The "triple threat" surgeon-one who excels as a clinician, researcher, and educator-has long represented the ultimate achievement in academic medicine. This model has guided generations of surgeons aspiring to excellence. The importance of leadership skills has also been recognized, leading to the modern concept of the "quadruple threat." Over the last decades, many challenges have threatened the existence of this model, including increasing competition for limited funding, declining reimbursement, and increasing administrative burdens. While some view the "triple threat" unachievable or unsustainable in the current environment, others use this as an opportunity to adapt the model to contemporary practice. This review examines the historical origins of the triple threat surgeon, the current challenges to this model and the steps necessary to ensure its success.

We report a 45-year-old woman with a papillary tumor of the pineal region (PTPR), a neuroepithelial neoplasm of the pineal gland, who presented with a one-year history of headaches, visual disturbance, and gait impairment and was found to have a pineal mass with obstructive hydrocephalus. She underwent endoscopic third ventriculostomy (ETV) with biopsy; the initial radiologic impression favored pineocytoma. Immunohistochemistry was nondiagnostic on the limited sample, and the diagnosis of PTPR was established only after review at two academic neuropathology centers. DNA methylation profiling was obtained for definitive molecular classification, with the result not yet available for review at the time of reporting. The lesion was resected via an interhemispheric transcallosal approach, but the patient developed recurrent hydrocephalus due to ETV failure, requiring a ventriculoperitoneal shunt. She completed adjuvant radiotherapy and showed no recurrence on the most recent surveillance MRI. In this patient, PTPR posed two challenges: diagnostic overlap with pineocytoma that required specialized and molecular workup, and persistent hydrocephalus after ETV failure that ultimately required permanent cerebrospinal fluid diversion.

Purpose: Dry needling (DN) regulations among the Canadian physiotherapy colleges were compiled to make recommendations toward a national guideline. Method: DN regulatory data extracted from regulatory body websites using an environmental scan framework was checked by an independent reviewer. Colleges were contacted to fill gaps identified from the web. Extracted content was compared to recommendations from two Canadian DN reviews to identify gaps in regulation. Results: DN regulation is done through legislation (two colleges), practice guidelines (one), or both (seven), depending on the college and its provincial or territorial jurisdiction. Three colleges have prerequisites for DN courses, four have approved DN courses, nine require specific course content, three require minimum course hours, nine require registration or rostering, and three have continued competency expectations. No colleges have evidence-based guidelines to inform requirements or meet all DN recommendations. Conclusions: Heterogeneity in regulation likely represents gaps that may potentially expose the public to risk. Physiotherapy colleges could review their regulatory process, address these gaps if they are deemed related to increase risk, and ultimately come to a consensus on what are the safest regulations of practice for Canadian physiotherapists.

Knee osteoarthritis (KOA) is a leading cause of chronic pain and physical disability in the aging global population, placing an immense burden on healthcare systems. Despite its rising incidence, clinical practice and research remain disproportionately focused on late-stage joint replacement, neglecting early-stage preventive and conservative care for high-risk individuals. To address this gap, this narrative review searched major databases including PubMed/MEDLINE, Embase, Web of Science, and the Cochrane Library for clinical guidelines, high-quality systematic reviews, and randomized controlled trials focusing on non-surgical interventions for early KOA and high-risk populations. Search terms included "early knee osteoarthritis," "non-surgical treatment," "exercise therapy," and "weight management". Literature analysis demonstrates that a structured, "lifelong, stepped" non-surgical paradigm yields significant clinical efficacy. Specifically, combining dietary weight loss with physical exercise optimally reduces mechanical joint loading and systemic inflammatory markers; targeted muscle strengthening, alongside mind-body exercises like Tai Chi or yoga, improves the joint microenvironment and neuromuscular control; biomechanical orthoses and physical therapies offer substantial short-term pain relief; and topical or systemic NSAIDs combined with intra-articular injections effectively manage refractory acute symptoms. Crucially, continuous clinical supervision and structured patient education are vital for enhancing long-term treatment adherence and delaying radiological disease progression. Ultimately, implementing early, proactive non-surgical interventions, grounded in patient education and integrating weight management, targeted exercise, and multimodal stepped therapies, effectively alleviates pain, restores physical function, and delays or entirely prevents the need for future joint replacement.

