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Editorial Note: Enhanced audience sentiment analysis in IoT-integrated metaverse media communication
Sex Hormone Influences on Cardiovascular Risk
Development and internal validation of a prediction model incorporating SOFA, Prognostic Nutritional Index, and Neutrophil-to-Albumin Ratio for early prediction of in-hospital mortality in patients with Sepsis: A single-center retrospective study
Objective Sepsis prognosis is influenced by organ dysfunction, inflammation, and nutritional status. We aimed to develop and internally validate a prediction model incorporating the Sequential Organ Failure Assessment (SOFA) score, prognostic nutritional index (PNI), and neutrophil-to-albumin ratio (NAR) for early risk stratification of in-hospital mortality in patients with sepsis. Methods We conducted a single-center retrospective study of 120 patients with sepsis. A multivariable logistic regression model was developed and internally validated using bootstrap resampling. Model performance was evaluated through discrimination, calibration, and decision curve analysis, with incremental predictive value assessed by net reclassification improvement and integrated discrimination improvement. Results The SOFA score and NAR were independently associated with in-hospital mortality, while PNI did not reach statistical significance in multivariable analysis. The combined model demonstrated good discrimination with an area under the receiver operating characteristic curve of 0.904, higher than SOFA score alone (0.845) and quick SOFA (0.700), although the difference versus SOFA alone was not statistically significant (P = 0.075). Bootstrap internal validation yielded an optimism-corrected AUC of 0.870. Calibration was acceptable (Hosmer-Lemeshow P = 0.057; Brier score = 0.098). Decision curve analysis demonstrated greater net clinical benefit compared with SOFA score alone. The combined model showed potential improvement in risk reclassification (net reclassification improvement = 0.90; integrated discrimination improvement = 0.15; both P < 0.001), although its improvement in discrimination over the SOFA score alone did not reach statistical significance. Conclusions The combined model showed statistically significant improvement in risk reclassification (net reclassification improvement = 0.90; integrated discrimination improvement = 0.15; both P < 0.001), although its improvement in overall discrimination (AUC) over the SOFA score alone did not reach statistical significance (P = 0.075).
LDL Cholesterol Targeting in Cardiovascular Disease
Rainy-weather speed limit strategies on highways with variable longitudinal slopes
Rainfall substantially degrades highway traffic safety by reducing pavement friction, shortening driver perception distance, and amplifying the adverse effects of longitudinal grade on vehicle dynamics. To support refined speed management under rainy-weather conditions, this study develops a dynamic safe speed-limit model that jointly accounts for pavement friction, longitudinal slope, and perception distance. An improved Intelligent Driver Model (IDM) is further proposed to represent rainy-weather car-following behavior and speed adaptation. The proposed model was evaluated using the Hangzhou West-Fuxi highway section, and simulation experiments were conducted under different rainfall intensities and slope conditions. Model validation showed that the simulated speeds were consistent with observed speed characteristics, with RMSE values of 2.13–3.08 km/h and MAPE values of 2.31%−4.12%. The safety evaluation results indicated that the proposed speed-limit strategy reduced conflict rates by 7.1%, 73.6%, and 82.4% across the three rainfall scenarios compared with the unrestricted-speed condition. Sensitivity analysis further showed that increasing rainfall intensity reduced the pavement friction coefficient, increased braking distance, and narrowed the safety boundary, particularly on downhill sections. The results indicate that no additional speed restriction is generally required for rainfall intensities of 0–1.0 mm/min, whereas rainfall intensities of 1.0–5.0 mm/min require progressively stricter speed limits. A longitudinal slope of +1% provides the most favorable operating condition, while a −3% slope represents the most adverse case. These findings provide a quantitative basis for adaptive highway speed-limit control under rainy-weather conditions.
