Clinics and Practice

10 pages, 208 KB

Open AccessStudy Protocol

Assessment of Physical Activity During Radiation Therapy for Lung Cancer: Study Protocol of the APART-LUNG Study

by Dirk Rades, Maria Karolin Streubel, Laura Doehring, Stefan Janssen, Sabine Bohnet, Christian F. Schulz, Hanne Falk Grauslund and Charlotte Kristiansen

Clin. Pract. 2026, 16(4), 80; https://doi.org/10.3390/clinpract16040080 - 20 Apr 2026

Abstract

Background/Objectives: Radiation therapy is a common treatment modality for non-small-cell and small-cell lung cancer that can be associated with considerable side effects, mainly reactions of healthy tissues in the radiation field. Radiation therapy may lead to significant fatigue, which can potentially be [...] Read more.

Background/Objectives: Radiation therapy is a common treatment modality for non-small-cell and small-cell lung cancer that can be associated with considerable side effects, mainly reactions of healthy tissues in the radiation field. Radiation therapy may lead to significant fatigue, which can potentially be mitigated by maintaining or increasing physical activity during treatment. Since achieving this goal may be a challenge for patients, they may benefit from a mobile application reminding them daily to perform a predefined number of steps. Such a reminder app will be investigated prospectively in a phase 2 trial. The current APART-LUNG study (NCT07380815) is a mandatory study for designing the prospective trial. Methods: The main objective of the APART-LUNG (exploratory non-interventional) study is to report patterns of physical activity during radiation therapy for lung cancer patients and generate hypotheses based on our findings. Our primary endpoint is the within-patient difference in weekly average steps per wear hour of the smartphone (week 5 minus week 1 of radiation therapy), and our secondary aim is to estimate differences in operational measures (wear time of the smartphone) between week 5 and week 1. The sample size of approximately 20 patients (full analysis set) allows us to detect a moderate-to-large standardized within-patient difference and is driven by feasibility and the intent to obtain preliminary estimates of effect size and variability. The results of the APART-LUNG study will be very important for appropriately designing a phase 2 trial. Full article

(This article belongs to the Special Issue Exercise and Sports for Chronic Diseases)

12 pages, 757 KB

Open AccessArticle

Outcomes of Intracranial Haemorrhage in Patients Taking Direct Oral Anticoagulants or Vitamin K Antagonists: A Seven-Year Single-Centre Retrospective Analysis

by Mallika Sathitwat, Surat Tanprawate, Atiwat Soontornpun, Chayasak Wantaneeyawong, Chutithep Teekaput, Nopdanai Sirimaharaj, Angkana Nudsasarn, Chatree Chai-Adisaksopha and Kitti Thiankhaw

Clin. Pract. 2026, 16(4), 79; https://doi.org/10.3390/clinpract16040079 - 18 Apr 2026

Abstract

Background: The clinical outcomes of patients with intracranial haemorrhage (ICH) whilst using direct oral anticoagulants (DOACs) and vitamin K antagonists (VKAs) are uncertain. This study aimed to assess outcomes and management in patients receiving DOACs compared with those receiving VKAs. Methods: In this [...] Read more.

Background: The clinical outcomes of patients with intracranial haemorrhage (ICH) whilst using direct oral anticoagulants (DOACs) and vitamin K antagonists (VKAs) are uncertain. This study aimed to assess outcomes and management in patients receiving DOACs compared with those receiving VKAs. Methods: In this retrospective study, patients hospitalised during the period from 1 January 2017 to 31 December 2023 for traumatic and non-traumatic ICH and using oral anticoagulants (OACs) were included. The primary outcomes were mortality and functional outcomes, as measured by the modified Rankin Scale (mRS) during admission and 90-day follow-up. ICH management and complications were studied and compared between the two OAC groups. Results: A total of 171 eligible patients were included, comprising 24 patients on DOACs and 147 patients on VKAs. Patients receiving DOACs were older (79.1 vs. 66.8, p < 0.001) and had a higher proportion of traumatic ICH (75.0% vs. 46.3%, p = 0.009) than those receiving VKAs. In-hospital and 90-day outcomes were not statistically different between the two groups, with an adjusted odds ratio (aOR) of 1.30 (0.39–4.36) for in-hospital mortality, p = 0.67, and an aOR of 0.89 (0.33–2.41) for mRS 0–2 at 90 days, p = 0.83. In total, 81.3% of patients received at least one reversal agent; fresh frozen plasma was commonly used in the VKA group (78.9% vs. 33.3%, p < 0.001), whereas prothrombin complex concentrate was significantly prescribed in patients with DOAC-associated ICH (29.2% vs. 3.4%, p < 0.001). Conclusions: Patients with DOAC-associated ICH had comparable in-hospital and long-term clinical outcomes to those with VKA use. Full article

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16 pages, 1263 KB

Open AccessArticle

by Sanjana Arun, Joaquin Cardozo, Andre Shon Hirakawa, Teresa Anh Tran, Van Dexter Calo and Robert Fauer

Clin. Pract. 2026, 16(4), 78; https://doi.org/10.3390/clinpract16040078 - 17 Apr 2026

Abstract

Background: Unhoused individuals face disproportionately high rates of preventable chronic disease due to fragmented access to care and prolonged exposure to environmental stressors. Street medicine programs offer a mobile, low-barrier model to assess and address these unmet needs. Despite well-documented disparities, no publications [...] Read more.