Mixed infections with multiple Porcine reproductive and respiratory syndrome virus (PRRSV) are common in swine production and complicate diagnostic interpretation, particularly when whole genomes cannot be recovered through next-generation sequencing (NGS). This study evaluated the ability of NGS to detect and characterize multiple PRRSV-2 strains present in controlled viral mixtures that varied in strain number, viral load, and proportional abundance, ultimately providing guidance for interpreting NGS outputs. Nine PRRSV-2 viruses, including three wild-type viruses and six commercial vaccine viruses, were spiked into processing fluid at Ct values of 21 and 27 to generate standardized combinations that reflect field conditions. Across all mixtures, NGS resulted in contigs that identified the correct strain composition in 89.7% of samples. NGS detected virus present at 10% concentration in 95.8% (23 of 24) of samples containing two viruses diluted at a 1:9 mixture. Contig nucleotide identity to reference strains decreased as viral load declined, yet accurate strain assignment was still achieved in most cases using a threshold of at least 98% nucleotide identity for high-concentration samples and at least 96% for lower-concentration samples. Detection failures occurred in 10.3% (8 of 78) of mixtures, 75% (6 of 8) of which contained four or more strains, indicating reduced NGS sensitivity under highly complex conditions with the same viral species. In different instances, NGS failed to detect MLV vaccines when 2 or more wild-type viruses were present. In 0.7% (8 of 1,147) of contigs, assembly artifacts were identified that proved to be artificial recombinant contigs, and 0.61% (7 of 1,147) were classified as inconclusive because they matched two highly similar vaccine strains at greater than 98% nucleotide identity. These results demonstrate that meaningful interpretation of PRRSV variant composition is possible from partial genome recovery, provided appropriate identity thresholds are applied and reference genetic sequences are available for comparison. The findings provide practical guidance for diagnostic laboratories and veterinarians who rely on NGS-derived contigs for PRRSV classification in field samples.

Livedoid vasculopathy (LV) is a rare, chronic vascular disorder marked by painful, recurrent ulcerations that primarily affect the lower extremities. It is frequently associated with hypercoagulable states, although its pathophysiology remains incompletely understood. We present the case of a 25-year-old woman with a longstanding history of LV, elevated factor VIII, increased lipoprotein(a), recurrent kidney stones, and iron deficiency anemia who presented with worsening lower-extremity ulcerations. An extensive workup excluded other hypercoagulable and connective-tissue conditions, leaving elevated factor VIII and lipoprotein(a) as the most likely contributors to her disease. Although her symptoms initially resolved with treatment, they recurred over time, and management was further complicated by her desire for future pregnancy, which precluded the use of several standard anticoagulant therapies. Her regimen was ultimately centered on pentoxifylline and low-dose aspirin to control symptoms while minimizing risk to a future pregnancy. This case illustrates the importance of individualized treatment planning in LV, particularly when hypercoagulable risk factors intersect with reproductive goals.

