During an outbreak, infectious disease can spread among populations through host movement, potentially fueling local outbreaks with their own epidemiological dynamics. However, it is difficult to know how often infections between populations are transmitted by diseased travelers infecting healthy residents when abroad, rather than by diseased residents infecting healthy travelers, who later return home with the new pathogen. In this paper, we introduce a phylogeographic model where pathogens spread through visitor dynamics, whereby hosts visit other populations through short trips before returning home. To do so, we used the stationary properties of an epidemiological compartment model with visitor dynamics to construct an approximation that is statistically accurate and computationally tractable for phylogenetic modeling. In addition, we derive mathematical properties for the approximating model that provide a sufficient condition under which the approximation remains accurate. We applied our model to empirical infection data and travel statistics from the European SARS-CoV-2 pandemic. Inference under our model suggests that, in the early stages of the outbreak, SARS-CoV-2 was more often "pulled" into the home countries of returning travelers than "pushed" into foreign countries by visitors from abroad. Estimates of host movement-related parameter values under our visitor model suggest that alternative migration models, with trips of indefinite length, may underestimate the magnitude of outbreaks caused by visitors. This study emphasizes the importance of carefully incorporating host movement dynamics into such models.

Unilateral vocal fold paralysis (UVFP) can lead to both voice impairment and dysphagia. Previous studies have suggested that surgeries aimed at improving voice function in patients with UVFP may also incidentally enhance swallowing. However, the preventive effect of such surgeries on pneumonia remains unclear. We evaluated the impact of laryngoplasty on the incidence of pneumonia in Japan using a large employment insurance claims database of corporate employees under 75 years of age and their family members.

The study cohort consisted of patients diagnosed with UVFP between January 2013 and December 2022, identified from an insurance claims database. A propensity score-matched cohort was created using a 1:3 matching ratio between the treatment and non-treatment groups. Follow-up began at the index date, defined as the initial diagnosis of UVFP, and continued until the end of the study period. The primary analysis compared the cumulative incidence of pneumonia between treatment and non-treatment groups. The secondary analysis employed a self-controlled design to compare pneumonia incidence before and after laryngoplasty within treated patients.

The full cohort included 7,641 patients with UVFP, of whom 914 comprised the matched cohort (treatment group, n = 230; non-treatment group, n = 684). The cumulative incidence of pneumonia tended to be higher in the treatment group than in the non-treatment group (hazard ratio, 1.39; 95% CI, 0.93-2.08; p = 0.098). In contrast, the self-controlled analysis demonstrated a lower pneumonia incidence after laryngoplasty compared with the pre-treatment period (incidence rate ratio, 0.36; 95% CI, 0.27-0.52; p < 0.001).

Given the discordant findings across analytical approaches, no definitive conclusion regarding a preventive effect can be drawn from the present study. Further studies are needed to evaluate long-term outcomes and to clarify causal relationships.

Legionellosis is a bacterial disease caused by inhalation or aspiration of Legionella bacteria; Legionnaires disease is a type of legionellosis characterized by illness with pneumonia. During November 2024, the U.S. Virgin Islands (USVI) Department of Health (VIDOH) was notified of two confirmed Legionnaires disease cases among travelers to two different hotels on St. Croix Island. VIDOH investigated to determine exposure sources and prevent additional cases. Two additional legionellosis cases were identified. The four patients with cases were aged 53-73 years; two patients were hospitalized and none died. At hotel A, L. pneumophila was detected in three of 21 (14%) environmental samples. VIDOH required hotel A to close one guest room, remediate, and retest. At hotel B, L. pneumophila was detected in 22 of 40 (55%) samples. VIDOH required hotel B to cease hotel operations until remediation and retesting were completed. L. pneumophila was isolated from shower samples at both hotels, in the cistern and cold water system at hotel A, and in cold and hot water systems at hotel B. The two USVI outbreaks underscore the importance of reporting legionellosis among returned travelers to facilitate local public health investigations and prevent additional cases. In addition, in tropical climates, cold water systems operate at temperatures favorable for Legionella growth (77°F-113°F [25°C-45°C]), highlighting the importance of effective water management programs and water system disinfection to prevent disease spread.

