Understanding the influence of cardiovascular diseases (CVD) on human regulatory functions is a major challenge in modern healthcare. This study explores whether the autonomic response to sleep arousals can serve as a diagnostic marker of the health of physiological networks. We introduce a novel method for the robust calculation of information transfer, based on the optimization of embedding parameters for transfer entropy (TE) calculation. Using this approach, we analyzed the information transfer dynamics of 8,136 sleep arousals from 1,956 subjects from the SHHS follow-up visit. Compared to three state-of-the-art approaches, our newly introduced method, max. TE, achieved a 17.9% more stable TE estimate than the second-best approach. Our results indicate a significantly ( p < 0.001 ) lower TE in patients with CVD ( 85.4 ± 0.8  mnats) than that in healthy controls ( 87.9 ± 0.5  mnats), indicating an impairment of regulatory control mechanisms. Furthermore, the TE decreases linearly with increasing age and shows significant differences between sleep stages, with the highest TE occurring during REM sleep ( p < 0.001 ) . These findings demonstrate that sleep arousals, as a physiological stimulus, can reveal sleep stage- and disease-related changes in cardiovascular networks and that our approach provides a robust group-level embedding strategy for physiological information-transfer analysis.

With the rapid advancement of China's aging population, the mental health problems of the elderly, especially depression, have become an important concern in the field of public health. However, research on the combined effect of education level and widowhood on depression is still relatively limited. The aim of this study is to explore the association between education level, widowhood status, and depression symptoms among elderly people in China, and further analyze the moderating effects of health status, demographic characteristics, and behavioral variables in this association. Data from the 2018 China Health and Retirement Longitudinal Study were used. A total of 3243 participants aged 50 and above were analyzed. A simplified 10 item CES-D scale was used to assess depression. Logistic regression models were used to examine the independent and interactive effects of education level and widowhood on depression, while adjusting for demographic variables (age, gender, type of residence), health status (chronic disease, self-rated health), and behavioral factors (physical activity, smoking). Even after controlling for confounding factors, lower levels of education were significantly associated with a higher risk of depressive symptoms (odds ratio [OR] = 1.52, P < .01). Widowhood is also a strong predictor of depression (OR = 1.79, P < .01), especially in women. Interaction analysis indicates that poor self-rated health and a sedentary lifestyle exacerbate the negative impact of low education and widowhood on depression. In addition, rural residents and individuals with lower socioeconomic status face a higher risk of depression symptoms. Low education level and widowhood are independent factors contributing to the high incidence of depression among elderly people in China. Health status and lifestyle factors play a crucial mediating role in this association. These findings emphasize the necessity of targeted intervention measures, such as community-based education programs, sports promotion, and strengthening social support networks, to reduce the risk of depression among vulnerable elderly people in China.

Training mental health clinicians to conduct standardized clinical assessments is challenging due to a lack of scalable, realistic practice opportunities. Traditional methods often fail to prepare trainees for the variability and complexity of real-world patient interactions, potentially impacting data quality in clinical trials. This paper introduces a novel approach to address this training gap using large language model (LLM)-based interview simulations.

This study aimed to develop and validate a voice-enabled virtual patient simulation system as a proof of concept. We described the development of the system and evaluated whether it could generate virtual patients that (1) accurately adhered to predefined clinical profiles, (2) maintained a coherent and consistent narrative, and (3) produced dialogue that is perceived as realistic.

We implemented a system that used an LLM to simulate patients with specified symptom profiles, demographic backgrounds, and distinct communication styles. The system's performance was analyzed through a mixed methods evaluation, which included a formal assessment by 5 experienced clinical raters who conducted simulated structured Montgomery-Åsberg Depression Rating Scale (MADRS) interviews with 4 virtual patient personae, scored them on the scale, and provided qualitative feedback on the system's clinical plausibility, narrative cohesion, and dialogue realism.

