Frontiers in Public Health

Abstract Objective To estimate the burden and patterns of multimorbidity and cardiometabolic multimorbidity among university employees undergoing a comprehensive health assessment programme, and to examine demographic and behavioural factors associated with multimorbidity. Design Cross-sectional study. Setting A public university in Maharashtra, India. Participants A total of 266 university employees who underwent a comprehensive health assessment were included. Main outcome measures Multimorbidity was defined as the presence of two or more of nine chronic conditions: hypertension, diabetes mellitus, dyslipidaemia, ischaemic heart disease, chronic kidney disease, thyroid disease, stroke, chronic obstructive pulmonary disease and cancer. Cardiometabolic multimorbidity was defined as the presence of two or more of hypertension, diabetes mellitus, dyslipidaemia, ischaemic heart disease and chronic kidney disease. Results Hypertension was identified in 119 participants (44.7%), comprising 50 participants with pre-existing hypertension and 69 newly identified during the assessment. Dyslipidaemia was present in 189 (71.1%) and diabetes mellitus in 45 (16.9%). Overall, 108 participants (40.6%) had multimorbidity and 103 (38.7%) had cardiometabolic multimorbidity. The prevalence of multimorbidity increased progressively with age, from 17.5% among participants aged <30 years to 83.3% among those aged [&ge;]60 years. The predominant exact multimorbidity patterns were hypertension with dyslipidaemia alone (49 participants) and hypertension, diabetes mellitus and dyslipidaemia (27 participants). Overall, 173 participants (65.0%) had at least one newly identified hypertension, diabetes mellitus or dyslipidaemia diagnosis. In multivariable logistic regression, age (adjusted OR [aOR] 1.058 per year, 95% CI 1.027 to 1.091), BMI (aOR 1.163 per kg/m2, 95% CI 1.076 to 1.257) and tobacco use (aOR 3.296, 95% CI 1.377 to 7.888) were independently associated with multimorbidity. The model had an area under the receiver operating characteristic curve of 0.731. Conclusion Multimorbidity affected approximately two in five university employees, with cardiometabolic conditions accounting for most of the observed disease clustering. Comprehensive health assessment identified a substantial burden of previously unrecognised chronic disease. Integrating institutional or occupational health assessment with longitudinal primary care follow-up may provide an opportunity for earlier detection, risk-factor modification and coordinated management of multimorbidity. Keywords: Multimorbidity; cardiovascular diseases; hypertension; diabetes mellitus; dyslipidaemia; occupational health; university employees; India

Introduction: Lichen sclerosus (LS) is a chronic inflammatory dermatosis predominantly affecting the anogenital region of both women and men. Sexual dysfunction remains among the most debilitating and overlooked consequences of the disease, as available patient-reported outcome measures are either restricted to one sex or capture sexual health only partially. The aim of the present work is to validate the Qualisex questionnaire (in its the Italian version) in patients with LS and to evaluate its psychometric properties, factor structure, convergent, discriminant validity, and sex symmetry. Methods: A cross-sectional study was conducted on 211 patients (167 women, 44 men; mean age 52.9 years) with a confirmed diagnosis of LS. Participants completed the Italian Qualisex, Skindex-29, DASS-21, and sexual-health-specific scales, the Female Sexual Function Index (FSFI) for women, and the International Index of Erectile Function (IIEF) for men. Construct validity was assessed via Principal Component Analysis (PCA), and reliability via Cronbach's alpha. Convergent and discriminant validities were evaluated against standard psychometric batteries. Results: Item 2 was removed due to low communality (0.167). PCA on the remaining 9 items revealed a two-factor structure accounting for 72.5% of total variance: Component 1 (Sexual Functioning and Satisfaction, 59.89%) and Component 2 (Partner Devaluation, 12.66%). Internal consistency was high (alpha= 0.911 overall; alpha= 0.841 in women; alpha= 0.899 in men). Qualisex scores correlated strongly with Skindex-29 Social Functioning (r = 0.582) and Emotions (r = 0.531) subscales, as well as FSFI (r = -0.391) and IIEF (alpha= -0.566). Discriminant validity was supported by low-to-moderate correlations with DASS-21 domains (r < 0.38). While FSFI and IIEF showed significant negative correlations with age (p = 0.002), Qualisex remained age-independent across sexes (p > 0.05). Conclusion. The 9-item Italian Qualisex is a reliable, sex-symmetrical, and age-independent patient-reported outcome measure for assessing sexual health impairment in LS, successfully isolating disease-specific distress from physiological aging and general distress.

