Personality and mental healthBarbera E Van Reijswoud, Nikola Doubkova, Gina Rossi, Arno van Dam, Wiebren Markus, Kasia Uzieblo
Personality disorders (PDs) are associated with significant clinical and societal consequences and are highly comorbid with other psychiatric conditions. In forensic mental health settings, PD diagnoses are particularly relevant because they are linked to antisocial behavior, recidivism risk, and specific treatment needs. However, empirical knowledge about the prevalence of PD diagnoses in outpatient forensic mental health (OFMH) care is limited. We aimed to conduct a comprehensive study of the prevalence of PD diagnoses in OFMH institutions and to describe the demographic, clinical, and legal characteristics of individuals with PD diagnoses. Data were collected from OFMH institutions across the Netherlands for all adult individuals who received treatment in 2023. Fifteen institutions provided usable data, resulting in a total sample of 10,560 individuals. Descriptive analyses were conducted to estimate the prevalence of PD diagnoses and to examine differences across individual characteristics and treatment variables. Overall, 19.3% of all individuals were diagnosed with at least one PD. PD was the primary diagnosis in 12% of all individuals and an additional diagnosis in 7.3%, which seems to indicate that PD diagnoses are under-recognized. The most frequently recorded specific PD diagnoses were other specified or unspecified PD, followed by borderline PD and antisocial PD. PD diagnosis prevalence was higher among female individuals, middle-aged individuals, individuals receiving voluntary treatment, and those involved in more serious violent offenses. These findings provide large-scale prevalence data on PD diagnoses in Dutch OFMH and highlight the importance of systematic assessment of personality pathology in forensic outpatient populations.
BACKGROUND: Health care organizations increasingly rely on business associates (BAs) to provide clinical, administrative, and technology services that require access to protected health information. While the Health Information Technology for Economic and Clinical Health (HITECH) Act and the Health Insurance Portability and Accountability Act (HIPAA) Omnibus Rule extended legal liability to BAs, the frequency and characteristics of data breaches involving BAs have not been systematically tracked across the entire post-HITECH reporting era. Understanding these trends is critical for health information managers and cybersecurity professionals who are directly responsible for managing third-party risk. OBJECTIVE: The author examined the longitudinal trends in BA involvement in health care data breaches reported to the US Department of Health and Human Services (HHS) Office for Civil Rights (OCR) from 2009 to 2025, including changes in frequency, breach mechanisms, breach locations, and severity profiles of BA-involved incidents across 3 regulatory periods. METHODS: The author conducted a retrospective longitudinal analysis of health care data breaches (N=6612) reported to the HHS OCR breach portal between October 2009 and December 2025. The author operationalized BA involvement as breaches reported by BA entities or flagged as BA-related. Using logistic regression models, the author estimated annual trends in BA involvement, breach mechanism, and breach location. Chi-square tests assessed associations between BA status and breach characteristics across 3 regulatory periods: pre-Omnibus (2009-2013), post-Omnibus (2014-2019), and 2020-2025. Proportion tests compared BA-involvement rates across periods. RESULTS: BA-involved breaches accounted for 1950 of 6612 (29.5%) incidents and 285,718,494 (48.8%) of all affected individuals. The annual BA-involvement rate increased from 22.1% in the pre-Omnibus period to 36.6% in the 2020-2025 period (z score=8.29, P<.001). Logistic regression confirmed an 8% annual increase in the odds of BA involvement (odds ratio [OR] 1.08, 95% CI 1.07-1.10; P<.001). Hacking/IT incidents shifted from a minority of incidents to the dominant breach mechanism (OR 1.41 per year, 95% CI 1.39-1.44; P<.001), and the odds of network server breaches increased by 29% per year (OR 1.29, 95% CI 1.26-1.31; P<.001). BA-involved breaches were significantly more concentrated in hacking (1282/1950, 65.7% vs 2351/4662, 50.4%) and network server locations (1084/1950, 55.6% vs 1435/4662, 30.8%) compared with non-BA breaches (P<.001). The proportion of mega breaches (≥100,000 individuals) also increased annually (OR 1.16, 95% CI 1.13-1.19; P<.001), with BA-involved breaches exhibiting a significantly higher rate of mega breaches (12.4% vs 8.2%; χ21=28.44; P<.001). CONCLUSIONS: Building on prior evidence linking BA involvement to breach severity, this study demonstrates that BA-involved health care data breaches accelerated substantially across the post-HITECH reporting era, with the steepest increase beginning in 2020. The concurrent growth of hacking and the concentration of breaches on network servers coincided with digital transformation, cloud migration, and the ransomware epidemic, which may have amplified third-party risk exposure. Health information managers and cybersecurity professionals should prioritize BA risk management strategies that account for the evolving threat landscape, including enhanced vendor security assessments and data compartmentalization requirements.
Journal of medical Internet researchMingming Deng, Weidong Xu, Fei Tang, Hong Chen, Zhen Yang, Feng Wang, Nan Zhang, Haihong Wu, Jia Li, Ziwen Zheng, Sinan Wu, Gang Hou
BACKGROUND: Risk disclosure before bronchoscopy should provide sufficient information for informed consent, but detailed text-based risk disclosure may increase procedural anxiety. Patient-specific visualization with a digital twin-based bronchoscopy simulator may help patients understand bronchoscopy and its risks in a more individualized manner. OBJECTIVE: This study evaluated whether digital twin-assisted risk disclosure reduces prebronchoscopy anxiety and improves postbronchoscopy satisfaction compared with conventional risk disclosure in adults scheduled for elective bronchoscopy. METHODS: We conducted a multicenter, parallel-group randomized controlled trial. Adults aged 18 years or older scheduled for elective bronchoscopy under local anesthesia were included. Participants were randomized to either a digital-twin informed-consent group, which received standard written information plus a physician-led oral explanation supported by a patient-specific simulator visualization, or a conventional informed-consent group, which received the same written information plus a standard physician-led oral explanation without simulator visualization. Owing to the nature of the intervention, participants and physicians were not blinded. The primary outcome was the change in self-reported anxiety after risk disclosure, measured using the visual analog scale (VAS) and the modified Amsterdam Preoperative Anxiety and Information Scale (APAIS). Linear mixed models with a group-by-time interaction were used for the main analysis. The secondary outcome was postbronchoscopy satisfaction. RESULTS: Of 150 patients assessed for eligibility, 122 were randomized and analyzed, with 61 participants in each group. Compared with conventional risk disclosure, digital twin-assisted disclosure produced greater reductions in anxiety on the VAS (group by time β=-15.89, SE 3.08, 95% CI -21.99 to -9.78; P<.001) and APAIS total anxiety score (β=-6.77, SE 0.98, 95% CI -8.71 to -4.83; P<.001). Similar effects were observed for APAIS procedure-related anxiety (β=-4.25, 95% CI -5.47 to -3.02; P<.001) and APAIS outcome-related anxiety (β=-2.52, 95% CI -3.46 to -1.59; P<.001). Clinically meaningful improvement occurred more often in the digital-twin group for VAS (30/61, 49.2% vs 4/61, 6.6%) and APAIS (33/61, 54.1% vs 6/61, 9.8%; both P<.001). Satisfaction was higher in the digital-twin group (mean 16.89, SD 2.08 vs mean 14.38, SD 1.89; P<.001). All participants completed bronchoscopy without complications or adverse conditions. CONCLUSIONS: Patient-specific digital twin-visualization during physician-led risk disclosure reduced short-term self-reported anxiety and modestly improved satisfaction. The innovation lies in using each patient's computed tomography-derived airway and lesion anatomy during consent rather than standardized text, audiovisual content, or graphic narratives evaluated previously. This multicenter trial extends digital-twin technology from bronchoscopy training to individualized risk communication. In clinical practice, the approach could supplement physician-led consent in units with computed tomography and simulator infrastructure; however, time-matched studies should establish objective benefits, workflow burden, cost-effectiveness, accessibility, and applicability to highly anxious or resource-limited populations before wider adoption.
European journal of pediatricsCeleste Cagnazzo, Ivana Ferrero, Katia Mareschi, Franca Fagioli
UNLABELLED: Biobanks are increasingly central to precision medicine, particularly in rare diseases and paediatric oncology, where small and molecularly heterogeneous populations make access to high-quality, longitudinally annotated biological material essential. This narrative review examines the scientific value of paediatric biobanking and the ethical, regulatory, and organisational challenges that distinguish it from adult biobanking. Relevant scientific literature, European and Italian regulatory sources, international biobanking standards, and guidance on data protection and research governance were narratively reviewed, with particular attention to paediatric oncology, rare diseases, consent and assent, secondary use, interoperability, and emerging European frameworks. Paediatric biobanks can support biomarker discovery, molecular stratification, investigation of treatment resistance, and future analyses not foreseeable at the time of collection. Their governance is complicated by evolving child autonomy, the significance of dissent, transition to adulthood, future reuse of samples, and the distinction between consent to sample donation and the legal basis for processing associated personal data. Quality management, traceability, interoperable metadata, and controlled access are essential to preserve scientific utility. Emerging frameworks, including the European Health Data Space and EDPB guidance, favour a shift from one-time consent towards accountable life-cycle governance. CONCLUSION: Paediatric biobanking should be conceived as a longitudinal research infrastructure rather than a storage activity. Sustainable models must integrate evolving autonomy, robust ethical oversight, data protection, quality, interoperability, and responsible secondary use while preserving irreplaceable biological resources for future research. WHAT IS KNOWN: • Biobanks are essential to precision medicine and are particularly valuable in rare diseases and paediatric cancer. • Paediatric biobanking raises specific issues concerning parental consent, assent, future use, and transition to adulthood. WHAT IS NEW: • Emerging European frameworks support a shift from static consent towards accountable life-cycle governance of samples and data. • A European paediatric sample-data continuum could connect biospecimens, longitudinal clinical information, omics data, and evolving participant preferences across infrastructures.
