Search Results (424)

Background: Coronary imaging is increasingly used in chronic total occlusion percutaneous coronary intervention (CTO-PCI), but the impact of different imaging strategies on procedural decisions and outcomes remains unclear. Methods: We retrospectively analyzed 171 consecutive patients undergoing CTO-PCI, stratified by imaging strategy into four groups: angiography-only (n = 48), IVUS-guided (n = 42), CT-guided (n = 40) and CT + IVUS-guided (n = 41). Procedural and in-hospital clinical outcomes were compared. A multivariable logistic regression identified predictors of intense debulking techniques (defined as the use of rotational atherectomy or intravascular lithotripsy). Results: Imaging guidance was associated with progressively longer procedural (p < 0.001) and fluoroscopic time (p = 0.007). Similarly, an increased number of guidewires (p = 0.005) and balloons (p = 0.003) was used in the imaging groups, with the CT + IVUS groups showing the highest features. Regarding stenting characteristics, higher stent length and diameter (p = 0.01) were observed in the imaging groups. In patients with J-CTO score > 2, procedural success rates significantly increased with the use of coronary imaging (p = 0.01). Multivariable analysis showed that both J-CTO score (OR 2.0; 95% CI 1.3–3.0; p = 0.001) and imaging strategies (OR 1.6; 95% CI 1.02–2.4; p = 0.04) independently predicted the use of intense debulking techniques. Importantly, no significant differences were observed in in-hospital complications across groups. Conclusions: The use of coronary imaging, particularly the combination of IVUS and CT, is associated with more complex CTO lesions and led to increased procedural time, fluoroscopic time and more extensive stenting, as well as higher debulking usage. In complex CTO cases, coronary imaging was associated with higher procedural success rates. Imaging strategies independently predicted the need for advanced lesion preparation, beyond anatomical complexity, without compromising safety. Despite higher procedural demands, coronary imaging enables a more tailored and successful approach to CTO-PCI, particularly in complex cases. These findings underscore the pivotal role of multimodal imaging in the procedural planning and optimization of CTO-PCI. Full article

Background: Coronary collateral circulation (CCC) plays a crucial protective role in patients with chronic total occlusion (CTO), mitigating ischemia and improving long-term outcomes. However, the degree of collateral vessel development varies substantially among individuals. Systemic inflammatory and nutritional status may influence this variability. The Naples Prognostic Score (NPS) is a composite index reflecting these parameters, yet its relationship with CCC remains incompletely defined. Methods: We retrospectively analyzed 324 patients with angiographically confirmed CTO at Selçuk University Faculty of Medicine between 2014 and 2025. Coronary collaterals were graded using the Rentrop classification, and patients were categorized as having poor (grades 0–1) or good (grades 2–3) collaterals. The NPS was calculated using serum albumin, cholesterol, neutrophil-to-lymphocyte ratio, and lymphocyte-to-monocyte ratio. Baseline clinical and laboratory data were compared between groups. Univariate and multiple binary logistic regression analyses were performed to identify independent predictors of collateral development. Results: Of the 324 patients, 208 (64.2%) had poor and 116 (35.8%) had good collateral circulation. Patients with good collaterals had higher body mass index, HDL Cholesterol (HDL-C), and triglyceride levels, and significantly lower NPS values compared with those with poor collaterals (p < 0.05 for all). In multiple binary logistic regression analysis, HDL-C (OR 1.035; 95% CI 1.008–1.063; p = 0.011) and NPS (OR 0.226; 95% CI 0.130–0.393; p < 0.001) emerged as independent predictors of well-developed collaterals. Conclusions: Both NPS and HDL-C are independently associated with the degree of coronary collateral circulation in CTO patients. These findings highlight the interplay between systemic inflammation, nutritional status, lipid metabolism, and vascular adaptation. As simple and routinely available measures, NPS and HDL-C may serve as practical tools for risk stratification and identifying patients at risk of inadequate collateral formation. Prospective studies with functional assessments of collateral flow are warranted to confirm these associations and explore potential therapeutic interventions. Full article

