Journal of Clinical Medicine

13 pages, 1247 KB

Open AccessArticle

Comparison of Ocular Wavefront in Seated and Supine Positions Using a Hand-Held Hartmann–Shack Aberrometer

by Noh Eun Kwon, Nicolas Brown, Jong Hwa Jun and Seung Pil Bang

J. Clin. Med. 2025, 14(18), 6688; https://doi.org/10.3390/jcm14186688 - 22 Sep 2025

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Background/Objectives: Intraoperative aberrometry has gained clinical relevance in correcting aberrations during cataract and corneal refractive surgeries. As wavefront aberrations are typically measured with patients seated, while surgeries are performed supine, this study aimed to compare ocular aberrations between seated and supine positions, [...] Read more.

Background/Objectives: Intraoperative aberrometry has gained clinical relevance in correcting aberrations during cataract and corneal refractive surgeries. As wavefront aberrations are typically measured with patients seated, while surgeries are performed supine, this study aimed to compare ocular aberrations between seated and supine positions, using a hand-held Hartmann–Shack aberrometer. Methods: Total ocular wavefront aberrations were measured five times consecutively from cyclopledged eyes for a 6 mm pupil, under three conditions: (1) seated with a holder-fixed mode (reference), (2) seated with a hand-held mode, and (3) supine with a hand-held mode. Condition 2 was included to assess potential measurement errors from the hand-held mode. Repeatability was assessed using the standard deviation of repeated measurements (Srm) and the intraclass correlation coefficient (ICC). Differences among the three conditions were analyzed to evaluate the effects of positional change and hand-held stability on ocular wavefront aberration measurements. Results: Eighteen healthy subjects (36 eyes) were enrolled. The Srms for the sphere were 0.37, 0.38, and 0.40 diopters (D); and for the cylinder, 0.10, 0.10, and 0.11 D, with no significant differences across conditions. ICC values exceeded 0.9 for both lower-order aberrations (LOAs) and higher-order aberrations (HOAs), indicating excellent repeatability. The mean root mean square HOAs (HOA_RMS) were 0.48, 0.49, and 0.45 µm, with no statistically significant differences by position (p = 0.913) or measurement mode (p = 0.966). Conclusions: The hand-held Hartmann–Shack aberrometer demonstrated satisfactory repeatability for LOAs and HOAs. Supine measurements did not differ from seated, supporting the feasibility of extending preoperative results to intraoperative aberrometry, regardless of positional differences. Full article

(This article belongs to the Section Ophthalmology)

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11 pages, 603 KB

Open AccessArticle

Textbook Outcomes of Totally Robotic Versus Totally Laparoscopic Pancreaticoduodenectomy for Periampullary Neoplasm: A Propensity Score-Matched Cohort Study

by Boram Lee, Ho-Seong Han, Yoo-Seok Yoon and Jun Suh Lee

J. Clin. Med. 2025, 14(18), 6687; https://doi.org/10.3390/jcm14186687 - 22 Sep 2025

Abstract

Background/Objectives: Textbook outcome (TO) is a composite quality measure in surgery, but few studies have compared TO between robotic pancreaticoduodenectomy (RPD) and laparoscopic pancreaticoduodenectomy (LPD). This study aimed to evaluate and compare TO following RPD and LPD for periampullary neoplasms. Methods: [...] Read more.

Background/Objectives: Textbook outcome (TO) is a composite quality measure in surgery, but few studies have compared TO between robotic pancreaticoduodenectomy (RPD) and laparoscopic pancreaticoduodenectomy (LPD). This study aimed to evaluate and compare TO following RPD and LPD for periampullary neoplasms. Methods: We retrospectively analyzed 322 patients who underwent minimally invasive PD between 2010 and 2023 (RPD, n = 60; LPD, n = 262). LPD was first introduced in 2004, but only cases performed since 2010 were included, while RPD has been performed since 2019. Propensity score matching (1:2) yielded 48 RPD and 96 LPD patients. TO was defined as the absence of pancreatic fistula, bile leak, post-pancreatectomy hemorrhage, severe complications (Clavien-Dindo ≥ III), readmission, and in-hospital or 30-day mortality. Results: In the entire cohort, 240 of 322 patients (74.5%) achieved TO. After matching, TO rates were 64.6% in RPD and 76.9% in LPD (p = 0.656). Perioperative outcomes, including operative time, blood loss, transfusion, hospital stay, and major complications, were comparable, although RPD showed a higher incidence of hemorrhage (p = 0.032). Multivariate analysis identified body mass index < 25 kg/m² as an independent predictor of achieving TO (OR 3.13, p = 0.008). Conclusions: RPD and LPD achieved comparable textbook outcomes in periampullary surgery. Both approaches are feasible when performed by experienced surgeons, but larger studies with long-term follow-up are needed to validate these findings. Full article

(This article belongs to the Section Gastroenterology & Hepatopancreatobiliary Medicine)

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26 pages, 597 KB

Open AccessReview

Recurrence of Glomerular Diseases (GN) After Kidney Transplantation: A Narrative Review

by Abbal Koirala, Aditi Singh and Duvuru Geetha

J. Clin. Med. 2025, 14(18), 6686; https://doi.org/10.3390/jcm14186686 - 22 Sep 2025

Abstract

Recurrence of the original glomerular disease (GN) poses a significant threat to kidney transplant function and longevity. The probability and severity of this recurrence vary, with C3 glomerulopathy and certain forms of FSGS exhibiting particularly high rates. Kidney transplant GN recurrence risk hinges [...] Read more.

Recurrence of the original glomerular disease (GN) poses a significant threat to kidney transplant function and longevity. The probability and severity of this recurrence vary, with C3 glomerulopathy and certain forms of FSGS exhibiting particularly high rates. Kidney transplant GN recurrence risk hinges on the characteristics of the initial GN, recipient/donor genetics, recipient age, donor type, end-stage kidney disease (ESRD) progression rate, and proteinuria levels. Standard immunosuppression has limited efficacy in preventing primary disease recurrence; however, agent selection and induction therapy can influence the risk for specific GNs. Diagnosing recurrent GN involves a comprehensive approach, including clinical evaluation, laboratory tests (such as proteinuria, hematuria, and specific biomarkers like anti-PLA2R for membranous nephropathy or complement for C3G), and, critically, an allograft biopsy analyzed with light, immunofluorescence, and electron microscopy. Treatment strategies are evolving towards targeted therapies, such as rituximab for antibody-mediated GN and complement inhibitors for C3G, moving away from broad immunosuppression. This narrative literature review provides practical monitoring algorithms for post-transplant settings, synthesizing information on the incidence, predictors, diagnostic strategies, and therapeutic options for various glomerular disease subtypes. The methodology involved searching MEDLINE, Embase, and Cochrane databases from 1996 to 2025, prioritizing systematic reviews, cohort studies, registries, and interventional reports. Eligibility criteria included adult transplant recipients and English-language reports on recurrent glomerular disease outcomes, excluding most single-patient case reports. Limitations include potential selection bias, omission of relevant studies, and the absence of a formal risk-of-bias assessment or meta-analysis. The evidence base is heterogeneous, with inconsistent outcome reporting and scarce randomized controlled trials. Future efforts should focus on developing predictive biomarkers, standardizing diagnostic and response criteria, conducting multicenter prospective cohorts and pragmatic trials, and creating shared registries with harmonized data. Full article

(This article belongs to the Special Issue Advances in Kidney Transplantation)

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18 pages, 2927 KB

Open AccessSystematic Review

Combined Liquid-Based Cytology and Conventional Smear Provides Better Sensitivity and Adequacy Rates After Endoscopic Ultrasound-Guided Tissue Acquisition of Abdominal Masses: A Systematic Review and Meta-Analysis

by Marie Anne Engh, Brigitta Teutsch, Alexander Schulze Wenning, Tamás Kói, Péter Hegyi and Bálint Erőss

J. Clin. Med. 2025, 14(18), 6685; https://doi.org/10.3390/jcm14186685 - 22 Sep 2025

Abstract

Background and Aims: Endoscopic ultrasound (EUS)-guided fine-needle aspiration (FNA) or biopsy (FNB) is the standard method for diagnosing abdominal masses, but sample inadequacy and diagnostic accuracy remain challenges. Conventional smear (CS) and liquid-based cytology (LBC) are standard processing methods, yet their comparative effectiveness [...] Read more.

