Category: 8. Health

Compared with standard intensive speech and language therapy (iSLT) alone, right-sided cervical C7 neurotomy combined with iSLT significantly improved language function in patients with chronic aphasia after left hemisphere stroke in a randomized controlled trial conducted in China.

Compared with patients who received iSLT alone, patients who received the combined treatment showed statistically significant improvements across all measured outcomes, including naming ability, functional language scores, quality of life, and post-stroke depression, with no severe adverse events.

The results of the study, with first author Juntao Feng, MD, PhD, Fudan University, Shanghai, China, were published online on June 25 in The BMJ.

A Challenging Condition

Chronic aphasia affects more than 60% of stroke survivors beyond the first year, impairing communication and reducing independence. While iSLT remains the standard intervention, its effect is often modest and no adjunct treatment has consistently delivered sustained benefit.

Recent anecdotal findings from C7 nerve transfer surgeries for spastic arm paralysis have hinted at coincidental improvements in language, particularly naming, prompting exploration of targeted neurotomy for chronic aphasia treatment.

Feng and colleagues enrolled 50 patients, aged 40-65 years, with aphasia for more than 1 year after a stroke affecting the left side of the brain, which is responsible for language. Most of the patients also had coexisting spasticity of the right arm.

Half were randomized to right C7 neurotomy at the intervertebral foramen followed by 3 weeks of iSLT and half to iSLT alone.

The primary endpoint was change on the 60-item Boston Naming Test (BNT, scores 0-60, with higher scores indicating better naming ability). BNT assessments occurred at baseline, 3 days, 1 month, and 6 months.

At 1 month, the average increase in BNT score was 11.16 points in the neurotomy plus iSLT group vs 2.72 points in the iSLT-only group — a significant 8.51-point difference (P < .001).

The difference favoring neurotomy add-on remained robust at 6 months (8.26-point difference; P < .001).

Of note, improvement in naming deficits — which are among the most resistant to therapy — were detectable within 3 days after surgery, before iSLT started, suggesting an immediate neuromodulatory effect of the neurotomy itself, the researchers said.

“It could be speculated that neurotomy of the seventh cervical nerve triggered changes in plasticity of the brain regions responsible for language,” they wrote.

Neurotomy was also associated with significant improvement in aphasia severity (difference at 1 month of 7.06 points on the aphasia quotient; P < .001), as well as patient-reported activity of daily life and post-stroke depression.

No major complications or long-term adverse effects were reported. Adverse events that were related to C7 neurotomy included transient neuropathic pain, decreased sensory and motor function in the right upper limb, and minor blood pressure elevations occurred in some patients, but resolved within 2 months post-surgery. No adverse events were noted at 6-month follow-up.

The investigators noted that the study population was limited to relatively young Mandarin-speaking Chinese patients treated at four urban centers, raising questions about generalizability. Additionally, follow-up was limited to 6 months.

The study team plans to follow the participants for 5 years and explore applicability in broader, international cohorts.

Based on their results, they concluded that right C7 neurotomy at the intervertebral foramen plus iSLT is “superior” to iSLT alone for chronic post-stroke aphasia and “could be considered an evidence-based intervention for patients aged 40-65 years with aphasia for more than 1 year after stroke.”

‘Provocative’ Research

Commenting on the study for Medscape Medical News, Larry B. Goldstein, MD, chair of the Department of Neurology and codirector of the Kentucky Neuroscience Institute at the University of Kentucky, Lexington, Kentucky, called the study results “interesting and provocative.” 

“Caveats are that the participants were predominately men (80%), young (about 52 years; much younger than most stroke patients), and a high proportion had brain hemorrhages (about half; in general only 15% of strokes are from bleeding),” Goldstein noted.

“The participants’ primary language was Chinese, and there was no control for medications they might have been receiving that could affect brain function. Additionally, both the participants and the therapists were aware of the treatment group (although the assessors were unaware of group assignment),” Goldstein pointed out.

“With those limitations in mind, the reported data suggests the potential viability of the approach. It will need to be assessed in a more typical population of patients (ie, older, a higher proportion of women, a higher proportion of ischemic stroke), account for medication use, blind therapists to treatment group, and involve participants speaking other languages,” Goldstein told Medscape Medical News.

The author of a linked editorial said the study is “an interesting step forward with room to explore further.” 

“Although intensive SLT remains the cornerstone of aphasia treatment, C7 neurotomy could become a potential adjunctive option for carefully selected individuals in the future,” wrote Supattana Chatromyen, MD, with the Neurological Institute of Thailand, Bangkok, Thailand.

“This research should spark further scientific research and a critical re-evaluation of rehabilitation paradigms and policies for chronic stroke care, fostering a more optimistic and proactive approach to long-term recovery,” Chatromyen concluded.

This study had no commercial funding. Feng, Goldstein, and Chatromyen had no relevant conflicts of interest.

Study setting {9}

The investigation will be carried out by the department of anesthesiology at Suzhou Ninth People’s Hospital, an affiliated hospital of Soochow University. Our hospital’s anesthesiology department is recognized as a key clinical discipline in the region. With around 5000 laparoscopic surgery patients treated annually, the hospital will provide a sufficient patient population to ensure an adequate sample size for the study. Figure 1 illustrates the research workflow.

Eligibility criteria {10}

Inclusion criteria

1. 1.

   Participants aged 18 to 65 years old.

2. 2.

   American Society of Anesthesiologists (ASA) physical status I to III.

3. 3.

   Body mass index (BMI) between 18 and 30 kg/m².

4. 4.

   Scheduled to perform general anesthesia with endotracheal intubation for laparoscopic surgery, including appendectomy, laparoscopic cholecystectomy and laparoscopic hernia repair.

5. 5.

   Expected duration of surgery between 30 and 120 min.

Exclusion criteria

1. 1.

   Sick sinus syndrome or severe bradycardia (heart rate less than 50 beats per minute).

2. 2.

   History of hypertension or cardiac insufficiency.

3. 3.

   Second-degree or higher atrial block without a pacemaker.

4. 4.

   Left ventricular ejection fraction less than 40%.

5. 5.

   Diagnosed with coronary artery disease or history of myocardial infarction.

6. 6.

   Hepatic or renal insufficiency, Child–Pugh class C, or undergoing renal replacement therapy.

7. 7.

   Parkinson’s disease or Alzheimer’s disease.

8. 8.

   Seizures or epilepsy.

9. 9.

   Current pregnancy or lactation status.

10. 10.

    History of persistent pain or prior use of sedatives or analgesics.

11. 11.

    Known allergies to the drugs used in this study.

12. 12.

    Participation in another clinical trial within the past 30 days.

13. 13.

    History of substance abuse.

14. 14.

    Psychiatric illness or current use of antipsychotic medications.

15. 15.

    Communication disorders such as deafness or cognitive impairment.

16. 16.

    Anticipated difficult airway or history of difficult intubation.

Drop out criteria

Participants will not be excluded from the final analysis solely due to adverse events or other post-randomization occurrences. All randomized participants will be included in the intention-to-treat (ITT) analysis.

However, the following circumstances will be considered as dropouts, and the reasons will be recorded in detail:

1. 1.

   Withdrawal of informed consent for continued participation or data use.

2. 2.

   Loss to follow-up before the assessment of primary or secondary outcomes.

3. 3.

   Conversion from laparoscopic to open surgery.

4. 4.

   Use of non-permitted medications, including:

   • – Additional antiemetics not specified in the protocol.

   • – Perioperative corticosteroids.

   • – Sedatives or analgesics outside the study regimen.

5. 5.

   Non-collection of data.

In contrast, the following events will be considered protocol deviations and addressed in sensitivity analyses:

1. 1.

   Non-administration of the study drug.

2. 2.

   Unplanned additional surgical procedures.

3. 3.

   Minor violations of timing or dosage not affecting outcome measurement.

Screening failures (participants who do not meet eligibility criteria before randomization) will be recorded separately and excluded from all analyses. All dropout events and reasons will be meticulously documented in the case report forms (CRFs) and stored for auditing and future reference.

Consent or assent {26a, 26b}

Eligible patients will be approached by research team members, all of whom are licensed medical doctors, to be invited to participate in the study. Detailed instructions regarding the study protocol, procedures, and potential risks and benefits will be provided in clear language. Written informed consent will be obtained from each participant one day prior to surgery to ensure voluntary participation and adequate understanding of the research process.

