This exploratory study examined five potential problems with attorneys' questions and 5- to 9-year-old children's responses to before/after questions in 156 child sexual abuse trials. Two problems have received some attention in prior research: the extent to which children were asked to backward sequence through before questions, and order of mention, which considers whether the order in which two events were mentioned in the question matched the order in which the events purportedly occurred. We found that 43% of before/after questions included before, and 55% of questions asking about two events violated order of mention. We also examined three issues involving potential ambiguity that have been overlooked: grain size ambiguity, in which the temporal interval to which before/after refer is unspecified; reference time ambiguity, in which before/after could refer to a prior time or the time when the question is asked; and focal ambiguity, in which the before/after question could be asking about sequence or occurrence. Eighty-four percent of questions exhibited grain size ambiguity, 18% of questions exhibited reference time ambiguity and 40% of questions exhibited focal ambiguity. Overall, 78% of before/after questions were option-posing and 84% of children's responses to those questions were unelaborated, which makes disambiguation of responses difficult. Even when questions were unambiguous, we found suggestive evidence that words used to specify grain size or reference time created other difficulties for children. The results highlight the need for additional research examining difficulties in before/after questions, and for educating attorneys and others who interview children about subtle difficulties.
When forensic mental health professionals find themselves working with seemingly impaired attorneys, a substantial dilemma is presented. The forensic professional must consider how, if at all, to respond to legal performance deficits that may reflect dementia, a substance use disorder, a mood disorder, or some other identifiable psychiatric condition. Two de-identified cases are presented that highlight the difficulty of providing expert witness and consultation services under such circumstances. Codified ethics guidance for attorneys, psychiatrists, and psychologists offers relevant, albeit rather limited, direction. Several overlapping options are proposed, including discreet inquiry, frank discussion, treatment referral, and withdrawal from participation.
In 2018, California passed Assembly Bill 1810, creating a pathway for pretrial diversion of individuals with mental health disorders. State statute dictates certain aspects of diversion eligibility and implementation. However, implementation of diversion occurs at the county level and counties have some degree of discretion as to how they implement the policy. This study conducted a qualitative implementation assessment of the contextual factors that have shaped the implementation of the state's mental health diversion policy. We recruited nine counties and conducted semistructured interviews with a total of 29 implementation partners. Qualitative coding was conducted to explore themes related to program implementation and these codes were analyzed using the Consolidated Framework for Implementation Research. An early challenge to the implementation process was the need to create infrastructure to support diversion and ensure oversight of mental health evaluations, treatment plans, and client progress. Many counties started with a decentralized process but found that standardizing the process was an important facilitator (e.g., having a dedicated judge for diversion cases). Some of the key implementation barriers related to perceptions of prosecutors and concerns related to public safety; however, even defense attorneys must balance diversion with other options their clients have (e.g., taking a plea in exchange for a short sentence). Jurisdictions implementing new mental health diversion programs can draw on the implementation science and literature related to other programs, such as drug courts, to address these implementation barriers. (PsycInfo Database Record (c) 2026 APA, all rights reserved).
In March 2025, the National Institute of Standards and Technology (NIST) published a series of primers designed to provide judges and attorneys with a neutral source of information on foundational forensic-science principles. Unfortunately, the primer on "Probability and Likelihood Ratios" gives a misleading negative portrayal of the likelihood-ratio framework. This perspectives paper refutes that misleading portrayal.
Canada's federal government recently proposed allowing Health Canada to deem certain drug submission requirements met based on foreign regulatory decisions. Proponents frame this as a solution to delayed drug access. Yet the major contributors to delayed access to new drugs in Canada are manufacturers' late submissions and prolonged public reimbursement processes-not regulatory review times. This Policy Comment argues that the proposal targets the wrong stage of the access pipeline. We propose feasible alternatives - earlier filing incentives, enforceable reimbursement clocks, and a pan-Canadian listing default - that would meaningfully accelerate patient access to new therapies in Canada.
The network approach to psychopathology conceptualizes mental disorders as systems with causally interacting symptoms. While the temporal stability of symptom networks has been examined in single-culture samples, no research has compared stability patterns across cultural contexts. Using longitudinal data from the Midlife in the United States (MIDUS; N = 673) and Midlife in Japan (MIDJA; N = 197), we estimated depression networks using four CES-D subscales (Depressed Affect, Positive Affect, Somatic Symptoms, Interpersonal Problems) at two time points (T1 and T2). Temporal stability was assessed using the Network Comparison Test and correlations between edge weights and centrality indices. Depression networks demonstrated high temporal stability in both samples, with edge weight correlations of r = 0.945 (MIDUS) and r = 0.902 (MIDJA) and centrality correlations of r = 0.957 (MIDUS) and r = 0.864 (MIDJA). Positive Affect showed moderate negative connections to other subscales in the American sample but was functionally independent in the Japanese sample across both time points. The Depressed Affect-Somatic connection was the strongest edge in both cultures but notably stronger in Japan. The MIDJA sample was relatively small, measurement intervals differed between samples, and findings may not generalize beyond these specific midlife populations. Depression symptom networks show high temporal stability within cultures while exhibiting stable cross-cultural differences in specific-symptom connections. The functional independence of positive affect in Japanese samples has implications for cross-cultural assessments and culturally adapted interventions.
