Neuro-Oncology Advances

Background. Tethered cord syndrome (TCS) is classically associated with a low-lying conus medullaris, yet many surgically treated children have a normally positioned conus (occult TCS). Large-scale normative data on conus position in children, and the diagnostic value of quantitative conus assessment, are limited. Purpose. To establish a large-cohort reference distribution for conus medullaris termination level in children, to quantify conus position in children surgically treated for presumed (occult) TCS, and to test whether automated conus segmentation and radiomics can distinguish TCS from normal. Materials and Methods. In this retrospective single-center study, conus termination level was extracted from structured radiology reports of consecutive pediatric lumbosacral MRI examinations and encoded numerically (L1 = 1, L2 = 2, etc.). Children surgically treated for tethered cord were identified by linkage to an operative registry (name and date of birth) and restricted to preoperative examinations. A deep-learning model (nnU-Net) was trained for conus segmentation on axial T2-weighted images. IBSI-compliant radiomic features were extracted; reproducibility was assessed by intra- and inter-observer intraclass correlation (ICC). A case-control radiomics analysis used batch-only ComBat harmonization and cross-validated L1-penalized logistic regression; discrimination was compared with conus level by paired bootstrap. Results. Among 9,808 examinations with a parseable conus level (98.5% of reports; parser validated against dual blinded annotation, 99.4% agreement, weighted kappa 0.946), the conus terminated in the L1 region in 85.7% and the L2 region in 14.3% of the reference cohort (postoperative examinations excluded, n = 9,655); a low-lying conus (>=L3) occurred in only 0.05% (5/9,655), and remained rare (0.14%, 14/9,808) including operated examinations (median L1; mean 1.13 +/- 0.33). A slightly more cephalad position was seen with increasing age (negligible correlation). Among 475 preoperative children surgically treated for tethered cord, 99.6% had a normally positioned conus (<=L2) and only 0.4% were low-lying. Automated conus segmentation achieved a held-out Dice of 0.85. Conus radiomics likewise did not distinguish TCS from controls (equivalence-tested null; full segmentation/radiomics pipeline reported in the companion methodological paper). Conclusion. In children, the conus medullaris terminates at L1-L2 in more than 99% of cases and is normally positioned in virtually all children surgically treated for TCS. Within the conus, neither position nor texture (radiomics) identifies tethered cord; whether the filum terminale carries a diagnostic signal was not tested here.

OBJECTIVE: Bladder cancer (BC) is predominantly a disease of older, comorbid adults, and radical cystectomy (RC), which is the gold standard treatment, carries considerable morbidity. We sought to determine the impact of baseline dementia and frailty on the care trajectory beyond the immediate postoperative period. We hypothesized that frail patients and those with dementia undergoing RC for BC will have poorer care trajectories. METHODS AND MATERIALS: We identified Medicare beneficiaries [&ge;] 66 years old who underwent RC for BC in 2017 with 12 months of pre- and post-RC enrollment. Frailty and dementia were characterized using validated, claims-based measures. Associations between baseline frailty and dementia with postoperative care trajectory outcomes were determined using Fine-Gray competing risk models. RESULTS: We identified 3,600 beneficiaries of whom 11.6% were frail and 3.4% met criteria for dementia. Patients with dementia were more likely to be frail, comorbid, and not receive standard-of-care neoadjuvant chemotherapy. Frailty was independently associated with [&ge;] 2 transitions in care level after index discharge from RC and skilled nursing facility (SNF) admissions within 1 year of RC, exposure to intensive post-RC interventions, including dialysis and feeding tube placement, and poorer survival. Dementia remained associated with SNF admissions regardless of frailty level. CONCLUSIONS: Among a contemporary cohort of older adults undergoing RC for BC, preoperative dementia and frailty were independently associated with poorer care trajectory beyond the immediate postoperative period after RC. Our work highlights a role for preoperative geriatric assessment in identifying and optimizing patients at greatest risk.

