Clinics and Practice

13 pages, 240 KB

Open AccessReview

Apert Syndrome: Oral, Maxillofacial and Dental Management—A Narrative Clinical Review

by Nikolaos G. A. Kolomvos, Thomai Papadaki and Gregoris Venetis

Clin. Pract. 2026, 16(7), 135; https://doi.org/10.3390/clinpract16070135 - 22 Jul 2026

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Apert syndrome is a rare genetic disorder characterized by premature fusion of the cranial sutures, syndactyly of the extremities, and distinct craniofacial deformities. The condition results from mutations in the FGFR2 gene, which disrupt normal craniofacial growth and lead to complex functional and [...] Read more.

Apert syndrome is a rare genetic disorder characterized by premature fusion of the cranial sutures, syndactyly of the extremities, and distinct craniofacial deformities. The condition results from mutations in the FGFR2 gene, which disrupt normal craniofacial growth and lead to complex functional and morphological abnormalities. Patients with Apert syndrome commonly present with stomatognathic abnormalities, which significantly affect oral function and facial development. The management of Apert syndrome requires a multidisciplinary therapeutic approach. Surgical treatment strategies are typically staged according to the patient’s age and clinical severity. Early interventions focus on cranial vault expansion procedures, such as fronto-orbital advancement and posterior vault distraction osteogenesis, aiming to relieve intracranial pressure and improve cranial morphology. During childhood and adolescence, midface advancement techniques are commonly performed to address midfacial hypoplasia and associated functional impairments. Early diagnosis and appropriate surgical planning play a crucial role in preventing complications and improving the functional, aesthetic, and psychosocial outcomes of patients with Apert syndrome. This narrative review summarizes current evidence while highlighting areas of ongoing controversy, particularly regarding surgical sequencing, orthodontic management and the integration of digital technologies into multidisciplinary care. Full article

(This article belongs to the Special Issue Clinical Outcome Research in the Head and Neck: 2nd Edition)

13 pages, 1132 KB

Open AccessArticle

Healthcare Indicators in Lithuania: A Descriptive Analysis of Their Contextual Relevance to Health Literacy

by Sonata Čerkauskaitė and Alina Liepinaitienė

Clin. Pract. 2026, 16(7), 134; https://doi.org/10.3390/clinpract16070134 - 17 Jul 2026

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Abstract

Background/Objectives: Chronic non-communicable diseases remain one of the main public health problems. Increasing multimorbidity and the importance of health literacy (HL) emphasize the need for a comprehensive assessment of health indicators. The aim of this study was to assess the main health [...] Read more.

Background/Objectives: Chronic non-communicable diseases remain one of the main public health problems. Increasing multimorbidity and the importance of health literacy (HL) emphasize the need for a comprehensive assessment of health indicators. The aim of this study was to assess the main health indicators of the Lithuanian population and trends in the use of healthcare services and to discuss the relevance of these indicators in the context of HL, based on the links between HL and these indicators described in the scientific literature. Methods: A retrospective longitudinal descriptive study was performed using publicly available Lithuanian population health statistics of 2005–2024. Mortality, morbidity, avoidable hospitalizations, subjective health assessment, and utilization of healthcare services and preventive programs were analyzed using descriptive statistical analysis. HL was not directly measured but was used as a conceptual framework for interpreting the findings. Results: In Lithuania, the highest mortality rate is due to cardiovascular diseases (CVDs) (~50.8%). CVD and infectious diseases also dominate the structure of avoidable hospitalizations, and their rates vary greatly across municipalities, being higher in less urbanized areas. The assessment of the population’s health is improving over time, but gender differences remain in the use of healthcare services and preventive programs. Conclusions: The findings demonstrate a high burden of chronic diseases and regional disparities in healthcare utilization in Lithuania. HL may provide a useful context for interpreting these findings, although it was not directly assessed. Future studies should directly evaluate HL and its association with health indicators in the Lithuanian population. Full article

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13 pages, 692 KB

Open AccessArticle

Indications, Causes, and Patient Risk Factors for Revision After Total Ankle Arthroplasty: A Descriptive Cross-Registry Analysis of the NJR, AOANJRR, and SwedAnkle Registries

by Sedeek Mosaid, Yousif Jihad, Mostafa Jihad, Ashok Marudanayagam and Paul Lee

Clin. Pract. 2026, 16(7), 133; https://doi.org/10.3390/clinpract16070133 - 17 Jul 2026

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Abstract

Background/Objectives: Total ankle arthroplasty (TAA) is increasingly used to treat end-stage ankle arthritis, but comprehensive cross-registry data on revision patterns remain limited. This study describes indications, causes, and patient risk factors for revisions using three national registries. Methods: Aggregate data were extracted from [...] Read more.

