Search Results (550)

Background: Dietary advice for Paralympic athletes (PAs) with a spinal cord injury (PAs-SCI) requires particular attention and has been widely studied. However, currently, no particular attention has been addressed to nutritional guidelines for athletes with an amputation (PAs-AMP). This study aimed at filling up this gap, at least partially, and compared veteran PAs-SCI with PAs-AMP. Methods: A sample of 25 male PAs (12 with SCI and 13 with AMP), recruited during two training camps, was submitted to the following questionnaires: allergy questionnaire for athletes (AQUA), Nordic Musculoskeletal Questionnaire (NMQ), Starvation Symptom Inventory (SSI), neurogenic bowel dysfunction (NBD), orthorexia (ORTO-15/ORTO-7), alcohol use disorders identification test (AUDIT), and Mediterranean diet adherence (MDS). The PAs were also submitted to the following measurements: dietary Oxygen Radical Absorbance Capacity (ORAC) and intakes, body composition, handgrip strength (HGS), basal energy expenditure (BEE), peak oxygen uptake (VO_2peak), peak power, peak heart rate (HR), post-exercise ketosis, and antioxidant response after a cardiopulmonary exercise test (CPET) to voluntary fatigue. Results: Compared to PAs-AMP, PAs-SCI had higher NBD and lower VO_2peak (p < 0.05), peak power, peak HR, peak lactate, phase angle (PhA) of the dominant leg (p < 0.05), and ORTO15 (p < 0.05). The latter was related to NBD (r = −0.453), MDS (r = −0.638), and ORAC (r = −0.529), whereas ORTO7 correlated with PhA of the dominant leg (r = 0.485). Significant differences between PAs-AMP and PAs-SCI were not found in the antioxidant response, glucose, and ketone levels after CPET, nor in dietary intake, AUDIT, AQUA, NMQ, SSI, BEE, HGS, and FM%. Conclusions: The present study showed that PAs-SCI and PAs-AMP display similar characteristics in relation to lifestyle, energy intake, basal energy expenditure, and metabolic response to CPET. Based on both the similarities with PAs-SCI and the consequences of the limb deficiency impairment, PAs-AMP and PAs-SCI require personalized nutritional advice. Full article

Background: Blood pressure (BP) variability has been increasingly recognized as a predictor of cardiovascular and renal outcomes. However, the relevance of specific dynamic indices such as the maximum slope of systolic blood pressure (max SBP slope), derived through partial Fourier series modeling, in relation to early renal damage remains underexplored. Methods: A total of 389 patients with essential hypertension were enrolled and stratified according to the estimated glomerular filtration rate (eGFR) ≥ or <90 mL/min/1.73 m² and the presence of subclinical renal damage, defined by elevated urinary albumin excretion (AER) and/or reduced eGFR. All participants underwent clinical and biochemical evaluation, as well as 24-h ambulatory blood pressure monitoring (ABPM), including advanced hemodynamic analysis using Fourier-based modeling. Results: Patients with eGFR < 90 mL/min/1.73 m² were older and exhibited higher waist circumference, uricemia, albuminuria, and systolic BP values, including the elevated max SBP slope (12.8 vs. 10.8 mmHg/h, p = 0.028). Subclinical renal damage was associated with older age; male sex; smoking; and higher levels of uricemia, clinical, and ambulatory BP, and the max SBP slope (14.2 vs. 10.7 mmHg/h, p = 0.007). The max SBP slope positively correlated with AER (r = 0.215, p < 0.001) and inversely with eGFR (r = −0.153, p = 0.002). In multivariate linear regression, the max SBP slope remained independently associated with AER (β = 0.220, p < 0.001), along with mean 24-h SBP, male sex, and the day–night SBP percentage dip. Logistic regression confirmed these associations with subclinical renal damage (max SBP slope OR: 1.536; 95% CI: 1.241–2.004; p = 0.001). Conclusions: The max SBP slope, a dynamic index of BP derived via Fourier analysis, is independently associated with markers of subclinical renal damage in hypertensive patients. This suggests that incorporating such advanced metrics into ABPM evaluation may improve early risk stratification and help identify individuals at greater risk of renal impairment, even in the absence of overt kidney disease. Full article

