Journal of Integrative Plant Biology

Quantitative genetic approaches such as genome-wide association studies and genomic prediction are widely used to identify favourable genetic variation, but they have limited resolution due to linkage disequilibrium. Comparative genomics approaches, especially Protein Language Models (PLMs), have emerged as powerful alternatives, by detecting phylogenetic residue conservation (PRC) across evolutionary time scales. However, the extent to which these tools can guide the detection of impactful variants for field agronomic traits is still unclear. In this study, we used the pre-trained PLM ESM2 to predict PRC scores of nonsynonymous mutations segregating within a diverse panel of 387 accessions in sorghum (SAP). The distribution of fitness effects (DFE) of the same set of nonsynonymous mutations was inferred using unfolded site frequency spectra to assess whether the DFE distribution covaried with PRC scores. Furthermore, we estimated the load of putatively nonneutral mutations of SAP accessions and evaluated associations between this mutation load and phenotypic performance across multiple agronomic traits. Our results show that ESM2 can detect mutations associated with fitness-enhancing effects in SAP, as indicated by enrichments in positive selection signatures among the variants with positive PRC scores. Significant associations were also detected between phenotypic performance and mutation load for several agronomic traits, indicating that PLMs can identify functionally important genetic variation. However, these signals were not consistent across all traits in the SAP population. Altogether, our findings suggest that large language models may support breeding efforts, as PLM predictions covaried with fitness effects and captured agronomic performance for some traits in plant populations.

O_LIWhether gymnosperm FLAGELLIN-SENSING 2 (FLS2) orthologues are functional receptors and whether their flg22-recognition spectra have already diversified remain unclear, despite the central role of FLS2 in flagellin perception in angiosperms. C_LIO_LIHere, we identified two gymnosperm FLS2 orthologues, GbFLS2 from Ginkgo biloba and PtFLS2 from Pinus tabuliformis, and analysed their function using transient and stable expression in the Nicotiana benthamiana fls2 mutant, in planta cross-linking assays, AlphaFold3 modelling and structure-guided mutagenesis. C_LIO_LIBoth receptors restored flg22Pst-triggered reactive oxygen species production and MAPK activation, physically associated with flg22Pst, and required conserved residues for flg22Pst recognition. In stable transgenic plants, both receptors mediated flg22Pst-triggered PTI outputs and flg22Pst-induced resistance to Pseudomonas syringae. PtFLS2 additionally mediated responsiveness to flg22Rso and enhanced resistance to Ralstonia solanacearum, whereas GbFLS2 retained a typical flg22Pst-recognition profile. C_LIO_LIThese findings provide direct evidence that gymnosperm FLS2 orthologues can function as bona fide flagellin receptors in a heterologous angiosperm background, and further suggest that diversification in flg22 recognition had already emerged within gymnosperms. C_LI

Cell surface auxin signaling is essential for rapid cellular and growth responses to auxin. Auxin-Binding Protein 1 (ABP1) has been proposed as an extracellular auxin receptor, yet how the ER-retained ABP1 reaches the apoplast to function as an extracellular auxin receptor remains unclear. Here, we show that the abp1 mutants had strong phenotype in the dark-triggered hypocotyl elongation in Arabidopsis. More interestingly, the dark-induced auxin drives ABP1 relocation from the ER to the plasma membrane (PM) through a LORELEI-like GPI-anchored protein 1 (LLG1)-based mechanism. Auxin promotes LLG1 expression and its interaction with ABP1, facilitating ABP1 trafficking via a GPI-AP-specific pathway. Upon reaching the apoplast, ABP1 dissociates from LLG1 under acidic conditions, enabling its competence for auxin perception and activation of the cell surface signaling. Together, our results uncover a GPI-AP-mediated transport mechanism for ABP1 auxin receptor and refine the molecular framework of cell-surface auxin perception.

