Healthcare

13 pages, 250 KB

Open AccessArticle

Effects of a Physiotherapist-Led School-Based Health Education Workshop on Spinal Pain Prevention in Schoolchildren: A Quasi-Experimental Study

by Manuel Fraiz-Barbeito, Sara Rey-Veiga, María Teresa Santamaría-Solís, Yoana González-González, Mercedes Soto-González, Iria Da Cuña-Carrera and Alejandra Alonso-Calvete

Healthcare 2026, 14(11), 1525; https://doi.org/10.3390/healthcare14111525 (registering DOI) - 30 May 2026

Abstract

Background/Objectives: Spinal pain is common among schoolchildren and is associated with poor postural habits and sedentary behavior. Schools represent an optimal setting for prevention; however, they are also key environments for prevention strategies in children who already experience spinal pain. This study focused [...] Read more.

Background/Objectives: Spinal pain is common among schoolchildren and is associated with poor postural habits and sedentary behavior. Schools represent an optimal setting for prevention; however, they are also key environments for prevention strategies in children who already experience spinal pain. This study focused on children aged 9–11 years and aimed to evaluate the effectiveness of a physiotherapist-led, classroom-based workshop as a prevention intervention to improve spinal pain outcomes. Methods: A quasi-experimental single-group pre–post intervention study was conducted in public primary schools. The intervention consisted of two 45 min theoretical–practical sessions. A 21-item questionnaire assessed spinal pain, postural habits, backpack-related behaviors, physical activity, screen use and spinal literacy at baseline and three months post-intervention. McNemar and Wilcoxon tests were applied (p < 0.05). Results: A total of 287 schoolchildren participated. Cervical and thoracic pain decreased significantly (p = 0.036; p = 0.040), while lumbar pain showed no change. Postural habits improved: sitting with back support increased (+12.7%; p < 0.001), sitting on the chair edge decreased (−10.5%; p < 0.001), and side-lying sleeping increased (p = 0.006). Knowledge of proper backpack load distribution also improved (+17.9%; p < 0.001). No significant changes were observed in physical activity, screen use, rising-from-bed technique, or backpack type. Conclusions: The workshop improved upper-spine pain, spinal literacy and modifiable habits, while automated motor behaviors and family-dependent routines showed limited change. Full article

(This article belongs to the Special Issue Therapeutic Exercise and Health Education in the Management of Back Pain)

21 pages, 6030 KB

Open AccessArticle

Multiparametric MRI Assessment of Cervical Lymphadenopathy: Combined Diagnostic Performance of Morphological Features and Apparent Diffusion Coefficient

by Iulian-Alexandru Taciuc, Mihai Dumitru, Daniela Vrinceanu, Andreea Nicoleta Marinescu, Crenguta Serboiu, Adrian Costache and Adina Zamfir-Chiru-Anton

Healthcare 2026, 14(11), 1524; https://doi.org/10.3390/healthcare14111524 (registering DOI) - 30 May 2026

Abstract

Background: Accurate differentiation between benign and malignant cervical lymphadenopathy remains clinically important for diagnostic stratification and treatment planning. This study evaluated the diagnostic performance of conventional morphological magnetic resonance imaging (MRI) features and apparent diffusion coefficient (ADC) values in a mixed cohort of [...] Read more.

Background: Accurate differentiation between benign and malignant cervical lymphadenopathy remains clinically important for diagnostic stratification and treatment planning. This study evaluated the diagnostic performance of conventional morphological magnetic resonance imaging (MRI) features and apparent diffusion coefficient (ADC) values in a mixed cohort of cervical lymphadenopathies. Methods: This retrospective lesion-based diagnostic study included 88 cervical lymph nodes from 39 patients who underwent head-and-neck MRI between September 2023 and December 2025. The cohort had malignant entities such as squamous cell carcinoma metastases, thyroid carcinoma, non-Hodgkin lymphoma, adenoid cystic carcinoma, and medullary thyroid carcinoma, as well as benign/reactive, inflammatory, CMV-related, tuberculous, Warthin tumor-associated, and cystic lymphangioma-related lymphadenopathies. MRI examinations were performed for heterogeneous indications, including the initial assessment of palpable cervical lymphadenopathy, oncological staging, post-biopsy follow-up, suspected recurrence, and benign/inflammatory lesion characterization; therefore, not all patients underwent MRI for the same clinical indication. Most examinations were performed during the initial diagnostic work-up, while six cases represented post-biopsy follow-up. Morphological features and ADC values were analyzed using Mann–Whitney U tests, chi-square tests, ROC analysis, DeLong testing, Firth penalized logistic regression, generalized estimating equations (GEE), patient-level bootstrap resampling, and calibration analysis. Statistical analyses were performed using Python (Version 3.12), with exploratory verification in JASP. Statistical significance was set at p < 0.05. Results: The cohort included 39 patients with a mean age of 54 years (range: 18–74 years), with 20 males and 19 females. Of the 88 lymph nodes, 33 were malignant and 55 benign. Malignant nodes demonstrated significantly lower ADC values than benign nodes (0.87 ± 0.23 vs. 1.25 ± 0.22 × 10⁻³ mm²/s; U = 207, p < 0.001). ADC alone showed good diagnostic performance, with an AUC of 0.886 (95% CI: 0.803–0.960). The optimal ADC cutoff was 0.900 × 10⁻³ mm²/s, yielding 75.8% sensitivity and 89.1% specificity. The final GEE model, including the ADC, nodal shape, and margin characteristics while accounting for intra-patient clustering, achieved an apparent AUC of 0.956. Leave-one-patient-out cross-validation yielded an AUC of 0.929, and the bootstrap optimism-corrected AUC was 0.949. DeLong testing confirmed that the combined model significantly outperformed the ADC alone (AUC improvement = 0.070; p = 0.006), and the inter- and intra-observer reproducibility for ADC was excellent. Conclusions: ADC values, nodal shape, and margin characteristics provide complementary diagnostic information for differentiating benign from malignant cervical lymph nodes. A structured multiparametric MRI approach demonstrated high diagnostic performance, although the findings should be interpreted in the context of the retrospective single-center design and histopathological heterogeneity. Full article

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22 pages, 806 KB

Open AccessArticle

Pathology-Informed Personalized Exoskeleton Assistance for Post-Stroke Gait Rehabilitation via Simulation-to-Real Reinforcement Learning

by Chuyi Ou, Yinbin Peng and Furong Zhang

Healthcare 2026, 14(11), 1523; https://doi.org/10.3390/healthcare14111523 (registering DOI) - 30 May 2026

Abstract

Background/Objectives: Post-stroke gait impairment is highly heterogeneous, which limits the effectiveness of standardized exoskeleton control strategies. Deep reinforcement learning offers a route to adaptive assistance, but its use in stroke rehabilitation is constrained by limited pathological gait data and the lack of interpretable [...] Read more.

