Journal of Clinical Medicine

Objective: The COVID-19 pandemic markedly altered social activity patterns, healthcare utilization, and the epidemiology of infectious diseases. However, its long-term impact on emergency otolaryngologic conditions remains incompletely understood. This study investigated long-term trends in emergency otolaryngologic conditions before, during, and after the COVID-19 pandemic using comprehensive data from a large urban emergency clinic in Osaka, Japan. Methods: All new otolaryngologic outpatients who visited the Chuo Emergency Medical Clinic (CEMC) in Osaka City between 2019 and 2024were retrospectively analyzed. Annual trends in absolute numbers and relative proportions of emergency otolaryngologic conditions were examined by anatomical region and disease category, using 2019 as the pre-pandemic baseline. Results: A total of 99,324 new otolaryngologic outpatients were analyzed. Overall emergency visits declined sharply to approximately half of baseline in 2020, followed by a gradual but incomplete recovery toward pre-pandemic levels by 2024. Most anatomical categories declined to 45-61% of baseline in 2020 and exhibited gradual yet incomplete recovery through 2023; in stark contrast, laryngeal conditions diverged sharply, surging beyond pre-pandemic levels after 2022. Acute infectious otorhinolaryngologic diseases fell to 23-50% of baseline in 2020 and showed variable recovery (69-103%) by 2024. Notably, laryngitis exceeded the baseline, reaching 132% in 2023, whereas epiglottic edema exhibited only a transient increase approaching the baseline in 2021. Non-infectious emergency conditions generally showed only a marginal decrease in 2020 and remained relatively stable throughout the study period, except for sudden sensorineural hearing loss (SSNHL), which dropped sharply to 39% of the baseline in 2020 and remained persistently reduced through 2024. Traumatic emergencies declined variably to 53-81% of the baseline in 2020, followed by an incomplete recovery, reaching only 55-69% by 2024. Conclusion: Emergency otolaryngologic conditions demonstrated heterogeneous recovery trajectories following the COVID-19 pandemic. While most infectious and traumatic conditions gradually but incompletely normalized, laryngeal conditions showed a distinct post-pandemic surge, and SSNHL remained persistently suppressed. These findings reveal heterogeneous, condition-specific recovery trajectories that reflect both genuine shifts in community pathogen burden, true traumatic incidence, and persistent alterations in healthcare-seeking behaviors, insights essential for resource allocation during future public health emergencies.

Background: Childhood and adolescent hearing loss affects not only communication and cognitive development but also motor skills and school participation. Consequently, it generates inequalities in learning and educational inclusion. Nevertheless, no systematic review has yet analyzed these differences from an inclusive education perspective. Methods: A systematic review with meta-analysis was conducted following PRISMA guidelines and registered in PROSPERO. Observational studies comparing physical fitness between children and adolescents with hearing loss and their hearing peers were included. Methodological quality was assessed using the Newcastle--Ottawa Scale, and standardized effect sizes were calculated with a random-effects model. Results: Five studies (n=404) were analyzed. Findings revealed significant differences in strength, agility, speed, and balance. Moreover, the meta-analysis showed a large standardized effect favoring hearing children (ES=-2.35; 95% CI: -3.34 to -1.37). Conclusions: Children and adolescents with hearing loss present significantly lower physical fitness, which may affect the planning of physical education activities if their capacities are misinterpreted. Implementing inclusive and adapted strategies within the school curriculum is essential to ensure equal opportunities, improve physical fitness, and promote educational equity.

