Clinical Management Research Articles

Personalized clinical management of patients with atrial fibrillation: is a biomarker-based strategy for prediction of sinus rhythm persistence ready for prime time?

Personalized clinical management of patients with atrial fibrillation: is a biomarker-based strategy for prediction of sinus rhythm persistence ready for prime time?

Clinical practice guidelines for the care of patients with a chronic subdural haematoma: multidisciplinary recommendations from presentation to recovery

Introduction A chronic subdural haematoma (cSDH) is an encapsulated collection of fluid and blood degradation products in the subdural space. It is increasingly common, affecting older people and those living with frailty. Currently, no guidance exists to define optimal care from onset of symptoms through to recovery. This paper presents the first consensus-built recommendations for best practice in the care of cSDH, co-designed to support each stage of the patient pathway. Methods Guideline development was led by a multidisciplinary Steering Committee with representation from diverse clinical groups, professional associations, patients, and carers. Literature searching to identify relevant evidence was guided by core clinical questions formulated through facilitated discussion with specially convened working groups. A modified Delphi exercise was undertaken to build consensus on draft statements for inclusion in the guideline using survey methodology and an in-person meeting. The proposed guideline was subsequently endorsed by the Society for British Neurological Surgeons, Neuroanaesthesia and Critical Care Society, Association of Anaesthetists, British Association of Neuroscience Nurses, British Geriatric Society, and Centre for Perioperative Care. Results We identified that high quality evidence was generally lacking in the literature, although randomised controlled trial (RCT) data were available to inform specific recommendations on aspects of surgical technique and use of corticosteroids. The final guideline represents the outcome of synthesising available evidence, consensus-built expert opinion and patient involvement. The guideline comprises 67 recommendations across eight major themes, covering: presentation and diagnosis, neurosurgical triage and shared decision-making, non-operative management, perioperative management (including anticoagulation), timing of surgery, intraoperative and postoperative care, rehabilitation and recovery. Conclusions We present the first multidisciplinary guideline for the care of patients with cSDH. The recommendations reflect a paradigm shift in the care of cSDH, recognising and formalising the need for multidisciplinary and collaborative clinical management, communication and decision-making delivered effectively across secondary and tertiary care.

Validation of a prognostic blood-based sphingolipid panel for men with localized prostate cancer followed on active surveillance

BackgroundWe previously reported that increases in circulating sphingolipids are associated with elevated risk of biopsy Gleason grade group (GG) upgrading in men on Active Surveillance (AS) for prostate cancer. Here, we aimed to validate these findings and establish a blood-based sphingolipid biomarker panel for identifying men on AS who are at high-risk of biopsy GG upgrading.MethodsMen diagnosed with low- or intermediate-risk prostate cancer in one of two AS cohorts (CANARY PASS and MDACC) were followed for GG upgrading after diagnostic and confirmatory biopsy. The PASS cohort consisted of 544 patients whereas the MDACC Cohort consisted of 697 patients. The number of patients with GG upgrading during course of study follow-up in the PASS and MDACC cohorts were 98 (17.7%) and 133 (19.1%), respectively. Plasmas collected prior to confirmatory biopsy were used for mass spectrometry-based quantitation of 87 unique sphingolipid species. A neural network layer based on 21 sphingolipids was developed in the CANARY PASS cohort for predicting biopsy GG upgrading. Tertile-based thresholds for low-, intermediate-, and high-risk strata were subsequently developed for the sphingolipid panel as well as a model that combined the sphingolipid panel with PSA density and rate of core positivity on diagnostic biopsy. The resultant models and risk thresholds for GG upgrading were validated in the MDACC cohort. Performance was assessed using Cox proportional hazard models, C-index, AUC, and cumulative incidence curves.ResultsThe sphingolipid panel had a HR (per unit standard deviation increase) of 1.36 (95% CI: 1.07–1.70) and 1.35 (95% CI: 1.11–1.64) for predicting GG biopsy upgrading in the PASS and MDACC cohort, respectively. The model that combined the sphingolipid panel with PSA density and rate of core positivity achieved a HR of 1.63 (95% CI: 1.33-2.00) and 1.44 (1.25–1.66), respectively. Tertile-based thresholds, established in the PASS cohort, were applied to the independent MDACC cohort. Compared to the low-risk group, MDACC patients in the high-risk strata had a GG biopsy upgrade HR of 3.65 (95% CI: 2.21–6.02), capturing 50% of the patients that had biopsy upgrading during study follow-up.ConclusionsThe sphingolipid panel is independently associated with GG biopsy upgrading among men in two independent AS cohorts who have previously undergone diagnostic and confirmatory biopsy. The sphingolipid panel, together with clinical factors, provides a potential means for risk stratification to better guide clinical management of men on AS.