Purpose: The internship period is a critical stage for nursing students to develop professional values. This study aimed to investigate the current status of professional identity among nursing interns, analyze the effects of social support, perceived stress, psychological resilience, and career adaptability on professional identity, and explore the mediating role of career adaptability between social support and professional identity, so as to provide empirical evidence for enhancing professional identity and optimizing nursing talent training systems. Methods: Using convenience sampling, 407 nursing interns from a tertiary hospital in Quanzhou were selected as participants from May to July 2025. Data were collected using a general information questionnaire, the Social Support Scale, the Perceived Stress Scale, the Psychological Resilience Scale, the Professional Identity Questionnaire for Nursing Students, the Career Adaptability Scale, and the Questionnaire for Nurse Intention to Retention Employed. SPSS 26.0 was used for reliability analysis, descriptive analysis, independent samples t-test, one-way ANOVA, Pearson correlation analysis, and multiple linear regression analysis. The PROCESS macro was employed to test the mediating effect. Results: The total score of professional identity among nursing interns was (61.74{+/-}11.08), with 73.5% showing moderate professional identity. Parents' attitude toward nursing, reasons for choosing the profession, personal attitude toward the major, and employment intention showed statistically significant differences in professional identity scores (p<0.05). Pearson correlation analysis revealed that professional identity was significantly positively correlated with social support (r=0.474), psychological resilience (r=0.389), and career adaptability (r=0.609) (p<0.01), and significantly negatively correlated with perceived stress (r=-0.378) (p<0.01). Multiple linear regression analysis indicated that career adaptability ({beta}=0.309, p<0.001) and social support ({beta}=0.383, p<0.001) were significant positive predictors of professional identity, whereas reasons for choosing the profession ({beta}=-3.603, p=0.001) and employment intention ({beta}=-7.116, p<0.001) were significant negative predictors. The model explained 49.2% of the variance in professional identity. Mediation effect analysis showed that career adaptability played a partial mediating role between social support and professional identity, with a mediation effect value of 0.288 (95% CI: 0.221-0.363), accounting for 40.2% of the total effect. Conclusions: Nursing interns' professional identity is at a moderately high level. Social support and career adaptability are positive influencing factors. Career adaptability plays a partial mediating role between social support and professional identity; social support indirectly enhances professional identity by strengthening career adaptability.

Background Chronic diseases are the leading causes of illness, disability, and death worldwide, with a disproportionate burden in low- and middle-income countries. Hospitalization is a critical outcome in chronic disease management, reflecting disease severity, treatment failure, and healthcare utilization. However, data on hospitalization burden and its associated factors among chronic disease patients in Ethiopia, are limited. This study aimed to determine the rate of hospitalization and its associated factors among patients with chronic diseases attending a tertiary hospital in Wolaita Zone, South Ethiopia. Methods A facility-based cross-sectional study was conducted among 321 patients with chronic diseases attending the chronic follow-up clinic at Wolaita Sodo University Comprehensive Specialized Hospital from November to December 2022. Consecutive recruitment was used, with unique medical record numbers tracked to prevent double recruitment. Data were collected through structured questionnaires and medical record review. Negative binomial regression was used to identify factors associated with hospitalization rate, with incidence rate ratios (IRR) and 95% confidence intervals (CI) reported. A p-value < 0.05 was considered statistically significant. Results Of the 321 participants, 66% reported at least one hospitalization while on treatment, with a mean of 1.70 {+/-} 1.81 hospitalizations per patient. Drug discontinuation was the most frequently documented reason for hospitalization (39.5%), followed by disease complications (22.3%) and infections (11.7%). Multimorbidity was prevalent, with the majority (59.8%) had 2-3 conditions, and a mean of 2.40 {+/-} 1.02 chronic diseases per patient. Male sex was associated with a higher hospitalization rate, while regular physical exercise was associated with a lower number of hospitalizations. Conclusion This study found a high burden of hospitalization among chronic disease patients, with drug discontinuation being the leading documented reason. Male sex and regular physical exercise were significantly associated highlighting the need for medication adherence support programs and structured exercise programs integrated into routine chronic disease care, as well as gender-sensitive interventions.

