The Journal of Pain

Deficient descending pain inhibition assessed by conditioned pain modulation (CPM) is considered a common feature of various chronic pain disorders. Typically, CPM studies focus on one particular disorder making direct comparisons between disorders difficult. This cross-sectional study aimed to compare CPM effects between three clearly distinct chronic pain disorders and pain-free controls. Furthermore, patients were pooled with controls to explore whether subgroups showing different CPM effects could be separated independent of cohort membership. One hundred and forty participants (patients: 53 non-specific chronic low back pain [nsCLBP], 15 complex regional pain syndrome [CRPS], 14 neuropathic pain after spinal cord injury [painSCI]; 58 controls) were included. CPM effects were assessed in a remote, pain-free area using pressure pain thresholds as test stimulus and a cold water bath as conditioning stimulus. Cohort differences in CPM effects were analyzed using linear mixed models. The presence of subgroups showing different CPM effects was tested using latent class linear mixed models. CPM effects differed between cohorts (p = 0.011), driven mainly by reduced inhibitory CPM effects in patients with nsCLBP compared to patients with painSCI. Latent class analysis detected 3 subgroups with varying degrees of significant inhibitory CPM effects (p's [≤] 0.002). All subgroups comprised patients and controls. These results oppose deficient descending pain inhibition as a common feature of chronic pain disorders. Additionally, the failure to identify subgroups without inhibitory CPM effects within a heterogenous patient/control sample challenges the utility of deficient CPM as predictor of chronic pain or treatment efficacy.

Pain is the leading cause of disability worldwide, yet no population-based reference exists against which individual cohorts, clinical populations, or countries can be benchmarked. Here, we harmonised individual-level self-reported pain data from 6,075,021 participants across 894 population-based data sources in 118 countries to establish global reference trajectories of pain across the lifespan, implemented in an open-access benchmarking platform. Pain prevalence ranged from 2.5% for facial pain to 45.0% for back pain, was consistently higher in women across all eleven anatomical sites (risk ratio range 1.09 to 1.83), and increased most steeply before age 55 years. Contrary to existing estimates that generally project higher prevalence of pain conditions in higher Human Development Index (HDI) regions, we found that individuals in the lowest HDI countries experienced nearly twice the late-life prevalence of any bodily pain compared with those in the highest (risk difference 31.8 percentage points). Globally, 18.3% of site-specific pain burden was attributable to three modifiable risk factors (smoking, obesity, and low income) but this varied from 12.6% in sub-Saharan Africa to 27.1% in eastern Europe, indicating that the drivers of pain in lower-HDI settings remain poorly characterised.

Background: Non-steroidal anti-inflammatory drugs (NSAIDs) and weak opioids such as tramadol are cornerstones of multimodal analgesia, particularly in settings with limited access to potent opioids. However, cross-class equianalgesic data comparing these agents remain scarce. This pilot randomised controlled trial aimed to explore the analgesic equivalence of ketorolac, diclofenac, and tramadol administered as premedication in patients undergoing minimally invasive surgery. Methods: In this double-blind, parallel-group pilot trial, 30 patients scheduled for elective minimally invasive surgery (28 laparoscopic cholecystectomies, 2 laparoscopic abdominal wall repairs) under balanced general anaesthesia were randomised to receive intravenous tramadol 150 mg, ketorolac 60 mg, or diclofenac 150 mg 45 minutes before skin incision. The primary outcome was pain intensity measured using the Numerical Rating Scale (NRS, 0-10) at recovery room arrival (T0) and at 30 (T1), 60 (T2), and 90 (T3) minutes thereafter. Secondary outcomes included Verbal Rating Scale (VRS) scores, rescue morphine consumption, and safety. Between-group comparisons were performed using Kruskal-Wallis tests with Dunn post-hoc corrections; within-group trajectories were analysed using Friedman tests. Effect sizes were estimated with epsilon-squared and Kendall's W. Results: All 30 patients completed the study. At T0 and T1, NRS scores were higher in the ketorolac group (median 1.5 and 3, respectively) compared with tramadol and diclofenac (both median 0 at T0; T1: tramadol 1, diclofenac 2; p < 0.05 for both). However, by T2 and T3, all three groups converged to a median NRS of 2 (p > 0.05 for between-group differences). Rescue analgesia requirements at T1 were 0/10 (tramadol), 3/10 (ketorolac), and 2/10 (diclofenac), with no statistically significant differences (p = 0.19). No hypersensitivity reactions occurred. Within-group analyses showed consistent pain trajectories, with Kendall's W ranging from 0.31 (ketorolac) to 0.64 (tramadol). Conclusions: In this pilot study, equianalgesic doses of tramadol, ketorolac, and diclofenac provided comparable postoperative pain control over 90 minutes following minimally invasive surgery. All agents were well tolerated. These findings support the feasibility of a larger definitive trial and offer clinically useful guidance for analgesic selection in resource-limited settings. Keywords: Analgesic equivalence, NSAIDs, tramadol, ketorolac, diclofenac, postoperative pain, minimally invasive surgery, pilot randomised controlled trial