Background and Aims: Endoscopic ultrasound (EUS)-guided fine-needle aspiration (FNA) or biopsy (FNB) is the standard method for diagnosing abdominal masses, but sample inadequacy and diagnostic accuracy remain challenges. Conventional smear (CS) and liquid-based cytology (LBC) are standard processing methods, yet their comparative effectiveness and potential combined benefit remain unclear. We performed a systematic review and meta-analysis to evaluate and compare the diagnostic performance and adequacy of CS, LBC, and their combination. Methods: A systematic search was conducted in Medline, Embase, and CENTRAL on 17 November 2024. Studies comparing CS, LBC, or their combination following EUS-FNA/FNB for abdominal masses were included. Diagnostic parameters, including sensitivity, specificity, accuracy, and inadequacy rates, were extracted and analyzed. Methodological quality was assessed using QUADAS-2. Results: 16 studies (2128 patients) were included. Sensitivity for pancreatic masses was 71.4% (CI: 62.9–78.7) for CS, 74.7% (CI: 64.3–82.8) for LBC, and 86.2% (CI: 82.4–89.3) for combined methods (p = 0.001). For all abdominal masses, sensitivity was 76.3% (CI: 67.9–83.0) for CS, 73.6% (CI: 65.6–80.2) for LBC, and 88.0% (CI: 84.0–91.2) for combined methods (p ≤ 0.006). Specificity was nearly 100%. Inadequacy rates were lowest for combined methods (1.5%, CI: 0–36.2), when compared to LBC (7.7%, CI: 2.7–20.4) and CS (4.4%, CI: 2.4–7.9). Moderate bias risk was noted, primarily due to incorporation bias. Domain 3 (reference standard) of QUADAS was uniformly moderate-risk across studies. Conclusions: Combining CS and LBC methods improves diagnostic sensitivity and reduces sample inadequacy after EUS-guided tissue acquisition for abdominal masses, particularly pancreatic lesions. Clinical guidelines should consider recommending the combined approach to enhance diagnostic yield and clinical outcomes. Full article

(This article belongs to the Section Gastroenterology & Hepatopancreatobiliary Medicine)

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17 pages, 1023 KB

Open AccessArticle

Impact of Surgical Delay on Two-Stage Breast Reconstruction During the COVID-19 Pandemic: A Retrospective Analysis

by Ferruccio Paganini, Elisa Bascialla, Beatrice Corsini, Chiara Truini, Monica Arcaini, Lorenzo Fresta, Federico Lo Torto, Marco Marcasciano, Sara Matarazzo, Diego Ribuffo and Luigi Valdatta

J. Clin. Med. 2025, 14(18), 6684; https://doi.org/10.3390/jcm14186684 - 22 Sep 2025

Abstract

Background: The COVID-19 pandemic caused unprecedented delays in elective surgery, including breast reconstruction, prolonging expander retention beyond recommended timelines. Methods: We retrospectively compared patients who underwent two-stage expander-to-implant reconstruction before the pandemic (2011–2020) and during the pandemic (2020–2022). Clinical outcomes and patient-reported experiences [...] Read more.

Background: The COVID-19 pandemic caused unprecedented delays in elective surgery, including breast reconstruction, prolonging expander retention beyond recommended timelines. Methods: We retrospectively compared patients who underwent two-stage expander-to-implant reconstruction before the pandemic (2011–2020) and during the pandemic (2020–2022). Clinical outcomes and patient-reported experiences were analyzed, and multivariate regression was used to adjust for confounders. Results: Expander retention was significantly longer in the pandemic cohort (481 vs. 280 days). Capsular contracture around the expander was markedly increased, with pandemic group assignment and prolonged expander retention emerging as independent predictors in multivariate analysis, while overall complication rates were unaffected. Patient-reported outcomes showed more functional limitations but paradoxically higher satisfaction with the definitive implant. Conclusions: Surgical delay selectively increased the risk of expander contracture without raising overall morbidity. Patient-reported findings highlight the dual impact of delay, with both greater burden and a potential “relief effect”. Full article

(This article belongs to the Section Plastic, Reconstructive and Aesthetic Surgery/Aesthetic Medicine)

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19 pages, 2611 KB

Open AccessReview

Interventional Management of Acute Pancreatitis and Its Complications

by Muaaz Masood, Amar Vedamurthy, Rajesh Krishnamoorthi, Shayan Irani, Mehran Fotoohi and Richard Kozarek

J. Clin. Med. 2025, 14(18), 6683; https://doi.org/10.3390/jcm14186683 - 22 Sep 2025

Abstract

Acute pancreatitis (AP) is the most common cause of gastrointestinal-related hospitalizations in the United States, with gallstone disease and alcohol as the leading etiologies. Management is determined by disease severity, classified as interstitial edematous pancreatitis or necrotizing pancreatitis, with severity further stratified based [...] Read more.

Acute pancreatitis (AP) is the most common cause of gastrointestinal-related hospitalizations in the United States, with gallstone disease and alcohol as the leading etiologies. Management is determined by disease severity, classified as interstitial edematous pancreatitis or necrotizing pancreatitis, with severity further stratified based on local complications and systemic organ dysfunction. Regardless of etiology, initial treatment involves aggressive intravenous fluid resuscitation with Lactated Ringer’s solution, pain and nausea control, early oral feeding in 24 to 48 h, and etiology-directed interventions when indicated. In gallstone pancreatitis, early endoscopic retrograde cholangiopancreatography (ERCP) with sphincterotomy is indicated in the presence of concomitant cholangitis or persistent biliary obstruction, with subsequent laparoscopic cholecystectomy as standard of care for stone clearance. The role of interventional therapy in uncomplicated AP is limited in the acute phase, except for biliary decompression or enteral feeding support with nasojejunal tube placement. However, in severe AP with complications, interventional radiology (IR) and endoscopic approaches play a pivotal role. IR facilitates early percutaneous drainage of symptomatic, acute fluid collections and infected necrosis, particularly in non-endoscopically accessible retroperitoneal or dependent collections, improving outcomes with a step-up approach. IR-guided angiographic embolization is the preferred modality for hemorrhagic complications, including pseudoaneurysms. In the delayed phase, walled-off necrosis (WON) and pancreatic pseudocysts are managed with endoscopic ultrasound (EUS)-guided drainage, with direct endoscopic necrosectomy (DEN) reserved for infected necrosis. Dual-modality drainage (DMD), combining percutaneous and endoscopic drainage, is increasingly utilized in extensive or complex collections, reflecting a collaborative effort between gastroenterology and interventional radiology comparable to that which exists between IR and surgery in institutions that perform video assisted retroperitoneal debridement (VARD). Peripancreatic fluid collections may fistulize into adjacent structures, including the stomach, small intestine, or colon, requiring transpapillary stenting with or without additional closure of the gut leak with over-the-scope clips (OTSC) or suturing devices. Additionally, endoscopic management of pancreatic duct disruptions with transpapillary or transmural stenting plays a key role in cases of disconnected pancreatic duct syndrome (DPDS). Comparative outcomes across interventional techniques—including retroperitoneal, laparoscopic, open surgery, and endoscopic drainage—highlight a shift toward minimally invasive approaches, with decreased morbidity and reduced hospital stay. The integration of endoscopic and interventional radiology-guided techniques has transformed the management of AP complications and multidisciplinary collaboration is essential for optimal patient outcomes. Full article

(This article belongs to the Special Issue Interventional and Surgical Treatment of Acute and Chronic Pancreatitis)

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13 pages, 639 KB

Open AccessArticle

Clinical Impact of External Carotid Artery Remodeling Following Carotid Artery Stenting

by Dorota Łyko-Morawska, Michał Serafin, Julia Szostek, Magdalena Mąka, Iga Kania and Wacław Kuczmik

J. Clin. Med. 2025, 14(18), 6682; https://doi.org/10.3390/jcm14186682 - 22 Sep 2025

Abstract

Background: Carotid artery stenting (CAS) is a common revascularization approach for carotid artery stenosis. While its impact on the internal carotid artery (ICA) has been extensively studied, the effects on the external carotid artery (ECA)—a key collateral pathway for cerebral perfusion—remain insufficiently [...] Read more.

Background: Carotid artery stenting (CAS) is a common revascularization approach for carotid artery stenosis. While its impact on the internal carotid artery (ICA) has been extensively studied, the effects on the external carotid artery (ECA)—a key collateral pathway for cerebral perfusion—remain insufficiently explored. This study aimed to assess structural changes in the ECA following CAS and their clinical significance. Methods: A retrospective observational cohort study of 963 patients treated with CAS between 2018 and 2024 was conducted. Demographic data, comorbidities, and procedural characteristics were collected. Pre- and postprocedural ICA and ECA diameters were measured via angiography. Spearman’s correlation, regression modeling, and receiver operating curver (ROC) analysis were used to identify predictors of ECA narrowing and occlusion and their relationship with neurological outcomes. Results: The median ECA diameter decreased post-CAS (from 4.7 mm to 3.8 mm, p < 0.001). ECA overstenting occurred in 96.4% of cases, with 71.7% exhibiting diameter reduction. De novo ECA occlusion occurred in 2.5% of patients and was associated with a higher incidence of stroke, transient ischemic attack, and in-stent restenosis (ISR). Multivariate analysis identified preoperative ECA diameter (p < 0.001), ICA diameter (p = 0.001), and second-generation stents (p = 0.02) as independent predictors of ECA narrowing. ROC analysis confirmed that a preoperative ECA diameter ≤ 3.05 mm strongly predicted occlusion (Area under the curve (AUC) = 0.93, p < 0.001). Conclusions: CAS frequently leads to ECA remodeling, including occlusion, compromising collateral perfusion and contributing to adverse ischemic incidences and ISR. Preprocedural ECA assessment may aid in optimizing patient selection and procedural planning. Full article

(This article belongs to the Special Issue Carotid Artery Disease (CAD) and Its Complications: A Comprehensive Update)

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12 pages, 1765 KB

Open AccessArticle

Nurse Specialising Consultation in Heart Failure: Impact on Drug Titration and Cardiovascular Events in Patients with Heart Failure and Reduced Ejection Fraction

by Jose Lopez-Aguilera, Jorge Perea-Armijo, Ana Belen Muñoz-Villarreal, Antonia Cepas-Sosa, Luisa Maria Luque-Serrano, Nerea Aguayo-Caño, Gloria Maria Heredia-Campos, Juan Diego Martin-Diaz, Rafael Gonzalez-Manzanares, Juan Carlos Castillo-Dominguez, Manuel Crespin-Crespin, Monica Delgado-Ortega, Martin Ruiz-Ortiz, Dolores Mesa-Rubio, Manuel Pan-Alvarez Osorio and Manuel Anguita-Sanchez

J. Clin. Med. 2025, 14(18), 6681; https://doi.org/10.3390/jcm14186681 - 22 Sep 2025

Abstract

Introduction: The increasingly active role of nurses in the management of heart failure (HF) has become important in HF units (HCUs). This study aims to determine the effect of opening a specialised HF nursing (NSHF) consultation in a tertiary hospital on drug titration, [...] Read more.

