Clinical Reality Research Articles

Basic medical sciences should be mainly taught by clinicians for a tight integration of basic and clinical sciences in medical education.

Today, medical education faces many problems. However, the most serious problem is the inability to integrate basic and clinical sciences. For this reason, students alienate from basic sciences, and clinicians are leaving sciences to basic scientists every day. Basic medical sciences learned in the preclinical term are remembered less by students and cannot be sufficiently associated with clinical reality. This is because basic scientific knowledge learned without a clinical framework is low-value data that the student does not know how to use. Therefore, all reform initiatives in the medical education curriculum stick to the obstacle of basic sciences. Now is the time to take bold steps. The first step should be to remove the preclinical term from medical education. Medical education should only consist of clinical education terms. This will gain the student and clinician a lot more time for clinical training. The second step should be to take basic sciences education from basic scientists and place it under the responsibility of clinicians. Clinicians can decide much better how much of basic science knowledge is clinically relevant. As a component of clinical education, it is best for students to internalize the basic sciences during classes, at the bedside, and in other clinical practices under the clinician's authority. Thus, students may be graduated as academic clinicians who have internalized the basic sciences and integrated the basic sciences with clinical reality.

Adipose-Derived Stromal Cells for Chronic Wounds: Scientific Evidence and Roadmap Toward Clinical Practice.

Chronic wounds, ie, non-healing ulcers, have a prevalence of ~1% in the general population. Chronic wounds strongly affect the quality of life and generate considerable medical costs. A fraction of chronic wounds will heal within months of appropriate treatment; however, a significant fraction of patients will develop therapy-refractory chronic wounds, leading to chronic pain, infection, and amputation. Given the paucity of therapeutic options for refractory wounds, cell therapy and in particular the use of adipose-derived stromal cells (ASC) has emerged as a promising concept. ASC can be used as autologous or allogeneic cells. They can be delivered in suspension or in 3D cultures within scaffolds. ASC can be used without further processing (stromal vascular fraction of the adipose tissue) or can be expanded in vitro. ASC-derived non-cellular components, such as conditioned media or exosomes, have also been investigated. Many in vitro and preclinical studies in animals have demonstrated the ASC efficacy on wounds. ASC efficiency appears to occurs mainly through their regenerative secretome. Hitherto, the majority of clinical trials focused mainly on safety issues. However more recently, a small number of randomized, well-controlled trials provided first convincing evidences for a clinical efficacy of ASC-based chronic wound therapies in humans. This brief review summarizes the current knowledge on the mechanism of action, delivery and efficacy of ASC in chronic wound therapy. It also discusses the scientific and pharmaceutical challenges to be solved before ASC-based wound therapy enters clinical reality.

Toward Participation-Focused School-Based Occupational Therapy: Current Profile and Possible Directions

ABSTRACT Enabling inclusive participation is an overarching goal of Occupational Therapy services in the school setting; however, evidence is scarce on practices addressing it. This study conducts an in-depth examination of actual Occupational Therapy practices with students with physical disabilities in mainstream schools and explores possible directions toward facilitation of successful participation. Eight Occupational Therapists representing different practice settings and regions of a large Canadian province were recruited, each providing two distinct charts of students with physical disabilities integrated in regular classrooms. Data extracted from charts was analyzed and coded based on the International Classification of Function, Disability, and Health. Chart-stimulated recall interviews were conducted with each therapist and analyzed thematically. Services focused predominantly on academic rather than social activities. Two overarching themes emerged describing the clinical reality including resources (e.g. time and teams) and the impact of occupational therapy (e.g. service delivery and promotion of the profession). Subthemes suggest expansion of practice scope and diversification of service delivery modalities as promising directions. Facilitation of fuller inclusion and participation of students with physical disabilities in the school setting by Occupational Therapy services may require additional resources including knowledge translation initiatives relating to collaboration and facilitation of social participation in schools.

Perinatal Oxidative Stress and Kidney Health: Bridging the Gap between Animal Models and Clinical Reality.

