Search Results (105)

Background: AMR causes a large global health burden, with approximately 4.95 million deaths linked to bacterial AMR in 2019, 1.27 million due to AMR directly. Although Brazil mandated prescriptions for systemic antibiotics in 2010/2011, self-medication and access without prescriptions continue, with community pharmacists playing a vital part in antimicrobial stewardship (AMS). This study examined antibiotic misuse and AMR in Brazil through community pharmacists’ perspectives, emphasising their dual role as professional actors and frontline observers of public behaviour. Methods: We conducted 20 semi-structured interviews with community pharmacists and performed reflexive thematic analysis of their accounts, repeating five independent analytic cycles to confirm thematic robustness. Results: Six themes were consistently identified as recounted by pharmacists in their practice contexts: Access and Self-Medication; Relationships with Healthcare Professionals; Knowledge and Beliefs about Antibiotics; Use and Adherence; Healthcare System Barriers; and Regulation and Enforcement. Pharmacists mentioned regular requests for antibiotics without prescriptions, drug reuse, and significant impact from community, i.e., from relatives, and peers. The common misunderstanding was that antibiotics treat viral illnesses. Structural issues, for instance GP appointment costs and long waits, made patients seek help from pharmacies. Due to regulation being applied inconsistently, pharmacies struggled to refuse unsuitable requests. Conclusions: Framed through pharmacists’ dual vantage as professionals and frontline observers, the findings highlight intertwined factors underpinning inappropriate antibiotic use in Brazil and support a multi-pronged intervention spanning health system strengthening, professional education, economic considerations, and community engagement. Full article

Background: The digitalization of medical services is promoted as a solution for improving access, quality, and efficiency within healthcare systems. In this context, the study investigates the extent to which digitalization in Romania meets the current needs of patients through a convergent analysis of user perceptions and managerial perspectives. Based on the specialized literature, the research tests two hypotheses: (H1) the implementation of digital technologies significantly contributes to improving the quality of medical services and operational efficiency; (H2) digitalization has a positive impact on patient satisfaction by facilitating access to care and improving communication with medical personnel. Methods: The study adopted methodology is cross-sectional and mixed, including an online mixed-methods questionnaire for patients, distributed between 6 and 14 May 2025, and a qualitative questionnaire with open-ended questions distributed via e-mail to managers from public hospitals through The Administration of Hospitals and Medical Services of Bucharest, between 3 and 24 March 2025. Results: In total, 125 patients and 15 hospital managers participated in the study. Statistical analysis (χ², ordinal regression) and data triangulation highlight a predominantly positive, yet heterogeneous, patient perception of digitalization, with Hypothesis H1 only partially supported (weak, inconsistent, and in some cases negative associations between technology use and perceived service quality). By contrast, H2 was robustly validated, with patient satisfaction strongly linked to tangible benefits, particularly easier access and online appointment scheduling. However, use remains limited to administrative functions, while advanced technologies such as telemedicine or electronic health records are poorly adopted. From an institutional perspective, hospitals predominantly use IT systems for internal purposes, without real patient access to their own data, no interoperability between medical units, and marginal implementation of telemedicine. This reveals a significant gap between user perception and organizational realities, emphasizing the lack of a patient-oriented digital infrastructure. Conclusions: The results highlight the potential of digitalization to enhance patient experience and service efficiency, while also pointing out structural limitations that hinder the full realization of this potential. Patient satisfaction is strongly associated with tangible benefits, particularly easier access and online scheduling, whereas the effect on perceived quality is weaker and sometimes inconsistent. There are significant disparities in digitalization levels between healthcare providers, perceived by patients as public–private differences, and gaps among public hospitals are also confirmed by managerial data. These findings suggest that a successful digital transformation of the medical system in Romania must address both technological infrastructure gaps and organizational barriers, within a coordinated national strategy that ensures interoperability, patient-centered design, and sustainable implementation. Full article

