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The combination of LILRB4-targeting NK cell engagers and cGAS–STING agonists enhances the anti–multiple myeloma immune activity of NK cells

Although significant progress has been made in immune-targeted therapy for multiple myeloma (MM), it remains highly recurrent and incurable. Consequently, there is still an urgent need to develop more effective strategies against the recurrent and refractory tumor subsets. LILRB4, which is expressed on MM and Myeloid-Derived Suppressor Cells (MDSC) and plays an important role in promoting tumor progression and regulating the immuno-suppressive microenvironment. Therefore, it is an attractive target for MM treatment. We developed a bispecific natural killer cell engager (BiKE), LILRB4/CD16A, to mediate NK cell-mediated lysis of MM cells. BiKE combined with CD16A strongly activated NK cells derived from human peripheral blood, and at the same time, BiKE bridged tumor cells to NK cells and promoted NK cytotoxicity, showing significant antitumor activity against LILRB4-high MM cells. NK cell cytotoxicity was further enhanced by the combined stimulation of innate immunity using cGAS-STING signaling agonists. In xenograft MM tumor models in immunodeficient mice, NK cells derived from human peripheral blood and expanded in vitro were combined with BiKE and cGAS-STING signaling agonists, demonstrating effective anti-tumor activity and inhibition of MM cell proliferation. Collectively, the combination of cGAS-STING agonists and LILRB4-targeting NK cell engagers offers a promising approach for treating relapsed/refractory MM.

Processing of social exclusion in a strict hierarchy

Exclusion is defined as a significant reduction of involvement or interaction with others. This threatens our social need for belonging and triggers a negative affective response. The response is associated with a P3 effect in the event-related brain potentials (ERP) indicating that the processing of exclusion is characterized by a violation of the expected social involvement. The majority of experimental findings relies on the Cyberball setup, in which two putative co-players exclude the participant in a virtual ball-tossing game. The current studies challenge the previous findings by introducing a novel paradigm, Cyberband , which simulates participation in an orchestra setting. Here, exclusion is defined by reducing the number of cues provided by a putative conductor. In experiment 1, the number of cues exclusively directed to the individual (solo) was reduced. In contrast to previous Cyberball findings, the self-reported threat to belonging as well as the P3 effect were clearly diminished. In experiment 2, participants were excluded from joint actions. Here, a reduced participation in common actions (tutti), but not in dyadic actions (duets), enhanced the P3 effect. In both experiments, the reduced participation primarily affected the expression of an early frontal ERP positivity (P2) indicating a change of cue salience. In sum, these results indicate that exclusion is processed differently if attributed to a single decider: The experience is reported to be less painful, and ERP signatures of a violation of the expected participation – prominent in the established Cyberball setup – are predominantly elicited by an exclusion from joint actions.

Comparative study of thoracolumbar fascia changes in weightlifters with and without low back pain

Background Thoracolumbar fascia (TLF) is thought to be linked to low back pain (LBP). This cross-sectional study aimed to investigate the difference in TLF thickness and stiffness between elite weightlifters with and without chronic LBP. Methods Forty-six elite weightlifters (aged 16–26 years; 23 with chronic bilateral LBP) were recruited. TLF thickness was measured in all participants, while stiffness was assessed in 17 of them (aged 19–25 years; 9 with chronic bilateral LBP). Investigations were conducted at the L3 level, about 2 cm lateral to midline, using ultrasound. Bright mode and shear wave elastography (SWE) mode were employed to measure the thickness and Young’s modulus (as an indicator of stiffness) of TLF, respectively. Analyses of covariates (ANCOVAs) were employed to compare the differences in TLF thickness and stiffness between LBP and non-LBP groups, controlling for pre-determined confounding factors. Repeated ANCOVAs were performed to investigate the side-to-side differences in TLF thickness and stiffness in weightlifters with and without LBP. The significance level was set as p  ≤ 0.05. Results The mean thickness and stiffness of TLF were 1.63 ± 0.38 mm and 47.77 ± 13.26 kPa on the dominant, and 1.88 ± 0.60 mm and 48.09 ± 12.62 kPa on the non-dominant sides respectively. The stiffness of the TLF on the dominant side was 42.4% higher in the LBP group compared to the non-LBP control (mean difference (MD) =16.55 kPa > MDC 95 , p  = 0.005, Cohen’s d = 1.58). No significant differences were detected in TLF thickness ( p  > 0.05). Additionally, LBP was found to be a factor influencing the side-to-side differences in stiffness but not in thickness. Specifically, the thickness of the non-dominant side was 15.3% higher than the dominant side (MD = 0.25 mm > MDC 95 , p  < 0.001, Cohen’s d = 0.63), which was not detected in stiffness. Conclusion Chronic LBP in elite weightlifters was associated with significantly higher TLF stiffness but unchanged thickness, suggesting stiffness is a more informative indicator of TLF health than thickness. Addressing stiffness in prevention and rehabilitation programs may improve weightlifters’ performance and career longevity.