Explanation for the choice of comparators {6b}

To provide a rigorous comparison, the comparator in this trial is the standard anesthetic regimen routinely used at our institution, consisting of intravenous induction with sufentanil and propofol, followed by maintenance with sevoflurane and a continuous remifentanil infusion. This approach is widely adopted in clinical practice and provides effective intraoperative analgesia with minimal postoperative sedation, making it particularly suitable for laparoscopic surgeries [11, 29]. The intervention group protocol is informed by the principles of OFA, where dexmedetomidine and esketamine are commonly utilized to achieve adequate analgesia and sedation while minimizing opioid exposure. The selected drug combination and administration strategy are based on published OFA studies and adapted for routine clinical application [13, 21, 25]. Given the established link between intraoperative opioid use and PONV, this study aims to determine whether an opioid-reducing approach incorporating these agents can improve PONV outcomes and postoperative recovery compared to the standard opioid-based regimen.

Interventions {11a, 11b, 11c, 11d}

Patients will be randomized into two groups using a computer-generated random number table at a 1:1 ratio, comprising the combination therapy group (dexmedetomidine and esketamine) and the control group. In the combination therapy group, anesthesia induction will involve intravenous infusion of dexmedetomidine (0.5 μg/kg over more than 10 min), followed by intravenous bolus administration of esketamine (0.3 mg/kg), sufentanil (0.2 μg/kg), and propofol (1.5–2.0 mg/kg). Anesthesia will be maintained with 2–3% sevoflurane. In the control group, anesthesia induction will consist of intravenous bolus administration of sufentanil (0.5 μg/kg) and propofol (1.5–2.0 mg/kg), while maintenance will include 2–3% sevoflurane inhalation and continuous intravenous infusion of remifentanil at 0.1 μg/kg/min. The selected remifentanil dose is within the low range and below thresholds typically associated with remifentanil-induced hyperalgesia, as supported by previous studies [30, 31].

All patients will receive 5 mg of dexamethasone intravenously after anesthesia induction, 4 mg of tropisetron at the end of surgery, and 50 mg of flurbiprofen axetil approximately 30 min before surgery completion to prevent PONV and manage postoperative pain. The intraoperative monitoring protocol includes ECG, SpO₂, non-invasive blood pressure, and end-tidal CO₂, with anesthesia depth maintained within a BIS range of 40–60. Vital signs will be continuously monitored using standard multi-parameter monitors. The dosages of anesthetic agents in both groups are derived from published literature and institutional protocols, with remifentanil and sufentanil dosing in the control group based on perioperative anesthesia studies [13, 32], and dexmedetomidine and esketamine dosing in the combination group adapted from opioid-free anesthesia protocols [13, 21].

Postoperative management will also be standardized. Pain and PONV assessments will be conducted at fixed time intervals: 0–6 h (PACU), 6–24 h, and 24–48 h after surgery. Pain intensity will be evaluated using the numerical rating scale (NRS) at 0, 6, 12, 24, and 48 h. Time to first PONV episode, time to first rescue medication use, and total dosage/frequency of rescue analgesics and antiemetics within 48 h will be recorded. Postoperative adverse events such as nightmares, drowsiness, bradycardia, length of hospital stay, and discharge condition will also be documented.

Rescue interventions are standardized. For pain (NRS ≥ 4), 5 mg of dezocine will be administered intravenously. Severe PONV, defined as ≥ 3 vomiting episodes or inability to perform daily activities, will be managed with 10 mg of azasetron; persistent vomiting post-treatment may lead to study withdrawal. Adverse reactions such as esketamine-related nightmares will be treated with 2 mg midazolam, while drowsiness will be managed with observation or opioid antagonists like naloxone in severe cases. Bradycardia (HR < 55 bpm) will be treated with 0.25 mg atropine or 2 μg isoproterenol and anesthetic dose adjustment.

To enhance adherence and consistency, interventions will be performed under general anesthesia, eliminating the need for patient cooperation during drug administration. Postoperative assessments will be carried out by trained personnel at predefined time points using standardized tools. Rescue medication criteria are clearly defined to minimize variability. Preoperative briefings for nursing and anesthesiology teams will ensure uniform postoperative care. The overall trial process, including patient enrollment, treatment, and data collection, will follow the SPIRIT guidelines as detailed in Table 2.

Outcomes {12}

Primary outcome

Postoperative pain and nausea severity will be assessed using the Numerical Rating Scale (NRS), an 11-point scale ranging from 0 (no symptom) to 10 (worst imaginable pain or nausea), based on patient self-report at predefined postoperative intervals. The incidence of nausea will be defined as any self-reported score ≥ 1, while vomiting will be defined as any observed or self-reported episode of forceful expulsion of gastric contents. Both nausea and vomiting episodes will be recorded separately by trained clinical staff through direct observation and/or patient reports. The primary outcome of this study is the incidence of PONV (including both nausea and vomiting) within 48 h after surgery. PONV will be assessed by trained clinical staff during three defined time intervals: 0–6 h, 6–24 h, and 24–48 h postoperatively. Both nausea and vomiting episodes will be recorded separately to allow for detailed analysis.

Secondary outcomes

Preoperatively, the Apfel simplified risk score will be used to evaluate each patient’s baseline risk of PONV, assigning one point for each of the following: female sex, non-smoking status, history of motion sickness or previous PONV, and anticipated postoperative opioid use (total score range: 0–4). The secondary outcomes include:

1. 1.

   Preoperative Apfel PONV risk score.

2. 2.

   NRS pain scores of the patients recorded at 0 h (in the PACU), 6 h, 12 h, 24 h, and 48 h after surgery.

3. 3.

   Time to first PONV episode and time to first rescue antiemetic administration.

4. 4.

   Time to first rescue analgesic administration.

5. 5.

   Total dosage and frequency of rescue analgesics and antiemetics within 48 h.

6. 6.

   Patient satisfaction score at discharge, rated on a 5-point Likert scale.

7. 7.

   Length of hospital stay (in days).

8. 8.

   Discharge condition score, assessed by the attending physician.

9. 9.

   Incidence and classification of AEs.

Participant timeline {13}

The timeline for participant involvement is illustrated in Table 2.

Sample size calculation {14}

In a recent investigation, OFA demonstrated a 65% reduction in the likelihood of PONV following laparoscopic gynecological surgery, decreasing the incidence from 42.5 to 15.0% (10). For the power analysis, we assume a baseline PONV incidence of 40% in laparoscopic surgery under traditional opioid anesthesia. With the hypothesis of a 50% average reduction in PONV, our combination therapy strategy is anticipated to lower the PONV incidence to 25%. To achieve a statistical power of 80% with a bilateral α level of 0.05, 64 patients per group will be deemed necessary to detect intergroup differences in PONV. Considering potential withdrawals, a planned recruitment of 140 patients will be intended, with 70 in each group. The sample size is determined using PASS software (V.11.0.7, NCSS, Kaysville, UT, USA).

Recruitment {15}

Patients participating in this study were enlisted from the anesthesia department. Our recruitment information was disseminated through the WeChat public platform. Additionally, soliciting recommendations from medical personnel constituted a significant aspect of our recruitment efforts. Furthermore, recruitment posters were prominently displayed in areas like the hospital outpatient and inpatient departments.

Allocation {16a, 16b, 16c}

In this study, randomization tables will be generated using IBM SPSS Statistics version 26.0 and maintained by independent statisticians overseeing the trial. Eligible participants will be randomly allocated to either the combination therapy group or the control group in a 1:1 ratio. To ensure allocation concealment, the randomization assignments will be enclosed in sealed, opaque envelopes and securely stored in a designated office. Neither the participants nor the investigators involved in clinical care or outcome assessment will be informed of group assignments, thereby maintaining the double-blind design. In cases of emergency or where clarification is required, only designated researchers will have access to the allocation list. Before surgery, coded study medications will be distributed to study personnel. The allocation sequence will remain confidential, accessible only to the principal investigator (PI) and an independent, unblinded researcher responsible for study drug preparation. The PI will assign participants to treatment groups according to the randomization list, while the unblinded researcher, who will not be involved in drug administration, anesthesia management, or outcome assessment, will prepare the corresponding study medications.

