Search Results (342)

This paper presents the first exploration of young carers in early childhood (YCEC), in the context of whole family support, through the application of the Power Threat Meaning Framework (PTMF). Existing contributions to young carer research have shaped social policy, legislation, and practice concerned with whole family approaches to the identification, assessment, and support for young carers globally. To date, the literature has predominantly focused on young carers in middle childhood to young adulthood, contributing to socially constructed Eurocentric ideologies of who young carers are likely to be. As such, YCEC remain disempowered in broader young carer and family science discourse. This qualitative exploration centers upon the experiences of three families. Primary data collated retrospective accounts of two adult siblings supported by documentary data obtained by participants through a subject access request (SAR). Secondary data derived from two case studies, drawn from the lead author’s master’s dissertation, offering experiences of families each with a young carer aged four years old. Participants lived in England, United Kingdom (UK). Deductive analysis utilized dual methodological approaches, offering nuanced insight. Thematic codes were synthesized into predetermined themes. ‘Power,’ ‘threat,’ ‘meaning,’ ‘threat responses,’ and ‘strengths’ to explore the application of the PTMF beyond individual experience. Findings show systemic and structural powers held within the lives of YCEC. This disempowers the ethos of whole family support, which should serve to endorse integrated working and foster the autonomous functioning of family life. Findings consider threats, worsening vulnerabilities, and exposure to harm. Meaning is deduced from findings offering recommendations for future research, practice, and policy decisions. In conclusion, opportunities for the prevention of inappropriate caring roles, early identification, and intervention have been missed. This study adds to the growing exploration of the PTMF. It harnesses its potential application as a holistic assessment tool and qualitative data analysis framework, helping to bridge structural and developmental viewpoints which typically frame the current understanding of family functioning and related social policy. Full article

Background: Pediatric asthma is a multifactorial condition influenced by environmental, biological, and social determinants. The COVID-19 pandemic introduced new variables that may have affected the severity and management of asthma in children and adolescents, particularly through changes in healthcare access, treatment adherence, and exposure to environmental risk factors. Objective: To evaluate the association between asthma severity and various factors including nutritional status, corticosteroid use, COVID-19 vaccination, and pollutant exposure before and during the COVID-19 pandemic in a pediatric population. Methods: A retrospective analysis was conducted using 307 medical records of patients aged 3 to 17 years. Data collected included sociodemographic characteristics, nutritional indicators, history of corticosteroid use, vaccination status against COVID-19, and exposure to environmental pollutants. Asthma severity was assessed using the pulmonary score, and multiple statistical analyses, including logistic regression using the Bayesian Logistic Regression Model (BLRM), were employed to identify significant associations. Results: The analysis revealed a statistically significant impact of the pandemic on hospitalization rates (p = 0.0187) and the use of corticosteroids (p = 0.009), indicating changes in asthma management during this period. Notable differences were observed in the geographic distribution of mild versus severe asthma cases prior to the pandemic, associated with nutritional status and gender (p = 0.018). During the pandemic, breastfeeding history, body weight, and hospitalization emerged as significant predictors of asthma severity (p < 0.05). In addition, breastfeeding in young children (aged 3 to 6 years) and hospitalization were strongly associated with pulmonary scores, with significance values of 0.022 and 0.012, respectively, as identified by the BLRM. Conclusions: These findings suggest that the pandemic context influenced both the clinical course and management of pediatric asthma. Preventive strategies should consider individual and environmental factors such as nutrition, early-life health practices (e.g., breastfeeding), and equitable access to appropriate asthma care and vaccination. Tailoring pediatric asthma management to these variables may improve outcomes and reduce disparities in disease severity. Full article

