Quishing, a form of phishing conducted through QR codes, has emerged as a critical threat to user information security in mobile environments. Quishing attacks exploit the QR scanning workflow by opening malicious URLs in WebView and impersonating legitimate services to steal user credentials. Recent variants further evade static inspection by exposing credential-harvesting behavior only after user interaction, form submission, redirection, or page-state changes. In this paper, we propose WebView-Based Hybrid Analysis of Link and Event for On-Device QR Phishing Detection (WHALE), an On-Device multi-stage phishing detection framework based on an isolated Sandbox WebView. WHALE first loads the QR-decoded URL into the Sandbox WebView instead of directly delivering it to the User WebView, thereby separating the analysis process from the user session. In the static stage, WHALE extracts 54 features from the URL string, initial HTML, and DOM snapshot, and computes a static phishing risk score using a lightweight model. Inputs with uncertain static scores are forwarded to the dynamic stage. In the dynamic stage, WHALE inserts decoy credentials instead of real user credentials, triggers a controlled submit event, and analyzes 59 credential-flow state-transition features extracted before and after submission. The static model achieved an accuracy of 93.86%, precision of 93.08%, recall of 94.78%, and F1-score of 93.92%. The dynamic model achieved an accuracy of 0.915, precision of 0.895, recall of 0.946, specificity of 0.882, and F1-score of 0.920 on a source-group-disjoint independent test set. Real-device evaluation on a Samsung Galaxy S23 Ultra showed that WHALE maintains practical mobile overhead, with an average static internal runtime of 58.75 ms, dynamic internal runtime of 4165.42 ms, combined model inference time of 0.088 ms, and model asset size of 0.681 MB. These results demonstrate that WHALE can detect QR-based phishing threats On-Device while reducing user credential exposure through sandboxed credential-flow analysis.
The secondary use of patient health data is critical for advancing clinical research, public health, and digital health innovation. However, traditional consent mechanisms are often static, complex, and insufficiently transparent, limiting patient control and trust. In response to regulatory requirements introduced by the General Data Protection Regulation (GDPR) and the European Health Data Space (EHDS), this article paper aims to design a secure, transparent, and revocable blockchain-based architecture for managing patient consent for the secondary use of health data, aligned with European legal frameworks and interoperability standards. A multilayered consent management architecture was designed by integrating blockchain smart contracts, decentralized identifiers, verifiable credentials, and Health Level Seven-Fast Healthcare Interoperability Resources. The system incorporates a patient-controlled digital wallet, off-chain health data storage, and on-chain enforcement of consent policies through smart contracts. Regulatory and technical requirements were systematically derived from GDPR and European Health EHDS provisions. The study follows a design science research methodology and includes threat modeling and a theoretical performance and scalability analysis. The design is guided by four core objectives: dynamic consent management, auditable governance, interoperability with healthcare standards, and compliance-by-design with European regulatory frameworks. The proposed architecture enables secure creation, delegation, and revocation of patient consent through immutable blockchain-based logging and Fast Healthcare Interoperability Resources-compliant data exchange. Consent records are tamper-evident, while sensitive health data remain off-chain, ensuring data minimization and privacy protection. Consent attributes such as purpose limitation, duration, and data scope are explicitly modeled to comply with GDPR and EHDS requirements. Theoretical evaluation indicates that the architecture can scale to large healthcare data ecosystems when deployed on Ethereum-compatible blockchains combined with external storage solutions. This study presents a modular, standards-based consent management framework that enhances patient autonomy, supports regulatory compliance, and strengthens governance for the secondary use of health data. By combining blockchain, digital identity, and healthcare interoperability standards, the architecture addresses key legal and technical challenges of dynamic consent. Future work will focus on developing a user-centered prototype and conducting empirical validation in real-world secondary-use health data ecosystems. The secondary use of patient health data plays a vital role in advancing clinical research, public health, and digital health innovation; however, prevailing consent mechanisms are often static, opaque, and difficult for patients to control. In response to regulatory requirements introduced by the General Data Protection Regulation (GDPR) and the European Health Data Space (EHDS), this paper proposes a secure, transparent, and revocable blockchain-based architecture for managing patient consent for the secondary use of health data. The proposed solution adopts a multilayered design integrating blockchain smart contracts, decentralized identifiers (DIDs), verifiable credentials (VCs), and Health Level Seven—Fast Healthcare Interoperability Resources. It combines patient-controlled digital wallets, off-chain health data storage, and on-chain enforcement of consent policies to ensure data minimization and privacy protection. Regulatory and technical requirements are systematically derived from GDPR and EHDS provisions, and the study follows a Design Science Research methodology supported by threat modeling and theoretical performance and scalability analysis. The architecture enables fine-grained consent creation, delegation, and revocation, with consent attributes such as purpose limitation, duration, and data scope explicitly modeled to support legal compliance. Immutable blockchain-based logging ensures auditability and trust while avoiding on-chain storage of sensitive health data. Theoretical evaluation indicates that the architecture can scale to large healthcare ecosystems when deployed on Ethereum-compatible blockchains with external storage solutions. The proposed framework enhances patient autonomy, strengthens governance for secondary health data use, and provides a standards-based foundation for future implementation and real-world validation.
