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Acceptability and Fidelity of a Cognitive Rehabilitation Intervention During and After Intensive Care: A Feasibility Evaluation.

Astrup K et al. · Jul 1, 2026

Background Cognitive impairment is common after critical illness, yet structured cognitive rehabilitation is rarely integrated into routine intensive care practice. ICU CogHab is a stakeholder- and theory-informed intervention comprising two components: Mindfulness and Brain Training, developed to support recovery from intensive care to 6-month follow-up. Aim To evaluate the feasibility of the ICU CogHab intervention, focussing on acceptability and fidelity among ICU patients and nurses. Study design A multi-method feasibility evaluation was conducted alongside a pragmatic, five-arm randomised controlled feasibility trial in four Danish ICUs. Data were collected using patient and nurse surveys and semi-structured interviews. Acceptability was explored in terms of three domains: affective attitude, burden and perceived effectiveness. Fidelity was assessed in relation to adherence and dose, with participant responsiveness and quality of delivery examined within adherence. Quantitative data were analysed descriptively, and qualitative data were analysed using deductive content analysis. Results Thirty-one patients contributed with survey data and nine participated in interviews. In addition, 53 nurses contributed with 194 session-based surveys and seven interviews, informing evaluation of delivery during ICU admission. Both components were generally perceived as relevant and appropriate by patients and nurses. Patients described the components as meaningful and supportive. Fidelity varied across settings and over time, with adherence and dose influenced by clinical condition, fatigue, patient readiness and competing rehabilitation demands, meaning that intervention use often required adaptation in timing and duration across recovery phases. Nurses reported contextual barriers to delivery, including high workload and competing clinical priorities. Conclusion The ICU CogHab intervention components demonstrated overall acceptability across ICU and post-discharge phases. Variation in fidelity reflected the patient condition, clinical context and competing demands, providing direction for further refinement before larger-scale evaluation. Relevance to clinical practice Cognitive rehabilitation may be acceptable and feasible to introduce within intensive care pathways but delivery may require flexible timing, integration into routine care and support across the ICU-to-home transition.

Medicine

Producing Mobility, Withholding Authority: Epistemic Drain and Nursing Sovereignty in Nepal.

Ghimire A. · Jul 1, 2026

Global discussions of nursing in low- and middle-income countries (LMICs) are dominated by the language of shortage, staffing, retention, and migration. Although useful, this technocratic vocabulary obscures a deeper philosophical crisis: nurses may be numerically produced yet institutionally denied authority over knowledge, care, and professional futures. Using Nepal as a theory-generating case, this conceptual article employs critical interpretive synthesis and philosophical analysis of nursing, policy, migration, and interdisciplinary scholarship to argue that the central problem is not workforce scarcity alone but a crisis of 'nursing sovereignty'. The paper introduces three concepts. First, epistemic drain extends the idea of brain drain by naming the erosion of mentorship, pedagogical continuity, professional memory, policy voice, research capacity, and the public credibility of nursing knowledge. Second, professionalised for exit captures a paradox of production in which nursing education expands global mobility more readily than local authority, making migration a morally justified reaction to constrained socioeconomic prospects, rather than a lack of professional dedication. Third, nursing sovereignty names the collective capacity of nurses to shape the ends, authority, knowledge, and institutional conditions of their profession. Drawing together social epistemology, feminist ethics, decolonial lens, political economy, sociology of professions, spatial theory, and digital pedagogy, the article argues that Nepal illuminates a wider LMIC condition in which nurses are essential yet disposable, mobile yet institutionally voiceless, and professionalised yet epistemically diminished. It concludes with a six-domain normative framework for institutional redesign: epistemic authority, educational integrity, governance voice, material justice, spatial and digital parity, and mobility justice. Reframing nursing in this way shifts debate from retention to justice, from labour supply to institutional re-design, and from workforce management to the political philosophy underpinning nursing practice.

Health Professions

Accuracy of Patient-Reported Exposure to New Psychoactive Substances and Other Illicit Drugs in Australian Emergency Departments: Findings From the Emerging Drugs Network of Australia.

