Search Results (12,548)

Title-abstract screening remains labour-intensive, especially in interdisciplinary domains where shared terminology increases misclassification risk. This study compared five LLM coordination strategies—single-agent baseline, majority voting, recall-focused ensemble, confidence-weighted aggregation, and two-stage filtering—using four 4-bit quantised open-source models (Mistral 7B, LLaMA 3.1 8B, Granite 3.3 8B, Qwen 2.5 7B) in zero-shot and few-shot configurations. The evaluation was conducted on a Gold Standard of 200 papers from a corpus of 2036 records on blockchain-based e-voting. The best-performing configuration—a single-agent strategy with Qwen 2.5 7B in few-shot mode—achieved recall of 100%, precision of 70.4%, F1 of 82.6%, and a 43.4% reduction in manual screening effort, outperforming all multi-agent alternatives. Confidence-weighted aggregation produced results identical to majority voting, indicating that self-reported confidence from 7–8B parameter models did not add discriminative value. All screening decisions were logged on a private blockchain with timestamped anchoring for reproducibility. These results suggest that, for domain-specific screening tasks, careful model selection outweighs multi-agent coordination overhead, and that few-shot prompting with a well-matched model can achieve human-level recall with substantially reduced manual effort. Full article

Anorexia nervosa is a clinically complex and ethically challenging psychiatric disorder. Clinicians are frequently confronted with ethical dilemmas arising from conflicts between core ethical principles in everyday clinical practice. Professional codes of ethics and legal frameworks often fail to provide a stable basis for resolving these dilemmas due to the fluctuating medical risk and the ego-syntonic nature of anorexia nervosa. Under conditions of heightened responsibility and medical risk, clinicians’ cognitive and emotional responses may be activated and may mediate ethical decision-making. Although such internal processes have been described in the literature, limited attention has been paid to their role in shaping ethical judgment in routine clinical care. The aim of this article is to conceptualize the decision-making processes that unfold in response to ethical dilemmas in the clinical context of anorexia nervosa and propose a sequential multi-level framework. A focused conceptual literature review was conducted to develop a reflective framework for clinical practice, drawing on selected studies in clinical ethics, healthcare law, anorexia nervosa care, and cognitive theory. Clinicians’ internal cognitive and emotional processes play a significant role in ethical decision-making in complex clinical contexts such as anorexia nervosa and should be explicitly recognized and brought into reflective awareness through supervision and reflective practice. Ethical decision-making is therefore conceptualized as a dynamic process linking clinical events, clinicians’ internal responses, ethical and legal considerations, and reflective clinical judgment. Incorporating structured reflection into clinical, educational, and supervisory settings may support more ethically informed and context-sensitive clinical judgment within multidisciplinary eating disorder services. Full article

Background/Objectives: Diabetes mellitus is a common chronic disease that may lead to multimorbidity and high drug use. Therefore, this study aims to examine the prevalence of polypharmacy and hyperpolypharmacy among adult patients diagnosed with type 2 diabetes mellitus (T2DM) with its associated factors. Methods: This is a retrospective cross-sectional study conducted from 1 May 2023 to 31 October 2024. The outcomes in our study were polypharmacy (from five to nine drugs) and hyperpolypharmacy (≥10 drugs). Baseline and demographic characteristics, along with multinomial logistic regression, were used to analyze the data. Results: The total number of patients with T2DM was 2435. The prevalence rate of polypharmacy was 46.98%, while hyperpolypharmacy was 24.27%. Older age was significantly associated with a higher risk of polypharmacy [OR = 1.031, 95% (1.022–1.040)] and hyperpolypharmacy [OR = 1.037, 95% (1.026–1.049)]. In addition, patients with higher levels of hemoglobin A1c showed a significantly higher risk of polypharmacy and hyperpolypharmacy ([OR = 1.162, 95% (1.105–1.221)] and [OR = 1.284, 95% (1.209–1.364)], respectively). The comorbidities that increased the odds of hyperpolypharmacy were hypertension [OR = 2.136, 95% (1.449–3.148)], pulmonary disease [OR = 2.375, 95% (1.292–4.367)], mental disorders [OR = 6.269; 95% (3.284–11.964], and congestive heart failure [OR = 8.014, 95% (2.768–23.200)]. Conclusions: The prevalence of polypharmacy and hyperpolypharmacy is high in patients with T2DM. The predictors that may play a significant role in increasing the risk of hyperpolypharmacy are the poor control of HbA1c and the coexistence of comorbidities. Providing proper prescribing of patients’ therapy plans can improve individuals’ health outcomes. Therefore, this study highlights the important role of primary care physicians in coordinating care, along with clinical pharmacists, in the identification of polypharmacy. Full article

