Despite a growing interest in the ribotoxic stress response (RSR), it remains unknown how the upstream p38- and JNK-activating MAP3 kinase ZAKα senses translational impairment. Combining AlphaFold3 prediction and RNA crosslinking and immunoprecipitation (CLIP), we uncover that ZAKα dynamically monitors the mRNA exit channel of elongating ribosomes. This is accomplished by ZAKα via direct interactions with the ribosomal proteins RACK1 and RPS27 as well as 18S rRNA helix-26. In this conformation, the RNA-binding S (sensing) and C-terminal domain of ZAKα span across the mRNA exit channel. Loss of ribosome processivity and mRNA stasis stabilizes the interaction allowing for kinase activation. Prolonged binding of ZAKα to stalled and collided ribosomes is associated with sequestration of the sterile alpha-motif (SAM) domain on RACK1, which allows for transient ZAKα dimerization, activation loop trans-autophosphorylation, and RSR activation. Our findings highlight how ZAKα senses both stalled and collided ribosomes in human cells through overlapping mechanisms.
Ixodes scapularis ticks transmit a number of pathogens important to human health, including Borrelia burgdorferi, the causative agent of Lyme disease. While I. scapularis is found across the Eastern United States, Lyme disease transmission is largely limited to the Northeast and Upper Midwest and is nearly absent in the South. This indicates that differences in northern versus southern clades of I. scapularis are associated with differences in Lyme disease transmission risk. I. scapularis is undergoing range expansion, including into the Great Plains region of the United States. Determining where I. scapularis populations in the Great Plains originated can inform future risk of Lyme disease transmission in this region. In this study, we use a population genomics framework to characterize diversity, structure, and B. burgdorferi infection rates of I. scapularis populations in the Great Plains region. We generated whole genome sequence data and single nucleotide polymorphism (SNP) datasets from I. scapularis ticks collected in Iowa, Kansas, Nebraska, and South Dakota to compare to publicly available data from across the species' range. Our analysis of 200 I. scapularis SNP datasets indicated geographically well-defined populations that correspond to historical northern and southern ancestral clades of I. scapularis. Ticks from South Dakota, Iowa, and northeastern Nebraska are genetically similar populations from the Upper Midwest, while ticks from Kansas are more genetically similar to ticks from the Southeast. Ticks collected in the central eastern region of Nebraska, however, represent an evenly admixed population of both northern and southern genomic backgrounds. Analysis of B. burgdorferi reads from genomic datasets shows ~50% infection rate in ticks from Iowa and northeastern Nebraska, whereas ticks from Kansas show no evidence of B. burgdorferi infection. Of note, evenly admixed ticks from the central eastern region of Nebraska also show no evidence of B. burgdorferi infection. These results provide further evidence that tick genomics may influence traits associated with B. burgdorferi infection status, and thus the potential for Lyme disease transmission. As the range of I. scapularis continues to expand, bringing historically isolated populations into contact, there is a clear need to understand the consequence of genomic admixture for B. burgdorferi transmission potential to inform future risk of Lyme disease in the United States.
BackgroundWhen patients refuse basic nursing care in the hospital setting, ethical tension arises between promoting patient dignity by providing hygiene and honoring bodily autonomy by respecting patient refusal of interventions.Research AimTo describe patient factors, clinical context, and the role of ethics consultation when basic care is refused to identify implications for future practice and/or policy.Research DesignWe conducted a retrospective qualitative content analysis of adult and pediatric ethics consultation documentation between January 2015 and December 2025 at a quaternary academic medical center, screening 2,381 consultations to identify cases involving refusal of basic nursing care. We collected patient demographics, admission and clinical information, reasons for ethics consultation, and actions taken by the ethics consultation service. Data were summarized via descriptive statistics, and categories were abstracted to develop a framework.Participants and Research ContextPatients receiving inpatient care at an academic medical center in the Midwestern United States.Ethical ConsiderationsUniversity of Michigan IRBMED deemed the study exempt (HUM00256591).Findings34 ethics consultations for 29 unique patients involved refusal of basic nursing care. Patients were adults (100%), with an average LACE score of 12.8; 15 (44%) had decision-making capacity. Care over objection was provided in 16 (47%) of cases, and physical restraints were used in 2 (6%) cases. Refusals involved hygiene (18, 53%), wound care (15, 44%), and repositioning (9, 26%), and occurred across nursing units and clinical services. Refusals were addressed through persuasion (9, 26%), soft paternalism (13, 38%), hard paternalism (3, 9%), or permitted refusal (9, 26%).DiscussionEthics consultation involvement resulted in four approaches to refusal of basic nursing care based on patient agency, decision-making capacity, and clinical context.ConclusionsWhen refusal results in dignitary or physical harm, healthcare teams should address barriers and encourage participation. In rare circumstances, care over objection is ethically permissible with multidisciplinary input.
