Interactive Journal of Medical Research

Intravenous N-Acetylcysteine in Patients With Dengue Fever With Marked Aminotransferase Elevation: Prospective Comparative Study

2026-10-05T16:30:17-04:00

Background: Dengue fever can lead to significant hepatic involvement and marked aminotransferase elevation and is associated with increased morbidity and prolonged hospitalization. N-acetylcysteine (NAC) has been proposed as a supportive therapy for dengue-induced liver injury. However, prospective comparative evidence from endemic regions such as Vietnam remains limited. Objective: This study aimed to evaluate the association between intravenous NAC administration and clinical outcomes (primarily length of hospital stay), as well as the secondary effects of NAC on liver transaminase levels (posttreatment aspartate aminotransferase [AST] and alanine aminotransferase [ALT] and their changes from baseline) and platelet recovery in patients with dengue fever with marked aminotransferase elevation (AST or ALT ≥400 U/L). Methods: A prospective, nonrandomized comparative study was conducted at the Department of Tropical Diseases, Viet Tiep Hospital, Hai Phong, Vietnam, from June to December 2024. A total of 128 adult patients with laboratory-confirmed dengue fever and marked aminotransferase elevation (AST and/or ALT ≥400 U/L) were enrolled. Treatment allocation was not randomized and was determined by the treating physicians based on aminotransferase elevation and overall clinical condition. Patients received either intravenous NAC (100 mg per kilogram per day) plus standard supportive care (NAC group; n=68) or standard care alone (non-NAC group; n=60). The primary outcome was length of hospital stay. Secondary outcomes included liver transaminase levels and platelet recovery at discharge. Results: Baseline AST, ALT, bilirubin, and international normalized ratio values were broadly comparable between groups, although several clinical and hematological characteristics differed at baseline. The NAC group had a significantly shorter hospital stay (mean 5.01, SD 1.28 vs 6.12, SD 1.25 days; P<.001). The AST and ALT levels were significantly lower in the NAC group (AST: mean 154.83, SD 67.22 vs 184.62, SD 79.88 U/L and P=.02; ALT: mean 113.09, SD 33.31 vs 156.35, SD 73.66 U/L and P=.004). The posttreatment platelet count was significantly higher in the NAC group (median 31.50, IQR 19.00-50.15 G/L vs 17.00, IQR 8.75-36.23 G/L; P=.001). The median increase in platelet count was also greater in the NAC group (15.05, IQR 7.05-26.10 G/L vs 6.95, IQR 4.22-15.43 G/L; P=.001). No severe infusion-related adverse events were documented during the study period. Conclusions: In this prospective, nonrandomized comparative study, intravenous NAC administration was associated with shorter hospitalization and lower posttreatment aminotransferase levels in adult patients with dengue fever and marked aminotransferase elevation. No severe infusion-related adverse events were documented during the study period. However, the nonrandomized design and potential for confounding limit causal inference. Larger, multicenter randomized controlled trials are warranted to clarify the therapeutic role of NAC in dengue-related hepatic complications.

Design, Facilitation, and Evaluation of Tabletop Exercises for Prehospital Mass Casualty Preparedness: Scoping Review

2026-10-05T15:45:03-04:00

Background: Tabletop exercises (TTXs) are commonly used to enhance prehospital readiness for mass casualty incidents (MCIs). However, evidence on their design, facilitation, and evaluation remains scattered. TTXs simulate organized interactions at 3 levels: among individual responders and response protocols, within interdisciplinary teams, and across organizations and systems. While existing reviews cover tabletop simulation generally, they do not specifically focus on the prehospital MCI interface or assess whether evaluation methods match the exercise objectives. Objective: This scoping review aimed to explore how TTXs are designed, facilitated, and evaluated in prehospital MCI preparedness. It classified outcomes using the Kirkpatrick Evaluation Model and analyzed how evaluation methods align with the purpose of each exercise. Methods: We performed a scoping review following Arksey and O’Malley’s framework, with enhancements from Levac et al, along with PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews) and PRISMA-S (PRISMA Extension for Reporting Literature Searches) guidelines. Searches across PubMed, Embase, Scopus, PsycINFO, CINAHL, the Cochrane Library, ClinicalTrials.gov, Google Scholar, and references were limited to English peer-reviewed and gray literature published from 2015 to May 2026. Eligible studies focused on TTXs related to prehospital disaster or MCI preparedness and reported measurable educational, clinical, or system outcomes. The review protocol was registered beforehand on Protocols.io. Two reviewers (PP and AA) independently screened records, extracted data, and classified outcomes using Kirkpatrick levels, with an added level 2+ (Applied Learning) category for structured performance evaluation during exercises. Results: Thirteen studies from 9 countries were included. They were categorized into a preliminary 3-tier typology called the TTX Design Spectrum, representing increasing levels of interaction: algorithm-rehearsal exercises (n=2) focused on individual responders’ interaction with triage protocols, scenario-based decision-training exercises (n=7) aimed at multidisciplinary team decision-making under realistic conditions, and systems integration exercises (n=4) centered on interagency coordination and system-level preparedness. Facilitation varied by exercise purpose, from standardized assessment-focused approaches to expert-led and multidisciplinary facilitation. Evaluation primarily targeted Kirkpatrick level 1: Reaction (n=10), level 2: Learning (n=10), and level 2+ (Applied Learning) (n=8), with fewer studies examining level 3: Behavior (n=2) or level 4: Results (n=3). Operational frameworks were reported more consistently than formal educational design or assessment frameworks. Additionally, natural disaster scenarios and evidence from resource-limited settings were underrepresented. Conclusions: TTXs for prehospital MCI preparedness should be viewed as a collection of related exercise types rather than a single, uniform intervention. This review introduces an initial typology called the TTX Design Spectrum, along with the level 2+ (Applied Learning) classification, which operationalizes the distinction between in-training performance and behavioral transfer. These tools aim to help align exercise purpose, facilitation, and evaluation strategies. Future research should focus on validating this typology, enhancing follow-up assessments of behavioral transfer, and adapting TTX design for natural disaster and resource-limited settings.

