Accurate identification of anatomical structures is essential for safe congenital cardiac surgery and for the development of assistive robotic systems. However, scalable annotation of open-heart surgical video remains a major challenge due to dynamic tissue motion, occlusion, and anatomical variability. The aim of this study was to develop and evaluate a human-in-the-loop segmentation and tracking pipeline for congenital open-heart surgery videos. A dataset of 72 annotated video clips comprising 27,461 frames was created from routine recordings of congenital cardiac surgery. Independent tracking evaluation was performed on 6 video clips (2,400 frames) from three surgical cases that were not used for training or validation. A hybrid framework combining fine-tuned Segment Anything Model 2 (SAM 2) for propagation-based tracking and YOLOv11 for detection-based monitoring was implemented and evaluated. Fine-tuning improved temporal tracking performance compared with the pretrained model, increasing the mean IoU from 82.1% to 92.2% and the proportion of frames with IoU ≥ 90% from 48.2% to 72.3% on the independent evaluation dataset. A graphical user interface enabled efficient dataset creation, reducing annotation time by approximately 40-fold compared with manual tracing. This study demonstrates that domain-adapted foundation-model tracking can provide robust anatomical tracking in a dynamic open surgical environment and offers a scalable framework for future assistive and robotic cardiac applications.
Fluid-structure interaction (FSI) simulation of biological systems presents significant computational challenges, particularly for applications involving large structural deformations and contact mechanics, such as heart valve dynamics. Traditional arbitrary Lagrangian-Eulerian methods encounter fundamental difficulties with such problems due to mesh distortion, motivating immersed techniques. This work presents a novel open-source immersed FSI framework that strategically couples two mature finite element libraries: MFEM, a GPU-ready and scalable library with state-of-the-art parallel performance developed at Lawrence Livermore National Laboratory, and FEBio, a nonlinear finite element solver with sophisticated solid mechanics capabilities designed for biomechanics applications developed at the University of Utah and Columbia University. This coupling creates a unique synergy wherein the fluid solver leverages MFEM's state-of-the-art parallel performance, while the immersed solid exploits FEBio's comprehensive suite of hyperelastic and viscoelastic constitutive models and advanced solid mechanics modeling targeted for biomechanics applications. FSI coupling is achieved using a fictitious domain/distributed Lagrange multiplier methodology with variational multiscale stabilization for enhanced accuracy on under-resolved grids expected with unfitted meshes used in immersed FSI. A fully implicit, monolithic scheme provides robust coupling for strongly coupled fluid-solid interactions characteristic of cardiovascular applications. The framework's modular architecture facilitates straightforward extension to additional physics and element technologies. Several test problems are considered to demonstrate the capabilities of the proposed framework, including a three-dimensional semilunar heart valve simulation. This platform addresses a critical need for open-source immersed FSI software combining advanced biomechanics modeling with high-performance computing infrastructure. The online version contains supplementary material available at 10.1007/s00366-026-02371-9.
Cardiac power output index (CPOi) has emerged as a prognostic marker after heart transplantation (HT), yet its application to donation after circulatory death (DCD) hearts remains unstudied. We compared early hemodynamic trajectories in DBD versus DCD HT and evaluated CPOi adjusted for vasoactive-inotropic score (CPOiVIS) as a screening tool for postoperative morbidity and mortality. This is a single-center retrospective study of adult heart transplants (2020-2025), excluding multiorgan transplants, congenital heart disease, and patients requiring VA-ECMO within 72 h. Hourly CPOi, VIS, CPOiVIS, right ventricular CPOi, and pulmonary artery pulsatility index were compared between groups. ROC analysis identified screening thresholds for a composite endpoint (ventilation >72 h, ICU >15 days, renal replacement therapy, or 90-day mortality). The effect of donor type on hemodynamics was assessed using multivariable regression. Among 500 patients (315 DBD, 185 DCD), hemodynamic trajectories did not differ across all metrics and timepoints. CPOiVIS was the strongest predictor of the composite endpoint (AUC 0.729-0.752 at T24-T72), outperforming CPOi alone. Optimal ROC thresholds demonstrated negative predictive values of 83-89%. After adjustment for recipient creatinine, hypertension, and ischemic time, donor type had no effect on any hemodynamic parameter. The composite endpoint occurred in 27.6% of DCD versus 23.2% of DBD recipients (p = 0.285). Among HT recipients who did not require early mechanical circulatory support, early allograft function did not differ significantly between DBD and DCD recipients. CPOiVIS outperformed CPOi as a screening metric for morbidity and mortality, with thresholds applicable regardless of donor type.
