Zoledronic acid (ZOL), a potent bisphosphonate, is increasingly used off-label in pediatric bone disorders, but its long-term effects on the growing skeleton remain underexplored. This study aimed to investigate the impact of ZOL dose, treatment duration, and age at treatment initiation on femoral structure and mechanical properties in growing rice rats, addressing a critical knowledge gap. Two complementary preclinical studies were performed in female rice rats. Study 1 examined dose-dependent effects by administering ZOL (0, 8, 20, 50, 125 µg/kg) every 4 weeks, starting at age 4 weeks, for up to 30 weeks. Study 2 investigated age at treatment initiation (4, 16, or 22 weeks) and durations (6, 12, or 18 weeks) using a single oncologic dose of ZOL (80 µg/kg every 4 weeks). Femoral cancellous and cortical pQCT assessed bone mineral content (BMC), volumetric bone mineral density (vBMD), area and microstructure. 3-point bending of the femoral diaphysis was used to determine biomechanical properties. ZOL increased total metaphyseal BMC, vBMD, and area, with oncologic doses (20-125 µg/kg) producing 15-25% greater increases in metaphyseal BMC than the osteoporosis dose (8 µg/kg) after 18-30 weeks of treatment. Cortical parameters (area and periosteal circumference) and mid-diaphyseal mechanical properties (ultimate load, moment of inertia) also increased when treatment began in young, growing rats and was maintained for 18-24 weeks, although clear dose-response effects were limited. When ZOL started later, skeletal responses were attenuated and required longer treatment durations to become significant. ZOL enhances metaphyseal and cortical bone properties while improving mechanical strength, particularly when treatment is initiated at an early age. The skeletal response depends on both duration and age at initiation. Notably, ZOL dose-response effects are pronounced in cancellous bone. Cortical structural and mechanical properties exhibit a nonlinear response, with significant differences observed only at extended treatment durations.
Maternal vitamin D is essential for fetal calcium homeostasis and skeletal development. The long-term impact of maternal vitamin D status during pregnancy on offspring bone health remains unclear, especially in populations with high sun exposure yet persistent deficiency. This systematic review synthesizes cohort study on the association between maternal serum 25-hydroxy-vitamin D (25[OH]D) levels during pregnancy and bone outcomes in offspring. A total of 19 cohort studies, comprising 12,835 mother-offspring pairs across diverse geographic regions, were systematically reviewed. Offspring bone health indicators included bone mineral content (BMC), bone mineral density (BMD), bone turnover biomarkers, and fracture risk, assessed using dual energy X-ray absorptiometry (DXA), quantitative ultrasound (QUS), and biochemical markers. Heterogeneity in vitamin D thresholds, measurement timing, and follow-up duration was noted. The findings were heterogeneous and often sex-specific. Some studies reported a positive association between higher maternal 25(OH)D levels and increased BMC/BMD, particularly in male offspring. Others showed no significant association after adjusting for maternal and neonatal confounders. Biomarker analyses generally supported an inverse relationship between maternal vitamin D deficiency and fetal bone turnover markers. However, evidence remains inconclusive regarding the benefits of prenatal vitamin D supplementation on long-term skeletal outcomes. Maternal vitamin D status appears to influence offspring bone development in a complex and multifactorial manner. Effects may be modified by child sex, timing of deficiency during gestation, and genetic factors. Future studies should prioritize standardized measurement protocols and expand cohort representation in under-researched regions, notably Southeast Asia, to inform public health guidelines and targeted interventions.