Background: Sleeve gastrectomy is the most frequently performed bariatric procedure worldwide but is associated with the development of de novo gastroesophageal reflux disease (GERD). Hiatal hernia has been identified as a relevant anatomical factor in postoperative reflux, although most studies evaluate it dichotomously without analyzing whether its size influences GERD risk. The aim was to evaluate the association between preoperative hiatal hernia size and de novo GERD after sleeve gastrectomy. Methods: Retrospective, single - center, observational study of patients undergoing sleeve gastrectomy at Hospital Central Norte de Petroleos Mexicanos (2018 - 2025). Demographic and clinical characteristics, endoscopic classification of hiatal hernia size (small <2 cm, medium 2.1 - 4 cm, large >4 cm), and evidence of de novo GERD were analyzed using descriptive statistics, Fisher's exact test, odds ratio (=R) estimation with 95% confidence intervals (CI), and binary logistic regression. Statistical significance was set at p<0.05. Results: Fiftysix patients were included (mean age 48.3 {+/-} 8.1 years; 67.9% male). Hiatal hernia classification was conclusive in 46 patients (82.1%): 63.0% no hernia, 4.3% small, 30.4% medium, and 2.2% large. De novo GERD occurred in 14.0% of patients without preexisting GERD (6/43). No significant association was found between hiatal hernia size and de novo GERD (Fisher p=0.515). In the reduced logistic model, neither hiatal hernia (medium/large vs. absent/small; OR 3.47; 95% CI 0.50 - 29.43; p=0.207) nor age (OR 1.02; 95% CI 0.90 - 1.13; p=0.754) was significantly associated. No evaluated factor (sex, smoking, alcohol, age) reached significance. Conclusions: In this cohort, no statistically significant association was demonstrated between preoperative hiatal hernia size and de novo GERD after sleeve gastrectomy; however, the low number of events limits the ability to exclude a clinically relevant association. These findings are compatible with a multifactorial mechanism rather than with the isolated presence of this finding. Prospective studies with larger sample sizes and standardized reflux assessment instruments are required to confirm these results.

Background Olfactory dysfunction (OD) affects approximately 22% of the general population, yet children account for only around 2% of specialist olfactory clinic attendees -- a striking disparity that likely reflects systematic under-detection rather than lower disease prevalence. There are currently no internationally endorsed clinical guidelines governing the assessment of children with suspected OD. A recent international survey of 167 paediatric otolaryngologists across 36 countries found that more than half never perform psychophysical olfactory testing, a majority routinely order neuroimaging, and that multidisciplinary collaboration is largely lacking - findings that collectively motivate this consensus effort. Materials and Methods This is a prospectively registered, multi-round modified Delphi consensus study. A steering committee of seven international experts spanning paediatric otorhinolaryngology, chemosensory science, neuropaediatrics, and research methodology will generate an initial set of candidate consensus statements across 12 pre-defined clinical domains, derived from a structured narrative evidence review and practice-gap data. A panel of 15-25 international experts will vote anonymously over two to three sequential rounds using a 9-point Likert scale. Consensus is defined a priori as a median score [&ge;]7 with [&ge;]75% of panellists rating 7-9 and an IQR of [&le;]2. A post-Delphi virtual ratification meeting will follow voting rounds. Patient and Public Involvement (PPI) is embedded throughout: a family advisory group of 4-6 parents, caregivers, and young people with lived experience of paediatric OD, recruited in partnership with anosmie.org, will review candidate statements before Round 1, and PPI findings will inform statement framing before expert voting begins. This study was assessed using the Health Research Authority (HRA) online decision tool for England and found not to require NHS Research Ethics Committee (REC) review. The study will be conducted in accordance with the Research Governance Framework for Health and Social Care (2nd Edition). Discussion The final consensus statements and supporting methodology will be submitted for peer-reviewed publication. The study will be reported in compliance with the ACCORD and DELPHISTAR reporting standards for consensus methods. The protocol has been pre-registered prospectively on the Open Science Framework (OSF) prior to data collection.

Objectives: To assess how patients with non-valvular atrial fibrillation (NVAF) receiving oral anticoagulants are managed in routine primary care practice in Spain. Methods: This observational, descriptive study included patients with NVAF treated with oral anticoagulants for at least 6 months before enrolment and managed in primary care settings in Spain. The Barthel and ACTS questionnaires were administered to evaluate functional autonomy and treatment satisfaction, respectively. Results: A total of 1,901 patients were included: 428 received vitamin K antagonists (VKAs) and 1,473 direct oral anticoagulants (DOACs). Compared with patients receiving DOACs, those treated with VKAs were significantly older and had a higher prevalence of more hypertension. Mean treatment duration was 7.6 years for VKAs and 3.8 years for DOACs. Among patients receiving VKAs, 56.2% and 59.0% achieved good anticoagulation control according to the direct and Rosendaal methods, respectively. Patients in the DOAC group reported greater satisfaction across several domains, including perceived treatment benefits, lower impact on daily life, and overall positive treatment effect. Event incidence rates (per 1,000 person-years) were higher with DOACs than with VKAs for stroke (1.75; 95% CI 1.05-2.92), ischemic stroke (1.78; 95% CI 1.06-3.00), acute myocardial infarction (1.64; 95% CI 0.97-2.79), and major bleeding (3.68; 95% CI 1.81-7.46). Conclusions: In routine primary care practice in Spain, patient profiles and treatment duration varied by oral anticoagulant type. These differences may partly explain the higher rates of stroke and major bleeding observed with DOACs versus VKAs, despite greater treatment satisfaction among patients receiving DOACs.