Journal of medical Internet researchLuis Madeira, Cíntia Águas, Meryam Schouler-Ocak, Jerzy Samochowiec, Silvana Galderisi, Mariana Pinto da Costa
AI is increasingly incorporated into psychiatric triage, risk prediction, passive monitoring, clinical documentation, and patient-facing conversational systems. These applications may improve access, continuity, efficiency, and pattern recognition, but they also redistribute epistemic authority and complicate responsibility when harm occurs. European regulation is developed in relation to market access, data governance, risk management, and product safety, yet remains fragmented regarding civil liability, organizational negligence, and the psychiatric standard of care. This Viewpoint examines how liability and standard of care should be understood when AI becomes part of psychiatric reasoning in Europe. It advances one central thesis: psychiatric AI requires justified integration supported by layered accountability within, but not determined by, European regulation. It presents a targeted doctrinal and normative synthesis of binding European Union instruments, regulatory guidance, selected national governance materials, and psychiatric, bioethical, legal, and digital mental health literature. It distinguishes binding law from guidance and policy, and separates ex ante regulation from ex post liability, and from professional standards of care. Four illustrative domains are analyzed: conversational or therapeutic chatbots, suicide prediction, digital phenotyping and passive monitoring, and large language model documentation. Psychiatric AI raises distinctive concerns because psychiatric judgment depends heavily on testimony, contextual meaning, therapeutic trust, risk interpretation, privacy, and liberty-sensitive decisions. Existing European instruments, including the AI Act, Medical Device Regulation, General Data Protection Regulation, revised Product Liability Directive, and European Health Data Space Regulation, establish governance duties, but do not provide a harmonized fault-based liability framework for AI-assisted health care. Regulatory compliance may inform later legal assessment, but it does not determine whether psychiatric care was reasonable. The proposed standard of justified integration requires knowledge of intended use and model limits, assessment of local and patient-level applicability, active clinical interpretation, disclosure when AI use is material to consent or trust, documentation in high-stakes decisions, and organizational audit. Accountability should be distributed across developers, deployers, and clinicians according to control and preventability. Mixed-fault scenarios are therefore likely to be common. The augmented-clinician model and layered accountability are offered as normative proposals rather than settled European legal standards. Clinicians should remain responsible for contextual, patient-centered judgment; developers for design, validation, documentation, and foreseeable misuse; and deployers for procurement, training, workflow integration, local validation, monitoring, and escalation. Future empirical research should evaluate effects on clinician reliance, documentation burden, patient outcomes, coercive interventions, therapeutic trust, and feasibility across differently resourced services.
Journal of robotic surgeryCiro Esposito, Anna Gargiulo, Claudia Di Mento, Marco Castagnetti, Vincenzo Coppola, Francesco Tedesco, Roberta Guglielmini, Maria Luisa Pirone, Chiara Caporal…
Robotic-assisted surgery offers significant technical advantages in pediatric procedures but presents complex, unresolved medico-legal challenges regarding liability. We retrospectively reviewed our ten-year experience comprising 205 pediatric robotic procedures. Technical issues related to the robot were encountered in 7 cases (3.4%). These included joystick latency (3/7), coagulation/cutting pedal malfunctions (2/7), and accidental power cable disconnections causing system shutdowns (2/7). A literature review was conducted to assess the current international state of the art regarding robotic medical liability. Although the technical events at our center did not result in clinical complications, they highlighted significant potential risks. The literature shows that specific guidelines governing human, product, and algorithm-related liability are still lacking. Robotic surgery shifts the focus from an exclusively fault-based liability of the surgeon to a network-based system involving multiple stakeholders: the surgeon, the healthcare institution, and the manufacturer. Determining whether an adverse event stems from human error, algorithmic malfunction, or a combination of both remains a critical challenge. Unlike open or laparoscopic surgery where liability is primarily attributed to the operator, robotic surgery involves a complex interaction between the surgeon's console inputs and the manufacturer's technology. Consequently, from a medico-legal standpoint, responsibility for complications should be shared among the surgeon, the hospital, and the device manufacturer.
Supportive care in cancer : official journal of the Multinational Association of Supportive Care in CancerAe Ri Kim, Kisook Kim, Hyohyeon Yoon
PURPOSE: To examine psychosocial and clinical factors associated with the intention to complete advance directives among patients with cancer undergoing treatment in South Korea. METHODS: Structured questionnaires assessed 200 patients receiving cancer treatment for their attitudes toward advance directives, subjective norm, perceived behavioral control, knowledge about advance directives, and cancer-related fatigue. Hierarchical multiple regression analysis was conducted in three steps: Step 1 included attitude and subjective norm (Theory of Reasoned Action); Step 2 added perceived behavioral control (Theory of Planned Behavior); and Step 3 incorporated knowledge and cancer-related fatigue (Extended Theory of Planned Behavior). RESULTS: Attitude, subjective norm, and perceived behavioral control significantly predicted behavioral intention, explaining 74.1% of the variance. Perceived behavioral control had the strongest effect. Knowledge and cancer-related fatigue were not statistically significant. CONCLUSIONS: These findings highlight the Extended Theory of Planned Behavior as a useful framework for understanding advance directive completion among cancer patients. Perceived behavioral control was identified as the strongest predictor of intention, underscoring the importance of enhancing patients' confidence and ability to engage in advance care planning. The results suggest that structured counseling and tailored education should be initiated early in the treatment process to support autonomous decision making that reflects patients' values and preferences for end-of-life care. Interventions that strengthen attitudes, foster supportive norms, and build perceived control may further promote advance directive planning.
BMC public healthLara Amling, Isabella Beyer, Felix Hambitzer, Nico Neu, Jonas Rickermann, Johannes Weidt, Timo Ulrichs
BACKGROUND: Russia's war against Ukraine has renewed discussion about a possible NATO Article 5 collective defense scenario in Europe. In such a situation, Germany would function as key logistical and medical hub, placing substantial strain on its healthcare system. Experience from the COVID-19 pandemic suggests that health system resilience not only depends on infrastructure but also on availability and commitment of health professionals. This study examined willingness of future health professionals in Germany to contribute beyond routine duties in such a crisis and assessed preparedness, ownership, and awareness as potential determinants. METHODS: Between 20 May and 15 July 2025, a cross-sectional online survey was conducted among German medical, nursing, and paramedic students (n = 514). Data were collected on demographics and self-assessed individual preparedness, perceived institutional preparedness, voluntary engagement as major indicator of ownership, and awareness regarding a NATO collective defense scenario. Willingness to contribute beyond routine practice was assessed across preparatory activities, crisis-specific medical tasks, and modified working conditions. Composite scores were calculated for awareness, individual and institutional preparedness, and willingness. Associations with willingness were examined using multivariable linear regression adjusted for predefined covariates. RESULTS: Overall, 48.8% considered a NATO collective defense scenario by 2030 likely, 83.3% anticipated negative effects on the German healthcare system, and 94.5% perceived the healthcare system as poorly prepared. Individual preparedness was low (median: 3 on 0-12 scale; IQR: 1-5), while recent voluntary engagement, including voluntary work during studies or apprenticeships in general or in civil aid organizations specifically, was common (59.1%). Participants showed high willingness to engage in preparatory measures and to provide care in Germany, but lower willingness to initiate trainings or to provide care for German or allied soldiers abroad. In adjusted regression analyses, higher perceived institutional preparedness, voluntary engagement, and awareness were significantly associated with greater willingness (all: p < 0.01). CONCLUSION: Willingness of future health professionals to support the German healthcare system in a NATO collective defense scenario was associated with perceived institutional preparedness, awareness, and voluntary engagement. Widespread perceptions of insufficient preparedness raise concerns about system resilience, and the associated factors might represent potential targets for policy interventions.
JAMA health forumAaron L Schwartz, Timothy Bulat, Eli Ben-Michael, Erkuan Wang, Jingsan Zhu, Emily Boudreau, Sumedha Chhatre, Soohyun Kim, David Pagnotti, Sara Riaz, Amanda Sut…
IMPORTANCE: Despite revived interest in reforming the physician fee schedule, it is unclear how policymakers should modify more than 1000 different physician service prices to promote high-value care. One systematic approach could leverage service-level utilization patterns in full-risk contracts, which have not been previously characterized. OBJECTIVE: To compare service-level utilization patterns between health care professional organizations in full-risk contracts and those in a traditional fee-for-service (FFS) payment structure, adjusted for detailed patient-level differences, and to simulate an FFS fee schedule reform that would encourage the service patterns observed in risk-based contracts. DESIGN, SETTING, AND PARTICIPANTS: This retrospective cross-sectional study used Humana Medicare Advantage claims, encounter, and administrative data from 2015 to 2019 for 585 487 beneficiaries attributed to full-risk contract, with 100% downside risk for total medical spending, and 1 153 455 beneficiaries in fee-for-service contract arrangements. Data were analyzed from September 2025 to June 2026. MAIN OUTCOMES AND MEASURES: The primary outcome was service-specific utilization (count per beneficiary-year), adjusted for beneficiary characteristics. A secondary analysis simulated a modified Medicare FFS schedule based on estimated service-level utilization differences and a supply elasticity drawn from prior literature. RESULTS: Among 1271 services examined, 940 (74%) had lower adjusted utilization in the risk cohort, and 331 (26%) had higher adjusted utilization. For 700 services (55%), adjusted utilization was at least 10% less in the full-risk cohort. For 199 services (16%), adjusted utilization was at least 10% greater. Low-level office visits and laboratory services were more common in risk-based settings, whereas higher-level office visits, hospital and emergency services, and rehabilitative therapies were less common. A simulated budget-neutral reform to the Medicare fee schedule, calibrated to shift utilization levels toward risk-based benchmarks, yielded a possible 6% increase in reimbursement to general practice physicians. CONCLUSION AND RELEVANCE: In this cross-sectional study, the association between risk-based contracts and service utilization varied substantially across 1271 individual services. Service-specific utilization levels in risk-based contracts may serve as a benchmark to guide reforms to fee-for-service prices.
