Scientists want to know everything, everywhere, and all the time. This is particularly true in Earth science, where we seek to understand processes that span from the molecular to the planetary scale in how the world works, how it affects us, and how we impact it-especially the water cycle. Evapotranspiration (ET) was the last component to be measured in closing the water cycle: for decades, closing the water budget meant adding up all the measurable components, then inferring ET as the residual. Early measurements relied on water loss from pans and weighing lysimeters, followed by sensors inserted into plants to monitor sap flow and leaf chambers capturing transpiration. Scaling up to ecosystems became possible through eddy-covariance flux towers and further across landscapes through proximal sensing with drones, aircraft, and, ultimately, with satellites. While enormous progress has been made to measure or estimate ET everywhere and all the time, no single approach has yet achieved both simultaneously. Flux towers help with all the time, but not everywhere. Satellites can do everywhere, but not all the time (except, in part, for geostationary satellites, though with insufficient spatial coverage and resolution). A new advent of smallsat constellations is moving us to everywhere and all the time in detail, though we are only in the beginning of that era. This paper discusses the evolution and revolution of Earth observation for ET, as we advanced from the first Landsat and development of ET models through the progression of increasingly higher spatiotemporal resolution across international space agencies and commercial industry with increasing ET model sophistication, cloud computing, and machine learning. We continue to march ahead towards ET everywhere, all the time, and use that knowledge to better manage water and sustain our planet.
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Drekolias and colleagues report a therapy-specific prognostic model integrating mutational and cytogenetic features to risk-stratify survival in patients with acute myeloid leukemia treated with venetoclax-based regimens, providing a clinically relevant framework amid a rapidly expanding landscape of competing models. See related article by Drekolias et al., p. 403.
Urban Somali refugees in Nairobi, Kenya, navigate healthcare within a landscape defined by chronic insecurity, fragmented governance, and racialized exclusion. This ethnographic study examines how Somali refugees in Eastleigh experience and respond to medical precarity, understood as a structurally produced condition where formal health institutions are present yet inaccessible. Drawing on key informant interviews and focus group discussions with 98 refugees, health workers, and community leaders, alongside field observations conducted between 2018 and 2019, the analysis shows how care is deferred, avoided, and reassembled under conditions of economic constraint, legal risk, and institutional mistrust. Rather than withdrawing from care altogether, participants navigated illness through relational infrastructures that include pharmacies, household networks, and trusted intermediaries providing credit, advice, and continuity. These practices make care possible while also exposing refugees to exploitation and uneven quality in poorly regulated pharmaceutical markets. Participants also articulated a moral horizon of health shaped by aspirations for dignified treatment and transnational imaginaries of functioning health systems. The findings show that improvised care is not an informal deviation but a rational and ethical response to structural neglect. Medical precarity, in this context, does not merely constrain care; it reorganizes care through relational infrastructures and a pastoralist logic of medical seeking, characterized by continual recalibration of trust, cost, safety, and recognition across fragmented health systems. Yet these practices cannot fully resolve the health capability gap between knowing what care requires and having the conditions to make such care possible.
Over recent decades, advances in molecular biology, genomics, and bioinformatics have substantially transformed the scientific understanding of cancer and reshaped clinical oncology. Technologies such as next-generation sequencing, molecular profiling, and biomarker identification have enabled more precise tumor classification and personalized therapeutic strategies, contributing to the consolidation of precision oncology. However, these advances are not equally accessible worldwide. While high-income countries increasingly incorporate molecular diagnostics and targeted therapies into routine clinical practice, many low- and middle-income countries still struggle to provide even basic oncological services. The objective of this reflection is to discuss the growing disparity in access to cancer knowledge, diagnostic technologies, and scientific participation between high-income and resource-limited settings. In many regions, essential tools such as immunohistochemistry, advanced imaging, and molecular testing remain limited or unavailable, leading to delayed diagnoses, empirically guided treatments, and poorer outcomes. These disparities also influence global scientific production, as most cancer research originates from well-resourced institutions, while populations with the highest burden of disease remain underrepresented in clinical trials and molecular studies. Addressing this imbalance requires global investment in diagnostic infrastructure, training of healthcare professionals, and equitable international research collaborations. Expanding access to cancer knowledge and technologies is essential to ensure that advances in oncology translate into meaningful improvements in outcomes for patients worldwide.
