Medicina

20 pages, 826 KiB

Open AccessArticle

Relative Grip Strength as a Screening Indicator for Metabolic Syndrome in Korean Adults: A Cross-Sectional Study Using Data from KNHANES

by Jongsuk Park and Sangho Kim

Medicina 2025, 61(8), 1473; https://doi.org/10.3390/medicina61081473 (registering DOI) - 16 Aug 2025

Abstract

Background and Objectives: This study aimed to assess the association between relative grip strength (RGS) and metabolic syndrome (MetS) in Korean adults and to explore sex- and age-specific cutoff values for screening purposes. Materials and Methods: This cross-sectional study analyzed data [...] Read more.

Background and Objectives: This study aimed to assess the association between relative grip strength (RGS) and metabolic syndrome (MetS) in Korean adults and to explore sex- and age-specific cutoff values for screening purposes. Materials and Methods: This cross-sectional study analyzed data from 12,072 Korean adults (aged 19–64 years) who participated in the 2017–2019 Korea National Health and Nutrition Examination Survey. Receiver operating characteristic (ROC) curve analysis was performed stratified by sex and age group, and participants were categorized into adequate (ARG) and low (LRG) RGS groups. Multivariable logistic regression was used to examine the association between RGS (as both categorical and continuous variables) and MetS, adjusting for lifestyle and behavioral covariates. Results: The RGS demonstrated moderate discriminatory power for MetS, with area under the curve (AUC) values ranging from 0.601 to 0.742. Age- and sex-specific cutoff values for RGS progressively decreased with age. Individuals in the LRG group had significantly higher odds of MetS across all age and sex groups. The LRG group had significantly greater odds of MetS in nearly all subgroups (e.g., women aged 20–39 years: odds ratio [OR] = 6.846; men: OR = 3.502). As a continuous variable, each 0.1-unit increase in RGS was associated with a 22.1–33.4% reduction in the odds of MetS (p < 0.001). Conclusions: RGS is inversely associated with MetS, particularly in women and younger adults. Although its discriminatory ability is moderate, the RGS may serve as a simple and accessible screening indicator to help identify individuals with an increased metabolic risk. Full article

(This article belongs to the Section Epidemiology & Public Health)

11 pages, 797 KiB

Open AccessReview

Heart Failure in Poland: A 20-Year Epidemiological Perspective

by Michał Bohdan, Anna Kowalczys, Jadwiga Nessler, Ewa Straburzyńska-Migaj, Marcin Gruchała and Małgorzata Lelonek

Medicina 2025, 61(8), 1472; https://doi.org/10.3390/medicina61081472 (registering DOI) - 16 Aug 2025

Abstract

Background and Objectives: Cardiovascular diseases (CVDs) remain the leading cause of mortality in Poland, with heart failure (HF) presenting a significant public health issue. Materials and Methods: This study aimed to analyze trends in HF incidence, hospitalization rates, patient demographics, and [...] Read more.

Background and Objectives: Cardiovascular diseases (CVDs) remain the leading cause of mortality in Poland, with heart failure (HF) presenting a significant public health issue. Materials and Methods: This study aimed to analyze trends in HF incidence, hospitalization rates, patient demographics, and mortality over two decades A comparative analysis was performed using data from two national reports: (1) the 2013 report “Heart Failure—Analysis of Economic and Social Costs, “ assessing HF patients from 2004 to 2012, and (2) the 2023 report “Heart Failure in Poland 2014–2021,” based on data from the Polish Ministry of Health, National Health Fund, and HTA Consulting. This study examined the prevalence of HF (ICD-10 codes: I50, J81), hospitalization rates, comorbidities, mortality trends, and access to rehabilitation. Results: Between 2014 and 2019, the number of HF patients grew by 34%, reaching 1.02 million in 2019. Only 9% of HF patients were younger than 60 years. Multimorbidity was common, with arterial hypertension, atherosclerotic cardiovascular disease, and arrhythmias, often preceding HF diagnosis. HF-related mortality increased, with 149,963 in 2021, compared to 16,606 in 2012. In 2019, hospitalizations related to HF increased by 41% compared to 2014. The economic burden of HF care increased by 117% between 2014 and 2020, with hospitalizations accounting for 94% of total costs, up from 65% in 2012. Access to cardiac rehabilitation remained limited. Conclusions: HF prevalence, hospitalization rates, and mortality have increased in Poland, alongside a rising burden of multimorbidity. These findings provide a foundation for future healthcare planning to reduce the impact of HF in Poland. Full article

(This article belongs to the Special Issue New Insights into Heart Failure)

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9 pages, 482 KiB

Open AccessArticle

Efficacy of Dupilumab in Patients with Chronic Rhinosinusitis with Nasal Polyps and Eosinophilic Otitis Media: A Six-Month Observational Study

by Cosimo Galletti, Federica Giammona Indaco, Daniele Portelli, Giulia Laterra, Patrizia Zambito, Maria Grazia Ferrisi, Leonard Freni, Francesco Ciodaro, Francesco Freni, Salvatore Maira and Bruno Galletti

Medicina 2025, 61(8), 1471; https://doi.org/10.3390/medicina61081471 - 15 Aug 2025

Abstract

Background and Objectives: Chronic rhinosinusitis with nasal polyps (CRSwNP) and eosinophilic otitis media (EOM) are frequently co-existing eosinophilic disorders related to type 2 inflammation, which significantly impair the quality of life of patients. Dupilumab, a monoclonal antibody targeting the IL-4 receptor alpha and [...] Read more.

