Founded in 1994. The periodical scholarly journal Acta medica Lituanica is published by the Lithuanian Academy of Sciences in collaboration with the Faculty of Medicine of Vilnius University and the National Cancer Institute. It publishes papers on high quality research, mostly from Lithuania, the Baltic states, and Eastern Europe. Indexed in the Scopus database since 2021.
Vilniaus universiteto leidykla / Vilnius University Press
Copyright (c) 2026 Authors https://creativecommons.org/licenses/by/4.0
Antibiotic and Heavy Metal Resistance Profiles of Staphylococcus aureus Isolates from Hospitals
Background: Staphylococcus aureus is a major opportunistic pathogen in hospitals, where sustained exposure to antimicrobial agents and disinfectants promotes the emergence and persistence of resistant strains. In addition, tolerance to heavy metals may facilitate co-selection and long-term survival of resistant S. aureus in clinical settings. Purpose: This study investigated the occurrence of methicillin-resistant S. aureus (MRSA), vancomycin-intermediate S. aureus (VISA), and vancomycin-resistant S. aureus (VRSA), and evaluated antibiotic and heavy metal resistance profiles among S. aureus isolates recovered from hospitals. Materials and Methods: Seventy-nine bacterial isolates were collected from three hospitals. Identification using Gram staining and biochemical tests identified 71 S. aureus isolates. Resistance to antibiotics was determined by disk diffusion, and was quantified using the multiple antibiotic resistance (MAR) index. Resistance to heavy metals was assessed at increasing concentrations, and the multiple heavy metal resistance (MHMR) index was calculated. MRSA, VISA, and VRSA were screened using selective agar containing oxacillin and vancomycin. Cluster analysis was performed based on combined antibiotic and heavy metal resistance profiles. Results: High resistance rates were observed for penicillin and ampicillin (95.8% each), whereas most isolates showed low levels of resistance to chloramphenicol, bacitracin, streptomycin, kanamycin, and methicillin. MAR index values ranged from 0 to 0.88, with most isolates exceeding 0.2. All isolates exhibited resistance to multiple heavy metals, with MHMR values between 0.57 and 0.71, and marked tolerance to chromium and lead. Screening identified 9 MRSA, 3 VISA, and 1 VRSA isolate, including one strain classified as both MRSA and VRSA. Cluster analysis resolved nine major resistance-associated groups. Conclusion: Hospital-associated S. aureus isolates showed extensive antibiotic and heavy metal resistance, supporting the likelihood of co-selection of resistance traits. These findings underscore the importance of integrated antimicrobial stewardship and environmental control strategies in hospitals.
Copyright (c) 2026 Nitipong Siriwong | Ekachai Chukeatirote https://creativecommons.org/licenses/by/4.0
Results of Treatment of Hypertriglyceridemia-induced Acute Necrotizing Pancreatitis with the Use of Plasmapheresis
<span style="color: #000000; font-family: 'Times New Roman'; font-size: medium; font-style: normal; font-variant-ligatures: normal; font-variant-caps: normal; font-weight: 400; letter-spacing: normal; orphans: 2; text-align: start; text-indent: 0px; text-transform: none; widows: 2; word-spacing: 0px; -webkit-text-stroke-width: 0px; white-space: normal; text-decoration-thickness: initial; text-decoration-style: initial; text-decoration-color: initial;">Introduction:<span style="color: #000000; font-family: 'Times New Roman'; font-size: medium; font-style: normal; font-variant-ligatures: normal; font-variant-caps: normal; font-weight: 400; letter-spacing: normal; orphans: 2; text-align: start; text-indent: 0px; text-transform: none; widows: 2; word-spacing: 0px; -webkit-text-stroke-width: 0px; white-space: normal; text-decoration-thickness: initial; text-decoration-style: initial; text-decoration-color: initial; display: inline !important; float: none;"> Additional risk factors have been identified, and the outcomes of surgical treatment in patients with hypertriglyceridemia-induced acute necrotizing pancreatitis treated with plasmapheresis have been analyzed.<br style="color: #000000; font-family: 'Times New Roman'; font-size: medium; font-style: normal; font-variant-ligatures: normal; font-variant-caps: normal; font-weight: 400; letter-spacing: normal; orphans: 2; text-align: start; text-indent: 0px; text-transform: none; widows: 2; word-spacing: 0px; -webkit-text-stroke-width: 0px; white-space: normal; text-decoration-thickness: initial; text-decoration-style: initial; text-decoration-color: initial;"><span style="color: #000000; font-family: 'Times New Roman'; font-size: medium; font-style: normal; font-variant-ligatures: normal; font-variant-caps: normal; font-weight: 400; letter-spacing: normal; orphans: 2; text-align: start; text-indent: 0px; text-transform: none; widows: 2; word-spacing: 0px; -webkit-text-stroke-width: 0px; white-space: normal; text-decoration-thickness: initial; text-decoration-style: initial; text-decoration-color: initial;">Aim:<span style="color: #000000; font-family: 'Times New Roman'; font-size: medium; font-style: normal; font-variant-ligatures: normal; font-variant-caps: normal; font-weight: 400; letter-spacing: normal; orphans: 2; text-align: start; text-indent: 0px; text-transform: none; widows: 2; word-spacing: 0px; -webkit-text-stroke-width: 0px; white-space: normal; text-decoration-thickness: initial; text-decoration-style: initial; text-decoration-color: initial; display: inline !important; float: none;"> To evaluate the effectiveness of plasmapheresis in the treatment of patients with hypertriglyceridemia-induced acute necrotizing pancreatitis, with an emphasis on the early use of minimally invasive techniques and delayed open surgical interventions, and to identify additional risk factors associated with adverse disease outcomes.<br style="color: #000000; font-family: 'Times New Roman'; font-size: medium; font-style: normal; font-variant-ligatures: normal; font-variant-caps: normal; font-weight: 400; letter-spacing: normal; orphans: 2; text-align: start; text-indent: 0px; text-transform: none; widows: 2; word-spacing: 0px; -webkit-text-stroke-width: 0px; white-space: normal; text-decoration-thickness: initial; text-decoration-style: initial; text-decoration-color: initial;"><span style="color: #000000; font-family: 'Times New Roman'; font-size: medium; font-style: normal; font-variant-ligatures: normal; font-variant-caps: normal; font-weight: 400; letter-spacing: normal; orphans: 2; text-align: start; text-indent: 0px; text-transform: none; widows: 2; word-spacing: 0px; -webkit-text-stroke-width: 0px; white-space: normal; text-decoration-thickness: initial; text-decoration-style: initial; text-decoration-color: initial;">Materials and methods:<strong style="color: #000000; font-family: 'Times New Roman'; font-size: medium; font-style: normal; font-variant-ligatures: normal; font-variant-caps: normal; letter-spacing: normal; orphans: 2; text-align: start; text-indent: 0px; text-transform: none; widows: 2; word-spacing: 0px; -webkit-text-stroke-width: 0px; white-space: normal; text-decoration-thickness: initial; text-decoration-style: initial; text-decoration-color: initial;"> <span style="color: #000000; font-family: 'Times New Roman'; font-size: medium; font-style: normal; font-variant-ligatures: normal; font-variant-caps: normal; font-weight: 400; letter-spacing: normal; orphans: 2; text-align: start; text-indent: 0px; text-transform: none; widows: 2; word-spacing: 0px; -webkit-text-stroke-width: 0px; white-space: normal; text-decoration-thickness: initial; text-decoration-style: initial; text-decoration-color: initial; display: inline !important; float: none;">The treatment outcomes of 82 patients have been analyzed: 53 patients (65%) were included in the main group, and 29 patients (35%) were included in the comparison group.<br style="color: #000000; font-family: 'Times New Roman'; font-size: medium; font-style: normal; font-variant-ligatures: normal; font-variant-caps: normal; font-weight: 400; letter-spacing: normal; orphans: 2; text-align: start; text-indent: 0px; text-transform: none; widows: 2; word-spacing: 0px; -webkit-text-stroke-width: 0px; white-space: normal; text-decoration-thickness: initial; text-decoration-style: initial; text-decoration-color: initial;"><span style="color: #000000; font-family: 'Times New Roman'; font-size: medium; font-style: normal; font-variant-ligatures: normal; font-variant-caps: normal; font-weight: 400; letter-spacing: normal; orphans: 2; text-align: start; text-indent: 0px; text-transform: none; widows: 2; word-spacing: 0px; -webkit-text-stroke-width: 0px; white-space: normal; text-decoration-thickness: initial; text-decoration-style: initial; text-decoration-color: initial;">Results:<span style="color: #000000; font-family: 'Times New Roman'; font-size: medium; font-style: normal; font-variant-ligatures: normal; font-variant-caps: normal; font-weight: 400; letter-spacing: normal; orphans: 2; text-align: start; text-indent: 0px; text-transform: none; widows: 2; word-spacing: 0px; -webkit-text-stroke-width: 0px; white-space: normal; text-decoration-thickness: initial; text-decoration-style: initial; text-decoration-color: initial; display: inline !important; float: none;"> The use of