Background/Objectives: Preclinical chest computed tomography (CT) imaging in small animals is often limited by low resolution due to scan time and dose constraints, which hinders accurate detection of subtle lesions. Traditional super-resolution (SR) metrics, such as peak signal-to-noise ratio (PSNR) and structural similarity index (SSIM), may not adequately reflect clinical interpretability. We aimed to evaluate whether deep learning-based SR models could enhance image quality and lesion detectability in rat chest CT, balancing quantitative metrics with radiologist assessment. Methods: We retrospectively analyzed 222 chest CT scans acquired from polyhexamethylene guanidine phosphate (PHMG-p) exposure studies in Sprague Dawley rats. Three SR models were implemented and compared: single-image SR (SinSR), segmentation-guided SinSR with lung cropping (SinSR3), and omni-super-resolution (OmniSR). Models were trained on rat CT data and evaluated using PSNR and SSIM. Two board-certified thoracic radiologists independently performed blinded evaluations of lesion margin clarity, nodule detectability, image noise, artifacts, and overall image quality. Results: SinSR1 achieved the highest PSNR (33.64 ± 1.30 dB), while SinSR3 showed the highest SSIM (0.72 ± 0.08). Despite lower PSNR (29.21 ± 1.46 dB), OmniSR received the highest radiologist ratings for lesion margin clarity, nodule detectability, and overall image quality (mean score 4.32 ± 0.41, κ = 0.74). Reader assessments diverged from PSNR and SSIM, highlighting the limited correlation between conventional metrics and clinical interpretability. Conclusions: Deep learning-based SR improved visualization of rat chest CT images, with OmniSR providing the most clinically interpretable results despite modest numerical scores. These findings underscore the need for reader-centered evaluation when applying SR techniques to preclinical imaging. Full article

Background/Objectives: Hematological toxicities (i.e., neutropenia, thrombocytopenia, and anemia), are common chemotherapy complications and may be exacerbated by renal or hepatic impairment due to altered drug exposure. This study assessed the association between renal and hepatic impairment and hematologic toxicities during chemotherapy in routine clinical practice. Methods: A single-center retrospective cohort study using the Utrecht Patient Oriented Database (UPOD) identified all chemotherapy administrations at the University Medical Centre Utrecht between 2011 and 2024. Regimens administered in ≥10 patients and ≥5 renally (GFR < 60 mL/min) or hepatically (bilirubin or AST > 1× ULN) impaired patients were included in descriptive analyses. Cox proportional hazards models estimated associations between organ impairment and grade ≥ 3 hematologic toxicities for regimens with ≥10 events per toxicity endpoint. Results: Overall, 4489 patients were included in renal analyses and 6218 in hepatic analyses, with smaller endpoint-specific subgroups for survival analyses. Renal impairment was associated with grade ≥ 3 neutropenia (HR: 1.43 [95% CI: 1.18–1.73]), thrombocytopenia (HR: 1.46 [95% CI: 1.15–1.86], and anemia (HR: 1.66 [1.27–2.16]). Hepatic impairment was similarly associated with neutropenia (HR: 1.25 [95% CI: 1.11–1.40]), thrombocytopenia (HR: 1.33 [95% CI: 1.13–1.57]), and anemia (HR: 1.62 [95% CI: 1.34–1.95]). Cyclophosphamide (pro-drug) regimens showed higher toxicity risk in renally impaired patients and reduced risk in hepatically impaired patients. Etoposide, melphalan and methotrexate were associated with increased toxicity in hepatically impaired patients. Conclusions: Renal and hepatic impairment significantly increase chemotherapy-induced hematologic toxicity. Several high-risk chemotherapy regimens were identified; however, larger multi-center datasets are needed to refine dosing guidance based on renal and hepatic function. Full article

Pleural Mesothelioma (PM) remains a challenging malignancy associated with asbestos exposure and characterized by poor prognosis. This review aims to consolidate recent findings on the efficacy of perioperative therapies encompassing chemotherapy, surgery, and emerging immunotherapy strategies. Current management strategies debate the role of surgery in early-stage patients, particularly due to the limited success of solitary treatment modalities and significant rates of postoperative complications. Retrospective studies indicate that multimodal treatment, incorporating surgical resection with perioperative chemotherapy, can enhance overall survival (OS), especially in favorable prognostic subsets. However, significant randomized trials, notably the MARS and MARS 2 trials, revealed that the addition of aggressive surgical strategies like extrapleural pneumonectomy (EPP) did not confer survival benefits and was accompanied by heightened morbidity. In light of persistent challenges, integrating perioperative chemotherapy—primarily with platinum-based regimens—has shown improved disease control outcomes. Neoadjuvant chemotherapy permits real-time assessment of tumor responsiveness, providing valuable clinical insights for surgical candidacy. The role of immunotherapy, particularly immune checkpoint inhibitors (ICIs), is also under active exploration, with preliminary results suggesting promising activity and manageable safety profiles. In conclusion, while current protocols primarily recommend surgery for a select group of patients, ongoing investigations into neoadjuvant approaches, adjuvant therapies, and novel immunotherapeutic strategies are crucial for developing effective, personalized treatment paradigms for PM. Future efforts should prioritize clinical trials that integrate these therapies within a structured multidisciplinary approach to optimize patient outcomes. Full article

