Healthcare

Background/Objectives: Endo-periodontal lesions (EPLs) represent complex pathological entities involving both periodontal and pulpal tissues, often implying diagnostic and therapeutic challenges. Limited evidence exists regarding the relationship between periodontal disease staging and grading and EPL subtype. The aim is to evaluate the clinical and statistical distribution of endo-periodontal lesions and investigate their association with periodontal stage and grade according to the European Federation of Periodontology (EFP) classification. Methods: An observational retrospective study was conducted in the Department of Periodontology, Faculty of Dental Medicine, Carol Davila University of Medicine and Pharmacy, Bucharest, Romania. Among 884 examined patients, 31 of them were diagnosed with EPLs and included in the analysis. Demographic variables, systemic conditions, affected tooth type, EFP stage and grade, and EPL type according to the Foce classification were recorded. Statistical analysis included Fisher’s exact test and univariable and multivariable binomial logistic regression models. Results: The mean age of the patients was 53.55 ± 9.42 years, with a nearly equal gender distribution. Most patients presented Stage III periodontitis (54.8%), Grade B periodontitis (71%), and EPL 3 (58.1%). Pluriradicular teeth were the most frequently affected (64.5%). The only statistically significant association identified was between EFP grading and EPL classification (p = 0.001). Grade B patients were significantly more likely to present EPL 3 than Grade C patients. Logistic regression analysis demonstrated that Grade B was a strong predictor of EPL 3 both in the univariable model (OR = 27.2; 95% CI: 2.712–272.828) and after adjustment for age and gender (OR = 32.676; 95% CI: 2.832–376.984). Neither age nor gender showed a significant association with EPL 3 occurrence. Conclusions: EPL 3 was the predominant lesion subtype in the study. EFP grading was significantly associated with EPL distribution, with Grade B emerging as an independent predictor of EPL 3. These findings suggest that periodontal disease progression may play a key role in the development and characterization of combined endo-periodontal lesions and highlight the importance of integrated periodontal–endodontic assessment in clinical practice. Full article

Background and Objectives: Despite extensive research on the management of chronic low back pain, evidence regarding the additional benefits of incorporating lumbar extension-specific exercises into conventional core stabilization programs remains limited. Therefore, the primary objective of this pilot study was to evaluate the feasibility of three 8-week exercise interventions in men in their 30s with chronic low back pain, including recruitment feasibility, retention rate, adherence to exercise sessions, intervention acceptability, and safety. The secondary and exploratory objective was to determine preliminary intervention effects and variability parameters for lumbar extensor strength, activities of daily living, and pain intensity. These findings may help in designing, selecting the outcome, and calculating sample size of a future definitive randomized controlled trial with adequate statistical power. Methods: The study included 30 male participants aged 30–39 years with low back pain persisting for more than 12 weeks. They were randomly divided into a MedX Exercise Program Group, a Deadlift Exercise Program Group, and a Core Exercise Program Group. The intervention consisted of exercise sessions conducted twice weekly for eight weeks. The intervention was evaluated by measuring lumbar extensor strength, the ability to perform activities of daily living, and pain intensity before and after the intervention. The collected data were tested for normality using the Shapiro–Wilk test, and homogeneity was tested using one-way analysis of variance. Group differences between time periods were tested using two-way analysis of variance with repeated measures. For outcome variables showing significant between-group differences at baseline, additional analyses of covariance were conducted with the corresponding baseline values included as covariates. Effect sizes and 95% confidence intervals were calculated and reported for all outcome variables. As this pilot study was not designed to provide confirmatory efficacy testing, analyses of secondary outcomes were considered exploratory in nature, and no adjustments for multiple comparisons were applied. Results: All 30 participants who underwent eligibility screening were randomized, and all participants completed the 8-week intervention and follow-up assessments, resulting in a 100% retention rate. Intervention adherence was also 100%, with all 480 scheduled sessions completed (480/480). No intervention-related adverse events were reported, and complete data were available for all outcome variables. For lumbar extensor strength, a significant main effect of time was observed across all seven lumbar extension angles (all p < 0.001), indicating significant improvements within all three groups. A significant time × group interaction was observed only at 0° (p = 0.048); however, subsequent pairwise comparisons revealed no significant differences between any groups at follow-up. Activities of daily living significantly improved in all three groups, and no significant between-group differences were observed in the baseline-adjusted analysis of variance (p = 0.226). Pain intensity significantly decreased in all groups, with the largest reduction observed in the core stabilization exercise group (−78.05%). Post-hoc analyses demonstrated that the reduction in pain intensity was significantly greater in the core stabilization exercise group than in both the MedX lumbar extension exercise group (p = 0.022) and the deadlift exercise group (p = 0.042). Conclusions: All three 8-week exercise interventions were feasible, achieving complete participant retention and adherence, with no reported adverse events. Although lumbar extensor strength, activities of daily living, and pain intensity significantly improved across all groups, no additional benefits were noted from incorporating MedX lumbar extension exercises or deadlift exercises into a common core stabilization exercise program. Notably, the greatest reduction in pain intensity was observed in the core stabilization exercise-only group. Given the exploratory nature and pilot design of this study, these findings should be interpreted cautiously and require confirmation in future adequately powered randomized controlled trials. Full article

