Medicina

Background: The Ejection Fraction (EF) represents a fundamental pillar for the phenotypic classification and clinical management of cardiovascular diseases. Although trans-thoracic echocardiography (TTE) acts as the first-line examination and cardiac magnetic resonance (CMR) is the reference gold standard, cardiac computed tomography (CCT) has undergone a technological evolution. The advent of wide-detector scanners and artificial intelligence (AI) models has enabled CCT to transition from a purely morphological tool to a modality capable of comprehensive, three-dimensional morpho-functional assessments. Methods: This narrative review evaluates the literature across Scopus, MEDLINE, and Web of Science regarding the calculation of biventricular function and EF using CCT. It provides an updated summary of current clinical applications, technological advancements, and comparative diagnostic reliability against TTE and CMR. Results: The CCT “one-stop-shop” concept allows for the simultaneous acquisition of anatomical data and systolic function metrics (EDV, ESV, SV, EF), optimizing clinical workflows at no additional cost. Being intrinsically three-dimensional, CCT bypasses the geometric assumptions and apical foreshortening artifacts typical of 2D-TTE, demonstrating high volumetric concordance with CMR. Nevertheless, structural limitations persist, primarily regarding ionizing radiation exposure, contrast media toxicity, dependence on heart rhythm stability, and lower temporal resolution compared to CMR. Conclusions: EF determination via CCT has achieved technical maturity and clinical validation. While it does not intend to replace TTE or CMR, it offers synergistic data when integrated with primary anatomical indications. Furthermore, AI integration has been shown to potentially automate this workflow, transforming CCT into an opportunistic screening tool for subclinical cardiac dysfunction. Full article

Background and Objectives: Peripheral artery disease (PAD) is a common manifestation of systemic atherosclerosis associated with significant morbidity and mortality, yet it remains underdiagnosed due to limited routine screening and its often-asymptomatic presentation. Although the ankle–brachial index (ABI) is the gold standard diagnostic tool for PAD, its use may be limited in some settings because it requires specialized equipment and trained personnel. In contrast, the electrocardiogram (ECG) is widely available and routinely performed. Given that ECG abnormalities may reflect systemic cardiovascular disease, we investigated the association between ECG findings and ABI classification. Materials and Methods: This retrospective case–control study analyzed patients with and without PAD who received care from outpatient vascular clinics between March 2018 and February 2022. PAD was defined as ABI ≤ 0.9 or toe–brachial index ≤ 0.67 with abnormal pedal pulses. The most recent ECG performed within one year of ABI measurement was retrieved for each patient and classified as normal, borderline, or abnormal according to standardized guideline recommendations. The association between ECG category and ABI classification was assessed using chi-square testing and multivariable logistic regression adjusted for age and sex, with results reported as odds ratios (ORs) and 95% confidence intervals (CIs). Discriminatory performance of the ability of ECG findings to predict ABI classification was evaluated using the area under the receiver operating characteristic curve (AUROC) with 95% CI. Model calibration was assessed using the Hosmer–Lemeshow test. Results: Overall, 491 patients had paired ECG and ABI data. ECGs were categorized as abnormal (n = 345), borderline (n = 58), or normal (n = 88). The prevalence of abnormal ABI (≤0.9) was highest among patients with abnormal ECGs (45.8%), compared to borderline (34.5%) and normal ECGs (28.4%) (p = 0.0067). On multivariable logistic regression analysis adjusted for age and sex, abnormal ECG findings were associated with increased odds of abnormal ABI compared to normal ECGs (adjusted OR 2.07, 95% CI 1.24–3.46, p = 0.005), whereas borderline ECGs were not (OR 1.31, 95% CI 0.64–2.68, p = 0.455). ECG categorization demonstrated moderate discrimination (AUROC 0.73, 95% CI 0.68–0.78) and good calibration (Hosmer–Lemeshow χ² 5.0, p = 0.76) for predicting abnormal ABI. Conclusions: In this retrospective case–control study, we found an association between abnormal ECG findings and abnormal ABI. These results support the concept that clinically significant ECG abnormalities may reflect systemic atherosclerotic burden rather than isolated cardiac pathology. Given the widespread availability and low cost of ECG testing, ECG interpretation may help identify patients who warrant further investigations, including PAD screening, vascular assessment, and risk-stratification, particularly in lower-resource settings without routine access to ABI testing. Prospective, multicenter studies are needed to validate these findings. Full article

