Systematic Reviews

Background Trials in occupational populations, such as surgeons, face feasibility challenges due to high workload, restricted availability, and clinical heterogeneity, which may compromise recruitment, adherence, and retention. Objective To prespecify the feasibility framework and progression criteria for an internal pilot phase embedded within a pragmatic randomized controlled trial (RCT) comparing Mechanical Diagnosis and Therapy with generalized exercise in surgeons with chronic spinal pain. Design Protocol for a prespecified internal pilot phase embedded within a pragmatic, two-arm, parallel-group RCT. Methods The internal pilot will include the first four months of recruitment and aims to randomize at least 12 participants. Feasibility will be assessed across predefined domains, i.e., recruitment, eligibility, consent, intervention uptake, adherence, retention, data completeness, and treatment fidelity. Each domain is operationally defined and linked to prespecified progression criteria to ensure interpretability and decision-making utility. Criteria will be interpreted collectively to guide trial continuation. A minimal qualitative process evaluation will be embedded. Ethics and dissemination The host trial has received ethical approval (N-20240046) and is registered at ClinicalTrials.gov (NCT07293130). The findings from the internal pilot will be reported in a separate feasibility manuscript.

Abstract Background Insomnia is a major public health problem affecting an estimated 852 million adults worldwide. Current pharmacological treatments, including benzodiazepines and Z-drugs, carry serious risks of dependency, cognitive impairment, and adverse events. These limitations have driven growing interest in complementary and alternative therapies, particularly herbal sedatives, which are perceived as natural and safer. However, evidence on their safety and efficacy remains insufficient and patchy. Objective: This review evaluated the effectiveness of lesser known herbal sedatives for insomnia. Methods The protocol was registered with PROSPERO (CRD420251101795). Eligibility was defined using the PICO framework: Population: adults aged [≥]18 years with insomnia; Interventions: Passiflora incarnata, Hawthorn, Melissa officinalis, Chamomile, Viola odorata, Nelumbo nucifera, Rhodiola rosea, and Eschscholtzia californica. Comparators: placebo or usual care; Primary and Secondary Outcomes: sleep quality (Pittsburgh Sleep Quality Index, Insomnia Severity Index, Epworth Sleepiness Scale), sleep duration, and sleep latency. Databases and registers were searched from January 2005 to July 2025. Randomized controlled trials, nonrandomized controlled trials, clinical trials, and observational studies were included. Five reviewers independently screened studies. Data extraction used a structured Excel spreadsheet. Risk of bias was assessed using RoB 2.0 for randomized trials and ROBINS-I V2 for nonrandomized studies. Random-effects meta-analyses (DerSimonian and Laird) were conducted in RevMan. Narrative synthesis followed SWiM guidelines. Results From 1,294 records, 32 studies met eligibility criteria. Meta-analysis of 23 RCTs demonstrated a statistically significant pooled effect favouring herbal sedatives (SMD -0.77, 95% CI -1.14 to -0.40, p=0.0001), with substantial heterogeneity (I square=92%). Subgroup analysis showed larger effects for chamomile (SMD -1.06) and Melissa officinalis (SMD -0.66). Most RCTs had high overall risk of bias; nonrandomized studies predominantly had critical risk of bias. Conclusions This systematic review provides preliminary evidence that several herbal sedatives, particularly chamomile and Melissa officinalis, may improve insomnia-related outcomes. However, methodological weaknesses, high risk of bias, and substantial heterogeneity limit evidence strength. Future research requires standardized extracts, large multicentre RCTs, and extended follow-up.

