Dogs are among the world’s most cherished companion animals, reflecting their increasingly close relationship with humans. As pets become integral members of households, the demand for accurate and reliable veterinary diagnostic tools is growing, particularly to ensure optimal health and clinical care. This study aimed at establishing species-specific reference intervals for canine serum biochemical parameters using the Respons®920 (DiaSys) liquid biochemistry analyser, with applicability in routine clinical practice. Additionally, the influence of sex and age on these parameters was assessed. A total of 193 clinically healthy dogs were included. Reference intervals were established for commonly used serum biochemical parameters: total proteins (TP), albumin, alanine aminotransferase (ALT), aspartate aminotransferase (AST), alkaline phosphatase (ALP), phosphorus, calcium, creatinine, urea, cholesterol, triglycerides, sodium, potassium, and chloride. Reference intervals were calculated using the Reference Value Advisor software, strictly following the American Society of Veterinary Clinical Pathology guidelines. Statistical analysis revealed significant sex-related differences for ALT, AST, and urea, with higher values observed in males. Age-related differences were also identified for ALP, phosphorus, and TP, particularly between younger and older age groups. Although these differences were not sufficient to justify separate reference interval partitioning, they should be considered by clinicians during interpretation. This study provides species- and instrument-specific reference intervals for canine serum biochemistry using the Respons®920 analyser, and contributes valuable data on the influence of sex and age on routine biochemical parameters in dogs.

To qualitatively understand the experiences of patient/caregivers, and clinicians of piloting a generic Paediatric Patient Reported Outcome Measure (P-PROM), the EQ-5D-Y-5L, in Routine Outpatient Care for Kids (ROCK), known as the P-PROM ROCK Program. Semi-structured interviews and focus groups were conducted online and in-person between April-June 2024. Participants were eligible if they received (patient/caregiver) or delivered (clinician) the P-PROM ROCK Program in the pilot feasibility and acceptability randomised clinical trial. Interviews were audio recorded and transcribed. Detailed notes were generated for focus groups. Transcripts and notes were coded and summarised into themes using thematic analysis. Nine interviews (n = 9 patient/caregivers) and two focus groups (n = 7 clinicians) were conducted. Participants shared that the simplicity and ease of the co-designed P-PROM ROCK Program (including EQ-5D-Y-5L, personalised PROMpt, patient and clinician resources, and integration with systems) was critical to completion and use of EQ-5D-Y-5L in clinical care. When P-PROM results were discussed in appointments, participants shared how this improved communication, resulted in more holistic care, and provided parents with new perspectives on their child's health. P-PROM results were not always discussed, and participants suggested reminder systems to minimise this. Additionally, short appointments and highly specialised clinical scope were barriers to holistic care. Finally, participants found the intervention too brief and wanted longer to better understand its benefits and limitations. The simplicity and ease of P-PROM programs are essential to their uptake and impact in clinical care. The P-PROM ROCK Program requires further refinements and piloting to truly understand its impact. ISRCTN16030620, https://www.isrctn.com/ISRCTN16030620 .

An increasing number of patients with congenital heart disease (CHD) are pursuing pregnancy with the potential for cardiovascular complications. This study aimed to establish patient-centered national research and care priorities to improve pregnancy-related outcomes for individuals with CHD. This mixed-methods study used a modified Stakeholder Engagement in Question Development methodology to systematically identify patient-centered priorities. Key activities included consortium engagement (phase 1), patient and provider questionnaires (phase 2), and an in-person facilitated meeting to explore survey results and follow-up virtual focus groups (phase 3). Reflexive thematic analysis was used to synthesize short- and long-term research priorities (phase 4). Three overarching goals emerged: (1) improving access to specialized CHD, cardio-obstetrics, and mental health care; (2) improving quality and consistency in clinical care; and (3) increasing patient and community engagement. These goals were then expanded into 5 central themes: (1) communication within the health care setting; (2) community engagement; (3) ancillary clinical support; (4) integration of patient-reported outcomes; and (5) implementation, education, and knowledge mobilization. Short-term (1-5-year) goals included expanded telemedicine use, best practice recommendations for multidisciplinary care coordination, and targeted educational resources. Long-term (5-10-year) goals included expansion of adult CHD and cardio-obstetrics programs, integration of mental health services, and advocacy to improve insurance coverage. The consortium provided a national, community-driven prioritization that highlights actionable pathways to improve pregnancy outcomes for people with CHD. Sustained engagement with patients and community partners is essential to achieving durable improvements across cardio-obstetric care, education, research, and mental health.

