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Health Care Administration, Leadership, and Management (HALM) has emerged as a growing area of expertise as physicians have assumed greater responsibility in healthcare leadership. The need to establish oversight of specialty development, including the creation of a Core Content for HALM to inform structured training and preparation for subspecialty certification examination, has been recognized by the American Board of Medical Specialties (ABMS). This article aims to describe the process used to define the HALM Core Content through the formation of a Task Force of subject matter experts. In February 2023, ABMS approved HALM as a new subspecialty. The first HALM written board certification examination was slated to be administered in October 2024. In preparation for this assessment, the American Board of Emergency Medicine convened a multi-specialty HALM Task Force to define the HALM Core Content that would serve as the basis for this first and subsequent HALM examinations. Informed by a literature review in conjunction with iterative review and expert consensus, the HALM Core Content was finalized. The HALM Core Content addresses nine major domains, including 1) Business of Health Care; 2) Care Innovation, Health Equity, and Population Health; 3) Governance; 4) Health Care Policy, Law, and Advocacy; 5) Health Information Technology; 6) Human Resource Management and Workforce Development; 7) Leadership in Patient Safety and Quality Improvement; 8) Organizational Leadership and Communication Skills; and 9) Professionalism and Ethics. The HALM Core Content lists topic areas within each of the domains, which will be reviewed and updated every five to seven years. Reviews may be conducted sooner if there are key advances in HALM content that should be incorporated promptly. The Core Content herein informs the organizational framework for the development of HALM subspecialty certification. Additionally, residency and fellowship program directors may reference the HALM Core Content to design curriculum focused on healthcare administration and leadership.

Description More than 45% of Americans have at least 1 chronic disease, with chronic disease also being a leading cause of death in the United States. In primary care settings, about 75% of visits are for management of multiple chronic diseases. Due to the increasing medical complexity of patients who present to primary care, these numbers make it more challenging for Primary Care Clinicians (PCCs) to manage these conditions alone and point to the need for innovative solutions to chronic disease care. One evidence-based innovation is team-based care to improve the treatment of these conditions. Clinicians such as clinical pharmacists, registered dietitians, behavioral health clinicians, oral health clinicians, and health educators have an important role in primary care to co-manage the patient population, but often, the primary care setting underutilizes these other health care team members. Therefore, if the PCC understands how the psychological and behavioral aspects of health behavior change and chronic disease management fit within a team-based care model, care may improve. Team-based care has been implemented and studied in many ways, but with the Accreditation Council for Graduate Medical Education recently necessitating significant behavioral health training and practice opportunities for medical residents in primary care residency training programs, new and innovative approaches to training medical residents in behavioral health are needed to meet the health behavior change needs of their future populations upon graduation. This article provides an overview of health behavior change theories and translates theory into primary care practice within medical education through case examples. Our goal is to provide PCCs in primary care specialties such as Family Medicine, Pediatrics, and Internal Medicine with evidence-based and inventive behavioral treatment approaches to increase their ability to holistically treat chronic conditions in primary care through collaboration with other health care team members as well as train upcoming PCCs in these important practices.

Chronic hepatitis B (CHB) is one of the most significant global public health issues because it is progressive and has long-term complications, with gaps in real-world management. Longitudinal cohort evidence is required to guide effective disease control strategies. This study aimed to evaluate the clinical burden, disease progression, and management strategies in patients with CHB and to identify factors influencing progression and treatment outcomes in a real-world setting. The study design was a retrospective longitudinal cohort study conducted at a tertiary-care academic referral centre between January 2020 and December 2025. A total of 520 patients were analysed, all of whom were confirmed to have CHB and followed longitudinally through routine clinical care for a mean duration of 4.1 years. Assessment was made on clinical burden, disease progression and management strategies. Kaplan-Meier analyses were used to determine progression-free survival, and multivariable Cox proportional hazards regression was used to determine independent predictors of disease progression. 21.5% of patients in the baseline group were found to have significant fibrosis, and 9.8% of the patients had cirrhosis. Follow-up discovered disease evolution in 22.3%, including cirrhosis (11.9%), hepatocellular carcinoma (6.9%), and liver death (5.4%). 46.2% of the patients received antiviral therapy, which was associated with a high rate of progression-free survival. Older age, high levels of HBV DNA, baseline fibrosis, ALT elevation and diabetes mellitus were all independent predictors of disease progression, and antiviral therapy had a very strong protective effect (adjusted HR 0.52, 95% CI 0.36-0.75). It is important to note that almost 20% of eligible patients were not treated, and unstable monitoring was associated with poor clinical outcomes. CHB is associated with a significant clinical and healthcare burden. Antiviral interventions and regular observation in the early stages of the disease can greatly slow disease progression, and it is therefore crucial to enhance population health interventions to ensure a smooth transition between the guidelines applied and actual practice.

