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01.
PLOS Computational Biology 2026-06-22

Cell-type resolved transcriptional network analysis of <i>in vivo</i> cellular senescence following injury

Authors:

by Alda Sabalic, Victoria Moiseeva, Andres Cisneros, Oleg Deryagin, Eusebio Perdiguero, Pura Muñoz-Cánoves, Jordi Garcia-Ojalvo Identifying the genetic correlates of complex phenotypes is a challenging task. Methods coming from the field of complex networks can help finding such molecular patterns, by revealing statistical associations among groups of genes that correlate with the phenotype. Here we study cellular senescence, a complex cell state whose molecular underpinnings are still under active investigation. We analyze cell type–resolved RNA sequencing data obtained from injured muscle tissue in mice, with a network-based approach that merges eigenvector centrality feature selection and community detection. Our analysis identifies genetic markers that had not been associated with senescence so far, which are validated with existing single-cell RNA sequencing data in a different type of tissue. The identified key genes belong to transcriptional pathways associated with established hallmarks of senescence, and thus can be interpreted as molecular correlates of such hallmarks. The method proposed here could be applied to any complex cellular phenotype even when only bulk RNA sequencing is available, provided the data is resolved by cell type.

02.
bioRxiv (Bioinfo) 2026-06-22

Few-Shot Classification of C. elegans Developmental Stages via Explainable Hierarchical Hyperbolic Graph Embeddings

Automated, accurate, and fast developmental-stage classification of C. elegans from microscopy-based morphological images is essential for aging research, drug screening, and disease modeling. However, it remains challenging due to morphological similarities between stages and the limited annotated data. In this work, we propose HyperDev, a hyperbolic few-shot learning framework that addresses these limitations by directly encoding developmental hierarchies in the embedding space, unlike conventional Euclidean approaches that treat stages as independent classes. HyperDev uses Poincare ball geometry, combined with a biologically informed developmental prior, to naturally represent stage relationships. We introduce our selfcurated C. elegans dataset spanning seven developmental stages (Egg, L1-L4, Adult, Dauer) with extreme class imbalance (6-8 samples per minority class). HyperDev achieves competitive classification accuracy (76.9-88.3%) while providing intrinsic explainability across nine 7-way few-shot evaluation settings. The learned embeddings exhibited strong biological alignment (Pearson r = 0.669, p < 0.001), while significantly outperforming ProtoNet (r = 0.187), MatchingNet (r = 0.235), and RelationNet (r = 0.464). These results establish hyperbolic geometry as a principled approach to explainable few-shot learning in biological imaging, where understanding learned representations is as critical as predictive performance. Clinical Relevance–By enabling explainable, data-efficient developmental staging from scarce samples, HyperDev supports improved phenotype quantification for aging research, disease modeling, and drug screening. Index Terms–Hyperbolic learning, few-shot classification, developmental staging, Caenorhabditis elegans, interpretability, explainability.

03.
bioRxiv (Bioinfo) 2026-06-22

PanRes: A database of latent and acquired antimicrobial resistance allowing 3D-based protein homology search

Antimicrobial resistance databases are central to genomic surveillance, but resistance determinants remain distributed across resources with different scopes, structures, and annotations. We developed PanRes, a curated resistance database of 11,717 genes integrating acquired and latent determinants of antibiotic, biocide, and metal resistance within a unified ontology. We predicted representative protein structures and clustered them by structural similarity, grouping proteins into 598 structurally conserved clusters coherent despite sequence divergence. Their structure-guided alignments were used to build Hidden Markov Models (HMMs) for remote homology search. In wastewater metagenomes from seven European cities, PanRes 3D-based HMMs expanded detection beyond high-confidence BLAST, with 35.2% of retained hits identified only by the HMMs and generally showing greater divergence from known proteins. For beta-lactamases, several proteins retained beta-lactamase-like folds and catalytic geometry despite weak sequence similarity. PanRes is available through an interactive web platform (https://panres.rambio.dk/), a structure-informed resource for exploring the whole resistome.

04.
medRxiv (Medicine) 2026-06-22

Development and validation of a risk prediction algorithm to estimate all-cause mortality among community-dwelling Canadians: the Mortality Population Risk Tool (MPoRT)

BACKGROUND: The risk of all-cause mortality can inform decision-making for chronic disease prevention. We developed a predictive algorithm to estimate the 5-year risk of death among community-dwelling adults. METHODS: We derived and validated the Mortality Population Risk Tool (MPoRT) using data from population health surveys in Canada (the Canadian Community Health Survey) and the United States (the National Health Interview Survey), survey years 2001 to 2011, linked to vital statistics. The outcome was death within five years of the survey response. The algorithm was developed using data from Ontario respondents using a Cox proportional hazards model, then modified and re-estimated to allow cross-national assessment in Canada and the United States. Twenty-three prespecified predictors were assessed: seven sociodemographic, six behavioural, and ten general health and chronic disease. RESULTS: 527,369 respondents aged 20 to 105 years were included in the Canadian and United States development and validation cohorts, with 43,758 deaths during 3.68 million person-years follow-up. The final sex-specific MPoRT algorithms each contained 21 variables, showing strong discrimination (C-statistic: females 0.874 [0.871–0.877]; males 0.867 [0.865–0.871]) and good calibration overall and in 246 of 247 subgroups. Discrimination was modestly attenuated (0.01 decrease in C-statistic) in cross-national validation between Canada and the United States, with good calibration across all 71 subgroups. INTERPRETATION: MPoRT accurately discriminated all-cause mortality using only self-reported data, enabling broad application without clinical measures. While validation outside North America is needed to confirm broader applicability, MPoRT is designed for straightforward recalibration using routinely available national mortality data. This supports targeted chronic disease prevention strategies at both the population and individual levels, though the limitations inherent to self-reported predictors should be considered when interpreting predictions.