Background: Genetic diseases pose a significant public health issue in Saudi Arabia, driven by relatively high prevalence and factors such as consanguineous marriage. Increasing public awareness and understanding are crucial to improving prevention, early detection, and the use of genetic healthcare services. This study aimed to evaluate residents’ knowledge, attitudes, and awareness of genetic diseases in the Qassim region. Methods: A web-based cross-sectional survey was conducted from March to May 2024 among Qassim residents, using an online questionnaire shared via multiple social media platforms. The survey assessed knowledge of genetic diseases, awareness of preventive measures and screening programs, and familiarity with genetic healthcare services. Descriptive statistics summarised the results, and binary logistic regression was conducted to identify factors independently associated with good awareness of genetic testing. Results: Of the 398 participants, about 66% knew about common genetic diseases in Saudi Arabia, while 92% recognised consanguineous marriage as a key cause of genetic disorders. Most respondents correctly identified that genetic diseases are not transmitted through infection (93%). Support for expanding premarital, prenatal, and newborn screening programs was high at 93%, 88.9%, and 90.7%, respectively. Nonetheless, only 38.7% were aware of specialised genetic laboratories and counselling services, and just 4.4% had consulted a genetic counsellor. Social media was the primary source of genetic information (36%). Despite limited awareness of available services, 94% supported establishing a regional genetic testing lab, and 71% were willing to participate in future genetic research. Multivariate analysis identified that marital status is the only variable significantly associated with genetics testing awareness status [aOR = 2.34; 95% CI (1.08–5.08); p = 0.030]. Conclusions: Participants demonstrated generally good knowledge of genetic diseases and positive attitudes towards preventive genetic screening programmes. However, awareness of and utilisation of specialised genetic healthcare services, including genetic counselling and genetic testing laboratories, remained limited. These findings underscore the need to enhance public education, expand genetic counselling, and improve access to specialised services to advance genomic medicine in Saudi Arabia. However, the predominance of younger participants and students may limit the generalisability of the findings to the broader Qassim population. Full article