Accurate preoperative assessment of glenoid bone loss is critical in revision shoulder arthroplasty. The aim of this study was to evaluate the reliability of the Blueprint Revision 3D-CT planning software (Stryker, Kalamazoo, MI, USA) by comparing preoperative reconstructions with intraoperative findings. Agreement between preoperative and intraoperative assessments was analyzed for glenoid containment status, comparing 2D-CT and 3D reconstructed images derived from CT imaging (3D-CT) with intraoperative findings. Forty-seven patients undergoing revision of the same stemless anatomic total shoulder arthroplasty with a cemented polyethylene glenoid component were included in this analysis. Glenoid bone defects were classified using the established systems according to Antuña and Williams-Iannotti. Defect containment (contained vs. uncontained) was assessed preoperatively using 3D-CT and 2D-CT imaging and compared with intraoperative findings. Agreement between different imaging methods was evaluated using Cohen's kappa coefficient (κ). The most common indication for revision was glenoid loosening (79%), with a mean time to revision of 7 ± 3 years. Intraoperative evaluation classified 68.1% of glenoid defects as contained, which was correctly depicted in 80.9% of 3D-CT and 65.9% of 2D-CT. Agreement between 3D-CT and intraoperative findings was moderate (κ = 0.58, 80.9%) and outperformed 2D-CT (κ = 0.37, 65.9%). Agreement between 3D-CT and 2D-CT was also moderate (κ = 0.48, 72.3%). 3D-CT-based preoperative planning using Blueprint Revision demonstrates higher agreement with intraoperative findings compared to traditional 2D imaging. These findings support the value of advanced 3D planning tools in evaluating glenoid containment and guiding surgical decision-making in revision shoulder arthroplasty.
Effective physician-patient communication is essential for high-quality medical care. However, digital transformation and the increasing use of tools based on artificial intelligence (AI) require new competencies that are not yet systematically integrated into medical curricula. Blended learning formats may offer a promising approach to addressing both patient-centered and technology-related communication skills. In this pilot study, sixth- and eighth-semester medical students (n = 6) participated in an NKLM-based blended learning elective course. The course combined H5P online modules on narrative and AI-related communication with face-to-face sessions involving standardized patients and structured feedback. A mixed-methods evaluation was conducted to assess feasibility and explore learning outcomes. This included a pre-post questionnaire assessing subjective competence gains and an objective structured clinical examination (OSCE) comparing intervention participants with a control group. The blended learning format was successfully implemented and completed by participating students. Pre-post analyses showed increases across all assessed domains, with larger absolute gains in competencies related to digital innovations than in narrative communication skills. In the OSCE, communication competencies were generally demonstrated across both groups, with the largest performance differences observed in AI-related counselling tasks and consultation closing. This pilot study supports the feasibility and acceptability of the integrated blended learning course. Exploratory findings suggest potential benefits for both narrative and digital communication competencies, with the strongest gains observed in digital communication competencies. These findings highlight the need to integrate AI- and technology-related communication skills more systematically into medical curricula. Given the exploratory design and small sample size, results should be interpreted as hypothesis-generating.
Somatic pain and depression are prevalent health concerns among Chinese adolescents. This study aims to examine the longitudinal reciprocal effects between these conditions in this population, explore the moderating role of gender, and propose recommendations to improve adolescent health. Utilizing a cross-lagged design, this longitudinal study tracked a convenience sample of seventh- and eighth-grade students (aged 12-16) from two middle schools in Sichuan between April 2023 and April 2024. Measures included the Patient Health Questionnaire (PHQ-9) to assess depression and a five-item somatic pain scale. Analytical methods comprised descriptive statistics, Harman's single-factor test, correlation analyses, t-tests, and structural equation modeling. Cross-lagged analyses reveal a dynamic interplay between somatic pain and depression over time among Chinese adolescents, with gender serving as a significant moderator in this reciprocal relationship. Specifically, among adolescent boys, depression predicts somatic pain over a one-year interval, and somatic pain similarly predicts depression. In contrast, among adolescent girls, depression unidirectionally predicts somatic pain over the same period, with no significant effect observed in the reverse direction. Additionally, the association between somatic pain and depression is significantly stronger in adolescent girls than in boys at both time points. Furthermore, adolescent girls report higher levels of both somatic pain and depression compared to boys at both time points. Somatic pain and depression exhibit a dynamic interplay over time among Chinese adolescents, with gender significantly moderating their reciprocal relationship. These findings highlight the need for gender-specific intervention strategies and underscore the importance of addressing both somatic pain and depressive symptoms with equal priority in adolescent health management programs.
