Antibiotics

Background: Antimicrobial resistance (AMR) disproportionately affects low- and middle-income countries (LMICs) such as Pakistan, where obstetric and gynaecological (OBGYN) patients carry high antibiotic exposure. Specialty-specific drug utilization data with concurrent stewardship audit remain scarce. This study evaluated antibiotic prescribing patterns, consumption metrics, and antimicrobial stewardship program (AMS) compliance in OBGYN inpatients at a public sector tertiary care hospital. Methods: A prospective cross-sectional study was conducted in OBGYN wards of Dow University Hospital, Karachi, from 1 September to 31 October 2025. Women receiving [≥]1 systemic antibiotic were included. Daily AMS rounds were conducted by an Infectious Diseases physician and pharmacist. Antibiotic consumption was measured as Defined Daily Doses (DDD) and Days of Therapy (DOT) per 1,000 patient-days (total = 821). Antibiotics were classified by WHO AWaRe (2023) framework. Results: Of 812 total admissions, 278 patients (34.2%) received [≥]1 antibiotic and were enrolled (205 obstetric, 73 gynaecological), generating 636 prescriptions (mean 2.29/patient). Surgical prophylaxis was the predominant documented indication (213, 33.5%); 65.1% carried no documented indication. By AWaRe classification, 53.6% were Access-group and 46.1% Watch-group. Ceftriaxone (38.4%) and metronidazole (36.8%) together represented 75.2% of prescriptions. Combined DDD/1,000 patient-days was 1,758.6 and DOT/1,000 patient-days was 1,852.7. AMS compliance was 0%. Conclusions: This study documents high antibiotic prescribing burden, near-universal documentation failure, and zero AMS compliance in OBGYN inpatients at a Pakistani public sector hospital. The predominance of Watch-group antibiotics and undocumented surgical prophylaxis highlights structural stewardship gaps. Findings support urgent need for institutional OBGYN antibiotic guidelines and structured pharmacist-led AMS programs.

Background and Aims The optimal treatment for first episodes and first recurrences of Clostridioides difficile infections (CDI) is unknown and there is emerging evidence for pulse and taper (P-T) regimens. Therefore, we sought to estimate the relative efficacy of treatment options. Methods MEDLINE and CENTRAL were searched from database inception to May 21, 2025 and unpublished conference abstracts were searched from recent infectious disease conferences. RCTs on the treatment of first episodes or first recurrences of CDI comparing fixed-dose or P-T regimens of fidaxomicin or vancomycin were included. The primary and secondary outcomes were 40- and 56-day CDI recurrence, respectively. A random-effects network meta-analysis on the risk ratio (RR) scale was conducted using a standard regimen (10-14 days) of vancomycin as the comparator. Treatments were ranked using the surface under the cumulative ranking curve (SUCRA). Results 8 RCTs were included comprising a total of 2181 patients. For 40-day recurrence, fidaxomicin P-T had the highest probability of ranking best (RR=0.10, 95%Confidence Interval [95%CI]=0.10-0.49, SUCRA=1.00), followed by vancomycin P-T (RR=0.49, 95%CI=0.32-0.76, SUCRA=0.61), fixed-dose fidaxomicin (RR=0.61, 95%CI=0.49-0.76, SUCRA=0.39), and, finally, fixed-dose of vancomycin (SUCRA=0.00). The treatments ranked in the same order for 56-day recurrence, though only 3 RCTs reported on this timepoint. Conclusion Vancomycin P-T, fidaxomicin P-T, and fixed-dose fidaxomicin were all superior to a fixed-dose vancomycin. Head-to-head comparative effectiveness RCTs are needed to quantify their relative effect sizes of and impact on long-term prevention of recurrent CDI.