Idiopathic angioedema is a potentially life-threatening cause of acute airway compromise, with reported mortality rates up to 30% when airway intervention is delayed. Methemoglobinemia, a dyshemoglobinemia that reduces hemoglobin's oxygen-carrying capacity, can be acquired from drugs such as dapsone and occurs in approximately 0.4-1% of exposed patients. The coexistence of these two entities is exceptionally rare, posing diagnostic and management challenges in the emergency setting. A 16-year-old male presented to the emergency department with an acute onset swelling of the tongue and lips, accompanied by hypoxia. Endotracheal intubation was performed for airway protection. Adrenaline and fresh-frozen plasma were administered, resulting in the rapid resolution of angioedema. However, refractory hypoxia persisted despite adequate ventilation, normal point-of-care lung ultrasound, and unremarkable chest radiography. Arterial blood gas analysis revealed elevated methemoglobin levels (28%), confirming methemoglobinemia, attributed to recent dapsone use. Intravenous methylene blue was administered, leading to prompt normalization of oxygen saturation. The patient was extubated and discharged the following day without complications. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: This case underscores the importance of recognizing that more than one life-threatening condition can coexist in the same patient. Anchoring on a single diagnosis may delay identification of an equally dangerous concurrent pathology. Emergency physicians should maintain diagnostic vigilance, especially when expected improvement after treatment is incomplete or followed by unexplained deterioration. Timely recognition and targeted management of each condition can be lifesaving.
This Viewpoint describes the role of the False Claims Act in health care fraud prevention and discusses current constitutional challenges to qui tam civil actions made possible under the act, including potential consequences for the US health care system.
Recurrence of atrial fibrillation (AF) and atrial flutter (AFL) after direct current cardioversion (DCCV) remains a common problem. Several predictors of recurrence have been identified in observational studies. Current guidelines recommend considering amiodarone as an adjunct in patients at high risk of AF/AFL recurrence. However, data in the available literature on the effectiveness of amiodarone in restoring and maintaining sinus rhythm (SR) are sparse. This observational cross-sectional study analysed retrospective data from 193 patients who underwent elective DCCV for AF/AFL at a single UK cardiac centre, with follow-up at 6 weeks and 12 months. Baseline patient characteristics, including demographic data, echocardiographic findings, co-morbidities, and SR maintenance rate, were compared between patients treated with amiodarone and those without. Multivariate logistic regression was performed to identify parameters associated with DCCV failure. A total of 13.0% of the study population were started on amiodarone before DCCV. Those on amiodarone were more likely to have had a previous failed DCCV (60.0% vs. 21.4%; p < 0.001), AF/AFL duration of at least 12 months (84.0% vs. 53.0%; p = 0.003), a left ventricular ejection fraction (LVEF) of less than 40% (32.0% vs. 14.3%; p = 0.03), and a diagnosis of coronary artery disease (CAD) (32.0% vs. 13.7%; p = 0.02). Treatment with amiodarone was not associated with an increased rate of SR restoration at the time of DCCV (96.0% vs. 92.3%; p = 0.50). However, amiodarone treatment was associated with SR maintenance at 6 weeks (92.0% vs. 54.8%; p < 0.001) and at 12 months (60.0% vs. 26.8%; p < 0.001). Multivariate logistic regression analysis identified obstructive sleep apnoea (OSA) as the only parameter associated with DCCV failure (adjusted odds ratio (OR) 10.5; 95% confidence interval (CI) 2.5-53.5; p = 0.005). There was an increased risk of peri-procedural bradyarrhythmia with amiodarone therapy (adjusted OR 8.85; 95% CI 1.84-42.7; p = 0.007). Amiodarone treatment is associated with maintenance of SR following elective DCCV for AF/AFL. This effect is observed even in patients with risk factors for recurrence, including previous failed DCCV, longer AF/AFL duration, and reduced LVEF. OSA is an independent predictor of DCCV failure; further research is required to delineate the role of early adjunctive amiodarone therapy in these patients.