Introduction: Precise anatomical navigation is fundamental to safe endoscopic pituitary surgery, a high-stakes procedure characterised by a challenging learning curve. While traditional navigation systems often rely on workflow-disrupting probes or static preoperative imaging, advancements in computer vision AI (CVAI) now enable dynamic, real-time anatomical segmentation directly from live surgical video1-3. Our group has previously conducted a series of preclinical human-computer interaction studies to refine the system's design, alongside digital and high-fidelity physical simulations demonstrating the benefit of AI assistance in improving overall performance, training, and safety4-8. Building on this foundation, the current study represents a first-in-human application of real-time CVAI assistance in the neurosurgical operating room, serving to assess feasibility and safety, and to iteratively improve the system. Method: Guided by DECIDE-AI and IDEAL frameworks, this single-centre evaluation comprises an initial proof-of-concept phase (n=6) for endoscopic transsphenoidal pituitary surgeries. The AI model utilised a DINOv3-derived vision transformer architecture, deployed via a high-performance edge computing unit to achieve low-latency, real-time inference without reliance on cloud infrastructure2. Given the high-risk nature of the procedure and the early stage of clinical AI integration, the system was initially deployed as an educational adjunct on a secondary monitor, ensuring the primary surgical feed remains uncompromised. Functionality and safety were assessed via structured questionnaire, prospective observation, and blinded retrospective review of the recordings of the endoscopic surgical video feed and wider operating room environment. Continuous multi-stakeholder feedback through validated human factors surveys drove iterative technical refinements between cases. Results: Six patients with pituitary adenomas were enrolled. The CVAI system was successfully deployed in four cases, demonstrating acceptable real-time sella segmentation accuracy. Deployment failed pre-operatively in two cases owing to a single recurring system reboot bug. Iterative refinement between cases were driven by our experience and surgical team feedback. This resulted in the integration of additional anatomical structure segmentations (e.g., carotid arteries), enhanced model accuracy via training dataset expansion, and hardware firmware upgrades. Multi-stakeholder surveys demonstrated satisfactory system feasibility, usability, and acceptability among the surgical team. Both prospective observation and retrospective video review confirmed the absence of adverse events, including no significant distraction to the primary surgeon, and there were no AI-related clinical complications. Conclusion: This first-in-human early clinical evaluation demonstrates the feasibility, safety and iterative development of real-time, CVAI-based anatomical navigation during high-stakes neurosurgery. Future work will include a larger single-centre case series (IDEAL Stage 2a) with more surgical teams to further iterate the system and explore its impact on training and workflow. As the underpinning technology improves, deployment will transition to direct intra-operative decision support and integration with other intra-operative navigational technologies.

INTRODUCTION Severe acute brain injury (stroke, traumatic brain injury or hypoxic-ischemic encephalopathy; SABI) is increasingly recognized as a chronic condition with care and communication needs beyond the initial hospitalization. This study aimed to characterize post-acute care patterns among SABI survivors, focusing on healthcare utilization and outpatient communication. METHODS Data were collected from a prospective cohort of hospitalized SABI patients using surveys, chart reviews, and the ED Information Exchange database. Socioeconomic disadvantage was assessed using the Area Deprivation Index (ADI), and qualitative analysis of outpatient notes examined conversations around palliative care needs and goals-of-care. RESULTS Two-thirds of patients (140/222) survived until discharge, primarily to nursing facilities (39%) or inpatient rehabilitation (38%). Among 109 with one-year follow-up, there were 89 hospitalizations, 104 ED visits, and 28 deaths. Patients from the most disadvantaged neighborhoods had significantly higher odds of rehospitalization or ED use within 30 days (OR 3.37, p=0.036). ADI was not linked to one-year utilization. seen outpatient by primary care (40%), neurology/neurosurgery (57%), and palliative care (1%), but conversations rarely revisited prognosis or goals-of-care. CONCLUSIONS Our findings highlight the need for improved long-term care planning and communication, particularly for socioeconomically disadvantaged survivors of SABI.

Objective: Outcome after surgical hematoma evacuation for intracerebral hemorrhage (ICH) depends on hematoma location. As corticospinal tract (CST) integrity affects motor recovery after stroke, we hypothesized that CST integrity drives heterogeneity in surgical outcomes and investigated this in a secondary analysis of MISTIE-III participants. Methods: Risk of CST injury was categorized into four levels, based on the interaction between the CST, the hematoma, and perihematomal edema (PHE) on automatically segmented stability CT: no risk, PHE infiltration, hematoma infiltration, and complete interruption of the CST. Associations with outcome were tested using multivariable linear regression for motor National Institutes of Health Stroke Scale (NIHSS) at day 180 and ordinal regression for modified Rankin Scale (mRS) at day 365, introducing an interaction term between CST risk and treatment group. Results: Day 180 motor NIHSS was significantly lower for 'no risk' ({beta}:-3.77, [95% confidence interval [CI]: -5.8 to -1.70], p=0.0003) and 'PHE infiltration' ({beta}:-2.3, [95%CI: -3.5 to -1.1]; p=0.0002) vs. 'complete interruption'. Surgery was associated with lower Day 180 motor NIHSS in participants with hematoma infiltration ({beta}:-2.07, [95%CI: -3.8 to -0.4], p=0.016). Compared to complete interruption, 'no risk' (adjusted odds ratio [aOR]:0.27, [95%CI: 0.10 to 0.74], p=0.01) and 'PHE infiltration' (aOR:0.41, [95%CI: 0.23 to 0.74]; p=0.003) were associated with lower odds of unfavorable day 365 mRS. Surgery was associated with lower mRS in participants with no risk (aOR:0.23, [95%CI: 0.05 to 0.97, p=0.045). Interpretation: Increasing CST risk is associated with worse motor recovery (day 180) and disability (day 365). CST risk modifies the effect of the MISTIE-III procedure on motor recovery and disability.