To evaluate the effects of a 10-week school-based flag football programme on fitness outcomes in Chinese children aged 9 to 11 years. A two-arm, parallel-group randomized controlled trial was conducted in a public primary school in Shanghai, China. Children (n = 147) were randomized to either flag football (n = 74; mean age, 9.7 ± 0.5 years; 30 girls) or usual physical education (PE; n = 73; mean age, 9.7 ± 0.5 years; 32 girls). The intervention comprised 60-min sessions, delivered twice weekly for 10 weeks. Outcomes were assessed at baseline and post-intervention: the 20 m shuttle run test (laps), estimated maximal oxygen uptake (VO₂max), the 1-min jump rope test (turns), and the 50 m dash (seconds). Primary analyses followed the intention-to-treat principle using multiple imputation and repeated-measures models; subgroup analyses were conducted by sex and baseline weight status. Session intensity was monitored through heart rate (HR) in a subsample. Post-intervention data were available for 128 children (87.1%). Compared with usual physical education, the flag football group showed greater improvements in 1-min jump rope performance (between-group difference in change = 7.4 turns; p = 0.03) and 50 m dash time (between-group difference in change = -0.3 s; p = 0.013). No between-group differences in change were observed for 20 m shuttle run performance (0.7 laps; p = 0.32) or estimated VO2max (0.19 mL·kg-1·min-1; p = 0.37). Subgroup analyses revealed the most significant effects in boys with normal weight for estimated VO2max and 20 m shuttle run, boys across BMI status groups for sprint performance, and girls across BMI status groups for jump rope. A PE-embedded flag football programme effectively improved sprint speed and 1-min jump rope performance. The observed sex- and weight-specific responses suggest the need for differentiated task progression in school-based interventions to maximize fitness benefits. Trial registration: ISRCTN registry (Current Controlled Trials), ISRCTN62093106; registered 04 February 2026 (retrospectively registered).
Clerkship evaluations play a critical role in assessing medical student performance and informing residency selection. Prior studies suggest there are gender-related differences in narrative feedback and numerical evaluations of medical trainees; however, findings remain inconsistent across specialties and institutions. This study examined whether preceptor gender and student gender were associated with differences in clerkship evaluation scores. A retrospective analysis was conducted using 6,855 clerkship evaluations from students in the graduating classes of 2022-2024 at a U.S. Osteopathic medical school. Evaluations were completed by 2,425 preceptors across six required clerkships: Family Medicine, Internal Medicine, Obstetrics and Gynecology, Pediatrics, Psychiatry, and Surgery. Associations between preceptor gender, student gender, and evaluation scores were analyzed using generalized linear mixed models, adjusting for academic year and clerkship rotation. Preceptor gender was significantly associated with evaluation scores, with female preceptors assigning modestly lower Total Average and Clinical Competence scores than male preceptors (P < 0.0001). Student gender demonstrated smaller effects, with female students receiving slightly higher Total Average scores (P = 0.0260) and Professionalism scores (P = 0.0026). No significant interaction between preceptor and student gender was observed. Clerkship rotation was strongly associated with evaluation scores, with higher adjusted scores in Family Medicine and Pediatrics and lower in Surgery and Internal Medicine. Evaluator characteristics and specialty-specific grading cultures appear to influence numerical clerkship assessments. Although findings may be limited by the single-institution design, these results highlight the potential value of increased standardization and target preceptor development to promote equity and consistency in clinical evaluation.
People with intellectual disabilities often have complex healthcare needs and may therefore experience different patterns of healthcare utilization. This study examined the overlap between the use of public and private healthcare providers as an indicator of access to choice-enabled healthcare providers within a patient-choice-based health system. We assessed overlap in two complementary ways: among people with at least one private healthcare contact and among those with at least one public healthcare contact in a cohort of people with intellectual disability (ID cohort) and a referent cohort from the general population (gPop cohort). The ID cohort comprised 2 813 children and 9 079 adults, whereas the gPop cohort comprised 146 048 children and 982 186 adults. Data regarding healthcare contacts in public and privately organized healthcare were collected from the Skåne Healthcare Register. Among those with at least one contact in privately organized healthcare, both children and adults with intellectual disabilities were as likely as those in the general population to also have contacts in public primary healthcare and public somatic specialist care. However, they were more likely to have contacts in public psychiatric specialist care. Among those with at least one contact in public healthcare, children with intellectual disabilities were as likely as their age peers in the general population to also have contacts in privately organized healthcare. However, adults with intellectual disabilities were less likely than their age peers to have contacts in privately organized healthcare. These findings have important implications for patient‑choice‑based health systems. They indicate that formally available provider choice does not result in similar patterns of utilisation across populations. Also, that adults with intellectual disabilities may face challenges in navigating and using privately organised providers within such systems. The prominent role of public psychiatric specialist services further highlights the continued importance of publicly provided specialist care for this group. Together, the results underscore the need for patient‑choice‑based healthcare systems to be designed and implemented in ways that support accessibility, coordination, and navigation for people with intellectual disabilities, particularly adults with complex healthcare needs and during periods of healthcare disruption.