Oxidative stress arises when the generation of reactive oxygen species or reactive nitrogen species overwhelms antioxidant systems. Developing kidneys are vulnerable to oxidative stress, resulting in adult kidney disease. Oxidative stress in fetuses and neonates can be evaluated by assessing various biomarkers. Using animal models, our knowledge of oxidative-stress-related renal programming, the molecular mechanisms underlying renal programming, and preventive interventions to avert kidney disease has grown enormously. This comprehensive review provides an overview of the impact of perinatal oxidative stress on renal programming, the implications of antioxidant strategies on the prevention of kidney disease, and the gap between animal models and clinical reality.

Golden Mean and Proportion in Dental Esthetics after Orthodontic Treatments: An In Vivo Study.

The definition of the golden ratio was established around the sixth century BC; Levin and Snow developed specific theories applicable in dentistry, which apply the golden proportion rule with the intention of reproducing a perfect smile. This study analyzed the literature and assessed whether these concepts remain valid and applicable in clinical practice, evaluating the theories with a group of patients followed by an experienced orthodontic team. This study was retrospectively performed on 400 patients (241 females and 159 males) who underwent orthodontic treatments. The analysis was conducted on intraoral frontal photos, both pre-treatment and post-orthodontic treatment, to observe if there was a statistically significant difference in the tooth display according to the golden mean and golden proportion theories. The canine at the end of the orthodontic treatment had a greater visibility than that proposed by Levin and Snow. This study revealed how these theories could be considered in certain respects, but nowadays are not totally valid and applicable to the clinical reality. Snow's theory appears to be more consistent with the clinical findings than Levin's theory.

CDK4/6 Inhibitors in Advanced HR+/HER2 – Breast Cancer: A Multicenter Real-World Data Analysis

Purpose: CDK4/6 inhibitors (CDK4/6i) combined with endocrine therapy are considered standard-of-care for first-line therapy of patients with hormone receptor positive, HER2 negative, advanced breast cancer (HR+/HER2- ABC). Superiority of combination therapy over endocrine monotherapy has been demonstrated in a multitude of randomized controlled trials (RCTs) in phase III and IV. However, RCTs reflect clinical reality only to a limited extent, as narrow inclusion criteria lead to a selected patient collective. Here, we present real-world data (RWD) on CDK4/6i treatment in patients with HR+/HER2- ABC at four certified German university breast cancer centers. Methods: Patients diagnosed with HR+/HER2- ABC who were treated in clinical routine with CDK4/6i between November 2016 and December 2020 at four certified German university breast cancer centers (Saarland University Medical Center, University Medical Center Charité Berlin, University Medical Center Bonn, and University Medical Center Hospital Schleswig-Holstein, Campus Kiel) were identified and enrolled in this retrospective study. Clinicopathological characteristics and clinical outcomes were recorded with particular emphasis on CDK4/6i therapy course [progression-free survival (PFS) following treatment initiation, toxicity, dose reduction, therapy discontinuation, prior and subsequent therapy line]. Results: Data from n = 448 patients were evaluated. The mean patient age was 63 (±12) years. Of these patients, n = 165 (36.8%) were primarily metastasized, and n = 283 (63.2%) had secondary metastatic disease. N = 319 patients (71.3%) received palbociclib, n = 114 patients (25.4%) received ribociclib, and n = 15 patients (3.3%) received abemaciclib, respectively. Dose reduction was performed in n = 132 cases (29.5%). N = 57 patients (12.7%) discontinued the treatment with CDK4/6i due to side effects. N = 196 patients (43.8%) experienced disease progression under CDK4/6i treatment. The median PFS was 17 months. Presence of hepatic metastases and prior therapy lines were associated with shorter PFS, whereas estrogen positivity and dose reduction due to toxicity were positively associated with PFS. Presence of bone and lung metastases, progesterone positivity, Ki67 index, grading, BRCA1/2 and PIK3CA mutation status, adjuvant endocrine resistance, and age did not significantly impact on PFS. Conclusion: Our RWD analysis on CDK4/6i treatment in Germany supports data from RCTs regarding both treatment efficacy and safety of CDK4/6i for treatment of patients with HR+/HER2- ABC. In comparison to data from the pivotal RCTs, median PFS was lower but within the expected range for RWD, which could result from inclusion of patients with more advanced diseases (i.e., higher therapy lines) to our dataset.