Cesarean sections (C-sections) are life-saving surgeries; however, rates exceeding 10-15% are not associated with reductions in maternal and neonatal mortality. In urban India, C-section rates were 32% in 2019-21. Research on C-section deliveries in urban informal settlements and among those primarily accessing public healthcare services has been limited. This study examined trends and underlying reasons for C-sections in informal settlements in the Mumbai Metropolitan Region, India, drawing insights from both women and obstetric practitioners (public and private). Through this, the study aimed to identify potential suggestions to improve obstetric care in vulnerable settings. The study employed an explanatory sequential mixed methods design. Quantitative data were collected through cross-sectional surveys in 2019, 2021, 2022 and 2024, including a pooled sample of 5,162 mothers of children aged 0-2 years. Logistic regression analysis was conducted to identify factors associated with C-sections. Qualitative data collection from October 2024 to February 2025 involved in-depth interviews (N = 44) with women who underwent C-sections and public and private practitioners. Thematic analysis was performed using substantive coding to inductively develop themes. C-section rates increased from 25% in 2019 to 37% in 2024, with a 15% increase in private facilities and 10% increase in public facilities. Maternal age, gravida, timing of antenatal care registration and number of antenatal visits were significantly associated with C-sections. Qualitative findings identified several interconnected reasons, such as institutional limitations, evolving obstetric practices, risk perceptions, awareness and lifestyle changes, to be contributing to C-sections. Likelihood of reported reasons was greater among primigravida women, contributing to a rise in repeat C-sections. Reported reasons were similar between public and private facilities, whereas practitioners and women had divergent perspectives towards rising C-section rates. C-sections are rising in urban informal settlements among women primarily accessing public facilities. Non-medical reasons influence medical indications and decisions for C-sections. A multi-pronged approach involving both community-based and systemic interventions is needed to reduce avoidable C-sections. This study provides critical evidence to inform interventions for improving patient-practitioner relations and delivery experiences while bettering obstetric outcomes in vulnerable settings.
Endoscopic retrograde cholangiopancreatography (ERCP) is a widely used therapeutic procedure for pancreatobiliary disorders but is associated with a range of complications, most commonly post-ERCP pancreatitis (PEP). Post-ERCP air leak syndromes-including pneumothorax, pneumomediastinum, pneumoperitoneum, and subcutaneous emphysema-are exceptionally rare, particularly in the absence of an identifiable gastrointestinal perforation. We report the case of a 72-year-old woman who developed severe abdominal pain, acute respiratory distress, and hypoxemia 6 hours after ERCP performed for common bile duct stenting and biopsy of a suspected biliary tumor. Laboratory investigations revealed markedly elevated serum amylase and lipase, consistent with acute pancreatitis. Imaging demonstrated a moderate right-sided pneumothorax, diffuse pneumomediastinum, pneumoperitoneum, pneumoretroperitoneum, extensive subcutaneous emphysema, and radiological features of acute pancreatitis, without evidence of duodenal or esophageal perforation. The patient was managed conservatively in the intensive care unit with bowel rest, intravenous fluids, antibiotics, supplemental oxygen, and close monitoring. Clinical and biochemical parameters improved progressively, with repeat imaging showing regression of air collections. This case highlights a rare constellation of post-ERCP complications occurring simultaneously without demonstrable perforation and underscores the importance of prompt recognition, multidisciplinary assessment, and individualized conservative management in selected stable patients.