Background and Objectives: Younger and middle-aged women may continue to describe psychological and psychosocial burden years after myocardial infarction (MI), yet multicenter real-world data remain limited on what women retrospectively report during long-term follow-up. This study examined such reports in younger and middle-aged women with prior MI while explicitly accounting for delayed, heterogeneous follow-up timing and the non-standardized nature of symptom ascertainment. Materials and Methods: We performed a cross-sectional analysis within a Croatian multicenter cohort of 957 women younger than 60 years hospitalized with STEMI or NSTEMI between 1 February 2020 and 28 February 2025. Psychological information was collected retrospectively during routine follow-up; the formal PHQ-4 instrument was not administered. A study-specific four-item summary informed by PHQ-4 content was described, and exploratory multivariable analyses modelled this summary as a continuous variable. Descriptive timing-stratified sensitivity analyses and a timing-restricted continuous-score sensitivity model were additionally performed. Results: Prior psychiatric diagnosis was recorded in 16.0% of women, post-MI psychiatric diagnosis in 31.4%, and any psychosocial stressor in 73.2%. Among women with complete item responses, the four-item summary showed a broad distribution rather than a discrete threshold pattern. In continuous-score analyses, higher observed summary values were associated with younger age, prior psychiatric diagnosis, any psychosocial stressor, non-partnered status, non-employment, pregnancy complications/adverse pregnancy outcomes, and greater peri-menopausal symptom burden. Median summary values were only modestly higher in the small ≤ 1-year stratum and were otherwise similar across the later follow-up strata. Higher summary values were also associated with lower odds of self-reported regular current statin-based lipid-lowering use. Conclusions: These findings are best interpreted as exploratory data on retrospectively reported and currently endorsed long-term psychological and psychosocial burden years after MI, not as contemporaneous measures of recovery-phase psychopathology. Prospective studies with predefined assessment windows and validated instruments are needed. Full article

Background and Objectives: The diagnostic accuracy of an artificial intelligence (AI)-derived initial 12-lead electrocardiogram (ECG) analysis was evaluated for early carbon monoxide-induced cardiomyopathy (CO-CMP) risk detection. Materials and Methods: Retrospective medical data of carbon monoxide poisoning (COP) cases between 1 January 2015 and 31 December 2024 were screened for the primary outcome: odds ratio (OR) for echocardiographically confirmed CO-CMP among those with high-risk probability score per the AI-derived model. Secondary outcomes included left ventricular ejection fraction (LVEF) and AI-derived probability score, critical care requirements, including intubation and intensive care unit (ICU) admission, and cardiac arrest events. Results: A total of 51 patients with acute COP were included in the final analysis, with 13 (25.5%) being diagnosed with CO-CMP. The LVEF in the CO-CMP group was lower than that in the non-CO-CMP group (40.00 ± 13.80% vs. 63.76 ± 6.24%, p < 0.001). The AI-derived probability score was higher in the CO-CMP group (11.3 [3.8–32.7] vs. 0.5 [0.2–2.2], p < 0.001). Among cardiac biomarkers, troponin I (2.37 [0.32–7.88] vs. 0.06 [0.06–0.95] ng/mL, p = 0.002) was higher in the CO-CMP group. Patients with CO-CMP required recurrent ventilator support (76.9% vs. 21.1%, p < 0.001) and ICU admission (92.3% vs. 42.1%, p = 0.003). In multivariable regression analysis, the AI-derived prediction model was independently associated with CO-CMP (OR 1.14; 95% confidence interval (CI) 1.02–1.27; p = 0.017; Firth-penalized OR 1.11; 95% CI 1.03–1.25; p < 0.001). Receiver operating characteristic analysis of the AI-derived model showed an area under the curve of 0.85 (95% CI 0.70–0.96) for the AI score alone and 0.92 (95% CI 0.83–0.99) for the Combined AI–cardiac marker model, with a sensitivity of 92.3% and specificity of 81.6%. Pairwise DeLong comparisons between the Combined AI model and comparator models did not reach statistical significance (Combined vs. AI-only, p = 0.092; Combined vs. cardiac markers, p = 0.052); however, the likelihood-ratio test for adding the AI probability score to the cardiac marker-only model demonstrated significant incremental information (χ² = 13.68, p < 0.001). Conclusions: AI-based ECG analysis showed exploratory diagnostic association with LV systolic dysfunction observed in suspected CO-CMP patients. Given the limited sample size, low events-per-variable ratio, and lack of external validation, these findings suggest that AI-ECG analysis may provide incremental information for early cardiac risk stratification in selected patients. Full article

