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176 papers

Antibiotics in Veterinary Ophthalmology: Resistance, Stewardship, and Emerging Antibiotic-Sparing Strategies.

Sebbag L et al. · Jul 1, 2026

Antimicrobial resistance (AMR) is a growing challenge in veterinary ophthalmology, particularly in cases of bacterial keratitis, where progressive stromal infection can threaten vision and globe integrity within hours to days. This review synthesizes current evidence on pathogen distribution, antimicrobial susceptibility profiles, multidrug resistance (MDR) prevalence, and determinants of nonsusceptibility in veterinary patients, highlighting the emerging role of antibiotic-sparing alternatives. Across contemporary studies, Staphylococcus pseudintermedius, β-hemolytic streptococci, and Pseudomonas aeruginosa are consistently among the most frequently isolated pathogens. The highest MDR burdens are reported in referral populations and among methicillin-resistant staphylococci worldwide. Feline data remain comparatively limited but show regional variability in resistance patterns, while equine studies reveal temporal shifts in isolate distribution and a rising prevalence of methicillin-resistant organisms in tertiary settings. Recent topical antimicrobial exposure is the most consistently identified predictor of reduced culture positivity and elevated resistance rates in subsequent ocular isolates, highlighting the importance of early microbiologic sampling and judicious antibiotic use. Interpreting antimicrobial susceptibility testing (AST) in ophthalmology remains challenging because clinical breakpoints are generally derived from systemic dosing regimens, despite substantially higher, albeit transient, drug concentrations being achieved at the ocular surface following topical administration. Moreover, the ocular surface microenvironment, including tear proteins, inflammation, biofilm formation, and concurrent serum therapy, may substantially influence antimicrobial activity and therapeutic response. The review concludes with practical ophthalmology-specific stewardship recommendations, a One Health perspective on resistant ocular pathogens, and a forward-looking discussion of antibiotic-sparing adjuncts within a broader multimodal strategy to preserve antimicrobial effectiveness.

Medicine

Swedish Intensive Care Physicians' Attitudes Towards Withholding or Withdrawing Life-Sustaining Treatment in Critically Ill Children.

Ahlerup M et al. · Jul 1, 2026

Background Decisions to withhold or withdraw life-sustaining treatments for critically ill children are challenging. This study aims to identify Swedish intensivists' attitudes, values and experiences towards the decision-making process concerning withholding or withdrawal of life-sustaining treatment in critically ill children. Methods The nine intensive care units in Sweden that treated more than 10 children for more than 48 h during 2023 were approached. A web-based questionnaire on attitudes and experiences on end-of-life decision-making in critically ill children was distributed to the 360 physicians employed at the above-mentioned intensive care units. The results were analysed descriptively. Results Fifty-five answers were retrieved. The participating physicians were experienced, 93% having personal experience with end-of-life decision-making in children. The main findings were that the child's wishes were considered important or very important by 93% of respondents. The guardians' wishes were considered important or very important by 82% of respondents. Seventy-three percent of physicians considered it ethically acceptable to withdraw life-sustaining treatment against the patients' and guardians' wishes. To continue life-sustaining treatment without the patient's and guardian's consent was considered ethically acceptable by 26% of participants. Conclusions This study demonstrated that Swedish intensivists share common attitudes and values regarding most issues related to end-of-life decisions in critically ill children. However, there is variability in attitudes concerning patients' and guardians' wishes. Further studies concerning end-of-life decisions in critically ill children within a Nordic context are warranted. Editorial comment This survey study presents a sampling of views on pediatric intensive care withholding or withdrawing of treatment and from specialist physicians in one Nordic country.

Medicine

Sarcopenia Predicts Mortality and Hepatic Encephalopathy After TIPS in Older Adults With Cirrhosis and Improves Prognostic Scores.

