Citations

ABSTRACT Aims This study aimed to describe how emergency nurses (ENs) experience secondary traumatic stress (STS) within their practice environments, focusing on the strategies they use to cope and the supportive resources they draw upon to manage its impact on their lives. Design This paper presents the qualitative findings from a larger mixed‐methods survey study on STS among ENs. Methods A geographically diverse U.S. sample of ENs was recruited through social media to participate in an online survey. All participants ( n = 275) were asked to respond to open‐ended survey questions, and 118 of these participants provided answers to at least one open‐ended question. A self‐selected sample of 20 ENs completed semi‐structured interviews. Inductive content analysis was used to analyse open‐ended survey responses and interview transcripts. Results Three themes reflected ENs' experiences with STS: STS Is Real—It's Going to Affect Your Life; Something Must Be Wrong With Me: A Culture of Disconnection; and It's a Systems Issue, but We're in It Together. Participants described individual, unit, and organizational factors that influenced their experiences of STS and their access to and use of coping strategies and supportive resources. Conclusion ENs and nurse leaders acknowledged the impact of STS on their personal and professional lives and emphasized how the practice environment shaped their experiences. They perceived the accessibility of organizational resources, leadership behaviours, and team culture as influencing the individual strategies ENs use to manage the effects of repeated exposure to others' traumatic experiences. STS is a predictable occupational hazard for ENs; thus, healthcare organizations must invest in nurse‐identified supports to preserve workforce well‐being and clinical expertise. Implications for the Profession Assessing organizational readiness to address STS is recommended to ensure ENs receive effective, timely support. In response to these assessments, healthcare organizations should develop and implement policies that prioritize the mental health and well‐being of ENs, including proactive support systems and accessible mental health resources. Impact This study identifies participant‐perceived individual, team, leadership, and organizational conditions that may hinder or support ENs' management of STS. These findings identify potential targets for organizational assessment and support strategies intended to foster healthier practice environments and promote safe, high‐quality care. Reporting Method Consolidated Criteria for Reporting Qualitative Research (COREQ). Patient or Public Contribution This study did not include patient or public involvement in its design, conduct, or reporting.

Abstract Objective Surgery is an effective, yet underutilized treatment for children with drug‐resistant epilepsy. Although predictors of surgical outcomes are well described, the decision to recommend surgery varies by institution. We aim to evaluate the rates of not recommending surgery, identify associated patient characteristics, and quantify variability across centers. Methods We queried the Pediatric Epilepsy Research Consortium Surgery database, a prospective multicenter cohort of children (0–18 years) undergoing initial evaluation for epilepsy surgery. Patients with documented surgical decisions were included. Demographic, clinical, and presurgical evaluation variables were compared by surgical recommendation status. Logistic regression identified factors associated with not recommending surgery. Mixed‐effects models quantified between‐center variability. Results Among 2480 patients across 29 centers, 532 (21%) were not recommended epilepsy surgery (median center rate 17%, interquartile range [IQR] 10%–28%). After accounting for patient characteristics associated with surgical candidacy, substantial variation in decision‐making remained across centers, with a median twofold difference in the odds of not recommending surgery between otherwise similar patients evaluated at different institutions (Median Odds Ratio = 2.25; Intraclass Correlation Coefficient = .18). The clinical characteristics most strongly associated with not recommending surgery included monthly or less frequent seizures (odds ratio [OR] 2.17, 95% confidence interval [CI] 1.75–2.69), non‐structural etiology (OR 2.02, 95% CI 1.56–2.61), and taking ≤2 anti‐seizure medications (ASMs) (OR 1.67, 95% CI 1.34–2.08, all p 's < .01). These characteristics showed minimal clustering across centers (ICCs < .05). Significance One in five children evaluated for epilepsy surgery are not recommended to pursue surgical treatment. Although clinical factors influence decision‐making, they do not explain the substantial variation in recommendations across pediatric epilepsy centers. Similar children evaluated at different institutions had significant differences in the odds of not being recommended surgery, suggesting that institutional decision‐making contributes importantly to surgical candidacy.

