The classroom study involved a screening of Dying to Survive, a Chinese film directed by Wen Muye and starring Xu Zheng. Adapted from the true story of Lu Yong, a patient with chronic myeloid leukemia, the film follows Cheng Yong, the owner of an Indian “magic oil” shop who smuggles inexpensive generic drugs from India for people with leukemia. Its narrative examines the relationship among medicine, social conditions, commerce and human morality, while Cheng Yong’s movement from commercial self-interest toward helping patients gives viewers a character whose motives and actions are morally complicated. Researchers selected the feature partly because this transformation could support the study’s interest in moral identity without relying on a single, uncomplicated moral perspective. Participants were 421 men and 633 women aged 18 to 23, with a mean age of 20.64 years and a standard deviation of 1.62. They were enrolled at Chengdu College of Arts and Sciences, had normal or corrected-to-normal vision without color deficiency, and had no background in psychology. All received written informed consent.

After the screening, participants completed four self-report instruments during the same class session. Narrative engagement was measured with a 12-item, seven-point scale covering narrative understanding, attentional focus, emotional engagement and narrative presence, with scores from 1 for strongly disagree to 7 for strongly agree. Its internal consistency in this sample was Cronbach’s alpha of 0.76, while the dimension-specific coefficients ranged from 0.74 to 0.94. Character identification was assessed with 11 items on a five-point scale, producing an alpha of 0.70. Moral identity was measured across 11 five-point items addressing the internalization and symbolization of traits such as caring, compassion, fairness, generosity, helpfulness, honesty and kindness; the total scale had an alpha of 0.85. The 23-item prosocial behavior scale covered public, anonymous, emergency, emotional, compliant and altruistic forms of helping and had a total alpha of 0.84. The study assessed tendencies immediately after viewing rather than observing helping conduct, making the outcome closer to reported motivation or intention than to enacted behavior.

Narrative transportation had a strong positive bivariate association with prosocial tendencies, with a Pearson correlation of r = 0.67, p < 0.01. It was also positively associated with character identification at r = 0.22, p < 0.01, while character identification correlated with prosocial tendencies at r = 0.23, p < 0.01. Moral identity had a small, nonsignificant correlation with prosocial tendencies at r = 0.03, p > 0.05, although such a correlation does not preclude an interaction in a regression model. Statistical mediation analysis supported a small indirect association: narrative transportation was positively associated with character identification, and stronger identification was associated with higher prosocial tendencies. The estimated indirect effect was 0.012, with a bias-corrected bootstrap 95% confidence interval of 0.005 to 0.020 from 5,000 resamples. The direct association was 0.426 and the total association was 0.438, both with p < 0.001, indicating that the identified character pathway explained only a small share of the broader relationship.

The researchers then tested whether moral identity altered the link between identification and prosocial tendencies. The interaction between character identification and moral identity was significant at b = 0.106, SE = 0.040, p = 0.009, although it added only 0.36% to the model’s explained variance in prosocial tendencies. At the 16th percentile of moral identity, equivalent to one standard deviation below the mean, the association between identification and prosocial tendencies was not significant: b = 0.013, SE = 0.033, p = 0.691, 95% CI [−0.051, 0.077]. At the median it was b = 0.090, SE = 0.022, p < 0.001, 95% CI [0.047, 0.133], and at the 84th percentile it was b = 0.139, SE = 0.032, p < 0.001, 95% CI [0.077, 0.200]. The corresponding indirect association from narrative transportation through identification was not significant at low moral identity, with an effect of 0.002 and a bootstrap 95% confidence interval from −0.008 to 0.012.

At moderate moral identity, however, the indirect effect reached 0.014, with a bootstrap 95% confidence interval of 0.007 to 0.023; at high moral identity, it rose to 0.022, with an interval of 0.011 to 0.034. The index of moderated mediation was 0.017, with a bootstrap 95% confidence interval of 0.005 to 0.031, supporting a statistical difference in the indirect pathways across levels of moral identity. A Johnson–Neyman analysis indicated that the identification–tendencies association was significant when mean-centered moral identity was at least −0.2804, a range comprising about 67.8% of the sample. The researchers cautioned that this is a region of statistical significance rather than a validated psychological threshold, and they also emphasized that the interaction’s incremental R² of 0.0036 was small. The pattern therefore provides evidence that the relationship varied across moral-identity levels, but not that the moderation had a large effect.

Several diagnostics supported the internal consistency of the main model. Variance inflation factors for all predictors were below 2, the Breusch–Pagan test was not significant at χ² = 0.73, p = 0.695, and residual skewness and kurtosis were each below 1 in absolute value. A single-factor model fit substantially worse than the four-factor parceled model, and a Harman single-factor test attributed 19.20% of variance to the first unrotated factor, below the study’s 40% reference threshold. Nevertheless, an unmeasured latent method model improved comparative fit from CFI = 0.909 to 0.965, indicating that some shared method variance was probably present. In particular, discriminant validity between narrative transportation and prosocial tendencies was incomplete: their HTMT ratio was 0.86, slightly above the stated 0.85 criterion, while the measurement model’s TLI of 0.875 and RMSEA of 0.116 did not fully meet conventional thresholds. The constructs central to the proposed moderation showed clearer separation, but the large total association between transportation and prosocial tendencies still requires caution.

The design also limits how the results can be interpreted. It was cross-sectional, included no randomized condition or control group, and measured all constructs through one self-report session immediately after the film. Moral identity was also assessed after viewing, so although it is theoretically a relatively stable self-concept, the movie may temporarily have activated it and altered how participants answered its questions. The strong total correlation between narrative transportation and prosocial tendencies leaves room for overlapping measurement or unmeasured factors, even though the common-method analyses suggest that one shared factor cannot explain the entire pattern. Post hoc calculations indicated adequate power for the moderation analysis, but post hoc power cannot replace an experimental design or establish temporal order. The sample was also relatively homogeneous, and the use of one film limits generalization to other genres, narrative structures, ages and cultural settings.

The results offer a testable framework for understanding how stories may connect emotionally to social motivation. Narrative transportation theory proposes that immersion focuses attention on a story world, while character-identification theory proposes that viewers can psychologically adopt a character’s perspective and emotions. The authors argue that students who already treat moral traits as central to their identity may be more likely to translate identification with an altruistic character into a stronger prosocial orientation. This remains an interpretation of a statistical association, not evidence that a screening changes behavior, and the 2.72% indirect share should not be presented as a large effect. The practical implications are similarly tentative: pairing films that contain moral dilemmas and character growth arcs with structured discussion is a hypothesis for future testing rather than a demonstrated educational intervention. Replication with pre-film moral-identity measures, multiple films, different ages and cultural settings, and behavioral tasks involving donation or helping choices will be needed to determine whether the pattern generalizes, persists over time or reflects actual changes in conduct.

Subject of Research: How cinematic narrative transportation is associated with college students’ reported prosocial tendencies through character identification and moral-identity moderation.

Article Title: Cinematic narrative transportation and prosocial tendencies in college students: a moderated mediation model

Article References: Tang, Y., Chen, M., Deng, Y., Wei, C., Zhou, Y., Wang, L., & Yang, Y. (2026). Cinematic narrative transportation and prosocial tendencies in college students: a moderated mediation model. Frontiers in Psychiatry, 17, 1976033. https://doi.org/10.3389/fpsyt.2026.1976033

Image Credits: AI Generated

DOI: 10.3389/fpsyt.2026.1976033

Keywords: film psychology, narrative transportation, character identification, moral identity, prosocial tendencies, college students, mediation analysis, Chinese undergraduates, cross-sectional study, Cinematic, narrative, transportation

The study, published in the Journal of General Internal Medicine by Rachel Cox, MD, and colleagues, was built around a deceptively simple question: if you teach the people who give and receive feedback what high-quality feedback actually looks like, does the feedback itself get better? To find out, the team implemented targeted educational interventions in 2022 and then compared the narrative assessments written before and after those interventions using a validated scoring tool. The results showed a statistically significant improvement in feedback quality, with mean scores rising from 2.48 to 3.37 on a 12-point scale, a change the authors describe as meaningful even though it also reveals how much room remains for growth.

The technical core of the study lies in how feedback quality was measured. The researchers collected narrative assessments and written faculty-to-resident feedback from resident feedback forms across two periods: the 2021 to 2022 academic year, before the intervention, and the 2022 to 2024 academic years, after it. All assessments were de-identified and then evaluated by two independent scorers using the Narrative Evaluation Quality Instrument, or NEQI, a tool developed to assess the assessor rather than the trainee. The NEQI quantitatively scores feedback across three categories: the performance domains commented on, the specificity of the comments, and the usefulness of the feedback to the trainee. Each assessment receives a total score ranging from 0 to 12, with higher numbers indicating higher quality. In total, 1206 narrative assessments met the inclusion criteria, 316 from the pre-intervention period and 890 from the post-intervention period, giving the comparison substantial statistical power.

The numbers tell a consistent story. The mean NEQI score increased from 2.48 before the educational workshops to 3.37 afterward, an improvement that reached statistical significance at P less than 0.001. The effect size was 0.5, which the authors characterize as moderate, suggesting the intervention is impactful rather than marginal. Perhaps most striking is the intraclass correlation coefficient of 0.92, an indicator of excellent interrater reliability. In practical terms, the two independent scorers agreed closely on how to rate both the pre- and post-intervention datasets, which strengthens confidence that the observed rise in scores reflects genuine improvement in the feedback itself rather than inconsistency in how it was judged.

The intervention itself was deliberately lean. Faculty members participated in biannual 90-minute interactive workshops covering the core principles of high-quality feedback, the common barriers to delivering it, and techniques for producing action-oriented comments. Residents, meanwhile, attended a single 60-minute workshop focused on deliberate practice, goal creation, and building expertise through feedback, with an emphasis on learners taking ownership of their own learning. Neither arm involved new technology, additional staffing, or sweeping curricular reform. The authors argue that this cost-effectiveness and relatively straightforward integration make the approach a scalable solution for other residency programs across various specialties, even though implementing such programs requires time and commitment from program leadership.

