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Ionised hypocalcaemia can worsen haemorrhage due to its role in clot formation, vascular tone and cardiac contractility. Current guidelines recommend maintaining normal ionised calcium levels in the bleeding trauma patient. However, guidance does not specify when to replace calcium, and for paediatric trauma, it is unclear when clinicians should measure or decide to replace calcium. This study aimed to survey the practices, protocols and opinions regarding the measurement and replacement of calcium in paediatric major trauma. A cross-sectional survey with single-stage voluntary and snowball sampling. Individual emergency departments (EDs) responded to questions on departmental practices, while individual clinicians provided opinions on the measurement and replacement of calcium based on a clinical vignette with two variations (a haemodynamically stable and a haemodynamically unstable). The survey was administered using Online Surveys V3 (JISC, 2025). Respondents were invited to participate through collaborative research networks. There were responses from 67 individual EDs and 99 individual respondents from 19 different countries. Most EDs had a paediatric major haemorrhage protocol (61/67, 91.0%), but this did not include calcium for 16/67 (23.9%) of the EDs. The timing of calcium replacement was either not included or not specified in most protocols (44/67, 65.7%), with variations in when it should be replaced when specified.Opinions on considering calcium replacement before blood products were significantly different based on whether the patient in the vignette was clinically stable or unstable. Opinions on replacement doses of exogenous calcium were significantly different when the calcium was moderately low (<1.12&#x2009;mmol/L), but were not significantly different if the calcium was severely low (<1.0&#x2009;mmol/L). There is considerable variation among EDs regarding ionised calcium measurement and calcium replacement, both before blood product transfusion and in major haemorrhage protocols. Clinicians' opinions on calcium measurement and replacement also vary widely. More research is needed to reach a consensus. III.

Book reviews express the opinions of the individual authors regarding the value of the book's content for Journal of Wildlife Diseases readers. The reviews are subjective assessments and do not necessarily reflect the opinions of the editors, nor do they establish any official policy of the Wildlife Disease Association.

Book reviews express the opinions of the individual authors regarding the value of the book's content for Journal of Wildlife Diseases readers. The reviews are subjective assessments and do not necessarily reflect the opinions of the editors, nor do they establish any official policy of the Wildlife Disease Association.

What is this summary about? This summary explains what both people living with hepatitis C and doctors think is meaningful when treating hepatitis C in Japan. We asked people living with hepatitis C and doctors about their opinions on hepatitis C treatment using a questionnaire. What was the study question? "What do people living with hepatitis C in Japan and their doctors consider most meaningful when choosing treatment?" Why was it asked? Understanding what people living with hepatitis C and doctors value when choosing hepatitis C treatment may help support continuing treatment, which is important for eliminating hepatitis C. What were the results? Among 95 people living with hepatitis C and 118 doctors, both groups thought that the total out-of-pocket costs for hepatitis C treatment was the most meaningful thing. Safety was ranked as the next most meaningful thing. People living with hepatitis C were more concerned about costs for treatment and less concerned about side-effect risks than doctors. People living with hepatitis C cared more about the number of tablets they had to take each day than the duration of treatment. For doctors, both were about the same. What do the results mean? For people living with hepatitis C, treatment costs are the most important concern. Improving awareness of Japan's financial assistance programs may help reduce out-of-pocket costs for hepatitis C treatment, thereby making it easier for people living with hepatitis C to receive treatment. Providing care that is adjusted to the situations, concerns, and treatment goals of people living with hepatitis C may help reduce barriers and gaps in hepatitis C treatment. Simple treatment options, such as one pill a day and/or minimized hospital visits during treatment course can make hepatitis C treatment more accessible. Good communication between people living with hepatitis C and doctors may help them make treatment decisions together, based on clear explanations of options and what matters most to people living with hepatitis C. In 2016, the World Health Organization (WHO) set a goal to eliminate HCV as a public health threat by 2030. These efforts will support achieving the goal in Japan.