Background: Unhoused individuals face disproportionately high rates of preventable chronic disease due to fragmented access to care and prolonged exposure to environmental stressors. Street medicine programs offer a mobile, low-barrier model to assess and address these unmet needs. Despite well-documented disparities, no publications in the current literature provide numerically specific screening recommendation guidelines tailored to unhoused populations. This study fills that gap using clinical data from Street Medicine Phoenix (SMP), a mobile healthcare initiative serving urban Arizona. Methods: We retrospectively reviewed 1322 clinical encounters recorded by SMP between August 2023 and October 2024. Diagnoses and treatments were manually categorized. Blood pressure (BP) and glucose values were analyzed using descriptive statistics and compared against national norms (CDC 50th percentile and ADA guidelines). Kruskal–Wallis and Dunn’s tests assessed age-based differences, while chi-square and Mann–Whitney U tests examined glucose patterns. Results: The mean patient age was 51.4 years; 34.5% identified as female. Cardiovascular issues (39.4%) and routine screenings (39.6%) were most frequently documented. Systolic and diastolic BP values were significantly elevated across all age groups except those 60+, with even the 18–39 group showing median systolic BP above CDC norms (124.0 mmHg). Among 60 patients with fasting glucose data, 41.4% met ADA criteria for diabetes, and 10.7% of those without a known diagnosis had diabetic-range values. Conclusions: Our findings suggest that cardiometabolic disease may emerge earlier and more aggressively among unhoused individuals than in the general U.S. population, reflecting patterns of accelerated biological aging. The elevation of cohort-based BP percentiles suggests that current national benchmarks may underrepresent clinical risk in this group. We propose initiating blood pressure screening at age 18 and fasting glucose screening by age 35 in unhoused individuals—adaptations of existing USPSTF recommendations based on cohort-specific trends. These screening thresholds can be feasibly implemented in street medicine settings to promote earlier detection and improve long-term health outcomes. Full article

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10 pages, 449 KB

Open AccessSystematic Review

Systematic Review: The Impact of COVID-19 Vaccination on Myocarditis Risk and Recovery

by Yibo Liu, Christopher Khatchadourian, Luke Sanders, Quincy Eweroke, Cyvannah Warner-McCutcheon, Jackson Lewis, Joaquin Santos and Vishwanath Venketaraman

Clin. Pract. 2026, 16(4), 77; https://doi.org/10.3390/clinpract16040077 - 17 Apr 2026

Abstract

Background: Myocarditis is an uncommon but recognized adverse event following mRNA COVID-19 vaccination, with risk varying by age, sex, dose number, and vaccine product. Clarifying the magnitude of risk, clinical course, and recovery—relative to myocarditis following SARS-CoV-2 infection—is essential for risk–benefit assessment and [...] Read more.

Background: Myocarditis is an uncommon but recognized adverse event following mRNA COVID-19 vaccination, with risk varying by age, sex, dose number, and vaccine product. Clarifying the magnitude of risk, clinical course, and recovery—relative to myocarditis following SARS-CoV-2 infection—is essential for risk–benefit assessment and public health guidance. Methods: We performed a systematic PubMed and Embase search (January 2020–December 2024) and synthesized cohort, registry, and surveillance data on myocarditis incidence and outcomes following mRNA COVID-19 vaccination. Outcomes included incidence, observed-to-expected (OE) or incidence rate (IRRs) ratios, hospitalization, and short-term recovery. Study selection followed PRISMA 2020 systematic review guidelines. Results: Myocarditis following mRNA COVID-19 vaccination was identified as a rare adverse event, most commonly occurring after the second dose and in younger male individuals. Across multiple cohort and registry-based studies, cases were generally mild and self-limited, with most patients recovering without complication. In contrast, myocarditis following SARS-CoV-2 infection was consistently associated with more severe outcomes, including higher rates of hospitalization and mortality. Conclusions: Vaccine-associated myocarditis is rare, typically mild, and self-limited, with excellent short-term recovery; vaccinated individuals also exhibit lower odds of in-hospital death and intubation. In contrast, infection-associated myocarditis is more frequent and severe. Overall, the benefit–risk profile of mRNA vaccination remains strongly favorable. Full article

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13 pages, 730 KB

Open AccessArticle

Angiogenic Imbalance Defines Multisystem Phenotypes of Preeclampsia: A Phenotype-Oriented Cohort Study

by Anca Tătaru-Copos, Florin Szasz, Anca Carmen Huniadi, Rodica Georgeta Negrini, Mircea Ioachim Popescu, Paula Trif, Gelu Florin Murvai, Radu Galiș, Cristian Sava and Romina Viorela Murvai

Clin. Pract. 2026, 16(4), 76; https://doi.org/10.3390/clinpract16040076 - 17 Apr 2026

Abstract

Background: Preeclampsia is a heterogeneous multisystem disorder characterized by endothelial dysfunction and angiogenic imbalance. While the sFlt-1/PlGF ratio is widely used for diagnostic purposes, its role in defining biological phenotypes of preeclampsia remains insufficiently explored. This study aimed to investigate whether angiogenic imbalance [...] Read more.

Background: Preeclampsia is a heterogeneous multisystem disorder characterized by endothelial dysfunction and angiogenic imbalance. While the sFlt-1/PlGF ratio is widely used for diagnostic purposes, its role in defining biological phenotypes of preeclampsia remains insufficiently explored. This study aimed to investigate whether angiogenic imbalance is associated with distinct multisystem phenotypes of preeclampsia and with perinatal outcomes. Methods: We conducted a retrospective cohort study including 320 pregnant women, of whom 68 were diagnosed with preeclampsia. Multisystem phenotypes were defined using laboratory markers reflecting renal, hepatic, and hematologic involvement. The sFlt-1/PlGF ratio was compared across phenotypes. Associations with gestational age at delivery, birth weight, Apgar score, and neonatal intensive care unit (NICU) admission were evaluated. Receiver operating characteristic (ROC) analysis assessed the discriminatory performance of the sFlt-1/PlGF ratio for identifying the renal-dominant phenotype. Results: The mean sFlt-1/PlGF ratio was higher in preeclampsia compared to normotensive pregnancies (58.5 ± 20.3 vs. 34.6 ± 15.9). Within preeclampsia, the renal-dominant phenotype showed the highest ratio (66.0 ± 22.5), followed by hepatic (55.9 ± 18.2) and hematologic phenotypes (52.0 ± 16.8). The renal phenotype was associated with earlier delivery (34.6 weeks), lower birth weight (2196 g), higher NICU admission (10.7%), and lower Apgar scores. The sFlt-1/PlGF ratio demonstrated moderate discrimination for the renal phenotype (AUC = 0.69). Conclusions: Angiogenic imbalance varies across multisystem phenotypes of preeclampsia and is associated with meaningful perinatal differences. The sFlt-1/PlGF ratio may contribute to phenotype-based risk stratification, supporting a move toward precision obstetrics. Prospective studies are needed to validate phenotype-oriented classification models. Full article