Introduction: The increasingly active role of nurses in the management of heart failure (HF) has become important in HF units (HCUs). This study aims to determine the effect of opening a specialised HF nursing (NSHF) consultation in a tertiary hospital on drug titration, and its subsequent impact on cardiac remodelling and prognosis. Methods: A retrospective cohort study was conducted on patients with HF with reduced ejection fraction (HFrEF) who were treated between 2017 and 2020. Patients who were followed by the NSHF were compared with those who underwent conventional clinical follow-up (non-NSHF), focusing on drug optimisation, echocardiographic parameters, biomarkers, and clinical outcomes in terms of mortality and hospital readmissions for HF. Results: A total of 411 patients were analysed, 85 of whom (20.7%) were treated with NSHF. There were hardly any differences in baseline characteristics. At the end of follow-up, the NSHF group had a higher prescription rate of angiotensin receptor–neprilysin inhibitor (+31.7% vs. +23.3%; p < 0.001), beta-blockers (+2.4% vs. −5.8%; p < 0.001), and sodium glucose co-transporter type 2 inhibitors (+24.7% vs. +17.8%; p < 0.001). There was also a higher rate of loop diuretic withdrawal (−16.7% vs. −6.7%; p < 0.001). However, no improvement in reverse remodelling or neurohormonal response was observed. Patients treated with NSHF had a lower probability of dying from HF (88.6% vs. 63.3%; p = 0.006), but this did not reduce hospital admissions for HF. Conclusions: Patients with HFrEF who are cared for through NSHF are more likely to be prescribed drugs that modify the prognosis of the disease. This has an impact on their mortality. Full article

(This article belongs to the Special Issue Patient-Oriented Treatments for Heart Failure)

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18 pages, 486 KB

Open AccessSystematic Review

Immune Checkpoint Inhibitors Beyond Progression in Various Solid Tumors: A Systematic Review and Pooled Analysis

by Fausto Petrelli, Antonio Ghidini, Maria Chiara Parati, Karen Borgonovo, Mauro Rossitto, Mara Ghilardi, Giuseppina Dognini, Daniela Petro’, Irene Angeli, Veronica Lonati, Lorenzo Dottorini and Alessandro Iaculli

J. Clin. Med. 2025, 14(18), 6680; https://doi.org/10.3390/jcm14186680 - 22 Sep 2025

Abstract

Background: Immune checkpoint inhibitors (ICIs) have transformed outcomes in advanced cancers; however, the value of continuing treatment after radiologic progression remains uncertain. We systematically assessed the efficacy and safety of ICI continuation beyond progression, focusing on the objective response rate (ORR), progression-free [...] Read more.

Background: Immune checkpoint inhibitors (ICIs) have transformed outcomes in advanced cancers; however, the value of continuing treatment after radiologic progression remains uncertain. We systematically assessed the efficacy and safety of ICI continuation beyond progression, focusing on the objective response rate (ORR), progression-free survival (PFS), and overall survival (OS). Methods: PubMed/MEDLINE, Embase, and the Cochrane Library were searched from inception to 31 March 2025. Eligible reports included retrospective cohorts, prospective trials, post hoc analyses, and pooled regulatory reviews that compared outcomes after ICI continuation versus discontinuation or historical controls. Quality was appraised with the Newcastle–Ottawa Scale (observational designs) and the Cochrane Risk-of-Bias tool (randomized trials). Results: Fifty studies involving 8989 patients met the inclusion criteria: 41 retrospective cohorts; 6 post hoc analyses; 2 randomized trials (1 phase III, 1 phase II); and 1 pooled FDA review. Continuing ICIs beyond progression produced ORRs of 9.3–39% in non-small cell lung cancer (n = 5102), 14–100% in melanoma (n = 669), and 8–33% in renal cell carcinoma (n = 458). Median OS ranged from 8.9 to 18.2 months in lung cancer, 12 to 29.9 months in melanoma, and up to 34.8 months in RCC. Modest but clinically meaningful benefits were reported in colorectal, head-and-neck, gastric, liver, and urothelial tumors. Conclusions: Select patients—particularly those with melanoma, lung cancer, RCC, or gastric cancer—may derive sustained benefit from ICI therapy after radiologic progression. Decisions should incorporate tumor biology, performance status, and emerging biomarkers. Prospective, biomarker-driven trials are needed to define optimal patient selection and the duration of post-progression immunotherapy. Full article

(This article belongs to the Section Oncology)

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25 pages, 3167 KB

Open AccessStudy Protocol

“HOPE-FIT” in Action: A Hybrid Effectiveness–Implementation Protocol for Thriving Wellness in Aging Communities

by Suyoung Hwang and Eun-Surk Yi

J. Clin. Med. 2025, 14(18), 6679; https://doi.org/10.3390/jcm14186679 - 22 Sep 2025

Abstract

Background/Objectives: As global aging accelerates, there is a pressing and empirically substantiated demand for integrated and sustainable strategies, as evidenced by the rising prevalence rates of chronic conditions, social isolation, and digital exclusion among older adults worldwide. These factors underscore the urgent need [...] Read more.

Background/Objectives: As global aging accelerates, there is a pressing and empirically substantiated demand for integrated and sustainable strategies, as evidenced by the rising prevalence rates of chronic conditions, social isolation, and digital exclusion among older adults worldwide. These factors underscore the urgent need for multidimensional interventions that simultaneously target physical, psychological, and social well-being. The HOPE-FIT (Hybrid Outreach Program for Exercise and Follow-up Integrated Training) model and the SAGE (Senior Active Guided Exercise) program were designed to address this need through a hybrid framework. These programs foster inclusive aging by explicitly bridging digitally underserved groups and mobility-restricted populations into mainstream health promotion systems through tailored exercise, psychosocial support, and smart-home technologies, thereby functioning as a scalable meta-model across healthcare, community, and policy domains. Methods: HOPE-FIT was developed through a formative, multi-phase process grounded in the RE-AIM framework and a Hybrid Type II effectiveness–implementation design. The program combines professional health coaching, home-based and digital exercise routines, Acceptance and Commitment Performance Training (ACPT)-based psychological strategies, and smart-home monitoring technologies. Empirical data from pilot studies, large-scale surveys (N = 1000), and in-depth user evaluations were incorporated to strengthen validity and contextual adaptation. Culturally tailored content and participatory feedback from older adults further informed ecological validity and program refinement. Implementation Strategy/Framework: The theoretical foundation integrates implementation science with behavioral and digital health. The RE-AIM framework guided reach, fidelity, and maintenance planning, while the Hybrid E–I design enabled the concurrent evaluation of effectiveness outcomes and contextual implementation strategies. Institutional partnerships with community centers, public health organizations, and welfare agencies further facilitated the translation of the model into real-world aging contexts. Dissemination Plan: The multi-pronged dissemination strategy includes international symposia, interdisciplinary academic networks, policy briefs, localized community deployment, and secure, authenticated data sharing for reproducibility. This design facilitates evidence-informed policy, empowers practitioners, and advances digital health equity. Ultimately, HOPE-FIT constitutes a scalable and inclusive model that concretely addresses health disparities and promotes active, dignified aging across systems and disciplines. Full article

(This article belongs to the Section Geriatric Medicine)

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18 pages, 327 KB

Open AccessPerspective

Rethinking the Diabetes–Cardiovascular Disease Continuum: Toward Integrated Care

by Alfredo Caturano, Cassandra Morciano, Katarzyna Zielińska, Vincenzo Russo, Marco Alfonso Perrone, Cesare Celeste Berra and Caterina Conte

J. Clin. Med. 2025, 14(18), 6678; https://doi.org/10.3390/jcm14186678 - 22 Sep 2025

Abstract

Type 2 diabetes mellitus (T2D) and cardiovascular disease (CVD) are not merely coexisting epidemics but co-evolving manifestations of a shared cardiometabolic continuum. Despite advances in glycemic, lipid, and blood pressure control, residual cardiovascular risk remains high, underscoring the limitations of siloed approaches. In [...] Read more.

