Journal of Clinical Medicine

14 pages, 1169 KiB

Open AccessArticle

Putting DOAC Doubts to Bed(Side): Preliminary Evidence of Comparable Functional Outcomes in Anticoagulated and Non-Anticoagulated Stroke Patients Using Point-of-Care ClotPro^® Testing

by Jessica Seetge, Balázs Cséke, Zsófia Nozomi Karádi, Edit Bosnyák, Eszter Johanna Jozifek and László Szapáry

J. Clin. Med. 2025, 14(15), 5476; https://doi.org/10.3390/jcm14155476 (registering DOI) - 4 Aug 2025

Abstract

Background/Objectives: Direct oral anticoagulants (DOACs) are now the guideline-recommended alternative to vitamin K antagonists (VKAs) for long-term anticoagulation in patients with non-valvular atrial fibrillation. However, accurately assessing their impact on ischemic stroke outcomes remains challenging, primarily due to uncertainty regarding anticoagulation status at [...] Read more.

Background/Objectives: Direct oral anticoagulants (DOACs) are now the guideline-recommended alternative to vitamin K antagonists (VKAs) for long-term anticoagulation in patients with non-valvular atrial fibrillation. However, accurately assessing their impact on ischemic stroke outcomes remains challenging, primarily due to uncertainty regarding anticoagulation status at the time of hospital admission. This preliminary study addresses this gap by using point-of-care testing (POCT) to confirm DOAC activity at bedside, allowing for a more accurate comparison of 90-day functional outcomes between anticoagulated and non-anticoagulated stroke patients. Methods: We conducted a retrospective cohort study of 786 ischemic stroke patients admitted to the University of Pécs between February 2023 and February 2025. Active DOAC therapy was confirmed using the ClotPro^® viscoelastic testing platform, with ecarin Clotting Time (ECT) employed for thrombin inhibitors and Russell’s Viper Venom (RVV) assays for factor Xa inhibitors. Patients were categorized as non-anticoagulated (n = 767) or DOAC-treated with confirmed activity (n = 19). Mahalanobis distance-based matching was applied to account for confounding variables including age, sex, pre-stroke modified Rankin Scale (mRS), and National Institutes of Health Stroke Scale (NIHSS) scores at admission and 72 h post-stroke. The primary outcome was the change in mRS from baseline to 90 days. Statistical analysis included ordinary least squares (OLS) regression and principal component analysis (PCA). Results: After matching, 90-day functional outcomes were comparable between groups (mean mRS-shift: 2.00 in DOAC-treated vs. 1.78 in non-anticoagulated; p = 0.745). OLS regression showed no significant association between DOAC status and recovery (p = 0.599). In contrast, NIHSS score at 72 h (p = 0.004) and age (p = 0.015) were significant predictors of outcome. PCA supported these findings, identifying stroke severity as the primary driver of outcome. Conclusions: This preliminary analysis suggests that ischemic stroke patients with confirmed active DOAC therapy at admission may achieve 90-day functional outcomes comparable to those of non-anticoagulated patients. The integration of bedside POCT enhances the reliability of anticoagulation assessment and underscores its clinical value for real-time management in acute stroke care. Larger prospective studies are needed to validate these findings and to further refine treatment strategies. Full article

(This article belongs to the Section Clinical Neurology)

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15 pages, 966 KiB

Open AccessArticle

Long-Term Follow-Up of Left Atrial Appendage Exclusion: Results of the V-CLIP Multi-Center Post-Market Study

by Elias Zias, Katherine G. Phillips, Marc Gerdisch, Scott Johnson, Ahmed El-Eshmawi, Kenneth Saum, Michael Moront, Michael Kasten, Chanderdeep Singh, Gautam Bhatia, Hiroo Takayama and Ralph Damiano

J. Clin. Med. 2025, 14(15), 5473; https://doi.org/10.3390/jcm14155473 (registering DOI) - 4 Aug 2025

Abstract

Background: Cardiac surgery patients with pre- or post-operative atrial fibrillation are at an increased risk for thromboembolic stroke, often due left atrial appendage (LAA) thrombus. Surgical LAA exclusion (LAAE) can be performed and must be complete to avoid increased thrombus formation. Methods [...] Read more.

Background: Cardiac surgery patients with pre- or post-operative atrial fibrillation are at an increased risk for thromboembolic stroke, often due left atrial appendage (LAA) thrombus. Surgical LAA exclusion (LAAE) can be performed and must be complete to avoid increased thrombus formation. Methods: This prospective, multi-center, post-market study (NCT05101993) evaluated the long-term safety and performance of the epicardial V-shape AtriClip device. Patients ≥18 years who had received V-shape AtriClip devices during non-emergent cardiac surgery consented to a prospective 12-month follow-up visit and LAA imaging. The primary performance was LAAE without residual left atrium-LAA communication, assessed by imaging at the last follow-up visit. The primary safety was device- or implant procedure-related serious adverse events (SAEs) (death, major bleeding, surgical site infection, pericardial effusion requiring intervention, myocardial infarction) within 30 days. Results: Of 155 patients from 11 U.S. centers, 151 patients had evaluable imaging. Complete LAAE was obtained in all patients. Primary performance in the intent-to-treat population was met, with 97% (95% CI 93.52%, 99.29%; p = 0.0001) complete LAAE. Primary safety was met, with 100% (95% CI 97.75%, 100%; p < 0.0001) of patients free from pre-defined SAEs within 30 days. One device-related SAE was reported, which resolved intraprocedurally. Conclusions: AtriClip V-Clip showed safe and successful LAAE through 12 months of follow-up. Full article

(This article belongs to the Special Issue Cardiac Surgery: Clinical Advances)

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Graphical abstract

14 pages, 2221 KiB

Open AccessArticle

Dynamic vs. Rigid: Transforming the Treatment Landscape for Multisegmental Lumbar Degeneration

by Caner Gunerbuyuk, Mehmet Yigit Akgun, Nazenin Durmus, Ege Anil Ucar, Helin Ilkay Orak, Tunc Oktenoglu, Ozkan Ates, Turgut Akgul and Ali fahir Ozer

J. Clin. Med. 2025, 14(15), 5472; https://doi.org/10.3390/jcm14155472 (registering DOI) - 4 Aug 2025

Abstract

Background: Multisegmental lumbar degenerative disease (ms-LDD) is a common condition in older adults, often requiring surgical intervention. While rigid stabilization remains the gold standard, it is associated with complications such as adjacent segment disease (ASD), higher blood loss, and longer recovery times. The [...] Read more.