Saltini D et al. · Jul 1, 2026

Background and aims The role of transjugular intrahepatic portosystemic shunt (TIPS) in older adults remains controversial because of limited risk-stratification tools. We aimed to assess whether sarcopenia and myosteatosis are independently associated with post-TIPS mortality and overt hepatic encephalopathy (OHE) in patients aged ≥ 70 years, and whether adding sarcopenia to established prognostic scores improves discrimination for post-TIPS mortality. Methods This multicenter retrospective study included 115 consecutive patients with cirrhosis aged ≥ 70 years undergoing TIPS for refractory ascites or secondary prophylaxis of variceal bleeding. Sarcopenia and myosteatosis were assessed by computed tomography at L3. Post-TIPS mortality and time to first OHE episode were analysed using Kaplan-Meier and Cox regression. Sarcopenia was integrated into established prognostic scores, and predictive performance was evaluated using time-dependent ROC analyses. Results Sarcopenia and myosteatosis were present in 60% and 80% of patients, respectively. During follow-up, 49% died and 45% developed OHE. Sarcopenia was independently associated with both mortality and OHE, whereas myosteatosis and adipose-tissue indices were not. Incorporating sarcopenia improved the discriminative performance of all scores, with MELD 3.0-sarcopenia showing the highest accuracy (AUC 0.845). Predicted survival probabilities clearly separated patients across MELD 3.0 categories according to sarcopenia status. For OHE, sarcopenia increased the risk while underdilated TIPS was protective, defining four distinct risk profiles. Conclusions Sarcopenia is highly prevalent and independently predicts both mortality and OHE after TIPS in older adults. Its integration into prognostic tools enhances risk stratification and supports individualised decision-making in this vulnerable population.

Medicine

'We Needed a Hell of a Lot More Support, the Emotional Side of It, the Physical Side of It. Every Side of It, We Just Didn't get It.' A Qualitative Study Exploring the Lived Experiences of Healthcare Services Following Discharge for People With a Total Laryngectomy and Their Families.

Watson LJ et al. · Jul 1, 2026

Introduction People with a laryngectomy (PwL) and their families commonly require sustained support from healthcare professionals. But the needs of PwL and their families once they return home following hospital discharge are not well understood. Moreover, community healthcare professionals are not specialists in laryngectomy; they work in pressurised environments and lack time and access to education and training. This could impact safety of care and overall adjustment to life after laryngectomy. To better support healthcare professionals in the community to offer a more tailored approach, we first need to understand the needs of PwL and their families. Aim This study aimed to understand the lived experience of healthcare services following discharge, including how services could improve, from the perspective of PwL and their families. Methods Semi-structured dyadic and individual qualitative interviews were conducted with PwL±family members. Participants were recruited purposively by clinicians from three head and neck centres in the UK. Interviews were audio-recorded, transcribed verbatim and analysed using Braun and Clarke's approach to reflexive thematic analysis. Results Nineteen interviews were conducted with seventeen PwL and thirteen family members. Three inter-related themes were established: 'Immediate Practical and Emotional Demands of Post-Discharge Life, 'I had no idea what to do…you don't know anything. What do I do?'; 'Learning to Cope and Find Acceptance in Everyday Home Life, 'It was just a matter of coming to terms with the fact that socially and physically I was not the same person I was… I cannot change this, so I don't worry about it, I just accept it.'; and Navigating Healthcare Services in the Post-Laryngectomy Journey, 'I understand it's, you know, it's exceptionally difficult to put it all together because there are so many different things…so many different departments all involved in everything.' Conclusion This study has highlighted a greater need for better support and intervention for PwL, and their families once discharged home after laryngectomy. Improved collaboration between healthcare professionals and services is needed, as well as better laryngectomy education and training for community healthcare professionals. Future research should focus on exploring how best to achieve this. What this paper adds What is already known on this subject People with a laryngectomy and their families experience devastating permanent changes to everyday life because of the long-term side effects of surgery. As such, they often require ongoing care following hospital discharge, however their needs are not well understood. What this study adds to existing knowledge This study improves understanding of the specific needs of people with a laryngectomy and their families following discharge after laryngectomy. Overall, people feel alone, anxious about equipment and safety and concerned about the need to carry out specialised care at home without specialist support. As such, they have identified a need for better collaboration between healthcare professionals and services involved in their care after laryngectomy. What are the potential or actual clinical implications of this work? There is a clear need for ongoing education and training for community healthcare professionals to build confidence and competence in managing people with a laryngectomy, particularly in non-specialist settings. Strengthening communication between acute, primary, and community care teams is also essential to ensure continuity of care and reduce gaps in service provision. Clinicians could seek to establish these networks within their local teams.

Medicine

Pre-Sport Cardiac Evaluation in Children: Detection of Risks Other Than Sudden Cardiac Death.