The healthcare challenges associated with multimorbidity, population ageing and socioeconomic disadvantage are well known. This requires primary care services to adapt to greater population complexity and embrace new models of care. One example is the community paramedic (CP) role, which can provide screening, education and care coordination for complex and underserved populations. While relatively new in Australia, CPs have the potential to bridge primary care gaps especially in rural settings with workforce shortages. In this study, we are implementing an established and evidence-based Canadian CP programme (CP@clinic) in a new context: rural Australian community health services. The aim of our realist evaluation is to explore and explain how, why, for whom and in what circumstances CP@clinic works to improve health and social outcomes; benefit the paramedic workforce; bridge the gaps in primary healthcare and reduce emergency healthcare utilisation. Realist methodology is a theory-driven approach that explores how the causal mechanisms of an intervention are shaped by different contexts, leading to a variety of outcomes. We have developed an initial programme theory based on the Canadian experience and an earlier Australian pilot of CP@clinic. We will collect qualitative and quantitative data, including individual health and social outcomes, emergency services usage, healthcare costs, case reports, interviews with participants, paramedics and external stakeholders and process data. Analysis will follow a realist paradigm, using retroduction to compare findings to the original programme theory enabling us to confirm, refute and interrogate the proposed mechanisms. Ethical approval has been granted (McMaster University HiREB15194; La Trobe University HEC24495, 22038 and 22295). We have developed a multilevel dissemination plan to inform government, the paramedic profession, project stakeholders and consumers. The work is funded by the Australian government with annual reports provided. Other dissemination products will include journal articles, conference presentations, government presentations and submissions, an implementation guidebook and national webinar.

Self-management is a key component of effective chronic obstructive pulmonary disease (COPD) management and is mainly promoted through pulmonary rehabilitation (PR) programmes. However, less than 2% of patients participate in PR programmes. Among those who do, approximately 40% fail to complete the programme. The reasons for this are multifactorial and include dyspnoea, reduced exercise tolerance, lack of motivation and inadequate transportation and infrastructure to access PR centres. In this context, self-management digital health interventions emerge as a promising approach to support the development of self-management competencies, contribute to changing and maintaining behaviours and prevent a downward spiral of deconditioning in this population. The aim of this study is to evaluate the feasibility, acceptability and preliminary effects of a theory-based self-management digital intervention (Respir'air BPCO) designed to promote physical activity in patients with COPD. This pilot randomised controlled trial will enrol 20 patients with COPD who are being followed at a Swiss pulmonary centre. Participants will be randomised using Global Initiative for Chronic Obstructive Lung Disease (GOLD) stage stratification (1:1) at the end of the in-person PR programme into either an experimental group receiving a mobile app-based self-management intervention aimed at promoting physical activity or a control group receiving only usual care. Data will be collected at three time points: immediately after completion of the PR programme (T0), 3 months post-PR (T1) and 6 months post-PR (T2). The study will assess trial methodological feasibility, including recruitment duration, consent rate, retention rate, acceptance of the allocated group and data completeness. Intervention feasibility will be evaluated through intervention fidelity, the number and type of technical problems reported by patients, and patients' and/or researchers' observations regarding the intervention design, content and use to inform future refinements. Intervention acceptability will be assessed using mobile app usage data and the Treatment Acceptability and Preferences questionnaire. In addition, preliminary effects will be evaluated through daily step count (pedometer), self-management (Self-Care in Chronic Obstructive Pulmonary Disease Inventory), motivational regulation of physical activity (Behavioural Regulation in Exercise Questionnaire-3), quality of life (St. George's Respiratory Questionnaire and EuroQol 5-Dimensions-5 Levels), severity of dyspnea (Modified Medical Research Council Dyspnea Scale) and the number of exacerbations and hospitalisations. Analyses will include descriptive statistics and estimation-based comparative analyses using generalised linear mixed-effects models under the intention-to-treat principle, which accommodate missing data under standard assumptions, with reporting of effect sizes and CIs. The study protocol has been approved by the Ethics Commission of the Canton of Vaud (registration no.: 2025-01697). Results will be published in international peer-reviewed journals and presented at national and international conferences. NCT07262229.

