IEEE Transactions on Computational Biology and Bioinformatics

Improvements in data availability, sharing, and integration, together with the development of explainable artificial intelligence (XAI) techniques, are advancing precision medicine for pediatric cancer by facilitating diagnosis, biomarker discovery, and drug development. Data sharing commons and initiatives like the Childhood Cancer Data Initiative (CCDI) provide access to pediatric-specific genomic and clinical data cohorts and improve data availability for pediatric cancer research. Based on CCDI, a scalable AI platform, Graph Artificial Intelligence for Pediatric Oncology (GAIPO), integrates various data modalities from bulk and single-cell omics data to clinical information. Such multi-modal data facilitates the training and development of advanced XAI models for pediatric cancers. We then developed an end-to-end multi-modality framework, PCGS, for pediatric cancer by incorporating omics-specific representation learning via GNN models with cross-attention fusion and multi-objective learning for downstream tasks such as classification, clustering, and survival analysis. This framework outperforms previous supervised multi-omics integration baseline approaches based on glioma and Wilms tumor cohorts and enables GNN model explainability via Shapley value-based feature attribution approaches to explain the contributions of gene-level features across various biomedical tasks, including classification and survival. Given specific background samples (e.g., age groups, sex, grades) as baselines, this explainable GNN model estimates and ranks the importance scores for input features from each omics modality. It identifies background-specific key features for biomarker discovery, risk group identification, and survival analysis in glioma and Wilms tumor, with potential applicability to other pediatric cancers.

Motivation: A continued decrease in sequencing costs has facilitated the exponential increase in available sequencing data, with public databases like the European Nucleotide Archive (ENA) and Sequence Read Archive (SRA) reaching well in the order of petabases. This has been the incentive to develop more scalable tools for common bioinformatics tasks. One such task is the approximate searching of short sequence patterns like genes or reads in reference data sets. In recent years, a variety of indexing data structures have been proposed for searching large sequencing databases. The state-of-the-art index, the Hierarchical Interleaved Bloom Filter (HIBF) was first-in-class to index one million samples. To be useful for expanding repositories, it must be extended to support dynamic updates. Results: In this paper, we introduce a scalable and updatable sequence-search index by extending the HIBF with partial rebuilding to support efficient updates. We demonstrate the Dynamic HIBF's capacity for large-scale data by iteratively creating an index from over 100 TB of compressed reads across more than 39,000 full human RNA-Seq samples, updated in consecutive batches of 100. To benchmark against state-of-the-art tools, we evaluated incremental performance on a subset of 5,000 samples sub-sampled to 1% of their original read depth. In this comparative setting, the dynamic HIBF completed the sequential insertion of all 5,000 samples within 5 hours--24 to 65 times faster than competing methods and twice as fast as the static HIBF.

Identifying causal connections between existing drugs and mechanistic profiles of diseases is a foundational step for effective drug repurposing. Although knowledge graphs (KGs) are highly suited for consolidating biomedical databases and tracking these connections, a single biomedical KG is constrained by its ingestion pipeline and knowledge sources. While different biomedical KGs could be complementary if combined, efforts to combine them into a unified and more comprehensive KG are hindered by lack of interoperability and poor provenance. To address those issues, we present EC-KG, a Biolink Model-compatible KG for computational drug repurposing. EC-KG is an interoperable, provenance-first KG which integrates RTX-KG2, ROBOKOP, and PrimeKG at the network-level, encapsulating over 7 million nodes and 81 million edges from 95 primary data sources. EC-KG has improved coverage of core biomedical entities such as drugs, targets, and diseases relevant to drug repurposing vs source graphs, and captures complex biomedical mechanisms within its topology. We demonstrate that the network unification in EC-KG leads to emergence of novel, mechanistically relevant pathways which are disconnected in the underlying constituent networks and show its applications in method development, benchmarking and predictive drug repurposing applications. EC-KG has already been successfully used in drug repurposing research to surface Botulinum Toxin A as a candidate to treat Major Depressive Disorder, as well as to validate repurposing of Lenalidomide and Dexamethasone for a subgroup of patients with Rosai-Dorfman Disease.

