Clinics and Practice doi: 10.3390/clinpract16050091

Authors: Gulzar Shah Anjana Kalathimekkattu Indira Karibayeva Bobbie J. Newell

Background/Objectives: Cost-related delays hinder access to dental care in the United States, while the growing use of telehealth has an uncertain impact on population-level access to dental services. The study examined factors associated with cost-related delays in dental care among U.S. adults and whether telemedicine use in the past year was associated with these delays. Methods: This cross-sectional study utilized nationally representative data from the 2023 National Health Interview Survey (NHIS) to examine the association between telehealth use and oral health services utilization in the past 12 months. All analyses were performed using R version 4.5.1 within the RStudio IDE (version 2025.09.0+387). Results: Adults who visited a dental provider within the past 12 months had lower odds of cost-related dental care delay, whereas telemedicine users had higher odds of delay. Higher odds of delayed dental care were observed among women, those aged below 65 years, Hispanics, those with poorer health, and those living in the Midwest, South, and West. Education and family income-to-poverty ratio were not significantly associated with delay in the adjusted analysis. Conclusions: Cost-related delays in dental care remain common and reflect persistent sociodemographic inequities and patterns of healthcare engagement. Telemedicine use alone does not appear to contribute to overcoming barriers to dental care access. Policies that reduce financial barriers and connect telehealth encounters with oral health referral pathways may improve equitable access to dental services.

Clinics and Practice doi: 10.3390/clinpract16050090

Authors: Maria Sobol Ewelina Sielska-Badurek Mariusz Cięciara Artur Wrzosek Justyna Tomaszewska Beata Roman

Purpose: The aim of this study was to investigate the safety and efficacy, as well as relief of symptoms after regular use, of 0.5% lidocaine hydrochloride solution in anhydrous glycerol (Auridol) in the form of ear drops, in patients with symptoms of otitis externa (OE) in a real-world setting. Methods: This real-world pre–post study included 64 subjects aged 1 to 69 years with symptoms as follow: swelling, pain due to regular exposure to water or caused by frequent use of detergents, pain due to prolonged wearing of earphones, or earwax clogging the external auditory canal. In each subject, following an otoscopic examination and interview given by an ENT, the Auridol treatment was initiated. The product was administered as two drops into the affected ear up to three times daily in patients with symptoms of OE. During each visit, physical and functional symptom were evaluated. In addition, the efficacy of using the product was assessment using a VAS scale. At the end of the study, subjects rated the product according to a Likert scale. Results: A statistically significant reduction in perceived pain was observed at t = 30’ as well as t = 3 days after application. For physical symptoms assessed by an ENT, a statistically significant difference was observed between consecutive scores for two of the assessed parameters (redness and swelling.) The product was rated very highly by the subjects. Conclusions: The results suggest that a combination of anhydrous glycerol and 0.5% of lidocaine in the form of ear drops has a positive effect in the treatment of symptoms of OE.

Clinics and Practice doi: 10.3390/clinpract16050089

Authors: Luciano Cellura Anna Maria Grugnetti Stefano Gabriele Scaglia Attilio Quaini Silvia Natoli Giuseppina Grugnetti

Introduction/Aim: Nursing care constitutes a fundamental determinant of patient outcomes in intensive care units (ICUs); however, the absence of standardised nursing-sensitive indicators constrains the objective evaluation of care quality within this setting. The present study aimed to develop an evidence-informed core set of nursing-sensitive patient outcomes (NSPOs) specific to intensive care nursing. Methods: A Delphi consensus study was conducted between September 2023 and February 2025 at the IRCCS Policlinico San Matteo Foundation, Pavia, Italy. The process comprised a preliminary scoping review, followed by two iterative Delphi rounds and a final consensus meeting aimed at refining conceptual domains without modifying item ratings. Thirty-eight ICU nurses evaluated 35 evidence-based NSPOs using a five-point Likert scale. Consensus was defined a priori as ≥75% agreement (scores 4–5), with a minimum response rate of ≥80%. Reliability was assessed using a two-way random-effects Intraclass Correlation Coefficient (ICC). Results: Fifteen NSPOs achieved the predefined consensus threshold and demonstrated moderate-to-excellent reliability (ICC = 0.65–0.85). The validated core set was organised into four domains—safety, clinical, functional, and perceptual—reflecting both preventive–technical and holistic dimensions of ICU nursing care. Conclusions: This study produced the first ICU-specific evidence-based NSPO core set in Italy, providing a measurable and reproducible framework to support systematic outcome monitoring, and quality improvement in critical care practice.

Clinics and Practice doi: 10.3390/clinpract16050088

Authors: Elena Maria Domsa Ioana Para Adela Viviana Sitar Taut Teodora Atena Pop Elena Ofelia Mosteanu Laura Elena Gligor Mihaela Elvira Cîmpianu Antonia Gabriela Nitescu Viorel Lucian Marina Bogdan Nicolae Mucea Vasile Andreica

Background/Objectives: Celiac disease (CD) is a chronic immune-mediated enteropathy triggered by gluten ingestion in genetically predisposed individuals, with a highly heterogeneous clinical presentation encompassing both intestinal and extraintestinal manifestations. Despite growing clinical awareness, diagnostic delay remains a significant challenge, and the evolution of clinical and histopathological features following gluten-free diet (GFD) initiation remains incompletely characterized. This study aimed to compare the clinical, serological, and histopathological profile of adults with newly diagnosed CD and those maintained on a long-term GFD. Methods: This prospective observational study enrolled 50 adult patients with biopsy-confirmed CD: 16 at the time of diagnosis (gluten-consuming) and 34 on a GFD for at least one year. All participants underwent standardized clinical assessment, serological testing (IgA anti-tissue transglutaminase [tTG] and/or IgA anti-endomysial antibodies [EMAs]), upper digestive endoscopy with duodenal biopsies graded according to the Marsh–Oberhuber classification, and evaluation for Helicobacter pylori co-infection. Between-group comparisons were performed using the Mann–Whitney U test, Fisher's exact test, and chi-square test, as appropriate. Results: Newly diagnosed patients exhibited a significantly longer median duration from symptom onset to diagnosis compared to the GFD group (p = 0.03). Histopathological severity was greater in the newly diagnosed group, with more advanced Marsh–Oberhuber grades (p = 0.03). Among individual symptoms, bloating was significantly more frequent in newly diagnosed patients (p = 0.02). Notably, thrombocytosis was identified significantly more often in the newly diagnosed group compared to GFD patients (p = 0.02), representing a potentially underrecognized extraintestinal marker of active CD. Overall rates of intestinal and extraintestinal manifestations and CD-specific seropositivity did not differ significantly between groups. Conclusions: The clinical and histopathological profile of adults with celiac disease differs meaningfully between the time of diagnosis and during GFD adherence. Bloating and thrombocytosis were significantly more prevalent at diagnosis, with thrombocytosis emerging as a potentially underrecognized marker of active disease. Conversely, several manifestations persisted despite dietary treatment, underscoring the heterogeneous nature of CD across its clinical course. These findings may support earlier disease recognition and more individualized follow-up strategies in routine clinical practice.

Clinics and Practice doi: 10.3390/clinpract16050087

Authors: Yakup Özgüngör Burak Emre Gilik Emre Karagöz Hicret Yeniay Mensure Çakırgöz Özlem Melis Korkmaz Özgüngör İhsan Birol Sıla Seven

Background: Non-thyroidal illness syndrome is frequent in critically ill patients, but the prognostic value of dynamic changes in thyroid function tests remains unclear. This study evaluated whether serial measurements of thyroid-stimulating hormone (TSH) and free triiodothyronine (FT3) provide additional predictive value for 30-day mortality beyond conventional severity scores in ICU patients. Methods: This single-center retrospective observational study included 74 adult patients treated for ≥72 h in a general ICU who had TSH and FT3 measured within 24 h of admission and repeated at 48–72 h. Patients aged 18 years or above admitted to the intensive care unit were included in the study. Demographic characteristics, comorbidities, APACHE II, SOFA, modified NUTRIC (mNUTRIC) scores, and routine laboratory data (including albumin, CRP, and lactate) were recorded. The primary outcome was 30-day mortality. Between-group comparisons were performed using t-tests, Mann–Whitney U, and Chi-square tests. Variables significant in univariate analyses were entered into binary logistic regression models, and predictive performance was assessed using receiver operating characteristic (ROC) curves and the Youden index. Results: The mean age was 68.7 ± 14.7 years, and 41.9% (n = 31) of the patients died within 30 days. Non-survivors had higher APACHE II, SOFA, and mNUTRIC scores and lower albumin, lymphocyte count, and second FT3 levels compared with survivors (all p ≤ 0.003). Baseline FT3 and TSH were not associated with mortality, whereas both the subsequent FT3 measurements and the ΔT3 (variance in former to latter FT3) were remarkably predictive. The latter FT3 < 1.63 pg/mL produced an AUC of 0.835 (sensitivity: 77%, specificity: 74%), and a ΔT3 log ratio threshold of −0.09 (≈20% early FT3 decline) produced an AUC of 0.835 (sensitivity: 71%, specificity: 81%). The APACHE II + ΔT3 (numeric) model showed the best discrimination (AUC: 0.921; sensitivity: 87.1%, specificity: 81.4%), outperforming APACHE II alone (AUC: 0.861). Conclusions: In critically ill adult patients, dynamic T3 kinetics—particularly premature decline in FT3 within the first 72 h—provide incremental prognostic value for 30-day mortality beyond APACHE II. Serial FT3 monitoring may help identify high-risk patients whose endocrine adaptation to critical illness is failing.

Clinics and Practice doi: 10.3390/clinpract16050086

Authors: Jelena Stojsavljevic Rafael R. Perez Emilia Petcu Celestine Odenigbo Cristian Madrid Igor Dumic Charles W. Nordstrom

Background: Acute transverse myelitis (ATM) is an inflammatory disorder of the spinal cord with heterogeneous etiologies, including autoimmune, infectious, paraneoplastic, and drug-induced causes. Tumor necrosis factor-alpha (TNF-α) inhibitors have been infrequently associated with inflammatory central nervous system events, including transverse myelitis. TNF-inhibitor-associated myelitis typically presents with short-segment lesions, a normal brain MRI, and partial responsiveness to corticosteroids. Longitudinally extensive transverse myelitis (LETM) and steroid-refractory cases are uncommon. Case Presentation: A 39-year-old woman with psoriatic arthritis treated with etanercept for two years presented with subacute progressive bilateral lower-extremity sensory loss and weakness. MRI revealed a T2 hyperintense spinal cord lesion extending from T11 to L1 with gadolinium enhancement, consistent with transverse myelitis, while brain MRI was normal. Cerebrospinal fluid analysis showed lymphocytic pleocytosis, elevated protein, oligoclonal bands, and increased kappa free light chains. Extensive infectious, metabolic, paraneoplastic, and autoimmune testing, including aquaporin-4 and MOG antibodies, was negative. Despite high-dose intravenous corticosteroids and the discontinuation of etanercept, the patient experienced clinical worsening with lesion expansion, meeting criteria for LETM, and developed urinary retention. She subsequently underwent plasma exchange, resulting in radiologic improvement and moderate clinical recovery. Conclusions: This case highlights an atypical presentation of TNF-inhibitor-associated myelitis characterized by a biphasic course, longitudinally extensive spinal cord involvement, steroid refractoriness, and responsiveness to plasma exchange. These features suggest either an unusually severe TNF-inhibitor-related inflammatory phenotype or a TNF-inhibitor-triggered antibody-mediated demyelinating process. Reports of TNF-inhibitor-associated myelitis evolving into longitudinally extensive, steroid-refractory disease remain limited, and this presentation may broaden the recognized clinical spectrum of TNF-α-related CNS inflammatory events. Close neurologic follow-up and heightened awareness of severe CNS complications associated with TNF-α inhibitors are warranted.

Clinics and Practice doi: 10.3390/clinpract16050085

Authors: Lucian Șerbănescu Sebastian Mirea Paris Ionescu Ionuț Iorga Traian-Virgiliu Surdu Vadym Rotar Stere Popescu Elena Mocanu Luana Alexandrescu Cosmin Nișcoveanu Radu-Andrei Baz

Background/Objectives: Urinary incontinence (UI) is a frequent condition in postmenopausal women and is associated with a substantial negative impact on quality of life. Conservative management can include pelvic floor muscle training (PFMT) and high-intensity focused electromagnetic stimulation (HIFEM); however, data regarding the potential benefit of combining these modalities remain limited. This study aimed to evaluate whether the addition of a structured Kegel exercise program to EMSELLA-based electromagnetic stimulation is associated with enhanced clinical outcomes in postmenopausal women with urinary incontinence. Methods: This prospective comparative study included 99 postmenopausal women with stress, urgency, or mixed urinary incontinence and an International Consultation on Incontinence Questionnaire–Urinary Incontinence Short Form (ICIQ-UI SF) score ≥ 6. Participants received either EMSELLA therapy alone (Group A, n = 49) or EMSELLA combined with a standardized Kegel exercise program (Group B, n = 50) over a three-month period. Symptom severity was assessed at baseline and at three months using the ICIQ-UI SF. Between-group comparisons were performed using analysis of covariance, adjusting for baseline scores. Results: Both therapeutic approaches were associated with clinically meaningful improvement in urinary incontinence symptoms. After adjustment for baseline severity, lower follow-up ICIQ-UI SF scores, greater mean symptom reduction, and higher response rates were observed in the combined-therapy group. Across all menopausal-duration subgroups, outcomes consistently favored the association of EMSELLA therapy with Kegel exercises. No treatment-related adverse events were reported. Conclusions: The association of EMSELLA electromagnetic stimulation with a structured Kegel exercise program was associated with greater symptom improvement than electromagnetic stimulation alone, suggesting an additive therapeutic effect of voluntary pelvic floor muscle training. This combined conservative approach was well tolerated and may represent a useful management strategy for postmenopausal urinary incontinence.

Clinics and Practice doi: 10.3390/clinpract16050084

Authors: Isabella Oliveira do Lago Bruna Moura Medina Diniz Daniela Vieira Buchaim Rogerio Leone Buchaim

In the original publication [...]

Clinics and Practice doi: 10.3390/clinpract16050083

Authors: Hasan M. Al-Dorzi Abdulaziz R. Al-Qwizani Turki F. Al-Saikhan Yousef Alshahwan Bandar F. Bindayel Raed Alharthi Raymond Khan

Background: Patients with traumatic brain injury (TBI) are often underfed and frequently experience enteral feeding (EF) intolerance. We examined the association between EF timing, caloric intake and EF intolerance, and mortality. Methods: We retrospectively evaluated adult patients with moderate-to-severe TBI in a tertiary-care ICU. In the first 7 days, we recorded daily caloric intake from EF and the occurrence of EF intolerance—defined as a gastric residual volume > 500 mL or >250 mL with vomiting. Results: Among 298 patients, 210 (70.4%) received early EF. The median 7-day cumulative caloric intake was 7766 kcal for the early EF group (64.7% of caloric requirement) and 2783 kcal (23.1% of caloric requirement) for the late (after 48 h) EF group (p < 0.001). EF intolerance occurred in only 24 patients (8.1%), with no significant difference between the early and late groups. Hospital mortality was 13.8% with early EF versus 30.7% with late EF (p = 0.001), 8.5% with caloric intake ≥ 80% of requirement versus 21.3% with lower caloric intake (p = 0.02) and 50% in patients with EF intolerance versus 16.1% in those without intolerance (p < 0.001). In multivariable logistic regression analysis, early EF was associated with lower mortality (odds ratio 0.326; 95% confidence interval 0.165–0.644), whereas EF intolerance was associated with higher mortality (odds ratio 7.451; 95% confidence interval 2.787–19.922). Conclusions: In patients with moderate-to-severe TBI, early EF was associated with higher caloric intake and lower mortality compared to late EF. EF intolerance was uncommon but strongly associated with higher mortality.

Clinics and Practice doi: 10.3390/clinpract16050082

Authors: Borislava Atanasova Mariya Tokmakova Angel M. Dzhambov Rafiela Chitak Penka Atanassova

Objectives: Atrial fibrillation (AF), the most common sustained cardiac arrhythmia, and cardiometabolic comorbidity, have been increasingly associated with cognitive impairment and dementia. These associations, however, remain underexplored and underappreciated in middle-aged individuals with AF. This study aimed to explore the associations of early cognitive impairment with the presence of cardiometabolic comorbidities and potential associations with echocardiographic markers in middle-aged patients with and without AF. Methods: Between 2023–2024, fifty-six consecutive outpatients with a diagnosis of AF aged 45–65 years underwent clinical evaluation, transthoracic echocardiography, and comprehensive neuropsychological assessment using the Montreal Cognitive Assessment (MoCA) and the Consortium to Establish a Registry for Alzheimer’s Disease battery (CERAD). A control group of 58 age group-matched individuals without known cardiometabolic disease was included in comparative cognitive analyses. Results: Patients with AF and cardiometabolic comorbidities demonstrated early cognitive deficits, particularly in episodic memory and visuospatial functions, detectable even in individuals with normal MoCA scores, compared with the control group. However, no associations were observed between cognitive performance and conventional echocardiographic parameters in the group with AF. Conclusions: This study corroborated prior evidence of an association between cardiometabolic impairment and subtle cognitive impairment, but did not identify a specific contribution of echocardiography markers. More extensive and sensitive biomarkers of left atrial structure and function may be required to detect harmful associations with subtle cognitive impairment in middle-aged individuals. Further prospective studies, with a more balanced control for comorbidities, are warranted to clarify the clinical relevance of atrial structural remodeling in this context.

