This scoping review aimed to identify factors associated with vaccination decisions among pregnant women in the UK, guided by the SAGE matrix on vaccine hesitancy, and explored differences between qualitative and quantitative findings and between vaccine intentions (attitudes) and actual uptake (behaviors). Embase®, MEDLINE®, PsycInfo, Web of Science, and Cochrane were searched; rapid review methodologies were applied. From 2,326 records, 49 primary studies were included (published 2010-2025). We identified 222 qualitative factors from 32 studies, and 114 quantitative factors from 30 studies. Qualitative studies frequently reported individual and group influences, particularly beliefs and attitudes about vaccine effectiveness and safety, and the role of healthcare professionals in decision-making. Quantitative studies highlighted sociodemographic influences, including older age, ethnicity, and lower social/economic deprivation. Factors found to be associated with vaccination intention vs. uptake were inconsistent, though these findings should be interpreted cautiously given the modest number of studies addressing this issue.
Collaborative deprescribing of fall-risk-increasing medication by community pharmacists and family physicians can reduce falls in older adults. No such exists in Türkiye. To identify factors related to community pharmacists' intention (1) to provide collaborative deprescribing service for fall-risk medications in older adults, and (2) to discuss older adults' potential fall-risk medications with the family physician. In this cross-sectional study, a web-based survey was conducted between November 2023 and February 2024 among Turkish community pharmacists recruited using convenience sampling. The questionnaire included items at the respondent level (including a theory of planned behaviour-based questionnaire) and the vignette level (including factorial vignettes). The factors related to their intention to perform two behaviours were evaluated: (1) providing collaborative deprescribing service and (2) discussing older adults' potential fall-risk medications with the family physician. Multilevel linear mixed-effects models were used. Based on responses from 398 community pharmacists (response rate of 93.2%), the intention to provide collaborative deprescribing service was related to their knowledge test score, self-reported rate of older adults served in the community pharmacy (61-80% category), their scores of subjective norm, self-efficacy, and perceived behavioural control (p < 0.05). Community pharmacists' intention to discuss older adults' potential fall-risk medications with the family physician was related to being male, younger age, their experience on patient-centred services, their higher scores of subjective norm, self-efficacy, and perceived behavioural control, and lower scores of attitude (p < 0.05). At vignette level, both intentions were linked to having a history of falls and the number of patients waiting in the community pharmacy (p < 0.05). A collaborative deprescribing service for fall-risk-increasing medications in older adults could be implemented by addressing key determinants of community pharmacists' intention at both respondent and vignette levels, including subjective norm, self-efficacy, perceived behavioural control, attitude, workload-related factors, and patient clinical history.
Young and middle-aged breast cancer patients suffer not only from physical pain but also from great psychological distress. Therefore, there is an urgent need to understand the factors influencing psychological distress in young and middle-aged breast cancer patients with the aim of reducing such distress. Cross-sectional descriptive study. To explore the current status and factors influencing psychological distress in young and middle-aged breast cancer patients. In this cross-sectional survey, relevant evaluations of the research subjects were conducted using a general information questionnaire, the Self-Rating Anxiety Scale, the Self-Rating Depression Scale and the Psychological Stress Thermometer. A total of 262 patients completed the survey, and anxiety and depression were positively correlated with psychological distress. Multiple linear regression analysis revealed that anxiety, depression, age, and fertility were factors influencing psychological distress among young and middle-aged breast cancer patients. Young and middle-aged breast cancer patients experience a high level of psychological distress. The mental health of these patients should be addressed, and such patients should be provided with timely emotional and psychological counseling to reduce their psychological distress.
