Neurosurgery

Background: Vertebroplasty and balloon kyphoplasty are used for symptomatic vertebral hemangiomas, although comparative evidence is limited. We summarized pain relief, cement leakage, and recurrence after vertebral augmentation and assessed whether direct comparison of the two techniques was feasible. Methods: Five databases were searched from inception to January 2, 2026, with an update on July 5, 2026. Because only one small cohort directly compared vertebroplasty with kyphoplasty, outcomes were pooled as single-arm proportions or, for early pain change, as a mean difference using random-effects models. Prespecified subgroup, sensitivity, small-study effect, and influence analyses were performed. Results: Forty-four studies were included: 33 case series, 10 cohort studies, and one randomized trial. Kyphoplasty-specific evidence comprised one dedicated series and one comparative cohort. Any cement leakage occurred in 10.5% of patients (14 studies; 95% CI 5.7-18.4%), while trim-and-fill gave an exploratory adjusted estimate of 20.4%. Early pain reduction averaged 5.13 points on a 0-10 scale (8 studies; 95% CI 4.48-5.77; I2=89.4%). Complete or near-complete pain relief occurred in 79.4% of patients (10 studies), and recurrence, progression, or retreatment occurred in 3.9% (13 studies). Symptomatic cement leakage was uncommon at 0.4%. Conclusion: The available literature, which is mainly retrospective and vertebroplasty-based, supports substantial pain relief with infrequent symptomatic complications. Kyphoplasty data remain insufficient for a reliable technique comparison. Prospective studies with standardized clinical and imaging outcomes are needed.

Background: Aneurysmal subarachnoid haemorrhage (aSAH) is frequently complicated by delayed cerebral ischaemia (DCI), for which current therapies incompletely target the underlying multifactorial pathophysiology. Transauricular vagus nerve stimulation (taVNS) modulates inflammatory, vasoactive and autonomic pathways and may attenuate secondary brain injury after aSAH. Methods: We conducted a prospective, single-centre, single-blind, randomised, sham-controlled pilot trial in adults within 5 days of aneurysm securing for non-traumatic aSAH. Participants were allocated 1:1 to active taVNS (left tragus) or sham (left earlobe) using a portable device delivered for 45 minutes twice daily over 5 days. Primary outcomes were safety (taVNS-related serious adverse events), acceptability, and compliance; secondary outcomes included inflammatory biomarkers, DCI, in-hospital complications, and functional outcomes to 1 month. Results: Thirty patients were randomised (16 taVNS, 14 sham), with numerically more severe aSAH at baseline in the taVNS arm. No taVNS-related serious adverse events occurred; side effects were generally mild and transient, and over 80% of planned sessions were completed. TaVNS produced greater reductions in serum tumour necrosis factor- and trends towards reductions in interleukin-1{beta} and interleukin-10, with numerically fewer DCI events (6.6% vs 35.7%) and neurological impairments (16.7% vs 53.8%), although functional outcomes were not statistically different at 1 month. Conclusions: Early taVNS after aSAH is safe, acceptable, and feasible in the neurocritical care setting and shows biologically plausible signals warranting evaluation in larger multi-centre trials.

Background: Unruptured intracranial aneurysms (UIAs) are increasingly identified incidentally, and management balances rupture risk against treatment risk. UIA diagnosis has been linked to psychological distress, but psychotropic medication initiation after UIA discovery has not been compared across the full UIA management spectrum. Methods: We conducted a retrospective cohort study using IBM MarketScan claims (CCAE, MDCD, and MDCR; 2009-2023) among adults with a UIA diagnosis, continuous enrollment for 365 days before and after the index date, and no SAH/rupture on or before the index date. We compared the prevalence of 6 mental-health diagnoses before versus after UIA discovery and used adjusted logistic regression to examine psychotropic medication initiation within 365 days by management strategy (untreated observation as the reference). Results: Among 54,945 patients (untreated, 78.5%; endovascular, 11.3%; clipping, 3.0%; other/uncertain, 7.2%), prevalence of every mental-health diagnosis was higher after UIA discovery, most for depression (+4.6 percentage points) and anxiety (+4.5 points). Medication initiation was most common for benzodiazepines (8.7%). Endovascular treatment was associated with higher adjusted odds of benzodiazepine (aOR, 1.21), SSRI (aOR, 1.20), and sedative-hypnotic (aOR, 1.25) initiation.Surgical clipping demonstrated the broadest association, with higher odds across 5 of 6 classes, including benzodiazepines (aOR, 1.71) and sedative-hypnotics (aOR, 1.86). Benzodiazepines had the lowest 1-year persistence (10.5%) despite being the most commonly initiated class. Findings were consistent across sensitivity analyses, with the exception of the increase in panic disorder, which was no longer observed after applying a 30-day post-index lag. Conclusions: Mental-health diagnoses and psychotropic medication initiation increased after UIA discovery, and medication initiation was most pronounced among patients treated with surgical clipping. These findings support psychological assessment as part of aneurysm management regardless of strategy.

