搜索结果：Journal of travel medicine

Dengue virus is transmitted by Aedes mosquitoes, which are now prevalent in destinations commonly visited by UK travelers. Increased international travel and factors including climate change, contribute to the global increase in dengue cases. Here, we evaluate the healthcare burden of dengue in England. This retrospective, descriptive, cohort study (2010-2023) utilized data collected from National Health Service healthcare records in the Clinical Practice Research Datalink (CPRD) Aurum linked with Hospital Episode Statistics, and Office for National Statistics mortality data. The primary objective was to determine the occurrence of hospitalized dengue. Other objectives were evaluation of healthcare resource utilization and costs, characteristics of hospitalized dengue cases, and complications due to dengue. Exploratory cohorts for suspected dengue in primary care were also reported. Data from CPRD-linked records for 596 patients comprising the hospitalized dengue cohort were evaluated; the incidence rate of hospitalized dengue progressively increased from 2010 until the highest in 2019 (5.8 per million person-years); rates increased in 2022 after COVID-19 lockdowns. Approximately one-third of hospitalized dengue cases were aged 18-29 years, most were White or Asian, and the most common complication was gastrointestinal conditions (gastroenteritis/colitis; 34.7 cases per 1000 person-years). Healthcare costs in the year following hospitalized dengue cases were mostly driven by inpatient admission costs; ~20% of cases had a subsequent hospital admission (~50% were dengue-related). A total of 2286 suspected cases of dengue were reported in primary care, with 1066 unconfirmed and 1220 confirmed cases. Increasing incidence of dengue cases in England has followed global trends. The associated healthcare burden of imported dengue suggests a need for targeted public health strategies, particularly among younger travelers. Improvements in general practitioners' reporting of suspected dengue cases and associated details of symptoms and travel history are warranted.

Cardiovascular-kidney-metabolic (CKM) syndrome has emerged as a major global health burden and driver of cardiovascular disease (CVD), the leading cause of death worldwide. Effective management of CKM depends on timely identification of underlying risk factors. Nevertheless, participation rates in primary care-based screenings are low. Consequently, CKM syndrome oftentimes remains undetected until organ damage is clinically present. Community pharmacies offer an accessible, yet underused, setting to enhance early detection. APOSCREEN-1 evaluates the feasibility and diagnostic yield of a pharmacy-based multi-parametric screening for cardiovascular-kidney-metabolic health. APOSCREEN-1 is a prospective single-arm clinical trial conducted in 20 community pharmacies in the German state of Schleswig-Holstein. Adults (n = 1000) aged ≥ 40 years with predefined risk criteria are included. Participants undergo standardized point-of-care testing (glycated hemoglobin, lipid profile, urinary albumin, blood pressure). Additionally, clinical history is assessed and results are transmitted to the study center via an online platform. Patients meeting pre-defined thresholds of the tested parameters are followed up by confirmatory laboratory testing at the study center or at the participants' general practitioner. Primary outcomes include completion rate, implementation metrics from the pharmacy perspective, and the number needed to screen to detect unknown or insufficiently managed cardiometabolic risk factors. Secondary outcomes comprise participant metrics, diagnostic metrics of the screening, evaluation of the clinical impact. This study aims to address the unmet need for scalable prevention of CVD by identification of CKM syndrome risk factors outside traditional primary care settings. Evidence on feasibility, acceptance, and diagnostic benefit may support the use of community pharmacies as an additional access point for early CKM syndrome detection. Future interventional studies will be required to evaluate structured follow-up pathways and long-term effectiveness. This study was registered with the German trial registry (Deutsches Register klinischer Studien) on 29.01.2026, under trial number DRKS00039149.

Parents of children with chronic diseases in rural Iran experience profound challenges, including limited access to pediatric specialists, social isolation, and severe financial strain. Concurrently, healthcare providers face workforce shortages, administrative burdens, and fragmented referral systems. This study aimed to explore unmet care needs and comparative perspectives of parents and providers regarding the integration of artificial intelligence to strengthen chronic disease management in resource-limited rural settings. Using a qualitative descriptive design, we conducted semi-structured interviews with 20 parents of children with chronic illnesses and 15 healthcare providers (physicians, nurses, and community health workers) from rural health centres in Iran. Participants were selected through purposive sampling based on direct experience with pediatric chronic disease management in villages (<&#x2009;20,000 population). Data were analysed using conventional content analysis with iterative coding to derive emergent themes. Five key themes emerged: (1) Unmet daily care needs including geographic barriers to specialists, maternal emotional isolation, and catastrophic out-of-pocket expenses; (2) Systemic constraints faced by providers, notably administrative overload ("pajama time"), critical workforce shortages, and inefficient referral pathways; (3) AI as a potential bridge through symptom prediction models for early intervention, chatbots for emergency guidance, and AI-enabled teleconsultations to reduce unnecessary travel; (4) Divergent trust narratives parents expressed skepticism about autonomous AI decision-making while providers raised concerns about data privacy, workload implications, and erosion of clinical authority; and (5) Integration pathways emphasising AI embedded within the existing Behvarz (community health worker) network, mandatory digital literacy training, and co-designed platforms incorporating local cultural beliefs. AI technologies show promise for augmenting, though not replacing, human-centred care in rural pediatric chronic disease management. Successful implementation requires culturally resonant, transparent tools developed through participatory design with families and providers, robust data governance, and strategic alignment with Iran's primary healthcare infrastructure. This context-sensitive framework prioritises equity, trust-building, and caregiver empowerment while acknowledging the irreplaceable role of human empathy in chronic care delivery. Parents of children with chronic illnesses and healthcare providers were central to this research as knowledge partners rather than passive subjects. Twenty parents with lived experience of caring for a child with chronic disease in rural settings, alongside 15 frontline healthcare providers, actively shaped the study through in-depth sharing of their experiences during semi-structured interviews. Their narratives directly informed all emergent themes and the resulting conceptual framework. To ensure interpretive validity, we conducted member checking with a purposive subset of participants (n&#x2009;=&#x2009;8 parents and n&#x2009;=&#x2009;6 providers) who reviewed preliminary findings and provided feedback on whether the themes accurately reflected their realities and concerns. This iterative validation process strengthened the trustworthiness of our analysis and ensured that the final framework resonated with the everyday challenges and aspirations of rural families and providers. While participants were not involved in the initial study design or manuscript drafting due to the exploratory nature of this qualitative investigation, their experiential expertise fundamentally shaped the research outcomes and recommendations for culturally grounded AI integration. Their contributions transformed abstract technological possibilities into contextually meaningful pathways for supporting rural pediatric chronic disease management.