Abstract Background: Cyprus has transitioned into a high-alert zone for mosquito-borne viruses. This necessitates a proactive assessment of its future physicians. Following the 2022 re-establishment of Aedes aegypti in Larnaca and Aedes albopictus in Limassol, Cyprus, the island is now biologically primed for local outbreaks of dengue, Zika, and chikungunya, alongside Culex-borne West Nile virus. The study assessed medical students' knowledge and risk perception. Methods: A cross-sectional online survey administered the validated MosquitoWise Health Belief Model instrument to undergraduate-entry and graduate-entry students at a university in Cyprus in mid-2026. Results: Of 1023 students, 119 responded (11.6%), with pre-clinical students overrepresented (p<0.001). Mean knowledge was 5.43/9, stronger on mosquito biology (72.5%) than virus knowledge (54.2%). Median severity was 6.00/7 against susceptibility 4.25/7. Knowledge differed by study stage (p<0.001), correlated with severity (rs = 0.399) but not susceptibility. Conclusions: The study establishes a critical baseline for pre-clinical medical students in Cyprus. Overall, participants performed better on mosquito biology when compared to mosquito-borne viruses and how they spread. Our findings highlight the value of integrating theoretical microbiology with clinical practice in medical education to enhance physicians' preparedness for the changing landscape of newly emerging infections in Cyprus and across Europe as a whole. Key Words: Arboviruses, Cross-Sectional Studies, Cyprus, Health Belief Model, Medical Students, Risk Perception.

Background: Antimicrobial resistance (AMR) is a growing global health threat, and India's high antibiotic consumption makes public knowledge, attitudes, and practices (KAP) a critical determinant of stewardship outcomes. Existing Indian KAP evidence is drawn from small, localised cohorts, leaving a gap in nationwide, digitally-sourced data. This study aimed to describe antibiotic-related knowledge, attitudes and self-reported practices among users of a digital healthcare platform in India, examine demographic and regional variation, and identify potential areas for future stewardship interventions. Methods: A cross-sectional survey was conducted among adult users of the Tata 1mg platform (December 2025-February 2026), with participants invited via an in-app banner. Knowledge and attitude were each scored on a 0-4 scale (4 items); practice was scored as a percentage of applicable items answered favourably, with scoring adjusted for branching logic based on antibiotic-access route. Of 10,726 respondents who started the survey, 4,883 completed it (45.5%). City of residence was mapped to one of six regions (India's five statutory Zonal Council zones plus a North-Eastern region) for 4,187 respondents. Associations with demographic characteristics were assessed using multivariable linear regression, and regional differences were assessed using one-way ANOVA. A parallel survey of 256 physicians was conducted to enable patient-provider comparison. Results: Mean scores were: knowledge 2.28 (SD 1.19), attitude 0.91 (SD 1.14), practice 44.9% (SD 33.4); attitude, not knowledge, was the weakest domain. Older age was associated with higher scores across all domains (practice: B=12.52, p<0.001 for age [&ge;]65 vs. 18-34); city tier was independently associated with lower knowledge and attitude (Tier 3 vs. Tier 1: p=0.010 and p<0.001, respectively). Regional differences were non-significant for knowledge and practice but significant for attitude (F=2.56, p=0.026, ^2=0.003), driven by lower scores in the North-Eastern region. In the parallel physician survey, 55.5% of respondents estimated that more than half of their patients self-medicated before consultation. Conclusion: In this platform-based sample, attitudes were the weakest domain, not knowledge, and 42.0% said their last antibiotic did not come on a doctor's recommendation. The findings may inform digital stewardship touchpoints, such as point-of-purchase guidance and prescription verification, in line with India's National Action Plan on Antimicrobial Resistance 2.0. As a cross-sectional survey of platform users, it cannot establish the relative contributions of knowledge, beliefs and access pathways to antibiotic use.