The present research aimed to develop a psychometrically sound measure of moral injury for lawyers. In study I, deductive and inductive approaches were used to generate an initial item pool. Furthermore, the item pool was reviewed and finalized with the help of experts' opinions. In order to explore factor structure and ensure psychometric properties of the scale, a purpose sample comprised of lawyers (N = 226, mean age = 31, SD = 5.2) was recruited. Results indicated a three-factor structure of moral injury-betrayal, transgression, and value system conflict. Four items were retained in each factor: betrayal (1,2,3,4), transgression (5,6,7,8), and value system conflict (9,10,11,12). In study II, another independent sample was recruited to confirm the factor structure. The three-factor structure produced by EFA was found to fit the data with three-factor solution with initial item loadings > 0.40. The Chi-square value was 70.41 (df = 51), with CFI = 0.97, GFI .95, TLI = 0.96, RMR = 0.01, and RMSEA = 0.04. The alpha reliability of the overall scale and subscales was 0.78, 0.70, 0.82, and .74, respectively. Study III demonstrated evidence of convergent and discriminant validity. Positive correlation of moral injury with pathological lying (r = 0.50, p < 0.01) and decisional fatigue (r = 0.49, p < 0.01) ensured its convergent validity, while a non-significant relationship with internet addiction provided evidence of discriminant validity.
Voice acts as a tool of trade among professionals. Consequently, people in such professions are more likely to experience vocal problems due to their frequent use of voice. Early intervention and preventative care can help patients avoid developing more serious vocal pathologies. The study aimed to provide vocal hygiene training (VHT) and determine its impact on reducing voice-related problems and improving voice quality among professionals in Pakistan. A quasi-experimental study was conducted among teachers, lawyers, and telemarketers who screened positive on Voice Handicap Index (VHI) and were divided into two groups: experimental and control, each having 30 participants from a specific profession. Literature-based VHT designed to improve the physical, emotional, and functional aspects of voice was provided to each of the three experimental groups. The post-assessment was conducted after a total of four training sessions, 20-35 minutes each, provided fortnightly. A significant decline in VHI scores, ie, 76.60 to 48.27 among teachers, 64.54 to 38.20 among lawyers, and 57.27 to 32.77 among telemarketers, has depicted a positive impact of VHT on voice problems. The findings strongly suggest that VHT had a significant impact on improving the quality of voice. Such techniques are suggested for embedding in the daily routine of professionals.
Sedation during mechanical ventilation is common in intensive care units (ICUs). Functional near-infrared spectroscopy (fNIRS) has shown potential in monitoring brain function. This study aimed to evaluate and compare the brain functional connectivity (FC) characteristics in different sedated patients using fNIRS. Thirty sedated patients in the ICU and 16 conscious, non-sedated patients from the emergency ward were enrolled. Sedated patients were assigned to insufficient sedation (+ 1 to + 4), light sedation (-2 to 0), or deep sedation (-5 to -3) groups based on the Richmond Agitation Sedation Scale. Six-minute resting-state light intensity signals were collected using fNIRS and converted into a time series of relative oxyhemoglobin concentrations. FC characteristics of the overall brain and six regions of interest (ROIs) were compared using Pearson's correlation coefficients calculation. Multiple comparisons were corrected using the False Discovery Rate method. The deep sedation group had the highest overall mean FC compared with the other groups, which may be associated with the alterations of sedatives on cortical activity. ROI-level analyses revealed higher FC in the prefrontal, parietal, and occipital cortices in the deep sedation group than in the other groups. The deep sedation group had higher channel-channel and ROI-ROI FC in the FC matrices than the other groups. ROI-ROI connections differences were observed between the deep sedation and insufficient sedation groups. No significant difference in FC was identified between the light sedation group and the conscious control group. Deep sedation exhibited the highest overall and regional FC, and light sedation and the conscious state had similar FC patterns, supporting the potential utility of fNIRS for sedation monitoring in the ICU setting.Trial registration: ChiCTR2300068437 registration May 15, 2023, https://clinicaltrials.gov/ct2/show/ChiCTR2300068437.
