Hispanic survival paradox: a systematic review of short-term hospital readmissions among Hispanic kidney transplant recipients in the United States

PURPOSE OF REVIEW

The epidemiologic phenomenon known as the "Hispanic paradox" postulates that Hispanic/Latino Americans generally tend to live longer than other racial/ethnic communities, despite facing many socioeconomic disadvantages and other healthcare barriers. Whether this phenomenon is relevant among kidney transplantation (KT) recipients remains unclear. To investigate the possibility of a Hispanic mortality advantage, we conducted a systematic review of the published literature comparing short-term KT outcomes (first 12-months) for US Hispanic versus non-Hispanic White KT recipients.

RECENT FINDINGS

This systematic review summarizes recent findings from sixteen observational retrospective cohort studies that met our study criteria. Study sample sizes ranged from 42 to 244 037 total KT recipients and examined data between 2005 and 2022. Compared to their Non-Hispanic comparator, the Hispanic sub-samples were more likely to be younger, spend more time on dialysis, and less likely to receive preemptive transplant or living donation. Hispanic KT recipients experienced similar or more favorable outcomes in eleven studies (ten studies examining patient and graft survival, one study examining readmissions), but only three studies with statistical significance.

SUMMARY

As the US Hispanic and Latino population continues to grow into the diverse American melting pot, this review highlights the need for better approaches to studying racial and ethnic variables within kidney transplantation.

Artificial intelligence for detection and characterization of focal hepatic lesions: a review

Focal liver lesions (FLL) are common incidental findings in abdominal imaging. While the majority of FLLs are benign and asymptomatic, some can be malignant or pre-malignant, and need accurate detection and classification. Current imaging techniques, such as computed tomography (CT) and magnetic resonance imaging (MRI), play a crucial role in assessing these lesions. Artificial intelligence (AI), particularly deep learning (DL), offers potential solutions by analyzing large data to identify patterns and extract clinical features that aid in the early detection and classification of FLLs. This manuscript reviews the diagnostic capacity of AI-based algorithms in processing CT and MRIs to detect benign and malignant FLLs, with an emphasis in the characterization and classification of these lesions and focusing on differentiating benign from pre-malignant and potentially malignant lesions. A comprehensive literature search from January 2010 to April 2024 identified 45 relevant studies. The majority of AI systems employed convolutional neural networks (CNNs), with expert radiologists providing reference standards through manual lesion delineation, and histology as the gold standard. The studies reviewed indicate that AI-based algorithms demonstrate high accuracy, sensitivity, specificity, and AUCs in detecting and characterizing FLLs. These algorithms excel in differentiating between benign and malignant lesions, optimizing diagnostic protocols, and reducing the needs of invasive procedures. Future research should concentrate on the expansion of data sets, the improvement of model explainability, and the validation of AI tools across a range of clinical setting to ensure the applicability and reliability of such tools.

Violence at work experienced by nursing professionals working in hospital units: an exploratory and correlational study

to identify the occurrence of violence at work affecting nursing professionals working in hospitals and to relate professional profile variables to this phenomenon.

this is an exploratory, cross-sectional, descriptive, correlational, field and quantitative study carried out with 218 nursing professionals working in hospital units in the 8th Health Region of Paraná, using a sociodemographic questionnaire and the Questionnaire for the Evaluation of Violence at Work Suffered or Witnessed by Nursing Workers. Data was analyzed using absolute and relative frequencies, and the Chi-squared test with Yates' continuity correction was used to verify the associated factors.

the sample included 218 nursing professionals, 44.0% of whom reported having suffered violence at work, 11.9% physical violence, 47.7% verbal abuse and 2.8% sexual harassment. When the association was made, it was observed that professionals over 30 and who work overtime suffer more violence than other professionals.

in view of the above, it was possible to see a significant occurrence of episodes of violence at work in the last 12 months, with verbal violence being the most frequently reported.

BACKGROUND

(1) Significant prevalence of violence in the workplace.

BACKGROUND

(2) Emphasis on workers' health for nursing professionals.

BACKGROUND

(3) Verbal violence affects 47.7% of the sample studied.

BACKGROUND

(4) The need for public policies to improve safety at work.

BACKGROUND

(5) Encouragement for further research on the subject.

Timing and Indications for Liver Transplantation for Children with Chronic Liver Disease

Chronic liver disease (CLD) in children poses significant challenges, necessitating timely management to mitigate morbidity and mortality. Liver transplantation (LT) has emerged as a transformative intervention, offering improved long-term survival for paediatric patients with CLD. This review explores the evolving landscape of liver transplantation, focusing on indications and timing considerations. The aetiology of CLD is diverse, encompassing intrahepatic, extrahepatic cholestatic conditions, metabolic diseases, malignancy, and drug-induced liver injury. LT is indicated when children exhibit signs of hepatic decompensation, necessitating a comprehensive evaluation to assess transplant suitability. Indications for LT include biliary atresia, inborn errors of metabolism, hepatocellular carcinoma, and emerging indications such as mitochondrial hepatopathies and acute on chronic liver failure. The timing of transplantation is critical, emphasizing the need for early recognition of decompensation signs to optimise outcomes. Advancements in LT techniques and immunosuppressive therapies have enhanced patient and graft survival rates. Various transplant modalities, including reduced-size LT and living-related LT, offer tailored solutions to address the unique needs of paediatric patients. While LT represents a cornerstone in the management of paediatric CLD, careful patient selection, multidisciplinary collaboration, and ongoing refinements in transplant protocols are imperative for optimizing outcomes and addressing the evolving landscape of paediatric liver disease management.

Prehospital paediatric trauma: equipping prehospital providers to deliver high-quality care

INTRODUCTION

Trauma is the leading cause of death in children over 1 year of age in the UK. However, individual prehospital clinicians only encounter paediatric trauma patients rarely. This study describes the frequency and type of paediatric trauma experienced by a mature prehospital trauma service in an urban environment to inform prehospital services about the type of injuries likely to be attended, and the key interventions that might be required on scene.

STUDY DESIGN

Retrospective review of patients 16 years of age and under attended by a physician-led prehospital trauma service between January 2017 and June 2022. Patients were divided into subgroups of 0-4 years, 5-11 years and 12-16 years.

RESULTS

782 paediatric patients were included, which comprised 8.3% of total patient workload. The median age was 15 years old (IQR 5-16 years) and the majority were male (n=597, 76.3%). The most common mechanism of injury for subgroups were falls from height (>2 m) in 0-4 year olds, road traffic collisions in 5-11 year olds and penetrating trauma in 12-16 year olds. 20.2% (n=158) of patients attended received critical care interventions. 9.8% (n=77) underwent prehospital emergency anaesthesia (PHEA) and 7.4% (n=58) received a blood transfusion.

CONCLUSION

Paediatric major trauma constitutes only a small minority of prehospital care workload. However, cases are attended regularly. Attending prehospital teams need to be trained to perform difficult resuscitations and perform high acuity, low frequency interventions. Educational and training strategies required to equip prehospital providers treating paediatrics may include checklists, algorithms, simulation training and mental health support.

From classroom to clinic: Addressing gaps in teaching and perceived preparedness for breaking bad news in medical education

BACKGROUND

Communicating bad news (BBN) is a significant challenge in medical practice, particularly in oncology, as it directly impacts patient care and follow-up. Despite existing protocols to aid this process, both patients and healthcare professionals frequently highlight insufficient training in BBN. This study evaluates [1] the curricula and methodologies of teaching BBN at the study institution and [2] medical students' perceptions of the effectiveness and adequacy of their BBN education and training.

METHODS

This cross-sectional, quantitative, exploratory study used a self-administered questionnaire with 25 questions developed by the researchers. Categorical variables were compared via the chi-square test or Fisher's exact test, with a significance level of 5%.

RESULTS

A total of 300 questionnaires were completed by medical students from the 8th to 12th periods, comprising 205 women and 95 men, with an average age of 23.9 ± 3.4 years. Among the participants, 220 (73.3%) reported receiving some formal instruction on breaking bad news, but only 17.3% felt prepared for this task. A vast majority (95.7%) recognized the importance of being prepared to communicate bad news. At the beginning of their practical cycle, 74.6% of the students found "discussing the end of therapeutic options and palliative care" the most challenging. For those already in the practical cycle, 54.8% identified "communicating about the worsening of the disease" as the most difficult.

CONCLUSION

Developing skills for breaking bad news is essential for a strong doctor-patient relationship. Teaching these skills in medical education is necessary to increase patient motivation and confidence in treatment.

The effectiveness of remote interventions based on digital health technology in kidney transplant recipients: a systematic review

PURPOSE

To evaluate the application effect of remote interventions based on digital health technology in kidney transplant patients through a systematic review.

DESIGN

Systematic review.

METHODS

The databases of PubMed, Embase, Cochrane Library, CINAHL, and Web of Science were systematically searched for randomized controlled trials and quasi - experimental studies on remote interventions based on digital health technology in kidney transplant recipients. The search time limit ranged from the establishment of the databases to September 2024.

RESULTS

A total of 10 articles were included, involving 535 patients. A total of 21 clinical outcomes were identified in this study and they were classified into three categories, namely: ① Health-related conditions: Number of steps (n = 1), heart rate (n = 1), self-burden score (n = 1), self-management ability (n = 1), quality of life score (n = 2), Self-rating Anxiety Scale (SAS) and Self-rating Depression Scale (SDS) (n = 1), psychological distress (n = 1). ② Medication adherence and average tacrolimus concentration: Medication adherence (n = 5), number of missed doses (n = 1), medication errors (n = 1), rejection reactions (n = 1), average creatinine level (n = 1), tacrolimus blood concentration level (n = 2), within-patient variability of tacrolimus (n = 1), coefficient of variation (CV) of tacrolimus (n = 1). ③ Medical economic status: Nursing satisfaction (n = 1), incidence of adverse events (n = 1), rate of unplanned hospitalization (n = 3), duration of unplanned hospitalization (n = 1), one-year medical cost (n = 2), nursing cost (n = 1).

