Journal of Clinical Medicine

14 pages, 1329 KB

Open AccessArticle

Comparison of Early Postoperative Recovery and Radiologic Outcomes Between Microscopic and Unilateral Biportal Endoscopic Posterior Cervical Foraminotomy for Cervical Radiculopathy

by Sang Youp Han, Sang Hyub Lee, Jae Won Jang, Choon Keun Park and Dong Geun Lee

J. Clin. Med. 2026, 15(12), 4589; https://doi.org/10.3390/jcm15124589 (registering DOI) - 12 Jun 2026

Abstract

Objective: This study aimed to compare the clinical and radiological outcomes between microscopic and unilateral biportal endoscopic (UBE) posterior cervical foraminotomy (PCF). Methods: This study included 73 patients who underwent microscopic PCF (n = 40) or UBE PCF (n [...] Read more.

Objective: This study aimed to compare the clinical and radiological outcomes between microscopic and unilateral biportal endoscopic (UBE) posterior cervical foraminotomy (PCF). Methods: This study included 73 patients who underwent microscopic PCF (n = 40) or UBE PCF (n = 33) for single-level cervical foraminal disc herniation or stenosis between January 2018 and December 2021. Clinical outcomes were measured using the Visual Analog Scale (VAS) and Neck Disability Index (NDI). Radiologic outcomes were evaluated with cervical range of motion (ROM) using computed tomography and flexion-extension dynamic radiography. Results: The mean follow-up period for microscopic and UBE PCF was 33.0 ± 7.6 months and 29.9 ± 5.9 months, respectively. The postoperative neck VAS until postoperative 2 weeks was significantly lower in the UBE PCF group than in the microscopic PCF group (p < 0.05). The estimated blood loss and operative time were significantly lower in the UBE PCF group than in the microscopic PCF group, while the length of hospital stay was numerically shorter but did not reach statistical significance. The two groups had no significant difference in the NDI on the preoperative and postoperative 3 months. The recurrence occurred in 1 patient (2.5%) of the microscopic PCF group and 1 patient (3%) of the UBE PCF group. The revision surgery was performed in 2 patients (5%) of the microscopic PCF group and in 1 patient of the UBE PCF group. There were no significant differences in motion and instability between the two groups. Conclusions: Both microscopic and UBE PCF are effective and safe procedures for treating cervical radiculopathy due to cervical foraminal disc herniation or stenosis. The UBE approach may provide advantages mainly in early postoperative recovery, including lower early postoperative neck pain, while long-term clinical and radiologic outcomes appear comparable to those of microscopic PCF. Full article

(This article belongs to the Special Issue Clinical Research on Minimally Invasive Spine Surgery)

17 pages, 45996 KB

Open AccessArticle

Drone-Induced Midfacial Blast Injuries: Early Definitive Reconstruction and 5-Year Outcomes from a Single-Center Cohort

by Anna Poghosyan, Martin Misakyan, Gurgen Mkhitaryan, Davit Minasyan, Irina Malkhasyan, Hayk Petrosyan, Anna Frangulyan, Aren Bablumyan, Armen Minasyan and Armen Muradyan

J. Clin. Med. 2026, 15(12), 4588; https://doi.org/10.3390/jcm15124588 (registering DOI) - 12 Jun 2026

Abstract

Background: Modern warfare has introduced novel mechanisms of injury, particularly drone-induced blast trauma, resulting in complex craniomaxillofacial injuries. These injuries differ substantially from typical ballistic wounds and require adapted surgical strategies. This study was conducted to evaluate the clinical characteristics, management approaches, and [...] Read more.

Background: Modern warfare has introduced novel mechanisms of injury, particularly drone-induced blast trauma, resulting in complex craniomaxillofacial injuries. These injuries differ substantially from typical ballistic wounds and require adapted surgical strategies. This study was conducted to evaluate the clinical characteristics, management approaches, and long-term outcomes of midfacial blast injuries. Methods: A retrospective analytical study was conducted on 41 patients with drone-induced midfacial blast injuries treated at a tertiary referral center in Armenia following the 2020 Nagorno-Karabakh War. All patients underwent surgical management after initial stabilization and were followed for 5 years. Clinical outcomes, complications, and reconstructive needs were assessed. Results: All patients presented with comminuted midfacial fractures, which were frequently associated with polytrauma (87.8%). Burns were observed in 82.9% of cases. Surgical management included radical debridement and early definitive osteosynthesis using titanium fixation systems. No cases of postoperative osteomyelitis, bone sequestration, or implant failure were observed during the 5-year follow-up period. Patients with extensive soft tissue defects, particularly nasal and lip amputations, required multiple reconstructive procedures. Long-term follow-up revealed progressive soft tissue thinning over titanium meshes, especially in the zygomatico-orbital region, necessitating secondary interventions such as lipofilling. Conclusions: Drone-induced midfacial blast injuries represent a distinct and severe form of trauma. Early definitive reconstruction following adequate debridement was associated with favorable outcomes. However, soft tissue reconstruction remains challenging and often requires staged procedures. Long-term follow-up is essential to manage delayed complications and optimize aesthetic outcomes. Full article

(This article belongs to the Special Issue Recent Advances in Prevention, Management, and Rehabilitation of Head and Neck Injuries)

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17 pages, 1752 KB

Open AccessArticle

Role of Oral Nutritional Supplements in Minimizing the Risk of Postoperative Malnutrition in Patients Undergoing Gastrointestinal Surgery

by Jarosław Cwaliński, Adam Bobkiewicz, Agnieszka Cwalińska, Wiktoria Zasada, Hanna Cholerzyńska, Tomasz Banasiewicz and Barbara Kuczyńska

J. Clin. Med. 2026, 15(12), 4587; https://doi.org/10.3390/jcm15124587 (registering DOI) - 12 Jun 2026

Abstract

Background/Objectives: Perioperative fasting combined with procedure-related trauma increases the risk of malnutrition and determines the treatment outcomes of surgical patients. The aim of this study was to assess the range of metabolic deficiencies and the effectiveness of oral nutritional supplements (ONSs) after [...] Read more.

