Search Results (1,093)

Echocardiographic assessment is essential for evaluating patients with cardiogenic shock (CS) and determining their potential need for mechanical circulatory support (MCS) implantation. The use of Impella devices has increased significantly in recent years, paralleling the growing recognition of their hemodynamic benefits in selected patient populations. As the clinical experience with these devices has expanded, the need for a more standardized imaging approach has emerged. Both transthoracic echocardiography (TTE) and transesophageal echocardiography (TEE) play complementary roles in guiding the pre-implantation evaluation, placement procedure, and post-implantation management of Impella devices. Currently, no comprehensive guidelines exist concerning the echocardiographic evaluation of Impella devices throughout their entire clinical course, from initial patient selection and device implantation to ongoing monitoring and eventual weaning. This gap in standardized guidance has led to significant variability in clinical practice across different institutions and healthcare systems. This comprehensive review examines the role of transthoracic echocardiography (TTE) and transesophageal echocardiography (TEE) in managing patients on Impella support across five distinct phases: candidate identification and pre-implantation assessment, intraoperative procedural guidance and device positioning, postoperative monitoring and haemodynamic optimisation, complication detection and troubleshooting, and weaning strategies with post-explantation surveillance. Both left-sided devices (Impella CP, CP Smart Assist, and Impella 5.5) and right-sided support (Impella RP) are covered, including combined configurations with VA-ECMO (ECPella). For each phase, we detail the recommended echocardiographic views, essential measurements and their evidence-based thresholds, signs of device malposition, and practical corrective strategies. A level-of-evidence approach is adopted throughout, specifying whether proposed thresholds derive from randomised trials, observational studies, expert consensus, or manufacturer recommendations. Summary tables and a bedside workflow are provided to facilitate immediate clinical application. Full article

Background: Eye-tracking (ET) devices are gaining attention in technology-based paediatric rehabilitation through their intrinsic ability to assess patients’ engagement and visual attention within motivating, technology-based environments. We conducted a systematic review of available evidence from 2004 to 2025 on the implementation of ET in rehabilitative trainings targeting paediatric populations with neurological and neurodevelopmental disorders. This paper aims to outline the rehabilitative outcomes pursued in the clinical populations considered. Methods: This systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Three electronic databases (PubMed, Web of Science, and Scopus) were consulted to summarise the state of the art of the last 20 years. Selected articles were categorised according to the type of treated disorder and the rehabilitated function. Results: ET devices have been increasingly integrated into paediatric rehabilitation with promising results across multiple neurodevelopmental conditions (e.g., ASD, ADHD, cerebral palsy). These systems have proven effective not only in training gaze control, but also in enhancing executive functions, social cognition, communication, and participation. Furthermore, they promote personalised and data-driven solutions and support high levels of engagement, feasibility, and user satisfaction. Conclusions: ET represents a promising frontier for paediatric rehabilitation, addressing various neurodevelopmental disorders. The gaze-contingent protocols employed have demonstrated potential effects in promoting adaptive behaviour across multiple developmental areas. Further research is warranted to provide shared guidance and to strengthen practice recommendations. Full article

Osteoarthritis (OA) has emerged as a significant public health crisis in Latin America, with prevalence rates in Mexico doubling over the last two decades. Despite this growing burden, current management in underrepresented populations —defined here as groups facing structural barriers to care, including rural or remote communities, uninsured individuals, and socioeconomically disadvantaged groups —is hindered by a critical mismatch between international guidelines and regional healthcare realities. This narrative review, synthesized under the SANRA framework, evaluates the last 20 years of evidence to address the structural and clinical barriers that sustain a 50% diagnostic gap at the primary care level and high rates of inadequate pain relief. Using Mexico as a primary case study, we move beyond conventional symptomatic treatment to explore the complex interplay of central sensitization, neuroinflammation, and metabolic phenotypes, factors often overlooked in standardized protocols. By identifying the limitations of current pharmacological reliance and the underutilization of non-pharmacological interventions, this work proposes a strategic shift toward a multidisciplinary, patient-centered model. We outline a translational roadmap that integrates multi-omic research with personalized therapeutic strategies, emphasizing the need for evidence-based clinical practice guidelines tailored to the socioeconomic and genetic contexts of Latin American patients. Ultimately, this review serves as a call to action to bridge the healthcare disparity gap, offering a framework for innovative, integrative care to transform long-term clinical outcomes in developing healthcare systems. Full article