Background and Objectives: Chronic rhinosinusitis with nasal polyps (CRSwNP) and eosinophilic otitis media (EOM) are frequently co-existing eosinophilic disorders related to type 2 inflammation, which significantly impair the quality of life of patients. Dupilumab, a monoclonal antibody targeting the IL-4 receptor alpha and anti-IL-13, has demonstrated a promising profile of efficacy and safety in the treatment of CRSwNP; however, evidence on its role in concomitant EOM and CRSwNP remains limited in the literature. This study aims to evaluate the clinical efficacy of dupilumab in patients with concomitant CRSwNP and EOM over a six-month observational period. Materials and Methods: A retrospective observational cohort study was conducted on twenty-two patients (aged 18–75 years) over six months with severe uncontrolled CRSwNP and confirmed refractory EOM who were treated with dupilumab (300 mg every two weeks). Demographic data are collected, and outcome measures included Nasal Polyp Score (NPS), Sino-Nasal Outcome Test (SNOT-22), Visual Analog Scale for nasal congestion (VAS), tympanogram classification, and Chronic Otitis Media Outcome Test (COMOT-15), evaluated at baseline and 6 months. Results: Over the six-month treatment period, patients with coexisting CRSwNP and eosinophilic otitis media experienced significant improvements across the multiple validated clinical and patient-reported outcome measures. The Nasal Polyp Score (NPS) significantly decreased from a median of 5.7 (IQR: 1.2) at baseline to 1.5 (IQR: 1.3) at six months (p < 0.0001). The SNOT-22 showed a substantial decline from a median of 77.6 (IQR: 19.0) to 21.5 (IQR: 13.4), p < 0.0001. Visual Analog Scale (VAS) scores for nasal congestion improved significantly from 8.4 (IQR: 1.1) to 1.7 (IQR: 1.2), p < 0.0001. Tympanogram scores improved from Tympanogram type “B” to Tympanogram type “A” (p = 0.018). COMOT-15 scale decreased from a median of 51.3 (IQR: 8.4) to 19.2 (IQR: 5.0) (p < 0.0001). Peripheral eosinophil counts remained unchanged or increased (baseline 0.80 vs. 0.84 cells/μL at six months, (p = 0.834)). Conclusions: Dupilumab treatment in patients with CRSwNP and EOM led to significant clinical improvements in sinonasal symptoms, middle ear function, and quality of life over six months, with no significant change in peripheral eosinophilia. Full article

(This article belongs to the Special Issue Chronic Rhinosinusitis with Nasal Polyps: Latest Trends in Diagnosis and Treatment)

19 pages, 1890 KiB

Open AccessReview

Coronary Angioplasty with Drug-Coated Balloons: Pharmacological Foundations, Clinical Efficacy, and Future Directions

by Valentin Chioncel, Flavius Gherasie, Alexandru Iancu and Anamaria-Georgiana Avram

Medicina 2025, 61(8), 1470; https://doi.org/10.3390/medicina61081470 - 15 Aug 2025

Abstract

Drug-coated balloons (DCBs) have transformed percutaneous coronary intervention (PCI) by delivering antiproliferative drugs directly to the arterial wall, offering a stent-less approach that mitigates the risks associated with permanent metallic implants. Initially developed for in-stent restenosis (ISR), DCBs have demonstrated robust efficacy in [...] Read more.

Drug-coated balloons (DCBs) have transformed percutaneous coronary intervention (PCI) by delivering antiproliferative drugs directly to the arterial wall, offering a stent-less approach that mitigates the risks associated with permanent metallic implants. Initially developed for in-stent restenosis (ISR), DCBs have demonstrated robust efficacy in reducing neointimal hyperplasia and target lesion revascularization (TLR) rates across diverse coronary lesions, including small vessel disease (SVD), de novo lesions, and complex anatomies such as bifurcation lesions. Paclitaxel-coated balloons have long been the cornerstone of DCB therapy due to their established clinical outcomes, but sirolimus-coated balloons are emerging as a promising alternative with potentially superior safety profiles and sustained drug release. The pharmacological mechanism of DCBs relies on rapid drug transfer during brief balloon inflation, achieving high local concentrations without residual foreign material. Landmark trials, such as BASKET-SMALL 2, RESTORE SVD, and AGENT IDE, have demonstrated comparable or non-inferior outcomes of DCBs versus drug-eluting stents (DESs) in specific settings, with lower rates of stent thrombosis and shorter dual antiplatelet therapy (DAPT) requirements. Despite these advances, challenges persist, including optimizing drug formulations, ensuring uniform delivery, and addressing calcified lesions. Ongoing research into novel coatings, dual–drug systems, and artificial intelligence (AI)-guided interventions is poised to redefine PCI strategies. This review provides a comprehensive analysis of drug-coated balloon (DCB) angioplasty, not limited to specific clinical scenarios such as in-stent restenosis, small vessel disease, or bifurcation lesions, highlighting their transformative role in coronary artery disease (CAD) management. Instead, it addresses the full spectrum of pharmacological principles, mechanisms of action, clinical indications, comparative efficacy across various coronary artery disease contexts, and future directions of DCBs. Full article

(This article belongs to the Special Issue Updates on Risk Factors and Prevention of Coronary Artery Disease)

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21 pages, 2752 KiB

Open AccessArticle

Right Ventricular Function Improves After Bench Press: A Speckle Tracking Echocardiography Study

by María Belén Martínez-Lechuga, Javier Hidalgo-Martín and Manuel Ruiz-Bailén

Medicina 2025, 61(8), 1469; https://doi.org/10.3390/medicina61081469 - 15 Aug 2025

Abstract

Objective: The association between right ventricular myocardial fiber deformation and nutrition in weightlifters has not been fully characterized. This study analyzed nutritional factors and right ventricle speckle tracking echocardiography parameters in weightlifters before and after bench press exercises. Methods: This interventional [...] Read more.

Objective: The association between right ventricular myocardial fiber deformation and nutrition in weightlifters has not been fully characterized. This study analyzed nutritional factors and right ventricle speckle tracking echocardiography parameters in weightlifters before and after bench press exercises. Methods: This interventional study examined the effects of bench press exercises on myocardial function. Nutritional parameters were assessed prior to exercise. Echocardiography with speckle tracking using vector velocity analysis was performed before and immediately after the bench press exercise. This study included a group of non-elite athlete weightlifters and a non-athlete control group to compare right myocardial function. In the athlete group, transthoracic echocardiograms (TTEs) were conducted before and after the exercise to assess changes in systolic and diastolic right heart function. A cohort of 30 weightlifters from 2014 who continued regular training was re-evaluated in 2024, and nutritional data were collected. Data analyses included ANOVA and Student’s T-tests, and correlation coefficients were calculated to explore associations with speckle tracking results. Results: This study involved 211 male weightlifters and a control group of 60 non-athletes. Measured values for the control group and athletes before and after bench press exercise were as follows: right longitudinal global strain (−27.31 ± 1.47, −23.55 ± 2.37, −30.98 ± 2.12); right global longitudinal strain rate (−1.79 ± 0.078, −1.48 ± 0.33, −2.88 ± 0.259 1/s), all p < 0.001; and isovolumic acceleration (2.38 ± 0.22, 3.52 ± 0.15, 6.66 ± 0.88 m/s², p < 0.001). Following exercise, right intraventricular synchrony increased, and longitudinal strain delay decreased (144.88 ± 22.52, 168.92 ± 29.35, 98.27 ± 12.11 ms, p < 0.001). The follow-up group demonstrated a similar response to exercise as the other weightlifters. Right ventricular longitudinal strain showed correlations with protein, vitamin E, and zinc levels (R² = 0.399, p = 0.021; R² = 0.378, p = 0.03; R² = 0.566, p < 0.01), and right ventricular radial velocities correlated with group B vitamins. Conclusions: Weightlifters show less right ventricular deformity before exercise compared to controls, but their strain increases significantly post-exercise. Speckle tracking values might correlate with nutrition. Full article

