Background  Ventilator-associated pneumonia (VAP) is a common nosocomial infection in pediatric intensive care units (PICUs), but its effect on clinical outcomes in resource-constrained settings is underexplored. Understanding these effects is essential for improving care. Objective Our aim is to evaluate the impact of VAP on clinical outcomes and identify baseline factors associated with VAP among mechanically ventilated pediatric patients. Methods This retrospective cohort study was conducted at the PICU of Jinnah Hospital, Lahore, from January to June 2023. Children aged 1 month to 18 years who required mechanical ventilation for at least 48 hours were included. We categorized patients into VAP and non-VAP groups based on CDC/NHSN 2023 criteria. We compared baseline characteristics and clinical outcomes. Categorical variables were analyzed using the chi-square test. Continuous variables were compared using the Mann-Whitney U test. Results Among 150 patients, 50 (33.3%) developed VAP. Patients with VAP had a significantly longer median duration of mechanical ventilation (12.0 days, IQR: 9.0-16.0) compared to non-VAP patients (5.0 days, IQR: 4.0-6.0; p < 0.001) and a longer median PICU stay (14.0 days, IQR: 10.0-18.0 vs. 7.0 days, IQR: 6.0-8.0; p < 0.001). Prior antibiotic use was documented in all 50 (100%) VAP patients compared to 17 (17.0%) in the non-VAP group (p < 0.001). Mortality was higher in the VAP group (16/50 patients, 32.0%) compared to the non-VAP group (0/100 patients, 0.0%; p < 0.001). Daily oral care with chlorhexidine was strongly protective (risk ratio = 0.46; 95% CI: 0.34-0.63). Standard multivariable logistic regression could not be performed due to the complete separation of data; therefore, Firth penalized logistic regression was performed using R. Conclusion VAP is linked to longer ventilation, extended PICU stay, and higher mortality. These findings stress the need for targeted preventive measures and improved ventilatory practices in resource-constrained PICUs.

Patients undergoing dialysis are at an elevated risk of cardiovascular events. This study aimed to develop machine learning (ML) prediction models to identify risk factors for major adverse cardiovascular events (MACE) in dialysis patients.

This retrospective study included 203 patients undergoing dialysis with a median age of 45.0 years and 64.0% male. The participants were divided into training and test sets in a 7:3 ratio. LASSO regression selected characteristic variables from patients'general information, laboratory tests, and echocardiographic parameters (including global longitudinal strain [GLS]). Eight ML models were constructed,and SHAP analysis evaluated feature importance.

The incidence of MACE (including myocardial infarction, unstable angina, heart failure, and cardiovascular death) in dialysis patients was 38.92%. The average follow-up period was 18 months. LASSO regression identified eight feature variables. Among the ML models, AdaBoost demonstrated superior performance, with an AUC of 0.883 (95% CI: 0.830-0.937), accuracy of 0.804, sensitivity of 0.864 and specificity of 0.762 in the training set, and an AUC of 0.809 (95% CI: 0.706-0.912), accuracy of 0.750, sensitivity of 0.90 and specificity of 0.675 in the test set. The SHAP analysis identified N-terminal pro-brain natriuretic peptide (NT-proBNP) level, estimated glomerular filtration rate (eGFR), GLS and age as the four most important features for predicting MACE in patients undergoing dialysis (mean absolute SHAP values: 0.199, 0.176, 0.096 and 0.091, respectively).

Elevated NT-proBNP, advanced age, reduced eGFR and impaired GLS were independently associated with an increased risk of MACE in patients undergoing dialysis.