Addressing Antiretroviral Therapy Nonadherence for Youth With HIV via a Technology-Enhanced Community Nursing Intervention: Primary Results From the TECH2CHECK Randomized Trial.

The FRAX model defines fractures occurring at the hip, vertebrae, humerus, and forearm as major osteoporotic fractures (MOF), leading to the misconception that fractures at other sites (NonMOF) are unimportant. We aimed to compare MOF and NonMOF to 1) assess their contribution to subsequent fracture and mortality risks and 2) the differences in subsequent fracture and mortality risks between MOF and NonMOF as well as 3) assess these contributions using an anatomical classification of hip, vertebral, proximal and distal fractures. Data from 7568 women and 3366 men aged 60+ were utilised from two Longitudinal cohorts (the Canadian Multicentre Osteoporosis Study and Dubbo Osteoporosis Epidemiology Study) to assess subsequent fracture and mortality following initial fractures. Initial fractures were classified as MOF or NonMOF for aim 1 and 2, and as hip, vertebral, proximal, or distal for aim 3. There were 1998 initial fractures (38% NonMOF) in women and 484 (48% NonMOF) in men. During 9551 person-years (py), women experienced 605 subsequent fractures (38% post-NonMOF) and during 2230 py, men had 97 subsequent fractures (48% post-NonMOF). Following the initial fracture, 556 women died (29% post-NonMOF) over 12065 py and 196 men died (38% post-NonMOF) over 2773 py. NonMOF were associated with 69% higher subsequent fracture risk in women (HR: 1.69; 95% CI: 1.47-1.95) and two-fold in men (2.06; 1.52-2.80), compared to initial fracture, comparable to MOF (women: 1.76; 1.56-1.98 and men: 2.09; 1.53-2.85. NonMOF imparted >30% excess mortality (women: 1.37; 1.16-1.60 and men: 1.33; 1.03-1.72), compared to fracture-free population, lower than MOF (women: 1.75; 1.54-1.99 and men: 2.26; 1.81-2.81) but still substantial. All anatomical fracture sites were associated with subsequent fracture risk, and the risk of mortality increased incrementally from distal to proximal, vertebral and hip. MOF and NonMOF showed comparable risks of subsequent fracture and mortality. All sites are associated with adverse outcomes and should be addressed in clinical care guidelines.

The clinical management of metabolic dysfunction-associated steatotic liver disease (MASLD) and metabolic dysfunction-associated steatohepatitis (MASH) is undergoing rapid evolution, driven by advances in noninvasive diagnostics and the recent approval of liver-directed therapies. Multiple professional societies have issued guidelines and clinical care pathways to address screening, risk stratification, treatment initiation, and monitoring; however, substantial heterogeneity exists across these documents. In this review, we systematically compare major contemporary guidelines from hepatology, gastroenterology, endocrinology, and diabetes societies, highlighting areas of consensus as well as key differences in target populations for screening, noninvasive test thresholds, treatment eligibility criteria, and monitoring strategies. We analyse the methodological underpinnings of these recommendations, emphasising important limitations related to reliance on trial-derived populations, the absence of head-to-head comparisons, and the use of noninvasive test cutoffs extrapolated from highly selected randomised controlled trials. We also discuss how subjective interpretation of emerging evidence, variable consideration of cardiometabolic comorbidities, and limited integration of cost and access considerations contribute to divergent recommendations. Finally, we propose a framework for improving future guidelines, including greater transparency regarding evidence limitations, adoption of prevalence- and outcome-informed thresholds, clearer guidance on therapy sequencing and combination strategies, and a more holistic approach that aligns liver-specific outcomes with broader cardiometabolic risk reduction. As the therapeutic landscape continues to expand, more adaptive and objective guideline frameworks will be essential to optimise real-world implementation and equity of care.

