Search Results (537)

Background/Objective: The COVID-19 pandemic profoundly transformed social life worldwide, indiscriminately affecting individuals across all age groups. Children have not been exempted from the risk of severe illness and death caused by COVID-19. Objective: This paper sought to describe the clinical findings, laboratory and imaging results, and hospital care provided for severe and critical cases of COVID-19 in unvaccinated children, with or without severe asthma, hospitalized in a public referral service for COVID-19 treatment in the Brazilian state of Pernambuco. Methods: This was a case series study of severe and critical COVID-19 in hospitalized, unvaccinated children, with or without severe asthma, conducted in a public referral hospital between March 2020 and June 2021. Results: The case series included 80 children, aged from 1 month to 11 years, with the highest frequency among those under 2 years old (58.8%) and a predominance of males (65%). Respiratory diseases, including severe asthma, were present in 73.8% of the cases. Pediatric multisystem inflammatory syndrome occurred in 15% of the children, some of whom presented with cardiac involvement. Oxygen therapy was required in 65% of the cases, mechanical ventilation in 15%, and 33.7% of the children required intensive care in a pediatric intensive care unit. Pulmonary infiltrates and ground-glass opacities were common findings on chest X-rays and CT scans; inflammatory markers were elevated, and the most commonly used medications were antibiotics, bronchodilators, and corticosteroids. Conclusions: This case series has identified key characteristics of children with severe and critical COVID-19 during a period when vaccines were not yet available in Brazil for the study age group. However, the persistence of low vaccination coverage, largely due to parental vaccine hesitancy, continues to leave children vulnerable to potentially severe illness from COVID-19. These findings may inform the development of public health emergency contingency plans, as well as clinical protocols and care pathways, which can guide decision-making in pediatric care and ensure appropriate clinical management, ultimately improving the quality of care provided. Full article

Background/Objectives: The demand for accessible and reliable digital health services has increased significantly in recent years, particularly in regions facing physician shortages. HomeDOCtor, a conversational AI platform developed in Slovenia, addresses this need with a nationally adapted architecture that combines retrieval-augmented generation (RAG) and a Redis-based vector database of curated medical guidelines. The objective of this study was to assess the performance and impact of HomeDOCtor in providing AI-powered healthcare assistance. Methods: HomeDOCtor is designed for human-centered communication and clinical relevance, supporting multilingual and multimedia citizen inputs while being available 24/7. It was tested using a set of 100 international clinical vignettes and 150 internal medicine exam questions from the University of Ljubljana to validate its clinical performance. Results: During its six-month nationwide deployment, HomeDOCtor received overwhelmingly positive user feedback with minimal criticism, and exceeded initial expectations, especially in light of widespread media narratives warning about the risks of AI. HomeDOCtor autonomously delivered localized, evidence-based guidance, including self-care instructions and referral suggestions, with average response times under three seconds. On international benchmarks, the system achieved ≥95% Top-1 diagnostic accuracy, comparable to leading medical AI platforms, and significantly outperformed stand-alone ChatGPT-4o in the national context (90.7% vs. 80.7%, p = 0.0135). Conclusions: Practically, HomeDOCtor eases the burden on healthcare professionals by providing citizens with 24/7 autonomous, personalized triage and self-care guidance for less complex medical issues, ensuring that these cases are self-managed efficiently. The system also identifies more serious cases that might otherwise be neglected, directing them to professionals for appropriate care. Theoretically, HomeDOCtor demonstrates that domain-specific, nationally adapted large language models can outperform general-purpose models. Methodologically, it offers a framework for integrating GDPR-compliant AI solutions in healthcare. These findings emphasize the value of localization in conversational AI and telemedicine solutions across diverse national contexts. Full article

