Hypertension

Src family kinases (SFKs) constitute a major non-receptor tyrosine kinase class that regulate processes important for pregnancy. We profiled placental SFKs to assess cell-specific expression, tissue localization, and clinical associations in early-onset preeclampsia (PE). Placental SFK transcripts were analyzed using bulk RNA sequencing discovery (GSE203507; n=15 PE, n=15 controls) and external validation (GSE114691; n=40 PE, n=21 controls) cohorts. Single-cell and single-nucleus RNA sequencing atlases mapped cell-specific expression. Computational deconvolution and causal mediation analyses were applied to bulk datasets. Findings were cross-validated by real-time quantitative PCR (qPCR; n=9 early-onset PE, n=7 controls) and immunohistochemistry (IHC). Transcriptomic data showed that LYN was the sole SFK member consistently elevated in early-onset PE placentas across discovery (1.8-fold, FDR<0.01) and validation cohorts (2.2-fold, FDR<0.001). Elevation was verified by qPCR (p<0.0001) and remained significant after adjusting for clinical covariates. Placental LYN abundance correlated positively with maximum antepartum maternal systolic blood pressure (r=0.63, p<0.01). Single-cell transcriptome atlases demonstrated LYN enrichment in myeloid lineages, extravillous trophoblasts, and syncytiotrophoblast (SCT). Deconvolution and mediation analyses indicated that altered tissue composition and increased per-cell expression each accounted for approximately half of the PE-associated LYN increase. IHC localized Lyn protein to Hofbauer macrophages and the apical microvillar SCT membrane in PE placentas. We conclude that placental LYN expression is selectively elevated in early-onset PE and correlates with maternal blood pressure severity. Lyn localization to trophoblasts and placental immune cells suggests potential roles in mediating inflammation and hypoxia-associated signaling in PE pathogenesis.

BACKGROUND: The chromosome 9p21.3 locus is among the strongest genetic risk loci for cardiovascular disease (CVD), yet the regulatory mechanisms underlying this association remain poorly understood. Previous vascular disease studies focused predominantly on the role of this locus in smooth muscle cell (SMC) dysfunction, whereas its potential role in endothelial cells (ECs) remains less well characterized. Here, we sought to identify candidate regulatory variants at 9p21.3, their distal target genes, and effector transcripts that contribute to CVD-related phenotypes in ECs. METHODS: Promoter capture Hi-C was used to map chromatin interactions at 9p21.3 in primary human ascending aortic SMCs (n=6), supplementing the previously obtained ECs (n=16) dataset. To support the regulatory relevance of these interactions, expression quantitative trait locus analysis was performed in 136 vascular biopsies. Variant effects were prioritized in silico using AlphaGenome. The regulatory activity of the prioritized region was validated using CRISPR activation. RESULTS: Chromatin interaction mapping identified a complex regulatory architecture at the 9p21.3 locus involving 19 putative regulatory elements and 15 genes across ECs and SMCs. MIR31HG showed the most recurrent distal promoter connectivity with the 9p21.3 region. Consistent with the chromatin interaction map, expression of MIR31HG transcripts was associated with genetic variation at the 9p21.3 locus. In ECs, the lncRNA MIR31HG, but not miR-31, was responsive to hemodynamic flow. Depletion of MIR31HG in ECs was associated with endothelial activation. Epigenetic tracks and deep learning predictions highlighted an active enhancer element at 9p21.3, which was subsequently validated by CRISPR activation and increased MIR31HG expression, confirming its capacity to regulate MIR31HG over a large genomic distance of approximately 538 kb. CONCLUSIONS: Altogether, these data implicate lncRNA MIR31HG as a likely effector of the 9p21.3 CVD locus, linking the cis-regulatory element and heritable genetic variation in the respective region to endothelial activation through long-range enhancer regulation.

BACKGROUND: White matter hyperintensities (WMHs), the principal imaging manifestation of cerebral small vessel disease, lack an animal model that produces pathology of sufficient magnitude to validate potential therapeutics. We characterized white matter (WM) degeneration in a renovascular hypertension (RVH) rat model, interrogated its mechanism, and tested its relevance in patients. METHODS: RVH was induced by two-kidney, two-clip surgery and assessed by T2-weighted and diffusion MRI, myelin and axonal histology, and blood-brain barrier (BBB) leakage markers. The influence of angiotensin II (Ang II) on barrier function in brain endothelial cells was examined using transendothelial electrical resistance and reactive oxygen species (ROS) assays. Losartan was infused intracerebroventricularly to block brain AT1R (Ang II type 1 receptor) without systemic blood pressure reduction. WMH burden was compared between patients with and without renal artery stenosis, and WMH progression across antihypertensive classes was assessed in the CHALLENGE (Korea), MSS2 (UK), LBC1936 (UK), and SPRINT-MIND-MRI (US) cohorts. RESULTS: Approximately two-thirds of RVH rats developed WMHs that expanded between 7 and 9 weeks, accompanied by reduced fractional anisotropy, demyelination, axonal and mature oligodendrocyte loss, and glial activation. IgG, albumin, and fibrinogen leakage was confined to affected WM. Ang II impaired endothelial barrier function and generated ROS through AT1R. Intracerebroventricular losartan attenuated WM pathology and improved behavior while blood pressure remained comparably elevated. Patients with renal artery stenosis had higher WMH volumes (10.52 versus 6.52 mL; P = 0.035). Angiotensin receptor blocker use was associated with the slowest tertile of annual WMH progression in the Korean cohort (OR, 2.57 [95% CI, 1.20-5.61]) and among White participants in SPRINT-MIND-MRI (OR, 3.52 [95% CI, 1.05-12.29]). CONCLUSIONS: RVH produces prominent ischemic WM degeneration driven by AT1R signaling, identifying a blood pressure-independent therapeutic target with corroborating clinical evidence.