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15 pages, 901 KB

Open AccessReview

Efficacy and Safety of Platelet-Rich Plasma in Knee Osteoarthritis: Umbrella Meta-Analysis Based on Clinical Evidence, Methodological Quality and Therapeutic Positioning

by María Ángeles Ventura-García, Tesifón Parrón-Carreño, David Lozano-Paniagua, Bruno José Nievas-Soriano, Antonio Fernando Murillo-Cancho, Elena María Gázquez-Aguilera and Delia Cristobal-Cañadas

Clin. Pract. 2026, 16(4), 75; https://doi.org/10.3390/clinpract16040075 - 14 Apr 2026

Abstract

Background/Objectives: Despite being a standard biological therapy for knee osteoarthritis, inconsistent results across studies—due to varied protocols—have obscured the clinical standing of platelet-rich plasma. This meta-analysis evaluates the efficacy and safety of PRP for pain, function, and adverse events, and examines the [...] Read more.

Background/Objectives: Despite being a standard biological therapy for knee osteoarthritis, inconsistent results across studies—due to varied protocols—have obscured the clinical standing of platelet-rich plasma. This meta-analysis evaluates the efficacy and safety of PRP for pain, function, and adverse events, and examines the potential benefits of combining it with hyaluronic acid. Methods: An umbrella review was conducted following the PRIOR (Preferred Reporting Items for Umbrella Reviews) and PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) recommendations. Meta-analyses evaluating PRP in knee osteoarthritis were included. Quantitative estimates of pain, function, and safety were extracted. Random-effects models were applied when possible. Methodological quality was assessed using AMSTAR 2, and study overlaps were assessed using the CCA method. Publication bias was analyzed using a funnel plot. Results: The meta-analyses included consistently showed the superiority of PRP over hyaluronic acid and placebo in reducing pain and improving function. Pooled estimates indicated clinically relevant improvements, especially in mild-to-moderate osteoarthritis. The combination of PRP and hyaluronic acid demonstrated superior functional recovery and a potential reduction in adverse events compared to PRP monotherapy. The overall safety profile was favorable. Conclusions: PRP is an effective and safe therapy for knee osteoarthritis, with consistent evidence of superiority over conventional intra-articular treatments. Combined PRP and HA administration suggests superior clinical efficacy compared to monotherapy. Standardization of protocols and appropriate patient selection will be key in future clinical guidelines. Full article

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18 pages, 1816 KB

Open AccessSystematic Review

Neuromuscular Characteristics Associated with Knee Instability in Osteoarthritis and After Total Knee Replacement: A Systematic Review and Meta-Analysis

by Ariane P. Lallès, Luisa Cedin and Markus A. Wimmer

Clin. Pract. 2026, 16(4), 74; https://doi.org/10.3390/clinpract16040074 - 14 Apr 2026

Abstract

Background/Objectives: Knee joint instability is frequently reported in individuals with knee osteoarthritis (OA) and may persist after total knee replacement (TKR), where it represents a leading cause of revision. However, neuromuscular factors associated with knee instability remain poorly understood. This systematic review [...] Read more.

Background/Objectives: Knee joint instability is frequently reported in individuals with knee osteoarthritis (OA) and may persist after total knee replacement (TKR), where it represents a leading cause of revision. However, neuromuscular factors associated with knee instability remain poorly understood. This systematic review and meta-analysis aimed to compare neuromuscular characteristics between individuals with stable and unstable knees in OA and TKR populations. Methods: PubMed, CENTRAL, Scopus, and EMBASE were searched from inception to 10 January 2025. Studies comparing neuromuscular outcomes between stable and unstable knees were included. Neuromuscular parameters included: muscle strength, muscle power, muscle activation pattern, and joint stiffness. Where appropriate, pooled standardized mean differences (SMD) were calculated using random-effects models. Certainty of evidence was evaluated using the GRADE approach. Results: Nineteen studies (16 OA, 3 TKR; n = 7369 participants) were included, with eleven studies eligible for meta-analysis. OA individuals with unstable knees demonstrated significantly lower limb muscle strength compared with stable counterparts (SMD = −0.49, 95% CI −0.81 to −0.16, p = 0.003). Muscle co-contraction did not differ significantly between groups (SMD = 0.12, 95% CI −0.70 to 0.94, p = 0.77). The overall certainty of evidence was rated as very low. Conclusions: Knee instability in OA populations is associated with reduced lower limb muscle strength, although evidence quality is limited and findings regarding neuromuscular control strategies remain inconclusive. Evidence in TKR populations is scarce. Future studies should investigate muscle activation patterns and dynamic joint stabilization during functional tasks to clarify the neuromuscular mechanisms underlying knee instability. Full article

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13 pages, 253 KB

Open AccessArticle

Complications Related to Urgent Initiation of Peritoneal Dialysis in a Mexican Hospital with Limited Resources: A Prospective Cohort

by Camila Baas-Yama, Eduardo Rivera-Huerta, Ivan Zepeda-Quiroz, Carlos A. Guzmán-Martín, Demian Trueba-Lozano, Sebastian Toledo-Ramirez, Ana Ortega-Gonzalez, Irma Archundia-Riveros, Brenda Barrera-Mota, María Jimenez-Baez, Ciria Vázquez-Macias and Daniel Juárez-Villa

Clin. Pract. 2026, 16(4), 73; https://doi.org/10.3390/clinpract16040073 - 13 Apr 2026

Abstract

Background: Urgent-start peritoneal dialysis (UPD) has emerged as an alternative modality for initiating kidney replacement therapy when immediate hemodialysis is not available. However, early initiation after catheter placement may increase the risk of mechanical complications. Evidence from real-world settings, particularly in resource-limited [...] Read more.