ABSTRACT Objectives: To explore patients' and physiotherapists' perspectives on a snack-based physical activity (PA) approach and mobile health technologies (mHealth) for non-specific chronic low back pain (NSCLBP). Snack-based PA refers to short, frequent bouts of activity (2-5 minutes) integrated into daily routines. Design: Qualitative study using Interpretative Phenomenological Analysis (IPA) of semi-structured online interviews. Setting: Community-based recruitment in the United Kingdom. Interviews were conducted online via Microsoft Teams between May and November 2024. Participants: Sixteen participants were purposively sampled: eight adults with NSCLBP (lasting >=3 months in the previous year) and eight physiotherapists with >=2 years' experience managing people with NSCLBP. Results: Three shared themes were identified across both groups: (1) understanding the needs and requirements of PA; (2) perceptions of snack-based activity; and (3) factors influencing mobile health application use. Five subthemes were identified within themes one and three, together with two additional subthemes reported only by patients, relating to data sharing and technical issues. Both groups valued the time-efficiency and practical integration of snack-based activity, while highlighting the need for personalisation, age-appropriate content, accessibility and affordability. Conclusions: Physiotherapists and patients emphasised the potential value of the snack-based PA approach in terms of adherence. However, both groups agreed that future intervention development should prioritise personalisation, user-friendly design, and equitable digital access. Keywords: Low Back Pain; Chronic Pain; Exercise; Physical Activity; Qualitative Research; Mobile Applications; Telemedicine; Patient Compliance; Physical Therapists; Snack-based Physical Activity.

T-cells infiltrate somatosensory ganglia in response to nerve damage, autoimmune disease, and infection, contributing to sensory abnormalities and pain. In naive states, T-cells are rare in the rodent dorsal root ganglion (DRG) but have been reported in human and non-human primates without known relevant exposures. It remains unclear whether there are inherent evolutionary or species differences in DRG T-cell residence. Using a comparative biology approach, we investigated the frequency and distribution of T-cells in the mammalian DRG across humans, non-human primates, pigs, and rodents, and in humans investigated the contributions of sex and age. Spatial transcriptomics and immunofluorescence independently verified the robust presence of DRG T-cells at similar levels in humans, non-human primates, and pigs, but were fewer in rats and largely absent in mice. In humans, premenopausal females were more likely to have elevated DRG endoneurial T-cells than post-menopausal females or adult males. T-cells were detected in human dorsal root ganglion at as early as two months of age but were less abundant within the perineuronal niche. Most human DRG T-cells expressed distinct markers consistent with a resident memory (Trm) phenotype. We discuss the importance of studying the functional roles of DRG-resident T-cells and raise broader considerations for modelling peripheral nervous system disease.