Background: Multisegmental lumbar degenerative disease (ms-LDD) is a common condition in older adults, often requiring surgical intervention. While rigid stabilization remains the gold standard, it is associated with complications such as adjacent segment disease (ASD), higher blood loss, and longer recovery times. The Dynesys dynamic stabilization system offers an alternative by preserving motion while stabilizing the spine. However, data comparing Dynesys with fusion in multisegmental cases are limited. Objective: This study evaluates the clinical and radiographic outcomes of Dynesys dynamic stabilization versus rigid stabilization in the treatment of ms-LDD. Methods: A retrospective analysis was conducted on 53 patients (mean age: 62.25 ± 15.37 years) who underwent either Dynesys dynamic stabilization (n = 27) or PLIF (n = 26) for ms-LDD involving at least seven motion segments. Clinical outcomes were assessed using the Visual Analog Scale (VAS) and Oswestry Disability Index (ODI), while radiological parameters such as lumbar lordosis (LL), sagittal vertical axis (SVA), and spinopelvic parameters (pelvic incidence, pelvic tilt and, sacral slope) were analyzed. A two-stage surgical approach was employed in the Dynesys group to enhance osseointegration, particularly in elderly osteoporotic patients. Results: Both groups showed significant improvements in VAS and ODI scores postoperatively (p < 0.001), with no significant differences between them. However, the Dynesys group demonstrated superior sagittal alignment correction, with a significant increase in LL (p < 0.002) and a significant decrease in SVA (p < 0.0015), whereas changes in the rigid stabilization group were not statistically significant. Additionally, the Dynesys group had fewer complications, including a lower incidence of ASD (0 vs. 6 cases). The two-stage technique facilitated improved screw osseointegration and reduced surgical risks in osteoporotic patients. Conclusions: Dynesys dynamic stabilization is an effective alternative to rigid stabilization in ms-LDD, offering comparable pain relief and functional improvement while preserving motion and reducing ASD risk. The two-stage approach enhances long-term stability, making it particularly suitable for elderly or osteoporotic patients. Further long-term studies are needed to confirm these findings. Full article

(This article belongs to the Special Issue Orthopedic Surgery: Latest Advances and Perspectives)

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13 pages, 471 KiB

Open AccessArticle

Outcomes Following Achilles Tendon Ruptures in the National Hockey League: A Retrospective Sports Database Study

by Bradley A. Lezak, James J. Butler, Rohan Phadke, Nathaniel P. Mercer, Sebastian Krebsbach, Theodor Di Pauli von Treuheim, Alexander Tham, Andrew J. Rosenbaum and John G. Kennedy

J. Clin. Med. 2025, 14(15), 5471; https://doi.org/10.3390/jcm14155471 (registering DOI) - 4 Aug 2025

Abstract

Background: The purpose of this study was to evaluate Achilles tendon ruptures (ATR) in NHL players and the effects on return to play and player performance metrics. The incidence, mechanism of injury, management strategy, return to play (RTP), and post-injury were assessed from [...] Read more.

Background: The purpose of this study was to evaluate Achilles tendon ruptures (ATR) in NHL players and the effects on return to play and player performance metrics. The incidence, mechanism of injury, management strategy, return to play (RTP), and post-injury were assessed from official online sports databases. Methods: A retrospective review of NHL players who sustained a partial or complete tear of the Achilles tendon from 2008 to 2024 was performed. Data were collected from NHL injury databases and media reports, and included player demographics, injury mechanism, treatment, and post-injury performance metrics. A Wilcoxon signed rank test was used to compare pre-injury and post-injury performance metrics, with significance set at p < 0.05. Results: Here, 15 NHL players with a mean age of 27.8 years were identified, with a prevalence rate of 0.125 injuries per 10,000 athletic exposures. Overall, 73.3% of ATRs were non-contact in nature, with 60.0% of ATRs occurring during off-season training. Fourteen players were managed with non-operative treatment, with no re-ruptures reported. The RTP rate was 93.3%, with players missing a mean number of 45.7 games. However, there was a deterioration in post-injury performance metrics, including games played per season, plus/minus rating, and time on ice per game post-injury. Conclusions: This study found that Achilles tendon ruptures are an uncommon injury in NHL players, with a prevalence rate of 0.125 injuries per 10,000 athletic exposures. A high RTP rate of 93.3% was observed in this cohort. However, there was a deterioration in post-injury performance metrics, including games played per season, plus/minus rating, and time on ice per game post-injury, highlighting the potential devastating sequelae of ATRs in elite NHL athletes. Full article

(This article belongs to the Special Issue Advances in Knee Surgery and Musculoskeletal Rehabilitation: 2nd Edition)

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12 pages, 411 KiB

Open AccessArticle

High Sensitive Cardiac Troponin-I (Hs-cTnI) Levels in Asymptomatic Hemodialysis Patients

by Ofir Rabi, Linda Shavit, Ranel Loutati, Louay Taha, Mohammad Karmi, Akiva Brin, Dana Deeb, Nir Levi, Noam Fink, Pierre Sabouret, Mohammed Manassra, Abed Qadan, Motaz Amro, Michael Glikson and Elad Asher

J. Clin. Med. 2025, 14(15), 5470; https://doi.org/10.3390/jcm14155470 (registering DOI) - 4 Aug 2025

Abstract

Background: High-sensitivity cardiac troponin (hs-cTn) is useful for detecting acute myocardial infarction, but chronic hemodialysis patients often have elevated baseline levels that exceed the upper reference limit (URL). This study aimed to determine whether hs-cTnI levels in asymptomatic hemodialysis patients exceed the [...] Read more.

