暂无摘要（点击查看详情）
暂无摘要（点击查看详情）
Recent US policy decisions affecting domestic and global health funding have renewed debate on the United States' disproportionate influence over global health governance, institutions, and priorities. Although some scholars call for defending existing frameworks and others advocate reimagining global health beyond US-centric paradigms, these discussions often remain focused on immediate geopolitical developments. We place these debates in a broader historical context by examining Latin America, where US-led political and economic interventions interacted with domestic elites to shape health policy trajectories. Drawing on the traditions of Latin American social medicine and collective health, we analyze how global and national political-economic forces reshaped health systems in Chile and Brazil. Neoliberal reforms emerged through the convergence of international financial pressures, domestic elite coalitions, and policy diffusion. These reforms occurred through 3 interconnected processes: the depletion of public health capacity, the marketization and fragmentation of services, and the weakening of community-based care models. Latin America's experience demonstrates how neoliberal governance commodified health while also fostering enduring traditions of resistance and rights-based care, offering lessons for reimagining social medicine and global health today. (Am J Public Health. Published online ahead of print July 23, 2026:e1-e8. https://doi.org/10.2105/AJPH.2026.308564).
Academic interest in ethical guidance for medical students from High-Income Countries (HICs) undertaking clinical electives in Low- and Middle-Income Countries (LMICs) has increased. Earlier ethical frameworks laid important groundwork but predate contemporary debates on social justice in global health. This study reviews recent literature to assess how these debates shape and produce ethical guidance, distinguish between ethical student conduct and elective programs, and how such guidance is translated into practice. A systematic review was conducted on ethical guidance for HIC medical schools and students regarding LMIC electives. Articles published between January 2018 and October 2023 were identified from PubMed, Embase, and Global Health. Thematic synthesis was combined with analysis of authorship (pose) and intended audience (gaze). Of 711 articles, 24 met inclusion criteria. Five interconnecting themes emerged: humility, reflection, local embeddedness, equitable partnerships, and student health and well-being. While these align with existing frameworks, guidance remains largely conceptual, with limited attention to implementation and accountability across ethical student conduct and program design, with responsibility predominantly located at the level of HIC students. Pose and gaze analysis revealed epistemic imbalances in authorship and intended audiences. Most articles reflected HIC-based perspectives, with North American authors overrepresented and no solely LMIC-authored articles. Ethical guidance remains dominated by HIC perspectives and focused on student conduct rather than program structures. By distinguishing between individual and institutional ethics, this study highlights the need for actionable, co-created frameworks that address accountability, equity, and sustainability in LMIC electives, including attention to institutional responsibility and LMIC perspectives.
Vaccine hesitancy is a global public health challenge, and its characteristics change according to the social and epidemiological context. This commentary seeks to stimulate debate on the dynamic nature of the definition and determinants of vaccine hesitancy, especially in the wake of the Covid-19 pandemic and the population's increased access to new forms of information-seeking, such as artificial intelligence. Scientific production on childhood vaccine hesitancy in Brazil before 2016 was focused on high-income families. After 2016, there was an increase in production on vaccine hesitancy, considering the World Health Organization's 2014 determinants model. After the start of the pandemic, there was a significant increase in studies on disinformation and the politicization of the vaccine. Currently, the use of generative artificial intelligence, which is increasingly common in the search for information on vaccines, is being considered. A hesitação vacinal é um desafio global à saúde pública e suas características mudam conforme o contexto social e epidemiológico. Neste comentário, busca-se estimular o debate sobre o caráter dinâmico da definição e dos determinantes da hesitação vacinal, especialmente após a pandemia de covid-19 e com o aumento do acesso da população a novas formas de busca de informação, como a inteligência artificial. A produção científica sobre a hesitação vacinal infantil no Brasil antes de 2016 era focada em famílias de alta renda. Após 2016, houve aumento da produção sobre a hesitação vacinal, considerando o modelo de determinantes da Organização Mundial da Saúde de 2014. Após o início da pandemia, destaca-se o aumento expressivo de estudos sobre desinformação e politização da vacina. Atualmente, põem-se em reflexão o uso da inteligência artificial generativa, cada vez mais frequente na busca de informações sobre vacinas.
