Epigenetics

Importance: Neuroinflammation is a key component of the response to injury after concussion, but direct links between diffusion MRI metrics and specific plasma inflammatory pathways in human concussion have not been established. Objective: To examine associations between diffusion MRI metrics and pathway-level inflammatory proteomic signatures in adolescents during the subacute period after concussion. Design, Setting, and Participants: Cross-sectional analysis of data from the CARE4Kids Consortium, a six-site prospective study. Participants were English-speaking adolescents ages 11-17.99 with concussion and symptoms at 7-35 days post-injury. Data were collected between 2022-2024. Of 370 enrolled participants, 122 had both diffusion MRI and plasma proteomics available for analysis. Exposure: Advanced diffusion MRI metrics were converted to z-scores and participants were grouped by the spatial extent of outlier values (potholes and peaks) across 15 white matter regions of interest. Nine non-redundant groupings were selected for primary analysis. Main Outcomes and Measures: Pathway-level inflammatory profiles derived from gene set enrichment analysis (GSEA) of ~5,400 plasma proteins measured by Olink proximity extension assay, targeting nine hallmark inflammatory pathways spanning initiation through resolution. Persistent symptoms were assessed 64-115 days post-injury. Results: Diffusion metrics reflecting tissue disorganization were associated with upregulation of the coagulation pathway, consistent with hemostatic-inflammatory signaling. Metrics reflecting reduced tissue complexity and neurite density were associated with upregulation of interferon- and interferon-{gamma} response pathways, consistent with microstructural remodeling driven by cellular immune activation. Elevated free water content was associated with downregulation of most inflammatory pathways and trend-level transforming growth factor - {beta} upregulation, reflecting inflammatory resolution. Time since injury did not differ between groups based on free water (Kolmogorov-Smirnov p = 0.97), suggesting these differences reflect individual variability in recovery pace. Exploratory analyses showed a trend toward lower odds of persistent symptoms in the group with elevated free water content (odds ratio = 0.51, p = 0.18). Conclusions and Relevance: Multiple diffusion MRI metrics are differentially sensitive to distinct neuroinflammatory states in the subacute period after adolescent concussion. These findings suggest that diffusion imaging could serve as a non-invasive tool for inflammatory phenotyping, with potential implications for identifying patients who may benefit from targeted immunomodulatory intervention.

Objectives: We tested how multi-level socioeconomic disadvantage relates to biological aging and systemic inflammation in women and men from the population-based Canadian Longitudinal Study on Aging (CLSA). Methods: We examined cross-sectional data from 8,516 CLSA participants with baseline measures on systemic inflammatory biomarkers (C-reactive protein, interleukin-6, and tumoral necrosis factor-) and biological aging (metabolomic and six DNA methylation [DNAm] age estimates). Plasma samples underwent metabolomic profiling by Metabolon, Inc. Metabolomic age was estimated separately in males and females using sex-stratified models based on age-correlated metabolite levels. DNAm data generated using the Illumina Infinium MethylationEPIC v1.0 array were used to estimate DNAm age across six established models, including Horvath, Hannum, PhenoAge, GrimAge, GrimAge2, and DunedinPACE. We used log-transformed metabolite levels to calculate metabolomic age by sex. We linked education, income, material and social deprivation to biomarkers of systemic inflammation and biological aging stratified by sex using generalized linear models. Multivariable models were adjusted by age, major behavioral risk factors, and chronic conditions. Results: Participants were aged on average of 62.6 years of age, and approximately 50% were females. In multivariable linear adjusted models, we found that in comparison to those earning [&ge;]$100K a year, women earning less <$20K were on average 1.14 (95%CI: 0.46, 1.82) year older with respect to metabolomic age; those earning [&ge;]$20K & <$50K were on average 0.90 (95%CI: 0.26, 1.53) years older; and those earning [&ge;]$50K & <$100K were on average 0.70 (95%CI: 0.05, 1.34) years older. We did not observe this dose response among men. A similar dose-response association was observed for interleukin-6 in both men and women. Discussion: These findings suggest that socioeconomic adversity influences not only inflammatory pathways but also distinct biological aging processes, including metabolomic aging.

