Search Results (18,693)

Modelling and prediction of mean monthly flow are of particular importance for long-term planning in hydrology and water resources management. Therefore, a simplified and robust modelling procedure, derived from clearly and concisely established methodology, can benefit both researchers and practitioners. The main objective of this study is to develop a robust yet simple model, capable of producing predictions of satisfactory accuracy on previously unseen data. Two chronological data allocation strategies (C1 and C2), differing in the proportions of training, calibration, and verification subsets, were evaluated to analyze their influence on model accuracy and reliability. Chain and ensemble modelling techniques were applied, resulting in several stacking regressors with different combinations of base models and final estimators. The best-performing ensemble (C2) consisted of a support vector machine, histogram gradient boosting regressor, elastic net, and two dummy regressors as base models, with an artificial neural network as the final estimator. Within the ensemble structure, dummy regressors and histogram gradient boosting regressor were used to extend the predictive range, while elastic net and support vector machine captured the overall flow bias and fundamental flow dynamics. The artificial neural network final estimator was used to integrate these components into the final flow prediction. Compared to C1, the C2 allocations strategy achieved improved generalization capability and narrower confidence intervals due to the larger training subset, indicating higher model reliability for long-term monthly flow forecasting. The study additionally emphasizes the importance of appropriate methodological workflow, careful dataset treatment, and comprehensive model evaluation using complementary statistical and hydrological analysis tools. Full article

Background: Total knee arthroplasty (TKA) is a common procedure to relieve pain and restore function in osteoarthritis patients. Postoperative rehabilitation is essential to address pain, swelling, reduced range of motion, and functional limitations. Hydrotherapy, using water buoyancy and resistance, may enhance recovery, but evidence on its effectiveness after these surgeries remains limited. Methods: A systematic literature search was conducted across six databases: PubMed, ProQuest, Science Direct, Google Scholar, Scopus, the Cochrane Library, and PEDro, covering studies published up to 30 November 2025. Only prospective randomized controlled trials were considered for inclusion. Studies such as case reports, uncontrolled case series, and those focused on outcomes other than postoperative pain and decreased muscle strength in patients undergoing total knee arthroplasty were excluded. This review was registered in PROSPERO (CRD420251164054). Results: Pooled analysis showed no statistically significant difference between hydrotherapy and land-based or usual-care rehabilitation in Visual Analogue Scale (VAS)-measured pain (MD ≈ −0.35; 95% CI $[-1.06, 0.36]$; $p=0.34$) or in WOMAC pain (MD ≈ −0.46; 95% CI $[-8.50, 7.58]$; $p=0.89$). In contrast, hydrotherapy produced a moderate, statistically significant improvement in lower-limb muscle strength (Hedges’ $g=0.46$; 95% CI $[0.23, 0.69]$), particularly in knee extensor and hip abductor strength. Heterogeneity was low for VAS pain and muscle strength but substantial for WOMAC pain ($I^2\approx 71\%$), and no evidence of publication bias was identified. Conclusions: Hydrotherapy did not reduce postoperative pain more than land-based exercise or usual care; pain relief was comparable between approaches, whereas hydrotherapy yielded greater gains in muscle strength. Heterogeneity in treatment parameters and the limited number of high-quality trials preclude definitive conclusions; future research should standardize hydrotherapy protocols and investigate long-term outcomes. Full article