05.
bioRxiv (Bioinfo) 2026-06-22

Dynamic balance of sparse flux vectors for efficient simulation of culture dynamics and metabolic network reduction

Dynamic Flux Balance Analysis (DFBA) enables simulation of microbial culture dynamics under changing environmental conditions, but remains computationally expensive for tasks such as parameter calibration and fermentation optimization when applied using genome-scale metabolic models (GEMs). To address this challenge, we introduce Dynamic Flux Vector Balancing (DFVB), a reformulation of DFBA that solves an equivalent problem using a pre-computed, sparse basis of flux solutions that reduces the dimensionality of the internal optimization problem without information loss. Notably, DFVB provides a compact, interpretable representation of flux states that can readily identify dynamically inactive pathways and enable simulation-based automatic metabolic network reduction. We showed that DFVB produces the same culture dynamics as DFBA across multiple model scales and conditions, and identifies inactive reactions more accurately than Flux Variability Analysis (FVA) when compared to transcriptomic data profiles. Furthermore, computational performance analyses demonstrated that integrating DFVB with solver warm-start strategies and model reduction enhances computational efficiency relative to DFBA, yielding up to 3-fold reductions in simulation time for large-scale metabolic models. Finally, kinetic parameter estimation of culture dynamics with DFVB in two fermentation scenarios using a large-scale yeast GEM reached equal or higher prediction fidelity and narrower confidence intervals than DFBA, indicating improved parameter identifiability and robustness. Together, these results position DFVB as a scalable, robust, and biologically coherent framework for dynamic metabolic modeling, easing the integration of GEMs for culture dynamics simulation.

06.
bioRxiv (Bioinfo) 2026-06-22

When Less Is Not More: DICEPro Mitigates the Impact of Incomplete Reference Matrices on Cellular Frequency Deconvolution.

Cellular deconvolution aims to estimate the frequencies of different cell populations from gene expression measurements in a biological sample. Supervised approaches, such as CIBERSORTx and DISSECT, critically depend on the reference signature matrix, which encodes the gene expression profiles of cell-types based on prior knowledge. Despite numerous deconvolution methods, the impact of missing cell populations in the reference matrix remains understudied. Here, we evaluate the robustness of state-of-the-art deconvolution approaches using simulations based on real dataset examples combined with statistical modeling, validated against published data, and multiple real benchmark datasets. Results show that deconvolution performance remains stable when the reference matrix includes most cell-types, but declines sharply as the matrix becomes incomplete, especially for abundant cell populations. To address the limitations of incomplete reference matrices, we introduce DICEPro, an optimization-based framework designed to enhance existing deconvolution methods. By systematically adjusting the reference signatures, DICEPro better accounts for missing or underrepresented cell populations, leading to improved precision and robustness. We show that DICEPro consistently boosts deconvolution performance across both simulated datasets, derived from real data examples, and multiple real biological datasets, offering a practical solution when standard methods are hindered by incomplete references.

07.
medRxiv (Medicine) 2026-06-22

Vaccine introductions in the WHO African Region, 2023-26: a country-level ecological analysis by Gavi eligibility and conflict-affected status

Background. The Immunization Agenda 2030 (IA2030) tracks new and underused vaccine introduction as an access metric, and its mid-term review calls for stronger country ownership, prioritisation, data use and tailored support in conflict-affected and resource-constrained settings; however, national launch status does not measure recurrent financing, implementation, safety or equity. We examined how recent vaccine-introduction activity was distributed across the WHO African Region. Methods. We conducted a descriptive country-level ecological analysis of all 47 Member States from January 2023 to June 2026. The country was the unit of analysis and contributed one cumulative, unweighted count of nationally endorsed vaccine-introduction and programme-change events. Counts were linked to Gavi eligibility, World Bank FY26 conflict-affected status, broader fragile and conflict-affected situation status in sensitivity analysis, and concurrent system-performance indicators, and modelled with Poisson regression using HC1 robust standard errors. Two Expanded Programme on Immunization (EPI) manager survey waves were summarised at country level. Reporting followed STROBE and RECORD. Results. Seventy-two events were recorded across 38 of 47 Member States: 48 new-antigen introductions, 20 dose or schedule expansions and four combination-vaccine introductions; malaria vaccines accounted for 21. Gavi-eligible conflict-affected countries averaged 2.50 events per country versus 1.27 in both comparison groups. Gavi-eligible conflict-affected status was associated with a higher count (incidence rate ratio [IRR] 1.97, 95% confidence interval [CI] 1.38-2.81; p