Blinding {17a, 17b}

To maintain double-blinding, each study syringe will be labeled solely with the participant’s unique identification number, without revealing the group allocation. The unblinded researcher, who is not involved in clinical care or outcome assessment, will prepare the study medication according to the randomization list and ensure that all other clinical staff and participants remain blinded throughout the trial. To ensure identical appearance and preserve blinding, both dexmedetomidine and esketamine (or their corresponding placebo components) will be diluted with 0.9% normal saline to a total volume of 20 ml. The final preparations, which are colorless and transparent, will be loaded into identical 20 ml syringes and handed over to the anesthesiologist immediately prior to anesthesia induction. All study personnel involved in clinical care, anesthesia management, outcome assessment, and data collection, as well as the participants themselves, will remain blinded to treatment allocation until data collection is completed and final analyses are conducted. In the event that unblinding is necessary due to medical emergencies or other justified reasons, access to allocation information will be strictly limited to designated personnel responsible for medication distribution.

Data collection methods {18a, 18b}

The subsequent data will be gathered as follows:

Preoperatively

1. 1.

   Patient’s general information (including height, weight, ASA classification, level of education, smoking habits, history of motion sickness, previous opioid use, allergies and surgical history).

2. 2.

   Apfel PONV risk score.

3. 3.

   Baseline NRS pain score.

4. 4.

   Results of laboratory tests.

Intraoperatively

1. 1.

   Hemodynamic parameters (such as NBP, HR, ECG and SpO₂).

2. 2.

   Surgical details (including duration of operation, anesthesia, pneumoperitoneum, dosage and concentration of anesthetic agents administered, blood loss, volume of fluid replacement, urine output, and body temperature).

Post-surgery

1. 1.

   Incidence of nausea and vomiting will be assessed at three intervals: 0–6 h (in the PACU), 6–24 h, and 24–48 h after surgery.

2. 2.

   NRS pain scores will be recorded at 0 h (PACU), 6 h, 12 h, 24 h, and 48 h postoperatively.

3. 3.

   Time to first PONV episode, time to first rescue antiemetic or analgesic administration, and the total dosage and frequency of rescue medications.

4. 4.

   Incidence of AEs.

5. 5.

   Postoperative laboratory results.

6. 6.

   Length of hospital stay and discharge condition.

All patient data will be meticulously recorded in a case report form by a designated independent researcher. These records will then be entered into an electronic database under the careful supervision of the PI. Oversight of data collection will be managed by a Data Monitoring Committee (DMC), with final analysis conducted by impartial statisticians.

To promote participant retention and ensure complete follow-up, investigators will provide a comprehensive explanation of the study protocol and expected outcomes during the preoperative assessment. Efforts will be made to maximize participants’ understanding of the study procedures through detailed instruction and clear guidance, thereby enhancing their compliance and engagement throughout the study period.

Data management {19}

Prior to commencing the study, members of our trial team will undergo training in the collection, management, storage and confidentiality of data to ensure comprehension and compliance with pertinent policies and regulations. Patient data will be securely stored in both paper and electronic formats. Coded paper records will be kept in designated, locked storage areas. Data entry for the study will be conducted using a password-protected Microsoft Access database by two trained team researchers employing a double-entry method, and the accuracy of entries will be verified against the electronic database. To minimize the risk of data loss, researchers will perform incremental backups on a daily basis.

Statistical analysis {20a, 20b, 20c}

The Shapiro–Wilk test will be employed to assess the normality of data distribution. Data will be presented as mean (standard deviation), median (interquartile range), or number (percentage), as appropriate. Descriptive statistics will be used primarily to summarize patient characteristics and baseline variables. Comparative analyses of perioperative variables and outcome measures will be performed using the Mann–Whitney rank sum test, chi-square test, or Fisher’s exact test, depending on data type and distribution. To evaluate the effect of combination therapy versus control, the median difference (MD) or odds ratio (OR) with corresponding 95% confidence intervals (CI) will be calculated.

Subgroup analyses of the primary outcome (PONV incidence) will be conducted based on gender, smoking status, and Apfel PONV risk score. No adjustments will be made for multiple testing in secondary outcome analyses, which will therefore be interpreted as exploratory. All statistical analyses will be conducted using IBM SPSS software (version 19.0; IBM SPSS, Chicago, IL, USA), with two-sided P-values < 0.05 considered statistically significant.

As the administration of study medications will be supervised by anesthesiologists, protocol adherence is expected to be high. Since outcome assessment is scheduled within 48 h postoperatively, the occurrence of missing primary outcome data is anticipated to be minimal. Any missing data will not be imputed.

Data monitoring {21a, 21b}

The data monitoring process for this study will be overseen by the monitoring manager, who is a member of the clinical trial management team at Suzhou Ninth Hospital Affiliated to Soochow University. This individual will be responsible for ensuring the proper preservation of informed consent documents, monitoring participant compliance, and verifying the validity and safety of the study data throughout the trial. Given the short duration of the study, the relatively small sample size, and the anticipated low incidence of serious adverse events (SAEs), no interim analysis is planned.

Harms {22}

All adverse events (AEs) will be closely monitored and documented throughout the perioperative period and until the patient is discharged from the hospital. Based on previous studies [27, 28], these include the following:

1. 1.

   Cardiovascular events: hypotension (systolic blood pressure < 90 mmHg), hypertension (systolic blood pressure > 180 mmHg), bradycardia (heart rate < 50 bpm), tachycardia (heart rate > 120 bpm), arrhythmias.

2. 2.

   Respiratory events: respiratory depression (respiratory rate < 8 breaths/min or SpO₂ < 90%), apnea, bronchospasm.

3. 3.

   Neurological and psychiatric events: emergence delirium or agitation, dizziness, headache, visual or auditory hallucinations, excessive sedation (BIS < 40 or unresponsiveness), seizures.

4. 4.

   Injection site reactions or hypersensitivity: rash, pruritus, swelling, or anaphylaxis.

Each AE will be classified by severity into mild, moderate, or severe according to the Common Terminology Criteria for Adverse Events (CTCAE) v5.0.

Severe adverse events (SAEs) are defined as unanticipated medical incidents that prolong hospitalization, result in persistent disability or dysfunction, pose a life-threatening risk, or cause death. If any SAE occurs, the infusion of dexmedetomidine and esketamine will be immediately discontinued, and the participant will be withdrawn from the study if necessary. All SAEs will be reported promptly to the Ethics Committee, and participants will be followed until the event resolves or stabilizes, or until hospital discharge, whichever comes later.

The attending anesthesiologists and trained research staff will be responsible for managing and recording all AEs and SAEs in the case report forms. An independent Data Monitoring Committee (DMC), composed of clinical experts not involved in the study, will review and categorize all AEs and SAEs according to predefined criteria. If a participant experiences more than three episodes of vomiting despite rescue treatment, or develops any SAE, the case will be considered for withdrawal from the study in accordance with the predefined discontinuation criteria.

Auditing {23}

There will be no plans for conducting formal trial audits.

Research ethics approval {24}

Ethical clearance for this investigation was granted by our hospital’s ethics committee on May 1, 2023 (2,023,067). Subsequently, the research protocol was registered with the China Clinical Trial Registry on June 14, 2023 (ChiCTR2300072455).

Protocol amendments {25}

Should there arise a need for protocol modifications, they will be duly registered at https://www.chictr.org.cn.

Confidentiality {27}

Confidentiality will be maintained for all potential and enrolled patients, with access restricted solely to the principal investigator. Anonymized patients will be assigned unique numerical identifiers (ID numbers) rather than names. Throughout the duration of the experiment, the DMC diligently oversees the database to enhance data integrity. Upon completion of the experiment, researchers will procure the results of statistical data analysis.

The patient sought medical attention a week ago due to sudden onset of generalized fatigue, dysuria, fever, rectal tenesmus, and constipation. The febrile episodes were characterized by recurrent spikes (39.4 °C) and rigors, notably without accompanying cough, sputum production, diarrhea, or cutaneous eruptions. Based on the provisional diagnosis of “hepatic malignancy with pulmonary metastases and superimposed infection” established at the local hospital, the patient received triple antimicrobial therapy with cefazolin sodium (1.5 g q8h IV) + moxifloxacin (0.4 g qd IV) + ornidazole (0.5 g q12h IV). The patient showed no clinical improvement, with persistent signs of sepsis and hypotension, ultimately necessitating transfer to our tertiary center’s ICU for further management.