Background/Objectives: Saudi Arabia implemented the Saudi Medical Appointments and Referrals Centre (SMARC) e-referral system to coordinate patient transfers and enhance healthcare access across the country. This nationwide system was established to improve coordination between healthcare facilities and provide timely access to specialized services. SMARC operates as a centralized coordination hub connecting secondary and tertiary care facilities across all specialties nationwide. This study evaluates SMARC’s evolution since 2020–2021 and efficiency improvements through 2023–2024 after major expansion efforts. Methods: This retrospective analysis examined 755,145 e-referrals across all 13 administrative regions of Saudi Arabia during 2023–2024. The study analyzed data extracted from the SMARC database covering two consecutive years. Outcomes assessed included acceptance rates, referral destinations (internal within the same region vs. external to other regions), and factors associated with system performance. Results: The total volume of e-referrals through SMARC increased substantially by 19.34% to 755,145 in 2023–2024. Acceptance rates for referrals improved markedly from 74.13% to 90.19% over this period. The proportion of internal referrals increased from 80.13% of total referrals to 87.52%. In contrast, external referrals to other regions declined from 19.87% to 12.48% of the total. Critical care referrals (ICU, CCU, NICU, PICU) decreased from 12.39% to 9.91%. Referrals for life-saving emergency conditions showed a noticeable decrease from 6.65% to 2.18%. Referrals to hospital outpatient departments (OPD) also showed an increase from 48.07% to 66.66% of total referrals. Conclusions: SMARC demonstrated considerable improvements in key metrics including referral acceptance rates and growth in regional self-sufficiency. This progress is associated with the Kingdom’s goals for advancing its healthcare system under Vision 2030 initiatives. The system has enabled more effective care coordination and access to specialized services across regions. These achievements were observed during a period of significant healthcare infrastructure expansion documented during this period, including growth in specialized centers, increased ICU bed capacity following governmental regulation after the COVID-19 pandemic, and expansion of trained medical subspecialists. Full article

Introduction: Adolescents and young adults (AYAs), especially those from underserved communities, often face barriers to sexual and reproductive health (SRH). This pilot study evaluated the implementation of mobile health technologies to promote SRH care, including the integration of the Rapid Adolescent Prevention Screening^TM (RAAPS) and the Health-E You/Salud iTu^TM (Health-E You) app at a School-Based Health Center (SBHC) in Los Angeles using the RE-AIM (Reach, Effectiveness, Adoption, Implementation, Maintenance) framework. Methods: This multi-method pilot study included the implementation of an integrated tool with two components, the RAAPS electronic health screening tool and the Health-E You app, which delivers tailored SRH education and contraceptive decision support to patients (who were sex-assigned as female at birth) and provides an electronic summary to clinicians to better prepare them for the visit with their patient. Quantitative data on tool usage were collected directly from the back-end data storage for the apps, and qualitative data were obtained through semi-structured interviews and in-clinic observations. Thematic analysis was conducted to identify implementation barriers and facilitators. Results: Between April 2024 and June 2024, 60 unique patients (14–19 years of age) had a healthcare visit. Of these, 35.00% used the integrated RAAPS/Health-E You app, and 88.33% completed the Health-E You app only. All five clinic staff were interviewed and expressed that they valued the tools for their educational impact, noting that they enhanced SRH discussions and helped uncover sensitive information that students might not disclose face-to-face. However, the tools affected clinic workflows and caused rooming delays due to the time-intensive setup process and lack of integration with the clinic’s primary electronic medical record system. In addition, they also reported that the time to complete the screener and app within the context of a 30-min appointment limited the time available for direct patient care. Additionally, staff reported that some students struggled with the two-step process and did not complete all components of the tool. Despite these challenges, clinic staff strongly supported renewing the RAAPS license and continued use of the Health-E You app, emphasizing the platform’s potential for improving SRH care and its educational value. Conclusions: The integrated RAAPS and Health-E You app platform demonstrated educational value and improved SRH care but faced operational and technical barriers in implementing the tool. These findings emphasize the potential of such tools to address SRH disparities among vulnerable AYAs while providing a framework for future implementations in SBHCs. Full article