Improved quality of care is fundamental for reducing patient mortality and building sustainable health systems. Currently, there is a lack of research on the role of hospital management in improving the quality of care and health outcomes, particularly in low-income settings. We examined associations between hospital management practices and neonatal quality of care in Malawi. We adapted the World Management Survey tool to measure 28 management practices across five domains - delivery of clinical care in the neonatal unit, human resource management, target setting, finances, and governance. In April 2022, we administered the tool to five clinical and administrative managers in each of the 36 central and first-level referral hospitals (n = 180 interviews). Further, we calculated a hospital-level management score (1 - poor, 5 - excellent) and linked these data to records of 20 831 neonatal admissions (February-July 2022). Our primary outcome was in-hospital neonatal mortality, and secondary outcomes included 14 clinical quality indicators. We examined associations between hospital-level management scores and individual-level patient outcomes using a multilevel mixed-effects Poisson regression. The mean hospital-level management score across the 36 hospitals was 3.35 (standard deviation = 0.4). Among 20 831 neonatal admissions, 2590 (12.4%; 95% confidence interval (CI) = 11.9-12.8) died, representing a mortality rate of 27.2 deaths per 1000 person-days. We found no relationship between the management score and in-hospital neonatal mortality (adjusted incidence rate ratio per unit increase in the score = 1.08; 95% CI = 0.81-1.44). Five management domains were not associated with mortality, and we found limited evidence that management practice scores were positively associated with quality of clinical care. This study presents novel, national evidence on the association between hospital management practices and neonatal mortality in a low-income country, with complementary data on quality of clinical care. We found no evidence that hospital management practices were associated with neonatal mortality and limited evidence of an association with the quality of clinical care. Rigorous impact evaluations of targeted management interventions, with embedded process evaluations, could address potential confounders and help understand how and under what circumstances management improvements could translate into better quality of care.

Chronic rhinosinusitis (CRS) and olfactory dysfunction (OD) are highly prevalent among people with cystic fibrosis (PwCF) and negatively impact quality of life. The 40-item Smell Identification Test (SIT) is widely used to assess psychophysical olfaction, but a CF-specific minimal clinically important difference (MCID) has not been established. This study aimed to determine the SIT MCID in PwCF treated with elexacaftor/tezacaftor/ivacaftor (ETI) and/or endoscopic sinus surgery (ESS). Data from three prospective, multi-institutional observational studies were pooled. Participants were ≥12 years old with confirmed CF and CRS who completed SIT at baseline and ≥1 follow-up (3, 6, 9, 12, or 24 months). Distribution-based MCIDs were calculated using four methods: standard error of measurement (SEM), minimal detectable change (MDC=1.96×SEM), 0.5×baseline standard deviation (SD), and 0.5×SD of change scores (ΔSD). A total of 122 participants were enrolled (mean age 32.9 years, 54% female). Of these, 99 contributed follow-up SIT scores (79 ETI, 20 ESS). SIT scores remained stable with ETI, with a small but statistically significant decline at 6 months (-1.4, p=0.02). ESS was associated with mean gains of 3.1-4.5 points at early follow-up, though these did not reach significance. Pooled distribution-based MCID estimates ranged from 2 to 4 points, with an overall threshold of 3.1 (95% CI: 2.1-4.1). This CF-specific SIT threshold provides a clinically interpretable cut-off for assessing olfaction. These findings establish a foundation for future work and highlight the importance of developing disease-specific MCIDs to guide clinical care and research.

Alzheimer's disease (AD) affects not only memory and cognition but also the body's automatic functions, such as heart rate and blood pressure. These changes reflect the early disruption of the central autonomic network, the system that links the brain and the heart to maintain physiological balance. Electroencephalography (EEG) measures the brain's electrical activity and reveals patterns of cortical slowing and desynchronization, while heart-rate variability (HRV) reflects how flexibly the heart responds to internal and external demands. This narrative review brings together evidence published between 2000 and 2025 on the combined use of EEG and HRV as a single, integrated biomarker for AD. Studies consistently show that EEG-HRV coupling, which reflects how well the brain and heart communicate, provides better accuracy in distinguishing mild cognitive impairment and early AD than either measure alone. The findings reveal a shared loss of co-ordination between neural and autonomic systems, which is a hallmark of neurovisceral decline. The review also identifies key methodological gaps, including inconsistent recording conditions and lack of standardized analytic methods, which currently limit reproducibility. To bridge this gap, a translational roadmap is proposed to outline short-, mid-, and long-term goals for clinical validation, wearable integration, and digital health applications. Together, EEG-HRV coupling represents a scalable, non-invasive, and physiologically grounded tool that could support earlier and personalized monitoring of AD, helping to connect laboratory discovery with real-world clinical care.