Economic inequality has widened considerably in the United States and globally, raising pressing questions about the mechanisms that reproduce social stratification. One prominent manifestation of this inequality is the "class ceiling" in organizations: individuals from lower social classes earn less and advance more slowly than their higher-class counterparts, even with comparable credentials. We identify a crucial behavioral pathway contributing to this class ceiling: a social-class gap in the propensity to negotiate. We propose that lower-class individuals are less likely to initiate negotiations than their higher-class counterparts, a pattern that can compound economic disadvantage over time. Across four studies (total N = 10,211)-including a nationally representative sample of employees (Study 1), a sample of business school students (Study 2), a field study of an online labor market (Study 3), and a survey study of workplace negotiations and career outcomes (Study 4)-we find consistent evidence for this gap. This gap is partially explained by lower-class individuals' reduced sense of power and heightened concerns about social backlash. Additionally, Study 5 (N = 1,133) finds that such concerns may be justified: an experiment with human resources (HR) professionals shows that identical negotiation requests elicit stronger social backlash when initiated by lower-class (vs. higher-class) individuals. Together, these findings reveal a pernicious double bind for lower-class individuals: remaining silent perpetuates economic disadvantage, yet initiating negotiation exposes them to greater social penalties. Addressing this double bind is critical for ensuring that negotiation serves as a vehicle for upward mobility rather than a gatekeeper of privilege.
Ivor Kramer was a distinguished oral pathologist with a very unusual beginning. He carried out microbiological research with Sir Alexander Fleming. Coming from a dental family he too became a dentist, studying at the Royal Dental Hospital as London was bombed during World War II. After his studies on the effects of penicillin on microorganisms and a developing interest in oral pathology, Kramer was appointed to the newly opened Institute of Dental Surgery at the Eastman Dental Hospital. With credentials as an outstanding researcher and teacher he eventually became professor of dental surgery and dean. Knowing his fame, postgraduates came from around the world to be trained by him. With many important pathological papers to his name, the World Health Organization asked him to co-edit the first and second editions of its Histological Typing Odontogenic Tumours, Jaw Cysts and Allied Lesions.
Falls constitute a leading cause of injury-related mortality among older adults globally. Chinese short-video platforms collectively reach over 900 million users, presenting unprecedented opportunities for health education, but the quality of fall prevention content and its relationship with user engagement have not been systematically evaluated. To evaluate fall prevention video quality across major Chinese short-video platforms, identify content creator characteristics associated with higher-quality information, and examine whether user engagement metrics correlate with video quality. We conducted a cross-sectional analysis of 216 fall prevention videos from five platforms (Douyin, Kuaishou, Bilibili, Xiaohongshu, Xigua Video) during October-November 2025. Two independent medical-school graduates with formal medical education and research expertise in medical informatics assessed video quality using the modified DISCERN instrument (mDISCERN; range 5-25) and Global Quality Scale (GQS; range 1-5). Interrater agreement was quantified using both intraclass correlation coefficients (ICC) and Cohen's weighted κ. User engagement metrics were extracted and analyzed using both Pearson and Spearman correlations. Interrater reliability was excellent for mDISCERN (ICC=0.890; weighted κ=0.890) and good for GQS (ICC=0.723; weighted κ=0.722). Mean mDISCERN score was 17.61 (SD 2.87), with 48.1% achieving high quality. Uploader type demonstrated the strongest quality association (ε²=0.64): healthcare professionals substantially outperformed self-media creators (Cohen d=3.42). Platform verification strongly predicted quality (88.7% vs 9.1% high-quality; φ=0.79). Engagement metrics showed weak association with quality in this sample (Spearman ρ=0.149 for likes, explaining only 2.2% of variance), with detection power constrained by severe right-skewness and floor effects (e.g., 30.1% of videos had zero comments). Content creator credentials and platform verification effectively discriminate video quality, while engagement metrics show only weak association in this sample. These findings support platform policies prioritizing verified professional content and indicate that engagement-based metrics, despite their algorithmic prominence, do not reliably signal health information quality in this dataset.