COGNITIVE- BEHAVIORAL THERAPIES, REALITY AND HOW TO APPLY THEM IN THE CLINICAL SETTING

In This research we will address the topic of cognitive behavioral therapy, which is considered one of the modern therapeutic methods, and although the Field of contemporary psychotherapy abounds with multiple schools and methods that may reach more than a hundred forms of psychotherapy, behind this contradiction, ron zen 1990 considered CBT as a model for the best therapeutic strategies because it contains an integrative view of the expression of behavior. This integration lies in the various currents in psychotherapy. cognitive behavioral therapy as in effective set of procedures that include assessment, planning, decision- making, and behavioral playing techniques, as the therapist plays an active and supportive role in it, using several technique, from psychological of thinking with education to role-playing and live or imagined behavioral exposure, which helps patients to deal, patterns adaptive. Is also based on cognitive-behavioral therapy on the cooperative therapeutic relationship between the therapist and the patient, in the light of which the personal responsibility of the patient is determined for all his distorted thoughts and irrational, dysfunctional beliefs that may be considered primarily responsible for those disorders he suffers from or the consequent distress and distress, cognitive-behavioral therapy is also based on the light of thinking, expectation and beliefs in the development and persistence of disorders and thus intends to change them by using procedures derived from learning theories based on learning and cognitive processes. Certain, the problem posed by this research is what are cognitivebehavioral treatments? How effective and efficient is it in solving psychological problems? Can it be a psychotherapeutic alternative to medication in solving psychological and mental disorders? The research aims to highlight the concept of cognitive-behavioral therapy and to indicate its principles, importance and goal- identifying the multiple theories of cognitive-behavioral therapies, highlighting examples of cognitive-behavioral therapy practices- detecting the extent to which this technique is practiced in reality in psychiatric clinics and the extent of the efficacy of these treatments in solving psychological problems and the various disorders of anxiety, tension and jealousy. - evaluation of the activities of psychiatric. - learn effective psychological therapies. Key words: Cognitive-Behavioral Therapy, Reality, Application, Clinical Medium

The future of engineered immune cell therapies.

Immune cells are being engineered to recognize and respond to disease states, acting as a "living drug" when transferred into patients. Therapies based on engineered immune cells are now a clinical reality, with multiple engineered T cell therapies approved for treatment of hematologic malignancies. Ongoing preclinical and clinical studies are testing diverse strategies to modify the fate and function of immune cells for applications in cancer, infectious disease, and beyond. Here, we discuss current progress in treating human disease with immune cell therapeutics, emerging strategies for immune cell engineering, and challenges facing the field, with a particular emphasis on the treatment of cancer, where the most effort has been applied to date.

The value of case history and early treatment data as predictors of enuresis alarm therapy response

Two central problems with the enuresis alarm are the family workload and the lack of predictors of therapy response. We wanted to look at predictors of alarm response in a setting reflecting clinical reality. An alarm linked to a smartphone app was provided to enuretic children managed at pediatric outpatient wards. Baseline data (sex, age, daytime incontinence, urgency, previous therapies, arousal thresholds and baseline enuresis frequency) were recorded. Further information, such as enuretic episodes and actual alarm use, was gathered via the app during therapy. Therapy was given for 8-12 weeks or until 14 consecutive dry nights had been achieved. For the 196 recruited children the outcome was as follows: full responders (FR) 18.4%, partial responders (PR) 20.4%, nonresponders (NR) 22.4% and dropouts 38.8%. We found no clear predictors of response or adherence among baseline data. But as treatment progressed responders reduced their enuresis frequency as compared to NR (week two P=0.003, week three and onwards P<0.001). This is further illustrated in the Figurebelow. Furthermore, the children unable to complete the full treatment had more non-registered nights already from the second week (week two P=0.005, week three P=0.002 and so on). Anamnestic data give little predictive information regarding enuresis alarm response or adherence. Contrary to common belief neither daytime incontinence nor previous alarm attempts influenced treatment success. But after 2-4 weeks of therapy the children with a good chance of treatment success could be discerned by decreasing enuresis frequency, and the families that would not be able to comply with the full treatment showed incomplete adherence already during the first weeks. Maybe the enuresis alarm strategy should be changed so that the treatment is reassessed after one month and only children with a high chance of success continue. This way, unnecessary frustration for the families of therapy-resistant children may be reduced.

Kidney xenotransplantation: Future clinical reality or science fiction?

