Citations

Background While rural health guidelines have often cautioned against digital interventions due to infrastructure and literacy barriers, this study introduces an SMS-based conversational artificial intelligence (CAI) that overcomes these limitations to promote HPV vaccination. Objective To evaluate an SMS-based CAI using the Centers for Disease Control (CDC)’s presumptive and CASE (Corroborate, About Me, Science and Explain) frameworks to promote HPV vaccination among rural parent-adolescent dyads by: (1) testing its usability; (2) assessing the feasibility of co-design with clinicians and parent-adolescents; (3) identifying adoption barriers and (4) examining communication preferences across behavioural profiles. Methods We developed a CAI simulator using the presumptive approach and the structured CASE method to address 11 common concerns about the HPV vaccine. A multimethod usability study with 13 rural parent-adolescent dyads (n=26) included in-depth interviews and the System Usability Scale. Results The CAI achieved excellent usability (mean SUS 85.2, ~96th percentile). A previously undocumented behavioural profile—vaccine-unaware—was identified, distinct from hesitancy, and best addressed through empathetic, exploratory dialogue. Key adoption barriers included integration with existing preventive care routines and endorsement by trusted local providers. Conclusions Contrary to the assumption that rural residents resist digital tools, participants engaged readily when content was credible, locally endorsed and accessible via SMS. Findings highlight the conditional effectiveness of the CDC’s presumptive style in CAIs—well-suited for vaccine-compliant users but less effective for sceptical or unaware groups, who, we argue, would respond better to conversational, empathetic tones.

ABSTRACT Background Decision‐making (DM) dynamics between adolescents and young adults (AYAs) with cancer, parents, and oncologists remain underexplored in diverse populations. We examined cancer treatment DM preferences among an ethnically and socioeconomically diverse group of AYAs and their parents. Procedure We surveyed AYAs with cancer ( n = 75) and their parents ( n = 52) participating in the Texas KidsCanSeq study. Among AYA‐parent pairs, we compared preferred and actual treatment DM roles. We explored associations among DM roles, having pediatric‐to‐adult care transition discussions, and clinical and sociodemographic characteristics. We report AYAs’ and parents’ preferences for involvement in shared decision‐making (SDM) with oncologists about cancer treatment. Results AYAs’ DM role preferences varied: 44% preferred to equally share DM with parents, 31% preferred AYA‐led DM, and 25% preferred parent‐led DM. Parents who preferred parent‐led DM had younger AYAs than parents who preferred equally shared DM ( p = 0.011). For actual DM, 48% of AYAs reported DM was equally shared, 24% reported DM was AYA‐led, and 28% reported DM was parent‐led. Most AYAs had their preferred role (73%). AYAs’ actual role did not significantly differ from their own or their parents’ preferences (both p > 0.05). Approximately half of AYAs reported recent pediatric‐to‐adult care transition discussions. AYAs’ DM preferences and participation in transition discussions did not significantly differ along clinical or sociodemographic characteristics (all p > 0.05). AYAs and parents perceived high importance across all aspects of SDM with oncologists. Conclusion In this diverse study population, AYAs desired engagement in treatment DM and SDM. Although specific role preferences varied, opportunities existed to increase discussion around pediatric‐to‐adult care transition.

Introduction Neurological post-acute sequelae of COVID-19 (neuroPASC) are associated with persistent cognitive dysfunction and quality-of-life decline. We aimed to identify clinical, behavioral and sociodemographic factors associated with neuroPASC symptom burden two years after COVID-19 among individuals without prior neurological disease. Methods In this prospective, observational study, individuals with neuroPASC ( n = 102) and controls without symptomatic COVID-19 ( n = 74), all without prior neurological, psychiatric, or post-viral conditions, were enrolled between February 2022 and June 2024 across five academic sites. An unsupervised algorithm identified clusters with differing self-reported neurological symptom burden within the neuroPASC group. Functional differences between clusters were evaluated using quality-of-life, neurological and cognitive evaluations. Demographics, behavioral history, comorbidities, and blood biomarkers were compared across clusters and controls. Multivariable logistic regression assessed predictors of neuroPASC severity, including demographics, body-mass-index, Charlson Comorbidity Index, Framingham Risk Score, pre-existing endocrine/metabolic and/or gastrointestinal/hepatobiliary conditions, COVID-19 vaccination prior to infection, hospitalization during acute infection, and cumulative alcohol use. Results Two clusters emerged based on neurological symptom burden, labeled “high-burden” and “low-burden” neuroPASC, reflecting differences in the number and frequency of symptoms. Both clusters had deficits in quality-of-life and cognitive function compared to controls, with greater impairment in high-burden than low-burden neuroPASC. The clusters did not differ by sex, education, tobacco and cannabis use, blood pressure, body-mass-index, HbA1C, days since infection, hospitalization during COVID-19, pre-COVID vaccination rate, antibody-positivity, inflammation, and neurodegeneration biomarkers. The high-burden cluster was older and exhibited higher comorbidity burden and greater cumulative alcohol use compared with the low-burden cluster and controls. Pre-existing endocrine/metabolic and gastrointestinal/hepatobiliary conditions were more common in high-burden (63%) than in low-burden neuroPASC (35%). After adjusting for clinical and demographic factors, these pre-existing conditions remained the only independent predictor of severity, conferring a 3.5-fold increase in the odds of high-burden versus low-burden neuroPASC. Discussion Older age, higher comorbidity burden, greater cumulative alcohol use, and endocrine/metabolic and gastrointestinal conditions, rather than acute COVID-19 severity, were observed in the high-burden neuroPASC cluster. After multivariable adjustment, only pre-existing endocrine/metabolic and/or gastrointestinal/hepatobiliary conditions remained independently associated with high-burden neuroPASC, conferring a 3.5-fold increase in odds and highlighting the need for targeted post-infection monitoring in at-risk patients.