Background Bethesda III thyroid nodules remain diagnostically indeterminate, and intraoperative frozen section is used selectively to support surgical decision-making. Its value in this specific cytological category is uncertain because a malignant result may be highly specific while non-malignant and non-definitive results may fail to exclude cancer. Objective To estimate the sensitivity and specificity of intraoperative frozen section for detecting malignancy in thyroid nodules with preoperative Bethesda III cytology. Methods The protocol was prospectively registered in PROSPERO (CRD420261416683). A systematic review was conducted in PubMed, Embase, Web of Science, Europe PMC, and the Cochrane Library. Studies were eligible when they reported a separable Bethesda III cohort, intraoperative frozen-section findings, and final histopathology. Frozen section was classified as positive only when malignancy was reported. Benign, suspicious, indeterminate, deferred, inconclusive, and follicular-pattern results were classified as non-malignant. Study-level 2 x 2 tables were synthesised with random-effects logit models. Because all studies reported zero false-positive results, a full bivariate model with freely estimated covariance was not identifiable; a pseudo-bivariate HSROC approximation was therefore used. QUADAS-2 was used for risk-of-bias assessment. Results Ten studies comprising 1,069 Bethesda III patients or nodules were included. The pooled sensitivity was 43.1% (95% CI, 21.3-67.9) and the pooled specificity was 98.8% (95% CI, 97.0-99.5). Sensitivity was highly heterogeneous (Q = 83.45, I2 >90%, T2= 2.15), whereas specificity showed negligible between-study variance. Excluding Mao 2023 reduced pooled sensitivity to 35.6% (95% CI, 23.8-49.5) and reduced sensitivity heterogeneity to moderate levels (Q = 12.44, I2 = 36%, T2 = 0.25); specificity remained 98.7% (95% CI, 96.7-99.5). The approximate HSROC AUC was 0.89 including Mao 2023 and 0.87 excluding Mao 2023, but these values were driven largely by the uniformly high specificity. Conclusions Intraoperative frozen section in Bethesda III nodules has excellent specificity but limited and variable sensitivity. It is more suitable as a rule-in test than as a rule-out test. A non-malignant or non-definitive result should not be used alone to exclude malignancy or determine the extent of thyroid surgery.

Introduction. Hypertrophic cardiomyopathy (HCM) is characterized by clinical and genetic heterogeneity. Age of manifestation, clinical and anatomical phenotypes of HCM vary significantly. This study discusses genetic causes and reconstructive surgery results for patients with particular intracardiac phenotype - diffused generalized HCM (DG-HCM). Methods: personal and familial medical history, general examination, 12-lead resting ECG, 24-hour ECG Holter monitoring, transthoracic and transesophageal EchoCG, cardiac MRI with gadolinium enhancement. A ten-gene panel was sequenced by IonTorrent PGM. Mutational screening in patients with suspected multisystemic diseases was performed by Sanger sequencing. Results: 170 patients with obstructive HCM (oHCM) requesting genetic counseling and surgical correction of HCM were evaluated. We distinguished particular DG-HCM subtype of oHCM (diffuse hypertrophy of IVS, LV free walls, papillary muscles displaced towards the LV apex) in 34 patients; 31 out of 34 underwent open heart reconstructive surgery. Patients with DG-HCM were younger at the time of surgery, had higher risk of SCD, and connective tissue dysplasia of the mitral valve. Hemodynamics normalization was observed in 1, 3, and 5 years after surgery. Eighteen ICDs were implanted; five patients experienced appropriate shocks. The genetic spectrum was enriched up to 30% by multisystem disorders. Mutations in "sarcomeric" genes were detected in 15%. Conclusion: Intracardiac phenotype of HCM may correlate with genetic cause and long-term prognosis. DG-HCM phenotype accounts for 20% oHCM patients and indications for open-heart surgery. Extended myectomy with parietal resection of papillary muscles and correction of mitral valve insufficiency provides long-term benefits for DG-HCM patients. Multisystem disorders in patients with DG-HCM should be of special attention. Study was supported by research project FURG-2024-0004.

