Journal of Clinical Medicine

15 pages, 775 KB

Open AccessArticle

A Novel Method for Assessing Sinusitis Activity in Minimally Symptomatic Patients with ANCA-Associated Vasculitis: A Pilot Study

by Michał S. Kaczmarczyk, Piotr Rot, Elżbieta Głuch, Maria Sobol, Arkadiusz Zegadło, Dariusz Jurkiewicz, Stanisław Niemczyk and Ksymena Leśniak

J. Clin. Med. 2025, 14(24), 8972; https://doi.org/10.3390/jcm14248972 - 18 Dec 2025

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Abstract

Objectives: Antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV) is a group of vasculitides sharing a common pathophysiology, which affects small and medium blood vessels. Sinonasal involvement is one of the most common manifestations of AAV. The goal of this study was to find [...] Read more.

Objectives: Antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV) is a group of vasculitides sharing a common pathophysiology, which affects small and medium blood vessels. Sinonasal involvement is one of the most common manifestations of AAV. The goal of this study was to find the most suitable method to assess paranasal sinus changes in a group of patients with ANCA-associated vasculitis and renal involvement. Subjective scales like Lund–Mackay and Zinreich were compared with a three-dimensional (3D) volumetric method. Pre- and post-treatment computer tomography were compared. Methods: Computer tomography, nasal symptoms, and endoscopy of 28 patients hospitalized at the Department of Internal Diseases, Nephrology and Dialysis, Military Institute of Medicine—National Research Institute were assessed retrospectively. Paranasal sinus tomography was performed during treatment induction and after achieving disease remission (BVAS = 0) to assess treatment effectiveness. Radiological analysis was performed with the Lund–Mackay scoring system, Zinreich scoring system, and 3D volumetric scoring system with the usage of Slicer 3D analysis. The radiologic scoring systems were compared. Results: The statistically significant differences in treatment effectiveness were observed for the Zinreich scale on both the right and left side. Similar to the 3D volumetric scoring system, the right and left maxillary sinuses demonstrated statistically significant differences. On the other hand, no statistically significant differences were found between the first and second visits for the Lund–Mackay or total Global Osteitis scores on either side. The strongest correlation was achieved between the Zinreich scoring system and 3D volumetric scale. Conclusions: The three-dimensional CT volumetric analysis demonstrated higher SRM (standardized response mean) values than the Zinreich score on both sides, but the differences were not statistically significant. The Zinreich scoring system should be used instead of the Lund–Mackay scale in everyday clinical practice. Full article

(This article belongs to the Section Otolaryngology)

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11 pages, 1988 KB

Open AccessArticle

Comparison of Invasive Versus Non-Invasive Pulse Contour-Based Cardiac Output Measurements at Rest and During Exercise in Pulmonary Hypertension

by Anna Titz, Julian Müller, Simon Raphael Schneider, Mona Lichtblau and Silvia Ulrich

J. Clin. Med. 2025, 14(24), 8971; https://doi.org/10.3390/jcm14248971 - 18 Dec 2025

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Abstract

Background/Objectives: Measuring cardiac output (CO) is essential for diagnosis and therapeutic monitoring in pulmonary hypertension (PH). CO assessment based on thermodilution (TD) or Direct Fick (DF) during standard right heart catheterization (RHC) is impractical for regular follow-up. We evaluated the accuracy and agreement [...] Read more.

Background/Objectives: Measuring cardiac output (CO) is essential for diagnosis and therapeutic monitoring in pulmonary hypertension (PH). CO assessment based on thermodilution (TD) or Direct Fick (DF) during standard right heart catheterization (RHC) is impractical for regular follow-up. We evaluated the accuracy and agreement of non-invasive Modelflow (MF)-based CO assessment compared with TD and DF during rest and exercise RHC in PH. Methods: This post hoc analysis from a crossover RCT included 24 PH patients (7 females, 59 ± 14 years; mean pulmonary artery pressure 37 ± 11 mmHg) who underwent RHC with repetitive CO assessments at rest and during exercise. CO was measured by TD, DF, and non-invasive MF by fingertip pulse contour analysis at rest and during stepwise cycling to maximal exertion. Results: At rest, mean CO was comparable between methods: TD = 6.05 ± 1.80 L/min, DF = 5.68 ± 1.88 L/min, MF = 6.09 ± 1.84 L/min. At end-exercise, CO increased to TD = 11.18 ± 4.38 L/min, DF = 11.84 ± 4.74 L/min, MF = 8.38 ± 2.93 L/min. Bland–Altman showed minimal bias at rest (MF vs. TD: 0.04 L/min; MF vs. DF: −0.07 L/min) but substantial variability during exercise, with underestimation of CO by MF with increasing workloads (MF vs. TD bias = −2.80 L/min; MF vs. DF bias = −4.38 L/min). Limits of agreement were wide across all workloads. Linear regression confirmed an increasing CO with workload, but MF slope was shallower than TD/DF, suggesting proportional bias. Taffé analysis identified a significant differential (5.847) and proportional bias (0.195) indicative of CO overestimation by MF at low CO and underestimation at high CO. Conclusions: MF group-level agreement is acceptable, but individual-level accuracy is limited, indicating that MF may be suitable for trend monitoring but its applicability for clinical decision-making is restricted, especially during exercise. Full article

(This article belongs to the Section Respiratory Medicine)

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24 pages, 677 KB

Open AccessArticle

Prospective Analysis of Perioperative Stress Response in Living Donor Liver Transplantation for Hepatitis B-Related Liver Disease

by Adem Tuncer, Sami Akbulut, Tevfik Tolga Sahin, Basri Satilmis, Zeki Ogut, Yasin Dalda and Sezai Yilmaz

J. Clin. Med. 2025, 14(24), 8970; https://doi.org/10.3390/jcm14248970 - 18 Dec 2025

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Abstract

Background: Liver transplantation is a life-saving procedure for patients with end-stage liver disease, yet the immunological consequences of surgical trauma in these patients are not fully understood. The liver plays a central role in immune regulation, and its dysfunction in HBV-related chronic [...] Read more.

Background: Liver transplantation is a life-saving procedure for patients with end-stage liver disease, yet the immunological consequences of surgical trauma in these patients are not fully understood. The liver plays a central role in immune regulation, and its dysfunction in HBV-related chronic liver disease may alter the systemic stress response to surgery. Aim: This study aims to evaluate the stress response to surgical trauma of patients undergoing living donor liver transplantation (LDLT) for HBV-related chronic liver disease in comparison to living liver donors (LLDs). Methods: This prospective study included 20 LDLT recipients with HBV infection and 20 LLDs who underwent living donor hepatectomy between August 2020 and February 2021. Specific biochemical markers (IL-1, IL-4, IL-6, IL-22, IFN-γ, TNF-α, TGF-β, GM-CSF, GLDH, and GalactB) were measured at designated intervals: preoperative day 0 (Preop), immediately after incision (Incision), post-hepatectomy (Hepatectomy), postoperative day 0 (POD0), POD1, and POD3 using enzyme-linked immunosorbent assay (ELISA). Routine hematological and biochemical parameters (WBC, HGB, PLT, RDW, MPV, PDW, AST, ALT, ALP, GGT, albumin, total bilirubin, plateletcrit, phosphorus, fibrinogen, and INR) were measured regularly at five predetermined times: Preop, POD0, POD1, POD2, and POD3. Results: Prior to LDLT, LDLT recipients had significantly lower levels of pro-inflammatory cytokines (IL-1, IL-6, TNF-α, IFN-γ) compared to LLDs (p < 0.05). However, following liver implantation, these cytokine levels increased significantly at POD0, POD1, and POD3 (p < 0.001). Specifically, IL-1 levels elevated from 0 in the preop period to 21.5 (97.5) in POD3, and IL-6 elevated from 0 in the preop period to 28.3 at POD3 (p = 0.056). Similarly, TNF-α and IFN-γ levels exhibited significant upward trends (p < 0.05). In contrast, cytokine levels in LLDs remained stable throughout the perioperative period, revealing no statistically significant variations (p > 0.05). Routine hematological and biochemical parameters demonstrated significant postoperative fluctuations in LDLT recipients, reflecting the metabolic and immune restoration process. Conclusions: These findings indicate that patients with HBV-related chronic liver disease exhibit a diminished stress response to trauma due to underlying immune dysregulation caused by chronic hepatic dysfunction. However, after LDLT, the stress response gradually normalizes, suggesting that liver transplantation not only restores hepatic function but also reestablishes immune homeostasis, potentially reducing infection risks and improving postoperative recovery. These findings emphasize the crucial role of the liver in regulating the body’s stress response to trauma and highlight the immunological benefits of LDLT in restoring immune homeostasis. Full article

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

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11 pages, 455 KB

Open AccessArticle

Echocardiographic Characteristics of Patients with Multiple Acute Concomitant Cerebral Infarcts

by Aviya R. Jacobs, David Leibowitz, Naaem Simaan, Issa Metanis, Hamza Jubran, Fatma Shalabi, Tamer Jubeh and Ronen R. Leker

J. Clin. Med. 2025, 14(24), 8969; https://doi.org/10.3390/jcm14248969 - 18 Dec 2025

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Abstract

Background/Objectives: Only limited data on the characteristics and outcomes of patients with multiple acute concomitant cerebral infarcts (MACCI) exist. MACCI may imply a cardioembolic source and echocardiography is important in evaluating for potential embolic sources. However, data comparing echocardiographic features in MACCI [...] Read more.