Nijmeijer MJ et al. · Jul 1, 2026

Introduction New psychoactive substances (NPS) present a unique challenge in clinical, public health and drug-policy contexts. Continued diversity, unknown potency and often unintentional exposure can limit the accuracy of self-reported data. This study examined the accuracy of patient-reported NPS and illicit drug exposure in Australian emergency departments (ED). Methods Patient-reported drug exposure, clinical and toxicology data were extracted from the Emerging Drugs Network of Australia Clinical Registry between 1 July 2021 and 30 June 2024 for patients presenting with severe and/or unusual illicit drug toxicity in the ED. Blood samples were analysed using mass spectrometry. Agreement between reported and confirmed exposure was assessed using Cohen's kappa, sensitivity, specificity and likelihood ratios. Logistic regression analysis identified factors associated with discrepancies between reported and confirmed exposures. Results There were 2044 presentations: 64.6% male, median age 33 years (Q1-Q3, 26-41). Complete agreement between patient-reported and confirmed drug exposures was 14.3% (n = 293). Agreement between reported and confirmed NPS exposure was poor (κ = 0.38). 1522 (74.5%) had more drugs detected than reported. Older age (OR 1.03 [CI 1.02, 1.04]) was associated with higher odds of discrepancy. Attendance from a licensed venue (OR 0.44 [CI 0.28, 0.70]) and Glasgow Coma Scale of 13-15 (OR 0.44 [CI 0.33, 0.57]) were associated with lower odds. Discussion and conclusions Poor agreement between patient-reported and analytically confirmed drug exposure highlights the need for continued partnerships between EDs, clinical toxicologists, and forensic laboratories to identify substances involved in acute intoxications and support public health and harm reduction responses.

Pharmacology, Toxicology and Pharmaceutics

The Reciprocal Insecurity Paradox: A Phenomenological Analysis of the Crisis Encounter Between the Mental Health Nurse and Service User With Complex Emotional Needs.

Haslam M et al. · Jul 1, 2026

While research is emerging, there remains an inadequate focus upon the experiences of those delivering and receiving care specifically for service users with complex emotional needs (CEN) within Crisis Resolution and Home Treatment (CRHT) settings. This study therefore utilised hermeneutic phenomenology to examine the lived experience of both those providing and receiving care within CRHT settings. Data were gathered via semi-structured interviews with 14 participants (seven mental health nurses working within CRHT settings and seven service users with CEN who have received CRHT intervention). Transcripts were analysed using van Manen's hermeneutic phenomenological reflective method. A synthesis of participant accounts revealed several areas of convergence across the two groups, thus highlighting those 'core structures' of mental health crisis care as lived by participants in these encounters. Fears arising from structural vulnerabilities were illuminated as the eidos (or the 'essence') of the crisis encounter in CRHT settings, and at the heart of the crisis encounter, a central phenomenon of reciprocal insecurity is illuminated, whereby both parties' attempts to achieve a sense of personal safety inadvertently threatens that of the other. Findings highlight an urgent need for hermeneutic mediators; structures that provide the space and containment necessary for both parties to feel safe.

Psychology

Moral Distress as Subordination by Design: Silence, Containment and the Ethical Erosion of Nursing.

Ramsay A et al. · Jul 1, 2026

Moral distress has become one of the most prominent ethical constructs in contemporary nursing, widely used to describe nurses' experiences of constraint, frustration and ethical unease. While moral distress scholarship continues to retain important ethical and structural dimensions, the broader operationalisation of moral distress within healthcare organisations and professional discourse may influence how ethical conflict is understood and managed within healthcare organisations. This paper argues that such framings can have unintended consequences for nursing's moral authority and professional standing. Adopting a critical theoretical and conceptual synthesis, and drawing on feminist theory, Foucauldian analyses of power and contemporary nursing scholarship, this paper reconceptualises moral distress as functioning within conditions of subordination by design, understood as organisational, discursive and material arrangements that may systematically constrain nursing authority while influencing the conditions under which ethical dissent is manageable and non-disruptive. Within this framework, this paper advances three related concepts: moral containment, referring to organisational responses that absorb and redirect ethical dissent; ethical erosion, describing the cumulative diminishment of nurses' moral agency over time, and ethical laundering, naming the institutional process through which ethical harm may be acknowledged yet rendered politically inert. Rather than rejecting moral distress scholarship, the paper situates moral distress within a broader architecture of organisational power, contributing to contemporary debates regarding nursing voice, professional authority and the structural conditions under which nursing ethics can be meaningfully enacted.

Health Professions

The Independent and Combined Roles of Attentional and Interpretative Biases in Antisocial Behavior, Trait Aggression and Aggressive Responses Under Provocation.