Clinical growth is outpacing educational growth at academic medical centers (AMCs) reducing traditional teaching opportunities, especially in rapidly expanding fields like hospital medicine. Despite these pressures, little guidance exists on how leadership should allocate limited teaching time. To explore academic hospitalists' preferences for allocating traditional teaching time (i.e., time on services with interns and residents) amid clinical expansion. A cross-sectional survey of academic adult hospitalists at six large AMCs across the United Stateswith survey responses andfree-response questions analyzed qualitatively. Of 572 hospitalists surveyed, 156 academic hospitalists responded (27%). Respondents averaged 8.9 years' experience and spent 25% of their clinical time on traditional teaching services. Teaching was a strong professional priority: 74% rated it very or extremely important when considering new job positions, and 66% preferred it as their primary service role. Most respondents (81%) preferred a merit-based model that rewards teaching skill development and learner engagement beyond clinical care. An external recognition-based model (i.e., teaching evaluations) was also supported (64%), although respondents raised concerns about bias. Equal distribution, seniority-based, and split-group models were less favored. Only 6% of respondents preferred working exclusively on direct care services (i.e., a service without learners). In this exploratory sample, academic hospitalists highly value teaching but most spend little time on it. Hospitalists preferred a merit-based model, where faculty demonstrate their interest in and commitment to education by improving their teaching skills.

University hospitals play akey role in research, clinical care and medical education; however, the number of pediatric anesthetic procedures performed at German university hospitals, including complex cases requiring specialized expertise and those relevant for training remains unknown. All chairs of anesthesiology at German university hospitals were invited via email to participate in asurvey. For the years 2022-2024, the number of anesthetic procedures, patient age groups (< 1, 1-4, 5-11, 12-17, ≥ 18years) and the American Society of Anesthesiologists (ASA) classification of pediatric cases were collected. The primary endpoint was the percentage of pediatric anesthetic procedures relative to the total number of anesthetic procedures. Secondary variables included age distribution, relative proportion, ASA classification and case volume-dependent structure of pediatric anesthesia services. In this study 23university hospitals participated (response rate: 43.6%). On average, 24,910 ± 9325 anesthetic procedures were performed per hospital and year. The proportion of children was 13.6% (of whom 11.6% were < 1year and 31.8% aged 1-4years). The relationship between total case volume and the pediatric proportion was positive and linear (y = 0.0017x + 7.0785; R2 = 0.69). The ASA classification of children was distributed as follows: 47.9% ASAI, 28.5% ASAII, 20.0% ASAIII, 3.3% ASAIV and 0.2% ASAV. Hospitals with the largest total caseloads had the highest pediatric proportion (16.5%), including the largest share of children aged 0-5years (52.2%) and the highest proportions of ASAIV-V cases (27.6%). There were marked differences in case volume among university hospitals; however, aclear correlation was observed between total anesthetic case volume and the pediatric proportion. The findings suggest that pediatric anesthesia services are increasingly concentrated in large centers.

Knee osteoarthritis in the intact- and amputation-side knees of UK military personnel and veterans with traumatic unilateral transtibial limb loss 8- and 11-years post-injury: the ADVANCE cohort.