08.
medRxiv (Medicine) 2026-06-22

A Controlled Human Malaria Infection model for relapsing Plasmodium vivax

Background Plasmodium vivax malaria relapses are a major source of morbidity and onward transmission of infection. The underlying mechanisms are poorly understood and current therapies sub-optimal. We examined the safety and feasibility of a controlled human malaria infection (CHMI) model for relapsing P. vivax. Methods We conducted an open-label, proof-of-concept, CHMI study of relapsing P. vivax. Healthy, malaria-naive, Duffy-positive adults aged 18-45 years with extensive CYP2D6 metaboliser phenotype and normal blood glucose-6-phosphate dehydrogenase (G6PD) levels were recruited in Oxford, UK. Mosquito-bite CHMI was performed in Nijmegen, The Netherlands, using Anopheles stephensi mosquitoes infected with PvW1, a clonal isolate of P. vivax from Thailand. All follow-up visits were conducted in Oxford, UK. Primary P. vivax infections (qPCR > 500 genome copies/mL) were treated with artemether-lumefantrine (80mg/480mg at 8, 24, 36, 48 and 60 hours). From Day 28 following CHMI, participants attended a fortnightly clinic for clinical review and qPCR blood sampling, with additional assessments performed for any reported symptoms. P. vivax relapse infections (qPCR > 500 genome copies/mL) were treated with artemether-lumefantrine as per primary infection. Definitive anti-malarial treatment with atovaquone-proguanil (1000mg/400mg once daily for three days) and primaquine (0{middle dot}5 mg/kg/day for 14 days) was administered six months following CHMI, regardless of parasitaemia or symptoms. The primary objective was to assess the safety, feasibility and frequency of relapsing P. vivax after CHMI. Remote follow-up (5 years) is ongoing. The study is registered with ISRCTN registry (ISRCTN48625883). Findings 20 participants were screened for eligibility from 21 January 2025. Five participants (median age 22 years) underwent CHMI (five infected mosquitoes per participant) on 15 April 2025. All participants developed primary P. vivax infection and experienced at least one relapse infection. Two participants experienced a second relapse. Overall incidence rate was 3{middle dot}6 relapse infections per person-year. Solicited adverse events were mild or moderate and there were no serious adverse events. Definitive anti-malarial treatment was administered to all participants. One participant experienced primaquine-induced methaemoglobinaemia, resolving with early discontinuation of treatment (total dose 5{middle dot}3 mg/kg). To date, more than six months after primaquine treatment, no further relapses have been recorded. Interpretation CHMI of relapsing P. vivax is safe and feasible, allowing exploration of the mechanisms underlying relapse infections and providing a platform for future anti-relapse efficacy studies. Funding European Union Horizon Europe programme and UK Research and Innovation (UKRI) via OptiVivax consortium; UK National Institute for Health and Care Research Biomedical Research Centre: Oxford; and UK Medical Research Council.

09.
medRxiv (Medicine) 2026-06-22

Evidence-guided AI regularization for suicidal ideation prediction in pediatric bipolar disorder

Background: Suicide prediction models in psychiatry often rely on purely data-driven feature selection, which can produce unstable and clinically opaque predictor sets in modest-sized samples. We developed Evidence-Based AI LASSO (EBAL), an evidence-guided regularization framework that incorporates curated clinical evidence into feature-specific penalty factors for interpretable prediction. Methods: Baseline data from 136 youth with confirmed bipolar spectrum disorder in the Greater Houston Area Bipolar Registry were analyzed using 20 candidate clinical predictors. Forty higher-level evidence documents on suicidality and related predictor domains were curated through a structured evidence synthesis workflow and indexed as an auditable evidence corpus. An open-weight large language model assigned feature-specific penalty factors using a prespecified scoring rubric, and these penalties were used to fit a weighted LASSO model. EBAL was compared with a standard evidence-agnostic LASSO using nested leave-one-out cross-validation. Results: For suicidal ideation, EBAL achieved an AUROC of 0.768, balanced accuracy of 0.757, sensitivity of 0.758, and specificity of 0.757. The standard LASSO achieved an AUROC of 0.760 and balanced accuracy of 0.715. EBAL improved balanced accuracy (+0.042, p=0.010) and Matthews correlation coefficient (+0.079, p=0.010), while retaining fewer stable predictors than standard LASSO (11/20 vs 18/20). The strongest positive predictors were current depressed mood, duration of mood disorder illness, and comorbid generalized anxiety disorder. For suicidal behavior, both models performed near chance and retained all candidate predictors. Limitations: The study was cross-sectional, single-site, and modest in sample size, with no external validation cohort. Conclusions: EBAL produced a sparser and more clinically coherent model for suicidal ideation in pediatric bipolar disorder, but did not improve prediction of suicidal behavior. These findings support evidence-guided regularization as a transparent strategy for aligning psychiatric prediction models with prior clinical knowledge while preserving interpretability.