Background/Objectives: Perioperative fasting combined with procedure-related trauma increases the risk of malnutrition and determines the treatment outcomes of surgical patients. The aim of this study was to assess the range of metabolic deficiencies and the effectiveness of oral nutritional supplements (ONSs) after surgical intervention. Methods: 84 patients undergoing elective abdominal surgery were included in this study. Patients were divided into three groups: receiving a low-osmotic ONS (Group I), high-osmotic ONS (Group II), and Group III, who did not receive any oral supplementation. The clinical assessment involved body weight measurements and metabolic blood tests preoperatively and on the 4th, 7th, 14th, and 28th postoperative days. Results: The mean blood levels of total protein, albumin, cholesterol, and blood lymphocyte count decreased in the first 4 days after surgery and returned to baseline between 7 and 14 days. Similarly, BMI dropped during the first two weeks and then stabilized or returned to pre-surgery values. Triglycerides initially increased and, after 14 days, started to normalize. Patients receiving an ONS compensated quicker than the control group and more efficiently with low-osmotic supplements. Conclusions: Surgical trauma is associated with metabolic deficiency. The early administration of ONSs provides significant benefits to patients undergoing abdominal surgery. Low-osmotic supplements are especially recommended due to better tolerance. Full article

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

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22 pages, 444 KB

Open AccessSystematic Review

Gut and Orbital Dysbiosis Associated with Graves’ Disease and Graves’ Orbitopathy: A Systematic Review

by Abdel Mohaimen Missaoui, Oumeyma Trimeche, Ekram Hajji and Helena Mosbah

J. Clin. Med. 2026, 15(12), 4586; https://doi.org/10.3390/jcm15124586 (registering DOI) - 12 Jun 2026

Abstract

Background/Objectives: Graves’ disease (GD) is a prevalent autoimmune thyroid disorder marked by thyrotoxicosis, goiter, and Graves’ orbitopathy (GO). Recent studies highlighted its association with dysbiosis. This systematic review aims to update the current literature and clarify the distinctive microbial signatures and dysbiosis associated [...] Read more.

Background/Objectives: Graves’ disease (GD) is a prevalent autoimmune thyroid disorder marked by thyrotoxicosis, goiter, and Graves’ orbitopathy (GO). Recent studies highlighted its association with dysbiosis. This systematic review aims to update the current literature and clarify the distinctive microbial signatures and dysbiosis associated with GD/GO. Methods: A systematic search for relevant studies was conducted across multiple databases (2000–2023), employing appropriate keywords. Relevant data were extracted from 25 eligible studies. Results: Microbiota analysis from 19 GD studies (713 patients, 546 controls) and eight GO studies (356 patients, 187 controls), primarily conducted in China (21/25), were examined. The gut microbiota richness and evenness were reduced in GD patients compared to controls in 62.5% of fecal samples. No consistent pattern in alpha diversity was observed in GO. Significant taxonomic divergence was observed between GD/GO and controls. At the phylum level, the Firmicutes to Bacteroidetes ratio was consistently decreased in GD patients (66.7%). Most GO patients also exhibited a similar disequilibrium in their gut and orbital adipose microflora. At the genus level, Prevotella (11 studies), genera within the Lactobacillaceae family (three studies), and Streptococcus (three studies) consistently showed an increase. Genera from the families Lachnospiraceae (nine studies), Ruminococcaceae (six studies), and Veillonellaceae (five studies), as well as the genus Bacteroides (three studies), were decreased. Conclusions: GD/GO-associated dysbiosis is characterized by reduced microbial richness and evenness and alterations in gut phyla balance (↓ Firmicutes, ↑ Bacteroidetes, ↑ Proteobacteria). Specific genera—including Lactobacillus, Prevotella, Bacteroides, and members of the Lachnospiraceae family—may plausibly act as contributors to the onset or progression of GD/GO by influencing the Th17/Treg balance, although their exact roles remain uncertain and largely hypothetical. Systematic review registration: PROSPERO identifier CRD42024512007. Full article

(This article belongs to the Section Endocrinology & Metabolism)

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10 pages, 456 KB

Open AccessArticle

Intraoperative Safety and Postoperative Complications After SMILE Pro: A Retrospective Case Series of 916 Eyes

by David Beckers, Florian Kretz, Lena Beckers, Amr Saad, Karsten Klabe, Hakan Kaymak, Mücella Kirca and Detlev Breyer

J. Clin. Med. 2026, 15(12), 4585; https://doi.org/10.3390/jcm15124585 (registering DOI) - 12 Jun 2026

Abstract

Purpose: To report intraoperative safety and postoperative complications after small-incision lenticule extraction using the 2 MHz femtosecond platform (SMILE Pro; VisuMax 800) in routine practice. Methods: Retrospective consecutive case series at a single center. All planned SMILE Pro procedures were analyzed [...] Read more.

Purpose: To report intraoperative safety and postoperative complications after small-incision lenticule extraction using the 2 MHz femtosecond platform (SMILE Pro; VisuMax 800) in routine practice. Methods: Retrospective consecutive case series at a single center. All planned SMILE Pro procedures were analyzed (916 eyes from 482 patients). Outcomes included completion rate, intraoperative events, postoperative complications stratified as <3 and >3 months, and retreatment rate. Results: Baseline age was 32.9 ± 6.9 years; average preoperative refraction was −3.60 ± 1.90/−0.87 ± 0.76 D (sphere/cylinder) with best corrected visual acuity of −0.08 ± 0.07 logMAR. Procedures were completed in 911 of 916 eyes (99.45%). Suction loss occurred in six eyes (0.66%); one was completed after redocking, four were converted (two ICL, two femtosecond LASIK) and one did not receive a second procedure. No failed lenticule separations occurred. Retreatment was performed in 14 eyes (1.54%): 11 re-LASIK, 2 ICL, and 1 cataract extraction. Early postoperative events (<3 months) were mainly superficial punctate keratitis (3.51%) and dry eye (1.32%); beyond 3 months, events remained uncommon (dry eye 1.65%, photopsia/halo/glare 0.88%). No severe or sight-threatening complications were observed. Conclusions: SMILE Pro on the VisuMax 800 showed a high completion rate, rare intraoperative disruption, low retreatment, and rare, mostly mild postoperative events. These findings support a favorable early safety profile in routine practice; longer-term follow-up is warranted. Full article