Background/Objectives: Integrating 3D visualization technologies, including virtual reality (VR), augmented reality (AR), and mixed reality (MR), into dental education may enhance students’ understanding of facial anatomy and clinical procedures. This study aimed to assess dental students’ perceptions of using MR for three-dimensional visualizations of impacted teeth. Methods: Cone-beam computed tomography (CBCT) scans of patients with impacted teeth were retrospectively selected from a university clinic database. The CBCT images were processed to adjust contrast for optimal visualization before being uploaded to MR goggles (HoloLens 2). A total of 114 final-year dental students participated, each manipulating the 3D images in space using the goggles. Following this, they completed a seven-question survey on a five-point Likert scale (1 = strongly agree, 5 = strongly disagree), evaluating image quality and the usefulness of 3D visualization. Results: The study group consisted of 29 males and 85 females (mean age = 24.11 years, SD = 1.48). The most favorable responses were for enhanced visualization of the impacted tooth’s position relative to adjacent structures and the inclusion of 3D image visualization as a teaching aid, which benefited students while learning and allowed them to better understand the course of the procedure for exposure/extraction of the impacted tooth, with median scores of 1, indicating a highly favorable opinion. A statistically significant relationship was found between the responses of females and males regarding the quality of the presented image using HoloLens 2 goggles. No significant correlation was found between participants with and without prior experience using VR/MR/AR. No significant correlation was found between age and responses. Conclusions: Students reported an improved understanding of the relationships between impacted teeth and adjacent structures, as well as potential benefits for clinical training. These findings demonstrate a high level of acceptance of MR technology among students; however, further research is required to objectively assess its effectiveness in enhancing learning outcomes. Full article

Methylphenidate (MPH) and its active enantiomer, dexmethylphenidate, are widely prescribed as first-line therapies for attention deficit hyperactivity disorder (ADHD), yet their increasing non-medical use highlights significant clinical and toxicological challenges. MPH blocks dopamine (DAT) and norepinephrine (NET) transporters, thereby elevating synaptic catecholamine levels. While this underpins therapeutic efficacy, prolonged or abusive exposure has been associated with mitochondrial impairment, disrupted bioenergetics, and excessive reactive oxygen species (ROS) production, which collectively contribute to neuronal stress and long-term neurotoxicity. Growing evidence suggests that the gut–brain axis may critically influence MPH outcomes: diet-induced shifts in microbiome composition appear to regulate oxidative stress, neuroinflammation, and drug metabolism, opening potential avenues for dietary or probiotic interventions. From a forensic perspective, the detection and monitoring of MPH misuse require advanced methodologies, including enantioselective LC–MS/MS and analysis of alternative matrices such as hair or oral fluids, which enable retrospective exposure assessment and improves abuse surveillance. Despite its established therapeutic profile, MPH remains a compound with a narrow balance between clinical benefit and toxicological risk. Future directions should prioritize longitudinal human studies, biomarker identification for abuse monitoring, and the development of mitochondria-targeted therapies to minimize adverse outcomes and enhance safety in long-term treatment. Full article

Background: Fixed-duration venetoclax plus rituximab (VR) is a standard therapy for relapsed/refractory (R/R) chronic lymphocytic leukemia (CLL). However, evidence supporting its use after covalent BTK inhibitor (c-BTKi) therapy is scarce in clinical trials and limited in real-world settings. Objectives: To assess the efficacy and safety of VR in a real-world cohort of patients with R/R CLL, including cBTKi-pretreated individuals, and to contextualize outcomes alongside published real-world studies and registrational trials of alternative therapies. Methods: We retrospectively analyzed 37 patients with R/R CLL treated with VR at our center between April 2018 and November 2024. Baseline characteristics, treatment responses, minimal residual disease (MRD), and adverse events were recorded. Survival was estimated using the Kaplan–Meier method. A structured review of relevant real-world evidence and pirtobrutinib clinical trials was also conducted. Results: Median age was 67 years; 35.1% had prior cBTKi exposure. The overall response rate (ORR) was 91.7% (22/24 evaluable patients), with 66.7% achieving complete remission (CR). Among evaluable c-BTKi-pretreated patients, the ORR was 87.5% (7/8) and the CR rate was 62.5%. Undetectable MRD (uMRD) rates were 78.6% in peripheral blood and 71.4% in bone marrow. Thirty-month progression-free survival (PFS), time to next treatment (TTNT), and overall survival (OS) were >90% for the whole cohort and for c-BTKi-pretreated patients. The most frequent adverse event was neutropenia grade ≥ 3, especially during combination therapy, which is easily managed with GCSF support. Conclusions: Our real-world evidence shows that VR is an effective and well-tolerated option even after c-BTKi therapy in R/R CLL. These data complement evidence from emerging therapies and inform post-c-BTKi treatment selection in clinical practice. Full article

