Healthcare doi: 10.3390/healthcare14162560

Authors: Hamza Moafa

Background/Objectives: As artificial intelligence (AI) continues to be integrated in healthcare settings, it enters clinical work as a support and a source of stress. Although AI anxiety acts as a psychological barrier to consistent engagement with AI technology, evidence on its relationships with nursing outcomes such as work engagement and task performance remains limited. This study examined the associations between AI anxiety, work engagement, and task performance among nurses using the challenge–hindrance stressor framework, considering work engagement as a hypothesized mediator. Methods: A quantitative cross-sectional correlational design was used. In December 2025, 106 nurses across various hospital units in Saudi Arabia were recruited through a non-probability strategy combining purposive, convenience, and snowball techniques. Participants completed the Artificial Intelligence Anxiety Scale, the 3-item Utrecht Work Engagement Scale, and the task performance subscale of the Individual Work Performance Questionnaire. Data were analyzed using Pearson correlations and PROCESS-based mediation analysis (Model 4), with 5000 bootstrap resamples and 95% percentile confidence intervals. Results: Work engagement statistically mediated the cross-sectional association between AI anxiety and task performance; the indirect effect was significant, whereas the direct effect was not. Higher AI anxiety was positively associated with higher work engagement (β=0.29, p=0.002), and higher work engagement with higher task performance (β=0.45, p<0.001). The total effect was significant (β=0.22, p=0.026), while the standardized indirect effect was 0.13 (95% CI: 0.036–0.248). Conclusions: AI anxiety may be tentatively interpreted as a possible challenge stressor, with its positive association with task performance appearing to operate indirectly through work engagement. These results indicate that strengthening AI competency and work engagement may support nurses’ task performance.

Healthcare doi: 10.3390/healthcare14162559

Authors: Julia Sánchez-Galloso Andrés Arana-Rodríguez José-Luis Sánchez-Ramos Almudena Garrido-Fernández Rocío Romero-Serrano Francisca María García-Padilla

Background/Objectives: Population ageing has increased the importance of promoting wellbeing and healthy ageing. Gerontological day centres may support the wellbeing of older adults. This study aimed to examine quality of life, active ageing, perceived social support, and loneliness in older adults attending gerontological day centres and to identify the factors associated with quality of life. Methods: A cross-sectional descriptive study was conducted with 109 participants aged 60–98 years recruited from gerontological day centres in Huelva and Seville, Spain. Data were collected using the WHOQOL-BREF, the Multidimensional Scale of Perceived Social Support (MSPSS), the ESTE II Loneliness Scale, and the Active Ageing Scale. Descriptive and comparative analyses were performed, followed by multiple linear regression to identify factors associated with quality of life. Results: Mean scores were 14.46 (SD = 1.83) for quality of life, 3.06 (SD = 0.36) for active ageing, 10.14 (SD = 3.00) for social loneliness, and 5.62 (SD = 0.93) for perceived social support. The multiple linear regression model accounted for 30.8% of the variance in quality of life (adjusted R2 = 0.288), leaving approximately 69.2% of the variance unexplained by these factors. In this model, active ageing (β = 0.395; p < 0.001), social loneliness (β = −0.246; p = 0.004), and perceived social support (β = 0.188; p = 0.027) were independent predictors of quality of life. Bivariate analyses should be interpreted with caution as they were strictly exploratory. Conclusions: The study demonstrates that active ageing, low social loneliness, and solid perceived social support are the core multivariable predictors of quality of life among older adults in day centres. Secondary exploratory trends suggested minor baseline links with sleep duration, marital status, and employment status. Interventions should prioritize promoting active ageing and strengthening social networks, while future research needs to explore additional covariates to account for the remaining unexplained variance in well-being.

Healthcare doi: 10.3390/healthcare14162558

Authors: Roman Skrypnyk Maksym Skrypnyk Margarita Skikevych Igor Skrypnyk Tetiana Yatsenko Tatiana Petrushanko Axel Spahr Chun Xu Satoshi Takahashi Taro Osada Shlomo Berkovsky Koichi Hattori Beate Heissig

Background: While acute coronavirus disease 2019 (COVID-19) infections of the oral cavity, with clinical signs such as taste loss, dry mouth, and mucosal lesions, are well-established health problems, involvement of the oral cavity as a sign of long COVID is poorly understood. One of the organs in the oral cavity that is prone to the virus is the salivary gland. Case presentation: We describe the case of an elderly patient with severe generalized xerostomia and left-sided facial swelling involving the submandibular gland, an uncommon presentation, as the parotid gland is typically involved COVID-19 infections. Ultrasound demonstrated marked ductal dilation without glandular tissue changes. The absence of other causes of sialodochitis, together with a history of repeated COVID-19 infections, led to the diagnosis of post-COVID sialodochitis. Management options were limited by the patient’s frailty and polypharmacy. Nevertheless, conservative symptomatic treatment led to clinical recovery, with no evidence of progression to bacterial or necrotizing sialadenitis. Conclusions: This case demonstrates that COVID-19 infection and its history should be included in the differential diagnosis of sialadenitis. Along with the clinical case presentation, a narrative review of similar studies on COVID-19-associated salivary gland disease was conducted, spanning molecular and post-mortem evidence, acute clinical cases, and post-COVID sequelae.

Healthcare doi: 10.3390/healthcare14162557

Authors: Marcello Torre Rosario Caruso Antonio Maria Giuseppe Staffa Cristina Arrigoni Arianna Magon

Background/Objectives: International nurse recruitment is increasingly important, but early integration depends on language, professional adaptation, organizational welcome, and retention support. Evidence from non-English-speaking healthcare systems and multi-stakeholder implementation evaluations remains limited. This study aimed to evaluate a structured onboarding pathway as an exploratory, response-level pilot and a feasibility platform. Methods: Anonymous five-point Likert questionnaires were administered to clinical coaches, ward teams, and newly hired international nurses at conceptual time points T0, T1, and T2. T0 was partly retrospective because the first survey wave, administered at approximately 3 months, asked respondents to rate both arrival status and current status. Analyses were response-level; T0–T1 ratings were summarized with a paired within-row sensitivity analysis when both ratings were available, whereas T2 could not be linked to the earlier wave. Results: The primary dataset contained 410 anonymous response-level observations, mostly from ward-team proxy ratings. Median language proficiency ratings were 3 (IQR 2–3) at T0, 3 (IQR 3–4) at T1, and 3 (IQR 3–4) at T2; the proportion of ratings at or above the pragmatic adequacy threshold (≥3) rose from 53.5% to 76.4% and 91.0%, respectively. For professional training/competence, median ratings were 3 (IQR 2–4), 3 (IQR 3–4), and 3 (IQR 3–4), with corresponding adequacy-threshold proportions of 53.5%, 78.0%, and 89.7%. However, stakeholder-specific patterns differed, and international nurses’ self-rated language proficiency followed a non-monotonic pattern. In the nurse-specific analytic subset (14 anonymous response rows), overall welcome was associated with intention to stay (Spearman rho = 0.73, FDR-adjusted p = 0.016) and willingness to recommend the experience (rho = 0.86, FDR-adjusted p = 0.002). Conclusions: The pilot generated hypotheses and, more importantly, mapped feasibility requirements for a future confirmatory study. Although the findings should not be interpreted causally or as paired longitudinal evidence, they provide an initial overview of issues related to the integration of international nurses in non-English-speaking healthcare settings. A future study should prospectively collect pseudonymized identifiers, objective and validated measures, and a pre-specified longitudinal analytic model.

Healthcare doi: 10.3390/healthcare14162556

Authors: Polliana Mihaela Leru Vlad Florin Anton Cristina Cercel Irina Anca Eremia Sergiu Marian Cazacu Carmen Daniela Neagoe

The incidence of neoplastic disorders worldwide has steadily increased, and Romania is no exception, showing a substantial rise in active oncologic surveillance cases. Family physicians are essential to the multidisciplinary team, providing screening, early diagnosis, care during and after cancer treatment, comorbidity management, and palliative care. Primary prevention through lifestyle behavioral changes and early detection in the asymptomatic phase remain the most effective strategies to reduce cancer morbidity and mortality. However, structural barriers within the Romanian primary healthcare system, specifically fragmented digital infrastructure, administrative workloads and limited patient health literacy, frequently restrict these preventive activities. The aim of this narrative review is to analyze cancer prevention and management within Romania’s current demographic and socio-economic context, comparing the national system to models from the UK, the Netherlands, and Spain. The analysis highlights operational gaps, including low breast, cervical, and colorectal screening uptake in Romania. We concluded that optimizing patient care requires transitioning to an integrated pathway, supported by practical reforms like digital fast-track scheduling modules managed directly by family physicians.

Healthcare doi: 10.3390/healthcare14162555

Authors: Zeynel Ertürk Bilgehan Kolutek Ay

Background: To compare the clinical and ultrasonographic effects of pulsed therapeutic ultrasound (US) and pulsed shortwave diathermy (SWD) in patients with mild-to-moderate carpal tunnel syndrome (CTS). Methods: In this randomized controlled trial, 40 patients with electrophysiologically confirmed mild-to-moderate CTS were randomly allocated into two groups. Both groups received wrist splinting and tendon–nerve gliding exercises. The US group received 15 sessions of pulsed ultrasound therapy (3 MHz, 0.8 W/cm2), whereas the SWD group received 15 sessions of pulsed shortwave diathermy (80 Hz, 19.2 W). Outcomes were assessed at baseline, 1 month, and 3 months using ultrasonographic median nerve cross-sectional area (MNCSA) (primary outcome), Boston Carpal Tunnel Questionnaire (BCTQ), Visual Analog Scale (VAS) for pain, Douleur Neuropathique 4 (DN4), and handgrip strength. Results: Baseline demographic characteristics, including age (mean ± SD) and sex distribution, were comparable between groups (p > 0.05), although BCTQ Functional Status and Total scores differed significantly at baseline. Repeated-measures analyses demonstrated significant time effects for MNCSA and all secondary clinical outcomes, including BCTQ scores, VAS pain, DN4 scores, and grip strength (all p < 0.001; partial η2 range: 0.51–0.75), indicating moderate-to-large effect sizes. Both the US and SWD groups showed sustained improvements at the 1- and 3-month follow-ups, with no significant differences between treatment modalities (all group × time interaction p > 0.05). Conclusions: In patients with mild-to-moderate CTS, both US and SWD administered alongside splinting and exercise were associated with significant clinical and ultrasonographic improvements over 3 months. No significant difference was observed between the two modalities. Both treatments may be considered adjunctive options within conservative management, although further controlled studies are needed to clarify modality-specific effects.

Healthcare doi: 10.3390/healthcare14162554

Authors: Han Shi Yizhan Wu Jiangwei Liu

Background/Objectives: The goal of the study is to examine associations of baseline residential elevation with blood biomarkers and newly reported multisystem chronic diseases among middle-aged and older adults, and to explore whether routine blood indicators may lie on these pathways. Methods: We analyzed 2011, 2015, and 2018 data from the China Health and Retirement Longitudinal Study (CHARLS). Wave 1 provided residential elevation, covariates, and 14 biomarkers; Wave 3 provided intermediate biomarkers; and Wave 4 identified 13 chronic disease outcomes based on participants’ reports of having received a physician diagnosis. High elevation was defined as ≥1500 m. Baseline and longitudinal samples included 11,371 and 9270 participants. Analyses used multivariable linear regression, attrition-weighted Cox models, logistic sensitivity models, restricted cubic splines, and exploratory mediation analysis. Results: High-elevation residence was associated with 9 of 14 biomarkers. Among 182 biomarker–disease Cox models, 35 associations had false-discovery-rate-adjusted q < 0.05, including 32 involving outcomes with at least 50 newly reported cases in the high-elevation group. Direct multiple-imputation inverse-probability-weighted (MI-IPW) Cox models showed that high-elevation residence was associated with higher estimated hazards over the interview interval for newly reported lung disease, kidney disease, arthritis, and hypertension; the first three associations remained significant in weighted logistic models. MI-IPW sensitivity analyses retained 31 of the 32 event-reliable biomarker–disease findings. No indirect effect survived multiple-comparison correction, including after excluding participants who had reported the relevant disease by Wave 3. Among the eight outcomes examined using restricted cubic splines, only kidney disease showed nominal evidence of nonlinearity (p = 0.017). Conclusions: Baseline residential elevation was associated with distinct biomarker patterns and heterogeneous disease risks. Routine blood biomarkers were prospectively associated with later disease reporting but did not provide stable evidence of mediation. These observational findings support cautious, disease-specific interpretation and further prospective and mechanistic research.

Healthcare doi: 10.3390/healthcare14162553

Authors: Ahmet Özsimsek Murat Terzi Saliha Ozpinar Sümeyye Koç Burak Yulug

Background: Studies indicate that depression and cognitive functions are important issues of mental health, a serious health issue worth evaluating with possible alternative non-medical treatment options in MS patients. Aim: The aim of this study was to investigate the effect of practice on fatigue, respiratory closure, depression and cognition in patients diagnosed with MS and whether the benefit of Hatha Yoga training is affected by personality structure. Methods: The study included 25 participants between the ages of 18 and 70 who were diagnosed with MS, with an EDSS of 6 and below and who did not show symptoms of depression and did not use antidepressants. Any previous cerebrovascular disease, hypertension (HTN), diabetes mellitus (DM), thyroid dysfunction, or vitamin B12 deficiency was determined as an exclusion criterion. In the study, patients received Hatha Yoga practice 2 days a week for 8 weeks. The MOCA (Montreal Cognitive Assessment) and Beck Depression Scale, personality analysis test, pulmonary function test, and Fatigue Impact Scale were applied to all patients fulfilling the inclusion criteria at the beginning and after the completion of Yoga practice. Results: According to the results obtained, a statistically significant decrease in Beck Depression Inventory scores (p = 0.020) and a significant increase in MOCA Cognitive Test scores (p < 0.001) were detected following the yoga intervention. Although an increase was observed in respiratory capacity (FVC), this change did not reach statistical significance (p = 0.082). These findings demonstrate that yoga practice significantly improves depression levels and cognitive functions. The relationship between the benefits derived from yoga training and personality traits was evaluated using the participants’ Temperament and Character Inventory (TCI) profiles. Following the yoga intervention, a statistically significant increase was observed in novelty seeking (p < 0.001) and persistence (p < 0.001). Conversely, participants exhibited a significant decrease in harm avoidance post-yoga (p < 0.001). However, no statistically significant changes were found in reward dependence (p = 0.766) or cooperation (p = 0.181) scores after the intervention.

Healthcare doi: 10.3390/healthcare14162552

Authors: Ourania-Themis Kouvela Nikolaos Veskoukis George Kritsotakis Michael Igoumenidis

Background/Objectives: Quiet quitting, workplace gaslighting, and moral resilience are increasingly recognized as important to employee wellbeing, yet they have rarely been studied together, and evidence from white-collar workforces outside healthcare is scarce. This study examined these three constructs, as well as the associations between them, among white-collar employees of a governmental organization in Greece. Methods: A cross-sectional study was conducted with a self-report questionnaire completed by 433 employees, about 90% of the target population. Quiet quitting, workplace gaslighting, and moral resilience were measured with the Quiet Quitting Scale, the Gaslighting at Work Scale, and the revised Rushton Moral Resilience Scale (RMRS-16). Results: The mean quiet quitting score was 2.26 (SD 0.69), the mean gaslighting score was 1.84 (SD 0.76), and the mean moral resilience score was 3.08 (SD 0.43). In multivariable analysis, higher moral resilience was independently associated with lower quiet quitting (b = −0.52, 95% CI: −0.65 to −0.39) and lower gaslighting (b = −0.49, 95% CI: −0.65 to −0.34). Higher gaslighting was associated with higher quiet quitting (b = 0.27, 95% CI: 0.19 to 0.35). Men and younger employees reported higher levels of both. Conclusions: Moral resilience was independently associated with both lower supervisory gaslighting and lower quiet quitting. These cross-sectional findings cannot establish causality. If confirmed in longitudinal research, interventions that strengthen moral resilience and improve supervisory practices may support employee engagement and wellbeing in white-collar workforces.

Healthcare doi: 10.3390/healthcare14162551

Authors: Irina Bodnar Anca Silvia Dumitriu Stana Păunică Marina Cristina Giurgiu Fidan Bahtiar Ismail Brindușa Florina Mocanu Nicolae Dragoș Ciongaru Ștefan Dimitrie Albu Ioana Suciu Roxana Eliss Budei

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.

Healthcare doi: 10.3390/healthcare14162550

Authors: Jin Woong Park Wi-Young So Jae Keun Oh Dong Chun Lim

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.

Healthcare doi: 10.3390/healthcare14162549

Authors: Hitham Aldharee Ghady Almutari Alanoud Alofi Mayyaz Alqubays Hamdan Z. Hamdan

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.

Healthcare doi: 10.3390/healthcare14162548

Authors: Natasha Mussa Małgorzata Nagórska

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.

Healthcare doi: 10.3390/healthcare14162547

Authors: Yuze Zhang Yinghai Liu Yang Wang Yanlan Guo

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.

Healthcare doi: 10.3390/healthcare14162546

Authors: Rocco Salvatore Calabrò Andrea Calderone Maria Felicita Crupi Marcello Nucifora Maurizio Lanza Angelo Quartarone

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.

Healthcare doi: 10.3390/healthcare14162545

Authors: Ege Miray Topcu Emel Öztürk Turgut Gizem Beycan Ekitli

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.

Healthcare doi: 10.3390/healthcare14162544

Authors: Cristina del Rocío Rodríguez-López Abel Checa-Peñalver Mónica Raquel Pereira-Afonso Victoria Lopezosa-Villajos Isabel Donoso-Calero Elena Arroyo-Bello Sagrario Gómez-Cantarino

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.

Healthcare doi: 10.3390/healthcare14162543

Authors: Dawid Koźlenia Marek Popowczak

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.

Healthcare doi: 10.3390/healthcare14162542

Authors: Jorge Martins António Oliveira Inês Chora Fernando Friões

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.

Healthcare doi: 10.3390/healthcare14162541

Authors: Enes Kaya Nazmiye Ekinci Imran Aslan Juan Gómez-Salgado Feten Fekih-Romdhane Carlos Laranjeira Murat Yıldırım

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.

Healthcare doi: 10.3390/healthcare14162540

Authors: Gulnara Batenova Diana Ygiyeva Zhanar Urazalina Andrey Orekhov Akbayan Markabayeva Maksim Pivin Adilzhan Zhumagaliyev Lyudmila Pivina

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.

Healthcare doi: 10.3390/healthcare14162539

Authors: Yoshikazu Noda Moa Yokota Kumiko Kishimoto Kenichi Asano

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.

Healthcare doi: 10.3390/healthcare14162538

Authors: Huei-Ying Chiu Ya-Ting Chuang Simona Zaami Tao-An Chen

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.

Healthcare doi: 10.3390/healthcare14162537

Authors: Eman Ramadan Abdalfadeel Eman Kamel Hossny Ahmed Zinhom Elkady Intisar Alsheikh Mohamed Ishraga Abdelgadir Ibrahim Mohamed Eman Yosry Mohamed

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.

Healthcare doi: 10.3390/healthcare14162536

Authors: Kübra Çakır Melis Almula Karadayı

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.

Healthcare doi: 10.3390/healthcare14162535

Authors: Hüseyin Karakaya Gökhan Doğukan Akarsu Rukiye Höbek Akarsu

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.

Healthcare doi: 10.3390/healthcare14162534

Authors: Rinat Tsruya Eran Shadach Leah Shelef

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.

Healthcare doi: 10.3390/healthcare14162533

Authors: María Rocío Meseguer-Fernández Bárbara Badanta

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.