Periodontitis is a chronic immune-inflammatory disease induced by dental plaque biofilms. Persistent host immune dysregulation disrupts the dynamic balance between local tissue repair and pathological destruction, ultimately leading to irreversible damage to the periodontal supporting tissues, including the alveolar bone, periodontal ligament, and cementum. As key post-transcriptional regulators, microRNAs (miRNAs) coordinate the osteogenesis-bone resorption balance, immune homeostasis, angiogenesis, and intercellular communication through multi-target synergistic mechanisms, and have thus emerged as promising intervention targets for restoring periodontal immune homeostasis and achieving tissue regeneration. However, existing studies predominantly follow a simplified "single miRNA-single target-single phenotype" paradigm, and the three stages-molecular mechanism elucidation, delivery vector construction, and clinical validation-remain disconnected from one another. Published reviews likewise lack a comprehensive analytical framework that integrates multi-level miRNA regulatory networks with engineered delivery strategies. This review first systematically elucidates how endogenous microenvironmental factors, exogenous interventions, and mechanical stimuli regulate miRNA expression in periodontal tissues. It then examines the core functions of miRNAs across three dimensions-osteogenic/osteoclastic differentiation, immune homeostasis, and angiogenesis-analyzes their molecular interactions with competing endogenous RNAs (ceRNAs), summarizes the intercellular communication functions of miRNAs mediated by extracellular vesicles (EVs), and provides a graded synthesis of the research evidence for core miRNAs. At the translational engineering level, this review comprehensively surveys five strategies: miRNA mimic delivery, miRNA inhibition and blockade, indirect regulation of endogenous expression, engineered EV delivery, and DNA nanorobots. On this basis, it identifies three core bottlenecks constraining the field-the complexity of molecular regulatory networks, insufficient adaptability of delivery systems, and an incomplete preclinical validation framework-and proposes a spatiotemporally coordinated model for periodontal regeneration based on three sequential stages of intervention: "inflammation regulation, osteogenic-vascular coupling, and tissue maturation and remodeling." This review aims to overcome the fragmentation of previous research by providing a systematic framework for elucidating the immune regulatory mechanisms of miRNA-mediated periodontal regeneration, developing smart responsive scaffolds, and conducting preclinical validation in large animals, while advancing the clinical translation of miRNA-based multi-target regulatory strategies in periodontal regeneration.

Nutrient availability can shape key life-history traits including behavior. However, many studies of nutrient-dependent behavior have focused on individual activity, whereas the effects of specific nutrients on social interactions and the resulting networks remain poorly understood, especially in insects that are neither eusocial nor solitary. As major nutritional components, amino acids and carbohydrates can influence individual condition, such that variation in the nutrient availability may alter individual activity, social interactions, and ultimately lifespan. We examined how variation in either amino acids or carbohydrates influenced activity and its short-term repeatability, social interaction networks (based on mating and agonistic interactions), and lifespan in adults of the turnip sawfly, Athalia rosae, which naturally encounter heterogeneity in these nutrients across the nectar of their host plants. We provided adults with different diets spanning ecologically realistic concentrations of either amino acids or carbohydrates, and recorded adult activity over 2 d along with social interactions in mixed-sex groups. We found that neither activity nor its short-term repeatability, ie the consistency of activity across the assay days, differed across individuals from different dietary treatments. Social interactions and the resulting networks also did not differ significantly among individuals from different diets, but high-carbohydrate diets extended lifespan, whereas amino acid variation had no detectable effect on survival. These findings suggest that short-term differences in nutrient availability can influence lifespan but not individual activity or social interactions.

This study developed ethylene-scavenging films by incorporating potassium permanganate (KMnO4)-impregnated diatomite into a low-density polyethylene (LDPE) matrix. Various additives, including raw, alkaline-activated, and KMnO4-impregnated diatomite (DA-KMnO4 and Alk-DA-KMnO4), were incorporated into the films and tested. The additives did not improve mechanical or gas-barrier properties; however, they significantly enhanced thermal stability, crystallinity, and ethylene-removal capacity. The highest ethylene-removal capacities were achieved by the 1% DA/LDPE and 1% Alk-DA-KMnO4/LDPE films, which exhibited capacities of 296.58 ± 2.07 μL/g, and 373.22 ± 13.83 μL/g, respectively. Practical storage trials using bananas, a climacteric fruit, demonstrated the efficacy of films. Bananas stored in neat LDPE ripened within 6 days, whereas those in 1% DA/LDPE films stayed green and fresh for up to 10 days, while those in 1% Alk-DA-KMnO4/LDPE turned green-yellow after 9 days. Ultimately, these KMnO4-based diatomite-LDPE films offer a viable solution for delaying ripening, maintaining firmness, and extending the shelf life of fresh produce.