Background/Objectives: Nonattendance at healthcare appointments remains a major challenge, particularly in chronic diseases like diabetes. Dietary therapy is essential in diabetes care, yet nonattendance at dietitian appointments persists. This study aimed to identify key drivers of nonattendance at dietitian appointments, explore prior experiences with dietary counseling, and determine factors motivating attendance. Methods: A mixed-methods approach was used in this quality improvement project, drawing on multiple data sources to explore nonattendance at dietitian appointments. This included combining a retrospective analysis of clinical and attendance data from patient records at a Danish outpatient diabetes clinic with semi-structured interviews with 25 individuals who had recently missed a dietitian appointment. Quantitative and qualitative data were analyzed separately and then integrated to characterize overall nonattendance patterns. Interview data were analyzed using systematic text condensation. Results: Individuals who missed dietitian appointments were also more likely to miss other healthcare appointments. Vulnerable individuals (i.e., those with complex health conditions or mental health issues) were more likely to miss appointments. Four principal barriers to attendance were identified: administrative, digital, and logistical challenges; competing health concerns; personal priorities; and unclear referral communication and patient involvement. Conclusions: Improving attendance at dietitian appointments requires a multifaceted approach. Key recommendations include optimizing scheduling practices, implementing digital reminders, offering continuity of care and virtual consultation options. Referring clinicians should improve patient communication by clearly explaining the purpose of the dietitian consultation and involving patients in shared decision-making prior to referral. Dietitians should collaborate with patients to establish realistic, personalized goals to foster engagement in their diabetes management. Full article

Background: Bronchiolitis accounts for a substantial number of pediatric hospitalizations and its epidemiology closely parallels that of respiratory syncytial virus (RSV), its principal etiological agent. International guidelines recommend supportive therapy based primarily on oxygen supplementation and hydration. Methods: This study aimed to assess, across three pediatric wards, the impact of internal monitoring and targeted educational interventions on adherence to bronchiolitis management guidelines. Focus was placed on evaluating the effectiveness of tailored strategies in enhancing the appropriateness of treatment practices. Each center independently developed an audit and feedback strategy aligned with local practices and available resources. In Center 1, monthly staff meetings included guideline refreshers throughout the epidemic season. Center 2 appointed two attending physicians to monitor treatment prescriptions and report deviations. Center 3 established an internal protocol through staff consensus, followed by monthly review sessions. In this retrospective analysis, all consecutive patients admitted with bronchiolitis during the winter seasons of 2022–2023 and 2023–2024 (Period 2) were compared with those admitted in 2021–2022 (Period 1). Results: A total of 623 infants under 24 months of age were included, 451 (72%) of whom tested positive for RSV. Their median length of hospital stay was 6 days; 26 infants (4%) required intensive care, and no deaths were recorded. A comparative analysis of the treatment modalities used—high-flow nasal cannula (HFNC) oxygen therapy, inhaled medications, corticosteroids, and antibiotics—revealed a reduced use of non-recommended therapies (e.g., nebulized β2-agonists, steroids, and antibiotics) in Period 2, alongside heterogeneous patterns in HFNC use. Center-specific strategies, tailored to team dynamics and resource availability, effectively promoted greater adherence to evidence-based guidelines. Conclusions: Our findings suggest that structured internal interventions can lead to more appropriate bronchiolitis management and the improved standardization of care. Full article