Healthcare doi: 10.3390/healthcare14162531

Authors: Mahmoud Alfatafta Nizar Alsubahi Huda Alfatafta Anthony McGarry Amani Al-Refai Mohannad Alkhateeb Noha Alaggad Alaeddin Ahmad

Background: Clinical competence is a fundamental outcome of prosthetics and orthotics (P&O) education and is expected to facilitate graduates’ transition into professional practice. However, limited evidence exists regarding the relationship between clinical competence and job market readiness among P&O graduates, particularly in low- and middle-income countries. Objective: To examine the relationship between perceived clinical competence and job market readiness among prosthetics and orthotics graduates in Jordan and to investigate whether openness moderates this relationship. Methods: A cross-sectional survey was conducted among graduates of the Bachelor of Science in Prosthetics and Orthotics program at the University of Jordan who had graduated within the previous five years. Data were collected between 1 July and 31 August 2025 using a structured online questionnaire comprising measures of clinical competence, job market readiness, and openness. Confirmatory factor analysis (CFA) was performed to assess the reliability and validity of the measurement model, followed by structural equation modeling (SEM) to examine the proposed relationships. The moderating effect of openness was further evaluated using Hayes’ PROCESS macro. Results: A total of 231 questionnaires were included in the final analysis. The measurement model demonstrated satisfactory reliability, convergent validity, discriminant validity, and overall model fit. Clinical competence was a significant positive predictor of job market readiness (β = 0.427, p = 0.013), explaining 37% of the variance in job market readiness. Openness did not have a significant direct effect on job market readiness (p = 0.072); however, it significantly moderated the relationship between clinical competence and job market readiness (B = 0.295, p = 0.021), indicating that the positive association between clinical competence and job market readiness was stronger among graduates with higher levels of openness. Conclusions: Clinical competence plays a central role in enhancing graduates’ readiness for professional employment in prosthetics and orthotics, while openness strengthens this relationship. These findings suggest that prosthetics and orthotics educational programs should integrate strategies that foster both clinical competence and adaptive personal attributes, and they may inform curriculum development and educational policies aimed at improving graduate employability and workforce readiness.

Healthcare doi: 10.3390/healthcare14162532

Authors: Mohammed Almutairi Abdulaziz M. Alodhailah Waleed M. Alshehri Bader M. Almutairy

Background: Health literacy is widely recognized as a fundamental determinant of chronic disease self-management. Despite the escalating burden of diabetes mellitus in Saudi Arabia, the relationship between health literacy and diabetes self-care management within specific urban–peripheral communities remains inadequately characterized. This study aimed to examine the relationship between health literacy and diabetes self-care management among adults with diabetes residing in southern Riyadh, and to examine associations with key sociodemographic variables, including age, income, gender, and educational attainment. Methods: A non-experimental, cross-sectional, correlational design was employed. A purposive sample of 92 adults with a confirmed diagnosis of diabetes was recruited from primary healthcare centers in southern Riyadh. Data were gathered using the Arabic-validated 12-item European Health Literacy Scale (HLS-Q12) and the 8-item Arabic Summary of Diabetes Self-Care Activities (SDSCA). Descriptive statistics and Spearman rank-order correlations were computed using IBM SPSS Statistics, Version 25. Results: A significant positive correlation was identified between health literacy and diabetes self-care management (rs = 0.64, 95% CI [0.50, 0.75], p < 0.01). Income level demonstrated significant positive associations with both health literacy (rs = 0.41, p < 0.01) and self-care practices (rs = 0.40, p < 0.01). Age exhibited significant negative correlations with health literacy (rs = −0.36, p < 0.01) and self-care management (rs = −0.49, p < 0.01). Educational attainment was significantly associated with both self-care management (rs = 0.29, p < 0.01) and health literacy (rs = 0.26, p < 0.05). Gender was not significantly associated with either outcome. Conclusions: Health literacy was significantly associated with diabetes self-care management in southern Riyadh and may represent a potentially modifiable target for nursing intervention. Findings point to the urgency of designing equity-sensitive, culturally responsive interventions targeting older adults and economically marginalized populations. These preliminary findings may carry implications for nursing practice, diabetes education, and health policy in Saudi Arabia, pending confirmation in larger, prospective samples.

Healthcare doi: 10.3390/healthcare14162530

Authors: Jungeun Lee Mansoo Ko

Background/Objectives: Late-life depression is associated with reduced physical activity, but evidence is limited regarding objectively measured weekday walking volume and cadence distribution in older women with clinician-diagnosed major depressive disorder (MDD). This exploratory study compared daily walking between an MDD group and an age-comparable comparison group and examined the post hoc within-sample discrimination of two cadence-based ratios. Methods: Forty women aged 60–93 years (mean age, 71.8 ± 9.7 years) were classified into an MDD group (n = 20) and an age-comparable comparison group without a documented depressive-disorder diagnosis (n = 20). Current depressive symptoms were quantified using the Beck Depression Inventory-II (BDI-II), and free-living ambulatory activity was measured over three weekdays using StepWatch 3 monitors. Total instrumented-leg steps were recalculated as the sum of the low-, intermediate-, and higher-cadence step counts from the same three weekday summaries. The feasibility-based sample was analyzed using an exploratory MANOVA with SPSS-based assumption checks, Holm-adjusted follow-up tests, partial eta-squared effect sizes, and post hoc exploratory ROC analyses. Results: The multivariate group difference was significant (Pillai’s trace = 0.407, F (8,31) = 2.656, p = 0.024, partial η2 = 0.407). After Holm adjustment, the MDD group demonstrated lower total instrumented-leg steps, fewer intermediate- and higher-cadence walking minutes, fewer intermediate-cadence instrumented-leg steps, and a lower Peak Activity Index; the higher-cadence step-count difference did not remain significant after multiplicity adjustment. The Intermediate + Higher-Cadence Step Ratio showed an AUC of 0.828 (95% CI: 0.701–0.954), and the Intermediate + Higher-Cadence Minutes Ratio showed an AUC of 0.818 (95% CI: 0.684–0.951). Conclusions: In this exploratory cross-sectional sample, lower weekday walking volume and less walking at intermediate and higher cadences were observed in the MDD group. These sample-derived discriminatory findings are not diagnostic and require independent validation.

Healthcare doi: 10.3390/healthcare14162528

Authors: Bandar S. Alharbi Majed M. Aljabri

Background: Quality of life (QoL) among university students is an important indicator of overall health and academic success. Although these factors are interrelated, few studies have simultaneously examined their structural associations with QoL among university students in Saudi Arabia. This study investigated the associations among demographic characteristics, lifestyle behaviors, psychological distress, and quality of life using structural equation modeling (SEM). Methods: We conducted a cross-sectional study among undergraduate students enrolled in public universities in Riyadh, Saudi Arabia. The survey included demographic characteristics, the Depression Anxiety Stress Scale-21 (DASS-21), the World Health Organization Quality of Life-BREF (WHOQOL-BREF), and measures of sleep quality, sleep duration, and physical activity. Confirmatory factor analysis was performed to evaluate the measurement model. We fitted SEM to examine associations among demographic characteristics, lifestyle behaviors, health status, and quality of life. Results: A total of 198 undergraduate students were included in the analysis. The measurement model demonstrated satisfactory psychometric properties. The SEM demonstrated acceptable model fit (χ2/df = 2.00, Comparative Fit Index = 0.937, Tucker–Lewis Index = 0.914, Root Mean Square Error of Approximation = 0.071, Standardized Root Mean Square Residual = 0.070). Male students reported poorer sleep quality (β = −0.405, p < 0.001), shorter sleep duration (β = −0.208, p = 0.019), and lower physical activity (β = −0.299, p < 0.001) than female students. Students with a GPA of 4.50 or above reported higher physical activity than those with lower GPAs (β = 0.182, p = 0.027). Better sleep quality (β = 0.169, p = 0.024) and very good or excellent self-rated health (β = 0.492, p < 0.001) were positively associated with quality of life, whereas sleep duration was not significantly associated with quality of life (p = 0.225). Conclusions: Quality of life among undergraduate students was associated with multiple interconnected demographic and lifestyle factors. Our findings highlight the importance of integrated university health-promotion strategies that simultaneously address sleep health, healthy lifestyle behaviors, and psychological well-being to improve students’ overall quality of life. Longitudinal studies should be conducted to clarify the temporal relationships among these factors.

Healthcare doi: 10.3390/healthcare14162529

Authors: Kangho Suh Sujin Lee Seung-Mi Lee

Background/Objectives: Obesity is associated with respiratory infection risk, but its relationship with post-discharge healthcare burden remains unclear. This study examined the associations of body mass index (BMI) and waist circumference (WC), evaluated separately, with hospitalization and post-discharge outcomes in analyses stratified by sex among South Korean adults with claims-defined hospitalizations involving influenza or pneumonia. Methods: This retrospective cohort study used the 2018 National Health Insurance Service (NHIS) Customized Research Database linked to health-screening data. Adults aged 20–89 years with claims-defined hospitalizations involving influenza or pneumonia were included if BMI and WC measurements were available from the most recent NHIS health-screening examination conducted within two years before the index admission. Length of stay and index hospitalization costs were summarized descriptively. Cox proportional hazards models were used to estimate hazard ratios (HRs) for all-cause and pneumonia-related readmission within two years after discharge, and two-part models were used to estimate readmission-related costs, expressed in US dollars (USD). Results: The cohort included 175,774 patients, of whom 80,257 (45.7%) were male. Category-specific associations varied according to the anthropometric measure, outcome, and sex stratum. In female patients, the highest WC category had the largest estimated all-cause readmission HR (HR 1.195, 95% confidence interval 1.157–1.235), and the highest model-based mean cost of the first all-cause readmission was also observed in this category (USD 1407.4). In male patients, several higher BMI categories had lower estimated readmission HRs than the reference category; however, these estimates should not be interpreted as protective effects because competing mortality was not accounted for using competing-risk methods. Patterns for pneumonia-related readmission and costs were less consistent. Conclusions: BMI and WC showed category-specific associations with readmission, while model-based mean readmission costs varied across anthropometric categories and sex strata. Higher WC categories were associated with higher all-cause readmission HRs in the female stratum; however, the independent or incremental prognostic value of BMI and WC was not evaluated.

Healthcare doi: 10.3390/healthcare14162527

Authors: Alejandra Galvez-Merlin Sandra Diaz-Gonzalez Esther Julian-Montaner Noelia Fuentes-Garcia Myriam Gonzalez-Gomez Jose Manuel Lopez-Villatoro Marina Diaz-Marsa Jose Luis Carrasco

Introduction: The recognition of Complex Post-Traumatic Stress Disorder (CPTSD) as a distinct diagnosis in ICD-11 has intensified the need to clarify its boundaries with Borderline Personality Disorder (BPD), given their symptom overlap and shared traumatic origins. Therefore, this systematic review aimed to examine whether CPTSD is distinct from BPD, assess their comorbidity and symptom overlap, identify key criteria for differential diagnosis, and explore therapeutic implications. Method: A systematic search was conducted in PubMed, Scopus, and Web of Science following PRISMA 2020 guidelines. Seven empirical studies (2015–2025) were included, comprising 2574 adults (mean age 40.4 years; 73.3% women). Methods included latent class analysis, structural equation modeling, and network analysis. The methodological quality of the included studies was evaluated independently by two reviewers using the JBI Critical Appraisal Checklist for Analytical Cross-Sectional Studies. Results: Findings consistently supported that CPTSD and BPD are empirically distinguishable, though substantially correlated, particularly within the ICD-11 framework. High symptom co-occurrence was observed, with affective dysregulation identified as the symptom most centrally connecting the two symptom networks. Self-concept emerged as the most robust differentiator: stable and persistently negative in CPTSD versus unstable and fragmented in BPD. Shame was a key affective marker of more severe presentations, and trauma severity, rather than diagnostic category, was associated with symptom variation across studies. Conclusions: CPTSD and BPD are distinct yet frequently co-occurring conditions. Differential diagnosis should focus on self-concept stability, patterns of behavioral dysregulation, and shame. Treatment requires individualized, trauma-informed, and shame-sensitive approaches, with transdiagnostic emotion regulation strategies across presentations. These conclusions should be interpreted with caution, given the predominantly cross-sectional design and methodological heterogeneity of the available evidence.

Healthcare doi: 10.3390/healthcare14162526

Authors: Eun Ju Lee Se Young Jung

Background: This study aimed to examine the levels of nursing managerial competency, perceived organizational support, and job stress among nurse managers, and to examine the factors associated with their job stress. Methods: The participants included 133 nurse managers from seven hospitals in B Metropolitan City. Data were collected using self-reported questionnaires including the Korean Occupational Stress Scale and scales measuring nursing managerial competency and perceived organizational support. Collected data were analyzed using descriptive statistics, t-tests or ANOVA, Pearson’s correlation, and hierarchical multiple regression, with participants’ general characteristics entered as covariates. Results: Mean scores were 4.16 (out of 5) for nursing managerial competency, 3.24 (out of 5) for perceived organizational support, and 2.31 (out of 4) for job stress. Job stress showed negative correlations with both nursing managerial competency (r = −0.57, p < 0.001) and perceived organizational support (r = −0.79, p < 0.001). After adjustment for general characteristics, hierarchical regression showed that both nursing managerial competency (β = −0.18, p = 0.009) and perceived organizational support (β = −0.70, p < 0.001) were significantly associated with job stress, and the model accounted for 65.6% of the variance. Conclusions: Nurse managers with higher managerial competency and organizational support perceptions reported lower job stress. Strategies to enhance nursing managerial competency and organizational support should be developed to effectively manage nurse managers’ job stress.

Healthcare doi: 10.3390/healthcare14162525

Authors: Diana-Maria Puscasu Ioana Creanga-Murariu Eliza-Maria Armeanu Diana Monor Ioan Matei Rusu Bogdan Gafton Vladimir Poroch Teodora Alexa-Stratulat

Background: In advanced cancer care, routine clinical assessment often focuses on symptoms, treatment tolerance, and disease status, while spiritual well-being remains insufficiently explored despite its relevance to quality of life (QoL). Standardized patient-reported tools may help identify spiritual and existential vulnerability in patients receiving palliative treatment. This study evaluated the EORTC QLQ-SWB32 as a structured spiritual well-being assessment tool in advanced cancer care through its cultural adaptation and clinical validation among Romanian patients. Furthermore, it evaluated the tool’s feasibility and explored the association between spiritual well-being and QoL in individuals receiving palliative systemic therapy. Methods: Following EORTC Quality of Life Group guidelines, the QLQ-SWB32 was translated and pilot-tested with ten cancer patients. A prospective, cross-sectional observational study was then conducted at the Regional Institute of Oncology in Iași, Romania. Over six months, 42 adult patients with metastatic or locally advanced inoperable malignancies undergoing palliative systemic therapy were enrolled. Participants completed the EORTC QLQ-SWB32 and EORTC QLQ-C15-PAL questionnaires, while sociodemographic and clinical variables were collected using structured case report forms. Results: The translated instrument showed good linguistic clarity and clinical acceptability during pilot testing. The study cohort was predominantly aged 40–64 years (52.38%) and was socio-culturally homogeneous, with all patients identifying as Romanian and most as Eastern Orthodox (92.85%). The Relationship with God/the Divine (RSG) domain showed a stronger association with QoL in male patients than in female patients, particularly in subsequent treatment lines. In the subsequent-line subgroup, residential environment reached statistical significance (p = 0.021), with a stronger RSG–QoL correlation among rural residents. Age-related inversion patterns in the RSG–QoL association were also observed across treatment lines. Conclusions: Spiritual well-being assessment may provide clinically relevant patient-reported information in advanced cancer care. The Romanian EORTC QLQ-SWB32 demonstrated feasibility, linguistic clarity, and clinical validity as a structured assessment tool. The association between the Relationship with God/the Divine domain and QoL varied according to sex, age, residential environment, and treatment trajectory, supporting the integration of standardized spiritual assessment into individualized palliative oncology care.

Healthcare doi: 10.3390/healthcare14162524

Authors: Eleonora Hristova-Atanasova Teodora Gencheva Elitsa Gyokova Georgi Iskrov Rumen Stefanov

Background: Premarital medical certification is required before civil marriage in Bulgaria, but little is known about how newly married couples perceive this process within the broader framework of preconception care and genetic counselling. This study examined couples’ perceptions of premarital preventive examinations, reported receipt of genetic counselling, preferred counselling providers, and associated sociodemographic factors. Methods: A cross-sectional online survey was conducted between 2023 and 2025 among a convenience sample of 623 newly married heterosexual couples residing in the South-Central Region of Bulgaria. Each couple jointly completed a study-specific questionnaire assessing perceptions of premarital medical examinations, sources of preconception information, preferred counselling providers, and reported receipt of genetic counselling. Two multivariable binary logistic regression models were fitted to examine factors independently associated with reported receipt of genetic counselling and affirmative support for the necessity of premarital medical examination. Results: Overall, 77.8% of couples considered the premarital medical examination necessary, whereas 57.1% perceived it as primarily formal and 38.5% reported having received genetic counselling. Family (90.6%) and school (63.8%) were identified as responsible sources of preconception information more often than general practitioners (19.6%). In the adjusted model, each additional year of female age was associated with lower odds of reported genetic counselling receipt (aOR = 0.929, 95% CI: 0.900–0.959, p < 0.001). Bulgarian ethnicity was also associated with lower odds of reported counselling receipt compared with non-Bulgarian ethnicity (aOR = 0.499, 95% CI: 0.291–0.856, p = 0.012). Female age (aOR = 1.043, 95% CI: 1.006–1.081, p = 0.021) and employment (aOR = 1.847, 95% CI: 1.109–3.076, p = 0.018) were associated with affirmative support for the necessity of premarital medical examination. Conclusions: The findings describe perceptions and reported experiences within a regional online convenience sample and should not be interpreted as causal evidence or as a direct assessment of healthcare-system performance. They indicate areas warranting further evaluation, including the organisation of genetic counselling, the role of primary care, and equitable access to comprehensive preconception services.

Healthcare doi: 10.3390/healthcare14162523

Authors: Maria Dimopoulou Maria Isakoglou Jonathan Hoes Odysseas Androutsos

Objective: The long-term management of cardiovascular diseases (CVDs) requires comprehensive rehabilitation strategies aimed at optimizing functional recovery and promoting behavioral changes. These interventions may include digital technologies that emerged as promising approaches to facilitate lifestyle changes, such as dietary behavior and physical activity (PA). Aim: This review aimed to synthesize the current evidence for the potential impact of remotely delivered nutrition interventions with or without a combination of PA interventions on biochemical biomarkers, cardiovascular indexes, anthropometric parameters, levels of PA, exercise and functional capacity, adherence to the Mediterranean Diet (MD), diet quality and quality of life, rehospitalization, urgent visits, death and acute events in adults (≥18 years) with CVDs. Secondary outcomes were accessibility, safety, usability, and adherence. Methods: The PubMed, Web of Science, and Scopus databases were comprehensively searched up to 2026 for Randomized Controlled Trials (RCTs) published in English, following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines. The methodological quality was assessed using the revised Cochrane Risk of bias tool for RCTs (RoB2). Results: 11 RCTs met the inclusion criteria. Sample sizes ranged from 66 to 879 participants. The duration of the interventions varied from 4 weeks to 12 months. The interventions were delivered remotely using a range of digital health technologies, including web-based programs, mobile phones, wearable devices, smartphone applications, and mini-apps. Favorable changes were observed in diet quality and in adherence to MD and PA levels, with no intervention-related adverse events reported. The RoB2 assessment indicated that the majority of included studies (6 out of 11) were classified as having some concerns regarding risk of bias. Conclusions: Remotely combined nutrition and PA interventions are a feasible and effective approach for improving mainly patient-reported outcomes in adults with CVDs. These findings support integrating remote multimodal rehabilitation into routine cardiovascular care and highlight the potential of telehealth-based models to enhance patients’ access to rehabilitation services.