Background: Urgent-start peritoneal dialysis (UPD) has emerged as an alternative modality for initiating kidney replacement therapy when immediate hemodialysis is not available. However, early initiation after catheter placement may increase the risk of mechanical complications. Evidence from real-world settings, particularly in resource-limited healthcare systems, remains limited. Objective: To determine the frequency of early complications associated with urgent-start peritoneal dialysis and to identify clinical factors associated with their occurrence. Methods: We conducted a prospective observational cohort study including adult patients with chronic kidney disease who initiated peritoneal dialysis within 14 days after catheter placement at a public hospital in Mexico. Patients were followed for 30 days after dialysis initiation. The primary outcome was the occurrence of any dialysis-related complication within 30 days after initiation of peritoneal dialysis. Comparisons were performed according to dialysis initiation timing (<72 h vs. ≥72 h). Multivariable logistic regression was used to identify independent predictors of complications. Results: Sixty-five patients were included, of whom 29 (44.6%) developed complications within the first 30 days. Mechanical complications predominated, particularly pericatheter leakage (18.5%) and drainage failure (10.8%). Patients who initiated dialysis within 72 h after catheter placement experienced a significantly higher complication rate. In multivariable analysis, initiation of peritoneal dialysis within <72 h remained independently associated with complications (OR 5.75, 95% CI 1.06–31.29, p = 0.043). Conclusions: Initiating peritoneal dialysis within 72 h after catheter placement was associated with a significantly increased risk of early complications. When clinically feasible, delaying dialysis initiation beyond 72 h may reduce mechanical complications in urgent-start peritoneal dialysis programs. Full article

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14 pages, 885 KB

Open AccessArticle

Real-World Distributions and Concordance of C-Reactive Protein and Erythrocyte Sedimentation Rate Across Rheumatic Diseases

by Claudiu C. Popescu, Luminița Enache, Carmen Ștențel, Corina Mogoșan and Cătălin Codreanu

Clin. Pract. 2026, 16(4), 72; https://doi.org/10.3390/clinpract16040072 - 13 Apr 2026

Abstract

Objective: The objective of this study was to characterize real-world distributions of C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) across major rheumatic diagnoses and to quantify concordance/discordance patterns and combined CRP-ESR inflammatory phenotypes. Methods: We retrospectively extracted all CRP and [...] Read more.

Objective: The objective of this study was to characterize real-world distributions of C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) across major rheumatic diagnoses and to quantify concordance/discordance patterns and combined CRP-ESR inflammatory phenotypes. Methods: We retrospectively extracted all CRP and ESR tests performed in a tertiary university rheumatology hospital (January 2018–December 2023), including ICD-10-coded diagnoses. Analyses were conducted at the measurement level and patient level (medians across repeated tests). CRP and ESR were expressed as raw values and multiples of ULN and categorized into severity strata. CRP and ESR datasets were merged by patient identifier and calendar date to define same-day pairs; paired analyses used Spearman correlations and ULN-based phenotype classes. Sensitivity analyses tested alternative pairing windows, first-pair-only analyses, phenotype persistence rules, and tertile/quartile discordance definitions. Results: Among 16,921 patients with ≥1 CRP and 17,126 with ≥1 ESR, CRP was more disease-discriminative and only negligibly age-related, whereas ESR increased modestly with age and showed marked sex shifts across severity categories. Inflammatory burden was highest in gout and rheumatoid arthritis, intermediate in psoriatic arthritis and ankylosing spondylitis, and lower in connective tissue diseases (systemic lupus erythematosus, mixed connective tissue disease, Sjogren’s disease, systemic sclerosis, and dermato/polymyositis) and osteoarthritis; CRP distributions were more strongly right-tailed than ESR. Merging yielded 44,427 same-day CRP-ESR pairs from 16,824 patients (99.1% match). CRP and ESR were moderately correlated at measurement and patient levels, yet discordance was common: 27.3% of pairs showed isolated elevation of a single marker. Conclusions: In routine rheumatology care, CRP and ESR provide complementary information. CRP-ESR dissociation is frequent, persists at the patient level, and follows diagnosis-dependent phenotype patterns. Full article

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11 pages, 2450 KB

Open AccessTechnical Note

High-Volume LVA—New Surgical Technique for Treatment of Lymphoceles in the Groin

by Daniel Schiltz, Mahsa Bagheri Borgolte, Stephan Schreml, Philipp Lamby, Adrian Vater, Lukas Prantl and Uwe von Fritschen

Clin. Pract. 2026, 16(4), 71; https://doi.org/10.3390/clinpract16040071 - 31 Mar 2026

Abstract

Background: Groin lymphoceles are common postoperative complications after vascular interventions that can be difficult to treat, especially in recurrent or complex cases. While lymphovenous anastomosis (LVA) is a potential, minimally invasive option, its limited flow capacity may not provide sufficient drainage in large [...] Read more.