Clinics and Practice doi: 10.3390/clinpract16040081

Authors: Silvia Iannelli Melania Scarcella Antonella Cusano Federica Feleppa Ylenia Pancione Luigi Michele Pavone Pasquale Cocchiaro

Background/Objectives: Serum protein electrophoresis (SPE) is a widely used laboratory test for the detection and monitoring of monoclonal gammopathies, including multiple myeloma (MM). Although SPE is usually recommended in the presence of specific clinical or laboratory abnormalities, monoclonal gammopathies may occasionally develop rapidly and without typical symptoms. This case report aims to emphasize the diagnostic value of SPE in identifying an unexpected and fast-evolving monoclonal gammopathy. Methods: We report the clinical and laboratory eight-month follow-up of a 58-year-old male who initially underwent SPE for unrelated clinical conditions. Serial SPE analyses were performed using capillary zone electrophoresis. When abnormalities emerged, immunotyping and serum free light chain (FLC) assays were conducted. The diagnostic workup was completed with bone marrow aspiration, flow cytometry, and imaging studies according to current international diagnostic criteria. Results: The initial SPE (November 2023) showed a normal protein profile. After eight months, follow-up SPE revealed a prominent monoclonal spike in the gamma region (2.9 g/dL), associated with increased total serum proteins (91 g/L; range 64–82 g/L), elevated IgA levels (20.0 g/L; range 0.4–3.5 g/L), and a markedly abnormal κ/λ FLC ratio (54.00; range 0.31–1.56). Bone marrow analysis demonstrated >18% plasma cell infiltration, confirming the diagnosis of IgA-κ MM. The patient underwent standard therapy followed by autologous stem cell transplantation, achieving disease remission. Conclusions: This case highlights that clinically relevant monoclonal gammopathies may arise rapidly in the absence of classical diagnostic features. Routine SPE represents a cost-effective and accessible screening tool that can identify subtle protein abnormalities, prompting the timely use of more specific and invasive diagnostic procedures for aggressive plasma cell disorders.

Clinics and Practice doi: 10.3390/clinpract16040080

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

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

Clinics and Practice doi: 10.3390/clinpract16040079

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

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

Clinics and Practice doi: 10.3390/clinpract16040078

Authors: Sanjana Arun Joaquin Cardozo Andre Shon Hirakawa Teresa Anh Tran Van Dexter Calo Robert Fauer

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

Clinics and Practice doi: 10.3390/clinpract16040077

Authors: Yibo Liu Christopher Khatchadourian Luke Sanders Quincy Eweroke Cyvannah Warner-McCutcheon Jackson Lewis Joaquin Santos Vishwanath Venketaraman

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

Clinics and Practice doi: 10.3390/clinpract16040076

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

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

Clinics and Practice doi: 10.3390/clinpract16040075

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

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

Clinics and Practice doi: 10.3390/clinpract16040074

Authors: Ariane P. Lallès Luisa Cedin Markus A. Wimmer

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

Clinics and Practice doi: 10.3390/clinpract16040073

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

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

Clinics and Practice doi: 10.3390/clinpract16040072

Authors: Claudiu C. Popescu Luminița Enache Carmen Ștențel Corina Mogoșan Cătălin Codreanu

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

Clinics and Practice doi: 10.3390/clinpract16040071

Authors: Daniel Schiltz Mahsa Bagheri Borgolte Stephan Schreml Philipp Lamby Adrian Vater Lukas Prantl Uwe von Fritschen

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

Clinics and Practice doi: 10.3390/clinpract16040070

Authors: Dora Martic Martin Miskovic Antonija Palac Bzik Ana Glavina Ivan Kovacic Antonija Tadin

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

Clinics and Practice doi: 10.3390/clinpract16040069

Authors: Carlos Ramon Hölzing Tristan Ernst Thomas Wurmb Tobias Grundgeiger Patrick Meybohm Oliver Happel

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

Clinics and Practice doi: 10.3390/clinpract16040068

Authors: Isabella Oliveira do Lago Bruna Moura Medina Diniz Daniela Vieira Buchaim Rogerio Leone Buchaim

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

Clinics and Practice doi: 10.3390/clinpract16040067

Authors: Paulina Rabiej-Krzys Karolina Szczygiel Rafal Lenard Francesco Perone Joanna Popiolek-Kalisz

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

Clinics and Practice doi: 10.3390/clinpract16040066

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

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

Clinics and Practice doi: 10.3390/clinpract16040065

Authors: Hyunhwa Lee Haehyun Lee Jinyoung Park Jessica Gill

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

Clinics and Practice doi: 10.3390/clinpract16040064

Authors: Maria E. Ramos-Nino

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

Clinics and Practice doi: 10.3390/clinpract16030063

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

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

Clinics and Practice doi: 10.3390/clinpract16030062

Authors: Filippo Murina Cecilia Fochesato Dario Recalcati Valeria Savasi

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

Clinics and Practice doi: 10.3390/clinpract16030061

Authors: Alessandro Guffanti Matteo Leonardi Natascia Brondino Bernardo Dell’Osso Vassilis Martiadis Miriam Olivola

Introduction: Major depressive disorder (MDD) is a leading cause of disability worldwide and contributes significantly to the global burden of disease. Recent data show an increasing prevalence of treatment-resistant depression (TRD). Patients with autism spectrum disorder (ASD) often exhibit MDD as a comorbidity and it is often resistant to conventional treatments. ASD determines emotional dysregulation and a reduced ability to understand mental states (mentalization). These features can lead to suicidal ideation and/or behavior. Intranasal esketamine may offer a novel therapeutic option for this population. Methods: This case series focuses on the clinical response to intranasal esketamine in patients with autism and TRD; esketamine is approved in Italy as an add-on therapy in TRD, so our case study is based on an in-label treatment. Three young patients (n = 3, F/M 2:1, age range 20–25 y) with light to moderate autism (Level 1 or 2) were treated. Esketamine was administered in augmentation with selective serotonin reuptake inhibitors (SSRIs) or serotonin-norepinephrine reuptake inhibitors (SNRIs) in accordance with EMA/AIFA guidelines. A structured follow-up protocol was set to monitor depressive symptoms, social cognition, and mentalization. Follow-up during treatment was maintained for six months, and psychometric evaluations were performed at six time points: baseline (T0), 1 week (T1), 1 month (T2), 2 months (T3), 3 months (T4), and 6 months (T5). Also, subjective quality of life was investigated before and after the observation period. Results: Despite differences in clinical profile, all patients showed good efficacy of esketamine in reducing depressive symptoms: two patients experienced clinical remission at T5 (MADRS < 10), one patient showed partial response (dMADRS = 43.24%). No major side effects were reported. Significant improvements were observed after the first week of treatment (P1: MADRS_T0 = 37, MADRS_T1 = 12; P2: MADRS_T0 = 32, MADRS_T1 = 21; P3: MADRS_T0 = 25, MADRS_T1 = 12). Depressive relapses occurred (e.g., P1, T3–T4), but they were not associated with hospitalizations and/or suicidal attempts. Suicidal ideation, when present, decreased by the end of the follow-up period. Lack of mentalization and in social cognition was noted, with just mild improvements during therapy. Subjective quality of life improved significantly for all patients (P1: 28% at T0, 73% at T5. P2: 25% at T0, 71% at T5. P3: 35% at T0, 80% at T5). Conclusions: Intranasal esketamine showed a favorable efficacy and safety in these three cases of TRD in comorbidity with ASD (at six months: total remission = 66.66%, partial remission = 33.33%, inefficacy = 0%, drop-out = 0, severe adverse events = 0). Besides improvements in depressive symptoms, esketamine was associated with a constant decrease in suicidal thoughts. A case series is unfit to form statistical conclusions; preliminary data warrant further investigation in randomized controlled studies to validate the therapeutic potential of esketamine in this population.

Clinics and Practice doi: 10.3390/clinpract16030060

Authors: Jissy Cyriac Richa Sood

Background and Objectives: Genitourinary syndrome of menopause (GSM), previously known as vulvovaginal atrophy, is a chronic, progressive hypoestrogenic condition affecting vulvovaginal, urinary and sexual health in women. Common symptoms include vaginal dryness, itching, dyspareunia, urinary urgency and recurrent urinary tract infections (UTIs). Despite the high prevalence, GSM is underdiagnosed and undertreated, thereby negatively impacting women’s quality of life. To illustrate the practical aspects of GSM diagnosis and provide evidence-based management, we present a case-based narrative review synthesizing recently published, high-quality evidence. Materials and Methods: Evidence was drawn from multiple sources through targeted searches of databases, and included the 2025 AUA/SUFU/AUGS guideline (AUA), the 2024 NICE network meta-analyses (NICE), a 2025 systematic review/meta-analysis in breast-cancer survivors, the 2020 Menopause Society GSM Position Statement, the 2018 NAMS/ISSWSH breast cancer consensus, several primary source citations and other high quality peer-reviewed publications. Results: Five illustrative composite case vignettes of GSM are presented to highlight the evaluation strategy and evidence-supported treatment choices. Nonhormonal options are the first line treatments for mild GSM symptoms, either with or without the addition of vaginal estrogen therapy. For moderate to severe GSM, low-dose vaginal estrogen, vaginal DHEA, and ospemifene are all effective FDA-approved options. In breast cancer survivors, individualized decisions with oncology input are warranted. Maximal caution and a shared decision-making approach is required for women using Aromatase Inhibitors (AIs) for breast cancer risk reduction when choosing treatments for GSM. Conclusions: Treating GSM improves vaginal, sexual and urinary outcomes and quality of life of women. Clinicians need to proactively screen for GSM and offer evidence-based treatment options. The treatment decisions in breast cancer survivors are nuanced, requiring a shared-decision approach.

Clinics and Practice doi: 10.3390/clinpract16030059

Authors: Andreea-Talida Tirziu Maria-Alexandra Preda Aimee Rodica Chis Ionela-Iasmina Yasar Norberth-Istvan Varga Florin George Horhat Mihnea Munteanu Rosca Cosmin

Background/Objectives: The ocular surface is continuously exposed to microorganisms, and disruption of host–microbial balance may lead to infection or postoperative complications. Increasing antimicrobial resistance and biofilm formation have highlighted the need for alternative or complementary non-antibiotic strategies to control ocular surface microbial burden. Liposomal ozonated oil eyedrops have demonstrated antimicrobial and antibiofilm activity in preclinical and preliminary clinical studies. The aim of this study was to evaluate changes in ocular surface microbiological culture results before and after treatment with liposomal ozonated oil eyedrops in a real-world clinical setting. Methods: This was a prospective, observational, real-world pre–post study including 101 eyes from 101 patients undergoing ocular surface microbiological sampling in routine clinical practice. Two samples were obtained per patient: Sample I immediately before treatment and Sample II at the routine follow-up visit after short-course treatment with liposomal ozonated oil eyedrops (1 drop, four times daily, for 4 days). The interval between samples ranged from 3 to 5 days (median 3 days). Microbiological cultures were classified as positive or showing no growth. Paired changes in culture positivity were analyzed using McNemar’s exact test. Results: At baseline, 87 of 101 samples (86.1%) yielded positive cultures, while 14 (13.9%) showed no growth. Following treatment, culture positivity decreased to 11 of 101 samples (10.9%), with 90 samples (89.1%) showing no growth. Among baseline-positive samples, microbiological clearance was observed in 76 cases (87.4%). No cases converted from culture-negative to culture-positive at follow-up. The reduction in culture positivity after treatment was statistically significant (McNemar’s exact test, p < 0.001). Recent antibiotic exposure within 14 days prior to baseline sampling was reported in 8 patients (7.9%). Persistent positive cultures were observed in a minority of cases and were mainly associated with common ocular surface pathogens. Conclusions: In routine clinical practice, short-term treatment with liposomal ozonated oil eyedrops was associated with a significant reduction in ocular surface culture positivity over a short follow-up interval.

Clinics and Practice doi: 10.3390/clinpract16030058

Authors: Maria Spyraki Evanthia Dimitriou Panagiotis Antzoulas Georgios Karpetas Francesk Mulita Vasileios Leivaditis Ejona Shaska John Lakoumentas Diamanto Aretha Andreas Panagopoulos

Background: Delirium is a frequent and serious complication in elderly patients with hip fractures and is associated with adverse outcomes. Early identification requires a brief and reliable screening tool suitable for routine clinical practice. The 4 ‘A’s Test (4AT) is a rapid instrument for delirium detection that requires minimal training. Objective: To translate, culturally adapt, and validate the Greek version of the 4AT in elderly patients with hip fractures. Methods: A total of 103 patients aged ≥65 years who were admitted with hip fracture were enrolled. The 4AT was translated using a forward–backward translation process and culturally adapted according to established guidelines. Delirium diagnosis was established using DSM-5 criteria by trained clinicians, serving as the reference standard. The 4AT was administered independently within 3 h. Diagnostic accuracy was assessed by calculating sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and area under the receiver operating characteristic curve (AUC). The optimal cut-off was determined using Youden’s index. Results: At a cut-off score ≥4, the Greek 4AT demonstrated a sensitivity of 87.5% and specificity of 91.1%, with PPV 75% and NPV 96%. The AUC was 0.94, indicating excellent diagnostic performance. Conclusions: The Greek version of the 4AT is a valid and reliable screening tool for detecting delirium in elderly patients with hip fractures.

Clinics and Practice doi: 10.3390/clinpract16030057

Authors: Ivana Pantic Nikola Grubor Sofija Lugonja Nina Rajovic Svetlana Miltenovic Marija Brankovic Tijana Gmizic Tamara Milovanovic

Background and Aims: Chronic liver diseases (CLD) represent a significant healthcare burden, mostly due to late diagnosis and numerous co-morbidities. We evaluated the effect of co-morbidities, cirrhosis, and disease etiology on hospitalization duration. Methods: Hospitalizations due to alcohol-related, viral, autoimmune, and overlapping liver disease in Belgrade, Serbia (2016–2022), were identified using pre-defined discharge codes. We investigated the hospitalization trend descriptively by plotting the relative mean change in the hospitalization length against time. Assuming the covariate relationship in the directed acyclic graph, we estimated the direct causal effect of the diagnosis type on the length of stay (LOS) by fitting pre-specified Bayesian distributional lognormal models based on domain knowledge. We conducted a post hoc analysis of the impact of cirrhosis on LOS per primary diagnosis. Results: The empirical data show a decrease in the estimated average LOS (8.25–5.51 days). For the same period, the median LOS decreased (4 days (IQR 0–12) to 1 day (IQR 1–7)). In 2021, the share of short-term hospitalizations rose to 46.94%, while the median long-term hospitalization peaked at 11.5 days (IQR 7–21). The expected LOS was the highest for the primary diagnosis of autoimmune liver disease (15.89, 95% CI [14.74, 17.2] days), followed by alcohol-related liver disease (14.22, 95% CI [13.68, 14.79] days). The largest impact of cirrhosis on LOS was observed among patients hospitalized due to viral disease (4.19, 95% CI [2.29, 6.33] days). Conclusions: The presence of co-morbidities and cirrhosis significantly affects LOS. In order to provide better treatment and reduce healthcare costs, there is the need to detect liver disease at earlier stages and better manage its associated co-morbidities.

Clinics and Practice doi: 10.3390/clinpract16030056

Authors: Ioana Ioniță Mădălina Iuliana Mușat Bogdan Cătălin Adela Magdalena Ciobanu

Background/Objectives: Gambling disorder (GD) is a behavioral addiction characterized by persistent and repetitive gambling behaviors that cause significant psychological distress and functional impairment. Increasing evidence indicates that difficulties in emotion regulation are a key factor in the development and persistence of GD. This systematic review aimed to summarize and critically evaluate the existing literature on the relationship between emotion regulation strategies and gambling disorder, with a specific focus on studies using the Emotion Regulation Questionnaire (ERQ) and the Cognitive Emotion Regulation Questionnaire (CERQ). Methods: The review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA 2020) guidelines. Systematic searches were performed in PubMed and Scopus databases for studies published between 25 October 2015 and 25 October 2025. The methodological quality and risk of bias of the included studies were evaluated using the Joanna Briggs Institute (JBI) Critical Appraisal Checklist and JBI Checklist for Randomized Controlled Trials. Data extraction and synthesis were performed manually by two independent reviewers. Eligible studies included adult participants (≥18 years) diagnosed with gambling disorder or pathological gambling and using the ERQ or CERQ to assess emotion regulation. Results: Nine studies met the inclusion criteria, comprising a total of 607 patients with GD. Across studies, individuals with GD consistently showed reduced cognitive reappraisal, greater expressive suppression, and higher use of maladaptive cognitive strategies such as rumination, catastrophizing, and self-blame. All studies identified impulsivity, emotion dysregulation, alexithymia, or gambling-related cognitive distortions as significant predictors of gambling severity. Neuroimaging evidence from one study further revealed altered activation of frontal regions during negative emotion regulation. Conclusions: This review highlights the central role of emotion regulation in GD. However, the limited available ERQ/CERQ studies in GD were mostly cross-sectional, limiting causal inferences. Second, samples were predominantly male, reducing generalizability to women. Finally, only one study used neurobiological measures, hindering integration of self-report and neural data. These findings emphasize the importance of integrating emotion regulation-based interventions within therapeutic programs for gambling disorder, with ERQ and CERQ being useful tools to assess the pathology.

Clinics and Practice doi: 10.3390/clinpract16030055

Authors: Alberto Cordero Mª Amparo Quintanilla Cristina Torres Natalia López Carles Bodí Germán Bixquert José Mª Lopez-Ayala

Introduction: Clinical diagnosis of chronic heart failure (HF) in ambulatory patients can be difficult. Echocardiography is the most widespread diagnostic imaging technique, although the usefulness of the global longitudinal strain (GLS) of the left ventricle (LV) in this clinical setting is less clear. Methods: We performed a cross-sectional study of stable outpatients and GLS was obtained with an automatic software that uses the three apical planes of the LV. We analyzed the improvement of the diagnostic capacity of including GLS above all the clinical and echocardiographic parameters using reclassification indexes. Results: We included 1362 patients, including 12.9% with HF who presented lower values of ejection fraction (EF) and GLS and worse diastolic function. Most patients (92.8%) with HF had a GLS < −14 as compared to patients without HF (36.1%). LV EF (OR: 0.93) and GLS (OR: 1.27 CI 95% 1.20–1.35) were associated with the presence of HF. The AUC was significantly higher (p < 0.001) in the logistic model that included GLS vs. without GLS, and the reclassification index for GLS was 19.8%. GLS was more affected in patients with HFpEF vs. controls as well as diastolic function parameters. The logistic regression model only identified age (OR: 1.07 95% CI 1.02–1.06) and GLS (OR: 1.29 95% CI 1.21–1.38) as independently associated with the presence of HFpEF. The AUC of the model for the presence of HFpEF with GLS was significantly higher (p < 0.01). The reclassification index for GLS was 38.8%. Conclusions: LV GLS assessment increased the diagnostic discrimination of chronic HF in stable patients.