Background and Objectives: Poor sleep is common in community and primary-care settings, yet very brief sleep measures suitable for routine use remain limited. We developed and evaluated the five-item Promoting Evaluation and Awareness of Comfort in Sleep (PEACE) scale and examined its associations with well-being and fatigue. Materials and Methods: In a cross-sectional, clinician-mediated online survey, 312 community-dwelling adults in Italy who were not receiving active treatment for major diseases completed PEACE, the World Health Organization-Five Well-Being Index (WHO-5), and a short fatigue questionnaire. The sample was stratified and split into exploratory and confirmatory subsamples for factor analyses. Results: Factor analyses supported the use of a single total score and showed acceptable reliability. Results were broadly similar in women and men, with no evidence of item-level bias, although some model-comparison indices were mixed. Higher PEACE scores were associated with better well-being and lower fatigue. Adding PEACE to a model predicting well-being from body mass index and sex increased explained variance from 4.0% to 11.5%. Conclusions: PEACE is a brief sleep-quality measure with promising initial psychometric properties. In this sample, it was associated with well-being and fatigue and may add information beyond body mass index and sex in community and primary-care settings. Full article

Background: In Spain, the number of patients anticoagulated with vitamin K antagonists (VKAs) is high. Among them, poor adherence is common, which may be justified by a low level of knowledge, and could affect their quality of life. We analyzed treatment adherence, health-related quality of life, and knowledge level about treatment, and evaluated the possible influence of these factors on patients’ time in the therapeutic range while also studying potential differences between patients under routine monitoring or self-monitoring. Methodology: A cross-sectional descriptive study was conducted using three validated and cross-culturally adapted questionnaires to study therapeutic adherence, health-related quality of life, and knowledge level about VKA treatment in a sample of anticoagulated patients. Additionally, it was assessed whether they were self-monitoring or not; the Rosendaal Time in Therapeutic Range (TTRr) was also administered for each patient at the time of recruitment. Descriptive analysis of all variables was performed, and a logistic regression model was constructed to evaluate the possible interaction of variables. Results: Ninety-eight patients participated and were selected sequentially from those attending the oral anticoagulation clinic at Hospital Universitario Virgen de la Victoria in Malaga. Of these, 39 were men and 59 were women. The mean age of these participants was 60.62 years (SD 11.67). Sixty-six were under conventional monitoring and thirty-two followed the self-monitoring program. The DecaMIRT had a mean score of 39.22 (SD 8.57), the SF-12 mean score was 31.73 (SD 6.21), and the knowledge questionnaire’s was 14.2 (SD 2.6). The mean TTRr value was 63.88 (SD 22.99). Self-monitored patients showed better results in DECAMirt and knowledge. Discussion: Overall, patients included in the sample presented satisfactory values in these three questionnaires, which seems to indicate that this was a treatment-compliant group with a correct quality of life, and adequately informed about their treatment. Conclusions: The work of nurses responsible for these aspects appears crucial in achieving these results. We aim to extend this study by focusing on groups with poorer results to design specific activities that allow for improvement in care and, as much as possible, homogenize outcomes. For this purpose, we intend to use all available tools, including those derived from the use of health-oriented artificial intelligence. Full article