Immunohistochemical Status Predicts Pathologic Complete Response to Neoadjuvant Therapy in HER2-Overexpressing Breast Cancers.

Human epidermal growth factor receptor 2 (HER2) overexpression (HER2+) is defined by immunohistochemistry (IHC) and in situ hybridization (ISH) as IHC3+ or IHC2+/ISH+. Response differences to neoadjuvant anti-HER2 therapy (NT) in IHC3+ versus IHC2+/ISH+ breast cancer patients are poorly characterized. We explored whether pathologic complete response (pCR) varies by HER2 IHC status. Patients with stage I-III HER2+ breast cancer undergoing NT and surgery between 2013 and 2020 were identified from the National Cancer Database and stratified by IHC status. Breast and nodal pCR were analyzed. Of 40,711 HER2+ patients, 83% were IHC3+ and 17% were IHC2+/ISH+. IHC3+ patients were more likely to be hormone receptor (HR)-negative (33 vs. 21%), have cT3/4 tumors (24 vs. 21%), and be cN+ (52 vs. 47%; all p < 0.0001). Breast conservation rates were similar (each 43%, p = 0.32), although IHC3+ axillary lymph node dissection rates were lower (41 vs. 45%, p < 0.0001). Among all patients, breast pCR was 49%, while nodal pCR was 64%. Compared with IHC2+/ISH+, IHC3+ had higher unadjusted breast (54 vs. 22%, p < 0.0001) and nodal (69 vs. 37%, p < 0.0001) pCR rates. When stratified by HR status, pCR was lower for HR+ disease but remained higher among IHC3+ patients. Analysis of T1cN0 primaries mirrored these trends. In multivariable analysis, IHC3+ remained an independent predictor of breast (odds ratio [OR] 3.91, confidence interval [CI] 3.65-4.19, p < 0.0001) and nodal (OR 3.40, CI 3.12-3.71, p < 0.0001) pCR. HER2 IHC status predicts pCR and may help select breast cancer patients who derive the greatest benefit from NT. These findings provide further evidence that revision of HER2 classification may improve clinical management.

Evaluating the Diagnostic Potential of Four-Dimensional Flow Magnetic Resonance Imaging in Aortic Stenosis Diagnosis: A Systematic Review and Meta-Analysis.