Large language models (LLMs) are now embedded in scientific, educational, and governance workflows, with debates centering on their capabilities, mechanisms, and impacts. Yet these debates remain structured by persistent folk theories-intuitive, informal explanatory models that guide attitudes and actions. Deflationary slogans ("just autocomplete," "stochastic parrots," and "average of the internet") and anthropomorphic framings ("emergent agents" and "proto-minds") each capture genuine features of current systems but mistake those features for the whole. This Perspective proposes a minimal working model of LLM-based systems centered on four distinctions: between pretraining and deployed systems; between the learned distribution and particular samples; among parametric, contextual, and external memory; and between task competence and agency. The model is used to diagnose six misconceptions about LLMs: next-token prediction, regression to the mean, training-data regurgitation, model memory, alignment, and understanding. For each, the analysis identifies what the misconception gets right, which distinctions it conflates, and what follows for capability evaluation, system design, and governance. Applied to publisher AI policies as governance case studies, the framework shows both how policy language can conflate these distinctions and how such errors can be corrected. The model thereby avoids the parrot-mind binary by treating LLMs as simulators of discourse and task performance, offering a diagnostic toolkit for locating and correcting the errors these folk theories perpetuate.
Digital technologies offer new opportunities to support family caregivers, a growing priority in ageing societies. Alles Clara is an Austrian digital service that provides low-threshold, individual support by professional counsellors from the fields of nursing and psychology. Central to its effectiveness is a person-centred approach to counselling. Moving beyond the conceptual debate on whether and how person-centred approaches align with digital services, we embarked on a transformational journey, translating practice development (PD) into the digital realm. Our journey unfolded in three phases: (1) Setting the Scene-analysing the app-usage and counselling characteristics through in-app tracking and user feedback; (2) Encompassing Change-co-creating a concept for PD in Alles Clara through a participatory approach together with counsellors (n = 10) and a newly-introduced practice facilitator; and (3) Packing for the Journey -outlining and structuring key PD strategies to sustainably enable and empower counsellors in providing person-centred counselling in Alles Clara. Baseline data from 1,263 family caregivers and 342 counselling sessions highlighted the heterogeneity of users and their needs. Requests ranged widely, reflecting the diverse demands placed on digital counselling. Defining our destination meant exploring counsellors' shared values and vision. Identifying key concepts for PD in Alles Clara led us to take first steps to bring the concept into action. Drawing on counsellors' experiences and perspectives, we shaped our approach to PD and jointly drew the map for the path towards high-quality person-centred online counselling. The adapted PD framework provided a coherent structure for organizing developmental strategies and measures, translating abstract values into tangible, actionable practices within the digital environment. For PD to succeed in digital healthcare, maintaining human connection must remain a deliberate and continuous effort. The cue does not lie in choosing between technology and humanity, but in learning how to travel both. In this sense, packing for the journey ahead becomes a necessity: equipping ourselves with the principles, processes, and attitudes that preserve the human core of care, even as digital transformation continues to reshape practice. PD offers a compass for navigating this terrain, ensuring that the person remains at the very centre of care.
Colorectal cancer (CRC) remains a leading cause of cancer-related death worldwide, prompting ongoing research into infectious agents that may contribute to colorectal carcinogenesis. Among candidate oncogenic viruses, JC polyomavirus (JCPyV), a ubiquitous human polyomavirus, has attracted considerable attention due to its potential involvement in tumour initiation and progression. Although several studies have reported the presence of JCPyV viral DNA, transcripts, and proteins in colorectal adenomas and carcinomas, the prevalence and clinical significance of these findings vary considerably across populations and diagnostic methods. Mechanistically, the viral Large T Antigen (TAg) is implicated in several oncogenic processes through its interactions with key cellular regulators, including p53, retinoblastoma protein (pRb), and components of the Wnt/β-catenin signalling pathway. These interactions may cause genomic instability, aberrant cell cycle progression, impaired DNA repair, and aberrant cell proliferation, thereby creating an environment conducive to malignant transformation. In addition, emerging evidence suggests that JCPyV may contribute to chromosomal instability and epigenetic changes that facilitate tumour progression. Despite these observations, the causal role of JCPyV in colorectal cancer remains controversial. Inconsistent epidemiological data, discrepancies in virus detection, geographic variation, and the inability to confirm direct causation of carcinogenesis have generated ongoing debates about the involvement of JCPyV as a stimulator factor or cofactor in colorectal tumourigenesis. This review critically evaluates the current evidence linking JCPyV to colorectal cancer, summarises the proposed molecular mechanisms of viral carcinogenesis, and highlights key unresolved questions that need to be addressed to clarify the biological and clinical significance of JCPyV in colorectal carcinogenesis.