Background: Digital antimicrobial stewardship (AMS) interventions, such as clinical decision support systems, audit and feedback platforms, and electronic prescribing tools, have been increasingly adopted to improve antibiotic use. However, the effectiveness of these interventions across healthcare settings remains uncertain, and the certainty of the evidence has not been comprehensively evaluated. The objective of this study was to provide a comprehensive understanding of the role of digital interventions in optimizing antimicrobial use and improving clinical outcomes within a broad spectrum of healthcare settings. Methods: We conducted a systematic review and meta-analysis of randomized controlled trials evaluating digital AMS interventions that followed PRISMA 2020 guidelines and registered in PROSPERO CRD420251178854 and funded by the Wellcome Trust CAMO Net programme. Searches were performed across major databases. Primary outcomes included the appropriateness of antibiotic prescriptions and the antibiotic prescription rate. Secondary outcomes included 30 day mortality, 30 day hospital readmission, and length of hospital stay (LOS). Random effects models were used to pool effect sizes. Risk of bias was assessed RoB 2, and certainty of evidence was rated using GRADE. A Summary of Findings table was prepared to present effect estimates, sample sizes, and evidence certainty. Results: Eleven RCTs met the inclusion criteria, and nine were included in the quantitative synthesis. Digital AMS interventions did not show a significant effect on appropriateness of antibiotic prescribing (RR 0.99, 95%CI 0.93 to 1.05; very low certainty). There was no reduction in antibiotic prescription (RR 0.98, 95%CI 0.88 to 1.09), with substantial statistical heterogeneity and very low certainty. Across clinical outcomes, digital AMS showed no effect on 30 day mortality (RR 0.91, 95%CI 0.77 to 1.09; very low certainty) or 30 day readmission (RR 0.95, 95%CI 0.79 to 1.14; very low certainty). For LOS, results were inconsistent across studies, and the pooled effect showed no clinically meaningful change (MD 0.17 days, 95%CI 0.01 to 0.35; very low certainty). Most trials had some concerns of bias due to deviations from intended interventions. Conclusion: Meta-analyses of digital AMS RCTs showed a lack of evidence with a high level of certainty on antibiotic prescribing or clinical outcomes due to high heterogeneity in interventions and study designs, as well as RCTs' limitations (no adoption/fidelity metrics).

Background Occupational exoskeletons are used to reduce physical workload and prevent work-related musculoskeletal disorders in physically demanding jobs. Although laboratory studies demonstrate reduced muscle load during simulated manual work tasks, evidence from long-term, real-world implementations remains very limited. The RELAX project aims to investigate the long-term effects of a passive back-support exoskeleton (BSE) during manual order-picking work in a Danish warehouse, focusing on health and socio-economic outcomes. Methods This 18-month controlled in-field intervention study compares outcomes at two warehouse departments: one where workers use a passive BSE and a control group where workers perform work tasks as usual. Approximately 90 full-time workers will be followed during the intervention period with questionnaires, interviews and company-registered performance indicators. Primary outcomes include perceived work intensity and musculoskeletal discomfort, while secondary outcomes include sickness absence, employee turnover, productivity and cost effectiveness. Furthermore, a process evaluation will be conducted based on questionnaires, focus-group interviews, and reported exoskeleton use. Quantitative effects will be analysed using difference-in-difference analysis with generalized linear mixed models to account for repeated measures over time. Employee turnover will be analysed using time-to-event analysis, and qualitative focus-group interviews will be analysed using reflexive thematic analysis to explore implementation processes and contextual factors. Cost-effectiveness and return on investment will be assessed by comparing the investment with potential savings in costs and resource use. Discussion By combining longitudinal quantitative outcomes with qualitative process evaluation, the study seeks to provide ecologically valid evidence on the effectiveness, feasibility and sustainability of occupational exoskeleton implementation. This approach will help clarify whether long-term exoskeleton use improves worker health without compromising productivity and may inform future workplace guidelines and large-scale adoption strategies.

Background and aimsWe evaluated the efficacy of the Stroke Riskometer mobile phone App to change the Lifes Simple 7(R) (LS7(R)) risk factor score at 6 months post-randomisation. Methods and designThis Phase III, prospective, outcome assessor-blinded, 2-arm randomised controlled trial (RCT) in Australia and New Zealand recruited participants from August 2021 to January 2024. Inclusion criteria: age [≥]35 and [≤]75 years; [≥]2 risk factors; smartphone ownership; no cardiovascular disease history. The intervention group was given access to the App; the usual care group received one e-mail with generic risk factor information. The primary outcome was the mean between group difference in LS7(R) (score 0 [poor] to 14 [ideal] comprising blood pressure, cholesterol, glucose, body mass index, smoking, physical activity and diet) from baseline to 6 months post-randomisation. Secondary outcomes were between group changes in individual LS7 items. Analyses were performed using intention to treat (ITT) principles with ANCOVA and linear mixed models to examine differences between groups, with pre-specified per protocol and subgroup analyses. ResultsWe randomised 862 participants (mean {+/-} SD age 58{+/-}11 years; 63% women; 74% Caucasian). At 6 months post-randomisation in ITT analyses, the mean difference between usual care (n=433) and intervention (n=429) groups in the change in LS7(R) score from baseline was 0.03 (95% CI -0.19, 0.25, p=0.79). Per protocol analyses (n=320 usual care; n=276 intervention) were similar (mean difference in change 0.11 95% CI -0.12, 0.34, p=0.34). Compared to usual care in ITT analyses, the intervention group had a borderline increase in metabolic equivalent of task (MET) minutes/week of physical activity (313.42 95% CI -2.80, 629.65, p=0.05), with no differences in other LS7(R) items. DiscussionAmong a general population aged 35 to 75 years with [≥]2 stroke risk factors, there was no evidence that having access to the App changed overall LS7(R) scores at 6-month follow-up. Participants in the intervention group did have a small increase in physical activity, compared to the usual care group after 6 months, but not other individual risk factors.