To evaluate whether parental resolution of infants' congenital heart disease (CHD) diagnosis contributes to parent-infant bonding above and beyond psychological distress during hospitalization in a pediatric cardiac ICU (PCICU). The study focused on an understudied population of ultra-Orthodox Jews and Muslim-Arabs. A cross-sectional study. PCICU; Hadassah University Medical Center, Israel. Fifty-eight parents (43% fathers; 72% ultra-Orthodox Jewish; 28% Muslim-Arab) of 37 infants (Mdays = 65.22; sd = 84.61) hospitalized after cardiac surgery or catheterization. None. Parents completed the Reaction to Diagnosis Questionnaire, the Postpartum Bonding Questionnaire, the Edinburgh Postnatal Depression Scale, and the posttraumatic stress disorder (PTSD) Checklist for Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, and responded to an open-ended question about how infants' birth and medical condition affected their lives. Responses' coding included affect, crisis, growth, religious faith, and social support. Clinical data were extracted from infants' medical records. Resolution was associated with healthier bonding (r = -0.55; p < 0.001; higher bonding scores indicate impaired bonding). Depressive and PTSD symptoms correlated with poorer resolution (r = -0.47; p < 0.001 and r = -0.51; p < 0.001) and more impaired bonding (r = 0.44; p = 0.001 and r = 0.48; p < 0.001). Controlling for depressive and PTSD symptoms and diagnosis timing (prenatally vs. postpartum), resolution predicted healthier bonding (β = -0.35;i p = 0.032; ΔR2 = 0.08). Parents who expressed less negative affect and addressed personal growth in the open-ended question demonstrated better resolution and healthier bonding (p's < 0.029). Lack of reference to religious faith and framing the experience as a crisis were associated with more impaired bonding (p's < 0.037). Parental resolution of infants' CHD diagnosis may contribute to the formation of nurturing parent-infant relationships. Findings highlight the need for early psychological interventions for families facing a CHD diagnosis.
Embolization of septal occluder devices is an uncommon complication of transcatheter atrial septal defect closure. Delayed recognition with chronic retention in the aortic arch is rare and presents complex management considerations. A 37-year-old woman with prior transcatheter secundum atrial septal defect closure was found on follow-up imaging to have an absent intracardiac occluder device. Computed tomography demonstrated embolization to the distal aortic arch near the origin of the left subclavian artery. Although asymptomatic at diagnosis, the device location, chronicity, residual atrial-level shunt, and suspected intimal incorporation favored operative management. She underwent open surgical retrieval under cardiopulmonary bypass with lower-body circulatory arrest and antegrade cerebral perfusion, with concomitant septal defect repair. Open surgical retrieval allowed controlled device removal, assessment of aortic wall integrity, and definitive repair of residual shunting when endovascular retrieval options were limited. Delayed recognition of septal occluder embolization should prompt careful evaluation of device location, chronicity, incorporation, embolic risk, and feasibility of endovascular retrieval. In selected patients, open surgical retrieval enables controlled device removal, assessment of aortic wall integrity, and concomitant repair of residual atrial-level shunting.
Balloon pulmonary angioplasty (BPA) improves haemodynamics and outcomes in patients with inoperable chronic thromboembolic pulmonary hypertension (CTEPH). Riociguat is frequently initiated before BPA to reduce procedural risks. However, evidence supporting continuation after successful BPA is lacking and current guidelines provide no criteria for treatment discontinuation. Consequently, many patients remain on long-term riociguat despite uncertain benefit, potential adverse effects and high costs. STOP-RIO is a multicentre, open-label, randomised, non-inferiority (NI) trial conducted in the two Dutch CTEPH expert centres. Seventy-four adult CTEPH patients treated with riociguat monotherapy with a mean pulmonary artery pressure (mPAP) <30 mmHg post-BPA will be randomised (1:1) to stop or continue the medication. The primary endpoint is the between-group difference in baseline-adjusted mPAP at rest measured by right heart catheterisation at 16 weeks. NI will be tested for the primary endpoint and for the two secondary endpoints highest in hierarchy N-terminal pro-B-type natriuretic peptide and 6-min walk distance. Additional secondary endpoints include haemodynamic parameters, safety outcomes, patient-reported outcomes and healthcare use. The primary analysis will be performed in a per-protocol population with secondary intention-to-treat and exploratory analyses. A prospective health economic evaluation will be conducted from a societal perspective. The study is conducted in accordance with the Declaration of Helsinki and Good Clinical Practice and has received ethical approval. Written informed consent will be obtained from all participants. Results will be disseminated through peer-reviewed publication and shared with patient organisations and scientific congress. EU Clinical Trials Register: 2024-5 19 225-38-00.