Recenti progressi in medicinaNicola Gentili, Valentina Danesi, Raffaella Gaggeri, Riccardo Tessarini, Oriana Nanni, Maria Livia Rizzo, Sara Ehsani, Mario Fregonara, Martina Farina, Valeria…
This position paper examines the strategic value of clinical and outcome research data for the National Health Service, with a specific focus on the dual mandate of Scientific Institutes for Research, Hospitalization and Healthcare (IRCCS) and the role of Local Health Authorities as custodians of extensive Real World Data repositories. Although the European regulatory framework - represented by the GDPR (Art. 89) and the upcoming European Health Data Space (EHDS) - alongside the Italian Privacy Code (Art. 110), provides solid legal bases for the secondary use of health data for scientific purposes, a significant gap persists between the potential of these informational assets and their effective exploitation. The document, resulting from a multidisciplinary collaboration involving researchers, legal experts, decision-makers, Data Protection Officers, Ethics Committees, and patient representatives, identifies current operational criticalities and proposes three priority strategic directions. First, it is imperative to systematize research governance to optimize resource allocation by integrating privacy by design principles and promoting interoperability standards and Federated Learning architectures. Second, the paper advocates transparency in management processes, urging institutions to move beyond the ineffective paradigm of security through obscurity in favor of verifiable architectures and clear traceability of data flows. Finally, the systematic development of the data stewardship function is recommended. Rather than acting as a bureaucratic control, the data steward should provide strategic mentorship and high-level consultation, bridging scientific research needs and regulatory compliance requirements. In conclusion, personal data protection must not be perceived as a barrier to biomedical progress, but as an enabling framework based on shared responsibility, safeguarding patients' rights while ensuring high standards of research excellence.
Australian occupational therapy journalAleksandra Westcott, Lorrae Mynard, Gabrielle Pitt, Susan Darzins
INTRODUCTION: Identifying and addressing the support needs of forensic mental health patients in daily life occupations is critical yet complex due to the health comorbidities and environmental restrictions impacting their participation. Occupational therapists support forensic patient recovery by facilitating their performance in daily life occupations required at home and in the community. Standardised assessments of daily living are important for guiding interventions. The Home Support Needs Assessment (HSNA) is a standardised measure identifying unmet support needs in daily life occupations. The aim of this study was to evaluate its initial acceptability and feasibility for occupational therapists' use in a forensic mental health setting. METHODS: An exploratory convergent, parallel mixed-methods design was used. Semi-structured interviews with five forensic occupational therapists explored their perspectives about using the HSNA in practice. Interview transcripts were analysed using reflexive thematic analysis. HSNA data were extracted from 13 patient medical records and summarised using descriptive statistics. CONSUMER AND COMMUNITY INVOLVEMENT: There was no consumer and community involvement in this research as the focus of the study was on occupational therapists. FINDINGS: Three overarching themes were generated: value of the assessment, informed care planning, and applicability to the environment. The HSNA was found to structure observations, facilitate discussions about daily life occupations, and clarify ongoing support needs. An over-support of some needs emerged as a unique factor of the forensic mental health environment. Some items were viewed as not applicable to the setting. CONCLUSION: The HSNA highlighted that the safety focus of the secure environment inadvertently limited opportunities for patients' involvement in daily life occupations. Acceptability was associated with enabling holistic occupational assessment. Further tailored training may increase overall implementability.
Nursing philosophy : an international journal for healthcare professionalsTove Stenman
Confidential conversations constitute an important, still insufficiently explored, aspect of palliative care. While described as valuable in clinical practice, their relational and existential significance remains difficult to conceptualise. This article examines confidential conversations through a philosophical dialogue between empirical insights from specialised palliative care and Paul Ricœur's philosophy of Homo Capax. Ricœur is not applied as a theoretical framework; rather, confidential conversations both illuminate and invite further reflection on his understanding of capability, vulnerability, practical wisdom, solicitude, and narrative identity. The article is based on a philosophical reflection of a synthesis of four qualitative studies conducted in specialised palliative care. It begins from recurring tensions within confidential conversations concerning spontaneity and structure, safety and uncertainty, everyday small talk and existential disclosure, professional responsibility and interpersonal presence. These tensions remain unresolved and are understood as relational conditions through which confidential conversations become possible. Dialogue with Ricœur suggests that confidential conversations can be understood as fragile relational events in which capability and vulnerability are mutually constitutive rather than opposed. This interpretation invites further philosophical reflection on autonomy, asymmetrical vulnerability, and the limits of practical wisdom. To deepen these questions, perspectives from Martin Buber and Hartmut Rosa are brought into dialogue with Ricœur, illuminating how confidential conversations become encounters characterised by responsiveness and resonance while remaining situated within asymmetrical relationships of care. This article suggests that confidential conversations are less understood as communicative interventions or professional techniques than as relational events in which meaning emerges through responsiveness under conditions of suffering, finitude, and institutional constraint. Their significance lies in the possibility that patient and nurse become responsive to one another within a relationship that neither fully controls. The article offers a philosophical interpretation of confidential conversations grounded in empirical experience.
Health affairs (Project Hope)Anna C Holdiman, Dale S Mantey, Tim Mercer, Alexander Testa, Shreya Jain, John Embers-Weems, Kasey Claborn, Justin Benzer
Timely access to substance use disorder (SUD) treatment is critical to improving health outcomes, yet treatment delays remain a barrier. Using national Treatment Episode Data Set-Admissions data from the period 2017-22, we conducted the first national study to examine the association of referral pathways and housing status with treatment delays among 962,702 first-time SUD admissions. Compared with individual referrals, criminal legal referrals were associated with more than twice the odds of delayed admission. This association differed by housing status and was strongest among people experiencing homelessness. These findings suggest that homelessness may intensify barriers to timely SUD treatment for people referred via criminal legal referral pathways. Our results are concerning in light of the 2025 executive order, "Ending Crime and Disorder on America's Streets," which emphasizes the use of civil commitment and institutionalization for people experiencing homelessness and people with SUD. To improve treatment retention and reduce substance use, policy efforts should prioritize removing administrative and legal barriers to SUD treatment. Low-threshold treatment models and treatment with low barriers to participation should be expanded.
Mayo Clinic proceedingsPritish K Tosh, Brian W Decker, Ashton L Boon
Cybersecurity has become a critical determinant of patient safety, business continuity, and organizational resilience in health care. Health care organizations are increasingly targeted by ransomware, data theft, and related attacks that disrupt clinical operations, threaten patient safety, delay care, and compromise sensitive information. Although often viewed as technical failures, many incidents originate in routine human behaviors, including phishing responses, credential misuse, unsafe downloads, and inappropriate use of personal devices or applications. This review focuses on clinician-level actions that can reduce both personal and organizational risk, including strong and unique passwords, multifactor authentication, phishing recognition and reporting, timely software updates, secure network use, careful management of personal devices and apps, and avoidance of risky removable media or untrusted downloads. It also emphasizes preparedness for extended network downtime, including familiarity with business continuity processes for documentation, ordering, communication, and care coordination when core digital systems are unavailable.
Supportive care in cancer : official journal of the Multinational Association of Supportive Care in CancerKouthar Sulaiman Al-Alawi, Hana Harib Al Sumri, Amal Sulaiman Al Fahdi, Moon Fai Chan, Zayana Talib Al Kayoumi, Mohammed Al-Azri
PURPOSE: Mothers diagnosed with breast cancer in collectivist, faith-oriented societies face dilemmas regarding the timing, manner, and extent of disclosure of their illness to their children and extended family members. However, evidence addressing this issue within Arab contexts remains limited. This phenomenological qualitative study explored how Omani mothers with breast cancer navigate disclosure, interpret familial and communal responses, and employ coping strategies within sociocultural and religious frameworks. METHODS: In-depth semistructured interviews were conducted in Arabic with 18 Omani mothers diagnosed with stage I-III breast cancer, parenting at least one child aged 6-18 years. Participants were recruited from a national cancer care center in Muscat. The interviews were audio-recorded, transcribed verbatim, translated into English, and analyzed using the framework method, supported by NVivo. RESULTS: Three themes emerged: (1) illness disclosure and communication strategies; (2) family and community responses to the diagnosis; and (3) coping strategies grounded in faith, patience, and behavioral adjustment. Women's experiences were shaped by maternal roles, anticipated stigma, and faith-informed interpretations of illness. Disclosure decisions influenced the mobilization of support within kinship networks. Furthermore, coping mechanisms integrated religious meaning-making with efforts to maintain normalcy. CONCLUSION: These findings underscore the need for culturally responsive, family-centered psychosocial care in cancer services.
