Social connection is a core determinant of mental and physical health, and connection-oriented services (e.g. peer programmes, groups, and social prescribing) are increasingly implemented. Yet social connection is culturally patterned. When participants' interaction styles align with a service's implicit organisational norms, belonging may be easier to achieve; when they do not, cultural mismatch may reduce recognition, constrain participation, and intensify loneliness, leaving some participants feeling more disconnected. This paper operationalises organisational norms around participation and help-seeking using three sociological elements (symbols, values, and norms), and proposes a brief reflective audit that can be embedded in routine quality improvement. The audit is intended to help services make implicit rules of engagement more visible (e.g. expectations around disclosure, turn-taking, help-seeking, disagreement, and what counts as "good participation"), and identify which interaction styles are more readily recognised versus under-supported. Two possible outputs are proposed: (1) a participant-facing, plain-language participation brief that may improve clarity about how participation works; and (2) an internal action plan intended to widen routes to connection (e.g. structured turn-taking, opt-in written or one-to-one routes, small-group formats, and facilitator prompts validating quiet participation). Making organisational norms more explicit may offer a practical reflective approach to strengthen inclusivity by design in connection-focused services.
Cytochrome P4501A (CYP1A) is a widely used biomarker of environmental stress in fish, primarily associated with xenobiotic metabolism but also responsive to broader changes in water quality. This study provides a region-specific, field-based assessment of hepatic CYP1A responses in Cyprinus carpio in relation to nutrient enrichment across freshwater lakes of the North-Western Himalayas. Fish and water samples were collected monthly over two consecutive years from four lakes representing contrasting trophic conditions Viz Dal, Wular, Manasbal, and Nilnag along with laboratory-maintained control fish. Hepatic CYP1A concentrations were quantified, and concurrent measurements of total phosphorus, nitrate-nitrogen, ammonical nitrogen, dissolved oxygen, temperature, and pH were conducted.CYP1A levels showed pronounced spatial and seasonal variability, with significantly higher concentrations in fish from nutrient-enriched lakes, particularly Dal and Wular, compared to less impacted lakes and laboratory controls. These lakes were characterised by elevated nutrient concentrations and comparatively lower dissolved oxygen levels, reflecting eutrophic conditions. To appropriately address repeated monthly sampling and non-independence of observations, linear mixed-effects models were applied, incorporating lake and season as fixed effects and sampling event as a random effect. Model outputs indicated that total phosphorus and nitrate-nitrogen were significant predictors of CYP1A variation after accounting for seasonal and site-specific effects, whereas ammonical nitrogen showed no independent influence. The results suggest that nutrient enrichment indirectly modulates CYP1A expression through altered environmental conditions such as oxygen availability and metabolic stress rather than direct contaminant exposure alone. Overall, this study demonstrates the utility of CYP1A as an integrative biomarker of ecological stress under eutrophic conditions and highlights the importance of mixed-effects modelling in long-term freshwater biomonitoring.
Sex-related differences have been consistently reported in the epidemiology of acute hypoxemic respiratory failure (AHRF) and COVID-19. However, whether computed tomography (CT)-derived measures of lung injury differ between sexes and contribute to outcome disparities remains unclear. In this large multicenter retrospective cohort study, we analyzed 850 spontaneously breathing patients with COVID-19-related AHRF who underwent early chest CT at hospital admission. Quantitative CT analysis provided measures of lung density, volume, mass, and superimposed pressure (SP), a CT-derived estimate of gravitational stress. Sex-stratified analyses compared morphological, physiological, and outcome variables. Multivariable logistic regression models identified independent predictors of mortality. Among 850 patients (35% women), men exhibited larger lung volume (2.91 vs. 2.28 L, p < 0.001), greater lung mass (1.14 vs. 0.93 kg, p < 0.001), and higher SP (5.79 vs. 5.21 cmH₂O, p < 0.001) despite similar fractions of ground-glass opacities and consolidation. In the multivariable model, older age (OR 1.08, 95% CI 1.06-1.11; p < 0.001), lower PaO2/FiO2 (OR 0.99, 95% CI 0.98-0.99; p < 0.001), higher SOFA score (OR 2.67, 95% CI 1.43-4.98; p = 0.002 for SOFA ≥ 2), higher global SP (OR 1.18, 95% CI 1.05-1.34; p = 0.005), and male sex (OR 1.76, 95% CI 1.06-2.92; p = 0.028) were independently associated with an increased risk of mortality. In the mediation analysis, the effect of global SP on mortality does not appear to be mediated by male sex (coefficient 0.00). Male patients with COVID-19-related AHRF exhibited higher global SP than females, reflecting greater gravitational lung load and mechanical disadvantage. Both global SP and male sex were independently associated with mortality, with no evidence of mediation of male sex on mortality. These finding suggest that, beyond anatomical and mechanical differences, biological and hormonal factors likely contribute to the increased disease severity observed in men.
