Clinics and Practice

14 pages, 16160 KB

Open AccessCase Report

Vasa Vasorum—A Silent Enemy After EVAR: A Case Report and Review of the Literature

by Ilias Prentzas, Vasileios Leivaditis, Chrysa Andrikopoulou, Konstantinos Nikolakopoulos, Chrysanthi Papageorgopoulou, Kate Tabaku, Melina Stathopoulou, Zafeiria Papathanassiou, Polyzois Tsantrizos, Francesk Mulita, Konstantinos Katsanos and Spyros Papadoulas

Clin. Pract. 2026, 16(6), 117; https://doi.org/10.3390/clinpract16060117 - 18 Jun 2026

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Abstract

Background/Objectives: Type II endoleaks (T2ELs) remain one of the most frequent causes of aneurysm sac enlargement following endovascular abdominal aortic aneurysm repair (EVAR). While embolization may be effective in typical T2ELs with a clearly identifiable feeding vessel, management becomes more challenging when no [...] Read more.

Background/Objectives: Type II endoleaks (T2ELs) remain one of the most frequent causes of aneurysm sac enlargement following endovascular abdominal aortic aneurysm repair (EVAR). While embolization may be effective in typical T2ELs with a clearly identifiable feeding vessel, management becomes more challenging when no visible communication with a side branch can be demonstrated. Emerging evidence suggests that hypertrophic vasa vasorum may contribute to aneurysm sac expansion in these atypical cases. We present a case of refractory atypical T2EL treated by open conversion and discuss the potential role of the vasa vasorum network in its pathophysiology. Case Presentation: A 77-year-old man presented with lumbar pain ten years after EVAR for a symptomatic abdominal aortic aneurysm. Computed tomography angiography demonstrated progressive aneurysm sac enlargement to 8.5 cm despite three previous translumbar embolization procedures. Multiple areas of contrast pooling were identified within the aneurysm sac, but no clear communication with a feeding side branch was observed. Owing to persistent sac expansion and symptoms, open conversion was performed with partial endograft explantation and reconstruction using a bifurcated PTFE graft. Results: After opening the aneurysm sac and evacuating the thrombus, diffuse bleeding was observed from numerous small vascular orifices distributed throughout the inner sac surface. These findings were considered consistent with a prominent vasa vasorum network. Hemostasis was achieved using a combination of figure-of-eight sutures and electrocautery. The postoperative course was uneventful, and the patient was discharged on postoperative day five. Follow-up imaging demonstrated normal graft patency without complications. Conclusions: This case supports the hypothesis that an extensive vasa vasorum network may contribute to aneurysm sac expansion in atypical T2ELs and possibly endotension after EVAR. In patients with refractory sac enlargement, open conversion remains a definitive treatment option. Further research is needed to clarify the underlying mechanisms and to explore targeted therapeutic strategies aimed at modulating angiogenesis and vascular remodeling. Full article

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14 pages, 1303 KB

Open AccessArticle

Post-Levothyroxine Thyroid Dysfunction in Saudi Arabian Patients with Hypothyroidism: A Cross-Sectional Study

by Baraah Ghssan AlHassan, Maujid Masood Malik, Ahmed Mohamedain, Adnan Jehangir, Farhana Ayub, Omer Musa, Ahmed Ibrahim, Habib Ahmad Qureshi and Hayder A. Giha

Clin. Pract. 2026, 16(6), 116; https://doi.org/10.3390/clinpract16060116 - 17 Jun 2026

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Abstract

Background: Post-thyroxine treatment of thyroid dysfunction remains a clinical concern, especially in Middle Eastern populations. Methods: This descriptive cross-sectional study was conducted in 2023 at King Fahad Hospital, Hufof, Kingdom of Saudi Arabia. Of the 237 patients treated with L-thyroxine (L-T4) for hypothyroidism, [...] Read more.