Patients with advanced chronic kidney disease (CKD) and dyslipidemia are at high risk of kidney failure and cardiovascular events, yet many do not receive lipid-lowering therapy. Pentoxifylline (PTX) has anti-inflammatory and antifibrotic properties, but its association with hard cardiorenal outcomes remains uncertain.

We conducted a retrospective cohort study of adults with stage 3b-5 CKD and dyslipidemia enrolled in a pre-end-stage renal disease program from 2007 to 2018. Patients receiving lipid-lowering therapy were excluded. PTX initiators were matched 1:1 to nonusers using propensity score matching. The primary outcome was progression to end-stage kidney disease (ESKD). Secondary outcomes included major adverse cardiovascular events (MACE), 50% estimated glomerular filtration rate decline within 2 years, and doubling of serum creatinine. Sensitivity analyses included time-varying exposure, lag, and landmark analyses.

Among 3,542 eligible patients, 2,776 were included in the matched cohort. PTX use was associated with lower risks of ESKD (hazard ratio [HR], 0.85; 95% confidence interval [CI], 0.75-0.96) and MACE (HR, 0.80; 95% CI, 0.65-0.98). No significant associations were observed for short-term kidney function decline or creatinine doubling. Time-related sensitivity analyses attenuated estimates toward the null but did not suggest harm.

In patients with advanced CKD and untreated dyslipidemia, PTX use was associated with lower risks of kidney failure in propensity score-matched analyses, whereas the association with cardiovascular events was less robust after sensitivity analyses. These findings require cautious interpretation and further validation.

The apelinergic system, composed of the ligands Apelin and Elabela and their shared receptor APLNR, has key functions in vascular development and endothelial homeostasis. Originally identified as an orphan G protein-coupled receptor, APLNR is now recognized as a receptor highly enriched in endothelial cells across organs, where it integrates developmental cues, mechanical forces, hypoxia, and inflammatory signals. Apelin and Elabela guide angiogenic patterning during cardiac, pulmonary, and retinal development, and in adulthood they support endothelial nitric oxide production, vascular stability, and tissue adaptation to stress. Pathological conditions expose the dependence of endothelial integrity on this pathway. Reduced Apelin availability or altered APLNR expression contributes to hypertension, cardiac remodeling, pulmonary vascular injury, and immune-driven inflammation. Conversely, restoring apelinergic signaling improves endothelial barrier function, limits leukocyte recruitment, and mitigates fibrotic and ischemic damage, including in experimental models of autoimmune encephalomyelitis and acute lung injury. Therapeutic interest in this pathway has increased with the development of stabilized Apelin analogs and small-molecule APLNR agonists that have longer half-lives than native peptides. Together, emerging evidence positions the Apelin-APLNR axis as a context-dependent regulator of endothelial function and a promising therapeutic target in cardiovascular, pulmonary, and inflammatory diseases.

Paraclinoid aneurysms, arising from the internal carotid artery between the proximal dural ring and the posterior communicating artery, pose significant microsurgical challenges due to their proximity to critical neurovascular structures. Despite advances in endovascular techniques, surgical clipping offers definitive exclusion with lower recurrence. This study evaluates surgical outcomes and operative nuances in clipping paraclinoid aneurysms over a 12-year period. A retrospective review was conducted of 116 patients with paraclinoid aneurysms who underwent surgical clipping at a tertiary centre between 2011 and 2023. Data on demographics, clinical presentation, aneurysm morphology, surgical strategy, and outcomes were analysed. The outcome was assessed using the modified Rankin Scale (mRS), with a favourable outcome defined as mRS 0-2. A p-value < 0.05 was considered significant. Informed consent was obtained from all the patients. Among 116 patients median age at presentation was 48 (38.25-59.75) years, 80.2% presented with subarachnoid haemorrhage (SAH). Most had good preoperative status (Hunt & Hess grade I-II: 63.8%; mRS 0-2: 66.4%). Clipping was performed in 84.5%, with alternative strategies including trapping (8.6%) and wrapping (3.4%). Anterior clinoidectomy was required in 70.7% (intradural: 41.4%, extradural: 29.3%). Intraoperative rupture occurred in 20.7%, and multiple clips were used in 27.6%. Postoperative complications included infarcts (23.3%), vasospasm (32.8%), and seizures (7.8%). At discharge, 58.6% had favourable outcome; mortality was 17.2%, increasing to 23.3% at final follow-up. Visual outcomes were better after extradural clinoidectomy, with improvement in 32.4% versus 4.2% for intradural approach. Microsurgical clipping remains a viable, effective treatment for paraclinoid aneurysms, particularly in younger patients and ruptured cases. Extradural anterior clinoidectomy may confer superior visual outcomes. Despite technical complexity, favourable functional outcomes (mRS 0-2) were achieved in 64.6% of patients, underscoring the continued relevance of surgical management in appropriately selected cases.