Recurrence after hiatal/paraesophageal hernia repair is variably defined, and radiographic criteria may overestimate clinically meaningful failure. We evaluated the incidence, timing, and operative predictors of recurrence, defined pragmatically as reoperation, in a large multi-hospital cohort. Retrospective cohort study of adults undergoing hiatal and/or paraesophageal hernia repair (April 2017-April 2025) using an enterprise administrative/operative database. Cases were identified using CPT codes supplemented by operative descriptors and nursing documentation. Patients with prior or concurrent bariatric surgery were excluded. The index repair was the first qualifying repair within the study window. The primary endpoint was clinically significant recurrence, defined as subsequent hiatal/paraesophageal hernia reoperation. Time-to-event was analyzed using survival models that incorporated operative factors and accounted for clustering. Among 2779 repairs, 900 bariatric-associated cases were excluded, leaving 1876 index repairs across 21 hospitals and 70 surgeons. Approach was laparoscopic in 49.3% and robotic in 48.0% (open 2.0%, thoracotomy 0.7%). Mesh was used in 51.1% and fundoplication in 39.4%. During follow-up, 49 reoperations (2.6%) occurred. Time to reoperation clustered early (median 348 days [IQR 107-623]), with follow-up extending to 3023 days. In unadjusted comparisons, reoperation was less frequent after fundoplication (1.86 vs. 2.99%) and more frequent with mesh reinforcement (3.04 vs. 2.03%). In adjusted time-to-event models accounting for clustering, fundoplication was independently associated with a lower hazard of reoperation, whereas mesh use was associated with a higher hazard. In routine practice, reoperation after hiatal/paraesophageal hernia repair was uncommon and concentrated within the first several postoperative years. Fundoplication was associated with lower risk of clinically significant recurrence, while mesh use identified higher-risk cases, likely reflecting operative complexity.
Urban river restoration requires understanding water-ecosystem coupling. This study investigated microhabitat construction effects across five Beijing river basins and a demonstration site. At 47 basin-wide monitoring sites (2024-2025), BOD5 and CODmn decreased (p < 0.01), while phytoplankton increased (p < 0.001), reflecting persistent eutrophication. TN was the strongest predictor of biodiversity (r = -0.773, p < 0.0001). PCA showed PC1 and PC2 explained 73.88% of total variance (PC1: 40.24%, PC2: 33.64%). At the Jinghe River demonstration site, integrated restoration was associated with 80.5% phytoplankton reduction (t = -4.690, p = 0.0001), transparency improved from 40-50 cm to 70-100 cm, and submerged vegetation exceeded 40%. Due to the observational design without control sites, causal attribution cannot be established; the results demonstrate associations between integrated restoration (∼200 yuan/m2) and improved ecological conditions, offering a cost-effective nature-based solution for water-scarce megacities.
This study evaluates the temporal occurrence of A-phases (TOAP) across superficial and deep electroencephalogram (EEG) recordings to investigate their self-similarity and regulation dynamics across different brain depths during sleep. Sleep recordings from 10 epileptic patients were analyzed to characterize the TOAP in scalp, neocortex (NC), and hippocampus (HPC) signal recordings. TOAP was represented as a binary series, with '1' indicating the presence and '0' the absence of an A-phase. Detrended fluctuation analysis (DFA) was applied to evaluate scale-free properties, and entropy metrics were used to quantify the occurrence probability of symbolic patterns in the binary signal. Mono and multiscale approaches captured TOAP dynamics across different time scales. DFA results revealed consistent correlation properties in TOAP across scalp and deep brain recordings. Monoscale analysis showed persistent long-range correlations, and multiscale analysis indicated a decrease in the scaling exponent from approximately 1.5 toward 0.5 at short scales, and the opposite trend at longer scales. Entropy analysis showed that the TOAP pattern distribution varies with brain region and scale, with higher diversity at the scalp and lower in the NC and HPC. Shannon entropy was positively correlated with cyclic alternating pattern rate. TOAP exhibits consistent scaling across brain regions, suggesting that A-phases follow a unified temporal structure throughout the brain, potentially reflecting a global mechanism of EEG modulation during sleep. In addition, entropy variations suggest that anatomical location and the analysis scale modulate A-phase occurrence. There is a potential relationship between symbolic entropy of TOAP patterns and sleep instability.