Background: High-sensitivity cardiac troponin (hs-cTn) is useful for detecting acute myocardial infarction, but chronic hemodialysis patients often have elevated baseline levels that exceed the upper reference limit (URL). This study aimed to determine whether hs-cTnI levels in asymptomatic hemodialysis patients exceed the URL established for the general population, evaluate the impact of high-flux hemodialysis on hs-cTnI concentrations, and examine associations between hs-cTnI levels and subsequent hospitalization or mortality. Methods: A prospective, single-center cohort study was conducted at a tertiary care center from August 2023 to July 2024. Blood samples for hs-cTnI were collected from asymptomatic hemodialysis patients aged ≥ 40 years, measured before and after dialysis within one month. Patients were followed for up to 12 months. Results: Fifty-six patients were enrolled. The mean hs-cTnI levels were 28.4 ng/L pre-dialysis and 27.9 ng/L post-dialysis, with ranges of <6–223 ng/L and <6–187 ng/L, respectively. The mean hs-cTnI delta between pre- and post-dialysis was −0.5 ng/L, with 52% showing a negative delta, 30% no change, and 18% a positive delta. No association was found between baseline hs-cTnI levels and mortality or hospitalization during follow-up. Conclusions: Most asymptomatic hemodialysis patients had hs-cTnI levels in the “gray zone”, thus neither confirming nor excluding acute myocardial infarction. Dialysis did not significantly affect hs-cTnI levels, and elevated baseline hs-cTnI was not linked to increased mortality or hospitalization over 12 months. Full article

(This article belongs to the Special Issue Acute Coronary Syndromes: Clinical Advances in Diagnosis and Treatment)

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10 pages, 506 KiB

Open AccessArticle

How Much Variance Exists Among Published Definitions of Proximal Junctional Kyphosis? A Retrospective Cohort Study of Adult Spinal Deformity

by Tim T. Bui, Karan Joseph, Alexander T. Yahanda, Samuel Vogl, Miguel Ruiz-Cardozo and Camilo A. Molina

J. Clin. Med. 2025, 14(15), 5469; https://doi.org/10.3390/jcm14155469 (registering DOI) - 4 Aug 2025

Abstract

Background/Objectives: We sought to characterize the variance and overlap among definitions of Proximal Junctional Kyphosis (PJK) used in the adult spinal deformity (ASD) literature. PJK is defined as excess in PJK angle, a Cobb angle between the upper-instrumented vertebra (UIV) and a [...] Read more.

Background/Objectives: We sought to characterize the variance and overlap among definitions of Proximal Junctional Kyphosis (PJK) used in the adult spinal deformity (ASD) literature. PJK is defined as excess in PJK angle, a Cobb angle between the upper-instrumented vertebra (UIV) and a supra-adjacent vertebra (SAV), either one (UIV+1) or two (UIV+2) levels rostral of the UIV. No expert consensus exists for threshold angle or which SAV to use. Methods: A total of 116 thoracolumbar fusion patients ≥ 65 years old were reviewed. The UIV+1 and UIV+2 angles were measured. Six definitions of PJK from the literature were evaluated. These definitions were selected based on citation frequency, historical relevance, and accessibility through commonly used databases. Pearson’s Chi-squared and pairwise comparisons were performed to evaluate the distinctness and agreement rates among these definitions. Results: The six definitions of PJK were as follows: [PJK20] PJK angle ≥ 20° with UIV+2 as the (SAV), [PJK10] PJK angle ≥ 10° with a >10° change from pre-op with UIV+2 as the SAV, [PJK2SD] PJK angle > 2 standard deviations from average with UIV+1 as the SAV, [PJK10+10] PJK angle ≥ 10° with a >10° change from pre-op with UIV+1 as the SAV, [PJK15] PJK angle > 15° with UIV+1 as the SAV, and [PJK30] PJK angle > 30° with UIV+2 as the SAV, or displaced rod fracture, or reoperation within 2 years for junctional failure, pseudoarthrosis, or rod fracture. [PJK10] and [PJK2SD] were the most distinct definitions while [PJK20], [PJK10+10], [PJK15], and [PJK30] showed no significant pairwise differences. [PJK2SD] was stringent, while definition [PJK30] included unique diagnostic information not captured by other definitions. Conclusions: The use of [PJK20], [PJK10+10], [PJK15], or [PJK30] is recommended for consistency, with [PJK15] presenting the best balance. Stringent [PJK2SD] may be beneficial for identifying severe PJK, though with low sensitivity. Overall, PJK definitions must be standardized for the consistent reporting of clinical outcomes and research comparability. Full article

(This article belongs to the Special Issue Optimizing Outcomes in Scoliosis and Complex Spinal Surgery)

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13 pages, 2643 KiB

Open AccessReview

Primary Hyperparathyroidism: 18F-Fluorocholine PET/CT vs. 4D-CT for Parathyroid Identification: Toward a Comprehensive Diagnostic Framework—An Updated Review and Recommendations

by Gregorio Scerrino, Nunzia Cinzia Paladino, Giuseppa Graceffa, Giuseppina Melfa, Giuseppina Orlando, Renato Di Vuolo, Chiara Lo Cicero, Alessandra Murabito, Stefano Radellini, Pierina Richiusa and Antonio Lo Casto

J. Clin. Med. 2025, 14(15), 5468; https://doi.org/10.3390/jcm14155468 (registering DOI) - 4 Aug 2025

Abstract

Introduction: Primary hyperparathyroidism (pHPT) is an endocrine disorder characterized by excessive parathyroid hormone production, typically due to adenomas, hyperplasia, or carcinoma. Preoperative imaging plays a critical role in guiding surgical planning, particularly in selecting patients for minimally invasive procedures. While first-line imaging [...] Read more.

Introduction: Primary hyperparathyroidism (pHPT) is an endocrine disorder characterized by excessive parathyroid hormone production, typically due to adenomas, hyperplasia, or carcinoma. Preoperative imaging plays a critical role in guiding surgical planning, particularly in selecting patients for minimally invasive procedures. While first-line imaging techniques, such as ultrasound and 99mTc-sestamibi scintigraphy, are standard, advanced second-line imaging modalities like 18F-fluorocholine PET/CT (FCH-PET) and four-dimensional computed tomography (4D-CT) have emerged as valuable tools when initial diagnostics are inconclusive. Methods: This article provides an updated review and recommendations of the role of these advanced imaging techniques in localizing parathyroid adenomas. Results: FCH-PET has shown exceptional sensitivity (94% per patient, 96% per lesion) and is particularly useful in detecting small or ectopic adenomas. Despite its higher sensitivity, it can yield false positives, particularly in the presence of thyroid disease. On the other hand, 4D-CT offers detailed anatomical imaging, aiding in the identification of parathyroids in challenging cases, including recurrent disease and ectopic glands. Studies suggest that FCH-PET and 4D-CT exhibit similar diagnostic performance and could be complementary in preoperative planning of most difficult situations. Conclusions: This article also emphasizes a multimodal approach, where initial imaging is followed by advanced techniques only in cases of uncertainty. Although 18F-fluorocholine PET/CT is favored as a second-line option, 4D-CT remains invaluable for its high spatial resolution and ability to guide surgery in complex cases. Despite limitations in evidence, these imaging modalities significantly enhance the accuracy of parathyroid localization, contributing to more targeted and minimally invasive surgery. Full article