This cross-sectional study explores expenditures, negotiated pricing, and potential additional savings for top-selling cancer products in Medicare Part B and Part D.
This 'How to' article explains how to perform a thorough and legal mental capacity assessment for adults in a safe, effective and supportive manner. Nurses undertaking this assessment must ensure they have the appropriate knowledge and skills, and must work within the limits of their competence. • Nurses should ensure they fully understand the definition of the phrase 'lacks capacity'. • A person must be assumed to have capacity unless it is established that they lack capacity. • A person must not be treated as unable to make a decision unless all practicable steps to help them do so have been taken without success. REFLECTIVE ACTIVITY: 'How to' articles can help to update your practice and ensure it remains evidence-based. Apply this article to your practice. Reflect on and write a short account of: • How this article might improve your practice when undertaking a mental capacity assessment. • How you could use this information to educate nursing students or your colleagues on what constitutes a thorough and legal mental capacity assessment.
In March 2020, the US Food and Drug Administration (FDA) issued a boxed warning for montelukast amid reports of neuropsychiatric adverse effects. To determine whether a boxed warning for montelukast was associated with changes in prescription rates of montelukast to treat asthma in the US. In this serial cross-sectional study using a national commercial insurance claims database, monthly cohorts of individuals aged 6 years and older with an asthma diagnosis and continuous insurance coverage in the past year were created from October 2017 to December 2022. Results were stratified by age group, inhaled corticosteroid (ICS) use, and 1 or more asthma-related emergency department visit or hospitalization in the prior year. Data were analyzed from August 2024 to June 2025. Announcement of a boxed warning for montelukast in March 2020. Monthly incidence and prevalence of montelukast use among patients with asthma. Data were analyzed with an interrupted time series analysis using segmented ordinary least-squares linear regression models with Newey-West standard errors. The number of patients with asthma ranged from 594 253 in October 2017 to 614 637 in December 2022. In October 2017, 348 359 patients (58.6%) were female, 113 913 (19.2%) were younger than age of 18 years, 292 730 (49.3%) used an ICS, and 105 869 (17.8%) had 1 or more asthma-related emergency department visit or hospitalization in the prior year. The baseline monthly prevalence of montelukast use was 160.0 per 1000 patients with asthma, and the baseline incidence of new montelukast use was 5.8 per 1000. After the boxed warning, the level of monthly incident montelukast prescriptions decreased by 1.7 (95% CI, -2.2 to -1.3) per 1000 and the trend in montelukast prevalence decreased by 0.9 (95% CI, -1.1 to -0.6) per 1000 per month relative to the prewarning trend. The trend in prevalent montelukast use decreased after the boxed warning across all age and asthma severity subgroups. In this cross-sectional study of commercially insured patients with asthma, an FDA boxed warning for montelukast was associated with changes in asthma treatment use among patients of all ages.
Several studies have documented racial and cultural inequities in the receipt of palliative care. With expanding home-based palliative care programs spreading across the United States and in other countries, understanding barriers to enrollment of diverse populations and promising practices to overcome these barriers is critical. To identify barriers to enrolling diverse patients in home-based palliative care, and to elicit successful strategies and best practices in engaging and communicating with diverse populations about palliative care. We conducted a qualitative study employing nine focus groups with staff from nine home-based palliative care agencies in Hawaii. Interviews were conducted via video conferencing and audio recorded. Using thematic analysis, we identified core themes related to challenges and best practices of engaging minorities in palliative care services. Barriers to care acceptance included perceptions of "giving up," lack of knowledge of palliative care, cultural values and attitudes, language barriers, and issues of healthcare accessibility and equity. In response, we identified facilitators and recommendations to care which highlighted the importance of community leader involvement, respect for patient and family-centered care, building trust and ensuring continuity in care, having staff and materials in diverse languages, in-person conversation about palliative care services, and the active engagement of family in healthcare decision-making. These findings highlight the importance of considering cultural factors in the provision of care and underscore the necessity for culturally sensitive, patient-centered approaches to hospice and palliative care.