Patient-reported outcome measures (PROMs), when used at the point-of-care, provide a mechanism to systematically integrate patients' voices into shared decision-making. We examined clinicians' perspectives on the acceptability and preferred timing of PROM completion in routine clinical care for respiratory, musculoskeletal, cardiac, kidney and diabetic condition management. Semi-structured interviews were conducted over videoconference between October 2024 and May 2025. Participants worked at various New South Wales Health clinics, providing care for patients with chronic conditions, and were eligible to collect and review PROMs digitally using the Health Outcomes Patient Experience platform (NSW PRMs-HOPE program). Reflexive thematic analysis was undertaken. Twenty-two physiotherapists and nurses were interviewed. Acceptability themes included: (1) purpose of PROMs; (2) broader ethical considerations for PROMs collection and use; (3) practical aspects of PROM administration. Findings highlighted the elusiveness of an "ideal" timing for PROMs. Timing themes included: (1) (mis)alignment in timing of PROM administration; (2) preferences for fixed or customised timing and frequency of administration; (3) temporal fit and workflow alignment. PROMs were reported as most acceptable when their selection, content, and timing aligned with clinical purpose, scope of practice, and existing workflows. Flexibility in PROM administration was perceived to enhance relevance at the point-of-care and support timely, condition-specific clinical conversations and interventions. However, clinicians also recognised that increased flexibility may reduce the comparability of aggregated PROM data across cohorts, highlighting an inherent acceptability trade-off between meeting individual clinical needs and supporting system-level performance monitoring and benchmarking. People with long&#x2011;term health conditions can fill out health surveys called patient&#x2011;reported outcome measures (PROMs). These health surveys help patients share how they are coping day to day and how their health condition or treatment is affecting their quality of life. PROMs are used more in healthcare now, but we do not know enough about how clinicians feel about using them or when they should be given to patients to improve their care.In this study, we spoke with physiotherapists and nurses who use PROMs. They told us what they think about PROMs and when these should be completed by patients.Physiotherapists and nurses said PROMs can help them better understand their patients, find changes in their patients' health, and support conversations about care. But they also said they needed extra time to help patients fill in PROMs, some of the questions were unclear for patients, there were language and cultural barriers for some patients, and they did not always know how to use the results.Overall, physiotherapists and nurses wanted more choice in which PROMs they use and when patients complete them. They felt this would make PROMs more useful for patient care. But, too much choice could make it harder to compare results across clinics and to see how well services are looking after people.