On admission, the patient appeared critically ill with tachypnea (respiratory rate 30/min), facial flushing, fever (38.9 °C), blurred mind, hypotension (BP 86/55 mmHg), and a pulse of 106 bpm. His qSOFA score was 3 and Glasgow Coma Scale score was 11 (E3, V4, M4). Pulmonary auscultation identified globally diminished breath sounds accompanied by coarse moist rales throughout all lung fields, particularly pronounced in bilateral lower zones. Abdominal inspection noted significant distension with marked tenderness localized to the right upper quadrant, where hepatic and renal angle percussion elicited reproducible pain; notably absent were peritoneal signs or shifting dullness. Bilateral lower extremities exhibited grade 2 pitting edema extending to mid-calf level. Rectal examination detected a 3 × 4 cm soft, exquisitely tender mass occupying the anterior rectal wall, demonstrating localized fullness without evidence of sphincter compromise. In addition, the patient had a 5-year history of type 2 diabetes mellitus (T2DM) that was completely untreated, with no documented history of glycemic monitoring or pharmacologic intervention. Point-of-care (POC) blood glucose testing showed a concentration of 18.2 mmol/L. The patient is administered 8 units of insulin Neutral Protamine Hagedorn daily at 10 PM and 8 units of insulin aspart before breakfast, lunch, and dinner (30 min prior to each meal). Blood glucose is monitored every 2 h with the goal of maintaining levels within normal limits.

The arterial blood gas showed pH 7.48, FiO₂ 41% with electrolytes Na⁺ 129 mmol/L, K⁺ 4.2 mmol/L, Cl⁻ 103 mmol/L. Complete Blood Count shows critical leukocytosis (white blood cell 30.93 × 10⁹/L) with severe anemia (hemoglobin 89 g/L), neutrophilia (absolute neutrophil count 15.64 × 10⁹/L), and decreased red blood cell count (2.95 × 10¹²/L). Biochemistry: Marked abnormalities include albumin 20.8 g/L, C-reactive protein 154 mg/L, and procalcitonin 5.9 ng/mL, with low total protein (54 g/L), alanine aminotransferas (8.8 U/L), and uric acid (119 µmol/L). Urinalysis shows 2 + protein, 2 + white blood cells, and 4 + glucose in the patient’s urine. The patient received empiric imipenem/cilastatin 500 mg q6h + vancomycin 1 g q12h with enoxaparin 1 mg/kg q12h, Fluid resuscitation and nutritional optimization.

Contrast CT scan Showed clots were seen in the right liver vein (Fig. 1A) and left kidney vein (Fig. 1B). Multiple low-density lesions with rim enhancement in the prostate (Fig. 1C) and right liver (Fig. 1A), likely abscesses. Mildly enlarged lymph nodes noted in both groin areas. There were bilateral patchy shadows and nodules in the lungs, a small amount of pleural effusion in the thoracic cavity (Fig. 1D). The cranial CT scan shows no abnormalities in the patient’s brain. The preliminary diagnosis was sepsis and septic embolism (in the right hepatic/left renal vein) secondary to prostatic and hepatic abscesses. Under ultrasound guidance, percutaneous drainage of the right hepatic lobe and transperineal prostatic drainage were sequentially performed, yielding a significant amount of purulent fluid, with subsequent placement of an indwelling catheter in the right hepatic lobe. The drained fluid was sent for bacterial culture and metagenomic next-generation sequencing (mNGS) analysis for pathogen identification.

KP was concordantly detected across blood culture, purulent fluid culture, and mNGS. Furthermore, mNGS analysis detected the presence of resistance genes to third-generation cephalosporins and penicillins in the identified Klebsiella pneumoniae strain. Therapy de-escalated to imipenem monotherapy. Following a two-week targeted therapy regimen, the patient exhibited significant clinical improvement with concomitant normalization of laboratory parameters. Radiological assessment further revealed complete resolution of the septic embolism (Fig. 2A-B). Contrast-enhanced imaging revealed substantial abscess regression (Fig. 2A-C). Concurrent thoracic imaging showed resolving pulmonary infiltrates and minimal residual pleural effusions (Fig. 2D), prompting discharge with scheduled surveillance.

At the 3-month follow-up after discharge, the patient was satisfied with the results of the treatment and has resumed his normal life. The ultrasound examination indicated that the prostate had returned to normal (Figure S1). After adhering to the doctor’s instructions, the patient’s blood glucose levels have been successfully controlled within the normal range. There were no adverse events throughout the process.

This study highlights a concerning prevalence of pediatric HIV among high-risk children admitted to a tertiary care hospital in Sukkur, Sindh. The HIV positivity rate of 9.6% observed in our study is significantly higher than national estimates, which suggest that approximately 2.2% of total HIV cases in Pakistan occur in children under 15 years of age [1]. A striking finding is that none of the HIV-positive children had parents who tested HIV-positive, strongly suggesting a non-vertical (horizontal) route of transmission. Globally, vertical transmission remains the predominant mode, accounting for over 90% of pediatric HIV infections according to UNAIDS and WHO [12]. In contrast, 50% of our cohort had a history of unsafe injection practices and 41.7% had received blood transfusions—indicating possible iatrogenic transmission. This pattern is consistent with the 2019 Larkana outbreak, where most HIV-positive children had HIV-negative mothers and shared histories of repeated injections with unsafe equipment [7, 13].

The gender distribution in our sample showed a slight male predominance (58.3%), consistent with some international data, although no biological rationale is firmly established. This may reflect healthcare-seeking behavior or sampling variation due to the small sample size [12, 14,15,16]. Geographically, most HIV-positive children were from Sindh (75%)—notably Khairpur, Kashmor, Ghotki, and Sukkur—while the remaining 25% were from adjacent districts in Balochistan. These areas share common healthcare challenges: poor immunization coverage, inadequate infection control, and widespread use of informal healthcare services, all of which may contribute to the transmission. This distribution reinforces earlier reports that Sindh carries the highest burden of HIV/AIDS in Pakistan [6].

Clinically, failure to thrive, weight loss, and chronic diarrhea were prominent features, aligning with classical pediatric HIV presentations. It is also concerning that only 33.3% of HIV-positive children were fully vaccinated, increasing their risk of preventable opportunistic infections [6,7,8,9,10,11].

These findings highlight the urgent need for broader HIV screening criteria in pediatric populations, extending beyond children of HIV-positive mothers. The absence of vertical transmission and the strong association with unsafe medical practices call for immediate public health action, including improved infection control, stricter regulation of medical procedures, and safer transfusion protocols.

Tuberculosis co-infection was found in 16.7% of cases—slightly lower than Pakistan’s national estimate of 23% [11]. None of the children tested positive for hepatitis B or C, which differs from findings in adult HIV cohorts. This points to a localized pattern of pediatric HIV transmission, primarily driven by unsafe healthcare practices rather than maternal transmission. Efforts were made to trace all HIV-positive children identified during the study. The corresponding author personally contacted caregivers using mobile numbers from hospital records. One patient had died, and two were successfully referred to the HIV Treatment Center in Larkana for antiretroviral therapy. The remaining families, however, did not follow through with care due to transportation barriers, financial constraints, and stigma. In response, hospital administration has been notified of the HIV burden, and protocols for screening high-risk admissions have been formalized. A formal request has also been submitted to the Sindh AIDS Control Program to establish a dedicated HIV treatment unit in Sukkur, aiming to reduce reliance on referral centers in distant districts.

These findings call for immediate, multi-level interventions. Routine HIV screening should be expanded to include all high-risk pediatric admissions. Infection prevention practices must be reinforced across healthcare facilities. Public education campaigns should target early testing and reduction of stigma. Immunization efforts must be scaled up for vulnerable children. Finally, it is essential to address broader social determinants—poverty, health literacy, and care accessibility—to reduce the pediatric HIV burden in this region.

Subjects

Study population

This study is a retrospective cohort analysis conducted at a single center, utilizing data from 195 consecutive cases of spinal cord injury (SCI) admitted to Huzhou First People’s Hospital in Huzhou City, Zhejiang Province, China, during the period from January 2023 to December 2024.