Background Endometrial cancer exhibits marked molecular and immune heterogeneity that is only partially explained by established genomic biomarkers. We investigated whether T cell receptor (TCR) repertoire architecture captures complementary dimensions of antitumor immunity beyond conventional molecular classification. Methods Paired tumor and peripheral blood samples from eight patients with molecularly characterized endometrial cancer underwent TCR repertoire profiling. Diversity, clonality, and tumor blood overlap metrics were integrated with genomic variables, including tumor mutational burden (TMB), genomic instability metric (GIM), and POLE status. Principal component analysis and correlation analyses were used to identify major dimensions of repertoire organization. Composite Immune Focusing and Immune Sharing Scores were derived to summarize dominant repertoire patterns. Results The first two principal components explained 70.1% of total repertoire variance and revealed substantial heterogeneity independent of histological subtype. TMB was strongly associated with reduced repertoire diversity and increased clonal dominance, resulting in a robust association with the Immune Focusing Score ({rho} = 0.88, p = 0.004). POLE mutated tumors occupied the extreme end of this focusing continuum. In contrast, genomic instability was associated with increased tumor blood repertoire overlap and preserved diversity, reflected by a strong correlation between GIM and the Immune Sharing Score ({rho} = 0.76, p = 0.027). The two immune scores showed minimal correlation with each other ({rho} = -0.24, p = 0.57), indicating that they capture largely independent aspects of immune organization. Conclusion Integrative analysis of TCR repertoire architecture and tumor genomics identifies distinct immunogenomic states in endometrial cancer that are not fully captured by conventional molecular classification. If validated in larger cohorts, immune focusing and immune sharing metrics may provide complementary biomarkers for patient stratification and immunotherapy-oriented precision oncology

Introduction: Structural neuroimaging relies on T1-weighted (T1w) magnetic resonance imaging (MRI) for brain morphometry, yet at 7 Tesla (7 T) transmit field (B1+) inhomogeneity remains a major source of bias. Although Magnetization Prepared 2 Rapid Acquisition Gradient Echoes (MP2RAGE) improves the tissue contrast, residual B1+ effects may persist and may be exacerbated in aging or clinical populations, where anatomical and physiological factors further challenge image quality and preprocessing. The impact of B1+ inhomogeneity on automated quality assessment and morphometric statistical inference remains insufficiently understood. Methods: Submillimeter 7 T MP2RAGE brain acquisitions from carriers of a mitochondrial gene mutation (m.3243A>G) and controls were retrieved from previous studies. Image quality before and after B1+ inhomogeneity correction was assessed by multiple automated pipelines. Case-control morphometric studies, including regional volume and mean cortical thickness, were analyzed in both registration based and deep learning based segmentation frameworks. Changes in image quality metrics (IQMs) and morphometric statistical significance were evaluated to determine the impact of B1+ inhomogeneity correction. Results: Overall image quality rating and metrics sensitive to intensity non-uniformity and topological integrity consistently improved after B1+ inhomogeneity correction. However, its impact on morphometric statistical inferences was strongly method-dependent. Some pipelines showed redistribution of significant regions, whereas others predominantly demonstrated increased effects in sensitivity. Across methods, B1+ inhomogeneity correction altered the findings of morphometric analyses, particularly in cortical regions. Conclusion: Residual B1+ inhomogeneity at 7 T substantially influences both image quality control and morphometric evaluations. Current automated quality control approaches can hardly capture these effects reliably. B1+ inhomogeneity correction will not only improve intensity uniformity, but also change sensitivity of morphometric statistical inferences. To establish reliable morphometric biomarkers at UHF strengths, explicit B1+ correction and customized preprocessing are practically necessary and highly recommended.