Background: This article presents an international comparative review of involuntary psychiatric care, Community Treatment Orders (CTOs), and forensic mental health services, with operational implications for Italy. Italy has a community-based model inspired by the “Basaglia Law” (Law No. 180/1978), emphasizing deinstitutionalization and continuity of care. Nevertheless, risk governance gaps persist for high-complexity patients, imposing a disproportionate legal and clinical burden on mental health professionals. This group includes individuals who refuse treatment despite meeting criteria for compulsory admission, patients at elevated risk with substantial management complexity, and offenders with a current or suspected psychiatric disorder. Methods: We conducted a comparative legal and policy review across seven jurisdictions (Italy, England and Wales (UK), France, Germany, Spain, the United States, and Canada) to map frameworks for involuntary treatment, forensic services, CTOs (or equivalents), and community-based risk management. We also extracted procedural safeguards, duration and renewal limits, and interfaces with forensic services. Results: CTOs are available in five of the seven jurisdictions (England and Wales, France, Spain, the United States, and Canada) but are absent in Italy and Germany. We propose a three-pillar framework: (1) enforceable outpatient measures, including CTOs; (2) Forensic Psychiatry Units within Local Health Authorities; and (3) oversight boards with judicial, clinical, and social representatives. These components aim to redistribute responsibility, ensure continuity of care, and provide proportional oversight within a least restrictive, graduated system. Conclusions: When narrowly targeted, time limited, and paired with robust safeguards and service-quality standards, CTOs can support adherence and continuity for patients who repeatedly disengage from care. For Italy, integrating this instrument within the three-pillar framework and under independent oversight could strengthen patient rights and public safety, reduce revolving-door admissions, and improve outcomes. Full article

In recent years, interest in lithium-ion batteries has grown significantly due to their dominance in electric mobility, driven by their high energy density. However, their performance and longevity are strongly influenced by the effectiveness of heat dissipation and thermal management. The literature indicates that battery temperature should be maintained within the optimal range of 20–40 °C, while also ensuring minimal temperature gradients within the battery pack. In this study, a thermal management system for electric vehicle batteries which combines two different cooling approaches (i.e., direct immersion cooling and pulsating heat pipes) is presented. In particular, the battery pack is placed inside a PVC case and completely submerged by a low-boiling dielectric fluid (T_bp = 33.4 °C at 1 atm) to take advantage of the excellent thermal properties of the liquid and of the latent heat during phase change. The evaporator section of the pulsating heat pipe is positioned in the vapor phase region of the dielectric fluid, while the condenser section is located outside the PVC box and cooled by an airflow in natural convection. This setup is a completely passive system. To evaluate the cooling performance of the dual two-phase cooling system, tests were conducted on the battery pack at three different discharge C-rates 0.5C, 1C, and 2C that reproduce the working conditions of a real-world battery. To evaluate the effectiveness of the new setup, its performance was compared with cooling based on natural convection and direct immersion cooling alone. These approaches were assessed under two controlled ambient temperatures—5 °C and 20 °C—to compare their performance in varying conditions. The results show that the hybrid system performs particularly well, especially because it can operate passively without requiring external power or active control mechanisms. Full article