Ultra-short-acting insulin analogues have the potential to achieve clinical benefits for people with type 1 diabetes, but their relative effects in relation to regular human insulin remain unclear. Primary objective: To compare the effects of long-term treatment with (ultra-)short-acting insulin analogues to regular human insulin or another (ultra-)short-acting insulin analogue in people with type 1 diabetes on multiple daily injections through a network meta-analysis. To obtain an estimate of the relative ranking of these (ultra-)short-acting insulin analogues compared to regular human insulin. We searched CENTRAL, MEDLINE, Web of Science, the WHO International Clinical Trials Registry Platform and ClinicalTrials.gov from inception to 14 May 2025, without language restrictions. We included all randomised controlled trials (RCTs) with an intervention duration of at least 24 weeks that compared (ultra-)short-acting insulin analogues with regular human insulins in non-pregnant adults with type 1 diabetes on multiple daily injections. Critical outcomes included glycaemic control, hypoglycaemia, diabetic ketoacidosis, quality of life and adherence to treatment. We evaluated studies with the Cochrane risk of bias tool (RoB 2). We performed statistical analyses using a frequentist network meta-analysis to compare estimates for the critical outcomes, with regular human insulin as the reference treatment, and a random-effects model for other outcomes and pairwise comparisons. We rated the certainty of the evidence using the CINeMA framework. We included 15 RCTs with 6335 participants evaluating insulin aspart, lispro, glulisine, ultra-rapid lispro (URLi) and fast-acting insulin aspart (FIAsp). The duration of interventions ranged from 24 to 52 weeks. Participants had a mean age of 36.4 years and a mean HbA1c of 8.1%. Participants had different basal insulin regimens. Thirteen studies were funded by the pharmaceutical industry. Network meta-analysis: (Ultra-)short-acting insulin analogues versus regular human insulin (RHI) Glycaemic control: haemoglobin A1c (HbA1c) Based on low-certainty evidence from 14 studies with 6039 participants, all five (ultra-)short-acting insulin analogues may result in little to no difference in HbA1c compared to RHI (mean difference (MD): URLi -0.25%, 95% confidence interval (CI) -0.51% to 0.00%; lispro -0.22%, 95% CI -0.46% to 0.02%; glulisine -0.21%, 95% CI -0.48% to 0.06%; FIAsp -0.17%, 95% CI -0.28% to -0.05%; aspart -0.14%, 95% CI -0.21% to -0.06%). Glycaemic control: fasting blood glucose (FBG) Based on extremely low-certainty evidence from four studies with 2737 participants, we are uncertain about the effects of aspart and FIAsp compared to RHI (MD: FIAsp 0.69 mmol/L, 95% CI -0.31 mmol/L to 1.69 mmol/L; aspart 0.80 mmol/L, 95% CI -0.01 mmol/L to 1.61 mmol/L). Lispro, glulisine and URLi could not be assessed in relation to RHI. Mild/moderate (non-severe) hypoglycaemia Based on very low-certainty evidence from six studies with 3967 participants, we are uncertain about the effects of aspart and FIAsp compared to RHI (risk ratio (RR): aspart 1.05, 95% CI 0.97 to 1.13; FIAsp 1.04, 95% CI 0.96 to 1.12). Lispro, glulisine and URLi could not be assessed in relation to RHI. Severe/serious hypoglycaemia Based on low- to very low-certainty evidence from 11 studies with 5390 participants, URLi may result in a reduction in severe/serious hypoglycaemia compared to RHI (RR: URLi 0.80, 95% CI 0.36 to 1.77), but the evidence is very uncertain for aspart and FIAsp (RR: aspart 0.89, 95% CI 0.73 to 1.09; FIAsp 0.79, 95% CI 0.55 to 1.15). Glulisine may result in an increase in severe/serious hypoglycaemia compared to RHI (RR glulisine 1.54, 95% CI 0.46 to 5.19). In contrast, lispro may result in little to no difference compared to RHI (RR: lispro 1.01, 95% CI 0.51 to 1.98). Mild/moderate nocturnal hypoglycaemia This outcome could not be evaluated with network meta-analysis. Severe/serious nocturnal hypoglycaemia Based on very low-certainty evidence from four studies with 3229 participants, we are uncertain about the effects of aspart and FIAsp compared to RHI (RR: aspart 0.63, 95% CI 0.46 to 0.88; FIAsp 0.52, 95% CI 0.26 to 1.04). Lispro, glulisine and URLi could not be assessed in relation to RHI. Diabetic ketoacidosis (DKA) Based on low- to very low-certainty evidence from nine studies with 4599 participants, lispro and URLi may result in a reduction in DKA compared to RHI (odds ratio (OR): lispro 0.74, 95% CI 0.10 to 5.39; URLi 0.74, 95% CI 0.03 to 16.64), whereas FIAsp may result in an increase compared to RHI (OR: FIAsp 1.18, 95% CI 0.12 to 11.24), but the evidence is very uncertain for aspart (OR: aspart 0.80, 95% CI 0.20 to 3.11). Glulisine could not be assessed in relation to RHI. Quality of life This outcome could not be evaluated with network meta-analysis. Adherence to treatment Based on very low-certainty evidence from five studies with 3579 participants, we are uncertain about the effects of aspart and FIAsp compared to RHI (RR: aspart 1.01, 95% CI 0.95 to 1.07; FIAsp 1.01, 95% CI 0.94 to 1.08). Lispro, glulisine and URLi could not be assessed in relation to RHI. (Ultra-)short-acting insulin analogues may result in little to no difference in glycaemic control, non-severe hypoglycaemia and treatment adherence at short-term follow-up, but some agents may reduce severe/serious hypoglycaemia and DKA. We are uncertain about the effects of these insulins on mild to moderate nocturnal hypoglycaemia and quality of life. There were no long-term follow-up data. World Health Organization (WHO). Protocol for this update: PROSPERO CRD42024599817 (https://www.crd.york.ac.uk/PROSPERO/view/CRD42024599817); DOI of the previous review: 10.1002/14651858.CD012161.

