Facioscapulohumeral muscular dystrophy (FSHD) is a progressive inherited myopathy characterized by muscle weakness, fatty infiltration, and consequent reduction in functional capacity. In this context, physical exercise (PE) has been proposed as a non-pharmacological strategy aimed at preserving physical efficiency. However, its prescription in FSHD has historically been approached with caution due to concerns regarding overwork weakness and potential exacerbation of muscle damage. As a result, clinical management has often remained conservative, with limited and non-standardized PE recommendations. Nevertheless, physical inactivity may further contribute to deconditioning, loss of autonomy, and deterioration in quality of life, highlighting a clear tension between perceived risk and potential benefit. In this framework, identifying safe and effective PE strategies represents a central unmet need in FSHD care. Possibly due to disease rarity and historical concerns, the available literature on PE in FSHD remains fragmented, limiting the strength of definitive conclusions. A structured synthesis of existing evidence may help clarify feasible and potentially effective exercise modalities, as well as guide the development of optimized intervention strategies. This review critically examines the current evidence on PE in FSHD, with specific reference to aerobic, anaerobic, and combined training interventions. The potential synergistic role of concomitant nutritional strategies is also considered. The critical analysis highlights exercise modalities that appear more consistently safe and potentially beneficial, while underscoring substantial methodological limitations across studies. Finally, emerging concepts in exercise tailoring are discussed, with the aim of addressing the clinical variability of FSHD and informing future prospective, controlled investigations.
Air pollution is a serious issue, and in recent decades, air quality has been considered an essential parameter for hosting mega-events like the Olympics, the Commonwealth Games, and the G20 summit. Air quality improvement has become a key focus for hosting nations, alongside infrastructural development. The study analyzed the air quality changes during the G20 event held in Delhi in 2023 and evaluated the efficiency of various mitigation measures initiated in Delhi city before the event. The study was conducted in three different periods: before, during, and after the G20 event. The study showed that stringent measures could reduce PM10 concentrations to around 30 µg/m3, which was ~5 times less than the concentrations observed during normal scenarios. During the event, the PM2.5 concentration ranged from 10 to 15 µg/m3, complying with WHO guideline levels. However, after the event, the concentration rose to approximately 30 to 35 µg/m3. The gaseous pollutants such as NOx also showed a significant reduction (~39%) during the event. The mitigation measures included comprehensive measures from administrative to short-term and long-term measures, focusing on different emission sources that helped reduce particulate matter concentrations of about 65 to 75%. The study also found that air quality again deteriorated when the measures were relaxed, and the mitigation measures were not stringent. Urban air quality improvement is possible only through different intensive mitigation measures, and investigating the efficiency of these measures helps keep the policy alive.
Pediatric intraspinal space-occupying lesions are rare but may cause substantial neurological morbidity when diagnosis or treatment is delayed. This study aimed to characterize the clinicopathological spectrum, anatomical distribution, operative management, and early neurological outcomes of pediatric intraspinal lesions treated at a single tertiary neurosurgical center. We retrospectively reviewed 27 consecutive patients aged 14 years or younger who underwent surgery or image-guided biopsy for confirmed intraspinal space-occupying lesions between January 2018 and February 2025. Clinical presentation, magnetic resonance imaging findings, lesion compartment, operative strategy, histopathology, extent of resection, Modified McCormick Scale status, complications, recurrence or progression, and follow-up outcomes were analyzed descriptively. The cohort included 14 girls and 13 boys, with a mean age of 10.11 years. Limb weakness and pain were the most common presenting symptoms. Lesions were intramedullary in 10 patients, intradural extramedullary in 10, and extradural in seven. Neoplastic pathology was confirmed in 23 cases. Gross-total resection was achieved in 19 patients, subtotal resection in five, partial resection in one, and biopsy in two. Limited resection or biopsy was selected when diffuse infiltration, suspected systemic malignancy, or unacceptable neurological risk precluded aggressive excision. Early postoperative neurological improvement was observed in 20 patients, whereas recurrent or progressive disease occurred in five during follow-up. Pediatric intraspinal lesions show marked biological, anatomical, and radiological heterogeneity. Careful clinical suspicion, contrast-enhanced MRI, individualized operative planning, and function-preserving resection remain central to management. Multicenter data collection is needed to refine prognostic assessment and treatment recommendations.