Background: The relationship between Helicobacter pylori (H. pylori) infection and gastroesophageal reflux disease (GERD) remains a topic of ongoing debate. In particular, the intragastric distribution of H. pylori—whether localized in the antrum or corpus—may influence gastric acid secretion and esophageal physiology in different ways. However, its potential effects on esophageal motility and reflux parameters have not been comprehensively evaluated using combined diagnostic tools. This study aimed to assess whether H. pylori positivity, based on its histologically confirmed intragastric localization, is associated with alterations in endoscopic, manometric, and reflux monitoring findings in patients with typical GERD symptoms. Methods: This retrospective study included 213 patients with typical reflux symptoms who underwent upper gastrointestinal endoscopy with gastric biopsies, high-resolution esophageal manometry (HREM), and 24 h multichannel intraluminal impedance–pH (MII-pH) monitoring. Based on histopathology, patients were classified into three groups: H. pylori-negative, antrum-predominant infection, and corpus-predominant infection. Clinical symptoms, endoscopic findings, reflux characteristics, and esophageal motility parameters were compared. Results: Of 213 patients, 90 were H. pylori-positive (60 antrum-predominant, 30 corpus-predominant). There were no significant differences between groups in terms of typical GERD symptoms, endoscopic esophagitis, DeMeester scores, acid exposure time, or mean nocturnal baseline impedance (MNBI). Nausea and chronic laryngitis were significantly more frequent in antral H. pylori-positive patients. Notably, contraction front velocity (CFV) was significantly lower in patients with antral H. pylori compared with H. pylori-negative individuals (p = 0.002), indicating subtle slowing of esophageal peristalsis. Although this reduction in CFV did not correlate with symptom severity or bolus clearance, it may represent early functional impairment of esophageal motility. Conclusions: Although H. pylori infection—particularly when antrum-predominant—is not associated with increased reflux burden or esophagitis, it may contribute to extra-esophageal symptoms and minor motility alterations such as reduced CFV. These findings suggest that routine H. pylori eradication in GERD patients may not be necessary solely based on reflux parameters. However, treatment decisions should be individualized based on symptom profiles and endoscopic findings, including the presence of peptic ulcers, premalignant gastric lesions, or a family history of gastric malignancy, in accordance with general H. pylori eradication criteria. Full article

Objectives: Human papillomavirus (HPV)-positive and HPV-negative oropharyngeal squamous cell carcinoma (OPSCC) represent biologically distinct subtypes. However, the role of tobacco exposure in the pathogenesis of each remains incompletely understood. This study aimed to evaluate the prognostic implications of smoking in patients with HPV-positive OPSCC, with stratification based on the eighth edition of the American Joint Committee on Cancer (AJCC-8) staging system. Methods: We retrospectively analyzed all OPSCC cases managed at our institution between January 2011 and January 2024. Smoking history was dichotomized into <10 and ≥10 pack-years. Survival outcomes—including overall survival (OS), disease-specific survival (DSS), and progression-free survival (PFS)—were calculated using the Kaplan–Meier method. Log-rank testing and multivariable Cox proportional hazards modeling were used to assess prognostic factors and identify risk groups. An interaction analysis was also conducted to determine whether smoking alters the survival benefit conferred by HPV positivity. Results: Of the 329 patients included, 181 (55%) had a history of smoking, while 148 (45%) had never smoked. Among all patients, 211 (64.1%) were HPV-positive. HPV-positive cases exhibited superior 3- and 5-year OS, DSS, and PFS compared with HPV-negative tumors (p < 0.001). Within the HPV-positive cohort, never-smokers had the most favorable survival outcomes. Notably, interaction modeling demonstrated that the survival benefit of HPV positivity was markedly diminished among smokers, with hazard ratios approaching unity. Conclusions: Tobacco use negates the survival advantage typically associated with HPV-positive OPSCC. These findings highlight the critical need to account for smoking history in treatment planning and when considering eligibility for de-intensification strategies in HPV-related diseases. Full article

