Healthcare doi: 10.3390/healthcare14091214

Authors: Neslihan Onenli Mungan Leyla Tumer Serap Sivri Nur Arslan Sema Kalkan Ucar Berna Seker Yilmaz Gulden Gokcay

Background: Mucopolysaccharidosis type II (MPS II; Hunter syndrome) is a rare X-linked lysosomal storage disorder caused by pathogenic variants in the iduronate-2-sulfatase gene, leading to progressive multisystem involvement. Although international management guidelines exist, challenges in their implementation across different healthcare systems remain insufficiently addressed. This study aimed to establish a national expert consensus in Türkiye on the treatment and management of MPS II, aligning local practice with international standards. Methods: A modified Delphi methodology was conducted using two rounds of online surveys supported by three steering committee meetings. The process involved 10 experienced clinicians and a scientific committee of six professors. Based on international guidelines and country-specific clinical challenges, 72 consensus statements and 84 exploratory questions were developed. Statements achieving ≥ 80% agreement were accepted as consensus. Results: Consensus supported initiating enzyme replacement therapy (ERT) in both severe and attenuated MPS II, guided by functional and cognitive status. Severe cognitive impairment was not considered an exclusion criterion for ERT, given its somatic benefits. Experts agreed on continuing ERT into adulthood with individualized discontinuation decisions. Routine evaluations every 6–12 months, including respiratory, cardiac, and neurocognitive assessments, were recommended. Additional consensus areas included individualized premedication strategies, structured transition to adult care, selective home infusion, annual patient-reported outcome assessments, and the establishment of a national MPS II registry. Hematopoietic stem cell transplantation was not endorsed. Conclusions: This Delphi study demonstrates strong expert consensus on MPS II management in Türkiye, providing a practical framework to guide clinical practice, support alignment with international recommendations, and inform future policy and research priorities.

Healthcare doi: 10.3390/healthcare14091213

Authors: Mariana Șerban (Grădinaru) Gabriela Isabela Verga (Răuță) Silvia Aura Mateescu Costin Adriana Capăt (Răileanu) Aurel Nechita Dana Tutunaru Simona Claudia Cambrea Mariana Stuparu-Creţu

Background: Respiratory viral infections remain a major cause of morbidity and hospitalization in children. The increased use of multiplex molecular assays has improved the detection of simultaneous viral pathogens, raising questions about the clinical relevance of pediatric viral co-infections. Objective: The aim of this study is to synthesize recent evidence on respiratory viral co-infections in children, focusing on clinical severity, healthcare burden, mechanisms, and interpretation of multiplex detections. Methods: This narrative review included studies published between 1 January 2022 and 30 September 2025, identified through PubMed and Web of Science. Eligible studies involved children and adolescents (0–18 years) with laboratory-confirmed respiratory viral co-infections, mainly detected by multiplex PCR. Evidence was synthesized qualitatively across severity, neutral or inconsistent impact, viral interference, and post-acute implications. Results: Forty-five studies were included. The most frequently reported viruses were respiratory syncytial virus (RSV), rhinovirus, adenovirus, influenza virus, and human metapneumovirus (HMPV). Clinical impact was heterogeneous and depended more on specific viral pairings and host factors than on the number of detected viruses. RSV-containing combinations, particularly with HMPV, adenovirus, or rhinovirus, were more often linked to increased respiratory burden, whereas some rhinovirus-associated combinations appeared compatible with viral interference. Conclusions: Pediatric respiratory viral co-infection is clinically relevant but context-dependent. Multiplex results should be interpreted together with clinical, laboratory, and radiological findings.

Healthcare doi: 10.3390/healthcare14091212

Authors: Cortney VanHook Hyunjin Lee Isaiah Ringo Heather A. Jones

Background/Objectives: Mental health service utilization gaps remain a persistent global public health challenge. Among the 61.5 million adults with any mental illness in the United States, nearly half went without treatment in the past year, and dropout rates from outpatient services among those who do enter care range from 19.7% to 30.8%. Only 30 to 60% of individuals with lifetime mental illness are in active recovery at any given time. Existing theoretical frameworks, including Andersen’s Behavioral Model, the Health Belief Model, and the COM-B framework, each address isolated phases of the care continuum but offer no unified structure for understanding the complete, sequential journey from first contact through sustained recovery. This article introduces the Access, Initiation, Engagement, Retention, and Recovery (AIERR) model to address this theoretical gap. Methods: A conceptual review was conducted following Hulland’s framework for theory development through narrative synthesis. Literature was identified through targeted searches in PubMed, PsycINFO, and Google Scholar, prioritizing peer-reviewed empirical studies, systematic reviews, and foundational theoretical frameworks. Sources were assigned to AIERR stages using predefined decision rules corresponding to each phase’s defining characteristics. Results: AIERR maps five sequential, interconnected stages: Access (structural, cultural, and systemic conditions enabling service reach), Initiation (the transition from provider identification to first appointment attendance), Engagement (active and meaningful treatment participation), Retention (sustained continuity of care), and Recovery (long-term reclamation of life quality and community belonging). For each stage, the framework identifies individual-level and structural-level barriers, facilitating conditions, and targeted intervention points. Conclusions: AIERR advances mental health services theory by unifying previously siloed frameworks, establishing stage-specificity as a core theoretical principle, and reorienting research and intervention strategy toward the upstream structural conditions that produce downstream utilization failures. These theoretical contributions require empirical testing to confirm. Implications for health equity research, clinical practice, and health systems design are discussed.

Healthcare doi: 10.3390/healthcare14091211

Authors: Nikola Stojanović Milica Filipović Vladimir Miletić Biljana Vitošević Tijana Purenović-Ivanović Željko Rajković Jovana Vitošević Katarina Milanović Slavka Durlević Igor Ilić

Background:Outdoor physical activity encompassing structured exercise, recreational activities, and environmentally facilitated movement, during pregnancy may confer benefits through both exercise and exposure to natural environments and sunlight. However, evidence on maternal health outcomes remains heterogeneous and has not been systematically mapped. This scoping review aimed to synthesize research on outdoor physical activity and nature-based environmental exposure during pregnancy, and their associations with maternal metabolic, cardiovascular, and mental health outcomes, as well as pregnancy-related outcomes. Methods: The review followed PRISMA-ScR guidelines. PubMed, Web of Science, Scopus, and Google Scholar were searched for studies published between January 2013 and February 2026. Records were screened against predefined eligibility criteria. Methodological quality was assessed with design-specific tools: PEDro for randomized controlled trials; the Newcastle–Ottawa Scale for cohort and case–control studies; and JBI and CASP checklists for cross-sectional, quasi-experimental, pilot, and qualitative studies. Results: Of 935 identified records, 22 met the eligibility criteria. Outdoor exposure was operationalized through structured outdoor programs (mainly walking-based), self-reported outdoor activity patterns, and environmental indicators such as residential greenness and neighborhood walkability. Outcomes clustered into metabolic and cardiometabolic measures, mental health indicators, pregnancy and birth outcomes, and behavioral or environmental determinants of physical activity. Overall, most studies (17 of 22) reported at least one positive association, with the most consistent evidence for metabolic outcomes and mental health, whereas pregnancy and birth outcomes yielded more heterogeneous results. Conclusions:Outdoor physical activity and supportive natural or built environments may be associated with favorable maternal metabolic and mental health during pregnancy. Nevertheless, heterogeneity in exposure assessment and study design limits comparability and constrains causal inference. Future research should standardize outdoor exposure metrics and apply designs capable of isolating environmental effects from exercise alone.

Healthcare doi: 10.3390/healthcare14091210

Authors: Jungmi Kang

Background/Objectives: Menopausal symptoms may negatively influence health-promoting behaviors in middle-aged women, but the psychological mechanisms underlying this association remain unclear. This study examined whether self-efficacy, self-acceptance, and aging anxiety mediate the relationship between menopausal symptoms and health-promoting behaviors. Methods: A cross-sectional survey was conducted among 114 middle-aged women. Data were analyzed using Pearson’s correlation analysis and a parallel multiple mediation model using Hayes’ PROCESS macro (Model 4) with bootstrapping (5000 resamples). Results: Menopausal symptoms were negatively correlated with self-efficacy, self-acceptance, and health-promoting behaviors and positively correlated with aging anxiety. Menopausal symptoms had a significant total effect on health-promoting behaviors (B = −0.126, p < 0.05), but the direct effect became non-significant after including the mediators (B = −0.006, 95% CI [−0.120, 0.111]). Significant indirect effects were observed through self-efficacy (B = −0.057, 95% CI [−0.121, −0.006]) and self-acceptance (B = −0.040, 95% CI [−0.074, −0.003]), whereas aging anxiety was not significant. The model explained 38.0% of the variance in health-promoting behaviors. Conclusions: The findings suggest that self-efficacy and self-acceptance play important mediating roles in the relationship between menopausal symptoms and health-promoting behaviors, highlighting the importance of psychological resources in the health management of middle-aged women.

Healthcare doi: 10.3390/healthcare14091209

Authors: Christoph Schäfer Nancy Garbe Florian Schmidt Annika Seider Katja Raberger Andreas Wienke Gernot Keyßer

Objective: Systemic lupus erythematosus (SLE) is a complex autoimmune disease, and its diagnosis can cause considerable anxiety and uncertainty for those affected. This study aimed to investigate the effect of a one-day educational seminar on disease-specific knowledge among patients with SLE. Additionally, the influence on subjective needs, the cognitive and emotional impact of the disease, and health-related lifestyle were examined. Methods: Patients were randomly assigned in a 1:1 ratio to an intervention group or a waiting list control group. Both groups attended the seminar. Disease-specific knowledge was measured using a multiple-choice questionnaire. The primary objective was the change in knowledge after the intervention. Results: Thirty-nine participants were included in the analysis. The mean score difference between the waiting list control group and the intervention group was 3.4 points out of a maximum of 20 (95% CI 1.8 to 5) immediately after the seminar and 1.6 (95% CI −0.6 to 3.5) three months later. Pooled data from both groups showed an increase in SLE-specific knowledge from 13.7 points to 17.3 points. Three months later, SLE-specific knowledge remained above the initial value at 15.4 points. However, no influence on lifestyle was observed. Conclusion: A one-day seminar can increase disease-specific knowledge and reduce unmet informational needs but does not lead to lifestyle modifications.

Healthcare doi: 10.3390/healthcare14091208

Authors: Xinyi Min Haru Kaneko Takeshi Takahama Yuka Shono Yuji Tanaka Sozo Inoue

Background: Job satisfaction remains a persistent concern in care facilities, where frontline caregivers work in highly relational and emotionally demanding environments. Although both personality traits and psychological safety have been associated with job satisfaction, their relative contributions and potential interrelationships in routine care settings remain unclear. Methods: Drawing on organizational and psychological theory, we hypothesized a priori that personality traits, psychological safety, and job satisfaction would be statistically associated, with psychological safety mediating the relationship between personality traits and job satisfaction. A cross-sectional questionnaire survey was conducted in care facilities, and the final analytical sample consisted of 183 frontline caregivers selected according to predefined inclusion criteria. Structural equation modeling (SEM) was used to test the hypothesized mediation model. Group comparison analyses examined differences in psychological safety across levels of job satisfaction. In addition, machine learning models were applied to explore predictive patterns among personality traits, psychological safety, and job satisfaction. Results: In the SEM analyses, psychological safety was significantly associated with job satisfaction (β = 0.207, p < 0.05), although the effect size was modest. Personality traits did not show direct associations with job satisfaction. Instead, agreeableness (β = 0.232, p < 0.01) and neuroticism (β = −0.235, p < 0.01) were associated with psychological safety, which, in turn, was related to job satisfaction. Bootstrap resampling supported the presence of significant indirect associations. At the item level, communication-related aspects of psychological safety were particularly salient. Caregivers with different levels of job satisfaction differed most clearly in communication-related items. Consistent with this pattern, exploratory machine learning analyses (XGBoost) also identified psychological safety as a more important predictor of job satisfaction than personality traits. Conclusions: These findings suggest that, among frontline caregivers working in healthcare facilities, psychological safety was more closely associated with job satisfaction than individual personality traits. In particular, the ability to speak openly and raise concerns was more strongly associated with higher levels of job satisfaction within this care context. Personality traits were associated with job satisfaction primarily through their relationship with psychological safety rather than through direct associations .

Healthcare doi: 10.3390/healthcare14091207

Authors: Ehab Ahmed Mohamed Raafat Atteya Hisham Mohamed Hussein Rania Youssef Rehab Ismail Saud Alrawaili Enas Abutaleb Mohamed Eldesoky

Background: Chronic nonspecific low back pain (CNLBP) with lumbar hyperlordosis leads to pain, dysfunction, and poor quality of life. Virtual reality (VR)-based training may enhance exercise engagement and outcomes. This study compared VR-based pelvic rocking training with conventional pelvic rocking training exercises. Methods: A triple-blind randomized controlled trial enrolled 100 participants with CNLBP and hyperlordosis, who were randomly allocated into two groups: the group, which performed pelvic rocking exercises using the TBed VR system (TbG), and the conventional group (CG), which performed the same exercises without VR. Both groups completed three sessions per week for eight weeks. Primary outcomes included pain (Numerical Pain Rating Scale, NPRS), lumbar lordotic angle (LLA), lumbar range of motion (ROM), and functional disability (Oswestry Disability Index, ODI). Secondary outcomes were patient satisfaction and commitment to exercise sessions. Assessments were conducted at baseline, immediately post-intervention, and after a one-month follow-up. Results: Both groups showed significant improvements in all outcome measures post-treatment (p < 0.016). Furthermore, some outcomes—specifically pain, LLA, and extension ROM—continued to improve during the follow-up period. The TbG demonstrated significantly greater reductions in pain, greater ROM improvements, greater functional gains, and higher levels of satisfaction and commitment than the CG (p < 0.05). These between-group differences persisted at the one-month follow-up, particularly for pain and ROM, which remained statistically significantly better in the TbG. Moreover, all between-group differences demonstrated medium to high clinical effects (d ≥ 0.3). Conclusions: Pelvic rocking exercises using the TBed VR system were superior to conventional exercises in terms of pain, ROM, and function at the immediate and intermediate time points. Using TBed led to better patient satisfaction and higher exercise commitment.

Healthcare doi: 10.3390/healthcare14091206

Authors: Melike Yüce Aktepe Özlem Çakın Özlem Esra Yıldırım Çağlayan Merve Ayaz Ceylan Hakan Çakın

Background: Clinical deterioration is common among patients hospitalized in Internal Medicine wards and frequently results in the need for Intensive Care Unit (ICU) admission. Limited ICU bed capacity may lead to delays or interhospital transfers, potentially affecting outcomes. This study evaluated the association between ICU follow-up location and mortality, and its relationship with organizational processes. Methods: In this prospective cohort study, adult patients (≥18 years) requiring ICU consultation between March 2024 and February 2025 were consecutively enrolled. Demographic characteristics, comorbidities, ICU indications, waiting times, mortality, and ICU type were recorded. Patients were categorized into three groups: Internal Medicine ICU, Anesthesiology ICU, and external ICU. The primary endpoint was overall ICU mortality. Multivariable logistic regression was performed to identify independent predictors. Results: A total of 331 patients were included (median age 64 years; 59.2% male). Of these, 34.7% were admitted to the Internal Medicine ICU and 24.5% to the Anesthesiology ICU, and 40.8% were transferred externally. Seven-day, 14-day, and overall ICU mortality were significantly higher in the external ICU group (all p < 0.001). External ICU transfer was independently associated with mortality (OR 3.26; 95% CI 1.70–6.26; p < 0.001), along with pre-ICU intubation and sepsis. Conclusions: Mortality is high among deteriorating Internal Medicine patients requiring ICU care. External ICU transfer is strongly associated with increased mortality, highlighting the potential relevance of ICU accessibility and continuity of care.

Healthcare doi: 10.3390/healthcare14091205

Authors: David G. Figueroa Monica Chen Matthew Phillipi Jordan E. Parker Jeffrey M. Hunger A. Janet Tomiyama

Background/Objectives: Classism, or discrimination based on social class, is associated with higher levels of depression and anxiety symptoms. However, limited research has examined the psychological processes that may help explain these associations. The present study tested whether perceived stress statistically mediated the associations between experienced and anticipated classism and mental health symptoms. Methods: A U.S. census-matched sample on age, gender, race/ethnicity, income, and census region (n = 1993) was analyzed. Missing data were addressed using Bayesian multiple imputation, and mediation models estimated total, direct, and indirect effects. Results: Results indicated that perceived stress statistically accounted for the associations between both experienced and anticipated classism and higher depression and anxiety symptoms, even after adjusting for income and education. In exploratory analyses, individuals living at or below the federal poverty line reported a higher likelihood of experiencing classism, and perceived stress significantly mediated the association between experienced classism and mental health symptoms within this population. Conclusions: These findings provide preliminary evidence that perceived stress is a statistical mediator of the association between classism and mental health symptoms. Future prospective and experimental work is required to establish potential causal relationships between the constructs.

Healthcare doi: 10.3390/healthcare14091204

Authors: Laura Ioana Bondar Roland Fazakas Cris Virgiliu Precup Denis Bogdan Butari Florin Mihai Șandor Ana-Liana Bouroș-Tataru Elisaveta Ligia Piroș Mariana Adelina Mariș Liviu Gavrila-Ardelean Florin Cornel Dumiter

Background/Objectives: Psychiatric inpatient care varies substantially in its clinical goals, resource demands, and financial implications. Acute units focus on short-term crisis stabilization, whereas chronic units provide prolonged supervision for patients with persistent functional impairment. Limited evidence exists from Eastern Europe on how these differing service models impact both hospital costs and clinical outcomes such as early rehospitalization. This study aimed to compare the economic and operational performance of Acute versus Chronic Psychiatry and to identify predictors of 30-day readmission following acute psychiatric hospitalization. Methods: This retrospective observational study analyzed routinely collected data from a Romanian public hospital. All adult admissions to Acute and Chronic Psychiatry recorded between 1 January 2024 and 31 December 2024 were included. Standardized financial indicators were derived from administrative data, while clinical variables and readmission outcomes were extracted from electronic medical records. Between-group comparisons of economic and operational indicators were performed using t-tests. Multivariable logistic regression was used to determine independent predictors of 30-day readmission in Acute Psychiatry, reporting adjusted odds ratios (aOR) with 95% confidence intervals (CI). Model performance was evaluated with area under the curve (AUC), Hosmer–Lemeshow tests, and Nagelkerke R2. Results: Acute Psychiatry demonstrated significantly higher mean cost per bed-day (798.76 vs. 373.75 lei; p < 0.001), but a lower mean cost per patient due to shorter hospitalization (10.17 vs. 53.32 days). A total of 188 acute patients (13.7%) were readmitted within 30 days. No early readmissions occurred in Chronic Psychiatry, consistent with its long-stay care model. Independent predictors of readmission included psychotic disorder diagnosis (aOR = 1.62, 95% CI: 1.18–2.23), multiple prior admissions (aOR = 1.35, 95% CI: 1.18–1.54), shorter length of stay (LOS) (aOR = 0.88 per 5-day increase, p = 0.006), and absence of a post-discharge plan (aOR = 0.54, 95% CI: 0.39–0.76). Model discrimination was acceptable (AUC = 0.74). Conclusions: Acute and chronic psychiatric services differ markedly in cost structures and care pathways. Early rehospitalization is a clinically relevant outcome within acute psychiatric care and is influenced by both patient-level and continuity-of-care factors. Enhancing discharge coordination, expanding continuity-of-care strategies, and optimizing resource allocation toward community-based support may reduce early rehospitalizations while improving hospital cost-efficiency.

Healthcare doi: 10.3390/healthcare14091203

Authors: Floris Cristian Stanculea Claudiu O. Ungureanu Octav Ginghina Razvan A. Stoica Raul Mihailov Valerii Lutenco Valentin T. Grigorean Mircea Litescu Niculae Iordache

Background/Objectives: Quality of life (QoL) and functional recovery are essential outcomes in patients undergoing rectal cancer surgery. In addition to oncological results, bowel dysfunction and stoma-related issues may significantly affect postoperative well-being. We aimed to evaluate QoL changes at 1 and 6 months postoperatively and functional outcomes in rectal cancer patients who underwent curative surgical treatment, sphincter-preserving surgeries (SPS) or abdominoperineal resection (APR). Owing to its impact on QoL, several functions were assessed using the Low Anterior Resection Syndrome (LARS) score. Methods: This retrospective observational study consisted of 99 patients who underwent curative rectal cancer surgery, of which 38 patients had colostomy, and 61 no colostomy. To assess patient-reported outcomes related to QoL, the EORTC QLQ-C30 questionnaire, QLQ-CR29 questionnaire, and LARS instrument were sent to the patients at 1 and 6 months postoperatively. Changes over time were analyzed using paired statistical tests, and subgroup analyses were performed according to colostomy status and surgical approach. Results: Significant improvements were observed in the global health status and all major functional domains between 1 and 6 months postoperatively. The global health status increased from 74.9% to 86.5% (p < 0.001). Symptom burden decreased significantly, particularly for fatigue (−18.31), pain (−14.48), diarrhea (−12.46), and insomnia (−11.45), representing clinically meaningful improvements. Patients who underwent abdominoperineal resection or resection with colostomy had lower QoL scores at 1 month but showed substantial improvement at 6 months, becoming comparable to those who underwent SPS. LARS outcomes demonstrated progressive functional recovery, with the proportion of patients without LARS increasing from 39 to 46, while major LARS decreased from 7 to 3 patients. However, approximately 40% of patients in the SPS group continued to report moderate-to-severe LARS symptoms. Conclusions: In this study, QoL and bowel function improved significantly during the first 6 months after colorectal cancer surgery. Although most patients demonstrated recovery, persistent bowel dysfunction and stoma-related challenges remain important issues. These findings highlight the need for comprehensive postoperative care and routine assessment of both QoL and functional outcomes.