Journal of robotic surgeryJianquan Shi, Na Zhuo, Can Wang, Basang Phuntsok, Jin Hu
Surgical robots are high-end medical equipment that deeply integrates surgery with mechanical engineering, control science, materials science, and information science. This study characterises the technological structure and innovation landscape of China's surgical robotics field through patent bibliometric analysis, identifying its developmental stages and weak links so as to inform research-and-development planning and industry-academia-hospital collaboration. Chinese invention patents granted in the field of surgical robotics were retrieved from the China National Key Industry Patent Information Service Platform. 8,781 patents with application years 2003-2025 were included. Descriptive and evolutionary analyses were performed across five dimensions: annual trends, International Patent Classification (IPC), innovation entities and collaboration, application fields, and key technology directions. Annual applications rose sharply from 562 in 2017 to a peak of 1,585 in 2021. The primary IPC subclass A61B34 (surgical robot systems) dominated with 4,809 patents (54.77%), followed by A61B17 (surgical instruments), A61B1 (endoscopes) and B25J9 (manipulators), whereas supporting subclasses such as image processing (G06T7, 1.29%) and force/torque measurement (G01L, 0.33%) each accounted for less than 2%. Enterprises accounted for 69.53% of first applicants and hospitals/medical institutions for only 6.49%; cross-institutional joint applications comprised merely 5.51%. Orthopaedics (712 patents), laparoscopic minimally invasive surgery (711), and percutaneous puncture/biopsy/ablation (670) were the leading application fields, with 65.66% of patents being generic-platform oriented. Among the patents with a recorded legal status, 91.5% remained in force, providing an aggregate quality indicator. Vision/imaging and display was the densest technology direction (1,984 patents, 22.59%), whereas force feedback/haptic perception (7.27%), artificial intelligence (2.59%) and single-port techniques (0.76%) remained under-represented. China's surgical robotics innovation has shifted from technology tracking to autonomous expansion, with an enterprise-led, whole-system-driven landscape largely established. Persistent weaknesses in core components and force sensing, low hospital patenting, and lagging frontier layouts call for strengthening fundamental links, medical-engineering collaboration mechanisms and differentiated technology directions.
Ulusal travma ve acil cerrahi dergisi = Turkish journal of trauma & emergency surgery : TJTESYusuf Atan, Muhammed Fatih Yaman, Ibrahim Uzunlu, Huseyin Cagri Sahin, Muhammed Oduncu, Mehmet Ali Yıldız, Mustafa Bilal Ceylan, Serkan Bayram
BACKGROUND: The objective of this study was to examine the characteristics of medical malpractice claims related to major joint dislocation cases. METHODS: Our database was used in the study to analyze major dislocation cases involving medical malpractice that were closed between 2018 and 2024. A complete and detailed dataset was collected for each case. This included information such as patients' demographics (age and sex), the specific anatomical location of the dislocation (ankle, knee, hip, wrist, elbow, shoulder, and acromioclavicular joint), the underlying cause of the dislocation, rationales for the claim, complications, and unique characteristics of each case. RESULTS: This retrospective study analyzed 64 cases of major joint dislocation referred to the Council of Forensic Medicine between 2018 and 2024. The mean age of patients was 30.21±15.3 years, with 60.9% being male and 39.1% being female. Upper extremity dislocations accounted for 78.1% of cases, with the elbow being the most common site. Patients were treated at university hospitals (12.5%), education and research hospitals (57.8%), and private hospitals (19.7%). Complications were observed in 50 patients (78.1%), with restricted joint mobility being the most common complication. The most prevalent complaint was delayed diagnosis (37.5%), followed by inappropriate postoperative management and negligence. The board deemed 35.9% of cases as malpractice, with a significant association between conservative treatment and malpractice. In 22 cases with malpractice rulings, the physician was deemed culpable, whereas in one case, malpractice was assigned to a healthcare worker. CONCLUSION: The primary causes of malpractice claims in major joint dislocation cases were delayed diagnosis and inadequate postoperative care. Conservative treatment was associated with high rates of medical malpractice. To reduce the risk of medical malpractice, it is necessary to standardize early diagnosis methods and ensure comprehensive postoperative follow-up.
Health expectations : an international journal of public participation in health care and health policyAlice Kim, Bronwen Merner, Mark Taylor, Yingyi Luo, Fabian Cannizzo, Alan Petersen, Clara Gaff, Ainsley J Newson, Kate Marchant, Louse Keogh
INTRODUCTION: The translational nature of genomics highlights the importance of developing a robust genomic data governance framework. To inform the development of such a framework for Australia, we conducted a scoping review to identify genomic data governance and management differences between research and clinical care. METHODS: For this scoping review, four databases were searched and 9528 relevant articles published between January 2013 and October 2024 were identified. After screening, 43 empirical, legal and theoretical/commentary articles were included. The differences reported to affect genomic data governance and management practices across clinical and research settings were extracted and synthesised. RESULTS: Fifteen empirical articles revealed that the 'community' and the 'workforce' reported different consent priorities and differing understandings of the expected benefits of providing genomic data for research. Three legal articles reiterated the influence of regulatory regimes on genomic data practices and rights. Lastly, all twenty-five theoretical/commentary articles were authored by researchers; none by community representatives. While 3/25 articles described the genomic data practices of rare and undiagnosed disease patient populations, 22/25 examined the ethical, legal and social implications arising from genomic data. Among the latter, 14/22 proposed 'solutions' to address identified genomic data challenges associated with consent, returning research genomic data to patients and advancing precision medicine. CONCLUSION: Differences in understanding, expectations and regulatory regimes can challenge genomic data governance and management practices and perceptions. Considering the implications of these challenges, meaningful community involvement will be critical in developing a governance framework that responsibly leverages genomic data to deliver more equitable health care. LIVED EXPERIENCE OR PUBLIC CONTRIBUTION: Members of the Genetic, Undiagnosed and Rare Disease (GUARD) Collaborative - the LINEAGE Consortium's Community Advisory Group partner - Emma Bonser, Monica Ferrie, Alex Fulton, Caroline Kiefer, Kate Marchant, Tony Neilson, Maya Pinn, Tania Prior-Smith, Heather Renton, Susie Roczo-Farkas and Joel Taggart contributed community perspectives and critical reflections during discussions of early findings, informing the development of this manuscript. Kate Marchant, a LINEAGE-GUARD member, is an author of this manuscript, contributing critical revisions and approving the final manuscript.
Chaos (Woodbury, N.Y.)Xu Wang, James Macinko, Maurizio Porfiri, Rifat Sipahi
Gun-related violence in the U.S. threatens public health and strains the healthcare system. Prior work suggests that self-protection is a key driver of gun prevalence in the U.S., whereby Americans seek to acquire a gun when they fear that they themselves or their loved ones may be at risk of violence. The more the gun homicides take place in a city, the stronger the tendency to own a gun by its residents. While it is tenable that economic conditions may modulate the strength of this association, we know little about how economic hardship shapes gun ownership in the U.S. Leveraging mutual information and time-series symbolization, and considering suicides with firearms as a proxy of gun prevalence, we examine how economic indicators modify the association between gun homicides and gun prevalence using a cross-sectional comparison of 884 metropolitan/micropolitan statistical areas in the U.S. and a temporal analysis of national monthly trends. Across these areas, gun prevalence rises roughly twice as fast with gun homicides in high income-inequality settings. Nationally, gun homicide-gun prevalence association emerges only when Economic Policy Uncertainty changes are sufficiently large. These findings suggest that reducing inequality and elevating economic confidence past a critical threshold may dampen gun prevalence and help mitigate public-health impacts of gun violence.
Health expectations : an international journal of public participation in health care and health policyCorey Adams, Lorelle Bowditch, Mia Bierbaum, Ramya Walsan, Jennifer Morris, Elizabeth Manias, Nicole Youngs, Lanii Birks, Jeffrey Braithwaite, Ashfaq Chauhan, …
BACKGROUND: The Statutory Duty of Candour (SDC) legally requires healthcare organisations to notify patients, families, and carers who experience a serious adverse patient safety event (SAPSE), provide an apology, and explain steps taken to prevent recurrence. However, despite growing international adoption of SDC, evidence on its implementation and impact on patients and families ('consumers') remains limited. This study examined consumer awareness, understanding, and lived experiences of SDC in Victoria, Australia, two years after its introduction. METHODS: A mixed-methods study integrated data from an online survey and semi-structured interviews with healthcare consumers in Victoria, Australia. Descriptive analysis was undertaken for quantitative items, while reflexive thematic analysis was applied to qualitative data from survey free-text responses and interview transcripts. RESULTS: In total, 80 consumers participated: 72 completed the survey and 13 completed interviews, with five participating in both. Although nearly two-thirds (61%) had no prior knowledge of SDC, over three-quarters (78%) perceived it as useful. Among those who had experienced an adverse event, half reported that staff were not open following the incident, over half reported that no post-incident meeting occurred, and satisfaction with meetings was low (26%). Six themes were identified: (1) Candour as Moral Reassurance; (2) Persistent Scepticism and Conditional Trust; (3) Limited Awareness and Accessibility of SDC; (4) Genuine Apology for Trust Repair; (5) Emotional Labour, Power, and the Risk of Re-traumatisation; and (6) Demonstrating Accountability with Organisational Learning and Improvement. An overarching theme, Candour as a Relational Process for Trust, described how trust was tested, repaired, or further eroded through SDC processes following an adverse event. CONCLUSION: SDC holds significant potential to repair trust following adverse events, but its impact depends on how it is enacted. When delivered with empathy and meaningful follow-up, SDC supports repair of trust. However, when experienced as procedural or defensive, SDC may compound distress and further erode trust. Therefore, SDC must be embedded not just as a regulatory requirement, but as a relational and person-centred practice for patients and families. PATIENT OR PUBLIC CONTRIBUTION: Healthcare consumer representatives were part of the research team, assisting with the study design, data analysis, and article writing.
