Cureus

We are pleased to submit our Original article entitled "Assessing medication-related burden and medication adherence among older patients from Central Nepal: A machine learning approach" for consideration in your esteemed journal. In this paper, we assessed medication burden using validated Living with medicines Questionnaire (LMQ-3) and medication adherence using Adherence to Medication refills (ARMS) Scale. In this paper we analysed our result through machine learning approach in spite of traditional statistical approach to identify the complex factors influencing both. Six ML architectures (Ordinary Least Square, LightGBM, Random Forest, XGBoost, SVM, and Penalized linear regression) were employed to predict ARMS and LMQ scores using various socio-demographic, clinical and medication-related predictive features. Model explainability was provided through SHAP (Shapley Additive exPlanations). Our study identified the moderate medication burden with moderate non-adherence among older adults. Requiring assistance for medication and polypharmacy were the strongest drivers for the medication burden and non-adherence. The high predictive accuracy by ML suggests the appropriate clinical intervention like deprescribing to cope with the high prevalent medication burden and non-adherence among older adults in Nepal.

Hypospadias, a common congenital anomaly requiring surgical correction, has seen growing research in surgical techniques and outcomes. However, no comprehensive bibliometric or disruption-based analysis exists to map the fields evolution. This study uses bibliometrics and the Disruption Index (DI) to identify key transformational research in hypospadias. A systematic search of five databases (PubMed, Web of Science, ScienceDirect, Scopus, and Dimensions) from January 1990 to December 2023 was conducted, yielding 7,732 articles. After applying inclusion criteria, 200 studies were analyzed. Citation data and DI scores were calculated using OpenCitations. Spearmans rank test assessed correlations between DI and citation metrics. A subgroup analysis identified trends based on the latest hypospadias research priorities. The mean citation count was 72.3 (SD = 43.1) with a mean DI of 0.011 (SD = 0.17). Five studies, focusing on complications, analgesia, and surgical techniques, had the highest DI (1.0). A moderate positive correlation was found between DI and citation rate ({rho} = 0.405, p < 0.001). Subgroup analysis showed most research focused on surgical techniques (30.5%) and etiology (25.8%), while areas like surgical training (2.6%) and innovation (0%) were underrepresented. This study identifies critical gaps in hypospadias research. The DI reveals influential studies that redirect research trajectories. Future work should focus on innovation and translational research to accelerate advancements in hypospadias care.

BackgroundLasers have wide applications in medicine and dermatology, but are associated with pain and anxiety, particularly in younger patients. Pain mitigation is often limited to topical anesthetics in the outpatient setting. Distraction techniques are limited by the need for ocular protection, which can include adhesive eye patches that can completely occlude vision. Virtual reality is effective at managing procedural pain and anxiety under other short medical procedures and is a promising tool for this population. ObjectiveThis trial aims to assess the safety, feasibility, and efficacy of Virtual Reality Pain Alleviation Therapeutic (VR-PAT) for pain management during outpatient laser procedures. Methods40 patients requiring outpatient laser therapy for at least two sessions will be recruited from a pediatric hospital in the midwestern United States for this crossover randomized, two-arm clinical trial with a 1:1 allocation ratio. During the first laser visit, the participant will be randomly assigned to either play the VR-PAT game during their procedure or wear the headset with a dark screen. Participants will answer questions about their pain (Numeric Rating Scale (NRS) 0-10), anxiety (State Trait Anxiety Inventory for Children, NRS 0-10, Modified Yale Preoperative Anxiety Scale (mYPAS)), and pain medication usage. Those playing the VR-PAT will additionally report simulator sickness symptoms and their experience playing the game. At their second laser visit, participants will crossover to the opposite intervention from their first visit. The primary outcomes are the difference in self-reported pain and anxiety between the two interventions. Feasibility outcomes include the proportion of screened patients who are eligible, consent, and complete both visits and adverse events reported. To evaluate the efficacy of pain reduction, composite scores of pain score, pain medication will be calculated for each laser visit. To evaluate the efficacy of anxiety reduction, the change of mYPAS scores will be compared between control and VR groups at each visit using Wilcoxon rank sum tests. All statistical analyses will follow the intention-to-treat principle in regard to intervention assignment at each visit. ResultsThe study was funded in January 2023 and began enrollment at that time. A total of n=44 participants were recruited and data collection was completed in November 2025, with n=40 subjects completing both visits. The sample was balanced with n=40 subjects using the intervention and participating in the control condition. The age range of the complete sample was 6 to 21 years at recruitment and was 55% female sex. Data analysis is in progress with final results planned for June 2026. ConclusionsFindings from this innovative randomized clinical trial will provide early evidence on the efficacy of the VR-PAT for reducing self-reported pain and anxiety during outpatient laser procedures. The results from this trial will inform a large-scale, multisite study. Trial RegistrationClinicalTrials.gov: NCT05645224 [https://clinicaltrials.gov/study/NCT05645224]