Clinics and Practice doi: 10.3390/clinpract16030054

Authors: Giuseppe Cota Gaetano Scaramozzino Marco Chiesa Lelio Gennaro Maurizio Pascadopoli Andrea Scribante Marco Colombo

Background: Dental radiographs are essential for diagnosis and treatment planning in modern dentistry. However, their manual interpretation is time-consuming and subject to variability, highlighting the need for automated tools to improve efficiency and consistency. This study aims to validate ORTHOSEG, a deep learning-based system designed to automate the segmentation of anatomical, pathological, and non-pathological elements in radiographs, including orthopantomograms, bitewings, and periapical images. Methods: ORTHOSEG’s performance was evaluated using a rigorously curated dataset of 150 dental radiographs, including 50 orthopantomograms, 50 bitewings, and 50 periapical images, with manual annotations by expert clinicians serving as the ground truth. The system’s segmentation performance was assessed using standard evaluation metrics, including mean Dice Similarity Coefficient (mDSC) and mean Intersection over Union (mIoU), and inference time was also recorded. Results: The system achieved high accuracy, with mDSC and mIoU values of 0.635 ± 0.233 and 0.576 ± 0.214, respectively. In particular for orthopantomograms, it achieved an mDSC of 0.756 ± 0.174 and an mIoU of 0.684 ± 0.172, surpassing existing benchmarks. Its segmentation capabilities extend to approximately 70 distinct elements, underscoring its comprehensive utility. The system demonstrated efficient computational performance, with processing times of 19.745 ± 3.625 s for orthopantomograms, 8.467 ± 0.903 s for bitewings, and 5.653 ± 0.897 s for periapical radiographs on standard clinical hardware. Conclusions: ORTHOSEG demonstrates efficiency suitable for integration into routine workflows. This study confirms ORTHOSEG’s reliability and potential to improve diagnostic workflows, offering clinicians a valuable tool for faster and more detailed radiograph analysis. Future research will focus on extending validation across diverse clinical scenarios to ensure broader applicability. However, this study has limitations, including the use of a dataset derived from a European population and the absence of usability and clinical workflow evaluation, which should be addressed in future studies.

Clinics and Practice doi: 10.3390/clinpract16030053

Authors: Eirini Stavrou Georgios Vasilopoulos Dionyssios Leftheriotis Panagiota Flevari Maria Polikandrioti

Background/Objectives: Permanent cardiac pacemakers (PPMs) are small electronic implanted devices that regulate cardiac rhythm. Measurement of quality of life (QoL) serves as a powerful tool for gaining in-depth insights into pacing therapy and ultimately guiding patient-centered management strategies. The aim of the present study was to evaluate factors affecting QoL among PPM patients by applying the two generic questionnaires: SF-36 and EQ-5D-5L. Materials and Methods: A total of 120 patients with PPM were enrolled. QoL data were collected through interviews using the 36-Item Short Form Health Survey (SF-36) and the Euro QoL 5-Dimensions 5-Levels Health Questionnaire (EQ-5D-5L). Patients’ characteristics were also recorded. Results: The majority of participants were male (54.2%), retired (83.3%) residents in urban areas (75.5%), had a DDD pacemaker (82.5%), had rate response programmed on (77.5%), and had comorbidities (83.3%). Regarding QoL measured by SF-36, the Physical Component Summary Score (PCS) was significantly associated with programming rate response in their pacemaker (p = 0.046), comorbidities (p = 0.047), and the NYHA functional class (p = 0.047). The Mental Component Summary Score (MCS) was significantly associated with sex (p = 0.034), place of residence (p = 0.003), NYHA functional class (p = 0.001), and patients’ level of information about the device (p = 0.039). Patients’ QoL, as measured by the EQ-5D-5L, was significantly associated with sex (p = 0.001), age (p = 0.019), occupation (p = 0.040), pacing mode (p = 0.034), comorbidities (p = 0.019), NYHA functional class (p = 0.047), and level of information about the device (p = 0.005). Conclusions: NYHA functional class, comorbidities, and level of information as reported by patients were the factors associated with QoL, as shown by the two scales. All three factors guide a personalized care plan since NYHA class shows the burden of disease, comorbidities add to the complexity, and patient information determines the effectiveness of management.

Clinics and Practice doi: 10.3390/clinpract16030052

Authors: Yazan Jumah Alalwani Munira Abdullah Aldossari Layan Adeeb Alzahrani Nouf Ibrahim Alhatlani Sarah Musaad Albarrak Waleed Khalid Moosa Raghad Ali Aloufi Ibtisam Heji AlBader Sadeem Khalid Almulhim Nurah Jamel Alnbi Leen Awad Alkahtani Fatimah Mohammed Alsayoud Ahmed Y. Azzam Ghada Fouad Al Yousif

Introduction: Falls and subsequent fractures represent a major public health concern among older adults. While fall prevention interventions have demonstrated efficacy in reducing falls, their impact on fracture outcomes remains unclear. Methods: We conducted a systematic review and meta-analysis following PRISMA 2020 guidelines. We searched multiple databases up to 7 June 2025 for studies investigating fall prevention interventions and fracture outcomes in community-dwelling older adults. A primary outcome was hip fractures; secondary outcomes included any fractures, falls, and serious fall injuries. Risk ratios (RRs) with 95% confidence intervals (CIs) were calculated, using random-effects meta-analysis where appropriate. Results: Seventeen studies were included, spanning over 25,000 participants. Interventions included exercise programs, multifactorial approaches, medication optimization, and vitamin D supplementation. For hip fractures, only two randomized controlled trials (RCTs) reported extractable outcome data (12,489 participants; 132 events); both showed non-significant reductions favoring intervention (RR 0.80–0.87), precluding pooled meta-analysis. For any fractures, five studies (18,519 participants; 1343 events) demonstrated no significant effect (RR 0.91, 95% CI 0.72–1.14; p-value = 0.40) with significant heterogeneity (I2 = 65%). Fall prevention interventions significantly reduced falls across 14 studies. GRADE assessment indicated very low certainty for both hip fractures and any fractures due to limited studies, inconsistency, and imprecision. Conclusions: Current evidence suggests fall prevention interventions may reduce hip fractures but do not significantly prevent fractures overall. Despite consistent fall reduction, the translation to fracture prevention remains uncertain, highlighting the need for integrated interventions targeting both fall risk and bone health.

Clinics and Practice doi: 10.3390/clinpract16030051

Authors: Nicolas Nassar Karim Corbani Rim Bourgi Roland Kmeid Carlos Enrique Cuevas-Suárez Ahmed A. Holiel

Objectives: This systematic review evaluated enamel surface alterations and residual composite following the removal of clear aligner attachments, with particular emphasis on the influence of removal techniques, instrument selection, operator experience, and the use of magnification on enamel preservation and cleaning efficiency. Methods: A comprehensive electronic search was performed in PubMed, Scopus, Embase, Web of Science, and Scielo up to October 2025. In vitro, ex vivo, and clinical studies assessing enamel loss, residual composite, surface roughness, or removal time after clear aligner attachment removal were included. Study selection, data extraction, and methodological assessment followed the PRISMA 2020 guidelines and Cochrane Handbook recommendations. Risk of bias was evaluated using a modified Joanna Briggs Institute checklist for laboratory-based studies. Due to substantial methodological heterogeneity, a narrative synthesis was conducted. Results: Of 656 identified records, three in vitro/ex vivo studies were assessed for eligibility. Reported enamel loss ranged from approximately 15 µm to more than 50 µm, depending on the removal protocol and visualization conditions. Residual composite covered approximately 20–40% of the treated enamel surface. Multi-step protocols combining tungsten carbide burs with silicone polishers under magnification demonstrated the most favorable balance between composite removal efficiency and enamel preservation. Fiberglass burs were associated with smoother enamel surfaces but increased enamel loss, whereas one-step polishing systems (OneGloss, Enhance, SM104) resulted in reduced surface roughness and shorter procedural time. The use of magnification loupes (≥2.5×) consistently improved removal precision and reduced residual composite. Meta-analysis was not feasible due to heterogeneity in outcome measures and testing methodologies. Overall risk of bias was deemed acceptable. Conclusions: Based on the limited number of available in vitro/ex vivo studies, removal of clear aligner attachments appears to be associated with measurable enamel loss and residual composite, largely influenced by the instruments and visualization aids used. Sequential carbide–silicone polishing protocols performed under magnification appear promising based on limited in vitro/ex vivo evidence, demonstrating a favorable balance between composite removal and enamel preservation under controlled laboratory conditions. However, given the scarcity of evidence and absence of clinical trials, these findings cannot be directly extrapolated to routine clinical practice. Further well-designed studies are required before definitive clinical recommendations can be established.

Clinics and Practice doi: 10.3390/clinpract16030050

Authors: Eva van der Meer Ven Yin Leong Gregory M. Peterson Woldesellassie M. Bezabhe

Background: Australian guidelines recommend conducting thyroid function tests (TFTs) before commencing amiodarone and every six months subsequently. This study sought to investigate thyroid monitoring in Australian general practice patients with atrial fibrillation (AF) who commenced amiodarone. Methods: We performed a retrospective observational analysis using a nationwide primary care dataset to examine whether TFTs were conducted according to guidelines following amiodarone initiation in euthyroid patients aged 18 years or older with AF. Secondary outcomes included the prevalence of amiodarone-induced thyroid dysfunction (AITD) and the identification of factors associated with its development. Results: In total, 12,932 patients with AF were included. Of these, 1306 (10.1%) had commenced long-term amiodarone. Two hundred twenty-six (17.3%) of the patients commenced on amiodarone did not have any recorded TFT results during an 18-month follow-up period. During follow-up, 18.1% and 4.4% of patients developed hypothyroidism in the amiodarone-treated and amiodarone-untreated groups, respectively (p < 0.0001). The corresponding values for hyperthyroidism were 7.3% and 2.5% in the amiodarone-treated and amiodarone-untreated groups, respectively (p < 0.0001). In the subset of patients commenced on amiodarone, after controlling for the number of TFTs within the follow-up, the risk factors independently associated with the development of hypothyroidism were baseline thyroid stimulating hormone (TSH) level (adjusted odds ratio/AOR: 3.80 (95% confidence interval: 3.00–4.82)) and the comorbidities heart failure (AOR: 1.64 (1.09–2.46)) and chronic kidney disease (AOR: 2.29 (1.26–4.18)). Baseline TSH (AOR: 0.43 (0.28–0.63)) was significantly associated with the development of hyperthyroidism in patients taking amiodarone. Conclusions: AITD was relatively common, occurring in one-quarter of patients within 18 months of initiation of amiodarone. Increased awareness is required amongst both clinicians and patients of the need for regular thyroid monitoring during therapy with amiodarone.

Clinics and Practice doi: 10.3390/clinpract16030049

Authors: Vanessa Castellanos-Arreola Ana Cristina Castañeda-Márquez Raúl Fernando Guerrero-Castañeda Dulce Milagros Razo-Blanco-Hernández Luís Ricardo Vázquez-García Juan Carlos Fernando Sánchez-Velázquez María del Carmen Velázquez-Núñez María Yazmin Castañeda-Ramírez José Ángel Hernández-Mariano

Background/Objectives: Cardiovascular diseases represent a considerable burden on healthcare systems. In coronary intensive care units (CICU), nursing staff play a key role in the care of critically ill patients. Nursing diagnoses (NDs) based on the NANDA-I (North American Nursing Diagnosis Association-International) taxonomy enable the identification of human responses to various clinical conditions. However, their association with adverse outcomes, such as in-hospital mortality, remains understudied. Therefore, we evaluated the association between NDs and in-hospital mortality in patients with cardiac disease. Methods: A retrospective cohort study was conducted in a tertiary care hospital. The paper clinical records of 195 patients admitted to the CICU for at least 48 h between January 2023 and March 2025 were reviewed. The association of interest was assessed using Poisson regression models adjusted for confounding variables. Results: Mortality was 24.1%. NDs focusing on cardiac and extracardiac responses, such as fluid volume excess (risk ratio [RR] = 2.67; 95% confidence interval [CI] = 1.23, 5.76), impaired cardiac output (RR = 1.84; 95% CI = 1.50, 2.25), risk of shock (RR = 3.12; 95% CI = 1.91, 5.11), risk for impaired cardiovascular function (RR = 2.01; 95% CI = 1.28, 3.17), and impaired gas exchange (RR = 2.67; 95% CI = 1.64, 4.34) were significant predictors of mortality. In contrast, diagnoses such as anxiety (RR = 0.46; 95% CI = 0.23, 0.91), impaired psychological comfort (RR = 0.31; 95% CI = 0.09, 0.95), and risk of unstable glycemia (RR = 0.46; 95% CI = 0.23, 0.91) were associated with a lower risk of death. Conclusions: NDs are independently associated with in-hospital mortality in critically ill patients with cardiac disease and may represent useful clinical markers for risk stratification in intensive care settings.

Clinics and Practice doi: 10.3390/clinpract16030048

Authors: Maria Ladisa Juan Luís Cabanilla-Moruno Lara Estefanía Jiménez-Ortega Manuel Delgado-Calderón Emilio García-Cabrera Julia Romero-Barranca Ángel Vilches-Arenas

Background: During the first wave of the COVID-19 pandemic, the importance of the recognition of vulnerable workers was well-established, but the specific impact of the timing of their recognition remains less understood. Objective: This study evaluates the impact of early recognition of vulnerable healthcare workers (VHCWs) and identifies factors associated with SARS-CoV-2 infection. Methods: We performed a retrospective cohort study at the Virgen Macarena University Hospital (HUVM) in Seville and included employees classified as VHCWs between January 2020 and December 2021. All data, including demographic, occupational, and clinical data, were collected from occupational health records and the Andalusian digital health system. The incidence of COVID-19 was analyzed using descriptive, bivariate statistics, and Cox regression. Results: A total of 471 VHCWs were included. Most of the VHCWs were women (79.8%) with a median age of 50 years. The most common vulnerability criteria were pregnancy (32.9%) and age > 60 (28.7%). During the study period, 58 VHCWs (12.3%) were diagnosed with COVID-19, compared to 18.35% of the general workforce. Recognition of VHCW status after the pandemic was declared was strongly associated with higher infection risk (HR = 48.84; 95% CI: 26.21–90.99; p < 0.001). Conclusions: The timing of vulnerability recognition emerged as the most critical protective factor in this cohort. Healthcare workers whose vulnerability was not proactively identified before the pandemic onset faced a substantially higher risk of infection (HR = 44.68; 95% CI: 26.21–90.99; p < 0.001) compared to those recognized early. These findings underscore that pre-pandemic identification facilitated the immediate implementation of task adaptations and workplace restrictions, effectively mitigating high-risk exposure during the most critical early stages of the crisis.

Clinics and Practice doi: 10.3390/clinpract16030047

Authors: Fabiana Di Duca Giancarlo Biondi Elvira De Rosa Alessandro Venuta Salvatore Di Sarno Alfonso Nardo Bartolomeo Ferrante Giovanni Mazzei Stefano Scippa Immacolata Russo Maria Triassi Paolo Montuori

Background: In recent years, aesthetic medicine and cosmetic surgery have seen significant growth, reflecting changing sociocultural views on beauty and self-care; however, public knowledge and awareness of associated risks remain inconsistent. This study aimed to assess knowledge, attitudes, and behaviours toward aesthetic medicine and cosmetic surgery in a large metropolitan population in Southern Italy using the Knowledge–Attitude–Practice (KAP) framework. Methods: A cross-sectional survey was conducted between June 2021 and January 2022 among 1079 adults aged 18–72 years residing in the metropolitan area of Naples. A structured questionnaire collected socio-demographic data and assessed knowledge, attitudes, and behaviours related to surgical and non-surgical aesthetic procedures. Descriptive statistics and multiple linear regression analyses were performed to identify predictors of knowledge, attitudes, and behaviours. Results: Overall, 66.8% of participants reported having undergone general beauty treatments, while 9.8% declared the use of cosmetic medicine procedures. A total of 5.1% had undergone botulinum toxin treatments, 11% reported filler injections, and 9.8% had experienced plastic surgery. A majority had strong knowledge, especially on non-surgical procedures, but there were gaps in their knowledge on side effects, regulations, age limits, and qualifications. Most viewed appearance as important, though with critical views of excessive aesthetic treatments and claimed limited social media influence. Female sex and parental status were positively associated with aesthetic behaviours, while attitudes emerged as the strongest predictor of engagement. Conclusions: Aesthetic practices are widely accepted within this urban population, yet important informational deficiencies persist. Targeted educational interventions based on the KAP framework are warranted to enhance health literacy, promote safe decision-making, and foster realistic expectations regarding aesthetic medicine and cosmetic surgery.

Clinics and Practice doi: 10.3390/clinpract16030046

Authors: Annunziata Dattola Raimondo Rossi Giuseppe Rizzuto Giacomo Caldarola Eleonora De Luca Viviana Lora Domenico Giordano Severino Persechino Claudio Bonifati Diego Orsini Dario Graceffa Arianna Zangrilli Gianluca Pagnanelli Paola Tribuzi Annamaria Mazzotta Gaia Moretta Adriana Micheli Alessia Provini Salvatore Zanframundo Vincenzo Panasiti Giovanni Pellacani Concetta Potenza Antonio Giovanni Richetta Nicoletta Bernardini

Objectives: To evaluate the impact of non-invasive imaging techniques such as dermoscopy, reflectance confocal microscopy (RCM) and optical coherence tomography (OCT) to monitor the efficacy of risankizumab on plaque psoriasis of the legs by analyzing morpho-histological changes. Materials and Methods: Multicentre, real-world retrospective study involving 37 adults with moderate-to-severe plaque psoriasis. Assessments performed during routine visits at baseline, Week 4 and Week 12 included clinical response, dermoscopy, RCM and OCT. Results: Thirty-seven patients were included (mean age 52.1 years; 54% male; mean BMI 27.0 kg/m2). Dermoscopy showed progressive vascular normalization: at Week 12, 94.29% of lesions had minimal or no vascular pattern. White and yellow scales decreased significantly. On RCM, dilated vessels, inflammatory infiltrate, and papillomatosis progressively normalized. OCT showed reduction in epidermal and stratum corneum thickness and a decline in vascular intensity at multiple depths. Baseline haemorrhagic dots predicted early complete response: 44.8% of lesions with dots achieved complete clearance at Week 4 versus 0% without. Conclusions: Risankizumab induced rapid, significant regression of psoriatic changes, normalizing vascular patterns and skin architecture and reducing epidermal thickness. Findings support its efficacy and rapid onset of action in difficult-to-treat areas and highlight the value of non-invasive imaging for monitoring.