Background/Objectives: Total ankle arthroplasty (TAA) is increasingly used to treat end-stage ankle arthritis, but comprehensive cross-registry data on revision patterns remain limited. This study describes indications, causes, and patient risk factors for revisions using three national registries. Methods: Aggregate data were extracted from the UK National Joint Registry (NJR; 22nd Annual Report 2025; n = 11,321), the Australian Orthopaedic Association National Joint Replacement Registry (AOANJRR; 2025 Ankle Supplementary Report; n = 5379), and the Swedish Ankle Registry (SwedAnkle; Annual Report 2024; n = 1852; survival estimates from a published sub-cohort, n = 1226). Metrics were compared descriptively without inferential pooling. Results: Across registries, 18,552 primary TAAs were identified. Ten-year cumulative per cent revision (CPR) was 9.54% (95% confidence interval [CI], 8.75–10.39) in the NJR, 13.5% (95% CI, 12.1–15.1) in the AOANJRR osteoarthritis sub-cohort, and approximately 26% (author-derived from Kaplan–Meier curves; see Methods) in SwedAnkle (1993 onwards implants). Aseptic loosening was the predominant cause of revision in all three registries; the rank of subsequent causes differed between registries (infection was second in the NJR and AOANJRR; in SwedAnkle, infection ranked below insert wear/breakage at 11.5%). AOANJRR Cox analysis identified younger age (hazard ratios (HRs), 2.00 for <55 vs. ≥75 years; 95% CI, 1.30–3.07; p = 0.001), earlier surgical era (HR, 1.91 for pre-2015 vs. 2015–2024; 95% CI, 1.53–2.38; p < 0.001), and obesity (HR, 1.52 for body mass index (BMI) ≥ 30; 95% CI, 1.06–2.19; p = 0.023) as significant independent predictors in AOANJRR Cox proportional hazards models (osteoarthritis sub-cohort for age, sex, BMI and ASA; all-diagnoses primary cohort for surgical era). Sex and American Society of Anesthesiologists (ASA) scores were not significant. Conclusions: Aseptic loosening was the predominant cause of revision in all three registries. The rank of subsequent causes differed: in the NJR and AOANJRR, infection was the second most frequent cause; in SwedAnkle, infection ranked below insert wear/breakage. Younger age, obesity, and earlier surgical era were independent predictors of revision in AOANJRR Cox proportional hazards models. The post-2015 era was associated with approximately 48% lower revision hazard; this association cannot be interpreted causally, as the independent contributions of implant design, surgical technique, patient selection, and other secular changes cannot be isolated from registry data. These findings may inform preoperative counselling, implant selection, and registry harmonisation efforts. Full article

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8 pages, 225 KB

Open AccessArticle

Sonographic Assessment of Fetal Anatomy in the First Trimester: A Comparative Study of Visualization Rates Using Two- and Three-Dimensional Ultrasound

by Savoia Fabiana, La Verde Marco, Giudicepietro Antonia, Minnella Gian Piero, Fantasia Ilaria, Sarno Laura, Quaresima Paola, Gerbino Martina, Volpe Grazia, Dall’Asta Andrea and Morlando Maddalena

Clin. Pract. 2026, 16(7), 132; https://doi.org/10.3390/clinpract16070132 - 15 Jul 2026

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Abstract

Background/Objectives: This study aimed to compare the visualization rates of fetal anatomical structures with standard 2D ultrasound examination versus a single 3D volume acquired during the first trimester. Methods: This multicenter prospective study was performed in nine tertiary referral centers, by experienced [...] Read more.

Background/Objectives: This study aimed to compare the visualization rates of fetal anatomical structures with standard 2D ultrasound examination versus a single 3D volume acquired during the first trimester. Methods: This multicenter prospective study was performed in nine tertiary referral centers, by experienced sonographers. A standard protocol was adopted in both 2D and 3D modalities to assess the 17 anatomical structures listed in the national and international guidelines. The included cases were non-anomalous fetuses from women booked for combined screening test between 11 + 0 and 13 + 6 weeks. Results: Two hundred and thirty-nine women were included in the study. The mean gestational age at ultrasound examination was 12 weeks ± 5 days (±5.4 SD). All the 17 structures were seen in 155/239 fetuses (64.85%) at 2D evaluation and in 84/239 (35.15%) at 3D evaluation (p = 0.001). Comparing 2D and 3D visualization, the following anatomical structures showed a statistical difference: posterior fossa (92% vs. 74%, p < 0.005); neck (94.2% vs. 87.2%, p < 0.001); orbits (93% vs. 85.6%, p < 0.001); nasal bone (93% vs. 88.8%, p = 0.016); lung fields (99.5% vs 96.7%, p = 0.046); cardiac axis (99.5% vs. 83.9%; p < 0.001); bladder (97.5% vs. 91.7%, p < 0.001); abdominal wall (98.7% vs. 94.2%, p < 0.001). For the other anatomical portion, no statistically significant differences were found. Conclusions: Our study demonstrates that a full assessment of fetal anatomy is best performed using 2D ultrasound, while 3D ultrasound showed lower overall visualization rates, with comparable performance for selected structures, suggesting a potential supplementary use in specific clinical contexts. Full article