(This article belongs to the Section General Surgery)

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14 pages, 1732 KiB

Open AccessArticle

A Promising Prognostic Indicator for Pleural Mesothelioma: Pan-Immuno-Inflammation Value

by Serkan Yaşar, Feride Yılmaz, Ömer Denizhan Tatar, Hasan Çağrı Yıldırım, Zafer Arık, Şuayib Yalçın and Mustafa Erman

J. Clin. Med. 2025, 14(15), 5467; https://doi.org/10.3390/jcm14155467 (registering DOI) - 4 Aug 2025

Abstract

Background: Pleural mesothelioma (PM) is a type of cancer that is difficult to diagnose and treat. Patients may have vastly varying prognoses, and prognostic factors may help guide the clinical approach. As a recently identified biomarker, the pan-Immune-Inflammation-Value (PIV) is a simple, comprehensive, [...] Read more.

Background: Pleural mesothelioma (PM) is a type of cancer that is difficult to diagnose and treat. Patients may have vastly varying prognoses, and prognostic factors may help guide the clinical approach. As a recently identified biomarker, the pan-Immune-Inflammation-Value (PIV) is a simple, comprehensive, and peripheral blood cell-based biomarker. Methods: The present study represents a retrospective observational analysis carried out within a single-center setting. Ninety-five patients with PM stages I–IV were enrolled in the study. We analyzed the correlation between patients’ demographic characteristics, clinicopathological factors such as histological subtypes, surgery status, tumor thickness, blood-based parameters, and treatment options with their prognoses. PIV was calculated by the following formula: (neutrophil count × monocyte count × platelet count)/lymphocyte count. Additionally, blood-based parameters were used to calculate the platelet-to-lymphocyte ratio (PLR), neutrophil-to-lymphocyte ratio (NLR), and systemic immune inflammation index (SII). Results: We categorized the patients into two groups, low PIV group (PIV ≤ 732.3) and high PIV group (PIV > 732.3) according to the determined cut-off value, which was defined as the median. It was revealed that high PIV was associated with poor survival outcomes. The median follow-up period was 15.8 months (interquartile range, IQR, 7.1 to 29.8 months). The median overall survival (OS) was significantly longer in patients in the low PIV group (median 29.8 months, 95% confidence interval (CI), 15.6 to 44) than the high PIV group (median 14.7 months, 95% CI, 10.8 to 18.6 p < 0.001). Furthermore, the study revealed that patients with low PIV, NLR, and SII values were more likely to be eligible for surgery and were diagnosed at earlier stages. Additionally, these markers were identified as potential predictors of disease-free survival (DFS) in the surgical cohort and of treatment response across the entire patient population. Conclusions: In addition to well-established clinical factors such as stage, histologic subtype, resectability, and Eastern Cooperative Oncology Group (ECOG) performance status (PS), PIV emerged as an independent and significant prognostic factor of overall survival (OS) in patients with PM. Moreover, PIV also demonstrated a remarkable independent prognostic value for disease-free survival (DFS) in this patient population. Additionally, some clues are provided for conditions such as treatment responses, staging, and suitability for surgery. As such, in this cohort, it has outperformed the other blood-based markers based on our findings. Given its ease of calculation and cost-effectiveness, PIV represents a promising and practical prognostic tool in the clinical management of pleural mesothelioma. It can be easily calculated using routinely available laboratory parameters for every cancer patient, requiring no additional cost or complex procedures, thus facilitating its integration into everyday clinical practice. Full article

(This article belongs to the Section Oncology)

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13 pages, 551 KiB

Open AccessArticle

Classifying Patient Characteristics and Determining a Predictor in Acute Stroke Patients: Application of Latent Class Analysis in Rehabilitation Practice

by Junya Uchida, Moeka Yamada, Hirofumi Nagayama, Kounosuke Tomori, Kohei Ikeda and Keita Yamauchi

J. Clin. Med. 2025, 14(15), 5466; https://doi.org/10.3390/jcm14155466 (registering DOI) - 4 Aug 2025

Abstract

Background/Objectives: Predicting comprehensive patient characteristics is essential for optimal individualized rehabilitation plans for acute stroke patients. However, current models primarily predict single outcomes. This study aimed to assess the applicability of latent class analysis (LCA) in rehabilitation practice by identifying comprehensive characteristics [...] Read more.

Background/Objectives: Predicting comprehensive patient characteristics is essential for optimal individualized rehabilitation plans for acute stroke patients. However, current models primarily predict single outcomes. This study aimed to assess the applicability of latent class analysis (LCA) in rehabilitation practice by identifying comprehensive characteristics and associated predictors in acute stroke patients. Methods: We conducted a retrospective observational study using the Japan Association of Rehabilitation Database, including 10,270 stroke patients admitted to 37 acute-care hospitals between January 2005 and March 2016. Patients were classified using LCA based on outcomes at discharge, including Functional Independence Measure (FIM), National Institutes of Health Stroke Scale (NIHSS) subscales for upper-extremity function, length of hospitalization, and discharge destination. Predictor variables at admission included age, FIM scores, NIHSS subscales for upper-extremity function, stroke type, and daily rehabilitation volume. Results: 6881 patients were classified into nine distinct classes (class size: 4–29%). Class 1, representing the mildest cases, was noted for independent ambulation and good upper limb function. Class 2 comprised those with the most severe clinical outcome. Other classes exhibited a gradient of severity, commonly encountered in clinical practice. For instance, Class 7 included right-sided paralysis with preserved motor activities of daily living (ADLs) and modified dependence in cognitive functions, such as communication. All predictors at admission were significantly associated with class membership at discharge (p < 0.001). Conclusions: LCA effectively identified unique clinical subgroups among acute stroke patients and demonstrated that key admission variables could predict class membership. This approach offers a promising insight into targeted, personalized rehabilitation practice for acute stroke patients. Full article

(This article belongs to the Section Clinical Rehabilitation)

