JMIRx Med

Background: Diabetes mellitus and hypertension are increasingly prevalent non-communicable diseases that often coexist due to their interrelated pathophysiology and commonalities of risk factors. Effective management of these two comorbid conditions often involves polypharmacy, defined as the concurrent use of five or more medications, which for therapeutically relevant outcomes requires a high-medication adherence. Limited data exist on the extent of polypharmacy and its impact on adherence among Tanzanian patients with these comorbidities. This study therefore aimed at evaluating the prevalence of polypharmacy and its impact on medication adherence levels among this population. Methodology: A cross-sectional study involving 396 outpatients was conducted at Muhimbili National Hospital. Consecutive sampling was used to recruit eligible participants. Data was collected using structured-questionnaire which captured information on socio-demographics, clinical characteristics and adherence behaviors. Polypharmacy was defined as using five or more medications. Medication adherence was assessed using the Medication Adherence Report Scale (MARS-5). Multivariable logistic regression was performed to identify factors associated with adherence. Results: 71% of the study participants were on five or more medications, indicating high polypharmacy prevalence, with a median of six medications. Medication adherence was reported at 55.1%. Factors associated with lower adherence included moderate (APR: 0.83, P = 0.001) and high fasting glucose (APR: 0.66, P < 0.001), herbal medicine use (APR: 0.72, P < 0.001), and uncontrolled blood pressure. Conclusion: This study reveals a high prevalence of polypharmacy with moderate medication adherence among patients with comorbid T2DM and hypertension. These findings suggest a targeted intervention utilizing such as patient education and medication reviews are essential to improve adherence and management in Tanzania.

Background: Academic achievement is crucial for university students, but various factors affect their performance. This study explores the impact of anxiety, sleep quality, social media use, and socioeconomic status on academic performance (CGPA) among public university students in Bangladesh. Data and Methods: Data were collected from 225 students using a structured questionnaire that assessed anxiety (GAD-7), sleep quality (PSQI), social media use (SMUQ), and socioeconomic status (income, parental education). Structural Equation Modeling (SEM) was used to analyze the relationships between these variables. Outcomes: The results showed that socioeconomic status had a strong positive effect on academic performance ({beta} = 0.745, p < 0.001), while anxiety negatively impacted academic outcomes ({beta} = -0.675, p < 0.001). Sleep quality was positively related to academic performance ({beta} = 0.113, p < 0.05), but with a weaker effect. Social media usage is found to have a negative significant effect on academic performance ({beta} = -0.137, p < 0.001). Conclusion: These findings highlight the importance of controlling social media usage and anxiety to enhance academic performance among adult students. Sleep quality and socioeconomic background of the students are also found to be meaningfully associated with their educational progress.

Introduction We are currently working on the BEARS (Both Ears) virtual reality (VR) Randomised Controlled Trial. We are recruiting 272 deaf children and young people who use bilateral (both ears) cochlear implants (CI) to examine if using the BEARS VR games helps their hearing in background noise and ultimately their quality of life. Clinical trial participants should be representative of the population with the health condition, although this is rarely achieved in practice as people from ethnic minorities or those from more deprived areas may face barriers to participation. Study Design Mixed methods design Objectives Use a literature review and collection of data from cochlear implant centres to establish the sociodemographic characteristics of deaf children aged 8 to 16 years with bilateral cochlear implants in the United Kingdom (UK). a. Establish the sociodemographic characteristics of the families recruited to the BEARS clinical trial in the first six months, and compare with the age-matched population of deaf children with bilateral cochlear implants in the UK. b. Analyse the BEARS clinical trial pre-screening diversity data. c. Implement an established recruitment intervention method in a workshop to explore and optimise recruitment number and diversity. d. Compare the final six months of recruitment data diversity with the initial six months. Use interviews and focus groups to collect qualitative data from children and their families who chose not to take part in BEARS, clinicians, and family representatives (e.g. teachers) to explore barriers and facilitators to families taking part in BEARS. Amend the BEARS scale-up plan based on new learning. Methods Literature and scoping reviews, quantitative analysis of BEARS recruitment data, in-depth interviews, paired interviews, focus groups Sample size Qualitative sample: 10-15 children aged 8-16 with bilateral CI, 10-15 parents/carers of children with bilateral CI, 10-12 clinicians and 10-12 family representatives. Significance This work will evaluate how diverse the BEARS clinical trial recruitment is and whether it is representative of the UK population of children with bilateral cochlear implants. We will investigate recruitment barriers and implement measures to try to improve recruitment diversity.