Purpose: To understand how the Philips PAP device recall affected patient experiences, clinical practice, and health system responses. Methods: From November 2022 to August 2023, we interviewed individuals with OSA, physicians, respiratory therapists and health system leaders. We also received emailed responses from Health Canada. Interviews explored participants' experiences with the recall announcement and communication, their own responses and perceptions of actions taken by others, the overall impact of the recall and suggestions for improving future recall processes. Interviews were analyzed using an inductive thematic approach. Results: We interviewed 47 participants (16 individuals with OSA, 10 physicians, 17 public or private respiratory therapists, five health system leaders). Themes were organized into four domains: recall communication, execution, participant experiences, and the policy and regulatory context. Participants were confused due to inadequate information from Philips throughout the process. The burden of notifying patients and tracing devices mostly fell to healthcare providers and vendors, while replacement efforts were disorganized and frustrating. Individuals with OSA experienced emotional distress over therapy decisions and difficulties navigating the recall. Healthcare providers described moral distress from being unable to support patients adequately, and vendors faced additional logistical and financial strain. While regulatory authorities reported that Philips followed standard procedures, participants expressed a loss of trust in both the manufacturer and oversight systems. Conclusions: Interviews revealed that poor communication and execution of the Philips recall caused confusion, frustration and significant emotional and financial burden. Collaborative, context-specific strategies are required to improve future recalls.

Background: With rising concerns about health impacts from climate change and environmental exposures, planetary health approaches are increasingly prominent, considering connections between human health and that of the natural environment. Naturopathy is an holistic traditional medicine system characterised by philosophies and practices rooted in nature that theoretically align with planetary health. However, it is unknown to what extent these philosophies translate into consideration of relevant factors during patient care. This study describes the perceptions and clinical behaviours of the global naturopathic workforce in addressing the health impacts of climate change and environmental pollutants. Methods: A cross-sectional online survey was administered to an international sample of naturopathic practitioners, recruited through communications from World Naturopathic Federation member organisations. The survey utilised the Climate Change Perceptions Scale, and asked participants about their perceptions of the health impacts of climate change and environmental pollutants. The survey also examined participant considerations of factors relating to climate change and environmental pollutants during clinical case assessment and prescribing of treatments. Data were descriptively analysed. Results: Of n=363 naturopathic practitioners who completed the survey, 88.7% agreed climate change is real, of whom the majority were concerned about impacts of climate change on their patients' health (89.1%). Almost all participants agreed that environmental pollutants harm human health (99.7%) and were concerned about impacts on their patients (99.5%). Climate-related health factors such as water intake (74.2%) and food security (72.9%) were frequently considered during patient assessment, while impacts of severe weather events (41.4%) were less commonly considered. Consideration of factors relating to environmental pollutants was more commonly reported, particularly for food quality (83.8%) and domestic/indoor sources of pollutants (73%). When formulating prescriptions, participants reported highly frequent consideration of all climate-related factors (73%-86.8%) and varied consideration of environmental pollutant exposures (54.4%-83.4%). Conclusions: The global naturopathic workforce demonstrates a high level of awareness and engagement with factors relating to health impacts of climate change and environmental pollutants, suggesting alignment with planetary health. While this engagement is evident in clinical behaviour, some gaps between awareness and application suggest a need for greater support to strengthen the naturopathic application of planetary and environmental health.

