Journal of Psychosomatic Research

ObjectiveTo develop and psychometrically evaluate an assessment of symptoms in myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS) MethodsAn initial symptom list was devised from the relevant literature with the patient and clinician advisory groups. An online survey with 85 symptom items in eight domains was completed by people with ME/CFS. Each item had two response structures (assessing symptom frequency and severity on five-point scales). Rasch analysis assessed each domain for unidimensionality, targeting, internal reliability, item fit and local dependency. ResultsSurvey data (n=721) indicated various item anomalies and inter-item dependencies, leading to item re-formatting or removal. The frequency and severity-based responses broadly replicated each other, and a four-point response format appeared more appropriate than a five-point response format. Following Rasch-based scale amendments, a revised version with a single four-point response format was re-administered to test the modifications. Validation data (n=354) showed the modified scale had an improved response structure and functionality across all domains, satisfying Rasch model assumptions. Additionally, domain-level super-items allowed for a summated total score along with sub-scales summarising neurological and autonomic symptoms, again satisfying Rasch model assumptions. ConclusionsThe Index of ME Symptoms (TIMES) and its associated sub-scales and domain scales are stable, valid assessments of symptoms in ME/CFS.

ObjectiveTo evaluate the criterion-related and discriminant validity, test-retest reliability and minimal detectable difference of The Index of ME Symptoms (TIMES) in myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS) MethodsPeople with ME/CFS in the UK completed the TIMES online (n=1055). Rasch-transformed interval data and parametric statistics were used: Pearson correlations (with the ME severity scale); analysis of variance; intra-class correlations (ICC) and standard error of measurement of ICC measured criterion-related and discriminant validity, test-retest reliability and minimal detectable difference respectively. ResultsHighly significant (P<0.001) moderate (r=0.400-0.528) correlations were seen between the TIMES scales and severity of ME/CFS except the gastro-intestinal and immune systems scales (r= 0.315 and 0.302 P<0.001 respectively). Discriminant validity was demonstrated with significant differences in TIMES scores between all five levels of ME severity, except between levels 4 and 5 in some cases, which were underpowered due to the small group numbers. Test-retest reliability was excellent (ICC>0.7, p<0.001) except the cranial nerves and immune system scales which were good (ICC = 0.681 and 0.669, p<0.001) and minimal detectable difference was excellent (3.95-17.45%). ConclusionsThe Index of ME Symptoms (TIMES) scales are valid, reliable, sensitive assessments of symptoms in ME/CFS. They are freely available for use.

ObjectiveAlthough trauma-focused psychotherapies are effective for posttraumatic stress disorder (PTSD), recovery under routine outpatient conditions remains variable. We examined whether participation in a structured Specialty Care (SC) model integrating clinician specialization, flexible treatment density, and coordinated navigation was associated with accelerated PTSD recovery compared with standard outpatient care. MethodsWe conducted a retrospective matched cohort study (2024-2025) of U.S. adults with active PTSD symptoms (PTSD Checklist for DSM-5 score [&ge;]31) receiving care through an employer-sponsored digital mental health platform. Access to SC was determined by employer benefit design. Propensity-score matching with weighting balanced cohorts on baseline severity and demographics. Primary outcomes included longitudinal PTSD symptom trajectories and time to recovery, remission, and reliable improvement. Secondary outcomes assessed depressive symptoms (PHQ-9). Linear mixed-effects and Cox proportional hazards models were applied. ResultsThe matched sample included 356 SC and 9,409 standard care participants. SC participants received higher treatment intensity, including greater session volume and faster early follow-up, and greater care navigation engagement. SC participation was associated with steeper PTSD symptom decline ({beta} = -1.3 per log-week, p < .001) and a higher likelihood of recovery (hazard ratio = 1.31; 95% CI, 1.10-1.57). At 12 weeks, predicted recovery was 29% in SC versus 23% in standard care. Depressive symptoms improved in both groups, without significant differences in time to categorical recovery. ConclusionsUnder routine outpatient conditions, a structured SC model was associated with accelerated PTSD recovery, suggesting that reorganization of outpatient delivery may improve real-world outcomes.