Abstract Background: Even though significant advances in diagnosis, treatment, and prevention strategies have been implemented, neonatal sepsis remains a common concern in clinical practice, especially in low-resource countries. It is one of the major causes of death during the first month of life. This study aimed to assess clinical outcomes and predictors of mortality among neonates with neonatal sepsis admitted to public hospitals in selected Hospitals in Addis Ababa, Ethiopia. Methods: A hospital-based prospective cohort study design was conducted among 466 neonates admitted with neonatal sepsis from September 2024 to January 2025. All neonates who were admitted to selected Hospitals of Addis Ababa city after being clinically or laboratory-diagnosed with neonatal sepsis by the attending physician were included in the study. Data were entered into EpiData 4.2 and analyzed by SPSS version 26. Bivariate and multivariate Cox regression were used to identify the relationship between dependent and independent variables. Finally, variables with p-value [&le;] 0.05 were taken as significant factors associated with poor clinical outcome. Results: The study was conducted among 466 neonates admitted with neonatal sepsis. Of all neonates admitted with neonatal sepsis, 372 (79.8%) were discharged with good outcomes, and 94 (20.2%) had a poor outcome/died. Duration of ruptured membrane being >12hr (AOR=7.02, 95 % (CI: 1.85, 26.57), marital status /divorced (AOR=3.12, 95 % (CI: 1.67, 7.45),rural residence (AOR= 6.05, 95 % (CI: 2.03-16.53), assisted instrumental delivery (AOR= 5.99, 95 % (CI: 1.46-17.11), meconium-stained amniotic fluid ((AOR= 9.48, 95 % (CI: 0.49-18.61)), no initiate exclusive breast feed within one hour (AOR= 3.20, 95 % (CI: 0.90-7.52), chest in drawing (AOR= 5.81, 95 % (CI: 1.75-11.23) were significantly associated with neonatal mortality. Conclusion: Neonatal mortality was moderately high. Meconium-stained amniotic fluid, prolonged duration of ruptured membrane (>12hr), Mode of delivery (instrumental delivery), and chest in drawing are among the predictors of neonatal mortality. Keywords: -Clinical outcome,Neonatal sepsis, Mortality, predictors, Ethiopia.

The availability of hearing aids that can connect wirelessly to smartphone technologies via Bluetooth has grown exponentially in recent years. However, there is limited evidence assessing the benefits of user-adjustability afforded by these devices. This study aimed to assess the benefits of smartphone-connected hearing aids and an accompanying application (or app) in new and existing hearing aid users. In this single-centre, prospective, observational study, 44 adult hearing aid users (14 new and 30 existing) were recruited. Participants were fitted bilaterally with smartphone-connected hearing aids that could be adjusted by the user via an app. Self-reported outcome measures were collected at fitting and after seven-weeks of using the device in everyday life. For both new and existing hearing aid users, significant improvements in social participation, hearing-related fatigue, and hearing aid benefit and satisfaction were found. For existing hearing aid users, all outcomes were significantly better for the smartphone-connected hearing aids plus app in comparison to their existing hearing aids that did not connect to a smartphone, all with moderate-to-large clinical effect sizes (d> .6). User-controllability via the app was identified as the key benefit, and most participants (68%) reported that the app met their needs 'extremely' or 'very well'. These results suggest that, when used in conjunction with an app, smartphone-connected hearing aids can improve hearing outcomes due to greater user-controllability to improve listening. Thus, smartphone-connected hearing aids have the potential to facilitate patient-centred care, empowering the individual to successfully manage their hearing loss.