Sleep disturbances are common in endogenous Cushing's syndrome (CS), impair quality of life, and often persist despite remission. We evaluated the diagnostic value of actigraphy in suspected CS, characterised sleep and rest-activity patterns during remission, and examined associations between late-night salivary cortisol (LNSC) and objective sleep measures. Exploratory prospective single-centre cohort study at LMU Hospital Munich with two cohorts: (1) individuals evaluated for suspected CS and (2) patients in remission, stratified by recovered versus persistent adrenal insufficiency. Participants wore an ActTrust2 actigraph for 21 days, provided daily LNSC samples, and completed the Munich Chronotype Questionnaire. Cohort 1 included 16 patients with confirmed CS and 13 with exclusion of CS. Actigraphy detected comparable sleep efficiency, fragmentation and circadian rest-activity rhythms in both groups, without distinct alterations attributable to active CS, except for a significantly earlier chronotype (p=0.022). Cohort 2 comprised 23 patients in remission (13 with persistent, 10 with recovered adrenal insufficiency) and showed similar sleep characteristics across subgroups. LNSC revealed high inter- and intraindividual variability without consistent associations with actigraphy-derived sleep parameters. Statistically significant effects were confined to patients with persistent adrenal insufficiency, in whom higher LNSC (likely reflecting non-physiological replacement therapy) was associated with earlier bedtime, longer time in bed, prolonged sleep-onset latency, and reduced sleep efficiency. Apart from chronotype, actigraphy showed limited discriminatory value between clinical groups. LNSC was highly variable and showed no consistent associations with sleep parameters, underscoring the need for improved biomarkers and monitoring strategies in CS.
Cystic fibrosis (CF) is a genetic lung disease in which thick mucus builds up in the airways, making patients highly vulnerable to chronic bacterial infections. One of the most problematic bacteria in these infections is Pseudomonas aeruginosa, an adaptable microbe that can survive antibiotics and persist in the lungs for many years. This bacterium uses a communication system called "quorum sensing (QS)" to coordinate group behaviors. Through this system, bacterial cells sense their population density and collectively switch on genes that control toxin production, biofilm formation, and resistance to treatment. In cystic fibrosis lungs, the protective lung surfactant layer, especially a major lipid component called dipalmitoylphosphatidylcholine (DPPC), becomes altered due to chronic inflammation. Emerging evidence suggests that altered surfactant lipids may influence bacterial behavior in addition to reflecting lung damage. Instead, they may actively signal to P. aeruginosa, triggering its QS system earlier than expected. This early activation promotes virulence, biofilm persistence, and long-term infection. This review highlights how host lung lipids interact with bacterial communication networks and discuss how targeting QS using surfactant-inspired molecules may offer new therapeutic strategies. Understanding this host-pathogen interaction could lead to innovative anti virulence treatments that weaken the bacteria without directly killing them, potentially reducing antibiotic resistance.
There has been an increasing interest in the use of classic psychedelics (such as psilocybin) and 3,4-methylenedioxymethamphetamine (MDMA) for treating mental health conditions. Individuals often describe psychedelic sessions as among the most significant experiences in their lives, emphasizing the sense of awe, connectedness, and spiritual transformation taking place. While the psychedelic literature from the past two decades has mostly focused on using these drugs in the treatment of major depressive, anxiety, and substance use disorders, researchers have also investigated the utility of classic psychedelics and MDMA for other conditions, including trauma- and stressor-related disorders. Trauma can profoundly affect biological systems, including stress hormone pathways and neural circuitry, often leading to hyperarousal and rigid cognitions. In this article, we discuss how some of the concepts posited by Wilfred Bion can be applied to neurobiological models of the mind and to the effects of these drugs. Relevant concepts from neurodevelopment are presented first, including how key areas can be significantly affected by early adversity. This is followed by a discussion of Bion's theory of containment and of how the K link (K denoting knowledge) is developed or disrupted, depending on one's experience. Finally, we present extant literature on the use of MDMA and classic psychedelics in trauma disorders, reflecting on how a Bionian lens can enrich our understanding of their therapeutic action.