Codeveloping a Clinical Pathway for Recurrent Clostridioides difficile Infection With Primary Care Providers: User-Centered Design Study

2026-09-30T13:45:12-04:00

Background: infection (CDI) is the most common cause of health care–associated infectious diarrhea; however, variability in laboratory testing results in uncertainty in diagnosis and clinical decision-making. Recurrent CDI (rCDI), defined as the return of infection following initial treatment, continues to present significant clinical challenges due to limited therapeutic options. Although health care providers are familiar with vancomycin as first-line therapy for CDI, many are less familiar with fecal microbiota transplantation (FMT), despite its recommendation in clinical guidelines for rCDI management. Consequently, primary care providers (PCPs) may experience uncertainty regarding diagnostic test interpretation, treatment selection, and referral for FMT, highlighting the need for practical clinical tools to support evidence-based management. Objective: This study will support the standardization of care and improve patient treatment experiences in Alberta by identifying barriers and facilitators encountered by PCPs in managing CDI and rCDI, using these findings to codevelop a provincial rCDI clinical pathway. Methods: This qualitative study investigated the codevelopment process of a provincial rCDI clinical pathway between the study team and intended end users. A draft pathway was developed by the study team comprising gastroenterology and infectious disease specialists, followed by an iterative end user–centered design approach. PCP participants completed 2 rounds of 60‐ to 90-minute virtual, one-on-one, semistructured interviews incorporating scenario-based usability testing with standardized clinical cases. Using a think-aloud approach, participants evaluated the pathway’s clarity, diagnostic decision-making, treatment recommendations, referral processes, and integration into clinical workflows. Feedback was analyzed using thematic analysis, informed iterative revisions were made to the pathway and accompanying user guide, and they were reevaluated in a second round of interviews. Results: Out of 30 invited PCPs, 3 (10%) participated in this study. During the first round of interviews, participants identified challenges interpreting PCR-positive vs toxin-positive test results, navigating the pathway layout, locating embedded hyperlinks, and understanding FMT referral processes. Iterative, feedback-driven revisions addressed these barriers by improving diagnostic guidance, simplifying navigation, increasing hyperlink visibility, and clarifying referral timing with a user guide. During the second round of interviews, all participants reported that modifications improved CDI test result interpretation, streamlined navigation, enhanced workflow integration, and increased confidence in applying the pathway to clinical scenarios. The final version of this pathway was well received for its clarity, readability, and clinical utility, and was viewed as a valuable educational resource for supporting evidence-based management of CDI. Conclusions: This study demonstrated the feasibility and value of codeveloping a provincial clinical pathway with physician partners for managing CDI and rCDI. The resulting tool was clear, practical, and aligned with primary care workflows. This iterative, user-centered design was useful for developing clinically relevant decision support tools. Future research should evaluate the pathway’s implementation and impact on physician practice, patient care, and clinical outcomes using quantitative and qualitative methods.