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Graphical abstract

15 pages, 1570 KiB

Open AccessArticle

Systemic Inflammation Indices as Early Predictors of Severity in Acute Pancreatitis

by José Francisco Araiza-Rodríguez, Brandon Bautista-Becerril, Alejandra Núñez-Venzor, Ramcés Falfán-Valencia, Asya Zubillaga-Mares, Edgar Abarca-Rojano, Samuel Sevilla-Fuentes, Luis Ángel Mendoza-Vargas, Espiridión Ramos-Martínez, Bertha Berthaúd-González, Mauricio Avila-Páez, Jennifer Manilla-González, José Manuel Guerrero Jiménez and Liceth Michelle Rodríguez Aguilar

J. Clin. Med. 2025, 14(15), 5465; https://doi.org/10.3390/jcm14155465 (registering DOI) - 4 Aug 2025

Abstract

Background/Objectives: Acute pancreatitis (AP) is a highly variable inflammatory condition that can lead to severe complications and high mortality, particularly in its severe forms. Early risk stratification is essential; however, the delayed availability of traditional scoring systems often limits its effectiveness. This [...] Read more.

Background/Objectives: Acute pancreatitis (AP) is a highly variable inflammatory condition that can lead to severe complications and high mortality, particularly in its severe forms. Early risk stratification is essential; however, the delayed availability of traditional scoring systems often limits its effectiveness. This study aimed to evaluate the clinical utility of systemic inflammation indices as early predictors of severity in patients with acute pancreatitis. Methods: A retrospective, observational study was conducted among patients diagnosed with acute pancreatitis, classified according to the revised Atlanta criteria. Upon admission, systemic inflammation indices were calculated from complete blood count parameters, including neutrophil-to-lymphocyte ratio (NLR), monocyte-to-lymphocyte ratio (MLR), systemic immune-inflammation index (SII), systemic inflammation response index (SIRI), and aggregate index of systemic inflammation (AISI). Severity was assessed using the APACHE II score. Statistical analysis involved Kruskal–Wallis tests, Dunn’s post hoc comparisons, ROC curve analysis, logistic regression for odds ratios (ORs), and Spearman correlations. Results: SII, NLR, MLR, SIRI, and AISI showed statistically significant associations with AP severity (p < 0.05). MLR and SIRI exhibited the highest predictive performance (AUC = 0.74). ORs for severe pancreatitis were: MLR = 19.10, SIRI = 7.50, NLR = 7.33, AISI = 5.12, and SII = 4.10. All four indices also demonstrated moderate positive correlations with APACHE II scores. Conclusions: Systemic inflammation indices are simple, cost-effective, and accessible tools that can aid in the early identification of patients at high risk for severe acute pancreatitis. Their integration into clinical practice may enhance early decision-making and improve patient outcomes. Full article

(This article belongs to the Special Issue Preventive, Diagnostic and Therapeutic Strategies for Abdominal Surgery Complications (Second Edition))

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9 pages, 364 KiB

Open AccessArticle

Impact of Surgical Margins and Adjuvant Radiotherapy on Local Recurrence and Survival in Sacral Chordoma

by Furkan Erdoğan, Alparslan Yurtbay, Bedirhan Albayrak, Tolgahan Cengiz and Nevzat Dabak

J. Clin. Med. 2025, 14(15), 5464; https://doi.org/10.3390/jcm14155464 (registering DOI) - 4 Aug 2025

Abstract

Background: This study aimed to evaluate the impact of surgical margin status, tumor size, and adjuvant radiotherapy on local control, overall survival, and postoperative complications in patients undergoing surgery for sacral chordoma. Methods: This retrospective analysis included 18 patients who underwent surgical treatment [...] Read more.

Background: This study aimed to evaluate the impact of surgical margin status, tumor size, and adjuvant radiotherapy on local control, overall survival, and postoperative complications in patients undergoing surgery for sacral chordoma. Methods: This retrospective analysis included 18 patients who underwent surgical treatment for primary sacral chordoma between 2002 and 2019. The variables assessed included patient demographics, tumor size and volume, surgical margin status, adjuvant radiotherapy, local recurrence, overall survival, and postoperative complications. Survival analysis was performed using the Kaplan–Meier method, and appropriate parametric or non-parametric tests were used for group comparisons. Results: The cohort’s mean age was 62.6 ± 7.9 years, with a mean follow-up of 8.8 ± 4.1 years and an average tumor volume of 235 cm³. Negative surgical margins (R0) were achieved in 44% of patients. Local recurrence occurred in 50% of R0 cases and 83% of R2 cases. Negative surgical margins (R0) were associated with significantly lower local recurrence rates compared to R1 and R2 resections (Fisher’s exact test, p = 0.043), and showed a trend toward improved overall survival (p = 0.077). Overall survival was significantly lower in patients with tumors measuring ≥ 5 cm (p = 0.031). Adjuvant radiotherapy did not significantly reduce local recurrence (p = 0.245); however, an increase in complication rates was observed, although this association did not reach statistical significance (p = 0.108). Bladder dysfunction was significantly more frequent in patients undergoing S1–S2 resections (p = 0.036). Conclusions: Achieving negative surgical margins improves local control and may prolong survival. Larger tumors (≥5 cm) were associated with worse prognosis. While adjuvant RT may be considered in selected high-risk cases, its efficacy in preventing recurrence is unclear and may increase complication rates. Full article

(This article belongs to the Special Issue Clinical Management and Treatment of Orthopedic Oncology: 2nd Edition)

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8 pages, 321 KiB

Open AccessArticle

High Variability in the Use of Cement for Femoral Stem Fixation in Hip Fractures—An Analysis of the Canadian Joint Replacement Registry

by Fernando Diaz Dilernia, Eric Bohm and Gavin C. A. Wood

J. Clin. Med. 2025, 14(15), 5463; https://doi.org/10.3390/jcm14155463 (registering DOI) - 4 Aug 2025

Abstract

Background: This study examines current trends in Canada using data from the Canadian Joint Replacement Registry (CJRR) and includes a national survey to understand the varied uptake of cement for femoral stem fixation. Methods: The survey was available online and the [...] Read more.