Childhood obesity is frequently accompanied by endocrine dysfunction and genetic susceptibility, but their combined contribution to metabolic risk remains insufficiently defined. This retrospective study evaluated hormonal, metabolic, and genetic determinants of metabolic syndrome (MetS) in children and adolescents with obesity. Electronic medical records from January 2021 to May 2025 were reviewed. A total of 429 children and adolescents with obesity were included. Clinical, biochemical, endocrine, and targeted SNP genotyping data for FTO rs9939609, MC4R rs17782313, and LEPR rs1137101 were analyzed. MetS was defined according to pediatric criteria. Multivariable logistic regression and receiver operating characteristic analysis were performed. MetS was present in 187 participants (43.6%). Fasting glucose averaged 5.3 ± 0.5 mmol/L, HbA1c averaged 5.24 ± 0.22%, and median HOMA-IR was 4.4 (2.7-5.7). Insulin resistance was observed in 68.0% of Tanner stage I participants and 73.3% of Tanner stage II-V participants. Elevated HOMA-IR was strongly associated with MetS (OR = 2.89, 95% CI: 1.71-4.99, P < 0.001). Leptin was positively associated with MetS risk (OR = 1.32, 95% CI: 1.02-1.70, P = 0.033), whereas adiponectin was inversely associated (OR = 0.63, 95% CI: 0.49-0.80, P < 0.001). FTO and MC4R risk allele carriage independently predicted MetS, with ORs of 1.88 and 1.71, respectively. The combined endocrine-genetic model showed acceptable discrimination (AUC = 0.751). Insulin resistance, adipokine imbalance, and FTO/MC4R variants were independently associated with MetS in pediatric obesity. Integrated endocrine-genetic profiling may improve early metabolic risk stratification. Not applicable.
Bone healing in osteoporotic bone represents a significant clinical challenge in oral and maxillofacial surgery. The aim of this experimental study was to evaluate the effects of melatonin and vitamin E supplementation on bone healing following alloplastic graft application in cranial bone defects created under osteoporotic conditions. A total of 35 male Wistar rats were randomly allocated into five groups. Experimental osteoporosis was induced by retinoic acid administration. Following osteoporosis induction, critical-sized cranial bone defects were created in the parietal bone. Except for the negative control group, all defects were filled with an alloplastic bone graft. Melatonin and/or vitamin E were administered systemically to the experimental groups. At the end of the experimental period, bone healing was evaluated histologically. No bone healing was observed in the negative control group, whereas mild to moderate new bone formation was detected in the graft control group. The melatonin-treated group demonstrated pronounced and high-grade bone formation. In contrast, the vitamin E-treated group did not show a significant improvement in bone healing compared to the graft control group. The findings of this experimental study suggest that melatonin may have a supportive effect on bone healing following alloplastic grafting in osteoporotic bone defects. Vitamin E, either alone or in combination with melatonin, did not provide an additional benefit in terms of bone regeneration. These results provide preclinical evidence to guide the selection of biological adjunctive agents in osteoporotic bone healing.
As the health of an older parent deteriorates, their transfer to a nursing home becomes inevitable to ensure that they receive safe and sufficient care, with the decision to transfer often being made and implemented within a matter of days. Family caregivers such as adult children remain actively involved in providing care after their parent's transfer to a nursing home, and are often described as an 'invisible workforce'. However, the impact of this situation on the health and well-being of adult children is rarely acknowledged. This study aimed to characterize the transition experiences of adult children during the weeks after their older parent's transfer to a nursing home, which is referred to as post-transition phase. This research study formed part of a larger qualitative project that had a narrative, longitudinal, prospective design. We conducted 22 narrative interviews with 8 adult children of older parents on 3 occasions in 2022. Narrative analysis was used to structure and systemize the generated data. The findings are presented as two narratives of one daughter ('Susan') and one son ('Phillip') that exemplify common characteristics shared by all of the participants. They illustrate the facilitators and barriers of a healthy transition-defined as a positive and successful transition outcome-during the complex post-transition phase. Although sharing similar contextual circumstances, their narratives diverge with Phillip's account conveying a sense of calm and relief, while Susan's narrative reflects stress and tension. These exemplar narratives of adult children highlight how personal, organizational and social factors both facilitate and hinder a healthy transition. The transfer of an older parent to a nursing home is often emotionally challenging for adult children. Healthcare personnel can help reduce the burden during the transition by supporting role mastery, subjective well‑being and well-being of relationships. Promoting the well‑being of adult children may have positive implications for their older parents as well as the healthcare services and society as a whole.