Heavy metals including mercury (Hg), lead (Pb), cadmium (Cd), and arsenic (As) remain significant global toxins due to their environmental persistence, widespread anthropogenic release, and serious biological effects. This review consolidates current understanding of their natural and industrial sources, environmental cycling, human exposure routes, and population-level vulnerabilities. It covers their toxicokinetics and toxicodynamics, emphasizing species-specific absorption, distribution, and injury mechanisms, including oxidative stress, thiol binding, mitochondrial dysfunction, endocrine disruption, and cancer risk. Clinical signs range from subtle neurocognitive impairment and kidney damage to severe acute poisoning. The review evaluates evidence-based approaches to risk assessment and biomonitoring, such as blood, urine, hair, and speciation tests, noting issues, including unvalidated provoked testing. Treatment focuses on removing exposure, providing nutritional support, and offering supportive care, with chelation therapy reserved for specific cases. It explains the chemistry, pharmacology, and roles of chelating agents—ALA, DMSA, DMPS, Cys, GSH, and physiologic thiols, comparing their effectiveness, limitations, and costs for various metals. Emerging therapies, precision toxicology, and public health strategies are discussed within a prevention-focused context. Unlike prior reviews focused primarily on toxic mechanisms or isolated clinical management, this review integrates mechanistic toxicology, biomarker interpretation and speciation, evidence-based clinical care, and ethical, cost-conscious decision-making within a single translational framework. This narrative review synthesizes foundational and contemporary literature published through 2025, with particular emphasis on studies published since 2000 that inform toxicokinetics, biomarker interpretation, diagnostics, clinical management, and prevention. Full article

Background: Emergency obstetric situations require rapid clinical decision-making, technical competence, and emotional preparedness to ensure safe and compassionate care for both mother and newborn. However, nursing students often have limited opportunities to experience such high-risk, low-frequency events during clinical placements. Simulation-based education has emerged as an effective strategy to prepare future nurses for caring in emergency contexts, allowing them to develop both technical and non-technical skills in a safe learning environment. This study aimed to evaluate the effects of a high-fidelity obstetric emergency simulation program on nursing students’ knowledge, perceived safety, and learning experience. Methods: A mixed-methods design was employed, combining a quasi-experimental pretest–posttest assessment without a control group and qualitative analysis of open-ended reflections. Eighty-two third-year nursing students participated in two simulation sessions addressing obstetric emergencies such as breech birth, shoulder dystocia, out-of-hospital delivery, eclampsia, postpartum hemorrhage, and maternal cardiac arrest. Data were collected using validated instruments measuring knowledge, perceived safety, and satisfaction and self-confidence in learning, and were analyzed using Wilcoxon signed-rank tests and thematic analysis. Results: Significant improvements were observed in specific knowledge areas related to complex obstetric maneuvers and in their perceived safety when managing emergency situations (p < 0.001, r > 0.40). Participants reported high levels of satisfaction and confidence in learning. Qualitative findings highlighted increased emotional preparedness, improved clinical reasoning, and recognition of the importance of teamwork and reflective debriefing in emergency care contexts. Conclusions: High-fidelity simulation appears to be an effective educational strategy for preparing nursing students to provide safe and confident care in obstetric emergencies. Integrating simulation into nursing curricula can strengthen both technical competence and the emotional readiness required for caring in urgent and high-pressure clinical situations. Full article

Background/Objectives: Molecular testing and targeted therapeutics remain inequitably delivered among patients with cancer. In response, we refined a multilevel intervention directed at clinicians, payers, and patients to determine whether it could improve patient knowledge and receipt of precision cancer care more than an intervention directed at clinicians and payers alone. Methods: This patient-level randomized trial was conducted in a community oncology clinic among low income and racial and ethnic minority adults who were newly diagnosed with cancer or relapsed disease. We compared a two-level enhanced usual care intervention, in which patients received usual care, clinicians received annual precision medicine training, and payers eliminated prior authorization for molecular testing and targeted therapeutics (control group), with a three-level intervention, in which patients received enhanced usual care along with a patient-level 12 month precision medicine education component led by community health workers (intervention group). The primary outcome was precision medicine knowledge. Secondary outcomes were health-related quality of life (HRQOL), patient activation, satisfaction, acute care use, molecular testing, and targeted treatment. Results: Among 110 participants, the three-level intervention resulted in greater improvement in knowledge of precision medicine compared with the two-level control group (mean difference of 4.17, 95% CI of 2.33–7.48; p < 0.001). Intervention participants also had greater patient activation and satisfaction with care, fewer emergency department visits and hospitalizations, and greater receipt of molecular testing and targeted therapy compared with patients in the control group. Conclusions: Multilevel interventions that include patient-level education can improve care delivery gaps. Trial Registration: clinicaltrials.gov, NCT04843332. Full article

