Search Results (2,077)

Background and Objectives: Surface electromyography (EMG) is widely used to assess muscle activation. However, direct interpretation of its functional biomechanical consequences remains challenging. This study aimed to develop and evaluate an EMG-driven musculoskeletal simulation framework for investigating how controlled modifications of muscle activation patterns influence joint-level biomechanics in the upper limb. The objective was not to reproduce specific clinical pathologies but to enable systematic virtual scenario analysis of activation-dependent movement alterations. Materials and Methods: Surface EMG signals were recorded from five healthy adults (3 males, 2 females; age 22 ± 1 years) during cyclic elbow flexion/extension tasks using a wireless system (sampling frequency: 2000 Hz). Processed and normalized EMG envelopes were directly applied as prescribed neural inputs in forward dynamic simulations implemented in OpenSim, without optimization-based muscle recruitment. Controlled virtual scenarios were generated through parametric modification of activation signals to represent reduced activation capacity, increased antagonist co-activation, spasticity-like activation modulation, and tremor-like oscillatory modulation. Joint kinematics, joint moments, and movement stability were evaluated. A Movement Quality Index (MQI) was introduced as a comparative research metric integrating biomechanical performance indicators. Simulations were deterministic and analyzed descriptively. Results: Distinct activation modifications produced characteristic kinematic and kinetic responses. Reduced activation capacity decreased simulated joint moment output, increased co-activation altered joint moment timing and mechanical stability, and tremor-like oscillatory modulation generated periodic fluctuations in joint kinematics and kinetics. The MQI enabled quantitative differentiation between simulated scenarios and severity levels within the controlled modelling framework. Conclusions: The proposed EMG-driven forward dynamic simulation framework provides a methodological platform for controlled virtual scenario analysis of activation-dependent biomechanical changes. The findings highlight the sensitivity of joint-level mechanics to altered muscle activation patterns, within the deterministic modelling environment. The framework is intended for research-oriented biomechanical investigation and hypothesis testing rather than direct clinical diagnosis of neuromuscular disorders. Full article

This study aimed to identify structural relationships between sports participation patterns and injury risk factors among older adults using data mining techniques, addressing limitations of prior descriptive research. Data from the 2024 Sports Safety Accident Survey were analyzed, including 352 adults aged 65 years and older. Eight key variables related to participation and injury were examined using association rule analysis with the Apriori algorithm. High-risk injury patterns were associated with irregular participation in non-sport-specific locations during late-night hours and with excessive movement during prolonged, daily participation, particularly in the morning. Injuries most frequently affected major joints of the upper and lower limbs. Sports injuries in older adults arise from complex interactions among temporal, environmental, and behavioral factors. These findings support the development of targeted safety guidelines and injury prevention strategies tailored to participation patterns in the aging population. Full article

Human locomotion relies on a proximal–distal organization of joint mechanical work that adapts to task constraints, such as those imposed by inclined walking. In individuals with transtibial amputation, loss of the biological ankle disrupts this organization, leading to proximal alterations and inter-limb asymmetries. Active mechatronic prosthetic feet have been developed within a biomechanical biomimicry framework to restore distal positive mechanical work. This exploratory study quantified the effects of an active mechatronic prosthetic foot on joint mechanical work during inclined walking. Four individuals with transtibial amputation performed instrumented treadmill walking at −3°, 0°, and +3° using their habitual passive foot and a powered foot. Positive and negative mechanical work at the ankle, knee, and hip were computed using inverse dynamics and compared with a normative reference database (n = 20). The powered foot induced modest, task-dependent modifications, mainly at the ankle and knee. In downhill walking, it promoted a more symmetrical redistribution of negative mechanical work, particularly at the knee, suggesting a partial reduction in contralateral overload. In uphill walking, distal assistance increased prosthetic-side positive work, reflecting slope-dependent reallocation rather than normalization. Although a multivariate deviation score indicated reduced deviation under the powered condition, full convergence toward the asymptomatic organization was not achieved. Full article