Fusarium head blight (FHB) is a major threat to global wheat production and food safety due to contamination with mycotoxins, such as deoxynivalenol (DON). The emergence of new mycotoxin chemotypes, including 7--hydroxy,15-deacetylcalonectrin (3ANX), presents an evolving challenge for disease management and resistance breeding. Here, we performed a field-based, systems-level proteome analysis of wheat infected with Fusarium graminearum strains belonging to the common 15ADON and recently emerged 15ADON/3ANX chemotypes. Across host and pathogen, we quantified more than 9,200 proteins, providing extensive coverage of infection-associated molecular responses. Infection with 15ADON/3ANX strains suppressed canonical wheat detoxification pathways while promoting structural and oxidative defence responses. Concurrently, the fungal proteome of 15ADON/3ANX-producing strains indicated altered mitochondrial ribosome function and alternative virulence strategies. Further investigation of the host-pathogen interface defined hub protein networks negatively regulating classical detoxification markers, suggesting coordinated regulation of host defence responses regardless of chemotype. Molecular responses were linked to field phenotypes by quantification of DON-3-glucoside/DON ratios and disease severity, defining positive correlations in 15ADON infections, which were abolished upon 15ADON/3ANX infection, indicating chemotype-specific evasion or suppression of host defenses. These findings demonstrate reprogramming of host-pathogen interaction networks and reveal molecular targets that may inform chemotype-aware breeding strategies to enhance crop resilience.

Harpagoside, a high-value anti-inflammatory iridoid compound, is traditionally extracted from the roots of Harpagophytum procumbens (Pedaliaceae, Lamiales), a Southern African desert plant widely used in traditional medicine but currently threatened by overexploitation. Scrophularia nodosa (Scrophulariaceae, Lamiales) is a perennial annual plant widely distributed in Western Europe and accumulates several iridoid compounds with known biological activities, such as catalpol, aucubin, harpagide and particularly harpagoside. We gathered extensive genomic and transcriptomics resources for this species and aimed at deciphering the biosynthetic pathway leading to the most abundant iridoid in S. nodosa, harpagoside. We found that the early iridoid pathway is well conserved with other iridoid-producing plants and validated the enzyme activities by transient co-expression in N. benthamiana. Investigation into the large BAHD family showed subclade 6i expanding in Scrophulariaceae, with an atypical VYPWG motif instead of the canonical DFGWG. In this branch, we discovered and characterized harpagoside synthase, a BAHD-type cinnamoyl transferase enzyme showing unique high specificity to the uncommon cinnamoyl-CoA acyl donor and catalyzing the final step of harpagoside biosynthesis. These results establish S. nodosa as a new model to investigate unexplored branches of the iridoids metabolism, and are a first step towards sustainable harpagoside and high-value cinnamoyl-containing conjugates production.

Successful soil emergence requires apical hook establishment during skotomorphogenesis. Soil salinity disrupts this process, but the mechanisms linking environmental stress to hook growth remain unclear. Here, we employed a genome-wide association study (GWAS) across Arabidopsis thaliana accessions to identify a locus associated with variation in the salt-induced reduction of apical hook curvature. Fine mapping reveals genetic variation in the promoter of 1-DEOXY-D-XYLULOSE 5-PHOSPHATE REDUCTOISOMERASE (DXR), encoding the first committed enzyme of the plastid-localized methylerythritol phosphate (MEP) pathway. Accessions carrying an alternative promoter haplotype exhibit elevated DXR expression and a stronger hook bending under salt. Salt treatment and loss of transcriptional repressor PHYTOCHROME INTERACTING FACTOR1 (PIF1) additively increase DXR transcript levels, and pif1-2 seedlings exhibit higher apical hook angles under salt stress. This phenotype is suppressed by inhibition of DXR activity, indicating that an increased MEP pathway flux reduces salt sensitivity in pif1-2 seedlings. Across accessions, DXR expression positively correlates with hook curvature under salt stress, further strengthening the link between DXR and modulation of hook bending under salt stress. Together, these findings identify plastid metabolism as a regulatory layer linking environmental stress to altered skotmomorphogenis, and raise important questions about how etioplast-derived signals interact with growth-control networks in the dark. HighlightA genome wide association study in Arabidopsis reveals that variation in DXR expression, encoding an essential enzyme in the MEP pathway, drives salt-induced repression of apical hook formation darkness.