Environmental education positively impacts the perceptions of learners towards bats in schools in a low socio-economic area in South Africa

Bats are amongst the most important ecosystem service providers in the world. This is in part due to their diversity as they are the second largest group of mammals with a widespread global distribution. Despite this, most cultures around the world have negative stereotypes towards bats, largely influenced by myths and beliefs stemming from misconceptions about them. In this study, we aimed to assess the impact of environmental education on enhancing awareness and positive perceptions towards bats and their natural ecosystem services by school learners of ages 11–18 years old in QwaQwa, in the eastern Free State Province of South Africa. Our study addressed negative stereotypes about bats through informed and interactive engagement of scientific and public communication in schools with the use of bat awareness classes, posters, a children’s book on bats, and engagement in bat research revolving around bat boxes installed at each school. We used a standardized questionnaire to assess individual attitudes towards bats pre- and post-intervention, targeting for each survey approximately 200 learners from two primary and one secondary schools in QwaQwa. The perceptions of students were divided into six categories namely scientistic, positivistic, behavioral negativistic, emotional negativistic, cognitive negativistic and myth categories. The intervention resulted in a significant change in negative perceptions of students towards bats for all categories, becoming more positive. We also found gender and age to be important influencers of perceptions for some of the categories. Considering the findings, we argued that intervention through environmental education can be a useful tool for changing negative perceptions of learners towards bats in local South African communities.

The mechanism of the ornamental plant variety rights value formation and enhancement strategy based on SEM-SD

With the acceleration of global urbanization, ornamental plants are playing an increasingly critical role in urban greening and climate regulation. Beyond improving urban landscapes, they mitigate the urban heat island effect through transpiration and enhance overall environmental quality. In developed countries, the surge of home gardening during the pandemic greatly stimulated the ornamental plant market, heightening interest in new variety development and the commercialization of plant variety rights. However, many newly bred ornamental varieties have failed to be effectively translated into productive resources, or their value has been underestimated, thereby constraining marketization. This study investigates the value formation mechanism of the Ornamental Plant Variety Rights (OPVR) and proposes optimization pathways for value enhancement. An OPVR value evaluation index system was first constructed through systematic literature review, expert consultation, and value chain analysis. A structural equation model (SEM) was then applied to examine the interrelationships among influencing factors, followed by a system dynamics (SD) model to explore the dynamic evolution of OPVR value and factor sensitivities. The SEM results indicate that four categories of factors contribute to OPVR value formation in the following order: variety value (Var)> technological level (Tec)> market and brand (Mar)> intellectual property protection (IPP). Specifically, variety value exerts both direct and indirect effects through its positive influence on technology and market performance, while IPP, though less influential, positively reinforces variety and market factors. The SD simulations further reveal that factor impacts are comparable during the first four years but diverge thereafter, with sensitivity ranking as follows: market and brand > technological level > variety value > intellectual property protection. Overall, this study clarifies the mechanisms underlying OPVR value formation and offers actionable insights for enterprises to design evidence-based strategies that enhance variety value, strengthen market positioning, and improve long-term competitiveness.