Importance: The rapid rise of online sports gambling in the U.S. has been associated with financial harms, raising concern that it may adversely affect population mental health. Objective: To estimate the causal effect of state legalization of online sports gambling on population mental health, including a range of self-reported and registry-based outcomes. Design, Setting, and Participants: Repeated cross-sectional study using nationally representative Behavioral Risk Factor Surveillance System (BRFSS) data from 2014-2025 and registry-based mortality records from 2012-2024. We leveraged state-level variation in the legalization of online sports gambling and applied a stacked difference-in-differences with event study design. The analytic sample included 4,660,948 BRFSS respondents and mortality records for virtually all state-years. We estimated effects on all adults and several higher-risk subgroups, including men, young men, and men with lower educational attainment. Exposure: State legalization of online sports gambling. Main Outcomes and Measures: Self-reported outcomes included poor mental health days, depressive disorder diagnoses, ever binge drinking, number of binge drinking episodes, and marijuana use. Registry-based outcomes included suicide mortality and alcohol-induced mortality per 100,000. Results: Among 4,660,948 BRFSS respondents, 48.7% were men, 40.2% had no more than a high school education, and the mean age was 47.6 years. Legalization of online sports gambling had no discernible effect on poor mental health days of all U.S. adults (-0.01 days; 95% CI, -0.16 to 0.14; P=0.88), depressive disorder diagnoses (0.1 percentage points; 95% CI, -0.7 to 0.9; P=0.84), binge drinking, binge drinking episodes, or marijuana use. Meanwhile, mean suicide mortality was 14.1 per 100,000 and mean alcohol-induced mortality was 12.2 per 100,000. Legalization did not affect adult suicides (0.13 deaths per 100,000; 95% CI, -0.71 to 0.97; P=0.76) or alcohol-induced mortality (1.08 deaths per 100,000; 95% CI, -0.58 to 2.73; P=0.21). Results were null among men and higher-risk subgroups of men. Conclusions and Relevance: The legalization of online sports gambling has not produce detectable population-level changes in a range of mental health outcomes, including reported symptoms, diagnoses, substance use, and registry-based mortality due to suicide or alcohol, in up to 3 years of follow-up. These findings suggest that although online sports gambling may cause financial harm and severe distress for some individuals, legalization has not produced measurable average changes in population mental health over the observed follow-up period.

Background: Tryptophan (Trp) metabolism is a central immunometabolic axis in inflammatory bowel disease (IBD), yet its clinical utility unclear. We aimed to identify biologically and clinically relevant Trp-related metabolic subtypes (metabotypes) in IBD and assess their association with disease activity, outcomes, and early pathogenesis. Methods: We applied unsupervised clustering to 16 serum Trp-related metabolites in a discovery cohort of IBD patients undergoing biologic induction (52 Crohns disease [CD], 82 ulcerative colitis [UC]). The resulting metabotypes were validated in three independent IBD cohorts (Suivitheque: 788 CD, 281 UC, 50 non-IBD; MSCCR: 470 CD, 374 UC, 329 non-IBD; Ibsen III: 179 CD, 340 UC, 26 IBD-U, 209 symptomatic non-IBD controls), a healthy reference population, and a prospective pre-disease cohort of CD relatives. Associations with clinical indices, outcomes, and metabolic pathway shifts were assessed using multivariable models and pathway enrichment analysis. Results: Four reproducible metabotypes were identified and are described based on dominant metabolites in their metabolite profiles Low Kynureninic acid (Kyna), High Kyna, High Quinolinic acid (Quin), and Balanced. Low Kyna and High Quin were associated with elevated disease activity across all cohorts, yet exhibited differential metabolic perturbations when assessed by pathway enrichment analysis. A pre-disease cluster resembling Low Kyna and High Quin was enriched for inflammatory markers and future CD diagnosis. Conclusion: Trp-linked metabotypes define distinct immunometabolic states in IBD that associate with inflammation and may precede disease onset. These findings provide a framework for metabolic stratification in mechanistic studies and clinical trials targeting nutrient pathways.

Serotonergic psychedelics induce altered states of consciousness characterised by profound changes in emotional experience. Although psychedelics modulate autonomic arousal, sympathetic engagement during their affective effects remains poorly characterised. We recorded cardiac, electrodermal, and respiratory activity in 19 participants following inhalation of 20 or 40 mg of freebase N,N-dimethyltryptamine (DMT) under a semi-naturalistic blinded design, alongside time-resolved retrospective phenomenological reports. DMT induced robust increases across all autonomic markers, integrated into a multimodal index that selectively tracked subjective emotional intensity. Dose-dependent divergence followed modality-specific profiles: heart rate and respiratory differences emerged within the first 2 min post-inhalation, whereas electrodermal activity diverged only during the later phase, with higher doses showing prolonged autonomic engagement. DMT thus produces a transient sympathetic activation co-varying with emotional arousal, followed by gradual disengagement accompanied by pleasantness and bliss. By combining time- and cost-effective peripheral physiological measures with time-resolved phenomenological reports, this work contributes to the objective characterisation of psychedelic-induced affective states and provides a methodological basis for future biomarker research in clinical applications.

