BACKGROUND AND HYPOTHESIS Kidney replacement therapy (KRT) practices in Europe are heterogeneous, with apparent differences between Western and Central/Eastern Europe. However, time trends in KRT incidence and prevalence in Central and Eastern Europe are not previously reported. Therefore, we aimed to describe trends in incidence and prevalence of KRT in Central and Eastern Europe from 2010 to 2021. METHODS Data on incident and prevalent KRT patients from 19 Central and Eastern European countries between the years 2010 and 2021 were derived from the European Renal Association (ERA) Registry. Time trends were calculated using JoinPoint regression. RESULTS Overall, KRT incidence increased with 1.5% (95% confidence interval (CI): +0.7 to + 2.6%) per year from 106.3 per million population (pmp) in 2010 to 119.6 pmp in 2019. However, trends differed within the region. While in Bosnia and Herzegovina KRT incidence significantly decreased from 2010 to 2019, it remained stable in nine and increased in eight countries. The overall KRT prevalence increased with 5.1% (95% CI: +4.5 to + 5.7%) per year from 426.2 pmp in 2010 to 651.2 pmp in 2019. KRT prevalence increased in all countries, except for Belarus where it remained stable, and was mainly attributable to increases in the prevalence of kidney transplantation. The COVID-19 pandemic did not have a major impact on KRT incidence and prevalence in the region, as most trends remained until 2021. CONCLUSIONS Although we found an overall increase in KRT incidence and prevalence in the region, large country variations remain, much larger than observed in Western Europe. The results of this study can help to define country-specific priorities for the optimization of KRT care in Central and Eastern Europe.

The growth of medical tourism has contributed to the expansion of dental tourism. With the rise of tourism in Albania, dental tourism has similarly progressed. This research aims to evaluate the quality of dental tourism services in Tirana, applying fuzzy methods such as CRITIC (CRiteria Importance Through Intercriteria Correlation) and CoCoSo (Combined Compromise Solution). These two methods were integrated into a hybrid approach, as described in this paper. Seven experts evaluated dental practices using linguistic values. The CRITIC method results indicated that, among the ten criteria, the most significant was the variety of services. According to the CoCoSo method, Biodent Denti e Sorrisi, Diamond Dental, and Dental Med Austria practices demonstrated the highest quality in dental tourism services. As research results indicate, these clinics could serve as models for improving dental tourism in Albania through a focus on quality development.

Non-small cell lung cancer (NSCLC) remains the leading cause of cancer mortality worldwide; however, precision oncology has fundamentally transformed its treatment landscape. In 2025, seven approvals by the U.S. Food and Drug Administration (FDA) further accelerated biomarker-driven care across critical molecular subsets. These include MET-directed and trophoblast cell-surface antigen-2 (TROP-2) antibody-drug conjugates (ADCs), expanded strategies targeting epidermal growth factor receptor (EGFR), notably those addressing exon 20 insertion mutations, a ROS proto-oncogene 1 (ROS1) inhibitor, and various human epidermal growth factor receptor 2 (HER2) options that encompass both tumor-agnostic and mutation-selected approaches. These advancements underscore the necessity for integrated diagnostics-such as next-generation sequencing (NGS), fluorescence in situ hybridization (FISH), and immunohistochemistry (IHC)-while also emphasizing ongoing challenges in biomarker selection, therapeutic sequencing, and equitable global implementation.

ABSTRACT Introduction Interindividual variability in drug response remains a significant clinical challenge, leading to therapeutic failure and toxicity. Much of this variability is unexplained by classical host-centric pharmacokinetic (PK) models, highlighting a critical gap in understanding of drug disposition. This review addresses this gap by establishing the gut microbiome as an important determinant of drug fate. Areas covered This narrative review with scoping approach examines how microbial enzymes affect therapeutics through comprehensive analysis of mechanistic and clinical studies. Key examples discussed include irinotecan, digoxin, and sulfasalazine. We highlight specific situations where the influence of gut bacteria is particularly significant, such as with low-bioavailability drugs and in patients with an ileocolonic anastomosis, where gut bacteria directly impact drug absorption and metabolism. Additionally, we address the limitations of current PK models and explore the potential of new integrated approaches. Expert opinion We propose that the gut microbiome should be recognized as a ‘fifth pillar’ of PKs. This shift in perspective is crucial for advancing personalized medicine. In this new model, a ‘PK profile card’ integrating microbial, genomic, and clinical data will help guide dosing. We anticipate microbiome analysis to become a standard clinical tool to optimize drug efficacy and safety.