Type 2 diabetes mellitus (T2DM) and obesity are commonly treated with glucagon-like peptide-1 receptor agonists (GLP-1 RAs). However, there have been growing concerns over the possibility that these medications may result in ocular adverse events, such as nonarteritic anterior ischemic optic neuropathy (NAION). Standard clinical care can overlook these potentially fatal adverse effects. The purpose of this review was to compile the most recent data on ocular side effects associated with GLP-1 RA therapy, assess their clinical relevance, and highlight necessary preventative and monitoring measures. A thorough search of the literature was conducted using Medline/PubMed/PMC, Google Scholar, Scopus, Web of Science, and ScienceDirect. Relevant literature, including observational studies, randomized trials, case reports, and pharmacovigilance data, was selected for its discussion of GLP-1 RAs and associated eye-related adverse events. Semaglutide, a GLP-1 RA, has been associated in a number of studies and safety assessments with an increased risk of NAION and the progression of diabetic retinopathy, especially in patients with underlying eye disorders. Findings, however, were mixed because no statistically significant link was found in a number of cohort studies and meta-analyses. The necessity for additional research was supported by data from adverse event reporting systems that showed disproportionality signals. Clinicians should be mindful of the potential ocular hazards associated with GLP-1 RAs, even though these medications remain useful in treating T2DM and obesity. Closer ophthalmologic monitoring may be beneficial for patients with known diabetic eye problems. Further prospective research with well-defined ocular outcomes is required to elucidate these correlations and guarantee the secure administration of GLP-1 RAs.

To identify barriers and facilitators to implementing an electronic shared decision-making tool for managing anticoagulant-related drug-drug interactions that affect bleeding risk in routine clinical care. Preimplementation qualitative study using semistructured interviews. Three academic medical centres in the southeastern and western USA. Interviews were conducted between 27 March and 25 September 2024. 36 participants, including 19 clinicians involved in prescribing or managing anticoagulants and seventeen patients prescribed anticoagulants, were recruited using purposive and convenience sampling. Participants identified multiple barriers and facilitators to tool implementation. Common barriers included limited visit time, challenges integrating the tool into existing workflows, role and scope-of-practice constraints, and variation in patient digital literacy. Facilitators included clear visualisation of bleeding risk, access to supporting evidence, familiar interface design and perceived potential to support patient engagement and shared decision-making. Several determinants functioned as both barriers and facilitators, depending on clinical context and user role. This preimplementation qualitative study identified context-specific determinants that influence the adoption of an electronic shared decision-making tool for anticoagulant-related drug-drug interactions. Findings highlight the importance of early attention to workflow integration, role alignment and usability to support uptake in routine care. Addressing these factors during design and implementation may inform strategies to support adoption and future evaluation in real-world clinical settings.

Despite federal mandates requiring qualified interpreter use, ad hoc interpreters, untrained individuals such as family members or bilingual staff, continue to be used in clinical care for patients with non-English language preference (NELP). Prior studies rely primarily on self-report or administrative data, leaving gaps in our understanding of how and when ad hoc interpretation is documented in real-world practice. To characterize the frequency, documentation, and contextual factors associated with untrained ad hoc interpreter use in inpatient medicine settings. We conducted a retrospective cohort study of adults with NELP admitted to a general medicine service at a large academic medical center between 2019 and 2023. We analyzed clinical notes using a large language model-based approach to identify documentation of interpreter use. Ad hoc interpretation cases were manually validated and categorized by interpretive role and documented rationale. Among 23,245 clinical notes from 2176 admissions involving 1379 patients with NELP, professional interpreter services were documented in 5921 notes (25.5% of notes). Ad hoc interpreter use was explicitly documented in 600 notes (2.6% of notes), across 324 admissions (14.9% of admissions) and 223 patients (16.2% of patients). Most ad hoc interpreter documentation involved family members (64.7%), and 7.7% occurred in conjunction with professional interpreters. Admissions with documented ad hoc interpreter use involved older patients, longer hospital stays, and higher comorbidity burden. Documented ad hoc interpreter use was more prevalent among non-Spanish language groups and increased with length of stay; nearly 75% of ad hoc interpreter notes lacked a documented rationale. Ad hoc interpreter use was relatively common among inpatients with NELP, particularly for less common languages and longer lengths of stay, and was most often provided by family members. Gaps in documented rationales for ad hoc interpreter use reveal systemic issues in language access workflows and underscore the need for improved access to professional interpretation, standardized documentation, and greater use of qualified bilingual staff to ensure equitable, policy-compliant communication for all language groups.