Daytime sleepiness and excessive sleep are frequent symptoms. When these symptoms are recognized, they are often attributed to comorbid depression or, following ambulatory screening, to obstructive sleep apnea (OSA). While OSA affects 20-50% of the population, more frequently in men, its contribution to sleepiness in the general population is modest, and subjective sleepiness shows stronger associations with depression, insufficient sleep, and shift work. As a result, mild OSA in the presence of sleepiness is often overtreated. Further, stimulants are used as adjunct therapy in depression despite limited evidence. When referred to sleep disorder specialists, after exclusion of OSA, these patients are typically evaluated using a daytime nap test, the Multiple Sleep Latency Test (MSLT). The MSLT is used to diagnose Narcolepsy or Idiopathic Hypersomnia. Problematically, the MSLT performs well only to confirm narcolepsy type 1, a disorder with cataplexy and caused by orexin deficiency. A high false positive rate occurs in the absence of cataplexy, leading to questionable diagnoses of narcolepsy type 2 and idiopathic hypersomnia. A return to four historical subtypes of central nervous system hypersomnolence independent of MSLT testing is proposed. Narcolepsy Type 1: cataplexy, refreshing naps, sleep-onset REM periods. It is caused by orexin deficiency, responds to oxybate, antidepressants, stimulants, and low dose orexin receptor 2 agonists (in development). Narcolepsy-like hypersomnolence: Irresistible sleep attacks with short, refreshing naps. Insufficient Sleep must be excluded. It is often responsive to modafinil. Idiopathic Hypersomnia with sleep inertia and unrefreshing sleep: Excessive sleep amounts, severe sleep inertia, and long, unrefreshing naps. Association with psychiatric comorbidities, notably resolved depression, is frequent. Sodium oxybate can be transformative. Kleine-Levin Syndrome: periodic extreme hypersomnia with apathy and derealization. Responds to lithium in &#x223c;50% of cases. A pathophysiological overlap with bipolar disorder is likely. A greater collaboration between psychiatry and sleep medicine is needed considering the emergence of orexin receptor agonists as potential therapies for hypersomnia.

Achieving universal health coverage is a key component of the Sustainable Development Goals, focusing on equitable access to quality health services and minimising financial hardship. While strategies often target the demand-side, supply-side barriers such as travel time and facility-level constraints are often overlooked. Accurately quantifying who is affected by these barriers and identifying their locations and specific barriers is critical to improving service delivery. This study examines these barriers in Mali, a country with significant health system challenges exacerbated by high fertility rates and political instability. Using the WHO's Health Resources and Services Availability Monitoring System, we conduct an analysis of the geographic accessibility of antiretroviral therapy (ART) services. Our aim is to estimate the number of people affected by supply-side barriers by using a geographic accessibility model that calculates travel time to facilities with ART services. The analysis applies a least-cost path algorithm to assess accessibility, where ART services are defined as accessible within 2&#x2009;hours travel time. People within this range with available services have access while those outside are geographically constrained. For those within 2&#x2009;hours but without ART access, we identified and quantified facility-specific barriers. The results show that nearly 2.7&#x2009;million Malians do not have timely access to ART within 2 hours. For about 70%, distance is the main barrier, while the rest face facility-level issues such as the fact that the service is not being planned in the facility, lack of medical supplies and lack of training. This study offers important insights for targeted interventions to scale up ART provision and provides a scalable model for other health services and contexts.

The burden of dengue disease in Germany is a growing public health concern. While travellers to dengue-endemic countries are at increased risk of contracting a dengue infection, data describing dengue-related healthcare utilization and outcomes in Germany are limited. This study investigated the healthcare burden of dengue disease in travellers returning to Germany. A retrospective analysis (InGef research database) was used to estimate dengue incidence using anonymized representative data from the German Statutory Health Insurance from approximately 7 million insured persons/year during 2015-23. Outpatient and inpatient healthcare use and dengue associated costs were investigated. From 2015 to 2023, among 10&#x2009;151&#x2009;240 insured persons, 887 dengue episodes were recorded. Patients had a median age of 33&#xa0;years (interquartile range 26-46) and 52% were male. Each year, 103-182 episodes were reported (COVID-19 pandemic period [2020-22]: 10-62). Excluding the pandemic years, incidence was 1.4-2.5/100&#x2009;000 persons, with an estimated total of 1453-2639 cases/year in Germany. Of the 37% hospitalized persons, 4% required intensive care. Mean hospital stay was 3.3&#xa0;days; most patients were discharged after 1 overnight stay and no dengue related deaths were reported. Overall, 41% of patients took sick leave during their episode (mean sick leave for hospitalized patients: 8.8 working days); 38% of those not hospitalized took sick leave lasting 6.9 working days on average. Patients with dengue had 2-fold increased healthcare visits, resulting in a 162% increase in costs (mean costs/episode/quarter: 930&#x20ac;) compared with the pre-index period, with these costs mainly driven by outpatient care (23%) and hospitalization (64%). Hospitalized patients had a 4-fold rise in costs (quarterly costs/episode: 1700&#x20ac;; inpatient care accounting for 80%) compared with the pre-index period. Dengue virus infection in travellers returning to Germany impacted the healthcare system in Germany, leading to high costs, hospitalizations and physician visits and considerable sick leave.