Inclusion criteria

This study was approved by the hospital ethics committee (approval number: 2022GZB05). All cases that satisfied the inclusion criteria throughout the study period were incorporated through a method of consecutive sampling. The inclusion criteria were as follows: (1)The evaluation of spinal cord injury severity is exclusively grounded in the International Standards for Neurological Classification of Spinal Cord Injury (ISNCSCI), which were updated by the American Spinal Cord Injury Association (ASIA) in 2019.(2) Age > 18 years; (3) Completed assessment of the Post-Traumatic Stress Disorder Self-Rating Scale (PTSD-SS), which has good reliability (Cronbach’s α = 0.92, split-half reliability = 0.95, and retest reliability = 0.87) [11, 12]; (4) No history of psychiatric disorders and no communication barriers; (5) Clinical data were complete (including: ① ASIA ISNCSCI assessment within 24 h of admission; ② MRI/CT of the spine (injury segments/grading); ③ weekly dynamic records of MBI and ASIA grading during the hospitalization period; and ④ PTSD-SS assessment 72 h before discharge).

Exclusion criteria

Patients meeting any of the following criteria were excluded: (1) History of SCI or related surgical procedures; (2) Coagulation disorders or infectious diseases; (3) Major life events within the past six months (e.g., bereavement, divorce, or natural disasters); (4) Psychiatric disorders, mental illness or relevant medical history; (5)Severe cardiovascular or cerebrovascular diseases, malignancies, or other serious conditions; (6) Neurological diseases unrelated to SCI, such as stroke, Parkinson’s disease, or Guillain-Barré syndrome; (7) Critically ill patients or those with excessive emotional distress preventing PTSD assessment.

Data collection

General patient information was collected, including age, sex, marital status, personal income level, and educational background. Clinical data included injury-related factors (cause of injury, severity of spinal cord injury, and estimated rehabilitation outcome) and complications (number of complications, pulmonary and urinary tract infections, pressure ulcers, deep vein thrombosis, autonomic nervous system dysfunction, and psychological disorders). The degree of spinal cord nerve injury is consistent with the American Spinal Cord Injury Association (ASIA) classification of injury. The PTSD Self-Rating Scale (PTSD-SS) consists of 24 items assessing five dimensions: subjective evaluation of the traumatic event, recurrent intrusive experiences, avoidance symptoms, heightened arousal, and impaired social functioning. Scores range from 24 to 120, with a total score of ≥ 50 indicating PTSD. Scores between 50 and 59 suggest mild PTSD, while scores of ≥ 60 indicate moderate to severe PTSD. PTSD incidence was analyzed, and patients were categorized into PTSD and non-PTSD groups accordingly.

Observational indicators

Differences in demographic characteristics, including age, sex, marital status, personal income level, and educational background, were analyzed between the PTSD and non-PTSD groups. Clinical factors, such as cause of injury, severity of spinal cord injury, expected rehabilitation outcomes, and complications, including the number of complications, pulmonary and urinary tract infections, pressure ulcers, deep vein thrombosis, autonomic nervous system dysfunction, and psychological disorders, were also compared. Factors showing significant differences were further analyzed using multivariate logistic regression.

Statistical analysis

Statistical analysis was performed using SPSS 26.0 (IBM Corp. Released 2019. IBM SPSS Statistics for Windows, Version 26.0. Armonk, NY: IBM Corp). Categorical variables, including demographic characteristics, injury-related factors, and complications, were expressed as percentages (%). The chi-square test was used to identify factors with statistically significant differences, which were subsequently analyzed using multivariate logistic regression.

Trial objective and study design

This study aims to evaluate whether combining oxytocin administration with mindfulness-based training can facilitate stress regulation in adults with heightened stress complaints, compared to each intervention delivered as a stand-alone treatment. A randomized, double-blind, placebo-controlled clinical trial will be conducted, in which 120 adults will be randomly assigned to one of the following four treatment groups (30 participants per group):

• (1) Oxytocin + Mindfulness-based intervention (MBI) (combined treatment group)

• (2) MBI + Placebo (MBI as stand-alone)

• (3) Oxytocin (oxytocin as stand-alone)

• (4) Placebo (control group)

Outcome measures will include both immediate and retention effects on behavioral, neurophysiological, neuroendocrine, epigenetic, and ambulatory stress markers. These will be assessed during three study visits: at baseline (T0), immediately after the six-week nasal spray and/or mindfulness training administration period (T1), and at a follow-up session, six weeks post-intervention (T2) (Fig. 1A).

Figure 1B shows the CONSORT flow diagram as an overview of the planned number of participants enrolled, randomized, and included in the data analysis.

Participants

Participants will be primarily recruited by research staff through established contacts with the Flemish Centers for Mental Health Care (Centra voor Geestelijke Gezondheidszorg, CGGs) and adults on waitlists for “Eerstelijnspsychologische zorg” (e.g., ELP Diletti or Vindplaatsen) in Belgium. Additional recruitment will take place at KU Leuven and the university hospital of Leuven through flyers, personal communication, and social media.

Participants meeting the following criteria will be included in the study: 1) sufficient proficiency in Dutch to complete study tasks; 2) age between 18 and 50 years old; and 3) presence of mild to severe stress symptoms, as assessed using the self-report stress subscale of the Depression, Anxiety, and Stress Scale (DASS-21). Exclusion criteria are 1) active use of psychotropic medication within 6 months prior to participation (including antidepressants, anxiolytics, and antipsychotics); 2) active engagement in psychological treatment within 6 months prior to participation (with a psychologist or psychiatrist); 3) substantial experience with meditative practices (including but not limited to mindfulness, yoga, tai chi, or other similar practices) and/or participation in a multi-day meditation retreat or program during the past six months and/or engagement in meditative practices on a weekly basis or more frequently, for at least six consecutive weeks, within six months prior to the study; 4) previous chronic treatment with oxytocin; 5) active use of anti-epileptic medication or has a significant active medical condition including hematological, endocrine, cardiovascular (including any rhythm disorder), respiratory, renal, hepatic, or gastrointestinal disease which influences the metabolism of oxytocin; 6) a history of active epilepsy, defined as individuals experiencing seizures or requiring anticonvulsant therapy within the past 12 months; 7) a known syndrome that interacts with the reproductive hormonal system (e.g. Prader-Willi or Angelman syndrome); 8) for women: pregnancy, breastfeeding, or planning to become pregnant; 9) significant hearing or vision impairments (that cannot be corrected); 10) participation in another clinical trial with an investigational medicinal product; 11) known hypersensitivity to active substance or ingredients of the nasal sprays, including e.g. (history of) latex allergy; and 12) the use of the following medicinal products during the nasal spray administration period: prostaglandins and their analogues, inhalation anesthetics, vasoconstrictors/sympathomimetic drugs, and caudal anesthesia.

Recruitment will begin in September 2025 and is expected to be completed by the end of September 2027. Participants will receive a total compensation of €120 for their participation in the study.

Sample size

In order to examine whether the combinatory treatment yields a superior treatment response compared to the stand-alone treatment arms, which in turn are expected to yield higher treatment responses compared to the placebo treatment arm, this exploratory trial will include a total of 100 + 20 participants (30 individuals/treatment arm), allowing for the detection of a small-to-medium-sized effect (f² = 0.10; Linear multiple regression: Fixed model, R2 deviation from zero; alpha = 0.05; power = 0.80; number of predictors = 2 estimated using G*power 3.1.9.7), accounting for a potential 15–20% attrition (i.e., n = 100 + 20 attrition). While dropout rates in oxytocin research have generally been low, we adopt a conservative estimate of 15–20% to ensure sufficient statistical power and accommodate potential participant loss throughout the trial. To the best of our knowledge, only one previous study has investigated the combinatory effects of administering oxytocin or placebo, 45 min prior to two sessions of mindfulness training [55]. While in this study, no benefit of oxytocin over placebo was observed for empathy, significant between-group differences favoring oxytocin were found for self-reported negative symptoms, with a reported effect size of f² = 0.12 (η²ₚ = 0.11). This effect size is within the range that the proposed sample size is expected to detect, as described above. Further, considering that this is an exploratory trial, the planned sample size is anticipated to provide sufficient power to yield proof-of-concept insights that will allow guiding sample size calculations for future combinatory trials.