Type 2 diabetes mellitus (T2D) and cardiovascular disease (CVD) are not merely coexisting epidemics but co-evolving manifestations of a shared cardiometabolic continuum. Despite advances in glycemic, lipid, and blood pressure control, residual cardiovascular risk remains high, underscoring the limitations of siloed approaches. In this perspective, we argue for reframing T2D and CVD as interconnected conditions driven by inflammation, adipose tissue dysfunction, and organ crosstalk. Beyond metformin, which remains foundational, several glucose-lowering drug classes are now evaluated not only for glycemic control but also for their cardiovascular and renal impact. Landmark trials and recent meta-analyses confirm that sodium-glucose co-transporter 2 inhibitors and glucagon-like peptide-1 (GLP-1) receptor agonists improve cardiorenal outcomes. More recently, tirzepatide, a dual glucose-dependent insulinotropic polypeptide (GIP)/GLP-1 receptor agonist, has shown unprecedented efficacy in weight and glucose management, with potential to further transform cardiometabolic risk reduction. Yet enthusiasm for these therapies must be tempered by heterogeneity of response, treatment costs, and inequitable access. Integrated care models, supported by multidisciplinary teams, digital health tools, and value-based reimbursement, are essential to close the gap between trial efficacy and real-world outcomes. Attention to sex, age, ethnicity, and comorbidity profiles is critical to ensure equity, as is the adaptation of strategies to low- and middle-income countries where the burden of cardiometabolic disease is rapidly rising. Ultimately, advancing cardiometabolic medicine requires not only novel therapies but also a unifying framework that integrates biology, behavior, economics, and health systems to deliver the right treatment to the right patient at the right time. Full article

(This article belongs to the Section Cardiovascular Medicine)

16 pages, 489 KB

Open AccessArticle

Lipid Profile, Obesity Indicators and Cardiometabolic Risk Factors in School-Aged Children and Adolescents: Sex-Specific Associations

by Rafał Baran, Joanna Baran, Justyna Leszczak, Anna Bartosiewicz and Justyna Wyszyńska

J. Clin. Med. 2025, 14(18), 6677; https://doi.org/10.3390/jcm14186677 - 22 Sep 2025

Abstract

Background: Childhood obesity and cardiometabolic disturbances are growing global health concerns. This study aimed to assess the prevalence of excess body weight, body fat, and selected cardiometabolic risk factors in school-aged children and adolescents, focusing on sex- and age-related differences. Methods: [...] Read more.

Background: Childhood obesity and cardiometabolic disturbances are growing global health concerns. This study aimed to assess the prevalence of excess body weight, body fat, and selected cardiometabolic risk factors in school-aged children and adolescents, focusing on sex- and age-related differences. Methods: A cross-sectional study was conducted among 318 Polish participants aged 6–17 years, including 169 children (6–12 years) and 149 adolescents (13–17 years). Anthropometric, blood pressure (BP), and fasting blood lipid and glucose measurements were collected and analyzed by age group (children 6–12 years; adolescents 13–17 years) and sex. Results: The prevalence of overweight and obesity was 18.5% (BMI-based) and 26.1% (body fat-based). Abdominal obesity and stage I–II hypertension were observed in 24.5% and 23.6% of participants, respectively. Children had higher rates of excess body fat, abdominal obesity, elevated BP, and lipid abnormalities than adolescents. Among adolescents, girls more frequently presented with borderline/high total cholesterol and Low-Density Lipoprotein (LDL cholesterol) and borderline/low High-Density Lipoprotein (HDL cholesterol), while boys more often had elevated BP. In girls, elevated triglycerides (TGs) were independently associated with abdominal obesity (odds ratio (OR) = 2.36, p = 0.015) and hypertension (OR = 2.47, p = 0.023); no such associations were observed in boys. Conclusions: Cardiometabolic risk factors may appear early in life and differ by age and sex. Routine screening and early interventions, particularly targeting lipid abnormalities in girls, are essential to prevent long-term health consequences. Full article

(This article belongs to the Special Issue The Complex Interplay Between Physical Activity, Sleep, Diet, and Obesity: Clinical Insights for Treatment and Prevention)

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18 pages, 957 KB

Open AccessArticle

Human-in-the-Loop Performance of LLM-Assisted Arterial Blood Gas Interpretation: A Single-Center Retrospective Study

by Sergio Ayala-De la Cruz, Paola Elizabeth Arenas-Hernández, María Fernanda Fernández-Herrera, Rebeca Alejandrina Quiñones-Díaz, Jorge Martín Llaca-Díaz, Erik Alejandro Díaz-Chuc, Diana Guadalupe Robles-Espino and Erik Alejandro San Miguel-Garay

J. Clin. Med. 2025, 14(18), 6676; https://doi.org/10.3390/jcm14186676 - 22 Sep 2025

Abstract

Background and Objectives: Interpreting acid–base disorders is challenging, particularly in complex or mixed cases. Given the growing potential of large language models (LLMs) to assist in cognitively demanding tasks, this study evaluated their performance in interpreting arterial blood gas (ABG) results. Materials [...] Read more.

Background and Objectives: Interpreting acid–base disorders is challenging, particularly in complex or mixed cases. Given the growing potential of large language models (LLMs) to assist in cognitively demanding tasks, this study evaluated their performance in interpreting arterial blood gas (ABG) results. Materials and Methods: In this single-center retrospective study, 200 ABG datasets were curated to include 40 cases in each of five diagnostic categories: metabolic acidosis, respiratory acidosis, metabolic alkalosis, respiratory alkalosis, and no acid–base disorder. Three medical students, each assigned to one LLM (ChatGPT GPT-4o, Copilot GPT-4, or Gemini 1.5-flash/2.5-flash), perform ABG interpretation using two evaluation methods: interpretation (LLM-I) and interpretation with supervision model (LLM-S). Two clinical pathologists independently performed the conventional evaluation to serve as the reference standard. Results: Agreement for identifying the primary acid–base (APD) disorder was strong across all approaches (Cohen’s κ ≥ 0.88). For identifying both primary and secondary disorders regardless of order (APSD), LLM-I showed moderate agreement (ChatGPT κ = 0.65, Copilot κ = 0.61, Gemini κ = 0.62), whereas LLM-S achieved strong agreement (ChatGPT κ = 0.91, Copilot κ = 0.81, Gemini κ = 0.81). Conclusions: LLM-assisted ABG interpretation demonstrates strong concordance with expert interpretation in detecting primary acid–base disorders. These tools may enhance the understanding of acid–base disorders while reducing calculation-related errors among medical students. Full article

(This article belongs to the Section Clinical Laboratory Medicine)

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11 pages, 1378 KB

Open AccessArticle

Sequential AI-ECG Diagnostic Protocol for Opportunistic Atrial Fibrillation Screening: A Retrospective Single-Center Study

by Ji-Hoon Choi, Sung-Hee Song, Jongwoo Kim, JaeHu Jeon, KyungChang Woo, Soo Jin Cho, Seung-Jung Park, Young Keun On, Ju Youn Kim and Kyoung-Min Park

J. Clin. Med. 2025, 14(18), 6675; https://doi.org/10.3390/jcm14186675 - 22 Sep 2025

Abstract

Background/Objectives: Atrial fibrillation (AF) often occurs in episodes that are sudden and go unnoticed, reducing the chances of anticoagulation. We evaluated a two-stage AI ECG screening protocol that uses a single ECG model at initial screening and, if necessary, a serial ECG [...] Read more.

Background/Objectives: Atrial fibrillation (AF) often occurs in episodes that are sudden and go unnoticed, reducing the chances of anticoagulation. We evaluated a two-stage AI ECG screening protocol that uses a single ECG model at initial screening and, if necessary, a serial ECG model after short interval follow-up to enhance accuracy while saving monitoring resources. Methods: We analyzed 248,612 12-lead ECGs from 164,793 adults (AF, n = 10,735) for model development and assessed the protocol in 11,349 eligible patients with longitudinal ECGs. The proposed algorithm first applied a single-ECG AI model at the initial visit, followed by a serial-ECG AI model three months later if AF was not initially detected. The model’s performance was evaluated using several metrics, including the area under the receiver operating characteristic curve (AUROC), sensitivity, specificity, accuracy, and F1 score. Results: The protocol achieved an AUROC of 0.908 with a sensitivity of 88.1%, specificity of 78.7%, positive predictive value (PPV) of 30.2%, negative predictive value (NPV) of 98.4%, accuracy of 79.6%, and an F1 score of 0.450. Among patients with a history of stroke (n = 551), 84.9% were correctly identified as AF-positive under the protocol. Conclusions: A sequential AI ECG strategy maintains high NPV at entry and improves PPV with longitudinal confirmation. This approach can prioritize ambulatory monitoring for those most likely to benefit and merits prospective, multi-center validation and cost-effectiveness assessment. Full article

(This article belongs to the Special Issue Advances in Arrhythmia Diagnosis and Management)

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9 pages, 423 KB

Open AccessArticle

Assessing the Reliability of Compliance with the General Treatment Recommendations by Patients Treated for Temporomandibular Disorders

by Małgorzata Pihut, Wojciech Maga and Andrzej Gala

J. Clin. Med. 2025, 14(18), 6674; https://doi.org/10.3390/jcm14186674 - 22 Sep 2025

Abstract

Background/Objectives: The aim of this study was to assess the accuracy of TMD patients’ adherence to treatment recommendations, given in writing, based on an anonymous survey. Methods: The study material included a group of 80 patients of both sexes, aged 21 to [...] Read more.

