Background/Objectives: War-related mandibular injuries result in extensive soft-tissue damage, severe comminution, and bone loss, and are associated with high rates of infection and delayed healing. No universally accepted management protocol exists for these injuries. External fixation is commonly used in this context, particularly when internal fixation is unavailable or contraindicated. This study aimed to analyze injury patterns, treatment outcomes, and complications of war-related mandibular fractures treated with external fixation as a primary and definitive stabilization method in a resource-limited setting in eastern Democratic Republic of Congo. Methods: A retrospective review was conducted of all patients who sustained war-related mandibular fractures and were treated with external fixation between January 2017 and December 2024 at the Hôpital Provincial Général de Référence de Bukavu. Demographic data, injury characteristics, treatment details, outcomes, and complications were collected. Factors associated with delayed union and fracture-related infection were evaluated using univariate analysis. Results: Ninety-one patients with severe mandibular war injuries were included. High-velocity gunshot wounds accounted for 94.5% of injuries. Clinical evidence of wound infection at admission was present in 29.7% of patients. The mean delay between injury and external fixation was 9.2 ± 6.6 days. Successful bone healing without secondary bone procedures was achieved in 71 patients (78.0%), with a mean healing time of 7.6 ± 3.0 weeks. Delayed bone grafting was required in 20 patients (22.0%), performed at a mean of 77.3 ± 30.5 days after initial fixation. The overall complication rate was 36.3%, with fracture-site infection being the most frequent complication (30.8%). Bone loss at presentation, clinical infection at admission, and the need for bone grafting were significantly associated with fracture-related infection (p < 0.05). Conclusions: War-related mandibular fractures in this series were characterized by severe comminution, bone loss, infection, and delayed presentation. Despite these challenges, external fixation provided acceptable fracture healing and functional outcomes. Small orthopedic external fixators represent a pragmatic and effective treatment option for complex mandibular war injuries in resource-limited settings.

Background/Objectives: Post-COVID-19 syndrome (PCS) is frequently accompanied by pain, which may coexist with alterations in multiple health domains. However, pain in PCS has rarely been explored from a multidimensional approach combining subjective and objective measures. Objective: To describe pain in subjects with PCS using pain intensity and the pressure pain threshold (PPT), and to examine the associations between these measures and descriptive characteristics as well as health status. Methods: A cross-sectional observational study was conducted in 45 previously hospitalised adults with PCS. Pain intensity was assessed using the visual analogue scale and PPT was assessed by algometry. Health status included fatigue, dyspnoea, anxiety, depression, quality of life, functionality, frailty, physical activity, muscle quality, muscle strength, physical performance, and functional capacity. Analyses were conducted using SPSS v30.0. Results: Participants showed moderate pain intensity and variability in PPT, with a significant inverse association between both measures. Bivariate analyses showed that higher pain intensity and lower PPT were associated with worse physical, psychological, and functional outcomes. In regression analyses, pain intensity was associated with sex, length of hospital stay, PPT, and quality of life; PPT was associated with sex, pain intensity, and grip strength. Model explanatory capacity varied, and some models were not statistically significant. Conclusions: Subjects with PCS exhibited moderate pain intensity and variability in pain sensitivity, with an association between subjective and objective pain measures. Pain measures were associated with multiple health domains at the bivariate level, while regression analyses identified a limited number of associations with variable explanatory capacity. These findings support comprehensive pain assessment in PCS.

OBJECTIVES:The aim of this study was to verify the efficacy of airway clearance technique on drug delivery by nebulization. DESIGN:Cross-over study. PARTICIPANTS:Stable patients with CF (PwCF) (n=8). INTERVENTIONS:Participants performed the airway clearance technique before or after the nebulization session. The Autogenic Drainage (AD) was the executed airway clearance techniques. The nebulization session was a delivery of 500 mg-amikacin with the AKITA®. MAIN OUTCOME MEASURES:The primary endpoint was the 24 h-urinary excretion of amikacin. RESULTS:PwCF were between 18 and 48 years old (FEV1: 43 to 92 %), all colonized by Pseudomonas aeruginosa, and all with bronchiectasis. Irrespective of the order of the nebulization and the physiotherapy sessions, the total amount of urinary amikacin excretion was similar (Median Difference (95%CI): 0 (-7 to 4)% of the nominal dose). The elimination constant rate for nebulization before (Median: 0.153 (IQR: 0.071 to 0.205)) and after the airway clearance technique (0.149 (0.041 to 0.182); p = 0.26) were similar (Median difference (95%CI): 0.02 (-0.004 to 0.023)). CONCLUSIONS:The lung delivery of nebulized medication in PwCF colonized with Pseudomonas aeruginosa was not improved by the order of the airway clearance and nebulization procedures. CONTRIBUTION OF THE PAPER.