Racial and ethnic disparities in diabetes prevalence and outcomes are well documented; however less is known about whether the selection of treatment modality itself differs across racial groups after adjustment for clinical correlates of disease severity. This cross-sectional analysis used National Health and Nutrition Examination Survey (NHANES) data from the 2017-March 2020 and August 2021-August 2023 cycles. The primary analytical sample comprised 1,688 adults aged 18 years and older with physician-confirmed diabetes, after excluding 46 probable Type 1 cases. Treatment modality was categorized as insulin-only, oral medication-only (base outcome), combination therapy, or no medication, based on self-reported use of insulin and oral antidiabetic medications. Survey-weighted multinomial logistic regression adjusted for age, gender, education, income, birthplace, insurance, HbA1c, body mass index (BMI), and self-reported diabetes duration. Race and ethnicity remained a significant overall predictor of treatment modality after full adjustment (joint Wald p = 0.012). Other/Multi-Racial adults had 57% lower relative risk of insulin-only therapy than Non-Hispanic White (NHW) adults (relative risk ratio [RRR] = 0.43, 95% CI: 0.24-0.76, p = 0.005), and Other Hispanic and Other/Multi-Racial adults had lower relative risk of combination therapy (RRR = 0.56, p = 0.034 and RRR = 0.47, p = 0.043, respectively). Non-Hispanic Black (NHB) adults did not differ from NHWs at the population level. HbA1c, diabetes duration, BMI, and insurance status were the strongest predictors of treatment modality. An exploratory race-by-income interaction model produced a non-significant joint test (p = 0.259) and is reported as hypothesis-generating. Differences in modality use persist after adjustments, suggesting that structural and healthcare-system factors may contribute to treatment variation independently of measured clinical and socioeconomic characteristics.
Survivors of oesophageal and gastric cancer frequently experience persistent symptoms and functional limitations that affect their health-related quality of life (HRQL). Although self-care is increasingly recognised as a central component of survivorship care, little is known about what determines self-care engagement or whether engagement is associated with better HRQL. This study examined the sociodemographic and healthcare-related variables associated with self-care engagement and explored its association with global quality of life (QOL) in a nationwide cohort. A cross-sectional survey was conducted among individuals diagnosed with oesophageal or gastric cancer in Sweden between 2021 and 2023. Participants completed the EORTC QLQ-C30 and a study-specific questionnaire assessing symptoms and self-care. Self-care engagement was operationalised as the ratio of self-care strategies used to the number of symptoms experienced and categorised into no, moderate, and high. Factors associated with self-care engagement were analysed using multinomial logistic regression, and the association between self-care engagement and global QOL was assessed using linear regression, adjusting for sociodemographic and clinical confounders. Of the 432 respondents, 422 reported at least one symptom and were included in the self-care analysis. One-third of the participants reported no self-care engagement, whereas two-thirds reported moderate or high engagement. Across all models, university education was the strongest and only consistent variable associated with self-care engagement (high vs. no self-care engagement: odds ratio 2.83, 95% confidence interval 1.48-5.42). Neither assignment of a designated contact nurse nor proximity to the treating hospital was associated with self-care engagement. Participants with high self-care engagement had substantially better global QOL than those with moderate or no self-care engagement, with mean differences exceeding 10 points on a 0-100 scale. Global QOL did not differ between the moderate and no self-care groups. Self-care engagement varies widely among oesophageal and gastric cancer survivors and appears to be influenced by educational level. High self-care engagement is associated with clinically meaningful improvements in global QOL, whereas no or moderate self-care appears insufficient to confer benefits. These findings suggest an equity gap in survivorship care, and future research should explore the development of structured and accessible interventions to enhance self-care capabilities among patients with lower educational attainment.