Background: Accelerated biological aging can be assessed with DNA methylation (DNAm)- based epigenetic clocks. Research suggests that greater DNAm is associated with faster cognitive decline and risk of Alzheimer disease (AD) and other dementias. However, most studies have relied on single-time-point measurements of clocks, rather than evaluating dynamic changes over time. We examined the association between 15-year epigenetic aging trajectories and brain health outcomes in midlife. Methods: We analyzed 2,833 middle-aged adults (mean baseline age 40 years, 59% female and 44% Black) with [&ge;]3 DunedinPACE (a recently developed epigenetic clock) measurements, collected over 15 years. Using mixed-effects modeling, we derived individual-specific slopes of epigenetic aging trajectories and categorized participants as Fast Agers (slopes > 1 SD above the mean), Slow Agers (slopes < 1 SD below the mean), or Typical Agers (within &plusmn1 SD of the mean). We examined associations between trajectory group and cognition on five cognitive domains as well as on plasma AD biomarkers (NfL, p-tau217, A{beta}42/A{beta}40), all assessed 15-20 years post-baseline. Models were adjusted for demographics, education, physical activity and APOE*{varepsilon}4 carrier status (with additional adjustments for eGFRcr for biomarker outcomes). Results: Epigenetic aging trajectories were associated with multiple domains of cognition and AD biomarkers (Figure 1). Compared to Typical Agers, Fast Agers showed worse processing speed, memory, executive function, and global cognition (all p<0.05), with no difference in verbal fluency. Slow Agers had better performance on memory and global cognition (both p < 0.05). Fast Agers also exhibited significantly lower A{beta}42/A{beta}40 levels (p = 0.011) compared to Typical agers; no significant associations with p-tau217 or NfL were observed in either group. Conclusion: Middle-aged adults with faster 15-year epigenetic aging trajectories demonstrated worse cognitive performance, whereas those with slower biological aging trajectories exhibited cognitive resilience and more favorable AD biomarker profiles. By examining long-term trajectories rather than single timepoints, these findings identify individuals at differential risk for brain health outcomes.

Copper (Cu) is an essential metal involved in neurobiological processes including energy metabolism and neurotransmission, yet dysregulated Cu levels may adversely affect brain health and olfactory performance. Although olfactory dysfunction has primarily been studied in older adults and neurodegenerative disease, adolescence is a critical period of brain maturation during which the olfactory system may be particularly vulnerable. This cross-sectional study examined associations between Cu exposure, olfactory bulb (OB) volume, and olfactory performance in 200 adolescents and young adults (64% female; ages 13 - 25) from the Public Health Impact of Metals Exposure cohort. Cu concentrations in blood, urine, hair, and saliva were measured using inductively coupled plasma mass spectrometry. T2-weighted magnetic resonance imaging scans estimated left, right, and total OB volumes using a three-stage deep learning pipeline. Olfactory performance was assessed using the Sniffin Sticks test. Weighted quantile sum regression evaluated associations between a Cu mixture index and OB outcomes, while standard linear regression models assessed individual Cu biomarkers. Models were adjusted for age and sex. A higher Cu index was associated with reduced left (Beta= -0.72, 95% CI [-1.42, -0.02]), right (Beta = -0.79, 95% CI [-1.43, -0.15]), and total OB volume (Beta= -1.55, 95% CI [-2.85, -0.25]), as well as lower odor threshold scores (Beta = -0.23, 95% CI [-0.42, -0.03]). Individual biomarkers were not independently associated with outcomes. These findings suggest that Cu exposure may adversely affect olfactory neurodevelopment during adolescence and highlight the importance of studying environmental exposures relevant to long-term neurological health.

