Journal of Clinical Medicine

16 pages, 11291 KB

Open AccessArticle

Closing the Gap: Endoscopic Management of Post-Surgical Gastrointestinal Fistulas Using the Padlock Clip™—A Single-Center Experience

by Gabriela Ivanov, Madalina Ilie, Gabriel Constantinescu, Christopher Pavel, Deniz Günșahin, Raluca-Ioana Dascalu, Mariana Mihaila, Mircea Bogdan Maciuceanu Zarnescu and Anca Monica Macovei-Oprescu

J. Clin. Med. 2026, 15(9), 3452; https://doi.org/10.3390/jcm15093452 (registering DOI) - 30 Apr 2026

Abstract

Background/Objectives: Post-surgical gastrointestinal fistulas represent severe complications associated with significant morbidity and therapeutic challenges. Over-the-scope clipping systems have expanded endoscopic management options; however, data regarding the Padlock Clip™ in mixed populations of acute and chronic fistulas remain limited. This study aimed to [...] Read more.

Background/Objectives: Post-surgical gastrointestinal fistulas represent severe complications associated with significant morbidity and therapeutic challenges. Over-the-scope clipping systems have expanded endoscopic management options; however, data regarding the Padlock Clip™ in mixed populations of acute and chronic fistulas remain limited. This study aimed to evaluate the feasibility, safety, and clinical outcomes of the Padlock Clip™ in the endoscopic management of post-surgical gastrointestinal fistulas in a tertiary referral center. Methods: We conducted a retrospective single-center study including 28 adult patients treated with the Padlock Clip™ between January 2021 and December 2025. Technical success, clinical success, reintervention rates, and adverse events were assessed. Exploratory subgroup analyses were performed according to surgical etiology and fistula complexity. Results: Technical success was achieved in 25/28 patients (89.3%), and clinical success occurred in 23/28 cases (82.1%). Reintervention was required in seven patients (25.0%). Adverse events occurred in three patients (10.7%) and were limited to clip migration. The median follow-up duration was 6.5 months (range 3–32 months). Sleeve gastrectomy-related fistulas demonstrated lower technical success compared with non-sleeve cases (72.7% vs. 100%). Immediate technical success was associated with a trend toward improved clinical outcomes. Complex fistulas showed lower healing rates and higher reintervention frequency. Conclusions: The Padlock Clip™ is a feasible and safe option for endoscopic management of post-surgical gastrointestinal fistulas. Immediate technical success appeared to be associated with improved clinical outcomes and may represent a potential factor in achieving durable fistula closure. Complex fistulas and sleeve gastrectomy-related defects may require multimodal therapeutic approaches. Full article

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

17 pages, 418 KB

Open AccessArticle

Preoperative Surgical Fear and Association with Postoperative Pain and Quality of Recovery After Total Joint Arthroplasty

by Kenan Gumus, Gülden Küçükakça Çelik and Özkan Öztürk

J. Clin. Med. 2026, 15(9), 3451; https://doi.org/10.3390/jcm15093451 - 30 Apr 2026

Abstract

Background: Recovery following total joint arthroplasty varies substantially among patients, and psychological factors may partly account for this variability. Although anxiety and depression have been widely investigated, the specific contribution of preoperative surgical fear to postoperative pain and quality of recovery remains unclear. [...] Read more.

Background: Recovery following total joint arthroplasty varies substantially among patients, and psychological factors may partly account for this variability. Although anxiety and depression have been widely investigated, the specific contribution of preoperative surgical fear to postoperative pain and quality of recovery remains unclear. This study aimed to examine the association between preoperative surgical fear and postoperative pain intensity and quality of recovery. Methods: This prospective, hospital-based observational study enrolled 89 patients undergoing primary total knee or hip arthroplasty. Preoperative surgical fear was measured using the Surgical Fear Questionnaire (SFQ). Pain intensity was assessed with the Numeric Rating Scale (NRS) preoperatively and at three postoperative time points. Recovery quality at 24 h was evaluated using the Quality of Recovery-40 (QoR-40). Pearson correlation and multiple linear regression analyses were performed to evaluate associations and identify variables independently associated with recovery outcomes, controlling for potential confounders, including age, sex, ASA physical status, and type of surgery. Results: The mean SFQ score was 26.62 ± 15.19, and the mean QoR-40 score was 157.63 ± 16.66. Surgical fear was moderately and negatively correlated with overall recovery quality (r = −0.546, p < 0.001). In multiple linear regression analysis, surgical fear was most strongly associated with poorer overall recovery quality (β = −0.563, p < 0.001), within a model explaining 30.3% of the variance (adjusted R² = 0.303). At the subscale level, surgical fear was significantly associated with emotional state, pain, physical comfort, and perceived support. Pain intensity at 12 h postoperatively was significantly associated with reduced physical independence (β = −0.218, p = 0.038). Pain intensity peaked at 12 h postoperatively (p < 0.001). Conclusions: Higher levels of preoperative surgical fear are associated with poorer quality of recovery following total joint arthroplasty. These findings highlight surgical fear as a potentially relevant perioperative factor and support the integration of routine psychological assessment into perioperative care pathways in relation to early postoperative recovery outcomes. From a clinical perspective, early identification of patients with high surgical fear may facilitate targeted perioperative counseling and supportive interventions by healthcare professionals, potentially improving recovery outcomes. Full article

(This article belongs to the Section Orthopedics)

16 pages, 780 KB

Open AccessArticle

Clinical Significance of Serum Soluble Klotho Levels in Sepsis-Associated Encephalopathy: A Single-Center Prospective, Preliminary Study

by Ali Cetinkaya, Koca Caliskan, Ahmet Bilal Kandemir, Deniz Avci, Sibel Kuzuguden, Hatice Aslan Sirakaya, Abdullah Ilik and Hilal Sipahioglu

J. Clin. Med. 2026, 15(9), 3450; https://doi.org/10.3390/jcm15093450 - 30 Apr 2026

Abstract

Background/Objectives: Sepsis-associated encephalopathy (SAE) is an acute brain dysfunction during sepsis with high mortality. Klotho protein is notable for its identified neuroprotective effects in chronic neurodegenerative diseases. This study evaluated temporal changes in serum soluble Klotho levels and their association with clinical recovery [...] Read more.