Abstract Background Personalized meal planning by registered dietitian nutritionists (RDNs) is time‐intensive. Large language models (LLMs) may automate drafting meal plans, but their nutritional accuracy in clinical practice is uncertain. Methods In this proof‐of‐concept study, five outpatient RDNs and four LLMs (Gemini, CoPilot, ChatGPT 4.0, and customized ChatGPT 4.0) each generated 3‐day meal plans for five validated clinical scenarios. Effectiveness was defined as accuracy in meeting pre‐specified energy, protein, carbohydrate, fat, and sodium targets. Time to create plans and RDN comfort (self‐rated confidence in nutritional accuracy and clinical appropriateness on 1–5 Likert scale) were recorded. Three independent RDNs, blinded to source, analyzed nutrient content using Nutritionist Pro. Group differences were assessed with t ‐test and ANOVA. Results All LLMs and RDNs produced feasible meal plans. LLMs generated meal plans in under 1 min, whereas RDNs required a mean of 44 min per scenario. RDNs reported comfort levels ranging from 3.8 to 4.8. Across most scenarios, LLM plans delivered a smaller proportion of requested energy than RDN plans, which more consistently approached energy targets. Both groups performed similarly for the Mediterranean diet scenario. Overall, protein accuracy did not differ. However, in chronic kidney disease, LLMs undershot the guideline‐based protein target, while RDNs tended to modestly exceed it. Accuracy for low‐carbohydrate, fat, and sodium diets was comparable. Conclusion LLMs can rapidly generate clinically plausible meal plans but are less reliable than RDNs in achieving prescribed energy and selected macronutrient goals. Prompt precision is essential for nutrient‐specific targets. A hybrid model in which RDNs refine LLM‐generated drafts may leverage efficiency without sacrificing clinical accuracy.

Abstract Objective Epilepsy duration is a modifiable risk factor in the outcome of definitive epilepsy surgery; however, an analogous effect in palliative procedures has not been shown. We reviewed the Pediatric Epilepsy Surgery Database data for an association between epilepsy duration and seizure reduction in palliative procedures. Methods Patients enrolled between January 2018 and April 2025 who underwent their first epilepsy surgery with palliative intent with 6 months of follow‐up were included. Procedures included neuromodulation, corpus callosotomy, hemispherotomy, lesionectomy, and lobectomy where surgical intent was not seizure freedom. Outcomes of seizure freedom, 90% seizure reduction, and 50% seizure reduction were considered at 6–12 months and >12 months from surgery. Duration from epilepsy onset to surgery was compared for patients above and below each outcome threshold at each time point. Logistic regression analysis for the association between epilepsy duration and seizure reduction adjusted for potential confounders including procedure type, etiology, and other clinical factors. Logistic regression analysis was performed on the overall cohort and subgroups of patients with each procedure. Results A total of 588 patients were included. Initial univariate analysis suggested that epilepsy duration at time of surgery was significantly associated with seizure freedom and 90% seizure reduction at both 6–12 months and >12 months. After adjusting for confounders, only seizure freedom at >12 months was significantly associated with duration of epilepsy. When individual procedures were considered, only lobectomy was sensitive to duration of epilepsy in multivariate analysis, with significant impacts on >50% and >90% seizure reduction at >12 months. Lesional epilepsy predicted seizure freedom at >12 months. Neuromodulation and corpus callosotomy were less likely to achieve seizure reduction than other procedures. Significance We did not find an association between early epilepsy surgery and seizure reduction. This reflects the heterogeneity of our population, including different types of surgical procedures and lesional and nonlesional epilepsies.

Abstract Introduction Bone marrow (BM) is the primary immune organ responsible for stem cell maintenance. Neurotropic infections elicit sequestration of T cells within the BM. Changes of the BM niche during brain viral infections are unknown. Intracranial infection with the neurotropic Theiler’s Murine Encephalomyelitis Virus (TMEV) in C57BL/6 mouse is cleared by 30 days due to generation of an antigen-specific CD8 T cell response. Methods We used brain viral infection and injury models to test T cell responses against brain antigens in the bone marrow. Results We determined that 1-10% of CD8 T cells present in the sternal, femoral, and cranial BM were virus antigen-specific 7 days post intracranial infection. Over 70% of these CD8 T cells were tissue resident. We determined antigen-specific CD8 T cells were generated in the BM within 4 days of infection. Continuous treatment with FTY720, which sequesters T cells outside of the blood, did not eliminate antigen-specific CD8 T cells in any BM compartment. CD8 T cells in the BM established durable memory populations and were reactivated upon antigen reencounter. In the memory phase (200 days post brain TMEV infection), bone marrow resident CD8 T cell could be reactivated upon cognate peptide delivery. Such reactivation of antigen specific memory CD8 T cells caused an increase in lineage-, Sca-1+, ckit + (LSK) cells in the BM in a CD8 dependent manner. Similarly, injection of the model antigen AF488-conjugated OVA mixed with Poly IC into the brain recapitulated antigen specific CD8 T cell generation within the bone marrow and further demonstrated the antigen presenting cell involved in the response to be a CD103 expressing myeloid DC. We conclude that viral infections and inflammatory stimulation in the brain induce in situ effector and memory T cell responses within the BM which is associated with significant stem cell dysregulation. Conclusion Our data paves the way for crucial studies of BM resident antigen-specific CD8 T cells in health and disease. Funding Source NIH K99/R00 Topic Categories Viral Immunology (VIR)