CONCLUSION

Remote interventions based on digital health technology can improve the health - related conditions, medication adherence and medical economic status of kidney transplant recipients. However, its impact on tacrolimus concentration remains unclear. Clinical medical staff should fully recognize its positive effects.

Personalised Risk Modelling for Older Adult Cancer Survivors: Combining Wearable Data and Self-Reported Measures to Address Time-Varying Risks

Recent advancements in wearable devices have significantly enhanced remote patient monitoring, enabling healthcare professionals to evaluate conditions within home settings. While electronic health records (EHRs) offer extensive clinical data, they often lack crucial contextual information about patients' daily lives and symptoms. By integrating continuous self-reported outcomes related to vulnerability, anxiety, and depression from older adult cancer survivors with objective data from wearables, we can develop personalised risk models that address time-varying risk factors in cancer care. Our study combines real-world data from wearable devices with self-reported information, employing process mining techniques to analyse dynamic risk models for vulnerability and anxiety. Unlike traditional static assessments, this approach recognises that risk factors evolve. Collaborating with healthcare professionals, we analysed data from the LifeChamps study to create two dynamic risk models. This collaborative effort revealed how activity and sleep patterns influence self-reported vulnerability and anxiety among participants. It underscored the potential of wearable sensors and artificial intelligence techniques for deeper analysis and understanding, making us all part of a larger effort in cancer care. Overall, patients with prolonged sedentary activity had a higher risk of vulnerability, while those with highly dynamic sleep patterns were more likely to report anxiety and depression. Prostate-metastatic patients showed an increased risk of vulnerability compared to other cancer types.

Incidence of intraoperative morbidities in anterior lumbar interbody fusion (ALIF): a comprehensive study of 5,299 levels

CONTEXT

Anterior Lumbar Interbody Fusion (ALIF) is performed via an abdominal approach to remove the intervertebral disc. Although academic reports suggest low intraoperative complication rates, the available data show significant variability. There is a lack of large-scale, robust studies that consistently evaluate the morbidity rates associated with this procedure.

OBJECTIVE

This study evaluates the operative parameters of this procedure based on a substantial number of cases.

STUDY DESIGN

A retrospective case series.

METHODS

Patient data were retrospectively collected from the database of the Instituto de Acessos à coluna Aécio Dias (IAAD). All patients aged 18 years or older who underwent ALIF surgery were included in the study. Patients who underwent other surgical approaches were excluded. Data on intraoperative morbidity (vascular injuries, injuries to intra- and extraperitoneal organs, dural sac injuries, and nerve root injuries), operative time, and blood loss were collected and analyzed.

RESULTS

A total of 3,438 patients were evaluated. 1,671 (48.6%) were male, and 1,767 (51.4%) were female. The mean age was 47.87 ± 12.10 years, ranging from 18 to 88 years. The reported incidence of complications was as follows: vascular injuries (3.25%), nerve root injuries (0.09%), dural sac injuries (0.06%), and injuries to intra- and extraperitoneal organs (0.03%).

CONCLUSIONS

ALIF surgery demonstrated safety and low morbidity. A multidisciplinary team, including access surgeons, played a pivotal role in reducing vascular complications, optimizing surgical times, and minimizing blood loss, aligning with the standards reported in the literature.

Development of a nomogram to predict in-ICU mortality of elderly patients with sepsis-associated liver injury: an analysis of the MIMIC-IV database

Background

Sepsis-associated liver injury (SALI) is a frequent and lethal complication among critically ill patients in the intensive care unit (ICU). Despite its significance, there has been a notable lack of specialized tools for evaluating the in-ICU mortality risk in these patients. This study seeks to address this gap by developing a practical nomogram to predict risk factors associated with in-ICU mortality in patients suffering from SALI.

Methods

Data were extracted from the MIMIC-IV database, a Critical Care Public Medical Information Mart. The diagnostic criteria for sepsis adhered to the Sepsis 3.0 guidelines, requiring a SOFA score of ≥ 2. SALI was defined as total bilirubin (TBIL) levels > 2 mg/dL in patients with sepsis and an International Normalized Ratio (INR) > 1.5. Lasso regression analyses were conducted on the training set (n = 653) to develop a predictive nomogram model. Receiver Operating Characteristic (ROC) curves were generated to evaluate model discrimination. Model calibration was assessed through calibration curves and Hosmer-Lemeshow goodness-of-fit tests. Clinical decision curves were plotted to analyze the net benefit of the model and evaluate its clinical applicability.

Results

A total of 934 elderly patients with SALI were included in the study. Random seeds were allocated in a 7:3 ratio, resulting in training and validation sets comprising 653 and 281 patients, respectively. Variables were selected using lasso regression, culminating in the inclusion of six final variables within the model. The nomogram was evaluated against standard ICU scoring systems, specifically SAPS II and SOFA scores, yielding AUROC values of 0.814, 0.798, and 0.634 for the training set, respectively. Conversely, the validation set demonstrated AUROC values of 0.809, 0.791, and 0.596. The nomogram exhibited strong predictive performance for in-ICU outcomes. P-values from the Hosmer-Lemeshow goodness-of-fit test for both training and validation sets were recorded at 0.627 and 0.486, respectively, indicating good fit quality. Decision curve analysis revealed that the nomogram consistently provides greater net benefits compared to SAPS II and SOFA scores.

Conclusion

A prediction model of in-ICU mortality in SALI elderly patients was established by screening variables through lasso regression. Nomgram was the best predictor of in-ICU mortality in SALI patients, which has a high reference value and clinical application.

Removal of a 'cold-welded' femoral head lag screw in a nail combination

We present a case of a femoral head lag screw 'cold welded' to an intramedullary nail (IMN) in a female in her 20s during exchange femoral nailing of a subtrochanteric femoral osteotomy non-union. We subsequently developed a reverse spiral-fluted bolt extraction socket, designed to engage the outer wall of a bolt or screw. The lag screw was removed from the Smith and Nephew Meta-Tan IMN, 1 week later, and exchange nailing was successfully completed. This case report describes a technically challenging situation of a cold-welded femoral head lag screw during a complex revision. This report introduces a novel removal device and technique for such cases.

Smart nanomedicines powered by artificial intelligence: a breakthrough in lung cancer diagnosis and treatment

Lung cancer remains one of the leading causes of cancer-related mortality worldwide, primarily due to challenges in early detection, suboptimal therapeutic efficacy, and severe adverse effects associated with conventional treatments. The convergence of nanotechnology and artificial intelligence (AI) offers transformative potential in precision oncology, enabling innovative solutions for lung cancer diagnosis and therapy. Intelligent nanomedicines facilitate targeted drug delivery, enhanced imaging, and theranostic applications, while AI-driven models harness big biomedical data to optimize nanomedicine design, functionality, and clinical application. This review explores the synergistic integration of AI and nanotechnology in lung cancer care, highlighting recent advancements, key challenges, and future directions for clinical translation. Ethical considerations, including data standardization and privacy concerns, are also addressed, providing a comprehensive roadmap to overcome current barriers and advance the adoption of AI-driven intelligent nanomedicines in precision oncology. This synthesis underscores the critical role of emerging technologies in revolutionizing lung cancer management.

Emergency medicine updates: Cardiopulmonary resuscitation

INTRODUCTION

Cardiac arrest is the loss of functional cardiac activity; emergency clinicians are integral in the management of this condition.

OBJECTIVE

This paper evaluates key evidence-based updates concerning cardiopulmonary resuscitation (CPR).

DISCUSSION

Cardiac arrest includes shockable rhythms (i.e., pulseless ventricular tachycardia and ventricular fibrillation) and non-shockable rhythms (i.e., asystole and pulseless electrical activity). The goal of cardiac arrest management is to achieve survival with a good neurologic outcome, in part by restoring systemic perfusion and obtaining return of spontaneous circulation (ROSC), while seeking to diagnose and treat the underlying etiology of the arrest. CPR includes high-quality chest compressions to optimize coronary and cerebral perfusion pressure. Chest compressions should be centered over the mid-sternum, with the compressor's body weight over the middle of the chest. A compression depth of 5-6 cm is recommended at a rate of 100-120 compressions per minute, while allowing the chest to fully recoil between each compression. Clinicians should seek to minimize any interruptions in compressions. When performed by bystanders, compression-only CPR may be associated with improved survival to hospital discharge when compared to conventional CPR with ventilations. However, in trained personnel, there is likely no difference with compression-only versus conventional CPR. Mechanical approaches for CPR are not associated with improved patient outcomes, including ROSC or survival with good neurologic function, but mechanical compression devices may be beneficial in select circumstances (e.g., few rescuers available, prolonged arrest/transport). Monitoring of chest compressions is not associated with improved ROSC, survival, or neurologic outcomes, but it can improve guideline adherence. Types of monitoring include real-time feedback, a CPR coach, end tidal CO2, arterial line monitoring, regional cerebral tissue oxygenation, and point-of-care ultrasound.

CONCLUSIONS

An understanding of CPR literature updates can improve the ED care of patients in cardiac arrest.