Background: Pain relief is the principal patient-centered goal of surgery for symptomatic lumbar synovial facet cysts, yet comparative reviews have often emphasized cyst recurrence. Whether adding fusion improves postoperative pain or reduces later surgery remains uncertain. Objective: To compare decompression alone with decompression plus fusion, with postoperative back- and leg-pain outcomes as the primary domain. Methods: PubMed, Embase, Scopus, Web of Science, and the Cochrane Library were searched from inception to 2 June 2026. Comparative cohorts and case series with at least five patients were eligible. Twenty-two studies were re-extracted for VAS/NRS scores, change scores, and persistent or recurrent pain. Random-effects restricted maximum likelihood models with Hartung-Knapp inference were used; clinically distinct pain outcomes were analyzed separately. Results: Twenty-two studies (16 cohorts, 6 case series; 51,899 participants) were included. Two studies provided compatible final VAS data. Fusion did not improve postoperative back pain (MD -0.04, 95% CI -0.17 to 0.10; I2=0%) or leg pain (MD -0.03, 95% CI -0.28 to 0.21; I2=0%). Postoperative back pain (RR 0.58, 95% CI 0.14-2.30) and leg/radicular symptoms (RR 0.75, 95% CI 0.42-1.32) were also not significantly reduced. Fusion decreased confirmed cyst recurrence (RR 0.29, 95% CI 0.15-0.57) but not reoperation or subsequent lumbar surgery (RR 0.80, 95% CI 0.42-1.50). Conclusion: Current comparative evidence does not demonstrate superior postoperative pain control with routine fusion. Fusion reduces cyst recurrence without clearly reducing reoperation, supporting selective use when instability is present or anticipated.

Objective: To evaluate decision concordance between commercially available multimodal large language models (LLMs), resident doctors, and senior-surgeon ground truth for surgical indication and spinal level in degenerative lumbar spine disease. Methods: We retrospectively analyzed 147 consecutive patients. Each case included clinical documentation and MRI presented as two composite PNG images. Two resident doctors and three multimodal LLMs (GPT 5.5, Claude Sonnet 4.6, Gemini 3.1 Pro) independently assessed operative versus conservative management and, if operative, the surgical level. Analyses used Cochran's Q, McNemar tests with Holm correction, and Bayesian methods. Results: LLMs achieved higher therapy-decision accuracy (66.0%-68.0%; 97-100/147) than residents (54.4%; 80/147) but over-recommended surgery. Conditional level accuracy when surgery was correctly indicated was 71.4% (20/28) for residents versus 33.3%-41.1% for LLMs. Conclusion: Off-the-shelf multimodal LLMs approximate human performance for binary surgical indication but remain inferior for precise level localization. These results establish a practice-relevant baseline of spatial reasoning limitations for tools already used by patients and junior doctors.