Clinics and Practice doi: 10.3390/clinpract16030045

Authors: Waleed Alharbi Turki Alasmari Najla Al Rasheed Jamila A. Alonazi Naif K. Alaqil Meshari Al Samih Nawaf S. Alzahrani Abdulaziz Bin Akrish Soliman Alaraidh

Background/Objectives: Inflammatory bowel disease (IBD) is associated with significant morbidity worldwide. While global epidemiological trends are well-documented, data on the clinical and demographic characteristics of IBD patients in Saudi Arabia remain limited. This study aimed to evaluate the distribution of multimorbidity among IBD patients in a tertiary Saudi hospital and assess associated clinical features and outcomes. Methods: A retrospective cross-sectional study of IBD patients treated at the National Guard Hospital over a seven-year period was conducted. Data on demographics, body mass indices (BMIs), hospitalizations, comorbidities, complications, and surgical interventions were extracted from medical records. Associations between categorical and continuous variables were analyzed using chi-square and t-tests, respectively, with significance being set to p < 0.05. Results: A total of 465 patients were included: 54.6% had Crohn’s disease (CD) and 45.4% had ulcerative colitis (UC). CD predominated in males (60.6%), while UC was more common in females (55.5%, p = 0.001). BMI distribution differed significantly between groups (p = 0.004). Hospital admission rates and length of stay were higher among CD patients (p = 0.032). CD patients experienced greater complication rates, including fistulas (41.3% vs. 7.1%, p < 0.001) and strictures (26.1% vs. 1.4%, p < 0.001). Surgical interventions such as fistulotomy (4.3% vs. 0.5%, p = 0.009) and stricturoplasty (9.1% vs. 1.9%, p = 0.001) were more frequent in patients with CD. Conclusions: This study characterizes IBD patients in Saudi Arabia, highlighting gender differences, BMI variations, and the greater severity of CD compared with UC. The higher rates of complications and surgical interventions among CD patients emphasize the need for tailored management strategies. Future prospective studies are warranted to investigate disease progression and optimize care for this population.

Clinics and Practice doi: 10.3390/clinpract16020044

Authors: John K. Triantafillidis Konstantinos Malgarinos Loukas Kaklamanis Emmanouil Kritsotakis Victoria Polydorou Konstantinos Pantos Konstantinos Sfakianoudis Agni Pantou Konstantinos Bramis Manousos M. Konstantoulakis Apostolos E. Papalois

Background: Ulcerative colitis (UC) and sarcoidosis are chronic inflammatory diseases that share immunological pathways but rarely coexist. The increasing use of biologic agents in inflammatory bowel disease (IBD) has raised concerns regarding paradoxical inflammatory manifestations, including sarcoidosis-like reactions. Case presentation: We report the case of a 63-year-old man with long-standing UC treated with vedolizumab who developed systemic sarcoidosis characterized by bilateral hilar lymphadenopathy, mediastinal and abdominal lymph node enlargement, pulmonary involvement, and erythema nodosum. Extensive diagnostic work-up, including imaging and histopathology, confirmed non-necrotizing granulomatous disease consistent with sarcoidosis, while alternative infectious, malignant, and drug-induced causes were excluded. Vedolizumab was temporarily discontinued, leading to UC relapse, and subsequently reintroduced with rapid clinical remission of UC. Discussion: Sarcoidosis remained clinically and radiologically stable despite vedolizumab re-initiation, suggesting a coincidental association rather than a direct causal relationship. This case highlights the diagnostic challenges and therapeutic dilemmas in patients with immune-mediated diseases receiving biologic therapy. Conclusion: The coexistence of UC and sarcoidosis during vedolizumab therapy is rare. Although causality cannot be established, our findings suggest that vedolizumab may be safely continued in selected patients under close multidisciplinary monitoring.

Clinics and Practice doi: 10.3390/clinpract16020043

Authors: Rosita Rupa Anastasios Tsogkas Dalibor Bockelmann Christopher Nimsky Benjamin Voellger

Background/Objectives: To estimate, against the background of the upcoming German healthcare reform, current access to neurosurgery for patients in Germany, and to derive improvement strategies from geographic information mapping. Methods: We defined access to neurosurgery on a geographical basis as the sum of all points from which one can reach a neurosurgical department within 40 min by car (A2N40). We identified 182 departments of neurosurgery, and we retrieved population numbers and geodetic information from open sources. We processed data and conducted statistical analyses in R. Results: Population density and A2N40 per square kilometer were significantly positively correlated (Spearman’s rho = 0.82, p = 0.0001). Population density is significantly lower (Wilcoxon rank sum test, p = 0.009) and A2N40 per square kilometer is significantly worse (Wilcoxon rank sum test, p = 0.005) in the new federal states (without Berlin) as compared to the rest of the country. Geographic information mapping yielded 3 distinct improvement strategies. Conclusions: In Germany, population density and A2N40 per square kilometer are significantly positively correlated, with significantly less A2N40 per square kilometer in the new federal states. Geographic mapping may inform tailored regional improvement policies.

Clinics and Practice doi: 10.3390/clinpract16020042

Authors: Adrian C. Chen Amit S. Rao Alisha Oropallo

Introduction: Chronic wounds affect approximately six million people in the United States. Despite established multidisciplinary wound care protocols, patient adherence to follow-up care remains suboptimal. We aimed to understand the impact of social drivers of health on patient decision-making for improving wound care follow-up adherence. Methods: We conducted a retrospective review of all hospitalized patients who consulted in-house wound care staff at a tertiary care center between August 2017 and June 2020, regardless of primary admission diagnosis. Referred patients received standardized care from a multidisciplinary team at an outpatient wound care facility. Primary endpoints were pre-discharge scheduling and follow-up rates. Follow-up efficacy was assessed through 90-day hospital readmission rates. Results: Of 444 patients, 205 (46.2%) were readmitted or expired within 90 days. Adjusted analysis identified lack of follow-up care reception as an independent predictor of hospital readmission (hazard ratio 2.39; 95% CI, 1.45–3.89; p < 0.001). Among 156 (35.1%) patients who scheduled follow-up, 110 (70.5%) adhered to their appointment. Patients not scheduling follow-up were older (median age 79 vs. 70 years, p < 0.001), longer hospital stays (median 9 vs. 6 days, p < 0.0001), and more frequently discharged to skilled nursing facilities (47.6% vs. 26.3%, p < 0.0001). Among scheduled patients, skilled nursing home residents demonstrated lower follow-up adherence (OR 0.3; 95% CI, 0.14–0.65; p < 0.01). Conclusions: Pre-hospital discharge communication for scheduling follow ups serves as a critical intervention point in patient decision-making for wound follow-up. Considering the limitations of a retrospective single-center study, we find that pre-discharge education about follow-up scheduling for high-risk groups, including patients ≥ 80 years and skilled nursing facility residents, may improve follow-up adherence and reduce readmissions.

Clinics and Practice doi: 10.3390/clinpract16020041

Authors: Maria Grazia Bocci Giulia Capecchi Antonio Lesci Dorotea Rubino Ilaria Caravella Giorgia Taloni Valerio Sabatini Candido Porcelli Giulia Valeria Stazi Gabriele Garotto Elena Mattiucci Emanuele Nicastri Tommaso Ascoli Bartoli Gaetano Maffongelli Emiliano Cingolani Fabrizio Albarello Giulia Anello Paolo Campioni Stefania Ianniello Daniele Guerino Biasucci

Background: Meningoencephalitis is a complex inflammatory condition of the CNS that can result in significant morbidity and mortality in critically ill adults. Accurate and timely neuromonitoring is essential for guiding management and improving outcomes. This study aimed to descriptively evaluate the prognostic value of early TCCD monitoring, particularly the pulsatility index, and its integration with conventional and perfusion MRI in patients with meningoencephalitis. Methods: We present an observational, retrospective, cohort study involving ten adult patients (median age 56 years, IQR 45.5–68.5; mean 55.9, range 35–76) with neurological syndromes caused by suspected or confirmed infectious meningoencephalitis. Etiologies included bacterial meningitis/meningoencephalitis (50%), viral meningoencephalitis (10%), neurotoxoplasmosis (10%), progressive multifocal leukoencephalopathy (10%), and undetermined origin (20%). Patients underwent TCCD and MRI within 24 h. In five cases, standard MRI sequences were acquired, while in the remaining five, perfusion imaging was performed using Arterial Spin Labelling (ASL). A favorable outcome was defined as survival with neurological recovery (Glasgow Outcome Scale > 5) at ICU discharge. Results: TCCD-derived PI provided valuable information on cerebral hemodynamics. PI values ≤ 1.25 were associated with favorable clinical outcomes and symmetrical MRI findings. Conversely, PI > 1.25 correlated with poor prognosis and often preceded MRI-detectable structural damage. When combined with ASL, PI mirrored the detected perfusion asymmetries and was associated with poor prognosis in fatal cases. Conclusions: Bedside TCCD can offer real-time assessment of cerebrovascular dynamics and, when integrated with conventional and ASL MRI, could enhance the understanding of pathophysiological processes in meningoencephalitis, supporting timely and informed decisions in neurocritical care.

Clinics and Practice doi: 10.3390/clinpract16020040

Authors: Gustavo Christofoletti Gabriela Maria da Silva Béé Otávio Reginato Nathalia Oliveira Rodrigues Sidineia Silva Pinheiro Cavalcante Franco Ana Beatriz Gomes de Souza Pegorare

Background: Previous studies have demonstrated the benefits of virtual reality (VR) as an intervention tool guided by specialists. However, little is known about whether VR may pose risks in uncontrolled environments. Considering its implications for clinics and practice, this study aimed to assess the potential risks of a 3D VR simulation on postural control in young adults. Methods: Seventy-nine community-dwelling young adults completed a VR program using a head-mounted display that simulated a 3D roller-coaster ride while standing. Postural control was assessed using a force platform measuring frontal and lateral sway, center-of-pressure sway area, and frontal and lateral imbalance speed. The assessments were conducted with and without VR. Statistical analyses were performed using paired comparisons. Significance was set at 5%. Effect sizes (ESs) are reported. Results: Engaging in a VR roller-coaster simulation increased the participants’ imbalance in terms of frontal sway (p = 0.001; ES = 0.919), center-of-pressure sway area (p = 0.001; ES = 0.849), frontal imbalance speed (p = 0.001; ES = 0.910), and lateral imbalance speed (p = 0.001; ES = 0.663). No significant difference was observed in the lateral sway (p = 0.383). During VR exposure, 25% of the participants showed a clinically significant increase in postural instability. Despite having normal baseline parameters, participants with higher postural instability showed greater deterioration in postural control during VR exposure than those with lower postural instability. Conclusions: A 3D VR simulation affected several measures of postural control in community-dwelling young adults. Precautions should be taken when engaging in VR without appropriate specialist supervision.

Clinics and Practice doi: 10.3390/clinpract16020039

Authors: Khaled Abdulalem Jonah Teich Erika Martinez Samuel D. Saibil

Background/Objectives: Cancer of unknown primary (CUP) remains a significant challenge in the field of oncology. Despite advances elsewhere in the field, there have been few advances in the treatment of CUP and correspondingly no improvements in patient survival. Recent studies utilizing molecular profiling, including next-generation sequencing (NGS), and molecularly targeted treatment of CUP have shown some promising initial results, but have yet to be integrated into the standard of care in most jurisdictions. This study aimed to assess the use of molecular characterization and targeted treatment of patients with CUP treated at Princess Margaret Cancer Centre (PMCC). Methods: This study is a retrospective audit of patients with CUP treated between January 2019 and April 2024 to build understanding of the accessibility and use of these molecular tools. Results: We found that 82% of the 28 patients identified received NGS analysis, though all received the results late in their disease course and all accessed molecular profiling via either clinical trials, a charitable access programme, or a privately source outside of the hospital network. Only 13% of the patients who received molecular analysis received any modification of care as a result of this profiling, and only as third line of treatment. Conclusions: Our data highlights a lag between current understanding and current practice, and identifies a possible area for improvement of patient care by standardizing the use of molecular analysis in the early workup and targeted therapy in the treatment of CUP.

Clinics and Practice doi: 10.3390/clinpract16020038

Authors: Pavol Vigláš Jan Raupach Aleš Hejčl David Černík Pavla Bradáčová Patrik Matras Filip Cihlář

Objectives: The goal of this study is to establish the incidence of high on-treatment platelet reactivity (HTPR) to aspirin and clopidogrel in patients undergoing carotid stenting and to evaluate the efficacy of ticagrelor and ticlopidine in patients with HTPR to clopidogrel. Methods: In a single institutional setting spanning eight years, every consecutive patient who underwent carotid artery stenting was incorporated into a study. Subsequently, a retrospective analysis of their platelet function was executed. Prevalence of high on-treatment reactivity to aspirin, clopidogrel, ticlopidine and ticagrelor was assessed. Platelet function testing was conducted by light transmission aggregometry and Multiplate®. Results: A total of 216 patients were tested for antiplatelet therapy efficacy. The high on-treatment reactivity to clopidogrel was observed in 68 patients (31.4%). No patients with high on-treatment reactivity to ticagrelor or ticlopidine were observed. There was a significant reduction in platelet reactivity with ticagrelor (p < 0.000) and ticlopidine (p < 0.000) in patients with HTPR to clopidogrel. Conclusions: High on-treatment platelet reactivity to clopidogrel is common in patients undergoing carotid artery stenting. Ticagrelor is a viable alternative to overcome HTPR to clopidogrel. These findings suggest that platelet function testing can identify patients who may benefit from tailored antiplatelet therapy in reducing thromboembolic complications after carotid stenting.

Clinics and Practice doi: 10.3390/clinpract16020037

Authors: Adriana-Luciana Luca Felicia Militaru Mădălina Iuliana Mușat Ion Udriștoiu Eugen Moța

Background/Objectives: Chronic kidney disease (CKD) progresses with the gradual and irreversible loss of renal function. In Romania, given the increasing number of patients undergoing hemodialysis (HD), the prevalence of psychiatric symptoms and disorders in this population has become particularly significant. Although important advances have been made in the management of psychiatric conditions in HD patients, their mental health remains relatively poor. The aim of this study was to observe the severity temporal trends of depression, anxiety and stress symptoms and correlations among HD patients. Methods: A total of 173 patients, underwent a detailed anamnesis, with emphasis dialysis duration, comorbidities and a complex psychiatric evaluation, followed by the application of the Socio-economic Scale (SES-3); Mini Mental State Examination (MMSE); and the Depression, Anxiety and Stress Scale 21R (DASS-21R). The dialysis performance (spKt/V) and Charlson Comorbidity (CCI) indices were provided by DIAVERUM Nephrology and Dialysis Center in Craiova. Results: The severity of depression and anxiety symptoms significantly increased over six months, 0.248 ± 1.432 vs. 0.453 ± 1.488 (p < 0.0001; rrb = 0.296) for depression, and −0.090 ± 1.004 vs. 0.089 ± 1.047 (p < 0.0001; rrb = 0.252) for anxiety; while stress-like symptoms remained stable 0.080 ± 1.318 vs. 0.164 ± 1.357 (p = 0.0661; rrb = 0.123), despite improvements in dialysis adequacy (spKt/V). Depression scores were moderately correlated with anxiety and weakly correlated with stress and spKt/V. Anxiety results were moderately correlated with stress, while both anxiety and stress showed negligible correlations with spKt/V. Clinical variables assessed showed moderate predictive value for psychological outcomes in this cohort. Conclusions: Our study confirms the temporal trend of severity of mental symptoms and their persistence among HD patients, highlighting the urge to integrate mental health screening and intervention programs and a multidisciplinary team adapted for each case.

Clinics and Practice doi: 10.3390/clinpract16020036

Authors: Iva Bešlić Alen Vrtarić Ivana Škrinjar Ema Barac Ana-Karla Vodanović Liborija Lugović-Mihić

Background: For the majority of chronic spontaneous urticaria (CSU) sufferers, nocturnal itch has a profound effect on quality of life (QoL), as it leads to sleep disturbances. To ensure good sleep quality (SQ), the body must produce an adequate amount of melatonin, which regulates the sleep cycle. Methods: This study examines the levels of salivary melatonin in 38 CSU patients and 38 healthy controls, as well as the relationship between CSU severity, QoL and SQ. The Enzyme-Linked Immunosorbent Assay (ELISA), Dermatology Quality of Life Index (DLQI), and Pittsburgh Sleep Quality Index (PSQI) were used to determine salivary melatonin levels, QoL, and SQ. In addition, the CSU participants were given the Urticaria Activity Score (UAS) and the Urticaria Control Test. Results: The median value of salivary melatonin in CSU patients was lower than that in healthy individuals (0.2 vs. 15.985 pg/mL; p < 0.001). A decreased melatonin level was seen in 90% of CSU patients and 18% of healthy individuals. Individuals with lower melatonin levels were significantly more likely to have CSU compared with those with higher melatonin levels (OR = 37.6; 95% CI 10.0–141.1). Melatonin was linearly related to QoL and sleep quality in the whole sample (r = −0.606 and −0.536; p < 0.001) but not in CSU patients. Impaired QoL in patients correlated with itch intensity and the number of hives (r = 0.740 and 0.646). The severity and activity of CSU are linearly related to impaired QoL and sleep quality (r = −0.606 and −0.536; p < 0.001). Sleep quality acts as the mediator of the association between QoL and salivary melatonin, when controlling for the effect of age and gender (B = −0.347; 95% CI = −0.679 to −0.080). Conclusions: The data suggest that melatonin may be more a non-specific marker of sleep disturbance than the severity of CSU. Sleep quality may act as a mediator linking dermatology-related QoL, circadian dysregulation and reduced melatonin secretion.