Background/Objectives: Sepsis-associated encephalopathy (SAE) is an acute brain dysfunction during sepsis with high mortality. Klotho protein is notable for its identified neuroprotective effects in chronic neurodegenerative diseases. This study evaluated temporal changes in serum soluble Klotho levels and their association with clinical recovery in SAE. Methods: In this prospective observational study, 750 intensive care unit (ICU) patients were screened and 42 patients with SAE were included. Serum soluble Klotho levels, inflammatory markers, and Glasgow Coma Scale (GCS) scores were recorded on days 1 and 3. Associations between changes in Klotho levels and clinical and inflammatory parameters were analyzed. Results: The median GCS score increased from 11 (IQR: 10–13) on day 1 to 12 (IQR: 10–13) on day 3 (p < 0.001). Serum soluble Klotho levels decreased significantly from 8114.5 ± 3515.7 pg/mL on day 1 to 6452.9 ± 3390 pg/mL on day 3 (p < 0.001). Inflammatory markers, including C-reactive protein and procalcitonin, also showed significant reductions over time (p < 0.001). A moderate negative correlation was observed between changes in Klotho levels and GCS scores (r = −0.56, p < 0.001). Changes in inflammatory markers were not significantly correlated with Klotho dynamics. Conclusions: Serum soluble Klotho levels decrease in parallel with neurological improvements in sepsis-associated encephalopathy and are significantly associated with changes in GCS scores. These findings suggest that Klotho may represent a potential biomarker of disease trajectory and neurological recovery. Full article

(This article belongs to the Special Issue Sepsis and Organ Dysfunction: New Insights into Diagnosis and Treatment—Second Edition)

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Graphical abstract

17 pages, 3564 KB

Open AccessReview

Managing Respiratory Failure in Late Pregnancy

by Kate Williams, Alastair White, Melanie Nana, Catherine Nelson-Piercy and Luigi Camporota

J. Clin. Med. 2026, 15(9), 3449; https://doi.org/10.3390/jcm15093449 - 30 Apr 2026

Abstract

Background/Objectives: Respiratory failure in late pregnancy represents a complex and high-risk clinical scenario due to physiological adaptations during pregnancy that reduce maternal respiratory reserve, with tightly coupled maternal and foetal outcomes. This review aims to synthesise current evidence on epidemiology, maternal–foetal physiology, and [...] Read more.

Background/Objectives: Respiratory failure in late pregnancy represents a complex and high-risk clinical scenario due to physiological adaptations during pregnancy that reduce maternal respiratory reserve, with tightly coupled maternal and foetal outcomes. This review aims to synthesise current evidence on epidemiology, maternal–foetal physiology, and management strategies for respiratory failure in late gestation. Methods: This narrative review integrates contemporary literature, national surveillance data, physiological principles, and expert consensus to summarise the causes, clinical implications, and management of respiratory failure in pregnancy. Results: Respiratory failure in pregnancy arises from diverse obstetric and non-obstetric conditions, including pneumonia, asthma, pulmonary embolism, cardiogenic pulmonary oedema, and ARDS. Maternal hypoxaemia is strongly associated with foetal compromise. Management requires pregnancy-specific ventilatory targets, avoidance of permissive hypercapnia, cautious use of non-invasive and invasive ventilation, and safe implementation of prone or semi-prone positioning. ECMO use has expanded, with maternal survival improving to approximately 75%, although optimal anticoagulation and timing of delivery remain uncertain. Conclusions: Effective management of respiratory failure in late pregnancy requires early recognition, multidisciplinary coordination, and adaptation of respiratory support to maternal–foetal physiology. Despite improvements in critical care and ECMO outcomes, key evidence gaps persist, underscoring the need for integrated maternal critical care pathways and further research to optimise outcomes for both mother and baby. Full article

(This article belongs to the Special Issue Acute Hypoxemic Respiratory Failure: Progress, Challenges and Future)

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12 pages, 2297 KB

Open AccessArticle

Anterior Tibial Vessel Turnover as an Alternative Recipient Strategy in Lower Extremity Free Flap Reconstruction

by Young Jun Kim, Jun Mo Kim, Woo Young Choi, Ji Seon Cheon and Jeong Yeol Yang

J. Clin. Med. 2026, 15(9), 3448; https://doi.org/10.3390/jcm15093448 - 30 Apr 2026

Abstract

Background/Objectives: Reconstruction of complex lower extremity soft tissue defects remains challenging, particularly in the proximal and middle tibial regions, including the knee, where suitable recipient vessels are often limited due to prior trauma, infection, or surgical intervention. This study aimed to evaluate the [...] Read more.

Background/Objectives: Reconstruction of complex lower extremity soft tissue defects remains challenging, particularly in the proximal and middle tibial regions, including the knee, where suitable recipient vessels are often limited due to prior trauma, infection, or surgical intervention. This study aimed to evaluate the feasibility and clinical applicability of anterior tibial vessel turnover as an alternative recipient vessel strategy in free flap reconstruction. Methods: A retrospective review was conducted of seven patients who underwent free flap reconstruction using anterior tibial vessel turnover as the recipient vessel between 2019 and 2024. Preoperative imaging was performed to assess vascular status and collateral circulation. Clinical data, including patient demographics, defect characteristics, flap parameters, and postoperative outcomes, were analyzed. Results: The mean patient age was 62.7 years (range, 38–86 years). Defects were primarily located in the proximal and middle tibial regions and were associated with trauma, postoperative infection, chronic osteomyelitis, or burn injury. The mean flap size was 137.4 cm² (range, 49.5–280 cm²). All flaps survived, resulting in a flap survival rate of 100%, with no cases of total flap loss or re-exploration due to vascular compromise. One patient experienced partial flap loss, while no other flap-related complications were observed. Most patients achieved stable wound coverage and favorable functional recovery. Conclusions: Anterior tibial vessel turnover may serve as an alternative recipient vessel strategy for selected cases of complex lower extremity free flap reconstruction. This technique enables microvascular anastomosis in a more superficial and accessible field and expands reconstructive options in cases with compromised recipient vessels. Full article

