Clinical Context Research Articles

Creating an Ellipsys percutaneous arteriovenous fistula after a failed ipsilateral WavelinQ fistula: A case report of an endovascular approach for access restoration.

The introduction of devices for endovascular dialysis access creation (WavelinQ and Ellipsys) offers practitioners more options for access management in dialysis patients. Especially in terms of reducing the usage of central venous catheters, a native fistula is desirable as an initial dialysis access. We present a case in which a failed WavelinQ type fistula was reactivated using the Ellipsys procedure on the same arm. This specific rescue method is based on the idea that the proximal part of an endoAVF from an earlier WavelinQ procedure which resulted in adequately dilated veins, comprising the perforating vein, may allow a subsequent Ellipsys procedure. This case report shows how the use of endovascular techniques such as WavelinQ and Ellipsys can be incorporated in a clinical context and create new options for the patient.

Prognostic utility of assessing ventricular-arterial coupling in arterial hypertension and cardiovascular diseases.

The assessment of myocardial function and its coupling with the arterial system, called ventricular-arterial coupling (VAC), is of paramount importance in many clinical fields, from arterial hypertension, which is the main cause of cardiovascular diseases and death, to heart failure. VAC has been the subject of studies for several decades both from an energetic cost and the impact it can exert on cardiovascular performance. Although more attention has been paid to the relationship between the left ventricle and the left arterial circuit in compromised hemodynamic stages, VAC has aroused interest in many other aspects of study, from its application in pathologies of the right sections of the heart to its clinical impact in prevention and cardiovascular risk factors. In this review we will focus on the importance of the hemodynamic data of the VAC in various clinical contexts and its possible applications in the future as a diagnostic and prognostic parameter in the cardiac clinic.

Acute effects of psilocybin on attention and executive functioning in healthy volunteers: a systematic review and multilevel meta-analysis.

Psilocybin shows promise for treating neuropsychiatric disorders. However, insight into its acute effects on cognition is lacking. Given the significant role of executive functions in daily life and treatment efficacy, it is crucial to evaluate how psilocybin influences these cognitive domains. This meta-analysis aims to quantify the acute effects of psilocybin on executive functions and attention, while examining how dosage, timing of administration, cognitive domain, and task characteristics moderate these effects. A systematic review and multilevel meta-analysis were conducted on empirical studies assessing psilocybin's acute effects on working memory, conflict monitoring, response inhibition, cognitive flexibility, and attention. Effect sizes for reaction time (RT) and accuracy (ACC) were calculated, exploring the effects of timing (on-peak defined as 90-180min post-administration), dosage, cognitive function categories, and task sensitivity to executive functions as potential moderators. Thirteen studies (42 effect sizes) were included. In the acute phase, psilocybin increased RTs(Hedges' g = 1.13, 95% CI [0.57, 1.7])and did not affect ACC (Hedges' g = -0.45, 95% CI [-0.93, 0.034]). Effects on RT were dose dependent. Significant between-study heterogeneity was found for both RT and ACC. Task sensitivity to executive functions moderated RT effects. Publication bias was evident, but the overall effect remained significant after adjustment for this. Our meta-analysis shows that psilocybin impairs executive functions and results in a slowing down of RT. We discuss potential neurochemical mechanisms underlying the observed effects as well as implications for the safe use of psilocybin in clinical and experimental contexts.

Umbrella Reviews: A methodological guide.

This paper aims to explore the significance of umbrella reviews as a methodological advancement in evidence synthesis, emphasizing their role in aggregating data from multiple systematic reviews and their impact on evidence-based practice and policy-making. The paper examines the evolution of systematic reviews and meta-analyses, highlighting the emergence of umbrella reviews as a comprehensive synthesis method. It details the key steps involved in conducting an umbrella review, including literature searches, study selection, quality appraisal, and data synthesis. Various types of umbrella reviews are discussed, along with the integration of advanced methodologies and interdisciplinary approaches that enhance their effectiveness. Umbrella reviews have become an essential tool in evidence synthesis, offering a higher-level aggregation of systematic reviews to inform decision-making in clinical and policy contexts. Their evolving methodologies, combined with interdisciplinary approaches, make them crucial in shaping the future of evidence-based practice globally.

Schlemm's Bidirectional Fluid Wave and Luminal Blood Reflux as Novel Intra-Operative Signs Confirming Optimal Placement of the iStent.