Background/Objectives: Chronic dermatological conditions increasingly require complex and patient-centered therapeutic management, including biologic therapies, injectable treatments, and multidisciplinary care. In this context, patient-reported experience measures (PREMs) may provide valuable insight into the quality and effectiveness of pharmacist-delivered care. This study aims to translate, culturally adapt, and evaluate the psychometric performance of the Patient Satisfaction with Pharmacist Services Questionnaire (PSPSQ 2.0) as a patient-reported experience measure in Romanian patients with chronic dermatological conditions. Methods: A cross-sectional validation study was conducted in community pharmacies across Romania (N = 220). The questionnaire was translated using a structured forward-translation and expert review process, in accordance with ISPOR and COSMIN recommendations. Internal consistency was assessed using Cronbach’s alpha and item-level statistics. Construct validity was examined using exploratory factor analysis (EFA), confirmatory factor analysis (CFA), and bifactor modeling. Known-groups validity and floor and ceiling effects were also evaluated. Results: The Romanian PSPSQ 2.0 demonstrated excellent internal consistency (α = 0.978; subscales α = 0.961–0.969). EFA indicated a dominant single-factor structure, explaining 84.0% of the variance. In CFA, the original three-factor model showed excellent relative fit (CFI = 0.999, TLI = 0.999), although RMSEA indicated some model misfit (0.109). Bifactor analysis revealed a strong general satisfaction factor, with consistently high loadings (0.80–0.99), suggesting that most item variance is attributable to a global patient satisfaction construct. These findings support the use of the instrument as a global measure of patient experience within contemporary dermatologic care pathways. Conclusions: The Romanian version of the PSPSQ 2.0 demonstrates excellent reliability and acceptable construct validity as a PREM for assessing patient satisfaction with pharmacist services. The findings support the use of total scores as a robust indicator of patient experience, while domain-level interpretation should be approached with caution due to substantial overlap between dimensions. This instrument may support the integration of patient-reported measures into routine evaluation of pharmaceutical care. Full article

Background/Objectives: Chronic heart failure (CHF) is a leading cause of global morbidity and mortality, particularly among older adults, significantly impacting their quality of life and imposing a substantial economic burden. While pharmacological and surgical treatments remain essential, non-pharmacological interventions led by nurses are gaining prominence due to their comprehensive approach and biopsychosocial impact. The objective of this study was to synthesise and integrate such interventions for community-dwelling older adults with CHF. Methods: An integrative review was conducted in accordance with the Joanna Briggs Institute protocols and the PRISMA statement, utilising a systematic search across databases including PubMed and Cochrane. Qualitative, quantitative, and mixed-methods studies evaluating non-pharmacological interventions in the home setting were included, whilst those targeting non-specific populations were excluded. Following a rigorous screening process, 12 studies were selected, and their methodological quality was appraised based on study design. Results: The 12 included studies involved a total of 2466 participants and addressed interventions across the domains of education, physical activity, telehealth, and nutrition, with programme durations ranging from 4 weeks to 16 months. Notable improvements were observed in physical capacity, cognitive function, quality of life, and self-care capabilities, alongside potential reductions in hospitalisations reported in some studies. However, considerable methodological variability was identified across the literature. Conclusions: This review synthesises non-pharmacological nursing interventions for older adults with CHF, demonstrating varied benefits across multiple biopsychosocial domains. The findings emphasise the critical need for further research to evaluate the economic viability of these programmes and to adapt interventions to enhance the delivery of community-based care. Full article

Motivational interviewing (MI) is gaining traction in veterinary medicine as an evidence-based approach for engaging clients in conversations that strengthen their intrinsic motivation to change behaviours that affect the welfare of animals in their care. While MI has a substantial and well-established evidence base across human healthcare and related fields, the veterinary evidence base remains small and is currently limited by study design challenges, inconsistent fidelity measurement, and outcome measures that rarely extend beyond short-term changes in communication behaviour. Existing methodological guidance addresses treatment integrity and theoretical mechanisms but does not provide an integrated framework for designing robust studies across the range of questions relevant to veterinary practice. This paper addresses that gap by providing practical methodological guidance for researchers designing MI studies in veterinary clinical settings. A novel conceptual model of the MI implementation pathway, mapping the journey from practitioner awareness through training and delivery to client outcomes, is used to organise key research questions that need to be answered in veterinary contexts. Guidance is then provided on selecting appropriate study designs, measuring fidelity and outcomes, estimating sample size, and managing the practical and ethical challenges specific to veterinary clinical settings, alongside minimum reporting standards to support more rigorous and reproducible MI research. Full article