Background/Objectives: In pre-pectoral breast reconstruction, both synthetic meshes (SM) and acellular dermis or pericardium matrixes (ADM/APM) present drawbacks that can be prevented with targeted device choosing. In daily practice, the authors wrap the implant with a human-derived ADM (hADM) when they found mastectomy flaps thinner than 1 cm. When hADM is not available, an APM is used. Here, the authors present their results with APM utilisation. Methods: From January to September 2024, patients undergoing pre-pectoral breast reconstruction with mastectomy flaps thinner than 1 cm were selected. Specifically, implants were wrapped in bovine pericardium (Exaflex—MAGGI Srl, TO, Italy). During a minimum 6 months follow-up, outcomes were recorded; in particular, rippling incidence was assessed with indication for secondary fat grafting. Results: Nineteen patients met the inclusion criteria. Average age was 54.4 years (range: 39–70), three of them were smokers (15.8%) and three were affected from diabetes or hypertension (15.8%). With one case bilateral, a total of 20 mastectomies were performed. Intra-operative mastectomy flaps’ thickness mean measure was 0.75 cm (range: 0.5–0.8). All of them underwent two-stage pre-pectoral IBR with APM covering the implant. During a mean follow-up of 9.5 months (range: 6–13), no major post-operative complications occurred and five cases (25%) presented rippling. Conclusions: With no consensus on the superiority of either biologic matrixes or SMs, the authors extended their patients’ selection tool to aid in the choice of peri-prosthetic device. The bovine APM use showed capacity of reducing secondary lipofilling interventions in patients with thin mastectomy flaps. Full article

The direct visualization of the Meissner effect is achieved by mapping the expulsion of static magnetic fields from a high-${\mathrm{T}}_{\mathrm{C}}$ superconductor, specifically Yttrium Barium Copper Oxide (YBCO). This is accomplished using a miniaturized scanning magnetometer based on an ensemble of nitrogen-vacancy (NV) centers in diamond, operating under ambient room-temperature conditions. By comparing the magnetic field profiles above the YBCO sample at temperatures above and below its critical temperature $T_C$, we observe clear suppression and distortion of the magnetic field in the superconducting state. These observations are consistent with both magnetic simulations and expected characteristics of the Meissner effect. This work introduces a novel and practical method for visualizing the Meissner effect, offering potential applications in educational demonstrations and the diagnostic testing of superconductivity using room-temperature quantum magnetometry. Full article

Diabetes mellitus (DM) and osteoporosis are among the most common non-communicable diseases worldwide. Beyond their considerable socio-economic burden, both conditions significantly impair quality of life and reduce life expectancy, representing major causes of disability. DM-induced osteoporosis has recently emerged as a notable and frequent complication. Patients with type 2 DM have a twofold increased risk of fragility fractures, while those with longstanding type 1 DM exhibit a fivefold higher risk of hip, vertebral, and non-vertebral fractures. Bone mineral density (BMD) assessed by Dual Energy X-ray Absorptiometry (DXA) often fails to predict fracture risk in this population, as bone mass tends to be normal, slightly reduced, or even elevated. However, DXA-derived indices can offer additional clinical value. The Trabecular Bone Score (TBS), which reflects bone microarchitecture, is frequently reduced in patients with DM and is associated with increased fracture risk, particularly in postmenopausal women. TBS is also linked to glycemic control and microvascular complications and can improve with bone-active medications, thus aiding follow-up assessments. Another useful DXA-based tool is the Bone Strain Index (BSI), which evaluates load resistance and has been shown to be degraded in diabetic patients, offering further predictive value for fractures. Additionally, Hip Structural Analysis (HSA) provides information on the mechanical integrity of the proximal femur, which may be compromised in DM. Based on the available evidence, this review aims to highlight the clinical utility of DXA-derived tools in DM-induced osteoporosis, emphasizing their ability to provide quantitative and qualitative information on bone health and to predict the risk of fragility fractures. Full article