Öncül M et al. · Jul 1, 2026

Objective Sudden deaths may occur in children and adolescents due to unexpected cardiac problems during sports. This study aimed to screen for abnormalities that may lead to future morbidity in addition to the risk of sudden death and to investigate the importance of electrocardiography and echocardiography in detecting cardiac problems before sports license. Method Pediatric patients who visited the Pediatric Cardiology outpatient clinic of Malatya Training and Research Hospital between April 2022 and April 2024 to obtain a sports license report and who did not have any known heart disease before were included. Data were analyzed using SPSS 22.0. Results A total of 2432 patients were admitted to our hospital for pre-sport evaluation within 2 years. In 2089 of those, there were no known heart problems. Various heart problems were detected in 195 (9.3%) of the 2089 cases. In our study, 169 (8.1%) patients had echocardiography (ECHO) and 33 (1.7%) had electrocardiography (ECG) abnormality. Eight patients (0.3%) showed pathological findings on both ECHO and ECG. In addition, elevated arterial blood pressure was detected in three (0.14%). Of the cases with cardiac abnormality, 110 (56%) were male and 85 (46%) were female, and the average age was 12 (5-18). Conclusion Our study shows that approximately one out of every 10 patients in the population may have cardiological problems and 2.3% of these patients have major cardiac problems. Therefore, we recommend that all pediatric patients undergo a detailed cardiac evaluation at least once in the early stages of their lives.

Medicine

Outcomes of Liver Transplant Versus Partial Hepatectomy for Perihilar Cholangiocarcinoma Patients Requiring Arterial Reconstruction.

Poletto E et al. · Jul 1, 2026

Background and aims Liver resection (LR) and orthotopic liver transplantation (OLT) are therapeutic options for locally advanced perihilar cholangiocarcinoma (pCCA) requiring hepatic artery reconstruction (HAR). This study aimed to compare short- and long-term outcomes of LR and OLT. Outcomes were major vascular complications, 90-day mortality, overall survival (OS) and recurrence-free survival (RFS). Methods A cohort of patients undergoing LR with HAR from 10 Western centres was compared with an OLT cohort comprising patients who received or did not receive neoadjuvant chemoradiotherapy (NACR). Results 109 patients, 60 LR and 49 OLT (22 OLT no-NACR and 27 OLT NACR) were included. LR patients were older and had fewer Bismuth type 4 tumours (38.3% vs. 69.4%, p = 0.009). Positive margins (49.2% vs. 6.5%, p Conclusions LR and OLT for locally advanced pCCA had similar rates of major complications and post-operative mortality, but NACR was associated with increased vascular complications. Survival was difficult to compare in the groups due to their heterogeneity, but OLT, especially with NACR, seems to give better results than LR.

Medicine

Effects of Sedation, TEmperature and Pressure After Cardiac Arrest and REsuscitation on Major Adverse Kidney Events (STEPCARE-MAKE): A Protocol for a Pre-Planned Sub-Study of a Randomized Clinical Trial.

M KK et al. · Jul 1, 2026

Background Acute kidney injury (AKI) is a common and serious complication after cardiac arrest, affecting more than 30% of initially successfully resuscitated patients, with around 10% receiving Kidney Replacement Therapy (KRT). Currently, treatment options to prevent renal complications are limited. In this predefined sub-study of the Sedation, TEmperature and Pressure after Cardiac Arrest and REsuscitation (STEPCARE) trial, we evaluate the effects of sedation depth, fever management strategies, and mean arterial pressure (MAP) targets on the risk of major adverse kidney events (MAKE) in post-cardiac arrest patients. Methods STEPCARE-MAKE is a predefined prospective sub-study of the international, randomized clinical STEPCARE trial. The main trial will enroll 3500 patients and employs a 2 × 2 × 2 factorial design, randomizing participants across three interventions: (1) deep sedation for 36 h or minimal sedation, (2) fever management with or without a feedback-controlled device, and (3) MAP target ≥ 65 mmHg or ≥ 85 mmHg. The primary outcome is the composite outcome MAKE, which includes death from any cause by day 30, initiation of KRT, or persistent renal dysfunction, defined as the final creatinine value ≥ 200% of the baseline at the time of discharge from the primary hospital or at day 30, whichever occurs first. Differences between baseline and the highest in-hospital creatinine, baseline and the last measured in-hospital creatinine, baseline and 72-h creatinine, and baseline and the highest creatinine within 72 h will be reported as secondary outcomes. Conclusion The findings of this sub-study will provide new evidence on the renal effects of the STEPCARE trial interventions and may inform the future of individualized kidney-protective treatment approaches.