Healthcare doi: 10.3390/healthcare14162522

Authors: Tina Merritt Meinholz Kelly Cleary Onyinye I. Iweala Sarah K. McGill Laura Rothfeldt Anneke Walters Melissa Olivadoti Genevieve Weseman Jennifer Platt

Background/Objectives: Alpha-gal syndrome (AGS) is an allergic condition that results in delayed symptoms in response to exposure to mammalian products. There is limited research on which healthcare professionals (HCPs) are diagnosing AGS, types of symptoms, time to reactions, and products that induce allergic responses in AGS. This survey study aimed to further identify the patient journey and characterize reactions for people with AGS. Methods: Adult patients with HCP-diagnosed AGS took a survey offered through social media and support organizations. Questions included diagnosing HCP type, time from exposure to symptom onset, and type of symptoms by body system. Results: Survey participants (n = 3437) were mostly white (95.8%) and female (81.5%), ranging from 18 to 86 years old, with a mean time from onset to diagnosis of 4.3 years. Most were diagnosed by an allergist (53.6%) or primary care doctor (30.7%). Participants reported gastrointestinal (86.2%), skin (83.5%), respiratory (59.8%), cardiovascular (41.3%), emotional (38.2%), motor (23.7%), and nervous system (23.3%) symptoms. Symptoms were most often reported at 4–6 h post-exposure (49.8%) and 6–8 h (28.6%), with a range from 0 min to 8+ hours. Products eliciting reactions included mammalian products (beef 97.7%, pork 87.2%, dairy 66.9%, gelatin 61.3%), prescription (41.3%) or over-the-counter medications (36.4%), and personal care products (42.0%). Most participants managed their reactions at home, and without epinephrine. Conclusions: This study demonstrates that patients with AGS may experience symptoms due to exposures from mammalian meat and a broad range of mammalian ingredient-containing products, including medications, personal care products, and dairy, with a wide range of body systems impacted. These results may be useful for educating patients and healthcare professionals to improve the accuracy and speed of AGS diagnosis.

Healthcare doi: 10.3390/healthcare14162521

Authors: Suzanna Chalecka Anna Glynn John Bogue Ruth Melia Mary O’Sullivan Karen Young Jim Duggan Hannah Wood Yvonne Bergmans Shane McInerney

Background/Objectives: Safety Planning Group Interventions (SPGI) represent a novel approach to suicide prevention. Following this three-week intervention, an individualised safety plan was produced by each participant. Within the context of the group setting, obstacles and solutions that may promote engagement with safety plans were discussed. Examining the obstacles and solutions identified by group participants may reveal how to better support people experiencing suicidality and what supports are identified that may support safety plan implementation. This research sought to determine what obstacles participants face when implementing their safety plans and what solutions could be identified for these obstacles. Methods: The study used a qualitative research design. Fifty participants completed an in-group list of potential obstacles and solutions to implementing safety plans, which were analysed using Reflexive Thematic Analysis. Results: The analysis yielded the results for two themes. The first theme, External Obstacles and Solutions, with subthemes of environmental and situational barriers, Interpersonal barriers to support, Behavioural and contextual influences, Adaptive coping and support strategies, was identified. The second theme, Internal Obstacles and Solutions, with subthemes of executive functioning and motivation, emotional distress and self-sabotage, stigma and help-seeking, and personal resilience and future-oriented coping, was identified. Conclusions: The findings of this research illustrate the various obstacles and their corresponding solutions that may facilitate safety plan implementation. Recommendations for future research are discussed.

Healthcare doi: 10.3390/healthcare14162520

Authors: Lourdes Gil-Fraguas Soraya Hijazi-Vega Michelle Catta-Preta Alex Trejo-Omeñaca Jan Ferrer-Picó Isabel Montes-Posada Jesús Vara-Paniagua Carolina de Miguel-Benadiba Josep Maria Monguet-Fierro Helena Bascuñana-Ambrós

Background/Objectives: Pelvic floor dysfunctions (PFDs) are highly prevalent chronic conditions associated with substantial functional and psychosocial burden. Although multidisciplinary pelvic floor rehabilitation is recommended as first-line management, its effectiveness depends not only on intervention efficacy but also on care delivery, communication, patient engagement, and long-term adherence. This study applied the Delphi-Dialogue Patients–Professionals (DDPP) framework to quantify patient–professional alignment and translate identified patient–professional perceptual differences into candidate service-improvement strategies. Methods: A two-phase observational study incorporating parallel stakeholder surveys and a modified Real-Time Delphi feasibility-assessment process was conducted under the auspices of the Spanish Society of Physical Medicine and Rehabilitation (SERMEF). In Phase 1, parallel online questionnaires were completed by 225 patients with PFD and 164 rehabilitation professionals. Shared items were rated on a six-point Likert scale, and patient–professional divergence was quantified using an operational composite index integrating standardized differences in mean ratings and high-agreement responses. In Phase 2, the implementation feasibility of 10 improvement recommendations was evaluated by a Delphi panel comprising 35 PM&R physicians and two representatives of the Spanish Incontinence Association (ASIA). Results: Patient–professional agreement was domain-specific. The greatest divergences concerned digital competence, timing of patient education, bladder and bowel diary use, and adherence to prescribed rehabilitation programmes. Professionals attributed greater value to bladder and bowel diaries and selected group-based interventions, whereas patients reported higher digital competence, more timely information delivery, and better adherence. Comparatively similar response patterns were observed regarding hybrid rehabilitation models, educational resources, app-supported follow-up, and overall satisfaction with rehabilitation care. The Delphi process identified structured home exercise programmes, adherence-monitoring strategies, and improved visibility of rehabilitation pathways as the recommendations with the highest perceived implementation feasibility. Conclusions: The findings suggest that important challenges in pelvic floor rehabilitation may arise from implementation-related factors in addition to the effectiveness of available interventions. The DDPP framework provides a structured, stakeholder-informed methodology for translating patient–professional divergence into candidate organizational recommendations with comparatively higher perceived implementation feasibility.

Healthcare doi: 10.3390/healthcare14162519

Authors: Simona Wójcik Anna Rulkiewicz Justyna Domienik-Karłowicz

Background/Objectives: Artificial intelligence (AI) is increasingly introduced into clinical trial operations, but operational usefulness does not imply regulatory or site-level readiness. This review maps AI applications across trial operations and proposes an author-developed, unvalidated site-level readiness framework and preliminary deployment-decision aid. Methods: We conducted a structured narrative review with evidence mapping of peer-reviewed literature, regulatory documents and contextual sources (2020–2026). AI use cases were mapped by lifecycle stage, technical-validity reporting, evidence maturity, autonomy, trial impact and governance implications. Maturity was assessed with an author-developed 0–8 score intended for transparent mapping, not risk-of-bias grading. Results: The comparatively strongest evidence concerns patient–trial matching and eligibility assessment, which nonetheless reached only moderate maturity, being evaluated mainly retrospectively or in simulated screening rather than inside a live trial; no use case reached the highest band. Other applications remain less mature or context-dependent. Recurrent risks include hallucination, automation bias, weak local validation, limited auditability, model drift and unclear accountability. We propose a preliminary framework linking evidence maturity, technical validity, AI autonomy, trial impact and site capacity. Conclusions: AI readiness in clinical trial operations should be assessed at the level of the AI-enabled workflow rather than the model alone. Safe adoption requires context-specific technical and operational validation, human accountability, auditability, lifecycle monitoring and alignment with Good Clinical Practice.

Healthcare doi: 10.3390/healthcare14162518

Authors: Eyad M. Albarrati Mohammad A. Jareebi Khalid I. Hakami Jawaher S. Farji Reema Nharri Emtenan A. Mawkili Ahmed Y. Najmi Saja A. Almraysi Mohammed A. Baowideen Asma A. Jabrah Yahya H. Khormi Farjah H. Algahtani Majed A. Ryani Ahmed A. Bahri Ghazi I. Al Jowf

Background/Objectives: Lumbar puncture (LP) is an essential diagnostic and therapeutic procedure in neurological practice. Despite its clinical value, misconceptions and fear may influence its acceptance among the public. This study aimed to assess knowledge, attitudes, and misconceptions regarding LP among adults in Saudi Arabia and to examine associated sociodemographic factors. Methods: A cross-sectional study was conducted between June 2025 and January 2026 using a structured, self-administered online questionnaire adapted from a previously validated instrument. Adults aged ≥18 years residing in Saudi Arabia were recruited via convenience sampling through open social media channels, so the sample is self-selected rather than population-representative. Knowledge and attitude scores were categorized into defined levels, and multivariable regression analyses were performed to identify independent predictors. Results: A total of 1267 participants were included. Knowledge of LP was limited (mean 6.1 ± 3.9 of 18), with 905 (71%) scoring poor and only 362 (29%) demonstrating good knowledge; misconceptions about complications such as urinary incontinence and erectile dysfunction were common. Attitudes appeared favorable, with 1182 (93%) reaching the pre-specified 50% threshold, but this cut-off is lenient because an entirely neutral respondent scores 60% on a summed five-point scale, and only 692 (55%) agreed they would sign consent if their physician recommended LP. Knowledge and attitude were weakly but significantly related (r = 0.21, 95% CI 0.16 to 0.26; adjusted β = 0.25 per additional correct item, p < 0.001). Higher education, student status, healthcare occupation, and higher income predicted better knowledge, and male sex predicted lower knowledge (all p < 0.05), whereas sociodemographic factors were weakly associated with attitude. Conclusions: Among self-selected online respondents in Saudi Arabia, knowledge of lumbar puncture was limited while attitudes were comparatively favorable, and the two were weakly but positively related. Targeted educational interventions are warranted to address misconceptions, enhance public awareness, and support informed decision-making within the healthcare system.

Healthcare doi: 10.3390/healthcare14162517

Authors: Seyedeh Hiva Houshyar Yazdian Karina Santos Guedes de Sá Wolfgang Jacquet Johan Stiens Yves Vanlandewijck

Background/Objectives: Urban accessibility is a key determinant of participation for manual wheelchair users, yet accessibility experiences vary according to physical impairment, self-efficacy in wheeled mobility, and wheelchair mobility proficiency. This scoping review examined urban accessibility challenges in relation to these three dimensions. Methods: Following PRISMA-ScR guidelines, eight databases were searched for English-language peer-reviewed studies published from January 2015 to May 2025. Eligible studies addressed outdoor or urban mobility challenges among manual wheelchair users in relation to at least one dimension. Two reviewers independently screened records, assessed full texts, and extracted data using a standardized form. Findings were synthesized within an International Classification of Functioning, Disability and Health-informed framework. Fourteen studies were included. Results: The evidence base was methodologically diverse and fragmented; no study examined all three dimensions simultaneously, and wheelchair mobility proficiency received the least attention. Greater physical impairment was associated with more perceived barriers and higher effort. Self-efficacy influenced avoidance of or engagement in mobility tasks beyond physical functioning. Wheelchair mobility proficiency, supported by training, experience, and wheelchair fit, was associated with managing ramps, uneven surfaces, and other environmental demands, but was rarely assessed using standardized performance measures. Conclusions: Urban accessibility reflects interactions among physical functioning, self-efficacy, wheelchair mobility proficiency, assistive-device characteristics, and environmental conditions. Accordingly, urban mobility should be understood as a person–wheelchair–environment interaction rather than solely as an interaction between the individual and the built environment. Integrative studies using standardized measures and more systematic reporting of wheelchair fit and configuration are needed to inform impairment-inclusive urban planning, rehabilitation, and policy.

Healthcare doi: 10.3390/healthcare14162516

Authors: Bestegül Çoruh Akyol Latife Merve Yildiz Yasemin Kiliç Öztürk Özgür Enginyurt

Background/Objectives: The aim of this study is to determine the extent to which early breast cancer detection behaviors in Türkiye are associated with age, education, income, and chronic disease status, and to evaluate the relationship of healthcare service utilization (contact with family physicians/general practitioners and specialists) with these behaviors. Methods: A cross-sectional secondary data analysis was conducted using nationally representative microdata from the Turkish Statistical Institute’s (TUIK) 2022 Turkiye Health Survey. The analysis included 5554 women aged 40–69. Descriptive statistics were calculated using the FERTFACTOR sample weight. Fully adjusted modified Poisson regression models were constructed for recent mammography (within the last 2 years) and monthly breast self-examination (BSE) (adjusted prevalence ratio, aPR), while Classification and Regression Tree (CART) analysis with five-fold cross-validation was applied to identify targetable risk profiles. (The maximum tree depth was set at 3, and the minimum terminal node size at 250 individuals.) Results: The rates of undergoing a recent mammogram and performing monthly BSE were 23.5% and 25.0%, respectively. Both early detection behaviors were more frequent among women who had contact with both a family physician/general practitioner and a specialist physician within the past 12 months. While contact with a specialist physician was independently associated with both behaviors, education level was positively associated with them, whereas the presence of a chronic disease was associated only with having a recent mammogram. In the CART analysis, the initial split occurred based on BSE behavior, and the prevalence of recent mammography varied approximately eightfold across the terminal nodes (cross-validated AUC = 0.681). Conclusions: In Türkiye, behaviors related to the early detection of breast cancer are associated with age, education, and contact with healthcare services. Fewer than one in four women were up to date with mammography, underscoring a substantial early detection gap. Contact with a specialist physician showed the strongest association; however, given the cross-sectional design, causality cannot be inferred and reverse causation cannot be excluded. Systematizing early detection recommendations within primary care and implementing targeted strategies for low-socioeconomic groups may help increase participation in screening.

Healthcare doi: 10.3390/healthcare14162515

Authors: Ekrem Aslan Duygu Kurtulus Ferhat Yakup Suceken

Background/Objectives: Fibromyalgia (FM) is increasingly recognized as a multisystem disorder characterized by central sensitization and visceral symptom involvement. Irritable bowel syndrome (IBS) and overactive bladder (OAB), which share overlapping pathophysiological mechanisms related to altered visceral processing, are both commonly reported in FM. However, whether gastrointestinal and urinary symptoms cluster within the same patients and whether such clustering is associated with greater FM severity remain insufficiently explored. This study aimed to evaluate the overlap between IBS and OAB in women with FM and to determine whether their coexistence is associated with differences in FM severity. Methods: This cross-sectional observational study included 74 women with FM evaluated at the Physical Medicine and Rehabilitation outpatient clinic of Memorial Ataşehir Hospital between August and December 2025. FM severity was assessed using the Widespread Pain Index (WPI), Symptom Severity Scale (SSS), and FM Severity Score (GSS). OAB symptoms were evaluated using the Overactive Bladder Symptom Score (OABSS), and IBS status was determined based on prior clinical diagnosis. For subgroup severity analyses, patients were categorized as IBS + OAB, OAB only, or neither condition; the two patients with IBS alone were excluded from these comparisons because of the small cell size (n = 72). Results: IBS was present in 13 patients (17.6%) and OAB in 46 patients (62.2%). A substantial overlap between bowel and bladder symptoms was observed: 84.6% of IBS-positive patients had OAB, and IBS prevalence was higher in OAB-positive than OAB-negative patients (23.9% vs. 7.1%; OR = 4.56, 95% CI 0.93–22.24), although this association did not reach statistical significance (p = 0.063). Significant overall group differences were observed for SSS (p < 0.001) and GSS (p = 0.001), whereas WPI did not differ significantly across groups (p = 0.228). Patients with concomitant IBS and OAB had significantly higher GSS scores than both the OAB-only (adjusted p = 0.003) and neither-condition groups (adjusted p = 0.001). In multivariable analysis adjusted for age, concomitant IBS and OAB remained significantly associated with higher GSS (B = 3.77, 95% CI 1.59–5.95; p = 0.001). The regression model explained 18.2% of the variance in GSS (R2 = 0.182; p = 0.003). Conclusions: Concomitant IBS and OAB in women with FM were associated with greater overall FM symptom burden, particularly higher SSS and GSS scores, whereas widespread pain severity did not differ significantly across groups. The presence of either IBS or OAB may warrant evaluation for the other condition, as bowel–bladder symptom clustering may characterize a subgroup with greater overall symptom burden and support consideration of a more integrated clinical assessment.

Healthcare doi: 10.3390/healthcare14162514

Authors: Joaquim Faria Monteiro Clémence Salvador-Entradas Dorian Marrot Maribel Teixeira Nuno Milhazes Vera Almeida Ana Teixeira

Background/Objectives: Dermatologic toxicities are among the most common adverse effects of anticancer therapies, including chemotherapy, targeted therapies, and immunotherapies. Although typically non-life-threatening, these conditions can significantly impair quality of life, alter body image, and lead to treatment non-adherence which may compromise health outcomes. This systematic review aims to synthesize the evidence on the incidence, severity, and management of treatment-related dermatologic toxicities, with a focus on pharmaceutical and multidisciplinary care strategies. Methods: This review followed the PRISMA 2020 guidelines. PubMed, ScienceDirect, and Cochrane were searched for studies published between 1 January 2015 and 31 December 2025. Eligibility criteria were defined using the PICO (R) framework. Study selection, data extraction, and risk-of-bias assessment were performed independently by two reviewers. Given study heterogeneity, a narrative synthesis was conducted. Results: Seventeen studies were included. Dermatologic toxicities were frequently reported during cancer treatment and were generally mild to moderate in severity, although they imposed a substantial burden on patients. Supportive dermatologic care strategies were associated with reduced symptom severity and improved quality of life in some studies. Evidence for pharmaceutical care and multidisciplinary management was more limited, and the available data do not allow firm conclusions regarding their effectiveness. Conclusions: Dermatologic toxicities remain an important challenge in oncological care. The evidence suggests potential benefits of supportive care approaches, but the certainty of the evidence is limited, particularly for pharmaceutical care. Further high-quality studies are needed to clarify the impact of these interventions and support standardized recommendations.

Healthcare doi: 10.3390/healthcare14162513

Authors: Nadia El-Agha Adina-Diana Moldovan Sorin-Ioan Tudorache Cristina Spirea Roxana Nemeş

Background/Objectives: Occupational burnout is a major challenge among healthcare workers. Night-shift work, insufficient sleep, and lifestyle factors may contribute to higher burnout levels. This study examined associations of night-shift work, sleep duration, and physical activity with burnout using the Burnout Assessment Tool (BAT). Methods: This cross-sectional study included 213 healthcare workers undergoing routine occupational health assessments in Bucharest, Romania, between January and April 2026. Burnout was assessed using the BAT-23 core questionnaire and BAT Secondary Symptoms module. Data on night-shift work, sleep duration, physical activity, age, sex, and professional experience were analyzed using group comparisons, correlations, and multivariable linear regression. Results: Night-shift workers had higher burnout scores than non-night-shift workers (3.36 ± 0.43 vs. 2.44 ± 0.41, p < 0.001), while physically active participants had lower scores than sedentary workers (2.46 ± 0.44 vs. 3.23 ± 0.52, p < 0.001). Burnout correlated negatively with sleep duration (r = −0.336, p < 0.001) and physical activity (r = −0.655, p < 0.001), and positively with night-shift work (r = 0.798, p < 0.001). In adjusted analysis, night-shift work (B = 0.831, 95% CI 0.637–1.024, p < 0.001), shorter sleep duration (B = −0.079, 95% CI −0.127 to −0.031, p = 0.001), and female sex (B = 0.162, 95% CI 0.029–0.295, p = 0.017; male = 0, female = 1) were associated with higher burnout; the model explained 58.6% of the variance. Conclusions: Night-shift work and shorter self-reported sleep duration were independently associated with higher burnout. Physical activity was associated with lower burnout only in unadjusted analyses. Owing to the cross-sectional design and self-reported exposures, findings should be interpreted as associations and confirmed longitudinally.