Backgroundand Objectives: The optimal timing of surgery after preoperative fluorouracil, leucovorin, oxaliplatin and docetaxel (FLOT) chemotherapy (ChT) in gastric cancer (GC) remains unclear. We aimed to evaluate the association between time to surgery (TTS) and pathological as well as survival outcomes in patients treated with perioperative FLOT. Materials and Methods: This retrospective cohort study included 76 patients with locally advanced gastric or gastroesophageal junction (GEJ) adenocarcinoma who underwent curative-intent surgery after preoperative FLOT at a single tertiary center. TTS was defined as the interval between completion of preoperative FLOT and surgery. Patients were categorized into two groups according to TTS: ≤4 weeks and >4 weeks. Pathological response (PR) was assessed using the Becker tumor regression grading system. The primary endpoint was PR, including tumor regression grade and pathological complete response (pCR). Secondary endpoint was overall survival (OS). Results: The median TTS was 31 days (IQR, 21–47). Forty-five (59.2%) patients underwent surgery within 4 weeks. Favorable PR was more frequently observed in the ≤4-week group. Becker TRG 0–1 was significantly more common among patients undergoing surgery within 4 weeks compared with those undergoing surgery after more than 4 weeks (26.2% vs. 6.5%, p = 0.03). Similarly, pCR was observed exclusively in the ≤4-week group (14.3% vs. 0%, p = 0.02). ypN0 status was numerically higher in the ≤4-week group (54.7% vs. 32.2%, p = 0.05). Postoperative complication rates did not differ significantly between groups (4.8% vs. 12.9%, p = 0.17). In multivariable Cox regression analysis, TTS was not independently associated with OS, whereas poor tumor differentiation remained an independent predictor of worse survival (HR 2.57, 95% CI 1.17–5.63, p = 0.01). Conclusions: Among patients treated with preoperative FLOT, surgery within 4 weeks was associated with improved PR without an apparent increase in postoperative morbidity. However, earlier surgery was not independently associated with improved OS. These findings suggest that prolonged delay after preoperative FLOT may not be necessary in clinically recovered patients and support the need for prospective multicenter studies to define the optimal surgical interval in FLOT-treated GC. Full article

Background and Objectives: Preoperative anaemia represents a key modifiable risk factor in obstetrics. Within the framework of Patient Blood Management (PBM), establishing precise hemoglobin (Hb) thresholds is essential for optimal clinical decision-making. This study aimed to assess the predictive value of preoperative hemoglobin levels and to determine the optimal cutoff associated with transfusion risk. Materials and Methods: A retrospective analysis was performed on 932 pregnant women. The association between preoperative hemoglobin, anticoagulant therapy, mode of delivery and maternal age with the need for red blood cell transfusion was evaluated using binary logistic regression and Receiver Operating Characteristic (ROC) curve analysis with the Youden index. Results: Red blood cell transfusion was required in 5.2% (n = 48) of the study population. Logistic regression identified preoperative hemoglobin as the strongest independent predictor (p < 0.001, OR = 0.216, 95% CI: 0.153–0.306), indicating that each 1 g/dL increase in Hb reduced the likelihood of transfusion by 78.4%. Anticoagulant therapy and age were not significant independent predictors (p > 0.05). ROC analysis demonstrated excellent predictive performance, with an Area Under the Curve (AUC) of 0.875 (95% CI: 0.823–0.927, p < 0.001). The optimal threshold for predicting transfusion risk was 10.9 g/dL (sensitivity: 89.6%, specificity: 60.5%). Conclusions: Preoperative hemoglobin concentration is the primary determinant of transfusion risk, outweighing the influence of clinical comorbidities. The integration of PBM protocols designed to sustain hemoglobin levels above 10.9 g/dL is essential to reduce perioperative transfusion requirements and to promote improved maternal safety and clinical outcomes. Full article

Background and Objectives: This study aimed to assess the association between the aponeurotic expansion of the supraspinatus tendon (AEST) and supraspinatus tendon tears utilizing magnetic resonance (MR) arthrography in an extensive patient cohort and to determine its clinical relevance. Materials and Methods: All MR arthrography images were retrospectively assessed by two radiologists with expertise in arthrography. In both the AEST group and the comparison group consisting entirely of patients with rotator cuff tendon tears, the location and extent of the tear were documented, along with the distance between the tear and the AEST in the study group. In patients with AEST, it was also noted whether the tear extended to or structurally involved the AEST. Results: AEST was identified in 61 (7.4%) of the 827 MR arthrograms. The isolated supraspinatus tendon tear emerged as the most prevalent, representing 33.3% of patients with AEST. The triple combination of tears involving the supraspinatus, subscapularis, and infraspinatus accounted for 25.9% of patients with AEST. AEST tears alone were observed in just 3.3% of cases. The incidence of triple combination tears in patients with AEST was found to be significantly lower at 25.9% compared to 59.3% in the control group without AEST (p = 0.028). Conclusions: In this study, the authors found that the incidence of combined tendon tears in patients with AEST was significantly lower compared to the control group. This result suggests that the AEST likely acts as a structural barrier limiting the anterior progression of rotator cuff tears, particularly toward the subscapularis tendon. Full article