Background: Psychological problems post-stroke can negatively impact stroke survivors. Although general psychological services exist (e.g., NHS Talking Therapies), access remains limited, particularly for individuals with post-stroke communication and cognitive impairments. Stroke service staff report low confidence in managing psychological distress. This study is the first to explore the barriers and facilitators to implementing a novel intervention package comprising a cross-service care pathway and staff training to enhance post-stroke psychological provision. Methods: Staff from stroke and mental health services in four UK regions, recruited through purposive sampling to ensure diversity of services and professional roles, participated in semi-structured interviews or focus groups, guided by the Theoretical Domains Framework (TDF), before and after implementation of the intervention package. Pre-implementation interviews/groups identified anticipated barriers and facilitators to implementation and training needs, informing the development of site-specific intervention packages; post-implementation interviews/groups explored experienced barriers, facilitators and perceptions of the intervention. Interviews underwent thematic analysis using the TDF. Results: Fifty-five staff participated pre-implementation and seventeen post-implementation, representing stroke (e.g., nurse, physiotherapist, consultant) and psychology (e.g., counsellor, psychological therapist) roles across acute, rehabilitation, community, and voluntary services. Challenges anticipated pre-implementation included: limited specialist post-stroke psychological support; low staff confidence; and fragmented service pathways. Post-implementation findings indicated increased staff knowledge and confidence, enhanced screening and referral processes, and stronger inter-service collaboration. Implementation success varied across sites (with some sites showing greater ownership and sustainability of the intervention) and across staff roles (with therapy staff more likely than nursing staff to have received training). Conclusions: Effective implementation of an intervention package to increase psychological provision post-stroke requires staff engagement at all levels across all services. Staff investment influenced ownership of the intervention package, beliefs about priorities and overall enhancement of service capability. Full article

Background/Objectives: To identify factors associated with the referral by a multiprofessional team to dental services for children and adolescents with rare genetic diseases. Methods: A cross-sectional study was developed with 87 children/adolescents with mucopolysaccharidosis (n = 26) and osteogenesis imperfecta (n = 61) and their caregivers. Recruitment took place at reference centers for rare genetic conditions in five Brazilian states. The caregivers answered a questionnaire on the children. They were examined for malocclusion, dental anomalies, caries experience, and gingivitis. Bivariate and multivariate analyses of the data were performed, considering a 95% confidence level. Results: The average age of children/adolescents was 10.4 years (±5.6) and 17.3% had never gone to a dentist. Among those with past dental experience, the reason for most appointments was oral prophylaxis/preventive maintenance (62.1%). With regard to referrals to a dentist by the multidisciplinary team, 29.9% had never received a referral. The likelihood of having been referred to a dentist by the multiprofessional team was 2.67 times greater for female patients (95% CI: 0.96–7.42) and 7.74 times greater for children/adolescents with a history of toothache (95% CI: 1.61–37.14). Conclusions: Female children/adolescents with mucopolysaccharidosis and osteogenesis imperfecta and those with a history of dental pain were more likely to have been advised by the multiprofessional team to seek dental treatment. Full article

Background/Objectives: Grief in cancer patients represents a multidimensional psychological response encompassing anticipatory, existential, and identity-related distress. While the recent literature has examined grief in caregivers, family members, and even healthcare professionals, the psychological grief experienced by patients themselves following a cancer diagnosis remains comparatively understudied and insufficiently characterized in empirical research. This systematic review aims to evaluate observational studies that used validated psychometric instruments to measure grief in adult cancer patients and to synthesize findings on the significance of grief in this population. Methods: Following PRISMA 2020 guidelines, a systematic search of PubMed, CINAHL, and PsycINFO was conducted to identify observational studies that employed validated tools to assess grief among adult cancer patients. The inclusion criteria required the use of psychometrically validated grief instruments and the collection of quantitative data. Fifteen studies met eligibility criteria and were included in the final analysis. Results: Grief symptoms were consistently present at moderate to high levels across diverse cancer types, care settings, and geographic regions. Preparatory Grief in Advanced Cancer (PGAC) scores often exceeded thresholds associated with clinical concern, with correlations observed between grief and psychological variables such as anxiety (r = 0.63), depression (r = 0.637), hopelessness (r = 0.63), and dignity (r = 0.654). Demographic factors (e.g., younger age, female gender) and illness perceptions (e.g., identity centrality, stigma) further intensified grief. Grief was a predominant psychological concern even when general distress measures failed to capture its presence. Conclusions: Future research is essential to identify an effective public health strategy for addressing grief through structured screening conducted in primary care and outpatient medical settings, coupled with accessible referral pathways to community-based support groups and coordinated follow-up services to facilitate grief management. Full article