Introduction: Health literacy enables refugees to assess, understand, and utilize health information effectively. This investigation aims to identify factors influencing health literacy levels among Afghan refugees in Pakistan. Methods: A cross-sectional survey using a multistage sampling approach was conducted to collect data from 1185 refugees. Health literacy levels were measured using the pre-validated All Aspects of Health Literacy tool in five districts of Punjab and Khyber Pakhtunkhwa provinces that met the inclusion criteria. We used logistic regression models to analyze the dichotomous dependent variables. Results: A significant proportion of Afghan refugees demonstrated low functional health literacy and required assistance with reading and completing health documentation. Afghan refugees in the younger age group, male gender, higher monthly income, and access to healthcare information and clean water were more functionally literate in health. More than two thirds of the Afghan refugee population had adequate communicative health literacy with health care professionals in Pakistan. Most refugees believed that healthy lifestyles information and encouragement were more crucial for health than housing, employment, education, and local infrastructure. Conclusions: Afghan refugees in Pakistan lacked functional health literacy, critical health literacy, and overall health literacy. However, they have adequate communicative health literacy. This initial survey added new data on Afghans’ health literacy levels, which could help stakeholders strengthen health promotion initiatives within the healthcare system to improve health outcomes. Full article

Objective: This study aimed to identify distinct dyadic coping profiles among infertile couples undergoing assisted reproductive technologies (ARTs) and to examine the associations between these coping profiles, depressive symptoms, and fertility quality of life (FertiQOL). Methods: A total of 271 infertile couples undergoing ARTs were recruited from a reproductive medicine center in Zhengzhou, China, and completed standardized self-report measures. Latent profile analysis was conducted to identify distinct dyadic coping profiles at the couple level. Multinomial logistic regression was used to examine sociodemographic and infertility-related predictors of profile membership. Differences in depressive symptoms and FertiQoL across profiles were analyzed using the Bolck–Croon–Hagenaars method. Results: Four dyadic coping profiles were identified: high-coping wife and low-coping husband (15.4%), low dyadic coping (20.1%), medium dyadic coping (31.5%), and high dyadic coping (33.0%). Couples in the high dyadic coping profile reported the lowest levels of depression and the highest level of FertiQoL. Women in the low dyadic coping profile reported the highest depressive symptoms, while men in the high-coping wife and low-coping husband profile demonstrated the highest depression among male partners. Sociodemographic factors (household registration, family income) and infertility characteristics (type of infertility, infertility duration) were significant predictors of profile membership. Conclusions: Dyadic coping among infertile couples undergoing ARTs is heterogeneous and differentially associated with depression and FertiQoL. Low and asymmetric dyadic coping represent high-risk profiles linked to poorer outcomes in both partners. These findings suggest that dyadic coping may serve as a protective resource for infertile couples to improve their psychological well-being and quality of life, highlighting the importance of incorporating dyadic coping assessment into routine care and providing couple-centered psychosocial interventions in fertility care practice. Full article