Classic Kaposi sarcoma (CKS) is a rare vascular neoplasm driven by infection with Kaposi sarcoma-associated herpesvirus (KSHV) and characterized by a heterogeneous geographic distribution. While the etiology of other Kaposi’s sarcoma (KS) variants is well established, the underlying mechanisms of CKS appear multifactorial, with several risk factors, among which advanced age and male sex are most significant. Due to the rarity of CKS and its often indolent clinical course, clinical trials are sparse, and current knowledge of therapeutic approaches remains limited. Most available clinical trials and practice guidelines focus on human immunodeficiency virus (HIV) -related Kaposi sarcoma. Therefore, specific recommendations for the classic form are restricted and rely on a low level of evidence, as categorized by the National Comprehensive Cancer Network (NCCN) Clinical Practice Guidelines, making disease management more challenging. Current approaches to treating CKS include both local and systemic therapies, selected based on disease stage, patient comorbidities, and individual preferences. Systemic treatment options may include immunotherapy, chemotherapy, or antiangiogenic agents. This review summarizes current management strategies and highlights emerging therapeutic approaches for CKS. It aims to support clinicians in optimizing therapeutic decision-making, including the use of novel and investigational therapies. Although several novel therapies are currently under investigation in clinical trials, significant gaps remain. Therefore, further research is needed to improve disease management. Full article

The transition from cash-based transactions to digital wallet usage represents a structural change in the business practices of micro and small enterprises (MSEs) in emerging economies. This study aims to synthesize scientific evidence on digital wallet adoption among microentrepreneurs, analyze the geographical distribution of research, and consolidate key empirical findings, with a specific focus on Asia and Latin America. These regions are of particular interest because they share high levels of economic informality, strong reliance on cash-based transactions, and rapid expansion of digital financial technologies, while also facing institutional, regulatory, and infrastructural constraints that shape technology adoption among microentrepreneurs. A systematic review was conducted following the PRISMA 2020 guidelines. Searches were performed in the Scopus and Web of Science databases, including open access empirical studies published between 2021 and 2025 in English or Spanish. After applying predefined eligibility criteria and removing duplicates, 39 studies were included in the final analysis. The results indicate that most publications originate from Asian countries, particularly India, Indonesia, Malaysia, and Vietnam, whereas Latin America is mainly represented by Colombia and Peru. Across both regions, digital wallet adoption is consistently influenced by trust, perceived security, perceived usefulness, and ease of use, while perceived risk and institutional weaknesses emerge as contextual barriers. Although several primary studies adopt a consumer-level analytical perspective, their findings are extrapolated to microentrepreneur contexts by emphasizing transaction-related behaviors directly linked to business operations. This review acknowledges that the predominance of consumer-focused evidence represents a limitation when interpreting firm-level outcomes. Overall, the findings suggest that digital wallet adoption among microentrepreneurs is a socio-technical process shaped by behavioral, institutional, and regulatory factors rather than technology alone. Full article