The increasing prevalence of inflammatory bowel disease (IBD) and constrained clinical resources necessitate a shift from fixed-interval outpatient visits towards patient-initiated, needs-based follow-up. Real-world evidence on whether such transitions maintain disease control and achieve patient acceptance remains limited. In 2024, Aalborg University Hospital (Denmark) transitioned all patients with IBD not receiving biological therapy to a digitally supported, patient-initiated monitoring model. We aimed to evaluate the quality of care and patient satisfaction after the transition. This pre-post quality improvement study included 966 patients with IBD (Crohn's disease (CD): n&#xa0;=&#xa0;279; ulcerative colitis (UC): n&#xa0;=&#xa0;687). Clinical data, disease activity scores, faecal calprotectin levels, and health-related quality of life were obtained from the GASTROBIO web-based regional database for two years before and up to two years after the transition. Patient satisfaction was assessed via a questionnaire adapted from the validated Danish "LUP survey". Entries of patient reported outcomes (PROs) and faecal calprotectin sampling increased following transition. The proportion of patients in faecal calprotectin-defined remission increased in both CD (63&#xa0;% to 76&#xa0;%; p&#xa0;=&#xa0;0.01) and UC (62&#xa0;% to 70&#xa0;%; p&#xa0;=&#xa0;0.04), while disease activity scores remained stable. Health-related quality of life improved in both CD (p&#xa0;=&#xa0;0.02) and UC (p&#xa0;<&#xa0;0.01). Of 966 eligible patients, 371 (38&#xa0;%) completed the satisfaction survey; the majority preferred the new model over standard of care (CD: 77&#xa0;%; UC: 84&#xa0;%) and rated satisfaction as high or very high (CD: 66&#xa0;%; UC: 71&#xa0;%). Higher satisfaction correlated with better health-related quality of life in both groups (CD: Spearman's &#x3c1;&#xa0;=&#xa0;&#xa0;-&#xa0;0.22, p&#xa0;=&#xa0;0.05; UC: &#x3c1;&#xa0;=&#xa0;&#xa0;-&#xa0;0.18, p&#xa0;=&#xa0;0.01). A patient-initiated, digitally supported remote monitoring model maintained disease control, improved health-related quality of life, and achieved high patient satisfaction in a large real-world IBD cohort. These findings support the feasibility and scalability of needs-based IBD follow-up underpinned by an integrated digital infrastructure.

Total hip arthroplasty (THA) is a highly effective procedure for improving pain and function in patients with advanced joint degeneration; however, revision surgery may be required because of complications or implant wear. Revision THA (rTHA) has a higher in-hospital mortality rate, longer hospital length of stay, are at higher risk of re-revision surgery and have worse physical and mental health outcome measures compared with primary THAs. The introduction of specialist revision hubs also means that patients frequently travel further for surgery. No specific guidelines have been established for rehabilitation after rTHA, leading to large variations in practice and potentially inadequate provision. We hypothesise that delivering a tailored physiotherapy intervention will improve and sustain greater functional outcomes and health-related quality of life compared with standard protocols currently in place. The aim of this study is to determine the feasibility and explore the acceptability of a trial investigating the effectiveness of a tailored physiotherapy intervention after rTHA. Multicentre, parallel two-arm feasibility randomised controlled trial with an embedded qualitative study. A total of 60 participants will be recruited from at least four UK NHS secondary care hospitals and randomly allocated (1:1 ratio) to either the tailored physiotherapy rehabilitation (THRIVE) programme or a standardised usual care arm. Eligible adults will be undergoing a single or final stage rTHA and participating in outpatient physiotherapy. Feasibility outcomes include recruitment rate, retention rate, adherence rate, intervention fidelity, outcome measure completion and acceptability of the intervention. Research assessments consisting of patient-reported and performance-based measures will occur preoperatively (baseline), with follow-ups at 4 and 8&#x2009;months postoperatively. Feasibility data will be analysed using descriptive statistics. The embedded qualitative study will include trial participants and physiotherapists from the THRIVE arm to explore their experience of the trial and understand measures to improve the delivery of a future trial. The study has received ethical approval (West of Scotland REC 25/WS/0080), and all participants will provide informed consent. It will assess trial feasibility while exploring operational and safety challenges, including recruitment barriers and the potential value of a hub-and-spoke model for delivering physiotherapy. Findings will be disseminated through trial registry reporting, peer-reviewed open-access publication, conference presentations and participant summaries, with reporting aligned to CONSORT guidelines for pilot and feasibility trials. ISRCTN10649335.

Dengue poses a growing threat to international travelers, yet vaccine uptake remains limited due to inconsistent guidelines and psychological barriers. This study provides barriers and determinants of hesitancy, which may guide strategies once global dengue vaccination guidelines for travelers are established. We conducted an explanatory sequential mixed-methods study from May 2024 to March 2025 in Bangkok, Thailand, assessing vaccine hesitancy among 429 international travelers using the 5C model and thematic analysis of interviews. The prevalence of dengue vaccine hesitancy was higher than previous literature. Dengue vaccine acceptance was 36.8%, with non-religious affiliation (adjusted odds ratio [aOR]: 4.89; 95% CI: 2.55-9.38), higher confidence, and lower perceived constraints significantly associated with acceptance. Non-acceptors reported significantly higher levels of complacency and constraints, and lower collective responsibility scores (all p&#x2009;<&#x2009;0.001). Travelers often underestimated dengue risk and cited logistical challenges and vaccine accessibility as barriers. Trust in healthcare providers, especially from endemic regions, influenced decisions, while collective responsibility was less relevant. High dengue vaccine hesitancy highlights the need for healthcare providers to enhance vaccine confidence through evidence-based counseling and address complacency by correcting risk misconception. Improving vaccine accessibility and aligning schedules with travel plans may reduce constraints and vaccine messaging may be more effective by prioritizing individual-level benefit to maximize impact once global guidelines are established. The study was registered with the Clinical Trials.gov (Clinical trial.gov NCT06418854).