Despite rapid advances in whole-genome sequencing (WGS), translating genomic findings into individualized insights remains challenging. We present GenRiskPro, a clinical decision-support and research platform, which automates WGS variant calling, annotation, prioritization, and reporting to deliver actionable findings and facilitate precision wellness. (To test the GenRiskPro platform, log on to https://www.phenomeportal.org/dashboard using the following credentials: Username: user@test.com; Password: test.) GenRiskPro integrates rare and common variant prioritization in a unified pipeline and in-house database, enabling both rare and complex disease and trait association analyses. Variant reporting is supported via LongevityCloud, which features a web portal for clinicians to review, adjust, and authorize the return of results in tabular and PDF formats, alongside a mobile app with artificial intelligence (AI) integration for sequenced individuals. Case studies using Turkish (TR, n = 275) and Swedish (SW, n = 101) WGS data assessed platform performance and variant prioritization: (a) predefined gene panels yielded a 1.82% positive rate for actionable findings per American College of Medical Genetics and Genomics (ACMG) secondary findings guidelines; (b) phenotype-driven support diagnosed cases including muscular dystrophy and microcephaly; (c) cohort-level ClinVar reassessment identified potentially misclassified pathogenic variants; (d) rare variant burden analysis revealed enrichment in ABCA4 for TR and SMPD1 in SW; and (e) population analysis highlighted carrier differences in trait-associated SNPs (rs12913832 and rs4988235) and PGx variants (CYP2B64 and CYP2B66). GenRiskPro unifies databases, literature, web development, and AI for rapid, user-friendly genomic analysis and reporting, which fosters collaboration among hospitals, researchers, clinicians, and patients.
Social media has become an important source of orthodontic information, yet patient experience content varies in completeness and may shape treatment expectations. This study evaluated information completeness, comment sentiment, and engagement patterns in orthodontic experience content on three major Chinese social media platforms. A cross-sectional sample of 180 eligible posts was collected from Bilibili, Douyin, and Xiaohongshu using two search terms, "orthodontic experience" and "braces diary." Information completeness was assessed using a modified 6-point Information Completeness Score (ICS). Comment sentiment and title sentiment were quantified using sentiment analysis scores (SAS). Engagement metrics, including likes, favorites, shares, and comments, were recorded. Platform differences and subgroup differences by appliance type, treatment population, video duration, and video age were analyzed. Inter-rater reliability for total ICS was excellent (ICC (3,1) = 0.954). The automated SAS classifications showed strong agreement with the human consensus gold standard, with an overall accuracy of 91.6% (κ = 0.848). ICS differed significantly across platforms (H = 40.70, p < 0.001), with Bilibili showing the highest score (3.53 ± 1.46) and Xiaohongshu the lowest (1.78 ± 1.24). Treatment details and treatment duration were the most frequently mentioned dimensions, whereas clinician or institution credentials and cost were least frequently covered. Title sentiment showed a statistically significant but weak positive correlation with comment sentiment in the full sample (rho = 0.247, p < 0.001), with platform-specific variation. Engagement indicators were strongly intercorrelated (rho = 0.69-0.87), but ICS showed no meaningful correlation with engagement. Longer videos, clear aligner content, adult orthodontic content, and older videos had higher ICS, whereas SAS varied only slightly across groups. Orthodontic patient experience content on Chinese social media shows substantial variation in information completeness. High engagement does not necessarily indicate high information quality. Professional orthodontic content should provide balanced information on treatment benefits, risks, costs, duration, and professional sources to support informed patient decision-making.