A third of schizophrenia cases are resistant to antipsychotics, where clozapine is the only FDA-approved medication. Clozapine use is often limited by intolerable adverse effects. Persistent tachycardia occurs in approximately 25-54% patients receiving clozapine. Heart rate variability (HRV) is a non-invasive, clinically relevant marker of autonomic nervous system functioning. Atenolol and Ivabradine are usually prescribed for clozapine-induced tachycardia (CIT), although evidence guiding their optimal use remains limited. This study aimed to compare the effects of atenolol versus ivabradine on HRV in patients with treatment-resistant schizophrenia (TRS) receiving clozapine. This open-label randomised clinical trial, conducted at a tertiary-care center over 20 months, involved TRS patients on clozapine for more than three months and having persistent tachycardia. Twenty patients received atenolol 25mg once-daily, while twenty received ivabradine 5mg twice-daily for two months. The primary outcome was the change in the frequency domain of HRV, while the secondary outcomes were time-domains, central and peripheral blood pressure, pulse rate and treatment-emergent adverse events (TEAE). While both drugs significantly reduced pulse-rates (atenolol: -20.56±13.00, p<0.001; ivabradine: -21.855±12.873, p<0.001). Within-group analysis showed that, the atenolol group had significant improvements in high-frequency [HF] power (p=0.048) and LF/HF ratio (p=0.044), along with a non-significant trend towards increased total power (p=0.053); no significant within-group changes were observed in the ivabradine group. No significant between-group differences in HRV parameters were established between atenolol and ivabradine. Ivabradine could be a viable option in patients where atenolol is either contraindicated or not tolerated. Future larger multicentric studies are needed for greater generalisability. ClinicalTrials.gov identifier: NCT06505668.
Choosing between endovascular and open (bypass) surgical revascularization for chronic limb-threatening ischemia has major implications for clinical practice. To evaluate the cost-effectiveness of endovascular vs bypass surgical revascularization. This economic evaluation used individual-level data from the Best Endovascular vs Best Surgical Therapy for Patients With Chronic Limb Ischemia (BEST-CLI) trial, with the first patient enrolled August 28, 2014, and the final October 18, 2019, for a median follow-up of 2.7 years. An individual-level, continuous-time Markov model with health states based on adjudicated clinical events from BEST-CLI was developed. Rates of clinical outcomes, health utilities, and health care resource use were derived from trial data. Unit costs came from Medicare insurance claims data and the physician fee schedule. The data were analyzed between June 27, 2025, and May 28, 2026. The main outcomes were incremental cost per life-years gained, incremental quality-adjusted life-years (QALYs) gained, incremental net monetary benefit, and cost per major events of revascularization and amputation avoided over a 5- and 10-year time horizon. One-way and probabilistic sensitivity analyses were performed to quantify uncertainty. The cohort included 1434 patients from BEST-CLI (mean [SD] age, 67 [10] years; 1026 male [71.5%]). In the base case analysis, over a 5-year time horizon, the mean per-person direct medical costs were $118 559 (95% credible interval [CrI], $86 978-$157 152) for bypass surgery and $125 535 (95% CrI, $96 205-$160 357) for endovascular surgery. The mean survival per person was 3.84 years (95% CrI, 3.74-3.93 years) and 3.78 years (95% CrI, 3.61-3.94 years) for bypass and endovascular surgery, respectively. The mean QALYs per person were 2.53 (95% CrI, 2.34-2.70) for bypass surgery and 2.48 (95% CrI, 2.28-2.67) for endovascular surgery. Bypass surgery dominated endovascular surgery with respect to both costs per life-year and per QALY gained. The results over 10 years were consistent with those of the 5-year BEST-CLI follow-up. In the Monte Carlo simulation, there was a 93% chance that bypass surgery was more cost-effective than endovascular surgery. This cost-effectiveness study found that bypass surgery was more cost-effective in most probabilistic simulations; however, uncertainty remained, highlighting the need for future research to identify subgroups in whom each approach may be cost-effective.
