There is a lack of understanding of the determinants of dietary habits in Asian American populations. We examined dietary habits and barriers to adopting healthier habits in Asian Americans, considering potential differences by ethnic subgroup and immigrant generation. We conducted an online survey of 1,041 Asian Americans aged 21 years and older, inquiring about socio-demographic characteristics, dietary intake, and barriers to healthier eating. Most participants (64.5%) often consumed foods from their culture of origin. Fewer than half of the participants consumed vegetables (47.4%), fruit (39.4%), or whole grains (34.7%) at least once a day. As immigrant generations increased, consumption of foods from their culture of origin decreased (P=0.002), whereas consumption of sugar-sweetened beverages (P=0.02) and the prevalence of obesity (P=0.01) increased. The most common barriers to consuming a healthy diet among the study population were the high price of healthy foods (39.3% often/always), friends preferring the taste of other foods (37.6%), and reluctance to give up foods they liked (34.7%). Although the top barriers were similar across immigrant generations and countries of origin, some significant differences were observed by ethnic subgroup. Our findings suggest that a majority of Asian Americans frequently consume foods from their culture of origin and do not meet dietary recommendations. Important barriers to eating healthier foods include the price and a preference for other foods. These findings can inform the development of policies and interventions to improve the dietary intake of Asian American populations.
Hereditary transthyretin amyloidosis (hATTR) is a progressive, multisystemic, and life-threatening disease that disproportionately affects individuals of African descent, with an estimated prevalence of 3.4% of Black Americans. hATTR is often mis- or underdiagnosed, partially because many of its symptoms overlap with other cardiac conditions. This study highlights additional factors that may be contributing to the underdiagnosis of hATTR in Black patients. Participants were ascertained from the Emory University Amyloidosis Clinic with purposive sampling. A total of 11 interviews were conducted via telephone, transcribed, and coded by two coders for thematic analysis. A Cohen's kappa of 0.74 was reached. The overwhelming majority of participants cited misdiagnosis, mistrust of healthcare providers, denial or misunderstanding of one's own health risks, and poor family communication as prevalent contributing factors to the underdiagnosis of hATTR. Participants cited appropriate referrals to heart failure providers and family letters as contributing factors to proper diagnosis of hATTR. Importantly, participants emphasized the need for more personal and intimate relationships with providers in order to improve uptake of genetic testing in this population. Participants suggested engaging directly with the Black community to improve trust. This study highlights the need for improvements to be made regarding the diagnosis of hATTR in the Black population. Participants suspected of having hATTR should be referred to a heart failure cardiologist for appropriate diagnosis. Genetic testing and follow-up genetic counseling is recommended to appropriately inform the patient of health risks for themselves and their family members.
A majority of Americans are against the denial of medical care to trans people, yet it remains unclear how healthcare workers view this issue. Drawing on data from a national survey experiment (n = 4991), we find healthcare workers are less likely than the public to endorse the denial of care to trans patients. However, much of this gap is attributable to healthcare workers being disproportionately women; a group that historically voices greater support for trans rights. Qualitative analyses reveal women are considerably more likely than men to view denial as discriminatory, and to assert doctors have an obligation to treat all patients. Men, by contrast, more often argue doctors cannot be compelled to provide care and invoke the non-urgent nature of the case to justify denial. A subset of these seemingly value-neutral justifications are suffused with gender essentialist ideology. We discuss the relevance of findings for addressing discrimination in healthcare settings.