The Medical journal of AustraliaAshleigh Hooimeyer, Annim Mohammad, Alice Fabbri, Lisa Parker, Kellia Chiu, Barbara Mintzes
OBJECTIVES: To analyse the extent and patterns of pharmaceutical industry funding of patient groups in Australia between 2013 and 2022, including the proportion of groups' income derived from industry payments in 2022. STUDY TYPE: Longitudinal observational study. SETTING, PARTICIPANTS: Australia, 1 January 2013-31 December 2022. Public disclosures of payments to patient groups from pharmaceutical companies who were members of Medicines Australia (the trade organisation for the prescription pharmaceutical industry in Australia) between 2013 and 2022 and from non-member companies with at least five registered prescription products in Australia. MAIN OUTCOME MEASURES: Value (in Australian dollars) of reported payments to patient groups from the pharmaceutical industry and trends in payments by clinical area and over time. For patient groups that received industry funding in 2022, we also examined how this compared with their total income for that year. RESULTS: Between 2013 and 2022, 45 pharmaceutical companies disclosed $95.7 million in funding to 390 patient groups. Funding was highly skewed, with 13 groups receiving 47.9% ($45,856,940/$95,724,493) of the total payments. The median funding over the decade was $34,374 (interquartile range [IQR], $8228-$122,898) per group. The total reported payments decreased by $293,246 (95% confidence interval, $125,489-$461,006) per year, but some clinical areas, such as oncology, saw an increase. For groups that received funding in 2022, the median proportion of income derived from industry was 2.2% (IQR, 0.3%-9.3%) and nine groups had over half their income from industry. CONCLUSIONS: Industry funding of patient groups was widespread but skewed towards a small subset of groups and clinical areas. This may shift the focus of advocacy efforts towards certain conditions that align with current industry interests. Although further research is still needed on links between funding and patient group priorities, current disclosure measures may be insufficient to manage risks and access to other funding sources and additional safeguards may be needed to maintain independence.
PloS oneKundan Mukhia, S R Luwang, Md Nurujjaman, Tanujit Chakraborty, Suman Saha, Chittaranjan Hens
Scaling laws offer a powerful lens to understand complex transactional behaviors in decentralized systems. This study reveals distinctive statistical signatures in the transactional dynamics of ERC20 tokens on the Ethereum blockchain by examining over 81 million token transfers across two independent time windows: July 2017 to March 2018 and December 2019 to February 2020. Transactions are categorized into four types: EOA-EOA, EOA-SC, SC-EOA, and SC-SC based on whether the interacting addresses are Externally Owned Accounts (EOAs) or Smart Contracts (SCs), and analyzed across four equal periods (each of 3 months). To characterize and identify specific statistical patterns, we investigate the presence of two canonical scaling laws: power-law distributions and temporal Taylor's law(TL). EOA-driven transactions exhibit consistent statistical behavior, including a near-linear relationship between trade volume and unique partners with stable power-law exponents (γ≈2.3), and adherence to TL with scaling coefficients (β≈2.3). In contrast, interactions involving SCs, especially SC-SC, exhibit sublinear scaling, unstable power-law exponents, and significantly fluctuating Taylor coefficients (variation in β to be Δβ=0.51). Moreover, SC-driven activity displays heavier-tailed distributions (γ<2), indicating bursty and protocol-level activity. The gas fee analysis further supports the difference between EOA and SC, with EOA-SC transactions incurring much higher gas fees, consistent with the greater computational complexity of smart contract execution and reinforcing the structural differences between EOA-driven activity and SC involvement. These findings reveal the characteristic differences between EOA-driven and SC-driven transaction behaviors in blockchain ecosystems. By uncovering scaling behaviors through the integration of complex systems theory and blockchain data analytics, this work provides a principled framework for understanding the underlying mechanisms of decentralized financial systems.
Japan journal of nursing science : JJNSKaito Sugima, Naoko Arimori, Mayumi Uchimura, Ai Miyauchi, Shigeko Horiuchi
AIM: This study aimed to map evidence on disclosure support for communicating hereditary tumor-related information to children and adolescents and identify evidence gaps. METHODS: This scoping review was conducted in accordance with the Joanna Briggs Institute methodology and reported in accordance with PRISMA-ScR. Guided by the Population-Concept-Context framework, we identified literature addressing support for disclosing hereditary tumor-related information to children aged ≤ 18 years. PubMed, MEDLINE, CINAHL, and the Cochrane Library were searched through April 2025, without language or study design restrictions. Data were charted and synthesized according to resource characteristics, support content, theoretical foundations, and evaluation approaches. RESULTS: Ten studies described eight resources, including booklets, picture books, decision-support tools, educational programs, and a multiple-family discussion group. Most resources focused on elementary school-aged children and emphasized parent-led disclosure. Common content included basic genetic concepts, disease and inherited risk information, and surveillance or preventive measures. In contrast, psychosocial elements were less consistently incorporated. Only three studies evaluated disclosure support (i.e., one randomized controlled trial, one pre-post study, and one qualitative study). Reported theoretical foundations included the Ottawa Decision Support Framework, health behavior change theories, bibliotherapy, and cognitive developmental theory. CONCLUSIONS: Only a small number of resources have been empirically evaluated, and psychosocial components were not consistently described or explicitly incorporated. Developmentally appropriate, theory-informed approaches-particularly decision-support and bibliotherapy-based resources-may help families engage in informed disclosure and build shared understanding. Future research should develop, implement, and rigorously evaluate structured interventions suitable for routine clinical practice, in collaboration with children, parents, and healthcare professionals.
JAMA network openLauren Hersch Nicholas, Scott D Halpern, Kenneth M Langa, Mario Macis
IMPORTANCE: End-of-life care for older individuals in the US frequently includes interventions that may be burdensome and inconsistent with patient preferences. Few experimental studies have assessed potentially modifiable factors associated with surrogate recommendations. OBJECTIVES: To assess whether experimentally varied patient and decision-context factors are associated with participant treatment recommendations for seriously ill older adults. DESIGN, SETTING, AND PARTICIPANTS: In this survey study, a nationally representative sample of US adults aged 18 years or older who were members of the Ipsos KnowledgePanel survey platform were surveyed from December 8 to 19, 2022. Data were analyzed from April 2023 to July 2026. EXPOSURE: Randomized vignettes with varying dementia status, advance directive status and wishes, treatment framing, physician recommendations, hospital norms for care of similar patients, patient sex, and the surrogate's relationship to the patient. MAIN OUTCOMES AND MEASURES: Whether participants recommended that surrogates choose life-sustaining treatments (LSTs) vs comfort-focused care for a hypothetical hospitalized patient aged 85 years who was severely ill, currently unconscious, and functionally dependent before admission. RESULTS: Of 6019 individuals who started the survey, 5965 (99.1%) completed at least 1 vignette response (mean [SD] respondent age, 53.7 [16.9] years; 3079 [51.6%] female), including 2004 caregivers of an adult and 3175 with chronic illness, a mobility limitation, and/or recent emergency or urgent care use. When holding other randomized vignette features constant, participants recommended that surrogates choose LSTs for 15.6% (95% CI, 14.0%-17.2%) of patients with dementia without an advance directive compared with 41.0% (95% CI, 38.8%-43.1%) of those with an advance directive requesting LSTs and 7.6% (95% CI, 6.4%-8.8%) of patients with an advance directive requesting comfort care only. For patients who did not have dementia, participants recommended that surrogates choose life-extending treatment for 38.9% (95% CI, 36.7%-41.0%), 66.3% (95% CI, 64.2%-68.3%), and 14.4% (95% CI, 12.8%-15.9%) of patients in the respective advance directive groups. CONCLUSIONS AND RELEVANCE: In this survey study of US adults, respondents were less likely to recommend that surrogates choose LSTs for patients with dementia than for patients without dementia even when advance directives requested all care possible. These findings highlight the importance of preparing patients and surrogates for care decisions through explicit discussions of goals of care and decision-making roles.