Introduction  Coronary heart disease (CHD) remains a leading cause of mortality in the United States. While traditional risk factors are well established, the structural impact of financial toxicity, defined as the inability to afford medical care, on cardiovascular outcomes is undercharacterized in nationally representative populations. Methods  A dual-level analysis was conducted. At the individual level, a pooled cross-sectional analysis using 2022-2024 Behavioral Risk Factor Surveillance System (BRFSS) data (N=1,336,111) was performed to calculate prevalence ORs. At the macro level, a Bayesian spatial hierarchical model using the Besag-York-Mollié (BYM) specification was implemented to evaluate the geographic association between state-level financial toxicity and CHD mortality. Results  Individual-level analysis revealed that financial toxicity was strongly associated with premature CHD, corresponding to more than three-fold higher odds of CHD among adults aged 25-44 years (OR=3.38; 95% CI: 2.78-4.12). At the macro level, structural financial toxicity and state uninsured rates were highly collinear (r=0.88). State-level multivariable modeling (R²=0.42) identified age-adjusted CHD prevalence as the dominant predictor of mortality. Furthermore, Bayesian spatial modeling (BYM) confirmed financial toxicity as a credible, independent correlate of cardiovascular mortality (β=2.51; 94% highest-density interval (HDI): 0.65-4.39), with pronounced residual geographic risk clustering in the Midwest and Mid-Atlantic regions. Conclusions  Financial toxicity is a critical structural correlate of premature cardiovascular disease and regional mortality. Improving population-level cardiovascular outcomes requires integrating structural competence and financial screening into primary care, alongside addressing state-level healthcare policy gaps.
Guideline-directed medical therapy (GDMT) is the foundation of pharmacologic management in HF with reduced ejection fraction offering mortality and morbidity benefits. GDMT use in patients supported by durable LVADs remains inconsistent. This is a retrospective, non-interventional, single-center cohort study conducted in adult patients (≥18 years) who underwent durable LVAD implantation between January 2009 and October 2024. GDMT was defined as the prescription of at least three of the following medication classes: beta-blockers, angiotensin-converting enzyme inhibitors (ACEIs) or angiotensin receptor blockers (ARBs), angiotensin receptor-neprilysin inhibitors (ARNIs), MRAs, and SGLT2i. Patients were divided into two groups GDMT group: ≥3 GDMT and Non-GDMT group: <3 GDMT. The aim of the study was to evaluate the association between the use of GDMT within 3 months after LVAD implantation and clinical outcomes, including all-cause hospital readmission, and 12-month mortality. A total of 220 patients were included in the final analysis. Of these, 49 patients (24.9%) received ≥3 classes of GDMT, while 171 patients (75.1%) received fewer than three agents. Baseline demographic and clinical characteristics showed higher creatinine, AST and lower hemoglobin on Non GDMT group. The mean age was similar between groups. Patients receiving GDMT exhibited lower NT-pro BNP levels during right heart catheterization at follow-up (1218±1025 pg/mL vs. 2051±2598 pg/mL, p=0.01). During the 12-month follow-up period, all-cause rehospitalization occurred less frequently among patients receiving GDMT (71.4% vs. 88.5%, p=0.004). In multivariable logistic regression analysis the use of GDMT within 3 months after LVAD implantation was independently associated with 62% lower odds of rehospitalization (OR 0.38, 95% CI 0.16-0.91, p=0.03). GDMT within 3 months post-implantation was associated with significantly fewer hospital readmissions for any cause. A favorable but non-significant trend toward lower 12-month mortality was observed. These findings support further prospective evaluation of GDMT optimization after LVAD implantation.