Background: Liver damage in COVID-19 is multifaceted, including liver steatosis and inflammation. Multiparametric ultrasound (mpUS) is an imaging modality that has the capacity to evaluate various facets of overall liver health and is relatively accessible and thus is an excellent choice to determine parenchymal changes. Methods: A longitudinal prospective study was designed to evaluate long-term hepatic damage following COVID-19 using mpUS. Patients were assessed within a 3–6-month period after the initial episode of COVID-19 and subsequently had a follow-up after 3 years compared to a control group. Liver stiffness (2D-SWE), attenuation (ATI), and shear wave dispersion (SWD) were measured to quantify liver stiffness, steatosis, and tissue viscosity. Results: A total of 129 patients were scanned at the baseline assessment, 90 patients in research group (58 patients had a follow-up) and 39 as a clinically healthy control group, and all were included in the follow-up for evaluation after 3 years. The mpUS evaluation in research group revealed a median SWE decrease from 5.04 ± 1.74 kPa to 4.59 ± 0.81 kPa and SWD decrease from 11.88 ± 1.73 m/s/kHz to 10.83 ± 1.49 m/s/kHz (p > 0.05); in contrast, median ATI values showed slight increase over time—0.56 ± 0.09 dB/cm/MHz to 0.60 ± 0.09 dB/cm/MHz (p > 0.05). Control group was stratified according to subsequent COVID-19 status. In both the COVID-negative and -positive subgroups SWE slightly increased from initial 4.55 ± 0.78 kPa to 4.8 ± 0.88 kPa and 4.7 ± 1.29 kPa, median SWD had a slight decrease from initial 10.80 ± 1.73 m/s/kHz to 10.15 ± 1.87 m/s/kHz and 10.6 ± 1.82 m/s/kHz (p > 0.05), and ATI increased significantly from initial 0.57 ± 0.08 dB/cm/MHz to 0.62 ± 0.09 dB/cm/MHz and 0.65 ± 0.07 dB/cm/MHz (p < 0.05), respectively. Conclusions: The study found that initially COVID-19-affected patients showed stable ATI and BMI values, no hepatic steatosis, normal SWE, and reduced dispersion which suggests resolving inflammation without fibrosis. Controls showed increased ATI and mild steatosis, likely linked to BMI and metabolic changes rather than direct viral liver injury. Full article

Background and Objectives: The optimal surgical technique for Chiari type I malformation (CM-I) remains debated, particularly in patients without syringomyelia. While duraplasty (DP+) may enhance radiological outcomes, it can carry higher complication risks. We compared clinical, radiological, and morphometric outcomes after suboccipital decompression with DP+ and without duraplasty (DP−), with prespecified subgroup analyses by syringomyelia status. Materials and Methods: Ninety-three consecutive adult CM-I underwent DP− (n = 54) or DP+ (n = 39) between 2014 and 2022. Pre- and post-operative MRI and neurological evaluations were obtained at 1 year. Functional recovery was assessed using the Chicago Chiari Outcome Scale (CCOS). Clinical and radiological outcomes, complication rates, and subgroup results (with vs. without syringomyelia) were compared. Results: Overall clinical improvement was observed in 92.5% of patients (DP−: 94.4%; DP+: 89.7%; p > 0.05). Among patients without syringomyelia, clinical improvement remained high with DP−. Radiological benefit—including syrinx regression and mega cisterna magna formation—was greater with DP+ (64.1% vs. 24.1%; p < 0.001), but this did not translate into improved functional outcomes (p > 0.05). Cerebellar slump occurred more often after DP+ (30.8% vs. 9.3%; p < 0.05). Complication rates, particularly CSF-related events, were significantly higher with DP+ (17.9% vs. 3.7%, p = 0.032). Morphometric expansion of the foramen magnum did not correlate with functional outcomes. Conclusions: At 1-year follow-up, suboccipital decompression without duraplasty appears to provide comparable clinical improvement to DP+, with fewer complications, in selected CM-I patients without syringomyelia. Duraplasty offers radiological advantages, especially for syringomyelia, but at the cost of increased risk. Longer follow-up is necessary to determine the durability of these findings. Full article