(This article belongs to the Special Issue New Insights into Heart Failure)

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16 pages, 1636 KiB

Open AccessArticle

Cardiovascular Risk in People Living with HIV: A Preliminary Case Study from Romania

by Manuela Arbune, Alina Plesea-Condratovici, Anca-Adriana Arbune, Geanina Andronache, Catalin Plesea-Condratovici and Cristian Gutu

Medicina 2025, 61(8), 1468; https://doi.org/10.3390/medicina61081468 - 15 Aug 2025

Abstract

Background and Objectives: AIDS-related mortality has significantly decreased due to antiretroviral therapy (ART), leading to a substantial increase in average lifespan. Consequently, cardiovascular diseases have become a growing concern among people living with HIV (PLWH). This study aimed to assess the cardiovascular risk [...] Read more.

Background and Objectives: AIDS-related mortality has significantly decreased due to antiretroviral therapy (ART), leading to a substantial increase in average lifespan. Consequently, cardiovascular diseases have become a growing concern among people living with HIV (PLWH). This study aimed to assess the cardiovascular risk profile of people living with HIV receiving ART and to explore the association between traditional and HIV-related factors with increased cardiovascular risk. Materials and Methods: We conducted a case study involving 112 PLWH receiving ART at a specialized clinic in southeastern Romania to estimate cardiovascular risk (CVR) using the Data Collection on Adverse Events of Anti-HIV Drugs (D:A:D^®) score. For participants aged 40 and above, the SCORE2 algorithm was additionally applied. Results: Most participants were male and under 40 years of age, including 34 individuals from Romania’s distinct pediatric HIV cohort. We observed a substantial cardiovascular risk burden: abdominal obesity was present in 24.1% of participants, active smoking was reported by 55.4%, and over 70% had low physical activity levels. Among participants aged 40 and above, the D:A:D^® and SCORE2 scores were strongly correlated, with an average cardiovascular age exceeding chronological age by a mean of 7.5 years. Although CVR remained similarly low among subgroups of PLWH under 40, the prevalence of metabolic syndrome was higher in patients from the pediatric cohort compared to those diagnosed later. Traditional risk factors—such as age, obesity, hypertension, dyslipidemia, smoking, and alcohol use—as well as elevated C-reactive protein levels, were significantly associated with increased CVR. Conclusions: Residual inflammation in PLWH, despite complete viral suppression in combination with metabolic syndrome, is associated with increased cardiovascular risk even in younger and clinically stable populations. Routine integration of metabolic and cardiovascular risk screening into HIV care may support timely prevention and personalized management strategies starting at an early age. Full article

(This article belongs to the Special Issue Updates on Risk Factors and Prevention of Coronary Artery Disease)

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16 pages, 1522 KiB

Open AccessArticle

Evaluation of PD-L1 Expression and Anti-EGFR Therapy in EGFR-Mutant Non-Small-Cell Lung Cancer

by Gizem Teoman, Elanur Karaman, Şafak Ersöz and Sevdegül Aydın Mungan

Medicina 2025, 61(8), 1467; https://doi.org/10.3390/medicina61081467 - 15 Aug 2025

Abstract

Background and Objectives: Non-small-cell lung cancer (NSCLC) often has epidermal growth factor receptor (EGFR) mutations, which are key targets for therapy. EGFR mutation subtypes, especially exon 19 deletions and exon 21 L858R mutations, influence responses to EGFR tyrosine kinase inhibitors [...] Read more.

Background and Objectives: Non-small-cell lung cancer (NSCLC) often has epidermal growth factor receptor (EGFR) mutations, which are key targets for therapy. EGFR mutation subtypes, especially exon 19 deletions and exon 21 L858R mutations, influence responses to EGFR tyrosine kinase inhibitors (TKIs) and patient survival. Despite progress in TKI treatments, resistance and different responses remain challenges. This study explores the relationship between EGFR mutation subtypes, PD-L1 expression, and patient outcomes after anti-EGFR therapy. Materials and Methods: We studied 176 cases of EGFR mutation-positive NSCLC. Next-generation sequencing was used to analyze EGFR and other mutations, while PD-L1 expression was evaluated through immunohistochemistry. We analyzed EGFR mutation subtypes, PD-L1 status, treatments, and survival outcomes. Results: Among 176 cases, 88.6% were adenocarcinomas. Within the EGFR mutation spectrum, exon 19 deletions were the most common subtype, accounting for 40.9% of cases, followed by the point mutation in exon 21, which occurred in 35.8% of cases. Less frequent alterations, making up 23.3% of all detected mutations, included mutations in exon 18, insertions, and point mutations such as S768I and T790M in exon 20, as well as changes in exon 2, exon 7, and other less frequently affected regions. Exon 19 mutations were associated with older age, female sex, adenocarcinoma, and bone metastasis (p < 0.05). TP53 was the most common concurrent mutation (44.3%). PD-L1 positivity (TPS ≥ 1%) was observed in 48.3%, with high expression (TPS ≥ 50%) in 25.9%. Exon 21 mutations were significantly linked to PD-L1 negativity (p = 0.008). The median overall survival was longest with TKI therapy (51 months), and this was also observed in PD-L1-positive patients, although the difference was not statistically significant. The median progression-free survival for patients treated with TKIs and those with EGFR mutations was 14 months. PD-L1-positive patients receiving TKIs had significantly longer survival than those who did not (51 vs. 17 months, p = 0.003). Conclusions: EGFR mutation subtypes and PD-L1 expression seem to affect treatment outcomes and survival in NSCLC. The observed links emphasize the potential value of combining molecular and immunological markers to guide therapy choices. Full article

(This article belongs to the Section Pulmonology)

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17 pages, 855 KiB

Open AccessArticle

Prognostic Significance of aVR Lead and QTc Prolongation in Patients with Early Repolarization

by Ertugrul Altinbilek, Abuzer Coskun, Burak Demirci, Ismail Oymak, Mustafa Calik, Derya Öztürk, Mustafa Ahmet Afacan and Burcu Bayramoglu

Medicina 2025, 61(8), 1466; https://doi.org/10.3390/medicina61081466 - 14 Aug 2025

Abstract

Background and Objectives: Early repolarization (ER), previously considered benign for many years, is now recognized as a substantial risk factor for malignant arrhythmia, coronary artery disease, and mortality. The ER pattern, previously regarded as a benign electrocardiographic characteristic, has lately been demonstrated [...] Read more.