To deal with the COVID-19 pandemic, Denmark implemented an aggressive program aimed at controlling the pandemic which included both testing and contact tracing programs. The large amount of data collected in Denmark on the pandemic and its integrated nature made it possible to investigate the effectiveness of the testing and contact tracing effort. The results of that investigation and a discussion of the effectiveness and limitations of the different control efforts are reported herein, as are lessons learned concerning possible improvements for the future. The analysis is limited to the period from the start of the COVID-19 pandemic in Denmark (late Feb. 2020) into May 2021, at which time the impact of vaccination intervention was already playing a role with ~25% of the Danish population at least partially vaccinated. From the available data sets we estimate the national Infection Detection Efficiency (IDE) starting around July 1, 2020, the time at which the national infection detection program started to be implemented in a more robust form. The results rely on daily COVID-19 hospital admissions, PCR test results, and anti-body prevalence values for the Danish population. We find that for the long-term average, the combined Danish national testing and contact tracing program identified on average about 55 to 60% of the infected individuals during the period from Sept. 1, 2020, into early May 2021. However, higher infection detection efficiencies were achieved in localized areas for short time intervals. Our investigations further indicate that the Danish testing and contact tracing program, which was among the most ambitious in the world, could have had a better balance between voluntary probing on the one hand and focused contact tracing and targeted testing on the other hand. As typically implemented, it proved to be largely ineffective in controlling the pandemic. However, in at least one case when it was implemented in an enhanced and focused mode, it was able to bring a large local outbreak that dominated the country's cases under control. We have compiled a list of lessons learned regarding the use of contact tracing procedures to control potential future pandemics before vaccinations become available.

Background: Lean Healthcare has been adopted as an approach to reducing waste, enhancing process efficiency, and optimizing clinical and administrative workflows. However, empirical evaluations aimed at establishing a causal relationship between Lean Healthcare interventions and outcomes remain limited. This evidence gap is particularly pronounced in the context of large-scale implementations in low- and middle-income countries, where more efficient allocation could yield substantial improvements in population health. Methods: We conducted an impact evaluation study employing a staggered difference-in-differences approach to estimate the effects of the Lean Healthcare in Emergency Departments (ED) initiative in the Brazilian context. The intervention was implemented between January 2017 and December 2025 across 309 hospitals. We analyzed hospital-level indicators of the number of hospitalizations and the average length of stay (in days) among patients admitted through urgent or emergency pathways. Results: Our estimates suggest that the intervention was associated with an average increase of 38.6 admissions per hospital per month (p = 0.033), corresponding to approximately a 5.9% increase relative to the monthly admission volume. We also observed a reduction of 0.184 days in the average length of stay (p = 0.058), equivalent to an approximately 3.0% decrease in hospitalization time. These effects exhibited distinct temporal dynamics: the effect on the number of hospitalizations emerged gradually and increased with the duration of the intervention, whereas the reduction in length of stay became evident earlier. Conclusion: This study provides evidence of a causal effect of Lean Healthcare implementation in emergency departments on operational performance. The simultaneous increase in admissions and reduction in length of stay suggests improved bed productivity and effective capacity without expanding physical infrastructure. These findings support the use of flow-management methodologies as an effective strategy for mitigating emergency department overcrowding while increasing service capacity.

This paper examines the impact of Cancer Care Ontario's regionalization of lung cancer surgery on blood transfusion use for thoracic surgery at The Ottawa Hospital. Using aggregate data scraped from the paper ''Changing trends in blood transfusion: an analysis of 244,013 hospitalizations'' by Shehata et al. (2014) we estimated the effect regionalization on the log mean number of blood transfusions among thoracic surgeons (who treat lung cancer), utilizing other surgical specialties as controls. We found that the average number of blood transfusions increased significantly among thoracic surgeons following the opening of a new cancer care centre at the hospital in December 2009, while control specialties showed no parallel change. Contextualizing these results in a modified ''population level'' treatment threshold model, it is argued that the main driver of this increase in blood transfusions among thoracic surgeons was due to the influx of less skilled thoracic surgeons to The Ottawa Hospital, and the closing of thoracic surgery units at smaller hospitals which was part of the broader regionalization process.

