Families have limited access to pediatric weight management services. To compare the effectiveness of enhanced standard of care (ESOC) with family-based behavioral treatment (FBT) vs ESOC alone in reducing percent over median body mass index (percent median BMI) among children and adolescents with obesity. ESOC+FBT was hypothesized to reduce relative weight more than would ESOC alone. This was a pragmatic, comparative-effectiveness randomized clinical trial (2019-2024). Data collectors were blinded, and patients were followed up at 18 months. The setting included a total of 41 primary care clinical practices in Louisiana, New York, Missouri, and Illinois. Children and adolescents aged 6 to 15 years with obesity were referred by their primary care practitioner (PCP) or self-selected into the trial. ESOC was led by the PCP and intensified depending on a child's response. ESOC+FBT included all ESOC components plus meetings with an FBT interventionist, focusing on nutritious eating, physical activity, positive parenting strategies, and management of social and environmental cues. Both interventions lasted 12 months. Change in percent median BMI at 12 months (end of treatment). A total of 1631 parents completed the web screen for their child, and 901 parent-child dyads were excluded or declined participation before randomization. The final sample of 730 children, each with a participating parent, had a mean (SD) age of 10.8 (2.5) years, 387 (54%) were female, 337 (47%) had Medicaid, and 160 (22%) had food insecurity. At the end of the treatment period, children in the group receiving ESOC+FBT experienced a significant reduction in percent median BMI (-6.4; 95% CI, -8.29 to -4.43) vs ESOC (-2.6; 95% CI, -4.46 to -0.71), with a mean between-group difference of -3.8 units (95% CI, -6.20 to -1.34 units; P = .002). Children's quality of life improved across both treatment arms at months 12 and 18. Similarly, weight-associated quality of life improved in both treatment arms, with greater improvements in ESOC+FBT at the end of the treatment period (6.8; 95% CI, 5.33-8.30 vs 4.8; 95% CI, 3.40-6.17; difference, 2.0 units; 95% CI, 0.05-4.00 units). There were no adverse events related to trial participation. Results of this randomized clinical trial show that ESOC+FBT demonstrated a significantly larger reduction in child percent median BMI than did ESOC alone. These findings support the added value of incorporating FBT into pediatric primary care settings and its feasibility in reaching a geographically and socioeconomically diverse patient population. ClinicalTrials.gov Identifier: NCT03843424.
Congenital laryngeal webs (CLW) are rare anomalies that result from failed recanalization of the larynx, resulting in abnormal tissue that can cause dysphonia, hoarseness, or stridor. Although the vast majority of cases are diagnosed and managed operatively before early childhood, we report a rare case of an adult laryngeal web in a 20-year-old female who presented with a lifelong whisper-like voice and difficulty breathing with exertion. Visualization with flexible laryngoscopy revealed a high-grade CLW extending from the anterior commissure to the vocal process of the arytenoids bilaterally, resulting in limited vocal cord abduction. Despite standard recommendations for open airway surgery, the patient was selected to undergo microlaryngoscopic cold steel division of the glottic web with topical mitomycin C application to reduce scar formation and potential further voice and breathing impairment. Following a successful operation and postoperative speech therapy, the patient had markedly improved phonation and breathing. The present work is the first documented case of a high-grade adult CLW managed endoscopically with cold steel lysis and mitomycin C application, demonstrating these patients may achieve significant functional improvement using this approach while avoiding the morbidity of open approaches.