Although there has been growing interest in better understanding risk factors for progression from psoriasis (PsO) to psoriatic arthritis (PsA), research on the role of ambient temperature in potentiating PsA risk has been limited. We sought to evaluate the association of average-annual ambient temperature exposure with prevalent PsA diagnosis among a large cohort of US adults with PsO. We studied electronic health record-data from participants with PsO, with and without an associated PsA diagnosis, who enrolled in the National Institutes of Health's All of Us Research Program between May 31, 2017, and July 1, 2022. Average-annual ambient temperature exposure data was obtained from the National Oceanic and Atmospheric Administration. Multivariable logistic regression analysis was utilized to assess the association between three-digit Zone Improvement Plan (ZIP) code-level ambient temperatures and prevalent PsA diagnosis, controlling for patient age, sex, body mass index, smoking history, race and ethnicity, income, urbanicity, and community deprivation. In this cohort of 5466 patients with PsO (mean age [SD], 61.86 years [15.45 years]; 3153 females [57.7%]) and 1080 patients with both PsO and PsA (mean age [SD], 60.76 years [13.48 years]; 665 females [61.6%]), each 1°F increase in average-annual ambient temperature was associated with 2% increased odds of prevalent PsA diagnosis (adjusted odds ratio [aOR], 1.02; 95% CI, 1.01-1.03). Our study provides data to support further investigation of long-term, warmer ambient temperature exposure as a potential risk factor for PsA among those with PsO.
There is growing concern that artificial intelligence (AI) may diminish the quality of human relationships. However, in a context of widespread social importance (empathetic conversations between doctors and patients), AI can actually improve human conversational skills, potentially enhancing professional relationships. Recent advances in AI allow for realistically role-prompted counterparts for practicing professional conversations, enabling relational learning without the need for human counterparts. This study aimed to show the effectiveness of AI chatbots for learning professional communicative skills in medical education. Specifically, we hypothesized that a single conversation with an AI chatbot improves communication skills in medical students across 4 different conversational competencies. We conducted a quasi-experimental intervention study involving 4 distinct role-prompted scenarios (ie, shared decision-making, motivational interviewing, sexually transmitted diseases, and breaking bad news)-each designed to elicit in-depth empathic conversational skills aligned with key learning objectives in medical curricula. Students rated their competence for the 4 scenarios before and after a conversation with GPT-4o (OpenAI) using default settings, without fine-tuning. We expected higher perceived communication competence (PCC) in their conversation topic after the interaction compared with before the interaction in a 2-sided paired t test. Participants received AI-generated feedback, which they rated regarding adequacy. Post hoc analyses addressed gender and case effects, feedback adequacy, and prevalues in PCC. This study shows that a role-prompted GPT chatbot improves PCC in 162 medical students after a single conversation with mean of 13 (SD 4.8; 95% CI 12-14) prompt-response pairs. We found an increase in PCC with a mean difference of 0.94 (SD 1.64; 95% CI 0.69-1.20; Cohen d=0.58) from 5.89 (95% CI 5.55-6.23; scale 0-10) before the conversation to 6.83 (95% CI 6.55-7.12) after the conversation across 4 different patient role prompts. Furthermore, we found participants rating AI feedback of their conversation to be useful (mean 7.92, SD 1.61; 95% CI 7.67-8.17; scale 0-10), but feedback adequacy did not correspond to PCC increase (r=0.08; P=.32). Our results demonstrate how role-prompted GPT increases self-assessed communication competencies, introducing a novel tool for teaching relational learning. Our results present a starting point for using AI in education, particularly teaching communication in professional roles. On the basis of our findings in medical education, we anticipate further studies to investigate conversational training between lawyers and clients, marketers and customers, or managers and employees. Our research thus has implications for any field with a need for conversational training and relational learning.
Our study examines modification patents across multiple New Drug Applications (NDAs), employed by pharmaceutical companies to extend patent protections. Ours is the only comprehensive study of modification patents by Active Pharmaceutical Ingredient (API) across multiple NDAs, the approach of current regulatory initiatives, investigating how these patents extend drug protections and impede generic entry. We examine 1028 modification patents, categorizing them as chemical variations, formulation changes, treatment methods, or device/agent. We tabulated additional granted protection time, correlations with new NDAs, and litigation from potential generics. On average, 5 modification patents protected each drug, extending granted protection periods by 10.9 years. Examining market outcomes for the 199 drugs with generics approved by August 2025, or whose primary patents had expired by then, modification patents provided a median of 2.3 years' median effective additional protection time before generic entry. Eighty-nine percent of drugs' protection periods were extended by modification patenting in some dimension. Fifty-eight percent had a modification patent associated with a new NDA, and 70% had at least 1 modification patent in Paragraph IV-related litigation. These findings suggest we reconsider societal resources dedicated to modification patenting, generally and during clinical decision-making. Hope for regulatory and legislative reform lies in a "one-and-done" policy and restricting certain patent types.