INTRODUCTION:Airway clearance techniques (ACT) are a longstanding modality of treatment in many chronic respiratory diseases. Their aims are to counteract airway obstruction by mobilizing airway secretions and/or by limiting the airway collapse. AREAS COVERED:This review first outlines the physiological mechanisms underlying ACT. In a second part, it categorizes the ACT into seven distinct groups. These groups include both instrumental and non-instrumental ACT. Strategies such as physical activity and upper airway clearance techniques are also considered as ACT due to their complementary roles in mobilizing airway secretions. EXPERT OPINION:The lack of standardized definitions for airway clearance techniques (ACT) leads to significant differences in the clinical practice and effects because the variability in physiological mechanisms. Studies show that both manual and instrumental ACT are influenced by therapist-dependent factors such as applied force, duration of the application, and patient positioning. To ensure reproducibility and effective teaching, a single, physiologically grounded description of ACT is urgently needed.

Introduction:Despite being a proposed treatment, there is no agreement on airway clearance management for patients hospitalised with an acute exacerbation of chronic obstructive pulmonary disease (AECOPD). The aim of this work was to establish international consensus on the selection of airway clearance techniques (ACTs) for these patients and identify which ACTs are commonly used. Methods:A modified Delphi study was employed. A panel of experienced physiotherapists working in Europe (n=162, 12 countries) was invited to respond to two online Delphi survey rounds. A 5-point Likert scale ranging from 1 (strongly disagree) to 5 (strongly agree) was used; consensus was defined as a median score of ≤2 or ≥4 and 75% agreement. Results:Consensus was reached for the use of seven ACTs, including forced expiratory techniques (FETs), positive expiratory pressure (PEP) and oscillatory positive expiratory pressure (OPEP), in cases of limited treatment time, obesity, low patient motivation or for localised secretions. Consensus was reached against the use of five ACTs, including manual percussion, vibrations and shaking, in patients with resting breathlessness, frailty, obesity or high resting lung volumes. The most used ACTs among participants were PEP, FETs and active cycle of breathing techniques. Participants from nine countries identified ACTs that are commonly used by all of the country's participants. Conclusions:European-based physiotherapists report using a variety of ACTs, with some regional preferences noted in certain countries. Consensus was able to be reached regarding which ACTs should be used or avoided for patients hospitalised with AECOPD under a range of clinical circumstances.

PURPOSE:To examine the relationship between post-COVID-19 frailty and dyspnea, fatigue, and physical and functional status in subjects with post-COVID-19 syndrome (PCS), and to compare these outcomes according to frailty level. METHODS:A cross-sectional study was conducted at the University of Granada (March-June 2024). Forty-five previously hospitalized subjects (18-80 years) with PCS were classified as robust (n = 13), pre-frail (n = 21), or frail (n = 11) using the FRAIL scale. Persistent symptoms and physical and functional parameters were assessed using validated questionnaires and standardized tests. RESULTS:Frailty correlated positively with dyspnea at light, moderate, and intense exercise, overall dyspnea, and fatigue, and negatively with physical activity, muscle quality, strength, and performance. Functionality showed a strong association with frailty. Regression analysis identified length of hospital stay and comorbidities as significant factors in the descriptive model, whereas persistent symptoms were not associated. In the physical-functional model, only functionality was associated. Group comparisons revealed a progressive pattern across frailty levels. CONCLUSION:Post-COVID-19 frailty is associated with greater dyspnea and fatigue, and reduced physical and functional status. Early identification and targeted interventions may be important, although causal inferences are limited by the cross-sectional design, small sample size, and potential overlap between frailty and outcome measures.