The paper systematically reviews the application status of virtual reality technology in the rehabilitation of upper-limb movement, lower-limb gait balance, and cognitive function of stroke patients. Based on electroencephalography (EEG), functional magnetic resonance imaging (fMRI), and functional near-infrared spectroscopy (fNIRS), the correlation mechanism of virtual reality promoting brain functional reorganization and neural remodeling is analyzed from the perspective of task-oriented training, reinforcement learning, and neural regulation. The virtual reality rehabilitation scheme can accurately match the actual needs of clinical rehabilitation, and exploring the internal mechanism of its intervention in the dynamic process of rehabilitation is helpful to promote the deep integration of virtual reality technology and rehabilitation medicine. This study integrates high temporal resolution EEG activity data, magnetic resonance imaging spatial positioning information, cerebral hemodynamic data, and virtual reality system behavior data, realizing the systematic quantitative output of rehabilitation effect in the “human-computer” interactive closed loop. Finally, the future development direction is projected from the aspects of system optimization, standard setting, and multi-technology integration to provide a reference for promoting the clinical application and development of virtual reality technology in stroke rehabilitation. Full article

Hollow hydrogels are promising for flexible electronics and bioengineering, yet their fabrication is limited by sacrificial templates, specialized equipment, and complex engineering processes. Herein, a facile wet-spinning strategy is developed to fabricate sodium alginate (SA) hollow hydrogels. Extruding SA/CaCO₃ precursor suspension into an acidic coagulation bath induces simultaneous ionic cross-linking and in situ CO₂ generation, driving the self-formation of hollow tubular architectures with tunable morphologies, mechanical performance, macroscopic architecture, and functional properties. Moreover, the introduction of secondary cross-linking enhances the SA hydrogels’ water retention and resistance to freezing conditions. Utilizing their intrinsic ionic conductivity, the hollow hydrogels demonstrate outstanding sensing performance, enabling reliable detection of both large-amplitude limb motions and subtle muscle activity in the human body. Furthermore, hollow hydrogel tubes with diverse geometries can be readily fabricated by simply modifying the spinning mold, thereby broadening their potential applications. In vitro cytotoxicity assessments further confirm that the SA hollow hydrogels exhibit excellent biocompatibility with minimal cytotoxicity, satisfying the fundamental criteria for bioengineering applications. The combination of a simple yet controllable fabrication strategy with the intrinsic multifunctionality of the SA hollow tubes confers substantial potential for their deployment in bioengineering and flexible electronic applications. Full article

Background/Objectives: This systematic review and meta-analysis was designed to examine the efficacy of extracorporeal shock wave therapy (ESWT) and ultrasound therapy in the treatment of upper and lower limb tendinopathies. Methods: The protocol was registered in PROSPERO (CRD420251113976) and conducted in accordance with PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Electronic searches were performed in the PubMed, Embase, EBSCOhost, and Ovid MEDLINE databases up to August 2025, to identify randomized controlled trials (RCTs). Mean differences (MDs) and standardized mean differences (SMDs) were calculated with 95% confidence intervals (CIs). Heterogeneity was assessed using the I² statistic, and a random-effects model was applied. Risk of bias was evaluated using the Risk of Bias (RoB 2) tool, and the certainty of evidence was assessed using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach. Results: Fourteen RCTs involving 639 patients with tendinopathies were included. All studies were characterized by a high risk of bias. Very low-certainty evidence suggested that ESWT as monotherapy may reduce pain at rest compared with ultrasound therapy in patients with lateral epicondylitis (MD = −1.51; 95% CI: −2.71 to −0.31; p = 0.01), although the effect was highly heterogeneous (I² = 89.8%; p = 0.002). In patients with upper- and lower-limb tendinopathy, ESWT combined with pharmacotherapy resulted in significantly lower pain intensity compared with ultrasound therapy combined with pharmacotherapy (SMD = −0.6; 95% CI: −1.07 to −0.14; p = 0.01). No significant differences in PRTEE (Patient-Rated Tennis Elbow Evaluation) scores were observed between ESWT and ultrasound monotherapy in patients with lateral epicondylitis (MD = −1.06; 95% CI: −11.06 to 8.94; p = 0.83; I² = 75.82%), or between ESWT combined with other conservative treatments and ultrasound combined with other conservative treatments (MD = 0.46; 95% CI: −10.22 to 11.15; p = 0.93; I² = 0%). Conclusions: Very low-certainty evidence suggests that ESWT may be more effective than ultrasound therapy in reducing pain when used as monotherapy in lateral epicondylitis, despite substantial heterogeneity, and when combined with pharmacotherapy in upper- and lower-limb tendinopathies. In terms of function, ESWT appears to provide improvements comparable to those of ultrasound therapy, as assessed by PRTEE scores, in patients with lateral epicondylitis, both as monotherapy and when combined with other conservative treatments. However, significant methodological limitations substantially limit confidence in these findings. Full article