Background: Olfactory dysfunction is a recognised but poorly characterised comorbidity of Primary Ciliary Dyskinesia (PCD). No prior systematic review has synthesised its prevalence or clinical correlates. Methodology: A PRISMA compliant systematic review and meta-analysis was conducted. Five databases were searched to February 2026. Observational studies reporting olfactory function in confirmed PCD were included. Risk of Bias was assessed using the Newcastle-Ottawa Scale. A random-effects meta-analysis using the Freeman-Tukey double arcsine transformation was performed to calculate pooled prevalence with 95% confidence intervals (CI) and prediction intervals (PI). Results: Twelve studies (n=865) were included. Overall pooled prevalence of olfactory dysfunction was 43.4% (95% CI 25.2-62.5%; 95% PI 0.1-99.0%). Objective psychophysical testing yielded a significantly higher pooled prevalence of 66.1% (95% CI 55.5-76.0%; 95% PI 38.4-88.9%) compared to patient-reported outcome measures (30.5%; 95% CI 11.4-54.0%). Older age, greater sinonasal disease burden, and specific ciliary ultrastructural defects were associated with worse olfactory function. A striking discordance between objective dysfunction and subjective awareness was observed across multiple studies. Conclusions: Olfactory dysfunction is highly prevalent in PCD and substantially under-recognised by patients. Routine objective olfactory screening should be integrated into standard multidisciplinary PCD care.

Objective. Older adults undergoing cardiac surgery may be vulnerable to postoperative cognitive decline. However, no studies have examined postoperative cognitive outcomes in older patients with cardiovascular disease (CVD) according to preoperative mild cognitive impairment (MCI). This study examined 12-month postoperative cognitive outcomes in older CVD patients according to preoperative MCI diagnosis and explored predictors of postoperative cognitive decline. Method. Twenty-two older CVD patients ([&ge;]65 years) and twenty-five controls were included. Neuropsychological assessment was conducted at baseline in both groups and repeated 12 months after surgery in the CVD group. MCI was diagnosed using current clinical criteria. Postoperative cognitive change was examined across preoperative MCI groups. Results. Fifty percent of patients met criteria for postoperative MCI, showing high diagnostic stability relative to preoperative frequency (45.5%). The preoperative CVD-MCI group showed a decline in working memory, executive functions, visual memory, and naming, whereas CVD-nMCI group declined only in verbal memory. Furthermore, CVD-MCI showed more heterogeneous postoperative cognitive trajectories of change than CVD-nMCI, who showed stability. Estimated IQ, APACHE-II score, and postoperative frailty were important variables in predicting the postoperative pattern. Conclusions. MCI frequency remained high and stable in older CVD patients across the preoperative and one-year postoperative period. However, this apparent diagnostic stability masks subclinical cognitive decline, particularly among patients with preoperative MCI, who showed greater susceptibility to further impairment. Estimated IQ, APACHE-II score, and postoperative frailty may be considered relevant predictors of outcome. These results highlight the value of preoperative neuropsychological assessment for characterizing postoperative cognitive risk in older CVD patients.

Background: Early access to pregnancy assessment units now detects many tubal ectopic pregnancies (TEP) at a stage when they could resolve spontaneously, creating a management dilemma. Methods: We performed a hypothesis-generating exploratory analysis in a retrospective study to assess whether serum progesterone (P4) levels in women with TEP are associated with management outcome. Results: Ninety-one cases of TEP managed in a single centre over three years were analysed. Receiver operating characteristic (ROC) curve analysis was used to explore serum levels of progesterone (P4), first human chorionic gonadotropin (hCG) and peak hCG (alone and in combination) in relation with successful completion of expectant management. Decision-tree analysis using first hCG and P4 was additionally performed to explore clinical sequential risk stratification. 23% (n=21) successfully completed expectant management. P4 concentrations in the expectant management group (median 3 nmol/L, IQR 2.00 to 8.50) were significantly lower than in those requiring surgical or medical management (median 17 nmol/L, IQR 5.75 to 29.25; p=0.0002). Area under the ROC curve (AUC) values for P4, log10 first hCG, log10 peak hCG and P4 with log10 first hCG were 0.766, 0.814, 0.811 and 0.835, respectively, for predicting successful expectant management. However, hCG was not significantly outperformed. Nonetheless, Youden optimised thresholds for hCG and P4 are reported, alongside decision-tree analysis that identified sequential first hCG and P4 thresholds associated with successful expectant management. Conclusion: Lower P4 levels are associated with successful expectant management of TEP but they do not outperform hCG either alone or as an adjunctive marker.