Background: Large language models have been proposed to improve patient comprehension of radiology reports. However, whether they improve objective understanding remains unproven. Purpose: To evaluate the effect of appending an LLM-generated lay summary to brain MRI reports on objective and subjective patient comprehension in a randomized controlled trial. Materials and Methods: In this randomized controlled trial, 2,727 adult participants from the ComPaRe e-cohort were randomly assigned to interpret six standardized brain MRI reports for headache, presented either in their native format (control; n = 1,401) or appended with a lay summary generated by an open-weights LLM (Mistral Small 3.2) (intervention; n = 1,326). The primary outcome was objective comprehension, defined as the rate of correct classification of whether the report provided a probable explanation for the headache, with ground truth established by four-radiologist consensus. Secondary outcomes included satisfaction, subjective comprehension, anxiety, and willingness to contact a healthcare professional. Generalized estimating equations accounted for repeated within-participant observations. Results: A total of 2,727 participants (mean age, 52 years +/- 15; 75.2% women) were evaluated. Objective comprehension did not differ between arms (58.3% vs 59.4%; odds ratio (OR) 0.97; 95% CI: 0.90-1.06; P = .54). The intervention significantly improved overall satisfaction (64.9% vs 36.7%; OR 3.26; 95% CI: 2.93-3.64; P < .001) and subjective comprehension (50.3% vs 24.0%; OR 3.17; 95% CI: 2.82-3.56; P < .001). High anxiety was modestly reduced (25.1% vs 26.6%; OR 0.92; P = .037). The effect on objective comprehension varied by report type (P for interaction < .001): summaries improved comprehension of symptom-explaining reports (42.4% vs 37.4%; P < .001) but reduced it for normal reports (72.5% vs 76.6%; P = .001). Conclusion: LLM-generated lay summaries appended to brain MRI reports improved patient satisfaction and subjective comprehension but did not improve objective comprehension, indicating a gap between perceived and actual understanding that should be addressed before clinical integration.

Background: Neuropathic pain (NP) remains a therapeutic challenge, with conventional repetitive transcranial magnetic stimulation (rTMS) of the primary motor cortex (M1) yielding a response rate of approximately 40%. Personalised targeting based on dysfunctional neurocircuitry offers a promising strategy to enhance efficacy, yet its application in NP is unexplored. This open-label trial investigated a novel targeting approach guided by the recently described cingulo-opercular and somato-cognitive action (CON-SCAN) network, a circuit integrating cognitive and affective dimensions of pain. Methods: Twenty patients with NP received 10 sessions of M1-rTMS over two weeks, with the stimulation site individually localised based on maximal functional connectivity to a CON template. Results: Increased CON-SCAN connectivity from baseline to post-treatment was associated with reduction in pain interference, anxiety and depression scores. The response rate was 50% post-treatment, which was maintained at the 1-month follow-up. Improvements were also observed in neuropathic pain symptoms, negative affect, and overall health. Conclusions: As the first connectivity-guided rTMS trial for NP, this study provides preliminary evidence that personalised targeting of the CON-SCAN network is feasible and associated with the analgesic effects of M1-rTMS, supporting further investigation in randomised controlled trials. Trial registration: Chinese Clinical Trial Registry, ChiCTR2500104679. Registered 20 June 2025, http://www.chictr.org.cn. Chinese Clinical Trial Registry, ChiCTR2400094568. Registered 24 December 2024, http://www.chictr.org.cn. Keywords: Personalised TMS; Pain; M1; CON; SCAN