Journal of evaluation in clinical practiceAntonio Ragusa
RATIONALE, AIMS, AND OBJECTIVES: Rare catastrophic obstetric outcomes are uncommon in high-income settings but may exert an influence on clinical practice that is disproportionate to their epidemiological frequency. This paper proposes the one-per-thousand effect, a conceptual framework describing how exceptional adverse events may progressively influence clinical judgement, organisational behaviour, and intervention thresholds. Although developed in obstetrics, the framework addresses broader questions of clinical decision-making under uncertainty, patient safety, and healthcare evaluation. METHODS: A conceptual analysis was undertaken by integrating evidence and theory from obstetrics, cognitive psychology, patient safety, human factors, and defensive medicine. The framework examines how organisational memory, availability effects, hindsight and outcome bias, asymmetric accountability, and anticipation of blame may interact to shape clinical behaviour following rare catastrophic events. RESULTS: The proposed model suggests that severe but infrequent adverse outcomes may produce organisational effects that extend beyond the individual case. Through reinforcing cognitive and organisational mechanisms, isolated catastrophes may progressively lower intervention thresholds, increase intervention rates and expose a much larger population to intervention-related harms. The framework distinguishes targeted learning from identifiable failures and broader behavioural adaptation driven primarily by exceptional events rather than by proportionate evidence. CONCLUSIONS: The one-per-thousand effect offers a conceptual explanation for how rare catastrophic events may reshape routine clinical practice through organisational learning processes operating under uncertainty. By distinguishing proportionate learning from defensive adaptation, the framework provides a basis for strengthening clinical governance through prospective sequential review, just culture, structured professional support, and no-fault compensation. Although illustrated in obstetrics, the proposed model may be applicable to other high-risk healthcare settings in which rare adverse outcomes exert disproportionate organisational influence.
There are clear legal and ethical requirements for informed consent in pediatric kidney transplantation. While much is done pre-transplant to educate patients and families on the risks and benefits of transplantation and its associated medical therapies, it can be difficult to truly prepare them for the transformative nature of the transplant- how it will change their lives, their families' lives, and their view of themselves and their world. Using the lens of "transformative experiences" as described by philosopher L.A. Paul, we describe the transformative nature of pediatric kidney transplantation. We encourage the health care team to acknowledge this transformative experience, and outline practical strategies including shared decision making and patient and family engagement to help communicate with families undergoing this transformation, both before and after pediatric kidney transplantation.
JMIR formative researchCüneyt Destan Cenger, Giray Kolcu, Mehmet Ali Malkoç, Birgül Tüzün, Meral Çevik Doğan, Tuğba Saraç Sivrikoz
BACKGROUND: Defensive medicine (DM) is particularly relevant in obstetrics and gynecology (OB/GYN), where physicians face substantial medicolegal risks and malpractice-related pressures. Defensive practices may involve cost-increasing diagnostic or therapeutic behaviors and avoidance of high-risk patients or procedures. Identifying factors independently associated with DM may help inform organizational and medicolegal interventions. OBJECTIVE: This study aimed to evaluate DM attitudes among physicians working in OB/GYN clinics in Istanbul, Türkiye, and to identify professional, organizational, and medicolegal factors independently associated with these attitudes. METHODS: A cross-sectional analytical study was conducted among resident physicians, specialists, and faculty members working in OB/GYN departments in Istanbul between June 2023 and February 2024. Participants were recruited using nonprobability convenience sampling through on-site visits and an online survey. DM attitudes were assessed using the 14-item Turkish Defensive Medical Practice Attitude Scale (TDMPAS). Multivariable linear regression models with heteroscedasticity-consistent HC3 SEs were used to identify factors independently associated with the total and subscale scores. Sensitivity analyses were used to assess the potential influence of the data collection modality. RESULTS: A total of 1069 physicians participated in the study. The mean total TDMPAS score was 48.12 (SD 10.59), with mean scores of 15.65 (SD 5.21) for cost-increasing behavior, 16.07 (SD 3.24) for defensive behavior, and 16.40 (SD 5.22) for avoidance behavior. Internal consistency was good for the total TDMPAS (Cronbach α=0.880), cost-increasing behavior (α=0.879), and avoidance behavior (α=0.879) and acceptable for defensive behavior (α=0.780). In the multivariable model, dissatisfaction with working conditions (B=6.62, 95% CI 4.19 to 9.05; P<.001), partial satisfaction (B=3.90, 95% CI 1.60 to 6.20; P<.001), and a history of administrative investigation (B=3.44, 95% CI 1.37 to 5.50; P=.001) were independently associated with higher total DM scores. Malpractice training (B=-2.18, 95% CI -3.54 to -0.82; P=.002), professor status compared with resident physician status (B=-7.53, 95% CI -12.22 to -2.83; P=.002), and longer experience in OB/GYN (B=-0.15 per y, 95% CI -0.29 to -0.01; P=.03) were associated with lower mean scores. The total-score model explained 17.6% of the variance (R²=0.176; adjusted R²=0.154). The data collection modality was not independently associated with the total TDMPAS score or any subscale score and did not materially alter the primary findings. CONCLUSIONS: DM attitudes were prominent among physicians working in OB/GYN and were independently associated with professional and organizational factors. Dissatisfaction with working conditions and previous administrative investigations were associated with stronger DM attitudes, whereas malpractice training and greater professional seniority showed inverse associations with these attitudes. These findings suggest that interventions addressing working conditions, medicolegal education, and institutional support for physicians may complement financial liability protection strategies. Prospective multicenter studies are required to clarify the causal relationships and evaluate the effectiveness of such interventions.
HIV research & clinical practiceRoberta Mensah, Aaron Asinor, Saansong Omar Ansir Ahmed, Prince Owusu Adoma
INTRODUCTION: The disclosure of HIV serostatus is central to HIV care and prevention across African countries; however, the psychological experience of the period preceding disclosure has received little direct attention in the Ghanaian evidence base. The research examined the psychosocial stressors experienced by people living with HIV during the pre-disclosure phase, defined as the period between diagnosis and disclosure to a given person, in Cape Coast, Ghana. METHODS: A qualitative study design with a focus on Moustakas' transcendental phenomenological approach was used. In-depth semi-structured interviews were conducted with 24 purposively sampled people living with HIV receiving antiretroviral therapy (ART) at the Cape Coast Metropolitan Hospital in Ghana. Data analysis was done with Moustakas' phenomenological analysis, aided by Quirkos 3 software. RESULTS: Four themes and twelve subthemes were identified. Theme A, emotional stress (two subthemes), comprised anxiety, depressive experience including suicidal ideation, and the repeated rehearsal of feared outcomes. Theme B, fear (six subthemes), spanned fear of infecting a partner, discrimination, intimate partner violence, disgracing the family, losing financial support and losing employment; for one participant, fear of job loss delayed the start of ART. Theme C, blame (two subthemes), comprised anticipated blame from partners and others, and self-blame. Theme D, structural stressors (two subthemes), comprised preparing for disclosure without professional guidance, and knowledge gaps expressed as denial and supernatural attribution of HIV. CONCLUSION: The pre-disclosure phase is a critical though under-resourced clinical moment. Psychological counselling, peer support and gender-sensitive economic and safety protections should be integrated into HIV care pathways from diagnosis, before disclosure takes place.
Global health actionAugustus Osborne, Ahmed Vandy, Camilla Bangura
BACKGROUND: Gender-based violence (GBV) intensifies during emergencies, yet health and protection systems in Sierra Leone remain inadequately prepared to respond. Survivors face barriers including stigma, breaches of confidentiality, and weak referral pathways. OBJECTIVE: This study explored how health and protection systems in three districts of Sierra Leone respond to GBV during emergencies. METHODS: A qualitative descriptive study was conducted across three districts, integrating semi-structured interviews with referral pathway mapping. Purposive sampling recruited 54 participants: 48 key informants across eight stakeholder groups and 6 survivors identified through referral organisations. Data were analysed using the framework method. Data collection took place outside an active emergency; emergency-specific findings therefore reflect participant recollection rather than direct observation. RESULTS: Four themes emerged: fragmented and under-resourced clinical readiness; confidentiality failures and stigma as structural barriers; dysfunctional referral pathways and coordination gaps; and limited, inconsistent survivor-centred psychosocial care. Participants reported that emergency contraception was frequently unavailable and, in some accounts, withheld on moral grounds. Referrals to police and social welfare were described as ad hoc, reliant on personal relationships, and severely disrupted when GBV was excluded from emergency coordination structures. Counsellors were largely absent from peripheral facilities. A minority of participants reported functioning one-stop centre care. CONCLUSIONS: Participants described GBV response arrangements that were fragile in stable periods and, in their recollection of previous emergencies, substantially weakened, alongside a smaller set of components that functioned. Emergency preparedness planning would benefit from explicit attention to survivor-centred GBV care; the applicability of these district-level findings elsewhere requires further study.
Epidemiology and psychiatric sciencesNicola Reavley, Anna Ross, Rachel Green, Gayle McNaught, Amy J Morgan
AIMS: Disclosure of a mental health problem carries both risks and benefits. It can be seen as a measure of perceptions of the social environment in which people with mental health problems live, work and study. A nationally representative Australian survey conducted in 2014 showed that, in many settings, non-disclosure was more common than disclosure. This study aimed to investigate whether disclosure in a broad range of settings has changed since the 2014 national survey. METHODS: Large nationally representative surveys of Australian adults were conducted in 2014 and 2024. For each, those who reported a mental health problem or were experiencing high psychological distress (n = 1381 in 2014, n = 2613 in 2024) were asked about disclosure in multiple settings. Regression analyses were used to explore whether changes between survey years were significant at p < 0.01, adjusting for sociodemographic variables of age, gender, education level, language spoken at home, country of birth and type of mental health problem. Secondary analyses assessed the sociodemographic and mental health problem characteristics associated with changes. RESULTS: In 2024, participants were less likely than in 2014 to have disclosed to friends, partners, family members and some people in the neighbourhood, with relative risk ratios (RRRs) ranging from 0.33 (99% confidence interval [CI]: 0.23, 0.48; p < 0.001) for all family members to 0.64 (99% CI: 0.46, 0.88; p < 0.001) for some people in the neighbourhood. Workplace disclosure did not change significantly. For health professionals not involved in mental health treatment, the RRRs of disclosure were higher in 2024 than in 2014 (RRR = 1.56 [99% CI: 1.16, 2.10; p < 0.001] for disclosure to some and RRR = 2.31 [99% CI: 1.61, 3.32; p < 0.001] for disclosure to all). CONCLUSIONS: Except for disclosure to health professionals not involved in mental health treatment, there have been decreases or no changes in disclosure of a mental health problem in most settings over the last 10 years. This likely reflects both perceptions of, and actual, reductions in supportive social environments. Urgent action is needed to ensure that, for people who do disclose a mental health problem, the benefits strongly outweigh the risks.