This systematic review and meta-analysis evaluates the potential of four-dimensionalflow magnetic resonance imaging(4DFM) in assessing aortic stenosis (AS) compared to traditional imaging modalities like two-dimensional phase contrast MRI (2D MRI) and transthoracic echocardiography (TTE). AS is a common and severe valvular heart disease, particularly in older adults, requiring accurate diagnosis for proper clinical management. Conventional imaging methods have limitations in capturing complex flow dynamics, prompting the need for advanced modalities like 4DFM. The objectives of the review were to determine whether 4DFM offers superior diagnostic metrics, including peak aortic jet velocity, transvalvular pressure gradients, and aortic valve area (AVA), and to identify potential advantages of 4DFM in overcoming the limitations of traditional modalities. This review included six cohort studies with 285 participants, examining the diagnostic accuracy of 4DFM in terms of peak aortic jet velocity, transvalvular pressure gradients, and aortic valve area (AVA). Studies were selected from MEDLINE (PubMed), Cochrane Library, and Google Scholar databases between December 2010 and October 2024. The study pool was limited by stringent inclusion criteria focusing on cohort studies that directly compared 4DFM with TTE or 2D MRI for AS assessment. The National Institutes of Health Quality Assessment Tool and Cochrane ROBINS-I tool were used to assess bias. Quantitative results showed that 4DFM typically measured higher AVA values than TTE, with a mean difference of 0.48 cm² (95% CI: -0.16 to 1.12). For mean pressure gradients, 4DFM reported slightly higher measurements in individual studies, but pooled results showed no significant difference compared to TTE (mean difference: 3.32 mmHg, 95% CI: -2.30 to 8.93). In terms of peak aortic jet velocity, 4DFM demonstrated a pooled mean difference of -0.18 m/s (95% CI: -0.44 to 0.08) compared to TTE. High heterogeneity was observed across studies (e.g., I² = 97% for peak velocity, I² = 93% for AVA), likely due to differences in patient populations, imaging protocols, and software for data analysis.4DFM demonstrates potential as a complementary imaging tool, particularly in complex AS cases where conventional methods like TTE may provide inconclusive results. Its capacity to capture intricate flow dynamics and deliver high spatial resolution could inform clinical decision-making, potentially influencing practice guidelines to integrate 4DFM as a supplementary tool. Limitations such as high costs, specialized training requirements, and access challenges currently restrict widespread adoption. Limitations of this review include small sample sizes, high heterogeneity, and variability in patient populations and imaging protocols. Despite these challenges, 4DFMI demonstrated superior spatial resolution and complex cardiovascular flow assessment, suggesting it could serve as a valuable complement to TTE for more detailed AS evaluation, particularly in complex cases.Future studies should aim to standardize imaging protocols, incorporate larger and more diverse populations, and conduct cost-benefit analyses to support the integration of 4DFM into clinical practice, potentially shaping future diagnostic guidelines.

Huge calcifying epithelial odontogenic tumor of the mandible and management with a teeth preserving surgical approach: a case report

BackgroundCalcifying epithelial odontogenic tumor is a rare benign tumor that predominantly occurs in posterior sites of the mandible in adults.Case presentationThis case report describes a case of calcifying epithelial odontogenic tumor in a 37-year-old Iranian female with the chief complaint of swelling in the anterior region of the mandible and tooth displacement. This paper summarized the pathological findings, radiographical features and clinical management of the patient. Clinical examinations revealed a bony hard swelling ~ 3 cm × 4 cm in size with tenderness in the chin area. Radiography revealed an expansile mixed radiolucent and radiopaque lesion with cortical borders. A minimally aggressive surgical approach is used to remove the lesion.ConclusionThis case report outlines the successful outcomes of this surgical approach and the positive outcome associated with the restoration of lost functions of displaced mobile teeth in an arranged and nonmobile way after treatment.

Prevalence of restless genital syndrome and its impact on quality of life in women with restless legs syndrome

ABSTRACT Background Restless genital syndrome (RGS), also known as persistent genital arousal disorder, is a distressing condition characterized by unwanted genital arousal in the absence of sexual desire. This study explores the prevalence of RGS in women with restless legs syndrome (RLS), investigates the associated psychological impacts, and assesses the overall effect on quality of life. Methods This retrospective study included 69 female patients who were diagnosed with RLS at two university medical centers. Data were collected via the RGS diagnostic form, Beck Depression Inventory, Beck Anxiety Inventory, and WHOQOL-BREF quality of life scale. Statistical analyses were used to assess the correlation between RGS and psychological health measures. Results Approximately 44.9% of the participants with RLS also reported symptoms of RGS. Significant findings included increased nighttime and rest-related exacerbation of RGS symptoms. Compared with those without RGS, participants with RGS presented significantly higher anxiety and depression scores. Moreover, RGS significantly impacted physical health and social relationships, as indicated by lower WHOQOL-BREF scores. Conclusion This study highlights a significant overlap between RGS and RLS, with substantial impacts on psychological well-being and quality of life. These findings underscore the importance of considering RGS in the clinical management of RLS, suggesting a need for integrated treatment strategies to address both the neurological and the psychological aspects of these conditions.