Trabecular micro-bypass devices (TBDs) such as the iStent series (Glaukos Corporation, Laguna Hills, CA), are effective in reducing intraocular pressure (IOP). However, precise placement of TBDs is crucial in achieving surgical efficacy, as device malpositioning may lead to suboptimal IOP reduction. We demonstrate two novel intra-operative signs to aid confirmation of accurate iStent placement, without reliance on imaging technologies. Surgical technique report with video accompaniment. Two intra-operative clinical signs which confirm optimal iStent placement are described: (1) Luminal Blood Reflux - achieved by gently decompressing the anterior chamber, with or without flushing of the stent lumen with balanced salt solution (BSS), thereby confirming stent positioning in the Schlemm's Canal (SC). (2) Schlemm's Bidirectional Fluid Wave (SBFW) - observable when flushing with BSS, suggesting fluid movement in the canal segments adjacent to the iStent device, thereby confirming stent patency and positioning in the SC. The identified signs are useful, feasible and reproducible indicators of accurate iStent placement. Future studies may evaluate the application of these confirmatory manoeuvres in diverse clinical contexts and further establish correlation with clinical outcomes.

Anabolic-androgen steroids: A possible independent risk factor to cardiovascular, kidney and metabolic syndrome.

Millions of individuals make illicit use of anabolic-androgenic steroids (AAS), remaining a public health issue. It often leads to detrimental effects, including cardiovascular and renal diseases, besides hormonal and metabolic imbalances. The objective of this review is to emphasize the contribution of oxidative stress and inflammation to these effects and connect the findings of experimental animal studies with the alterations found in clinical contexts, in AAS users. The study's results showed that AAS promotes a redox disruption and a pro-inflammatory state on organs that are involved in important physiologic processes. These drugs increase inflammatory high-sensitivity C-reactive protein (hs-CRP) and cytokines that contribute to the progression of atherosclerosis, cardiovascular disease risk or endpoints, including stroke, myocardial infarction and death. In the kidney, the AAS increase proteinuria and structural damage. Studies have linked AAS abuse with high BP, low HDL-C levels, high triglyceride levels and impaired fasting blood glucose that characterize Metabolic syndrome. Overall, the studies indicate that oxidative stress, apoptosis, and AAS-mediated inflammation play a significant role in tissue damage, regardless of the dose and duration of exposure, and we point it as a putative independent risk factor to Cardiovascular, Kidney and Metabolic syndrome.

A Mixed Method Study of Nursing Students' Experiences of Discrimination Within Their Programs.

This research aimed to explore nursing students' experiences and perspectives on discrimination within nursing programs across classroom and clinical contexts, as well as structural discrimination through institutional policies and processes. Convergent mixed methods. Survey and individual interviews to capture students' experiences and perspectives on discrimination within nursing programs. Quantitative findings suggest that the majority of nursing students (79.2%) self-reported experiencing discrimination during their nursing program. These experiences stem from racism, homophobia, transphobia, and mental health stigma. While most of these experiences were reported in clinical contexts from nurses, patients, and clinical educators, students also reported experiencing discrimination in classroom and program contexts through nurse educators, peers, and policies. Qualitative findings provided nuanced insights into these discriminatory experiences across contexts and sources. Additionally, findings suggest that the majority of the students perceive stigma and discrimination to be a significant issue within nursing education and recommend priorities for addressing this issue. Despite nursing professions' central commitment to addressing discrimination and promoting social justice, stigma and discrimination faced by nursing students within nursing programs remain a significant concern. Preventing discrimination and promoting social justice within nursing is a central responsibility of the nursing profession. Student-identified priorities suggest an upstream approach that involves education for nurse educators and staff to redress ongoing discrimination experienced by nursing students. This research contributes to the growing empirical evidence that nursing students experience discrimination within nursing programs across clinical, classroom, and program contexts and highlights student-identified priorities for addressing discrimination. No patient or public contribution.

MARVELD1 Promotes the Invasiveness in Pancreatic Adenocarcinoma through the Activation of Epithelial-to-Mesenchymal Transition.