Background/Objectives: Post-stroke gait impairment is highly heterogeneous, which limits the effectiveness of standardized exoskeleton control strategies. Deep reinforcement learning offers a route to adaptive assistance, but its use in stroke rehabilitation is constrained by limited pathological gait data and the lack of interpretable transfer frameworks. We developed a data-efficient, pathology-informed reinforcement learning framework for personalized exoskeleton assistance under limited clinical gait data. Methods: The framework combines neuromuscular-inspired parametric augmentation (NIPA) with parameter-efficient transfer learning. NIPA synthesizes pathological gait trajectories by modeling weakness, stiffness or contracture, and abnormal synergies. A policy is first pretrained in simulation and then adapted to clinical gait data by freezing a shared feature extractor and fine-tuning the output heads. The framework was evaluated on a public clinical gait dataset of 50 stroke survivors using tracking error, reward, smoothness, generalization, and data efficiency as main outcomes. Results: The proposed method outperformed zero assistance, rule-based control, and reinforcement learning from scratch on the test set. Compared with scratch, it reduced total MSE from 14.8681 to 11.9369 (

p = 5.96 \times 10^{- 8}

) and improved reward from −21.2264 to −18.4798 (

p = 3.76 \times 10^{- 4}

). Hip MSE decreased from 5.9544 to 4.0143 (

p = 7.51 \times 10^{- 8}

) and knee MSE decreased from 6.5507 to 5.4507 (

p = 1.51 \times 10^{- 5}

), with significant improvements in repeated experiments. Conclusions: The proposed framework reduces reliance on large pathological training datasets and improves offline trajectory-level personalization under limited clinical data. It also provides an interpretable basis for quantitative characterization of post-stroke gait heterogeneity and may support individualized rehabilitation assessment and assistance planning. Full article

(This article belongs to the Section Artificial Intelligence in Healthcare)

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14 pages, 550 KB

Open AccessArticle

Real-World Associations Between Physical Activity, LDL Cholesterol, and Functional Performance in Primary Care: A Cross-Sectional Study

by Peter Marián Kalanin and Ivan Uher

Healthcare 2026, 14(11), 1522; https://doi.org/10.3390/healthcare14111522 (registering DOI) - 30 May 2026

Abstract

Background: Physical activity (PA) is associated with cardiometabolic health and functional performance, but evidence from real-world primary care populations simultaneously examining PA, low-density lipoprotein cholesterol (LDL-C), and functional performance remains limited. Objective: This study evaluated associations between PA, LDL-C, and functional [...] Read more.

Background: Physical activity (PA) is associated with cardiometabolic health and functional performance, but evidence from real-world primary care populations simultaneously examining PA, low-density lipoprotein cholesterol (LDL-C), and functional performance remains limited. Objective: This study evaluated associations between PA, LDL-C, and functional performance in a real-world primary care cohort. Methods: This cross-sectional observational study included 863 adult primary care patients evaluated between February 2021 and March 2026. The overall cohort had a mean age of 52.4 ± 14.8 years, and 53.3% of participants were female. PA was assessed using self-reported activity categories (low, moderate, or high) obtained during a routine clinical evaluation. LDL-C concentrations were analyzed in the full cohort, while Timed Up and Go (TUG) functional performance assessment was available in an exploratory subgroup (n = 214). Multivariable regression analyses were adjusted for age, sex, body mass index (BMI), diabetes mellitus, and arterial hypertension in the TUG analysis. Results: Higher PA categories were associated with lower LDL-C concentrations across groups (p < 0.001). Mean LDL-C concentrations were 3.68 ± 1.05 mmol/L in the low PA group, 3.39 ± 0.97 mmol/L in the moderate PA group, and 3.12 ± 0.89 mmol/L in the high PA group. In the exploratory TUG subgroup, higher PA categories were also associated with better functional performance (p < 0.001). These associations remained significant after multivariable adjustment. Conclusions: Higher self-reported PA levels were associated with lower LDL-C concentrations in the full cohort and with better functional performance in the subgroup with available TUG data. Because of the cross-sectional observational design, these findings should be interpreted as associations and do not establish causality or directionality. Residual confounding, particularly from unavailable data on lipid-lowering medication use, smoking status, diet, socioeconomic status, and other cardiovascular risk factors, cannot be excluded. Future longitudinal studies using objective PA assessment, a more complete confounder assessment, and direct measurement of regulatory processes are warranted. Full article

(This article belongs to the Section Public Health and Preventive Medicine)

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14 pages, 240 KB

Open AccessArticle

Authoritative Parenting Is Associated with Healthier Lifestyle Patterns in University Students

by Maja Strauss, Barbara Cussigh and Leona Cilar Budler

Healthcare 2026, 14(11), 1521; https://doi.org/10.3390/healthcare14111521 (registering DOI) - 30 May 2026

Abstract

Background: Health-promoting lifestyle behaviors established during young adulthood play a crucial role in shaping long-term physical and mental health outcomes, including the risk of chronic disease, psychological well-being, and quality of life. Parenting styles represent an important psychosocial factor that may be associated [...] Read more.