Background: Cubital Tunnel Syndrome (CuTS) is the second-most common compressive neuropathy of the upper limb, traditionally associated with prolonged elbow flexion, trauma, or anatomical constraints. With the widespread adoption of smartphones, sustained upper-limb postures have emerged as potential novel risk factors for ulnar nerve compression. This retrospective study aimed to investigate the potential correlation between smartphone use patterns and the development of CuTS. Methods: A retrospective observational study was conducted on 100 subjects recruited between 2021 and 2024, including 50 patients with EMG-confirmed CuTS who underwent surgical decompression and 50 matched controls without clinical or electrophysiological evidence of ulnar neuropathy. Demographic variables, daily smartphone use (h/day), predominant activity type, and habitual posture during device handling were collected through clinical records and questionnaires. Group comparisons were performed using t-tests and Chi-square analyses, with significance set at p < 0.05. Results: Daily smartphone use was higher in the CuTS group compared with controls (4.94 ± 1.8 vs. 4.04 ± 1.5 h/day), although the difference did not reach statistical significance (p = 0.0716). Posture during device use showed a significant association with CuTS: 82% of affected patients reported using smartphones with the elbow flexed, compared with 56% of controls, whereas supportive postures were less frequent among CuTS patients (16% vs. 38%) (p = 0.019). No significant differences were found between groups regarding smartphone activity type (p = 0.858). Conclusions: Smartphone use may contribute to ulnar nerve compression primarily through ergonomically disadvantageous postures, particularly sustained elbow flexion, rather than total usage time. These findings highlight a modifiable behavioral risk factor relevant to the rising prevalence of CuTS in the digital era. Increased clinical attention to device-handling habits and public-health strategies promoting ergonomic posture may support CuTS prevention. Prospective and biomechanically informed studies are warranted to further elucidate causal mechanisms. Unmeasured confounders (e.g., occupational and sleep-related elbow flexion) may influence these associations. Full article

Manual wheelchair users with spinal cord injury (SCI) rely heavily on upper-limb function for independent mobility, which often leads to cumulative musculoskeletal loading due to repetitive propulsion. To address limitations associated with conventional unidirectional pushrim propulsion, this study presents the design and development of a detachable bidirectional wheelchair propulsion system that enables mode-dependent push and pull inputs through a mechanically reconfigurable lever mechanism. The proposed system allows conventional forward propulsion through forward pushing, while enabling alternative propulsion patterns through lever mode switching. Depending on the selected mode, either pushing or pulling inputs can be mechanically coupled to forward or backward wheel rotation, without requiring powered actuation or permanent modification of the wheelchair structure. This design expands the range of feasible propulsion strategies by allowing a selectable relationship between propulsion input direction and wheelchair movement direction through mechanical mode switching via a purely mechanical transmission architecture. The system is designed as a modular add-on compatible with standard manual wheelchairs, incorporating a clamp-based detachable interface and a gear-driven bidirectional transmission mechanism. Design considerations emphasize mechanical simplicity, controllability, and compatibility with existing wheelchair configurations, while preserving baseline pushrim functionality. This design-focused study reports the engineering rationale, mechanical architecture, and feasibility of a detachable bidirectional propulsion concept for manual wheelchairs. By explicitly documenting the system configuration and mode-switching logic, this work aims to provide a transparent design framework that can support future experimental validation and user-centered evaluation of bidirectional propulsion strategies for manual wheelchair users with SCI. Full article