Background: Post-thyroxine treatment of thyroid dysfunction remains a clinical concern, especially in Middle Eastern populations. Methods: This descriptive cross-sectional study was conducted in 2023 at King Fahad Hospital, Hufof, Kingdom of Saudi Arabia. Of the 237 patients treated with L-thyroxine (L-T4) for hypothyroidism, 163 patients, almost exclusively females (152 females, 11 males), met the inclusion criteria and were enrolled. Thyroid hormones, lipid profiles, and 25-hydroxyvitamin D (25OH-D) were measured using standard laboratory assays. Results: Only 57% of patients achieved euthyroid status following L-T4 treatment, while 12.3% developed post-thyroxine-treatment (PTT) hyperthyroidism, and 30.7% developed PTT hypothyroidism. Older age was significantly associated with dysthyroidism (p = 0.018), whereas obesity (p = 0.937) and vitamin D levels (p = 0.982) were not. Total cholesterol (TC) and LDLc positively correlated with TSH levels, while elevated triglycerides (TGs) were significantly associated with PTT hyperthyroidism. The two dysthyroid subgroups were comparable across all non-thyroid parameters, including age, BMI, 25(OH)D levels, and lipid fractions. However, free T4 was significantly higher in PTT hyperthyroidism (p < 0.001); free T3 showed a trend toward higher levels in PTT hyperthyroidism (p = 0.052); and TSH was significantly higher in PTT hypothyroidism (p < 0.001). Conclusions: The proportions of patients with PTT hypo- and hyperthyroidism are aligned with international observations. Furthermore, the age was significantly associated with dysthyroidism, and dyslipidemia is the most consistent biochemical correlate of suboptimal thyroid status; however, the associations of PTT dysthyroidism with hypovitaminosis D and BMI were not noticed in this setting. Full article

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8 pages, 1446 KB

Open AccessCase Report

Pycnodysostosis: Report of Two Novel CTSK Variants in a Child

by Daniela Trotta, Rossella Ferrante, Michele Sallese, Marianna Viele, Claudia Rossi, Vincenzo Scorrano, Sara Savelli, Milena Catenaro, Vincenzo De Laurenzi and Maurizio Aricò

Clin. Pract. 2026, 16(6), 115; https://doi.org/10.3390/clinpract16060115 - 16 Jun 2026

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Abstract

Background: Pycnodysostosis is a rare autosomal recessive skeletal disorder caused by biallelic pathogenic variants in CTSK, which encodes cathepsin K, a lysosomal cysteine protease required for osteoclast-mediated degradation of bone matrix. Case Report: We describe a girl with short stature, skeletal deformities, [...] Read more.

Background: Pycnodysostosis is a rare autosomal recessive skeletal disorder caused by biallelic pathogenic variants in CTSK, which encodes cathepsin K, a lysosomal cysteine protease required for osteoclast-mediated degradation of bone matrix. Case Report: We describe a girl with short stature, skeletal deformities, osteosclerosis, craniofacial features, clavicular dysplasia, and radiological evidence of fractures. Clinical exome sequencing identified two heterozygous CTSK variants, c.85T > C (p.Trp29Arg) and c.679A>T (p.Ile227Phe), both currently classified as variants of uncertain significance. Segregation analysis showed that the variants were inherited in trans. Computational modeling and in silico prediction tools supported a possible deleterious effect on cathepsin K structure or function. Serum cathepsin K was higher in the patient than in two age-matched controls; this result is reported as an exploratory observation only. Increased serum cathepsin K may reflect altered expression, secretion, clearance, or accumulation of dysfunctional protein, but cannot be interpreted as proof of compensatory upregulation. Conclusions: The patient’s clinical and radiographic features, the biallelic trans configuration of the CTSK variants, their rarity in population databases, and computational predictions support p.Trp29Arg and p.Ile227Phe as strong candidate disease-associated variants. Functional studies are required to confirm their effect on cathepsin K expression, maturation, and enzymatic activity. Full article

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14 pages, 968 KB

Open AccessArticle

Prevalence of and Factors Associated with Overactive Bladder, Anxiety, and Depression Among Patients with Multiple Sclerosis: A Cross-Sectional Study in Saudi Arabia

by Mohammed Alqwaifly, Samer A. Almuqairsha, Emad Alwashmi, Yousef M. Alharbi, Adi A. Aldubaiyan, Raghad H. Aldligan, Abdulmajeed A. Alkhamees, Ayham Abazid, Rehana Khalil and Osama Al-Wutayd

Clin. Pract. 2026, 16(6), 114; https://doi.org/10.3390/clinpract16060114 - 15 Jun 2026

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Abstract

Background: Over the years, it has become increasingly clear that neurological conditions, such as multiple sclerosis (MS), commonly exhibit other health problems. Therefore, this is the first study aimed at investigating the prevalence of and factors associated with three binary outcomes: depression, anxiety, [...] Read more.

