Medicina

Background and Objectives: The aim of this study was to compare the short- and long-term effectiveness of ultrasound-guided percutaneous release (CTR-US) and mini-open surgery in the treatment of carpal tunnel syndrome (CTS). Materials and Methods: A retrospective analysis was conducted on 172 patients who underwent surgical treatment for CTS between 2015 and 2020. The patients were divided into two groups: those who underwent CTR-US (Group A, n = 66) and those treated with mini-open surgery (Group B, n = 106). All patients were evaluated using the Boston Carpal Tunnel Questionnaire (BCTQ) and the Quick Disabilities of the Arm, Shoulder, and Hand (QDASH) scores before surgery and at 3 months, 6 months, 1 year, 2 years, and 5 years postoperatively. Electrophysiological and ultrasound findings were also compared. Statistical analyses were performed using t-tests, Mann–Whitney U tests, and Chi-square tests, with significance set at p < 0.05. Results: A total of 172 patients who met the study criteria were included. Among the participants, 112 were women and 60 were men. The mean age was calculated as 61 years for female patients and 54 years for male patients. No significant differences were found between the groups in terms of age, gender, laterality, and disease duration. Both groups demonstrated significant improvements in BCTQ and QDASH scores at all postoperative time points compared to preoperative scores (p < 0.001). The CTR-US group showed advantages in shorter treatment duration (p < 0.001), lower cost (p < 0.05), and faster recovery time. Electrophysiological evaluations revealed faster improvements in distal motor latency (DML) and sensory conduction velocity (SCV) in the CTR-US group (p < 0.05). Ultrasound assessments indicated that both methods achieved effective release of the transverse carpal ligament. No significant differences were observed between the groups in long-term questionnaire scores. Conclusion: CTR-US offers advantages such as shorter treatment duration, lower cost, and faster recovery due to its minimally invasive nature. Consistent with the literature, CTR-US provided faster recovery and improved patient comfort. However, mini-open surgery remains a reliable alternative with long-term symptom control and low complication rates. Our study found that both methods are effective, but CTR-US stands out for its esthetic and functional advantages.

Background and Objectives: Despite the growing amount of new research, the pathophysiology of glaucoma remains unclear. The aim of this study was to determine the relationship between intracranial pressure (ICP), ocular blood flow and structural optic nerve parameters. Materials and Methods: A prospective clinical study was conducted involving 24 patients with open-angle glaucoma and 25 healthy controls. Routine clinical examination was performed. Swept-source optical coherence tomography (SS-OCT) and OCT angiography (OCTA) images were taken (DRI-OCT Triton, Topcon). The vessel density (VD) values of the ONH were calculated around the optic nerve head (ONH). An orbital Doppler device (Vittamed 205, Kaunas, Lithuania) was used for non-invasive ICP measurements. Color Doppler imaging (CDI) (Mindray M7, Shenzhen, China) was used for retrobulbar blood flow measurements in the ophthalmic artery (OA), central retinal artery (CRA) and short posterior ciliary arteries (SPCAs). Results: ICP was 8.35 ± 2.8 mmHg in the glaucoma group and 8.45 ± 3.19 mmHg in the control group (p = 0.907). In the glaucoma group, the VD of the superficial vascular plexus in the inferior-nasal (NI) sector of the ONH showed a correlation with ICP (r = 0.451, p = 0.05). In contrast, the control group exhibited weaker correlations. CRA peak systolic velocity (PSV) demonstrated significant moderate correlations with VD in multiple retinal layers, including the avascular retina layer in the temporal (T) sector (r = 0.637, p = 0.001). Conclusions: Lower ICP was significantly associated with the lower VD of the superficial plexus layer in the inferior-nasal sector in the glaucoma group, with the control group exhibiting weaker correlations in all sectors. Further longitudinal studies with larger sample sizes are needed to establish associations between intracranial pressure, ocular blood flow and ONH parameters.

Background and Objectives: Spondylarthritis is a complex group of inflammatory diseases closely associated with the HLA-B27 antigen. However, the role of non-HLA-B27 alleles in the disease’s pathogenesis has gained significant scholarly attention in recent years. Case presentation: This case study presents a 49-year-old male with a history of progressive inflammatory back pain, characterized by morning stiffness and restricted spinal mobility developed over several years. Initially presenting with non-specific symptoms, the patient eventually experienced persistent axial pain and deteriorating functional limitations, which required further evaluation. Radiographic imaging supported the diagnosis of ankylosing spondylitis (AS) by identifying bilateral sacroiliitis. HLA genotyping revealed a negative result for HLA-B27 but positive results for HLA-B13 and HLA-B37. This finding serves as a foundation for exploring alternative genetic factors contributing to spondylarthritis (SpA). HLA-B13 and HLA-B37 exhibit structural and functional similarities to HLA-B27, particularly in their peptide-binding grooves. This resemblance may lead to overlapping peptide repertoires and increased T cell cross-reactivity. Moreover, these alleles belong to overlapping cross-reactive groups (CREGs) and share the Bw4 epitope. This suggests that they may contribute to disease pathogenesis via similar mechanisms, such as molecular mimicry and the dysregulation of natural killer (NK) cell interactions, as observed in HLA-B27. Conclusions: This case emphasizes the necessity of expanding diagnostic criteria to incorporate non-HLA-B27 markers, particularly for patients who are HLA-B27-negative. Enhancing our understanding of the roles of alternative genetic markers can improve diagnostic accuracy, enable personalized treatment approaches, and enhance outcomes for the diverse SpA patient population.