Abstract Introduction Emergent intracranial stenting (EIS) is increasingly employed in the context of the acute ischaemic stroke treatment, but requires intraprocedural antiplatelet therapy (APT), which may raise haemorrhagic risk. This study aimed to evaluate the safety and effectiveness of different APT regimens during EIS. Patients and methods This is a subanalysis of the RESISTANT registry, which is a multicenter retrospective registry of patients with acute ischaemic stroke treated with intracranial EIS between 2016 and 2023. Patients receiving intraprocedural antithrombotics were included. Primary efficacy outcomes were stent patency (intraprocedural and within 24 hours) and 3-month mRS. Secondary outcome was successful reperfusion (modified thrombolysis in cerebral infarction ≥ 2b), and the safety outcome was sICH. Multivariable and propensity score-matched analyses were performed. Results Among 827 patients, 4 APT strategies were identified: single APT (n = 102), oral dual antiplatelet therapy (dAPT) (Aspirin + Clopidogrel or Ticagrelor; n = 83), Cangrelor (n = 92) and GP IIb/IIIa inhibitors (GPi) (n = 550). Intravenous agents (Cangrelor/GPi) showed a trend towards lower risk of intraprocedural stent occlusion compared to oral dAPT (adjusted odds ratio [aOR] 0.30, [95% CI, 0.09–1.01], P = .053), though this did not reach statistical significance. GP IIb/IIIa inhibitors continued to demonstrate a protective trend at 24 hours (aOR 0.25, [95% CI, 0.06–0.99], P = .047), without a significant increase in sICH. Both intravenous agents were independently associated with higher odds of successful final reperfusion (odds ratio [OR] 4.35, [95% CI, 1.57–12.09], P = .001). No significant differences emerged between GPi and Cangrelor in matched analysis. No significant difference was observed on good functional outcome between APT strategies. Conclusion In the setting of EIS, intravenous APT agents (Cangrelor or GPi) were associated with improved stent patency and higher rates of successful reperfusion, without a significant increase in symptomatic haemorrhage.

Abstract Rationale Intra-arterial fibrinolytics may be used for distal remaining vessel occlusions after incomplete mechanical thrombectomy (MT). However, their efficacy in improving reperfusion in this specific clinical scenario is unclear. While better reperfusion may lead to improved clinical outcomes, additional fibrinolytics could also increase the risk of hemorrhagic complications. Aim To assess the safety and reperfusion efficacy of intra-arterial tenecteplase (TNK) compared to no further interventional treatment in patients with incomplete reperfusion and mechanically non-amendable residual occlusions after MT. Methods and design This is an international, multicenter, randomized (1:1) controlled, two-arm, open, assessor-blinded, surrogate endpoint trial. The interventional arm receives 3 mg (not weight-adjusted) intra-arterial TNK, administered as close as possible to the residual occlusion. The control arm receives no further interventional treatment. Sample size TECNO will randomize 156 participants 1:1 to 3 mg intra-arterial tenecteplase or no further interventional treatment. This sample size is based on anticipated absolute improvements in early and late reperfusion with intra-arterial TNK of 25% and 30%, respectively. Outcomes The two co-primary imaging outcomes are early and late reperfusion. Early reperfusion is defined as an extended Thrombolysis in Cerebral Infarction (eTICI) score ⩾ 2a for residual occlusions on angiography 25 min after randomization. Late reperfusion is defined as the absence of a wedge-shaped perfusion delay on delay-sensitive perfusion maps assessed on 24 h ± 6 h perfusion imaging. Standard secondary clinical outcomes will be assessed at 24 h and 90 ± 15 days. Discussion The TECNO trial will provide evidence on the safety and reperfusion efficacy of locally administered intra-arterial TNK in patients with residual occlusions following MT.

Abstract Background The no-reflow phenomenon, characterized by impaired microvascular reperfusion despite successful macrovascular recanalization, has been identified as a potential contributor to poor outcomes in acute ischemic stroke (AIS) treated with endovascular therapy (EVT). This systematic review and meta-analysis aimed to assess the prevalence and clinical impact of no-reflow phenomenon in AIS patients undergoing EVT. Methods We conducted a systematic review and meta-analysis of randomized controlled trials (RCTs) and observational studies reporting the no-reflow phenomenon after EVT. Databases searched included PubMed, Embase, and CENTRAL (inception to February 9, 2025). Outcomes included no-reflow prevalence, functional outcomes (mRS), early neurological recovery, infarct volume, hemorrhagic complications, and 90-day mortality. Pooled risk ratios (RR) or mean differences (MD) were calculated using random-effects meta-analysis, and heterogeneity was assessed with I2. Results Eight studies (n = 1483 patients) were included. The pooled prevalence of no-reflow was 20.5% (95% CI 6.2%–49.9%; I2 = 96.9%). Compared with controls, patients with no-reflow had reduced early neurological recovery (RR 0.76; 95% CI 0.64–0.90) and increased risk of hemorrhagic transformation (RR 1.82; 95% CI 1.18–2.79) and symptomatic intracranial hemorrhage (RR 1.88; 95% CI 1.00–3.56). Differences in functional independence (mRS 0–2) and mortality were not statistically significant. Subgroup analyses based on study design revealed divergent patterns, particularly for infarct volume, which was significantly greater in no-reflow patients in post-hoc RCTs but not in the overall analysis. Conclusion No-reflow affects one in five EVT-treated patients and is associated with adverse neurological and hemorrhagic outcomes. Findings highlight the need for standardized definitions and prospective trials to clarify its clinical impact.