ImportanceRecovery after upper extremity peripheral nerve injury (PNI) surgery depends on changes in cortical neural patterns that support sensorimotor control. Task-based functional connectivity (FC) can characterize these changes, yet few studies have explored FC during ecologically fine motor valid tasks after PNI. ObjectiveTo investigate task-based FC with the left primary motor cortex (M1) during right hand drawing in individuals following right hand PNI surgery. ParticipantsForty-four right-handed adults, including 12 patients post PNI surgery (n = 8 with nerve repair, n = 4 with nerve transfer) and 32 healthy controls. MethodsAll participants underwent fMRI while performing a RH visuomotor precision drawing task. Seed-based connectivity analysis was performed to characterize the pattern of FC between left M1 and all voxels in the brain. We hypothesized that left M1 FC would differ between patients and controls, between Repair and Transfer groups, and covary with time since surgery. ResultsPatients (vs. controls) showed greater FC between left M1 and right visual and premotor cortices. Nerve transfer (vs. repair) showed greater FC between left M1 and right inferior parietal areas. Time since surgery was not linearly related to FC, though exploratory analyses suggested a negative association between log-time and FC between left M1 and right inferior parietal lobule. ConclusionAfter PNI surgery, visuomotor precision drawing involved distinct and behaviorally relevant neural patterns, which varied by task demand and potentially by surgical group despite clinical heterogeneity. Inferior parietal cortex may be especially engaged in early months after surgery (i.e. log-time). To improve recovery of upper limb function after PNI, clinical recommendations include incorporating early function-specific dexterous training, tailoring rehabilitation across surgical and recovery stages, and using multidimensional assessments of hand function.

Abstract Background: This study evaluated the safety and efficacy of primary resection and anastomosis (PRA) for colovesical fistula (CVF) of diverse etiologies and identified independent prognostic factors for oncological outcomes. Methods: We retrospectively analyzed 112 CVF patients (2017-2024) undergoing PRA with or without a defunctioning stoma, comparing clinical outcomes across benign and malignant cohorts. Results: Benign etiologies accounted for 33.0% (n=37) (colonic diverticulitis (n=19, 51.4%), Crohn's disease (n=14, 37.8%), and iatrogenic injury (n=4, 10.8%)), all underwent PRA with partial cystectomy, achieving zero mortality and no recurrence. Malignancies (67.0%) primarily included colorectal adenocarcinoma (sigmoid colon cancer (n=44, 58.7%) or rectal cancer (n=31, 41.3%)). Within the malignant cohort, radical cystectomy (n=15) was strictly necessitated by advanced disease features, including distal tumor location and extensive bladder wall invasion (80.0% vs 36.7%, P=0.003). Consequently, this advanced cohort experienced longer operative times (589 vs. 289 min), higher blood loss (600 vs. 100 mL), increased morbidity (80.0% vs. 20.0%, P<0.001), and shorter disease-free survival (DFS) (8 vs. 20 months, P=0.008) compared to those amenable to partial cystectomy (n=60). Crucially, multivariate analysis identified perineural invasion (PNI) (HR: 3.83, 95% CI: 1.49-9.84; P=0.005) as a critical independent predictor of recurrence, reflecting the impact of tumor biology over surgical extent. Conclusions: PRA is a definitive and versatile strategy for CVF. In malignant cases, bladder-preserving strategies are oncologically viable when R0 margins are achievable. Integration of PNI status and neoadjuvant therapy was essential for refining personalized multidisciplinary management.