(This article belongs to the Section Ophthalmology)

10 pages, 215 KB

Open AccessArticle

Seasonal Effects on Corneal Densitometry and Haze After Mitomycin C-Assisted Photorefractive Keratectomy

by Halil Emre Özdemir, Muzaffer Talha Albayrak and Yusuf Koçluk

J. Clin. Med. 2026, 15(12), 4584; https://doi.org/10.3390/jcm15124584 (registering DOI) - 12 Jun 2026

Abstract

Purpose: To investigate whether the season in which photorefractive keratectomy (PRK) with mitomycin C (MMC) is performed influences postoperative corneal transparency considering seasonal variations in ultraviolet (UV) exposure. Methods: This retrospective study included 100 eyes of 50 patients who underwent MMC-assisted [...] Read more.

Purpose: To investigate whether the season in which photorefractive keratectomy (PRK) with mitomycin C (MMC) is performed influences postoperative corneal transparency considering seasonal variations in ultraviolet (UV) exposure. Methods: This retrospective study included 100 eyes of 50 patients who underwent MMC-assisted PRK for myopic refractive error. Patients were divided into two groups based on the season of surgery: winter (November–April, low UV exposure) and summer (May–October, high UV exposure). All patients were evaluated preoperatively and at 12 months postoperatively. Corneal transparency was objectively assessed using Scheimpflug-based corneal densitometry obtained with the Pentacam system, focusing on the central (0–2 mm) and paracentral (2–6 mm) zones. Postoperative densitometry values were compared between seasonal groups. Results: Corneal densitometry values showed a significant reduction postoperatively compared with preoperative measurements in both central and paracentral zones. When comparing seasonal groups, no statistically significant differences were observed in postoperative densitometry values between eyes operated on during summer and winter months. No clinically detectable corneal haze was observed in any patient throughout the follow-up period. Conclusions: Surgical season did not significantly influence postoperative corneal densitometry or clinically detectable haze formation after MMC-assisted PRK for low-to-moderate myopia, suggesting that deferral during high-UV months may not be necessary with standard postoperative UV protection. Full article

(This article belongs to the Section Ophthalmology)

19 pages, 3000 KB

Open AccessSystematic Review

Epidemiology, Risk Factors, Diagnosis, and Comorbidities of Endometriosis: An Umbrella Review

by Gulfiruz Urazbayeva, Shugyla Amirtayeva, Almagul Kurmanova, Damilya Salimbayeva, Madina Khalmirzaeva, Gaukhar Kurmanova, Zhanar Kypshakbayeva, Ainur Veliyeva and Altynay Nurmakova

J. Clin. Med. 2026, 15(12), 4583; https://doi.org/10.3390/jcm15124583 (registering DOI) - 12 Jun 2026

Abstract

Background: Endometriosis is a chronic estrogen-dependent inflammatory disease estimated to affect up to 190 million women of reproductive age worldwide based on clinical and population-based estimates, although only 22.3 million prevalent cases were formally documented—a gap that itself reflects substantial under-diagnosis. Despite an [...] Read more.

Background: Endometriosis is a chronic estrogen-dependent inflammatory disease estimated to affect up to 190 million women of reproductive age worldwide based on clinical and population-based estimates, although only 22.3 million prevalent cases were formally documented—a gap that itself reflects substantial under-diagnosis. Despite an exponential increase in systematic reviews (SRs) and meta-analyses (MAs), the evidence base remains fragmented across clinical domains. An umbrella review provides the methodologically highest level of evidence synthesis and allows critical appraisal and hierarchical classification of published SRs and MAs. Objective: The aim of this study was to conduct a comprehensive critical synthesis of published SRs and MAs on the epidemiology, pathogenesis, diagnosis, treatment, and long-term consequences of endometriosis and to assess their methodological quality using AMSTAR-2. Methods: Systematic searches were conducted in PubMed, Embase, Cochrane Library, and Scopus (2016–2026). Eligibility: SRs with or without MA covering any clinical aspect of endometriosis in women were considered eligible. Quality was assessed using AMSTAR-2. Association strength was classified as convincing (Class I), highly suggestive (Class II), suggestive (Class III), weak (Class IV), or non-significant (NS). Results: Fifty-two SRs and MAs were included (total sample > 6,000,000 participants). AMSTAR-2 quality: high 25% (n = 13), moderate 40% (n = 21), low 29% (n = 15), critically low 6% (n = 3). Class I evidence: short menstrual cycle (<27 days) associated with endometriosis risk (OR 1.68; 95% CI 1.48–1.89). Class II: post-operative dienogest reduces recurrence by 70% (OR 0.30; 95% CI 0.18–0.53); the risks of anxiety (RR 2.82; 95% CI 1.69–4.68) and depression (RR 2.78; 95% CI 1.63–5.25) are markedly elevated. Diagnostic delay persists at 4–12 years globally. Multi-biomarker platforms and AI-assisted imaging (e.g., PromarkerEndo and IMAGENDO) have shown promising preliminary diagnostic performance (reported AUCs of 0.997 and 0.906, respectively) in initial validation studies, although external validation in larger and more diverse cohorts is required before clinical implementation can be recommended. Conclusions: Endometriosis is a systemic, chronically under-diagnosed disease requiring a multidisciplinary approach. The available evidence supports dienogest as one of the preferred options for post-operative maintenance therapy, identifies multi-biomarker platforms as a promising—though not yet clinically validated—avenue for non-invasive diagnosis, and underscores the importance of incorporating psychological assessment into multidisciplinary management. Full article

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

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11 pages, 1750 KB

Open AccessArticle

Lymphatic Invasion Acts as a ‘Hidden Risk Factor’: Four-Fold Increased Mortality Risk in Early-Stage (TNM Stage I, N0) Non-Small Cell Lung Cancer

by Kadir Burak Özer, Suat Erus, Ezgi Cesur, Özgür Güzey, Pınar Bulutay, Serhan Tanju, Pınar Fırat and Şükrü Dilege

J. Clin. Med. 2026, 15(12), 4582; https://doi.org/10.3390/jcm15124582 (registering DOI) - 12 Jun 2026

Abstract

Background/Objectives: Despite advances in the TNM staging system, prognostic heterogeneity persists in early-stage non-small cell lung cancer (NSCLC). Lymphatic invasion (LI) is a known marker of aggression, but its independent significance in the critical, low-risk Stage I, N0 subgroup—typically ineligible for adjuvant [...] Read more.