Chronic insomnia, as defined by the DSM-5 and ICSD-3, is characterized by difficulties falling asleep, maintaining sleep, or waking up too early, occurring at least three times a week for more than three months, with daytime consequences. Long considered a secondary symptom, it is now recognized as a distinct condition resulting from a persistent disruption of sleep-wake regulation. Genetic and epigenetic studies show substantial heritability, suggesting a strong biological influence. More than 500 loci have been identified, linking insomnia to both metabolic and psychiatric traits. Gene-environment interactions, particularly through DNA methylation, may explain how stress can durably alter sleep system reactivity and promote chronicity. Brain imaging research highlights hyperactivation of key regions such as the anterior cingulate cortex, thalamus, insula, and precuneus, which are involved in arousal, vigilance, and emotional regulation. Electroencephalography confirms increased cortical activity, particularly in the beta and alpha bands, reflecting a persistent state of wakefulness during sleep. Explanatory models describe a set of mechanisms in which conditioning, stress reactivity, and co-activation of sleep and wake networks maintain the disorder. Insomnia thus appears as a hybrid state between wakefulness and sleep. These advances underline the complexity of insomnia and the need for integrated therapeutic approaches combining cognitive, behavioral, and physiological interventions to restore normal sleep regulation.
Robotic pancreatoduodenectomy (RPD) has emerged as a safe and feasible alternative to open surgery, extending the benefits of minimally invasive surgery to complex pancreatic procedures. However, standardized and comparable metrics to evaluate surgical quality in RPD remain limited. This study aimed to evaluate surgical and oncologic textbook outcomes (TO and TOO) and to identify predictors of success across multiple European centers. All consecutive RPDs performed between 2010 and 2024 in six European pancreatic centers were retrospectively analyzed. Textbook outcome (TO) was defined as the absence of major complications (Clavien-Dindo ≥ III), clinically relevant pancreatic fistula, post-pancreatectomy hemorrhage or bile leak, 30-day or in-hospital mortality, and 30-day readmission. An extended composite (TO + LOS) additionally incorporated prolonged hospital stay (> 14 days). In patients with pancreatic ductal adenocarcinoma (PDAC), textbook oncologic outcome (TOO) included six oncologic and perioperative quality items. A total of 403 RPDs were analyzed. Overall morbidity and major complications occurred in 61% and 26% of patients, respectively. TO and TO + LOS were achieved in 63% and 52% of cases, with no significant intercountry differences among countries. Independent predictors of TO were female sex (OR 2.32, p < 0.001), neoadjuvant therapy (OR 2.85, p = 0.018), preoperative biliary drainage (OR 1.87, p = 0.012), and shorter operative time (p < 0.001). Among 247 PDAC cases, TOO was achieved in 33.6%, mainly limited by inadequate lymph node retrieval. RPD achieves reproducible and high-quality composite outcomes across experienced European centers. Our findings suggests that these composite measures may provide a reliable tool for quality assessment in RPD, reflecting the combined impact of patient selection and perioperative management.
Recycling wastewater is one of the viable solutions to overcome freshwater scarcity; however, its suitability for reuse needs a systematic quality assessment. This study proposes an integrated hydrochemical and AI-based framework to evaluate the suitability of untreated domestic wastewater for a residential population of approximately 10,000 people at NIT Durgapur, West Bengal, India. Thirty-two samples from four different sources (boys, girls, residential, and junction point) were assessed to develop the Irrigation Water Quality Index (IWQI). Piper diagrams, Pearson correlation analysis, and principal component analysis (PCA) were used to interpret hydrochemical variations. A strong correlation was observed among EC, TDS, and major ions, while BOD and COD showed positive correlation and a negative relationship with dissolved oxygen. The wastewater was predominantly classified as mixed Ca2⁺-Mg2⁺-Cl⁻ type, reflecting anthropogenic influence, while PCA showed that the first two principal components explained 45.5% of the total variance, with salinity and organic contamination as significant controlling variables. IWQI values varied from 49.4 to 79.1 revealed that 84.4% of samples fall into combined poor (78.2%) and very poor (6.2%) categories, indicating the unsuitability for reuse. The sodium absorption ratio (SAR) values are between 0.41 and 1.03, signifying low sodium hazard. An artificial neural network (ANN) model (6-6-1-1 architecture) demonstrated strong predictive performance (R2 = 0.968, RMSE = 1.725), representing its reliability for IWQI estimation. Despite low sodium risk, elevated organic and ionic loads necessitate appropriate treatment before reuse. The research work provides an effective tool for decentralized wastewater management and reuse planning.