Background/Objectives: Perinatal care is essential for the health and well-being of women and adolescent girls from conception through the first year postpartum. The World Health Organization (WHO) provides evidence-based recommendations aimed at improving the quality of antenatal, intrapartum, and postnatal care. This study mapped 51 WHO perinatal care recommendations against Zambian guidelines to identify areas of alignment, as well as gaps and challenges related to their implementation. Methods: The review was conducted following Joanna Briggs Institute (JBI) guidance. Published recommendations and relevant documents issued from 2016 onwards were included. National guidelines, policy documents, professional standards, and literature related to perinatal care in Zambia were identified through searches of PubMed, Google Scholar, WHO resources, and relevant institutional websites. WHO recommendations were mapped against Zambian guidelines and classified according to their level of alignment. Results: The findings demonstrated significant alignment between WHO recommendations and Zambian guidelines in perinatal healthcare. However, important implementation gaps remain; for example, only 4.7% of pregnant women attended all eight recommended antenatal care visits. Intrapartum care largely aligns with WHO standards, though there are differences in pain-relief choices. Furthermore, difficulties in adopting WHO recommendations are mostly due to health system constraints. Conclusions: Most of the Zambian guidelines align with the WHO recommendations. However, ten were classified as partly aligned, and one did not align. This small proportion of non-alignment may reflect adaptation for a national context and require further evidence-based evaluation. In addition, consolidating existing recommendations, strengthening health-system capacity, and addressing implementation gaps may support the delivery of standardized, high-quality perinatal care and contribute to improved maternal and newborn health outcomes. Full article

Background: Q&A corpora generated through university student–AI mental health support tools may reveal how physical activity (PA) and psychosocial themes are represented in support-oriented text. However, the absence of individual-level demographic metadata and the pooling of prompt and response fields limit attribution of any expression to a particular speaker, and the corpus describes a specific student population rather than a general or clinical one. Objective: This exploratory study described PA-, sport-, physical education (PE)-, body-, lifestyle-, and emotion-related patterns in a large corpus of university student–AI mental health exchanges collected through an institutional counselling platform. Methods: This study analysed 209,715 paired prompt–response records as combined exchange-level units using a BERTopic-based computational text-mining workflow. The full corpus was used for the main 18-topic model and overlapping dictionary analyses. After secondary data-quality filtering, 178,062 eligible exchanges formed the sampling frame from which a systematic sample of 10,000 exchanges was drawn for a separate complementary BERTopic and scenario-mapping analysis. The workflow used Qdrant/bge-small-zh-v1.5 embeddings, NFKC normalisation, an archived stop-word list, UMAP (n_neighbors = 15, n_components = 5, min_dist = 0.0, cosine metric, seed = 42), HDBSCAN (min_cluster_size = 300, min_samples = 10, Euclidean metric, EOM), c-TF-IDF topic representations, overlapping dictionary screens, and stability testing across seeds 42, 52, and 62. Results: A student/school/family-context lexical screen matched 83,215 exchanges (39.68%), and a broad PA/body/lifestyle screen matched 82,464 exchanges (39.32%). These overlapping indicators describe topical co-occurrence and do not establish PA behaviour or which party to the exchange produced a given term. Eighteen corpus-level themes were retained. In the 10,000-exchange analysis, 13.11% of exchanges matched a narrow movement-related expression screen, with the highest within-topic rate in the sample topic labelled emotional outburst and relaxation regulation (51.09%). Conclusions: The findings describe exchange-level lexical and topic patterns in student–AI interactions rather than actual PA behaviour, intervention delivery, clinical efficacy, or population prevalence, and they do not identify which party introduced the language. The mapping to autonomy, competence, relatedness, and emotional regulation is a post hoc interpretive lens, offered as a hypothesis to inform future, prospectively validated design work in PE and digital mental health support rather than as a demonstrated result. Full article