Mildew resistance Locus O (MLO) proteins have been originally identified as susceptibility factors for the fungal powdery mildew disease. Beyond immunity, they function in polarized secretion, including root and root hair elongation, trichome development, and fertilization. Moreover, MLO proteins mediate Ca{superscript 2} influx, either indirectly by recruiting Ca{superscript 2}-permeable channels to the plasma membrane or by acting as ion channels themselves. The latter raises the question of whether MLO proteins oligomerize to mediate ion transport across membranes. Here, we present an AlphaFold 3-based modeling pipeline for the reproducible assessment of MLO-containing protein complexes using AlphaFolds built-in confidence metrics together with structural and dynamic analyses. The resulting predictions for homo-oligomers of the prototypic barley Mlo support dimeric and trimeric assemblies, with the trimer forming a central membrane-spanning pore. Notably, AlphaFold 3 captured discrete conformational states of this trimer, as reflected by the clustering of confidence metrics. Computational structural analyses indicated that higher-confidence models adopt a closed pore conformation, whereas lower-confidence predictions reflect progressively expanding pore diameters. Molecular dynamics simulations further showed Ca{superscript 2} permeability of the putative open models. Our pipeline similarly predicts trimeric assemblies for MLO variants from Arabidopsis thaliana and Marchantia polymorpha, suggesting a conserved MLO structural scaffold within the land plant lineage. Additional Molecular Dynamics simulations revealed that closed models of barley Mlo and A. thaliana MLO2 open under simulated membrane tension, supporting the notion that MLO proteins are mechanosensitive ion channels. Moreover, predictions of MLO proteins with its known interactors, EF-hand proteins and exocyst complex subunit EXO70 proteins, suggest a mechanism for feedback inhibition of MLO-mediated ion flux and provide comprehensive experimental support for AlphaFold 3-predicted protein interfaces. Altogether, our results provide a structural framework for MLO channel architecture and regulation, while our prediction, modeling, and simulation pipeline should be useful beyond the study of this specific protein family. One-sentence summaryThis article describes AlphaFold 3-based analyses of MLO proteins, revealing the predicted structure of MLO membrane pores, their dynamic opening and closing, and their association with interacting proteins, including calmodulin and calmodulin-like calcium sensor proteins and exocyst complex subunit EXO70 proteins.

The ability of protoplasts to regenerate into whole plants underpins advances in crop engineering and pluripotency research. However, most protoplasts exhibit poor division and limited shoot regeneration, restricting their broader utility. Here, we present EppTec (Efficient regeneration of transgene-free whole Plants from Protoplasts reprogrammed by Transiently Expressed Combinatorial factors), a transient expression platform using defined combinatorial factors (CFs) to unlock protoplast pluripotency and enable transgene-free whole-plant regeneration. Among 24 CFs tested, co-transfection of SEPW (SCR, ESR1, PSK5, and WOX5) markedly enhanced regeneration across diverse plant species in an evolutionarily conserved manner. We demonstrate that SEPW co-transfection induces epigenomic reprogramming, formation of a distinct cell cluster undergoing reprogramming and cell-cycle re-entry, and long-term reprogramming into pluripotent cells. These findings establish EppTec as a robust strategy to restore the regenerative capacity of plant cells from diverse species. EppTec may serve as a platform to revolutionize regeneration-based plant biotechnologies and conserve endangered plant species.

Introduction Pathogenic germline variants in the BRCA1 and BRCA2 genes confer a markedly increased risk of breast and ovarian cancer, for which effective preventive strategies are available. Although national and international guidelines recommend BRCA testing and cascade screening of relatives, implementation in Italy remains highly heterogeneous across regions. This study estimates the potential population health and cost impact of achieving full nationwide implementation of BRCA1/2 cascade screening in Italy and identifies key organisational barriers and priority actions for implementation. Methods We conducted a Health Impact Assessment integrating literature review, simulation modelling, and stakeholder consultation. A decision tree and Markov model compared the current heterogeneous implementation of BRCA screening in Italy with an ideal scenario reflecting full adherence to national guidelines, optimal cascade screening, and uptake of preventive strategies. Outcomes included breast and ovarian cancer incidence and mortality, healthcare costs over a lifetime horizon (80 years). Key barriers affecting organisational feasibility, acceptability, and patient well-being were assessed, and a set of priority action recommendations was developed. Results In the ideal scenario, 25,626 eligible cancer patients would undergo BRCA testing annually, identifying 4,254 mutation carriers and enabling cascade testing of 27,650 relatives, of whom 8,682 would be BRCA-positive. Under the current implementation, only 8,807 patients and 2,168 relatives are tested, identifying 948 carriers. Over 30 years, full implementation would prevent 821 cancer cases (- 27.9%) and 1,282 deaths (- 49.7%) compared with the current scenario. While initial expenditures increase due to expanded testing and preventive interventions, cumulative costs decrease over time, resulting in net savings of 5.8 million euros at 30 years and a saving per event avoided (- 2,779 euros). Major implementation barriers include fragmented governance, limited access to genetic counselling, heterogeneous laboratory practices, insufficient professional training, and weak referral pathways. Conclusion Full implementation of BRCA1/2 cascade screening in Italy would yield substantial population health benefits and long-term cost savings. Coordinated national governance, standardised pathways, investment in counselling and workforce capacity, and robust monitoring systems are essential to ensure equitable access and sustainable delivery of personalised cancer prevention. This study demonstrates the value of the HIA methodology for evaluating and guiding genomic prevention policies.