Background: This study examines current trends in Canada using data from the Canadian Joint Replacement Registry (CJRR) and includes a national survey to understand the varied uptake of cement for femoral stem fixation. Methods: The survey was available online and the website link was distributed to all orthopaedic surgeons through the Canadian Orthopaedic Association between September and December 2022. The CJRR obtained data from the Canadian Institute for Health Information (CIHI), and information pertaining to patients 55 years of age and older who underwent hemiarthroplasty for hip fracture in Canada between April 2017 and March 2022 was used. Results: Most respondents practiced in an academic community setting (52%). Only 53% of respondents reported using cement, and 71% indicated that cemented fixation was the best practice. The main reasons for using uncemented stems were less operative time (23%), cement disease concerns (11%), and surgeons’ comfort (10%). Similarly, CJRR data showed only 51% cemented fixation among 42,386 hemiarthroplasties performed between 2017 and 2022. The proportion of cemented implants varied by province, but overall, the increase in the use of cement from 2017 to 2022 was from 42.9% to 57.7%. Conclusions: This study demonstrates variability in the use of cement for femoral fixation despite solid evidence showing improved outcomes using cement. Some of the main reasons in favour of uncemented stems include operative time, surgical training, and concerns about cement disease. Establishing clear position statements and guidelines supporting cemented fixation may be prudent to build universal consensus on this practice. Full article

(This article belongs to the Special Issue Hip Diseases: From Joint Preservation to Hip Arthroplasty Revision)

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12 pages, 480 KiB

Open AccessArticle

A Novel Deep Learning Model for Predicting Colorectal Anastomotic Leakage: A Pioneer Multicenter Transatlantic Study

by Miguel Mascarenhas, Francisco Mendes, Filipa Fonseca, Eduardo Carvalho, Andre Santos, Daniela Cavadas, Guilherme Barbosa, Antonio Pinto da Costa, Miguel Martins, Abdullah Bunaiyan, Maísa Vasconcelos, Marley Ribeiro Feitosa, Shay Willoughby, Shakil Ahmed, Muhammad Ahsan Javed, Nilza Ramião, Guilherme Macedo and Manuel Limbert

J. Clin. Med. 2025, 14(15), 5462; https://doi.org/10.3390/jcm14155462 (registering DOI) - 3 Aug 2025

Abstract

Background/Objectives: Colorectal anastomotic leak (CAL) is one of the most severe postoperative complications in colorectal surgery, impacting patient morbidity and mortality. Current risk assessment methods rely on clinical and intraoperative factors, but no real-time predictive tool exists. This study aimed to develop [...] Read more.

Background/Objectives: Colorectal anastomotic leak (CAL) is one of the most severe postoperative complications in colorectal surgery, impacting patient morbidity and mortality. Current risk assessment methods rely on clinical and intraoperative factors, but no real-time predictive tool exists. This study aimed to develop an artificial intelligence model based on intraoperative laparoscopic recording of the anastomosis for CAL prediction. Methods: A convolutional neural network (CNN) was trained with annotated frames from colorectal surgery videos across three international high-volume centers (Instituto Português de Oncologia de Lisboa, Hospital das Clínicas de Ribeirão Preto, and Royal Liverpool University Hospital). The dataset included a total of 5356 frames from 26 patients, 2007 with CAL and 3349 showing normal anastomosis. Four CNN architectures (EfficientNetB0, EfficientNetB7, ResNet50, and MobileNetV2) were tested. The models’ performance was evaluated using their sensitivity, specificity, accuracy, and area under the receiver operating characteristic (AUROC) curve. Heatmaps were generated to identify key image regions influencing predictions. Results: The best-performing model achieved an accuracy of 99.6%, AUROC of 99.6%, sensitivity of 99.2%, specificity of 100.0%, PPV of 100.0%, and NPV of 98.9%. The model reliably identified CAL-positive frames and provided visual explanations through heatmaps. Conclusions: To our knowledge, this is the first AI model developed to predict CAL using intraoperative video analysis. Its accuracy suggests the potential to redefine surgical decision-making by providing real-time risk assessment. Further refinement with a larger dataset and diverse surgical techniques could enable intraoperative interventions to prevent CAL before it occurs, marking a paradigm shift in colorectal surgery. Full article

(This article belongs to the Special Issue Updates in Digestive Diseases and Endoscopy)

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15 pages, 1265 KiB

Open AccessSystematic Review

Optimal Recipient Nerve Selection for Breast Neurotization with Abdominal Flaps: A Comprehensive Meta-Analysis of Anterior and Lateral Intercostal Approaches

by Woonhyeok Jeong, Jaehoon Choi, Junhyung Kim, Daegu Son and Taehee Jo

J. Clin. Med. 2025, 14(15), 5461; https://doi.org/10.3390/jcm14155461 (registering DOI) - 3 Aug 2025

Abstract

Background: Breast reconstruction post-mastectomy has increasingly emphasized the importance of sensory restoration. This study aimed to evaluate the comparative efficacy of anterior versus lateral cutaneous intercostal nerve branches in neurotization during abdominal-based autologous breast reconstruction. Methods: Through a systematic literature search and meta-analysis, [...] Read more.

Background: Breast reconstruction post-mastectomy has increasingly emphasized the importance of sensory restoration. This study aimed to evaluate the comparative efficacy of anterior versus lateral cutaneous intercostal nerve branches in neurotization during abdominal-based autologous breast reconstruction. Methods: Through a systematic literature search and meta-analysis, we reviewed studies published between January 2003 and August 2023. Our methods involved categorizing studies based on the nerve branch used, extracting relevant data, and conducting a quality assessment. To determine the difference in the magnitude of sensory recovery, a meta-analysis was conducted to pool the effect sizes (mean differences) from individual studies. Given the potential for heterogeneity across studies, a random-effects model was employed using the DerSimonian and Laird method. Subgroup analysis was then performed to separately evaluate the effect sizes for the anterior and lateral groups. Results: We identified five studies for the anterior group and five studies for the lateral group. The anterior group included a total of 225 non-neurotized and 240 neurotized breasts, while the lateral group consisted of 62 non-neurotized and 51 neurotized breasts. The anterior group exhibited superior sensory recovery compared to the lateral group (p = 0.08 for the common effect model). The result was borderline significant, suggesting a trend towards a difference between the two groups. In terms of patient-reported outcomes, the anterior group provided data, while the lateral group lacked such data, underscoring a potential research gap. Conclusions: Results indicated a trend favoring the anterior cutaneous branch, with studies showing improved sensory outcomes and patient satisfaction. However, the choice between the two should be individualized, considering the patient’s unique needs and the surgeon’s expertise. Full article

(This article belongs to the Special Issue Current State of Breast Reconstruction)

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11 pages, 876 KiB

Open AccessArticle

Body Composition Changes in Hospitalized Patients with Community-Acquired Pneumonia

by Ryuji Sugiya, Osamu Nishiyama, Masashi Shiraishi, Kazuya Yoshikawa, Kyuya Gose, Ryo Yamazaki, Takashi Oomori, Akiko Sano, Shinichi Arizono, Yasushi Uchiyama, Yuji Higashimoto and Hisako Matsumoto

J. Clin. Med. 2025, 14(15), 5460; https://doi.org/10.3390/jcm14155460 (registering DOI) - 3 Aug 2025

Abstract

Background: The influence of hospitalization owing to pneumonia on changes in body composition has not been specifically reported. We conducted a prospective cohort study of patients with community-acquired pneumonia (CAP) requiring hospitalization to test the hypothesis that hospitalization affects body composition. Methods [...] Read more.