Background/Objectives: Opioid-induced constipation (OIC) is a frequent adverse effect of opioid therapy. In contrast to other opioid-related side effects, OIC usually does not improve over time and significantly impairs the quality of life of affected patients. Despite its high prevalence, OIC remains underdiagnosed and undertreated in clinical practice, which has been demonstrated in several European countries. Healthcare data indicates that approximately 2.3 million people in Germany received potentially OIC-inducing opioids in 2023, the majority being patients with chronic non-cancer pain. Methods: An interdisciplinary board of experts in gastroenterology, pain medicine, neurology, oncology, and palliative care developed consensus-based recommendations to improve the diagnosis and management of OIC. Fifteen statements were drafted according to current national German and international guidelines and literature and subsequently discussed. Out of the fifteen statements, twelve statements remained, which achieved consensus with at least 90% agreement. Results: The consensus statements address key aspects of OIC management, including pathophysiology, patient education, diagnosis, prevention, treatment and structured follow-up. Following the statements, a practical treatment algorithm was developed to facilitate clinical implementation. Use of validated tools such as the Bowel Function Index (BFI) for diagnosis and monitoring, early initiation of laxative therapy and timely escalation to mechanism-oriented therapy with peripherally acting μ-opioid receptor antagonists (PAMORAs) in cases of inadequate response have been recommended by the panel. Accordingly, treatment should follow an approach with the following steps: (1) Laxative, (2) switch to PAMORA, (3) rotation of PAMORA, and (4) combination of PAMORA with laxative. In Europe, the PAMORAs methylnaltrexone, naloxegol and naldemedine are approved for the treatment of OIC. Conclusions: This consensus paper provides both evidence-based and practice-oriented recommendations for the systematic management of OIC. By promoting patient education, early recognition, structured evaluation and stepwise treatment escalation, the presented statements and algorithm aim to improve patient outcomes and quality of life under opioid therapy including better adherence to opioid therapy. Full article

Background: Evidence-based medicine (EBM) improves quality by ensuring clinical decisions are based on the latest, most reliable evidence, leading to better patient outcomes, reduced practice variability, and safer care. It fosters continuous learning and the adoption of effective interventions tailored to individual patients. Despite its recognized importance, physicians may encounter cognitive barriers (e.g., limited research literacy), organizational barriers (e.g., workload and time constraints), and resource-related barriers (e.g., limited access to specialized databases) that hinder consistent integration into daily decision-making. Limited data are available regarding EBM implementation in the Aseer Region of Saudi Arabia. Objective: To assess the level of EBM implementation among practicing physicians in Abha, identify perceived barriers, and compare EBM utilization between government teaching hospitals and private hospitals. Methods: This analytical cross-sectional study involved 273 physicians from major government and private hospitals in Abha. Data were collected using a validated 27-item questionnaire covering demographics, daily information-seeking practices, attitudes toward EBM, and perceived barriers. Descriptive statistics, independent-samples t-tests, and Pearson correlation coefficients were employed to evaluate determinants of EBM practice. Results: Most participants were males (71.8%), aged 25–35 years (57.5%), employed in government hospitals (86.4%), and had less than 10 years of experience (68.9%). The median proportion of daily practice based on EBM was 50% (IQR: 10–80). While attitudes toward EBM were strongly positive—particularly regarding its role in improving patient care and work quality—the actual use of high-quality databases (Cochrane, Embase, Web of Science) remained limited. PubMed and clinical guidelines were the most frequently consulted resources. The most commonly reported barriers were limited time and the belief that research findings may not be universally applicable. Positive attitudes showed a moderate correlation with higher EBM use (r = 0.35–0.42, p < 0.001). No significant difference in EBM integration was observed between government and private hospitals (p = 0.511). Conclusions: Physicians in Abha demonstrate positive attitudes toward EBM; however, actual use in clinical practice remains moderate and is hindered by time constraints and perceived challenges in applying research to practice. Enhancing access to evidence resources, improving research literacy, and integrating EBM into daily workflows may promote more consistent use in clinical care. Full article