Bioinformatics software and databases are essential components of modern life science research, yet their mentions in the scientific literature are often inconsistent and difficult to systematically identify at scale. The lack of a comprehensive and up-to-date catalog of bioinformatics resources hinders efforts toward automated biomedical knowledge extraction and streamlined data analysis. Here we present SNAIL, a hybrid named entity recognition framework designed to automatically identify bioinformatics software and database (SW/DB) names from biomedical texts. SNAIL integrates complementary lexical and semantic modeling strategies. The lexical component captures orthographic patterns and contextual cues characteristic of SW/DB names, while the semantic component leverages contextual embeddings generated by transformer-based language models such as SciBERT, combined with an explicit token-masking strategy to enhance entity-focused representations. A large training corpus was constructed automatically through a hybrid pipeline that integrates citation-hinted extraction with large language model-assisted distillation. Evaluation on two independent benchmark datasets and real-world research articles demonstrates that SNAIL substantially outperforms existing approaches, including domain-specific methods such as bioNerDS2 and general-purpose large language models such as ChatGPT, Gemini, Grok and Claude. Applying SNAIL to large-scale literature analysis further reveals distinct journal-level preferences across bioinformatics subfields. These results demonstrate that SNAIL provides an accurate and scalable solution for identifying bioinformatics resources in scientific texts and enables systematic meta-analysis of tool usage and research trends.

Abstract Imaging-based spatially resolved transcriptomics (imSRT) technologies provide high-throughput molecular-resolution spatial characterization of genes within cells. Conventional analysis methods to identify cell-types and states in imSRT data rely on gene count matrices derived from tallying the number of mRNA molecules detected for each gene per segmented cell, thereby overlooking subcellular heterogeneity that can be useful in defining cell states. To take advantage of the molecular-resolution information in imSRT data and potentially identify cell-states based on subcellular heterogeneity, we developed STARIT (Spatial Transcriptomics As Rasterized Image Tensors). STARIT converts transcripts within segmented cells in imSRT data into an image-based tensor representation that can be combined with deep learning computer vision models for downstream analysis. Using simulated and real imSRT data, we demonstrate that STARIT distinguishes transcriptionally distinct cell-types and further separates cell states based on subcellular transcript localization, which conventional gene count analysis fails to capture. By providing a standardized framework to encode subcellular molecular information in imSRT data, STARIT will enable deeper insights into subcellular heterogeneity and enhance the identification and characterization of cell-types and states that are overlooked by gene count representations.

Standard methods for ancestral sequence reconstruction (ASR) rely on substitution models for the residues in a biological sequence and assume independent evolution across these sites, ignoring the epistatic interactions that shape molecular evolution. In contrast, deep learning models like variational autoencoders (VAEs) can learn low-dimensional representations ("embeddings") of sequences in a protein family that may implicitly handle these dependencies, raising the possibility of performing more accurate ASR by interpolating between extant sequence embeddings within the VAE's latent space. In this study, we test this hypothesis by developing and evaluating a VAE-based ASR pipeline. Benchmarking this approach against established likelihood-based and parsimony methods using various simulations of protein evolution, including scenarios with and without epistasis, we find that the VAE-based approach is consistently and significantly outperformed by standard methods, even in epistatic regimes where it was hypothesized to have an advantage. We further show that this failure is not due to a lack of phylogenetic structure in the latent space, which does contain evolutionary signal. Rather, the primary limitation is the information loss inherent to the autoencoding process: the VAE's decoder cannot generate sequences with sufficient fidelity for the precise demands of ASR.