Effects of adenosine triphosphate, thiamine pyrophosphate, melatonin, and liv-52 on subacute pyrazinamide proliferation hepatotoxicity in rats

BACKGROUND

Hepatotoxicity of pyrazinamide, an antituberculosis drug, limits its therapeutic use and oxidative stress has been implicated in this toxicity. This study investigated the protective effects of adenosine triphosphate (ATP), thiamine pyrophosphate (TPP), melatonin, and Liv-52, which have previously been shown antioxidant activities, on pyrazinamide-induced hepatotoxicity.

METHODS

36 albino Wistar male rats were divided into randomized six groups; healthy (HG), pyrazinamide (PZG), ATP + pyrazinamide (APZG), TPP + pyrazinamide (TPZG), melatonin + pyrazinamide (MPZG) and Liv-52 + pyrazinamide (LPZG) groups. ATP 4 mg/kg and TPP 25 mg/kg were administered intraperitoneally (IP). Melatonin 10 mg/kg and Liv-52 20 mg/kg were given orally. One hour after administration of ATP, TPP, melatonin, and Liv-52, 250 mg/kg pyrazinamide was applied orally to all rats except HG group. The treatment was repeated (1 × 1) for 4 weeks. Then, blood samples were taken for determination of alanine aminotransferase (ALT) and aspartate aminotransferase (AST) activities. Immediately after, the rats were euthanized with thiopental sodium (50 mg/kg, IP), and the livers were removed. The tissues were analyzed for malondialdehyde (MDA), total glutathione (tGSH), superoxide dismutase (SOD), and catalase (CAT) also hydropic degeneration, necrosis, and apoptosis (caspase 3) were examined.One-Way ANOVA was used in biochemical analyses and Tukey test was used as post-hoc. For histopathological and immunohistochemical analysis, the Kruskal-Wallis test was used and Dunn's test as a post-hoc.

RESULTS

Pyrazinamide increased MDA land decreased tGSH, SOD, and CAT levels in liver tissues (p < 0.001). It also increased serum ALT and AST activities and caused severe hydropic degeneration and necrosis in liver tissue (p < 0.001). ATP, TPP, melatonin, and Liv-52 significantly prevented the biochemical and histopathological changes induced by pyrazinamide (p < 0.05). On the other hand, Liv-52 was more successful than other potential protectors in protecting liver tissue from pyrazinamide damage (p < 0.05).

CONCLUSIONS

ATP, TPP, melatonin, and Liv-52 can be used to protect liver tissue from pyrazinamide-induced hepatotoxicity in rats.

Single-Stage Management of Benign Thyroglossal Duct Cyst in the Setting of Papillary Thyroid Cancer

INTRODUCTION

The presented case is unique as the patient presented with biopsy-proven papillary thyroid carcinoma (PTC) of the thyroid gland with an incidentally found concurrent thyroglossal duct cyst (TGDC) on computed tomography (CT). The patient was managed with a one-stage procedure.

CASE REPORT

A 26-year-old previously healthy female presented with a progressively enlarging neck lump over 6 months. Thyroid ultrasound revealed a 2.6 cm mass of the inferior right thyroid lobe, classified as TIRADS 5. Subsequent fine-needle aspiration of the mass confirmed PTC (Bethesda VI). A neck CT scan revealed a calcified, heterogeneous 2.6 cm mass in the right thyroid lobe along with a cystic lesion at the base of the tongue with likely extension into the floor of the mouth, consistent with a TGDC. The patient underwent simultaneous thyroidectomy and TGDC excision in a single operative session after discussion due to concerns for possible malignancy within the thyroglossal duct as well as possible enlargement of the TGDC leading to dyspnea or even dysphagia. At follow-up, the patient was doing well.

DISCUSSION

TGDCs are typically benign which is consistent with the findings in this case. The presence of biopsy-proven glandular thyroid cancer and an incidentally found TGDC present a unique challenge in surgical decision-making. In this case, there were no signs on imaging of malignancy of the TGDC so it was likely a primary glandular PTC. In this case, a one-stage procedure, combining total thyroidectomy and Sistrunk procedure, was selected based on the confirmed diagnosis of PTC with slight potential for synchronous cancer in the TGDC as well as prophylaxis against future aerodigestive tract symptomatology caused by the TGDC.

Innovations in otolaryngology using LLM for early detection of sleep-disordered breathing

Sleep Disordered Breathing (SDB), including conditions like Obstructive Sleep Apnea (OSA), represents a major health concern, characterized by irregular airflow during sleep due to airway obstruction. SDB can result in serious health problems. Implementation of early intervention is vital whenever patient outcomes are to be considered. This research aims to advance research on otolaryngology using Machine Learning (ML) models, and Large Language Models (LLM) for identification of SDB using Electronic Health Record (HER). The approach proposes a hybrid ML framework combining the Dynamic Seagull Search algorithm-driven Large Language model (DSS-LLM). The extensive clinical dataset is used to train the model. It includes patient demographics, medical history, sleep habits, comorbidities, and physical measurements. Data pre-processing involves handling missing values, applying NLP techniques, and normalization. Feature extraction is done using Principal Component Analysis (PCA) to reduce the dimensionality of the hyperparameters and finally for selecting the best set of predictors. The extracted features are then used to train the proposed DSS-LLM model, which incorporates the DSS algorithm to optimize the LLM classifier, improving classification accuracy and model robustness. Subsequently, the idea of LLM is introduced for its application on textual clinical records comprising physicians' reports and patients' symptoms. The findings from an experiment suggest that the proposed model enhances the classification accuracy achieved to 98.91 %, precision attained by 98.9 %, recall achieved to 98.92 % and F-1 score attained by 98.58 % as compared to the models developed earlier. This research provides a novel solution to the screening of OSA at the pre-clinical level which involves hybrid machine learning models integrated with LLMs. This proposed framework is expected to boost clinical judgment and thereby increase better ophthalmology outcomes for patients.

Impact of obstructive sleep apnea on inpatient outcomes of COVID-19: a propensity-score matching analysis of the US Nationwide Inpatient Sample 2020

Background

Obstructive sleep apnea (OSA) is associated with health complications, but its impact on COVID-19 outcomes is not known. This study investigated the association between OSA and outcomes of hospitalized COVID-19 patients.

Methods

The Nationwide Inpatient Sample 2020 was searched for adults hospitalized for COVID-19. The outcomes of interest were in-hospital mortality, non-routine discharge, prolonged length of stay (LOS), and complications. Patients with OSA were matched to those without OSA in a 1:4 ratio using propensity score matching (PSM) according to age, sex, and major comorbidities.

Results

After PSM, there were 54,900 adult COVID-19 patients consisting of 10,980 with OSA and 43,920 without OSA. The mean age was 63.2 years and 62.8% were male. Patients with OSA had higher odds of respiratory failure (adjusted OR [aOR] = 1.20, 95% confidence interval [CI]: 1.14-1.25), heart failure (aOR = 1.71, 95% CI: 1.60-1.82), and arrhythmias (aOR = 1.18, 95% CI: 1.08-1.30). Conversely, OSA was associated with lower odds of cerebrovascular accidents (CVAs) (aOR = 0.71, 95% CI: 0.62-0.81, p < 0.001), and a reduced likelihood of in-hospital mortality among patients ≥70 years old (aOR = 0.82, 95% CI: 0.75-0.89, p < 0.001) and males (aOR = 0.79, 95% CI: 0.72-0.88, p < 0.001), but not females.

Conclusion

OSA is associated with higher risks of respiratory failure, heart failure, and arrhythmias in patients hospitalized for COVID-19. However, patients with OSA who are ≥70 years old and those who are male are less likely to have CVAs and in-hospital mortality. These findings underscore the complex relationship between OSA and COVID-19. As the study focused on hospitalized patients, the findings may not apply to mild or asymptomatic COVID-19 cases. Future research should include community-based cohorts and prospective studies to better understand this association.

Mortality in Critically Ill Patients with Liberal Versus Restrictive Transfusion Thresholds: A Systematic Review and Meta-Analysis of Randomized Controlled Trials with Trial Sequential Analysis

Background/Objectives: Anemia is common in critically ill patients, yet red blood cell (RBC) transfusion without active bleeding does not consistently improve outcomes and carries risks such as pulmonary injury, fluid overload, and increased costs. Optimal transfusion thresholds remain debated, with some guidelines recommending a restrictive target of 7 g/dL instead of a more liberal target of 9 g/dL. Methods: We conducted a systematic review and meta-analysis following PRISMA guidelines, searching PubMed, EMBASE, and LILACS from January 1995 to October 2024. Thirteen randomized controlled trials involving 13,705 critically ill adults were included, with 6855 assigned to liberal and 6850 to restrictive transfusion strategies. The risk of bias was assessed using the Cochrane Risk of Bias Tool 2, and the pooled effect sizes were estimated with a random-effects model. We registered the protocol in PROSPERO International Prospective Register of Systematic Reviews (CDR42024589225). Results: No statistically significant difference was observed in 30-day mortality between restrictive and liberal strategies (odds ratio [OR] 1.02; 95% confidence interval [CI], 0.83-1.25; I2 = 49%). Similarly, no significant differences emerged for the 90-day or 180-day mortality, hospital or intensive care unit (ICU) length of stay, dialysis requirement, or incidence of acute respiratory distress syndrome (ARDS). However, patients in the restrictive group received significantly fewer RBC units. The trial sequential analysis (TSA) indicated that the evidence accrued was insufficient to definitively confirm or exclude an effect on the 30-day mortality, as the required sample size was not reached. Conclusions: In conclusion, while our meta-analysis found no statistically significant difference in the short-term mortality between restrictive and liberal transfusion strategies, larger trials are needed to fully determine whether any clinically meaningful difference exists in critically ill populations.