IntroductionFamily Constellation Therapy (FCT) has been widely disseminated in clinical, public health, and judicial settings despite persistent concerns regarding its theoretical basis, safety, and the limited availability of rigorous randomised evidence supporting its clinical use. ObjectiveThe aim of this systematic review is to assess the effects of FCT across all clinical conditions, explicitly considering both benefits and harms; and summarise the characteristics of studies and intervention settings used in randomised controlled trials of FCT. MethodsFollowing a prospectively registered protocol (CRD420251136190), we conducted a systematic search of seven databases (PubMed, EMBASE, APA PsycInfo, CENTRAL, BVS, Web of Science, and CINAHL) and grey literature (ICTRP and ProQuest database) without language or date restrictions to identify published and unpublished randomised controlled trials of FCT. Study selection, data extraction, risk of bias (RoB 2), and certainty of evidence (GRADE) were performed in duplicate. Statistical analyses followed a prospectively registered analysis plan with prespecified criteria for data pooling and for handling analytical limitations. ResultsNo reliable evidence was found to support the use of FCT for any condition across both clinical and non-clinical samples. All trials included were judged to be at high risk of bias and all comparisons were rated as very low-certainty evidence. Concerns regarding potential adverse effects were identified, and the available data was insufficient to establish the effectiveness of the intervention, precluding any clinical recommendation. ConclusionClinicians, policymakers, and consumers should reconsider adopting FCT while reliable evidence is not available.

Importance: Severe stroke is a leading cause of death and disability worldwide. Survivors and their families face long-term unmet needs, including care that does not reflect patients' values, fragmented care, and high rates of psychological distress among caregivers. Objective: To describe the conceptual framework of the longitudinal transdisciplinary neuropalliative care support (LOTUS) intervention and assess its fidelity in a pilot feasibility study. Design: Pilot feasibility randomized study; fidelity was assessed using weekly checklists completed by the LOTUS nurse and qualitative analysis of weekly LOTUS team meeting transcripts. Setting: Single comprehensive stroke center in Western New York. Participants: Patients hospitalized with severe stroke and their caregivers. Dyads were randomized to usual care or intervention. Intervention: The LOTUS intervention is implemented in a stepped-care fashion using 5 strategies: Awareness, Assistance, Adjustment, Acceptance and Alignment (5As). Led by a specially trained nurse with a chaplain, social worker, psychologist, and neuropalliative care physician, the LOTUS team follows dyads from early in the hospital course through 6 months. Main Outcomes and Measures: Fidelity, the degree to which the intervention was delivered as intended, assessed via (1) utilization of 5A activities from weekly LOTUS checklists; (2) thematic analysis of weekly LOTUS team meeting transcripts. Results: Of 26 patients in the trial, 13 were randomized to intervention. The LOTUS nurse completed 108 checklists, with an average of 619 minutes of direct contact per participant over 6 months. Each component of the 5A's was utilized. Awareness and Assistance predominated early after enrollment and revolved around personhood, support, and self-efficacy. Adjustment was especially relevant during care transitions and was typically supported by the LOTUS social worker. Acceptance and Alignment were more prevalent during later meetings, with the LOTUS psychologist supporting identification and modeling of coping skills and the LOTUS physician guiding prognosis and goals-of-care conversations. The LOTUS nurse served as primary point of contact, providing continuity and a trusting relationship, while other team members functioned in a predominantly advisory role. Conclusions: The LOTUS intervention was delivered with fidelity to the 5A-framework, supporting a future randomized clinical trial to evaluate its efficacy in patients with severe stroke and their caregivers.

1.This paper reports the statistical analysis plan for the AVERT-DOS trial: A Phase 3, Multi Arm, Multi Stage, Covariate Adjusted, Response Adaptive, Randomised Trial to Determine Optimal Early Mobility Training after Stroke. It contains a trial overview, regulatory information and details of the planned main analyses for the study protocol version Version 5; 15 June 2025.