​Background: The relationship between obstructive sleep apnea (OSA) and hypertension is well established, but whether OSA contributes similarly to hypertension detection and blood pressure control remains unclear.Objective: To assess whether OSA severity and its physiological components are associated with newly detected hypertension and blood pressure control in treated patients.Methods: We conducted a retrospective cohort study of 4,371 adults undergoing diagnostic polysomnography. Patients were classified into four groups: no hypertension, undiagnosed hypertension, controlled hypertension, and uncontrolled hypertension. Multivariable logistic regression assessed associations between OSA severity and hypertension phenotypes using the apnea–hypopnea index (AHI), desaturation index, and arousal index, adjusted for age, sex, and body mass index. Among patients with established hypertension, treatment intensity and its interaction with AHI were also evaluated.Results: Among patients without prior hypertension (n=2,716), 913 (33.6%) had newly detected hypertension. AHI was independently associated with undiagnosed hypertension (adjusted OR 1.008/event/h, 95% CI 1.003–1.013; p<0.001). Among patients with established hypertension (n=1,655), 883 (53.4%) had uncontrolled blood pressure. AHI showed no overall association with blood pressure control, but a significant interaction with treatment intensity was observed (p=0.018), with the association progressively attenuating as pharmacological burden increased. This interaction was predominantly driven by systolic blood pressure. The arousal index showed a borderline association with uncontrolled hypertension, whereas the desaturation index did not.Conclusions: OSA is associated with unrecognized hypertension detection, whereas its impact on blood pressure control appears context-dependent and modulated by treatment intensity. These findings support a phenotype-based approach to OSA-related cardiovascular risk assessment.

AIMS:Mechanical insufflation-exsufflation (MI-E) is effective for pediatric airway clearance. A novel coaching module using playful visual feedback is available, but its learning efficacy is unknown. This study investigated whether adding the module to physiotherapist guidance improves learning speed. METHODS:In this randomized controlled trial, healthy children aged 6-10 years, naive to MI-E, were assigned to a coaching group with the coaching module plus physiotherapist guidance or a control group (physiotherapist guidance only). Learning was assessed over two sessions by the number of sets to achieve success and visual analog scales (VAS) for playfulness and ease of learning. RESULTS:Twenty children were included in the final analysis (9 girls, 11 boys; mean age 9.0 ± 1.3 years), including 11 in the coaching group and 9 in the control group. The coaching group required significantly fewer sets in session one (2.3 ± 1.1 vs 4.1 ± 1.9; p = 0.01), but not during the second session. VAS scores showed no significant differences. CONCLUSION:Playful visual feedback can accelerate initial MI-E learning in children, offering a promising strategy for early training. Further research is needed to evaluate long-term outcomes and home-based implementation.

BACKGROUND:As reduced exercise capacity and muscle weakness are common in people with cystic fibrosis (pwCF) and associated with worse life prognosis and quality of life, we aimed to evaluate the changes in functional exercise performance and peripheral muscle strength in pwCF after two years of elexacaftor/tezacaftor/ivacaftor (ETI). METHODS:The 6-Minute Walk Test (6MWT), 1-Minute Sit-to-Stand Test (1STST) and measurement of Maximal isometric Voluntary Contraction of the Quadriceps (MVCQ) with a dynamometer were performed before initiating ETI and after one and two years of ETI. RESULTS:82 pwCF (≥12y) were recruited. The 6MWT distance increased significantly after one and two years of ETI compared with baseline (608±73 m at baseline; 636±75 m after one year of ETI, p < 0.0001; 641±71 m after two years of ETI, p < 0.0001). The number of repetitions during the 1STST enhanced significantly after one and two years of ETI compared with baseline (51±15 at baseline; 55±14 after one year of ETI, p = 0.0022; 56±14 after two years of ETI, p = 0.0042). MVCQ also showed a significant improvement after one and two years of ETI compared with baseline (69±29Nm at baseline; 76±28Nm after one year of ETI, p = 0.0015; 82±29Nm after two years of ETI, p < 0.0001) as well as between one and two years (p = 0.0139). In contrast, no significant change was observed when comparing results in 6MWT and 1STST between one and two years of ETI. CONCLUSION:6MWT, 1STST and MVCQ improved after one year of ETI with improvements persisting at two years of treatment.

This study provides the first direct evaluation of regional ventilation distribution during airway clearance techniques (ACTs) in the lateral posture using electrical impedance tomography. We show that the intended increase in dependent-lung ventilation is not achieved; instead, ventilation shifts toward a more homogeneous right-left ventilation distribution, particularly during slow expiration with open glottis, in both healthy and chronic obstructive pulmonary disease (COPD) individuals. These findings refine the physiological understanding of ACTs and their potential optimization in clinical practice.