Background/Objectives: Rehabilitation robotics is increasingly used in neurorehabilitation, yet evidence on how robotic services are organized, maintained and scaled in routine care remains fragmented. This mapping review examined service-delivery models, implementation determinants, strategies, outcomes, workflows and resource signals for robotic rehabilitation in service-linked clinical care. Methods: Six search sources were queried from inception to 21 February 2026. Eligible reports were studies addressing rehabilitation robotics within clinical pathways and reporting an implementation-relevant element. Data from 55 studies were systematically charted and mapped to CFIR determinants, ERIC strategies and Proctor implementation outcomes. Design-appropriate appraisal was applied once per included report to contextualize methodological confidence. Results: Staffing and supervision were reported in 50 studies (90.9%), workflow and scheduling in 43 (78.2%), safety governance in 32 (58.2%) and training and competency in 29 (52.7%). Feasibility was mapped in 40 studies (72.7%), acceptability in 31 (56.4%) and adoption in 23 (41.8%), whereas sustainability, penetration, technical support, documentation infrastructure and implementation cost were less consistently reported. Two randomized trials were appraised with RoB 2 and four non-randomized comparative studies with ROBINS-I; the remaining 49 reports received design-appropriate methodological or reporting appraisal. Conclusions: Routine-care rehabilitation robotics is best understood as a service configuration rather than a device alone. Transferable implementation requires explicit reporting of workforce, workflow, safety, documentation, technical support, infrastructure, cost, equity and sustainment. Frequencies indicate reporting presence, not practical importance or causal influence. The proposed workflow, logic model and minimum reporting set are evidence-informed, inductively derived proposals requiring prospective validation. Full article

Background/Objectives: Antenatal depressive symptoms are common but frequently under-recognized. Although mental health literacy may support symptom recognition and help-seeking, its relationship with antenatal depressive symptoms remains unclear. This study examined the association between overall mental health literacy and antenatal depressive symptoms among women in the second and third trimesters of pregnancy. Methods: This cross-sectional correlational study included 568 pregnant women consecutively recruited from a university hospital’s obstetrics and gynecology outpatient clinics. The Edinburgh Postnatal Depression Scale (EPDS) and Mental Health Literacy Scale (MHLS) were administered. Spearman correlation and multivariable linear and logistic regression were used; multiple imputation handled missing covariates. Results: The mean EPDS score was 8.92 ± 5.68, and 41.9% (n = 238) screened positive for elevated depressive symptoms at the EPDS ≥ 10 threshold. A one-standard-deviation increase in the MHLS total score was associated with neither EPDS total scores (B = 0.011, 95% CI: −0.451 to 0.473, p = 0.963) nor EPDS ≥ 10 screening positivity (aOR = 1.093, 95% CI: 0.911 to 1.312, p = 0.337). Unplanned pregnancy (aOR = 1.975, p = 0.001) and third-trimester status (aOR = 1.774, p = 0.014) were associated with higher odds of screening positivity. In exploratory joint analyses, knowledge-oriented literacy was positively and resource-oriented literacy negatively associated with EPDS scores; both remained significant after Holm correction. The resource-oriented association was no longer significant when examined separately. Conclusions: Overall mental health literacy was not associated with antenatal depressive symptom severity or screening positivity. Opposing, model-dependent subscale findings require replication. These findings support assessing depressive symptoms independently of mental health literacy scores and considering pregnancy planning and gestational stage during antenatal psychosocial assessment. Full article

Background/Objectives: Adolescent sexuality is multidimensional, yet brief instruments assessing attitudes, experiences, and contextual influences from a biopsychosocial perspective remain limited. This study aimed to develop the Comprehensive Questionnaire on Attitudes, Experiences, and Contexts of Adolescent Sexuality (CIAECSA) and examine its content validity, comprehensibility, feasibility, internal consistency, and exploratory internal structure. Methods: A cross-sectional methodological study comprised three phases: theoretical delimitation and generation of 30 initial items; content evaluation by nine experts and semantic validation with 26 adolescents; and pilot administration to 51 adolescents from educational settings in Toledo, Spain. The pilot sample included 35 females (68.6%), 15 males (29.4%), and one gender-fluid participant (2.0%), aged 12–17 years (mean = 14.41; SD = 1.72). Content validity, perceived clarity, feasibility, Cronbach’s alpha, and principal component analysis with Varimax rotation were examined. Results: The final questionnaire comprised 18 items across three domains: sexuality/gender/anatomy, emotional/physical pain, and self-care/environment. The scale-level Content Validity Index (S-CVI/Ave) was 0.955, and mean perceived clarity was 4.53/5. The mean completion time was 5.52 min. Cronbach’s alpha was 0.800, 0.780, and 0.740 for the three domains and 0.715 for the total scale. The KMO was 0.659, Bartlett’s test was significant (p < 0.001), and an exploratory three-component solution, examined against the prespecified domains, explained 51.4% of the variance. Conclusions: The findings provide favorable evidence of content validity, comprehensibility, feasibility, and internal consistency. The CIAECSA may help identify educational needs and psychosocial factors related to adolescent sexuality, although its internal structure and additional measurement properties require examination in larger, balanced, and independent samples. Full article