The Impact of Sleep Deprivation on Orthopaedic Surgeons: A Systematic Review

Sleep deprivation is known to impact cognition, health and mood. Although the effect of sleep deprivation among medical and certain surgical specialties has been explored, there is a paucity of literature regarding sleep in orthopaedic surgeons. This systematic review attempts to provide a comprehensive overview of the current state of research on sleep in orthopaedic surgeons. Following the PRISMA guidelines for systematic reviews, we conducted a search of MEDLINE, Psychinfo and EMBASE to find all articles about sleep in orthopaedic surgeons. Inclusion criteria were non-review articles discussing sleep in orthopaedic surgery, English text, enrollment of attending or resident or fellow orthopaedic surgeons, reporting of sleep-related variables and publishing in a peer-reviewed journal. Out of 539 studies generated from our search, 10 were included in this review. The resulting study population included 232 residents, 10 fellows and 560 attendings. Average sleep was reported in nine articles; however, only two articles used objective measurements of sleep. Other reported outcomes varied widely, which included cognitive tests, reaction time, burnout/mood, self-reported sleepiness and arthroscopic skill. No articles reported on race, biochemical assays, call schedule, exercise, or utilised any intervention to improve sleep. Our systematic review concludes that not only is there a lack of research on sleep in orthopaedic surgeons, but that future research should include objective sleep measurements, including a greater breadth of outcome measures and potential interventions. Such studies will specifically target improvements in physician mental health and overall well-being, as well as promote durable patient safety.

Artificial intelligence-assisted point-of-care devices for lung cancer

Lung cancer is the leading cause of cancer-related deaths worldwide, primarily due to late-stage detection, which limits treatment options. Early detection and screening can increase survival rates, but traditional medical imaging methods are costly and inconvenient. Point-of-care biosensors present a promising alternative, being user-friendly, less labor-intensive, and minimally invasive. With high sensitivity and selectivity, these biosensors detect lung cancer-associated biomarkers, including protein and nucleic acid, in biological fluids such as serum, urine, and saliva. Integrating artificial intelligence (AI) with biosensors has further improved their performance. AI algorithms can analyze complex data, differentiate lung cancer patients from healthy individuals, and even predict the risk of cancer metastasis. Despite these advancements, a comprehensive review of AI-coupled biosensors for lung cancer screening and detection has not yet been conducted. The clinical translation of these biosensors is challenged by a lack of standardization in biomarker selection, the number of biomarkers tested, and the determination of clinical cut-off values. This review focuses on recent advances in biosensors for lung cancer screening and detection, the challenges in their clinical application, and the role of AI in improving biosensor performance. Additionally, it explores future perspectives on the evolution of AI-assisted biosensors into comprehensive health monitoring systems, aiming to bridge the gap between technological innovation and practical clinical use.

Predictors of post-traumatic stress disorder among healthcare workers during the COVID-19 pandemic in Poland

The COVID-19 pandemic has significantly impacted the mental health of healthcare workers globally. Given the critical role these professionals play, understanding the prevalence and predictors of post-traumatic stress disorder (PTSD) among healthcare workers is crucial for developing targeted interventions. Comprehensive data on the predictors of PTSD symptoms within this population remain limited. This cross-sectional study surveyed 852 healthcare workers across 4 Polish regions between 2021 and 2022. Data were collected using the Post-traumatic Stress Disorder Checklist-Civilian Version (PCL-C), which was culturally adapted and validated for Polish respondents. To identify key predictors of PTSD symptoms, researchers employed various statistical methods: Descriptive Statistics summarized key variables (e.g. age, job tenure) to provide an overview of data distribution and sample characteristics. Pearson Correlations examined linear relationships among variables like age, work experience, and PTSD severity, ensuring no multicollinearity through variance inflation factor checks. t-Tests and Mann-Whitney U tests compared PTSD symptom severity across demographic and professional subgroups, accounting for normality using the Kolmogorov-Smirnov test. And Hierarchical Regression Analysis identified significant predictors, incorporating demographic factors first and work-related variables (e.g. fear for personal health) in a second step. A total of 88.1% of participants were female, and 82.6% were nurses. The overall prevalence of PTSD symptoms was high, with a mean total PTSD score of 37.87. Gender differences were significant, with women reporting higher scores across the PTSD subscales, including avoidance and hyperarousal. Nurses had significantly higher intrusion symptoms compared to other professionals. Fear for personal health was the strongest predictor of PTSD symptoms (β = 0.15, P < .001), explaining 11% of the variance in the final regression model (R2 = 0.11, P < .001). The findings underscore the urgent need for targeted mental health interventions, particularly for women and nurses, who are disproportionately affected by PTSD during the pandemic. Predictive models should guide the development of support programs to mitigate the long-term psychological impact of COVID-19 and ensure better preparedness for future pandemics. The significant influence of fear for personal health on PTSD outcomes highlights the importance of protective measures and psychological support for frontline healthcare workers.

Anterior rotation of the temporalis muscle for prevention of temporal hollowing in cranial surgeries: Esthetic and patient-reported outcomes

Background

Temporal hollowing is a common cosmetic complication following pterional craniotomies. To address this issue, we evaluated the efficacy of anterior rotation of the temporalis muscle at closure. Although this technique is not new and has been generally reported, no research studies have been conducted to evaluate its objective and patient-reported outcomes in the long term.

Methods

We retrospectively reviewed 22 patients treated with pterional, fronto-orbitozygomatic, or frontotemporo-zygomatic craniotomies from March 2021 to 2023. A 12-month postoperative magnetic resonance imaging was used to evaluate the degree of temporal hollowing. To quantify temporal hollowing, we measured the distance of depression at the level of the temporal fossa. This distance, or "temporal thickness," was defined as the widest distance between the skull's outer cortical bone and skin surfaces at the level of the anterior clinoid process (D1) and foramen of Monro (D2). Furthermore, pre and postoperative cosmetic results were evaluated using the Rostock Functional and Cosmetic Cranioplasty (RFCC) Score. For reasons of objectivity, RFCC was tested by two independent plastic surgeons against the patient's rating.

Results

After a year or more follow-up, 54.5% of patients exhibited no hollowing, while 31.8% had mild or moderate hollowing. Moreover, 91% reported good esthetic outcomes. No cases of severe hollowing were observed. Importantly, temporomandibular joint dysfunction was not observed.

Conclusion

These results suggest that anterior rotation of the temporalis muscle is an effective primary strategy to mitigate cosmetic deformities without compromising masticatory function. Further studies with larger sample sizes are warranted to confirm these findings.

Surgical Resection of Vascular Anomalies of the Upper Extremity-An Observational Study

Background/Objectives: This study aimed to investigate surgical resections of vascular malformations and haemangiomas of the upper extremity, pre- and postoperative symptoms, complications and recurrences. Methods: A total of 82 patients with vascular malformations and haemangiomas treated by surgical resection from 2010 to 2020 were included in this observational study. Pre- and postoperative symptoms, including pain and swelling, as well as complications and recurrence rates, were assessed. Descriptive statistics were provided for all reported data. Parametric and non-parametric tests were used for group comparisons. Alterations of reported pain were assessed. A two-sided alpha of 5% determined statistical significance. Results: A total of 88 procedures were performed in 82 patients. The most common vascular malformation was a venous malformation, followed by arterio-venous malformations. More than 50% of the patients reported pain prior to the surgery, while 14.6% of patients experienced pain postoperatively, which indicated significant improvement (p = 0.001). Minor postoperative complications occurred in 31.7% of patients. Overall, a recurrence rate of 17.1% was recorded during postoperative follow-up, mostly occurring in diffuse and infiltrating types of vascular malformations. Conclusions: Surgical resections of vascular anomalies of the upper extremity led to symptom improvement and are an important part of the multidisciplinary treatment algorithm.

Does the hepatologist still need to rely on aminotransferases in clinical practice? A reappraisal of the role of a classic biomarker in the diagnosis and clinical management of chronic liver diseases

Aminotransferases, particularly alanine aminotransferase (ALT), are commonly used in the detection, diagnosis, and management of chronic liver diseases. ALT, a sensitive and cost-effective marker of liver injury, remains pivotal in predicting clinical outcomes and guiding interventions in several chronic liver diseases including metabolic dysfunction-associated steatotic liver disease, and chronic viral hepatitis. This study aims to explore the evolving role of ALT as a biomarker. A comprehensive review of evidence was conducted, focusing on studies evaluating ALT thresholds, diagnostic accuracy, and integration with non-invasive liver assessment tools. Special emphasis was given to novel approaches, including artificial intelligence-driven algorithms. Expert opinions from hepatology care perspectives were considered to assess the practical implications of refining ALT-based diagnostic strategies. ALT levels are influenced by diverse factors such as age, gender, and metabolic risks, challenging the use of specific thresholds as biomarker of disease and prognosis. Emerging evidence suggests redefining ALT ranges to enhance sensitivity and accuracy in detecting liver abnormalities. The integration of ALT with advanced non-invasive diagnostic tools, artificial intelligence, and comprehensive patient assessments can optimize early detection of liver disease, thus reducing underdiagnosis, particularly in asymptomatic or vulnerable populations. This work highlights the urgency to tailor the diagnostic approaches in primary and specialised care, ensuring timely and targeted intervention to effectively address the global burden of liver diseases.