What makes the improvement technically interesting is that it emerged from education aimed at both sides of the feedback exchange. Prior research cited in the study has described the highest quality narrative feedback as specific, actionable, and constructive, and has emphasized that feedback should incorporate and be targeted to learner goals. The faculty workshops aligned with those best-practice components, teaching clinicians how to deliver effective comments. The resident workshop tackled the other half of the equation, encouraging trainees to seek feedback deliberately, set explicit goals, and treat feedback as raw material for deliberate practice. The literature has long noted that residents often describe seeking feedback as burdensome and anxiety producing, even though residents and faculty tend to agree on what constitutes effective feedback. The authors suggest their intervention may reduce those perceived barriers to engagement, bridging the persistent gap between intention and execution.

The study’s framing within competency-based medical education gives the findings broader significance. Under the ACGME milestones framework, feedback is not an optional courtesy but a mandated mechanism for achieving clinical competence and progressing through training. Inconsistent feedback quality can potentially impede residents’ progression and development toward clinical independence, which is why addressing the gap in feedback quality is framed as crucial to ensuring residents reach their milestones on schedule. By demonstrating that structured education can enhance feedback processes within this framework, the study provides program directors with an evidence-based lever they can pull without waiting for system-wide reform of how feedback is standardized across graduate medical education.

Even so, the raw scores carry a sobering message. The authors acknowledge that the average scores of both the pre-intervention and post-intervention groups are low overall on the NEQI scale, given that the maximum score, representing the highest quality feedback, is 12. A rise from 2.48 to 3.37 is statistically robust and practically relevant, but it also means that even after targeted education, the typical narrative assessment in this program still scored far below what the instrument defines as excellent. The authors point to prior descriptions of best practices, including specific, actionable, and constructive comments targeted to learner goals, as the direction in which feedback should continue to move, and they suggest that providing targeted education on how to deliver effective feedback could improve quality further, given the effect size observed here.

The study’s limitations are candidly stated. It examined only a single residency program and only a single year of residents across two specialties, which constrains how far the results can be generalized. The authors also note that the datasets generated and analyzed during the study are available from the corresponding author on reasonable request, and that the authors received no funding related to the manuscript and declare no conflict of interest. The research team, spanning Wright Patterson Medical Center, Wright State University Boonshoft School of Medicine, and Uniformed Services University in Bethesda, Maryland, included Kelsey Wilson, DO, Marc Gutierrez, MD, John Arthur, DO, Bryan Harper, DO, and Kathryn M. Burtson, MD, with contributions ranging from conception and design to analysis, interpretation, and critical revision.

For the wider world of medical education, the takeaway is both encouraging and demanding. The study demonstrates that targeted education on feedback significantly improves the quality of narrative feedback in an internal medicine residency program, making feedback more focused, specific, and valuable, and thereby contributing to optimal resident progression through training. A few workshops, delivered consistently to faculty and residents alike, shifted the measurable quality of more than a thousand written assessments in a statistically significant way. But the same data show that feedback across graduate medical education remains, by validated standards, far from excellent. The intervention offers a scalable starting point; the distance to the top of the NEQI scale defines the work that remains.

Subject of Research: Impact of Faculty and Resident Education on the Quality of Narrative Feedback in Residency: An Interventional Study

Article Title: Impact of Faculty and Resident Education on the Quality of Narrative Feedback in Residency: An Interventional Study

Article References: Cox, R., Wilson, K., Gutierrez, M., Arthur, J., Harper, B., & Burtson, K. M. (2026). Impact of Faculty and Resident Education on the Quality of Narrative Feedback in Residency: An Interventional Study. Journal of General Internal Medicine. https://doi.org/10.1007/s11606-026-10447-x

Image Credits: AI Generated

DOI: 10.1007/s11606-026-10447-x

Keywords: Impact, Faculty, Resident, Education, Quality, Narrative, Feedback, Residency, Interventional, scientific research

Kaposi sarcoma, once the most common malignancy among Nigerians with HIV, has declined substantially with the scale-up of antiretroviral therapy. A national analysis of more than 2,000 patients across six geopolitical zones found that sarcoma incidence fell from 2.5 cases per 1,000 person-years in the pre-therapy era to 1.5 cases per 1,000 person-years after therapy became widely available. The review noted that sarcoma now accounts for a smaller share of malignancies among people with HIV, though it remains an important cause of cancer in this population, particularly in regions where therapy coverage is incomplete.

Cervical cancer, by contrast, remains poorly controlled. The review found that women with HIV face a substantially elevated risk of cervical cancer, driven by higher rates of human papillomavirus persistence and lower rates of screening. A national analysis of more than 1,500 women across six zones found that cervical cancer incidence among women with HIV was roughly three times higher than among women without HIV, and that fewer than one in five women with HIV had ever been screened for cervical cancer. The review noted that cervical cancer now accounts for a growing share of malignancies among Nigerian women with HIV, particularly in northern regions where screening coverage is lowest.

Non-AIDS-defining cancers are rising as people with HIV survive longer on therapy. The review found that malignancies such as liver cancer, lung cancer, and Hodgkin lymphoma now account for a growing share of cancers among Nigerians with HIV, driven by longer life expectancy, higher rates of viral hepatitis co-infection, and greater exposure to tobacco. A national analysis of more than 1,000 patients across six zones found that non-AIDS-defining cancers accounted for roughly one in three malignancies among people with HIV, up from one in five a decade earlier. The review noted that these tumors are often detected late, when curative treatment is no longer possible.

The health system remains poorly equipped to manage the HIV-cancer overlap. The review found that cancer registries cover only a fraction of the population, that pathology services are concentrated in urban centers, and that oncology services are largely separate from HIV care. A national analysis of more than 500 patients across six zones found that fewer than one in five people with HIV who developed cancer received coordinated care addressing both conditions. The review noted that this fragmentation is particularly acute in rural regions, where most Nigerians live and where both HIV and cancer services are scarcest.

The researchers called for coordinated action to address the HIV-cancer overlap. They recommended scaling up cervical cancer screening among women with HIV, integrating oncology services with HIV care, expanding cancer registries and pathology services, and strengthening surveillance of non-AIDS-defining cancers. They also called for greater investment in rural health services, where both HIV and cancer services are scarcest, and for research into the drivers of rising non-AIDS-defining cancers among people with HIV. The review noted that without such action, the HIV-cancer overlap will continue to grow as people with HIV survive longer, and the health system will remain poorly equipped to manage it.

The epidemiologic backdrop of this review is striking. Globally, the number of people living with HIV rose from 27.2 million in 2000 to 40.8 million in 2024, and Nigeria accounts for roughly 4.5 to 5.0 percent of that total, placing it fourth worldwide. Current national estimates suggest approximately 1.9 to 2.0 million Nigerians are living with the virus. Notably, an earlier figure of about 3.2 million was revised downward after the 2018 Nigeria HIV/AIDS Indicator and Impact Survey, a nationally representative household survey that reduced estimated prevalence from 2.8 percent to 1.4 percent. The authors emphasize that this revision reflects improved measurement rather than a genuine epidemiological decline, an important distinction for anyone interpreting trends in the country’s HIV burden over time.

As survival on antiretroviral therapy improves, the clinical picture among people living with HIV has shifted from acute opportunistic infections toward chronic, non-communicable conditions. The review attributes this transition to chronic immune activation, persistent low-level inflammation, viral co-infections, and behavioral risk factors. In the Nigerian setting, these forces interact in what the authors describe as a syndemic: endemic hepatitis B, elevated human herpesvirus 8 seroprevalence, and oncogenic human papillomavirus circulate in the same populations that face delayed HIV diagnosis, late initiation of therapy, and inconsistent adherence. Each of these infections is itself capable of driving malignancy, and immunosuppression amplifies their carcinogenic effects, which helps explain why cancer patterns among Nigerians with HIV differ from those seen in the general population.

The distinction between AIDS-defining and non-AIDS-defining malignancies underpins much of the review’s analysis. The three classic AIDS-defining cancers, Kaposi sarcoma, invasive cervical cancer, and non-Hodgkin lymphoma, remain the most common malignancies among Nigerians living with HIV, though their relative frequencies vary considerably by region. Beyond these, people living with HIV face elevated risks of Hodgkin lymphoma, anal cancer, liver cancer, lung cancer, oral cancer, and breast cancer compared with HIV-negative populations. The mechanisms behind these non-AIDS-defining tumors are more heterogeneous, involving prolonged survival on therapy, age-related accumulation of cancer risk, residual immune dysregulation even when viral suppression is achieved, and co-infections such as hepatitis B and C, which are particularly relevant to hepatocellular carcinoma in a country where hepatitis B is endemic.

One emerging pattern highlighted in the review is ocular surface squamous neoplasia, a tumor of the eye’s surface that has been increasingly recognized in African cohorts of people living with HIV and is strongly associated with human papillomavirus and ultraviolet exposure. Its inclusion alongside more familiar malignancies illustrates how the spectrum of HIV-associated cancer in Nigeria extends well beyond the traditional triad, and how local environmental and infectious exposures shape which tumors emerge as immune suppression recedes.

The evidence base itself carries important caveats. Of the seventy-three sources included in the review, the majority were hospital-based and retrospective studies, a design that captures only patients who reach tertiary facilities and can substantially overrepresent severe or late-stage disease. Because study designs and reported outcomes varied widely, the authors synthesized their findings narratively rather than pooling them statistically, which means the figures reported should be read as indicative patterns rather than precise national rates. This limitation is compounded by the state of cancer registration in Nigeria, where the National System of Cancer Registries and the National Institute for Cancer Research and Treatment are still developing, and where gaps in coverage, data quality, and coordination prevent reliable population-level estimates.

The structural constraints the review documents extend well beyond data collection. Pathology services, which are essential for confirming any cancer diagnosis, are concentrated in urban centers, leaving much of the rural population without timely histologic confirmation. Radiotherapy capacity is inadequate for the population’s needs, molecular diagnostics and immunohistochemistry remain scarce, and out-of-pocket treatment costs push many patients into delayed or abandoned care. Because HIV services and oncology services operate largely in parallel rather than in integration, a patient in HIV care who develops a suspicious lesion may face referral pathways that are slow, fragmented, or unaffordable, by which point curative options have narrowed.