Background/Objectives: Immune checkpoint inhibitors (ICIs) have revolutionized the treatment of various malignancies, but their use is frequently accompanied by immune-related adverse events, among which immune-mediated colitis (IMC) represents one of the most common and clinically significant gastrointestinal toxicities. IMC may lead to treatment interruption, increased morbidity, and compromised quality of life. This review aims to provide a comprehensive overview of the pathophysiology, risk factors, diagnosis, management, and emerging therapeutic strategies with particular emphasis on the role of the gut microbiota and fecal microbiota transplantation (FMT). Methods: This review integrates current international guidelines, meta-analyses, clinical trials, and recent translational studies addressing IMC. The available evidence on immunological mechanisms, predictive biomarkers, clinical presentation, diagnostic algorithms, and treatment options was critically synthesized to outline a structured and multidisciplinary management approach. Results: IMC is driven by dysregulated immune activation, cytokine release, and alterations in gut microbiota. Incidence and severity vary according to ICI class, combination regimens, tumor type, and patient-related factors. Diagnosis requires exclusion of infectious causes, laboratory assessment, and endoscopic and histologic evaluation with CTCAE-based severity grading. Corticosteroids remain the cornerstone of first-line therapy, while infliximab and vedolizumab are effective in steroid-refractory cases. Emerging therapies, including JAK inhibitors and FMT, have shown promising results in refractory disease. Conclusions: IMC is a complex and potentially severe complication of ICI therapy that necessitates early recognition, accurate grading, and individualized, multidisciplinary management. Severity-guided treatment, timely escalation to biologics, and careful balancing of immunosuppression with antitumor efficacy are essential for optimal outcomes. Future research should focus on biomarker validation, microbiome-targeted therapies, and prospective trials to refine therapeutic algorithms and define the optimal role and timing of FMT in clinical practice. Full article

Background: Malignant pleural effusion (MPE) represents a frequent and clinically challenging manifestation of advanced malignancy, particularly in metastatic non-small cell lung cancer (NSCLC). Its management requires integration of diagnostic imaging, symptom-directed therapeutic strategies, and, increasingly, molecular profiling technologies. Recent advancements in this field based on liquid medium (so-called liquid biopsy) have achieved a significant increase in sensitivity, enhancing our ability to investigate biofluids and suggesting their potential integration into standard diagnostic practices, far beyond the canonical plasma biopsies. Fluid obtained from MPE after cytological sample centrifugation is rich in cell-free DNA and less susceptible to nucleic acid degradation during processing, improving overall diagnostic accuracy. Methods: This narrative review summarizes current evidence on the clinical management of malignant pleural effusions in patients with metastatic NSCLC, integrating imaging, procedural management, and molecular profiling from a multidisciplinary tumor board perspective. The primary objective was to synthesize contemporary knowledge with particular attention to the feasibility, reliability, and reproducibility of pleural fluid-based molecular testing. Results: MPE poses diagnostic and therapeutic challenges for all members of the multidisciplinary tumor board, traditionally associated with an adverse prognosis. However, recent advances in cytopathology, histopathology, and liquid-based techniques demonstrate that MPE could be an important source of prognostic or predictive information. At the same time, optimal patient management requires careful integration of imaging findings and procedural strategies (such as pleurodesis or indwelling pleural catheters) with individualized systemic therapy selection. Cell-free DNA in pleural effusions is a promising field of exploration and study, potentially suitable for future guideline implementation, after validation in adequately powered studies, contributing to improving patient management, particularly useful in fragile subsets. Conclusions: The management of MPE in advanced NSCLC is evolving toward a multidisciplinary, precision-oriented model that integrates clinical evaluation, imaging, procedural interventions, and molecular testing. Liquid biopsy technology has gained enough analytical robustness and clinical feasibility to be a useful tool in routine analysis. Biofluid-based molecular testing may have outstanding potential, contributing to improving patient management, avoiding repetitive procedures, and optimizing the overall efficiency and cost-effectiveness of diagnostic practices. Moreover, collaborative projects among different specialties help in consolidating trust in the tumor board decision-making process. Full article