Background: Over the years, it has become increasingly clear that neurological conditions, such as multiple sclerosis (MS), commonly exhibit other health problems. Therefore, this is the first study aimed at investigating the prevalence of and factors associated with three binary outcomes: depression, anxiety, and an overactive bladder (OAB) among MS patients in the Qassim region, Saudi Arabia. Methods: This cross-sectional study was conducted in the neurological department of King Fahad Specialist Hospital in the Qassim region, Saudi Arabia, from January to December 2024. Data on age, sex, marital status, occupation, body mass index (BMI), MS duration, comorbidities, anxiety, depression, and OAB symptoms (frequency, nocturia, urgency, and urge incontinence) were obtained. Results: Of the 262 MS patients in this study, 184 (70.2%) were females, and 78 (29.8%) were males. The median values [IQR] of age and MS duration were 34 [26–40] and 5 [2–9] years, respectively. The prevalence of depression, anxiety, and OAB were 53.4%, 43.9%, and 50%, respectively. Nocturia was the most frequent urinary symptom, and urge incontinence was significantly higher among females. Multiple logistic regression analyses were conducted to assess factors associated with three binary outcomes: depression, anxiety, and OAB. For depression, being single and anxiety were associated with increased risk. Regarding anxiety, being a student was related to decreased risk, while being female and having depression were associated with increased risk. For OAB, only anxiety was associated with increased risk. Conclusions: Approximately one in two MS patients experience either depression or OAB, while anxiety was reported by fewer than half of the patients. This high prevalence of the three outcomes has critical implications for healthcare policy and resource allocation. Thus, screening, early diagnosis, and intervention, as well as integrated care, should be prioritized by healthcare institutions and practitioners to address these conditions and improve MS patients’ quality of life. Full article

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13 pages, 600 KB

Open AccessArticle

Trends in Comorbidity for Patients with Venous Thromboembolism in a General Hospital: 2018 to 2022

by Luisa Jiménez Reyes, José Javier Jareño Esteban, Lara Almudena Fernández Bermejo, Carlos Gutiérrez Ortega and Javier de Miguel-Díez

Clin. Pract. 2026, 16(6), 113; https://doi.org/10.3390/clinpract16060113 - 15 Jun 2026

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Abstract

Background/Objectives: Recent trends show a rising incidence of venous thromboembolism (VTE) that does not correlate with increased mortality; however, population aging and the proliferation of comorbidities are fundamentally reshaping the VTE patient landscape. The aim of this study is to evaluate potential [...] Read more.

Background/Objectives: Recent trends show a rising incidence of venous thromboembolism (VTE) that does not correlate with increased mortality; however, population aging and the proliferation of comorbidities are fundamentally reshaping the VTE patient landscape. The aim of this study is to evaluate potential differences in clinical characteristics, comorbidities, and survival rates between patients diagnosed with pulmonary embolism (PE) during the pre-pandemic period (2018–2019) and those diagnosed during the pandemic era (2020–2022). Additionally, as a secondary objective, we analyze the clinical profiles, risk factors, and survival outcomes of patients with and without COVID-19 infection during the 2020–2022 period. Methods: A retrospective observational study was conducted to analyze survival and comorbidities in patients admitted for PE at the Hospital Central de la Defensa ‘Gómez Ulla’ between 2018 and 2022, comparing two periods (2018–2019 and 2020–2022). In addition, a sub-analysis was performed within the second period group comparing patients with and without COVID-19. Results: It was observed that the majority of patients in the first period were men, while in the second period, 55% were women. With regard to comorbidity and risk factors, thrombophilia and dementia were more prevalent in the first period, while asthma was more prevalent in the second period. No differences were found with regard to mortality. Conclusions: Significant differences were observed between the two periods of the study with regard to some comorbidities. Patients with COVID-19 showed a greater tendency toward immobilization and a higher prescription of thromboprophylaxis during hospitalization. Full article

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

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11 pages, 772 KB

Open AccessArticle

Beyond Coiling: A Comparative Analysis of Survey-Reported Preferences for Endovascular Cerebral Aneurysm Occlusion

by Sanjana R. Salwi, Thilan Tudor, Oleg Shekhtman, Georgios S. Sioutas, Pious D. Patel, Irina-Mihaela Matache, Mohamed M. Salem, Sonia Ajmera, Sandeep Kandregula, Jan-Karl Burkhardt and Visish M. Srinivasan

Clin. Pract. 2026, 16(6), 112; https://doi.org/10.3390/clinpract16060112 - 15 Jun 2026

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Abstract

Background: Aneurysm treatment options are rapidly evolving, as evidenced by the recent introduction and widespread adoption of flow diversion and intrasaccular devices. However, there is a need to understand how these newer technologies are used for difficult-to-treat aneurysms. The main aims of this [...] Read more.