Background/Objectives: Despite advances in the TNM staging system, prognostic heterogeneity persists in early-stage non-small cell lung cancer (NSCLC). Lymphatic invasion (LI) is a known marker of aggression, but its independent significance in the critical, low-risk Stage I, N0 subgroup—typically ineligible for adjuvant therapy—remains poorly defined. We hypothesized that LI acts as a powerful, yet hidden, risk factor in this highly favourable cohort. Methods: This retrospective cohort study included 988 consecutive patients who underwent curative anatomical resection for NSCLC. All patients underwent complete resection with pathologically confirmed negative surgical margins (R0 resection). Cases were staged according to the 9th Edition of the TNM Classification of Malignant Tumours (TNM-9) and grouped as LI-positive or LI-negative. A critical subgroup analysis focused on 347 truly low-risk patients (TNM Stage I, N0, no vascular or pleural invasion). Overall survival (OS) was evaluated using the Kaplan–Meier method and multivariable Cox proportional hazards models. Results: In the entire cohort (n = 988), LI was present in 40.9% of cases. LI positivity was an independent predictor of worse OS in multivariable analysis (HR: 1.520, 95% CI: 1.004–2.301, p = 0.048). In the low-risk subgroup (n = 347), the presence of LI resulted in a drastic survival divergence, with 5-year OS declining from 96.1% (LI-negative) to 83.8% (LI-positive). Multivariable analysis confirmed LI as an independent adverse prognostic factor in this subgroup (HR: 4.002, 95% CI: 1.567–10.221, p = 0.004). Conclusions: Lymphatic invasion is a robust, independent adverse prognostic factor in resected NSCLC. LI may identify a subset of early-stage N0 NSCLC patients who warrant closer postoperative surveillance and prospective evaluation for adjuvant treatment strategies. Validation in prospective cohorts is required before LI can be formally integrated into staging algorithms or treatment guidelines. Full article

(This article belongs to the Section Respiratory Medicine)

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14 pages, 1071 KB

Open AccessArticle

Triglyceride Threshold for Intensive Lipid-Lowering Therapy in Acute Hyper-Triglyceridemic Pancreatitis: A Retrospective Study

by Meiling Yu, Enqiang Mao, Yanyan Xu and Tongtian Ni

J. Clin. Med. 2026, 15(12), 4581; https://doi.org/10.3390/jcm15124581 (registering DOI) - 12 Jun 2026

Abstract

Background: The prognostic significance of early triglyceride (TG) reduction in hyper-triglyceridemic acute pancreatitis (HTG-AP) remains controversial. This study aimed to investigate the association between admission TG levels, early TG goal achievement, and clinical outcomes in patients with HTG-AP. Methods: This retrospective [...] Read more.

Background: The prognostic significance of early triglyceride (TG) reduction in hyper-triglyceridemic acute pancreatitis (HTG-AP) remains controversial. This study aimed to investigate the association between admission TG levels, early TG goal achievement, and clinical outcomes in patients with HTG-AP. Methods: This retrospective study included 345 patients with HTG-AP. Early TG goal achievement was defined as TG ≤ 5.65 mmol/L within 72 h of admission. Disease severity was classified according to the Revised Atlanta Classification. Associations between TG parameters and outcomes were analyzed using ordinal logistic regression. Results: No significant differences were observed between the goal-achieved (n = 274) and non-goal-achieved (n = 71) groups regarding pancreatic necrosis, hospital stay, or in-hospital mortality. Admission TG levels demonstrated that the highest TG levels did not correspond to the most severe disease course. Compared to patients with admission TG > 90.4 mmol/L, those with TG levels between 11.3 and 56.5 mmol/L had significantly lower odds of more severe disease, while no significant differences were found for TG levels between 56.5 and 90.4 mmol/L. Neither admission TG levels nor the degree of TG reduction within 72 h was significantly correlated with pancreatic necrosis. Conclusions: Early TG goal achievement was not associated with improved clinical outcomes in patients with HTG-AP. The routine use of aggressive early lipid-lowering therapy requires further validation before it can be routinely recommended. TG ≥ 56.5 mmol/L might represent a threshold for disease progression risk. Further studies are needed to determine the clinically meaningful cutoff value. Full article

(This article belongs to the Section Emergency Medicine)

15 pages, 1094 KB

Open AccessArticle

Inclusivity in Oral Care: A Comprehensive Dental Prevention Approach to Improve Cooperation and Oral Hygiene in Children with Special Needs

by Dalma Tábi, Orsolya Németh, Bálint Zsombor Sárai, Péter Hársfalvi, Kornélia Farkas, Tímea Vissi, Péter Hegyi, Gábor Varga, Dániel Végh, Alexander Schulze Wenning and Ibolya Túri

J. Clin. Med. 2026, 15(12), 4580; https://doi.org/10.3390/jcm15124580 (registering DOI) - 12 Jun 2026

Abstract

Objectives: Special care dentistry provides essential, customized oral health care for individuals with significant disabilities, addressing higher rates of dental issues and enhancing overall well-being. The aim of this pilot study was to evaluate the effect of an eight-week dental prevention program on [...] Read more.