Childhood cancer survivors (CCSs) are at increased risk for chronic health issues due to late effects of cancer and its treatment. We address the impact of environmental exposures, such as air pollution, tobacco smoke, extreme weather events, and pesticides, on the health and survival of CCSs. These environmental hazards have been associated with worsening health outcomes and decreased survival among CCSs on a global scale. We also highlight that providers at a major pediatric cancer center in the United States have limited knowledge and practical skills about environmental risk factors and how to reduce exposures. Our survey results show that pediatric oncology providers would find an environmental referral service helpful and useful in their department. Integrating environmental health into pediatric cancer care can empower patients and families, promote healthier behaviors, and potentially reduce morbidity and mortality in this vulnerable population. Full article

Background/Objectives: The prevalence of people with incurable and progressive diseases in primary health care is high. Family doctors and nurses must be active agents in the early identification of palliative needs and the implementation of palliative approaches in cases of low to intermediate complexity. While there is a need for early referral of more complex palliative care (PC) cases to specialized teams, primary health care (PHC) professionals lack the confidence or skill to describe their role. This study sought to explore and describe (a) the practices of PHC professionals regarding their PC provision; (b) the barriers regarding access and referral of patients to specialized PC services; and (c) the strategies used or recommended to mitigate difficulties in accessing and referring to specialized PC. Methods: A descriptive qualitative study was carried out, using five focus groups conducted with nursing and medical staff at three local health units in the central region of Portugal. Semi-structured interviews were conducted, and then recorded, transcribed, and analyzed through a thematic analysis approach. The reporting of this research follows the COREQ checklist. Results: In total, 34 PHC professionals participated in this study. The majority of participants were women (n = 26) and family doctors (n = 24). Their mean age was 43.8 ± 11.9 (range: 29 to 65 years). The findings were organized into three core themes: (1) the contours of palliative action developed by PHC teams; (2) barriers to access and safe transition between PHC and specialized PC; and (3) ways to mitigate difficulties in accessing and referring to specialized PC. Conclusions: Our findings highlight the fundamental role of PHC professionals in providing primary PC, and in identifying PC needs and referring patients to PC early on, while exposing the systemic and interpersonal challenges that hinder these processes. To overcome these challenges, it is essential to invest in the development of integrated care models that promote practical, low-bureaucratic referral processes and capture the human resources necessary for the adequate follow-up of users. Full article

Background/Objectives: Ultrasonography is a diagnostic modality characterized by high sensitivity in detecting hepato-biliary pathology, particularly intrahepatic biliary duct dilation. This study compares the sonographic findings obtained by a radiographer/sonographer in a Basic Emergency Service (BES) using Point-of-Care Ultrasonography (POCUS) in Portugal with the sonographic findings from the same patients acquired by radiologists at a referral hospital (RH) for suspected intrahepatic biliary dilatation. Methods: Nineteen patients presenting with right upper quadrant (RUQ) pain and suspected abdominal pathology underwent sonographic screening using POCUS in the BES. Subsequently, the same patients were referred to the RH, where a radiologist performed a comprehensive ultrasound. Both examinations were compared to determine whether the findings obtained in the BES were confirmed by radiologists in the RH. Results: Cholestasis, cholangitis, lithiasis, pancreatitis, peri-ampullary lithiasis, and neoplasms were observed in association with intrahepatic biliary dilation in this study sample. All six variables showed a strong association between the BES and RH findings (Cramer’s V > 0.6; p < 0.006). A strong kappa measure of agreement between the radiographer and radiologist findings was obtained in “cholelithiasis/sludge/gallbladder acute sonographic changes” (k = 0.802; p = 0.000). A moderate kappa value was obtained for the variable “abdominal free fluid”, (k = 0.706; p = 0.001). Conclusions: In this study, all patients referred from the BES to the RH required hospitalization for treatment and additional imaging exams. Although pre-hospital screening ultrasound is not intended for definitive diagnoses, the early detection of intrahepatic biliary tract dilatation through screening sonography played a significant role in the clinical referral of patients, with a sensitivity of 94% and specificity of 75%. Full article