Cow’s milk allergy (CMA) remains one of the most common food allergies in infancy, requiring the avoidance of cow’s milk and its derivatives. Breast milk is the best source of nutrition for infants. For those infants with CMA whose mothers are unable to breastfeed or choose not to, extensively hydrolysed formulas (eHFs) are widely recommended as first-line milk substitutes, whereas hydrolysed rice formulas (HRFs) are increasingly recognised as a viable alternative. This concept paper provides a healthcare professional (HCP) perspective on HRF, drawing on expert consensus from two meetings convened in 2025. Discussions noted the long history of safe and effective HRF use in Europe, its nutritional adequacy, and the evolving international guidelines supporting HRF as an alternative first-line option. A key meeting outcome was the development of a practical decision tree to help UK clinicians decide when HRF should be the preferred choice. Key considerations for its use in non-breastfed infants include the following: parental/caregiver stress related to persistent symptoms; ongoing symptoms despite multiple interventions; cultural and lifestyle choices; religious dietary requirements; and specialists’ recommendations. Secondary considerations highlighted by HCPs include the following: proven reactions whilst infants are breast-milk-fed together with parental request for formula; faltering growth; multiple symptoms; taste acceptance (older infants); and parental preference based on experience. The role of functional components, such as prebiotics and human milk oligosaccharides (HMOs), was noted in regard to the emerging evidence of benefits to the microbiome and immune development. The experts emphasised the importance of engaging HCPs across all levels of CMA care and addressing challenges in translating current guidance into treatment practice. It was concluded that, overall, HRF represents a nutritionally complete, plant-based alternative that has been shown to be well tolerated (taste, symptoms) in clinical studies. It can be used to broaden therapeutic options for infants with CMA in the UK who are not exclusively fed breast milk. Full article

Objectives: Outpatient antibiotic prescribing is a major driver of antimicrobial resistance, yet detailed long-term analyses of prescribing patterns in Croatia remain limited. This study aimed to analyze trends in outpatient antibiotic prescriptions issued in Croatian primary healthcare from 2015 to 2024, stratified by antibiotic class, substance, and the WHO AWaRe classification. Methods: A retrospective analysis of nationwide data on antibiotic prescriptions issued in primary care outpatient settings was conducted using the data from the Central Health Information System of the Republic of Croatia. All prescriptions for ATC group J01 antibiotics issued between 1 January 2015 and 31 December 2024 were included. The primary outcome was the annual number of issued outpatient antibiotic prescriptions, described overall and by substance. Annual counts were additionally expressed as a percentage of the 2015 baseline (index year = 100%) to enable the comparison across substances with different prescribing volumes. The prescriptions were classified according to the WHO AWaRe framework. Results: A total of 31,048,414 outpatient antibiotic prescriptions were issued between 2015 and 2024. Overall prescribing declined by 5.6% from 2015 to 2019, followed by a marked decrease of 21.0% in 2020, and subsequently rebounded to 3,338,235 prescriptions by 2024, a number virtually identical to pre-pandemic levels. Co-amoxiclav and azithromycin together accounted for 49.5% of all prescriptions. By 2024, prescribing third-generation cephalosporins increased by 281.9% compared to the 2015 levels, while prescribing amoxicillin decreased by 43.6% over the same period. The proportion of Access antibiotics declined from 64.7% in 2015 to 57.9% in 2024. Conclusions: The main challenge for antimicrobial stewardship in Croatia lies not only in overall prescribing volume but in prescribing composition. Targeted interventions are needed to reduce reliance on broad-spectrum agents and promote the use of narrower-spectrum first-line alternatives. Full article

Background/Objectives: Patient-Reported Experience Measures (PREMs) help us understand how patients perceive healthcare quality. Yet most studies look at complaints in isolation, without tying them to the structural features of medical practice. This study asks whether the nature of clinical work—shaped by diagnostic pathways, interaction patterns, and professional focus—predicts what patients complain about. Methods: We analyzed 18,492 negative reviews from infodoctor.ru, collected between 2012 and 2023 across 16 Russian cities with populations over one million. We used a mix of methods: machine learning (logistic regression) to classify complaints as medical (M-type) or organizational (O-type), statistical tests (chi-square, proportion analysis), and expert validation by nine independent specialists. We also built a novel multidimensional classification of medical practices based on three criteria: diagnostic pathway length, frequency and duration of patient interaction, and whether the work is mainly technical or communicative. Results: Technical specialties received far more medical complaints than communicative ones (39.8% vs. 29.3%, p < 0.001), while communicative specialties received more organizational complaints (45.7% vs. 35.0%, p < 0.001). Specialties that manage chronic conditions over the long term had the highest share of organizational complaints (41.6%). At the city level, the share of communicative specialists correlated negatively with complaints per capita (r = −0.541, p = 0.0306). We found no meaningful gender differences in complaint patterns. Conclusions: The type of medical practice systematically shapes what patients complain about. Technical specialties draw criticism on clinical quality; communicative specialties draw criticism on how care is organized. Long-term care faces challenges rooted more in administrative friction than in clinical competence. These findings show that PREMs, when analyzed through a practice-based lens, can support targeted quality improvement—moving from simply tracking complaints to acting on them in specialty-specific ways. Full article