What makes a system-evolved, engineered, or hybrid-describable by teleological and mentalistic terms such as intelligent, goal-directed, cognitive, and intentional? In this two-part article, we review classical thought on teleology in the life sciences and defend a new approach to goal-directedness that stems from an emerging field-diverse intelligence. This field seeks to characterize what all active agents, regardless of their composition or provenance, have in common. Our approach emphasizes: (1) empirical testability (not philosophical commitments to linguistic categories), (2) fecundity in discovery of new capabilities (not just reductive mechanistic explanations of results after they are made, but worldviews that facilitate and enable novel research), (3) operationalization of terminology by reference to conceptual and empirical toolkits shown to be effective for a given system (cognitive and teleological claims are really hypotheses of optimal interaction protocols), and (4) continuity of human goal-directedness with our unicellular origins (which implies a need for models of scaling of cognition). In Part One, we reviewed historical and contemporary debates about teleology in biology and described some ground-breaking experimental results from morphogenesis, synthetic biology, and other areas of research involving the coordination of cellular behavior by means of bioelectric networks. In Part Two, we argue that current approaches to goal-directedness in biology cannot accommodate these results in a manner that helps us better understand how these systems work and fruitfully guides experimental work and practical applications in these areas of research. What is needed, therefore, is an approach to teleology in biology, informed by mentalistic concepts, such as intelligence, cognition, and intentionality. We describe and explain our mentalistic approach in greater depth, show how it can be applied to specific cases, and address some important objections to our view. By abandoning the reductionistic aversion to mentalistic concepts in biology in favor of principled and testable frameworks for understanding diverse minds embodied in the physical world, the plasticity and problem-solving competency of the agential material of life can provide fodder for advances in philosophical thought, as well as for biomedical and bioengineering applications.
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Minimally invasive surgical approaches, including laparoscopic and robotic techniques, have been shown to improve the outcomes in colorectal cancer resection by decreasing pain, hospital length of stay, and perioperative mortality. However, broader adoption of robotics faces several barriers. This study aimed to evaluate national trends in robotic colorectal surgery using the National Cancer Database (NCDB). Patients with stage I to III colon and rectal adenocarcinomas who underwent resection (2010-2021) were identified. Trends in surgical approaches (open, laparoscopic, and robotic) were analyzed. Multivariate logistic regression identified factors associated with the adoption of robotics. A total of 537,627 colon and 116,763 rectal resections were included. Robotics were used in 61,640 (11.5%) colon and 30,569 (26.1%) rectal cases. For colon cancer, the adoption of robotics increased by +2.4% annually, nearly equaling open surgery by 2021 (26.7% vs 27.2%). For rectal cancer, adoption of robotics increased by +4.28% annually, surpassing both laparoscopic and open approaches by 2018. Robotic surgery was predominantly performed in metropolitan centers (87.2%) compared with rural areas (1.5%). Regionally, the adoption of robotics was the highest in the West North Central (+5.0%/y) and West South Central (+3.3%/y) regions and the lowest in New England (+1.3%/y). Compared with New England, all regions were more likely to use robotics, with the West North Central region demonstrating the highest odds (odds ratio, 2.15 [95% CI, 1.95-2.38]). Robotic colorectal cancer surgery has expanded substantially over the past decade, with marked regional and institutional disparities. Understanding these patterns may inform targeted educational initiatives and promote nationwide equitable adoption of robotic surgery.