There is a global shortage of organs for transplantation and despite many governments making significant changes to their organ donation systems, there are not enough kidneys available to meet the demand. This has led scientists and clinicians to explore alternative means of meeting this organ shortfall. One of the alternatives to human organ transplantation is xenotransplantation, which is the transplantation of organs, tissues, or cells between different species. The resurgence of interest in xenotransplantation and recent scientific breakthroughs suggest that genetically engineered pigs may soon present a realistic alternative as sources of kidneys for clinical transplantation. It is therefore important for healthcareprofessionals to understand what is involved in xenotransplantation and its future implications for their clinical practices. First, we explore the insufficiency of different organ donation systems to meet the kidney shortage. Second, we provide a background and a summary of the progress made so far in xenotransplantation research. Third, we discuss some of the scientific, technological, ethical, and public health issues associated with xenotransplantation. Finally, we summarize the literature on the attitudes of healthcare professionals toward xenotransplantation.

Stem Cell Therapy, Artificial Heart or Xenotransplantation: What will be New "Regenerative" Strategies in Heart Failure during the Next Decade?

The main limitation of allotransplantation and in particular heart transplantation is the insufficient supply of donor organs. As alternative strategies to heart transplantation, stem cells opened the way of regenerative medicine in early 2000. While new biotechnologies tried to minimize side effects due to hemocompatibility in artificial hearts, progress in xenotransplantation allowed in 2022 to realize the first pig-to-human heart transplant on a compassionate use basis. This xenotransplantation has been successful thanks to genetically modified pigs using the CRISPR-Cas9 technology. Indeed, gene editing allowed modifications of immune responses and thrombotic potential to modulate graft and systemic reaction. Academic research and preclinical studies of xenogeneic tissues already used in clinic such as bioprosthesis valve and of new xenotransplantation options will be necessary to evaluate immune-thrombosis and organ/vascular damages more deeply to make this hope of xenotransplantation a clinical reality. Stem cells, artificial heart and xenotransplantation are all in line to overcome the lack of donor hearts. Combination of stem cell approaches and/or xenogeneic tissue and/or artificial organs are probably part of the research objectives to make these projects real in the short term.

Vector Analysis of Multicentric Lymphoma in a Severe Hemophilia Α Dog after AAV Gene Therapy

Background Adeno-associated viral (AAV) vector gene therapy for severe hemophilia A (HA) is approaching a clinical reality with multiple successful clinical trials. Despite this success, questions remain about the long-term safety of AAV vectors, especially regarding genomic integration and resulting oncogenesis. Studies of neonatal mice have demonstrated AAV integrations that drive hepatocellular carcinoma formation (Donsante et al. Science, 2007). Studies in HA canine models have also demonstrated AAV integrations and clonal expansion of hepatocytes with integrated vector genomes, but no evidence of tumor formation (Nguyen et al. Nat Biotechnol, 2021). Additionally, three tumors have been reported in AAV gene therapy recipients with HA or hemophilia B in clinical trials, without evidence of vector integrations driving oncogenesis. Though overall reassuring, these data highlight that the field needs to remain vigilant about the possibility of AAV integrations driving cancer development. Thus, the assessment of tumors in gene therapy recipients remains important for the AAV field. Aims To determine the role of AAV vector in the development of multicentric lymphoma in a severe HA dog that received liver-directed gene therapy. Methods Vector genome copy numbers in relevant tissues were determined by real-time PCR with primers situated in the 3'-end of the promoter and the 5'- end of the transgene. The vector copy number was calculated by comparing the analyte amplification signal against a standard curve of the plasmid DNA. Results A privately owned mixed-breed dog (PC9) with a history of recurrent spontaneous bleeding events presented with canine factor VIII (cFVIII) levels <1% normal, consistent with severe HA. At 9-months of age, he received liver-directed AAV8 gene therapy with a high-expressing canine factor FVIII (cFVIII-ΔF/V3) variant transgene at a dose of 6 x 1012 vg/kg via intravenous administration. Following gene therapy, his cFVIII levels increased to 2-3% normal and remained stable through duration of follow-up. His annualized bleeding rate decreased from 8 pre-gene therapy to 0 post-gene therapy. At 3.5 years after vector administration, PC9 was diagnosed with a widely disseminated cancer and euthanized due to complications of the disease. At autopsy, he was diagnosed with multicentric lymphoma involving peripheral and visceral lymph nodes, spleen, liver, and lungs. The average age of lymphoma diagnosis in dogs is between 6-9 years of age (Edwards et al. Vet Comp Oncol, 2003), so the development of cancer at an early age in a gene therapy recipient warranted additional study. Vector copy number analysis showed that the liver had the highest levels of AAV vector genomes, as expected. Liver samples showed a heterogenous distribution of vector genomes, consistent with previous studies of AAV8 transduction (Bell et al. Hum Gene Ther, 2011). Splenic samples also had a high level of AAV vector genomes, which again is consistent with known targeting of AAV8. Importantly, the lymph nodes had no detectable AAV vector genomes present, suggesting that vector integration could not contribute to lymphoma development. cFVIII levels remained stable before and after diagnosis of lymphoma, supporting lack of vector integration in the malignant cells. Conclusions AAV gene therapy resulted in a 100% reduction in the annualized bleeding rate in this pet dog with severe HA. Furthermore, the multicentric lymphoma that developed 3.5 years after liver-directed gene therapy is unlikely related to the AAV vector. We are unable to rule out other factors that may have contributed, including environmental influences or genetic predispositions for lymphoma. These results support the ongoing efforts to treat HA with AAV-based gene therapy and reinforce the safety profile of AAV vectors outside of a laboratory environment.