Background/Objectives: Only limited data on the characteristics and outcomes of patients with multiple acute concomitant cerebral infarcts (MACCI) exist. MACCI may imply a cardioembolic source and echocardiography is important in evaluating for potential embolic sources. However, data comparing echocardiographic features in MACCI to those observed in patients with single presumed embolic cerebral infarctions (SACI) are lacking. Thus, we aim to compare echocardiographic features between MACCI and SACI patients. Methods: We retrospectively analyzed data from a prospective stroke registry. The diagnosis of stroke secondary to MACCI and SACI was confirmed by MRI. Data on echocardiographic features, demographics, medical history, and functional status were extracted and compared between the groups. Results: Overall, 145 patients were included (83 SACI and 62 MACCI). MACCI patients were significantly older (mean ± sd 68.08 ± 13.04 vs. 62.70 ± 14.18; p = 0.021) and had higher rates of diabetes (35% vs. 25%; p = 0.014) and prior strokes (15% vs. 8%; p = 0.032). The only echocardiographic parameter that differed between the groups was left ventricular mass index (LVMI), which was significantly higher in the MACCI group after adjusting for age (aOR 1.02, 95% CI [1,1.04]; p = 0.042). MACCI was associated with higher mortality rates (34.4% vs. 18.1%, p = 0.041). No correlation was found between LVMI and stroke severity or outcomes. Conclusions: LVMI was significantly higher in MACCI patients, possibly reflecting undiagnosed hypertension, cardiomyopathy or systemic disease as potential thromboembolic mechanisms responsible for stroke. Larger studies are needed to further assess its potential role in the pathology of MACCI. Full article

(This article belongs to the Section Clinical Neurology)

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15 pages, 765 KB

Open AccessReview

Frailty-Informed Decision Making During Acute Health Crises: A Competency-Based Framework for Person-Centered Care

by Paige Moorhouse and Laurie H. Mallery

J. Clin. Med. 2025, 14(24), 8968; https://doi.org/10.3390/jcm14248968 - 18 Dec 2025

Viewed by 288

Abstract

Frailty profoundly influences the risks, benefits, and outcomes of medical care, yet clinical decision making during an acute health crisis is often driven by single-system treatment paradigms rather than a holistic understanding of patient values, prognosis, and personhood. This review outlines a practical, [...] Read more.

Frailty profoundly influences the risks, benefits, and outcomes of medical care, yet clinical decision making during an acute health crisis is often driven by single-system treatment paradigms rather than a holistic understanding of patient values, prognosis, and personhood. This review outlines a practical, competency-based framework to guide clinicians through key clinical tasks that reliably align treatment decisions with what matters most to individuals living with frailty. The approach distinguishes between interventions that remain medically reasonable versus those that are unlikely to provide benefit and acknowledges that appropriate treatments evolve as frailty progresses. Anchoring the framework is an emphasis on dignity and the preservation of personhood through every stage of care. Much like a clinical procedure, these clinical tasks require defined intent, structured steps, and practice to ensure competence. When performed skillfully, these tasks may reduce low-value interventions, support autonomy, and promote compassionate, goal-concordant care during the most challenging moments of aging. Full article

(This article belongs to the Special Issue Clinical Management of Frailty)

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14 pages, 280 KB

Open AccessArticle

Association Between Nociplastic Pain Criteria and Clinical and Physiological Features in Temporomandibular Disorders: A Cross-Sectional Study

by Flora Dantony, Daniel Romero-Rodríguez, David Blanco, Carlos Antonio Zárate-Tejero, Carolina Climent-Sanz, Cristina Pérez-Mánen, Natalia Felipe-Spada and Andoni Carrasco-Uribarren

J. Clin. Med. 2025, 14(24), 8967; https://doi.org/10.3390/jcm14248967 - 18 Dec 2025

Viewed by 396

Abstract

Background/Objective: Emerging evidence indicates that temporomandibular disorders (TMD) patients may present features of nociplastic pain (NP), characterized by central sensitization (CS)-related symptoms. This study aims to identify factors associated with CS-related symptoms and pain sensitivity in patients with TMD and NP-related features. Methods: [...] Read more.

Background/Objective: Emerging evidence indicates that temporomandibular disorders (TMD) patients may present features of nociplastic pain (NP), characterized by central sensitization (CS)-related symptoms. This study aims to identify factors associated with CS-related symptoms and pain sensitivity in patients with TMD and NP-related features. Methods: In this cross-sectional study, 43 TMD patients were assessed for CS-related symptoms (CSI), proximal, distal, global pressure pain threshold (PPTs, algometer), orofacial pain intensity (VAS), jaw impairment (FAI), maximal isometric strength of four muscle groups (dynamometer), resting heart rate (RHR, chest band), kinesiophobia (TKS-11), physical activity level (IPAQ), anxiety (HADS), and sleep quality (PSQI). Associations were analyzed using linear regression models adjusted for gender, age, and symptoms duration. Results: Multivariate analysis showed that higher CSI was significantly associated with greater jaw impairment (Estimate 0.09, 95% CI 0.01 to 0.18) and higher pain intensity (Estimate 0.26, 95% CI 0.14 to 0.38). Lower PPT was significantly associated with lower grip strength (Proximal: Estimate 0.03, 95% CI 0.01 to 0.05; Distal: Estimate 0.07, 95% CI 0.01 to 0.14; Global: Estimate 2.44, 95% CI 0.57 to 4.31), and proximal PPT with higher RHR (Estimate −0.02, 95% CI −0.03 to 0). Conclusions: Association was found between CS-related symptoms and pain intensity and jaw impairment, while lower PPTs were related to decreased maximal isometric grip strength and elevated RHR, thus highlighting the need for multimodal treatment in TMD patients. Full article

(This article belongs to the Section Clinical Rehabilitation)

12 pages, 1899 KB

Open AccessCase Report

A Novel Surgical Treatment Approach for Vertical Root Fractures of Endodontically Treated Molars: A Report of 3 Cases

by Nuo Chen, Chang Lu, Xinling He, Yuexing Zheng, Ying Yang and Wei Fan

J. Clin. Med. 2025, 14(24), 8966; https://doi.org/10.3390/jcm14248966 - 18 Dec 2025

Viewed by 478

Abstract

Background: Vertical root fracture (VRF) is a severe complication of endodontically treated teeth with a poor prognosis. Despite many tentative tooth-preserving approaches, the current main treatment remains tooth extraction or root resection, which is largely due to the difficulty in balancing the mechanical [...] Read more.

Background: Vertical root fracture (VRF) is a severe complication of endodontically treated teeth with a poor prognosis. Despite many tentative tooth-preserving approaches, the current main treatment remains tooth extraction or root resection, which is largely due to the difficulty in balancing the mechanical strength for fracture fixation and biological properties for periodontal healing. Moreover, all documented reports regarding VRF repairing so far were limited to anterior teeth and premolars. Thus, the objective of this case report was to present a novel surgical treatment approach for repairing VRF of molars. Methods: Three patients (2 females, 1 male; aged 30–33 years) with endodontically treated molars (Tooth #46, #16, #37) diagnosed with VRF were treated with a dual-layered repair approach with modified fracture lines and retention forms through intentional replantation. Results: After 18, 21, and 36 months of follow-up, respectively, all three cases showed no clinical symptoms, normal tooth mobility and periodontal probing, as well as reduced periradicular radiolucency on radiographs. Root resorption or ankylosis was not observed. Conclusions: The novel surgical treatment approach demonstrates effectiveness in preserving endodontically treated molars with VRF, but its long-term treatment results for various VRF of molars need further randomized and controlled clinical investigations. Full article

(This article belongs to the Section Dentistry, Oral Surgery and Oral Medicine)

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13 pages, 882 KB

Open AccessArticle

Utility of TyG-Based Indices for Predicting Insulin Resistance in Turkish Adults: Insights from the TEKHAP Study

by Ayşe Kevser Demir, Şafak Şahin, Rıza Çıtıl, Osman Demir and Zeliha Cansel Özmen

J. Clin. Med. 2025, 14(24), 8965; https://doi.org/10.3390/jcm14248965 - 18 Dec 2025

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Abstract

Background/Objectives: Insulin resistance (IR) is a key feature of metabolic disorders and a major precursor of type 2 diabetes and cardiovascular disease. The triglyceride–glucose (TyG) index and TyG-based indices—including TyG–body mass index (TyG–BMI), TyG–waist circumference (TyG–WC), and TyG–waist-to-height ratio (TyG–WHtR), have been proposed [...] Read more.