IntroductionThe insula is an increasingly important target for functional neurosurgery given its involvement in a range of neurological and neuropsychiatric disorders, including epilepsy and chronic pain. As this practice evolves, optimal targeting will require standardized outcome measures that relate electrode or laser trajectory to postprocedural outcome. Traditional whole- brain registration approaches fail to capture the substantial person-to-person variability in insular gyral configuration, including the relative internal rotation of the insular gyri with respect to standard stereotactic space. ObjectiveWe propose and validate a stereotactic coordinate system based on local anatomical landmarks to facilitate surgical planning and standardized outcome assessment within the insular cortex. MethodsOur approach transforms brain MRI first into standard AC-PC space, and then into an insular-specific space defined by five anatomical landmarks: four points along the central sulcus of the insula and one point at the middle cerebral artery (MCA) bifurcation (at the limen insulae). The system calculates two angles - {theta} (axial) and {varphi} (sagittal) - between the AC-PC line and the insular axis, and the brain volume undergoes sequential rotation through these angles followed by translation to place the coordinate systems origin along the insular axis. ResultsIn a sample of 32 patients, the angle between the AC-PC line and the insular axis ranged from -17{degrees} to 17{degrees} in the axial plane ({theta}) and 31{degrees} to 69{degrees} in the sagittal plane ({varphi}). In the resulting coordinate system, the insular axis defines z = 0 and the MCA turning point defines y = 0. We developed a custom, open-access MATLAB graphical interface that allows intuitive implementation of this system for both surgical planning and postoperative analysis; implanted electrodes, laser fiber position, and ablation geometry can each be localized within this common space. As a demonstration of its utility for pooling data across subjects, we applied the transformation to a previously acquired intracranial electrophysiology dataset and found that anatomically consistent, effector-specific motor representations emerged across 18 subjects once electrode positions were expressed in insular-specific coordinates. ConclusionAs stereotactic surgery for insular targets becomes more common with expanding scientific inquiry, an insular-specific coordinate system may facilitate operative planning and functional mapping, and may help standardize outcome assessment across patients and institutions. SIGNIFICANCE STATEMENTThe insular cortex represents an increasingly important surgical target for therapeutic interventions, yet substantial person-to-person anatomical variability hampers standardized targeting and outcome comparison. The insula is simultaneously the subject of expanding scientific inquiry -- into interoception, pain, autonomic regulation, salience processing, and sensorimotor representation -- much of it now pursued through intracranial recording and stimulation in humans, where cohorts are small, electrode sampling is idiosyncratic, and progress therefore depends on pooling data across patients in a frame that respects insular gyral architecture. We present "Insulotaxy," a stereotactic coordinate system built from consistent, easily identifiable local anatomical landmarks that accounts for the insulas unique rotational relationship to standard brain coordinates. An open-source MATLAB tool transforms imaging into insular-specific coordinates, facilitating surgical planning for ablation and electrode placement while enabling standardized outcome reporting across institutions. By providing locally anchored, anatomically aligned coordinates rather than relying on whole-brain registration, this framework addresses a practical gap in functional neurosurgery and lays a foundation for pooling clinical and electrophysiological data as insular interventions become more prevalent.

Gaps remain in the evidence base for postoperative management following forefoot surgery. A recent randomized controlled trial (ClinicalTrials.gov NCT04927234) demonstrated improved outcomes with intermittent one Hertz (Hz) neuromuscular electrical stimulation (NMES) of the common peroneal nerve. This sub-analysis evaluates its effect in patients undergoing forefoot surgery. Forty-two patients undergoing forefoot procedures were included; 26 received NMES plus standard of care (SOC) and 16 received SOC alone. Wound healing was assessed at 14 days. Edema was measured using the figure-of-eight (FO8) method. Patient-reported outcomes were assessed using the Manchester-Oxford Foot Questionnaire (MOXFQ). At 14 days, complete wound healing occurred in 77% of patients receiving NMES plus SOC compared with 40% in the SOC group (p<0.05). Edema reduction was significantly greater in the NMES group, with a 74% relative reduction compared with SOC (p=0.02). Intermittent one Hz NMES of the common peroneal nerve was associated with improved wound healing and reduced postoperative edema following forefoot surgery.

Optimal blood pressure management after thrombectomy remains uncertain, and individualized autoregulation-based targets typically require continuous neuromonitoring. We developed an angiography-derived autoregulatory metric using intraprocedural data and applied it retrospectively to a single-center cohort of patients who underwent thrombectomy for acute stroke. From 62 patients with 3-month functional outcomes, greater time within the predicted autoregulatory range during the first 24 hours after thrombectomy was independently associated with improved outcome after adjustment for covariates (odds ratio per 10% increase, 1.86; 95% CI, 1.31-2.66; P = .0006). These findings support routine angiography as a potential source of early, patient-specific hemodynamic targets after thrombectomy.