Background and Objectives: To evaluate the prognostic value of end-tidal carbon dioxide (ETCO₂), arterial carbon dioxide (PaCO₂), their difference (ΔCO₂ = PaCO₂–ETCO₂), and the ETCO₂/PaCO₂ ratio for 30-day mortality in adult patients intubated for acute respiratory failure in the emergency department (ED). Materials and Methods: In this single-center, prospective observational study, we enrolled consecutive adults intubated in the ED who had at least two paired arterial blood gas and capnography measurements within 90 min post-intubation. PaCO₂ and ETCO₂ were recorded at 0, 30, 60, and 90 min, and ΔCO₂ and ETCO₂/PaCO₂ were calculated at each time point. Between-group comparisons, repeated-measures analyses, and logistic regression were used to explore associations, and prognostic performance was assessed using receiver operating characteristic curves. Results: Among 100 patients (36% female); 30- and 90-day mortality were 64% and 70%, respectively. Non-survivors were older, had lower mean arterial pressure after intubation, higher inflammatory and coagulation markers, and more frequent pneumonia and pulmonary embolism. ETCO₂ values were consistently lower in non-survivors at 0, 30, and 60 min, while PaCO₂ was also lower at early time points. ΔCO₂ and the ETCO₂/PaCO₂ ratio did not differ between survivors and non-survivors. Among all CO₂ metrics and time points, only ETCO₂ showed low-to-moderate discrimination for 30-day mortality (area under the curve 0.65–0.70). Conclusions: In ED patients emergently intubated for acute respiratory failure, absolute ETCO₂ values in the early post-intubation period provide modest prognostic information for short-term mortality, whereas ΔCO₂ and ETCO₂/PaCO₂ do not appear to add prognostic value beyond ETCO₂ alone. Full article

Background and Objectives: Vitamin D signaling plays critical roles in immune regulation, bone metabolism, and cellular differentiation across multiple tissues. However, the spatial and temporal expression patterns of key vitamin D signaling components—the vitamin D receptor (VDR) and the enzyme 1α-hydroxylase (encoded by CYP27B1)—during human nephrogenesis have not been mapped at the protein level. The primary objective of this study was to characterize VDR and 1α-hydroxylase expression across critical stages of human kidney development, complementing prior transcriptomic and single-cell descriptions, and to contextualize these developmental observations against the dysregulation of vitamin D pathway genes in adult renal and urothelial malignancies. Materials and Methods: Immunofluorescence analysis was performed on FFPE kidney tissue from 12 specimens (3 per stage) at 10, 22 and 38 gestational weeks and postnatally at 1.5 years. For each specimen, at least three non-adjacent sections were stained and 6 non-overlapping cortical fields were imaged at ×40 (18 fields per stage). Fluorescence-area percentages were quantified in ImageJ 1.54g, and group differences were assessed by one-way ANOVA with Tukey’s post hoc test at both field- and specimen-level. An accompanying bioinformatic analysis evaluated the differential expression of VDR, CYP27B1, and CYP24A1 in adult renal and urothelial malignancies (TCGA cohorts: KICH, KIRC, KIRP, BLCA) using unpaired Welch’s t-test, with Benjamini–Hochberg FDR correction applied across all 16 tumor-versus-normal comparisons (12 gene-wise + 4 post hoc log₂(CYP24A1/CYP27B1) ratios). Results: VDR showed its highest mean fluorescence area at 10 weeks (3.40% (95% CI 3.24–3.56); field-level Tukey p < 0.0001 versus other stages) and its lowest at 22 weeks (0.69% (0.64–0.74)). 1α-hydroxylase was also highest at 10 weeks (5.44% (5.29–5.60); p < 0.0001) and stabilized at lower levels thereafter (3.04–4.26%). Co-expression of both proteins was observed throughout development except in 22-week glomeruli. In TCGA, all 12 significant gene-wise comparisons retained significance after BH FDR correction (q < 0.05). VDR showed cohort-specific dysregulation: reduced in KICH (q = 2 × 10⁻⁴) but increased in KIRC and KIRP (q = 2 × 10⁻⁴ for both). CYP24A1 was reduced in all three renal cohorts (q ≤ 0.029) and unchanged in BLCA. CYP27B1 showed cohort-specific direction (reduced in KIRC; increased in KICH, KIRP, and BLCA). Conclusions: This study provides an initial immunofluorescence-based spatial description of VDR and 1α-hydroxylase across human kidney development, revealing a coordinated redistribution from immature glomeruli at 10 weeks to mature tubular segments at later stages. The TCGA analysis demonstrates that vitamin D pathway dysregulation in renal carcinoma is cohort-specific and is not abolished by multiple-testing correction. Together, these results indicate that the developmentally engaged vitamin D pathway retains kidney-specific functional relevance in adult renal pathology and provide a baseline reference for future mechanistic studies. Full article