BackgroundAlthough Blood Pressure (BP) self-management and physical activity (PA) are secondary stroke preventive behaviors, adherence gaps exist. This study explored factors influencing these behaviors after telemonitoring experience among patients in an underserved urban community. MethodsWe conducted semi-structured interviews with purposive sampling of patients discharged home after mild stroke who had hypertension and participated in the Telehealth After Stroke Care (TASC) trial. Self-reported short form (SF) surveys included Patient Reported Outcomes Measurement Information System-Physical Function-SF, International Physical Activity Questionnaire-SF, and University of Rhode Island Change Assessment. The first interview assessed knowledge of BP and PA guidelines with perceived barriers, facilitators and BP telemonitoring experience, while the second was after PA monitoring for one month. We performed open (inductive) and social cognitive theory-based (deductive) coding. ResultsWe included 14 participants: mean age 59 {+/-} 9.6 years; 7 women (50%); 57% Black, 29% Hispanic; 29% [≤] high school education, 43% Medicaid or no insurance. Mean daily step count was 5147 {+/-} 2534. Three themes interpreted included: 1) positive outcome expectations; 2) self-efficacy; and 3) agency. Participants associated BP control with reduced recurrence risk and PA to functional recovery (1) but lacked knowledge of specific targets (2). High self-efficacy individuals (2) used action planning to navigate environmental constraints. Both BP and PA monitoring with feedback facilitated self-regulation, goal setting and problem solving (3). ConclusionGaps between knowledge of and participation in health behaviors after stroke persist. Targeting outcome expectations, self-efficacy, and agency through educated training, tailored support, and telemonitored feedback may promote sustained positive health behaviors.

BackgroundWork-related stress (WRS) accounts for 52% of self-reported work-related ill-health. In 2004, the Health and Safety Executive (HSE) developed the Management Standards (MS), aimed at helping organisations reduce WRS. This work investigates WRS post implementation, with reference to six MS risk factor domains: control, support, relationships, demand, change, and role. MethodCases of WRS were extracted from The Health and Occupation Research (THOR) database and mapped to the six domains. Trends in WRS incidence rates attributed to each of the domains were split at 2004 and compared with the overall WRS trend using mixed generalised regression models. ResultsBefore 2004, annual incidence in WRS increased by 1.4%(-0.5%,3.1%), whereas after 2004, there was a decrease of -0.9%(-1.5%,-0.2%), based on 10,815 WRS cases reported between 1996 and 2019. Three of the six MS domains (demands, relationships, and change) were reported in [~]82% of cases. Pre-2004, four of the six domains were observed to be increasing per year. Post 2004, cases increasingly contained multiple precipitating events e.g. demands + another (+2.6% per year) and relationships + another (6.1%). Reports of the two most common domains decreased post 2004 (demands -0.46%, relationships -0.55% per year), whereas incidence in less common domains increased (change 1.1%, support 2.4%, control 4.8%, role 4.7%). ConclusionTrends in WRS, and their common risk factors appear to be decreasing gradually, since introduction of MS in 2004. However, less common risk factors are becoming more prominent, contributing to reporting of WRS with multiple risk factors.

BackgroundThe assessment of daily-life physical activity (DLPA) using wearables in patients with pulmonary hypertension (PH) can provide information on real-world function, potentially enhancing the evaluation of disease progression. Research QuestionWhat is the existing evidence on sensor-based DLPA assessment in patients with PH and its quality? Study Design and MethodsWe searched MEDLINE and Embase from inception to January 13, 2026, extracting data on devices, DLPA outcomes, and associations with clinical outcomes. We obtained pooled estimates through random-effects models and assessed evidence quality using a customized tool. ResultsWe identified 33 studies (29 adult, 4 pediatric) including 1,257 patients mainly with pulmonary arterial hypertension (PAH), followed by chronic thromboembolic PH (CTEPH), and only rarely with PH due to lung diseases and/or hypoxia. Participants were predominantly female, WHO functional class II-III. Most studies investigated step count and time spent in different physical activity levels, but showed substantial heterogeneity in devices and their utilization. The meta-estimate was 4,811 daily steps. A moderate positive correlation was found between daily step count and six-minute walking distance (6MWD) (r=0.59, 95%CI 0.47-0.69); a weak positive correlation was found between time spent in moderate-to-vigorous physical activity and 6MWD (r=0.38; 95% CI 0.26-0.49). Inconsistent wear-time definition, non-wear reporting and temporal misalignment of DLPA may compromise validity and comparability. InterpretationWearable-based DLPA assessment in PH is feasible, though high-quality evidence remains scarce. Future research should standardize procedures, terminology, and reporting of DLPA outcomes. Concordance with established measures such as the 6MWD, and their ability to predict clinical outcomes and disease progression need to be demonstrated.