Healthcare doi: 10.3390/healthcare14091202

Authors: Junko Ochi Noriyuki Kida

Background/Objectives: Attitudes toward health conditions involving physical dysfunction may differ between healthcare professionals (HCPs) and the general public. This study compared affective responses to stroke, femoral neck fracture (FNF), and spinal cord injury (SCI) across both groups within a unified framework. Methods: We conducted an online cross-sectional survey of 400 members of the general public (stratified by age and gender) and 400 HCPs representing 18 professions. Affective responses were measured using scales assessing negative affect, interpersonal avoidance, and impressions (physical strength, mental resilience, and mental strength). A 2 × 3 mixed-model ANOVA (group × condition) and correlation analyses were conducted. Results: Negative affect showed a significant group × condition interaction (p < 0.001, ηp2 = 0.030). HCPs scored lower than the general public for stroke and FNF, with no significant difference for SCI. HCPs also reported lower interpersonal avoidance across all conditions. Impression scales showed no interaction; however, HCPs rated higher physical strength and mental strength, while mental resilience showed no group difference. Condition effects were significant, with a consistent hierarchy of SCI > stroke > FNF for both negative affect and interpersonal avoidance. Negative affect and interpersonal avoidance were moderately correlated in both groups. Among HCPs, FNF-related interpersonal avoidance negatively correlated with years of clinical experience. Conclusions: HCPs generally report less negative affect and interpersonal avoidance and hold more positive perceptions of patient capability than the general public. However, both groups share a negativity hierarchy across conditions, suggesting persistent perceptions associated with specific health labels.

Healthcare doi: 10.3390/healthcare14091201

Authors: Maryam Abdulrahman Almoosa Alnuaimi Syed Arman Rabbani Khulood Ebrahim Ali Alnaeimi Khalid Abdulaziz Abu Obaid Syed Sikandar Shah Mohamed El-Tanani Aftab Alam

Background: Osteoporosis is a chronic bone disease characterized by reduced bone mass and structural deterioration, increasing fracture risk and affecting patients’ quality of life (QoL). Pharmacological treatments are essential in managing osteoporosis; however, suboptimal prescribing patterns and poor medication adherence can limit therapeutic outcomes. This study primarily aimed to assess medication adherence among patients with osteoporosis using the MMAS-8, as well as prescribing patterns and patient beliefs. Methods: We conducted a single-center cross-sectional observational study at Saqr Hospital, Ras al Khaimah, UAE, between October 2024 and May 2025, enrolling 300 adults with clinically diagnosed osteoporosis and/or a bone mineral density T-score ≤ −2.5. Data were collected through structured interviews and medical-record review. Medication adherence was assessed using the 8-item Morisky Medication Adherence Scale (MMAS-8), and beliefs about medicines were measured using the Beliefs about Medicines Questionnaire (BMQ). Prescribing patterns were characterized by drug class, dose, and frequency, and prescribing appropriateness was evaluated using prescribed daily dose/defined daily dose (PDD/DDD) ratios based on WHO ATC/DDD standards. Predictors of adherence were examined using univariate and multivariable Firth penalized logistic regression. Results: The median age was 70 years (IQR 63–76), 89.0% of participants were female, and 32.0% had a prior fracture history. Denosumab was the most frequently prescribed anti-osteoporotic therapy (59.0%), followed by romosozumab (30.7%), whereas bisphosphonates and parathyroid hormone analogues were infrequently used (2.7% and 4.7%, respectively). Prescribed dosing closely aligned with WHO standards for all evaluated agents. Overall, 40.7% of patients were classified as adherent and 59.3% as non-adherent. Adherence was not significantly associated with age, gender, nationality, fracture history, polypharmacy, or most comorbidities. In contrast, medication beliefs demonstrated a strong relationship with adherence. In multivariable Firth regression, stronger medication concerns were independently associated with lower odds of adherence (adjusted OR 0.033, 95% CI 0.003–0.355; p = 0.0049), while having more than two comorbidities was also associated with reduced adherence (adjusted OR 0.076, 95% CI 0.008–0.688; p = 0.022). Conclusions: In this UAE real-world cohort, osteoporosis pharmacotherapy was dominated by injectable biologic agents and was prescribed in close agreement with standard dosing recommendations. However, medication adherence remained suboptimal. Patient beliefs, particularly treatment-related concerns, emerged as a more important determinant of adherence than demographic or most clinical characteristics. These findings highlight the need for belief-sensitive, patient-centered adherence interventions alongside optimized pharmacotherapy to improve osteoporosis outcomes in routine practice.

Healthcare doi: 10.3390/healthcare14091192

Authors: Mario Scheurer Philip Haller Johannes Schulze Stefan Kist Robin Kasper Lukas Greber Alisa Schramm Majeed Rana Alexander Schramm Stefan Repky Andreas Sakkas Marcel Ebeling Frank Wilde

Background/Objectives: Patient satisfaction and supportive care are key quality indicators in certified Head and Neck Cancer Centers (HNCC). We assessed patient-reported experiences across diagnostic staging and surgical treatment pathways, focusing on discharge management and supportive service integration. Materials and Methods: In this prospective cross-sectional study, 84 inpatients were surveyed at the time of hospital discharge after diagnostic tumor staging (n = 45) or surgical treatment (n = 39) at a German tertiary HNCC. Phase-specific standardized questionnaires with five-point Likert scales were analyzed using Pearson’s chi-square and Fisher’s exact tests. Associations of sex and treatment intensity with satisfaction and supportive care utilization were explored descriptively and in an exploratory manner. Results: Overall ratings were high across both cohorts for admission processes, inpatient organization and medical and nursing care, with no statistically significant between-group differences (p > 0.05). Information regarding diagnostic and perioperative procedures was rated very positively in both groups. Discharge-related items were generally favorable. However, patients who underwent surgery reported greater uncertainty and lower reported utilization of formal discharge management. This difference did not reach statistical significance (p = 0.0559) and should therefore be interpreted as a non-significant trend toward less positive evaluation compared with diagnostic patients. Supportive services were rated predominantly good to very good by users (>95% positive ratings). Utilization differed by treatment intensity: Speech therapy was more frequent in operative patients (p < 0.001) and social work counseling was offered and utilized more often in patients undergoing extensive surgery (p = 0.042 and p = 0.027, respectively). Overall dissatisfaction was strongly associated with perceived deficiencies in information on diagnostic procedures and tumor-related counseling (both p < 0.001), whereas waiting time for surgery was not associated with negative overall ratings. Conclusions: Patient satisfaction was consistently high across diagnostic and surgical pathways. Adequate, transparent and repeated information, particularly on diagnostics and tumor counseling, was strongly associated with higher overall satisfaction, whereas objective timing metrics were not associated with negative ratings. Discharge management may represent a sensitive transition point, particularly after extensive surgery and may therefore be a relevant target for further optimization and proactive integration of supportive care services. Sex-specific findings were limited and should be interpreted cautiously due to small subgroup sizes.

Healthcare doi: 10.3390/healthcare14091200

Authors: Sonya Moore Teale Vella Jessica Norton Kai Lin Foong Mitchell Barbara Chris Musgrave Kuan-Yin Lin Jennifer R. A. Jones

Background/Objectives: Acute health impacts and longer-term sequelae of sport-related concussion (SRC) are recognized concerns in football (soccer), warranting investigation of interventions to reduce the incidence. The purpose of this study was to identify, synthesize and evaluate interventions used in preventing sport-related concussion (SRC) in adult soccer players. Methods: Five databases (MEDLINE, CINAHL, Embase, SPORTDiscus, PsycINFO) were searched on 6 September 2024 and updated on 17 December 2025 for concussion prevention intervention studies involving adult footballers. Study quality was assessed with the Modified Downs and Black Checklist. A narrative synthesis of all included studies followed Synthesis Without Meta-Analysis (SWiM) guidelines. Results: From 3463 records, five studies met inclusion criteria: three reported rule changes and two reported head-neck training interventions. The low volume of studies discovered were non-randomized and rated fair or poor on quality assessment. Whilst these interventions were grounded in sound and well-reasoned mechanisms to mitigate SRC risks, none reported statistically significant directional effects. This, combined with high heterogeneity, prevented data pooling and no firm conclusions could be drawn about the effectiveness of any intervention. Conclusions: Sparce, preliminary, heterogeneous evidence represents research to reduce SRC in adult soccer players, and this is limited to investigating rule changes and head-neck training and interventions. A larger volume of primary research is needed to determine meaningful practice recommendations of these and other conceivable interventions.

Healthcare doi: 10.3390/healthcare14091199

Authors: Oğuzhan Çiçek Burak Keklikçioğlu Hakan Uslu İsmail Akçay Ziya Çay Osman Çiloğlu Fırat Seyfettinoğlu Evren Karaali

Background: Implant-related mechanical failure remains a clinically relevant concern following posterior decompression and fusion in elderly patients with lumbar spinal stenosis (LSS). The relative contribution of host-related versus construct-related factors to failure risk requires further clarification. Methods: This retrospective single-center cohort study included 118 patients aged ≥65 years who underwent single-level hemilaminectomy with posterolateral fusion (PLF) for isolated L4–5 central LSS, with a minimum follow-up of 48 months (mean 51.0 ± 2.0 months). All procedures were performed using a standardized posterior technique with uniform 6.5-mm titanium rods and 6.5-mm pedicle screws. Mechanical failure was defined as revision surgery due to radiographically and clinically confirmed hardware-related complications in the absence of infection. Exploratory univariable analyses were conducted to evaluate associations between baseline variables and mechanical failure. Clinical outcomes were assessed using validated patient-reported outcome measures. The Oswestry Disability Index (ODI), Roland Morris Disability Questionnaire (RMDQ), and Visual Analog Scale (VAS) for pain were recorded. Results: Overall revision rate was 13.6% (16/118), including 14 cases (11.9%) of implant-related mechanical failure and 2 cases (1.7%) of infection-related revision. Higher age (p = 0.005), higher body mass index (BMI) (p = 0.005), lower bone mineral density (BMD) (p < 0.001), active smoking (p < 0.001), and diabetes mellitus (DM) (p = 0.023) were significantly associated with mechanical failure. Functional outcomes (ODI, RMDQ, VAS) improved significantly at final follow-up (all p < 0.001). Conclusions: Mechanical failure following hemilaminectomy with PLF appears to be predominantly influenced by host-related factors rather than construct characteristics when a standardized surgical technique is applied. Bone quality and modifiable systemic risk factors may play a critical role in long-term construct durability.

Healthcare doi: 10.3390/healthcare14091197

Authors: Yaolong Xu Jiaxin Zhao Ligang Yang

Objectives: Educational attainment appears to be associated with non-alcoholic fatty liver disease (NAFLD). The inconsistent findings across existing studies necessitate a thorough meta-analysis to elucidate this association. Methods: A systematic search of PubMed, Web of Science, and Scopus was conducted from inception to 31 December 2024, without language restrictions. Data were analyzed using Review Manager 5.4, with pooled odds ratios (ORs) and 95% confidence intervals (CIs) estimated via appropriate models. Results: 27 studies involving 446,312 participants (93,116 NAFLD; 353,196 healthy individuals) were included. Noteworthy heterogeneity was detected, with I2 = 96% for more-than-high-school and I2 = 95% for high-school-education when we pooled all the studies together. Further subgroup analyses suggested that higher education was inversely associated with NAFLD risk in some developed countries, like the United States, while potential gender-specific effects were found among the Chinese population. Conclusions: The current meta-analysis suggests that the association between educational attainment and NAFLD is complex and context-dependent, and it may vary across different countries and types of sex.

Healthcare doi: 10.3390/healthcare14091198

Authors: Shu Fen Wu Hong Yi Tung Yu Rong Hsu Shih Ting Lo Tien Chou Soong

Background: Metabolic bariatric surgery (MBS) yields significant but heterogeneous recovery patterns. The longitudinal interplay between evolving eating behaviors and health-related quality of life (HRQoL) remains insufficiently characterized. Objectives: To identify trajectories of eating behavior and HRQoL during the first postoperative year and examine their associations with 12-month outcomes. Methods: A total of 244 patients from two hospitals in Taiwan were followed for 12 months. Dutch Eating Behavior Questionnaire, and Impact of Weight on Quality of Life-Lite were assessed. Group-based trajectory modeling (GBTM) identified latent subgroups, and multiple regression analyzed associations with 12-month HRQoL, adjusting for clinical covariates. Results: GBTM identified two distinct trajectories for restrained, emotional, and external eating. For HRQoL, three trajectories emerged: high-start stable (45–50%), moderate-decline (30–35%), and low-start improving (~20%). In the regression model (R2 = 0.37, p < 0.001), eating behavior trajectories were not independently associated with total HRQoL at 12 months after adjusting for covariates, including baseline BMI and comorbidities. Specifically, restrained eating (β = −1.42, p = 0.502), emotional eating (β = −10.33, p = 0.110), and external eating (β = −5.33, p = 0.160) trajectories did not significantly predict global HRQoL scores. Conclusions: Postoperative adaptation is characterized by substantial heterogeneity, with a significant subgroup experiencing HRQoL decline despite surgery. While eating behavior trajectories align with domain-specific psychosocial trends, early postoperative clinical factors appear to exert a more dominant influence on total HRQoL during the first year. These findings suggest that multidisciplinary support should target specific vulnerable trajectories to optimize long-term outcomes.

Healthcare doi: 10.3390/healthcare14091196

Authors: Marina S. Cunha Sara Videira Matilde A. Rodrigues João Martins Manuela V. da Silva

Introduction: The increasing use of fluoroscopy-guided procedures raises concerns about occupational radiation exposure, underscoring the need for effective radiation protection (RP) practices among healthcare professionals. The primary objective was to evaluate compliance with the use of personal protective equipment (PPE) and dosimeters, and to identify factors influencing safety behaviors among exposed workers. Methods: A cross-sectional, exploratory quantitative study was conducted at a hospital centre using a self-administered questionnaire in fluoroscopy-guided operating and interventional settings. The questionnaire collected sociodemographic and professional data, information on RP training, compliance with personal and collective protective equipment, and dosimeter use, as well as perceptions of occupational risk. Results: The study included 52 workers. Compliance with PPE use varied across professions, with radiographers reporting significantly higher use of lead aprons/skirt-coats and thyroid shields than other professionals (p < 0.05). The RP training was significantly associated with compliance with PPE and dosimeter use (odds ratios: 4.2–8.9). Older age groups reported lower compliance with PPE use. Overall, risk perception of radiation-related diseases was low (46.2%), and no statistically significant association was found between risk perception and reported PPE use. Regarding protection practices, 67% reported appropriate use of the apron/skirt-coat, 65% of the thyroid shield, and 62% of the dosimeter. The main barriers to PPE use were discomfort, weight, and inadequate cleaning, while forgetfulness was the most reported reason for not using the dosimeter. Conclusions: Inconsistent use of protective equipment and dosimeters may lead to unnecessary exposure and underestimation of occupational radiation doses, whereas RP training is a key determinant of compliance and a strong safety culture.

Healthcare doi: 10.3390/healthcare14091195

Authors: Salma Elhag Lama Althagafi Shroog Almouabdi

Background: Hospital appointment systems suffer from extended patient waits, manual interventions, and suboptimal resource allocation, reducing satisfaction and efficiency. Methods: This study develops IPAS using Business Process Analysis (BPA), Bizagi modeling for As-Is/To-Be workflows, SWOT analysis, TQM, and Six Sigma DMAIC. It integrates ML/NLP with BioBERT-BiLSTM triage (AUC 0.92, F1 0.87) for symptom analysis, specialist matching, and automated booking, validated via Bizagi simulations. Results: Simulations show booking time was reduced 96.3% (155 to 5.73 min) and human intervention was cut 70%, with enhanced patient satisfaction and process capability. Conclusions: IPAS demonstrates simulation-based gains in scheduling efficiency, pending real-world validation.

Healthcare doi: 10.3390/healthcare14091193

Authors: Alexandru Marius Petrusan Catalin Vladut Ionut Feier Calin Muntean Vasile Gaborean Andrei Stefan Petrusan Delia Nicoara Emil Marius Puscas Ioan Paul Tiberiu Puia Andrei Pasca Patriciu Achimaș-Cadariu

Background/Objectives: High-grade serous ovarian carcinoma (HGSOC) is associated with high relapse rates despite aggressive multimodal treatment. BRCA mutations, present in a substantial subset of patients, confer homologous recombination deficiency and increased sensitivity to platinum-based chemotherapy. This study evaluated the association between BRCA mutation status and clinical outcomes, focusing on dissemination patterns, treatment allocation, perioperative parameters, and progression-free survival (PFS). Methods: This prospective single-center cohort included 133 consecutive patients with newly diagnosed HGSOC treated between January 2020 and December 2025. Primary treatment strategy (primary debulking surgery [PDS] or neoadjuvant chemotherapy [NACT]) was determined by multidisciplinary assessment. BRCA testing was performed using tumor tissue or germline analysis. Patients were followed for 24 months. PFS was analyzed using Kaplan–Meier estimates and Cox regression models. Results: Pathogenic BRCA mutations were identified in 39.1% of patients. BRCA-mutated tumors demonstrated significantly lower rates of peritoneal carcinomatosis (50% vs. 77.77%, p = 0.001) and were more frequently managed with PDS (59.6% vs. 41.8%, p = 0.048). Perioperative outcomes were comparable between groups. Disease progression occurred less frequently in BRCA-mutated patients (32.69% vs. 51.85%, p = 0.017). In univariate analysis, BRCA mutation was associated with a 48% reduction in progression risk (HR 0.52, 95% CI 0.27–0.99, p = 0.048). After adjustment for age, FIGO stage, and residual disease, BRCA mutation was not independently associated with progression (HR 0.57, p = 0.124), although a protective trend was observed, while residual disease remained a significant predictor. Conclusions: In this prospective cohort, BRCA mutation status was associated with distinct dissemination patterns and a significant reduction in progression risk in HGSOC. Although residual disease remained the strongest independent prognostic factor after multivariable adjustment, a trend toward improved PFS observed among BRCA-mutated patients supports the role of homologous recombination deficiency as a meaningful modifier of disease trajectory. These findings reinforce the clinical relevance of molecular stratification in the contemporary management of HGSOC.

Healthcare doi: 10.3390/healthcare14091194

Authors: Nayla M. Khoury Maureen Ryan Jessica Hoff Melissa Dhundale Eric MacMaster Ryan D. Heath

Background: Youth mental health needs are critically undertreated. Access and engagement remain challenging, particularly for disadvantaged youth, due to barriers such as limited clinic hours, insurance, transportation, bias, and stigma. School-focused collaborative approaches may reduce mental health care inequities. In this study, we illustrate a pilot intervention by process documentation, participant feedback, and two case studies. Method: To address local service gaps, a virtual collaborative care process was piloted with a child and adolescent psychiatrist (CAP) and psychologist from Project TEACH, a New York State Office of Mental Health funded Child Psychiatry Access Program (CPAP), primary care representatives, and multiple school mental health teams. Demographic data, participant feedback and the collaborative process is reviewed with two case studies created to highlight the collaborative process. Results: Most participants report utility and felt supported. The majority also report a positive impact on communication and collaboration between teams serving students; challenges with family follow up persist. Streamlined communication and consent was helpful. Demographic data suggests that this model can help reach disadvantaged youth. Conclusions: School-focused collaborative mental health requires regular communication and coordination between youth-serving providers. This pilot implementation study shows promise for reaching disadvantaged youth and providing multidisciplinary support.

Healthcare doi: 10.3390/healthcare14091191

Authors: Abdulmajeed M. Alenezi Mahmoud Sameh Meshal Aljohani Hosam Alharbi

Background/Objective: Emergency Departments (EDs) face persistent challenges with overcrowding, unpredictable patient arrivals, and difficulty forecasting short-term demand. Precise hourly arrival predictions are crucial for effective staffing, optimal resource management, and minimizing entry delays. Methods: This paper develops and evaluates a forecasting framework comparing six approaches (a Seasonal Naive baseline, Exponential Smoothing (ETS), Ridge Regression, LightGBM, a hybrid Temporal Convolutional Network (TCN), and a hybrid Long Short-Term Memory (LSTM) network) using de-identified hourly patient arrival records from an ED in Madinah, Saudi Arabia, covering January–November 2024. A set of 183 engineered features is constructed from cyclical time encodings, weekend and public-holiday indicators, structured autoregressive lags, and volatility measures, with all lag-based features verified to use strictly retrospective information. Models are optimized using Bayesian hyperparameter search and trained under an asymmetric loss function that penalizes underprediction to reflect operational risk. Results: Results on a 14-day hold-out test set show that Ridge Regression achieves the lowest MAE (3.75, R2 = 0.52), with TCN and LSTM essentially tied (MAE 3.80 and 3.85). Diebold–Mariano tests confirm that Ridge, TCN, and LSTM are statistically indistinguishable from one another and that Ridge is marginally significantly better than LightGBM (p=0.028); all four ML models significantly outperform ETS and the Seasonal Naive baseline (p<0.001). On the asymmetric metric, TCN achieves the best AsymRMSE (5.59), reflecting its tendency to err on the safe side of staffing decisions. Robustness is confirmed through sensitivity analysis across penalty factors, feature ablation demonstrating the contribution of each feature group without overfitting, expanding-window cross-validation across three independent monthly test periods, and conformal prediction intervals achieving well-calibrated coverage. Conclusions: These results demonstrate that combining engineered temporal features with either a lightweight linear model or a hybrid sequence model yields accurate hourly ED arrival forecasts; whether the achieved accuracy is operationally sufficient for staffing decisions remains a site-specific question that requires clinical validation beyond the scope of this single-center study.