Clinics and Practice doi: 10.3390/clinpract16020035

Authors: Paul Carroll Alyson Boudreau Haoning Hu Ryan P. Lin Bilal Louzati Eddie Davis

Background: Ledderhose Disease, or plantar fibromatosis, is a fibroproliferative disorder affecting the plantar fascia with limited effective treatment options. Although hyaluronidase has a long history of clinical use, it has not been previously used for Ledderhose Disease. This study explores the use of combined hyaluronidase and triamcinolone acetonide enzymatic injections as a novel and promising technique for managing Ledderhose Disease. Methods: This paper investigates the use of combination therapy with hyaluronidase, triamcinolone acetonide, and lidocaine injections in three patients with Ledderhose Disease. Injection protocols, dosage, frequency, and patient outcomes are all discussed. Additionally, this study explores the underlying mechanisms of hyaluronidase action in Ledderhose Disease, shedding light on its potential to modulate fibrotic tissue and alleviate symptoms. Results: All three patients treated with a series of hyaluronidase, triamcinolone acetonide, and lidocaine anesthetic injections experienced either a significant reduction in or elimination of nodules and associated pain within 6 weeks after initial injection. Patients were asymptomatic at two years follow-up after injections. Conclusions: The combination of hyaluronidase and triamcinolone acetonide injections significantly decreased pain and softened fibromas faster than triamcinolone acetonide injection alone, as explored in previous studies. Large prospective studies are needed to further compare enzymatic injection therapies in the management of Ledderhose Disease.

Clinics and Practice doi: 10.3390/clinpract16020034

Authors: Antonios Saramantos Athanassios Kyrgidis Gregorios Venetis Georgios Hatziantoniou Anestis Chrysostomidis Chrysanthi Sardeli Ioannis Tilaveridis

In the original publication [...]

Clinics and Practice doi: 10.3390/clinpract16020033

Authors: Luca Gentili Roberto Fontanella Marco Messi Cosimo Galletti Roberto Lo Giudice Francesco Puleio

Background: Rotary instrument fracture during third molar extraction is rare but clinically relevant, presenting diagnostic and therapeutic challenges. Aim: This scoping review summarizes available evidence on bur breakage and displacement during third molar surgery, focusing on causes, clinical manifestations, and management strategies. Materials and Methods: A systematic search of PubMed, Virtual Health Library, and Google Scholar was conducted for studies published from January 2008 to March 2025 reporting rotary instrument fracture during third molar extraction. Extracted data were qualitatively analyzed. Results: Eight studies reporting eleven clinical cases were included. All fractures occurred during mandibular third molar extractions. Pain was the most frequent symptom (45%), followed by swelling (27%) and trismus (18%). Management varied from immediate surgical retrieval to conservative observation. Conclusions: Although uncommon, rotary bur fracture during third molar extraction requires preventive attention and accurate reporting. Adherence to manufacturer recommendations, single-use bur policies, and adequate irrigation should be considered. Prospective multicenter and mechanical studies are needed to establish standardized management protocols.

Clinics and Practice doi: 10.3390/clinpract16020032

Authors: Erick Ordoñez-Villordo Monica Alethia Cureño-Díaz Erika Gómez-Zamora Miguel Trujillo-Martínez Ricardo Castrejón-Salgado Fani Villa-Rivas Rocío Castillo-Díaz Nadia Velázquez-Hernández Juan Carlos Fernando Sánchez-Velázquez Ximena Solis-Gómez José Ángel Hernández-Mariano

Background/Objectives: Hypertensive disorders of pregnancy (HDP) remain a major contributor to maternal morbidity and mortality worldwide, yet early-life reproductive factors such as age at menarche have been insufficiently explored in relation to HDP. Therefore, we aimed to evaluate the association between age at menarche and the risk of HDP in a cohort of Mexican pregnant women. Methods: We conducted a retrospective cohort study among 1344 women with singleton pregnancies receiving care at a tertiary hospital in Mexico City in 2024. Age at menarche was categorized as <12, 12–14, and >14 years. HDP diagnoses were extracted from clinical records. Poisson regression with robust variance was used to estimate adjusted risk ratios (RRs). Sensitivity analyses included alternative menarche categorizations and restricted cubic spline models. Counterfactual mediation analyses assessed indirect effects through reconstructed prepregnancy BMI and gestational diabetes. Results: Both early (<12 years) and late (>14 years) menarche were associated with higher HDP risk than the 12–14-year reference (adjusted RR = 1.81; 95% CI 1.42–2.30, and 1.74; 95% CI 1.27–2.38, respectively). Spline models confirmed a U-shaped association. Mediation analyses indicated that prepregnancy BMI did not meaningfully mediate the association for either early or late menarche (<5% mediated). Gestational diabetes explained a modest proportion of the association for early menarche (≈14%), but not for late menarche. Conclusions: Age at menarche showed a robust U-shaped association with HDP, mostly independent of adiposity and gestational diabetes, within the limits of the available measurements. Incorporating pubertal timing into routine reproductive history taking may enhance contextual risk assessment for HDP.

Clinics and Practice doi: 10.3390/clinpract16020029

Authors: Edoardo Agosti Sara Antonietti Michael Viola Marco Maria Fontanella Alessandro Fiorindi

Background/Objectives: Third ventricle colloid cysts (TVCCs) are benign lesions that may cause acute hydrocephalus and, rarely, sudden death. Endoscopic resection has emerged as a minimally invasive alternative to microsurgical approaches. This systematic review aimed to evaluate the safety and efficacy of endoscopic resection of TVCCs. Methods: Following PRISMA guidelines, a systematic search of major databases was performed to identify studies reporting clinical outcomes of endoscopic resection of TVCCs. Extracted data included the surgical technique, extent of resection, complications, recurrence, and reoperations. Results: Thirty-four studies comprising 1123 patients were included. Gross total resection (GTR) was achieved in 767 patients (68.3%), with higher rates for the transforaminal (88.4%) and transeptal (86.9%) approaches (z = 0.309; p = 0.76). Capsule removal was performed in 87.4% and coagulation alone in 11.6%. Postoperative remnants occurred in 172 patients (17.1%). Recurrence was observed in 41 cases (3.7%) after a mean follow-up of 46.3 months, with 33 patients (2.9%) requiring reoperation. Preoperative hydrocephalus was present in 51% of cases. Septostomy and external ventricular drainage were performed in 15.7% and 15.5% of patients, respectively. Complications included memory deficits (3.6%), meningitis (3.6%), intraventricular hemorrhage (2.7%), ischemia (1.1%), shunt dependency (2.1%), and seizures (0.6%). Mortality occurred in eight patients (0.7%). Conclusions: Endoscopic management of TVCCs is associated with a low complication rate and favorable long-term outcomes. Capsule resection reduces the risk of recurrence and the need for reoperation.

Clinics and Practice doi: 10.3390/clinpract16020031

Authors: Evgeniya Melnik Ekaterina Petrova Tatiana Markova Ksenya Zabudskaya Elena Dadali

Background: The PITX1 gene encodes a transcription factor that plays a crucial role in the development of the lower limbs, pelvis, and structures derived from the first branchial arch. Pathogenic variants in PITX1 are associated with a limited spectrum of rare disorders, including congenital talipes equinovarus with or without long bone anomalies and/or mirror-image polydactyly, and Liebenberg syndrome. In 2020, a novel clinical phenotype, Mandibular–Pelvic–Patellar (MPP) syndrome, resulting PITX1 missense variants, was proposed. Case presentation: We report the fourth documented case of MPP syndrome worldwide, identified in a 17-year-old female patient presenting with congenital lower limb deformities, patellar aplasia, and micrognathia. Whole-genome sequencing revealed a heterozygous PITX1 missense variant NM_002653.5: c.412A>C, p.(Lys138Gln). The clinical phenotype included knee flexion contractures and severe equinovarus and planovalgus foot deformities requiring multiple staged reconstructive surgical procedures. Conclusions: This case supports recognition of MPP syndrome as a clinically and genetically distinct PITX1-related disorder. Our findings expand the phenotypic spectrum of MPP syndrome and suggest that severe congenital foot deformities represent a consistent and clinically relevant feature of this condition.

Clinics and Practice doi: 10.3390/clinpract16020030

Authors: Alexandru Lisias Dimitriu Monica Georgiana Roman Elisa Georgiana Popescu Eduard Cătălin Georgescu Dragoș Ene Răzvan Ene

Background: The optimal management of comminuted proximal humerus fractures in the elderly remains controversial. Although hemiarthroplasty is widely used for complex fracture patterns, its functional superiority over reconstruction is not consistently demonstrated. The aim of this study was to compare early functional outcomes following open reduction and internal fixation (ORIF) versus hemiarthroplasty in elderly patients with three- and four-part proximal humerus fractures. Methods: This retrospective single-center study included elderly patients with comminuted proximal humerus fractures treated between 2020 and 2024 by either ORIF or hemiarthroplasty. Functional outcomes were assessed at 6 months using the Constant–Murley and DASH scores. Secondary outcomes included complication rates, range of motion, and early reintervention. Results: At 6 months, the ORIF group showed a mean Constant–Murley score of 62.1 ± 9.4 compared with 58.0 ± 10.2 in the hemiarthroplasty group. DASH scores were 34.2 ± 10.8 for ORIF and 38.5 ± 11.3 for hemiarthroplasty. Pain levels were similarly low in both groups (VAS 2.6 ± 1.1 vs. 2.9 ± 1.2). Complication rates were comparable, with fixation-related issues occurring in 17% of ORIF cases and tuberosity-related complications in 11% of hemiarthroplasty cases. Conclusions: Hemiarthroplasty should not be regarded as the default treatment strategy for comminuted proximal humerus fractures in elderly patients. When stable anatomic reduction is achievable, ORIF can yield comparable early functional results, emphasizing that patient selection and tuberosity management remain more important than the choice of implant.

Clinics and Practice doi: 10.3390/clinpract16020028

Authors: Enrico Matteini Fabio Artosi Giacomo Caldarola Lorenzo Maria Pinto Alfredo Rossi Lorenzo Ala Gaetana Costanza Luca Bianchi Elena Campione Laura Diluvio

Background/Objectives: Alopecia areata (AA) and psoriasis are immune-mediated diseases that can coexist, suggesting shared pathogenic mechanisms. While Janus kinase inhibitors (JAKi) are approved for AA treatment, their role in managing concomitant psoriasis and psoriatic arthritis (PsA) remains unclear. This study evaluates the efficacy and safety of baricitinib in patients with severe AA and coexisting psoriasis and/or PsA. Materials and Methods: A retrospective case series of five patients (mean age 53.2 years) with severe AA (SALT > 80) or alopecia universalis (AU) and concomitant psoriasis (n = 2) and/or PsA (n = 3) was conducted in the Dermatology Unit of Policlinico of Tor Vergata, Catholic University of the Sacred Heart and La Sapienza University of Rome, Italy. Patients received baricitinib 4 mg/day and were assessed at weeks 4, 24, and 52 using SALT, PASI, and pVAS scores. Results: At week 52, one patient achieved complete AA remission, while two improved to SALT < 20 (mean SALT 83 to 8.75). Psoriasis remained stable (mean PASI 1.4 to 0.5). However, one PsA patient worsened (pVAS 9) and discontinued the treatment. Conclusions: Baricitinib was effective for AA, with potential benefits for psoriasis, but it may not be optimal for PsA. Further studies are needed to define its role in multiple immune diseases.

Clinics and Practice doi: 10.3390/clinpract16020027

Authors: Kostadin Gigov Petra Kavradzhieva Ivan Ginev Mihaela Bogdanova

Background: Auricular carcinoma is a malignant neoplasm arising from the epithelial or adnexal tissues of the external ear, most commonly representing cutaneous squamous cell carcinoma, basal cell carcinoma, or, less frequently, melanoma, characterized by early cartilage invasion and regional spread due to the thin soft-tissue envelope of the ear. Such malignancies involve radical resection, producing wide defects, which require complex reconstructive approach. Case Presentation and Methods: We describe a 45-year-old male patient who presented with a basal cell carcinoma, affecting the lobulus of the ear and the retroauricular and mastoid region. He underwent successful tumor resection with clear resection margins in an ENT department with a subsequent referral to our department for reconstruction. This report presents a successful reconstruction of a large post-excisional defect, 10 × 10 cm in diameter, with mastoid process exposure. Temporal muscle flip flap and skin graft, along with the preservation of the external auditory canal with Z-plasty, were incorporated for reconstruction after subtotal auricular amputation due to BCC. It highlights the importance of a diligent long-term follow-up, the preservation of the canal, preventing meatal stenosis, and the reconstructive potential of the muscle flap in patients with mastoid bone exposure in a single stage. Conclusions: A temporalis muscle flap with skin graft coverage offers a reliable, vascularized solution for large post-oncologic auricular defects while preserving the external auditory canal. Z-plasty remains a critical technique for preventing meatal stenosis.

Clinics and Practice doi: 10.3390/clinpract16020026

Authors: Desislav Tomov Boryana Levterova Valentina Mihailova Dimitar Troev Zlatina Tomova Yordanka Uzunova Maria Orbetzova

Background: Hashimoto’s thyroiditis (HT) is a prevalent autoimmune disorder, often diagnosed late due to its asymptomatic or nonspecific presentation. Emerging evidence suggests that gut-derived lipopolysaccharides (LPS) may contribute to autoimmune activation. Objective: The primary objective of this study was to assess circulating LPS concentrations and dietary patterns in patients with Hashimoto’s thyroiditis compared to healthy controls. Methods: A hospital-based case–control study was conducted involving 105 HT patients and 25 healthy controls. Serum LPS concentrations, thyroid hormone profiles, and autoantibody levels were assessed. Dietary patterns were evaluated using the validated KomPAN questionnaire. Results: HT patients exhibited significantly higher serum LPS levels, particularly those with elevated anti-TPO and TRAB antibodies. A positive correlation was found between LPS and the fT3/fT4 ratio (r = 0.247, p = 0.006), and a negative correlation with fT4 (r = −0.314, p < 0.001). Dietary analysis revealed lower Pro-Healthy Diet Index scores in HT patients (3.94 vs. 5.34, p = 0.001), with increased consumption of processed foods and reduced intake of whole grains and oats. Conclusions: Elevated levels of lipopolysaccharides (LPS) and unhealthy dietary patterns may play a role in the development of thyroid autoimmunity. Taken together, these observations are consistent with a multifactorial model that potentially involves gut barrier dysfunction, endotoxemia, and nutritional factors in HT pathogenesis.

Clinics and Practice doi: 10.3390/clinpract16020025

Authors: Francesca K. Martino Alessandro Martella Francesca Fioretti Leda Cattarin Federica L. Stefanelli Federico Nalesso

Background: Comprehensive conservative management (CCM) is a possible option in end-stage clinical disease, requiring multidisciplinary support and offering survival comparable to dialysis while improving quality of life in frail patients. Despite its potential benefits, CCM is often underutilized because nephrologists may perceive it as less effective compared to dialysis. We present two case reports of hemodialysis failure and of successful CCM. Case presentation: We present two case reports of elderly female patients—referred to as Patient 1 and Patient 2—who had multiple comorbidities but preserved urine output. Both patients, in accordance with their medical team, chose to discontinue hemodialysis due to poor treatment tolerance and declining overall health. They were successfully managed with CCM, leading to follow-up that revealed survival beyond 24 months, improvements in metabolic complications and quality of life, and a reduction in hospitalizations. Conclusions: These case reports demonstrate the effectiveness of dietary and medical management for end-stage kidney disease, particularly when dialysis negatively affects patients’ clinical conditions and quality of life. They also highlight the importance of considering CCM as a preferable option for frail elderly patients facing kidney failure.

Clinics and Practice doi: 10.3390/clinpract16020024

Authors: Kensuke Kitsugi Kazuhito Kawata Yoshisuke Hosoda Yashiro Yoshizawa Masaharu Kimata Yosuke Kobayashi Shuhei Unno Yosuke Yamada Hidenao Noritake Takeshi Chida Go Murohisa

Objective: Although non-hepato-pancreato-biliary (non-HPB) cancer, such as gastric and colorectal cancer, may cause biliary obstruction, the efficacy of endoscopic transpapillary drainage remains unclear. We investigated the clinical outcomes of endoscopic transpapillary drainage for biliary obstruction due to non-HPB cancer. Methods: This was a two-center retrospective observation study. We evaluated the technical success, clinical success, recurrent biliary obstruction (RBO), time to RBO (TRBO), adverse events (AEs), and overall survival (OS). OS was determined using the Kaplan–Meier method, and the significance was tested using the log-rank test. Cox regression hazard models were performed to identify the independent association of clinical parameters with OS. Results: This study included 43 cases. The technical success was achieved in all cases (100%), and the clinical success was achieved in 35 cases (81%). The occurrence rate of RBO and non-RBO AEs were 33% and 12%, respectively. The median TRBO was 176 days. Systemic chemotherapy was introduced in 17 cases (40%) after biliary drainage, and cases with the introduction of systemic chemotherapy had a significantly longer OS. C-reactive protein <3.4 mg/dL and biliary obstruction due to lymph node metastasis were independently associated with the introduction of systemic chemotherapy. In survival analysis, serum albumin >3.1 g/dL and the introduction of systemic chemotherapy were significant and independent predictive factors for the prolongation of OS. Conclusions: The endoscopic transpapillary drainage for biliary obstruction due to non-HPB cancer can provide favorable outcomes with appropriate patient selection.