Sexual and reproductive health (SRH) education is an essential component of nursing curricula; however, optimal teaching methodologies are still debated. This study evaluated the comparative effectiveness of e-learning and modular learning approaches in improving the knowledge and decision-making skills regarding Integrated Sexual and Reproductive Health (ISRH) among nursing students. A quasiexperimental pretest-posttest design was used with 68 nursing students from a B.Sc. Nursing (4th year) and Post-basic Nursing (2nd year) programs. Participants were assigned to either the e-learning group (n = 34) or modular learning group (n = 34). The e-learning group used a UNFPA-designed online module, whereas the modular group received equivalent traditional classroom instructions. Both interventions spanned 4 days, covering the Introduction to ISRH, Family Planning, Safe Abortion and Reproductive Rights, and Maternal Health topics. Validated questionnaires were used to assess knowledge and decision-making abilities before and 15 days after intervention. Significant improvements in knowledge scores were observed in both the e-learning (mean pretest: 14.97 ± 3.88; post-test: 20.06 ± 3.95; ((t (62) =3.21, p = 0.002, 95% CI 0.72-2.98))) and modular learning groups (mean pre-test: 16.61 ± 3.85; post-test: 20.79 ± 3.59; ((t (62) =3.21, p=0.002, 95% CI 0.72-2.98))). Decision-making abilities improved significantly in the e-learning group (7.29 ± 2.61 to 12.81 ± 2.46; ((t (62) =3.21, p = 0.002, 95% CI 0.72-2.98))) and modular group (7.82 ± 2.28 to 12.36 ± 2.88; ((t (62) =3.21, p = 0.002, 95% CI 0.72-2.98))). Between-group comparisons revealed no statistically significant differences in the post-test knowledge (p = 0.446) or decision-making (p = 0.513) scores, indicating equivalent effectiveness. E-learning and modular learning methods were equally effective in improving nursing students' ISRH knowledge and decision-making skills. Institutions may choose between these approaches based on resource availability and learner preferences without compromising educational outcomes.
The glymphatic system is a cerebrospinal fluid-interstitial fluid exchange pathway that clears metabolic waste and maintains brain fluid homeostasis. Aquaporin-4 (AQP4), a water channel at astrocytic endfeet along the neurovascular interface, supports perivascular water transport and glymphatic flow. Disruption of this glymphatic-AQP4 unit is implicated in conditions with altered fluid dynamics, including traumatic brain injury (TBI) and brain tumors. We reviewed experimental and clinical studies examining glymphatic pathways and AQP4 regulation in TBI and brain tumors, and synthesized evidence on glymphatic physiology, AQP4 polarization, and imaging-based assessment to compare mechanisms of disruption in injury versus tumor remodeling. Evidence shows reduced glymphatic transport in both conditions, commonly accompanied by altered AQP4 localization. In TBI, mechanical injury triggers astrocytic reactivity, blood-brain barrier disruption, and loss of perivascular AQP4 polarization, impairing clearance across phases of injury. In brain tumors, parenchymal remodeling, vascular compression, and vasogenic edema disrupt cerebrospinal fluid dynamics and glymphatic pathways. Across disease states, total AQP4 expression alone poorly predicts glymphatic function; instead, spatial localization and polarization of AQP4 at astrocytic endfeet more consistently correlate with clearance efficiency. Emerging imaging approaches, including diffusion-based MRI metrics and perivascular space quantification, offer potential noninvasive methods for assessing glymphatic alterations in vivo, although their reliability and biological specificity remain debated and under active investigation. Overall, the glymphatic-AQP4 system is a key neurovascular interface regulating brain fluid balance. Disrupted AQP4 polarization and glymphatic transport contribute to edema and impaired solute clearance in both TBI and brain tumors. Future work should prioritize standardized imaging biomarkers and time-dependent strategies to restore glymphatic function and perivascular AQP4 organization.