Aims: Youth loneliness is a prevalent global health concern with lifelong health ramifications. Schools, as children's primary peer environments, are promising settings for loneliness interventions. However, school-based interventions are highly heterogeneous and no review to date has evaluated their effect on loneliness specifically. Methods: A systematic review was conducted to identify studies of school-based interventions measuring loneliness as an outcome in children and young people aged up to 18. Meta-analyses were conducted using a random-effects model to pool effect sizes and examine the significance of intervention characteristics and study design. Reported implementation factors were extracted and narratively synthesised. Results: Thirty-eight studies were included in meta-analysis, of which 19 were randomized controlled trials, ten were non-randomized controlled, and nine were single group studies. A small-to-moderate effect estimate was found, Hedges' g = -0.42 [95% CI: -0.71, -0.13], p = .006, and sub-group analyses indicated that differences in study design and quality did not result in significantly different effect estimates. Psychological interventions, followed by social and emotional skills training, produced significantly higher effects estimates compared with other intervention types. Conclusions: Findings indicate that school-based interventions are effective in reducing youth loneliness. However, study heterogeneity, reporting inconsistencies, and a wide prediction interval indicates this finding should be interpreted with caution. Future research may benefit from improved measurement and reporting of implementation factors, particularly dosage and fidelity.

Military aviation training noise remains understudied despite its widespread impacts across urban, rural, and wilderness areas. The predominance of low-frequency noise and repetitive training can create pervasive noise pollution, yet past research often fails to capture the full range of health and quality-of-life effects. This study analyzed two complaint datasets related to Whidbey Island Naval Air Station noise: U.S. Navy records (2017-2020) and Quiet Skies Over San Juan County data (2021-2023). We analyzed and mapped sentiment intensity from noise complaints relative to modeled annual noise exposure, developed a typology to classify impacts, and modeled the environmental and operational factors influencing complaints. Findings revealed widespread negative sentiment and anger, often beyond the bounds of estimated noise contours, suggesting that annual cumulative noise models inadequately estimate community impacts. Complaints consistently highlighted sleep disturbance, hearing and health concerns, and compromised home environments due to shaking, vibration, and disruption of daily life. Residents also reported significant social, recreational, and work disruptions, along with feelings of fear, helplessness, and concern for children's well-being. The number of complaints were strongly associated with training schedules, with late-night sessions being the strongest predictor. A delayed response pattern suggests residents reach a frustration threshold before filing complaints. Overall, our findings demonstrate persistent negative sentiment and diverse impacts from military aviation noise. Results highlight the need for improved noise metrics, modeling and operational adjustments to mitigate the most disruptive effects.

Introduction Access to safe water, sanitation, and hygiene (WASH) in schools is critical for child health, learning, and gender equity. In Kenya, the Kenya School Health Policy and the Basic Education Act outline standards for school WASH; however, implementation remains uneven due to inadequate infrastructure, weak inter-sectoral coordination, and limited financing. This study aimed to identify priority components for strengthening school WASH implementation and generate policy-relevant recommendations based on expert consensus in Uasin Gishu County, Kenya. Methods and Results A Delphi technique consisting of two iterative rounds was used to reach expert consensus. In Round 1, 20 purposively selected experts including head teachers, county education officials, public health officers, water and public works officers, and NGO representatives participated in key informant interviews. Emergent themes informed development of a structured Round 2 questionnaire administered through CommCare online app. Quantitative data were analyzed using descriptive statistics (means, standard deviations, percentage agreement), while qualitative responses underwent thematic coding using NVivo 12. Experts reached strong consensus on essential components required for strengthening school WASH implementation. Key priorities included clear governance structures, designated budget lines, inclusive infrastructure, menstrual hygiene management (MHM), curriculum integration, sustained capacity building, and systematic monitoring. Multi-sectoral collaboration and recognition of best-performing schools were also emphasized as important motivators for compliance and sustainability. Equity considerations particularly the need for disability-friendly facilities and school-community outreach were highlighted as critical. Agreement levels ranged from 74% to 100%, with most items scoring mean values between 4.5 and 4.8 on a 5-point Likert scale, indicating strong consensus among experts. Conclusion strengthening implementation of school WASH in Kenya requires coordinated governance, predictable funding, reliable water systems, inclusive sanitation, strengthened MHM, and consistent monitoring beyond infrastructure investment alone. Integrating these expert-validated priorities within existing national policies offers a practical pathway to improving learner health, reducing absenteeism especially among girls and promoting equitable educational outcomes.

