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We performed a comprehensive systematic review and meta-analysis of repetitive transcranial magnetic stimulation (rTMS) to explore its use as an adjunctive therapy for adult patients with drug-resistant epilepsy (DRE). Following PRISMA guidelines, PubMed and Ovid MEDLINE databases were searched until January 2025 for English-language studies reporting pre- and post-rTMS seizure frequencies and detailed protocols in adult patients with DRE. Random-effects meta-analyses pooled standardized mean differences in weekly seizure frequency at immediate, 4-week, and 8-week follow-ups. Risk of bias was assessed using the Joanna Briggs Institute (JBI) critical appraisal tools, and evidence certainty was graded using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) and Oxford Centre for Evidence-Based Medicine (OCEBM) frameworks. 12 studies involving 150 participants were included, with seven contributing to the meta-analysis. Meta-analysis demonstrated a small but statistically significant reduction in seizure frequency at 4 and 8 weeks following rTMS (pooled SMD -.49 [95% CI -.98 to -.01, p = .46] and -.19 [95% CI -.35 to -.02, p = .91]), with insignificant heterogeneity (I2 = 0%). In contrast, no statistically significant difference was observed immediately after rTMS (pooled SMD .19 [95% CI -1.69 to 1.31, p = .38]). Common adverse effects included headaches (14%-33%) and hearing problems (9%-14%). Quality of life improved significantly in two of three studies, and one study reported depression improvement in 67% of participants. Risk of bias was low in three studies, moderate in five, and high in four. rTMS use as adjunctive therapy for DRE demonstrated moderate (GRADE level 2) and low-quality (OCEBM level 3) evidence. rTMS was associated with modest reductions in seizure frequency in selected populations. However, effect sizes were small and heterogeneous. Larger, prospective, multicenter studies are needed to further evaluate its efficacy. International Prospective Register of Systematic Reviews (PROSPERO) (ID #CRD42024553998).

Geo-information extraction from satellite imagery has become crucial to carry out large-scale ground surveys in a short amount of time. With the increasing number of commercial satellites launched into orbit in recent years, high-resolution RGB color remote sensing imagery has attracted a lot of attention. However, because of the high cost of image acquisition and even more complicated annotation procedures, there are limited high-resolution satellite datasets available. Compared to close-range imagery datasets, existing satellite datasets have a much lower number of images and cover only a few scenarios (cities, background environments, etc.). They may not be sufficient for training robust learning models that fit all environmental conditions or be representative enough for training regional models that optimize for local scenarios. Instead of collecting and annotating more data, using synthetic images could be another solution to boost the performance of a model. This article proposes a GAN-assisted training scheme for road segmentation from high-resolution RGB color satellite images, which includes three critical components: (a) synthetic training sample generation, (b) synthetic training sample selection, and (c) assisted training strategy. Apart from the GeoPalette and cSinGAN image generators introduced in our prior work, this article explains in detail how to generate new training pairs using OpenStreetMap (OSM) and introduces a new set of evaluation metrics for selecting synthetic training pairs from a pool of generated samples. We conduct extensive quantitative and qualitative experiments to compare different image generators and training strategies. Our experiments on the downstream road segmentation task show that (1) our proposed metrics are more aligned with the trained model performance compared to commonly used GAN evaluation metrics such as the Fréchet inception distance (FID); and (2) by using synthetic data with the best training strategy, the model performance, mean Intersection over Union (mean IoU), is improved from 60.92% to 64.44%, when 1,000 real training pairs are available for learning, which reaches a similar level of performance as a model that is standard-trained with 4,000 real images (64.59%), i.e., enabling a 4-fold reduction in real dataset size.

Inhaled corticosteroid (ICS) is the mainstay therapy for asthma, but general adherence is low. There is a paucity of real-world inhaler prescribing and adherence data from Asia and at the population level. To address these gaps, we performed a real-world data analysis of inhaler prescribing pattern and adherence in a multi-ethnic Asian asthma cohort and evaluated the association with asthma outcomes. We performed a retrospective analysis of adult asthma patients (aged ≥18 years) treated in the primary and specialist care settings in Singapore between 2015 to 2019. Medication adherence was measured using the medication possession ratio (MPR), and categorised into good adherence (MPR 0.75-1.2), poor adherence (MPR 0.75) or medication oversupply (MPR > 1.2). All statistical analyses were performed using R Studio. 8023 patients, mean age 57 years, were evaluated between 2015 and 2019. Most patients were receiving primary care (70.4%) and on GINA step 1–3 therapies (78.2%). ICS-long-acting beta-2 agonist (ICS-LABA) users increased over the years especially in the primary care, from 33% to 52%. Correspondingly, inpatient admission and ED visit rates decreased over the years. Between 2015 and 2019, the proportion of patients with poor adherence decreased from 12.8% to 10.5% (for ICS) and from 30.0% to 26.8% (for ICS-LABA) respectively. Factors associated with poor adherence included minority ethnic groups (Odds ratio of MPR 0.75–1.2: 0.73–0.93; compared to Chinese), presence of COPD (OR 0.75, 95% CI 0.59–0.96) and GINA step 4 treatment ladder (OR 0.71, 95% CI 0.61–0.85). Factors associated with good adherence were male gender (OR 1.14, 95% CI 1.01–1.28), single site of care (OR 1.22 for primary care and OR 1.76 for specialist care), GINA step 2 treatment ladder (OR 1.28, 95% CI 1.08–1.50). Good adherence was also associated with less frequent inpatient admission (OR 0.91, 95% CI 0.84–0.98), greater SABA overdispensing (OR 1.66, 95% CI 1.47–1.87) and oral corticosteroids use (OR 1.10, 95% CI 1.05–1.14). Inhaled corticosteroid (ICS) adherence has improved generally, however, poor adherence was observed for patients receiving asthma care in both primary and specialist care, and those from the minority ethnicities.