Assessing the impact of a leadership development programme on self-reported confidence of Community Pharmacy Neighbourhood Leads in South East London

Abstract Introduction Community Pharmacy (CP) integration is a key NHS England strategy, including for South East London (SEL) Integrated Care Board (ICB). To drive forward this strategy in SEL, the ICB medicines team created and funded community pharmacy neighbourhood lead (CPNL) roles. The CPNLs provide local leadership to strengthen CP-GP relationships and increase uptake of CP services (now badged Pharmacy First). To support implementation, a leadership programme was developed with system partners and delivered by Kaleidoscope,1 building on previous work.2 Core themes were building trust, driving collaboration and embedding innovation. Aim To measure the confidence level of CPNLs in SEL throughout the development programme, and associated outcomes. Methods There were five leadership sessions delivered to invited CPNLs and ICB colleagues between November 2023 and March 2024. The first and last sessions were face-to-face with the others virtual. Sessions covered both theory and implementation. At the end of each session all participants were asked to complete an online Microsoft forms survey compiled by Kaleidoscope, asking about their confidence in the CPNL role (where 1 is not at all confident and 5 is extremely confident), current relationships locally and actions planned and completed to date, using tick box, Likert scale and free text responses. Data was analysed in Microsoft Excel and through content analysis, with analysis completed for all attendees per session and separately for those attending 4 or 5 sessions. This study received ethics approval from Kingston University Ethics Committee (3396). Results A total of 37 individuals attended one or more sessions, with 16 attending 4 or 5 sessions. For all attendees, mean confidence score increased from 3.7 in session one to 4.14 in session five (out of 5) (session two:3.77; session three:4.05; session 4:4.17). Those who attended four or five sessions finished with a mean confidence score of 4.33, starting at 4.00 (session two:3.86; session three:4.19; session four:4.27). Comments showed participants initially reporting that there was room to improve relationships with key stakeholders, such as clinical directors, GPs, ICB and CP colleagues. By session five confidence had increased with comments noting that there was confidence to meet new people, network appropriately, and fulfil the required role. ‘Through the network we have created through this programme, confidence has grown with shared learning and new relationships.’ Comments were also received relating to improved joint working supporting the rollout of community pharmacy initiatives such as the Pharmacy First scheme. ‘Our confidence has grown, and we are arranging training sessions with the clinical directors with the local surgeries for some of the newer services like Pharmacy First.’ Discussion / Conclusion Our programme has increased CPNL confidence and engagement with local stakeholders, with greater confidence seen in those engaging most with the leadership programme. Limitations include not having consistent attendance at sessions. The launch of the national ‘Pharmacy First’ service halfway through the programme had a significant impact on the community pharmacy sector,3 with CPNLs being pivotal in building success in partnership. Further evaluation should assess impact of CPNLs on community pharmacy service provision and referrals by GPs.

Nurses’ knowledge to identify, prevent and manage hypertensive disorder of pregnancy

Background: Hypertensive disorders of pregnancy are major contributors to maternal mortality in South Africa. Preventative strategies in low- and middle-income countries emphasise frequent antenatal visits, symptom identification, patient education and the prophylactic use of calcium and low-dose aspirin to prevent HDP for nurses because they are the frontline workers at antenatal clinics countrywide.Methods: This was a cross-sectional study where a self-administered questionnaire was conducted among nurses (midwives and professional nurses) employed at hospitals and clinics in Durban, South Africa, to assess their understanding and practices regarding identification and initial management of HDP, particularly for eclampsia and PE with severe features. The questionnaires were distributed in person by the researcher.Results: Of the 106 respondents, most (88.7%) worked in the public sector, with over 5 years of experience (64.9%). There was a varied understanding of HDP categories: 72.6% identified gestational hypertension correctly; 49.1%, chronic hypertension; 93.4% PE and 83.0% eclampsia. Knowledge of the recommended treatments for severe PE (55.7%) and eclampsia (66.0%) was moderate with respect to the recommended anticonvulsant and rapid-acting antihypertensive agents, with only 10% recognising the role of aspirin for the prevention of HDP.Conclusion: Substantial knowledge deficiencies existed among nurses in managing HDP.Contribution: Their crucial role in both emergency and preventative care in South African healthcare settings, enhancing educational training on clinical management by providing continuous training and regular updates are imperative to reduce maternal and perinatal complications associated with HDP.