Background: Health-promoting lifestyle behaviors established during young adulthood play a crucial role in shaping long-term physical and mental health outcomes, including the risk of chronic disease, psychological well-being, and quality of life. Parenting styles represent an important psychosocial factor that may be associated with health-related behaviors; however, evidence regarding their association with multidimensional health-promoting lifestyles among university students remains limited. Methods: A cross-sectional study was conducted among 700 university students. Parenting styles (authoritative, authoritarian, and permissive) were assessed using validated self-report measures. Health-promoting lifestyle behaviors were measured with the Health-Promoting Lifestyle Profile II (HPLP II), including six subscales: Health Responsibility, Physical Activity, Nutrition, Spiritual Growth, Interpersonal Relations, and Stress Management, as well as the overall HPLP II score. Multiple linear regression analyses were performed to examine associations between parenting styles and each HPLP II subscale and the total score. Results: All regression models were statistically significant (p < 0.001), explaining between 5.2% and 13.5% of variance across HPLP II subscales and 11.8% of variance in the total score. Authoritative parenting was significantly positively associated all health-promoting lifestyle domains (β = 0.22–0.33, p < 0.001), including physical activity, interpersonal relations, stress management, and overall health-promoting lifestyle. Permissive parenting was negatively associated with several domains, particularly physical activity, interpersonal relations, stress management, and the total HPLP II score (β = −0.07 to −0.12, p < 0.05). Authoritarian parenting showed weaker and more selective negative associations, most notably with nutrition and stress management. Conclusions: Parenting styles are significantly associated with health-promoting lifestyle behaviors among university students. Authoritative parenting was consistently associated with more favorable health-promoting lifestyle patterns across multiple domains, whereas permissive and authoritarian parenting may be linked to less favorable health behaviors. These findings suggest that perceived parenting styles are associated with health-related behaviors among university students. Full article

(This article belongs to the Special Issue Health Promotion, Health Behaviors, and Preventive Care: Multi-Level Educational Approaches)

16 pages, 3646 KB

Open AccessArticle

Adoption and Efficiency of an Anesthesia Information Management System: Evaluation of Workflow Integration in Perioperative Care

by Nikola Prpic, Ileana Lulic, Laura Karla Bozic, Mario Staresinic, Dinka Lulic, Dinko Tonkovic, Neven Henigsberg, Iva Bacak Kocman, Gorjana Erceg and Jadranka Pavicic Saric

Healthcare 2026, 14(11), 1520; https://doi.org/10.3390/healthcare14111520 (registering DOI) - 30 May 2026

Abstract

Background: Anesthesia Information Management Systems (AIMSs) support perioperative documentation and clinical decision-making, but their real-world adoption remains heterogeneous and incompletely understood. Methods: This study combined a cross-sectional survey with a randomized crossover simulation study conducted at a tertiary care center following AIMS implementation. [...] Read more.

Background: Anesthesia Information Management Systems (AIMSs) support perioperative documentation and clinical decision-making, but their real-world adoption remains heterogeneous and incompletely understood. Methods: This study combined a cross-sectional survey with a randomized crossover simulation study conducted at a tertiary care center following AIMS implementation. All anesthesiologists were invited to complete a structured questionnaire assessing satisfaction, usability, adoption, and use of decision-support functionalities. In the simulation study, participants entered standardized intraoperative data into both paper-based records and the electronic AIMS, with documentation time recorded. Survey data were analyzed descriptively with subgroup analyses, and documentation times were compared using the Wilcoxon signed-rank test. Results: A total of 27 anesthesiologists participated. Overall satisfaction and workflow integration were high, with 81.48% reporting that the system was easy to use and well-integrated into clinical practice. Electronic documentation was preferred across multiple domains, including time efficiency (92.59%) and accuracy (85.19%). In the simulation study, electronic documentation was significantly faster than paper-based documentation (median 540 vs. 1140 s; p = 0.0016). Adoption patterns demonstrated a bimodal distribution, with no association with technological literacy or engagement with educational materials. Decision-support features embedded within routine workflows were used more frequently than those requiring additional navigation. Conclusions: AIMS implementation was associated with high user satisfaction and improved documentation efficiency, but showed heterogeneous adoption and selective feature use. Effective integration appears to depend on workflow alignment rather than user characteristics alone. Full article

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14 pages, 438 KB

Open AccessArticle

ERAS Implementation Fidelity, Care Complexity, and Postoperative Outcomes in Oncological Colorectal Surgery: A Real-World Observational Study

by José Antonio Jerez González, Miguel Ángel Hidalgo-Blanco, Montserrat Puig Llobet, Jordi Adamuz, Maria Eulàlia Juvé-Udina, Oliver Polushkina-Merchanskaya, Bernat Miguel-Huguet, Mireia Mariscal Cabeza and Carmen Moreno Arroyo

Healthcare 2026, 14(11), 1519; https://doi.org/10.3390/healthcare14111519 - 29 May 2026

Abstract

Background: Enhanced Recovery After Surgery (ERAS) programmes are structured perioperative care pathways in which clinical outcomes are closely linked to the degree of implementation fidelity. However, the interaction between ERAS adherence, care complexity, and postoperative outcomes in real-world settings remains insufficiently explored. Objective: [...] Read more.

Background: Enhanced Recovery After Surgery (ERAS) programmes are structured perioperative care pathways in which clinical outcomes are closely linked to the degree of implementation fidelity. However, the interaction between ERAS adherence, care complexity, and postoperative outcomes in real-world settings remains insufficiently explored. Objective: To evaluate the association between ERAS adherence and postoperative length of stay in oncological colorectal surgery and to analyse whether Care Complexity Individual Factors (CCIFs) influence this relationship. Methods: A retrospective observational cohort study was conducted in two university hospitals in Barcelona, including 90 adult patients undergoing elective colorectal cancer surgery (2022). ERAS adherence was assessed globally and by phase (pre-, intra-, and postoperative) using structured indicators. CCIFs were classified into five domains. Associations between adherence, care complexity, and outcomes were analysed using bivariate methods. Results: Overall adherence was 64%. Higher adherence was associated with shorter hospital length of stay (median 4 vs. 5 days; p = 0.033) and greater compliance with expected length of stay (37.8% vs. 17.0%; p = 0.047). Adherence varied across perioperative phases, with higher compliance in the preoperative phase and lower compliance postoperatively. Care complexity was high (mean CCIF 2.62) and was not significantly associated with adherence or compliance with expected length of stay. Conclusions: Higher ERAS adherence is associated with shorter hospital stay in oncological colorectal surgery within a real-world context. These findings support the importance of implementation fidelity across the perioperative pathway. Further research incorporating multivariable analyses and patient-centred outcomes is needed to better understand the interaction between care complexity and recovery trajectories. Full article