Background and Objectives: Distal radius fractures (DRFs) are among the most common fractures globally, with a lifetime incidence of around 9%. They typically present in two age peaks: high-impact trauma in patients under 40 and low-energy trauma in those over 40. Intra-articular DRFs are classified according to the Arbeitsgemeinschaft für Osteosynthesefragen (AO) classification, influencing the treatment approach. Surgical management, particularly open reduction and internal fixation (ORIF) using volar plate osteosynthesis, is considered the gold standard. This study aims to compare the treatment costs of fluoroscopy-assisted ORIF and arthroscopy-assisted ORIF for intra-articular DRF. The analysis includes surgical procedure costs, material expenses, and operating time to evaluate the cost-effectiveness of both methods, considering reimbursement within the German healthcare system. Materials and Methods: A retrospective, monocentric study was conducted at Ludwig-Maximilians-University (LMU) Hospital, a supraregional hand trauma center in southern Germany. Patients with DRFs requiring ORIF were treated either with fluoroscopy or arthroscopic assistance. Group 1 included patients treated by the Department of Hand Surgery (Plastic Surgery), subdivided into Group 1a (arthroscopy-assisted) and Group 1b (fluoroscopy-only). Group 2 comprised patients treated by Orthopaedics and Trauma Surgery (fluoroscopy-only). Costs associated with surgical procedures, including materials, operating time, and postoperative care, were analyzed. Results: A total of 43 DRFs were treated. Group 1 consisted of 17 cases, with an average age of 49.6 years (SD = 19.4) and a 64% majority of female patients. Of these, 10 cases were treated with arthroscopy-assisted ORIF (Group 1a) and 7 with fluoroscopy-only ORIF (Group 1b). In Group 1a, the average age was 53.9 years (SD = 16.3) with 60% female and 40% male patients, while in Group 1b, the average age was 43.6 years (SD = 23.1) with 71.4% female patients. Group 2 included 25 cases, with an average age of 54.2 years (SD = 21.0) and a distribution of 64% female and 36% male patients. There was no significant difference in age and gender distribution within the groups and subgroups (p > 0.05). The mean procedure time was longer for arthroscopically assisted ORIF (111.5 min) compared to fluoroscopy-only ORIF (80.1 min), and even longer compared to Group 2 (65.0 min). Material costs were slightly higher in Group 1. Total costs for Group 1 averaged EUR 4906.58, with subgroup costs of EUR 5448.24 for arthroscopy-assisted and EUR 4132.80 for fluoroscopy-only. In comparison, Group 2 costs averaged EUR 3344.08. Conclusions: Intra-articular DRFs with severely displaced fragments or concomitant injuries benefit from arthroscopically assisted fracture treatment. While material costs do not significantly differ between arthroscopically assisted and fluoroscopy-only treatments, the significantly longer procedure time for arthroscopy-assisted ORIF results in the largest cost component. Despite this, reimbursement through the DRG system remains fixed and does not account for the increased operative duration or complexity of arthroscopic procedures. Our findings demonstrate that DRF treatment, regardless of the method used, is either not or only marginally cost-covering under the current German reimbursement structure. In the context of the ongoing shift towards outpatient hand surgery, including the management of DRF, adequate reimbursement rates are necessary to ensure the economic viability of DRF management, particularly for complex intra-articular fractures requiring arthroscopic assistance.

Background and Objectives: Extracorporeal membrane oxygenation (ECMO) can support patients with severe cardiopulmonary failure, but it poses risks such as hemolysis, leading to complications. Plasma-free hemoglobin (PFH) is a hemolysis biomarker, with elevated levels linked to mortality. This study evaluates PFH and ECMO survival in COVID-19, non-COVID-19 pulmonary, and cardiac patients, focusing on late PFH spikes. Materials and Methods: We retrospectively analyzed 122 ECMO patients treated at our tertiary hospital (January 2020–December 2021). Patients were categorized by indication: post-COVID-19, non-COVID-19 pulmonary, or cardiac. We classified patients as Expired (died during ECMO or ≤30 days post-ECMO) or Survived (>30 days post-ECMO). Data included demographics, ECMO duration, and PFH values at 24 h and during the last 3 and 5 ECMO days. Groups were compared using two-tailed t-tests, with p < 0.05 indicating significance. Results: COVID-19 patients survived after significantly longer ECMO duration than non-COVID-19 pulmonary and cardiac patients. Expired COVID-19 patients had higher PFH values during the last 3 and 5 days of ECMO compared to survivors. Cardiac patients had the highest overall PFH levels regardless of mortality. No significant differences in PFH trends were observed between non-COVID-19 pulmonary and cardiac patients. Conclusions: Late PFH spikes correlated with mortality in COVID-19 patients, suggesting the utility of measuring late PFH spikes in ECMO management. Additionally, COVID-19 pulmonary patients survived when undergoing ECMO significantly longer than both groups, while VA ECMO was more prone to hemolysis. However, technical cannulation differences and frequent use of an Impella pump in cardiac patients may increase blood stress and PFH values.

Background and Objectives: Forward head posture (FHP) is associated with reduced stability limits, impaired balance performance, and compromised cervical proprioception. This study investigated the effects of capital flexion exercise (CFE) on the craniovertebral angle (CVA), trunk control, balance, and gait in chronic stroke patients with forward head posture. Materials and Methods: Twenty-six subjects were randomly assigned to the CFE group or the control group (n = 13 each). The CFE group underwent a familiarization process and performed CFE for 9 min per session, 3 times a week for 6 weeks, as well as the existing neurodevelopmental treatment (NDT). The control group received only the existing NDT. Results: The CVA, the Korean version of the Postural Assessment Scale for Stroke (K-PASS), the Berg Balance Scale (BBS), and the Timed Up and Go test (TUG) improved after the intervention in the CFE group (p < 0.05). In the control group, CVA and TUG improved after the intervention (p < 0.05). The CVA (d = 1.34, p = 0.002), K-PASS (d = 1.36, p = 0.000), and BBS (d = 1.68, p = 0.000) values of the CFE group showed statistically significant improvement compared to the control group. Although TUG improved in the CFE group, the between-group difference was not statistically significant (d = −0.28, p = 0.467). Conclusions: This study suggests that capital flexion exercises effectively improve craniovertebral angle, trunk control, and balance in chronic stroke patients with forward head posture.