The effect of an enhanced fetal growth ultrasound protocol on pregnancy outcomes: A retrospective service evaluation within a single UK National Health Service centre between 2014 and 2022

Aim: Growth Assessment Protocol is a fetal growth initiative designed to improve antenatal detection of babies who are small-for-gestational-age and reduce stillbirths. However, its direct impact on pregnancy outcome and stillbirth rates is questioned. This service evaluation aimed to assess Growth Assessment Protocol’s influence on pregnancy outcomes at a National Health Service hospital. Method: Anonymous, maternity and ultrasound data, routinely acquired between 2014 and 2022 were extracted from clinical databases (Viewpoint, Euroking). Trends in maternity data and ultrasound scan volume were explored with descriptive statistics. Variables of stillbirth, antenatal small-for-gestational-age detection and scan volume were compared before and after Growth Assessment Protocol implementation. Associations between these variables were evaluated using Spearman’s rho. Results: The percentage of babies born small-for-gestational-age reduced by 0.3% across the evaluation period. Antenatal small-for-gestational-age diagnosis rose from 4.1% to 14.3%. However, the number of false-positive cases of antenatally diagnosed small-for-gestational-age increased fivefold from 2.2% to 11.5%. Although stillbirth rates remained consistent post-Growth Assessment Protocol, complex scan volume (e.g. number of growth scans using Doppler) increased annually. The peak incline coincided with the Growth Assessment Protocol implementation period (2016–2018). Complex scan volume was significantly associated with overall small-for-gestational-age detection (rho = 0.8, p =&lt; 0.001), but not with stillbirth frequency (rho = −0.1, p = 0.4). Conclusion: Small-for-gestational-age detection increased following Growth Assessment Protocol implementation, although this was associated with a high false-positive rate and no reduction in stillbirths. The potential implications associated with clinical management, parent experiences and departmental workflow, alongside the benefits for stillbirth reduction, should be fully considered prior to the introduction of a new fetal growth initiative to the antenatal care pathway.

Impact of the COVID-19 Pandemic on Microbial Profiles and Clinical Outcomes in Orbital and Preseptal Cellulitis

Orbital cellulitis and severe preseptal cellulitis are critical periocular infections with potential vision- and life-threatening implications. The COVID-19 pandemic is hypothesized to have had an influence on their presentation and pathogenesis; however, the real impact remains unclear. In this retrospective multicenter cohort study from January 2017 to December 2022, we analyzed 1285 cases with preseptal or orbital cellulitis in pre-pandemic (2017–2019) and pandemic (2020–2022) cohorts. A notable decrease in hospitalized cases during the pandemic period was observed (97 patients in the pre-pandemic group vs. 54 in the pandemic group, p = 0.004), particularly among individuals aged 30–39 (p = 0.028). Sinusitis remained the leading cause, but odontogenic cases increased (p = 0.025). In addition, microbial diversity decreased during the pandemic, with the effective number of species decreasing from 17.07 to 8.87, accompanied by a rise in antibiotic resistance, notably against erythromycin, oxacillin, penicillin, and metronidazole. While visual outcomes appeared worse in the pandemic group, statistical significance was not reached. These findings suggest that the characteristics, etiology, microbial profiles, resistance patterns, and visual outcomes of orbital and preseptal cellulitis have undergone alterations post-COVID-19 pandemic. Vigilance in clinical management and public health measures is crucial, with further research needed to optimize treatment strategies.

Is Screening for GERD Necessary in All Asymptomatic Lung Transplant Candidates?

Background: Gastroesophageal reflux disease (GERD) is a known contributor to allograft dysfunction after lung transplantation. Evaluation for GERD has been advocated for all lung transplant candidates. The aim of this study is to evaluate the outcomes of GERD testing in lung transplant patients without GERD symptoms and determine if a subset can skip/defer these tests. Methods: A retrospective chart review was conducted on lung transplant candidates who had pre- transplant GI evaluation at our institution between 2019 and 2022. Adult patients were included if they reported no GERD symptoms and completed GERD screening with Multichannel intraluminal impedance-pH testing. Demographics and results of prior testing were collected for included patients. Results were analyzed using STATA. Results: 176 patients met inclusion criteria. 88 (50%) tested positive for GERD and 88 (50%) tested negative. 68/88 (77.3%) were positive by pH alone. Only 20/176 (11%) had elevated reflux episodes and were recommended to undergo anti-reflux procedures. There were no statistically significant differences in evaluated variables differentiating GERD+ versus GERD- patients. Conclusion: Lung transplant candidates without symptoms concerning for GERD tested positive for GERD 50% of the time with no reliable pre-test characteristics to stratify patients. The large majority of positive results were from high acid exposure time alone without elevated reflux episodes—a low risk phenotype for allograft dysfunction. Only 11% had increased reflux episodes and thus were recommended for anti-reflux procedures. Thus, deferring GERD screening in asymptomatic low-risk candidates until post-transplant is unlikely to impact clinical management while benefiting patients and health systems.

