Clinics and Practice

12 pages, 528 KB

Open AccessArticle

Efficacy of Non-Invasive Monopolar Radiofrequency for Treating Genitourinary Syndrome of Menopause: A Prospective Pilot Study

by Mariachiara Palucci, Marta Barba, Alice Cola, Clarissa Costa, Desirèe De Vicari and Matteo Frigerio

Clin. Pract. 2025, 15(8), 155; https://doi.org/10.3390/clinpract15080155 - 20 Aug 2025

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Abstract

Introduction: The decline of serum estrogen in postmenopausal women leads to several changes in the vulvovaginal and vesicourethral areas, resulting in the genitourinary syndrome of menopause (GSM), characterized by bothersome symptoms such as vaginal atrophy, lack of lubrication, dyspareunia, urgency, dysuria, and [...] Read more.

Introduction: The decline of serum estrogen in postmenopausal women leads to several changes in the vulvovaginal and vesicourethral areas, resulting in the genitourinary syndrome of menopause (GSM), characterized by bothersome symptoms such as vaginal atrophy, lack of lubrication, dyspareunia, urgency, dysuria, and recurrent urinary tract infections. Nevertheless, this condition could also be experienced by younger women affected by hormone-dependent tumors. Although topical estrogens are considered “the gold standard”, hormonal treatments cannot be indicated in cancer survivors. As a result, energy-based devices using radiofrequency and laser technologies have emerged as alternative options. This prospective study aimed to evaluate the benefits of non-invasive monopolar radiofrequency (RF) in women affected by GSM who have contraindications to, did not respond to, or declined local estrogen therapy. Methods: The patients underwent five weekly sessions of second-generation monopolar RF. At baseline and at the fifth session, two validated questionnaires were administered to the patients: the Visual Analogue Scale (VAS) and the Female Sexual Function Index (FSFI-19). On the other hand, the vaginal mucosa status was evaluated by clinicians through the Vaginal Health Index (VHI). At the end of the cycle, the Patient Global Impression of Improvement (PGI-I) questionnaire was collected. Results: Based on 44 patients who completed five sessions of radiofrequency, a significant improvement was observed in sexual function according to the FSFI scale (22.9 vs. 38.6; p < 0.001) and in VVA atrophy symptoms, as documented by the VAS score (223 vs. 125; p < 0.001). The mean VHI score increased by 3 points (p < 0.001). Moreover, according to PGI-I, 96% of patients reported a perceived improvement (PGI-I score ≤ 3). Conclusions: Radiofrequency could provide an innovative and safe therapeutic approach for patients suffering from GSM and VVA, especially when hormonal strategies are unsuitable. Full article

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10 pages, 251 KB

Open AccessArticle

Allelic and Genotypic Distribution of MMP13-77 A/G Polymorphism in Salvadoran Children With and Without Caries

by Wendy Escobar-González, Jorge Alegría-Torres, Yolanda Terán-Figueroa, Vianney Castañeda-Monroy, Aurelio Álvarez-Vargas, Carlo Eduardo Medina-Solís and Nuria Patiño-Marín

Clin. Pract. 2025, 15(8), 154; https://doi.org/10.3390/clinpract15080154 - 19 Aug 2025

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Abstract

Background/Objectives: Polymorphisms in metalloproteinases (MMPs) have the potential to be probable genetic biomarkers of dental caries. The aim of this study was to evaluate the distribution of the MMP13 A/G rs2252070 single nucleotide polymorphism (SNP) according to caries experience in Salvadoran children. [...] Read more.

Background/Objectives: Polymorphisms in metalloproteinases (MMPs) have the potential to be probable genetic biomarkers of dental caries. The aim of this study was to evaluate the distribution of the MMP13 A/G rs2252070 single nucleotide polymorphism (SNP) according to caries experience in Salvadoran children. Methods: A cross-sectional study was carried out on 185 Salvadorian school children between 7 and 12 years of age. Demographic data, frequency of toothbrushing, dental flossing and consumption of sugar-sweetened beverages were recorded. Caries data were collected by clinical examination. Genomic DNA was obtained from oral cells of the children. Polymorphism genotyping was performed by PCR-RFLP. Allele and genotypic frequencies were compared between the healthy and caries-experiencing groups. Data were analyzed with SPSS 26.0 using the chi-square test, the Kruskal–Wallis test and logistic regression analysis. Results: The allele frequencies of MMP13-77 A/G were 0.7 and 0.3 following the Hardy–Weinberg equilibrium (X² = 0.22, p = 0.63). 72% of subjects with caries experience were carriers of the A allele. Caries experience was higher for the GG genotype group for permanent and primary surfaces (DMFS = 2.11; dmfs = 5.64) and for permanent teeth (DMFT = 1.50). No significant differences were found in the allelic and/or genotypic frequencies of the SNP polymorphism between subjects with dental caries and healthy subjects (p > 0.05). Conclusions: The distribution of MMP13-77 A/G rs2252070 in the study population showed no association with caries experience. However, our findings highlight the importance of promoting oral hygiene habits from an early age. Full article

(This article belongs to the Topic Advances in Diagnosis and Treatment of Dental Diseases and Temporomandibular Joints)

13 pages, 252 KB

Open AccessArticle

Association Between Emotional Intelligence and Stress Management in Hemodialysis Patients

by Orchan Impis, Afroditi Zartaloudi, Eirini Grapsa and Georgia Gerogianni

Clin. Pract. 2025, 15(8), 153; https://doi.org/10.3390/clinpract15080153 - 19 Aug 2025

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Abstract

Background: Emotional intelligence refers to individuals’ ability to recognize and manage their own emotions as well as those of others, playing a crucial role in stress management. This study aimed to investigate the relationship between different dimensions of emotional intelligence and stress management [...] Read more.