Routine semen analysis provides limited diagnostic and prognostic insight into male reproductive potential, contributing to the increasing use of sperm DNA fragmentation (SDF) testing in fertility evaluation. However, the clinical application of SDF testing appears to outpace the strength and consistency of the supporting evidence. This opinion paper critically appraises SDF testing through established screening, diagnostic, and prognostic test-performance frameworks, drawing on published observational studies, meta-analyses, and international guideline statements across natural conception and ART. The available evidence indicates that SDF testing does not meet the criteria for population-level screening or for routine diagnostic or prognostic use in unselected infertile populations and is frequently applied beyond its validated scope. Interpretation is further limited by assay heterogeneity, lack of standardization, variable thresholds, reliance on surrogate outcomes, and the limited effectiveness of available interventions. Routine implementation therefore risks overdiagnosis, unnecessary interventions, and premature escalation to assisted reproduction without proven benefit. When applied selectively within an aetiology-driven framework, particularly in defined subgroups, SDF testing may provide adjunctive risk stratification rather than deterministic clinical guidance. All stakeholders must be made aware of these limitations before the test is offered, interpreted, or used to modify treatment.

Acute bacterial skin and skin structure infections (ABSSSI) are common infections associated with relevant clinical and organizational burden. Their management requires appropriate antibiotic therapy and integrated healthcare organization; however, real-world practices remain heterogeneous. The objective was to explore current clinical and organizational practices in ABSSSI management across expert Italian centres, identifying strengths, critical issues, and unmet needs through a multicentre survey with expert interpretation. A structured 107-item questionnaire was administered via e-mail to 9 Italian centres with consolidated experience in ABSSSI management. A single senior specialist provided a comprehensive response for each centre. Findings were subsequently discussed by a multidisciplinary group of key opinion leaders to contextualize results and identify priority areas for improvement. Marked heterogeneity was observed across centres in organizational models and care pathways. Infectious Diseases specialists were central to management, although 24/7 availability was limited. Access to microbiology services and vulnology support varied across centres. No centre reported fully structured ABSSSI care pathways, although informal internal manuals were common. Dedicated multidisciplinary teams were present in a minority of centres. Structured communication with general practitioners and defined hospital-to-community pathways were generally lacking. Monitoring systems and dedicated databases were inconsistently implemented, with limited pharmacoeconomic evaluation. This multicentre survey highlights substantial variability in ABSSSI management across Italian expert centres, with key gaps in care pathways, specialist availability, and data collection. Addressing these issues may improve standardization and efficiency of care.

This study investigated the financial impact of introducing the once-daily single-inhaler triple therapy (SITT) fluticasone furoate/umeclidinium/vilanterol (FF/UMEC/VI) in Saudi Arabia for adult patients with uncontrolled asthma. The expected 5-year budget impact of introducing FF/UMEC/VI for asthma was modeled using an epidemiology-based approach that included both acquisition and efficacy-related costs. Year-on-year costs were estimated for 2026 through 2030. Changes in healthcare resource utilization after FF/UMEC/VI introduction were estimated from the expected change in asthma control reported in the Phase IIIa CAPTAIN trial. The perspective of the model was the Saudi national healthcare payer; only direct medical costs were included. The robustness of the model was tested using sensitivity and scenario analyses. It was estimated that in 2026, 12,108 patients in Saudi Arabia would receive FF/UMEC/VI, which will likely increase over subsequent years (2027: 29,615 patients; 2028: 31,191 patients; 2029: 32,938 patients; 2030: 34,727 patients), as validated by local expert opinion. The introduction of FF/UMEC/VI was estimated to save a total of United States Dollars (USD) 10,654,389 over 5&#x2009;years, or USD 16.32 per patient, with savings increasing each year after introduction. Drug acquisition costs contributed to the greatest impact on the budget, and the model was most sensitive to changes in the market uptake of FF/UMEC/VI. Across all sensitivity and scenario analyses, FF/UMEC/VI was consistently cost saving. Various model inputs could not be derived from published sources, so multiple assumptions were used. Future market share was estimated from current competitor market share data; as FF/UMEC/VI is the first SITT for asthma to be introduced into Saudi Arabia, there is no historical data on which to base these estimates. Introducing FF/UMEC/VI in Saudi Arabia has the potential to deliver meaningful clinical and economic benefits at both the individual patient and healthcare system level.