Background Inflammatory markers play an important role in the pathophysiology of Lumbar disc herniation (LDH). This study presents a comprehensive multi-assessment of the inflammatory landscape by combining serum inflammatory cytokines quantification, their diagnostic performance, associations with radiological features, and integrating the experimental findings into an in-silico protein-protein interaction network. Methods A multifaceted study design was utilized to quantify and compare the distribution of selected inflammatory cytokines in patients with LDH and control subjects. The diagnostic ability of these cytokines was assessed using receiver operating characteristic curve analysis. The cytokines values were correlated with selected radiological findings including disc herniation subtypes (protrusion, extrusion, and sequestration), and further categorized as contained and non-contained in patients using a Spearmans rank correlation test. Additionally, computational analysis was performed to identify the central hubs and functionally enriched pathways. Results In patients with LDH, IL-6 and IL-1{beta} showed statistically significant (IL-6: p < 0.001; IL-1{beta}: p = 0.001) rise, but IL-6 showed high diagnostic and discriminative power (AUC = 0.99; cut-off: 19.99 pg/mL). Further IL-1{beta} exhibited a positive correlation with non-contained disc herniation (extrusion and sequestration), while displaying a significant (p < 0.05) negative correlation with protrusion. In silico analysis identified IL-1{beta}, IL-8, TNF-, IL-6, IL-1, CSF2, CSF3, and IL-10 as central hubs, with IL-1{beta} being the top ranked hub in determining functionally enriched cytokine-cytokine receptor interaction. Conclusions Study confirmed IL-6 as a powerful diagnostic marker for LDH, while IL-1{beta} aids in determining contained and non-contained disc herniation. Further, IL-1{beta} was identified as the central hub, triggering functionally enriched pathways in the pathogenesis of LDH.

ObjectiveOnly preliminary investigations on the use of the 445 nanometer wavelength blue light laser (BLL) for various laryngeal pathologies have been described. Currently, no standard exists for reporting treatment technique and tissue effect with this modality. Here, we aim to establish and validate a classification system to describe laser-induced tissue effects. Study DesignRetrospective video-based study for classification development and reliability validation. MethodsVideo recordings from procedures performed with the BLL by multiple academic laryngologists were retrospectively reviewed. A preliminary 6-point classification (BLL 1-6) was developed based on expert consensus. Thirteen additional procedural clips were independently rated utilizing the classification schema to assess perceived tissue effect, and measure inter- and intra-rate reliability. ResultsThe final 5-point classification system (BLL 1-5) included angiolysis, blanching, tissue vaporization, ablation with mechanical tissue removal, and cutting. The consensus of the combined reviewers in rating all cases was 89% (58 of 65). Complete consensus was not achieved in 11% (7/65) of cases. Of those incorrect, 57% (4/7) were of clips illustrating the BLL-2 classification. Intra-rater reliability amongst the reviewers was 100%. ConclusionTissue effect of the 445 nm blue light laser can reliably be standardized with this proposed classification system. This rating system can be used to facilitate future systematic study of outcomes and effective communication between laryngologists and trainees.

ObjectiveThis study evaluates the impact of systemic GLP-1 receptor agonist (GLP-1RA) use on surgical wound healing in high-risk surgical populations, including patients with diabetes, and implications for perioperative planning and healing outcomes. ApproachThis pilot retrospective cohort study compared adult surgery patients with non-healing postoperative wounds by their GLP-1RA use. Outcomes included healing status, time to wound closure, and number of surgical interventions. ResultsThe cohort included 35 non-GLP-1RA users and 16 GLP-1RA users with comparable baseline characteristics, except for significant higher prevalence of venous insufficiency among users. Though median time to closure was similar for all patients, users required fewer surgical interventions and their wounds reached closure in significant difference from non-users. Among patients with diabetes, all GLP-1RA users healed significantly compared to non-users. InnovationThe impact of GLP-1RA therapy on wound healing in high-risk reconstructive and soft-tissue surgery remains poorly defined. This pilot cohort addresses that gap, offering an early signal that GLP-1RA use is associated with improved wound healing and fewer postoperative interventions. These findings may inform perioperative practice by identifying a systemic pharmacologic factor that optimizes surgical outcomes in high-risk populations. ConclusionGLP-1RA use was associated with higher healing rates and fewer interventions, particularly among patients with diabetes. These findings support a beneficial role in surgical wound healing and warrant larger multi-site studies.