Puzzo I et al. · Jul 1, 2026

Aggressive behavior has been linked to biases in social information processing, including heightened attention to threat and hostile interpretations of ambiguous social cues. The extent to which attention and interpretational biases uniquely or jointly contribute to aggression under provocation remains unclear. The present study investigated the effects of attentional bias toward angry faces and hostile interpretation bias on aggression using both self-report and behavioral measures in a non-clinical sample. Participants (n = 67) completed an emotional attentional blink task and a hostile interpretation bias measure, alongside self-report indices of aggression and antisocial behavior, and an experimental measure of provoked aggression. Hostile interpretation bias was positively associated with self-reported aggression and antisocial tendencies, whereas attentional bias toward angry faces was selectively associated with behavioral aggression. Critically, these cognitive biases were examined as potentially independent, overlapping, or interactive contributors to aggression under provocation, and attentional and interpretation biases interacted to predict aggressive behavior under conditions of high provocation, such that individuals high in both biases displayed the greatest levels of aggression. No interaction effects were observed for self-reported outcomes. These findings support social information-processing models proposing that multiple cognitive biases jointly contribute to aggression and highlight the importance of considering situational provocation and outcome modality when examining cognitive risk factors for aggressive behavior and preventive cognitive interventions in at risk populations.

Psychology

Childhood Speech Impairment and Dementia Risks Among U.S. Older Adults.

Wang H et al. · Jul 1, 2026

Background Speech problems in childhood have profound implications for learning, communication, as well as the development of social and cognitive skills in adulthood. However, research has yet examined how early life speech problems may be associated with subsequent dementia risks in later life. Aims Using nationally representative data from the longitudinal Health and Retirement Study, this study aimed to investigate how the experience of speech problems before age 16 was associated with the risk of dementia among older adults aged 50 and older. Methods and procedures The analysis pooled the full life history information about childhood speech problems for N = 17,863 participants who had one to eleven observations for cognitive and sociodemographic information from 2000 to 2020. We constructed person-interval data and estimated discrete-time event history models to examine risks for developing dementia, which was measured using a validated Langa-Weir classification of cognitive function. Results Results showed that older adults with childhood speech problems had a higher risk of developing dementia in later life, compared to those who never had speech problems in childhood. The effect of childhood speech problems on cognitive function was partially explained by economic status and health conditions in midlife. Conclusions and implications Findings highlight the long-arm implications of early life health adversity and suggest needs for screening and early intervention programs for childhood speech impairment. What this paper adds What is already known on this subject Literature had documented various developmental and health outcomes of childhood speech impairment. This research addresses the gap in the literature by examining the long-term implications of childhood speech impairment on dementia risk in later life. What this paper adds to existing knowledge Using longitudinal data from the Health and Retirement Study, this study investigated how the experience of childhood speech impairment was associated with the risk of dementia among U.S. older adults. We found about 3% of U.S. older adults had speech impairments in childhood, and they had a higher risk of developing dementia in later life compared to those who did not have speech impairments in childhood. What are the potential or actual clinical implications of this work? Findings suggest needs for screening and early intervention programs for childhood speech impairment.

Central Venous Pressure Referencing in the Lateral Position: Comparison With Direct Right Atrial Pressure in Mechanically Ventilated ICU Patients.

Sjödin C et al. · Jul 1, 2026

Background Right atrial pressure (RAP) is a key determinant of venous return and reflects right-sided filling pressures in critically ill patients. Central venous pressure (CVP) is commonly used as a surrogate, but its accuracy depends on appropriate transducer levelling. While reference points have been evaluated in supine positions, evidence is lacking for the lateral position, despite its frequent use in intensive care. Furthermore, it remains unclear whether lateral positioning alters RAP itself. Methods In this prospective observational study, 16 sedated, mechanically ventilated ICU patients with central venous catheters were included. RAP was measured using a solid-state catheter positioned in the mid-right atrium, confirmed by waveform analysis and echocardiography. Simultaneous CVP was recorded with the transducer levelled 5 cm below the mid-sternum. Measurements were obtained at end-expiration in supine, 45° left lateral, and 45° right lateral positions. Agreement between RAP and CVP was assessed using Bland-Altman analysis, intraclass correlation coefficients, and predefined clinical thresholds. Stepwise hydrostatic adjustments were applied to identify optimal reference levels. Results In the right lateral position, CVP referenced 5 cm below the sternum closely approximated RAP (bias -0.4 mmHg; limits of agreement -3.2 to +2.4; ICC 0.85). In the left lateral position, the same reference point systematically overestimated RAP (bias -2.2 mmHg; limits of agreement -5.0 to +0.7; ICC 0.58). Adjustment to approximately 2 cm below the sternum minimised bias (-0.1 mmHg) and improved agreement (ICC 0.82). RAP increased in the right lateral position compared with both supine (Δ +2.9 mmHg, p Conclusion In mechanically ventilated ICU patients, central venous pressure accuracy was position-dependent, and optimal external reference levels differed between lateral positions. Right atrial pressure increased in the right lateral position, suggesting that lateral positioning influences cardiopulmonary physiology beyond hydrostatic measurement effects alone. Trial registration https://clinicaltrials.gov/study/NCT06705374, registration date 30 April 2024 EDITORIAL COMMENT: The study showed that central venous pressure systematically overestimated right atrial pressure in mechanically ventilated patients placed in the left lateral position. This means that preload and venostasis can be misinterpreted in this position. The influence of increased right atrium pressure on venous return and cardiac output during left lateral positioning in mechanically ventilated patients requires further studies before the clinical relevance can be assessed.