In late 2025, the Cyberspace Administration of China released new requirements around the provision of online professional advice by users without relevant credentials, as part of broader efforts to curb misinformation. In this News and Perspectives article, JMIR Correspondent and long-time PC and consumer technology analyst Tim Bajarin reports his opinion on the potential implications of this initiative for the United States.
Advanced practice nursing in anesthesia (APNA) has emerged as an important workforce strategy to address global anesthetist shortages and rising surgical demand. However, the scope of practice and level of professional autonomy granted to APNAs vary substantially across healthcare systems. Existing literature has focused primarily on clinical competencies while paying less attention to the structural conditions shaping APNA roles. To examine global variation in APNA scope of practice and identify the structural determinants influencing professional autonomy across healthcare systems. A scoping review of peer-reviewed and gray literature published between 2001 and 2025 was conducted using the Arksey and O'Malley framework and reported according to the Preferred Reporting Items for Systematic reviews and meta-analyses extension for scoping reviews (PRISMA-ScR) guidelines. Searches were performed in PubMed, Embase, CINAHL, PsycINFO, the Cochrane Library, and selected organizational websites. Data were charted and synthesized using inductive thematic analysis. Thirty-five sources were included. Thematic synthesis identified a global spectrum of APNA autonomy ranging from independent practice to strict physician supervision. Six interrelated structural determinants shaped this variability: legislative and regulatory mechanisms, educational standards and credentials, economic incentives and reimbursement models, health system demands and access, professional power and interprofessional conflict, and macro-political forces and policy reform. Across jurisdictions, formal regulatory frameworks frequently diverged from actual clinical practice, particularly in rural and resource-constrained settings where workforce shortages expanded APNA responsibilities beyond statutory boundaries. Global variation in APNA scope of practice appears to be shaped more strongly by structural and political conditions than by clinical capability alone. Harmonized educational standards, clearer regulatory recognition, and reimbursement policies not contingent upon physician supervision may facilitate more consistent integration of APNAs within the global anesthesia workforce.
The journey from nurse anesthesiology resident (NAR) to certified registered nurse anesthetist (CRNA) is a profound transformation, one that extends beyond skill acquisition to the evolution of professional identity. Using the metaphor of a caterpillar's metamorphosis into a butterfly, this article explores how academic rigor, clinical immersion, and mentorship shape resilience, adaptability, and confidence in future CRNAs. Grounded in growth mindset theory, it highlights how embracing challenges, seeking feedback, and reframing setbacks as opportunities for learning build both competence and self-efficacy. As residents transition from novice learners to autonomous practitioners, engagement with professional organizations such as the American Association of Nurse Anesthesiology becomes essential to sustaining lifelong growth and leadership. The metamorphosis from NAR to CRNA, therefore, reflects more than a change in credentials, it signifies emergence into a profession defined by reflection, excellence, and service.
The transition of municipal wastewater treatment plants towards energy-neutral, resource-efficient facilities is a cornerstone of sustainable urban management. However, selecting core technologies with verifiable low-carbon and resource-recovery credentials remains a critical challenge. This study addresses this gap by piloting and comprehensively assessing an enhanced rotating algal biofilm (RAB) reactor as a viable core unit. Through microalgae-activated sludge co-inoculation, the system achieved efficient nutrient removal at a commercially viable 24-h hydraulic retention time, reducing direct CO2 emissions by 72.6% while producing valuable biomass (37.7 g/m2/day). A subsequent life cycle assessment (LCA) of a scaled-up process (20,000 m3/d), which was designed based on pilot data to integrate the enhanced RAB with necessary downstream units, confirmed its superior environmental profile compared to conventional A2/O and MBR processes. Crucially, the biodiesel production pathway was identified as optimal, with sensitivity analysis revealing its potential for net negative carbon emissions under optimal summer conditions and with cleaner electricity grids. Furthermore, the environmental merit of this pathway was found to be highly dependent on regional grid cleanliness, providing a clear decision-making framework for technology selection based on local contexts. This work delivers a validated, resource-recovering technology option and a robust, data-driven guide for environmental managers overseeing the sustainable transformation of wastewater infrastructure.