Antimicrobial resistant (AMR) gonorrhea poses an increasing threat to public health, yet evidence on the cost-effectiveness of surveillance systems that inform treatment policy is lacking. We assessed the long-term, population-level health benefits, costs, and cost-effectiveness of the Gonococcal Isolate Surveillance Project (GISP), the US national surveillance system for AMR gonorrhea. We developed an agent-based model of gonococcal transmission among men who have sex with men to project gonorrhea-associated costs (healthcare sector perspective) and quality-adjusted life-years (QALYs) lost under GISP and three hypothetical scenarios in the absence of GISP: Randomized Treatment, Test-of-Cure, and a Combination strategy, representing a combination of clinical strategies for treating gonorrhea. Over 20 years in a population of 100,000 men who have sex with men, all strategies resulted in similar overall gonorrhea incidence, but GISP achieved the lowest treatment failure incidence (1852 vs. 86,526, 144,063, and 119,258) and lowest AMR gonorrhea incidence (105,564 vs. 530,854, 631,123, and 575,309 infections). GISP resulted in lower costs and QALYs compared with each of the counterfactual strategies considered in our analysis. Our findings highlight the health and economic benefits of GISP in controlling AMR gonorrhea and can be an efficient use of public health resources in the US. Additional studies are required to investigate the generalizability of our findings for other countries. National Institutes of Health.

Background: Migrant agricultural workers in Italy often experience social and health vulnerabilities, including unstable housing and limited access to primary care. In Southern Italy, many live in informal settlements and seek care through outreach services. This study describes patterns of pharmacological treatment in this population and examines how they relate to the clinical conditions managed in mobile clinics. Methods: We analyzed routinely collected data from 2928 unique patients (8547 clinical encounters; 8965 treatment occurrences) managed by Doctors with Africa CUAMM mobile clinics in 12 informal settlements in Apulia, Italy, between 2017 and 2026. Diagnoses were grouped into clinical categories, and pharmacological treatments were classified by therapeutic class. We conducted a descriptive analysis of the distribution of diagnostic categories and associated treatments. Results: The population was predominantly male (96.5%), young (81% <45 years), and largely excluded from regular primary care (93.5% without a General Practitioner). Musculoskeletal disorders and fatigue were the leading diagnostic category (34.0%), followed by gastrointestinal (13.5%) and respiratory conditions (13.0%). Non-steroidal anti-inflammatory drugs (NSAIDs) and analgesics were the most frequently recorded treatments (32.6% of treatment occurrences). Among musculoskeletal presentations, NSAIDs were used in 76% of cases. Gastroprotective agents were documented in 52% of encounters with gastrointestinal symptoms. Among cardiovascular presentations, 87.7% of treatment occurrences involved chronic management with antihypertensives or beta-blockers. Conclusions: In this outreach setting, medication use provides a descriptive picture of common health problems and treatment responses among migrant agricultural workers living in informal settlements. The prominent use of symptomatic pharmacological relief, particularly NSAIDs in musculoskeletal conditions, suggests that care is often focused on managing pain and acute complaints in a population facing barriers to continuous primary care. These findings support the need for stronger inclusion of migrant workers in the National Health Service and for policies that address underlying social and structural determinants of health.