Background and Objectives: Laryngeal cancer imposes a disproportionate burden on speech, airway protection and long-term quality of life. Contemporary population-based data for Central and Eastern Europe remain scarce, and the post-pandemic trajectory is uncertain. Materials and Methods: We performed a nationwide, retrospective ecological time-series study using Romanian mortality registers and hospital-discharge files for 2017–2023. Crude and age-standardised mortality rates (ASMRs) were calculated, county-level indirect standardisation and spatial autocorrelation assessed and joinpoint regression quantified temporal trends. Forecasts to 2040 combined Holt–Winters/ARIMA models with Elliott-wave heuristics anchored to Fibonacci retracements. Results: In 2023, 798 laryngeal cancer deaths yielded a crude mortality of 3.65/100,000 (95% CI 3.41–3.91). Male mortality (7.07/100,000) exceeded female mortality 18-fold. Rural residents experienced a higher rate than urban counterparts (4.26 vs. 3.04/100,000), a difference unchanged after indirect age standardisation. National ASMR fell by 3.7% annually (p < 0.01), yet five counties formed a high-risk corridor (standardised mortality ratios 1.59–1.82); Moran’s I = 0.27 (p < 0.01) indicated significant spatial clustering. Pandemic-era surgical throughput collapsed by 48%, generating a backlog projected to persist beyond 2030. Ensemble forecasting anticipates a doubling of discharges and mortality between 2034 and 2037 unless smoking prevalence falls by ≥30% and radon exposure is curtailed. Conclusions: Although overall laryngeal cancer mortality in Romania is declining, the pace lags behind Western Europe and is threatened by geographic inequities and pandemic-related care delays. Aggressive tobacco control, radon-remediation policies and expansion of surgical and radiotherapeutic capacity are required to avert a forecasted surge in the next decade. Full article

Background: Arterial switch operation (ASO) is the standard surgical treatment for dextro-transposition of great arteries (d-TGA). Long-term complications affecting pulmonary arteries, coronary arteries, and aortic root necessitate detailed surveillance, but the optimal imaging strategy remains undefined. Methods: We retrospectively analyzed 47 patients with d-TGA who underwent ASO between January 2023 and June 2025 with at least six months postoperative follow-up. All patients underwent both transthoracic echocardiography (TTE) and ECG-gated cardiac CT angiography (CTA). Anatomical measurements, functional parameters, and diagnostic completeness were compared between modalities. Results: Median age at follow-up was 37.2 months. CT detected pulmonary artery stenosis in 31 patients (65.9%) and aortic root dilatation in 31 patients (65.9%). TTE provided incomplete pulmonary artery assessment in 11 patients (23.4%) and incomplete coronary evaluation in 13 patients (27.6%), while CT successfully evaluated all patients (100%). Strong correlation was found between left pulmonary artery bending angle and aortic root dimensions (r = 0.65, p = 0.016), suggesting mechanical interdependence of post-surgical anatomical changes. Median radiation exposure was 2.684 mSv (IQR: 1.5–4.6). During follow-up, 10 patients (21.3%) required cardiovascular interventions, with CT providing complete pre-intervention assessment in all cases. Conclusions: TTE alone is insufficient for complete anatomical assessment following ASO. An integrated imaging approach utilizing TTE for functional assessment and CT for anatomical evaluation optimizes post-ASO surveillance. Full article

Background/Objectives: Antibiotic pharmacokinetics (PK) and pharmacodynamics (PD) are altered during extracorporeal membrane oxygenation (ECMO). Meropenem and piperacillin are among the most commonly prescribed antibiotics for infections in this population. However, guidance on dosage adjustments in the ECMO setting remains limited. We aim to assess differences in meropenem and piperacillin concentrations achieved and identify the clinical, physiological, and mechanical factors influencing antibiotic exposure. Methods: This is a retrospective, single-centre, observational study comparing an ECMO cohort with a population control group from a prior study, without renal dysfunction. Demographic, clinical, PK/PD parameters, and ECMO-related data were analysed using univariate and generalised estimating equations. For both antimicrobials, the PK/PD target was set at 100%fT_>4xMIC. Results: A total of 130 critically ill patients were included: 18 in the ECMO group and 112 in the control group. The mean age was 65 years (23), 67% were male and 26.9% were classified as obese. For meropenem, renal function and ECMO support significantly influenced drug exposure, with PK/PD targets being achieved in 67% of measurements; in contrast, piperacillin exposure exhibited greater variability, primarily driven by renal function and mechanical ventilation. Notably, PK/PD targets for piperacillin were met in only 20% of measurements. Conclusions: Our findings highlight the considerable variability in β-lactam exposures and PK/PD target attainment in critically ill patients. This study underscores the importance of therapeutic drug monitoring and individualised dosing in attempts to improve antimicrobial efficacy and patient outcomes in this challenging setting. Full article