Healthcare doi: 10.3390/healthcare14162507

Authors: Sung Min Kim JaeLan Shim

Background/Objectives: Patients undergoing hemodialysis experience psychosocial burdens that may hinder self-management. Guided by Bandura’s social cognitive theory, this study examined whether self-esteem statistically mediated the association between perceived social support and self-management behavior. Methods: A descriptive cross-sectional study was conducted with 145 patients receiving regular hemodialysis at three medical institutions in South Korea. The mediation model was tested using Hayes’ PROCESS macro Model 4 with 5000 bootstrap samples and 95% bias-corrected confidence intervals, adjusting for relevant covariates. Results: Self-management behavior was positively correlated with social support (r = 0.41, p < 0.001) and self-esteem (r = 0.52, p < 0.001). Social support was also positively correlated with self-esteem (r = 0.67, p < 0.001). Social support was associated with self-management both directly and indirectly through self-esteem. The bootstrap confidence interval for the indirect association excluded zero, consistent with partial statistical mediation. The indirect association accounted for approximately 45% of the total association. Conclusions: Higher perceived social support and self-esteem were associated with better self-management behavior among patients undergoing hemodialysis. Nursing interventions that strengthen supportive social resources and self-esteem may help promote sustained self-management in this population.

Healthcare doi: 10.3390/healthcare14162512

Authors: Alaeddin Ahmad Nizar Alsubahi Fahad Alhazmi Amani Al-Refai Sara Fuad Talafha Mohannad Alkhateeb Mahmoud Alfatafta

Background: Digital transformation has changed how patients interact with hospitals, making online supplementary services an important part of perceived service quality and relationship outcomes. This study examined the association between cyberspace supplementary health services (CSS), conceptualized as the Online Flower of Service (OFOS), and patient loyalty in private hospitals in Jeddah, Saudi Arabia, and evaluated whether patient experience mediates this relationship. Methods: A cross-sectional survey was conducted among adult inpatients and outpatients who had used at least one online hospital service. Data were collected electronically between 10 February 2026 and 10 May 2026 using a structured Arabic questionnaire administered via Google Forms. The final sample included 730 complete responses. CSS was measured across five digital supplementary dimensions (E-Information, E-Order Taking, E-Consultation, E-Billing, and E-Payment), alongside patient experience and patient loyalty, using five-point Likert scales. The measurement model was evaluated using confirmatory factor analysis, and the structural relationships were tested using structural equation modeling. Results: CSS demonstrated a significant positive association with patient loyalty (β = 0.282, p < 0.001) and a strong positive association with patient experience (β = 0.591, p < 0.001). Patient experience was also positively associated with patient loyalty (β = 0.431, p < 0.001), supporting its mediating role in the CSS–patient loyalty relationship. Conclusions: Digitally delivered CSS components were positively associated with patient loyalty, with patient experience serving as an important mediating mechanism. Strengthening online information access, appointment-related processes, digital consultation, billing transparency, and payment convenience may be associated with more favorable patient experiences and stronger loyalty intentions in private hospital settings in Saudi Arabia.

Healthcare doi: 10.3390/healthcare14162510

Authors: Nizar Alsubahi Milena Pavlova Mohannad Alkhateeb Sami Alanazi Wim Groot

Background: Patient-centered care is a fundamental element of effective diabetes management; however, validated Arabic instruments assessing this concept are currently lacking in Arab countries. This study examined the validity and reliability of the Arabic version of the patient-centered care instrument among patients with diabetes. Methods: A face-to-face administered questionnaire among 594 patients with diabetes in Saudi Arabia between July and August 2023. The questionnaire consisted of 36 items that assessed patient-centered care (PCC-36). PCC-36 was translated into Arabic in accordance with the World Health Organization guidelines for the translation of instruments before psychometric evaluation. For each PCC-36 function, confirmatory factor analysis was conducted, and Cronbach’s alpha coefficients were used to test the reliability and internal consistency of the measures. The data were analyzed using SPSS version 28 and AMOS version 28. Results: The Arabic translation of PCC-36 showed high interitem correlations, and confirmatory factor analysis indicated an acceptable fit to the data (CFI = 0.936, GFI = 0.90, CMIN/DF = 2.42, RMSEA = 0.079). Cronbach’s alpha confirmed the internal consistency of the eight PCC-36 functions, with an alpha value of 0.96. Conclusions: This study demonstrates that the Arabic version of PCC-36 is a valid and reliable instrument for measuring patient-centered care among patients with diabetes in Saudi Arabia. However, further validation in other Arab countries and healthcare settings is recommended.

Healthcare doi: 10.3390/healthcare14162511

Authors: Mohammed S. Alharthi Nehmat Ghaboura Daniyah A. Almarghalani Masi A. Almalki Nasser M. Alorfi Ahmed Alnemari Ahmed Alshehri Fahad T. Alsulami Musaad M. Althobaiti

Background: Deprescribing is a supervised, patient-centred process for reducing or stopping medicines when their burden, harm, or lack of continuing indication outweighs expected benefits. This study assessed attitudes toward deprescribing, examined the exploratory psychometric performance of the revised Patients’ Attitudes Towards Deprescribing (rPATD) questionnaire, and identified factors associated with stated willingness to deprescribe among adults using prescribed medicines in western Saudi Arabia. Methods: An analytical cross-sectional survey was conducted from 15 February to 30 April 2025 in six community pharmacies and three outpatient clinics in Taif, Makkah, and Jeddah. Adults taking at least one prescribed medicine completed a paper-based Arabic rPATD questionnaire. Internal consistency, exploratory factor analysis, Spearman correlations, Mann–Whitney U tests, ordinal logistic regression, and a fully adjusted binary logistic regression sensitivity analysis were used. Results: Of 362 adults assessed, 320 were included in the final analysis. Overall, 254/320 (79.4%) agreed or strongly agreed that they would stop one or more medicines if their physician recommended it. Cronbach’s alpha ranged from 0.77 to 0.84, and McDonald’s omega ranged from 0.79 to 0.85. The four-factor exploration solution explained 61.4% of the variance. Greater involvement (adjusted odds ratio [aOR] 2.84, 95% confidence interval [CI] 1.98–4.06) and greater perceived medication inappropriateness (aOR 2.31, 95% CI 1.67–3.20) were associated with higher willingness, whereas concerns about stopping were associated with lower willingness (aOR 0.54, 95% CI 0.39–0.75). Medication burden was correlated with willingness but was not independently associated after adjustment (aOR 1.28, 95% CI 0.94–1.75; p = 0.112). Conclusions: Participants reported generally favourable stated willingness to deprescribe when advised by a physician. Involvement, perceived medication inappropriateness, and concerns about stopping were independently associated with willingness. These cross-sectional findings concern intention rather than actual deprescribing behaviour or clinical outcomes.

Healthcare doi: 10.3390/healthcare14162501

Authors: Nicolò Panattoni Alessia Campoli Alessandro Spano Carmelina De Stefano Daniele De Rossi Federica Sorrenti Albina Paterniani Aurora De Leo Fabrizio Petrone Laura Iacorossi Emanuele Di Simone

Background/Objectives: Patient education (PE) is a key component in the management of chronic conditions, including living with an entero-urostomy. Exploring patients’ and caregivers’ experiences may inform the development of tailored educational interventions. This study aimed to explore the perceptions, experiences, and needs of adult oncology patients with entero-urostomies and their caregivers as part of the patient education process. Methods: A descriptive qualitative study was conducted at a single Italian cancer centre using two focus group sessions integrated with PE activities. Discussions were audio-recorded and analysed through thematic analysis following the framework described by Dawadi. NVivo was used to support data management and facilitate the assessment of data saturation. Results: A total of 28 participants (15 patients and 13 caregivers) were recruited. Three main themes emerged: translational patient education as a co-constructed educational process, time as a protective and regulatory resource in everyday stoma management and living with a stoma requires adaptation and meaning-making. The first theme describes a dynamic integration of clinical, peer, and relational knowledge co-constructed by nurses, patients, and caregivers. The second theme referred to the perception of time and care contexts, including telenursing, as protective spaces supporting anticipatory coping and daily life planning. The last theme captured the embodied and psychological adaptation to living with a stoma, characterised by heterogeneous processes of acceptance and meaning-making. Conclusions: PE emerges as a relational and interactive process that supports self-care, emotional adjustment, and quality of life. The concept of translational patient education, as part of the patient education process, offers a novel framework for integrating multiple forms of knowledge within educational practices, strengthening the person-centred nature of PE programmes. These findings support the development of tailored, person-centred PE interventions that incorporate the dynamic educational ecosystem involving patients, caregivers, and stoma care nurses. They also highlight the need for further research to validate this conceptual model across diverse settings and populations.

Healthcare doi: 10.3390/healthcare14162509

Authors: Alicia Francisca Ponce-Valencia Diana Jiménez Rodríguez Leonor Alberola Amores Alba Álvarez Pujante Manuela Pérez-Chacón Antonio Chacón Paloma Echevarría Pérez

Background/Objectives: Highly sensitive persons (HSPs) are characterized by increased emotional and sensory responsiveness, which may predispose them to anxiety, emotional dysregulation, and sensory overload. Music therapy based on gong sound sessions has emerged as a complementary intervention aimed at promoting emotional well-being. This study analyzed immediate pre- and post-intervention variations in an adult population with sensory processing sensitivity. Methods: A quantitative, quasi-experimental, single-group (non-controlled), pre–post intervention study was conducted using music therapy in a sample of N = 93 individuals, who were evaluated during an initial session (62 Highly Sensitive Persons [HSPs] and 31 Non-HSPs), from which a synchronized longitudinal sub-cohort of 39 participants (27 HSPs and 12 Non-HSPs) completed a second exposure. Indicators were assessed using the Questionnaire on the Impact of Music Therapy Sessions in Adult Patients (CISMA), whose technical designation corresponds to an acronym of Spanish-language origin. Results: Participants demonstrated significant score variations following gong sound therapy in each session. In the first session, the mean CISMA score changed by 7.0 points (p < 0.001), while the second session showed a mean variation of 7.0 points (p < 0.001). Participants reported favorable trends in emotional self-regulation, reduced anxiety, mitigated pain intensity, increased tolerance to sensory overload, and greater overall psychological well-being. Conclusions: Music therapy using gong sound appears to be a promising complementary framework, contributing to immediate positive shifts in emotional regulation, anxiety, pain, and sensory distress. Within the limitations of this non-controlled framework, these immediate shifts describe a specific statistical variation within the observed sample, which cannot be generalized as clinical efficacy. Controlled trials are needed to confirm these insights and show the potential integration of music therapy using gong sound into holistic nursing and mental health care models.

Healthcare doi: 10.3390/healthcare14162508

Authors: Xuehong Zhu Lina Ge Guanghui Dong Yanlin Tang Zhong Lin Feng Han

Background: Polycystic ovary syndrome (PCOS) is a leading cause of anovulatory infertility and a frequent indication for in vitro fertilization/intracytoplasmic sperm injection (IVF/ICSI). Multivariable regression estimates adjusted associations, whereas association rule mining (ARM) can describe frequently co-occurring attributes; however, ARM outputs are unadjusted and may be sensitive to analytic specification. Objectives: We used ARM alongside multivariable logistic regression and internal robustness analyses to describe combinations of clinical and treatment-related variables that co-occurred with clinical pregnancy failure among women with PCOS undergoing IVF/ICSI. Methods: We retrospectively analyzed 733 deidentified patients with PCOS from the Reproductive Hospital of Guangxi. The original one-hot-encoded analytic file was linked to a supplemental clinical record file containing continuous age, BMI, infertility duration, anti-Müllerian hormone, total gonadotropin dose, fertilization method, embryo-transfer day, number of embryos transferred, and embryo score. Embryo quality was derived from D3 cleavage-stage and blastocyst morphology records. Multivariable logistic regression was used to estimate adjusted associations. ARM results were assessed using Fisher’s exact test, Benjamini–Hochberg false discovery rate (FDR) correction, 1000 bootstrap resamples, fivefold cross-validation, and threshold/cutoff sensitivity analyses. Results: In the multivariable model (n = 730), age remained associated with clinical pregnancy failure (adjusted odds ratio [aOR] = 1.04 per year, 95% CI 1.00–1.08, p = 0.031), whereas BMI was not independently associated with failure (aOR = 1.00 per kg/m2, 95% CI 0.96–1.05, p = 0.860). Transfer of two embryos (aOR = 0.55, 95% CI 0.35–0.85, p = 0.008), D5 blastocyst transfer (aOR = 0.49, 95% CI 0.32–0.75, p = 0.001), and transfer of at least one high-quality embryo (aOR = 0.63, 95% CI 0.43–0.93, p = 0.020) were associated with lower odds of failure. Under the primary host-factor specification, age > 35 years + BMI ≥ 24 kg/m2 + pelvic adhesion defined 48 patients, 30 of whom had clinical pregnancy failure (support = 0.07; confidence = 0.63; lift = 1.38; FDR q = 0.098). In the secondary treatment-inclusive analysis, infertility duration > 5 years + no high-quality embryo transferred defined 43 patients with 30 failures (support = 0.06; confidence = 0.70; lift = 1.54; FDR q = 0.026). Lift represents the subgroup failure proportion divided by the overall failure proportion and is not an adjusted risk ratio. The rule composition and the number of FDR-supported rules changed under alternative cutoffs and confidence thresholds. Conclusions: ARM described transparent but specification-sensitive co-occurrence profiles that complement, rather than compete with, regression. Treatment-inclusive profiles combine baseline and downstream cycle characteristics and are therefore especially exploratory. These findings require prospective multicenter validation before any clinical decision-support use.

Healthcare doi: 10.3390/healthcare14162504

Authors: Seçkin Özcan Erdinç Genç

Background/Objectives: Osteoarthritis (OA) is a common degenerative joint disease associated with pain, functional limitation, and reduced quality of life. Interest in orthobiological treatments, including platelet-rich plasma (PRP), mesenchymal stem cells (MSCs), bone marrow aspirate concentrate (BMAC), exosomes, and biomaterial-based approaches has increased markedly in recent years. This study was aimed at investigating the bibliometric characteristics, research trends, and future directions of scientific literature on orthobiological treatments in OA. Methods: Publications indexed in the Web of Science Core Collection (WoSCC) between 2000 and 2026 were searched on 3 June 2026 using keywords related to OA and orthobiological therapies. The WoSCC was selected because it provides standardized citation data and comprehensive coverage of high-impact scientific journals for bibliometric analyses. In the study, 7875 publications were included. Bibliometric analyses were performed using the Bibliometrix package and Biblioshiny interface. Publication trends, country and institutional contributions, influential publications, keyword patterns, trending topics, and thematic structures were analyzed. Results: Scientific production on orthobiological treatments in OA increased substantially, particularly after 2015, with an annual growth rate of 22.8%. China was the most productive country, whereas the United States had the highest scientific impact. The most productive institutions were mainly universities in China. The most frequent keywords were “osteoarthritis,” “mesenchymal stem cells,” “platelet-rich plasma,” “knee osteoarthritis,” and “cartilage.” Trend analyses indicated a shift from PRP- and stem cell-based applications toward emerging regenerative strategies, including exosomes, extracellular vesicles, biomaterials, and controlled drug delivery systems. Thematic mapping demonstrated that MSCs and cartilage regeneration formed the central research axis. Conclusions: While MSCs and PRP remain key research topics in orthobiological treatments for OA, exosomes, biomaterials, and smart drug delivery systems are attracting increasing attention as crucial areas for future research.

Healthcare doi: 10.3390/healthcare14162505

Authors: Agnieszka Rusiecka Dorota Stefanicka-Wojtas Aneta Soll-Morka Tomasz Hikawczuk Maria Kasprzyk-Smardz Monika Zadka Norbert Zachara Jarosław Zachara Stanisław Karol Manulik Joris van Loenhout Izabella Uchmanowicz Donata Kurpas

Background: The secondary use of routinely collected medical data is increasingly important for healthcare research and public health. However, the validity and representativeness of consent-based datasets depend on patients’ willingness to allow their medical information to be used. Although vaccination behaviour and trust in healthcare systems have both been extensively studied, little is known about their relationship with consent to medical data processing. Objective: This study aimed to identify factors associated with consent to medical data processing among adult primary care patients, with particular emphasis on vaccination status, vaccination attitudes, information-seeking behaviours, and trust-related factors. Methods: A cross-sectional study was conducted among 921 adult patients recruited from three primary healthcare centres in Poland representing different organizational and geographical settings. Data were collected using a standardized questionnaire. The primary outcome was participants’ consent to the transfer of vaccination-history data (yes/no), referred to throughout the manuscript as “consent to medical data processing”. Associations between consent status and socio-demographic characteristics, vaccination-related attitudes, information sources, and trust-related factors were assessed using chi-square tests and non-parametric methods. Hierarchical multivariable logistic regression models were constructed to identify factors independently associated with consent. Model performance was evaluated using the area under the receiver operating characteristic curve (AUC), Nagelkerke’s R2, and the Hosmer-Lemeshow goodness-of-fit test. Results: Overall, 565 participants (61.3%) provided consent to medical data processing and 356 (38.7%) declined consent. Among participants who provided consent, 88.5% were classified as vaccinated, compared with 69.1% among those who did not provide consent (p < 0.001). In multivariable analyses, vaccination status remained independently associated with consent across all hierarchical models. The fully adjusted model showed that vaccinated participants had more than twice the odds of providing consent compared with unvaccinated individuals (OR = 2.27; 95% CI: 1.32–3.92; p = 0.003). Older age was also positively associated with consent (OR = 1.02 per year; 95% CI: 1.01–1.03; p = 0.004). Significant and persistent differences were observed between healthcare centres, suggesting that organizational and contextual factors may play an important role. By contrast, vaccination attitudes, trust in the healthcare system, perceived accessibility of vaccination information, and information-source were not independently associated with consent after adjustment. The final model demonstrated good discrimination (AUC = 0.892), satisfactory calibration (Hosmer–Lemeshow p = 0.647), and moderate explanatory power (Nagelkerke’s R2 = 0.557). Conclusions: Consent to medical data processing was independently associated with vaccination status and healthcare centre among adult primary care patients. The findings suggest that vaccination behaviour and organizational context are important correlates of consent to medical data processing. Organizational characteristics may also play an important role in shaping consent behaviour in healthcare settings. Researchers using consent-based medical data should consider the potential impact of differential consent behaviour on the representativeness of study populations. Further research is needed to understand contextual and behavioural determinants of consent to medical data processing.

Healthcare doi: 10.3390/healthcare14162506

Authors: Omar Sabri Salem Ahemd Alabdali

This study presents a bibliometric analysis of AI healthcare research related to implementation science and governance frameworks from 2016 to 2026. A systematic search of the Scopus database identified 3780 peer-reviewed articles published across 1500 sources. The dataset was analyzed using Biblioshiny. The findings show an annual growth rate of 47.65% in governance-focused publications, exceeding the growth rate of technical AI research. Four main research themes were identified: regulatory compliance, ethical frameworks with limited operational measures, organizational readiness, and clinical workflow integration. The United States, China, and the United Kingdom are the leading contributors, while the Journal of Medical Internet Research and BMJ Open are among the main publication outlets. International collaboration (34.66%) remains concentrated among high-income countries. Thematic development has progressed from general ethical discussions to pandemic-related applications and more specific regulatory frameworks. Three research gaps contribute to the algorithm-to-policy translation deficit: the principles–practice gap, the regulatory–evidence gap, and the innovation–implementation gap. This study proposes an integrated governance framework based on five evidence-based principles. The framework is a conceptual model derived from bibliometric findings and requires further empirical validation in clinical settings before practical adoption. The study contributes by providing a bibliometric analysis of AI governance research and introducing the concept of the “algorithm-to-policy translation deficit” as an analytical framework. It also offers a structure to support future research and practice toward safe, effective, and equitable clinical implementation of AI. These findings guidance for regulators, healthcare organizations, AI developers, and researchers.