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

17 pages, 3206 KB

Open AccessArticle

Early Risk Stratification of Delirium in Intermediate Care Units and Its Impact on 30-Day Mortality: A Decision-Tree Analysis

by Fabrizio Lucente, Lucia Filippi, Arian Zaboli, Alessandra Eugenia Bionda, Michael Maggi, Marta Parodi, Alice Bresolin, Arianna Pretto, Martina Da Meda, Silvia Greselin, Francesca Fulghesu and Gianni Turcato

Clin. Pract. 2026, 16(7), 131; https://doi.org/10.3390/clinpract16070131 - 13 Jul 2026

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Abstract

Background: Delirium is an under-recognized complication in hospitalized acute care patients, associated with worse outcomes including increased length of stay, higher ICU admission rates and greater mortality. Although screening tools exist for early diagnosis, the absence of admission-based tools limits early risk stratification [...] Read more.

Background: Delirium is an under-recognized complication in hospitalized acute care patients, associated with worse outcomes including increased length of stay, higher ICU admission rates and greater mortality. Although screening tools exist for early diagnosis, the absence of admission-based tools limits early risk stratification and timely prevention strategies. Aim: To identify early risk factors for delirium development in IMCU patients and quantify its prognostic role on 30-day mortality. Methods: In this prospective single-center study, 651 consecutive IMCU patients without delirium at admission were enrolled. Admission variables were analyzed using multivariable logistic regression and Classification and Regression Tree (CART) analysis to identify clinically relevant risk phenotypes. The association between delirium and 30-day mortality was assessed in adjusted models. Results: Delirium developed in 18.6% of patients within 96 h. Key independent risk factors included age (OR 1.04), male sex (OR 1.75), alcohol use disorder (OR 3.59), cognitive impairment (OR 3.35), COPD (OR 1.68), NEWS (OR 1.18), and need for NIV (OR 3.83). CART analysis identified NIV as the dominant early discriminator, followed by cognitive vulnerability and acute severity. 30-day mortality was significantly higher in patients with delirium (22.3% vs. 9.8%, p = 0.001). Delirium remained an independent risk factor after adjustment (OR 2.53). CART analysis further corroborates delirium as a significant determinant, enhancing prognostic stratification beyond its role as a mere surrogate of disease severity. Conclusions: Admission-level clinical variables and exploratory CART analysis identified clinically interpretable delirium risk phenotypes in IMCU patients. Delirium was independently associated with increased 30-day mortality. These findings provide a preliminary framework for future validation studies and development of IMCU-specific risk-stratification approaches. Full article

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14 pages, 337 KB

Open AccessArticle

Knowledge, Attitudes, and Perceptions of Midwives and Obstetricians/Gynecologists on Sexual Activity During Pregnancy: A Cross-Sectional Study in Greece

by Eleni Charitopoulou, Angeliki Bolou, Vikentia Harizopoulou, Antigoni Sarantaki, Athina Diamanti, Irene Athina Avramidou and Giannoula Kyrkou

Clin. Pract. 2026, 16(7), 130; https://doi.org/10.3390/clinpract16070130 - 10 Jul 2026

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Abstract

Background: Sexual health is a key component of quality of life and an essential aspect of holistic maternity care. During pregnancy, changes in sexual function are often accompanied by fears and misconceptions, which are influenced by healthcare professionals’ counseling. Objectives: The present [...] Read more.

Background: Sexual health is a key component of quality of life and an essential aspect of holistic maternity care. During pregnancy, changes in sexual function are often accompanied by fears and misconceptions, which are influenced by healthcare professionals’ counseling. Objectives: The present study aimed to investigate the knowledge, attitudes, and perceptions of midwives and obstetricians/gynecologists in Greece regarding sexual activity during pregnancy. Methods: A cross-sectional study was conducted using an anonymous, self-administered questionnaire. Participants included 121 healthcare professionals (73 midwives and 48 obstetricians/gynecologists). Data were analyzed using appropriate non-parametric statistical tests and multiple linear regression analysis. Results: The majority of participants (97.5%) considered sexual activity during pregnancy to be beneficial. Midwives demonstrated significantly higher scores on the knowledge assessment compared to obstetricians/gynecologists (67.7 ± 18.0 vs. 54.8 ± 24.2, p = 0.001) and more frequently selected the questionnaire response indicating benefits for both the couple and the fetus (46.6% vs. 27.1%, p = 0.031). A higher proportion of midwives perceived that pregnant women do not receive adequate information regarding their sexual health (93.2% vs. 68.8%, p < 0.001). Obstetricians/gynecologists were more likely to recommend restrictions even in low-risk pregnancies. Conclusions: The findings highlight the need for improved education and standardized counseling protocols on sexual health during pregnancy, with particular emphasis on strengthening the role of midwives in delivering holistic, woman-centered care. Full article

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

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9 pages, 212 KB

Open AccessArticle

Awareness of Dental Professionals of the Relationship Between Prosthetic Pressure Lesions and Infective Endocarditis: A Cross-Sectional Observational Study

by Francesco Saverio Ludovichetti, Serena Zanatta, Davide Scettri, Valentina Brun, Sergio Mazzoleni, Edoardo Stellini and Christian Bacci

Clin. Pract. 2026, 16(7), 129; https://doi.org/10.3390/clinpract16070129 - 10 Jul 2026

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Abstract

Background: Infective endocarditis is a serious disease affecting cardiac tissues and may arise following episodes of transient bacteremia. Oral prosthetic pressure lesions, characterized by mucosal ulcerations, may facilitate the entry of pathogenic microorganisms into the systemic circulation. In predisposed individuals, the presence [...] Read more.