Abstract Introduction Covert brain infarctions (CBIs) are associated with cardiovascular risk factors (cvRFs). We aimed to evaluate the presence and therapeutic implications of modifiable cvRFs in patients with incidentally discovered CBI on routine neuroimaging. Patients and methods The SILENT cohort (NCT05685069) is a prospective, multicentred European cohort recruiting patients with incidentally detected focal CBIs on routine MRI, without prior clinical stroke. Modifiable cvRFs and their control were assessed using applicable international guidelines during a dedicated outpatient visit, including a clinical examination and laboratory work-up. Associations between cvRF profiles and the number of CBIs were analysed using linear regression. Results We included 231 patients (mean age 65 years, n = 130 [56%] male) with a total of 445 CBI lesions. Most CBIs were of lacunar type (n = 226; 51%) and the most common location was the cerebellum (n = 220; 50%). One hundred and fifty (65%) patients had at least 1, 112 (49%) at least 2 and 56 (24%) at least 3 known modifiable cvRFs. Among hypertensive patients, 69 (53%) had uncontrolled hypertension; 22 (65%) of diabetics were insufficiently controlled and 74 (58%) patients with dyslipidaemia had poorly controlled low-density lipoprotein cholesterol. Therapeutic measures were made for 144 patients (62%), including antiplatelet initiation in 107 (46%) and a statin in 69 (30%). The number of cvRFs per patient was significantly associated with the number of CBIs, rate ratio 1.08 (95% Confidence Interval (CI), 1.04−1.13). Conclusion In patients with incidentally discovered CBI, we found a high burden of poorly controlled cvRFs. Our findings highlight the importance and yield of a dedicated clinical and laboratory assessment of cvRFs in patients with CBIs.

For patients presenting with non-ST-elevation acute coronary syndrome (NSTE-ACS) who are not considered to be at very high mortality risk at the time of admission, current clinical guidelines advocate for coronary angiography (CAG) to be performed during hospitalization. Therefore, in these patients, introduction of novel non-invasive methods for prediction of severity of coronary artery disease is needed in order to identify patients who could benefit from CAG earlier during their hospital stay. The aim of this study was to evaluate the association between severity of CAD and echocardiographically assessed global longitudinal strain (GLS) and post-systolic shortening (PSS) of left ventricular myocardium in patients with NSTE-ACS. This prospective cross-sectional study included patients admitted to the cardiology clinic with the diagnosis of NSTE-ACS. Inclusion criteria were: preserved left ventricular ejection fraction (>50%), absence of regional wall motion abnormalities and indication for CAG set by interventional cardiologist and performed during the hospital stay. Patients who were estimated to be at very high mortality risk were excluded from the study. In addition to conventional echocardiography parameters, post-systolic shortening index (PSI), LAD specific PSI (PSI-LAD) and GLS were measured. PSI was calculated as the average PSS across all 17 myocardial segments, generated from strain curves, while PSI-LAD was calculated as the average PSS across 10 myocardial segments vascularized by LAD. The severity of CAD was assessed using the SYNTAX score. Significant coronary artery stenosis was defined as ≥90% narrowing in one of the three main epicardial arteries. Among the 70 enrolled patients, 45.7% (n=32) were diagnosed with unstable angina, while 54.3% (n=38) were diagnosed with NSTEMI. There was a significant positive correlation between SYNTAX score and both GLS (rho=0.504; p<0.001) and PSI (rho=0.249; p=0.035). Patients with significant LAD stenosis had higher GLS values (-14.88±2.53% vs. -17.02±3.23%, p=0.001) and higher PSI-LAD values (10.65 [3.13–18.53] vs. 4.2 [2.53–8.3], p=0.015) compared to those without significant LAD stenosis. GLS emerged as an independent predictor of significant stenosis on one of three main epicardial arteries (p=0.001; OR 1.43; 95% CI: 1.16–1.76). Both PSI-LAD and GLS demonstrated significant predictive value for LAD stenosis, with AUCs of 0.672 (p=0.020) and 0.675 (p=0.019), respectively. In addition to other known clinical factors, GLS and PSI may serve as feasible non-invasive echocardiographic parameters for additional risk stratification in NSTE-ACS patients who are not at very high risk. These measures could help identify individuals who might benefit from earlier CAG during hospitalization. Further research is warranted to develop precise risk assessment models incorporating these parameters.