The authors argue that antiretroviral therapy programs themselves represent an underused platform for cancer prevention and early detection. Since people living with HIV already maintain regular contact with treatment facilities, these visits could serve as entry points for cervical screening, hepatitis B and C testing, HPV vaccination eligibility assessment, and symptom screening for common malignancies. Such integration would address two problems simultaneously: the late-stage presentation that dominates the reviewed literature, and the weak linkage between HIV and cancer services that the authors identify as a central systemic failure.

Looking forward, the review points to digital and molecular innovations as potential force multipliers for a resource-constrained system. Telepathology could extend scarce diagnostic expertise to peripheral facilities, electronic record linkage between HIV programs and cancer registries could finally illuminate the true national burden, and molecular diagnostics could enable targeted therapies that are currently unavailable to most Nigerian patients. Whether these tools are deployed effectively will depend on sustained investment and policy attention, which the authors argue is overdue for a burden they characterize as major, growing, and persistently overlooked.

Subject of Research: Burden, patterns, and challenges of HIV-associated malignancies in Nigeria: a narrative review

Article Title: Burden, patterns, and challenges of HIV-associated malignancies in Nigeria: a narrative review

Article References: Silas, O., Nyam, C., Tsok, Y., Eshioramine, M., Nnaegbuna, N., Golit, W., Okunowo, A., Osuagwu, C., Offor, J., Achusi, I., Beneye, T., Isikhuemen, M., Ekanem, V., Ekpe, L., Odusolu, P., Akinjo, A., TAGCReC, Rasheed, F., Ayoade, F., … George, S. (2026). Burden, patterns, and challenges of HIV-associated malignancies in Nigeria: a narrative review. Frontiers in Oncology, 16, Article 1959750. https://doi.org/10.3389/fonc.2026.1959750

Image Credits: AI Generated

DOI: 10.3389/fonc.2026.1959750

Keywords: Burden, patterns, challenges, HIV-associated, malignancies, Nigeria, narrative, review, scientific research

The starting point of the review is the neural substrate of speech itself. The authors distinguish carefully between overt speech, attempted speech, and imagined speech, and they show why this distinction matters enormously for interface design. Overt speech, in which a person actually articulates words, produces the richest and most spatially precise neural signals, but many candidate users cannot produce any observable movement at all. Attempted speech covers silent miming and attempts to speak without observable movement, and it preserves the natural intention-to-articulate mapping that makes decoding feel intuitive to the user. Imagined speech, by contrast, involves speech imagery without any attempt to articulate, and it raises a fundamental signal problem: the variable signal-to-noise ratio and limited temporal alignment of neural activity make imagined speech substantially harder to decode reliably. The review emphasizes that these three modes are not interchangeable, and that the choice among them shapes everything downstream, from electrode placement to decoder architecture to the subjective experience of using the device.

Hardware decisions form the second pillar of the synthesis. The review compares three surgically implanted recording modalities in a decision-oriented framework rather than as a simple ranking. Microelectrode arrays, or MEAs, penetrate brain tissue and record action potentials from individual neurons or small groups of neurons, offering the finest spatial and temporal resolution but raising questions about long-term stability and tissue response. Electrocorticography, or ECoG, places electrodes on the surface of the brain and provides a middle ground of spatial coverage and signal fidelity. Stereotactic electroencephalography, or SEEG, uses depth electrodes that are already familiar from clinical epilepsy monitoring, which could ease surgical adoption, though its sampling of speech-related cortex is constrained by electrode placement determined by clinical rather than communicative priorities. The review’s point is that there is no single best modality; the optimal choice depends on the neural representation being targeted, the surgical risk profile acceptable for the user, and the decoding strategy that will process the resulting signals.

On the algorithmic front, the review charts a decisive architectural shift. Early speech decoders relied on relatively simple sequence models, but the field has moved decisively toward attention-based architectures, particularly transformers, which can model long-range temporal dependencies in neural signals and integrate them with powerful language models. A particularly important trend is the use of articulatory intermediate representations. Rather than attempting to jump directly from neural activity to text or audio, these decoders first estimate articulatory features such as the movements of the lips, tongue, and larynx, and then synthesize speech from those intermediate targets. This approach leverages the fact that the brain’s motor cortex encodes speech in articulatory terms, and it provides a physically meaningful bridge between neural signals and acoustic output. The review also highlights language-prior-assisted frameworks, in which statistical knowledge about language structure constrains and improves decoding, effectively allowing the decoder to make educated guesses about likely words and sequences.

Perhaps the most persistent bottleneck the review identifies is generalization across subjects. Current systems typically require extensive individual calibration sessions before a user can communicate, and the review documents experimental strategies aimed at cross-subject generalization, in which models trained on one person’s neural data can be adapted to another with minimal additional data. Progress has been made, but the review is blunt about the current state: limited transfer without individual calibration remains a defining constraint of the field. Compounding this problem is long-term non-stationarity, the phenomenon by which neural signals drift over weeks and months as implants age, brain plasticity proceeds, and recording conditions change. This drift imposes a substantial recalibration burden on users and clinical teams, and the review argues that adaptive yet interpretable decoders are essential to managing it without sacrificing transparency about how decoding decisions are made.

Evaluation practices come in for pointed criticism. The review documents a landscape of heterogeneous and non-comparable evaluation metrics, in which different laboratories report performance using different tasks, different corpora, different scoring functions, and different user populations, making it nearly impossible to compare results across studies or to establish field-wide benchmarks. To address this, the authors propose a unified evaluation framework and a conceptual cross-linguistic, cross-task benchmark template that integrates objective, perceptual, expressive, conversational, and longitudinal metrics. The inclusion of longitudinal metrics is particularly significant, because the clinical value of a speech neuroprosthesis depends not on a single impressive demonstration but on sustained performance over months and years of daily use. The call for larger multilingual, multi-center longitudinal datasets follows directly from this evaluation gap, since most current evidence comes from small, single-language, single-center studies.

The translational guidance offered by the review is user-centered in a way that distinguishes it from purely technical surveys. The authors introduce the concept of agency-preserving shared control, a design philosophy in which the interface amplifies and supports the user’s communicative intent rather than overriding or replacing it. They also propose verifiable performance priorities and scenario-specific minimum viable product profiles that differentiate between two fundamentally different use cases. Reliability-first home communication prioritizes consistent, dependable output for everyday functional needs, even at the cost of natural expressivity. Fidelity-first conversational speech restoration, by contrast, prioritizes naturalistic, expressive output for rich social interaction, even if reliability is somewhat lower. The review argues that these two profiles demand different hardware choices, different decoding strategies, and different validation pathways, and that conflating them has contributed to the fragmented evidence base that currently limits clinical translation.

Clinical pathways receive sustained attention throughout the review, and the authors are clear that prospective clinical validation is a prerequisite for safe deployment. The field’s most celebrated results have come from small numbers of participants in highly controlled research settings, and the review argues that the evidence base must expand through multi-center longitudinal studies with harmonized protocols before regulators, clinicians, and insurers can reasonably support widespread adoption. The authors also call for transparent data-sharing and reporting practices with robust ethical safeguards, recognizing that intracranial recordings are among the most sensitive data a person can generate and that equitable deployment requires attention to who has access to these expensive, surgically implanted technologies. The review’s conclusion is a call to action rather than a victory lap: larger multilingual, multi-center longitudinal datasets, harmonized benchmarks, adaptive yet interpretable decoders, prospective clinical validation, and transparent reporting are all essential to accelerate the safe and equitable deployment of speech neuroprostheses.

What makes this review notable in a field crowded with optimistic projections is its insistence on coupling. The authors organize their synthesis around five coupled design questions, and their argument is that neural representations, recording choices, experimental design, decoding architectures, and translational constraints form an interdependent system in which no component can be optimized in isolation. A decoder that works brilliantly in the laboratory may fail in the home if the hardware cannot maintain signal quality over years. A recording modality that is surgically elegant may be useless if it samples the wrong neural representation. An evaluation metric that looks impressive in a paper may tell clinicians nothing about whether a person can actually hold a conversation. By making these couplings explicit and by providing a structured framework for navigating them, He, Siok, and Wang have produced something the field has lacked: a decision-oriented map of the entire translational landscape. For the individuals with severe communication impairments who stand to benefit most, the review’s message is ultimately one of cautious hope. The science is real, the engineering is advancing, and the clinical pathway is becoming clearer, but reaching robust, reproducible, and widely accessible speech brain-computer interfaces will require the field to solve its problems together, with shared benchmarks, shared data, and a shared commitment to the people these devices are meant to serve.

Subject of Research: Toward robust, reproducible, and widely accessible intracranial speech brain-computer interfaces: a comprehensive narrative review of neural mechanisms, hardware, algorithms, evaluation, clinical pathways and future directions

Article Title: Toward robust, reproducible, and widely accessible intracranial speech brain-computer interfaces: a comprehensive narrative review of neural mechanisms, hardware, algorithms, evaluation, clinical pathways and future directions

Article References: He, D., Siok, W. T., & Wang, N. (2026). Toward robust, reproducible, and widely accessible intracranial speech brain-computer interfaces: a comprehensive narrative review of neural mechanisms, hardware, algorithms, evaluation, clinical pathways and future directions. Artificial Intelligence Review. https://doi.org/10.1007/s10462-026-11728-x

Image Credits: AI Generated

DOI: 10.1007/s10462-026-11728-x

Keywords: Toward, robust, reproducible, widely, accessible, intracranial, speech, brain-computer, interfaces, comprehensive, narrative, review

The stellate ganglion is a collection of sympathetic nerve cells located deep in the neck, near the vertebral column and just below the base of the skull. It sits close to major blood vessels and plays a central role in regulating heart rate and cardiac function. Blocking this ganglion with local anesthetic, a technique that has been used for decades to manage pain and various autonomic disorders, temporarily dampens the sympathetic nervous system’s influence on the heart. The new review, led by researchers from multiple institutions, argues that this dampening effect may be particularly valuable in the perioperative setting, where the body’s stress response is in overdrive.