Background: The central variant of posterior reversible encephalopathy syndrome (cvPRES) is an atypical subtype of PRES. Although no unifying definitions exists, it is most often characterized by vasogenic edema involving “central” structures, such as the brainstem, subcortical nuclei, and spinal cord, with relative sparing of the parieto-occipital lobes. Methods: This systematic review and meta-analysis followed the PRISMA guidelines and was pre-registered on PROSPERO [CRD42023483806]. Both the Joanna Briggs Institute and New-Castle Ottawa scale were used for case reports and cohort studies, respectively. The meta-analysis was completed using R-Studio and its associated “metafor” package. Results: A comprehensive search in four databases yielded 70 case reports/series (n = 100) and 12 cohort studies. The meta-analysis revealed a pooled incidence rate of 13% (95% CI: 9–18%) for cvPRES amongst included cohort studies on PRES. Significant heterogeneity was observed (I² = 71% and a τ² = 0.2046). The average age of affected individuals was 40.9 years, with a slightly higher prevalence in males (54%). The most common etiological factor was hypertension (72%). Fifty percent had an SBP >200 mmHg at presentation and a mean arterial pressure (MAP) of 217.6 ± 40.82. Imaging revealed an increased T₂ signal involving the brain stem (88%), most often in the pons (62/88; 70.45%), and 18/100 (18%) cases of PRES with spinal cord involvement (PRES-SCI). Management primarily involved blood pressure reduction, with adjunctive therapies for underlying causes such as anti-seizure medications or hemodialysis. The MAP between isolated PRES-SCI and cvPRES without spinal cord involvement did not show significant differences (p = 0.5205). Favorable outcomes were observed in most cases, with a mortality rate of only 2%. Conclusions: cvPRES is most often associated with higher blood pressure compared to prior studies with typical PRES. The pons is most often involved. Despite the severity of blood pressure and critical brain stem involvement, those with cvPRES have favorable functional outcomes and a lower mortality rate than typical PRES, likely attributable to reversible vasogenic edema without significant neuronal dysfunction. Full article

Mercury is a highly toxic heavy metal that poses serious threats to human health and environmental safety, highlighting the critical importance of accurate Hg²⁺ detection. In this study, a novel fluorescent probe AP was synthesized by conjugating fluorescein, serving as the luminescent group, with pyridine-2-carboxaldehyde to enable selective Hg²⁺ detection. Hg²⁺ binds to AP in a 1:2 stoichiometric ratio, inducing the opening of the spiro-lactam ring and resulting in a significant fluorescence enhancement. The probe exhibited excellent selectivity and sensitivity toward Hg²⁺. A strong linear correlation was observed between its fluorescence intensity and Hg²⁺ concentration (R² = 0.99952), with a detection limit of as low as 9.75 × 10⁻⁸ mol/L. The average recoveries of Hg²⁺ across various water matrices ranged from 95.23% to 103.40%, with relative standard deviations (RSDs) below 3.07%. These results indicate that the probe performs effectively in real water-sample testing. Full article