Evo 2 is the largest openly available genomic foundation model, but its forty billion parameter configuration cannot be loaded onto a single 80 GB accelerator, placing genome-scale analysis beyond most laboratories. We present TurboQuant-Bio, an open toolkit that compresses Evo 2s weights and attention cache to four bits without calibration data, and serves both through fused kernels. Compression is near-lossless across perplexity spanning the tree of life, genomic classification, splice-site prediction, gene completion and clinically relevant variant-effect prediction. It brings Evo 2 40B onto one 80 GB GPU and Evo 2 7B to its full million-token context within a 40 GB memory budget, an eightfold gain in reachable context. We further show that the released chunked-prefill path is silently incorrect, returning plausible but uncorrelated likelihoods, and derive the block-wise continuation that repairs it: a complete 580-kilobase bacterial genome is now scored in one context in 22 minutes rather than 13.7 hours.

Proteins are dynamic molecules existing in diverse conformational states underlying their biological functions. Although recent approaches have enabled diverse conformational sampling by emulating molecular dynamics simulations, perturbing evolutionary information, or steering internal mechanisms of structure prediction models, predicting conformations resulting from major domain motions or motions that occur over long timescales still remains a challenge. To this end, we introduce GNMCADS, a conformational sampling strategy that enhances the diversity of protein diffusion models by selectively annealing the conditioning signal guided by the intrinsic dynamical organization of the sampled protein. Further, we implement GNMCADS in the diffusion module of AlphaFold3, enabling the generation of diverse protein conformations. When benchmarked across 92 proteins that include 54 class A GPCRs, 15 transporters, and 23 proteins with major domain movements, GNMCADS exhibits improved sampling diversity compared to other current conformational sampling methods.

Network-based analyses of molecular interactions are useful for interpreting high-throughput omics data and identifying therapeutic targets. Cytoscape is the standard platform for these tasks, but users face a trade-off between accessible graphical workflows that are difficult to document and reproducible automation in Python or R that requires programming expertise. General-purpose coding assistants can generate Cytoscape Automation scripts, but remain external to Cytoscape. We present CyChat, a Cytoscape Desktop app that integrates a chat interface and a large language model (LLM) agent into the application. CyChat translates natural language into executable Cytoscape Automation workflows, runs generated Python code, and exports chat sessions with executed code as standalone Jupyter notebooks. To reduce setup barriers, CyChat includes an embedded Python runtime and supports both cloud-based and locally hosted LLMs. CyChat was evaluated across ten Cytoscape workflows using seven LLM providers, each represented by one LLM. The strongest configuration achieves a pass rate above 99%. In a qualitative evaluation based on a published network visualization, CyChat completes the task in 1.5-5 minutes, compared with 15-20 minutes for manual GUI workflows by computational biologists. CyChat is available through the Cytoscape App Store at https://apps.cytoscape.org/apps/cychat.

Scaling the structural annotation of protein-coding genes to all eukaryotic genomes remains a major challenge. While recent deep learning methods rival evidence-based pipelines without requiring RNA-seq or alignments, they are entirely supervised. They depend on large, high-quality training sets from diverse genomes, leaving many basal eukaryotic clades without an accurate ab initio gene finder. We present Vipsania, the first unsupervised deep gene finder. A differentiable hidden Markov layer inside a deep sequence model learns to predict gene structures from unannotated genomes alone. Vipsania is pretrained for virtually all eukaryotes and finetunes without supervision on the target genome. It is, on average, more accurate than supervised methods across most clades and avoids the accuracy drop that supervised models suffer on distant target genomes. Vipsania adapts to non-standard genetic codes and provides a fast and highly versatile tool for unbiased, pan-eukaryotic genome annotation. The source code is available at https://github.com/gaius-augustus/vipsania.