Background and Objectives: Early repolarization (ER), previously considered benign for many years, is now recognized as a substantial risk factor for malignant arrhythmia, coronary artery disease, and mortality. The ER pattern, previously regarded as a benign electrocardiographic characteristic, has lately been demonstrated to have a strong association with malignant arrhythmias, coronary artery disease, and elevated death rates. This study seeks to illustrate the prognostic significance of QT interval (QTc) prolongation on electrocardiograms for acute coronary syndrome and death in emergency cases. Prolongation of QTc duration on electrocardiography in emergency room cases may serve as a possible predictor for acute coronary syndrome and mortality. Materials and Methods: A retrospective study was conducted on 924 patients diagnosed with ER in the emergency department from 2020 to 2023. The QTc durations, serum glucose levels, troponin I levels, and additional auxiliary data of the patients were assessed. The alteration in the aVR derivation, often overlooked and deemed insignificant, was compared with clinical severity in ER cases. Results: The average age of the 924 patients in the study was 48.43 (9.65) years, with 30.7% being female. In the non-cardiac group, the mean age was 51.67 (7.98) years, with 738 females (31.9%). The QTc interval in the patient group was 409.54 (33.46) ms, while in the control group it was 411.57 (27.91) ms (p < 0.001). The one-year death rate was 49 (5.3%) for the ER group and nine (0.9%) for the follow-up group. The most common comorbid condition in both groups was tobacco and/or tobacco product intake. Univariate and multivariate regression analyses conducted for both ER types and mortality indicated that QTc prolongation may serve as a predictive factor (p < 0.001). The sensitivity and specificity of prolonged QTc in predicting acute coronary syndrome and mortality were determined to be 76% at the lowest and 98% at the highest levels in ER cases (p < 0.001). The Kaplan–Meier survival analysis for ER types revealed 321 days for the horizontal type and 363 days for the ascending type. Conclusions: Prolonged QTc duration in early repolarization cases may serve as an independent predictor of acute coronary syndrome and mortality. Full article

(This article belongs to the Section Cardiology)

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22 pages, 1383 KiB

Open AccessArticle

The Association Between Borderline Personality Disorder Symptoms and Social Behaviour Among University Students

by Andreea Sălcudean, Iustin Olariu, Mădălina-Gabriela Cincu, Ramona Amina Popovici, Iuliana Comșulea, Cristina-Raluca Bodo, Dora-Mihaela Cîmpian and Elena-Gabriela Strete

Medicina 2025, 61(8), 1465; https://doi.org/10.3390/medicina61081465 - 14 Aug 2025

Abstract

Background and Objectives: Borderline personality disorder (BPD) is a complex psychiatric condition characterized by emotional instability, impulsivity, a fluctuating self-image, and persistent difficulties in maintaining close interpersonal relationships. Among university students, these traits may be associated with social adjustment and academic functioning difficulties. [...] Read more.

Background and Objectives: Borderline personality disorder (BPD) is a complex psychiatric condition characterized by emotional instability, impulsivity, a fluctuating self-image, and persistent difficulties in maintaining close interpersonal relationships. Among university students, these traits may be associated with social adjustment and academic functioning difficulties. The present study aimed to examine the prevalence of borderline traits within a Romanian student population and to investigate the associations between these traits and interpersonal difficulties encountered in family life, romantic relationships, and academic environments. Materials and Methods: This cross-sectional study included a total of 151 undergraduate students enrolled in higher education institutions across Romania. Data were gathered through an online questionnaire available between March and May 2025. The instrument comprised items addressing socio-demographic characteristics, diagnostic criteria for borderline personality traits according to the DSM, as well as self-reported social behaviour patterns. Statistical analysis was performed using GraphPad Prism 9, version 9.3.1 for Windows, employing Fisher’s exact test and the odds ratio (OR), with a significance threshold set at p < 0.05. Results: Most participants reported experiencing affective instability (71.5%) and distorted self-image (58.9%). Fear of abandonment was present in 29.4% of the respondents, while impulsivity was identified in 37.7%. Borderline personality traits were significantly associated with a range of social difficulties, including relational anxiety, outbursts of anger, peer conflicts, social withdrawal, and dissociative symptoms. Individuals who exhibited impulsivity, self-injurious behaviours, or dissociative episodes demonstrated a markedly increased risk of social dysfunction, with odds ratios ranging from 3 to 10 (p < 0.0001). Conclusions: The findings reveal a high prevalence of borderline traits within the analysed sample, along with statistically significant associations with social and emotional difficulties. These results underscore the importance of implementing psychological screening programs in universities, as well as early intervention strategies focused on the mental well-being of young adults. Establishing a supportive academic environment and fostering collaboration between faculty members and mental health professionals may play a key role in preventing symptom escalation and in promoting healthy personal and relational development. Full article

(This article belongs to the Special Issue Mental Health Care: Pandemic and Beyond)

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11 pages, 935 KiB

Open AccessArticle

Androgen Receptor: Clinical Importance in Breast Cancer Patients Receiving CDK 4/6 Inhibitor Treatment

by Seray Saray, Tufan Yılmaz, Hüseyin Kanmaz and Yakup İriağaç

Medicina 2025, 61(8), 1464; https://doi.org/10.3390/medicina61081464 - 14 Aug 2025

Abstract

Background and Objectives: The effect of AR expression on prognosis in hormone receptor-positive her2-negative breast cancer is controversial. There are studies showing that AR is a treatment target, a mechanism of resistance to endocrine treatments, and a prognostic indicator in these patients whose [...] Read more.