Background/Objectives: The aim of this study was to assess the accuracy of TMD patients’ adherence to treatment recommendations, given in writing, based on an anonymous survey. Methods: The study material included a group of 80 patients of both sexes, aged 21 to 45 years, who came for prosthetic treatment due to symptoms of TMD at the Department of Prosthetics and Orthodontics, Jagiellonian University Medical College in Krakow. Axis I of the DC/TMD was used in the diagnosis of dysfunction. The study used an anonymous questionnaire survey, which asked specific questions regarding the reliability of the implementation of the therapeutic recommendations contained in the written treatment instructions, given to patients at the first diagnostic visit. The questionnaire survey was completed by patients once, at the second visit, which was routinely made after 4 weeks. Results: The analysis showed that the most frequent adherence of respondents was to physiotherapy treatments. The same number of patients (57.5% each) used sleep hygiene, stress management, and maintenance of dental arch dislocation during the day. More than half of the subjects used orthopaedic pillows during sleep and performed daily relaxation exercises. Less than half of the subjects (46.3–47.5%) used hot compresses on the masticatory muscles, took prescribed supplements, controlled the position of the jaw, and used an occlusal splint at the required time. Conclusions: The results of the study indicate a low percentage of adherence to the recommendations made by the doctor. Full article

(This article belongs to the Special Issue Multidisciplinary Approach to the Diagnosis and Treatment of Temporomandibular Disorders: Patient Care Challenges—2nd Edition)

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2 pages, 130 KB

Open AccessEditorial

Interstitial Lung Disease in 2025—Progress, Challenges, and Hope Ahead

by Sameep Sehgal and Atul Mehta

J. Clin. Med. 2025, 14(18), 6673; https://doi.org/10.3390/jcm14186673 - 22 Sep 2025

Abstract

Interstitial lung disease (ILD) remains one of the most challenging conditions in respiratory medicine, with outcomes often as poor as those seen in advanced malignancies [...] Full article

(This article belongs to the Special Issue Updates on Interstitial Lung Disease)

21 pages, 1371 KB

Open AccessReview

Activated Complement System’s Impact in Antiphospholipid Syndrome Thrombosis: From Pathophysiology to Treatment

by Sofia Tagara, Serena Valsami, Eleni Gavriilaki, Elias Kyriakou, Elisavet Grouzi, Paschalis Evangelidis, Paraskevi Karvouni, Georgia Kaiafa, Ioannis Papadakis, Aristarchos Poulis, Eleni Petrou, Marianna Politou and Styliani Kokoris

J. Clin. Med. 2025, 14(18), 6672; https://doi.org/10.3390/jcm14186672 - 22 Sep 2025

Abstract

Antiphospholipid syndrome (APS) is the most common acquired form of thrombophilia and is associated with the presence of antiphospholipid antibodies (aPL) in the patient’s serum. Until now, the “double-hit” hypothesis remains the prevailing theory for APS pathogenesis. According to this model, the presence [...] Read more.

Antiphospholipid syndrome (APS) is the most common acquired form of thrombophilia and is associated with the presence of antiphospholipid antibodies (aPL) in the patient’s serum. Until now, the “double-hit” hypothesis remains the prevailing theory for APS pathogenesis. According to this model, the presence of aPL (first hit) is insufficient to trigger thrombosis. A secondary event, such as an inflammatory trigger or vascular injury (second hit), is required to initiate immunothrombosis, which ultimately leads to thromboembolism. Although immunothrombosis has a critical role in several mechanisms, such as in defense against pathogens, chronic immune system activation by aPL appears to disrupt its protective function. In the last three decades, the role of the complement system has gained increasing recognition in the pathophysiology of APS. aPL are involved in the dysregulation of multiple components, such as platelets, β2-glycoprotein I, and complement factor H, resulting in excessive activation of the complement system. Thus, the complement system is a key driver of thrombosis in APS and stands as a promising target for the development of future therapeutic strategies. In the current review article, we aim to summarize the ongoing research regarding the role of complement system dysregulation in APS-associated thrombosis development, while recognizing potential therapeutic targets. In the era of precision medicine, more data concerning targeted therapeutics in the field of APS are essential. Full article

(This article belongs to the Special Issue Clinical Advances in Treatment for Venous Thromboembolism)

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14 pages, 452 KB

Open AccessArticle

Prevalence and Trends in Active Smoking Among Adults Living with HCV in the U.S. over the Last Decade: A Population-Level Analysis

by Mohammad Alabbas, Jingyi Shi, Yuqi Guo, Hongke Wu, Ibukunoluwa Oshobu, Maria Castano, Walaa Mahmoud, Shreya Sengupta and Omar T. Sims

J. Clin. Med. 2025, 14(18), 6671; https://doi.org/10.3390/jcm14186671 - 22 Sep 2025

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Abstract

Background: Smoking in patients with hepatitis C (HCV) amplifies the risk of cirrhosis and hepatocellular carcinoma. We aimed to estimate the prevalence of active smoking over the last decade at the population level among adults living with HCV in the U.S., estimate [...] Read more.

Background: Smoking in patients with hepatitis C (HCV) amplifies the risk of cirrhosis and hepatocellular carcinoma. We aimed to estimate the prevalence of active smoking over the last decade at the population level among adults living with HCV in the U.S., estimate temporal trends in active smoking, and identify factors associated with active smoking. Methods: We analyzed repeated cross-sectional NHANES data (2007–2018) of adults ≥20 years old with serologic evidence of HCV and complete smoking data (unweighted [n = 621] and weighted [n = 3,620,603] sample size). Temporal trends were evaluated using linear regression and joinpoint regression. Survey-weighted multivariable logistic regression was used to identify factors associated with active smoking. Results: The cumulative prevalence of active smoking was 56.4% (95% CI, 49.2–63.4). Linear trend testing was not significant (p = 0.93). Joinpoint regression suggested a slope change near 2013–2014, but neither segment-specific annual percent changes nor the slope change reached significance. Factors associated with higher odds of active smoking included female sex (aOR = 2.23; 95% CI, 1.17–4.24), low poverty income ratio (aOR = 3.33; 1.41–7.84), lifetime substance use (aOR = 10.63; 3.08–36.70), and depression (aOR = 2.65; 1.29–5.45). Lower odds were observed with >high-school education (aOR = 0.50; 0.26–0.94), obesity (aOR = 0.32; 0.18–0.58), and ≥2 yearly healthcare visits (aOR = 0.27; 0.10–0.68). Conclusions: Smoking appears to be endemic within the HCV population, and rates have remained alarmingly high and stagnant (i.e., unchanged or have not decreased) over the last decade, which consequently can lead to heightened incident cases of HCV-related cirrhosis and hepatocellular carcinoma in the near future. Full article

(This article belongs to the Special Issue Advances in Hepatitis: Prevention, Treatment, and Global Health Impact)

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8 pages, 633 KB

Open AccessArticle

Optimizing Perioperative Glycaemic Control with Continuous Glucose Monitoring in Pregestational Diabetes: Feasibility and Comparative Analysis of Two Systems: A Pilot Study

by Joanna Kacperczyk-Bartnik, Aleksandra Urban, Paweł Bartnik, Piotr Świderczak, Aneta Malinowska-Polubiec, Aleksandra Bender, Ewa Romejko-Wolniewicz, Krzysztof Czajkowski and Jacek Sieńko

J. Clin. Med. 2025, 14(18), 6670; https://doi.org/10.3390/jcm14186670 - 22 Sep 2025

Abstract

Background: Continuous glucose monitoring (CGM) has changed the clinical practice in diabetes management during pregnancy; however, its application during caesarean section remains understudied. This feasibility study evaluates the performance, reliability, and clinical utility of two CGM systems—FreeStyle Libre 2 and Medtronic Guardian Connect—during [...] Read more.

Background: Continuous glucose monitoring (CGM) has changed the clinical practice in diabetes management during pregnancy; however, its application during caesarean section remains understudied. This feasibility study evaluates the performance, reliability, and clinical utility of two CGM systems—FreeStyle Libre 2 and Medtronic Guardian Connect—during caesarean delivery and the early postpartum period in a patient with pregestational diabetes mellitus (PGDM). Methods: A prospective, single-patient study was conducted. A 32-year-old woman with type 1 diabetes underwent elective caesarean section at 38 weeks of gestation. Both CGM systems were applied over 18 h prior to surgery and monitored continuously through the intraoperative and five-day postpartum period. Glucose data, device performance, and usability were assessed. Results: Both CGM systems provided uninterrupted, high-quality glucose data throughout the perioperative period, including during spinal anaesthesia, surgical manipulation, and postoperative recovery. No sensor displacement nor signal loss occurred. Glycaemic readings remained within the normoglycaemic range (90–100 mg/dL) during surgery, with mild elevations observed during anaesthesia initiation. Postoperatively, both systems showed comparable glucose trends, with slightly lower readings from FreeStyle Libre 2. Conclusions: CGM is feasible and reliable during caesarean section in PGDM patients. These findings support the integration of CGM into obstetric surgical care and highlight the need for larger studies to validate clinical benefits. Full article

(This article belongs to the Special Issue Clinical Translation of Technological Innovations in Diabetes Therapeutics)

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14 pages, 1589 KB

Open AccessArticle

Tenascin-C and Thrombospondin-1 as a Potential Link Between Sleep Bruxism and Cardiovascular Diseases—A Case–Control Study

by Helena Martynowicz, Monika Kosacka, Piotr Macek, Gabriella Lachowicz, Rafal Poręba, Agnieszka Kusnerz, Aleksandra Jaremków, Cyryl Daroszewski, Agnieszka Bronowicka-Szydełko, Katarzyna Madziarska and Paweł Gać

J. Clin. Med. 2025, 14(18), 6669; https://doi.org/10.3390/jcm14186669 - 22 Sep 2025

Abstract

Background: Sleep bruxism (SB), a sleep behavior, is one of the most common sleep pathologies. Tenascin-C (TnC) and thrombospondin-1 (TSP-1) are involved in the pathogenesis of cardiovascular disease. The aim of our study was to assess the relationship between SB and TSP-1 [...] Read more.