Randomization

For the randomization procedure, the pharmacy A15 (The Netherlands), will use Sealed Envelope Ltd. (2022) to implement a permuted-block randomization scheme. Participants will first be randomly assigned in a 1:1 ratio to receive either oxytocin or placebo, using permuted blocks of size 4. Each block will then be randomly assigned to either the mindfulness intervention or no mindfulness using a block-wise randomization procedure, with the constraint that no more than two consecutive blocks are assigned to the same condition.

This randomization procedure will allow obtaining four equal-sized treatment arms (n = 30 each): (1) oxytocin + MBI, (2) oxytocin alone, (3) placebo + MBI, and (4) placebo alone. After all participants have finalized the last follow-up session and the database is locked, the randomization code in the envelope will be opened for analysis of the response data.

Blinding

All participants will be randomized to receive either oxytocin (Oxytocin CD Pharma®, CD pharmaceuticals AB) or placebo nasal sprays (Physiological water, sodium chloride (NaCl 0.9%) solution, with added preservatives (aqua conservans, methocel)). All experimenters involved in patient contact and data collection, as well as all participants will be blind to the nasal spray assignment. To ensure full blinding, oxytocin and placebo nasal sprays are packaged in identical bottles and labelled with a number. Pharmacy A15 is responsible for preparing the study medication, repackaging it to ensure blinding, and randomization.

Interventions

Oxytocin/placebo nasal spray administration

The nasal spray will be administered in the morning, prior to the mindfulness training sessions. The training will take place within 2 h after the nasal spray administration to ensure peak oxytocin levels during the session [56, 57]. Participants will be instructed to wait at least 15 min after the nasal spray administration before starting the mindfulness training. Oxytocin will be administered as a single intranasal dose of 24 IU (three puffs in each nostril; 4 IU per puff), 4 times per week for six weeks. The total dose of 24 IU is the standard dose adopted in prior single-dose administration studies in adults and children [58]. The duration and intermittent dosing scheme was chosen to resemble a prior six-week trial with 3–8 year old children [27], in which a similar infrequent dosing regimen was adopted to reduce the possible impact of repeated dosing on receptor desensitization and down-regulation [59, 60]. The schedule could be as follows: administration on Monday, followed by group-based mindfulness training; on Wednesday, Friday, and a weekend day, followed by training using the mobile application.

Mindfulness-based intervention

Half of the participants assigned to oxytocin and half assigned to placebo will receive the nasal spray within the standardized framework of a six-week mindfulness-based intervention. The mindfulness training will take place in groups of 10–15 participants, with a blended approach, such that each week, participants will receive one in-person, group-based mindfulness training (2 h); and three individual, app-based, mindfulness trainings in the participants home-setting (minimum 15 min). This approach is based on a similar blended protocol as developed by Van der Gucht et al. [61].

Sessions will include guided formal meditation exercises (e.g., body scan, mindful movement, sitting meditation, loving kindness/compassion meditation), informal exercises that can be practiced during the day (e.g., mindful eating), experiential exercises, and inquiry. The training will be delivered by a certified trainer with more than 15 years of experience. The training is supported by the use of homework exercises and audio material available on their smartphone via a mobile application developed at the Leuven Mindfulness Consortium (LMC), Leuven, Belgium [61,62,63]. Attendance to the live sessions and compliance with the app-based trainings will be monitored via the app. In case participants are not able to attend one of the live sessions (and are not able to join another group in the same week), they will be provided with recorded audio material of the session to complete the session (and concomitant administration of nasal spray) at a later time. Prior to the six-week training, a meet-and-greet session will be organized (without nasal spray administration) to create a safe and familiar environment among the group participants. To assess the therapeutic relationship toward the whole group, other individual participants, and the mindfulness trainer, the Group Questionnaire GQ (30 items) [64] will be assessed at the third and sixth weeks of the training.

Outcome measures

All outcome assessments will be performed at the baseline session before randomization (T0), immediately after the six-week intervention period (T1), and at a six-week follow-up session (T2). Prior to the start of any trial assessments, participants will sign the informed consent form during an intake session. The session will also include eligibility screening and the collection of participant demographics and medical history, including details of any background treatments or psychoactive medication.

Primary outcome measures

The primary endpoints are assessments of self-perceived emotional stress, measured using the Dutch versions of the Perceived Stress Scale (PSS) [65] and the Depression Anxiety Stress Scale (DASS-21) [66]. The PSS is a self-report questionnaire designed to measure the perception of stress in individuals. The questionnaire was originally developed by Cohen et al. in 1983 and asks participants to rate how often they find their lives to be unpredictable, uncontrollable, and overloaded within the past month [65]. It consists of 10 items that are rated on a 5-point Likert scale. Example items include: “In the last month, how often have you felt that you were unable to control the important things in your life?” and “In the last month, how often have you felt nervous and ‘stressed’?” Higher scores indicate greater perceived stress. The presence and severity of symptoms of emotional distress are measured using the DASS-21, developed by Lovibond and Lovibond in 1995 [66]. The DASS-21 is a measure of distress that distinguishes between symptoms of anxiety, stress, and depression. The three subscales have demonstrated good convergent and discriminant validity and high internal consistency both in clinical and nonclinical samples [66]. Example items include: “I found it hard to wind down” (stress subscale), “I felt scared without any good reason” (anxiety subscale), and “I felt that life was meaningless” (depression subscale). Items are scored on a 4-point Likert scale, where high scores indicate higher levels of symptoms of stress, anxiety, and depression. In this study, we will use the total score as a measure of emotional distress.

Secondary outcome measures

The secondary endpoints include assessments of the following self-report questionnaires: State Adult Attachment Measure (SAAM) [67] to assess feelings of (secure) attachment/bonding towards others, Self-Compassion Scale-Short Form (SCS-SF) [68] to assess self-compassion, Pittsburg Sleep Quality Index (PSQI) [69] for sleep quality, Quality of life World Health Organization Five (WHO-5) Well-Being Index for quality of life [70], Perseverative Thinking Questionnaire (PTQ) [71] for repetitive negative thinking, and the Three-Facet Mindfulness Questionnaire-Short Form (TFMQ-SF) [72] for trait mindfulness. During the six-week intervention period, participants will additionally be asked to complete the Profile of Mood State (POMS) [73] at the end of each weekly group training session.

Exploratory outcome measures

Aside from standardized behavioral (self-report) assessments of stress, the study will also include exploratory assessments of stress neurophysiology and biological samplings. Since most prior studies predominantly focus on assessing oxytocin administration effects on clinical scales and questionnaires, the current inclusion of stress neurophysiology assessments and biological samplings will allow to gain important mechanistic insights into the bio-physiological aspects that are anticipated to underlie or precede the clinical improvements.

Stress neurophysiology assessments

As an exploratory outcome, intervention-induced changes in stress neurophysiological recordings will be acquired at each assessment session (T0, T1, T2) during rest, meditation, stress induction, and stress recovery.

Resting-state recording: During the resting-state recording, participants will be instructed to sit still, keep their eyes closed and patiently wait for a duration of 5 min while neurophysiological measures are taken. Auditory cues will signal the start and end of the recording.

Meditation: During the meditation recording, participants will be instructed to engage in 10 min of focused-attention meditation. Specifically, they will be instructed to sit still with closed eyes and to focus their attention on an anchor point (i.e., the contact point between their bottom and the chair [74]). Participants will be encouraged to notice whenever distractions arise and gently redirect their attention back to the anchor point. Auditory cues will signal the start and ending of this recording.

Stress induction: The socially evaluated cold-pressor test (SECPT [75]) will be used to trigger a physiological stress response. This test involves a physiological stressor (immersing one’s hand in cold water) combined with socially-evaluative elements (observation by the experimenter and facing a camera). Specifically, participants will be instructed to immerse their hand and wrist into near-freezing (2°C) water without moving or making a fist, while facing a camera recorder and being observed by the experimenter. After a duration of 3 min, participants will be instructed to remove their hand from the water, although this duration will not be disclosed beforehand. If the participant cannot tolerate the temperature of the water any longer and takes their hand out of the water, the camera and the evaluation by the experimenter will still continue until the three minutes are over. Research shows that the SECPT leads to reliable increases in subjective stress levels, autonomic arousal, and cortisol [76].