Objectives To describe the design, operational safeguards, and early use of ChatIBD, a specialty-specific generative AI platform for inflammatory bowel disease (IBD), during its first 6 months of live deployment. Methods ChatIBD is an online question-answering platform that uses retrieval-augmented generation over a curated corpus of IBD guidelines. Queries undergo hybrid semantic and keyword retrieval with query expansion and reranking, and the model is instructed to answer only from retrieved material and return linked citations. Safeguards include fixed medication dosing information from European Medicines Agency (EMA), user feedback capture, and clinician review of flagged outputs. We performed a descriptive service evaluation of aggregated, de-identified platform metrics collected between 1 October 2025 and 1 April 2026. Results During the study period, ChatIBD registered 913 users and processed 7,222 messages across 3,855 conversations. Activity was recorded across 69 countries and 28 languages, with the highest message volumes from the United Kingdom (27.1%) and Spain (12.3%). Median daily message volume was 35.5 (IQR 20 to 52), and 85.1% of messages were submitted on weekdays. Medication-related queries accounted for the largest use domain, while guideline synthesis was the most frequent inferred intent. Sixteen explicit feedback events were recorded, including one negative rating that triggered clinician review and system changes. Conclusions ChatIBD showed early international uptake and repeat use as a specialty-specific, retrieval-grounded generative AI tool for IBD professionals. These findings support the feasibility of deploying a guideline-grounded clinical AI service with practical safeguards, but do not establish response accuracy, safety, or clinical effectiveness. Formal validation is in progress.

Background: Friction at the bracket-archwire interface is traditionally considered a key determinant of orthodontic tooth movement efficiency. However, clinical evidence remains inconsistent despite advances in low-friction systems, including self-ligating brackets, coated archwires, and frictionless mechanics. Objective: To evaluate the clinical impact of friction-related interventions on tooth movement, anchorage control, and patient-centered outcomes. Methods: A scoping review with supplementary meta-analysis was conducted following PRISMA-ScR guidelines. Electronic searches of the Cochrane Library (1 systematic review: CD003453), PubMed (128 primary studies), and Google Scholar (approximately 2,500 results, screened to 45 relevant studies) were performed. Randomized controlled trials comparing friction-modifying interventions were included. Primary outcomes included rate of tooth movement, anchorage loss, and molar rotation. Secondary outcomes included pain and treatment duration. Random-effects meta-analysis (DerSimonian-Laird method) was performed using RevMan 5.4; this method was chosen due to expected clinical heterogeneity. Risk of bias was assessed using Cochrane RoB 2, and certainty of evidence was evaluated using GRADE. Given the small number of studies, pooled estimates should be interpreted cautiously due to potential small-study effects. Results: Nineteen RCTs were included in quantitative synthesis. Frictionless mechanics did not significantly increase the rate of space closure (MD = 0.15 mm/month; 95% CI: -0.08 to 0.38; P = 0.20; I-squared = 68%) but resulted in significantly greater molar rotation (MD = 6.1 degrees; 95% CI: 4.8 to 7.4; P < 0.001; I-squared = 45%). Self-ligating brackets showed no consistent advantage in treatment duration or pain reduction. Active self-ligating brackets demonstrated slightly faster alignment than passive systems (MD = 10.24 days; 95% CI: 2.80 to 17.68). Low-friction ligatures and coated archwires did not improve clinical efficiency. Surgical acceleration methods reduced treatment time by 25-50% but increased early discomfort. Low-level laser therapy showed potential for accelerating tooth movement and reducing pain. Conclusions: High-level clinical evidence does not support the long-held assumption that reducing friction accelerates orthodontic tooth movement. The evidence fails to demonstrate a clinically meaningful acceleration effect from friction reduction alone. Resistance to sliding appears to be predominantly governed by binding and biological patient response, not friction alone--necessitating a shift in biomechanical strategy. A proposed evidence-informed conceptual model and clinical algorithm are presented to guide decision-making.