The association of atrial fibrillation (AF) and neck of femur fractures (NOF) are common in old people, creating a complex clinical scenario with significant implications for morbidity, mortality, and healthcare systems. This narrative review explores the bidirectional relationship between AF and NOF, focusing on shared risk factors, pathophysiological links, and challenges in clinical management, and also reviews the benefit of an orthogeriatric model. Advanced age, frailty, osteoporosis, polypharmacy, and cardiovascular comorbidities predispose patients to both conditions, while AF itself increases fall risk through haemodynamic instability, syncope, and adverse effects of rate- or rhythm-controlling medications. Importantly, the physiological stress of hip fracture and subsequent surgery can precipitate new-onset or worsening AF via inflammatory, neurohormonal, and metabolic mechanisms. The main challenge for ortho-geriatricians lies in anticoagulation management and preoperative and postoperative management. While anticoagulation reduces thromboembolic risk in AF, it increases perioperative bleeding risk in patients with NOF, often leading to delays in surgery that are independently associated with poorer outcomes. This review examines the current evidence regarding perioperative anticoagulation strategies, timing of surgery, and postoperative resumption of therapy. In addition, the review examines important outcome parameters such as mortality, stroke, bleeding, length of hospital stay, and functional recovery. This highlights the importance of not only improving multidisciplinary care involving orthopaedics, cardiology, geriatrics, and anaesthesia to optimise outcomes, but also enhancing risk stratification. Standardised perioperative pathways and integrated geriatric-cardiac assessment may help mitigate complications. Therefore, understanding how AF and NOF interact is key to delivering holistic, patient-centred care for an increasingly elderly population in orthogeriatric wards.
Our objective was to compare the severity of pelvic inflammatory disease (PID) in hospitalized women with and without endometriosis, and to assess whether deep endometriosis is associated with worse clinical outcomes. A single-center retrospective cohort study was conducted from January 2018 to December 2023, including women hospitalized for PID in a tertiary care endometriosis center. Patients were classified based on the presence of endometriosis, as diagnosed by transvaginal ultrasound (TVUS). Clinical, microbiological, and imaging data were analyzed. Primary outcomes included treatment failure, length of hospital stay, need for urgent surgery, and recurrence. A subgroup analysis was performed within the endometriosis group to assess the impact of deep endometriosis. Of 159, 48 (30.2%) had endometriosis. Compared to those without the disease, women with endometriosis were older and had significantly higher rates of adnexal findings on TVUS (95.8% vs. 73.8%, p = 0.01), mostly suspected infected endometrioma. Vaginal and endocervical cultures were negative in 72.9% of endometriosis patients, and only one tested positive for sexually transmitted disease, in contrast to 42.3% positivity in the non-endometriosis group (p <0.01). Patients with endometriosis showed significantly higher rates of treatment failure (35.4% vs. 17.1%, p = 0.01), recurrence (31.3% vs. 11.7%, p = 0.01), and longer hospital stays (6.1 vs. 3.9). In the deep endometriosis subgroup, treatment failure and recurrence rates were higher, although these differences did not reach statistical significance. Endometriosis is a significant risk factor for more severe PID, contributing to worse clinical outcomes, including higher treatment failure, prolonged hospitalization, and greater recurrence. Particularly, those with deep endometriosis seem to have a more severe clinical course.
War as a collective trauma can severely harm the psychosocial well-being of individuals, disrupting their sense of safety, autonomy, and meaning of life. War also weakens individual and communal senses of safety and stability, erodes social cohesion, and forces large-scale displacement, as civilians seek security elsewhere. Research indicates that individuals with prior exposure to traumatic events may be more susceptible to experiencing distress when confronted by additional stressors, especially in times of continuous traumatic stress, such as war. This study examines the impact of the October 7 War on survivors of past sexual violence (SV) in Israel, with a particular focus on the intersection of past SV and the collective trauma of war. We conducted an online qualitative study using reflexive thematic analysis, supplemented by descriptive quantitative summaries based on the responses of 126 survivors to an online qualitative survey, to explore the impact of war on their mental and physical well-being and coping mechanisms. Participants described "re-living the trauma," and reported marked deterioration in their perceived mental and physical states, including heightened post-traumatic symptoms and disruptions in aspects such as sleep, eating, and interpersonal relationships. Participants identified emotional and structural factors they perceived as exacerbating these conditions (e.g., Relegation to the bottom of social priorities), along with accounts of coping strategies and protective resources described by some participants, and recommendations for the healthcare system during wartime. These exploratory, context-specific findings suggest that individuals with a history of SV may experience particular vulnerabilities during periods of collective trauma, particularly during war, and emphasize the need to adapt frontline SV services to address health crises effectively.