Meningioma is a known adverse reaction of high-dose progestogens, but evidence regarding the risk associated with progestogens used as contraception is limited. To examine whether different progestogens used as hormonal contraception are associated with increased risk of meningiomas. This nested case-control study conducted over a 25-year study period from January 1, 2000, to December 31, 2024, is a Danish nationwide population-based register study, which included 3 million females aged 15 to 59 years with residence in Denmark. Meningioma cases were dentified, and for each case, 10 controls were matched on age, birthplace, and marital status and randomly selected from the cohort if considered eligible on the day of the case's meningioma diagnosis. Data were analyzed from July 10, 2025, to May 12, 2026. Use of progestogens was identified in the registers by date of dispensing or procedural records and grouped by route of administration and active substance. Exposure time was determined by redeemed daily doses or product duration. If a female switched to a different product or became pregnant, her exposure time was changed to the new exposure. The females included were allocated to their most recent use, defined as the exposure closest to the matching date. The main outcome was incident meningioma and was identified in the Danish National Cancer Register using validated International Statistical Classification of Diseases and Related Health Problems, Tenth Revision diagnoses and International Classification of Diseases for Oncology, Third Edition codes. A total of 1473 cases and 14 717 controls with a median age of 48 years (IQR, 42-53 years) were included in the nested cohort. For combined oral contraceptives, the estimated odds ratios (ORs) for the association between use of progestogens and meningioma were 1.61 (95% CI, 1.00-2.59) with cyproterone, 1.66 (95% CI, 1.31-2.10) with desogestrel, 1.58 (95% CI, 1.05-2.37) with drospirenone, 1.44 (95% CI, 1.17-1.77) with gestodene, 1.40 (95% CI, 1.12-1.76) with levonorgestrel, 1.38 (95% CI, 0.77-2.47) with norethisterone, and 1.04 (95% CI, 0.70-1.54) with norgestimate. For oral progestogen-only contraceptives, the ORs were 1.73 (95% CI, 1.17-2.56) with desogestrel and 0.95 (95% CI, 0.57-1.57) with norethisterone. For injectable medroxyprogesterone, the OR was 4.55 (95% CI, 2.19-9.45). For intrauterine devices (IUDs) with high-dose levonorgestrel, the OR was 1.58 (95% CI, 1.28-1.94), and for IUDs with low-dose levonorgestrel, the OR was 1.14 (95% CI, 0.59-2.22). Exposure within the past year was associated with the highest risk. In this case-control study conducted using data from the entire Danish population, recent use of the contraceptive progestogens cyproterone, desogestrel, drospirenone, gestodene, levonorgestrel, injectable medroxyprogesterone, and high-dose IUD was associated with increased risk of meningioma. These findings are considered relevant information for the treated women and the prescribing physicians.
Neurodegenerative diseases include Alzheimer's and Parkinson's disease which are progressive loss of neurons due to oxidative stress, mitochondrial dysfunction and long-term neuroinflammation. The approach of attacking these intertwined pathological processes has emerged as a major approach in identifying effective neurotherapeutics. In that regard, the use of ethnomedicine has immense potential. Ficus virens is a medicinal plant that is traditionally used and has drawn attention because of its wide range of pharmacological activities and high phytochemical composition. This review is an overall summary of botanical properties, ethnomedicinal properties, phytochemical composition and pharmacological functions of Ficus virens, with special consideration to neuroprotective properties. Bioactive constituents found in abundance in the plant include flavonoids, phenolics, and terpenoids, and they help in its antioxidant and anti-inflammatory properties. Ficus virens has a neuroprotective effect, which is primarily mediated by the regulation of the Nrf2/Keap1 signaling pathway, which increases the expression of the endogenous antioxidant enzymes and redox homeostasis. Moreover, it inhibits neuroinflammatory responses by suppressing the major signaling pathways such as the NF-ĸB signaling pathway and inhibits production of pro-inflammatory cytokines and mediators. The review also cites the experimental results of both in vivo and in vitro studies which show that Ficus virens has the capacity to inhibit oxidative damages, mediate apoptotic mechanisms, and enhance neuronal survival. New methods, such as network pharmacology and advanced delivery systems based on nanotechnology are also mentioned as possible means of improving its therapeutic efficacy and bioavailability, especially to overcome the problem of the BBB.