Prognostic factors for recurrence and malignant transformation after treatment of oral epithelial dysplasia: A mixed cohort study

Purpose Oral epithelial dysplasia (OED) is a premalignant condition with a variable risk of malignant transformation (MT). This study investigates the recurrence and MT rates in an Iranian patient cohort with OED, evaluating associations with demographic factors, lifestyle habits, and histopathologic grading systems, with the aim of providing population-specific prognostic insights and enhancing disease prediction and patient outcomes. Methods This mixed cohort study included 89 surgically treated patients with OED, followed for 24–168 months. Demographic data, smoking and alcohol consumption history, recurrence, and MT status were collected from medical records. Histopathological grading was performed using both the WHO 2017 classification and a binary grading system. Kaplan-Meier survival analysis, Cox regression, and statistical tests were applied to identify prognostic factors. A p-value <0.05 was considered statistically significant. Results During follow-up, 22.5% (20/89) of patients experienced recurrence, and 30.3% (27/89) underwent MT. The tongue was the most common site for OED (48.3%), recurrence (55%), and MT (44.4%). Males were more frequently affected than females (60.7% vs. 39.3%,), but females tended to remain cancer-free more often. Smoking and alcohol consumption did not significantly influence cancer development. Kaplan-Meier analysis showed 50% of MT cases occurred after about 108 months (mean: 114.8 months). The combined mean survival for recurrence and MT was 92.8 months. Cox regression identified WHO grading as the only statistically significant predictor of MT and recurrence/MT (p = 0.001). Conclusions The WHO grading system plays a crucial role in predicting the likelihood of OED recurrence and malignant transformation. Lesion location showed only a non-significant trend, suggesting that its effect may be mediated by grade. These findings highlight the importance of using grading-based risk assessments and ensuring close follow-up care to better manage OED and improve patient outcomes.

Retraction: In Vitro Study of Novel Collagenase (XIAFLEX®) on Dupuytren’s Disease Fibroblasts Displays Unique Drug Related Properties

FLUid management and InDividualized resuscitation in Sepsis (FLUIDS)—A Study protocol for a single-centre, open-label, randomized clinical trial

Introduction Early septic shock results from complex hemodynamic disturbances, including vasodilation, capillary leakage, and hypovolemia, requiring timely resuscitation to prevent organ failure. Initial fluid administration in the emergency department (ED) varies widely, influenced by clinician experience, patient comorbidities, and infection source. Fluid therapy is frequently not tailored to individual patient responsiveness and tolerance, highlighting the importance of personalized resuscitation strategies. Objective This study evaluates the effectiveness of a personalized hemodynamic resuscitation strategy during the initial management of sepsis in the ED, using continuous non-invasive stroke volume index (SVI) measurements to guide intravenous (IV) fluid therapy and early vasopressor initiation. Method This single-centre, open-label, randomized clinical trial at the Emergency Department of the University Medical Centre Groningen, the Netherlands, will enroll 188 adults with suspected sepsis requiring hemodynamic resuscitation, defined by a mean arterial pressure (MAP) <70 mmHg, systolic blood pressure (SBP) <90 mmHg, shock index >0.9, or lactate concentration >4.0 mmol/L. Deferred consent will be obtained within 30 days of ED presentation. Patients will be randomized to the intervention group, in which fluids and vasopressors will be guided by changes in SVI (ΔSVI) after IV fluid administration, or to the control group, where fluids and vasopressors will be administered at the discretion of the treating physician during the initial 3-hour resuscitation phase. The primary endpoint is the volume of IV fluids administered within the first three hours after enrollment. Secondary endpoints include cumulative fluid balance, timing and dose of vasopressors, incidence of organ failure, hospital length of stay, mortality and fluid-related adverse events, including venous congestion assessed by point-of-care ultrasound. Expected results We anticipate that SVI-guided resuscitation will reduce IV fluid volume compared to standard care. This personalized approach, tailoring fluid and vasopressor administration to the individual’s hemodynamic needs, has the potential to improve outcomes for patients with sepsis. Trial registration ClinicalTrials.gov NCT07009665

The effect of recall period on reported out-of-pocket health expenditure in Ghana