Background/Objectives: Neuroprognostication after out-of-hospital cardiac arrest (OHCA) remains clinically challenging, particularly when withdrawal of life-sustaining treatment (WLST) is considered. International guidelines recommend delayed, multimodal assessment, but real-world descriptions of how this is operationalised within multidisciplinary pathways remain limited. Methods: We conducted a single-centre retrospective observational cohort study of adults admitted to a tertiary cardiac arrest centre intensive care unit following OHCA between June 2022 and December 2025. Patients were conveyed according to the British Cardiovascular Intervention Society OHCA pathway; therefore, this was a selected cardiac arrest centre cohort enriched for shockable rhythms and suspected reversible cardiac causes, rather than an unselected OHCA population. Patients who remained unconscious at ≥72 h following a sedation hold entered a structured multidisciplinary team (MDT) neuroprognostication pathway. Outcomes included survival to hospital discharge, Cerebral Performance Category (CPC) at discharge, neuroprognostication investigation use, and timing of WLST. Results: Of 406 patients admitted following OHCA, 310 were admitted to ICU and included in the analysis. The cohort was predominantly male (82.3%), with a mean age of 63.8 years; 82.9% had ventricular fibrillation as the initial rhythm. Overall, 182 patients (58.7%) survived to hospital discharge, of whom 160 (87.9%) had a favourable neurological outcome (CPC 1–2). A total of 119 patients entered the neuroprognostication pathway. Of these, 72 underwent WLST after completed MDT review, 10 died before MDT decision-making, and 37 survived to hospital discharge. Among patients undergoing WLST, investigation use was high: CT brain 100%, NSE 91.7%, EEG 90.3%, SSEP 88.9%, and MRI brain 27.8%. Median time to WLST was 5.5 days. Conclusions: In this selected tertiary CAC cohort, enriched for shockable rhythms through BCIS pathway-based conveyance, survival to hospital discharge was high and neurological outcomes among survivors were predominantly favourable. Within this setting, delayed, multimodal neuroprognostication and WLST decision-making were operationalised through a structured MDT pathway aligned with contemporary guideline recommendations. These findings provide contemporary real-world benchmark data on pathway implementation for comparable centres seeking to evaluate or develop structured neuroprognostication services. Full article

Early engagement with psychotherapy is a public mental health issue because potential patients’ first appraisals of psychological care may shape treatment expectations, willingness to continue, and openness to receiving effective support. In first-contact therapeutic encounters, people respond not only to the content of a therapist’s intervention but also to the interpersonal meaning conveyed by the therapist’s response style. Guided by a recognition–resistance framework and models of narcissistic self-regulation, we examined how therapist response style and trait narcissistic admiration and rivalry shape early appraisals of psychological care in a vignette-based psychotherapeutic encounter. In a between-subjects vignette experiment, Hebrew-speaking adults in Israel (N = 972) were randomly assigned to read a validation-based, recognition-supportive, autonomy-supportive therapist response or a more directive and challenging response to the same clinical scenario. Participants then reported perceived recognition, autonomy-related resistance, anticipated alliance, therapist credibility, expected benefit, and willingness to continue. The validation-based response elicited higher perceived recognition, lower autonomy-related resistance, and greater willingness to continue. Perceived recognition and autonomy-related resistance mediated the effects of response style on all therapy-related outcomes. Narcissistic admiration predicted more favorable appraisals, and narcissistic rivalry predicted lower recognition and greater resistance, but neither moderated style effects nor indirect pathways. Recognition and autonomy-related resistance emerged as proximal appraisal pathways linking therapist response style to anticipated engagement with psychological care in this analogue vignette context. However, the predicted moderation and moderated-mediation effects involving narcissistic admiration and rivalry were not supported. This pattern suggests that, in the present design, admiration and rivalry functioned more as general appraisal orientations than as differential-susceptibility moderators of therapist response style. The moderated-mediation component of the recognition–resistance framework should therefore be regarded as unsupported pending independent replication and more ecologically valid tests. These findings position first-contact therapist communication as a candidate modifiable feature of public mental health engagement, with implications for future research on treatment uptake, early retention, trust in services, and access to effective psychological care. Full article