Objectives: This study examined the associations of habitual sleep quality, insomnia symptoms, and perceived fatigue with countermovement jump (CMJ) performance across repeated trials in resistance-trained adults. Methods: A total of 118 resistance-trained adults (90 men and 28 women) completed the Pittsburgh Sleep Quality Index (PSQI), Insomnia Severity Index (ISI), and Fatigue Severity Scale (FSS). Participants performed six maximal CMJ trials at 0, 2, 4, 6, 8, and 10 min. Mean and best CMJ height, within-participant coefficient of variation, first-to-last change, and individual performance slope were calculated. Linear mixed-effects models and adjusted regression analyses were applied. Results: PSQI was not associated with mean CMJ height, best CMJ height, or within-participant variability (all p > 0.05). However, a significant PSQI × time interaction was observed (B = −0.061 cm/min per 1-SD higher PSQI, 95% CI −0.099 to −0.023; p = 0.002; q = 0.005), indicating that poorer sleep quality was associated with a smaller increase in CMJ height across repeated trials. Exploratory participant-level analyses derived from the same six CMJ measurements showed associations in the same direction for first-to-last change and individual CMJ slope. These associations remained significant after correction within the six trajectory-focused analyses but not after correction across all 18 participant-level regressions. ISI and FSS were not associated with CMJ trajectory or variability (all p > 0.05). Conclusions: Poorer habitual sleep quality was not associated with maximal or average CMJ performance, but was related to an attenuated improvement across repeated maximal CMJ trials. The observed association was small, and its practical significance remains uncertain. The within-session CMJ trajectory should therefore be considered exploratory rather than a validated indicator of recovery or neuromuscular readiness. Full article

Background: Complex chronic patients (CCPs) frequently experience fragmented care and high healthcare utilization. Integrated multidisciplinary care may improve care coordination and reduce reliance on acute healthcare services, although evidence regarding its impact on healthcare utilization and costs remains inconsistent. This study evaluated the real-world impact of a multidisciplinary integrated care program on healthcare utilization and provider costs among CCPs. Methods: This retrospective before-and-after study included CCPs enrolled in a multidisciplinary integrated care program between 2016 and 2023. Healthcare utilization and provider costs from the provider perspective were compared for up to two years before and after enrollment. Results: The study included 473 patients with a median age of 82 years, 56.7% of whom were women. Significant reductions in acute and ambulatory healthcare utilization and overall provider costs were observed following enrollment and were sustained over two years (p < 0.001). Exploratory economic analyses showed that lower provider costs occurred alongside reductions in acute healthcare utilization. Conclusions: A multidisciplinary integrated care program for CCPs was associated with sustained reductions in healthcare utilization and provider costs over two years. These findings support the potential value of integrated multidisciplinary care for CCPs. Full article