ObjectiveTo explore how younger and older adults in the UK experience, manage, and seek treatment for long COVID-related cognitive impairments, and to identify their treatment preferences and expectations. DesignQualitative study using Charmazs (2014) constructivist grounded theory methodology. SettingOnline, semi-structured interviews conducted with UK adults reporting long COVID-related cognitive symptoms, recruited via patient support groups and research panels. ParticipantsTwenty-one adults with long COVID cognitive impairments: 10 younger participants aged 25-38 years and 11 older participants aged 60-72 years. Main outcome measuresPatients lived experiences, coping strategies, healthcare interactions, and treatment preferences and expectations for non-pharmacological and pharmacological interventions, analysed through iterative coding, constant comparison, and theory generation. ResultsIn the absence of effective treatments, both age groups relied heavily on self-management strategies (e.g., memory aids, structured routines, pacing). Interactions with healthcare were characterised by validation from some clinicians but widespread frustration at the lack of treatment options. Younger adults were more proactive in seeking experimental therapies and clinical trials, while older adults emphasised pragmatic adaptation, independence, and cautious optimism. Across groups, participants preferred non-pharmacological interventions (e.g., cognitive rehabilitation) but also expressed hope for biomedical treatments. The central process identified was "striving for agency" in the face of ongoing cognitive difficulties. ConclusionsThis study highlights the urgent unmet need for evidence-based interventions to address long COVID-related cognitive impairment. Health services should provide practical cognitive rehabilitation and support, and clinicians should acknowledge and validate patients cognitive struggles rather than dismissing them as normal ageing or purely psychogenic in origin. Research into therapeutics (e.g. cognitive training programs, pharmacotherapies) is urgently desired by the participants in this study. Effective solutions will need to be holistic and individualised - addressing not only memory and concentration deficits but also the psychological and social challenges associated with long COVID cognitive impairment in different age groups. WHAT IS ALREADY KNOWN ON THIS TOPICO_LIA large proportion of people with long COVID experience persistent cognitive difficulties, often described as "brain fog," with substantial impact on daily functioning and employment. C_LIO_LIMost studies have focused on symptom prevalence, biological mechanisms, or broad psychosocial consequences. C_LIO_LILittle is known about patients treatment preferences and expectations, and almost no research has explored generational differences between younger and older adults. C_LI WHAT THIS STUDY ADDSO_LITo our knowledge, this is the first qualitative study in the UK to compare younger and older adults perspectives on managing long COVID-related cognitive impairment. C_LIO_LIBoth groups described "striving for agency" through self-management, validation-seeking in healthcare, and balancing preferences for pharmacological and non-pharmacological treatments. C_LIO_LIYounger adults were more proactive in seeking experimental therapies and trial participation, while older adults emphasised pragmatic adaptation and maintaining independence. C_LI HOW THIS STUDY MIGHT AFFECT RESEARCH, PRACTICE, OR POLICYO_LIHealthcare services should expand access to cognitive rehabilitation and psychosocial support, while clinicians should validate patients experiences rather than attributing them to ageing or stress. C_LIO_LIFuture research must test both pharmacological and non-pharmacological interventions, with study designs informed by patient priorities and generational needs. C_LIO_LIPolicymakers and service providers should tailor care pathways to life stage: supporting younger adults with workplace accommodations and research opportunities, while providing older adults with reassurance, independence-focused care, and monitoring for possible accelerated cognitive ageing. C_LI

BackgroundApproximately 1 in 5 Canadians experience a mental health illness in any given year. While most individuals can be successfully treated within a primary care setting, a subset of individuals present with a severity and complexity requiring specialist care. Unfortunately, a shortage of psychiatrists (especially in rural regions) can result in wait times of months to years. MethodsWe designed the Alberta Network for Community Health Outreach and Rural Mental Health. ANCHOR-MH is a 12-week program that includes a unique educational intervention, collaborative case conferencing, and a community of practice between family medicine (FM) physicians and psychiatrists. We enrolled two pilot cohorts of n=20 FM physicians each and measured participants confidence and comfort in diagnosing, managing, and treating psychiatric conditions. We also conducted qualitative analyses of their experience. ResultsData from participants that completed both the pre- and post-program survey (n=34) showed increased confidence in screening for, diagnosing, and managing psychiatric issues, as well as increased comfort discussing mental health concerns with patients and families and reduced stigma towards certain psychiatric conditions. Qualitative thematic analysis (n=39) reflected this increased confidence, revealed an increased sense of connectedness to the mental healthcare landscape, and highlighted specific examples of practice changes. Participants broadly agreed that the program improved their ability to provide mental healthcare and would improve psychiatric outcomes within their practice. InterpretationANCHOR-MH improved FM physicians confidence and ability to deliver mental healthcare in their primary care settings. Increasing the reach of this program may improve mental healthcare in underserved communities.

