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Background Glioblastoma (GBM) remains the most aggressive primary adult brain cancer attributed to its immunosuppressive nature. Radiation therapy (RT) and concurrent temozolomide chemotherapy are the standard treatments for GBM. Emerging evidence indicates that metformin has potential as an anti-tumor agent that can reshape the immune landscape across various malignancies. We thus postulate that metformin may enhance the anti-tumor effect of RT by modulating the immunosuppressive milieu in GBM. Methods We first explore multiple in vitro conditions, with or without pre-induction, and mimicked a tumor microenvironment to demonstrate a highly context-dependent effect of metformin on the polarization of bone marrow-derived macrophages (BMDMs). We then investigated the antitumor activity and immune-modulatory effects of metformin in combination with RT in GBM-bearing mice. Results The in vitro experiment showed that metformin inhibited the immunosuppressive effects of IL-4/IL-13 but also the immunostimulatory effects of Lipopolysaccharide (LPS) on BMDMs, demonstrating bidirectional immunomodulatory properties that depend on the baseline inflammatory stimulus. In tumor cell co-culture environment, metformin exhibited context-dependent immunoregulatory effects, predominantly promoting M1-associated activation. Notably, concurrent metformin treatment counteracted M2 polarization typically induced by the tumor microenvironment. In a high m-MCSF inducted M2-dominated condition, metformin preferentially shifted the highly polarized M2 phenotype toward an M1-like state in a time and dose-dependent manner but with limited promotion of M1 subtype maturation. RNAseq results on BMDM treated with metformin showed increased homeostasis. Metformin showed dose-dependent immunomodulatory effects when combined with RT in vitro . In syngeneic GBM mouse models, concurrent metformin + RT significantly prolonged survival and reduced tumor burden by reprogramming tumor-associated macrophages (TAMs), elevating intratumoral CD8+ T-cell infiltration and the CD8+/Treg ratio, increasing circulating CD8+ T cells, reversing RT-induced expansion of monocytic myeloid-derived suppressor cells (mMDSCs), and expanding CD4+ and CD8+ effector memory populations in peripheral blood. Conclusion Metformin demonstrates inhibitory effects on M2 phenotype of macrophages. However, it is not a simple M2 inhibitor; instead, it functions primarily as a neutralizer of highly polarized macrophage states by promoting transcriptomic homeostasis. This context-dependent activity enables metformin to relieve the profoundly immunosuppressive TME of GBM to potentiate the anti-tumor effects of RT and by enhancing systemic immune memory.

ABSTRACT Bardet‐Biedl syndrome (BBS) is a rare autosomal recessive disorder characterized by clinical and genetic heterogeneity. Data on the prevalence of clinical manifestations and comorbidities in BBS, particularly in pediatric patients, are limited. This study aimed to assess the prevalence and various manifestations of endocrine and other clinical comorbidities among pediatric and adult patients with BBS. This retrospective chart review included pediatric and adult patients with BBS evaluated at an academic tertiary care center in the United States between 2000 and 2024. The study included 31 patients (7 children and 24 adults) with seven identified pathogenic variants associated with BBS. The most common genetic etiology was biallelic variants in BBS1 (36%). Obesity was diagnosed in 86% of children and 100% of adults. No children had diabetes or prediabetes, whereas 46% of adults were affected. Dyslipidemia was identified in 29% of children and 46% of adults. No thyroid abnormalities were identified in children, whereas 25% of adults were affected. Retinal dystrophy was present in 71% of children and 96% of adults. Polydactyly was observed in 100% of children and 75% of adults. Chronic kidney disease was present in 29% of children and 63% of adults. This study highlights the clinical heterogeneity and substantial multisystem burden of BBS across pediatric and adult patients. The greater prevalence of diabetes/prediabetes, dyslipidemia, thyroid abnormalities, chronic kidney disease, and visual impairment among adults suggests that these complications may emerge or progress over time. Early recognition, proactive longitudinal surveillance, and comprehensive multidisciplinary care are essential to optimize management across the lifespan.