Problematic Internet Use (PIU)--marked by compulsive or maladaptive online behavior--is an emerging public health issue among adolescents and is associated with psychological distress, social difficulties, and academic problems. In Finnmark County, Norways northernmost and ethnically diverse region, limited research has examined the underlying mechanisms of PIU among Sami and non-Sami youth, despite increasing levels of digital engagement. This study protocol outlines a population-based cross-sectional survey investigating the associations between social norms (descriptive and injunctive), ethnic identity, and ethnicity-based discrimination in relation to PIU among Sami and non-Sami adolescents in Finnmark. Guided by Social Norm Theory and Ethnic Identity Theory, the study aims to examine risk and resilience factors associated with adolescents digital behavior in a geographically sparsely populated, multiethnic region. A population-based, cross-sectional school survey will include all upper secondary school students in Finnmark County (N {approx} 2,230). A culturally adapted, bilingual questionnaire (Northern Sami - Norwegian) will measure problematic internet use, perceived social norms in family, peer, and school contexts, ethnic identity, ethnicity-based discrimination, positive internet use, and key covariates. Ethnicity will be classified based on indicators of Sami language use and self-identification. Data will be prepared using prespecified quality procedures and analyzed with partial least squares structural equation modeling (PLS-SEM) to examine associations between social norms, ethnic identity, ethnicity-based discrimination, and internet use outcomes, including mediation and moderation. Group differences between Sami and non-Sami adolescents will be assessed using PLS Multi-Group Analysis. The findings may inform the development of culturally appropriate approaches to screening, prevention, and early intervention, and are relevant for mental health services, school-based programs, and public health strategies targeting Indigenous youth in rural and semi-rural regions.

Perioperative safety checklists standardize critical actions, but reliable completion depends on the surrounding work system and team behavior. We conducted a prospective observational analytic study from April to May 2026 in the central surgical unit of a high-volume public teaching referral hospital in Indonesia to examine whether patient safety culture and teamwork were associated with directly observed perioperative safety compliance and whether teamwork mediated the culture-compliance relationship. Patient safety culture was measured with the Hospital Survey on Patient Safety Culture 2.0, teamwork with a 35-item TeamSTEPPS Teamwork Perceptions Questionnaire research adaptation, and compliance by direct role-based observation using a 45-item checklist derived from the AORN Comprehensive Surgical Checklist. Eighty of 92 recruited professionals contributed 240 person-operation observations across 50 operations. Overall compliance was 74.75%, with sign-out lowest at 70.68%. Patient safety culture was associated with teamwork ({beta} = 0.590; 95% CI 0.510-0.770) and directly with compliance ({beta} = 0.407; 95% CI 0.187-0.712). The teamwork-compliance coefficient was positive ({beta} = 0.285; p = 0.046), but the prespecified percentile 95% CI included zero (-0.045 to 0.517). The indirect effect through teamwork was not supported ({beta} = 0.168; p = 0.079). These findings support a system-level interpretation of perioperative safety and identify learning-oriented responses to error, situation monitoring, and sign-out fidelity as measurable targets for future improvement efforts.