Background: Pneumonia remains the leading infectious cause of under-five mortality, particularly in low- and middle-income countries (LMICs) where translation of evidence-based guidelines into practice faces systemic barriers. Although India launched the Childhood Pneumonia Management Guidelines (CPMG), effective implementation remains suboptimal. This study demonstrates how implementation research can support the systematic development and optimisation of a primary care--focused implementation model for childhood pneumonia management in a low-resource setting. Methods: This manuscript reports findings from Phases I and II of a 26-month, pre-post quasi-experimental implementation research project conducted in Palwal district, Haryana, India. The Phase I is formative research including a baseline survey (June-August 2023); Phase II: development and iterative optimisation of the implementation model through co-design within a learning cluster (September 2023-May 2024); and Phase III: implementation and evaluation of the optimised model followed by district-wide scale-up (May 2024-March 2025). Phase I (June-August 2023) employed the Consolidated Framework for Implementation Research (CFIR) to systematically identify multilevel determinants affecting CPMG implementation across a study area of approximately 108,000 inhabitants. Phase II (September 2023-May 2024) focused on co-designing context-specific implementation strategies using the CFIR-ERIC (Consolidated Framework for Implementation Research-Expert Recommendations for Implementing Change) Barrier Busting Tool and iteratively refining an implementation model through participatory co-design workshops with government and community stakeholders within a learning block of approximately 50,000 inhabitants. An optimised Implementation Research Logic Model (IRLM) was developed to align determinants, strategies, mechanisms of change, and implementation outcomes. Results: Thirty-three tailored implementation strategies were identified, addressing barriers across inner (e.g. implementation climate), outer (e.g., socio-cultural norms), individual (e.g. skills), process (e.g., planning), and innovation (e.g., complexity) CFIR domains. Iterative refinement through three successive models (Model 0+, Model 1, and Model 2) within the learning block was associated with improvements in key outcomes: care-seeking from appropriate primary care facilities increased from 0.8% at baseline to over 76% [193/254 cases], appropriate diagnosis improved from 0% to 92.7% [179/193 cases], and fidelity to guideline-based management reached 86% [154/179 cases] by the end of Phase II. These improvements informed the finalised IRLM which was subsequently implemented and evaluated in Phase-III. Conclusions: This study demonstrates a systematic, transparent, and participatory approach to developing and optimising an implementation model for primary care-based childhood pneumonia management in a resource-constrained setting. The co-designed IRLM, grounded in established implementation research frameworks, offers a replicable process for translating evidence-based guidelines into primary care practice in similar LMIC settings. Phase III along with the district-wide implementation and evaluation findings will be reported in a forthcoming paper. Trial Registration: Clinical trial registry CTRI/2021/03/031622 [date: 01/03/2021].

Objective. To evaluate the perceived usability, acceptability, and user experience (rather than the clinical effectiveness) of Boora, an AI-assisted, human-supervised digital platform prototype for longitudinal overweight and obesity care, among users and health professionals in Brazilian primary care. Design. Convergent mixed-methods formative evaluation. Perceived usability was measured with the System Usability Scale (SUS) and summarised descriptively; semi-structured interviews conducted after hands-on use were analysed with codebook thematic analysis (Braun and Clarke); the two strands were integrated through a joint display. Qualitative reporting followed the Consolidated Criteria for Reporting Qualitative Research (COREQ). Setting. Primary health care network of Ananindeua, Para, within the Brazilian Unified Health System (January to February 2026). Participants. Fifteen adults with overweight or obesity (BMI at least 25 kg/m2, confirmed via electronic health records) who used the patient application on their own smartphones for 24 hours, and eight primary care professionals (nurses, physicians, and a dietitian) who used the professional dashboard for approximately 20 minutes on predefined tasks with synthetic data. Main outcome measures. SUS scores and qualitative themes addressing usability, acceptability, perceived usefulness, barriers, and perceived clinical and workflow fit. Results. Boora showed good perceived usability in both cohorts (users mean 76.5, SD 10.3; professionals mean 77.5, SD 4.6; both above the SUS normative average of 68). Four themes emerged per cohort. Users valued an accessible interface and visible progress but described daily logging burden, fragile anticipated engagement, and digital-literacy and accessibility barriers. Professionals valued a clear interface and the prospect of panel-managed, proactive follow-up, while requiring training, AI governance, protected time, and interoperability with the national record. Integration indicated that the disengagement users anticipated was the risk professionals perceived the dashboard could help identify, whereas the educational AI assistant was the weakest and most ambiguous component for both groups. Conclusions. Boora was perceived as usable and acceptable, with perceived value concentrated in human-supervised, longitudinal follow-up rather than autonomous self-tracking or AI advice. These findings concern perceived usability and acceptability, not clinical effectiveness or sustained engagement. Real-world adoption would depend on accessibility refinements, electronic-record integration, and clear AI governance aligned with the principles of Brazil's proposed risk-based AI framework and the LGPD.