Background: The influence of hospitalization owing to pneumonia on changes in body composition has not been specifically reported. We conducted a prospective cohort study of patients with community-acquired pneumonia (CAP) requiring hospitalization to test the hypothesis that hospitalization affects body composition. Methods: Sixty-four consecutive patients with CAP were recruited. Body composition was measured within 24 h of admission and 24 h before discharge using bioelectrical impedance analysis. The association between changes in body composition and variables obtained at admission was investigated. Index values were calculated as weight divided by height squared. Results: The mean age of the patients was 76.0 ± 8.7 years (78.1% males). The median length of hospitalization was 12.0 days. Weight, body mass index (BMI), skeletal muscle (SM), SM index, fat-free mass (FFM), and FFM index significantly decreased (p < 0.001 for each), but fat mass (FM) and FM index did not. The serum total protein level was the only independent predictor of the lowest quartile of change in SM index (<−0.4) after adjusting for age and sex (p = 0.004). Conclusions: In summary, weight and BMI significantly decreased during hospitalization in patients with CAP, which was attributed to SM reduction. Patients with low serum total protein levels on admission were at risk of an accelerated decrease in the SM index. Nutritional intervention and rehabilitation are important for these patients. Full article

(This article belongs to the Special Issue Advancements in Gait Rehabilitation: Innovative Approaches and Clinical Insights)

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10 pages, 229 KiB

Open AccessArticle

The Impact of Obesity on Clostridioides difficile Infection Outcomes: A Retrospective Cohort Study

by Alaa Atamna, Manar Khalaila, Tanya Babich, Anan Zriek, Haim Ben Zvi, Gida Ayada, Avishay Elis, Jihad Bishara and Amir Nutman

J. Clin. Med. 2025, 14(15), 5459; https://doi.org/10.3390/jcm14155459 (registering DOI) - 3 Aug 2025

Abstract

Background: Studies have demonstrated a positive correlation between high body mass index (BMI) and an increased risk of Clostridioides difficile infection (CDI), independent of antibiotic usage or healthcare exposures. Aim: To compare the outcomes of obese (BMI ≥ 30 kg/m²) and [...] Read more.

Background: Studies have demonstrated a positive correlation between high body mass index (BMI) and an increased risk of Clostridioides difficile infection (CDI), independent of antibiotic usage or healthcare exposures. Aim: To compare the outcomes of obese (BMI ≥ 30 kg/m²) and non-obese (BMI < 30 kg/m²) hospitalized patients with CDI. Methods: This retrospective cohort study included patients with CDI hospitalized in Beilinson hospital between January 2013 and January 2020. The primary outcome was 90-day all-cause mortality. Secondary outcomes included 30-day mortality, colectomy, intensive care unit (ICU) admission and length of hospital stay (LOS). Multivariate analysis was performed to identify the risk factors independently associated with 90-day mortality. Results: The study included 889 patients: 131 (15%) obese and 758 (85%) non-obese. The obese group was younger (median age 65 years vs. 73 years (p < 0.01)) and with a higher rate of diabetes mellitus (57/131 (44%) vs. 180/758 (24%) (p < 0.01)). The 90-day mortality was lower in the obese group: 19/131 (15%) vs. 170/752 (23%) (p = 0.04). The 30-day mortality was 8/131 (6%) vs. 96/757 (13%) (p = 0.03). ICU admission was 9/131 (7%) vs. 23/758 (3%) (p = 0.03), and median LOS was 19 vs. 12 days (p < 0.01) in obese and non-obese groups, respectively. In the multivariable analysis, after adjustment for age, Charlson’s comorbidity index ≥3, assistance in activities of daily living, treatment with proton pump inhibitors and severity of illness, obesity was not a significant risk factor for 90-day mortality (OR = 0.65, 95% CI: 0.38–1.01; p = 0.1). Conclusions: In this study, obesity was not significantly associated with 90-day mortality after adjustment for other risk factors; however, ICU admission was higher and LOS longer in this group. Full article

(This article belongs to the Special Issue Hospital-Acquired Infections: Evolving Threats and Epidemiological Insights)

17 pages, 1857 KiB

Open AccessSystematic Review

Effects of Pomegranate Juice on Androgen Levels, Inflammation and Lipid Profile in Polycystic Ovary Syndrome: A Systematic Review and Meta-Analysis

by Vitória Silveira, Pamela Braz, Antonio Jose Grande, Tamy Colonetti, Maria Laura Rodrigues Uggioni, Gabriele da Silveira Prestes, Leonardo Roever, Valdemira Santina Dagostin and Maria Inês da Rosa

J. Clin. Med. 2025, 14(15), 5458; https://doi.org/10.3390/jcm14155458 (registering DOI) - 3 Aug 2025

Abstract

Background/Objectives: Polycystic ovary syndrome (PCOS) is a multifactorial endocrine disorder frequently associated with metabolic and inflammatory disturbances. Due to its antioxidant and anti-inflammatory properties, pomegranate juice has been proposed as a potential adjunctive therapy in managing PCOS. To evaluate the effects of pomegranate [...] Read more.