Background. Metabolic syndrome is a cluster of cardiometabolic risk factors that may increase the risk of cardiovascular disease and type 2 diabetes, and African studies report a higher prevalence in women than in men. Prevention may depend, in part, on whether women recognise the condition and its modifiable risk factors. Relatively little appears to be known about this among women using primary-level health facilities in fast-growing peri-urban areas of Ghana. Objective. To assess knowledge of metabolic syndrome, describe lifestyle risk behaviours, self-reported cardiometabolic conditions and preventive practices, and examine selected lifestyle correlates of self-reported diabetes and hypertension among women attending Kasoa Polyclinic, Ghana. Methods. A descriptive cross-sectional survey was conducted in June and July 2024 among 174 women aged 18-45 years recruited by convenience sampling. A structured, interviewer-assisted questionnaire covered knowledge, lifestyle behaviours, self-reported diagnoses and preventive practices. Data were summarised as frequencies and percentages, and associations were examined with Pearson's chi-square test. Results. Only 37 women (21.3%) described metabolic syndrome as a condition that raises the risk of heart disease and type 2 diabetes, 40 (23.0%) identified central (apple-shaped) fat as the high-risk pattern and 31 (17.8%) knew that dietary recommendations exist. Most reported no weekly physical activity (116; 66.7%), daily sugary drinks (109; 62.6%), daily processed or fast food (100; 57.5%), high stress (103; 59.2%), and less than six hours' sleep (94; 54.0%). Self-reported diagnoses were hypertension in 60 (34.5%) and type 2 diabetes in 49 (28.2%). Fifty-nine (33.9%) had never received advice on prevention and 105 (60.3%) did not monitor their weight or waist. Self-reported diabetes was associated with short sleep (36.2% among those sleeping under six hours; p = 0.035) and with stress level (p = 0.028), being most frequent among women reporting low stress. Self-reported hypertension was more common with high stress (42.7%; p = 0.022) and with some physical activity (p = 0.005). Conclusion. Women attending this polyclinic appeared to have limited understanding of metabolic syndrome and a high burden of modifiable risk behaviours. Routine counselling on diet, activity, sleep, and weight monitoring at the polyclinic may be warranted. The bivariate, self-reported associations should be interpreted cautiously.

Objectives: Women's empowerment is a key determinant of health and well-being and may shape how women access and benefit from publicly-funded health insurance (PFHI). We aimed to examine whether different levels of women's empowerment were associated with 1) verification in India's PFHI Pradhan Mantri Jan Arogya Yojana (PM-JAY), 2) outpatient care utilization, and 3) resultant out-of-pocket expenditure. Design: We conducted a cross-sectional observational study. We analyzed data from a household survey, created a composite empowerment index using structural equation models, and used multivariate regression models to test associations between women's empowerment and the outcome variables. Setting: The study was conducted between December 2019 and February 2020 among PM-JAY eligible households in six Indian states (Bihar, Chhattisgarh, Gujarat, Meghalaya, Tamil Nadu, and Uttar Pradesh). Participants: 14,378 women across the six states. Results: Three main findings emerged: First, high levels of women's empowerment were associated with higher odds of completing PM-JAY verification (AOR: 1.22, 95% CI: 1.09-1.36). Second, women's empowerment was not associated with outpatient service utilization. And third, either medium levels of empowerment (coef = -0.49, p = 0.020) or PM-JAY verification (coef = -0.37, p = 0.034) was associated with lower OOPE for outpatient services. Women who had both, PM-JAY verification and medium levels of empowerment, experienced higher OOPE (coef = 0.45, p = 0.058). Conclusions: Women's empowerment is an important factor related with PM-JAY verification, but not with outpatient service use. OOPE varied depending on whether women were both empowered and PM-JAY verified or not. Our results suggest that institutional and structural barriers may play a greater role in healthcare access than individual factors pertaining to empowerment alone. Achieving equitable access therefore requires gender-responsive systems that reduce administrative barriers and support women in navigating the healthcare pathway. Our findings highlight the importance of integrating outpatient care into PM-JAY to increase financial protection, streamlining verification processes to improve women's engagement with PM-JAY and the broader health system, and advancing health financing reforms that better support women.

Sepsis is a global health problem. Patients in the Intensive Care Unit (ICU) are at risk of having sepsis because of their vulnerability and use of invasive medical devices. Emerging antimicrobial-resistance complicates treatment. Understanding bacterial profiles and antibiotic sensitivity patterns in the ICU plays an important role in managing sepsis, optimizing antimicrobial use, and improving patient outcomes. The aim of this study was to show bacterial profiles and antibiotic sensitivity patterns among patients who were admitted to the ICU at Mbeya Zonal Referral Hospital for 12 months. This was a prospective cross-sectional study among 187 sepsis-suspected patients. Data analysis was performed using SPSS Version 27. Categorical data were summarized by frequency and percentage. Fishers exact test, chi-square test, and modified Poisson regression were used to show the association between patients clinical variables and culture positivity at a 95% CI. Statistical significance was set at a p-value < 0.05. Out of 187 samples, 41.7% were culture positive. Gram-negative bacteria were commonly isolated (65.4%, with Klebsiella pneumoniae and Escherichia coli being commonly isolated. Commonly isolated Gram-positive bacteria were Coagulase-negative Staphylococcus species (19%). 100% of gram-positive bacteria and 96% of gram-negative bacteria were Multi-Drug Resistant (MDR), respectively. In multivariable analysis, patients who were intubated and mechanically ventilated (aPR = 2.208, 95% CI: 1.133-4.305, p = 0.020) and post-laparotomy patients (aPR = 3.241,95% CI: 1.320-7.958, p = 0.010) independently had a higher proportion of Gram-negative bacteria. The study reveals a high level of resistance to commonly used antimicrobials in our setting, necessitating strengthening of the antimicrobial stewardship program and routine surveillance of antimicrobial resistance patterns.