Abstract Objective. To identify and rank the leadership traits most valued by medical staff in public hospitals, and to compare them with an established generic instrument and a generative artificial intelligence source. Design. Sequential exploratory qualitative-quantitative (QUAL QUAN) mixed-methods study: focus groups followed by an online ranking survey, with cross-comparison against the Northouse Leadership Traits Questionnaire (LTQ) and a ChatGPT derived list (LAIT). Setting. Major public hospital affiliated with Monash University, Melbourne, Australia, in 2023. Participants. Twenty-four senior medical staff (16 men, 8 women; 18 clinicians, 6 administrators) recruited through opportunistic sampling. Main outcome measures. Weighted ranking of the ten most desired leadership traits (Leadership Enabling Traits Survey, LETS); internal consistency (Cronbach s alpha); agreement between LETS and LTQ self-scores; and strong overlap with the AI-derived list. Results. The first most-weighted LETS traits were integrity (1.526), communication (1.435), compelling vision (1.404), emotional intelligence (1.040) and empathy (0.969), the same five identified by the AI source. Integrity was weighted 3.6 times more heavily than rebelliousness (0.424). Both LETS and LTQ achieved Cronbach s alpha > 0.7. Unweighted total self-scores did not differ between LETS (77.4 +/- 7.6) and LTQ (78.4 +/-6.9); weighted emotional intelligence related and other-trait sub-scores diverged significantly (p<0.001). Survey power was 45% at alpha=0.05.

Objectives: To evaluate the sustainability of Lean Healthcare practices after the implementation phase of a national quality improvement programme and to identify organisational factors associated with maintaining results over time. Design: Multicentre cross-sectional study with a mixed-methods approach. Setting: Twelve public and philanthropic hospitals in Brazil participating in Phase 2 of the Lean in Emergency Departments Project. Participants: Key respondents in managerial or leadership roles from participating hospitals (response rate: 75.0%). Outcome measures: Sustainability of Lean practices and organisational readiness, assessed through a structured survey and triangulated with operational indicators collected across successive implementation cycles at hospital level. Results: During one year of structured follow-up, 66.7% of respondents reported maintenance of Lean practices; this decreased to 33.3% after the end of structured follow-up. Although 66.7% considered professionals capable of maintaining results, only 58.3% positively evaluated institutional structure, indicating a discrepancy between individual capacity and organisational readiness. Operational indicators showed heterogeneous behaviour across hospitals, with no consistent pattern of sustained improvement. Qualitative analysis identified professional and managerial turnover, formal governance structures, and continuous monitoring as key factors associated with sustainability. Conclusions: The sustainability of Lean Healthcare practices is more strongly associated with institutional capacity to embed and sustain changes over time than with isolated individual training. Quality improvement programmes should incorporate structured strategies for the post-implementation phase. Keywords: Lean Healthcare; Sustainability; Quality improvement; Hospital flow; Health systems; Organisational factors

Measuring health literacy is important in addressing health inequity. However, current measures are developed from the individualistic perspective that values personal autonomy and choice. Applying such measures to people from a communal culture that values collective actions may lead to biased responses. To address this gap, a health literacy measure drawing on the communal perspective was developed in Thailand. With the aim to also develop an equitable measure, a grounded approach including strategies to include people with special needs such as people with chronic illness or physical disabilities, blind people and deaf people, was used. Concept mapping workshops were conducted, involving 254 participants including general community members, people with special needs, health professionals and policymakers. The result was a draft questionnaire of 17 hypothesized scales. Psychometric testing involving a survey of 2,228 participants resulted in a 14-scale questionnaire, the Information and Support for Health Actions Questionnaire (ISHAQ). This paper reports on the psychometric testing of the 14-scale ISHAQ and its supplementary scales for people with special needs. Item difficulty, scale reliability, one-factor confirmatory factor analysis using robust maximum likelihood estimator, and measurement invariance across groups with special needs using the alignment method with Bayesian estimation, were evaluated. A total of 2,262 respondents participated in the survey. Six scales achieved excellent model fit while one with reasonable fit and seven scales achieved reasonable to excellent fit following modifications. Supplementary scales also achieved reasonable to excellent model fit. Reliability for all scales were acceptable to good. Measurement invariance was confirmed for eight scales. With strong validity evidence, the ISHAQ is translated into English and ready for implementation. With the potential to be applied in different settings given cultures exist in a continuum, the ISHAQ can be used for health literacy needs assessment to support intervention development to improve health outcomes and equity.