Background and rationale: Knee osteoarthritis (KOA) is a leading cause of lower limb disability worldwide, characterized by functional limitations, stiffness and pain. The incidence of KOA is especially tied to age and obesity. It is a disabling disease that often makes patients less physically active, thus increasing the risk of other diseases and mortality1. The clinical diagnosis of KOA is based on the symptoms and functional limitations of the joint. The diagnosis is usually supported with a radiograph (X-ray) of the weight-bearing knee. Radiographic features, such as Kellgren-Lawrence grade, are used as eligibility criteria for clinical studies while other features, such as joint space width (JSW), are used as endpoints for structural KOA progression2,3. While the use of these radiographic features is standard in academia, the use of JSW as a structural biomarker has received criticism. Critics point out that JSW is an indirect and projection dependent measure of cartilage deterioration which is sensitive to technical factors such as the angulation of the X-ray beam and the positioning of the knee. Small differences in these factors can alter the measured joint space and may not reflect true disease progression4,5. Despite limitations, minimum joint space width (mJSW) remains as one of the most widely used structural biomarkers in KOA trials and is currently one of the only structural imaging accepted in regulatory guidance as evidence of disease modification in OA drug development3. For JSW to be reliable and consistent in determining the advancement of KOA, the use of fixed-flexion devices is crucial to reduce the risk of unwanted narrowing or widening of the radiographic joint space width6,7. The LOSEIT trial, which the present study is based on, acknowledges the angulation problem and uses a standard clinical fixed-flexion device in weight-bearing PA views to get reliable JSW results8. Historically, a radiologist would draw on and grade radiographs of the knee-joint to extract the features. However, manual reading and annotation is time consuming with notable interobserver variance9. With increasing computational power and the use of deep neural networks, off-the-shelf artificial intelligence (AI) tools have become available for automatic extraction of radiograph features. Automation would free up time from radiologists and provide more consistent measurements due to the reproducible nature of the models10. These tools have received regulatory approval for commercial use, however, regulatory approval does not guarantee uniform or bias free performance when used on real-world data11. Furthermore, in a large multi-hospital chest X-ray study, Zech et al., showed that convolutional neural networks achieved worse results on data from other hospitals than on the original hospitals in which it was tested12. This highlights the risk of overestimating the accuracy of AI tools when only internally validated. It is therefore apparent that external validation is required when testing these AI models. Objectives: The aim of this analysis is to evaluate the agreement of a commercially available AI tool for measuring JSW with the best practice radiologist annotation in the tibiofemoral joint of the knee in radiographs stabilized with a fixed-flexion device and acquired as part of a clinical trial. Methods: This study is a secondary analysis of the data from the LOSEIT trial, a randomized, double-blind, placebo-controlled, single-center trial, where patients were randomized to either liraglutide or identically appearing placebo after an initial weight-loss period to investigate the effects on KOA. Radiographs of the tibiofemoral joint were acquired at enrollment (week -8) and at end-of-trial (week 52) for a total acquisition-to-acquisition time of 60 weeks13. The primary analysis will assess agreement between AI-derived and reference-derived change in JSW from enrolment to follow-up. Change will be calculated as follow-up minus enrolment separately for the AI tool and the reference measurement. The main measure of interest will be the change in medial minimal JSW (mmJSW), with change in lateral minimal JSW (lmJSW), medial fixed JSW (mfJSW) and lateral fixed JSW (lfJSW) as secondary measures. This study will follow an equivalence framework using the two one-sided tests (TOST) approach with a Bland-Altman analysis as the main outcome. The equivalence margin will be set at {delta} = 0.5 mm. Agreement consistent with equivalence will be considered established if the upper limit of the 95% confidence interval (95% CI) for the upper limit of agreement (LoA) and the lower limit of the 95% CI for the lower LoA are within the established margins. The reference JSW will be the average measurement of two independent resident radiologists. If there is a mismatch in the measurements of more than 0.40 mm between the two radiologists, the radiologists will re-annotate the case independently. If the difference remains greater than 0.40 mm, a musculoskeletal radiology consultant will review the radiograph and establish the reference JSW. The index test will be the measurements output by the AI tool. Populations: Patients aged 18 to 74 with symptomatic knee osteoarthritis, radiographically confirmed KL grade 1-3, with a BMI [&ge;]27, motivated for weight loss and in accordance with the LOSEIT trial inclusion criteria Further statistical details Sample size: Not applicable as this is a secondary analysis. Framework: This is an agreement study assessing the equivalence of a commercially available AI tool for radiographic evaluation of knee osteoarthritis with best practice radiologist measurements. Confidence intervals and P values: All 95% confidence intervals and P-values will be two-sided. Statistical software: SAS Studio and/or R version 4.2.2 (or newer).