Peripheral arterial disease (PAD) is a manifestation of systemic atherosclerosis in which inflammation plays a central pathogenic role. Endovascular revascularisation may transiently amplify inflammation due to vascular injury, but successful restoration of perfusion could reduce inflammatory burden over time. This prospective, observational, single-centre pilot study aimed to characterise the temporal dynamics of inflammatory biomarkers during the first three months following endovascular revascularisation of the lower limbs. Consecutive patients with PAD who underwent successful percutaneous femoropopliteal revascularisation at the Department of Vascular Diseases, University Medical Centre Ljubljana, Slovenia, between January 2022 and January 2024 were enrolled. Venous blood was obtained one hour before the procedure, one day afterwards, and again approximately three months later. Concentrations of high-sensitivity C-reactive protein (hsCRP), interleukins (IL-6, IL-8, IL-10), and tumour necrosis factor-alpha (TNFα) were measured. Temporal changes in biomarker levels were analysed using Friedman and Wilcoxon signed-rank tests where appropriate. Clinical outcomes were evaluated at three months and one year post-procedure and were further verified through patient telephone interviews. The observed outcomes were worsening of PAD symptoms, newly diagnosed angina pectoris, myocardial infarction, stroke, transient ischaemic attack (TIA), or death. Twenty-eight patients (median age 69 years) completed all blood samplings. IL-6 concentrations increased significantly one day after revascularisation and decreased below preprocedural levels at three months, with significant differences observed across all time points (p < 0.001). IL-10 and TNFα decreased significantly between the postprocedural and three-month measurements (p = 0.012 and p = 0.016, respectively), but not below preprocedural levels. No significant changes were observed in hsCRP or IL-8. Over a median follow-up of 732 days, 9 patients experienced worsening PAD symptoms in the treated limb, 2 developed new-onset PAD symptoms in the contralateral limb, and 1 was newly diagnosed with angina pectoris. No myocardial infarction, stroke, TIA, or death occurred. To conclude, endovascular femoropopliteal revascularisation induces distinct short-term inflammatory responses, with IL-6 showing the most pronounced peri-procedural dynamics. The observed reductions in some inflammatory biomarker levels at three months suggest that restored limb perfusion may modulate systemic inflammation. Larger studies are warranted to clarify the prognostic relevance of these biomarkers. Full article

Background: The infraclavicular brachial plexus block is a widely used regional anesthesia technique for surgery of the distal upper limb. Although generally considered safe—particularly with ultrasound guidance—a range of vascular, neurological, respiratory, and anesthetic-related complications continues to be reported. Understanding how anatomic factors can influence the occurrence of these events is essential for improving procedural safety. Objective: This narrative review aims to correlate clinically reported complications of the infraclavicular block with underlying anatomical mechanisms that may predispose to their development. Methods: A narrative review of the literature was conducted using PubMed, Scopus and Web of Science to identify clinical studies, observational series, and case reports published between 1995 and 2025 that documented complications associated with infraclavicular brachial plexus block in adults. Publications were selected based on relevance to vascular, neurological, respiratory, infectious, and local anesthetic systemic complications. Findings were synthesized descriptively, with emphasis on anatomical-clinical correlations rather than quantitative meta-analysis. Results: Reported complications include vascular puncture and hematoma formation, transient or persistent neurological deficits, Horner’s syndrome, hemidiaphragmatic paralysis, pneumothorax, local anesthetic systemic toxicity, and infectious complications. The incidence of these events varies widely across studies, reflecting differences in block technique, use of ultrasound guidance, injected anesthetic volume, and operator experience. Anatomical factors—such as the close relationship of the cords of the brachial plexus to the axillary vessels and the continuity of fascial planes—provide plausible explanations for these variations. Conclusions: Most complications of the infraclavicular block can be understood and anticipated through careful consideration of regional anatomy. Integrating anatomical knowledge with ultrasound guidance and optimized injection strategies may substantially reduce the risk of adverse events. This review highlights key anatomical mechanisms underlying reported complications and outlines practical implications for clinical practice. Full article