Accurate anthropometric data of the pediatric orbit is critical for diagnosing and managing various pediatric orbital pathologies and for planning surgical and reconstructive interventions. The purpose of this study was to establish MRI-based normative anthropometric data for pediatric orbital structures, analyze age-related variations, and evaluate interobserver reliability among expert neuroradiologists. This retrospective study included 64 healthy pediatric patients (32 males, 32 females; age range, 1-17 years) who underwent MRI scans for indications unrelated to orbital pathology. Patients were categorized into three age groups: pre-school (3-6 years), school-age (7-12 years), and adolescent (13-17 years). MRI scans acquired at 1.5 Tesla and 3 Tesla were independently evaluated by three neuroradiologists to measure orbital anthropometric parameters, including extraocular muscle dimensions, orbital breadth, orbital height, interzygomatic line length, intercanthal distance, optic nerve sheath width, and optic nerve angle. Statistical analyses included Spearman's correlation, Kruskal-Wallis tests, Mann-Whitney U tests, and intraclass correlation coefficients (ICC) to assess interobserver reliability. Significant positive correlations were identified between patient age and orbital parameters, particularly the interzygomatic line length (Spearman's r = 0.772, p < 0.001). Orbital breadth (right: r = 0.674; left: r = 0.703) and orbital height (right: r = 0.608; left: r = 0.644) also significantly increased with advancing age (all p < 0.001). Interobserver reliability demonstrated excellent reproducibility, with ICC values notably high for orbital breadth (ICC = 0.92, 95% CI: 0.89-0.95) and orbital height (ICC = 0.90, 95% CI: 0.87-0.93). MRI-based normative anthropometric measurements provide precise and reliable reference values for pediatric orbital anatomy. These measurements reveal significant age-related developmental trends, enhancing diagnostic accuracy, clinical management, and surgical planning in pediatric orbital conditions.
Binswanger's disease, a rare form of subcortical vascular dementia, presents with a progressive decline in cognitive and motor functions due to chronic small vessel ischemic changes in the brain. Its clinical presentation often overlaps with other neurological conditions, particularly Wernicke's encephalopathy, leading to potential diagnostic delays. We report the case of a 45-year-old male who presented with altered mental status, gait abnormalities, memory impairment and ocular pain. Given his significant history of alcohol consumption, an imperial diagnosis of Wernicke's encephalopathy was made, and treatment was commenced with thiamine supplementation. However, the persistence of behavioural changes, right-sided pyramidal signs, extrapyramidal features and cognitive deficits prompted further evaluation. The clinical findings, combined with the patient's history of hypertension, diabetes and prior stroke, led to the diagnosis of Binswanger's disease. This case highlights the importance of considering vascular dementia in differential diagnoses of subacute encephalopathy and emphasises early recognition to initiate appropriate management.
To address the issues of low remediation efficiency and microbial toxicity stress in soils contaminated with both Cd(II) and pyrene, this study prepared Fe/Mn-modified biochar from buckwheat hulls, screened pyrene-degrading bacterial strains, and developed an immobilized bacterial agent (PFMBC). Using free-living bacteria (YL) and unmodified biochar-immobilized bacterial agent (PBC) as controls, to investigate their pyrene degradation performance and mechanisms under different Cd(II) concentrations. Carrier properties were characterized using XPS and FTIR, microbial physiological indicators and enzyme activities were measured, and pyrene metabolites were analyzed via GC-MS. The results showed that PFMBC exhibited the best degradation performance, achieving a 77.23% pyrene degradation rate after 15 days under 20 mg/L Cd(II) conditions and 60.09% under 60 mg/L Cd(II) stress, which was significantly superior to the controls. Fe/Mn modification enhances the Cd(II) adsorption and immobilization capacity of biochar, promotes microbial secretion of extracellular polymeric substances(EPS), increases biofilm stability, reduces cell membrane damage and ROS accumulation, significantly boosts the activity of catechol dioxygenase, dehydrogenase, and catalase, accelerates the ring-opening oxidation and metabolism of pyrene, alters the degradation pathway, and reduces the accumulation of recalcitrant intermediate products. This study elucidated the synergistic mechanism by which Fe/Mn-modified biochar-immobilized bacterial agents enhance pyrene degradation under laboratory simulated Cd(II)-pyrene co-contamination conditions. The results offer a laboratory-scale theoretical basis and experimental reference for the remediation of Cd(II)-pyrene co-contaminated soil, whereas its actual field remediation efficiency and environmental applicability remain to be verified in further field investigations.