Background: Groin lymphoceles are common postoperative complications after vascular interventions that can be difficult to treat, especially in recurrent or complex cases. While lymphovenous anastomosis (LVA) is a potential, minimally invasive option, its limited flow capacity may not provide sufficient drainage in large lymphoceles. We present a novel high-volume LVA technique that uses larger veins to directly drain the lymphocele cavity. Methods: Five patients with six groin lymphoceles, all previously treated unsuccessfully with conventional methods (mean 3.3 surgeries), underwent high-volume LVA (HV-LVA). The technique involved direct anastomosis of a large regional vein to the lymphocele cavity. Lymphatic inflow points were identified with Patent Blue or ICG when possible. Outcomes were assessed over 6–14 months. Results: In total, seven HV-LVAs were performed. Three lymphoceles (50%) were successfully treated with a single operation; three required revisions due to venous occlusion. All patients were successfully treated without recurrence. The average number of surgeries per patient was 2.2. Conclusions: High-volume LVA may be an effective option for therapy-resistant inguinal lymphoceles, providing greater drainage capacity than standard techniques. Further studies are needed to confirm its long-term efficacy and safety. Full article

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13 pages, 255 KB

Open AccessArticle

Knowledge and Clinical Approaches to Temporomandibular Disorders in Primary Healthcare: A Cross-Sectional Comparative Study of Physicians and Dentists in Croatia

by Dora Martic, Martin Miskovic, Antonija Palac Bzik, Ana Glavina, Ivan Kovacic and Antonija Tadin

Clin. Pract. 2026, 16(4), 70; https://doi.org/10.3390/clinpract16040070 - 31 Mar 2026

Abstract

Objectives: Temporomandibular disorders (TMDs) are common but often underrecognized and inadequately managed in primary healthcare, which may delay diagnosis and appropriate care. This study aimed to compare TMD-related knowledge, awareness, and clinical practices between dentists and physicians working in primary care and to [...] Read more.

Objectives: Temporomandibular disorders (TMDs) are common but often underrecognized and inadequately managed in primary healthcare, which may delay diagnosis and appropriate care. This study aimed to compare TMD-related knowledge, awareness, and clinical practices between dentists and physicians working in primary care and to identify factors associated with higher diagnostic confidence. Methods: A cross-sectional survey was conducted among dentists and physicians working in Croatian primary healthcare. TMD-related knowledge, clinical confidence, screening practices, and referral patterns were assessed using a structured questionnaire. Results: Dentists demonstrated significantly higher overall knowledge scores than physicians (15.6 ± 1.7 vs. 13.2 ± 4.1; p < 0.001), as well as greater diagnostic and therapeutic confidence (all p < 0.001). Routine TMD screening was reported by only 21.8% of participants, more frequently by dentists than physicians (36.1% vs. 8.2%; p < 0.001). Most respondents preferred referral rather than independent management. Regression analysis identified profession as the only independent predictor of higher TMD-related knowledge (p = 0.003). Insufficient knowledge, experience, and lack of confidence were the most reported barriers, particularly among physicians. Conclusions: The findings indicate clinically relevant gaps in TMD preparedness within primary healthcare, especially among physicians, despite frequent patient contact. Strengthening undergraduate and continuing education, promoting interdisciplinary training, and establishing clearer referral pathways may enhance early recognition and improve primary-level management of TMD. Full article

13 pages, 1395 KB

Open AccessArticle

Evaluation of a Cognitive Aid Application to Improve Non-Technical Skills in Simulated Cardiopulmonary Resuscitation (CPR): A Randomised Controlled Trial

by Carlos Ramon Hölzing, Tristan Ernst, Thomas Wurmb, Tobias Grundgeiger, Patrick Meybohm and Oliver Happel

Clin. Pract. 2026, 16(4), 69; https://doi.org/10.3390/clinpract16040069 - 30 Mar 2026

Abstract

Background/Objectives: The success of cardiopulmonary resuscitation relies on both technical and non-technical skills. Cognitive aids, such as checklists, have been shown to enhance technical performance in emergencies. The aim of this study was to evaluate the capabilities of a cognitive aid app (CA-App) [...] Read more.

Background/Objectives: The success of cardiopulmonary resuscitation relies on both technical and non-technical skills. Cognitive aids, such as checklists, have been shown to enhance technical performance in emergencies. The aim of this study was to evaluate the capabilities of a cognitive aid app (CA-App) in improving non-technical skills. Methods: In this single-centre randomised controlled trial, 62 teams, each consisting of an experienced physician and a specialised nurse, were randomised either to CA-App or control (No-App) groups performing cardiopulmonary resuscitation. The study was registered with the German Clinical Trials Register (DRKS) on 4 November 2025 (DRKS00038336). The primary outcome was the team leader’s performance in non-technical skills, assessed via the validated Team Emergency Assessment Measure (TEAM™) questionnaire by two raters. Secondary analyses examined TEAM™ subdomains (leadership, teamwork, task management) and the correlation between app usage duration and performance. Results: 62 out of 67 teams were finally randomised, with 31 teams in each group. The CA-App group demonstrated a marginally elevated median TEAM™ total score (83.33%) in comparison to the control group (79.33%), although this difference was not statistically significant (p = 0.190). The leadership subgroup score was significantly higher in the app group (p = 0.006). There was no significant correlation between the time spent using the app and improved team performance (r = 0.260, p = 0.166). Conclusions: The CA-App demonstrated potential for improving leadership skills, a critical component of non-technical skills in emergency scenarios. These findings highlight the potential capability of cognitive aids to improve non-technical skills and the need for further research to explore their optimal design and integration into clinical practice to enhance team performance and patient safety. Full article

(This article belongs to the Special Issue Emergency and Disaster Medicine: Preparedness, Response, and Resilience in Health Systems)

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23 pages, 1424 KB

Open AccessEditor’s ChoiceReview

Serotonin–Norepinephrine Reuptake Inhibitors in Fibromyalgia Management: An Integrative Literature Review of Clinical Evidence

by Isabella Oliveira do Lago, Bruna Moura Medina Diniz, Daniela Vieira Buchaim and Rogerio Leone Buchaim

Clin. Pract. 2026, 16(4), 68; https://doi.org/10.3390/clinpract16040068 - 28 Mar 2026

Abstract

Fibromyalgia (FM) is a chronic pain syndrome characterized by central sensitization and impaired pain modulation, involving dysfunctional descending inhibitory pathways and altered nociceptive processing. These processes contribute to persistent musculoskeletal pain, difficulties with sleep, feelings of depression, and ongoing fatigue. Serotonin and norepinephrine [...] Read more.