To evaluate the face and construct validity of a grapefruit arthroscopy training model with active fluid management across varying levels of arthroscopic experience. Orthopaedic residents, fellows, and attending surgeons were stratified into novice (n&#x2009;=&#x2009;10), intermediate (n&#x2009;=&#x2009;10), and advanced (n&#x2009;=&#x2009;9) groups. Participants performed 5 standardized arthroscopic tasks on the grapefruit arthroscopy training model with active fluid management, including fluid management and precision resection. Performance was assessed using a composite scoring system evaluating task completion, accuracy, and water management (maximum 31 points), and total task completion time was recorded. Construct validity was evaluated by comparing performance metrics across experience levels. Face validity was assessed by attending surgeon survey responses. Median composite performance scores increased with experience level (novice, 21.5; intermediate, 28.5; advanced, 31; P&#x2009;<&#x2009;.001). Advanced participants outperformed both intermediate (P&#x2009;=&#x2009;.001) and novice participants (P&#x2009;<&#x2009;.001). Median total task completion time decreased from 18&#x2009;min in novice participants to 6.3&#x2009;min in advanced participants (P&#x2009;<&#x2009;.003). Advanced participants showed superior water management compared with less experienced groups (P&#x2009;=&#x2009;.009). Survey responses from 9 attendings supported face validity, with 77.8% to 100% rating the model as "very closely" aligned with training objectives. This grapefruit arthroscopy training model with active fluid management showed face and construct validity, with increasing arthroscopic experience associated with higher performance scores and shorter task completion times. A validated arthroscopic training model with active fluid management may serve as an accessible educational tool for early arthroscopic skill development and assessment.

Hereditary breast and ovarian cancer (HBOC) syndromes, responsible for 5%-10% of all breast and ovarian cancers in the general population, are largely associated with pathogenic variants of the BRCA1 and BRCA2 genes. Yet, the role of other cancer susceptibility genes highlights the genetic etiology of HBOC as complex, thus requiring thorough investigation beyond these main mutations, highlighting a need for a comprehensive genetic assessment in disease management strategies. In India, advances in genetic research and clinical management have significantly impacted the knowledge of HBOC. A definitive prevalence of BRCA1/2 mutations among Indian populations has catalyzed the adoption of genetic counseling for precision diagnosis and treatment strategies in recent times, with collateral support extended from communities among oncologists, geneticists, and reproductive medicine specialists. The integration of next-generation sequencing and multiplex gene panels creates a platform for identifying high-risk subjects, leading to individualized care pathways and enhanced disease management plans. These programs have increased access to essential services such as genetic counseling, multidisciplinary management, and fertility preservation to provide holistic care to HBOC patients. Future efforts should explore further the genetic heterogeneity of HBOC in Indian populations. There needs to be wider access to genetic testing and counseling services, and the implementation of strong, ethical policy guidelines for equitable use of genetic information. Through the creation of innovative, collaborative methods, these measures have tremendous potential to improve patient care, early detection, and outcomes for individuals affected by HBOC in India.

Menopause is a natural biological transition characterized by the permanent cessation of menstruation, typically occurring between the ages of 45 and 55 years. Despite its significance, menopause remains underrecognized in many low- and middle-income settings, where limited awareness and socio-cultural factors may negatively affect women's health and quality of life. This study assessed the knowledge, attitude, and self-care management of menopausal symptoms among middle-aged women in the Federal Capital Territory (FCT), Nigeria. A community-based descriptive cross-sectional study was conducted among 115 middle-aged women aged 40-60 years in selected Area Councils of the Federal Capital Territory (F.C.T), Nigeria. Participants were recruited using a multistage sampling technique. Data were collected using a structured questionnaire assessing socio-demographic characteristics, knowledge of menopausal symptoms, attitudes toward menopause, and selfcare management practices. Data were analyzed using descriptive statistics, including frequencies, percentages, means, and standard deviations. The mean knowledge score was 10.49 &#xb1; 4.56 out of a maximum of 20. More than half of the respondents (53.9%) demonstrated moderate knowledge, while 35.7% had low knowledge and 10.4% had good knowledge. The mean attitude score was 40.08 &#xb1; 3.35, with the majority of participants (55.7%) exhibiting a negative attitude toward menopause. The mean self-care score was 23.82 &#xb1; 3.76 out of 80, and all respondents (100%) demonstrated poor selfcare management practices. The study revealed moderate knowledge, negative attitudes, and poor self-care practices regarding menopause among middle-aged women in the FCT. These findings highlight the need for targeted health education and community-based interventions to improve awareness, promote positive attitudes, and enhance self-care practices among women in this population.