Background Out-of-pocket health payments (OOPs) are a key indicator of health financing systems’ performance. Measuring OOPs through household surveys is challenging and yet it is the primary source of information in the absence of comprehensive data on user charges in the public sector and market data from the private sector. The choice of the recall period has been identified as a source of bias in previous studies. This study investigates the effect of two different types of recall periods on the agreement between OOPs reported by households and providers. Methods Households were sampled for our community survey from the Navrongo Health and Demographic Surveillance System, Ghana. Two versions of a health expenditure module were developed differing only in the recall periods, “shorter recall periods” 2 weeks for medicines and outpatient care, 3 months for preventive care and 6 months for inpatient care and medical products. The longer recall periods were 4 weeks, 6 months and 12 months. Households from both community and provider sampling were randomly assigned to the two questionnaires. The providers included the hospital, one clinic and, health facilities and drug shops in the area. We estimated the ratio between the overall mean household OOPs and overall mean provider OOPs. We assessed agreement between the individual matched household-provider OOPs using Bland-Altman analysis. Findings The short and long-recall period versions of the questionnaires were administered to 746 and 480 households with matching success to provider records of 72% and 84%, respectively. The most common spending categories were inpatient care and medicines in this sample. The overall mean OOPs reported by the households were higher than provider records for both recall periods. For matched household-provider data, there was no evidence of a difference in the agreement between the household and provider OOPs for inpatient care, the ratio of household to provider for the 12 months recall was estimated to be 0.74 (95% CI 0.45, 1.19; p = 0.22) that of the ratio of household to provider for the 6-month period, where less than 1 would indicate better agreement. For medicines, the ratio of 4 weeks to 2 weeks was 1.26 (0.93, 1.39; p = 0.39). Conclusion There were considerable challenges in using provider data to assess the accuracy of reported OOPs in this setting. There was no evidence from this study that the agreement between household and provider data differed by recall period, however the confidence intervals of the effect were wide, and an effect cannot be ruled out. These findings underscore the need for caution in relying solely on provider-reported data and highlight the importance of considering alternative data collection methods to improve the accuracy of healthcare cost assessments.

Top ten priorities identified by healthcare professionals to support the clinical care of individuals with attention-deficit/hyperactivity disorder: A Canadian Delphi study

Background Limited research exists on key issues that healthcare professionals perceive as important for optimizing Attention-Deficit/Hyperactivity Disorder (ADHD) care. This study identified the top ten priorities that healthcare professionals consider vital to support ADHD care in Canada. Methods A three-round online Delphi study was conducted using electronic surveys from 2022–2024 across Canada. In Round 1, healthcare professionals were asked to rate 21 predetermined items using a 5-point Likert scale and re-evaluated those rankings in Round 2. In Round 2, a new set of 34 items identified from Round 1 were rated and the rankings re-evaluated in Round 3. Consensus was determined by percentage agreement ≥ 90% with a Likert score ≥ 4. For each priority item, the mean Likert score, standard deviation, 95% confidence interval (CI), and the minimum and maximum Likert scores were calculated. Results 96 Canadian healthcare professionals completed Round 1. 82 (85% response rate) completed Round 2 and 73 (89% response rate) completed Round 3. The two highest ranked priorities that achieved 100% consensus agreement were: providing access to well-trained healthcare providers in ADHD (mean score 4.74, 95% CI 4.65–4.84) and access to ADHD-related services (mean score 4.50, 95% CI 4.39–4.61). Among the top ten consensus-derived items, the highest frequency pertained to providing access to healthcare experts in ADHD and related-services (50%) followed by research into ADHD on socio-emotional functioning, co-existing conditions and in diagnosing ADHD in females (30%). Increasing knowledge and educating healthcare professionals and school systems on ADHD was also identified among the top ten priorities (20%). Conclusions Healthcare professionals identified ten top priorities by consensus where most focused on providing access to trained healthcare providers and services to support ADHD care in Canada. Implementing strategies to improve access on a national level will improve the quality of life for individuals living with ADHD.