Background: Noninvasive biomarkers capable of detecting kidney allograft injury and distinguishing rejection from infection remain an important clinical need. Torque teno virus (TTV) reflects host immune status, but its utility in urine has not been well established. We evaluated urinary TTV, total cell-free DNA (cfDNA), cfDNA fragmentation, and BK polyomavirus (BKV) as potential biomarkers of kidney transplant rejection and BK polyomavirus-associated nephropathy (BKPyVAN). Methods: Urine samples from 334 kidney transplant recipients were analyzed in association with kidney biopsies performed within 30 days of sample collection. TTV and cfDNA were measured by multiplex quantitative PCR (qPCR), with a subset analyzed by digital PCR (dPCR), and BKV was quantified by qPCR. Associations with biopsy results were evaluated using group comparisons and nominal logistic regression. Changes associated with outcomes of consecutive biopsies were assessed by matched pairs analysis. Results: Among 544 unique urine samples, the urinary TTV/cfDNA ratio was significantly lower in rejection than in non-rejection samples (P<0.0001). Logistic regression adjusted for demographic factors confirmed an inverse association between the qPCR-derived TTV/cfDNA metric and rejection (adjusted odds ratio per delta Cq, 0.91; 95% CI, 0.88-0.94; P<0.00001). Significant differences were observed for all types of rejection. Association was confirmed by dPCR: higher TTV was associated with lower rejection odds, whereas higher cfDNA was associated with greater rejection odds. A nominal logistic model incorporating dPCR measurements achieved an AUROC of 0.76 (95% CI, 0.69-0.82). Matched pairs analysis showed a significant decrease in TTV/cfDNA when rejection developed and an increase following recovery from rejection, with no significant changes when biopsy status remained unchanged. BKV levels were strongly associated with BKPyVAN. No correlation between TTV and BKV was observed. Nominal logistic regression integrating TTV, cfDNA, and BKV measurements yielded AUROCs of 0.75, 0.97, and 0.73 for rejection, BKPyVAN, and non-rejection, respectively. Conclusions: A reduced urinary TTV/cfDNA ratio is associated with biopsy-defined kidney transplant rejection, and changes in the ratio correlate with transitions in biopsy results. Combined TTV, cfDNA, and BKV measurements showed differential associations with rejection and BKPyVAN, supporting further evaluation as complementary urinary biomarkers.

Rural patients with heart failure (HF) have poor access to care, worse outcomes, and may benefit from at-home monitoring. We evaluated whether foot temperature measured using a thermographic floor mat was associated with invasively measured cardiac output and whether longitudinal temperature changes preceded HF events. We conducted a two-part prospective, observational single-center study using the SmartMat (Podimetrics, Somerville, MA), which acquires plantar thermograms and ambient temperature. In the acute study, patients undergoing clinically indicated right heart catheterization completed 4 scans on the same day. In the chronic study, patients with a HF hospitalization in the past year and New York Heart Association Class II-III symptoms were instructed to use the device and a scale daily for 6 months. A HF event was defined as receiving at least one dose of intravenous or subcutaneous diuretic. Thirty patients were enrolled in the acute study. Mean right hallux temperature positively correlated with thermodilution cardiac output (r=0.63, p<0.001). 42 patients were enrolled in the chronic study. Among patients experiencing an HF event, ambient-adjusted hallux temperature declined in the 15 days immediately preceding the event compared with days 15-30 before the event. Plantar thermograms are associated with invasively measured cardiac output and may detect subclinical worsening before HF events. Foot temperature may provide complementary information regarding HF decompensation, supporting further evaluation of plantar thermography for remote HF monitoring.