Limited information is available on the impact of the COVID-19 pandemic on supported accommodations (SAs) for people with serious mental disorders. A quantitative study recently conducted in Portugal showed that these services struggled with a more challenging environment, residents' fears, and a lack of support from community services. We now aim to complement it by reporting qualitative data on the experiences of residents and professionals of SAs for people with serious mental disorders during the pandemic. A purposive sample of 11 residents and 11 professionals from 11 different organisations responsible for SAs in Portugal was included. Data were collected through semi-structured interviews. The interview guide included questions regarding changes in the functioning of SAs and implemented measures during COVID-19 and the impact of the pandemic on the well-being of residents and professionals. Thematic analysis was used. Some SAs had to close or relocate, and several procedures were changed. Residents felt that the most impactful changes included not being able to go outside or see loved ones. Despite some residents reporting anxiety or sadness, almost none relapsed. However, some professionals noted an impact on the autonomy and cognition of residents. Despite reporting a negative impact of the pandemic on their own well-being, professionals struggled to maintain the functioning of SAs and the well-being of residents. Residents recognised the effort made by professionals and felt supported by them during COVID-19. The COVID-19 pandemic significantly impacted the functioning of SAs. In line with our findings, some actions seem fundamental to improve SAs' resilience in the future. These relate to human resources, training, structural conditions, new technologies, and professionals' well-being. A informação sobre o impacto da pandemia de COVID-19 em residências apoiadas (RAs) para pessoas com doença mental grave é limitada. Um estudo quantitativo realizado recentemente em Portugal mostrou que estes serviços enfrentaram dificuldades devido a um ambiente mais desafiador, aos medos dos residentes e à falta de apoio por parte dos serviços comunitários. Pretendemos agora complementar o mesmo estudo reportando dados qualitativos sobre as experiências de residentes e profissionais de RAs durante a pandemia. Foi incluída uma amostra intencional de 11 residentes e 11 profissionais de 11 organizações diferentes responsáveis por RAs em Portugal. Os dados foram colhidos através de entrevistas semiestruturadas. O guião de entrevista incluiu perguntas sobre as mudanças no funcionamento das RAs e medidas implementadas durante a pandemia de COVID-19 e o impacto da pandemia no bem-estar dos residentes e profissionais. Foi posteriormente realizada análise temática. Algumas RAs tiveram de fechar ou se mudar e vários procedimentos foram alterados. Os residentes sentiram que as mudanças mais impactantes incluíram não poder sair de casa ou ver os seus entes queridos. Apesar de alguns residentes relatarem ansiedade ou tristeza, quase nenhum teve recaída. Contudo, alguns profissionais notaram impacto na autonomia e cognição dos residentes. Apesar de relatarem um impacto negativo da pandemia no seu próprio bem-estar, os profissionais lutaram para manter o funcionamento das RAs e o bem-estar dos residentes. Os residentes reconheceram o esforço dos profissionais e sentiram-se apoiados por eles durante a pandemia. A pandemia de COVID-19 teve um impacto significativo no funcionamento das RAs. Algumas ações parecem fundamentais para melhorar a resiliência das RAs no futuro. Estas dizem respeito aos recursos humanos, à formação, às condições estruturais, às novas tecnologias e ao bem-estar dos profissionais.
Charles Bonnet syndrome (CBS) refers to visual hallucinations that can occur following a decline in vision. Although vision loss increases fall risk and susceptibility to falls-related variables such as activity limitation, the potential contribution of CBS is unclear. The present study adopted a qualitative approach to explore experiences of CBS from different perspectives, including its impact on physical activity and falls. Semistructured interviews were conducted with 17 older adults living with CBS (mean age = 76 years) and 12 community falls and sight loss professionals. Reflexive thematic analysis guided data analysis. Themes represent the 'CBS journey' moving from symptom onset to living with CBS. Low CBS awareness, anticipated stigma and professionals' failure to raise CBS had negative psychological impacts. While walking, recognisable images could evoke a behavioural response and delay insight. Falls occurred when CBS distracted attention from actual surroundings, automatic reactions led to a loss of balance, and panoramic hallucinations caused disorientation and obscured real hazards. CBS also contributed to concern about falling. While moving about, precipitating factors for CBS included fluctuations in light level and situational stress. Common relief techniques were least effective for people with intrusive symptoms. Instead, engaging in enjoyable multisensory activities or low to moderate physical activity for health provided relief. CBS adds an additional layer of complexity to the aetiology of sight-related falls. To reduce the risk of falls caused by CBS, a multifaceted strategy is indicated that addresses factors at the individual, organisational, educational and health care policy levels.