Host Serine Proteases and Antiviral Innate Immunity as Potential Therapeutic Targets in Influenza A Virus Infection-Induced COPD Exacerbations

Lung manifestations of chronic obstructive pulmonary disease (COPD) are often exacerbated by influenza A virus infections; however, the underlying mechanisms remain largely unknown, and hence therapeutic options are limited. Using a physiologically relevant human lung airway-on-a-chip (Airway Chip) microfluidic culture model lined with human airway epithelium from COPD or healthy donors interfaced with pulmonary microvascular endothelium, we observed that Airway Chips lined with COPD epithelium exhibit an increased sensitivity to influenza virus infection, as is observed clinically in COPD patients. Differentiated COPD airway epithelial cells display increased inflammatory cytokine production, barrier function loss, and mucus accumulation upon virus infection. Transcriptomic analysis revealed gene expression profiles characterized by upregulation of serine proteases that may facilitate viral entry and downregulation of interferon-related genes associated with antiviral immune responses. Importantly, treatment of influenza virus-infected COPD epithelium with a protease inhibitor, nafamostat, ameliorated the disease phenotype, as evidenced by dampened viral replication, reduced mucus accumulation, and improved tissue barrier integrity. These findings suggest that targeting host serine proteases may represent a promising therapeutic avenue against influenza-afflicted COPD exacerbations.

Post-induction hypotension during rapid sequence intubation in the operating room: A post hoc analysis of the randomized controlled REMICRUSH trial

BACKGROUND

We explored the risk factors of post-induction hypotension during rapid sequence intubation.

METHODS

We performed an ancillary analysis of a multicenter randomized clinical trial comparing remifentanil versus neuromuscular blockers associated with hypnotic in patients at risk for aspiration who underwent tracheal intubation in the operating room. The primary outcome was post-induction hypotension, defined as an episode of hypotension (MBP ≤ 55 mmHg and/or SBP ≤ 80 mmHg) within 10 min after anesthetic induction.

RESULTS

From 15 hospitals, 1137 adult patients were included, and 291 (26%) had post-induction hypotension. Propofol was used in 1117 (98%) patients and was associated with low doses of ketamine in 209 (18 %) patients. The independent risk factors associated with post-induction hypotension were age (OR 1.03, 95% CI [1.02; 1.04] p < 0.0001), baseline heart rate (p = 0.0068), bowel occlusion requiring nasogastric tube placement before intubation (OR 1.96, 95% CI [1.33; 2.87] p = 0.0006) and use of remifentanil (OR 3.54, 95%CI (2.61; 4.81) p < 0.0001). Use of low doses of ketamine (OR 0.61, 95% CI [0.41; 0.92] p = 0.0175) and basal SBP (OR 0.98, 95% CI [0.97; 0.99] p < 0.0001) were protective factors. The precision of the final model including the above-mentioned variables gave an AUC of 0.74 [95% CI 0.71; 0.77] for post-induction hypotension prediction.

CONCLUSIONS

Post-induction hypotension was frequent during rapid sequence intubation. Sedation associating propofol with low doses of ketamine was associated with a low risk of post-induction hypotension. Further studies are required to demonstrate a causal effect.

REGISTRATION

ClinicalTrials.gov NCT03960801.

Violence against healthcare workers in Kenya: a cross-sectional sub-analysis of the global vishwas study

BACKGROUND

Global concern exists for workplace violence against healthcare workers (HCWs), especially in low and middle-income nations. This violence includes physical, verbal, or sexual abuse and has a significant impact despite initiatives like Occupational Safety and Health Administration (OSHA) guidelines. We conducted a study in Kenya to address this issue.

METHODS

We did a cross-sectional survey that collected responses during June 6th to August 9th, 2022, focused on healthcare professionals in Kenya within the global ViSHWaS study. Violence against healthcare professionals in multiple Kenyan counties was analysed, The study reached participants through social media, emails, and other channels using a snowball sampling technique.

RESULTS

The survey included 1,458 HCWs, primarily females (66.5%), aged 36-45 (42.4%), and of African race, representing 40 counties, with the majority from Nairobi (28.9%) and working in government academic (35.5%) and private academic institutions (20.6%). Most had over 11 years of healthcare experience (64.4%), and registered nurses were the most common cadre (27.8%). Approximately half of enrolled participants (49.9%) reported experiencing violence, with verbal violence (80.6%) and emotional abuse (78.6%) being common. Online harassment was reported by only 3.5%, mainly on Facebook (63.2%), involving hate speech (92.1%). Patients or their relatives were the most common aggressors (44.7%), while supervisors accounted for 12.5%. The frequency of violence varied, and 80.2% noted an increase after the COVID-19 pandemic. Only 41.2% of incidents were reported. Most were familiar with safety guidelines (93.6%). Self-violence was associated with familiarity with guidelines, concern about violence, preparedness, and night shifts, while colleague violence was associated with age, gender, race, work experience, training, preparedness, and night shifts.

CONCLUSION

Our Kenya-based cross-sectional sub-analysis highlights that a significant number of HCWs experienced violence, especially during the COVID-19 pandemic, which negatively affected job satisfaction. Although most HCWs were familiar with OSHA guidelines, there were difficulties in their practical implementation.

Accurate Diagnosis of High-Risk Pulmonary Nodules Using a Non-Invasive Epigenetic Biomarker Test

BACKGROUND/OBJECTIVES

Accurate non-invasive tests to improve early detection and diagnosis of lung cancer are urgently needed. However, no regulatory-approved blood tests are available for this purpose. We aimed to improve pulmonary nodule classification to identify malignant nodules in a high-prevalence patient group.

METHODS

This study involved 806 participants with undiagnosed nodules larger than 5 mm, focusing on assessing nucleosome levels and histone modifications (H3.1 and H3K27Me3) in circulating blood. Nodules were classified as malignant or benign. For model development, the data were randomly divided into training (n = 483) and validation (n = 121) datasets. The model's performance was then evaluated using a separate testing dataset (n = 202).

RESULTS

Among the patients, 755 (93.7%) had a tissue diagnosis. The overall malignancy rate was 80.4%. For all datasets, the areas under curves were as follows: training, 0.74; validation, 0.86; and test, 0.79 (accuracy range: 0.80-0.88). Sensitivity showed consistent results across all datasets (0.91, 0.95, and 0.93, respectively), whereas specificity ranged from 0.37 to 0.64. For smaller nodules (5-10 mm), the model recorded accuracy values of 0.76, 0.88, and 0.85. The sensitivity values of 0.91, 1.00, and 0.94 further highlight the robust diagnostic capability of the model. The performance of the model across the reporting and data system (RADS) categories demonstrated consistent accuracy.

CONCLUSIONS

Our epigenetic biomarker panel detected non-small-cell lung cancer early in a high-risk patient group with high sensitivity and accuracy. The epigenetic biomarker model was particularly effective in identifying high-risk lung nodules, including small, part-solid, and non-solid nodules, and provided further evidence for validation.

"Floating Island" Technique: Case Series of a Novel Technique for Surgical Management of Interdigitating Calcified Thoracic Disc Herniations

OBJECTIVE

The objective of this study was to describe the use of a novel approach, the "floating island" technique, to surgically address calcified thoracic disc herniation (cTDH) that interdigitates with adjacent dura and to report clinical and radiographic outcomes of patients.

METHODS

A retrospective case series was conducted by examining the electronic medical records of consecutive patients who underwent thoracic discectomy from August 2017 to December 2022. Of 65 patients treated for thoracic disc herniation, 37 had cTDHs. Five of these 37 patients underwent treatment with the floating island technique, which involves osseous separation, debulking, and ligamentous separation.

RESULTS

The floating island technique was applied using the posterolateral approach in 3 patients and the anterolateral approach in 2 patients. One patient experienced a cerebrospinal fluid leak, which was managed without a lumbar drain. All patients showed radiographic improvement of spinal cord compression postoperatively and were admitted to an intensive care unit for 1 night. Hospital stays ranged from 2 to 6 nights, with 4 patients discharged home and 1 to a rehabilitation facility. Neurological improvement or baseline status was observed in all patients at discharge, with follow-up ranging from 9 to 24 months. Nurick grade improved in all patients by at least 1 point, with no progression of symptoms.

CONCLUSIONS

The floating island technique offers a promising option for the surgical management of interdigitating cTDH, demonstrating excellent immediate radiographic and long-term clinical outcomes. Further studies are needed to validate these findings and determine the technique's generalizability.

Ethical and legal considerations in normothermic regional perfusion for donation after circulatory death

PURPOSE OF REVIEW

This study aims to examine the ethical and legal discourse surrounding normothermic regional perfusion (NRP) for donation after circulatory death (DCD).

RECENT FINDINGS

NRP is well established within Europe but faces challenges in the US and is not utilized in a variety of other countries. NRP compliance with the dead donor rule (DDR) and Uniform Declaration of Death Act (UDDA) is the most significant recently addressed US ethical and legal issue. Additionally, NRP procedures raise concerns regarding public education, informed consent, public engagement, and trust. Inconsistent NRP regulation - such as in the US- is a cause for concern with the anticipated increase in NRP frequency in support of organ recovery and transplantation. There is no single repository for NRP technical and outcome data to support practice refinement - a key aspect given practice variation between centers and countries.

SUMMARY

NRP-based organ recovery presents ethical and legal challenges to be addressed by organ donation and transplantation clinicians and organizations in conjunction with public representatives. Additional inquiry into the determination of donor circulatory death, family information needs for authorization, and coordinated regulation of NRP practice is needed to ensure that ethical and legal concerns are appropriately addressed. Public engagement is essential to bolster and preserve trust.