Importance. Plasma phosphorylated tau 217 (p-tau217) is entering clinical use with fixed diagnostic threshold that do not account for kidney function. Chronic kidney disease (defined as estimated glomerular filtration rate (eGFR) below 60 mL/min/1.73 m2), raises plasma p-tau217 concentrations and can produce false positive results. It remains unclear whether milder reductions in kidney function, above the CKD threshold, have the same effect. Objective. To determine whether plasma p-tau217 is elevated with mildly reduced kidney function, above the chronic kidney disease threshold, in adults without neurological disease. Design. Cross-sectional analysis of a cohort enrolled between 2023 and 2025 and biomarker analysis blinded to clinical data. Setting. Two private psychiatric inpatient facilities in Australia. Participants. Adults admitted with psychiatric disorders and free of neurological disease. Exposures. eGFR calculated from serum creatinine using the CKD-EPI 2021 equation. Main Outcomes and Measures. Plasma p-tau217, neurofilament light chain (NfL), and glial fibrillary acidic protein (GFAP), measured on the Simoa platform. Multivariable linear regression compared eGFR groups (< 60, 60 to 90, and [&ge;] 90 mL/min/1.73 m2), adjusted for age, BMI, and sex. Results. Among 180 participants (median age, 50.5 years [IQR, 38.0-61.5]; 94 [52%] female), eGFR was [&ge;] 90 mL/min/1.73 m2 in 106 (59%), 60 to 90 in 61 (34%), and < 60 in 13 (7.2%). Compared with an eGFR [&ge;] 90, plasma p-tau217 was 36% higher in both the 60 to < 90 group ({beta} = 0.42 [95% CI: 0.11, 0.74]; P = .008) and 116% higher in the < 60 group ({beta} = 1.05 [95% CI: 0.43, 1.72]; P = .002). Plasma NfL and GFAP were elevated in the < 60 group but differences in the 60 to < 90 group did not reach significance. Modelled continuously, plasma p-tau217 was 9.5% lower per 10 mL/min/1.73 m2 higher eGFR (95% CI: 3.3%, 15.4%). Conclusions and Relevance. Plasma p-tau217 was elevated in adults with mildly reduced kidney function, above the CKD threshold, in a cohort free of neurological disease. Kidney function across its full range should be incorporated into plasma p-tau217 reference ranges and clinical interpretation to reduce false positive and false negative results.

Background: Genomic reassessment may reveal clinically relevant diagnoses in patients with young-onset kidney failure despite established clinical diagnostic labels. We evaluated this approach after excluding clinically apparent polycystic kidney disease (PKD). Methods: Among 1,139 patients receiving maintenance dialysis at participating Japanese facilities, 355 had initiated dialysis at age [&le;]50 years. After excluding 17 patients with clinically apparent PKD, 108 of 338 eligible patients underwent whole-genome sequencing through voluntary, nonrandom enrollment. Analysis included 465 nuclear candidate genes, mitochondrial DNA, and copy-number/structural variants. Clinically concordant diagnoses were adjudicated using integrated clinical and genetic evidence, with a separate pathogenic/likely pathogenic (P/LP)-supported subset. Results: Diagnoses were identified in 10/108 participants (9.3%; 95% confidence interval, 5.1-16.2), comprising seven renal and three systemic/metabolic diagnoses. Nine diagnoses were P/LP-supported (8.3%; 95% confidence interval, 4.4-15.1). The remaining diagnosis was phenotype-based clinical Dent disease associated with a CLCN5 variant of uncertain significance. Diagnoses occurred across diabetic kidney disease, nephrosclerosis, chronic glomerulonephritis, unknown-cause, and other clinical categories. In a post hoc analysis excluding three participants with low target coverage, the integrated and P/LP-supported proportions were 9/105 (8.6%) and 8/105 (7.6%). Six exploratory findings were excluded from both diagnostic numerators. Gitelman syndrome was included as a clinically manifest renal disorder, although its contribution to kidney failure remained uncertain. Conclusions: Integrated genomic assessment can uncover renal and systemic/metabolic diagnoses across conventional labels in young-onset kidney failure after exclusion of clinically apparent PKD. Nonrandom enrollment and variable sequencing coverage limit generalizability and interpretation of negative results.