Background and objectives Spontaneous bacterial peritonitis (SBP) is a life-threatening complication of cirrhosis with ascites, carrying one- and two-year mortality rates exceeding 70% and 80%, respectively. Fluoroquinolone prophylaxis is the cornerstone of SBP prevention. Real-world longitudinal data on prescribing practices and clinical outcomes from Indian tertiary care centers are sparse. We aimed to evaluate fluoroquinolone prescribing patterns, guideline adherence, and six-month clinical outcomes in SBP patients at a tertiary academic center in North India. Methods This was a pre-specified sub-analysis of a 15-month analytical longitudinal study at AIIMS Rishikesh. Adults (age >/=18 years) admitted with SBP and initiated on fluoroquinolone prophylaxis were enrolled consecutively and followed for six months. Prescribing practices were compared against EASL and AASLD recommendations. The primary outcome was the rate of guideline-directed prescribing. Secondary outcomes included clinical cure at discharge, six-month cure, relapse, regimen modification, adverse drug reactions, and treatment compliance. Categorical variables were compared by Fisher's exact test or chi-squared test (SPSS). Results Forty-eight SBP patients were included (mean age 44.75 +/- 11.94 years; 85.4% male). Guideline-directed fluoroquinolone prophylaxis was prescribed to all patients (100%). Norfloxacin 400 mg once daily was predominant (85.4%), followed by levofloxacin (10.4%) and moxifloxacin (4.2%). Cure at discharge was 85.4%. At six months, 64.6% maintained sustained cure and 22.9% relapsed. Regimen modification occurred in 22.9%, most commonly antimicrobial substitution. Nausea was the only adverse drug reaction (4.8%). Treatment compliance was 73.8%. No patient underwent therapeutic drug monitoring. Conclusions Fluoroquinolone prescribing for SBP prophylaxis at AIIMS Rishikesh was fully concordant with standard guidelines. Despite complete adherence, a relapse rate of 22.9% and frequent regimen modification underscore the limitations of long-term fluoroquinolone prophylaxis, likely reflecting emerging quinolone resistance. Strengthening antimicrobial stewardship is essential to sustain prophylaxis effectiveness in Indian tertiary care settings.

Background Post-infection conditions (PICs), such as Long Covid, are associated with heterogeneous, fluctuating symptoms that profoundly affect daily functioning. Despite moderate-certainty evidence from the NIHR-funded LISTEN trial (COV-LT2-0009) that personalised self management support improves outcomes and may reduce societal and economic impacts of Long Covid, many people living with PICs still receive condition-specific services, generic advice, or stand-alone digital tools that do not address their complex needs. Aim To map care approaches in general practice and synthesise UK evidence for PIC management. Design and setting Scoping review and online survey. Method A two-phase study was conducted: (1) a scoping review of UK evidence on PIC management in general practice; and (2) a supplementary online survey of practitioners working in UK general practice to provide contextual insights. Results The scoping review identified 32 studies focused on Long Covid. One study included a comparator group (ME/CFS). Study populations were predominantly white ethnicity and female. Evidence for non-Covid PICs in UK general practice was largely absent. The supplementary survey (n=46) provided preliminary practice-level insights. Healthcare practitioners reported varied PIC presentations, diagnostic uncertainty, limited referral pathways, inequitable access, and low confidence in managing PICs. Conclusion Evidence informing PIC management in UK general practice remains predominantly Long Covid-focused and may not reflect the range of PICs encountered in practice. While survey findings are preliminary and require confirmation in larger samples, they highlight uncertainty around PIC management. Further research is needed to evaluate whether existing Long Covid pathways should be expanded or complemented by broader PIC models. Keywords general practice; Long Covid; self-management; post-viral syndromes

Background: Oral care is a critical nursing intervention for mechanically ventilated patients in intensive care units because it reduces oral microbial colonization and contributes to the prevention of ventilator-associated pneumonia, a major cause of morbidity, prolonged hospitalization, and increased healthcare costs among critically ill patients. Despite the availability of evidence-based guidelines, gaps in nurses knowledge and inconsistent implementation of oral care practices remain challenges, particularly in low- and middle-income settings. Objective: This study aimed to assess the level of knowledge among intensive care unit nurses regarding oral care for mechanically ventilated patients at Tenwek Hospital, Kenya, determine factors influencing knowledge, and examine the relationship between nurses knowledge and selected demographic and professional characteristics. Methods: An analytical cross-sectional study design was employed. The study was conducted among intensive care unit nurses at Tenwek Hospital. A sample of 38 nurses was selected from a target population of 60 intensive care unit nurses using simple random sampling. Data were collected using a structured self-administered questionnaire assessing socio-demographic characteristics, knowledge of evidence-based oral care practices, awareness of guidelines, and factors influencing knowledge. Data were analyzed using descriptive statistics, chi-square tests, Pearson correlation, and logistic regression, with statistical significance set at probability value less than 0.05. Results: Thirty-five nurses participated, yielding a response rate of 92.1 percent. The findings demonstrated generally high knowledge levels regarding oral care practices for mechanically ventilated patients. Most nurses correctly identified recommended oral care frequency (88.6 percent), oral assessment before care (91.4 percent), suctioning before and after oral care (94.3 percent), and the role of oral care in preventing ventilator-associated pneumonia (97.1 percent). However, knowledge gaps were identified in areas such as toothbrushing practices and documentation of oral care procedures. Training, continuing professional education, availability of guidelines, workload, resources, supervision, and teamwork were identified as important factors influencing knowledge. The findings revealed that professional qualification (probability value equal to 0.02), intensive care unit experience (probability value equal to 0.030) and formal oral care training (probability value equal to 0.021) were significantly associated with nurses knowledge of oral care practices. Conclusion: Intensive care unit nurses at Tenwek Hospital demonstrated adequate knowledge of evidence-based oral care practices for mechanically ventilated patients. However, targeted educational interventions are required to address identified gaps and strengthen standardized oral care delivery. Continuous professional development, consistent use of guidelines, supportive supervision, and adequate resource provision are recommended to enhance patient safety and reduce preventable intensive care unit complications such as ventilator-associated pneumonia. Keywords: Intensive care unit nurses; Oral care; Mechanically ventilated patients; Ventilator-associated pneumonia; Nursing knowledge; Evidence-based practice