Benign uterine disorders, including uterine leiomyomas and uterine endometriosis/adenomyosis-related conditions, are common causes of gynecologic morbidity and represent an important women's health issue. Although these conditions are generally non-malignant, a subset of hospitalizations may involve substantial anemia-related clinical burden. Evidence describing severe inpatient anemia, red cell product ordering, intensive care unit (ICU) use, and short-term hospital outcomes in this population remains limited. We conducted a retrospective cohort study using hospital data from the Medical Information Mart for Intensive Care IV (MIMIC-IV). Adult female hospitalizations with diagnostic codes related to benign uterine disorders were identified. Hospitalizations with missing hemoglobin data, pregnancy- or obstetric-related diagnoses, and gynecologic malignancy-related diagnoses were excluded. The unit of analysis was hospitalization. Severe anemia was defined as a minimum inpatient hemoglobin level < 8 g/dL during hospitalization. The main outcome was red cell product ordering identified from Blood Bank provider order entry records, which was interpreted as a transfusion-related resource use indicator rather than confirmed red cell administration. Additional hospital burden outcomes included hospital length of stay, ICU admission during hospitalization, in-hospital mortality, and gynecologic procedure-related outcomes. Multivariable logistic regression was used to evaluate the association of severe anemia with red cell product ordering and ICU admission. Models were adjusted for age, race/ethnicity, insurance status, marital status, admission type, and disease group. Sensitivity analyses used hemoglobin < 10 g/dL as an alternative anemia threshold. The final cohort included 1,860 non-obstetric, non-malignant hospitalizations with available hemoglobin data. Severe anemia was present in 425 hospitalizations (22.8%). Compared with hospitalizations without severe anemia, those with severe anemia had a higher proportion of red cell product orders (63.29% vs. 5.09%), longer hospital length of stay [3.436 (1.911-6.389) vs. 2.310 (1.335-3.816) days], and more frequent ICU admission during hospitalization (15.06% vs. 6.13%). In-hospital mortality was uncommon overall and was analyzed only exploratorily. After multivariable adjustment, severe anemia was associated with red cell product ordering [adjusted odds ratio (OR) 33.61, 95% confidence interval (CI) 24.23-47.29] and ICU admission during hospitalization (adjusted OR 2.69, 95% CI 1.84-3.91). In the fibroid-only subgroup, the corresponding adjusted ORs were 35.55 (95% CI 24.96-50.64) for red cell product ordering and 2.68 (95% CI 1.83-3.92) for ICU admission. Sensitivity analyses using hemoglobin < 10 g/dL showed directionally consistent findings. Additional sensitivity analyses using earlier hemoglobin definitions showed that early 24-hour Hb < 8 g/dL remained strongly associated with red cell product ordering (adjusted OR 22.57, 95% CI 15.54-32.80), whereas the corresponding ICU admission estimate was attenuated and not statistically significant (adjusted OR 1.09, 95% CI 0.66-1.80). Among women hospitalized with benign uterine disorders, severe inpatient anemia was common and was associated with greater red cell product ordering and higher hospital resource use. These findings suggest that severe inpatient anemia may serve as a practical marker of anemia-related hospital burden in this defined hospitalized population, while ICU-related findings and causal interpretation require caution.