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

18 pages, 392 KB

Open AccessSystematic Review

Complications and Revision Patterns After 3D-Printed Vertebral Body Replacement for Spinal Tumors: A Systematic Review and Critical Appraisal

by Viktor Aleinikov, Talgat Kerimbayev, Daryn Borangaliyev, Galymzhan Kadirbekov, Zhandos Tuigynov, Nurzhan Abishev, Daniyar K. Zhamoldin, Meirzhan Oshayev, Yergen Kenzhegulov, Yermek Urunbayev, Zhanibek Baiturlin, Makar Solodovnikov and Serik Akshulakov

J. Clin. Med. 2026, 15(9), 3447; https://doi.org/10.3390/jcm15093447 - 30 Apr 2026

Abstract

Background: Three-dimensional (3D)-printed vertebral body replacement (VBR) and artificial vertebral body (AVB) implants are increasingly used for anterior column reconstruction after spinal tumor resection. However, the available evidence on complications remains limited, heterogeneous, and methodologically inconsistent. This systematic review aimed to synthesize [...] Read more.

Background: Three-dimensional (3D)-printed vertebral body replacement (VBR) and artificial vertebral body (AVB) implants are increasingly used for anterior column reconstruction after spinal tumor resection. However, the available evidence on complications remains limited, heterogeneous, and methodologically inconsistent. This systematic review aimed to synthesize reported complications, revision patterns, and mechanical outcomes of 3D-printed VBR/AVB implants in spinal oncology and to critically appraise the quality of the available clinical literature. Methods: This systematic review was conducted in accordance with PRISMA 2020. PubMed/MEDLINE, Embase, and the Cochrane Library were searched from 1 January 1980 to 26 February 2026. Eligible studies included clinical series and cohort studies reporting extractable complication and/or revision data in patients who underwent spinal tumor resection followed by reconstruction with a 3D-printed VBR/AVB implant. Methodological quality was assessed using the Joanna Briggs Institute Critical Appraisal Checklist for Case Series. Due to substantial clinical and methodological heterogeneity, a structured narrative synthesis was performed. Results: Eleven studies comprising 217 analyzable 3D-printed reconstructions were included. Most were retrospective single-center series and showed marked heterogeneity in tumor histology, spinal level, implant strategy, follow-up duration, and complication definitions. Because adverse-event reporting was inconsistent across studies, no pooled overall complication rate was calculated. Reported perioperative non-mechanical complications included neurological deterioration, cerebrospinal fluid- or dural-related events, wound infection, pleural effusion, pneumonia, and vascular injury. Mechanical implant failure appeared relatively uncommon, although radiographic subsidence was variably defined and inconsistently reported. Implant mismatch and hardware-related problems were infrequent but clinically relevant, particularly with prefabricated or off-the-shelf devices. Revision procedures were most commonly associated with wound complications, clinically significant subsidence, hardware failure, or tumor recurrence. Overall study quality was limited by retrospective designs, small sample sizes, and non-standardized outcome reporting. Conclusions: Current evidence suggests that 3D-printed VBR/AVB implants are a feasible option with encouraging mechanical performance for spinal reconstruction after tumor resection. Most reported adverse events appear to reflect the complexity of oncologic spine surgery rather than device-specific failure alone. However, the available evidence remains low level and heterogeneous. Larger multicenter comparative studies with standardized outcome definitions and longer follow-up are needed to better define the clinical value and durability of 3D-printed vertebral reconstruction in spinal oncology. Full article

(This article belongs to the Section Oncology)

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16 pages, 1310 KB

Open AccessArticle

Thromboelastography-Based Risk-Stratified Transfusion Strategy in Acute Stanford Type A Aortic Dissection: A Predictive Model and Prospective Validation

by Jiawei Zhu, Qiuyong Guo, Yi Jiang, Xinlong Tang, Xiyu Zhu, Hoshun Chong, Yunxing Xue, Jun Pan, Jinfeng Yu, Qing Chen, Fudong Fan and Dongjin Wang

J. Clin. Med. 2026, 15(9), 3446; https://doi.org/10.3390/jcm15093446 - 30 Apr 2026

Abstract

Objectives: Perioperative blood transfusion for acute type A aortic dissection (ATAAD) lacks clinical guidelines. This study aims to investigate the application of a thromboelastography (TEG)-based risk-stratified transfusion protocol in these patients. Methods: We conducted a two-stage study. Firstly, a retrospective analysis [...] Read more.

Objectives: Perioperative blood transfusion for acute type A aortic dissection (ATAAD) lacks clinical guidelines. This study aims to investigate the application of a thromboelastography (TEG)-based risk-stratified transfusion protocol in these patients. Methods: We conducted a two-stage study. Firstly, a retrospective analysis of ATAAD patients undergoing surgery in 2023 was performed to identify predictors of postoperative/perioperative excessive bleeding and develop a predictive model. Subsequently, a single-center prospective validation study was conducted in 2024, comparing a TEG-based risk-stratified transfusion protocol against conventional empirical transfusion. Results: In the retrospective phase (n = 57), 18 patients (31.6%) developed perioperative excessive bleeding. Preoperative activated clotting time (ACT) and TEG parameters (K-time) were independent predictors. A predictive model incorporating these variables achieved an AUC of 0.788. In the prospective phase (n = 47), 21 patients received the TEG-based risk-stratified transfusion protocol. Compared to the conventional group, the TEG risk-stratified group exhibited significantly lower postoperative drainage volume (p = 0.046), a reduced incidence of perioperative excessive bleeding (4.8% vs. 34.6%, p = 0.033), and lower transfusion costs (p = 0.029), without an increase in total transfusion volume. Conclusions: Preoperative ACT and TEG parameters effectively predict perioperative excessive bleeding in ATAAD patients. Implementing a TEG-based risk-stratified transfusion protocol optimizes blood product utilization, improves clinical outcomes, and reduces costs, offering a promising evidence-based approach for perioperative management. Full article

(This article belongs to the Section Cardiovascular Medicine)

17 pages, 731 KB

Open AccessArticle

Clinical Effectiveness and Magnetic Resonance Imaging-Based Endurability of Matrix-Associated Autologous Chondrocyte Implantation with an Autologous Periosteal Flap for Articular Cartilage Defects of the Knee Joint

by Taku Tadenuma, Yuji Uchio, Takuya Wakatsuki, Hiroshi Takuwa and Suguru Kuwata

J. Clin. Med. 2026, 15(9), 3445; https://doi.org/10.3390/jcm15093445 - 30 Apr 2026

Abstract

Objectives: To evaluate the effectiveness and durability of matrix-associated autologous chondrocyte implantation with periosteal flap (pMACI) in treating knee cartilage defects using clinical scores and MRI evaluations. Methods: Data were collected from 37 knees of 17 patients, with a mean follow-up [...] Read more.