Controlled human infection models (CHIMs) are increasingly used in infectious disease research to study pathogen dynamics and evaluate interventions under controlled conditions. However, these studies are resource-intensive and involve ethical and safety constraints, making efficient study design critical. Dose-finding is a key early component in CHIMs, where the aim is to identify a challenge dose that achieves a target infection probability. Traditional rule-based designs are commonly used but can be inefficient, motivating the use of model-based adaptive approaches such as the Bayesian Continual Reassessment Method (CRM). Although CRM has been extensively studied and widely adopted in Phase I oncology trials for identifying the maximum tolerated dose of therapeutics, its application in CHIM settings remains limited, particularly when the endpoint of interest is infection. This tutorial provides step-by-step guidance for implementing a Bayesian CRM in dose-finding CHIMs, using an oropharyngeal Neisseria gonorrhoeae challenge as a motivating case study. The framework outlines key design components, including dose-grid specification, dose-response model, prior elicitation, Bayesian updating, decision rules, and stopping criteria, with particular emphasis on a clinically interpretable parameterisation. Trial operating characteristics are evaluated through simulation studies under multiple dose-response scenarios and prior-predictive analyses, and compared with a commonly used '3+3' type rule-based design. This work highlights the advantages of Bayesian model-based designs for dose-finding in CHIMs over classic rule-based designs and provides a structured, reproducible framework for implementing CRM, supporting their application in future CHIM studies.

Background: Urinary tract infection (UTI) is the most common secondary condition among people with spinal cord injury/disease (SCI/D). Intravesical Lacticaseibacillus rhamnosus GG (LGG) is an antibiotic-sparing approach to managing urinary symptoms. Objective: Determine the optimal number of doses of intravesical LGG for urinary symptom reduction. Design: Prospective, randomized, two-arm dosing trial. Setting: National recruitment with a local subsample providing urine samples in Washington, DC, USA. Participants: Adults with SCI/D and neurogenic lower urinary tract dysfunction (NLUTD) who use intermittent catheterization (IC); 177 enrolled and randomized (intention-to-treat), with 76 compliant instillers (39 low-dose, 37 high-dose) in the per-protocol analytic sample. Interventions: Two (2 doses/24 hours) or four (4 doses/36 hours) intravesical LGG regimens, self-initiated in response to cloudier or malodorous urine per the Self-Management Protocol using Probiotics (SMP-Pro). Main Outcome Measures: Primary: proportion achieving [≥]20% reduction on the Urinary Symptom Questionnaire for Neurogenic Bladder-Intermittent Catheter version (USQNB-IC). Secondary: urinary biomarkers (leukocyte esterase, nitrite, white blood cells, urinary neutrophil gelatinase-associated lipocalin [uNGAL]) and standard urine culture (SUC) in a local subsample. Results: By Day 2, 57.9% (63.8% low-dose; 51.2% high-dose) achieved [≥]20% total symptom reduction; high-dose success rose to 70.0% by Day 4. Thirty percent of high-dose participants did not respond at either time point and could not be distinguished from responders by demographics or urine biomarkers. Urinary biomarkers and SUC were unchanged pre- to post-instillation. No serious adverse events were adjudicated as attributable to intravesical LGG by an independent Data Safety Monitoring Board (DSMB). Conclusions: A two-dose course of intravesical LGG yields clinically meaningful symptom improvement in the majority of people with SCI/D and NLUTD who use IC; four doses benefits a meaningful subgroup of two-day non-responders, while a small cohort remains nonresponsive. These results provide preliminary dosing guidance and support progression to a definitive trial.