Background: Emotional intelligence refers to individuals’ ability to recognize and manage their own emotions as well as those of others, playing a crucial role in stress management. This study aimed to investigate the relationship between different dimensions of emotional intelligence and stress management strategies in patients undergoing hemodialysis. Methods: In this cross-sectional study, 468 patients on hemodialysis completed the (i) Wong and Law Emotional Scale (WLEIS) and (ii) Trait Emotional Intelligence Questionnaire Short Form (TEIQue-SF) for the assessment of emotional intelligence as an emotional ability or as a personality trait, respectively; (iii) the Brief COPEQuestionnaire (Brief- COPE) for the assessment of stress management strategies; and (iv) a questionnaire about demographic characteristics. Spearman’s correlations coefficients were used to explore associations between two continuous variables. Multiple linear regression analysis was used with Brief-COPE dimensions as the dependent variable. Results: High levels of emotionality were associated with an active approach to coping with stress (p = 0.018), while increased well-being and high regulation of emotions were associated with decreased behavioral disengagement (p < 0.001). Moreover, high emotional appraisal of others was linked to an increased use of humor (p = 0.042), while self-control and use and regulation of emotions were associated with decreased expression of negative feelings (p < 0.001). Conclusions: The current findings suggest potential links between emotional intelligence and stress management strategies in patients undergoing hemodialysis. Full article

19 pages, 671 KB

Open AccessArticle

Macrovascular Involvement in Systemic Sclerosis: Association Between Carotid Ultrasound Hemodynamics Parameters and Digital Ulcers

by Eugenio Capparelli, Francesco Lapia, Luca Clerici, Eleonora Zaccara, Giusy Cinzia Moltisanti, Francesca Capelli, Daniela Bompane, Laura Castelnovo, Antonio Tamburello, Maria Iacovantuono, Maria Sole Chimenti, Paola Maria Luigia Faggioli and Antonino Mazzone

Clin. Pract. 2025, 15(8), 152; https://doi.org/10.3390/clinpract15080152 - 18 Aug 2025

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Abstract

Background: Digital ulcers (DUs) are among the most debilitating vascular complications in SSc and are commonly attributed to microvascular damage. However, recent evidence suggests a potential involvement of macrovascular abnormalities, including subclinical atherosclerosis and altered hemodynamic parameters. Objectives: This study aimed to investigate [...] Read more.

Background: Digital ulcers (DUs) are among the most debilitating vascular complications in SSc and are commonly attributed to microvascular damage. However, recent evidence suggests a potential involvement of macrovascular abnormalities, including subclinical atherosclerosis and altered hemodynamic parameters. Objectives: This study aimed to investigate the association between a history of DUs and macrovascular involvement in SSc patients through carotid and vertebral Doppler ultrasonography, with a focus on hemodynamic indices such as Peak Systolic Velocity (PSV), End-Diastolic Velocity (EDV), Resistive Index (RI), and Intima–Media Thickness (IMT). Methods: A cross-sectional study was conducted on 107 SSc patients. Clinical, serological, cardiovascular, and metabolic data were collected, and carotid–vertebral ultrasound was performed. Patients were stratified based on DU history. Statistical analyses assessed associations between DU status and carotid–vertebral US findings. Results: Patients with DUs showed a significantly higher PSV in both right (86.9 ± 67.9 vs. 64.2 ± 20.5 cm/s, p = 0.010) and left ICA (78.9 ± 29.6 vs. 63.4 ± 18.2 cm/s, p = 0.002). Right ICA RI vas elevated in the DU group (p = 0.021). PSV in the external carotid arteries was also bilaterally increased in DU patients (p < 0.005). DU-positive patients had a higher prevalence of left carotid plaques (p = 0.012) and right-sided ICA RI > 0.75 (p = 0.01). Logistic regression identified DU history as an independent predictor of PSV at ICA (β = 31.89, p = 0.043) and carotid plaque presence at any side (OR 14.34, p = 0.012). Conclusions: A history of digital ulcers in SSc patients is associated with altered carotid hemodynamics and an increased subclinical atherosclerotic burden. These findings suggest that DUs may reflect not only microvascular damage, but also macrovascular dysfunction, supporting the need for integrated vascular assessment in SSc clinical practice. Full article

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10 pages, 793 KB

Open AccessSystematic Review

Prevalence of Free Flap Failure in Patients Undergoing Reconstruction for Medication-Related Osteonecrosis of the Jaw: A Systematic Review and Meta-Analysis

by Evangelos Kostares, Georgia Kostare, Michael Kostares, Fani Pitsigavdaki, Athanassios Kyrgidis, Christos Perisanidis and Maria Kantzanou

Clin. Pract. 2025, 15(8), 151; https://doi.org/10.3390/clinpract15080151 - 14 Aug 2025

Viewed by 322

Abstract

Background/Objectives: Medication-related osteonecrosis of the jaw (MRONJ) is a serious complication in patients treated with antiresorptive or antiangiogenic agents, particularly those with cancer-related comorbidities. This systematic review and meta-analysis aimed to estimate the prevalence of free flap failure in patients undergoing microvascular [...] Read more.

Background/Objectives: Medication-related osteonecrosis of the jaw (MRONJ) is a serious complication in patients treated with antiresorptive or antiangiogenic agents, particularly those with cancer-related comorbidities. This systematic review and meta-analysis aimed to estimate the prevalence of free flap failure in patients undergoing microvascular reconstruction for MRONJ. Methods: A comprehensive literature search was conducted across Medline/PubMed, Scopus, and Web of Science up to 30 January 2025. Inclusion criteria were observational studies involving MRONJ patients treated with free flap reconstruction. Risk of bias was assessed using the Newcastle–Ottawa Scale. The pooled prevalence of free flap failure was calculated using a random-effects model with Freeman–Tukey double arcsine transformation. Results: Twelve studies were included in the quantitative analysis. The fibula free flap was the most frequently used flap. The pooled prevalence of free flap failure was 0.1% (95% CI: 0–2.3%), with no significant associations observed in meta-regression analyses for publication year, patient age, or sex. All included studies were of moderate methodological quality. Conclusions: These findings suggest that free flap reconstruction is a reliable and effective surgical option for managing advanced MRONJ in well-resourced and specialized healthcare settings; however, limitations such as small sample sizes and heterogeneity in protocols must be considered. Further high-quality, multicenter studies are needed to evaluate long-term outcomes and refine perioperative management strategies. Full article

(This article belongs to the Special Issue Clinical Outcome Research in the Head and Neck: 2nd Edition)

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11 pages, 221 KB

Open AccessReview

Cognitive Impairment in Adult Attention Deficit Hyperactivity Disorder: Clinical Implications and Novel Treatment Strategies

by Alexis J. Vega, Gabriel V. Hernandez, Ahmed I. Anwar, Bahareh Sharafi, Rahib K. Islam, Sahar Shekoohi and Alan D. Kaye

Clin. Pract. 2025, 15(8), 150; https://doi.org/10.3390/clinpract15080150 - 12 Aug 2025

Viewed by 833

Abstract

Attention Deficit Hyperactivity Disorder (ADHD) is a lifelong condition; however, traditional treatment focuses on hyperactivity and inattention, which is largely a manifestation of pediatric ADHD. Studies are limited regarding cognitive difficulties, as seen in adult ADHD, as well as treatment strategies for this [...] Read more.