(This article belongs to the Special Issue Advancing Healthcare Delivery and Patient Quality of Care Through Healthcare Professionals’ Development)

17 pages, 1137 KB

Open AccessArticle

Effects of Vibro-Stimulation Ankle Bracing on Tactile Sensation and Center of Pressure Dynamics in Individuals with Chronic Ankle Instability: A Randomized Clinical Trial

by Hanieh Khaliliyan, Mahmood Bahramizadeh, Amirhossein Zare, Majid Ansari, Farhad Ghaffari, Arash Sharafatvaziri, Hicham Khabbache, Francesco Chirico, Diego Burzomati, Aldo Sitibondo and Amelia Rizzo

Healthcare 2026, 14(11), 1518; https://doi.org/10.3390/healthcare14111518 - 29 May 2026

Abstract

Background/Objectives: Chronic ankle instability (CAI) is a common sequela of lateral ankle sprain and is characterized by recurrent episodes of giving way, sensorimotor deficits, impaired postural control, and diminished functional performance. While exercise-based rehabilitation, including neuromuscular training and proprioceptive exercises, remains the gold [...] Read more.

Background/Objectives: Chronic ankle instability (CAI) is a common sequela of lateral ankle sprain and is characterized by recurrent episodes of giving way, sensorimotor deficits, impaired postural control, and diminished functional performance. While exercise-based rehabilitation, including neuromuscular training and proprioceptive exercises, remains the gold standard for managing CAI, patients often require additional support during daily activities. Orthotic interventions predominantly address mechanical instability, yet there is a clinical gap in providing integrated solutions that simultaneously offer mechanical support and sensory feedback to enhance postural control. This study aimed to investigate the effects of a semi-rigid ankle brace combined with vibro-stimulation on tactile sensation and center of pressure excursion in individuals with CAI. Methods: A randomized clinical trial was designed with two parallel groups and repeated measurements over time. Thirty adults (n = 15 per group) aged 18–35 years, who met the International Ankle Consortium criteria for CAI, were recruited. Participants in the experimental group received a semi-rigid ankle brace integrated with a wearable vibro-stimulation system, whereas those in the comparison group used the ankle brace alone. Outcome measures were collected at baseline, after 10 min, and after 2 and 4 weeks. Primary outcomes included Vibration Detection Rate and phase plane portraits assessed using a 128 Hz tuning fork and a force plate. Results: The ankle bracing plus vibration band group demonstrated significantly greater improvement at 4 weeks than the orthosis group in Vibration Detection Rate (F (3,26) = 31.93, p < 0.001, η² = 0.78). Also, the largest effect was observed for the anteroposterior phase plane portrait at 4 weeks (MD = −2.10 ± 0.42, 95% CI: −2.96 to −1.23, p < 0.001, d = −1.79). Conclusions: The findings suggest that combining a semi-rigid ankle bracing with vibro-stimulation provides additional benefits over the use of bracing alone in individuals with CAI. Full article

(This article belongs to the Special Issue Recent Advances in Motor Rehabilitation in Healthcare: Bridging Neuroscience, Technology, and Clinical Practice)

15 pages, 482 KB

Open AccessArticle

Personality, Emotion Regulation, and Psychological Distress in Italian Women with Feeding and Eating Disorders: A Cross-Sectional Study

by Maria Rosaria Juli, Laura Muzi, Valentina Tavoloni and Mariagrazia Di Giuseppe

Healthcare 2026, 14(11), 1517; https://doi.org/10.3390/healthcare14111517 - 29 May 2026

Abstract

Background/Objectives: Feeding and Eating Disorders (FEDs) are among the most challenging mental disorders due to their pervasive symptomatology and high relapse rates. While considerable research has focused on the role of personality in the onset and maintenance of FEDs, it remains unclear [...] Read more.

Background/Objectives: Feeding and Eating Disorders (FEDs) are among the most challenging mental disorders due to their pervasive symptomatology and high relapse rates. While considerable research has focused on the role of personality in the onset and maintenance of FEDs, it remains unclear whether specific personality dimensions and emotion dysregulation mechanisms predict clinical severity and purging behaviors. This study aimed to explore the role of personality dimensions, emotion dysregulation, and purging behaviors in predicting psychological distress in patients with FEDs, adopting a dimensional and integrated perspective. Methods: A sample of cisgender women in a semi-residential treatment for FEDs or obesity (n = 124) was recruited in southern Italy and assessed using a psychodiagnostics survey, including the Eating Disorder Inventory-3 (EDI-3), the Symptom Checklist-90-R (SCL-90-R), and the Personality Inventory for DSM-5 (PID-5). Results: Patients with bulimia nervosa exhibited higher psychological distress compared to patients with other FEDs and Obesity, which was not significantly determined by the co-occurrence of personality disorders. Negative affectivity, detachment, and purging symptoms were significantly related to psychological distress in patients with FEDs and Obesity (p ranging from 0.028 to <0.001). Moreover, the results showed an indirect effect of emotion regulation on the relationship between self-esteem and purging symptoms in patients with FEDs and Obesity (β = 0.107; p = 0.046). Conclusions: These findings suggest that specific personality dimensions, emotion dysregulation, and purging symptoms are associated with psychological distress in individuals with FEDs and Obesity. Therefore, it is necessary to reflect on the impact of these psychological components in planning tailored treatment for FED patients. Full article

(This article belongs to the Special Issue Interdisciplinary Advances: Bridging Clinical Medicine and Clinical Psychology)

15 pages, 696 KB

Open AccessPerspective

Supporting Parental Decision-Making After Life-Limiting Fetal Diagnoses: The Role of Perinatal Hospice and the NOVA-L Decision Support System

by Margherita Dahò

Healthcare 2026, 14(11), 1516; https://doi.org/10.3390/healthcare14111516 - 29 May 2026

Abstract

Background: Prenatal diagnosis of life-limiting fetal conditions often leads to counseling focused primarily on therapeutic abortion. Perinatal hospice has emerged as an alternative model of care for families who choose to continue the pregnancy. This paper has two primary aims. First, it [...] Read more.