Objectives: The objective of this study was to evaluate the agreement and clinical interchangeability of intraocular pressure (IOP) measurements obtained with the mechanical Haag-Streit AT900 Goldmann applanation tonometer (mGAT) and the digital Huvitz HT5000 applanation tonometer (dGAT). Methods: This retrospective comparative study included 53 eyes of 28 patients undergoing routine ophthalmologic evaluation. Each eye underwent IOP measurement using both mGAT and dGAT in a randomized sequence. Central corneal thickness (CCT) was also recorded. Pearson’s correlation coefficient was used to determine correlation between paired IOP measurements. Bland–Altman plots were graphed for the analysis of differences for IOP between the instruments. Results: A total of 53 eyes of 28 patients (15 males) were included in the study. The mean age of the patients was 62.6 years. The mean mGAT and dGAT measurements were 16.3 ± 6.6 mmHg (range 9–50) and 16.4 ± 6.2 mmHg (range 8.8–45.9), respectively (p = 0.53). A strong, significant positive correlation was found for paired IOP measurements by the two instruments (r = 0.98; p < 0.0001). Bland–Altman analysis revealed 95% limits of agreement from −2.5 to +2.3 mmHg, with a small but statistically significant proportional bias favoring mGAT at higher IOP levels. Additionally, 91% of paired measurements were within ±2 mmHg. CCT-related differences were statistically and clinically insignificant. Conclusions: IOP measurements obtained with mGAT and dGAT were highly correlated and clinically interchangeable for the range tested. The Huvitz HT5000 may serve as a reliable alternative to the classic Goldmann tonometer in routine clinical settings. Full article

A novel single-walled carbon nanotube (SWNT), silver (Ag) nanoparticle, and zinc benzene carboxylate (ZnBDC) metal–organic framework (MOF) composite was synthesised and systematically characterised to develop an efficient platform for mercury ion (Hg²⁺) detection. X-ray diffraction confirmed the successful incorporation of Ag nanoparticles and SWNTs without disrupting the crystalline structure of ZnBDC. Meanwhile, field-emission scanning electron microscopy and energy-dispersive spectroscopy mapping revealed a uniform elemental distribution. Thermogravimetric analysis indicated enhanced thermal stability. Electrochemical measurements (cyclic voltammetry and electrochemical impedance spectroscopy) demonstrated improved charge transfer properties. Electrochemical sensing investigations using differential pulse voltammetry revealed that the SWNTs/Ag@ZnBDC-modified glassy carbon electrode exhibited high selectivity toward Hg²⁺ ions over other metal ions (Cd²⁺, Co²⁺, Cr³⁺, Fe³⁺, and Zn²⁺), with optimal performance at pH 4. The sensor displayed a linear response in the concentration range of 0.1–1.0 nM (R² = 0.9908), with a calculated limit of detection of 0.102 nM, slightly close to the lowest tested point, confirming its high sensitivity for ultra-trace Hg²⁺ detection. The outstanding sensitivity, selectivity, and reproducibility underscore the potential of SWNTs/Ag@ZnBDC as a promising electrochemical platform for detecting trace levels of Hg2+ in environmental monitoring. Full article

Background and Objectives: Low-pressure pneumoperitoneum (PP) during robot-assisted radical prostatectomy (RARP) has been shown to improve postoperative recovery in patients with non-obesity. However, its efficacy in individuals with obesity remains unclear. This study aimed to evaluate postoperative outcomes in patients with obesity undergoing RARP with low-pressure (7 mmHg) versus standard-pressure (12 mmHg) PP. Materials and Methods: In this retrospective cohort study, 130 patients with obesity (BMI > 30 kg/m²) undergoing RARP were divided into low-pressure (n = 60) and standard-pressure (n = 70) groups. Postoperative recovery was assessed using the Quality of Recovery-15 (QoR-15) questionnaire on postoperative days (POD) 1, 3, and 30. Secondary outcomes included surgical workspace (SWS) scores, operative time, blood loss, intraoperative and postoperative complications, hospital stay, and pathological results. ANCOVA and chi-square tests were used for analysis. Results: QoR-15 scores were significantly higher in the low-pressure group on POD1 (123.58 vs. 111.41), POD3 (128.37 vs. 116.41), and POD30 (132.88 vs. 125.61; p < 0.001). Operative time (98.5 vs. 71.57 min; p < 0.001) and blood loss (129 vs. 97.07 mL; p = 0.039) were higher in the low-pressure group. SWS scores were lower in the low-pressure group (p < 0.001). There were no significant differences between groups in complication rates, hospital stay, or positive surgical margins. Conclusions: In patients with obesity undergoing RARP, low-pressure PP improves postoperative recovery without increasing complications. Despite longer operative times and higher blood loss, this approach is a viable option to enhance recovery in this population. Full article