Cross-Correction in HSC Gene Therapy for Metachromatic Leukodystrophy
Resilience factors, pain, and physical activity in adolescent chronic musculoskeletal pain: Design and protocol of a pilot phase 2 single-group, non-randomized clinical trial
Introduction Chronic musculoskeletal pain (CMSKP) in adolescence is associated with physical, psychological, social, and academic impairment and increased risk for chronic pain in adulthood. Although physical activity interventions are an evidence-based approach for managing pediatric chronic pain, many adolescents with CMSKP avoid physical activity due to fear of increased pain, low confidence in physical functioning, and other pain-avoidance behaviors. Resilience-focused interventions targeting self-efficacy, motivation, and mental flexibility may improve engagement in valued activities despite pain. This study describes the design and protocol of the Pain REsilience Promotion for Youth (PREP-Y) intervention, a resilience-focused physical activity intervention for adolescents with CMSKP. Methods and analysis This single-site, pilot phase 2, single-group, non-randomized clinical trial will enroll 40 adolescents aged 12–17 years with CMSKP from Nationwide Children’s Hospital in Columbus, Ohio, USA. Participants complete questionnaires, objective physical functioning assessments, and physical activity monitoring using activPAL devices as baseline measures. Participants then complete 4 virtual resilience-focused intervention sessions targeting pain resilience, self-efficacy, motivation, and adaptive coping related to physical activity. Garmin watches are used to track activity during the intervention period. Follow-up assessments occur post-intervention and at 3 months post-intervention. Primary outcomes include feasibility and acceptability, assessed through recruitment, retention, attendance, intervention fidelity, and completion of study measures. Exploratory outcomes include physical activity, sedentary behavior, pain-related functioning, pain catastrophizing, kinesiophobia, self-efficacy, and resilience-related constructs. Ethics and dissemination The study was approved by the Nationwide Children’s Hospital Institutional Review Board. Findings will inform a future randomized clinical trial. This manuscript reflects protocol version 5.0 dated 23 March 2026. Trial registration ClinicalTrials.gov NCT06923891 .
Medical Standards by Federal Fiat
Current immunosuppressive treatment and self-reported lifetime stroke history among United States adults: A cross-sectional study
Current immunosuppressive treatment is used for autoimmune, inflammatory, malignant, transplant-related, and other chronic conditions that may carry elevated cerebrovascular burden. Nationally representative evidence on current immunosuppressive treatment status and self-reported lifetime stroke history remains limited. This cross-sectional study used pooled 2023–2024 National Health Interview Survey Adult Sample data. The analytic sample included adults aged 18 years or older with valid survey weights and complete data on exposure, outcome, and selected covariates. The exposure was current self-reported use of medications that weaken the immune system. The outcome was self-reported lifetime stroke history. Survey-weighted logistic regression estimated odds ratios and 95% confidence intervals, accounting for National Health Interview Survey stratification, clustering, and adjusted sampling weights. The final analytic sample included 60,026 adults, representing approximately 250 million United States adults. The weighted prevalence of current immunosuppressive treatment was 4.6%. Stroke history was more common among adults receiving immunosuppressive treatment than among those not receiving treatment (6.0% versus 2.8%). In unadjusted analysis, immunosuppressive treatment was associated with higher odds of stroke history (odds ratio 2.24, 95% confidence interval 1.86–2.70, p < 0.001). After full adjustment for age, sex, race/ethnicity, hypertension, diabetes, smoking status, coronary heart disease, and income-to-poverty category, the association persisted (adjusted odds ratio 1.71, 95% confidence interval 1.40–2.08, p < 0.001). Current immunosuppressive treatment status, likely reflecting both medication exposure and underlying disease burden, was associated with higher odds of self-reported lifetime stroke history among United States adults. Because of the cross-sectional design, broad exposure definition, self-reported outcome, and potential confounding by indication, these findings should be interpreted as an association rather than evidence of causation.
Platelet-Activating Anti–Platelet Factor 4 Disorders
Negative interpretation bias and emotional responses to positive contexts
Negative interpretation bias, the tendency to interpret ambiguous situations as negative or threatening, is associated with reports of intense and more frequent negative affect. However, there is a relative paucity of work seeking to determine whether this cognitive bias might account for individual differences in affective responses to positive content. Given the wealth of benefits associated with positive emotional experiences, such as greater psychological wellbeing and better physical health, this investigation tested the influence of negative interpretation bias on emotion responses to evocative positive film clips as positive emotion-eliciting contexts. Negative interpretation bias was indexed using a novel word matching task. In each investigation, careful consideration of dispositional or trait-level influence on interpretation bias (i.e., dispositional negativity) was considered. Investigations conducted across three samples of college students at a large, Midwestern public university reveal complexity to this question: in one study, a small significant indirect effect of negative interpretation bias on the association between dispositional negativity and self-reported affect following positive emotionally-evocative films was found, while in the two subsequent studies, no significant mediation was found. Certain contextual factors, such as the explicit or discrete nature of the clip presentation as well as more stable tendencies toward positive emotional responsivity and the capacity to self-report emotional experiences, appear to be important. Finally, the novel task was found to be reliable and demonstrated convergent validity with established indicators. Future work should continue to clarify the conditions under which negative interpretation bias may influence responses to positive emotional contexts, given the importance of positive emotionality for lifelong physical and mental health.