ABSTRACT Background While vaccination is a key strategy to mitigate the severity of coronavirus disease 2019 (COVID‐19) in children, the risk factors for symptomatic, medically attended (hereon referred to as “symptomatic”) COVID‐19 and the impact of vaccination are not well defined among pediatric solid organ transplant recipients (PSOTR). Methods PSOTR aged six months through 21 years at 11 centers in the Pediatric Infectious Diseases Transplant Network (PIDTRAN) were analyzed retrospectively for symptomatic COVID‐19 between July 2021 and May 2023. Using a Cox proportional hazards model, risk factors associated with COVID‐19‐associated hospitalization, in‐hospital oxygen use, mechanical ventilation, and the impact of COVID‐19 vaccination were analyzed. Results Of 1370 PSOTR, 410 (29%) had symptomatic COVID‐19 infection. Among those with symptomatic infection, 115 (28%) were hospitalized, 35 required in‐hospital oxygen, and three required mechanical ventilation. In the study, 45% were unvaccinated against COVID‐19. Compared to unvaccinated PSOTR, incompletely vaccinated PSOTR had 56% lower hazard (95% CI 0.26, 0.72, p = 0.001) of COVID‐19‐associated hospitalization whereas completely vaccinated did not have a statistically significant difference in hazard of hospitalization. Receipt of at least one dose of the bivalent vaccine was also associated with 92.5% lower hazard (95% CI 0.010, 0.55, p = 0.011) of hospitalization. Risk factors for hospitalization included chronic kidney disease, underlying heart disease, neurodevelopmental delay, and lymphocytopenia. Conclusions Most PSOTR with symptomatic COVID‐19 did not require hospitalization or respiratory support. Several comorbidities and lymphocytopenia are associated with severe COVID‐19 in PSOTR. COVID‐19 vaccination, mostly, protected PSOTR against COVID‐19‐associated hospitalization, but vaccine uptake among PSOTR was low. image

ABSTRACT Background Chimeric antigen receptor T‐cell (CAR‐T) therapy has revolutionised the treatment of hematologic malignancies, and its use is expanding rapidly into numerous other disease states including autoimmune diseases. However, CAR‐T therapy is associated with a spectrum of immune‐related toxicities. In addition to the already well characterized cytokine release syndrome and immune effector cell‐associated neurotoxicity syndrome, it has become apparent that rarely, CAR‐T can cause gastrointestinal mucosal inflammation, termed immune effector cell‐mediated enterocolitis (IEC‐EC). Aims This state‐of‐the‐art review highlights the CAR‐T mechanism and details the epidemiology, pathophysiology, clinical manifestations, endoscopic and histopathologic features, and management of IEC‐EC. Methods This review presents the current state of knowledge through a comperhensive and detailed synthesis of all case series reported in the literature to date. Results Occurring in up to approximately 6% of patients typically following B cell maturation antigen‐targeted CAR‐T therapy, IEC‐EC presents with severe diarrhoea and malabsorption, responds poorly to treatment, and portends a dire prognosis. Multi‐disciplinary management should centre on early diagnosis, supportive cares, assessment and treatment of infections, and step‐up pharmacotherapy, often featuring biologics and small molecules drawn from the inflammatory bowel disease pharmacologic armamentarium. Conclusions Clinicians should maintain a high degree of vigilance for IEC‐EC in patients presenting with gastrointestinal symptoms following CAR‐T treatment. Early recognition and multi‐disciplinary treatment may improve patient outcomes.

This systematic review evaluates current computer vision models and their applications in laparoscopic cholecystectomy. Using PRISMA guidelines, we analyzed studies reporting on primary computer vision model applications in laparoscopic cholecystectomy, from inception to March 2026. A total of 85 studies were included: workflow analysis (n = 26), anatomy recognition and segmentation (n = 14), safety assessment (n = 14), instrument detection (n = 12), tissue/image characterization (n = 7), event detection and scene understanding (n = 6), and surgical performance assessment (n = 6). The performance of the computer vision models in the studies was heterogeneous, with accuracy, F1-score, mean average precision, Dice coefficient, mean absolute error, and area under the receiver operating characteristic curve being commonly reported. Despite strong model performances in several studies, implementation in the clinical setting remains a challenge. We highlight the need for standardized model performance reporting, broader external and multi-institutional validation of models, and coordinated frameworks for safe and effective implementation of computer vision models in laparoscopic cholecystectomy.