Background/Objectives: Musculoskeletal disorders causing chronic pain are increasingly prevalent due to factors such as injury, overuse, and aging, leading to interest in porcine collagen injections as a potential therapeutic and conservative option. Despite promising results, evidence-based information on this treatment is scarce. To address this gap, the authors conducted an eDelphi consensus among expert Italian physicians in musculoskeletal pain to gather their perspectives on collagen injections. Methods: A Steering Committee and a Panel of 23 physicians developed the statements list (36) including the modalities, safety, and efficacy of intra- and extra-articular collagen injections. Panelists rated their agreement with each statement on a 5-point Likert scale (5 means “Strong Agreement”). Consensus was defined as when at least 75% of the panelists voted with a score of ≥4/5 after two rounds of votes. The weighted average (WA) was calculated for each statement. As control, we elaborated a Hypothetical Parametric Distribution (HPD WA equal to 3.00), where the percent of panelists is equally distributed along each Likert Scale Value (LSV). The maximum WA for 75% of the consensus is established at 3.75. Indeed, the combination of 75% having WA > 3.75 was defined as “Strong Agreement”. While, if the consensus was under 75%, the WA vs. HPD comparison was performed using the Wilcoxon Test. Significant differences among the distribution of LSVs judged the statement as “Low Level of Agreement”. Disagreement was evaluated when the WA was under the PHD. Results: The consensus was reached “Strong Agreement” after twin rounds in 29 out of 36 (8.55%). In 5 out of 36 statements (13.89%), the panelists reached the “Low Level of Agreement” by statistical tests. In the remaining two statements, there was a “Consensus of Disagreement”. All panelists unanimously agreed on crucial points, such as contraindications, non-contraindication based solely on comorbidity, and the importance of monitoring collagen’s effectiveness. Unanimous agreement was reached on recommending ultrasound guidance and associating collagen injections with therapeutic exercise and physical modalities. Substantial consensus (concordance > 90%) supported collagen injections for osteoarthritis, chondropathy, and degenerative tendinopathies, emphasizing intra- and peri-articular treatment, even simultaneously. However, areas with limited evidence, such as the combination of collagen with other injectable drugs, treatment of myofascial syndrome, and injection frequency, showed disagreement. The potential of intra-tendinous porcine collagen injections for tendon regeneration yielded mixed results. Conclusions: Clinicians experts in musculoskeletal pain agree on using collagen injections to treat pain originating from joints (e.g., osteoarthritis) and periarticular (e.g., tendinopathies). Full article

Background/Objectives: Peripheral nerve tumours are commonly encountered in clinical practice. Although most are benign, a subset can exhibit aggressive and invasive behaviour, evolving into malignant peripheral nerve sheath tumours (MPNSTs). Due to their rarity and overlapping features with benign lesions, MPNSTs are frequently misdiagnosed during the initial evaluation. Preoperative biopsy may aid in distinguishing malignant from benign lesions. This single-center study aimed to develop and validate a diagnostic algorithm—based on a systematic literature review and institutional case series—to assess the role of preoperative biopsy in the diagnostic workflow. Methods: A systematic review of the literature was conducted in accordance with PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, covering the period from 1998 to 2024. Additionally, a retrospective case series of patients with peripheral nerve lesions treated at the authors’ institution between January 2018 and June 2024 was analysed. Results: Forty-eight articles met the inclusion criteria and were categorized into five key domains: radiological features of MPNSTs, associated risk factors and genetic conditions, the role of preoperative biopsy, use of radiotherapy, and general clinical management strategies. The proposed diagnostic algorithm was applied to a series of 36 patients, four of whom met the criteria for preoperative biopsy. In three of these cases, early diagnosis of MPNSTs was achieved. Conclusions: Preoperative biopsy appears to be a safe and cost-effective tool for the early identification of MPNSTs. Early diagnosis may facilitate the use of neoadjuvant therapies—such as radiotherapy or chemotherapy—potentially enabling more radical surgical resection and improving overall patient outcomes. Full article