Background: Evidence regarding delayed cerebral ischemia (DCI) after aneurysmal subarachnoid hemorrhage (aSAH) remains sparse. We aimed to identify its predictors and occurrence and evaluate its role in ischemic stroke and functional outcome under treatment with interventional rescue therapy (IRT). Methods: This retrospective single-center study included 628 adults with aSAH from 2014?2023. The primary endpoint was occurrence of refractory DCI (= refractory despite induced hypertension) treated with at least one IRT. Multivariable models evaluated refractory DCI, new ischemic stroke, and poor functional outcome (mRS 3?6) at 6?12 months. Results: Among 628 included patients, 61 who died within 3 days were excluded from DCI analysis; 166/567 (29%) developed refractory DCI. Younger age (OR = 0.98; P<0.001), female sex (OR = 0.57; P=0.007), and higher WFNS grade (OR = 1.18; P=0.011) were independently associated with refractory DCI. Earlier first IRT was associated with longer DCI duration (IRR = 0.88; P<0.001) and more required IRTs (IRR = 0.91; P<0.001). IRT was performed later than day 14 in 29/166 patients (17.5%); none was older than 70 years. Refractory DCI was associated with new ischemic stroke (OR = 4.68; P<0.001) and poor functional outcome (OR = 2.37; P<0.001); earlier first IRT was associated with poor outcome within the refractory DCI subgroup (OR = 0.86; P=0.03). Outcomes after 1?2 IRTs did not differ from those without refractory DCI (P=0.4), whereas ?3 IRTs were associated with poor outcome (P=0.04). Conclusions: Refractory DCI affected 29% of aSAH patients, predominantly younger women and patients with poorer initial neurological status, and extended beyond day 14 in nearly 20% of affected patients, none of whom was older than 70 years. Refractory DCI and earlier onset were associated with poorer radiological and functional outcomes. The absence of a detected outcome difference after 1?2 IRTs suggests that favorable outcomes may remain achievable despite refractory DCI.

Background Cervical spondylotic myelopathy (CSM) is the most common cause of nontraumatic spinal cord dysfunction in adults. For mild disease, guidelines recommend shared decision-making between surgery and structured rehabilitation on the basis of clinical equipoise, yet no comparative effectiveness study has reported outcomes in this population. Whether a randomized trial is feasible is unknown. Methods We conducted two cross-sectional surveys between December 2025 and July 2026: one of patients with surgeon-confirmed CSM recruited from academic outpatient spine clinics, and one of practicing neurosurgical and orthopedic spine surgeons. Respondents rated willingness to participate in (1) a randomized trial of early surgery versus observation and (2) a prospective observational study in which treatment was patient-selected. Responses of likely or very likely were classified as willing. Groups were compared using Fisher exact tests, designs within respondents using exact McNemar tests, and predictors using univariable logistic regression. Results Fifty-four patients and 52 surgeons completed the surveys. Patients were markedly less willing than surgeons to accept randomization (15 of 54, 27.8% versus 44 of 52, 84.6%; p < 0.001). Both groups accepted the observational design (39 of 54, 72.2% versus 51 of 52, 98.1%; p < 0.001), and 26 of 39 patients unwilling to be randomized were willing to enroll in an observational study (p < 0.001). Willingness to be randomized did not differ across mJOA severity (mild 30.4%, moderate 25.0%, severe 27.3%; p = 0.93). Among patients declining randomization, 85.2% cited a wish to retain control over treatment, whereas fear of surgery was cited by one respondent. Forty-five surgeons (86.5%) considered both surgery and observation reasonable, and preference was divided (46.2% favoring early surgery, 48.1% favoring initial observation). Conclusions Surgeons report equipoise and high willingness to randomize, but most patients would decline random allocation, citing a wish to retain treatment choice rather than fear or distrust. A prospective observational study appears the more feasible route to comparative evidence in mild CSM. Feasibility assessments restricted to clinicians may substantially overestimate attainable accrual.