plasmapheresis resulted in a significant reduction in blood triglyceride levels (<em style="color: #000000; font-family: 'Times New Roman'; font-size: medium; font-variant-ligatures: normal; font-variant-caps: normal; font-weight: 400; letter-spacing: normal; orphans: 2; text-align: start; text-indent: 0px; text-transform: none; widows: 2; word-spacing: 0px; -webkit-text-stroke-width: 0px; white-space: normal; text-decoration-thickness: initial; text-decoration-style: initial; text-decoration-color: initial;">p<span style="color: #000000; font-family: 'Times New Roman'; font-size: medium; font-style: normal; font-variant-ligatures: normal; font-variant-caps: normal; font-weight: 400; letter-spacing: normal; orphans: 2; text-align: start; text-indent: 0px; text-transform: none; widows: 2; word-spacing: 0px; -webkit-text-stroke-width: 0px; white-space: normal; text-decoration-thickness: initial; text-decoration-style: initial; text-decoration-color: initial; display: inline !important; float: none;">=0.002), total cholesterol (<em style="color: #000000; font-family: 'Times New Roman'; font-size: medium; font-variant-ligatures: normal; font-variant-caps: normal; font-weight: 400; letter-spacing: normal; orphans: 2; text-align: start; text-indent: 0px; text-transform: none; widows: 2; word-spacing: 0px; -webkit-text-stroke-width: 0px; white-space: normal; text-decoration-thickness: initial; text-decoration-style: initial; text-decoration-color: initial;">p<span style="color: #000000; font-family: 'Times New Roman'; font-size: medium; font-style: normal; font-variant-ligatures: normal; font-variant-caps: normal; font-weight: 400; letter-spacing: normal; orphans: 2; text-align: start; text-indent: 0px; text-transform: none; widows: 2; word-spacing: 0px; -webkit-text-stroke-width: 0px; white-space: normal; text-decoration-thickness: initial; text-decoration-style: initial; text-decoration-color: initial; display: inline !important; float: none;">=0.001), low-density lipoproteins (<em style="color: #000000; font-family: 'Times New Roman'; font-size: medium; font-variant-ligatures: normal; font-variant-caps: normal; font-weight: 400; letter-spacing: normal; orphans: 2; text-align: start; text-indent: 0px; text-transform: none; widows: 2; word-spacing: 0px; -webkit-text-stroke-width: 0px; white-space: normal; text-decoration-thickness: initial; text-decoration-style: initial; text-decoration-color: initial;">p<span style="color: #000000; font-family: 'Times New Roman'; font-size: medium; font-style: normal; font-variant-ligatures: normal; font-variant-caps: normal; font-weight: 400; letter-spacing: normal; orphans: 2; text-align: start; text-indent: 0px; text-transform: none; widows: 2; word-spacing: 0px; -webkit-text-stroke-width: 0px; white-space: normal; text-decoration-thickness: initial; text-decoration-style: initial; text-decoration-color: initial; display: inline !important; float: none;">=0.012), and the atherogenic index (<em style="color: #000000; font-family: 'Times New Roman'; font-size: medium; font-variant-ligatures: normal; font-variant-caps: normal; font-weight: 400; letter-spacing: normal; orphans: 2; text-align: start; text-indent: 0px; text-transform: none; widows: 2; word-spacing: 0px; -webkit-text-stroke-width: 0px; white-space: normal; text-decoration-thickness: initial; text-decoration-style: initial; text-decoration-color: initial;">p<span style="color: #000000; font-family: 'Times New Roman'; font-size: medium; font-style: normal; font-variant-ligatures: normal; font-variant-caps: normal; font-weight: 400; letter-spacing: normal; orphans: 2; text-align: start; text-indent: 0px; text-transform: none; widows: 2; word-spacing: 0px; -webkit-text-stroke-width: 0px; white-space: normal; text-decoration-thickness: initial; text-decoration-style: initial; text-decoration-color: initial; display: inline !important; float: none;">=0.001). In the comparison group, the decrease in these parameters was not significant. In the main group, a favorable disease course and the effectiveness of minimally invasive interventions were achieved in 60% of the patients (29/48), compared with 46% (12/26) in the comparison group (<em style="color: #000000; font-family: 'Times New Roman'; font-size: medium; font-variant-ligatures: normal; font-variant-caps: normal; font-weight: 400; letter-spacing: normal; orphans: 2; text-align: start; text-indent: 0px; text-transform: none; widows: 2; word-spacing: 0px; -webkit-text-stroke-width: 0px; white-space: normal; text-decoration-thickness: initial; text-decoration-style: initial; text-decoration-color: initial;">p<span style="color: #000000; font-family: 'Times New Roman'; font-size: medium; font-style: normal; font-variant-ligatures: normal; font-variant-caps: normal; font-weight: 400; letter-spacing: normal; orphans: 2; text-align: start; text-indent: 0px; text-transform: none; widows: 2; word-spacing: 0px; -webkit-text-stroke-width: 0px; white-space: normal; text-decoration-thickness: initial; text-decoration-style: initial; text-decoration-color: initial; display: inline !important; float: none;">=0.238).<br style="color: #000000; font-family: 'Times New Roman'; font-size: medium; font-style: normal; font-variant-ligatures: normal; font-variant-caps: normal; font-weight: 400; letter-spacing: normal; orphans: 2; text-align: start; text-indent: 0px; text-transform: none; widows: 2; word-spacing: 0px; -webkit-text-stroke-width: 0px; white-space: normal; text-decoration-thickness: initial; text-decoration-style: initial; text-decoration-color: initial;"><span style="color: #000000; font-family: 'Times New Roman'; font-size: medium; font-style: normal; font-variant-ligatures: normal; font-variant-caps: normal; font-weight: 400; letter-spacing: normal; orphans: 2; text-align: start; text-indent: 0px; text-transform: none; widows: 2; word-spacing: 0px; -webkit-text-stroke-width: 0px; white-space: normal; text-decoration-thickness: initial; text-decoration-style: initial; text-decoration-color: initial;">Discussion:<span style="color: #000000; font-family: 'Times New Roman'; font-size: medium; font-style: normal; font-variant-ligatures: normal; font-variant-caps: normal; font-weight: 400; letter-spacing: normal; orphans: 2; text-align: start; text-indent: 0px; text-transform: none; widows: 2; word-spacing: 0px; -webkit-text-stroke-width: 0px; white-space: normal; text-decoration-thickness: initial; text-decoration-style: initial; text-decoration-color: initial; display: inline !important; float: none;"> According to the ROC analysis, adverse prognostic factors for a complicated disease course included arterial hypertension (<em style="color: #000000; font-family: 'Times New Roman'; font-size: medium; font-variant-ligatures: normal; font-variant-caps: normal; font-weight: 400; letter-spacing: normal; orphans: 2; text-align: start; text-indent: 0px; text-transform: none; widows: 2; word-spacing: 0px; -webkit-text-stroke-width: 0px; white-space: normal; text-decoration-thickness: initial; text-decoration-style: initial; text-decoration-color: initial;">p<span style="color: #000000; font-family: 'Times New Roman'; font-size: medium; font-style: normal; font-variant-ligatures: normal; font-variant-caps: normal; font-weight: 400; letter-spacing: normal; orphans: 2; text-align: start; text-indent: 0px; text-transform: none; widows: 2; word-spacing: 0px; -webkit-text-stroke-width: 0px; white-space: normal; text-decoration-thickness: initial; text-decoration-style: initial; text-decoration-color: initial; display: inline !important; float: none;">=0.042), overweight with a body mass index greater than 27.6 kg/m² (<em style="color: #000000; font-family: 'Times New Roman'; font-size: medium; font-variant-ligatures: normal; font-variant-caps: normal; font-weight: 400; letter-spacing: normal; orphans: 2; text-align: start; text-indent: 0px; text-transform: none; widows: 2; word-spacing: 0px; -webkit-text-stroke-width: 0px; white-space: normal; text-decoration-thickness: initial; text-decoration-style: initial; text-decoration-color: initial;">p<span style="color: #000000; font-family: 'Times New Roman'; font-size: medium; font-style: normal; font-variant-ligatures: normal; font-variant-caps: normal; font-weight: 400; letter-spacing: normal; orphans: 2; text-align: start; text-indent: 0px; text-transform: none; widows: 2; word-spacing: 0px; -webkit-text-stroke-width: 0px; white-space: normal; text-decoration-thickness: initial; text-decoration-style: initial; text-decoration-color: initial; display: inline !important; float: none;">=0.030), diabetes mellitus (<em style="color: #000000; font-family: 'Times New Roman'; font-size: medium; font-variant-ligatures: normal; font-variant-caps: normal; font-weight: 400; letter-spacing: normal; orphans: 2; text-align: start; text-indent: 0px; text-transform: none; widows: 2; word-spacing: 0px; -webkit-text-stroke-width: 0px; white-space: normal; text-decoration-thickness: initial; text-decoration-style: initial; text-decoration-color: initial;">p<span style="color: #000000; font-family: 'Times New Roman'; font-size: medium; font-style: normal; font-variant-ligatures: normal; font-variant-caps: normal; font-weight: 400; letter-spacing: normal; orphans: 2; text-align: start; text-indent: 0px; text-transform: none; widows: 2; word-spacing: 0px; -webkit-text-stroke-width: 0px; white-space: normal; text-decoration-thickness: initial; text-decoration-style: initial; text-decoration-color: initial; display: inline !important; float: none;">=0.021), and hypertriglyceridemia (<em style="color: #000000; font-family: 'Times New Roman'; font-size: medium; font-variant-ligatures: normal; font-variant-caps: normal; font-weight: 400; letter-spacing: normal; orphans: 2; text-align: start; text-indent: 0px; text-transform: none; widows: 2; word-spacing: 0px; -webkit-text-stroke-width: 0px; white-space: normal; text-decoration-thickness: initial; text-decoration-style: initial; text-decoration-color: initial;">p<span style="color: #000000; font-family: 'Times New Roman'; font-size: medium; font-style: normal; font-variant-ligatures: normal; font-variant-caps: normal; font-weight: 400; letter-spacing: normal; orphans: 2; text-align: start; text-indent: 0px; text-transform: none; widows: 2; word-spacing: 0px; -webkit-text-stroke-width: 0px; white-space: normal; text-decoration-thickness: initial; text-decoration-style: initial; text-decoration-color: initial; display: inline !important; float: none;">=0.001). This study will allow us to evaluate the results of the treatment of patients with hypertriglyceride-induced acute necrotic pancreatitis and the effectiveness of plasmapheresis, as well as to identify additional prognostic risk factors leading to laparotomy.