Polymeric fiber sensors for insertion forces and trajectory determination of cochlear implants in hearing preservation

The level of hearing restoration in patients with severe to profound sensorineural hearing loss by means of cochlear implants (CIs) has drastically risen since the introduction of these neuroprosthetics. The proposed CI integrated with polymer optical fiber Bragg gratings (POFBGs) enables real-time evaluation of insertion forces and trajectory determination during implantation irrespective of the speed of insertion, as well as provides high signal quality, low stiffness levels, minimum induced stress even under forces of high magnitudes and exhibits significant reduction of the risk of fiber breakage inside the constricted cochlear geometry. As such, the proposed device opens new avenues towards atraumatic cochlear implantations and provides a direct route for the next generation of CIs with intraoperative insertion force assessment and path planning capacity crucial for surgical navigation. Hence, adaptation of this technology to clinical reality holds promising prospects for the hearing impaired.

Xenotransplantation and Risks: The Opinion of Veterinary Students at Spanish Universities

Understanding the perception of the risks associated with xenotransplant, especially among professionals who will contribute to the care of the animals, is important for xenotransplant to become a clinical reality. The objective of this study was to analyze opinions regarding the risks of organ xenotransplant among veterinary university students in Spain. The study population was 2683 veterinary students from different courses and universities in Spain. Instrument valuation: Validated self-administered questionnaire completed anonymously (PCID-XENOTx-Ríos). Consent to collaborate in the study was requested. Variables for the study: attitude toward xenotransplant and risks (infectious, immunologic, ethical/moral, philosophical, religious, other unspecified risks). descriptive analysis, Student t test, χ2 test, and Fisher exact test. Of the total number of respondents, 2646 students answered this question, with a completion rate of 98.6%. They considered immunologic risk 78.4% (n=2074), infectious risk 48.6% (n=1286), ethical/moral risk 10.7% (n=284), philosophical risk 5.2% (n=137), religious risk 1.5% (n=40), and other risks 3.9% (n=104). Significant relationships were observed between immunologic risks (P < .001), ethical/moral risks (P < .001), and other risks (P=.002). Despite the consideration of different types of risks, the favorable attitude toward xenotransplant among veterinary students at Spanish universities is highly prevalent, and evidence-based information campaigns on the different risks associated with xenotransplant are important.