The prevalence of pre-diabetes mellitus (pre-diabetes, pre-DM) is increasing globally, with 5%-10% of adults with pre-DM progressing to type 2 DM (T2DM) annually. Despite the availability of national screening programmes and lifestyle interventions, uptake remains suboptimal and the lived experiences of individuals navigating pre-DM diagnosis and care in Singapore remain poorly understood. Understanding these experiences is critical, as patient perspectives can reveal gaps in care delivery, particularly in a multiethnic population where cultural, social and systemic factors intersect in complex ways. The current study explores the barriers and facilitators in detecting and managing pre-DM in Singapore's multiethnic population. This qualitative study employed purposive sampling and a phenomenological approach to capture the experiences of those living with pre-DM (n=13). Participants were recruited from National Healthcare Group polyclinics through clinician referrals and through self-referrals. Eligible participants were aged 21 and above, Singapore citizens or permanent residents, diagnosed with pre-DM and conversant in at least one local language, while those with T2DM or type 1 DM were excluded. One-to-one in-depth interviews were conducted between August 2023 and February 2024, which were audio-recorded, transcribed verbatim and analysed through reflexive thematic analysis. Six overarching themes were identified: a) pathways to pre-DM diagnosis (detection during management of chronic conditions, self-initiated detection through health screening (HS)), b) dealing with diagnosis: navigating shock, acceptance and worry about the future, c) life before diagnosis: living in comfort and the absence of consequences (dietary habits and lifestyle choices before diagnosis, when not knowing felt safer: the reasons for not doing HS), d) life after diagnosis: reconfiguring daily life (lifestyle changes: renegotiating diet and exercise habits, alternative therapies: integrating traditional approaches), e) pre-DM care (challenges and enablers of pre-DM management) and f) reimagining care: suggestions for improving pre-DM care. The main barriers were i) personal factors: the struggle to sustain behavioural changes (such as lack of awareness, difficulty with dietary and physical activity changes, lack of self-discipline), ii) navigating social and environmental barriers to lifestyle change, iii) the financial burden of lifestyle changes, iv) work-related factors: competing priorities and time constraints,v) feeling unheard: the healthcare team-related barriers to care and vi) gaps in the systems: structural barriers to care (such as long waiting times, clinician rotation, short consultations). Enablers included i) fear to action: personal drivers of pre-DM self-management (such as personal factors including fear of developing T2DM), ii) family, peers and domestic help as daily support, iii) feeling heard and cared for: healthcare team-related factors, iv) seamless care through operational excellence and v) knowledge about pre-DM: sources and information seeking. Our findings suggest the need for multilevel collaboration to promote effective strategies to manage pre-DM in the community. This requires interventions to promote early screening, healthcare reforms to reduce waiting times and clinician rotation, and sustaining lifestyle modifications. Interventions should leverage the enablers identified in the study while addressing the barriers to ensure healthcare reforms. The insights derived from this study can directly inform locally contextualised interventions and policy reforms to strengthen pre-DM care delivery within a multiethnic healthcare setting.

Spine-related leg pain (SRLP) is a common and clinically important presentation, affecting a substantial proportion of individuals with lumbar spine disorders. Compared to those with isolated axial low back pain, these patients experience higher pain intensity, greater disability, worse long-term outcomes, and increased healthcare utilization. Clinical management is complicated by inconsistent terminology among musculoskeletal healthcare providers, with the widespread and imprecise use of the term sciatica contributing to diagnostic uncertainty and treatment variability across heterogeneous conditions. The International Association for the Study of Pain (IASP) distinguishes three categories of SRLP: radiculopathy, radicular pain, and somatic referred pain, each differing in underlying mechanisms, clinical presentation, prognosis, and management considerations. Lumbar radiculopathy is characterized by nerve root loss of function and corresponding neurologic deficits; radicular pain involves irritation of the nerve root with neural gain of function; and somatic referred pain results from nociceptive input from spinal structures that produce distal pain without direct nerve root dysfunction. This commentary operationalizes the updated IASP framework for physical therapists by synthesizing contemporary mechanistic concepts into a pragmatic, clinically oriented resource to support structured, mechanism-based clinical reasoning. Emphasis is placed on differentiating SRLP phenotypes during examination, setting appropriate expectations, guiding conservative management, and identifying when escalation, interdisciplinary collaboration, or referral is warranted. By adopting standardized terminology and applying a structured yet adaptable reasoning framework, physical therapists may enhance diagnostic precision, improve individualized decision-making, and more effectively guide patients with SRLP toward meaningful recovery.