Populationwide Screening for Chronic Kidney Disease

Sodium-glucose cotransporter-2 (SGLT2) inhibitors have changed clinical management of chronic kidney disease (CKD) and made populationwide screening for CKD a viable strategy. Optimal age of screening initiation has yet to be evaluated. To compare the clinical benefits, costs, and cost-effectiveness of population-wide CKD screening at different initiation ages and screening frequencies. This cost-effectiveness study used a previously published decision-analytic Markov cohort model that simulated progression of CKD among US adults from age 35 years and older and was calibrated to population-level data from the National Health and Nutrition Examination Survey (NHANES). Effectiveness of SGLT2 inhibitors was derived from the Dapagliflozin and Prevention of Adverse Outcomes in Chronic Kidney Disease (DAPA-CKD) trial. Mortality, quality-of-life weights, and cost estimates were obtained from published cohort studies, randomized clinical trials, and US Centers for Medicare & Medicaid Services data. Analyses were performed from June 2023 through September 2024. One-time or periodic (every 10 or 5 years) screening for albuminuria, initiated at ages between 35 and 75 years, with and without addition of SGLT2 inhibitors to conventional CKD therapy (angiotensin-converting enzyme inhibitors/angiotensin receptor blockers). Cumulative incidence of kidney failure requiring kidney replacement therapy (KRT); life years, quality-adjusted life years (QALYs), lifetime health care costs (2024 US currency), and incremental cost-effectiveness ratios discounted at 3% annually. For those aged 35 years, starting screening at age 55 years, and continuing every 5 years through age 75 years, combined with SGLT2 inhibitors, decreased the cumulative incidence of kidney failure requiring KRT from 2.4% to 1.9%, increased life expectancy by 0.13 years, and cost $128 400 per QALY gained. Although initiation of screening every 5 years at age 35 or 45 years yielded greater gains in population-wide health benefits, these strategies cost more than $200 000 per additional QALY gained. The comparative values of starting screening at different ages were sensitive to the cost and effectiveness of SGLT2 inhibitors; if SGLT2 inhibitor prices drop due to patent expirations, screening at age 55 years continued to be cost-effective even if SGLT2 inhibitor effectiveness were 30% lower than in the base case. This study found that, based on conventional benchmarks for cost-effectiveness in medicine, initiating population-wide CKD screening with SGLT2 inhibitors at age 55 years would be cost-effective.

Identifying colorectal cancer subtypes and establishing a prognostic model using metabolic plasticity and ferroptosis genes

Metabolic plasticity and ferroptosis are essential for colorectal cancer (CRC) progression. The effects and prognostic value of metabolic plasticity- and ferroptosis-related genes (MPFRGs) in CRC remain unclear. We established a prognostic model for CRC patients by identifying important genes in metabolic plasticity and ferroptosis. Data of CRC patients were retrieved from The Cancer Genome Atlas (TCGA) and Gene Expression Omnibus; MPFRG data were obtained from GeneCards and FerrDb. We performed functional (to explore differences between the two metabolic subtypes) and single-sample gene set (to assess the immune environment) enrichment analyses. Immunophenotype, tumor immunological dysfunction, and exclusion scores were assessed to determine patient immune responses. A least absolute shrinkage and selection operator-Cox regression model comprising 10 significant differentially expressed genes of metabolic plasticity and ferroptosis (MPFDEGs) was constructed using TCGA training cohort and validated using the GSE17536 and GSE39582 datasets. We established a nomogram comprising metabolic plasticity- and ferroptosis-based signatures, revealing the clinical application and potential molecular mechanisms underlying the role of MPFRGs in CRC. Our model (developed based on 10 MPFDEGs) is efficient for calculating the overall survival of CRC patients. Our findings provide new strategies for the clinical management and individualized treatment of these patients.