Exposure to higher levels of ambient air pollution during pregnancy has been linked to multiple adverse pregnancy outcomes. However, studies on acute exposures and reduced gestation length have reported inconsistent findings. This project aims to examine the acute association between ambient air pollution and preterm (28-36 gestational weeks) or early-term (37-38 gestational weeks) births. Daily concentrations of 12 air pollutants, based on bias-corrected numerical model outputs, were linked to vital records of singleton live preterm and early-term births from 2005-2017 in California, Florida, Georgia, Kansas, Nevada, New Jersey, North Carolina (2005-2015), and Oregon. Under a time-stratified case-crossover design, odds ratios (OR) were estimated via conditional logistic regression with adjustment for risks among ongoing pregnancies, meteorology, time trends and federal holidays. We estimated cumulative associations up to a 6-day lag using distributed lag models. Risk estimates per interquartile range (IQR) increase in exposure were pooled across states using inverse-variance weighting. Our study included 1,085,162 preterm and 3,901,185 early-term births. We observed positive associations between 0-2 day cumulate exposure to several air pollutants and early-term births, including NO2 (OR: 1.0023, 95% CI:1.0010, 1.0037 per 7.1 g/m3 increase), PM2.5 (OR=1.0022, 95% CI: 1.006, 1.0038 per 4.6 g/m3 increase), PM2.5 organic carbon (OR= 1.0026, 95% CI: 1.0013, 1.0039 per 1.7 g/m3 increase) and PM2.5 elemental carbon (OR=1.0025, 95% CI: 1.0014, 1.0035 per 0.26 g/m3 increase). Associations with preterm birth were mostly null. In conclusion, we found positive associations between short-term air pollution exposure, including PM and major PM2.5 components, and risks of early-term birth.

Prenatal alcohol exposure (PAE) is a major cause of neurodevelopmental disorders, yet most children are diagnosed late or misdiagnosed. Neuroplacentology suggest that placental factors released into maternal and/or umbilical cord blood contribute to fetal brain development. Consistently, a preclinical inter-organ transcriptomic database revealed that PAE disrupts the expression ratio of angiogenic and inflammatory factors suggesting an angio-inflammatory response. This study aimed i) to assay, by multiplex immunoassay, angiogenic and inflammatory factors in maternal and umbilical cord blood from alcohol-consuming women and ii) to perform a maternofetal analysis according to neonatal sex. Afterwards, dysregulated factors from mothers who gave birth to females or males were submitted to STRING and ShinyGO analyses. Results showed that PAE differently altered the distribution profiles of dysregulated angiogenic and inflammatory factors in maternal and umbilical cord blood. Moreover, sex-specific differences were observed, with 36% of dysregulated proteins specific to males, 48% to females, and 16% common to both. STRING analysis revealed robust functional protein-protein interactions linking together inflammatory and angiogenic clusters while the ShinyGO analysis identified enriched pathways related to vascular shear stress. These findings provide the first maternofetal analysis of combined angiogenic and inflammatory factors from alcohol-consuming mothers.

Social relationships are an important social determinant of health. Loneliness, the perceived gap between one's actual and desired relationships, has emerged as an important mechanism through which social relationships impact health. Like other intrapersonal-level factors associated with health, loneliness is influenced by broader social and structural factors, including characteristics of one's neighborhood social environment. Although neighborhood-level protective and risk factors for loneliness and for mental health have been identified, prior studies have often focused solely on self-reported perceptions of the neighborhood environment. Further, few have considered aspects of the neighborhood social environments, such as neighborhood stability (i.e., stability of the community with long or short-term residents), independent of neighborhood socioeconomic conditions. In the current analysis, we explored longitudinal patterns of loneliness in conjunction with neighborhood stability among women with HIV (WWH) enrolled into the MACS/WIHS Combined Cohort Study (MWCCS) from 2014-2019 (N2019=1,394) to examine whether trajectories of loneliness and neighborhood stability were associated with depressive symptoms, non-prescription substance use, past-year cannabis use, number of alcoholic drinks per week, and several domains of quality of life. Loneliness at baseline (Betas = 0.24 - 0.54) and changes in loneliness over time (Betas = 0.11 - 0.26) were associated with each outcome, except for the association between changes in loneliness over time and drinks per week (Beta=0.13, p = 4.14x10-2), which did not persist after correcting for multiple comparisons. Neighborhood stability at baseline was associated with past year cannabis use (Beta=0.26, p = 1.00x10-2), depressive symptoms (Beta=-0.12, p = 1.54x10-3), and overall self-reported health (Beta=-0.08, p = 2.05x10-2). Changes in neighborhood stability across time were not associated with any outcome. Neighborhood stability moderated the association between changes in loneliness and general health perceptions. Our results demonstrate both overall loneliness and changes in loneliness over time have implications for current mental health in WWH, while changes in neighborhood stability did not.