Healthcare doi: 10.3390/healthcare14162503

Authors: Nannan Wen Xia Zhong Peijin Hu Jun Ma Ning Li Jiayi Guo Dachao Zhang Ziyue Sun Yang Yang Kaiheng Zhu Yajie Wang Jing Li Yi Song

Background/Objectives: The association between sleep deprivation and mental well-being in school-aged children and adolescents has been well documented, but the specific relationship between sleep debt and mental well-being remains unclear. This study aimed to evaluate the association between sleep debt and mental well-being in school-aged children and adolescents. Methods: This cross-sectional study included 4967 children and adolescents aged 9–18 years from eight provincial-level regions in China, using data from a multicenter school-based survey conducted within the framework of the Chinese National Survey on Students’ Constitution and Health (CNSSCH). Participants self-reported relevant sleep parameters, and the sleep debt was calculated based on the difference in sleep duration between weekdays and weekends. The main outcome was mental well-being. Adjusted covariates were age, sex, urban–rural residence, body mass index (BMI), vital capacity, and waist-to-hip ratio. Results: A total of 4967 children and adolescents were included (mean [SD] age 12.77 [2.59] years; 2475 [49.83%] girls) with 3176 participants classified as having higher mental well-being and 1791 participants classified as having lower mental well-being. After adjustment for covariates, sleep debt was associated with greater odds of lower mental well-being (adjusted odds ratio [aOR] = 1.095; 95% CI, 1.050–1.143; p < 0.001). Although statistically significant, the magnitude of this association was modest. In stratified analyses, each quartile increase in sleep debt was associated with 17.8% higher odds of lower mental well-being in boys (95% CI, 8.6–27.8%), 33.8% higher odds in girls (95% CI, 23.8–44.6%), 25.3% higher odds in urban students (95% CI, 16.3–35.0%), and 28.2% higher odds in rural students (95% CI, 17.6–39.7%) (all p < 0.001). In addition, weekend sleep patterns significantly interacted with the sleep debt–mental well-being association (p for interaction < 0.05), while age-specific nonlinear patterns involving nap duration were observed among adolescents aged 15–17 years (p for nonlinearity = 0.004). Conclusions: Sleep debt showed a statistically significant but modest cross-sectional association with lower mental well-being. Numerically larger subgroup-specific estimates were observed among girls and rural students. Given the cross-sectional design, these findings should not be interpreted as evidence of causality. Despite its modest magnitude, the association may have public health relevance at the population level. The observed patterns involving weekend sleep and age-specific nap duration warrant further evaluation in longitudinal and, where appropriate, intervention studies.

Healthcare doi: 10.3390/healthcare14162502

Authors: Jerica Zaloznik Djordjevic Zvonka Fekonja Matej Strnad

Background: The Manchester Triage System (MTS) is one of the most widely used emergency department (ED) triage tools worldwide, aiming to standardize patient prioritization through structured flowcharts and discriminators. Despite its broad adoption, concerns remain regarding its reliability, adaptability, and performance across diverse clinical and operational contexts. Objective: This narrative review aimed to identify and narratively synthesize evidence on the validity, reliability, and contextual performance of the MTS, with particular attention to inter-rater variability, cultural and linguistic adaptation, and operational limitations in real-world ED settings. Methods: A structured literature search was conducted across four databases from inception to January 2026 and analyzed according to the methodological recommendations for narrative biomedical reviews proposed by Gasparyan et al. to identify studies assessing the performance, implementation, and limitations of the MTS across different healthcare systems. Included studies were analyzed qualitatively, focusing on outcome measures related to accuracy, consistency, and contextual applicability. Results: The reviewed evidence supports the MTS’s ability to identify high-acuity patients; however, considerable variability in reliability and performance was observed across settings. Subjectivity in symptom interpretation and discriminator selection, challenges in non-English-speaking environments, and the lack of integration of operational factors, such as ED crowding and staffing levels, were recurrent findings. Conclusions: While the MTS remains a cornerstone of emergency triage, its effectiveness is influenced by human, cultural, and system-level factors. Future research should explore complementary strategies, including enhanced training, local adaptation, point-of-care testing, and artificial intelligence-based decision support, to improve triage consistency and patient outcomes.

Healthcare doi: 10.3390/healthcare14162500

Authors: Jiayi Cui Zhizhou Duan Jun Wang

Background: Hypertension and diabetes commonly coexist in patients with chronic obstructive pulmonary disease (COPD), but their associations with arterial blood gas parameters remain insufficiently characterized, particularly after accounting for measured differences in baseline characteristics. This study aimed to examine the associations between coexisting hypertension and diabetes and selected arterial blood gas parameters in older patients with COPD. Propensity score matching (PSM) was used to improve the comparability of the study groups and reduce confounding from measured baseline covariates. Patients and Methods: A retrospective cross-sectional study was conducted involving 1030 patients. The comorbidity group comprised COPD patients with both hypertension and diabetes (n = 340), while the COPD-only group refers to COPD patients without hypertension or diabetes (n = 690). Propensity score matching (PSM) was estimated using a regression model with covariates including age, sex, marital status, BMI, temperature, and pulse. Balance was assessed using standardized mean difference (SMD), and linear regression models were adopted to evaluate the association between coexisting hypertension and diabetes and each blood gas indicator (PCO2, PO2, SaO2). Results: We performed 1:1 nearest-neighbor matching and successfully generated 340 matched pairs, forming a total matched cohort of 680 patients; all unmatched participants from the original 1030 subjects were excluded from subsequent outcome comparisons. Covariate balance was optimized for most baseline indicators after PSM, although mild residual imbalance remained in age and BMI after matching. The comorbidity group demonstrated a statistically significant reduction in PCO2 (B: −2.54, 95% CI: −4.52 to −0.56) compared to the COPD-only group, while no significant differences were observed in PO2 (B: −2.48, 95% CI: −7.6 to 2.64) or SaO2 (B: −1.16, 95% CI: −2.67 to 0.35). In addition, a sensitivity analysis adjusting for age and BMI was conducted to evaluate the robustness of the findings. Conclusions: After propensity score matching, coexisting hypertension and diabetes were associated with lower PCO2 levels in elderly COPD patients, while no significant associations were found for PO2 or SaO2.

Healthcare doi: 10.3390/healthcare14162499

Authors: Marta Soave Giovanni Marchese Nicola Veronese Annalisa Baldan Domenico Bagnara Sara Antoniazzi Federico Cavallari Francesco Bortoluzzi Chiara Bovo Giovanni Carretta Stefano De Boni Andrea Cozza Stefano Vianello

Background: Lower gastrointestinal endoscopy is a critical diagnostic and therapeutic procedure that is inherently resource-intensive. Following the COVID-19 pandemic, backlogs grew significantly, necessitating innovative management solutions. This study evaluates a multidisciplinary strategy integrating organizational interventions supported by a machine-learning-based semantic appropriateness assessment system to reduce pre-appointment waiting lists within the ULSS (Unità Locale Socio Sanitaria) 3 Serenissima health authority in the Venice metropolitan area. Methods: We retrospectively analyzed administrative and prescription data for adult patients undergoing lower gastrointestinal endoscopy from 2021 to 2024 across five hospitals. Evaluation metrics included the size and composition of the pre-appointment list (first vs. follow-up), service volumes, and prescription trends. Clinical appropriateness was assessed pre-procedure by adherence to RAO (Raggruppamenti di Attesa Omogenea, i.e., Homogeneous Waiting Groups) priority protocols and post-procedure by specialist reviews against guideline-based criteria in two samples from 2023 and 2024. Results: The pre-appointment list decreased significantly from 1, 542 in 2021 to only 14 in 2024. Procedural volume increased (+8% in 2023 vs. 2022), while overall prescriptions decreased, reflecting improved demand management. The provided-to-prescribed ratio rose from 64% in 2021 to 80% in 2024. Furthermore, RAO priority discordance declined, and inappropriate priority-class lower gastrointestinal endoscopy dropped from 26% in 2023 to 21% in 2024—a 5% absolute reduction. Conclusions: A combined strategy targeting both supply and demand—utilizing multidisciplinary governance, computerized decision-support management based on semantic analysis and RAO appropriateness assessment, structured pathways, and continuous audit—was associated with a marked reduction in waiting lists and improved appropriateness while simultaneously increasing service delivery. Expanding specialist–primary care consultation pathways, including teleconsultation, may further consolidate these improvements.

Healthcare doi: 10.3390/healthcare14162498

Authors: Clara Rodríguez-Gude María Teresa Rocío Rial-Rodríguez Lorenzo Antonio Justo-Cousiño

Background/Objectives: Musculoskeletal injuries are highly prevalent among musicians, with the neck and shoulders being the most frequently reported areas of pain. Preventive education should be included to help understand and avoid health risks associated with musical performance. The objective is to assess the level of satisfaction with a workshop on injury prevention among string and wind musicians, and to determine the prevalence and location of their musculoskeletal pain. Methods: This was an observational study consisting of the administration of a questionnaire following a workshop on musculoskeletal injury prevention. Inclusion criteria: string and wind musicians aged between 11 and 20 years. Results: A total of 83% were bowed string musicians. A total of 98.3% of participants indicated that the duration was appropriate, with a score of 8.9 for both overall satisfaction and perceived usefulness in instrumental practice. Thirty-five musicians reported musculoskeletal pain at some point in their lives, and it was present in 12 participants during the previous week. The most common pain locations were the left shoulder and left hand (45% and 40%, respectively), the cervical region (35%), and the right shoulder (33%). Conclusions: Musicians show a high level of satisfaction with the workshop received, considering it interesting and important for their instrumental practice. In addition, the participants expressed a high level of intention to carry out the proposed exercises. The prevalence of musculoskeletal pain is high, particularly in the shoulders, left hand, and cervical region.

Healthcare doi: 10.3390/healthcare14162497

Authors: Iris Feinberg Heewon Lee-Laminack Elizabeth L. Tighe Ifedola Owoeye

Background/Objectives: AI voice interpretation applications like Google Translate in speech/voice mode are increasingly used in clinical settings to address verbal language access challenges, yet evidence comparing their performance to qualified in-person medical interpreters in authentic clinical encounters remains limited. The aim of this study is to compare the linguistic and clinical accuracy of AI-based Google Translate in speech/voice mode and qualified in-person medical interpretation using spoken real-world speech segments from clinical encounters. Methods: Outpatient clinical encounters involving patients with limited English proficiency were audio-recorded. Fourteen physician speech segments (mean length 78.5 words) representing common diagnostic, treatment, and counseling content were extracted, spoken in English into Google Translate speech/voice mode, and translated into six languages. Audio recordings of the same sentence segments were provided to qualified in-person medical interpreters. All non-English translations were back-translated into English by professional interpreters. Researchers and a clinician evaluated the back-translated English speech segments for linguistic accuracy, completeness, and clinical significance. Qualitative analyses examined error patterns and contextual loss; quantitative comparisons assessed error rate differences across languages and interpretation conditions. Results: Google Translate in speech/voice mode exhibited significantly higher linguistic errors (χ2[1] = 19.78, p < 0.001) and clinical accuracy errors (χ2[1] = 45.07, p < 0.001) than qualified medical interpreter translations. Clinically significant error rates were 33.3% for Google Translate in speech/voice mode versus 4.8% for interpreter-generated translations. Error rates were also higher for less commonly spoken languages compared to commonly spoken languages when using Google Translate in speech/voice mode (42.9% vs. 14.3%). Conclusions: Qualified in-person interpreters provided translated speech segments that had fewer errors that were either linguistically or clinically significant, and remain essential for safe, accurate clinical communication.

Healthcare doi: 10.3390/healthcare14162495

Authors: Eun Sook Lee Nam Joo Je Yeong-Mi Seo

Background/Objective: Subjective cognitive decline (SCD) and depressive symptoms are among the most prevalent mental health concerns in older populations, and SCD has been consistently associated with depressive symptoms. However, whether individual Fried Frailty Phenotype (FFP) components modify the association between SCD and depressive symptoms, and whether these moderating patterns differ across sex, has yet to be empirically examined. This study aimed to examine whether individual FFP components moderate the association between SCD and depressive symptoms in older adults, using sex-stratified analyses. Methods: Using data from the Korea National Health and Nutrition Examination Survey, complex sample general linear models were applied to 1404 adults aged 65 years and older. Five FFP components were tested as moderators separately for men and women. Results: SCD was positively associated with depressive symptoms in both sexes. Unintentional weight loss (B = 0.43, p = 0.009) and exhaustion (B = 0.18, p = 0.037) were significant moderators in men. Among women, muscle weakness (B = −0.26, p = 0.002), slowness (B = 0.18, p = 0.020), and unintentional weight loss (B = −0.34, p = 0.022) were identified as significant moderators. Additionally, a formal interaction test indicated a statistically significant sex difference only for unintentional weight loss. Conclusions: The findings underscore the value of examining frailty at the individual-component level, rather than as a single construct, offering a more nuanced understanding of the association between SCD and depressive symptoms through sex-stratified analyses.

Healthcare doi: 10.3390/healthcare14162496

Authors: Panagiota Tragantzopoulou Aikaterini Tragantzopoulou Vaitsa Giannouli

Background/Objectives: Endometriosis is a chronic gynecological condition affecting approximately 10% of women of reproductive age and is associated with chronic pain, fatigue, infertility, and reduced quality of life. Beyond its physical burden, delayed diagnosis, healthcare dismissal, and inadequate support may contribute substantially to psychological distress. In line with growing efforts to promote mental health and wellbeing within healthcare settings, this study explored women’s experiences of healthcare services and the psychological impact of living with endometriosis. Methods: A qualitative study was conducted using thematic analysis of 2500 publicly available Twitter/X posts shared by accounts self-presenting as women discussing experiences of endometriosis. Results: Three overarching themes were identified: (1) Institutional Invalidation of Women’s Endometriosis Experiences, (2) Living with the Multidimensional Burden of Endometriosis, and (3) Reimagining Endometriosis Care. Participants described chronic pain, reproductive uncertainty, and significant emotional distress that were frequently intensified by delayed diagnosis and experiences of not being believed or taken seriously within healthcare settings. Accounts suggested that suffering was shaped not only by disease symptoms but also by interactions with healthcare systems that undermined the legitimacy of women’s experiences. Conversely, validation, empathy, and collaborative communication were associated with improved wellbeing and engagement with care. Participants advocated for greater awareness of endometriosis, earlier diagnosis, and more integrated models of support. Conclusions: Endometriosis should be understood as a biopsychosocial condition whose impact extends beyond physical symptoms alone. The narratives analyzed highlight how psychological distress may be amplified by experiences of invalidation, delayed recognition, and fragmented care. Improving outcomes requires timely diagnosis, patient-centered healthcare interactions, and the integration of psychological support within multidisciplinary endometriosis services.

Healthcare doi: 10.3390/healthcare14162494

Authors: José Gijón Meriem Khaled María J. Lirola Miguel C. Botella

Background/Objectives: Dog-assisted wellbeing activities are increasingly used in higher education, but their short-term cardiovascular correlates and the usefulness of integrated physiological indices remain insufficiently examined. This study evaluated cardiovascular changes associated with participation in StressLess, a multicomponent university wellbeing program involving supervised interaction with trained dogs, and explored several integrated cardiovascular indices. Methods: A total of 147 students participated voluntarily, generating 379 attendances, of which 375 complete session-level pre–post records were retained. Systolic blood pressure (SBP), diastolic blood pressure (DBP), and heart rate (HR) were measured before and after standardized rest periods and 30–40 min of supervised interaction. The primary analysis was restricted to each participant’s first attendance (N = 147) to ensure independence. Sensitivity analyses included all valid session records and participant-level averages. Results: At first attendance, mean SBP decreased from 117.56 to 112.88 mmHg, DBP from 74.05 to 70.95 mmHg, and HR from 82.11 to 75.09 beats/min (all p < 0.001; r = 0.41–0.59). The StressLess Cardiovascular Dynamics Index also decreased significantly (mean reduction = 0.408; p < 0.001; r = 0.66), and alternative formulations produced comparable results. Both sensitivity analyses reproduced the direction and statistical significance of the primary findings. Conclusions: Participation in the complete StressLess session was associated with short-term cardiovascular reductions. Because no control condition was included, the specific contribution of dog interaction cannot be separated from rest, social contact, expectancy, and temporary disengagement from academic activity. Integrated indices may provide useful exploratory summaries but require external validation before diagnostic or clinical use.

Healthcare doi: 10.3390/healthcare14162493

Authors: Melanie Joshi Mareike Loebberding Eva Bothe Lisanne Herzhoff Julia Schmidtke Raymond Voltz Julia Strupp

Background: Patients receiving palliative and hospice care frequently experience high symptom burden alongside altered body perception due to progressive disease and physical decline. While acupressure has demonstrated beneficial effects on symptoms such as nausea, pain, fatigue, and anxiety, its potential influence on body awareness has not been systematically investigated. Furthermore, evidence regarding the feasibility and implementation of nurse-led acupressure interventions across different palliative and hospice care settings remains limited. This study aims to explore the feasibility, acceptability, and potential effects of acupressure on symptom burden and body awareness in palliative care settings. Methods: This pilot study evaluates a nurse-led acupressure intervention aimed at improving body awareness in patients receiving palliative and hospice care across specialized inpatient and outpatient settings. This study is designed as a prospective, exploratory, mixed-methods pilot and feasibility study using a pre-post design across multiple care settings, including a palliative care unit, specialized palliative home care (SAPV), an inpatient palliative consultation service (PMD), and a hospice. A total of 60–80 adult patients with incurable illnesses will be recruited. The intervention consists of standardised acupressure administered by trained nursing staff, with at least two sessions per participant. Primary outcomes focus on feasibility and acceptability indicators, including recruitment, retention, adherence, intervention documentation, and data completeness. Exploratory clinical outcomes include symptom burden, body awareness, and use of on-demand medication. Quantitative outcomes include symptom burden (MIDOS), body awareness (State Mindfulness Scale—Body subscale), and use of on-demand medication. Qualitative data will be collected through brief patient interviews using the Body Image Assessment (BIA) and semi-structured interviews with patients and healthcare providers after the completed intervention. Data will be analysed using descriptive and exploratory inferential statistics, alongside a linguistic and thematic analysis. Quantitative and qualitative findings will be integrated using a convergent triangulation approach. Discussion: This study will provide first insights into the feasibility and acceptability of acupressure in palliative and hospice care and generate hypotheses regarding its potential effects on symptom relief and body awareness. Findings will inform the design of a future randomized controlled trial and contribute to the implementation of complementary therapies in integrative palliative care.