Crassostrea gigas survives in the intertidal zone by relying on tissue-specific mucus secreted by different organs. However, the macroscopic differentiation of mucus physical properties and their molecular mechanisms remain poorly understood. Here, we integrated proteomics and rheological analysis to investigate the molecular basis potentially underlying the viscosity hierarchy of mucus and its functional match across three key tissues (mantle, labial palps, and gill) in the C. gigas. Proteomic analysis suggested that varying levels of extracellular matrix (ECM) components and glycosaminoglycan (GAG) synthesis are closely associated with this physical hierarchy. Specifically, active GAG synthesis and high ECM enrichment in the labial palps are consistent with a dense hydrated gel network. In contrast, progressively lower ECM accumulation and downregulated carbohydrate metabolism in the mantle and gill correlate with weaker hydrogen bond networks. Rheological characterization suggested a clear viscosity hierarchy that is consistent with each tissue's physiological role: labial palps mucus displayed the highest complex viscosity (0.046 Pa·s), reflecting properties that may contribute to feeding; mantle mucus exhibits elastic-dominant suitable for surface protection; and gill mucus showed the lowest viscosity (0.028 Pa·s), which is consistent with facilitating gas exchange. Ultimately, this study indicates that tissue-specific molecular and metabolic profiles are associated with mucus viscoelasticity to meet physiological requirements. These findings not only provide insight into the tissue-specific molecular basis of mucus viscosity in C. gigas, but also provide inspiration for designing marine bionic intelligent hydrogels and the development of anti-corrosion coatings, addressing longstanding challenges in offshore engineering.
Chondrichthyans are among the most ancient vertebrates, and their morphology has enabled adaptation to diverse marine environments. In sharks, the head is the functional center for feeding, respiration, and sensory perception, reflecting a balance between phylogenetic constraints and ecological demands. Striking specializations, such as the cephalofoil of hammerhead sharks or the elongated rostrum of sawsharks, illustrate remarkable adaptations. Most studies on head shape have focused on single species or restricted clades, whereas broader analyses have focused on parts of the skull. We analyzed the ventral head morphology of 453 shark species (Selachii), focusing on the relative position of the rostrum, mouth, and nostrils (in a subset of 395 species), using standardized illustrations and landmark-based geometric morphometrics. Shape variation was related to ecological and anatomical factors. The morphological space reveals a phylogenetic signal, with reconstructed ancestral shapes close to the overall mean configuration, indicating strong morphological conservatism. Evolutionary model fitting supports Brownian motion dynamics with limited divergence from ancestral forms. Correlations with habitat and body size are weak, whereas stronger associations are observed with the number of olfactory lamellae. Our results provide a large-scale comparative framework of ventral head morphology in sharks, highlighting its evolutionary stability and predominant phylogenetic control.
The complexity of phenomena governing alloy crystal growth can be unraveled by examining the three-dimensional atomic-level distribution of elements and impurities incorporated during growth. These species act as fingerprints, revealing the thermodynamic constraints that shape material structure and composition. Herein, we combine transmission electron microscopy and atom probe tomography to investigate single tellurium (Te) inclusions within cadmium zinc telluride (CZT) monocrystals. These analyses uncover nanoscale precipitates embedded within Te inclusions, consisting of CZT nanocrystals with a Zn content of 1.5 at. %. Surrounding these precipitates, a ∼10 nm-thick shell, enriched with copper and indium impurities, is observed. In addition, traces of sodium and sulfur are detected within the nanocrystals. These findings provide direct evidence of the complex segregation and precipitation processes occurring during CZT crystal growth, reflecting the interplay between thermodynamic driving forces and kinetic constraints that govern solute redistribution. The resulting insights contribute to a deeper understanding of impurity behavior and phase separation mechanisms in CZT alloys.