Familial Mediterranean Fever (FMF) is characterized by recurrent febrile attacks and serositis. While colchicine is the primary treatment for FMF, some patients present resistance or intolerance with respect to this drug. Anakinra—an IL-1 receptor antagonist—has demonstrated efficacy in colchicine-resistant or -intolerant FMF patients. Background and Objectives: This study aimed to evaluate the clinical characteristics, treatment duration, response to therapy, dose interval modifications, and long-term outcomes in FMF patients treated with anakinra. Materials and Methods: We retrospectively analyzed data from 68 FMF patients who were colchicine-resistant or -intolerant and received anakinra treatment. Results: The median patient age was 40.2 years, with a predominance of female patients (57.3%). The median follow-up duration for patients treated with anakinra was 34.2 months. Anakinra dosing was successfully extended in 30.8% of patients. Eight patients discontinued anakinra due to remission, with a median remission duration of 18.4 months. In a subgroup analysis of 57 patients treated with anakinra for at least 12 months, a significant decrease was observed in Pras scores at 0 months, 3 months, and 12 months, as well as in Erythrocyte Sedimentation Rate, C-reactive protein, and Serum Amyloid A values (all p < 0.001). Statistically significant decreases in 24 h proteinuria values were found between 0 and 3 months, 3 and 12 months, and 0 and 12 months (p = 0.011, p = 0.006, and p = 0.007, respectively). Anakinra use in pregnancy and kidney transplant recipients was well tolerated. Dose extension and treatment discontinuation in remission are feasible strategies. Conclusions: These findings support the use of anakinra as a good treatment option in selected patients.

Background and Objectives: In contrast to the standardization of laparoscopic gastrectomy techniques, the complexity of intracorporeal anastomosis techniques in totally laparoscopic total gastrectomy, the lack of standardization, the positional challenges posed by working in a confined space, and varying complication rates have prevented a consensus on the optimal intracorporeal digestive tract reconstruction method. Selecting an appropriate reconstruction method for esophagojejunostomy is crucial for a successful surgical outcome. This study aims to define a modified anastomotic technique for TLTG and share our experience with this technique. Materials and Methods: A total of 21 patients who underwent TLTG with D2 LND between July 2024 and December 2024 using the sutureless L-shape esophagojejunostomy (SLEJ) technique at the Surgical Oncology Clinic of Gulhane Training and Research Hospital due to gastric cancer were included in the study. In our technique, gastrectomy, lymph node dissection, anastomosis preparation, esophagojejunostomy anastomosis, and enteroenterostomy anastomosis were all performed laparoscopically and intracorporeally. Results: The mean operative time was 180.48 min, with a mean EJ anastomosis duration of 40.24 min. In the standard technique, two Endo GIA™ staplers were used for pyloric and small bowel transection, two for EJ anastomosis, and one for intracorporeal jejunojejunostomy. In only one patient, three staplers were used for anastomosis. Therefore, the average number of staplers was 5.05, with a mean of 2.05 staplers used for anastomosis. The mean hospital stay was 8.19 days, and there were no mortalities. The number of patients with an anastomotic leakage was 1. Since the patient’s general condition remained stable, percutaneous drainage or laparotomy was not planned. The patients’ esophagojejunostomy anastomotic leak was classified as Class 1 and Grade 3a according to the Clavien–Dindo classification. The average size of our widest incision was 3.28 cm, and surgical site infections were developed in two patients. Conclusions: Sutureless L-Shape With Endoscopic Assistance (SLEJ) is an easily applicable, technically simpler, shorter-in-duration, easier-to-learn, and safer intracorporeal EJ anastomosis technique with a low rate of postoperative complications.

Background and Objectives: Non-dipping blood pressure (BP) patterns are associated with increased cardiovascular risk, but their role in periprocedural myocardial infarction (PMI) during elective percutaneous coronary intervention (PCI) remains insufficiently clarified. The objective was to investigate whether a non-dipping BP profile independently predicts PMI in hypertensive patients undergoing elective PCI. Materials and Methods: This prospective observational study enrolled 462 hypertensive patients undergoing elective PCI, categorized as dipping or non-dipping based on 24 h ambulatory BP monitoring (ABPM). Clinical, laboratory, and angiographic data were compared. PMI was defined according to the Fourth Universal Definition of Myocardial Infarction. Independent predictors of PMI were identified using multivariate logistic regression. Results: Of the 462 patients, 243 (52.6%) exhibited a non-dipping BP pattern. Non-dipping status was significantly associated with higher incidence of PMI (32.5% vs. 13.7%, p < 0.001) and a worse metabolic profile, including elevated blood glucose (p = 0.001), Hemoglobin A1c (p = 0.002), and white blood cell count (p = 0.001), and lower high-density lipoprotein cholesterol (p = 0.047). These patients more frequently underwent complex PCI (25.1% vs. 5.0%, p < 0.001). In multivariate analysis, the non-dipping BP pattern emerged as the strongest independent predictor of PMI (odds ratio 25.99, 95% confidence interval 3.16–213.92, p = 0.002), followed by complex PCI, number of stents, stent length, and diabetes mellitus. Conclusions: Non-dipping BP pattern is a powerful and independent predictor of PMI in hypertensive patients undergoing PCI. Incorporating ABPM into routine cardiovascular risk assessment may improve the identification of high-risk patients and allow for tailored preventive strategies.