Background and AimIndividuals with non-binary gender commonly face minority stress such as invisibility, identity invalidation or even hostility within various social contexts. The COVID-19 pandemic represented an exceptional form of societal stress that presented mental health challenges in the population and probably even more so for vulnerable groups including non-binary gender individuals. We investigated whether there are gender differences in the impact of the COVID-19 pandemic on functional ability. MethodUniversity students and personnel (n=1998) responded to an online survey in May 2021, when the measures for preventing COVID-19 infections had sustained about a year and a half. Based on the gender option responses, groups of non-binary and binary (male or female) gender identity were formed. Current functioning (FUNCT), and subjective assessment of the effect of COVID-19 on functioning (COFUNCT) were recorded. Psychosocial and mental health characteristics were included in the statistical models. ResultsThe non-binary group represented 3,6 % of all study participants. The gender option "Male" was selected by 23.8% and the gender option "Female" by 72.7% of respondents. Compared to the binary group, those in the non-binary group exhibited poorer socioeconomic living situation and less favourable previous psychosocial development. Non-binary participants reported lower FUNCT and more negative COFUNCT than binary participants. In non-binary participants, a poor work situation was directly associated with poor FUNCT, while multiple adverse childhood experiences and loneliness were indirectly associated with lower FUNCT via depressive symptoms. Conversely, high family support and previous mental health care were directly associated with more negative COFUNCT, and loneliness was indirectly associated with low COFUNCT via depression. In binary participants, family support, good economy, resilience and active physical exercise associated with good FUNCT, while age, family support, good economy, resilience, active physical exercise and adverse childhood experiences associated with good COFUNCT. ConclusionsIndividuals with non-binary gender are more vulnerable for functional deficits in a period of serious societal stress such as COVID-19 pandemic. The related psychosocial and mental health factors should be taken into account when planning tailored interventions for vulnerable groups during periods of exceptional societal circumstances. Graphical abstract O_FIG O_LINKSMALLFIG WIDTH=200 HEIGHT=113 SRC="FIGDIR/small/25343131v1_ufig1.gif" ALT="Figure 1"> View larger version (45K): org.highwire.dtl.DTLVardef@1bd9d76org.highwire.dtl.DTLVardef@1acee78org.highwire.dtl.DTLVardef@5c1eaeorg.highwire.dtl.DTLVardef@1e26602_HPS_FORMAT_FIGEXP M_FIG C_FIG

Managing chronic diseases with unpredictable care demand creates significant operational challenges for healthcare systems. Mapping long-term care trajectories is crucial for improving resource allocation, anticipating service needs, and designing efficient care pathways. We used a data-driven approach to map six-year care trajectories for 962 newly diagnosed multiple sclerosis patients, identify utilization clusters, and determine predictors of high utilization. We analyzed Event logs of remote, outpatient, emergency, and inpatient contacts from one year pre- to five years post-diagnosis using K-means clustering to identify utilization clusters, logistic regression to identify predictors of high utilization, and process mining to model variation between care trajectories. We identified two distinctive utilization clusters: a high-utilization cluster (14.1 % of patients) with persistently elevated annual encounter volumes across all care settings and low-utilization cluster (85.9 % of patients) with lower and declining use. Median service costs were {euro}18,736 vs. {euro}6,052 in high- and low-utilization clusters, respectively. Two or more early relapses were the strongest predictor of high utilization (OR = 6.33, 95 % CI 3.49-11.50, p < 0.001), with number of planned early remote and outpatient care contacts being also associated with future service utilization (OR = 1.07, 95 % CI 1.04-1.10, p < 0.001). High-utilization trajectories were approximately three times longer (82.4 vs 25.9 events) and more variable (3.1 vs 2.4 unique events per patient). These utilization clusters and their distinct trajectories provide a pragmatic segmentation of multiple sclerosis patients to support early identification of high-utilization subgroups and more robust capacity planning in specialist care. HighlightsO_LIWe tracked the care trajectories of 962 people with relapsing-remitting multiple sclerosis using a Finnish population-based specialist-care datalake covering both inpatient and outpatient neurology services. C_LIO_LIPatients fell into two distinct utilization clusters: a high-utilization cluster with frequent contacts across all care settings and a low-utilization cluster with lower and declining use. C_LIO_LITwo or more early relapses, and the number of early outpatient and remote contacts were strong predictors of a patients long-term affiliation in the high-utilization cluster. C_LIO_LISegmented care trajectories showed that high-utilization patients followed longer, more varied, and acute-oriented care patterns and had much higher service encounter costs. C_LIO_LIThese findings can help clinicians and managers identify potential high-utilization patients early, target resources more effectively, and plan for future healthcare demand. C_LI