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Human papillomavirus (HPV) can cause six cancer types but can be prevented with timely vaccination in early adolescence. However, despite the wide availability of the HPV vaccine, uptake remains suboptimal among US adolescents. School nurses are invaluable resources to students and their families regarding adolescent immunization needs. As part of the All for Them vaccination program, we assessed the impact of the continued nurse education (CNE) intervention on school nurses' HPV vaccine communication with parents. Seventy-two school nurses and nurse administrators in Texas participated in the study. Using a single-arm study design, we measured participants' potential barriers to and self-efficacy for recommending the HPV vaccine, and knowledge about HPV and the vaccine. Data were collected between November 2021 and May 2023. We evaluated differences in survey responses using paired t-test and McNemar-Bowker chi-square test. Participants' uncertainty about HPV vaccine efficacy was significantly reduced at follow-up (P < .001). More participants indicated that their HPV knowledge (P = .003) and understanding of the recommended dosing schedule for the vaccine (P = .003) were not barriers at all at follow-up. Participants' confidence to communicate with parents about HPV vaccination significantly increased across six self-efficacy variables at follow-up (P < .001). The CNE intervention appeared to improve nurses' HPV and HPV vaccine-related knowledge and increased their self-efficacy to communicate about HPV vaccination with parents, while lessening their perceived barriers to do so. The CNE can be a key resource to support school nurses' professional practice, facilitating their high-quality HPV vaccine recommendations to adolescents and parents.
Multiple sclerosis (MS) is a rare disease in China. Evidence on the extent and contributing factors of diagnostic delay in China remains limited. This study aimed to assess the proportion and duration of diagnostic delay in MS and to identify associated factors in the Chinese context. In July 2022, we conducted a nationwide cross-sectional survey in collaboration with a major Chinese MS patient network. A random sample of adults (≥ 18 years) with a clinically confirmed MS diagnosis was recruited through online patient support groups. Diagnostic delays were defined as the time between symptom onset and a confirmed MS diagnosis, with delays exceeding 3 months classified as "delayed". Delay was further classified into pre-first-consultation and post-first-consultation intervals. Multivariable logistic regression and sensitivity analyses were used to assess associations between diagnostic delay and sociodemographic, clinical, and health system-related factors. Among the 722 participants (mean (SD) age 34.62 (9.86) years; 488 women (67.60%), 48.48% experienced a diagnostic delay longer than 3 months. The mean (SD) time from symptom onset to diagnosis was 16.23 (35.33) months (median 3.0 months), with the majority (mean (SD) 11.27 (27.83) months; median 1.0 month) of delays occurring after the first clinical consultation. Higher health literacy (odds ratio (OR) 0.41; 95% CI 0.20-0.84), initial consultation in a neurology/neurosurgery department (OR 0.19; 95% CI 0.12-0.29), and symptom onset in/after 2018 (OR 0.49; 95% CI 0.32-0.75) were associated with lower odds of diagnostic delay. Sensitivity analyses using 2-month and 5-month thresholds confirmed the robustness of these findings. MS diagnostic delays are common in China, driven by low health literacy and suboptimal healthcare pathways. Efforts to improve public awareness, implement structured referral systems, and enhance diagnostic capacity are urgently needed. These insights may inform strategies for reducing diagnostic delays in developing countries and improving outcomes for patients with MS.
The COVID-19 pandemic resulted in substantial changes to clinical work, particularly the rise of telehealth, with indeterminate benefits and challenges for healthcare providers (HCPs). HCPs serving American Indian and Alaska Native (AI/AN) patients may face additional challenges working in the unique healthcare systems designed for these populations. Seventy-seven providers working at five healthcare organizations that serve urban AI/AN peoples completed questionnaires between January and May 2021. The questionnaire examined mental health symptoms using the Kessler Psychological Distress Scale 6 (K-6) and assessed self-reported emotional health compared to pre-pandemic levels, and inquired about potential risks of distress including demographics, telehealth use, work hours, and COVID-19 related stressors. We assessed the associations between risk factors and K-6 scores using a series of univariate Ordinary Least Squares regressions. Multiple factors were significantly associated with higher distress, including female sex, level of concern about self and colleagues contracting COVID-19, and number of hours worked per week. AI/AN identity was a protective factor for distress. Telehealth use increased from 37% pre-pandemic to 84% during the pandemic, but providing telehealth was not associated with distress. Psychological distress among HCPs who work in clinics which primarily treat AI/AN patients from January to May 2021 was linked to heightened occupational demands, collective wellbeing, and demographic factors. Support strategies in AI/AN-serving healthcare institutions should leverage the protective assets of cultural identity and collective resilience.