Central venous access devices (CVADs) are commonly inserted in paediatric patients requiring cancer treatment and supportive care. However, these devices carry a high risk of complications such as central line-associated bloodstream infections (CLABSI), venous thromboembolism (VTE), and occlusion, and are associated with significant management costs. This study aimed to determine the average cost of each CVAD-associated complication type, per complication event, and investigate which elements are the key cost drivers of these estimates. This Australian prospective observational cohort study, embedded within a randomised controlled trial, acquired data from hospital purchasing departments, the Medicare Benefits Schedule Book, the National Hospital Cost Data Collection (NHCDC) Public Sector 2022-2023 Report, and local (state-based) enterprise bargaining agreements. Price per resource unit was multiplied by associated resource use and summed across all resources to estimate the mean complication cost per event. An average cost per complication event for each complication type was then determined. In a sample of 310 paediatric oncology patients, 101 unique patients experienced 275 CVAD-associated complication events. Of these events, estimated per-event direct costs for CVAD-associated complications were as follows: occlusion (A$2712 (95% CI $1198-$4225)), CVAD-associated venous thromboembolism (A$17,510 (95% CI $5840-$29,181)), confirmed CLABSI (A$38,995 (95% CI $22,394-$55,596)), and suspected CLABSI (A$16,030 (95% CI $12,971-$19,090)). CVAD-associated complications remain a palpable cost in paediatric cancer care, with CLABSI carrying the highest cost burden. Therefore, investing in preventative care is encouraged to minimise the burden of complication costs to the healthcare system, and reduce the physical and emotional burden on patients and their families. With admission costs comprising a high percentage of complication-associated costs, efficient and effective evidence-based care must be delivered to ensure a shorter length of stay, simultaneously improving the patient experience.
Ecological risk assessments estimate chemical exposures in wildlife from contaminant concentrations within their surrounding environment. This approach precludes a detailed understanding of interactions between biota and contaminant sources. It also overlooks how the uneven and irregular use of space by animals influences variability in exposure. Here, we conducted a meta-analysis to examine whether site-specific variability in lead exposure was associated with the home range size and movement-related traits of terrestrial bird species. We constructed a series of linear models to test the effect of ecological and environmental predictors on variability in lead exposure, which we quantified using the coefficient of variation for site-specific feather lead concentrations. Accounting for variance across study, site, species, and phylogeny, we show that birds with larger home ranges exhibited more variable levels of lead exposure than those with more restricted movement patterns. This relationship was moderated by foraging niche and was significant in ground foraging birds but non-significant in generalists and arboreal-aerial foragers, which may relate to differences in dietary lead sources and niche complexity. Site-specific variability in feather lead concentrations was further structured by feather type, with contour feathers exhibiting lower variability than wing, tail, or mixed feather samples. Our findings highlight how the use of space at varying scales might influence divergent patterns of chemical exposure in terrestrial birds. We discuss how incorporating movement-related traits into wildlife risk assessments can reduce uncertainties associated with spatial variability in exposure and improve the ecological relevance of monitoring outcomes.
Emergency department (ED) overcrowding is a major global healthcare challenge associated with increased mortality, prolonged waiting times, and inefficient use of hospital resources. Although ED crowding is commonly described through the input-throughput-output framework, the relative effectiveness of organizational interventions targeting each component remains uncertain. A hybrid dynamic simulation model integrating discrete-event simulation and agent-based modeling was developed to create a digital twin of the Emergency Department of a large university hospital in Northern Italy. The model was calibrated using real-world operational data and validated against observed process indicators. Alternative organizational scenarios targeting input, throughput, and output factors were simulated. Primary outcomes were time to first medical contact and overall ED length of stay. Diverting 12% of low-priority patients who did not require hospitalization produced modest improvements, reducing time to first medical contact by 14% and ED length of stay by 11.6%. Increasing diagnostic capacity through the addition of a second X-ray room showed negligible effects on ED performance. In contrast, eliminating the clinical workload associated with the management of "boarding" patients awaiting hospital admission resulted in substantially greater improvements, reducing time to first medical contact by approximately 70% and ED length of stay by about 50%. Interventions targeting the output phase of the ED process, particularly those addressing the organizational burden associated with boarding patients, have a substantially greater impact on reducing overcrowding than strategies focused on decreasing patient inflow or increasing diagnostic resources. Hospital-wide bed management strategies appear essential to effectively mitigate ED overcrowding.