Background/Objectives: Insulin resistance (IR) is a key feature of metabolic disorders and a major precursor of type 2 diabetes and cardiovascular disease. The triglyceride–glucose (TyG) index and TyG-based indices—including TyG–body mass index (TyG–BMI), TyG–waist circumference (TyG–WC), and TyG–waist-to-height ratio (TyG–WHtR), have been proposed as simple, cost-effective surrogate markers of IR. However, population-based data from Türkiye are limited. To evaluate the association between TyG-based indices, triglycerides/high-density lipoprotein cholesterol (TG/HDL-C) ratio, and IR defined by Homeostasis Model Assessment–IR (HOMA-IR) in adults from the TEKHAP study—a province-wide, population-based survey in Tokat, Türkiye. Methods: A total of 1854 adults (≥20 years) were included in the analysis. Physiologically implausible HOMA-IR outliers were identified using statistical criteria and excluded. IR was defined as HOMA-IR ≥ 2.46, previously validated in this population. TyG and its derivatives were calculated from fasting triglyceride, glucose, and anthropometric measurements. Group comparisons between IR and non-IR individuals, correlation analyses, receiver operating characteristic (ROC) curves, and multivariate logistic regression models were conducted to evaluate the diagnostic and independent associations of these surrogate markers with IR. Results: IR prevalence was 27.2%. Participants with IR had significantly higher triglycerides, fasting glucose, insulin, C-peptide, BMI, and waist circumference and lower HDL-C levels (all p < 0.001). All TyG-based indices were higher in the IR group and showed weak-to-moderate positive correlations with HOMA-IR. TyG–BMI showed the highest diagnostic accuracy in ROC curve analyses (AUC = 0.765); however, this association could not be interpreted as an independent predictive effect in adjusted models because of collinearity with BMI. In multivariable logistic regression, the TyG index demonstrated the strongest independent association with IR (OR = 4.14; 95% CI: 3.32–5.18; p < 0.001), while TyG–WC and the TG/HDL-C ratio also retained significant independent predictive value. Conclusions: The TyG index showed the strongest independent association with IR, while the TG/HDL-C ratio and TyG–WC also demonstrated significant independent predictive value. TyG-based indices may represent practical, low-cost surrogate markers for early metabolic risk stratification in community settings; however, their role in formal screening strategies requires external validation and calibration in independent populations. Full article

(This article belongs to the Section Endocrinology & Metabolism)

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16 pages, 538 KB

Open AccessArticle

Digital Transformation in Critical Care: Implications for Quality of Care, Infection Control, and Clinical Outcomes

by Daiana Toma, Laura Andreea Ghenciu, Ovidiu Horea Bedreag, Adelina Băloi, Carmen Alina Gizea, Stelian Adrian Rițiu, Emil Robert Stoicescu, Claudiu Rafael Bârsac, Marius Păpurică, Alexandru Rogobete and Dorel Săndesc

J. Clin. Med. 2025, 14(24), 8964; https://doi.org/10.3390/jcm14248964 - 18 Dec 2025

Viewed by 381

Abstract

Background/Objectives: Digitalization of intensive care units (ICUs) aims to enhance patient safety and efficiency through standardized documentation, real-time data integration, and clinical decision support. This study evaluated whether the implementation of a patient data management system (PDMS) was associated with improvements in quality [...] Read more.

Background/Objectives: Digitalization of intensive care units (ICUs) aims to enhance patient safety and efficiency through standardized documentation, real-time data integration, and clinical decision support. This study evaluated whether the implementation of a patient data management system (PDMS) was associated with improvements in quality of care, infection prevention, and patient outcomes in a trauma ICU. Methods: We conducted a single-center, retrospective, before–after cohort study comparing a pre-digitalization period (2021–2022) with a post-digitalization period (2025). Consecutive adult trauma ICU admissions were analyzed. The exposure was unit-wide adoption of a PDMS implemented in 2024. The primary outcome was ICU length of stay (LOS); secondary outcomes included ICU mortality, nosocomial infection rates (episodes per 1000 ICU-days), ventilation- and antibiotic-days, device utilization, and infection epidemiology. Prespecified sensitivity analyses were performed. Results: A total of 108 patients were included (43 pre- and 65 post-digitalization). Baseline characteristics were comparable between groups. Median ICU LOS decreased from 13.0 to 6.0 days (p = 0.02). Mortality declined from 18.6% to 6.2% (p = 0.06), and crude infection rates decreased from 42.2 to 30.8 per 1000 ICU-days (rate ratio 0.73; p = 0.28). Adjusted analyses showed no statistically significant differences for mortality (aOR 0.40; p = 0.45), infection rates (aIRR 0.88; p = 0.68), LOS (aRR 1.04; p = 0.87), ventilation-days (aRR 0.86; p = 0.65), or antibiotic-days (aRR 0.70; p = 0.30). Per-patient rates of ventilator-associated pneumonia and bloodstream infection were significantly lower after digitalization (both p = 0.04), and Acinetobacter spp. infections decreased markedly (7 to 0 cases; p = 0.001). Findings were consistent after exclusion of ICU stays < 24 h. Conclusions: ICU digitalization was associated with shorter unadjusted ICU stays and favorable trends in infection and mortality outcomes, though adjusted analyses were neutral. Larger multicenter studies incorporating device-day denominators and time-to-event analyses are needed to confirm the causal impact of digital transformation on ICU quality of care. Full article

(This article belongs to the Special Issue Clinical Management and Long-Term Prognosis in Intensive Care)

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27 pages, 3309 KB

Open AccessFeature PaperReview

The Vagal Link: Autonomic Nervous System Dysfunction in Cardiac Amyloidosis

by Federico Barocelli, Eleonora Canu, Nicolò Pasini, Isabella Allegri, Alessandro D’Orsi, Alberto Bettella, Antonio Crocamo, Filippo Luca Gurgoglione, Laura Torlai Triglia, Francesca Russo, Angela Guidorossi, Maria Francesca Notarangelo, Nicola Gaibazzi, Livia Ruffini and Giampaolo Niccoli

J. Clin. Med. 2025, 14(24), 8963; https://doi.org/10.3390/jcm14248963 - 18 Dec 2025

Viewed by 832

Abstract

Cardiac amyloidosis (CA) is an increasingly recognized cause of restrictive cardiomyopathy in which extracellular amyloid deposition leads to progressive structural and functional impairment. Beyond myocardial infiltration, growing evidence highlights the central role of autonomic nervous system dysfunction (ANS) —particularly the vagal nerve involvement—as [...] Read more.

Cardiac amyloidosis (CA) is an increasingly recognized cause of restrictive cardiomyopathy in which extracellular amyloid deposition leads to progressive structural and functional impairment. Beyond myocardial infiltration, growing evidence highlights the central role of autonomic nervous system dysfunction (ANS) —particularly the vagal nerve involvement—as a contributor to orthostatic intolerance, syncope, exercise limitation, arrhythmias, and reduced quality of life. Emerging data suggest that autonomic impairment may precede overt cardiac manifestations, offering a potential window for earlier recognition. This narrative review summarizes current knowledge on the mechanisms and clinical relevance of autonomic dysfunction in CA, emphasizing the novelty of the “vagal link” as a unifying framework connecting with a specific focus on the vagus nerve (VN) and its complex interplay with cardiac structure and function. We further discuss diagnostic approaches and the potential role of autonomic assessment in early detection, risk stratification, and personalized treatment strategies. A clearer understanding of vagal dysfunction may provide new insights into disease progression and identify opportunities for therapeutic innovation. Full article

(This article belongs to the Special Issue Symptoms and Treatment of Cardiac Amyloidosis)

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Graphical abstract

10 pages, 285 KB

Open AccessArticle

Partner Ethnicity and Assisted Reproductive Technology Outcomes: A Retrospective Cohort Study

by Shu Qin Wei, Michael H. Dahan, Yu Lu, Mingju Cao, Justin Tan and Seang Lin Tan

J. Clin. Med. 2025, 14(24), 8962; https://doi.org/10.3390/jcm14248962 - 18 Dec 2025

Viewed by 350

Abstract

Background: Despite significant advances in assisted reproductive technology (ART), disparities in clinical outcomes persist. While patient-related factors are well-studied, the role of partner ethnicity remains understudied. We hypothesized that partner ethnicity affects ART outcomes. This study examined the association between partner ethnicity and [...] Read more.

Background: Despite significant advances in assisted reproductive technology (ART), disparities in clinical outcomes persist. While patient-related factors are well-studied, the role of partner ethnicity remains understudied. We hypothesized that partner ethnicity affects ART outcomes. This study examined the association between partner ethnicity and ART outcomes. Methods: We conducted a retrospective cohort study among patients and their partners undergoing IVF treatment in the United Kingdom between 2017 and 2018. The exposure was partner ethnicity. Outcomes included biochemical pregnancy, clinical pregnancy, pregnancy loss, and live birth. We calculated risk ratios (RR) and 95% confidence intervals (CI) using multivariable regression models to estimate the association between partner ethnicity and IVF outcomes, adjusting for female patient age, partner age, patient ethnicity, gravidity, infertility diagnosis, treatment type, preimplantation genetic testing for aneuploidy, and number of prior in vitro fertilization (IVF) cycles. Results: Among 158,813 IVF cycles, live birth rates per cycle were 26.3% for couples with White partners and 23.1% for those with non-White partners. Non-White partners were associated with a 5% lower clinical pregnancy rate (RR 0.95, 95% CI 0.92–0.97) and a 6% lower live birth rate (RR 0.94, 95% CI 0.92–0.97). Specifically, Black (RR 0.82, 95% CI 0.77–0.87) and Asian (RR 0.67, 95% CI 0.59–0.76) partners had significantly reduced live birth rates, though these associations were attenuated after adjusting for patient ethnicity. Couples in which both the partner and patient were Black or Asian had 24–42% lower live birth rates compared with White couples (Black: RR 0.76, 95% CI 0.70–0.82; Asian: RR 0.58, 95% CI 0.49–0.68). Conclusions: Partner ethnicity is independently associated with IVF outcomes, with non-White partners showing lower rates of these outcomes. These findings suggest the clinical relevance of partner ethnicity in reproductive outcomes. Further research is warranted to elucidate the mechanisms underlying these associations. Full article

(This article belongs to the Section Reproductive Medicine & Andrology)

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18 pages, 1998 KB

Open AccessReview

Full-Endoscopic Lumbar Discectomy: A Review of the Surgical Techniques, Indications and Anatomical Considerations

by Stylianos Kapetanakis, Mikail Chatzivasiliadis, Nikolaos Gkantsinikoudis and Konstantinos Pazarlis

J. Clin. Med. 2025, 14(24), 8961; https://doi.org/10.3390/jcm14248961 - 18 Dec 2025

Viewed by 593

Abstract

Full-endoscopic lumbar discectomy (FELD) has emerged over time as a minimally invasive alternative to conventional microdiscectomy. This narrative review summarizes the available evidence regarding the evolution, indications, techniques, and outcomes of FELD, with a particular focus on how different types of lumbar disc [...] Read more.