STRUCTURED ABSTRACTO_ST_ABSImportanceC_ST_ABSSexual dysfunction can occur after midurethral sling (MUS) and transvaginal prolapse surgery. It remains unclear whether these procedures impact the clitoris, despite its role in sexual function and proximity to the MUS and vagina. ObjectivesTo compare postoperative sexual function and clitoral features by MUS and vaginal surgery approach after transvaginal prolapse repair with/without concomitant MUS. DesignCross-sectional ancillary study of magnetic resonance imaging (MRI) and sexual function data from the Defining Mechanisms of Anterior Vaginal Wall Descent study. SettingEight clinical sites in the US Pelvic Floor Disorders Network. Participants: 88 women with uterovaginal prolapse who underwent vaginal mesh hysteropexy or vaginal hysterectomy with uterosacral ligament suspension with/without MUS between 2013-2015. Data were analyzed between September 2021-June 2023. ExposuresBetween June 2014-May 2018, participants underwent pelvic MRI 30-42 months after surgery, or earlier if reoperation was desired. Sexual activity and function at baseline and 24-48-month follow-up were evaluated using the Pelvic Organ Prolapse/Incontinence Sexual Questionnaire, IUGA-Revised (PISQ-IR). Clitoral features were obtained from postoperative MRI-based 3-dimensional models. Main Outcomes and MeasuresPISQ-IR scores and clitoral features (size, position). ResultsEighty-two women (median [range] age, 65 [47-79] years) were analyzed: 45 MUS (22 hysteropexy, 23 hysterectomy) and 37 No-MUS (19 hysteropexy, 18 hysterectomy). Postoperatively, 25 MUS, 12 No-MUS, 20 hysteropexy, and 17 hysterectomy patients were sexually active (SA). Overall, within the MUS and vaginal surgery groups, sexual function remained unchanged or improved (most PISQ-IR change from baseline scores were [&ge;]0) among SA and NSA women. Among SA women after surgery, the MUS group (vs No-MUS) had a poorer PISQ-IR arousal/orgasm (SA-AO) score (median, 3.5 vs 4.3; P=.02). The hysteropexy group (vs hysterectomy) had less improvement in PISQ-IR SA-AO score (median, 0.0 vs 0.3; P=.01). Women with MUS (vs without) had a smaller clitoral glans thickness (median, 9.0 mm vs 10.0 mm; P=.008) and clitoral body volume (median, 2783.5 mm3 vs 3587.4 mm3; P=.01). Conclusions and RelevanceSA women with MUS (vs without) or hysteropexy (vs hysterectomy) experienced poorer postoperative sexual function. MUS was linked to a smaller clitoris. Future studies should explore surgery-induced changes in clitoral anatomy and sexual function. KEY POINTSO_ST_ABSQuestionC_ST_ABSHow do sexual function and clitoral anatomy differ by midurethral sling placement and vaginal surgery approach? FindingsThis cross-sectional study compared patient-reported sexual function outcomes and 30-42-month postoperative magnetic resonance imaging-based 3-dimensional clitoral models of 82 women after vaginal prolapse surgery with or without concomitant midurethral sling. Midurethral sling (vs no sling) and vaginal mesh hysteropexy (vs vaginal hysterectomy) were associated with poorer postoperative sexual function outcomes. Additionally, midurethral sling was associated with a smaller clitoral glans and body. MeaningMidurethral sling and vaginal mesh hysteropexy were associated with, and may adversely alter, postoperative sexual function and/or clitoral anatomy. VISUAL ABSTRACT/PROMOTIONAL IMAGE O_FIG O_LINKSMALLFIG WIDTH=200 HEIGHT=113 SRC="FIGDIR/small/26351291v1_ufig1.gif" ALT="Figure 1"> View larger version (33K): org.highwire.dtl.DTLVardef@904497org.highwire.dtl.DTLVardef@187514aorg.highwire.dtl.DTLVardef@e9e799org.highwire.dtl.DTLVardef@640f1a_HPS_FORMAT_FIGEXP M_FIG C_FIG

IntroductionFamily Constellation Therapy (FCT) has been widely disseminated in clinical, public health, and judicial settings despite persistent concerns regarding its theoretical basis, safety, and the limited availability of rigorous randomised evidence supporting its clinical use. ObjectiveThe aim of this systematic review is to assess the effects of FCT across all clinical conditions, explicitly considering both benefits and harms; and summarise the characteristics of studies and intervention settings used in randomised controlled trials of FCT. MethodsFollowing a prospectively registered protocol (CRD420251136190), we conducted a systematic search of seven databases (PubMed, EMBASE, APA PsycInfo, CENTRAL, BVS, Web of Science, and CINAHL) and grey literature (ICTRP and ProQuest database) without language or date restrictions to identify published and unpublished randomised controlled trials of FCT. Study selection, data extraction, risk of bias (RoB 2), and certainty of evidence (GRADE) were performed in duplicate. Statistical analyses followed a prospectively registered analysis plan with prespecified criteria for data pooling and for handling analytical limitations. ResultsNo reliable evidence was found to support the use of FCT for any condition across both clinical and non-clinical samples. All trials included were judged to be at high risk of bias and all comparisons were rated as very low-certainty evidence. Concerns regarding potential adverse effects were identified, and the available data was insufficient to establish the effectiveness of the intervention, precluding any clinical recommendation. ConclusionClinicians, policymakers, and consumers should reconsider adopting FCT while reliable evidence is not available.