Background: Aneurysm treatment options are rapidly evolving, as evidenced by the recent introduction and widespread adoption of flow diversion and intrasaccular devices. However, there is a need to understand how these newer technologies are used for difficult-to-treat aneurysms. The main aims of this study were to investigate the variation in aneurysm treatment recommendations among neurosurgeons, interventional radiologists, and interventional neurologists and to generally describe trends in endovascular treatment. Methods: In this survey-based study conducted from June to September 2024, participants were presented with clinical vignettes and asked to choose preferred treatment options, with responses analyzed based on demographic variables including specialty, age, and training prior to and after the introduction of flow diversion. Results: A total of 108 respondents completed the study with a representative mix of specialties—(45 (42.5%) radiologists, 22 (20.8%) neurologists, and 39 (36.8%) neurosurgeons. Sixty-six (61.1%) trained after the introduction of flow diversion. Treatment recommendations were significantly different by specialty (p < 0.001). The Kappa statistic to assess variation in responses showed significant variation in treatment preferences across aneurysm subtypes, ranging from poor (κ = 0.07) to fair (0.31). Treatment of ruptured aneurysms varied by specialty with radiologists opting for stent-assisted coiling at a higher rate than neurologists or neurosurgeons (p < 0.001). There was no significant difference in rates of recommending flow diversion or intrasaccular devices between those who had trained before and after their introduction (p = 0.97). Conclusion: The study highlights the dynamic nature of aneurysm management and considerable variability among different specialties. Further exploration into the rationale for each decision is needed to understand how specialty training affects these decisions. 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

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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, 843 KB

Open AccessArticle

Intranasal Esketamine Versus Other Pharmacological Strategies in Treatment-Resistant Depression with High Suicide Risk: A Six-Month Naturalistic Study

by Ana María de Granda-Beltrán, Alejandro Porras-Segovia, Daniel Núñez-Arias, Alba Rodríguez-Jover, Maria Paula Jassir Acosta, Philippe Courtet, Enrique Baca-García and Inmaculada Peñuelas-Calvo

Clin. Pract. 2026, 16(6), 110; https://doi.org/10.3390/clinpract16060110 - 12 Jun 2026

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Abstract

Background: Treatment-resistant depression (TRD) poses a major clinical challenge, particularly when accompanied by suicidal behavior. Intranasal esketamine has demonstrated rapid antidepressant effects in TRD, but real-world comparative evidence remains limited. Methods: We conducted a six-month naturalistic prospective cohort study in two Spanish mental [...] Read more.

Background: Treatment-resistant depression (TRD) poses a major clinical challenge, particularly when accompanied by suicidal behavior. Intranasal esketamine has demonstrated rapid antidepressant effects in TRD, but real-world comparative evidence remains limited. Methods: We conducted a six-month naturalistic prospective cohort study in two Spanish mental health centers, including 62 TRD patients with high suicide risk undergoing fourth-line treatment. Thirty patients received intranasal esketamine and thirty-two alternative pharmacological interventions. Suicidal ideation (C-SSRS), depressive symptoms (HAM-D-17) and functional status (FAST) were assessed at baseline and at 1-, 3- and 6-month follow-ups. Results: Both groups showed significant improvement during follow-up; however, esketamine-treated patients exhibited a faster and greater reduction in suicidal ideation and depressive symptoms than those receiving alternative pharmacological strategies. The number needed to treat to prevent one case of high suicide risk was 1.35. Functional improvement was comparable between groups. Conclusions: In real-world clinical settings, intranasal esketamine was associated with a faster and greater reduction in suicidal ideation and depressive symptoms among TRD patients with high suicide risk, supporting its role as a rapid-acting therapeutic option within comprehensive and closely monitored care. Full article

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7 pages, 15778 KB

Open AccessCase Report

Clinical and Radiological Findings in Endorectal Migration of a Metallic Ureteral Stent

by Szabolcs André, Daniela Dobru, Árpád-Olivér Vida, Miheler Dora, Rares-Florin Vascul, Călin Chibelean, Lorand Tibor Reman, Raul-Dumitru Gherasim, Edva Anna Frunda and Orsolya Katalin Ilona Martha

Clin. Pract. 2026, 16(6), 109; https://doi.org/10.3390/clinpract16060109 - 11 Jun 2026

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Abstract

Hydronephrosis caused by malignant ureteral obstruction or radiotherapy-induced ureteral stenosis is a frequent complication in patients with cervical cancer. Effective management requires continuous urinary drainage, which can be achieved either internally through ureteral stent placement or externally via percutaneous nephrostomy. Among available devices, [...] Read more.