BackgroundEffective pain management is critical following hemorrhoidectomy due to the dense nerve distribution in the anorectal region. Although compound methylene blue and liposomal bupivacaine are both used for postoperative analgesia, their comparative efficacy and safety profiles have not been systematically evaluated. This study aimed to compare the analgesic efficacy, opioid-sparing effects, and safety of liposomal bupivacaine with compound methylene blue in patients undergoing mixed hemorrhoidectomy.MethodsThis was a single-center, prospective observational cohort study involving 150 patients undergoing elective hemorrhoidectomy for stage III-IV mixed hemorrhoids. Patients were allocated into two groups: (a) the compound methylene blue group (n = 75) and (b) the liposomal bupivacaine group (n = 75). Postoperative pain was assessed using the numerical rating scale at rest over 72 h. Primary outcomes included cumulative pain scores, time to first rescue analgesia, and total rescue opioid consumption. Secondary outcomes included patient satisfaction, recovery metrics, and adverse events.ResultsThe liposomal bupivacaine group demonstrated significantly lower cumulative pain scores over 72 h than the compound methylene blue group. Although the compound methylene blue group demonstrated marginally better pain control in the immediate postoperative period, liposomal bupivacaine provided superior and stable analgesia from 12 to 72 h. The proportion of patients who required rescue opioids was significantly lower in the liposomal bupivacaine group than in the compound methylene blue group. Patient satisfaction was significantly higher in the liposomal bupivacaine group. Furthermore, the incidence of adverse events was significantly lower in the liposomal bupivacaine group than in the compound methylene blue group.ConclusionsSingle-dose perianal infiltration of liposomal bupivacaine provides superior and more sustained postoperative analgesia than that of compound methylene blue in patients who have undergone mixed hemorrhoidectomy. Liposomal bupivacaine significantly reduces rescue opioid requirements, delays the need for supplemental analgesia, and improves patient satisfaction with a favorable safety profile.

Preeclampsia remains a leading cause of preterm delivery (PTD). Conventional average causal effect estimands may not always be perfectly suited for assessing preeclampsia's contributions because they rely on uniform counterfactual scenarios, such as everyone suffering from preeclampsia. A complementary approach is the incremental propensity score intervention (IPSI), which can address a more action-oriented causal inquiry: How would the population average risk of PTD change from current observed levels if each individual's odds of preeclampsia were reduced by a given amount?

We applied IPSI to two US population cohorts of singleton pregnancies, separated by two decades (1998-2002, 16.7 million; 2020-2023, 14.2 million), to evaluate the causal effects of gestational hypertension/preeclampsia (GHTN/PE) on PTD within each cohort. We developed and implemented a sensitivity analysis procedure using bias formulas to gauge the impact of potential unmeasured confounding.

Between 1998 and 2002, halving the individual odds of GHTN/PE would reduce the population average risk of PTD from observed [risk ratio (RR) = 0.969, 95% confidence interval (CI) 0.969-0.970]. Between 2020 and 2023, when GHTN/PE was more prevalent, halving the odds of preeclampsia would lead to an even greater reduction in average PTD risk (RR = 0.948, 95% CI 0.947-0.948). Sensitivity analyses demonstrated that these conclusions held under assumptions encoding relatively strong unmeasured confounding.

The IPSI approach offers more nuanced understanding and clinically meaningful interpretations of causal effects, such as by how much partially reducing the odds of GHTN/PE, while allowing it to remain non-zero, can lower the average risk of PTD.

Ischemic events after contemporary percutaneous coronary intervention (PCI) are uncommon but carry high morbidity/mortality. Identifying patients at highest risk is critical to guide dual antiplatelet therapy (DAPT) intensity while minimizing bleeding. Current machine learning (ML) model-developed risk scores do not incorporate pharmacogenetic data. To develop and externally validate ML models that integrate clinical, demographic, and CYP2C19 genetic information to predict 1-year ischemic outcomes post-PCI to refine clinical decision making. We analyzed 8317 patients from TAILOR-PCI trial (n = 4572) and the Precision PCI registry (n = 3745). The outcome was a composite of cardiovascular death, myocardial infarction, stroke, and stent thrombosis at 1 year. Boruta feature selection identified 11 predictors. Multiple ML algorithms were trained in TAILOR-PCI and validated in Precision PCI using cross-validation and synthetic minority oversampling (SMOTE). Model performance was assessed by area under the receiver operating characteristic curve (AUC), sensitivity, and specificity. The best external performance was achieved with a support vector machine (SVM, polynomial kernel) (AUC 0.667; sensitivity 0.871; specificity 0.282), while XGBoost provided a more balanced profile (AUC 0.619; sensitivity 0.442; specificity 0.688). Variable importance for the SVM polynomial model demonstrated that all 11 included Boruta feature selected predictors had relatively high importance (> 75). ML models trained on large clinical trial and real-world registry datasets can help identify the small subset of patients at high ischemic risk after PCI. This distinction is of relevance because ischemic events are rare, and most patients may safely de-escalate DAPT to reduce bleeding risk while maintaining ischemic protection through a multimodal approach to risk stratification. Trial Registration: TAILOR-PCI URL: https://clinicaltrials.gov/ct2/show/NCT01742117.