Bacteriophages can only be understood through their interactions with bacterial hosts. As environmental sequencing efforts expanded, the number of available phage genome sequences has exploded, yet the vast majority of these sequences lack host information. Predicting the host of a newly observed phage is therefore a key challenge in virology. Several computational tools can predict phage-host relationships from genomic data, but they share notable limitations: (1) the number of different hosts that can be predicted remains relatively restricted; (2) tools tend to assign confident host predictions to non-viral input sequences; and (3) most tools have a trade-off between accuracy and speed. Here we present PhageTransformer (PT), a deep learning model for phage-host prediction that addresses these limitations. We benchmark PT against existing tools on 3,881 independent phage-host pairs from GenBank and public HiC data, and demonstrate that it achieves competitive or superior prediction accuracy at greatly reduced runtime.

Causal mediation analysis is widely used to identify biological pathways linking exposures to outcomes, but most methods assume homogeneous mediation effects across individuals. In high-dimensional omics settings, this assumption can mask important heterogeneity driven by demographic, genetic, or environmental factors. We propose the M-high-learner, a flexible framework for detecting heterogeneous mediation effects with high-dimensional mediators. The method identifies mediators with subgroup-specific indirect effects while distinguishing them from null or homogeneous signals and controlling the type I error rate. It is computationally efficient, scalable, and yields interpretable sub-types. Simulation studies show that the proposed approach achieves high power while maintaining accurate error control. Applications to the Framingham Heart Study and the Multi-Ethnic Study of Atherosclerosis reveal that the mediation role of gene expression in sexs effect on high-density lipoprotein varies across subgroups defined by body mass index and age. Our framework provides a practical tool for uncovering heterogeneous biological mechanisms in high-dimensional genomic studies. Author SummaryBiological processes linking risk factors to disease often differ across individuals, but many existing methods assume these processes are the same for everyone. This can hide important differences between groups. We developed a powerful method to identify when these pathways vary across subgroups using large-scale molecular data. Our approach detects differences in how intermediate biological factors contribute to outcomes in populations defined by characteristics such as age and body mass index. Applying our method to population studies, we found that some biological pathways operate differently across groups, suggesting that key mechanisms may be missed when differences are ignored. Our work provides a tool to better understand how disease-related processes vary across individuals, which may support more targeted and personalized approaches to health research.

Motivation: Cell-free DNA methylation provides a minimally invasive signal for early cancer detection and tissue-of-origin prediction. Most methods represent methylation measurements as independent fixed-window features and therefore do not explicitly model relationships among genomic regions. Results: We developed PANGEM (Pan-cancer Graph-based Cancer Detection Using the Cell-free DNA Methylome), a graph-learning framework that represents genomic bins as nodes and integrates CpG context, genomic proximity, and sample-specific methylation similarity in the graph topology. Across five repeated stratified train-test splits, PANGEM achieved the highest mean performance among evaluated methods, with an AUROC/AUPR of 0.997/1.000 for binary cancer detection and macro-AUROC/AUPR of 0.977/0.870 for multiclass tissue-of-origin prediction. In the independent INSPIRE cohort, 72 of 78 cancer cases (92.3%) exceeded the binary classification threshold, and PANGEM correctly classified 9 of 17 head and neck cancer cases (52.9%), the highest accuracy among evaluated methods. Subnetwork analysis further identified recurrent, graph-connected methylation patterns, including a 111-DMR subnetwork with increased methylation in cancer samples.