Attention Deficit Hyperactivity Disorder (ADHD) is a lifelong condition; however, traditional treatment focuses on hyperactivity and inattention, which is largely a manifestation of pediatric ADHD. Studies are limited regarding cognitive difficulties, as seen in adult ADHD, as well as treatment strategies for this population. This review of the literature examines multiple recent studies that discuss various novel treatment strategies for cognitive impairment in adults with ADHD. A targeted literature review was conducted using PubMed to identify recent studies on cognitive dysfunction in adults with ADHD, with an emphasis on emerging treatment strategies. Data collected included sample size, intervention strategies, cognitive function, and side effects. Studies on non-invasive brain stimulation revealed significant effects on executive function in adult ADHD patients. Other studies revealed statistically significant improvements in cognitive flexibility and response inhibition in modafinil users. Another study demonstrated significant improvement in working memory with off label use of viloxazine for adults. This review of the literature describes the effectiveness of novel treatment strategies of adult ADHD including non-stimulant medications, behavioral therapies and neurofeedback. This highlights the need for treatment modalities that enhance cognitive outcomes and further research into long-term efficacy and safety of these novel interventions and implementing psychological treatment into medical management of adult ADHD. Full article

17 pages, 241 KB

Open AccessArticle

Creating and Validating a Questionnaire on Dentists’ Perceptions Regarding Periodontics–Prosthodontics Interdisciplinary Clinical Practice

by Gabriel Rotundu, Dragos Ioan Virvescu, Zinovia Surlari, Dana Gabriela Budala, Florin Razvan Curca, Carina Balcos, Cristian Cojocaru, Vlad Constantin, Razvan Gradinariu and Ionut Luchian

Clin. Pract. 2025, 15(8), 149; https://doi.org/10.3390/clinpract15080149 - 7 Aug 2025

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Abstract

Background: The interaction between prosthetic restorations and periodontal health is a critical factor for the long-term success of dental treatments. A biologically compatible prosthetic design supports periodontal stability, whereas neglecting periodontal principles can compromise treatment outcomes. This study aimed to validate a questionnaire [...] Read more.

Background: The interaction between prosthetic restorations and periodontal health is a critical factor for the long-term success of dental treatments. A biologically compatible prosthetic design supports periodontal stability, whereas neglecting periodontal principles can compromise treatment outcomes. This study aimed to validate a questionnaire designed to assess dentists’ perceptions regarding the influence of prosthetic restorations on the periodontium. Material and Methods: An observational cross-sectional study was conducted using a self-administered questionnaire distributed to licensed dentists across Romania. The questionnaire underwent expert review, pilot testing (n = 50), and statistical validation, including the Content Validity Index (CVI), Cronbach’s alpha for internal consistency, and Exploratory Factor Analysis (EFA) using Principal Component Analysis (PCA) with Varimax rotation. The final sample included 39 respondents. Data was analyzed using SPSS v26.0. Results: The questionnaire demonstrated excellent internal consistency (Cronbach’s alpha = 0.900; standardized alpha = 0.917). Most items had corrected item-total correlations > 0.40. EFA revealed eight coherent factors explaining 81.68% of total variance, with high communalities (0.549–0.966), strong Kaiser–Meyer–Olkin test (KMO) values, and significant Bartlett’s test values, confirming construct validity. Descriptive statistics showed predominantly positive attitudes among dentists regarding the periodontal considerations in prosthetic treatment. The highest-rated items emphasized oral hygiene, periodontal stability, and biological adaptation of restorations. Lower scores were associated with routine use of periodontal indices and recognition of failures due to insufficient evaluation. Conclusions: The validated instrument proved reliable and demonstrated strong psychometric properties in this exploratory validation, supporting its use in research and education. Romanian dentists demonstrated a favorable perception of the role of periodontal health in prosthetic success. This tool can inform curriculum development and interdisciplinary clinical protocols in prosthodontics and periodontology. Full article

(This article belongs to the Special Issue New Trends, Materials, and Technologies and Consolidating Best Practices in Dentistry, 2nd Edition)

16 pages, 786 KB

Open AccessReview

The Role of Vitamin D Supplementation in Type 1, Type 2, and Gestational Diabetes: A Comprehensive Updated Narrative Review

by Asala Nasser, Dimitrios Papandreou, Sousana K. Papadopoulou and Leila Cheikh Ismail

Clin. Pract. 2025, 15(8), 148; https://doi.org/10.3390/clinpract15080148 - 7 Aug 2025

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Abstract

Vitamin D has emerged as a modulatory factor in the pathogenesis and management of diabetes mellitus due to its influence on pancreatic β-cell function, immune regulation, and inflammatory pathways. This narrative review critically examines mechanistic and clinical evidence linking vitamin D status with [...] Read more.

Vitamin D has emerged as a modulatory factor in the pathogenesis and management of diabetes mellitus due to its influence on pancreatic β-cell function, immune regulation, and inflammatory pathways. This narrative review critically examines mechanistic and clinical evidence linking vitamin D status with type 1 diabetes (T1DM), type 2 diabetes (T2DM), and gestational diabetes (GDM). In T1DM, vitamin D’s immunomodulatory effects are thought to protect β-cells from autoimmune destruction; epidemiological studies associate vitamin D sufficiency with lower T1DM incidence and improved glycemic control, although causality remains under investigation. In T2DM, vitamin D deficiency is associated with worsened metabolic control and may contribute to disease development in at-risk individuals; however, it does not influence the initial onset of T2DM in patients who are already diagnosed. Intervention trials indicate that correcting the deficiency can modestly improve insulin sensitivity, β-cell function, and metabolic parameters. GDM has similarly been linked to hypovitaminosis D, with low maternal vitamin D levels associated with higher GDM risk and adverse perinatal outcomes; mechanistic insights suggest that adequate vitamin D supports glucose homeostasis in pregnancy, and emerging trials demonstrate improved insulin resistance with maternal vitamin D supplementation. Across these diabetes subtypes, maintaining sufficient vitamin D levels appears to confer metabolic benefits and may serve as an adjunct to current preventive and therapeutic strategies. However, definitive evidence from large-scale trials is required to establish optimal vitamin D supplementation protocols and confirm its efficacy in diabetes care. Full article