MARVEL domain-containing 1 (MARVELD1) has been implicated in the progression of several cancers, but its role in pancreatic adenocarcinoma (PAAD) remains poorly understood. RNA-seq data from the TCGA-PAAD and GTEx-Pancreas cohorts were analyzed to assess MARVELD1 expression. Stable MARVELD1 knockdown and overexpression were conducted in BxPC3 and PANC-1 cells. Cell viability, proliferation, migration, and invasion were evaluated using functional assays, and western blotting was employed to examine EMT-associated protein levels, including Vimentin, MMP2, MMP9, and E-cadherin. Differentially expressed genes (DEGs) between MARVELD1-high and MARVELD1-low groups were identified, and pathway enrichment analyses were performed. We observed a significant increase of MARVELD1 in PAAD patient samples, with elevated MARVELD1 levels correlating with poor clinical survival. Knockdown of MARVELD1 in PAAD cells remarkably decreased cell proliferation and colony formation, while overexpression of MARVELD1 enhanced these properties. Moreover, simulated cell invasion and migration assay further suggested that MARVELD1 might contribute to PAAD cell aggressiveness. Mechanistically, MARVELD1 promoted tumor cell migration and invasion through the activation of Vimentin, MMP2, and MMP9 protein while suppressing E-cadherin. Bioinformatics analysis revealed that MARVELD1-high samples were enriched in EMT-related pathways, including TGF-β receptor signaling, actin cytoskeleton regulation, and cell adhesion. Taken together, our study highlights the roles of MARVELD1 in promoting tumor cell proliferation and invasion, suggesting its potential application as a prognostic and diagnostic biomarker for PAAD in the clinical context.

Acute leukemia in children: evaluating the necessity of routine biochemical analysis of cerebrospinal fluid.

Without therapeutic impact, we conclude that routine measurement of biochemical analysis in the CSF is not indicated in children with acute leukemia. • Biochemical analysis of the cerebrospinal fluid (CSF) is routinely performed in children with acute leukemia in some centers while its clinical value remains uncertain. • Cytology is the gold standard technique for the detection of central nervous system (CNS) involvement in leukemia. • No significant correlation was found between CSF biochemical and cytological analyses and CSF biochemical analysis had no added clinical value in this study. • Our results suggest that routine CSF biochemical analysis may be omitted in this clinical context.

Outcomes of fingertip injury treatment with semi-occlusive dressings combined with surgical management within an expanded indication

Since their introduction by Mennen and Wiese in 1993, semi-occlusive film dressings (SOFD) have been increasingly used in various clinical contexts, including the treatment of Allen type IV fingertip injuries, fingertip necrosis, and cases involving embedded foreign material.This study aimed to investigate whether and, if so, how the outcomes of Allen type III and IV fingertip injuries and fingertip necrosis differ from those of Allen types I and II. In addition, it aimed to investigate if the presence of embedded foreign material under a film dressing increases the risk of complications.A total of 50 patients with 44 fingertip injuries and 13 fingertip necroses were treated with an SOFD in combination with surgical intervention. In 22 out of 50 patients, foreign material was present under the film dressings. During follow-up, cold sensitivity, pain at rest and during activity, the usage of the injured finger in daily life, patient satisfaction with the aesthetic outcome, sensitivity, sweat secretion, papillary ridges, nail deformity, and mobility were assessed. The fingertips were examined for nail growth abnormalities. The results of the Allen type I-IV fingertip injuries and fingertip necrosis were compared with each other and related to findings from the uninjured fingers of the opposite hand. Clinical outcomes showed that SOFD led to good fingertip regeneration at any amputation level and in cases of fingertip necrosis. However, nail deformities increased with shorter lengths of the distal phalanx. Patients with necrosis were less satisfied with the aesthetic outcome compared to those receiving primary treatment after amputation injury. The presence of foreign material under the film dressings did not influence the healing process, and no infections were observed.SOFDs demonstrate good outcomes in Allen type III and IV fingertip injuries as well as in fingertip necrosis, comparable to those of Allen type I and II. However, it is essential to inform patients about potential risks such as nail deformities and compromised aesthetic appearance. Surgical interventions involving foreign material under an SOFD do not affect the healing of fingertip injuries, thus allowing for an expanded range of indications for SOFDs.