‘A serious problem’: peer reviews created using AI can avoid detection

Preoperative and perioperative factors that predict endothelial cell loss 1 year after uncomplicated Descemet membrane endothelial keratoplasty

Purpose To identify pre/perioperative variables that shape endothelial cell loss (ECL) after uncomplicated Descemet membrane endothelial keratoplasty (DMEK). Methods This retrospective study included all consecutive patients with Fuchs endothelial corneal dystrophy who underwent DMEK surgery without perioperative or postoperative complications in 2015–2023 and were followed for 12 months. To identify covariates that predicted 12-month ECL, primary hierarchical multivariable analysis was conducted with 12 variables: patient age and sex; donor age; preoperative axial length, visual acuity, central corneal thickness, and graft endothelial cell density; endotamponade with sulfur hexafluoride (SF6) or air; triple-DMEK or pseudophakic-DMEK; operative time; graft marking; and rebubbling. Results 137 eyes (112 patients) were included. Multivariable analysis showed that SF6 predicted 13.6 ± 3.4% greater ECL vs . air (p < 0.0001) and accounted for 10% of total ECL variation. Longer operative time and multiple (≥2) rebubbling also predicted 0.4 ± 0.7% ( p  = 0.046) and 11.7 ± 5.1% ( p  = 0.02) higher ECL, respectively. SF6 significantly reduced rebubbling on univariable analysis (13% vs . 41% for air, p  = 0.01). Conclusions SF6 use for endotamponade may increase ECL after DMEK. There is an urgent need for randomized controlled trials that estimate the relative disadvantages (endothelial toxicity) and advantages (less bothersome rebubbling) of SF6. Trial registration ClinicalTrials.gov Identifier: NCT02535819 .

Identifying and assessing nonlinear drivers of capelin and Atlantic cod population dynamics using empirical dynamic modelling (EDM) scenario exploration

As anthropogenic stressors such as climate change and fisheries continue to disrupt marine ecosystems, it is becoming more important to understand and predict resulting nonlinear effects on species population dynamics. The marine ecosystem of the Newfoundland Shelf serves as a unique case study for this purpose. Capelin ( Mallotus villosus ) and Atlantic cod ( Gadus morhua ) were dominant species of the Newfoundland Shelf community before populations of both species collapsed in the early 1990s during a period of abnormally cold climate and overfishing of groundfish, culminating in a regime shift. In this study, we examine 12 climatic and ecological covariates for driving effects on capelin and cod population dynamics using Convergent Cross-Mapping (CCM). We then examine the magnitude and direction of identified drivers on capelin and cod population dynamics, and identify nonlinear relationships between these drivers and resulting population dynamics using Empirical Dynamic Modelling (EDM) scenario exploration. The drivers of cod and capelin were mostly common and synergistic. For both cod and capelin, we found long-term climatic change was the strongest climatic driver of biomass, with warming temperatures predicted to increase biomass for both species in the near future. We observed nonlinearity in this relationship for capelin, with warming temperatures becoming a negative driver at high biomass. Capelin and cod biomass were the strongest ecological drivers of each other, with increasing biomass in either benefitting the other. Overall, this study shows EDM scenario exploration can be used to identify primary drivers of a species’ population dynamics, and predict nonlinear reactions to environmental and/or ecological changes in their environment.

The cost-effectiveness of penicillin allergy testing: Evidence and gaps from a systematic review