Diabetic foot is a serious complication of diabetes that significantly impairs patients' quality of life. Nursing education plays an important role in shaping students' knowledge, skills, and attitudes related to diabetic foot care. However, there is limited research assessing their cognitive, affective, and behavioral attitudes toward diabetic foot care. Therefore, this study aimed to assess nursing students' attitudes toward diabetic foot care across cognitive, affective, and behavioral domains and identify factors associated with these attitudes. This descriptive, cross-sectional study was performed between May and June 2024 with third- and fourth-year nursing students enrolled at a public university in western Türkiye. The sample comprised 230 nursing students who were actively involved in clinical practice and volunteered to participate. Data were collected using the student information form and attitude toward diabetic foot care form, which includes cognitive, affective, and behavioral subscales. Descriptive statistics, independent samples t-test, one-way analysis of variance, and Pearson correlation analysis were applied. The overall attitude level toward diabetic foot care was moderate. Cognitive and behavioral attitude scores were higher than affective attitude scores. In particular, female students had significantly higher cognitive, behavioral, and total attitude scores than male students (p < 0.05). Students with a first-degree relative with diabetes and those who had encountered diabetic amputation during clinical practice demonstrated significantly higher attitude scores compared with others (p < 0.05). Positive and significant correlations were identified among all attitude subscales (p < 0.001). Nursing students demonstrated a moderate attitude level toward diabetic foot care, with relatively stronger cognitive and behavioral components and a weaker affective component. These findings indicate the need to strengthen structured, practice-based educational strategies and interventions that enhance affective awareness related to diabetic foot care in nursing education. Clinical trial number: not applicable.
To evaluate whether the timing of luteal phase support (LPS) initiation affects pregnancy outcomes in natural cycle vitrified-warmed blastocyst transfer (NC-FET) cycles. This retrospective cohort study included NC-FET cycles performed between January 2022 and December 2024 at a tertiary university fertility center. Only true natural cycles with blastocyst transfer were analyzed. Patients were divided into two groups according to the initiation of LPS: two days before embryo transfer (Group 1) or on the day of embryo transfer (Group 2). All patients received vaginal and subcutaneous progesterone for LPS. Baseline characteristics, embryo features, serum progesterone levels on transfer day, and reproductive outcomes were compared. Multivariate logistic regression and receiver operating characteristic (ROC) analyses were performed to identify factors associated with clinical pregnancy. A total of 246 NC-FET cycles were analyzed (Group 1: n = 172; Group 2: n = 74). Baseline characteristics, embryo quality, and transfer parameters were comparable between groups. Serum progesterone levels on the day of transfer were significantly higher in Group 1 (32.1 ± 13.0 ng/mL) compared with Group 2 (10.3 ± 3.8 ng/mL; p = 0.001). However, total pregnancy rate (66.2% vs. 47.1%, p = 0.006), clinical pregnancy rate (56.8% vs. 40.7%, p = 0.020), and live birth rate (52.7% vs. 37.2%, p = 0.024) were significantly higher in Group 2. Logistic regression analysis showed that initiation of LPS on the day of transfer was independently associated with increased clinical pregnancy (OR 2.37, 95% CI 1.17-4.81). Serum progesterone level did not predict pregnancy outcomes. In NC-FET cycles, initiating luteal phase support on the day of embryo transfer is associated with improved pregnancy and live birth rates compared with earlier initiation, despite lower serum progesterone levels.