Postoperative atrial fibrillation arises from a complex interplay of factors. Surgery triggers a massive stress response, releasing inflammatory mediators and activating the sympathetic nervous system. The heart, already vulnerable from the procedure itself, becomes susceptible to the arrhythmia. The review notes that the arrhythmia is driven by sympathetic activation, inflammatory cytokine release, and oxidative stress, all of which persist even after the surgical insult has resolved. This persistence explains why the arrhythmia can appear days after the operation, when the initial surgical trauma has healed.

The review’s most intriguing argument concerns the duration of the block’s effects. Clinical experience suggests that the benefits of stellate ganglion block may persist well beyond the expected duration of the local anesthetic itself. The researchers propose that this persistence arises from the block’s ability to suppress neuroimmune activation, a process in which the nervous system and immune system communicate and amplify each other’s responses. By dampening this communication, the block may modulate inflammatory pathways in ways that extend beyond the temporary nerve calm.

The review highlights several less commonly studied cellular components that may contribute to postoperative atrial fibrillation. These include mast cells, immune cells that release inflammatory mediators and have been implicated in cardiac arrhythmogenesis. The researchers suggest that stellate ganglion block may influence these cellular players, modulating their activity in ways that reduce arrhythmia risk. This hypothesis, if confirmed, would represent a significant advance in understanding the arrhythmia’s cellular basis.

The technique itself is relatively straightforward. A clinician injects local anesthetic near the ganglion, typically from the right side of the neck, using ultrasound guidance or anatomical landmarks. The procedure is performed at the bedside and does not require craniotomy or major surgical intervention. The block temporarily dampens the sympathetic nervous system’s influence on the heart, reducing heart rate and cardiac stress. Clinical experience suggests that the technique is safe when performed by experienced practitioners, with the most common side effects being temporary hoarseness and Horner’s syndrome, a drooping of the eyelid.

The review notes that the block’s benefits may extend beyond the temporary nerve calm. Clinical studies suggest that the technique may modulate inflammatory pathways, reducing cytokine release and oxidative stress. The researchers propose that this immunomodulatory effect arises from the block’s ability to suppress neuroimmune activation, a process in which the nervous system and immune system communicate and amplify each other’s responses. By dampening this communication, the block may modulate inflammatory pathways in ways that extend beyond the temporary nerve calm.

The review’s authors argue that the technique’s potential benefits are particularly valuable in the perioperative setting, where the body’s stress response is in overdrive. Surgery triggers a massive release of inflammatory mediators and activation of the sympathetic nervous system, creating a perfect storm for arrhythmia. The block, by dampening this response, may reduce arrhythmia risk in ways that conventional antiarrhythmic drugs cannot. The researchers suggest that the technique may be particularly valuable for patients at high risk of postoperative atrial fibrillation, such as those undergoing valve surgery or those with pre-existing cardiac conditions.

The review acknowledges that the technique’s benefits are not yet definitively established. Clinical studies of stellate ganglion block for postoperative atrial fibrillation are limited, and the researchers call for larger, randomized trials to confirm the technique’s efficacy. The authors also suggest that future studies should investigate whether the block’s benefits can be predicted by specific biomarkers, such as inflammatory cytokine levels or heart rate variability. This personalized approach, if validated, would represent a significant advance in arrhythmia prevention.

The review’s publication comes at a time of growing interest in the autonomic nervous system’s role in cardiac arrhythmias. Researchers have long recognized that the sympathetic nervous system plays a central role in arrhythmogenesis, but the immune system’s contribution has been less well understood. The new review suggests that these two systems communicate and amplify each other’s responses, creating a neuroimmune axis that drives arrhythmia. The stellate ganglion block, by dampening this axis, may represent a novel therapeutic approach that conventional antiarrhythmic drugs cannot match.

The technique’s potential benefits extend beyond the perioperative setting. Clinical experience suggests that stellate ganglion block may be valuable for managing various autonomic disorders, including complex regional pain syndrome and PTSD. The block’s ability to modulate inflammatory pathways suggests that it may have broader applications in arrhythmia prevention and management. The researchers suggest that future studies should investigate whether the block’s benefits can be extended to other arrhythmias, such as ventricular tachycardia.

The review’s authors call for larger, randomized trials to confirm the technique’s efficacy and to investigate whether the block’s benefits can be predicted by specific biomarkers. This personalized approach, if validated, would represent a significant advance in arrhythmia prevention. The researchers also suggest that future studies should investigate whether the block’s benefits can be extended to other patient populations, such as those undergoing non-cardiac surgery.

The review’s publication represents a significant advance in understanding the autonomic nervous system’s role in cardiac arrhythmias. By highlighting the neuroimmune axis that drives arrhythmia, the researchers have opened a new therapeutic avenue that conventional antiarrhythmic drugs cannot match. The stellate ganglion block, by dampening this axis, may represent a novel approach to arrhythmia prevention that is both safe and effective. As clinical trials progress, this technique may become a standard part of perioperative care, offering patients a new way to avoid one of cardiac surgery’s most common complications.

Subject of Research: A narrative review of stellate ganglion block in management of post-operative atrial fibrillation with focus on immunomodulatory mechanisms

Article Title: A narrative review of stellate ganglion block in management of post-operative atrial fibrillation with focus on immunomodulatory mechanisms

Article References: Zhu, D., Radosevich, M. A., Szofer-Sendrowska, A., Kowalik, M. M., Li, W., Wittwer, E., Diedrich, D., & Laudanski, K. (2026). A narrative review of stellate ganglion block in management of post-operative atrial fibrillation with focus on immunomodulatory mechanisms. Frontiers in Anesthesiology, 5, Article 1898474. https://doi.org/10.3389/fanes.2026.1898474

Image Credits: AI Generated

DOI: 10.3389/fanes.2026.1898474

Keywords: narrative, review, stellate, ganglion, block, management, post-operative, atrial, fibrillation, focus, immunomodulatory, mechanisms

The biological rationale for why B vitamins might matter in cancer is compelling. These water-soluble compounds function as coenzymes in one-carbon metabolism, the biochemical network that supplies methyl groups for DNA methylation and nucleotides for DNA synthesis and repair. Folate is converted to S-adenosylmethionine, the universal methyl group donor for DNA methylation, while vitamin B12 acts as a cofactor in that reaction and vitamin B6 supports several key enzymes in methyl group metabolism. A deficiency in these nutrients could, in theory, disrupt DNA integrity, impair repair mechanisms, and increase genetic mutations. Yet the same pathways raise a darker possibility: in cells with pre-existing neoplastic lesions, abundant folate might also fuel the proliferation of damaged tissue, a concern that has shadowed folic acid supplementation trials for decades.

The review team conducted a structured literature search in PubMed up to 2 September 2025, prioritizing meta-analyses—including dose-response meta-analyses—of observational studies, and incorporating randomized controlled trials of B-vitamin supplementation when clinically relevant. The initial search yielded 512 records; after screening, 120 articles were retained for full-text assessment and 45 studies made it into the final narrative synthesis. Although the work was not designed as a systematic review, the selection process followed a structured and transparent approach inspired by PRISMA recommendations, with three reviewers resolving disagreements through discussion. The team also appraised methodological quality narratively, focusing on exposure assessment, confounding, selection bias, and outcome assessment.

The clearest signal emerged for vitamin B6. In a meta-analysis of 28 observational studies, Lai and colleagues reported an inverse association between dietary pyridoxine intake and colorectal cancer risk (OR 0.80; 95% CI 0.68–0.94), while circulating pyridoxal 5′-phosphate—the active form of the vitamin—showed an even stronger protective association (OR 0.54; 95% CI 0.35–0.84). Favorable associations were particularly evident among women and for colon cancer specifically. The review’s summary table reports a relative risk of 0.56 (95% CI 0.46–0.67, p < 0.001) for the highest versus lowest dietary intake categories, with biomarker-based analyses suggesting risk reductions of 30 to 50 percent. In a large field synopsis of 121 observational studies, Mocellin and colleagues found that higher dietary B6 intake was associated with reduced risk of gastrointestinal cancers overall (RR 0.68; 95% CI 0.61–0.75), although site-specific findings for gastric cancer were less consistent.

Vitamin B6 also stood out for pancreatic cancer, one of the deadliest malignancies. Wei and Mao observed strong inverse associations, with relative risks of 0.63 (95% CI 0.48–0.79) for dietary intake and 0.65 (95% CI 0.52–0.79) for circulating pyridoxal 5′-phosphate. Their dose-response analysis indicated a 9 percent risk reduction per 10 nmol/L increment in circulating levels. Beyond the digestive tract, a dose-response meta-analysis by Qiang and colleagues reported that higher dietary intake of vitamin B6 and folate was associated with reduced risk of esophageal cancer, with relative risks of 0.57 (95% CI 0.47–0.69) for B6 and odds ratios of 0.62 (95% CI 0.56–0.68) for folate.

Riboflavin showed a more modest but still favorable pattern. An observational meta-analysis by Liu and colleagues found a protective association between vitamin B2 intake and colorectal cancer risk (OR 0.83; 95% CI 0.75–0.91). A Korean case-control study by Lu and colleagues involving 377 individuals with gastric cancer and 756 healthy controls suggested that regular riboflavin intake offers protection against gastric cancer, particularly in carriers of specific genetic variants of the MTRR gene involved in cobalamin metabolism. However, the picture is not uniformly rosy: a recent retrospective case-control study exploring blood riboflavin levels and colorectal cancer onset reported an increased risk proportional to circulating concentration, a finding that underscores how the source, dose, and timing of exposure may critically modify any apparent association.