Peer review is the cornerstone of scholarly publishing and, in medicine, the ultimate guarantor of the reliability of clinical evidence that informs guidelines, therapeutic strategies, and patient care. However, the current peer review system is increasingly strained by bias, abuse, and reviewer overload. Favoritism toward prominent authors, editorial “nepotism,” coercive citation practices, superficial evaluations, and even documented cases of idea theft from confidential manuscripts undermine the trustworthiness of the scientific literature upon which clinical decisions depend. In this paper, we argue that artificial intelligence (AI) and large language models (LLMs) offer a transformative opportunity to strengthen the integrity and efficiency of medical peer review. AI-driven tools can perform rapid consistency checks, detect statistical errors or plagiarism, and enforce compliance with ethical and methodological standards across thousands of manuscripts. Early implementations of AI-guided review platforms, plagiarism detectors, and citation-anomaly algorithms demonstrate that machine assistance can make reviews more thorough, objective, and reproducible. At the same time, we acknowledge the limitations of AI, including hallucinations, a lack of human judgment, and risks to confidentiality if misused. To address these concerns, we propose a hybrid model in which AI handles routine screening and technical tasks under strict safeguards, while human experts retain final responsibility for scientific evaluation. This human–AI partnership may represent an essential step toward improving the quality, fairness, and reliability of the clinical evidence base. Full article

Background/Objectives: Retrospective projects including audits and observational research advance the practice of emergency medicine but face methodological challenges affecting data quality. This guideline presents an 11-step framework to guide the conduct of high-quality retrospective projects, minimizing bias and enhancing reproducibility for clinicians. Methods: The stepped approach mirrors the standard sections of a study protocol but reframes them as guiding questions to make each section’s content and purpose more practical, intuitive, and clear for users. Conclusions: This framework equips clinicians with a practical entry point to retrospective study design, distilling methodological nuances and strategies to bridge theory and application. Systematic adherence promotes rigor, reduces bias, and elevates retrospective chart review from a convenient tool to a robust method for evaluating practice patterns, interventions, and quality improvement in emergency care. Implementation also fosters a culture of evidence-based inquiry essential to advancing emergency medicine. Full article

This study assesses the extent to which an AI-driven circular waste management tool, previously developed by the same authors as a decision-support system for the circular management of healthcare waste in compliance with international guidelines, reflects the operational needs and perceived priorities of healthcare professionals and environmental managers. Within a context characterised by high regulatory complexity and increasing pressure toward more sustainable management models, the research adopts a qualitative approach based on the thematic analysis of 11 semi-structured interviews, followed by a systematic mapping of the emergent themes onto the tool’s thematic areas, indicators, and operational actions. The results demonstrate a high degree of alignment between the tool and operational practice, with 93% of the tool’s actions supported by empirical evidence and the emergence of a shared core cluster focused on hard-to-manage waste streams, mandatory training, and day-to-day operational challenges. The alignment between the priorities expressed by interviewees and the importance scores generated by the computational model is high for actions of greater relevance, while it decreases for less frequent actions that are more context-dependent. Circular economy practices are recognised as relevant but remain predominantly positioned at a strategic rather than an operational level. Overall, the study confirms the conceptual robustness of the tool and identifies its main limitations and the conditions required for its integration into hospital workflows. Full article