While artificial intelligence's (AI's) transformative potential in health care is widely acknowledged, its application in highly sensitive, humanistic domains like pediatric palliative care (PPC) remains largely unexplored. This study aims to explore the attitudes and needs of health care providers on the PPC assisted by AI, with the goal of informing future development and implementation of AI systems in this field.  This was an explanatory sequential mixed methods study consisting of a nationwide cross-sectional questionnaire survey (March-April 2025) followed by qualitative semistructured interviews (August-October 2025). The quantitative study aimed to investigate PPC health care providers' experiences, attitudes, and needs for the application of AI. Participants included team members of all recognized PPC teams in mainland China. The qualitative study aimed to explore in greater depth the potential future roles of AI in this field, as well as the features of an ideal AI-assisted tool for PPC. Potential interviewees were recruited from the pool of quantitative survey respondents.  Among 352 survey respondents, most (n=205, 58.24%) reported moderate familiarity with AI, with large language models being the most commonly used (n=280, 79.55%). Among large language model users, over half (161/280, 57.50%) reported using them for clinical purposes. Attitudes were generally positive: 67.05% (236/352) believed AI's benefits would outweigh drawbacks, and 75% (264/352) considered its implementation feasible. The most desired applications were patient and family education (276/352, 78.41%) and symptom management (257/352, 73.01%). Interviews with 17 providers revealed three themes: (1) clinical roles and boundaries, (2) elements for clinical integration, and (3) challenges in development and deployment.  This study reveals that PPC providers express positive attitudes and strong demand for AI-assisted clinical work. Furthermore, the research clarifies appropriate roles for AI, outlines elements for clinical integration, and highlights potential challenges in development and integration. This study provides evidence for the feasibility of AI application in PPC and offers guidance for the future development and deployment of AI tools.
Stable isotope analysis provides an integrated approach to tracing animal dietary sources and trophic structures while being sensitive to environmental and land-use changes. It therefore serves as a powerful tool for evaluating the interactions between animal resource use and environmental variation. However, spatial isotopic patterns across large numbers of species and their responses to climate change and anthropogenic activities remain poorly understood. Here, we applied a Bayesian mixed-effects modeling framework and isotopic niche analyses using feather samples from 766 individuals of 200 bird species in southwestern China (1958-2007) to assess how ecological, climatic, and anthropogenic factors jointly shaped the spatial patterns of feather carbon (δ1 3C) and nitrogen (δ1 5N) isotopes across taxa. The results revealed that the δ1 3C and δ1 5N values differed markedly across dietary and migratory guilds, highlighting distinct strategies of resource use and trophic organization among species. The feather δ1 5N values increased with increasing pasture coverage, suggesting a potential elevation of the baseline δ1 5N in grazing landscapes. δ1 5N also showed a positive trend with precipitation, indicating that wetter environments may be associated with elevated nitrogen isotopic baselines. Furthermore, isotopic niche analyses revealed that farmland habitats exhibited broader isotopic niches than forest habitats, especially for herbivores, highlighting the influence of agricultural expansion on resource use. Overall, this study demonstrates how ecological traits, climatic factors, and human disturbances jointly shape avian trophic patterns across taxa and scales, providing new insights into trophic structure and the consequences of land use change for ecosystem function across diverse ecosystems.
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The safety of single-stage bilateral total knee arthroplasty (TKA) has been a subject of debate due to concerns of morbidity and mortality. The advantages of one-stage (OS) bilateral TKA include shorter recovery time, a shorter hospital stay and perhaps reduced total treatment costs. This study aimed to evaluate the clinical outcomes and complications following OS versus two-stage (TS) bilateral TKA for severe osteoarthritis of both the knees. This retrospective comparative analysis was carried out between January 2021 and December 2025 at the National Orthopaedic Hospital, Dala, Kano, and the University of Abuja Teaching Hospital, Gwagwalada. Clinical outcomes using the KSS scoring system and the rate of complications were recorded. Patients' satisfaction was also documented using the Likert scale. The statistical analysis was performed using SPSS version 26.0. Using a level of significance of 0.5, the two independent groups were compared using independent Student's t -test. There was no significant difference in post-operative KSS between the two groups ( P = 0.717). The mean post-operative KSS in the OS and TS groups were 97.78 ± 1.78 and 97.76 ± 1.74, respectively. Post-operative complications also did not significantly differ in the two groups ( P = 0.712). In properly selected cases, OS bilateral TKA is less expensive and yields clinical outcomes, complication rate and patient satisfaction comparable to those of a TS procedure.