Background/Objectives: Polycystic ovary syndrome (PCOS) is a multifactorial endocrine disorder frequently associated with metabolic and inflammatory disturbances. Due to its antioxidant and anti-inflammatory properties, pomegranate juice has been proposed as a potential adjunctive therapy in managing PCOS. To evaluate the effects of pomegranate juice on hormonal, inflammatory, and lipid parameters and body mass index (BMI) in women with PCOS. Methods: A systematic review and meta-analysis of randomized controlled trials (RCTs) was conducted following PRISMA guidelines. Comprehensive searches were performed in electronic databases including Medline, Scopus, Web of Science, Cochrane CENTRAL, and Embase from inception to July 2025, using keywords and MeSH terms related to “polycystic ovary syndrome” and “pomegranate juice” without language restrictions. The primary outcomes were changes in serum testosterone, luteinizing hormone (LH), high-sensitivity C-reactive protein (hs-CRP), lipid profile parameters (HDL, LDL, triglycerides, and total cholesterol), and body mass index (BMI). Results: Four RCTs published between 2020 and 2023, encompassing 128 women with PCOS, were included. The meta-analysis revealed significant reductions in testosterone (MD: −0.05; 95% CI: −0.07 to −0.03; p < 0.0001; I² = 0%, two studies, 85 participants) and hs-CRP (SMD: −0.85; 95% CI: −1.35 to −0.35; p = 0.0009; I² = 20%, two studies, 85 participants), along with increases in HDL (MD: 6.21; 95% CI: 2.43 to 10.00; p = 0.001; I² = 0%, two studies, 85 participants) and reductions in triglycerides (MD: −23.30; 95% CI: −45.19 to −1.42; p = 0.04; I² = 0%, two studies, 85 participants). No significant changes were observed in LH, LDL, total cholesterol, or BMI. Conclusions: Pomegranate juice demonstrates promising effects as an adjunctive intervention in women with PCOS, improving androgen levels, inflammatory markers, and certain lipid parameters. Further long-term studies are needed to confirm these findings. Full article

(This article belongs to the Section Clinical Laboratory Medicine)

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11 pages, 890 KiB

Open AccessArticle

Failure to Improve Lumbar Lordosis After Single-Level TLIF for Degenerative Spondylolisthesis Does Not Impair Clinical Outcomes at 8.6 Years Postoperatively: A Prospective Cohort of 32 Patients

by Klemen Bošnjak and Rok Vengust

J. Clin. Med. 2025, 14(15), 5457; https://doi.org/10.3390/jcm14155457 (registering DOI) - 3 Aug 2025

Abstract

Background: We aimed to analyze radiographic sagittal balance parameters in patients who underwent a TLIF procedure for single-level degenerative spondylolisthesis with a mean follow-up of 8.6 years and to determine whether lumbar lordosis affects long-term clinical outcomes. Methods: This prospective study [...] Read more.

Background: We aimed to analyze radiographic sagittal balance parameters in patients who underwent a TLIF procedure for single-level degenerative spondylolisthesis with a mean follow-up of 8.6 years and to determine whether lumbar lordosis affects long-term clinical outcomes. Methods: This prospective study included 32 patients who underwent single-level TLIF surgery for degenerative spondylolisthesis. Radiographic analysis of sagittal balance parameters and clinical examination including Oswestry Disability Index (ODI) scores were performed preoperatively, postoperatively, and at the last follow-up. A minimal clinically important difference threshold of 30% was accepted as clinically relevant. Results: Mean postoperative lumbar lordosis (LL) and segmental lordosis (SL) failed to improve postoperatively; nevertheless significant improvements in short- and long-term postoperative ODI scores were demonstrated (p < 0.001). Thoracic kyphosis (TK) and global sagittal balance parameters shifted anteriorly after 8.6 years (p < 0.001), but this increase did not affect clinical outcomes. Conclusions: Adequate decompression and solid bone fusion are foremost required to achieve improved long-term clinical outcomes in single-level TLIF procedures. In our studied cohort, failure to improve lordosis did not impair clinical outcomes postoperatively. With aging, thoracic kyphosis and anterior malalignment increase, and after 8.6 years, clinical improvements are starting to become insignificant. Full article

(This article belongs to the Section Orthopedics)

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27 pages, 2226 KiB

Open AccessReview

Uncovering Plaque Erosion: A Distinct Pathway in Acute Coronary Syndromes and a Gateway to Personalized Therapy

by Angela Buonpane, Alberto Ranieri De Caterina, Giancarlo Trimarchi, Fausto Pizzino, Marco Ciardetti, Michele Alessandro Coceani, Augusto Esposito, Luigi Emilio Pastormerlo, Angelo Monteleone, Alberto Clemente, Umberto Paradossi, Sergio Berti, Antonio Maria Leone, Carlo Trani, Giovanna Liuzzo, Francesco Burzotta and Filippo Crea

J. Clin. Med. 2025, 14(15), 5456; https://doi.org/10.3390/jcm14155456 (registering DOI) - 3 Aug 2025

Abstract

Plaque erosion (PE) is now recognized as a common and clinically significant cause of acute coronary syndromes (ACSs), accounting for up to 40% of cases. Unlike plaque rupture (PR), PE involves superficial endothelial loss over an intact fibrous cap and occurs in a [...] Read more.

Plaque erosion (PE) is now recognized as a common and clinically significant cause of acute coronary syndromes (ACSs), accounting for up to 40% of cases. Unlike plaque rupture (PR), PE involves superficial endothelial loss over an intact fibrous cap and occurs in a low-inflammatory setting, typically affecting younger patients, women, and smokers with fewer traditional risk factors. The growing recognition of PE has been driven by high-resolution intracoronary imaging, particularly optical coherence tomography (OCT), which enables in vivo differentiation from PR. Identifying PE with OCT has opened the door to personalized treatment strategies, as explored in recent trials evaluating the safety of deferring stent implantation in selected cases in favor of intensive medical therapy. Given its unexpectedly high prevalence, PE is now recognized as a common pathophysiological mechanism in ACS, rather than a rare exception. This growing awareness underscores the importance of its accurate identification through OCT in clinical practice. Early recognition and a deeper understanding of PE are essential steps toward the implementation of precision medicine, allowing clinicians to move beyond “one-size-fits-all” models toward “mechanism-based” therapeutic strategies. This narrative review aims to offer an integrated overview of PE, tracing its epidemiology, elucidating the molecular and pathophysiological mechanisms involved, outlining its clinical presentations, and placing particular emphasis on diagnostic strategies with OCT, while also discussing emerging therapeutic approaches and future directions for personalized cardiovascular care. Full article

(This article belongs to the Special Issue Advances in Clinical Practice and Personalized Approaches in Cardiovascular Disease)

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