10.
medRxiv (Medicine) 2026-06-22

The Unsteady Return of Command-Following: Recovery and Instability of Bedside Motor Command-Following After Acute Brain Injury

Background/Objective: Following a verbal command marks the bedside transition from unresponsiveness to overt recovery of consciousness after acute brain injury. Its timing across phenotypes, stability once present, and dependence on sedation are uncharacterized at scale. Methods: Retrospective cohort of adults with acute brain injury, first intensive care unit stay, MIMIC-IV. Command-following was the Glasgow Coma Scale motor response "Obeys Commands." Among patients not following commands at admission, cumulative incidence was estimated with death or hospice and discharge without recovery as competing events. Instability was quantified as transient first recovery and threshold crossings; examinations were tagged for concurrent sedation. Principal findings were externally validated in the multicenter eICU Collaborative Research Database. Results: Of 13,900 brain-injured patients with three or more motor examinations, 5,498 (39.6%) were not following commands at admission. The cumulative incidence of first command-following was 43.5% by 24 hours and 65.0% by 14 days, ranging at 14 days from 36.9% in anoxic injury to 77.2% in ischemic stroke (anoxic versus ischemic stroke at 72 hours, difference 0.41; adjusted P = .002). Among 3,573 patients who recovered, the first recovery was transient in 22.2%, and 62.4% crossed the threshold repeatedly. Non-following was strongly associated with sedation, consistent with an arousal-dependent examination. In eICU, the 14-day incidence was 64.8%, and transient first recovery was 22.7%, closely matching the primary cohort. Conclusions: After acute brain injury, overt bedside command-following returns early but unsteadily, with phenotype-dependent timing, threshold fluctuation, and strong dependence on sedation. A single charted observation is an unreliable index of the underlying state.

11.
medRxiv (Medicine) 2026-06-22

Understanding and Usefulness of Effect Size and Certainty of Evidence: A Cross-sectional Survey of Evidence-Based Practice Competencies Among Registered Dietitians

Introduction: Understanding of absolute and relative estimates (i.e., effect size), and certainty of evidence corresponding to those estimates, is a fundamental evidence-based practice competency to promote informed clinical decision-making. While research has been conducted in the medical profession, there is no published research on these competencies in the nutrition and dietetics profession. Methods: Among registered dietitians, our main objectives were to assess (1) their understanding and perceived usefulness of three absolute and two relative estimate approaches to assess effect size, (2) their perceived usefulness of certainty of evidence, and (3) factors influencing their understanding and perceived usefulness. We conducted a web-based, cross-sectional survey among dietitians recruited from the Academy of Nutrition and Dietetics (United States). Participants received effect estimates based on hypothetical dietary interventions vs. usual diet for reducing myocardial infarction risk. Results: Of the 11,050 dietitians who received the survey link, 210 participated (2.0% response rate), and only completers (n=114) were included in the analysis. Participants demonstrated a similar understanding of the relative (27.6%) and absolute (27.5%) estimates, with Risk Difference (30.7% correct responses) being the best understood approach and Number Needed to Treat (24.6%) being the least. The understanding of five approaches was not different than random guessing (p>0.05). While perceived usefulness scores were similar between five approaches, they were highest when data was presented as Relative Risk [mean (SD): 4.82 (1.50)]. Dietitians rated the usefulness of certainty of evidence favorably [mean (SD): 5.07 (1.83), on a 7-point scale), and no factors were associated with correct understanding. Conclusion: Dietitians may have limited understanding of how to interpret effect sizes, a finding consistent with surveys of other health professionals. To optimize informed decision-making between dietitians and clients, dietetic programs and continuing education platforms should consider additional training on interpreting effect sizes and certainty of evidence for effect sizes.

12.
medRxiv (Medicine) 2026-06-22

Rare loss-of-function variants in POLD1, PMS1 and FAN1 modify age at onset of motor symptoms in Huntington's disease

Huntington's disease is a rare neurodegenerative disease whose primary risk factors are inherited expansions of a CAG repeat tract in the HTT gene. Somatic expansion of these tracts leads to neuronal toxicity, neuronal death and clinical disease progression. To identify genetic factors with a major impact on disease onset and progression, we genome sequenced 18,825 individuals for the ENROLL-HD study. Our results show rare inactivating mutations in three genes, all involved in DNA damage repair, are major determinants of age of onset for motor symptoms (n=10,610) and other clinical manifestations. Heterozygote carriers of predicted loss-of-function (pLoF) variants in POLD1 and PMS1 developed motor symptoms an average 20 years (n=3; P=1x10-5) and 7 years (n=6; P=2x10-3) later than non-carriers, respectively. Conversely, heterozygote carriers of pLoF variants in FAN1 (n=30) developed symptoms 10 years earlier (P=2x10-10). Our findings highlight therapeutic strategies and help predict age of onset for at-risk individuals.

13.
medRxiv (Medicine) 2026-06-22

Repeat expansions in Parkinson's disease and parkinsonism across ancestries: insights from a global genetic cohort