Background: Prenatal diagnosis of life-limiting fetal conditions often leads to counseling focused primarily on therapeutic abortion. Perinatal hospice has emerged as an alternative model of care for families who choose to continue the pregnancy. This paper has two primary aims. First, it discusses structured perinatal hospice programs and their role in supporting parental decision-making after such diagnoses, with attention to ethical and emotional complexities. Second, the paper introduces NOVA-L (Navigating Options & Vital Assistance for Life-limiting conditions), a conceptual Decision Support System (DSS) designed to complement perinatal hospice care. Methods: The paper provides a conceptual and descriptive analysis of the Comfort Care clinical model. It also outlines the proposed architecture of NOVA-L. DSSs combine clinical guidelines, research data, and outcome registries on digital platforms, providing evidence-based information and AI-supported analytical tools. Their potential adaptation to perinatal hospice care is explored. Results: The Comfort Care model involves interdisciplinary counseling, structured communication, and psychosocial support to facilitate clarification of parental values and care pathways. NOVA-L is presented as a complementary tool that may enhance transparency in risk evaluation and option comparison through accessible interfaces under professional supervision. Conclusions: Structured perinatal hospice programs may enhance clarity and compassion in decision-making. The conceptual integration of AI-supported DSS tools, such as NOVA-L, could strengthen ethically grounded, emotionally sensitive parental support. Full article

(This article belongs to the Special Issue AI-Driven Healthcare: Transforming Patient Care and Outcomes)

18 pages, 687 KB

Open AccessArticle

Clinical, Neuropathic, and Sudomotor Correlates of Orthostatic Hypotension in Type 2 Diabetes: A Cross-Sectional Study

by Bianca Iliescu, Andreea Herascu, Laura Gaita, Vlad Florian Avram, Adina Braha and Bogdan Timar

Healthcare 2026, 14(11), 1515; https://doi.org/10.3390/healthcare14111515 - 29 May 2026

Abstract

Background/Objectives: Orthostatic hypotension (OH) is a clinically relevant manifestation that may reflect cardiovascular autonomic dysfunction in type 2 diabetes (T2D), yet its correlates remain incompletely characterized. This cross-sectional study evaluated clinical, neuropathic, and sudomotor factors associated with OH and explored balance-related outcomes as [...] Read more.

Background/Objectives: Orthostatic hypotension (OH) is a clinically relevant manifestation that may reflect cardiovascular autonomic dysfunction in type 2 diabetes (T2D), yet its correlates remain incompletely characterized. This cross-sectional study evaluated clinical, neuropathic, and sudomotor factors associated with OH and explored balance-related outcomes as secondary analyses. Methods: In this cross-sectional study, 124 adults with T2D aged ≥60 years underwent standardized orthostatic blood pressure testing. Peripheral neuropathy was assessed using the Michigan Neuropathy Screening Instrument (MNSI), and sudomotor function was assessed by electrochemical skin conductance measured with Sudoscan. Balance, mobility, and fear of falling were evaluated as exploratory secondary outcomes. Active antihypertensive treatment was recorded at the time of assessment and considered a potential confounder. Multivariable logistic regression was used to identify factors associated with OH. Results: OH was associated with longer diabetes duration (OR = 1.11/year, p = 0.002), higher objective neuropathy severity (MNSI-B; OR = 1.27, p = 0.049), and increased urinary albumin-to-creatinine ratio (OR = 1.01, p = 0.035). Sudomotor parameters did not differ significantly between OH groups in univariate analyses and were not retained in the final parsimonious model. Exploratory analyses showed no significant univariate differences in balance or fear-of-falling outcomes by OH status. Model discrimination was acceptable (AUC = 0.787), whereas calibration was imperfect according to the Hosmer–Lemeshow test; therefore, model performance should be interpreted as apparent and explanatory rather than predictive. Conclusions: In older adults with T2D, OH was associated with longer disease duration, greater neuropathy burden, and microvascular involvement. Sudoscan-derived measures were not independently associated with OH in this cohort. Because of the cross-sectional design and residual medication confounding, all findings should be interpreted as associations only. These results support routine orthostatic evaluation alongside neuropathy and albuminuria assessment, while predictive modeling requires external validation in larger cohorts. Full article

16 pages, 305 KB

Open AccessReview

Family Medicine in Gulf Cooperation Council Countries: Perspectives, Directions, and Future Opportunities; A Narrative Review

by Asma Said Hamed Al Shidhani, Maisa Hamed Al Kiyumi, Buthaina Ahmed Al Zaabi, Badriya Saleh Al Farsi, Faisal A. Alnaser and Abdulaziz Al Mahrezi

Healthcare 2026, 14(11), 1514; https://doi.org/10.3390/healthcare14111514 - 29 May 2026

Abstract

Family medicine has attracted increasing policy and institutional support across the Gulf Cooperation Council (GCC) countries through health system reform, expansion of the healthcare workforce, and sustained public investment. Nevertheless, important challenges continue to affect the strength of primary healthcare systems, access to [...] Read more.