Background: Infective endocarditis is a serious disease affecting cardiac tissues and may arise following episodes of transient bacteremia. Oral prosthetic pressure lesions, characterized by mucosal ulcerations, may facilitate the entry of pathogenic microorganisms into the systemic circulation. In predisposed individuals, the presence of such lesions may therefore contribute to the development of infective endocarditis. The objective of this study was to assess dental professionals’ knowledge, awareness, and self-reported clinical practices related to the possible relationship between oral prosthetic pressure lesions and infective endocarditis. Materials and Methods: A cross-sectional observational study was conducted using an anonymous online questionnaire specifically developed for this study and subjected to preliminary content validation and pilot assessment before administration. The survey was distributed online to oral health professionals working in the Italian public and private sectors; for the present analysis, only complete responses provided by licensed dental professionals practicing in Italy were included. Results: Among the 268 dental professionals analyzed, an overall limited awareness of the possible relationship between oral prosthetic pressure lesions and infective endocarditis emerged. Only 16.8% of participants reported being familiar with the most recent guidelines for the prevention of infective endocarditis. Conclusions: The findings suggest the need to strengthen continuing education, improve familiarity with current infective endocarditis prevention guidelines, and promote more structured clinical protocols for the assessment and management of prosthetic pressure lesions in patients at risk. Full article

20 pages, 1526 KB

Open AccessArticle

Epidemiological Patterns and Determinants of Subclinical and Overt Hypothyroidism in a Clinical Cohort from the Hail Region, Saudi Arabia: A Retrospective Cross-Sectional and Cluster Analysis Study

by Tareq Nafea Alharby, Sultan Almuntashiri, Majd Habib Alshammari, Shahad Hassan Alshammari, Ahad Fhaid Alzabni, Asyah Awad Alnomassi, Hanadi Saleh Alrashidi, Saleh Alghamdi, Nafees Ahemad and Sirajudheen Anwar

Clin. Pract. 2026, 16(7), 128; https://doi.org/10.3390/clinpract16070128 - 9 Jul 2026

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Abstract

Background: Hypothyroidism is a globally prevalent disorder with variations in its occurrence. However, few studies have reported its prevalence in Saudi Arabia. This study aimed to establish the prevalence, characteristics, and predictors of subclinical and overt hypothyroidism in a clinical cohort from [...] Read more.

Background: Hypothyroidism is a globally prevalent disorder with variations in its occurrence. However, few studies have reported its prevalence in Saudi Arabia. This study aimed to establish the prevalence, characteristics, and predictors of subclinical and overt hypothyroidism in a clinical cohort from the Hail region of Saudi Arabia. Methods: A retrospective cross-sectional design was used. Electronic medical records of adults (aged ≥18 years) who underwent thyroid function testing (TSH, FT4, and FT3) at the study institution were reviewed. Participants with missing laboratory or demographic data and those with hyperthyroidism (TSH < 0.4 mIU/L) were excluded. Hypothyroidism was classified biochemically using internationally accepted TSH and FT4 thresholds. The final analysis cohort comprised 724 participants. Results: Of 724 participants, 471 (65.1%) were euthyroid, 234 (32.3%) had subclinical hypothyroidism, and 19 (2.6%) had overt hypothyroidism, yielding a total biochemical hypothyroidism prevalence of 34.9% (n = 253). Women were over-represented (89.6%), and obesity was prevalent (69%). The biochemical results confirmed that overt hypothyroidism showed significantly elevated TSH and decreased FT4 compared to subclinical hypothyroidism. There were non-significant associations between gender, BMI, and hypertension with thyroid status. Age was an independent predictor of hypothyroid status (OR = 0.983, 95% CI: 0.970–0.995, p = 0.008), and systolic blood pressure was also independently associated (OR = 1.011, 95% CI: 1.002–1.019, p = 0.016). Multiple regression showed age, hypertension, gonarthrosis, and chest pain were independently associated with TSH levels. Hierarchical clustering suggested potential regional patterns in hypothyroidism prevalence. Conclusions: Hypothyroidism, mostly subclinical, was prevalent in this clinical cohort. Age and systolic blood pressure were independent predictors, while BMI and gender were not. Biochemical assessment is essential for detection, and larger prospective studies are recommended. Full article

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24 pages, 3648 KB

Open AccessArticle

Beyond National Averages: Spatial and Temporal Patterns in Type 2 Diabetes Dynamics in Romania—A 10-Year Time Series Study

by Cristina Gena Dascalu, Diana Tatarciuc and Magda Ecaterina Antohe

Clin. Pract. 2026, 16(7), 127; https://doi.org/10.3390/clinpract16070127 - 4 Jul 2026

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Abstract

Background/Objectives: This study analyzes the temporal and spatial evolution of type 2 diabetes prevalence in Romanian counties over a 10-year period (2012–2021), based on the time series autocorrelation and cross-correlation coefficients. Methods: The autocorrelation coefficients were calculated within each county’s data series, in [...] Read more.