This study aimed to evaluate global research trends in robotic surgery in andrology using a bibliometric approach. A comprehensive search was conducted in the Web of Science Core Collection using predefined keywords related to robotic-assisted techniques and andrological procedures. Publications between 2003 and 2025 were included. After applying eligibility criteria, 69 studies (37 articles and 32 reviews) were analyzed. Bibliometric analyses were performed using Biblioshiny and VOSviewer to assess publication output, citation patterns, leading sources, countries, authors, and collaborative networks. The results demonstrated fluctuations in annual scientific production, with the highest number of publications recorded in 2014. Citation trends varied across publication years. Publications were primarily concentrated in leading peer-reviewed journals in the fields of urology, andrology, and robotic surgery, reflecting the specialized and interdisciplinary nature of the field. The United States ranked first in both publication output and citation impact, while Turkey exhibited the highest collaborative strength based on total link strength. Keyword analysis identified vasovasostomy, microsurgery, varicocelectomy, and male infertility as the dominant research themes. Co-authorship and co-citation analyses indicated that the field is shaped by a limited number of influential authors and core studies. In conclusion, robotic surgery in andrology represents a steadily expanding research area characterized by increasing scientific output and evolving collaboration patterns. From a clinical perspective, the concentration of current evidence may limit its generalizability to broader practice. Future multicenter studies evaluating procedure-specific outcomes, functional results, pain relief, complications, long-term durability, and cost-effectiveness may further clarify the role of robotic techniques in andrology.
Outcomes of anterior cruciate ligament reconstruction (ACLR) vary significantly depending on autograft selection, particularly in restoring knee flexor and extensor strength, which are essential for athletic performance. The aim of this study was to investigate the impact of ACLR with different autografts on the recovery of knee flexor and extensor muscle strength. Subgroup analyses by follow-up duration were performed to characterize recovery across postoperative phases. A frequentist network meta-analysis of randomized controlled trials (RCT) and observational studies was conducted. Databases (PubMed, Embase, Web of Science, Cochrane Library) were searched from inception to January 2025. Eligible studies reported isokinetic strength outcomes after ACLR. The primary outcome was the limb symmetry index (LSI) for peak torque, which represented the ratio of injured-limb strength to uninjured-limb strength, reflecting inter-limb symmetry. Secondary outcomes were peak torque, the hamstring-to-quadriceps (H/Q) ratio and side-to-side deficit. Risk of bias (RoB) was assessed using the Cochrane RoB and the Risk of Bias Assessment Tool for Non-randomized Studies (RoBANS). Certainty of evidence was graded using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) framework. Graft performance was ranked using surface under the cumulative ranking curve (SUCRA) probabilities, and mean differences (MDs) with 95% confidence intervals (CIs) were calculated. Thirty-one studies involving 2384 patients were included in the quantitative analysis. For knee extensor strength, assessed using LSI at 60°/s, 4-strand semitendinosus tendon (4S-ST) and 4-strand hamstring tendon (4S-HT) autografts outperformed bone-patella tendon-bone (BPTB) and quadriceps tendon (QT) autografts. At 180°/s, the 4S-HT autograft showed higher knee extensor strength LSI than the QT autograft, significantly outperformed the BPTB autograft at long-term follow-up (≥ 18 months), and consistently ranked highest according to SUCRA. The BPTB autograft also showed higher knee extensor strength LSI than the QT autograft. For knee flexor strength (LSI, at 60°/s and 180°/s), the QT autograft outperformed the 4S-HT autograft, with SUCRA consistently identifying the QT autograft as the top-ranked option and the 4S-HT autograft as the lowest-ranked option. No significant intergroup LSI differences were observed at short-term follow-up (≤ 6 months), whereas QT autograft's superiority in knee flexor strength became evident in the mid-term follow-up (6-12 months). The 4S-ST autograft may be superior to 4S-HT autograft in knee flexor strength LSI. Network inconsistency tests showed no significant inconsistency. However, GRADE assessments rated the certainty of evidence for comparisons of knee extensor and flexor strength between autografts as very low to low. The 4S-HT autograft was associated with greater knee extensor strength LSI, whereas the QT autograft had the most consistent advantage in knee flexor strength LSI. The 4S-ST autograft ranked between these grafts, but may provide greater knee flexor strength LSI than the 4S-HT autograft. The BPTB autograft was associated with greater knee extensor strength LSI than the QT autograft. Given the very low to low certainty of evidence, these findings should be interpreted with caution. CRD42024530838.