The Paradox of Medical Aid in Dying
Primary cesarean section in Sub-Saharan Africa: A systematic review and meta-analysis using the Robson Ten-Group Classification System
Background The overuse of cesarean sections, mainly of primary procedures, is a major contributor to perinatal mortality in Sub-Saharan Africa. The Robson Ten-Group Classification System is the global standard for cesarean section rate. Evidence on the pooled primary cesarean section rate using this system in Sub-Saharan Africa SSA remains limited. Materials and methods A systematic review and meta-analysis were conducted. PubMed, Scopus, ScienceDirect, Google Scholar, Google, and ResearchGate were searched for studies published between 2001 and February 22, 2025. Data were extracted into Microsoft Excel and analyzed using Stata 17. A random-effects model was applied to calculate the pooled rate. Study quality was assessed using the Joanna Briggs Institute Critical Appraisal Checklist for Studies Reporting Prevalence Data. Publication bias was assessed using a Doi plot and the Luis Furuya-Kanamori index. Heterogeneity was assessed using the I² statistic. Results The pooled facility‑based primary cesarean section rate, derived from 25 institution‑based studies (213,117 births; predominantly secondary and tertiary hospitals), in Sub-Saharan Africa was 18.7% (95% CI: 16.2–21.4; 95% prediction interval: 8.4%−36.8%). Robson Groups 1 and 2 were the largest contributors (47.5%), with Group 1 alone accounting for 37.1%. In both nulliparous and multiparous women, primary cesarean section was more common after spontaneous labor than after induction or elective procedures. Significant heterogeneity was observed across studies (I² = 99.64%, p < 0.001). No evidence of publication bias was found (LFK index = −0.27). Conclusion The facility‑based primary cesarean section rate in Sub-Saharan Africa exceeded the WHO global reference, with Robson Groups 1 and 2 being the largest contributors. High rates of prelabor cesarean and elevated rates following spontaneous labor raise concern for possible overuse, but unmeasured comorbidities and referral bias cannot be excluded. Stricter adherence to evidence-based protocols, routine use of the Robson classification for clinical audits, and linkage with indication‑level data are essential for improving obstetric care.
Case 22-2026: A 37-Year-Old Woman with Persistent Nasal Ulceration
Prevalence and associated factors of intimate partner violence against reproductive-age women in Africa and Asia regions: Insights from 2022–2024 DHS datasets
Background Intimate partner violence is a major public health and human rights issue, affecting one in four women globally. It is particularly prevalent in low‑ and middle‑income countries, where reproductive‑age women face heightened risks due to cultural norms, poverty, and weak legal protections. It is linked to severe mental, physical, and reproductive health consequences, as well as intergenerational and societal impacts. Using recent demographic and health survey data, this study provides updated cross‑regional insights into intimate partner violence among women in Africa and Asia to inform culturally tailored interventions and strengthen policy frameworks. Methods A cross-sectional study was conducted using recent demographic and health survey data (2022–2024) from twelve countries in sub-Saharan Africa and Asia, including 88,414 women aged 15–49 years. Intimate partner violence was measured using 13 self‑reported items adapted from the Conflict Tactics Scale and coded as a binary outcome. Explanatory variables were selected based on the WHO ecological model, covering individual, relationship, community, and societal factors. Weighted data were analyzed in STATA 17 using multilevel logistic regression to account for clustering, with associations reported as adjusted odds ratios and 95% confidence intervals. Results The overall prevalence of intimate partner violence among reproductive‑age women in sub-Saharan Africa and Asia was 29.51% (95% CI: 29.21–29.81), with emotional (21.03%) being most common. Prevalence ranged from 51.74% in the Democratic Republic of Congo to 13.53% in the Philippines. Multilevel analysis identified significant predictors, including age, education, marital and employment status, early cohabitation, number of children, maternal abuse exposure, attitudes toward wife‑beating, partner jealousy, fear of partner, smoking, partner alcohol use, and region. Notably, partner alcohol consumption (AOR = 3.10), fear of partner (AOR = 2.98), and partner jealousy (AOR = 2.96) showed the strongest associations with intimate partner violence. Conclusions Nearly one in three reproductive‑age women experienced intimate partner violence, highlighting its magnitude and public health importance. Intimate partner violence was strongly associated with socio‑demographic, behavioral, and attitudinal factors and regional differences. These findings call for multi‑level interventions that promote women’s empowerment, challenge harmful gender norms, strengthen legal frameworks, and expand community‑based support, while future longitudinal and qualitative research should deepen understanding and guide evidence‑based policy.