Background and Objectives: The effect of AR expression on prognosis in hormone receptor-positive her2-negative breast cancer is controversial. There are studies showing that AR is a treatment target, a mechanism of resistance to endocrine treatments, and a prognostic indicator in these patients whose standard treatment is a CDK 4/6 inhibitor added to endocrine treatment. We aimed to investigate the effect of AR, the AR/ER ratio, and the AR/PR ratio on CDK4/6 inhibitor treatment response in breast cancer, as well as their effects on PFS, and to validate the hypothesis that AR is a target for research. Materials and Methods: Patients who were diagnosed with metastatic hormone receptor-positive her2-negative breast cancer and received cdk4/6 inhibitor + aromatase inhibitor in first-line therapy were included in this study conducted at Balıkesir Atatürk City Hospital. The tru-cut biopsy samples of the patients were evaluated immunohistochemically for AR, ER, and PR. Kaplan–Meier analysis was used to calculate the estimated median survival in PFS analyses, and the variables were compared with the Log-Rank test. Receiver Operating Characteristic (ROC) analysis was applied to determine the ideal cut-off. Cox regression analysis was used in univariate survival models, and the multivariate model was established with the “Forward: Likelihood Ratio (LR)” method. Hazard ratios (HRs) were also calculated as 95% confidence intervals (95% CIs). A p value below 0.05 was accepted for statistical significance. Results: In total, 41 patients were included in the study, and 73% (n = 30) of the patients were AR-positive. Increased AR (HR 1.014; 95% CI: 1.002–1.026; p = 0.023) was an unfavorable prognostic indicator. In our study, being ≥55 years old, being postmenopausal, not having visceral metastasis, having a non-IDC histology, having a low AR level (<50%), having an AR/ER ratio < 0.74, and having an AR/PR ratio < 1.00 were found to be associated with longer PFS. All factors were evaluated with univariate Cox regression analysis. Increasing AR (HR 1.014; 95% CI: 1.002–1.026; p = 0.023) was an unfavorable prognostic marker. Having an AR/ER ratio ≥ 0.74 (HR: 2.522; 95% CI: 1.004–6.336; p = 0.049) and having AR/PR ≥ 1 (HR: 2.659; 95% CI: 1.029–6.869; p = 0.043) were negative prognostic indicators. Conclusions: Our results were consistent with the literature and demonstrated the value of the androgen receptor as a therapeutic target, a mechanism explaining resistance to endocrine therapy, and an adverse prognostic indicator for creating resistance to endocrine therapy in breast cancer. Full article

(This article belongs to the Collection Frontiers in Breast Cancer Diagnosis and Treatment)

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22 pages, 4538 KiB

Open AccessSystematic Review

Total Intravenous Versus Inhalational Anesthesia in High-Grade Glioma Surgery: A Systematic Review and Meta-Analysis

by Plamen Penchev, Boris Tablov, Mariano Gallo Ruelas, Daniela Milanova-Ilieva, Lyubomir Gaydarski, Nikolay Yordanov, Eduardo Alonso, Danna Espinoza, Petar-Preslav Petrov, Ivelina Lukanova, Pavel Stanchev, Julian Dichev, Ivana Korentova and Nikolai Ramadanov

Medicina 2025, 61(8), 1463; https://doi.org/10.3390/medicina61081463 - 14 Aug 2025

Abstract

Background and Objectives: High-grade gliomas (HGGs) are aggressive primary brain tumors with a poor prognosis despite multimodal treatment. The anesthetic technique used during surgery may influence tumor progression and survival, but its role in HGGs remains unclear. This meta-analysis evaluated the effect [...] Read more.

Background and Objectives: High-grade gliomas (HGGs) are aggressive primary brain tumors with a poor prognosis despite multimodal treatment. The anesthetic technique used during surgery may influence tumor progression and survival, but its role in HGGs remains unclear. This meta-analysis evaluated the effect of total intravenous anesthesia (TIVA) versus inhalational anesthesia (INHA) on overall survival (OS) and progression-free survival (PFS) in HGG patients. Materials and Methods: A systematic search was conducted in PubMed, Scopus, and Cochrane databases for studies assessing the impact of TIVA versus INHA on OS and PFS in HGG patients. Statistical analysis was performed using R version 4.3.1. Heterogeneity across studies was quantified using the Cochrane Q test alongside the I² statistic. A random-effects model was employed to derive the pooled hazard ratios (HRs). Results: A total of five studies involving 827 participants (mean age 58 years, mean females 38%) were included, of whom 406 (49%) received TIVA. No statistically significant differences were observed in OS (HR 0.77; 95% CI [0.58–1.02]; p = 0.07; I² = 67%) or PFS (HR 0.88; 95% CI [0.70–1.10]; p = 0.27; I² = 51%) between the groups. A subgroup analysis revealed that TIVA was associated with improved OS in patients with grade IV tumors (HR 0.70; 95% CI [0.51–0.96]; p = 0.03), while no significant effect was observed in the mixed grade III–IV subgroup. However, the test for subgroup differences was not statistically significant (p = 0.0669), and this finding should be interpreted with caution. No significant differences were observed in median OS or PFS, or in single-arm meta-analyses. Conclusions: This meta-analysis found no statistically significant differences in overall or progression-free survival between TIVA and INHA in patients undergoing surgery for HGGs. Although a subgroup analysis suggested a possible survival advantage of TIVA in grade IV tumors, the lack of a statistically significant subgroup difference test limits the strength of this finding. Further investigation is needed to determine whether anesthetic technique influences outcomes in this subgroup. Full article

(This article belongs to the Special Issue High-Grade Gliomas: Updates and Challenges)

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44 pages, 3081 KiB

Open AccessReview

From Better Diagnostics to Earlier Treatment: The Rapidly Evolving Alzheimer’s Disease Landscape

by Anastasia Bougea, Manuel Debasa-Mouce, Shelly Gulkarov, Mónica Castro-Mosquera, Allison B. Reiss and Alberto Ouro

Medicina 2025, 61(8), 1462; https://doi.org/10.3390/medicina61081462 - 14 Aug 2025

Abstract

Background and Objectives: Over the past few years, there has been a significant shift in focus from developing better diagnostic tools to detecting Alzheimer’s disease (AD) earlier and initiating treatment interventions. This review will explore four main objectives: (a) the role of [...] Read more.