Background/Objectives: This study analyzes the temporal and spatial evolution of type 2 diabetes prevalence in Romanian counties over a 10-year period (2012–2021), based on the time series autocorrelation and cross-correlation coefficients. Methods: The autocorrelation coefficients were calculated within each county’s data series, in order to identify the internal temporal dependencies, and the cross-correlation coefficients were calculated on administrative regions, in order to identify epidemiological patterns. Results: The type 2 diabetes prevalence rates in most counties follow autoregressive series, with significant positive correlations at lag 1, indicating cyclical fluctuations. Cross-correlation analysis revealed 3 regional patterns: North-East and West regions showed highly synchronized dynamics with cross-correlations exceeding 0.9, South-East and South regions showed mixed synchronization, with temporal lags of 1–2 years between counties, while the other regions (Center, South-West and North-West) revealed a synchronized core and an isolated county, with atypical dynamics (e.g., Cluj, Alba, Mehedinți, Ialomița). Conclusions: These findings highlight the utility of time series analysis in understanding the specificity of such data and their practical applicability in customizing the required public health interventions. Full article

(This article belongs to the Topic Health Monitoring in the Context of Medical Big Data)

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15 pages, 265 KB

Open AccessReview

Unusual Manifestations of Sinonasal Osteomas: A Narrative Review

by Spyridon Lygeros, Alkmini Gatsounia, Ioanna Athanasiadou, Aris I. Giotakis, Foteini Tsapardoni and Gerasimos Danielides

Clin. Pract. 2026, 16(7), 126; https://doi.org/10.3390/clinpract16070126 - 4 Jul 2026

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Abstract

Background/Objectives: Sinonasal osteomas are benign, slow-growing tumors that are typically asymptomatic and incidentally detected. However, in rare cases, they may present with atypical and potentially serious complications involving other sinonasal, orbital, or intracranial structures. This review aims to synthesize these unusual manifestations [...] Read more.

Background/Objectives: Sinonasal osteomas are benign, slow-growing tumors that are typically asymptomatic and incidentally detected. However, in rare cases, they may present with atypical and potentially serious complications involving other sinonasal, orbital, or intracranial structures. This review aims to synthesize these unusual manifestations and to highlight the underlying mechanisms, diagnostic challenges, and management implications. Methods: A narrative review of the literature was conducted, focusing on reported cases of sinonasal osteomas with rare or complicated presentations. Studies were analyzed with emphasis on clinical features, imaging findings, pathophysiological mechanisms, and treatment strategies. Results: Unusual presentations of sinonasal osteomas are primarily driven by sinus obstruction, progressive expansion, and skull-base erosion. These processes may result in complications such as pneumocephalus, intracranial mucoceles, cerebrospinal fluid leaks, orbital compression, and secondary infections. Clinical manifestations are often nonspecific, including headache, seizures, visual disturbances, or focal neurological deficits, which may delay diagnosis. High-resolution computed tomography is essential for identifying the osseous lesion and associated bone changes, while magnetic resonance imaging is critical for assessing soft-tissue involvement and intracranial extension. Management is individualized, with surgical resection indicated in most symptomatic or complicated cases, using endoscopic, open, or combined approaches. Conclusions: Although rare, atypical manifestations of sinonasal osteomas can result in significant morbidity. A mechanism-based understanding, supported by appropriate imaging, is essential for accurate diagnosis and timely management. Increased clinical awareness is crucial to improving outcomes in these uncommon but clinically significant cases. Full article

9 pages, 3587 KB

Open AccessCase Report

Limb Salvage After Chronic Nonunion Following Deformity Correction in Congenital Fibular Deficiency: A Cautionary 12-Year Follow-Up Case Highlighting Biological and Mechanical Reconstructive Challenges

by Koji Nozaka, Shohei Murata and Naohisa Miyakoshi

Clin. Pract. 2026, 16(7), 125; https://doi.org/10.3390/clinpract16070125 - 3 Jul 2026

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Abstract

Background: Congenital fibular deficiency is a rare longitudinal deficiency of the lower extremity associated with limb-length discrepancy, ankle and foot deformity, soft-tissue imbalance, and functional impairment. Reconstruction may be challenging because bone healing, regenerate maturation, and mechanical stability can be less predictable [...] Read more.