Rhodopsin-like G protein-coupled receptors (GPCRs) play a pivotal role in ophthalmic pathologies, and recent studies have substantially advanced our understanding of their underlying molecular mechanisms. Amine-responsive Rhodopsin-like GPCRs (ARh-GPCRs), encompassing adrenoceptors, dopamine receptors, muscarinic acetylcholine receptors, histamine receptors, serotonin receptors, melatonin receptors, and trace amine-associated receptors, are involved in a variety of ocular pathological processes and have emerged as key therapeutic targets. Elucidating their functional roles, alongside those of their ligands and downstream signaling macromolecules, holds considerable potential for the development of candidate biomarkers for early diagnosis, disease classification, prognostication, and predicting treatment response in specific ocular disorders. Despite significant progress, a comprehensive integration of their dual candidate biomarker-therapeutic roles across diverse ocular disorders remains largely unexplored. This narrative review summarizes and critically integrates current evidence on the regulatory roles and therapeutic potential of these receptors in ocular pathologies, with particular attention to their mechanistic involvement, candidate biomarker potential, and therapeutic relevance. Furthermore, we summarize the current research limitations and propose future directions to enhance the understanding of their molecular mechanisms, ultimately facilitating the development of precise diagnostic and therapeutic strategies.

Transition-metal functionalization and charge-state engineering provide complementary strategies for tailoring the electronic phases of graphene nanoribbons, yet their cooperative influence on spin polarization, optical response, and quantum transport remains poorly understood. Here, we employ spin-polarized density functional theory combined with nonequilibrium Green's function calculations to systematically investigate vanadium-decorated hydrogen-passivated 7-armchair graphene nanoribbons under varying adsorption coverages and charge states. Increasing vanadium coverage progressively strengthens V-3d/C-2p hybridization, enhances adsorption stability through cooperative electronic interactions, and drives the electronic structure from semiconducting to spin-polarized and ultimately half-metallic behavior. Charge-density-difference analysis reveals a transition from localized to delocalized charge redistribution, providing the microscopic origin of the enhanced orbital coupling and magnetic ordering. Charge-state modulation introduces a pronounced electron-hole asymmetry: hole doping reinforces charge transfer, spin polarization, and low-energy optical absorption through stronger V-3d/C-2p hybridization, whereas electron doping produces comparatively weaker electronic reconstruction. The coupled evolution of the electronic structure is reflected in the transport properties, which exhibit a crossover from impurity-assisted conductance enhancement at low vanadium coverage to spin-selective, localization-dominated transport at higher adsorption densities due to the competition between orbital hybridization and carrier scattering. These results establish transition-metal functionalization and charge-state engineering as cooperative approaches for simultaneously tuning the structural, electronic, optical and transport properties of armchair graphene nanoribbons, providing a general framework for the rational design of graphene-based nanoelectronic, optoelectronic, and spintronic devices.

Microorganisms within tumors, also known as intratumoral microbiota, actively shape the tumor microenvironment (TME), influencing cancer progression and treatment response. Research has therefore expanded beyond the gut microbiota to intratumoral bacterial and fungal communities. Advances in low-biomass sequencing, contamination control, and spatial profiling have made it possible to detect these low-abundance microbes within the TME and map their marked heterogeneity across cancer types and tissue compartments. However, their origins, causal functions, and clinical relevance remain debated. Here, we summarize contamination-sensitive workflows and high-resolution techniques required for low-biomass tissues, and compare representative taxa in major cancer settings. We further explore microbial origins, taxonomic diversity, and localized interactions with malignant, immune, and stromal cells. We synthesize mechanistic evidence linking intratumoral microbes to genomic instability, epigenetic regulation, oncogenic signaling, metabolic reprogramming, and metastasis. Based on these insights, we evaluate their impact on cancer therapies, alongside emerging microbial interventions and barriers to clinical translation. Ultimately, this review provides a framework for assessing intratumoral microbiota as biomarkers, treatment-response modifiers, and therapeutic targets, while highlighting the key evidence needed to translate these findings into the clinic.