To explore the impact of dual sensory impairments (DSI) on new-onset cardiometabolic multimorbidity (CMM) among middle-aged and older adults, further analyze the mediating role of frailty. The data was drawn from the University of Michigan Health and Retirement Study (HRS, 2018-2022), which is a longitudinal survey for Americans. Participants included adults aged 50 years who were free of cardiometabolic disease (CMD) at baseline. DSI encompasses vision impairment (VI) and hearing impairment (HI). CMM is defined as the coexistence of two or more CMDs, including diabetes, heart disease, and stroke. DSI and CMM were assessed through self-reporting, frailty was assessed using the frailty index (FI). The group-based trajectory model (GBTM) was employed to fit the DSI trajectories. Cox proportional hazards models were applied to evaluate potential risk and mediating role. A total of 5933 participants were included, the incidence density of CMM is 3.034/1000 person-years during the 4-year follow-up. This study identified three DSI trajectories: persistently low DSI (n = 1798, 30.305%), persistently moderate DSI (n = 2975, 50.143%), and persistently high DSI (n = 1160, 19.551%). Compared with the persistently low DSI, persistently high DSI has a higher risk of CMM (HR: 2.014, 95%CI: 1.087, 3.732), specifically, CMD (HR: 1.515, 95%CI: 1.289, 1.780), diabetes (HR: 1.483, 95%CI: 1.179, 1.864), heart disease (HR: 1.459, 95%CI: 1.153, 1.846), stroke (HR: 2.136, 95%CI: 1.301, 3.506). Notably, frailty mediated 26.93% of the association between persistently high DSI and new-onset CMD. Mediation effects for diabetes, heart disease, and stroke were 21.52%, 34.31%, and 38.81%, respectively. DSI was associated with an increased risk of CMM, and this association is partially mediated by frailty.
Gastrointestinal endoscopy has undergone rapid technological evolution, yet many clinician innovators remain unfamiliar with the pathways required to translate ideas into commercially viable technologies. This practical primer from the ASGE Fostering Innovation Task Force provides an overview of the innovation and commercialization process for endoscopists, including concept development, prototyping, intellectual property strategy, regulatory pathways, startup formation, funding mechanisms, and common pitfalls that hinder successful translation. The article also reviews the roles of technology transfer offices, FDA regulatory frameworks, reimbursement considerations, and emerging issues related to software and artificial intelligence-enabled medical devices. By outlining key strategic, regulatory, and operational considerations, this primer aims to equip clinician innovators with foundational knowledge to navigate the pathway from unmet clinical need to scalable endoscopic technology.
Oncolytic virotherapy represents a promising yet under-explored approach for precision cancer treatment, particularly when tailored to tumor-specific molecular profiles. Patients with high-grade isocitrate dehydrogenase (IDH) mutant astrocytomas have limited treatment options and poor prognoses. Here, we investigate the therapeutic efficacy of rQNestin34.5 v.2 (CAN-3110), an engineered oncolytic herpes simplex virus 1 (oHSV-1), in IDH1-R132H-mutant diffuse gliomas. We demonstrate that the IDH1-R132H mutation enhances glioma susceptibility to viral infection through upregulation of Nectin-1, the main HSV-1 entry receptor. Concurrently, IDH1-R132H-driven DNA hypermethylation suppresses interferon (IFN) signaling, creating a permissive microenvironment that facilitates viral replication and tumor cell apoptosis. In immunocompetent murine glioma models, intratumoral administration of rQNestin34.5 v.2 induces robust antitumor immune activation, including increased immune infiltration and systemic IFN-γ release. However, elevated expression of poliovirus receptor (PVR) and the immune checkpoint T-cell immunoreceptor with immunoglobulin and ITIM domain (TIGIT) on tumor-infiltrating leukocytes suggests a potential resistance mechanism to virotherapy. Combining rQNestin34.5 v.2 with TIGIT blockade enhances therapeutic efficacy compared to monotherapy, identifying IDH1-R132H as a potential predictive biomarker for oncolytic virotherapy response.
In this article, an advanced nonlinear control strategy is proposed to address the trajectory tracking problem of a quadrotor under external disturbances. The controller is formulated as an Adaptive Fractional-Order Sliding Mode Controller (AFOSMC), which employs a super-twisting reaching law to achieve robust tracking, while an adaptive barrier function is incorporated to alleviate the effects of control signal saturation. In addition, the conventional discontinuous signum function is replaced with a smooth saturation function to effectively mitigate the chattering phenomenon. To further strengthen the performance of AFOSMC, ant colony optimization is used for tuning the controller gain parameters. The quadrotor dynamics are derived using the Euler-Lagrange formulation, providing a rigorous basis for controller design. Lyapunov-based analysis is conducted to verify system stability, ensuring reliable operation under varying conditions. Additionally, stochastic noise is incorporated into the quadrotor model to investigate the proposed controller's robustness. The proposed strategy is evaluated via numerical simulations, while its practical applicability is further assessed using controller-in-the-loop experiments. The obtained findings indicate that AFOSMC provides improved tracking precision while maintaining robustness and smooth control action.