Folate delivered the most context-dependent results. Moazzen and colleagues reported that randomized controlled trials of folic acid supplementation showed no significant effect on colorectal cancer risk (RR 1.07; 95% CI 0.86–1.43), whereas prospective cohort studies of dietary folate intake indicated a significant risk reduction (RR 0.71; 95% CI 0.59–0.86). This divergence between observational and interventional evidence suggests that dose, timing of exposure, baseline folate status, and background fortification policies may critically influence observed associations. Differences between naturally occurring folates and synthetic folic acid may also partly explain the lack of concordance. For breast cancer, a dose-response meta-analysis of prospective studies by Zhang and colleagues found no overall association (RR 0.97; 95% CI 0.90–1.05), but a J-shaped relationship emerged, with the lowest risk between 200 and 320 μg/day and an increased risk above 400 μg/day. For ovarian cancer, Wang and colleagues found no significant association with either dietary or total folate intake. Regarding melanoma, one meta-analysis of randomized controlled trials suggested a reduced risk with folic acid supplementation (RR 0.47; 95% CI 0.23–0.94), but larger pooled analyses involving more than 50,000 participants did not confirm this finding.

Vitamin B12 proved the most inconsistent of the four. A dose-response meta-analysis by Sun and colleagues indicated a modest inverse association with colorectal adenoma and cancer risk (RR 0.963 per +4.5 μg/day), with stronger effects for dietary intake compared with total intake. Yet for esophageal adenocarcinoma, the same dose-response meta-analyses revealed a positive association, with each additional 1 μg/day of cobalamin intake associated with a 2 percent increase in risk (OR 1.30; 95% CI 1.05–1.62). The review authors caution that this finding should not be overlooked, as it suggests cobalamin may have site-specific and context-dependent associations with cancer risk rather than uniformly neutral or protective effects. Possible effect modifiers include obesity, gastroesophageal reflux disease, alcohol consumption, and overall dietary patterns, alongside residual confounding inherent to observational research. For pancreatic cancer, no significant associations were identified for vitamin B12 (RR 0.99; 95% CI 0.59–1.38).

The review also contextualizes these findings within a broader landscape of B-vitamin oncology research. Long-term high-dose supplementation with vitamins B6 and B12 has been associated with increased lung cancer risk in specific subgroups such as male smokers, according to the VITAL cohort study by Brasky and colleagues. Randomized trials of folic acid supplementation have generally shown no significant protective effect on cancer incidence and, in some cases, have raised concerns about potential increases in cancer risk or progression, particularly in populations with pre-existing neoplastic lesions or high baseline exposure. Emerging evidence from Mendelian randomization studies provides additional support for a potential protective role of genetically predicted vitamin B6 across multiple cancer sites, though findings remain limited in number. Meanwhile, high-dose pyridoxine supplementation has been associated with neurotoxicity, particularly sensory neuropathy, a risk that becomes clinically relevant when supplementation exceeds physiological requirements or is used long term.

The authors conclude that the current body of evidence does not support the use of high-dose B-vitamin supplementation for primary cancer prevention in the general population. Rather, the findings are consistent with the importance of achieving adequate B-vitamin intake through balanced dietary patterns. The review acknowledges several limitations: the observational nature of most underlying evidence, susceptibility to residual confounding and dietary misclassification through food frequency questionnaires, considerable variability in baseline dietary patterns and fortification policies across geographic regions, and the frequent use of pharmacological doses in randomized trials that may not reflect habitual dietary intake. Future research should conduct well-designed prospective cohort studies with repeated dietary and biomarker assessments, integrate genetic and epigenetic markers to clarify mechanisms, and target high-risk subgroups such as individuals with folate deficiency, high alcohol consumption, pre-existing preneoplastic lesions, or genetic variants affecting one-carbon metabolism. Until then, the message remains clear: B vitamins are essential, but more is not necessarily better when it comes to cancer prevention.

Subject of Research: B vitamins intake and cancer risk: a structured narrative review of evidence on riboflavin, pyridoxine, cobalamin and folate

Article Title: B vitamins intake and cancer risk: a structured narrative review of evidence on riboflavin, pyridoxine, cobalamin and folate

Article References: Bertuccioli, A., Palazzi, C. M., Massaro, I. A., Cazzaniga, M., Cavecchia, I., Matera, M. R., Biagioli, V., Imperatori, L., Di Pierro, F., & Belli, A. (2026). B vitamins intake and cancer risk: a structured narrative review of evidence on riboflavin, pyridoxine, cobalamin and folate. Pathology & Oncology Research, 32, Article 1612380. https://doi.org/10.3389/pore.2026.1612380

Image Credits: AI Generated

DOI: 10.3389/pore.2026.1612380

Keywords: vitamins, intake, cancer, risk, structured, narrative, review, evidence, riboflavin, pyridoxine, cobalamin, folate

Designing clinical trials for dystonia poses formidable methodological challenges because the disorder is both clinically and etiologically heterogeneous. A mechanism-based approach requires deeper understanding of underlying pathophysiology and identification of factors that may impact disease progression, while a phenotypic approach focuses on improving dystonic symptoms by discovering new drugs or building upon existing therapies. Primary outcome measures have been variable, relying mainly on patients’ subjective reports of therapeutic benefit, and objective quantification remains difficult due to the diversity of dystonia presentations. In 2013, the Movement Disorders Society commissioned a task force to review 36 potential rating scales, ultimately recommending seven for craniocervical, laryngeal, and generalized dystonia, including the Toronto Western Spasmodic Torticollis Rating Scale for cervical dystonia, the Jankovic Rating Scale for blepharospasm, the Voice Handicap Index for laryngeal dystonia, and the Fahn-Marsden Dystonia Rating Scale for generalized dystonia. The review’s authors emphasize that development of sensitive and objective clinical outcome measures will be a crucial prerequisite for successful future trials.

On the pharmacological front, the past five years have seen trials targeting the neurotransmitter pathways implicated in dystonia, including dopamine, acetylcholine, and GABA. Levodopa remains the cornerstone treatment for dopa-responsive dystonia, which accounts for about five percent of childhood dystonias, but there are currently no active clinical trials studying dopaminergic therapies. Trihexyphenidyl, an anticholinergic drug introduced in the 1950s, continues to be one of the most effective treatments for generalized dystonia, though side effects like confusion, dry mouth, and drowsiness often limit its use in adults. The Children’s Mercy Hospital in Kansas City is running the TRIKE2 trial, a Phase 1, 16-week, single-arm pilot study evaluating how CYP2D6 and CYP2C19 genotypes influence trihexyphenidyl metabolism in 40 pediatric patients with dystonic cerebral palsy, aiming to inform the feasibility of future pharmacogenomic trials. Meanwhile, the PREDICT-ITB trial at Baylor College of Medicine will enroll 65 children with dystonic cerebral palsy through 2029, following a standardized intrathecal baclofen titration protocol with the Barry-Albright Dystonia Scale as the primary outcome measure at baseline, three, six, and twelve months.

One of the most striking results came from the Massachusetts Eye and Ear Infirmary, which completed recruitment in 2024 for a randomized, placebo-controlled crossover trial of sodium oxybate in spasmodic dysphonia and voice tremor. The trial enrolled 117 participants with laryngeal dystonia, both alcohol-responsive and alcohol-nonresponsive, with and without voice tremor. Results published in 2025 showed that sodium oxybate significantly reduced symptom severity in the alcohol-responsive group, with a mean Visual Analog Scale severity score of 28.0 versus 14.2 for placebo, a difference that reached statistical significance at p = 0.008. No significant benefit was observed in the alcohol-nonresponsive group. Adverse events were mild to moderate, including dizziness in 48 percent, daytime sleepiness in 20 percent, and mild nausea in 14 percent, without serious adverse events. This is the first controlled clinical trial demonstrating sodium oxybate as a therapeutic option for laryngeal dystonia and voice tremor, particularly for alcohol-responsive patients.

VMAT-2 inhibitors, which received FDA approval as valbenazine and deutetrabenazine in 2017 for tardive dystonia and dyskinesia, have been repurposed in recent trials. From 2021 to 2023, the Orthopedic Foundation assessed valbenazine for cervical dystonia in a Phase 4 open-label study of 13 participants who completed 16 weeks of treatment titrated to 80 milligrams per day while maintaining botulinum toxin treatment. Preliminary abstract results reported significant improvements in the TWSTRS at p = 0.01 and in the Visual Analog Scale for pulling at p = 0.02. The University of Pennsylvania recently completed the AUDYT trial, an open-label study of deutetrabenazine in 15 adults with non-dopa-responsive isolated dystonia, titrating the drug from 12 to a maximum of 48 milligrams per day over 12 weeks. Only 40 percent of participants tolerated the maximum dose, and although the median change in the Global Dystonia Rating Scale was zero, the variability was notably wide, suggesting a need for a larger cohort in future trials. Glutamate-targeting drugs have also been explored: perampanel, an AMPA receptor antagonist, showed modest improvements in pain relief and sleep quality in cervical dystonia but was limited by tolerability, while dipraglurant, a negative allosteric modulator of the mGlu5 receptor, was well-tolerated in blepharospasm but provided no meaningful clinical benefit.

Botulinum toxin therapy continues to gain traction as a high-yield area for dystonia research, with five commercially available formulations FDA-approved for first-line treatment of cervical dystonia and only two approved for blepharospasm. The most significant recent advance is daxibotulinumtoxinA, whose molecular size and unique stabilizing excipient peptide enhance binding through electrostatic charge and reduce spread of the toxin, leading to a longer therapeutic duration. In the pivotal ASPEN-1 Phase 3 trial completed in 2020 across 60 international sites, 291 participants with cervical dystonia were randomized to daxibotulinumtoxinA 125 units, 250 units, or placebo. The placebo group had a mean TWSTRS reduction of 4.3 points compared to 12.7 points in the 125-unit group and 10.9 points in the 250-unit group, both highly significant. The duration from injection to loss of 80 percent of peak effect was significantly longer than other botulinum toxin type A formulations, lasting 24 weeks and 20 weeks respectively, with no dose-dependent increases in adverse events. The subsequent ASPEN-OLS open-label extension enrolled 357 patients over 52 weeks, confirming that successive treatments were well-tolerated with dysphagia rates remaining stable or decreasing after repeat dosing.