Objectives: To evaluate the effectiveness and durability of matrix-associated autologous chondrocyte implantation with periosteal flap (pMACI) in treating knee cartilage defects using clinical scores and MRI evaluations. Methods: Data were collected from 37 knees of 17 patients, with a mean follow-up of 5 years (range: 0.1–20 years). Clinical outcomes were assessed using the Lysholm Knee Scoring Scale (LKS) and Knee Injury and Osteoarthritis Outcome Score (KOOS). Tissue quality was quantitatively evaluated using MRI T1ρ and T2 mapping (biochemical) and MR observation of cartilage repair tissue: MOCART 2.0 (morphological). A linear mixed model was used to identify factors affecting outcomes, including etiology (trauma, OCD, OA), graft site, and defect size. Results: At the 20-year follow-up, clinical scores remained significantly improved from baseline (mean LKS: 55.6 to 86.5; KOOS: 37.8 to 70.8). The biochemical MRI parameters (T1ρ and T2 values) stabilized at levels comparable to native cartilage across all etiologies and sites (p = 0.326 and 0.412, respectively), indicating stable long-term tissue quality. In contrast, the MOCART 2.0 scores significantly declined over time (annual rate: −1.14 points; p < 0.001). Etiology was a significant factor; the OA group showed significantly lower clinical and MOCART scores compared to the trauma/OCD groups (p < 0.05). However, no significant differences were found in LKS and KOOS based on graft site (p = 0.489) or defect size (p > 0.05). Conclusions: pMACI may be a highly durable treatment capable of maintaining biological tissue quality and providing clinical benefits for two decades. The observed morphological deterioration after 20 years likely reflects joint-wide aging—especially in OA cases—rather than graft failure, highlighting the importance of long-term MRI monitoring. Full article

(This article belongs to the Special Issue Clinical Advancements in Orthopedic Trauma Treatments)

13 pages, 1377 KB

Open AccessSystematic Review

Melatonin Supplementation and Cardiovascular Outcomes: A Systematic Review and Meta-Analysis of Randomized Trials

by Song Peng Ang, Jia Ee Chia, Umabalan Thirupathy, Madison Laezzo, Vikash Jaiswal, Joseph Varon, Matthew Halma, Eunseuk Lee, George Davidson and Jose Iglesias

J. Clin. Med. 2026, 15(9), 3444; https://doi.org/10.3390/jcm15093444 - 30 Apr 2026

Abstract

Background: Melatonin has antioxidant and anti-inflammatory properties that may attenuate ischemia-reperfusion injury, but randomized cardiovascular trial data remain inconsistent. Objectives: This study sought to evaluate the association of melatonin supplementation with cardiovascular outcomes across randomized trials. Methods: We performed a [...] Read more.

Background: Melatonin has antioxidant and anti-inflammatory properties that may attenuate ischemia-reperfusion injury, but randomized cardiovascular trial data remain inconsistent. Objectives: This study sought to evaluate the association of melatonin supplementation with cardiovascular outcomes across randomized trials. Methods: We performed a systematic review and meta-analysis of randomized trials comparing melatonin with placebo, usual care, or no melatonin in patients with cardiovascular disease. PubMed, Embase, and CENTRAL were searched from inception to 1 January 2026. Random-effects models with Hartung–Knapp–Sidik–Jonkman confidence intervals were used. Prespecified outcomes included left ventricular ejection fraction (LVEF), change in LVEF, troponin, infarct size by cardiac magnetic resonance, heart failure outcomes, inflammatory and oxidative stress biomarkers, and adverse events. Results: A total of 14 randomized controlled trials involving 1027 participants were included. Melatonin significantly improved change in LVEF from baseline to follow-up (mean difference: 3.95 percentage points; 95% CI: 1.70–6.20; p < 0.001), with the most consistent signal in coronary artery bypass grafting studies (mean difference: 4.65 percentage points; 95% CI: 2.56–6.74). Final LVEF was numerically higher with melatonin but not statistically significant. Troponin reduction was not significant. Narrative synthesis suggested lower inflammatory and oxidative stress markers after coronary artery bypass grafting and improvement in heart failure symptoms and quality of life, whereas infarct size findings in ST-segment elevation myocardial infarction were mixed and timing-dependent. Conclusions: Melatonin was associated with improved LVEF change, particularly in coronary artery bypass grafting settings, but benefit was not consistently demonstrated across final LVEF, troponin, or infarct size outcomes. Full article

(This article belongs to the Special Issue Cardiovascular Disease Risk Assessment and Clinical Management)

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13 pages, 596 KB

Open AccessArticle

Implementation of a Rapid Response System in a University Hospital: Impact on In-Hospital Mortality and Surgical Patient Outcomes

by Daiana Toma, Ovidiu Horea Bedreag, Diana Andrei, Marius Păpurică, Claudiu Rafael Bârsac, Adelina Băloi, Alexandru Rogobete, Laura Andreea Ghenciu and Dorel Săndesc

J. Clin. Med. 2026, 15(9), 3443; https://doi.org/10.3390/jcm15093443 - 30 Apr 2026

Abstract

Background/Objectives: Inpatient clinical deterioration is a major contributor to adverse hospital outcomes, such as unplanned intensive care unit (ICU) admissions and death. Rapid response systems aim to address this challenge by enabling early identification and intervention in at-risk patients. This study evaluated the [...] Read more.