Please confirm that an ethics committee approval has been applied for or granted: Not relevant (see information at the bottom of this page)Background and AimsMedulloblastomas are one of the most common malignant brain tumours in the paediatric population. Originating from the cerebellum, they have the potential to spread to other areas of the central nervous system, and can be very aggressive. Symptoms can be particularly debilitating in the terminal period, with refractory headaches, nausea and vomiting, and altered mental status that adversely affect the patient‘s quality of life.MethodsWe present the case of a 5-year-old boy with terminal medulloblastoma who was referred to the paediatric pain team for symptom relief. He had undergone surgical resection followed by adjuvant chemoradiotherapy prior to this but experienced an eventual relapse of the disease. The oncological team had assessed his disease to be terminal with a palliative intent of treatment. The main symptom that was causing him significant distress was severe headaches throughout the day that was refractory to conventional treatment modalities.ResultsHe was already on high doses of multiple analgesia, including morphine, ketamine and clonidine. However the intensity of his headaches persisted while the side-effects of these medications were becoming increasing pronounced with drowsiness, nausea and vomiting. As a result of this, he was either very drowsy or in severe pain most of the time, which limited his function and quality of life. After a multi-disciplinary discussion with the palliative team, a tailored analgesia plan was introduced which included opioid rotations and methadone.ConclusionsTerminal medulloblastoma can be particularly debilitating. A comprehensive multi-modal analgesia plan should aim to limit adverse effects of drugs to maximise quality of life.

The aims of this systematic review and meta-analysis are to synthesise quality of life (QOL) of family caregivers of children and young adults with Down syndrome (DS) and determine factors affecting their QOL. This review was conducted as per Preferred Reporting Items for Systematic Reviews and Meta-Analyses guideline. Key search terms were "quality of life", "down syndrome" and "trisomy 21". Meta-analysis using random effect model was conducted where feasible. All studies underwent qualitative synthesis. The study protocol was registered with PROSPERO (CRD42023413532). Eighteen studies with 1956 caregivers were included. Of the 10 studies utilising the World Health Organization Quality of Life Instrument-Brief Version, 5 were included in the meta-analysis. Psychosocial domain had the highest score with mean (95% confidence interval [CI]) of 63.18 (39.10-87.25). Scores were poorer in physical, environmental and social domains: 59.36 (28.24-90.48), 59.82 (19.57-100.07) and 59.83 (44.24-75.41), respectively. Studies were heterogenous with I2 values ranging from 99-100% (P<0.01). The remaining 8 studies used 6 other instruments. Qualitative synthesis revealed that caregivers' QOL was adversely affected by child-related factors, such as level of functional independence, developmental delay, presence of multiple comorbidities, impaired activities of daily living and poor sleep quality. Environmental factors that adversely affected caregivers' QOL included number of children, housing and support from the family. Personal factors that affected caregivers' QOL included age, being a single mother, low education and low income. QOL of caregivers of children with DS was lower than population reference data. Understand-ing the factors that influence family caregivers' QOL is an essential step towards improving the QOL of caregivers and their children with DS.

BackgroundThe working population encounters unique work-related stressors. Despite these challenges, accessibility to mental healthcare remains limited. Digital technology-enabled mental wellness tools can offer much-needed access to mental healthcare. However, existing literature has given limited attention to their relevance and user engagement, particularly for the working population.AimThis study aims to assess user perceptions and feature utilisation of mindline at work, a nationally developed AI-enabled digital platform designed to improve mental wellness in the working population.MethodsThis study adopted a mixed-methods design comprising a survey (n=399) and semistructured interviews (n=40) with office-based working adults. Participants were asked to use mindline at work for 4 weeks. We collected data about utilisation of the platform features, intention for sustained use and perceptions of specific features.ResultsParticipants under 5 years of work experience reported lower utilisation of multimedia resources but higher utilisation of emotion self-assessment tools and the AI chatbot compared with their counterparts (p<0.001). The platform received a moderate level of satisfaction (57%) and positive intention for sustained use (58%). Participants regarded mindline at work as an ‘essential’ safeguard against workplace stress, valuing its secure and non-judgmental space and user anonymity. However, they wanted greater institutional support for office workers’ mental wellness to enhance the uptake. The AI chatbot was perceived as useful for self-reflection and problem-solving, despite limited maturity.ConclusionIdentifying the unique benefits of specific features for different segments of working adults can foster a personalised user experience and promote mental well-being. Increasing workplace awareness is essential for platform adoption.