Background: Sleep bruxism (SB), a sleep behavior, is one of the most common sleep pathologies. Tenascin-C (TnC) and thrombospondin-1 (TSP-1) are involved in the pathogenesis of cardiovascular disease. The aim of our study was to assess the relationship between SB and TSP-1 and TnC. Methods: A total of 80 participants, who were hospitalized in the Sleep Laboratory of the Department of Internal Medicine, Occupational Diseases, Hypertension, and Clinical Oncology at Wroclaw Medical University, were enrolled in the study. Polysomnographic examination was conducted following the standard sleep evaluation criteria set by the American Academy of Sleep Medicine, utilizing the Nox-A1 device. Serum TnC and TSP-1 concentrations were determined using Elisa Kits. Results: The study showed an increased concentration of TnC in the group of patients with a BEI (bruxism episode index) >10.3, compared to <10.3 (6786.79 ± 5655.62 vs. 1585.16 ± 2526.56). In regression analysis, higher values of phasic bruxism, smoking, and older age were independently associated with increased concentrations of TnC in the serum. Moreover, higher values of tonic bruxism, as well as smoking, were independently associated with TSP-1. Conclusions: Since tenascin-C and thrombospondin-1 levels are associated with sleep bruxism, atherosclerosis may be a potential consequence of SB. This relationship is especially noticeable in severe bruxism. Therefore, monitoring for clinical signs of atherosclerosis should be considered in patients with severe bruxism. Full article

(This article belongs to the Section Respiratory Medicine)

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22 pages, 3089 KB

Open AccessReview

What Cardiologists Should Know About Amyloidosis

by Rama Alashqar, Ahmad Alkhatib, Ala W. Abdallah, Mahmoud Odeh, Mustafa Al-Taei, Own Khraisat, Mohammed Al-Hiari, Hazem Taifour, Amer Hammad and Ahmed Sami Abuzaid

J. Clin. Med. 2025, 14(18), 6668; https://doi.org/10.3390/jcm14186668 - 22 Sep 2025

Abstract

Background: Cardiac amyloidosis (CA) is an increasingly recognized but historically underdiagnosed cause of restrictive cardiomyopathy and heart failure with preserved ejection fraction (HFpEF). It results from the extracellular deposition of misfolded protein fibrils, most commonly transthyretin (ATTR) or immunoglobulin light chains (AL), leading [...] Read more.

Background: Cardiac amyloidosis (CA) is an increasingly recognized but historically underdiagnosed cause of restrictive cardiomyopathy and heart failure with preserved ejection fraction (HFpEF). It results from the extracellular deposition of misfolded protein fibrils, most commonly transthyretin (ATTR) or immunoglobulin light chains (AL), leading to progressive myocardial dysfunction and multi-organ involvement. Objective: This review provides a comprehensive, cardiology-centered overview of cardiac amyloidosis, with an emphasis on early recognition, diagnostic strategies, subtype differentiation, and the evolving therapies. Content: We summarize the epidemiology, pathophysiology, and clinical manifestations of both ATTR and AL subtypes. Key diagnostic tools, including echocardiography, cardiac magnetic resonance imaging, bone scintigraphy, monoclonal protein screening, and endomyocardial biopsy, are reviewed in the context of a stepwise diagnostic approach. Special attention is given to clinical presentation, electrocardiographic and imaging “red flags,” and to differentiating CA from mimickers such as hypertrophic cardiomyopathy, hypertension-induced left ventricular hypertrophy, and aortic stenosis. Staging systems are detailed, highlighting the prognostic role of cardiac biomarkers. Therapeutic strategies are explored, including subtype-specific regimens (e.g., daratumumab-based therapy for AL; tafamidis and gene silencers for ATTR), the judicious use of conventional heart failure medications, and emerging therapies such as CRISPR-based gene editing. Conclusions: Timely recognition and accurate diagnosis of cardiac amyloidosis are critical to improving outcomes. As diagnostic tools and disease-modifying therapies evolve rapidly, cardiologists must remain at the forefront of multidisciplinary care. A structured biomarker- and imaging-guided approach can enhance diagnostic yield, inform prognosis, and optimize patient-specific management. Full article

(This article belongs to the Special Issue Advances in the Management of Cardiac Amyloidosis and Hypertrophic Cardiomyopathy)

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11 pages, 211 KB

Open AccessArticle

Open Fractures on the Field: Two Decades of Pediatric Sports Injuries in a Level 1 Trauma Cohort

by Britta Chocholka, Lara Marie Bogensperger, Iryna Yegorova, Vanessa Groß, Manuela Jaindl, Bikash Parajuli, Sanika Rapole, Thomas Manfred Tiefenboeck and Stephan Payr

J. Clin. Med. 2025, 14(18), 6667; https://doi.org/10.3390/jcm14186667 - 22 Sep 2025

Viewed by 1

Abstract

Background: Open fractures in pediatric patients are uncommon but clinically relevant, often resulting from high-energy trauma or sports-related incidents. This study analyzes the demographic patterns, types of sports, injury mechanisms, treatment strategies, and outcomes in children and adolescents with sports-related open fractures. [...] Read more.

Background: Open fractures in pediatric patients are uncommon but clinically relevant, often resulting from high-energy trauma or sports-related incidents. This study analyzes the demographic patterns, types of sports, injury mechanisms, treatment strategies, and outcomes in children and adolescents with sports-related open fractures. Methods: In this retrospective study, 74 pediatric patients with sports-related open fractures treated at a level 1 trauma center between 2002 and 2023 were documented. Parameters such as age, sex, fracture location, sport type, treatment modality, complications, and outcomes were evaluated. Results: The cohort included 74 patients, with a mean age of 13 ± 3.6 years. Open fractures of the upper extremity were most common (seen in 34 patients). Moreover, 10 open craniofacial and 27 open nasal fractures represented 50.0% of injuries, mainly in male athletes involved in contact sports. Soccer was the leading injury-related sport (n = 14; 18.9%). Surgical treatment was required in 28 patients (37.8%), most frequently using elastic stable intramedullary nailing, Kirschner wire fixation in the upper extremities or nasal bone reduction. Antibiotics were administered in 46 patients (62.2%), with a mean documented duration of 2.7 ± 3.1 days. An excellent outcome was documented in 95%. Conclusions: Sports-related open fractures in children primarily affect male adolescents in contact sports and involve the upper extremities and facial region. Conservative management is effective in stable, non-displaced and low-grade injuries. Surgical treatment is frequently indicated in open forearm fractures. The implementation of a structured trauma care protocol, incorporating early debridement, definitive treatment, and antibiotics, has been demonstrated to yield a safe and effective treatment outcome with a favorable prognosis for sports-related open fractures in children. Full article

(This article belongs to the Special Issue Advancing Pediatric Sports Medicine: Insights and Innovations)

13 pages, 475 KB

Open AccessArticle

Minimally Invasive Mitral Valve Replacement in the Gray Zone: Bioprosthetic vs. Mechanical Valves in Patients Aged 50–69 Years

by Alexander Weymann, Sadeq Ali-Hasan-Al-Saegh, Sho Takemoto, Nunzio Davide De Manna, Jan Beneke, Lukman Amanov, Fabio Ius, Ruemke Stefan, Bastian Schmack, Alina Zubarevich, Aburahma Khalil, Arjang Ruhparwar and Jawad Salman

J. Clin. Med. 2025, 14(18), 6666; https://doi.org/10.3390/jcm14186666 - 22 Sep 2025

Abstract

Background: Mitral valve replacement presents considerable challenges in the field of cardiothoracic surgery, particularly in patients aged 50 to 69, where the decision between bioprosthetic and mechanical valves is critical. Nevertheless, the optimal selection of prosthetic valves for candidates within this age-related [...] Read more.

Background: Mitral valve replacement presents considerable challenges in the field of cardiothoracic surgery, particularly in patients aged 50 to 69, where the decision between bioprosthetic and mechanical valves is critical. Nevertheless, the optimal selection of prosthetic valves for candidates within this age-related gray zone remains inadequately defined, necessitating a thorough evaluation of long-term outcomes and associated risks. Objective: This study aims to assess mid-term outcomes of MIMVR in patients aged 50 to 69, comparing reoperation rates, prosthesis-related morbidity, and overall survival between bioprosthetic and mechanical valves. While many prior studies on valve choice in patients aged 50 to 69 years are derived from sternotomy cohorts, the novelty of our work lies in the exclusive focus on patients undergoing minimally invasive techniques. Methods: A retrospective analysis was conducted in accordance with the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines, including 172 patients aged 50–69 years who underwent minimally invasive mitral valve replacement via right minithoracotomy at a high-volume center in Germany between 2011 and 2023. Of the 172 patients, 95 underwent MIMVR using biological prostheses, while 77 received mechanical prostheses. Comprehensive data on demographics, surgical procedures, and postoperative complications, as well as long-term outcomes, were analyzed. Results: With a mean follow-up of 7.1 years, early outcomes revealed no significant differences in 30-day mortality (7.4% for bioprosthetic vs. 2.6% for mechanical; p = 0.06). There was no significant differences in all-cause mortality at 1 year (8.4% vs. 3.9%; p = 0.22), 3-year (9.5% vs. 7.8%; p = 0.69), and 5-year (13.7% vs. 10.4%; p = 0.19), or at the longest follow-up (13.7% vs. 10.4%; p = 0.51). Kaplan–Meier analysis showed no significant difference in long-term survival between the groups (p = 0.5427). Postoperative arrhythmia occurred significantly more frequently in the biologic group compared to the mechanical group (18.9% vs. 6.5%; p = 0.01). Conclusions: For patients aged 50–69 undergoing MIMVR using a bioprosthetic or mechanical valve, the mid-term survival and incidence of reoperation and re-hospitalization were comparable up to 7 years. This provides evidence supporting the safe application of the MICS approach with either valve type in this gray-zone age group. Full article

(This article belongs to the Special Issue Innovations and Challenges in Cardiovascular Surgery)

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19 pages, 984 KB

Open AccessArticle

Retrospective Observational Study of Nintedanib in Managing Idiopathic and Progressive Pulmonary Fibrosis in Routine Practice

by Alessia Giovanna Andrisano, Nadia Castaldo, Francesco Giuliana, Davide Femia, Giuseppe Morana, Vincenzo Patruno, Giorgio Monteleone, Nicolò Reccardini, Rossella Cifaldi, Michael Hughes, Yukai Wang, Paola Confalonieri, Francesco Salton, Pietro Geri, Marco Confalonieri and Barbara Ruaro

J. Clin. Med. 2025, 14(18), 6665; https://doi.org/10.3390/jcm14186665 - 22 Sep 2025

Abstract

Background/Objectives: Idiopathic pulmonary fibrosis (IPF) is the most common form of pulmonary fibrosis (PF) and serves as a key reference for disease severity. Progressive pulmonary fibrosis (PPF), a distinct yet heterogeneous entity arising from various interstitial lung diseases (ILDs), shares similar pathogenetic mechanisms [...] Read more.