We describe LRSPAT (low-rank spatial toolkit), a fast and memory-efficient framework for approximating measures of spatial association for high-dimensional data. While LRSPAT can be applied to any multivariate spatial dataset, development was motivated by the computational challenge of identifying spatially variable genes in high-resolution spatial transcriptomics (ST) data generated by technologies such as 10x Visium HD, Xenium and Atera. LRSPAT leverages a truncated SVD of the expression data and a thresholded spatial weights matrix to perform reduced-rank reconstruction of spatial statistics in the quadratic form family, including global and local versions of Moran's I, Geary's C, and Getis-Ord G. A regularization approach is leveraged to account for the inflated null distribution of spatial statistics computed on latent variables. By performing key operations on the low-dimensional embeddings, LRSPAT is orders of magnitude faster than standard implementations with significantly lower memory requirements. Because the low-rank approach denoises and desparsifies ST data, LRSPAT is also more accurate than standard techniques at identifying genes with true spatial expression patterns. The dramatic improvements in execution time and memory consumption enable the genome-wide analysis of spatially variable genes (SVGs) and exploration of the full range of hyperparameters including spatial scale, distance metric, and embedding rank. This preprint outlines the background and mathematical details of the approach with limited preliminary results and a short conclusion.

The interpretation of missense variants remains a major challenge in clinical genetics. "Meta-domains" aggregate population and pathogenic variation across homologous Pfam domain instances in the human proteome, providing per-residue context for interpreting variants of uncertain significance (VUS). Our 2019 implementation, MetaDome, is widely used and named in clinical variant-classification guidelines. Here we present the MetaDome 2027 update, featuring a comprehensively updated dataset and GRCh38 support. The redesigned pipeline enables incremental updates of GENCODE, UniProtKB/Swiss-Prot, Pfam, gnomAD, and ClinVar while maintaining 100% sequence-identity gene-to-protein mapping. Annotated Pfam domain instances grew 14.9% from 71,419 to 82,069 and meta-domain-eligible Pfam families ([≥]2 human occurrences) by 73.3% from 3,334 to 5,778; Pfam domains are annotated to 92% of human proteins. Approximately 43% of mapped protein-coding nucleotides (14.3 million in GRCh38, 13.8 million in GRCh37) are in a meta-domain; in GRCh38 67.9% (37,692 of 55,548) of pathogenic or likely pathogenic ClinVar missense variants fall at such a position. We show how MetaDome helped reclassify a de novo missense VUS in RALA and identify 52,463 ClinVar missense VUS for which meta-domains supply otherwise unavailable pathogenic evidence. MetaDome is freely available at www.metadome.app.

Background Elexacaftor-tezacaftor-ivacaftor (ETI) has been demonstrated to improve lung function in clinical trials; however, evidence describing effects on trajectories and whether long-term improvements are sustained (>1-year) is lacking. We estimated within-person lung clearance index (LCI) trajectories before and after ETI initiation, assessing changes in level and rate of change, alongside acute LCI change, up to three years after ETI initiation. Methods Prospective observational study of children at a tertiary hospital. Children aged 3-17 years with [&ge;]2 LCI testing occasions (i) before and (ii) after starting ETI were used to describe lung function trajectories. Children with [&ge;]1 pre-ETI and [&ge;]1 post-ETI LCI occasion(s) were used to describe acute LCI change after ETI initiation. Age-adjusted LCI trajectories for time periods (i) before and (ii) after ETI initiation were estimated using linear mixed-effects models, and pre- and post-ETI LCIs were compared using paired Wilcoxon tests. Results Mean pre-ETI and post-ETI longitudinal changes in LCI were -0.007 (95% CI: -0.28, 0.27; n=35) and 0.12 (95% CI: -0.17, 0.41; n=20) turnovers per year, respectively. Before ETI initiation, 57% (30/53) of patients had an LCI[&ge;]7.1 turnovers (indicating impaired lung function), compared to 26% (14/53) post-ETI, with a median LCI difference of -0.70 (95% CI -0.84, -0.46; p<0.001) turnovers. Within-individual variability in LCI decreased post-ETI. Conclusions Our real-world data within a unique longitudinal study provide a comprehensive picture of ETI benefit by outlining not only acute improvement in LCI but maintained stability in LCI trajectories and improved LCI stability sustained up to three years post-initiation.