Restful sleep is essential for health, yet many children with Attention Deficit Hyperactivity Disorder (ADHD) experience disturbances such as delayed sleep onset, shorter total sleep time, frequent awakenings, and daytime fatigue. Accurate detection of these issues is important for clinical care, but existing tools have limitations: polysomnography is costly and complex, while wrist devices often miss subtle movement or physiological changes. This study introduces a deep learning approach using data from RestEaze, a leg-worn multimodal wearable that records photoplethysmography (PPG), motion from accelerometer and gyroscope, and temperature signals. Overnight recordings were collected from 14 children referred for ADHD evaluation. A Support Vector Machine (SVM) using handcrafted features was implemented to establish a traditional baseline. Two convolutional neural network (CNN-BiLSTM) models were then developed, employing early and late-fusion of raw multimodal inputs to classify sleep and wake states in short windows. The late-fusion model achieved an area under the ROC curve of 90.94% in five-fold cross-validation. Derived metrics included total sleep time, wake after sleep onset, sleep onset latency, and awakenings. A temporal label-smoothing method further improved consistency. These findings demonstrate the feasibility of leg-based multimodal sensing and deep learning for noninvasive sleep monitoring in pediatric neurodevelopmental populations.

When Tourette syndrome is reduced to a debate about offence, clinical care suffers.

This review summarizes the most recent advances in the field of chronic pain, highlighting how the discipline is shifting from heterogeneous approaches toward more standardized, mechanistic, and personalized frameworks, both in clinical care and research. Recent progress in phenotyping and person-centered analytical approaches (like based on the ergodicity concept) have been proposed to reduce the structural heterogeneity of studies. At higher levels, the implementation of the WHO International Classification of Disease, 11th Revision and the Enhancing and Facilitating the TRUST worthiness initiative are reshaping methodological thinking in pain research. These initiatives emphasize the importance of universal and robust frameworks in pain research. Clinically, recent data are reinforcing the role of active strategies, digital therapeutics, and novel mechanistic approaches, including new pharmacological targets and less (or non-) invasive neuromodulation approaches. Issues related to problematic opioid use remain central, underscoring the need for better-integrated multimodal models. Robust, reproducible, and less variable pain research and clinical practices are increasing. Future perspectives rely on large-scale phenotyping, longitudinal data, the integration of digital technologies, and precision-medicine approaches applied to chronic pain.

Stab wounds inflicted by a third party represent an increasingly relevant form of penetrating trauma in Germany, gaining attention both in the public sphere and in clinical emergency care. This retrospective study investigated the incidence, injury severity, anatomical distribution, and clinical outcomes of stab wound cases treated at aGerman levelI trauma center over a3-year period. All patients presenting with stab injuries to the inner city emergency department of LMU University Hospital between September 2021 and August 2024 were included. Astructured analysis of demographic data, injury characteristics, therapeutic interventions and clinical outcomes was conducted. Atotal of 48cases were identified (47male, 1female; mean age 36.6 years, median 27years). The most frequently affected anatomical regions were the upper extremities (25%) and thorax (20.3%). Hospital admission was required in 41.7% of cases, 14.6% sustained major trauma (abbreviated injury scale, AIS ≥ 3) and 1 patient died. Stab wounds continue to pose arare yet clinically significant challenge. The findings underline the necessity for structured interdisciplinary management and targeted emergency preparedness protocols in trauma systems.

A neglected area of patient safety research is how the characteristics of mental health staff and teams may influence incidents, specifically, through unintended and harmful consequences of clinical care. While the research literature into patient safety has increased, there is still a need to further consider safety on mental health wards, for example, the role of the staff team in containment and conflict. This review aims to explore the question, 'How do staff and team characteristics relate to safety incidents in adult inpatient mental health settings?'. The review will follow Whittemore and Knafl's integrative review framework. CINAHL, Cochrane, Embase, MEDLINE, PsycINFO, Web of Science will be searched. Literature published after 1999, that includes extractable quantitative, qualitative and mixed methods data exploring the relationship between staff and team characteristics on incidents in adult inpatient mental health settings, will be suitable for inclusion. The Mixed Methods Appraisal Tool will be used for quality appraisal and data analysis and will comprise data reduction, display and comparison. No new data or access to participants will be involved in this review. As such, ethical review will not be required. Dissemination will include publication in peer-reviewed journals and presentations at national and international conferences. This review has been registered on PROSPERO (ref. CRD420251119981; https://www.crd.york.ac.uk/PROSPERO/view/CRD420251119981).