ObjectiveTo develop and conduct preliminary testing of the reliability and validity of the Healthcare Worker (HCW) Culture of Support Scale (COS), intended to assess health worker perceptions of institutional support resources and organizational culture related to their well-being. MethodsA cross-sectional survey was conducted with 533 HCWs from ambulatory clinic and rural hospital settings. The survey included validated measures and newly developed items. Exploratory and confirmatory factor analyses (EFA/CFA) were employed to determine the factor structure. Internal consistency and construct validity were assessed using Cronbachs and correlation with mental health outcomes. ResultsThe COS demonstrated a robust three-factor structure: 1) Organizational Support ( = 0.83), 2) Access to Peer Support ( = 0.92), and 3) Availability of Support ( = 0.97), accounting for 84.9% of variance. Cronbachs alpha for the overall scale was 0.94. CFA confirmed excellent model fit (RMSEA =.049, CFI =.992). Higher COS scores correlated with lower burnout (r = -.47, p <.001) and anxiety (r = -.35, p <.001), and greater resilience (r =.30, p <.001). ConclusionPreliminary evidence suggests that the COS is a reliable and valid measure of HCWs perceptions of organizational support for worker well-being. This scale and the three subscales can provide healthcare institutions with a way to evaluate organizational initiatives to enhance worker well-being and workforce resilience. Further testing is recommended in diverse settings.

QuestionDo advanced practice physiotherapists succeed in conducting shared decision-making (SDM)? DesignA prospective cross-sectional observational study of patients with musculoskeletal pain and their perceptions of SDM measured using the CollaboRATE instrument. Written feedback was collected after consultation to gain understanding of patients experiences of their consultations. ParticipantsChronic pain patients (n = 5123) diagnosed with either upper limb (n = 1230, 24%), lower limb ((n = 3044, 59.4%), or foot/ankle pain (n = 849, 16.6%) consulting an advanced practice physiotherapist across two hospitals in the UK between January 2023 and December 2024. ResultsMean total CollaboRATE scores across all items were 11.9 ({+/-}0.53). Overall, 4906 (95.8%) of participants gave the maximum CollaboRATE score of 12. No significant differences were observed between sites (p < .001). A regression model including site and pain category was statistically significant but explained minimal variance (R{superscript 2} = 0.004), suggesting other factors contribute more substantially to SDM perceptions. From 949 patient responses, our qualitative analysis revealed a generally positive SDM experience with advanced practice physiotherapists. Feedback clustered around five key themes: 1) feeling valued and involved, 2) communication, expertise, and clarity, 3) compassionate and professional care, 4) efficient organisation, and 5) negative experiences. ConclusionAdvanced practice physiotherapists were largely successful in facilitating SDM, with patients reporting positive experiences across both clinical sites. While quantitative findings showed minimal influence of site or pain category, qualitative insights highlighted the importance of clinician communication, empathy, and involvement of patients in care planning as key drivers of SDM perceptions.

Burnout, a state of chronic exhaustion often characterized by feelings of emotional exhaustion, cognitive and emotional dysregulation, and psychological distancing, is an increasingly recognized issue within most professions. This syndrome results in diminished job satisfaction, strained interpersonal relationships, and decreased well-being. Socio-demographic factors have been shown to play a role in burnout risk, while trait mindfulness has been identified as an effective method to mitigate it. This study aimed to identify the prevalence of burnout risk and its relationship with mindfulness and socio-demographics among medical researchers. An anonymous, online, cross-sectional survey was administered to corresponding authors published in MEDLINE. The survey consisted of screening and socio-demographic questions, as well as validated assessment tools (i.e., shortened work-related Burnout Assessment Tool [BAT-12] and shortened Freiburg Mindfulness Inventory [FMI-14]). Responses were analysed according to the BAT and FMI guidelines, alongside regression analyses. A total of 1,732 participants completed the survey, yielding a response rate of 1.88%. Overall, 38.8% of participants were at risk or at very high risk of burnout, and the mean mindfulness score was 37.51. Multiple linear regression analysis indicated that sex, age, and employment status were significant predictors of burnout risk, while age and region significantly predicted mindfulness. Hierarchical regression analysis showed that, after controlling for socio-demographic variables, mindfulness was a strong and independent negative predictor of burnout risk. These findings on burnout risk and the influence of mindfulness and socio-demographics could guide future research in developing tailored interventions and policies that improve the well-being of medical researchers.