Background: An acute angle-closure attack (AAC) is an ocular emergency that results from a rapid increase in intraocular pressure (IOP). Sustained IOP elevation induces severe degeneration of retinal ganglion cells (RGCs) without treatment. Overactivated microglia, key participants in innate immune responses, have critical roles in the pathogenesis of IOP-induced RGC death, although precise mechanisms remain unclear. In the present study, we used a rat ex vivo acute glaucoma model to investigate the role of microglial signaling in RGC death and examined whether pharmacological depletion of microglia using a CSF-1R inhibitor, PLX5622, exerts neuroprotection against pressure-induced retinal injury. Methods: Ex vivo rat retinas were exposed to hydrostatic pressure (10 mmHg or 75 mmHg) for 24 h. Pressure-dependent changes in retinal microglia and RGCs were detected by immunofluorescence. Morphological changes in the retina and RGC apoptosis were examined using light microscopy and TUNEL staining, respectively. The expression of NLRP3, active caspase-1, pro IL-1β, and IL-1β were examined using Western blotting. Effects of PLX5622, an agent that depletes microglia, were examined in morphology, apoptosis, and protein expression assays, while TAK-242, a TLR4 inhibitor, was examined against protein expression. Results: Pressure loading at 75 mmHg markedly increased activated microglia and apoptotic RGCs in the isolated retinas. Western blotting revealed increases in expression of NLRP3, active caspase-1, pro IL-1β, and IL-1β at 75 mmHg compared to 10 mmHg. Inhibition of pressure-induced increases in NLRP3 by TAK-242 indicates that pressure elevation induces RGC death via activation of the TLR4–NLRP3 inflammasome cascade. PLX5622 depleted microglia at 75 mmHg and significantly decreased expression of NLRP3, active caspase-1, pro IL-1β, and IL-1β at 75 mmHg, resulting in preservation of RGCs. Conclusions: These results indicate that pressure elevation induces proliferation of inflammatory microglia and promotes IL-1β production via activation of the TLR4–NLRP3 inflammasome cascade, resulting in RGC death. Pharmacological depletion of microglia with PLX5622 could be a potential neuroprotective approach to preserve RGCs from inflammatory cytokines in AAC eyes. Full article

Background: Intra-aortic balloon pump (IABP) augments coronary perfusion during high-risk percutaneous coronary interventions (PCI). We sought to identify patients who benefited from prophylactic IABP (P-IABP) compared to rescue-IABP (R-IABP). Methods: All consecutive non-cardiogenic shock patients undergoing high-risk PCI with IABP support at Ulm University Hospital, Germany, between 2012 and 2020 were grouped based on the timing of IABP insertion in the pre-interventional P-IABP or peri-interventional R-IABP group. We compared the primary endpoint peri-interventional high-sensitivity Troponin T (hsTnT) increase, sought baseline characteristics associated with the endpoint in the R-IABP group, and compared their correlation strengths between the groups. Results: Interventional outcomes of 44 patients with P-IABP implantation were compared with those of 15 patients with R-IABP implantation. P-IABP was associated with a lower peri-interventional hsTnT increase (p = 0.008, r = 0.390). In the R-IABP group, the presence of ST-segment elevation (p = 0.037, r = 0.631), low systolic blood pressure (RRsyst) (p = 0.007, r = 0.893 (inverse correlation)), and elevated NT-proBNP levels (p < 0.001, r = 0.953) were associated with higher hsTnT increases. HsTnT increase was significantly smaller in the P-IABP group in patients with low RRsyst (IZI = 2.6) and high NT-proBNP levels (IZI = 3.36). Patients with RRsyst < 120 mmHg (p = 0.007) and NT-proBNP levels ≥ 900 pg/mL (Cohen’s d = 0.70, respectively 1.17 for ≥5000 pg/mL and 5.01 for ≥10,000 pg/mL) showed lower peri-interventional hsTnT increase when treated with P-IABP compared to R-IABP, while patients with NT-proBNP levels < 900 pg/mL showed a contrary effect (Cohen’s d = −0.90). Cox regression analysis showed that a high peri-interventional hsTnT increase was significantly associated with a shorter survival time (p = 0.046). Conclusions: P-IABP use in high-risk PCI was associated with reduced peri-interventional myocardial injury, as measured by lower hsTnT increase, which was associated with improved survival in patients with low systolic blood pressure and elevated NT-proBNP levels. Thus, these conditions should be considered for indicating P-IABP. Full article