Introduction: Kidney volume is associated with renal function, but conventional whole-organ measurements may miss regional changes in kidney substructures. We used magnetic resonance imaging (MRI) to test whether kidney substructure volumes and three-dimensional (3D) thickness phenotypes are associated with disease, adiposity, and incident outcomes. Methods: Automated abdominal MRI segmentations from 70,270 UK Biobank participants were used to quantify left and right kidney cortex, medulla, and parenchyma volumes and mesh-based thickness maps. Mass univariate regression generated statistical parametric maps linking regional thickness to anthropometric traits and disease (CKD, type-2 diabetes [T2D], hypertension). Bidirectional causal mediation analyses were performed using kidney substructure volumetric, thickness PCs and kidney adiposity. Longitudinal changes were assessed in 2,610 participants with repeat imaging. Cox proportional hazards models tested the associations between kidney volumes and principal component (PC) scores of thickness and incident CKD, T2D, hypertension, cardiovascular disease (CVD), and mortality. Results: CKD was associated with thinning of the parenchyma and most pronounced in the medulla (87.7% left, 72.8% right), whereas associations in the cortex were mixed. In contrast, T2D and hypertension were predominantly associated with increased thickness, most extensively in the cortex (T2D: 84.39% left, 96.35% right; hypertension: 94.8% left, 99.9% right). Age-disease interactions were associated with reduced thickness across all conditions. Smaller medulla volume and lower cortical thickness mediated the association between CKD and renal sinus fat. Kidney substructure volume was inversely associated with incident CKD across all substructures and both kidney sides (p<0.05), but positively associated with incident hypertension and mortality (p<0.05). Thickness PC scores also predicted outcomes independently of volume, with PC3 in the left cortex (HR 0.91 [0.84-0.98]), reflecting inferior pole/hilar thickness, associated with incident CKD. Conclusions: MRI-derived kidney substructure volumes and 3D thickness maps provide complementary, spatially-resolved markers of kidney morphology, that are mechanistically linked to renal adiposity and future disease risk.

Abstract Background: Placental insufficiency (PI), characterized by impaired placental function, is a leading cause of stillbirth. Although rare coding variants are known to cause a subset of stillbirths, their contribution to PI is poorly understood. Methods: We conducted a secondary analysis of stillbirth cases (N=292) of the Stillbirth Collaborative Research Network study with exome sequencing available on postmortem placental or fetal samples. PI was defined by standardized placental pathological lesions (e.g., maternal vascular malperfusion) and prespecified clinical criteria for placental dysfunction. Candidate gene-based rare-variant burden analysis was performed using the Sequence Kernel Association Test-Optimal framework, focusing on evolutionarily constrained developmental and placental-function genes. Primary analysis compared stillbirths with and without placental vascular malperfusion. Similar comparisons by clinical PI and other placental pathological lesions were conducted in secondary analysis. Results: Stillbirths with PI phenotypes demonstrated different patterns of genetic variation than stillbirths without PI. Specifically, we observed nominal differential enrichment of constrained variants in biologically prioritized placental-function genes, regulating extravillous trophoblast invasion and spiral artery remodeling (CTNND2, PHACTR1, SLIT1, VEGFA), placental angiogenesis (IGF2R, TEK), mitochondrial homeostasis (OPA1), and fetal growth (DLK1, GNAS). Secondary analyses on specific placental pathological lesions suggested recurrent enrichment of genes within similar placental developmental pathways. Conclusions: We observed nominal differential enrichment of constrained developmental and placental-function genes in stillbirths with PI compared to stillbirths without PI. The observed genetic signals across PI phenotypes suggest shared biological pathways underlie placental dysfunction. Our findings advance genotype-phenotype characterization and help prioritize candidate pathways for larger collaborative genomic and functional studies to improve stillbirth risk stratification and prevention.

Objectives Uncontrolled hypertension is the leading preventable cause of death and disability worldwide, with nearly two-thirds of affected individuals living in low- and middle-income countries (LMICs). Despite this disproportionate burden, epidemiological data necessary to combat the development of hypertension and its associated complications in LMICs remains scarce. The objective of this study was to assess risk factors for elevated blood pressure and hypertension diagnosis among adults living in a rural indigenous region of Guatemala. Methods A cross-sectional analysis was conducted using physician assessment data from 359 patients aged 18 years or older, who participated in a 2022 paired community health worker and physician hypertension study in San Lucas Toliman, Guatemala. Outcome variables were systolic and diastolic blood pressure, and diagnosed hypertension. Risk factors examined included age, sex, body-mass index (BMI), smoking status, alcohol use, antihypertensive use, language preference, and other clinical and behavioral characteristics. Multivariable linear regression models were used to assess factors associated with systolic and diastolic blood pressure, while multivariable logistic regression was used for assessing diagnosed hypertension. Results Higher systolic blood pressure was associated with increasing age, higher BMI, Spanish language preference, and low-intensity physical activity. Diastolic blood pressure was positively associated with increasing BMI, pre-existing diabetes, and Spanish language preference. There was a negative association with high-intensity physical activity. Hypertension diagnosis was associated with increasing age, higher BMI, and pre-existing diabetes. Conclusion This analysis confirms established hypertension risk factors in a rural indigenous population in Guatemala and identifies additional risk factors that may be relevant in this setting.