Community-based hepatitis B virus (HBV) screening programs are widely used to identify chronic infection in high-risk immigrant populations in the United States. However, screening alone does not ensure engagement in care, and the processes that determine progression from diagnosis to sustained clinical management remain poorly characterized. In particular, there is limited longitudinal evidence evaluating real-world implementation across the full HBV care continuum. We conducted a RE-AIM-based implementation evaluation of a longstanding community-based HBV screening and education program among Korean American immigrant communities in the northeastern United States from 2009 to 2016. Through 152 outreach events, we delivered culturally and linguistically tailored education, venipuncture-based serologic testing, direct disclosure of results, and referral to care. Using prospectively collected programmatic data, we assessed reach, operational yield, and attrition across the care continuum among individuals testing positive for hepatitis B surface antigen (HBsAg), with longitudinal follow-up of up to eight years. Among 8,453 individuals screened, 204 (2.4%) were HBsAg positive. Of these, 121 (59.3%) had longitudinal follow-up data available, and 71 (58.7%) accessed clinical care, corresponding to 34.8% of all HBsAg-positive individuals. Most participants who accessed care received follow-up through private community-based outpatient practices (64/71; 90.1%) rather than centralized systems. Approximately 42 individuals required screening to identify one case, and 104 to achieve one confirmed linkage to care. Substantial attrition occurred between diagnosis and initial clinical engagement, representing the primary loss point in the care continuum. Lack of health insurance was the most frequently reported structural barrier. Community-based HBV screening effectively identifies individuals with chronic infection but does not ensure completion of the prevention pathway. This study provides longitudinal, real-world evidence quantifying attrition across the HBV care continuum and demonstrates that prevention is an implementation-dependent process requiring sustained engagement beyond initial screening. Strategies that integrate screening with patient navigation, longitudinal follow-up, and improved access to care are needed to enhance linkage to care and clinical outcomes in high-risk populations.
In response to increasing demands for accountability and quality assurance in higher education, internal evaluation has become a core mechanism for improving educational performance. Internal evaluation refers to a systematic self-assessment process through which faculty and staff examine educational, research, and administrative performance to identify strengths, weaknesses, and areas for improvement. Faculty members play a central role in implementing internal evaluation; however, their engagement is shaped by multiple facilitators and barriers. Evidence from resource-constrained contexts remains limited, particularly qualitative insights into faculty perceptions. This study qualitatively examines faculty members' perceptions of the facilitators and barriers influencing internal evaluation. This qualitative study used a conventional content analysis approach. Semi‑structured interviews were conducted with 16 faculty members at Fasa University of Medical Sciences using purposive sampling until data saturation was achieved. Data were collected between January and October 2025 and analyzed using conventional content analysis. Trustworthiness was ensured using Lincoln and Guba's criteria. Three overarching categories emerged inductively from the data: (1) conceptualizations of internal evaluation, including its role as a systematic performance review, a reflective process for identifying strengths and weaknesses, and a cultural mechanism for promoting quality; (2) facilitators, encompassing individual factors (intrinsic motivation, self-efficacy, training), organizational factors (structural support, adequate infrastructure), and cultural factors (learning-oriented culture, collaboration); and (3) barriers, including individual challenges (resistance to change, workload), organizational constraints (limited resources, inefficient procedures), and cultural obstacles (negative attitudes, interdepartmental tensions). Internal evaluation is shaped by intersecting individual, organizational, and cultural dynamics. Recognizing these influences can guide context-appropriate strategies; for example, shifting from a compliance-driven model to a developmental model that emphasizes workload adjustments, targeted capacity building, and transparent feedback loops to increase faculty engagement. not applicable.