Objectives: We argue that the current landscape requires not only clinical competency but also care systems capable of supporting providers operating within politically and organizationally ambiguous environments. More specifically, we propose a forward-looking framework that emphasizes actionable strategies to strengthen interdisciplinary collaboration, formalize community partnerships, and support sustainability. Background: Gender-affirming care in college health settings is supported by an evidence base demonstrating improvements in mental health, academic persistence, and well-being among transgender and gender diverse students. However, implementation has become constrained by legislative uncertainty, bureaucracy, and burnout. This commentary builds on the 2023 White Paper: Gender Affirming Care in College Health, the American College Health Association's Trans-Inclusive College Health Programs guidelines, and Ilgen and Dhaliwal's (N Engl J Med. 2025;393(16):1624-1632) article, "Educational Strategies to Prepare Trainees for Clinical Uncertainty." Conclusion: Such approaches are necessary to preserve access to affirming care and ensure continuity of services amid structural and policy-related pressures within higher education health systems.
Mental health stigma and underutilization of psychiatric care remain significant challenges in Asian American, Native Hawaiian, and Pacific Islander (AANHPI) communities, driven by cultural norms of silence, the model minority myth, and structural barriers to care. Narrative medicine, a clinical approach that utilizes storytelling, reflective writing, and deep listening, offers a promising approach to address these challenges by centering identity, voice, and meaning making in mental health engagement, processes that are foundational to psychological healing. In this Perspective, we describe "A is for ___", a novel narrative medicine-based empowerment framework developed through A-Team Med, a community-based nonprofit organization. The framework is left intentionally blank to symbolize the tremendous diversity of the AANHPI experience and counter monolithic representations of Asian American identity. Applied in community settings, the framework invites participants to complete the prompt "A is for ___" by selecting a personally meaningful word beginning with the letter "A" that reflects the individual's AANHPI lived experience. This open-ended structure serves as an accessible entry point for self-authorship, critical reflection, and dialogue about the AANHPI experience and mental health topics traditionally underdiscussed within this community. We situate this intervention within theories of narrative identity, cultural psychiatry, and the social determinants of mental health. We describe the implementation of this framework in a community workshop with over 50 AANHPI adolescents across multiple underserved community centers in Los Angeles. Author observations of participant experiences suggest that the exercise facilitated emotional expression, reduced stigma surrounding mental health conversations, and fostered validation and a sense of belonging. We further discuss practical applications of this framework in clinical encounters, community psychoeducation, and youth programs, as well as its potential for digital and telehealth adaptation. By reframing mental health engagement through narrative agency rather than pathology, "A is for ___" offers a low-cost, scalable, and culturally responsive tool to support mental health destigmatization and empowerment in AANHPI and other marginalized communities.
Studies have suggested that the quality of the lands surrounding habitat patches can modify the effects of habitat loss and fragmentation on species and influence biodiversity predictions across regions. As landscape matrices tend to be complex and vary with habitat change, isolating such effects is challenging. Here we disentangle the effects of habitat loss, fragmentation and surrounding landscape quality in a large, multiscale manipulative experiment on a plant-herbivore system. We find that habitat loss, fragmentation and surrounding matrix quality all affect survival rates, with the greatest negative effects of fragmentation and lower matrix quality under high habitat loss. Demographic rate changes resulted in strong negative effects of habitat loss, fragmentation and low matrix quality on population size at the landscape scale. Our findings indicate that the benefits of high landscape quality are greater in landscapes with low habitat fragmentation, contesting the common expectation that the surrounding matrix matters only in the most fragmented landscapes. This underscores that the quality of the surrounding landscape can have outsized effects on biodiversity in remaining habitats.
暂无摘要（点击查看详情）
Winners of aggressive intergroup encounters are often assumed to benefit from increased access to resources, but few studies have measured whether there is differential access to resources based on the intergroup outcome. To investigate whether winning intergroup encounters is associated with increased access to food, we used 13 months of data on intergroup dynamics, feeding by 61 females, and the phenology and spatial distributions of food trees from the home ranges of 8 groups of white-thighed black-and-white colobus (Colobus vellerosus) at Boabeng-Fiema, Ghana. Contested trees were important food species more often than expected based on the occurrence of these species in the study area. Contested trees had young leaves, fruits, and seeds more often than expected based on the presence of these plant parts on trees monitored via monthly phenology surveys. Focal females were more likely to feed on the contested tree than other trees they were in during and immediately after the intergroup encounter. Based on group scan data collected throughout the day of an intergroup encounter, the likelihood of females feeding on any food species before and during the intergroup encounter was similar regardless of the outcome. The likelihood of feeding was higher after the intergroup encounter if the group had won compared to if the group had lost. These findings indicate that groups compete over access to important food resources and winners benefit from increased access to food. Future studies should investigate whether winning intergroup encounters is associated with long-term benefits such as increased reproductive success.