Recognizing the challenges faced by primary caregivers regarding the health of children with congenital craniofacial anomalies (CCAs) contributes to strengthening healthcare programs according to patient[s] and families differential needs. This qualitative study presents the experiences of 25 caregivers of children with CCAs from Bogota and Cali, Colombia, identified from care registries and consultation statistics provideed from public high-complexity healthcare institutions. Grounded in Giorgis descriptive phenomenology and employing thematic analysis, this research utilized semi-structured interviews and focus groups to explore the diagnostic process and its impact, experiences with healthcare services, and the caregivers role and daily care activities. Data were analyzed using MAXQDA(R) qualitative software. Findings highlighted the emotional complexity of caring for childre[n]s health. Challenges included late diagnoses, pessimistic views of the children with CCAs condition by healthcare team members; lack of effective support, information, and guidance from health staff; absence of clear care and referral protocols, and limited access to specific adaptations and timely specialized care for children with CCAs. There were also reduced therapeutic services, and a pronounced gendered caregiving burden when responsibilities fall almost exclusively on mothers. System fragmentation, reflected in deficiencies in communication and a lack of clear, coordinated, and timely pathways of care, as well as the absence of adequate psychosocial support for families, emerged as common structural problems in healthcare services in both geographic settings where this research has been conducted. Gender-sensitive strategies focused on alleviating emotional concerns and the burden of caregiving from diagnosis onward within a patient and family-centered care model are decisive. Improving comprehensive CCAs training for healthcare personnel and making adjustments to care pathways are suggested to contribute to the implementation of inclusive health programs that address the diverse needs of children and their families.

Objective: To describe the clinical characteristics of term neonates with neonatal bacterial meningitis (NBM) and explore the association between different pathogens and imaging complications, providing clinical evidence for early identification and individualized management. Methods: A retrospective study was conducted on 531 term neonates diagnosed with NBM admitted to the Capital Institute of Pediatrics from 2013 to 2025. Demographics, clinical manifestations, laboratory parameters, etiological results, imaging complications and treatment measures were collected. Patients were divided into favorable/adverse discharge outcome groups and pathogen-positive/negative groups. Statistical analyses were performed using appropriate tests, and Cramers V coefficient was used to analyze the association between pathogens and imaging complications. Results: (1) The most common clinical manifestations were abnormal body temperature (79.85%), altered consciousness (55.18%) and jaundice (46.52%). CSF/blood culture was positive in 133 cases (25.05%), with Escherichia coli (27.07%), group B streptococcus (17.29%) and Staphylococcus species (16.54%) as predominant pathogens. The overall incidence of imaging complications was 22.22%, mainly hydrocephalus (5.84%), subdural effusion (4.90%) and encephalomalacia (2.64%). (2) Adverse discharge outcomes occurred in 107 cases (20.15%). Compared with the favorable group, the adverse group had higher incidences of convulsions, altered consciousness, anterior fontanelle bulging, abnormal muscle tone and primitive reflexes (all P<0.001), more obvious laboratory abnormalities (higher CRP, CSF leukocytes and protein, lower CSF glucose, all P<0.05), higher culture positive rates and greater need for adjuvant therapy (all P<0.001). (3) Pathogen-positive patients had higher imaging complication rates. Gram-negative infections were associated with higher hydrocephalus and subdural effusion rates, while Gram-positive infections had higher brain abscess risk. Specifically, Escherichia coli correlated with hydrocephalus and subdural effusion; group B streptococcus with cerebral infarction and encephalomalacia; LM with intracranial hemorrhage and brain abscess; negative cultures correlated with no imaging complications (all P<0.05). Conclusion: Term NBM neonates have non-specific manifestations, mainly abnormal body temperature and altered consciousness. Predominant pathogens are Escherichia coli, group B streptococcus and Staphylococcus species, with hydrocephalus and subdural effusion as common imaging complications. Adverse outcomes are associated with severe symptoms, obvious laboratory abnormalities and higher pathogen positivity. Specific pathogens correlate with distinct imaging complications.