Background and Objectives: Effects of allergen exposure may be modified through endogenous and exogenous factors, resulting in heterogeneity of clinical features, time course and intensity of symptoms of allergic disease. This creates challenges in allergy diagnosis and management, yet studies addressing the variability of allergen reactivity in relation to potential modifying factors are not numerous. The aim of the study was to retrospectively analyze the frequency and profile of reactivity to inhalant allergen extracts in patients followed in a single center in the years 2017–2020, in relation to sex, age, clinical symptoms and final clinical diagnosis. Materials and Methods: This is a retrospective analysis of skin prick test (SPT) results in 1711 outpatients, performed with dust mites, pollen (alder, hazel, birch, grasses, rye, mugwort), cat, dog and Alternaria allergens. Reactivity profiles were assessed in the entire population divided into sex and age subgroups. Relationships between SPT results, age, sex and clinical diagnosis were assessed using factor analysis. Results: The highest reactivity frequencies were found for grass (60.5%), rye (57.22%), birch (47.34%), alder (42.5%) and Dermatophagoides pteronyssinus mites (41.8%). Monovalent reactivity was found mainly to mugwort (3.2%, n = 55), followed by cat and mites allergens. Reactivity to ≥1 allergen was more frequent in males. The risk of allergic rhinitis (AR) was significantly higher in subjects allergic to grass, rye, hazel and alder pollen, as compared to subjects non-sensitized to these allergens. Reactivity to perennial allergens (dog, cat and dust mites) was significantly associated with asthma diagnosis. The risk of developing atopic dermatitis was significantly associated with reactivity to birch and alder pollen. Conclusions: SPTs are a valuable tool for assessing the occurrence of atopy and allergy. Reactivity to specific aeroallergens may be associated with increased probability of development of a given atopic condition. This warrants further studies regarding the interplay between possible modifiers of allergen exposure effects. Full article

Background and Objectives: Hemophilic arthropathy, the end result of recurrent hemarthroses in patients with hemophilia, often necessitates total knee arthroplasty (TKA) using constrained implants to address severe deformities and joint destruction. Revision TKA is often required due to aseptic loosening, implant malposition, infection, or periprosthetic fractures. The extended tibial tuberosity osteotomy (ETTO) has emerged as a critical technique for the safe removal of well-fixed tibial stems in such complex cases, demonstrating high union rates and minimal complications. The aim of this study is to evaluate the safety, effectiveness, and clinical outcomes of the ETTO technique during complex revision TKA in patients with hemophilia. Materials and Methods: A retrospective analysis was conducted on seven male hemophilic patients who underwent revision TKA with ETTO between 2015 and 2023. The procedure involved the creation of an extended proximal tibial bone flap, laterally retracted to facilitate tibial stem exposure and removal. Postoperative outcomes included radiological confirmation of osteotomy union, assessment of complications, and evaluation of functional outcomes, including range of motion and extensor mechanism integrity. Results: Osteotomy union was achieved in all patients (mean age 57.5 ± 1.50 years and mean body mass index 26.07 ± 0.67 kg/m²) within four months, confirmed by radiographic evidence of bridging callus. No significant complications, such as nonunion, fragment displacement, or symptomatic hardware, were observed. There was one patient who experienced delayed wound healing, managed successfully with surgical debridement. Postoperative mean knee flexion was 92°, with no extensor lag reported. ETTO enabled safe tibial stem removal and successful revision arthroplasties in all cases. Conclusions: ETTO is a technically demanding but indispensable approach for addressing the challenges of revision TKA in patients with hemophilia. It allows for secure tibial stem removal while maintaining excellent union outcomes and a low rate of complications. Due to its complexity, ETTO should be performed by experienced surgeons in specialized centers. Full article