Health research policy and systemsJustin Aunger, Jane Ferguson, Esra Alkim Karaagac, Tommer Spence, Jill Maben, Ashok Patnaik, Russell Mannion, Yingxi Zhao, Nathan Proudlove, Helen Bodenham-Chi…
Sensitive healthcare workforce research relies on credible assurances of confidentiality for participating staff and organizations. Yet, National Health Service (NHS) research governance processes can compromise these assurances even before recruitment begins, particularly through processes such as site documentation, local principal investigator (PI) requirements, research passports, and portfolio reporting. These risks are especially important for studies examining organizationally sensitive topics such as bullying, speaking up, or patient safety issues, where perceived employer awareness may reduce participation or encourage self-censorship. From March 2026, the Health Research Authority introduced reforms for staff-only studies, including streamlined site set-up, reduced site visibility, and fewer requirements for local PIs or research passports in remote studies. However, further changes are needed to better balance transparency, oversight and confidentiality. Potential improvements include dedicated pathways for sensitive organizational research, restricted-access portfolio reporting, and more centralized governance documentation. Future changes should be co-designed with researchers and NHS research and development departments to protect confidentiality and improve research productivity, while maintaining ethical standards and accountability.
PloS oneGraham Johnson, Sarah Edwards, Heather Jarman, Elizabeth Peel, Marco Pino
BACKGROUND: Breaking bad news is a core component of emergency care, but the emergency department (ED) environment of urgency, crowding, and limited privacy presents challenges for sensitive communication. Many communication frameworks originate from other specialities, but the ED has limited evidence and guidance tailored to its context. OBJECTIVE: This scoping review aimed to map the extent, nature, and characteristics of the literature on delivery of bad news in EDs, including terminology, frameworks, stakeholder perspectives, barriers and facilitators, educational resources, reported metrics, and evidence gaps. METHODS: The review followed Joanna Briggs Institute (JBI) methodology and was prospectively registered on the Open Science Framework (OSF https://osf.io/f6q59/overview). Four databases (MEDLINE, EMBASE, EMCARE, CINAHL) and grey literature sources were searched in July 2025. Eligible sources included empirical studies, training evaluations, reviews, guidelines, consensus statements, editorials, commentaries, opinion pieces, educational articles, conference abstracts, and relevant grey literature reporting on adult patients, relatives, or clinicians in ED contexts. Data were charted and synthesised narratively. RESULTS: From 7985 records, 156 publications were included. Studies originated from 26 countries, though the United States of America (USA) (n = 85) and United Kingdom (UK) (n = 18) dominated the literature. There was a rise in publications from 2010, particularly post-COVID-19. Twenty-five communication frameworks were identified; most were adapted from oncology (with SPIKES most frequently cited). Three frameworks developed specifically for ED practice (GRIEV_ING, 8S, EMTalk) were identified. Stakeholder perspectives were unevenly represented, with a predominance of healthcare professional perspectives. Reported metrics centred on clinician confidence; patient- and family-centred studies were uncommon. Barriers to effective communication consistently included time scarcity, lack of privacy, and insufficient training. CONCLUSIONS: Research on delivering bad news in EDs is dominated by educational and simulation-based studies, and is largely clinician-centred, with limited evidence of patient and family perspectives, with no studies examining long-term outcomes. Reliance on frameworks from other specialties risks overlooking the contextual specifics of emergency care. Future research should prioritise ED-centred frameworks, patient outcomes, and systemic enablers to support compassionate, effective communication in this demanding environment.
Swiss medical weeklyMichelle Raess, Annora Celant, Mirjam Mäusezahl
The structured processes of clinical medicine and epidemiology are closely aligned, with disease reporting serving as the critical interface between individual patient care and population-level public health action. In Switzerland, mandatory reporting of communicable diseases forms the backbone of national infectious disease surveillance and relies on coordinated contributions from clinicians and laboratories. The Swiss reporting system is regulated by an ordinance that defines notifiable diseases, reporting criteria and strict timelines. It encompasses severe diseases, outbreak-prone infections, and endemic or vaccine-preventable conditions, and is continuously updated to reflect evolving epidemiological threats. Accurate case classification depends on the integration of both clinical and laboratory data; incomplete reporting compromises data quality and can lead to misclassification and biased epidemiological conclusions. In recent years, reporting compliance - particularly for clinical notifications - has declined significantly. This deterioration in data completeness limits the ability to detect outbreaks, assess trends and implement timely and targeted public health interventions. Contributing factors include administrative burden, limited awareness of reporting obligations and insufficient understanding of the public health value of reporting. High-quality reporting is essential for multiple public health functions: enabling rapid containment measures such as contact tracing and isolation, supporting outbreak detection through statistical surveillance and genomic analysis, informing national health policies and vaccination strategies, and facilitating research. Surveillance data are routinely analysed and disseminated via national dashboards and international collaborations. In conclusion, although reporting imposes additional demands on clinicians, it remains a fundamental component of effective public health practice. Strengthening reporting compliance and data quality is critical to ensuring timely interventions, reducing disease burden and maintaining resilient health systems. Improved digital solutions may alleviate reporting burdens; however, sustained clinician engagement and recognition of their role in public health are indispensable.
Annals of transplantationPaulina Kurleto, Lucyna Tomaszek, Irena Milaniak
BACKGROUND Deceased organ donation is the principal source of transplantable organs; however, organ shortages remain a major public health challenge. Healthcare professionals play a pivotal role in shaping societal attitudes toward transplantation. This study aimed to identify sociodemographic, psychological, and attitudinal factors independently associated with lack of willingness to consent to deceased organ donation among nurses and physicians working in dialysis units. MATERIAL AND METHODS A nationwide cross-sectional survey was conducted in Poland between February 2023 and June 2024 among 850 nurses and 243 physicians. Data were collected using paper-based and online questionnaires, incorporating sociodemographic variables, donation-related attitudes, and validated psychometric scales assessing life satisfaction, self-esteem, self-efficacy, and empathy. The primary outcome was lack of willingness to consent to deceased organ donation. Group comparisons were performed using Mann-Whitney U and chi-square tests. Multivariable logistic regression identified independent determinants. RESULTS Overall, 35.2% of participants either declined or did not clearly express willingness to consent to deceased organ donation. Higher levels of personal distress were associated with increased odds of lack of willingness to consent (B = 0.05; OR = 1.05; 95% CI, 1.00-1.10; P = 0.04), whereas higher empathic concern was associated with decreased odds (B = -0.06; OR = 0.94; 95% CI, 0.89-0.98; P = 0.01). Belief in the safety of blood donation was linked to lower odds of lack of willingness to consent (B = -0.28; OR = 0.76; 95% CI, 0.63-0.91; P < 0.001). The strongest association was observed for acceptance of organ donation from a deceased close family member (B = -2.36; OR = 0.09; 95% CI, 0.07-0.13; P < 0.001). Donation-related beliefs demonstrated stronger associations with consent attitudes than sociodemographic characteristics. CONCLUSIONS Unwillingness to consent to deceased organ donation among dialysis staff was associated with empathy dimensions and donation-related beliefs.
BACKGROUND: Orthopedic surgery is the second most common subspecialty involved in medical malpractice claims, wherein lower limb surgery carries a higher risk of claims and involves higher compensation amounts. However, effective tools for postjudgment estimation of high compensation ratios and consistency assessment against prior similar cases after lower limb fracture surgery are currently lacking in medicolegal risk management and judicial practice. OBJECTIVE: This study aimed to develop and validate multiple machine learning (ML) models to estimate a medical malpractice compensation ratio of ≥50% in postjudgment, nonfinalized medicolegal cases, and to systematically evaluate the models' discriminative ability, stability, calibration performance, and medicolegal utility. METHODS: This study developed binary classification models based on 451 medical malpractice cases after lower limb fracture surgery in China from 2004 to 2025. Among these cases, 360 cases from eastern, northeastern, and central China constituted the development dataset and were randomly split at a 7:3 ratio into a training set (n=251) and an internal test set (n=109), whereas 91 cases from western China were held out as an independent geographical external validation set. Least Absolute Shrinkage and Selection Operator (LASSO) was used for feature selection. Logistic regression (LR), k-nearest neighbors (KNN), support vector machine (SVM), random forest (RF), and extreme gradient boosting (XGBoost) were trained using 5-fold cross-validation and grid search. Model performance was assessed using the receiver operating characteristic (ROC) curve, area under the receiver operating characteristic curve (AUROC), bootstrap resampling, calibration curves, and decision curve analysis (DCA). RESULTS: LASSO identified following 8 predictors: inappropriate surgical procedure, age, inadequate medical records, lack of informed consent, disability severity grade 1-4, sex, treatment delay, and inadequate preoperative preparation. In the test set, the LR model achieved an AUROC of 0.933, with recall, precision, accuracy, and F1-score of 0.810, 0.940, 0.872, and 0.870, respectively. Inappropriate surgical procedure and lack of informed consent were the strongest model-associated factors. Bootstrap analysis showed stable LR discrimination, and calibration was favorable, with a Brier score of 0.105. DCA suggested a potential reference value across threshold probabilities. Considering discrimination, calibration, classification performance, parsimony, and interpretability, the LR model was selected as the final model. External validation provided preliminary support for cross-regional transportability. CONCLUSIONS: ML-based models for postjudgment estimation may provide a nonbinding historical benchmark for estimating whether a compensation ratio of ≥50% is broadly consistent with previous similar cases in medical malpractice claims. Notably, the LR model showed the most favorable overall performance among the compared models in terms of discriminative ability, stability, calibration, and medicolegal utility, providing an auxiliary postjudgment reference for hospital risk management and legal departments, legal practitioners, courts, and other judicial professionals before a case becomes final or is practically concluded. TRIAL REGISTRATION: OSF Registries 10.17605/OSF.IO/EMAKT; https://osf.io/emakt/overview.