Background. Videolaryngoscopy still requires adjuncts or hyperangulated rescue in a clinically important minority, and bedside screening discriminates modestly. Point-of-care ultrasound (POCUS) of the anterior airway is a promising alternative, but existing prediction models are opaque or assume a pre-specified functional form. We developed and internally validated a parsimonious, fully disclosed POCUS risk equation whose form is recovered from data and whose structural properties are machine-checked by formal proof - to our knowledge the first formally verified clinical risk predictor - following TRIPOD+AI 2024. Methods. In a prospective single-centre, single-operator cohort of 259 adults undergoing elective videolaryngoscopy (no-Easy airway 68/259, 26.3%), Sequentially Thresholded Least Squares with bootstrap stability selection (B=300) screened a 71-term library of nine POCUS features and retained a seven-term logistic equation; a two-term bootstrap-stable model was pre-specified as robustness analysis. Internal validation used 5x10 repeated cross-validation plus temporal and device hold-outs, with pre-specified overfitting and optimism assessments. Five behavioural properties of the deployed equation were machine-checked in Lean 4. Results. Two interactions met the |c|/sigma_c>2 stability criterion: skin-to-epiglottis x skin-to-hyoid-bone distance and tongue volume x sagittal tongue area. The seven-term equation reached a 5x10 cross-validated C-statistic of 0.966 (optimism-corrected 0.968) and held across temporal and device hold-outs (0.94-0.97). Calibration-in-the-large matched prevalence, with cross-validated slope 0.90 attenuating to 0.625 out-of-time; standard recalibration restored 0.92 without loss of discrimination. The pre-specified two-term robustness model reproduced this performance (C-statistic 0.964-0.968; events-per-parameter 34; shrinkage 0.99), confirming the result is not an artefact of the screening stage. Net benefit over a clinical baseline was positive across 10-50% thresholds. All five Lean 4 theorems compiled without sorry. Conclusions. A sparse, formally verified POCUS equation predicts difficult videolaryngoscopy with high internally validated discrimination and quantified, modest overfitting. Because the equation was developed in a single-operator cohort and its inputs are operator-dependent, external validation requires prior harmonisation of the measurement protocol and operator credentialing.

Purpose: To evaluate the safety, procedural performance, sample recovery, and surgeon preference of an ophthalmic needle designed specifically for anterior chamber (AC) paracentesis. Methods: In this multicenter study, AC paracentesis was performed in clinic and operating-room settings using a 32-gauge x 4-mm needle with low dead space. The procedure was evaluated using a standardized physician survey. Prespecified outcomes included procedure-related adverse events (primary outcome), needle entry and handling, aspiration and sample recovery, comparative performance versus a 30-gauge needle, and physician preference for future use. Results: A total of 110 needle uses by eight surgeons were included. No ocular complications occurred, including lens or iris injury, hyphema, AC collapse, wound leak, hypotony, infection, or retinal complication, and no procedure required needle exchange or conversion to another device. Two technical events without ocular sequelae were noted, in which needle entry was partial thickness and did not reach the AC (1.8%; exact 95% CI, 0.2%-6.4%). Physicians rated needle entry, handling and sample recovery as good or excellent. Compared with a 30-gauge needle, the study needle was rated as at least comparable across all assessed domains. All surgeons rated it better or much better for intra-procedural safety and preferred it for future AC taps. Conclusions and Relevance: This short, 32-gauge low-dead-space ophthalmic needle demonstrated a favorable safety profile and was preferred over a 30-gauge needle by all surgeons. As aqueous humor liquid biopsy expands in clinical diagnostics and trials, an ophthalmic-specific needle design may help improve the consistency and safety of aqueous humor collection for molecular analysis and broader clinical use. Keywords: Anterior chamber paracentesis; Aqueous humor; Liquid biopsy; Low dead space; Ophthalmic needle