Background/Objectives: Southeastern Europe and Croatia have served as a genetic crossroads between the Near East and Europe since prehistoric times, shaped by numerous and repeated migrations. By integrating 19 newly generated ancient genomes with 285 previously published ancient genomes from Croatia, we investigated patterns of maternal and paternal landscapes from the Neolithic, Bronze, and Iron Ages through to the Antiquity and medieval periods, as well as the modern Croatian population. Methods: Ancient DNA extraction from human remains and library preparation were conducted in dedicated clean-room facilities, followed by high-throughput sequencing on the Illumina platform. Sequencing data were analyzed with established pipelines to determine mitochondrial and Y-chromosomal haplogroups and the genetic sex of individuals. Results: New ancient data reveal a predominantly European maternal profile, dominated by haplogroups H, U, and HV0, whereas Y-chromosomal lineages are characterized by J subclades and R1a, with limited representation of R1b and the absence of I2a. When combined with published ancient Croatian genomes, the results reveal similar haplogroup diversity and patterns, as well as the expansion of mtDNA haplogroup H over time and a substantial increase in Y-chromosome R1a and I2a haplogroup frequency from the prehistoric to the modern period. Conclusions: Although the analyzed samples are heterogeneous and originate from different historical periods, their genetic signatures conform to the broader patterns expected for the region. In a wider context, the ancient Croatian mitochondrial data reveal stronger genetic persistence from prehistory to modern times, unlike paternal lineages, which show significantly higher divergence.

Humans are exposed to environmental or occupational air pollution from combustion emissions in outdoor and indoor environments. Irrespective of the sources, combustion emissions are characterized by being a complex mixture of particles, volatile compounds and gases. The present systematic review summarizes results on DNA strand breaks measured by the comet assay in leukocytes, from studies on human exposure to traffic-related vehicle exhaust, biomass combustion and coke oven work environments. These exposures have in common the combustion of fuel, which generates particles and polycyclic aromatic hydrocarbons. Standardized mean differences (SMDs) have been calculated by random effects models. Meta-analyses show increased levels of DNA strand breaks in studies on traffic-related exhausts (SMD = 0.62, 95% CI: 0.36, 0.89, n = 21), biomass combustion (1.73, 95% CI: 0.72, 2.74, n = 10) and coke oven emission (0.84, 95% CI: 0.30, 1.37, n = 10). Studies from high-income countries have reported much smaller differences in DNA strand break levels than have studies from middle-income countries. These differences may be attributed to higher exposures related to less strict emission control, and more susceptible populations in middle-income populations; unrecognized confounding despite efforts to match subjects on traditional confounders; or higher risk of comet assay measurement bias and exposure misclassification. In conclusion, this systematic review and meta-analysis show that exposure to combustion-derived air pollution, with clear exposure gradients in terms of particulate matter or polycyclic aromatic hydrocarbons, is associated with increased levels of DNA strand breaks in human leukocytes.

Exposure to volatile organic compounds (VOCs) such as benzene, styrene, toluene and formaldehyde is associated with genotoxicity and increased risk of cancer. In this systematic review and meta-analysis, we have assessed the effects of VOCs exposure on levels of DNA strand breaks in leukocytes, measured by the comet assay, in human biomonitoring studies. The literature search led to 57 studies included in the review. Of these, 50 studies met the criteria to be used in the meta-analysis. Using standardized mean difference and 95% confidence interval (CI), the meta-analyses show increased levels of DNA strand breaks in subjects exposed to benzene (1.59, 95% CI: 0.94, 2.24), styrene (0.87, 95% CI: 0.23, 1.51), formaldehyde (0.39, 95% CI: -0.15, 0.92) and other organic solvents (2.14, 95% CI: 1.48, 2.81). Results originate mainly from studies on workers, with only a few studies on environmental benzene exposure. Subgroup analysis indicates that all studies combined from middle-income countries have a higher effect size (1.81, 95% CI: 1.26, 2.36, n = 28) than studies from high-income countries (0.87, 95% CI: 0.49, 1.24, n = 22). This difference between middle- and high-income countries may be due to differences in exposure levels or exposure assessment. However, this might not be the only reason, as sensitivity analysis indicates that effect sizes are at risk of comet assay measurement bias, as 78% (39 out of 50 studies) and 60% (30 studies) have not reported the use of assay controls and blinded analysis of samples, respectively. Relatively few studies have a high risk of bias due to an inadequate comet assay procedure description (14%, 7 studies) and exposure misclassification (16%, 8 studies). Limitations of the study were the differences in protocols, comet descriptors, exposure assessment and control for confounding factors among the studies. In conclusion, this systematic review and meta-analysis shows that exposure to VOCs - benzene, styrene, formaldehyde and others - is associated with increased levels of DNA strand breaks in human leukocytes.