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Malignant pericardial effusion is a life-threatening manifestation of advanced non-small-cell lung cancer (NSCLC). Cardiac tamponade as an initial presentation is uncommon, and coexistent pathologies can complicate diagnosis and management. A 72-year-old man with mild chronic obstructive pulmonary disease (COPD) and a remote 2-pack-year smoking history was admitted with COVID-19 infection and possible superimposed pneumonia. Initial imaging revealed pericardial inflammation and a small effusion, raising concern for pericarditis. Subsequent echocardiography demonstrated a large pericardial effusion with tamponade physiology requiring pericardiocentesis, while cardiac magnetic resonance and computed tomography suggested possible malignancy. Cytology from pericardial and pleural fluid confirmed adenocarcinoma and bronchoscopy established stage IV epidermal growth factor-mutant NSCLC with cerebellar metastases. The patient experienced recurrent malignant effusions, managed successfully with balloon pericardiotomy and was treated with Osimertinib, resulting in sustained remission of effusions and clinical recovery. Careful review of multimodality imaging also revealed partial anomalous pulmonary venous return with significant left-to-right shunting, which may have exerted a protective hemodynamic effect on tamponade physiology. This may suggest a potential, though speculative, contribution of the anomalous pulmonary venous return to the observed tamponade physiology. At 2-year follow-up, the patient remains clinically and hemodynamically stable. This case illustrates the interesting duality of how multiple concurrent pathologies-including COVID-19 pneumonia, pericarditis, malignant pleuro-pericardial effusions, metastatic lung adenocarcinoma, and PAPVR-can coexist and probably shape the clinical course. The case underscores the indispensable role of multimodality imaging, molecular profiling, and minimally invasive pericardial interventions in guiding diagnosis, therapy, and prognosis in complex cardio-oncology presentations.
Digital HIV prevention interventions (DHIs) are efficacious in increasing prevention behaviors, and delivering them direct-to-consumer (DTC) expands their reach. However, few have successfully moved rigorously-studied DHIs from research to public health practice. Hybrid type 3 effectiveness-implementation studies promise to approximate more naturalistic settings and accelerate translation from research to practice, and few DTC DHIs have been tested this way. This study describes lessons learned from a hybrid type 3 study of a DTC DHI for young men who have sex with men (YMSM) ages 18-29 called Keep It Up! (KIU!) 3.0. KIU! 3.0 was initially designed as a cluster-randomized hybrid type 3 implementation-effectiveness study across 44 United States counties with high HIV incidence among YMSM (22 DTC; 22 implemented in community-based organizations). The DTC strategy relied on online recruitment, at-home HIV/STI testing, and centralized intervention delivery. Over the course of the trial (October 2019-March 2023), we adapted our implementation four times in response to recruitment and retention challenges. Data sources included enrollment logs, advertising expenditures, participant communications, and internal documentation, which are used to characterize recruitment, costs, and recruitment/retention patterns. Due to challenges in recruitment and retention, four major changes were made over the course of the trial: 1) streamlining enrollment procedures, including shortening screening and verification steps, 2) modifying eligibility criteria, including expanding age limits, removing sexual risk requirements, and including gender-diverse participants, 3) introducing and increasing financial incentives for intervention completing and follow-up measures, and 4) shifting from county-level to nationwide recruitment. Following this fourth change in March 2021, enrollment increased by 301%, and cost per enrolled participant decreased. Ultimately 1,468 participants were enrolled nationwide. Nevertheless, retention and return of at-home STI test kits remained challenging, and guaranteed incentives increased the prevalence of imposter participants. Implementing a DTC DHI within a hybrid type 3 study required balancing pragmatic implementation goals with effectiveness outcomes measurement. Future hybrid studies of DTC digital health interventions should consider eligibility criteria, incentive structures, outcomes measurement strategies, and the distinction between research and service components to better align research with real-world implementation contexts.