Background: Total knee arthroplasty (TKA) has evolved significantly, yet achieving consistently optimal outcomes remains challenging across diverse patient populations. This comprehensive narrative review identifies evidence-based “game changers” that genuinely transform TKA success while distinguishing them from interventions lacking clinical superiority. The analysis organizes findings across three perioperative phases: preoperative optimization, intraoperative techniques, and postoperative management. Preoperative game changers include end-stage bone-on-bone osteoarthritis, preoperative medical optimization of patients performed by dedicated practitioners, cryocompression therapy, and perioperative dexamethasone administration. Intraoperative interventions demonstrating substantial impact encompass reduced surgical time and optimized surgical instrumentation, personalized alignment, medial congruent bearings, cementless implants for high-demanding and high-BMI patients, and perioperative tranexamic acid. Postoperative game changers include early mobilization following surgery, venous thrombo-embolic prophylaxis avoiding high-bleeding-risk pharmaceuticals, and multimodal pain management. The review also identifies those initial promises without established clinical advantages, or “fake game changers”, that consume resources without meaningful benefits. This evidence synthesis demonstrates that TKA optimization requires systematic implementation of validated interventions rather than pursuing technological innovations indiscriminately. The future of TKA lies in evidence-based adoption of proven strategies that translate to genuine patient outcome improvements rather than merely increasing procedural complexity. Full article

Background/Objective: Traumatic injuries to the flexor tendons of the hand are frequently treated by hand surgeons. Late repair is not classically considered to be feasible due to the high risk of failure and functional complications. The present study aims to present the functional results of primary flexor tendon repairs performed more than three months after trauma, along with evidence regarding the time limit for primary flexor tendon repair. Methods: The clinical outcomes of direct flexor tendon repairs in zones 1 and 2 of the long fingers or thumb are reported herein. A scoping review was undertaken using Medline and CINHAL to identify studies reporting the functional outcomes of flexor repair following trauma. Results: In this series, four patients were treated with direct M-Tang and epitendinous suture or pull-out reinsertion. Accessory procedures were required to perform a direct repair. The mean delay was 5.5 months, and the follow-up period was 24 months. The mean total active movement was 195°. Extension lags of 10° and 20° were registered at the proximal interphalangeal and distal interphalangeal joints, respectively. While a literature review showed that most cases treated with primary repair after three months resulted in functional complications, these procedures were performed around 40 years ago and no recent reports were found. Conclusions: In the small cohort of patients here reported it has been possible to repair flexor tendons in zones 1 and 2, and to reinsert a jersey finger, even three months after trauma. Accessory procedures were required. Accurate patient selection and counseling is mandatory before surgery to inform patients about alternatives. The literature review confirmed that no positive results have previously been reported in the literature on this topic. It is thought that modern materials and surgical techniques for flexor tendon repair should extend the edge for primary repair in selected patients, as compared to previous practices. Full article

Background: Eccentric cycling exercise (ECC) offers a low-metabolic-demand approach to exercise, potentially making it valuable for patients with pulmonary vascular disease (PVD). The aim of this study was to investigate how quadriceps and frontal cortex oxygenation, assessed by near-infrared spectroscopy (NIRS), differs during ECC compared to concentric cycling exercise (CON) in patients with PVD and in healthy individuals. Methods: This randomized controlled crossover trial involved patients with PVD, defined as either pulmonary arterial hypertension (PAH) or chronic thromboembolic pulmonary hypertension (CTEPH), and healthy volunteers. Participants performed both CON and ECC at identical submaximal work rates, following a stepwise incremental protocol. NIRS was used to continuously monitor tissue oxygenation and surrogates for blood volume changes in the quadriceps and frontal cortex. Results: A total of 57 participants were included, 33 PVD patients (19 with PAH and 14 with CTEPH; 13 women; mean age: 50 ± 15 years) and 24 healthy volunteers (14 women; 50 ± 14 years). In PVD patients, at end-exercise, cerebral tissue oxygenation (CTO) was significantly higher during ECC compared to CON (6.10%; 95% CI: 1.85 to 10.42; p < 0.01), whereas muscle tissue oxygenation (MTO) was similar. In healthy individuals, at end-exercise, CTO was similar during ECC and CON, whereas MTO was significantly higher (2.60%; 95% CI: 0.03 to 5.17; p = 0.047). There were no significant differences in CTO and MTO between patients with PVD and healthy individuals. Discussion: In this randomized controlled crossover trial, patients with PVD exhibited higher CTO during ECC compared to CON, which may indicate altered cerebral oxygen extraction and hemodynamic responses potentially related to impaired vascular function. In contrast, healthy individuals demonstrated higher MTO during ECC, likely reflecting improved muscular oxygen utilization and efficiency due to the mechanical and metabolic characteristics of eccentric exercise. Full article