Background: Congenital fibular deficiency is a rare longitudinal deficiency of the lower extremity associated with limb-length discrepancy, ankle and foot deformity, soft-tissue imbalance, and functional impairment. Reconstruction may be challenging because bone healing, regenerate maturation, and mechanical stability can be less predictable in selected patients. Case Presentation: A man with congenital fibular deficiency developed chronic distal tibial nonunion after corrective osteotomy at another institution. The nonunion persisted for four years, and the patient presented to our hospital with inability to bear weight and wheelchair dependence. A comprehensive salvage strategy was performed, including Achilles tendon lengthening using the Vulpius technique, removal of retained fixation material, debridement and refreshment of the nonunion site, negative bacteriological cultures, autologous cancellous iliac bone grafting, acute shortening and compression of the docking site, circular external fixation, proximal tibial osteotomy, and gradual lengthening. Low-intensity pulsed ultrasound was applied postoperatively as an adjunctive biological stimulus. Results: Bone union was achieved, and the external fixator was removed approximately one year after surgery. A total lengthening of 78 mm was achieved. At 12-year follow-up, the AOFAS ankle-hindfoot score was 90, ankle range of motion was 5° dorsiflexion and 40° plantarflexion, and the JOA knee score was 95. The patient walked independently without assistive devices and continued to work. Mild residual varus deformity of the proximal tibia was present, but the patient reported no knee pain, ankle pain, or ankle instability, and radiographs showed no progressive osteoarthritic changes. Conclusions: In selected patients with congenital fibular deficiency and chronic nonunion after previous treatment, durable limb salvage may be achieved using an individualized strategy that addresses both biological and mechanical factors. Full article

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14 pages, 2563 KB

Open AccessSystematic Review

Serum or Plasma Oncostatin M for Predicting Primary Non-Response to Tumor Necrosis Factor-α Antagonist Therapy in Inflammatory Bowel Disease: A Systematic Review and Meta-Analysis

by Maxwell A. Barffour, Elizabeth Karanja, Mustafa Gandhi, Susan S. Kais, Saurabh Kapur and Yezaz A. Ghouri

Clin. Pract. 2026, 16(7), 124; https://doi.org/10.3390/clinpract16070124 - 2 Jul 2026

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Abstract

Background: Over 30% of patients with inflammatory bowel disease (IBD) experience primary non-response to tumor necrosis factor-α antagonists (anti-TNFs). Oncostatin M (OSM), a TNF-α-independent pro-inflammatory signaling cytokine, is emerging as a potential predictive biomarker of treatment response. Through a systematic review and [...] Read more.

Background: Over 30% of patients with inflammatory bowel disease (IBD) experience primary non-response to tumor necrosis factor-α antagonists (anti-TNFs). Oncostatin M (OSM), a TNF-α-independent pro-inflammatory signaling cytokine, is emerging as a potential predictive biomarker of treatment response. Through a systematic review and meta-analysis, we assessed the utility of baseline serum or plasma OSM for predicting anti-TNF response in IBD patients. Methods: We searched PubMed, Embase, Cochrane Library, and Web of Science through March 2026 for studies reporting associations between baseline serum/plasma OSM and endoscopic or clinical response to anti-TNF therapy in adult IBD patients. We used a bivariate random-effects model to estimate pooled sensitivity, specificity, diagnostic odds ratio (DOR), and area under the receiver operating characteristic (ROC) curve (AUC). Quality was assessed using QUADAS-2. Results: Data from four studies (n = 441 patients) were pooled. We estimated a pooled sensitivity of 82.8% (95% CI 71.4–90.3%) and a specificity of 88.4% (95% CI 82.7–92.4%) for predicting anti-TNF non-response. The pooled AUC was 0.899 (95% CI 0.858–0.940), with low heterogeneity (I² = 16.0%). The pooled DOR was 36.7 (95% CI 15.7–85.8), with a positive likelihood ratio of 7.1 and a negative likelihood ratio of 0.19. Risk of bias was low across the studies. Conclusions: Higher serum OSM was associated with treatment failure in IBD patients receiving anti-TNF therapy, with a pooled AUC of 0.899 in assay-stratified analysis and 0.820 when all studies were included. However, the small number of available studies, substantial variability in OSM cutoffs (14–233.6 pg/mL) and assay heterogeneity limit the robustness and generalizability and call for additional prospective data to more-robustly characterize the clinical utility of OSM. Full article

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15 pages, 2278 KB

Open AccessArticle

Accessory Navicular on MRI in an Adult Ankle MRI Referral Cohort (N = 1988): Prevalence, Subtypes, and Edema Correlates

by Zülküf Akdemir, Amed Çekdar Altındağ, Rıdvan Çeçen and Harun Arslan

Clin. Pract. 2026, 16(7), 123; https://doi.org/10.3390/clinpract16070123 - 2 Jul 2026

Viewed by 357

Abstract

Purpose: To determine the prevalence and subtype distribution of accessory navicular (AN) on adult ankle MRI and to evaluate MRI factors associated with AN-related bone marrow edema (BME); bilaterality was explored in patients with available contralateral MRI data. Methods: In this retrospective cross-sectional [...] Read more.