Background: Job stress is a pervasive issue in modern workplaces and is associated with numerous adverse outcomes, including employees’ turnover intention when stress levels are high. Objective: This study aimed to examine the association between job stress and turnover intention among employees working in healthcare institutions through meta-analysis. Methods: A systematic literature review and meta-analysis were performed following PRISMA guidelines. The study was registered in the International Prospective Register of Systematic Reviews (PROSPERO; ID: CRD42024581906). Considering variations in sample sizes, publication years, and measurement scales, a random-effects model was employed. Effect sizes were illustrated with a forest plot, and publication bias analyses were performed. Subgroup analyses were conducted by occupational group, COVID-19 period, and geographic region, while meta-regression tested the moderating effects of publication year. Study quality was assessed using the AXIS tool. Results: Based on predefined inclusion criteria, 38 independent studies were included. Findings revealed a moderate-to-high, positive, and statistically significant relationship (r = 0.441; 95% CI [0.389, 0.490]) between job stress and turnover intention among healthcare workers. Moreover, although between-study heterogeneity was substantial (I² = 95.5%), the direction and statistical significance of the association remained consistent across different countries and healthcare systems. Conclusions: This meta-analysis demonstrated a statistically significant positive association between job stress and turnover intention among healthcare workers (r = 0.441). Although substantial heterogeneity was observed across studies, the relationship remained consistent across occupational groups, regions, and study contexts. Addressing job stress may therefore play an important role in supporting workforce retention in healthcare organizations. Full article

Background/Objectives: Emergency medical care is a critical component of the healthcare system. The aim of the study was to forecast the number of general practitioner and paramedic teams, the number of ambulance stations, and the number of calls per 1000 population in Kazakhstan until 2030. Methods: We conducted a retrospective longitudinal ecological time-series study of the staffing and structure of the emergency medical service in Kazakhstan for 2000–2023. Data were provided by emergency medical stations in 16 regions of Kazakhstan. We also used data from the statistical digest “Health of the Population of the Republic of Kazakhstan and the Activities of Healthcare Organizations”. Results: A progressive decrease in the absolute number of emergency medical system (EMS) stations by an average of 4.19% (95% CI: [−5.00%, −3.37%]) was found. In the period from 2000 to 2023, a relative average annual decrease was found in the number of medical teams by 7.94% [CI −10.14%, 5.69%] and pediatric teams by 7.73% [CI −10.36%, 5.02%]. An analysis showed an average annual growth rate of paramedic teams of 1.62% [CI 0.19%, 3.46%]. The construction of a predictive model for the number of medical and pediatric teams and EMS stations in the country for the coming years demonstrates a further gradual decrease in their number. Conclusions: A predictive model for the number of physician teams predicts a further decline through 2030, while the forecast for the number of paramedic teams remains relatively stable. Full article

Background/Objectives: Nurses are frequently exposed to emotionally demanding situations, placing them at risk of adverse psychological outcomes such as secondary traumatic stress (STS) and burnout. Personality traits, particularly perfectionism, may influence these outcomes. Submissive compassion, characterized by caring behavior motivated by a desire for approval or avoidance of rejection, may play an explanatory role in these relationships. Methods: This study examined whether submissive compassion was statistically associated with the relationship between perfectionism and professional quality of life (ProQOL) among hospital nurses, while accounting for potential confounding and moderating factors. A cross-sectional online survey was conducted among ward nurses working in hospitals in Japan. Participants completed measures of perfectionism, submissive compassion, and ProQOL. Data from 218 nurses were analyzed using structural equation modeling. Results: Socially prescribed perfectionism was positively associated with submissive compassion and STS. Submissive compassion was significantly associated with the indirect relationship between socially prescribed perfectionism and STS. Age moderated the association between submissive compassion and STS, with stronger indirect effects observed among older nurses. Additionally, self-oriented perfectionism showed a relationship with stress-related outcomes, whereas socially prescribed perfectionism was associated with burnout. Conclusions: The findings suggest that submissive compassion may contribute to the association between perfectionism and adverse psychological outcomes among nurses. These results underscore the potential importance of maladaptive compassion motives in understanding how perfectionism relates to STS in this population and may help inform interventions aimed at supporting nurses’ psychological well-being. Full article