Diversity Competence in Healthcare: A minimal definition

Abstract Background Health professionals face a variety of professional challenges in today's plural societies. Sciences propose a specific skill set can help to meet those challenges. Various terms and sometimes extensive concepts are provided for diversity competence. The related learning processes are time-consuming and demanding to implement in hectic clinical realities, so that a basic, easy to deplore training package of essential skills would be desirable in order to enable health professionals to take equally good care of all patients including migrants and minorities. Methods A two-round Delphi study was conducted to prioritise teaching objectives; 31 clinical and academic migrant health experts from 13 European countries participated. A round of open questions was followed by a standardised rating round of 65 items. Data was descriptively analysed (m, M, SD) and consensus defined as 80% of experts assigning high importance to a competence. Results The process identified essential competences as well as high priority cognitive, affective and pragmatic competences, leading to a minimal definition of diversity competence for health professionals which includes respectfulness, empathy, diversity awareness and reflection, knowledge on social determinants as well as ethics and human rights; Further skills are: being able to listen, observe and communicate understandably, including professional usage of interpreters, shared decision-making and individual, need-based care. Conclusions The panel reached consensus on many of the competences. In general, attitudes and practical skills were considered essential. Basic trainings that meet the needs of professionals and help them cope with everyday challenges can be designed on the grounds of these findings. We provide a working definition of ‘diversity competence of health professionals’ for scientific exchange and investigation and propose the conscious use of a ‘diversity’ instead of ‘intercultural” terminology. Key messages

Informed consent for psychotherapy: Ethical illusion or clinical reality? A survey about psychotherapists' attitudes and practices in Germany.

This study aimed to assess clinicians' attitudes and their current clinical practices regarding informed consent for psychotherapy. A convenience sample of N = 530 clinicians in Germany (n = 418 licensed psychotherapists and n = 112 postgraduate psychotherapy trainees) took part in an online survey. Most clinicians (84%) reported obtaining informed consent for psychotherapy in their daily routine. However, many psychotherapists felt unsure about satisfactorily fulfilling the legal (63%) and ethical obligations (52%). The two most frequently reported components of information disclosure related to explaining the terms and conditions of psychotherapy (96%) and the psychotherapeutic approach (91%). Providing information about mechanisms of psychotherapy (33%) and the role of expectations (30%) were least practiced. One in five psychotherapists reported not informing clients about potential risks and side effects. A considerable proportion reported concern about inducing anxiety in patients by disclosing information about risks and side effects (52%). Although obtaining informed consent for psychotherapy seems to be the rule rather than the exception in clinical practice, the quality of its implementation in terms of legal, ethical and clinical demands remains questionable. Training psychotherapists in providing comprehensive informed consent enables informed decision-making and might have a positive influence on treatment expectations and outcomes.

Ischemic Stroke, Lessons from the Past towards Effective Preclinical Models.

Ischemic stroke is a leading cause of death worldwide, mainly in western countries. So far, approved therapies rely on reperfusion of the affected brain area, by intravenous thrombolysis or mechanical thrombectomy. The last approach constitutes a breakthrough in the field, by extending the therapeutic window to 16–24 h after stroke onset and reducing stroke mortality. The combination of pharmacological brain-protective strategies with reperfusion is the future of stroke therapy, aiming to reduce brain cell death and decrease patients’ disabilities. Recently, a brain-protective drug—nerinetide—reduced brain infarct and stroke mortality, and improved patients’ functional outcomes in clinical trials. The success of new therapies relies on bringing preclinical studies and clinical practice close together, by including a functional outcome assessment similar to clinical reality. In this review, we focused on recent upgrades of in vitro and in vivo stroke models for more accurate and effective evaluation of therapeutic strategies: from spheroids to organoids, in vitro models that include all brain cell types and allow high throughput drug screening, to advancements in in vivo preclinical mouse stroke models to mimic the clinical reality in surgical procedures, postsurgical care, and functional assessment.

Digestive tract reconstruction in pancreaticoduodenectomy in University Hospitals of China: a national questionnaire survey