Abstract Introduction Glioblastoma is an aggressive brain cancer with poor prognosis for which immunotherapies have fared poorly. In part, the failure in immunotherapies is attributed to the existence of severe local and systemic immunosuppression in GBM. We determined that majority of hallmark features of systemic immunosuppression were linked to immunosuppressive factors in serum. Our data indicate that serum of glioma-bearing mice harbors heightened levels of cell-free DNA (CF-DNA). Methods We evaluated the extent to which CF-DNA contributes to systemic T cell dysfunction in mouse models of GBM and GBM patient plasma samples. Results We determined that majority of hallmark features of systemic immunosuppression were linked to immunosuppressive factors in serum. Our data indicate that serum of glioma-bearing mice harbors heightened levels of cell-free DNA (CF-DNA). Removing CF-DNA from serum improves T cell responses while adding CF-DNA derived from serum of glioma-bearing subjects to healthy T cells directly inhibits their functions. We have also verified that CF-DNA is detectible in sera isolated from patients with GBM. When compared to healthy controls, GBM patients have higher quantities of CF-DNA is their plasma. Interestingly, our preliminary data implicates neutrophil NETosis as the likely source of CF-DNA in sera of GBM patients. Moreover, we stained GBM tumor sections with citrullinated histone 3 (cit-H3) to evaluate the extent of NETosis in GBM patients. We determined evidence of significant NETosis within patient brain tumors. Systemic immunosuppression is detrimental to the success of immune-modulating therapies and patient survival. By identifying and removing the source of systemic immunosuppression, we will enhance immune responses against the tumor likely improving patient survival. Conclusion Glioblastoma causes immune suppression outside of the brain via the released CF-DNA. Our studies in GBM patients and mouse models help develop strategies to reverse immune dysfunction and improve outcomes. Funding Source NIH K99/R00 Topic Categories Immune Mechanisms of Human Disease (HUM)

ABSTRACT Approximately 30% of patients with acute graft-versus-host disease (GVHD) develop steroid-refractory disease and have very poor outcomes. Ruxolitinib has become the standard of care for steroid-refractory acute GVHD, but it is unclear which patients derive benefit. The MAGIC Composite Score (MCS), an algorithm that combines clinical symptoms and biomarkers, has been validated to predict outcomes at the start of primary GVHD treatment. Here, we evaluated its performance at the initiation of second-line treatment in 278 patients. MCS stratified patients into three risk groups (MCS1-3), with the majority (88%) classified as intermediate or high risk. Increasing MCS score was associated with progressively higher 1-year non-relapse mortality (NRM) rates (16%, 41%, and 73%; p<0.001), lower 1-year survival (77%, 56%, and 24%; p<0.001), and lower complete response (CR) rates at day 28 (47%, 38%, and 20%, respectively; p<0.01). The area under the receiver operating characteristic curve (AUROC) for 1-year NRM was significantly higher with MCS compared to clinical symptoms alone (0.70 vs. 0.63; p=0.023). Among patients treated with ruxolitinib, higher MCS similarly predicted higher NRM and lower survival and CR rates. Patients classified as MCS2/3 had poor outcomes despite ruxolitinib, underscoring the need for novel therapies in this patient population. In conclusion the MCS is an accurate predictor of outcomes for patients who require second-line treatment and may be of use as an eligibility criterion for future clinical trials in this high-risk population. Key Points MAGIC Composite Scores that integrate clinical symptoms and biomarker scores predict outcomes of second-line therapy for acute GVHD more accurately than clinical symptoms alone. MCS identifies patients with high NRM despite treatment with ruxolitinib.