Background/Objectives: Idiopathic pulmonary fibrosis (IPF) is the most common form of pulmonary fibrosis (PF) and serves as a key reference for disease severity. Progressive pulmonary fibrosis (PPF), a distinct yet heterogeneous entity arising from various interstitial lung diseases (ILDs), shares similar pathogenetic mechanisms and clinical courses driven by self-perpetuating fibrosis. Antifibrotic therapy, notably nintedanib, can slow disease progression. However, real-world data on antifibrotic therapy’s impact on survival, especially in PPF, are limited. This study aims to compare IPF and PPF regarding phenotype, radiological patterns, comorbidities, prognostic factors, and response to nintedanib, focusing on identifying the patient subsets most likely to benefit. Outcomes assessed include safety, survival, and disease progression over one year, considering various prognostic factors. Methods: This retrospective observational study evaluated patients with fibrosing ILD, affected by either IPF or PPF, and treated with nintedanib. Data collected encompassed clinical, radiological, functional, and treatment-related information. Assessments included chest CT, pulmonary function tests, comorbidities, and survival analysis, utilizing standardized methods and statistical tools to interpret outcomes and tolerability. Results: The study population was composed of 97 patients: 64 were diagnosed with IPF and 33 with PPF. The analysis showed that in PPF patients, ongoing antifibrotic treatment resulted in higher survival (71.1 months vs. 27.4 months, p < 0.001), while no statistically significant differences were found in the IPF group (67.4 months vs. 52.5 months, p = 0.216). Nintedanib was generally well tolerated. Gastrointestinal side effects, predominantly diarrhea, were reported in 61% of patients with IPF and 50% of those with PPF. Dose reduction occurred in 43.75% of IPF patients and 36% of PPF patients, while treatment discontinuation was required in 21.87% of IPF and 21% of PPF patients. Conclusions: This study highlights that in PPF patients, antifibrotic therapy with nintedanib can improve survival. This statement underlines that the primary outcome of antifibrotic treatment should focus on improving patients’ survival. Full article

(This article belongs to the Special Issue Clinical Advances in Autoimmune Disorders)

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13 pages, 1382 KB

Open AccessArticle

Nutritional Status Assessment Using the Patient-Generated Subjective Global Assessment (PG-SGA) in Individuals with Colorectal Cancer Undergoing Chemotherapy Regimens

by Luis Enrique Sánchez-Diestro, Raquel Macias-Montero, Ana Isabel Ramalho-Galhanas, Ana Maria Aguiar-Frias, María Sandra Paniagua-Vivas and Jorge Guerrero-Martín

J. Clin. Med. 2025, 14(18), 6664; https://doi.org/10.3390/jcm14186664 - 22 Sep 2025

Abstract

Background/Objectives: Colorectal cancer (CRC) has high prevalence and mortality, with a high frequency of malnutrition during chemotherapy (60–70%). Malnutrition reduces treatment tolerance, quality of life, and survival. The Patient-Generated Subjective Global Assessment (PG-SGA) is effective in detecting it, but its use is not [...] Read more.

Background/Objectives: Colorectal cancer (CRC) has high prevalence and mortality, with a high frequency of malnutrition during chemotherapy (60–70%). Malnutrition reduces treatment tolerance, quality of life, and survival. The Patient-Generated Subjective Global Assessment (PG-SGA) is effective in detecting it, but its use is not systematic. This study aims to analyze the prevalence and degrees of malnutrition in CRC patients undergoing active chemotherapy, using the PG-SGA, and to propose its systematic implementation in oncology care protocols. Methods: Observational, cross-sectional, and descriptive study in patients with stage III–IV CRC receiving FOLFOX, XELOX, or irinotecan regimens. Nutritional status was assessed with PG-SGA and body composition by bioimpedance. Results: The study includes 91 patients. A total of 45.05% of patients required intensive nutritional intervention, 39.56% needed dietary and pharmacological measures, 10.99% required health education, and only 4.4% did not require intervention. FOLFOX was significantly associated with taste alterations (p < 0.001), nausea (p = 0.020), unpleasant odors, and eating problems; XELOX with diarrhea (p = 0.009) and xerostomia (p = 0.038). Irinotecan was related to poorer functional capacity (p = 0.042). Oxaliplatin was linked to loss of appetite (p = 0.034) and unpleasant odors (p = 0.035). Older age correlated with a greater need for intensive interventions. Conclusions: The study shows a high nutritional risk in oncology patients, particularly in those with colorectal cancer undergoing FOLFOX treatment, associated with symptoms that impair intake and functional capacity. The systematic implementation of nutritional screening from the onset of treatment, using tools such as the PG-SGA and GLIM criteria, is essential for early detection and individualized management, improving therapy tolerance, clinical outcomes, and quality of life. Full article

(This article belongs to the Section Clinical Nutrition & Dietetics)

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14 pages, 456 KB

Open AccessArticle

Endoscopic Outcomes and Inflammatory Marker Correlation in Adult Patients with Corrosive Substance Ingestion

by Seymur Aslanov, Ali Senkaya, Nalan Gulsen Unal, Cengiz Karahanlı, Idris Kurt, Ferit Celik, Alper Uysal, Ozan Fatih Sarıkaya and Ahmet Omer Ozutemiz

J. Clin. Med. 2025, 14(18), 6663; https://doi.org/10.3390/jcm14186663 - 22 Sep 2025

Abstract

Background/Objectives: Corrosive substance intake remains a significant public health concern due to its potential for severe gastrointestinal (GI) injury and associated morbidity. Early risk stratification is crucial for appropriate management, yet there is a lack of reliable non-invasive predictors of injury severity. This [...] Read more.

Background/Objectives: Corrosive substance intake remains a significant public health concern due to its potential for severe gastrointestinal (GI) injury and associated morbidity. Early risk stratification is crucial for appropriate management, yet there is a lack of reliable non-invasive predictors of injury severity. This study aimed to evaluate the clinical characteristics of adult patients with corrosive ingestion and to investigate the correlation between inflammatory markers and endoscopic injury severity. Methods: In this retrospective study, 83 adult patients who underwent esophagogastroduodenoscopy (EGD) following corrosive ingestion between January 2017 and January 2021 were analyzed. Endoscopic injuries were graded using the Zargar classification and categorized as mild (grades 0–2a) or severe (grades 2b–4). Demographic, clinical, endoscopic, and laboratory data, including neutrophil-to-lymphocyte ratio (NLR) and C-reactive protein (CRP) levels, were recorded. The correlation between inflammatory markers and injury severity was assessed, and receiver operating characteristic (ROC) analysis was performed to determine diagnostic accuracy. Results: Among the patients, 55.4% were female with a mean age of 41.5 ± 17.3 years. Most ingestions were accidental (74.7%), with bleach being the most common agent (41%). Endoscopic injury was detected in 55.4% of patients, predominantly in the stomach and esophagus. Severe injuries were associated with longer intensive care and hospital stays, increased complication rates, and more frequent organ involvement (p < 0.001). A weak but statistically significant correlation was found between injury severity and both NLR (r = 0.357, p = 0.001) and CRP (r = 0.247, p = 0.024). ROC analysis revealed an NLR cut-off of 2.95 (AUC = 0.804) and CRP cut-off of 2.5 (AUC = 0.706) for predicting severe injury. Conclusions: Early endoscopic evaluation remains essential for assessing corrosive injury severity. However, NLR and CRP may serve as useful, non-invasive indicators in predicting injury severity, potentially aiding clinical decision-making, especially in settings where endoscopy is not readily available or is contraindicated. Full article

(This article belongs to the Section Gastroenterology & Hepatopancreatobiliary Medicine)

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25 pages, 618 KB

Open AccessPerspective

Post-Heroin Post-Traumatic Stress Disorder Spectrum: Heroin Addiction as a Generator of Trauma Sensitisation in Everyday Life: A Perspective Review

by Icro Maremmani, Filippo Della Rocca, Manuel Glauco Carbone and Angelo Giovanni Icro Maremmani

J. Clin. Med. 2025, 14(18), 6662; https://doi.org/10.3390/jcm14186662 - 22 Sep 2025

Abstract

Background: Heroin addiction is associated with profound dysregulation of the endogenous opioid and stress response systems, yet current diagnostic frameworks may inadequately capture the traumatising aspects of this condition. This perspective proposes the concept of post-heroin post-traumatic stress spectrum (pH-PTSD/S) as a clinical [...] Read more.