Background: Pancreaticoduodenectomy (PD) has been widely applied in general hospitals in China; however, there is still a lack of unified standards for each surgical technique and procedure. This survey is intended to investigate the current status of digestive tract reconstruction after PD in university hospitals in China. Method: A cross-sectional survey was conducted among the members of the Young Elite Pancreatic Surgery Club of China by using the Questionnaire for Digestive Tract Reconstruction after Pancreaticoduodenectomy. The questionnaire was disseminated and collected by point-to-point communication via WeChat public platforms. Results: A total of 73 valid questionnaires were returned from 65 university hospitals in 28 provincial divisions of mainland China. The respondents who performed PD surgery with an annual volume of over 100 cases accounted for 63%. Generally, laparoscopic PD was performed less often than open PD. Child and Whipple reconstructions accounted for 70% and 26%, respectively. The sequence of pancreatoenteric, biliary-enteric, and gastrointestinal reconstruction accounted for 84% of cases. In pancreatoenteric anastomosis, double-layer anastomosis is the most commonly employed type, accounting for approximately 67%, while single-layer anastomosis accounts for 30%. Of the double-layer anastomoses, duct-to-mucosa/dunking (94%/4%) pancreatojejunostomy was performed with duct-mucosa using the Blumgart method (39%) and Cattel-Warren (29%), with continuous/interrupted sutures in the inner layer (69%/31%) and continuous/interrupted sutures in the outer layer (53%/23%). In single-layer anastomosis, continuous/interrupted sutures accounted for 41%/45%. In hepatojejunostomy, single-layer/double-layer suture accounted for 79%/4%, and continuous/interrupted suture accounted for 75%/9%. Forty-six percent of the responding units had not applied double-layer biliary-intestinal anastomosis in the last 3 years, 75% of the responding surgeons chose the anastomosis method according to bile duct diameter, with absorbable/non-absorbable suture accounting for 86%/12%. PD/pylorus-preserving PD accounted for 79%/11% of gastrojejunostomy (GJ) cases, the distance between GJ and hepaticojejunostomy &lt; 30, 30–50, and &gt; 50 cm were 11%, 75%, and 14%, respectively. Antecolic/retrocolic GJ accounted for 71%/23% of cases. Twenty-two percent of GJ cases employed Braun anastomosis, while 55% and 19% of GJ cases used linear cutting staplers/tube-type staplers, respectively; 60%/14% were reinforced/not reinforced via manual suturing after stapler anastomosis. Manual anastomosis in GJ surgery employed absorbable/non-absorbable sutures (91%/9%). Significant differences in reconstruction techniques were detected between different volumes of PD procedures (&lt;100/year and &gt;100/year), regions with different economic development levels, and between north and south China. Conclusion: Digestive tract reconstruction following PD exists heterogeneity in Chinese university hospitals. Corresponding prospective clinical studies are needed to determine the consensus on pancreatic surgery that meets the clinical reality in China.

Novel scoring system combined with a virtual reality technique for the preoperative evaluation of the stone-free status after flexible ureteroscopy: the H.L.P.E.S. score

ObjectiveThe original S.O.L.V.E. scoring system was modified using virtual reality technology, and a new H.L.P.E.S scoring system was constructed to improve the accuracy of predicting the stone-free rate after flexible ureteroscopy.MethodsWe retrospectively analyzed clinical and virtual reality data of 150 patients with renal calculi who underwent flexible ureteroscopy at the First Affiliated Hospital of Chongqing Medical University, Chongqing, China, from September 2019 to January 2022. Factors affecting the stone-free rate were evaluated in univariate and multiple logical regression analyses. Factors were divided by cut-off value under the receiver-operating characteristic curve and scored accordingly to a well-known international scoring system. Area under the curve predicted the stone-free rate. The accuracy and superiority of the stone-free rate after flexible ureterorenoscopy was compared between this scoring system and the S.O.L.V.E, R.I.R.S, T.O.HO, and RUSS scores.ResultsMultiple logistic regression showed that the stone surface area, renal pelvis volume, and length of the calyces funnel were correlated with stone-free rate (P < 0.01, P = 0.021, P = 0.019, respectively). The H.L.P.E.S. score included stone surface area (1–2 points), renal pelvis volume (1–2 points), length of calyces funnel (1–2 points), pelvic calyceal height (1–2 points), and essence of stone (1–2 points). The area under the receiver-operating characteristic curve of H.L.P.E.S. score was 0.927, which was higher than the S.O.L.V.E., R.I.R.S., T.O.HO, and RUSS scores.ConclusionH.L.P.E.S. scoring can effectively predict the stone-free rate after flexible ureteroscopy for renal calculi and is superior to other scoring systems.

Sequels.

The termination ideal for analytic work stands at a considerable distance from clinical reality; "complete" terminations are rare indeed. This gap is perhaps best explored by considering <i>sequels</i>-instances in which ex-analyst and ex-patient become nonsexual friends post treatment. The meanings and implications of these post-termination friendships-their complexities, problematic edges, serious difficulties, and the potential therapeutic benefit of this deviation from the termination ideal-are illustrated using the unfinished story of a good treatment and its yet-to-be-defined ending. Thus, the psychoanalytic model of termination is interrogated, and the complexities of treatment sequels, for both patient and analyst, are elucidated.