Purpose: There is a long-standing perception that individuals who stutter are less intelligent, with the disfluencies unique to stuttered speech often assumed to be the overt reflection of lower intelligence, despite no supporting evidence. The purpose of the present study was to explore the validity of this assumption by examining the cognitive abilities of adults who stutter compared to the general population using the NIH Toolbox (C) Cognition Battery (NIHTB-CB). Method: Sixty-three adults who stutter completed the NIHTB-CB, which includes seven standardized measures assessing crystallized cognition (Picture Vocabulary, Oral Reading) and fluid cognition (List Sorting Memory Test, Pattern Comparison Processing Speed Test, Flanker Inhibitory Control Test, Dimensional Change Card Sort Test, Picture Sequence Memory Test). The NIHTB-CB generates t-scores adjusted for demographic variables based on a large sample of neurotypical adults. Results: Composite scores of overall cognition for adults who stutter were not statistically equivalent, rather, their scores were higher than the general population. Higher scores were driven by crystallized cognition, with significantly higher scores on Oral Reading subscale. Conclusions: Present findings demonstrate that adults who stutter possess cognitive skills that are comparable to or potentially higher, than the general population. These results challenge the misconception that stuttering reflects diminished intelligence and offer evidence to mitigate stereotype threat.

Introduction Deafness is the most common human sensory deficit. Cochlear implantation is the primary intervention for severe-to-profound deafness. Currently, over 7000 people have bilateral cochlear implants (CIs) in the United Kingdom (UK), most of whom are children. Patient feedback suggests that for children with bilateral CIs, everyday communication is challenging and tiring, with extra effort required to integrate information from two ears, especially in noise, and that current rehabilitation techniques are not engaging, or appropriate to their lifestyles. To address these issues, researchers developed the Both EARS (BEARS) training package comprised of three virtual reality games to improve sound localization and listening in noise. Objectives This protocol describes the design and methodology of a multi-center phase III randomized controlled trial (RCT) to evaluate whether use of the BEARS training package alongside usual care compared to only receiving usual care improves speech-in-noise perception, hearing experiences, vocabulary and quality of life and reduces listening effort in children and young people (aged 8 -16 years (inclusive) with bilateral CIs. Methods This RCT is currently underway in 16 clinical CI departments in National Health Service or university hospitals across the UK. The intervention involves 3 months of spatial-listening training delivered via the BEARS training package in addition to any routine rehabilitation. The control is usual care (routine rehabilitation clinical care pathway). The primary outcome is the difference between the intervention groups in speech-in-noise perception score at 3 months derived from the spatial speech in noise (SSiN-VA) test. Recruitment closes at the end of the day on 31st July 2026, and end of data collection is 31st October 2026. Data analyses will be reported by 31st March 2026. Significance This is the largest known trial of children and young people with bilateral CIs. It will generate high-quality evidence on speech-in-noise outcomes and inform training interventions to improve spatial listening. Trial registration ClinicalTrials.gov registration: NCT05808543; UKs clinical study registry (ISRCTN92454702)

Cancer prevalence is distributed unevenly across regions and caused by the interaction of multiple risk factors. Previous studies focused on the use of global modeling techniques to predict cancer at the county level that overlooks important spatial differences. This study aims to develop geographically weighted machine learning models to predict cancer prevalence at the census tract level in the United States and identify local determinants of cancer burden. First, a scoping review was conducted to find a list of measurable drivers of cancer in the United States. Using this list, the data of these variables for 84415 census tracts were obtained from the Center for Disease Control and Prevention PLACES dataset and other publicly accessible resources. Then, several predictive models, including Ordinary Least Squares (OLS) and Geographically Weighted Regression (GWR), as well as Random Forest, XGBoost, and Deep Neural Network and their geographically weighted counterparts, were developed and compared using the Coefficient of Determination, Root Mean Square Error, and Absolute Error. Results presented that geographically weighted models outperformed other methods, and geographically weighted XGBoost achieved the strongest and most consistent overall performance with pseudo-R2 ranging between 0.89 and 0.98. Feature importance analysis of this model illustrated that most important cancer drivers changed location by location. Aged people, racial composition, preventative behaviors, and metabolic conditions such as diabetes, hypertension, and high cholesterol were determined as influential predictors, although their relative importance varied across regions. These findings revealed the value of localized models at a small geographic scale to identify regional cancer risk patterns and help the allocation of proper resources to hotspot areas. Keywords: Cancer prevalence, Census tracts, geographically weighted machine learning models, Deep neural network, XGBoost, Random Forest, Ordinary Least Squares, risk factor, determinant