Broad demographic representation is important in population-based research to enhance generalizability. The purpose of this manuscript is to describe strategies used to promote broad representation in the RISE FOR HEALTH study (RISE), consistent with its prioritized representation goals; and to compare participants to American women to gauge the success of these strategies. RISE was a large population-based cohort study of community-dwelling women selected by probability sampling of adult female residents of 57 geographically dispersed U.S. counties. Participation entailed completing self-administered surveys and an optional in-person assessment. Diversity goals and associated strategies were to: 1) ensure representation by race, ethnicity, and age similar to the U.S. population (by stratified probability sampling from a large marketing database); 2) remove barriers to participation by preferred Spanish language speakers (cultural adaptation, linguistic translation, bilingual mailings); and 3) promote diversity more broadly (marketing-style materials, community engagement). In 2024-2025, participant characteristics were compared to those of American women, using data from two national surveys (American Community Survey, National Health and Nutrition Examination Survey). 3,400 participants (of 50,367 invited) completed the baseline survey from 2022-2023 and were eligible. Consistent with the stratified sampling plan, participants were similar to the U.S. population with respect to race, ethnicity, and age. In contrast, they differed by Spanish as a primary language spoken (4.4% versus 12.9% in the U.S.) and completion of a high school degree or less (13.8% versus 35.9%). Strategies designed to promote diversity were variably successful in RISE, offering insight for future population-based research.
Parental distress impacts children's emotional adjustment, highlighting the need to identify protective factors. Promising candidates include positive control (i.e., autonomy support, indexed by parental encouragement, praise, and open-ended questions) and representational mind-mindedness (the propensity for parents to view children as independent agents). To counterbalance the focus on European and North American samples, we included 849 parent-child dyads from England, Hong Kong and Mainland China (Mchild age = 5.17 years, SD = 0.51). Parents rated their own distress and child internalizing problems; their interactions with their children were assessed for positive control, and their speech samples were coded for representational mind-mindedness. In a single-paper meta-analysis, parental distress was associated with elevated child internalizing problems and low positive control consistently across sites, but only associated with low mind-mindedness in England. Within-site analyses showed that intergenerational associations in distress-internalizing problems were attenuated by positive control in Mainland China and by mind-mindedness in England; multi-group modeling demonstrated that this latter effect was site-specific. These findings highlight the importance of widening the cultural scope of this research field.
To assess if hospitals with high physician employment differ in risk-standardized mortality and readmission rates. A cross-sectional evaluation of data from the 2021 Hospital Readmission Reduction program, Hospital Value-Based Purchasing Program, American Hospital Association and Area Health Resource Files was utilized. A binary variable was created to identify hospitals with ≤ 50% or >50% employed physicians. Dependent variables included 30-day mortality and readmission rates for acute myocardial infarction (AMI), congestive heart failure (CHF), pneumonia (PN), and chronic obstructive pulmonary disease (COPD) hospitalizations. Propensity score matching was utilized to compare hospitals. The final matched cohort compared 200 hospitals in each group ( ≤ 50% physicians and > 50% physicians). After matching, hospitals with > 50% physician employment were associated with improved mortality scores for AMI (-0.36, 95% CI: -0.58, -0.14), COPD (-0.38, 95% CI: -0.63, -0.14), and PN (-0.71, 95% CI: -1.15, -0.27). No significant differences were noted for CHF mortality or readmission rates. There has been a growth in hospitals employing physician in the United States. This work demonstrates that hospitals with higher physician employment levels are associated with lower mortality scores. This likely reflects a broader organizational phenotype characterized by alignment, scale and clinical integration rather than physician employment as an isolated strategy. Further research should examine organizational features to better disentangle the structure and combination of organizational characteristics underlying these associations.