Pulmonary echinococcosis, or pulmonary hydatid disease, caused by Echinococcus larvae, presents a significant health challenge, particularly in endemic areas. While surgery is the primary treatment for viable cysts, the optimal approach for this remains under debate. There is a lack of comparative evidence comparing traditional open thoracic surgery (OTS) with minimally invasive video-assisted thoracic surgery (VATS). This systematic review and meta-analysis aims to comprehensively compare the efficacy and safety of VATS versus OTS for pulmonary hydatid disease; it will expand on prior research by including patients of all ages and conducting detailed subgroup analyses, sensitivity analyses, and publication bias assessments. Following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines and International Prospective Register of Systematic Reviews registration (CRD420251012764), major databases (PubMed, Scopus, Cochrane Library, Web of Science) were searched up to 5 March 2025, without language or date restrictions. Comparative studies (randomised controlled trials and observational studies) reporting perioperative, postoperative, and recovery outcomes for VATS versus OTS were included. Data were synthesised using random-effects models (calculating mean differences [MDs] or risk ratios with 95% confidence intervals). Heterogeneity (I2), risk of bias (Risk Of Bias In Non-randomised Studies of Interventions) and publication bias (Doi plots, Luis Furuya-Kanamori index) were assessed. Nine retrospective cohort studies met the inclusion criteria. Compared with OTS, VATS was associated with significantly shorter operation times (MD -38.08 min; p<0.001; I2=92%), lower perioperative blood loss (MD -64.02 mL; p=0.006; I2=98%), reduced postoperative drainage volume (MD -124.46 mL; p=0.003; I2=85%), earlier chest drain removal (MD -2.27 days; p<0.001; I2=92%), and shorter hospital stays (MD -3.68 days; p<0.001; I2=98%). Although VATS showed a trend towards fewer postoperative complications, the difference was not statistically significant (risk ratio 0.72; p=0.13; I2=0%). Significant heterogeneity (I2>85%) was present for most continuous outcomes, and risk of bias assessment indicated high risks in confounding and reporting domains for several studies. Potential publication bias favouring VATS was detected for multiple outcomes. VATS appears to offer significant perioperative and recovery advantages over OTS for the surgical management of pulmonary hydatid disease. However, these findings must be interpreted with caution. While this review incorporates recently available randomised evidence, the majority of the data remains retrospective, and the pooled results are affected by significant heterogeneity and a high risk of bias in several domains.
To evaluate resource use and clinical outcomes in patients with lower extremity acute limb ischemia (LE-ALI) managed with computer-assisted vacuum thrombectomy (CAVT), embolectomy alone (EA), or embolectomy with adjunctive bypass (EAB) in the United States. A retrospective analysis of discharged adult LE-ALI inpatients (07/01/2020 - 09/30/2023) with a 1:1 propensity score matching using the Vizient Clinical Data Base was performed. Outcomes included length of stay (LOS), post-procedure LOS (PPLOS), post-procedure intensive care unit stay (PPICU), post-procedure composite complications, individual organ system adverse events, 30-day all-cause and ALI-related readmissions, major limb amputation, in-hospital mortality, and discharge destination. A total of 873 patients per group were matched. Baseline characteristics were similar. CAVT was associated with shorter LOS [5.3±4.4d vs. 7.2±5.76d (EA) and 9.8±6.04d (EAB), P<0.0001] and PPLOS [4.1±4.09d vs 6.1±5.58d (EA) and 7.3±5.41d (EAB), P<0.0001]. PPICU stay was similar across groups. CAVT had fewer composite complications [5.7% vs. 8.2% (EA), P=0.0389 and 12% (EAB), P<0.001]. CAVT had lower 30 days all-cause [14.8% vs. 18.6% (EA), P=0.0358 and 26.6% (EAB), P<0.001] and ALI-related readmissions [6.9% vs. 10.3% (EA), P=0.0130 and 15.3% (EAB), P<0.0001]. Major amputation at 30-days was lower in CAVT [0.93% vs. 2.12% (EA), P=0.0455 and 2.23% (EAB), P=0.0316]. Discharge to home was more common in CAVT [64.6% vs 44.4% (EA) and 36.9% (EAB), P<0.0001]. In hospital mortality was comparable. Compared to EA and EAB, CAVT is associated with shorter LOS, fewer complications, reduced readmissions and major amputations, and higher rates of discharge to home, without increased mortality.