ObjectivesFunctional neurological symptoms which do not meet clinical definitions of functional neurological disorder (FND) are common in clinical practice. Understanding the distinction between these benign functional symptoms and FND is crucial in defining FND as an entity for study, and as a clinical syndrome. We aimed to measure the frequency of functional symptoms in people who do not have FND. MethodsA survey was administered to 95 clinicians who attended an international conference on FND. Participants were asked to report the occurrence and characteristics of experiences with features of functional sensory or motor symptoms, or dissociation. ResultsOf the 95 people who responded to the survey, 57.4% reported having experienced any functional symptoms, and 47.9% reported having experienced functional motor or sensory symptoms. The symptoms reported were generally short-lived and caused only mild distress and disruption. Most respondents who reported having experienced a functional symptom reported having had multiple events through their lives. InterpretationThe results suggest that the lifetime occurrence of functional neurological symptoms is at least two orders of magnitude higher than the prevalence of FND. The high prevalence of functional symptoms in people who have never had FND challenges the common assumption that the occurrence of functional neurological symptoms is synonymous with FND. We propose that FND is better conceived of as a failure of the mechanisms by which functional neurological symptoms resolve, rather than the occurrence of functional symptoms per se. This reconceptualization implies new research directions for the underlying aetiology of FND.

Safety is a foundational concern in adolescent behavioral health crisis units (BHCUs), where therapeutic care must be delivered in complex, rapidly evolving environments. However, limited research has explored how key personnel involved in shaping the environment of care in such units, such as clinicians and healthcare designers, understand and prioritize safety. To address this gap, one-hour, online semi-structured interviews were conducted with a panel of experts (N = 13) at a national level in the U.S., comprising of eight designers (healthcare designers and medical planners) and five clinicians (psychologists and psychiatric nurses) actively involved in designing or construction of BHCUs or providing care in these units for adolescent patients in the past five years. The interviews were recorded, transcribed verbatim, and analyzed via MAXQDA (2024) for qualitative content analysis. Analysis of interviews revealed 592 codes forming four preliminary categories related to safety in adolescent BHCUs: 1) Barriers and facilitators to patient safety and comfort (f = 52%), 2) Care processes and clinical workflows (f = 21%), 3) Care outcomes (f = 19%), and 4) Laws, regulations, and guidelines (f = 7%). Findings highlighted several points of divergence in clinicians versus designers perception of safety related to environmental features, such as nursing station designs, patients access and control over unit features, and furniture type or layout in the unit. Results also showed differences in understanding care processes and outcomes related to safety among the two groups. Addressing such discrepancies can contribute to the development of safer BHCUs that support adolescents healing.

Academic institutions privilege norms of continuous productivity and uninterrupted availability, creating conformity pressures that systematically disadvantage those who deviate from an implicit template of the ideal academic. This study explores how doctoral students and faculty in the health sciences perceive the reproduction of social homogeneity. Semi-structured interviews were conducted with nine participants at a German university hospital. Data were analysed using reflexive thematic analysis with extended idiographic engagement. Participants perceived homogeneity as reproduced through external exclusion, enacted by others through networks, normative expectations, or institutional arrangements, and self-exclusion, whereby individuals withdrew, reduced visibility, or reshaped identity in anticipation of exclusion ( anticipatory compliance). Across both processes, the tacit norm of the ideal academic organised access and belonging. Supportive supervision and visible role models were perceived as partial buffers but did not structurally alter underlying norms. Interpreted through the social identity threat framework, these findings are consistent with a self-reinforcing cycle: structural homogeneity may generate identity-threatening environments that activate concealment and withdrawal, concentrating homogeneity further. These findings suggest that achieving substantive inclusion requires challenging the structural conditions that naturalise presence, mobility, and availability as measures of academic success.