Background and Objectives: Cutaneous melanoma (CM) poses a continuous challenge in oncology due to the developing resistance to available treatments. Doxorubicin (DOX) is noted as one of the most effective chemotherapeutics, although associated toxicity and resistance limit its use in CM treatment. Consequently, DOX has become a promising candidate for combination therapies targeting this neoplasm. Genistein (GEN) gathered significant attention due to its anti-neoplastic properties and ability to enhance the effects of DOX against several cancers, yet this association remains underexplored in CM. Therefore, this study investigated the combination therapy regimen comprising GEN and DOX in terms of anti-melanoma activity and safety profile. Materials and Methods: The in vitro experiments were performed on SK-MEL-28 and HaCaT cells. Cell viability was determined using MTT assay. Cell morphology and confluence were inspected microscopically. Nuclear and cytoskeletal aspects were assessed via immunofluorescence. Apoptosis and oxidative stress were quantified through caspase activity and intracellular reactive oxygen species (ROS) production, respectively. The irritant effect was evaluated on the chorioallantoic membrane. Results: The results revealed that the combination of GEN 10 µM with DOX (0.5 and 1 µM) provided augmented cytotoxic events (e.g., reduced cell viability, altered cell morphology and confluence, apoptotic-like impairments in nuclear shape and cytoskeletal network, increased caspases-3/7 and -9 activity, and elevated ROS) in SK-MEL-28 cells, compared to individual treatments, and exerted a strong synergistic interaction. Simultaneously, GEN 10 µM efficiently surpassed the toxic effects (e.g., viability and confluence loss, hypertrophy, and cytoskeletal condensation) of DOX (0.5 and 1 µM) in HaCaT cells. In ovo, GEN 10 µM + DOX 1 µM treatment was classified as non-irritant. Conclusions: These findings stand as one of the first contributions revealing the beneficial therapeutic interplay between GEN and DOX at physiologically achievable concentrations that resulted in elevated anti-tumor properties in CM cells and alleviated toxicity in keratinocytes.

Abstract: The last decade of anaesthesia practice worldwide has seen considerable ad- vancements in the field of regional anaesthesia with new equipment, techniques, and drug developments. With these advancements, regional anaesthesia practice has gained considerable momentum, and more patients benefit from it. Here, we review rebound pain after regional anaesthesia, a common yet poorly understood phenomenon that all regional anaesthesiologists should be familiar with in order to recognise, manage, and, where possible, prevent it.

Background and Objectives: Coronary artery bypass graft (CABG) surgery is the most common cardiac surgery. One of the main causes of postoperative complications and increased mortality after CABG is the inflammatory response. The aim of this study was to investigate whether continuous intraoperative dexmedetomidine can reduce the increase of IL-6 and other inflammatory markers after CABG surgery. Materials and Methods: The study is registered with ClinicalTrials.gov, NCT06378827, accessed on 23 April 2024. This prospective experimental study was conducted from April to December 2024 and included 100 patients undergoing CABG surgery. Patients in the experimental group (50 patients) received a continuous infusion of dexmedetomidine (0.5 μg/kg/h) from anesthesia induction until the end of surgery, while the patients in the control group (50 patients) received the same volume of saline. The primary outcomes were the changes in the values of interleukin-6 (IL-6), C-reactive protein (CRP), white blood cells (WBC), and fibrinogen on the first postoperative day (POD1) compared to the basal, preoperative values. Results: The patients in the control group were on average 65.26 years old, and the patients in the experimental group were 66.28 years old (p = 0.555). From the control group, 40 (80%) patients were male compared to 37 (74%) patients from the experimental group (p = 0.635). Median IL-6 before surgery was 2.0 pg/mL, while on POD 1 it was 76.2 pg/mL (p < 0.001). Median CRP before surgery was 2.5 mg/dL, while the POD1 value was 45.5 mg/dL (p < 0.001). Median WBC values were 6.7 × 109/L before surgery and 13.6 × 109/L on POD1 (p < 0.001). The average value of fibrinogen was 3.19 g/L before surgery, while on POD1 it was 3.37 g/L (p = 0.024). The increase in IL-6 on POD1 (ΔIL-6) was 72.4 pg/mL in the control group and 73.0 pg/mL in the experimental group (p = 0.427). ΔCRP was 41.2 mg/mL (control group) and 38.0 mg/mL (experimental group) (p = 0.725). ΔWBC was 7.45 × 109/L (control group) and 6.81 × 109/L (experimental group) (p = 0.407). Δfibrinogen was 0.16 g/L (control group) and 0.2 g/L (experimental group) (p = 0.771). Conclusions: Intraoperative administration of dexmedetodine during CABG surgery at a dose of 0.5 µg/kg/h without a loading dose does not lead to a decrease in the intensity of the inflammatory response after surgery.