Timely reperfusion is central to the management of ST-segment elevation myocardial infarction (STEMI), but dynamic coronary processes such as vasospasm may complicate primary percutaneous coronary intervention (PCI). We present a 50-year-old male with hyperlipidemia, active tobacco use, daily nicotine vaping, and a family history of heart disease who presented approximately three hours after the onset of persistent chest pain, following three days of intermittent left arm pain radiating to the left shoulder. Initial troponin was negative. His initial electrocardiogram was unremarkable, but repeat electrocardiography 30 minutes later demonstrated inferior ST-segment elevation, prompting emergent transfer for primary PCI. Coronary angiography demonstrated a smooth proximal right coronary artery narrowing and a separate distal stenotic lesion. The proximal narrowing resolved completely after intracoronary nitroglycerin, and intravascular ultrasound showed no plaque or thrombus at that site. ST-segment elevations did not improve after intracoronary nitroglycerin alone. Despite nitroglycerin administration, the distal lesion persisted and was treated with balloon angioplasty followed by stent implantation, with a door-to-balloon time of 117 minutes. He was discharged on vasodilator therapy (initially nitrates, later transitioned to a calcium channel blocker due to intolerance). This case highlights how coronary vasospasm may accompany fixed obstructive disease during STEMI and create additional diagnostic complexity during primary PCI, with implications for lesion assessment, avoidance of unnecessary intervention, and post-PCI vasodilator therapy.
As competition among cities increases, shrinkage is increasingly observed in contemporary urban development. However, the systematic, fine-scale ecological impact of shrinkage, particularly on vegetation dynamics, remain poorly characterized. This study identified shrinking and non-shrinking counties in China using nighttime-light data during 2001-2020, examined vegetation growth dynamics using net primary productivity (NPP) validated by normalized difference vegetation index (NDVI), enhanced vegetation index (EVI) and leaf area index (LAI), and analyzed influencing mechanisms via XGBoost modelling and SHAP interpretation. We reported three findings: (1) 39.8% of 2891 counties shrank, most severely in Northeast China. (2) Most shrinking counties showed an amplified vegetation greening trend, with median NPP trend (3.43 g C m-2 yr-1) 11.7% higher than non-shrinking counties (3.07 g C m-2 yr-1). Shrinkage intensity exerted a hump-shaped relationship with NPP trend, peaking at moderate levels, indicating an optimal shrinkage intensity for greening. (3) Differentiated strategies are needed: moderately shrinking counties can amplify gains with passive rewilding; severely shrinking ones need enhanced fiscal transfers for erosion controls and afforestation; non-shrinking collided with an NPP ceiling at ∼20% land conversion, necessitating densification-resistant designs and strict urban-growth boundaries. These findings advance our understanding of social-ecological coupling mechanisms between shrinkage and vegetation dynamics, offer critical insights for developing context-differentiated ecological strategies and enhancing county-level development quality.
Hydrogen spillover involves the migration of hydrogen atoms from metal to another component, yet it remains challenging to achieve on non-reducible supports. This paper describes the observation of hydrogen spillover on non-reducible Al2O3-supported Pd single-atom catalysts, facilitated by phosphorus-hydroxyl (P-OH) bridge sites, for acetylene semi-hydrogenation. Through in situ spectroscopy, kinetic analysis, and computational analyses, we show that Pd single atoms promote the heterolytic activation of H2, while phosphorus doping on Al2O3 lowers energy barrier for hydrogen spillover via the formation of P-OH species. Gas-phase acetylene collides and hydrogenates with as-formed P-OH, following Eley-Rideal type mechanism, making inert Al2O3 active in hydrogenation reaction. This unconventional relay pathway reduced Pd usage by one order of magnitude and improved catalytic stability, with over 95% ethylene selectivity at 99% acetylene conversion in ethylene-rich stream at 100 °C for more than 200 hours. This work elucidates the mechanism of hydrogen spillover on non-reducible Al2O3 and relay hydrogenation on supported single-atom catalysts.