It has been previously shown that chronic social defeat stress caused by paired agonistic interactions between male mice is accompanied by the development of depression-like state and immune deficiency. The aim of this study was to investigate changes in the expression of C1qtnf superfamily genes (encoding the complement component related with tumor necrosis factor) in the hypothalamus, thymus and lungs against the background of the Lewis lung adenocarcinoma growth. In the experiments, on the 5th day of social stress, male mice were injected with tumor cells into the tail vein. Chronic social stress continued for the next two weeks. The transcriptomes of the hypothalamus, thymus and lungs of mice were sequenced at the Genoanalytica Collective Center (http://genoanalytica.ru/, Moscow). Changes in the expression of the C1qtnf genes in the tissues of stressed mice were studied compared with the control and mice that were additionally injected with tumor cells. Overall, significant correlations were found between expression of most genes in each tissue of the experimental groups. In the hypothalamus of stressed animals, when tumor cells were introduced, an increase in the expression of the genes C1qtnf1, C1qtnf2, C1qtnf3, C1qtnf6 and C1qtnf7 was observed compared to controls. In the thymus of these animals, tumor cell injection increased expression of the C1qtnf1, C1qtnf5, and C1qtnf6 genes. In the lung of tumor-injected stressed mice, expression of the C1qtnf1, C1qtnf2, C1qtnf7, and C1qtnf9 genes was decreased relative to controls and non-tumor-injected depressed mice, reaching near-zero levels in some mice. Analysis of C1qtnf superfamily gene expression in the all tissues revealed negative correlations between the expression of the C1qtnf1, C1qtnf2, and C1qtnf7 genes in the hypothalamus and lungs indicating synchronization of processes against the background of social stress and Levis lung adenocarcinoma.

Objective: To evaluate the rate, timing, and predictors of additional therapy among women with idiopathic overactive bladder (OAB) following initial minimally invasive treatments (MIT). Study Design: Retrospective single center cohort study of women with idiopathic OAB treated between 2012 and 2021. Using ICD and procedural codes, we identified women who underwent posterior tibial nerve stimulation (PTNS), sacral neuromodulation (SNM), or intradetrusor onabotulinumtoxinA (BTX). The primary outcome was receipt of additional OAB treatments,OAB medication initiation or a different MIT. Kaplan-Meier analysis estimated time to additional therapies; Cox proportional hazards and random survival forest models identified predictors. Results: 1,007 women were included (PTNS: 459; SNM: 192; BTX: 356). At three years, 75% of PTNS patients, 58% of BTX patients, and 40% of SNM women required additional therapies with most patients choosing additional pharmacotherapy rather than crossover to a different MIT. Median time to additional treatments was 10 months (PTNS), 19 months (BTX), and 53 months (SNM). Higher BMI was associated with increased risk of further treatment after SNM (HR 2.1, 95% CI: 1.1-4.2), while recurrent urinary tract infections were associated with needing additional therapies in the BTX cohort (HR 1.8, 95% CI: 1.1-3.2). Random survival forest models resulted in poor model performance. Conclusions: Following initial MIT for idiopathic OAB, many women required additional treatment within three years, many choosing pharmacotherapy rather than transition to another MIT.

Objective: To test the hypothesis that body mass index (BMI) replaces sex as the core risk factor for cholecystitis in plateau populations, and to characterize the true risk factor profile of gallstone patients at high altitude. Methods: A single-center retrospective cohort study included 605 elective laparoscopic cholecystectomy patients at Qinghai Red Cross Hospital (2,260 m; 2020-2023), categorized into simple gallstones (n=434) and gallstones with cholecystitis (n=171). Univariate analysis, multivariate logistic regression, nested model comparison, interaction analysis, and sensitivity analyses were performed. All statistics were independently recomputed using Python 3.11 and cross-validated against original statistical deliverables. Results: The original hypothesis was falsified. The cohort had a mean age of 43.7+/-11.8 years, BMI of 24.2+/-3.8 kg/m^2, female-to-male ratio of 2.10:1, and SBP of 117.4+/-15.8 mmHg. Multivariate logistic regression (adjusting for age, BMI categories, sex, SBP, and DBP) showed that SBP was the only significant positive predictor (OR=1.027/mmHg, 95%CI: 1.008-1.047, P=0.005), while BMI overweight (OR=1.038, P=0.856) and obesity (OR=0.645, P=0.137) were non-significant, as was sex (OR=0.814, P=0.322). Age showed a significant negative association (OR=0.978/year, P=0.007), constituting an "age paradox" with younger patients having higher cholecystitis rates (<30 years: 36.8% vs >=60 years: 25.0%; Spearman rho=-0.087, P=0.032), which may reflect selection bias or plateau-specific mechanisms. Nested model comparison showed that adding blood pressure to the classical model (age+BMI+sex, AUC=0.575) significantly improved discrimination (AUC=0.615, DeltaAUC=+0.040, 95%CI: +0.007 to +0.084; LR chi^2=8.19, P=0.017). SBP was non-significant in univariate analysis (OR=1.005, P=0.346) due to a suppression effect: age was a negative confounder, simultaneously increasing SBP and decreasing cholecystitis risk, thereby masking the true SBP effect. Conclusion: The risk weight of cholecystitis is remodeled in the plateau hypoxic environment, but in a direction opposite to the original hypothesis: SBP is the only significant positive predictor (P=0.049 in the SBP-only recommended model), while BMI and sex are non-significant, and age shows an inverse association. Blood pressure management should be integrated into the risk stratification system for plateau cholecystitis. The original hypothesis that BMI replaces sex is explicitly falsified.