Objectives: Special care dentistry provides essential, customized oral health care for individuals with significant disabilities, addressing higher rates of dental issues and enhancing overall well-being. The aim of this pilot study was to evaluate the effect of an eight-week dental prevention program on oral health outcomes and cooperation during dental treatment in children with special needs. Methods: The study targeted 97 children from Pető András Conductive Practical Primary School. A total of 16 children participated in the program, which consisted of eight weeks of education sessions focusing on oral hygiene practices and dental cooperation strategies. Dental assessments were conducted at baseline, weeks 8, 16, 52 and 104 using WHO protocols. Results: Significant improvements were observed following the 8-week preventive education program. OHI-S, DI-S, and CI-S values showed significant reductions at both week 8 and week 16 compared to baseline (p < 0.05). Patient cooperation, assessed using the Frankl scale, also improved significantly during the intervention period. Accommodation type demonstrated a significant association with OHI-S values, while diagnosis did not significantly influence the measured outcomes. Long-term follow-up demonstrated sustained improvements in oral hygiene and cooperation scores at both week 52 and week 104, indicating the potential long-term effectiveness of the preventive education program in children with special needs. Conclusions: The specific prevention program significantly improved oral health outcomes and cooperation among children with special needs. Full article

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

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8 pages, 1488 KB

Open AccessCase Report

Hypertrophic Olivary Degeneration Following Brainstem Hemorrhage in a Patient with Tremor: A Case Report with Serial MRI Follow-Up

by Seung Yoon Choi, Ji Woo Lee, Yu Jin Choi, Jin Hwan Cheong and Yeo Joon Yoon

J. Clin. Med. 2026, 15(12), 4579; https://doi.org/10.3390/jcm15124579 (registering DOI) - 12 Jun 2026

Abstract

Background: Hypertrophic olivary degeneration (HOD) is a rare neurological condition resulting from trans-synaptic degeneration of the inferior olivary nucleus (ION) following disruption of the dentato-rubro-olivary pathway, also known as the Guillain–Mollaret triangle (GMT). Although the clinical and radiologic features of HOD have [...] Read more.

Background: Hypertrophic olivary degeneration (HOD) is a rare neurological condition resulting from trans-synaptic degeneration of the inferior olivary nucleus (ION) following disruption of the dentato-rubro-olivary pathway, also known as the Guillain–Mollaret triangle (GMT). Although the clinical and radiologic features of HOD have been previously described, the precise temporal correlation between clinical symptom onset and manifestations on magnetic resonance imaging (MRI) remains difficult to establish, and the factors contributing to accelerated disease progression are poorly understood. Case Presentation: A 43-year-old male presented with intracerebral hemorrhage involving the left midbrain, bilateral pons, and cerebellum. Serial MRI was prospectively performed starting four weeks post-hemorrhage, at which time no signal abnormalities were detected in the ION. However, at 9 weeks, T2 hyperintensity first emerged in the bilateral ION. Approximately 2 weeks after this finding, the patient developed characteristic palatal and lingual tremors, accompanied by a dissociated vertical pendular nystagmus that was predominantly monocular (right eye). In addition, severe dysphagia was also noted, with videofluoroscopic swallowing study (VFSS) showing aspiration across all diets. A subsequent MRI obtained at 13 weeks post-insult (two weeks after tremor onset) revealed newly developed bilateral ION hypertrophy, with the maximal diameter increasing from a 5 mm baseline to 7 mm. Follow-up MRI at 17 weeks post-hemorrhage revealed further progression with increased hypertrophy and signal intensity. Dysphagia persisted throughout the clinical course, ultimately necessitating percutaneous endoscopic gastrostomy (PEG) tube insertion. Conclusions:This case provides rare, longitudinal documentation of the clinico-radiologic progression of HOD, facilitated by a pre-insult baseline MRI and prospective serial imaging. Our findings provide a detailed timeline of the transition from signal abnormality to hypertrophy in correlation with clinical symptom emergence. Full article

(This article belongs to the Section Clinical Neurology)

25 pages, 2005 KB

Open AccessReview

SGLT2 Inhibitors in Elderly Patients: Clinical Perspectives from Metabolic and Cardiorenal Protection to Implementation

by Iris Parrini, Roberto Ceravolo, Carmelo Massimiliano Rao, Fabiana Lucà, Michele Massimo Gulizia, Sandro Gelsomino, Nadia Ingianni, Giuseppe Carullo, Sebastiano Quartuccio, Stefania Renne, Claudio Bilato, Giovanna Geraci, Fabrizio Oliva, Federico Nardi and Massimo Grimaldi

J. Clin. Med. 2026, 15(12), 4578; https://doi.org/10.3390/jcm15124578 (registering DOI) - 12 Jun 2026

Abstract

The prevalence of diabetes and heart failure rises sharply with age, and their coexistence amplifies cardiovascular and renal risk. Elderly patients display unique clinical and biological profiles characterised by frailty, multimorbidity, and pharmacodynamic variability that challenge conventional treatment strategies. Sodium–glucose co-transporter-2 inhibitors (SGLT2i) [...] Read more.

The prevalence of diabetes and heart failure rises sharply with age, and their coexistence amplifies cardiovascular and renal risk. Elderly patients display unique clinical and biological profiles characterised by frailty, multimorbidity, and pharmacodynamic variability that challenge conventional treatment strategies. Sodium–glucose co-transporter-2 inhibitors (SGLT2i) have emerged as a cornerstone of cardio–renal–metabolic protection, with the most consistent cardiovascular benefit being the reduction in heart failure hospitalisation, whereas effects on cardiovascular death and major adverse cardiovascular events vary according to baseline cardiovascular risk, heart failure phenotype, diabetic status, and trial design. However, real-world use among the elderly remains limited due to concerns about tolerability, polypharmacy, and cost. This review analyses the pharmacological rationale and evidence base for SGLT2i therapy in older adults, highlighting mechanisms beyond glucose control, quantitative data from pivotal trials, and practical issues for geriatric implementation. Full article

(This article belongs to the Section Cardiology)

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10 pages, 731 KB

Open AccessArticle

Characteristics and Prediction Accuracy According to Corneal Stiffness in Suspected Keratoconus

by Se Hoon Choi, Seung Hyen Lee and Hyun Sung Leem

J. Clin. Med. 2026, 15(12), 4577; https://doi.org/10.3390/jcm15124577 (registering DOI) - 12 Jun 2026

Abstract

Background/Objectives: This study aimed to evaluate the biomechanical characteristics of the cornea to assess their diagnostic accuracy in distinguishing normal eyes from those suspected keratoconus eyes. Methods: In this cross-sectional study, corneal elevation and curvature radius were measured in 217 participants [...] Read more.