(This article belongs to the Special Issue The Effect of Dietary Compounds on Inflammation-Mediated Diseases)

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10 pages, 203 KB

Open AccessArticle

Minimally Invasive Off-Pump Coronary Artery Bypass as Palliative Revascularization in High-Risk Patients

by Magdalena Rufa, Adrian Ursulescu, Samir Ahad, Ragi Nagib, Marc Albert, Rafael Ayala, Nora Göbel, Tunjay Shavahatli, Mihnea Ghinescu, Ulrich Franke and Bartosz Rylski

Clin. Pract. 2025, 15(8), 147; https://doi.org/10.3390/clinpract15080147 - 6 Aug 2025

Viewed by 465

Abstract

Background: In high-risk and frail patients with multivessel coronary artery disease (MV CAD), guidelines indicated complete revascularization with or without the use of cardiopulmonary bypass (CPB) bears a high morbidity and mortality risk. In cases where catheter interventions were deemed unsuitable and conventional [...] Read more.

Background: In high-risk and frail patients with multivessel coronary artery disease (MV CAD), guidelines indicated complete revascularization with or without the use of cardiopulmonary bypass (CPB) bears a high morbidity and mortality risk. In cases where catheter interventions were deemed unsuitable and conventional coronary artery bypass grafting (CABG) posed an unacceptable perioperative risk, patients were scheduled for minimally invasive direct coronary artery bypass (MIDCAB) grafting or minimally invasive multivessel coronary artery bypass grafting (MICS-CABG). We called this approach “palliative revascularization.” This study assesses the safety and impact of palliative revascularization on clinical outcomes and overall survival. Methods: A consecutive series of 57 patients undergoing MIDCAB or MICS-CABG as a palliative surgery between 2008 and 2018 was included. The decision for palliative surgery was met in heart team after carefully assessing each case. The patients underwent single or double-vessel revascularization using the left internal thoracic artery and rarely radial artery/saphenous vein segments, both endoscopically harvested. Inpatient data could be completed for all 57 patients. The mean follow-up interval was 4.2 ± 3.7 years, with a follow-up rate of 91.2%. Results: Mean patient age was 79.7 ± 7.4 years. Overall, 46 patients (80.7%) were male, 26 (45.6%) had a history of atrial fibrillation and 25 (43.9%) of chronic kidney disease. In total, 13 patients exhibited a moderate EuroSCORE II, while 27 were classified as high risk, with a EuroSCORE II exceeding 5%. Additionally, 40 patients (70.2%) presented with three-vessel disease, 17 (29.8%) suffered an acute myocardial infarction within three weeks prior to surgery and 50.9% presented an impaired ejection fraction. There were 48 MIDCAB and nine MICS CABG with no conversions either to sternotomy or to CPB. Eight cases were planned as hybrid procedures and only 15 patients (26.3%) were completely revascularized. During the first 30 days, four patients (7%) died. A myocardial infarction occurred in only one case, no patient necessitated immediate reoperation. The one-, three- and five-year survival rates were 83%, 67% and 61%, respectively. Conclusions: MIDCAB and MICS CABG can be successfully conducted as less invasive palliative surgery in high-risk multimorbid patients with MV CAD. The early and mid-term results were better than predicted. A higher rate of hybrid procedures could improve long-term outcome in selected cases. Full article

13 pages, 504 KB

Open AccessArticle

Fear of Falling After Total Knee Replacement: A Saudi Experience

by Turki Aljuhani, Jayachandran Vetrayan, Mohammed A. Alfayez, Saleh A. Alshehri, Mohmad H. Alsabani, Lafi H. Olayan, Fahdah A. Aljamaan and Abdulaziz O. Alharbi

Clin. Pract. 2025, 15(8), 146; https://doi.org/10.3390/clinpract15080146 - 6 Aug 2025

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Abstract

Background: Fear of falling (FOF) is a significant concern among older adults, especially after total knee arthroplasty (TKA). FOF can limit daily activities, reduce quality of life, and hinder recovery. This study aimed to investigate the prevalence, severity, and impacts of FOF [...] Read more.

Background: Fear of falling (FOF) is a significant concern among older adults, especially after total knee arthroplasty (TKA). FOF can limit daily activities, reduce quality of life, and hinder recovery. This study aimed to investigate the prevalence, severity, and impacts of FOF in patients undergoing TKA and identify factors contributing to increased FOF. Methods: A prospective observational study was conducted at King Abdulaziz Medical City in Riyadh, Saudi Arabia, from April 2024 to December 2024. This study included 52 participants aged 20 to 75 years who had undergone primary TKA. Data were collected at two time points: after TKA and at three months post-surgery. The Short Falls Efficacy Scale-International (SFES-I) was used to assess the severity of FOF, and the Short Form 36 (SF-36) was used to measure the quality of life. Descriptive statistics, t-tests, and logistic regression were used for analysis. Results: This study included 52 participants (mean age: 63.77 ± 6.65 years; 82.7% female). Post-TKA, all participants exhibited high FOF (mean SFES-I score: 56.75 ± 8.30). After three months, the mean SFES-I score decreased significantly to 49.04 ± 12.45 (t = 4.408, p < 0.05). Post-TKA, SF-36 showed significant improvements in the physical function, role of physical limitations, bodily pain, vitality, social function, role of emotional limitations, and mental health subdomains. Bilateral total knee arthroplasty, body mass index, and some SF-36 subcomponents—such as general health, vitality, and role of emotional limitations—were identified as factors leading to increased FOF. Conclusions: FOF remains prevalent and severe in TKA patients, even at three months post-surgery, affecting rehabilitation outcomes. Early identification and tailored interventions for FOF should be considered essential components of comprehensive TKA recovery programs. Full article

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14 pages, 2501 KB

Open AccessArticle

Therapeutic Patterns and Surgical Decision-Making in Breast Cancer: A Retrospective Regional Cohort Study in Romania

by Ramona Andreea Cioroianu, Michael Schenker, Virginia-Maria Rădulescu, Tradian Ciprian Berisha, George Ovidiu Cioroianu, Mihaela Popescu, Cristina Mihaela Ciofiac, Ana Maria Petrescu and Stelian Ștefăniță Mogoantă

Clin. Pract. 2025, 15(8), 145; https://doi.org/10.3390/clinpract15080145 - 5 Aug 2025

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Abstract

Background: Breast cancer is the most prevalent malignancy among women globally. In Romania, it is the most frequent form of cancer affecting women, with approximately 12,000 new cases diagnosed annually, and the second most common cause of cancer-related mortality, second only to [...] Read more.