BackgroundAdvance care planning documentation allows individuals to communicate preferences for medical care and designate surrogate decision-makers. It is unknown if comprehensive documentation confers additional benefits.ObjectivesThis study examined additive associations between comprehensive advance care planning (ACP) documentation and end-of-life care (EOL) outcomes among older adults in the United States.Setting/SubjectsData from the Health and Retirement Study exit interviews (2010-2022) indicated ACP documentation status, based on proxy-reported completion of a living will (LW) and/or durable power of attorney (DPOA) for 5622 decedents representing 23.2 million individuals.MeasurementDocumentation was operationalized as a binary variable (any document, no document) and an ordinal variable (no documentation, one document, two documents). EOL outcomes included binary indicators of intensive care unit use in the last two years of life, use of life-sustaining treatments, hospice utilization prior to death, and location of death (out-of-hospital, hospital).ResultsAbout 42.7% decedents had two documents and 28.9% had none, documentation increased substantially around 2014. Compared with no documentation, having any documentation was associated with lower likelihood of life-sustaining treatment (aRR = 0.85, 95% CI: 0.74-0.98) and higher likelihood of hospice utilization (aRR = 1.43, 95% CI: 1.28-1.60) and out-of-hospital death (aRR = 1.11, 95% CI: 1.06-1.18), but not ICU use. Having two documents showed similar patterns. Associations were stronger among decedents with expected death and attenuated among those with unexpected death.ConclusionsACP is associated with less aggressive EOL care and greater hospice use, although the incremental benefits of having both documents are modest.
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The Third National Pediatrics Congress was held in Zaragoza in 1925. There were 208 registered delegates. Among those registered were fourteen French pediatricians and three Italian pediatricians. The president of the meeting was Dr Patricio Borobio Díaz. This paper presents an overview of the content of the conference presentations, which were divided into four sections: Pedagogy, Pediatric and Orthopedic Surgery, Hygiene, Nutrition and Child Protection, and Pediatric Medicine. In the latter section, the most common topics were infectious diseases (whooping cough, diphtheria, meningitis/encephalitis). Several papers attested to the effectiveness of ultraviolet light as a treatment for rickets and spasmophilia. Gregorio Vidal Jordana deduced that the increase in phosphatemia levels served as an exact test to verify the effectiveness of ultraviolet treatment and was superior to X-rays. Several pediatric surgeons debated the treatment of pyloric stenosis in infants. There is no record of any female pediatricians attending the Congress. Four women who were not doctors presented papers on legal and family changes in favor of children, abandoned and delinquent children, and education issues. Within the Child Protection Section, there were debates on the subject of illegitimate children and wet nursing. The conference was a harmonious international gathering where current pediatric issues were discussed alongside other topics related to child protection. Participation was diverse, with contributions from doctors, lawyers, teachers and people in other professions.
Cognitive behavioural therapy (CBT) is recommended as a first-line treatment for depression and anxiety disorders, but its utilisation under Japan's national health insurance remains poorly understood. This study aimed to describe CBT utilisation patterns, quantify regional disparities across prefectures and analyse temporal trends from fiscal year (FY)2015 to FY2023. This was a nationwide repeated cross-sectional study. Japan's National Database of Health Insurance Claims and Specific Health Checkups Open Data (NDB Open Data), FY2015-2023. All patients who received insurance-covered CBT in FY2023, with a longitudinal comparison across FY2015-2023. The primary outcomes were annual CBT claims and patient counts. The secondary outcomes included prefecture-level distribution, population-adjusted utilisation rates per 100 000 population, distribution by sex and age, monthly trends and temporal changes over 9 years. Regional variation in physician-delivered CBT was assessed using the coefficient of variation (CV) and extremal quotient (EQ). In FY2023, the total CBT claims numbered 38 045 with 8299 patients, representing only 0.14% of an estimated 6.03 million psychiatric patients. Physician-delivered CBT accounted for 99.6% (37 886 claims), whereas nurse-delivered CBT introduced in 2016 remained at 0.4% (159 claims). 13 of the 47 prefectures (27.7%) had zero or fewer than 10 claims. The population-adjusted physician-delivered CBT claims ranged from 370.96 per 100 000 in Okayama to 0.99 per 100 000 in Kumamoto, yielding an EQ of 375-fold. The CV among the 34 prefectures with measurable physician-delivered CBT was 174.8%. Despite indication expansions in 2016 and 2018, claims decreased by 9.9% from 42 216 in FY2015 to 38 045 in FY2023. Insurance-covered CBT in Japan remains severely underused, with significant regional disparities. Incremental policy measures, including indication expansions and nurse-delivered CBT, have failed to improve access. Fundamental system reforms, potentially including dedicated psychological therapy services, are needed to ensure equitable access to evidence-based psychological treatments.