In the Danish population-based Lolland-Falster Health Study (LOFUS), conducted in a socioeconomically disadvantaged area with marked regional health inequalities, we recently identified a hypertension prevalence of 45%. A more detailed understanding of recognition, control, and treatment of hypertension in this setting may help improve interventions to reduce hypertension-related cardiovascular disease. This was a cross-sectional study including participants with hypertension identified in LOFUS using data from clinical examinations and questionnaires. Recognition was assessed by a registered diagnosis or self-reported hypertension and factors associated with recognition status were analyzed. Cardiovascular risk stratification was applied to individuals with unrecognized hypertension to determine treatment indication. Blood pressure (BP) control and antihypertensive treatment patterns were evaluated among participants with recognized hypertension. Among 7329 participants with hypertension, 39% were unrecognized. Individuals with unrecognized hypertension were younger, had higher educational attainment and fewer comorbidities than those with recognized hypertension. Larger household size was associated with higher odds of unrecognition. Two-thirds of individuals with unrecognized hypertension were classified as having high 10-year cardiovascular risk and met criteria for antihypertensive treatment. Among participants with recognized hypertension, 51% had uncontrolled BP despite >50% receiving ≥2 antihypertensive agents. The group with uncontrolled BP had fewer comorbidities than those with controlled BP. In this rural cohort with a high prevalence of hypertension, a large proportion remained unrecognized despite elevated cardiovascular risk, and among individuals with recognized hypertension, treatment targets were often not achieved. These findings indicate a substantial unmet need for improved recognition and management of hypertension, with important implications for public health.

Body composition is a major determinant of health, yet the role of fat-free mass, a key component of body composition, in mortality remains unclear.

A PRISMA-guided systematic review and meta-analysis (PROSPERO: 321722) of observational cohort studies in community-dwelling adults was conducted. PubMed was searched from inception to 25 October 2025, and Web of Science and Embase were searched from inception to 31 July 2025. Eligible studies assessed fat-free mass using computed tomography, dual-energy X-ray absorptiometry (DXA), bioelectrical impedance analysis (BIA) or anthropometry. Studies involving hospitalized participants were excluded. Maximally adjusted effect estimates were pooled using random-effects models to calculate summary risk ratios (RRs) and 95% confidence intervals (CIs). Publication bias was assessed using graphical and statistical methods; influence analyses evaluated robustness; E-values quantified potential unmeasured confounding; and meta-regression explored between-study heterogeneity.

Of 7741 screened records, 49 studies met the inclusion criteria (1 149 807 participants; 83 798 deaths). Low versus high fat-free mass was associated with higher all-cause mortality (RR: 1.42, 95% CI: 1.30-1.55). Trim-and-fill analysis indicated publication bias (adjusted RR: 1.31, 95% CI: 1.20-1.44). Sensitivity analyses confirmed robustness (leave-one-out RR range: 1.39-1.43; E-value: 2.19). Associations were consistent across age (p_{difference; within-study} = 0.133), geographic region (p_difference = 0.983) and cause of death (p_{difference for cardiovascular diseases; within-study} = 0.240, p_{difference for cancer; within-study} = 0.136). Effect sizes varied by sex (men RR: 1.56, 95% CI: 1.32-1.85; women RR: 1.25, 95% CI: 1.11-1.39; p_difference < 0.0001) and measurement method: strongest for calf circumference (RR: 2.19, 95% CI: 1.50-3.20), moderate for DXA (RR: 1.52, 95% CI: 1.29-1.79) and weakest for BIA (RR: 1.23, 95% CI: 1.07-1.41).

Low fat-free mass is associated with a 42% higher risk of all-cause mortality in community-dwelling adults. Routinely assessing fat-free mass provides clinical value in identifying high-risk individuals and informing preventive care strategies.