While outside chief executive officers (CEOs) are often viewed as catalysts for strategic change compared to their inside counterparts, this study reveals their potential to undermine firms’ environmental responsibility. Integrating agency theory with social capital theory, we investigate whether and how board-level social capital can moderate the sustainability risks associated with outside CEO succession. Using a panel dataset of 989 pollution-intensive Chinese firms from 2010 to 2022, we apply propensity score matching (PSM) to reduce endogeneity in CEO succession decisions, followed by fixed-effects regressions. The empirical results show that outside CEOs, particularly during their early tenure, are more likely to prioritize short-term financial performance over environmental goals—due to limited firm-specific knowledge and heightened external pressure. However, external board social capital (e.g., ties to government and industry associations) enhances resource access and post-appointment accountability, while internal social capital (e.g., co-working experience among directors) establishes common norms that facilitate strategic continuity. This study positions board social capital as a relational governance mechanism that complements formal oversight. The findings contribute to succession and environmental research by linking executive origin to sustainability outcomes and provide practical guidance on leveraging board networks to support leadership transitions. Full article

Background/Objectives: Children with Down syndrome (DS) have distinct oral care needs and challenges, yet research on their care experiences, exploring caregiver and provider perspectives, is limited. Therefore, this study aimed to describe the barriers and facilitators to oral care for children with DS, as reported by caregivers and dental professionals. Methods: In this qualitative inquiry, semi-structured questions were used to elicit narratives describing oral care experiences from one caregiver focus group (n = 5), individual caregiver interviews (n = 9), and individual dentist interviews (n = 8). The transcripts were coded and thematically analyzed. Results: Three themes emerged in both groups. The first theme, Access, described the challenges in locating a dentist willing and knowledgeable about how to treat children with DS, and the variability in experiences between different contexts (i.e., community-based vs. specialty clinics). The second theme, Pre-visit Preparation, noted the potential impact of dental trauma on dental visits and recommended the use of preparation strategies, such as desensitization appointments, strategic scheduling, and visual or verbal scripts or social stories, to introduce dental encounters. The final theme, Dental Encounters, dealt with the importance of communication and interpersonal connection, as well as concerns about and support for active/passive immobilization techniques and pharmacological intervention. Sensory strategies for auditory, tactile, and vestibular input were discussed, in addition to distraction techniques, the timing and pacing of dental encounters, and parental presence/absence. Conclusions: Tailoring dental care around the unique sensory and behavioral needs of children with DS and building effective partnerships between children, parents, and dentists were emphasized for optimizing the dental care experiences of children with DS. Full article

Background/Objectives: The Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) improves the health of nutritionally at-risk populations. However, engagement challenges, such as missed appointments and unredeemed food benefits, may limit program efficacy. Barriers to engagement are heightened among American Indian populations, who often experience disproportionately high levels of participation-related challenges. This study assessed whether newly developed health communication theory-based text messages incorporating persuasive language and different message framing (i.e., gain-framed and loss-framed) improved WIC appointment attendance and food benefit redemption rates, above and beyond standard information-based reminders. Methods: The sample included participants served by the Inter Tribal Council of Arizona WIC between the months of September 2022 and February 2023 who (a) had an appointment during the intervention period (n = 7584) or (b) were eligible to receive a reminder text about unused food benefits during the intervention period (n = 2177). A three-phase intervention design was used, with each phase lasting six weeks. During the baseline phase, participants received standard information-based text messages, while during the two intervention phases, participants received newly developed messages using (1) gain-framed and (2) loss-framed persuasive language. Difference-in-difference regression analyses compared whether differences in outcomes (i.e., appointment attendance and monthly food benefit redemption rates) between participants who received reminder messages and those who did not differed over intervention phases. Results: Receipt of both gain-framed and loss-framed theory-based messages was associated with higher appointment attendance, when compared to receipt of standard information-based messages during baseline (p = 0.003 and p = 0.01, respectively). Neither the gain-framed nor loss-framed messages were associated with higher food benefit redemption rates than standard messages. Conclusions: Results indicated that persuasive communication theory-based text reminders may be an effective, low-cost strategy to boost WIC appointment attendance among American Indians. Full article