Fibromyalgia (FM) is a chronic pain syndrome characterized by central sensitization and impaired pain modulation, involving dysfunctional descending inhibitory pathways and altered nociceptive processing. These processes contribute to persistent musculoskeletal pain, difficulties with sleep, feelings of depression, and ongoing fatigue. Serotonin and norepinephrine are key mediators of pain control, and evidence indicates that dual reuptake inhibition provides superior analgesia compared to single-pathway approaches. Accordingly, serotonin–norepinephrine reuptake inhibitors (SNRIs), including milnacipran and duloxetine, approved for FM treatment, show favorable efficacy and tolerability compared with tricyclic antidepressants. This integrative literature review aimed to evaluate the impact of SNRIs on musculoskeletal pain, fatigue, depression, and quality of life in patients with FM by analyzing randomized clinical trials (RCTs), identified via PubMed/MEDLINE searches (2015–2025) in English/Portuguese using descriptors: “Fibromyalgia”, “Serotonin and Norepinephrine Reuptake Inhibitors”, “Duloxetine” and “Milnacipran”. From 195 records screened, 18 studies met inclusion criteria (9.2% inclusion rate); duloxetine evaluated in 16 studies (88.9%), milnacipran in 2 (11.1%); SNRIs demonstrated superior efficacy vs. placebo: pain reduction 30–40%, fatigue improvement 25%, quality of life enhancement 20%. SNRIs were overall more effective than placebo but did not achieve high levels of analgesia, underscoring the need for further research on long-term efficacy and comparisons with combination pharmacological and non-pharmacological therapies. SNRIs significantly alleviate musculoskeletal pain (30–50% of patients), fatigue, depression symptoms, and improve quality of life in FM versus placebo. Duloxetine showed superior efficacy for pain/depression; milnacipran excelled in sleep quality. Long-term studies and combination therapies warrant further investigation. Full article

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12 pages, 225 KB

Open AccessArticle

Atrial Fibrillation Modifies the Relationship Between Beta Blocker Dose and Physical Capacity After Myocardial Infarction

by Paulina Rabiej-Krzys, Karolina Szczygiel, Rafal Lenard, Francesco Perone and Joanna Popiolek-Kalisz

Clin. Pract. 2026, 16(4), 67; https://doi.org/10.3390/clinpract16040067 - 28 Mar 2026

Abstract

Background: Atrial fibrillation (AF) is a common arrythmia in post-myocardial infarction (MI) cardiac rehabilitation (CR) cohorts, and beta-adrenergic signaling remodeling and rate-control pharmacotherapy may influence functional capacity. Methods: We retrospectively studied 117 consecutive male post-MI patients referred to outpatient CR. Functional capacity was [...] Read more.

Background: Atrial fibrillation (AF) is a common arrythmia in post-myocardial infarction (MI) cardiac rehabilitation (CR) cohorts, and beta-adrenergic signaling remodeling and rate-control pharmacotherapy may influence functional capacity. Methods: We retrospectively studied 117 consecutive male post-MI patients referred to outpatient CR. Functional capacity was assessed with a 6 min walk test (6MWT). AF was identified from clinical records, and beta-blocker exposure was unified as carvedilol-equivalent daily dose. Results: Beta-blockers were used in 94.1% of patients and AF was present in 10.3%. Patients with AF were older (72.7 ± 6.6 vs 58.1 ± 9.3 years) and walked shorter distances (430.0 [375.0–497.5] vs. 540.0 [480.0–570.0] m). In the prespecified interaction model, age remained independently associated with lower 6MWT (−4.29 m/year; p < 0.001), AF was associated with lower 6MWT (−137.21 m; p = 0.01), and the beta-blocker dose × AF interaction was positive (+6.78; p = 0.02; R² = 0.44). Importantly, the beta-blocker dose was not associated with 6MWT in patients without AF, whereas a positive association was observed in AF (B = 7.55, p = 0.04). Conclusions: In this exploratory analysis, AF identified a subgroup with markedly reduced functional capacity in early post-MI CR, supporting the potential of phenotype-informed assessment. Additionally, the association between beta-blocker dose and 6MWT distance differed by rhythm status. These preliminary findings require confirmation in larger prospective cohorts. Full article

(This article belongs to the Special Issue Exercise and Sports for Chronic Diseases)

10 pages, 358 KB

Open AccessArticle

Quality of ChatGPT-Generated Responses to Common Patient Questions About Peripheral Nerve Stimulation: A Cross-Sectional Study

by Charles A. Odonkor, Muhammad Uzair Siddique, Sarvesh Palaniappan, Jacob Locklear, Sreekrishna Pokuri, Alexandra Adler, Peju Adekoya, Annie W. Hsu, Jonathan Paek, Hari Prabhakar, Yuri Chaves Martins, Christina Smith, Uzondu Osuagwu, Frederick K. Comrie and Alaa Abd El Sayed

Clin. Pract. 2026, 16(4), 66; https://doi.org/10.3390/clinpract16040066 - 25 Mar 2026

Abstract

Background: Peripheral nerve stimulation (PNS) is increasingly used in selected patients with neuropathic pain, and many individuals seek supplemental online information to clarify procedural expectations and postoperative care. Large language models such as ChatGPT may provide scalable patient education; however, their performance [...] Read more.