Structural Competence in Social Work

ABSTRACT This article reviews the concept of structural competence as a powerful analytic tool to advance social work education and improve social work pedagogy, practice, and research. Structural competence offers a promising avenue for improving approaches to understanding and addressing the root causes of the social, economic, and health disparities affecting social work clients and historically marginalized communities. A tailored social work definition of structural competence is presented and related core competencies are discussed. Three case examples are provided to demonstrate how to apply a structural competence lens, even in clinical contexts.

Validity and reliability of the Swedish version of the Visual CARE Measure for assessing children’s perceptions of nurses’ empathy

The purpose of this study was to translate and validate a questionnaire to be used by children with chronic diseases during procedures. Specific research questions were as follows: Is the translated versions reliable? Is there a correlation between VCM and another questionnaire measuring discomfort to enhance the validity of VCM? The three versions of Visual CARE measure (VCM) were translated following the principles of good practice for translation and cultural adaptation of patient-reported outcome measures, according to the International Society for Pharmacoeconomics and Outcomes Research (ISPOR). Cognitive debriefing interviews with children, parents, and healthcare professionals were carried out. The correlation between empathy and discomfort was evaluated using DISCO-RC. The final versions of VCM were administered to children and their parents after a needle procedure or a nasal tube insertion. The Cronbach’s alpha was 0.89 for the 5Q version, 0.93 for the 10Q version, and 0.96 for the 10Q-Parent version, which implies high internal consistency. The intra-class correlation was 0.623 for VCM 5Q, with a mean difference of 1.35 and an ICC of 0.767 for VCM 10Q, with a mean difference of 1.17. This is considered a good agreement between children’s and their parents’ assessments. A significant difference in the children’s reports could be seen when experiencing high discomfort as opposed to low discomfort.Conclusion: VCM is a useful Patient-Reported Experience Measure (PREM) that can help enhance the quality of care for children in a paediatric setting by capturing their perception of the empathy shown.What is known:• Parents’ by-proxy reports are not always aligned with children’s self-reports. In healthcare situations, children can be hurt when they are ignored.• Research shows that empathic encounters relieve distress, improve the relationship between the patient (who could be a child) and carer, and create an open, trusting relationship.What is new:• This study shows that all three versions of the Visual CARE Measure are valid for assessing children’s experience of empathy shown by nurses during a procedure..• This is one of the first studies that confirms the correlation between children’s experience of nurses’ levels of empathy and the child’s discomfort.• This study shows that the Visual CARE Measure can support the evaluation of children’s rights with regards to communication in a clinical context.

Acute kidney injury.

Acute kidney injury (AKI) is a common, heterogeneous, multifactorial condition, which is part of the overarching syndrome of acute kidney diseases and disorders. This condition's incidence highest in low-income and middle-income countries. In the short term, AKI is associated with increased mortality, an increased risk of complications, extended stays in hospital, and high health-care costs. Long-term complications include chronic kidney disease, kidney failure, cardiovascular morbidity, and an increased risk of death. Several strategies are available to prevent and treat AKI in specific clinical contexts. Otherwise, AKI care is primarily supportive, focused on treatment of the underlying cause, prevention of further injury, management of complications, and short-term renal replacement therapy in case of refractory complications. Evidence confirming that AKI subphenotyping is necessary to identify precision-oriented interventions is growing. Long-term follow-up of individuals recovered from AKI is recommended but the most effective models of care remain unclear.

Evaluation of Medical Diagnosis Capabilities of Three Artificial Intelligence Models – ChatGPT-3.5, Google Gemini, Microsoft Copilot: Sustainable Development Goals (SDGs)

Objectives: This study aims to assess and compare the diagnostic accuracy of three artificial intelligence (AI) models—ChatGPT-3.5, Microsoft Copilot, and Google Gemini—through their performance on clinical vignettes. Theoretical Framework: Building on prior research into the application of AI in healthcare, particularly in diagnostic support, this study examines the potential of AI models to aid clinicians by providing accurate medical diagnoses, thus supporting decision-making in clinical contexts. Methodology: A meta-analysis was conducted, followed by a comparative analysis using 34 clinical vignettes from Texas Tech University Health Sciences Center. Each AI model’s responses were evaluated for accuracy in diagnosing medical cases, and statistical significance was tested using the chi-square test. Results and Discussion: ChatGPT-3.5 achieved the highest diagnostic accuracy (70.59%), outperforming Google Gemini (61.76%) and Microsoft Copilot (35.29%). ChatGPT-3.5 provided concise answers, while Google Gemini and Microsoft Copilot included disclaimers and additional recommendations. Chi-square analysis confirmed significant differences in performance, highlighting variations in diagnostic capabilities across models. Research Implications: These findings underscore the importance of model selection when integrating AI into clinical workflows. AI models show promise in diagnostics but vary in approach and accuracy, warranting further refinement. Originality/Value: This study is among the first to compare the diagnostic accuracy of ChatGPT-3.5, Google Gemini, and Microsoft Copilot, contributing valuable insights into AI’s application in healthcare diagnostics and supporting evidence for its potential role in enhancing patient care.