Claims data from statutory health insurance (SHI) funds are increasingly used in public health research. We evaluated the representativeness and external comparability of the InGef research database (RDB), which contains anonymized claims data from approximately 10 million SHI-insured individuals in Germany, using selected disease-specific indicators. A retrospective cohort study combining cross-sectional and longitudinal analyses (2015-2023) was conducted. We assessed (1) follow-up duration, (2) demographic representativeness, and external comparability based on two complementary reference indications (3) incidence and mortality of lung cancer, and (4) prevalence and pharmaceutical treatment of bronchial asthma. All outcomes were compared with external reference data from the German Federal Statistical Office (DESTATIS), the German Centre for Cancer Registry Data (ZfKD), and the SHI Pharmaceutical Index (GKV-AI). Direct age and sex standardization was applied to ensure comparability. The InGef-RDB showed high concordance with the general German population in terms of age and sex distribution (maximum deviation < 0.6 percentage points). 73% of all insured persons remained continuously observable over 9 years. 6.9% died and 19.5% left the database due to changes in their insurance provider, corresponding to an average annual attrition rate of approximately 2.4%. Overall mortality was slightly lower than national statistics (- 0.3 to - 0.4 percentage points). Between 2016 and 2022, the standardized asthma prevalence rose from 5,938 to 6,602 per 100,000 population, before decreasing to 5,977 per 100,000 in 2023. Monoclonal antibody prescription rates for asthma deviated by < 0.01 percentage points from SHI benchmarks. Lung cancer incidence (2016-2022) averaged 41.8 cases per 100,000 persons, closely matching ZfKD data. The InGef-RDB demonstrates strong demographic alignment and good external comparability across distinct epidemiologic and health care use scenarios. Based on these evaluations, it represents a valid and reliable real-world data source for population-based epidemiological and health services research, provided that appropriate methodological adjustments are applied.
Suicide is a leading cause of death among adolescents and youth globally and represents an important public health concern in low- and middle-income and conflict-affected settings. Prior evidence from Ethiopia showed substantial levels of suicidal behavior among young populations even before the recent conflict. Exposure to war-related trauma, violence, displacement, and disruption of health and social systems may further increase the risk of suicidality among adolescents and youth. However, there is limited evidence regarding suicidal ideation and suicide attempts among adolescents and youth in post-war Tigray, Ethiopia. Therefore, this study aimed to assess the prevalence and associated factors of suicidal ideation and suicide attempts among adolescents and youth in the aftermath of the Tigray War. A school-based cross-sectional study was conducted among 599 adolescents and youth aged 15-24 years in post-war Tigray, Ethiopia, of whom 57.4% were female. Data were collected using validated tools assessing suicidal ideation, suicide attempts, depression, anxiety, post-traumatic stress disorder, and exposure to violence. Bivariate and multivariable logistic regression analyses were performed to identify factors associated with suicidal ideation and suicide attempts. The prevalence of suicidal ideation was 19.9% (95% CI: 16.7%, 23.3%), while the prevalence of suicide attempts was 9.7% (95% CI: 7.4%, 12.3%).Depression, anxiety, and post-traumatic stress disorder were significantly associated with both suicidal ideation and attempts. Sexual abuse and witnessing physical violence increased the odds of suicidal Attempts. However, physical activity was protective against suicidal ideation. The findings suggest that suicidal ideation and suicidal attempts represent important mental health concerns among adolescents and youth in post-war Tigray. Depression, anxiety, PTSD symptoms, and trauma-related experiences were significantly associated with suicidality in this study. Given the cross-sectional nature of the study, causal relationships cannot be inferred. Nevertheless, the findings underscore the need for strengthened adolescent mental health services and trauma-informed support programs in conflict-affected settings. Not applicable.
Palliative care is a core component of holistic nursing practice, yet international and regional evidence indicates persistent gaps in nursing students' preparedness, particularly in knowledge, attitudes, and spiritual care competence. In Saudi Arabia, these gaps are influenced by cultural expectations and variable curricular integration. To assess palliative care preparedness among undergraduate nursing students in Northern Saudi Arabia across three domains knowledge, attitudes toward caring for the dying, and spiritual care preparedness and to examine their associations with palliative care training and clinical experience. A cross-sectional study was conducted among 232 third- and fourth-year nursing students using stratified random sampling. Data were collected using the Palliative Care Knowledge Test (PCKT), the Frommelt Attitude Toward Care of the Dying Scale-B (FATCOD-B), and the Student Survey of Spiritual Care (SSSC). Descriptive statistics, Mann-Whitney U tests, Pearson correlations, and multiple linear regression were performed. Students demonstrated moderate knowledge (M = 13.78/20), with higher scores in psychiatric and dyspnea management domains. Clinical experience with dying patients was associated with significantly higher knowledge (p = 0.0189). Attitude scores were generally positive (M = 3.13/5), though slightly lower among students with training or clinical experience. Spiritual care preparedness was moderate (M = 3.86/6) and did not differ by training or experience. A weak negative correlation was observed between knowledge and attitudes (r = - 0.143, p = 0.0296). Nursing students in Northern Saudi Arabia exhibit moderate preparedness for palliative care. Clinical exposure enhances knowledge, while spiritual care readiness appears culturally grounded rather than training dependent. Findings highlight the need for integrated, culturally responsive palliative and spiritual care education within undergraduate nursing curricula.