Background: Coronary perivascular fat attenuation index score (FAI-Score) on coronary computed tomography angiography (CCTA) quantifies vascular inflammation and predicts cardiac mortality in symptomatic cohorts. However, its prevalence, anatomical distribution, and clinical correlates in asymptomatic primary prevention populations remain uncharacterized. Methods: In an IRB-approved prospective study across two clinical sites, 84 consecutive asymptomatic adults (mean age 53.7 {+/-} 8.6 years; 63.1% men) with no prior coronary artery disease underwent screening CCTA and comprehensive clinical, metabolic, and biomarker profiling. AI-standardized FAI-Score was quantified across three epicardial vessels (LAD, LCx, RCA). High and very high perivascular inflammation were pre-specified as any vessel [&ge;]75th and [&ge;]90th percentiles, respectively. Luminal stenosis and plaque were graded using CAD-RADS 2.0. Results: Elevated FAI-Score ([&ge;]75th percentile) was present in 42.9% of participants (36/84; 95% CI 32.8% - 53.5%), with 17.9% (15/84; 95% CI 11.1% - 27.4%) exhibiting very high inflammation ([&ge;]90th percentile). Multi-vessel inflammation was identified in 17.9% (15/84), with the RCA most frequently involved ([&ge;]90th percentile in 13.1%). Standard circulating biomarkers, including ApoB, non-HDL-C, HbA1c, and PREVENT-ASCVD 10-year risk showed no association with binary inflammation. Systemic hs-CRP (median 0.8 mg/L) exhibited an inverse correlation with maximum vessel FAI-Score (Spearman {rho}=-0.27, p=0.014). Men demonstrated higher rates of elevated FAI-Score than women (52.8% vs. 25.8%, p=0.016; [&ge;]90th percentile: 26.4% vs. 3.2%, p=0.007). Strikingly, 46.2% (30/65) of participants with normal luminal anatomy (CAD-RADS 0) and 47.2% (25/53) with zero plaque burden harbored elevated FAI-Score; all 15 individuals with very high FAI-Score had CAD-RADS 0 (Fisher's exact p=0.018). Body mass index was the sole secondary correlate surviving false discovery rate correction (AUC = 0.71, p=0.001, all-test FDR q=0.028). Regularized multivariable models showed modest out-of-sample discrimination for FAI-Score elevation (cross-validated AUC = 0.71). Conclusions: Coronary perivascular inflammation is common among asymptomatic adults and frequently uncouples from structural plaque and luminal stenosis. Routine circulating biomarkers and clinical risk calculators fail to identify inflamed vessels, highlighting FAI-Score as an independent dimension of primary cardiovascular risk assessment.

Purpose Prescribing to lactating women is constrained by limited evidence. Published compatibility classifications provide clinical guidance and a discrete research comparator. How often prescribing diverges from that guidance, and what characteristics are associated with divergence, is unknown at national scale. Methods Retrospective analysis of prescriptions filled during lactation, identified in the 2012-2014 MarketScan Commercial Claims Database. Prescriptions were classified as concordant (Hale's lactation risk category L1-L3) or discordant (L4-L5). Multivariable logistic regression identified factors associated with concordance. Results Of 96,484 new prescriptions, 95,710 (99.2%) were concordant and 774 (0.8%) were discordant. Discordant prescriptions were filled later after delivery (median 59 vs 33 days) and had a day supply three times longer (30 vs 10 days). In multivariable analysis (N=28,732), concordant prescriptions were associated with maternal age under 35 (adjusted odds ratio (aOR)=1.34, 95% confidence interval (CI): 1.02-1.75) and chronic-condition medications (aOR=10.94, 95% CI: 6.47-18.50), and were less likely within 14 days of delivery (aOR=0.53, 95% CI: 0.38-0.73) and with each additional day of supply (aOR=0.96, 95% CI: 0.96-0.96). Compared with family practice, concordance did not differ for obstetric, internal medicine, or emergency medicine prescriptions, but prescriptions from other provider types had lower odds of concordance (aOR=0.57, 95% CI: 0.41-0.79). Conclusions Prescribing during lactation was overwhelmingly concordant with published compatibility guidance; the rare divergence was patterned by prescription and prescriber characteristics. Because the categories are an expert classification rather than consensus guidance, divergence should not be read as inappropriate prescribing.

Background: Transthoracic echocardiography (TTE) remains the gold standard for assessing left ventricular (LV) diastolic dysfunction (DD), but noninvasive alternatives are needed to overcome geometric and acoustic limitations. 4D-Flow MRI enables comprehensive assessment of intraventricular pressure differences (IVPDs) and flow propagation velocity (VP). We aimed to evaluate 4D-Flow-derived IVPDs and VP in patients with hypertrophic cardiomyopathy (HCM). Methods: Thirty-eight HCM patients and 38 age- and sex-matched healthy controls underwent TTE and 4D-Flow MRI. Spatiotemporal maps of velocity and IVPDs, decomposed into inertial and convective components, were derived along the main inflow streamline from the mitral valve to the apex. Peak early filling rate (PEFR) was used to normalize IVPDs and VP. Results: While absolute peak flow rates were comparable, HCM patients exhibited significantly faster VP (100.4 vs. 60.2 cm/s, p < 0.01) and higher positive early E IVPD (1.40 vs. 0.92 mmHg, p < 0.01) compared to controls. Normalizing IVPDs by PEFR amplified group differences, revealing a markedly increased flow-normalized E-IVPD (5.13 vs. 2.94 x 103 mmHg.ml1.s, p < 0.001) and deeper reverse ER IVPD (-6.06 vs. -4.61 x 103 mmHg.ml1.s, p < 0.01) in HCM. These differences were primarily driven by the inertial components. Multivariable analysis demonstrated that ER IVPD is independently determined by PEFR and the TTE E/E' ratio (r = 0.65, p < 0.001). Conclusions: 4D-Flow MRI-derived, flow-normalized IVPDs and propagation velocity provide robust, noninvasive markers of altered LV chamber stiffness and impaired diastolic filling in HCM, offering deeper 3D hemodynamic insights into diastolic dysfunction.