Background/Objectives: The COVID-19 pandemic exposed critical vulnerabilities in healthcare systems, especially in ensuring continuity of care for patients with chronic diseases. Rehabilitation services, essential for recovery following SARS-CoV-2 infection, were among the most disrupted. This exploratory study aimed to assess Romanian patients’ perceptions of the accessibility and quality of post-COVID-19 rehabilitation services, focusing on individuals with chronic conditions. Methods: This exploratory cross-sectional study was conducted over a 12-month period in 2024. Data were collected from 76 adult patients diagnosed with at least one chronic condition (hypertension, diabetes mellitus, ischemic heart disease, cancer, or chronic obstructive pulmonary disease) and with confirmed prior SARS-CoV-2 infection. Most participants were recruited during outpatient specialty consultations, with a smaller number included from hospital settings, all located in Bucharest. A structured questionnaire was administered by the principal investigator after obtaining informed consent. Quantitative data were analyzed using non-parametric methods following confirmation of non-normal distribution via the Shapiro–Wilk test (p < 0.05). Satisfaction scores were reported as medians with interquartile ranges (IQR), and group comparisons were performed using the Mann–Whitney U test. A mixed-methods approach was employed, including thematic analysis of open-ended responses. Results: Patient satisfaction with rehabilitation services was consistently low. The median satisfaction scores [IQR] were accessibility 1.0 [0.0–2.0], quality of services 0.0 [0.0–4.0], staff empathy 0.0 [0.0–5.0], and perceived effectiveness 0.0 [0.0–5.0]. The median score for perceived difficulties in access was 1.0 [1.0–2.0], indicating widespread barriers. No statistically significant differences were observed between urban and rural participants or across chronic disease categories. Thematic analysis (n = 65) revealed key concerns including lack of publicly funded services, cost barriers, limited physician referral, service scarcity in rural areas, and demand for home-based rehabilitation options. Conclusions: Romanian patients with chronic illnesses and previous SARS-CoV-2 infection continue to face substantial barriers in accessing post-COVID-19 rehabilitation services. These findings highlight the need for more equitable and integrated recovery programs, especially for vulnerable populations in underserved settings. Full article

Background: Respiratory infections (RIs) are a common cause of care by Prehospital Emergency Medical Services (PEMS). Early Warning Scores (EWS) are tools used by PEMS to assess patients with acute pathology. However, there is little evidence of their application in RIs. The primary aim of this study was to assess the ability of five EWS to predict one-year mortality (M1Y) and two-year (M2Y) mortality in patients with suspected RI assisted by PEMS. The secondary objective was to perform a survival analysis. Methods: An observational and prospective study was conducted in adult patients with RIs transferred by EMS to their referral hospital. The variables necessary for the calculation of EWS [National Early Warning Score 2 (NEWS2), Quick Sequential Organ Failure Assessment (qSOFA) score, Quick COVID-19 Severity Index (qCSI), CURB-65 Score for Pneumonia Severity (CURB-65) and BAP-65 Score for Acute Exacerbation of COPD (BAP-65) score] were collected. The prognostic ability of the EWS was assessed by the area under the receiver operating characteristic curve (AUC). Patients were followed up and a survival study was performed. Results: A total of 819 patients met the inclusion criteria. M1Y was 55.9% and M2Y was 63.5%. BAP-65 showed the best predictive ability at both 1 and 2 years, with AUC of 0.716 and 0.711, respectively. 48.8% of deaths took place during the first month. Conclusions: BAP-65 was the score with the best ability to predict both M1Y and M2Y after the index event in patients with RIs. All other EWS analyzed showed poor performance except in patients with low comorbidity. Full article