Parasite virulence, a key regulator in ecosystems, critically influences wildlife population dynamics and food web stability. Although classical co-evolutionary theory posits a trend toward benign symbiosis, empirical evidence demonstrates that virulence is shaped by complex trade-offs among host, parasite, and environmental factors. This study provides a comprehensive analysis of the drivers of virulence, including host strategies (immune competence, density-dependent transmission, spatial behavior), parasite strategies (transmission mode,within-host competition, genetic diversity), and environmental dimensions (climate change, habitat fragmentation, species invasions). We further examine how disruptions to this tripartite equilibrium can precipitate population declines, biodiversity loss, and increased zoonotic spillover risk. Within the "One Health" framework, we highlight the necessity of maintaining dynamic balance among virulence, hosts, and the environment to safeguard ecological integrity and public health. Accordingly, we propose integrated management strategies to sustain these interactions. This work underscores the interdependence of virulence evolution and ecosystem processes, offering insights for proactive conservation and disease mitigation.

Frailty is characterized by multisystem dysregulations leading to reduced physiological reserve with greater vulnerability to morbidity and mortality. Community asset interventions have emerged as multidimensional approaches to supporting people with frailty that improve quality of life, strengthen social bonds, and promote wellbeing. While community participation is associated with a higher quality of life, robust evidence on the economic effectiveness of these approaches in populations with or at risk of frailty remains scarce. A systematic review was conducted following PRISMA 2020 guidelines and registered on PROSPERO. Five databases were searched from January 2000 to August 2025. Two reviewers screened titles, abstracts, and full texts using the Covidence systematic review management software. A narrative synthesis was conducted following Synthesis without Meta-analysis (SWiM) guidelines. Twelve studies were included in the review. Five studies were cost-effectiveness analyses (CEA), three applied cost-consequence analyses (CCA), three investigated healthcare resource utilization (HRU)/modeling, and one applied cost-benefit analysis (CBA). Results varied according to methodology, outcome measures, and follow-up periods. In the CEA studies, four interventions were reported as dominant (less costly and more effective than usual care). CCA and HRU/modeling evidence reported inconsistent findings but indicated cost reductions through fewer hospitalizations and delayed transitions to long-term care. A modeling study predicted cost neutrality within 5-7&#x202f;months and substantial 5-year savings. CBA evidence was limited, as only one study was included. While multi-component community assets offer potential economic benefits over usual care for frailty management, weak evidence and methodological inconsistencies preclude definitive conclusions. High-quality, future research utilizing standardized economic frameworks and, population-specific outcome tools are needed to inform policy and resource allocation decisions. https://www.crd.york.ac.uk/PROSPERO/view/CRD420251018547, CRD420251018547.

Medicaid care-management programs typically allocate scarce outreach capacity to beneficiaries with the highest predicted risk of an acute event, assuming that risk and responsiveness are aligned and stable across short intervals. The authors tested whether targeting outreach by predicted individualized treatment effect-the conditional average treatment effect (CATE) recomputed each calendar month-outperforms risk-based targeting. The authors analyzed 164,063 adult Medicaid beneficiaries (2,670,806 person-months) enrolled in community-based care management in Washington and Virginia between January 2023 and December 2025. The exposure was a completed care-manager telephone contact within a calendar month; the primary outcome was an emergency department visit or hospital admission within 30 days. CATEs were estimated using a causal forest with cross-fitted propensity and outcome-model nuisance functions, augmented by within-person fixed effects. Two monthly allocation rules were compared at 10% population capacity: a risk-based rule (top decile predicted event probability) and an effect-based rule (top decile predicted CATE). Policy values were estimated via doubly-robust off-policy evaluation. Findings were validated by cross-state replication, a marginal structural model targeting for time-varying confounding, and a staggered-rollout instrumental variable with pretrend, exclusion-restriction, and monotonicity diagnostics. Effect-based targeting prevented 13.3 (95% CI, 12.8-13.9) acute events per 2000 members per month versus 2.5 (95% CI, 2.3-2.7) under risk-based targeting-a 5.3-fold (95% CI, 4.9-5.7) improvement. Within-person variance accounted for 63.6% of total CATE variance. Gains were similar across racial/ethnic groups and states. Monthly allocation of Medicaid care-management outreach by predicted treatment effect substantially increased the number of acute events prevented at fixed capacity without widening between-group disparities.