Healthcare doi: 10.3390/healthcare14162492

Authors: Emma Dando Juergen Hahn David A. Geier Athena Whiteley Paul Whiteley

Background/Objectives: Autism spectrum disorder (ASD) is currently singularly described as a behaviourally defined neurodevelopmental diagnosis with symptoms affecting social communication and social understanding alongside the presence of restricted patterns of behaviour. Wide, and often very personal, variations in symptom intensities and differing developmental trajectories, reflective of large heterogeneity, are an important feature of the label. ASD carries enhanced risks for multiple over-represented, sometimes overlapping, comorbidities spanning behavioural, psychiatric and somatic domains. Said comorbidities often have numerous and far-reaching effects on quality of life by way of their impacts and, in extreme cases, their potential effects on life expectancy. It is of paramount importance that data on the risks of such comorbidities are available and, where possible, screening, preventive and/or treatment options implemented. Methods: In this narrative review, the authors searched databases (PubMed/Medline, ScienceDirect, Google Scholar) for papers published between 1 January 2015 and 16 February 2026 that were pertinent to comorbidity and autism. Results: We present data on the frequency of various somatic (gastrointestinal, immunological, metabolic, neurological, motor-sensory disorders), psychiatric (anxiety, mood, schizophrenia spectrum, personality, substance abuse, trauma, feeding and eating, sleeping, self-harm, neurocognitive disorders) and neurodevelopmental comorbidities (intellectual, attentional, speech and language, motor disorders) that can present alongside a diagnosis of ASD. We provide accompanying data on the magnitude of potential risk and, where available, information on comorbidity risks according to sex and age. Conclusions: This review paper deals with an extremely broad field. Limitations of the narrative review strategy are discussed alongside how the variable risk of comorbidity mimics the heterogeneity present in autism, thus inviting further investigations.

Healthcare doi: 10.3390/healthcare14162491

Authors: Fabrizio Petrone Simona Sgromo Sara Dionisi Alessandro Spano Emanuele Di Simone Gloria Liquori Noemi Giannetta Priscilla Molinaro Marco Di Muzio Nicolò Panattoni Lorenzo Pietropaolo Aurora De Leo

Background: Nurses’ perspectives on telenursing are essential to improving its use by patients and nurses. Objective: This descriptive pilot study aims to assess the acceptability and usefulness of telenursing among nurses through a questionnaire developed by the authors. Additionally, the internal consistency of the instrument was assessed. Methods: A cross-sectional descriptive pilot study was conducted using an online survey and a 43-item questionnaire in October 2024. Convenience sampling was used to enrol interested nurses employed in any setting. Inferential statistical tests were conducted to assess the associations between the variables. Additionally, the internal consistency of the questionnaire was tested using Cronbach’s alpha. The study was conducted in accordance with the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines. Consent was obtained from the involved nurses and the relevant Ethics Committee. Results: In total, 53 Italian nurses were included. A total of 94.4% of them would use telenursing in clinical practice and would be interested in attending educational programmes on telenursing (86.8%). The analysis suggested that nurses’ positive attitudes towards telenursing are predicted by their gender (being female), knowledge, strategic management support, and the time-saving potential of telenursing. A Cronbach’s α of 0.86 suggested a good internal reliability of the questionnaire. Conclusions: The study findings suggest positive nurses’ acceptability and utility for telenursing, positively predicted by gender, knowledge, potential time-saving benefits of telehealth nursing, and organisational support. A positive attitude towards telenursing could encourage its use among nurses and patients. These preliminary findings should be confirmed in a future validation study.

Healthcare doi: 10.3390/healthcare14162490

Authors: Sang Seok Yeo Dong Hyun Byun Fang He

Background/Objectives: Dizziness is a common clinical symptom that can develop from various diseases and affect activities of daily living. This study investigated and compared brain activation in people with and without dizziness during different head position gait sessions using functional near-infrared spectroscopy (fNIRS). Methods: We included eight adults with symptoms of dizziness as the dizziness group and eight control participants without dizziness. Dizziness symptoms were evaluated using the Dizziness Handicap Inventory (DHI) and Vertigo Symptom Scale—short form (VSS-sf). Results: Compared with the control group, we found the activation of the bilateral middle temporal gyrus (MTG) when looking forward, the activation of the left superior parietal lobule (SPL) and right angular gyrus (AG) when looking upward, the activation of the left AG and the deactivation of the right MTG when looking rightward, the activation of the right SPL when looking leftward, and the activation of the left MTG and the deactivation of the right MTG when looking downward in the dizziness group at an exploratory, uncorrected threshold (p < 0.05). Notably, while all identified regions exhibited large effect sizes (Cohen’s d > 0.8), only the activation in the left SPL (channel 11) remained statistically significant after false discovery rate (FDR) correction when looking upward compared with the control group (corrected p < 0.05). Conclusions: These exploratory and hypothesis-generating findings suggest that altered cortical activation associated with multisensory integration may reflect changes in sensory reweighting during gait in individuals with dizziness under different head position conditions.

Healthcare doi: 10.3390/healthcare14162489

Authors: Qi Zhou Ying Zhang Dan Ma Fengjie Lyu Suxin Luo Shenglan Yang

Background: Device-independent, lifestyle-integrated active pursed-lip diaphragmatic breathing (PLDB) may overcome respiratory rehabilitation barriers in chronic heart failure (CHF). This retrospective real-world study evaluated its prognostic association with functional capacity, quality of life (QoL), and major adverse cardiovascular events (MACE). Methods: A total of 58 CHF patients (NYHA II–IV) were categorized by 6-month post-discharge PLDB adherence into a Respiratory Training Group (RTG; n = 20) and Control Group (n = 38). Functional, structural, QoL metrics, and MACE outcomes were analyzed. Results: After 6 months, the RTG demonstrated significant intra-group improvements in 6 min walk test (6MWT) distance (302.00 [243.60, 408.15] m to 386.00 [339.50, 439.00] m, p = 0.006; baseline-adjusted between-group gain: +76.16 m), handgrip strength (p = 0.046), LVEF (p = 0.003), and scores on the Minnesota Living with Heart Failure Questionnaire (MLHFQ) (p < 0.001), Generalized Anxiety Disorder-7 (GAD-7) (p = 0.010), and Self-rating Somatic Symptom Scale-China (SSS-CN) (p = 0.004). Post-intervention, the RTG outperformed controls in handgrip strength (p = 0.012), MLHFQ (p = 0.001) and SSS-CN (p = 0.020). The RTG exhibited a significantly lower MACE incidence (5.0% vs. 42.1%, p = 0.003) and superior MACE-free survival (log-rank p = 0.005). Multivariable Cox regression confirmed high PLDB adherence was independently associated with a lower MACE risk (adjusted HR = 0.103, 95% CI: 0.014–0.779, p = 0.028). Conclusions: High adherence to a 6-month lifestyle-integrated PLDB program correlates with clinically meaningful improvements in exercise capacity, cardiac function, and QoL, and is independently associated with a lower risk of short-term MACE in CHF patients.

Healthcare doi: 10.3390/healthcare14162488

Authors: Lingfeng Cai Mingxia Xiong Dandan Sheng Weichun He

Objective: To investigate the effects of parathyroidectomy (PTX) on muscle mass, muscle strength, and motor function at different postoperative stages in uremic patients with secondary hyperparathyroidism (SHPT). Methods: A total of 47 uremic patients with SHPT who underwent PTX were enrolled in this study. General clinical data, including age and blood biochemical parameters, were collected. Pre- and postoperative measurements of lean body mass, the appendicular skeletal muscle index (ASMI), skinfold thickness, grip strength, and 6-m walk time were recorded. Patients were divided into three groups—short-term, mid-term, and long-term—based on the timing of postoperative follow-up, and the patterns of change in muscle mass, strength, and function at different time points following PTX were analyzed. Results: In the short-term postoperative period, patients’ grip strength increased significantly, and their 6-m walk time decreased significantly (p < 0.05), whilst lean body mass, the ASMI and skinfold thickness showed no significant changes compared with preoperative levels (p > 0.05). In the mid-term postoperative period, lean body mass, the ASMI and grip strength all increased significantly, whilst the 6-m walk time decreased significantly (p < 0.05); there was no significant change in skinfold thickness (p > 0.05). In the long-term postoperative period, skinfold thickness and grip strength increased significantly, and the 6-m walk time was significantly reduced (p < 0.05), whilst lean body mass and the ASMI showed no statistically significant difference compared to preoperative levels (p > 0.05). Conclusions: PTX can effectively improve muscle strength and lower limb motor function in uremic patients with SHPT, and these improvements persist during long-term postoperative follow-up; improvements in muscle mass-related indicators exhibit a phased pattern, with significant increases observed in the mid-postoperative period, suggesting that the improvement in muscle mass following PTX is subject to a certain time-dependent effect.

Healthcare doi: 10.3390/healthcare14162485

Authors: Kristen R. Choi Gery Ryan Sarah E. Choi Luisa R. Blanco

Background/Objectives: Older adults have high rates of suicide, but there is little research on age-specific correlates of suicide. The purpose of this study was to examine risk and protective factors for suicidal ideation and attempts across adult and older adult age groups in a racially diverse sample. Methods: Using a cross-sectional analysis of California Health Interview Survey (CHIS) data from 2021 to 2024 (N = 92,397) linked with 2020 CDC/ATSDR Social Vulnerability Index data, the analytic sample was 64,263 California adults selected by address-based sampling and stratified by age: 45–64 years (31.5% of the overall pooled sample), 65–74 years (12.6%), and ≥785 years (9.1%). Outcomes were lifetime suicidal ideation and attempts. Weighted logistic regression models examined risk and protective factors. Results: Approximately 19% of the sample reported lifetime suicidal ideation, and 6% reported lifetime attempts. Psychological distress, childhood exposure to household mental illness or suicidality, and poor self-rated health were risk factors across all age groups, with associations strengthening with age. Among those with lifetime ideation, these risk factors showed even larger associations in older adults. Protective factors included indicators of sociodemographic vulnerability. Conclusions: Suicide risk and protective factors differ substantially across older adulthood. Findings highlight the need for tailored interventions and integration of suicide screening into primary care for older adults.

Healthcare doi: 10.3390/healthcare14162487

Authors: Chitra Banarjee Anthony Bilic Yong Jae Kwon Sofia Rojas Aristizabal Janet Lopez Rui Xie Chen Chen Ladda Thiamwong

Background/Objectives: This scoping review evaluates the use of computer vision (CV) for analyzing conventional video recordings of gait in older adults. In the rapidly evolving world of CV, methods that use conventional video recordings offer a practical and affordable solution to quantifying gait impairments, especially in resource-limited areas. In this review, we evaluate the aims, methods, variables, and validation of the literature utilizing videos of gait in older adults. Methods: Inclusion criteria were limited to journal articles and conference papers published between 2020 and 2025. Three reviewers extracted data from selected articles. Results: The search identified 46 studies that demonstrate a wide variety of clinical conditions, methodological approaches, and analyzed variables. Three main aims emerged, with 15 screening studies for clinical conditions, 14 studies classifying severity or mobility levels, 16 characterization studies of healthy and pathological gait, and one person-identification study. Methodological approaches ranged across 35 studies utilizing commercially available cameras, six studies utilizing conventional video from specialized cameras, two using surveillance-style cameras, and four that did not specify. Methods of validation were inconsistent, comparing either to lab-based biomechanical gold standards or broad clinical labels, with limited interdisciplinary validation through both methods. Conclusions: This scoping review demonstrates methodological growth and diversification in CV-based gait analysis using conventional video in older adults. The available evidence primarily supports technical feasibility and preliminary screening or classification performance rather than established clinical validity. Standardized methods and external, longitudinal, and real-world validation are needed before these approaches can reliably support routine clinical decision-making.

Healthcare doi: 10.3390/healthcare14162486

Authors: Soner Yeşilyurt Olcay Şenay

Background/Objectives: Depression and anxiety are common among individuals with type 2 diabetes mellitus (T2DM) and are associated with poorer clinical outcomes. Although diabetes stigma and perceived social support have been linked to psychological distress in T2DM, they have largely been investigated separately and with limited adjustment for potential confounders. This study aimed to examine whether diabetes stigma and perceived social support are independently associated with depression and anxiety after adjustment for sociodemographic and clinical confounders and, secondarily, to evaluate the association of insulin use with these psychological outcomes. Methods: In this single-center, cross-sectional study, 209 adults with T2DM attending a tertiary internal medicine outpatient clinic were enrolled. Diabetes stigma was assessed using the Type 2 Diabetes Stigma Assessment Scale (DSAS-2), depression using the Beck Depression Inventory (BDI), anxiety using the Beck Anxiety Inventory (BAI), and perceived social support using the Multidimensional Scale of Perceived Social Support (MSPSS). Mann–Whitney U tests, Spearman correlation analyses, and two-step hierarchical linear regression models were performed. Results: Diabetes stigma was positively correlated with depression (ρ = 0.351) and anxiety (ρ = 0.432), whereas perceived social support was negatively correlated with both depression (ρ = −0.394) and anxiety (ρ = −0.275) (all p < 0.001). After adjustment for sociodemographic and clinical covariates, the addition of diabetes stigma and perceived social support explained an additional 21.4% of the variance in depression (ΔR2 = 0.214) and 17.9% of the variance in anxiety (ΔR2 = 0.179) (both p < 0.001). Both diabetes stigma and perceived social support remained independently associated with depression and anxiety, whereas insulin use was not independently associated with either outcome. Conclusions: Diabetes stigma and perceived social support exhibit independent and additive associations with depression and anxiety among individuals with T2DM. Integrating psychosocial assessment, stigma-reduction strategies, and interventions aimed at strengthening social support into routine diabetes care may contribute to improved psychological well-being in this population.

Healthcare doi: 10.3390/healthcare14162484

Authors: Ahmed Alqheedan Saleh Alzughaibi Eman Alanazi Mohammed Alsahli Amani Othman Rasha Alhazzaa Mansour Almanaa

Background/Objectives: Virtual home health care (VHHC) is increasingly used to support chronic disease management, yet patient satisfaction is often examined through a linear barrier-focused lens, in which more barriers are assumed to produce lower satisfaction. This study introduced a satisfaction resilience framework to identify factors associated with preserved satisfaction among barrier-exposed VHHC users. Methods: This cross-sectional analysis included 517 adults with chronic diseases who had used VHHC services and were recruited across five regions of Saudi Arabia. Patients were classified by barrier load and overall satisfaction into four groups: Resilient, Vulnerable, Comfortable, and Disengaged. Group differences were examined using one-way ANOVA, chi-square tests with Cramér’s V, point-biserial correlations, and a linear probability model restricted to high-barrier patients. Results: Overall, 167 patients (32.3%) reported high barrier exposure. Among them, 109 (65.3%) were classified as Resilient and 58 (34.7%) as Vulnerable, despite statistically equivalent barrier counts. Resilient patients reported higher motivation count, provider trust, perceived effectiveness, and functional equivalence with in-person care. Lifestyle-integration motivations, particularly avoiding work absence and waiting rooms, differentiated Resilient from Vulnerable patients, whereas access-related motivations did not. Perceived functional equivalence showed the largest between-group effect. In the high-barrier subsample, motivation count and provider trust were independently associated with Resilient status, while demographic variables were not significantly associated with it. Conclusions: Satisfaction with VHHC among chronic disease patients is not determined by barrier exposure alone. Service-design and communication strategies that strengthen lifestyle integration, functional equivalence beliefs, and provider trust may help healthcare teams support satisfaction resilience among patients who experience barriers to virtual care.

Healthcare doi: 10.3390/healthcare14162483

Authors: Ozge Kama Basci Hasan Huseyin Zorlu

Background: Hedonic hunger and problematic internet use (PIU) have been linked to excess adiposity, but their differential associations with adiposity measures in medical students remain unclear. Methods: This cross-sectional study included 256 medical students (63.3% female; mean age 22.1 ± 2.4 years) at Balıkesir University in 2024. Hedonic hunger was assessed using the Power of Food Scale (PFS), and PIU using the Problematic Internet Use Scale (PIUS). Anthropometric measurements included body mass index (BMI), waist circumference, and waist-to-hip ratio (WHR). Multivariable linear and binary logistic regression analyses were performed, together with secondary correlation and group-comparison analyses. Results: Overall, 32.1% of participants had overweight or obesity. Mean PFS and PIUS total scores were 3.25 ± 0.73 and 2.61 ± 0.74, respectively. In multivariable models, higher PFS scores were associated with greater BMI (B = 1.32, p = 0.001) and higher odds of overweight/obesity (OR = 1.79, 95% CI: 1.13–2.84). Higher PIUS scores were associated with waist circumference (B = 3.85, p < 0.001) and WHR (B = 0.023, p = 0.027), but not with BMI. The association between PIUS and waist circumference was stronger in male students (PIUS × sex interaction, p = 0.006). PFS and PIUS scores were positively correlated (r = 0.299, p < 0.001). Conclusions: Hedonic hunger and PIU showed different cross-sectional associations with adiposity measures: hedonic hunger was associated primarily with BMI and overweight/obesity status, whereas PIU was associated with central adiposity measures. The association between PIU and waist circumference differed by sex. Longitudinal studies are needed to clarify the temporal relationships among these variables.

Healthcare doi: 10.3390/healthcare14162482

Authors: Dhiyaa A. H. Otayf Albaraa H. Hakami Saja A. Almraysi Mohammad A. Jareebi Saud N. Alwadani Khalid I. Hakami Waleed A. Alabdali Yazan A. Bajawi Abdullah Mawkili Tawfiq Khurayzi Mashael Solan Mahnashi Raghad Wasil AlNahwe Farjah H. Algahtani Amal J. Alfaifi Ghazi I. Al Jowf

Background/Objectives: Personal listening devices (PLDs) have become ubiquitous in modern daily life, raising growing concerns about their cumulative impact on auditory health. This study examined the prevalence and patterns of PLD use and the independent predictors of perceived hearing handicap among Saudi adults. Methods: A nationwide cross-sectional survey was conducted between November 2025 and January 2026 among 2018 adults (aged 18 years or older) residing in Saudi Arabia. Participants completed a self-administered online questionnaire assessing sociodemographic characteristics, PLD usage patterns, and hearing handicap measured by the Revised Hearing Handicap Inventory (RHHI-18). Results: Participants had a mean age of 29 ± 12 years, 54.0% were female, and 93.9% were Saudi nationals. Earphones and headphones were used by 51.1% and 47.7% of participants, respectively, and 68.1% reported current use of at least one personal listening device. The mean RHHI-18 total score was 10 ± 18, and 23.0% of participants scored within the hearing handicap range (mild-to-moderate: 16.2%; significant: 6.8%). All PLD use categories were independently associated with higher RHHI-18 scores relative to non-use: headphones only (beta = 4.58; p < 0.001), earphones only (beta = 3.29; p = 0.002), and combined use (beta = 2.87; p = 0.005). Further independent correlates of higher RHHI-18 scores were stroke (beta = 21.51; p < 0.001), diabetes mellitus (beta = 8.64; p < 0.001), hypertension (beta = 4.84; p = 0.006), non-Saudi nationality (beta = 3.92; p = 0.014), male sex (beta = 3.09; p < 0.001), and older age (beta = 0.16; p = 0.002). Conclusions: PLD use is highly prevalent among Saudi adults and is independently associated with greater perceived hearing handicap. These findings support public health efforts promoting safe listening practices at the population level.

Healthcare doi: 10.3390/healthcare14162481

Authors: Durdane Yılmaz Güven Büşra Salar

Background and Objectives: Postoperative recovery after orthopedic surgery is associated with psychological and functional factors, yet the independent associations of anxiety and care dependency with postoperative recovery remain unclear. This study aimed to identify factors independently associated with postoperative quality of recovery and to examine the relationships among anxiety, care dependency, and recovery quality. Methods: This analytical cross-sectional study included 155 patients who underwent orthopedic surgery. Data were collected on the first postoperative day using a Patient Identification Form, the Beck Anxiety Inventory, the Care Dependency Scale, and the Quality of Recovery-40 (QoR-40) questionnaire through face-to-face interviews. Data were analyzed using descriptive statistics, Mann–Whitney U, Kruskal–Wallis, Spearman’s rank correlation, and multivariable linear regression analyses. Results: Older age, female sex, and hypertension and/or diabetes mellitus were significantly associated with higher anxiety and greater care dependency (p < 0.05), whereas older age was significantly associated with poorer quality of recovery (p < 0.05). Anxiety was negatively correlated with quality of recovery (r = −0.707, p < 0.001) and functional independence (r = −0.367, p < 0.001), whereas functional independence was positively correlated with quality of recovery (r = 0.557, p < 0.001). Multivariable linear regression analysis showed that higher anxiety (β = −0.52), greater functional independence (β = 0.31), and older age (β = −0.18) were independently associated with quality of recovery. Conclusions: Older age, female sex, and hypertension and/or diabetes mellitus were independently associated with higher anxiety and greater care dependency. Higher anxiety and lower functional independence were independently associated with poorer postoperative recovery. These findings support the integration of psychological assessment and functional evaluation into routine postoperative nursing care.