Introduction: Polyendocrine metabolic ovarian syndrome (PMOS), formerly known as polycystic ovary syndrome (PCOS), is a common endocrine disorder affecting women of reproductive age. Besides reproductive and metabolic disturbances, PMOS negatively impacts psychological well-being and quality of life. Despite available treatment options, there remains a need for safe and effective therapies that improve both clinical symptoms and fertility outcomes. Aim: To compare the efficacy of VAMHA and MYRHA tablet combination therapy with standard non-hormonal therapy in restoring regular menstruation. Secondary objectives included assessment of ovulation, menstrual symptoms, polycystic ovarian morphology, hormonal and metabolic parameters, anthropometric measures, and skin manifestations. Study Design: Open-label, randomized, multicentre, prospective comparative clinical study. Methods: Seventy-one women with PMOS were randomized to Group A (n=37) or Group B (n=34). Group A received VAMHA and MYRHA tablets (2 tablets each), while Group B received Metformin 500 mg plus Myoinositol 600 mg (1 tablet), twice daily for 180 days. Data were recorded in Case Report Forms. Statistical Analysis: Continuous variables were summarized using mean and standard deviation, while categorical variables were expressed as frequencies and percentages. Appropriate statistical tests, including Chi-square, were used. A p-value [&le;]0.05 was considered significant. Results: Significantly more participants in Group A achieved regular menstrual cycles than Group B (31 vs. 22; p<0.05). Ovulation occurred in 16 participants in Group A compared with 6 in Group B (p<0.05). Both groups showed significant improvement in menstrual irregularity and related symptoms. Significant reductions in Anti-Mullerian Hormone (AMH), fasting insulin, and body mass index (BMI) were observed in both groups (p<0.05). Resolution of polycystic ovarian morphology occurred in 13 participants (38.23%) in Group A and 10 (33.33%) in Group B. Both treatments were well tolerated with no major safety concerns. Conclusions: VAMHA and MYRHA combination therapy was superior to standard non-hormonal therapy in improving menstrual regularity and ovulation. It also produced favourable metabolic, hormonal, and ultrasonographic outcomes, suggesting its potential as a safe and effective option for comprehensive PMOS management and fertility enhancement.

Background & Aims: Fatigue is a central symptom of chronic liver disease (CLD), substantially impacting health-related quality of life (HRQoL). This study aimed to further understand CLD symptomatology, including fatigue, and its impact on HRQoL from a patient perspective. Methods: Abbott Global Assessment of Patients unmet needs (aGAP) was a multinational, cross-sectional survey in adults with compensated CLD in China, India and Mexico, conducted between July and November 2024. Adult participants who self-reported that they had physician-diagnosed CLD and were experiencing fatigue completed a quantitative survey to assess symptom burden and included three HRQoL patient-reported outcome (PRO) questionnaires (Patient-Reported Outcomes Measurement Information System [PROMIS]-29+2, Work Productivity and Activity Impairment - Specific Health Problem version 2.0 [WPAI: SHP], Multidimensional Fatigue Inventory [MFI]). Results: Overall, 505 participants (China: 200; Mexico: 105; India: 200) completed the study. Participants reported that their CLD-related fatigue sometimes, often or always affected their self-esteem/confidence (45.1%) and ability to maintain or acquire new employment (38.6%). Most participants reported moderate (51.3%) or serious (26.9%) fatigue, with 33.5% experiencing fatigue every day or almost every day. Many participants felt their social life was negatively impacted by their fatigue (47.3%) and that there were related financial difficulties (53.9%). Use of validated PRO tools demonstrated severe fatigue (MFI: overall mean [SD] 13.9 [3.4] general fatigue and 13.4 [3.6] physical fatigue) as well as substantial levels of work and activity impairment (WPAI: SHP overall mean [SD] 53.0 [26.4]) and high levels of anxiety, pain interference, depression and sleep interference (PROMIS T-scores [&ge;]54). Conclusions: Fatigue has a substantial impact on HRQoL among adults with CLD across several countries, highlighting a global unmet need for targeted interventions to effectively identify and manage the condition.