Summary Background We used sequential target trial emulation (TTE) to examine associations between opioid analgesic initiation and adverse maternal and neonatal outcomes while accounting for gestational timing, time at risk, and potential confounding. Methods Using the Early Life Course platform, comprising linked population-based data for births in New South Wales, Australia (2013-2019), we emulated a new trial at each gestational week, comparing women who initiated a prescribed opioid analgesic with eligible non-initiators. Baseline covariates were balanced using inverse probability weighting. Weighted logistic regression estimated odds ratios (ORs) for neonatal outcomes, postpartum haemorrhage, and severe maternal morbidity. Pooled logistic regression estimated hazard ratios (HRs) for other maternal outcomes, combined across gestational weeks using fixed-effects meta-analysis. Sensitivity analyses assessed unmeasured confounding, exposure misclassification, and potential reverse causation. Findings Among 511,357 pregnancies, over 80% of opioid initiators received only one dispensing. Opioid initiation was not associated with increased risks of placental abruption (HR 0.94, 95% CI 0.75-1.16), severe maternal morbidity (OR 1.05, 0.97-1.11), postpartum haemorrhage (OR 0.98, 0.95-1.02), low Apgar score (OR 0.99, 0.87-1.08), small for gestational age (OR 0.90, 0.85-0.95), or neonatal abstinence syndrome (OR 0.98, 0.72-1.30). Risks were elevated for PPROM (HR 1.10, 0.98-1.23), preterm birth (HR 1.26, 1.19-1.33), severe neonatal morbidity (OR 1.08, 1.02-1.17), and perinatal death (OR 1.29, 1.10-1.52). Perinatal death estimates attenuated in analyses addressing potential reverse causation. Interpretation Using a TTE approach that accounted for gestational timing and time at risk, we found no appreciable increase in most maternal or neonatal outcomes following predominantly short-term opioid initiation. Elevated risks of preterm birth, perinatal death, and third-trimester PPROM may reflect causal effects or confounding by pregnancy-related indications. Studies using time-appropriate designs and detailed information on prescribing indications and their timing are needed to clarify these associations.

Background: Anatomic isthmus 3 (AI 3) is defined as the myocardium between the pulmonary valve annulus and the ventricular septal defect patch that persists after tetralogy of Fallot (ToF) repair. Ventricular tachycardia (VT) propagated through slow conducting AI 3 (SCAI 3) represents a significant cause of morbidity in ToF. There is an unmet need for non-invasive identification of SCAI 3 in patients with ToF. Objectives: To assess whether the anatomic features of AI 3 as derived from cardiac computed tomography (CT) can predict slow conduction velocity during EP study. Methods: This retrospective single-center study included patients with ToF who underwent an electrophysiologic study and had AI 3 width measured from the pre-procedure cardiac CT. All patients underwent programmed ventricular stimulation, and electroanatomic. Logistic regression was performed to assess the relationship between AI 3 width and the presence of SCAI 3. Results: Of 27 consecutive patients with ToF, twelve patients were found to have SCAI 3, and ten patients were found to have SCAI 3 mediated VT. The AI 3 was significantly narrower in patients with SCAI 3 compared to those with normal AI 3 conduction (18.4 +/- 6.6 mm vs. 29.2 +/- 9.0 mm; p = 0.001). An AI 3 width above 21.5 mm carried a negative predictive value of 80.0%. Conclusion: In adults with repaired ToF referred for electrophysiology study, a narrower CT-derived AI 3 width was associated with SCAI 3 identification. AI 3 width measured on a CT obtained before PV replacement could help guide invasive risk stratification.