Background: Peripheral nerve stimulation (PNS) is increasingly used in selected patients with neuropathic pain, and many individuals seek supplemental online information to clarify procedural expectations and postoperative care. Large language models such as ChatGPT may provide scalable patient education; however, their performance for PNS-related questions has not been evaluated. This study assessed the reliability, accuracy, and comprehensibility of ChatGPT-5.0 responses to common PNS patient questions. Methods: We conducted a cross-sectional evaluation of ChatGPT-5.0 responses to 21 standardized questions derived through expert consensus, spanning pre-implantation, implantation, and post-implantation domains. Sixteen board-certified interventional pain specialists and a nurse educator independently rated each response using validated scales for reliability (1–6), accuracy (1–3), and comprehensibility (1–3). Descriptive statistics were calculated, and domain-level patterns were examined. Results: Clinician ratings demonstrated generally strong performance across all domains. Mean reliability was 4.7 ± 1.4, mean accuracy 2.6 ± 0.6, and mean comprehensibility 2.8 ± 0.5. Foundational questions addressing mechanisms, expectations, and postoperative care received the highest ratings. Lower ratings were observed for implantation-focused items requiring procedural nuance. No response fell below predefined acceptability thresholds, and sensitivity analyses confirmed that including one partial evaluator did not alter the observed trends. Conclusions: ChatGPT-5.0 generated responses to PNS-related patient questions that clinicians rated as generally reliable, accurate, and understandable, particularly for foundational and postoperative topics. Performance was more variable for procedural questions, underscoring the need for clinician oversight and verification. These findings provide a benchmark of current LLM capabilities and highlight the importance of ongoing evaluation as models evolve and as patients access versions with differing functionalities. Full article

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20 pages, 2455 KB

Open AccessEditor’s ChoiceArticle

Pre-Injury Adversity, Functional Recovery, and Salivary microRNA Changes After a Dual-Task Exercise in Asians and Pacific Islanders with Mild Traumatic Brain Injury: A Feasibility Study

by Hyunhwa Lee, Haehyun Lee, Jinyoung Park and Jessica Gill

Clin. Pract. 2026, 16(4), 65; https://doi.org/10.3390/clinpract16040065 - 25 Mar 2026

Abstract

Background: Mild traumatic brain injury (mTBI) is frequently associated with persistent cognitive and psychosocial symptoms, yet biological correlates of recovery remain poorly understood, particularly among Asian and Pacific Islander (API) populations. Pre-injury psychosocial adversity may further shape post-injury recovery trajectories. This pilot study [...] Read more.

Background: Mild traumatic brain injury (mTBI) is frequently associated with persistent cognitive and psychosocial symptoms, yet biological correlates of recovery remain poorly understood, particularly among Asian and Pacific Islander (API) populations. Pre-injury psychosocial adversity may further shape post-injury recovery trajectories. This pilot study examined associations between participation in a 2-week, home-based, dual-task cognitive–walking intervention (Daily Brain Exercise; DBE) and changes in cognitive, psychological, and salivary microRNA (miRNAs) measures among APIs with and without a self-reported history of mTBI. Methods: API participants completed remote cognitive testing (CNS Vital Signs), psychosocial assessments (Neuro-QoL), and saliva collection before and after DBE participation. Salivary RNA was purified, and miRNA expression was profiled using nCounter^® Human v3 miRNA Expression Panels (NanoString). Differential expression analyses were conducted using ROSALIND^® platform (OnRamp Bioinformatics, San Diego, CA, USA), a cloud-based bioinformatics analysis system, to calculate fold changes and p-values. Pre-injury psychosocial adversity was assessed via the Trauma History Screen and examined descriptively as a contextual modifier of functional outcomes. Results: Twenty-one APIs (mean age 22.9 years; 76.7% female) were enrolled, including 14 individuals with a self-reported history of mTBI (mean 4.64 years post-injury; 50% with multiple injuries). Following DBE participation, increases in cognitive flexibility and executive function scores were observed in both mTBI and control groups. Additional increases in psychomotor speed, processing speed, sleep disturbance, and depressive symptoms were observed descriptively within the mTBI group. Subgroup analyses suggested variability in pre–post patterns across combinations of mTBI history and pre-injury psychosocial adversity. Exploratory miRNA analyses identified seven miRNAs that were differentially expressed in the mTBI group following DBE (unadjusted p < 0.005), including hsa-miR-7-5p, previously reported in association with neurodevelopmental and neurological pathways. Conclusions: In this pilot, feasibility-focused study, participation in a brief, home-based, dual-task intervention was associated with descriptive changes in selected cognitive and psychosocial measures among APIs, particularly those with a history of mTBI and pre-injury adversity. The observed subgroup patterns warrant confirmation in adequately powered, controlled studies. Exploratory changes in salivary miRNAs co-occurred with functional improvements, thus generating a hypothesis for a future investigation. Full article

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23 pages, 2513 KB

Open AccessEditor’s ChoiceReview

Triple Latency as a Driver of Chronic Inflammation: An Integrative View of HSV, EBV, and CMV Persistence in Immunocompetent Hosts

by Maria E. Ramos-Nino

Clin. Pract. 2026, 16(4), 64; https://doi.org/10.3390/clinpract16040064 - 24 Mar 2026

Abstract

Background: Herpes simplex virus (HSV), Epstein–Barr virus (EBV), and cytomegalovirus (CMV) establish lifelong latency in sensory neurons, lymphoid tissue, and myeloid–endothelial cells, respectively. A substantial proportion of adults worldwide are infected with all three viruses and may experience concurrent herpesvirus latency, yet they [...] Read more.