Cycle ergometer in the postoperative period of open-heart surgery is a safe and economical exercise option. However, its specific effects, whether or not associated with conventional physiotherapy, are not well established in current literature. The objective of this study was to evaluate the effects of cycle ergometer exercise associated or not with conventional physical therapy, compared with only conventional physical therapy, on functional capacity, hospitalization time, peripheral muscle strength, and pulmonary complications of patients after open-heart surgery. MEDLINE, Cumulative Index to Nursing & Allied Health Literature, Latin American and Caribbean Health Sciences Literature, Web of Science, Scopus, Embase, Physiotherapy Evidence Database, and Cochrane Library were searched; manual searches were also conducted in the references of the included studies. Randomized controlled trials that analyzed the effects of cycle ergometer exercise associated or not with conventional physical therapy compared with only conventional physical therapy in adult patients after an open-heart surgery were included. Methodological quality was assessed by Cochrane risk-of-bias tool, and the meta-analysis was undertaken using RevMan 5.3. Mean difference in the six-minute walk test (31 meters, 95% confidence interval [CI]: 1.59 to 60.3 meters, P = 0.04) was higher and in intensive care unit stay was lower (-0.5 days, 95% CI: -0.86 to -0.14 days, P = 0.007) in the intervention group. The total hospitalization time (-0.18 days, 95% CI: -0.73 to 0.38 days, P = 0.53) didn't change between groups. Cycle ergometer exercises improved functional capacity but with no clinically relevant effects on hospitalization time after open-heart surgeries.
Diastolic dysfunction, defined by impaired relaxation and increased ventricular stiffness, is central to heart failure with preserved ejection fraction, yet cardiomyocyte-intrinsic mechanisms remain incompletely understood. Here, we show that SORBS2 is a vital component of murine cardiomyocyte adhesion complexes. Its genetic ablation in mice causes progressive diastolic dysfunction with preserved systolic function, accompanied by atrial enlargement and reduced survival. Postnatal cardiomyocyte-directed re-expression of SORBS2 restores diastolic indices and significantly improves longevity. Mechanistically, SORBS2 functions as an integrative scaffold linking adhesome integrity, cytoskeletal remodeling, and calcium homeostasis. SORBS2 deficiency increases microtubule detyrosination, reduces SERCA2 abundance, disrupts dyad-associated organization, which collectively impair active cardiomyocyte relaxation. Concurrently, this deficiency promotes extracellular matrix remodeling and myocardial fibrosis, driving passive ventricular stiffness. Pharmacological inhibition of microtubule detyrosination partially rescues relaxation defects. These findings establish SORBS2 as a key regulator of diastolic function and define a structural axis governing myocardial mechanics, offering potential therapeutic targets.
There are some major controversies surrounding the use and longevity of pyrocarbon interposition shoulder arthroplasty (PISA). The objective of this study was to investigate the long-term survival and outcomes (minimum 10-year) following PISA for osteoarthritis (OA) in young and active patients. This was a retrospective review of prospectively collected data of patients who underwent PISA (InSpyre; Tornier-Stryker) for OA between 2009 and 2012. Arthroplasty survival was known for 71 patients followed longitudinally for a minimum of 10 years. The clinical and radiologic outcomes were assessed in 62 patients (62 shoulders) reviewed with radiographs. The mean age at surgery was 60 years (range, 23-72 years), and 31 shoulders (50%) underwent prior surgery before PISA. The diagnosis was primary osteoarthritis (POA = 29), post-traumatic osteoarthritis (PTOA = 23), and postinstability osterarthritis (PIOA = 10). Clinical failure was defined as repeat surgical intervention involving prosthesis revision. Clinical outcomes were assessed with the Constant score (CS) and Subjective Shoulder Value (SSV). The mean duration of follow-up was 11 ± 0.6 years (range, 10-14 years). Overall, the survival rate was 90% (95% confidence interval [CI] 82.8-96.8) at 5 years and 87% (95% CI 79-94.8) at a 10-year follow-up. Survival was 100% in PTOA (type 1 fracture sequelae) and in PIOA as well as 95% in primary OA with type A glenoid. Revision surgery was significantly higher in biconcave (type B2) glenoid (44%) compared with concentric (type A) glenoid (2%), respectively (P = .002). Among the 7 patients who were revised to reverse shoulder arthroplasty, 5 had painful glenoid erosion and 2 had bipolar (glenoid and humeral) erosion with thinning and finally fracture of the greater tuberosity. Two shoulders with glenohumeral erosion were associated with secondary rotator cuff tears (1 supraspinatus and 1 subscapularis tear). The mean time to revision and revision was 4 ± 1.7 years. Glenoid wear was more often superior (81%) than central (19%), P < .001. For those shoulders not revised, the mean CS and SSV significantly increased from 39 ± 14 to 70 ± 14 points and 34% ± 15% to 75% ± 17%, respectively (P < .001). PISA is an efficient and durable surgical procedure for the treatment of young and active patients with post-traumatic OA, postinstability OA, and primary OA with concentric (type A) glenoid erosion, but not for those with biconcave (type B2) glenoid. Biconcave (type B2) glenoid and subscapularis tear or insufficiency are risk factors for failure and revision.