Background. Guidelines recommend surgery for moderate and severe cervical spondylotic myelopathy (CSM) but support either surgery or nonoperative care for mild disease. How patients weigh the adverse events associated with each pathway is not well characterized. Methods. We conducted a three-arm randomized vignette experiment among United States adults aged 40 years and older recruited through an online research panel. All participants read an identical description of mild CSM and were randomized to one of three scenarios: surgery that improved symptoms, surgery that halted progression without improvement, or nonoperative management with symptom progression. Participants in the surgical scenarios rated 12 possible complications and those in the nonoperative scenario rated 8 progression outcomes. For each item, participants rated how strongly it would influence their decision (0-10) and whether they would still choose the same treatment. Items for which participants would no longer choose the same treatment were termed dominant decision factors. Results. Of 276 respondents, 263 (95.2%) were analyzed. Dominant factor rates ranged from 13.5% to 87.8% across complications. Complications described as persisting at one year produced substantially higher rates than the same complications described as resolving by three months. Adverse events more frequently constituted dominant factors when surgery was framed as offering less benefit, although differences between scenarios were not statistically significant. In the nonoperative scenario, worsening bladder control (56.6%) and neck pain interfering with sleep (53.0%) were the strongest influences, exceeding needing a cane to walk (32.1%). Conclusions. Treatment decisions for mild CSM are driven primarily by the expected permanence of adverse events and their anticipated impact on daily quality of life, rather than by conventional neurological metrics or surgical benefit framing.

The subgenual anterior cingulate cortex (sgACC) is a key node in treatment-resistant depression (TRD), but precise non-invasive neuromodulation of this target is challenging. Preclinical studies of non-ablative stereotactic radiosurgery (SRS) have shown neuromodulatory ("radiomodulation") effects. In this single-center, double-masked, randomized, dose-seeking pilot trial, nine adults with TRD were randomly assigned to bilateral sgACC radiomodulation at a dose of either 15, 20, or 25 Gy per hemispheric target. Primary endpoints were safety and feasibility; the efficacy endpoint was week-4 change in the Montgomery-Asberg Depression Rating Scale (MADRS). Both primary endpoints were met: the only treatment-related adverse event was transient grade 1 dizziness, with no structural MRI abnormality through week 12. Mean MADRS fell from 33.0 to 17.0 (48.5% reduction); 67% responded and 44% remitted, with benefit sustained to week 12. Resting-state fMRI revealed regional connectivity changes correlating with clinical improvement, with tractography showing streamline counts differing by response status. These first-in-human findings support a larger randomized controlled trial of sgACC radiomodulation for TRD. ClinicalTrial.gov registration: NCT07274917.

Background and Objectives: Recurrence following burr-hole drainage of chronic subdural haematoma (cSDH) occurs in 10-25% of cases, sustained by neovascularisation of the subdural neomembrane supplied by the middle meningeal artery (MMA). MMA embolisation reduces recurrence; whether incidental burr-hole intersection of MMA branches during drainage confers similar benefit is unknown. Methods: We performed a multicentre retrospective cohort study of consecutive adults undergoing burr-hole drainage for cSDH at two UK tertiary neurosurgical centres. Postoperative thin-slice CT was used to classify burr-hole intersection of the underlying MMA groove (no hit, distal-branch hit or main-branch hit) and measure perpendicular burr-hole-to-MMA-groove distance. Co-primary outcomes were radiological recurrence and recurrence requiring intervention. Patient-clustered multivariable logistic regression adjusted for prespecified clinical covariates and treating site. Results: 227 patients (284 operated hemispheres) were included. Radiological recurrence decreased from 34.4% with no branch hit to 22.9% with main-branch intersection, with the gradient confined predominantly to unilateral cSDH. Main-branch intersection was associated with lower adjusted odds of radiological recurrence in unilateral cSDH (adjusted OR 0.30, 95% CI 0.11- 0.81; P = .018), with a similar but non-significant association in the overall cohort (adjusted OR 0.53, 95% CI 0.26-1.07; P = .075). Burr-hole-to-MMA-groove distance demonstrated a more consistent association: in the overall cohort, each 5-mm increase independently increased the odds of radiological recurrence (adjusted OR 1.38, 95% CI 1.04-1.82; P = .025). In unilateral cSDH, each 5-mm increase was independently associated with both radiological recurrence (adjusted OR 1.45, 95% CI 1.03-2.04; P = .034) and recurrence requiring intervention (adjusted OR 1.52, 95% CI 1.05-2.20; P = .027). Conclusion: Main-branch intersection of the middle meningeal artery during routine burr-hole surgery is associated with lower recurrence of unilateral cSDH, while the accompanying burr-hole-to-MMA-groove distance gradient provides biologically plausible support for a dose-response relationship. Together, these findings provide mechanistic rationale for prospective evaluation of intentional neuronavigation-guided MMA targeting (BURR-MMA; NCT07549893).