<br style="color: #000000; font-family: 'Times New Roman'; font-size: medium; font-style: normal; font-variant-ligatures: normal; font-variant-caps: normal; font-weight: 400; letter-spacing: normal; orphans: 2; text-align: start; text-indent: 0px; text-transform: none; widows: 2; word-spacing: 0px; -webkit-text-stroke-width: 0px; white-space: normal; text-decoration-thickness: initial; text-decoration-style: initial; text-decoration-color: initial;"><span style="color: #000000; font-family: 'Times New Roman'; font-size: medium; font-style: normal; font-variant-ligatures: normal; font-variant-caps: normal; font-weight: 400; letter-spacing: normal; orphans: 2; text-align: start; text-indent: 0px; text-transform: none; widows: 2; word-spacing: 0px; -webkit-text-stroke-width: 0px; white-space: normal; text-decoration-thickness: initial; text-decoration-style: initial; text-decoration-color: initial;">Conclusions:<span style="color: #000000; font-family: 'Times New Roman'; font-size: medium; font-style: normal; font-variant-ligatures: normal; font-variant-caps: normal; font-weight: 400; letter-spacing: normal; orphans: 2; text-align: start; text-indent: 0px; text-transform: none; widows: 2; word-spacing: 0px; -webkit-text-stroke-width: 0px; white-space: normal; text-decoration-thickness: initial; text-decoration-style: initial; text-decoration-color: initial; display: inline !important; float: none;"> Plasmapheresis in the early stages of hypertriglyceride-induced acute necrotic pancreatitis had a positive effect on the course of the disease and ensured the final effectiveness of mini-invasive surgical interventions in 60% of the patients in the main group. Additional prognostic factors for complicated hypertriglyceride-induced acute necrotic pancreatitis, accompanied by purulent-septic complications and requiring laparotomy, are arterial hypertension, a body mass index greater than 27.6 (kg/m<span style="color: #000000; font-family: 'Times New Roman'; font-size: medium; font-style: normal; font-variant-ligatures: normal; font-variant-caps: normal; font-weight: 400; letter-spacing: normal; orphans: 2; text-align: start; text-indent: 0px; text-transform: none; widows: 2; word-spacing: 0px; -webkit-text-stroke-width: 0px; white-space: normal; text-decoration-thickness: initial; text-decoration-style: initial; text-decoration-color: initial;">2<span style="color: #000000; font-family: 'Times New Roman'; font-size: medium; font-style: normal; font-variant-ligatures: normal; font-variant-caps: normal; font-weight: 400; letter-spacing: normal; orphans: 2; text-align: start; text-indent: 0px; text-transform: none; widows: 2; word-spacing: 0px; -webkit-text-stroke-width: 0px; white-space: normal; text-decoration-thickness: initial; text-decoration-style: initial; text-decoration-color: initial; display: inline !important; float: none;">), diabetes mellitus, and hypertriglyceridemia.
Copyright (c) 2026 Igor Shevchuk | Roman Kuzenko | Volodymyr Pylypchuk | Igor Нalipchak | Sergiy Gedzuk | Sergiy Snizhko https://creativecommons.org/licenses/by/4.0
Comparative Study of Haemostatic Agents in Tactical Environments and Their Impact on Survival Time before Evacuation
Aim: Uncontrolled external bleeding remains a leading cause of preventable death in military and civilian tactical environments, necessitating continuous improvement in the means and algorithms for haemorrhage control. The aim of this study was to determine the comparative effectiveness and optimal sequence of application of modern methods for controlling external bleeding in tactical medicine, in order to maximise survival of the wounded until evacuation to hospital. Materials and methods: The study was conducted as a systematic review with a semi-quantitative comparison of efficacy and safety based on registries, clinical cohorts, and severe animal models of coagulopathic haemorrhage. Result: The results demonstrated that new-generation chitosan dressings provide 100% survival for up to 180-240 minutes with minimal blood loss (112-300 ml) in models of severe coagulopathy, outperforming kaolin-based standards (86% survival, blood loss 260-1021 ml). The use of any modern topical haemostatic agent in real combat conditions increases survival by 7%, while the systematic introduction of tourniquets and haemostatic agents reduces preventable mortality from extremity bleeding by 67-87%, saving 1,000-2,000 lives in the conflicts in Iraq and Afghanistan alone. Injectable sponges achieve 100% stable haemostasis for up to 72 hours and are applied three times faster than traditional tamponade, which is critically important for deep, narrow wound channels. Early administration of tranexamic acid (within the first three hours) further reduces the risk of death from bleeding by 10-20%. Under the most challenging conditions, the greatest benefit is achieved through the combined use of tourniquets, new-generation chitosan agents, and specialised devices. Conclusions: The proposed differentiated algorithm enables rapid and reliable haemostasis even in cases of deep traumatic coagulopathy and prolonged evacuation, making it a practical tool for updating tactical medicine protocols and significantly improving survival prior to hospital evacuation.
Copyright (c) 2026 Aleksandra Kuliś https://creativecommons.org/licenses/by/4.0
Sciatic Nerve Anatomical Variations and Deep Gluteal Syndrome: Clinical Relevance and Current Evidence — A Narrative Literature Review
Background: The aim of the study - based on the latest literature, this narrative literature review aims to provide a comprehensive evaluation of deep gluteal syndrome (DGS) and to assess the significance of anatomical variations of the sciatic nerve (SN) in relation to the syndrome. Materials and methods: A review of the scientific literature was conducted using the PubMed, ClinicalKey, and ScienceDirect databases. Publications were selected from 2015 to 2026. All publications were written in English. The following keywords and their combinations were used during the search: “deep gluteal syndrome,” “sciatic nerve variations,” “sciatic nerve entrapment,” and “piriformis syndrome.” Results: The sciatic nerve, characterized by significant anatomical variability in the deep gluteal space, may result in altered biomechanics and predispose the nerve to compression. Anatomical variations of the sciatic nerve, depending on their relationship with the piriformis muscle, are categorized according to the Beaton and Anson classification (types A–F). In recent decades, the term “deep gluteal syndrome” has come into use, encompassing extrapelvic non-discogenic sciatic nerve compressions. The syndrome most commonly manifests as persistent, “shooting” pain that worsens after prolonged sitting and radiates toward the back of the knee, hip, and/or gluteal region, as well as dysesthesia and nocturnal pain. There is currently no gold standard for the diagnosis of DGS. Diagnostic criteria may include compression of the SN in the deep gluteal region, sciatica-like pain, and a non-discogenic origin of symptoms. First-line treatment options include physical therapy, nonsteroidal anti-inflammatory drugs (NSAIDs), muscle relaxants, and rest. In addition, intramuscular injections of a local anaesthetic may be administered to alleviate symptoms. If conservative treatment proves ineffective, surgical nerve decompression should be considered. Conclusions: The most common abnormal sciatic nerve variation worldwide is the type B variant. Although anatomical variations of the sciatic nerve alter its biomechanics, they have no direct, statistically significant association with the development of deep gluteal syndrome, according to the latest literature. Anatomical variations of the sciatic nerve may be considered a predisposing factor that increases the risk of DGS when additional primary etiological factors are present. However, more comprehensive scientific studies are needed to assess this.