Development of a Preoperative Psychological Screening Tool: Piloting the Cosmetic Readiness Questionnaire (Pilot-CRQ).

Patients with psychological risk factors such as body dysmorphic disorder (BDD) and unmanaged mental health concerns are considered at higher risk for dissatisfaction with aesthetic procedures. Identifying these risks before a procedure may decrease the chance of adverse outcomes for patients and practitioners. In this study we aimed to develop a comprehensive psychological screening tool to assess patient's psychological suitability for surgical and nonsurgical aesthetic procedures. Items for the Pilot Cosmetic Readiness Questionnaire (CRQ) were developed by psychologists (n = 3) and then reviewed by plastic surgeons (n = 2) and nonsurgical cosmetic doctors (n = 3). Patient interviews (n = 15) and piloting of the questionnaire (n = 69) provided data regarding the scale's initial psychometric properties. Results supported the reliability and validity of the Pilot-CRQ's subscales of Body Dysmorphia, Psychological Distress, Self-Criticism, Perfectionism, and Lack of Openness. Lack of Openness was a validity scale that examined the degree that respondents might be underreporting symptoms. The CRQ predicted individuals with a BDD diagnosis, as rated by a blinded expert clinical psychologist, with high sensitivity and specificity. These results provide support for the Pilot-CRQ identifying people with BDD and psychological factors related to aesthetic treatment outcomes and provide a strong basis for employing the CRQ in clinical contexts and in future research.

Research progress on Sertoli cell secretion during spermatogenesis

Sertoli cells (SCs), as the somatic cells in the testis of male mammals, play a crucial role in the close association with germ cells. The blood-testicular barrier (BTB), established by their tight junctions, provides immune protection to germ cells, leading to their characterization as "sentinel" cells. Moreover, the physiological process of testicular development and spermatogenesis in male animals is intricately tied to the secretory activities of SCs. These cells secrete a diverse array of proteins and cytokines that interact with various targets, working in concert with mechanisms in the spermatogenesis pathway and contributing to each stage, from spermatogonial cell division to the maturation of spermatozoa. Hence, the secretory products of SCs are pivotal in fostering germ cell development and directing the appropriate maturation of sperm. This study is dedicated to investigating the varied secretions of SCs, outlining their critical functions throughout distinct phases of spermatogenesis, thus elucidating the substantial influence of SC secretion on male fertility. Furthermore, it offers valuable perspectives on reproductive disorders stemming from irregular spermatogenesis in clinical contexts.

CXR-LLaVA: a multimodal large language model for interpreting chest X-ray images.

This study aimed to develop an open-source multimodal large language model (CXR-LLaVA) for interpreting chest X-ray images (CXRs), leveraging recent advances in large language models (LLMs) to potentially replicate the image interpretation skills of human radiologists. For training, we collected 592,580 publicly available CXRs, of which 374,881 had labels for certain radiographic abnormalities (Dataset 1) and 217,699 provided free-text radiology reports (Dataset 2). After pre-training a vision transformer with Dataset 1, we integrated it with an LLM influenced by the LLaVA network. Then, the model was fine-tuned, primarily using Dataset 2. The model's diagnostic performance for major pathological findings was evaluated, along with the acceptability of radiologic reports by human radiologists, to gauge its potential for autonomous reporting. The model demonstrated impressive performance in test sets, achieving an average F1 score of 0.81 for six major pathological findings in the MIMIC internal test set and 0.56 for six major pathological findings in the external test set. The model's F1 scores surpassed those of GPT-4-vision and Gemini-Pro-Vision in both test sets. In human radiologist evaluations of the external test set, the model achieved a 72.7% success rate in autonomous reporting, slightly below the 84.0% rate of ground truth reports. This study highlights the significant potential of multimodal LLMs for CXR interpretation, while also acknowledging the performance limitations. Despite these challenges, we believe that making our model open-source will catalyze further research, expanding its effectiveness and applicability in various clinical contexts. Question How can a multimodal large language model be adapted to interpret chest X-rays and generate radiologic reports? Findings The developed CXR-LLaVA model effectively detects major pathological findings in chest X-rays and generates radiologic reports with a higher accuracy compared to general-purpose models. Clinical relevance This study demonstrates the potential of multimodal large language models to support radiologists by autonomously generating chest X-ray reports, potentially reducing diagnostic workloads and improving radiologist efficiency.