Introduction Post stroke dysphagia is common, associated with poor functional outcome and lacks treatment strategies beyond behaviour therapies delivered by speech & language therapists. Here, we present the statistical analysis plan for the ongoing pharyngeal electrical stimulation for acute stroke dysphagia trial (PhEAST). PES is a candidate treatment for dysphagia present in non-ventilated stroke patients. Methods PhEAST is an investigator-initiated international prospective randomised open-label blinded-endpoint phase-4 superiority trial involving 650 participants with tube-dependent post-stroke dysphagia. Consenting patients are randomised to PES versus no PES given on top of standard care with PES given daily for 6 days. The primary outcome is the dysphagia severity rating scale (DSRS), a measure of swallowing impairment, made at days 14 and 90 and analysed using repeated measures regression. Conclusion We present the statistical analysis plan for the main analyses based on data up to day 90 along with planned secondary analyses including presentation of baseline data, health economics, cognition and extended follow-up to 12 months.

Objectives: Non-invasive brain stimulation (NIBS) holds significant promise for treating neurological and neuropsychiatric conditions, yet translation into routine clinical practice remains limited. We aimed to explore stakeholder perceptions of NIBS and barriers to its clinical adoption. Methods: We conducted focus-group interviews with 33 participants across three key stakeholder groups in the UK: (1) people with lived experience of brain injury, depression, or dementia; (2) healthcare professionals; and (3) researchers. Reflexive thematic analysis was used to identify themes in the data. Findings: Seven key themes emerged spanning preferences, hope and disappointment, communication, accessibility, infrastructure, ethical/regulatory uncertainty, and the evidence base. Across groups, NIBS was viewed positively and with cautious optimism, but substantial barriers were highlighted, including limited public and clinical awareness, challenges in demonstrating cost-effectiveness, infrastructure constraints, and difficulties navigating regulatory and translational pathways. Participants emphasised the importance of clear communication, improved education, and stronger interdisciplinary collaboration to support adoption. Notably, stakeholders prioritised evidence of clinical efficacy and usability over detailed mechanistic understanding. Conclusions: These findings provide actionable insights into the translational gap in NIBS and highlight priorities for facilitating its integration into clinical care.

Background: Low-frequency repetitive transcranial magnetic stimulation (LF-rTMS) over the contralesional primary motor cortex is widely used for post-stroke upper-limb rehabilitation, but treatment response varies substantially. This systematic review and meta-analysis aimed to quantify the efficacy of contralesional LF-rTMS and to examine whether baseline motor impairment severity and corticospinal tract (CST) integrity modify treatment effects. Methods: We searched seven databases from inception to July 2026 for randomized controlled trials of contralesional LF-rTMS ([&le;]1 Hz) versus sham after stroke, with comparable rehabilitation in both arms. The primary outcome was the change in Fugl-Meyer Assessment for the upper extremity (FMA-UE) scores. Random-effects meta-analysis used restricted maximum likelihood estimation with Knapp-Hartung adjustment. Effect modification was examined through meta-regression and biomarker-stratified analyses, and neurophysiological outcomes were also synthesized. Results: Thirty trials (33 comparisons, 1,668 participants) were included. LF-rTMS produced greater FMA-UE improvement than sham (mean difference 4.11 points, 95% CI 2.83-5.39; Hedges g 0.64, 95% CI 0.45-0.84), with substantial heterogeneity. Baseline severity did not significantly modify the effect in continuous meta-regression. However, exploratory within-trial biomarker-stratified analyses suggested larger effects in participants with preserved CST integrity or positive motor-evoked potential (MEP) status. LF-rTMS also shortened MEP latency and central motor conduction time, but these measures could not be validated as surrogate endpoints. Conclusions: Contralesional LF-rTMS provides a statistically significant but modest improvement in post-stroke upper-limb motor recovery. Baseline clinical severity alone may not identify responders, whereas CST integrity is an exploratory, hypothesis-generating candidate biomarker. It requires confirmation in adequately powered biomarker-stratified trials before it can inform clinical decisions. Trial Registration The study was registered with the International Prospective Register of Systematic Reviews (PROSPERO: CRD420261441561).