Acute myocardial infarction is one of the leading causes of death worldwide, with mortality primarily resulting from complications such as arrhythmia, cardiogenic shock, and heart failure, which are closely related to the success of reperfusion therapy. Among electrocardiogram (ECG) parameters, the QT interval reflects ventricular homogeneity as well as predicts electrical instability. QT dispersion (QTd), the difference between maximum and minimum corrected QT (QTc) intervals, is associated with fatal cardiac arrhythmia. However, the effect of reperfusion therapy on QTd remains controversial. Although successful reperfusion is a major determinant of outcome in ST-segment elevation myocardial infarction (STEMI), adverse complications such as arrhythmia, cardiogenic shock, and heart failure may still occur despite restoration of coronary blood flow. Currently, no specific marker can reliably predict these adverse events. Assessment of QTd may provide additional prognostic information regarding myocardial electrical recovery following primary percutaneous coronary intervention (PPCI). This study aimed to evaluate the association between QTd after PPCI and reperfusion status as well as in-hospital complications among patients with STEMI. A total of 108 STEMI patients who underwent PPCI were enrolled. A 12-lead ECG was recorded one hour after PPCI, and QT intervals from 12 leads were manually measured using the slope-intercept method. The QTc interval was calculated using the Fridericia formula. QTd was calculated as the difference between the maximum and minimum QTc intervals. The mean QTd was 67.68 ± 37.88 milliseconds (ms). QTd was categorized into two groups: >50 ms and ≤50 ms. Reperfusion was measured by ST-segment resolution (STR) and thrombolysis in myocardial infarction (TIMI) flow. In the QTd >50 ms group, 32% had STR ≥70%, while 68% had STR <70%. About 46.6% of the QTd ≤50 ms group had STR ≥70%, whereas 53.4% had STR <70%. This demonstrated that there was no statistically significant association between QTd and STR (p = 0.123). Due to the small sample size and time limitation, only two patients had TIMI 2 flow, whereas the remaining patients had TIMI 3 flow. No statistical significance was observed between QTd and TIMI flow grade (p = 1.000). Cardiogenic shock, heart failure, and reduced ejection fraction (EF) were more frequently observed in the QTd >50 ms group, accounting for 48%, 12%, and 52%, respectively. In the QTd ≤50 ms group, only 5.2% had cardiogenic shock, and 19% had reduced EF but no symptomatic heart failure. There was a significant association between QTd and cardiogenic shock, reduced EF, and symptomatic heart failure with p = 0.001, p = 0.001, and p = 0.008, respectively. There was a significant association between QTd and cardiogenic shock, heart failure, and an EF of less than 50%. Ventricular tachycardia and post-infarction angina occurred in the QTd >50 ms group, despite the lack of statistical significance due to the limited sample size. QTd may reflect electrical instability of the myocardium and could be a non-invasive tool to identify patients at higher risk of adverse in-hospital complications.
Kounis syndrome is an underrecognized cause of acute coronary syndrome characterized by the coexistence of allergic reactions and myocardial ischemia. We report a case of Type 1 Kounis syndrome in a 51-year-old male who presented with acute chest discomfort, diaphoresis, and dyspnea following ingestion of diclofenac and ondansetron. Initial evaluation revealed transient anterior wall ST-segment elevation (V2-V5) with normal cardiac biomarkers and no regional wall motion abnormalities. The patient was initially managed for acute coronary syndrome; however, rapid resolution of symptoms and electrocardiographic changes, along with normal echocardiography and coronary angiography findings, suggested an alternative diagnosis. Clinical features, including GI symptoms without cutaneous manifestations, further supported an atypical allergic presentation. He was treated with intramuscular epinephrine, antihistamines, and corticosteroids, with prompt clinical improvement. A diagnosis of Type 1 Kounis syndrome secondary to drug-induced coronary vasospasm was established. This case underscores the importance of early recognition of Kounis syndrome in acute coronary presentations, particularly in the absence of biomarker elevation and obstructive coronary disease.