Background and Objectives: Ureteral access sheaths (UASs) are widely used in retrograde intrarenal surgery (RIRS) to facilitate irrigation and instrument access. Recently, flexible and navigable suction UASs (FANS-UASs) have been developed to enhance visibility and stone fragment evacuation; however, their comparative effectiveness remains uncertain. This study aimed to evaluate the clinical outcomes of FANS-UAS versus conventional UAS during RIRS for renal stones. Materials and Methods: A systematic review and meta-analysis were performed following PRISMA guidelines. PubMed, Embase, and the Cochrane Library were searched through May 2025 for comparative studies of FANS-UAS and conventional UAS. Study quality was assessed using the Scottish Intercollegiate Guidelines Network checklist. Primary outcomes included stone-free rate (SFR), operative time, complications, and hospital stay. Subgroup analyses were conducted according to stone size (≤2 cm vs. >2 cm). Results: Nine studies involving 1791 patients were included. FANS-UAS demonstrated a significantly higher SFR (OR = 5.99, 95% CI: 2.86–12.51; I² = 86.7%) and fewer complications (OR = 0.33, 95% CI: 0.23–0.45; I² = 0%). Operative time and hospital stay did not differ significantly between groups. Subgroup analysis showed no significant SFR difference for stones ≤2 cm, whereas for stones >2 cm, FANS-UAS tended to yield higher SFR—though based on limited evidence. Conclusions: FANS-UASs appear to improve stone clearance and reduce perioperative complications in RIRS without increasing operative burden. While further high-quality randomized trials are needed, current evidence supports the growing adoption of FANS-UAS in endourological practice. Full article

Background/Objectives: Myocardial injury after non-cardiac surgery (MINS) is a common and serious postoperative complication. Its largely asymptomatic course hampers early recognition, highlighting the importance of systematic biomarker monitoring. The aim of this review is to summarize current evidence on the diagnosis, risk factors, and management of MINS, with a focus on otolaryngology, where intraoperative hypotensive techniques may increase risk. Methods: A basic science review was conducted using PubMed, Embase, and the Cochrane Library (2005–2025). From 2712 records, 30 studies met the inclusion criteria after removing duplicates, screening titles/abstracts, and full-text assessment. These studies formed the basis for the final analysis. Results: Observational studies and reviews identify perioperative troponin monitoring as the diagnostic gold standard. However, no evidence-based management guidelines exist, and otorhinolaryngology-specific data remain rare but not entirely absent. Troponin elevation in the early postoperative period reliably predicts adverse outcomes. While MINS is well documented in vascular and orthopedic surgery, evidence in otolaryngology is limited. Controlled hypotension in procedures such as functional endoscopic sinus surgery or head and neck tumor resection may further elevate risk. Conclusions: MINS is an underrecognized complication with major prognostic significance. The lack of standardized management and the absence of large otolaryngology cohorts underscore an urgent need for targeted research and specialty-specific guidelines and support the justification for integrating existing evidence into otolaryngologic practice. Full article

Background: Dental anxiety remains a prevalent and persistent challenge in pediatric dentistry, significantly affecting children’s cooperation, treatment outcomes, and long-term oral health behaviors. Despite advances in minimally invasive care, anxiety continues to act as a barrier to effective clinical management. This narrative review aims to synthesize current evidence on validated assessment tools for pediatric dental anxiety and to examine contemporary non-pharmacological management strategies applicable in routine clinical practice. Methods: A structured literature search was conducted in major electronic databases to identify relevant studies, systematic reviews, and clinical guidelines addressing dental anxiety assessment and behavioral management in children. Particular emphasis was placed on validated anxiety scales, communication strategies, environmental adaptations, and emerging digital interventions such as immersive distraction technologies. Results: Multiple validated instruments are available to assess pediatric dental anxiety; however, their applicability varies by age, cognitive development, and clinical context. Non-pharmacological approaches including tell–show–do, modeling, parental guidance, audiovisual distraction, and virtual reality-based techniques demonstrate consistent effectiveness in reducing anxiety and improving behavioral cooperation. Recent trends emphasize multimodal, patient-centered strategies integrating communication, environmental modification, and digital tools. Conclusions: Structured anxiety assessment combined with contemporary multimodal management strategies can enhance clinical efficiency, improve child cooperation, and promote positive dental experiences. The integration of emerging digital technologies represents a promising advancement in pediatric anxiety management and supports a more individualized approach to care. Furthermore, a structured multimodal clinical framework is proposed to facilitate chairside decision-making and practical implementation. Full article