The relationships between depression, inflammation and self-reported disease activity in IBD and their impact on healthcare usage

BACKGROUND

Depression is common in people living with Inflammatory Bowel Disease (IBD). Depression rates increase with active disease and are linked to poorer clinical outcomes. Previous studies investigating the relationship between contemporaneous IBD disease activity and depression are often poorly controlled, use small samples and/or rely on self-reported measures of disease activity. Depression and self-reported disease activity (SRDA) are linked to increased healthcare usage, however, objective inflammation is rarely statistically controlled. The primary aim was to understand how self-reported disease activity and inflammation are related to depression. Secondary aims included assessing the relative influence of self-reported disease activity, inflammation and depression on healthcare usage.

METHODS

This was a cross-sectional analysis of baseline data collected as part of a randomised controlled trial (trial registration no: ISRCTN71618461) of a digital treatment for symptom self-management in IBD (n = 599). Bivariate associations of demographic and clinical variables with depression were conducted to identify relevant covariates. Multiple linear regressions assessed (i) the relationships between depression (Patient Health Questionnaire-9 (PHQ-9)), SRDA (IBD-Control) and intestinal inflammation (faecal calprotectin (FCP)) and (ii) whether these variables explained variance in healthcare usage and economic indicators.

RESULTS

Depression was significantly predicted by SRDA (β = -0.82, p < 0.001) but not FCP, with the model explaining 37% of the variance in depression (F(2,596) = 175.1, p < 0.001). FCP was only weakly associated with SRDA (r = -0.16, p < 0.001). Depression was independently associated with visits to primary care (β = 0.19, p < 0.001), IBD secondary care (β = 0.13, p < 0.001), IBD-related A&E attendance (β = 0.10 p < 0.05) and the impact of IBD on productivity (β = 0.24 p < 0.001) in the last 3 months.

CONCLUSIONS

Depression was related to SRDA but not FCP. Depression was also associated with healthcare usage even when SRDA and inflammation were statistically controlled. Routinely assessing and treating depression in IBD alongside managing inflammation may improve symptoms for patients and reduce healthcare costs.

Case report: Free autologous costal cartilage transplantation for osteochondral lesions of the talus: three cases with 2-5 years follow-up

Background

Osteochondral lesions of the talus (OLT) is a common and clinically challenging condition with no consensus on the optimal treatment. The prospective case series aim to evaluate the feasibility and clinical outcomes of free autologous costal cartilage transplantation (ACCT) for OLT.

Methods

From April 2018 to October 2022, three patients who were diagnosed with OLT underwent free ACCT. Demographic characteristics, including age, gender, lesion size and location were collected at baseline. Functional and imaging outcomes were evaluated at 1 year, 2 years, and 5 years postoperatively. The primary outcomes were American Orthopedic Foot and Ankle Society (AOFAS) score and Foot and Ankle Ability Measure (FAAM) score. Secondary outcomes included Numeric Rating Scale (NRS), Tegner Activity Scale, and evaluations of images. A paired t-test was used for preoperative and postoperative comparison of the paired-design dataset.

Results

Three patients (37.33 ± 16.50 years old) were included in the study with 2-5 years follow-up. AOFAS score improved from 60 ± 11 at baseline to 96 ± 6.93 at 2 years (p < 0.01) and 94 ± 8.49 at 5 years. FAAM/ADL improved from 60.97 ± 6.58 at baseline to 98 ± 1.83 at 2 years (p < 0.01) and 97 ± 0.85 at 5 years. FAAM/Sports improved from 56.4 ± 11.95 at baseline to 88.23 ± 11.34 at 2 years (p < 0.01) and 89 ± 4.67 at 5 years. Other functional scores in patient reported outcomes also showed significant improvements. Postoperative CT and MRI showed complete defect filling and robust tissue integration after ACCT. Arthroscopic evaluations further confirmed solid integration of costal cartilage into the underlying subchondral bone with a smooth surface over the repair site.

Conclusion

Free ACCT is a feasible method for improving ankle function and quality of life for at least 2 years in patients with OLT. Promising long-term outcomes may be possible because of the good integration between the recipient talus and the implanted ACCT.

Factors associated with sleep quality among medical students in Vietnam: a national cross-sectional study

OBJECTIVE

This study explored factors associated with sleep quality among medical students in Vietnam.

DESIGN

Cross-sectional study.

SETTING

The study was conducted from December 2019 to February 2020 among medical students in Vietnam.

PARTICIPANTS

Medical students were defined as those enrolled in undergraduate medical programmes. 1284 medical students who met the inclusion criteria participated in this study.

OUTCOME MEASURES

The Pittsburgh Sleep Quality Index (PSQI) was used to measure participants' sleep quality, with a score of 5 or higher indicating poor sleep quality. Multivariable logistic and linear regression models were employed to identify the factors associated with poor sleep quality.

RESULTS

36.6% of the study participants had poor sleep quality. There were statistically significant differences in the percentage of poor sleep quality across genders, health-related quality of life, morbidity status and depression (p<0.05). Depression (Coef.=0.54, 95% CI 0.17, 0.91 and OR=1.50, 95% CI 1.13, 1.99) and any morbidity (Coef.=0.64, 95% CI 0.28, 0.99 and OR=1.44, 95% CI 1.09, 1.88) were factors associated with higher PSQI Score and increased risk of poor sleep quality. In contrast, higher health-related quality of life scores (EuroQOL-5 dimensions-5 Levels Index: OR=0.01; 95% CI 0.002, 0.03 and Coef.=-7.11; 95% CI -8.65, -5.56; and EuroQOL-Visual Analogue Scale: OR=0.99; 95% CI 0.98, 1.00 and Coef.=-0.03; 95% CI -0.04, -0.01) were related to lower PSQI Score and reduced risk of poor sleep quality.

CONCLUSIONS

This study reveals that health conditions and psychological well-being were associated with sleep quality among medical students. Reducing stress, improving quality of life and improving morbidity have the potential to improve the sleep quality of medical students.

A Thorough Review of the Clinical Applications of Artificial Intelligence in Lung Cancer

According to data from the World Health Organization (WHO), lung cancer is becoming a global epidemic. It is particularly high in the list of the leading causes of death not only in developed countries, but also worldwide; furthermore, it holds the leading place in terms of cancer-related mortality. Nevertheless, many breakthroughs have been made the last two decades regarding its management, with one of the most prominent being the implementation of artificial intelligence (AI) in various aspects of disease management. We included 473 papers in this thorough review, most of which have been published during the last 5-10 years, in order to describe these breakthroughs. In screening programs, AI is capable of not only detecting suspicious lung nodules in different imaging modalities-such as chest X-rays, computed tomography (CT), and positron emission tomography (PET) scans-but also discriminating between benign and malignant nodules as well, with success rates comparable to or even better than those of experienced radiologists. Furthermore, AI seems to be able to recognize biomarkers that appear in patients who may develop lung cancer, even years before this event. Moreover, it can also assist pathologists and cytologists in recognizing the type of lung tumor, as well as specific histologic or genetic markers that play a key role in treating the disease. Finally, in the treatment field, AI can guide in the development of personalized options for lung cancer patients, possibly improving their prognosis.

Colon obstruction due to sunflower seed bezoar: A case report

INTRODUCTION

This case report aims to present a rare case of colon obstruction caused by a bezoar in a 15-year-old teenager. The significance of this case lies in the rarity of such obstructions and the necessity for early diagnosis and appropriate intervention to optimize patient outcomes.

PRESENTATION OF CASE

A 15-year-old teenager presented with colicky abdominal pain, abdominal distension, nausea, vomiting, and rectal bleeding for three days. Initial investigations yielded normal results, but a digital rectal examination and abdominal X-ray suggested colon obstruction. The patient underwent surgical consultation and emergent laparotomy, during which a bezoar was identified and successfully removed endoscopically. Colonoscopy revealed that the bezoar was composed of shelled sunflower seeds, which correlated with the patient's dietary history.

DISCUSSION

This case highlights the rarity of bezoars causing colon obstruction. Early recognition and appropriate intervention are crucial for optimizing patient outcomes and preventing complications associated with colon obstruction.

CONCLUSION

This report highlights the importance of considering bezoars as a differential diagnosis in patients with colon obstruction. Early identification and treatment can prevent serious complications and improve clinical outcomes.

Rare Encounter With Hepatic Epithelioid Hemangioendothelioma: A Case Report

Malignant hepatic epithelioid hemangioendothelioma (HEHE) is a rare vascular tumor with variable malignant potential, often affecting middle-aged individuals. Hepatic involvement is uncommon, presenting diagnostic challenges due to overlapping imaging features with other liver pathologies. We report a case of a 35-year-old female with HEHE initially presenting with epigastric pain and an incidental liver mass. Imaging revealed multifocal hepatic lesions, confirmed as HEHE through biopsy and immunohistochemistry. Despite initial stability on tamoxifen, disease progression occurred after seven years, manifesting as an increase in the size and number of hepatic lesions. Hepatic transplantation was planned, which was refused by the patient. Subsequently, the disease progressed to a large confluent hepatic mass with calcifications, lymphadenopathy, and pulmonary metastases. Systemic chemotherapy was henceforth initiated. This case underscores the importance of a multimodal approach integrating imaging, histopathology, and tailored therapeutic strategies for diagnosing and managing HEHE. Early detection and comprehensive management are critical to improving outcomes where liver transplantation offers a potential cure.