ABSTRACT Introduction Postoperative mortality commonly follows complications that are not prevented, recognised or managed effectively. Ward‐based nursing care is central to surveillance, escalation and rescue, but population‐level evidence using shift‐level staffing data is limited. This national population‐based cohort study examined the association between surgical ward nurse staffing and postoperative outcomes. Methods Adults aged 18 years or older undergoing inpatient surgery under general or neuraxial anaesthesia in public hospitals in Aotearoa New Zealand between 2022 and 2024 were included. Prospectively recorded TrendCare staffing data were linked to administrative health datasets. The exposure was shift‐level staffing variance, defined as the difference between required and available nursing care hours on surgical wards in the treating hospital during admission. The primary outcome was 90‐day postoperative mortality. Secondary outcomes were postoperative complications and failure to rescue. Results The cohort included 202 428 patients undergoing 223 415 surgical admissions. Within 90 days, 6296 admissions resulted in death (2.8%). Complications occurred in 41 722 admissions (18.7%), with failure to rescue in 15.1%. Of 281 147 surgical ward shifts, 122 186 (43.5%) were understaffed. After adjustment, each one‐nurse reduction in staffing per shift was associated with higher odds of mortality (aOR: 1.13, 95% CI: 1.07–1.18), complications (aOR: 1.07, 95% CI: 1.05–1.10) and failure to rescue (aOR: 1.07, 95% CI: 1.00–1.14). Modelling estimated that correcting observed staffing deficits was associated with 182 fewer deaths annually. Conclusion Lower surgical ward nurse staffing was associated with increased postoperative mortality, complications and failure to rescue. Nurse staffing is a modifiable system factor associated with postoperative safety and should be prioritised to improve surgical outcomes.

Introduction: Understanding mid-term test-retest reliability and within-subject variability is important for interpreting changes observed in longitudinal and intervention studies. The reliability of resting-state functional magnetic resonance imaging (rs-fMRI) is known to vary across measures and brain regions. However, how reliability differs across functional networks and connectivity- and amplitude-based measures, and whether multi-echo acquisition and processing modify these patterns, remain incompletely characterized. Methods: Twenty-two healthy volunteers underwent two rs-fMRI sessions 15.7 ± 4.0 days apart on a Compact 3T scanner. Multi-echo, middle-echo, and independently acquired single-echo datasets were compared, with multi-echo independent component analysis additionally evaluated as a denoising approach. Functional connectivity (FC) and three amplitude-based measures were evaluated using the Schaefer 400 parcellation. Reliability was systematically assessed using intraclass correlation coefficient (ICC), within-subject standard deviation (wSD), and systematic bias at edge or regional, and network levels. Results: Acquisition-dependent differences in reliability were generally modest. Multi-echo acquisition and processing increased functional connectivity strength and the magnitude of amplitude-based measures and improved inferior cortical coverage, but these enhancements did not consistently translate into substantially higher ICC or lower wSD. In contrast, reliability showed clear network-dependent differences. FC reliability varied markedly across network pairs and was not explained by connectivity strength alone; pairs involving the default mode and control networks generally showed more favorable profiles than several somatomotor and visual network pairs. Fractional amplitude of low-frequency fluctuations (fALFF) also showed network-dependent reliability, with the most favorable regional reproducibility observed in the default mode and control networks and lower reproducibility in the somatomotor and visual networks. Conclusion: These findings provide practical mid-term reliability benchmarks for rs-fMRI on a Compact 3T scanner and show that measurement stability varies more clearly across measures and functional networks than across acquisition approaches.

Background Despite advances in cervical cancer screening, cervical cancer rates have been increasing in the last decade. Hispanic women have higher cervical cancer incidence and mortality rates compared to non-Hispanic women in the United States. These disparities are primarily due to language barriers experienced in this Spanish-preferred population. Our study aims to improve cervical cancer screening rates among Spanish-preferred patients through a Spanish-language multimedia presentation on cervical cancer screening. Methods In patients not adherent to U.S. cervical cancer screening guidelines, we conducted a non-randomized study comparing standard care in Family Medicine (FM) to standard care plus a multimedia presentation with Spanish voiceover intervention in Internal Medicine (IM). We evaluated whether baseline characteristics differed between the two study arms using the Wilcoxon rank sum test and either the Chi-Square test or Fisher’s exact test. For the primary goal, we examined whether there was a difference in screening scheduling rates between the intervention and standard care groups using the Chi-Square test. Using descriptive statistics, we investigated whether there was a difference in characteristics for those who scheduled screening and those who did not. Results We had 52 patients in IM and 58 in FM, differing in age and insurance status, with median ages of 45.5 and 40.0, and percent insured of 65.4% and 82.8%. Post-study, 25.0% (13/52) in IM and 15.5% (9/58) in FM scheduled cervical screening appointments, which was not significantly different, p=0.21. Patients who scheduled screening had higher rates of insurance coverage, at 95.5% compared to 69.3%. Conclusion No statistically significant difference in scheduling rates among Spanish-preferred patients was observed in this study. Further efforts should include larger samples and randomization.