Background The faecal immunochemical test (FIT) is central to triaging symptomatic patients with suspected colorectal cancer (CRC) in UK primary care, yet only about one in eleven patients above the NICE 10 ug/g threshold have CRC. Existing prediction models attempting to improve on FIT have relied on conventional statistics and limited predictors. Methods GP-requested FITs with linked data (Jan 2017 - May 2025) were extracted from the Oxford University Hospitals (OUH) datawarehouse. Patients aged [≥]18 with core bloods and 180-day CRC follow-up were included. Machine learning (ML) models were trained on up to 1,025 predictors: FIT, age, sex, blood tests and their time series slopes, diagnoses/procedures/prescriptions, deprivation, BMI, and ethnicity. Models comprised penalised logistic regression, generalised additive models (EBM, NAM, SNAM, NODE-GAM), decision tree ensembles (random forests, XGBoost), and a multilayer perceptron. Referral reduction versus FIT [≥]10 ug/g was evaluated at model risk score thresholds capturing the same cancers (conservative) or same proportion of cancers (less conservative) as FIT. Potential to prioritise referred patients was assessed by examining whether positive predictive value (PPV) is very high (>30%) at any substantial sensitivity (>10%). Nested twice-repeated five-fold cross-validation provided unbiased estimates. An existing COLOFIT model was evaluated alongside. Findings 62,219 individuals (746 CRC) were analysed; 30,862 patients (315 CRC) with high/low risk symptoms and buffered FITs formed the primary subset. At [≥]10 ug/g, FIT had 91.4% sensitivity, 84.2% specificity, 5.6% PPV, and 99.9% NPV. No model reduced referrals when required to capture the same cancers as in the FIT [≥]10 ug/g cohort. Generalised additive models achieved up to 18.5% referral reduction when detecting the same proportion but some different cancers as FIT [≥]10 ug/g (EBM: 18.5%, NODE-GAM: 17.5%, SNAM: 17.4%, COLOFIT: 16.7%). At 30% sensitivity, EBM, NAM and NODE-GAM had average PPVs between 34.6%-35.0%, while FIT had a PPV of 14.6%. Interpretation Generalised additive models (GAMs) reduced referrals on average by 19% if a small proportion of the FIT-positive CRCs were substituted with originally FIT-negative CRCs by the models. No model, including COLOFIT, reduced referrals while capturing all FIT-positive cancers. Generalised additive models could detect about a third of CRCs faster, as one in three patients flagged by the models had CRC at 30% sensitivity. Funding EPSRC Centre for Doctoral Training in Health Data Science; National Institute for Health Research (NIHR) Oxford Biomedical Research Centre; Cancer Research UK. Keywords Colorectal cancer, faecal immunochemical test, machine learning, positive predictive value

Aims To develop the Bowel Irrigation Questionnaire (BIQ), a patient-reported experience measure (PREM) designed to assess the user experience of transanal irrigation (TAI). Methods Statements were generated through literature review and qualitative interviews with healthcare professionals (HCPs) and product users. Statements were rated on a 6-point content validity index scale through an international three-round online Delphi survey by 20 expert panel members. Consensus attainment was defined based on percentage agreement, statements which did not meet consensus were discussed at a final international online consensus meeting. The content validity of the PREM was evaluated through cognitive interviews and the Questionnaire on Questionnaires (QQ-10). Reliability was assessed using a test-retest design, where users completed the BIQ on two occasions one week apart. Results 215 statements were generated from 9 multi-disciplinary qualitative interviews and literature review. Statements were refined to reduce repetition and ensure clarity. 73 statements grouped into 11 domains were reviewed through the Delphi survey. Following the Delphi survey and clinical consensus meeting, the preliminary BIQ consisted of 15 items. Six cognitive interviews were conducted, resulting in a finalised BIQ of 16 items. 32 product users completed both the QQ-10 and test-retest study, the results of which demonstrated good content validity and temporal stability respectively. Conclusions The Bowel Irrigation Questionnaire is a novel PREM designed to assess the user experience of TAI in both clinical and research settings. The instrument demonstrates good validity, acceptability and temporal stability, supporting its use as a reliable measure of patient experience.

Background Oral care is a critical nursing intervention for mechanically ventilated patients in intensive care units (ICUs) and plays an important role in preventing ventilator-associated complications. However, variability in nurses' competency in oral care remains a concern, particularly in resource-limited settings. Objective To assess ICU nurses' competency in providing oral care to mechanically ventilated patients and determine factors associated with competency at Tenwek Hospital, Kenya. Methods An analytical cross-sectional study was conducted among ICU nurses at Tenwek Hospital. A total of 38 nurses were invited, and 35 participated, yielding a response rate of 92.1%. Data were collected using a structured questionnaire and an observational competency checklist. Descriptive statistics and inferential analysis, including chi-square tests and binary logistic regression, were performed using SPSS version 30. Statistical significance was set at p<0.05. Results ICU nurses demonstrated generally high competency in key oral care practices, including use of personal protective equipment (100%), suctioning before and after oral care (91.4%), and oral assessment (80.0%). However, gaps were identified in documentation of oral care (62.9%) and adherence to standardized protocols (65.7%). Formal oral care training was significantly associated with competency (OR=5.63, 95% CI: 1.78-17.81, p=0.002), as were professional qualification (p=0.030) and ICU experience (p=0.021). In multivariable analysis, oral care training (OR=3.01, p=0.006), ICU experience (OR=2.85, p=0.015), and availability of guidelines (OR=2.17, p=0.047) were independent predictors of competency. Conclusion ICU nurses at Tenwek Hospital demonstrate satisfactory competency in oral care for mechanically ventilated patients, although gaps remain in documentation and protocol adherence. Strengthening training, guideline availability, and institutional support systems is essential to improve consistency and quality of oral care practice. Keywords Intensive care unit; oral care; nursing competency; mechanically ventilated patients; ventilator-associated pneumonia; Kenya.