Many animals build nests. As external structures that can influence survival and reproduction, nests are often considered extended phenotypes. Birds are key examples of nest builders and some species add green plant material to their nests. Yet, the adaptive value of this behaviour remains debated. Non-mutually exclusive hypotheses propose roles in courtship signalling, parasite defence and enhancement of offspring condition through pharmacological effects independent of parasite reduction. Here, we conducted a pre-registered systematic review and meta-analysis of 28 experimental studies (26 published, 2 unpublished), spanning seven bird species and 274 effect sizes, to test whether green nest material enhances fitness and to evaluate competing functional explanations. Our meta-analysis shows that green nest material can increase fitness; however, this effect varied depending on the fitness proxy investigated, being strongest for morphological proxies. We found no compelling evidence to preferentially support the courtship, nest protection or drug hypothesis. Nonetheless, experimental design (i.e. treatment-control comparison type) was the moderator explaining most effect size variation, challenging the traditionally held role of aromatic compounds in the fitness benefits of green nest material. Our synthesis provides evidence for the adaptive significance of green nest material and highlights the need for further research into the underlying mechanisms.
Lumbar spinal stenosis (LSS) is a prevalent degenerative condition that severely impairs mobility and quality of life in older adults. Decompressive surgery, often combined with spinal arthrodesis, remains the cornerstone of treatment. However, the role of instrumentation, particularly the use of interbody cages, remains debated. Instrumented arthrodesis may enhance fusion and segmental stability but is associated with higher morbidity, while uninstrumented techniques are less invasive but may compromise long-term fusion. This study compared clinical, radiographic, and surgical outcomes of three approaches: decompression with instrumented arthrodesis using interbody cages, decompression with instrumented arthrodesis without cages, and decompression with uninstrumented arthrodesis. In this prospective comparative study, 74 patients with LSS underwent one of the three procedures at a spine-specialized center and had ≥24 months of follow-up. Patients were stratified into Group 1 (n = 30), instrumented arthrodesis with interbody cages; Group 2 (n = 20), instrumented arthrodesis without cages; and Group 3 (n = 24), uninstrumented arthrodesis. Clinical outcomes were assessed using the Oswestry Disability Index (ODI), Roland-Morris Disability Questionnaire (RMDQ), Short Form-36 (SF-36), and Visual Analog Scale (VAS) for lumbar and radicular pain. Radiographic assessments included sagittal balance, lumbar lordosis, and fusion, which were carried out by two independent radiologists. Statistical analyses were performed using chi-square tests, paired and unpaired t-tests, Pearson correlations, and logistic regression. All groups showed significant improvement in ODI, RMDQ, SF-36, and VAS scores (p < 0.001). Postoperative sagittal balance improved significantly in Groups 2 and 3 (p = 0.001), whereas changes in lumbar lordosis were not significant (p = 0.663). Fusion rates were highest in Group 2 (95%) and lowest in Group 3 (75%; p = 0.018). Complications were most frequent in Group 3 (20.8%), largely incidental durotomies and wound infections. Reoperations were most common in Group 1 (23%), predominantly due to adjacent segment disease and implant failure. Despite comparable functional improvements, the three strategies demonstrated distinct radiographic and surgical profiles. Instrumented arthrodesis without cages achieved superior fusion and sagittal correction with fewer complications, whereas uninstrumented arthrodesis, though effective for symptom relief, carried higher intraoperative complication rates. Cage-assisted fusion did not improve clinical or radiographic outcomes and was associated with more reoperations, particularly due to adjacent segment disease. These findings support tailoring instrumentation to patient comorbidities, stability requirements, and the need for anterior column support. All three surgical techniques improved function and pain in LSS patients. Instrumented arthrodesis without interbody cages provided the most favorable balance between fusion success and complication risk. Cages should be reserved for selected patients requiring sagittal realignment or foraminal restoration. Given the increased reoperation burden associated with instrumentation, surgical planning should be individualized, prioritizing stability, complication avoidance, and patient-specific risk factors, such as bone quality and comorbidities.