Despite growing coverage of health insurance among the Indian population, the indigenous (tribal) populations, who are socio-economically disadvantaged, are yet to be covered. This leaves many households vulnerable to out-of-pocket and catastrophic healthcare expenditures. The present study reports the prevalence of health insurance coverage and its associated factors among the tribal communities in India. A cross-sectional study was conducted across 19 tribal-dominated districts in 12 states of India. A sample of 35,870 households was selected using a multi-stage sampling method. A pre-tested, interviewer-administered questionnaire was used to collect data on socio-demographic characteristics, healthcare access, health worker contact, and coverage under health insurance schemes. Andhra Pradesh and Uttarakhand states show higher proportions (~ 93%) of health insurance coverage, followed by Meghalaya (78%) and Assam (70%). In contrast, Himachal Pradesh (1%) and Madhya Pradesh (4%) have very poor health insurance coverage. Multiple logistic regression analysis reveals a significant geographical variation across states. Other variables, such as gender, age, tribe type, education, occupation, annual income, health worker's visit to the village, regular source of health care, and village type, were found to be significant factors associated with households having insurance coverage (p < 0.001). These study findings indicate considerable inter-state variation and persisting inequities in health insurance coverage among tribal populations. Strengthening awareness, enrolment support, and outreach through frontline health workers is essential to improve equitable coverage in these communities.
Although Black women are known to have higher hypertension rates than White women, longitudinal investigations of racial disparities in early hypertension onset and the role of neighborhood factors in shaping these differences are severely limited. To quantify racial disparities in early hypertension onset among women and examine the degree to which these disparities vary across levels of neighborhood socioeconomic disinvestment. This study used data from women participating in the Reasons for Geographic and Racial Differences in Stroke (REGARDS) study, a national longitudinal cohort study. Participants were recruited between 2003 and 2007. Data analyses were carried out from January to August 2025. Self-reported race and ethnicity and level of neighborhood (ie, census-tract) socioeconomic disinvestment (low, moderate, or high), determined using a summary score of 6 socioeconomic indicators from US Census Bureau data. The primary outcome was age of hypertension onset, which was based on age at self-reported physician diagnosis or measured high blood pressure (≥140 mm/Hg systolic or ≥90 mm/Hg diastolic). Weibull accelerated failure time models with age as the time scale were used to estimate racial differences in age of hypertension onset, accounting for left, interval, and right censoring. Estimates were adjusted for individual-level sociodemographic characteristics and health-related factors. Models evaluating disparities across neighborhood disinvestment additionally accounted for neighborhood clustering and rurality. There were 15 313 women included in the study (mean [SD] age at baseline, 64 [9.5] years), of which 7079 (46.2%) self-identified as Black and 8234 (53.8%) self-identified as White. Black women acquired hypertension a median of 9.6 (95% CI, 9.0 to 10.2) years earlier than White women, independent of sociodemographic factors. Inequities persisted across levels of neighborhood disinvestment. In neighborhoods with low disinvestment Black women had hypertension a median of 9.2 (8.2 to 10.3) years earlier than White women. Within highly disinvested neighborhoods, hypertension occurred a median of 8.0 (95% CI, 6.9 to 9.1) years earlier in Black than White women. In this cohort study, earlier hypertension onset experienced by Black compared with White women persisted regardless of neighborhood context, even after controlling for a wide range of covariates.