Stress recovery: Following the stress induction procedure, participants will be left alone in the room for an initial eyes-closed recovery phase of 17 min during which participants are instructed to wait patiently and let their thoughts wander freely, similar to the resting-state recording phase. This initial recovery phase will be followed by a subsequent recovery phase of 40 min during which participants are asked to open their eyes. During this remaining waiting time, participants will be watching a neutral and muted video (i.e. BBC documentary Spy in the wild; as used in the study by De Calheiros Velozo et al., 2021 [77]).

The following neurophysiological recordings will be conducted during the specified experimental conditions using the Nexus-32 device with BioTrace software (V2018A1) (Mind Media, The Netherlands).

Electroencephalography. EEG recordings will be conducted using a 19-electrode EEG cap (plus two reference electrodes and one ground electrode) positioned according to the 10–20 system. Vertical [vertical electro-oculogram (VEOG)] and horizontal [horizontal electro-oculogram, (HEOG)] eye movements will be recorded using pre-gelled foam electrodes (Kendall, Germany) placed above and below the left eye, as well as next to the left and right eye (sampling rate of 1024Hz). Skin abrasion and electrode paste (Nuprep) will be applied to reduce the electrode impedances during the recordings. The EEG signal will be amplified using a unipolar amplifier with a sampling rate of 512 Hz.

Electrocardiography. ECG will be measured by placing one ECG electrode below the left rib cage and another electrode just below the right collarbone.

Electrodermal recordings. Electrodermal recordings will be performed using two silver chloride (Ag–AgCl) electrodes attached to the middle and ring fingers of the left hand. A low current will be applied to the electrodes to measure skin conductance.

Respiration. Respiration will be measured using a belt with a respiration sensor on the chest, measuring the relative expansion and contraction of the chest. The belt can be applied on top of the clothing of the participant.

Intervention-induced changes in biological samples (oxytocin and cortisol hormonal levels; epigenetics)

Oxytocin and cortisol hormonal levels. Salivary samples for hormonal assessments will be collected using Salivette cotton swaps (Sarstedt AG & Co., Germany) at each assessment session (T0, T1, T2) to explore levels of peripheral (endogenous) oxytocin and cortisol as indicative of variations of arousal/ (social) stress. Analyses of the oxytocin levels will be performed by using Oxytocin Enzyme-Linked Immunosorbent Assay (ELISA) kits from Enzo Life Sciences, Inc., USA. The analyses of the cortisol levels will be performed by applying the Salivary Cortisol ELISA kits by Salimetrics, USA. For each participant, salivary samples will be acquired at four time points during the same day: a sample, acquired at home, in the morning, within 30 min after awakening and before breakfast, and three additional samples, acquired right before the start of the stress induction task, and respectively, 20 and 60 min later. Sample concentrations (100 µl/well) will be calculated according to plate-specific standard curves.

Epigenetic variation. In the healthy population, imaging genetic studies assessing OXTR (Online Mendelian Inheritance in Man entry 167,055) methylation provided consistent evidence of a relation between OXTR methylation and individual attachment-related behaviors [78, 79]. We aim to explore these topics further by characterizing OXTR methylation in the current population and to explore whether variations in OXTR methylation relate to possible variations in oxytocin treatment responses. At the baseline assessment (T0) and at every post-administration assessment (T1, T2), an additional saliva sample will be collected right before the start of the stress induction task, using the Oragene DNA (OG-500) kit, to specifically explore the level of DNA methylation of the oxytocin receptor gene (OXTR) (epigenetic variations).

All outcome measures will be assessed by the study researchers, including PhD students and research staff, who are trained in the relevant data collection procedures. The assessments will be conducted at the Brainshub facility at KU Leuven, Belgium. Since the acquisition of some of these assessments may be challenging, they are considered exploratory. Each testing session will last no longer than 3 h, with adequate breaks provided to avoid fatigue.

Stress reactivity in daily life (experience sampling and ambulant physiology recording).

Experience sampling method (ESM). The experience sampling method will be used to assess self-reported stress reactivity in daily life. This is a momentary assessment method that allows for repeated and ecologically valid measurements of participants’ mood state by collecting in-the-moment data [80]. Here, participants will be prompted on their smartphone at semi-random moments during the daytime to indicate how they are feeling in daily life for 4 consecutive days and will receive 10 prompts a day. The experience sampling will be administered using the m-path app [81]. At each beep, participants will be asked to indicate their current experience of emotional distress, attachment, self-compassion, mindfulness skills, and negative feelings. Before answering the ESM questions, they will be prompted to indicate whether they are at home, at work, or elsewhere. This 4-day experience sampling protocol will be administered at T0, before the first nasal spray administration; at T1, starting two days prior to the last nasal spray administration; and at T2, six weeks after the intervention, allowing to calculate changes in psychological resilience following the nasal spray administration.

Whoop wristband. A subset of participants will be asked to wear a WHOOP wristband (WHOOP, Inc., Boston, MA, USA), mobile sensor for ambulatory recordings of heart rate and sleep architecture, including measures of deep sleep stages, total sleep duration, sleep onset latency, sleep efficiency, and sleep fragmentation. These recordings will be collected three times over 4 consecutive days, following the same schedule as the ESM, allowing for the assessment of changes in ambulatory stress physiology.

Statistical analysis

It is hypothesized that the combined treatment of pairing mindfulness and oxytocin will result in better stress regulation than either intervention alone or placebo, particularly at each timepoint (baseline, post-intervention, and 6-week follow-up). Specifically, it is expected that participants receiving both interventions will show the greatest improvement in stress regulation, followed by those receiving only one of the interventions (mindfulness + placebo or oxytocin alone), with the placebo group showing the least improvement. The expected order of effectiveness is as follows: [mindfulness + oxytocin] > [mindfulness + placebo] = [oxytocin] > [placebo].

While changes in stress regulation will also be explored over time (baseline, post-intervention, and 6-week follow-up), the primary interest lies in comparing the effects of the combined treatment to each stand-alone treatment and placebo at each timepoint.

Intervention effect

To assess whether the combinatory treatment (mindfulness + oxytocin) leads to greater improvements in stress regulation than either intervention alone or placebo, a linear mixed-effects model (LMM) will be used.

Primary analyses will be conducted separately at post-intervention (T1) and 6-week follow-up (T2), including fixed effects for mindfulness (yes/no), oxytocin (yes/no), and their interaction (mindfulness × oxytocin). Baseline (T0) scores will be included as a covariate to account for pre-treatment individual differences. This approach will also allow examining whether the oxytocin or mindfulness stand-alone treatments are superior to the other for particular outcomes.

As an exploratory analysis, a LMM including all three time points (baseline, post-intervention, and 6-week follow-up) will be performed to examine how treatment effects evolve over time. This model will include fixed effects for mindfulness, oxytocin, time, and their two- and three-way interactions. Baseline (T0) scores will be included as a covariate to account for pre-treatment differences.

Cohen’s d or f² effect sizes will be reported for the treatment variable.

The primary analysis will be conducted according to a modified Intention-to-Treat (mITT) principle, based on the Full Analysis Set (FAS). The FAS will include all randomized participants, except participants who received no treatment (i.e., less than one nasal spray administration) and provided no post-baseline data.

Per protocol set is planned, which will be fully defined after completion of all data entries, but before database lock and unblinding. Protocol violations under consideration will include, but are not necessarily limited to, the following: insufficient compliance regarding study medication (defined as use of less than two-thirds of the prescribed dose); and post-randomization violations or the inclusion or exclusion criteria.

All efficacy analyses will be performed for both the FAS and per protocol set, whereby the analysis of the FAS will be considered of primary importance and per protocol set will be considered a sensitivity analysis.

The planned LMM is sufficiently robust to accommodate moderate amounts of missing data, provided they are missing at random. To examine whether data were missing at random, patterns of missing data will be explored descriptively, and baseline characteristics of participants with and without missing follow-up data will be compared. If substantial differences are observed, sensitivity analyses using multiple imputation or pattern-mixture models may be performed to evaluate the impact of missing data on the results.

All statistical analyses will use a two-sided significance level of α = 0.05. Primary outcomes will be assessed at this threshold without correction for multiple comparisons. Secondary outcomes will be reported both with and without correction for multiple testing, using the false discovery rate (FDR) approach where applicable.