Background: Breast cancer is the most prevalent malignancy among women globally. In Romania, it is the most frequent form of cancer affecting women, with approximately 12,000 new cases diagnosed annually, and the second most common cause of cancer-related mortality, second only to lung cancer. Methods: This study looked at 79 breast cancer patients from Oltenia, concentrating on epidemiology, histology, diagnostic features, and treatments. Patients were chosen based on inclusion criteria such as histopathologically verified diagnosis, availability of clinical and treatment data, and follow-up information. The analyzed biological material consisted of tissue samples taken from the breast parenchyma and axillary lymph nodes. Even though not the primary subject of this paper, all patients underwent immunohistochemical (IHC) evaluation both preoperatively and postoperatively. Results: We found invasive ductal carcinoma to be the predominant type, while ductal carcinoma in situ (DCIS) and mixed types were rare. We performed cross-tabulations of metastasis versus nodal status and age versus therapy type; none reached significance (all p > 0.05), suggesting observed differences were likely due to chance. A chi-square test comparing surgical interventions (breast-conserving vs. mastectomy) in patients who did or did not receive chemotherapy showed, χ² = 3.17, p = 0.367, indicating that chemotherapy did not significantly influence surgical choice. Importantly, adjuvant chemotherapy and radiotherapy were used at similar rates across age groups, whereas neoadjuvant hormonal (endocrine) therapy was more common in older patients (but without statistical significance). Conclusions: Finally, we discussed the consequences of individualized care and early detection. Romania’s shockingly low screening rate, which contributes to delayed diagnosis, emphasizes the importance of improved population medical examination and tailored treatment options. Also, the country has one of the lowest rates of mammography uptake in Europe and no systematic population screening program. Full article

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15 pages, 980 KB

Open AccessArticle

Wilson’s Disease in Oman: A National Cohort Study of Clinical Spectrum, Diagnostic Delay, and Long-Term Outcomes

by Said A. Al-Busafi, Juland N. Al Julandani, Zakariya Alismaeili and Juhaina J. Al Raisi

Clin. Pract. 2025, 15(8), 144; https://doi.org/10.3390/clinpract15080144 - 3 Aug 2025

Viewed by 363

Abstract

Background/Objectives: Wilson’s disease (WD) is a rare autosomal recessive disorder of copper metabolism that results in hepatic, neurological, and psychiatric manifestations. Despite being described globally, data from the Middle East remains limited. This study presents the first comprehensive national cohort analysis of [...] Read more.

Background/Objectives: Wilson’s disease (WD) is a rare autosomal recessive disorder of copper metabolism that results in hepatic, neurological, and psychiatric manifestations. Despite being described globally, data from the Middle East remains limited. This study presents the first comprehensive national cohort analysis of WD in Oman, examining clinical features, diagnostic challenges, treatment patterns, and long-term outcomes. Methods: A retrospective cohort study was conducted on 36 Omani patients diagnosed with WD between 2013 and 2020 at Sultan Qaboos University Hospital using AASLD diagnostic criteria. Clinical presentation, biochemical parameters, treatment regimens, and progression-free survival were analyzed. Results: The median age at diagnosis was 14.5 years, with a slight female predominance (55.6%). Clinical presentation varied: 25% had hepatic symptoms, 22.2% had mixed hepatic-neurological features, and 16.7% presented with neurological symptoms alone. Asymptomatic cases identified via family screening accounted for 33.3%. Diagnostic delays were most pronounced among patients presenting with neurological symptoms. A positive family history was reported in 88.9% of cases, suggesting strong familial clustering despite a low rate of consanguinity (5.6%). Regional distribution was concentrated in Ash Sharqiyah North and Muscat. Chelation therapy with trientine or penicillamine, often combined with zinc, was the mainstay of treatment. Treatment adherence was significantly associated with improved progression-free survival (p = 0.012). Conclusions: WD in Oman is marked by heterogeneous presentations, frequent diagnostic delays, and strong familial clustering. Early detection through cascade screening and sustained treatment adherence are critical for favorable outcomes. These findings support the need for national screening policies and structured long-term care models for WD in the region. Full article

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14 pages, 2736 KB

Open AccessCase Report

Renal Malacoplakia Following Obstetric Intervention: A Rare Cause of Acute Kidney Injury in a Young Woman

by Letícia Miyuki Ito, Juliana Miki Oguma, André Kiyoshi Miyahara, Marco Aurélio Sales da Veiga, Leandro Favaro, David Wesley de Godoy, Bárbara Antunes Bruno da Silva, Luiz Antônio Moura, Marcelino de Souza Durão and Érika Bevilaqua Rangel

Clin. Pract. 2025, 15(8), 143; https://doi.org/10.3390/clinpract15080143 - 3 Aug 2025

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Abstract

Introduction: Renal malacoplakia is a rare chronic granulomatous disease, often associated with immunosuppression and persistent Gram-negative infections, particularly Escherichia coli. Case Presentation: We present a case involving a 31-year-old woman with hypertension, gestational diabetes, and prior uterine curettage after labor [...] Read more.

Introduction: Renal malacoplakia is a rare chronic granulomatous disease, often associated with immunosuppression and persistent Gram-negative infections, particularly Escherichia coli. Case Presentation: We present a case involving a 31-year-old woman with hypertension, gestational diabetes, and prior uterine curettage after labor induction for preeclampsia at 23 weeks. She developed urinary sepsis post-procedure. Imaging revealed bilateral nephromegaly, while laboratory tests showed acute kidney injury (KDIGO stage III), anemia, and thrombocytopenia. Blood and urine cultures grew Escherichia coli. Renal biopsy confirmed malacoplakia, demonstrating PAS-positive Michaelis–Gutmann bodies and Von Hansemann cells. The patient responded to prolonged antibiotic therapy and supportive care. Discussion and Conclusion: This case highlights the importance of considering renal malacoplakia in patients with atypical urinary tract infections and nephromegaly, particularly in obstetric settings. Histopathological confirmation is essential, and timely treatment with intracellularly active antibiotics can lead to favorable outcomes. Early diagnosis is critical to prevent irreversible renal damage. Full article

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21 pages, 936 KB

Open AccessArticle

Reframing Polypharmacy: Empowering Medical Students to Manage Medication Burden as a Chronic Condition

by Andreas Conte, Anita Sedghi, Azeem Majeed and Waseem Jerjes

Clin. Pract. 2025, 15(8), 142; https://doi.org/10.3390/clinpract15080142 - 31 Jul 2025

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Abstract

Aims/Background: Polypharmacy, or the concurrent intake of five or more medications, is a significant issue in clinical practice, particularly in multimorbid elderly individuals. Despite its importance for patient safety, medical education often lacks systematic training in recognising and managing polypharmacy within the framework [...] Read more.