Health professions educators widely agree that inquiry must be fostered in trainees, yet fundamental questions remain about how to cultivate it as a habit. This scoping review examined instructional approaches to teaching inquiry in medicine and nursing through the lens of John Dewey's philosophical framework, which conceptualizes inquiry as comprising both a five-phase method and a psychological attitude toward inquiry methods. Our analysis of 103 articles describing inquiry-focused educational interventions in medical and nursing education shows that, beyond clinical reasoning and evidence-based practice, current approaches predominantly emphasize research participation, focusing on building knowledge and skills in inquiry methods while largely neglecting two critical components of Deweyan inquiry. First, interventions rarely engage learners in the initial phase of recognizing and experiencing uncertainty-the crucial starting point that drives authentic inquiry. Second, despite well-established links between attitudes and behavior, promoting positive attitudes toward inquiry methods was rarely an explicit educational objective. We conclude that teaching inquiry purely as a method, without attending to the formative experiences of uncertainty and attitude development, falls short of cultivating inquiry as a sustained professional habit. Future educational interventions can be strengthened by explicitly designing for awareness of uncertainty, including clear attitudinal objectives, and measuring not only the skills acquired but also the attitude formed toward inquiry methods.

This study explored emergency nurses' lived experiences and perceived challenges during the triage process. This qualitative study was conducted with 25 emergency department nurses at Atat&#xfc;rk University Research Hospital. Criterion sampling was used to include nurses with direct triage experience. Data were collected through face-to-face, semi-structured interviews and analyzed using Colaizzi's descriptive phenomenological method. Significant statements were extracted, meanings were formulated, and these were organized into theme clusters. To enhance credibility, 2 researchers conducted the analysis independently, and a consensus was reached through discussion. Four main themes, 10 sub-themes, and 35 codes were identified. Nurses reported multiple challenges, including lack of institutional support, high patient load, time pressure, and patient dissatisfaction. Decision-making was influenced by both environmental and individual factors. Triage assessment involved a combination of subjective judgment and objective tools. Common errors included misdirection and insufficient questioning. Nurses also suggested improvements related to staffing, training, and organizational conditions. Triage was experienced as a complex and demanding process shaped by workload, time pressure, and limited support. Findings highlight the importance of organizational and contextual factors in shaping triage practices.

The integration of artificial intelligence (AI) in education depends on teachers' cognitive, affective, and motivational dispositions toward complex digital tools, yet limited research has examined how school leadership shapes these mechanisms. This study tested an integrated model positioning digital leadership as an environmental antecedent and combining the Unified Theory of Acceptance and Use of Technology 2 (UTAUT2) with the General Extended Technology Acceptance Model for E-Learning (GETAMEL) to explain teachers' behavioral intention to adopt AI-based educational technologies. A cross-sectional survey was administered to 477 teachers working in public and private schools in T&#xfc;rkiye. The model included digital leadership, self-efficacy, anxiety, perceived enjoyment, subjective norm, experience, perceived usefulness, perceived ease of use, attitude, facilitating conditions, habit, price value, and behavioral intention. Measurement and structural models were evaluated using Structural Equation Modeling. The integrated model demonstrated good model fit and explained 61% of the variance in behavioral intention, outperforming standalone UTAUT2 and GETAMEL models. Digital leadership positively predicted self-efficacy, perceived enjoyment, subjective norm, experience, and behavioral intention, while negatively predicting technology-related anxiety. Self-efficacy, enjoyment, experience, subjective norm, and anxiety influenced perceived usefulness and perceived ease of use. Perceived usefulness, perceived ease of use, and attitude were strong predictors of behavioral intention, while facilitating conditions, habit, and price value also directly contributed to intention. Teachers' AI adoption is shaped not only by perceived utility but also by emotional regulation, intrinsic motivation, social expectations, and routinization processes. The findings suggest that school leaders should provide hands-on AI training, school-based support structures, low-risk experimentation opportunities, and clear school-level guidance to strengthen teachers' readiness for AI adoption.