Full-endoscopic lumbar discectomy (FELD) has emerged over time as a minimally invasive alternative to conventional microdiscectomy. This narrative review summarizes the available evidence regarding the evolution, indications, techniques, and outcomes of FELD, with a particular focus on how different types of lumbar disc herniations influence the choice of surgical approach. The literature indicates that the transforaminal approach is most suitable for foraminal and upper lumbar disc herniations, whereas the interlaminar approach is preferred for central or migrated L5–S1 herniations due to the larger interlaminar window at this level. Unilateral biportal endoscopy (UBE) provides better flexibility, visualization, and instrument maneuverability, making it particularly useful in certain cases. Reported complication rates remain low overall but vary according to surgical technique and surgeon experience. The learning curve for FELD typically ranges from approximately 20 to over 50 cases, depending on the approach and individual proficiency. Overall, full-endoscopic techniques are redefining the management of lumbar disc herniations by offering less invasive alternatives with favourable clinical outcomes, and their role is expected to expand further as both technology and surgical expertise continue to evolve. Full article

(This article belongs to the Special Issue Minimally Invasive and Endoscopic Neurosurgery)

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13 pages, 733 KB

Open AccessArticle

Intraoperative Nociception Monitoring Using the NoL Index: Phase-Specific Assessment of Nociceptive Responses During Spinal Surgery

by Amran Khalaila, Mahmod Hasan, Yaron Berkovich, Ali Sleiman, Eitan Mangoubi, Michael Grach, Umar Ibrahim, Adva Gutman Tirosh, Daniel Shpigelman and Arsen Shpigelman

J. Clin. Med. 2025, 14(24), 8960; https://doi.org/10.3390/jcm14248960 - 18 Dec 2025

Viewed by 284

Abstract

Background: Quantifying intraoperative nociceptive responses under general anesthesia remains challenging, particularly during complex procedures such as spinal surgery. The Nociception Level (NoL) index is a multiparametric tool designed to reflect the dynamic balance between nociception and analgesia in anesthetized patients. This study [...] Read more.

Background: Quantifying intraoperative nociceptive responses under general anesthesia remains challenging, particularly during complex procedures such as spinal surgery. The Nociception Level (NoL) index is a multiparametric tool designed to reflect the dynamic balance between nociception and analgesia in anesthetized patients. This study aimed to evaluate NoL fluctuations during predefined phases of spinal surgery and assess their relationship to anesthetic administration. Methods: This prospective observational study enrolled 44 adult patients undergoing lumbar discectomy, laminectomy, or spinal fusion under remifentanil–propofol anesthesia. Continuous NoL monitoring was performed using the PMD100™ system. Sixteen anatomically and procedurally defined surgical phases were analyzed. The primary outcome was the mean NoL value in each phase. The secondary outcome was the association between NoL values and intraoperative infusion rates of remifentanil and propofol. Repeated-measures ANOVA with Bonferroni correction was used for phase comparisons. Results: Mean NoL values remained within the target range (10–25) in most phases. However, significant elevations were observed during pedicle screw insertion (mean 27.9, SD ± 17.7), cage insertion (27.6, SD ± 10.5), and flavectomy (28.0, SD ± 27.0), indicating increased nociceptive burden. The lowest NoL values occurred during skin closure (16.6, SD ± 11.2) and discectomy (18.0, SD ± 2.8). Propofol and remifentanil infusion rates remained within standard clinical ranges but were slightly elevated during high-NoL phases. Conclusions: Despite standardized anesthesia, distinct nociceptive peaks were observed during specific stages of spinal surgery. These findings suggest that NoL monitoring may help identify high-nociception phases and guide tailored analgesic strategies. Future randomized trials are warranted to assess whether protocolized NoL-guided anesthesia improves intraoperative management and postoperative outcomes. Full article

(This article belongs to the Section Orthopedics)

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16 pages, 3051 KB

Open AccessArticle

Automated Classification of Enamel Caries from Intraoral Images Using Deep Learning Models: A Diagnostic Study

by Faris Yahya I. Asiri

J. Clin. Med. 2025, 14(24), 8959; https://doi.org/10.3390/jcm14248959 - 18 Dec 2025

Viewed by 759

Abstract

Background: Dental caries is a prevalent global oral health issue. The early detection of enamel caries, the initial stage of decay, is critical to preventive dentistry but is often limited by the subjectivity and variability of conventional diagnostic methods. Objective: This study aims [...] Read more.

Background: Dental caries is a prevalent global oral health issue. The early detection of enamel caries, the initial stage of decay, is critical to preventive dentistry but is often limited by the subjectivity and variability of conventional diagnostic methods. Objective: This study aims to develop and evaluate two explainable deep learning models for the automated classification of enamel caries from intraoral images. Dataset and Methodology: A publicly available dataset of 2000 intraoral images showing early-stage enamel caries, advanced enamel caries, no-caries was used. The dataset was split into training, validation, and test sets in a 70:15:15 ratio, and data preprocessing and augmentation were applied to the training set to balance the dataset and prevent model overfitting. Two models were developed, ExplainableDentalNet, a custom lightweight CNN, and Interpretable ResNet50-SE, a fine-tuned ResNet50 model with Squeeze-and-Excitation blocks, and both were integrated with Gradient-Weighted Class Activation Mapping (Grad-CAM) for visual interpretability. Results: As evaluated on the test set, ExplainableDentalNet achieved an overall accuracy of 96.66% and a Matthews Correlation Coefficient [MCC] = 0.95, while Interpretable ResNet50-SE achieved 98.30% accuracy (MCC = 0.975). McNemar’s test indicated no significant prediction bias, with p > 0.05, and internal bootstrap and cross-validation analyses indicated stable performance. Conclusions: The proposed explainable models demonstrated high diagnostic accuracy in enamel caries classification on the studied dataset. While the present findings are promising, future clinical applications will require external validation on multi-center datasets. Full article

(This article belongs to the Special Issue Artificial Intelligence (AI) in Dental Clinical Practice)

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16 pages, 1688 KB

Open AccessArticle

Outcome of Allogeneic Penetrating Limbo-Keratoplasty: A Single-Center Retrospective Cohort Study

by Marie Ella Horstmann, Alexander K. Schuster, Norbert Pfeiffer and Joanna Wasielica-Poslednik

J. Clin. Med. 2025, 14(24), 8958; https://doi.org/10.3390/jcm14248958 - 18 Dec 2025

Viewed by 255

Abstract

Introduction: Allogeneic penetrating limbo-keratoplasty (limbo-PK) is one of the surgical methods for the treatment of limbal stem cell deficiency (LSCD). We report real-life results on different entities. Methods: Patients treated with limbo-PK at the Department of Ophthalmology of the University Medical Center [...] Read more.

Introduction: Allogeneic penetrating limbo-keratoplasty (limbo-PK) is one of the surgical methods for the treatment of limbal stem cell deficiency (LSCD). We report real-life results on different entities. Methods: Patients treated with limbo-PK at the Department of Ophthalmology of the University Medical Center Mainz were evaluated retrospectively. The primary endpoint was the epithelialization of the graft one year postoperatively. In addition, the postoperative best corrected visual acuity (BCVA), ocular concomitant diseases, drug treatment, and the need for further eye surgery postoperatively were examined. Results: We included 14 eyes of 13 patients (4 female) aged 59.8 ± 14.1 years who underwent limbo-PK between 2020 and 2024. Indications for limbo-PK included chemical burns (n = 4), blast injuries (n = 4), thermal burns (n = 2), trauma (n = 1) graft-versus-host disease (n = 1), and ectrodactyly-ectodermal dysplasia (EEC) (n = 1). The mean preoperative BCVA was 2.2 ± 0.6 logMAR (range: light perception to 0.7 logMAR). Four limbo-PK-grafts were HLA-typed. All limbo-PKs were combined with amniotic membrane transplantation; three with cataract surgery and one with tarsorrhaphy. Postoperatively, all patients received local immunosuppression, and 12 (85.7%) received additional systemic immunosuppression. At one-year follow-up mean BCVA increased to 1.0 ± 0.7 logMAR (range: 2.3 to 0.1, p-value = 0.03) and 11 of 14 eyes showed a functional graft with closed epithelium. In the further postoperative course, four patients needed a further Limbo-PK due to graft failure (n = 2), immune graft rejection after stopping local immunosuppressive therapy (n = 1) and perforation of the graft in a severe case of GvHd (n = 1). Conclusions: Limbo-PK is an effective surgical method for the treatment of LSCD. In our study cohort, we observed a significant improvement in mean BCVA one year postoperatively, with a functional, epithelialized graft achieved in 11 of 14 eyes. Full article

(This article belongs to the Section Ophthalmology)

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19 pages, 2316 KB

Open AccessReview

Growth Without GH: A Case Series and Literature Review

by Stefana Catalina Bilha, Cristina Preda, Letitia Leustean, Nada Akad, Anca Matei and Maria-Christina Ungureanu

J. Clin. Med. 2025, 14(24), 8957; https://doi.org/10.3390/jcm14248957 - 18 Dec 2025

Viewed by 509

Abstract

Linear growth is traditionally attributed to the growth hormone (GH)/insulin-like growth factor-1 (IGF-1) axis, yet “growth without GH” is documented. We report five patients with severe GH deficiency—one congenital and four acquired, who reached normal or tall stature despite persistently low IGF-1. All [...] Read more.