Background/Objectives: Inpatient clinical deterioration is a major contributor to adverse hospital outcomes, such as unplanned intensive care unit (ICU) admissions and death. Rapid response systems aim to address this challenge by enabling early identification and intervention in at-risk patients. This study evaluated the impact of implementing a mobile intensive care team on clinical outcomes in surgical patients. Methods: A retrospective observational cohort study was conducted in a tertiary care hospital, comparing two consecutive periods: a pre-intervention phase (PRETIM) and a post-intervention phase (TIM). The study included 17,156 adult surgical patients. The TIM consisted of a proactive outreach team composed of one attending intensivist and two resident physicians, focusing on post-ICU monitoring and early identification of clinical deterioration on surgical wards. The primary outcome was in-hospital mortality. Secondary outcomes included ICU readmission and length of stay. Multivariable logistic regression adjusted for age, sex and surgical section was performed, along with subgroup and sensitivity analyses excluding early non-modifiable deaths. Results: Baseline characteristics were comparable between groups. In-hospital mortality decreased significantly following implementation of the TIM (8.0% vs. 5.3%; p < 0.001), corresponding to an absolute risk reduction of 2.7% and a number needed to treat of 37. ICU readmission rates did not differ significantly between groups. Sensitivity analysis excluding early deaths confirmed the mortality reduction. Subgroup analysis demonstrated consistent effects across surgical specialties, with the largest reductions observed in neurosurgery and general surgery. Conclusions: The implementation of a mobile intensive care team was associated with a significant and clinically meaningful reduction in in-hospital mortality among surgical patients. The findings support the role of proactive post-ICU monitoring and early intervention strategies in improving patient outcomes in high-risk hospital populations. Full article

(This article belongs to the Special Issue Advances in Anesthesia and Intensive Care During Perioperative Period)

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13 pages, 426 KB

Open AccessArticle

Association of Depressive and Negative Symptoms with Quality of Life in Schizophrenia: A Cross-Sectional Inpatient Study

by Jonas Montvidas, Paulina Petraitytė, Edas Kačerginskis, Algirdas Musneckis, Sonia Dollfus and Virginija Adomaitienė

J. Clin. Med. 2026, 15(9), 3442; https://doi.org/10.3390/jcm15093442 - 30 Apr 2026

Abstract

Background/Objectives: Identifying the factor most strongly associated with patients’ quality of life (QoL) is crucial for establishing treatment goals focused on improved recovery. This study aimed to determine whether sociodemographic factors, negative, or depressive symptoms have the strongest association with QoL. Methods [...] Read more.

Background/Objectives: Identifying the factor most strongly associated with patients’ quality of life (QoL) is crucial for establishing treatment goals focused on improved recovery. This study aimed to determine whether sociodemographic factors, negative, or depressive symptoms have the strongest association with QoL. Methods: Inpatients diagnosed with schizophrenia were recruited. We collected data on sociodemographic factors, asked patients to rate their well-being on a subjective well-being scale, and evaluated their psychopathology using observer-rated psychometric scales (Positive and Negative Symptoms Scale (PANSS), Brief Negative Symptoms Scale (BNSS), and Calgary Depression Scale for Schizophrenia (CDSS) as well as self-rated scales (Self-evaluation Negative Symptoms Scale (SNS). QoL was evaluated using Short-Form 36 (SF-36). Patients were also divided into primary, prominent, and predominant negative symptom groups. We conducted correlation and linear regression analyses to identify which factors were most strongly associated with QoL. Results: In this study, 323 participants were included. The CDSS total score showed the strongest correlation with QoL scores, followed by negative symptoms assessed with the SNS. Positive and negative symptoms, assessed using either the PANSS or the BNSS, showed weak or insignificant correlations with QoL. Among sociodemographic factors, the subjective well-being score, previous history of hospitalization, or suicide attempts had the strongest correlation with QoL. CDSS scores were the variable with the strongest independent association with QoL in regression analysis. Conclusions: Depressive symptom severity showed the strongest and most consistent association with QoL across both correlation and multivariable analyses. These findings are hypothesis-generating and require longitudinal confirmation. Full article

(This article belongs to the Special Issue Schizophrenia and Psychotic Disorders: Clinical Updates)

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27 pages, 6465 KB

Open AccessSystematic Review

Are AI Neuroimaging Models Ready for Clinical Use? A Systematic Methodological Review

by Umid Sulaimanov, Nafiye Sanlier, Ariorad Moniri, Behman Demir, Yerkebulan Serikkanov, Ahmed Rasim Bayramoglu, Maryam Sabah Al-Jebur, Irem Uslu, Oyku Ozturk, Mariagrazia Nizzola, Erkin Ötleş, Simon Gashaw Ammanuel, Abdullah Keles, Ufuk Erginoglu and Mustafa K. Baskaya

J. Clin. Med. 2026, 15(9), 3441; https://doi.org/10.3390/jcm15093441 - 30 Apr 2026

Abstract

Background/Objectives: Artificial intelligence (AI) has rapidly expanded across medical imaging with proposed applications in diagnosis, prognostication, and surgical planning. Concerns remain regarding methodological robustness and clinical readiness for many published models. This systematic review aimed to conduct a methodological audit of AI [...] Read more.

Background/Objectives: Artificial intelligence (AI) has rapidly expanded across medical imaging with proposed applications in diagnosis, prognostication, and surgical planning. Concerns remain regarding methodological robustness and clinical readiness for many published models. This systematic review aimed to conduct a methodological audit of AI imaging studies relevant to contemporary neurosurgical practice—including intracranial, cerebrovascular, spinal, and connectomics-based applications—published in 2025. Methods: Following PRISMA guidelines and PROSPERO registration (CRD420261284068), PubMed was searched for studies published in 2025 evaluating machine learning or deep learning applications in MRI- or CT-based imaging. Three reviewers independently extracted data on validation strategy, data leakage risk, human comparator use, calibration reporting, and CLAIM/TRIPOD-AI adherence. Risk of bias was assessed using PROBAST+AI. Results: Of 1776 screened records, 91 studies met the inclusion criteria. China led contributions (54.9%), oncology was the most common domain (37.4%), and MRI was the predominant modality (67.0%). External validation was reported in 75.8% of studies, and 66.0% used multicenter cohorts. Data leakage risk was low in 93.4%. However, only 18.7% included human comparators, calibration was reported in 30.8%, and none achieved full CLAIM/TRIPOD-AI compliance. Conclusions: AI imaging studies published in 2025 demonstrate encouraging progress in multicenter design and external validation. However, persistent gaps in human benchmarking, calibration, and reporting suggest further methodological development is needed. Full article