Background: Herpes simplex virus (HSV), Epstein–Barr virus (EBV), and cytomegalovirus (CMV) establish lifelong latency in sensory neurons, lymphoid tissue, and myeloid–endothelial cells, respectively. A substantial proportion of adults worldwide are infected with all three viruses and may experience concurrent herpesvirus latency, yet they have largely been studied independently. This review examined whether latent and intermittently reactivating herpesviruses share overlapping inflammatory signatures and whether their combined presence contributes to chronic inflammatory burden. Methods: A narrative integrative review was conducted using MEDLINE, Embase, and Google Scholar (inception–October 2025). Evidence from thirty-one cohort studies and mechanistic investigations spanning virology, immunology, neurology, and clinical medicine was synthesized. Results: Herpesvirus reactivation rates ranged from 23% in general Intensive Care Unit (ICU) populations to 85% in severe COVID-19. Concurrent reactivation of multiple viruses occurred in 34–63% of critically ill patients and was associated with worse clinical outcomes. Notably, simultaneous CMV and EBV reactivation independently predicted mortality (adjusted hazard ratio, 3.17; 95% CI, 1.41–7.13). Across infections, overlapping inflammatory biomarkers, including IL-6, TNF-α, CRP, and PGE₂, were consistently elevated, reflecting convergent activation of IFN and NF-κB signaling pathways. Mechanistic studies suggest cross-compartment immune priming, where CMV-driven T-cell exhaustion facilitates EBV reactivation, and viral cytokine signaling enhances HSV-associated neuroinflammation. Conclusions: HSV, EBV, and CMV triple latency may represent an underrecognized contributor to chronic inflammation in immunocompetent hosts. Understanding this multi-virus inflammatory network may inform mechanistic research, biomarker-guided risk stratification, and therapeutic strategies targeting convergent inflammatory pathways. Prospective interventional studies incorporating concurrent multi-virus monitoring are needed to clarify causal relationships. Full article

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12 pages, 1149 KB

Open AccessArticle

Preoperative Administration of Levosimendan to Prevent Low Cardiac Output Syndrome Following Pediatric Cardiac Surgery: A Retrospective Study

by Laurence Boillat, Laure Pache-Wannaz, Guillaume Maitre, Frida Rizzati, Maria Pérez Marin, Vivianne Chanez, Stefano Di Bernardo and Maria-Helena Perez

Clin. Pract. 2026, 16(3), 63; https://doi.org/10.3390/clinpract16030063 - 22 Mar 2026

Abstract

Background: Low cardiac output syndrome (LCOS) is a significant cause of postoperative morbidity and mortality in children with congenital heart disease. Prophylactic levosimendan is increasingly used to prevent LCOS, but its superiority to other strategies remains unproven. Based on the pharmacokinetics of levosimendan, [...] Read more.

Background: Low cardiac output syndrome (LCOS) is a significant cause of postoperative morbidity and mortality in children with congenital heart disease. Prophylactic levosimendan is increasingly used to prevent LCOS, but its superiority to other strategies remains unproven. Based on the pharmacokinetics of levosimendan, we hypothesize that preoperative administration is beneficial for preventing LCOS in a specifically at-risk population. Methods: This is a retrospective single-center cohort study in a tertiary pediatric intensive care unit. All patients under one year of age undergoing surgery for congenital heart disease using cardiopulmonary bypass and receiving levosimendan within 24 h before or after surgery were included and classified into two groups: preoperative and postoperative administration. Results: Overall, 107 patients were included. Fifty-three patients (49.5%) received levosimendan before surgery, with significantly lower mortality, fewer LCOS markers, and lower LCOS scores compared to patients receiving levosimendan after surgery. Although not significant, the use of extracorporeal membrane oxygenation, renal replacement therapy, and temperature control was also lower in the preoperative group. There was no difference in mechanical ventilation duration and length of stay. Conclusions: Preoperative administration of levosimendan seems associated with a lower incidence of LCOS and reduced mortality in high-risk children with congenital heart surgery. Full article

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8 pages, 360 KB

Open AccessArticle

Efficacy of Escherichia coli Nissle 1917 for the Prevention of Recurrent Urinary Tract Infections in Women: A Preliminary Controlled Prospective Study

by Filippo Murina, Cecilia Fochesato, Dario Recalcati and Valeria Savasi

Clin. Pract. 2026, 16(3), 62; https://doi.org/10.3390/clinpract16030062 - 21 Mar 2026

Abstract

Background/Objectives: More than 50% of adult women experience at least one urinary tract infection (UTI) during their lifetime, and approximately 25% develop recurrent UTIs (rUTIs), defined as ≥2 episodes within six months. Management of rUTI is challenging and often requires long-term, multimodal preventive [...] Read more.

Background/Objectives: More than 50% of adult women experience at least one urinary tract infection (UTI) during their lifetime, and approximately 25% develop recurrent UTIs (rUTIs), defined as ≥2 episodes within six months. Management of rUTI is challenging and often requires long-term, multimodal preventive strategies. Escherichia coli Nissle 1917 (EcN) is a non-pathogenic probiotic strain with demonstrated antagonistic activity against pathogenic enterobacteria. This study evaluated the efficacy and safety of EcN in preventing symptomatic recurrences in premenopausal women with rUTI. Methods: In this prospective observational study, 40 premenopausal women with rUTI were enrolled. Twenty patients received EcN prophylaxis (twice daily for four weeks, followed by once daily for eight weeks), while 20 patients received no prophylaxis and served as controls. Patients were followed for six months (three months of treatment and three months post-treatment). The primary outcome was the frequency of symptomatic rUTI episodes during follow-up. Results: Forty patients were analyzed (20 EcN; 20 controls). During the six-month observation period, 55% (11/20) of patients in the EcN group remained UTI-free compared with 35% (7/20) in the control group. Two patients (10%) in the EcN group experienced a single recurrence versus three (15%) in the control group. Recurrent episodes (≥2 UTIs) occurred in 35% (7/20) of EcN-treated patients compared with 50% (10/20) of controls. Overall, EcN prophylaxis was associated with a lower proportion of patients experiencing multiple recurrences. Conclusions: Prophylaxis with E. coli Nissle 1917 was associated with a reduced rate of recurrent UTIs compared with no prophylaxis in premenopausal women, supporting its potential role as a non-antibiotic preventive strategy in rUTI management. Full article

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