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Degenerative osteoarthritis (OA) of the hip often arises from structural abnormalities that alter load distribution, which leads to progressive chondrolabral damage. Although substantial advances have been made, the existing terminology in the field of hip preservation remains heterogeneous and inconsistently applied, limiting scientific communication and treatment standardization. The aim of this article is to link evidence from existing literature to develop a framework in the form of a structured lexicon, one that defines the morphological features and pathomechanical mechanisms that are relevant to the symptomatic, pre-arthritic hip. This descriptive framework was developed through the synthesis of current biomechanical, radiographic, and clinical evidence, combined with expert consensus from an international, multidisciplinary panel. Foundational concepts were derived from basic science research, including tribology, mechanobiology, and contact mechanics, to establish a unified terminology. Three principal wear modes-instability, impingement, and mixed mechanisms-are proposed, corresponding to distinct pathological loading environments. Wear mechanisms include dysplasia with rim overload and stress-related cartilage failure, impingement with cam-induced shear or pincer rim conflict, and secondary inflammatory degeneration. Wear damage is classified by tissue involvement, encompassing labral degeneration, chondrolabral detachment, staged cartilage delamination, and subchondral bone changes (sclerosis, cystic change). By linking lesion topography to underlying mechanics, this framework has diagnostic and therapeutic relevance as well as encompasses radiographic measurements and clinical features of wear that are pertinent to hip instability and femoroacetabular impingement. This lexicon provides a coherent framework for pre-arthritic hip disease, establishing a shared terminology to guide basic-science research integration and the interpretation of current clinical practice in hip preservation.
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Low back pain is a leading cause of disability, largely due to intervertebral disc (IVD) degeneration. Obesity is a risk factor for IVD degeneration and promotes the release of pro-inflammatory cytokines from adipocytes, leading to inflammation and triggering catabolic degenerative pathways. Western diets high in omega-6 fatty acids (n-6 FAs) exacerbate inflammation and obesity, increasing the risk for musculoskeletal diseases. Conversely, omega-3 (n-3) FA enriched diets may mitigate these adverse effects. The nonmammalian fat-1 gene converts n-6 to n-3 FAs, thereby reducing n-6:n-3 ratios and systemic inflammation. This study aims to elucidate the role of n-6:n-3 FA ratios in IVD degeneration by comparing wildtype (WT) and fat-1 transgenic mice fed n-6 enriched HFD (n-6 HFD). Male and female WT and fat-1 transgenic mice were fed control or n-6-HFD. Body composition (weight, adiposity) and disc height index (DHI) were assessed at 16 weeks of age using microCT imaging. Chronic effects were evaluated at 60 weeks of age via serum cytokines (inflammatory panel), bone parameters (microCT), DHI, and histological grading of H&E staining. At 16 weeks, HFD increased adiposity, while fat-1 mice exhibited reduced weight gain. In vivo microCT revealed lower DHI in HFD-fed animals but higher DHI in fat-1 groups, with sex and lumbar level differences. At 60 weeks, inflammatory cytokines (IL-6, IL-17A) were elevated in the serum of WT HFD mice compared to fat-1 HFD mice. Histopathological staining revealed increased fibrosis, cell loss, and matrix disorganization in the IVDs of HFD-fed WT mice. However, IVDs of fat-1 mice were protected from the degenerative effects of HFD. Lowering the n-6:n-3 FA ratio via endogenous fat-1 activity modulates systemic inflammatory profiles in a sex-dependent manner and protects against obesity-driven IVD degeneration. These findings highlight the potential of dietary interventions or fat-1 gene therapy for treating obesity-associated IVD pathology.
Consumer food characteristics have been correlated with dietary behaviors. However, the pathways in which these factors relate to one another and impact health outcomes have yet to be elucidated. We used structural equation modeling to identify pathways between consumer food characteristics and self-reported health outcomes. We constructed a conceptual model and hypothesized 10 pathways in the model based on previous literature. Eight-hundred and eighty adults completed a series of measures for different food consumer characteristics and their health. We used Mplus to estimate and validate our hypothesized model of pathways between food consumer characteristics. We then applied multiple group analyses to determine the magnitude of associations found in the final structural model across demographic and food consumer characteristics by conducting measurement invariance testing. Our final structural model yielded excellent fit (comparative fit index = 0.960, Tucker-Lewis index = 0.954, root mean square error of approximation = 0.047, standardized root mean square residual = 0.050) with all hypothesized paths being statistically significant. Results also revealed differences in the strength of some of the pathway relations based on age, education, income, grocery spending, snack spending, and active control of eating. Findings have implications for how to improve consumer food characteristics to enhance health and well-being, with particular attention to nutrition self-efficacy.