Rationale: Conventional CT-derived pulmonary vascular metrics quantify vascular pruning but do not assess the spatial heterogeneity of vascular architecture. In COPD, peripheral microvascular pruning coexists with compensatory central vessel dilation, paradoxically preserving total vessel volume while reducing effective vascular penetration into lung parenchyma. Objectives: To develop and evaluate Vascular Proximity Coverage (VPC), a distance-based CT biomarker quantifying the spatial efficiency of pulmonary vascular distribution. Methods: This retrospective analysis included 7,881 COPDGene participants [PHASE] with complete vascular segmentations. VPC was estimated by integrating the area under the cumulative lung tissue coverage curve at distances of 0-10 mm from segmented vessel voxels. Multivariable models assessed associations with lung function, six-minute walk distance (6MWD), St. George's Respiratory Questionnaire (SGRQ) score, mMRC dyspnea score, and all-cause mortality over a median follow-up of [10.8] years, adjusting for demographics, smoking, emphysema, scanner type, and BV5. The cohort was stratified at median BV5 and VPC into concordant (high/high, low/low) and discordant (high-BV5/low-VPC, low-BV5/high-VPC) vascular phenotypes. Results: VPC declined across disease severity (5.82 {+/-} 0.50 [UNITS] in non-smokers to 5.21 {+/-} 0.64 in GOLD 4; p < 0.001). Among spirometrically normal smokers, current smokers had lower VPC than former smokers (5.31 vs. 5.68; p < 0.001). Each standard deviation decrease in VPC was independently associated with reduced 6MWD ({beta} = -16.8 m, 95% CI: -19.5 to -14.0), worse SGRQ ({beta} = 1.9, 95% CI: 1.4 to 2.4), and greater dyspnea (RR = 1.05, 95% CI: 1.03 to 1.08; all p < 0.001). The lowest VPC quartile was associated with 38% higher mortality than the reference quartile (HR = 1.38, 95% CI: 1.18 to 1.62; p < 0.001). The high-BV5/low-VPC phenotype showed 24% higher mortality than high-BV5/high-VPC (HR = 1.24, 95% CI: 1.08 to 1.42; p = 0.002) despite preserved vessel volume. Conclusions: VPC captures spatial heterogeneity of vascular architecture independent of vessel volume, is reduced in smokers without airflow obstruction, and identifies excess mortality risk among individuals whose total vessel volume appears preserved.

Introduction: Raised blood pressure is an important cardiovascular risk factor in Cambodia; however, national averages may obscure substantial local geographic heterogeneity. We assessed the spatial distribution of raised blood pressure and its demographic, metabolic, behavioural, built-environment, and environmental correlates using the 2023 Cambodia STEPwise approach to noncommunicable disease (NCD) risk factor surveillance (STEPS) survey. Methods: We analysed 289 georeferenced primary sampling units (PSUs) from the 2023 Cambodia STEPS Survey. PSU-level case counts and numbers of adults with valid blood pressure data were modelled using a frequentist binomial generalised additive model with a two-dimensional Gaussian-process smooth. An explanatory model included selected PSU-level and contextual covariates; a separate mapping model used spatially continuous predictors to generate predictions on a 5-km grid. Design-based national and residence-specific prevalence estimates were calculated separately using the survey design and Step-2 weights. Results: Among 4,225 adults with valid blood pressure data, unweighted prevalence of raised blood pressure was 28.6%, compared with 18.8% after Step-2 weighting; weighted prevalence was 17.5% in rural areas and 21.7% in urban/suburban areas. Mean observed unweighted PSU-level prevalence was 29.0%. In the adjusted spatial explanatory model, the proportion aged 60-69 years ({beta}=1.969, SE=0.327; p<0.001) and overweight/obesity prevalence ({beta}=0.996, SE=0.265; p<0.001) were positive ecological correlates. The spatial model had lower Akaike information criterion and residual deviance than its non-spatial counterpart, although Bayesian information criterion was higher. Prediction uncertainty was greater in some sparsely sampled areas. Conclusions: Raised blood pressure showed significant geographic heterogeneity across Cambodia. Older age composition and overweight/obesity prevalence were positive PSU-level correlates, not individual-level causal effects. Predicted prevalence should be interpreted alongside uncertainty and should complement, rather than replace, design-based STEPS prevalence estimates for geographically informed NCD planning.

Background. Real-world 12-lead electrocardiograms (ECGs) often have missing or corrupted leads. A deep-learning classifier can be prepared for this by random lead masking during training, or by injecting clinical knowledge, for example by pulling its attention towards the leads that guidelines use for each diagnosis. Whether this knowledge adds robustness beyond masking is unknown. Methods. Pre-registered comparison of three arms sharing one network (per-lead 1D-ResNet encoder and per-diagnosis attention over the 12 leads): standard training (M0); random whole-lead masking (M1); masking plus a Kullback-Leibler penalty pulling attention towards a fixed guideline-derived key-lead map (M2, guideline-based attention guidance). Six diagnoses; five seeds per arm. Development on PTB-XL (21,799 ECGs); single sealed evaluation on PTB-XL fold 10 (2,198 ECGs) and on CODE-15% (233,204 exams, external validation). Primary endpoint: AUROC difference M2 - M1, averaged over first-degree AV block, right and left bundle branch block and atrial fibrillation and over 1 to 6 lost (zeroed) leads, with a patient-level paired BCa bootstrap 95% confidence interval. Results. The guidance did not change robustness: {Delta}AUROC -0.0010 (95% CI -0.0033 to +0.0006), an interval entirely within the pre-specified +-0.02 margin; the result was unchanged with another bootstrap seed, other interval methods and leave-one-diagnosis-out analyses. Masking improved AUROC: M1 - M0 = +0.0134 (95% CI +0.0102 to +0.0172) when one key lead was lost, and the number of lost leads tolerated before AUROC fell by more than 0.02 rose from 7 (M0) to 10 (M1). M2 attention matched the map and M2 was non-inferior on intact ECGs, but its calibration slope was lower for all six diagnoses in both datasets. M2 lost slightly more when all key leads were lost together (-0.0067) and gained only when one to three leads remained (exploratory; AUROC 0.9408 vs 0.9210 with 11 leads lost). CODE-15% reproduced every pattern (primary -0.0007, 95% CI -0.0011 to -0.0003). Conclusions. Random lead masking suffices to make an ECG classifier robust to missing leads; adding guideline knowledge aligns attention with clinical criteria but adds no robustness and worsens calibration. Guideline-aligned attention should not be taken as evidence of robustness.