ObjectiveTo establish a standardized training program for endoscopic pathogen visualization literacy (EPVL) based on fluorescence rapid on-site evaluation (ROSE) technology for gastroenterologists, and to evaluate its training efficacy. MethodsA prospective quasi-experimental study was conducted. A total of 54 gastroenterology trainees were non-randomly allocated into the EPVL training group (Group A, n=28, 16-hour comprehensive training) and the control group (Group B, n=26, 3.5-hour traditional teaching). Pre- and post-training assessments included theoretical examinations, fluorescence ROSE image interpretation tests (30 parallel images per set), interpretation speed measurement, and clinical decision-making integration evaluation. The primary outcome was the change in image interpretation accuracy, analyzed by ANCOVA with pre-test scores as the covariate. ResultsBaseline characteristics were comparable between groups (P>0.05 for all demographic variables and pre-test scores). Group A showed significant improvement in image interpretation accuracy from 57.8{+/-}13.6% pre-training to 82.5{+/-}11.2% post-training (improvement of 24.7%, paired t=-12.86, P<0.001), while Group B improved from 58.5{+/-}13.0% to 71.0{+/-}13.5% (improvement of 12.5%, paired t=-5.24, P<0.001). After ANCOVA adjustment for pre-test scores, the between-group difference was significant (F(1, 51)=10.95, P=0.0017, 2=0.177), with Cohens d=0.94 (large effect size). Interpretation speed in Group A (19.2{+/-}2.8 s/image) was significantly faster than in Group B (32.5{+/-}6.0 s/image, t=-10.45, P<0.001). Clinical decision-making scores were significantly higher in Group A (80.5{+/-}8.0 vs. 65.3{+/-}11.5, t=5.60, P<0.001). The Kappa agreement with the gold standard in Group A improved from 0.56{+/-}0.18 to 0.84{+/-}0.11 (t=-8.35, P<0.001). Participant satisfaction exceeded 88%. ConclusionThe EPVL training program significantly improves gastroenterologists fluorescence ROSE image interpretation accuracy, speed, and clinical decision-making integration, providing a novel and effective standardized training paradigm for digestive endoscopy education.

Background. A primary constraint on the capacity of EMS programs to meet industry demand is psychomotor instruction and verification, requiring direct observation of each student by a qualified evaluator. Whether AI video analysis can relieve it is untested; none has been applied to EMS skill examination or compared with human examiners. Objective. To quantify human EMS evaluator inter-rater reliability and evaluate an AI video-analysis platform against it. Methods. In a prospective, fully crossed study, five certified EMS evaluators and an AI platform independently scored identical video-recorded EMT performances of cervical collar application (n=15), bag-valve-mask (BVM) ventilation (n=14), and medical assessment (n=15) on dichotomous checklists with critical-failure criteria. Agreement was assessed at item, score, and decision levels using Fleiss' kappa, Krippendorff's alpha, Gwet's AC1, and ICC(2,1)/ICC(2,k). Results. Human item agreement was moderate (kappa 0.409 to 0.467), as was single-rater reliability (ICC(2,1) 0.539 to 0.694), against good panel reliability (ICC(2,k) 0.854 to 0.919). Recorded pass/fail agreement was fair (kappa 0.297 to 0.388) and critical-failure agreement near zero for two skills (kappa 0.028, 0.119). AI alignment tracked rubric observability rather than task complexity: r = 0.857 (collar, exceeding every human), -0.173 (BVM), 0.664 (medical), and it was most lenient on two skills. Conclusions. Human evaluators are an imperfect standard, especially on critical failures. The AI was a legitimate additional rater where checklist items were discrete and visually verifiable, but not where credit required judging continuous quantities such as ventilation rate, volume, or suction duration. Defensible uses are formative and archival, not summative. These results reflect an early, non-specialist configuration: a baseline, not a limit.