Background: Childhood obesity is a prevalent public health concern, particularly among children from marginalized backgrounds. Epigenomic mechanisms, including DNA methylation (DNAm), offer insight into the biological embedding of metabolic risk, yet protective family-level factors remain understudied. This study examined whether participation in a positive parenting intervention was associated with reduced epigenetic cardiometabolic risk among preschool-aged children. Methods: Participants were 74 children (n = 35 intervention; n = 39 services-as-usual; mean age = 36 months). Using a secondary analysis of a randomized controlled trial, DNAm-derived body mass index (BMI) and anthropometric BMI were assessed at baseline and 12-month follow-up, and parenting practices were observed post-treatment. Results: Children in the intervention group demonstrated significantly lower DNAm BMI at 12 months relative to controls, adjusting for child sex, race and/or ethnicity, and anthropometric BMI. No treatment effect was observed for anthropometric BMI, and DNAm BMI was not associated with anthropometric BMI at 12 months. Although parenting practices improved, they did not mediate intervention effects on DNAm-derived BMI. Conclusions: Parenting interventions may influence biological pathways related to cardiometabolic risk, even before changes in anthropometric outcomes, underscoring the potential of family-centered approaches to promote early metabolic health.

Fracture nonunion remains a major cause of morbidity, yet patient-specific factors associated with impaired healing remain incompletely characterized. Anemia has been associated with adverse orthopaedic outcomes, but its relationship with fracture nonunion is poorly understood. We examined whether pre-fracture anemia, anemia burden, and clinically relevant anemia subtypes were associated with nonunion following tibial or femoral fractures. Using commercial and Medicare fee-for-service claims from 2016 through 2023, we identified adults aged 19 years or older with a tibial or femoral fracture, continuous enrollment during the preceding year and for at least six months after fracture, and no baseline cancer. Pre-fracture anemia was evaluated as any anemia, the number of distinct anemia diagnoses, and nutritional, hemolytic, aplastic, and other anemia subgroups. Nonunion occurring six to eighteen months after fracture was assessed using incidence rates and multivariable-adjusted hazard models. Among 326,673 adults, 149,704 had pre-fracture anemia and 176,969 did not. The crude incidence of nonunion was 42% higher among individuals with anemia than among those without anemia (incidence rate ratio, 1.42; 95% confidence interval, 1.32 to 1.53) and increased with greater anemia burden. After adjustment for demographic and clinical characteristics, including prior fractures at other anatomical sites, pre-fracture anemia remained associated with nonunion following tibial and femoral fractures, with hazard ratios of 1.83 (95% confidence interval, 1.54 to 2.18) and 1.38 (95% confidence interval, 1.26 to 1.50), respectively. Associations were also observed for nutritional and other anemias, whereas estimates for hemolytic and aplastic anemias were limited by few nonunion events. Within the femur, the association was strongest for distal fractures. These findings demonstrate that pre-fracture anemia is independently associated with nonunion. The increase in risk with greater anemia burden and findings across evaluable subgroups suggest that pre-fracture anemia may help identify patients at increased risk of impaired fracture healing.

Background: Prospective pregnancy registries and biobanking infrastructures are essential for future translational studies investigating maternal, placental and offspring health. However, circulating nucleic acid analyses are highly sensitive to preanalytical variability, particularly regarding blood-collection tube type and sample processing conditions. We established a prospective pregnancy registry and biobanking workflow at Cruces University Hospital and evaluated the impact of preanalytical variables on circulating cell-free DNA (cfDNA) and cell-free RNA (cfRNA) preservation in maternal plasma collected at delivery. Methods: The Registry of Pregnant Women at Cruces University Hospital was designed as a prospective infrastructure integrating placental sampling, maternal blood collection and ethically controlled future access to maternal and offspring clinical data. Within this framework, peripheral blood samples from 50 women at delivery were simultaneously collected into EDTA, Norgen and Roche tubes. Plasma samples processed within or after 24 hours following collection underwent cfDNA/cfRNA extraction, electrophoretic profiling, fluorometric quantification and RT-qPCR analyses targeting different stress-related genes. Results: By the end of June 2026, 1,127 women had been prospectively recruited into the registry, with 661 plasma samples, 637 serum samples and 858 sets of four placental biopsies collected, processed and stored in the Basque Biobank. In the preanalytical substudy, EDTA tubes yielded higher cfDNA concentrations, likely reflecting reduced cellular preservation and genomic DNA contamination. In contrast, Roche tubes showed superior cfRNA preservation, with higher cfRNA concentrations and more consistent detection of the characteristic 5S rRNA peak compared with EDTA and Norgen tubes. Processing delays beyond 24 hours reduced cfRNA concentration, while associations between circulating transcripts and gestational age were more consistently detectable in preservative-containing tubes. Conclusions: Prospective infrastructures like ours offer strong foundation for large scale, long-term studies in the framework of the Developmental Origins of Health and Disease hypothesis. Technically, Roche tubes provided superior cfRNA preservation and enhanced sensitivity for detecting subtle biological associations, supporting the importance of standardized preanalytical workflows within prospective pregnancy biobanking resource.