Violence against women is a key contributor to mental health gender disparities, with greater gender gaps observed in low-and middle-income countries. This study examines state-level associations between gender-based violence against women and mental health burden in India over time. We linked 1) annual state-level age-standardised disability-adjusted life year rates (ASDR) from the Global Burden of Disease study for overall mental health disorders, depressive disorders, anxiety disorders, bipolar disorder, schizophrenia and self-harm, with 2) annual state-level gender-based violence rates from the Open Government Data Platform, India. We used descriptive ecological analyses and multilevel modelling to estimate the state-level association between gender-based violence and sex-stratified mental health outcomes over time (2001 - 2021). Results showed higher state-level gender-based violence (GBV) rates were associated with higher state-level ASDR of schizophrenia ({beta}women = 0.39 [95%CI 0.25 - 0.52]; {beta}men = 0.42 [0.29 - 0.55]) and bipolar disorder ({beta}women = 0.02 [0.01- 0.03]; {beta}men = 0.04 [0.03 - 0.05]), after adjustment for state-level social development, but not with other outcomes. Higher GBV rates were associated with a lower gender disparity in depressive disorders. Longitudinal findings revealed that the state-level association between GBV rates and ASDR of overall mental health disorders strengthened over time ({beta}women = 5.08 [3.96 - 6.20]; {beta}men = 3.38 [2.60 - 4.15]), whereas the association weakened for self-harm and schizophrenia. Lagged findings suggested that with an increase in GBV rate, ASDR of overall mental health disorders increased for men over two years and for both sexes over five years. Our findings highlight the importance of considering state-level trends in GBV and related policies, and considering impacts of GBV on both men and women's mental health.

Background: While health system costs of COVID-19 are well documented, evidence on out-of-pocket costs to patients and families, including non-medical and time burden, is limited. This study aimed to estimate out-of-pocket medical, non-medical, and time burden of COVID-19 illness directly from patients and caregivers. Methods: Two cross-sectional surveys were fielded to national nonprobability samples of U.S. adults in Fall 2023: a personal burden survey (adult sample) and a caregiver burden survey (child sample). Surveys collected data on care setting, visit duration including travel and wait time, and medical and non-medical out-of-pocket costs. After applying quality-based exclusion criteria, 409 adult sample and 52 child sample responses were analyzed. Results: Over 87% of respondents were insured. Median out-of-pocket medical costs per visit were low, ranging from $5 (emergency department) to $10 (urgent care) in the adult sample, and from $0 (emergency department) to $75 (hospitalization) in the child sample. Median non-medical costs were $28 or less across care settings. Median time spent receiving care ranged from 90 minutes (primary care, child sample) to 300 minutes (emergency department, adult sample). Despite the relatively low reported out-of-pocket costs, COVID-related financial challenges were reported by 34% of the adult sample and 29% of the child sample, with the most common difficulty being paying non-medical bills (11% and 15%, respectively). Twelve percent in both groups reported problems paying COVID-19-related medical bills. Conclusions: In this post-pandemic non-probability sample, individual out-of-pocket costs for COVID-19 illness were relatively modest. However, time burden was substantial and one-third of respondents reported financial hardship. These estimates, including non-medical and time burden not captured in administrative data, can support more robust economic evaluations of COVID-19 prevention and treatment interventions.