The emergence of high-cost therapies, particularly in oncology, rare diseases, and advanced therapy medicinal products, has increased the need for robust pharmacoeconomic evaluations to support healthcare decision-making. These innovative interventions often promise substantial clinical benefits but also pose challenges due to limited long-term data, high upfront costs, and uncertain cost-effectiveness. This narrative review critically examines key pharmacoeconomic frameworks, e.g. cost-effectiveness analysis and cost-utility analysis, and highlights their limitations in assessing such novel therapies. The role of real-world evidence, advanced modeling techniques, and patient-reported outcomes is explored, alongside the ethical and policy considerations that arise in pricing, access, and reimbursement. Recent literature and case studies involving gene and cell therapies are reviewed, illustrating the complexity of determining value under uncertainty. The paper advocates for a more flexible, transparent, and patient-centered approach to health technology assessment, integrating societal values and dynamic reassessment mechanisms. Such strategies are essential for achieving sustainable access to high-value therapies while maintaining health system efficiency and equity.

General practitioners (GPs) frequently serve as the first or only point of contact for patients with mental health disorders, playing crucial roles in detection, prevention, and management. Despite this, many GPs feel poorly prepared to address mental health issues, often citing the barriers of limited time, heavy workloads, and insufficient training. The present study's main objective was to make an in-depth exploration of the potential difficulties encountered by GPs as they manage and follow up with patients with mental health problems. Our qualitative approach involved semi-structured individual interviews with 17 GPs from French-speaking Switzerland. Interviews were transcribed and analysed using reflexive thematic analysis within an inductive theoretical framework. Once the most important themes and subthemes had emerged, we externally and internally validated them. Four principal themes emerged. GPs reported that: (i) they enjoyed caring for patients with mental health issues, valuing their unique position in providing comprehensive, long-term support; (ii) they faced significant systemic barriers, including frustration with limitations related to Switzerland's health assurance scheme; (iii) collaboration with psychiatrists was lacking and resources were insufficient; and (iv) they required help and new ideas to improve the quality of their care. GPs' experiences revealed a mixed reality: their dedication to patient care existed alongside their frustration with systemic constraints, highlighting the complexity of mental health management in primary care. Sustainable improvements would require addressing gaps in caregivers' training, greater interprofessional collaboration, and more public health initiatives to mainstream mental health care into society.

Iron-deficiency anemia is the most common micronutrient deficiency and a leading cause of disability-adjusted life years among adolescent girls and young women (AGYW) globally. Although multiple micronutrient supplementation (MMS) provides a broader range of micronutrients than iron-folic acid supplementation (IFAS) prior to conception, the acceptability of MMS and home-based supplementation strategies remains underexplored. We assessed the acceptability of MMS, IFAS, and a contextualized nutrition curriculum delivered via school clubs in a two-arm cluster-randomized trial across three rural secondary schools in Monapo District, Mozambique. Fourteen teachers (clusters) were randomized to deliver either weekly school-based IFAS or daily home-based MMS. A total of 492 AGYW aged 13-20 years were enrolled (240 IFAS; 252 MMS); both arms received the same nutrition curriculum. Participants in both arms reported increased energy, improved appetite, and relief from menstrual symptoms. IFAS was significantly more acceptable than MMS for smell, and some participants perceived the once-weekly IFAS regimen as less burdensome than daily MMS. Some AGYW also reported that male peers perceived MMS as birth control, or assumed the girls were pregnant, due to the image of a pregnant woman on the pill bottle. Ratings of the nutrition curriculum and teachers' facilitation were positive in both arms. Participants generally preferred the regimen they were assigned, and family support facilitated adherence. These findings suggest home-based supplementation may be a feasible and acceptable strategy for reaching in-school and out-of-school AGYW in Mozambique. Including boys in future interventions and redesigning the MMS label could help reduce misconceptions and enhance acceptability.