(This article belongs to the Special Issue Neural Application of Artificial Intelligence in Clinical Neuroscience)

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12 pages, 535 KB

Open AccessArticle

Convergent Hybrid Ablation and Concomitant Left Atrial Appendage Exclusion for Stroke Prevention and Rhythm Control in Persistent Atrial Fibrillation

by Yonas R. Toma, Sune Damgaard and Christian L. Carranza

J. Clin. Med. 2026, 15(9), 3440; https://doi.org/10.3390/jcm15093440 - 30 Apr 2026

Abstract

Background/Objectives: Persistent and long-standing persistent atrial fibrillation (AF) presents a therapeutic clinical challenge balancing complex rhythm management with a heightened stroke risk. The left atrial appendage (LAA) is the primary source of thromboembolisms in these patients. This study evaluated the safety and efficacy [...] Read more.

Background/Objectives: Persistent and long-standing persistent atrial fibrillation (AF) presents a therapeutic clinical challenge balancing complex rhythm management with a heightened stroke risk. The left atrial appendage (LAA) is the primary source of thromboembolisms in these patients. This study evaluated the safety and efficacy of combining LAA exclusion with Convergent Hybrid Ablation for stroke prevention and rhythm control in a refractory patient cohort. Methods: A single-center observational cohort study was conducted including 28 patients with symptomatic persistent or long-standing persistent AF. The cohort was highly refractory, with 82.1% having failed at least one endocardial catheter ablation. The hybrid procedure consisted of sub-xiphoid epicardial ablation, thoracoscopic LAA exclusion (AtriClip), and endocardial catheter ablation. Safety and efficacy were assessed at 3 months and 12 months. Results: LAA exclusion was successfully performed in 96.4% of patients. The peri-operative safety profile was acceptable, with zero procedure-related strokes or deaths. At the 12-month follow-up, the rate of stroke or any other major adverse events was at 0.0%. Freedom from AF was 75.0%, shown by a 12-lead electrocardiography (ECG). Freedom from any atrial arrhythmia off anti-arrhythmic drugs (AADs) was achieved in 50.0% of patients. A total of 32.1% of the cohort required catheter ablation within 12 months to maintain sinus rhythm as part of the hybrid treatment. Conclusions: Concomitant LAA exclusion during Convergent Hybrid Ablation is a safe procedure with a high clinical success rate in maintaining sinus rhythm in a highly complex AF patient group. While no thromboembolic events were observed at 12 months, larger studies with longer follow-up are needed to confirm the potential for long-term stroke risk reduction. The findings suggest that for many patients, the hybrid procedure should be viewed as part of a multi-step strategy often requiring endocardial “touch-up” ablation. Full article

(This article belongs to the Special Issue Stroke in Patients with Atrial Fibrillation: Risk, Manifestation and Prevention)

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8 pages, 1058 KB

Open AccessArticle

Bleb Compressive Sutures in Descemet Stripping Automated Endothelial Keratoplasty for Eyes with Filtering Blebs Following Trabeculectomy

by Noriko Toyokawa, Kaoru Araki-Sasaki, Hideya Kimura and Shinichiro Kuroda

J. Clin. Med. 2026, 15(9), 3439; https://doi.org/10.3390/jcm15093439 - 30 Apr 2026

Abstract

Background/Objectives: A disadvantage of Descemet stripping automated endothelial keratoplasty (DSAEK) in eyes with prior glaucoma filtration surgery is the difficulty in maintaining air tamponade during the procedure. Herein, we report the use of bleb compressive sutures in managing air tamponade in the [...] Read more.

Background/Objectives: A disadvantage of Descemet stripping automated endothelial keratoplasty (DSAEK) in eyes with prior glaucoma filtration surgery is the difficulty in maintaining air tamponade during the procedure. Herein, we report the use of bleb compressive sutures in managing air tamponade in the anterior chamber during DSAEK in eyes with blebs following trabeculectomy. Methods: This retrospective case series included 34 eyes of 33 patients that developed bullous keratopathy following trabeculectomy. Bleb compression suturing was performed using a 10-0 nylon suture in eyes with an intraocular pressure (IOP) < 10 mmHg or a fragile ischemic bleb. Postoperative IOP, air ingress into the bleb, rebubbling, bleb leakage, and bleb damage were evaluated. Results: Of the 34 eyes, 13 underwent bleb compression suturing before DSAEK (suture group), whereas 21 eyes did not (non-suture group). The mean preoperative IOP was 7.5 ± 2.5 mmHg and 11.2 ± 4.2 mmHg in the suture and the non-suture groups, respectively. The IOP was measured 2 h postoperatively in 14 eyes, increasing by 18 ± 9.3 and 11.7 ± 3.1 mmHg in the suture and non-suture groups, respectively, compared to the preoperative IOP, with no significant differences. At 2 h postoperatively, two eyes in the suture group and one eye in the non-suture group exhibited an IOP spike (≥30 mmHg). One eye in the non-suture group required rebubbling owing to air ingress into the bleb. The mean IOP was 7.1 ± 3.2 and 9.4 ± 4.6 mmHg in the suture and non-suture groups, respectively, 1–2 weeks postoperatively. Preoperative and postoperative IOPs did not significantly differ in either group, and no suture-related complications were observed. Conclusions: For eyes with blebs, bleb compression suturing in DSAEK provides effective air tamponade during graft adhesion. Full article

(This article belongs to the Special Issue Prevention, Diagnosis, and Clinical Treatment of Corneal Diseases)

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16 pages, 746 KB

Open AccessFeature PaperArticle

Lung Ultrasound Abnormalities and LUS Score After COVID-19 Pneumonia: Determinants and Associations with Dyspnoea in a Prospective Cohort

by Francisco Navarro-Romero, Cristina Asencio-Méndez, Francisco Rivas-Ruiz, Blanca Sánchez-Mesa, María Dolores Martín-Escalante and Julián Olalla-Sierra

J. Clin. Med. 2026, 15(9), 3438; https://doi.org/10.3390/jcm15093438 - 30 Apr 2026

Abstract

Background/Objectives: The clinical determinants and functional relevance of persistent lung ultrasound (LUS) abnormalities after COVID-19 pneumonia remain poorly characterized. We aimed to identify determinants of qualitative LUS abnormalities and global lung involvement assessed by the LUS score, and to evaluate their association [...] Read more.