Adult Refsum disease (ARD; OMIM 266510) is a degenerative autosomal recessive condition typically diagnosed in adulthood. It affects visual, auditory and nervous system function. It is characterised by plasma, neuro-ophthalmological and adipose tissue accumulation of the dietary-derived phytanic acid (PA). This guidance reviews the clinical aspects of ARD and discusses interventions to address various co-morbidities of the disease. This GRADE-aligned guidance is based on a review of the literature and a consensus statement reflecting the conclusions of professionals with experience in the diagnosis and management of ARD. This statement reviews clinical aspects of ARD and discusses current and potential interventions to address various symptoms of the disease. It provides an overview of the clinical phenotype, reviews the clinical, biochemical, and genetic findings in ARD, and the neurological and ophthalmological investigations needed at diagnosis and during follow-up. It highlights the importance of dietary management and its role in situations such as acute hospital admissions for inter-current illness. Furthermore, it provides guidance on the acute management of decompensation in ARD and outlines when therapeutic plasma exchange/lipoprotein plasmapheresis should be considered. Greater clinician and patient awareness will lead to early diagnosis and improved outcomes. Implementation of a low PA diet before further end organ involvement offers the best prognosis. Life-long dietary therapy, along with therapeutic plasma exchange/lipoprotein apheresis during acute decompensations, remains the mainstay of management. Patients should have access to a multidisciplinary team to ensure specialist dietary input and supportive management of comorbidities.
Unprecedented advances in Artificial Intelligence (AI)-assisted automation continue to drive the demand for hardware that is significantly more scalable, compact, and energy-efficient. Neuromorphic electronics, which offers event-driven and massively parallel information handling capabilities inspired by the biological cognition, provides a compelling solution, especially as emerging device technologies now enable true in-memory computation and tightly integrated sensing capabilities far beyond what CMOS alone can achieve. To keep pace with rapid progress in AI algorithms, the discovery of new functional materials and their integration into unconventional computing architectures has become a critical research frontier. This perspective highlights the potential of various classes of device technologies for next-generation neuromorphic AI hardware, showcasing key breakthroughs in robust, flexible, and conformable device platforms. Such technologies are particularly promising for resource-constrained edge platforms, such as wearable electronics, soft robotics, and autonomous embedded sensing systems. Lastly, we discuss that circuit- and system-level design must advance alongside device innovation, including robust biasing schemes, reliable peripheral integration, and scalable architectures that can support dense neuromorphic arrays. Looking forward, the field must embrace full-stack co-optimization from materials and device physics to circuits, architectures, and learning algorithms, ultimately enabling adaptive, autonomous computing embedded seamlessly into everyday environments.
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Generative artificial intelligence(GenAI) is increasingly being used in the health sector. Much of the current discourse on GenAI is focused on technical accuracy and bias in its outputs. This editorial argues the need to go beyond bias mitigation and take a pro-justice approach for ethical GenAI use in health and medicine: one that actively confronts injustices, addresses structural inequities, and considers our intrinsic intergenerational responsibilities towards nature, humans everywhere , and other species. The piece draws from feminist ethics, justice theories, and decolonial practices to outline four key principles for a pro-justice approach for ethical GenAI use in medicine and health: intersectionality, epistemic justice, environmental justice, and social justice. It highlights the importance of such an approach, particularly for women's health. Research to develop, validate, and implement generative artificial intelligence (GenAI) tools is becoming increasingly common. However, most discussions about GenAI focus on whether it works accurately and whether it produces biased results (responsible AI). While these issues are important, this editorial argues that this is not enough for the health sector. It outlines the need for asking deeper questions about fairness and justice, that go beyond individual-level benefit-harms assessment. Drawing on feminist ethics, justice theories, and decolonial perspectives, the editorial outlines four principles for pro-justice ethical GenAI use: intersectionality (recognising how different forms of disadvantage overlap), epistemic justice (being inclusive of different types of people and diverse kinds of knowledge), social justice (fair distribution of resources, health and social benefits across populations), and environmental justice (considering intergenerational responsibilities toward humans everywhere, the nature, and other species). Considerations around ethics, governance and policy for GenAI use are also outlined.