Ultrasmall Black Phosphorus Quantum Dots with Robust Antioxidative Properties for Acute Kidney and Liver Injury Therapy.

Acute organ injuries, such as acute kidney injury (AKI) and acute liver injury (ALI), usually present high morbidity and mortality in patients. However, the current clinical treatments remain limited, especially the lack of effective drug-based treatment. Since these acute injuries are often associated with reactive oxygen species (ROS) overproduction, it is a promising strategy to develop therapeutic agents with potent ROS scavenging ability and excellent biocompatibility for efficient antioxidation therapy. Black phosphorus quantum dots (BPQDs), low-dimensional nanomaterials prepared through a straightforward one-step method and capable of complete controllable biodegradation, offer significant potential. This study comprehensively explores the extensive free-radical scavenging capabilities of BPQDs, underscoring their immense potential in treating ROS-related organ injuries. BPQDs could simultaneously achieve radical scavenging of DPPH, ABTS·, OH·, and O2 -· and exhibit excellent cytoprotective effects against ROS-mediated damage even at extremely low dosages. Besides, the ultrasmall size of BPQDs (≈3-5nm) allows them to effectively penetrate the glomerular filtration barrier (≈6nm), significantly improving the symptoms of AKI and ALI in vivo. The therapeutic efficacy and great biocompatibility of BPQDs facilitate the clinical management of ROS-related diseases, which will broaden the applications of QDs in the field of biomedicine.

Temporal Bone Gunshot Wounds: A Multi-institutional Retrospective Study.

To investigate management practices and outcomes in a retrospective cohort of patients who have sustained temporal bone gunshot wounds (TBGSW). Retrospective chart review. Five participating hospitals. Twenty-two patients met inclusion criteria: experienced a TBGSW, survived ≥30 days following the injury, and were evaluated and managed by a neurotologist between 2019 and 2023. No specific interventions were performed for the purposes of this study. Characteristics, evaluation, management, and outcomes of TBGSW survivors. Patients were found to have a mean age of 33 ± 18 years and were predominantly male (18/22, 81.8%). Majority of patients (17/22, 77.3%) had mastoid injury. Most patients (14/22, 63.6%) had some evidence for vascular injury, most frequently the internal carotid artery (9/22, 40.9%). Almost three-quarters (17/22, 77.3%) of patients had clinical exam findings of facial nerve injury, which was the most common indication for surgery. Otologic surgery was performed in 72.7% (16/22), with delayed adverse events most commonly including cholesteatoma and external auditory canal stenosis. Though evidence for hearing impairment was clinically present in at least 15 of 22 patients (68.2%), hearing rehabilitation was pursued in only two patients. With increasing numbers of TBGSW survivors, there is a growing need for practicing neurotologists to be familiar with the wide spectrum of injury patterns and possible complications to inform clinical management in these patients. Early neurotologic assessment and follow-up beyond the acute period is crucial to minimize morbidity in this high-risk cohort.

Recurrence Detection by Hybrid [18F]FDG-PET in Advanced Head and Neck Squamous Cell Carcinoma.

In the clinical management of advanced stage head and neck squamous cell carcinoma, the use of hybrid [18F]FDG-PET imaging is well established. However, there is ongoing debate regarding the optimal frequency of hybrid PET scans to be included in follow-up protocols, particularly if the initial post-therapeutic scan is negative. We conducted a single-center 10-year retrospective study involving all patients who underwent hybrid PET scans for the follow-up of advanced stage head and neck cancer. A total of 285 patients were included. Out of 199 patients with a negative 3-month hybrid PET, 15% subsequently developed a recurrence during further follow-up. Notably, 90% of these recurrences were detected by hybrid PET. Fifteen percent of patients with a negative 3-month hybrid PET experienced a recurrence. Given that the majority of recurrences were detected by hybrid PET scans, there is a compelling argument for incorporating regular repetitive scans during follow-up.

Experience of physical activity in patients with stroke: A qualitative meta-synthesis.