PURPOSE: Alzheimer disease (AD) is associated with cognitive impairment, brain atrophy, and elevated amyloid-beta and tau. The study aimed to characterize regional atrophy associated with elevated amyloid-beta and tau, as measured by [18F]florbetapir (FBP) and [18F]flortaucipir (FTP) positron emission tomography (PET), respectively, and determine whether combining PET and atrophy data improves the prediction of cognitive impairment. METHODS: Alzheimer Disease Neuroimaging Initiative data (n = 381) were retrospectively analyzed. PET results were correlated with cortical thickness, gray matter (GM) volumes, Mini-Mental State Examination, and Montreal Cognitive Assessment. Linear/logistic regression and area under the curve (AUC) were used to evaluate for significant correlations and compare performances in distinguishing cognitive impairment, respectively. RESULTS: Incremental loss of cortical thickness and GM volume was observed from FBP-/FTP- (n = 205) to single PET-positive (FBP+/FTP-, n = 133; FBP-/FTP+, n = 5) and FBP+/FTP+ (n = 38) groups, particularly in the temporal and parietal lobes. FBP+/FTP+ showed the most severe cortical thickness loss in the entorhinal cortex, temporal lobe GM atrophy, and cognitive impairment. Adding brain atrophy as the third variable resulted in higher odds ratios and improved AUCs for cognitive impairment, with FBP+/FTP+/temporal GM or entorhinal cortical atrophy+ demonstrating the strongest associations with cognitive impairment. CONCLUSION: A multimodal approach combining PET and MRI may help improve the assessment of cognitive impairment in AD.

Purpose: Pathogenic or likely pathogenic (P/LP) variants are increasingly identified in genes more commonly associated with adult-onset cancer predisposition, but their prevalence and relevance to children who present with cancer remain unclear. Methods: We retrospectively analyzed 1,280 consecutive pediatric patients with cancer who underwent clinical germline sequencing, using a virtual panel, from 2021 to 2024. Genes with P/LP variants were categorized as aoCPG or pediatric-onset cancer predisposition genes (poCPG) according to cancer risk before age 18 years and pediatric surveillance recommendations. Variant relevance was adjudicated using tumor diagnosis/histopathology, immunohistochemistry, and tumor molecular features and classified as primary, secondary, or indeterminate. Results: Among 1,280 patients, 197 (15.4%) harbored 211 P/LP variants across 54 genes. Sixty-six variants (31.3%) occurred in aoCPG, 87 (41.2%) in poCPG, and 58 (27.5%) were heterozygous variants in autosomal recessive genes. Among adult-onset variants, 7 (10.6%) were primary, 54 (81.8%) secondary, and 5 (7.6%) indeterminate. Among pediatric-onset variants, 77 (88.5%) were primary and 10 (11.5%) secondary. Six patients (3 adult-onset variants; 3 pediatric-onset variants) received targeted therapy informed by germline/somatic sequencing results. Conclusion: In pediatric oncology, most variants in aoCPG are secondary rather than tumor-related findings. Tumor-informed interpretation, beyond variant classification, may improve reporting, counseling, and therapeutic decision-making

The purpose of this work is to analyze the 2-year overall survival (OS2y) of limited-stage small cell lung cancer (LS-SCLC) treated with chemoradiotherapy (CRT), aiming at characterizing the response of LS-SCLC, and in particular the /{beta} value and proliferation parameters. Through a systematic analysis of the literature, we collated a dataset containing 57 entries (3363 patients) of response of LS-SCLC treated with CRT. Radiotherapy schedules ranged from hyper- to hypofractionation. Four radiobiological models to describe the OS2y were investigated, with progressive levels of complexity including the effect of radiotherapy, chemotherapy, treatment year and toxicity. The Akaike Information Criterion (AIC) was used to compare models, and the profile likelihood methodology to compute confidence intervals. Model 4, which includes the effect of radiotherapy, chemotherapy, treatment year and dose-dependent toxicity, provided the best fits of the experimental data (lowest AIC value). While being the best model, model 4 still fails to provide a good prediction of the OS2y, in particular failing to predict the survival of the schedules achieving the lower/higher survivals. The radiobiological analysis of the dose-response of LS-SCLC to CRT does not allow to narrowly constrain the value of response parameters. We attribute this limitation to the large heterogeneity of this disease. Nonetheless, our analysis shows a large /{beta} value (>9 Gy, 95% CI), which implies a low fractionation effect in the radiotherapy of LS-SCLC. and an accelerated proliferation of tumor cells, {lambda}' > 1.6 Gy/day (95% CI), after a kick-off time of ~4-5 weeks, which supports the use of accelerated protocols to avoid the effect of tumor proliferation on the clinical outcome.

During the 2026 Bundibugyo virus disease outbreak in the Democratic Republic of the Congo and Uganda, we projected potential airline-mediated importation risk using contemporary airline network and an externally calibrated Ebola importation hazard. Effective-distance analyses identified major international hub countries, including Belgium, France, South Africa, Kenya, and the United Arab Emirates, as higher-probability gateways within 30 days. These early projections provide a reproducible framework for real-time international situational awareness, while emphasizing that importation risk does not imply local transmission risk.