Purpose: To compare the performance of three large language models (LLMs), ChatGPT-o1, Grok 3, and Gemini 2.0 Pro, on the American College of Prosthodontists' National Prosthodontic Resident Examination (NPRE). Materials and Methods: Official NPRE examinations from years 2015-2024 were retrieved from the American College of Prosthodontists website and used to prompt each LLM. Paid access tiers and advanced reasoning were enabled. Responses from LLMs were recorded and compared against the official answer keys for accuracy, variability across years, and consistency of responses. Duplicate questions were retained for the primary analysis and removed in a sensitivity analysis. Accuracy (percent correct) was compared using generalized estimating equations binary logistic regression (primary); Cochran's Q with Bonferroni-adjusted McNemar tests (sensitivity). Year-to-year variability (SD of annual accuracy) was compared using weighted Levene tests. Consistency across duplicate items was quantified as the percentage of perfect matches and compared using Cochran's Q with Bonferroni-adjusted McNemar tests. Results: Across 1,487 questions, overall accuracy differed among models (global P < 0.001). ChatGPT-o1 achieved 78.4% correct, Grok 3 76.4%, and Gemini 2.0 Pro 73.2%; ChatGPT-o1 and Grok 3's accuracy significantly exceeded Gemini 2.0 Pro (both P [&le;] 0.016), with no significant difference between ChatGPT-o1 and Grok 3 (P = 0.099). After removing duplicates (n = 1,200), results were similar: ChatGPT-o1, Grok 3, and Gemini 2.0 Pro were 77.1%, 76.6%, and 71.5% correct, respectively; ChatGPT-o1 and Grok 3's accuracy was significantly higher than Gemini 2.0 Pro (both P < 0.001). Variability across years did not differ significantly (P [&ge;] 0.097). Grok 3 showed significantly higher perfect-match consistency (79.2%) than ChatGPT-o1 (69.4%) and Gemini 2.0 Pro (64.5%) (P [&le;] 0.010). Conclusions: Contemporary LLMs showed 70-80% accuracy on postgraduate prosthodontic multiple-choice content. While promising for educational support, residual error and inconsistency warrant human oversight and transparent methods reporting before curricular adoption.

Recent industry surveys have reported widespread concern about mental health, working conditions, and harassment in the UK film and television industry, but no peer-reviewed empirical study has examined the determinants of occupational burnout in this workforce. The present study tested whether physical health, mental wellbeing, perceived public stigma, intrinsic job quality, and sexual harassment exposure predict burnout in industry professionals. A cross-sectional online survey was completed by 415 individuals across more than 100 job titles, with 286 also completing an optional harassment module. Mental wellbeing sat well below population norms, with 68% scoring in the range indicative of probable depressive symptoms and 82% in the high-exhaustion range on the Maslach Burnout Inventory General Survey. Mental wellbeing and intrinsic job quality were the strongest predictors of burnout (R2 = .56), with meaningfulness accounting for most of the job-quality effect. Working hours independently predicted emotional exhaustion. Harassment exposure was associated with burnout in women but not men, approximately 30% mediated by mental wellbeing; sexist behaviour directly predicted exhaustion in women. Workers with a disability reported higher stigma. Burnout was strongly associated with intent to leave, and the findings collectively indicate an industry-wide occupational health concern requiring structural rather than individual-level intervention.

Background: Both over- and under-antibiotic use pose major global health challenges, yet there is no consensus on how to quantify deviations from optimal prescribing or set evidence-based targets. We developed a benchmarking tool for inpatient antibiotic use and evaluated its application in 10 countries. Methods: We developed decision-tree models to estimate expected empiric antibiotic use for 11 indications, based on the WHO AWaRe book for two age groups: 28 days to 12 years and >12 years. We parameterised the models using country-specific antimicrobial resistance estimates in the 10 countries and cross-sectional Global Point Prevalence Survey (Global-PPS) case-mix data from 2021 for 10 countries and from 2015-2022 in a subset of five countries. We then compared estimated expected antibiotic use with observed empiric use (from Global-PPS) in defined daily doses for adults and days of therapy for children, across indications and AWaRe categories. Findings: In 2021, among patients aged >12 years, in all countries but one, observed empiric Access antibiotic use, as a proportion of total antibiotic use, was lower than expected and empiric Watch antibiotic use was higher than expected. Similar patterns were observed in all countries but one in patients aged 28 days to 12 years. The magnitude of discrepancies between expected and observed Access and Watch antibiotic use varied across indications and countries. The median observed-to-expected ratios of usage across countries ranged from 0.3-0.8 for Access antibiotics, and 0.7-5.3 for Watch antibiotics in patients aged >12 years in 2021. Temporal trends from repeated surveys from 2015 to 2022 showed little change in observed-to-expected ratios for Access and Watch antibiotics. Interpretation: This benchmarking tool uses Global-PPS data to quantify differences between observed antibiotic use and WHO AWaRe recommendations. Our tool can be adaptable to local guidelines, provides policy-relevant estimates of expected antibiotic use to support monitoring, procurement planning, and targeted stewardship intervention.