Fluid and electrolyte management is a crucial component of care in critically ill patients with severe infections. Patients with sepsis, septic shock, or multiorgan dysfunction syndrome struggle to maintain fluid balance due to increased capillary permeability, inflammation, vasodilation, and organ dysfunction. Inadequate fluid balance can increase complications, morbidity, and mortality. Fluid management is complex because sepsis disrupts vascular permeability, tissue perfusion, and cellular function. Infectious disease care is further challenged by antimicrobial resistance, drug stewardship, and infection control. Skilled nursing, advanced monitoring, and continuous education are essential to optimize outcomes and ensure high-quality management in this vulnerable population.

Despite recent advances in the treatment of locally advanced non-small cell lung cancer (NSCLC), most patients relapse after definitive chemoradiotherapy followed by durvalumab consolidation. Due to limited evidence on post-relapse management, no standard treatment approach has been established for this patient population. The objective of this study was to evaluate real-world treatment strategies and clinical outcomes in patients with NSCLC who experienced disease recurrence after durvalumab consolidation. This was a multicenter, retrospective cohort study conducted across 12 German lung cancer centers. A total of 145 patients with recurrent NSCLC following chemoradiotherapy and durvalumab consolidation were analyzed. Clinical, pathological, and treatment-related data were collected, including smoking status, histology, molecular testing, therapeutic sequences, and survival outcomes. Overall survival (OS) and progression-free survival (PFS) were estimated and compared across subgroups according to relapse characteristics and post-relapse treatment strategies. Multivariate analyses were performed to identify independent prognostic factors. The median OS from initial diagnosis was 27.1&#x2009;months (95% confidence interval (CI): 22.5-31.8). After relapse, median OS was 12.2&#x2009;months (95% CI: 9.9-14.4), and median PFS was 7.1&#x2009;months (95% CI: 5.7-8.4). Approximately 70% of patients received systemic therapy after relapse, including platinum-based chemotherapy (18.6%), single-agent chemotherapy (18.6%), immune checkpoint inhibitors with or without chemotherapy (28.3%), and targeted therapy (4.8%). Patients treated with immune checkpoint inhibitors or targeted therapies showed a numerical improvement in OS compared with chemotherapy alone, although this difference did not reach statistical significance. Multivariate analysis identified first-line post-relapse treatment, Eastern Cooperative Oncology Group performance status, and histologic subtype as independent prognostic factors for OS. Patients with relapsed NSCLC after durvalumab consolidation have a poor prognosis and remain a therapeutically underserved population. Clinical outcomes appear to be influenced by performance status, histology, and the choice of post-relapse therapy. Prospective clinical trials are urgently needed to define optimal treatment strategies for these patients. Understanding treatment options and outcomes for patients with lung cancer that comes back after chemoradiotherapy and durvalumab: results from a study of 145 patients in 12 German cancer centers Lung cancer is one of the most common and deadly cancers worldwide. For many patients with locally advanced non-small cell lung cancer (NSCLC), the standard treatment includes chemotherapy and radiation, followed by an immunotherapy drug called durvalumab. This approach has improved survival for many people, but unfortunately, most patients still experience relapse meaning the cancer comes back. When relapse happens, doctors have limited evidence to guide the next steps in treatment. To better understand what happens to these patients, we analyzed real-world data from 145 people with NSCLC treated at 12 lung cancer centers in Germany. All had received chemoradiotherapy and durvalumab before their cancer returned. We looked at how these patients were treated after relapse and how long they lived. About 70% received further systemic therapy either chemotherapy, immunotherapy, or targeted treatment. The average survival time after relapse was around 12&#x2009;months. Patients who received immunotherapy or targeted therapy tended to live longer than those treated with chemotherapy alone, although this difference was not statistically significant. We also found that certain factors such as a patients general health (performance status), the type of lung cancer (histology), and the kind of treatment given after relapse were important for predicting survival. Overall, our results show that people whose lung cancer returns after durvalumab still face a poor prognosis and limited treatment options. This group of patients urgently needs better, more effective therapies. Future clinical studies should focus on developing new treatment strategies to improve their outcomes.