Background: Large language models (LLMs) are increasingly used in medical education and clinical decision-making, but their reliability in high-risk medication dosing remains unclear. Opioid rotation is a common task requiring precise calculations where errors may result in overdose or inadequate pain relief. Methods: Thirteen LLMs were tested using an API-based framework to ensure independent queries across trials. First, fictional clinical scenarios were tested to simulate real-world clinical situations involving opioid rotation; to test the effects of changes in wording, scenarios were revised into 4 vignettes showing the same clinical situation. Next, opioid pairs were tested with a random-dose paradigm across a clinically-pertinent range (5-120 mg daily morphine equivalents). LLM outputs were compared with expected values derived from reference standards. Accuracy was assessed using predefined safety thresholds: tight accuracy (0.85-1.15x expected dose) and broad accuracy (0.6-1.7x). We tested models naively and with prompts augmented with reference tables and unit explanations. Results: Naive models generally exhibited low tight-range accuracy across opioid pairs. For any given opioid pair, each model would consistently produce similar incorrect conversion ratios despite wide variability across opioid pairs and language models. Vignette wording changes accounted for 76% of within-scenario response variance. Reference-based prompt augmentation significantly improved performance, with over half of models achieving high proportions of conversions within tight accuracy for morphine equivalent conversions. Conclusions: While commercial LLMs demonstrated variable accuracy in the native state, prompt augmentation significantly improved their performance.

Objective To quantify waiting time in days for scheduled outpatient specialist consultations and to compare waiting time between standardized and non-standardized access pathways in Ecuadorian public hospitals. Methods We analyzed hospital-based survey data from Ecuadorian public hospitals, restricted to adults attending a scheduled outpatient specialist consultation (n = 4,436). Emergency care, unscheduled urgent visits, procedures, and follow-up visits were excluded by design. Access pathway was classified from participants self-report as standardized (institutional or system-based) or non-standardized (informal or non-system-based). Waiting time, defined as the number of days between obtaining the appointment and attending the consultation, was compared using the Mann-Whitney U test. Sociodemographic correlates of non-standardized access were examined using adjusted logistic regression, and adjusted median differences were estimated using quantile regression ({tau} = 0.50). Analyses were stratified into direct-access specialties and referral-required specialties. Results Non-standardized access was associated with shorter waiting times than standardized access. In adjusted median regression, non-standardized access was associated with a 3.2-day shorter median waiting time (95% CI -4.6 to -1.8). The difference was larger in direct-access specialties (-15.0 days, 95% CI -15.0 to -6.0) than in referral-required specialties (-5.0 days, 95% CI -5.0 to 0.0). Conclusion Among patients who attended a scheduled outpatient specialist consultation in Ecuadorian public hospitals, non-standardized access was associated with shorter waiting times, particularly in direct-access specialties. These findings suggest that, within routine outpatient care, parallel access pathways may shape timeliness and warrant greater transparency in appointment allocation and referral coordination.

Background and objective In cluster-randomised trials (CRTs), different estimands can be targeted, such as the individual- or cluster-average effect. These two estimands can differ in magnitude when outcomes or treatment effects vary with cluster size (termed informative cluster size (ICS)). When ICS is present, commonly used estimators for CRTs, such as mixed-effects model and generalised estimating equations with an exchangeable correlation structure (termed GEEs(exch)), can be biased for both these estimands. With little documented evaluation of ICS, it is currently unknown how commonly it occurs in practice. The aim of this work was to explore whether ICS is present in a published CRT and to investigate its impact on trial results. Methods We re-analysed the RESTORE CRT, which compared protocolised sedation with usual care for critically ill children. For each outcome, we first modelled the association between cluster size and outcome/treatment effect; next, we assessed the impact of ICS by comparing differences between (i) individual- vs. cluster-average estimates and (ii) estimates from mixed-effects models and GEEs(exch) (which can be affected by ICS) to those from IEEs (which are robust to ICS). Results We found evidence of an association between cluster size and either outcomes or treatment effects for 16/33 outcomes (48%). This led to statistically significant differences between the individual- and cluster-average treatment effects for 5 of 33 outcomes (15%). There were >10% differences between (i) individual- and cluster-average treatment effect estimates for 17 outcomes (52%) and (ii) estimates from mixed-effects models/GEEs(exch) and estimates from unweighted IEEs for 13 outcomes (39%). For some outcomes, differences in the choice of estimator or estimand led to differences in the interpretation of results. For example, for the outcome postextubation stridor, the individual-average estimate showed a significant harmful effect (OR=1.65, 95% CI 1.02 to 2.67), unlike the cluster-average (OR=1.38, 95% CI 0.87 to 2.19) or GEEs(exch) estimate (OR=1.57, 95% CI 0.98, 2.50). Discussion ICS can occur in CRTs, and the use of estimators that are not clearly aligned to the target estimand can affect the interpretation of some results.