Charge nurses are pivotal frontline leaders in acute care, yet many assume the role without formal preparation, particularly in multicultural health systems. Confidence in leadership, clinical judgment, and communication is central to safe and effective charge nurse practice, but evidence from Gulf-region tertiary hospitals remains limited. To evaluate the effectiveness of a structured Charge Nurse Development Program (CNDP) in improving nurses' confidence in leadership, clinical, and professional responsibilities within a large multinational tertiary hospital in the United Arab Emirates. A quantitative quasi-experimental pre-post design was conducted with 103 nominated registered nurses working in inpatient and critical care units. The three-phase CNDP combined self-directed e-learning, a didactic workshop with simulation and case-based activities, and three supervised charge nurse shadowing shifts, guided by Bandura's Self-Efficacy Theory, adult learning principles, and experiential learning. Confidence was measured before and 1 week after the program using the 21-item Confidence in Managing Challenging Situations Scale (CMCS). Data were analyzed using paired-samples t-tests, Welch's ANOVA, and multiple linear regression; effect sizes and internal consistency (Cronbach's α) were reported. Confidence improved significantly across all 21 items and both subscales. Leadership & Ethical Practice increased from 27.48 ± 5.31 to 32.95 ± 4.05, and Clinical & Communication Confidence from 36.26 ± 7.01 to 43.56 ± 5.43; total confidence rose from 63.74 ± 11.74 to 76.51 ± 9.26 (all p < 0.001, d ≈ 0.82-0.87). Cronbach's α for the Confidence Scale was 0.963. Baseline differences by credential favored charge nurses, but post-intervention scores no longer differed significantly. No meaningful differences were found across nationality, age, qualification, years of experience, or unit, and regression analyses showed no consistent demographic predictors of change. The CNDP was associated with educationally meaningful improvements in nurses' self-reported leadership and clinical confidence in a highly multicultural workforce. These findings suggest that structured, theory-informed charge nurse development may support perceived readiness for frontline leadership responsibilities. Further controlled and longitudinal studies using objective behavioral, clinical, and organizational outcomes are needed to determine whether confidence gains translate into sustained practice change.
This case report details the diagnostic, therapeutic, and aeromedical trajectory of a 58-yr-old pilot diagnosed with squamous cell carcinoma exhibiting perineural invasion and orbital floor involvement with treatment goal of return to flight. The malignancy presented with insidious symptoms of fascial swelling, numbness, and tingling, complicated by initial diagnostic anchoring bias. The patient had a relevant past medical history of squamous and basal cell carcinomas, including a Mohs micrographic surgery for a lesion on the left nares 10 yr prior. Treatment necessitated a total maxillectomy with multiple skin flaps, and orbital floor reconstruction initially using a titanium implant and later an autologous scapular bone graft. Postoperative management addressed complex ocular manifestations, including mechanical diplopia and inferior rectus muscle dysfunction, alongside the challenges caused by multiple skin-flap failures. From an aeromedical perspective, the case highlights the rigorous standards of the Federal Aviation Administration for First-Class medical certification, focusing on binocular fusion, visual acuity, and auditory thresholds. The report outlines the regulatory pathway for Special Issuance and the eventual return to flight duty, emphasizing the balance between aggressive oncological control and the preservation of critical sensory functions required for aviation safety. This case provides an example of a structured framework for managing high-stakes professional requirements in the context of advanced midfacial malignancy and complex reconstructive surgery. Krebsbach SK, Fredricks TR. Ocular management and aeromedical certification of maxillary squamous cell carcinoma. Aerosp Med Hum Perform. 2026; 97(8):644-647.
OECD health systems face rising demand for health workers, increasingly relying on international recruitment of doctors and nurses. Growing dependence raises "brain drain" concerns, particularly when recruits originate from WHO Health Workforce Support and Safeguards List countries. This study examines how mobility to OECD countries has evolved over two decades, focusing on Canada, and considers implications for destination and origin countries. Using harmonised data on foreign-born and foreign-trained doctors and nurses, we analyse stocks and annual inflows across OECD countries since 2000 and benchmark reliance through a foreign-trained dependency ratio. Results demonstrate sustained growth in migrant health worker stocks and inflows, with international migration contributing substantially to workforce expansion. Canada exhibits amongst the highest foreign-trained dependency ratios for doctors, whilst recent years have shown marked acceleration in migrant nurse inflows. Census microdata reveals increased mobility accompanies rising "brain waste", with only a minority of foreign-born foreign-trained physicians and nurses working in their trained profession. Policy frameworks have adapted through targeted migration channels and credential recognition reforms, yet further alignment is needed so admission, recognition and registration proceed cohesively. Following the WHO Global Code of Practice on International Recruitment of Health Personnel, closer cooperation with origin countries is essential to ensure mobility benefits both source and destination nations.