Cervical cancer remains a leading cause of cancer-related mortality among women in Sub-Saharan Africa, despite the expansion of H uman papillomavirus (HPV) vaccination and screening programmes. While HPV is a necessary cause of cervical cancer, prevention strategies that focus exclusively on HPV risk overlooking female genital schistosomiasis (FGS), a neglected tropical disease affecting millions of women and girls in schistosomiasis-endemic regions. FGS causes chronic genital inflammation and mucosal damage that may increase susceptibility to HPV infection, complicate cervical cancer screening, and contribute to diagnostic misclassification, yet female genital schistosomiasis is rarely considered in cervical cancer prevention policies or clinical algorithms. In this Comment, we argue that integrating FGS diagnosis and prevention into HPV-based cervical cancer strategies is essential for achieving equitable progress towards the World Health Organization cervical cancer elimination targets in Africa. Addressing FGS represents a pragmatic, gender-responsive, and context-specific opportunity to strengthen cervical cancer prevention across endemic settings.

There is a pronounced gap between demand and actual mental health service utilization, with earlier estimates suggesting that nearly 90% of affected individuals with depression or anxiety do not receive the care they need despite being the most prevalent and highest contributor for global burden. The present study aims to identify contact coverage gap and explore barriers while seeking care among those who screen positive for depression and anxiety. A community-based cross-sectional study was conducted among 1304 adults aged 20-60 years who had resided in Kailali, Nepal for at least 6 months. Multistage random technique was utilized to select the participants from three rural municipalities and three municipalities. Depression and anxiety were assessed by using widely recognized screening tools, namely, the Patient Health Questionnaire-9 (PHQ-9) and the Beck Anxiety Inventory (BAI). Barriers to care were measured using the Barriers to Access to Care Evaluation (BACE). Out of 1304 study participants, around 15.2% were screened positive for at least one (depression and/or anxiety) illness. Screening positive for depression (13.3%) was higher than anxiety (7.5%). Only 28.3% of individuals who were positive for anxiety and/or depression contacted with service providers. Among those who sought care, most had visited traditional healers (98.2%). Major barriers to care were unaffordable cost (38.4%), self-solving attitude (22.2%), preference for alternative types of care (21.7%), busy schedule with work (16.7%), speculating it will resolve itself (15.2%), and not being sure where to seek for mental health services (12.6%). Contact coverage was significantly associated with morbidity and lack of awareness on available services. There was a significant contact coverage gap in mental health care, as we found that only 28.3% of adults who tested positive for depression and/or anxiety had contact with any provider, largely due to barriers such as financial constraint, busy schedule, self-reliant attitude, preference for traditional healing, and lack of awareness on available services. These results warrant efforts to close the gap in coverage for care through addressing barriers.