Advances in machine learning, predictive analytics, and clinical prediction modeling have accelerated the development of algorithmic tools for estimating reproductive outcomes after cancer treatment. In female oncofertility counseling, these models may support individualized assessment of treatment-related amenorrhea, premature ovarian insufficiency, and fertility risk, thereby improving risk communication and timely fertility-preservation referral. However, their use raises ethical concerns beyond predictive accuracy. This narrative review examines algorithmic prognostication in female oncofertility counseling, focusing on predictive uncertainty, surrogate reproductive endpoints, missing data, heterogeneous datasets, limited external validation, algorithmic bias, reproductive inequity, and the influence of algorithmic authority on patient autonomy and shared decision-making. We argue that predictive algorithms should be understood as decision-support tools rather than determinants of reproductive futures. Responsible implementation requires transparency, explainability, fairness assessment, ongoing validation, and meaningful human oversight. Algorithmic risk estimates should be communicated as conditional and contextual probabilities within patient-centered counseling, ensuring that predictive tools support informed, transparent, and value-concordant fertility-preservation decisions for women facing cancer treatment. Full article

Background: Sustainable leadership has emerged as a critical approach for promoting long-term organizational effectiveness and workforce well-being in healthcare settings. However, empirical evidence linking sustainable leadership to workplace integration and resilience among nurses remains limited. Objective: This study aimed to examine the association between sustainable leadership and both workplace integration and resilience among staff nurses. Methods: A descriptive cross-sectional correlational design was used. Data were collected from 200 staff nurses working in intensive and intermediate care units at a tertiary healthcare institution. Standardized instruments were used to measure sustainable leadership, workplace integration, and resilience. Data were analyzed using descriptive statistics, Pearson correlation, and linear regression analysis. Results: Sustainable leadership was positively associated with workplace integration (r = 0.43, p < 0.001) and resilience (r = 0.24, p < 0.001). Regression analysis indicated that sustainable leadership was associated with workplace integration (β = 0.43, R² = 0.18, p < 0.001) and resilience (β = 0.24, R² = 0.10, p < 0.001), explaining a modest proportion of variance in both outcomes. Conclusions: Sustainable leadership is significantly associated with improved workplace integration and resilience among nurses. Healthcare organizations should adopt sustainable leadership practices such as providing consistent mentorship and professional development chances to improve workplace integration, and implementing supportive supervision and wellness initiatives to improve nurse resilience. However, the relatively low explained variance suggests that additional individual and organizational factors contribute to these outcomes. Therefore, sustainable leadership should be integrated with complementary strategies, including peer support programs and workload management interventions, to comprehensively strengthen workforce integration and resilience. Full article

Background/Objectives: Health systems involve numerous stakeholders interconnected through nonlinear relationships. While Data Envelopment Analysis (DEA) has been widely used to measure health system efficiency, conventional estimates may exhibit finite-sample bias. An important question, therefore, concerns how health system performance can be measured more reliably, and what factors explain cross-country differences in efficiency. This study introduces an integrated framework that combines Two-Stage Bootstrap DEA with machine learning to assess the performance of the health systems of 26 OECD countries using 2022 data. Methods: In the first step, technical efficiency scores are computed using an output-oriented constant returns to scale (CRS) DEA model. Subsequently, bias-corrected efficiency estimates are derived using the Bootstrap procedure proposed by Simar and Wilson. In the second step, truncated regression analysis and machine learning-based partial dependence analysis, the latter validated through leave-one-out cross-validation, are employed to investigate the determinants of efficiency. Results: The Bootstrap procedure reveals statistically significant differences from conventional DEA results, and bias-corrected results indicate that South Korea, Canada, and the United States achieve the highest efficiency levels. The findings show that tobacco use prevalence has a significantly negative association with health system efficiency and alcohol consumption exhibits a negative, threshold-type pattern, while GDP per capita and out-of-pocket health expenditure display more complex, nonlinear effects. Furthermore, the scenario analysis indicates that a 10% reduction in tobacco use yields the largest predicted single-intervention improvement, while combined interventions produce additional but sub-additive gains. Conclusions: The proposed framework presents a transparent and validated approach for assessing and explaining health system performance, generating findings relevant to the development of evidence-based health policy. Full article