Introduction Individuals with Gastroesophageal Reflux Disease (GERD) often experience airway inflammation and bronchoconstriction as a result of reflux aspiration and/or vagally mediated reflexes. The Impulse Oscillometry System (IOS) is a sensitive, non-invasive tool that can detect subtle changes in airway resistance. While there are few studies exploring airway resistance in GERD globally, no studies have been conducted in Sri Lanka. Therefore, we aim to compare the airway resistance using IOS in medical undergraduates with and without symptomatic GERD. Methods A cross-sectional study was conducted among 811 medical undergraduates (31.1% male; mean age 22.9 years) at the Faculty of Medicine, Rajarata University of Sri Lanka. Symptomatic GERD was screened using the validated GerdQ, and a cutoff of[&ge;]8 was used to diagnose those with GERD symptoms. Of the 242 (29.8%) with GERD symptoms, 188 with chronic respiratory diseases or recent respiratory symptoms were excluded, and 50 with GERD symptoms and 50 healthy, age- and sex-matched controls were recruited. Lung function was assessed using IOS and spirometry, according to American Thoracic Society (ATS) and European Respiratory Society (ERS) guidelines. Results Prevalence of symptomatic GERD among medical undergraduates was 29.8% (242/811). The common symptoms among GERD were heartburn (89.6%, 217/242) and regurgitation (85.5%, 207/242). Oscillometry parameters including, R5-R20 Hz (15.29% vs 9.69%, p=0.002), Fres (14.95 1/s vs 13.37 1/s, p = 0.04), and AX (0.66 vs 0.48, p = 0.02) were significantly higher in students with symptomatic GERD (mean = 15.29%) than in healthy controls (mean = 9.69%; p = 0.002). However, spirometry parameters including FEV1, FVC, and PERF did not differ between the GERD-positive and control groups. Conclusion Individuals with symptomatic GERD demonstrated a higher peripheral airway resistance compared to controls, whereas no significant difference was observed in upper airway resistance. This could be due to the gastric acid stimulation of vagal nerve terminations in the lower part of the esophageal wall, leading to increased resistance in the peripheral airways through vagally mediated bronchoconstriction.

Background Thoracoscopic esophagectomy with intrathoracic carbon dioxide insufflation and lung collapse, usually performed in the prone position, can markedly alter respiratory physiology and acid-base balance. Serum potassium elevation is often observed during acute respiratory acidosis in these procedures, despite the conventional view that respiratory acidosis has little effect on potassium. We quantified the intraoperative potassium change and explored associated factors. Methods This multicenter retrospective study included adults undergoing thoracoscopic esophagectomy with carbon dioxide insufflation in the prone or lateral decubitus position during 2022-2024. Arterial blood gas variables were evaluated after anesthesia induction and at the time of the lowest arterial pH during carbon dioxide insufflation. The primary outcome was the paired difference in serum potassium. Sensitivity, subgroup, and regression analyses were performed. Results All 131 patients were included: 117 in the prone position and 14 in the lateral decubitus position. Serum potassium increased from 3.96 {+/-} 0.38 to 4.59 {+/-} 0.63 mEq/L (mean increase, 0.64 mEq/L; 95% confidence interval, 0.55-0.73; p < 0.001). During the same period, pH decreased from 7.387 to 7.247 and arterial carbon dioxide tension increased from 41.48 to 58.60 mmHg. After excluding marked metabolic acidosis, the increase remained significant and similar in magnitude (0.618 mEq/L). In the centered multivariable model, lactate change was independently associated with potassium change ({beta} = 0.303; p = 0.004), whereas arterial carbon dioxide change and preoperative renal function were not. The intercept remained significantly positive. Conclusions A clinically meaningful potassium increase was observed during thoracoscopic esophagectomy with carbon dioxide insufflation, while acute respiratory acidosis developed during the same period. The increase persisted after excluding marked metabolic acidosis and may not be explained solely by metabolic stress. Arterial blood gas assessment, including potassium measurement, is warranted during significant hypercapnia, and potential electrolyte consequences should be considered when permissive hypercapnia is accepted.