BackgroundLife-sustaining hemodialysis (HD) is onerous for patients, especially those with multiple co-morbidities and advanced age. A standard HD prescription is 720 minutes per week. Alternative HD regiments have been proposed in attempt to maintain quality of life (QOL). Studies are needed to investigate the efficacy and safety of less frequent HD prescriptions in this population. This is an institution-wide observational study in New Brunswick, Canada to compare HD prescriptions and the impact on QOL and mortality. ObjectiveThe purpose of this study is to assess the current HD prescribing practices at a provincial healthcare institution in relation to patient QOL. DesignProspective Observational Study. SettingSingle centre hospital and satellite hemodialysis units. PatientsVoluntarily consented patients undergoing in-centre hemodialysis treatment. MeasurementsObservational clinical data was collected for each study participant from their hospital and dialysis electronic medical records. The KDQOL-36TM questionnaire was used to assess patient-reported quality of life at the time of consent. MethodsAdults undergoing in-centre or satellite site HD for at least 3 months were eligible to participate. Consenting patient participants were grouped by HD prescription whether they were prescribed 720 minutes or more per week or less than 720 minutes per week. All participants completed the KDQOL-36 TM questionnaire to estimate QOL and groups were compared using the Mann-Whitney U statistical test. Emergency department visits, hospitalizations, and mortality were analyzed using a negative binomial regression or a logistic regression. ResultsWe enrolled 140 patient participants; 41 were undergoing less than 720 minutes per week of HD and 99 were undergoing 720 minutes or more of HD per week. Patients who were undergoing less than 720 minutes per week of HD were older [Median (IQR): 76 (72- 81) yrs. vs. 64 (55 - 75) yrs.; p < 0.001], had higher median (IQR) QOL scores on the Symptoms/ Problems List scale on the KDQOL-36 TM questionnaire [79.2 (70.8 - 88.5 vs. 70.8 (62.5 - 81.3); p = 0.0022], and were less likely to present to the emergency department (incident rate ratio 0.52, 95% confidence interval [CI] 0.33-0.81). Mortality was similar between groups, even when adjusted for age and comorbidity score (odds ratio 1.62, 95% CI 0.59-4.49). LimitationsPatient participant enrollment was limited by the single centre nature of this study. As this was an observational study, we did not account for how long the patients had been prescribed less than 720 minutes of hemodialysis. We did not include a frailty assessment of the study participants. A higher number of study participants may have identified significant trends in mortality. ConclusionsThe results of this study show that patients undergoing less than 720 minutes of weekly HD had a higher QOL score for the KDQOL-36 TM Symptoms/ Problems List scale, were less frequently in the emergency department and were not more likely to die than patients undergoing 720 minutes or more of weekly HD. Further studies are required to assess the feasibility and safety of a conservative model of HD prescribing to improve QOL of patients with palliative care treatment goals.

BackgroundPatients who have undergone Anterior Cruciate Ligament Reconstruction (ACLR) have a 6-24% chance of either re-tearing or having subsequent knee surgery. To date there have been no practical validated risk prediction models that can be easily implemented into clinical workflow for re-injury risk. Micro-Doppler radar (MDR) provides a promising solution. ObjectiveThe purpose of this study was to investigate the predictive ability of MDR to identify persons with a previous ACLR relative to an age and sex matched healthy control. MethodsACLR patients (n=81) and controls (n=100) performed drop box jump, sit to stand (STS), and walking trials as MDR signatures were collected. A 1D Convolutional Neural Network was developed to evaluate each activity individually followed by the development of a fusion model validation using all three activities. ResultsThe STS model individually achieved the highest overall accuracy of 82.3%, with a sensitivity of 71.6% and specificity of 91.0%. The fusion model using all activities achieved a peak overall accuracy to detect ACLR of 86.2%, 80.3% sensitivity, and 91% specificity. ConclusionsCurrently, there is no clinically validated, efficient approach to objectively evaluate human motion at the point of care. When coupled with machine learning, MDR accurately differentiates ACLR from control groups by identifying complex biomechanical asymmetries, with classification performance comparable to or exceeding that of motion capture. Future research is needed to determine if MDR can be used in conjunction with risk prediction modeling. Key pointsMicro-Doppler radar provides a promising new solution to identify important human motion asymmetries in clinical settings. Here we evaluated a group of patients who have a history of Anterior Cruciate Ligament reconstruction versus a control group. Simple movements performed in the presence of the micro-Doppler radar system were used to identify the 2 groups with accuracy comparable or superior to motion capture systems.