Postoperative arrhythmias are common in pediatric patients undergoing cardiopulmonary bypass (CPB); however, their impact on long-term cardiac function remains unclear. To investigate the association between postoperative arrhythmias and long-term cardiac function, and to develop a prediction model for adverse outcomes. This retrospective cohort study included 712 children with congenital heart disease who underwent CPB. Postoperative arrhythmias were assessed using continuous electrocardiographic monitoring. The primary outcome was impaired long-term cardiac function at 6-12 months postoperatively. Multivariable logistic regression and least absolute shrinkage and selection operator (LASSO) regression were used to identify associated factors. The incidence of postoperative arrhythmias was 40.6%. Prolonged corrected QT (QTc) interval and premature ventricular contractions (PVCs) were significantly associated with impaired long-term cardiac function. A dose-response relationship was observed between the number of postoperative arrhythmia types and the risk of adverse outcomes (P for trend < 0.001). Multivariable analysis identified CPB duration (odds ratio [OR] = 1.02), QTc prolongation (OR = 2.70), and PVCs (OR = 1.88) as independently associated factors. The prediction model demonstrated moderate discriminative ability (area under the curve [AUC] = 0.67) and provided a certain degree of clinical net benefit. Risk stratification analysis revealed a clear gradient in the incidence of adverse outcomes across risk groups (6.3% vs 12.3% vs 21.8%).  Conclusions: Postoperative arrhythmias, particularly QTc prolongation and PVCs, are closely associated with impaired long-term cardiac function. The developed prediction model enables effective risk stratification and may facilitate individualized postoperative management.
Unhealthy dietary patterns are increasingly recognized as important modifiable factors associated with cognitive decline and Alzheimer's disease (AD). Diets characterized by high intake of saturated fats, refined sugars, and ultra-processed foods are consistently linked to metabolic dysfunction, systemic inflammation, and impaired brain health. Epidemiological and interventional studies suggest that these dietary patterns are associated with poorer cognitive outcomes, whereas adherence to nutrient-rich dietary patterns such as the Mediterranean, MIND, and DASH diets is linked to improved metabolic profiles and slower cognitive decline. Several biological mechanisms have been proposed to explain these associations, including insulin resistance, oxidative stress, neuroinflammation, vascular dysfunction, and alterations in gut-brain axis signaling; however, much of the current human evidence remains observational, limiting definitive causal inference. Emerging research also indicates that individual susceptibility to diet-related AD risk may be modified by genetic background, metabolic status, and sex-specific biological factors. Despite variability in study findings, the overall body of evidence supports a biologically plausible relationship between dietary quality and key processes implicated in AD pathogenesis. Future research should prioritize long-term, biomarker-driven randomized controlled trials, alongside life-course approaches that consider early- and mid-life dietary exposures, to better clarify causal pathways and inform targeted nutritional strategies for AD risk reduction.
Recent literature suggests that vicarious racism is linked to adverse psychological health outcomes. However, our understanding of protective and risk factors in this context remains limited. This study examined the relationships among social media use integration, vicarious racism, individual differences (race-based rejection sensitivity and racial centrality), and psychological outcomes (anxiety and depression) in a sample of Black American adults. We hypothesized that higher social media use integration would predict greater anxiety and depression, with vicarious racism accounting for these associations, and that individual differences would moderate these relationships. The sample consisted of 244 Black adults (Mage = 30.85, SD = 10.83) who reported having a social media account. Participants completed self-report measures assessing experiences of vicarious racism, race-based rejection sensitivity, racial centrality, social media use integration, and symptoms of both anxiety and depression. Results indicated a significant indirect association between social media use integration and psychological distress through vicarious racism, such that greater integration was associated with higher anxiety and depression via increased exposure to these expereiences. Neither race-based rejection nor racial centrality moderated these indirect effects; however, both showed direct effects on mental health, with racial centrality inversely related to anxiety and race-based rejection sensitivity positively related to depression. Findings underscore the psychological risks of digital racial exposure and highlight the role of identity-related factors in shaping mental health outcomes. Implications for interventions addressing online racial stressors are discussed.