Healthcare doi: 10.3390/healthcare14091190

Authors: Makgandeni Libby Pholofolo Bernard Hope Taderera

Background: Mental healthcare has emerged as a major public health issue in the aftermath of COVID-19 worldwide due to global health system challenges which hinder effective healthcare. In this, there is a knowledge gap on research exploring the perceived quality of mental healthcare amongst hospital-based health workers with a particular focus on knowledge and practice, organization and system, and job satisfaction factors for an insight towards strengthening ongoing effort for the realization of the universal health coverage goal of the comprehensive global mental health action plans. The aim of this study was to assess health workers’ perceptions of quality in mental healthcare at three district hospitals in Johannesburg, South Africa. Methods: An exploratory cross-sectional research design was used on a stratified random sample of 160 health workers recruited as participants at the three selected hospitals in Johannesburg. Data were collected using a self-administered questionnaire and then subjected to descriptive statistical analysis using SPSS Version 29. Results: It was established that healthcare workers’ at the three district hospitals in Johannesburg were generally familiar with mental health guidelines and mental disorders which resulted in better patient engagement and prioritisation of mental health as being important as physical health. However the majority of these healthcare workers perceived the quality of mental healthcare at the three hospitals was low. Further assessment however revealed that these perceptions may have emanated from organizational and system incapacity, and limited satisfaction with compensation and benefits, recognition for work done and limited training. Conclusions: Health worker perceptions of quality in mental healthcare help provide an insight into what health systems may need to address mental health service delivery. The study of the three hospitals in Johannesburg, South Africa underscore the need to reinforce knowledge sharing through healthcare worker training, strengthen organisational and system capacity, provide adequate remuneration and benefits, and reinforce clear referral pathways and collaboration with specialists for the realisation of quality improvement and sustenance in pursuing the universal health coverage goal of the WHO Comprehensive Mental Health Action Plans and the Sustainable development Agenda on health of 2030 and beyond.

Healthcare doi: 10.3390/healthcare14091189

Authors: Raffaele Pezzani Susi Barollo Sara Vitalini Francesco Trevisan

Background: The use of food supplements (FS) is rapidly increasing, particularly in Italy, which leads the European market. This trend is driven by various factors, including the pursuit of physical well-being, the influence of advertising, and concerns about disease prevention. This exploratory pilot descriptive study aimed to characterize FS use among patients attending general practitioner (GP) offices and examine potential patterns with psychophysical well-being. Methods: Two questionnaires were administered to participants: one on FS use and another on physical and mental health (SF-12 questionnaire). General information and anthropometric characteristics were also collected. Results: 230 questionnaires on FS use and 192 on psychophysical well-being were analyzed. The majority of participants (73.5%) reported using FS, primarily for general well-being (21.0%), immune system support (12.2%), and increased energy (11.4%). The most commonly consumed FS were vitamins (19.4%), minerals (16.9%), and probiotics (15.7%). Only 57.4% of patients reported informing their doctor about FS use, while 66.3% engaged in self-prescription. The SF-12 questionnaire revealed lower mental health scores (mood, energy, anxiety, and depression) in the studied population, while physical health remained unaffected. Importantly, no significant associations were observed between FS use and either physical or mental health scores, suggesting these patterns are independent of supplement consumption. Conclusions: FS use is prevalent among patients attending GP offices. The observed decrease in mental health scores may indicate psychological distress though this pattern was not associated with FS consumption. Given the exploratory nature of this study, findings should be interpreted with caution. This study highlights the need for improved health education and professional training to promote safer and more informed FS use. Further research is required to expand upon these initial findings.

Healthcare doi: 10.3390/healthcare14091188

Authors: Sarah A. AlAbdalhai Ali Kerari Sanaa Ghulman

Background: Critical care nurses are frequently exposed to traumatic clinical events and occupational stress, increasing the risk of post-traumatic stress disorder (PTSD), compassion fatigue, and compromised psychological well-being. However, the interrelationships among these variables in Saudi Arabia remain unclear. This study investigated the associations between PTSD symptoms, compassion fatigue, and psychological well-being among critical care nurses. Methods: A descriptive cross-sectional study was conducted between October and December 2025 with 210 critical care nurses from the Eastern and Riyadh regions of Saudi Arabia. Data were collected using the PTSD Checklist for DSM-5 (PCL-5), the Professional Quality of Life Scale, and the WHO-5 Well-Being Index. Data analysis included descriptive statistics, t-tests, one-way analysis of variance, Pearson’s correlation coefficients, and multiple linear regression. Results: The mean PCL-5 score was 27.44, with 38.1% of participants meeting the cutoff for probable PTSD. Compassion fatigue was moderate. The mean WHO-5 score was 54.60, indicating moderate well-being, though a substantial proportion reported poor well-being. Psychological well-being was negatively correlated with both PTSD symptoms and compassion fatigue, while PTSD symptoms were strongly positively correlated with compassion fatigue. Both PTSD and compassion fatigue independently predicted lower well-being, explaining 21% of the variance. Sociodemographic variables were not significant predictors after adjustment. Conclusions: Critical care nurses experience moderate PTSD symptoms and compassion fatigue, adversely affecting psychological well-being. These findings underscore the interconnected nature of trauma-related distress and professional quality of life, highlighting the need for routine psychological screening, trauma-informed support, and resilience-focused interventions.

Healthcare doi: 10.3390/healthcare14091187

Authors: Yau Ni Wan Gail Forey Winnie Zeng

Background: Hospice refers to specialised end-of-life care that supports patients and families, making it an important area for studying how language shapes experiences and expectations of care. This study compares hospice discourse on websites in Hong Kong and the United Kingdom, analysing how NLP-based sentiment and interpersonal features, such as personal pronouns and conjunctions, shape logical relations, structure information, and express emotion in patient narratives. Methods: Using a mixed approach that integrates sentiment analysis with Systemic Functional Linguistics (SFL), and taxonomy of conjunctions in particular, this study draws on a 52,086-word corpus from 40 hospice websites (20 from each region). The corpus analytical tool AntConc was used to identify co-occurrence, interpret log-likelihood, and perform concordance analysis. Results: The findings reveal significant differences in the digital delivery of hospice care across regions. According to our data, UK websites tend to express a wider range of personal emotions and frequently use concessive conjunctions when discussing sensitive palliative care topics. In contrast, Hong Kong websites tend to use more additive and causal conjunctions, projecting a stronger focus on institutional care. For example, Hong Kong texts tend to use formal, service-oriented connections such as “we + offer”, reflecting a more informational communicative style. However, both regions frequently use personal pronouns such as “you” and “we” to convey positive sentiment and demonstrate empathy towards patients and their caregivers. Conclusion: These patterns appear to be used strategically by hospice providers to build trust, signal alignment, and strengthen relationships tailored to each region. Lastly, this study makes an original contribution by combining computational and functional linguistic approaches to develop a systematic method for examining culturally shaped digital communication in end-of-life contexts, thereby enriching the field of healthcare discourse analysis.

Healthcare doi: 10.3390/healthcare14091184

Authors: Yothaka Meelong Kiatkamjorn Kusol Thidarat Eksirinimit

Background: Thalassemia is an inherited hemoglobin disorder and is among the most prevalent genetic diseases worldwide. In adolescents, the physical consequences of thalassemia extend beyond physiological impairment and affect daily functioning, education, and body image. Objective: This research aimed to promote resilience and quality of life among adolescents with thalassemia, with the goal of increasing mean resilience and quality-of-life scores before and after participation. Methods: This cluster quasi-experimental study employed a two-group pretest–posttest design with a sample of 58 adolescents aged 12–17 years diagnosed with thalassemia. Participants were allocated to the experimental (n = 29) and control (n = 29) groups using a cluster-based approach at the district level. The intervention lasted 8 weeks. The assessment tools included the Pediatric Quality of Life Inventory and the Resilience Scale. Data were analyzed using descriptive statistics, including frequency distributions, percentages, means, standard deviations, t-tests, chi-square tests, and Fisher’s exact tests. Results: Baseline comparisons indicated no statistically significant differences in personal characteristics between the two groups (p > 0.05). Before the intervention, the mean resilience scores in both groups were low. The mean quality-of-life scores for the experimental and control groups were moderate. After participating in the resilience enhancement program, the experimental group showed statistically significant increases in both resilience and quality-of-life scores relative to pre-intervention levels (p < 0.001). Additionally, these post-intervention scores were significantly higher than those of the control group (p < 0.001). Conclusions: These findings indicate that the resilience enhancement program effectively improved resilience and enhanced the quality of life among adolescents living with thalassemia.

Healthcare doi: 10.3390/healthcare14091186

Authors: Adriano Friganović Biljana Filipović Sabina Krupa-Nurcek Kristian Civka Cecilija Rotim Jelena Slijepčević Ana Brčina Mohamed Mouhajir Željko Vlaisavljević

Background/Objectives: Many frontline healthcare professionals had not previously faced a crisis of the magnitude of the COVID-19 pandemic, and prolonged exposure to high-stress clinical environments may adversely affect psychological well-being. This study aimed to assess and compare burnout severity among critical care nurses in two clinical settings—one hospital in Croatia and one in Poland—with particular attention to emotional exhaustion, depersonalization, and personal accomplishment in the post-pandemic period. Methods: A cross-sectional comparative design was conducted across two hospitals (Croatia and Poland). Data were collected from 346 critical care nurses between September and December 2023. Burnout was assessed using the Maslach Burnout Inventory Human Services Survey, analyzed primarily as continuous scores across its three dimensions. Results: No statistically significant differences were observed between the two groups in continuous burnout scores (Emotional Exhaustion p = 0.224, Depersonalization p = 0.852, Personal Accomplishment p = 0.636, total MBI score p = 0.394). Secondary cut-off-based analyses yielded some categorical differences, including a higher proportion classified as having high burnout in the Polish sample (43.2%) than in the Croatian sample (31.5%); however, these findings were exploratory and should not be interpreted as overriding the primary continuous-score results. Regression analyses demonstrated low explanatory power, with education level emerging as a significant predictor only in the Croatian sample (OR = 0.320, 95% CI: 0.125–0.824, p = 0.018). Conclusions: Burnout severity did not differ significantly between the two clinical settings when assessed using continuous measures. These findings suggest that burnout among ICU nurses may be driven primarily by shared occupational and organizational stressors rather than setting-specific differences. Categorical findings should be interpreted as complementary and exploratory.

Healthcare doi: 10.3390/healthcare14091185

Authors: Safaa Saad Salim Abdullahi Abdu Ibrahim

Background: Hospital readmission among patients with diabetes remains a major challenge for healthcare systems, contributing to increased costs and adverse patient outcomes. Early identification of high-risk patients may support targeted interventions and improved care management. Objectives: This study aimed to develop and rigorously evaluate a machine learning framework for predicting 30-day hospital readmission in patients with diabetes using a large multi-institutional clinical dataset. Methods: The study utilized the Diabetes 130-US Hospitals dataset from the UCI Machine Learning Repository, comprising 101,766 hospital encounters. Data preprocessing included missing-value handling and feature engineering. Several machine learning models were evaluated, including Logistic Regression, Random Forest, XGBoost, and LightGBM, alongside a stacking ensemble model. Model performance was assessed using nested cross-validation (5 outer folds, 3 inner folds), probability calibration via Platt scaling, and statistical robustness through 1000 bootstrap resamples. Clinical utility was evaluated using decision curve analysis and clinical impact curves, while SHAP analysis was applied for model interpretability. Results: The stacking ensemble model achieved a nested cross-validated ROC–AUC of 0.664 and a calibrated AUC of 0.688, with a Brier score of 0.094. Risk stratification demonstrated a clear gradient between low- and high-risk groups, and decision curve analysis indicated positive clinical net benefit across relevant decision thresholds. Conclusions: The proposed machine learning framework provides a robust and clinically interpretable approach for predicting 30-day hospital readmission in diabetic patients, with potential utility for supporting clinical decision-making and care management.

Healthcare doi: 10.3390/healthcare14091183

Authors: Roza Kuanyshbekova Venera Baisugurova Gulzar Shah Bushra Shah Gulshara Aimbetova Manshuk Ramazanova Indira Karibayeva Nargiza Yussupova Botagoz Turdaliyeva

Background: New psychoactive substances (NPS) represent an evolving component of global substance use patterns and may contribute to HIV transmission through both injection-related and sexual risk behaviors. In Kazakhstan, where HIV incidence has increasingly shifted toward sexual transmission, evidence on HIV testing among NPS users remains limited. This study examined behavioral, social, and structural factors associated with HIV testing in this population. Methods: A cross-sectional study was conducted among 1500 adults reporting NPS use across six regions of Kazakhstan. Data were collected using structured interviewer-administered questionnaires. The primary outcome was self-reported HIV testing (ever tested: yes/no). Independent variables included sociodemographic characteristics, substance use behaviors, sexual practices, peer communication about HIV, and structural access to prevention services. Univariable logistic regression with Bonferroni correction (p < 0.001) was used for variable screening. Multivariable logistic regression models estimated adjusted odds ratios (AORs) with 95% confidence intervals (CIs). Model discrimination was assessed using the area under the receiver operating characteristic curve (AUC). Results: Overall, 86.7% of participants reported prior lifetime HIV testing. In the multivariable model (n = 1482), older age was associated with higher odds of testing (AOR 1.06 per year; 95% CI 1.04–1.08; p < 0.001). Compared with participants holding a bachelor’s degree or higher, those without a high school diploma had lower odds of testing (AOR 0.50; 95% CI 0.28–0.89). Injectable psychostimulant use was also associated with testing (AOR 1.40; 95% CI 1.21–2.01). Participants who never discussed HIV within peer networks were less likely to have been tested (AOR 0.69; 95% CI 0.49–0.97). Engagement with HIV prevention services (AOR 0.54; 95% CI 0.39–0.75) and use of prevention centers (AOR 0.63; 95% CI 0.45–0.87) were significantly associated with testing. The model demonstrated acceptable discrimination (AUC = 0.725). Conclusions: Lifetime HIV testing uptake among NPS users in Kazakhstan is high but influenced by educational attainment, peer communication, injection practices, and engagement with prevention services. Strengthening integration of prevention services and expanding peer-based outreach may improve equitable access to HIV testing in this population.

Healthcare doi: 10.3390/healthcare14091182

Authors: Misook Park Chung-uk Oh

Background/Objectives: Nursing students are often exposed to bullying in clinical settings. Bullying in a practice environment is an important issue that causes psychological, physical, and mental health problems in nursing students. However, in South Korea, few qualitative studies have examined bullying among nursing students in clinical practice environments. This study aimed to explore the lived experiences of bullying among South Korean nursing students during clinical practice. Methods: A qualitative descriptive study using a semi-structured interview guide was employed to collect data from nursing students in a focus group. Overall, three focus groups were used, with seven students in each group comprising males and females. The sample size was based on data saturation and saturated on three focus group discussions, giving a sample size of 21. Purposeful sampling was used to select students who had completed one or more semesters of clinical practice (six credits, 270 h) from two nursing colleges. Interviews were conducted in May 2025. Data were analyzed using Colaizzi’s method. Results: A total of 23 meaning units, 14 themes, and 7 thematic clusters were identified. Seven overarching thematic clusters emerged: (1) exposure to harsh speech; (2) experiencing physical harm; (3) being considered a sexual object; (4) disrespected as a nursing student; (5) assigned tasks beyond an individual’s capabilities; (6) restricted educational opportunities corresponding to clinical practice objectives; and (7) discriminatory treatment due to healthcare professionals’ prejudice. Conclusions: These findings highlight the need for raising the awareness of bullying and applying the strategies to prevent bullying and protect nursing students during clinical practice.

Healthcare doi: 10.3390/healthcare14091181

Authors: Andrian Țîbîrnă Floris Petru Iliuta Mihnea Costin Manea Mirela Manea

Background/Objectives: The COVID-19 pandemic intensified concerns regarding the resilience and financing architecture of mental health services, yet it remains unclear whether crisis-induced adjustments fundamentally altered hospital case-mix complexity or merely exposed pre-existing structural configurations. This study examines the relationship between financing regimes and case-mix complexity in psychiatric hospitals in Romania, a Central and Eastern European health system characterized by mixed financing arrangements and pronounced interregional heterogeneity. Methods: Using administrative data comprising 752 hospital section–year observations (2019–2024), we identify structural financing–organization regimes through a two-step clustering procedure (hierarchical Ward method followed by K-means refinement) based on revenue composition, expenditure allocation, workforce structure, and operational pressure indicators. Results: Three distinct regimes emerge, reflecting persistent institutional configurations rather than temporary crisis-induced groupings. Chi-square tests confirm that regime membership is statistically independent of pandemic timing. A multivariate regression model controlling for financing composition and expenditure structure shows that structural variables (particularly the share of contract-based revenues and the allocation of expenditures) exert systematic and economically meaningful effects on the case-mix index (CMI). Pandemic and post-pandemic indicators do not retain robust explanatory power once structural determinants are accounted for. Regional robustness analyses further demonstrate that financing architecture consistently outweighs temporal shock effects in explaining territorial variation in clinical complexity. Conclusions: The findings suggest that psychiatric hospital case-mix dynamics are structurally embedded within differentiated financing regimes whose influence persists beyond crisis periods. By integrating regime identification with outcome modeling in a Central and Eastern European context, this study contributes to the international literature on health system resilience and highlights the primacy of institutional financing architecture over episodic shock effects in shaping hospital complexity.

Healthcare doi: 10.3390/healthcare14091180

Authors: Stephanie Kauffmann Montserrat Girabent Farrés Cristina Naranjo Ortiz Laia Blanco-Ratto Manuel Del Campo Rodríguez Inés Ramírez-García

Background/Objectives: This exploratory single-arm study evaluated the effects of non-ablative Erbium-doped Yttrium Aluminum Garnet (Er:YAG) laser therapy in a real-world healthcare setting. Methods: A prospective pre–post study was conducted in 47 postmenopausal women who received two sessions of non-ablative Er:YAG vaginal laser therapy (IncontiLase®®/IntimaLase®®). Assessments were performed at baseline and two follow-ups (FSFI, ICIQ-SF, I-QOL, and Oxford Scale). Wilcoxon signed-rank tests and Spearman correlations were used. Results: Vaginal hiatus was significantly reduced from 2.5 cm (IQR 2.0–3.0) to 2.0 cm (IQR 1.0–3.0) (p < 0.001). Vaginal length showed a small, non-significant increase, and pelvic floor strength was unchanged. Total FSFI scores remained stable; pain showed a non-significant upward trend, and arousal decreased transiently. ICIQ-SF scores did not significantly improve, although they correlated inversely with vulvar energy at second follow-up (r = −0.424; p = 0.016). I-QOL domains showed short-term improvements in social embarrassment (p = 0.002), psychosocial impact (p = 0.002), and behavioral limitations (p = 0.013) at first follow-up. Cystocele stage improved at second follow-up (p = 0.013). Conclusions: Non-ablative Er:YAG vaginal laser therapy was associated with reduced vaginal hiatus and produced short-term improvements in select quality-of-life domains and cystocele stage, while effects on sexual function and urinary symptoms were limited. Findings remain exploratory and inform the design of future controlled studies evaluating innovative outpatient care models for GSM. Given the absence of a control group and short follow-up, these findings should be interpreted as hypothesis-generating and may be influenced by placebo or expectation effects.

Healthcare doi: 10.3390/healthcare14091179

Authors: Patricia Martínez-Miranda María Jesús Muñoz-Fernández Abel Rosales-Tristancho Cristina García-Muñoz

Background: Educational interventions are central to breast cancer survivorship care, yet adherence may vary depending on delivery modality. Objective: To compare the effectiveness of face-to-face, online, telephonic, and mixed educational modalities on patient adherence among breast cancer survivors. Methods: A systematic review of randomized controlled trials and Bayesian network meta-analysis were conducted following PRISMA 2020 guidelines. Randomized controlled trials evaluating educational interventions in breast cancer survivors were included. Methodology quality of included studies was assessed using the RoB-2 tool. Pairwise meta-analyses using random-effects models estimated Odds Ratios (ORs) for adherence. A Bayesian network meta-analysis synthesized direct and indirect evidence, and treatment rankings were calculated using SUCRA values. Results: Eleven trials comprising 963 participants were included. In pairwise meta-analysis, no modality demonstrated statistically significant superiority over usual care: face-to-face (OR 0.79; 95% CI 0.44–1.41), mixed (OR 0.42; 95% CI 0.07–2.37), online (OR 0.90; 95% CI 0.49–1.68), and telephonic (OR 0.57; 95% CI 0.18–1.78). The network meta-analysis confirmed the absence of statistically significant differences across modalities. SUCRA rankings suggested that usual care (76.7%) and online modalities (73.1%) had the highest probability of being among the best-performing strategies, followed by face-to-face (51.9%), telephonic (25.4%), and mixed (23.0%). Conclusions: No educational modality demonstrated superior adherence compared to usual care. Delivery format alone may not determine engagement in breast cancer survivorship programs. Decisions should prioritize feasibility and patient preference.