Background: Despite evidence-based guidelines for cardiovascular risk management, many patients fail to achieve therapeutic targets. The relative contribution of medication non-adherence versus suboptimal treatment optimization to poor cardiovascular outcomes remains unclear in real-world primary care settings. The aim of this study was to describe changes in cardiovascular risk factor control following protocolized adherence reinforcement combined with physician-driven treatment optimization in high-risk patients. Methods: This multicenter, real-world longitudinal study included 789 participants with high or very high cardiovascular risk enrolled from primary care settings across 9 Spanish regions between 2023 and 2025. All participants received a protocolized intervention combining adherence reinforcement and physician-driven treatment optimization. This was a single-arm, pre–post study without a concurrent control group; observed changes therefore cannot be attributed to the intervention alone. Of 789 participants screened, all completed the baseline assessment, and 628 (79.6%) completed the 90-day follow-up. A total of 161 participants (20.4%) were lost to follow-up. Primary outcomes included changes in systolic and diastolic blood pressure, lipid parameters (total cholesterol [TC], low-density lipoprotein cholesterol [LDL-c], high-density lipoprotein cholesterol [HDL-c], triglycerides [TG]), glucose, glycated hemoglobin (HbA1c), and body mass index (BMI) from baseline to 90-day follow-up. Changes were assessed using linear mixed models. Results: Among participants with complete paired data (n = 453–615 depending on the outcome), significant improvements were observed in most cardiovascular risk factors (HDL-c and HbA1c did not change significantly). Mean changes (95% confidence interval [CI]) were: systolic blood pressure, −9.24 mmHg (−10.41 to −8.06; p < 0.001); diastolic blood pressure, −4.75 mmHg (−5.49 to −4.01; p < 0.001); LDL-c, −22.29 mg/dL (−25.59 to −19.00; p < 0.001); TC, −23.24 mg/dL (−26.73 to −19.74; p < 0.001); TG, −16.75 mg/dL (−23.03 to −10.46; p < 0.001); fasting plasma glucose, −10.03 mg/dL (−12.61 to −7.46; p < 0.001); and BMI, −0.46 kg/m² (−0.58 to −0.35; p < 0.001). Linear mixed models including all available data (n = 628 at 90-day follow-up) confirmed these findings. No significant interactions were observed between assessment timepoint and sex, age, or overweight/obesity status for most outcomes, except for age-related differences in lipid responses. Conclusions: Protocolized adherence reinforcement combined with physician-driven treatment optimization was associated with clinically meaningful improvements in multiple cardiovascular risk factors in high-risk primary care patients. Given the single-arm pre–post design, the observed improvements are associative and cannot establish causality. Residual uncontrolled risk, particularly in lipid management and among older adults, persisted despite active treatment optimization (treatment was modified in 82.0% of participants), consistent with residual suboptimal treatment intensification even after adherence had been reinforced. These findings suggest that achieving optimal cardiovascular risk factor control requires addressing both medication adherence and treatment intensification, particularly in patients with multimorbidity. Full article

Treatment of non-small cell lung cancer (NSCLC) has been transformed by immunotherapy and targeted therapies. We aimed to characterize clinical features, treatment patterns, and healthcare resource use in patients with early and locally advanced NSCLC before incorporation of these therapies. This retrospective observational study included adults diagnosed with stage I–III NSCLC at four Spanish hospitals between 2014 and 2018, with follow-up until 2021, using artificial intelligence to extract data from electronic health records. A total of 951 patients were included (34.7% stage I, 16.7% stage II, 48.6% stage III), with a median age of 66 years and 31.9% female. Surgery was performed in 78.5% of stage I, 74.8% of stage II, and 35.5% of stage III patients. Among surgical patients, 62.5% received adjuvant chemo- and/or radiotherapy, 20.8% neoadjuvant therapy, and 15.7% both; among non-surgical patients, chemoradiotherapy was the most common treatment (50.4%). Beyond hospitalization, outpatient visits were the most frequently used healthcare resource. These findings provide a historical benchmark of NSCLC care before introduction of immunotherapy and targeted therapies in these settings, highlighting treatment variability and the need for earlier diagnosis, structured treatment pathways, and multidisciplinary management. Full article

Atrial fibrillation (AF) and heart failure (HF) frequently coexist and mutually worsen prognosis, creating a complex clinical scenario in which treatment decisions are increasingly imaging driven. Catheter ablation has emerged as a pivotal rhythm control strategy in selected patients with HF, but careful phenotyping of the atrial and ventricular substrate is essential to balance potential benefits against procedural risk and the likelihood of durable sinus rhythm. In this narrative review, we summarize the role of multimodality imaging across the entire AF care pathway in patients with HF, from candidate selection to intraprocedural guidance and post-ablation follow-up. Ultrasound imaging remains the cornerstone of pre-procedural assessment. Cardiac computed tomography (CCT) refines anatomical characterization of the left atrium, pulmonary veins, and left atrial appendage. Cardiovascular magnetic resonance (CMR) offers comprehensive tissue characterization of atrial and ventricular fibrosis, allowing distinction between atrial primary and atrial secondary AF phenotypes and informing expectations of reverse remodelling. During ablation, intracardiac echocardiography and transesophageal echocardiography optimize transseptal access, catheter navigation, and complication monitoring, and they are particularly relevant with contemporary Pulsed Field Ablation systems. In follow-up, echocardiography, CCT, and CMR are pivotal for quantifying structural reverse remodelling and detecting rare but life-threatening complications such as atrio esophageal fistula and pulmonary vein stenosis. An integrated, multimodality, substrate-based imaging strategy is therefore crucial to personalize rhythm versus rate control decisions and to guide safe, effective ablation in patients with AF and HF. Full article