The surgical management of tibial plateau fractures in geriatric patients presents relevant challenges compared with younger patient populations. In addition to fracture-specific aspects, these particularly include patient-related factors, such as osteoporosis, multimorbidity and cognitive impairment, all of which can influence the interpretation of indications, operative strategy and postoperative management. This review article provides an overview of the key considerations for osteosynthesis of geriatric tibial plateau fractures and summarizes the relevant influencing factors that should be taken into account. Die operative Versorgung geriatrischer Tibiakopffrakturen weist im Vergleich zu jüngeren Kollektiven relevante Besonderheiten auf. Diese betreffen neben frakturspezifischen Aspekten insbesondere patientenbezogene Faktoren wie z. B. Osteoporose, Multimorbidität und kognitive Einschränkungen, die sowohl die Indikationsstellung als auch die operative Strategie und Nachbehandlung beeinflussen können. Der vorliegende Übersichtsartikel gibt einen Überblick über die wesentlichen Besonderheiten der Osteosynthese bei geriatrischen Tibiakopffrakturen und fasst die hierbei relevanten Einflussfaktoren zusammen.
Postoperative bulging has been reported after enhanced-view totally extraperitoneal (eTEP) repair, but its underlying mechanisms remain unclear. This study aimed to objectively evaluate postoperative abdominal wall contour changes after eTEP repair with systematic posterior rectus sheath (PRS) closure and to identify factors associated with postoperative bulging using the Ellipse 9 tool. A retrospective observational study was conducted including patients who underwent eTEP repair with systematic posterior rectus sheath closure for midline hernias with rectus diastasis between 2019 and 2024 and had available preoperative and postoperative computed tomography scans. Abdominal morphometric parameters were analyzed using the Ellipse 9 tool at standardized anatomical levels. Rectus muscle density was assessed. Patients were classified into bulging and non-bulging groups. Preoperative and postoperative measurements were compared within and between groups. Thirty-three patients were included: 24 patients (73%) did not develop postoperative bulging (non-bulging group), whereas 9 patients (27%) developed bulging (bulging group). In the overall cohort, a significant bilateral reduction in rectus muscle density was observed (p<0.001), with no relevant modifications in global abdominal contour. The non-bulging group showed decreased muscle density (right: p=0.036; left: p=0.012) without significant geometric contour changes. In contrast, the bulging group demonstrated significant increases in abdominal dimensions (p≤0.002) and greater reductions in eccentricity (p<0.001), indicating a rounder contour, along with a predominant reduction in right-sided rectus muscle density (p=0.036). Postoperative bulging may occur despite systematic PRS closure, supporting a multifactorial origin. Rectus atrophy was insufficient as a sole mechanism, suggesting additional contributions from surgical and functional factors. Structured rehabilitation may improve postoperative outcomes.
Myopia is a common ocular condition that threatens the vision of children and adolescents. This study aimed to investigate the effect of the Rho-kinase inhibitor Y27632 on retinal oxidative stress, tissue structure, and myopia progression in guinea pigs with lens-induced myopia. The animals were randomly assigned to five groups: normal control, lens-induced myopia (LIM), Y27632 low-dose (LD), Y27632 medium-dose (MD), and Y27632 high-dose (HD). Refraction was measured by retinoscopy, axial length (AL) was determined using A-scan ultrasonography, and retinal tissue morphology was examined by hematoxylin and eosin staining. The mRNA and protein expression levels of related factors were analyzed using quantitative polymerase chain reaction and Western blotting. Retinal levels of catalase, glutathione, superoxide dismutase, and malondialdehyde (MDA) were measured using an enzyme-linked assay. The results showed that, compared with the LIM group, guinea pigs in the LD, MD, and HD groups exhibited reduced myopic diopters, slower AL elongation, significantly increased retinal cell counts, decreased expression of Rho/ROCK pathway-related factors, a lower matrix metalloproteinase/tissue inhibitor of metalloproteinase ratio, and enhanced antioxidant activity. These findings suggest that the Rho-kinase inhibitor Y27632 may regulate Rho/ROCK signaling in the retina of guinea pigs with lens-induced myopia, improve the retinal microenvironment, and delay the progression of myopia.