Glaciers are significant sources of fresh water on planet Earth. The Hindukush–Karakoram–Himalayan (HKH) glaciers provide the water supply to more than half of the human population of the globe, for agricultural activities, biodiversity survival, and ecosystem services. In recent years, the loss of glacial ice has been forecasted to cause problems such as sea level rise, changes in water availability, and release of contaminants that reside in the surfaces of glaciers or within them. In this regard, mineralogical sediments play a significant role in the geochemistry of glaciers and element cycling. This study analyzed elemental pollutants found in the glaciers of Pakistan and investigated the diverse bacterial communities residing therein. Samples of ice and sediments were collected from the Gilgit, Hunza, and Swat glaciers in northern Pakistan. Nine elements, including co-factors, heavy metals, and nutrients, were assessed using atomic absorption spectrophotometry. The research findings indicate higher concentrations of the elements K, Fe, Cu, and Cr in Hunza glacier ice (Hgi) and Ni, Zn, As, and Cd in Gilgit glacier ice (Ggi). In terms of glacier sediments, Swat (Sgs), Gilgit (Ggs), and Hunza (Hgs) samples showed the highest concentrations of K, Cu, Ni, Zn, As, Pb, Cd, and, respectively, of Fe, and Cr. The amount of Cu and Cr is the same in Swat glacier ice and Swat glacier foot. However, the concentration of some elements (As, K, Pb, Zn) is higher in Swat glacier ice, while the amount of some elements (Cd, Ni) is greater in Swat glacier foot. Furthermore, microbial cultivation techniques revealed diverse bacterial communities inhabiting the sampled glaciers. Phylogenetic analysis of the bacterial isolates, based on 16S rRNA gene sequences, showed high homology (99–100%) with previously reported species. The resultant phylogenetic tree grouped the bacterial isolates, such as Serratia marcescens, Cupriavidus sp., and Bacillus cereus, with closely related species known for their roles in nutrient cycling, environmental resilience, and metal tolerance. These findings highlight the ecological significance and adaptive potential of microbial communities in glacier environments, emphasizing their role in elemental cycling and environmental resilience. Full article

Background: The venous-to-arterial difference in partial pressure of carbon dioxide (CO₂ gap) has been suggested as a marker of cardiac output and clinical outcomes. This study aimed to evaluate the CO₂ gap as a prognostic indicator for 28-day survival in patients undergoing transcatheter aortic valve replacement (TAVR) and to explore its relationship with cardiac function and lactate levels. Methods: In this prospective cohort study, 50 TAVR patients were stratified based on their left ventricular ejection fraction (LV-EF) and survival status. Central venous and arterial blood samples were collected at five time points to measure blood gas parameters. The primary endpoint was the prognostic value of the CO₂ gap for 28-day survival. Secondary endpoints included group differences in the CO₂ gap, its correlation with lactate levels, and CO₂ content analysis. Results: ROC analysis indicated limited prognostic value for 28-day survival. The CO₂ gap was higher in non-survivors than in survivors (11.1 mmHg vs. 6.8 mmHg, p = 0.039), but showed no significant difference between individual time points. The CO₂ gap between cardiac (LV-EF $\le$ 50%) and non-cardiac (LV-EF > 50%) groups showed no significant difference. Lactate and CO₂ gap showed no correlation, except at T2 in the cardiac group (p = 0.039, r = 0.525). CO₂ content showed no significance, except at T5, where it was significantly higher in survivors (5.3 mL/dL vs. 1.1 mL/dL, p = 0.003). Conclusions: The CO₂ gap did not emerge as a reliable prognostic marker for 28-day survival in TAVR patients. Further studies are needed to explore its clinical relevance. Full article