Background: Generative AI is evolving at a rapid pace, and many individuals are utilizing chatbots for mental health support. The safety of chatbots amid suicide disclosures is a major public health focus. However, the rate and correlates of intentions to seek help from chatbots for suicide thoughts is unknown. Objective: We sought to understand intentions to seek help from chatbots for suicide thoughts, compared to informal, formal, and anonymous online sources. Methods: Participants with clinically significant depression or anxiety (N=58) completed the General Help Seeking Questionnaire regarding help-seeking intentions for suicide thoughts and general emotional problems. Two questions were added to assess intentions to seek help from chatbots and anonymous online sources. Wilcoxon tests were used to compare intentions to use chatbots with intentions to use anonymous online sources and with groupings of informal (e.g., friends, family) and formal (e.g., therapist, general practitioner) sources. Kendall's correlations were used to examine correlations among groupings and individual informal and formal sources, and regression models further examined individual source associations adjusting for general help-seeking intentions. Exploratory analyses assessed whether demographic characteristics, mental health symptoms, and suicide risk were associated with help-seeking intentions for chatbots. Results: Participants endorsed lower help-seeking intentions for suicide thoughts from chatbots than from informal and formal sources. Intention to use chatbots for suicide thoughts was not correlated with informal and formal sources but was correlated with anonymous online sources. At the individual source level, chatbot intentions were positively associated with intimate partners but negatively associated with outreach to friends after adjustment for general help seeking tendency. Anxiety symptom severity was positively correlated with chatbot use intentions, but not with other sources of support. Conclusions: While preliminary, intentions to use chatbots for suicide thoughts appear mostly disconnected from intentions to seek help from other informal and formal supports. Future studies should evaluate the dynamics of help seeking for suicide thoughts via chatbots amidst and, perhaps in place of, other sources of support.

Background HIV testing is a key entry point for prevention and treatment in Nigeria, yet age-related disparities persist. Adolescent girls and young women (AGYW) are disproportionately affected by HIV but often demonstrate lower uptake of testing services. This study examined differences in HIV self-testing awareness, use, and antenatal HIV testing between AGYW and older women, the distribution of HIV testing service uptake, and identified multilevel factors associated with HIV self-test awareness and testing among AGYW. Methods This study analyzed cross-sectional data from the 2023-2024 Nigeria Demographic and Health Survey (NDHS), including women aged 15-49 years. Descriptive statistics were used to assess differences in HIV self-testing awareness, use, antenatal HIV testing, and place of HIV testing between Adolescent Girls and Young Women (AGYW) (15-24 years) and older women (25-49 years). Among AGYW, bivariate and multivariate logistic regression were conducted to identify socioecological factors associated with HIV self-testing, awareness and use. Results A total of 14,708 AGYW and 24,342 older women were included in the analysis. The median age of AGYW was 19 years (IQR: 17-22), compared to 35 years (IQR: 25-41) among older women. Older women reported significantly higher awareness of HIV self-testing (13.1%) compared to AGYW (8.8%). Use of the HIV self-testing kit was low overall but higher among older women (2.3%) than among AGYW (1.1%). Older women reported greater uptake of antenatal HIV testing (57.9%) than AGYW (48.4%). Education, wealth, and internet use were positively associated with awareness, while AGYW aged 15-19 had significantly lower odds of awareness than AGYW women aged 20- 24. Regional disparities were also observed in the awareness and use of HIV self-test kits. Conclusions Findings support that targeted, AGYW-centred strategies are needed to improve equitable access to HIV testing and achieve national and global HIV prevention goals.