Linear growth is traditionally attributed to the growth hormone (GH)/insulin-like growth factor-1 (IGF-1) axis, yet “growth without GH” is documented. We report five patients with severe GH deficiency—one congenital and four acquired, who reached normal or tall stature despite persistently low IGF-1. All patients had obesity and metabolic complications (insulin resistance, dyslipidemia, and/or fatty liver). Catch-up or sustained growth occurred before or independent of sex-steroid replacement in most cases. One patient with lifelong hypogonadism showed slow, prolonged growth with delayed epiphyseal fusion. Three patients also received recombinant human GH (rhGH), without a significant impact on overall growth velocity, but with favorable metabolic outcomes. Findings support multifactorial drivers of linear growth beyond the GH/IGF-1 pathway. Likely contributors include insulin signaling associated with adiposity, permissive thyroid hormone action, local growth-plate paracrine pathways, and, in hypogonadism, delayed epiphyseal closure. Genetic modifiers that enhance chondrogenesis or delay growth-plate fusion may contribute. We also reviewed the published literature on “growth without GH,” integrating single-case reports and series to contextualize these mechanisms and outcomes. In conclusion, profound GH deficiency does not preclude near-normal or accelerated growth. In “growth without GH,” therapeutic priorities should pivot from stature to cardiometabolic risk reduction. rhGH may be considered to improve metabolism when individualized and closely monitored, recognizing that height velocity is often adequate. Notably, rhGH consistently improved lipid profiles and steatohepatitis in two patients, suggesting a primarily metabolic benefit. Lifelong follow-up from childhood into adulthood is essential. Full article

(This article belongs to the Special Issue New Advances and Clinical Outcomes of Endocrinology)

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12 pages, 911 KB

Open AccessArticle

Predictors of Cage Subsidence After Oblique Lumbar Interbody Fusion

by Bongmo Koo, Jiwon Park and Jae-Young Hong

J. Clin. Med. 2025, 14(24), 8956; https://doi.org/10.3390/jcm14248956 - 18 Dec 2025

Viewed by 352

Abstract

Background/Objective: Oblique lumbar interbody fusion (OLIF) achieves indirect decompression through restoration of disc height. Because maintenance of the restored disc space is essential for sustained neural decompression, solid fusion without cage subsidence is a key determinant of successful surgical outcomes. This study [...] Read more.

Background/Objective: Oblique lumbar interbody fusion (OLIF) achieves indirect decompression through restoration of disc height. Because maintenance of the restored disc space is essential for sustained neural decompression, solid fusion without cage subsidence is a key determinant of successful surgical outcomes. This study aimed to evaluate preoperative and intraoperative predictors of cage subsidence and radiographic fusion after OLIF. Methods: Seventy patients (119 levels) who underwent OLIF using a polyether–ether–ketone cage and posterior screw fixation between 2015 and 2023 were retrospectively reviewed. Preoperative bone quality was assessed using the computed tomography-based Hounsfield unit (HU) and magnetic resonance imaging-based vertebral bone quality (VBQ) score on T1-weighted images. Radiographic parameters of anterior and posterior disc height (ADH, PDH), segmental and lumbar lordotic angle (SLA, LLA), foraminal height (FH), and cage position were measured preoperatively at one-year follow-up. Results: Cage subsidence occurred in 21.0% of spinal levels (25/119 levels). Multivariate analysis identified these measures as independent predictors: HU (OR 1.017; p = 0.012), VBQ score (OR 2.716; p = 0.016), and PDH distraction (OR 1.418; p = 0.019). ROC analysis identified cutoff values of HU < 145.86 (AUC = 0.654), VBQ score > 3.30 (AUC = 0.723), and PDH distraction > 4.79 mm (AUC = 0.672). None of the evaluated factors were significantly associated with one-year radiographic fusion. Conclusions: Lower HU, higher VBQ score, and excessive PDH distraction are independent risk factors for cage subsidence after OLIF, although these factors do not appear to affect short-term fusion outcomes. Full article

(This article belongs to the Special Issue Advancements in Lumbar Spine Surgery: Modern Strategies and Techniques)

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13 pages, 2741 KB

Open AccessArticle

Treatment and Outcomes of Chronic Locked Posterior Shoulder Dislocations: A Retrospective Case Series

by Marco Filipponi, Alberto Casto, Giuseppe Rollo, Filippo Tonelli, Andrea Pautasso, Fabio D’Angelo, Pietro Maniscalco, Corrado Ciatti and Paolo Pichierri

J. Clin. Med. 2025, 14(24), 8955; https://doi.org/10.3390/jcm14248955 - 18 Dec 2025

Viewed by 310

Abstract

Background/Objectives: Chronic locked posterior shoulder dislocations (PSDs) are rare and often misdiagnosed, leading to delayed treatment and complex management. This study retrospectively evaluates surgical outcomes in patients treated for chronic PSDs and reports our clinical experience. Methods: Ten male patients with [...] Read more.

Background/Objectives: Chronic locked posterior shoulder dislocations (PSDs) are rare and often misdiagnosed, leading to delayed treatment and complex management. This study retrospectively evaluates surgical outcomes in patients treated for chronic PSDs and reports our clinical experience. Methods: Ten male patients with chronic PSDs treated between 2016 and 2022 at “Vito Fazzi Hospital” (Lecce) were analyzed. Lesions were classified according to the Randelli system (Type 1: 20–50% bone loss; Type 2: >50%; Type 3: fracture dislocation without bone loss; Type 4: multifragmentary fracture dislocation). Surgical options—subscapularis transposition, bone grafting, osteosynthesis, and reverse shoulder arthroplasty—were selected based on lesion type, age, and functional demand. Follow-ups at 1, 3, 6, and 12 months assessed ROM, SF-36, and SDQ scores. Results: Six patients had Type 1 lesions, two Type 2, and two Type 4. The mean diagnostic delay was 6 weeks (up to 5 months). Early follow-ups showed superior ROM and SDQ in patients with reverse prostheses, while at 12 months, cancellous grafts achieved better functional recovery. Subscapularis transpositions resulted in minor internal rotation loss and increased pain. One Type 4 case developed avascular necrosis. Mean healing time was 2.9 ± 0.5 months. Although SDQ differences at 12 months were not significant, internal rotation was reduced by 10% in patients treated with the McLaughlin technique (p < 0.05). Conclusions: Prompt diagnosis and tailored surgical management are key to favorable outcomes in chronic PSDs. While various techniques provide good results, subscapularis transposition should be limited to unstable cases, and osteosynthesis should be used only when strictly indicated due to necrosis risk. Full article

(This article belongs to the Section Orthopedics)

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9 pages, 1579 KB

Open AccessArticle

Prevalence and Underreporting of Crowned Dens Syndrome-Associated Calcifications on Cervical Spine CT in Patients with Neck Pain

by Shira Dor, Iris Eshed and Merav Lidar

J. Clin. Med. 2025, 14(24), 8954; https://doi.org/10.3390/jcm14248954 - 18 Dec 2025

Viewed by 281

Abstract

Background: Crowned dens syndrome (CDS) is characterized by acute neck pain and restricted motion due to calcium pyrophosphate (CPP) crystal deposition around the atlantoaxial joint. Although recognized as sufficient for the diagnosis of CPP deposition disease (CPPD), its prevalence remains uncertain. Given the [...] Read more.

Background: Crowned dens syndrome (CDS) is characterized by acute neck pain and restricted motion due to calcium pyrophosphate (CPP) crystal deposition around the atlantoaxial joint. Although recognized as sufficient for the diagnosis of CPP deposition disease (CPPD), its prevalence remains uncertain. Given the high prevalence of CPPD in the general population, CDS may be more common than currently appreciated among patients with neck pain undergoing cervical spine imaging. Methods: This retrospective study included patients aged ≥40 years who underwent cervical spine CT for evaluation of neck pain between 2022 and 2024. Of 500 consecutive scans, 195 were eligible after excluding trauma-related, post-operative, and metastatic cases. Results: Periodontoid calcifications were identified in 29.2% of patients (mean age 61.5 ± 11.7 years; 37.4% male). Prevalence increased significantly with age (p < 0.001), reaching nearly 50% in those over 70 years. Linear calcifications were rare before 60 years (1.2%) but present in 24.5% of patients over 70. Calcifications were mentioned in only 3.5% of radiology reports. Conclusions: Periodontoid calcifications are relatively common in patients with neck pain, affecting nearly one-third of individuals over 40 and almost half of those over 70. Their frequent underreporting highlights a critical gap in recognition. Greater awareness and systematic reporting are warranted, as CDS may represent a common, underdiagnosed, and treatable cause of neck pain. Full article

(This article belongs to the Section Nuclear Medicine & Radiology)

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13 pages, 801 KB

Open AccessArticle

Comparative Analysis of Graft Survival in Older and Younger Kidney Transplant Recipients: A Single-Center Cohort Study

by Adolfo González Serrano, Ricardo José Guldris García, Gonzalo Gómez Marqués, Mercedes Ruiz Hernández and Enrique Carmelo Pieras Ayala

J. Clin. Med. 2025, 14(24), 8953; https://doi.org/10.3390/jcm14248953 - 18 Dec 2025

Viewed by 292

Abstract

Background/Objectives: We hypothesized that older recipients have a higher rate of kidney graft failure compared to younger recipients. Thus, we assessed 60-month kidney graft failure (KGF) among deceased donor recipients aged 65 years or older and compared it with that of younger recipients. [...] Read more.