Background and Objectives: Over the past few years, there has been a significant shift in focus from developing better diagnostic tools to detecting Alzheimer’s disease (AD) earlier and initiating treatment interventions. This review will explore four main objectives: (a) the role of biomarkers in enhancing the diagnostic accuracy of AD, highlighting the major strides that have been made in recent years; (b) the role of neuropsychological testing in identifying biomarkers of AD, including the relationship between cognitive performance and neuroimaging biomarkers; (c) the amyloid hypothesis and possible molecular mechanisms of AD; and (d) the innovative AD therapeutics and the challenges and limitations of AD research. Materials and Methods: We have searched PubMed and Scopus databases for peer-reviewed research articles published in English (preclinical and clinical studies as well as relevant reviews and meta-analyses) investigating the molecular mechanisms, biomarkers, and treatments of AD. Results: Genome-wide association studies (GWASs) discovered 37 loci associated with AD risk. Core 1 biomarkers (α-amyloid Aβ42, phosphorylated tau, and amyloid PET) detect early AD phases, identifying both symptomatic and asymptomatic individuals, while core 2 biomarkers inform the short-term progression risk in individuals without symptoms. The recurrent failures of Aβ-targeted clinical studies undermine the amyloid cascade hypothesis and the objectives of AD medication development. The molecular mechanisms of AD include the accumulation of amyloid plaques and tau protein, vascular dysfunction, neuroinflammation, oxidative stress, and lipid metabolism dysregulation. Significant advancements in drug delivery technologies, such as focused Low-Ultrasound Stem, T cells, exosomes, nanoparticles, transferin, nicotinic and acetylcholine receptors, and glutathione transporters, are aimed at overcoming the BBB to enhance treatment efficacy for AD. Aducanumab and Lecanemab are IgG1 monoclonal antibodies that retard the progression of AD. BACE inhibitors have been explored as a therapeutic strategy for AD. Gene therapies targeting APOE using the CRISPR/Cas9 genome-editing system are another therapeutic avenue. Conclusions: Classic neurodegenerative biomarkers have emerged as powerful tools for enhancing the diagnostic accuracy of AD. Despite the supporting evidence, the amyloid hypothesis has several unresolved issues. Novel monoclonal antibodies may halt the AD course. Advances in delivery systems across the BBB are promising for the efficacy of AD treatments. Full article

(This article belongs to the Section Neurology)

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15 pages, 2605 KiB

Open AccessArticle

Dual-Compartment Anti-Inflammatory and Chondroprotective Effects of Intra-Articular Hydrolyzed Collagen in Experimental Osteoarthritis

by Mustafa Dinç, Ömer Cevdet Soydemir, Recep Karasu, Aysun Saricetin and Hunkar Cagdas Bayrak

Medicina 2025, 61(8), 1461; https://doi.org/10.3390/medicina61081461 - 14 Aug 2025

Abstract

Background and Objectives: Osteoarthritis (OA) is a degenerative joint disease involving inflammation, oxidative stress, and extracellular matrix (ECM) degradation, leading to cartilage damage and joint dysfunction. This study aimed to evaluate the chondroprotective effects of intra-articular hydrolyzed collagen in a rat model [...] Read more.

Background and Objectives: Osteoarthritis (OA) is a degenerative joint disease involving inflammation, oxidative stress, and extracellular matrix (ECM) degradation, leading to cartilage damage and joint dysfunction. This study aimed to evaluate the chondroprotective effects of intra-articular hydrolyzed collagen in a rat model of knee OA using a dual-compartment biochemical and histological approach. Materials and Methods: Twenty male Sprague-Dawley rats underwent ACL transection to induce osteoarthritis and were randomly assigned to receive intra-articular hydrolyzed collagen or saline once weekly for three weeks. At six weeks, knee joints were evaluated histologically using the Mankin score. Synovial fluid and cartilage homogenates were analyzed via enzyme-linked immunosorbent assay (ELISA) for cytokines, cartilage degradation markers, and oxidative stress indicators. Results: The collagen-treated group demonstrated significantly lower Mankin scores. Levels of pro-inflammatory cytokines, interleukin-1 beta (IL-1β), interleukin-6 (IL-6), and tumor necrosis factor-alpha (TNF-α), as well as cartilage degradation markers, matrix metalloproteinase-13 (MMP-13), C-terminal crosslinked telopeptide of type II collagen (CTX-II), and cartilage oligomeric matrix protein (COMP), were significantly reduced (p < 0.05). Additionally, oxidative stress indicators including inducible nitric oxide synthase (iNOS), total oxidant status (TOS), and oxidative stress index (OSI) were decreased, while total antioxidant status (TAS) was increased in both synovial fluid and cartilage homogenates (p < 0.05). Conclusions: Intra-articular hydrolyzed collagen reduced inflammation, oxidative stress, and extracellular matrix (ECM) degradation, indicating potential chondroprotective effects across both synovial and cartilage compartments. Full article

(This article belongs to the Section Orthopedics)

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11 pages, 594 KiB

Open AccessReview

Applications of Deep Learning Models in Laparoscopy for Gynecology

by Fani Gkrozou, Vasileios Bais, Charikleia Skentou, Dimitrios Rafail Kalaitzopoulos, Georgios Grigoriadis, Anastasia Vatopoulou, Minas Paschopoulos and Angelos Daniilidis

Medicina 2025, 61(8), 1460; https://doi.org/10.3390/medicina61081460 - 14 Aug 2025

Abstract

Background and Objectives: The use of Artificial Intelligence (AI) in the medical field is rapidly expanding. This review aims to explore and summarize all published research on the development and validation of deep learning (DL) models in gynecologic laparoscopic surgeries. Materials and [...] Read more.

Background and Objectives: The use of Artificial Intelligence (AI) in the medical field is rapidly expanding. This review aims to explore and summarize all published research on the development and validation of deep learning (DL) models in gynecologic laparoscopic surgeries. Materials and Methods: MEDLINE, IEEE Xplore, and Google scholar were searched for eligible studies published between January 2000 and May 2025. Selected studies developed a DL model using datasets derived from gynecologic laparoscopic procedures. The exclusion criteria included non-gynecologic datasets, non-laparoscopic datasets, non-Convolutional Neural Network (CNN) models, and non-English publications. Results: A total of 16 out of 621 studies met our inclusion criteria. The findings were categorized into four main application areas: (i) anatomy classification (n = 6), (ii) anatomy segmentation (n = 5), (iii) surgical instrument classification and segmentation (n = 5), and (iv) surgical action recognition (n = 5). Conclusions: This review emphasizes the growing role of AI in gynecologic laparoscopy, improving anatomy recognition, instrument tracking, and surgical action analysis. As datasets grow and computational capabilities advance, these technologies are poised to improve intraoperative guidance and standardize surgical training. Full article

(This article belongs to the Section Obstetrics and Gynecology)

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15 pages, 1227 KiB

Open AccessReview

Peripheral Parenteral Nutrition and Personalized Nutritional Approach After Colorectal Resection Surgery: A Comprehensive Review of Current Evidence

by Maximos Frountzas, Dimitrios Stefanoudakis, Evgenia Mela, Panagiotis Theodorou, George E. Theodoropoulos, Dimitrios Theodorou and Konstantinos G. Toutouzas

Medicina 2025, 61(8), 1459; https://doi.org/10.3390/medicina61081459 - 14 Aug 2025

Abstract

Major surgical operations of the gastrointestinal tract, such as colorectal resections, lead to significant burden on the human body, which is expressed during the first postoperative hours with an intense inflammatory reaction and consumption of a large amount of energy, increasing patients’ nutritional [...] Read more.