Background and Objectives: The labyrinthine artery (LA) is a small but surgically important vessel encountered during procedures involving the cerebellopontine angle (CPA). Variations in its number, origin, and relationship to the facial–vestibulocochlear nerve complex may increase the risk of vascular injury during CPA surgery. The aim of this cadaveric microdissection study was to evaluate the number, origin, and course of the LA within the CPA and to characterize its relationship to the anterior inferior cerebellar artery (AICA) and the facial–vestibulocochlear nerve complex. Materials and Methods: Microsurgical dissections were performed bilaterally in 45 formalin-fixed adult cadavers (90 CPAs) using an operating microscope and vascular injection. The number, origin, and course of the LA were analyzed together with its relationship to the AICA and the facial–vestibulocochlear nerve complex. Results: The LA was identified in all specimens. A single LA was observed in 57.8% of CPAs, whereas multiple LAs were identified in 42.2%. The artery most commonly originated from the AICA (65.6%), followed by a common trunk shared with the AICA (21.1%) and direct origin from the basilar artery (13.3%). In specimens with bifurcated AICAs forming double loops, multiple LAs frequently arose from both loops. Considerable variability was observed in the course of the LA relative to the facial–vestibulocochlear nerve complex, including superior, inferior, and interposed courses. Bilateral asymmetry was identified in 15.6% of cadavers. Conclusions: The LA demonstrates substantial anatomical variability within the CPA regarding its number, origin, and neurovascular relationships. Although the artery most commonly arises from the apex or medial aspect of the AICA loop, its subsequent course may vary considerably. Careful microsurgical inspection remains essential during CPA surgery, as the configuration of the AICA alone is insufficient to reliably predict the distal trajectory of the LA. Full article

Background and Objectives: To examine the psychological parameters among pregnant organ transplant recipients that are understudied compared to the physical health of women during post-transplantation pregnancy. Materials and Methods: Systematic review based on PubMed, EMBASE, CINAHL, and PsycInfo that were searched until 15 January 2025. Quality Assessment and meta-aggregation were applied to qualitative studies. Results: Out of 4361 screened unique studies, six are included. Most studies were retrospective and focused on liver, kidney, and heart transplants. Meta-aggregation identified four synthesized findings: “Perception of Pregnancy after Transplantation”, “Concerns about Maternal Physical Health”, “Concerns about Fetal Health”, and “Emotional Burden by Expectant Mothers and Coping Strategies”. The review was constrained by the potential exclusion of relevant studies due to language restrictions and uncontrolled bias in the included studies. Conclusions: Several psychological themes were identified, not all exclusive to transplant recipients. Developing a targeted questionnaire to gather primary data could enhance clinical practice and improve counseling services for this patient population. Full article

Background and Objectives: Many patients suffer from chronic pain of the shoulder, neck, upper back, and/or arm. They may be diagnosed with fibromyalgia, complex regional pain syndrome, myofascial pain, thoracic outlet, subacromial pain, cervical radiculopathy, cervicogenic headaches, post-mastectomy pain, and/or occupational shoulder disorder. The pectoralis minor (PM) is the only muscle of the scapula controlled by the lower trunk of the brachial plexus. In the Human Disharmony Loop (HDL), this neurologic asymmetry produces persistent protraction of the scapula. Protraction deforms the scapula’s connections, generating headaches and neck stiffness, upper back tightness, shoulder weakness, and hand numbness. We hypothesize patients with the above who meet HDL diagnostic criteria will benefit from PM tenotomy with brachial plexus neurolysis (PM+ICN). Materials and Methods: Patients diagnosed with the above disorders who also met HDL criteria of medial coracoid tenderness and scapula protraction on exam underwent PM+ICN, with secondary neurolysis after 3 months if needed. Clinical neuropathy was diagnosed via the scratch-collapse test. Outcomes included self-reported Visual Analogue Score pain scores, active shoulder abduction range of motion (ROM), prevalence of occipital headaches. Results: N = 318 patients were included. Average age was 51; 68.0% were female. Following treatment, average pain decreased from 7.3/10 to 2.1/10 (p < 0.001), average shoulder ROM increased from 96 to 170 degrees (p < 0.001), and occipital headaches decreased from 76.7% to 1.6% (p < 0.001). Scapular protraction normalized from 98.8% static to 92.5% none (p < 0.001). Overall, 17% required subsequent neurolysis, chiefly of the axillary, radial, and ulnar nerves. The pain reductions were statistically indistinguishable across all diagnoses (p = 0.709, I² = 0.02%). Average follow-up was 22 months. Conclusions: PM+ICN significantly reduced self-reported pain and headaches in select intractable patients. The PM pathologizing the scapula may constitute a shared anatomic mechanism that contributes to chronic pain across heterogenous disorders of the upper limb. Full article