This global consensus conference was designed to define best practice for the controversial aspects of primary surgical management of uterovaginal pelvic organ prolapse (U-POP), to identify unanswered clinical questions, and to educate junior researchers on systematic review and meta-analysis methodology. Eleven committees were created with geographically diverse representation and tasked with answering pragmatic questions specific to U-POP surgical decision making. A systematic search of MEDLINE, Embase, and ClinicalTrials.gov from 2000 through December 2025 was performed with specific search terms for each committee. Relevant abstracts and full texts were doubly screened and included articles were doubly extracted. Guided by literature, consensus statements were created and assigned high, moderate, and low levels of evidence. Statements with low levels of evidence were presented and voted upon in-person at a consensus conference, hosted by the Department of Urology at Wake Forest University School of Medicine in Winston Salem, NC, USA. Contributions from 154 participants (including 33 junior researchers) from 19 countries led to 29 systematic searches, screening of 51,143 abstracts and 3,869 full-text manuscripts. There were 133 consensus statements presented at the conference; 6 were supported by high-quality, 28 by moderate-quality, and 99 by low-quality or no evidence respectively, and required Delphi process consensus. Among expert opinion statements, 58 were accepted, 32 were rejected, and 9 were eligible for revision. A total of 92 statements are presented here to guide clinical decision making and best practices in surgical management of primary U-POP.
Dutch elm disease (DED), caused by the invasive vascular pathogen Ophiostoma novo-ulmi, is one of the most devastating pandemics affecting elms. Within beetle galleries and on elm bark beetle vectors, O. novo-ulmi co-occurs with fungi of the genus Geosmithia, yet the functional significance of this association remains poorly understood. This study investigates metabolic interactions between O. novo-ulmi and Geosmithia spp. using in vitro dual-culture experiments and phenotype microarray analysis to elucidate ecological mechanisms potentially influencing disease development and vector ecology. Dual-culture assays on dH2O agar revealed that O. novo-ulmi subsp. novo-ulmi exhibited significantly enhanced radial growth rates when cultured in proximity to Geosmithia isolates. Phenotypic analysis revealed distinct metabolic strategies: O. novo-ulmi subsp. novo-ulmi utilised substrates within 12-24 h and preferred polyols and simple carbohydrates, while G. pumila adopted a progressive colonization strategy, ultimately utilising 92 substrates in 90 h and demonstrating greater utilisation of nitrogen-enriched substrates, nucleosides and complex organic acids. Co-culture revealed utilization of adenosine and nitrogen-rich compounds, but antagonistic interactions for polyols and amino sugars. Niche overlap analysis showed asymmetric resource partitioning: O. novo-ulmi subsp. novo-ulmi utilized 98% of G. pumila's substrates versus 81% reciprocal overlap, while fungal competitiveness analysis indicated G. pumila superiority. The distinct metabolic strategies and complementary patterns of substrate utilisation suggest niche construction and the functional partitioning of resources. These findings provide evidence supporting the hypothesis of a functional association within the DED pathosystem. The results highlight the ecological importance of microbial community complexity in pathogenic interactions and suggest that understanding these multitrophic relationships is essential for the development of effective disease management strategies.