Hydronephrosis caused by malignant ureteral obstruction or radiotherapy-induced ureteral stenosis is a frequent complication in patients with cervical cancer. Effective management requires continuous urinary drainage, which can be achieved either internally through ureteral stent placement or externally via percutaneous nephrostomy. Among available devices, the Allium^TM fully covered nitinol mesh ureteral stent is designed to treat ureteral or urethral strictures while allowing safe and easy removal. However, serious complications have been reported, including uretero-enteric, uretero-arterial, and uretero-vaginal fistulas, pseudoaneurysm, ureteral perforation and sepsis. We report the case of a 44-year-old woman diagnosed in 2020 with stage IIIC1 cervical cancer (FIGO classification) who underwent surgery followed by adjuvant radiotherapy. In 2021, a right metallic ureteral stent was placed to treat ureteral obstruction. Two years later, she presented with right lumbar pain, and abdominal ultrasonography revealed grade III right hydronephrosis. CT scan demonstrated migration of the metallic ureteral stent into the rectal wall. Endoscopic extraction of the migrated stent was successfully performed via colonoscopy. Retrograde pyelography and CT imaging confirmed the presence of a recto-ureteral fistula. A 6 Ch/26 cm double-J ureteral stent was subsequently placed with good positioning and drainage. At the six-month follow-up, replacement of the double-J stent was performed. Imaging studies showed only minor residual hydronephrosis. Although metallic ureteral stents are effective for managing malignant ureteral obstruction, particularly in complex oncologic cases, they are not free of severe complications. The risk appears increased in patients who have undergone radiotherapy, emphasizing the need for careful monitoring and long term follow-up. Full article

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8 pages, 688 KB

Open AccessCase Report

Successful Limb Salvage in MRSA Bacteremic Septic Charcot Midfoot Using Continuous Local Antibiotic Perfusion and Circular External Fixation: A Case Report

by Koji Nozaka and Naohisa Miyakoshi

Clin. Pract. 2026, 16(6), 108; https://doi.org/10.3390/clinpract16060108 - 9 Jun 2026

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Abstract

Background: Septic Charcot neuroarthropathy is a limb- and life-threatening condition characterized by the coexistence of neuropathic joint destruction and infection. In patients with severe systemic compromise, major amputation is often considered inevitable. Case Presentation: A 47-year-old man with untreated diabetes mellitus [...] Read more.

Background: Septic Charcot neuroarthropathy is a limb- and life-threatening condition characterized by the coexistence of neuropathic joint destruction and infection. In patients with severe systemic compromise, major amputation is often considered inevitable. Case Presentation: A 47-year-old man with untreated diabetes mellitus presented with progressive painless swelling of the left foot. He had morbid obesity (120 kg, 165 cm; body mass index 44.1 kg/m²), severe hypoalbuminemia, and chronic kidney disease associated with nephrotic syndrome. Laboratory tests showed marked inflammation and poor glycemic control, and blood cultures were positive for methicillin-resistant Staphylococcus aureus (MRSA). Radiographs and computed tomography demonstrated destructive changes involving the talonavicular and subtalar joints, consistent with septic Charcot neuroarthropathy involving the midfoot. Because of sepsis, pulmonary edema, and heart failure, below-knee amputation was proposed at the referring hospital. However, limb salvage was attempted using aggressive debridement, continuous local antibiotic perfusion (CLAP; gentamicin 1200 μg/mL) administered for 14 days, and temporary circular external fixation. Serum gentamicin concentrations and renal function were regularly monitored to ensure systemic safety and avoid nephrotoxicity. Results: Repeat irrigation and final debridement were performed 20 days after the index surgery, at which time the external fixator was removed and intraoperative cultures were negative. The patient was discharged 2 months after surgery without evidence of recurrent infection. At 4-year follow-up, no recurrence had occurred, and the patient was able to walk independently. Conclusions: Limb salvage may be feasible even in severely compromised patients with septic Charcot midfoot and MRSA bacteremia when aggressive debridement, CLAP, and temporary external fixation are combined with careful systemic safety monitoring. This case suggests that limb salvage may be considered in selected high-risk patients, although further studies are required. Full article

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14 pages, 35225 KB

Open AccessCase Report

Rare Implantation Sites of Ectopic Pregnancy: A Case Series of Ovarian and Hepatic Pregnancy and Review of Diagnostic Challenges

by Stefan Ivanovic, Ljubomir Srbinovic, Milica Ivanovic, Dragana Maglic, Nenad Kokošar and Rastko Maglic

Clin. Pract. 2026, 16(6), 107; https://doi.org/10.3390/clinpract16060107 - 31 May 2026

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Abstract

Background: Ectopic pregnancy remains a significant cause of maternal morbidity in early pregnancy. While most ectopic pregnancies happen within the fallopian tube, implantation may rarely occur in atypical locations such as the ovary or abdominal cavity. These rare forms often present with nonspecific [...] Read more.