Introduction Education is a core social determinant of health for children and adolescents. Unfortunately, academic achievement, health, and wellbeing of adolescents have decreased in many developed countries in the past decade. The purpose of the Wellbeing and Education linkages in school-aged children (WELL-ED) study is to examine associations of school absences and academic achievement with use of school-based and community-based health and social welfare services. In addition, we will assess user experiences and multi-sector services pathways of school-aged children for a better understanding of how the service system could respond to the needs of children. Methods and analysis WELL-ED is a large population-based study that combines register data on school absences and educational support from municipalities with register data on healthcare and social service use collected from wellbeing services counties in Finland. The study cohort includes all children who attended mandatory education in public schools in Southern Finland in school year 2023-2024. A smaller cohort of adolescents in school year 8 was invited to complete a user experience survey. The primary outcomes of this study are related to equity of service use. Ethics and dissemination The Regional Committee on Medical Research Ethics of the Helsinki and Uusimaa Hospital District (2803/2024) has approved the WELL-ED study protocol. For the survey, adolescents in year 8 and parents of adolescents younger than 15 provided informed consent. Results will be published in peer-reviewed journals, summaries will be sent to participating municipalities and wellbeing services counties and press releases will be written on key findings.

Abstract Objective: The onset of hypertension occurs at a younger age in China, and the relationship between health literacy and quality of life among middle-aged and older hypertensive patients remains unclear. This study explored whether perceived social support and self-efficacy mediate the association between health literacy and quality of life in middle-aged and older hypertensive patients. Methods: A questionnaire was administered to 1,015 middle-aged and older hypertensive adults from communities in six central provinces of China. The EQ-5D scale, Perceived Social Support (PSS) scale, Self-Efficacy Scale (SES), and Health Literacy Scale (HLS) were used to assess quality of life, social support, self-efficacy, and health literacy, respectively. Mplus 8.3 software was used to construct a structural equation model for path analysis. Results: The mean PSS, SES, HLS, EQ-5D, and EQ-VAS scores were 15.57{+/-}3.45, 10.61{+/-}2.41, 9.49{+/-}2.86, 0.88{+/-}0.18, and 71.06{+/-}17.49, respectively. Health literacy and quality of life scores significantly differed among middle-aged and older hypertensive patients, and both showed positive correlations with perceived social support and self-efficacy (both P<0.001). Perceived social support and self-efficacy exhibited a chain mediated effect on the relationship between health literacy and quality of life (EQ-5D utility index and EQ-VAS), accounting for 28.57% of the total effect of the EQ-5D utility index and 27.26% of that of the EQ-VAS. This study is the first to elucidate the mechanism by which health literacy influences quality of life in middle-aged and older hypertensive patients through the chain-mediated effect of perceived social support and self-efficacy. Conclusion : Health literacy is significantly correlated with quality of life in middle-aged and older hypertensive patients. This correlation can directly or indirectly explain the impact on quality of life through mediating pathways involving perceived social support and self-efficacy. Keywords: hypertensive patients, perceived social support, self-efficacy, health literacy, quality of life, mediating effect

Background Totally endoscopic aortic root (AR) surgery via right anterior minithoracotomy (RAMT) may reduce surgical trauma and accelerate recovery compared with full sternotomy (FS). However, the approach is technically demanding due to limited access and anatomical complexity. This study compares early clinical outcomes and quality of life (QoL) after RAMT versus FS to evaluate the feasibility and safety of the totally endoscopic approach. Methods This single-center, retrospective study included 149 patients underwent AR surgery via RAMT (n=74) or FS (n=75) between January 2021 and March 2026. Patients with aortic dissection, infective endocarditis, redo surgery, concomitant procedures, or arch replacement were excluded. Operative outcomes, postoperative recovery, 30-day and 1-year mortality were analyzed. QoL was assessed using the Short Form-8 (SF-8) questionnaire. Results The median age was 60.0 years, and 79.9% of patients were male. Bentall procedure was performed in 84.6% of patients, 15.4% underwent a David procedure. Compared with FS-AR, RAMT-AR was associated with shorter median operative time (147.0 vs. 178.0 min; p<0.001), lower median chest drainage volume (650.0 vs. 850.0 mL; p<0.001), and shorter median ICU stay (24.0 vs. 25.0 h; p=0.008) and hospital stay (6.0 vs. 8.0 days; p=0.028). Overall, 30-day and 1-year mortality was 0.7%. SF-8 analysis demonstrated significantly higher physical and mental component scores in RAMT-AR patients. Conclusion In specialized centers, totally endoscopic AR surgery via RAMT is a safe and feasible minimally invasive approach associated with favorable early outcomes and a potential benefit in postoperative physical and mental QoL by reducing surgical trauma.