Braking Bad News
First report of Corynespora cassiicola causing leaf spot on Begonia fimbristipula in China
Background Begonia fimbristipula , an economically important medicinal plant in southern China, has recently suffered severe yield losses from leaf spot disease in Guizhou and Hunan Provinces; the causal pathogen remains unknown. Methods Field surveys were conducted across multiple locations in Guizhou and Hunan Provinces to record disease symptoms and incidence. The pathogen was isolated from diseased leaves via tissue culture, and identified by combining morphological characteristics and multilocus phylogenetic analysis (ITS, TEF1α, RPB2). Pathogenicity was verified by fulfilling Koch’s postulates through artificial inoculation and re-isolation assays. Results Severe leaf spot outbreaks were observed in August 2024, with over 60% disease incidence across 667 hectares and >20% fresh leaf yield loss. The isolated pathogen was identified as Corynespora cassiicola based on gray to dark-gray colonies, pale-brown olivaceous conidia with 0–15 pseudosepta, and ≥98% bootstrap support in phylogenetic clustering with known C. cassiicola strains. Koch's postulates were fulfilled by reproducing typical field symptoms on inoculated B. fimbristipula seedlings and re-isolating the pathogen. Conclusions This is the first report of C. cassiicola causing leaf spot on B. fimbristipula in China, expanding the host range of this pathogen. Our findings provide a critical basis for the accurate diagnosis of this newly emerging disease on the medicinal plant.
Milwaukee Shoulder Syndrome
School leadership and indigenous student outcomes: A correlational study of Student Needs Management Practices based on Maslow’s Hierarchy of Needs
Indigenous students continue to face persistent educational disadvantages, including lower academic attainment and reduced school engagement, often linked to school systems that do not systematically address students’ hierarchical needs. This study examined the association between principal-led Student Needs Management Practices (SNMP) and Indigenous student outcomes across 93 national primary schools in Orang Asli settlement areas in Peninsular Malaysia. Using a quantitative cross-sectional design, data were collected from 342 teachers through multi-stage sampling. SNMP was operationalised across five Maslow-derived dimensions physiological, safety, belongingness, esteem, and self-actualisation needs while Indigenous student outcomes encompassed academic achievement, co-curricular participation, and character development. Both SNMP (M = 4.63, SD = 0.39) and student outcomes (M = 4.26, SD = 0.49) were rated at very high levels by teacher respondents. Pearson correlation revealed a significant, moderate positive association between SNMP and student outcomes (r = .411, p < .001). Multiple regression indicated that the five SNMP dimensions collectively explained 18.8% of the variance in student outcomes (R 2 = .188, adjusted R 2 = .176), F(5, 336) = 15.559, p < .001. Belongingness needs emerged as the only statistically significant predictor (β = .298, p < .001); safety needs approached significance (β = .124, p = .061); physiological, esteem, and self-actualisation needs were not significant predictors. These findings suggest that emotional and relational dimensions of leadership practice are more directly associated with Indigenous student outcomes than material or recognition-based dimensions, and that the modest direct association is consistent with leadership-influence models in which principals affect student outcomes substantially through intermediate mechanisms such as teacher commitment. The study offers evidence-based implications for needs-responsive school leadership in Indigenous education contexts.