Definitive radiotherapy (RT) for prostate cancer (PC) with dose intensification and/or focal boosting has excellent oncologic outcomes, but many patients experience adverse events. Dose escalation to the whole prostate improves outcomes at the expense of increased late adverse events. Intraprostatic recurrence after definitive RT typically occurs at the site of the primary tumor, suggesting that dose to the site of the dominant lesion is an important predictor of future failure. The efficacy and safety of tumor-focused RT compared to that of standard RT for definitive treatment of localized PC has not been assessed. RadTARGET (RAdiation Dose TAiloRing Guided by Enhanced Targeting) is a phase II randomized trial that aims to demonstrate superior safety of image-guided, tumor-focused RT compared to standard RT for acute genitourinary (GU) or gastrointestinal (GI) in the setting of definitive RT for intermediate- and high-risk PC. The study intervention is image-guided, tumor-focused RT with dose intensification of cancer visible on imaging and dose de-intensification to remaining prostate. Patients will be randomized to two arms: those who receive standard RT dose and those that receive tumor-focused RT. The study population will be patients with intermediate- or high-risk PC planning to undergo definitive RT with or without systemic therapy. The primary endpoint to compare between randomized arms is acute GU or GI grade [&ge;]2 adverse events. Participant and study duration are 5 years and 8 years, respectively. RadTARGET will compare the efficacy and safety of tumor-focused RT to that of standard RT for definitive treatment of localized PC. We hypothesize that the tumor-focused approach will substantially reduce adverse events after prostate RT while retaining high efficacy. If this hypothesis is confirmed, we will conclude that a phase III randomized control trial is warranted to formally establish oncologic non-inferiority compared to the current standard of whole-gland dose escalation.

Abstract: Background: Vascular access is essential in treating patients undergoing prolonged endovenous therapy such as chemotherapy, antibiotics, and parenteral nutrition. Since the 1990s, when PICCs (peripherally inserted central catheters) appeared, vascular access options have expanded significantly, revolutionizing the treatment landscape for all types of patients. Objective: To analyze and describe the profile of the use of PICCs in a Brazilian quaternary hospital over 10 years with data collected by the infusion therapy team. Evaluating the number of PICCs implanted over the years, patients epidemiology and clinical characteristics, insertion details, associated complications, and the reason for removal. Methods: A retrospective cohort study that employs a quantitative, non-experimental approach to classify and statistically analyze past events associated with 21,652 PICCs implanted from January 2012 to December 2021 in a quaternary hospital at Sao Paulo - Brazil. All the catheters were implanted, and the data was collected by a team of nurses specializing in infusion therapy. We analyzed the number of catheters implanted over the years, insertion characteristics, patients epidemiology and clinical data, possible associated complications, and the reason for removal. Statistical analyses were conducted using R software (version 4.4.1) and SPSS (version 29) for Windows (IBM Corp, Armonk, NY). Results: During the specified period, 21,652 catheters were analyzed. The patients gender distribution was nearly balanced (48.2% versus 51.8%), and the average age was 66 years. Cardiovascular and metabolic issues were the most common comorbidities, and between 2020 and 2021, 29.3% of the sample tested positive for COVID-19. The most common location of hospitalization and implantation was the medical-surgical clinic (31.6% - 41.4%), and the most used type of catheter was the Power Picc (83.9%). The estimated complication incidence density is 2.94 complications per 1,000 catheter-days. Almost all the PICCs (98,2%) were adequately located at the cavo-atrial junction after the first attempt, 82.2% of catheters were removed after therapy, and the median duration of catheter use was 12 days. Conclusion: PICCs are widely employed for drug infusion, with their use growing progressively due to specialized teams greater availability and training. The high efficiency of these devices with a relatively low risk of complications already observed in previous studies was reinforced by the findings of this study of more than 20,000 catheters.

Purpose: This study aimed to examine the effects of formative and summative assessments on college students tennis performance and basic psychological needs. Methods: A total of 128 undergraduate students (64 males, 64 females; Mage = 19.22, SD = 0.91) participated in this study. Participants were cluster-randomized to either a formative assessment group (n = 64) or a summative assessment group (n = 64). The formative assessment intervention involved setting personalized learning goals and success criteria, administering periodic tests, and providing process-oriented and individualized feedback. The summative assessment intervention involved setting uniform goals for all students, offering instructor feedback only on common problems, and requiring students to practice independently after class without personalized guidance. Both interventions were implemented over 10 weeks, with one 90-minute session each week. Tennis skills and basic psychological needs (i.e., autonomy, competence, and relatedness) were assessed before and after the intervention. Tennis skills were reassessed 1 week after the intervention. Two-way mixed-effects analysis of variance (ANOVA) was used to examine the impact of group, time, and their interaction on tennis skills and basic psychological needs. Results: The results showed that the interaction between group and time was significant for all of the outcome variables. Simple effects analyses indicated that, at pre-test, the two groups did not differ significantly in tennis performance or in satisfaction of autonomy, competence, and relatedness (p > 0.05). At post-intervention, the formative assessment group demonstrated significantly better performance than the summative assessment group in tennis skills (MD = 3.50, 95% CI = [1.303, 5.697], p = 0.002), autonomy (MD = 2.44, 95% CI = [1.816, 3.059], p < 0.001), relatedness (MD = 1.33, 95% CI = [0.679, 1.977], p < 0.001), and competence (MD = 1.75, 95% CI = [1.046, 2.454], p < 0.001). At the 1-week follow-up session, the formative assessment group also showed significantly better tennis performance than the summative assessment group (MD = 6.81, 95% CI = [4.667, 8.958], p < 0.001). Conclusion: Formative assessment was more effective than summative assessment in improving college students tennis performance and satisfying their basic psychological needs. These findings suggest that incorporating personalized goals, process-oriented evaluation, and individualized feedback into tennis instruction could promote both skill development and psychological outcomes in college physical education.