Background. The emergency department in the United States of America functions as a residual access point for healthcare and social services for populations including rural communities, the uninsured, mental health and addiction patients, and the unhoused. The workforce variable that determines unit function (experience density, the concentration of accumulated clinical judgment within a unit workforce) is not measured in hospital accounting systems. Objective. To document workforce composition changes in U.S. emergency nursing across the 2018 and 2022 cycles of the National Sample Survey of Registered Nurses (NSSRN), and to specify falsifiable predictions for the 2026 cycle. Methods. We analyzed NSSRN public-use files using a four-way ED definition extending Castner et al. (2024) and a hospital-bedside-restricted comparator. Variance estimation used jackknife replicate weights for 2018 and Successive Differences Replication for 2022. Burnout was operationalized using the Norful et al. (2023) leaving-reasons proxy across cycles, with sensitivity analysis using the 2022 direct burnout item. Results. A 15-year trajectory (2008-2022) documents progressive experience-density compression: the ED's 15+ year veteran cohort fell from 41.9% to 28.0% over the decade preceding the pandemic, a loss of nearly a third of the senior cohort and a 19.6% decline in mean experience density, before recovering modestly to 33.3% as veteran nurses remained through the pandemic acute phase, leaving the ED as the youngest hospital setting throughout. Hospital non-ED bedside nurses lost senior tenure between cycles (mean 15.65[-&gt;]14.06 years since first licensure; 15+ year share 43.5%[-&gt;]38.7%), while ED nurses retained their senior tail (mean 11.60[-&gt;]12.58). Burnout endorsement rose sharply in both populations (non-ED 27.3%[-&gt;]46.0%; ED 34.2%[-&gt;]61.2%), with the ED-vs-non-ED gap more than doubling. Controlling for tenure, ED status was not independently associated with burnout in 2018 (OR 1.15, 95% CI 0.83-1.59) but was strongly associated in 2022 (OR 1.92, 95% CI 1.44-2.55; p<.001). The direct burnout item showed a parallel pattern (OR 2.92, 95% CI 1.62-5.28). Conclusions. A pandemic-era setting-specific burnout effect emerged in emergency nursing that workforce-composition controls cannot explain. The 2022 cycle establishes a pre-exit baseline against which the 2026 NSSRN will serve as the falsifiable test of post-Omicron veteran exit. Nursing pipeline replacement lag exceeds the interval before 2026 data arrives; the consequences of inaction fall on populations dependent on ED-based residual access.

Background: In atrial fibrillation (AF), cerebral microbleed (CMB) burden guides anticoagulation decisions, yet AF is itself inconsistently associated with CMBs, a paradox unexplained by frameworks that treat CMBs as a unitary marker of small vessel disease. We hypothesized that the white matter hyperintensity (WMH) context in which CMBs arise modifies their vascular meaning, and that this context-dependence underlies the inconsistent AF-CMB association. Methods: From a multicenter Korean stroke registry, we analyzed 5,735 first-ever ischemic stroke patients imaged at nine centers using susceptibility-weighted MRI. WMH volume and CMB count were extracted by validated deep learning pipelines. Patients were cross-classified by age-adjusted WMH residual (median split) and CMB count (2) into four groups. The AF-CMB association was estimated by multivariable logistic regression within each WMH stratum with formal interaction testing. Spatial CMB distribution was analyzed against the Automated Anatomical Labeling atlas. Results: In the full cohort (mean age 69.5 years; 57.7% male), AF was not associated with CMBs (OR 1.04; 95% CI 0.87-1.25). Stratification yielded divergent estimates: the adjusted AF OR was 1.46 (1.11-1.93; P = 0.007) in the WMH-low stratum and 0.95 (0.73-1.22; P = 0.665) in the WMH-high stratum, with significant interaction (OR 0.56; P < 0.001). The discordant phenotype (low WMH, high CMB; 8.9%) was enriched for AF (28.0%) and showed fronto-temporal cortical predominance with deep structure sparing. AF independently reduced the proportion of deep CMBs (IRR 0.80; P = 0.040). The interaction was preserved across prespecified sensitivity analyses. Conclusions: The AF-CMB association is confined to patients with low WMH burden relative to age and is accompanied by a topographically distinct CMB distribution. Clinical assessment of small vessel disease based on WMH alone may overlook a CMB phenotype linked to AF.

