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Respiratory failure is associated with increased mortality in COVID-19 patients. There are no validated lower airway biomarkers to predict clinical outcome. We investigated whether bacterial respiratory infections were associated with poor clinical outcome of COVID-19 in a prospective, observational cohort of 589 critically ill adults, all of whom required mechanical ventilation. For a subset of 142 patients who underwent bronchoscopy, we quantified SARS-CoV-2 viral load, analysed the lower respiratory tract microbiome using metagenomics and metatranscriptomics and profiled the host immune response. Acquisition of a hospital-acquired respiratory pathogen was not associated with fatal outcome. Poor clinical outcome was associated with lower airway enrichment with an oral commensal ( Mycoplasma salivarium ). Increased SARS-CoV-2 abundance, low anti-SARS-CoV-2 antibody response and a distinct host transcriptome profile of the lower airways were most predictive of mortality. Our data provide evidence that secondary respiratory infections do not drive mortality in COVID-19 and clinical management strategies should prioritize reducing viral replication and maximizing host responses to SARS-CoV-2. Analysis of lower respiratory tract microbiome of mechanically ventilated COVID-19 patients rules out a role for secondary respiratory infections as drivers of increased mortality.

Although technology is rapidly advancing in immersive virtual reality (VR) simulation, there is a paucity of literature to guide its implementation into health professions education, and there are no described best practices for the development of this evolving technology. We conducted a qualitative study using semi-structured interviews with early adopters of immersive VR simulation technology to investigate utilization and motivations behind employing this technology in educational practice, and to identify the educational needs that this technology can address. We conducted 16 interviews with VR early adopters. Data were analyzed via Directed Content Analysis through the lens of the Unified Theory of Acceptance and Use of Technology (UTAUT). The main themes that emerged included Focus on Cognitive Skills, Access to Education, Resource Investment, and Balancing Immersion. These findings help to clarify the intended role of VR simulation in health professions education. Based on our data, we synthesize a set of research questions that may help define best practices for future VR development and implementation. Immersive VR simulation technology primarily serves to teach cognitive skills, to expand access to educational experiences, to act as a collaborative repository of widely relevant and diverse simulation scenarios, and to foster learning through deep immersion. By applying the UTAUT theoretical framework to the context of VR simulation, we not only collected validation evidence for this established theory, but also proposed several modifications to better explain use behavior in this specific setting.

This study analyses patterns of research and writing activity on the role of artificial intelligence in inclusive pedagogy across school education contexts through bibliometric analysis, focusing on classical laws of scientometrics. A total of 2,490 research publications published between 2016 and 2025 from the Dimensions AI database were identified using a comprehensive search string on the topic. The dataset was analysed to uncover trends in country and university contributions, author collaborations, and themes in abstract co-occurrences. It was then examined for author productivity, journal productivity, frequency patterns of keywords in abstracts, and citation analysis of authors, countries, institutions, and sources. The research output has notably increased in recent years. Globally, China recorded the highest publication count within the dataset, followed by the USA and Australia. in this field. A systematic analysis revealed that the dataset aligned with Lotka's Law to some extent, strongly adhered to Bradford's Law, and exhibited Zipfian behaviour. We identified eight thematic clusters ranging from the ethics of AI adoption, pedagogy in curriculum design, and equity considerations to policy innovation. Our citation analysis revealed two complementary forms of influence, illustrating collaborative centrality linked to both research areas and the impact of individual studies.

A 53-year-old woman with a history of traumatic laryngeal fracture in childhood was referred for evaluation of excessive daytime somnolence. Inspiratory stridor was evident on physical examination. A spirometric flow-volume loop (Panel A) revealed an abnormal inspiratory airflow plateau (dashed line) and inspiratory flow oscillations (arrowhead), a pattern suggesting the presence of a dynamic extrathoracic airway obstruction (a normal flow-volume loop is shown in orange). Polysomnography confirmed that intermittent dynamic limitation of inspiratory flow was resulting in snoring and sleep disruption. Laryngoscopy revealed redundant supraglottic mucosa of the aryepiglottic folds (Panel B, arrows) that fluttered during inhalation and exhalation (Video). . . .