This study aimed to analyze the clinical studies of TCM in treating unstable angina pectoris(UAP) in elderly patients through evidence mapping. The objective was to understand the current status and deficiencies of evidence in this field and to provide directions for future research. A systematic search was conducted across multiple databases, including CNKI, Wanfang, VIP, SinoMed, PubMed, EMbase, Web of Science, and Cochrane Library, covering the period from January 1, 2005 to August 31, 2025. This search included clinical studies on TCM for the treatment of UAP in elderly patients and aimed to present the distribution characteristics of the evidence in tables and charts. Ultimately, a total of 306 randomized controlled trials(RCTs), 6 non-randomized controlled trials(non-RCTs), 4 systematic reviews, 4 observational studies, and 1 guideline were included. The research interest remained stable over the past seven years, reflecting a trend of low attention. The studies involved 54 types of Chinese patent medicines, with Danhong Injection, Salvia Miltiorrhiza Polyphenol Hydrochloride Injection, and Tongxinluo Capsules comprising the largest proportion. Most studies were single-center with small sample sizes(predominantly between 60-120 cases) and short treatment durations(mostly 2-4 weeks). Outcome indicators primarily focused on symptoms/signs and electrocardiograph(ECG), with less emphasis on prognosis, quality-of-life indicators, and TCM syndromes. The overall quality of literature for RCTs, non-RCTs, and systematic reviews/Meta-analyses was generally low, and the guideline development process lacked standardization, which resulted in an extremely low level of evidence quality. The results indicated that, despite the substantial number of clinical studies on the treatment of UAP in elderly patients with TCM, the level of evidence remained constrained by the quality of the literature. Moving forward, it is essential to conduct more large-scale, multi-center, and long-term clinical trials, standardize systematic reviews, and actively develop a core outcome indicator set that integrates the unique characteristics of TCM. These efforts are crucial for advancing the high-quality development of clinical research on TCM in the treatment of UAP in elderly patients.

Meta-epidemiology is an emerging research approach that incorporates systematic reviews(SRs) or Meta-analyses to examine the impact of specific characteristics of clinical studies on observed effects. It aims to identify potential sources of bias and to accurately estimate between-trial heterogeneity and changes in average bias within Meta-analyses, thereby enhancing the quality of primary studies and SRs. As the methodological framework of Meta-epidemiology continues to mature and the demand for precise evidence linking trial characteristics with heterogeneity increases in the field of TCM, the application value of Meta-epidemiology has become increasingly prominent. This article systematically elaborates on the core methodological characteristics of Meta-epidemiological studies that take SRs or Meta-analyses as the unit of analysis. By integrating multidimensional visual analyses, including publication volume characteristics, national and regional collaboration networks, author collaboration networks, and keyword co-occurrence and clustering, the development trends and research hotspots in this field are comprehensively mapped. The results indicate that, in recent years, Meta-epidemiological research has developed rapidly worldwide, with increasingly close international collaboration between the United Kingdom and the United States. Research themes have mostly focused on disease areas such as osteoarthritis, acute exacerbations of chronic obstructive pulmonary disease, and cardiovascular diseases. On this basis, the article further explores the application value of Meta-epidemiology in the field of TCM. Using acupuncture and moxibustion as an example, it analyzes the adaptability of this approach in addressing key issues in TCM clinical trials, such as high heterogeneity and difficulties in risk-of-bias assessment. The study aims to establish a more robust methodological framework for TCM research and to support the generation of higher-quality evidence and more reliable inference.