Medicine

Hypertrophic Osteopathy Associated With Primary Pulmonary Histiocytic Sarcoma in a Dog.

Rinaldi V et al. · Jul 1, 2026

Hypertrophic osteopathy (HO) is a paraneoplastic or parainflammatory syndrome characterised by painful periosteal new bone formation and soft tissue swelling, most commonly associated with thoracic neoplasia. The pathogenesis of HO remains incompletely understood and may involve neurovascular mechanisms, altered pulmonary filtration of megakaryocytes and platelets and increased release of growth factors such as vascular endothelial growth factor (VEGF) and platelet-derived growth factor (PDGF). This report describes the first documented case of HO associated with primary pulmonary histiocytic sarcoma (PHS) in a dog. A 7-year-old male Golden Retriever was referred for evaluation of diffuse pain, limb swelling and lameness. Diagnostic imaging revealed bilateral periosteal proliferation affecting the forelimbs and a pulmonary mass within the right caudal lung lobe. Histopathology and immunohistochemistry following lung lobectomy and lymphadenectomy confirmed a diagnosis of PHS with nodal metastasis. Surgical excision resulted in complete clinical resolution of pain despite persistent radiographic evidence of HO. Subsequent disease progression occurred despite multiple chemotherapy protocols, including lomustine, vinorelbine, and metronomic chemotherapy; however, the dog remained consistently pain-free throughout follow-up. Overall survival time was 450 days. This case expands the spectrum of neoplasms associated with HO and further supports the hypothesis that tumour location, rather than histotype, plays a central role in the development of this syndrome. Moreover, the sustained absence of pain despite persistent periosteal lesions and metastatic progression suggests that tumour burden and tumour microenvironment may significantly influence clinical manifestations of HO.

Medicine

How Uncertainty Affects Children's Exploration and Exploitation in Statistical Learning.

Tong SX et al. · Jul 1, 2026

Environmental input is inherently uncertain at both global and local levels. Depending on the level of uncertainty, cognitive systems dynamically adapt by shifting attention between exploiting learned regularities and exploring less predictable alternatives. While these dynamics are well documented in adults, how local and global uncertainty jointly influences children's exploration-exploitation strategies during statistical learning remains unclear. Combining eye-tracking with a probabilistic cueing task, this study quantified local and global uncertainty on a trial-by-trial basis to examine their effects on children's attentional preferences for cues differing in predictive value. Overall, 158 children aged 4 to 13 years passively viewed cue-target sequences in which target shapes were predicted by cues with high- and low-transitional probabilities. Results showed that under high global uncertainty, high local uncertainty biased attention toward high-predictive cues, indicating uncertainty-exploitation, whereas low local uncertainty biased attention toward low-predictive cues, suggesting certainty-exploration. Conversely, under low global uncertainty, attentional strategies reversed, shifting toward certainty-exploitation and uncertainty-exploration. These patterns were amplified in older children but attenuated in younger ones. These findings support a developmental dynamic model of exploration-exploitation in which children's attention strategies are jointly regulated by local and global uncertainty and undergo systematic change across childhood. SUMMARY: How local and global uncertainty jointly shapes the development of children's exploration-exploitation behavior during statistical learning across different ages remains poorly understood. Using eye-tracking in a probabilistic learning task, we showed that 4-13-year-olds adapt their information sampling and choices in response to overarching and trial-by-trial uncertainty. Under high global uncertainty, children relied on local uncertainty for exploitation and exploration; under low global uncertainty, they favored certainty-driven exploitation and uncertainty-driven exploration. These uncertainty-regulated strategies were amplified in older children but attenuated in younger children.

Psychology