Background/Objectives: We hypothesized that older recipients have a higher rate of kidney graft failure compared to younger recipients. Thus, we assessed 60-month kidney graft failure (KGF) among deceased donor recipients aged 65 years or older and compared it with that of younger recipients. Methods: A single-center, retrospective cohort study was conducted at Son Espases University Hospital in Palma, Spain, including all consecutive deceased donor kidney transplant recipients from 2011 to 2021. The primary outcome was 60-month KGF, analyzed using the cumulative incidence function (CIF). A multivariable semi-parametric Fine and Gray model was used to estimate the subhazard of KGF in older versus younger recipients, adjusting for variables associated with recipients aged 65 years or older, including KGF and overall survival. Results: The study included 618 recipients, with a median age (interquartile range) of 58 years (47–66 years); of these, 187 (30%) were aged 65 years or older, and 498 (81%) received grafts from donors after brain death. The 60-month CIF (95% confidence interval) of KGF for the entire cohort was 12% (9.1–15). Candidate variables for multivariable analysis included recipient sex, body mass index, donor age, presence of hypertension or diabetes, donor sex, length of hospital stay, cold ischemia time, donor type, multiple renal veins, and Clavien-Dindo grade ≥ 3 complications. After adjustment, KGF risk did not significantly differ between age groups (sHR: 0.75; 95% CI: 0.41–1.38; p = 0.36). Conclusions: Despite having worse baseline characteristics, receiving lower-quality grafts, and experiencing a higher incidence of postoperative complications, we observed comparable 60-month kidney graft survival in older recipients relative to younger ones. These findings support the viability of kidney transplantation in well-selected older patients. Full article

(This article belongs to the Section Nephrology & Urology)

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13 pages, 696 KB

Open AccessArticle

The Development of an Automated Fluid Infusion Management System to Prevent Hypotension During General Anesthesia: A Randomized Clinical Trial

by Yuka Matsuki, Yukie Mizuta, Shuko Matsuda, Koyo Nishio, Midoriko Higashi, Ken Yamaura and Kenji Shigemi

J. Clin. Med. 2025, 14(24), 8952; https://doi.org/10.3390/jcm14248952 - 18 Dec 2025

Viewed by 276

Abstract

Background/Objectives: This study aimed to develop and evaluate an automated fluid infusion management system for preventing hypotension during general anesthesia. Methods: This study was a single-blind, randomized, non-inferiority, clinical trial. Seventy-nine patients undergoing surgery under general anesthesia were randomly assigned to either an [...] Read more.

Background/Objectives: This study aimed to develop and evaluate an automated fluid infusion management system for preventing hypotension during general anesthesia. Methods: This study was a single-blind, randomized, non-inferiority, clinical trial. Seventy-nine patients undergoing surgery under general anesthesia were randomly assigned to either an automatic group or a manual group. In the automatic group, the infusion rate was automatically adjusted based on stroke volume (SV) and effective arterial elastance (Ea), whereas in the manual group, the attending anesthesiologist manually adjusted the infusion rate according to the Enhanced Recovery After Surgery (ERAS) protocol. The primary endpoint was the proportion of time during anesthesia that mean arterial pressure (Pm) was maintained at ≥65 mmHg. Secondary endpoints included the proportion of time the estimated stroke volume index (esSVI) was below the threshold, total fluid volume administered, total phenylephrine dose, urine output, blood loss, and average estimated stroke volume variation (esSVV). Results: The results demonstrated non-inferiority of the automatic group to the manual group in maintaining Pm ≥ 65 mmHg (automatic group: 82.0 ± 12.7%, manual group: 79.9 ± 15.7%; difference [automatic group−manual group]: 2.0 percentage points; one-sided 97.5% CI lower limit: −4.7%; non-inferiority margin: −5%). There were no significant differences between the groups in total fluid volume, phenylephrine dose, urine output, or blood loss. No severe adverse events or device-related adverse events were observed. Conclusions: The automated system maintained intraoperative blood pressure safely and effectively. Full article

(This article belongs to the Special Issue Cardiac Anesthesia: Current Research and Future Prospects)

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13 pages, 1211 KB

Open AccessArticle

Comparison of Two Different Norepinephrine Bolus Doses for Management of Spinal Anesthesia-Induced Maternal Hypotension in Cesarean Section: A Double-Blind Randomized Controlled Study

by Levent Özdemir, Gönül Sarı Pire, Aslınur Sagün, Mustafa Azizoğlu and Tuğsan Egemen Bilgin

J. Clin. Med. 2025, 14(24), 8951; https://doi.org/10.3390/jcm14248951 - 18 Dec 2025

Viewed by 446

Abstract

Background/Objectives: The bolus dose of norepinephrine (NE) for the treatment of spinal anesthesia-induced maternal hypotension remains unclear. The aim of this study was to compare the efficacy and safety of two different bolus doses of NE in the treatment of spinal anesthesia-induced [...] Read more.

Background/Objectives: The bolus dose of norepinephrine (NE) for the treatment of spinal anesthesia-induced maternal hypotension remains unclear. The aim of this study was to compare the efficacy and safety of two different bolus doses of NE in the treatment of spinal anesthesia-induced maternal hypotension during cesarean section (CS). Methods: This study has a prospective, randomized and double-blinded design. A total of 150 patients with ASA physical status I and II who underwent CS included the study at a tertiary-care university hospital. Patients were randomly assigned to either the 6 µg NE bolus (Group 6 µg, n = 75) or 8 µg NE bolus (Group 8 µg, n = 75) group. The primary outcome of this study was to determine the success rate of treatment using a 6 or 8 µg NE bolus in cases of maternal hypotension. Secondary outcomes included comparing fetal umbilical blood gas values and APGAR scores in neonates born to mothers who received a NE bolus before delivery, determining the incidence of NE-induced reactive bradycardia and hypertension, and comparing the groups for intraoperative nausea and vomiting. Results: The 8 µg group showed fewer hypotensive episodes (245 vs. 174 episodes, p = 0.012) and required fewer norepinephrine boluses. Additionally, the success rate of hypotension treatment was higher in the 8 µg group (61.2% vs. 78.5%, p < 0.001). There was no difference in APGAR scores between the groups of neonates born to women who received norepinephrine before delivery. However, in the group with 8 µg NE, slightly better results were obtained in blood gas samples, excluding the pH value. Nausea was more frequently observed in the 6 µg group (p = 0.046). Conclusions: We concluded that an 8 µg bolus administration of NE was more effective than a 6 µg bolus administration in treating maternal hypotension induced by spinal anesthesia, without any increase in the rate of side effects. Full article

(This article belongs to the Section Anesthesiology)

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16 pages, 1462 KB

Open AccessArticle

Analyses of Final Trends and Comorbidity of Eosinophilic Granulomatosis with Polyangiitis in Patients Hospitalized in Poland in 2014–2023

by Aleksandra Hus, Krzysztof Kanecki, Katarzyna Lewtak, Paweł Goryński and Małgorzata Wisłowska

J. Clin. Med. 2025, 14(24), 8950; https://doi.org/10.3390/jcm14248950 - 18 Dec 2025

Viewed by 231

Abstract

Background: Eosinophilic granulomatosis with polyangiitis (EGPA) is a rare vasculitis, and contemporary population data from Central and Eastern Europe are limited. Aim: To describe hospital-based incidence, patient characteristics and comorbidities among EGPA hospitalizations in Poland (2014–2023), including differences by age, sex [...] Read more.

Background: Eosinophilic granulomatosis with polyangiitis (EGPA) is a rare vasculitis, and contemporary population data from Central and Eastern Europe are limited. Aim: To describe hospital-based incidence, patient characteristics and comorbidities among EGPA hospitalizations in Poland (2014–2023), including differences by age, sex and place of residence. Methods: This retrospective, population-based study used nationwide hospital discharge records with an EGPA diagnosis. First EGPA-coded hospitalizations were used to estimate annual incidence per 1,000,000 inhabitants. Demographics, duration of stay and accompanying comorbidities (cardiovascular disease, pulmonary disease, and asthma) were analyzed for all EGPA hospitalizations. Place of residence was classified as urban or rural. Group differences and temporal trends were assessed using appropriate parametric and non-parametric tests and regression models, with a two-sided p value < 0.05 considered statistically significant. Results: Between 2014 and 2023, 911 patients had a first EGPA-coded hospitalisation in Poland, corresponding to a mean annual hospital-based incidence of 2.38 per 1,000,000 inhabitants (range 1.28–3.38); incidence declined significantly from 2014 to 2019 (p < 0.001) and was disrupted during the COVID-19 period. Overall, 3524 EGPA hospitalisations were recorded, and women were more frequently hospitalised than men (54.5% vs. 45.2%; p < 0.001). Mean age at hospitalisation increased over time, with patients in 2023 being about 5–6 years older than in 2014 (p ≤ 0.009). Median length of stay was 8 days for first admissions and 5 days for all EGPA stays and shortened significantly over the study period (p < 0.001). Cardiovascular disease, pulmonary disease and asthma were present in 23.6%, 35.3% and 32.3% of patients, respectively. Cardiovascular disease was more common in men and in rural residents (both p < 0.001) and was associated with older age (p < 0.001), whereas pulmonary disease was associated with younger age (p < 0.001). Among women, the proportions with pulmonary disease and asthma decreased over time (p = 0.009 and p = 0.025). Conclusions: EGPA in Poland is rare, with hospital-based incidence comparable to other European and Asian populations. The hospitalized EGPA population is aging and cardiovascular comorbidity is increasingly prominent, especially in older and rural patients, while recorded pulmonary disease and asthma in women are decreasing. Full article