OBJECTIVE:To assess the impact of combining positive expiratory pressure (PEP) and nebulisation on lung delivery by measuring the urinary concentration of amikacin, used as a biomarker in people with cystic fibrosis. DESIGN:Randomised crossover study. PARTICIPANTS:Nine people with cystic fibrosis. INTERVENTION:A solution of amikacin was nebulised using a nebuliser alone or a nebuliser in combination with a PEP device. OUTCOME MEASURES:After nebulisation, urine samples were collected over 24 hours. The total amount of amikacin excreted in urine was calculated, reflecting the lung dose. The elimination rate constant was also calculated, and represents total drug elimination by excretion and metabolism. RESULTS:No differences in lung dose, half-life or elimination rate constant were observed between the two methods of nebulisation. Lung dose divided by respiratory rate was significantly greater for nebulisation in combination with PEP. CONCLUSION:The use of nebulisation in combination with PEP does not result in clinically significant improvements in drug delivery in people with mild-to-moderate cystic fibrosis. However, this combination can be used safely to reduce the duration of physiotherapy sessions without compromising drug delivery. TRIAL REGISTRATION:NCT02535130. CONTRIBUTION OF THE PAPER.

Despite its well-known benefits, respiratory rehabilitation (RR) remains underutilized among people with chronic obstructive lung disease (COPD) due to both patient- and physician-related barriers. This qualitative study (October 2023-March 2024) used two questionnaires: one for people with COPD to assess disease severity and access challenges, and another for pulmonologists to identify prescription obstacles. Distributed via associations and mailing lists, the survey reached 3,000 people with COPD and 500 pulmonologists, revealing shared concerns about facility shortages, poor information, and transportation issues. Enhancing RR access through better training, patient education, and expanded facilities should be a public health priority.

Purpose: Maximal inspiratory pressure (MIP) is a simple measure that reflects inspiratory muscle strength, which is often impaired in individuals with chronic obstructive pulmonary disease (COPD). This study aimed to assess the test–retest reliability, minimal detectable change (MDC) of MIP in persons with COPD, as well as to revisit its relationship with the 1-minute sit-to-stand test (1STST). Methods: Individuals with stable COPD were recruited. The study protocol included 2 visits. During the first visit, participants performed the MIP measurement and the 1STST with a 30-minute interval. The second visit was repeated within 10 days to assess between-day test–retest reliability. Results were reported as mean and SD. Results: The MIP measurement demonstrated excellent test–retest reliability (intraclass correlation coefficients [ICC] = 0.94, 95% CI: 0.89, 0.97, P = .001). Bland–Altman plots revealed a mean bias in the MIP measurement of 3.3 cmH 2 O, with limits of agreement ranging from −17.7 to 24.3 cmH 2 O. The MDC for MIP was estimated to be 7.3 cmH2O, respectively. A weak positive correlation (r = 0.29, P = .03) was observed between MIP and 1STST performance. Conclusions: This study demonstrated excellent between-day test–retest reliability of MIP measurement in persons with mild to moderate COPD. In addition, a weak positive correlation was found between 1STST and MIP in this population.

INTRODUCTION:The Nijmegen Questionnaire assesses hyperventilation syndrome (HVS), but a validated Vietnamese version is lacking. This study investigates the cross-culture validity, structural validity, and reliability of the Vietnamese Nijmegen questionnaire (VNQ) for screening HVS in primary healthcare settings. METHODS:Following Beaton's guidelines, translation and adaptation involved two independent expert panels for content validity. Exploratory factor analysis (EFA) and confirmatory factor analysis (CFA) examined the VNQ's structure. Reliability was assessed via Cronbach's alpha, intraclass correlation coefficients, Bland-Altman analysis, and linear regression. RESULTS:Content validity was excellent (all I-CVIs > 0.79 and all S-CVIs > 0.8). EFA revealed a four-factor structure, including the original three NQ factors and a new "psychology" factor, confirmed by CFA. Cronbach's alpha and ICC values exceeded 0.7 and 0.8, respectively, indicating good internal consistency and test-retest reliability. Bland-Altman analysis showed low systematic error, and linear regression revealed no proportional bias (P > 0.05). CONCLUSION:The VNQ demonstrates excellent content validity, acceptable structural validity, and reliable psychometric properties for HVS screening in primary healthcare settings.