INTRODUCTION: Brain age gap (BAG) is the difference between a person's chronological age and the age predicted from the structural appearance of their brain on MRI. A higher BAG indicates an older-appearing brain and provides a global marker of structural brain aging across the Alzheimer's disease continuum. Prior studies suggest that females may show greater Alzheimer's disease-related pathology or faster late-stage neurodegeneration than males. We tested whether sex was associated with baseline BAG or longitudinal BAG change after accounting for APOE {epsilon}4 genetic risk, amyloid positivity, cognitive severity, and disease stage. METHODS: We developed a domain-adaptive deep learning model to estimate BAG from T1-weighted MRIs, training it on 26,512 neurologically healthy UK Biobank data and fine-tuning it on 2,974 amyloid-negative cognitively normal samples from Mayo Clinic Study of Aging and OASIS-3 cohorts. We applied the model to ADNI and used hierarchical mixed-effects models to test whether sex was associated with BAG trajectories after adjusting for Alzheimer's disease risk factors. RESULTS: After adjustment for Alzheimer's disease risk factors, there was no baseline sex differences in BAG. Longitudinally, females showed greater BAG acceleration than males, but this effect was moderated by APOE {epsilon}4 status. APOE {epsilon}4 accelerated brain aging in a dose-dependent manner, independent of amyloid burden. DISCUSSION: Sex differences in BAG across the AD continuum were largely explained by APOE {epsilon}4-related acceleration rather than by an independent effect of sex alone. These findings suggest that females may be more vulnerable to APOE {epsilon}4-associated structural brain aging over time.

Background: Cerebral vasospasm is a frequent complication after aneurysmal subarachnoid hemorrhage (aSAH) and is associated with delayed cerebral ischemia (DCI) and unfavorable outcome. While CTA-based vasospasm grading is frequently used, its relationship with actual cerebral perfusion remains incompletely understood. This study investigates the association between vasospasm severity and distribution and territorial perfusion deficits. Methods: In this retrospective single-center study, 513 CT examinations (CTA and CT perfusion) from 194 patients with aSAH were analyzed. Vasospasm was graded per vessel segment using the CTA Vasospasm Score, and perfusion deficits were assigned to corresponding vascular territories (left/right anterior circulation, posterior circulation). Vasospasm distribution was further classified by severity and multifocality. Associations between vasospasm score and perfusion deficits were assessed using a generalized linear mixed model with binomial distribution, adjusting for Hunt & Hess grade, modified Fisher score, and days since hemorrhage. Results: Vasospasm was detected in 79.3% of examinations, and a perfusion deficit in at least one territory was present in 62.6%. The proportion of perfusion deficits increased progressively with both vasospasm severity and multifocality, ranging from 21.7-25.0% in the absence of vasospasm to 81.2-82.2% in severe multifocal vasospasm. The CTA Vasospasm Score was significantly associated with perfusion deficits in all territories (OR 1.36-1.50), with stronger associations in the anterior than posterior circulation. Conclusion: Vasospasm severity and distribution are strongly associated with perfusion deficits, supporting a continuum model of ischemic risk. However, the substantial proportion of perfusion deficits occurring independent of vasospasm suggests additional microcirculatory mechanisms not captured by CTA. CT perfusion should be considered complementary to CTA, particularly in clinically deteriorating or non-assessable patients.