Across 20 interviews, the virtual patients demonstrated reasonable adherence to their configured clinical profiles, with human rater scores falling near their predefined score configurations. The mean item difference between MADRS rater scores and configured scores was 0.52 (SD 0.75); interrater reliability for the total score was 0.90 (95% CI 0.68-0.99). Expert raters consistently gave average ratings of "agree" to "strongly agree" when asked to evaluate the qualitative realism and cohesion of the virtual patients.

LLM-powered virtual patient simulations offered a promising, scalable tool for training clinicians in standardized clinical assessment. This pilot study provides initial evidence for the system's ability to produce clinically relevant practice scenarios with reasonable fidelity.

Globally, the mental health of children and adolescents is a public health concern. Schools are a primary access point for youth mental health support, yet traditional delivery models remain constrained by limited resources, shortage of specialised professionals, and high counsellor caseloads. Digital mental health interventions may help address these gaps by offering scalable, accessible, and less-stigmatising support.

This review aimed to map and characterise school-based digital mental health interventions for children and adolescents by examining intervention characteristics, implementation, and intervention outcomes.

A comprehensive search of peer-reviewed studies (2008-2025) was conducted across PsycNet, ERIC, and PubMed, using the PRISMA-ScR Checklist. Eligible studies evaluated a digital mental health intervention delivered in a school setting among K-12 students and reported at least one implementation and/or mental health outcome.

Across 40 studies, most were conducted in high-income countries and used randomised designs. Web-based, structured cognitive behavioural therapy (CBT) modules in classroom settings predominated. Intervention delivery ranged from teacher-led to self-directed use, with some hybrid clinician-supported models. Findings were heterogeneous for internalising symptoms (e.g., depression and anxiety), with evidence of benefit in some CBT-oriented interventions but mixed effects in universal programmes. In contrast, mental health literacy, stigma, and well-being outcomes showed more consistent positive effects. Engagement and implementation quality appeared closely linked to effectiveness.

School-based digital mental health interventions can improve mental health literacy and stigma-related outcomes when grounded in CBT. Future research should prioritise standardised outcome measurement (e.g., fidelity, adoption), theory-to-component linkages, co-design elements, and hybrid effectiveness-implementation, particularly in low-and middle-income settings.

While there is much research on stigma toward marginalized populations, public perceptions regarding deservingness of basic human and civil rights of these groups have not been examined in a nationwide sample of US adults.

To understand the US public's perceptions regarding deservingness of basic human and contested civil rights for people with severe physical disabilities (SPDs), severe mental illness (SMI), and substance use disorders (SUDs).

This cross-sectional study was a nationwide US internet-based quota panel survey of US adults (aged ≥18 years) who completed the survey. Responses were collected from January 17 to February 12, 2025.

Participants rated their support for 5 human rights (adequate standard of living, high standards of health, legal capacity, freedom from torture, living independently) and 3 civil rights (being a parent, running for political office, owning a gun) for people with SPDs, SMI, and SUDs using a 5-point Likert scale, with marginalized subgroups presented to participants in randomized order. McNemar test for paired binary data was used to examine differences in mean support across subgroups, and linear probability regression models were used to identify demographic variables associated with support.

In this survey of 1442 US adult participants (849 female [58.9%]; 588 male [40.8%]; 3 nonbinary [0.2%]; and 2 preferred not to say [0.1%]), the SPD subgroup received significantly higher support across all 5 human rights and 3 civil rights compared with SMI and SUD subgroups. For example, 79.0% (95% CI, 76.9%-81.2%) of participants supported the right to live independently for people with SPDs, while 67.0% supported this right for those with SMI (95% CI, 64.6%-69.5%) and 68.4% supported this right for those with SUDs (95% CI, 66.0%-70.9%). Civil rights received lower support across all 3 subgroups; for example, 40.1% (95% CI, 37.5%-42.6%) supported the right to run for political office for those with SMI and 41.4% (95% CI, 38.8%-44.0%) for those with SUDs compared with 62.7% (95% CI, 60.1%-65.2%) for those with SPDs. Democratic affiliation and lived experience with behavioral health care were associated with higher support for human rights (eg, among those with SUDs, up to 17.1 and 14.2 percentage points higher support, respectively). Male sex and younger age (18-24 years) were associated with greater support for civil rights (eg, male sex with 17.9 percentage points higher support for gun ownership among those with SPDs and age 18-24 years with a 27.1 percentage-point difference among those with SMI).