Background/Objectives: This study aimed to evaluate the biomechanical characteristics of the cornea to assess their diagnostic accuracy in distinguishing normal eyes from those suspected keratoconus eyes. Methods: In this cross-sectional study, corneal elevation and curvature radius were measured in 217 participants using Pentacam. Average values were obtained based on the best-fit sphere (BFS) and the enhanced best-fit sphere (EBFS). The biomechanical characteristics of the cornea were assessed using the Corvis ST device. Receiver operating characteristic curve analysis was performed to determine the diagnostic accuracy. Results: The radii of the BFS in the anterior and posterior corneas were significantly larger in the normal group compared to the suspected keratoconus group. Conversely, EBFS elevation values in both the anterior and posterior corneas were lower in the normal group. The velocity at which the cornea was first flattened had the highest diagnostic accuracy for identifying suspected keratoconus. Conclusions: Eyes with suspected keratoconus had a significantly smaller corneal radius on both the anterior and posterior surfaces compared with normal eyes. In addition, due to the increased deformability and reduced resistance to a given force, these parameters serve as valuable biometric indicators for distinguishing suspect eyes from normal eyes. Full article

(This article belongs to the Special Issue Anterior Segment Disorders)

73 pages, 2473 KB

Open AccessSystematic Review

Neurophysiology of Sleep-Deprivation Part 1: Effects of Sleep-Deprivation on Event-Related Potentials (ERPs)—Systematic and Mechanistic Review

by James Chmiel and Jarosław Nadobnik

J. Clin. Med. 2026, 15(12), 4576; https://doi.org/10.3390/jcm15124576 (registering DOI) - 12 Jun 2026

Abstract

Background: Sleep deprivation is one of the major public health and performance risk factors, with documented effects on vigilance, executive function, emotional regulation, and safety-critical behaviour. This review examines how event-related potentials (ERPs)—which provide millisecond-level resolution of cognitive processing stages—can clarify which neural [...] Read more.

Background: Sleep deprivation is one of the major public health and performance risk factors, with documented effects on vigilance, executive function, emotional regulation, and safety-critical behaviour. This review examines how event-related potentials (ERPs)—which provide millisecond-level resolution of cognitive processing stages—can clarify which neural processes are most affected by sleep loss, from early sensory encoding to later evaluative and control-related stages. Materials and Methods: This study was conducted as a systematic review of human studies on sleep deprivation and ERPs. Eligible studies included human participants, focused primarily on acute/total sleep deprivation, and reported ERP outcomes (e.g., amplitude, latency, topography, or related event-locked EEG measures). Searches were performed in major biomedical/psychology databases using sleep deprivation and ERP terms, with additional forward/backward citation searching. Data was extracted in a structured format (participant characteristics, deprivation protocol, ERP methods, behavioural outcomes, ERP findings, and recovery/countermeasure effects). Due to substantial heterogeneity in paradigms, protocols, and ERP methods, findings were synthesised narratively rather than meta-analysed. Risk of bias was assessed with RoB 2 and ROBINS-I. Results: The search identified 854 records, of which 82 studies were included following deduplication, screening, full-text review, and citation chasing. Samples were typically small, highly selected, and dominated by healthy young adults, with frequent attrition related to prolonged wakefulness and EEG data-quality constraints. Across studies, sleep deprivation produced stage-specific and task-dependent ERP effects rather than a single uniform pattern. The most consistent findings involved mid-to-late components. These components typically showed prolonged latency and reduced amplitude. In some cases, amplitude increases were observed and interpreted as compensatory recruitment. Early sensory/pre-attentive components (e.g., P1/N1/MMN/P50) were often relatively preserved, but showed selective vulnerability, including latency slowing, reduced filtering/gating, or decreased phase locking. A recurring observation was a behaviour–ERP dissociation, where ERP abnormalities were detectable even when behavioural impairment was modest, indicating covert neural inefficiency or compensation. Recovery sleep, naps, and countermeasures (e.g., modafinil, caffeine) produced partial, component-specific recovery, with amplitude and latency often recovering at different rates. Conclusions: The evidence indicates that sleep deprivation primarily disrupts higher-order, late-stage, and temporally coordinated neural processing, while earlier sensory processing is often preserved but becomes slower and less stable. Among ERP markers, the P300/P3 family is the most robust and informative signature of sleep loss effects and recovery. ERPs are therefore a sensitive tool for detecting neural dysfunction and compensation under sleep deprivation, including changes that may precede overt behavioural decline. Future research must improve the generalisability and reproducibility of ERP findings by employing larger, more diverse samples, alongside more standardised methodological, recording, and reporting practices. Full article

(This article belongs to the Special Issue Sleep Disorders: Current Research and Future Directions—Second Edition)

11 pages, 839 KB

Open AccessTechnical Note

Contralateral-Structure-Preserving Endoscopic Resection of Cervical Osteochondroma: A Technical Note

by Chun-Gon Park, Hyun-Seong Kim and Sung-Kyu Kim

J. Clin. Med. 2026, 15(12), 4575; https://doi.org/10.3390/jcm15124575 (registering DOI) - 12 Jun 2026

Abstract

Background: Cervical osteochondromas invading the vertebral canal are rare but may cause spinal cord compression requiring surgical resection. Conventional open laminectomy may disrupt posterior stabilizing structures and potentially increase the risk of postoperative cervical deformity. This technical note describes a contralateral-structure-preserving endoscopic technique [...] Read more.