Background: Ectopic pregnancy remains a significant cause of maternal morbidity in early pregnancy. While most ectopic pregnancies happen within the fallopian tube, implantation may rarely occur in atypical locations such as the ovary or abdominal cavity. These rare forms often present with nonspecific clinical findings and may represent a considerable diagnostic challenge. Methods: We report a case series of three rare ectopic pregnancies managed at a tertiary referral center. Two cases involved ovarian pregnancy, and one case represented an exceptionally rare hepatic ectopic pregnancy. Clinical presentation, diagnostic pathway, surgical management, and outcomes were analyzed and compared with available literature. Results: In the first two cases, ovarian pregnancy was confirmed intraoperatively and treated surgically, with ovarian preservation in one patient and adnexectomy in the other due to active bleeding. The third case had an unusual course: initial surgery was performed for hemoperitoneum caused by a ruptured corpus luteum cyst, while persistent β-hCG elevation later led to identification of hepatic ectopic pregnancy, confirmed by imaging and surgery. All patients recovered favorably, with complete β-hCG negativization. Conclusions: Rare ectopic implantation sites may mimic acute abdominal conditions and remain difficult to diagnose preoperatively. High clinical suspicion, serial β-hCG monitoring, and appropriate imaging are essential. Surgical management remains central, particularly in life-threatening bleeding. Standard algorithms for tubal ectopic pregnancy may not be fully applicable and should be adapted to the clinical context. Full article

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

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18 pages, 1443 KB

Open AccessCase Report

Challenges in Diagnosis and Management of Spondylodiscitis of L-5/S-1 Due to Propionibacterium acnes in a Patient with a Twenty-Year History of Tetraplegia

by Vaidyanathan Subramanian, Bakulesh Madhusudan Soni, Peter Lyndon Hughes and Tun Oo

Clin. Pract. 2026, 16(6), 106; https://doi.org/10.3390/clinpract16060106 - 31 May 2026

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Abstract

Objectives: To present novel strategies in the diagnosis and management of spondylodiscitis in a patient with tetraplegia. Case Presentation: A 44-year-old man presented with increased spasms despite having a SynchroMed II Medtronic for intrathecal infusion of baclofen. The C-reactive protein level was raised. [...] Read more.

Objectives: To present novel strategies in the diagnosis and management of spondylodiscitis in a patient with tetraplegia. Case Presentation: A 44-year-old man presented with increased spasms despite having a SynchroMed II Medtronic for intrathecal infusion of baclofen. The C-reactive protein level was raised. Infection was suspected, but there were no localising signs. Positron Emission Tomography (PET) was performed to identify the focus of infection. PET showed an increased Fluorodeoxyglucose uptake in the L-5 vertebral body and the associated ill-defined soft tissue anteriorly. There was significant erosion and destruction of the S-1 vertebra. Magnetic Resonance Imaging of the lumbo-sacral spine revealed destruction and collapse of the S-1 vertebral body and a 6 cm × 2 cm anterior paravertebral abscess collection. This patient was managed in his home. Intravenous administration of 1 g of Ertapenem daily was provided by community nurses for eight weeks. Blood tests were performed in the community setting, and the patient was monitored by spinal unit doctors. Results: Follow-up CT revealed abnormal soft tissue, expanding and replacing the S-1 vertebral body, with appearances in keeping with an infective process. Using CT guidance and the Madison bone biopsy kit, multiple cores were obtained from the left sacral bone. Four of the five specimens showed no growth after extended incubation. Propionibacterium acnes were isolated after 10 days of incubation from the tissue from the sacral bone biopsy only. A shared decision was made towards active surveillance. Follow-up CT of the abdomen showed a stable appearance of the lumbar and sacral spine. Conclusions: A complex case of spondylodiscitis can be diagnosed and managed while the patient stays mainly in their home, avoiding prolonged admission to the spinal unit, in alignment with the “hospital to community” aspect of the National Health Service’s 10-year Health Plan for England. A diagnostic pathway with PET-CT as the first approach proved useful when the site of infection was unclear. Active surveillance obviated the need for extended periods of antibiotic therapy, which could have led to complications such as antibiotic-induced toxicity and microbial resistance to antibiotics. Full article

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

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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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17 pages, 299 KB

Open AccessArticle

Developing the Spanish Version of the Fraboni Scale of Ageism: Cross-Cultural Adaptation with Initial Reliability and Content Validity Findings

by Juan Ramón de-Moya-Romero, Alexis Caballero-Bonafé, Laura Fernández-Puerta, Raquel Valera-Lloris and Antonio Martínez-Sabater

Clin. Pract. 2026, 16(6), 104; https://doi.org/10.3390/clinpract16060104 - 31 May 2026

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Abstract

Background: Ageism is a global public health concern associated with poorer health outcomes and inequities in care. Culturally adapted instruments are needed to assess ageist attitudes among healthcare professionals in Spain. This study aimed to cross-culturally adapt and evaluate the preliminary psychometric properties [...] Read more.