In this study, kaolinite-based clay (Ka-Clay) was used as an adsorbent for the efficient removal of Pb(II), Cd(II) and Hg(II) ions from aqueous media. The selection of Pb(II), Cd(II) and Hg(II) ions for experimental studies took into account their high toxicity, while the choice of Ka-Clay, the ease of preparation and high availability of this material were the most important arguments. Ka-Clay exhibits high adsorption performance, with removal percents over 98% for Pb(II) and 93% for Cd(II), even at high concentrations of metal ions (over 150 mg/L, pH = 6.5, 4 g adsorbent/L, 21 ± 1 °C). For Hg(II) ions, the adsorption percent does not exceed 55%, and this moderate value is mainly due to the significant change in pH. The adsorption behavior was in accordance with the Langmuir model (R² > 0.95) and the pseudo-second order kinetic model (R² > 0.99), indicating an adsorption process that occurs mainly through chemical interactions at the adsorbent surface between the metal ions and the functional groups. Adsorption processes are spontaneous (ΔG = −8.66 ÷ −15.76 kJ/mol) and endothermic (ΔH = 7.09 ÷ 21.81 kJ/mol), and the adsorption mechanism is the results of elementary processes of electrostatic attraction, ion exchange and superficial complexation. The insignificant effect of other ions (Ca(II), Mg(II), Na(I), K(I)) present in real wastewater samples as well as the desorption behavior of exhausted adsorbent highlight the practical utility of this adsorbent on a large scale. The experimental results included in this study suggest that Ka-Clay can be used as a promising adsorbent for the removal of high concentrations of toxic heavy metals with low cost and high efficiency, and this can contribute to the design of a sustainable wastewater treatment method. Full article

Background: Left ventricular filling pressure (LVFP) is pivotal in heart failure management, yet non-invasive assessment remains challenging. While echocardiography is the first line, cardiovascular magnetic resonance (CMR) offers enhanced accuracy. This study evaluates the interplay between CMR-derived LVFP and echocardiography, focusing on sex differences and correlations with N-terminal pro-brain natriuretic peptide (NT-proBNP). Methods: In this prospective study, 222 patients with CMR-derived LVFP > 14 mmHg underwent transthoracic echocardiography (TTE) and CMR. Sex-specific CMR equations (incorporating left atrial volume and ventricular mass) were used to estimate pulmonary capillary wedge pressure (PCWP). Correlations between imaging parameters and NT-proBNP were assessed. Results: CMR-derived LVFP showed no sex-based differences (p = 0.3143), unlike echocardiographic indices: women had higher E/e′ (p < 0.0001) and lower lateral mitral annular velocities (p = 0.0159). CMR-derived LVFP correlated strongly with NT-proBNP (r = 0.47, p < 0.0001), outperforming E/e′ (r = 0.41). Stratification by CMR PCWP tertiles revealed higher NT-proBNP (p = 0.0003), left atrial volumes (p < 0.0001), and septal thickness (p < 0.0001) in the highest tertiles. CMR-derived LVFP demonstrated superior diagnostic accuracy (AUC = 0.754 vs. 0.740 for E/e′) in identifying elevated NT-proBNP (>400 pg/mL). Sex-independent CMR measures contrasted with echocardiography, where parameters like left atrial volume varied by sex (p = 0.012). Conclusions: CMR-derived LVFP is a robust, sex-independent biomarker strongly linked to NT-proBNP, offering superior diagnostic performance over echocardiography. Its integration with echocardiographic indices enhances the non-invasive assessment of cardiac filling pressures, advocating a synergistic imaging approach to refine heart failure management. Full article