Background: Cervical osteochondromas invading the vertebral canal are rare but may cause spinal cord compression requiring surgical resection. Conventional open laminectomy may disrupt posterior stabilizing structures and potentially increase the risk of postoperative cervical deformity. This technical note describes a contralateral-structure-preserving endoscopic technique for cervical osteochondroma resection. Methods: A 25-year-old man with multiple hereditary exostosis presented with neck pain, mild numbness, and a positive Lhermitte’s sign. Computed tomography and magnetic resonance imaging revealed a 9 × 6 × 10 mm osteochondroma originating from the base of the C3 spinous process and extending into the vertebral canal with spinal cord compression and cord signal change. Preoperative clinical assessment included a Visual Analog Scale (VAS) for neck pain of 6/10, a modified Japanese Orthopedic Association (mJOA) score of 16/18, a Neck Disability Index (NDI) of 30%, and Nurick grade 1. The lesion was treated using unilateral biportal endoscopic spine surgery through a partial unilateral laminectomy and sublaminar endoscopic corridor, aiming for en bloc resection while preserving the contralateral lamina, posterior ligamentous complex, and posterior tension band. Continuous intraoperative neurophysiological monitoring (SSEP and MEP) was used throughout the procedure. Results: The osteochondroma was completely resected en bloc using a diamond burr and Kerrison rongeur. Histopathological examination confirmed osteochondroma, and negative margins were identified without residual tumor. The patient’s symptoms resolved completely without postoperative complications, and he was discharged on postoperative day 3. At the 18-month clinical and radiological follow-up, the patient remained symptom-free, with VAS improved to 1–2/10, mJOA improved to 18/18, NDI improved to 4%, and Nurick grade improved to 0, with partial regression of the cord signal change and no evidence of tumor recurrence on follow-up imaging. Cervical lordosis was maintained at the immediate postoperative timepoint. Conclusions: Contralateral-structure-preserving endoscopic resection may represent a potential minimally invasive alternative to conventional wide laminectomy or fusion-based approaches in carefully selected cases of benign cervical osteochondroma. Larger comparative studies with long-term follow-up are required to confirm the potential biomechanical and clinical benefits of this approach. Full article

(This article belongs to the Special Issue Recent Advances and Future Perspectives on Spinal Surgeries)

10 pages, 22170 KB

Open AccessCase Report

Open-Window Thoracostomy Closure Using a Free Musculocutaneous Flap, Fascia Patch Graft, and Postoperative Compression Guided by Near-Infrared Spectroscopy: A Case Report

by Paloma Malagón, Cristian Carrasco, Carlos Martinez-Barenys, Sebastián Peñafiel, Martin Marzabal, Linda Klimavicius Palma and Carmen Higueras

J. Clin. Med. 2026, 15(12), 4574; https://doi.org/10.3390/jcm15124574 (registering DOI) - 12 Jun 2026

Abstract

Bronchopleural fistula is a rare but severe complication of lung resection, associated with significant morbidity and mortality, especially when an open-window thoracostomy is required. The clinical and surgical management is complex and becomes even more challenging in the presence of underlying conditions such [...] Read more.

Bronchopleural fistula is a rare but severe complication of lung resection, associated with significant morbidity and mortality, especially when an open-window thoracostomy is required. The clinical and surgical management is complex and becomes even more challenging in the presence of underlying conditions such as recurrent infections or malignancy. Postoperative management is equally demanding, as local compression may help prevent fistula recurrence but can compromise flap perfusion. A 65-year-old male with a history of right upper lobectomy and subsequent sublobar resection for lung adenocarcinoma presented with an 8 × 4 cm open-window thoracostomy complicated by chronic bronchopleural fistula and empyema. Extensive fibrosis of the surrounding tissues, including the ipsilateral latissimus dorsi muscle, limited the available reconstructive locoregional options. Reconstruction was performed using primary fistula closure reinforced with a contralateral free latissimus dorsi musculocutaneous flap and a fascia patch graft secured with cyanoacrylate-based bioadhesive. Postoperatively, continuous near-infrared spectroscopy monitoring enabled safe application of compressive bandage while minimizing the risk of flap perfusion compromise. Complete fistula closure was achieved. Apart from a surgical site abscess requiring debridement on postoperative day 7, no further complications occurred. At the 2-year follow-up, the patient remains free of fistula recurrence, wound dehiscence, or oncological relapse. We describe a novel approach for open-window thoracostomy closure combining a free musculocutaneous flap with a fascia patch graft reinforced by bioadhesive, together with postoperative perfusion monitoring using near-infrared spectroscopy. This strategy may help address both the reconstructive and postoperative challenges associated with complex bronchopleural fistulas. Full article

(This article belongs to the Special Issue Advances and Innovations in Reconstructive Microsurgery: Techniques, Outcomes, and Future Directions)

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13 pages, 948 KB

Open AccessArticle

Cancer History and Subjective Sleepiness in Obstructive Sleep Apnea: A Real-World Observational Study

by Giulia Sartori, Claudia Di Chiara, Andrea Gretter, Alberto Fantin and Ernesto Crisafulli

J. Clin. Med. 2026, 15(12), 4573; https://doi.org/10.3390/jcm15124573 (registering DOI) - 12 Jun 2026

Abstract

Background/Objectives: Daytime sleepiness in obstructive sleep apnea (OSA) shows substantial variability and is not fully explained by disease severity. This study aimed to evaluate whether a history of cancer is associated with subjective daytime sleepiness independently of respiratory burden. Methods: In this [...] Read more.