Background Azithromycin (ATM) has limitations, such as poor oral bioavailability and gastrointestinal (GI) side effects that restrict its widespread application. Objective To develop a localized hydroxy propyl β-cyclodextrin (HP-βCD) inclusion complex-based in situ pH-responsive mucoadhesive gel of azithromycin (ATM) and evaluate its performance for the treatment of upper respiratory tract infections (URTIs). Methods According to the phase solubility diagram, the ATM HP-βCD complex was prepared and analyzed by FT-IR, DSC, and SEM. Then, using a quality-by-design approach, pH-responsive in-situ gel was prepared. It was characterized in terms of their gelling capacity, pH, spreadability, swelling index, rheological properties and antimicrobial potential. Results ATM HP- βCD complex 20-fold increased solubility of ATM, i.e., 49.84 ± 1.39 µg/mL with improved dissolution profile compared to pure ATM. Optimized formulation characterized by its gelation pH (6.7), time (1.59 min), and viscosity (1607.9 Pa.s). The developed gel showed a good spreadability index (322.6 ± 0.5%), swelling index (98.26 ± 1.54% after 10 h) and mucoadhesive strength (589 g/cm 2 ). Also, it exhibits a sustained drug release profile for 12 h(94 ± 1.37%) and a broader zone of Staphylococcus aureus growth inhibition (31 ± 3.54 mm). Conclusion The developed mucoadhesive in situ gels demonstrated promising in vivo performance, primarily due to their effective antimicrobial activity. In vivo, local retention studies confirmed that the formulations adhered to the throat mucosa and remained in place for up to 24 h after application. The findings presented here suggested that this localized delivery system could serve as a useful strategy for improving the therapeutic effects of ATM against URTIs. Graphical Abstract

Importance The spring 2020 surge of COVID-19 unprecedentedly strained ventilator supply in New York City, with many hospitals nearly exhausting available ventilators and subsequently seriously considering enacting crisis standards of care and implementing New York State Ventilator Allocation Guidelines (NYVAG). However, there is little evidence as to how NYVAG would perform if implemented. Objectives To evaluate the performance and potential improvement of NYVAG during a surge of patients with respect to the length of rationing, overall mortality, and worsening health disparities. Design, Setting, and Participants This cohort study included intubated patients in a single health system in New York City from March through July 2020. A total of 20 000 simulations were conducted of ventilator triage (10 000 following NYVAG and 10 000 following a proposed improved NYVAG) during a crisis period, defined as the point at which the prepandemic ventilator supply was 95% utilized. Exposures The NYVAG protocol for triage ventilators. Main Outcomes and Measures Comparison of observed survival rates with simulations of scenarios requiring NYVAG ventilator rationing. Results The total cohort included 1671 patients; of these, 674 intubated patients (mean [SD] age, 63.7 [13.8] years; 465 male [69.9%]) were included in the crisis period, with 571 (84.7%) testing positive for COVID-19. Simulated ventilator rationing occurred for 163.9 patients over 15.0 days, 44.4% (95% CI, 38.3%-50.0%) of whom would have survived if provided a ventilator while only 34.8% (95% CI, 28.5%-40.0%) of those newly intubated patients receiving a reallocated ventilator survived. While triage categorization at the time of intubation exhibited partial prognostic differentiation, 94.8% of all ventilator rationing occurred after a time trial. Within this subset, 43.1% were intubated for 7 or more days with a favorable SOFA score that had not improved. An estimated 60.6% of these patients would have survived if sustained on a ventilator. Revising triage subcategorization, proposed improved NYVAG, would have improved this alarming ventilator allocation inefficiency (25.3% [95% CI, 22.1%-28.4%] of those selected for ventilator rationing would have survived if provided a ventilator). NYVAG ventilator rationing did not exacerbate existing health disparities. Conclusions and Relevance In this cohort study of intubated patients experiencing simulated ventilator rationing during the apex of the New York City COVID-19 2020 surge, NYVAG diverted ventilators from patients with a higher chance of survival to those with a lower chance of survival. Future efforts should be focused on triage subcategorization, which improved this triage inefficiency, and ventilator rationing after a time trial, when most ventilator rationing occurred.

Background The trigger thumb is a clinically unusual and rare phenomenon. The trigger finger is most observed on the ring or middle fingers. Clinical signs include reduced tendon excursion and the formation of nodules at the base of the metacarpals. As a result, grip strength may be reduced, making gripping tasks uncomfortable. Many treatments have been proposed to treat trigger finger symptoms; however, the effectiveness of shockwave therapy is still being contested. As a result, the purpose of this trigger thumb case study is to assess the effect of shockwave therapy on grip performance. Case presentation A 53-year-old housewife reported to the outpatient department with pain at the base of her right thumb, recurring locking episodes, morning pain and stiffness, and a 10-year history of diabetes. Based on the clinical presentation and physical examination of the patient, an orthopedic sports physician diagnosed it as a trigger thumb. Analgesics were initially administered, and the patient was then referred to physiotherapy for rehabilitation. All outcomes improved substantially during the follow-up after six sessions of physical therapy, which included shockwave therapy and an exercise program. Conclusion This study concluded that the protocol developed specifically for the treatment of the trigger thumb is efficacious. Therefore, future research with a larger number of participants is required to validate this approach.