Major surgical operations of the gastrointestinal tract, such as colorectal resections, lead to significant burden on the human body, which is expressed during the first postoperative hours with an intense inflammatory reaction and consumption of a large amount of energy, increasing patients’ nutritional requirements. Therefore, specific protocols have been implemented for the early initiation of oral feeding. However, not every patient could meet them due to old age and associated pathophysiological changes, the use of opioid drugs for the management of postoperative pain (which is associated with postoperative ileus or nausea), as well as open resections which might lead to gastrointestinal impairment during the first postoperative days. Therefore, a tailored nutritional approach after colorectal resections seems necessary under specific conditions. Parenteral nutrition could be part of this personalized treatment, as it might counterbalance the energy deficit occurring during the early postoperative period, which appears to be associated with adverse clinical outcomes. Nevertheless, the conventional way of administration through central venous lines is associated with significant complications. On the other hand, the alternative administration of parenteral nutrition through a peripheral venous catheter could avoid morbidity, maintaining patients’ energy balance even during the first postoperative hours. However, the efficacy of peripheral parenteral nutrition on the postoperative outcomes of patients undergoing colorectal resections needs to be investigated in prospective randomized trials. The aim of the present review is to present the current trends regarding administration of peripheral parenteral nutrition (PPN) after colorectal resections and highlight any potential correlations between PPN and postoperative inflammatory reaction, as well as short-term nutritional status. Full article

(This article belongs to the Special Issue Recent Advances and Future Challenges in Colorectal Surgery)

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9 pages, 471 KiB

Open AccessArticle

Distribution of Hemoglobinopathy Disorders in Al-Kharj Province Based on Data from the Premarital Screening and Genetic Counseling Program

by Noura Al-Dayan

Medicina 2025, 61(8), 1458; https://doi.org/10.3390/medicina61081458 - 14 Aug 2025

Abstract

Background and Objectives: Hemoglobinopathies are genetic disorders of hemoglobin and are among the most common inherited diseases. The prevalence rates of sickle cell disease and thalassemia in Saudi Arabia are higher than those in other countries in the Middle East. Saudi Arabia [...] Read more.

Background and Objectives: Hemoglobinopathies are genetic disorders of hemoglobin and are among the most common inherited diseases. The prevalence rates of sickle cell disease and thalassemia in Saudi Arabia are higher than those in other countries in the Middle East. Saudi Arabia has launched many prevention programs such as a premarital screening program, genetic counseling programs, and neonatal screening in order to reduce the incidence of genetic diseases. The former program includes the most common genetic diseases: sickle cell disease and thalassemia. Many studies conducted since the premarital program started have reported a decrease in the prevalence of sickle cell disease and thalassemia. However, all studies focus on large cities, including their subdivisions, but there is a lack of studies on subdivisions specifically. Materials and Methods: The aim of this study was to assess the prevalence, 5-year time trend, and distribution of β-thalassemia and sickle cell traits in Al-Kharj province using the data of the PMSGC program during the period from January 2017 to February 2021. Results: A total of 21,150 individuals were screened, and 508 were diagnosed with sickle cell disease and thalassemia. Also, we showed that thalassemia was more prevalent than sickle cell disease (66% and 34%, respectively), and there was an increase in β-thalassemia and α-thalassemia. Conclusions: Riyadh city’s prevalence rate of β-thalassemia was reported as 7 per 1000, while the current study found a prevalence rate of 5.6 per 1000 in Al-Kharj, which suggests a possible increase as a result of population growth in Al-Kharj province as part of Riyadh city. This study recommends further improvement in preventive measures in high-risk regions, as well as enhanced community awareness, to provide the highest rate of reduction for disorders. Full article

(This article belongs to the Special Issue Advances in Public Health and Healthcare Management for Chronic Care)

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13 pages, 1225 KiB

Open AccessArticle

Challenges in Diagnosing Pediatric Monteggia Fractures: Role of Clinical Experience and Imaging

by Min Hyeok Choi, Min Hui Moon, Suk Woong Kang, Kyeong Baek Kim, Tae Young Ahn and Jung Yun Bae

Medicina 2025, 61(8), 1457; https://doi.org/10.3390/medicina61081457 - 13 Aug 2025

Abstract

Background and Objectives: Monteggia fracture-dislocations are rare but critical injuries in children. Accurate early diagnosis is essential to avoid long-term complications; however, such injuries are frequently missed. Therefore, this study aimed to assess the diagnostic accuracy of Monteggia fractures among physicians of [...] Read more.

Background and Objectives: Monteggia fracture-dislocations are rare but critical injuries in children. Accurate early diagnosis is essential to avoid long-term complications; however, such injuries are frequently missed. Therefore, this study aimed to assess the diagnostic accuracy of Monteggia fractures among physicians of varying specialties and experience levels and to identify factors influencing diagnostic performance. Materials and Methods: This retrospective study analyzed the radiographic interpretations of pediatric elbow and forearm injuries by six physician groups: orthopedic residents, general orthopedic surgeons, pediatric orthopedic surgeons, general radiologists, and subspecialized musculoskeletal radiologists. The final diagnosis established by pediatric radiology experts served as the reference standard. Influential variables, such as image quality, splint application, and age-related ossification, were evaluated. Results: In total, 120 patients were included, 40 (33.3%) of whom were diagnosed with Monteggia fractures and 80 (66.7%) with other fracture types. The diagnostic accuracy of Monteggia fractures varied significantly according to the physician’s experience. First-year residents and non-subspecialty radiologists had the highest rate of missed diagnoses. While other fracture types were occasionally influenced by technical factors, most missed Monteggia fracture cases stemmed from recognition failure. Subtle imaging features, plastic deformation of the ulna, and the omission of dedicated elbow views contributed to the misdiagnosis. Awareness and training improved performance, and a high index of suspicion was identified as crucial. Early follow-ups and standardized imaging protocols were identified as effective safeguards. Conclusions: Experience level, awareness, and imaging protocol quality were identified as being central to the accurate diagnosis of pediatric Monteggia fractures. Implementing educational strategies, promoting systematic imaging reviews, and reinforcing team-based approaches may reduce the rate of missed diagnoses. Full article