NT-proBNP for Heart Failure Screening in Primary Care in an Eastern European Country: What We Know and Proposed Steps.

Epidemiological studies indicate that heart failure (HF) prevalence and associated mortality are significantly higher among Eastern European countries as compared to their Western European counterparts. The significant financial burden on the healthcare system matches these sobering data. Thus, efficient programs for patients with HF have been called for. N-terminal prohormone of brain natriuretic peptide (NT-proBNP) represents a widely used, cost-effective, and readily available test that can be used to evaluate HF risk. However, it should not be used as a universal assessment, given the existing variability in proposed cut-off scores for various subgroups of patients. Thus, the clinical context needs to always be considered, and alternative diagnoses need to be ruled out. Based upon evidence from the literature for the above assumptions, the advantages and limitations of using NT-proBNP in primary care settings, along with other HF diagnostic modalities, are discussed in this paper. Also, this paper argues that an effective primary care network, in collaboration with specialist providers, may avoid a delay in HF diagnoses, may help provide on-time treatments, and may ultimately cut unnecessary healthcare expenditures associated with HF hospitalizations. Therefore, the present paper proposes an algorithm for diagnosing HF in primary care settings and discusses specific knowledge and skills that family physicians should be well equipped with in order to successfully respond to the needs of their patients with HF.

Extended reality in anesthesia: a narrative review.

The application of extended reality (XR) technology is rapidly expanding in the medical field, including anesthesia. This review aims to introduce the current literature on XR utilization to help anesthesiologists adopt this technology in education and clinical practice. XR is useful for both knowledge acquisition and skill training in a wide range of settings, from students to medical professionals. One of its major benefits is harm reduction through simulation scenarios that allow for immersion in clinical situations and opportunities to practice procedures and tasks. These scenarios often involve both technical and non-technical skills, enabling clinicians to enhance their capabilities without risking patient safety. In clinical settings, XR can also be used with patients to increase familiarity with medical procedures, provide education, and reduce anxiety. XR can also serve as a distraction technique, diverting the patient's attention from medical procedures and enhancing comfort, which may contribute to reduced opioid use. Although the potential benefits of XR in anesthesia have been reported in various educational and clinical contexts, challenges, such as limited financial reimbursement and restricted technical accessibility, remain. With further research and technological advancements, XR technology has the potential for widespread adoption in anesthesia practice.

SARCOMA HEPÁTICO FUSOCELULAR ATÍPICO: UM RELATO DE CASO

Primary hepatic sarcoma is a rare malignant tumor originating from mesenchymal cells. Most individuals are asymptomatic or present with few symptoms. Imaging studies do not reveal specific findings for this type of tumor, nor is there an increase in major tumor markers or any association with viral hepatitis. The diagnosis is based on histological and immunohistochemical results. This report aims to describe the clinical and surgical context of a specific case and the approach adopted. It was conducted as a descriptive retrospective study based on a case report managed by the general surgery team in 2014 at a public hospital in Belo Horizonte. The patient was a 70-year-old female presenting with persistent diarrhea. Imaging studies identified a tumor affecting the left lobe of the liver. After multidisciplinary analysis, a trisegmental hepatectomy was performed. The patient, initially stable in the ICU, was discharged to the general ward on the fifth postoperative day and left the hospital three weeks after surgery. She remained asymptomatic with no signs of disease recurrence after nine months of follow-up. This case highlights that primary hepatic sarcoma is a rare neoplasm identified through surgical procedures and is seldom discussed in both national and international literature. The cornerstone of treatment is surgical resection, which plays a crucial role in tumor recurrence and prognosis