Background Direct endoscopic necrosectomy (DEN) is commonly performed for walled-off necrosis (WON), yet optimal timing remains uncertain. Step-up strategies defer necrosectomy until clinical deterioration, whereas immediate DEN may provide earlier source control but risks unnecessary intervention. We conducted a systematic review and meta-analysis of randomized controlled trials (RCTs) comparing immediate versus step-up DEN. Methods Major databases were searched through April 26, 2026, for RCTs comparing immediate versus step-up DEN. The primary outcome was clinical success. Secondary outcomes included technical success, necrosectomy sessions, total interventions, length of stay, adverse events, bleeding, organ failure, mortality, recurrence, and readmission. Random-effects meta-analysis was performed using Hartung-Knapp adjustment. Certainty of evidence was assessed using Grading of Recommendations, Assessment, Development, and Evaluation (GRADE). Results Five randomized trials, including 269 patients (134 immediate DEN; 135 step-up strategy), were analyzed. In four trials reporting standalone study-defined clinical success, immediate DEN was associated with higher success than step-up strategy (OR 2.56, 95% CI 1.03-6.37; p=0.046; I²=0%). A post hoc sensitivity analysis including ACCELERATE yielded a similar estimate (OR 2.59, 95% CI 1.33-5.04; p=0.017; I² = 0%). Immediate DEN was associated with shorter length of stay (MD -8.02 days, 95% CI -15.00 to -1.05; p=0.033; I²=42%). Technical success, necrosectomy sessions, total interventions, adverse events, bleeding, organ failure, mortality, and readmission did not differ significantly. Conclusions Immediate DEN was associated with higher clinical success and shorter hospital stay compared with a step-up strategy. These findings support selective consideration of immediate DEN in appropriate patients with WON, while timing remains individualized.
Traumatic events and life stressors play a central role in shaping population physical and mental health, yet recent global evidence on their prevalence and demographic distribution remains limited. This study examined the prevalence and demographic patterning of lifetime traumatic events and stressors over the past 12 months across eight countries. The Global Social Determinants of Health Survey (GSDS) collected cross-sectional, nationally representative data from adults aged 18 years and older in Brazil, France, India, Indonesia, Nigeria, the Philippines, Turkey, and the United States from 2023 to 2024. Using weighted analyses and Poisson regression models, we assessed the distribution of 20 traumatic events and life stressors by age, gender, educational attainment, income, marital status, area of living, and country. The analysis included 8,198 participants. Overall, 66.7%, 95% CI [65.5%, 67.9%], of respondents reported experiencing at least one lifetime traumatic event. Compared to respondents in the United States, those in the Philippines reported the highest mean number of traumatic events, whereas those in India reported the lowest. The most frequently reported traumatic events were losing a loved one and exposure to natural disasters. In the past 12 months, 67.0%, 95% CI [65.7%, 68.2%], of respondents experienced at least one life stressor. All countries demonstrated higher mean stressor levels than the United States. Feeling alone was the most frequently reported stressor, particularly among young adults. Traumatic events and stressors are unequally distributed across countries and demographic groups, with some populations reporting higher exposure and certain experiences more prevalent among specific demographic groups.
The Amaryllidaceae family is a rich source of structurally diverse alkaloids with recognized neuroactive and antiparasitic properties. This study provides the first phytochemical and biological characterization of Pyrolirion boliviense and wild Stenomesson miniatum from Bolivia. Alkaloid extracts from bulbs and leaves were analysed by GC-MS and evaluated for acetylcholinesterase (AChE), butyrylcholinesterase (BuChE), and Trypanosoma cruzi inhibitory activities. Thirty-two Amaryllidaceae alkaloids were identified, with P. boliviense exhibiting greater alkaloid diversity (25 compounds) and S. miniatum a higher total alkaloid content (227.86 vs. 138.92 μg Gal/100 mg DW). P. boliviense bulb extracts showed the strongest cholinesterase inhibition (AChE IC50 = 6.07 ± 0.47 μg·mL-1; BuChE IC50 = 30.93 ± 1.17 μg·mL-1), whereas S. miniatum extracts displayed weaker AChE inhibition and no detectable BuChE activity. In anti-T. cruzi assays, bulb extracts were the most active, with S. miniatum showing an IC50 of 0.90 ± 0.15 μg·mL-1 (SI = 20.12) and selective anti-amastigote activity (IC50 = 1.42 ± 0.66 μg·mL-1; SI = 12.77). These findings identify Bolivian Andean Amaryllidaceae as promising sources of bioactive alkaloids with potential applications for Alzheimer's disease and Chagas disease drug discovery.