Studies have indicated that exposure to household pesticides is prevalent among the population. Nevertheless, the relationship and contributing factors linking urinary metabolites of household pesticides to circulating levels of sex steroid hormones in human serum remain insufficiently explored. To examine the correlation between household pesticides metabolites and serum sex steroid hormones levels. This study utilized data from 3,884 participants obtained through the National Health and Nutrition Examination Survey (NHANES) conducted between 2013 and 2016. NHANES measured urinary metabolites of household pesticides and serum levels of sex steroid hormones. The study utilized weighted multiple linear regression modeling combined with restricted cubic spline (RCS) analysis to investigate relationships and dose-response patterns between residential pesticide metabolites and serum sex steroid hormones across both genders. Additionally, the research examined potential modifying effects of obesity status on pesticide metabolite-sex hormone associations through interaction analysis. Following adjustment for potential confounders, concentrations of 3,5,6-trichloro-2-pyridinol (TCPY), para-nitrophenol (PNP), and 3-phenoxybenzoic acid (3-PBA) demonstrated negative correlations with total serum testosterone (TT), estradiol concentrations(E2), and free androgen index (FAI) across all three statistical models (Ps < 0.05), while positive relationships emerged with sex hormone-binding globulin (SHBG). We found the similar results among male participants. However, the negative correlation was not found between TCPY, PNP, 3-PBA and SHBG among female participants RCS modeling revealed complex nonlinear interactions between DCBA and serum sex steroid hormone levels. Analysis stratified by body mass index showed that TCPY, PNP and 3-PBA exhibited similar negative correlations with TT, E2 and FAI in the non-obese participants. The study reveals that the metabolites from household pesticides exhibited negative correlations with serum sex steroid hormone levels across both genders. Associations were more consistent for non-obese populations.

Malnutrition and cognitive impairment are 2 common and interrelated conditions among older adults, each of which is linked to adverse health outcomes. Previous studies have usually examined these factors separately, and less is known about their combined association with mortality. This study examined whether the coexistence of nutritional risk (NR), defined using multiple nutritional indices, and digit symbol substitution test (DSST)-defined low cognitive performance was associated with all-cause mortality in older adults. Data were obtained from the National Health and Nutrition Examination Survey 2011 to 2014 with mortality follow-up through 2019. Nutritional status was evaluated using 3 validated indices that capture distinct dimensions of nutritional health: the Geriatric Nutritional Risk Index, Prognostic Nutritional Index, and Controlling Nutritional Status. Participants were classified as having high NR if any index indicated abnormal status. DSST-defined low cognitive performance was defined as a digit symbol substitution test score below the 25th percentile. Survey-weighted Cox regression models were applied to estimate hazard ratios and 95% confidence intervals for all-cause mortality after adjustment for demographic, socioeconomic, and clinical covariates. Among 1937 participants aged 60 years or older, 338 deaths occurred during a median follow-up of 6.6 years. In fully adjusted models, neither DSST-defined low cognitive performance nor high NR alone was significantly associated with mortality. Participants with both high NR and DSST-defined low cognitive performance had a higher mortality hazard (hazard ratio&#x2005;=&#x2005;1.60; 95% confidence interval: 1.24-2.06; P = .032). Survival analysis revealed a gradual increase in mortality risk across the 4 combined exposure categories. The coexistence of high NR and DSST-defined low cognitive performance was associated with higher all-cause mortality among older adults and should be interpreted as a joint risk profile rather than evidence of synergy. These findings support the potential value of considering nutritional and cognitive information together in geriatric risk assessment.