Background Functional neurological disorder (FND), one of the most common neurological conditions, affects women almost twice as frequently as men. The reasons for this are unknown, and there has been minimal research into how physiological and pathological features of women's health interact with symptoms of FND. Methods We conducted an online survey assessing the effect of several aspects of women's health with the severity of symptoms of FND. Results 484 people completed the survey. Among the 223 who had regular or fairly regular menstrual cycles, a strong difference across the menstrual cycle was seen, with symptoms at their best in the follicular phase, worsening in the luteal phase, and worst in the pre-menstrual period and the menses. This effect was not moderated by a proxy measure of pre-menstrual dysphoric disorder (PMDD). Participants who were taking the combined oral contraceptive (COC, n=43) and progesterone-based contraception (n=80) were more likely to report symptom improvement from starting the medication than worsening. When compared to menstruating participants who were not taking the COC, participants taking the COC reported less worsening in their symptoms of FND in the luteal, pre-menstrual, and menstrual phases. Of the 99 women who had passed menopause since developing FND, 76% reported worsening of their FND symptoms after menopause. Discussion This study demonstrates interactions between several aspects of women's health and symptoms of FND. The observed pattern of symptom fluctuation across hormonal states suggests a potential modulatory role of oestrogen, warranting further targeted investigation.

ABSTRACT Background: Onset of cancer is linked to psychological distress and cancer is prevalent in older adults. Yet, the association to suicide is scarcely examined. The aim of this study was to assess whether cancer diagnosed in older adults is associated with suicide incidence. Methods: All older adults (65+ years) who lived in Austria in the years 2014-2021 (n=2,175,134) were followed. Of these, 223,932 were diagnosed with a new cancer. We used non-parametric survival models with inverse-probability-treatment weights to compare risk ratios (relative risk) and risk differences (absolute risk) of older adults with and without cancer. Results: Out of 2,158 suicide deaths, 442 (20.5%; 83.7% males) occurred among older adults with a new cancer diagnosis. The incidence rate was 74 among those with a new cancer diagnosis versus 23 per 100,000 person-years among those with no new cancer. One year after being diagnosed, older adults with a new cancer had a 4 times higher relative risk of dying by suicide compared to those without. The risk was highest within the first three months after diagnosis and for cancers with a poor prognosis (disseminated disease; lung, oesophagus, stomach, liver, pancreas, and brain cancers). The absolute risk of dying by suicide within 5 years after cancer diagnosis was 0.18% versus to 0.11% among those with no new cancer. Discussion: Older adults who received a new cancer diagnosis had elevated suicide risks. Provision of support to cope with mental distress should be considered at cancer diagnosis, especially for older adults with a poor prognosis.

Background. Given uncertainty about whether later-life health at similar ages is improving over time, we examined trends across multiple health domains. Methods. We analysed data from community-dwelling adults aged 50 and older in the English Longitudinal Study of Ageing in 2004/05, 2012/13, and 2023/24 (main survey: N=8389, 8549, and 6090, respectively). Outcomes included self-rated health, limiting long-standing illness, pain, mobility limitations, cardiometabolic and chronic conditions, obesity, inflammation, mental health, quality of life and memory. Weighted pooled modified Poisson and linear regressions compared outcomes over time, overall, and by age group and education, with additional adjustment for sex and wealth. Results. Adjusted estimates showed divergent trends. Fair/poor self-rated health increased from 27% to 34%, and any pain from 37% to 47%, whereas mobility impairments declined from 58% to 52%. Self-reported high cholesterol increased from 19% to 39%, while biomarker-defined high cholesterol declined from 78% to 54%; diabetes increased on both measures. Psychiatric problems increased from 6% to 10%, quality of life declined, and memory improved. However, trends differed by age and education, particularly for limiting long-standing illness, mobility limitations, cholesterol biomarkers, and mental health, indicating that aggregate trends masked unevenly distributed changes. Conclusion. Later-life health in England has not improved uniformly. Gains in functioning, biomarkers, and cognition coexist with rising pain and poorer mental health. Trends were also socially and age patterned, producing increasingly multidimensional and socially patterned health outcomes. Multidomain health monitoring is essential for interpreting population health trends and planning healthy ageing, prevention, long-term care, and work policies.