Background/Objectives: The clinical determinants and functional relevance of persistent lung ultrasound (LUS) abnormalities after COVID-19 pneumonia remain poorly characterized. We aimed to identify determinants of qualitative LUS abnormalities and global lung involvement assessed by the LUS score, and to evaluate their association with persistent dyspnoea. Methods: We conducted a prospective observational study that included 261 patients who were hospitalized for COVID-19 pneumonia and were assessed 1–6 months after discharge. A standardized 14-zone LUS protocol was used to assess qualitative abnormalities (pleural line irregularity, ≥3 B-lines, and subpleural consolidations) and to calculate the LUS score. Associations with clinical variables, including dyspnoea assessed by the modified Medical Research Council (mMRC) scale, were analyzed using multivariable logistic regression. Results: The severity of the acute pneumonia episode emerged as the strongest determinant of qualitative LUS abnormalities and elevated LUS score (>6). Increasing age was independently associated with ultrasound findings. Persistent dyspnoea (mMRC ≥ 1) was associated with all qualitative abnormalities and with a higher prevalence of elevated LUS score (56.6% vs. 22.1%; p < 0.001). A graded association was observed between dyspnoea severity and both qualitative findings and LUS score. An increase in dyspnoea from baseline (ΔmMRC ≥ 1) remained independently associated with an elevated LUS score. Conclusions: Persistent LUS abnormalities are strongly associated with the severity of the acute episode. The LUS score provides a robust, clinically meaningful measure of residual lung involvement and shows a stronger association with persistent dyspnoea than qualitative findings, supporting its role in follow-up and risk stratification. Full article

(This article belongs to the Special Issue Update on Acute Severe Respiratory Infections: 2nd Edition)

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14 pages, 1818 KB

Open AccessArticle

Clinical, Physiologic, and Anatomic Outcomes of a Novel Bioprosthetic Aortic Valved Conduit

by Sedem Dankwa, Ely Erez, Adrian R. Acuna Higaki, Shiv Verma, Irbaz Hameed, Sriharsha Talapaneni, Kristina Wang, Sem Asmelash, Titilayo Oden Shobayo, Pavan Khosla, Kwasi Ansere Ofori, Roland Assi and Prashanth Vallabhajosyula

J. Clin. Med. 2026, 15(9), 3437; https://doi.org/10.3390/jcm15093437 - 30 Apr 2026

Abstract

Background: In 2020, the first pre-assembled bioprosthetic aortic valved conduit (AVC) was approved in the United States. This study compares its anatomic and functional outcomes to traditional hand-sewn composite conduits in patients undergoing aortic root replacement. Methods: This retrospective study compared 118 patients [...] Read more.

Background: In 2020, the first pre-assembled bioprosthetic aortic valved conduit (AVC) was approved in the United States. This study compares its anatomic and functional outcomes to traditional hand-sewn composite conduits in patients undergoing aortic root replacement. Methods: This retrospective study compared 118 patients receiving the pre-assembled AVC (2021–2023) versus 66 patients with hand-sewn conduits (2012–2020) after elective bio-Bentall procedures. Primary outcomes were post-operative mortality and complication rates. Secondary outcomes included anatomic and hemodynamic changes. Graft dimensions were obtained from post-operative computed tomography (CT). Echocardiographic parameters were collected at early and late follow-up. Between-group differences and longitudinal changes were assessed using linear mixed-effects models. Results: Groups were comparable in age (pre-assembled 63 ± 11 vs. hand-sewn 64 ± 11 years) and predominantly male. Despite significantly higher concomitant hemiarch rates in pre-assembled conduits (91.5% vs. 28.8%, p < 0.001), 30-day mortality, stroke, and reoperation for bleeding were comparable between groups. Pre-assembled conduits demonstrated superior hemodynamics with lower baseline peak gradients (Δ 9.1 mmHg, p < 0.001), lower mean gradients (Δ 5.3 mmHg, p < 0.001), and larger indexed effective orifice area (Δ 0.27 cm²/m², p = 0.018). Annual rates of hemodynamic and dimensional change were minimal and comparable between groups. Kaplan–Meier analysis showed no survival difference at 3 years. Conclusions: The pre-assembled AVC demonstrates equivalent safety and superior early hemodynamic performance compared to hand-sewn conduits, with stable mid-term anatomic and functional outcomes. Full article

(This article belongs to the Special Issue Aortic Surgery: State of the Art and Future Directions)

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16 pages, 2508 KB

Open AccessArticle

Metabolic Signatures in Pericardial Fluid and Serum Are Associated with Long-Term Restenosis After Isolated Coronary Artery Bypass Grafting

by Xiaozheng Zhou, Lin Zheng, Zhiyong Du, Jiyuan Luo, Kun Hua and Xiubin Yang

J. Clin. Med. 2026, 15(9), 3436; https://doi.org/10.3390/jcm15093436 - 30 Apr 2026

Abstract

Background/Objectives: Restenosis following coronary artery bypass grafting (CABG) remains a major long-term complication that adversely affects patient prognosis. Although prior studies have investigated clinical features, imaging parameters, and circulating biomarkers for restenosis risk stratification, the metabolic mechanisms underlying long-term restenosis—particularly those reflecting both [...] Read more.