Clinics and Practice doi: 10.3390/clinpract16020023

Authors: Rosanna Carmela De Rosa Antonio Romanelli

Background: Awake carotid endarterectomy (CEA) under local anesthesia demands an optimal sedation strategy that ensures patient comfort while preserving the ability for real-time neurological assessment. Dexmedetomidine (DEX) and remifentanil (REMI) are widely used agents, but direct comparisons in this setting remain scarce. Methods: Exploratory, retrospective, single-center study of awake CEA (March–July 2019). DEX or REMI infusions were titrated to a Richmond Agitation–Sedation Scale (RASS) of −1 to −2. Outcomes were sedation failure (RASS ≥ +2 despite maximum infusion rate), bradycardia, hypotension, and neurologic events. Statistical analyses used χ2 test (categorical variables) and Student’s t-test or Mann–Whitney test (continuous variables). Associations were assessed with Firth’s logistic regression (univariable and bivariate models), reporting odds ratios (OR) with 95% confidence intervals (CI95%). Trends in the Bispectral Index (BIS), hemodynamic, and respiratory parameters were assessed using two-way repeated-measures Analysis of Variance (ANOVA). A p-value < 0.05 was considered significant. Results: Fifty-two patients were included (DEX = 25; REMI = 27). DEX group showed more frequent sedation failure (32.0% vs. 3.7%; p = 0.020), bradycardia (36.0% vs. 3.7%; p = 0.009), and hypotension (28.0% vs. 0%; p = 0.011). DEX was associated with increased risk in sedation failure (OR 8.58, CI95% 1.70–85.81), bradycardia (OR 10.17, CI95% 2.05–101.21), and hypotension (OR 22.30, CI95% 2.46–2959.60); the direction of associations remained consistent in bivariate models adjusted for baseline confounders. ANOVA showed group-by-time interactions for BIS, heart rate, mean arterial pressure, and end-tidal CO2. No intraoperative complications or adverse outcomes were observed. Conclusions: In this retrospective cohort of awake CEA, DEX was associated with higher rates of sedation failure and hemodynamic adverse events compared with REMI, without an apparent impact on procedural success. Given non-random allocation and baseline imbalances, these findings are hypothesis-generating and warrant confirmation in larger, robust, and prospective studies.

Clinics and Practice doi: 10.3390/clinpract16010022

Authors: Eleni Maria Mitrou Lamprini Avramopoulou Dimitrios Alefragkis Athanasia Tsami Maria Polikandrioti

Introduction: Caregiving has been an emerging public health priority mainly due to the rapid pace of population aging, increase in chronic diseases and shortages of health professionals. In clinical settings, caregivers have a crucial role by providing support to patients. Consequently, they may experience physical and emotional burden mainly attributed to environmental, personal or family stressors. The aim of this study was to evaluate fatigue and the associated factors among caregivers of hospitalized patients in medical-surgical wards. Methods and Material: In the present study caregivers of hospitalized patients in medical and surgical wards were enrolled. Collection of data was performed with the following: a. Fatigue Assessment Scale (FAS), b. Zung Self-Rating Anxiety Scale (SAS) and c. Athens Insomnia Scale (AIS), which included patients’ characteristics. In this cross-sectional study, participants were selected using the method of convenience sampling. Results: Of the 142 participants, the majority were spouses (64.8%), female (64.8%) and over 60 years old (53.6%). The mean FAS score was 25.9 ± 9.3, the mean SAS was 38.1 ± 9.0, and the mean AIS score was 7.6 ± 4.7, indicating moderate, moderate to low and moderate levels of fatigue, anxiety and insomnia, respectively. Moreover, fatigue showed a positive linear correlation with both anxiety (Spearman’s rho = 0.713) and insomnia (Spearman’s rho = 0.671). The factors found to be statistically significantly associated with caregivers’ fatigue were the following: gender (p = 0.001), length of hospitalization (p = 0.013), experience of environmental stressors (p = 0.045), experience of financial stressors (p = 0.001), and unfamiliarity with the provision of care (p = 0.001). Conclusions: Provided that caregivers’ involvement in care not only enhances patient well-being but also supports clinical teams, it is widely comprehended that addressing their needs should be emphasized.

Clinics and Practice doi: 10.3390/clinpract16010021

Authors: Takahiko Nagamine

Elderspeak is a form of communication overaccommodation directed toward older adults, characterized by simplified language and an elevated pitch. While typically well-intentioned, it is rooted in ageist stereotypes and linked to negative health outcomes. A literature search was conducted in PubMed, CINAHL, and PsycINFO (2018–2025), yielding 24 key articles focusing on acute and surgical settings. The purpose of this narrative review is to synthesize current evidence on Elderspeak within acute care hospitals and propose a research framework and intervention strategies. Elderspeak is a key determinant of resistiveness to care (RTC), particularly in acute settings where it is triggered by functional impairment. Exposure increases patient distress and negatively impacts vital signs and cooperation with medical interventions. Inconsistent measurement is being addressed through standardized schemes like the Iowa Coding Scheme for Elderspeak (ICodE). This paper proposes that future research must employ mixed-methods, longitudinal designs to capture the impact of Elderspeak on long-term outcomes. Drawing on the ICodE, we propose a qualitative self-reflection tool for clinicians to enhance awareness in high-stakes acute settings. Eliminating Elderspeak is a foundational necessity for patient safety and dignity-affirming care in advanced nursing.

Clinics and Practice doi: 10.3390/clinpract16010020

Authors: Tetsuro Shiraishi Iori Kisu Naomi Kaneko Takaaki Fukuda Jun Watanabe Ryoma Hayashi Akihisa Ueno Katsura Emoto Kanako Nakamura Yuya Nogami Kosuke Tsuji Kenta Masuda Wataru Yamagami

Background: Nuclear protein in testis (NUT) carcinoma is a rare, aggressive, and poorly differentiated epithelial malignancy characterized by the rearrangement of NUTM1 (NUT midline carcinoma family member 1) on 15q14. It primarily originates along the midline structures, including the head, neck, thorax, and mediastinum. Although NUT carcinoma of the pelvic gynecological organs is exceedingly rare, reported cases have been limited to primary or metastatic ovarian tumors. Here, we present the first documented case of primary uterine NUT carcinoma. Case presentation: A 53-year-old postmenopausal woman presented with abnormal uterine bleeding and a uterine mass. She underwent a total abdominal hysterectomy with bilateral salpingo-oophorectomy. The initial postoperative histopathological evaluation suggested undifferentiated endometrial sarcoma; however, subsequent immunohistochemical (IHC) analysis and fluorescence in situ hybridization revealed NUTM1 rearrangement, confirming the diagnosis of NUT carcinoma. The patient experienced tumor recurrence six months postoperatively and succumbed to the disease nine months later. Discussion: The pathological diagnosis was challenging; the presence of abrupt squamous differentiation prompted further IHC analysis, leading to the definitive diagnosis. Primary uterine NUT carcinoma may be misdiagnosed as other undifferentiated uterine tumors due to its rarity and histological overlap. Conclusions: Given the diagnostic challenges, NUT IHC staining and molecular testing for NUTM1 rearrangement should be considered in undifferentiated uterine tumors with ambiguous histopathological features.

Clinics and Practice doi: 10.3390/clinpract16010019

Authors: Tiziano Serfilippi Silvia Piccirillo Alessandra Preziuso Valentina Terenzi Francesca Romagnoli Marella Tarini Vincenzo Lariccia Agnese Secondo Simona Magi

Background: Aripiprazole is an atypical antipsychotic that acts as a partial agonist on the dopamine receptor D2 while also displaying agonistic activity on the 5-HT1A and antagonistic activity on the 5-HT2A receptors. As a partial agonist, aripiprazole stabilizes the activity of the D2 receptor, preventing overactivation. Case presentation: Within our deprescribing activity, we came across the case of a 30-year-old antipsychotic-naïve patient treated with the depot formulation of aripiprazole for bipolar disorder and acute mania, possibly developing hypersexuality due to an overdose that impacted negatively and heavily on his personal life. Results: The patient developed a peculiar subset of hypersexuality, changing his sexual orientation. Of interest, one month after discontinuing aripiprazole and switching to paliperidone, all the sexual-related symptoms and impulse control disorders resolved. Conclusions: We suggest stronger communication among the clinical teams involved in the patient’s care and screening patients for impulse control disorder prior to the administration of aripiprazole and monitoring them during treatment.

Clinics and Practice doi: 10.3390/clinpract16010018

Authors: Panagiota Makrygianni Maria Polikandrioti Ioannis Koutelekos Ilias Tsiampouris Georgios Vasilopoulos

Introduction: Patients with colorectal cancer who undergo ileostomy surgery confront multifaceted challenges that significantly impact their daily lives and cause symptoms of anxiety and depression. The aim of this study was to explore the anxiety and depression experienced by colorectal cancer patients undergoing ileostomy with three assessments. Materials and Methods: This longitudinal study included 96 patients with newly diagnosed colorectal cancer who underwent scheduled ileostomy surgery at two public hospitals in Attica. The Hospital Anxiety and Depression Scale (HADs) was used, which included patients’ characteristics. Measurements were collected at three distinct time points: preoperatively (Time 1), postoperatively between the 12th and 14th day (Time 2), and after stoma closure, approximately one year later (Time 3). Statistical analysis was performed using the SPSS 26.0 statistical package and the statistical significance level was set at p < 0.05. Results: The proportion of participants reporting moderate levels of anxiety (scores 8–10) was 15.6% at Time 1, which increased to 27.1% at Time 2, and had a slight increase to 28.1% at Time 3. The increase was statistically significant between Time 1 and Time 2 and at Time 1 and Time 3 (p < 0.001). Regarding high levels of anxiety (scores >11), the percentage of affected individuals increased from 13.5% at Time 1 to 17.7% at Time 2 and reached 15.6% at Time 3. The comparison between Time 1 and Time 2 revealed a statistically significant increase (p = 0.016), while the subsequent decrease between Time 2 and Time 3 was not statistically significant (p = 0.508). In terms of depression, at Time 1, 84.4% of patients had low depression, which decreased significantly to 56.3% at Time 2 and 39.6% at Time 3 (p < 0.001 for all comparisons). The percentage of patients who were moderately depressed at Time 1 was 9.4%; this percentage increased significantly to 32.3% at Time 2 and remained high, reaching 29.2% at Time 3. Finally, the proportion of patients who had high levels of depression at Time 1 was 6.3%, a figure that rose to 11.5% and 31.3% for Time 2 and Time 3, respectively. Conclusions: Anxiety and depression experienced by colorectal cancer patients undergoing ileostomy surgery escalate postoperatively and remain at high levels after ileostomy closure. Understanding these mental health challenges is crucial for providing comprehensive patient care. Further research is needed on the early recognition and management of these emotional difficulties, which are key elements of holistic oncology care.

Clinics and Practice doi: 10.3390/clinpract16010017

Authors: Marina Leitman Vladimir Tyomkin Shmuel Fuchs

Background: Cardiac amyloidosis is characterized by progressive myocardial and atrial infiltration, leading to atrial mechanical dysfunction, atrial fibrillation, and thromboembolic complications. Left atrial (LA) strain is an established marker of atrial function; however, data on triplane LA strain in cardiac amyloidosis are limited. Methods: We evaluated transthoracic echocardiographic examinations of 24 patients with cardiac amyloidosis and 24 age-, sex-, rhythm-, and ejection fraction-matched control subjects (9 with atrial fibrillation in each group). Among amyloidosis patients, 21 had transthyretin and 3 had light-chain cardiac amyloidosis. All examinations were performed during 2025. Triplane and biplane LA reservoir strain were assessed using speckle-tracking echocardiography. Two-way analysis of variance tested the effects of disease (amyloidosis vs. control) and rhythm (sinus rhythm vs. atrial fibrillation). Agreement between triplane and biplane measurements was evaluated using Pearson correlation and Bland–Altman analyses. Results: Triplane LA reservoir strain was significantly lower in patients with cardiac amyloidosis compared with controls (6.7 ± 2.7% vs. 16.2 ± 8.3%, p < 0.001). Even in sinus rhythm, amyloidosis patients demonstrated markedly impaired LA strain, with mean values similar to those observed in control subjects with atrial fibrillation. Two-way ANOVA revealed significant main effects of disease (F = 68.9, p < 0.0001) and rhythm (F = 45.0, p < 0.0001), as well as a significant disease–rhythm interaction (F = 26.5, p < 0.0001). Triplane and biplane LA strain showed strong correlation (r = 0.90, p < 0.0001) with good agreement. Reproducibility was excellent (intra-observer ICC = 0.97; inter-observer ICC = 0.94). Conclusions: Triplane LA reservoir strain is markedly reduced in cardiac amyloidosis and enables comprehensive visualization of atrial mechanical dysfunction. The technique demonstrates high reproducibility and strong agreement with biplane analysis, supporting its use as a complementary tool for characterizing amyloid atriopathy.

Clinics and Practice doi: 10.3390/clinpract16010016

Authors: Nataša Prebil Rozalija Kušar Maja Šereg Bahar Irena Hočevar Boltežar

Background/Objectives: The aim of this study was to assess the short-term and long-term effectiveness of group voice therapy in changing vocal behaviour and improving voice quality (VQ) among teachers with hyperfunctional voice disorders (HFVD), using both subjective and objective measures. Methods: Thirty-one teachers participated in a structured group voice therapy programme. Participants underwent videoendostroboscopic evaluation of laryngeal morphology and function, perceptual assessment of voice, acoustic analysis of voice samples, and aerodynamic measurements of phonation. Patients’ self-assessment of VQ and its impact on quality of life were measured using a Visual Analogue Scale (VAS) and the Voice Handicap Index-30 (VHI-30). Evaluations were conducted at four time points: pre-therapy (T0), immediately post-therapy (T1), and at 3-month (T3) and 12-month (T12) follow-up visits. Results: Significant improvement was observed between T0 and T1 in perceptual voice evaluations: grade, roughness, asthenia, strain, loudness, fast speaking rate, as well as in neck muscle tension, shimmer, patients’ most harmful vocal behaviours, VHI-30 scores, patients VQ evaluation, and its impact on quality of life (all p < 0.05). Almost all parameters of subjective and objective voice assessment improved over the 12-month observation period, with the greatest improvement between T0 and T12 (all p < 0.05), indicating lasting reduced laryngeal tension and improved phonatory efficiency. Conclusions: Group voice therapy has been shown to be an effective treatment for teachers with HFVD, leading to significant and long-lasting improvements in perceptual, acoustic, and self-assessment outcomes. Therapy also promoted healthier vocal and lifestyle behaviours, supporting its role as a successful and cost-effective rehabilitation and prevention method for occupational voice disorders.

Clinics and Practice doi: 10.3390/clinpract16010015

Authors: Ioana Ioniță Mădălina Iuliana Mușat Bogdan Cătălin Constantin Alexandru Ciobanu Adela Magdalena Ciobanu

Background/Objectives: Gambling disorder (GD) is characterized by a high prevalence of co-occurring psychiatric disorders, including personality disorders (PDs), which may negatively influence clinical presentation, treatment outcomes, and relapse rates. The aim of this systematic review was to synthesize recent evidence regarding the association between GD and formally diagnosed PD and/or diagnostically anchored PD symptomatology, and to describe the main personality dimension most frequently reported in affected individuals. Methods: A systematic search was conducted in the PubMed and Dialnet databases for articles published between 30 November 2015 and 30 November 2025, according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA 2020) guidelines. PubMed was selected as the primary database because it is the most comprehensive source for peer-reviewed biomedical and psychiatric research, while Dialnet was included to complement PubMed by ensuring coverage of peer-reviewed psychiatric and psychological research published in other Romance-language journals, which are often underrepresented in international databases. The methodological quality and risk of bias of the included studies were evaluated using the Joanna Briggs Institute (JBI) Critical Appraisal Checklist for cross-sectional studies and the Newcastle–Ottawa Scale (NOS) for observational studies. Data extraction and synthesis were performed manually by two independent reviewers. Eight studies, predominantly cross-sectional in nature, assessing exclusively formally diagnosed personality disorders in adult individuals (≥18 years) diagnosed with GD were included. Results: Eight studies met the inclusion criteria, including a total of 4607 patients with GD. Across studies, personality pathology was highly prevalent among individuals with GD, with antisocial and borderline personality disorders most consistently reported. Elevated levels of impulsivity, emotional dysregulation, and narcissistic traits were frequently observed and were additionally associated with greater gambling severity, earlier onset, and poorer clinical outcomes. Antisocial personality symptoms were strongly linked to high-risk gambling subtypes, while obsessive–compulsive personality traits showed a more heterogeneous relationship with gambling severity. Conclusions: These results underscore the importance of personality assessment in individuals with GD and highlight the need for longitudinal studies using standardized diagnostic frameworks to inform tailored prevention and treatment strategies.

Clinics and Practice doi: 10.3390/clinpract16010014

Authors: Romil R. Parikh Nishka U. Shetty Chinar Singhal Prachi Patel Priyanka Manghani Ashwin A. Pillai Luz Angela Chocontá-Piraquive Mary E. Butler

Objective: The aim of this study was to systematically map evidence to inform best practices for sexual and reproductive healthcare delivered via telehealth (TeleSRH) in United States-based Title X-funded clinics. Methods: We searched three databases (2017–2025) for studies evaluating effectiveness, harms, patient and provider experiences, barriers/facilitators, and engagement strategies encompassing TeleSRH for sexually transmitted infections (STIs), contraceptive care/family planning (CC/FP), and sexual wellness, in countries with a human development index of ≥0.8. Results: From 5963 references and 436 articles, we included 142 eligible publications. TeleSRH use declined since the COVID-19 pandemic’s peak but remains higher than pre-pandemic. Evidence comes mostly from poor-quality studies. TeleSRH increases access and adherence to STI prevention (e.g., pre-exposure prophylaxis for HIV). Tele-follow-up may safely facilitate HIV care continuity. For CC/FP, TeleSRH is comparable to in-person care for patient satisfaction and uptake; patients are less likely to select long-acting reversible contraception but post-initiation tele-follow-up may increase its continuation rates. Vasectomy completion rates may be similar between pre-procedural counseling via telehealth versus in-person. TeleSRH’s potential benefits might include reduced travel time, wait times, no-show rates, and clinic human resource burden (via tele-triaging) and increased preventative screening rates for STIs and non-communicable diseases, prescription refill rates, ability to receive confidential care in preferred settings, and rural/marginalized community outreach. Implementation challenges span technological and capital constraints, provider availability, staff capability building, restrictive policies, language incompatibility, and patient mistrust. Supplementing synchronous TeleSRH with asynchronous communication (e.g., mobile application) may improve continued patient engagement. Conclusions: Preventive, diagnostic, and therapeutic TeleSRH can be effective, with high patient acceptability; however, effectiveness and adoption hinge on contextual factors outlined in this review.