Automating administrative tasks, such as compiling a patient's medical history, could help general practitioners in their daily work. AI performance has improved in recent decades, but skepticism among professionals limits its use in medical practice, due to fears of gaps and biases. This study attempts to evaluate the effectiveness of AI in recording patient histories compared to general practitioners. Cross-sectional study. SITE: Online study in France. French general practitioners recruited online. We compared the performance of a general practitioner with that of AI in collecting a patient's history during an initial consultation. Medical histories were classified into categories: long-term chronic diseases, medical, surgical, obstetric, occupational, drug allergies, other allergies, and family history of cancer. With 204 general practitioners, we obtained 942 patient histories. AI was more effective than traditional physicians in collecting patient histories, especially in older age groups and in categories such as allergies and family history. The relevance and reliability of those histories depend on the age and type of history reported. Older patients, obstetric history, and drug allergies were the most relevant factors. AI is expected to become a major player in the healthcare sector due to its efficiency and accuracy. However, there is still debate about its potential to replace doctors in tasks such as diagnosis, prevention, therapy, or patient information. The ethics of data collection and AI remain a subject of debate, with the importance of training healthcare professionals to ensure they respect medical and patient ethics. The study highlights the importance of integrating new technologies into general medicine and the doctor-patient relationship in the profession.
Nursing education faces faculty shortages and debates about the most suitable doctoral degrees for nurse educators. Divergent viewpoints about nursing-specific and non-nursing doctoral degrees influence faculty career progression and perceptions of teaching effectiveness. Thirty-eight doctorally-prepared nurse educators employed in nursing programs across the United States ranked 37 statements about doctoral degree types in this Q-methodology study. Factor interpretation was based on principal component analysis and open-ended responses. Four distinct viewpoints emerged, accounting for 50% of the variance: Doctoral Degree Egalitarians, PhD Research Advocates, Nursing Degree Idealists, and Degree Hierarchists. The doctoral degree participants held differentiated their viewpoints. Years of experience, professional role, and geographic region did not emerge as differentiators. Degree holders advocate for their own degrees, possibly reflecting lived experiences and socialization during doctoral education. Institutions can address divergent viewpoints on degree types by implementing role-based evaluation criteria and transparent policies valuing diverse academic preparation.
The benefit of laparoscopy in blunt abdominal trauma (BAT) remains debated. This study analyzed patients with BAT treated by laparoscopy in a tertiary reference trauma service in Brazil. A retrospective clinical study of hemodynamically stable patients with BAT treated by laparoscopy over a 12-year period was conducted. Laparoscopies were classified as diagnostic (DL) or therapeutic (TL). Over a 12-year period, 85 patients with BAT were treated laparoscopically. The median age was 30 years, and most patients were male (80%) and had an ASA of I (72%). Collision was the most frequent mechanism (46%). The main indications for laparoscopy were the presence of free fluid without parenchymal lesions on CT (59%) and abdominal pain/signs of peritoneal irritation (11.5%). The conversion rate was 26%, and these patients were included in the control group (n=22). Among the laparoscopies (n=63), 36% (n=31) were DL, and 38% (n=32) were TL. The seat belt sign was present in 12% of the patients in the total series. The most frequent therapeutic procedure is suturing of the bladder, colon, and diaphragm. There was correspondence between the CT and intraoperative findings, and there were no unnoticed injuries. The surgical time was longer in the CG (p<0.05). Laparoscopy can be safe and effective for the management of patients who are victims of blunt abdominal trauma, selected preoperatively and hemodynamically stable. Success in this type of approach depends on a tripod: adequate selection of patients, trained surgeons and full-time availability of materials and subsidiary tests.