Expanded short tandem repeats contribute to a broad spectrum of neurodegenerative diseases, yet their roles in Parkinson's disease (PD) and parkinsonism remain incompletely characterized, especially across diverse ancestries. We analyzed short-read whole-genome (WGS) and clinical exome sequencing (CES) data from 38,365 individuals (28,861 WGS; 9,504 CES), encompassing 23,242 patients with PD, 4,729 patients with atypical parkinsonism and 10,394 healthy controls from 11 genetic ancestries. To determine carrier frequencies and characterize repeat structures across diverse ancestries, we genotyped 12 established pathogenic loci where normal, intermediate, and pathogenic alleles can be reliably differentiated using short-read sequencing data. Additionally, we conducted threshold-based associations to determine the minimum threshold associated with increased PD risk in 15,995 individuals (8,591 PD, 7,404 controls) of European ancestry. Pathogenic repeat expansions were detected in 62 patients (56 PD and 6 atypical parkinsonism) and 5 controls across seven loci (AR, ATXN1, ATXN2, ATXN3, CACNA1A, HTT and THAP11), spanning seven ancestries. Among these, ATXN2 expansions were the most frequently observed in PD and were present in African, East Asian, European and Middle Eastern ancestries. Additionally, intermediate ATXN2 repeat expansions exhibited a strong, length-dependent association with PD risk in the European population, with individuals with [&ge;]32 repeats having a more than four-fold increased risk (odds ratio 4.25, 95% confidence interval 1.80-12.05). Overall, >92% of expanded alleles harbor CAA interruptions within the CAG tract. Pathogenic expansions at other loci, such as ATXN3 and THAP11, showed more ancestry-specific distributions. Clinically, individuals with pathogenic ATXN2 and ATXN3 expansions most often presented with typical PD features but frequently showed earlier disease onset and a strong family history of PD. This large-scale, multi-ancestry study comprehensively maps the genetic landscape of pathogenic and intermediate repeat expansions in PD. Our findings confirm a length- and structure-dependent risk association for ATXN2 with PD in the European population, and highlight the pleiotropic effects of repeat expansions across the parkinsonian spectrum.

14.
medRxiv (Medicine) 2026-06-22

AFFORDABILITY OF INTOXICATION FROM CHEAP ETHANOL: EVIDENCE FROM RETAIL ALCOHOL MARKETS IN UGANDA

Background: Alcohol affordability is a determinant of consumption and alcohol-related harm. In many low- and middle-income countries (LMICs), informal production, variable alcohol strength, and non-standard packaging complicate conventional affordability measures, limiting evidence on the economic accessibility of alcohol and the cost of intoxication. Objective: To assess the affordability of intoxication in Uganda by estimating the cost of obtaining ethanol to reach intoxication across alcohol products, packaging types, and retail contexts. Methods: Data were collected on 824 alcoholic beverages from urban, rural, and urban-slum retail markets. Ethanol-standardized pricing (price per gram of alcohol) was calculated, and the cost of consuming 60 g of ethanol was estimated. Multivariate regression identified determinants of ethanol affordability. Results: Affordability varied by product type and packaging. Opaque beers and illicit spirits provided the cheapest pathways to intoxication, with median costs of UGX 1,200-1,500 per 60 g of ethanol. Plastic packaging was associated with lower ethanol costs than glass packaging. Ethanol prices differed across formal and informal markets (p < 0.01), while rural areas and urban informal settlements had 20-25% lower costs than urban areas. Regulatory status alone did not predict affordability. Conclusions: In Ugandas diverse alcohol market, affordability is driven by access to ethanol rather than beverage price alone. Low-cost, high-strength alcohol sold through informal channels enables intoxication at minimal expense, among disadvantaged populations. Implications: Alcohol policies should target ethanol content through minimum unit pricing, alcohol-content-based taxation, and regulation of informal markets and packaging practices to reduce harmful consumption and inequities.

15.
medRxiv (Medicine) 2026-06-22

''Circumstantial Determinants'': An Efficient Approach to Reaching People in Need of HIV Prevention?

HIV prevention and testing programmes primarily reach people who self-refer or attend routine health services. Higher-risk individuals are missed if they are healthy, under-estimate their risk of infection or under-report sexual risk-behaviours. We assess a new approach to address limitations in existing programmes by targeting HIV services on ''Circumstantial Determinants'' (CDs) of HIV risk - the social circumstances, settings, and norms associated with behaviours that increase risk of HIV acquisition. Data on potential CDs and sexual behaviour were collected in a population survey in Zimbabwe in 2018/19 (N=9141). HIV-negative individuals reporting [&ge;] 1 sexual risk-behaviours were defined as the 'priority population' for HIV prevention. For each sex, six circumstantial determinants were associated with being in the priority population (aOR [&ge;] 1.30; p [&le;] 0.01). Reach and efficiency of CDs (and combinations) were calculated; ROC curve algorithms evaluated their ability to identify priority population membership; and HIV prevention condom cascades were compared between CD-defined priority population subgroups. Example findings include that targeting men at bars and beerhalls could reach 48.5% of the priority population and 25.1% of lower-risk men. These percentages increase to 77.1% and 53.7% if men with poor mental health, no religious affiliation, negative social capital, or living on agricultural estates are also targeted. Targeting women with poor mental health could reach 32.0% of the priority population and 21.3% of lower-risk women. Targeting additional circumstantial determinants increases these percentages to 54.1% and 37.5%, respectively. Cascade barriers to condom use differed between CD-defined subgroups. The Circumstantial Determinants approach demonstrates proof-of-concept potential to strengthen HIV prevention services.