Comparative Efficacy of Continuous Positive Airway Pressure and Antihypertensive Medications in Obstructive Sleep Apnea-Related Hypertension: A Narrative Review

INTRODUCTION

Obstructive sleep apnea (OSA) presents a significant global health concern, affecting a substantial portion of the population, particularly among young and middle-aged adults.

AIM

This review aims to assess the efficacy of continuous positive airway pressure (CPAP) compared to antihypertensive medications in managing OSA-related hypertension.

METHODS

A comprehensive literature search was conducted across multiple databases, yielding studies published from 2000 to March 2024 that investigated CPAP, antihypertensives, or their combination therapy in OSA patients. Six definitive studies were analyzed, including two randomized controlled trials (RCTs), one randomized double-blind placebo-controlled crossover trial, one placebo-controlled trial, one open-label multicenter trial, and one longitudinal cohort study. These studies comprised 939 participants, with intervention durations ranging from four weeks to six months.

RESULTS

Analysis of CPAP monotherapy revealed variable efficacy, with some studies demonstrating significant reductions in 24-hour mean blood pressure and diastolic pressure, while others reported non-significant changes. CPAP therapy combined with antihypertensives showed additive effects, particularly in reducing office blood pressure measurements. Antihypertensive medications, such as valsartan, exhibited superior efficacy in reducing blood pressure compared to CPAP alone. Factors influencing therapy effectiveness included CPAP compliance, patient characteristics, and coexisting comorbidities. Patients with good CPAP adherence experienced greater reductions in blood pressure. The duration of exposure to OSA and the type of hypertension also impacted the therapy response.

CONCLUSION

While CPAP and antihypertensive medications offer significant benefits in managing hypertension among OSA patients, challenges such as CPAP intolerance and medication side effects exist. Personalized treatment considering individual patient factors is crucial for optimal management.

Evaluation of a disease-state education program in asthma: Application of the Knowledge-to-Action Framework

Background: In patients with asthma, bronchoconstriction and airway inflammation both contribute to airway narrowing and airflow limitations, which lead to symptoms and exacerbations. Short-acting β₂-agonist (SABA)-only rescue therapy addresses only bronchoconstriction and is associated with increased morbidity and mortality. Current asthma management guidelines recommend concomitant treatment of symptoms and inflammation with a fast-acting bronchodilator and inhaled corticosteroid (ICS) as rescue therapy for patients ≥12 years of age. However, there is an education and outreach gap for the wider adoption of anti-inflammatory rescue therapy in clinical practice. Objective: AstraZeneca has developed an education program for health-care practitioners (HCPs) based on a Knowledge-to-Action Framework, with the aim of increasing HCPs' understanding of key disease-state concepts related to evidence-based management of asthma. Methods: A multichannel, evidence-based education program was presented at medical conferences across the United States between December 2022 and December 2023. Before and after each event, attendees were asked to complete a survey that rated their agreement with six disease-state concepts on a five-point Likert scale. These concepts related to the role of airway inflammation, fluctuations in inflammation, SABA and ICS therapy, and the risk of exacerbations. Postevent responses to the survey were assessed relative to pre-event responses and longitudinally over 12 months by using calculated odds ratios and 95% confidence intervals. Acceptance and/or understanding of a concept was defined as a rating of "agree" or "strongly agree" from at least 80% of respondents. Results: The proportion of respondents who agreed or strongly agreed with each concept was significantly higher postevent versus pre-event (p < 0.001). The 80% acceptance and/or understanding threshold was surpassed for all concepts after the event. Conclusion: The medical education program improved understanding and/or acceptance of key disease-state concepts related to asthma management among participating HCPs. Effective communication of disease management concepts may lead to improved patient health outcomes through more rapid acceptance of guideline-recommended medical therapies.

Intravesical foreign bodies in pediatric: A case report highlighting the critical role of psychosocial assessment and intervention

A 12-year-old female presented with lower abdominal pain and hematuria following the self-insertion of a pencil into her bladder. Imaging revealed a 10.2 cm radiopaque object, which was removed intact via cystoscopy. Postoperative recovery was uneventful, and psychiatric evaluation diagnosed mild depression, highlighting the need for integrated psychosocial intervention. This case underscores the critical importance of a multidisciplinary approach that combines medical and psychosocial care in the management of intravesical foreign bodies, particularly in pediatric populations. Proactive measures, including mental health education and early psychosocial support, are essential for prevention and recurrence mitigation.

Evaluation of adherence to the Preferred Reporting of CasE Series in Surgery (PROCESS) 2020 guideline in case series describing endovascular management of vein of Galen malformation demonstrates suboptimal reporting practices

BACKGROUND

Interventional neuroradiology is a dynamic field with technological advancements constantly driving evolution in clinical practice. Case series provide interventional neuroradiologists the opportunity to describe the clinical implications of novel equipment and techniques almost in real-time, informing broader adoption and directing future research. Complete reporting in case series is vital in enabling readers to detect bias, determine the generalizability of results and replicate study methodology. The aim of this study was to assess the quality of reporting in case series describing endovascular management of vein of Galen malformations.

METHODS

A systematic search for case series describing endovascular management of vein of Galen malformations in paediatric patients was conducted using a previously published search strategy in Medline, Embase and Web of Science in February 2024. Screening and data extraction were performed by two independent reviewers with disagreements resolved by consensus discussion. Quality of reporting was assessed using adherence to the Preferred Reporting of CasE Series in Surgery (PROCESS) 2020 checklist.

RESULTS

We included 19 case series representing a broad range of approaches and endovascular techniques for management of vein of Galen malformations. Overall adherence to the PROCESS 2020 guideline was moderate with a mean of 7.0/13 (54%; range 5.2 - 9.7/13; SD 1.1) items reported. The most consistently reported items related to characteristics of the clinical cohort and details regarding the specific image-guided intervention(s) provided. Items relating to study design, source of funding, pre-intervention patient optimisation, clinical follow-up and potential complications and alternatives for novel techniques/devices were less frequently reported.

CONCLUSIONS

The quality of reporting in case series describing endovascular management of vein of Galen malformation is suboptimal. Measures to improve the quality of reporting in neurointerventional case series include mandating adherence to reporting guidelines in journal instructions for authors and requiring submission of completed copies of relevant reporting guidelines alongside manuscripts.

Cardiovascular-obstetric state-of-the-art review: pulmonary hypertension in pregnancy

ABSTRACT

Pulmonary hypertension in pregnancy has been associated with negative maternal and fetal outcomes over the past decades. With the emergence of novel treatment modalities, morbidity and mortality of women who have pulmonary hypertension in pregnancy have improved. In this review, we aim to explore the contemporary updates in the management of pre-capillary and post-capillary pulmonary hypertension in pregnancy.

Explainable AI-driven scalogram analysis and optimized transfer learning for sleep apnea detection with single-lead electrocardiograms

Sleep apnea, a fatal sleep disorder causing repetitive respiratory cessation, requires immediate intervention due to neuropsychological issues. However, existing approaches such as polysomnography, considered the most reliable and accurate test to detect sleep apnea, frequently require multichannel ECG recordings and advanced feature extraction algorithms, significantly restricting their wider application. Deep learning has recently emerged as a viable method for detecting sleep apnea. Our study describes a unique method for detecting sleep apnea utilizing single-lead ECG signals and deep learning techniques. In our proposed method, we have employed the continuous wavelet transform to convert electrocardiogram (ECG) signals into scalograms, which allows us to capture both the time and frequency domains. To enhance the classification performance, we have implemented an optimized pre-trained GoogLeNet architecture as a transfer learning model. In this study, we have analyzed the PhysioNet Apnea ECG dataset, UCDDB dataset and the MIT-BIH polysomnographic dataset for training and evaluation for per-segment classification, to demonstrate the effectiveness of our approach. In our experiments, the proposed model achieves remarkable results, with an accuracy of 93.85%, sensitivity of 93.42%, specificity of 94.30%, and F1 score of 93.83% for the Apnea ECG dataset in per-segment classification. Our model excels on the UCDDB dataset with 87.20% accuracy, 80.99% sensitivity, 93.39% specificity, and an 86.34% F1-score. Furthermore, the model obtains 88.58% accuracy, 88.78% sensitivity, 88.38% specificity, and 88.61% F1 score on the MIT BIH polysomnographic dataset, showing its robust performance and balanced precision-recall trade-off. Afterwards, LIME, an explainable AI method, has been implemented to illustrate the insights responsible for predicting apnea or non apnea.

Predictors of Postoperative Segmental and Overall Lumbar Lordosis in Minimally Invasive Transforaminal Lumbar Interbody Fusion: A Consecutive Case Series

STUDY DESIGN

Retrospective Case-Series.

OBJECTIVES

Due to heterogeneity in previous studies, the effect of MI-TLIF on postoperative segmental lordosis (SL) and lumbar lordosis (LL) remains unclear. Therefore, we aim to identify radiographic factors associated with lordosis after surgery in a homogenous series of MI-TLIF patients.

METHODS

A single-center retrospective review identified consecutive patients who underwent single-level MI-TLIF for grade 1 degenerative spondylolisthesis from 2015-2020. All surgeries underwent unilateral facetectomies and a contralateral facet release with expandable interbody cages. PROs included the ODI and NRS-BP for low-back pain. Radiographic measures included SL, disc height, percent spondylolisthesis, cage positioning, LL, PI-LL mismatch, sacral-slope, and pelvic-tilt. Surgeries were considered "lordosing" if the change in postoperative SL was ≥ +4° and "kyphosing" if ≤ -4°. Predictors of change in SL/LL were evaluated using Pearson's correlation and multivariable regression.