Prophylactic ureteral catheterization (PUC) facilitates ureteral identification during colorectal surgery, but little is known about outcomes when catheterization is performed by the index colorectal surgeon rather than a separate surgeon. We performed a retrospective cohort study using the American College of Surgeons National Surgical Quality Improvement Program targeted colectomy and proctectomy data from 2012 through 2024. Adult patients undergoing colectomy and proctectomy with PUC were classified according to whether PUC was performed by the index surgeon (IS-PUC) or separate surgeon (SS-PUC). Temporal trends, patient and operative characteristics, postoperative outcomes, and operative time were compared using unadjusted analyses and multivariable regression. Among 24,072 cases, catheterization was performed by the index surgeon in 1,365 cases (5.7%) and by a separate surgeon in 22,707 cases (94.3%). IS-PUC remained uncommon, showed no significant linear increase over time, and was more frequent in robotic operations, colectomy, non-elective cases, women, and older patients. After adjustment, IS-PUC was not associated with higher odds of overall complication, serious complication, urinary tract infection, ureteral injury, or mortality. IS-PUC was associated with shorter operative time (β -10.47minutes, 95%CI -16.58 to -4.36; p<0.001). IS-PUC remained uncommon nationally and was associated with shorter operative time, while no statistically significant differences in adjusted 30-day outcomes were observed compared to SS-PUC. These findings provide hypothesis-generating data regarding IS-PUC in selected settings and warrant prospective evaluation of case selection, workflow, training, and credentialing.
To determine the prevalence of visual field (VF) defect among Indian driving licence (DL) holders and to evaluate their eligibility according to UK Driver and Vehicle Licensing Agency (DVLA) visual fitness standards. Design: This hospital-based cross-sectional observational study included individuals holding a valid Indian DL who were actively engaged in driving and visiting a tertiary care center in Western India. Participants underwent detailed demographic and driving history assessment, visual acuity (VA) evaluation, comprehensive anterior and posterior segment examination, and binocular Esterman visual field testing using the Humphrey Field Analyzer. VF results were interpreted according to UK-DVLA criteria due to the absence of defined national standards. Data were analyzed using descriptive statistics. A total of 1900 participants were included in the analysis. The mean age was 47.6 years (range, 18-82 years), and 93% were male. The best corrected visual acuity in the better eye was ≥6/18 in 99% of participants. Binocular VF defects were detected in 86 individuals (4.5%). All 86 participants with VF defects failed to meet the more stringent DVLA Group 2 criteria. Of these, 31 participants (1.6% of the total sample) also failed to meet the Group 1 criteria. VF defects were most frequent in 61-70 years (29%). Glaucoma (46.8%) was the leading cause, followed by retinal diseases (25.5%) and cataract (10.6%). Night-driving glare was reported by approximately one-third of participants. A measurable proportion of active drivers were found to have VF defects that would disqualify them under international standards, despite having normal VA. Incorporating standardized VF testing into driver licensing and periodic renewal, with stricter reassessment beyond 40 years of age, could substantially improve road-traffic safety.
State legislative initiatives that were started in 2023 to streamline the licensing of internationally trained physicians (ITPs) have garnered bipartisan interest and support across the country. The new approach, more broadly applicable than previous efforts, precludes a requirement for Accreditation Council for Graduate Medical Education-accredited graduate medical education conducted in the United States. The change is the most recent development in our nation's long and winding history of licensing international medical graduates (IMGs). At the turn of the 20th century, only about 100 IMGs presented to state medical boards each year for licensure. Medical graduates around the world who sought quality postgraduate training opportunities, including those from the United States, looked to Europe. Nativist sentiment and state and federal laws in the 1920s discouraged or prohibited immigration for many internationally educated or trained physicians. That changed substantially during and after World War II when a population surge, an increase in physician refugees, and, later in the 1960s, relaxed immigration laws combined with a robust expansion of hospitals to shift the medical regulatory landscape. The result was greater receptivity to IMGs, with concerns about prevailing credentialing models predicated on recognition by state medical boards of "approved" international medical schools. The establishment of the Educational Commission for Foreign Medical Graduates in the 1950s mirrored a broader shift toward evaluation of persons and their capabilities. Recent demographic pressures (for example, a growing and aging patient population and a maldistributed and insufficient physician workforce) are prompting a flurry of state legislative initiatives to improve access to care and welcome more IMGs, especially ITPs, in a trend that runs counter to growing federal restrictions on immigrants and international workers.