Background and Aims The optimal treatment for first episodes and first recurrences of Clostridioides difficile infections (CDI) is unknown and there is emerging evidence for pulse and taper (P-T) regimens. Therefore, we sought to estimate the relative efficacy of treatment options. Methods MEDLINE and CENTRAL were searched from database inception to May 21, 2025 and unpublished conference abstracts were searched from recent infectious disease conferences. RCTs on the treatment of first episodes or first recurrences of CDI comparing fixed-dose or P-T regimens of fidaxomicin or vancomycin were included. The primary and secondary outcomes were 40- and 56-day CDI recurrence, respectively. A random-effects network meta-analysis on the risk ratio (RR) scale was conducted using a standard regimen (10-14 days) of vancomycin as the comparator. Treatments were ranked using the surface under the cumulative ranking curve (SUCRA). Results 8 RCTs were included comprising a total of 2181 patients. For 40-day recurrence, fidaxomicin P-T had the highest probability of ranking best (RR=0.10, 95%Confidence Interval [95%CI]=0.10-0.49, SUCRA=1.00), followed by vancomycin P-T (RR=0.49, 95%CI=0.32-0.76, SUCRA=0.61), fixed-dose fidaxomicin (RR=0.61, 95%CI=0.49-0.76, SUCRA=0.39), and, finally, fixed-dose of vancomycin (SUCRA=0.00). The treatments ranked in the same order for 56-day recurrence, though only 3 RCTs reported on this timepoint. Conclusion Vancomycin P-T, fidaxomicin P-T, and fixed-dose fidaxomicin were all superior to a fixed-dose vancomycin. Head-to-head comparative effectiveness RCTs are needed to quantify their relative effect sizes of and impact on long-term prevention of recurrent CDI.

Background The 2022-2023 global mpox outbreak highlighted the critical need for robust genomic surveillance capabilities to track mpox virus (MPXV) evolution and transmission dynamics. Methods Building upon our established SARS-CoV-2 sequencing infrastructure, we implemented a Molecular Loop probe-based long-read sequencing approach using Pacific Biosciences Sequel II technology for comprehensive MPXV genomic surveillance across the United States (US). From August 2024 to June 2025, we generated 326 high-quality whole genome sequences from residual mpox-positive clinical specimens collected by Labcorp across all 10 US Department of Health and Human Services regions. Results Our analysis identified two samples containing clade Ib MPXV in January and June 2025 and captured shifting trends in clade IIb diversity, with 13 distinct lineages observed. We also identified multiple instances of large (~1.6-17.6kb) deletions proximal to the inverted terminal repeats in clade IIb genomes. APOBEC3 mutation analysis indicated substantial evidence of human-to-human transmission among both clades. Further, we observed significantly higher APOBEC3-associated SNPs per kilobase (P<0.001) in clade IIb genomic variable regions relative to their central conserved region. Our assay exhibited strong reproducibility across biological replicates from individual patients and accuracy was confirmed via parallel sequencing of select specimens by US Centers for Disease Control and Prevention (CDC) using metagenomic sequencing. We also demonstrated via custom simulation that our assay discriminates all known MPXV clades and lineages, including those we have not observed in the US. Conclusions Our integrated nationwide surveillance system facilitates real-time genomic tracking of outbreak evolution, with demonstrated capacity across SARS-CoV-2 and MPXV, positioning this platform for rapid deployment during future pathogen emergence.