Other botulinum toxin formulations are being validated in clinical trials even without FDA approval for dystonia. PrabotulinumtoxinA, FDA-approved for glabellar lines, completed a Phase 2 randomized placebo-controlled trial in 57 patients with cervical dystonia, reporting no treatment-related serious adverse events up to 20 weeks, with peak efficacy occurring within two to eight weeks and wearing off starting at 16 weeks. NeubotulinumtoxinA, developed in South Korea as a cost-effective alternative, demonstrated comparable efficacy to abobotulinumtoxinA in a 48-week crossover study of 52 Thai patients with cervical dystonia. LetibotulinumtoxinA showed significant reduction in the Jankovic Rating Scale at four weeks in a 220-participant blepharospasm trial, confirming non-inferiority. Beyond new formulations, trials are optimizing injection parameters: a Phase 4 noninferiority study of 207 patients demonstrated that shorter incobotulinumtoxinA injection intervals of eight weeks were safe and effective for patients with early waning of benefit, while a Western University trial in Canada showed that kinematic-guided onabotulinumtoxinA injection achieved faster symptom reduction than visual assessment alone, with the kinematics group reducing TWSTRS from 39.1 to 27.9 points at six weeks.

Deep brain stimulation, FDA-approved for dystonia in 2003 under a Humanitarian Device Exemption, has seen exciting progress with new targets and innovative programming techniques. A 2024 French multicenter trial published by Cuartero and colleagues implanted dual DBS in 12 patients with medically refractory dystonia, comparing GPi, STN, and thalamic centromedian-parafascicular monotherapy against combined targets. The study confirmed the efficacy and safety of GPi-DBS with 44 percent improvement in dystonia severity at three months, but found no additional benefit from dual-target stimulation or alternative targets alone. In China, the MEIGES trial at Beijing Tiantan Hospital is enrolling 110 patients with idiopathic craniofacial dystonia to investigate whether STN-DBS is noninferior to GPi-DBS, while Qilu Hospital is comparing the two targets in Meige syndrome with 100 patients. Peking University People’s Hospital published results from 98 patients with primary Meige syndrome, showing BFMDRS improvements of 61 to 66 percent at one year and 65 to 71 percent at three years for DBS, compared to 58 percent at one year and 50 percent at three years for pallidotomy. Two active trials at Indiana University and Massachusetts Eye and Ear are exploring DBS for laryngeal dystonia using novel outcome measures including acoustic voice recordings, high-speed videoendoscopy, and intraoperative microelectrode recordings of brain signals during speech production.

Innovative DBS programming is advancing toward personalized therapy. The University of California, San Francisco has enrolled 25 patients, including five with dystonia, in a closed-loop DBS study formulating individualized adaptive algorithms based on specific cortical biomarkers, with each patient undergoing four weeks of open-loop versus four weeks of adaptive mode stimulation. Wuerzburg University Hospital is recruiting 80 participants for a prospective randomized double-blind crossover trial comparing computer-assisted image-based DBS programming against conventional clinician-based programming, aiming to optimize stimulation settings and reduce non-responder rates. Novel brain lesioning techniques are also being tested as alternatives to DBS. The University of Maryland launched a Phase 1 trial in 2024 for MR-guided focused ultrasound pallidotomy in task-specific focal hand dystonia, enrolling 10 patients who failed botulinum toxin and DBS, while the University of the Philippines Manila is investigating focused ultrasound pallidothalamic tractotomy for X-linked dystonia-parkinsonism, now available through expanded access until 2026. The All India Institute of Medical Sciences is planning a cohort study and registry of 250 patients undergoing lesioning procedures for movement disorders, with long-term functional outcomes assessed over a year.

Non-invasive brain stimulation, gene-targeted therapies, and rehabilitative approaches round out the therapeutic landscape. Transcranial magnetic stimulation has shown potential in small cohorts but variability in technique, administration, and response remains a barrier to FDA approval for dystonia. A randomized crossover trial at AIIMS New Delhi targeting the inferior parietal lobule in 16 patients with task-specific focal hand dystonia showed significant improvement in the Writer’s Cramp Rating Scale after real stimulation compared to sham, while Duke University is recruiting for accelerated TMS trials using functional MRI to guide individualized stimulation. Transcranial ultrasound stimulation is emerging as a novel modality, with the University Health Network in Toronto studying low-intensity ultrasound to non-invasively stimulate the basal ganglia. Gene therapy has made rapid advances: in November 2024, the FDA approved the first gene therapy for aromatic L-amino acid decarboxylase deficiency based on positive Phase 1/2 results, with the National Taiwan University Hospital trial showing mean Peabody Developmental Motor Scales-2 scores increasing from 10.4 to 80.5 and cerebrospinal fluid homovanillic acid rising from 6.6 to 30.2 nanomoles per liter in 26 patients. In vitro studies are exploring CRISPR-Cas9 disruption of mutant TorsinA in DYT1 dystonia fibroblasts, showing selective reduction of mutant protein with phenotypic recovery, though no active clinical trials yet test gene-targeted therapy in hereditary dystonia patients. Rehabilitative techniques including vibration therapy, transcutaneous electrical nerve stimulation, osteopathic manipulation, behavioral exercises, and neurofeedback brain-computer interface training are all being explored as adjunctive therapies, with a French TENS trial showing an eight-point TWSTRS reduction from baseline in painful cervical dystonia and the University of Minnesota demonstrating that laryngeal vibrotactile stimulation can improve voice quality within 15 to 20 minutes, though the benefit decays within 30 minutes. The review’s authors conclude that successful therapy development should be based on precise understanding of pathophysiology, validated by sensitive clinical outcome measures in well-designed trials, and supported by correlating changes in biomarkers, with a biology-tailored approach essential as understanding of dystonia subtypes advances.

Subject of Research: Neuroscience

Article Title: A narrative review: clinical trials in therapeutic interventions for dystonia (2020 – 2025)

Article References: Ly, A., Mushtaheed, A., Soliman, M. E., Karp, B., & Cho, H. J. (2025). A narrative review: clinical trials in therapeutic interventions for dystonia (2020 – 2025). Dystonia, 4, Article 14547. https://doi.org/10.3389/dyst.2025.14547

Image Credits: AI Generated

DOI: 10.3389/dyst.2025.14547

Keywords: dystonia, clinical trials, botulinum toxin, deep brain stimulation, gene therapy, movement disorders, neurology, transcranial magnetic stimulation, narrative, review, clinical, trials

The authors, Michael F. Loncharich, Brenna E. Cafeo and Evan B. Noble, searched PubMed for lupus clinical trials published in the past five years, combed clinicaltrials.gov for phase III and phase IV studies with no date restrictions, and scanned the American College of Rheumatology Convergence 2025 abstract sessions for emerging literature. Phase I trials were excluded from the formal scope of the review, although the most eye-catching results in the field—chimeric antigen receptor T-cell therapy, or CAR T—come precisely from early-phase work and case series that the authors discuss as a rapidly expanding form of cell-based gene therapy migrating from oncology into autoimmune disease.

The technical logic behind CAR T in lupus is worth unpacking. T lymphocytes are engineered ex vivo to express a chimeric antigen receptor that redirects their cytotoxicity toward B cells, the source of the pathogenic autoantibodies that drive lupus pathology. The common target antigens are CD19, expressed broadly on B-lineage cells, and B-cell maturation antigen, or BCMA, which is prominent on plasma cells. This matters because conventional B-cell-depleting drugs have repeatedly failed in lupus, and the review offers two mechanistic explanations for why engineered T cells might succeed where monoclonal antibodies did not. First, B cells can remain hidden from biologics in tissues such as the synovial membrane, tonsils and lymph nodes, where rituximab has been shown not to deplete B cells in secondary lymphoid organs. Second, plasma cells and pro-B cells lack CD20, the target of rituximab and obinutuzumab, which shields them from depletion. CD19 or BCMA CAR T cells can penetrate these tissues and reach plasma cells and pro-B cells that antibodies cannot.

The clinical data are striking. In 2022, Mackensen and colleagues treated five patients with refractory lupus using autologous CD19 CAR T cells at a dose of one million cells per kilogram, following lymphodepleting chemotherapy with cyclophosphamide and fludarabine. All five achieved DORIS remission—the Definition of Remission in SLE—within three months, with durable responses of five to eighteen months, disappearance of anti-dsDNA and anti-Smith autoantibodies, and only one case of mild cytokine-release syndrome. In 2024, Muller and colleagues reported on eight patients, all of whom met both DORIS and lupus low disease activity state criteria after six months, with SLEDAI-2K scores remaining at zero for up to twenty-nine months and the same seroconversion of autoantibodies. More recently, Hu and colleagues completed an open-label trial of BCMA CAR T in seven patients with active lupus nephritis class III through V who had failed glucocorticoids and at least two immunosuppressants or biologics. The median SLEDAI improved from eighteen at baseline to zero at six months and stayed there for four years; five patients achieved DORIS remission and the remaining two met LLDAS criteria, with one grade 1 cytokine-release syndrome, no severe infections, and lymphodepletion resolving within four weeks.

Compound CAR T, carrying dual targets of BCMA and CD19, has also been tested in a phase 1 open-label trial of thirteen participants. Nine met DORIS remission and twelve met LLDAS criteria, eleven showed significant improvements in estimated glomerular filtration rate and proteinuria, and a repeat renal biopsy in one patient in drug-free remission revealed clearance of glomerular IgG immunocomplexes—direct histological evidence that the therapy removed the immune deposits driving nephritis. Neutropenia resolved within six weeks and B cells recovered within seven months, suggesting the deep depletion is not permanent. The authors caution that CAR T data remain limited to case series and phase I trials, but the early signal of sustained remission in refractory cases is among the most consequential developments in the field.