Healthcare doi: 10.3390/healthcare14091176

Authors: Mohammad Ali AL-Qarni Ahmet Sami Bosnak Esra’ O. Taybeh

Background: Treatment-related problems (TRPs), including patient adherence, knowledge, and medication errors, affect hospitalized patients’ outcomes worldwide. Effective clinical pharmacist communication is essential for proper patient counselling and medication safety. However, the effect of clinical pharmacist communication skills on TRPs has not been adequately studied. Objective: This study aimed to assess patients’ satisfaction with clinical pharmacists’ communication components (appropriate timing, language, and empathy) and examine their association with TRPs, including patient adherence, knowledge, and medication errors. Method: A cross-sectional study was conducted in two Jordanian public hospitals between October 2023 and April 2024 through a structured questionnaire to assess patients’ satisfaction, adherence, and knowledge. Medication errors were detected in collaboration with other healthcare providers through reviewing medical records and direct patient assessment based on the American Society of Health-System Pharmacists classification. Data analysis was conducted using SPSS version 27. Results: A total of 613 adult inpatients were included. Overall, 82.1% (n = 503) of patients were satisfied with the clinical pharmacist communication, 75.5% (n = 463) showed good adherence, and 76% (n = 466) showed good knowledge. A total of 42.4% of medication errors (n = 260) were identified. Errors with harm or fatalities were not observed. The regression results showed that the overall satisfaction level was positively associated with patients’ adherence rate (B = 0.59; p < 0.001) and patients’ knowledge (B = 0.978; p < 0.001) and negatively associated with the number of medication errors (B = −0.024; p < 0.001). Conclusions: Clear, timely, and empathetic communication by clinical pharmacists was associated with patient satisfaction and was linked to better patient adherence and knowledge and fewer medication errors. Improving communication skills among clinical pharmacists could be a practical way to reduce TRPs.

Healthcare doi: 10.3390/healthcare14091178

Authors: Bayader Kalkatawi Bashaer Saber Raghad Alhuthil Hanadi Alahdali Razan Al-Alkami Walaa Alsanoosi Hassan Hawa Mohammad S. Dairi Namareq Fahad Aldardeer

Background: Tranexamic acid (TXA) is an antifibrinolytic agent that helps prevent and manage bleeding events. In patients with trauma, TXA reduced bleeding-related deaths by one-third. Moreover, TXA showed a lower risk of mortality from bleeding in postpartum patients. Few studies have examined the appropriateness of TXA use for the management of bleeding in critically ill patients. This study aimed to describe the clinical outcomes and the safety of TXA use in critically ill patients with bleeding. Methods: This single-center, single-arm descriptive study was conducted at King Faisal Specialist Hospital & Research Center, Jeddah, between January 2018 and March 2023. The study included adult patients 18 years or older who were admitted to the medical intensive care unit (ICU) for ≥48 h and had documented bleeding that was treated with TXA for at least one dose. The primary outcome was the frequency of thrombotic events. Secondary outcomes included time from bleeding onset to bleeding resolution, rebleeding event at 30 days, time from bleeding onset to rebleeding event, ICU and hospital length of stay, and 30-day all-cause mortality. Results: A total of 129 patients were included in the study, 55% of whom were male. The median age was 60.9 years. The median APACHE II score was 22 (15–29). At baseline, 24.8% of patients had a history of bleeding. Major bleeding occurred in 86.1% of the patients. The frequency of thrombotic events was 2.3%. The median bleeding duration was 3.9 days (1.9–7.0). Rebleeding events at 30 days occurred in 24.8% of patients, with a median time of 11.7 days (8–14.8) from bleeding onset to rebleeding. The average ICU length was 12 days (6–24), and the average hospital length of stay was 25 days (15–50). The 30-day all-cause mortality rate was 55.8%. Multivariable analysis assessing factors contributing to mortality revealed that higher APACHE II score was strongly associated with increased mortality (adjusted OR 1.14 per point increase, 95% CI 1.07–1.21, p < 0.001), while higher platelet counts were independently protective, with each 10 × 109/L increase associated with a 4% reduction in mortality odds (adjusted OR 0.96, 95% CI 0.93–0.99, p = 0.034). Conclusions: In this descriptive study, TXA use in critically ill patients was accompanied by low absolute rates of thrombotic and rebleeding events. Further studies with larger sample sizes and comparable groups are needed to examine the appropriateness of TXA use in managing bleeding events in the ICU.

Healthcare doi: 10.3390/healthcare14091177

Authors: Anasztázia Kész Ildikó Balatoni

Globalization refers to the increasing density of economic, social, and technological interconnections on a global scale. In the healthcare industry, it simultaneously accelerates innovation and increases systemic vulnerabilities. This study aims to review and conceptually synthesise the main channels of impact: (1) pharmaceuticals, clinical development, and regulation; (2) supply chains and resilience; (3) service mobility (health tourism); (4) human resources and competencies; (5) digitalization, artificial intelligence (AI), and data governance; (6) ethics, law, and public policy; and (7) sustainability and climate change. The COVID-19 pandemic highlighted the risks associated with global interdependencies, particularly in supply chains, while also demonstrating the innovation-accelerating effects of knowledge sharing and international cooperation. Particular attention is given to artificial intelligence and digital health, which open up new potential for efficiency and quality improvement from research and development through diagnostics to healthcare organization, while simultaneously intensifying concerns related to data protection, cyber security, and liability. Telemedicine, platform-based systems, and real-world data may contribute to addressing the care needs of ageing societies, but only when supported by appropriate competencies and sound data governance. As global data flows intensify, the importance of data protection, bias mitigation, transparency, and accountability correspondingly increases. Through the cultural channels of globalization, health-conscious lifestyles and complementary approaches are also spreading, which we address in a brief, separate subsection. The guidelines of international organizations foster standardization; however, due to differences in local capacities and institutional environments, the effects are not homogeneous. In conclusion, the study emphasises the dual nature of globalization; it expands access and accelerates innovation, while at the same time creating new vulnerabilities—in supply chains, labour mobility, and data security—and, together with climate-related risks, generating complex adaptive pressures for the healthcare industry.

Healthcare doi: 10.3390/healthcare14091175

Authors: Heba H. Salem Ayesha Siddiqua Refal Saeed Aljali Ahad Ibrahim Alshardi Refal Mansour Abusllam Rasha Mohammed Alqahtani Lina Saad Alshehri Naglaa S. Bazan

Introduction: Asthma is a chronic inflammatory disease that impairs daily functioning and quality of life. Despite effective therapies, asthma control remains suboptimal and may improve through greater engagement of community pharmacists. This study assessed the knowledge, practices, and perceived barriers of community pharmacists regarding asthma management in the Aseer region, Saudi Arabia. Methods: A cross-sectional study was conducted using a self-administered online questionnaire covering demographics, asthma-related knowledge, practice, and perceived barriers. Results: A total of 290 community pharmacists participated. Overall, 64.8% showed high asthma-related knowledge, while 51.7% reported high asthma counseling practice. Pharmacists showed strong knowledge of asthma symptoms, triggers, determinants of poor control, and counseling on medication-related adverse effects, but moderate knowledge of asthma control assessment, guideline-based management, and treatment-related side effects. Commonly reported services included patient education on asthma and medications, identification of modifiable risk factors, and discussion of treatment side effects, whereas written asthma action plans, symptom control assessment, and follow-up visits were less common. In multivariable logistic regression, high knowledge (p = 0.002), interest in asthma training (p < 0.001), and greater work experience (p = 0.01) were associated with higher counseling practice, while patient volume showed a borderline association (p = 0.051). Conversely, higher practice (p = 0.002), working in independent community pharmacies (p < 0.001), and pharmacy location (p = 0.034) were associated with higher asthma knowledge. Conclusions: Community pharmacists demonstrated moderate-to-high knowledge of asthma management, but gaps remain in guideline-based practice and follow-up. Strengthening guideline-oriented training and pharmacist integration into asthma care may improve outcomes.

Healthcare doi: 10.3390/healthcare14091174

Authors: Omar Gammoh Alaa A. A. Aljabali Sireen Abdul Rahim Shilbayeh Mariam Al-Ameri

Background/Objectives: Attention-deficit hyperactivity disorder (ADHD) in adults is often overlooked in refugees, especially those displaced by war and diagnosed with chronic issues such as hypertension and type 2 diabetes mellitus. We sought to provide a preliminary screening to align with ADHD screening and to examine its related demographic and clinical factors. Methods: This cross-sectional study recruited Syrian refugees residing in Jordan. The Adult ADHD Self-Report Scale-V1.1 (ASRS) was employed to provide a preliminary screening of “Consistency with ADHD screening”. Multivariable regression analysis was used to identify the risk factors associated with the “Consistency with ADHD screening”. Results: Data analysis included 345 patients; 179 (51.9%) were females. β-Blockers were used in 151 (43.8%), metformin in 134 (38.8%), and sulfonylurea in 86 (24.9%). In the study, 158 participants (45.8%) reported very consistent results related to ADHD. We used multivariate binary logistic regression, which showed that in our groups that received metformin (OR of 2.08, 95% CI 1.32–3.27, p = 0.001) and insulin (OR of 2.25, 95% CI 1.00–5.04, p = 0.04), we observed a positive association with ADHD symptoms. Also, we noted that high school education was negatively associated with the results of the ADHD screen (OR of 0.58, 95% CI of 0.36–0.94, p = 0.02). Conclusions: This preliminary study guides future steps in addressing ADHD symptoms in war-displaced refugees; proper diabetes management and education seem to be important factors.

Healthcare doi: 10.3390/healthcare14091173

Authors: Daniele Giansanti

Following the success of the first Special Issue, “The 10th Anniversary of Healthcare—TeleHealth and Digital Healthcare” [...]

Healthcare doi: 10.3390/healthcare14091172

Authors: Catarina Fonseca Sara Palma Mónica Antunes

Background/Objectives: Human immunodeficiency virus remains a significant public health challenge, with breastfeeding contributing to the risk of mother-to-child transmission. Although antiretroviral therapy significantly reduces this risk, obstetric nurses face complex challenges in translating evolving guidelines into clinical practice. This scoping review aims to map existing scientific evidence on obstetric nurses’ approaches to evidence-based practice regarding breastfeeding in the context of HIV. Methods: Following the Joanna Briggs Institute methodology and PRISMA-ScR guidelines, a search was conducted across PubMed, Scopus and EBSCOhost (MEDLINE Complete, CINAHL Complete, Cochrane Central Register of Controlled Trials, and Nursing & Allied Health Collection: Comprehensive) for studies published in Englissh and Portuguese between 2015 and 2025. Studies were included if they focused on the role of obstetric nurses, nurse-midwives, or midwives in infant-feeding practices for women living with HIV. Results: Eight studies were included, predominantly from sub-Saharan Africa, with additional evidence from Europe and Canada. Findings reveal that infant-feeding counseling is shaped by a complex interplay of clinical protocols and personal beliefs. Significant gaps in knowledge translation were identified. While nurses demonstrate high technical confidence in lactation support, their distinct professional contribution is often obscured by research that aggregates all healthcare providers. Conclusions: The challenge of supporting breastfeeding in the context of HIV extends beyond technical protocol adherence. It points to persistent gaps in knowledge translation, variability in counselling practices, and the influence of contextual and professional factors on guideline implementation. Strengthening care requires sustained investment in profession-specific education, institutional support, and evidence-informed practice frameworks that enable obstetric nurses to exercise informed clinical judgement.

Healthcare doi: 10.3390/healthcare14091171

Authors: Slim Saaidia Hamdi Henchiri Hela Znazen Amr Chaabeni Abdulazeem Alotaibi Abdullah H. Alliheibi Noureddine M. Ben Said Fairouz Azaiez

Background: Grounded in Self-Determination Theory (SDT) and the Dualistic Model (DM) of Passion, this study examined the motivational mechanisms underlying psychological well-being among Tunisian physical education teachers. The objectives were twofold: to examine validity evidence of the Arabic version of the Basic Psychological Need Satisfaction and Frustration Scale (BPNSFS) and to test an integrative structural model linking harmonious passion, need satisfaction and frustration, well-being, vitality, happiness, and perceived stress. Methods: A representative sample of physical education teachers (1238) completed standardized instruments to assess passion, basic psychological needs, and well-being. To conduct exploratory and confirmatory factor analyses, the group was randomly divided into two independent subgroups. Reliability and validity were assessed using additional psychometric indicators, and a structural equation model was used to test the hypothesized relationships. Results: The results support the multidimensional structure and psychometric validity of the scale in the Tunisian context. Harmonious passion appears to be a positive factor in the satisfaction of psychological needs and a negative factor in cases of frustration. The satisfaction of these needs is closely linked to a high level of well-being, whereas their dissatisfaction is associated with adverse consequences. Well-being is also associated with increased vitality, greater happiness, and reduced stress, reflecting adaptive psychological functioning. Conclusions: Harmonious passion and basic psychological need satisfaction emerge as central resources for sustaining teacher well-being, vitality, and resilience against stress in educational contexts.

Healthcare doi: 10.3390/healthcare14091169

Authors: Haoqi Yan Jingjing Liang Haozhe Huang Ming Chen Cheng Hu Leyan Wang Wei Li Botao Wu Guantong Fang Juan Ge

(1) Background: Frailty is a major geriatric syndrome associated with adverse health outcomes, while direct assessment of cardiorespiratory fitness (CRF) is often impractical in routine clinical settings. This study investigated the association between estimated cardiorespiratory fitness (eCRF) and incident frailty in middle-aged and older adults from three nationally representative aging cohorts. (2) Methods: We analyzed longitudinal data from the Health and Retirement Study (HRS; 2006–2020) in the United States, the English Longitudinal Study of Ageing (ELSA; 2004–2018) in England, and the China Health and Retirement Longitudinal Study (CHARLS; 2011–2018) in China. Participants aged 50 years or older were included. eCRF was calculated using validated sex-specific non-exercise algorithms. Frailty was assessed using a 30-item Frailty Index (FI), and incident frailty was defined as FI ≥ 0.25. Cox proportional hazards models were used to evaluate the association between baseline eCRF and incident frailty. (3) Results: A total of 8152 participants (3982 women and 4170 men) were included in the longitudinal analysis. Each 1-SD increase in eCRF was associated with a lower risk of incident frailty in HRS (HR = 0.60, 95% CI: 0.54–0.68), ELSA (HR = 0.54, 95% CI: 0.46–0.64), and CHARLS (HR = 0.74, 95% CI: 0.63–0.87). Compared with the low-eCRF group, the moderate- and high-eCRF groups had progressively lower risks of incident frailty across all three cohorts, indicating a graded inverse dose–response relationship. Findings were generally consistent across subgroup and sensitivity analyses. (4) Conclusions: Higher eCRF was associated with a lower risk of incident frailty among middle-aged and older adults across three nationally representative cohorts. As an accessible, non-invasive metric, eCRF may be useful for identifying individuals at elevated risk of incident frailty.

Healthcare doi: 10.3390/healthcare14091170

Authors: Leni Porto Costa Siqueira Valentina Acosta Bermúdez Valentina Franco Gomes Guilherme Carvalho de Paula Francisco Felipe Alckmin-Carvalho Piyali Bhattacharya Andrew D. R. Surtees Maria Cristina Triguero Veloz Teixeira

Introduction/Objectives: Intersectoral collaboration between education and mental health services is central to the care of autistic children and adolescents. However, recent literature indicates that evidence remains limited regarding how these collaborative arrangements are implemented in routine public services, particularly in low- and middle-income countries (LMICs). This study aimed to assess the intersectoral collaboration between Brazilian educational and mental health services for autistic children and adolescents and to examine the frequency and type of intersectoral contact. Methods: An exploratory cross-sectional study was conducted in the municipal public education system of Niterói, a city in the Southeast region of Brazil. Participants included parents of 123 autistic children and adolescents, 49 teachers from mainstream education and specialized educational services (SES), and 24 health professionals. Data were collected using structured questionnaires with multi-informant reports. The instruments were specifically developed for the study and submitted to expert content-validation procedures. Analyses included descriptive statistics and, in a subsample of 51 matched cases with paired responses from teachers and health professionals, Cohen’s kappa to assess agreement between reports. Results: Low levels of intersectoral collaboration were observed, characterized by infrequent contact, limited information exchange, and slight agreement between reports from teachers and health professionals (κ = 0.25; p = 0.01). Teachers were more likely to know where care was provided than to know which specialists were involved, while more than half of health professionals did not know which school the child attended. Conclusions: In the investigated municipal network, care appeared fragmented, highlighting difficulties in translating intersectoral recommendations from public policies into routine collaborative practices.

Healthcare doi: 10.3390/healthcare14091168

Authors: Malak Abu Khashan Shahd Aldarak Marwa Zahdeh Ayah Alawneh Nada Abo Dyak Shahd Qazae Shahd Ghanem Mohammad N. S. Al-Mohtaseb Hadeel Ayesh Abdallah Alwawi Azzam Zrineh

Background: Premenstrual syndrome (PMS) significantly impacts daily functioning among women of reproductive age. Medical and nursing students face exceptional stressors that may exacerbate PMS, yet the interrelationships between sleep quality, perceived stress, and PMS remain understudied in Middle Eastern contexts. This study aimed to investigate the relationships between sleep quality, perceived stress, and self-reported PMS symptoms among Palestinian female medical and nursing students, to assess their prevalence and severity, and to examine variations across sociodemographic and lifestyle factors. Methods: This cross-sectional correlational study recruited 708 female medical and nursing students from three Palestinian universities. Validated Arabic instruments assessed sleep quality (PSQI), perceived stress (PSS-10), and PMS symptoms (A-PMSS). Analyses included Spearman’s correlations, non-parametric tests (Mann–Whitney U Test, Kruskal–Wallis Test), and multivariable linear regression. Results: Nearly all participants (98%) reported some degree of self-reported PMS symptoms at any severity level, with 76% experiencing moderate-to-severe symptoms. Poor sleep quality (PSQI > 5) affected 62.1%, while 94.5% reported moderate-to-high perceived stress. Significant positive correlations were identified between PSQI and PMS (rho = 0.295, p < 0.001) and between PSS-10 and PMS (rho = 0.483, p < 0.001). Multivariable regression revealed that perceived stress and sleep quality were significant independent predictors of PMS severity after adjusting for covariates, with the overall model explaining 27.5% of variance in PMS scores. Conclusions: This study reveals a substantial burden of PMS, poor sleep quality, and stress among Palestinian female medical and nursing students. Perceived stress and sleep quality were independently associated with PMS severity. These findings highlight need for integrated wellness programs in healthcare education for Palestinian students.

Healthcare doi: 10.3390/healthcare14091167

Authors: Nektaria Kossyva Marios Spanakis Lena Borboudaki Dimitrios Stylianakis Nikos Rikos Michael Rovithis Chryssoula Perdikogianni Manolis Linardakis Emmanouil K. Symvoulakis

Background/Objectives: Vaccination represents a significant achievement of public health and should be regarded not only as a protective measure against infectious diseases but also an active preventive intervention and a component of health promotion. Methods: This cross-sectional study assessed vaccination coverage among adults aged ≥60 years who attended a Primary Health Care Center during a predefined period of at least two months (November–December 2025) in a rural area of Crete, Greece, and examined determinants of immunization, including demographic, clinical, psychosocial, and health service utilization factors. The sample comprised 366 participants who consented to complete a structured questionnaire, primarily via interview, followed by verification of vaccination status through medical records. Results: High vaccination coverage was observed for influenza (82.5%), moderate coverage for pneumococcal (68.3%) and herpes zoster (56.0%) vaccines, and very low coverage for tetanus–diphtheria–pertussis booster doses (≈13%) and RSV vaccination (5.2%). For SARS-CoV-2, 96.2% received the three doses which were mandatory during the pandemic years. The overall Vaccination Coverage Score (VCS) averaged 43.1/100, while only 10.1% of participants achieved high coverage. Regression analysis showed that higher educational level, multimorbidity, and extensive use of health services were independently associated with better vaccination coverage (p < 0.05). Conclusions: The findings reveal fragmented vaccination patterns and underscore the need for systematic assessment of adult vaccination status within routine Primary Health Care. Targeted counseling, promotion of health literacy, and preventive vaccination strategies are expected to reduce vaccine-preventable morbidity and support healthy aging.

Healthcare doi: 10.3390/healthcare14091166

Authors: María del Carmen López-García Gabriel Lara-Hernández Hamlet Avilés-Arnaut Virginia Sánchez-Monroy Eduardo Nateras-Molina Ernesto Fragoso-Paniagua Ericka Flores-Berrios Elvia Pérez-Soto

Background/Objectives: Work stress (WS), occupational fatigue (OF), and Burnout syndrome (BS) among administrative workers are associated with negative psychosocial and metabolic effects. Although antioxidant-rich nutritional strategies have been proposed to help manage stress, evidence from real-world occupational settings is still limited. This study evaluated the total antioxidant capacity (TAC) of a multi-antioxidant dietary supplement 2.0 (DS2.0; apple polyphenols, [APP], astaxanthin [AXT], and fucoxanthin [FXT]; 387:12:1 ratio) and explored its association with metabolic parameters, OF, psychosocial outcomes, and hair cortisol concentration (HCC) in administrative workers with and without obesity. Methods: A quasi-experimental pilot study was conducted among 22 workers, who received DS2.0 (52.13 mg/day, n = 17) or a placebo (n = 5) for 30 days. TAC was analytically assessed using standardized assays. Metabolic outcomes (lipid profile, fasting plasma glucose), psychosocial variables (SOFI-SM, CESQT/SBI, and IMSS tests), and HCC (competitive immunoassay) were evaluated before and after supplementation. Statistical analyses included within-group pre–post comparisons, independent-sample tests, and effect size estimation. Results: DS2.0 demonstrated high TAC. Supplementation was associated with reductions in total lipids, total cholesterol, and non-HDL cholesterol, as well as decreases in OF, BS, and WS scores. HCC decreased in the overall sample (217.19 vs. 31.64 pg/mg; p = 0.000) and among workers with obesity (276.80 vs. 34.13 pg/mg; p = 0.002). Stress-related symptoms, including sleep deprivation, exhaustion, appetite changes, difficulty waking, and palpitations, also improved (p ≤ 0.05). Conclusions: An antioxidant-rich DS2.0 supplement may be associated with psychosocial and stress-related biomarkers; however, these exploratory findings require confirmation in larger randomized controlled trials. Trial registration: ISRCTN 12762846.

