficacy of RSB and TEA in managing early postoperative pain and enhancing recovery after open gastrectomy. Materials and Methods: Between October 2021 and December 2024, 70 patients scheduled for elective open gastrectomy were randomized into two groups: Group A (RSB with continuous bupivacaine infusion) and Group B (TEA with 10 mg bupivacaine plus 1 µg/mL fentanyl). Primary outcomes included opioid consumption within 72 h postoperatively and pain intensity measured using the visual analog scale (VAS). Statistical analysis was conducted using the Mann–Whitney U test, Friedman’s ANOVA with Bonferroni correction, and Chi-square or Fisher’s exact test for categorical variables. Results: A total of 64 patients were finally included (30 in RSB, 34 in TEA). VAS scores in the RSB group were significantly lower at 24 and 48 h postoperatively compared to baseline (p < 0.001). Between-group comparisons showed consistently lower pain scores in the RSB group at all measured time points. At 48 h, 94% of patients in the TEA group required rescue analgesia, compared to only 17% in the RSB group. Additionally, the RSB group had a significantly shorter postoperative hospital stay (mean 6 vs. 9 days) and demonstrated earlier return of bowel function. Conclusions: RSB is a safe and effective alternative to TEA for analgesia after open gastrectomy. It significantly lowers pain scores, reduces opioid and rescue medication use, shortens hospital stay, and enhances early recovery. Bilateral rectus sheath block with continuous bupivacaine infusion significantly lowers pain scores, reduces opioid and rescue medication use, shortens hospital stay, and facilitates early recovery. Full article

Background and Objectives: Traditionally regarded as a purely motor disorder, amyotrophic lateral sclerosis (ALS) is a progressive neurodegenerative disease characterized by the degeneration of upper and lower motor neurons. However, it is increasingly recognized as a condition with a broader clinical spectrum, encompassing a variety of non-motor symptoms (NMS) that significantly impact patients’ quality of life and may influence disease progression and prognosis. Materials and Methods: The study included 44 patients diagnosed with probable or definite ALS and 35 healthy controls (HC). Functional neurological status, non-motor manifestations, and cognitive and affective domains were evaluated using the revised ALS Functional Rating Scale (ALSFRS-R), the Non-Motor Symptoms Questionnaire (NMSQuest), the Frontal Assessment Battery (FAB), and the Beck Depression Inventory (BDI), respectively. Results: A majority of ALS patients exhibited non-motor symptoms (NMS). Significant associations were identified between specific NMS domains and ALSFRS-R subdomains: sleep disturbances were associated with lower fine motor, respiratory, and total scores; digestive symptoms with lower bulbar, respiratory, and total scores; cardiovascular symptoms with lower total scores; urinary symptoms with higher bulbar subscores and a significantly slower progression rate (ΔPR); and sensory symptoms with higher gross motor subscores. BDI scores were negatively correlated with respiratory and bulbar functions, whereas FAB scores showed positive correlations with both bulbar and total ALSFRS-R scores. Conclusions: Non-motor symptoms are highly prevalent in this ALS cohort. These symptoms do not consistently correlate with greater motor impairment, as urinary and somatosensory involvement may occur independently of functional decline. Cognitive, affective, and behavioral alterations co-exist with motor symptoms and are associated with poorer overall functional performance. Full article

Neurological disorders significantly affect ocular surface homeostasis, influencing parameters such as blink rate (BR), tear production, corneal nerve density, and sensitivity. This review summarizes recent findings on ocular surface alterations associated with neurological diseases, including Alzheimer’s disease (AD), Parkinson’s disease (PD), Guillain-Barré syndrome (GBS), trigeminal neuralgia (TN), multiple sclerosis (MS), and Charcot–Marie–Tooth disease (CMT). Notably, ocular manifestations such as reduced BR, decreased tear break-up time (TBUT), impaired tear secretion, and corneal nerve fiber loss are consistently reported. In AD, elevated tear amyloid-beta and tau proteins emerge as promising biomarkers for early disease detection. PD patients frequently experience dry eye symptoms attributed to reduced BR and tear film instability. GBS is linked to lagophthalmos and corneal nerve impairment, potentially leading to severe ocular surface damage. TN demonstrates bilateral ocular surface dysfunction despite unilateral neuropathic symptoms. MS is associated with significant ocular surface alterations, reflecting broader neuroinflammatory and autonomic disturbances. Similarly, CMT patients show reduced corneal sensitivity and tear production, underscoring the systemic nature of neurological impacts. Awareness of these ocular manifestations is essential for improving patient care and guiding future research into ocular biomarkers and targeted therapies. Full article