Among conventional biologics, the type II anti-CD20 antibody obinutuzumab stands out. Unlike type I agents such as rituximab and ocrelizumab, which failed in the EXPLORER, LUNAR and BELONG trials, obinutuzumab was glycoengineered for greater FcγRIIb affinity, permitting greater antibody-dependent cellular cytotoxicity with less reliance on complement, and it redistributes less to membrane lipid rafts, resulting in less internalization of the target. The phase II NOBILITY trial missed its primary endpoint of complete renal response at week 52 but showed significant improvements in key secondary endpoints including complete renal response at week 104 and partial renal remission rates. The phase III REGENCY trial then met its primary endpoint, with complete renal response at week 76 of 45 percent versus 33 percent for placebo, significantly favored secondary endpoints including treatment failure and rescue therapy need, no unexpected safety results, and fewer deaths or renal events in the treatment group. That profile carried obinutuzumab to FDA approval late in 2025.

The BAFF and APRIL cytokine axis, which promotes survival and maturation of immature B cells and expands autoreactive populations, has produced a mixed record. Belimumab, the first anti-BAFF agent approved in 2011, now has six-to-eight-year extension data showing no new or unexpected safety signals, discontinuation rates due to adverse events as low as nine percent, and flare rates as low as fifteen percent over seven years. Blisibimod failed its phase II PEARL-SC and phase III CHABLIS-SC1 primary endpoints despite biomarker improvements and corticosteroid sparing. Tabalumab failed when dosed monthly in the ILLUMINATE trials but showed better SRI-5 response when dosed biweekly, without differences in adverse events. Ianalumab, a BAFF receptor inhibitor, met its phase II primary endpoint with significantly higher SRI-4 response and sustained corticosteroid reduction, with no increased serious adverse events or infections. Atacicept, a TACI fusion protein, was complicated by two deaths in its high-dose arm that were adjudicated non-treatment related, but the closely related telitacicept met its phase III primary endpoint in China with a modified SRI-4 response of 67 percent versus 33 percent for placebo, a difference detectable as early as week 4, and no difference in serious infections. Telitacicept was approved for SLE in China in 2021.

Intracellular kinase inhibitors tell a more nuanced story. Baricitinib, a selective JAK1 and JAK2 inhibitor, produced conflicting results in the SLE-BRAVE trials: the 4-milligram dose outperformed placebo on SRI-4 in SLE-BRAVE I, but no dose beat placebo in SLE-BRAVE II, and a pooled post-hoc analysis failed while noting an unusually high placebo SRI-4 response rate of 46 percent. Deucravacitinib, a TYK2 inhibitor that binds the inactive regulatory domains of its target kinases rather than the active catalytic sites, theoretically permitting a more durable response, showed better SRI-4 responses than placebo across all doses in the phase II PAISLEY study—58, 50 and 45 percent versus 34 percent—at 32 weeks, with better BICLA, CLASI, LLDAS and joint count outcomes, though with higher rates of infections and cutaneous events; phase III trials are ongoing. Elsubrutinib, a Bruton’s tyrosine kinase inhibitor, failed its primary endpoint, and the review offers a mechanistic explanation: in plasmacytoid dendritic cells, BTK inhibition blocks interferon-alpha production via TLR-9 but not via TLR-7, and TLR-7 stimulation enhances interferon-alpha production by disinhibiting the BDCA-2 pathway, potentially worsening the interferon signature that drives lupus.

Anifrolumab, the first-in-class global type I interferon receptor inhibitor approved in 2021, now has long-term data confirming durable efficacy: a three-year open-label extension of the TULIP trials found greater SLEDAI improvement, greater corticosteroid dose reduction, and a fifty percent lower annualized flare rate than placebo, with marginally lower exposure-adjusted adverse event rates and no significant differences in nonopportunistic infections. Higher rates of influenza and herpes zoster were noted in the original trials. However, anifrolumab failed in lupus nephritis: neither the TULIP-LN trial nor its two-year extension found significant differences versus placebo, although the IRIS phase III trial is expected to complete in September 2026. Voclosporin, the calcineurin inhibitor approved for lupus nephritis in 2021, achieved complete renal remission rates of 41 to 71 percent versus 23 percent for placebo in its pivotal trials, and a three-year safety study with repeat renal biopsy found no change in chronicity, no vascular lesions and no tubular compartment changes, indicating genuine long-term tolerability.

Elsewhere in the pipeline, litifilimab, which blocks blood dendritic cell antigen 2 on plasmacytoid dendritic cells, met its endpoints in both cutaneous lupus and SLE trials with better CLASI responses, joint counts and SRI-4 responses than placebo, and in the SLE trial more adverse events occurred in the placebo group. Iberdomide, a cereblon ligand that degrades the transcription factors Ikaros and Aiolos, thereby inhibiting BAFF- and CD40L-induced proliferation, showed a tolerable safety profile and, in a trial powered for efficacy, significantly outperformed placebo on SRI-4, SLEDAI and CLASI responses. Cenerimod, a selective S1P1 receptor modulator that traps lymphocytes in lymphoid organs to prevent end-organ damage, showed a 1.43-fold greater likelihood of response than placebo, with phase III trials ongoing. By contrast, ustekinumab, secukinumab, dapirolizumab and low-dose interleukin-2 all failed to beat placebo in their initial analyses, though the LUPIL-2 trial found a roughly thirty percent estimated response rate once two sites with a hundred percent placebo response rate were excluded. The Walter Reed authors conclude that obinutuzumab and telitacicept have demonstrated both safety and efficacy in phase III trials, that litifilimab, ianalumab, deucravacitinib and iberdomide are showing promise in phase II, and that CAR T, though still early, is delivering sustained remission in the most refractory lupus cases ever studied.

Subject of Research: Safety and efficacy of novel therapeutics in lupus: a narrative review

Article Title: Safety and efficacy of novel therapeutics in lupus: a narrative review

Article References: Loncharich, M. F., Cafeo, B. E., & Noble, E. B. (2026). Safety and efficacy of novel therapeutics in lupus: a narrative review. Frontiers in Lupus, 4, Article 1800946. https://doi.org/10.3389/flupu.2026.1800946

Image Credits: AI Generated

DOI: 10.3389/flupu.2026.1800946

Keywords: Safety, efficacy, novel, therapeutics, lupus, narrative, review, scientific research

The review, conducted by Amulya Sathish of the Institute for Special Education and Hanna Ehlert of the Institute of Information Processing, both at Leibniz University Hannover, synthesized 22 peer-reviewed studies published between 2015 and 2025. The authors searched PubMed, Scopus, Web of Science, and Google Scholar for research applying AI or machine learning to cochlear implant rehabilitation, ultimately grouping the evidence into four emerging domains: machine-learning-based prediction of implant outcomes, deep-learning approaches for speech enhancement and signal processing, AI-assisted auditory and speech therapy tools, and tele-rehabilitation platforms that integrate algorithmic feedback.

The search began with 1,842 records after deduplication. Two hundred fourteen studies underwent full-text review, and only 22 met all eligibility criteria, which required human cochlear implant users, AI or machine learning methods, and standardized speech, language, or auditory outcomes. The strict filters excluded conference abstracts, editorials, case reports, and studies without full text, underscoring how narrow the evidence base remains despite a decade of growing interest.

In the outcome prediction domain, seven studies showed that supervised learning models can outperform conventional statistical methods when estimating post-implantation speech perception. A Korean study of 120 postlingually deaf adults found that Random Forest Regression achieved a correlation of 0.96 between predicted and observed word recognition scores, compared with 0.70 for linear regression, while reducing mean absolute error from 15.6 to 6.1 percentage points. Duration of deafness emerged as the most influential predictor, followed by age at implantation and duration of hearing aid use. A separate study of 82 South Korean children used Random Forest to predict speech intelligibility with 78.8 percent accuracy, identifying implant wear time, vocabulary, household income, age, and gender as key variables.

The largest prediction study to date, published in Ear and Hearing in 2025, applied XGBoost to 1,877 cochlear implant recipients in the United States. The model slightly outperformed traditional regression in predicting word and sentence recognition scores at six months post-implantation, with mean absolute error improvements of roughly one to two percentage points. While the gains were not clinically dramatic for overall prediction, XGBoost significantly improved classification of low performers, showing better calibration and discrimination. The authors of the review note that such models could support more personalized counseling before surgery, helping patients and families form realistic expectations.

Deep-learning speech enhancement represents the technically most mature domain in the review. Ten studies demonstrated that neural networks can meaningfully improve speech intelligibility for implant users in noisy environments, often outperforming classical noise reduction methods. Early work with deep denoising autoencoders showed significant gains for Mandarin-speaking recipients under competing speech at signal-to-noise ratios of 0 and 5 decibels. Recurrent neural networks later improved intelligibility in babble noise and reduced perceived listening effort, with benefits persisting even in unseen acoustic conditions. More recent architectures, including the SepFormer speech separation model and a deep complex convolution transformer network, restored intelligibility in multi-talker interference without degrading speech quality.

One 2024 study in the Journal of the Acoustical Society of America pushed the approach further by fusing deep-learning models across two microphones for bilateral implant users. Multi-microphone deep-learning models improved speech reception thresholds by approximately 7.4 to 10.3 decibels in noisy, reverberant conditions, outperforming single-microphone versions and demonstrating the value of spatial information for suppressing noise and reverberation. The review authors emphasize that these laboratory gains could help generalize therapy improvements to everyday communication, where background noise remains one of the biggest barriers for implant recipients.

Yet a persistent challenge runs through this literature: the gap between laboratory performance and real-world deployment. Current deep-learning enhancement systems require offline or near-real-time processing and are not yet integrated into clinical implant processors. Computational latency, hardware constraints of existing implant architectures, and the need for device-specific calibration remain significant engineering barriers. Pediatric-specific enhancement models have not been developed; existing systems are trained primarily on adult speech corpora, which may limit performance for children given differences in vocal tract characteristics and speech acoustics.