The right ventricle (RV) is a primary determinant of outcomes in cardiac critical care. RV dysfunction independently predicts morbidity and mortality in conditions such as acute coronary syndromes, pulmonary embolism, and cardiogenic shock. This review synthesizes RV evaluation and management by integrating physiologic principles with bedside diagnostic and therapeutic strategies. The RV is exceptionally sensitive to acute afterload increases due to its adaptation to low-pressure pulmonary circulation. Evaluation utilizes a multimodal approach combining echocardiography, invasive hemodynamics, and specifically the pulmonary artery pulsatility index and central venous pressure/pulmonary capillary wedge pressure (CVP/PCWP) ratio and biomarkers. Management focuses on three pillars: individualized preload optimization, afterload reduction via selective pulmonary vasodilators, and contractility augmentation with inotropes. For refractory cases, mechanical circulatory support options like Impella RP, ProtekDuo, and VA-ECMO provide critical bridges to recovery or transplantation. Full article

Background and Objectives: Muscle hypertrophy and strength increase are significantly influenced by the distribution of muscle fiber types in individuals. Individuals exposed to similar training intensity in fitness and bodybuilding exhibit different levels of adaptation suggesting that muscle fiber type may influence training outcomes. The aim of this study is to comparatively examine the strength development that occurs in fitness and bodybuilding athletes with different muscle fiber types (Type I, Type II, and Mixed) following a standardized resistance training program. Materials and Methods: The study was conducted using a quasi-experimental design based on a single-group pre-test–post-test model, with no control group. A total of 48 male athletes aged 19–26 years (22.75 ± 1.68) who had been regularly training in fitness and bodybuilding for at least two years voluntarily participated in the study. Muscle fiber types of the participants were indirectly estimated based on the number of repetitions performed at 80% of one-repetition maximum (1RM) in the bench press exercise, and individuals were divided into three groups: Type I, Type II, and mixed. All participants underwent a resistance training program for 6 weeks, 3 days a week, at 80% 1RM intensity and in the range of 8–12 repetitions. Data were analyzed using Shapiro–Wilk normality test, Wilcoxon Signed-Rank Test, and Mann–Whitney U. Results: The findings showed statistically significant increases between pre-test and post-test measurements in all groups. When percentage improvements were examined, the highest increase was observed in individuals with Type II muscle fiber type, and the lowest increase was observed in individuals with Type I muscle fiber type. Conclusions: In conclusion, the findings indicate that resistance training increases strength development in all muscle fiber types, but the level of development differs depending on the muscle fiber type. These findings highlight the importance of training programs based on individual muscle fiber type characteristics. Full article

Background and Objectives: Non-traumatic osteonecrosis of the femoral head (ONFH) is a multifactorial disorder influenced by both environmental and genetic factors. The nuclear receptor subfamily 3 group C member 1 (NR3C1) gene encodes the glucocorticoid receptor, which plays a key role in bone metabolism, vascular regulation, and stress response. This study aimed to investigate the association between NR3C1 polymorphisms and susceptibility to ONFH, with particular emphasis on age-related genetic effects. Materials and Methods: A hospital-based case–control study was conducted using genotyping data from the Taiwan Biobank version 2 (TWBv2) custom array. A total of 609 patients with ONFH and 2436 age- and sex-matched controls were included. Forty-nine single-nucleotide polymorphisms (SNPs) within or near the NR3C1 gene with a minor allele frequency greater than 5% were analyzed. Logistic regression models were applied to estimate odds ratios (ORs) and 95% confidence intervals (CIs) under multiple genetic inheritance models. Age-stratified analyses were also performed. Results: Among the analyzed SNPs, rs28593206 and rs315199 demonstrated nominally significant differences in allele distributions between cases and controls (p = 0.024 and p = 0.009, respectively), with minor alleles showing nominal associations with increased odds of ONFH. Additional exploratory analyses under different genetic models identified several SNPs with nominal associations with ONFH susceptibility, while rs7709864 showed a possible nominal protective association. In age-stratified analyses, several SNPs showed nominal associations with ONFH risk among individuals older than 40 years, whereas no nominally significant associations were observed in younger individuals. Conclusions: This exploratory study suggests that NR3C1 polymorphisms may be nominally associated with susceptibility to ONFH, particularly among individuals older than 40 years. However, because no formal correction for multiple comparisons was performed and detailed etiological data were unavailable, these findings should be interpreted cautiously and regarded as hypothesis-generating rather than clinically applicable evidence. Further studies incorporating larger cohorts, etiological stratification, multiple-testing correction, replication analyses, and functional validation are required to confirm these observations and clarify the underlying biological mechanisms. Full article