Objectives To quantify the frequency of baseline control-group use in published long COVID prevalence studies and assess their key methodological features. Design Cross-sectional meta-epidemiological evaluation of published post-acute COVID-19 prevalence studies, supplemented by a corresponding-author survey. Setting Published studies identified through a systematic review by Hou et al. (2025) and supplementary data obtained through direct email contact with corresponding authors. Participants A total of 440 published long COVID prevalence studies. Main Outcome measures Presence and type of comparator group, reliance on solely self-reported outcomes, acknowledgment of lack of a control group among uncontrolled studies, and availability of additional comparator data through author survey. Results Among 440 studies, 372 (84.5%) reported no control group on their publication. Healthy or uninfected comparators were reported in 55 studies (12.5%) and other comparator types in 14 (3.2%); 1 study included both categories. Solely self-reported outcomes were used in 279 studies (63.4%). Among 372 uncontrolled studies, 244 (65.6%) did not explicitly acknowledge the absence of a baseline comparator as a limitation anywhere in text. Corresponding authors of 140 studies (31.8%) responded to the survey; among them, 126 (90.0%) reported no additional comparative data, while 14 (10.0%) mentioned some available comparative datasets (19 additional datasets). Almost all of that information (10/14, 17/19) had been already published in other articles not captured by the Hou et al. systematic review. Conclusions Most published long COVID prevalence studies lacked comparator groups and relied exclusively on self-reported outcomes without acknowledging this limitation. Direct author contact identified little additional comparator information. Much of the long COVID prevalence literature may therefore be poorly suited to estimating burden attributable specifically to SARS-CoV-2, underscoring the need for appropriately matched comparators and more objective outcome assessment. Registration The protocol was prospectively registered on the Open Science Framework (https://osf.io/f4hra).

Abstract Background: The association between chronic lung disease (CLD) and osteoporosis (OP) is well-recognized, but the direction and magnitude of this relationship remain debated, particularly in aging populations. We aimed to quantify the bidirectional association between CLD (including COPD and asthma) and incident OP using a two-stage individual participant data (IPD) meta-analysis of three large longitudinal cohorts. Methods: We harmonized and analyzed individual-level data from the Health and Retirement Study (HRS, USA), the Survey of Health, Ageing and Retirement in Europe (SHARE, Europe), and the English Longitudinal Study of Ageing (ELSA, UK), all comprising adults aged greater than or equal to[≥]50 years. In the first stage, Cox proportional hazards models were fitted separately in each cohort to estimate hazard ratios (HRs) for the forward (CLD[->]OP) and reverse (OP[->]CLD) associations, adjusting for a comprehensive set of confounders (demographics, lifestyle, comorbidities, functional status). In the second stage, cohort-specific log HRs were pooled using fixed-effect meta-analysis. Heterogeneity was assessed with the I-squared statistic. Results: A total of 40,050 participants were included across the three cohorts. The pooled HR for incident OP among individuals with baseline CLD was 1.37 (95% confidence interval [CI] 1.24-1.51), with similar estimates for COPD (HR 1.47, 95% CI 1.27-1.69) and asthma (HR 1.35, 95% CI 1.22-1.50). For the reverse association, baseline OP was associated with increased risk of incident CLD (pooled HR 1.16, 95% CI 1.05-1.29), COPD (HR 1.28, 95% CI 1.11-1.47), and asthma (HR 1.17, 95% CI 1.05-1.30). Heterogeneity was low across all analyses (I2[≤]7.5%). Conclusion: This two-stage IPD meta-analysis provides robust evidence of a bidirectional relationship between CLD and OP in older adults. These findings underscore the need for integrated screening and management of both conditions in aging populations.