Advances in paediatric intensive care have resulted in a growing population of survivors exposed to long-term morbidity. Paediatric post-intensive care syndrome (PICS-p) encompasses new or worsened physical, cognitive, psychological/psychiatric, and socio-familial impairments that may affect children and their families after discharge from the paediatric intensive care unit (PICU). Despite increasing recognition of PICS-p, post-PICU follow-up remains highly heterogeneous worldwide, and systematic screening and management strategies are rarely integrated into routine care. These guidelines were issued at the initiative of the French national health authority (Haute Autorit&#xe9; de Sant&#xe9;: HAS) to improve the prevention, identification, and management of PICS-p. Clinical practice guidelines developed following the HAS standardized methodology (Recommandations de Bonne Pratique), including systematic literature review, multidisciplinary expert elaboration, formal external review, and HAS board approval. Reporting follows the AGREE II framework. Clinical questions were predefined by HAS project leads. A systematic literature search ([dates]) was conducted across Embase, EmCare, Medline, and the Cochrane Library, prioritising guidelines, meta-analyses, and systematic reviews. Two field experts drafted initial recommendations, graded A (established evidence) to Expert Opinion (absence of evidence). An 18-member multidisciplinary working group refined the draft through two in-person meetings. A 52-member external review panel formally voted on agreement for each recommendation. The final version was approved by the HAS board. Fourty recommendations were issued: 5 with a moderate level of evidence (grade B), 8 low level (grade C) and 27 very low (expert opinion). Strong agreement by the panel of experts was achieved for all recommendations except for one (moderate). The recommendations define PICS-p as a prevalent, multidimensional condition and emphasize systematic, repeated screening of children and families from PICU admission through the first year after discharge. Key preventive strategies include implementation of ABCDEFGH bundle, early mobilization, optimized analgesia and sedation, delirium prevention, and family-centred psychological support. Structured care pathways and pragmatic screening tools are proposed to ensure continuity of care. These guidelines emphasize the importance of structured, multidisciplinary, and family-centred strategies, to improve the prevention, early identification, and management of PICS-p and optimize long-term outcomes for children and their families.

This report examines the evolution of Spain's relationship with Europe and the European Union (EU), as well as the rise and impact of populism and Euroscepticism within its political system. Following the democratic transition, European integration became a central pillar of Spain's modernization and political legitimization, supported by a broad consensus among both elites and public opinion. Since joining the European Economic Community in 1986, support for the EU has remained consistently high, albeit sometimes characterized by limited public engagement. This consensus began to weaken after the 2008 financial crisis, which created opportunities for the emergence of new populist actors. In this context, Podemos on the radical left and Vox on the radical right gained prominence. Both parties incorporate elements of Euroscepticism, though in distinct ways. Podemos advances a form of soft Euroscepticism, criticizing neoliberal EU policies and political elites while maintaining a fundamentally positive view of the European project and advocating institutional reform. In contrast, Vox promotes a more nationalist and confrontational discourse, portraying EU elites as part of a "globalist" agenda and advocating a restructuring of the EU toward greater national sovereignty. Despite the rise of these challengers, mainstream parties-namely the PSOE and the PP-have maintained strong pro-European positions. Although they have adopted partially accommodative strategies in response to political competition, they have not significantly altered their support for European integration. Overall, Spain continues to exhibit a predominantly pro-EU political system and public opinion, where Euroscepticism, while increasingly visible, remains largely moderate in nature.

Model-Informed Precision Dosing (MIPD) has improved individualized therapy, but in critical illness its reliance on intermittently updated data creates a temporal mismatch between pharmacokinetic (PK) models and rapidly evolving physiology. Synthesizing population pharmacokinetic (popPK) and data science literature, we examine the limitations of snapshot-based dosing, using vancomycin as example. We propose the Dynamic Living Digital Twin (DLDT) framework, which integrates high-frequency electronic health record data into adaptive state-space models such as Kalman filtering. Rather than adding more covariates, the DLDT reframes patient physiology as a continuously evolving latent state that can be updated using temporally dense clinical data. Methodological, infrastructural, and regulatory Software as Medical Device (SaMD) barriers are also evaluated. A non-systematic PubMed search identified relevant publications available up to March 2026. The next advance in precision dosing will come from temporally adaptive PK reasoning. In this paradigm, patient physiology is treated as an evolving latent state, and clinical pharmacists may increasingly interpret exposure trajectories rather than isolated dose recommendations. Although technically feasible, implementation remains constrained by data interoperability and workflow integration challenges. Clinical pharmacists may therefore increasingly act as stewards of dynamic model outputs, using anticipated exposure trajectories to preempt PK shifts.