Sleep and obesity are tightly interconnected, with bidirectional relationships that influence cardiometabolic health and the development and progression of sleep disorders. In this review, we synthesize current evidence linking insufficient sleep, insomnia, obstructive sleep apnea (OSA), and other sleep disorders with obesity, with a focus on pathophysiology, clinical implications, and emerging therapeutic strategies. Insufficient sleep is consistently associated with weight gain through hormonal, behavioral, and metabolic mechanisms, whereas the relationship between insomnia and obesity appears weaker and more heterogeneous. Obesity is a major driver of OSA via effects on upper airway anatomy, respiratory mechanics, and ventilatory control, though reciprocal effects of OSA on weight remain less clear. Recent advances in obesity pharmacotherapy, particularly incretin-based therapies such as dual GIP/GLP-1 receptor agonists, will likely reshape treatment paradigms. Clinical trial data demonstrate meaningful improvements in both weight and OSA severity, highlighting the potential for integrated management of comorbid obesity and OSA (COBOSA); however, traditional therapies-including continuous positive airway pressure (CPAP), exercise, and lifestyle modification-remain foundational components of care. We also review obesity hypoventilation syndrome and other sleep disorders associated with obesity, emphasizing shared and distinct mechanisms. Despite substantial progress, key knowledge gaps remain regarding optimal treatment integration, heterogeneity of treatment response, and long-term outcomes. Overall, effective management of obesity is increasingly central to sleep medicine, underscoring the need for multidisciplinary, patient-centered approaches and further research. Likewise, promoting adequate sleep should be considered an important component of weight management and overall health.
Cardiac complications from prior oncologic therapies and radiation are being increasingly recognized and patients with symptomatic severe aortic valve disease and a history of prior chest radiation represent a high-risk group in which the best management approach has not yet been established. A systematic search of PubMed, Scopus, and Cochrane identified studies comparing outcomes of transcatheter aortic valve replacement (TAVR) vs surgical aortic valve replacement (SAVR) in patients with a history of prior chest radiation. Nine studies comprising 11,572 patients were included in this meta-analysis. There were no significant differences between TAVR and SAVR in postoperative mortality (OR: 0.70; 95% CI 0.44-1.13, p = 0.147) or 1-year mortality (OR: 1.04; 95% CI 0.71-1.53, p = 0.84). TAVR was associated with significantly lower rate of postoperative major bleeding (OR: 0.38; 95%CI: 0.25-0.57, p < 0.01), acute kidney injury (AKI) (OR: 0.51; 95%CI: 0.27-0.97, p: 0.04), postoperative atrial fibrillation (OR: 0.20 95%CI: 0.16-0.24, p: <0.01) and respiratory complications (OR: 0.39; 95%CI: 0.24-0.63, p < 0.01) compared to SAVR. The incidence of postoperative permanent pacemaker insertion (OR: 2.27; 95%CI: 1.79-2.87, p < 0.01) and at least moderate aortic regurgitation (OR: 4.44 (95%CI: 2.93-6.73), p < 0.01) were higher among the patients undergoing TAVR. TAVR in patients with a history of prior radiation was associated with a lower risk for postoperative complications albeit at an increased risk for pacemaker insertion in the postoperative period compared to SAVR. In patients who have previously received radiation treatment to the chest and have severe narrowing of their aortic valve, replacing the aortic valve using a minimally invasive procedure, which is called transcatheter aortic valve replacement, had similar survival rates in the short term and at 1 year compared to replacing the valve with open-heart surgery. However, there were differences in the risks with each procedure. Patients that had the transcatheter procedure experienced fewer complications such as bleeding, an abnormal heart rhythm called atrial fibrillation, lung complications, and kidney problems compared with those undergoing open-heart surgery. On the other hand, the transcatheter aortic valve procedure was associated with a higher likelihood of needing a permanent pacemaker and a higher risk of valve leakage through or around the newly placed valve.