Mosquito-borne diseases continue to pose significant public health challenges worldwide, particularly in densely populated regions of South Asia and parts of North America experiencing increasing vector prevalence due to climate and environmental changes. Commercial mosquito repellents are widely used as a primary preventive measure; however, their efficacy, safety, and public health impacts vary depending on formulation, active ingredients, environmental conditions, and user practices. This study presents a comparative evaluation of commonly used mosquito repellent products in South Asia and North America, including coils, vaporizers, sprays, creams, and Natural repellents. The research aims to assess repellent efficacy against major mosquito vectors, evaluate potential health and respiratory effects associated with prolonged exposure, and analyze consumer awareness and usage patterns across different regions. Laboratory-based efficacy testing and field observations were conducted to compare protection duration, repellency rate, and environmental performance under varying climatic conditions. Safety assessments included analysis of chemical composition, indoor air quality impact, and reported adverse health symptoms among users. The findings indicate significant differences in effectiveness and safety profiles among product categories and geographical regions. Synthetic repellents generally demonstrated higher repellency duration, while herbal formulations showed improved safety and environmental compatibility. The study highlights the importance of standardized evaluation protocols, regulatory oversight, and public awareness in promoting safe and effective mosquito control strategies. These findings may support policymakers, healthcare professionals, and manufacturers in improving mosquito repellent technologies and reducing the burden of mosquito-borne diseases globally.

Background: Chronic diseases and symptom syndromes often develop after prolonged biological changes that may precede formal diagnosis. RNA-based metatranscriptomics captures active microbial and human gene expression and may provide a functional layer for disease risk evaluation. To address this translational gap, we developed and validated a Disease Risk Score (DRS) framework that integrates metatranscriptome-derived pathway activity scores from stool, saliva, and blood samples, and evaluated its potential clinical utility as an adjunct risk-evaluation tool. Methods: DRS uses disease-specific sets of pathway activity scores derived from stool and saliva microbial functions, stool and saliva microbial taxa, and blood human gene expression. For each disease, 'not optimal' pathway scores are aggregated into a normalized cumulative odds ratio, or cOR, using score-level odds ratios, statistical significance, and literature-supported biological relevance derived from a Development Cohort of 22,369 individuals. A cOR [&ge;] 5 is defined as high risk. Performance is evaluated in an independent Validation Cohort of 15,908 individuals using self-reported diseases as the reference. Disease support requires both significant cOR separation between self-reported and not-reported (Cohen's d [&ge;] 0.2) and risk ratio enrichment of self-reported disease among individuals classified as high risk (95% CI of Risk Ratio > 1). Results: Of 20 initially evaluated diseases, 15 meet the prespecified validation criteria on the independent validation cohort: ADHD, anxiety, chronic fatigue syndrome, depression, GERD, hypertension, inflammatory bowel disease, IBS-C, IBS-D, insomnia, MASLD, obesity, obstructive sleep apnea, Sjogren's syndrome, and type 2 diabetes. Five selected clinical scenarios illustrate how DRS can support clinician-mediated decision making, including IBS subtype reclassification, improved diagnostic acceptance in IBS-D, personalized lifestyle counseling in MASLD and early type 2 diabetes, and diagnostic uncertainty in atypical GERD. Conclusions: DRS is a metatranscriptomics-based risk-stratification framework that aggregates active microbial and human pathway signals into interpretable disease-specific risk estimates across a wide range of disease conditions. Validation against self-reported disease labels in an independent cohort shows significant risk enrichment for each of 15 diseases. DRS is intended as an adjunct to clinical evaluation: a decision support tool in situations where routine care encounters uncertainty, delay, or low patient engagement. Future prospective studies using clinically adjudicated endpoints are needed to assess calibration and clinical outcomes.

Objective: To characterize pregnancy outcomes and menstrual irregularities in Mexican women with systemic lupus erythematosus (SLE) and identify clinical factors associated with adverse pregnancy outcomes and early-onset menopause. Methods: We conducted a cross-sectional study of women with SLE enrolled in the Mexican Lupus Registry (LupusRGMX) between May 2021 and September 2024. Clinical and reproductive data were collected using standardized questionnaires. Menopause was defined as the absence of menstruation for [&ge;]12 consecutive months, and early menopause as onset before age 40. Univariable and multivariable logistic regression analyses were used to identify factors associated with pregnancy complications and early menopause. Results: A total of 210 women were included. Median age was 38 years (IQR 29-46) and median disease duration was 4 years (IQR 1-10). Among women with a history of pregnancy (47%), full-term delivery predominated (61%), while pregnancy loss occurred in 26% and preterm delivery in 13%. Pregnancy complications were reported in 9.6%, most commonly preeclampsia (6.7%). Younger maternal age was independently associated with pregnancy complications (OR 0.89, 95% CI 0.83-0.95) and adverse outcomes (OR 0.95, 95% CI 0.92-0.98). Higher disease activity was associated with complications in univariable analysis. Most pregnancies (68.3%) occurred before diagnosis. Early menopause was observed in 6.2% and independently associated with longer disease duration and older age. Conclusion: Younger maternal age was independently associated with adverse pregnancy outcomes, whereas disease activity showed an association in univariable analysis. Most pregnancies occurred prior to SLE diagnosis. Early menopause was associated with longer disease duration, suggesting impact of cumulative disease burden on ovarian function.