Aims Indoor air pollution resulting from combustion of unclean cooking fuels has been linked to adverse health outcomes, but evidence regarding its association with mental health in low- and middle-income countries remains limited. We investigated the association between household use of unclean cooking fuels, as a proxy for indoor air pollution, and depression symptoms among adults aged 45 years and older in India, and assessed effect modification by age, sex, caste, and rural/urban residence. Methods We conducted a cross-sectional analysis of the first wave (2017-2018) of data from the Longitudinal Aging Study in India (LASI), a nationally representative survey of adults aged [≥]45 years. Cooking fuel type was classified as clean or unclean, and depression symptoms were assessed using the 10-item Centre for Epidemiologic Studies Depression (CES-D-10) scale. We used logistic regression to estimate odds ratios for depression symptoms, and linear regression to compare mean CES-D-10 scores by cooking fuel type, adjusting for sociodemographic and housing characteristics. Results We included 62,650 respondents. Median age was 57 years (IQR: 50-65), 46.7% were women, 47.6% reported using unclean cooking fuels, and 27.6% screened positive on the CES-D-10. After adjusting for sociodemographic and housing characteristics, use of unclean cooking fuels was associated with higher odds of screening positive on the CES-D-10 (aOR: 1.08; 95% CI: 1.02, 1.15), and higher mean CES-D-10 scores (adjusted mean difference: 0.34; 95% CI: 0.24, 0.44). The association was more pronounced among individuals living in urban areas (aOR: 1.36; 95% CI: 1.21, 1.53). Conclusion Use of unclean cooking fuels was associated with depression symptoms among older adults in India, and especially among those living in urban areas.

In the context of global health, the ability of frontline primary health providers to identify potential Drug-Drug Interactions (DDIs) is a critical component of patient safety. This is particularly true in settings like Tanzania, where drug dispensers often serve as the primary point of contact for healthcare. In this study, we establish a baseline for drug decision-making capabilities across multiple cadres of healthcare providers in Kibaha, Tanzania. We specifically distinguish between the ability to recognize safe drug combinations versus harmful ones. The findings reveal a critical asymmetry in provider performance: while professional training improves the recognition of safe combinations, it provides no advantage over lay intuition (and in some cases, a significant disadvantage) in detecting potentially harmful interactions.

Female genital cutting (FGC) is identified within global health and human rights discourse as aligned with gender inequality and female disempowerment. The persistence of FGC in high-prevalence societies is assumed to reflect womens limited influence over decisions concerning their daughters. Yet anthropological research has questioned whether this interpretation adequately reflects how FGC is organized within practicing communities. Across two studies with 176,728 participants from 15 African and Asian countries, we examine whether mothers attitudes toward FGC predict daughters circumcision status and whether this relationship varies with regional FGC prevalence. Multilevel logistic regression models show that maternal attitudes strongly predict daughter circumcision status across both datasets. Contrary to expectations derived from disempowerment frameworks, the association between maternal attitudes and daughter outcomes is not weaker in high-prevalence contexts, it is stronger. These findings suggest that interpretations of FGC as reflecting female disempowerment may mischaracterize the social dynamics of societies in which FGC is common. Policy implications of the findings are discussed.