These findings contribute important evidence to the existing literature on stigma, highlighting discrepancies in public support for basic human and contested civil rights across marginalized subgroups, which can inform interventions to address public attitudes toward people with behavioral health conditions.

Hepatocellular carcinoma (HCC) is a cancer with rising incidence and economic burden. However, evidence on healthcare resource utilization (HCRU) and associated costs is scarce in Europe. This study aims to determine HCRU and costs of HCC from a German third-party payer's perspective.

This longitudinal claims study (BARMER statutory health insurance) included patients with HCC (ICD-10-GM C22.0; 2016-2020). HCRU and costs within 2 years after diagnosis were analyzed descriptively and reported per patient (PP) and per patient per month (PPPM).

The cohort included 2778 patients. Mean age was 71.9 years (SD ±9.7); 69% were male. Total cost within 2 years after diagnosis was approximately €105 million, with mean cost PP of €37,970 (SD ±€43,840), primarily due to inpatient stays (67%). Median costs PP were highest for patients receiving liver transplantation (€126,943; interquartile range [IQR]: €104,340-€167,205) and lowest for patients without any tumor-specific therapy (€10,132; IQR: €5875-€19,663). Considering the observation period, costs PPPM were lowest for liver resection (€2434; IQR: €1282-€5425) and thermal ablation (€2349; IQR: €1233-€4316), whereas costs PPPM were highest for patients without tumor-specific HCC treatment (€5984; IQR: €2764-€10,908). Similar patterns were observed in the HCRU assessment.

In this German claims data analysis, PP costs and HCRU in patients with HCC were higher among those who underwent liver transplantation and lower among those without tumor-specific treatment. However, after adjustment for follow-up duration, the high costs PP among patients receiving curative-intent treatments were significantly relativized. These findings support structured HCC surveillance to potentially improve clinical and economic outcomes.

Burning mouth syndrome (BMS) is a chronic orofacial neuropathic pain disorder, occurring in the absence of clinically evident mucosal lesions or identifiable oral pathology that can explain the symptoms. A significant proportion of patients experience uncontrolled symptoms despite multiple therapies. OnabotulinumtoxinA (onaBoNT/A) is used in neuropathic pain, as clinical trials have shown benefits in peripheral and central neuropathic pain management with its application. We present an exploratory case series of four patients with refractory BMS treated with intradermal onaBoNT/A injections.

Four patients with refractory BMS were included in this study. OnaBoNT/A intradermal injections were performed in the inner labial mucosae and tip of the tongue. We assessed pain intensity before the procedure and after 15 days, adverse effects, time to symptom recurrence, cumulative effects with multiple procedures, and patients' global impression of change.

All patients reported the procedure was quick and well tolerated. No immediate adverse effects were identified. All patients had significant pain reduction at 15-day follow-up assessment. Regarding adverse effects, one patient reported transient lower lip asymmetry in one procedure, and another reported transient mild mouth closure impairment. Symptoms recurred between 2.5 and 3.0 months after the first procedure. Three patients desired to continue the treatment. One patient reported no symptom recurrence after four procedures with three-month intervals; after four procedures, the treatments were suspended, and she remained asymptomatic until the end of follow-up. One patient reported incremental benefit from repeated procedures. All patients reported the treatment had a meaningful impact on their daily life.

Our results suggest that intradermal onaBoNT/A injections may constitute an effective and durable treatment option for patients with BMS refractory to conventional therapies. Despite these favourable outcomes, adverse events were noted in procedures targeting the labial mucosa. In future applications, we aim to examine technical variations between sessions associated with and without adverse effects, to optimise safety and refine the technique.