Background/Objectives: Heart failure (HF) with reduced ejection fraction (EF) has, in more than 50% of cases, an ischemic etiology and continues to be associated with increased mortality and morbidity despite all the progress registered in the field of medical therapy and interventional revascularization. Myocardial revascularization is extensively used in clinical practice based on the traditional concept that it can improve myocardial function and outcome in ischemic HF. This review is aimed at presenting current knowledge regarding revascularization in patients with chronic ischemic HF and reduced EF. Methods: The impact of revascularization on symptomatology, left ventricle reverse remodeling, major adverse cardiac events (MACEs), and the role of complete revascularization and of percutaneous interventional revascularization in chronic total occlusion (PCI-CTO) were analyzed. The best therapeutic strategies, revascularization and/or optimal medical therapy (OMT), are debated in different categories of patients, in order to identify who will benefit more from revascularization strategies. Results: Based on the long-term results of the STICH trial incorporated in the guidelines with a class I-b recommendation, coronary artery bypass graft (CABG) remains the main modality of revascularization for prognostic improvement in ischemic HF with multivessel disease. But real-life patients are usually old with multiple comorbidities and high surgical risk. In this category, the Heart Team opinion is required to evaluate the probability of complete revascularization and to choose between percutaneous coronary intervention (PCI) and CABG according to clinical status and coronary anatomy. Conclusions: However, until further studies are available, the results of the REVIVED-BCIS2 trial encourage OMT over PCI in patients with ischemic cardiomyopathy. The available randomized controlled trials (RCTs) showed improved angina and quality of life in PCI-CTO versus OMT, but the effect on MACEs was not demonstrated. Full article

Introduction: Octogenarians undergoing unicompartmental knee arthroplasty (UKA) face increased risks of complications due to reduced bone support following osteoporosis. The aim of this study was to describe our preferred technique to balance robotic-assisted UKA in this specific patient population and to present its results. Methods: This retrospective analysis of prospectively collected data examined 121 consecutive octogenarian patients (median age 84 years, IQR 82–86) who underwent robotic-assisted medial UKA between September 2018 and December 2022 with ≥24 months follow-up. Patients aged ≤80 years, with ≤2 years of follow-up, or without informed consent were excluded. Data collection included radiographic measurements (HKA, LDFA, MPTA, joint line height), patient-reported outcome measures (Oxford Knee Score, Knee Society Score), and complications. Statistical analysis employed descriptive statistics, paired t-tests, Cohen’s d for effect sizes, and the McNemar test for categorical variables. Results: The hip–knee–ankle angle improved significantly from 174.43° to 178.04° (mean difference 3.61°, 95% CI 3.13–4.09, p < 0.001). Patient-reported outcomes demonstrated substantial improvements: the Knee Society Score increased by 83.09 points (95% CI 79.76–86.42, p < 0.001, Cohen’s d = 4.53), and the Oxford Knee Score increased by 17.09 points (95% CI 15.42–18.76, p < 0.001), with both exceeding minimal clinically important differences. Only 7.4% (9/121) of cases exhibited joint line lowering of >2 mm, with 1.7% (2/121) having both post-operative HKA <175° and joint line lowering of >2 mm. The implant survival rate was 100% with minimal complications, including two conservatively managed tibial plateau fractures and two cases of wound dehiscence with no further surgery needed. Conclusions: Robotic-assisted medial UKA can consistently preserve joint line height while achieving excellent alignment correction and clinical outcomes in octogenarians, potentially addressing failure risks in this specific population. Full article