Copyright (c) 2026 Mantas Leskauskas | Laura Nedzinskienė https://creativecommons.org/licenses/by/4.0
The Impact of Comorbidities on the Effectiveness of Noninvasive Ventilation in Patients with Chronic Obstructive Pulmonary Disease
<span style="color: #000000; font-family: 'Times New Roman'; font-size: medium; font-style: normal; font-variant-ligatures: normal; font-variant-caps: normal; font-weight: 400; letter-spacing: normal; orphans: 2; text-align: start; text-indent: 0px; text-transform: none; widows: 2; word-spacing: 0px; -webkit-text-stroke-width: 0px; white-space: normal; text-decoration-thickness: initial; text-decoration-style: initial; text-decoration-color: initial;">Background:<strong style="color: #000000; font-family: 'Times New Roman'; font-size: medium; font-style: normal; font-variant-ligatures: normal; font-variant-caps: normal; letter-spacing: normal; orphans: 2; text-align: start; text-indent: 0px; text-transform: none; widows: 2; word-spacing: 0px; -webkit-text-stroke-width: 0px; white-space: normal; text-decoration-thickness: initial; text-decoration-style: initial; text-decoration-color: initial;"> <span style="color: #000000; font-family: 'Times New Roman'; font-size: medium; font-style: normal; font-variant-ligatures: normal; font-variant-caps: normal; font-weight: 400; letter-spacing: normal; orphans: 2; text-align: start; text-indent: 0px; text-transform: none; widows: 2; word-spacing: 0px; -webkit-text-stroke-width: 0px; white-space: normal; text-decoration-thickness: initial; text-decoration-style: initial; text-decoration-color: initial; display: inline !important; float: none;">Noninvasive ventilation (NIV) is a cornerstone treatment for hypercapnic respiratory failure in patients with chronic obstructive pulmonary disease (COPD). The aim of this study was to evaluate the impact of selected comorbidities on the effectiveness of NIV in these patients, and to compare clinical characteristics and outcomes between continuous positive airway pressure (CPAP) and bilevel positive airway pressure (BiPAP) modalities.<br style="color: #000000; font-family: 'Times New Roman'; font-size: medium; font-style: normal; font-variant-ligatures: normal; font-variant-caps: normal; font-weight: 400; letter-spacing: normal; orphans: 2; text-align: start; text-indent: 0px; text-transform: none; widows: 2; word-spacing: 0px; -webkit-text-stroke-width: 0px; white-space: normal; text-decoration-thickness: initial; text-decoration-style: initial; text-decoration-color: initial;"><span style="color: #000000; font-family: 'Times New Roman'; font-size: medium; font-style: normal; font-variant-ligatures: normal; font-variant-caps: normal; font-weight: 400; letter-spacing: normal; orphans: 2; text-align: start; text-indent: 0px; text-transform: none; widows: 2; word-spacing: 0px; -webkit-text-stroke-width: 0px; white-space: normal; text-decoration-thickness: initial; text-decoration-style: initial; text-decoration-color: initial;">Materials and methods:<span style="color: #000000; font-family: 'Times New Roman'; font-size: medium; font-style: normal; font-variant-ligatures: normal; font-variant-caps: normal; font-weight: 400; letter-spacing: normal; orphans: 2; text-align: start; text-indent: 0px; text-transform: none; widows: 2; word-spacing: 0px; -webkit-text-stroke-width: 0px; white-space: normal; text-decoration-thickness: initial; text-decoration-style: initial; text-decoration-color: initial; display: inline !important; float: none;"> This prospective, randomized, single-center study included 80 patients with hypercapnic respiratory failure due to COPD, randomized 1:1 to CPAP or BiPAP. Demographic and clinical data, comorbidities, vital signs, and arterial blood gas parameters were recorded at admission and during NIV. The primary outcome was pCO₂ reduction at the end of treatment compared with baseline.<br style="color: #000000; font-family: 'Times New Roman'; font-size: medium; font-style: normal; font-variant-ligatures: normal; font-variant-caps: normal; font-weight: 400; letter-spacing: normal; orphans: 2; text-align: start; text-indent: 0px; text-transform: none; widows: 2; word-spacing: 0px; -webkit-text-stroke-width: 0px; white-space: normal; text-decoration-thickness: initial; text-decoration-style: initial; text-decoration-color: initial;"><span style="color: #000000; font-family: 'Times New Roman'; font-size: medium; font-style: normal; font-variant-ligatures: normal; font-variant-caps: normal; font-weight: 400; letter-spacing: normal; orphans: 2; text-align: start; text-indent: 0px; text-transform: none; widows: 2; word-spacing: 0px; -webkit-text-stroke-width: 0px; white-space: normal; text-decoration-thickness: initial; text-decoration-style: initial; text-decoration-color: initial;">Results:<strong style="color: #000000; font-family: 'Times New Roman'; font-size: medium; font-style: normal; font-variant-ligatures: normal; font-variant-caps: normal; letter-spacing: normal; orphans: 2; text-align: start; text-indent: 0px; text-transform: none; widows: 2; word-spacing: 0px; -webkit-text-stroke-width: 0px; white-space: normal; text-decoration-thickness: initial; text-decoration-style: initial; text-decoration-color: initial;"> <span style="color: #000000; font-family: 'Times New Roman'; font-size: medium; font-style: normal; font-variant-ligatures: normal; font-variant-caps: normal; font-weight: 400; letter-spacing: normal; orphans: 2; text-align: start; text-indent: 0px; text-transform: none; widows: 2; word-spacing: 0px; -webkit-text-stroke-width: 0px; white-space: normal; text-decoration-thickness: initial; text-decoration-style: initial; text-decoration-color: initial; display: inline !important; float: none;">Arterial hypertension significantly enhanced pCO₂ reduction with CPAP, but not with BiPAP. Systolic and mean arterial pressure independently predicted the magnitude of pCO₂ reduction, regardless of NIV modality. Patients treated with BiPAP more frequently had decompensated cor pulmonale and severe pulmonary hypertension, while pneumonia was more common in the CPAP group. NIV modality itself was not an independent predictor of pCO₂ reduction.<br style="color: #000000; font-family: 'Times New Roman'; font-size: medium; font-style: normal; font-variant-ligatures: normal; font-variant-caps: normal; font-weight: 400; letter-spacing: normal; orphans: 2; text-align: start; text-indent: 0px; text-transform: none; widows: 2; word-spacing: 0px; -webkit-text-stroke-width: 0px; white-space: normal; text-decoration-thickness: initial; text-decoration-style: initial; text-decoration-color: initial;"><span style="color: #000000; font-family: 'Times New Roman'; font-size: medium; font-style: normal; font-variant-ligatures: normal; font-variant-caps: normal; font-weight: 400; letter-spacing: normal; orphans: 2; text-align: start; text-indent: 0px; text-transform: none; widows: 2; word-spacing: 0px; -webkit-text-stroke-width: 0px; white-space: normal; text-decoration-thickness: initial; text-decoration-style: initial; text-decoration-color: initial;">Conclusion:<span style="color: #000000; font-family: 'Times New Roman'; font-size: medium; font-style: normal; font-variant-ligatures: normal; font-variant-caps: normal; font-weight: 400; letter-spacing: normal; orphans: 2; text-align: start; text-indent: 0px; text-transform: none; widows: 2; word-spacing: 0px; -webkit-text-stroke-width: 0px; white-space: normal; text-decoration-thickness: initial; text-decoration-style: initial; text-decoration-color: initial; display: inline !important; float: none;"> Systemic hemodynamic status and arterial hypertension influence NIV effectiveness in hypercapnic COPD. The cardiovascular status should be considered alongside respiratory parameters when selecting the NIV strategy.
Copyright (c) 2026 Aida Mujaković | Nejra Mlačo-Vražalić | Nejra Prohić | Akif Mlačo https://creativecommons.org/licenses/by/4.0
The Impact of Genetic Factors on the Development of Type 2 Diabetes and Possible Pathways for its Correction
Aim: The aim of this study was to investigate the impact of genetic factors on the development of type 2 diabetes in the population of Kazakhstan. Materials and methods: The methodology included the collection of demographic data, the analysis of biochemical parameters, and the application of polymerase chain reaction genotyping for single-nucleotide polymorphisms in genes associated with type 2 diabetes. Result: The main results of the study demonstrated that patients with type 2 diabetes had a 20% higher body mass index (29.5±4.2 kg/m2 versus 24.3±3.1 kg/m2) and 29% lower physical activity (3.2±1.5 hours per week versus 4.5±2.0 hours per week) compared with the control group. Biochemical parameters showed a 50% higher glucose level (7.8±2.1 mmol/L versus 5.2 ± 0.8 mmol/L), insulin levels by 76% (15.3±5.2 microunits per millilitre versus 8.7±2.5 microunits per millilitre), and glycated haemoglobin by 42% (7.5±1.2% versus 5.3±0.5%) in patients with type 2 diabetes. The genetic analysis revealed substantial associations between type 2 diabetes and risk alleles in the TCF7L2 (rs7903146), KCNJ11 (rs5219), FTO (rs9939609), PPARG (rs1801282), and ADIPOQ (rs1501299) genes, which were linked to compromised insulin secretion and metabolic anomalies in the study population. Conclusions: The practical significance of the study lies in the potential application of these findings to develop personalised approaches for the prevention and treatment of type 2 diabetes, including lifestyle modification, the use of modern pharmaceuticals, and anti-inflammatory drugs to improve glucose control in patients.
Copyright (c) 2026 Zhibek Sembayeva | Oralbek Ilderbayev | Damira Tazhibayeva | Ainur Zhanilova | Aruzhan Ilderbayeva https://creativecommons.org/licenses/by/4.0
Type III Fetal Sacrococcygeal Teratoma: Prenatal Diagnosis, Delivery and Postnatal Course
Background: Sacrococcygeal teratoma (SCT) is the most common congenital neoplasm in fetuses and newborns. Altman Type III lesions may be difficult to diagnose and manage prenatally because of their marked intrapelvic extension. Materials and Methods: A 24-year-old primigravida woman was referred at 20 weeks of gestation after routine ultrasonography revealed a sacrococcygeal mass extending into the abdomen. Prenatal evaluation included ultrasonography, fetal magnetic resonance imaging, and chromosomal microarray analysis. The pregnancy was managed by a multidisciplinary team with serial fetal surveillance. Results: Imaging demonstrated a predominantly cystic lesion consistent with Altman Type III SCT. During follow-up, bilateral fetal hydronephrosis, gestational diabetes mellitus, and mild polyhydramnios developed. At 38 weeks, an elective cesarean section was performed. On postnatal day 4, total tumor resection with coccygectomy was successfully completed. Histopathology confirmed a mature teratoma. At 6 months, persistent hydronephrosis remained under follow-up, with no documented recurrence. Conclusions: Accurate prenatal imaging, close surveillance, multidisciplinary planning, and timely postnatal surgery are essential for favorable outcomes in Type III fetal SCT.