16.
medRxiv (Medicine) 2026-06-22

Accounting for uncertainty in the expected treatment effect substantially increases the sample size required for randomised trials: implications for the feasibility of clinical trials in anaesthesia and critical care

Background Multicentre trials in anaesthesia and critical care report low rates of statistically significant differences. This finding may partly reflect conventional sample size methods, which assume a fixed treatment effect. Assurance methods use a design prior to represent uncertainty in the expected treatment effect, which may provide a more realistic way of estimating sample sizes. Methods We calculated power curves across a range of effect sizes, design priors, and sample sizes using frequentist and Bayesian assurance methods and compared the sample sizes required to achieve 80% and 90% power to the conventional method. We standardised the design priors across effect sizes using the coefficient of variation. We derived a theoretical limit for achievable power. We validated a normal approximation to the Bayesian posterior distribution. Results Frequentist and Bayesian assurance methods produced similar power curves across all scenarios. At a coefficient of variation of 0.5 - reflecting realistic prior uncertainty in the expected effect size - both methods required sample sizes that were approximately 1.5 to 3.5 times larger than the conventional method. The theoretical power limit depends only on the coefficient of variation of the design prior and holds true across all effect sizes. The normal approximation to the Bayesian posterior distribution matched the results obtained from Markov chain Monte Carlo sampling. Conclusions Incorporating clinical uncertainty in the expected effect size substantially increases the sample size required to achieve adequate power, which has important implications for the feasibility of randomised trials in anaesthesia and critical care.

17.
medRxiv (Medicine) 2026-06-22

The impact of changes in age-based eligibility criteria on seasonal influenza vaccine uptake in England between 2019 and 2024: A retrospective cohort study

Objectives: To examine changes in seasonal influenza vaccine uptake among clinical risk groups over periods of differing age-based eligibility. Design: Retrospective cohort study. Setting: Individuals in England registered in the Clinical Practice Research Datalink Aurum. Participants: Between 1,239,802 (2019/20) and 1,289,330 (2023/24) individuals aged 40-69 years in clinical risk groups. Interventions: Natural experiment involving temporary expansion of age-based eligibility for influenza vaccination to include 50-64-year-olds from 2020/21 to 2022/23. Main outcome measures: Influenza vaccine uptake from 1st September to 28th February, incidence rate ratio (IRR) of vaccine uptake across consecutive seasons within age groups, and the ratio of IRRs between age groups. Results: Influenza vaccine uptake increased in all age groups in 2020/21 relative to 2019/20. The increase was larger in individuals aged 50-64 years (13.3%; IRR 1.50, 95% CI 1.50-1.51) compared with those aged 40-49 years (8.3%; IRR 1.35, 95% CI 1.34-1.35) and 65-69 years (6.8%; IRR 1.34, 95% CI 1.33-1.35). From 2020/21 to 2022/23, vaccine uptake decreased, with a more pronounced decline among those aged 40-49 years (-5.4%) compared with age-eligible groups (50-64 years: -3.0%; 65-69 years: -3.1%). The reversion of age eligibility in 2023/24 was associated with a larger decrease in uptake among those aged 50-64 years (-9.6% vs 2022/23; IRR 0.79, 95% CI: 0.79-0.79) compared with those aged 40-49 years (-4.9%; IRR 0.87, 95% CI: 0.87-0.88) and 65-69 years (-3.3%; IRR 0.97, 95% CI: 0.96-0.97). Patterns were broadly consistent across clinical risk groups. Conclusions: The COVID-19 pandemic saw a general increase in seasonal influenza vaccine uptake in clinical risk groups. This increase was larger and more sustained in 50-64 year-olds who had also become eligible based on age. Our findings highlight the potential gains in vaccine coverage among clinical risk groups based on expanded age-based eligibility.

18.
medRxiv (Medicine) 2026-06-22

Body composition subphenotypes, cardiometabolic risk and incident outcomes: validation in the population-based NAKO and UK Biobank imaging cohorts

Background Anthropometric measures do not adequately capture heterogeneity in body fat distribution and corresponding cardiometabolic risk, whereas magnetic resonance imaging (MRI) enables precise differentiation and quantification of adipose tissue compartments and ectopic fat. We aimed to validate previously derived MRI-based body composition subphenotypes and their cardiometabolic risk profiles in two independent European cohorts. Methods Using deep learning-based image analysis, we quantified bone marrow, visceral, subcutaneous, cardiac, renal sinus, hepatic, skeletal muscle, and pancreatic fat in the imaging substudies of two population-based cohorts: the German National Cohort (NAKO, N=29,314, age range 19-74 years) and the UK Biobank (N=36,109, age range 40-69 years). Body composition subphenotypes, previously identified by k-means clustering, were evaluated using a rigorous statistical cluster validation framework with method-based and results-based approaches. In NAKO, cross-sectional associations between subphenotypes and estimated cardiovascular disease risk scores were examined using linear regression. In UK Biobank, longitudinal associations between subphenotypes and incident cardiometabolic outcomes, ascertained through hospital record linkage, were analysed using Cox regression. Findings All five body composition subphenotypes were robustly validated across both cohorts, and showed distinct fat distribution patterns and cardiometabolic risk profiles: I "lean", II "average adiposity", III "bone and muscle adiposity", IV "hepato-abdominal adiposity", and V "general and pancreatic adiposity". Subphenotypes I-III showed progressive adipose tissue remodelling patterns likely reflecting ageing trajectories. The "hepato-abdominal adiposity" subphenotype showed highest risk of incident diabetes, whereas the "general and pancreatic adiposity" subphenotype showed highest overall cardiovascular disease burden and metabolic impairment. Interpretation MRI-derived body composition subphenotypes represent distinct fat distribution patterns that reflect ageing- and disease-related processes, which supports the potential of body composition phenotyping for improved cardiometabolic risk stratification and targeted prevention.