Objective: To assess the efficacy of an executive peer coaching program, Charting Champions Program (CCP), in helping physicians manage their administrative workload, thereby improving time management, workflow and well-being. Findings: In this longitudinal survey study, physicians self-reported significant improvements in completing charting and administrative paperwork during their clinical day. Physicians reported significant improvements in mental, cognitive and emotional states after the program. Meaning: The Charting Champions Program is an effective intervention that supports physicians in problem-solving the administrative burden of their clinical day, improving workflow efficiency, completing administrative requirements during clinical hours, and enhancing work-life balance and personal satisfaction. Background: Physicians are subject to high levels of mental, physical, and emotional stress, partly due to increasing administrative burdens. Online coaching is a proven intervention to help physicians improve workflow efficiency, reduce administrative burden and improve job satisfaction. Design: This voluntary longitudinal survey took place between 2020 and 2023. Physicians were asked to complete a survey at program entry and again 30-90 days after program completion. The survey consisted of 14 Likert scale questions, and a final sample of 280 physicians completed both surveys. Intervention: CCP contains modules that teach workflow improvements for clinical days, including timely charting, administrative task workflow, managing patient consultations and reducing interruptions. Interventions include self-paced modules, live coaching, recordings and an online peer community. Results: Post-CCP physicians reported a significant decrease in hours spent charting (P<0.0001) and completing clinical paperwork outside of clinical hours (P<0.006). Physicians also reported a decrease in work-related dread (P<0.001), feelings of burnout (P<0.001), and thoughts of quitting due to administrative burdens (P<0.001). Physicians felt more focused at work (P<0.001), felt more in control of the clinical day (P<0.001), and rated their mental energy at work higher (P<0.001). The program did not affect the number of patients seen in a full clinical day (P > 0.918). Conclusion and Relevance: The CCP reduces the time physicians spend on tasks outside of clinical hours, increasing free time without decreasing the number of patients seen per day.

Ambient artificial intelligence scribes are being increasingly used in healthcare to improve efficiency and reduce provider clinical documentation burden, yet their performance across linguistically diverse patient populations is not well characterized. We conducted a retrospective analysis of 54,160 outpatient encounters within a U.S. safety net health system to evaluate the performance of an artificial intelligence documentation tool in English and non-English clinical encounters, and in encounters where an interpreter or bilingual provider was present. Documentation performance was measured by the percentage of words in the final note that were generated by the ambient AI documentation tool and not edited by the provider. Associations between language factors and documentation performance were measured using Generalized Estimating Equations with exchangeable correlation structures to account for clustering of multiple encounters within unique patients. Univariable models were fitted to estimate the odds of adequate performance by language and interpreter modality, and a multivariable interaction model was used to evaluate within-language differences between bilingual providers and interpreter-mediated encounters. Non-English encounters were 21% to 25% less likely than English encounters to achieve the same performance threshold. There was no significant difference in generative documentation performance between interpreter-mediated and bilingual provider encounters. These findings underscore the importance of equity-focused evaluation and multilingual model refinement to ensure that artificial intelligence documentation benefits are distributed fairly across diverse patient populations.