A macular hole is a defect of the neurosensory retina at the fovea. Post-traumatic holes can occur immediately after blunt trauma, causing severe non-penetrating retinal contusion or after sudden detachment of the vitreous from the retina. Post-traumatic macular holes can close spontaneously or may require vitreoretinal surgery. This paper aims to present the case of an 11-year-old boy with a macular hole following a ball injury. The child reported deterioration of visual acuity. Ophthalmic examination, ocular ultrasound, optical coherence tomography (OCT), perimetry, and a pattern visual evoked potential (VEP) test were performed. On the day of injury, the visual acuity of the right eye was 0.04 and intraocular pressure was 28 mmHg; the eyelid skin was reddened, and superficial conjunctival injection was observed. A fundus examination revealed oedema, pre-retinal haemorrhages, and a macular hole; peripheral retinal oedema in the superior temporal quadrant with pre-retinal haemorrhages was also seen. At the follow-up appointment scheduled 5 months following hospital discharge, visual acuity of the right eye was 0.3 and intraocular pressure was 20 mmHg. Follow-up OCT images of the OD macula were comparable to the findings obtained on the day of hospital discharge, i.e., 10 days after blunt trauma to the right eye. The left-eye OCT did not reveal any abnormalities. Full article

Kidney transplantation stands as the preferred treatment for end-stage kidney disease, significantly improving both the quality and longevity of life compared to dialysis. In recent years, the survival rates for patients and grafts have markedly increased thanks to innovative strategies in desensitization protocols for incompatible transplants and advancements in immunosuppressive therapies. For kidney transplant recipients, preventing allograft rejection is of paramount importance, necessitating the use of immunosuppressive medications. Regular follow-up appointments are essential, as monitoring the function of the kidney allograft is critical. Currently, established biomarkers such as serum creatinine, estimated Glomerular Filtration Rate (eGFR), proteinuria, and albuminuria are commonly employed to assess allograft function. However, these biomarkers have limitations, as elevated levels often indicate significant allograft damage only after it has occurred, thereby constraining treatment options and the potential for restoring graft function. Additionally, kidney biopsies, while considered the gold standard for diagnosing rejection, are invasive and carry associated risks. Consequently, the identification and development of new, sensitive, and specific biomarkers like dd-cfDNA, microRNAs (e.g., miR-21, miR-155), and sCD30 for allograft rejection are crucial. To tackle this challenge, intensive ongoing research employing cutting-edge technologies, including “omics” approaches, like genomic techniques, proteomics, or metabolomics, is uncovering a variety of promising new biomarkers. Full article

Background/Objectives: Persons with multiple sclerosis (MS) are interested in diet as a second-line approach for disease management. This study examined potential variables that correlate with inaccuracy of self-reported energy intake (EI) in adults with MS. Methods: Twenty-eight participants completed two assessment appointments within a 14-day period that included a standard doubly labeled water (DLW) protocol for estimating total energy expenditure (TEE). The participants reported their EI using the Automated Self-Administered 24 h (ASA24) Dietary Assessment Tool. The primary variables of interest for explaining the discrepancy between TEE and ASA24 EI (i.e., inaccuracy) included cognition (processing speed, visuospatial memory, and verbal memory), hydration status (total body water), and device-measured physical activity. Pearson’s correlations assessed the association between absolute and percent inaccuracy in reporting of EI with outcomes of interest, followed by linear regression analyses for identifying independent correlates. Results: California Verbal Learning Test—Second Edition (CVLT-II) z-scores and light physical activity (LPA) were significantly associated with mean absolute difference in EI (r = –0.53 and r = 0.46, respectively). CVLT-II z-scores and LPA were the only variables significantly associated with mean percent difference in EI (r = –0.48 and r = 0.42, respectively). The regression analyses indicated that both CVLT-II and LPA significantly explained variance in mean absolute difference in EI, and only CVLT-II explained variance for percent difference in EI. Conclusions: The results from this study indicate that verbal learning and memory and LPA are associated with inaccuracy of self-reported EI in adults with MS. This may guide timely research identifying appropriate protocols for assessment of diet in MS. Full article