Background: Diabetes mellitus is an increasing public health challenge in Sierra Leone, where access to diagnosis, treatment, and long-term care remains limited. Traditional medicine continues to play a significant role in disease management; however, ethnobotanical knowledge related to diabetes remains insufficiently documented. Methods: A cross-sectional ethnobotanical survey was conducted among 40 informants, including traditional healers, herbalists, and knowledgeable community members in Waterloo, Pendembu, and Bo. Data were collected using structured questionnaires administered via Kobo Toolbox and paper-based tools. Information on medicinal plants, plant parts used, preparation methods, routes of administration, and knowledge transmission pathways was obtained. Quantitative ethnobotanical indices, including Frequency of Citation (FC), Relative Frequency of Citation (RFC), and Informant Consensus Factor (ICF), were calculated. Results: A total of 21 medicinal plant species were documented. The most frequently cited species were Moringa oleifera (FC = 9; RFC = 0.225), Vernonia amygdalina (FC = 7; RFC = 0.175), and both Cassia siberiana and Telfairia occidentalis (FC = 6; RFC = 0.150). Leaves were the most commonly utilized plant part (40.9%), and decoction was the predominant preparation method (76.2%), with oral administration accounting for 95.2% of use. The Informant Consensus Factor (ICF = 0.69) indicated a relatively high level of agreement among informants. Knowledge was primarily transmitted through apprenticeship and inherited family practices. Conclusion: Traditional medicinal plants remain an important component of diabetes management in Sierra Leone. The high level of consensus among informants and the repeated citation of specific plant species suggest structured and culturally validated therapeutic practices. The findings provide a foundation for future phytochemical and pharmacological investigations and highlight the need for documentation, preservation, and sustainable utilization of ethnobotanical knowledge.

Objective: There is a bidirectional relationship between emotional distress and pain. However, this relationship is understudied in people with HIV in low-resource settings. This study sought to describe the temporal relationship between emotional distress and pain in people with HIV. Design: Longitudinal observational study. Methods: Participants with virally suppressed HIV, reporting either no pain or persistent pain at baseline, provided weekly remote ratings of distress, worst pain, and average pain using 0-10 visual analogue scales. Within-individual fluctuations in distress and pain were visualised over time. Group-level correlations were determined using Spearman's correlation tests. Cumulative link mixed models assessed whether distress and pain each predicted the other in the following week. Results: 72 participants provided responses over 49 weeks. The participants had a median (IQR) age of 43 (37-51) years, 63% (n=45) were unemployed and most were females (n=51;71%). Distress and pain fluctuated concurrently within individuals: distress was positively correlated with worst pain ({rho}=0.66, 95% CI= 0.60-0.72, p<0.001) and average pain ({rho}=0.70, 95% CI=0.64-0.75, p<0.001) intensity within the same week. Worst pain (OR=1.42, 95% CI=1.17-1.71, p<0.001) and average pain (OR=1.43, 95% CI=1.20-1.71, p<0.001) intensity both predicted distress in the next week. Distress predicted worst pain intensity (OR=1.25, 95% CI=1.07-1.46, p=0.023) but not average pain intensity (OR=1.19, 95% CI=1.01-1.40, p=0.152) in the next week. Conclusions: The temporal relationship between distress and worst pain intensity was bidirectional, whereas distress did not temporally predict average pain intensity. Both pain and emotional distress should receive attention from HIV research and clinical care in low-resource settings.

Introduction: Recommendations from physicians and peers play a crucial role in promoting vaccination. This study evaluated differences in recommendations to others regarding four vaccines with varying efficacy (seasonal influenza, measles, human papillomavirus [HPV], and coronavirus disease 2019 [COVID-19]) between physicians and the general public and examined the impact of birth-year-based vaccination policy changes on these recommendations. Methods: This cross-sectional study was conducted in February 2026 among 492 physicians and 5,252 members of the general public in Japan. Consistency in recommendations across the four vaccines was assessed using the intraclass correlation coefficient (ICC[3,1]), and group differences were examined using a two-way mixed-design analysis of covariance. Multilevel regression discontinuity analyses were performed to evaluate the effects of birth-year-based vaccination policy. Results: Physicians showed significantly stronger recommendations to others than the general public, and their recommendation patterns generally reflected vaccine efficacy. However, physicians showed lower consistency across vaccine types than the general public (ICC[3,1]), driven primarily by heterogeneity in COVID-19 vaccine recommendations. Regression discontinuity analyses showed that birth-year-based vaccination policy, including routine vaccination opportunities, was significantly associated with recommendations to others for measles and HPV vaccines, independently of perceived benefits and risks. Conclusion: To improve vaccination coverage from a public health perspective, it is important for physicians to provide effective vaccination recommendations to the general public on a broader scale; however, it is also necessary to address the heterogeneity in vaccine-specific recommendation patterns among physicians, as observed for COVID-19. Routine vaccination opportunities may increase vaccination coverage not only through the routine vaccination program itself but also through peer effects among the general public. Vaccination policy may therefore influence vaccination coverage not only in the current generation but also in future generations. Designing vaccination policy should consider its long-term impact on future vaccination coverage as well as herd immunity.