Background and Objectives: Idiopathic scoliosis (IS) has been conceptualized as a structural spinal deformity; emerging evidence suggests that postural control and vestibular mechanisms may contribute to curve development and functional severity. This study investigated the relationship between radiological parameters, postural stability, and vestibular dysfunction in adolescents with IS. Materials and Methods: A retrospective cohort of 177 patients aged 8–22 years was analyzed between 2022 and 2024. Standard radiography was performed on 135 participants to evaluate the major curve as established by the Cobb method, Nash–Moe classification, and Risser stage. Peripheral vestibular syndrome (PVS) was investigated using the Fukuda (FST), video-nystagmography (VNG), and instrumental Romberg tests on a stable and unstable platform. Associations between vestibular variables and radiographic parameters were explored using Mann–Whitney U and Kruskal–Wallis tests, supported by non-parametric correlations. Results: Female participants (63%) exhibited significantly higher initial major curve angle value compared with males (median 14° vs. 10.5°, p = 0.004). Positive FTS findings and the presence of peripheral vestibular syndrome were strongly associated with higher baseline and final major curve angles (both p < 0.001). Romberg performance showed significant correlations with major curve angle across stable and unstable conditions (r = 0.298–0.396, all p < 0.001). VNG identified multi-canal vestibular involvement, particularly anterior–horizontal combinations on the right ear, as being associated with substantially greater curve magnitude; left-ear impairment demonstrated similar non-significant trends. Curve localization did not differ by vestibular involvement. Conclusions: Patients with idiopathic scoliosis (IS) display consistent associations between vestibular dysfunction, impaired postural control, and greater curve severity. These findings support the clinical relevance of vestibular assessment in scoliosis evaluation and suggest a potential role for sensorimotor rehabilitation strategies. Integrating vestibular screening into standard care may enhance risk stratification and inform the clinician on individualized conservative management. Full article

Background and Objectives: Post-stroke spasticity is a frequent complication that contributes to impaired mobility, reduced functional independence, and decreased exercise tolerance. While botulinum toxin A (BoNT-A) is widely used to improve muscle tone, its effects on cardiopulmonary exercise capacity remain insufficiently characterized. This study aimed to evaluate the impact of BoNT-A treatment on cardiopulmonary performance and functional outcomes in patients with post-stroke spasticity. Materials and Methods: A prospective before–after study was conducted including 50 patients with post-stroke spasticity. Cardiopulmonary exercise testing was performed before and after BoNT-A administration. The primary outcome was peak oxygen consumption (VO₂ peak), while secondary outcomes included anaerobic threshold (AT), exercise duration, maximal workload, 10 m walk test time, Barthel Index, and modified Rankin Scale (mRS). Paired comparisons and multivariable linear regression analyses were performed to assess changes and associated factors. Results: VO₂ peak increased significantly following treatment (12.96 ± 2.70 vs. 13.55 ± 2.85 mL/kg/min; mean change 0.59 mL/kg/min, 95% CI 0.36–0.82; p < 0.001). Similar improvements were observed for AT (10.47 ± 2.77 vs. 10.97 ± 2.97 mL/kg/min; p < 0.001), exercise duration (6.70 ± 1.48 vs. 7.11 ± 1.55 min; p < 0.001), and maximal workload (44.70 ± 10.97 vs. 48.06 ± 12.60 W; p < 0.001). Functional performance improved, as indicated by reduced 10 m walk time (18.33 ± 4.67 vs. 17.36 ± 4.82 s; p < 0.001) and increased Barthel Index (57.62 ± 19.18 vs. 61.92 ± 21.10; p < 0.001). A modest but significant reduction in disability was observed on the mRS (p = 0.003). Baseline values were the strongest predictors of post-treatment outcomes, while smoking status was associated with worse walking performance. Conclusions: BoNT-A treatment was associated with modest but consistent improvements in cardiopulmonary exercise capacity and functional performance in patients with post-stroke spasticity. These findings suggest that spasticity management may be associated with functional and exercise-related benefits extending beyond local neuromuscular effects, although causal relationships cannot be established based on the present study design. Further controlled studies are needed to confirm these findings and evaluate their long-term clinical significance. Full article