Purpose: To determine the prevalence and subtype distribution of accessory navicular (AN) on adult ankle MRI and to evaluate MRI factors associated with AN-related bone marrow edema (BME); bilaterality was explored in patients with available contralateral MRI data. Methods: In this retrospective cross-sectional study, consecutive adult patients (≥18 years) who underwent ankle MRI between January 2022 and January 2025 at a single institution in Van, eastern Türkiye, were identified from the institutional archive. Two blinded readers assessed AN presence, classified subtypes using Coughlin criteria, measured maximal ossicle dimension for types 1–2, and recorded BME on fluid-sensitive sequences. Prevalence with 95% CIs was estimated, and multivariable logistic regression assessed factors associated with BME in patients with types 1–2. Results: Among 1988 unique patients (mean age: 42.2 ± 14.2 years; 42.6% male and 57.4% female), AN prevalence was 24.4% (95% CI: 22.6–26.4%), and type 2 predominated (50.2%). In the subgroup of AN-positive patients with available contralateral MRI data, AN was bilateral in 61 of 69 patients (88.4%). Interobserver agreement was excellent for AN detection and subtype classification (κ = 1.00 and κ = 0.98). Among types 1–2 included in the BME analysis (n = 385), BME occurred in 81 patients (21.0%). In the multivariable model, the adjusted ORs for BME were 4.46 for type 2 morphology, 1.24 per 1 mm increase in maximal dimension, 2.08 for female sex, and 0.71 per 10-year increase in age; concomitant os trigonum was not associated with BME. Conclusions: AN was common on ankle MRI, and type 2 was most strongly associated with BME; however, because this was a retrospective, cross-sectional, symptom-blinded study, causality and clinical correlation could not be established. Clinical Significance: Type 2 AN, particularly with a larger ossicle dimension, should prompt careful evaluation for MRI-detected BME, which should be interpreted as an imaging finding requiring clinical correlation. Full article

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20 pages, 319 KB

Open AccessArticle

Exploratory Associations of Personality Traits, Cognitive Emotion Regulation, and Quality of Life with DSM-Related Symptom Burden in Gambling Disorder

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

Clin. Pract. 2026, 16(7), 122; https://doi.org/10.3390/clinpract16070122 - 29 Jun 2026

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Abstract

Background and Objectives: Gambling disorder (GD) is a behavioral addiction associated with distress, comorbidity, and functional impairment. This exploratory cross-sectional study examined associations between DSM-5-TR symptom burden, personality dimensions, cognitive emotion regulation, quality of life, and sociodemographic variables in a Romanian clinical sample. [...] Read more.

Background and Objectives: Gambling disorder (GD) is a behavioral addiction associated with distress, comorbidity, and functional impairment. This exploratory cross-sectional study examined associations between DSM-5-TR symptom burden, personality dimensions, cognitive emotion regulation, quality of life, and sociodemographic variables in a Romanian clinical sample. Materials and Methods: The sample included 122 adults with psychiatrist-confirmed pathological gambling/GD recruited from “Prof. Dr. Alexandru Obregia” Clinical Hospital of Psychiatry, Bucharest. Personality was assessed with the Personality Clinical Form (PCF; 109 valid profiles), cognitive emotion regulation with the Cognitive Emotion Regulation Questionnaire, and quality of life with the Quality of Life Inventory. Symptom burden was measured using a nine-item binary DSM-5 symptom burden index. Results: The symptom burden index showed a pronounced ceiling effect: median = 9.00 (IQR = 9.00–9.00; range = 4–9), with 91.0% classified as severe and 77.9% meeting all nine criteria. In PCF analyses, symptom burden was positively associated, after Benjamini–Hochberg correction, with broad personality pathology, including maladaptive personality dimensions, personality-functioning indicators, and personality-disorder feature scales; the strongest association involved borderline features. Catastrophizing and Blaming Others were positively associated with severity, whereas Positive Reappraisal, Putting into Perspective, and Positive Refocusing were negatively associated. Quality of life was very low overall and associated with personality and coping variables, but not directly with symptom burden. Criterion-count rank distributions differed by marital status and perceived social support; occupational status showed an omnibus distributional difference, but no pairwise contrast survived correction. Conclusions: GD was characterized by severe symptom burden and restricted score variability. Findings support multidimensional assessment of personality functioning, emotion regulation, quality of life, and social–contextual vulnerability. Full article

16 pages, 298 KB

Open AccessEditor’s ChoiceReview

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

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

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

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Abstract

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

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

21 pages, 2554 KB

Open AccessEditor’s ChoiceReview

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

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

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

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Abstract

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

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

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10 pages, 2091 KB

Open AccessArticle

Effectiveness of Guselkumab for the Treatment of Moderate-to- Severe Psoriasis in Elderly Patients: A Retrospective, Real-World Multicenter Study in the Lazio Region

by Giuseppe P. A. Gemma, Nicoletta Bernardini, Francesca Paola Sasso, Giacomo Caldarola, Eleonora De Luca, Maria Elisabetta Greco, Viviana Lora, Annamaria Mazzotta, Emanuele Miraglia, Diego Orsini, Gianluca Pagnanelli, Antonio Giovanni Richetta, Nevena Skroza and Annunziata Dattola