Hypertension, often described as a "silent killer," remains one of the leading modifiable risk factors for cardiovascular disease, stroke, chronic kidney disease, and premature mortality worldwide. Its burden is rising most rapidly in low- and middle-income countries, where health systems are least equipped to respond. Nigeria, Africa's most populous nation, faces a particularly severe challenge. Current estimates indicate that approximately 36% of Nigerian adults are living with hypertension, yet awareness, treatment, and control rates remain critically low. As Nigeria undergoes rapid demographic growth, urbanization, and epidemiologic transition, the absolute number of individuals affected is projected to increase substantially, amplifying pressure on the health system and national workforce. This narrative review synthesizes peer-reviewed literature, national surveys, and global health reports published between 2010 and 2025 to examine the burden of undiagnosed and poorly controlled hypertension in Nigeria. We reviewed the trends, sociocultural and structural drivers, health system barriers, and public health responses within the Nigerian context. Evidence highlights the role of dietary transitions, physical inactivity, low health literacy, cultural misconceptions, and limited access to affordable primary care in sustaining the epidemic. The review suggests that effective responses must extend beyond individual behavior change to include community-based screening, workplace health programs, culturally tailored education, sodium reduction strategies, and strengthened primary healthcare delivery, hence framing hypertension as a shared public health and development challenge, rather than solely an individual clinical condition, is essential for reducing preventable morbidity and mortality, protecting workforce productivity, and supporting Nigeria's long-term health and socioeconomic development.
Individuals with chronic pain experience comorbid insomnia, heightened arousal, and abnormal pain-related brain activation. Although opioid therapy is commonly prescribed for widespread pain, it offers questionable long-term benefit and is associated with arrhythmias, overdose, and death. The Cognitive Activation Theory of Stress (CATS) suggests poor sleep and arousal lead to critical changes in brain activation that increase pain severity and lead to opioid use. Cognitive Behavioral Therapy for Insomnia (CBT-I) improves sleep and holds promise for improving arousal, abnormal brain activation, and pain in individuals with comorbid chronic pain and insomnia, but does not reduce opioid use. Because CBT-I improves each mediator hypothesized to contribute to opioid use, it warrants evaluation as a neoadjuvant to opioid tapering. This trial tests whether improving sleep and decreasing arousal can normalize brain activation and decrease pain prior to gradual opioid tapering, facilitating reduced opioid use. 165 adults with comorbid chronic widespread pain and chronic insomnia who use prescription opioids will be recruited from Tampa, Florida, and surrounding areas, and randomized to CBT-I or Sleep Hygiene and Related Education (SHARE). Following intervention, they will undergo gradual opioid tapering. Two booster sessions will be administered after intervention and withdrawal, but before the 6-month follow-up. Compared with SHARE, CBT‑I is expected to improve insomnia severity, reduce physiological and subjective arousal, reduce pain intensity, and normalize pain‑related brain activation (i.e. reduced BOLD responses to painful stimuli in the Right Insula, Left Inferior Frontal Gyrus, and Right Lentiform Nucleus) and altered functional connectivity, at post‑treatment and 6‑ month follow‑up.
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Trypanosomiasis remains a major neglected tropical disease, largely uncontrolled due to rising drug resistance and the absence of an effective vaccine. Decades of vaccine failure are primarily linked to the parasite's immune-evasion strategy of Antigenic Variation (AV), driven by continual switching of the Variant Surface Glycoprotein (VSG) coat. This review proposes an integrated immuno-epidemiologic framework that moves beyond VSG-focused strategies by targeting conserved functional vulnerabilities and incorporating population-level transmission dynamics. The approach redirects vaccine development toward invariant, indispensable antigens such as the Transferrin Receptor (TfR), Invariant Surface Glycoproteins (ISGs), and Paraflagellar Rod (PFR) components. Antibodies against these molecules can induce conserved killing mechanisms, including iron starvation or disruption of essential membrane functions - regardless of VSG switching. Advances in reverse vaccinology enable multi-epitope and mRNA platforms to encode these structurally constrained targets, while complementary transmission-blocking and vector-focused strategies aim to interrupt parasite development within tsetse flies. A central argument is that partially protective vaccines (PPVs) can produce substantial epidemiologic benefits by lowering parasitemia, shortening infectious duration, and reducing the probability of vector infection. Such effects can meaningfully suppress transmission without requiring sterilizing immunity. A One Health approach, coupled with realistic population-based efficacy metrics, is essential for future vaccine development. By exploiting conserved molecular constraints and integrating immunologic, ecological, and epidemiologic insights, this framework outlines a practical pathway toward effective trypanosomiasis vaccination.