Exploratory analysis. Variation in person-dependent characteristics is highlighted to be an important factor for explaining heterogeneity in treatment responses [26]. For further translation, it is important to delineate possible subpopulations of participants/patients that may benefit the most from receiving allocated treatments. To examine the potential impact of distinct person-dependent variables, exploratory analyses will examine whether inter-individual variations in symptom load (e.g., higher stress/anxiety), higher baseline stress neurophysiology, and/or lower endogenous oxytocin levels (at baseline) impact treatment outcome. Also, the effects of age or biological sex will be examined. To do so, general linear model analysis, including these variables as covariates in the model, will be performed.

Compliance and adverse event monitoring

During the course of the intervention, the participant will be asked to keep a trial diary for logging the time point of the day of the nasal spray administration. Participants will be supported by research staff for adhering to and logging of the timings.

Upon receiving the supply of nasal sprays, participants will receive a side-effect report form on which they can record any possible adverse events associated with the administration of the nasal sprays during the nasal spray administration period.

On completion of the treatment period, participants will be asked to return the used nasal sprays to measure the amount of dispensed fluid for monitoring of compliance. While adherence will be monitored tightly and is expected to be high, skipped nasal spray administrations will be monitored tightly and will be included as dimensional covariates in data analyses. A protocol deviation will be recorded if less than two-thirds of the expected volume of oxytocin nasal spray fluid is used by the participant over the entire administration period. Here, secondary analyses are envisaged, conducting analyses with and without participants with less than two-thirds of the administered oxytocin nasal spray volume.

Next to monitoring nasal spray compliance, adherence to mindfulness training will also be tracked. In addition to logging the timings of their mindfulness sessions in a trial diary, the m-path app will track whether the home-based individual trainings have been completed.

Finally, at each post-treatment assessment session (T1, T2), participants will report whether they believe they received the verum oxytocin or placebo nasal spray.

Concomitant / Prohibited medication / Treatment

While the use of psychoactive medications constitutes an exclusion criterion for participation, participants will not be asked to halt their participation or be excluded from the trial if their medication use changes during the course of the study. However, participants will be asked not to change their psychoactive medication or psychosocial treatment during the six weeks of nasal spray administration. If a change in psychoactive medication or psychosocial treatments is necessary during this period, participants must contact the study doctor to monitor the change. No list of prohibited or non-banned medications will be provided, as there are no known contraindications or interactions between other medications and the oxytocin nasal spray. Antiepileptic medication forms an exception, as the use of antiepileptic medication within the last 12 months is considered an indicator of active epilepsy (i.e., an exclusion criterion). Simultaneous participation in another clinical trial involving an approved or non-approved investigational medicinal product is prohibited.

Trial status

The current protocol version is 1.0 (18 March 2025). Recruitment has not yet started but is expected to begin in September 2025 and conclude in September 2027.

A major new study has added to a growing body of research highlighting the health risks associated with marijuana use—particularly its impact on heart function—reinforcing concerns long voiced by Christian medical professionals. As global support for recreational legalization expands and acceptance increases among Christians, some Christian leaders are urging caution, citing both emerging health data and biblical principles that call believers to sobriety and self-control, especially in protecting young people from non-medical use.

The June 2025 study published in Heart, a peer-reviewed journal of the British Medical Association, found that daily marijuana users are 34% more likely to develop heart failure than non-users. Drawing on data from over 150,000 U.S. adults tracked over several years, the study also linked marijuana use with an increased risk of heart attack and stroke.

Reporting on the study, The New York Times noted that marijuana is now the most widely used federally illegal drug in the U.S., with daily use particularly prevalent among men ages 18 to 44. Experts cited in the article expressed concern about the drug’s cardiovascular impact. 

Dr. Matthew Springer, a heart disease biologist at the University of California, San Francisco (UCSF), commented to the Times that marijuana inhalation delivers “thousands of chemicals deep into the lungs,” potentially increasing cardiovascular risk. His lab recently found that both edible and inhaled forms of marijuana were associated with comparable levels of blood vessel dysfunction.

Complementing these findings, a March 2025 publication by the American College of Cardiology revealed that marijuana users under 50 are six times more likely to suffer a heart attack and three times more likely to die from cardiovascular causes compared to non-users.

Despite mounting clinical evidence of health risks, marijuana continues to gain legal and public acceptance in the U.S. and worldwide. Although it remains illegal at the federal level, marijuana has been legalized for recreational use in nearly half of U.S. states, contributing to its growing normalization and widespread use.

A 2024 PRRI survey found that 66% of Americans support legalizing marijuana in most or all cases, with support somewhat lower among White evangelical Protestants (56%) and less than half of Hispanic Protestants (39%). A 2021 Pew Research study, however, highlighted that support for legalization of marijuana was significantly lower among White evangelical Protestants who attend church weekly or more (29%) versus those who attend less than weekly (64%). 

In 2019, the Christian Medical & Dental Associations (CMDA)—a U.S.-based nonprofit representing thousands of Christian healthcare professionals—issued a position statement cautioning against recreational marijuana use.

“[T]here is a need for limiting access to marijuana,” the CMDA said. It warned of addiction, cognitive impairment, psychosis, and long-term health effects, especially among youth. “The adolescent brain is still developing and more vulnerable to the adverse effects of marijuana,” the statement emphasized.

From a biblical perspective, Kevin J. Vanhoozer, research professor of systematic theology and contributor to The Gospel Coalition, comments that Christian discipleship calls for sobriety and alertness of both body and spirit. In his article titled Should followers of Christ use recreational marijuana?, he argues that while Scripture does not specifically mention marijuana, it consistently warns against intoxication and spiritual dullness. “[M]arijuana clouds our ability to perceive the world clearly and dulls our sense of urgency about what disciples should be doing,” Vanhoozer writes. 

Marijuana use extends well beyond North America, with changing laws and shifting social attitudes increasing access across Europe, Africa, Latin America, and Asia. According to the 2024 UN World Drug Report, an estimated 228 million people worldwide used cannabis in 2022, making it the most commonly used drug among the 292 million total drug users globally—a figure that has risen by 20% over the past decade.

Though the Heart study primarily analyzed U.S. data, it draws on international research to provide global context. This includes cohort studies from Europe examining cardiovascular outcomes linked to cannabis use; early recreational legalization experiences in Canada; rising use across Latin America; and limited but growing data from Africa and Asia. The study suggests that the biological effects of cannabis on heart health—such as elevated heart rate and blood pressure—are likely consistent across populations.

Saima Wazed, Regional Director WHO South-East Asia, was today felicitated with Mental Health Award 2025 at the 24^th Annual International Mental Health Conference in Thailand. 

“The award is in recognition of her invaluable contribution and transformative leadership, and a tribute to her profound impact in shaping the future of global mental health,” the award citation said. The award was presented on the opening day of the annual conference organized by the Department of Mental Health, Ministry of Public Health, Thailand, in collaboration with the Jittavejsart Songkrao Foundation and the Somdet Chaopraya Institute of psychiatry at ICONSIAM, Bangkok. 

“Saima Wazed is a widely respected leader in the field of mental health and autism, recognized internationally for her lifelong dedication and tireless efforts in advancing mental health and autism policies and driving globally acknowledged agendas. Her visionary work is firmly grounded in human rights, holistic care, and a deep understanding of cultural contexts. She has received numerous prestigious awards and has held significant leadership positions within the World Health Organization in the South-East Asia, fostering academic exchange and strengthening Thailand’s position as a center of global learning in mental health,” the citation read. 

In her acceptance speech Wazed said, “I started this journey 20 years ago, when the mental health landscape in our region – in fact, around the world – looked very different to what it is today…. I’ve been fortunate to work in this field both as a practitioner and as a policy specialist…. On behalf of everyone I have worked with on this journey, I thank you for this award.” 

The Regional Director lauded Thailand’s efforts in prioritising mental health, “I have seen with great appreciation and admiration all that Thailand has done for mental health.”

The partnership between WHO and Thailand on mental health has been one of the most effective ones with initiatives such as the International Mental Health Workforce Training Program; Mental health and digital technologies Step-by-Step program, and ‘Tor-Tuem-Jai’ platform; implementation of the LIVE LIFE initiative for suicide prevention and evidence-based parenting interventions with LEGO Foundation, she said. 

“As WHO’s Regional Director for South-East Asia, my colleagues and I have placed mental health as our very first priority area for the duration of my term. We look forward to continuing to work with you and look forward to all that we will achieve together,” Wazed said.