Background/Objectives: Restenosis following coronary artery bypass grafting (CABG) remains a major long-term complication that adversely affects patient prognosis. Although prior studies have investigated clinical features, imaging parameters, and circulating biomarkers for restenosis risk stratification, the metabolic mechanisms underlying long-term restenosis—particularly those reflecting both the local cardiac microenvironment and systemic circulation—remain poorly defined. Therefore, this study aims to identify restenosis-associated metabolic alterations and develop a risk prediction model based on integrated targeted metabolomic profiling of pericardial fluid (PF) and serum in patients undergoing isolated CABG. Methods: Patients undergoing isolated CABG were prospectively enrolled. Paired PF and serum samples were collected during surgery or the perioperative period for targeted metabolomic analysis. Differential metabolite (DM) analysis was performed between patients with and without restenosis. Key metabolites were selected to construct a restenosis risk prediction model, which was subsequently evaluated in training and validation cohorts. Results: Compared with patients without restenosis, those who developed restenosis exhibited two key differential metabolites identified in PF and serum: 7α-Hydroxy-4-cholesten-3-one and Phenoxyacetic acid (PAA). A logistic regression-based prediction model incorporating these metabolites was developed and evaluated using receiver operating characteristic (ROC) analysis, integrated discrimination improvement (IDI), and decision curve analysis (DCA). The model demonstrated robust predictive performance in both training and validation cohorts. Kaplan–Meier survival analysis further revealed that higher model scores were significantly associated with an increased risk of long-term restenosis in the training cohort (HR = 1.44, p = 0.047) and validation cohort (HR = 1.83, p = 0.012). Conclusions: This study provides the first evidence that integrated metabolomic signatures derived from PF and serum are associated with long-term restenosis after CABG. By capturing complementary metabolic information from the local cardiac microenvironment and systemic circulation, this integrated approach enhances current understanding of restenosis biology and supports the potential clinical utility of targeted metabolomics for long-term restenosis risk prediction following CABG. Full article

(This article belongs to the Section Cardiology)

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13 pages, 1831 KB

Open AccessArticle

Nomogram-Based Prediction Model for Postherpetic Neuralgia in Immunosuppressive Patients

by Xiao-Yuan Pan, Li-Na Lu, Jing Wang, Li-Hong Mei and Gao Yang

J. Clin. Med. 2026, 15(9), 3435; https://doi.org/10.3390/jcm15093435 - 30 Apr 2026

Abstract

Background/Objectives: Herpes zoster is caused by varicella-zoster virus reactivation, which often leads to a chronic pain condition named postherpetic neuralgia (PHN). Patients with immunosuppressive conditions face a heightened risk of developing PHN. This study aims to identify factors contributing to PHN development [...] Read more.

Background/Objectives: Herpes zoster is caused by varicella-zoster virus reactivation, which often leads to a chronic pain condition named postherpetic neuralgia (PHN). Patients with immunosuppressive conditions face a heightened risk of developing PHN. This study aims to identify factors contributing to PHN development in immunosuppressive patients. Methods: This retrospective cohort study was conducted involving 219 immunosuppressive patients from two centers and split into training and test cohorts. Participants were divided into PHN (n = 88) and acute phase pain (ACP, n = 131) groups. Univariate and multivariate logistic regression analyses were used to identify clinical predictors of PHN. A nomogram was constructed to predict PHN risk by integrating significant predictors. The discrimination, calibration and clinical usefulness of the nomogram were evaluated. Results: Multivariate analysis revealed metabolic syndrome, older age, higher lactate dehydrogenase (LDH), and higher neutrophil-to-lymphocyte ratio (NLR) as significant PHN predictors. The nomogram showed good discrimination in both training (AUC of 0.83 [95% CI 0.77–0.90] with a specificity of 0.78, sensitivity of 0.87, NPV of 0.90, and PPV of 0.73) and test cohorts (AUC of 0.85 [95% CI 0.75–0.96] with a specificity of 0.82, sensitivity of 0.85, NPV of 0.89, and PPV of 0.76). Clinical decision curve analysis confirmed the practical utility of the nomogram. Conclusions: The nomogram incorporating age, metabolic syndrome, LDH, and NLR are useful in estimating PHN risk among immunosuppressed patients. Full article

(This article belongs to the Special Issue Skin Disease and Inflammation)

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15 pages, 537 KB

Open AccessFeature PaperArticle

A Double-Blind Randomized Comparison Trial of Postoperative Pain in Patients Undergoing Total Shoulder Arthroplasty Who Receive Interscalene Blocks with near Equipotent Doses of Plain 0.5% Bupivacaine vs. Liposomal Bupivacaine

by Johnny K. Lee, Rebecca Shamberg, Andrew R. Locke, Chi Wang, Steven Levin, Jason Koh, Laura Eldridge and Steven B. Greenberg

J. Clin. Med. 2026, 15(9), 3434; https://doi.org/10.3390/jcm15093434 - 30 Apr 2026

Abstract

Background/Objectives: Interscalene brachial plexus block (ISB) is a common regional anesthesia technique for analgesia in patients undergoing shoulder surgery. Liposomal bupivacaine (LB) was developed to prolong analgesia duration; however, the existing literature demonstrates mixed results regarding its efficacy. This study aimed to [...] Read more.

Background/Objectives: Interscalene brachial plexus block (ISB) is a common regional anesthesia technique for analgesia in patients undergoing shoulder surgery. Liposomal bupivacaine (LB) was developed to prolong analgesia duration; however, the existing literature demonstrates mixed results regarding its efficacy. This study aimed to compare the analgesic effectiveness of near-equipotent doses of LB and plain bupivacaine (PB) for patients undergoing total shoulder arthroplasty (TSA). Methods: This prospective double-blinded randomized controlled trial enrolled 78 elective TSA patients. Participants were randomized to receive an ISB with either 36 mL of 0.5% PB (180 mg) or a mixture of 10 mL of LB, 20 mL of 0.25% PB, and 6 mL of saline (183 mg). The primary outcome was the proportion of patients with clinically tolerable pain scores (visual analog scale (VAS) ≤ 4) on postoperative day (POD) 1 in each group. Secondary outcomes included the proportion of patients with clinically tolerable pain scores on POD 2–5, overall pain scores in the post-anesthesia care unit (PACU) and on POD 1–5, Quality of Recovery Survey-15 (QoR-15) scores on POD 1–5, analgesic consumption on the day of surgery and on POD 1–5, and adverse events. Results: A total of 67 patients completed the study. There was a statistically significant increase in median body mass index (BMI) in the PB vs. LB group (30.0 (27.4–33.1) vs. 27.0 (24.3–29.4), p = 0.0197). All other demographic characteristics were comparable between groups. There was no difference in the primary outcome or any of the secondary outcomes. Conclusions: LB did not reduce postoperative pain compared to PB. Larger, multicenter studies are warranted to further evaluate the clinical benefit of LB in this population. Full article

(This article belongs to the Section Anesthesiology)

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