(This article belongs to the Section Orthopedics)

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23 pages, 8560 KiB

Open AccessArticle

Methylene Blue Alleviates Inflammatory and Oxidative Lung Injury in a Rat Model of Feces-Induced Peritonitis

by Cengiz Dibekoğlu, Kubilay Kemertaş, Hatice Aygun and Oytun Erbas

Medicina 2025, 61(8), 1456; https://doi.org/10.3390/medicina61081456 - 13 Aug 2025

Abstract

Background and Objectives: Feces-induced peritonitis (FIP), a clinically relevant model of polymicrobial sepsis, induces systemic inflammation and acute lung injury (ALI). Methylene blue (MB), a phenothiazine-based compound, exhibits vasoregulatory, antioxidant, and anti-inflammatory properties in the context of sepsis. This study aimed to evaluate [...] Read more.

Background and Objectives: Feces-induced peritonitis (FIP), a clinically relevant model of polymicrobial sepsis, induces systemic inflammation and acute lung injury (ALI). Methylene blue (MB), a phenothiazine-based compound, exhibits vasoregulatory, antioxidant, and anti-inflammatory properties in the context of sepsis. This study aimed to evaluate the protective effects of MB on pulmonary injury in a rat model of FIP-induced sepsis. Materials and Methods: Forty male Wistar rats were randomly assigned to four groups: control, FIP, FIP + Saline, and FIP + MB. MB was administered intraperitoneally at a dose of 20 mg/kg, 1 h after FIP induction. At 24 h post-induction, plasma levels of inflammatory markers [interleukin-6 (IL-6), interleukin-1 beta (IL-1β), tumor necrosis factor-alpha (TNF-α), C-reactive protein (CRP)], oxidative stress marker [malondialdehyde (MDA)], metabolic indicator [lactic acid], and vascular signaling marker [cyclic guanosine monophosphate (cGMP)] were measured. Lung injury was evaluated through histopathological analysis and thoracic computed tomography (CT)-based Hounsfield unit (HU) quantification, while pulmonary function was assessed via arterial blood gas analysis, including arterial oxygen pressure (PaO₂) and carbon dioxide pressure (PaCO₂). Results: FIP induction led to significant increases in plasma levels of IL-6, IL-1β, TNF-α, CRP, MDA, cGMP, and lactic acid, accompanied by elevated CT attenuation (HU) values and a marked reduction in arterial PaO₂ and PaCO₂. MB treatment significantly decreased the levels of IL-6, IL-1β, TNF-α, CRP, MDA, lactic acid, and cGMP, improved PaO₂, and attenuated both histopathological lung injury and CT-assessed parenchymal density. No significant differences were observed in PaCO₂ among the groups. Conclusions: MB mitigates inflammation, oxidative damage, and pulmonary dysfunction in FIP-induced sepsis. Further studies are warranted to optimize dosing and timing and to evaluate long-term outcomes. Full article

(This article belongs to the Section Infectious Disease)

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12 pages, 471 KiB

Open AccessArticle

Predictive Value of the Cally Score in Determining Surgical Strategy for Complicated Left-Sided Colonic Diverticulitis: A Retrospective Cohort Study

by Feyyaz Gungor, Huseyin Kılavuz, Muhammed Furkan Arslan, Murat Demir, Yusuf Yunus Korkmaz, Ali Bekraki and Idris Kurtulus

Medicina 2025, 61(8), 1455; https://doi.org/10.3390/medicina61081455 - 13 Aug 2025

Abstract

Background and Objectives: Complicated left-sided colonic diverticulitis is one of the important causes of hospital admissions and emergency surgery in industrialized societies and requires serious clinical decision-making processes for patient management. This study aims to evaluate the predictive role of albumin-based nutritional [...] Read more.

Background and Objectives: Complicated left-sided colonic diverticulitis is one of the important causes of hospital admissions and emergency surgery in industrialized societies and requires serious clinical decision-making processes for patient management. This study aims to evaluate the predictive role of albumin-based nutritional indices in deciding on surgical strategy (primary anastomosis vs. Hartmann procedure) in patients treated operatively for complicated left-sided colonic diverticulitis. Materials and Methods: This retrospective single-center study included 57 patients who were operatively treated for Hinchey stage III–IV diverticulitis between 2021 and 2024. Patients were divided into two groups according to surgical method: Hartmann procedure (n = 40) and primary anastomosis (n = 17). Prognostic Nutritional Index (PNI), Hemoglobin–Albumin–Lymphocyte–Platelet Score (HALP), CRP–Albumin–Lymphocyte (CALLY) Index, and Modified Glasgow Prognostic Score (mGPS) were evaluated as albumin-based nutritional indices in the preoperative period. Predictive parameters were determined using ROC analysis and multivariate logistic regression. Results: Albumin level, PNI, HALP, and CALLY scores were found to be significantly lower in the Hartmann procedure group. Additionally, the proportion of patients with mGPS score 2 was significantly higher in the Hartmann procedure group (57.5% vs. 5.9%; p < 0.001). In the ROC analysis, the cut-off value for the CALLY index was determined as 0.45 (AUC: 0.826). In multivariate analysis, albumin < 38.5 g/L (OR: 16.53), CALLY index < 0.45 (OR: 6.40), and systemic inflammatory response syndrome (SIRS) detection (OR: 12.98) were determined as independent factors predicting the Hartmann procedure. Conclusions: A low CALLY index was found to be independent predictors for the Hartmann procedure. The CALLY index, which reflects the inflammatory response, immune capacity and nutritional status, can assist surgeons in making objective, and individualized decisions by holistically evaluating the patient’s physiological status. Multicenter prospective studies are required to confirm the clinical validity of the findings. Full article

(This article belongs to the Section Surgery)

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