This study explores the challenges experienced by Malaysian nurses working in Singapore, Saudi Arabia, and Brunei. Global nurse migration has intensified in response to workforce shortages and transnational healthcare demands. Although the experiences of internationally educated nurses have been widely examined, limited research has focused on the context-specific challenges encountered by Malaysian nurses across different host-country environments. A qualitative design was employed. In-depth virtual interviews were conducted with 12 Malaysian nurses recruited through purposive and snowball sampling. Interviews were transcribed verbatim and analyzed using thematic analysis with the support of NVivo software. The study adhered to the Consolidated Criteria for Reporting Qualitative Research (COREQ) guidelines to ensure methodological rigor and transparency. Three themes were identified: (1) professional and practice challenges, (2) social and cultural challenges, and (3) psychological and interpersonal challenges. Participants reported experiences of restrictive credentialing systems, intensified workload expectations, technological and systematic adaptation pressures, dietary and cultural adjustment, and psychological stress. The nature and intensity of these challenges varied across host countries, reflecting differences in regulatory frameworks, institutional cultures, and sociocultural environments. The findings demonstrate that migrant nurses' experiences are shaped not only by individual adjustment processes but also by structurally mediated and context-dependent factors within transnational healthcare systems. This study highlights the importance of host-country-sensitive and stakeholder-specific strategies to promote equitable professional integration, psychological well-being, and long-term workforce sustainability. Nursing leaders and healthcare institutions should implement culturally responsive orientation, structured mentorship, and supportive workplace environments to facilitate the professional integration and well-being of migrant nurses. Coordinated transnational policies are needed to address institutional, regulatory, and professional barriers affecting migrant nurse integration.
Point-of-care ultrasound (POCUS) has become an increasingly important component of perioperative medicine, supporting real-time assessment of cardiovascular function, pulmonary pathology, gastric content, airway anatomy, vascular access, regional anesthesia, and perioperative complications. Perioperative POCUS is relevant to anesthesiologists and to the broader perioperative team, including critical care clinicians, pain physicians, emergency clinicians, surgeons, and ultrasound educators who participate in perioperative diagnosis, procedures, resuscitation, and postoperative care. Despite its growing clinical relevance, POCUS education in anesthesiology and perioperative medicine remains heterogeneous, with variable curricular scope, inconsistent assessment strategies, and persistent barriers related to faculty expertise, protected training time, equipment access, and competency verification. This narrative review used a transparent, targeted search strategy across biomedical and education databases, with adapted PRISMA reporting elements used to describe sources, search concepts, and selection boundaries while preserving the interpretive purpose of a narrative synthesis. Simulation-based education offers a practical and ethically sound approach for teaching POCUS before learners perform examinations in high-stakes perioperative environments. This review synthesizes educational theory, perioperative POCUS competency frameworks, empirical ultrasound simulation evidence, cross-disciplinary procedural simulation literature, and assessment scholarship to propose an integrated training model for perioperative POCUS. We organize simulation-based POCUS education into six complementary models: low-fidelity task training, standardized-patient and peer scanning, high-fidelity physiologic simulation, hybrid operating-room crisis simulation, virtual and augmented reality platforms, and longitudinal simulation-based mastery learning. Effective perioperative POCUS education should progress from cognitive preparation and deliberate image acquisition practice to interpretation, clinical integration, documentation, and team-based decision-making. Assessment should combine image-quality rubrics, interpretation tests, entrustable professional activities, objective structured clinical examinations, image portfolios, and longitudinal workplace-based feedback. Because the evidence base differs across simulation modalities and assessment tools, programs should distinguish empirically tested instruments from locally adapted or theoretical tools and should validate competency thresholds before using them for high-stakes credentialing. Key research priorities include multicenter validation of competency thresholds, comparative effectiveness studies of simulation modalities, cost-effectiveness analyses, faculty development models, responsible integration of artificial intelligence, and studies linking simulation-based training to clinical performance and patient outcomes. Simulation is not a substitute for supervised clinical scanning; rather, it is a bridge between theoretical knowledge and safe, competent bedside practice.