Background: Heroin addiction is associated with profound dysregulation of the endogenous opioid and stress response systems, yet current diagnostic frameworks may inadequately capture the traumatising aspects of this condition. This perspective proposes the concept of post-heroin post-traumatic stress spectrum (pH-PTSD/S) as a clinical syndrome emerging from chronic opioid-induced neurobiological and psychosocial dysregulation, even in the absence of Criterion A trauma. Methods: The authors review evidence from neuroendocrinology, behavioural neuroscience, and clinical psychopathology to support a sensitisation-based model of trauma vulnerability in heroin use disorder (HUD). Results: Findings suggest that HUD patients frequently exhibit PTSD-spectrum symptoms, including hyperarousal, avoidance, emotional dysregulation, and altered stress reactivity. Opioid agonist treatment (OAT) may mitigate these symptoms by stabilising HPA axis function and reducing exposure to trauma-related contexts. The pH-PTSD/S construct, measured through a dedicated instrument, identifies patients with subthreshold trauma-related symptoms and greater psychopathological burden. Conclusions: Heroin dependence may constitute a traumatising condition, requiring dimensional diagnostic tools and trauma-informed treatment strategies. Further research is needed to validate the nosological status of pH-PTSD/S, clarify its distinction from protracted withdrawal or complex PTSD, and determine its implications for OAT duration and integrated care pathways. Full article

(This article belongs to the Section Mental Health)

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12 pages, 1071 KB

Open AccessArticle

Preoperative Opioid Use Disorder Predicts Prolonged Ventilation, Central Line Placement, and Major Anesthesiology Complications After ACDF Surgery: A Big Data Analysis of 180,000 Cases

by David Maman, Maneesh Nandakumar, Yaniv Steinfeld and Yaron Berkovich

J. Clin. Med. 2025, 14(18), 6661; https://doi.org/10.3390/jcm14186661 - 22 Sep 2025

Abstract

Background: Opioid use disorder (OUD) has emerged as a growing public health challenge, increasingly affecting surgical populations. While anterior cervical discectomy and fusion (ACDF) is a common spinal procedure with known perioperative risks, the specific impact of preoperative OUD on anesthesia-related complications in [...] Read more.

Background: Opioid use disorder (OUD) has emerged as a growing public health challenge, increasingly affecting surgical populations. While anterior cervical discectomy and fusion (ACDF) is a common spinal procedure with known perioperative risks, the specific impact of preoperative OUD on anesthesia-related complications in ACDF remains poorly studied. Methods: We analyzed adult patients undergoing elective single-level ACDF between 2016 and 2022 using the Nationwide Inpatient Sample (NIS) database. Patients with and without OUD were identified using ICD-10 codes. Propensity score matching was applied to adjust for baseline differences. Primary outcomes included prolonged ventilation, central line placement, and major anesthesiology complications. Secondary outcomes included total charges, length of stay, and number of procedures. A cost-effectiveness analysis of universal preoperative urine drug screening was also performed. Results: Among 178,215 patients undergoing ACDF, 1.5% had documented OUD. Following propensity matching, OUD patients had a significantly increased risk of prolonged ventilation (>24 h and >96 h), central line placement, blood transfusion, feeding tube insertion, and major anesthesiology complications. OUD patients experienced longer hospital stays (7.9 vs. 2.7 days), more procedures (4.2 vs. 3.0), and higher total charges ($139,207 vs. $82,179; all p < 0.01). The estimated excess cost attributable to OUD per surgical patient was $855, compared to a $75 screening cost. Conclusions: Preoperative OUD is associated with significantly increased perioperative risk, ICU-level intervention, and healthcare costs in ACDF patients. These findings support systematic preoperative screening and multidisciplinary management for patients with OUD undergoing spine surgery. Full article

(This article belongs to the Special Issue Perioperative Anesthesia: State of the Art and the Perspectives)

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15 pages, 10663 KB

Open AccessArticle

The Value of Early Active Rehabilitation on Long-Term Functional Outcomes in Neer Type-4 Valgus Impacted Proximal Humeral Fractures Treated with Open Reduction and Internal Fixation: A Retrospective Cohort Study

by Haiyan Zhou and Liming Cheng

J. Clin. Med. 2025, 14(18), 6660; https://doi.org/10.3390/jcm14186660 - 22 Sep 2025

Abstract

Objectives: The optimal rehabilitation protocol following open reduction and internal fixation (ORIF) for Neer type-4 valgus impacted proximal humeral fractures (VIPHF) remains controversial. This study aimed to compare the long-term efficacy and safety of early active mobilization versus conventional rehabilitation in these patients. [...] Read more.

Objectives: The optimal rehabilitation protocol following open reduction and internal fixation (ORIF) for Neer type-4 valgus impacted proximal humeral fractures (VIPHF) remains controversial. This study aimed to compare the long-term efficacy and safety of early active mobilization versus conventional rehabilitation in these patients. Methods: We conducted a retrospective cohort study at a single tertiary hospital involving 128 patients who underwent ORIF for Neer type-4 VIPHF between January 2018 and December 2022. Participants were divided into two groups based on the rehabilitation protocol received: the Early Active Activation (EAA) group (n = 64), which initiated controlled active exercises on postoperative day 1, and the Conventional Rehabilitation (CR) group (n = 64), which followed a delayed protocol. The primary outcome was the Constant–Murley score at 24 months. Secondary outcomes included scores at 3, 6, and 12 months, pain VAS scores, active range of motion, fracture healing time, and complications. Results: The EAA group demonstrated significantly superior outcomes, including a higher 24-month Constant–Murley score (88.7 ± 6.5 vs. 75.3 ± 9.2, p < 0.001), lower VAS scores at all time points (p < 0.001), greater range of motion (p < 0.001), and shorter fracture healing time (10.2 ± 1.8 vs. 12.5 ± 2.3 weeks, p < 0.001). Complication rates did not differ significantly (4.7% vs. 6.3%, p = 0.718). Conclusions: For patients with surgically stabilized Neer type-4 VIPHF, early active rehabilitation initiated on postoperative day 1 was associated with significantly improved functional outcomes, accelerated recovery, and a favorable safety profile. However, these findings should be interpreted with caution due to the retrospective design, single-center setting, and potential residual confounding. Further validation through prospective, multicenter studies is recommended. Full article

(This article belongs to the Section Clinical Rehabilitation)

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15 pages, 858 KB

Open AccessArticle

Electrocardiographic Predictors for Early Risk Stratification: 30-Day Mortality in Older Adult Trauma Patients

by Sedat Ozdemir, Mehmet Murat Oktay, Iffet Tiftikci and Kazim Ersin Altinsoy

J. Clin. Med. 2025, 14(18), 6659; https://doi.org/10.3390/jcm14186659 - 22 Sep 2025

Abstract

Objectives: This prospective observational study aimed to assess the prognostic value of electrocardiographic (ECG) findings obtained at emergency department (ED) admission in adult patients presenting with trauma-related fractures, with a focus on their association with 30-day all-cause mortality. Materials and Methods: A total [...] Read more.

Objectives: This prospective observational study aimed to assess the prognostic value of electrocardiographic (ECG) findings obtained at emergency department (ED) admission in adult patients presenting with trauma-related fractures, with a focus on their association with 30-day all-cause mortality. Materials and Methods: A total of 391 patients aged ≥18 years with trauma-induced fractures were enrolled at a tertiary emergency center between February and May 2025. Baseline demographic and clinical data, including comorbidities, trauma mechanisms, and 12-lead ECG findings at admission, were recorded. Patients were monitored for 30-day mortality. Logistic regression analysis was used to identify independent predictors of mortality. Results: The mean age of the patients was 73.9 ± 6.7 years, and 50.1% were female. Normal sinus rhythm was the most common ECG finding (31.5%), followed by sinus tachycardia (20.5%) and bundle branch block (15.3%), while atrial fibrillation (AF) was present in 9.5% of cases. Thirty-day mortality occurred in 5.1% of the cohort (n = 20). Non-survivors had significantly higher frequencies of AF (35.0% vs. 8.1%, p = 0.001), head trauma (70.0% vs. 18.1%, p < 0.001), cerebrovascular disease (55.0% vs. 16.4%, p < 0.001), and polypharmacy (100% vs. 62.8%, p = 0.001) compared with survivors. Conversely, low-energy falls were more common among survivors (74.7% vs. 20.0%, p < 0.001), whereas falls from stairs or a bed and high-energy trauma were significantly more frequent among non-survivors (all p < 0.05). In multivariate logistic regression, AF (OR: 6.112; 95% CI: 1.612–23.176; p = 0.008), head trauma (OR: 16.514; 95% CI: 4.925–55.367; p < 0.001), and cerebrovascular disease (OR: 6.725; 95% CI: 2.219–20.385; p = 0.001) emerged as independent predictors of 30-day mortality. Although normal sinus rhythm was associated with survival in univariate analysis (p = 0.034), it did not retain independent significance in multivariate modeling. Patients with AF had significantly lower 30-day survival compared with those without AF (65.0% vs. 96.3%, p = 0.001). Conclusions: This prospective study demonstrates that electrocardiographic abnormalities—especially atrial fibrillation—are strong predictors of 30-day mortality in older adult trauma patients. Their prognostic value was further reinforced when assessed alongside head trauma and cerebrovascular disease. These findings emphasize ECG as a rapid, practical, and noninvasive tool for early risk stratification and clinical decision-making in the emergency care of geriatric fracture patients. Full article

(This article belongs to the Special Issue The “Orthogeriatric Fracture Syndrome”—Issues and Perspectives)

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J. Clin. Med., Volume 14, Issue 18 (September-2 2025) – 341 articles

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