As survival rates for teenagers and young adults (TYAs) with cancer exceed 80%, they are living longer post treatment, yet often experience prolonged health and quality of life concerns. Many TYAs also experience unmet support needs. This study aimed to identify TYAs support needs following treatment at a UK hospital and explore how and when TYAs prefer to receive support. This study involved two phases: Phase 1 involved semi-structured interviews with 16 TYAs, 1–6 years post-treatment, aged 16–25 years at time of treatment completion and examined their experiences of support services, and preferences for future care. Phase 2 consisted of co-design workshops with eight TYAs and feedback from five healthcare/allied professionals (HCAPs) to refine and develop recommendations. Phase 1 findings revealed six key themes: (1) survivorship as disrupted continuity; (2) negotiating legitimacy and relational safety in help seeking; (3) support offered vs. support sought: pathways of referral and self-initiation; (4) emotional readiness as context dependent and non-linear; (5) support as an ecosystem, not a moment; and (6) personalised autonomy in support engagement. Phase 2 findings informed recommendations that emphasise the importance of flexible, personalised, and accessible post-treatment support, with pathways of care/support that can adapt to TYAs changing needs and preferences over time. Full article

The evaluation of port service quality (PSQ) is critical for enhancing the competitiveness of container terminals. As technological innovation continues to reshape port operations, PSQ has shifted beyond operational efficiency to deliver smart, reliable, and sustainable services. However, few studies have addressed PSQ in the context of smart port evolution, especially with a focus on container terminals. This study employs a five-dimensional framework, comprising resources, outcomes, process, management, image, and social responsibility, to analyze how PSQ influences customer satisfaction and how customer satisfaction, in turn, affects customer loyalty and referral intention. The data was collected through a survey targeting users of container terminals in five major ports in Korea that undergoing smart port transformation, resulting in a final sample of 324 respondents. The findings reveal that resource-related, process-related, and image- & social responsibility-related PSQ dimensions significantly enhance customer satisfaction, which in turn has a positive effect on customer loyalty and referral intention. In contrast, the outcome-related and management-related dimensions did not have a significant impact on customer satisfaction. The analysis results and various implications discussed in this study are expected to provide helpful information and insights for establishing strategies to enhance the competitiveness of smart ports in the future. Full article

Background: Prior to the COVID-19 pandemic, the mortality of patients admitted to intensive care units (ICUs) in the UK reached 20%. Studies show up to 40% of these patients may have been eligible for palliative care (PC) referral on admission to the ICU. The involvement of PC teams improves the quality of care delivered and improves patient and family satisfaction. Several trigger tools have been developed to identify ICU patients most likely to benefit from palliative care; however, no consensus exists regarding the most effective tool. Methods: We conducted a retrospective study to identify the number of PC referrals, prior to death in a general ICU setting over a 7-month period in 2019. For patients not referred to PC, three separate “trigger tools”, previously described in the literature, were retrospectively applied to explore the potential impact each tool may potentially have had on PC referral rates. Results: We identified 121 ICU deaths, of which 28 patients (23%) were referred to PC during their admission to the ICU. After retrospective application of the trigger tools to those who were not referred, 75% (n = 70) of patients triggered at least one criterion using the “Zalenski et al.” tool and 71% (n = 66) of patients were eligible for referral had the “Hua et al.” tool had been used. Overall, 82% (n = 36) of cancer patients met at least one criterion for referral with the Royal Marsden tool. Conclusions: Our study supports a finding of poor utilisation of PC services in an ICU patient population. The use of trigger tools can be used to significantly increase the number of appropriate PC referrals in an intensive care setting and may be useful in predicting those who may die. The benefit of PC intervention is aimed at providing holistic support to both patient and family and is associated with better patient and family experience towards the end of life. Full article