Background: Trauma from occlusion (TFO) is a frequently under-recognized clinical entity. While narrative reviews exist, no prior systematic review has quantitatively synthesized the prevalence of TFO signs in orthodontic patients, the distribution of the Akerly classification for deep traumatic overbite, the efficacy of orthodontic intrusion, or the outcomes of immediate orthodontic repositioning of traumatized incisors. Furthermore, the knowledge-practice gap among orthodontists regarding trauma management has not been meta-analyzed. Methods: Systematic review and meta-analysis of observational and interventional studies, including cross-sectional studies, randomized controlled trials, and before-after studies. We searched PubMed (n=57), PubMed Central (n=538), the Cochrane Library (n=11: 2 reviews, 9 trials), and Google Scholar (~3,930) up to December 2025. Studies reporting prevalence of TFO signs, Akerly classification distribution, overbite reduction following orthodontic intrusion, success of immediate orthodontic repositioning, or orthodontist knowledge/practice were included. Random-effects meta-analyses were performed using the 'meta' package in R (DerSimonian-Laird estimation for tau-squared). The protocol was not registered due to the exploratory nature of this multi-domain synthesis; however, the methodology strictly adhered to PRISMA 2020 guidelines. Results: Twenty-seven studies (n=8,432 participants) were included. The pooled prevalence of any TFO sign was 34% (95% CI: 27-42%, I-squared = 86%), with wide prediction intervals indicating substantial between-study variability. TFO was variably defined across studies as the presence of at least one of the following: fremitus, increased mobility, occlusal interference, soft tissue trauma, or CR-CO discrepancy. Higher prevalence was observed in Class II malocclusion (46% vs. 22%). Among deep traumatic overbite cases classified using the Akerly system, Type II was most common (52%, 95% CI: 44-60%), followed by Type I (31%) and Type III (17%). Orthodontic intrusion reduced overbite by a mean of 2.8 mm (95% CI: 2.1-3.5, I-squared = 72%); TAD-assisted intrusion produced greater reduction (3.4 mm) than conventional archwires (2.1 mm, p < 0.001). Immediate orthodontic repositioning of traumatized incisors with light forces ([&le;] 50 g) achieved 91% success (95% CI: 84-96%) at 12 months, comparable to splinting (84%), with no statistically significant difference between groups. The orthodontic group required fewer visits and reported better comfort. Meta-analysis of orthodontist knowledge showed correct awareness of specific trauma management protocols was below 40% in most domains, indicating a substantial evidence-practice gap. Conclusion: This first systematic review and meta-analysis on TFO in orthodontics provides preliminary quantitative benchmarks. One-third of orthodontic patients exhibit TFO signs; Akerly Type II is the dominant deep overbite pattern; orthodontic intrusion effectively reduces overbite by approximately 3 mm; immediate light-force repositioning is comparable to splinting in success and superior in efficiency. However, the disconnect between high clinical efficacy (e.g., 91% success of repositioning) and low practitioner awareness (<40%) represents a substantial translational gap in clinical practice. Assessment of publication bias was limited due to the small number of studies in several analyses (<10), precluding reliable funnel plot interpretation.

Background Internalizing disorders and cardiometabolic disease are common conditions that frequently co-occur in later life and may be attributed to shared genetic influences. While phenotypic effects of polygenic liability of adult disorders may emerge early in life, studies have not investigated this in the context of multimorbidity. This study set out to investigate early manifestations of polygenic liability to adult internalizing-cardiometabolic multimorbidity (ICM-MM) in a UK population birth cohort. Methods We used data from 5,821 individuals in the Avon Longitudinal Study of Parents and Children (ALSPAC). We modelled trajectories of 12 mental and cardiometabolic health outcomes using mixed effects models, and investigated effects of adult ICM-MM polygenic liability on these trajectories. We also investigated associations of adult ICM-MM polygenic liability with circulating inflammatory proteins (Olink Target 96 Inflammation panel) at ages 9 and 24. Results Adult ICM-MM polygenic liability is associated with cardiometabolic traits and inflammation, and with changes in depressive symptoms and cardiometabolic traits over time in childhood through to early adulthood. A notable early life biological footprint is inflammation. We found that higher ICM-MM polygenic liability is consistently associated with higher interleukin-6 (IL6), tumor necrosis family superfamily member 14 (TNFSF14) and hepatocyte growth factor (HGF) levels in both childhood and early adulthood. Conclusions Adult ICM-MM polygenic liability manifests early in life through changes in mental and cardiometabolic health and blood biomarkers, especially in increases of circulating inflammatory proteins related to obesity, immune cell chemotaxis and migration that may contribute to disease pathogenesis by seeding inflammation in relevant tissues.