This study investigated the distribution and source of heavy metals and dispersed elements in the high-salinity brine of Qarhan Salt Lake. The brine with an average total dissolved solid content of 332.22 g/L, dominated by Cl⁻ (216.41 g/L) and Mg²⁺ (44.76 g/L), indicated strong evaporation and dolomite dissolution. As (6.57 ± 3.59 μg/L) and Hg (0.48 ± 0.14 μg/L) showed uniform distribution while Li (69.66 mg/L), B₂O₃ (317.80 mg/L), and Zn (5.69 mg/L) were highly enriched, highlighting the resource potential and geochemical complexity. Correlation analysis revealed that water–rock interaction played a key role in element differentiation, with Sr and Ca²⁺/Cl⁻ showing strong positive correlations (r = 0.693/0.768), reflecting isomorphic substitution and dissolution. Meanwhile, Na⁺ and Mg²⁺/Ca²⁺ showed negative correlations (r = −0.732/−0.889), suggesting cation exchange and gypsum precipitation. The self-organizing map yielded four clusters of elements and positive matrix factorization model identified four sources; the elements in the Salt Lake brine mainly came from the river water supply, weathering and leaching of minerals, and dissolution of salt-bearing layers and were locally influenced by human activities. The research provided valuable insights for future sustainable development and the environmental protection of the region. Full article

Background and Objectives: Negative-pressure wound therapy (NPWT) expedites tissue repair, yet functional recovery depends on adjunct rehabilitation. Evidence from high-resource settings is difficult to translate to Romanian county hospitals, where advanced devices are scarce. The objective of this study is to determine whether two tiers of low-technology, therapist-delivered exercise improve mobility, oedema resolution, pain and quality-of-life (QoL) beyond NPWT alone in adults with acute lower-limb wounds. Methods: A single-centre, prospective observational study (January 2021–June 2024) enrolled 92 patients and randomised them unevenly into: Group A, NPWT only (n = 39); Group B, NPWT + routine physiotherapy (n = 33); Group C, NPWT + enhanced manual programme (n = 20). All received −125 mmHg continuous suction; rehabilitation started 48 h post-operation. Primary outcomes were ankle dorsiflexion and knee flexion at 12 weeks. Secondary outcomes included calf circumference, ultrasound oedema depth, Manual Muscle Testing (MMT), pain (VAS), analgesic use and SF-36 domains through 24 weeks. Results: Baseline characteristics were similar (p > 0.40). At 12 weeks dorsiflexion reached 20.1 ± 1.8° in Group C, surpassing Group B (18.4 ± 2.1°; p = 0.004) and Group A (16.0 ± 2.3°; p < 0.001). Knee flexion followed the same gradient (140.8 ± 3.2°, 137.6 ± 3.4°, 133.4 ± 3.8° respectively). Oedema depth fell fastest in Group C (0.4 ± 0.2 mm by day 42) versus B (0.6 ± 0.2 mm) and A (0.8 ± 0.3 mm). Week-12 MMT grade ≥ 4.5 was attained by 95% of Group C, 85% of B and 72% of A (χ² = 10.9, p = 0.004). VAS pain fell more steeply with each rehabilitation layer, paralleled by a stepwise decline in daily tramadol. All SF-36 domains were highest in Group C at 24 weeks (Physical Function 88.7 ± 4.8 vs. 85.1 ± 5.4 vs. 78.2 ± 5.9; p < 0.001). Mobility correlated positively with QoL (r = 0.66) and inversely with pain and oedema. Conclusions: In a resource-constrained Romanian setting, adding structured manual physiotherapy to NPWT produced meaningful functional and patient-centred gains, while an “enhanced” programme incorporating daily PNF and elastic-band strengthening delivered the largest observed benefit. These findings justify prioritising therapist-led interventions even where sophisticated equipment is unavailable. Full article