Many school districts offer restorative conferences as a means to resolve discipline incidents. Yet, few studies closely examine their implementation processes. Unknown is why students who are referred for restorative conferences may, in fact, not ultimately participate in them. The current multimethod study examined 1,217 restorative conference referrals from two school years. Results showed that 60% of referrals (n = 714) culminated in restorative conferences with 40% never reaching completion. The most common reasons for noncompletion were that participants refused to proceed or facilitators deemed it not appropriate to bring the parties together. Further, more serious incidents of threat, assault, and student/staff conflict were less likely to result in a completed conference than more minor incidents. Given the need for equitable access to fully implemented conferences, sociodemographic characteristics of enrolled students were also examined as predictors of conference noncompletion. Compared to the conference-level predictors, there was a relatively weaker association between school demographic variables and conference noncompletion. Implications for addressing challenges that arise during the pathway from referral to completed restorative conference are discussed. (PsycInfo Database Record (c) 2026 APA, all rights reserved).
Contemporary surgical and medical management has enabled excellent long-term survival and quality of life for children following repair of tetralogy of Fallot. However, most patients are left with residual pulmonary regurgitation that requires long-term surveillance and eventual pulmonary valve replacement to prevent right ventricular failure. Guidelines have been developed regarding the indications for and timing of pulmonary valve replacement in adults, but such do not exist for children. This expert consensus document aimed to address those gaps by supporting clinical decision-making regarding the surgical and transcatheter management of chronic pulmonary regurgitation in children with repaired tetralogy of Fallot. The Society of Thoracic Surgeons Workforce on Evidence Based Surgery assembled a multidisciplinary expert panel composed of congenital surgeons and cardiologists. A focused literature review was performed, and expert consensus statements were developed using a Modified Delphi process and clustered under two key topics: (1) pediatric-specific considerations and (2) surgical versus transcatheter techniques. Consensus was reached for 13 recommendations. The recommendation statements reflect contemporary expert opinion on the timing and decision-making for pulmonary valve replacement in children. While decision-making regarding the management of chronic pulmonary regurgitation after repair of tetralogy of Fallot in children is complex, this document provides guidance for congenital heart teams to optimize management based on a synthesis of contemporary evidence.
Persistent pain, stiffness, or suspected infection following shoulder arthroplasty remains a challenging clinical problem. Arthroscopy has emerged as a minimally invasive diagnostic and therapeutic tool in selected patients with painful anatomic total shoulder arthroplasty, reverse shoulder arthroplasty, or hemiarthroplasty. This review summarizes the current evidence regarding indications, outcomes, complications, and technical considerations for arthroscopy in the setting of pain following prior shoulder arthroplasty. Shoulder arthroscopy after arthroplasty has been described for glenoid component loosening, polyethylene wear, rotator cuff pathology, biceps tendon disease, postoperative stiffness, impingement, and suspected periprosthetic joint infection. Reported outcomes suggest that arthroscopy may improve pain and function in selected patients, particularly after glenoid component removal, biceps procedures, capsular release, and lysis of adhesions. Arthroscopic tissue biopsy also demonstrates greater diagnostic utility than aspiration or serum inflammatory markers for suspected periprosthetic shoulder infection. Technical strategies, including initial subacromial evaluation and controlled glenohumeral entry through the rotator interval, may reduce iatrogenic implant damage during arthroscopic evaluation. Arthroscopy can be both diagnostic and therapeutic in well-selected patients with painful or stiff shoulder arthroplasty. Although it is not a substitute for revision surgery in cases of clear implant failure, instability, or massive cuff insufficiency, it may help clarify the diagnosis, treat focal pathology, and delay or avoid open revision in selected patients.