Medicine

Phenylalanine Versus Tyrosine (Pos. 367/332 in MCT1/MCT4) in the Substrate Binding Site Defines Affinity and Preferred Directionality of Human Monocarboxylate Transporters 1-4.

Menzel M et al. · Jul 1, 2026

Aim Human monocarboxylate transporters 1-4, MCT, are key for the lactate/H + exchange between glycolytic and oxidative cancer cells, white and red muscle fibers, or in the astrocyte-neuron shuttle. The common MCT transport mechanism involves three conserved residues, that is, a substrate-attracting Lys and a conformation-locking Asp/Arg salt bridge (positions 38 and 309/313 in MCT1). Yet, it remained unclear which sites define isoform-specific substrate affinity and preferred transport directionality. Methods Here, we analyzed structural differences in the binding sites of MCT1-4 and determined their impact on the biophysical transport properties and inhibitor binding using radiolabeled transport assays in yeast. Results We found differences in amino acid positions with sidechain hydroxyl groups. While the higher affinity MCT1 and MCT2 carry Phe/Ser-OH (pos. 367/371 in MCT1), the lower affinity MCT3 and MCT4 have Tyr-OH/Gly. Mutation of Phe/Ser-OH in MCT1 to Tyr-OH/Gly markedly decreased the affinity for lactate and pyruvate, while it did not change the affinity for propionate. The maximal transport velocity increased with decreasing affinity, and the preferred transport directionality shifted toward export. Likewise, replacing Met151 by Ala shifted transport bias possibly by eliminating conformation-stabilizing sulfur-aromatic interactions. Moreover, these mutations lowered the activity of the clinical candidate MCT1 inhibitor AZD3965 by three orders of magnitude providing insight into the molecular drug binding mode and explaining the strong preference for MCT1 over MCT4. Conclusions Together, subtle changes in the arrangement of sidechains in the MCT binding site determine basic monocarboxylate/H + transport properties that impact lactate-related physiology, namely cellular metabolism, reprogramming, and signaling.

Medicine

Effects of Green Tea Extract and (+)-Catechin Hydrate on Sperm Quality and Seminal Plasma Antioxidant Activity: An In Vitro Study in Rams.

Nabhani R et al. · Jul 1, 2026

Background Antioxidants have gained significant attention for improving sperm parameters. Green tea and catechin, known for their potent antioxidant properties, are particularly interesting in this context. Objective This study investigated the in vitro effects of green tea extract (GTE) and (+)-catechin on semen quality parameters of Arabi rams during chilled storage. Methods The pooled and diluted semen was divided and supplemented with GTE and (+)-catechin (50, 100, 150 and 200 µg/mL levels). The control group did not receive any supplements. Sperm quality and semen pH were evaluated at 1, 24, 48 and 72 h after storage. Seminal plasma MDA level was measured at 72 h of semen storage. Results Supplementation with GTE and (+)-catechin improved sperm motility more than control (p Conclusions GTE and catechin enhance semen parameters during chilled storage, with optimal effects at specific concentrations. High levels of GTE may negatively impact sperm quality, underscoring the importance of precise dosing in semen preservation.

Medicine

Establishing Expert Consensus on Competencies for Safe Ward-Based Postoperative Epidural Analgesia Management: Protocol for a Modified Delphi Study.

Lamprecht CC et al. · Jul 1, 2026

Postoperative epidural analgesia (EA) is an important analgesic strategy for selected surgical procedures. However, clinical practice and training vary across settings, and no consensus-based framework currently defines the competencies required for safe ward-based EA management. A modified Delphi study will establish expert consensus on competencies for ward-based postoperative EA management. Items derived from prior empirical work will be rated by experts across three Delphi rounds: two rounds in which experts rate the relevance of each item on a seven-point Likert scale with controlled feedback between rounds, followed by a third round in which experts rate the required competence level for included items using Miller's pyramid. The study is expected to generate consensus on essential competencies and their required level for safe ward-based postoperative EA management. The findings will inform the development of a competency-based training framework and may contribute to more consistent practice and improved patient safety.

Medicine