Healthcare doi: 10.3390/healthcare14091165

Authors: José Manuel Cuevas-Sánchez Sergio Barrientos-Trigo José Algaba-del-Castillo Manuel Coheña-Jimenez

Background/Objectives: Postgraduate training is an essential component for the development of professional skills in health sciences. Our research question was: How does the implementation of structured residency and fellowship programs in podiatry and foot and ankle surgery impact the acquisition of clinical and surgical skills, academic productivity, interprofessional integration, leadership development, and resident well-being compared to less structured or traditional programs? Methods: We conducted a systematic review of published research, between September and November 2025, selecting observational studies that evaluated structured training programs compared to traditional approaches. The studies included reported residency or fellowship programs in podiatry and foot and ankle surgery that described clinical, surgical or academic experiences, together with the factors that influence learning variability. Results: Eleven cross-sectional studies were included. Program structure, mentorship, clinical exposure, availability of educational resources, and individual motivation are determining factors in the variability of skills acquisition. Structured programs were associated with better academic and clinical performance, greater technical confidence, and professional leadership development. However, substantial heterogeneity was observed among programs, particularly regarding access to resources, which contributed to differences in the ultimate preparation of residents and fellows. The Newcastle–Ottawa Scale adapted assessed methodological quality, showing a low-to-moderate risk of bias. Conclusions: The literature suggests that although the programs generally achieve basic training objectives, the standardization and implementation of structured educational strategies could optimize skills acquisition and reduce variability across programs. Furthermore, multicenter research incorporating objective outcome measures would facilitate the development of internationally applicable standards for evaluation in health education.

Healthcare doi: 10.3390/healthcare14091164

Authors: Özge Sarıca Acaröz Mehmet Çakıcı

Background/Objectives: Psychological variables such as body image, self-esteem, and life satisfaction have become important research topics in recent years, particularly in their relationships with individuals’ eating attitudes. The purpose of this study is to examine the predictive effect of body image and self-esteem on eating attitudes in emerging adults and to evaluate the mediating role of life satisfaction in this relationship. Method: The study included 402 participants aged 18–30. Data were collected using the Eating Attitudes Test (EAT-26), the Rosenberg Self-Esteem Scale (RSS), the Body Image Scale (BIS), and the Life Satisfaction Scale (LSS). The analyses included correlational analyses to examine relationships among eating attitudes, body image, self-esteem, and life satisfaction; multivariate regression to test the predictive roles of body image, self-esteem, and life satisfaction on eating attitudes; and structural equation modeling to evaluate the mediating role of life satisfaction in the relationships between body image, self-esteem, and eating attitudes. Result: The correlational analysis revealed that eating attitudes are associated with body image, life satisfaction, and self-esteem. Body image was identified as the most influential predictor of eating attitudes. Structural equation modeling indicated that life satisfaction mediates the relationship between self-esteem and eating attitudes. Conclusions: Body image, self-esteem, and life satisfaction play a crucial role in shaping eating attitudes among emerging adults. The mediating effect of life satisfaction underscores psychological well-being as a key regulatory factor rather than solely an outcome. Promoting positive body image, strengthening self-esteem, and enhancing life satisfaction through preventive and psychoeducational programs may help protect against disordered eating attitudes in this population.

Healthcare doi: 10.3390/healthcare14091163

Authors: Alba Navas-Otero Mirella Villegas-López Jessie Jambón-Folea Susana Varón-Jiménez Irene Cabrera-Martos Araceli Ortiz-Rubio María del Carmen Rodríguez-Martínez

Objective: The aim of this study will be to evaluate the effectiveness of a task-oriented training program in improving functional performance and health outcomes in patients with MS. Methods: A pilot randomized clinical trial will be conducted according to SPIRIT guidelines. Participants will be randomly assigned to the experimental group or the control group. Assessment and treatment will take place at patient association facilities or research center. Participants diagnosed with MS by a neurologist and meeting the inclusion criteria will be invited to participate voluntarily. The experimental group will undergo an 8-week TOT intervention, twice weekly, 45 min. The control group will maintain usual care and be given a fatigue management pamphlet. The main variable in this study will be the Canadian Occupational Performance Measure. The level of fatigue will be assessed with the Modified Impact Fatigue Scale and the Fatigue Severity Scale, upper limb strength using the Arm Curl Test, hand and pinch dynamometer, motor speed with the Finger Tapping Test, manual dexterity with the Nine Hole Peg Test, Purdue Pegboard Test and the Coin Rotation Test. Satisfaction and adherence with the intervention will be recorded with the Sport Injury Rehabilitation Adherence Scale. Results: The results will be published as a peer-reviewed article. Conclusions: The present protocol aims to fill a relevant gap in the literature, offering a structured intervention based on task-oriented training principles, specifically tailored to the functional and occupational needs of people with MS.

Healthcare doi: 10.3390/healthcare14091162

Authors: Özlem Akkoyun Sert Ece Ekici Ümit Yüzbaşıoğlu

Background: Wrist pain is frequently reported among housewives and linked to repetitive household tasks, yet the drivers of pain-related disability remain unclear. Beyond physical load, psychosocial factors such as catastrophizing, mood symptoms, and self-efficacy may shape severity and functional impact. Purpose: To evaluate the severity of wrist pain and wrist-related disability in Turkish housewives and to identify the psychosocial and symptom-related factors associated with these outcomes. Methods: This cross-sectional study was conducted with 92 Turkish housewives reporting wrist pain ≥ 3/10 on the Numeric Pain Rating Scale (NPRS) and who have been married for at least 1 year and performing at least 1 h of housework, via Google Forms. Fatigue and wrist pain were measured using the Numeric Rating Scale (NRS), as well as the Patient-Rated Wrist Evaluation–Turkish version (PRWE-T), Pain Self-Efficacy Questionnaire (PSEQ), Patient Health Questionnaire-4 (PHQ-4), and Pain Catastrophizing Scale (PCS). Sociodemographic data were also collected. Associations were analyzed with Spearman’s correlation, and simple linear regression identified factors explaining wrist pain severity and disability. Results: PRWE-T total scores showed strong positive correlations with pain catastrophizing (p < 0.001), PHQ-4 depression (p < 0.001), and PHQ-4 anxiety (p < 0.001), while correlating negatively with pain self-efficacy (p < 0.05). PCS was also strongly correlated with PHQ-4 anxiety (p < 0.001) and PHQ-4 total (p < 0.001), but negatively with PSEQ (p < 0.001). Multivariable regression analyses have shown that PCS and fatigue may be predictory of wrist pain and disability. Additional factors included fatigue severity (p = 0.002), PHQ-4 depression (p < 0.001), and PHQ-4 anxiety (p = 0.001). Conclusions: These findings highlight the multidimensional nature of wrist symptoms in this population.

Healthcare doi: 10.3390/healthcare14091161

Authors: Asrar Salem Almutairi Owen Price Abdullah Hassan Alqahtani Antonia Marsden Karina Lovell

Background/Objectives: Physical restraints and seclusion remain ethically contested interventions in psychiatric care, raising significant concerns regarding patient safety, dignity, and therapeutic impact. Despite growing international momentum towards restraint-reduction strategies, their use persists across the Eastern Mediterranean Region (EMR), an area that has been the subject of limited systematic attention. This review synthesises evidence on the knowledge, attitudes, and experiences of nurses and individuals with mental illness regarding these practices in EMR psychiatric settings. Methods: Following PRISMA 2020 guidelines (PROSPERO: CRD42023383751), we systematically searched nine electronic databases for studies published up to June 2023, supplemented by backward and forward citation searching. Multiple reviewers independently screened records against predefined eligibility criteria, with disagreements resolved through consensus. Methodological quality was assessed using Joanna Briggs Institute (JBI) Critical Appraisal tools, and reporting quality was evaluated using an adapted CROSS checklist; these two appraisal dimensions were conducted and reported independently. Findings were integrated through narrative synthesis. Results: From 4634 identified records, 19 studies conducted across 11 EMR countries met the inclusion criteria. Nursing knowledge deficits were identified across multiple settings, and attitudes towards restraint practices were predominantly negative. Individuals with mental illness consistently described restraint as humiliating, punitive, and physically distressing. Recurrent challenges identified across studies included inadequate staff training, chronic understaffing, and limited access to restraint-reduction alternatives. Conclusions: Substantial gaps in nursing knowledge and training persist across the EMR. The findings of this review, while derived predominantly from cross-sectional studies with convenience samples, suggest that evidence-based education programmes, standardised restraint-reduction policies, and patient-centred care frameworks warrant prioritisation to safeguard the rights, safety, and dignity of individuals with mental illness in this region. Longitudinal and experimental research is needed to confirm these directions and establish their effectiveness within EMR contexts.

Healthcare doi: 10.3390/healthcare14091160

Authors: Guillermo Ceniza-Bordallo Ana Belén del Pino Dino Soldic Angel Torrado-Carvajal

Introduction: Distress during pediatric magnetic resonance imaging (MRI) neuroimaging can compromise scan quality and negatively impact children’s experiences. This review aimed to systematically synthesize biomarkers and psychological factors associated with distress in children, adolescents, and young adults undergoing neuroimaging. Methods: This systematic review was conducted according to PRISMA and AMSTAR-2 guidelines and preregistered in OSF. A systematic search was performed in six electronic databases, including observational articles published between 2000 and 2025 that assessed distress during MRI and functional MRI (fMRI). Data extraction and risk of bias assessment (QUIPS tool) were performed independently by two reviewers. Results: Ten studies (n = 558) examining distress during neuroimaging were included in this review. Distress was assessed through subjective self- and parent-reports, objective physiological measures, and qualitative interviews. Overall, distress levels were low to moderate; most participants tolerated scans well, though younger age, male sex, parental anxiety, procedure length, and chronic illness were associated with greater discomfort. Noise, immobility, and boredom emerged as the most frequent triggers, while strategies such as distraction, age-appropriate information, and reducing waiting times were perceived as helpful. Among participants with cancer, scan-related anxiety was closely linked to fear of recurrence and perceived stress. Risk of bias across studies was moderate to high, particularly in domains of attrition and statistical reporting. Conclusions: Distress during scanning is driven by anticipatory and parental anxiety, procedure length, and chronic illness. Biomarkers (e.g., cortisol, blood pressure) showed inconsistent links with subjective distress, highlighting the need for integrated measures.

Healthcare doi: 10.3390/healthcare14091159

Authors: Balázs Lukács Amr Sayed Ghanem Judit Molnár Ilona Veres-Balajti Attila Csaba Nagy

Introduction: Low back pain (LBP) is the leading cause of disability worldwide, with substantial variation in prevalence across regions. It is associated with a wide range of biophysical, psychological, social, and lifestyle factors, as well as comorbid conditions. Given its high impact, identifying population-level correlations of LBP is essential for informing prevention strategies. This study aimed to assess demographic, socioeconomic, lifestyle, and health-related factors associated with LBP in Hungary. Methods: A repeated cross-sectional analysis was conducted using secondary data from three waves of the European Health Interview Survey (EHIS) carried out in Hungary in 2009, 2014, and 2019. Results: The prevalence of LBP increased over the study period. Female sex, higher educational attainment, normal body mass index, non-smoking status, abstaining from alcohol, and good self-perceived health were associated with lower odds of LBP. In contrast, older age (≥65 years), unfavorable financial status, residence in socioeconomically disadvantaged regions, use of over-the-counter medications, and several chronic conditions were associated with higher odds. Conclusions: Reducing the impact of low back pain requires its integration into comprehensive public health frameworks that combine chronic disease management with consideration of socioeconomic inequalities at the population level.

Healthcare doi: 10.3390/healthcare14091158

Authors: Ohsuk Hwang Miran Jung

Background/Objectives: Breast engorgement and associated pain, often resulting from milk stasis, impaired circulation, and tissue edema, may adversely affect maternal and neonatal health, as well as maternal mental health and quality of life in early postpartum women. Despite the availability of massage-based methods, the evidence supporting structured self-care programs remains limited. This study aims to develop and evaluate a natural breast self-circulation program and assess its effectiveness in improving breast engorgement, mental health, and quality of life among early postpartum women. Methods: The sample for this quasi-experimental study, comprising both an experimental group (n = 36) and a control group (n = 36), consisted of pregnant women at or before 37 weeks of gestation who intended to breastfeed. Breast engorgement and circumference, stress, anxiety, and EQ-5D-3L scores were measured before and after implementation of the intervention (the natural breast self-circulation program). Results: The program significantly reduced breast engorgement (F = 33.97, p < 0.001, partial η2 = 0.327), breast circumference (F = 105.52, p < 0.001, partial η2 = 0.601), and anxiety (F = 37.43, p < 0.001, partial η2 = 0.348) in women during the early postpartum period. Conclusions: These findings demonstrate that an early postpartum natural breast self-care program can alleviate breast engorgement and maternal anxiety. They provide a rationale for implementing self-managed breast care. Active implementation of this program may help alleviate physical and emotional difficulties and enhance confidence in breast care among pregnant women.

Healthcare doi: 10.3390/healthcare14091157

Authors: Xinfang Li Mingqiang Li Zhihui Li

Objectives: This study examines how different benefit payment modes under China’s long-term care insurance (LTCI) program influence healthcare utilization and medical expenditures among middle-aged and older adults. Specifically, it compares the effects of in-kind benefits and mixed benefits on healthcare service use and financial burden. Methods: This study uses data from the China Health and Retirement Longitudinal Study (CHARLS) from 2011 to 2018, focusing on middle-aged and older adults with functional limitations. Exploiting the staggered implementation of LTCI pilot programs across 14 cities, a difference-in-differences (DID) approach is employed to estimate the causal effects of different benefit payment modes on healthcare utilization and expenditures. Heterogeneity analyses are conducted to explore differences between rural and urban populations. Results: The results indicate that the in-kind benefit mode significantly reduces inpatient visits, total medical costs, and out-of-pocket expenditures. By contrast, the mixed benefit mode shows only a modest reduction observed mainly in outpatient visits. Heterogeneity analysis further reveals that in-kind benefits are particularly effective in reducing healthcare utilization and medical expenditures among rural residents, while urban residents experience higher reductions in out-of-pocket spending. Conclusions: These findings highlight the importance of benefit design in shaping the effectiveness of LTCI policies. Prioritizing service-based benefits may improve healthcare system efficiency and reduce financial burdens among older adults. The results provide policy-relevant insights for optimizing LTCI benefit design in China and other aging societies.

Healthcare doi: 10.3390/healthcare14091156

Authors: Wojciech Kasperek Fabian Strus Łukasz Rydzik Tadeusz Ambroży Joanna Baran Maciej Kochman

Background/Objectives: Strength training is a widely recommended form of physical activity due to its extensive health benefits and positive effects on musculoskeletal function, although improper technique and balance deficits may increase injury risk. While sex differences in spinal curvature and postural control have been identified in the general population, it remains unclear whether these differences persist among recreationally strength-trained individuals. This cross-sectional study investigated sex-specific differences in sagittal spinal alignment and static balance and examined potential associations between spinal curvature and postural control in trained young adults. The authors hypothesized that sex-related differences would persist despite regular training and that relationships between spinal alignment and balance would demonstrate sex-specific patterns. Methods: This cross-sectional study included 124 young adults (59.7% men and 40.3% women). Anthropometric measurements included height, weight, waist circumference, and hip circumference. Sagittal spinal curvature was assessed using an electronic inclinometer, and balance parameters were evaluated using a stabilometric platform under eyes-open and eyes-closed conditions. Results: Statistically significant sex-related differences were observed in sacral angle (p < 0.001) and lumbar lordosis (p = 0.02). Balance assessment revealed significant differences between sexes in several parameters under eyes-open conditions (p < 0.05), as well as in mean COP velocity in the anteroposterior direction under eyes-closed conditions (p = 0.003). In women, sacral inclination was positively but weakly correlated with selected balance parameters (r = 0.299–0.306, all p < 0.05), indicating an association between spinal alignment and postural control. Conclusions: The findings indicate sex-specific differences in sagittal spinal curvature and balance, with sacral alignment associated with balance performance in women. Differences in selected balance parameters were also observed independently of spinal curvature. These results highlight the importance of considering sex and spinal biomechanics when assessing postural control in strength-trained individuals and support further research in larger, more diverse populations with varying training experience and age ranges.

Healthcare doi: 10.3390/healthcare14091155

Authors: Giovanna Lima Fortunato Gabriel Pereira Nunes Isabela dos Santos de Deus Priscila Toninatto Alves de Toledo Guilherme Assumpção Silva Cristina Antoniali Silva Aimée Maria Guiotti Daniela Atili Brandini

Background/Objectives: Dental caries is one of the most prevalent chronic diseases in childhood, disproportionately affecting socially vulnerable populations. This scoping review aimed to analyze the clinical effects of selected minimally invasive materials and approaches, specifically mouthrinses, fluoride varnishes, silver diamine fluoride, and glass ionomer-based interventions, for the prevention and management of dental caries in pediatric patients, with emphasis on public health and community-based settings. Methods: This scoping review followed the Population, Concept, and Context (PCC) framework. Electronic searches were conducted up to 23 January 2026, using tailored strategies for mouthrinses, fluoride varnishes, silver diamine fluoride (SDF), and glass ionomer cements (GICs). Randomized clinical trials (RCTs) were included. Data extraction and qualitative synthesis focused on clinical outcomes and applicability in public health contexts. Results: Fifty-five RCTs were included. Fluoride- or chlorhexidine-based mouthrinses showed potential in controlling cariogenic biofilm, with evidence primarily based on microbiological outcomes. Fluoride varnishes were associated with enamel remineralization and control of early white spot lesions, particularly in supervised programs. SDF was reported to achieve high caries’ arrest rates in cavitated dentin lesions of primary teeth, while its preventive effect on sound surfaces appeared comparable to other fluoride-based interventions. GICs were associated with acceptable clinical performance as pit-and-fissure sealants and in atraumatic restorative treatment. Conclusions: Minimally invasive dentistry (MID) approaches show promise for the prevention and management of childhood dental caries in public health and community-based settings. However, these findings should be interpreted with caution due to the heterogeneity of interventions and outcome measures, the predominance of short-term and surrogate (microbiological) outcomes, and the absence of a formal risk-of-bias assessment. As a scoping review, the synthesis is narrative in nature, which limits the ability to draw definitive conclusions. Further studies with standardized clinical outcomes and longer follow-up are needed to strengthen the evidence.

Healthcare doi: 10.3390/healthcare14091154

Authors: Nicholas C. Watson Kathrine Kelly Laura Krech Alistair Chapman Steffen Pounders Matthew Armstrong Charles J. Gibson Gaby Iskander

Background/Objectives: The coronavirus disease 2019 (COVID-19) pandemic presented significant psychosocial challenges to intensive care unit health care workers (ICU HCW). Prior studies typically used single cross-sectional samples to focus on elements of burnout and psychological stress. We sought to serially assess quality of life and willingness to work before, during, and after the first peak of COVID-19. Methods: Two survey instruments were prospectively administered at regular intervals to multidisciplinary ICU HCWs, initiating at the local onset of COVID-19 and ending 6 months after the first peak ICU census of COVID-19 patients. Results: ICU HCWs reported high levels of compassion satisfaction, burnout, and secondary traumatic stress before, during and after the first peak of COVID-19. Motivation to work declined, and hesitation to work increased from study initiation to the peak ICU census of COVID-19 patients. Hesitation to work was greater in female HCWs and cardiothoracic ICU HCWs. Motivation to work was higher in those working in operating rooms compared to those in the ICU. Concerns about becoming infected, feelings of isolation, and exhaustion were associated with high hesitation to work. Feeling protected by the government and hospital was associated with decreased hesitation and increased motivation to work. Conclusions: ICU HCWs experienced high levels of stress throughout the first year of COVID-19, while satisfaction with work remained high. Willingness to work was associated with gender, work location, ICU subtype, concerns about infection risk, feelings of exhaustion, and feelings of institutional protection. Because the study methodology precludes causal inference and low survey response rates indicate that findings should be interpreted with caution, these results are best viewed as hypothesis-generating for future work aimed at improving stress mitigation in ICU HCWs.

Healthcare doi: 10.3390/healthcare14091153

Authors: Charalampos Milionis Eftychia G. Koukkou Kostas B. Markou Ioannis Ilias

Iodine is an essential trace element for thyroid hormone synthesis, metabolic homeostasis, and fetal neurodevelopment. During pregnancy, maternal iodine requirements increase substantially, yet global recommendations are primarily based on population-level biomarkers rather than individualized physiological data. In this review, we examine current international guidelines for iodine adequacy in pregnancy, evaluate the limitations of population-based metrics—such as urinary iodine concentration (UIC) and serum thyroglobulin (Tg)—and highlight emerging evidence on physiological adaptations, functional biomarkers, and individualized risk factors. We incorporated data from population surveillance studies, mechanistic investigations of thyroid adaptation, and clinical outcome research identified through a literature search of PubMed/MEDLINE and Scopus (2016–2025). Evidence indicates that the widely adopted WHO range for iodine intake in pregnant women may overestimate the actual needs of gestation. There is a U-shaped relationship between iodine intake and thyroid outcomes, meaning both low and high iodine exposure adversely affect maternal thyroid function and fetal neurodevelopment, highlighting the narrow optimal intake window. Individualized considerations—including autoimmune thyroid disease, supplementation practices, environmental exposures, and coexisting micronutrient deficiencies—further modulate iodine requirements. Functional indices, such as the Thyroid Feedback Quantile-based Index (TFQI), may offer complementary tools for assessing iodine adequacy beyond traditional biomarkers.