Background: Diabetic foot infections (DFIs) are a major cause of hospitalization, limb loss, and mortality among patients with diabetic foot ulcers (DFUs). This study evaluated the risk of developing DFIs among patients with newly diagnosed DFUs across insurance categories. Methods: Adults ≥18 years with a new DFU diagnosis were identified in the PearlDiver insurance claims database (2010–2020) using validated ICD-9/10 codes. Insurance status at the index DFU was categorized as Medicaid, Medicare, commercial, or self-pay. Propensity score matching (1:3) based on age, sex, Charlson Comorbidity Index, and major comorbidities was used to compare Medicaid vs. non-Medicaid patients. Results: Among 258,122 patients with new DFUs, 20,638 (8.0%) were Medicaid beneficiaries. Medicaid patients were younger (50.1 ± 10.2 vs. 60.6 ± 12.1 years, p < 0.001) but had similar comorbidity burden compared with commercially insured and Medicare patients. In matched analysis post-matching, Medicaid insurance was independently associated with higher odds of DFI-related hospitalization within 12 months (aOR 1.18, 95% CI 1.14–1.24) and major amputation at 3 years (aOR 1.72, 95% CI 1.39–2.13). Higher CCI, chronic kidney disease, congestive heart failure, COPD, and peripheral vascular disease also predicted adverse outcomes. Conclusions: Medicaid insurance was independently associated with increased risks of DFI and major amputation among patients with newly diagnosed DFUs. These findings highlight infection as a potentially modifiable pathway driving limb loss and emphasize the need to improve early ulcer evaluation and infection management for Medicaid beneficiaries. Full article

Background/Objectives: Intensive care unit-acquired weakness (ICUAW) is a frequent complication characterized by symmetrical and proximal limb muscle weakness. Its diagnosis is primarily based on clinical symptoms; however, ICUAW assessment can often be uncertain. Blood biomarkers have not yet been widely investigated for this purpose. Serum gelsolin (GSN) is synthesized by skeletal muscle cells. It plays a crucial role in binding extracellular actin filaments and pro-inflammatory cytokines. In sepsis-associated ICUAW, GSN levels might massively decrease due to their buffering activity and muscle wasting. We elucidated the predictive capacity of GSN regarding ICUAW and its additional diagnostic/prognostic potential in sepsis compared to classical parameters. Methods: We recruited septic and non-septic ICU patients for our follow-up study. Patients were retrospectively categorized into ICUAW positive (n = 26) and negative (n = 47) groups based on their clinical characteristics. Sera were collected on the 1st, 2nd and 3rd days of ICU stay. Ambulatory patients (n = 34) served as controls. GSN levels were measured by our previously developed automated immunoturbidimetric assay. Clinical and laboratory parameters were collected from our hospital information system. Results: Admission GSN levels were significantly reduced in ICU patients compared to controls (median: 11.60 vs. 75.99 mg/L). ICUAW positive patients had significantly lower admission GSN levels than ICUAW negative patients (median: 8.10 vs. 14.30 mg/L), and a similar tendency was observed during follow-up. GSN showed predictive capacity regarding ICUAW (ROC AUC: 0.711, p < 0.01), especially when combined with albumin (ROC AUC: 0.750, p < 0.01). The combination of admission GSN, albumin, and procalcitonin demonstrated significant diagnostic performance (ROC AUC: 0.803) regarding the requirement for invasive ventilation, and GSN had prognostic value for 28-day mortality as well. Conclusions: GSN might serve as an intriguing marker in the prediction of ICUAW, especially when combined with albumin. The parallel decline of GSN and albumin could reflect the combined effects of systemic inflammation and muscle wasting seen in ICUAW. Full article

Background/Objectives: Head and neck squamous cell carcinoma (HNSCC) affects over 600,000 individuals worldwide each year, and its incidence continues to rise. There is a growing need for novel therapeutic strategies that achieve high antitumor efficacy while minimizing functional impairment. We developed a novel approach to enhance intracellular delivery of immunotoxins (ITs) by combining a photosensitizer under illumination. This method, termed intelligent Targeted Anti-body Phototherapy (iTAP), utilizes light as a spatiotemporal trigger to promote the cytoplasmic release of toxins. In the present study, we investigated the in vivo therapeutic efficacy of iTAP using an EGFR-targeted IT composed of cetuximab conjugated to saporin (IT-Cmab), administered in combination with the clinically used photodynamic therapy (PDT) photosensitizer NPe6, in a xenograft mouse model. Methods: Sa3 cells were implanted subcutaneously into the right hind limb of nude mice. Mice were randomized into four groups (n = 5): (i) iTAP (IT-Cmab plus NPe6), (ii) IT-Cmab alone, (iii) NPe6 alone, and (iv) saline control. Treatment was initiated once tumors exceeded 40 mm³. Mice received intraperitoneal IT-Cmab (0.5 mg/kg), followed 72 h later by intravenous NPe6 (5 mg/kg). Tumors were irradiated 3–4 h later using a custom LED device (670 nm, 262 mW/cm², 30 J/cm²). Tumor volume and body weight were monitored over time, and antitumor effects were analyzed using a linear mixed-effects model. Results: iTAP treatment produced the earliest and most pronounced inhibition of tumor growth among the four groups. Significant suppression was observed from day 9 and persisted throughout the study. IT-Cmab alone showed a moderate but sustained antitumor effect with a later onset, whereas NPe6-mediated PDT exhibited only a delayed and weaker response. On the final day, median tumor volumes showed substantial reductions relative to the Control group (601%), with decreases of 41% in PDT (357%), 55% in IT-Cmab (271%), and 70% in iTAP (178%). Overall, iTAP demonstrated the strongest and most durable therapeutic efficacy in vivo. Conclusions: These findings indicate that iTAP represents a promising therapeutic strategy for HNSCC. Full article