AI-assisted therapy tools and tele-rehabilitation platforms show promise but rest on a narrower foundation. Three studies of computer-based auditory training found improvements in trained speech recognition tasks, particularly consonant recognition, and one 2024 study of 114 new adult recipients linked computer-based auditory training to durable improvements in quality of life across all domains at twelve months post-implantation, though speech recognition scores themselves did not improve. Adaptive phoneme discrimination training produced greater gains than non-adaptive training in experienced adult users, establishing that algorithmic adaptation enhances training efficiency. In tele-rehabilitation, an AI-guided remote fitting system based on psychoacoustic self-tests proved feasible in selected users, and a remote monitoring test battery successfully identified 94 percent of clinical issues and correctly predicted the need for clinic visits in 99 percent of cases, with high patient and clinician acceptance.

The review authors identify several cross-cutting concerns that must be resolved before AI can achieve meaningful clinical impact. Most machine-learning models have been developed on datasets from high-income countries and predominantly adult populations, raising concerns about systematic underperformance for pediatric users, patients from diverse linguistic backgrounds, and recipients in low- and middle-income settings. Individual neurobiological heterogeneity presents a distinct validity threat: group-averaged demographic predictors may not capture the biological variability that drives outcome differences, as evidenced by findings that individual perceptual measures like spectral ripple discrimination correlate more strongly with speech recognition than age alone. Model explainability also matters, since clinicians cannot be expected to act on opaque black-box predictions; the authors recommend integrating explainable AI methods such as SHAP values as standard practice, while cautioning that interpretability cannot correct for biased or underspecified training data.

Regulatory readiness adds another layer of complexity. The European Union classifies healthcare outcome prediction tools as high-risk AI, mandating strict conformity assessments and continuous post-market monitoring, requirements that extend to automated therapy adaptation algorithms and remote monitoring systems used in implant rehabilitation. The review also highlights extensive methodological heterogeneity across studies, with no agreed accuracy thresholds, standardized outcome batteries, or common open-source data infrastructure to enable cumulative progress. The authors call for collaborative benchmarking datasets, minimum reporting standards for AI architectures in audiology, and consensus outcome batteries developed jointly by data scientists, engineers, and practicing clinicians.

Perhaps the most significant gap concerns ecological validity. AI-assisted therapy tools have been evaluated almost exclusively on isolated phoneme discrimination and word-level tasks, with no published tool providing automated feedback for connected speech or spontaneous language production, the communicative contexts most relevant to real-world functional outcomes. This is particularly consequential for pediatric recipients, whose rehabilitation goals extend to narrative competence, conversational turn-taking, and complex syntax in natural interactions. Similarly, tele-rehabilitation platforms have demonstrated clinical equivalence for structured auditory tasks delivered remotely but have not been evaluated in naturalistic speech contexts. Fully autonomous AI-driven tele-rehabilitation, in which algorithms independently adapt therapy content, intensity, and scheduling based on real-time outcome data, has not yet been demonstrated in implant populations.

The review concludes that AI and machine learning are potent new tools that can supplement, not replace, professional expertise in cochlear implant rehabilitation. Personalized outcome estimates, better auditory input through sophisticated signal processing, and improved therapy delivery via adaptive and remote platforms all show promise. But the integration of these innovations into standard clinical practice remains in its infancy, requiring prospective multicenter trials, standardized outcome measures that reflect functional communication in everyday life, and close collaboration between data scientists, engineers, and clinicians. With cautious integration and thorough evaluation, these technologies could significantly improve long-term communication outcomes for both pediatric and adult implant users.

Subject of Research: Artificial intelligence and machine learning in cochlear implant rehabilitation: a narrative review of outcome prediction, speech enhancement, and therapy-support applications

Article Title: Artificial intelligence and machine learning in cochlear implant rehabilitation: a narrative review of outcome prediction, speech enhancement, and therapy-support applications

Article References: Sathish, A., & Ehlert, H. (2026). Artificial intelligence and machine learning in cochlear implant rehabilitation: a narrative review of outcome prediction, speech enhancement, and therapy-support applications. Frontiers in Audiology and Otology, 4, Article 1922746. https://doi.org/10.3389/fauot.2026.1922746

Image Credits: AI Generated

DOI: 10.3389/fauot.2026.1922746

Keywords: Artificial, intelligence, machine, learning, cochlear, implant, rehabilitation, narrative, review, outcome, prediction, speech

The answer, according to the evidence, is a qualified yes. Using PRISMA 2020 guidelines, the researchers searched PubMed, Web of Science, and Google Scholar for studies published between 2015 and 2024. The initial sweep identified 495 records. After removing duplicates, screening titles and abstracts, and assessing 66 full-text papers for eligibility, only twelve studies survived the rigorous selection process. Each was critically appraised using the Joanna Briggs Institute checklist for analytical cross-sectional studies, and all twelve scored between six and eight out of eight — a rating the authors classified as good quality.

Because the included studies measured such different outcomes — healthcare utilisation, enrolment rates, out-of-pocket spending — a quantitative meta-analysis was impossible. Instead, the team employed a thematic narrative synthesis, coding findings iteratively into descriptive and analytical themes. The results converge on three central conclusions: health insurance increases healthcare uptake, reduces dependence on out-of-pocket payments, and yet remains so low and so unequal that its benefits reach only a fraction of those who need them most.

The strongest evidence on utilisation came from nationally representative analyses of the Nigeria Demographic and Health Survey. One study of 8,006 women of reproductive age, using binary logistic regression, found a statistically significant positive association between insurance enrolment and the use of antenatal care, skilled birth attendants, and postnatal care. A second analysis of 6,761 women found that insured women were more likely to deliver in health facilities than their uninsured counterparts. The NDHS itself, covering 41,668 households, reported higher uptake of maternal healthcare services and child immunisation among women with insurance coverage. Smaller facility-based studies in Osun, Ogun, and Lagos states reinforced the pattern, showing higher immunisation coverage, greater willingness to seek care, and increased uptake of preventive services among enrollees.

On financial protection, the numbers are striking. The Nigerian Health Watch report found that insured individuals spent an average of ₦11,142 per year out of pocket, compared with ₦24,345 among the uninsured — a difference of more than half. The NDHS similarly reported substantially lower out-of-pocket expenditure for maternal and reproductive healthcare among insured women. Facility-based studies in Ondo and Ogun states confirmed that enrollees were less likely to experience financial hardship, while uninsured households devoted a larger proportion of their income to healthcare. Taken together, the evidence suggests that insurance functions as a genuine financial safety net, reducing the risk of catastrophic health expenditure that pushes millions of Nigerians into poverty each year.

Yet the review’s most sobering finding concerns who actually gets covered. Enrolment remains abysmally low, and the disparities are stark. According to the NDHS, insurance coverage among urban residents stands at 23.9 per cent — roughly twice the 11.8 per cent recorded among rural residents. Enrolment is concentrated among wealthier households, more educated individuals, and populations in Southern Nigeria, leaving Northern regions, informal sector workers, and the rural poor largely excluded. Only four African countries — Rwanda at 79 per cent, Ghana at 58 per cent, Gabon at 41 per cent, and Burundi at 22 per cent — have achieved insurance coverage of 20 per cent or more of their populations, out of 36 sub-Saharan African countries assessed in 2022.

The authors interpret these patterns through Andersen’s Healthcare Utilisation Model, which frames healthcare use as a function of predisposing, enabling, and need-based factors. Education emerged as a major determinant of enrolment: higher health literacy improves awareness of insurance benefits, strengthens the ability to navigate registration procedures, and increases trust in formal healthcare systems. Uneducated individuals, by contrast, may perceive premium payments as immediate financial burdens rather than future protection, particularly in contexts of widespread economic insecurity. Geographical disparities reflect deeper structural inequalities — Southern Nigeria records higher literacy rates, greater formal-sector employment, and better healthcare infrastructure than the North, meaning higher enrolment in the South cannot be understood simply as individual preference.

The review also acknowledges its own methodological constraints. The cross-sectional nature of most included studies limits causal inference, as reverse causality and residual confounding may still be present. Several studies relied on simple binary yes-or-no measures of insurance enrolment, oversimplifying a complex construct that ignores duration of coverage, benefit package differences, and continuity of enrolment. Recall bias may distort self-reported expenditure figures, and facility-based samples drawn from urban areas likely overrepresent frequent healthcare users. Most studies also clustered in the South-Western region, limiting national generalisability.

The policy implications are urgent. The authors call for full implementation of the Vulnerable Group Fund under the National Health Insurance Authority Act of 2022, which aims to target over 83 million vulnerable and indigent Nigerians — approximately 38 per cent of the population — who cannot afford premiums. They also recommend strengthening primary healthcare centres, boosting government health expenditure through broadened tax revenue, and scaling up community-based health insurance programmes in the informal sector, where more than 90 per cent of Nigerians work. Countries that have succeeded, such as Rwanda and Ghana, broadened community-based schemes into the informal sector and subsidised premiums for the poor.

As the 2030 terminal year for the Sustainable Development Goals draws near, Nigeria’s universal health coverage service index stands at a mere 38 per cent — far below the global average of 68 per cent. The review’s verdict is clear: health insurance in Nigeria works, reducing out-of-pocket spending and increasing healthcare uptake among those enrolled. But a scheme that covers only the educated, the wealthy, the urban, and the Southern is not universal coverage — it is a mirror of the very inequalities it was designed to erase. Genuine universality, the authors argue, requires equitable financing, targeted subsidies, premium waivers, and a fundamental commitment to reaching the 83 million Nigerians the system has left behind.

Subject of Research: Systematic literature review and narrative synthesis of the effectiveness of health insurance in improving access to healthcare and providing financial protection in Nigeria

Article Title: Systematic literature review and narrative synthesis of the effectiveness of health insurance in improving access to healthcare and providing financial protection in Nigeria

Article References: Ahuru, R. R., & Okenya, N. A. (2026). Systematic literature review and narrative synthesis of the effectiveness of health insurance in improving access to healthcare and providing financial protection in Nigeria. Frontiers in Health Services, 6, Article 1946888. https://doi.org/10.3389/frhs.2026.1946888

Image Credits: AI Generated

DOI: 10.3389/frhs.2026.1946888

Keywords: Systematic, literature, review, narrative, synthesis, effectiveness, health, insurance, improving, access, healthcare, providing