Background/Objectives: Daytime sleepiness in obstructive sleep apnea (OSA) shows substantial variability and is not fully explained by disease severity. This study aimed to evaluate whether a history of cancer is associated with subjective daytime sleepiness independently of respiratory burden. Methods: In this observational cohort study, 402 untreated patients with OSA were included. Cancer history was defined as a documented diagnosis of malignancy prior to baseline polygraphy. Daytime sleepiness was assessed using the Epworth Sleepiness Scale (ESS). Multivariable linear and logistic regression models were used to evaluate the association between cancer history and ESS (continuous and dichotomized as >10), adjusting for age, sex, body mass index, smoking status, chronic obstructive pulmonary disease, and apnea–hypopnea index (AHI). Sensitivity analyses additionally adjusted for heart disease and nocturnal hypoxic burden. Results: Sixty-two patients (15%) had a history of cancer. OSA severity and hypoxemia indices were comparable between groups. In multivariable analysis, cancer history was independently associated with modestly lower ESS scores (B = −1.66, 95% confidence interval [CI] −2.96 to −0.37; p = 0.012) and a reduced likelihood of excessive daytime sleepiness (ESS > 10) (odds ratio [OR] = 0.25, 95% CI 0.07 to 0.85; p = 0.027). Conclusions: In this real-world cohort of untreated patients with OSA, cancer history is associated with modestly lower subjective daytime sleepiness despite comparable disease severity, supporting a potential dissociation between physiological burden and symptom perception. These findings indicate that reliance on subjective sleepiness alone may contribute to under-recognition of clinically relevant OSA in patients with a cancer history. Full article

(This article belongs to the Special Issue Obstructive Sleep Apnea: Advances and Challenges in Diagnosis, Phenotyping, and Clinical Impact)

13 pages, 1450 KB

Open AccessPerspective

The Implementation Gap in Early Septic Shock Resuscitation: A Three-Barrier Framework

by Sajid Kadir, Travis Murphy and Joseph Shiber

J. Clin. Med. 2026, 15(12), 4572; https://doi.org/10.3390/jcm15124572 (registering DOI) - 12 Jun 2026

Abstract

The case for early vasopressor initiation in septic shock has been argued in detail in physiologic reviews and randomized trials. The evidence base is no longer the limiting factor. What remains limiting is delivery. Across most U.S. emergency departments and many international settings, [...] Read more.

The case for early vasopressor initiation in septic shock has been argued in detail in physiologic reviews and randomized trials. The evidence base is no longer the limiting factor. What remains limiting is delivery. Across most U.S. emergency departments and many international settings, patients with septic shock still do not reliably receive norepinephrine within the first hour of recognition. This review reframes the early-vasopressor question from a physiologic argument into an implementation problem and identifies three structural barriers that operate independently of any individual clinician’s understanding of the underlying evidence. The first is regulatory: the SEP-1 quality measure, despite a documented physician exception for the fluid requirement, continues to incentivize a fluids-first sequence as the institutional default. The second is cultural: the gap between policies that permit peripheral norepinephrine administration and the workflows, scope-of-practice arrangements, and standing orders required to actually start it at the bedside. The third is upstream: time-to-vasopressor is partly a downstream surrogate for time-to-recognition, and interventions that target only the pressor decision miss the larger source of delay. We propose a parallel resuscitation framework with explicit protocolized triggers and stratify implementation considerations across U.S. academic centers, U.S. community emergency departments, and resource-limited international settings. Closing the gap means stopping the physiology argument and rebuilding the operational architecture. Full article

(This article belongs to the Section Emergency Medicine)

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14 pages, 255 KB

Open AccessArticle

Long-Term Weight Loss Outcomes Following Sleeve Gastrectomy and Their Association with Diet Quality, Postoperative Complications, and Sociodemographic Factors: A Retrospective Cohort Study in Jeddah, Saudi Arabia

by Khalid A. Khormi, Walaa A. Mumena, Ahmed K. M. Salman, Ahmed A. Faden, Maryam S. Hafiz and Hebah A. Kutbi

J. Clin. Med. 2026, 15(12), 4571; https://doi.org/10.3390/jcm15124571 (registering DOI) - 12 Jun 2026

Abstract

Background/Objectives: Bariatric surgery is an effective intervention for severe obesity; however, long-term outcomes may be influenced by postoperative dietary behaviors, nutritional status, and complications. In Saudi Arabia, longitudinal evidence on weight trajectories and postoperative diet quality remains limited. The present study aimed at [...] Read more.

Background/Objectives: Bariatric surgery is an effective intervention for severe obesity; however, long-term outcomes may be influenced by postoperative dietary behaviors, nutritional status, and complications. In Saudi Arabia, longitudinal evidence on weight trajectories and postoperative diet quality remains limited. The present study aimed at evaluating three-year weight status trends; assessing sociodemographic factors, baseline BMI, and postoperative diet quality; and examining nutrition-related complications following bariatric surgery. Methods: This retrospective longitudinal study included 189 adults who underwent sleeve gastrectomy at two tertiary hospitals in Jeddah, Saudi Arabia. Anthropometric data were obtained from medical records at six time points: preoperative, two weeks, six months, one year, two years, and three years postoperatively. Diet quality and postoperative complications were assessed via structured telephone interviews. Weight outcomes were expressed as percentage of total body weight loss (%TBWL), excess body weight loss (%EWL), excess body mass index loss (%EBMIL), and weight regain. Statistical analyses included Friedman’s test, Mann–Whitney U test, and multiple linear regression. Results: Significant improvements in all weight loss indicators were observed over three years (p < 0.001). Diet quality score was the only significant variable associated with weight loss at three years, with higher scores associated with greater %EWL and %EBMIL. Baseline BMI and DQS were significantly associated with %EWL (Beta = −0.17, 95% CI: −1.72 to −0.13 and Beta = 0.21, 95% CI: 1.37 to 7.12, respectively) and %EBMIL (Beta = −0.15, 95% CI: −1.68 to −0.07 and Beta = 0.24, 95% CI: 1.90 to 7.66, respectively). Age was significantly associated with weight regain (Beta = 0.20, 95% CI: 0.02 to 1.08). Conclusions: Bariatric surgery resulted in sustained weight reduction over three years. Postoperative baseline BMI and diet quality were significantly associated with %EWL and %EBMIL, underscoring the importance of structured nutritional follow-up and counseling. Full article

(This article belongs to the Special Issue Bariatric Surgery: Current Status and Emerging Clinical Trends)

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