Background/Objectives: Early integration of palliative care (PC) improves outcomes for patients with life-limiting diseases (LLDs). This study evaluated the effectiveness of the Palliative Care and Rapid Emergency Screening (P-CaRES) tool—originally developed for emergency settings—in identifying unmet PC needs among patients admitted to internal medicine wards. Methods: In this retrospective study, the P-CaRES tool was applied to medical records of patients with LLDs. Demographic and clinical data were extracted from charts. Logistic regression identified predictors of PC receipt; survival was analyzed using Kaplan–Meier estimates and log-rank tests. Results: Among 2509 patients screened, 631 (23.9%) had at least one LLD. Of these, 451 (71.5%) were identified as having PC needs. However, only 132 (20.9%) received PC services—126 with documented need and 6 without. Advanced cancer (OR = 6.46, p < 0.001), a positive response to the surprise question (OR = 4.88, p = 0.008), and frequent hospitalizations (OR = 2.24, p < 0.001) predicted PC receipt. Median survival declined with increasing disease burden (10 vs. 372 days for patients with ≥3 vs. 1 LLD), unmet PC needs (85 vs. 1383 days), and a “yes” response to the surprise question (79 vs. 1598 days) (all p < 0.001). Conclusions: The P-CaRES tool effectively identified PC needs in patients with LLDs, including those with cancer. Clinical indicators such as frequent hospital admissions, a positive response to the surprise question, and multimorbidity predicted both the need for PC and shorter survival. Nonetheless, substantial gaps existed between identified needs and PC delivery—especially for non-cancer patients. Structured screening and timely referrals may bridge this gap and improve care for seriously ill individuals. Full article

Background: Colon capsule endoscopy (CCE) or panenteric capsule endoscopy (PCE) offers a promising, non-invasive diagnostic approach for patients with iron deficiency anaemia (IDA). However, high rates of conversion to conventional colonoscopy (CCC) following capsule procedures reduce cost-effectiveness and patient satisfaction. Optimising the faecal immunochemical test (FIT) threshold may improve patient stratification and reduce unnecessary conversions in future applications within the IDA diagnostic pathway. Methods: The CLEAR IDA study was a multicentre, retrospective observational study conducted across four UK hospitals. Data were collected over a six-month study period and included patients referred via the two-week-wait (2WW) cancer pathway for iron deficiency, with or without anaemia, over a 12-month timeframe. Colonoscopy findings were analysed and extrapolated using NHS England’s CCE-to-colonoscopy referral criteria to assess the predictive value of FIT for colorectal cancer (CRC), polyp burden, and CCC using ROC curve analysis. The optimal FIT threshold was identified through three complementary approaches: threshold-based analysis, decision curve analysis, and cost–benefit modelling. Results: A total of 1531 patients were analysed; only 1.6% underwent small bowel capsule endoscopy. The diagnostic accuracy (AUC) of FIT for predicting CRC, polypoidal lesions, and CCC was 0.78, 0.58, and 0.69, respectively. Threshold-based analysis identified FIT = 15 µg/g as the lowest level at which CCC rates significantly increased (p = 0.02; OR = 1.87; 95% CI: 1.07–3.14). Decision curve analysis showed a maximum net benefit at FIT = 17.6 µg/g, while cost–benefit modelling identified 9 µg/g as the most cost-effective. Raising the threshold to 10 µg/g resulted in a net loss of GBP –294.4 per patient. An optimal cost-effective FIT threshold range was identified between 10 and 17.6 µg/g. The threshold selection should be tailored to local service capacity and resource availability. Conclusions: While FIT alone is an imperfect triage tool, optimising thresholds between 10 and 17 µg/g may enhance cost-effectiveness and guide appropriate PCE use in IDA. Full article