Healthcare doi: 10.3390/healthcare14091152

Authors: Meropi Mpouzika George Athinis Maria Karanikola Stelios Parissopoulos Georgios Papageorgiou Christos Rossis Evangelia Giannelou

Background/Objectives: Trauma management in emergency departments (EDs) requires rapid and reliable diagnostic tools. The Focused Assessment with Sonography in Trauma (FAST) is a bedside ultrasound examination used for the early detection of free fluid in the intraperitoneal cavity, pericardium, and pleural spaces. Expanding FAST use to trained emergency nurses may support timely bedside evaluation in high-demand settings. However, data on agreement with physicians remains limited. This study aimed to evaluate the inter-rater agreement between a trained emergency nurse and physicians in performing FAST and to explore the diagnostic accuracy of nurse-performed FAST compared with computed tomography (CT). Methods: A prospective pilot observational agreement study was conducted between October and December 2023 in the ED of a general hospital in Cyprus. FAST examinations were independently performed by a nurse trained in FAST and by physicians from the radiology department. Four anatomical areas were assessed: right upper quadrant (RUQ), left upper quadrant (LUQ), subxiphoid-pericardial area (SUPH), and suprapubic area (BLADDER). Findings were recorded independently to promote blinding. Diagnostic performance of nurse-performed FAST was explored in a subset of patients undergoing CT. Results: The sample included 68 trauma patients, of whom 58 underwent FAST by both the nurse and the radiologists and were included in the inter-rater agreement analysis. Fluid was detected in four patients (6.9%) in the RUQ area and in one patient (1.7%) in both the LUQ and SUPH regions, while no positive findings were recorded in the BLADDER area. Agreement in the RUQ area was 98.3% (Cohen’s kappa = 0.85, p < 0.001) while agreement was observed in all cases in the SUPH region (100%, Cohen’s kappa = 1.00, p < 0.001), although this finding was based on a single positive case. High observed agreement was also noted in LUQ (98.3%) and BLADDER regions; however, Cohen’s kappa could not be reliably estimated in these regions due to limited variability and the very small number of positive cases. In a subgroup of patients who underwent CT (n = 23), as well as in an additional Trauma Team subgroup (n = 10), diagnostic accuracy estimates were 100% for sensitivity and specificity; however, these estimates were based on a very small number of positive cases (only two positive cases in each subgroup) and were associated with wide confidence intervals. Conclusions: This pilot study suggests that, under specific training conditions, a trained emergency nurse may achieve a high level of agreement with physician assessments when performing FAST. The findings regarding diagnostic accuracy are preliminary and should be interpreted with caution due to the small sample size and low number of positive cases. Further studies with larger samples and multiple operators are required to confirm these findings and to evaluate their clinical implications. Future research is also needed to determine whether nurse-performed FAST may contribute to improved patient safety and emergency department workflow.

Healthcare doi: 10.3390/healthcare14091151

Authors: Jo Bell Cathy Brennan

Self-harm and suicide among young people represent one of the most pressing public health challenges facing contemporary societies [...]

Healthcare doi: 10.3390/healthcare14091150

Authors: Elif Kerimoğlu

Objective: This study evaluated the relationships between the development and clinical course of pressure injuries (PIs) and neurological status, nutritional risk, and laboratory parameters among patients admitted to a tertiary intensive care unit. Materials and Methods: The single-center, retrospective, observational study included 220 patients hospitalized in the intensive care unit for at least 5 days. On the day of admission, Glasgow Coma Scale (GCS), Acute Physiology and Chronic Health Evaluation II (APACHE II), Braden, and Nutritional Risk Screening 2002 (NRS-2002) scores were assessed. Demographic characteristics, comorbidities, need for sedation and vasopressors, and laboratory parameters during the first 24 h (albumin, C-reactive protein, lactate, D-dimer) were analyzed. Factors independently associated with new PI development and clinical improvement were identified using binary logistic regression. Results: New PIs developed in 25% of patients. Patients with PI progression were older and had lower GCS and Braden scores, higher NRS-2002 scores, lower albumin levels, and higher D-dimer levels (p < 0.05). In multivariable analysis, low GCS (OR = 0.824), presence of comorbidity (OR = 2.327), and a high NRS-2002 risk level were independent predictors of new PI development. The model’s discriminative ability was acceptable (AUC = 0.756). Among patients with existing PIs, NRS-2002 score (OR = 0.450) and age (OR = 1.058) were independently associated with clinical improvement in an exploratory multivariable model. Conclusions: NRS-2002 was the only variable independently associated with both new PI development and the clinical improvement of existing lesions, underscoring the central role of nutritional risk assessment in ICU-based PI prevention and prognosis.

Healthcare doi: 10.3390/healthcare14091149

Authors: Lujayn Altahan Jasna Twynstra Jamie A. Seabrook Michelle F. Mottola

Objectives: The objectives of this review are to explore the effects of various nutrition and exercise lifestyle interventions on pregnancy outcomes in individuals with, or at risk of, gestational diabetes mellitus (GDM), as well as to examine whether interventions that are culturally and/or religiously sensitive influence clinical and behavioural outcomes. Methods: This study was conducted as a narrative review. PRISMA was used solely as a reporting guide to enhance transparency in the search and study selection process. PubMed/MEDLINE, CINAHL, and Scopus were searched for studies published up to November 2025. Intervention-based studies evaluating nutrition, physical activity, or combined lifestyle interventions targeting either GDM incidence, insulin use, or glycemic outcomes were included. Forty-three studies met eligibility criteria. Study designs consisted primarily of randomized controlled trials (RCTs) with one case–control and one quasi-experimental design trial. Results: Combined lifestyle interventions generally showed the most consistent improvements in glycemic control; however, findings were not uniform across all studies, and reporting on insulin outcomes was limited. The Mediterranean, low-glycemic index (LGI) and DASH diets, along with supervised, prenatal exercise programs with low–moderate intensity, delivered at least three times per week, were effective in managing GDM. Regarding culturally or religiously sensitive interventions, only one study was identified. Conclusions: Lifestyle interventions may improve glycemic outcomes in GDM; however, further high-quality research is needed, particularly studies incorporating culturally and religiously sensitive approaches and improved reporting of insulin-related outcomes.

Healthcare doi: 10.3390/healthcare14091148

Authors: Niki Syrou Ioannis G. Fatouros George S. Metsios Athanasios Z. Jamurtas Dimitrios Draganidis Konstantinos G. Perivoliotis Athanasios Poulios Panagiotis Tsimeas Konstantinos Papanikolaou Theodore J. Angelopoulos Ioannis Adamopoulos George Mastorakos

Background/Objectives: The multiple benefits of physical activity and exercise (PAE) for non-communicable diseases (NCDs) and, thus, for public health underscore the importance of their multidisciplinary implementation in clinical practice. However, there is a lack of validated instruments that comprehensively assess physicians’ knowledge, attitudes, intentions, abilities, and behaviour (KAIAB) regarding PAE promotion in NCD management. Methods: This study aimed to develop and validate a new questionnaire to assess physicians’ KAIAB towards PAE and to evaluate their KAIAB levels. A two-stage design, including an e-Delphi method and a cross-sectional study, was conducted in Greece from January 2022 to May 2022. Results: In the first stage, after achieving consensus and stability within a purposive sample of 16 physician–experts (response rate 100%), the questionnaire was effectively developed and validated (Content Validity Ratio: 0.5–1) using a two-round e-Delphi method. In the second stage, a cross-sectional study was conducted in two physician populations from 12 medical specialities (response rate: 18.2%) and demonstrated that the new questionnaire had sufficient face validity and high reliability (Cronbach’s alpha: 0.805– 0.931). The three original Bloom levels’ cut-off points were also used to classify physicians’ KAIAB levels in the second stage. KAIAB levels were assessed using median and interquartile range (Mdn/IQR) and were found to be low (13/6), moderate (128/79), high (35/9), moderate (21/8), and moderate (33/8), respectively. Conclusions: The new questionnaire is reliable and valid. It is recommended that the questionnaire be applied in larger studies to further verify its validity and applicability. Additionally, it was found that although physicians reported high intentions and moderately positive attitudes toward PAE promotion, their knowledge in these domains and their exercise prescription practices remained limited. This underscores the need to enhance policies and initiatives in medical education and the healthcare system.

Healthcare doi: 10.3390/healthcare14091147

Authors: Iván Martín-Miguel Millán Aguilar-Navarro Juan Del Coso Arturo Franco-Andrés Carolina García Alejandro Muñoz

Doping remains a major threat to athlete health and sport integrity. Although anti-doping efforts have traditionally focused on athletes, increasing attention has turned to Athlete Support Personnel (ASP) due to their influence on athletes’ decisions, behaviors and involvement in anti-doping rule violations. This narrative review aimed to synthesize the existing literature on the role of ASP (including coaches, physicians, pharmacists, sport psychologists, nutritionists, physiotherapists, parents and other family members) in anti-doping, with particular attention to their influence on athletes’ knowledge, attitudes, behaviors, education and decision-making related to doping. Coaches, physicians, and pharmacists are among the ASP groups most frequently examined in the literature, although substantial knowledge gaps remain across all groups. Coaches shape motivational climates and ethical norms but often lack adequate understanding of anti-doping regulations and supplement risks. Physicians and pharmacists play key roles in medication management and Therapeutic Use Exemptions procedures, though incomplete regulatory knowledge may contribute to inadvertent violations. Nutritionists are central in preventing supplement-related doping, while research on sport psychologists and physiotherapists remains limited despite their preventive potential. Parents significantly shape athletes’ moral development and susceptibility to doping, acting as protective or risk factors depending on family dynamics. Overall, anti-doping education for ASP remains inconsistent. In conclusion, ASP plays an essential yet heterogeneous role in influencing doping-related behaviors. Strengthening role-specific and interdisciplinary anti-doping education, particularly within university programs and professional development, appears critical for enhancing ASP competence and promoting a sustainable culture of clean sport.

Healthcare doi: 10.3390/healthcare14091143

Authors: Saud Ibrahim Altilasi Dima Hamze Mazin Elsarrag Muhammad Raihan Sajid Salman Aldosari

Background/Objectives: Blood donation is a critical component of healthcare systems worldwide, yet donor recruitment remains challenging. This study evaluates the knowledge, attitudes, motivations, and practices (KAP) of blood donation among the general population in Saudi Arabia to identify key barriers and propose targeted interventions. Methods: A cross-sectional study was conducted using a structured, validated questionnaire distributed over five months (December 2022 to April 2023) via social media and in-person recruitment at the Central Blood Bank in Riyadh. A total of 1150 participants aged 18–60 years residing in Saudi Arabia were included in the final analysis. Statistical analysis was performed using SPSS version 22, with p < 0.05 considered significant. Results: Participants demonstrated moderate knowledge (mean score 5.43 ± 1.81 out of 9), with significantly higher scores among males, individuals aged 21–30 years, and those holding a bachelor’s degree. Attitudes toward donation were highly positive (mean score 15.46 ± 2.74 out of 20) and correlated with age, gender, marital status, and occupation. Despite this positive outlook, only 34.96% of participants had donated blood previously, although 95.25% expressed willingness to do so. Primary motivators included mobile donation units (89.22%) and paid leave (89.22%), whereas 51.22% of respondents considered current media campaigns ineffective. Common barriers to donation included health concerns (25.30%), time constraints (12.87%), and fear of needles (7.74%). Conclusions: This study reveals a critical disparity between positive public attitudes and actual donation practices in Saudi Arabia. To enhance donor participation, we recommend implementing convenient donation strategies such as mobile blood drives, workplace incentives, and more effective, culturally tailored educational campaigns. Addressing these factors could help Saudi Arabia improve its voluntary donation rates and ensure a sustainable, safe blood supply.

Healthcare doi: 10.3390/healthcare14091146

Authors: Anabel Fernández-Vargas Otilia Vanessa Cordero-Ahiman Diana Patricia Vanegas-Coveña Andrea C. Valencia-Altamirano Juan José González-Gerez Cayetano Fernández-Sola José Manuel Hernández-Padilla

Objective: The aim of this study was to explore how healthcare professionals in the Republic of Ecuador perceive violence against women, its underlying social determinants, and their role in prevention and response within the healthcare setting. Methodology: A qualitative descriptive study was conducted using purposive sampling. Ten healthcare professionals with experience in managing cases of violence against women participated. Data were collected through semi-structured interviews and analysed using Braun and Clarke’s reflective thematic analysis. The ATLAS.ti software was used throughout the analysis process. Results: The participants emphasised the normalisation of microaggressions, institutional shortcomings in prevention systems, and the need for gender-sensitive professional training. Three main themes emerged from the data analysis: (1) the characteristics and identification of violence against women, (2) the social dimensions of violence against women, and (3) combating violence against women in clinical and educational settings. Conclusions: The healthcare professionals highlighted the need to recognise normalised and less visible forms of violence reflected in everyday attitudes and behaviours. They emphasised the importance of early identification, multidisciplinary care and sex education as preventive strategies. The social context and deep-rooted power dynamics favour the perpetuation of violence against women. Healthcare professionals can play an important role in the prevention of violence against women by improving care for survivors, identifying areas for improvement within existing prevention systems, and promoting sex education.

Healthcare doi: 10.3390/healthcare14091145

Authors: Vanessa Santos Joana Serpa Mariana Parreira Vanda Correia Priscila Marconcin

Background: Health-related behaviors often cluster during young adulthood, potentially increasing the risk of long-term adverse health outcomes. Understanding how lifestyle risk behaviors co-occur among university students is essential for developing targeted health promotion strategies. Objective: This study aimed to identify lifestyle risk profiles among university students based on the co-occurrence of smoking behavior, alcohol consumption, sedentary behavior, and body weight status. Methods: A cross-sectional study was conducted with 147 university students enrolled in a physical education and sport undergraduate program (mean age: 20.58 ± 2.94 years; 80.3% male). Physical activity and sedentary behavior were assessed using the International Physical Activity Questionnaire–Short Form (IPAQ-SF), while smoking and alcohol consumption were self-reported. Body mass index was used to classify weight status. Lifestyle risk profiles were identified using two-step cluster analysis based on regular smoking, alcohol consumption, sedentary behavior, and overweight/obesity. Differences in cluster distribution according to sex and federated athlete status were examined using chi-square tests. A two-step cluster analysis based on the Bayesian Information Criterion (BIC) and silhouette measure was used to identify lifestyle risk profiles. Results: Overall, 46.9% of participants had experimented with tobacco, 11.6% were current smokers, and 74.8% reported alcohol consumption. Participants accumulated an average of 3772.25 ± 1957.99 MET-min/week of physical activity. Three distinct lifestyle risk profiles were identified. Cluster 1 (46.9%), labeled the alcohol profile, was characterized by alcohol consumption without smoking and no prevalence of being overweight. Cluster 2 (20.4%), the multiple-risk profile, included participants who reported regular smoking, with nearly half presenting sedentary behavior and overweight/obesity. Cluster 3 (32.7%), the overweight profile, was characterized by overweight/obesity combined with alcohol consumption but no smoking. No significant differences were observed in the distribution of lifestyle profiles according to sex (p = 0.111) or federated athlete status (p = 0.087). Conclusions: Lifestyle risk behaviors cluster into distinct profiles among university students, with alcohol consumption appearing across multiple profiles and smoking concentrated in a specific high-risk group. These findings highlight the need for targeted health promotion strategies addressing multiple co-occurring behaviors within university populations.

Healthcare doi: 10.3390/healthcare14091142

Authors: Federico Abate Daga Stefania Cazzoli Samuel Agostino

Background/Objectives: Physical activity behaviours are established early in life and tend to track across developmental stages. However, the role of continuity of sport participation across multiple developmental periods in shaping current physical activity levels remains insufficiently understood. This study aimed to examine the association between continuity of sport participation across developmental stages and current physical activity levels in university students, and to assess whether this association followed a graded pattern and differed by sex. Methods: A cross-sectional study was conducted among 796 fourth-year undergraduate students enrolled in a Primary School Education degree program at the University of Turin. Data were collected using an anonymous online survey. Current physical activity was assessed using the International Physical Activity Questionnaire—Short Form (IPAQ-SF) and categorised as non-active, sufficiently active, or active. Sport participation across six developmental stages was retrospectively assessed and summarised into a three-level continuity variable (discontinuous, intermediate, continuous). Associations were examined using chi-square tests and ordinal logistic regression models adjusted for sex, age, and body mass index (BMI). Predicted probabilities were estimated to aid interpretation. Results: Continuity of sport participation was significantly associated with current physical activity levels (χ2(6) = 67.55, p < 0.001), with a graded pattern evident. In adjusted models, discontinuous participation (OR = 0.24, 95% CI 0.14–0.39) and intermediate participation (OR = 0.62, 95% CI 0.46–0.82) were associated with lower odds of belonging to higher physical activity categories than continuous participation. Predicted probabilities showed a clear dose–response pattern, with progressively higher likelihoods of being active as continuity increased. This pattern was consistent across sexes, although males exhibited higher overall activity levels. Conclusions: Greater continuity of sport participation across developmental stages is associated with higher current physical activity levels. Promoting sustained engagement in sport may support the development of active lifestyles across the lifespan.

Healthcare doi: 10.3390/healthcare14091144

Authors: Clarissa Santos de Lima Araújo Larissa Maiara da Silva Alves Souza Agueda Mª Ruiz Zimmer Cavalcante Janaína Guimarães Valadares Flaviana Vely Mendonça Vieira Dorothy Jones Natália Del Angelo Aredes Luca Bertocchi

Background/Objectives: Nursing assessment frameworks play a critical role in guiding holistic patient evaluations, standardizing documentation, and supporting organizational quality and safety initiatives. Among these, Gordon’s Functional Health Patterns (FHPs) offer a comprehensive and widely used framework for nursing assessment. However, no review has synthesized evidence on their association with outcomes. This scoping review aimed to map evidence on the use of FHPs in relation to patient and organizational outcomes, and to examine their integration into electronic health records (EHRs) and the analytical methods employed. Method: A scoping review was conducted following Joanna Briggs Institute methodology and PRISMA-ScR guidelines. PubMed, CINAHL, and Scopus were searched for quantitative primary studies reporting associations between FHPs and outcomes, and the final search was conducted on 22 March 2024. Three reviewers independently screened abstracts and full texts and extracted data. Results: Seven studies met the inclusion criteria. FHPs’ use was associated with improvements in several patient outcomes, including quality of life, psychological well-being, clinical parameters, self-management, dependency level, and functional performance. Organizational outcomes included reduced hospital readmission rates and a positive association between FHP-derived nursing diagnoses and nursing workload. Most studies used standardized nursing terminologies such as NANDA-I, NOC, or NIC, in conjunction with FHPs. Over half of the studies used EHR-based nursing documentation, reflecting increasing digital integration and enabling more structured and interoperable nursing data. Methodological approaches varied widely: most studies used associative analyses, two employed experimental designs, and one investigated the predictive utility of FHP-based assessment data. Conclusions: FHPs provide a structured framework for nursing practice with potential benefits for patient and organizational outcomes. Their increasing integration into EHRs supports standardized documentation and data-driven nursing practice, enhancing assessment quality, diagnostic accuracy, and the availability of structured data for clinical and managerial decision-making in health information systems. Further experimental and longitudinal research is needed to strengthen causal evidence and guide implementation.

Healthcare doi: 10.3390/healthcare14091141

Authors: Ther Lim Yun Hu Ada Wah Yean Lee Jit Kai Tan Qi Yin Ngoi Naiying Liu Audrey Cai Ling Tay Justin Guang Jie Lee Yeuk Fan Ng

Background/Objectives: Health systems globally are transforming toward population-based, person-centred care, yet measurement systems frequently remain anchored in provider-centric or disease-specific frameworks. This paper presents the Systemic Health System Measurement Framework (SHSMF), a population health systems measurement architecture that completes a conceptual systemic health systems design and transformation trilogy with the Unified Care Model (UCM) and Systemic Health System Population Segmentation Model, addressing how health systems can measure whether systems integration is succeeding. Methods: This study employs a conceptual framework development and implementation case study design approach, with the Systemic Health System Measurement Framework (SHSMF) developed using the Health System Transformation Playbook (HSTP) methodology. The framework organises measurement around needs-based population segments, integrates Lifelong Care and Episodic Care measurement within a unified architecture, and cascades indicators across macrosystem, mesosystem and microsystem levels. Implementation was demonstrated through the development of performance and governance dashboards development at Yishun Health, a regional population health system serving approximately 320,000 residents in Singapore (2022–2024). Results: Descriptive analytics from the Lifelong Care Dashboard (207,980 residents across seven segments) and the Episodic Care Dashboard (230,365 inpatient cases across six segments) revealed systemic patterns not readily apparent through conventional approaches. Psychosocial complexity was consistently associated with disproportionate cost trends across both dashboards despite lower medical acuity. Quality indicator performance across psychosocially complex segments was not proportionally worse, yet these segments bore disproportionate costs, a pattern consistent with the view that segment-specific care redesign addressing psychosocial needs may be associated with both an improvement in outcomes and cost efficiencies. Conclusions: The Systemic Health System Measurement Framework (SHSMF) demonstrates that a measurement architecture explicitly designed around systemic needs-based population segments improves systemic health systems accountability and provides governance opportunities that conventional approaches may not achieve. The framework and its dashboard implementation offer a transferable methodology for health systems globally seeking to implement a whole-systems measurement architecture for value-based population health management.