19.
medRxiv (Medicine) 2026-06-22

Burden of Cardiovascular Disease in Brazil, 1996-2023: A Retrospective Descriptive Study of the Epidemiology and Impact on Public Healthcare with Emphasis on Acute Myocardial Infarction

Background Cardiovascular diseases (CVD) are the leading cause of death worldwide, and their epidemiology is correlated with genetic predisposition, exposure to risk factors, sex, age, access to medical care, and other sociodemographic characteristics. Brazil is a developing country with a vast territory, which leads to structural inequalities. Estimates of CVD in Brazil, in its regions, and in its population are poorly evaluated and analysed. Methods We obtained CVD-related data from the Brazilian Unified Health System (SUS) and analysed mortality and morbidity from 1996 to 2023 by sex, race/ethnicity, age, and region. We calculated the risk of death from the most prevalent diseases, the average length of hospital stay, and the costs associated with heart transplantation. Findings In Brazil, acute myocardial infarction was the pathology that led to the highest number of deaths across all variables analysed during the evaluated period. Other CVD were also related to causes of death and morbidity, such as hypertensive diseases and heart failure. Interpretation Brazil presents a serious challenge to the public health system due to the high number of deaths and the progressive mortality rate. This study represents a fundamental contribution to the basis for formulating public health policies aimed at reducing the growing impact associated with these diseases. Funding CNPq, CAPES, FAPEMIG, INCT

20.
medRxiv (Medicine) 2026-06-22

Survival differences and artemisinin resistance in severe malaria among HIV coinfected patients: data from Mozambique

Abstract Background Malaria remains a significant cause of morbidity and mortality, especially in sub-Saharan Africa, where rates of HIV coinfection are high. This study aimed to determine whether Plasmodium falciparum malaria treatment outcomes and rates of antimalarial resistance markers differ according to HIV serostatus in Mozambique. Methodology We conducted an observational study of non-pregnant adults, with and without HIV coinfection, admitted to the Hospital Central de Maputo for treatment of severe malaria. Plasmodium falciparum DNA was extracted from whole blood and sequenced to identify single-nucleotide polymorphisms. Statistical analyses to compare clinical outcomes and rates of nonsynonymous mutations in genes associated with drug resistance were performed in R version 4.2. Results We recruited 149 study participants aged between 18-62 years, 72 (48.3%) were female, and 59 (39.6%) were infected with HIV. Comparing clinical outcomes, we found a significant difference in anemia (hemoglobin

21.
Nature (Science) 2026-06-22

Cancer cells adopt unprecedented strategies to produce a molecule that protects them from iron-dependent death

The finding that spermine molecules in cells bind to iron to prevent it unleashing ferroptosis, a type of cell death, opens up strategies for treating tissue damage and cancer. The finding that spermine molecules in cells bind to iron to prevent it unleashing ferroptosis, a type of cell death, opens up strategies for treating tissue damage and cancer.

22.
medRxiv (Medicine) 2026-06-22

Toward less intrusive pubertal assessment: longitudinal evaluation of tanner and non-tanner metrics in East African adolescents

Background: Accurate pubertal assessment is essential in pediatric endocrinology and adolescent health research. While Tanner staging remains the gold standard, its subjective nature and invasive genital examination limit feasibility and acceptability, especially in longitudinal studies and culturally sensitive settings. This study evaluated less intrusive pubertal assessment combinations that maintain discriminative accuracy. Methods: We conducted a longitudinal study among 200 uncircumcised, sexually naive males aged 15-17 years in Southwestern Uganda, with quarterly follow-up over three years. Clinicians assessed Tanner staging metrics (pubic hair, testicular volume, penile length, scrotal color), axillary hair, and serum testosterone. Markov transition models estimated Tanner stage progression. Ordinal logistic regression and area under the receiver operating characteristic curve (AUC) analyses quantified discriminative performance of individual and combined metrics. Results: At baseline, participants were distributed across Tanner stages II (6.0%), III (13.5%), IV (55.0%), and V (25.5%). Among individual metrics, pubic hair distribution best predicted overall Tanner stage (AUC=0.867), while penile length was least predictive (AUC=0.833). The full four-metric Tanner model achieved high discrimination (AUC=0.993). However, a less intrusive combination of pubic hair and scrotal color achieved comparable discrimination (AUC=0.942), improving to AUC=0.953 with axillary hair and age. Markov modeling demonstrated frequent bidirectional transitions between Tanner stages IV and V, reflecting variability in longitudinal staging. Conclusions: A minimally intrusive assessment combining pubic hair, scrotal color, axillary hair, and age reliably predicts pubertal stage, offering an acceptable alternative to traditional Tanner staging for research and surveillance contexts where genital manipulation is impractical or unethical.