Copyright (c) 2026 Orhan Ay | Fethiye Şahin | Pelin Bahçeci | Hasan Madenci | Ali Acar https://creativecommons.org/licenses/by/4.0
The Role of Triglycerides in the Development of Atherosclerosis
Objective: To review the pathogenesis of triglycerides (TG), triglyceride-rich lipoproteins (TRL) and their remnants as well as their role in the development of atherosclerosis and clinical relevance for assessing residual ASCVD risk. Materials and methods: A literature search was conducted using keywords relevant to the topic and their combinations. A targeted PubMed search prioritized English-language guidelines, consensus statements, randomized clinical trials, cohort studies, and meta-analyses published between 2019 and 2025, with older landmark publications included where necessary. Reference lists of key articles were also manually screened to identify additional relevant studies. Results: The literature shows that elevated TG concentrations are associated with a higher risk of ASCVD, regardless of LDL-C. Given that no clear signal indicates which features of TRL give rise to risk of ASCVD, plasma TG levels remain a reasonable surrogate marker for risk assessment. Evidence suggests that the atherogenicity of TRL is driven primarily by the cholesterol carried within TRL and their remnants rather than TG themselves. TRL remnants may be at least as atherogenic as, and potentially more atherogenic than, low-density lipoproteins (LDL) because they can be taken up by intimal macrophages without prior oxidative or structural modification, persist longer within the intima, are larger in size, and carry more cholesterol per particle. They also more effectively promote foam-cell formation and contribute to low-grade inflammation. Given the conflicting results of large-scale randomized clinical trials, it is not yet possible to conclude that lowering TG concentrations alone reduces the ASCVD risk. Conclusions: Elevated plasma TG concentrations are associated with an increased risk of ASCVD, independent of LDL-C levels. Given the ongoing need to identify the most reliable metric for risk stratification, TG remain a rational surrogate marker for estimating residual ASCVD risk related to TRL and their remnants.
Copyright (c) 2026 Vaida Cerebiejūtė | Živilė Girkantaitė | Egidija Rinkūnienė | Silvija Gimžauskaitė | Jolita Badarienė https://creativecommons.org/licenses/by/4.0
A Novel RNF216 Variant Causing Gordon Holmes Syndrome in Three Lithuanian Siblings
Background: Gordon Holmes syndrome (GHS) is a rare genetic disorder, usually manifesting as a broad spectrum of neurological symptoms and hypogonadotropic hypogonadism. Only a limited number of cases presenting this congenital disorder have been reported in the literature. Since the genetic and phenotypic heterogeneity of GHS, it is crucial to report novel cases. Case presentation: Here we report a novel homozygous missense variant in RNF216 gene c.1055T>G (p.(Phe352Cys)) in three siblings. Primary concerns were absence of secondary sexual characteristics, and amenorrhea occurred among female patients. Based on laboratory test results and clinical features, hypogonadotropic hypogonadism was diagnosed. Neurological examination revealed no signs of ataxia in siblings. However, brain magnetic resonance imaging revealed pronounced changes in the cerebral white matter for female patients. Due to primary amenorrhea and the absence of secondary sexual characteristics, treatment was initiated. Treatment might be adjusted in the presence of fertility considerations. Conclusions: This case contributes to the limited knowledge of GHS and highlights the importance of hypogonadotropic hypogonadism treatment and close observation of neurological symptoms that may develop over time.
Copyright (c) 2026 Melita Karlonaitė | Ugnė Kanapickaitė | Romena Laukienė | Algirdas Utkus | Birutė Burnytė https://creativecommons.org/licenses/by/4.0
Misdiagnoses of Intracranial Hypotension: A Systematic Literature Review and Case Report
Background: Despite the difficulties of diagnosing intracranial hypotension (IH), the literature focusing on specific IH misdiagnoses remains scarce. We report on the case of a pediatric patient with spontaneous intracranial hypotension (SIH) caused by thecal sac dilatation due to Marfan syndrome, who was initially misdiagnosed. Additionally, a systematic literature review was conducted, focusing specifically on misdiagnoses of IH. Materials and Methods: The material search for the literature review was performed across PubMed, Scopus, and Web of Science databases. The inclusion criteria were: published within the last ten years, involved human participants, written in English, and included case reports or series with a clear diagnostic pathway, in which a specified initial misdiagnosis was followed by IH as the final diagnosis. Publications were excluded if they did not meet these criteria. Due to the nature of the case reports, reporting bias and certainty assessment were not formally evaluated. Additionally, a single-patient case report was retrospectively analyzed. Results: A 13-year-old woman presented to the emergency department complaining of a severe postural headache, nausea, sleepiness, generalized weakness, dizziness, and loss of appetite. An asymptomatic venous thrombosis and functional headaches were suspected. The patient was transferred to a third-level hospital, where a magnetic resonance imaging scan of the whole spine revealed thecal sac dilatation. SIH was diagnosed, and, after 3 weeks of conservative treatment, the patient was discharged from the hospital with full recovery. In the systematic review, 24 studies containing 28 patients were included in the final report. The most frequent initial misdiagnoses were Chiari I malformation (39.29%) and migraine (21.43%). 75% of studies identified SIH as a cause of IH, 16.67% determined it was iatrogenic, 4.17% - traumatic, and 1 case report did not include the cause of IH. Conclusions: While the case report illustrates the difficulties in diagnosing IH, the systematic review distinguishes initial misdiagnoses of this condition, of which the most common are migraine and Chiari I malformation.
Copyright (c) 2026 Gertrūda Kaubrytė | Rūta Samaitienė-Aleknienė https://creativecommons.org/licenses/by/4.0
Microsurgical Treatment of Cranial Dural Arteriovenous Fistulas: A Case Series and Literature Review
<span style="color: #000000; font-family: 'Times New Roman'; font-size: medium; font-style: normal; font-variant-ligatures: normal; font-variant-caps: normal; font-weight: 400; letter-spacing: normal; orphans: 2; text-align: start; text-indent: 0px; text-transform: none; widows: 2; word-spacing: 0px; -webkit-text-stroke-width: 0px; white-space: normal; text-decoration-thickness: initial; text-decoration-style: initial; text-decoration-color: initial; display: inline !important; float: none;">Dural arteriovenous fistulas are pathological vascular malformations within the dura mater, characterized by abnormal connections between pial arteries and veins. These are rare lesions that can present with a variety of neurological symptoms, and, when ruptured, can result in a fatal hemorrhage. This disease can be managed by endovascular embolization, surgical resection, and stereotactic radiosurgery. Particularly with the advancement of endovascular techniques, surgery is less frequently used to treat these lesions. However, it remains a viable treatment option in certain cases. In this article, we present a series of 17 patients with dural arteriovenous fistulas treated at a single tertiary neurosurgical center. This study was conducted at São João University Hospital in Porto, Portugal. We retrospectively collected data from all patients who underwent microsurgical or endovascular treatment for dural arteriovenous fistulas between 2014 and 2023. We collected information regarding the patients’ sex, age, and radiological classification of the dAVF, also, the treatment modality chosen, dAVF obliteration rate and information about any complications that have resulted from the treatment. Endovascular treatment had been attempted in 5 patients (29.4%), resulting in partial embolization of the dural arteriovenous fistulas in 3 patients (17.6%). In 2 patients (11.8%), embolization was attempted but deemed technically unfeasible. The remaining cohort, comprising 12 patients (70.6%), underwent surgical intervention as the primary treatment modality. Overall, all of the patients presented in this cohort underwent surgical resection. The factors why patients underwent surgical resection as the primary treatment modality were: endovascular embolization was deemed technically unfeasible due to the location in the anterior cranial fossa, or due to the multidisciplinary decision to operate on these lesions. Lesions were also operated on in the presence of a hematoma that required an evacuation. Immediate postoperative angiography showed that 94.1% (n = 16) of the patients achieved complete exclusion of the lesion. At the time of the latest follow-up, a second DSA was performed, and 88.23% (n = 15) of the patients showed complete obliteration of the lesion. 41.17 % of the patients (n = 7) had resolution of their pre-operative symptoms. 58.8 % (n = 10) remained symptomatic after the surgical procedure. The cumulative surgical complication rate in this cohort was 23.6% (n = 4). In this article, we also provide a comprehensive review of the literature regarding the treatment modalities that are available to treat this complex condition. In conclusion, surgical treatment is nowadays less frequently used, but it still remains a viable option for the treatment of dural arteriovenous fistulas. Our patient cohort demonstrated that selective treatment of these rare and complex lesions surgically is associated with high obliteration rates and relatively low rates of complications. Surgical treatment can be considered a primary treatment option when dealing with ethmoidal-type dural arteriovenous fistulas or others located within the anterior cranial fossa, and the presence of a hematoma requiring urgent evacuation.