Clinics and Practice doi: 10.3390/clinpract16010013

Authors: Sucharu Ghosh Sandra Armanious Anirudh Nair Zeynep Ulku Daniel Sultan Robert Pellecchia

Introduction: The trigeminocardiac reflex (TCR) is a brainstem reflex in which trigeminal stimulation precipitates abrupt vagally mediated cardiovascular changes, ranging from bradycardia to asystole. While classically described during down-fracture or pterygomaxillary disjunction in Le Fort I osteotomy, rhinocardiac events from lateral nasal wall manipulation are less emphasized in orthognathic surgery. Case presentation: A 32-year-old man undergoing Le Fort I osteotomy developed ventricular asystole during lateral nasal osteotomy. The maneuver was stopped immediately; chest compressions and a single dose of epinephrine were administered, with return of spontaneous circulation within approximately one minute. Surgery was aborted and the patient was transferred to the surgical ICU. Clinical discussion: The temporal association with lateral nasal wall manipulation, in the setting of controlled hypotension and multimodal anesthesia, is most compatible with a peripheral (V2) TCR-type event, although drug-related and hemodynamic contributors cannot be excluded. A mini review of orthognathic TCR reports underscores recurring high-risk steps (down-fracture, pterygomaxillary disjunction, mandibular maneuvers) and highlights lateral nasal osteotomy as a potential additional trigger. Management principles remain the immediate cessation of the stimulus, optimization of oxygenation and ventilation, anticholinergics for bradycardia, and epinephrine/advanced cardiac life support for instability or arrest. Conclusion: Lateral nasal osteotomy may trigger a TCR-like event with severe bradyarrhythmia or asystole during Le Fort I osteotomy, particularly in hemodynamically vulnerable patients. Anticipation, swift recognition, and prompt, protocolized management are essential for favorable outcomes.

Clinics and Practice doi: 10.3390/clinpract16010012

Authors: Miriam Olivola Serena Chiara Civardi Silvia Carnevali Roberta Anniverno Federico Durbano Bernardo Maria Dell’Osso

Background/Objectives: Suicide is the second leading cause of death among adolescents and young adults. Those suffering from psychiatric illnesses are at particular risk. Our study, conducted at an outpatient mental health facility in Northern Italy, aimed at delineating demographic and psychopathological features of youths aged 16–29 who attempted suicide and were referred to our community-based outpatient service. Methods: We identified 63 subjects, most of whom suffered from personality disorders, mood disorders, and schizophrenia spectrum disorders. Analysis of variance and post hoc pairwise comparisons were performed. Results: Inferential analysis yielded significant results in terms of age at index suicide attempt across diagnostic groups. Patients with personality disorders attempted suicide at a younger age (M = 18.70) compared to those with schizophrenia spectrum disorders (M = 23.64; η2 = 0.32). Conclusions: Our findings highlighted the period of transition from adolescence to adulthood as a stress on the need of preventive approaches towards suicidality in young people in both clinical and non-clinical settings. Moreover, the difference of age at index suicide attempt across different diagnostic groups stresses the need for tailored clinical interventions based on the specific psychopathological trajectories and natural histories of the diseases.

Clinics and Practice doi: 10.3390/clinpract16010011

Authors: George M. Pamboris Spyridon Plakias Charalambos Papacharalambous Kyriakos Pavlou Andrew Smythe Anna Christakou Eleftherios Paraskevopoulos

Background: Rotator cuff-related shoulder pain (RCRSP) is a prevalent musculoskeletal disorder treated by physiotherapists. Although international guidelines support active, exercise-based management, little is known about current physiotherapy practices in Cyprus. Aim: To investigate physiotherapy management practices for RCRSP in Cyprus, assess adherence to recommended clinical guidelines, and compare findings with practices in other countries. Methods: A cross-sectional online survey was conducted among Cypriot physiotherapists between June and July 2024. An English case vignette-based questionnaire, adapted from validated international surveys, examined demographics, clinical reasoning, treatment preferences, and guideline adherence. Descriptive statistics summarised responses; chi-square tests and logistic regression identified associations between demographics and clinical decisions. Content analysis was performed on open-ended responses. Results: A total of 143 physiotherapists completed the survey. Most adhered to guideline-recommended care, with 99.3% (n = 142/143) prescribing exercise and 100% (n = 143/143) providing patient education. Conservative management was preferred, with 64.3% (n = 91/143) not recommending imaging, 72.0% (n = 103/143) not recommending injections, and 73.4% (n = 104/143) not recommending surgical referrals. Significant associations were found between special interest in shoulder conditions and recommendations for surgery (χ2 = 4.937, p = 0.026) and injections (χ2 = 9.143, p = 0.002). Physiotherapists recommending surgery were nearly seven times more likely to suggest MRI (Exp(B) = 6.944, p < 0.001). Conclusions: Cypriot physiotherapists predominantly use exercise and education for the management of RCRSP, aligning closely with international recommendations. Conservative strategies were favoured, with limited use of imaging, injections, and surgical referrals. However, variation in clinical decision-making, particularly regarding referrals and imaging, indicates partial adherence to best practice and highlights opportunities for enhanced guideline implementation and targeted clinical training.

Clinics and Practice doi: 10.3390/clinpract16010010

Authors: Abdulkarim Hasan Yasien Mohammed Mostafa Basiony Mehenaz Hanbazazh Abdulhadi Samman Mohamed Fayek Abdelaleem Mohamed Nasr Hesham Abozeid Hassan Ismail Mohamed Mahmoud Faisal Eslam Mohamed Diaa Ashmawy Mohamed Tharwat Deaa Fekri Morsi Abeer Said Farag Eman Mohamed Ahmed Noha M. Aly Hala E. Abdel-Hamied Doaa E. A. Salama Essam Mandour

We would like to thank Harsanyi et al [...]

Clinics and Practice doi: 10.3390/clinpract16010009

Authors: Stefan Harsanyi Zuzana Varchulova Novakova Stanislav Ziaran Lubos Danisovic Katarina Bevizova

We read with great interest the article Clinico-Pathological Features and Immunohistochemical Comparison of p16, p53, and Ki-67 Expression in Muscle-Invasive and Non-Muscle-Invasive Conventional Urothelial Bladder Carcinoma by Hasan et al [...]

Clinics and Practice doi: 10.3390/clinpract16010008

Authors: Kanthida Methaset Arom Jedsadayanmata

Background: Potential drug–drug interactions (pDDIs) present substantial challenges to medication safety during care transitions. Warfarin, with its narrow therapeutic index and extensive interaction profile, provides a strategic model for examining pDDIs at discharge. This study aimed to characterize the burden and determinants of major warfarin pDDIs among patients discharged from a tertiary-care hospital. Methods: This retrospective cross-sectional study analyzed electronic health records of 1667 patients discharged home on warfarin. Major pDDIs were identified using the Micromedex® Drug Interaction database. Log-binomial regression was used to assess predictors of ≥1 major pDDIs, and generalized Poisson regression was used to model the number of pDDIs per patient. Results: Major warfarin pDDIs were identified in 81.6% (95% CI: 79.6–83.4%) of patients at hospital discharge. The burden was considerable: 35.1% (95% CI: 32.8–37.4%) of patients had one major pDDI, while 46.5% (95% CI: 44.1–48.9%) had two or more. Polypharmacy (≥5 concurrent medications) was the strongest predictor, associated with a higher risk of any major pDDI (adjusted risk ratio 1.72, 95% CI: 1.46–2.02) and nearly three times the burden of interactions per patient (adjusted incidence rate ratio (IRR) 2.87, 95% CI: 2.36–3.49). When modeled as a continuous variable, each additional discharge medication was associated with a 9% increase in predicted pDDI burden (IRR 1.09, 95% CI: 1.08–1.10). Conclusions: Using warfarin as a model for high-risk medication safety, major pDDIs were highly prevalent at hospital discharge, with polypharmacy as a significant predictor of both the presence and burden of interactions. These findings emphasize the importance of identifying polypharmacy-related pDDIs to reduce potential drug interaction risk during care transitions.

Clinics and Practice doi: 10.3390/clinpract16010007

Authors: Oren Gal Dorin Nicola Amir Mari Randa Natour Noor Fanadka Ahlam Bsoul Ahmad Mahamid Rawi Hazzan Fadi Abu Baker

Background: Dyspepsia is a common indication for gastroscopy, yet its diagnostic yield for malignancy and other clinically significant findings (CSF) remains low. Improved risk stratification is therefore essential to guide endoscopic referral. This study evaluates the diagnostic yield of gastroscopy in dyspepsia and investigates the predictive roles of age, ethnicity, and alarm symptoms. Methods: This retrospective single-center study was conducted at a university-affiliated hospital in Israel and included 3022 patients who underwent gastroscopy for dyspepsia over a five-year period. Multivariate logistic regression identified independent predictors of CSF, and receiver operating characteristic (ROC) analysis determined optimal age thresholds for malignancy and CSF. Results: Functional dyspepsia accounted for 55.9% of cases, while precancerous gastric lesions and upper gastrointestinal malignancies were identified in 12.8% and 0.79%, respectively. In multivariable models, age ≥ 50 years (OR = 2.59; CI: 2.02–3.32) and alarm symptoms (OR = 1.79; 95% CI: 1.33–2.41) independently predicted CSFs. Malignancy was similarly associated with age ≥ 50 years (OR = 4.89; CI: 1.11–21.60) and alarm symptoms (OR = 31.42; CI: 10.26–96.19). ROC analysis identified optimal age thresholds of 50 years for CSF (AUC = 0.65) and 54 years for malignancy (AUC = 0.72). Ethnicity did not independently predict malignancy, though minority patients showed differing precancerous lesion patterns. Conclusions: Age ≥ 50 years and alarm symptoms significantly increased the likelihood of CSFs and malignancy, supporting a selective approach to gastroscopy. ROC-derived thresholds may support reconsideration of age criteria in settings with similar epidemiologic patterns, highlighting the need for region-specific risk stratification.

Clinics and Practice doi: 10.3390/clinpract16010006

Authors: Antonios Michailidis Ioannis Tsifountoudis Evangelos Perdikakis Georgios Fragkos Ola Furmaga-Rokou Prodromos Koutoukoglou Danae Makri Evangelos Petsatodis Stefanos Finitsis

Background: Vascular malformations (VMs) are congenital anomalies of the vascular system—capillary, venous, lymphatic, arteriovenous, or combined—frequently associated with notable morbidity and reduced quality of life. Electrochemotherapy (ECT), a locoregional treatment that combines chemotherapeutic agents (most commonly bleomycin) with electroporation, has emerged as a promising alternative in managing therapy-resistant or anatomically challenging lesions. Methods: A systematic review of the literature was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. PubMed, Embase, and the Cochrane Library were searched from inception to January 2025 for studies reporting on the efficacy and/or safety of ECT for vascular malformations. Data extraction encompassed study design, patient demographics, VM type, ECT protocols, outcomes, follow-up duration, and adverse events. Studies that lacked relevant outcome data or focused solely on other therapeutic approaches were excluded. Results: Twelve primary studies met the inclusion criteria and were analyzed. These covered diverse VMs, including venous, slow-flow, high-flow malformations, aggressive hemangiomas, and composite lesions in adult and pediatric populations. ECT protocols usually combined bleomycin (or occasionally other agents such as pingyangmycin or polidocanol foam) with various electroporation parameters. Across studies, ECT resulted in meaningful lesion-size reduction (50–97% in most cohorts), symptom relief (e.g., reduced pain and bleeding), and favorable cosmetic outcomes. While side effects (local edema, hyperpigmentation, procedure-related discomfort) were occasionally reported, they were typically mild and transient. Conclusions: ECT represents a valuable minimally invasive option in the therapeutic armamentarium for vascular malformations. Despite consistent demonstrations of efficacy and acceptable toxicity profiles, future high-quality, multicenter studies are warranted to confirm outcomes, refine treatment guidelines, and potentially expand its use as a standard of care.

Clinics and Practice doi: 10.3390/clinpract16010005

Authors: Amit Bharkhada Neena Lakhani Sandra Hall Martin Grootveld

Background: Clinical pharmacists are increasingly demonstrating their value within primary care; this process directly improves patient experiences and outcomes. However, many undergraduate pharmacy students have little or no experience in this area, so that when they first qualify from training, their previous lack of exposure could affect future patient care in this environment. Aim: This study aims to evaluate how pharmacy undergraduate students’ learning and development of competencies are managed and received by general practitioner (GP) educators, clinical tutors, students, and patients in a general practice setting. Design and setting: The General Practice Pharmacy Educational Placement (GPEP) for undergraduates was designed and delivered in half-a-day each week across five weeks in general practice. Students observed patient consultations, interviewed patients, conducted medication reviews, used medicines reconciliation techniques, and also produced patient care plans. Method: Students participating in GPEP completed both pre- and post-course questionnaires rating eight learning outcomes, using a five-point Likert scale. Data analysis incorporated multivariate principal component analysis (PCA) and partial least squares-discriminant analysis (PLS-DA) strategies, and thematic analysis was applied to student focus groups, patient interviews, and GP staff interviews. Following the patient medication interview, students recorded findings and potential interventions for consideration. Results: A total of 112/157 students (71%) completed the questionnaires (June 2016–March 2019), with significant statistical differences in student confidence (p < 0.0005 for all learning outcomes). Thematic analysis revealed largely positive attitudes towards GPEP. Healthcare professionals highlighted benefits and challenges of GPEP. More than 40 issues relating to medicines optimisation and patient safety were identified, with some requiring immediate interventions from GP teams. Conclusions: GPEP demonstrated a positive clinical impact, improving patient safety. The undergraduate activities may encourage students to consider roles in primary and community care, enabling a resilient and able future workforce.

Clinics and Practice doi: 10.3390/clinpract16010004

Authors: Dragoș Ștefan Lazăr Adina-Alexandra Nanu Ilie-Andrei Condurache Maria Nica Catrinel Tudosie Maria Alexandra Malciolu-Nica Alexandra Ioana Grigore George Sebastian Gherlan Corneliu Petru Popescu Simin Aysel Florescu

Background: Measles re-emergence has been reported across Europe, with Romania being among the most affected countries in 2023–2024. Although ocular manifestations are recognized in measles, their frequency and inflammatory correlates in hospitalized adults have not been well characterized. Methods: This study retrospectively analyzed the medical records of adults treated for laboratory-confirmed measles at a Bucharest hospital between July 2023 and July 2024. Data from specialist eye examinations were used to compare patients with keratitis against those with other ocular issues. Results: A total of 250 adult patients were included. Of the 88 patients referred for ophthalmologic examination, 93.2% showed ocular lesions. Keratitis was the primary form, identified in 64.6% of these cases. Patients with keratitis had blood markers indicating a more activated inflammatory profile (higher neutrophile-to-lymphocytes ratio). Pneumonia and respiratory failure were not associated with ocular lesion status; inflammatory markers were more strongly linked to respiratory failure than to ocular involvement. Conclusions: Ocular lesions were highly prevalent in hospitalized adult measles cases during the 2023–2024 Romanian epidemic wave, and keratitis was common. Ocular involvement correlated with mucosal disease expression and systemic inflammatory activation. Systematic ophthalmologic assessment should be considered during measles epidemic peaks to improve early identification of clinically relevant ocular complications.

Clinics and Practice doi: 10.3390/clinpract16010003

Authors: Danjela Ibrahimi José R. García-Martínez

Aim: To propose a standardized clinical protocol for cone-specific neuromodulation that classifies therapeutic filters for selective stimulation of S-, M-, and L-cones and translates optical and safety parameters into condition-specific frameworks for amblyopia, strabismus, and ADHD. Methods: Previously characterized spectral filters were re-evaluated using published transmittance and cone-excitation data to identify a reduced set of monochromatic and combined options with meaningful cone bias. These were integrated with α-opic metrology, international photobiological and flicker standards, and condition-specific neurophysiological evidence to define reproducible ranges for wavelength, corneal illuminance, exposure timing, temporal modulation, and safety verification. Results: The protocol consolidates eleven monochromatic and six combined filters into operational classes mapped onto mechanistic profiles for amblyopia, esotropia, exotropia, vertical deviations, and exploratory ADHD applications. All time frames and applications are presented as methodological anchors rather than efficacy claims. Conclusions: This work provides a structured, safety-anchored framework intended to guide protocol design and comparability in future cone-specific neuromodulation trials; therapeutic benefit must be demonstrated in prospective clinical studies.

Clinics and Practice doi: 10.3390/clinpract16010002

Authors: Patrick F. Marko Lukas K. Kriechbaumer Marian Mitterer Sebastian Filipp

Background: Patient-specific instrumentation (PSI) in total knee arthroplasty represents an increasingly relevant component of personalized surgical planning. As nearly half of orthopedic patients search online for medical information before or after clinical consultation, the quality, accuracy, and readability of publicly available digital resources directly influence patient expectations, shared decision-making, and rehabilitation engagement. This study assessed the content, quality, and readability of online information about PSI in TKA. Methods: Google searches using four predefined PSI-related terms were conducted on 6 March 2025. After applying exclusion criteria, 71 websites were included for evaluation. Websites were categorized as academic or non-academic and analyzed for authorship, reporting of advantages and disadvantages, inaccurate assertions, use of peer-reviewed references, multimedia content, and mention of specific PSI platforms. Website quality was assessed using validated quality evaluation tools (QUEST and JAMA criteria), and readability was evaluated using established readability indices (SMOG, FKGL, and FRE). Results: Academic websites demonstrated significantly higher quality than non-academic sources based on QUEST (25.4 vs. 9.8; p < 0.001) and JAMA criteria (3.7 vs. 1.7; p < 0.001). Disadvantages of PSI were reported in 69.1% of academic sites versus 12.5% of non-academic sites (p < 0.001). Inaccurate claims occurred in 31.3% of non-academic sites but were absent in academic sources (p < 0.001). Peer-reviewed references were present in 81.8% of academic websites and only 12.5% of non-academic sites (p < 0.001). Readability was uniformly poor across all websites, with no significant group differences (mean SMOG 13.5; mean FKGL 11.8; mean FRE 32.4). Conclusions: Online information about PSI in total knee arthroplasty varies widely in transparency and accuracy, with non-academic websites frequently omitting risks or presenting misleading claims. Given the role of individualized implant planning, accessible and evidence-based digital content is essential to support personalized patient education and shared decision-making. Because limited readability restricts patient comprehension and informed participation in personalized orthopedic care, improving the clarity and accessibility of digital patient resources is essential.