(This article belongs to the Section Immunology & Rheumatology)

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21 pages, 1836 KB

Open AccessSystematic Review

Fecal Short-Chain Fatty Acids in Colorectal Cancer Patients Versus Healthy Controls: A Systematic Review and Meta-Analysis

by Tomasz Sylwestrzak, Michalina Ciosek, Krzysztof Pastuszak and Tomasz Jastrzębski

J. Clin. Med. 2025, 14(24), 8949; https://doi.org/10.3390/jcm14248949 - 18 Dec 2025

Viewed by 426

Abstract

Background: Short-chain fatty acids (SCFAs), the main microbial fermentation products in the colon, have immunometabolic and anti-neoplastic properties. Alterations in fecal SCFA profiles have been proposed as potential non-invasive biomarkers for colorectal cancer (CRC), but previous findings remain inconsistent. This systematic review [...] Read more.

Background: Short-chain fatty acids (SCFAs), the main microbial fermentation products in the colon, have immunometabolic and anti-neoplastic properties. Alterations in fecal SCFA profiles have been proposed as potential non-invasive biomarkers for colorectal cancer (CRC), but previous findings remain inconsistent. This systematic review and meta-analysis aimed to determine whether fecal acetate, propionate, and butyrate concentrations differ between patients with CRC and healthy individuals. Methods: A comprehensive search of PubMed, Web of Science and Cochrane Library was conducted on 18 September 2025. Eligible studies were observational, included adults with histologically confirmed CRC and healthy controls, and reported fecal concentrations of at least one SCFA quantified using validated analytical methods. Two independent reviewers performed study screening, data extraction, and risk-of-bias assessment. Random-effects models were applied to calculate pooled standardized mean differences (SMDs) with 95% confidence intervals (CIs). Results: Thirteen studies met inclusion criteria for qualitative synthesis, and four (141 CRC cases, 98 controls) were eligible for meta-analysis. Compared with healthy controls, patients with CRC had significantly lower fecal acetate (pooled SMD −0.37; 95% CI −0.63 to −0.10; p = 0.006; I² = 0%) and butyrate (pooled SMD −0.59; 95% CI −1.10 to −0.07; p = 0.026; I² = 64.4%), whereas propionate did not differ significantly (pooled SMD −0.02; 95% CI −0.85 to 0.82; p = 0.971; I² = 89%). Conclusions: CRC is associated with reduced fecal butyrate and, to a lesser extent, acetate, suggesting impaired microbial fermentation. Propionate shows no consistent difference. SCFA profiling currently lacks sufficient standardization and validation for clinical application. Future harmonized, longitudinal studies integrating diet, microbiome, and metabolomic data are warranted to confirm SCFAs as reproducible biomarkers of CRC. Full article

(This article belongs to the Section Oncology)

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25 pages, 1895 KB

Open AccessReview

Physical Therapist-Led Therapeutic Exercise and Mobility in Adult Intensive Care Units: A Scoping Review of Operational Definitions, Dose Progression, Safety, and Documentation

by Kyeongbong Lee

J. Clin. Med. 2025, 14(24), 8948; https://doi.org/10.3390/jcm14248948 - 18 Dec 2025

Viewed by 476

Abstract

Background/Objectives: Intensive care units (ICU) immobility and weakness impair recovery, yet practice for Physical Therapist (PT)-led therapeutic exercise and mobility varies in definitions, dosing, safety, and documentation, which limits comparability and complicates quality assessment. This study aims to integrate adult ICU evidence [...] Read more.

Background/Objectives: Intensive care units (ICU) immobility and weakness impair recovery, yet practice for Physical Therapist (PT)-led therapeutic exercise and mobility varies in definitions, dosing, safety, and documentation, which limits comparability and complicates quality assessment. This study aims to integrate adult ICU evidence and present PT-led operational definitions, dose progression principles, safety parameters, outcome measurement, and a documentation minimum dataset. Methods: A scoping review following PRISMA-ScR is used. Eligibility used Population, Concept, and Context: adults in ICU; PT-led therapeutic exercise or mobility; and ICU-initiated or directed care. Primary studies and prespecified quality-improvement reports were included. Data were extracted with a standardized form and summarized descriptively without meta-analysis. Results: Sixty studies were included. Based on the extracted data, this review synthesizes current evidence to propose standardized PT-led operational definitions and a graded progression from in-bed exercise to ambulation. While the individual components are derived from the literature, the conceptual framework for safety parameters and the stop rules were integrated and elaborated to guide clinical decision-making. Adverse events were uncommon and manageable. Outcome measurement centered on validated mobility and function measures at prespecified time points. A concise electronic record minimum dataset specifies provider attribution, timing and duration, activity level with assistance or device, planned and delivered dose with progression, in-session responses, and adverse events, supporting unit-level quality review and comparisons across ICU. Conclusions: A PT-led, graded program that applies shared thresholds, uses validated outcome measures, and employs standardized electronic documentation is feasible and supports safe delivery, clinically meaningful change, and quality improvement across adult ICU. Full article

(This article belongs to the Special Issue Rising Star: Advanced Physical Therapy and Expansion)

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17 pages, 637 KB

Open AccessArticle

Feasibility and Safety of an Outdoor-Simulated Interactive Indoor Cycling Device for Cardiac Rehabilitation: A Pilot Validation Study

by Jin Taek Lee, Bo Ryun Kim, Sung Bom Pyun, Young Mo Kim, Ho Sung Son, Jae Seung Jung and Hee Jung Kim

J. Clin. Med. 2025, 14(24), 8947; https://doi.org/10.3390/jcm14248947 - 18 Dec 2025

Viewed by 278

Abstract

Background/Objectives: To examine the safety and clinical applicability of a newly developed outdoor-simulated interactive indoor cycling device as a potential exercise modality for cardiac rehabilitation (CR) in patients with cardiovascular disease (CVD). Methods: Twenty patients with CVD with low-to-moderate cardiovascular exercise [...] Read more.

Background/Objectives: To examine the safety and clinical applicability of a newly developed outdoor-simulated interactive indoor cycling device as a potential exercise modality for cardiac rehabilitation (CR) in patients with cardiovascular disease (CVD). Methods: Twenty patients with CVD with low-to-moderate cardiovascular exercise risk performed a symptom-limited cardiopulmonary exercise stress test (CPET) using a modified Bruce protocol to obtain peak cardiopulmonary responses. After a 30–60 min rest, they rode the outdoor-simulated interactive indoor cycling device for 10 min with continuous gas exchange and electrocardiography monitoring. The treadmill-based CPET results were compared with those from the cycling device, focusing on key cardiopulmonary variables, such as VO₂, HR, METs, and Rating of Perceived Exertion (RPE). Results: The 20 male participants had a mean age of 56.1 years. When treadmill peak values were used as reference, the cycling device elicited responses corresponding to moderate-to-vigorous intensity. In subgroup analysis, treadmill-derived peak VO₂, peak HR, and peak MET values were significantly lower in patients aged ≥60 years compared with those aged <60 years. However, no significant differences were observed in cycling-derived values between the two groups, suggesting that cycling may represent a relatively higher-intensity exercise compared with treadmill in older patients. No significant adverse cardiac events were observed during cycling. Conclusions: The outdoor-simulated interactive indoor cycling device delivered exercise intensity within the therapeutic range recommended for CR in patients with CVD. Furthermore, it appeared to elicit relatively higher exercise intensity in older patients, supporting its potential as a safe and effective alternative exercise modality for CR. Full article

(This article belongs to the Special Issue Advances in Cardiovascular Rehabilitation: The Central Role of Exercise in Prevention and Care)

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18 pages, 1750 KB

Open AccessArticle

Preoperative Diquafosol vs. Intense Pulsed Light with Gland Expression for MGD: Effects on Refractive Accuracy and Tear Film Stability in Cataract Surgery

by Takeshi Teshigawara, Tatsukata Kawagoe, Yuki Mizuki, Miki Akaishi, Takuto Sakono, Kazuro Yabuki, Seiichiro Hata, Akira Meguro and Nobuhisa Mizuki

J. Clin. Med. 2025, 14(24), 8946; https://doi.org/10.3390/jcm14248946 - 18 Dec 2025

Viewed by 255

Abstract

Objectives: To compare the effects of two preoperative dry eye treatments—3% diquafosol sodium (DQS) and intense pulsed light with meibomian gland expression (IPL-MGX)—on refractive accuracy in cataract surgery and identify tear break-up time (TBUT) thresholds predictive of refractive success. Methods: In [...] Read more.