BackgroundLarge sporting events, such as the FIFA World Cup, attract global attention and raise questions about psychological impact. Anxiety is among the most common mental health symptoms, but little is known about its predictors during international tournaments. This study explored predictors of anxiety during the FIFA 2022 World Cup. MethodsThis cross-sectional study included 1,331 respondents mostly residing in Saudi Arabia who completed an online survey during the FIFA 2022 World Cup (November-December 2022). The survey included sociodemographic variables, items related to the World Cup viewing habits, perceived effects of the tournament, and the Generalized Anxiety Disorder 7-item (GAD-7) scale. ResultsAlthough most respondents reported minimal anxiety symptoms (GAD-7 median score = 5, IQR = 6), 41.5% of the sample felt that watching the World Cup made them feel nervous. Females and younger adults reported significantly higher GAD-7 scores (p < 0.001). Employment status and method of watching the matches were not significant predictors. Regression modelling revealed that age, gender, and perceived sleep disruption predicted 9.1% of the variance in GAD-7 scores (p < 0.001). Younger age was the strongest predictor, while perceived sleep disturbance related to watching the matches predicted higher GAD-7 scores. ConclusionsThis was a population-based study of anxiety during the FIFA 2022 World Cup. Younger adults were more likely to report elevated anxiety, and sleep disruption was linked to higher GAD-7 scores. These findings highlight modifiable and non-modifiable predictors of anxiety and may inform public health strategies ahead of FIFA 2026.

AimsTo identify barriers and facilitators to physical activity (PA) in adults with type 1 diabetes (T1D) living in the United States (U.S.) and identify sociodemographic factors related to meeting recommended PA. MethodsWe conducted a cross-sectional online survey study of adults with T1D aged [&ge;]18 years recruited through online-based platforms. Quantitative questions related to exercise quantity and intensity, demographic characteristics, and exercise barriers and facilitators. Wilcoxon rank sum tests or independent t-tests were used to compare quantitative responses in individuals meeting or below target PA. Barriers and facilitators were also assessed qualitatively with open-ended questions. Logistic regression was performed to determine if the following characteristics were independently associated with meeting PA recommendations: age, sex, income level, and automated insulin delivery system use. ResultsOf 281 respondents who completed questions about exercise quantity, 162 (57.7%) were women, mean age 52.6 {+/-} 16.6 years, and 151 (53.7%) met PA guideline recommendations. Common barrier themes related to T1D included hypoglycemia, time, lack of knowledge about glycemic management, cost, and failure of available treatments to accommodate exercise. Common facilitator themes were insurance reimbursement of exercise program/facility, peer exercise groups, health/fitness advising, and T1D tailored fitness. Middle (vs. upper) income level was independently associated with lower odds of meeting PA recommendations (adjusted odds ratio 0.46, 95% CI: 0.27, 0.78, p = 0.004). ConclusionsIn this predominately U.S. cohort with T1D, financial factors were common novel themes related to PA. Further validation in more socioeconomically diverse cohorts and research examining PA reimbursement cost-efficacy are needed. Novelty statementO_ST_ABSWhat is already known?C_ST_ABSO_LIIn prior qualitative studies in type 1 diabetes, hypoglycemia is a commonly reported barrier to physical activity (PA) engagement. Most studies were conducted outside the United States (U.S.). C_LI What this study foundO_LIIn a predominately U.S. cohort of adults with type 1 diabetes, cost is a newly identified barrier to PA. C_LIO_LIInsurance reimbursement of PA programs/facilities was a reported facilitator. C_LIO_LIIndividuals with highest income were 54% more likely to achieve recommended PA compared to other income categories. C_LI What are the implications of the study?O_LICost-efficacy research examining PA programs/facility reimbursement in type 1 diabetes is needed. C_LI

BackgroundPatient activation, defined as the knowledge, skills, and confidence to manage ones health, is associated with better outcomes in chronic disease. However, evidence on interventions that improve activation in people with end-stage kidney disease on hemodialysis remains limited. Methods and analysisThis single-centre, prospective, participant-blinded, randomised controlled trial conducted with adults undergoing chronic hemodialysis in an acute dialysis unit tests the hypothesis that adding tailored activation interventions to usual care improves patient activation and reduces complications in hemodialysis patients compared to usual care alone. A target sample size of 140 patients was recruited and randomised to iPAD interventions or usual care in a 1:1 ratio with an expected intervention period of at least 6 months. The primary outcome of iPAD was change in patient activation from baseline to 18 months. Ethics and disseminationThis study has been approved by all institutional ethics review boards involved in the study. Participants could only be enrolled following informed written consent. Results will be published in peer-reviewed journals and presented at scientific and clinical conferences. ConclusionRecruitment and enrolment targets were successfully achieved, with the cohort broadly representative of the dialysis population, including strong participation from culturally and linguistically diverse and socioeconomically disadvantaged groups. The careful planning and successful execution of the study in resource-constrained environments highlight its feasibility and flexibility, establishing it as a scalable and cost-efficient model for broad implementation in dialysis care globally.