BackgroundMindfulness-based interventions (MBIs) have been increasingly adopted in educational settings to support cognitive development in youth. Executive function (EF)--encompassing inhibitory control, working memory, and cognitive flexibility--is a plausible target of MBI given its reliance on attention regulation. However, prior reviews have yielded mixed conclusions, partly due to inconsistent construct definitions and the pooling of heterogeneous outcome measures. ObjectivesTo (1) estimate the pooled effect of MBI on EF in youth aged 3-18 years using only construct-validated, direct EF measures, (2) examine potential moderators including age group, EF domain, and risk of bias, and (3) test dose-response relationships via meta-regression on intervention duration. MethodsWe searched PubMed, PsycINFO, CINAHL, Scopus, and Web of Science from inception to March 2026, supplemented by reference-list searches from two existing systematic reviews and a scoping review. Only English-language publications were eligible. Eligible studies were randomised controlled trials (RCTs) or quasi-RCTs of MBI (excluding yoga-only interventions) in typically developing youth, with at least one direct behavioural or computerised EF outcome. Risk of bias was assessed using Cochrane RoB 2. Hedges g was computed for each study, and pooled using a DerSimonian-Laird random-effects model. Subgroup analyses by age group, EF domain, and risk of bias were conducted, alongside leave-one-out sensitivity analyses, Eggers regression test, trim-and-fill, and Knapp-Hartung-adjusted meta-regression on intervention duration. Evidence certainty was rated using GRADE. ResultsThirteen RCTs (nine school-age, four preschool; total N = 1,560) met inclusion criteria. The pooled effect was g = 0.365 (95% CI 0.264 to 0.465; p < .00001), with negligible heterogeneity (I2 = 0.0%; Q = 6.76, p = .87). Effects were consistent across age groups (school-age g = 0.389; preschool g = 0.318) and EF domains (inhibitory control, working memory, cognitive flexibility; pbetween = .60). Meta-regression on intervention duration (4-20 weeks) was non-significant (p = .79). The effect was robust in leave-one-out analyses, in the low risk-of-bias subgroup (g = 0.361; k = 8), and after trim-and-fill adjustment (g = 0.354). The 95% prediction interval (0.252 to 0.477) was entirely positive. GRADE certainty was rated MODERATE, downgraded once for risk of bias. ConclusionsMBIs appear to produce a small, statistically significant improvement in EF in youth aged 3-18 years, with moderate certainty of evidence per the GRADE framework. The effect is consistent across preschool and school-age samples and across EF domains, with no significant dose-response relationship within the 4-20 week range studied. Emerging mediation evidence suggests that EF improvement may serve as an important pathway through which MBI supports emotion regulation, though this requires replication. Further large-scale, pre-registered RCTs with active control conditions and longitudinal follow-up are warranted.

Background: Occupational therapists can improve stroke survivors hand and arm movement and participation in daily activities through action observation (AO). AO involves watching another persons hand or arm complete a movement or task. While research generally supports the use of AO with stroke survivors, there are limited AO videos are available to occupational therapists which makes applying AO challenging. Objective: The purpose of this work is to develop structured and widely accessible tool to support access to AO for stroke survivors, occupational therapists, and researchers. Methods: To develop an AO video library for stroke rehabilitation, functional and non-functional upper limb task deficits were first identified through clinical observations and clinician interviews to establish a prioritized list of daily activities. In collaboration with media production specialists, healthy adult volunteers were recruited and filmed performing these tasks from both first- and third-person perspectives. The recorded videos were then systematically edited, enhanced with instructional title slides, and distributed via a public YouTube channel for clinical application and a categorized digital repository for research purposes. Results: Initial assessments revealed a complete lack of familiarity, awareness, and utilization of AO resources among local occupational therapists, despite high perceived clinical utility. To address this gap, a final library of 150 tasks was established, resulting in the production of 419 finalized, standardized videos featuring six healthy volunteers. For clinical application, these videos were hosted on a free, public YouTube channel organized into 18 functional playlists, while a parallel set was structured into distinct movement categories for research repository storage. Conclusion: By providing a structured and highly accessible tool, this repository enables clinicians, researchers, and caregivers to readily implement evidence-based action observation interventions in both clinical and home settings.

Participatory qualitative methods such as Photovoice are increasingly used to link research with social action. Recent advances in artificial intelligence (AI) may enhance data analysis, inference, and action planning within such participatory approaches. This study explored medical students' perceptions of social justice using conventional Photovoice analysis and assessed the potential contribution of generative AI (genAI). Nine students joined a six-week seminar, "Exploring the Concept of Social Justice Using Photovoice." An initial two-hour session covered ethics, the Photovoice framework, and photography techniques. Participants then captured images reflecting their views on social justice, wrote narratives, and engaged in guided group discussions. Human researchers and students conducted a three-stage Photovoice analysis: 1) selecting photographs, 2) contextualizing them with participant narratives, and 3) inductively coding themes. To explore how AI might support data analysis, the research team analyzed the same data with five generative tools including Sonix, ChatGPT, and Copilot. AI-generated themes and visual representations were compared with human-derived results for congruence, depth, and suggested action steps. Conventional analysis identified five major themes: (1) Social Justice and Inequality, (2) Contradictions and the Costs of Justice, (3) Community and Collective Action, (4) Environment and Environmental Justice, and (5) Perception, Subjectivity, and Perspective. AI-assisted analysis yielded six unified themes that closely aligned with human findings. Traditional Photovoice images conveyed authentic, lived experiences and strong emotional meaning, providing a powerful foundation for advocacy. AI-generated images and thematic summaries offered efficiency, creativity, and reduced researcher bias, improving generalizability. However, they lacked the emotional depth and contextual nuance present in participant-created visuals.