Ribosome rescue pathways recycle the subunits from stalled ribosomes and target the aborted nascent peptide for degradation. Building upon seminal studies in eukaryotes, recent work in bacteria shows that rescue pathways are triggered by ribosome collisions. When an upstream ribosome catches up to a stalled one, a unique interface that directly recruits rescue factors forms between them. The nuclease SmrB in Escherichia coli, for example, cleaves mRNA, targeting it for decay and triggering the rescue of upstream ribosomes by transfer-messenger RNA (tmRNA). In contrast, MutS2/RqcU in Bacillus subtilis splits stalled ribosomes into subunits without mRNA cleavage. Finally, the helicase HrpA splits stalled ribosomes in E. coli through a different mechanism. This review focuses on the discovery of these factors; the structural basis of their activities on collided disomes; and how, after splitting, the nascent chains trapped on 50S are targeted for degradation by the ribosome-associated quality control pathway.
As European care systems increasingly depend on informal support, family members often assume caregiving roles without clear legal recognition. This paper examines to what extent such caregivers qualify as rights-holders under international human rights law, focusing on their position vis-à-vis care recipients and professionals. Drawing on the European Convention on Human Rights (ECHR) and the Convention on the Rights of Persons with Disabilities (CRPD), it identifies three types of caregiver rights: (1) Derivative rights, when inadequate support for recipients imposes a disproportionate burden; (2) Autonomous parallel rights, when caregivers' own rights, such as privacy or moral integrity, are directly affected; and (3) Autonomous conflicting rights, when caregiver and recipient claims collide, requiring balancing. The CRPD promotes a relational but subordinate recognition of caregiver rights, whereas the ECtHR adopts a balancing approach that can afford greater weight. A coherent rights-based framework must recognize interdependence and ensure principled balancing where rights intersect.
Safety control for automated vehicles under occluded visibility has emerged as a key research topic. Nevertheless, prior work largely focuses on risk-aware control based on onboard sensing, with limited discussion of cloud-supported proactive safety decision-making and control (CPSC) for occluded scenarios. To address this gap, we analyze the key characteristics of the vehicle-road-cloud integrated control system (VRCICS) and develop a generic and scalable CPSC architecture across different SAE Levels of Driving Automation. Using the lead-vehicle cut-out with occluded hazard exposure (LVCO) as a representative scenario, we propose a cloud-based TTC interaction-matrix risk assessment method that leverages predicted spatiotemporal trajectory interactions to dynamically identify potential collision points and risk targets. A risk-transfer-aware proactive safety decision algorithm is then developed to enable timely risk warnings and adaptive safe-speed planning. Simulation and ablation studies verify risk-transfer identification and adaptive safety control in potential multi-vehicle rear-end crash chains, and highlight the role of vehicle-side safety functions in the hierarchical architecture. Field tests show that conventional AEB collides at 50 km/h (headway level 1) and 60 km/h (headway level 1/2), whereas CPSC avoids collisions with early warning and proactive deceleration (mean≤4m/s2). Moreover, a sensitivity analysis of roadside perception refinement indicates that the false-trigger rate decreases by 72.7% and the collision-avoidance success rate increases by 18.5%. Additionally, Joint experiments across multiple OEMs confirm the system's engineering feasibility, scalability, and robust performance across diverse vehicle platforms. This study provides a practical guidance and insights for VRCICS-based assisted driving applications.
This descriptive qualitative study explores how dental academics in a single resource-constrained Malaysian private university experience and negotiate emotional labour (EL), using Bourdieu's relational concepts-habitus, cleft habitus, emotional capital, symbolic violence, and field-as analytic tools. Drawing on in-depth qualitative interviews of eleven faculty across academic ranks, we employed abductive thematic analysis to interpret how EL is performed, silenced, and resisted within institutional logics that prioritise visibility, compliance, and performative professionalism. Our findings illuminate three interrelated tensions: the moral pull of teaching amid institutional constraint; the symbolic misrecognition of care and affective investment; and the identity fragmentation that emerges when emotional authenticity collides with managerial norms. Participants frequently described the experience of "splitting" themselves-managing emotional expectations while preserving their sense of vocational integrity. We argue that EL in this setting cannot be reduced to individual psychological strain; rather, it is a sociologically embedded and symbolically governed practice shaped by institutional hierarchies and cultural expectations. By advancing the concept of cleft habitus in relation to EL, the study offers a theoretically grounded contribution to health professions education from a unique sociological vantage point. We conclude with implications for faculty development, well-being policy, and equity-informed institutional reform. Recognising and redistributing EL, particularly in private and low-resource settings, is essential to cultivate sustainable academic environments that affirm the emotional, pedagogical, and relational dimensions of educational work.