ABSTRACT Background Before obtaining professional medical care, many people in peri-urban and rural Pakistan contact herbalists, spiritual healers, and unlicensed caregivers. This study examined the social, economic, and cultural factors influencing the use of informal care by analysing the health-seeking behaviours of individuals in the Faisalabad District. Methods An exploratory mixed-methods study was conducted in Makkuana and the surrounding villages of Faisalabad District, Punjab. The quantitative component involved a cross-sectional survey of 69 adults using a structured questionnaire adapted from the I-CAM-Q. The qualitative component comprised twelve in-depth interviews and two focus group discussions. Descriptive statistics and chi-square analysis were used for quantitative data. Thematic analysis, guided by the Health Belief Model and Andersen's Behavioural Model, was applied to qualitative data. Results The mean age of participants was 40.4 years; 62.3% were female, and 79.7% had monthly household incomes below PKR 60,000. Of the 69 participants, 68 (98.6%) sought care from an informal provider first, most commonly an unqualified practitioner (50.7%), herbal practitioner (29.0%), or homeopath (17.4%). Trust was the leading reason for provider choice (43.5%), followed by proximity (24.6%) and low cost (15.9%). Complications were reported by 21.7% of participants, and 39.1% later required formal care for the same illness. Eight qualitative themes emerged: structural and economic barriers to formal care; proximity and convenience as determinants of informal care; trust, familiarity, and social networks; cultural and religious normalisation of traditional practices; poor doctor-patient communication in formal settings; perceived safety and naturalness of alternative remedies; awareness deficits about provider qualifications; and treatment-related harm and delayed escalation to formal care. Conclusion Informal health care seeking is nearly universal in this community, driven by intersecting economic, structural, cultural, and interpersonal factors. Enhancing primary care affordability, accessibility, and the quality of provider-patient communication together with culturally sensitive health literacy programs, is essential to redirect care seeking toward qualified providers.

ObjectiveThis study aimed to assess the effectiveness of SMS and voice message reminders in reducing the dropout rate in Lome-Togo, in 2026. MethodsWe conducted a cross-sectional study between October 2025 and March 2026 in the Grand Lome region. The intervention consisted of an integrated digital system used by health facilities to send automated SMS. Categorical variables were described in terms of frequency and proportion; Fishers exact test was used to compare proportions. Quantitative variables were described by their means accompanied by their standard deviation; the Wilcoxon rank-sum test was used to compare means. The significance level for statistical tests was set at 5%. ResultsA total of 30 health facilities were included. Seventy percent (70.0%) of the health facilities used messages associated with calls. Ninety percent (90.0%) of participants found the reminders useful, and 60.0% reported an improvement in Expanded Program on Immunization services related to their use. Among participants who received a reminder, 51.0% kept their vaccination appointments. The Penta 1/3 dropout rate decreased from 3.2% before the intervention to 1.3% (p < 0.001). Among the 323 parents of children included, only 20.74% reported receiving a reminder by phone. Sixty-point-five percent (60.5%) preferred to receive both text messages and voice calls. ConclusionThis study demonstrates the operational feasibility of an SMS/call-based reminder system in reducing dropout rate for childhood vaccination in Togo.

This research demonstrates that the trans-aqueduct approach is a feasible, minimally invasive access pathway to the third ventricle, offering a potential route to the deep brain for therapeutic technologies. Further pre-clinical investigation is required to thoroughly evaluate physiological tolerance, trauma risk, and the long-term implications of intraventricular implantation. The third ventricle is a high-value site for neuromodulation due to its proximity to deep-brain targets, including the subthalamic nucleus (STN) and globus pallidus internus (GPi). This study defined the anatomical pathway; and evaluated the technical feasibility of retrograde access to the third ventricle via the cerebral aqueduct using minimally invasive interventional techniques. Evaluation was conducted in three phases using human MRI datasets (n=16; mean age 48.4 years) and cadaveric specimens (n=6; mean age 88.2 years). Phase 1 involved morphometric MRI analysis of the aqueduct and ventricles. Phase 2 tested trans-aqueduct access on cadaver specimens via fluoroscopically guided guidewires and catheters. Phase 3 utilized direct anatomical dissections on cadaver specimens (n=3) to morphometrically measure the third ventricular cavity and its relationship to deep-brain nuclei. Measurements across the sample groups showed a mean aqueduct diameter of 1.6 mm (SD=0.14). Third ventricle dimensions averaged 27.6 mm (ventral-dorsal), 19.9 mm (caudal-cranial), and 5.7 mm (lateral). Successful access to the third ventricle was achieved in 83% (5/6) of cadaveric specimens. The optimal technical configuration utilized a 0.018'' angled-tip guidewire and 5-6 Fr catheters; the aqueduct accommodated diameters up to 2.0 mm with minimal resistance. The STN and GPi were localized within 5-20 mm of the ventricular volumetric centroid. The trans-aqueduct approach is a technically feasible, minimally invasive pathway for accessing the third ventricle. This route offers a potential alternative for the delivery of therapeutic neurotechnologies. Further research is required to assess physiological tolerance, trauma risk, and the long-term safety of intraventricular implantation.