Background and Objectives: Metabolic-flow (<0.35 L/min) anesthesia is practiced more often as manufacturers provide newer technologies, yet the benefits of metabolic-flow anesthesia have not been fully investigated. This study aimed to investigate the feasibility and safety of automated gas control (AGC®) mode, which provides metabolic-flow anesthesia, in a pediatric population. Materials and Methods: Pediatric surgery patients between 1 and 10 years of age were included in this prospective observational trial. After intravenous induction and safe orotracheal intubation, AGC® was initiated, and total sevoflurane consumption (mL) and wash-in speed-based sevoflurane consumption data were collected to measure feasibility. For safety, inspired (FiO2), alveolar (FAO2), and expired (FEO2) oxygen concentration data, and inspired and alveolar sevoflurane (FiSevo and FASevo, respectively) concentration data, were recorded. Changes in fresh gas flow (FGF) throughout the procedure and postoperative recovery data were also compared. Results: A total of 130 patients were eligible for this study, and 121 patients were included in the analyses; 30 patients had a wash-in speed of 4 (WI4) and 91 patients had a wash-in speed of 8 (WI8) at follow-up. The total mean sevoflurane consumption was 9.35 ± 4.93 mL for a median surgery duration of 100 min. WI8 patients consumed more sevoflurane (9.92 ± 5.08 mL vs. 7.79 ± 4.19 mL, p = 0.04). At the 15th and 30th minutes, the FGF dropped under minimal flow and metabolic flow limits, respectively (p < 0.001). The times to extubation and obeying commands were shorter in WI8 patients (8 (5–10) vs. 11 (5–15) p = 0.03, and 9.5 (5–10.5) vs. 13 (9–17) p < 0.01). Conclusions: Maintenance with AGC® may offer up to 40 h of anesthesia, considering that the volume of a sevoflurane bottle is 250 mL, reflecting exceptional savings compared to conventional anesthesia management. Metabolic flow anesthesia driven by AGC® is feasible and safe in pediatric anesthesia practice.

Background and Objectives: The male urethra is a complex structure that plays a critical role in genitourinary health and function. Despite its importance, histological descriptions of the penile urethra, particularly its epithelial components, remain incomplete. This study offers a comprehensive histological analysis of the penile urethra, focusing on the epithelium across distinct anatomical regions, including the glans, distal and proximal fossa navicularis and spongy urethra. Materials and Methods: Utilizing five human penile specimens, we employed various staining techniques to elucidate the structural characteristics of these epithelial tissues. Results: Our findings reveal notable variations in epithelial composition, such as the presence of glycogen-rich cells in the distal fossa navicularis and the presence of mucous glands in the spongy urethra and proximal fossa navicularis. Additionally, we identified a previously underreported valvule-like structure in the distal fossa navicularis in two of the specimens. In addition, the epithelium of the glans and the distal fossa navicularis are thicker than the ones of the proximal fossa navicularis and the spongy urethra. With a similar vascular density, the orientation of the blood vessels also diverges starting with the distal fossa navicularis. Conclusions: This study provides new insights into the histological organization of the penile urethra, offering critical reference data that can enhance our understanding of urethral pathologies and improve the outcomes of surgical interventions, particularly in the context of tissue engineering and reconstructive surgery.

Background and Objectives: The occlusal–temporomandibular disorder (TMD) relation is a contentious issue in dentistry to date. This scoping review’s purpose was to map the existing literature on occlusal abnormalities and their potential role in the development and progression of TMD. Materials and Methods: A search in PubMed, Scopus, Cochrane Library, Embase, Lippincott, Medknow, and ClinicalKey was conducted. Articles researching the relationship between TMD and occlusion have been selected. A narrative data synthesis was conducted to chart and summarize the main findings from the included studies. Results: A total of 29 articles were included in this review. These studies confirm that angle class II and angle class III malocclusions, deep bite, and crossbite have a high prevalence of symptoms of TMD, including mandibular deviation, arthritic pain, and tenderness of the muscles. Malocclusion, edentulous spaces, and a reduced vertical dimension of occlusion (VDO) also contribute to the severity of TMD, most prominently in older adults. TMD is also seen with high prevalence in females, with a female-to-male ratio of 2:1 to 20:1, according to studies. Bruxism, premature occlusal contacts, and occlusal interferences also contribute towards symptoms of TMD, in agreement with multiple facets of the disorder. Conclusions: Occlusal abnormalities have a significant association with TMD, but causality cannot be established with most observational studies. This review emphasizes the need for early occlusal examination and intervention to reduce TMD risk.

Background and Objectives: Osteoporosis (OP) is a prevalent condition among postmenopausal women, with an estimated 40% of Saudi women affected. Concurrently, type 2 diabetes mellitus (T2DM) is highly prevalent in the Qassim region, affecting 45% of individuals aged 40 and older. Despite conflicting evidence regarding the impact of T2DM on bone health, its role in OP development remains uncertain. Materials and Methods: This study investigates site-specific bone mineral density (BMD) variations and their metabolic correlations in postmenopausal Saudi women with T2DM. A cross-sectional study included 250 postmenopausal Saudi women, 100 without diabetes (Group 1) and 150 with diabetes (Group 2), matched for age, menopausal duration, and body mass index (BMI). BMD at the femoral neck (FN) and lumbar spine (LS) was assessed using dual-energy X-ray absorptiometry (DXA). Biochemical markers, including parathyroid hormone (PTH), alkaline phosphatase (ALP), estrogen, calcium, and HbA1c, were assessed. Statistical analyses, including chi-square tests, t-tests, ANOVA, Pearson correlation, and multivariate regression, evaluated BMD variations and biochemical associations.Results:Patients with diabetes exhibited significantly higher FN T-scores than those without diabetes (p = 0.001), while LS T-scores showed no significant difference. BMD distribution (normal, osteopenia, OP) did not differ between the groups (p > 0.05). FN T-scores correlated positively with parathyroid hormone (PTH) and alkaline phosphatase (ALP) levels, reduced estrogen, and prolonged menopause duration (p < 0.01) but were inversely associated with estrogen levels and menopause duration (p < 0.01). Conclusions: No significant association was found between HbA1c and BMD. Additionally, BMI demonstrated a protective effect on FN BMD. T2DM appears to influence bone metabolism without directly causing OP in postmenopausal women. Aging, menopause duration, metabolic markers (PTH, ALP, estrogen), and BMI play crucial roles in BMD variations, with a protective effect of BMI. These findings underscore the importance of site-specific BMD assessment and metabolic profiling in postmenopausal women with diabetes. Further longitudinal research is needed to elucidate the underlying mechanisms affecting bone health in postmenopausal women with diabetes.