Inadequate physical activity (PA) is increasingly common among stroke patients, we aim to comprehensively analyze the experience of stroke patients delivering physical activity, understand the obstacles and promoting factors of physical activity, and summarize clinical management strategies. An electronic search of PubMed, Web of Science, Cochrane Library, ProQuest, SinoMed, CNKI, and WanFang Database was conducted for qualitative studies on the experience of PA in stroke patients. The review was appraised using the Joanna Briggs Institute methodology, the subsequent findings were synthesized via the Thomas and Harden approach and the credibility of the research results was evaluated by the CERqual tool. Six thousand five hundred forty-nine findings were yielded through the search, ultimately 11 studies were included through screening, a total of 194 stroke patients participated in the study, and 3 synthesized themes that emerged were identified: barriers to PA, facilitators to PA, and strategies to improve compliance with physical activity in stroke patients. All selected articles were of medium quality and all themes were of medium or high quality. The experience of PA among stroke patients should be given more attention. Healthcare professionals should provide physical activity-related knowledge education, social support, personalized care, improved environments, and create more opportunities for PA. In the future, more tailored interventions should be carried out to develop PA habits and improve compliance.

Removable partial dentures: Part 3.

The provision of removable partial dentures (RPDs) is an important skill for practitioners and it can often be challenging to make a successful prosthesis which the patient finds satisfactory. This three-part series has been designed to provide an overview of the clinical management of patients requiring RPDs. This final part describes more complex techniques that may be faced by dentists with additional training or experience in fixed and removable prosthodontics. These scenarios include the use of precision attachments to provide additional retention for an RPD, swinglock dentures to aid retention in cases with unfavourable tooth or alveolar undercuts, and sectional dentures for patients with challenging paths of insertion. For each clinical technique, the advantages, disadvantages and indications are summarised.

Combating Antimicrobial Resistance Through a Data-Driven Approach to Optimize Antibiotic Use and Improve Patient Outcomes: Protocol for a Mixed Methods Study.

It is projected that drug-resistant infections will lead to 10 million deaths annually by 2050 if left unabated. Despite this threat, surveillance data from resource-limited settings are scarce and often lack antimicrobial resistance (AMR)-related clinical outcomes and economic burden. We aim to build an AMR and antimicrobial use (AMU) data warehouse, describe the trends of resistance and antibiotic use, determine the economic burden of AMR in Uganda, and develop a machine learning algorithm to predict AMR-related clinical outcomes. The overall objective of the study is to use data-driven approaches to optimize antibiotic use and combat antimicrobial-resistant infections in Uganda. We aim to (1) build a dynamic AMR and antimicrobial use and consumption (AMUC) data warehouse to support research in AMR and AMUC to inform AMR-related interventions and public health policy, (2) evaluate the trends in AMR and antibiotic use based on annual antibiotic and point prevalence survey data collected at 9 regional referral hospitals over a 5-year period, (3) develop a machine learning model to predict the clinical outcomes of patients with bacterial infectious syndromes due to drug-resistant pathogens, and (4) estimate the annual economic burden of AMR in Uganda using the cost-of-illness approach. We will conduct a study involving data curation, machine learning-based modeling, and cost-of-illness analysis using AMR and AMU data abstracted from procurement, human resources, and clinical records of patients with bacterial infectious syndromes at 9 regional referral hospitals in Uganda collected between 2018 and 2026. We will use data curation procedures, FLAIR (Findable, Linkable, Accessible, Interactable and Repeatable) principles, and role-based access control to build a robust and dynamic AMR and AMU data warehouse. We will also apply machine learning algorithms to model AMR-related clinical outcomes, advanced statistical analysis to study AMR and AMU trends, and cost-of-illness analysis to determine the AMR-related economic burden. The study received funding from the Wellcome Trust through the Centers for Antimicrobial Optimisation Network (CAMO-Net) in April 2023. As of October 28, 2024, we completed data warehouse development, which is now under testing; completed data curation of the historical Fleming Fund surveillance data (2020-2023); and collected retrospective AMR records for 599 patients that contained clinical outcomes and cost-of-illness economic burden data across 9 surveillance sites for objectives 3 and 4, respectively. The data warehouse will promote access to rich and interlinked AMR and AMU data sets to answer AMR program and research questions using a wide evidence base. The AMR-related clinical outcomes model and cost data will facilitate improvement in the clinical management of AMR patients and guide resource allocation to support AMR surveillance and interventions. PRR1-10.2196/58116.