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Functional/dissociative seizure (FDS) disorder presents diagnostic challenges due to its complex semiology and the lack of positive diagnostic biomarkers. Current evidence suggests that specific patterns of brain activity and distinct dynamics in the brain network may underlie the neurobiological mechanisms of FDS. We retrospectively analyzed ictal EEG recordings from 46 patients with FDS, in three different conditions: during resting wakefulness (RW), during resting while having eyes closed (EC), and during functional/dissociative seizures of variable semiology (FDS). The occipital EEG in the alpha band (8-13 Hz) was assessed in terms of power and functional connectivity, quantified by debiased weighted phase lag index (dwPLI). Heart rate was also analyzed across conditions. Statistical comparisons were performed via paired permutation testing with Benjamini-Hochberg correction for multiple comparisons, complemented by Bayes factors for the key FDS-EC comparisons. EEG during FDS exhibited significantly higher occipital alpha power than RW (p = 0.0003) and levels not significantly different from EC, with moderate Bayesian evidence for the absence of a difference (BF01 = 6.1). Alpha power was elevated across all FDS subtypes and was, paradoxically, numerically highest in hypermotor seizures, although subtype differences did not survive correction for multiple comparisons. Control analyses showed that the alpha power did not significantly differ across video-rated states of eyes during FDS (open, intermittently closed, closed), including when conditions were matched for eye state. Functional whole-brain connectivity in the alpha band was intermediate between the two resting conditions, being higher during FDS than during RW but lower than during EC. Heart rate was highest during FDS, with a non-significant tendency toward higher rates in hypermotor than atonic FDS. No significant correlation was found between occipital alpha power and heart rate during FDS. Our findings suggest that FDS are characterized by a paradoxical hypersynchronization in the EEG alpha band, similar to EC, despite concurrent motor activity. Increased functional alpha connectivity, simultaneous with elevated heart rate during FDS, suggests that FDSs involve altered brain network dynamics rather than simple alpha power suppression by voluntary motor activity. These findings may aid in developing positive biomarkers for FDS diagnosis.
Social anxiety disorder has a considerable negative impact on educational attainment, employment status, and relationship development. Exposure therapy is an established method used to treat social anxiety by getting patients used to talking to other people. However, this procedure requires patients to have conversations with strangers, which may impose a psychological burden. This study aimed to examine whether the burden could be reduced during a first-time face-to-face interaction by using a human digital twin avatar technology that we call "Another Me." We conducted an exploratory, randomized, open-label, controlled study with 30 young participants who self-reported nervousness during conversations with strangers. Participants were divided into an intervention group and a control group. The intervention group (n = 15) watched a generated video of a conversation between their Another Me and the Another Me of an assigned interlocutor. After viewing the video, they engaged in an online conversation with the assigned interlocutor. The control group (n = 15) watched a video of a conversation between the avatars of two strangers and then engaged in a conversation with an assigned interlocutor. Results showed that the primary endpoint-the between-group difference in heart rate change from before to after the online conversation-was not statistically significant. However, exploratory secondary analyses suggested that heart rate decreased in the intervention group after viewing the pre-dialogue simulation video and remained relatively stable until the completion of the online conversation. In contrast, the control group exhibited an increase in heart rate before the online conversation. Additionally, the intervention group reported lower anxiety levels and a greater willingness to converse until the end of the face-to-face conversation. These findings should be interpreted as preliminary and hypothesis-generating. Further confirmatory trials with rigorous physiological monitoring are required.
Disease profiles and access to care differ between rural and urban populations. The aim of this study is to examine the association of rurality with electronic health record-derived disease profiles and heart failure risk. We conducted a retrospective observational study of 242 758 participants enrolled in the All of Us Research Program. Rurality status was estimated using 2010 Rural-Urban Commuting Area codes from participant home 3-digit zip code prefixes, and participants were grouped into rural, mixed, and urban arms. We compared the disease profiles with phenome-wide association studies and the risks of heart failure between arms. The final cohort included 5581 participants in the rural arm, 62 287 in the mixed arm, and 174 890 in the urban arm. Compared to the urban setting, 70 phecodes were significantly enriched in the rural arm including obesity (odds ratio [OR], 1.42, 95% confidence interval [CI], 1.34-1.51) and related diagnoses. Cancer screening-, dermatological-, and eye care-related diagnoses were significantly depleted in the rural arm. The rural arm also showed a greater risk of heart failure (adjusted hazard ratio [HR], 1.20, 95% CI, 1.10-1.31). With the national dataset in All of Us, we found that rural participants had significantly higher risks for obesity-related diseases and heart failure in this study. Depleted phecodes in the rural participants suggested a lack of access to cancer screening, stressing the potential importance of targeted cancer disease management in rural communities.