After resuscitation from out of hospital cardiac arrest (OHCA), mechanical ventilation (MV) and respiratory management are fundamental to support patients in the intensive care unit (ICU) and to minimise secondary brain injury. Best practices for MV and association with clinical outcomes in patients with OHCA remain unclear. This protocol describes a pre-planned respiratory-focused series of sub-analyses within the Sedation, Temperature and Pressure after Cardiac Arrest and Resuscitation (STEPCARE) trial, an ongoing interventional study evaluating 6-month mortality after randomisation in patients admitted to ICUs following OHCA. The primary aim is to describe real-world ventilator settings and gas-exchange targets during the first 72 hours after ICU admission in patients receiving invasive mechanical ventilation after OHCA. Secondary aims include to estimate the incidence of respiratory complications during ICU stay (eg, ventilator-associated pneumonia, acute respiratory distress syndrome, barotrauma); and to explore the association between early ventilator settings/gas-exchange parameters and 6-month outcomes (mortality and neurological status). Exploratory aim is to characterise weaning and extubation practices, including timing and failure rates.Eligible patients will include adult STEPCARE participants receiving invasive MV after return of spontaneous circulation with available respiratory data recorded within the STEPCARE database.Data collected in the STEPCARE trial that will be analysed include patients' prehospital characteristics; clinical examination at hospital admission and at ICU admission; ventilator settings and arterial blood gases recorded at predefined time points during ICU stay. In particular: MV setting (mode, tidal volume, positive end-expiratory pressure, fraction of inspired oxygen, tidal volume, mechanical power, plateau/driving pressures), gas-exchange values (arterial partial pressure of oxygen and carbon dioxide, pH, arterial saturation of oxygen), timing of measurements and the occurrence/timing of respiratory complications and weaning outcomes. The STEPCARE study has been approved by the regional ethics committee at Lund University (Dnr 2022-02425-01, Approved IRB on 2022-06-18) and by all ethics boards in the participating countries. No additional ethical approval is required for this predefined secondary analysis, as no further data collection or interventions will be performed. Findings will be disseminated through publication in peer-reviewed journals and, where appropriate, conference abstracts and presentations. Patients and the public were not involved. NCT05564754.

Assessment of lower limb alignment is a cornerstone of orthopaedics. Few studies look at rotational alignment in the axial plane as measured by femoral version (FV) and tibial torsion (TT), both of which have implications for hip, knee, and ankle pathology. This review provides an overview of the axial rotation and evaluates CT-based measurement methods for FV and TT to identify the most reliable and reproducible techniques for use in clinical practice. A systematic PRISMA-guided review assessed original CT-based methods, examining inter- and intraobserver reliability (intraclass correlation coefficient (ICC)), frequency of use, and validation. Seven FV and nine TT CT-based techniques were identified. FV had a weighted mean of 17.8&#xb0; anteversion (-9&#xb0; to 60&#xb0;). TT had a weighted mean of 30.8&#xb0; (2&#xb0; to 82&#xb0;). ICCs ranged from good to excellent. The Murphy method (FV) and Goutallier method (TT) had the highest reliability and clinical utility. Lower limb axial rotational profile plays an important role in the management of hip, knee, and ankle arthroplasty surgery as well as many other orthopaedic pathologies. The Murphy and Goutallier methods should be adopted as standard for measuring FV and TT. Their high reproducibility and validation make them ideal for consistent clinical and research use.

Patients with chronic diseases in Malaysia frequently return to public health facilities for their monthly medication supply, contributing to congestion and increased workload. At the same time, community pharmacists remain underutilized due to limited dispensing opportunities. This study explored community pharmacists' perspectives on participating in a public-private partnership model to supply repeat medicines to patients from public health facilities. A concurrent embedded mixed-methods design was employed, combining a nationwide quantitative survey of 433 community pharmacists with in-depth interviews involving 15 pharmacists from different states. Quantitative data were analyzed using descriptive and inferential statistics, while qualitative interviews underwent thematic analysis. Most community pharmacists perceived community pharmacy-based repeat medicine supply as beneficial, citing patient convenience in terms of accessibility (96.3%), time saving (95.6%) and reduced travel costs (88.5%). They viewed community pharmacies as suitable service points (94.3%) and supported appropriate remuneration for their services (90.6%). Fewer pharmacists considered potential barriers such as increased workload (44.8%), operating costs (39.8%), or space constraints (43.0%). Strongly endorsed facilitators included timely reimbursement to the pharmacists, clear procedures and guidelines, and structured collaboration with public facilities. A high proportion (88.4%) expressed willingness to participate. Qualitative findings reinforced perceived benefits for patients, community pharmacists, and public health system. Participants highlighted the importance of a clear operational framework, efficient reimbursement systems, and avoidance of previous pitfalls in public-private collaborations. While challenges were noted, pharmacists believed these could be mitigated through proper systems including communication platforms, scheduling mechanisms, and defined formularies. Overall, community pharmacists demonstrated strong support for participating in repeat medicine supply services. Their motivation stems from patient benefits, professional fulfilment, and commercial sustainability. Realizing this model, however, requires system-level reforms, stakeholder engagement, and robust implementation mechanisms to ensure an effective and sustainable collaboration.