Acromial stress fractures can occur after reverse total shoulder arthroplasty (rTSA). We performed this study to assess the incidence, risk factors, characteristics, and outcome of acromial stress fractures and reactions after rTSA. We determined the incidence of acromial stress fractures and reactions in a cohort of patients who underwent rTSA, and assessed risk factors using a case-control design. Each patient who developed an acromial stress fracture or reaction after rTSA (case) was matched by date of rTSA with 2 patients who did not develop acromial stress fractures/reactions after rTSA (control subjects); univariate and multivariable analyses were performed to identify risk factors. Characteristics of acromial stress fractures/reactions are described. Outcomes were compared between cases and control subjects. The incidence of acromial stress fracture/reaction after rTSA was 11% (24/220 rTSAs). Acromial stress fractures/reactions occurred at a median time of 5.5 months after rTSA (range: 20 days-118 months) and most were fractures (18/24, 75%). Using a multivariable analysis, we found 2 factors to be independently associated with the occurrence of an acromial stress fracture/reaction after rTSA: corticosteroids use (adjusted OR: 9.6, 95% confidence interval: 1.1-86.1, P = .04) and previous shoulder surgery (adjusted OR: 7.2, 95% confidence interval: 1.4-36.6, P = .02). In this cohort, in which the management was exclusively conservative, the occurrence of post-rTSA acromial stress fracture/reaction was associated with a significantly worse functional outcome at last follow-up visit, as compared with control subjects. This was illustrated by significantly lower American Shoulder and Elbow Surgeons Shoulder score, higher Shoulder Pain and Disability Index and Disabilities of the Arm, Shoulder and Hand scores, and worse forward elevation and internal rotation as compared with control patients who did not develop acromial stress fracture/reaction after rTSA. In our Australian cohort, acromial stress fractures/reactions were relatively common after rTSA, and independently associated with corticosteroids use and previous shoulder surgery. The occurrence of acromial stress fracture/reaction was associated with a significantly worse functional outcome, as compared with patients who do not develop this complication after rTSA.
Fibronodular hepatocellular carcinoma (FN-HCC) is a newly described variant of hepatocellular carcinoma (HCC), with only 29 cases reported. Histologically, it is divided into multiple smaller, well-defined tumor nodules by extensive fibrosis. Its differential diagnosis includes other HCC variants characterized by fibrous stroma, such as fibrolamellar hepatocellular carcinoma and scirrhous hepatocellular carcinoma. Fibronodular hyperplasia may also be considered in the differential diagnosis. We are reporting 7 cases to help better understand this entity. We retrospectively identified 7 cases of FN-HCC and analyzed the clinical and histologic features of each tumor, as well as disease progression and patient prognosis. The FN-HCC cases were diagnosed at a median age of 58 years (range, 40-75 years), with a male predilection (n = 6, 86%). Most patients were White (n = 6, 86%), and 1 was African American (n = 1, 14%). Tumors had a mean size of 3.15 cm (range, 1-9 cm) and were mainly located in the right lobe (n = 5, 71%). Background liver was cirrhotic in 6 cases (86%). Five patients were hepatitis C positive (71%). All tumors were surgically removed, with a free resection margin. Among 3 patients with evident vascular invasion, 1 had a positive lymph node. This patient had tumor metastasis 6 years later; otherwise, all patients were disease free on follow-up. Our cohort was concordant with published data showing a male predilection, hepatitis C association, and good prognosis when the disease is discovered before metastasis and is surgically excised with negative margins. However, it contradicts the published literature that associates FN-HCC with the absence of advanced fibrosis/cirrhosis.