Abstract Background: Metabolic dysfunction-associated steatotic liver disease (MASLD) is linked to obesity and cardiometabolic dysfunction, yet local prevalence data from Mexican first-level care units are scarce. We estimated the prevalence of MASLD by B-mode ultrasonography and characterized the clinical profile of obese adults in a family medicine unit in Leon, Mexico. Methods: Cross-sectional study of 55 adults with obesity (body mass index [BMI] >=30 kg/m2) registered at one medical office of a Mexican Social Security Institute family medicine unit (April-October 2024). Hepatic steatosis was graded by B-mode ultrasonography; MASLD was defined as ultrasonographic steatosis plus at least one cardiometabolic criterion (all participants met the obesity criterion). Prevalence was reported with Wilson 95% confidence intervals (CIs); associations with obesity grade were assessed by Cochran-Armitage trend and Fisher exact tests. Results: MASLD was present in 37 of 55 participants (67.3%; 95% CI, 54.1-78.2). Mild (grade 1) steatosis predominated (45.5%). Prevalence increased across obesity grades: 59.0%, 75.0%, and 100% for grades 1, 2, and 3, respectively (trend P=0.022). Type 2 diabetes and hypertension each affected 50.9% of participants; the sample was predominantly female (74.5%). Conclusion: Two of every three obese adults screened in primary care had ultrasonographic MASLD, with a significant rise across obesity grades. Opportunistic ultrasonography in obese primary-care patients may enable earlier MASLD detection. Keywords: Non-alcoholic Fatty Liver Disease; Fatty Liver; Obesity; Ultrasonography; Primary Health Care; Prevalence

Background: Early identification of complicated appendicitis is essential for appropriate management, yet accurate preoperative risk stratification remains challenging. Whether objective laboratory-based models can achieve predictive performance comparable to models incorporating clinical findings remains unclear. Objective: To compare clinical, laboratory-based, and combined clinical-laboratory prediction models for complicated appendicitis and to evaluate the incremental value of the Prognostic Nutritional Index (PNI). Methods: This retrospective study included 1,132 consecutive patients with acute appendicitis. Cases were classified as uncomplicated or complicated appendicitis based on pathological findings and imaging. Three multivariable logistic regression models were developed: a clinical model (Model A), a laboratory-based model (Model B), and a combined clinical-laboratory model (Model C). Model discrimination was assessed using the area under the receiver operating characteristic curve (AUC), and AUCs were compared using DeLong's test. Results: Complicated appendicitis was identified in 341 patients (30.1%). Higher C-reactive protein, higher neutrophil percentage, and lower PNI were independent predictors of complicated appendicitis. The AUCs were 0.791 for Model A, 0.847 for Model B, and 0.857 for Model C. Model B significantly outperformed Model A (P = 0.0020), whereas no significant difference was observed between Models B and C (P = 0.0816). PNI remained an independent predictor after adjustment for conventional inflammatory markers. Conclusion: A laboratory-based prediction model incorporating PNI demonstrated discrimination comparable to that of a combined clinical-laboratory model while relying exclusively on routinely available objective laboratory parameters. These findings support laboratory-based risk stratification as a practical adjunct to clinical assessment for the early identification of complicated appendicitis.