Objective: Obstructive sleep apnea (OSA) during pregnancy is associated with adverse maternal and fetal outcomes, yet commonly used screening questionnaires may perform differently because of pregnancy-specific physiological changes. This study compared questionnaire-based OSA risk classifications obtained using the Berlin Questionnaire and STOP-BANG and examined their associations with metabolic parameters and diabetes-related history. Methods: This cross-sectional study included 210 pregnant women attending a tertiary obstetrics clinic. Berlin Questionnaire high risk was defined as positivity in at least two categories. STOP-BANG scores of 0–2, 3–4, and 5–8 indicated low, moderate, and high risk, respectively. Sociodemographic, obstetric, anthropometric, and biochemical variables were analyzed using multivariable logistic regression. Results: The Berlin Questionnaire classified 34 participants (16.2%) as high risk. STOP-BANG classified 183 (87.1%) as low risk, 5 (2.4%) as moderate risk, and 22 (10.5%) as high risk. Higher current weight was associated with increased questionnaire-based OSA risk according to both tools. In the Berlin model, HbA1c, BMI, and family history of diabetes were independently associated with high questionnaire-based OSA risk. No independent associations were identified in the STOP-BANG model. Although the Berlin model had 83.3% overall accuracy, it correctly classified only 2.9% of high-risk participants. Conclusions: The questionnaires identified different patterns of OSA risk. Findings were instrument-specific and do not indicate confirmed OSA. Given the absence of polysomnography, modest model performance, and limited high-risk classification, the results should be interpreted cautiously. Full article

Background: Emergency medical service (EMS) personnel and volunteers are frequently exposed to traumatic events, placing them at elevated risk for psychological distress, including post-traumatic stress symptoms (PTSSs), depression, and dissociation. This study examined the relationships among PTSS, depression, and dissociation in Israeli EMS personnel, with a particular focus on whether dissociation mediates the association between depression and PTSS. Methods: A cross-sectional study was conducted with 60 EMS personnel in Israel, including 7 paid employees, 37 volunteers, and 16 participants who did not report their employment status. PTSSs were assessed using the Impact of Event Scale-Revised (IES-R), depressive symptoms were measured with the Depression, Anxiety, and Stress Scale (DASS-21), and dissociative experiences were evaluated using the Dissociative Experiences Scale-II (DES-II). Correlational analyses and mediation analyses were performed. Results: Significant positive correlations were found among PTSS, depression, and dissociation. However, mediation analysis indicated that dissociation did not significantly mediate the relationship between depression and PTSS. Conclusions: Although depression and dissociation were both strongly associated with PTSS, dissociation did not account for the association between depression and PTSS in this sample of EMS personnel. These findings suggest that other psychological mechanisms may underlie the relationship between depression and trauma-related symptoms in emergency responders. Further research is warranted to identify these mechanisms and to inform targeted interventions aimed at promoting the mental health and resilience of EMS personnel. Full article

Introduction: Long COVID-19 is a complex and multifaceted condition characterized by persistent and fluctuating symptoms extending beyond the acute phase of infection. Aim: To explore the health and support experiences of the Spanish population living with long COVID-19. Methodology: A qualitative study with an interpretative phenomenological approach was used. Semi-structured interviews were conducted over 10 months (2023–2024) across 17 Spanish provinces. The sample included 36 participants. Results: Participants reported persistent and fluctuating symptoms that severely limited daily functioning and generated anxiety, depression, and post-traumatic distress. Chronic fatigue and cognitive impairment affected social participation and work performance, frequently leading to absenteeism and job loss. Delayed diagnosis limited professional knowledge, and perceived lack of credibility contributed to dissatisfaction with healthcare services. Family members and patient associations were key sources of emotional and practical support. Conclusions: Long COVID-19 has a multidimensional impact that requires a comprehensive and multidisciplinary approach. Participants’ narratives reveal how underestimation of symptoms, delayed diagnosis, social stigma, limited healthcare and social support, additional family burdens, and disrupted work and social routines create complexity in care and challenge existing health and economic systems. Full article