Background and Objectives: The neutrophil-percentage-to-albumin ratio (NPAR) has been recognized as an independent risk factor for cardiovascular diseases. In our study, we investigated whether the NPAR is associated with the formation of coronary collateral circulation (CCC) in patients with chronic coronary syndrome (CCS). Materials and Methods: A total of 681 patients with CCS were included in this study. Of these patients, 571 had chronic total occlusion in at least one major vessel and developed collateral vessels. In total, 110 patients were in the control group, who had CCS but did not have complete occlusion in a major vessel and did not develop collateral vessels. Patients with collateral vessels on coronary angiography were divided into two groups according to the Rentrop score: poor CCC (Rentrop 0–1) and good CCC (Rentrop 2–3). Blood samples were taken for the NPAR and other biochemical parameters in all patients during hospitalization. The NPAR was calculated as the neutrophil-percentage-to-albumin ratio. Results: The group of patients with poor CCC had a higher white blood count (WBC), neutrophil, C-reactive protein (CRP), neutrophil–lymphocyte ratio (NLR), CRP/albumin ratio (CAR), and NPAR values than patients with good CCC (p < 0.001, for all). Multivariate logistic regression analysis showed that high NPAR levels were an independent predictor of poor CCC (OR: 2.79, 95% CI:1.7–4.6, p < 0.001), accompanied by neutrophil, CRP, CAR, and NLR levels. In the receiver operator characteristic curve (ROC analysis), the cut-off value for the NPAR to indicate poor CCC was 1.78 with a sensitivity of 76.6% and specificity of 81.4% (area under ROC curve = 0.804 95% CI (0.753–0.854), p < 0.001). Conclusions: We demonstrated that the NPAR may be an independent predictor of poor CCC development in clinical practice.

Background and Objectives: Frailty can represent the transitional stage between successful aging and old age in need of care; it is a guide for setting goals for regaining robust old age in the individual at risk. Frailty is associated with longer intensive care unit duration, hospital stay, and higher mortality. The aim of this study was to evaluate the relationship between mortality and frailty in geriatric patients (65 years and older) admitted to the intensive care unit with a diagnosis of pneumonia. Materials and Methods: In total, 478 patients were included in the study. The demographic data, such as age, gender, body mass index (BMI), Charlson comorbidity index (CCI), Clinical Frailty Scale (CFS), acute physiology and chronic health evaluation (APACHE II) scores, sequential organ failure assessment score (SOFA), invasive/noninvasive mechanical ventilator days, length of stay in the hospital and intensive care unit, inotropic requirement, and 28-day mortality, were retrospectively scanned and recorded. Results: Advanced age, lower BMI, higher Charlson Comorbidity index (CCI), SOFA score, and CFS increased 28-day mortality. CFS was found to be associated with 28-day mortality similar to the use of inotropic agents, prolonged MV duration, and ICU length of stay (LOS). Conclusions: CFS is effective in predicting 28-day mortality in geriatric patients diagnosed with pneumonia in intensive care. It also provides insights into morbidity parameters such as requirement for inotropic agents, duration of mechanical ventilation (MV), and LOS ICU.

Background and Objectives: Sleep disorders are highly prevalent in society and require focused attention within healthcare systems. While patient history, reported complaints, and subjective sleep questionnaires can provide initial insights into potential sleep issues, polysomnography (PSG) remains the gold standard for diagnosing various sleep disorders. However, long waiting times for PSG appointments in many healthcare facilities pose challenges for timely diagnosis and treatment. This study aimed to evaluate the diagnostic value of subjective measures, including patient-reported parameters, in comparison to the objective findings of PSG. Materials and Methods: In this study, we retrospectively analysed the data from 562 patients who underwent clinical evaluation and PSG testing at the Hospital of Lithuanian University of Health Sciences Kaunas Clinics between 2018 and 2024. We report the diagnostic accuracy of different sleep questionnaires to detect various sleep disorders in our population. Results: We report the corresponding sensitivity and specificity values: the Epworth Sleepiness Scale (ESS)—73.2% and 44.1% for detecting severe obstructive sleep apnoea and 87.1% and 76.8% for detecting hypersomnia; the Insomnia Severity Index (ISI)—77.2% and 63.3% for detecting insomnia; the Berlin Questionnaire (BQ)—67.8% and 68.8% for detecting obstructive sleep apnoea; the Ullanlina Narcolepsy Scale (UNS)—84.4% and 58.9% for detecting hypersomnia; the Innsbruck REM Sleep Behaviour Disorder Inventory (RBD-I)—93.3% and 52.5% for detecting RBD; the REM Sleep Behaviour Disorder Single-Question Screen (RBD1Q)—73.3% and 81.0% for detecting RBD; and the Paris Arousal Disorder Severity Scale (PADSS)—57.5% and 90.5% for detecting parasomnia. Conclusions: When comparing our findings with the previous literature, we found that the screening tools generally demonstrated a slightly poorer performance in our population. However, our results suggest that certain individual questions from the comprehensive questionnaires may provide comparable diagnostic values, while reducing the patient burden. We propose a targeted screening approach that integrates fundamental clinical parameters, key screening questions, and selected validated questionnaires, enabling primary care and outpatient clinicians to more efficiently identify patients who may require referral for specialised sleep evaluation and treatment.