Healthcare doi: 10.3390/healthcare14162480

Authors: Nahed N. Mahrous Samia T. Al-Shouli Yousef M. Hawsawi Mohammed Aljuwayd Abdullah AlDhuwaihy Abdulrahman AlOmar Yahya F. Jamous

Background: Antimicrobial resistance (AMR) remains a major global public health threat, largely driven by inappropriate antibiotic use. Smart health technologies (SHTs), including mobile health applications and digital stewardship tools, offer promising opportunities to improve antibiotic use and strengthen antimicrobial stewardship. This study assessed public knowledge, practices, and stated acceptance of selected SHTs related to antibiotic use and AMR management among adults residing in Saudi Arabia. Methods: A cross-sectional online survey was conducted among adults residing in Saudi Arabia between November 2025 and January 2026 using a structured questionnaire assessing knowledge and practices related to antibiotic use, awareness of SHTs, perceived barriers, and acceptance of digital health technologies. Descriptive and inferential statistical analyses were performed. Results: A total of 434 consenting participants were included in the final analysis. Participants demonstrated gaps in knowledge of antibiotic use and AMR, while misconceptions and inappropriate practices remained common, including lifetime non-prescription antibiotic use (37.8%) and sharing antibiotics (31.3%). Awareness of SHTs was limited, with only 30.4% aware of antibiotic-related mobile health applications. Despite limited awareness, 61.8% were willing to use medication-reminder applications and 87.3% preferred electronic prescriptions. The mean acceptance score was 4.39 ± 0.66/5, and 79.7% had high stated acceptance. In an exploratory adjusted analysis, female respondents had higher odds of meeting the predefined high-acceptance threshold (AOR = 1.88, 95% CI: 1.04–3.40); however, this finding should be interpreted cautiously because the overall regression model was not statistically significant and showed modest discrimination. Perceived barriers were not independently associated with acceptance. Conclusions: Despite gaps in knowledge and persistent inappropriate antibiotic-use practices, the surveyed online respondents demonstrated favorable stated attitudes toward selected smart health technologies. These findings should not be interpreted as evidence of actual adoption or national implementation readiness. Further nationally representative and prospective studies are required before broader implementation can be recommended.

Healthcare doi: 10.3390/healthcare14162479

Authors: Mai Adil Ghabashi

Background: Generalized anxiety symptoms represent an important public health concern in Saudi Arabia, yet evidence concerning their associated factors remains limited. Guided by the biopsychosocial framework, this study aimed to examine the independent associations of sociodemographic, health-related, psychological, and dietary factors with moderate-to-severe generalized anxiety symptoms among adults residing in Saudi Arabia. Methods: This cross-sectional study included an online convenience sample of 2044 adults. Participants completed self-reported sociodemographic, health-related, psychological, and dietary measures, together with the validated seven-item Generalized Anxiety Disorder scale (GAD-7) screening instrument. Multiple logistic regression was used to identify factors associated with moderate-to-severe generalized anxiety symptoms, defined as a GAD-7 score ≥ 10. Results: Overall, 33.2% of participants (n = 679) reported moderate-to-severe generalized anxiety symptoms. Women had higher odds of reporting these symptoms than men (odds ratio [OR] = 2.57, 95% confidence interval [CI]: 1.71–3.87; p < 0.001). Increasing age was associated with lower odds (OR = 0.97, 95% CI: 0.96–0.98; p < 0.001), whereas excess body weight was associated with higher odds (OR = 1.27, 95% CI: 1.02–1.59; p = 0.03). Daily consumption of soft drinks (OR = 1.62, 95% CI: 1.18–2.22; p = 0.002) and snacks (OR = 1.24, 95% CI: 1.00–1.54; p = 0.04) was also associated with higher odds. Conclusions: Within this predominantly female convenience sample, weight-related and dietary factors were associated with moderate-to-severe generalized anxiety symptoms. These findings may inform the development and evaluation of integrated mental health promotion initiatives, although prospective studies are needed to confirm the observed associations.

Healthcare doi: 10.3390/healthcare14162478

Authors: Ibrahim Alliu Gulzar Shah Subash Thapa Olamide Asifat

Background/Objectives: Multimorbidity is associated with substantial healthcare burdens, but its associations with health and economic outcomes among young adults remain poorly characterized. This study examined associations between clinically defined multimorbidity profiles and expenditures, catastrophic healthcare expenditure, health-related quality of life, and inpatient utilization across adult life stages. Methods: Medical Expenditure Panel Survey Panel 24 data were analyzed for 4331 U.S. adults followed from 2019 through 2022, including 942 young adults. Respondents were classified into five profiles: no included conditions, respiratory only, cardiometabolic only, any-cancer involved, and cardiorespiratory. Longitudinally weighted generalized estimating equations were fitted. Results: Profile distribution differed significantly across age groups. Among young adults, overall profile and profile-by-year tests were nonsignificant for total expenditures and most other outcomes. In 2019, the cardiorespiratory profile was associated with higher expected expenditures than no included conditions (expenditure ratio = 3.44, 95% CI: 1.59–7.46; p = 0.002). It was also associated with higher hospitalization odds across 2019–2022 (OR = 3.39, 95% CI: 1.28–8.99; p = 0.014), although the overall profile test was nonsignificant. Sex, insurance, and income were associated with several outcomes. Mental health scores were lower in 2021 and 2022 than in 2019 within the reference profile, without evidence of uniform changes across profiles. Conclusions: Overall profile effects were not consistently demonstrated among young adults. Parameter-specific cardiorespiratory estimates suggested a potentially elevated burden but remained exploratory because of sparse observations and nonsignificant overall tests. Socioeconomic vulnerability remained an important correlate of healthcare burden.

Healthcare doi: 10.3390/healthcare14162477

Authors: Shifaa’ Al Qa’qa’ Amal Abu Omar Abdellateef Abdelhafez Alqawasmi Khairat Battah Yamamah Al-Hmaid Raya Marji Mais Alkhalili Dima Hamarsheh Silvia D. Boyajian Ensaf Y. Almomani Lama Hamadneh Ayssar Tashtush

Background/Objectives: Cystic echinococcosis (CE) remains endemic in many regions worldwide, including Jordan. It is one of the three zoonotic infections caused by the tapeworm of the genus Echinococcus. The epidemiology of CE in Jordan remains poorly defined, with systematic national investigations being absent for the past three decades. International Classification of Diseases (ICD) is a universal coding system for disease archiving within healthcare facilities. This coding system is utilized by the Hakeem program, a health informatics system that includes all Ministry of Health (MOH) hospitals and medical centers in Jordan. In this study, we assessed the frequency, plausibility, internal consistency, and administrative limitations of CE-related ICD codes within the MOH database, which have never been tested, and determined the validity of using the administrative data for epidemiological studies of CE in the future. Methods: A retrospective database study was conducted, using 12 echinococcosis-related ICD codes for electronic health record review. Data were retrieved from the Hakeem program. Unique patient entries recorded between 2010 and 2024 were extracted, and descriptive analytical methods were applied. Results: Over a 15-year period, 45,702 echinococcosis-related entries were reported across 178 healthcare facilities, with Amman accounting for the majority (59.1%) of reported entries. Entry numbers rose in the first 10 years (2010–2019) before a measurable decline and fluctuations in the following 5 years (2020–2024). Entries spanned all age groups, with middle-aged adults being the most frequently reported age group (42.45%). Females accounted for 74.4% of entries, reflecting a marked female predominance among coded entries. The most commonly reported ICD code was B67.8 (unspecified echinococcosis of the liver, 64.22%), followed by B67.5 (Echinococcus multilocularis infection of the liver, 33.57%). Confirmatory diagnostic data could not be extracted from the coding system. As a result, clinical validation could not be performed. Conclusions: The high frequency of echinococcosis-related entries suggests artificial inflation of CE-related codes, along with other data anomalies, reflecting internal inconsistencies and epidemiological implausibility of the administrative data within the Hakeem program. MOH should implement a dual, system-user-level plan to improve CE-related coding in the future.

Healthcare doi: 10.3390/healthcare14162476

Authors: Rong Wang Tangxiaoxue Zhang Cailiang Zhou Claudio L. Battaglini Ting Jiang

Background: The relationships of different physical activity domains [e.g., Occupation-related Physical Activity (OPA), Transportation-related Physical Activity (TPA), and Leisure-time Physical Activity (LTPA)] with sleep disorders (SD) remain poorly elucidated. This study investigated the associations of OPA, TPA, and LTPA with SD in American adults. Methods: Data were derived from 25,732 adults with a mean (standard deviation) age of 49.72 (17.53) years (12,692 male and 13,040 female) participating in the 2007–2018 cycles of the National Health and Nutrition Examination Survey (NHANES). The PA domains were assessed using the Global Physical Activity Questionnaire (GPAQ), and adherence to PA recommendations was determined according to the 2018 PA guidelines. SD were identified by self-reported or doctor-diagnosed questionnaire items. Survey-weighted logistic regression models were applied to evaluate the associations between PA domains and SD, and restricted cubic spline (RCS) analyses were conducted to examine potential nonlinear associations. Results: In the fully adjusted model, total PA was not significantly associated with SD (OR 1.01, 95% CI 0.89–1.13, p = 0.912). Regarding specific PA domains, TPA was associated with lower odds of SD (OR 0.79, 95% CI 0.67–0.93, p = 0.006), whereas OPA was associated with higher odds of SD (OR 1.15, 95% CI 1.02–1.30, p = 0.023). No significant association was observed between LTPA and SD (OR 0.96, 95% CI 0.85–1.09, p = 0.511). The multivariable-adjusted RCS analysis further indicated significant nonlinear associations between PA domains and SD (all p for non-linear <0.001). Conclusion: Our findings underscore a prominent “PA paradox” in sleep health among US adults, suggesting that active commuting (TPA) exerts a protective role against SD, whereas OPA serves as a potential behavioral risk factor. Future longitudinal studies and objective PA measurements are needed to validate these cross-sectional associations.

Healthcare doi: 10.3390/healthcare14162475

Authors: Su Sean Yong Qifei Chen Zhiping Liao Fangchao Wu Jianhua Li Qi Si

Background/Objectives: Exercise is an important component of rehabilitation programmes for stroke survivors, and adherence is key to ensuring the effectiveness of rehabilitation. However, adherence declines over time, especially as stroke survivors transition from in-hospital to post-discharge settings. The present review synthesised evidence on factors associated with exercise adherence among stroke survivors in China across two settings, using the socio-ecological model. This could provide a basis for developing effective intervention strategies to improve exercise adherence. Methods: A literature search was conducted via China National Knowledge Infrastructure, Wanfang, Weipu, PubMed, and Web of Science from inception to 30 December 2025. Only cross-sectional studies that examined factors associated with exercise adherence were included. Studies were screened against the inclusion and exclusion criteria. Data were extracted, categorised, and analysed using a semi-quantitative approach. The review protocol was not prospectively registered but was later registered on the Open Science Framework. Results: Twenty-three studies were included, of which 13 focused on the in-hospital setting and 10 on the post-discharge setting, published between 2013 and 2025, involving 7557 stroke survivors aged 18 to over 75 years, with a mean quality assessment score of 85.33%. Exercise adherence was generally at a medium level in both settings, with a slightly lower adherence index after discharge. During hospitalisation, 34 intrapersonal and five interpersonal factors were identified, while 29 intrapersonal, five interpersonal, and one environmental factor were identified after discharge. Sufficient evidence showed that educational level, functional independence, and self-efficacy were positively associated with exercise adherence across both settings. During hospitalisation, social support was also positively associated with adherence, while age and stroke severity were negatively associated. After discharge, marital status, knowledge, and attitude were positively associated, while time since stroke onset and balance impairment were negatively associated. Conclusions: Previous studies mainly focused on intrapersonal factors, followed by interpersonal factors, while environmental factors received limited attention. Future studies should examine potentially modifiable factors at all three levels and determine whether addressing these factors supports exercise adherence among stroke survivors during hospitalisation and after discharge.

Healthcare doi: 10.3390/healthcare14162474

Authors: Kostadin Kostadinov Victoria Mandova Vanya Rangelova Ani Kevorkyan Ralitsa Raycheva

Background: Human papillomavirus (HPV)-attributable cancers remain largely preventable but continue to generate increasing treatment costs where vaccination and screening coverage are limited. We estimated direct inpatient pharmaceutical reimbursement attributable to HPV-related cancers in Bulgaria and examined the drivers of expenditure growth. Methods: National Health Insurance Fund reimbursement data (2021–2025) were analysed for antineoplastic medicines used to treat eight HPV-associated cancer sites. Site-specific population-attributable fractions (PAFs) were applied to estimate HPV-attributable expenditure. Uncertainty in PAFs was quantified using 10,000 Monte Carlo simulations and discrete attribution scenarios. Expenditure growth was decomposed into price, volume, and net product-entry/exit effects using Fisher indices. Expenditure was additionally expressed in constant 2021 euros using the Harmonised Index of Consumer Prices. Results: Estimated HPV-attributable inpatient pharmaceutical reimbursement totalled EUR 54.2 million (probabilistic median; 95% uncertainty interval: EUR 53.3–55.0 million). Cervical cancer accounted for 81.8% of the total. Results varied by less than ±6% across attribution scenarios and remained EUR 44.6 million when head-and-neck cancers were excluded. Annual expenditure increased from EUR 3.67 million in 2021 to EUR 19.89 million in 2025, representing a 5.4-fold nominal and 4.2-fold inflation-adjusted increase. Growth was concentrated in cervical cancer and was driven primarily by the introduction of new therapies rather than higher prices or greater use of existing medicines. Net product entry explained 88.8% of total log growth, while reimbursement prices for continuing products declined by approximately 31%. Pembrolizumab, first reimbursed for cervical cancer in 2023, accounted for EUR 16.03 million of cervical cancer expenditure in 2025. Conclusions: These ecological estimates indicate a rapid increase in HPV-attributable inpatient pharmaceutical reimbursement in Bulgaria, largely driven by cervical cancer and the introduction of immunotherapy. The findings have implications for budget forecasting, procurement planning, and economic evaluation of HPV prevention strategies.

Healthcare doi: 10.3390/healthcare14162473

Authors: Zbigniew Waśkiewicz

Professional and elite sport represents a high-pressure healthcare environment in which standard principles of patient-centered care, confidentiality, informed consent, shared decision-making, and clinical independence are tested by organizational and performance-related pressures. This narrative review examines reliance management in athlete–physician relationships. Reliance is conceptually distinguished from trust: whereas trust is an interpersonal attitude that can be betrayed, reliance denotes the broader dependence of the athlete-patient on the physician, the care process, and the surrounding governance system—a dependence that may persist even where trust is absent. Reliance management is conceptualized as the deliberate, multi-level design and maintenance of communicative, ethical, and governance conditions under which such reliance is well-placed. A structured, non-systematic literature search of PubMed, Scopus, Web of Science, SPORTDiscus, and Google Scholar, supplemented by backward citation tracking, informed a thematic synthesis organized around three dimensions: clinical ethics, patient-centered care, and governance. The synthesis distinguishes empirical findings, professional consensus guidance, ethical and legal analysis, and illustrative cases, and identifies domains in which evidence remains weak. An integrative conceptual model is proposed that links governance antecedents at the dyadic, clinical, organizational, and system levels to mechanisms of well-placed reliance and to outcomes that require empirical evaluation. Proposed safeguards—independent medical oversight, documented return-to-play pathways, formal data-sharing rules, second-opinion access, and contractual protection of physician autonomy—are intended to protect patient-centered care and patient safety; their effectiveness has, however, rarely been evaluated and should be the object of future intervention research.

Healthcare doi: 10.3390/healthcare14162472

Authors: Rosa Areiza Fermina Vasquez Osorio Leily Montoya-Alvarez Edgar Rodriguez-Sepulveda Lizt Perez Ana Sánchez Pérez Sergey Camilo Echeverri Martínez

Background: Physical inactivity and functional decline are common among institutionalized older adults, increasing the risk of cardiovascular disease and loss of independence. Innovative strategies such as virtual reality-assisted exercise may enhance adherence and improve health outcomes in this population. Methods: A pilot intervention study with a pre-post design was conducted in five institutionalized older adults who participated in a virtual reality-assisted multicomponent exercise program. The intervention included sessions combining strength, aerobics, balance, and flexibility exercises. Anthropometric, cardiovascular, and functional variables were assessed before and after the intervention. Physiological responses were assessed at the beginning of the sessions, midway through the intervention, and at the end of the program, along with participant satisfaction. Results: Preliminary descriptive changes were identified following the intervention, including lower values for body mass, body fat percentage, and systolic blood pressure, together with higher scores in several functional capacity measures, such as lower and upper body strength, aerobic endurance, and mobility. Physiological responses during exercise remained within expected ranges across sessions. All participants reported high satisfaction with the intervention, and no adverse events were documented. Conclusions: A multicomponent exercise program integrating virtual reality appears to be a feasible and well-tolerated intervention for institutionalized older adults. The preliminary descriptive findings suggest potential favorable changes in cardiovascular health and functional capacity; however, because no control group was included, the specific contribution of the virtual reality component cannot be determined.

Healthcare doi: 10.3390/healthcare14162471

Authors: Lianel P. Rosario-Ramos Carolina Quiles-Bengochea Guillermo Laporte-Estela Nashali Rivera Angelique M. Graulau-Burgos Cristina Peña-Vargas Ruthmarie Hernández-Torres Cynthia Cortes-Castro Zindie Rodriguez-Castro Eida M. Castro-Figueroa Normarie Torres-Blasco

Background/Objectives: End-of-life (EOL) preparedness remains critically understudied among Hispanic patients with advanced breast cancer and their patient–caregiver dyads, despite evidence that preparedness significantly influences quality of life, care decisions, and caregiver well-being. This study aimed to explore how Hispanic patient–caregiver dyads conceptualize and experience EOL preparedness. Methods: A qualitative descriptive design was employed, guided by the Dyadic Cancer Outcomes Framework, which highlights patient and caregiver characteristics, relationship processes, individual and relational outcomes, the cancer care trajectory, and the broader social context as interrelated influences on dyadic experience. Semi-structured individual interviews were conducted in Spanish with 11 metastatic patient–caregiver dyads (n = 22 participants) recruited through Ponce Health Sciences University and the Ponce Research Institute in Puerto Rico. Data were analyzed using codebook thematic analysis in NVivo 15, with themes interpreted through the framework’s components. Results: Six interdependent themes of EOL preparedness were identified: psychological and emotional, spiritual, informational, practical, physical, and caregiver role preparedness. Spiritual preparedness, grounded in faith, prayer, and surrender to divine will, functioned as the foundational axis organizing all other themes. Preparedness was dynamic and turning-point-driven, challenged anew at each stage of disease progression. Financial vulnerability, caregiver invisibility within formal care systems, and insufficient anticipatory information were identified as primary barriers. Family support and faith communities were the most consistently cited facilitators. Conclusions: The findings yield the first grounded, dyadic conceptualization of EOL preparedness with Hispanic advanced breast cancer patient–caregiver dyads. We propose a formal definition positioning preparedness as a dynamic, multidimensional, relationally embedded, and spiritually anchored process that is fundamentally interdependent between patient and caregiver. These results directly inform the development of a culturally tailored, dyadic EOL preparedness intervention for this underserved population.