Copyright (c) 2026 Domantas Jakštas | Carolina Santos Silva | Pedro Alberto Silva | Antonio Vilarinho https://creativecommons.org/licenses/by/4.0
Temporal Stability of In-Hospital Mortality in Acute Pancreatitis: A Nine-Year Tertiary Center Cohort Study
Background. Acute pancreatitis (AP) is a leading cause of gastrointestinal hospitalization and remains associated with measurable in-hospital mortality despite advances in supportive care. While earlier decades were characterized by declining mortality, contemporary temporal patterns within mature tertiary-care systems remain uncertain. We aimed to evaluate longitudinal trends in admission volume, demographic characteristics, intensive care unit (ICU) utilization, and crude, age-standardized, and adjusted in-hospital mortality in a tertiary academic center. Materials and Methods. We conducted a retrospective cohort study of consecutive adult hospitalizations with a primary diagnosis of acute pancreatitis at a tertiary referral center between 2016 and 2024. Temporal trends were assessed using linear and logistic regression models. Age-standardized mortality rates were calculated using direct standardization to a fixed reference population. Multivariable logistic regression evaluated the independent association between year of admission and in-hospital mortality, adjusting for age and sex. A prespecified sensitivity analysis excluded ICU admissions. Analyses were limited by the lack of reliably recorded etiologic and standardized severity data within the administrative dataset. Results. A total of 1,981 hospitalizations were included. Overall, in-hospital mortality was 5.0%. Annual admission volume, median age, sex distribution, and ICU utilization showed no significant temporal trends. Crude mortality ranged from 1.8% to 6.5% annually and demonstrated no significant temporal association. Age-standardized mortality likewise showed no significant trend. In multivariable analysis, year of admission was not independently associated with mortality, whereas advancing age was the strongest measured independent predictor, with a 34% increase in odds of death per 10-year increment. Exclusion of ICU admissions yielded consistent findings. Conclusions. In this nine-year tertiary-center cohort, in-hospital mortality for acute pancreatitis was approximately 5% and did not demonstrate a statistically significant temporal change. After adjustment, mortality risk was more strongly associated with age than with calendar year of admission. These findings suggest relative stability within this cohort; however, given the limitations of the study, further research using larger and more detailed datasets is needed to better characterize temporal trends and determinants of mortality.
Copyright (c) 2026 Abdulrahman Al-Dawoudi | Daniil Varlamov | Mujahed Dalain | Davis Freimanis https://creativecommons.org/licenses/by/4.0
Gastrointestinal Symptoms in Systemic Sclerosis: Prevalence and Severity across Disease Subtypes and Autoantibody Profiles
Background: This study aimed to evaluate the prevalence and severity of gastrointestinal (GI) symptoms in patients with systemic sclerosis (SSc), their impact on social functioning and emotional well-being, and to compare findings between patients with limited cutaneous systemic sclerosis (lcSSc) and diffuse cutaneous systemic sclerosis (dcSSc), as well as between patients positive for anticentromere (ACA) or anti-topoisomerase I (ATA) antibodies. Materials and methods: Forty-two consecutive patients with SSc were included: 31 with lcSSc and 11 with dcSSc. ACA antibodies were detected in 26 patients, and ATA antibodies in 16 patients. The UCLA SCTC GIT 2.0 self-assessment questionnaire was used to assess the severity of GI symptoms across seven subscales: reflux, distention/bloating, diarrhea, fecal soilage, constipation, social functioning, and emotional well-being. Results: Symptoms of reflux (lcSSc/dcSSc = 64.5%/81.8%), distention/bloating (lcSSc/dcSSc = 61.3%/81.8%), constipation (lcSSc/dcSSc = 45.2%/45.5%), and fecal soilage (lcSSc/dcSSc = 6.4%/18.2%) were similarly frequent in lcSSc and dcSSc. Diarrhea was more common in dcSSc (45.5% vs. 16.1%, p = 0.04), with a higher median index value (0.25 vs. 0.00, p = 0.02), thus indicating more severe symptoms. No differences were observed in the prevalence or severity of GI symptoms between ACA- and ATA-positive patients. Median index values for social functioning and emotional well-being did not differ by the disease subtype or antibody status. Conclusions: Diarrhea was more prevalent and more severe in patients with dcSSc, while other gastrointestinal manifestations showed no major differences between subtypes. Symptom prevalence and severity did not differ according to the antibody status, and their impact on social and emotional functioning was similar across the groups.
Copyright (c) 2026 Marina Vujović Šestakov | Sretko Lukovic | Ivana Pavlovic | Maja Zlatanovic | Predrag Ostojic https://creativecommons.org/licenses/by/4.0
The Use of Virtual Reality for Pain and Anxiety Reduction: A Literature Review
<span style="color: #000000; font-family: 'Times New Roman'; font-size: medium; font-style: normal; font-variant-ligatures: normal; font-variant-caps: normal; font-weight: 400; letter-spacing: normal; orphans: 2; text-align: start; text-indent: 0px; text-transform: none; widows: 2; word-spacing: 0px; -webkit-text-stroke-width: 0px; white-space: normal; text-decoration-thickness: initial; text-decoration-style: initial; text-decoration-color: initial; display: inline !important; float: none;">Virtual reality (VR) is being increasingly used as an adjunctive tool to reduce procedural pain and anxiety during various interventional procedures. Forty articles published between 2020 and 2025 were reviewed. The articles reviewed discuss the use of virtual reality to reduce procedural pain and anxiety during various interventional procedures. The results of the literature analysis show that VR can effectively direct patients’ attention and reduce the subjective intensity of pain and fear during procedures across different age groups. VR has been successfully applied to interventional procedures such as vaccination, blood draws, and peripheral vein punctures in children, as well as to a wide range of interventions in obstetrics, orthopaedics, endovascular surgery, cardiology, and dentistry. The studies reviewed confirm that VR is a safe method that rarely causes adverse side effects and can be integrated into clinical practice, contributing to patient comfort, emotional well-being, and the overall satisfaction with the procedure.
Copyright (c) 2026 Gerda Marčiūtė | Ignas Lapeikis | Greta Kasputytė https://creativecommons.org/licenses/by/4.0
Copyright (c) 2025 Authors https://creativecommons.org/licenses/by/4.0
Pulmonary Artery Thromboembolism (PATE) in Paediatrics: Three Clinical Case Presentations
Background: Pulmonary artery thromboembolism in children is an exceptionally rare condition. Because its clinical presentation and associated risk factors differ from those observed in adults, the condition is frequently underdiagnosed. Case description: We present three cases of paediatric pulmonary artery thromboembolism, each with distinct clinical presentations and differing risk factors. The first case involved a 15-year-old boy who developed fatal massive bilateral pulmonary artery thromboembolism after having spinal trauma, surgery, immobility, and central venous catheter placement. The second case concerned a 17-year-old girl with Prader–Willi syndrome and multiple comorbidities, who presented with severe respiratory failure and laboratory evidence suggesting pulmonary thromboembolism, although imaging to confirm the diagnosis was limited. The third case involved a previously healthy 17-year-old boy with upper-extremity deep venous thrombosis and confirmed pulmonary artery thromboembolism despite the absence of identifiable provoking factors. Conclusions: These cases illustrate the heterogeneity of paediatric PATE presentation, the variability of underlying risk factors, and the diagnostic challenges encountered in clinical practice, underscoring the need for heightened awareness among clinicians.
Copyright (c) 2026 Gabija Asipauskaitė | Greta Miškinaitė | Algirdas Dagys | Vaidotas Gurskis https://creativecommons.org/licenses/by/4.0
Chronic Kidney Disease in Lithuanian Children: Single Center Experience
Background: Chronic Kidney Disease (CKD) in children is relatively rare but carries high burden due to increased morbidity and mortality rates. Unlike adults, where CKD is often secondary to other conditions, pediatric CKD is primarily caused by Congenital Anomalies of the Kidney and Urinary Tract (CAKUT). In Lithuania, data on pediatric CKD are limited, and center-specific patient characteristics and management practices remain underreported in real life settings. This study aimed to assess the current patterns of pediatric CKD in a major Lithuanian tertiary center and evaluate how current practice aligns with guideline recommendations. Material and Methods: A cross-sectional study of children (<18 years) with CKD stages 2–5 at Vilnius University Hospital Santaros Klinikos Pediatric Center was conducted. CKD stages were defined according to the Kidney Disease: Improving Global Outcomes (KDIGO) 2024 guidelines, and the patients were categorized into seven groups according to CKD etiology. Anthropometric measurements, complications, comorbidities, and ongoing treatments were analyzed. Results: A total of 65 children were included (mean age 11.1 years; male-to-female ratio 1.7:1). CAKUT was the most common etiology of CKD (61.5%), with renal hypoplasia being the predominant variant, followed by cystic kidney diseases (13.9%), glomerulopathies (9.2%), and other or unknown causes (9.2%). The mean estimated glomerular filtration rate (eGFR) was 60.5 mL/min/1.73 m², and most children were in CKD stage 2 (66.2%). Differences in age, sex, eGFR, and the CKD stage across the etiology groups were not statistically significant (all p >0.05). Normal weight remained the predominant category at every CKD stage, with a prevalence of 60.0–66.7%. Nearly half of the patients had CKD-related complications, most commonly CKD-mineral and bone disorder, proteinuria, and arterial hypertension. Most children (76.9%) had received at least one treatment for CKD-related complications. Conclusions: Pediatric CKD in Lithuania remains predominantly caused by CAKUT, with most children diagnosed with CKD stage 2. Complications occur even in early stages, and the body mass index distribution does not vary significantly across the CKD stages. Management generally aligned with KDIGO guidelines, but gaps in treating proteinuria, anemia, and growth impairment remain.