Family medicine has attracted increasing policy and institutional support across the Gulf Cooperation Council (GCC) countries through health system reform, expansion of the healthcare workforce, and sustained public investment. Nevertheless, important challenges continue to affect the strength of primary healthcare systems, access to care, and the management of non-communicable diseases. The aim of the narrative review is to identify future trends, directions, perspectives, and opportunities that can strengthen implementation of family medicine across GCC countries and improve healthcare delivery. This review is based on a structured search of major databases such as PubMed, Scopus, and Google Scholar. The focus was evaluation of literature associated with family medicine and primary healthcare development in GCC countries. Regional priorities now include improving medical education and training, expanding the family medicine workforce, strengthening links with communities, promoting more equitable access to healthcare, and managing treatment costs through workforce development and digital health initiatives. Family medicine practice across the GCC is being supported increasingly by electronic health records, telemedicine, and interprofessional education. Policy directions in the region also suggest growing interest in value-based research, international collaboration, multidisciplinary care, and innovation in healthcare delivery. The future of development of family medicine in the GCC will depend on better integration of digital health, more effective use of data in planning and policy, continued investment in training, and broader adoption of patient-centred models of care. In general, strengthening family medicine through sustained investment in workforce development, primary healthcare infrastructure, research capacity, and digital health integration is essential for achieving resilient, equitable, and patient-centered healthcare systems across the GCC. Full article

(This article belongs to the Section Healthcare Organizations, Systems, and Providers)

17 pages, 543 KB

Open AccessReview

Cultural Alignment and Psychological Well-Being: Insights from Person–Culture Match Research

by Vera Vogel

Healthcare 2026, 14(11), 1513; https://doi.org/10.3390/healthcare14111513 - 29 May 2026

Abstract

Background: Research on psychological well-being has traditionally focused on individual characteristics such as personality traits, values, and beliefs. However, comparatively less attention has been paid to the sociocultural contexts in which individuals are embedded and that influence how the individual characteristics are [...] Read more.

Background: Research on psychological well-being has traditionally focused on individual characteristics such as personality traits, values, and beliefs. However, comparatively less attention has been paid to the sociocultural contexts in which individuals are embedded and that influence how the individual characteristics are expressed, evaluated, and rewarded. One theoretical framework that captures this interaction is person–culture match (PCM), defined as the alignment between individual traits, values, or beliefs and those prevalent within the surrounding culture. Objectives: This narrative review synthesizes conceptual and empirical research on PCM and discusses its implications for psychological well-being and broader societal consequences. Methods: A narrative review of the literature was conducted to identify key theoretical contributions and empirical studies on PCM. The reviewed literature includes cross-cultural research examining the alignment between personal characteristics and corresponding cultural characteristics, as well as its implications for well-being and broader societal processes. Results: Across a wide range of studies, individuals tend to report higher well-being when their personal traits, values, or beliefs align with characteristics prevalent within their sociocultural context. This pattern has been documented across multiple characteristics, including personality traits, religiosity, political ideology, and personal values. Higher PCM has been associated with higher life satisfaction, greater positive affect, stronger self-esteem, and lower levels of stress and depressive symptoms. Conclusions: The literature suggests that well-being is shaped not only by individual characteristics but also by their alignment with one’s sociocultural contexts. Future research is needed to clarify the mechanisms underlying these effects and to explore the broader societal consequences of PCM. Considering cultural alignment may therefore be valuable for both advancing research and informing public health strategies and policy interventions aimed at enhancing well-being and social cohesion. Full article

(This article belongs to the Special Issue Global Health and Health Care Services: Social Psychological Determinants of Health and Well-Being)

18 pages, 736 KB

Open AccessSystematic Review

Mindfulness on the Palm of Your Hand: A Systematic Review of Mobile Mindfulness Apps and Their Effects on Well-Being, Compassion, and Aggression in Non-Clinical Adults

by Félix Alberto Véliz-Montoya, Sandra Nieto-González, Antonio Salinas-Layana and Juan Pablo Pizarro-Ruiz

Healthcare 2026, 14(11), 1512; https://doi.org/10.3390/healthcare14111512 - 29 May 2026

Abstract

Background/Objectives: Mindfulness has emerged as a widely studied approach for promoting psychological well-being, evolving from its contemplative origins into a secular, evidence-based intervention. In recent years, the proliferation of mobile applications has enabled the delivery of mindfulness-based interventions (MBIs) in accessible and scalable [...] Read more.

Background/Objectives: Mindfulness has emerged as a widely studied approach for promoting psychological well-being, evolving from its contemplative origins into a secular, evidence-based intervention. In recent years, the proliferation of mobile applications has enabled the delivery of mindfulness-based interventions (MBIs) in accessible and scalable formats. This systematic review examined the efficacy of MBIs delivered via mobile applications in non-clinical adult populations, with a focus on well-being, compassion, and aggression. Methods: A comprehensive search was conducted across six databases (Web of Science, PubMed, MEDLINE, Scopus, SciELO, and Dialnet) for studies published from 2014 onward, following PRISMA 2020 guidelines. A total of 23 randomized controlled trials met the inclusion criteria. Additionally, a risk-of-bias assessment was performed using the Cochrane RoB-2 tool. Results: Results indicated small to moderate improvements in well-being outcomes, including positive affect, life satisfaction, and psychological well-being. Evidence regarding compassion was limited and mixed, while no studies addressing aggression met the inclusion criteria. Additionally, substantial variability in adherence rates and a high overall risk of bias were observed. Conclusions: These findings suggest that mindfulness applications may represent accessible tools for enhancing individual well-being; however, their effect on broader socio-emotional functioning remains unclear. Further research should prioritize more rigorous study designs, including active control conditions and behavioral outcome measures, to better establish their effectiveness and underlying mechanisms. Full article

(This article belongs to the Special Issue Advancing Health Education: Integrating Education, Evaluation and Intervention for Population Well-Being in Healthcare and Sexuality)

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21 pages, 542 KB

Open AccessReview

Integrating Cardiopulmonary Exercise Testing, Stress Echocardiography and Near-Infrared Spectroscopy for Multimodal Assessment of Exercise Intolerance: A Narrative Review

by Geza Halasz, Raffaella Mistrulli, Marco Di Francesco, Guido Giacalone, Gianluca Ferri, Stefano Beato, Francesca Moschella Orsini, Giovanni Nardecchia, Bernadette Corica, Furio Colivicchi, Stefania Angela Di Fusco, Federica Re and Domenico Gabrielli

Healthcare 2026, 14(11), 1511; https://doi.org/10.3390/healthcare14111511 - 29 May 2026

Abstract

Cardiopulmonary exercise testing (CPET) is the reference method for the objective assessment of exercise capacity because it provides an integrated appraisal of cardiovascular, respiratory and metabolic responses to exertion. However, CPET alone quantifies the magnitude of functional impairment without fully resolving the central [...] Read more.