Aims/Background: Polypharmacy, or the concurrent intake of five or more medications, is a significant issue in clinical practice, particularly in multimorbid elderly individuals. Despite its importance for patient safety, medical education often lacks systematic training in recognising and managing polypharmacy within the framework of patient-centred care. We investigated the impact of a structured learning intervention introducing polypharmacy as a chronic condition, assessing whether it enhances medical students’ diagnostic competence, confidence, and interprofessional collaboration. Methods: A prospective cohort study was conducted with 50 final-year medical students who received a three-phase educational intervention. Phase 1 was interactive workshops on the principles of polypharmacy, its dangers, and diagnostic tools. Phase 2 involved simulated patient consultations and medication review exercises with pharmacists. Phase 3 involved reflection through debriefing sessions, reflective diaries, and standardised patient feedback. Student knowledge, confidence, and attitudes towards polypharmacy management were assessed using pre- and post-intervention questionnaires. Quantitative data were analysed through paired t-tests, and qualitative data were analysed thematically from reflective diaries. Results: Students demonstrated considerable improvement after the intervention in identifying symptoms of polypharmacy, suggesting deprescribing strategies, and working in multidisciplinary teams. Confidence in prioritising polypharmacy as a primary diagnostic problem increased from 32% to 86% (p < 0.01), and knowledge of diagnostic tools increased from 3.1 ± 0.6 to 4.7 ± 0.3 (p < 0.01). Standardised patients felt communication and patient-centredness had improved, with satisfaction scores increasing from 3.5 ± 0.8 to 4.8 ± 0.4 (p < 0.01). Reflective diaries indicated a shift towards more holistic thinking regarding medication burden. The small sample size limits the generalisability of the results. Conclusions: Teaching polypharmacy as a chronic condition in medical school enhances diagnostic competence, interprofessional teamwork, and patient safety. Education is a structured way of integrating the management of polypharmacy into routine clinical practice. This model provides valuable insights for designing medical curricula. Future research must assess the impact of such training on patient outcomes and clinical decision-making in the long term. Full article

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18 pages, 1352 KB

Open AccessStudy Protocol

Effects of Hydrodilatation at Different Volumes on Adhesive Capsulitis in Phases 1 and 2: Clinical Trial Protocol HYCAFVOL

by Javier Muñoz-Paz, Ana Belén Jiménez-Jiménez, Francisco Espinosa-Rueda, Amin Wahab-Albañil, María Nieves Muñoz-Alcaraz, José Peña-Amaro and Fernando Jesús Mayordomo-Riera

Clin. Pract. 2025, 15(8), 141; https://doi.org/10.3390/clinpract15080141 - 26 Jul 2025

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Abstract

Background: Adhesive capsulitis (AC) causes a global limitation of both active and passive range of motion (ROM) in the shoulder, with or without pain, and no specific radiographic findings. Its course is self-limiting and progresses through three or four stages. The diagnosis [...] Read more.

Background: Adhesive capsulitis (AC) causes a global limitation of both active and passive range of motion (ROM) in the shoulder, with or without pain, and no specific radiographic findings. Its course is self-limiting and progresses through three or four stages. The diagnosis is primarily clinical, since imaging tests are nonspecific. Treatment options include physical therapy (PT), intra-articular corticosteroid injections, suprascapular nerve block (SSNB), and hydrodilatation (HD). The latter is useful for expanding and reducing inflammation of the joint capsule through the insufflation of saline solution, anesthetics, and corticosteroids. Objectives: To compare whether patients with AC, stratified by phase 1 and 2, who receive high-volume HD as treatment achieve better outcomes in terms of shoulder pain and function compared to patients who receive low-volume HD. To compare whether there are differences in PT times and to determine mean axillary recess (AR) values. Methods: A randomized, parallel-block, triple-blind clinical trial will be conducted in 64 patients with AC in phases 1 and 2, aged 30 to 70 years, with limited active and passive ROM in two planes, and shoulder pain lasting more than 3 months. HD will be administered with volumes of 20 mL or 40 mL, followed by a conventional rehabilitation program. Outcomes will be reviewed at the 1st, 3rd, and 6th months of HD. Variables collected will include Shoulder Pain and Disability Index (SPADI), Visual Analog Scale (VAS), Range of motion (ROM), Lattinen index (LI), AR size, and time to completion of PT. Results: HD has been gaining clinical relevance in interventional rehabilitation as a treatment for AC, although its medium- and long-term efficacy remains a matter of debate. The variability in the volumes used for capsular expansion, with studies ranging from 18 mL to 47 mL, is compounded by the fact that most of these studies do not differentiate between AC stages. This could influence treatment effectiveness. Furthermore, diagnosis remains a challenge since valid and specific diagnostic parameters are lacking. Conclusions: Understanding the differences between HD techniques, considering the influence of certain factors such as the volume used or the stages of AC, as well as improving diagnosis and the coordination of scientific work. This could facilitate the development of protocols for the use of HD in AC. Full article

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19 pages, 967 KB

Open AccessArticle

Clinical–Biological Assessment of Prosthetic Field Following Pre-Prosthetic Phase Related to Prosthetic Treatment Solutions

by Petruţa Siminiuc, Doriana Agop-Forna, Cristina Dascălu and Norina Forna

Clin. Pract. 2025, 15(8), 140; https://doi.org/10.3390/clinpract15080140 - 26 Jul 2025

Viewed by 259

Abstract

Background. Extensive partial edentulism alters the biological and functional balance of the stomatognathic system, requiring targeted pre-prosthetic procedures to optimize treatment outcomes. Objectives. The aim of this study was to assess the extent of improvement in the clinical–biological scores of the [...] Read more.