Background: HIV/AIDS remains a major public health challenge in Tanzania, where viral load suppression among adults on ART stands at 78% and HVL testing uptake among eligible patients is approximately 22%. Since the introduction of the National HVL Testing Guideline in 2015, little has been done to systematically evaluate its implementation. Objective: To evaluate adherence to the National HVL Testing Guideline across CTC clinics in Dar es Salaam Region, covering ART monitoring, documentation, turnaround time, and factors affecting implementation. Methods: A cross-sectional study was conducted in 2021 across 15 public health facilities with CTC clinics in all five Dar es Salaam districts. A total of 330 PLHIV on ART for more than six months were selected through systematic random sampling with proportional to size allocation, and 45 healthcare providers through convenient sampling. Data were collected via abstraction forms and self-administered questionnaires, and analysed using SPSS Version 23 with descriptive statistics, bivariate analysis, and binary logistic regression. Results: Only 25.1% of patients had their first HVL sample taken at six months as per guideline, with 68.8% delayed beyond six months. Second and third samples were similarly delayed. MoHCDGEC sample tracking forms were absent in 96.7% of facilities and incomplete in 99.1%, and no facility captured specimen acceptance or rejection as site feedback. Turnaround time exceeded the 14-day guideline threshold in 64.5%, 66.7%, and 69.4% of first, second, and third results respectively. Patient negligence (AOR=9.84; 95% CI: 1.83-52.77) and storage (AOR=5.72; 95% CI: 0.94-35.0) were independently associated with guideline adherence. Conclusion: Adherence to the National HVL Testing Guideline in Dar es Salaam is suboptimal across testing timelines, documentation, and turnaround time, with patient negligence and storage capacity as significant determinants. Targeted interventions are needed to strengthen patient education, improve storage infrastructure, enhance documentation systems, and support providers in adhering to guideline-specified timelines.

BackgroundProspective studies of pregnant adolescents are essencial to effectively address this global health priority. They help answer vital questions about their health, but such studies are uncommon due to the difficulty in retaining adolescents. This paper describes the successes and challenges of the research strategies used to ensure sufficient recruitment and retention of pregnant adolescents in a longitudinal study about adolescent childbearing in an under-resourced setting. MethodsThe Adolescence and Motherhood Research project was conducted in a rural region of Northeast Brazil in 2017-2019 and assessed 50 primigravids between 13-18 years (adolescents) and 50 primigravids between 23-28 years (young adults) during the first 16 weeks of pregnancy with two follow-ups (third trimester of pregnancy, and 4-6 weeks postpartum). Recruitment strategies involved engagement of health sector and community, as well as referrals from health care professionals and dissemination of the project in different locations. Retention strategies included maintaining contact with the participants between assessments and providing transportation for them to attend the follow-up procedures. ResultsRecruitment took 10 months to complete. A total of 78% of the participants were recruited from the primary health care units, mainly after referral from a health care provider. Retention reached 95% of the sample throughout the study (90%: adolescents; 98%: adults). ConclusionA combination of approaches is necessary to successfully recruit and retain youth in longitudinal studies and engaging local stakeholders may help to increase community-perceived legitimacy of the research. Working closely with front-line staff is essential when conducting research in rural low-income communities.

Background: Large language models (LLMs) are increasingly used in mental health contexts, yet their detection of suicidal ideation is inconsistent, raising patient safety concerns. Objective: To evaluate whether an independent safety monitoring system improves detection of suicide risk compared with native LLM safeguards. Methods: We conducted a cross-sectional evaluation using 224 paired suicide-related clinical vignettes presented in a single-turn format under two conditions (with and without structured clinical information). Native LLM safeguard responses were compared with an independent supervisory safety architecture with asynchronous monitoring. The primary outcome was detection of suicide risk requiring intervention. Results: The supervisory system detected suicide risk in 205 of 224 evaluations (91.5%) versus 41 of 224 (18.3%) for native LLM safeguards. Among 168 discordant evaluations, 166 favored the supervisory system and 2 favored the LLM (matched odds ratio {approx}83.0). Both systems detected risk in 39 evaluations, and neither in 17. Detection was highest in scenarios with explicit suicidal ideation and lower in more ambiguous presentations. Conclusions: Native LLM safeguards frequently failed to detect suicide risk in this structured evaluation. An independent monitoring approach substantially improved detection, supporting the role of external safety systems in high-risk mental health applications of LLMs.