Background/Objectives: Intensive care unit (ICU) e-referrals are an important indicator for exploring potential deficiencies in critical care resources. This study aimed to examine the epidemiology and patterns of ICU e-referrals across all regions of Saudi Arabia during the COVID-19 pandemic using routinely collected data from April 2020 to December 2021. Methods: This descriptive epidemiological study analyzed data from the Saudi Medical Appointments and Referrals Centre (SMARC). This study reveals novel regional ICU e-referral patterns for critical cases using national unique digital health data, adding insights beyond the existing literature. Variables included age, sex, referral timing, reason, specialty, and region of origin. Descriptive statistics and mapping of administrative areas were performed based on e-referral request rates per 10,000 population. Results: During the study period, 36,619 patients had ICU e-referral requests. The mean age was 54.28 years, with males constituting 64.81% of requests. Out-of-scope e-referrals comprised 71.44% of requests. Referrals related to medical specialties, such as cardiology and pulmonology, were the most common (62.48%). Referral patterns showed peaks in July–August 2020 and May 2021. The Northern Border and Albaha areas had the highest request rates per population, potentially reflecting a higher proportion of severe cases requiring ICU-level care compared to other regions. Conclusions: The temporal pattern and geographic distribution of ICU e-referrals mirrored previously reported critical COVID-19 cases in Saudi Arabia. Preventive measures and vaccination programs contributed to a significant decline in ICU e-referral requests, suggesting a positive impact on controlling severe COVID-19 cases. Population-adjusted analysis revealed regional disparities, highlighting the importance of considering population size in healthcare resource management and policy. Full article

Background: This study investigates patients’ use of eHealth services, their awareness of the availability of these services, and their intention to use them in primary care. It also examines patient characteristics and factors that influence the use of these services. Methods: A cross-sectional design using questionnaires was conducted. Based on the unified theory of acceptance and use of technology (UTAUT), the participants rated the two most common services. Descriptive analyses and linear correlation analyses were performed. A simple linear regression was conducted to identify factors influencing the participants’ intention to use eHealth services. Results: In total, 1203 participants with an average age of 43.7 years were surveyed. The participants’ usage rates varied, with the lowest at 2.4%, for measuring vital signs, and the highest at 47.4%, for booking appointments. The intentions to use the services ranged from 22.5%, for video consultations, to 46.6%, for prescription refill requests. Approximately 20% of the respondents were unaware of each service’s availability. Positive associations were found between all the constructs and the intention to use online services, with a younger age being the most significant factor. Conclusions: The use of and intention to use eHealth services varied greatly. The participants were often unaware of the availability of these services. Promoting the availability and benefits of eHealth services could enhance patient engagement in primary care settings. Full article

Children and adolescents with autism spectrum disorder (ASD) are at a greater risk of seeking emergency department (ED) services during behavioral crises, such as acute aggression, suicidal or homicidal ideation, self-injury, or other types of challenging behavior (e.g., pica, dangerous behaviors). Research demonstrates children and adolescents with ASD often return to the ED due to challenging behavior, suggesting that gaps in care exist (e.g., follow-up appointments, referrals). However, the current knowledge basis is largely based on data from other countries. Given the unique landscape of healthcare in the United States, it is prudent to elucidate characteristics of children and adolescents with ASD who are seeking emergency care due to challenging behavior, as well as systems-level factors that both contribute to our understanding of challenging behavior and ASD in ED settings. In this study, we focus on frequency and characteristics of children and adolescents with ASD presenting to the ED with challenging behavior over the course of a 6-year period in the Midwest region of the United States. Clinical implications for ED staff are discussed. Full article