While the biogeographic patterns of animals and plants are well defined, the distribution of the microbial eukaryotic world remains contentious. Classically, protists were assumed to be cosmopolitan, dispersing everywhere with little geographic constraint. We tested this hypothesis by compiling 88 marine cytochrome oxidase subunit I metabarcoding studies to perform a global population-genetic analysis. We uncovered a fundamental biogeographic divide: most animal (Metazoa) and plant (Archaeplastida) phyla have haplotype diversity that is strictly concentrated within specific ocean basins, while most protist phyla share identical haplotypes across multiple, distant oceans. The combination of large geographic ranges with moderate among-ocean genetic differentiation in protists is inconsistent with strict historical cosmopolitanism and is compatible with high connectivity and range expansion dynamics, including, but not limited to, recent colonization events. Our findings provide a unified population-genetic perspective on marine eukaryotic biogeography and refine current views of microbial dispersal at ocean-basin scales.
In this Opinion Paper, we argue that the absence of animal welfare in the United Nations' sustainable development goals (SDGs) may not be as detrimental as some suggest. We put forward the view that the welfare of animals is an integral part of the concept of sustainability, that development which affects animals cannot be sustainable without due consideration to their welfare, and we give examples in support of this position. Put simply: no mention means animal welfare could be, and potentially should be, anywhere and everywhere in the goals. For livestock species, we submit that the synergies between the SDGs when animal welfare is included greatly outweigh the conflicts usually highlighted. Further, considering animal welfare as both an achievable goal and as a mechanism for sustainable development allows improvement of animal welfare to carry the weight it warrants: an animal with poor welfare is not a sustainable animal. By extension, products from animals with poor welfare cannot be considered sustainable, and animal welfare is necessarily included in a well-functioning ecosystem. Through the paper we argue that the challenge is not to add in animal welfare, but to think sustainability with animal welfare. We conclude by giving directions to where animal welfare can be integrated when developing sustainable actions.
Postpartum hemorrhage (PPH) remains the leading cause of maternal mortality worldwide, disproportionately affecting women in low- and middle-income countries. Despite updated WHO recommendations and the availability of newer technologies-including heat-stable carbetocin, tranexamic acid as part of a clinical care bundle, misoprostol, and calibrated drapes-adoption and scale-up remain limited due to persistent supply and demand-side barriers. This article provides an overview of the Accelerating Measurable Progress and Leveraging Investments for Postpartum Hemorrhage Impact (AMPLI-PPHI) project. Led by Jhpiego, in partnership with PATH and FIGO, AMPLI-PPHI aims to reduce maternal mortality from PPH by catalyzing the adoption of effective drugs for PPH prevention and treatment as part of quality of intrapartum care, at all levels of the health system. Working in partnership with governments in project target countries (Democratic Republic of the Congo, Guinea, India, Kenya, Nigeria, and Zambia), AMPLI-PPHI helps to increase women's access to PPH prevention and management. AMPLI-PPHI introduces and integrates proven approaches and PPH commodities into routine maternal health systems, generates evidence, and supports countries in scaling up these practices. Globally, the project focuses on reducing supply-side barriers to help create the market for affordable and accessible PPH commodities. AMPLI-PPHI also fosters a regional exchange network-propelling shared learning and best practices-to light the spark for transformation in PPH care, thereby reducing maternal deaths from PPH-ensuring every woman, everywhere, has access to lifesaving care.