Copyright (c) 2026 Ugnė Rukšėnaitė | Karolis Ažukaitis | Rimantė Čerkauskienė | Dovilė Ruzgienė | Renata Vitkevič | Darija Litvinenko | Augustina Jankauskienė https://creativecommons.org/licenses/by/4.0
Stroke and Recurrent Thrombosis of the Coronary Arteries Probably due to Patent Foramen Ovale and Antebrachial Vein Thrombosis in Patient with STEMI – Case Report
74- years old woman with history of cryptogenic stroke in 2010 (during hospitalisation at neurological department possible reasons of stroke were excluded at that time), with less than one year history of paroxysmal atrial fibrillation (AF) treated with apixaban, hypertension, diabetes type II, hypothyreotocsicosis and obesity was admitted to our hospital twice. For the first time admitted due to ST segment elevation myocardial infarction (STEMI) and episode of AF. Coronary angiography revealed occlusion of left circumflex coronary (LCX) artery and percutaneous coronary intervention (PCI) with stent implantation was performed. Conversions of AF episodes to sinus rhythm were spontaneous. Patient was discharged home and admitted once again three days after discharge. STEMI of anterior wall and a new episode of AF was diagnosed. Immediate plain old balloon angioplasty (POBA) with implantation of an additional stent in left anterior descending coronary artery (LAD) was performed. Sixty minutes after procedure, the patient developed symptoms of mild right-sided pyramidal syndrome and slight aphasia. Patient’s status was assessed on 3 points according to the National Institutes of Health Stroke Scale (NIHSS) and patient was not qualified for thrombolysis and mechanical thrombectomy of cerebral artery. Four days after symptoms of stroke, CT did not reveal new significant lesions of the brain and 8-th days after stroke aphasia almost completely disappeared. Thrombus in the left atrium appendage was excluded and patent foramen ovale (PFO) with left to right flow was revealed. Due to the risk of reverse flow as a possible reason of strokes (now and 15 years ago) and recurrent thromboembolisation of coronary arteries and presence of thromboembolisation of antebrachial vein the successful occlusion of PFO with Amplatzer Septal Occluder was performed. In good condition, patient was discharged home.
Copyright (c) 2026 Anna Konopka | Karolina Marzec | Katarzyna Paschalis-Purtak | Marcin Demkow | Joanna Zalewska | Elżbieta Smaga | Ilona Michałowska https://creativecommons.org/licenses/by/4.0
Embryological Basis and Genetic Considerations of Right Lumbar Undescended Caecum with Paracaecal Appendix and Aberrant Vascular Supply
The caecum normally descends to the right iliac fossa during embryogenesis. Disruptions in midgut development may result in its atypical positioning. In a male cadaver, the small, conical caecum and paracaecal appendix were in the right lumbar region. The ileocaecal orifice was on the anterior caecal wall, and the appendicular orifice opened on the medial caecal wall inferior to it. The ascending colon was short and the hepatic flexure was inferior to hepatic quadrate lobe. The right colic artery was absent. The ascending branch of ileocolic artery supplied the caecum, and appendix. The disposition of the rest of the intestinal tract and peritoneum were observed, and measurements taken. Midgut development involves multiple regulatory genes, signalling pathways, transcription factors and mesenchyme-endoderm cross-talk. Mutations in several candidate genes were identified as contributing to midgut malrotation. Awareness of such rare anatomical variation is essential to avoid misdiagnosis of atypical appendicitis or intestinal obstruction.
Copyright (c) 2026 Anand Verma | Madhumita Patnaik | Praveen Kumar Ravi | Sayan Biswas | Manisha R. Gaikwad | Aarthi Manokaran https://creativecommons.org/licenses/by/4.0
Cement Spacer versus Endoprosthesis as Reconstruction Modality after Limb Salvage for Shoulder Malignancies: Systematic Review and Meta-Analysis
Background: Limb salvage is the mainstay of surgical treatment for primary sarcomas as well as metastatic lesions of the proximal humerus. This involves wide excision of the involved humeral segment followed by a reconstruction of the defect. The purpose of this review was to determine which reconstruction modality offers a better overall functional outcome. Methods: After registering a review with the PROSPERO database (ID No. CRD 42025642215), PubMed and Cochrane Library databases were systematically screened for relevant studies meeting our inclusion criteria. The Methodological Index for Non-randomized studies (MINORs) questionnaire was the primary Risk Of Bias (ROB) assessment tool. The included articles were compared with respect to their intra-operative parameters, functional outcome scores, postoperative shoulder Range Of Motion (ROM), as well as complication rates. Results: A total of eight studies, involving 348 subjects in total, were included in this review, out of which, only four articles were found eligible for meta-analysis. Primary malignancy of the bone was the most common diagnosis (Osteogenic sarcoma followed by Ewing sarcoma). A higher frequency of axillary nerve sacrifice was seen in patients undergoing spacer implantation. Musculoskeletal Tumour Society Scores (MSTS) were used as the chief functional outcome determinant and were significantly better in patients undergoing arthroplasty (73.7+7.9 versus 68.9+8.5). A similar trend was observed with regards to shoulder flexion, extension and abduction. The most common complication noted with a cement spacer was proximal implant migration followed by implant failure. On the other hand, dislocation or subluxation of the prosthesis was the most frequently reported issue with arthroplasty. Overall, the local recurrence rate was 9.5%. Conclusion: Cement spacers are ideally suited for patients with a poor socio-economic background, aggressive lesions and a shorter life expectancy, while joint replacement is the reconstructive modality of choice in low-grade, well differentiated, isolated malignancies with negligible chances of sacrificing the shoulder abductor mechanism.
Copyright (c) 2026 Akshat Gupta | Divesh Jalan | Nishith Gupta | Nupur Aggarwal | Kshitish Behera | Princi Jain https://creativecommons.org/licenses/by/4.0
An Unusual Case of a Vulva Tumor in an Adolescent: A Case Report and Literature Review
Background: We present the case of a 15-year-old adolescent with swelling in the left vulva that was found to have a tumor measuring approximately 20x15 cm in her vulva. Ewing’s sarcoma/primitive neuroectodermal tumors (ES/PNET) are rare and malignant. Materials and Methods: Preoperative magnetic resonance imaging and computed tomography performed to screen for metastasis were negative. The mass was surgically excised in total. Results: Immunohistochemistry showed the mass to be ES/PNET. The patient underwent positron emission tomography-computed tomography which revealed metastasis to inguinal lymph nodes and bone. While under chemotherapy for stage-4 ES/PNET, the patient was found to have lung metastasis. She died due to recurrent chemotherapy complications during treatment. Conclusions: This rare case highlights that significant of early diagnosis and multidisciplinary approach to treatment of ES/PNET cases.
Copyright (c) 2026 Hayriye Nihan Karaman Ayyildiz | Zekeriya İlçe | İlkay Tosun | Funda Tekkesin https://creativecommons.org/licenses/by/4.0
Challenges in the Diagnosis of Multiple Sclerosis: A Case Report
Introduction: Multiple sclerosis (MS) may present as a tumor-like, or tumefactive demyelinating lesion, that is indistinguishable clinically and radiologically from a brain tumor. This poses a diagnostic challenge. Case presentation: We present a case report of a 23-year-old woman who was hospitalized in the Neurosurgery Department for biopsy of a brain mass. She had been diagnosed with Hodgkin’s lymphoma at the age of 12, underwent surgery and chemotherapy, and had been in remission ever since. During her annual follow-up a magnetic resonance imaging (MRI) of the brain was performed that revealed a lesion in the right temporal lobe. It was interpreted as central nervous system (CNS) lymphoma. Before arranged neurosurgical intervention, a follow-up MRI scan revealed multiple new small lesions in both hemispheres. Biopsy was not performed, and the patient was referred to the Neurology Department for clarification of the diagnosis. No abnormalities were detected in the tests performed. Cerebrospinal fluid (CSF) was not tested due to the patient’s refusal to repeat the unsuccessful procedure. The patient was discharged from the hospital. Three months later she arrived at the Emergency Department abroad with impaired coordination and hypoesthesia on the right side of the body. Two MRI scans revealed a new lesion in the left posterior periventricular area. CNS lymphoma was suspected again. The patient received treatment with levetiracetam and dexamethasone. Upon her return, an MRI scan was repeated, which revealed an enlargement of the lesion. CSF testing showed indistinct oligoclonal bands. As CNS lymphoma could not be excluded, a lesion biopsy was performed after discontinuation of the steroids therapy. Histological examination excluded malignancy. Later an MRI scan was repeated that showed two new contrast-enhancing lesions. Relapsing-remitting multiple sclerosis (RRMS) diagnosis was confirmed and treatment with disease-modifying therapies (DMTs) was planned. Conclusions: Open-ring enhancement with little or no mass effect on MRI suggests a tumefactive demyelinating lesion (TDL). Moreover, TDLs tend to have a lower relative cerebral blood volume, and higher minimum and average apparent diffusion coefficient values compared to CNS lymphomas. Flow cytometry shows a monotypic B lymphoid population in cases of CNS lymphoma, not in MS.
Copyright (c) 2026 Kristina Galinytė | Gintarė Butenytė | Gintarė Žemgulytė | Jurgita Makštienė | Renata Balnytė https://creativecommons.org/licenses/by/4.0
Teenagers in Face of the War in Ukraine: Experience of Lithuanians
Background: The war in Ukraine, starting on February 24, 2022, shocked Lithuanians who actively support Ukraine and who are still experiencing the threat of an extended war. Adolescents are a sensitive group in society. They go through many changes at their age and are in the process of revealing their feelings and forming their worldviews. The study aimed to investigate how war events in Ukraine affected Lithuanian adolescents’ everyday life, relationships, health, attitudes, concentration, and learning. Materials and methods: Adolescents in 6 high schools filled out an anonymous Google Forms survey developed by the authors comprising general data about the respondent, their interest in war events and their involvement in following the news about the war in media, the impact of war events on their physical and mental health, and the feeling of fear about the threats of the war in Lithuania. Results: 395 adolescents aged 16–19 (mean age 17.01±0.97) filled in the questionnaire. This research revealed that adolescents in Lithuania are moderately interested in war events in Ukraine, and 25.3% noted that they follow news about the war once a week. Most teenagers did not note that the ongoing war in Ukraine would affect their communication, ability to concentrate and learn, hobbies, appetite, and sleep. However, 48.9% indicated that war events affected their emotions and mood. Adolescents who talked about the ongoing war with their parents (55.4%, p=0.00006), who were more interested in war events in the media (median=229.7, p<0.001), and girls (53.3%, p=0.008) were statistically significantly more likely to notice that the ongoing war would affect their emotions and mood. 60.8% of the respondents felt fear and threat that war may break out in Lithuania as well. Conclusions: The news in the media and the constant threat of war affect Lithuanian youth, mostly their emotions and mood. Therefore, it is crucial to research and monitor their emotional health, discuss things with teenagers, and provide them with a possibility to share their views, thoughts, perceptions, fears, and feelings. Talking with youth about the war situation responsibly, promptly, and age appropriately is essential.