Objective: To evaluate the efficacy, engagement, and usability of Tune Out, an unguided, self-paced online tinnitus management program, for reducing tinnitus severity in adults with tinnitus. Design: A two-arm, parallel-group randomised controlled trial was conducted with Australian adults reporting diagnosed or self-reported tinnitus. Participants were randomised to immediate access to Tune Out or a waitlist control group. Outcomes were assessed at baseline, 6 weeks, and 12 weeks. The primary outcome was tinnitus severity measured using the Tinnitus Functional Index (TFI). Secondary outcomes included tinnitus handicap, psychological symptoms, program engagement, self-efficacy, and usability. Results: Eighty-eight participants were randomised: 43 to the intervention group and 45 to the waitlist control group. The primary outcome analysis included 63 participants at 12 weeks. A significant Group x Time interaction was observed for TFI total score, indicating greater reductions in tinnitus severity over time in the intervention group compared with waitlist control, F(2, 102.57) = 5.95, p = .004, partial 2= .104. Significant effects were also observed for tinnitus handicap, F(2, 106.76) = 4.12, p = .019, partial 2 = .072. Effects on psychological symptoms were less consistent, although anxiety showed a significant Group x Time interaction, F(2, 116.85) = 3.63, p = .030, partial 2 = .059. At 12 weeks, 23.1% of intervention participants achieved a clinically meaningful reduction in tinnitus severity compared with 5.4% of controls. Program use was highly variable, with a median use of 1.10 hours, and 25.6% of intervention participants recording no use. Usability ratings were favourable among respondents, with a mean System Usability Scale score of 73.13. Conclusions: Tune Out demonstrated preliminary efficacy for reducing tinnitus severity and tinnitus handicap compared with waitlist control. Effects on broader psychological symptoms were less consistent. Although usability was rated positively, low and variable engagement highlights the need for strategies to support uptake and sustained use in unguided digital tinnitus interventions.

Introduction Deafness is the most common human sensory deficit. Cochlear implantation is the primary intervention for severe-to-profound deafness. Currently, over 7000 people have bilateral cochlear implants (CIs) in the United Kingdom (UK), most of whom are children. Patient feedback suggests that for children with bilateral CIs, everyday communication is challenging and tiring, with extra effort required to integrate information from two ears, especially in noise, and that current rehabilitation techniques are not engaging, or appropriate to their lifestyles. To address these issues, researchers developed the Both EARS (BEARS) training package comprised of three virtual reality games to improve sound localization and listening in noise. Objectives This protocol describes the design and methodology of a multi-center phase III randomized controlled trial (RCT) to evaluate whether use of the BEARS training package alongside usual care compared to only receiving usual care improves speech-in-noise perception, hearing experiences, vocabulary and quality of life and reduces listening effort in children and young people (aged 8 -16 years (inclusive) with bilateral CIs. Methods This RCT is currently underway in 16 clinical CI departments in National Health Service or university hospitals across the UK. The intervention involves 3 months of spatial-listening training delivered via the BEARS training package in addition to any routine rehabilitation. The control is usual care (routine rehabilitation clinical care pathway). The primary outcome is the difference between the intervention groups in speech-in-noise perception score at 3 months derived from the spatial speech in noise (SSiN-VA) test. Recruitment closes at the end of the day on 31st July 2026, and end of data collection is 31st October 2026. Data analyses will be reported by 31st March 2026. Significance This is the largest known trial of children and young people with bilateral CIs. It will generate high-quality evidence on speech-in-noise outcomes and inform training interventions to improve spatial listening. Trial registration ClinicalTrials.gov registration: NCT05808543; UKs clinical study registry (ISRCTN92454702)

Background: Olfactory dysfunction (OD) is common in COVID-19 and in a small percentage of patients it can become persistent, substantially impacting on quality of life. Effective treatment options for persistent COVID-19-related OD (C19OD) remain limited. Functional septorhinoplasty (fSRP) can improve olfaction in persistent C19OD by increasing nasal airflow to the olfactory cleft and improving olfactory epithelium (OE) stimulation. However, this implies a retained and functioning OE in C19OD patients. This study evaluates the 12-month outcomes of fSRP and investigates the histopathological correlates supporting the role of nasal airflow improvement to restore olfaction. Methods: This observational cohort study enrolled 12 patients with persistent C19OD who underwent fSRP. Olfactory function (Sniffin Sticks TDI scores) and nasal airflow were assessed at baseline, 3, 6, and 12 months. Endoscopic olfactory mucosa biopsies were obtained at baseline from 8 patients for immunohistochemical analysis. Results: fSRP led to statistically significant and clinically relevant TDI improvements at 12 months (median improvement 8.0 from baseline, p<0.005) accompanied by sustained improvement of nasal airflow (p=0.01). Histological analysis showed the presence of immature and mature olfactory sensory neurons in 3 patients (37.5%). In one specimen, intact OE was identified containing horizontal basal cells, indicating preserved regenerative capacity more than two years post-infection. Conclusions: fSRP provides sustained clinical benefits for patients with persistent C19OD. The survival of sensory neurons and progenitor cells in the olfactory mucosa beyond two years suggests a biological substrate for olfactory recovery, which may be facilitated by surgically improved nasal airflow and OE stimulation.