Cardiopulmonary exercise testing (CPET) is the reference method for the objective assessment of exercise capacity because it provides an integrated appraisal of cardiovascular, respiratory and metabolic responses to exertion. However, CPET alone quantifies the magnitude of functional impairment without fully resolving the central and peripheral mechanisms that determine exercise intolerance. The integration of CPET with exercise stress echocardiography and near-infrared spectroscopy (NIRS) has therefore emerged as a clinically relevant multimodal strategy. Stress echocardiography provides real-time information on ventricular reserve, filling pressures, pulmonary pressure response, valvular function, pulmonary congestion and dynamic outflow obstruction, whereas NIRS provides continuous insight into skeletal muscle oxygen delivery, extraction and utilization. This narrative review summarizes the physiological rationale, practical workflow, methodological limitations and clinical applications of combined CPET, stress echocardiography and NIRS across heart failure, pulmonary hypertension, peripheral artery disease, cardiomyopathies and sports cardiology. By linking systemic gas exchange, central hemodynamics and peripheral oxygen handling, this approach may move exercise evaluation from a descriptive measure of performance toward a mechanism-based framework for phenotyping, risk stratification and individualized therapeutic decision-making. Further studies are needed to harmonize protocols, validate reproducible multimodal indices and demonstrate incremental prognostic value over conventional testing. Full article

(This article belongs to the Special Issue Cardiopulmonary Exercise Testing: A Key Player in Cardiovascular Disease Management)

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15 pages, 374 KB

Open AccessReview

Healthcare Quality Systems: International Frameworks, Evaluation and Improvement Strategies

by Christos Ntais and Michael A. Talias

Healthcare 2026, 14(11), 1510; https://doi.org/10.3390/healthcare14111510 - 29 May 2026

Abstract

Healthcare quality systems have evolved from narrow inspection and compliance mechanisms into broader, multi-level architectures that combine standards, measurement, organizational learning, patient safety, equity and patient-reported outcomes. Yet the field remains fragmented, with substantial variation in how quality is defined, measured and operationalized [...] Read more.

Healthcare quality systems have evolved from narrow inspection and compliance mechanisms into broader, multi-level architectures that combine standards, measurement, organizational learning, patient safety, equity and patient-reported outcomes. Yet the field remains fragmented, with substantial variation in how quality is defined, measured and operationalized across countries and healthcare settings. This narrative review synthesizes major international quality systems and frameworks used in healthcare delivery, examines principal methods for evaluating and improving quality, and critically discusses organizational and policy conditions associated with successful implementation. A purposive review of the seminal conceptual literature and authoritative documents from major international organizations was undertaken to identify cross-cutting themes relevant to hospitals, ambulatory care and health systems. The review shows that influential approaches—including the World Health Organization’s quality and patient safety frameworks, Joint Commission International accreditation, NCQA/HEDIS, the EFQM model, ISO-based management systems, AHRQ quality indicators and OECD performance initiatives such as PaRIS—should be viewed as complementary rather than competing models. Their effectiveness depends less on formal adoption alone than on leadership commitment, workforce engagement, data infrastructure, patient involvement and alignment with financing and regulation. Evidence is strongest for gains in standardization, safety processes, teamwork and selected efficiency outcomes; direct causal effects on patient outcomes remain less consistent, particularly when quality systems become compliance-driven or are insufficiently adapted to local context. Future healthcare quality systems should integrate equity, digital interoperability, AI-enabled learning capabilities, patient-reported measures and continuous improvement while reducing measurement burden and indicator proliferation. Full article

(This article belongs to the Special Issue Healthcare Management: Improving Patient Outcomes and Service Quality)

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18 pages, 606 KB

Open AccessSystematic Review

Clinical Outcomes for Emergency Department Presentations of Sepsis Managed on a Clinical Pathway: A Systematic Review and Meta-Analysis

by Andrew McKinlay, Giles Barrington, Sarah J. Prior and Viet Tran

Healthcare 2026, 14(11), 1509; https://doi.org/10.3390/healthcare14111509 - 29 May 2026

Abstract

Background: Sepsis is a time-critical condition requiring early recognition and intervention. Many emergency departments (EDs) have adopted clinical pathways to standardise sepsis care; however, the impact of these pathways on patient outcomes remains unclear. Methods: A systematic review and meta-analysis was [...] Read more.

Background: Sepsis is a time-critical condition requiring early recognition and intervention. Many emergency departments (EDs) have adopted clinical pathways to standardise sepsis care; however, the impact of these pathways on patient outcomes remains unclear. Methods: A systematic review and meta-analysis was conducted in November 2024 searching PubMed, Embase, and Scopus. Studies were included if they assessed the impact of a clinical pathway on adult or paediatric patients with sepsis presenting to the ED. Results: Thirty-three studies were included, of which the majority were retrospective cohort designs and were rated serious overall risk of bias. Pathway implementation was associated with faster time to antibiotics across all subgroups (135 min before vs. 93 min after; MD −43 min, p < 0.001). In-hospital mortality appeared reduced in the primary analysis (RD −2.4%, p = 0.032); however, this finding was fragile under sensitivity analysis and was not observed in prospective or randomised designs. The apparent reduction in hospital length of stay was driven by paediatric and low- and middle-income country studies and was non-significant when restricted to adult studies. ICU admission rate, ED length of stay, and time to IV fluid resuscitation were not significantly reduced. Conclusions: ED sepsis pathway implementation is associated with improved time to antibiotics across clinical settings and populations. Current evidence is insufficient to demonstrate a reduction in mortality; the apparent signal in retrospective studies is attributable to secular improvements in sepsis care and asymmetric patient identification rather than a true pathway effect. Future research should prioritise prospective controlled studies with standardised screening methods, time zero definitions and control of confounding variables. Full article