Objectives: To compare the effects of two preoperative dry eye treatments—3% diquafosol sodium (DQS) and intense pulsed light with meibomian gland expression (IPL-MGX)—on refractive accuracy in cataract surgery and identify tear break-up time (TBUT) thresholds predictive of refractive success. Methods: In this prospective, paired-eye study, 62 patients (124 eyes) with meibomian gland dysfunction underwent bilateral cataract surgery with the same trifocal intraocular lens. One eye received DQS, while the fellow eye underwent four IPL-MGX sessions before biometry. Postoperative absolute prediction error (P-SE) was compared. TBUT and higher-order aberrations (HOAs) were evaluated. Logistic regression identified predictors of refractive accuracy, and receiver operating characteristic (ROC) analysis assessed the predictive value of TBUT for P-SE thresholds of <0.25 D and <0.50 D. Results: P-SE was significantly lower in IPL-MGX–treated eyes than in DQS-treated eyes (mean paired difference −0.11 D, p < 0.001). Success rates within <0.25 D and <0.50 D were higher with IPL-MGX (p < 0.01). TBUT and HOAs were predictors in univariate models, but only TBUT remained significant in the multivariable analysis (odds ratio, 4.90 per 1-s increase; 95% confidence interval, 1.92–12.51; p < 0.001). ROC analysis supported TBUT cutoffs of 7 s (<0.25 D) and 6 s (<0.50 D). Conclusions: IPL-MGX may improve refractive accuracy compared to DQS. TBUT appeared to be the most consistent predictor, and achieving ≥6 s was associated with higher likelihood of refractive success. Full article

(This article belongs to the Special Issue Cataract and Refractive Surgery and Intraocular Lens Implantation: Clinical Advances and Perspectives)

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12 pages, 7495 KB

Open AccessArticle

Streamlined Management of Basal Cell Carcinoma with Dermoscopy: A Retrospective Case–Control Study

by Francisca Donoso, Rosario Aguero, Marie-Chantal Caussade, Dominga Peirano, Leonel Hidalgo, Sofía Villagrán, Pascal De Amesti, Víctor Meza, Josefina Hasenberg, Katherine Droppelmann, Álvaro Abarzúa-Araya, Juan Camilo Castro-Ayala, John Paoli, Pablo Uribe and Cristián Navarrete-Dechent

J. Clin. Med. 2025, 14(24), 8945; https://doi.org/10.3390/jcm14248945 - 18 Dec 2025

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Abstract

Background/Objective: The standard approach for managing suspected basal cell carcinoma (BCC) involves performing a biopsy to confirm the diagnosis before treatment. This process often leads to multiple visits and increased healthcare costs. We aimed to evaluate the effectiveness of direct surgical excision of [...] Read more.

Background/Objective: The standard approach for managing suspected basal cell carcinoma (BCC) involves performing a biopsy to confirm the diagnosis before treatment. This process often leads to multiple visits and increased healthcare costs. We aimed to evaluate the effectiveness of direct surgical excision of BCCs diagnosed clinically and dermoscopically, without the need for prior biopsy. Methods: We conducted a retrospective case–control study at a tertiary cancer center. Lesions suspected to be BCC, based on clinical and dermoscopic criteria, were divided into two groups: (1) a streamlined treatment group (cases), in which lesions were treated without a confirmatory biopsy (either excised with a 4 mm margin or managed with curettage and electrodesiccation); (2) and a biopsied group (controls). Clinical and histopathological data were analyzed and compared between groups to assess diagnostic accuracy, margin status, and treatment outcomes. Results: Of 389 BCCs, 167 (42.9%) were streamlined, while 222 (57.1%) underwent a biopsy before definitive treatment. The streamlined group demonstrated higher diagnostic accuracy, with 94.6% of excised lesions confirmed as BCC, compared with 73.4% in the biopsy group (p < 0.001). Among lesions excised with 4 mm margins, 97.9% achieved clear margins with the streamlined approach. Margin involvement was associated with high-risk BCC (p = 0.048), particularly with recurrent BCCs (p = 0.023). Conclusions: Streamlined management of BCC through direct excision without prior biopsy is an efficient and cost-effective strategy that reduces patient visits, costs, and waiting times, particularly for low-risk BCCs and older patients. Advances in dermoscopy and non-invasive tools support their accuracy, making it a feasible option in resource-limited settings. Full article

(This article belongs to the Special Issue Advances in the Diagnosis and Treatment of Skin Cancer)

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14 pages, 2574 KB

Open AccessArticle

The Role of Patient Motivation in Single-Sided Deafness: Patterns in Treatment Selection and Cochlear Implant Outcomes

by Leena Asfour, Allison Oliva, Erin Williams and Meredith A. Holcomb

J. Clin. Med. 2025, 14(24), 8944; https://doi.org/10.3390/jcm14248944 - 18 Dec 2025

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Abstract

Background/Objectives: Single-sided deafness (SSD) treatment options include Contralateral Routing of Signal (CROS) or Bilateral Routing of Signal (BiCROS) systems, bone conduction devices, cochlear implants (CIs) and no intervention. Aligning treatment recommendations with patient motivations is fundamental for satisfaction and successful outcomes. At our [...] Read more.

Background/Objectives: Single-sided deafness (SSD) treatment options include Contralateral Routing of Signal (CROS) or Bilateral Routing of Signal (BiCROS) systems, bone conduction devices, cochlear implants (CIs) and no intervention. Aligning treatment recommendations with patient motivations is fundamental for satisfaction and successful outcomes. At our institution, a structured telehealth consultation precedes formal testing and includes treatment motivation exploration and comprehensive review of all interventions. This study examined SSD treatment motivations and their association with pursuing cochlear implantation. Methods: Adults who completed a pre-treatment SSD telehealth consultation over a four-year period were identified. Charts were retrospectively reviewed for demographics, SSD characteristics, treatment motivations, treatment choice, and CI outcomes. Results: A total of 122 adults were evaluated. Mean age was 56.3 (±13.0) years, and 59.8% were male. Mean SSD duration was 10.8 (±15.8) years. The most common etiology was sudden sensorineural hearing loss. The top primary motivations were improving overall hearing (23.0%), restoring hearing to the deaf ear (22.1%), and improving hearing in noise (21.3%). Most patients (45.1%) opted for a hearing aid, CROS or BiCROS system; 38.5% chose CI; and 14.8% declined treatment. Only 57.4% of those who selected CI had the implant, primarily due to surgery avoidance (31.5%) and insurance limitations (10.5%). Motivation did not predict treatment choice or CI receipt. Among CI recipients (n = 27), those motivated by hearing restoration demonstrated poorer speech outcomes and datalogging. Conclusions: Improving overall hearing and restoring hearing to the deaf ear were the most common motivations for seeking SSD treatment. Adult CI recipients had similar motivations to those who chose non-surgical options. Full article

(This article belongs to the Special Issue Clinical Challenges and Innovations in Cochlear Implantation and Hearing Rehabilitation)

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17 pages, 289 KB

Open AccessSystematic Review

Biomarkers of Sarcopenia and Sarcopenic Obesity in Renal Transplant Recipients: A Systematic Review and Evidence Quality Assessment

by Ioanna Soukouli, Thomas Karagkounis, Konstantinos S. Mylonas, Theofanis Kalathas, Kalliopi-Anna Poulia, Alexander Kokkinos and Smaragdi Marinaki

J. Clin. Med. 2025, 14(24), 8943; https://doi.org/10.3390/jcm14248943 - 18 Dec 2025

Viewed by 292

Abstract

Background: Sarcopenia and sarcopenic obesity are increasingly recognized in kidney transplant recipients (KTRs), yet their molecular underpinnings remain poorly defined. We sought to synthesize current evidence on biomarker associations with muscle loss and function in the post renal transplant setting. Methods: A comprehensive [...] Read more.

Background: Sarcopenia and sarcopenic obesity are increasingly recognized in kidney transplant recipients (KTRs), yet their molecular underpinnings remain poorly defined. We sought to synthesize current evidence on biomarker associations with muscle loss and function in the post renal transplant setting. Methods: A comprehensive search of PubMed/MEDLINE and Cochrane databases was conducted according to PRISMA guidelines. Studies evaluating biomarkers related to sarcopenia or sarcopenic obesity in adult and pediatric KTRs were included. Quality assessment was performed with the NHLBI tool. Results: Seven studies were included, encompassing 548 KTRs. Myostatin levels predicted sarcopenia in KTRs (cut-off: 390 pg/mL) and inversely correlated with Metabolic equivalent of Tasks (METs), handgrip strength (HGS), and graft performance. Although adiponectin was negatively correlated with body fat, its high-molecular-weight isoform was linked to lower muscle mass and long-term graft decline. Leptin was associated with sarcopenic obesity and lower estimated Glomerular Filtration Rate (eGFR). Insulin like Growth Factor-1 (IGF-1) independently predicted HGS but not muscle mass. Brain-derived neurotrophic factor (BDNF) levels predicted sarcopenia (cut off: 17.8 ng/mL) and reflected physical activity levels. Visfatin showed no association with sarcopenia but it was positively correlated with eGFR. Lastly, certain polymorphisms of Alpha-actinin-3 (ACTN3) were shown to genetically predispose to post-transplant sarcopenia. Conclusions: These emerging candidate biomarkers provide promising mechanistic insight into post-transplant muscle decline and may ultimately support more personalized risk assessment. Further validation is needed, and functional measures remain the most reliable clinical tools at present. Full article

(This article belongs to the Special Issue Clinical Outcomes Improvement and Perioperative Management of Surgical Patients: 3rd Edition)

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J. Clin. Med., Volume 14, Issue 24 (December-2 2025) – 357 articles

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