Behavioral addictions, including internet addiction, gaming disorder, and problematic smartphone and social media use, represent an emerging public health concern among adolescents globally, with particular urgency in Latin America where research remains scarce and health system capacity is limited. This narrative review synthesizes evidence on prevalence, mental health comorbidities, social determinants, and gaps in care related to behavioral addictions in Latin American adolescents aged 10 to 19 years. A structured search was conducted in PubMed and the Virtual Health Library across four thematic axes, covering studies published from 2013 onwards. Four prevalence studies were identified, with estimates ranging from 10.6% to 54.9%, reflecting instrument heterogeneity rather than true geographic variation. ADHD, depression, anxiety, and suicidality are the most consistently documented comorbidities; addictive screen use is associated with risk ratios of 2.14 to 2.39 for suicidal behaviors. Socioeconomic deprivation, limited parental monitoring, and restricted access to offline alternatives amplify risk. Evidence-based interventions remain unevaluated in the region, ICD-11-aligned instruments validated for regional populations are largely lacking, and specialist workforce capacity is limited. This near-absence of data raises an equity concern with implications for health policy. Population-based surveillance, culturally adapted instruments, task-shifting models, and intersectoral digital governance are urgently needed.
This article proposes an updated conceptualization of the psychotherapeutic frame, emphasizing its adaptive functions, particularly in the treatment of patients with complex trauma histories or disrupted early attachment relationships. Although conventional views emphasizing the frame's static elements need to be considered, they are insufficient for managing complex relational dynamics, frame departures, impasses, and enactments that commonly arise in treatment with patients who have experienced significant trauma. Integrating insights from attachment theory and the neuroscience of memory systems, this article argues that the frame's interaction with implicit memory systems, especially procedural memory, underlies the frame's therapeutic significance. Departures from the frame are conceptualized primarily as activations of these procedural scripts, often reflecting attempts to navigate relational distress based on past experiences. A systematic, "frame-in" approach treatment is proposed, involving monitoring of six core frame constituents-roles, logistics, tasks/boundaries, goals, abstinence from maladaptive behaviors, and safety. This approach facilitates early detection and management of potentially disruptive enactments, protects the therapeutic alliance, helps regulate overwhelming affect, and promotes therapeutic implicit/procedural learning by modifying maladaptive relational patterns within a secure therapeutic framework. The frame-in approach is presented as a specific set of techniques for actively managing the therapeutic alliance, rather than viewing the alliance as a separate construct.
Severe hypertriglyceridemia can cause significant metabolic complications and spurious laboratory results, complicating clinical decision-making. Chylomicronemia syndromes, particularly multifactorial forms, are underrecognized, and may present with both pancreatitis and premature atherosclerotic cardiovascular disease. A 51-year-old man with diabetes and hypertension presented with chest pain and recent hypertriglyceridemia-induced normoenzymatic pancreatitis. Ischemic electrocardiographic changes prompted coronary angiography. Preprocedural testing showed a prothrombin time reported as "infinite" (no clot detected). Serum appeared grossly lipemic (triglycerides 4,038 mg/dL) with a creamy supernatant after centrifugation. Mixing study revealed normal coagulation parameters, confirming analytical interference rather than true coagulopathy. The combination of severe hypertriglyceridemia, relatively preserved apolipoprotein B, and multisystem manifestations favored a chylomicronemia phenotype (type IV-V spectrum). Coronary angiography confirmed obstructive disease, and following triglyceride-lowering therapies, successful percutaneous coronary angioplasty was performed. This case highlights the multisystem impact of severe hypertriglyceridemia and the importance of recognizing lipemia-related laboratory artifacts to avoid misdiagnosis and enable timely management. Severe hypertriglyceridemia reflects a spectrum of triglyceride-rich lipoprotein disorders, often with combined chylomicron and very-low-density lipoproteins excess due to genetic-environmental interactions. Lipemia, associated with severe hypertriglyceridemia, may interfere with routine laboratory assays, leading to spurious results posing significant diagnostic and therapeutic challenges.