Background: Limb-salvage surgery using extendable distal femoral endoprostheses has become the standard reconstruction following tumor resection in skeletally immature patients, allowing continued growth and improved function. However, mechanical complications, particularly tibial pain, remain challenging and poorly understood. This study aimed to identify radiographic predictors of tibial pain and evaluate their potential utility in early risk detection. Methods: A retrospective cohort study was conducted of 29 skeletally immature patients (mean age 10.4 years) who underwent expandable distal femoral endoprosthetic replacement between 2008 and 2018 at a tertiary orthopedic oncology center. Standardized radiographs were analyzed at 6 months and final follow-up (mean 75 months) to assess cortical thickness, stem-to-cortex distances, stem migration, stress shielding, pedestal formation, and periosteal reaction. Associations between radiographic parameters and tibial pain were assessed using multivariable logistic regression, t-tests, and chi-square analyses. Results: Seventeen patients (58.6%) developed activity-limiting tibial pain requiring analgesics, as documented during follow-up. Mean medial and lateral cortical thickness increased from 3.0 mm and 3.4 mm to 4.1 mm and 5.1 mm, respectively. The logistic regression model demonstrated strong explanatory power (Pseudo R² = 0.57, p = 0.004). Medial cortical thickness at last follow-up was the only significant independent predictor of tibial pain (p = 0.042), and was significantly associated with tibial pain. Patients with tibial pain exhibited greater medial cortical thickening (p < 0.001). Stem migration (φ = 0.421, p = 0.065), stress shielding (φ = 0.476, p = 0.044), pedestal formation (φ = 0.608, p = 0.004), and periosteal reaction (φ = 0.569, p = 0.008) were also associated with pain. Conclusions: Medial cortical hypertrophy emerged as a potential radiographic biomarker for tibial pain. after expandable distal femoral endoprosthesis in growing patients. The findings suggest that cortical remodeling, stress shielding, and pedestal formation collectively reflect stem micromotion and bone adaptation. Early radiographic surveillance of these parameters warrants further investigation in prospective studies to determine their clinical utility. Larger multicenter studies are warranted to validate these predictors and refine postoperative monitoring protocols. Full article

Viper bites are medical emergencies that can develop into serious clinical complications and can endanger the life of the paediatric patient. This observational retrospective study analyses 24 cases of viper bites involving paediatric patients (<18 years) encountered over 10 years (2016–2025) in the emergency department of Saint Mary Emergency Hospital of Iasi, Romania, with a focus on those requiring specialised surgical monitoring. Sociodemographic factors, toxicity, and surgical management of snakebites were analysed. In 83.33% cases, viper bites were found on the lower limb. The retrospective study was completed through an in-depth analysis of two representative cases, with a particular focus on the evolution up to compartment syndrome. Of the 24 cases presented in the Emergency Department, one was a rare and severe case, which evolved into compartment syndrome and required fasciotomy to save the limb in the Plastic Surgical Department. Another one, with the bite localised at the upper limb, had perilesional oedema, without skin colour changes or secretions, preservation of joint contours, and normal nail colouration. Both were analysed and described in detail with all available data (images, investigations, etc.) to highlight pathophysiological and therapeutic aspects. Appropriate, multidisciplinary treatment considerably improves the functional prognosis of patients with viper bites; administration of antivenom and selective fasciotomy contribute to successful outcomes. The study emphasises that viper bites in children remain a public health problem in Romania and require prompt and multidisciplinary treatment. Full article