Copyright (c) 2026 Sigita Lesinskienė | Augustė Lapinskaitė | Augustė Česnauskaitė https://creativecommons.org/licenses/by/4.0
The Influence of Meteorological Factors on Osteoarthritis Symptoms and Physical Activity: A Narrative Review
Background: Meteorological conditions are suspected to influence osteoarthritis (OA) symptoms, but findings across climates and populations are inconsistent. Understanding how temperature, humidity, and barometric pressure affect pain, stiffness, and physical activity is relevant for clinical counselling and study design. Objective: To synthesize recent evidence on associations between natural weather variation and OA symptomatology, including impacts on physical activity and rehabilitation participation. Methods: We searched PubMed, ScienceDirect, and Google Scholar for peer-reviewed human studies published from January 2010 to May 2024 by using terms related to osteoarthritis and meteorological factors (temperature, humidity, barometric pressure, precipitation, seasonal variation) combined with pain, stiffness, function, or physical activity. Inclusion criteria comprised clinically or radiographically confirmed OA and quantitative outcomes linked to measured meteorological exposures. Interventional artificial heat/cold studies and non-primary data were excluded. Two reviewers independently screened, selected, and extracted data with consensus resolution. Results: Temperature showed the most consistent patterns: colder and more variable conditions were linked to increased pain and stiffness, whereas warmer, stable conditions favored mobility. Humidity and barometric pressure fluctuations showed modest effects, particularly under cool and damp conditions. Precipitation, sunlight, and wind had minimal or inconsistent associations. Adverse weather was associated with a reduced outdoor activity and lower rehabilitation participation. Conclusions: Weather acts as a contextual modifier rather than a primary determinant of OA symptoms. Recognizing meteorological influences may aid patient counselling, season-sensitive rehabilitation planning, and the design of outcome studies.
Copyright (c) 2026 Karolis Strašunskas | Matas Mikalauskas | Ona Montvydaitė-Kreivaitienė https://creativecommons.org/licenses/by/4.0
Acute Pancreatitis Unmasking an Ectopic Parathyroid Adenoma in MEN1 Syndrome and Cushing’s Syndrome: A Rare Clinical Convergence
Ectopic parathyroid adenoma within the spectrum of Multiple Endocrine Neoplasia Type 1 (MEN1) is an extremely rare clinical entity. We report a 27-year-old woman who presented with acute pancreatitis as the sentinel manifestation of MEN1, an atypical and intriguing clinical scenario. Initially, her serum calcium levels were deceptively normal, only to surge later, unmasking a deeper endocrine pathology. Subsequent biochemical evaluation established primary hyperparathyroidism (PHPT), and a MIBG scan revealed an ectopic parathyroid adenoma as the culprit lesion. Further endocrine profiling disclosed Cushing’s syndrome (CS), confirmed through a low-dose dexamethasone suppression test, while a positive family history of MEN1-related tumors in her sister solidified the syndromic diagnosis. She was treated with aggressive hydration, analgesia, antibiotics, and supportive therapy, followed by successful parathyroidectomy. This case illustrates a remarkable convergence of conditions ectopic parathyroid adenoma, acute pancreatitis, and MEN1 with the additional complexity of initially normocalcemic presentation during the acute phase of pancreatitis. Although the pathophysiological link between hypercalcemia and pancreatitis remains debated, pancreatitis secondary to hypercalcemia from primary hyperparathyroidism is rare, and its presentation as the first clue to MEN1 is exceptionally uncommon. ACTH-secreting pituitary adenomas causing Cushing’s syndrome are also a rare manifestation of MEN1, and the concomitant presence of an empty sella on MRI further underscores the uniqueness of this case. To the best of our knowledge, this represents the first documented instance in which acute pancreatitis with normocalcemia concealed an underlying ectopic parathyroid adenoma in MEN1, accompanied by Cushing’s syndrome and an empty sella, making this a noteworthy clinical and diagnostic rarity.
Copyright (c) 2026 Asif Dabeer Jafri | Om Prakash Sanjeev | Aftab Hasan Nazar | Ratender Kumar Singh https://creativecommons.org/licenses/by/4.0
When Local Beats Systemic: Durable Control of Metastatic Undifferentiated Uterine Sarcoma and Surveillance Uncovering a Second Primary
Introduction: Undifferentiated uterine sarcoma (UUS) is a rare, aggressive uterine mesenchymal malignancy with poor prognosis, for which, evidence supporting metastasis-directed treatment strategies is limited. Case presentation: A 59-year-old woman underwent total hysterectomy with bilateral salpingo-oophorectomy (R0) for stage IB UUS in 2016, followed by adjuvant doxorubicin–ifosfamide. Three years later, surveillance CT identified bilateral pulmonary metastases. Video-assisted thoracoscopic resection confirmed metastatic UUS, and stereotactic body radiotherapy (SBRT) was delivered to residual and subsequent lung lesions, achieving sustained local control without systemic therapy. The patient remained progression-free for almost three years. In 2024, follow-up imaging showed no active sarcoma but incidentally detected a left breast lesion; biopsy revealed invasive ductal carcinoma with mucinous features. She underwent breast-conserving surgery with sentinel lymph node biopsy (pT1N0(sn)), followed by adjuvant whole-breast radiotherapy and endocrine therapy with tamoxifen. Outcomes: At 8.5 years from UUS diagnosis and one year after breast cancer treatment, the patient remains alive with no evidence of recurrent or metastatic disease and with excellent performance status (ECOG 0). Conclusions: This case demonstrates prolonged, chemotherapy-free control of metastatic UUS using a metastasis-directed strategy combining surgery and SBRT, and highlights the importance of continued surveillance for secondary primary malignancies. It supports considering an oligometastatic treatment paradigm and multidisciplinary management in selected UUS patients despite the absence of prospective data.
Copyright (c) 2026 Ignas Lapeikis | Vakarė Baranauskytė | Dainius Jančiauskas | Lina Pužauskienė | Erika Korobeinikova https://creativecommons.org/licenses/by/4.0
Combined Anatomical Variation of Axillary Artery and Biceps Brachii Muscle: A Case Report
Anatomical variations of the axillary artery and its branches are clinically relevant as they may complicate surgeries in the axilla and shoulder. Accessory heads of the biceps brachii can compress key neurovascular structures. The present report describes these variations observed on the left upper limb of a 79 years old male cadaver during cadaveric dissection. We observed that the usual branches of the 3rd part of the axillary artery as well as the profunda brachii artery originated from the 2nd part of the axillary artery via a common trunk in the left axilla. In addition to that, a small accessory head of the biceps brachii was observed on the left arm originating from the shaft of the humerus. Knowledge about variant branches of the axillary artery is surgically important for establishment of collateral circulation around the scapula following shoulder surgeries. The accessory head of biceps brachii may cause nerve entrapment neuropathy leading to mysterious pain syndrome in the upper limb.
Copyright (c) 2026 Dibakar Borthakur | Parul Kaushal | S. B. Ray https://creativecommons.org/licenses/by/4.0
Forecasting the Impact of Knowledge of International Humanitarian Law Acquired by Ukrainian Medical Students on Their Practical Activities and the Formation of Humanity in Society
Purpose: International humanitarian law (IHL) and the principle of medical neutrality are vital for safeguarding human life and dignity during armed conflicts. This study aimed to evaluate the current state of IHL education in Ukrainian medical institutions and forecast its impact on future healthcare professionals’ professional practice and humanistic orientation. Methods: A mixed-methods design was applied, including content analysis of curricula from 17 higher education institutions across different ministries and an online sociological survey of 174 respondents, primarily medical students and healthcare professionals. Quantitative data were analyzed by using frequency distributions and Spearman correlation, while qualitative analysis explored the respondents’ ethical reasoning in conflict-related scenarios. Results: Only one-third of Ukrainian medical universities included dedicated IHL courses, primarily as electives. Self-reported awareness of IHL was low to moderate, with 23% rating their knowledge as good and 26% as poor. Despite this, 81.4% of medical students agreed with impartial medical assistance to all victims, regardless of affiliation. A weak but positive correlation (ρ=0.15) was found between IHL knowledge and humanitarian attitudes. Female students demonstrated stronger humanitarian orientations compared to males. Conclusion: IHL education in Ukraine remains fragmented and insufficient, yet students display a high ethical potential aligned with humanitarian principles. Structured, value-oriented IHL curricula, including practical training and case-based learning, are needed to strengthen medical neutrality, enhance ethical decision-making, and foster the formation of humanistic values in Ukrainian society.
Copyright (c) 2026 Oksana Soroka | Volodymyr Voloshynovych | Yulia Kotsyubynska https://creativecommons.org/licenses/by/4.0