Background: Ageism is a global public health concern associated with poorer health outcomes and inequities in care. Culturally adapted instruments are needed to assess ageist attitudes among healthcare professionals in Spain. This study aimed to cross-culturally adapt and evaluate the preliminary psychometric properties of the Spanish version of the Fraboni Scale of Ageism (FSA-SV). Methods: A methodological study was conducted, including translation and back-translation, expert review, and a pilot test. Content validity was assessed using the content validity index (CVI), the modified kappa coefficient, and Aiken’s V. A descriptive cross-sectional pilot study was conducted with 101 healthcare professionals from a single health department in Valencia to evaluate comprehension and reliability. Internal consistency was examined using Cronbach’s alpha and McDonald’s omega. Results: Content validity indices indicated acceptable agreement among experts (S-CVI = 0.745; Aiken’s V = 0.770). All items were retained to preserve conceptual and structural equivalence with the original instrument. The FSA-SV demonstrated high internal consistency (Cronbach’s alpha = 0.903; McDonald’s omega = 0.915). The mean total score was 51.2 (SD = 9.62), with no significant associations observed between ageism and participants’ sociodemographic or professional variables. Conclusions: This pilot study represents a first step in the cross-cultural adaptation and preliminary psychometric evaluation of the FSA-SV for use among healthcare professionals in Spain. The results suggest that the instrument shows promising initial properties for the preliminary assessment of ageism, supporting its potential utility in future research and in evaluating educational and organizational interventions aimed at reducing ageism and improving the quality and safety of care for older adults. Further studies with larger, more diverse samples are required to evaluate additional psychometric properties, including the factorial structure. Full article

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

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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

16 pages, 6548 KB

Open AccessCase Report

Random-Pattern Skin Paddle on a Free Latissimus Dorsi Flap as an Intraoperative Backup for Distal Lower-Limb Reconstruction: A Case Report

by Ivan Budimir, Borna Vojvodić, Rado Žic, Zlatko Vlajčić, Domagoj Eljuga, Božo Gorjanc, Željka Roje, Hrvoje Tucaković, Željka Godeč, Marko Barić, Josip Jaman, Rhea Marie Mužar and Krešimir Martić

Clin. Pract. 2026, 16(6), 102; https://doi.org/10.3390/clinpract16060102 - 28 May 2026

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Abstract

Background: The latissimus dorsi free flap is a workhorse for extensive lower-extremity soft tissue defects. Conventionally, the skin paddle is designed according to the anticipated defect and left in place on the muscle as a single composite unit. This report describes an alternative [...] Read more.

Background: The latissimus dorsi free flap is a workhorse for extensive lower-extremity soft tissue defects. Conventionally, the skin paddle is designed according to the anticipated defect and left in place on the muscle as a single composite unit. This report describes an alternative approach in which the skin paddle is secondarily mobilized through subcutaneous undermining and rotated as a separate propeller-type local extension flap on random-pattern vascularization, without a specifically identified perforator—a technique that has not been previously reported. Case Presentation: A 38-year-old male with a high-energy distal lower-extremity defect exposing bone, Achilles tendon, and hardware underwent free latissimus dorsi reconstruction with an empirically designed skin paddle over the constant perforator zone. The skin paddle was subsequently mobilized and rotated as a separate propeller-type extension flap to cover the Achilles region, with additional areas managed using split-thickness skin graft and a reverse soleus flap. Results: The latissimus dorsi flap and skin paddle remained viable, providing stable coverage of the defect. The additional reverse soleus flap achieved durable medial coverage, and the limb was ultimately preserved with satisfactory soft-tissue stability. Conclusion: A random-pattern latissimus dorsi skin paddle designed within the anatomically constant perforator zone can provide a feasible new option offering intraoperative flexibility in complex lower-extremity trauma when perforator mapping is impractical. Full article

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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

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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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20 pages, 615 KB

Open AccessArticle

A Pilot Study of Circulating microRNA Expression in Newly Diagnosed Type 2 Diabetes Using a Pooled Sample Approach

by Loredana Deaconu, Romulus Zorin Timar, Cristiane Dragomir, Edward Seclaman, Anca Marcu and Diana Nitusca

Clin. Pract. 2026, 16(6), 100; https://doi.org/10.3390/clinpract16060100 - 26 May 2026

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Abstract

Background and Objectives: MicroRNAs (miRNAs) are small non-coding RNAs that regulate gene expression and have emerged as potential biomarkers in type 2 diabetes mellitus and its complications. This pilot exploratory study aimed to identify circulating miRNAs with differential expression in plasma from [...] Read more.