Factors Influencing Adherence to Digital Lifestyle Interventions for Adolescents: Systematic Review and Meta-Analysis of Attrition

2026-09-30T13:30:12-04:00

Background: Intervention studies frequently report that fewer than half of adolescent participants complete digital health interventions as intended, yet a systematic synthesis of the factors driving this low adherence across lifestyle domains is lacking. Understanding these factors is essential for informing the design of interventions that can sustain adherence and achieve meaningful behavioral outcomes. Objective: This systematic review identified and analyzed factors influencing adherence to digital health interventions targeting key adolescent lifestyle domains: physical activity, dietary habits, obesity management, alcohol consumption, and tobacco use. Methods: We systematically searched PubMed, PsycINFO, Embase, and CINAHL in March 2024, with the search updated in June 2026, for studies of digital interventions targeting adolescents (10‐19 years). Studies were included if they reported adherence outcomes. Data on intervention characteristics, user-related factors, and adherence outcomes were extracted and narratively synthesized using a framework distinguishing intervention-related and user-related factors across 3 evidence types (statistical, descriptive, and qualitative). Study-level attrition was additionally pooled in a random-effects meta-analysis. Results: A total of 116 studies, comprising 46,029 participants, were included. The average completion rate (binary measure) was 66.9% (SD 26%), while average adherence to individual intervention components was 55.2% (SD 25.5%). A meta-analysis of attrition across 108 comparisons yielded a pooled dropout of 16.9% (95% CI 13.6‐20.9), with very high between-study heterogeneity and no significant moderators. Consistently reported facilitators included personalization, user-friendly design, reminders, goal setting, gamification, and human support (particularly health coaching and parental involvement). The most common barriers were technical difficulties and poor system usability. Evidence regarding the effects of intervention duration and social components on adherence was inconsistent. Conclusions: Given that adolescents frequently underuse digital health interventions, completing only about half of intervention components on average, the effectiveness of these interventions is fundamentally constrained by adherence challenges. Adherence is primarily driven by user-centered design features and robust technical performance, while the impact of social and user-related factors varies by health domain and study context. Future research should adopt standardized adherence frameworks and reporting standards to enable meaningful cross-study comparisons and the development of evidence-based engagement strategies.

The Shifting Landscape of Natural Health Product Licensing in Canada: The e-Commerce Case of Stem Cell Supplements

2026-09-28T15:00:14-04:00

Natural health product (NHP) regulations have shifted in Canada, with the aim of reducing “red tape” and enabling market entry. This study assessed how many “stem cell” supplements for sale on Amazon.ca had Health Canada–required natural product number (NPN) licenses compared with vitamin D and “longevity” supplements. It also conducted a marketing overview analysis comparing the Amazon.ca discourse across the 3 product types. Findings show a gap in regulatory licensing compliance between “stem cell” supplements and vitamin D or “longevity” supplements. Marketing discourse also presented potential conflict with regulatory parameters. We discuss the impacts of loosening NHP regulations and the potential for products with weak evidentiary bases to enhance validation through NPN licensing.

Clinical Effectiveness and Cost-Effectiveness of Blended Treatment for Major Depression Compared With Treatment as Usual Within Routine Care in Europe: A Noninferiority Randomized Controlled Trial

2026-09-24T16:45:10-04:00

Background: Cognitive behavioral therapy (CBT) is an effective and widely used treatment for major depressive disorder (MDD). However, access is limited by long waiting lists and a shortage of trained therapists. Evidence-based guided and self-guided digital interventions can address these challenges, but their large-scale adoption in routine primary and specialized mental health care has been slow. Blended CBT (bCBT), combining face-to-face therapy with structured, guided digital treatment modules, may increase treatment capacity while maintaining the benefits of therapist support. Objective: The European Comparative Effectiveness Research on Internet-based Depression Treatment study, conducted across 9 European countries, is the first large-scale comparative bCBT study for MDD. The hypothesis was that bCBT is clinically noninferior and cost-effective when compared with treatment as usual (TAU), which mainly consisted of face-to-face CBT. Methods: A multisite randomized controlled trial was conducted with a noninferiority margin of =0.20. Main inclusion criteria were age ≥18 years, a diagnosis of MDD based on the Mini International Neuropsychiatric Interview, and a baseline Patient Health Questionnaire-9 (PHQ-9) score of ≥5. The primary outcome was the PHQ-9, with secondary outcomes including MDD remission at 12 months, therapeutic alliance, and costs. Intention-to-treat analyses were performed, and linear mixed modeling was used to assess intervention effects. Cost-effectiveness analyses were conducted from a health care perspective. Results: A total of 835 patients were included in the study. bCBT was shown to be noninferior to TAU on the primary PHQ-9 outcome during treatment (3 months after the baseline assessment, =−0.26, 95% CI −0.43 to −0.09), at 6 months (posttreatment, =−0.21, 95% CI −0.39 to−0.04), and at 12-month follow-up (=−0.01, 95% CI −0.19 to 0.17). Furthermore, the bCBT group had a significantly lower likelihood of experiencing an MDD episode at 12 months (odds ratio 0.67, 95% CI 0.45‐0.99). Subgroup analyses indicated that participants with and with no antidepressant use at baseline in both groups benefited equally from their treatment. Deterioration rates (Reliable Change Index) were below 5% in both groups. bCBT appeared acceptable for patients and therapists, with a strong working alliance in both groups. From a health care perspective, bCBT was not cost-effective at 12 months' assessment, as its total costs were not significantly lower than TAU. However, the probability that bCBT is cost-effective is high (0.95) at a willingness to pay (WTP) of €3800 per improvement in the PHQ-9 score, and 0.76 at a WTP of €10,000 per MDD case prevented (average 2017 exchange rate was €1=US $1.13). Conclusions: bCBT offers an effective and safe digitally supported alternative to face-to-face TAU for patients with MDD and their therapists in routine clinical care. From a health care perspective, its cost-effectiveness depends on policymakers’ WTP for the additional clinical benefits achieved. Trial Registration: ClinicalTrials.gov NCT02796573; https://clinicaltrials.gov/study/NCT02796573 and ClinicalTrials.gov NCT02542891; https://clinicaltrials.gov/study/NCT02542891 and German Clinical Trials Register DRKS00006866; https://drks.de/search/en/trial/DRKS00006866 and Netherlands Trials Register NTR4962; https://www.onderzoekmetmensen.nl/en/trial/25452 and ClinicalTrials.gov NCT02389660; https://clinicaltrials.gov/study/NCT02389660 and ClinicalTrials.gov NCT02361684; https://clinicaltrials.gov/study/NCT02361684 and ClinicalTrials.gov NCT02449447; https://clinicaltrials.gov/study/NCT02449447 and ClinicalTrials.gov NCT02410616; https://clinicaltrials.gov/study/NCT02410616 and ISRCTN Registry ISRCTN12388725; https://www.isrctn.com/ISRCTN12388725 International Registered Report Identifier (IRRID): RR2-10.1186/s13063-016-1511-1