23.
medRxiv (Medicine) 2026-06-22

Effectiveness of Stress Management to Reduce Stress Eating for Women: A Systematic Review and Meta-analysis of Intervention Studies

Objective: This systematic review and meta-analysis examined 1) the effects of stress management interventions on changes in stress eating for women, and 2) the longevity of these effects, by summarizing and assessing evidence from controlled and non-equivalent pretest-posttest intervention studies. Method: Five databases (PsycINFO, PubMed, Medline, Web of Science, CINAHL), existing sources, and grey literature were searched (February - June 2025). Studies that assessed stress eating or emotional eating, included a stress management intervention, and comprised at least 70% women were included. The primary outcome was reduction in stress eating. Data were pooled in meta-analyses using multi-level random-effects models and subset by follow-up period. Risk of bias was assessed via funnel plots and sensitivity analyses. Results: Sixty studies with 119 effect size estimates were included in the primary analysis. Pooled estimates indicated that stress management interventions significantly reduced stress eating (Hedges g = -0.4174, p < 0.001), with pre-post designs having larger effects than controlled trials. Subgroup analyses of follow-up periods found small effects in the short-term (before 3 months; Hedges g = -0.4202, p < 0.0001) and moderate effects for mid-term (3-6 months; Hedges g = -0.5886, p < 0.0001). Effects beyond 6 months were small and nonsignificant (Hedges g = -0.4370, p = 0.0660). Conclusion and Relevance: Stress management interventions appear to be effective for reducing stress eating for women, suggesting the potential to incorporate stress management in interventions targeting obesity. Effects may be only sustained 6 months post-intervention, suggesting the need for strategies to bolster long-term effectiveness.

24.
medRxiv (Medicine) 2026-06-22

How knowledge shapes community stigma and social support for women seeking abortion in the Democratic Republic of Congo: A cross-sectional study.

Background The Democratic Republic of Congo (DRC) bears one of the highest maternal mortality ratios globally (746 per 100,000 live births), with nearly 11% of deaths attributable to complications of unsafe abortion. Despite ratification of the Maputo Protocol and related national policies, access to safe abortion remains limited, largely due to entrenched stigma. Social support, encompassing emotional, informational, and instrumental assistance, is critical in shaping womens abortion-seeking behaviors and health outcomes. This study examines the influence of community-level knowledge on stigma and social support for women seeking abortion care. Methods A cross-sectional survey was conducted from May 2024 to June 2024 among 1,715 adults in Kinshasa and North Kivu provinces. Analyses focused on a sub-sample of 574 respondents reporting familiarity with women who had undergone abortion. Structural Equation Modeling (SEM) was applied to estimate direct and indirect pathways linking community knowledge, stigma, and social support. Results Two core knowledge indicators, recognition of abortion as a safe medical procedure and awareness of legal conditions for access, were significantly associated with outcomes. A one-unit increase in knowledge corresponded to a 0.39-point increase in social support and a 0.19-point reduction in stigma. Enhanced knowledge promoted empathetic attitudes, reinforced practical support, and mitigated moralizing judgments toward women seeking abortion. Conclusions Strengthening community knowledge emerges as a strategic lever to reduce abortion-related stigma and enhance social support in the DRC. These findings underscore the importance of integrating stigma-reduction and knowledge-enhancement interventions into reproductive health programs to improve womens access to safe and dignified abortion care.

25.
medRxiv (Medicine) 2026-06-22

Knowledge, Attitudes, and Practices Regarding Maternal Nutrition Counselling Among Frontline Health Workers in Udupi, Karnataka, India: A Sequential Explanatory Mixed-Methods Study

Background Indias maternal nutrition profile is undergoing a dual-direction shift, with persistent undernutrition coexisting alongside rising overweight and micronutrient deficiencies. Despite national efforts through Integrated Child Development Services (ICDS) and the National Health Mission (NHM), maternal dietary diversity remains suboptimal in India. Frontline health workers (FLWs) play a central role in delivering nutrition counselling; however, gaps remain between knowledge and its translation into practice, highlighting the need to strengthen training, applied competencies, and health system support within primary care settings. Objective To assess knowledge, attitudes, and practices (KAP) regarding maternal nutrition counselling among FLWs and to explore contextual factors influencing counselling delivery. Methods A sequential explanatory mixed-methods study was conducted in Udupi, Karnataka, India. In phase one, 46 FLWs- Accredited Social Health Activists (ASHA), Community Health Officers (CHO), and Primary Health Care Officers (PHCO) completed a validated Knowledge, Attitudes, and Practices (KAP) questionnaire. Data were analysed using descriptive statistics, Kruskal-Wallis test, Spearman correlation, and exploratory multiple linear regression. In phase two, one focus group discussion with 21 participants was conducted and analysed using reflexive thematic analysis. Results FLWs demonstrated moderate KAP scores (37.50 {+/-} 5.09), with lower scores observed in dietary diversity knowledge and counselling practices. CHOs and PHCOs had significantly higher knowledge (p < 0.001) and practice scores (p = 0.002) compared to ASHAs, while attitudes were similar across cadres. Knowledge was positively associated with practice ({rho} = 0.389, p = 0.008). Exploratory regression indicated that cadre and knowledge were associated with practice, while attitude was not statistically significant. Qualitative findings suggested that counselling was largely protocol-based and constrained by workload, limited counselling tools, economic barriers, and cultural food practices. Conclusion Despite positive attitudes towards maternal nutrition counselling, frontline health workers demonstrated gaps in knowledge and counselling practices. Mixed-methods findings suggest that counselling delivery is shaped by both provider competencies and health-system constraints, highlighting the need for implementation-focused strategies to strengthen maternal nutrition counselling in routine antenatal care.