Abstract Importance Patients with behavioral health presentations leave the emergency department (ED) before evaluation more often than other patients, but outcomes after leaving without being seen (LWBS) have not been described in this population. Objective To compare return visits, admission, and mortality after LWBS vs completed care among behavioral health ED episodes. Design, Setting, and Participants This retrospective episode-level cohort study used a multisystem deidentified electronic health record database of US health systems (data snapshot June 4, 2026). Participants were patients of all ages with an ED visit and same-day behavioral health diagnosis. Index visits (recorded January 26, 2001 to April 13, 2025) each opened a 30-day episode window; in-window were counted as outcomes, and patients could contribute episodes to either group. Data were analyzed in October 2026. Exposure LWBS (diagnosis code Z53.21 on a date with an ED encounter) vs completed care ending in discharge home. Main Outcomes and Measures The primary outcome was ED return visit within 7 days. Secondary outcomes were return visit within 3 and 30 days; admission on day 0, on days 1-7 (principal measure), and within 30 days; and all-cause death within 7 and 30 days, assessed among episodes from 2017 through 2023 using a verified death-record definition. Results The analysis included 1,305,812 episodes (12,248 LWBS; 1,293,564 completed care) from 525,490 patients; 666,930 episodes (51.1%) involved female patients and 66,733 (5.1%) involved patients younger than 18 years. Return visit within 7 days followed 24.5% of LWBS episodes vs 13.2% of completed-care episodes (risk ratio [RR], 1.86; 95% CI, 1.81-1.92), and admission on days 1-7 followed 17.1% vs 3.9% (RR, 4.41; 95% CI, 4.24-4.59). Among 2017-2023 episodes, 30-day mortality was 0.69% (70 of 10,141) after LWBS vs 0.32% (2,426 of 756,140) after completed care (RR, 2.15; 95% CI, 1.70-2.73). Results were similar under alternative episode definitions. Conclusions and Relevance Among patients with behavioral health ED presentations, LWBS was followed by higher rates of return visits, admission, and short-term mortality than completed care. These unadjusted findings describe outcome burden, not causal effects, and highlight patients who leave as a target for rapid follow-up.

Aims: Myocardial strain enables sensitive assessment of cardiac function, but its clinical application has largely focused on individual chambers or selected patient populations. We evaluated the feasibility and clinical relevance of fully automated multi-chamber strain assessment in consecutive patients undergoing routine transthoracic echocardiography (TTE). Methods and results: This retrospective study included 8,350 consecutive adults undergoing TTE. A hospital-wide artificial intelligence (AI)-based system automatically measured left ventricular (LV) global longitudinal strain (LVGLS), left atrial (LA) reservoir strain (LASr), and right ventricular (RV) free-wall strain (RVFWS). AI-derived LVGLS was available from at least one apical view in 97.1% of patients and from all three views in 94.8%; LASr and RVFWS were available in 94.1% and 94.5%, respectively, resulting in complete multi-chamber strain assessment in 90.3%. Strain measures showed modest correlations with conventional chamber-specific echocardiographic parameters and differential associations with clinical outcomes. Gaussian mixture modeling identified three distinct clusters characterized by preserved multi-chamber function, RV-dominant dysfunction, and pan-chamber dysfunction. Compared with the preserved cluster, pan-chamber dysfunction was associated with the highest risk of all-cause death or heart failure hospitalization (adjusted hazard ratio, 3.44; 95% CI, 2.43-4.88; P<0.001). Prognostic associations remained evident in patients with LV ejection fraction (LVEF) [&ge;]50%, and cluster assignment provided incremental prognostic information beyond clinical factors, LVEF, and RV fractional area change. Conclusions: Fully automated multi-chamber strain assessment was feasible in a large consecutive TTE cohort. Integrating strain across cardiac chambers may provide complementary functional characterization and identify clinically relevant clusters with prognostic information beyond conventional assessment.