Access to healthcare is a fundamental determinant of public health sustainability. Current literature on healthcare access tends to focus largely on vulnerable groups and objective indicators where access is defined through service utilization. When the literature on "perceived access to healthcare" is examined, it is observed that perceived access is generally treated as a determining factor explaining health outcomes or behaviors. However, the investigation of the socioeconomic, self-rated health, health literacy and spatial features that shape this perception itself within a holistic framework remains a less focused area in the literature. Methodologically, perceived access to healthcare is often defined with a limited number of variables or specifically within particular disease groups. Especially in regions such as Trabzon, where rugged topography and geographical barriers are intertwined with socio-cultural dynamics, analyzing the factors shaping the individual's perception of access within a comprehensive framework will offer a significant contribution to the literature. This study aims to integrate multidimensional factors -including socioeconomic status (SES), self-rated health, health literacy, health-seeking behavior, and travel time-into a comprehensive structural framework for the first time in the literature; to validate their effects through Structural Equation Modeling (SEM), and to uncover the spatial dependence patterns in access. This reearch was conducted with 1,491 adults. Data were analyzed using Structural Equation Modeling (SEM) to evaluate multidimensional pathways, and geospatial analysis was performed to determine spatial dependence patterns. The results of the research demonstrate that health literacy and professional health-seeking behavior are the primary elements strengthening the perception of access, whereas online health-seeking and increased travel time weaken this perception. One of the most original findings of the study is that the direct negative effect of SES on access is balanced through health literacy; this indicates that cognitive capacity can mitigate socioeconomic disadvantages. Spatial models confirm that while the general perceived access to healthcare is shaped by personal factors, the "accessibility" dimension exhibits a spatial dependence tied to local topography within a 1-km radius. Consequently, these findings scientifically support that health planning should shift from macro-scale strategies toward micro-spatial interventions aimed at minimizing physical barriers at the neighborhood and street levels. Integrating approaches that improve health literacy with interventions that minimize travel barriers will play a fundamental role in reducing health inequalities.

BackgroundPre-exposure prophylaxis (PrEP) is highly effective in preventing human immunodeficiency virus (HIV) transmission, particularly for individuals at increased risk. However, uptake and long-term adherence remain challenging, with limited data on pharmacies beyond pilot studies. This study explored how psychological, social, and structural factors shape perceptions of HIV risk and influence PrEP adherence, using the Tripartite Risk Perception (TRIRISK) model, Protection Motivation Theory, and the Theory of Planned Behavior.MethodsA qualitative design using in-depth interviews (IDIs) was conducted pre-implementation (May 2023) and during implementation (April-July 2024) of pharmacy-based PrEP services. Participants were adults (18+years) accessing pharmacy-based PrEP services in Gauteng and the Western Cape, South Africa. Data were analyzed thematically using Excel and MAXQDA, guided by the integrated behavioral frameworks.ResultsA total of 99 IDIs were conducted, 30 in 2023, 69 in 2024. Through the TRIRISK model, this study found that decisions to start or continue PrEP were shaped by perceived vulnerability to HIV, awareness of risky sexual behaviors, mistrust of partners, and emotional experiences like fear and trauma. The PMT further highlighted how emotional triggers, along with perceived severity and coping efficacy, affected motivation to initiate or continue PrEP. The TPB helped explain how subjective norms, such as stigma and social judgment, and perceived behavioral control, shaped by access, convenience, and privacy, impacted adherence.ConclusionIntegrated behavioral frameworks offer critical insights into PrEP-related decision making. Interventions, including pharmacy-based PrEP models, should address emotional barriers, such as stigma-sensitive messaging, strengthening social support, and reducing structural inequalities. HIV Risk Perception and PrEP UsePre-exposure prophylaxis (PrEP) is a highly effective medicine that helps prevent human immunodeficiency virus (HIV). However, not everyone who needs PrEP uses it effectively. In South Africa, PrEP is being offered in some pharmacies to make it easier to access compared to most public clinic settings. This study looked at what people think and feel about their risk of getting HIV, and how those thoughts shape their decision to take PrEP. We interviewed 2 groups of pharmacy clients at different stages of implementation: one group before pharmacy-based PrEP was rolled out, and another group during implementation after PrEP had been initiated. We used 3 behavioral theories to understand how people assess their risk and make decisions about PrEP use. We found that people were more likely to start PrEP when they felt personally at risk of HIV, for example due to a partner's unfaithfulness or past traumatic experiences. Support from peers, privacy at the pharmacy, and easy access made it easier to keep using PrEP. However, stigma, travel, and life challenges like family responsibilities often made it harder to continue. This study shows that providing PrEP through pharmacies can work well, but emotional, social, and structural barriers must be addressed. PrEP programs should include supportive messaging, flexible access options, and tools that help people stay on PrEP even when life gets difficult.