BackgroundCommercial motorcycle riders are among the most vulnerable road users in low- and middle-income countries and contribute substantially to the burden of road traffic injuries. The use of personal protective equipment (PPE), including helmets and protective clothing, reduces injury severity; however, uptake remains suboptimal. This study evaluated the effectiveness of a theory-driven health education intervention in improving knowledge, attitudes, and use of PPE among commercial motorcycle riders in Cameroon. MethodsA quasi-experimental, non-randomized controlled before-and-after study was conducted in Limbe (intervention) and Tiko (control) Health Districts between August 4, 2024, and April 6, 2025. Participants were recruited from a cohort of commercial motorcycle riders and followed over an eight-month intervention period. The intervention, guided by the Health Belief Model and developed using the Intervention Mapping framework, combined face-to-face sensitization sessions with mobile phone-based educational messaging adapted to participants literacy levels and communication preferences. Data were collected at baseline and endline using structured questionnaires and direct observation checklists. Intervention effects were estimated using difference-in-differences analysis with generalized estimating equations, adjusting for socio-demographic factors. ResultsA total of 313 riders were enrolled at baseline (183 intervention, 130 control), with 249 retained at endline (149 intervention, 100 control). The intervention was associated with significant improvements in PPE knowledge ({beta} = 2.91; 95% CI: 2.14-3.68; p < 0.001) and attitudes ({beta} = 5.76; 95% CI: 4.32-7.21; p < 0.001) compared with the control group. No statistically significant effect was observed for PPE practice scores ({beta} = 0.21; 95% CI: -0.09-0.52; p = 0.171). Among individual PPE items, helmet use increased significantly in the intervention group relative to the control group (AOR = 2.38; 95% CI: 1.19-9.45; p = 0.036), while no significant effects were observed for gloves, trousers, eyeglasses, or closed-toe shoes. ConclusionThe theory-driven health education intervention significantly improved knowledge and attitudes toward PPE and increased helmet use among commercial motorcycle riders but did not lead to broader improvements in the uptake of other protective equipment. These findings highlight the need for complementary structural and policy interventions to address persistent barriers to PPE use in similar low-resource settings. Trial registrationClinicalTrials.gov Identifier: NCT07087444 (registered July 28, 2025, retrospectively)

Background and ObjectiveIncreasing screening volumes, combined with global shortage of radiologists and a high proportion of normal mammograms, challenge the efficiency and sustainability of breast cancer screening. Artificial intelligence (AI) has the potential to improve resource allocation, workflow efficiency and diagnostic performance by supporting and partially replacing radiologists in the interpretation process. This randomized, controlled, parallel-group, non-inferiority, single-blinded trial evaluates whether an AI-supported reading strategy, involving one or two radiologists depending on AI risk stratification, is non-inferior to standard independent double reading. The primary outcome is the number of screen-detected breast cancer cases in each group. MethodsWomen invited to BreastScreen Norway in the Western, Central, and Northern Norway Regional Health Authorities are eligible for inclusion. Following written informed consent, participants are randomized 1:1 to the control group (standard independent double reading by two radiologists) or the intervention group. In the intervention group, mammograms are analyzed using Transpara. Examinations with AI scores of 1-7 are interpreted by a single radiologist, whereas examinations with scores of 8-10 undergo independent double reading. Radiologists are blinded to AI scores and AI image markings during the initial interpretation; this information is disclosed during consensus meetings. Non-inferiority will be assessed by estimating confidence interval for the difference in screen-detected cancer rates between groups. Non-inferiority will be concluded if the upper bound of the confidence interval does not exceed the predefined non-inferiority margin. ConclusionsThe trial addresses a critical challenge in breast cancer screening: maintaining diagnostic performance while improving efficiency in the context of workforce constraints and a high prevalence of normal examinations. By evaluating a risk-stratified AI-supported reading strategy within a population-based screening program, the study will provide important evidence on whether AI can be safely integrated to optimize workload distribution while preserving cancer detection rates. Trial registrationThe ClinicalTrials.gov registry (NCT06032390)