ObjectivesThere is currently insufficient evidence linking COVID-19 infection with Graves disease (GD). Following the complete lifting of COVID-19 restrictions on December 13, 2022, widespread infection in Guangzhou provides a basis for this study. This research aims to investigate the correlation between COVID-19 infection and GD onset, explore the epidemiological characteristics of newly diagnosed GD post-infection, and offer a scientific basis for treatment. MethodsThe study population included 494 GD outpatients treated in the Department of Endocrinology at the Second Affiliated Hospital of Guangzhou Medical University from January 1 to June 30 each year between 2021 and 2023. They were divided into two groups: 2023 (N=219) and 2021-2022 (N=275), based on the time node of widespread COVID-19 infection in 2023. The new diagnosis rate, general clinical characteristics, and serological test results of GD patients were analyzed before and after the outbreak of COVID-19. ResultsCompared with the 2021-2022 group, the new diagnosis rate of GD patients in 2023 showed a significant increase (12.8% vs. 8.4%, P<0.001). Furthermore, there was a significant decrease in pre-treatment thyrotropin receptor antibody levels (P=0.01), white blood cell count (P=0.02), and neutrophil proportion (P=0.04), while there was a significant increase in the proportion of patients with a family history (P=0.047). Follow-up until June 30 of that year revealed that the proportion of newly diagnosed GD patients developing hypothyroidism during treatment in 2023 significantly increased compared to the 2021-2022 group (P<0.001). ConclusionsAfter widespread infection of COVID-19, the diagnosis rate of newly diagnosed GD increased, which may influence the epidemiological characteristics of related GD patients before initial treatment and during treatment.

BackgroundChronic autoimmune diseases such as Chronic Inflammatory Demyelinating Polyneuropathy (CIDP), Multifocal Motor Neuropathy (MMN), and Thyroid Eye Disease (TED) impose a considerable burden on affected individuals. Patient-reported outcome measures (PROMs)--both disease-specific and generic--are widely used to assess functioning, quality of life, and treatment effects in these populations. However, most PROMs currently lack reference values derived from the general population, limiting the interpretability of patient scores. ObjectiveThe GENESIS (GENEral population normS--An International Survey) study aims to establish general population norms for a range of PROMs used in CIDP, MMN, and TED across six countries: Germany, Italy, Japan, Spain, the United Kingdom, and the United States. These norms will improve patient score interpretation and help quantify unmet needs in patients with these rare autoimmune diseases. MethodsGENESIS is an observational, cross-sectional, online survey of the adult general population (N=21,000). Participants will be recruited to be representative by age, gender, region, and education. The survey includes validated instruments such as the EQ-5D-5L, I-RODS, MMN-RODS, CAP-PRI, GO-QoL, BPI-SF, RT-FSS, FACIT-Fatigue, HADS, and WPAI, along with items on demographics, caregiver need, and healthcare utilization. To reduce respondent burden, participants will be randomized into two groups, each completing a subset of the full questionnaire. A subset of respondents (n=2,333) will be re-surveyed after two months to support psychometric validation. Data will be analyzed descriptively to generate normative values for each PROM by country and in aggregate. Results and DisseminationData collection is scheduled to begin in August 2025, with results expected by Q4 2025. Findings will be disseminated via peer-reviewed publications and conference presentations. ConclusionGENESIS will provide foundational normative data across six countries for PROMs commonly used in rare autoimmune diseases. These data will support more meaningful interpretation of PROM scores in both clinical practice and research settings.