Importance: Suicide is a leading cause of death in the United States with risk strongly influenced by Interpersonal trauma, contributing to treatment resistance and clinical complexity. Objective: To assess clinical and genetic factors in individuals who died from suicide, with and without interpersonal trauma exposure. Design: Individuals who died from suicide with and without trauma were compared in a retrospective case-case design. Prevalence of 19 broad clinical categories was assessed between groups. Results directed selection of 42 clinical subcategories, and 40 polygenic scores (PGS) for further assessment. Multivariable logistic regression models, adjusted for critical covariates and multiple tests, were formulated. Models were also stratified by age group (<26yo and >=26yo), sex, and age/sex. Setting: A population-based evaluation of comorbidity and polygenic scoring in two suicide death subgroups. Participants: A total of 8 738 Utah Suicide Mortality Research Study individuals (23.9% female, average age = 42.6 yo) who died from suicide were evaluated, divided into trauma (N = 1 091) and non-trauma exposed (N = 7 647) individuals. A subset of unrelated European genotyped individuals was also assessed in PGS analyses (Trauma N = 491; Non-trauma N = 3 233). Exposures: Trauma is here defined as interpersonal trauma exposure, including abuse, assault, and neglect from International Classification of Disease coding. Main Outcomes and Measures: Prevalence of comorbid clinical sub/categories and PGS enrichment in trauma versus non-trauma exposed suicide deaths. Results: Overall, trauma-exposed individuals died from suicide earlier (mean age of 38.1 yo versus 43.3 yo; P <0.0001) and were disproportionately female (38% versus 21%, OR = 3.3, CI = 2.9-3.8). Prevalence of asphyxiation and overdose methods, prior suicidality, psychiatric diagnoses, and substance use (OR range = 1.3-3.7) were elevated in trauma exposed individuals who died from suicide. Genetic PGS were also elevated in trauma-exposed individuals who died from suicide for depression, bipolar disorder, cannabis use, PTSD, insomnia, and schizophrenia (OR range = 1.1-1.4) with ADHD and opioid use showing uniquely elevated PGS in trauma exposed males (OR range = 1.2-1.4). Conclusions and Relevance: Results demonstrated multiple convergent lines of age- and sex-specific evidence differentiating trauma-exposed from non-trauma exposed suicide death. Such findings suggest unique biological backgrounds and may refine identification and treatment of this high-risk group.

BackgroundMajor depressive disorder (MDD), a leading cause of disability worldwide, exhibits substantial heterogeneity in treatment outcomes. Patients who do not respond to standard antidepressant therapy account for the majority of MDDs disease burden. Risk factors have been implicated in treatment response, including genes impacting on how antidepressants are metabolised. Yet, despite its clinical importance, risk factors for treatment-resistant depression (TRD) remain unexplored in low- and middle-income countries (LMIC). We used data from the DIVERGE study on MDD to investigate the risk factors of TRD in Pakistan. MethodsDIVERGE is a genetic epidemiological study that recruited adult MDD patients ([&ge;]18 years) between Sep 27,2021 to Jun 30, 2025, from psychiatric care facilities across Pakistan. Detailed phenotypic information was collected by trained interviewers and blood samples taken. Infinium Global Diversity Array with Enhanced PGx-8 from Illumina was used for genotyping followed by DRAGEN calling to infer metaboliser phenotypes for Cytochrome P450 (CYP) enzyme genes. We defined TRD as minimal to no improvement after [&ge;]12 weeks of adherent antidepressant therapy. We conducted multi-level logistic regression to test the association of demographic, clinical and pharmacogenetic variables with TRD. FindingsAmong 3,677 eligible patients, polypharmacy was rampant; 86% were prescribed another psychotropic drug along with an antidepressant. Psychological therapies were uncommon (6%) while 49% of patients had previously visited to a religious leader/faith healer in relation to their mental health problems. TRD was experienced by 34% (95%CI: 32-36%) patients. The TRD group was characterised by more psychotic symptoms and suicidal behaviour (OR=1.39, 95%CI=1.04-1.84, p=0.02; OR=1.03, 95%CI=1.01-1.05, p=0.005). Social support (OR=0.55, 95%CI=0.44-0.69, p=1.4x10-7) and parents being first cousins (OR=0.81, 95%CI=0.69-0.96, p=0.01) were associated with lower odds of TRD. In 1,085 patients with CYP enzyme data, poor (OR=1.85, 95%CI=1.11-3.07, p=0.01) and ultra-rapid (OR=3.11, 95%CI=1.59-6.12, p=0.0009) metabolizers for CYP2C19 had increased risk of TRD compared with normal metabolisers. InterpretationThere was an excessive use of polypharmacy in the treatment of depression while psychological therapies were uncommon highlighting the need for more evidence-based practice. This first large study of MDD from Pakistan uncovered the importance of culture-specific forms of social support in preventing TRD, highlighting opportunities for interventions in low-income settings. Pharmacogenetic markers can be leveraged to predict TRD.