Background: Live oral rotavirus vaccines were found to be less effective in low-income countries compared to high-income countries when using the same product and dosing schedule. We investigated whether altering dose timing may improve immune protection using a target trial emulation approach. Methods: We emulated a target trial with clone-censor weighting to compare the effectiveness of the recommended 2-dose rotavirus vaccine schedule with a delayed schedule among children under two years of age in Peru and Brazil. Secondary data from the Malnutrition and Enteric Disease Study (MAL-ED) birth cohort (2009-2014) were analyzed. Children were followed from the date of birth until the earliest occurrence of a rotavirus outcome (infection confirmed by PCR or enzyme immunoassay (EIA) or diarrhea confirmed by EIA), protocol nonadherence, loss to follow-up, or their second birthday. Results: We included 154 children in Brazil and 192 in Peru. At two years of follow-up, the risk ratio (RR) for PCR-confirmed infection, using the recommended schedule as the reference, was 1.00 (95% confidence interval [CI]: 0.73-1.37) in Peru and 0.85 (95% CI: 0.31-1.66) in Brazil. In Peru, the delayed schedule was associated with a higher cumulative risk of EIA-confirmed rotavirus diarrhea (RR at two years: 1.73; 95% CI: 1.02-2.77). Conclusions: Delaying the two-dose rotavirus vaccine schedule did not change the cumulative risk of rotavirus infection, but the delayed schedule was associated with a higher risk of rotavirus diarrhea in Peru, where rotavirus incidence was higher.

Objectives: To compare the effectiveness of povidone-iodine ear wash compared to no ear wash and oral cotrimoxazole compared to placebo given in addition to standard topical antibiotic treatment (ciprofloxacin drops) for chronic suppurative otitis media (CSOM) in Australian Aboriginal children. Methods: A randomised, parallel, 2 x 2 factorial design, assessor-blinded clinical trial in the remote Northern Territory of Australia. Aboriginal children with confirmed CSOM were eligible to be randomised into four treatment groups, allowing two primary treatment comparisons in a 2-in-1 trial approach. Participants received standard treatment (twice daily cleaning and topical ciprofloxacin drops) plus: i) either 16 weeks of pre-treatment povidone-iodine ear wash or no povidone-iodine ear wash; and ii) either 16 weeks of oral cotrimoxazole or placebo. Central randomisation with allocation concealment and triple-blinding of the oral antibiotic treatment arms was used. The relative risk (RR) and risk difference (RD) were estimated after adjustment for age, community, and the other intervention. The primary outcome was the proportion of children with any otorrhoea (clinical failure) after 16 weeks of treatment. Secondary outcomes included size of tympanic membrane (TM) perforation and amount of discharge, time to cessation of discharge, proportion of children with respiratory and other pathogens in ear discharge (at baseline and 16 weeks) and hearing levels (at 12 months). Findings: 280 children with CSOM were randomised and 270 had their primary outcome assessed. Clinical failure (presence of any ear discharge) after 16 weeks of treatment was 66/134 (49%) in the povidone-iodine group versus 69/136 (51%) in the no povidone-iodine group (RD= -1% (-12,11), p= 0.93) and 56/134 (42%) in the cotrimoxazole group versus 79/136 (58%) in the placebo group (RD=-16% (-28,-4), p=0.007). The amount of discharge, TM perforation size, the level of hearing impairment, and serious adverse events were not significantly different in both treatment comparisons. Anaerobic growth (24%), Pseudomonas aeruginosa (21%) and Haemophilus influenzae (17%) were the most common pathogens found in the ear discharge before treatment. Fungi or yeast (24%), Staphylococcus aureus (15%), and anaerobic growth (10%) were the common pathogens after 16 weeks of treatment, with no significant differences between groups. At 12 months post-randomisation, 55-60% of children had at least one discharging ear and there was no difference between treatment groups. Interpretation: Povidone-iodine ear washes did not contribute to better ear outcomes in this study. Cotrimoxazole for 16 weeks resulted in more children with clinical improvement to dry ears. Oral cotrimoxazole may play a role in reducing the burden of CSOM in populations with high rates of persistent disease.