Post-pulmonary embolism syndrome (PPES) encompasses a diverse spectrum of long-term complications that are associated with persistent dyspnea, exercise intolerance, and a decrease in quality of life. The PPES constellation ranges from life-threatening conditions such as chronic thromboembolic pulmonary hypertension (CTEPH) to nonlife-threatening but still debilitating conditions such as chronic thromboembolic pulmonary disease (CTED) or post-PE deconditioning. The safety and efficacy of exercise and cardiopulmonary rehabilitation programs to prevent and manage these symptoms in PPES has not been well established. Herein, we review contributors to PPES and synthesize the evidence for exercise training after PE to treat and prevent PPES.

Abstract Faciobrachial dystonic seizures (FBDS), paroxysmal dizziness spells, and thermal sensory attacks are highly frequent and stereotypic phenomena experienced in leucine‐rich glioma inactivated 1 (LGI1)‐antibody encephalitis. This study aims to describe the electrophysiologic mechanism underlying these pathognomonic symptoms. LGI1‐antibody encephalitis patients with active symptoms were enrolled from two separate centers in South Korea and the United States. Patients were evaluated with simultaneous magnetoencephalography (306 channels) and electroencephalography. Regional alterations in neuronal excitability represented by interictal epileptiform discharges were present in the faciobrachial area of the motor cortex, insula, and somatosensory cortex, somatotopically aligned with each of the ictal semiologies observed in patients. FBDS and other LGI1‐antibody encephalitis‐specific spells localized to cortical regions neuroanatomically corresponding to ictal semiologies: the faciobrachial homunculus (FBDS), insular cortex (paroxysmal dizziness spells), and somatosensory cortex (thermal sensory attacks). Our findings support the ictal hypothesis underlying these unique phenomena.

Background Individuals with intellectual and developmental disabilities experience substantial disparities across the cancer care continuum, including delayed diagnosis, limited access to supportive resources, and heightened psychosocial distress. These challenges are intensified in high-acuity settings where care models are not adapted to their developmental and cognitive needs. Methods We describe an interdisciplinary, patient-centered approach to the care of a 34-year-old patient with developmental delay and metastatic adenocarcinoma. Key strategies emphasized education, preparation, and communication tailored to her cognitive abilities. Collaboration with her family informed effective strategies to reduce distress and improve compliance. Results Tailored interventions – including simplified communication, visual supports, and continuity of providers – improved the patient’s coping, reduced distress, and enabled completion of comprehensive oncologic evaluation and treatment. Conclusions This case demonstrates that structured, interdisciplinary, patient-centered approaches to care can mitigate disparities and support equitable, compassionate care for individuals with intellectual and developmental disabilities facing serious illness.