The use of Hospital Electronic Prescribing and Medicines Administration (HEPMA) data in automated patient prioritisation (APP) tools is an emerging area of interest within pharmacy practice and research. As the Scottish Government continues to invest in digital transformation across health and social care, pharmacy professionals are increasingly required to adapt to new technologies whilst maintaining high standards of patient care. APP tools offer the potential to enhance operational efficiency and support clinical decision making. However, despite growing implementation internationally, there is a scarcity of published research exploring the ethical considerations associated with use. To explore hospital pharmacists' perspectives of ethical considerations from APP tool use prior to adoption in the hospital pharmacy setting. Two focus groups were conducted with a total of 12 hospital pharmacists (Pharmacist Team Manager n = 2, Advanced Pharmacist n = 5, Specialist Pharmacist n = 3, Pharmacist n = 2) from a Scottish Health Board prior to the implementation of APP using the 'CoRE-Values' ethical decision-making framework, with the aid of a clinical vignette for context. Focus group transcripts were analysed thematically with the four domains of the framework as mapped themes. Participants considered the use of APP to be a fair and pragmatic approach to managing daily workload, enabling pharmacy teams to focus on patients most at risk of medication related harm. However, professional judgement remains essential when interpreting APP outputs, and caution must be exercised to avoid an overreliance on automation. The clinical rules underpinning APP must be regularly reviewed to ensure alignment with current practice and emerging evidence. While complete visibility of high-risk patients offers significant clinical value, it may also expose limitations in workforce capacity. Participants noted that this visibility could be leveraged to support business case development to secure further staff resource and/or service transformation. APP use can support clinical decision making by directing pharmacy staff to patients at risk of medication related harm in hospitals, but ethical concerns can arise if organisations do not give due consideration to these issues prior to adoption.
To determine whether nonpharmacological interventions reduce delirium incidence in adult patients with cancer and to identify effective intervention strategies. We conducted a systematic review and meta-analysis following PRISMA guidelines. PubMed, CENTRAL, CINAHL, and Ichushi-Web were searched through September 30, 2024, for randomized controlled trials (RCTs). Two authors independently extracted data, assessed the risk of bias using the Cochrane Risk of Bias 2 tool, and evaluated the certainty of evidence using the Grading of Recommendations Assessment, Development and Evaluation approach. The primary outcome was delirium incidence. A random-effects model was used for the meta-analysis. The study protocol was registered with UMIN-CTR (No. UMIN000051804; registered August 2, 2023). Overall, 12 RCTs involving 2,747 patients were included. Interventions were categorized into multicomponent interventions, bright light therapy, rehabilitation, and anesthesia or oxygen management. The meta-analysis of five trials showed that multicomponent interventions significantly reduced delirium incidence (risk ratio [RR], 0.43; 95% confidence interval [CI], 0.31-0.60; moderate-certainty evidence), with benefit predominantly observed in postoperative settings. The evidence for bright light therapy was inconclusive (RR, 0.31; 95%CI, 0.07-1.31; very low-certainty evidence). Most of the included studies had concerns regarding the risk of bias, mainly due to a lack of blinding. Multicomponent nonpharmacological interventions may reduce delirium incidence in adult patients with cancer, particularly in postoperative or perioperative settings. However, the certainty of evidence is moderate, and the included studies vary in patient populations, intervention components, and healthcare settings. Evidence for standalone interventions and prevention strategies in palliative or end-of-life care remains limited and inconclusive.
Chronic kidney disease (CKD) in childhood, although uncommon, has profound lifelong consequences. Because disease onset occurs early, even modest slowing of CKD progression may translate into decades free from dialysis, transplantation, and premature death. Progressive proteinuria is a central driver of nephron loss in pediatric CKD, making early and sustained antiproteinuric strategies particularly impactful. Despite heterogeneous etiologies, including congenital and immune-mediated kidney diseases, CKD progression in children converges on shared mechanisms such as glomerular hypertension, podocyte injury, tubular epithelial dysfunction, and fibrosis. Targeting these final common pathways offers the greatest opportunity to modify long-term outcomes. Several emerging pharmacological strategies are reshaping the therapeutic landscape of CKD. Sodium-glucose cotransporter 2 inhibitors (SGLT2i) reduce intraglomerular pressure by restoring tubuloglomerular feedback and exert additional natriuretic, metabolic, and anti-inflammatory effects. Endothelin A (ETA) receptor antagonists counteract endothelin-1-mediated vasoconstriction, inflammation, and fibrotic remodeling, key drivers of proteinuric kidney damage. Dual endothelin-angiotensin receptor antagonists (DEARAs) integrate selective ETA blockade with angiotensin II type 1 receptor inhibition, simultaneously suppressing two tightly interconnected pathways that amplify glomerular hypertension, podocyte injury, and fibrosis. Robust randomized trials support the efficacy and safety of these agents in adults, whereas pediatric evidence remains limited, particularly regarding long-term safety. In this review, we summarize the mechanistic rationale and available clinical data for these novel antiproteinuric therapies in children, highlighting ongoing trials and key knowledge gaps relevant to future pediatric CKD management.