Clin. Pract. 2026, 16(7), 119; https://doi.org/10.3390/clinpract16070119 - 26 Jun 2026

Viewed by 488

Abstract

Background: Guselkumab, a selective interleukin-23 inhibitor, is effective in moderate-to-severe plaque psoriasis, but real-world long-term data in elderly patients remain limited. Objective: To evaluate the long-term effectiveness of guselkumab in elderly patients with moderate-to-severe psoriasis in a real-world setting. Methods: This retrospective, multicenter [...] Read more.

Background: Guselkumab, a selective interleukin-23 inhibitor, is effective in moderate-to-severe plaque psoriasis, but real-world long-term data in elderly patients remain limited. Objective: To evaluate the long-term effectiveness of guselkumab in elderly patients with moderate-to-severe psoriasis in a real-world setting. Methods: This retrospective, multicenter study included 102 patients aged 65 years or older treated with guselkumab across seven Italian centers. PASI scores and PASI 75/90/100 responses were assessed as observed cases at weeks 4, 16, 28, and 52, and annually up to 4 years, with last-observation-carried-forward and non-responder imputation as sensitivity analyses. Subgroups by biologic experience and BMI were analyzed. Results: Mean PASI decreased from 12.4 to 0.3 at week 52, remaining low through year 4 (p < 0.001). At week 52 and year 4, PASI 90 was achieved by 89.7% and 86.5%, and PASI 100 by 79.3% and 73.0%, respectively. Responses were comparable between biologic-naïve and biologic-experienced patients. Obese patients had higher baseline PASI; after adjustment for baseline severity, responses did not differ from non-obese patients. Conclusions: Guselkumab was associated with high and durable PASI improvement in elderly patients, regardless of prior biologic exposure or body weight. The retrospective design and absence of systematic safety data warrant cautious interpretation. Full article

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17 pages, 909 KB

Open AccessSystematic Review

Bilateral Iris Metastasis of Small Cell Lung Carcinoma: A Case Report and Systematic Review

by Stipe Vidović, Egon Biuk, Greta Biuk, Marija Jelić Vuković, Maja Vinković, Andrijana Kopić and Dubravka Biuk

Clin. Pract. 2026, 16(7), 118; https://doi.org/10.3390/clinpract16070118 - 23 Jun 2026

Viewed by 509

Abstract

Objective: To report a rare case of bilateral iris metastasis from small cell lung carcinoma (SCLC) and systematically review the literature on SCLC-associated iris metastases, with emphasis on clinical presentation, management, and outcomes. Materials and Methods: A systematic literature review was conducted in [...] Read more.

Objective: To report a rare case of bilateral iris metastasis from small cell lung carcinoma (SCLC) and systematically review the literature on SCLC-associated iris metastases, with emphasis on clinical presentation, management, and outcomes. Materials and Methods: A systematic literature review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. PubMed, ScienceDirect, Scopus, and Web of Science were comprehensively searched on 10 July 2025. Eligible studies included English-language reports of iris metastasis originating from SCLC in human subjects. Case report: A 58-year-old woman with previously treated SCLC developed bilateral iris metastases one year after complete remission of the primary tumor. Ophthalmic examination revealed whitish-gray, vascularized iris masses with iridocorneal angle involvement, associated with secondary angle-closure glaucoma and markedly elevated intraocular pressure (48 mm Hg) in the left eye. Cyclocryotherapy, preceded by systemic and topical antiglaucoma therapy, resulted in pain relief and a reduction in intraocular pressure; the patient died four months later due to pneumonia. Results (Systematic Review): Seventeen studies comprising 17 patients were included; the median age was 60 years, and 64.7% were male. The median interval from SCLC diagnosis to ocular presentation was 4 months, although iris metastasis was occasionally the initial or concurrent manifestation of disease. The most common presenting features were visual impairment (58.8%), ocular pain (41.2%), and elevated intraocular pressure (41.2%), while iris neovascularization (35.3%) and synechiae (29.4%) were also frequent. Bilateral involvement was reported in only one previous case. Treatment approaches were heterogeneous and included antiglaucoma therapy, systemic chemotherapy, local radiotherapy, anti-VEGF therapy, and enucleation. Among patients with available follow-up (n = 12), 58.3% died within a median follow-up of 7.5 months. Conclusions: Bilateral iris metastasis from SCLC is rare and may occur as a manifestation of recurrent disease after remission. It is an aggressive condition characterized by nonspecific ocular symptoms, variable management, and poor survival, underscoring the importance of early recognition and the need for evidence-based diagnostic and therapeutic strategies. Full article

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Clin. Pract., Volume 16, Issue 7 (July 2026) – 18 articles

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