Introduction Patients with a penicillin allergy label (PAL) use more and broader-spectrum antibiotics, have worse health outcomes and cost more to treat than patients without a PAL. A significant proportion of penicillin allergy labels are incorrect; here we review the published evidence on the costs, health-related quality of life, and cost-effectiveness of penicillin allergy testing. Methods We conducted a systematic review of published economic evaluations of penicillin allergy testing in accordance with Cochrane guidelines. We searched Medline, Embase, Scopus, Web of Science, EconPapers (RePeC) and the International HTA Database (INAHTA) and included reports of full or partial economic evaluations of costs and/or health benefits of penicillin allergy testing strategies. The outcomes of interest were healthcare resource use, medical costs, and health-related quality of life for patients with a penicillin allergy label and for patients with the label removed, and cost-effectiveness. We evaluated the methodological quality of the studies using a published checklist designed for systematic reviews. The review followed a narrative synthesis. Results Thirty-six studies met the inclusion criteria. Most studies analysed the effect of testing on the costs of antibiotic use among patients admitted to hospital with a PAL. Studies measured costs of testing (n = 19); antibiotic medication use (n = 23); adverse reactions with penicillin use (n = 4), alternative antibiotic drugs (n = 3); length of hospital stay (n = 5); subsequent health care use episodes (n = 4); and antibiotic medication use in subsequent care episodes (n = 3). The median cost of skin testing plus oral challenge across six primary costing studies was USD 246 (range: 164, 514), which contrasts with the USD 42–258 range of antibiotic cost savings during the initial hospital admission. Two studies presented evidence that penicillin allergy testing is cost-saving in an outpatient setting over 3.5–4.5 years. One model-based study reported that testing in inpatient settings is cost-saving. No reports on the effect of penicillin allergy testing on health-related quality of life were found and the two cost-effectiveness studies that accounted for this outcome employed the opinion of healthcare professional or an assumption of a common generic value for adverse reactions. Conclusions While penicillin allergy testing shows promise in reducing antibiotic costs, the evidence remains insufficient to definitively establish whether these savings consistently outweigh testing costs across various healthcare settings.

Nature's News & Views roundup of 2025

Generation and characterization of a mouse model of conditional Chd4 knockout in the endometrial epithelium

Chromatin remodeling plays an integral part in endometrial homeostasis through its roles in the maintenance of cell identity, epithelial integrity, and prevention of endometrial disease. Chromodomain-helicase-DNA-binding protein 4 (CHD4) is a chromatin remodeling protein and member of the NuRD complex, which predominantly represses transcription. CHD4 is mutated in endometrial carcinoma, with most mutations resulting in loss of function. CHD4 has been identified as a tumor suppressor and regulator of stemness in human endometrial carcinoma cell lines, but little is known about the tissue-specific roles of CHD4 in the endometrial epithelia in vivo. We generated a conditional Chd4 floxed allele and combined it with BAC-Sprr2f-Cre to drive CHD4 loss in the endometrial epithelium. Consistent with previous reports, BAC-Sprr2f-Cre shows variegated expression within the endometrial epithelium and lacks expression in the oviducts, ovaries, and kidneys. Loss of CHD4 was confirmed by immunohistochemistry, and the percentage of endometrial epithelial cells with and without CHD4 was quantified. Compared to the glandular epithelium, the extent of CHD4 loss was higher in the luminal epithelium and unaffected by age. Mice with conditional knockout of Chd4 had normal endometrial histology. A six-month breeding trial was performed to assess the functional effects of endometrial epithelial CHD4 loss on fertility and found no difference in litter size, average litter size per dam, or pup weight between genotypes. These findings demonstrate that Chd4 conditional knockout using BAC-Sprr2f-Cre is not sufficient to alter the structure and function of the endometrial epithelium or drive tumorigenesis. As CHD4 is frequently co-mutated with other cancer driver genes such as TP53 , PIK3CA , and PTEN , future mouse modeling efforts emulating patient mutational profiles might provide insight into the role of CHD4 in endometrial carcinoma.

Ethical compliance and institutional policy support for artificial intelligence integration in African TVET Education: A structural equation modeling approach