Healthcare doi: 10.3390/healthcare14091140

Authors: Maks Tušak Aleš Porčnik Ivan Kneževič Jasmina Markovič-Božič Matej Tušak Andrej Lapoša

Breast reconstruction represents an integral component of contemporary breast cancer management, with substantial impact on patients’ psychological well-being, body image, and overall quality of life. Given the profound symbolic and personal significance of the breast, mastectomy—whether total or partial—extends beyond oncologic resection and may result in considerable aesthetic, functional, and psychosocial consequences. For this reason, reconstructive planning should be incorporated into the initial multidisciplinary treatment strategy while ensuring that oncologic safety and adjuvant therapies are never compromised. Breast reconstruction may be achieved using autologous tissue, implant-based techniques, or a combination of both approaches. Each method carries specific advantages, limitations, and potential complications and must be tailored to the individual patient’s oncologic status, anatomy, and expectations. This article provides a historical overview of the evolution of breast cancer treatment and reconstructive techniques. It further examines the principles, benefits, and challenges associated with different reconstructive modalities, highlighting key considerations in clinical decision-making and long-term outcomes.

Healthcare doi: 10.3390/healthcare14091139

Authors: Didem Aybike Haspolat Aslı Gizem Çapar Şule Göktürk

Introduction: Accurately meeting the energy requirements of patients in intensive care units (ICUs) is crucial to prevent catabolism, muscle loss, and complications. We assessed their energy needs in this study using indirect calorimetry (IC) and predictive formulas, comparing the results with delivered energy intake and evaluating agreement. Materials and Methods: A total of 38 mechanically ventilated patients in seven ICUs at Kayseri City Hospital were included; eligible patients were ≥18 years old and mechanically ventilated for at least 24 h. Disease severity and nutritional risk were evaluated using validated indices (prognostic nutritional index (PNI) and Modified Nutrition Risk in the Critically Ill (mNUTRIC)), and basal energy expenditure (BEE) was measured by IC and calculated using the Harris–Benedict (HB) and ESPEN formulas. IC measurements lasted 15 min under resting conditions in conscious patients and, according to acute phase criteria, in unconscious patients in a quiet, temperature-controlled environment. Nutrition was provided enterally or parenterally based on patient condition and disease severity. Agreement between IC and predictive formulas was assessed using Bland–Altman analysis, a statistical method that evaluates agreement between two measurement techniques. Results: Estimated energy requirements differed significantly from delivered energy intake (p < 0.001). IC-derived values were significantly lower than those estimated by the HB equation and ESPEN recommendations (p < 0.001), suggesting that predictive equations may overestimate energy requirements in this population. By contrast, delivered energy intake was lower than IC-measured values, with a mean difference of approximately 503 kcal, indicating a potential risk of underfeeding in clinical practice. Weak correlations were observed between methods (IC vs. HB: r = 0.35, p = 0.003; IC vs. ESPEN: r = −0.21, p = 0.02), indicating limited agreement between predictive equations and IC measurements, and Passing–Bablok regression analysis further supported this lack of agreement between methods. Conclusions: The energy intake delivered to patients was lower than the calculated values. Indirect calorimetry is important for accurately monitoring and determining energy requirements based on delivered energy intake, and further research in this area is needed. These findings highlight the importance of individualized monitoring of energy expenditure in critically ill patients and suggest that reliance solely on predictive equations may lead to clinically relevant discrepancies in energy delivery.

Healthcare doi: 10.3390/healthcare14091138

Authors: Ayfer Atav Aysenaz Gunes Emre Ovsay Celalettin Topbaş

Objectives: Oral healthcare and regular dental follow-up are important during pregnancy, as maternal oral health may have important implications for both maternal and fetal well-being. However, dental attendance remains low. Therefore, this cross-sectional e-survey aimed to explore pregnant women’s dental pain management strategies, their perceptions of endodontic treatment, and avoidance of specific endodontic procedures during pregnancy. Methods: An 18-item online questionnaire was administered to 130 pregnant women. Data were collected on dental attendance, experiences of toothache, use of analgesics or antibiotics, and perceptions of the safety of dental anesthesia and radiographic procedures during pregnancy. Statistical analyses were conducted using Chi-square or Fisher’s exact tests and multivariate logistic regression (p < 0.05). Results: The mean age of participants was 32 years. Only 26.15% reported attending regular dental visits during pregnancy. Among participants who experienced toothache, 51.52% used analgesics and 1.54% used antibiotics. Although 92.31% believed dental infections should be treated during pregnancy, concerns regarding dental procedures were common; 76.92% considered dental radiography unsafe and only 50% considered local anesthesia safe. Multivariate analysis showed that the number of pregnancies was associated with dental visits during pregnancy (p = 0.048), age with analgesic use (p = 0.018), and education level with perception of dental radiography safety (p = 0.013). Conclusions: Despite awareness of the importance of treating dental infections, pregnant women may delay endodontic care during pregnancy, highlighting a need for improved patient education and clearer clinical guidance.

Healthcare doi: 10.3390/healthcare14091137

Authors: Köksal Sarihan Ali İnaltekin Onur Alp Yilmaz

Background: This cross-sectional study aimed to determine the status of kinesiophobia in patients with fibromyalgia syndrome (FMS) and to evaluate its relationship with cognitive functions, anxiety, depression, disease severity, and pain level. Methods: Fifty FMS patients (mean age 44.06 years; range 18 to 60 years) were included in the study. Fifty healthy participants (mean age 42.04 years; range 18 to 60 years) were included in the study as a control group. Participant recruitment for the study was conducted in a state hospital in Türkiye. Disease severity level in the FMS group was assessed using the Fibromyalgia Impact Questionnaire (FIQ). The Tampa Scale for Kinesiophobia (TSK) was administered to determine the participants’ kinesiophobia status. The Hospital Anxiety and Depression Scale (HADS) was used to assess the participants’ anxiety and depression status. The Montreal Cognitive Assessment (MoCA) test was administered to assess cognitive functions. Results: TSK, HADS-Anxiety, Visual Analog Scale (VAS), and FIQ scores were higher in the FMS group compared to the control group (p < 0.05). MoCA total scores, MoCA-Visuospatial/Executive, and MoCA-Attention scores were higher in the control group (p < 0.05). There was a weak positive correlation between TSK and FIQ scores in the FMS group (p: 0.02, r: 0.31). There was a weak negative correlation between TSK and MoCA-Naming scores in the FMS group (p: 0.02, r: −0.31). Conclusions: Increased kinesiophobia was found in FMS patients compared to the general population. It was determined that the level of kinesiophobia in FMS patients was related to disease severity and naming-related cognitive functions. Clinicians dealing with FMS should take this into particular consideration.

Healthcare doi: 10.3390/healthcare14091136

Authors: Haowen Huang Ting Liu La Pan Shuo Man Ling Xia Yuan Wang

Background: Emotional distress (ED) is common among patients with gynecological malignancies and is associated with reduced quality of life and suboptimal health outcomes. Total-score approaches may overlook the complex interrelationships among individual emotional symptoms. Objective: This study provides a theory-informed contextual application and empirical boundary test of symptom network analysis, organized by the Stress Process Model (SPM), to examine not only how ED symptoms cluster and connect with psychosocial correlates and quality-of-life domains, but also whether psychosocial stratification is reflected in altered symptom topology or primarily in differences in distress burden. Methods: A cross-sectional study was conducted among 415 patients with gynecological malignancies recruited from a tertiary hospital in China. ED was assessed using the Brief Profile of Mood States-Short Form (BPOMS-SF30). An exploratory three-track screening strategy was used to derive a focused 16-node set of frequent negative mood symptoms. Gaussian graphical models with EBICglasso regularization were estimated for the symptom network and for extended networks including demographic/clinical variables, SPM-related psychosocial variables, and quality-of-life indicators. Results: The ED network showed dense positive connectivity, with strong within-domain clustering and several cross-domain associations. Exhaustion, restlessness, and irritability were relatively more relationally prominent in the primary network, although centrality stability was low to moderate across models. Fatigue-related symptoms were closely connected with anxiety, depressive symptoms, and impaired quality of life. Among psychosocial variables, self-perceived burden showed the strongest conditional association with fatigue. Adjusting for demographic and clinical variables did not materially alter the core symptom network, and no significant subgroup differences in global strength or overall structure were observed across psychosocial strata. Conclusions: In this sample, psychosocial risk stratification appeared to relate more to the overall severity and burden of distress than to major reorganization of symptom topology. The study therefore contributes primarily as a theory-informed contextual application of network methods and as an empirical boundary test showing that several psychosocial strata did not exhibit major topological differences. Because the retained nodes were selected for prevalence, association strength, and selection stability, the observed prominence of fatigue- and activation-related symptoms should be interpreted as conditional on this focused symptom subset. Overall, the findings are correlational, exploratory, and hypothesis-generating.

Healthcare doi: 10.3390/healthcare14091135

Authors: Maciej Biały Rafał Gnat

Background/Objectives: The optimal management of anterior cruciate ligament (ACL) rupture remains debated, especially regarding long-term outcomes after early ACL reconstruction (ACLR) versus rehabilitation-first with optional delayed ACLR. The interpretation of randomized evidence is complicated by frequent treatment crossover. This review synthesized evidence from randomized controlled trial (RCT) cohorts comparing surgical versus rehabilitation-first management strategies across available follow-up durations. Methods: A structured review based on a systematic literature search and narrative synthesis was conducted, with study identification and reporting guided by PRISMA 2020. MEDLINE (via PubMed) and Google Scholar were searched in February 2026 for English-language human RCTs (2000–2026) comparing early ACLR plus rehabilitation with rehabilitation-first management allowing delayed ACLR for persistent instability. A linked-report PubMed search using the KANON trial registration number (ISRCTN84752559) was additionally performed to identify cohort-derived follow-up publications. Reports were grouped by underlying RCT cohort. Data were extracted on crossover, follow-up, and clinical outcomes. Risk of bias for primary RCT reports was assessed with Cochrane RoB 2. Results: Twenty-seven reports representing three RCT cohorts (KANON, COMPARE, ACL SNNAP) were included; six index reports were prioritized for synthesis. In acute ACL rupture (KANON, COMPARE), early ACLR did not show a consistent long-term superiority in patient-reported outcomes versus rehabilitation-first with optional delayed ACLR, although COMPARE reported a statistically significant 2-year subjective functional difference favoring early ACLR; early ACLR more consistently improved mechanical stability and reduced instability episodes. Crossover from rehabilitation to delayed ACLR was common. In non-acute ACL injury with persistent symptomatic instability (ACL SNNAP), surgery-first improved 18-month patient-reported outcomes. Meniscal procedure rates and osteoarthritis-related outcomes did not consistently favor early ACLR. Conclusions: In acute ACL rupture, rehabilitation-first with timely access to delayed ACLR appears to provide long-term patient-reported outcomes comparable to an early ACLR strategy in many patients, while early ACLR more consistently improves knee stability. In non-acute symptomatic ACL deficiency, a surgery-first strategy appears more effective in the mid-term. These randomized trials should be interpreted as comparisons of management strategies rather than of “pure” operative versus nonoperative treatment approaches.

Healthcare doi: 10.3390/healthcare14091134

Authors: Francesco Sferrazzo Beatrice Marchi Anna Savio Andrea Roletto Simone Zanoni

Background/Objectives: Healthcare facilities are among the most energy-intensive public buildings, yet hospital decision-support models rarely integrate energy-related performance indicators alongside operational metrics. This study aims to address this gap by developing a discrete-event simulation framework capable of jointly evaluating clinical efficiency and energy consumption in elective orthopedic surgical pathways. Methods: A comprehensive discrete-event simulation model was developed to represent the diagnostic imaging and orthopedic surgical process. The model was parameterized using a hybrid data-collection approach that combined clinical activity data, scientific literature, and expert judgment. Energy consumption was modeled by differentiating fixed loads, such as heating, ventilation, and air-conditioning systems and lighting, from activity-dependent loads associated with diagnostic and surgical equipment. Baseline performance was assessed and compared with alternative scenarios for organizational and technological improvements. Results: The analysis showed that fixed infrastructural loads, particularly HVAC systems, were the main drivers of per-patient energy consumption, with inefficient space utilization and prolonged idle times. Scenario analysis demonstrated that organizational interventions, such as increasing operating room throughput and optimizing MRI scheduling, can substantially reduce energy intensity by diluting fixed loads and decreasing idle consumption. Technological interventions, such as replacing conventional surgical lamps with LED systems, produced smaller but still beneficial reductions. The combined implementation of organizational and technological strategies yielded the greatest overall improvement. Conclusions: Integrating energy metrics into discrete-event simulation provides effective support for hospital decision-making by revealing the interaction between workflow design, resource utilization, and environmental performance. The findings indicate that organizational redesign, particularly when combined with technological upgrades, can significantly improve both operational efficiency and sustainability in hospital settings. This study highlights discrete-event simulation as a promising tool for energy-aware healthcare planning.

Healthcare doi: 10.3390/healthcare14091133

Authors: Saar Baert Mariska Meersschaut Kristien Roelens Sara Van Belle Paul Gemmel Iva Bicanic Ines Keygnaert

Background: Sexual Assault Care Centres (SACCs) in Belgium provide integrated medical and psychological care, a forensic examination and the option to report to the police to victims of sexual assault (SA). Understanding victims’ acceptability of these services is essential for improving SACC’s effectiveness and informing policy. Methods: In-depth interviews were conducted with 19 victims and 14 support persons to explore victims’ experiences with SACCs. The victims represented diverse characteristics (gender, age, SACC site and police reporting status). Data were analysed using thematic framework analysis, guided by Sekhon’s “Theoretical Framework of Acceptability”. Results: Participants viewed SACCs as a highly acceptable integrated model of specialised care for victims of recent SA. They expressed strong appreciation for the care provided at the SACC and its set-up (affective attitude), and they identified key professional qualities of SACC professionals (ethicality). Participants demonstrated good understanding of the functioning of the SACCs (intervention coherence). The model was perceived as effective in providing medical care, mental health support, and facilitating police reporting, though gaps were noted in linking victims with other actors in the criminal justice system (perceived effectiveness). Organisational strengths included the holistic, long-term, proactive, affordable and accessible nature of the care offered (perceived effectiveness, burden and opportunity cost). Victims faced challenges in linking to, engaging with and remaining in care due to distress post-SA, with support persons playing a crucial role in helping them navigate these challenges (self-efficacy). Conclusions: The study highlights the acceptability of an integrated, multidisciplinary approach to specialised SA care. Key elements include embedded psychological support, the option for forensic examination without mandatory reporting, and the possibility of police reporting at the SACC. These findings may inform the development of specialised SA services in other settings.

Healthcare doi: 10.3390/healthcare14091132

Authors: Woo-Hyuk Kim Eunhye Park

Background: This study examines how medical consumption is discussed in online communities among individuals who are blind or visually impaired using the Social Ecological Model (SEM) to capture multilevel healthcare experiences within digital discourse. Methods: A total of 428 posts and comments were collected from Reddit’s r/Blind community. Term frequency–inverse document frequency keyword extraction and a theory-driven LLM-based classification approach were applied to categorize texts into five SEM levels: intrapersonal, interpersonal, institutional, community, and public policy. Results: The findings show that intrapersonal (44.4%) and public policy (29.8%) levels were the most prominent, indicating a strong emphasis on personal coping experiences alongside structural constraints in healthcare access. Institutional-level discourse accounted for 15.8%, whereas interpersonal (6.2%) and community (3.8%) discourse were relatively limited. Keywords and qualitative analyses revealed themes related to emotional adaptation, social support, service accessibility, mobility constraints, and welfare policy barriers. The Jaccard similarity analysis indicated stronger associations between institutional and policy levels, whereas community-level discourse remained relatively distinct. Conclusions: These findings highlight the importance of understanding healthcare experiences, both individually and structurally, in online environments. This study also demonstrated the potential of integrating LLM-based classification with theory-driven frameworks to enable an interpretable and scalable analysis of complex health-related discourse.

Healthcare doi: 10.3390/healthcare14091131

Authors: Zepeda-Lugo Insfran-Rivarola Sanchez-Lizarraga Macias-Velasquez Arevalos Baez-Lopez Tlapa

Background/Objectives: Efficient management of intensive care unit (ICU) resources is a critical challenge for modern healthcare systems, which must balance high-quality patient care with operational and financial performance. ICU length of stay (LOS) is a key metric of clinical complexity and hospital efficiency. However, traditional methods for predicting LOS often fail to capture the complex, nonlinear interactions among physiological, demographic, and treatment-related variables. Machine learning (ML) and deep learning (DL) models have emerged as promising tools for enhancing predictive accuracy and supporting data-driven decision-making. Methods: This study presents a systematic review and meta-analysis of ML and DL approaches for predicting ICU LOS in adult patients. Following PRISMA guidelines, eight scientific databases were searched, yielding 33 eligible studies published between 2015 and 2025. Results: Mixed medical–surgical ICUs were the most common setting (51.5%), and 45.5% of datasets were sourced from public repositories. Most studies (19/33) focused on binary classification of prolonged stays, although thresholds ranged from >48 h to ≥14 days. The pooled results from ten studies yielded an AUROC of 0.9005 (95% CI: 0.8890–0.9121), indicating strong predictive capability across diverse clinical contexts. Subgroup analyses showed comparable performance between specialized surgical and general ICUs. Conclusions: These findings suggest that AI-driven LOS prediction models exhibit strong discriminatory power for ICU LOS prediction, supporting hospital capacity planning. However, to translate this into reliable clinical support, the methodological heterogeneity, scarcity of external validation, and near absence of calibration reporting identified in this review need to be addressed.

Healthcare doi: 10.3390/healthcare14091130

Authors: Jui-Kun Chiang Po-Chen Chiang Malcolm Koo

Background/Objectives: Zinc deficiency has been associated with increased cancer-related mortality, yet its prognostic relevance in patients with breast cancer and comorbid diabetes remains unclear. This study evaluated the association between zinc deficiency and adverse 5-year clinical outcomes in this population. Methods: This retrospective cohort study used the TriNetX database to identify women aged ≥20 years with breast cancer and type 2 diabetes who had recorded serum zinc levels within 3 months before the index date during the period from 1 January 2013 to 4 April 2026. Patients were categorized into zinc-deficiency, normal-zinc, or high-zinc groups. Outcomes included all-cause mortality, hospitalization, intensive care unit admission, and emergency department visits at the 1-, 3-, and 5-year follow-ups. Cox proportional hazards regression models were applied after 1:1 propensity score matching across 12 demographic and clinical variables. Results: Among 648 eligible patients, 282 had zinc deficiency, 311 had normal zinc levels, and 55 had high zinc levels. After matching, 218 remained in each of the zinc-deficient and control groups. Zinc deficiency was associated with higher all-cause mortality at 1 year (hazard ratio [HR], 2.45; 95% CI, 1.41, 4.28), 3 years (hazard ratio [HR], 2.09; 95% CI, 1.34, 3.28), and 5 years (HR, 1.92; 95% CI, 1.27, 2.92), as well as increased risks of emergency department visits, hospitalization, and ICU admission across follow-up periods. No significant differences were observed between the high-zinc and zinc-normal groups, possibly due to limited sample size. Subgroup analyses identified several exploratory subgroup-specific associations. Conclusions: Zinc deficiency was associated with poorer clinical outcomes in women with breast cancer and type 2 diabetes. However, because low serum zinc may also reflect malnutrition, systemic inflammation, frailty, or disease burden, these findings should be interpreted as hypothesis-generating rather than causal.

Healthcare doi: 10.3390/healthcare14091129

Authors: Mehmet Salık Elif Pınar Bakır Şeyhmus Bakır

Background/Objectives: This study aimed to evaluate the self-reported knowledge levels of evidence-based practice among actively practicing dentists in Türkiye in relation to restorative material selection, and to identify the demographic and professional factors associated with this knowledge. Materials and Methods: This cross-sectional descriptive survey included 341 dentists and was conducted using an online questionnaire. Descriptive statistics were expressed as frequencies, percentages, means, and standard deviations. Factors associated with self-reported knowledge levels of evidence-based dentistry were initially assessed using ordinal logistic regression. As the proportional odds assumption was violated, multinomial logistic regression analysis was employed as the final model. Statistical significance was set at p < 0.05. Results: Aesthetic expectations and durability were identified as the primary factors influencing restorative material selection. Approximately half of the participants reported low-to-moderate levels of knowledge regarding evidence-based dentistry. Multinomial logistic regression analysis demonstrated that professional experience, professional status, and type of institution were significant predictors of knowledge level (p < 0.05). General dental practitioners were significantly less likely to have high knowledge levels compared to specialists. Certain experience groups also showed a lower likelihood of achieving higher knowledge levels relative to the reference group. Although the type of institution was statistically significant, its overall effect was limited. Conclusions: The findings indicate that knowledge of evidence-based approaches in restorative material selection among dentists in Türkiye remains suboptimal. While professional status and experience play a significant role in shaping knowledge levels, institutional factors appear to have a comparatively minor impact. These results underscore the need for structured continuing education programmes—particularly for general dental practitioners—and highlight the importance of strengthening evidence-based decision-making in clinical practice.