Objective: Impaired understanding of noisy or degraded speech is a central feature of listening difficulties (LiD), but the possible causes of these symptoms are wide-ranging. Accordingly, recent research underscores the need to study these deficits using a test battery approach. Event-related potentials are useful objective metrics for studying LiD, but probing function across the speech processing hierarchy using traditional protocols is sequential and unrealistic in clinical settings. The novel chirped speech (Cheech) method combines natural speech with acoustic chirps to overcome these limitations. This study examines its utility for profiling childhood LiD. Methods: Twenty-eight children (15 typically developing, 13 with LiD), aged 8-17 years old, listened to a 17-minute Cheech story and detected a target word within the story via button press while EEG data were collected from 53 scalp sites. Results: Cheech successfully evoked responses from the auditory brainstem response through to the brain's language centers, as reflected by the N400 effect. Unlike TD children, those with LiD demonstrated N400 effects with atypical distributions that favored frontal rather than the typical parietal sites. A trend towards a delayed and reduced amplitude Wave V was also observed. Conclusions: Hierarchical examination of speech processing using Cheech primarily implicates altered language processing as a contributing factor to LiD, with the frontal topography of the N400 effect for those with LiD potentially suggesting a greater reliance on deliberate memory retrieval during the speech perception task. Significance: LiD could arise due to auditory and/or cognitive factors. The present results demonstrate the feasibility of objective, parallel measurement across this hierarchy and point to impaired language processing as a possible mechanism.

AVATAR therapy is an effective relational therapy for persistent distressing auditory verbal hallucinations (voices). A digital representation of the embodied persecutory voice (avatar) is created and used in a series of dialogues in which the voice hearer is supported to be more assertive and the avatar concedes power. In the first mediation analysis of AVATAR therapy examining the role of power-related constructs, we investigate whether treatment effects on total severity, frequency, and distress of voices are mediated by changes in beliefs about voices and the self, voice relationship appraisals and anxiety. Mediation effects were evaluated in relation to decomposing treatment offer and treatment receipt effects using both Intention to treat (ITT) and Complier Average Causal Effect (CACE) analyses. One hundred and fifty participants from AVATAR1, a randomised control trial (RCT) comparing AVATAR therapy to Supportive Counselling took part in this study, with their baseline and end of treatment (12 weeks) data used. As hypothesised, across both ITT and CACE analyses, reductions in perceived voice omnipotence and increased assertiveness in relation to voices emerged as consistent mediators of AVATAR therapy on reductions in overall severity, frequency and distress of auditory hallucinations compared to SC, whereas voice malevolence, perceived power differential, self-esteem and anxiety did not. Exploratory analysis also indicated that increases in acceptance and autonomy in relation to voices mediated the impact of AVATAR therapy on overall voice severity and distress. This mediation analysis refines our understanding of AVATAR therapy and highlights agency, voice omnipotence and acceptance as intervention targets.

Background Non-alcoholic fatty liver disease (NAFLD) has become a common metabolic disorder in paediatric age groups and is a major contributor to the burden of health economics. However, there is a lack of comprehensive data on the prevalence of this condition among children. Methods English language literature published from inception until April 2025 was searched from the electronic databases, i.e., PubMed/Medline, Scopus, Embase, and CINAHL. Original data published in any form that reported NAFLD prevalence among children and/or adolescents in India were included. The subgroup analysis of prevalence was done based on the risk category, i.e., average risk group and high risk group (obesity or overweight, metabolic syndrome, etc.). The prevalence estimates were pooled using the random-effects model. Results A total of 11 studies (six in high-risk populations and 5 in the average-risk general population) comprising data from 3512 individuals were found eligible and were included. The overall pooled estimate of NAFLD prevalence among the children and adolescents was 35.4% (95% CI: 19.7% to 52.9%) with very high heterogeneity(I2=99.0%). The pooled prevalence of NAFLD among average/low risk children and adolescents was 10.7% (95%CI: 5.2% to 20.5%) with high heterogeneity across the studies (I2= 96.6%, p=0.001) whereas the pooled prevalence of NAFLD in high risk overweight/obese children and adolescents was found to be 59.7% (95% CI:55.2% to 64.1%) with moderate heterogeneity across the studies (I2=50.90%; H2=2.04; Q (5) = 10.03; p=0.07) Conclusion This systematic review demonstrates that non-alcoholic fatty liver disease (NAFLD) poses a growing health concern among Indian children and adolescents, as 1 out of 3 children/adolescents is suffering from it, with a disproportionately high burden observed in those who are overweight or obese.