Healthcare doi: 10.3390/healthcare14162469

Authors: Hooyeon Lee Ji Eun Kim Kyungin Lee Dong Jun Kim Kwangmo Yang Kyounga Lee Myung-Il Hahm

Background: In September 2024, South Korea launched a nationwide Tertiary Hospital Restructuring Project to refocus tertiary hospitals on severe, emergency, and rare disease care, amid a tertiary care system long burdened by patient concentration and acutely strained by the mass resignation of trainee doctors. In the early phase of implementation, understanding how the decision-makers who translate policy into institutional change perceive the project is essential. Methods: We employed a qualitative design using reflexive thematic analysis. Semi-structured, in-depth interviews were conducted with directors from five tertiary hospitals—four in the capital area and one in a non-capital area—selected through purposive sampling. Interviews were conducted between 30 October and 7 November 2025, transcribed verbatim, and analyzed following the six-phase approach of Braun and Clarke. Results: Four themes were constructed. First, directors described the project as catalyzing a cultural shift toward a high-severity-centered model, though contested at the departmental level. Second, a severity paradox emerged, in which treating sicker patients worsened profitability while large restructuring costs strained sustainability. Third, referral networks expanded but were constrained by the absence of an integrated information technology (IT) system across the referral network. Fourth, a specialist- and physician assistant (PA)-centered workforce model stabilized care yet remained institutionally unsettled. Participants recommended refined severity criteria, complexity-based reimbursement, a legal framework for PAs, an integrated IT referral system, and network-based training. Conclusions: As perceived by the participating directors, the project reshaped organizational culture and clinical case-mix, but its long-term viability depends on financial, infrastructural, and workforce supports that have not kept pace with structural change. Sustaining the reform will likely require a shift from competition toward a collaborative, region-centered network.

Healthcare doi: 10.3390/healthcare14162470

Authors: Silvana Krnić Ana Jerončić Varja Gaić Ðogaš

Background/Objectives: The mental health of university students is a global public health priority. While pathological narcissism is increasingly recognized as a source of significant psychological suffering, its developmental and somatic correlates remain insufficiently explored. This study examines the sociodemographic, familial, and health-related correlates of pathological narcissism and its association with global psychological distress. Methods: A cross-sectional study was conducted with 888 university students (M = 21.3 years; 78.5% female) recruited from three faculties—Humanities and Social Sciences, Civil Engineering, and Medicine. Participants completed the Pathological Narcissism Inventory (PNI), Brief Symptom Inventory (BSI), and sociodemographic, familial, and health-related characteristics, including trauma exposure. Multivariable linear regressions and hierarchical regression analyses were conducted. Results: Pathological narcissism was robustly and positively associated with global psychological distress (r = 0.636, p < 0.001). Multivariable regression models identified chronic fatigue as the strongest somatic correlate of narcissistic pathology, consistent with an ego-depletion account of self-regulatory failure. Additional significant correlates included trauma history, insomnia, and prior use of psychological services. Students from the Faculty of Humanities and Social Sciences reported significantly higher narcissism scores than medical students. Poorer perceived family relationship quality was associated with higher narcissism scores. The full models accounted for 14.4% to 16.9% of the variance in narcissistic dimensions. Conclusions: These cross-sectional findings suggest that pathological narcissism is not merely a personality trait but a clinically relevant construct deeply intertwined with psychological distress and somatic exhaustion. The strong association between narcissism and chronic fatigue points to a substantial physiological cost of sustained self-regulatory effort. Findings highlight the need for integrated screening protocols in university counseling services that account for somatic symptoms (fatigue, insomnia), traumatic experiences, and family dynamics, alongside efforts to destigmatize help-seeking, given that fewer than 1% of students turn to faculty for support.

Healthcare doi: 10.3390/healthcare14162467

Authors: Esther Ramos-Castellano Teresa Mayordomo-Rodriguez Ivan Chulvi-Medrano Carlos Guillamo-Minguez Pedro Gargallo-Bayo

Background/Objectives: Urinary incontinence (UI) and impaired balance are common geriatric syndromes that negatively affect health and quality of life in older women. However, the combined effects of power-based multicomponent training (PMT), pelvic floor muscle (PFM) activation instructions, and psychoeducational (PSY) support remain unclear. This study aims to evaluate the effects of a PMT, alone or progressively combined with PFM activation instructions and PSY support, on PFM function, UI symptoms, balance, fear of falling, and physical function in community-dwelling older women. Methods: This study describes the protocol for an 18-week, four-arm additive, parallel-group, assessor- and analyst-blinded randomized controlled trial with a 6-month follow-up. A total of 120 women aged 60–80 years with UI will be randomly assigned to four groups: (1) PMT only (EX), (2) PMT plus verbal PFM activation instructions (EXVERB), (3) PMT combined with PFM activation instructions and psychoeducational sessions (EXVERBPSY), or (4) a control group receiving educational sessions on geriatric syndrome prevention. Sessions will be conducted twice weekly for 18 weeks. The single primary endpoint is maximal PFM strength assessed by the manometric perineometry. Pre-specified secondary outcomes include additional PFM function measures, upper- and lower-limb (LL) strength and power, balance performance, fear of falling, quality of life, psychological well-being, and anthropometric variables. Assessments will be conducted at baseline, post-intervention, and 6-month follow-up. The trial is registered at ClinicalTrials.gov (NCT06839040). Expected results: This trial is expected to provide evidence on the effectiveness of a multidisciplinary intervention combining exercise, PFM activation strategies, and PSY support for reducing UI severity and improving balance performance and fear of falling in older women. Conclusions: This protocol describes a four-arm additive randomized controlled trial evaluating a multidisciplinary intervention targeting two highly prevalent and interrelated geriatric syndromes. The study may contribute to the development of more comprehensive exercise-based and PSY interventions for older women and may inform healthcare strategies aimed at promoting healthy ageing and improving the management of UI and fear of falling.

Healthcare doi: 10.3390/healthcare14162468

Authors: Donghai Xu Misaki Matsunaga Masahiro Matsui Kenta Toyama Yibo Gao Koya Suzuki

Background/Objectives: Physical literacy (PL) is increasingly being recognized as an important factor associated with physical activity participation and health outcomes. However, evidence remains limited regarding the association between PL and quality of life (QOL) in adults, particularly the statistical indirect association through moderate-to-vigorous physical activity (MVPA). Therefore, this cross-sectional study aimed to examine the associations among PL, MVPA, and QOL in Japanese adults and to assess the statistical indirect association between PL and QOL through MVPA. Methods: Japanese adults aged 18–64 years were recruited from a commercial online survey panel using age- and sex-quota sampling in 2023. After excluding incomplete or inconsistent responses and participants with missing or incomplete MVPA data, 861 participants were ultimately included. PL, QOL, and MVPA were assessed using the Physical Literacy for Life tool, World Health Organization QOL-26, and International Physical Activity Questionnaire, respectively. Associations among PL, MVPA, and QOL were examined using Pearson’s correlations, multiple linear regression, and mediation analysis with PROCESS macro (Model 4). Results: PL was positively correlated with MVPA (r = 0.257, p < 0.01) and QOL (r = 0.416, p < 0.01); MVPA was positively correlated with QOL (r = 0.248, p < 0.01). PL remained significantly associated with QOL after including MVPA and covariates (β = 0.374, p < 0.01). The statistical indirect association between PL and QOL through MVPA was significant (b = 0.0011, BootSE = 0.0003, 95% bootstrap confidence intervals: 0.0005–0.0018), indicating a modest indirect association through MVPA. Conclusions: PL was positively associated with QOL among Japanese adults, and MVPA partially explained this association in a statistical mediation model.

Healthcare doi: 10.3390/healthcare14162466

Authors: Seeun Choi Junjoeng Hwang Min Sik Choi Su-Jin Kang Kiyon Rhew

Background: Foodborne illness surveillance commonly focuses on reported outbreaks and laboratory-confirmed infections. Nationwide information on foodborne illness-related diagnoses recorded during routine healthcare encounters remains limited in South Korea. This study described the volume and distribution of claims-defined foodborne illness-related episodes and associated diagnostic category records documented in the 2023 HIRA database. Methods: This nationwide retrospective descriptive study used administrative reimbursement claims data from the Health Insurance Review and Assessment Service in 2023. Repeated qualifying encounters for the same patient were grouped into episodes using a 30-day gap rule. For the monthly analysis, each episode was counted once and assigned to the diagnostic category first recorded during the episode; other category-specific analyses used non-mutually exclusive diagnostic category records. Unique episodes were summarized by calendar month, whereas diagnostic category records were summarized by demographic characteristics, selected underlying diseases, healthcare institution type, and region. Results: A total of 6,829,577 unique claims-defined episodes generated 7,754,215 diagnostic category records because an episode could contribute to more than one diagnostic category. Unspecified records accounted for 79.3%, followed by bacterial records (12.1%), viral records (8.6%), and protozoal/other-cause records (<0.1%). Viral and unspecified records were more frequently observed in younger age groups, whereas bacterial records were concentrated among adults aged 19–64 years. Most records were associated with clinic visits (80.3%). Monthly episode counts showed variation, with the highest count observed in July and relatively high counts also observed in January, August, and September. Crude record rates based on healthcare institution location varied across regions. Conclusions: Foodborne illness-related diagnostic records were predominantly unspecified and were most frequently documented in clinics, suggesting limited etiologic specificity in routine diagnostic coding. Claims-based findings may complement existing surveillance but should not be interpreted as confirmed disease incidence or etiologic distribution.

Healthcare doi: 10.3390/healthcare14162465

Authors: Carla Aurelia Stoiacovici Adrian Cosmin Ilie Felicia Marc Silviu Brad Alina Doina Tanase Horia Silviu Branea

Background and objectives: Artificial intelligence (AI) is increasingly embedded in public health workflows, yet adoption among practitioners remains uneven and is shaped by knowledge, legal awareness, and operational barriers. This cross-sectional study characterised determinants of AI adoption among healthcare professionals and examined how legal concern moderates the translation of technical knowledge into practical use, at a single Romanian tertiary academic centre. Methods: We surveyed 93 healthcare professionals (physicians, nurses, public health specialists, residents) at the “Pius Brînzeu” Clinical Emergency County Hospital and “Victor Babeș” University of Medicine and Pharmacy Timișoara. Participants were classified as AI adopters or non-adopters. Likert-derived composite scores (0–100; Cronbach’s α 0.79–0.88) quantified knowledge, trust, legal concern, privacy concern, and workflow confidence. Group comparisons used independent-samples t-tests and χ2 tests; associations used Pearson correlation; predictors of adoption and usage intensity were modelled with logistic and multiple linear regression; a two-way ANOVA tested profession-by-training effects. Significance was set at p < 0.05. Benjamini–Hochberg false-discovery-rate correction was applied across the 18 bivariate tests reported in this study, and adjusted q-values are reported alongside unadjusted p-values. Results: Adopters (n = 51) were younger (34.7 ± 7.5 vs. 43.2 ± 8.5 years; p < 0.001) and reported higher knowledge (67.3 vs. 48.6; p < 0.001) and workflow confidence (64.2 vs. 41.9; p < 0.001) but lower legal concern (58.4 vs. 71.2; p < 0.001). Knowledge correlated positively with usage intensity (r = 0.536; p < 0.001), whereas legal concern correlated negatively (r = −0.426; p < 0.001). In multivariable models, younger age (OR = 0.91; p = 0.004), knowledge (OR = 1.06; p = 0.005), and trust (OR = 1.07; p = 0.005) independently predicted adoption. The linear model explained 46.1% of usage variance. Stratified analysis suggested legal concern attenuated the knowledge–usage slope (β: 0.51→0.18); however, the formal knowledge-by-concern interaction term was not statistically significant (p = 0.191), and this pattern is therefore exploratory. Conclusions: In this modest, single-centre sample, AI adoption was independently associated with knowledge and trust, and legal concern was independently and negatively associated with usage intensity; the apparent dampening of the knowledge–usage relationship by legal concern was suggestive but not statistically confirmed. Targeted legal-regulatory literacy and structured training may support practical AI uptake in public health settings, pending confirmation in larger, multicentre studies.

Healthcare doi: 10.3390/healthcare14162464

Authors: Christina Gkaripi Maria Moutzouri Eirini Grammatopoulou Petros Tatsios Stefanos Karanasios Georgios Krekoukias

Background/Objectives: Osteoarthritis of the hip and/or knee is a major contributor to pain, disability, and reduced quality of life. The aim of this study was to provide preliminary validity and reliability evidence for a Greek adaptation of the Quality Indicators for Physiotherapy Management of Hip and Knee Osteoarthritis (QUIPA) questionnaire. Methods: This cross-sectional methodological study involved cross-cultural adaptation and psychometric evaluation of the Greek QUIPA in 90 adults aged 45–65 years with hip and/or knee osteoarthritis attending private physiotherapy clinics. Participants completed the questionnaire twice, seven days apart. Structural validity was explored using exploratory factor analysis, and exploratory subgroup analyses by age and sex were also conducted. Internal consistency, categorical item-level test–retest reliability, total-score test–retest reliability, and floor/ceiling effects were assessed. Results: Exploratory factor analysis of the initial 18-item pool suggested a three-factor 12-item solution explaining 51.5% of the total variance, with eigenvalues of 3.11, 1.58, and 1.49. Internal consistency was borderline for the total score (Cronbach’s alpha = 0.675) and the first factor (alpha = 0.662), and poor for the second (alpha = 0.424) and third (alpha = 0.598) factors. Item-level observed agreement ranged from 79.7% to 97.8%, with Cohen’s kappa values ranging from 0.580 to 0.887. Total-score test–retest reliability was good (ICC = 0.829, 95% CI = 0.748–0.896), although the total proportion-positive score increased by 5.6 percentage points at retest. Ceiling effects were observed for Q1, Q7, and Q8. Conclusions: The present study provides preliminary validity and reliability evidence for a derived 12-item Greek QUIPA short-form model. However, given the marginal sampling adequacy, low-to-moderate communalities, six-item reduction from the original 18-item questionnaire, categorical item properties, and borderline-to-poor internal consistency of some factors, the findings should be interpreted cautiously. At present, the Greek QUIPA is best interpreted using the total proportion-positive score, whereas factor-level scores should be treated as exploratory. Independent confirmatory factor analysis and further validation in larger and more diverse samples are required.

Healthcare doi: 10.3390/healthcare14162463

Authors: Myong-Won Seo Joon Young Kim

Background/Objectives: A body shape index (ABSI) has been proposed as an anthropometric measure reflecting abdominal body shape beyond body mass index (BMI). However, its relative cross-sectional discriminative ability compared with conventional anthropometric measures and surrogate markers of insulin resistance for prevalent diabetes and cardiovascular disease (CVD) remains poorly characterized in Korean adults. Methods: This cross-sectional study included 11,448 Korean adults aged 18–64 years from the 2019–2021 Korean National Health and Nutrition Examination Survey (KNHANES). Using receiver operating characteristic (ROC) curve analyses, we compared the discriminative ability of ABSI with BMI, waist circumference, waist-to-height ratio, homeostatic model assessment for insulin resistance (HOMA-IR), triglyceride-to-HDL cholesterol ratio (TG/HDL-C), and the triglyceride–glucose index (TyG) for prevalent diabetes and CVD. Multivariable logistic regression analyses assessed associations after adjustment for demographic and socioeconomic factors. Results: ABSI showed the highest ROC-AUC for both prevalent diabetes (74%) and CVD (74%) among the compared indices. In multivariable-adjusted analyses, individuals in the very high ABSI risk group had higher odds of prevalent CVD (OR, 3.75; 95% CI, 1.60–8.78) than those in the very low-risk group. Among individuals with diabetes, the odds of comorbid CVD were also higher in the very high ABSI group (OR, 3.38; 95% CI, 2.26–5.07). Similar patterns appeared in obesity-subgroup analyses. Conclusions: ABSI showed greater discriminative ability for prevalent diabetes and CVD than several conventional measures and insulin-resistance markers, supporting its potential utility as a simple marker of cardiometabolic disease burden. Prospective studies are needed to determine its prognostic value.

Healthcare doi: 10.3390/healthcare14162462

Authors: Se Kwang Oh

Background/Objectives: Foreign body aspiration is a potentially life-threatening emergency that commonly requires bronchoscopic removal. Dental aspiration in elderly patients may occur following trauma, seizures, or altered mental status and can lead to airway obstruction and respiratory complications. We report a rare case of simultaneous airway and esophageal foreign bodies caused by tooth dislodgement after a generalized seizure in an elderly patient. Methods: An 85-year-old man presented to the emergency department with decreased consciousness and recurrent generalized seizures. Chest computed tomography revealed two tooth-like foreign bodies located in the right main bronchus and the mid-esophagus. Endotracheal intubation was performed because of persistent altered mental status, oral bleeding, and retained airway secretions. Although emergency bronchoscopy was considered necessary, it was not immediately available overnight. Repeated endotracheal suctioning was performed while maintaining airway protection and oxygenation. Results: Approximately 12 h later, a tooth-like foreign body was recovered attached to the tip of the suction catheter immediately after withdrawal during routine endotracheal suctioning, suggesting spontaneous proximal migration before its removal. Follow-up imaging confirmed disappearance of the bronchial foreign body, whereas the esophageal foreign body was subsequently removed endoscopically. The patient remained clinically stable without procedure-related complications. Conclusions: This case demonstrates that routine endotracheal suctioning may occasionally facilitate the incidental removal of a small, mobile tracheobronchial foreign body under exceptional circumstances. To our knowledge, reports of aspirated teeth being removed solely by routine endotracheal suctioning without bronchoscopic intervention are extremely rare. However, bronchoscopy remains the standard treatment for tracheobronchial foreign body removal, and suction-assisted removal should be regarded only as an incidental event rather than an alternative therapeutic strategy.

Healthcare doi: 10.3390/healthcare14162461

Authors: Yuichi Murakawa Akira Tamaki Ryota Matsuzawa Shinjiro Miyazaki Koji Fujishima Tatsuma Hori Miki Naide Kenichiro Sakai Tomoya Ishii

Background/Objectives: Trunk muscle mass and quality may be related to swallowing function; however, it is unclear whether the same trend is observed in older patients with pneumonia. We aimed to determine the impact of the mass and quality of the erector spinae muscles (ESM), measured using chest computed tomography (CT), on swallowing function decline during hospitalization. Methods: The participants were patients hospitalized at Sanuki Municipal Hospital with a diagnosis of pneumonia who underwent pulmonary rehabilitation (PR). A total of 450 patients met the eligibility criteria and were included in the analysis. The cross-sectional area of the ESM normalized by body surface area (ESMCSA/BSA) was measured from chest CT images as an indicator of muscle mass, whereas the CT attenuation value of the ESM (ESMCT) was used as an indicator of muscle quality. The primary outcome was the Functional Oral Intake Scale (FOIS) score at discharge. Results: Patients with a FOIS score of 6–7 at discharge exhibited significantly higher ESMCSA/BSA values than those with lower FOIS scores. In ordinal logistic regression analysis, ESMCSA/BSA was independently associated with the FOIS score at discharge (odds ratio, 1.09; 95% confidence interval, 1.03–1.15; p = 0.004). However, this association was no longer significant after adjustment for the Functional Independence Measure score at the start of PR. In contrast, ESMCT, an indicator of muscle quality, was not associated with FOIS score at discharge. Conclusions: In older patients with pneumonia, ESM may reflect overall physical function, which should be considered when interpreting its association with swallowing outcomes.