Coronary artery disease is a leading cause of morbidity and mortality. Invasive coronary angiography is currently the gold standard in disease diagnosis. Several studies have attempted to use artificial intelligence (AI) to automate their interpretations with varying levels of success. However, most existing studies cannot generate detailed angiographic reports beyond simple classification or segmentation. This study aims to fine-tune and evaluate the performance of a Vision-Language Model (VLM) in coronary angiogram interpretation and report generation. Using twenty-thousand angiogram keyframes of 1987 patients collated across four unique datasets, we finetuned InternVL2-4B model with Low-Rank Adaptor weights that can perform stenosis detection, anatomy labelling, and report generation. The fine-tuned VLM achieved a precision of 0.56, recall of 0.64, and F1-score of 0.60 for stenosis detection. In anatomy segmentation, it attained a weighted precision of 0.50, recall of 0.43, and F1-score of 0.46, with higher scores in major vessel segments. Report generation integrating multiple angiographic projection views yielded an accuracy of 0.42, negative predictive value of 0.58 and specificity of 0.52. This study demonstrates the potential of using VLM to streamline angiogram interpretation to rapidly provide actionable information to guide management, support care in resource-limited settings, and audit the appropriateness of coronary interventions. AUTHOR SUMMARYCoronary artery disease has heavy disease burden worldwide and coronary angiogram is the gold standard imaging for its diagnosis. Interpreting these complex images and producing clinical reports require significant expertise and time. In this study, we fine-tuned and investigated an open-source VLM, InternVL2-4B, to interpret and report coronary angiogram images in key tasks including stenosis detection, anatomy identification, as well as full report generation. We also referenced the fine-tuned InternVL2-4B against state-of-the-art segmentation model, YOLOv8x, which was evaluated on the same test sets. We examined how machine learning metrics like the intersection over union score may not fully capture the clinical accuracy of model predictions and discussed the limitations of relying solely on these metrics for evaluating clinical AI systems. Although the model has not yet achieved expert-level interpretation, our results demonstrate the potential and feasibility of automating the reporting of coronary angiograms. Such systems could potentially assist cardiologists by improving reporting efficiency, highlightning lesions that may require review, and enabling automated calculations of clinical scores such as the SYNTAX score.

PurposeObstructive sleep apnea (OSA) is a common comorbidity in heart failure (HF) patients with prevalence increasing as HF severity worsens. While CPAP/BiPAP has been shown to reduce disease burden and mortality in the general HF population, it is unclear whether these benefits extend to patients with left ventricular assist devices (LVADs). We sought to determine whether OSA affects long-term survival in newly implanted LVAD patients and whether CPAP/BiPAP treatment confers mortality benefits. MethodsThis single-center retrospective study included patients who underwent LVAD implantation between January 2007 and February 2022. Recipients were stratified by OSA status (OSA vs No-OSA), and those with OSA were further categorized based on CPAP/BiPAP compliance. Comparative statistics and Kaplan-Meier survival analyses were performed, with log-rank tests used to compare groups and assess survival differences. A Cox proportional hazards model was conducted to evaluate the association between risk factors and survival among patients with OSA and No-OSA. ResultsBefore LVAD implantation, patients with OSA had higher body mass index, hypertension, and a higher rate of implantable cardioverter-defibrillator placement than those without OSA. OSA was not associated with increased postoperative complications. Although survival did not differ significantly between OSA and No-OSA patients (p=0.33), CPAP/BiPAP-compliant OSA patients had significantly better survival than noncompliant patients (p=0.0099). ConclusionsLVAD patients with OSA who consistently use CPAP/BiPAP have better survival than those who do not. CPAP/BiPAP is a simple, low-risk treatment that can reduce mortality in this population. Therefore, increased perioperative screening for OSA should be considered for patients receiving LVADs. Multicenter studies are needed to confirm our findings further.