Introduction: Nicotine dependence is a chronic disorder with both psychological and somatic components which, in the intensive care unit (ICU) setting, may affect the course of treatment through mechanisms related both to long-term nicotine exposure and to the consequences of its abrupt cessation. The aim was to collect and map the current knowledge on smoking-related complications, the prevalence of nicotine withdrawal symptoms in this group, and to identify and describe interventions used to prevent or alleviate nicotine withdrawal symptoms in patients hospitalised in the ICU. Methods: The review included sources retrieved from databases such as PubMed, CINAHL, Scopus, Web of Science, and the Cochrane Library, published in English, that met the PCC criteria, with no time restrictions. Results: Forty-four sources were included. Twenty-nine contributed evidence on smoking-related status as an exposure or associated factor, five explicitly focused on abrupt nicotine cessation or nicotine withdrawal syndrome, and fifteen addressed interventions; categories overlapped. Delirium was the most frequently investigated outcome in smoking-related exposure studies. Withdrawal-focused sources reported or discussed nonspecific manifestations, including agitation, restlessness, anxiety, craving, and delirium-like presentations, but no validated ICU-specific diagnostic approach or robust prevalence estimate was identified. NRT was the only intervention evaluated. Conclusions: Smoking-related status was associated with agitation and delirium in several observational studies; however, heterogeneous exposure definitions and inconsistent evidence syntheses preclude causal or general prognostic conclusions. Evidence specific to nicotine withdrawal syndrome was limited, and the effectiveness and safety of NRT remain uncertain. Implications for clinical practice included routine identification of nicotine dependence at ICU admission, early monitoring of withdrawal symptoms, individualisation of sedation management, careful and selective consideration of nicotine replacement therapy (NRT), education of the therapeutic team, planning of further care, and smoking cessation interventions. Full article

Objectives: Pediatric nasopharyngeal carcinoma (NPC) is rare and often presents at an advanced stage. Although multimodal treatment can achieve favorable survival, long-term survivors may experience substantial treatment-related morbidity. We aimed to evaluate survival outcomes according to stage and metastatic status and to characterize late toxicity in a 20-year single-center pediatric NPC series. Methods. We retrospectively reviewed 24 pediatric patients diagnosed with NPC between 2003 and 2023. Histology was classified according to WHO criteria, and tumors were staged using the AJCC TNM system. Overall survival (OS) and event-free survival (EFS) were estimated using the Kaplan–Meier method. Survival distributions were compared using the log-rank test. Late treatment-related toxicities documented during follow-up were recorded descriptively. Results: Twenty-four patients with WHO type III NPC were included. Fourteen patients had stage III disease and 10 had stage IV disease; three had distant metastasis at diagnosis. The median follow-up duration was 50.5 months. At last follow-up, 19 patients were alive and five had died. The estimated 5- and 10-year OS rates were both 72.7%, and the corresponding EFS rates were both 63.7%. Stage IV disease and metastatic presentation were associated with inferior OS. Dysphagia, malnutrition, xerostomia, fibrosis, hypothyroidism, and deafness were the most frequently recorded adverse health effects. Conclusions: This 20-year single-center experience shows that AJCC stage and metastatic status remain key determinants of survival in pediatric NPC. The high burden of late treatment-related complications highlights the importance of integrating long-term multidisciplinary survivorship surveillance into the care of pediatric NPC survivors. Full article