This study aimed to investigate the presenting characteristics and outcomes of ROP patients with late retinal detachment (RD). A retrospective chart review was performed for patients with ROP who presented with a late RD, occurring at least 2 years after initial ROP diagnosis. Demographic information, visual outcomes, and RD characteristics were obtained. A total of 38 patients with a history of ROP who presented with a late RD were included (57.9% males). The median birth weight was 851.5 g and median gestational age at birth was 26.5 weeks. The median age at presentation for RD was 19 years. More than half of the RDs were diagnosed incidentally on routine examination, and 51.7% had macula-off RD. Fifty percent of patients had a rhegmatogenous RD, 35.3% had tractional RD, and 14.7% had combined rhegmatogenous and tractional RD. The majority of patients (78%) underwent surgical intervention for RD repair with either combined pars plana vitrectomy and scleral buckle (46.9%), scleral buckle alone (34.4%), or pars plana vitrectomy alone (18.7%), and 22% were observed due to guarded prognosis. The median logMAR vision was 1.8 at presentation and 1.18 at final follow-up. Redetachment occurred in 23.6% of patients, of whom 88.9% had additional surgery. Late RDs can develop in the setting of ROP and usually occur in young adulthood. More than one half of patients were found asymptomatically on routine examination and had macula-off RD. Many required complex surgery with silicone oil. Long-term follow-up for ROP patients may be indicated to monitor for progressive traction and retinal breaks.
Glycemic control is vital in the management of critically ill patients. Scientific evidence has proven that a drastic change in blood glucose levels can lead to adverse outcomes including increased hospital, ICU length of stay, morbidity, and mortality. Despite the challenges in developing standardized intravenous insulin protocols, institutions have successfully implemented protocols in various settings. Our tertiary care hospital has an established intravenous insulin protocol for the cardiac ICU. Given the complexity of managing critically ill patients, an intravenous insulin protocol for such patients was implemented in February 2022. The study aimed to evaluate the effectiveness of the newly implemented intravenous insulin protocol in glycemic control of critically ill trauma and burn patients. A single center retrospective chart review was conducted on 230 patients: 119 patients were extracted from the pre-protocol implementation and 111 patients post-protocol implementation periods. Ninety-nine patients were excluded due to on-admission diagnosis of diabetic ketoacidosis, hyperosmolar hyperglycemic state, or incomplete data. Data collection included: type of injury; body mass index, pre-existing comorbidities; insulin administration times; target glucose actualization; glycemic events; hospital and ICU length of stay, mortality rates in the ICU, hospital, and 30 days post-hospitalization. In the post-implementation group, the time to reach target glucose was significantly reduced when compared to the pre-implementation group. The rates of glycemic events after achieving target glucose were similar with a slightly lower rate post-implementation. There were no differences in the length of stay or mortality rates during hospitalization or 30-days post-hospitalization between the groups. However, when comparing routes of insulin administrations, the intravenous insulin significantly showed better glucose control and reduced the rates of glycemic events than the subcutaneous route. Intravenous insulin protocol demonstrated a significant reduction in the time to target glucose levels for the critically ill patients.
Adeno-associated virus (AAV) is a small ssDNA satellite virus that receives wide attention due to its popularity as a safe and effective gene therapy vector. The AAV cell entry receptor (AAVR) for most serotypes is a glycoprotein containing five polycystic kidney disease (PKD) domains with which AAV interacts. AAV serotypes can be classified into three groups: those that interact primarily with PKD1, those whose interactions with PKD2 are stronger, and AAV4-like serotypes whose transduction is AAVR-independent. A phylogenetic analysis of AAVR and paralog KIAA0319 revealed AAVR amino acid variability in the region of PKD1 that is bound by AAV. We hypothesized that the substitution, in all cat-like animals, of a glutamate at a site that is an arginine (R353) in human AAVR may interfere with the binding of clade H AAVs that interact exclusively with PKD1. Analysis of PKD1 mutations, including ELISA, shows that an R353E substitution of glutamate for arginine affects the binding of the clade H AAVs that interact primarily with PKD1.