Background/Objectives: Patients with COPD have altered self-esteem, and good self-esteem promotes personal, health, and social success. Improving self-esteem could be a method for encouraging the maintenance of physical activity. Only one study has evaluated the effects of pulmonary rehabilitation (PR) on self-esteem in moderate COPD patients. The objective was to assess the evolution of self-esteem in COPD patients of all stages of severity during PR. Methods: COPD patients undergoing PR were included in this prospective observational study. Patients were evaluated before and after the 4-week PR program. The objectives were to (1) assess the evolution of self-esteem using the Physical Self Inventory-6 questionnaire (PSI-6), (2) assess the evolution in each sub-score of PSI-6, (3) examine the correlations between the evolution of self-esteem and the evolution of parameters usually used during PR, and (4) determine an MID for self-esteem. Results: In total, 76 patients were included. We found that there was a significant increase in the total score in PSI-6 (9.29, p < 0.001), CI 95% [6.74; 11.83], and in the sub-scores of PSI-6. The evolution of the PSI-6 score was moderately correlated with changes in exercise capacity using STST1 (r = 0.352, p = 0.002) and quality of life (r = -0.361, p = 0.001) and weakly correlated to changes in dyspnea (r = -0.245, p = 0.03), anxiety (r = -0.248, p = 0.03), and depression (r = -0.290, p = 0.01). Using a distribution-based analysis, we found an MID between 5.2 and 5.6. Conclusions: We showed a significant increase in global score and in each sub-score of self-esteem using PSI-6 in COPD patients undergoing a PR program. We propose an MID of 5.6.

INTRODUCTION:Nasal irrigations are a longstanding modality of treatment. Mechanical nasal lavage and irrigation of the nasal cavities and paranasal sinuses are frequently conflated under the principle of nasal irrigations even if the objectives are different. AREAS COVERED:The aims and principles of these two different modalities are described in the first part of the paper. In the second part, the literature is summarized based on the data related to the clinical efficacy of the nasal irrigation and on the results of the studies assessing the physical efficacy of the delivery. EXPERT OPINION:Although abundant, the literature does not provide strong enough evidence about the optimal nasal irrigation modality. There is a genuine need for a clear definition of terms and evidence-based recommendations on the techniques that should be proposed to patients according to specific clinical objectives. The authors proposed a new terminology to distinguish between nasal clearance irrigation and nasal drug irrigation.

IntroductionAcute exacerbations of COPD (AECOPD) often involve mucus hypersecretion. Thus, management of sputum retention is critical. However, the use of airway clearance techniques (ACTs) in people with AECOPD across different healthcare settings and factors influencing their selection remain unclear.ObjectiveTo identify and map ACTs used for AECOPD in different healthcare settings and the factors influencing clinical decision-making worldwide.MethodsFour electronic databases and grey literature were searched from 1995 to December 2023, with hand-searching of eligible records. The Joanna Briggs Institute methodology for scoping reviews was followed.Results25 articles were included: 14 clinical studies, five guidelines/statements and six surveys/audits. Clinical studies reported the use of a wide range of single or combined ACTs, with no clear pattern in using particular ACTs in different parts of the world. Recent guidelines advise using ACTs for certain patients with AECOPD, particularly those with hypersecretion, with most guidelines recommending positive expiratory pressure (PEP) therapy. According to surveys, the most used ACTs in Australia and Europe are active cycle of breathing techniques, PEP or forced expiratory technique, while vibrations are most frequently used in Canada. Factors influencing the selection of specific ACTs include the presence of contraindications, level of dyspnoea, access to resources/equipment and ease of learning/performing the technique. All information was derived from hospital settings.ConclusionsThis scoping review identified and mapped ACTs used for people with AECOPD worldwide and their decision-making factors. Future work should focus on community settings.

Background/Objectives: In maxillo-facial high-velocity complex war injuries, a rigid internal fixation is inappropriate, and external fixation is suitable with described benefits. This systematic review aimed to summarize the literature regarding the benefits, side effects and complications of external fixators in the management of mandibular war-related injuries. Methods: An electronic search was performed in the databases of PubMed and Google Scholar in December 2024. The title and abstracts from retrieved items were read by two reviewers to identify studies within the selection criteria. Included articles had to be published in English up to December 2024 and related to external fixators used in mandibular fracture war injuries. Results: The search strategy initially identified 445 studies through PubMed and 987 studies through Google Scholar. Following the application of inclusion criteria, 12 articles were selected for this review, describing the use of an external fixator for a mandibular fracture in a war injury. Conclusions: The external fixator offers effective treatment for severe mandibular fractures in war-related injuries with low rates of complications and high success rates. Where a manufacturer external fixator is not available, orthopedic external fixators and self-crafted external fixators are used.