Clinics and Practice doi: 10.3390/clinpract16010001

Authors: Suguru Yokoo Yukimasa Okada Kyotaro Ohno Takahiko Ichikawa Chuji Terada Keiya Yamana

Background/Objectives: Cement augmentation of cephalomedullary head elements can improve the purchase of osteoporotic bone; however, it does not eliminate the need for accurate implant positioning or the preservation of sliding. We report the case of an 87-year-old woman who underwent intramedullary nailing with a cement-augmented helical blade for intertrochanteric fracture. Methods: This is a single-patient case report. Calibrated radiographic measurements—tip–apex distance (TAD), calcar-referenced TAD (CalTAD), neck–shaft angle (NSA), and telescoping—were obtained immediately postoperatively and at 4, 7, 12, and 15 months. CT was performed at postoperative week 1 and at failure, and MRI was performed for clinical deterioration. In addition, a targeted narrative review summarizes the evidence on the head-element position, sliding behavior, reduction alignment, and augmentation. Results: Immediate postoperative indices were within the accepted targets: TAD 22.6 mm, CalTAD 22.8 mm, NSA 134°, with the head element inferior on the anteroposterior view and central on the lateral view. Rehabilitation proceeded with full weight bearing as tolerated. Early telescoping was minimal (3.8–3.9 mm). Between 7 and 15 months, progressive varus with shortening of TAD/CalTAD and little additional telescoping was observed, radiographically consistent with relative proximal migration of the head–cement complex and a cleavage plane along the inferior cement mantle, culminating in a subcapital femoral neck fracture with the implant in situ. Emphasis should be placed on accurate implant positioning and preservation of sliding capacity, because cement augmentation alone may not prevent mechanical failure when the implant position or load transfer is suboptimal. Conclusions: Cement augmentation stiffens the interface and reduces micromotion but does not neutralize malposition-induced stresses. Accurate positioning, preservation of sliding, and timely conversion when sliding fails to progress are advisable; these findings are hypothesis-generating from a single case. We propose a position- and sliding-based decision guide to support clinical decision-making; its usefulness remains to be validated in larger studies.

Clinics and Practice doi: 10.3390/clinpract15120237

Authors: Anabel Franco-Moreno Luis Escobar-Curbelo Juan Torres-Macho Nuria Muñoz-Rivas Cristina Lucía Ancos-Aracil Ana Martínez de la Casa-Muñoz Ana Bustamante-Fermosel Paz Arranz-García Miguel Ángel Casado-Suela

Background/Objectives: Unusual-site venous thrombosis (USVT) lacks robust evidence guiding anticoagulant selection between vitamin K antagonists (VKAs) and direct oral anticoagulants (DOACs). This study aimed to evaluate recanalization, recurrence, and major bleeding outcomes in real-world USVT patients and to replicate these findings through a validated digital twin model with Monte Carlo simulation. Methods: We conducted a retrospective study of 90 USVT patients (72% VKAs, 28% DOACs). A conditional generative adversarial network was used to generate digital twins matched on age, sex, thrombosis site, and malignancy. Logistic regression was applied to estimate treatment-specific outcome probabilities for recanalization, recurrence, and major bleeding. A nested stochastic simulation framework simulated 500 iterations across clinical scenarios, including increased DOAC use, cancer prevalence, cerebral vein thrombosis proportion, and optimized VKA control. Results: The mean age was 67.5 years, and 54.4% were female. 61.1% of splanchnic vein thrombosis, 36.7% of upper extremity deep vein thrombosis, and 2.2% of cerebral vein thrombosis were included. In the real cohort, complete recanalization occurred in 40.0% of patients with DOACs and 36.0% with VKAs. Recurrence was 8.0% with DOACs and 7.7% with VKAs, and major bleeding occurred in 8.0% and 10.8% of cases, respectively. All-cause mortality was 20% in DOAC-treated patients and 60% in those receiving VKAs. Digital Twin-based predictions replicated these results (recanalization 40.3% versus 38.0%; recurrence 10.9% versus 8.6%; bleeding 7.6% versus 9.1%). Simulated scenarios preserved the directionality effect, with the most significant differences observed in high-cerebral vein thrombosis and cancer-enriched patients. Conclusions: DOACs showed comparable efficacy and slightly lower bleeding risk than VKAs in USVT. Digital twin and Monte Carlo modeling provided robust, reproducible simulations of treatment effects under varying clinical conditions. Separating empirical and simulation-based findings, the digital twin supported the internal consistency of real-world observations and demonstrated the potential of in silico modeling as a complementary tool in rare thrombotic diseases.

Clinics and Practice doi: 10.3390/clinpract15120236

Authors: Lauren Thornley James Craig Thomas W. Wainwright Robert G. Middleton

Introduction: Total hip replacements and total knee replacements are among the most frequently performed operations worldwide, and the demand for such procedures is ever-growing. It is essential to focus on preventable medical complications that can arise from these procedures, specifically postoperative hyponatraemia. Postoperative hyponatraemia has an incidence of 20–40% in total hip and knee replacement patient cohorts. Even mild postoperative hyponatraemia is clinically relevant, as it is associated with cognitive impairment and gait disturbance and may undermine the aims of enhanced recovery protocols. Severe postoperative hyponatraemia can lead to seizures, coma, intensive care admission, and death. Although uncommon, the high volume of patients treated in busy orthopaedic centres means such cases will inevitably be encountered. This narrative review summarises the current evidence on incidence, risk factors and consequences of postoperative hyponatraemia in total hip and knee replacement populations. Methods: A literature review was performed through the EBSCO and PubMed databases to identify relevant studies. Key search terms included were “hyponatraemia”, “total hip replacement”, and “total knee replacement”. Results: The incidence of postoperative hyponatraemia is largely between 20% and 40%; however, there are some outliers to this. Multiple risk factors have been identified through observational studies, including age, preoperative hyponatraemia, female sex and certain medications, which signal a need for a risk stratification strategy that can assist in preoperative assessment and the early identification of patients at higher risk of developing postoperative hyponatraemia. Evidence is scarce regarding interventional studies for the prevention and management of postoperative hyponatraemia, despite multiple studies highlighting the issue. Conclusion: Future work should focus on testable, quality improvement interventions, such as automatic sodium checks on postoperative day one, weight-based oral fluid protocols, oral salt supplementation, and escalation pathways for high-risk patients. Incorporating these into enhanced recovery frameworks has the potential not only to optimise safe early discharge for the majority but also to prevent rare but significant complications.

Clinics and Practice doi: 10.3390/clinpract15120235

Authors: Constantin Aleodor Costin Adriana Grigoraș Elena Corina Andriescu Cornelia Amalinei

Background: Epidemiological studies on benign epithelial salivary gland tumors are challenging due to their rarity, pathological heterogeneity, variable tumor locations, and the limited national data collection in Romania. Our study aimed at the evaluation of benign epithelial salivary gland tumors collected over fifteen years in a tertiary center, in order to characterize their demographic and histopathological profiles and to contribute to their diagnostic and therapeutic strategies. Materials and Methods: A retrospective analysis of 404 cases of benign epithelial salivary gland tumors diagnosed in “Sf. Spiridon” County Hospital, Iasi, from 2010 to 2024, has been performed. Results: The analyzed cases showed a slight female predominance (52.97%) and a mean patient age of 54.55 ± 14.207 years. Tumor frequency increased progressively with age, peaking in the sixth and seventh decades of life. The most common histological types were pleomorphic adenoma (62.62%) and Warthin tumor (29.95%), both types showing a predominant parotid gland involvement (88.51%). The recurrences were rare, being registered only in 1.58% of pleomorphic adenomas. A significant association between tumor histological type and both gender (p < 0.001) and age group (p < 0.001) was registered, while no significant correlation between gender and age group (p = 0.288) or between tumor location and gender or age group (p = 0.382; p = 0.383) was found. Conclusions: The frequency of pleomorphic adenoma is increasing, showing an age-related distribution and parotid gland propensity. Key morphological features in each histological type support a better preoperative stratification, a more confident margin assessment, and an individualized extent of excision with function preservation.

Clinics and Practice doi: 10.3390/clinpract15120234

Authors: Soudah Bisharah Mieke Raap Mahmoud Abbas

Background: Urine cytology is a highly effective, straightforward, and cost-efficient diagnostic tool for identifying neoplastic and non-neoplastic changes in the bladder, ureter, and renal pelvis. The aim of this study is to demonstrate the high sensitivity and specificity of urine cytology in detecting a wide range of urothelial lesions, including metastatic involvement. Material and Methods: Urine cytology was performed on 9639 cases between 2000 and 2025. The samples, collected from patients, were processed at the Institute of Pathology. Cytological slides were prepared using cytocentrifugation and stained with May–Grünwald–Giemsa (MGG) and Papanicolaou stains. The cytological findings were classified according to WHO, 2004 compared with histological specimens. Additionally, selected cases underwent immunohistochemical and molecular analyses. All samples were anonymized and retrospectively analyzed following the guidelines and regulations of the local ethics committee. Results: Of the total cases, 7051 were classified as benign, 1269 as malignant, and 88 as normal findings. Insufficient material was obtained in 336 cases. No complications were reported during sample collection or processing. The concordance with histological findings for neoplastic lesions was over 96%, with a false-negative rate of 1.84%. The diagnostic methods demonstrated a sensitivity of 90.7% and a specificity of 96.64%. Among the 6956 cases analyzed, 3139 were women (45.13%) and 3817 were men (54.87%). Conclusions: The diagnostic value of urine cytology in representative material is relatively high in assessing both the presence or absence of malignancy and, when applicable, the tumor grade. This large 25-year single-center review demonstrates that urine cytology retains high sensitivity and specificity for the detection of urothelial malignancy, particularly high-grade disease. However, the atypical category remains a major diagnostic challenge and contributes substantially to false-positive results.

Clinics and Practice doi: 10.3390/clinpract15120233

Authors: Maria E. Ramos-Nino

Background/Objectives: Chronic inflammation arises from self-reinforcing immune–metabolic circuits encompassing pattern-recognition signaling, inflammasome activation, cytokine networks, immunometabolic reprogramming, barrier–microbiome disruption, cellular senescence, and neuro–immune–endocrine crosstalk. This review synthesizes these mechanistic axes across diseases and introduces an operational endotype-to-care framework designed to translate mechanistic insights into precision-based, scalable, and equitable interventions. Methods: A narrative, mechanism-focused review was performed, integrating recent literature on immune–metabolic circuits, including pattern-recognition receptors, inflammasome pathways, cytokine modules, metabolic reprogramming, barrier–microbiome dynamics, senescence, and neuro–immune–endocrine signaling. Validated, low-cost screening biomarkers (hs-CRP, NLR, fibrinogen) were mapped to phenotype-guided endotyping panels and corresponding therapeutic modules, with explicit monitoring targets. Results: We present a stepwise, pragmatic pathway progressing from broad inflammatory screening to phenotype-specific endotyping (e.g., IL-6/TNF for metaflammation; ISG/IFN for autoimmunity; IL-23/17 for neutrophilic disease; IL-1β/NLRP3 or urate for crystal-driven inflammation; permeability markers for barrier–dysbiosis). Each module is paired with targeted interventions and prespecified treat-to-target outcomes: for example, achieving a reduction in hs-CRP (e.g., ~40%) within 8–12 weeks is used here as a pragmatic operational benchmark rather than a validated clinical threshold. Where feasible, cytokine and multi-omic panels further refine classification and prognostication. A tiered implementation model (essential, expanded, comprehensive) ensures adaptability and equity across clinical resource levels. Conclusions: Distinct from prior narrative reviews, this framework defines numeric triage thresholds, minimal endotype panels, and objective monitoring criteria that make chronic inflammation management operationalizable in real-world settings. It embeds principles of precision, equity, and stewardship, supporting iterative, evidence-driven implementation across diverse healthcare environments.

Clinics and Practice doi: 10.3390/clinpract15120232

Authors: Rachel E. Barenie Devin Scott David Rhys Axon Alina Cernasev

Background: The scope of practice for pharmacists in the United States (US) is expanding rapidly, with the majority of states allowing pharmacists to prescribe to some degree. Doctor of Pharmacy (PharmD) programs are required to include medication prescribing effective 1 July 2025, ensuring program alignment with modern pharmacy practice. Objective: This study aimed to characterize student pharmacists’ beliefs about education on prescribing in the US PharmD program. Methods: Focus group discussions (FGDs) were conducted with student pharmacists enrolled in the PharmD curriculum at two different universities in the US. The conceptualization and data collection, guided by Self-Determination Theory, occurred over three months during the 2024 Fall semester. Data analysis was performed using thematic analysis, and themes were identified through inductive and deductive coding. Results: Twenty-two student pharmacists participated in three FGDs. Thematic analysis revealed two major themes: (1) essential role of didactic education in the prescribing process and (2) enhancing student preparedness to prescribe through experiential training. These themes uncover student pharmacists’ beliefs that prescribing education is vitally important to the didactic and experiential curriculum, highlighting the need to take a comprehensive approach to incorporate these topics into the PharmD program. Conclusions: Teaching medication prescribing in the PharmD didactic curriculum using a state’s scope of practice as a framework for its delivery, with reinforcement in their experiential training, to ensure pharmacy students are practice-ready, may be a preferred approach for delivery. This area remains ripe for further study to determine an evidence-based approach to teaching medication prescribing to pharmacy students.

Clinics and Practice doi: 10.3390/clinpract15120231

Authors: Moteb AlSaadi Salem Alghamdi Fayyaz Mazari Sabah Alshuhri Rustom Bashtawi Raghad Aljehani Basmah Alwuqaisi Rawan Almohammadi Mahmoud Alfirikh Sameer Desai Ebrahim Mahmoud

Background: Surgical site infections (SSIs) are common postoperative complications. Data on SSIs following breast surgery in Saudi Arabia are limited because these procedures are not included in the national SSI surveillance system. This study determined the SSI incidence rate, identified associated risk factors, and described the microbiological profiles of patients undergoing breast surgery at two tertiary hospitals in Saudi Arabia. Methods: This bicentric retrospective case–control study analyzed 1841 breast surgeries performed at two tertiary hospitals between July 2021 and July 2024. Demographic, surgical, and microbiological data were extracted from electronic medical records. SSIs were defined according to National Healthcare Safety Network criteria. Descriptive statistics summarized patient and surgical characteristics and SSI rates. A matched case–control analysis (1:4 ratio based on age and hospital site) included 172 patients. Multivariable logistic regression was used to identify predictors of SSI. Results: The cumulative SSI incidence was 2.4%, and most infections occurred within 30 days of surgery (69%). Gram-negative organisms were predominant in microbiologically positive cases (53.6%), mainly Klebsiella pneumoniae and Pseudomonas aeruginosa, whereas Staphylococcus aureus (including MRSA) accounted for 25%. Immunocompromised status (OR 3.32, 95% CI 1.35–8.14) and surgical drain use (OR 4.07, 95% CI 1.68–9.87) were independently associated with SSI. Conclusions: The incidence of SSIs after breast surgery in Saudi Arabia was relatively low. The predominance of Gram-negative pathogens and the identification of immunocompromised status and surgical drain use as major risk factors highlight opportunities for targeted infection prevention strategies. Further studies should validate these findings in larger and more diverse populations and healthcare settings.

Clinics and Practice doi: 10.3390/clinpract15120230

Authors: Marino Lupi-Ferandin Dinko Martinovic Ema Puizina Mislav Usljebrka Andrija Rados Lovre Martinovic Neven Ercegovic Josko Bozic Slaven Lupi-Ferandin

Background: Chronic maxillary sinusitis is most often linked to dental, allergic, or anatomical etiologies, with foreign body-induced forms remaining rare. This case report describes a unique occurrence of chronic maxillary sinusitis resulting from misplaced hyaluronic filler due to a facial esthetic procedure. Case presentation: A 60-year-old woman experienced right-sided maxillary sinusitis symptoms for three years after hyaluronic filler injections. Multi-slice computed tomography showed total sinus opacification, a vermicular foreign body, and a small anterior wall perforation. The patient underwent Caldwell-Luc surgery for foreign body removal and mucosal excision, followed by histopathological analysis. Results: The procedure was successful, with complete extraction of the foreign body compatible with hyaluronic filler. Postoperative recovery was uneventful, and symptoms resolved. This rare complication likely resulted from accidental filler penetration into the maxillary sinus during the injection. Conclusions: To the best of our knowledge, after a detailed search of the available literature, this is the first reported case of chronic maxillary sinusitis caused by material that is compatible with misplaced hyaluronic filler. It stresses the critical need to minimize serious complications in the facial esthetic procedures through detailed anatomical knowledge, technical skill, and a strict credentialing protocol of practitioners. Further awareness and regulations could improve patient safety.

Clinics and Practice doi: 10.3390/clinpract15120229

Authors: Óscar Gasulla Antonio Sarría-Santamera Ferran A. Mazaira-Font Cielo García-Montero Oscar Fraile-Martinez Diego Cantalapiedra Manuel F. Carrillo-Rodríguez Belen Gómez-Valcárcel Miguel Á. Ortega Melchor Álvarez-Mon Angel Asúnsolo

Background: This study investigates the possible role of cultural biases in clinical variation. Methods: An observational, analytical, and retrospective cohort design, using a Spanish primary care database, was used, on which a cross-sectional analysis was performed. Diseases were classified into the following: generic conditions with established protocols (control group), specialist-diagnosed diseases, women’s diseases, and psychiatric diseases. Diagnostic incidence was calculated across 25 geographical clusters, and variability was measured using the coefficient of variation (CV). To test systematic differences, multivariate linear regression models were adjusted for socio-demographics and healthcare system proxies. Results: The final sample for analysis consisted of 617,222 women aged 15 to 65, with a mean age of 43. The results did not reveal significant variability between generic and specialized diseases, but women’s and psychiatric diseases showed consistently higher CVs in all models (p < 0.05), indicating that approximately 20% to 30% of the clinical variation observed in these groups was unexplained. Conclusions: Although we cannot establish causality, these findings may suggest that cultural taboos and gender biases likely contribute to unjustified clinical variation, highlighting cultural bias as a plausible explanatory factor.