Background: Frequent pivoting, rotation, and deep hip flexion place football players at high risk for femoroacetabular impingement (FAI), a leading cause of hip pain in this population. Previous studies have primarily focused on professional National Football League athletes undergoing mixed surgical techniques, including labral debridement. Limited data exist on outcomes in younger, amateur players treated with labral repair. Purpose: To report return to sport (RTS) rates and functional outcomes at a minimum 5-year follow-up in primarily active high school and college football players undergoing primary hip arthroscopy with labral repair for FAI. Study Design: Case series, Level of evidence, 4. Methods: All football players who underwent primary hip arthroscopy with labral repair for FAI between 2010 and 2019 were identified from an institutional database. Collected data included descriptive data, radiographic parameters, surgical details, and reoperations. At a minimum 5-year follow-up, RTS outcomes and patient-reported outcome measures (PROMs), such as the Modified Harris Hip Score (mHHS) and Hip Outcome Score (HOS), were evaluated. Results: A total of 36 hips in 27 male athletes (mean age, 18 years; body mass index, 28.1 kg/m 2 ) were included. The majority of athletes competed at the high school (70%) or collegiate level (26%). Mean preoperative radiographic measurements were as follows: lateral center-edge angle, 31.6°; Tönnis angle, 4.1°; and alpha angle, 61.4°. Femoroplasty and acetabuloplasty were performed in 100% and 86% of cases, respectively. Also, 84% of players returned to football, all at the same or higher level than before surgery. At a mean follow-up of 9.8 years, all PROMs improved significantly from baseline ( P < .002). Outcome scores at follow-up were as follows: mHHS 90.5; HOS-Activities of Daily Living, 94.5; HOS-Sports-Specific Subscale, 91.1; and visual analog scale (VAS) pain with use, 2.3/10; VAS pain at rest, 1.3/10; and surgical satisfaction, 8.5/10. No patients required revision surgery. However, 2 patients (7%) underwent reoperations—including 1 for heterotopic ossification excision and 1 for periacetabular osteotomy. Conclusion: American football players who underwent primary hip arthroscopy with labral repair for FAI achieved excellent long-term outcomes, with high RTS rates at the same or higher levels, and improvements in PROMs and patient satisfaction. Despite favorable outcomes, nonmedical factors, such as graduation, may influence RTS in competitive athletes, particularly at the high school and collegiate levels.

Asthma is a heterogeneous chronic respiratory disease driven by diverse inflammatory pathways that vary across patients. The recognition of distinct molecular endotypes has led to the development of targeted biologic therapies that have transformed the management of moderate-to-severe asthma. However, selecting the most appropriate biologic therapy for each patient remains challenging. Health providers often rely on trial-and-error approaches that may delay disease control, increase costs, and expose patients to unnecessary side effects. Biomarkers are key to precision asthma care, as they provide objective measures of underlying disease mechanisms. Established biomarkers such as blood eosinophil count, fractional exhaled nitric oxide, and serum total immunoglobulin E are important for identifying type 2-high asthma. Sputum biomarkers offer direct insight into airway inflammation, but their use is limited by technical complexity and availability across centers. Emerging biomarkers, including proteomic, transcriptomic, metabolomic, and genomic biomarkers, show promise in further refining biologic therapy selection. In addition, digital biomarkers derived from electronic health records, wearable devices, and artificial intelligence-based algorithms offer new opportunities to capture real-world changes in disease and treatment response. Non-medical drivers of health, particularly socioeconomic factors, are increasingly recognized as modifiers of biologic effectiveness and may also be helpful in selecting biologic therapies. This review summarizes the existing evidence on established and emerging biomarkers used to guide biologic therapy selection in asthma. Integrating multiple biomarkers will be essential to improve biological selection, monitor response, and ultimately achieve the goal of remission in asthma.