Background and Objectives: Low back pain (LBP) is a highly prevalent musculoskeletal condition that frequently recurs, leading to increased healthcare utilization and socioeconomic burden. While short-term management strategies are well-documented, long-term recurrence patterns remain insufficiently studied. This study aims to describe the long-term recurrence patterns and healthcare utilization associated with LBP in a nationwide cohort over a 17-year period. Materials and Methods: This descriptive, retrospective longitudinal cohort study utilized data from the Korean National Health Insurance Service (NHIS) database (2002–2018). We included 3,086,665 patients who sought medical care for LBP (ICD-10 code M54.5) at least once in 2010. Patients with a history of disability rating assessments were excluded. The primary outcomes included the number of LBP episodes, episode duration, recurrence patterns, and changes in healthcare utilization. We assessed the number of healthcare visits per episode and the interval between episodes over time. Results: Among the study population, 79.4% experienced recurrent LBP, with an average of 5.0 ± 4.9 episodes per patient. Recurrence rates increased with each episode. In addition, episode duration lengthened, and intervals between episodes shortened. Healthcare utilization also increased, with patients requiring more visits per episode over time. The demographic and socioeconomic characteristics of the LBP patients in our sample were also described. Conclusions: In this population-based sample, LBP follows a progressive course, with increasing episode frequency, prolonged duration, and escalating healthcare utilization over time. These findings highlight the need for early intensive management and long-term follow-up strategies to mitigate the growing burden of recurrent LBP on individuals and healthcare systems.

Background and Objectives: Elderly trauma patients face unique physiological challenges that often lead to undertriage under the current guidelines. The present study aimed to develop machine-learning (ML)-based, age-specific triage guidelines to improve predictions for intensive care unit (ICU) admissions and in-hospital mortality. Materials and Methods: A total of 274,347 trauma cases transported via Emergency Medical System (EMS)-119 in Seoul (2020–2022) were analyzed. Physiological indicators (e.g., systolic blood pressure; saturation of partial pressure oxygen; and alert, verbal, pain, unresponsiveness scale) were incorporated. Bayesian optimization was used to fine-tuned models for sensitivity and specificity, emphasizing the F2 score to minimize undertriage. Results: Compared with the current guidelines, the alternative guidelines achieved superior sensitivity for ICU admissions (0.728 vs. 0.541) and in-hospital mortality (0.815 vs. 0.599). Subgroup analyses across injury severities, including traumatic brain and chest injuries, confirmed the enhanced performance of the alternative guidelines. Conclusions: ML-based, age-specific triage guidelines improve the sensitivity of triage decisions, reduce undertriage, and optimize elderly trauma care. Implementing these guidelines can significantly enhance patient outcomes and resource allocation in emergency settings.

Background and Objectives: Sarcopenia is frequently observed in cancer patients and is associated with short survival. In this study, the aim was to research the sarcopenia risk factors, the correlation of sarcopenia with inflammatory biomarkers, and the prognostic significance of sarcopenia and inflammation markers in patients with metastatic gastric cancer. Material and Method: The study included 177 patients diagnosed with metastatic gastric cancer attending Dokuz Eylül University Faculty of Medicine (DEUFM) Medical Oncology clinic from 2016 to 2022. The skeletal muscle area at L3 vertebral level was identified on abdominal computed tomography (CT) images, and the skeletal muscle index (SMI, cm2/m2) was calculated. Additionally, PLR, MLR, NLR, dNLR, SIRI, SII, PIV, PNI, CAR, and LAR were assessed among systemic inflammatory biomarkers. Cut-off values were determined with ROC curve analysis. Survival analyses were performed with the Kaplan–Meier method, and risk factors were investigated with Cox regression analysis. For all statistical analyses, p < 0.05 was accepted as significant. Results: Among patients, 71.8% were identified to have sarcopenia. Significant levels of difference were identified for median SIRI, NLR, MLR, PLR, SII, PNI, and dNLR values between patients with and without sarcopenia (p < 0.05). The sarcopenia risk was assessed between groups created according to the cut-off values for inflammation markers. Univariate regression analysis found that SIRI, PIV, NLR, MLR, PLR, SII, PNI, and dNLR were statistically significant (p < 0.05). Multivariate analysis identified SIRI and PNI as independent risk factors. For all patients, median overall survival was identified to be 12.4 ± 0.8 months (CI 95%, 10.8–13.9). For patients with sarcopenia, overall survival duration was 11.5 ± 0.8 months, while survival duration for patients without sarcopenia was 17.5 ± 4.6 months (p = 0.010). Elevation in the inflammatory biomarkers of SIRI, NLR, SII, LAR, and CAR and low PNI values appear to be associated with short survival (p < 0.05). Conclusions: In this study, sarcopenia was frequently observed in patients with metastatic gastric cancer and sarcopenia was associated with shorter survival. A significant correlation was observed between sarcopenia and inflammatory biomarkers, with SIRI and PNI identified to be independent risk factors for sarcopenia. Our study emphasizes the prognostic importance of sarcopenia and inflammatory markers for the management of patients with metastatic gastric cancer.