Healthcare doi: 10.3390/healthcare14091128

Authors: Shin-Young Lee

Background/Objectives: Despite the availability of the National Cancer Screening Program in Korea, participation rates remain suboptimal. The literature demonstrates that cancer screening participation extends beyond individual-level knowledge and attitudes and is largely associated with trust. This study examines the role of trust—across cancer screening tests, health care providers, and health care organizations—as a central determinant of cancer screening participation among Koreans. Methods: A cross-sectional study was conducted with 369 Korean adults aged 40 years and older, recruited through convenience sampling from community centers in a metropolitan city. Data were collected using structured, paper-based questionnaires assessing socio-demographic factors and multilevel trust across specific screening tests, doctors, and health care organizations. Following descriptive statistics, bivariate and multivariate logistic regression analyses were performed to identify significant predictors of cancer screening utilization. Results: Koreans had relatively high trust in doctors and cancer screening tests. On an 11-point numeric rating scale ranging from 0 (not at all) to 10 (completely), the mean scores were 7.47 for the trust in doctors; colonoscopy had the highest trust score (M = 7.71), whereas the fecal occult blood test had the lowest (M = 7.14). Multivariate logistic regression revealed that trust and distrust were associated with the utilization of Pap smear, gastroscopy, upper gastrointestinal series, and colonoscopy in complex and sometimes paradoxical ways, and having a usual source of care was a consistent facilitator of cancer screening. Conclusions: These findings suggest that future research is needed to examine the complex interplay among trust, access to health care, and national policy in shaping cancer screening utilization in the Republic of Korea.

Healthcare doi: 10.3390/healthcare14091127

Authors: Yile Li Yingying Tao Luyu Mo Dan Wu Chengcheng Li Xuehui Meng

Background: Chronic Obstructive Pulmonary Disease (COPD) poses a substantial public health challenge in China owing to its increasing prevalence and substantial economic burden. In response, the diagnosis–intervention packet (DIP) payment reform was implemented to control healthcare costs and enhance service efficiency. Methods: To evaluate the effect of the DIP reform on medical costs, hospitalization days, and individual out-of-pocket payments for COPD inpatients in M City, a pilot city in central China, we conducted an interrupted time series (ITS) analysis using monthly reimbursement records from January 2020 to December 2023. The study included 84,410 hospitalized patients from a city-wide database of 3,241,233 inpatient records with COPD who met the inclusion criteria. The analysis focused on the total healthcare costs, length of stay, and individual out-of-pocket costs. Results: The DIP reform resulted in a 3.7% reduction (95% CI: 0.9% to 6.5%) in the total hospitalization costs in the first month post-reform, with a sustained monthly decline of 0.8% (95% CI: 0.5% to 1.1%). The length of stay decreased from 9.53 (95% CI: 9.31 to 9.75) to 8.74 days (95% CI: 8.62 to 8.86). Conversely, the proportion of out-of-pocket payments relative to total costs increased. Conclusions: While the DIP reform effectively reduced hospitalization costs and days, it led to an increase in individual out-of-pocket payments. Future research should focus on optimizing payment rules, enhancing the supervision of medical services, and refining health insurance policies to achieve the reform’s objectives better and alleviate the financial burden on patients.

Healthcare doi: 10.3390/healthcare14091125

Authors: Jiahao Li Yang Chu Shan Liu Yanfang Liu Jie Xu

Background: Nomophobia, the fear of being without a mobile phone, has become an increasing public health concern. While existing theories suggest that smartphones often serve as tools for emotional regulation, the situational mechanisms driving these compensatory behaviors remain under-explored. This study investigated how nomophobia levels interact with daily emotional fluctuations and busyness to influence smartphone-based coping patterns. Methods: We employed an intensive longitudinal approach combining objective smartphone tracking with a 4-week daily diary design. Thirty-seven participants were monitored, yielding 837 daily observations. Smartphone use was categorized into Instant Messaging (IM), Social Media Use (SMU), and Non-social Use (NSU). Multilevel linear regression analyzed the interaction effects on usage metrics. Results: Nomophobia significantly correlated with the duration and frequency of SMU, but not IM or NSU. A significant three-way interaction was observed: individuals with high levels of nomophobia exhibited a significantly increased frequency of overall usage, SMU and NSU when experiencing negative emotions during periods of low busyness. In contrast, low-nomophobia individuals maintained stable usage patterns regardless of situational stressors. Conclusions: By conceptualizing smartphone usage as a behavioral proxy for the coping process, this study provides preliminary evidence that nomophobia is associated with a situation-dependent coping pattern, primarily involving increased social media usage. These findings underscore the importance of integrating situational contexts and underlying coping processes to better understand and manage problematic smartphone use.

Healthcare doi: 10.3390/healthcare14091126

Authors: Steliyana Valeva Nazife Bekir Katya Mollova Andriana Kozareva Ivelina Stoyanova Pavlina Teneva

Background: Obesity represents a major public health challenge worldwide and contributes substantially to the burden of type 2 diabetes and hypertension. While body mass index (BMI) is widely used in clinical practice, indices reflecting central adiposity may provide additional prognostic value. This study aimed to assess the prevalence of general and central obesity in an adult population across different age groups from Stara Zagora, Bulgaria, and to examine their associations with cardiometabolic outcomes and lifestyle factors. Methods: A quasi-representative cross-sectional study was conducted among 3512 adults (mean age 53.7 ± 14.9 years). Anthropometric indices, including BMI, waist circumference, waist-to-hip ratio, and waist-to-height ratio were measured. Cardiometabolic outcomes included diabetes, hypertension, and their combined presence. Multicollinearity was assessed using the Variance Inflation Factor (VIF), and the discriminatory ability of indices was evaluated using Receiver Operating Characteristic (ROC) analysis and DeLong’s test. Results: The prevalence of overweight/obesity (BMI ≥25) was 68.4%, while central obesity (WHtR ≥0.5) affected 66.9% of participants. BMI demonstrated the highest discriminatory ability in this dataset for hypertension (AUC = 0.852) and diabetes (AUC = 0.796), significantly outperforming WC and WHR (p < 0.05). However, 24.4% of individuals with normal BMI exhibited high-risk central adiposity. Significant sex-specific differences were observed: short sleep duration (<6 h) was a strong predictor of obesity in women (aOR = 2.98), whereas smoking showed stronger associations in men. Age-stratified analyses revealed that while BMI stabilizes in the oldest age group (75–89 years), WHtR continues to increase, reflecting age-related redistribution of visceral fat. A strong protective effect of physical activity was observed, supported by quasi-complete separation in active subgroups. Conclusions: General and central obesity represent a substantial health burden in this urban population. While BMI remains a robust screening tool, the integration of WHtR enhances the identification of “hidden” cardiometabolic risk particularly in older adults and individuals with normal BMI. Given the quasi-representative nature of the sample, these findings are primarily generalizable to similar urban populations and may inform targeted regional public health strategies.

Healthcare doi: 10.3390/healthcare14091124

Authors: Ana Suárez-Carrasco Álvaro León-Campos Maria José Peláez-Cantero Silvia García-Mayor Bibiana Pérez-Ardanaz

Background: Families caring for children with medical complexity (CMC) face sustained psychosocial demands that may impair health-related quality of life (HRQoL) and mental health. A clear map of how these outcomes are assessed and which factors shape them is needed to guide family-centered care. Methods: We conducted a scoping review following the Joanna Briggs Institute guidelines, and reports were prepared according to the PRISMA guidelines. Searches were conducted in PubMed, CINAHL, and EMBASE (January 2011 to December 2023) to find studies reporting on health-related quality of life (HRQoL) and/or mental health outcomes (anxiety, depression, burden) of family members and/or caregivers of CMC, including operationalization based on complex chronic condition (CCC) classifications, technology dependency, or the Pediatric Medical Complexity Algorithm (PMCA). Two reviewers independently screened records and recorded data, and the findings were synthesized narratively and thematically. Results: Sixty-seven studies met the inclusion criteria and spanned cross-sectional, cohort, case–control, pre–post and qualitative designs across conditions such as epilepsy, congenital heart disease, cerebral palsy, technology dependence and cancer. Common measures were PedsQL™ Family Impact Module, SF-36/12, HADS, Beck inventories and Zarit burden scales. Across the included studies, caregivers, predominantly mothers, frequently reported poorer HRQoL and higher levels of anxiety, depressive symptoms, or burden than comparison groups when these were available. Six recurrent themes emerged: (1) gendered caregiving with disproportionate maternal burden; (2) socio-economic gradients and financing models shaping outcomes; (3) culture, religion and spirituality as coping resources; (4) family and social support buffering distress; (5) school participation and coordinated services potentially reducing burden; and (6) interdependence between caregiver and child outcomes. Conclusions: Heterogeneous CMC definitions, outcome measures, and study designs limited comparability across studies. The mapped evidence suggests that family HRQoL and mental health outcomes are shaped by interacting clinical, social, and contextual factors. These findings may inform more family-centered and equity-oriented approaches to care. Future research should harmonize CMC definitions, standardize outcome measures, and prospectively evaluate multicomponent interventions.

Healthcare doi: 10.3390/healthcare14091123

Authors: Dorothy Day Huntsman Desiree Jenkinson Grzegorz Bulaj

Home has been recognized as a health infrastructure through hospital-at-home, home care, and direct-to-consumer wellness and fitness products. However, the patient home environment has been largely overlooked by healthcare as a means to improve therapy outcomes for difficult-to-treat chronic conditions, such as migraine; high-impact pain; and treatment-resistant depression, anxiety, or insomnia. Growing research evidence enables the formulation of a therapeutic home environment standard consisting of three pillars: biophilic design, indoor environmental quality, and intentional self-care spaces that serve as habit cues and foster sleep hygiene, stress management, relaxation, physical activity, and social interactions. Together, these environmental and behavioral interventions can transform real-world inputs into clinical benefits through autonomic, circadian, and emotional regulation. We also highlight the converging roles of self-management, self-efficacy, self-regulation, and self-compassion in sustaining patient engagement and healing at home. The applicability of the therapeutic home environment as an adjunct is illustrated in the case of chronic migraine, a debilitating neurological condition commonly associated with comorbidities. Current challenges in achieving migraine freedom with FDA-approved pharmacotherapies, neuromodulation devices, and digital health technologies are underscored by the high prevalence of refractory, chronic, episodic, and pediatric migraine. Perspectives on developing a personalized, multimodal cure for migraine are illustrated through a hypothetical drug + digital combination therapy comprising anti-CGRP drugs and an AI-powered digital health platform that promotes daily self-care practices within the therapeutic home environments. In conclusion, achieving sustained freedom from high-morbidity conditions requires end-to-end care ecosystems that integrate pharmacological, cognitive, behavioral, and environmental interventions into real-world settings.

Healthcare doi: 10.3390/healthcare14091122

Authors: Eleftheria Morela Evgenia Kouli Evangelos Galanis Nerantzoula Koufou Konstantinos Astrapellos

Background: Hatha yoga has gained increasing popularity worldwide and has been associated with benefits for mental health and short-term emotional functioning. Objective: The present study examined pre–post changes in mood states following a single Hatha yoga session in adult women participating in community-based exercise programs. Methods: A total of 253 adult women participated in the study. Participants completed the Profile of Mood States (POMS) questionnaire immediately before and after a single 60 min Hatha yoga session. The questionnaire assesses anxiety–tension, depression, anger, fatigue, confusion, and vigor. Repeated measures ANOVA was used to examine the changes in mood states and the potential differences between the age groups. Results: Significant improvements in mood states were observed following the session. Anxiety–tension, depression, anger, fatigue, and confusion decreased, while vigor increased. No significant time × age group interaction was observed for most mood variables. However, a significant interaction was found for vigor, indicating that women aged 41 and older showed a greater increase following the session. Conclusions: Participation in a single Hatha yoga session was associated with short-term changes in mood states among adult women, suggesting that yoga may represent a potentially beneficial community-based activity for supporting short-term mood regulation.

Healthcare doi: 10.3390/healthcare14091121

Authors: Antonio Brugos-Larumbe Alba Equiza-Vaquero Carmen Hugo-Vizcardo Laura Guillen-Aguinaga Francisco Guillen-Grima Ines Aguinaga-Ontoso

Background: Food bank users experience food insecurity, a social determinant of health linked to poorer physical and mental health. However, evidence on the health-related quality of life (HRQoL) of food bank users in Spain is scarce. Objectives: This study sought to assess HRQoL among users of the Navarra Food Bank and identify associated sociodemographic factors. Methods: We performed a cross-sectional study of heads of household using the Navarra Food Bank. A simple random sample of 350 participants was selected from a population of 2749 families. HRQoL was assessed by telephone using the EQ-5D-5L. We described the prevalence of problems in the five EQ-5D-5L dimensions, calculated the EQ-5D-5L utility index using the Spanish value set, and analyzed EuroQol Visual Analogue Scale (EQ-VAS) scores. Associations with sociodemographic characteristics were examined using multivariable general linear models. Results: Mean EQ-VAS was 73.56 (95% CI: 71.62–75.50), and mean EQ-5D-5L utility index was 0.815 (95% CI: 0.800–0.831). The most frequently reported problems were anxiety/depression (62.9%) and pain/discomfort (55.7%), while mobility (25.5%), usual activities (19.7%), and self-care (8.7%) were less commonly affected. Older age was significantly associated with both EQ-VAS and EQ-5D-5L utility index. Employment status and nationality were significantly associated with EQ-VAS, whereas sex was significantly associated with the EQ-5D-5L utility index. Conclusions: HRQoL was impaired among users of the Navarra Food Bank, with the greatest burden observed in the anxiety/depression and pain/discomfort dimensions. Older age and selected sociodemographic characteristics were associated with poorer HRQoL. Given the cross-sectional design, the findings should be interpreted as associative rather than causal.

Healthcare doi: 10.3390/healthcare14091120

Authors: Yih-Ming Weng Gia-Wei Chang Meng-Siew Hii Hsiu-Chun Chien Jong-Long Guo

Background/Objectives: Sarcopenia and age-related muscle weakness pose significant global health challenges, highlighting the need for innovative and sustainable exercise interventions for older adults. This study developed and evaluated an Interactive Smart Mirror Exercise Program and investigated the factors associated with older adults’ usage intention toward the program based on the Decomposed Theory of Planned Behavior (DTPB). Methods: A cross-sectional survey was conducted with 92 community-dwelling older adults in northern Taiwan. Structural equation modeling was applied to test the proposed framework and examine the relationships among the study variables. Results: The results showed a satisfactory model fit (SRMR = 0.071). Attitude, subjective norms, and perceived behavioral control together explained 41.6% of the variance in usage intention. In addition, perceived usefulness, perceived compatibility, interpersonal influence, and self-efficacy were identified as factors significantly associated with usage intention, both directly and indirectly. Conclusions: These findings might support the applicability of the DTPB framework in explaining older adults’ usage intention toward technology-assisted exercise programs and provide insights for the design and implementation of digital exercise interventions in community settings.

Healthcare doi: 10.3390/healthcare14091119

Authors: Carmen García-Gomariz Sonia Andrés-Reig María-José Chiva-Miralles Roi Painceira-Villar José-María Blasco

Introduction: Although gait alterations associated with excess body weight have been widely studied, most available evidence comes from laboratory-based analyses, which limit ecological validity and the translation of findings into clinical practice. This study addresses this gap by examining gait biomechanics across BMI categories using portable sensor-based insoles that allow gait assessment in real-world conditions. Methods: A cross-sectional study including 96 adults categorized as normal weight (NW), overweight (OW), or obese (OB) was conducted. Gait biomechanics were recorded using PODOSmart® intelligent insoles, which capture spatiotemporal and angular parameters during natural walking. Foot health, quality of life and comorbildities were evaluated throught valeted questionnarires. Differences between groups were analyzed using ANOVA and chi-square tests. Age and sex, known to influence gait, were comparable across BMI groups and were considered in the interpretation of the results. Results: Overall, the participants in the OB group exhibited reduced stride length, gait speed, and swing time, increased double-support time, and greater pronation–supination and progression angles than OW and NW participants. Partial eta-squared values (η2p) were predominantly medium to large, reinforcing the robustness of these between-group differences (e.g., double-support time, p > 0.001; η2p = 0.19). Individuals with obesity reported poorer general and foot health and more difficulty finding suitable footwear. BMI was also significantly associated with hypertension, dyslipidemia, arthritis, and depression (all p <0.05), whereas diabetes, cardiopathies, knee pain, and fatigue andwalking or social activity limitations showed no significant differences. Conclusions: By using portable gait analysis technology in ecological conditions, this study provides novel evidence of clinically meaningful gait impairments across BMI groups. Higher BMI is associated with clinically relevant gait impairments, poorer perceptions of foot and general health, and a higher prevalence of several comorbidities.

Healthcare doi: 10.3390/healthcare14091118

Authors: Ahmad Rajeh Saifan Murad Sawalha Ibtisam A. Alarabyat Hanan F. Alharbi Zyad Saleh Osama Alkouri Rani Shatnawi Dana Anwer Abujaber Rami Eid Samarah Nabeel Al-Yateem

Background: Telehealth has expanded access to care for people with chronic diseases, but little is known about how patients in Jordan become activated, motivated, and ready to use these services, particularly during early adoption. Aim: To explore how patients with chronic diseases in Jordan describe their initial activation, readiness, and experiences with telehealth services. Methods: This exploratory qualitative study used interviews with 14 purposively selected adults with chronic diseases from three hospitals in Jordan. Data was analyzed using Braun and Clarke’s six-step thematic analysis. Results: Four interrelated themes emerged. First, patients valued telehealth for preserving independence and ensuring continuity of care, particularly by reducing reliance on family members for transportation to health facilities. Second, readiness was shaped by geography, mobility, and finances. Although telehealth reduced transport costs and lost wages, patients still had to pay for devices and internet access, creating an economic paradox for poorer patients. Third, participation was supported by families but hindered by low digital literacy, platform changes, and unstable internet connectivity. Fourth, trust in telehealth was conditional and depended on patients’ perceptions of convenience and responsiveness. Conclusions: Readiness to use telehealth was relational, structural, experiential, and conditional rather than purely individual. Patients with chronic diseases in Jordan need hybrid care models that engage families and leverage affordable digital technologies to support sustained telehealth use for disease management.

Healthcare doi: 10.3390/healthcare14091117

Authors: Adil M. Hazara Maureen Twiddy Victoria Allgar Sunil Bhandari

Background: The optimal method of starting maintenance haemodialysis (HD) in patients with kidney failure is not known. We have compared early treatment characteristics, blood pressure trajectories, and selected dialysis-related safety events in patients who started HD using a stepped and phased approach, with those who received conventional care. Method: A single-centre cohort feasibility study was conducted. Participants with kidney failure, about to start maintenance HD, were enrolled prospectively (intervention arm). They started treatment on a novel regime comprising four pre-specified incremental steps (Phases 1 to 4) over 14 weeks. They were matched using propensity scores with historical controls: patients who had previously started HD on a three-times weekly basis from the outset (control arm). Results: The final cohort comprised 15 and 29 participants in the intervention and control arms respectively (1:2 ratio; one control excluded after matching). Intervention group participants were slightly older with a higher proportion of men. The rate of decline in blood pressure was slower in the intervention group. There were also signals for fewer events of intra-dialytic hypotension (211 vs. 379 per 100 person-year), infections not requiring admission (56 vs. 114 per 100 person-year) and loss of vascular access (56 vs. 79 per 100 person-year) in intervention group. There was a signal for higher incidence of severe hypertension (systolic BP ≥ 180 or diastolic BP ≥ 110 mmHg) in the intervention group. Hospitalisation rates were similar; there were no deaths and one non-fatal major cardiac event (MACE) in the intervention group, and one death and no MACE in the control group. Conclusions: Implementing a short transitional regime of incremental HD may be possible in clinical settings, potentially helping to reduce the gradient of physiological change and burden of early treatment. The findings of this feasibility study are exploratory, and fully powered randomised controlled trials are needed to establish the efficacy and safety of such a programme.

Healthcare doi: 10.3390/healthcare14091116

Authors: Seoyoon Heo Taeseok Choi Wansuk Choi

There was an error in the funding statement of the original publication [...]

Healthcare doi: 10.3390/healthcare14081115

Authors: Alexandra Herlaș-Pop Andrei-Flavius Radu Ada Radu Gabriela S. Bungau Delia Mirela Tit Cristiana Bustea Elena Emilia Babes

Background/Objectives: The intersection of mental health and acute coronary syndromes has become an increasingly prominent area of cardiovascular and psychosomatic research, yet its temporal dynamics and intellectual structure remain incompletely characterized. Methods: This study analyzed 13,646 peer-reviewed documents spanning five decades, employing advanced changepoint detection (PELT) algorithms, network visualization (VOSviewer), and bibliometric performance metrics (Bibliometrix) to quantify the evolution of the mental health–ACS intersection. Results: Statistical analysis identified two robust inflection points at 1990 and 2005 that demarcate distinct developmental periods. The 1990 breakpoint marked an important transition, although additional metadata-completeness analysis indicated that part of the increase from 72 to 142 publications may reflect improved availability of non-title Topic-field metadata in WoSCC around 1990–1991. The 2005 breakpoint represented the most critical transition (Cohen’s d = 4.05, p < 0.000001), initiating exponential growth from 349 to over 600 annual publications by 2022 and coinciding with growing research attention to psychiatric comorbidity within ACS literature. Keyword co-occurrence networks revealed a shift in research focus: early publications predominantly addressed mental health as a psychological reaction to cardiac events, whereas more recent publications increasingly frame depression, anxiety, and PTSD alongside mechanistic constructs such as inflammatory pathways, autonomic dysfunction, and platelet reactivity. Although seminal intervention trials (i.e., ENRICHD, SADHART) established pharmacological safety and symptom improvement, keyword analyses indicate that following these trials, research attention increasingly shifted toward precision psychiatry concepts and mechanistic pathway elucidation. Conclusions: These findings provide a quantitative map of how publication activity at the mental health–ACS intersection has evolved, offering a structured basis for identifying under-researched areas and informing future research agendas.