To evaluate the efficacy of a teledentistry-based follow-up approach compared with standard in-person follow-up for monitoring oral health among patients with head and neck cancer (HNC) after the completion of radiotherapy, using a noninferiority framework. In this two-arm, noninferiority randomized controlled trial, teledentistry was compared with standard in-person follow-up in patients with HNC after the completion of radiotherapy. The participants were randomized 1:1 and followed up at 1, 3, and 6 months. For teledentistry, a secure digital platform incorporating live video and self-photography was used. The primary outcomes were the percentage of tooth surfaces with plaque (plaque index) and bleeding on probing. The secondary outcomes were radiotherapy-related oral complications (i.e., dental caries incidence, trismus assessed via maximal mouth opening, mucositis severity, xerostomia severity, and osteoradionecrosis incidence) and patient-reported measures, including oral health-related quality of life (Oral Health Impact Profile, OHIP-14) and patient satisfaction. Noninferiority was assessed using analysis of covariance and risk difference calculations, comparing outcomes between groups based on data collected 2 weeks after the 6-month follow-up. A predefined noninferiority margin of 15%, representing the maximum clinically acceptable difference between groups, was applied with 95% confidence intervals (CI). Twenty-seven participants completed the study (teledentistry group: n = 14; standard group: n = 13), with no statistically significant baseline differences. Teledentistry was noninferior to standard follow-up for the plaque index (mean difference: 1.9% points; 95% CI [- 8.6, 12.4]) and bleeding on probing (mean difference: -2.2% points; 95% CI [- 17.2, 12.8]). The incidence of osteoradionecrosis was also noninferior (risk difference: -0.15; 95% CI [- 0.35, 0.04]). Patient satisfaction was high across the groups. Outcomes related to other radiotherapy-related oral complications and oral health-related quality of life were inconclusive. Teledentistry appears to be a feasible and noninferior follow-up modality for patients with HNC during the initial 6 months after radiotherapy. TCTR20221008001, registered on October 8, 2022.
Takedowns are a central grappling action in mixed martial arts (MMA), but long-term evidence on time-normalized takedown output across competitive eras and weight classes remains limited. This study examined takedown density (TDpM; successful takedowns per minute) as a descriptive performance indicator in professional MMA. We analyzed publicly available UFC bout-level records from 1997 to 2025, comprising 8,461 bouts and 16,922 fighter-bout observations. TDpM was calculated as successful takedowns divided by bout duration in minutes. Temporal trends were examined separately for men and women, with sensitivity analyses excluding bouts shorter than 90 s and excluding pre-2002 men's observations. Weight-class differences were evaluated using Kruskal-Wallis tests with Dunn-Holm post hoc comparisons. Division-specific percentile values were calculated as descriptive TDpM benchmarks, and winner-loser differences in TDpM, takedown success rate (TD%), and control time per successful takedown (CTRL/TD) were examined exploratorily. Men's annual mean TDpM declined significantly across 1997-2025 (β = -0.00426 takedowns·min⁻¹·year⁻¹, r = - 0.753, p < 0.001), and the negative direction remained in the 2002-2025 sensitivity analysis (β = -0.00202, r = - 0.712, p < 0.001). Women's TDpM showed no significant trend across 2013-2025 (β = -0.00252, r = - 0.394, p = 0.183). Men's TDpM differed significantly across weight classes (Kruskal-Wallis p < 0.001), although effect sizes were small (ε² ≈ 0.005-0.007); women's between-division differences were not significant. Winners showed higher TDpM (median 0.067 vs. 0.000 takedowns·min⁻¹), TD% (50.0% vs. 20.0%), and CTRL/TD (99.75 vs. 78.88 s) than losers. TDpM provides a simple, time-normalized descriptive indicator of takedown-related performance in professional MMA. Men's TDpM declined over time and differed modestly across weight classes, whereas women's patterns were comparatively stable in the available sample. Percentile benchmarks and winner-loser contrasts offer descriptive reference values, but TDpM should not be interpreted as a causal determinant of victory or a training-prescription threshold. Future studies incorporating video-coded context and training data are needed to clarify its broader applied value.