Human embryonic kidney 293 (HEK293) cells have been successfully adapted from adherent to suspension culture and widely applied in both scientific research and the pharmaceutical industry. Although some studies investigated the variances between established adherent and suspension HEK293 cells of different strains, specific alterations in the cells during this consecutive process of suspension adaptation and possible factors driving this process have not been well described. Here, we adapted adherent HEK293 to suspension with desirable cell growth and high productivity for recombinant adenoviral vectors, and cells at several stages throughout the process were characterized. Slower cell growth, lower glucose uptake, increased lactate production, and weaker cell-surface adhesion were observed in suspension cells compared to their adherent counterparts. We further performed transcriptomics, proteomics, and metabolomics analysis to identify key cellular switches. A total of 2476 differentially expressed genes were found, including 1218 upregulated and 1258 downregulated genes in suspension cells. A similar and correlated pattern was observed in the proteomic study, and 702 differentially expressed metabolites were identified by untargeted metabolomics. In light of enrichment analysis, we summarized that HEK293 adherent cells survived and adapted to suspension culture via structural remodeling, metabolic shift and stress resistance. Our results provide a molecular enlightenment for suspension adaptation and potential directions for rational modification of HEK293 cell lines for future use. KEY POINTS: • Suspension adaptation reduced adhesion and reshaped the HEK293 cytoskeleton. • Multi-omics revealed metabolic rewiring and enhanced stress resistance. • An optimized suspension line outperformed an internal HEK293 suspension reference.
Robotic liver surgery (RLS) is expanding in recent years. Complication prediction is crucial for postoperative outcomes. Traditional MIS scores are poorly studied in RLS, and conventional statistics often oversimplify the multifactorial and interrelated nature of these complications. This study aimed to evaluate the three-level complexity Institut Mutualiste Montsouris (IMM) classification in RLS and assess its integration into an AI algorithm to predict major complications. We retrospectively analyzed data of patients underwent RLS. Surgical complexity was stratified into grades I (low complexity), II (intermediate), and III (high). The cumulative incidence rate and conditional probability of postoperative complication and risk factors for complication ≥ Clavien-Dindo grade II were assessed. The prediction model was developed by training/testing a machine learning (ML) algorithm after feature selection with uni-multivariate analysis. We calculated the receiver operating characteristic (ROC) curve and model accuracy. We analyzed 1,045 patients who underwent RLS, classifying them into three complexity levels: Grade I (n = 581), Grade II (n = 267), and Grade III (n = 109). Significant differences were observed in intra- and postoperative outcomes across the three grades. Multivariate analysis identified ASA score (HR 2.1, p = 0.02), number of lesions (HR 1.8, p = 0.001), and operative time (OR 1, p = 0.004) as key predictors of complications. Associated with the three-level complexity classification, the Neural Network showed the best performance with AUC (0.653) and a precision of 0.996. Three-level complexity IMM classification is a useful tool in RLS for predicting intra-postoperative outcomes. It can be integrated into the Neural Network algorithm to predict major complications.
Viruses play a significant role in microbial ecology, yet their impact on drinking water systems remains poorly understood. We collected water from different treatment process streams of an ozone-bioactivated carbon (O3-BAC) advanced drinking water treatment plant in eastern China. DNA viral metagenomic sequencing was then performed to analyze viral abundance, community structure, diversity, host prediction, virulence factors, potential viral pathogens, and functional genes, including carbohydrate-active enzymes (CAZymes), auxiliary metabolic genes (AMGs), and antibiotic resistance genes (ARGs). The results revealed that treatment reduced viral abundance and diversity, although certain taxa not detected in raw water or sedimentation water (e.g., Preplasmiviricota) were detected in sand-filtered water and finished water. Caudoviricetes were the most abundant viruses in the water treatment process. The virus host types were predominantly bacteria, mainly Lactobacillus, Mycoplasma, Staphylococcus, Bacillus, and Streptococcus. Functional analysis revealed viral involvement in carbohydrate degradation via CAZymes and modulation of host metabolism through AMGs and ARGs to support viral replication. Potential human pathogens were identified within Poxviridae and Herpesviridae. This study provides novel insights into DNA viral ecological dynamics in engineered water systems and supports enhanced pathogen control strategies.