(This article belongs to the Section Healthcare Organizations, Systems, and Providers)

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25 pages, 2865 KB

Open AccessArticle

Process and Strategies for Implementing an Antenatal Psychosocial Clinical Decision Support System Within an Inter-Organisational Care Context: The Born in Belgium Professionals Platform

by Kelly Amuli, Kim Decabooter, Caroline Germanes, An-Sofie Van Parys, Sabine Verschelde, Emilie Saey, Manon Moulin, Pieter Cornu and Katrien Beeckman

Healthcare 2026, 14(11), 1508; https://doi.org/10.3390/healthcare14111508 - 29 May 2026

Abstract

Background/Objectives: Despite ongoing innovation, few interventions—including Clinical Decision Support Systems (CDSS)—are successfully integrated into routine care. Understanding the process through which innovations are implemented is therefore essential for advancing practice and research. In perinatal settings, evidence on how CDSS implementation unfolds and [...] Read more.

Background/Objectives: Despite ongoing innovation, few interventions—including Clinical Decision Support Systems (CDSS)—are successfully integrated into routine care. Understanding the process through which innovations are implemented is therefore essential for advancing practice and research. In perinatal settings, evidence on how CDSS implementation unfolds and which strategies support adoption, scale-up, and sustainment remains limited. This study aimed to understand the implementation process, key determinants and implementation strategies of a shared antenatal psychosocial CDSS (i.e., the Born in Belgium Professionals [BIB-Pro]) implemented in a real-world, cross-sectoral perinatal care setting. Methods: A qualitative exploratory case study was conducted between January and March 2025. Data included semi-structured interviews with all seven implementation agents, document analysis of the implementation plan. Directed content analysis was applied using the Exploration, Preparation, Implementation, Sustainment (EPIS) framework to categorise contextual determinants and the ERIC taxonomy to classify implementation strategies. Data were synthesised across the four EPIS phases. Results: The implementation process unfolded across all EPIS phases, showing a shift in responsibility from the policy level to the implementation team and healthcare organisations. Implementation was shaped by key determinants across multiple levels: (1) the bridging functions by the BIB-Pro implementation agents connecting policy, innovation, and organisational practice; (2) the system-level leadership and funding by the National Institute for Health and Disability Insurance that enabled initiation and sustainability; and (3) the multilevel stakeholder involvement and inter-organisational collaboration across care settings. In addition, the personal attributes of implementation agents—accessibility, active listening, adaptability, and persistent follow-up—were also identified as relevant factors in the implementation process. Across the implementation process, a broad range of implementation strategies was identified. The most prominent ERIC strategies were developing stakeholder interrelationships, evaluative and iterative strategies, engaging stakeholders, training and educating stakeholders, and providing interactive assistance. Barriers encountered during the implementation process included fragmented care networks, inconsistent regional referral structures, legal uncertainties, and variable digital readiness. In response to these challenges, implementation strategies were applied to support collaboration, clarify procedures and provide targeted support. Conclusions: This study provides insight into how a CDSS was introduced, scaled, and sustained across complex multiple Belgian perinatal care settings. Strong bridging functions, stakeholder interrelationships, iterative evaluation, and system-level support were key factors throughout the implementation process. Across all phases, stakeholder interrelationship strategies and evaluative and iterative strategies were the most prominent and consistently applied, supporting stakeholder engagement and sustained use of the platform. These findings offer actionable guidance for implementing digital tools in multi-organisational and multi-level contexts within perinatal care and other healthcare settings. Full article

(This article belongs to the Special Issue Evaluating Health Technology Implementation and Adoption in Hospital Settings)

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15 pages, 1495 KB

Open AccessArticle

Sleep Quality and Influencing Factors of Nurses in Fever Clinics During Closed-Loop Management: An Exploratory Mixed-Methods Study

by Fenglin Wang, Yue Hu, Dongli Wei, Fengqin Zhou, Yilan Liu and Weixian Wang

Healthcare 2026, 14(11), 1507; https://doi.org/10.3390/healthcare14111507 - 29 May 2026

Abstract

Background: During the COVID-19 pandemic, fever clinic nurses under closed-loop management faced high occupational stress and strict isolation, which may impair sleep quality. However, evidence in this population remains limited. This study investigated the sleep quality of fever clinic nurses during closed-loop COVID-19 [...] Read more.

Background: During the COVID-19 pandemic, fever clinic nurses under closed-loop management faced high occupational stress and strict isolation, which may impair sleep quality. However, evidence in this population remains limited. This study investigated the sleep quality of fever clinic nurses during closed-loop COVID-19 management and identified associated factors. Methods: A sequential explanatory mixed-methods design approach was employed. Quantitative data were collected using the Pittsburgh Sleep Quality Index (PSQI) and Nurses’ Psychological Capital Scale from 33 front-line nurses, acknowledging the limited sample size. Semi-structured in-depth interviews were conducted with six nurses to provide qualitative insights. Results: The mean PSQI score was 8.16 ± 4.25, indicating moderate sleep disturbances among nurses. Factors associated with sleep quality included demographic and occupational factors (e.g., night shifts, work pressure) and psychological capital (self-efficacy, resilience, hope, and optimism). Qualitative analysis identified three themes: the impact of personal circumstances on sleep quality, psychological pressures during closed-loop management, and the role of self-regulation in coping. Conclusions: During the closed-loop management for COVID-19 pandemic prevention and control, the sleep quality of nurses in fever clinics was poor. This study identified personal circumstances, work pressure, and psychological capital as potential factors associated with sleep quality, suggesting that further research is needed to develop and test targeted interventions. These findings provide preliminary evidence that may inform future management strategies, but do not support definitive intervention recommendations. Full article

(This article belongs to the Section Mental Health and Psychosocial Well-being)

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