Background: The 2024/25 influenza season in Hungary experienced a major surge in cases, the largest since the COVID-19 pandemic. We evaluated influenza vaccine effectiveness (VE) in primary care settings among adults and vaccination target groups, and also according to time since vaccination, prior seasonal vaccination, and influenza type. Methods: A test-negative case–control study was conducted in Hungary. Data and specimens were collected from primary care patients with an acute respiratory infection (ARI). Patients with positive PCR test results for influenza were classified as cases, while those with negative test results for influenza were classified as controls. Adjusted VEs were calculated using logistic regression as (1−odds ratio of vaccination) ×100. Results: Between November 2024 and May 2025, 2074 patients were included in the analysis, of whom 395 cases had influenza. Of the 129 vaccinated patients, 123 (95%) received trivalent inactivated adjuvanted whole-cell vaccine (TIAV), and 6 (5%) received quadrivalent split-virion vaccine. The VE against any influenza was 53% (95% CI: 13–74) in the 18+ age group and 52% (95% CI: 7–75) in the target group for vaccination. The VE against any influenza was 63% (95%CI: 17–84) 14–89 days after vaccination, and 27% (95%CI: −67–68) 90 days or more after vaccination. The VE against any influenza was 56% (95%CI: 1–80) with both current and prior seasonal vaccination, and 5% (95%CI: −64–45) with only prior seasonal vaccination. The VE against influenza A was 39% (95%CI: −16–68), and against influenza B was 80% (95%CI: 2–96). Conclusions: We observed moderate vaccine effectiveness against any influenza, with higher protection within three months after vaccination. Our research findings provide evidence to inform the development of vaccines and the scheduling of vaccination campaigns, with the aim of maximizing the level of protection provided by vaccines throughout the entire influenza season. Full article

Background: Technology such as telerehabilitation, virtual reality, robotics, and wearable systems are reshaping pediatric physiotherapy. While evidence remains fragmented, there is little guidance on how these approaches can be integrated into coherent, family-centered care pathways. Objective: To develop the Digital Pediatric Physiotherapy Framework (DPPF) based on a systematic review of randomized evidence on digital interventions in pediatric physiotherapy. Methods: Several databases were searched for randomized trials published after 1 January 2020, including PubMed, Web of Science Core Collection, and Google Scholar. The included studies assessed the results of physiotherapist-delivered or physiotherapist-supervised digital interventions in children and adolescents aged 18 and younger. Population, intervention, outcome, implementation, and safety data were extracted. Considering the substantial heterogeneity of the findings, they were synthesized narratively. Cochrane RoB 2 was used to assess risk of bias, and GRADE was used to evaluate certainty of evidence. Results: Twenty-nine trials involving 1196 participants were included. Most studies examined virtual reality and gaming-based interventions, with fewer evaluating telerehabilitation/tele-exercise and robotic or wearable technologies. Digital interventions were most often directed at body-function and activity-level outcomes, while participation outcomes were less frequently studied. The strongest evidence supported short-term benefits in balance, gross motor function, upper-limb activity, pain, and selected fitness outcomes, particularly in children with cerebral palsy. Evidence for telerehabilitation and robotic or wearable approaches was more limited but generally promising. Implementation, equity, cost, and long-term outcomes were rarely reported. No eligible trial directly evaluated electronic patient-reported outcome measures, digital triage, or clinical decision support as stand-alone interventions. Conclusions: Digital interventions have the potential to strengthen pediatric physiotherapy, particularly for short-term motor and functional outcomes. The proposed DPPF provides an implementation-informed structure to guide future research, pathway design, and more purposeful integration of digital health into pediatric rehabilitation practice. Full article