Background. Extensive partial edentulism alters the biological and functional balance of the stomatognathic system, requiring targeted pre-prosthetic procedures to optimize treatment outcomes. Objectives. The aim of this study was to assess the extent of improvement in the clinical–biological scores of the prosthetic field in patients with extensive edentulism, following pre-prosthetic interventions. Materials and Method. This prospective, cross-sectional study investigated 194 subjects with extensive partial edentulism. Clinical–biological scores, initially and following the pre-prosthetic phase, were recorded using a scoring system that evaluated dental and periodontal status, bone and mucosal support, occlusion, and mandibulo-cranial relationships. Statistical comparisons of clinical–biological scores were related to the type of prosthetic therapy. Statistical significance was considered at a p-value < 0.05. Results. There was an overall significant improvement in the clinical–biological scores initially (mean value 20.2) and after pre-prosthetic procedures (mean value 23.22) (p < 0.001). When treatment groups were divided, the implant-assisted prosthesis group showed the best improvement in all domains, followed by the conventional fixed-prostheses group (p < 0.01). Dental support improved significantly in those with semi-rigid composite prostheses (p = 0.014), while periodontal support was improved in both fixed- and hybrid-implant groups. Mucosal and bone support improved mostly in the fixed-implant groups (p = 0.014). Conclusions. Pre-prosthetic procedures significantly enhance the biological and functional readiness of the prosthetic field, with the degree of improvement influenced by the complexity and type of planned prosthetic rehabilitation. The findings underscore the value of individualized pre-prosthetic protocols as an essential component of prosthetic treatment planning. Full article

(This article belongs to the Special Issue New Trends, Materials, and Technologies and Consolidating Best Practices in Dentistry, 2nd Edition)

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10 pages, 207 KB

Open AccessStudy Protocol

Assessment of Physical Activity During Chemotherapy and/or Immunotherapy for Non-Small Cell Lung Cancer (NSCLC): Protocol of the APACHIE-01 Study

by Dirk Rades, Laura Doehring, Christian Staackmann, Maria Karolin Streubel, Stefan Janssen, Tobias Bartscht and Sabine Bohnet

Clin. Pract. 2025, 15(8), 139; https://doi.org/10.3390/clinpract15080139 - 25 Jul 2025

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Abstract

Background/Objectives: Most patients with non-small cell lung cancer (NSCLC) receive chemo- and/or immunotherapy, which can be associated with adverse events including fatigue. Affected patients may not be able to receive the complete chemo- and/or immunotherapy as planned. In this context, patients may benefit [...] Read more.

Background/Objectives: Most patients with non-small cell lung cancer (NSCLC) receive chemo- and/or immunotherapy, which can be associated with adverse events including fatigue. Affected patients may not be able to receive the complete chemo- and/or immunotherapy as planned. In this context, patients may benefit from maintaining their physical activity, which can be challenging. An app reminding patients to perform a certain number of steps may have a positive effect on physical activity during chemo- and/or immunotherapy. Such an app is under development and will be tested in a prospective trial. The current APACHIE-01 study (NCT06993896) is required for proper sample size calculation and design of the planned trial. Methods: The main goal of the APACHIE-01 study is to evaluate patterns and predictors of physical activity during chemo- and/or immunotherapy for locally advanced or metastatic NSCLC. The primary endpoint is the assessment of the mean number of steps per week during the first three cycles of chemo- and/or immunotherapy for lung cancer. The baseline value is represented by the mean number of steps during the last week prior to chemotherapy and/or immunotherapy. Secondary endpoints include associations between mean number of steps per week and a pain score, a distress score, and a fatigue score. The recruitment of the required 38 patients should be completed within 4 months and the treatment period will be 9–10 weeks (three cycles of chemo- and/or immunotherapy), resulting in a total running time of approximately 6 months. The APACHIE-01 study will contribute to the optimal design of a subsequent prospective trial. Full article

19 pages, 290 KB

Open AccessArticle

Artificial Intelligence in Primary Care: Support or Additional Burden on Physicians’ Healthcare Work?—A Qualitative Study

by Stefanie Mache, Monika Bernburg, Annika Würtenberger and David A. Groneberg

Clin. Pract. 2025, 15(8), 138; https://doi.org/10.3390/clinpract15080138 - 25 Jul 2025

Viewed by 616

Abstract

Background: Artificial intelligence (AI) is being increasingly promoted as a means to enhance diagnostic accuracy, to streamline workflows, and to improve overall care quality in primary care. However, empirical evidence on how primary care physicians (PCPs) perceive, engage with, and emotionally respond [...] Read more.

Background: Artificial intelligence (AI) is being increasingly promoted as a means to enhance diagnostic accuracy, to streamline workflows, and to improve overall care quality in primary care. However, empirical evidence on how primary care physicians (PCPs) perceive, engage with, and emotionally respond to AI technologies in everyday clinical settings remains limited. Concerns persist regarding AI’s usability, transparency, and potential impact on professional identity, workload, and the physician–patient relationship. Methods: This qualitative study investigated the lived experiences and perceptions of 28 PCPs practicing in diverse outpatient settings across Germany. Participants were purposively sampled to ensure variation in age, practice characteristics, and digital proficiency. Data were collected through in-depth, semi-structured interviews, which were audio-recorded, transcribed verbatim, and subjected to rigorous thematic analysis employing Mayring’s qualitative content analysis framework. Results: Participants demonstrated a fundamentally ambivalent stance toward AI integration in primary care. Perceived advantages included enhanced diagnostic support, relief from administrative burdens, and facilitation of preventive care. Conversely, physicians reported concerns about workflow disruption due to excessive system prompts, lack of algorithmic transparency, increased cognitive and emotional strain, and perceived threats to clinical autonomy and accountability. The implications for the physician–patient relationship were seen as double-edged: while some believed AI could foster trust through transparent use, others feared depersonalization of care. Crucial prerequisites for successful implementation included transparent and explainable systems, structured training opportunities, clinician involvement in design processes, and seamless integration into clinical routines. Conclusions: Primary care physicians’ engagement with AI is marked by cautious optimism, shaped by both perceived utility and significant concerns. Effective and ethically sound implementation requires co-design approaches that embed clinical expertise, ensure algorithmic transparency, and align AI applications with the realities of primary care workflows. Moreover, foundational AI literacy should be incorporated into undergraduate health professional curricula to equip future clinicians with the competencies necessary for responsible and confident use. These strategies are essential to safeguard professional integrity, support clinician well-being, and maintain the humanistic core of primary care. Full article

12 pages, 619 KB

Open AccessReview

Manganese-Based Contrast Agents as Alternatives to Gadolinium: A Comprehensive Review

by Linda Poggiarelli, Caterina Bernetti, Luca Pugliese, Federico Greco, Bruno Beomonte Zobel and Carlo A. Mallio

Clin. Pract. 2025, 15(8), 137; https://doi.org/10.3390/clinpract15080137 - 25 Jul 2025

Viewed by 594

Abstract

Background/Objectives: Magnetic resonance imaging (MRI) is a powerful, non-invasive diagnostic tool capable of capturing detailed anatomical and physiological information. MRI contrast agents enhance image contrast but, especially linear gadolinium-based compounds, have been associated with safety concerns. This has prompted interest in alternative contrast [...] Read more.