Abstract Colony-stimulating factor 1 receptor-related adult-onset leukoencephalopathy with axonal spheroids and pigmented glia (CSF1R-ALSP) is a rare, fatal, autosomal-dominant neurodegenerative disorder caused by pathogenic CSF1R variants and characterized by progressive cognitive, neuropsychiatric, and motor dysfunction, white matter lesions on brain imaging, and white matter demyelination, swollen axons, and pigmented glial cells on pathology. Limited data regarding clinical, biofluid or radiological biomarkers of disease severity are available, and no clinical trial endpoints have yet been validated. The objectives of this first-of-its-kind, prospective, observational natural history study were to characterize the clinical trajectory of CSF1R-ALSP and to identify and evaluate key biomarkers and clinical endpoints indicative of disease severity and progression. ILLUMINATE (NCT05020743) was a multicentre, noninterventional natural history study of adults with CSF1R-ALSP and prodromal carriers of CSF1R variants. Participants were followed for up to 36 months, with clinical assessments, fluid biomarkers and volumetric MRI assessments of brain atrophy collected at screening and every 6 months. This study was terminated early (4 June 2025). The analyses reported here include data collected through 19 February 2025. Of 53 participants, 19 were prodromal and 34 were symptomatic (11 of whom had a history of haematopoietic stem cell transplant and 23 who did not). Mean participant age was 47.8 (standard deviation, 4.5) years, and 36.4% were female. Prodromal participants remained relatively stable over 36 months, with little change in neurological function, neurodegeneration biomarkers or radiological disease burden. Impaired neurological function, MRI characteristics of CSF1R-ALSP, and elevated NfL (neurofilament light chain; neurodegeneration biomarker) and GFAP (glial fibrillary acidic protein; astrogliosis biomarker) levels were more pronounced at baseline and often showed progression over time among symptomatic participants who had not previously received haematopoietic stem cell transplant compared with participants who had previously received haematopoietic stem cell transplant. Significant correlations were observed at baseline and longitudinally between MRI measures of brain atrophy and clinical outcome measures. Based on the fluid biomarkers, MRI measures, and clinical outcome assessments evaluated here, active neurodegeneration, widespread changes visualized on brain MRI, and impaired cognitive and motor function were observed in symptomatic patients with CSF1R-ALSP. The neurological impairment can be assessed using the Montreal Cognitive Assessment and Cortical Basal ganglia Functional Scale. Our data suggest that quantification of brain atrophy using MRI volumetry is a potential biomarker of disease severity and progression in CSF1R-ALSP. It is hoped that this report will contribute to the understanding of disease progression in CSF1R-ALSP and inform future drug development.

Importance TMEM106B is a frontotemporal lobar degeneration (FTLD) genetic susceptibility factor, and TMEM106B protein aggregates are a feature of aging and neurodegeneration. Whether TMEM106B protein levels are associated with clinical features is unknown. Objective To investigate the clinical associations of cerebrospinal fluid (CSF) TMEM106B in FTLD. Design, Setting, and Participants This cross-sectional study was conducted in 2 independent frontotemporal dementia (FTD) cohorts (recruitment from April 2009 through July 2023, with analyses from January 2025 through April 2026), with a 2-year follow up. This multicenter clinical study integrated clinical, genetic, biomarker, and neuroimaging data. Individuals were recruited through the University of California, San Francisco (n = 3733), or ALLFTD (n = 2343). Participants with available CSF were included. A discovery cohort (n = 271) included participants with sporadic neuropathology-confirmed FTLD; presymptomatic or symptomatic carriers of pathogenic variants in C9orf72 , GRN , or MAPT ; or controls. An independent validation cohort (n = 383) included participants with clinically diagnosed sporadic FTD, Alzheimer disease (AD), and controls. Exposures CSF samples for TMEM106B quantification with aptamer proteomics (SomaScan version 3.0 [discovery cohort] and SomaScan version 4.1 [validation cohort]). Main Outcomes and Measures Parametric tests compared the primary outcome, CSF TMEM106B, by disease severity, TMEM106B rs1990622 genotype, sex, clinical syndrome, pathological diagnosis, and pathogenic variant and determined associations with brain volume. Results In the discovery (n = 271; 136 women [51%]; median [IQR] age, 59 [38-80] years) and validation (n = 383; 183 women [48%]; median [IQR] age, 64 [50-78] years) cohorts, lower CSF TMEM106B was associated with more severe disease (β, −0.15; 95% CI, −0.24 to −0.04; P = .003), lower frontotemporal brain volumes (β, 0.42; 95% CI, 0.24-0.61; P &amp;lt; .001), and faster clinical progression (β, −2.21; 95% CI, −3.70 to −0.72; P = .001). Associations of TMEM106B with clinical disease severity were independent of those with neurofilament light chain. TMEM106B levels were influenced by TMEM106B rs1990622 genotype, where individuals with the protective G/G genotype had lower levels than the risk A/A genotype. CSF TMEM106B levels did not differentiate between FTLD subtypes or between FTLD and AD. Conclusions and Relevance Per the results of this cross-sectional study, TMEM106B is detectable in CSF and levels reflect disease severity in sporadic and genetic FTLD and AD, but levels are also influenced by the TMEM106B rs1990622 genotype. CSF TMEM106B could support further studies to understand the mechanisms of disease and develop clinical tools in FTLD and other neurodegenerative diseases.