Background: HS is a chronic inflammatory skin disease in which inflammatory nodules and abscesses coexist with tunnels, fibrosis, and scarring. This dual biology explains why medical therapy often improves inflammatory dissease activity without fully addressing fixed tissue damage, whereas surgery can achieve durable local control but does not treat diffuse inflammatory burden. Contemporary international guidelines increasingly endorse multimodal and medicosurgical care. Objective: To critically compare the evidence supporting medical and surgical management of HS, with emphasis on outcomes, indications, limitations, and clinical decision-making relevant to contemporary practice. Methods: A structured review was undertaken using PubMed/MEDLINE, the Cochrane Library, and major dermatology guideline sources, with searches updated to 7 May 2026. Priority was given to clinical guidelines, systematic reviews and meta-analyses, randomized controlled trials, and higher-quality observational studies. Evidence was synthesized narratively because endpoints, populations, and follow-up intervals differed markedly across medical and surgical studies. Results: Medical evidence is strongest for biologic therapy in moderate-to-severe inflammatory HS. Weekly adalimumab improved week-12 HiSCR in the phase 3 PIONEER trials; secukinumab improved week-16 and week-52 outcomes in SUNSHINE/SUNRISE; and bimekizumab improved week-16 HiSCR50 in BE HEARD I/II. Surgical evidence is strongest for wide excision in structurally advanced disease, particularly when compared with local excision or incision and drainage. Meta-analytic data consistently show lower recurrence after wide excision than after local excision, and lower recurrence after flap or graft reconstruction than after primary closure. Combined therapy is increasingly supported: peri-operative adalimumab improved outcomes in SHARPS, and surgery plus adalimumab outperformed adalimumab alone in a pragmatic 12-month RCT. Conclusions: HS is best managed by matching treatment to disease phenotype. Medical therapy is essential for inflammatory control; surgery is essential for persistent tunnels, fibrosis, and scarred regional disease. The strongest overall clinical position is an integrated, multidisciplinary model in which systemic therapy reduces inflammatory load and surgery definitively treats irreversible tissue damage. Full article

Enhanced Recovery After Surgery (ERAS) pathways have improved perioperative outcomes by standardizing evidence-based interventions across the surgical continuum. However, substantial variability in postoperative recovery persists, even within well-implemented ERAS programs. This heterogeneity reflects differences in clinical risk, functional reserve, biological response to surgical stress, treatment responsiveness, and contextual factors that are not fully captured by uniform protocols. Precision medicine provides a potential framework for refining ERAS by integrating patient-specific data into perioperative risk assessment, intervention selection, patient monitoring, and recovery planning. Nevertheless, most precision medicine tools remain insufficiently validated for routine ERAS implementation, and their clinical utility is limited by heterogeneous evidence, data integration challenges, costs, workflow complexity, and equity concerns. Future progress will require prospective validation, pragmatic implementation studies, interoperable data systems, and evaluation of patient-centered outcomes. This narrative review examines the emerging role of precision medicine tools in perioperative practice and proposes an idealized conceptual model of “precision ERAS” in which standardized evidence-based care is preserved as the foundation, while selected interventions are adapted according to individual risk, biological phenotype, and recovery trajectory. Full article

Since 2020, recurrent waves of SARS-CoV-2 infection have persisted globally. Despite the advancements in vaccines and pharmacological treatments, a subset of patients still exhibits an aggressive form of COVID-19 requiring prolonged stays in the intensive care unit (ICU) or experiences major acute infections (or reinfections) and long-term symptoms. Endothelial dysfunction is one of the key events contributing to both the severity of acute COVID-19 and the development of long COVID (LC)/post-acute sequelae of SARS-CoV-2 infection (PASC) syndrome. Since the beginning of the pandemic, the efficacy of nutraceuticals, particularly essential micronutrients, has been investigated as a complementary treatment to prevent disease onset and improve clinical outcomes. One such bioactive molecule is folate (vitamin B9), a member of the B-vitamin family involved in the pathogenesis of multiple diseases, including viral infections and vascular disorders. This review examines the role of folic acid in COVID-19 and its interaction with homocysteine metabolism, which is frequently dysregulated in inflammatory endothelial diseases. It further discusses the potential benefits of folic acid supplementation for the prevention and treatment of COVID-19 in both the acute and long-term phases of the disease, alongside the therapeutic role of vitamin B12 supplementation in LC syndrome. Full article