The procedure of percutaneous nephrolithotomy (PCNL) is widely recognized as the primary approach for the removal of large renal stones, yet the optimal postoperative drainage strategy in tubeless procedures remains debated. This study compares external ureteral catheter (EUC) and double-J stent (DJS) regarding patient comfort and complications. This retrospective analysis included patients undergoing tubeless PCNL from July 2021 to June 2025, divided into DJS and EUC groups based on drainage method. Pain in the postoperative period was measured using the visual analogue scale (VAS) at both 24 and 48 hours. Stent-related symptoms (SRS) were assessed two weeks, and a voiding cystourethrogram was conducted prior to catheter removal for the evaluation of vesicoureteral reflux (VUR) grade. Analgesic requirements, hospital stays, and complications (fever, urinary extravasation, perirenal hematoma) were recorded. The study encompassed 262 patients, of whom 135 were allocated to the DJS cohort and 127 to the EUC cohort. The frequency of SRS was markedly greater in the DJS group than the EUC group (60.74% vs. 19.69%, P<0.001). Furthermore, the DJS group had a markedly greater percentage of patients with high-grade VUR (42.22% vs. 24.41%, P=0.002). There were no notable differences found between the groups regarding postoperative VAS scores, analgesic requirements, hospital stays, or the incidence of fever, urinary extravasation, or perirenal hematoma (all P>0.05). Multivariate analysis confirmed EUC as a protective factor against SRS (OR=0.200, P<0.001). EUC drainage following tubeless PCNL significantly reduces SRS and severe VUR compared to DJS, while maintaining comparable safety.
This study examines how Chinese small and medium-sized cities gain visibility and sustain place-based meaning within Douyin's platformized short-video ecology. Focusing on Shaoguan, Guangdong Province, it analyzes 30 high-interaction Douyin videos published between May 2023 and May 2025 and applies crisp-set Qualitative Comparative Analysis (csQCA) to identify configurations associated with high dissemination performance. The findings suggest that city-related hashtags function as a necessary platform-indexing condition in the sampled archive, while emotional resonance and narrative structure strengthen specific high-impact configurations. Two communicative logics are particularly salient: non-local creators can generate rapid visibility through immersive, fragmented, and affective presentations, whereas locally embedded storytelling can reinforce cultural resilience and place identity. The study contributes to digital urban communication by integrating the Heuristic-Systematic Model with debates on platformization, algorithmic visibility, and digital place branding.
Children of adolescent mothers face elevated risks of early childhood development (ECD) delay. Whether this reflects maternal age or the socioeconomic disadvantage that predisposes young women to early childbearing remains debated. We conducted a secondary analysis of Multiple Indicator Cluster Survey data (rounds 5 and 6, 2013-2022) from 15 Latin American and Caribbean countries, comprising 23,650 children aged 36-59 months. Using survey-weighted regression with cluster-robust standard errors, we examined associations between adolescent motherhood and ECD scores, discipline practices, and beliefs about physical punishment and partner violence. Children of adolescent mothers had lower weighted mean ECD scores in 11 countries. After adjusting for wealth, maternal education, and urban/rural residence, significant adverse associations persisted only in Paraguay and Suriname. Violent discipline was significantly higher among adolescent mothers only in Honduras after covariate adjustment. Adolescent mothers were significantly more likely to justify partner violence in Belize, Paraguay, and Suriname. Justification of partner violence was associated with lower ECD scores among non-adolescent mothers in the Dominican Republic and El Salvador. The ECD disadvantage associated with adolescent motherhood is largely accounted for by socioeconomic factors in most countries. Addressing poverty and gender inequity remains the most broadly applicable strategy for reducing ECD inequity in the region.
The Kawashima procedure is a variant of the bidirectional Glenn used in patients with interrupted inferior vena cava (IVC) and azygos continuation, though optimal timing and the role of fenestration remain debated. We report a 5-month-old boy with functional single ventricle physiology, transposition of the great arteries, pulmonary valve atresia with ventricular septal defect, interrupted IVC with azygos continuation, and bilateral superior vena cavae, who presented with cyanosis and failure to thrive. Imaging confirmed complex venous anomalies with hepatic venous drainage directly into the right atrium. The patient underwent a Kawashima procedure without fenestration, with stable postoperative hemodynamics, improved oxygen saturation, and an uncomplicated recovery. This case demonstrates that early Kawashima without fenestration is feasible in carefully selected infants, although exclusion of hepatic venous flow may predispose to pulmonary arteriovenous malformations, necessitating eventual Fontan completion. Favorable outcomes can be achieved in resource-limited settings with appropriate patient selection and multidisciplinary care.