Abstract BackgroundThe risk of HIV transmission during antenatal care (ANC) in Cameroon remains a concern. According to recent studies, the prevalence of HIV in the country is around 4.5%, which increases the likelihood of vertical transmission.ObjectiveTo identify the determinants of HIV infection among pregnant women attending antenatal clinics (ANC) in Cameroon and to estimate HIV seroprevalence.MethodsA cross-sectional study was conducted among ANC attendees aged ≥15 years from September 2022 to June 2023 in 324 health facilities in 08 regions of Cameroon (Adamaoua, Yaounde, East, Far-North, Douala, North, West, South). Sociodemographic and clinical data were collected using questionnaire. HIV screening was performed according to the national algorithm. Estimates of HIV seroprevalence and identification of its determinants using multivariable logistic regression (95% CI) were performed with Excel and SPSS 22 software.ResultsOverall, 10674 pregnant women were enrolled, with median [IQR] age 25 years [21– 30]; 40.0% at a secondary educational level; 44.1% married monogamously; 46.3% multiparous; 38.8% in the second quarter of pregnancy and 16.5% reporting at least one abortion. Overall HIV seroprevalence was 2.6% [95%CI: 2.33; 2.93]. Significantly higher prevalence was found with the regions of Adamaoua (aOR 3.78 [95%CI: 1.87-7.67], p&lt;0.001), East (9.38 [5.6-15.67], p&lt;0.001), North (3.07 [1.74-5.42], p&lt;0.001), South (2.93 [1.66-5.16]; p&lt;0.001); lack of education (2.08 [1.06-4.06], p=0.032), primary education (2.44 [1.32-4.50], p=0.004) and secondary education (2.29 [1.28-4.08], p=0.005) were significantly associated with HIV infection, while monogamous marriage (0.33 [0.22-0.51], p&lt;0.001), the absence of abortion (0.59 [0.37-0.98], p=0.036) and large multiparous (0.38 [0.17-0.82]; p=0.015) were protective.ConclusionDespite the overall low-prevalence among pregnant women at national-level, several factors are associated with HIV in ANC, the absence or low-level of education, being elderly (&gt;30 years), singleness, history of abortion and low parity predicted the HIV status during ANC. Thus, public health interventions towards these at-risk target groups will help to reduce new infections among pregnant women, hence contributing to achieve eMTCT in Cameroon.

Gut microbiome dysbiosis contributes to the pathophysiology of both gestational diabetes mellitus (GDM) and its associated adverse outcomes in the woman and offspring. Even though GDM prevalence, complications, and outcomes vary among different ethnic groups, limited information is available about the influence of ethnicity on gut microbiome dysbiosis in pregnancies complicated by GDM. This pilot prospective cohort study examined the impact of ethnicity on gut dysbiosis in GDM among three Asian ethnic groups (Chinese, Malay, Indian) living in Singapore, and investigated the potential modulatory roles of diet and lifestyle modifications on gut microbiome post-GDM diagnosis. Women with GDM (n = 53) and without GDM (n = 16) were recruited. Fecal samples were collected at 24–28- and 36–40-weeks’ gestation and analyzed by targeted 16S rRNA gene-based amplicon sequencing. Permutational multivariate analysis of variance (PERMANOVA) analysis was performed to evaluate differences between groups. Differentially abundant taxa were identified by DeSeq2 based analysis. Functional prediction was performed using the phylogenetic investigation of communities by reconstruction of unobserved states (PICRUSt2). Among women with GDM, gut microbiome from different ethnicities harbored common microbial features. However, among those without GDM, there was contrasting microbiome composition between ethnic groups. Microbial members such as Collinsella, Blautia, Ruminococcus, Ruminococcus gnavus, Ruminococcus torques, and Eubacterium hallii groups were differentially enriched (p < 0.05) in women with GDM compared to those without. Among women with GDM, no differences in alpha- and beta- diversity were observed when comparing 24–28 weeks’ samples with 36–40 weeks’ samples, a period covering intense dietary and lifestyle modification, suggesting an inability to modulate gut microbiota through classic GDM management. Women with GDM have a distinct gut microbiome profile which harbours common features across different Asian ethnic groups, consistent with the notion that specific microbes are involved in the pathogenesis of insulin resistance, pro-inflammatory conditions, and other metabolic dysregulation known to be present in GDM.