As artificial intelligence (AI) reshapes educational landscapes, ensuring ethical alignment and institutional responsiveness is essential particularly in skill-intensive sectors such as Technical and Vocational Education and Training (TVET). In this study, we examined the predictive roles of Ethical Principles Guiding AI adoption (EPG), Compliance with AI Ethical Guidelines (CAEG), and Perceived AI Adoption Outcomes (PAAT), while testing the moderating effect of Institutional Policy Support (IPS). Grounded in Rest’s Four Component Model of ethical behavior, we adopted a cross-sectional, quantitative design and surveyed 400 TVET educators across Nigeria using a rigorously validated instrument. Our analysis through Partial Least Squares Structural Equation Modeling (PLS-SEM) revealed that Ethical Principles Guiding AI adoption significantly influenced both Compliance with AI Ethical Guidelines and Perceived AI Adoption Outcomes. Moreover, CAEG partially mediated the relationship between EPG and PAAT, highlighting compliance as a vital conduit for ethical adoption. However, IPS did not significantly moderate the EPG–CAEG relationship, indicating that personal ethical orientation may remain influential even in the absence of institutional frameworks. Our model demonstrated strong explanatory and predictive validity, particularly in institutions without formal AI policies underscoring the compensatory role of ethical leadership. We contribute novel empirical insights to the emerging scholarship on AI ethics in education by integrating ethical compliance and policy dynamics into a unified framework contextualized within African TVET systems. Our findings emphasize the importance of empowering educators with ethical competencies and call for urgent institutional action in policy formulation, infrastructure investment, and professional development to support responsible AI integration in education.

Are we living in a parallel universe? The strange physics of Stranger Things

Understanding the feasibility of home-based rehabilitation in kidney transplant recipients: A mixed-methods interpretation

Background The ECSERT randomised controlled feasibility trial reported that a structured home-based exercise programme was feasible in kidney transplant recipients (KTRs). This study presents a qualitative evaluation of the trial and programme of exercise. The results are integrated and interpreted via a mixed methods analysis. Methods Fifty stable KTRs > 1-year post-transplant were randomised 1:1 to a 12-week home-based exercise programme or guideline-directed care control. Participants from the ECSERT trial intervention group ( n  = 12) completed individual semi-structured interviews immediately and 3 months after the 12-week exercise programme. Interviews were analysed using reflexive thematic analysis. Quantitative data on feasibility (recruitment, adherence, and attrition) and qualitative data were collected concurrently, and combined using convergent mixed methods analysis with a joint display to further explore the primary feasibility findings. Results The mixed methods analysis facilitated the explanation and exploration of the successful feasibility findings. A key factor in recruitment was initial contact from a trusted healthcare professional. The benefits of additional health monitoring and the option to complete the programme later surpassed the disappointment of allocation to the control group. Key facilitators to exercise session completion were seeing change and preserving health, getting into a routine and the flexibility of home-based exercise, the variety of options, the importance of progression, the obligation to complete/being monitored, and the importance of support. At 3 months, many participants maintained some physical activity but described challenges with motivation, time, and illness. Conclusion Elements of the ECSERT trial design, trial procedures, and exercise programme that contributed to the successful feasibility of the main trial were identified. These results will allow researchers and practitioners to maximise the effectiveness of future trials and programmes of home-based exercise in KTRs.

Cognitive load in cyclists while navigating in traffic: Effects of static and dynamic route events on neural activity of cyclists measured by fNIRS

Increased cognitive load during cycling can lead to safety issues, particularly during complex situations such as participating in motorised traffic or manoeuvring at intersections. Understanding the patterns of cognitive activity in cyclists across various events can provide valuable insights into cyclists’ cognitive load. Therefore, this study aims to investigate when cyclists undergo cognitive load changes during cycling and how these changes manifest in neural activity and connectivity. For this purpose, we analysed neural activity data collected during a real-life field experiment by a non-invasive portable method, namely Functional Near-Infrared Spectroscopy (fNIRS), sensitive to neural activity in the prefrontal cortex region. Findings indicate differences in cognitive load, as shown by varying oxygenation levels, during both static (i.e., presence of traffic lights, intersections, roundabouts, or crosswalks) and dynamic (i.e., presence of motorised vehicles, cyclists, pedestrians, or avoiding objects) route events. Neural activity patterns highlight how different road events elicit varying cognitive and neural demands in cyclists. Events like intersections and pedestrian encounters show dense connectivity, particularly in regions related to decision-making, attention, and motor planning, implying a high cognitive load on cyclists. Roundabouts and traffic light scenarios demonstrate intermediate connectivity, indicating the need for adaptive attention and action selection. This study contributes to understanding the underlying cognitive mechanisms during cycling in real-life conditions and the neural markers that can identify different route events encountered while cycling.