Introduction The purpose of the study was to find out the relationship of hyper-pronated foot with anterior pelvic tilt and dynamic balance in recreational runners. Hyper-pronated foot is a functional deformity which mainly affects the total body kinematic chain during dynamic weight-bearing events such as running when the foot lands on the ground. Furthermore, individuals with hyper-pronated foot may exhibit anterior pelvic tilt owing to the biomechanical relations, which alters balance as well. Runners with hyper-pronated feet are at high risk of injury, possibly because of larger torque generated at the lower limb. Methods A cross-sectional study was conducted in 55 healthy recreational runners with hyper-pronated foot aged 19–30 years. They were assessed by foot posture index for hyper-pronated foot, Star Excursion Balance Test for dynamic balance evaluation, and the photogrammetry method to determine the anterior pelvic tilt angle. Results The results revealed a poor correlation between foot posture index and dynamic body balance (r = 0.23) and a moderate correlation between foot posture index and anterior pelvic tilt angle (r = 0.47). Conclusions There was no significant correlation of foot posture index with dynamic body balance, whereas a minimal correlation was found between foot posture index and the anterior pelvic tilt angle. Therefore, hyper-pronated foot does not significantly directly influence balance or posture.

Background: The knee joint plays a crucial role in various badminton-related functional movements for both stability and mobility. Specifically, an optimal flexion and valgus angle upon landing tasks ensures less injury risk. Aims: Thus, the study aimed to investigate the prevalence and biomechanical analysis of knee joint flexion and valgus angle among badminton athletes. Methods: Sixty players were included in this study. The study conducted a two-dimensional biomechanical analysis using the Kinovea software to measure the knee flexion and valgus angle while hop and step-down tests, respectively. Results: The study found that for the 13-17 age group, the mean knee flexion angle is 109.8° ± 8.0° (right) and 112.9° ± 8.7° (left), whereas for the 18-25-year age group, it is 110.4° ± 10.1° (right) and 111.7° ± 9.6° (left). The knee valgus angle for 13-17 years is 11.0° ± 5.5° (right) and 11.1° ± 5.7° (left), and for 18-25 years, it is 12.6° ± 6.1° (right) and 11.9° ± 4.0° (left). The difference in knee flexion and valgus angle between legs or the age groups did not find statistically different (P > 0.05). Conclusion: The findings conclude that there was a high prevalence of increased valgus angle among badminton players. However, the flexion angle was found to be optimal. There was no meaningful differences in the knee joint alignments neither between both the legs and the age groups. The study findings can underscore the potential mechanisms and necessary training modifications by emphasising certain neuromuscular control trainings and optimal landing mechanics to ensure a safe and effective badminton-related mechanics, thereby reducing injury risks.

Psoriasis is a complex and persistent autoimmune skin disease. The present research focused on the therapeutic evaluation of betulin-loaded nanostructured lipid carriers (BE-NLCs) towards managing psoriasis. The BE-NLCs were synthesized using the emulsification cum solidification method, exhibiting a spherical shape with a particle size of 183.5±1.82nm and a narrow size distribution window (PDI: 0.142±0.05). A high zeta potential -38.64±0.05mV signifies the relative stability of the nano-dispersion system. BE-NLCs show a drug loading and entrapment efficiency of 47.35±3.25% and 87.8±7.86%, respectively. In vitro release study, BE NLCs show a cumulative percentage release of 90.667±5.507% over BE-sol (57.334±5.03%) and BD-oint (42±4.58%) for 720min. In an ex vivo 24-h permeation study, % cumulative amount permeated per cm 2 was found to be 55.667±3.33% from BE-NLCs and 32.012±3.26% from BE-sol, demonstrating a better permeability of 21.66% when compared to the standard formulation BD-oint. The in vivo anti-psoriatic activity in the IMQ-induced model shows topical application of BE-sol, BE-NLCs, and BD-oint resulted in recovery rates of 56%, 82%, and 65%, respectively, based on PASI (Psoriasis Area and Severity Index) score. Notably, BE-NLCs demonstrated a more significant reduction in spleen mass, indicating attenuation of the local innate immune system in psoriatic mice. Reductions in TNF-α, IL-6, and IL-17 levels were observed in both BE-sol and BE-NLCs groups compared to the disease control (DC) group, with BE-NLCs exhibiting superior outcomes (74.05%, 44.76%, and 49.26% reduction, respectively). Soy lecithin and squalene-based NLCs could be better carrier system for the improvement of the therapeutic potential of BE towards management of psoriasis. Graphical Abstract