BACKGROUND: Patients with locally advanced rectal cancer face substantial costs related to multimodal therapy. However, the extent of this burden is poorly characterized. OBJECTIVE: To characterize the prevalence and predictors of patient-reported financial toxicity after treatment for locally advanced rectal cancer. DESIGN: Multicenter retrospective cohort study with a cross-sectional survey administered to assess patients’ financial concerns as well as clinicodemographic data. SETTING: Three high-volume tertiary academic centers. PATIENTS: Patients who completed treatment for pathological stage II to III rectal adenocarcinoma between 2000 and 2019 and were alive. MAIN OUTCOME MEASURES: Patient-reported financial toxicity and risk factors associated with financial toxicity. RESULTS: A total of 523 patients were identified, 190 (36.3%) responded to the survey, and 2 were excluded for incomplete surveys. Of the responders, 163 (86.7%) were identified as having financial toxicity related to their cancer diagnosis, and most (96.8%) had insurance. Patients with financial toxicity were less likely to have fully paid medical leave (39.8% vs 75%; p = 0.03) compared to patients without financial toxicity. They also reported increased difficulty paying bills ( p < 0.001) and decreased monthly household income ( p < 0.001) due to their diagnosis. Furthermore, these patients reported increased difficulty paying for transportation to medical appointments ( p = 0.002) and were less likely to be completely satisfied with their insurance coverage ( p = 0.003). Feeling well informed regarding treatment-related costs was associated with decreased odds of financial toxicity (OR 0.14; 95% CI, 0.02–0.78; p = 0.02), whereas taking unpaid leave for treatment was associated with increased odds of financial toxicity (OR 4.71; 95% CI, 1.36–16.34; p = 0.01). LIMITATIONS: Cross-sectional design and moderate response rate may introduce selection and recall bias. CONCLUSIONS: Patients undergoing treatment for locally advanced rectal cancer, including those insured, are at risk for financial toxicity due to direct and indirect costs. Effective communication between these patients and physicians regarding the economic implications of treatment is essential to reducing financial toxicity. See Video Abstract . TOXICIDAD FINANCIERA TRAS EL TRATAMIENTO DEL CÁNCER RECTAL LOCALMENTE AVANZADO ANTECEDENTES: Los pacientes con cáncer de recto localmente avanzado enfrentan costos sustanciales relacionados con la terapia multimodal. Sin embargo, la magnitud de esta carga está poco caracterizada. OBJETIVO: Caracterizar la prevalencia y los predictores de la toxicidad financiera reportada por los pacientes después del tratamiento para el cáncer de recto localmente avanzado. DISEÑO: Estudio de cohorte retrospectivo multicéntrico con una encuesta transversal para evaluar las preocupaciones financieras de los pacientes, así como datos clínico-demográficos. ESCENARIO: Tres centros académicos terciarios de alto volumen. PACIENTES: Pacientes que completaron el tratamiento para el adenocarcinoma de recto en estadio patológico II-III entre 2000 y 2019 y estaban vivos. PRINCIPALES MEDIDAS DE RESULTADOS: Toxicidad financiera reportada por los pacientes y factores de riesgo asociados con la toxicidad financiera. RESULTADOS: Se identificó a un total de 523 pacientes, 190 (36,3%) respondieron a la encuesta y 2 fueron excluidos por encuestas incompletas. De los encuestados, 163 (86,7 %) presentaron toxicidad financiera relacionada con su diagnóstico de cáncer, y la mayoría (96,8 %) contaba con seguro médico. Los pacientes con toxicidad financiera tuvieron menos probabilidades de tener licencia médica con goce de sueldo completo (39,8 % frente a 75 %; p = 0,03) en comparación con los pacientes sin toxicidad financiera. También informaron mayor dificultad para pagar facturas ( p < 0,001) y una disminución de los ingresos familiares mensuales ( p < 0,001) debido a su diagnóstico. Además, estos pacientes informaron mayor dificultad para pagar el transporte a las citas médicas ( p = 0,002) y menor probabilidad de estar completamente satisfechos con su cobertura médica ( p = 0,003). Sentirse bien informado sobre los costos relacionados con el tratamiento se asoció con una menor probabilidad de toxicidad financiera (OR: 0,14; IC del 95 %: 0,02-0,78; p = 0,02), mientras que tomar una licencia sin sueldo para el tratamiento se asoció con una mayor probabilidad de toxicidad financiera (OR: 4,71; IC del 95 %: 1,36-16,34; p = 0,01). LIMITACIONES: El diseño transversal y la tasa de respuesta moderada pueden introducir sesgos de selección y de recuerdo. CONCLUSIONES: Los pacientes en tratamiento para el cáncer de recto localmente avanzado, incluidos los asegurados, corren el riesgo de sufrir toxicidad financiera debido a los costos directos e indirectos. Una comunicación eficaz entre estos pacientes y los médicos sobre las implicaciones económicas del tratamiento es esencial para reducir la toxicidad financiera. ( AI-generated translation )

Abstract Aim Rectal prolapse is a full‐thickness intussusception of the rectum beyond the anal canal. It is often mistaken for other anorectal pathologies, leading to inaccurate referrals to colorectal surgeons and inappropriate management. However, the frequency of misdiagnosis is not well characterized. We aimed to assess the diagnostic accuracy of rectal prolapse referrals to three tertiary medical centres. Methods This is a retrospective study of patients referred for rectal prolapse to colorectal surgeons at the Mayo Clinic in Rochester, Jacksonville, and Phoenix from 2020 to 2024. The primary outcome is the accuracy of rectal prolapse diagnosis. The secondary outcomes are factors that correlate with diagnostic accuracy. Results Rectal prolapse was inaccurately diagnosed in 38.7% (186/480) of patients. Among misdiagnosed patients, the correct diagnosis was haemorrhoids (68.0%, n = 134), pelvic floor dysfunction (24.3%, n = 48) and rectocele (18.7%, n = 37). A diagnosis of rectal cancer was found in 3 patients (1.5%). The most common presenting symptoms were protrusion (66.3%, n = 345) and bleeding (33.6%, n = 175). Among the referring physicians, only 50.5% ( n = 227) performed an anorectal examination. Overall, there was significant variability in diagnostic accuracy across different specialties, with the highest accuracy from colorectal practices (84.0%) and the lowest from urologists (50.0%). Internal medicine physicians had a lower diagnostic accuracy with anorectal examination than without, though it did not reach statistical significance (44.0% vs. 59.5%, p = 0.2). Conclusion Over one‐third of rectal prolapse referrals were incorrectly diagnosed. This study highlights the opportunity for further training of referring providers on anorectal pathologies to improve diagnostic accuracy which could reduce treatment delays and optimize clinical outcomes.