Point-of-care Ultrasound (POCUS) is increasingly introduced in obstetrics and gynecology as a focused bedside extension of conventional ultrasound, although evidence on its implementation in routine care remains limited. This study examined physicians' attitudes towards POCUS, their perceived diagnostic confidence across different clinical scenarios, and their preference for POCUS compared with standard ultrasound devices. These outcomes were assessed during early implementation in routine care accompanied by structured training. In this prospective, longitudinal implementation study, 22 physicians from a university department of gynecology and obstetrics evaluated standard ultrasound devices at baseline (T0a), completed a structured hands-on POCUS training, and assessed POCUS immediately after training (T0b) and after 2 weeks (T1), 1 month (T2), and 3 months (T3) of clinical use. Evaluations were conducted using repeated quantitative surveys. Outcomes were attitude (4 items, 7-point Likert), perceived diagnostic confidence in obstetric and gynecologic scenarios (17 items, 7-point Likert), and device preference (7-point Likert and dichotomous). Quantitative analyses included descriptive statistics, paired tests, mixed-effects models, and non-parametric sensitivity analyses. Attitude toward POCUS was significantly more favorable than attitude toward standard devices at baseline (T0a 3.69 vs. T0b 5.83; p < .001) and remained high throughout follow-up. Perceived diagnostic confidence for POCUS was not higher immediately after training but increased significantly over time in both obstetrics and gynecology after independent clinical use (both p < .001). Highest confidence was observed in focused bedside scenarios relevant to rapid orientation and immediate decision-making, including fetal vitality assessment, placental localization, amniotic fluid assessment, postvoid residual urine measurement, and urinary tract obstruction, whereas confidence remained lower for more complex applications such as cervical length assessment, Doppler-based examinations, and fetal growth restriction. Preference for POCUS was already high at baseline and remained stable over time. POCUS showed high acceptance in gynecologic and obstetric care from early implementation to routine use. Its clinical relevance appears greatest for focused mobile use and rapid bedside decision-making. These findings were observed during early implementation and support the role of POCUS as a complement to comprehensive ultrasound. German Registry of Clinical Trials; registration number: DRKS 00036941; date of registration: July 16, 2025; title: GO-POCUS: Point-Of-Care UltraSound in Gynecology and Obstetrics: Attitude and Perceived Diagnostic Confidence among Physicians.

Growing evidence has linked bullous pemphigoid (BP) to immune checkpoint inhibitor (ICI) therapy in cancer treatment. However, the immunological features of ICI-associated BP (ICI-BP) are not yet fully elucidated. In order to characterize the humoral response in ICI BP patients and investigate whether their epitope profile differs from idiopathic BP (IBP), 53 ICI-BP patients were enrolled, immunologically characterized and compared with 59 IBP patients. ICI-BP had a distinctive IgG humoral profile, with reduced reactivity toward BP230 and recognition of multiple BP180 epitopes beyond the immunodominant extracellular noncollagenous 16A domain (NC16A). Specifically, reactivity to BP180 ectodomain was present in 94% of ICI-BP and 78% of IBP (p=0.044). Moreover, BP180 C-terminal epitope was more frequently targeted in ICI-BP than IBP (72% vs 41%, p=0.002). Notably, the combined use of an in-house BP180 ectodomain ELISA and the commercial BP180 test increased diagnostic sensitivity from 83% to 100%. Enhanced IgG reactivity toward nonimmunodominant epitopes, and especially C-terminal epitope recognition, characterize the humoral immune response in ICI-BP. Our data suggest that combining NC16A and fulllength BP180 ectodomain ELISAs may help reduce diagnostic delay in ICI-BP patients, in whom a timely diagnosis is crucial to appropriately manage the disease and ultimately avoid discontinuation of cancer therapy.

Chronic breathlessness causes reduced quality of life (QoL) and high healthcare costs. Accumulating evidence shows that multidisciplinary breathlessness services can ameliorate breathlessness which persists despite guideline-directed treatments. Current literature largely reflects trials of interventions in European settings applied to cancer-predominant populations, raising doubt about broad applicability. The research objective was to evaluate whether Macarthur Breathless Clinic (MBC), a bespoke health service intervention, could reduce the impact of chronic breathlessness for a cohort of Australians with COPD. The MBC intervention was tested in a prospective, single-arm cohort study, targeting recruitment of 92 patients. Eligible patients had chronic breathlessness impacting QoL and at least moderately severe COPD, defined by spirometry. Following detailed case review to ensure optimal medical therapy, an individualized program was developed and implemented by MBC's multidisciplinary team during a nine-week program. Questionnaires assessing breathlessness burden, mental health and QoL were administered at baseline, repeated on program completion and again at 12 months. Eighty-nine eligible subjects were mean age 71 years, 65% female and 10% Aboriginal Australian with 18% reporting breathlessness at rest. Mean FEV1 was 37% predicted. Compared with baseline, the primary outcome, Chronic Respiratory Questionnaire - Mastery Subscale improved after program completion (0.5 at nine and 0.8 at 52&#xa0;weeks, p<0.0001). Measures of confidence, COPD symptom burden and breathlessness also yielded durable positive results at 12 months. Clinically relevant gains seen after MBC were retained or even increased at 12 months and more reflected enhanced coping skills and confidence than reduced breathlessness intensity. Breathlessness is a distressing, disabling symptom, contributing to high healthcare costs. Hence, addressing breathlessness represents an unmet need for patients and a health system priority. Breathlessness intervention services, largely comprising non-pharmacological strategies have proven beneficial for patients in the short term; largely for those patients with life-limiting disease such as cancer. Chronic obstructive pulmonary disease (COPD) and emphysema are common conditions, increasing in prevalence worldwide. Even with best available treatments, such patients have persistent and pervasive symptom burden, particularly from breathlessness. This research explores the utility of a breathlessness intervention service for durable impact when applied to patients with COPD. We report sustained improvements in breathlessness mastery and related symptom burden at 12 months following a multidisciplinary, home-based breathlessness intervention program in a cohort of Australians with COPD.