Background and Objectives: MicroRNAs (miRNAs) are small non-coding RNAs that regulate gene expression and have emerged as potential biomarkers in type 2 diabetes mellitus and its complications. This pilot exploratory study aimed to identify circulating miRNAs with differential expression in plasma from patients with newly diagnosed type 2 diabetes mellitus compared to age- and sex-matched healthy controls. Materials and Methods: Peripheral venous blood samples were collected from diabetic patients (n = 24) and controls (n = 12). Due to the exploratory nature of the study and limited sample material, samples were pooled within each group prior to plasma separation. Total RNA, including miRNAs, was extracted from plasma and analyzed using a high-throughput qPCR panel. Two normalization methods were applied to assess miRNA expression, and overlapping results were used for downstream analysis. Fold regulation was calculated using the 2^(−ΔCt) method. Results: A total of 33 and 42 miRNAs were identified as differentially expressed using the first and second normalization methods, respectively. Fourteen miRNAs were consistently downregulated across both methods. Several of these miRNAs, including hsa-miR-26a-5p, hsa-miR-146a-5p, hsa-miR-186-5p, hsa-miR-19a-3p, and hsa-miR-652-3p, have been previously associated with glucose metabolism, inflammation, and diabetic complications, such as retinopathy, neuropathy, and endothelial dysfunction. The pooling strategy enabled an efficient exploratory assessment of miRNA expression patterns while reducing inter-individual variability. Conclusions: This exploratory pilot study identifies a panel of circulating miRNAs with altered expression in pooled plasma samples from patients with newly diagnosed type 2 diabetes mellitus. These findings provide preliminary insights that warrant further validation in larger, individual-level studies to assess their diagnostic and prognostic potential. Full article

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10 pages, 1016 KB

Open AccessCase Report

Segmental Arterial Mediolysis Associated with Renal Allograft Artery Dissection and Thrombosis During Kidney Transplantation

by Matteo Zanchetta, Natale Calomino, Giuseppe Ietto, Vanessa Borgogni, Giorgio Micheletti, Sergio Antonio Tripodi, Daniele Marrelli, Franco Roviello and Gian Luigi Adani

Clin. Pract. 2026, 16(6), 99; https://doi.org/10.3390/clinpract16060099 - 24 May 2026

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Abstract

Background: Segmental arterial mediolysis (SAM) is a rare, non-inflammatory, non-atherosclerotic, non-hereditary arteriopathy of unknown etiology that typically affects medium-sized visceral arteries. The absence of reliable diagnostic criteria poses a significant challenge. Consequently, the diagnosis of SAM should be considered in the setting [...] Read more.

Background: Segmental arterial mediolysis (SAM) is a rare, non-inflammatory, non-atherosclerotic, non-hereditary arteriopathy of unknown etiology that typically affects medium-sized visceral arteries. The absence of reliable diagnostic criteria poses a significant challenge. Consequently, the diagnosis of SAM should be considered in the setting of a distinctive combination of clinical features, angiographic findings, and histopathology. Renal artery involvement is uncommon, and its occurrence in the donor graft during kidney transplantation (KT) has not previously been reported. Case presentation: We report the case of a kidney graft from a deceased donor in her seventh decade of life, transplanted into a recipient in her seventh decade of life. Donor–recipient ABO compatibility was confirmed, and both complement-dependent cytotoxicity crossmatch and flow cytometry crossmatch were negative. Cold ischemia time was 14 h, and warm ischemia time was 20 min. Immediately after declamping, massive thrombosis of the graft renal artery was observed and confirmed using an intraoperative flowmeter. The arterial anastomosis was taken down, the thrombus was removed, the artery was flushed with heparin, and the anastomosis was reconstructed using interrupted sutures. Despite revision, no arterial flow was detected, and the graft was deemed unsalvageable and explanted. Histopathological examination showed thinning of the tunica media, reduced smooth muscle cells on desmin staining, medial-adventitial dissection, and occlusive thrombosis, findings considered likely attributable to SAM. Conclusions: This case suggests that occult donor arterial wall disease compatible with SAM may present catastrophically during KT and may lead to immediate graft loss despite standard surgical salvage attempts. Although no validated strategy currently exists to screen for or prevent occult SAM in asymptomatic donors, awareness of this entity may assist transplant surgeons and pathologists in the evaluation of unexplained early graft arterial thrombosis, donor-graft vascular pathology, and communication with centres receiving paired organs from the same donor. Full article

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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

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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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Clin. Pract., Volume 16, Issue 6 (June 2026) – 20 articles

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