Task shifting and task sharing are strategies for redistributing healthcare responsibilities to optimise healthcare services. The World Health Organization (2008) framed 'shifting' as the delegation of tasks from higher- to lower-qualified workers, while subsequent scholarship characterised 'sharing' as collaborative, team-based redistribution. However, the two approaches are often used interchangeably in literature and by practitioners. Drawing on interviews and observations across 16 Indian organisations working in primary healthcare, mental health, and emergency medical services, we identified two types of operational ambiguities: organisations simultaneously employed both strategies for different tasks within the same service and also demonstrated practices that did not match their design intent or initial appearances. Based on these, we reiterate the importance of classifying task redistribution (Shifting OR Sharing) at individual task levels, consistent with the task-specific wording of conventional definitions, and additionally propose a new operational criterion: whether the delegating provider is functionally present or absent during task execution. We suggest revised working definitions incorporating this criterion as a hypothesis for prospective testing, and invite the global health community to validate these for clearer implementation, evaluation, and policy.

The educational alliance describes a framework for the trusting relationship between trainee and supervisor as they engage in meaningful, effective feedback. This framework emphasizes interpersonal relationships, shared goals, and agreement on actionable steps to achieve these goals. In this theory-informed conceptual analysis, the authors propose that the educational alliance logically extends to support and enhance competency-based medical education and health professions education, collectively known as competency-based health professions education (CBHPE). Authors describe how key features of the educational alliance align with the five core components of CBHPE: outcome-based competencies, sequenced progression, tailored learning experiences, competency-focused instruction, and programmatic assessment - by facilitating individualized learning that is centered on the trainee-supervisor relationship. Relevant theories that support the effective implementation of the educational alliance in CBHPE to advance learning include growth mindset and self-regulated learning theories. Authors present specific actionable recommendations regarding trainee and supervisor roles and responsibilities within an educational alliance for creating shared mental models, building relationships, engaging in team training, and attending to ethical considerations, including conflicts of interest and using data for the determination of trainee competency and advancement. Additionally, the authors introduce an Educational Agreement applicable to all training levels, designed to foster, guide, and strengthen the educational alliance. The Agreement is intended to be voluntary, co-constructed, and may be adapted to local contexts. Finally, the authors identify areas for future empirical examination through research on the educational alliance in CBHPE programs.

Peer mentorship by individuals with lived experience is increasingly recognized as supporting recovery after severe injury. Yet evidence on its role in hospital-based rehabilitation remains limited, particularly in cases of severe war-related physical injury during ongoing military conflict. This study examines the benefits and barriers of peer mentorship within the Israel Defense Forces Casualties Affairs Unit, which trains previously injured veterans to accompany newly injured soldiers during hospitalization in healthcare settings as part of their reserve duty.

The study employed a qualitative design, comprising 41 in-depth interviews: 21 with severely injured soldiers (with amputations, traumatic brain injury, spinal cord injury, burns, polytrauma) who were assigned peer mentors, and 20 with parent-caregivers. Interviews underwent linguistic and thematic analyses.

Peer mentorship was found to support recovery across three domains: functional (independent functioning, exercising rights, community participation), social-emotional (fostering hope, belonging, trust, and mediation of re-entering the public space), and cognitive (autonomous choice, insight, identity reconstruction, and developing an effective mindset when interacting with others). Barriers were also identified across three domains: technical-functional (matching and timing issues), emotional (managing rejection, shattering the illusion of full recovery, appearance-related avoidance), and cognitive (discrepancies in worldviews).

Integrating peer mentorship into the post-acute continuum of care facilitates recovery of severely injured soldiers and their families but requires careful implementation. Healthcare systems and rehabilitation units may integrate peer mentorship as part of their comprehensive support framework. The study's significance lies in the need to develop diverse responses for war casualties following military conflicts worldwide.