To explore the experience of participants using the Neurofenix (Naples, Florida, USA) platform for hospital and home-based upper limb rehabilitation in acute and subacute stroke, and to report acceptability of trial and data collection processes in a feasibility randomised controlled trial (Rehabilitation using virtual gaming for Hospital and hOMe-Based therapy for the Upper limb in acute and subacute Stroke (RHOMBUS II)). The trial investigated safety, feasibility and acceptability of the platform, a non-immersive virtual reality (VR) tool, to facilitate upper limb rehabilitation following stroke. The intervention group (n=16) received usual care plus the platform for 7 weeks. The control group (n=8) received usual care only.

A qualitative descriptive approach using semi-structured interviews. Interviews were audio-recorded, transcribed verbatim, and analysed using the Framework Method. The Theoretical Framework of Acceptability informed the development of the topic guide and the analysis.

Homes of participants and an inpatient stroke rehabilitation unit, London, UK.

A purposive sample of 11 adults (≥18 years) was recruited from the trial intervention group, 35-89 years of age, ranging from mild to severe upper limb impairment and representing varying levels of engagement with the Neurofenix platform. Additionally three participants were recruited from the trial control group.

Six themes were developed: (1) trial enrolment, indicated that participants enrolled in the study due to hope and for distraction; (2) affective attitude, described feelings associated with the platform, such as the subthemes 'enjoyment of the games' but also 'frustration', often caused by Wi-Fi connection issues; (3) barriers and facilitators, explored environmental factors such as having a suitable space to use the platform, usability factors such as comfort and the need for support from others; (4) perceived effectiveness of the intervention, described an overall belief that the platform had beneficial effects on both upper limb and cognitive function; (5) self-efficacy, showed how confidence with the platform grew with time and the value placed on performance tracking and routine; (6) trial processes, indicated that assessment burden was manageable and potential allocation to the control group was not a deterrent to trial enrolment.

This study demonstrated the overall acceptability of the platform and offers valuable insights to guide the further development of rehabilitation technologies. This study also adds to the limited literature on the user experience of VR technologies early post-stroke.

ISRCTN11440079.

To quantify out-of-pocket (OOP) costs and catastrophic health expenditure (CHE) among patients hospitalised with heart failure (HF) and to identify factors associated with CHE during a single index admission in northern Tanzania.

Prospective cross-sectional study.

Medical ward of Kilimanjaro Christian Medical Centre, a tertiary referral hospital in northern Tanzania, from 1 May to 31 October 2024.

Consecutive patients aged 14 years or older admitted with acute decompensated HF diagnosed using Framingham criteria. Of 309 eligible patients, 290 completed the study and were included in the analysis.

The primary outcome was CHE, defined as OOP spending exceeding 40% of household non-food expenditure for the index hospitalisation. Secondary outcomes included total inpatient OOP cost and cost distribution by category. Factors associated with CHE were assessed using multivariable logistic regression.

Among 290 hospitalised patients with HF, 201 (69.3%) experienced CHE during the index admission. The median total cost of hospitalisation was US$229 (IQR 155-405), and the median OOP payment was US$192 (IQR 39-360). Diagnostic investigations accounted for the largest share of OOP expenditure. In multivariable analysis, family income US$≤115 (adjusted OR (aOR) 10.0, 95% CI 4.3 to 23.0) and lack of health insurance (aOR 22.9, 95% CI 9.3 to 56.1) were strongly associated with CHE. Other independent associated factors were non-use of mineralocorticoid receptor antagonists before admission (aOR 4.1, 95% CI 1.5 to 11.1), reduced left ventricular ejection fraction (aOR 3.1, 95% CI 1.2 to 8.0) and length of stay >7 days (aOR 4.1, 95% CI 1.7 to 10.0).

CHE was common among patients hospitalised with HF in northern Tanzania during a single admission, driven mainly by diagnostic costs and limited financial protection. Expanding insurance coverage, improving access to guideline-directed HF therapy and reducing patient payment for essential diagnostics may lessen the financial burden of HF care.