Background and Objectives: Dexmedetomidine is a potent selective α2 receptor agonist with analgesic and sedative effects. Many reports indicate that compared to fentanyl, the combination of dexmedetomidine with propofol provides comparably acceptable conditions for a laryngeal mask airway (LMA). However, no study has evaluated the effectiveness of combined dexmedetomidine and thiopental in LMA insertions compared to that of combined dexmedetomidine and propofol. This prospective, randomized, double-blind study aimed to compare the effects of dexmedetomidine with thiopental or propofol on LMA insertion conditions, hemodynamic responses, and pharyngolaryngeal morbidity, which in this study was defined as the presence of postoperative sore throat, dysphagia, or visible blood in the airway following a laryngeal mask airway (LMA) insertion. Materials and Methods: A total of 80 premedicated ASA I-II patients aged 18–65 years were randomized to the propofol group (Group P, n = 40) or thiopental group (Group T, n = 40). Anesthesia was induced by infusing 1 μg·kg−1 dexmedetomidine over 10 min followed by 2.5 mg·kg−1 propofol or 5 mg·kg−1 thiopental. LMA insertion conditions were evaluated on a scale assessing six variables. Systolic arterial pressure (SAP), diastolic arterial pressure (DAP), mean arterial pressure (MAP), heart rate (HR), and bispectral index values were recorded at baseline; 1 min before; and at 1, 2, 3, 4, and 5 min after an LMA insertion. The baseline values for the systolic arterial pressure (SAP), diastolic arterial pressure (DAP), mean arterial pressure (MAP), heart rate (HR), and bispectral index (BIS) values were recorded before dexmedetomidine infusion. Measurements for all patients were then taken 1 min before and at 1, 2, 3, 4, and 5 min after the LMA insertion Results: Demographic data were similar between the groups. In Group P, the time to loss of eyelash reflex and LMA insertion time were significantly shorter, the apnea duration was significantly longer, and the rates of full jaw opening and optimal LMA insertion conditions were significantly higher when compared with those of Group T (p < 0.05). Group P showed a significantly greater percentage decrease in HR compared to that of Group T at 1 min before and 1, 2, and 3 min after the LMA insertion (p < 0.05). Group T had a greater decrease in SAP and MAP at 1 min before insertion, while the SAP decrease was lower in Group T at 3, 4, and 5 min after insertion. The MAP and DAP values after the LMA insertion showed a greater decrease in Group P compared to in Group T (p < 0.05) The incidence of bradycardia was significantly (p < 0.05) higher in Group P than in Group T. There was no significant difference between the groups in terms of the frequency of hypotension, sore throat, presence of blood, or dysphagia at discharge from the recovery unit (p > 0.05). Conclusions: This study showed that the use of dexmedetomidine with thiopental provided comparably acceptable LMA insertion conditions with more stable hemodynamics compared to propofol.

Background and Objectives: Carotid artery stenosis is a significant risk factor for ischemic stroke due to impaired cerebral blood flow (CBF). Even asymptomatic unilateral stenosis can induce subclinical cerebrovascular changes, potentially affecting both hemispheres through collateral circulation. This study aimed to systematically assess cerebral perfusion in asymptomatic individuals with unilateral carotid artery stenosis by comparing ipsilateral and contralateral hemispheres with healthy controls, challenging the assumption that the contralateral hemisphere remains unaffected. Materials and Methods: This cross-sectional study included 114 participants, comprising 54 asymptomatic individuals (mean age 65.5) with significant unilateral carotid stenosis and 60 age-matched controls (mean age 64.8). Cerebral perfusion was assessed using 1.5T Magnetic Resonance Imaging (MRI) with pseudo-continuous arterial spin labeling (pCASL). CBF was measured bilaterally in four predefined middle cerebral artery (MCA) regions: precentral gyrus, lentiform nucleus, insular cortex, and temporal cortex. Statistical analyses included multivariate analysis of variance (MANOVA), analysis of variance (ANOVA), paired t-tests, and discriminant analysis (DA). Results: Significant bilateral reductions in CBF were observed in individuals with carotid stenosis compared to controls (MANOVA and ANOVA, p < 0.001). The greatest perfusion deficit was in the ipsilateral insular cortex (49.88 ± 10.83 mL/100 g/min), followed by intermediate contralateral perfusion (51.49 ± 8.86 mL/100 g/min) and higher control values (58.78 ± 10.44 mL/100 g/min). DA indicated the insular cortex as the region with the highest discriminative contribution (64.7%). Conclusions: Unilateral carotid artery stenosis in asymptomatic individuals is associated with significant bilateral cerebral hypoperfusion, suggesting widespread hemodynamic effects. Pronounced perfusion deficits in the insular cortex underline its vulnerability. The observed contralateral perfusion reductions challenge the traditional use of the contralateral hemisphere as a reference standard, underscoring the need for comprehensive perfusion assessment in carotid artery disease.

Background and Objectives: This study aimed to evaluate the diagnostic potential of systemic inflammatory indices such as Systemic Inflammation Response Index (SIRI) and Systemic Inflammatory Response (SIR). These were assessed in combination with CA 125 to distinguish ovarian carcinoma (OC) from borderline ovarian tumors (BOT) in patients with suspicious adnexal masses. Materials and Methods: A retrospective multicenter observational study including patients undergoing surgery for suspected ovarian neoplasms was conducted. Inclusion criteria required preoperative blood sampling for inflammatory markers and CA 125. SIR-125 and SIRI-125 were developed by combining SIR and SIRI with CA 125 levels. Diagnostic performance was assessed using ROC curve analysis and linear regression models. Results: A total of 63 patients (42 BOT, 21 OC) were analyzed. OC patients exhibited significantly higher SIR-125 and SIRI-125 values (p < 0.001). ROC analysis demonstrated good diagnostic accuracy, with AUCs of 0.83 (SIR-125) and 0.82 (SIRI-125). SIR-125 showed higher specificity (0.83), while SIRI-125 had superior sensitivity (0.86). Conclusions: SIR-125 and SIRI-125 enhance diagnostic differentiation between OC and BOT, providing a simple, cost-effective preoperative tool. Future prospective studies are needed to validate these findings in broader patient populations.