Clinical oral investigationsThanatchaporn Jindanil, Pierre Lahoud, Maxime Ducret, Raphael Richert, Jennifer K Wagner, Reinhilde Jacobs
OBJECTIVES: To provide an overview of facial scanners and scanning applications used in dentistry, focusing on clinical validation, certification status, and to identify ethical and regulatory concerns. MATERIALS AND METHODS: A literature search was performed with eligibility criteria that included studies in dentistry that used at least one facial scanner or smartphone scanning application in human facial region in any language. Scanners and applications identified from literature and International Dental Show 2025 were manually noted, and subsequently searched for detailed certification (medical, general, others) and technical information. Furthermore, studies explicitly/implicitly mention/discuss ethical and/or regulatory concerns were included. RESULTS: Ninety-five scanners and 23 smartphone-based applications were identified, of which 90 scanners and all applications were clinically validated. Six scanners (6%, FusionFaceScanner, Carestream CS9600, Planmeca ProFace, Planmeca ProMax 3D Mid, Planmeca ProMax 3D ProFace, Planmeca Viso G7) were Medical Device Regulation-certified, 49% held other certifications, and 51% had unverifiable certification status. Among 19,789 records, six scientific studies discussed ethical concerns, including ethical approval, informed consent, privacy, accuracy, and medical regulatory obligations. CONCLUSION: Despite validation, publicly accessible, verifiable medical-related certification remained limited among the identified scanners, highlighting that ethical and regulatory considerations are underreported in the scientific literature rather than absent from clinical practice. Informed consent, data privacy, accuracy, and medical device compliance were addressed in the included studies. CLINICAL RELEVANCE: As facial scans provide comprehensive information for esthetic- and facial-driven treatment planning, the findings of this study highlight the need for practitioners and researchers to remain cautious regarding device safety, regulatory compliance, and technological limitations.
TrialsKajsa Norberg Wieslander, Sara Frygner-Holm, Stefan Nilsson, Malin Lövgren, Anna Höglund, Tove Godskesen
BACKGROUND: Research is essential for improving outcomes in paediatric oncology, yet decisions about research participation often occur during emotionally vulnerable periods for families. Although children's assent is ethically required, it is not always meaningfully implemented in practice. Understanding how children, siblings and parents experience the child's involvement in the assent process, including their attitudes towards research, is crucial for promoting ethically sound research and supporting genuine child participation. The aim of this study was to describe how children with cancer, siblings and parents experience the child's assent process during research recruitment in paediatric oncology, with particular attention to its motivational and relational dimensions. METHODS: A descriptive qualitative study design. Interviews were undertaken with children with cancer (n = 11), siblings (n = 17) and parents (n = 9) regarding their experiences of recruitment to various types of research in Sweden. Data was analysed using reflexive thematic analysis. RESULTS: Two main themes were identified: a moral and emotional commitment to research, and relational assent-trust, loyalty and parental mediation. Children, siblings and parents described research participation as meaningful and morally significant in a vulnerable situation. Children's involvement in assent ranged from active participation to limited influence, with some decisions made primarily by parents. Decisions about research participation were shaped by relational dynamics, in which trust, loyalty, and emotional vulnerability and parental mediation played central roles. CONCLUSIONS: Families are strongly motivated to contribute to research in paediatric oncology. However, sustaining trust and safeguarding research integrity require consistent and meaningful implementation of children's assent. Child-centred, flexible, and context-sensitive assent processes are key, alongside ethical awareness of how relational dynamics shape children's autonomy. Recognising parents as key partners is essential for upholding both ethical standards and children's rights in paediatric research.
Quality of life research : an international journal of quality of life aspects of treatment, care and rehabilitationHimel Mondal, Shaikat Mondal
Published studies reporting newly developed questionnaires often provide detailed information on development and validation but do not clearly report how the questionnaire can be reused. Basic information such as copyright ownership, licensing, permission requirements, fees, and conditions for translation, modification, reproduction, or distribution may be missing or difficult to locate. Existing guidance, including COSMIN, focuses on methodological quality and measurement properties rather than reuse conditions. We propose that every study reporting the development of a questionnaire, scale, or structured measurement instrument include a standardized instrument reuse and licensing information table. This table should clearly report the copyright holder, applicable licence, permission and payment requirements, permitted uses, modification and translation conditions, reproduction and distribution requirements, and contact details. Such a simple reporting practice would reduce uncertainty, save researchers time, and promote transparent, reproducible, and responsible reuse of validated measurement instruments. A questionnaire should not only be validated for use; its conditions for reuse should also be clearly reported.
BMJ openMiia Rahja, Ling W Davies, Robert N Jorissen, Maria Crotty, Craig Whitehead, Keith Evans, Megan Corlis, Carly Meyer, Gillian E Caughey, Maria C Inacio
OBJECTIVES: Long-term care facility (LTCF) ownership and location can influence resident outcomes in multiple ways, with concern that they are associated with quality of care and resident outcomes. The aim of this study was to assess whether LTCF ownership was associated with risks of mortality, emergency department (ED) presentations, unplanned hospitalisations and hospital days during the first 12 months after LTCF entry, and whether these associations varied by geographical region in Australia. DESIGN: A retrospective propensity score-matched cohort study. SETTING: Registry of Senior Australians National Historical Cohort (2013-2018). PARTICIPANTS: Non-indigenous LTCF residents aged ≥65 years. EXPOSURE: LTCF ownership type: government, not-for-profit or for-profit. Analyses were stratified by LTCF geographical remoteness: metropolitan, inner regional or outer regional/remote/very remote area. PRIMARY AND SECONDARY OUTCOME MEASURES: Cox proportional hazards, Fine-Gray competing risks and negative binomial models were employed. We report adjusted HRs, sub-distribution HRs (sHR), rate ratios, CIs and cumulative incidence estimates. RESULTS: Of 205 079 residents studied, 8961 (4.4%) lived in government-run, 105 144 (51.3%) in not-for-profit and 90 974 (44.4%) in for-profit LTCFs. Compared with residents in not-for-profit LTCFs, mortality risk was higher in for-profit (HR=1.17, 95% CI 1.09 to 1.26) and government facilities (HR=1.20, 95% CI 1.08 to 1.35) located in inner regional areas (24.1% of residents). Residents in government LTCFs had lower ED presentation risk than residents in not-for-profit (sHR=0.68, 95% CI 0.57 to 0.82) and for-profit (sHR=0.61, 95% CI 0.52 to 0.72) LTCFs. Similar observations were made for unplanned hospitalisations and hospital days, and across regions. CONCLUSIONS: Government LTCF residents had fewer hospital-related events, while not-for-profit residents had lower mortality, with differences most evident in inner regional areas. Ongoing monitoring of LTCF ownership trends and their association with resident outcomes is vital for policy development.
The journal of the American Academy of Psychiatry and the LawLindsey D Ryan-Jones, Richard Rogers, Mackenzie S Baranski, Ayomide V Ayoola
Forensic evaluators commonly conduct evaluations of sexually violent persons (SVPs) but often retrofit generic risk assessments to assess SVP legal criteria. As a 20-year follow-up to "The Risky Enterprise of Risk Assessment," this article critically evaluates updated versions of common risk measures (Historical-Clinical-Risk Management Scale 20 (HCR-20V3), Sexually Violent Risk 20 (SVR-20 V2), Violence Risk Appraisal Guide-Revised (VRAG-R), Static-99R, and Risk for Sexual Violence Protocol (RSVP V2)) to determine their appropriateness for SVP evaluations. For more balanced appraisals, risk assessments have more recently considered protective factors (Inventory of Offender Risk, Needs, and Strengths (IORNS), Structured Assessment of Protective Factors-Sex Offenders (SAPROF-SO), and Short-Term Assessment of Risk and Treatability (START)), given their growth in forensic research. Importantly, some risk measures demonstrated substantial improvements. Empirical support for predicting violent sexual recidivism, the legal standard in many SVP jurisdictions, has yet to be reached. Most studies assess general sexual recidivism rather than sexual violence, per se This disconnect presents a professional challenge for evaluators in determining whether previously convicted offenders pose such a risk of sexual violence, following their criminal sentence, as to warrant indefinite civil commitment. This review underscores the need for stronger alignments between SVP legal criteria and forensic assessment instruments to solidly support their empirical use in SVP determinations.