Severe aortic stenosis (AS) carries a poor prognosis when symptomatic, particularly in cardiogenic shock (CS). Emergency transcatheter aortic valve replacement (TAVR) is rarely performed but may represent a rescue therapy. Coexistent carotid artery stenosis (CAS) further increases procedural risk. We report the case of an 83-year-old female patient with severe AS and beginning CS. Imaging revealed severe right internal CAS and occlusion of the left internal carotid artery. Despite the use of norepinephrine, the patient progressed to deteriorating CS with acute kidney injury and impaired mental status. Given high surgical risk, a combined strategy was performed: right carotid stenting followed by transfemoral TAVR. Post-procedure, renal replacement therapy was initiated with rapid recovery of renal function. The patient was hemodynamically stabilized and discharged 14 days after the procedure with normalized ventricular function and a well-functioning prosthesis. This case illustrates the feasibility of consecutive transfemoral TAVR and interventional revascularization of CAS as life-saving rescue therapy in severe AS complicated by CS and cerebrovascular disease (CVD). A combined interventional approach addressing both CVD and valve obstruction enabled procedural safety and favorable recovery, supporting TAVR as a viable option in selected high-risk patients.

Serum uric acid to creatinine ratio (SUA/sCr) has emerged as potential biomarker for non-albuminuric diabetic kidney disease (NA-DKD), a recently recognized high-prevalence DKD phenotype. However, the relationship between SUA/sCr and cardiovascular and renal injury profile in this population is not well established. This study aimed to evaluate SUA/sCr across the spectrum of DKD, particularly focusing on NA-DKD, and to test its association with subclinical vascular damage, urinary biomarkers and ultrasound features of kidney damage.

Presence of carotid plaques, pulse wave velocity (PWV), renal resistive index (RRI), and urinary biomarkers of tubular injury were assessed in 207 individuals with type 2 diabetes. Participants were split based on estimated-glomerular-filtration-rate (eGFR) and urinary-albumin-to-creatinine-ratio (UACR) into four groups: controls (UACR < 30 mg/g, eGFR ≥ 60 ml/min/1.73m²), A-DKD (Albuminuric-DKD; UACR ≥ 30 mg/g, eGFR ≥ 60 ml/min/1.73m²), NA-DKD (Non-albuminuric-DKD; UACR < 30 mg/g, eGFR < 60 ml/min/1.73m²), A&L-DKD (Albuminuric-and-Low-eGFR-DKD; UACR ≥ 30 mg/g, eGFR < 60 ml/min/1.73m²).

Participants with NA-DKD showed a lower SUA/sCr than those with A-DKD and controls (4.71 ± 1.52 vs 6.06 ± 1.70 vs 6.67 ± 1.87, both P < 0.0001). A lower SUA/sCr was independently correlated with NA-DKD (β = -1.63, P < 0.0001) and A&L-DKD (β = -2.01, P < 0.0001). SUA/sCr was inversely and independently associated with urinary β2-microglobulin (β = -0.21, P = 0.0082). Moreover, lower SUA/sCr was associated with PWV > 10 m/s (OR 0.77, 95%CI 0.63-0.95, P = 0.014), the presence of carotid plaques (OR 0.78, 95%CI 0.63-0.96, P = 0.020), and higher RRI (β = -0.18, P = 0.0082).

In T2D, lower SUA/sCr correlated with NA-DKD, but not with A-DKD. Lower SUA/sCr was associated with subclinical vascular and tubular damage. Future studies are needed to test SUA/sCr as candidate biomarker to improve DKD risk stratification.

Cardiovascular diseases (CVD) are the most common cause of death in the world. A number of scoring systems have been proposed to predict CVD risk. In this study, we aimed to assess the cardiovascular risk scores of transgender men receiving gender-affirming hormone therapy (GAHT).

A total of 73 participants were included in this cross-sectional study: 43 transgender men, 15 cisgender men, and 15 cisgender women. For each participant, sociodemographic data were collected, glucose, lipid profiles and total testosterone levels were measured and the atherogenic index of plasma (AIP) and visceral adiposity index (VAI) were calculated.

The mean age of transgender men was 29.1 ±5.7. The neck circumference (NC), waist-to-hip ratio (WHR) and Waist-to-Height Ratio (WtHR) of transgender men was statistically higher than that of cis-women (p < 0.001, for all). Also, AIP was significantly higher in transgender men compared to cis- women (p = 0.003).

In conclusion, transgender men receiving GAHT exhibited differences in several cardiometabolic and anthropometric markers compared with cisgender women, with a profile more closely resembling that of cisgender men. These findings should be interpreted as descriptive differences rather than evidence of increased cardiovascular risk, particularly in the context of a cross-sectional design. The observed reduction in HDL cholesterol may be of clinical interest. Further longitudinal studies are warranted to better elucidate the long-term cardiometabolic effects of GAHT.