The Leray-XT primer pair has been widely used to amplify the mitochondrial cytochrome c oxidase subunit I (COI) gene from animals. In some marine metabarcoding studies, protists have also been amplified and sequenced using these primers. Here, we ask if the Leray-XT COI primer pair is suitable for observing ciliates and radiolarians, which are numerically and ecologically important components of marine protistan communities. We show that while there are sufficient COI reference sequences for ciliates in NCBI for taxonomic assignments, there are currently only two COI reference sequences for radiolarians. Using in-silico analyses, we additionally show that while the reverse primer Leray-XT primer can bind and potentially amplify both ciliates and radiolarians, the forward primer cannot bind to either taxon. These results show that the Leray-XT primer pair is not suitable for observing ciliates and radiolarians, although it may be useful for observing other marine protistan taxa.

Mixed-linkage {beta}-glucans (MLGs) are emerging as promising biopolymers with significant biotechnological potential due to their unique structural and rheological properties. In rhizobia, MLG biosynthesis is controlled by the second messenger cyclic di-GMP (c-di-GMP) and mediated by the bicistronic operon bgsBA. However, the full composition of the biosynthetic machinery and strategies for enhanced production remain incompletely understood. In this study, we demonstrate that the outer membrane protein TolC is essential for MLG production in Sinorhizobium meliloti. Genetic disruption of tolC abolished MLG synthesis, while its complementation restored production. We propose that TolC forms a tripartite complex with BgsA and BgsB, enabling efficient polymer synthesis and export. Furthermore, co-overexpression of tolC, bgsBA, and a constitutively active diguanylate cyclase (pleD*) yielded a 10-fold increase of MLG over a control plasmid without tolC, reaching up to [~]10 g/L under bioreactor conditions. Additionally, this genetic module enabled de novo MLG production in otherwise non-producer rhizobial hosts (e.g. Mesorhizobium japonicum), allowing bacterial chassis exchanges and highlighting its portability and potential for synthetic biology applications. Overall, our findings identify TolC as a key component of the MLG biosynthetic machinery and provide a robust platform for the scalable production of this valuable biopolymer. Graphical Abstract O_FIG O_LINKSMALLFIG WIDTH=200 HEIGHT=134 SRC="FIGDIR/small/721817v1_ufig1.gif" ALT="Figure 1"> View larger version (46K): org.highwire.dtl.DTLVardef@ad064borg.highwire.dtl.DTLVardef@17842feorg.highwire.dtl.DTLVardef@7666c4org.highwire.dtl.DTLVardef@154d233_HPS_FORMAT_FIGEXP M_FIG C_FIG

Cells continuously generate and respond to mechanical forces across compartments, with the plasma membrane acting as a nanoscale interface for sensing and transmitting tension. How intracellular forces are translated into membrane tension during dynamic processes such as neutrophil extracellular trap (NET) formation remains unclear. Here, we combine the mechanosensitive fluorescent probe Flipper-TR with fluorescence lifetime imaging microscopy (FLIM) to map spatiotemporal changes in plasma membrane tension in living cells. After validation in HeLa and dHL-60 cells under osmotic perturbation, we apply this approach to primary human neutrophils undergoing NETosis. Membrane tension transiently increases during chromatin decondensation and nuclear swelling within 90 min and is followed by a marked decrease 30 min after membrane rupture. Prior to rupture, tension is spatially heterogeneous, indicating localized nanoscale mechanical regulation. Cholesterol depletion abolishes the transient increase and reduces heterogeneity without affecting overall NETosis kinetics. Together, these findings establish the plasma membrane as a dynamic nanoscale reporter of intracellular mechanical stress during NETosis.