Background: Monoclonal antibodies have emerged as a prophylactic strategy to prevent symptomatic SARS-CoV-2 infection in immunocompromised individuals. However, the evolutionary and clinical implications of breakthrough infections under this regime remain unclear. Methods: A male in their 80s with a haematological/oncological diagnosis received a 2000 mg intravenous infusion of sotrovimab in March 2023 and was diagnosed with COVID-19 by RT-qPCR from a nasopharyngeal swab in August 2023. Weekly samples (n=24) were collected through February 2024 (171 days). All samples underwent whole-genome sequencing, with select mutations subjected to functional assessment. Findings: Sequencing identified the GE.1 lineage at all timepoints. An intra-host recombination event in ORF1ab (positions 8942-12458) was detected prior to 23 weeks post-detection, followed by a 14-fold increase in viral load (7.42e+06 to 1.00e+08 RNA copies/mL) and a marked shift in the viral population. E340D, a sotrovimab resistance mutation, was detected at low abundance (46%) within the first week post-infection, fluctuated over time, and was nearly fixed by week 15 (107 days) post-detection. We assessed five spike mutations - V36M, S98F, and V213G in the N-terminal domain, Y505P in the receptor-binding domain, and P681Q near the S1/S2 cleavage site - and additionally evaluated the impact of E340D. V36M conferred the highest infectivity across all cell lines, with the most significant effect in low-TMPRSS2 cells. While all mutations showed enhanced infectivity with the addition of E340D, the effect was most pronounced in mutations with lower baseline infectivity. The addition of E340D significantly decreased relative neutralizing titres for V36M, S98F, and V213G, enabling escape from neutralizing antibodies in XBB-responsive individuals, illustrating an enhanced phenotypic advantage. Patient neutralizing activity was absent pre-sotrovimab, and sotrovimab-induced neutralization was further compromised by selection of E340D. Interpretation: Sotrovimab pre-exposure prophylaxis in an immunocompromised patient did not prevent SARS-CoV-2 infection, and selected for resistant mutation E340D, with unexpected fitness consequences across non-receptor binding domain spike regions.

Objective: There is a bidirectional relationship between emotional distress and pain. However, this relationship is understudied in people with HIV in low-resource settings. This study sought to describe the temporal relationship between emotional distress and pain in people with HIV. Design: Longitudinal observational study. Methods: Participants with virally suppressed HIV, reporting either no pain or persistent pain at baseline, provided weekly remote ratings of distress, worst pain, and average pain using 0-10 visual analogue scales. Within-individual fluctuations in distress and pain were visualised over time. Group-level correlations were determined using Spearman's correlation tests. Cumulative link mixed models assessed whether distress and pain each predicted the other in the following week. Results: 72 participants provided responses over 49 weeks. The participants had a median (IQR) age of 43 (37-51) years, 63% (n=45) were unemployed and most were females (n=51;71%). Distress and pain fluctuated concurrently within individuals: distress was positively correlated with worst pain ({rho}=0.66, 95% CI= 0.60-0.72, p<0.001) and average pain ({rho}=0.70, 95% CI=0.64-0.75, p<0.001) intensity within the same week. Worst pain (OR=1.42, 95% CI=1.17-1.71, p<0.001) and average pain (OR=1.43, 95% CI=1.20-1.71, p<0.001) intensity both predicted distress in the next week. Distress predicted worst pain intensity (OR=1.25, 95% CI=1.07-1.46, p=0.023) but not average pain intensity (OR=1.19, 95% CI=1.01-1.40, p=0.152) in the next week. Conclusions: The temporal relationship between distress and worst pain intensity was bidirectional, whereas distress did not temporally predict average pain intensity. Both pain and emotional distress should receive attention from HIV research and clinical care in low-resource settings.

Background: Opioid use disorder (OUD) is heritable, yet most genome-wide association studies (GWAS) have focused on European populations, leaving the genetic architecture of OUD in non-European populations underexplored. Methods: We conducted GWAS of OUD across three ancestries using electronic health records and genomic data from 52,357 All of Us Research Program participants (8,912 cases; 43,445 matched opioid-exposed controls; 48.5% female). Participants were stratified into European (EUR), African (AFR), and Admixed American (AMR) ancestry groups for logistic regression GWAS, with independent replication in the Million Veteran Program. We then applied the deep-learning model AlphaGenome to predict the tissue-specific transcriptomic and splicing consequences of top risk variants across 13 reward-pathway brain regions. Results: We identified and replicated a novel DDX6 risk locus, alongside established OPRM1 and FURIN signals. AlphaGenome predicted the DDX6 regulatory allele downregulates the stress-resistance gene FOXR1 in the nucleus accumbens, while the protective OPRM1 variant (rs1799971) upregulates OPRM1 expression across reward networks. Other signals of interest included IL6R and SHISA9 (EUR); GHR (AFR); and ASTN2 (AMR). Conclusions: This study identifies DDX6 as a novel OUD risk locus, replicates associations with OPRM1 and FURIN, and highlights biologically plausible ancestry-specific signals in AFR and AMR populations. We also replicated top variants in an independent population. Finally, integrating GWAS with deep-learning annotations provides specific, localized biological hypotheses to guide future experimental validation and targeted therapeutics.