Malaria remains a severe health problem in endemic regions because people lack adequate diagnostic tools, leading to delayed medical care and elevated death rates. This research introduces a dual-mode artificial intelligence system that uses two complementary models to enhance malaria pre-screening and diagnosis. The patient-centered model uses multivariate logistic regression to analyze biosignals, including heart rate, body temperature, and oxygen saturation, collected through a wearable sensor prototype and a mobile interface for symptom analysis. The system enables patients to begin self-assessment to determine their level of need before scheduling a doctor's appointment. The clinician-centered model represents a customized convolutional neural network that uses annotated microscopy images of red blood cells to achieve 94.84% accuracy, 95.71% precision, 93.87% recall, 94.78% F1 score, and 0.84 Area Under Curve (AUC). The patient model achieved 94.6% accuracy and an AUC of 0.985 using a 70/30 train-test split. These systems work together to create a layered diagnostic system that can operate independently or together to detect malaria at an early stage, especially in areas with limited resources. The findings demonstrate that wearable biosignal data integration with image-based deep learning can produce dependable, scalable, and user-friendly systems for malaria pre-screening. Keywords - malaria diagnosis, artificial intelligence (AI), convolutional neural networks (CNN), wearable biosensors, multivariate logistic regression

Abstract Background: Remote clinical reviews have become an integral component of contemporary nursing practice across community and acute care settings. Nurses increasingly make autonomous clinical decisions using telephone, video, and online/digital systems, often with limited sensory information and under conditions of uncertainty. However, empirical understanding of how nurses make clinical decisions via remote reviews remains limited. Aim: To explore and understand how registered nurses (RNs) make clinical decisions about patient care via remote reviews. Methods: A convergent mixed-methods design was employed. Quantitative data (analytic quantitative sample N=53) were collected using validated questionnaires that measured decision-making processes, physician-nurse collaboration, decision-making stress, and perceived decision-making ability. Qualitative data (N=23) were generated through semi-structured interviews. Data collection took place between October 2024 and April 2025. Quantitative data were analysed using descriptive statistics, correlation, and multiple regression. Qualitative data were analysed using framework analysis. Integration was achieved through pillar-building and theory-driven synthesis and illustrated by joint display tables. Results: Most nurses demonstrated a flexible decision-making style, integrating analytical and intuitive reasoning. Both analytical and intuitive processes were positively associated with perceived decision-making ability. Physician-nurse collaboration emerged as a strong predictor of decision-making confidence, while decision-related stress was not a significant predictor. Qualitative findings identified three themes: characteristics of remote review; making adaptive decisions shaped by both internal and external constraints and enablers; and external influencing factors. The integrated findings informed a theory-informed ICE framework to illustrate how nurses make clinical decisions via remote reviews. Conclusion: Remote clinical decision-making is a dynamic cognitive-environmental process rather than a purely individual cognitive act. The ICE framework conceptualises this interaction, extending existing decision-making theories to digitally mediated care. Impact: Understanding remote decision-making supports training design, clinical governance, and the development of Artificial Intelligence-enhanced decision-support tools grounded in ecological bounded rationality. Patient or Public Contribution: Patient and public representatives contributed to stakeholder discussions that informed the development of the interview topic guide and the theoretical model. Patients or members of the public were not involved in recruitment, data collection, analysis, interpretation of findings, or preparation of the manuscript. Keywords: clinical decision-making, remote reviews, telehealth, nursing, mixed methods, ecological bounded rationality

Background: International Classification of Diseases (ICD) codes are often used in epidemiological studies to track disease rates over time. Objective: This evaluation of ICD-code-based algorithms for electronic medical record (EMR) studies of Alzheimers disease (AD) and related dementias (ADRD) examines the impact of incorporating Centers for Medicare and Medicaid (CMS) data as an additional source of diagnostic and treatment information in Department of Veterans Affairs (VA) EMR studies. Methods: We performed a chart review of 100 VA Million Veteran Program (MVP) participants to evaluate algorithm performance. We also assessed genetic associations across algorithms in a large MVP cohort (n=396k). Results: Adding CMS data increased the number of detected cases, sensitivity, and positive predictive value, but decreased specificity and negative predictive value. Genetic analyses showed that broader (ADRD/dementia) algorithms with just VA data performed similarly to narrow (AD-focused) algorithms incorporating both VA and CMS ICD codes. Additionally, narrow AD algorithms based solely on VA data yielded the highest ORs, indicating the largest proportion of late-onset AD cases. Conclusions: We recommend using a broad (ADRD) algorithm without CMS or medication data, particularly for epidemiological studies or a strict AD algorithm including CMS and medication cases for genetic discovery of late-onset AD associations in VA EMR, and a strict AD algorithm without CMS data for applications focused solely on AD and sensitive to misspecification. Careful evaluation of algorithm performance is warranted in different EMR systems, as ICD coding practices vary by institution, as demonstrated by this comparison of VA EMR and CMS data.