BackgroundHealthcare quality is a key determinant of patient experience, satisfaction, and loyalty, yet the mechanisms linking quality to loyalty remain underexplored in Egypts Health Insurance Organization (HIO). This study examines the mediating role of patient satisfaction in the relationship between healthcare quality and patient loyalty among HIO beneficiaries. MethodsA cross-sectional study was conducted with 983 beneficiaries from four HIO hospitals in Alexandria. Data was collected using a validated questionnaire covering eight healthcare-quality domains, patient satisfaction, and loyalty. Confirmatory factor analysis (CFA) assessed construct validity, and structural equation modeling (SEM) tested direct and mediated pathways. Bootstrapping (5,000 samples) evaluated mediation significance. ResultsHealthcare quality significantly predicted patient satisfaction ({beta} = 0.607, p < 0.001), which in turn strongly influenced patient loyalty ({beta} = 0.545, p < 0.001). Direct effects of healthcare quality on loyalty were reduced and non-significant when satisfaction was included. The indirect effect via patient satisfaction was significant ({beta} = 0.331, 95% CI: 0.262-0.404), confirming partial mediation. Transition of Care, Empathy, and Responsiveness were the most influential quality domains. Model evaluation demonstrated a strong fit across all indices (CFI = 0.967, TLI = 0.960, RMSEA = 0.043). ConclusionPatient satisfaction is a key link between healthcare quality and loyalty. Enhancing communication, competence, responsiveness, and transitional care as satisfaction-driven domains can strengthen trust, continuity, and loyalty, supporting patient-centered reforms and Egypts Universal Health Insurance implementation. What is already known- Healthcare quality strongly influences patient satisfaction and loyalty. - Patient loyalty is critical for continuity of care, trust, and system sustainability. - Few Egyptian studies have applied structural equation modeling to explore mediation pathways between quality, satisfaction, and loyalty. What this study adds- Validation of a mediation model examining healthcare quality, patient satisfaction, and loyalty among HIO beneficiaries in Alexandria. - Patient satisfaction partially mediates the relationship between healthcare quality and loyalty. - Identifies key quality domains that drive satisfaction-related loyalty, providing actionable targets for improvement. How this study might affect research, practice, or policy- Supports integrating patient satisfaction as a core indicator in HIO performance monitoring. - Informs targeted quality-improvement interventions focusing on satisfaction-sensitive domains. - Provides a robust mediation framework to guide evidence-based UHI policy and implementation in Egypt.

BackgroundPatient satisfaction and loyalty are key indicators of healthcare quality and are influenced by multiple service domains. Understanding which aspects of care drive these outcomes is essential for Health Insurance Organization (HIO) hospitals aiming to improve patient experience. MethodsAn analytical cross-sectional study was conducted across four hospitals in Alexandria, Egypt. A total of 983 patients were recruited using stratified random sampling from various hospital departments. Data was collected through structured face-to-face interviews using a validated Arabic National Patient Satisfaction Survey covering eight healthcare quality domains. Multivariate linear regression models were fitted to assess the impact of these domains on patient satisfaction and loyalty. Mediation analysis examined the indirect effect of satisfaction on the relationship between quality and loyalty. ResultsThe regression model significantly predicted patient satisfaction (Adjusted R{superscript 2} = 0.573, F(8, 974) = 165.93, p < 0.001), with Information, Empathy, and Organization emerging as the strongest predictors. All eight service quality dimensions contributed positively, and no multicollinearity issues were detected. The hierarchical model predicting loyalty was significant, explaining 52.5% of the variance in Model 1 and increasing to 64.8% after adding satisfaction (F(9, 973) = 198.59, p < 0.001). Patient satisfaction became the dominant predictor of loyalty, and the effect of Transition became non-significant once satisfaction was included, indicating full mediation. Overall, satisfaction mediated the relationship between service quality and loyalty, substantially strengthening predictive power. ConclusionEffective communication, clinical competency, organizational consistency, and responsive care are central drivers of patient satisfaction and loyalty in HIO hospitals. Enhancing these domains may improve patient retention and overall healthcare experiences. Study highlightsO_LIProvides actionable priorities for clinicians and managers, showing that improving communication, empathy, and care organization yields the largest gains in patient satisfaction. C_LIO_LIIdentifies system-level gaps (waiting times, discharge transition, payment processes) that hospital managers and policymakers can directly target for quality improvement. C_LIO_LIDemonstrates that patient satisfaction is the main driver of loyalty, informing policy decisions on where investments will have the greatest impact. C_LIO_LIUses a large, multicenter sample and validated tool, offering reliable, generalizable evidence to guide HIO performance monitoring and reform. C_LI