Background: Although point-of-care testing is the standard method for inpatient glucose monitoring; it is associated with patient discomfort and late detection of dysglycaemic events. Continuous glucose monitoring (CGM) may improve glycaemic management; however, limited staff education and experience among may hinder its implementation. Aim: To investigate experience, perceptions and training needs on CGM use among inpatient nursing staff across diverse hospital wards. Methods: This is a single-centre, 38-item online survey recruited inpatient nurses in a hospital in the UK. Participants were invited via the e-newsletter and posters; the survey remained open for five months. Results: Nineteen nurses reported positive perceptions of inpatient CGM. Most considered CGM reliable (77.8%) and preferred CGM combined with POCT (66.7%). Views on its impact on workload and patient-room entries were mixed (30% agreed, 30% disagreed). Training needs included sensor placement (92.9%) and alarm management (78.6%). Conclusion: Nurses viewed CGM favourably but highlighted important training needs for inpatient use.

Importance: Clinicians often look for a dental source in Staphylococcus aureus bacteremia (SAB), but how often dental disease is found, compared with other bacteremias, is unclear. Objective: To compare documented dental disease in adults with SAB, Escherichia coli bacteremia, and a general population cohort. Design, Setting, and Participants: Retrospective cohort study in the Protege database of 48 975 adults with bacteremia from January 1, 2015, through December 31, 2023, assigned by earliest in-window organism, and 81 945 general population adults. Exposures: SAB, with E coli bacteremia as the primary comparator and the general population as the secondary comparator. Main Outcomes and Measures: Documented dental disease from 7 days before through 30 days after index, defined by a qualifying dental procedure or disease-specific note text and adjusted for age, sex, race, and documentation intensity. Results: Dental disease occurred in 528 of 16 435 patients with SAB (3.21%) and 179 of 24 942 patients with E coli bacteremia (0.72%). The adjusted odds ratio was 3.86 (95% CI, 3.23 to 4.63). By the pathology-only definition, disease occurred in 517 patients with SAB (3.15%) and 399 general population patients (0.49%). The adjusted odds ratio was 3.71 (95% CI, 3.08 to 4.46). Within SAB, rates were highest with prior infective endocarditis (9.8%), opioid use disorder (6.2%), injection drug use (5.3%), and prosthetic valve (5.0%). Prevalence ranged from 0.49% in the general population to 7.98% in other streptococcal bacteremia. Of 437 patients with SAB and an assignable first finding date, 333 (76.2%) had the finding after the index date. Conclusions and Relevance: Dental disease was documented more often in SAB than in E coli bacteremia after adjustment. Most findings were first recorded after bacteremia was recognized, during SAB evaluation. These data do not show that dental disease caused the bacteremia.

Background: Workplace discrimination and violence against health workers including sexual harassment is a societal problem worldwide. We aimed to assess the frequency, predictive factors, and effects of sexual harassment using a nationwide survey of physicians working in Switzerland. Materials and Methods: We conducted a self-administered questionnaire survey of physicians working in Swiss healthcare institutions. The questionnaire assessed experiences of sexual harassment at work, including frequency, types, and sources of harassment. It also asked about the impact of sexual harassment, whether incidents were reported, and what actions were taken following a report. Results: Among the 1837 physicians that participated in the survey, 575 (31.3%) had experienced sexual harassment at least once during their career. Among those reporting sexual harassment, 39.1% of women and 13.2% of men had experienced harassment at least once in their job. Women reported more verbal harassment, while men reported more physical harassment. Women were also more likely to face both forms combined. The main sources of harassment were colleagues of the same profession (46.7%), patients (42.3%), and superiors (41.0%). The most frequently reported impacts included stress (60.1%), emotional exhaustion (34.7%), reduced motivation at work (30%), and considering leaving the job (7.5%). Gender-men was associated with a lower likelihood of experiencing harassment 0.24 (0.18 to 0.31), whereas working in the German-speaking region was associated with a slightly higher likelihood of having experienced sexual harassment at least once (OR 1.35, 95% CI:1.02-1.81). Conclusions: Sexual harassment is common among physicians in Swiss healthcare institutions. It adversely affects the mental health and career trajectories of both men and women yet remains widely underreported due to fears of reprisals and inaction. Institutions should effectively intervene to ensure that reported incidents result in appropriate actions, and that those who report them receive adequate protection from reprisals.