Background/Objectives: Magnetic resonance imaging (MRI) is a powerful, non-invasive diagnostic tool capable of capturing detailed anatomical and physiological information. MRI contrast agents enhance image contrast but, especially linear gadolinium-based compounds, have been associated with safety concerns. This has prompted interest in alternative contrast agents. Manganese-based contrast agents offer a promising substitute, owing to manganese’s favorable magnetic properties, natural biological role, and strong T1 relaxivity. This review aims to critically assess the structure, mechanisms, applications, and challenges of manganese-based contrast agents in MRI. Methods: This review synthesizes findings from preclinical and clinical studies involving various types of manganese-based contrast agents, including small-molecule chelates, nanoparticles, theranostic platforms, responsive agents, and controlled-release systems. Special attention is given to pharmacokinetics, biodistribution, and safety evaluations. Results: Mn-based agents demonstrate promising imaging capabilities, with some achieving relaxivity values comparable to gadolinium compounds. Targeted uptake mechanisms, such as hepatocyte-specific transport via organic anion-transporting polypeptides, allow for enhanced tissue contrast. However, concerns remain regarding the in vivo release of free Mn²⁺ ions, which could lead to toxicity. Preliminary toxicity assessments report low cytotoxicity, but further comprehensive long-term safety studies should be carried out. Conclusions: Manganese-based contrast agents present a potential alternative to gadolinium-based MRI agents pending further validation. Despite promising imaging performance and biocompatibility, further investigation into stability and safety is essential. Additional research is needed to facilitate the clinical translation of these agents. Full article

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13 pages, 1565 KB

Open AccessCase Report

A Mixed-Methods Case Report on Oral Health Changes and Patient Perceptions and Experiences Following Treatment at the One Smile Research Program: A 2-Year Follow-Up

by Mona Abdelrehim, ZhuZhen (Hellen) Huang, Christiana Martine, Imon Pal, Kamini Kaura, Anuj Aggarwal and Sonica Singhal

Clin. Pract. 2025, 15(8), 136; https://doi.org/10.3390/clinpract15080136 - 23 Jul 2025

Viewed by 399

Abstract

Background: In Canada, despite universal healthcare coverage, dental care remains predominantly privately financed, creating financial barriers that prevent many from accessing essential services. This case study is part of a larger initiative, the One Smile Research program, which evaluates the impact of [...] Read more.

Background: In Canada, despite universal healthcare coverage, dental care remains predominantly privately financed, creating financial barriers that prevent many from accessing essential services. This case study is part of a larger initiative, the One Smile Research program, which evaluates the impact of cost-free dental care on the oral health and overall well-being of individuals who have been unable to access dental services in the past two years due to financial constraints. Participants in the program receive necessary dental care and attend follow-up appointments to assess the long-term effects of continuous cost-free care. Clinical Case: This mixed-methods case report focuses on a 26-year-old male participant and integrates a qualitative semi-structured interview with clinical and self-reported data, providing an in-depth understanding of his experiences. Results: Clinical outcomes demonstrated the effectiveness of the provided dental treatments, while self-reported measures indicated improved oral health, satisfaction with dental appearance, enhanced psychosocial well-being, increased self-esteem, reduced dental anxiety, and better oral hygiene habits. The qualitative interview identified three key themes reflecting positive experiences with the program: ease of admission, staff kindness, and overall well-being improvement. The integration of both quantitative and qualitative analyses revealed significant advancements in both objective and subjective measures, particularly regarding overall well-being. Conclusions: The continuity of cost-free dental care effectively addressed the participant’s oral health and overall well-being, with most benefits sustained even at the two-year follow-up. These individual-level outcomes offer preliminary insight into the potential advantages of universal dental coverage within the Canadian healthcare system. Full article

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12 pages, 508 KB

Open AccessArticle

Responders to Cervical Facet Platelet-Rich Plasma Demonstrate Synergistic Improvements in Pain and Isometric Strength in Chronic Whiplash-Associated Disorders: A Series of Mediation Analyses

by Ashley D. Smith, Benjamin Andruski, George Deng, Colin Bouma, Marc Pesant, Fiona Magill and Robert Burnham

Clin. Pract. 2025, 15(8), 135; https://doi.org/10.3390/clinpract15080135 - 23 Jul 2025

Viewed by 404

Abstract

Background/Objectives: Platelet-rich plasma (PRP) is emerging as a safe and effective treatment for facet-mediated pain. Studies have demonstrated reductions in pain and improvements in function, both in the short (3 months) and longer term (6 and 12 months). The mechanisms underlying clinical improvements [...] Read more.

Background/Objectives: Platelet-rich plasma (PRP) is emerging as a safe and effective treatment for facet-mediated pain. Studies have demonstrated reductions in pain and improvements in function, both in the short (3 months) and longer term (6 and 12 months). The mechanisms underlying clinical improvements are largely unknown. It is also unclear whether reported outcomes are due to the PRP administered or concurrently applied rehabilitation. Methods: A prospective case series was conducted in a single, multidisciplinary chronic pain centre. Forty-two participants with chronic WAD and cervical facet-mediated pain who received PRP (64% female; mean age (SD) 42.8 (11.6) years; median WAD duration [IQR] 23 [18,29] mths), attended rehabilitation, and reported successful outcomes 3 months post-PRP fulfilled the inclusion criteria. Measures of pain, cervical isometric strength, and range of motion were collected at baseline and 3 months post-PRP. Mediation analyses were performed to determine how these factors influenced disability. Results: Participants demonstrated clinically significant and relevant improvements in pain, disability, and isometric strength measures (all p < 0.01). Causative mediation analyses demonstrated independent direct, but not indirect, effects of both pain and strength on disability (both p < 0.001), with no direct or indirect effects of cervical ROM on disability. Full article

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Clin. Pract., Volume 15, Issue 8 (August 2025) – 21 articles

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