RESULTS

A total of 73 patients with an average follow-up of 22.5 (range 12-61) months were included. Patients experienced significant improvements in ODI (29% ± 22% improvement, P < .001) and NRS-BP (3.3 ± 3 point improvement, P < .001). There was a significant increase in mean SL (Δ3.43° ± 4.37°, P < .001) while LL (Δ0.17° ± 6.98°, P > .05) remained stable. Thirty-eight (52%) patients experienced lordosing MI-TLIFs, compared to 4 (5%) kyphosing and 31 (43%) neutral MI-TLIFs. A lower preoperative SL and more anterior cage placement were associated with the greatest improvement in SL (β = -.45° P = .001, β = 15.06° P < .001, respectively).

CONCLUSIONS

In our series, the majority of patients experienced lordosing or neutral MI-TLIFs (n = 69, 95%). Preoperative radiographic alignment and anterior cage placement were significantly associated with target SL following MI-TLIF.

[Hypovolaemic and haemorrhagic shock]

Hypovolemic and hemorrhagic shock are life-threatening conditions that, if untreated, rapidly lead to multi-organ failure and death. These conditions result from significant intravascular fluid or blood loss, causing critical organ hypoperfusion. The underlying pathophysiology involves complex hemodynamic, inflammatory, and coagulation disturbances that may progress to irreversible organ dysfunction. Rapid diagnosis, early hemorrhage control, and targeted hemodynamic and hemostatic therapy are crucial to improve patient outcomes. Diagnosis is based on clinical symptoms, laboratory parameters, and imaging or endoscopic assessments. The primary therapeutic approach focuses on addressing the underlying cause while implementing fluid resuscitation and vasopressor support. In hemorrhagic shock, coagulation management is of paramount importance. Essential treatment principles include maintaining normothermia, a pH above 7.2, and normocalcemia. If no contraindications exist, permissive hypotension should be applied to limit ongoing bleeding. Early goal directed administration of tranexamic acid and fibrinogen is recommended to stabilize coagulation. For patients experiencing severe hemorrhagic shock, transfusion strategies must be optimized. A hemoglobin target of 7-9g/dL is generally recommended, and in cases requiring massive transfusion, a ratio of red blood cells, plasma, and pooled platelets of 4:4:1 should be used. Additionally, patients receiving effective anticoagulation require specific reversal agents to restore hemostasis. In summary, the successful management of hypovolemic and hemorrhagic shock depends on early recognition, rapid hemorrhage control, and individualized goal directed resuscitation and hemostatic strategies.

The future of nephrology in 2050

As medicine advances at an unprecedented pace, the field of nephrology is poised for transformative change. By 2050, breakthroughs in kidney disease prevention, dialysis, transplantation, and omics-driven precision medicine could redefine patient care and outcomes. Here, we share our perspectives on the challenges faced and how changes in health policy, emerging technologies, novel therapies, and data-driven approaches might shape the future of nephrology. From innovative dialysis solutions to xenotransplantation and AI-powered diagnostics, we explore the possibilities that could revolutionise kidney health in the decades to come.

Social Media Engagement Among Oculoplastic Surgeons in India: Patterns and Perceptions

AIM

Social media engagement in the form of sharing before and after photographs following surgery and posting surgical videos and patient testimonials has become a popular form of promotion and marketing for clinicians. A significant proportion of patients undergoing cosmetic surgery are influenced by the results or before/after photos. Different geographical regions, though, have variations both among surgeons posting content and the viewers being influenced by them. The aim of the survey was to assess the patterns of social media use for professional promotion and patient outreach and the self-reported perceived impact of social media among oculoplastic surgeons in India.

METHODS

An online survey was sent to members of the Oculoplastics Association of India (OPAI) in early 2023.

RESULTS

This was an anonymized survey and had a response rate of 36% (252/702). Of the 252 responses, 66% were women. In all, 28.6% of the respondents had their own professional website. When asked if they felt social media engagement was an important part of practice building, 73% agreed, 9% disagreed, and 19% were unsure. However, only 34% of the respondents had a social media presence related to their practice/professional account. Of those with a social media presence, the most popular platform was Facebook (77%), followed by Instagram (72%) and YouTube (48%). In all, 52/86 (61%) surgeons reported that social media posts had translated into patient visits. Posts on ptosis and blepharoplasty resulted in maximum engagement and patient visits. Of those who did not have a social media presence, constant pressure to post content regularly and unfamiliarity with the platform were the most common reasons cited. Also, 65% of the respondents under the age of 40 reported having a professional practice-related social media profile as compared to 31% of those above 40 (p<0.0001).

CONCLUSIONS

Members of OPAI largely see social media engagement as an important part of practice building, but unfamiliarity with the platform and constant pressure to post content are challenges faced by them. Social media presence appears to benefit some surgeons by way of an increase in clinic visits and improved visibility. Facebook and Instagram remain the most popular platforms favored by the OPAI members. The proportion of oculoplastic surgeons below 40 years of age who are active on social media is significantly higher than those aged over 40 (p<0.0001).

A novel technique for rapid localization of pulmonary nodules on-site in operating room followed by lung resection: a case series

BACKGROUND

The localization of pulmonary nodules is crucial for surgical intervention. However, a safe, simple, and efficient method remains elusive. This study aims to evaluate the safety and feasibility of a newly developed preoperative localization method for pulmonary nodules called Rapid Localization of Pulmonary Nodules On-Site (RLPN-OS).

METHODS

This study is a single-center, single-arm prospective investigation that collects and analyses the clinical data of patients who underwent RLPN-OS and lung resection, primarily evaluating the safety and feasibility of this technique.

RESULTS

A total of 200 lung nodules from 190 patients who underwent RLPN-OS and partial lobectomy were included in this study. The success rate of localization was 98.0%, and minor intercostal bleeding was observed in 3 (1.5%) cases. All targeted lesions were located and resected successfully. No patients reported experiencing anxiety or pain during or after the procedure.

CONCLUSIONS

This novel RLPN-OS technology represents a safe, feasible, patient-friendly, and cost-effective method for lung nodule localization. It has the potential to serve as an alternative to traditional CT-guided percutaneous localization techniques.

Deep Learning-Based Techniques in Glioma Brain Tumor Segmentation Using Multi-Parametric MRI: A Review on Clinical Applications and Future Outlooks

This comprehensive review explores the role of deep learning (DL) in glioma segmentation using multiparametric magnetic resonance imaging (MRI) data. The study surveys advanced techniques such as multiparametric MRI for capturing the complex nature of gliomas. It delves into the integration of DL with MRI, focusing on convolutional neural networks (CNNs) and their remarkable capabilities in tumor segmentation. Clinical applications of DL-based segmentation are highlighted, including treatment planning, monitoring treatment response, and distinguishing between tumor progression and pseudo-progression. Furthermore, the review examines the evolution of DL-based segmentation studies, from early CNN models to recent advancements such as attention mechanisms and transformer models. Challenges in data quality, gradient vanishing, and model interpretability are discussed. The review concludes with insights into future research directions, emphasizing the importance of addressing tumor heterogeneity, integrating genomic data, and ensuring responsible deployment of DL-driven healthcare technologies. EVIDENCE LEVEL: N/A TECHNICAL EFFICACY: Stage 2.

Enhancing root coverage and esthetic outcomes in isolated gingival recession using orthodontic intervention and lateral closed tunnel technique: An interdisciplinary prospective case series

BACKGROUND

Gingival recession (GR) in malposed tooth in association with bone dehiscence and/or fenestration poses a challenge for successful root coverage treatment. Lateral closed tunnel (LCT) technique is particularly useful in isolated GR in mandibular anterior region, where the shallow vestibular depth prevents tension-free coronal mobilization of tissues.

METHODS

Twenty patients with GR associated with tooth malposition were treated using a combined orthodontic-periodontic approach with a torquing auxiliary spring followed by LCT technique.

RESULTS

The two techniques resulted in a combined recession depth reduction from 3.75 ± 1.14 mm to 0.40 ± 0.50 mm at the end of 6-month study period. The orthodontic intervention led to an increase in labial marginal bone levels, as assessed through cone beam computed tomography (CBCT), while the LCT achieved closure of residual recession defect. Also, an increase of keratinized tissue width from 0.81 ± 0.88 mm at baseline to 3.30 ± 0.67 mm at 6 months was achieved. Mean root coverage percentage (MRC%) of 91.40% + 10.25% was seen, with 11 out of 20 sites (55%) showing complete root coverage (CRC).

CONCLUSIONS

Single tooth orthodontic repositioning followed by LCT technique proved effective in successfully managing isolated recession defects in the mandibular anterior gingival region, which often presents challenging mucogingival conditions. The precise single tooth repositioning resulted in labial marginal bone augmentation, while the LCT surgical approach allowed residual defect closure.

KEY POINTS

Why are these cases new information? Correction of single tooth malposition is achieved before recession coverage treatment to achieve a favorable environment for graft uptake. The reduction in denuded root surface along with the bone remodeling results in increasing the ratio of vascular to avascular region, thus improving the overall prognosis of the treatment. What are the keys to successful management of these cases? The lateral closed tunnel technique involves creating a mucoperiosteal tunnel to close the recession site. Precision is crucial to avoid damage to surrounding tissues. The recipient site should be wider than the width of recession to improve graft vascularity. What are the primary limitations to success in these cases? Limitations may arise when dealing with complex cases, such as multiple teeth involvement or teeth with significant vertical or horizontal bone loss.