Burden of Insomnia Among Individuals With Major Depressive Disorder: Cross-Sectional Observational Study

2026-09-21T16:30:12-04:00

Background: Insomnia is a common and persistent symptom in major depressive disorder (MDD), associated with poorer outcomes and reduced quality of life (QoL). Despite its prevalence, recent patient-reported data on the burden of insomnia symptoms in MDD remains limited. Objective: This study aimed to assess the burden of insomnia among individuals with MDD experiencing insomnia symptoms (MDDIS) and its impact on patient-perceived disease burden and QoL. Methods: A noninterventional, cross-sectional online study was conducted from October 2022 to February 2023 in adults with self-reported MDD and insomnia symptoms, residing in the United States or 1 of 5 European countries (EU5: France, Germany, Italy, Spain, and the United Kingdom). Participants completed validated questionnaires (Patient Health Questionnaire-9 [PHQ-9] for depression severity and Insomnia Severity Index [ISI] for insomnia severity) and provided data on demographics, clinical history, treatment experience, and perceptions. Descriptive statistics were used to summarize results, and subgroup analyses were conducted based on depression status and severity. Results: Among 1250 participants (United States: 500; EU5: 750), most were cisgender women (United States: 363/500, 72%; EU5: 637/750, 85%), aged ~48 years, and on average 13.4 years in the United States and 11.2 years in EU5 had passed since being diagnosed with MDD. Around 60% (United States: 312/500; EU5: 439/750) reported having moderate to severe insomnia symptoms. Most had used antidepressants (United States: 460/500, 92%; EU5: 646/750, 86%) at least 40% (United States: 198/500; EU5: 343/750) in both regions reported using sleep-related medications (over-the-counter sleep aids, dual-purpose medication, or sleep-specific medication). However, insomnia symptoms persisted, with around half of participants reporting 8 to 15 insomnia nights over 2 weeks. Insomnia symptom severity differed significantly according to depression severity and current depressive episode status. Nearly all participants reported negative consequences for daily functioning, including irritability, cognitive impairment, and reduced productivity, and approximately two-thirds identified sleep disturbances as having a major impact on their daily lives. Satisfaction with current treatments, particularly their effectiveness on sleep, was low, and 65%‐71% (488/750-354/500) of participants expressed a desire for alternative therapies. Conclusions: Insomnia symptoms are highly prevalent and burdensome among patients with MDD, severely affecting daily life and perceived treatment success. Insomnia remains inadequately controlled despite high medication use. These findings emphasize the need for integrated treatment strategies targeting both mood and sleep symptoms. Given its role in depression relapse, suicidality, and treatment resistance, addressing insomnia symptoms in MDD should be a clinical priority.

Factors Affecting the Accuracy of Clinical Coding in the Casemix System in a Teaching Hospital: Cross-Sectional Study

2026-09-17T16:00:17-04:00

Background: Accurate clinical coding is critical in the casemix system to ensure proper resource allocation, health care policy planning, and data reliability. Inaccurate coding can result in significant financial losses to the hospital. To date, the implications of inaccurate coding in casemix implementations in Malaysia have rarely been explored. Objective: This study aimed to evaluate the accuracy of clinical coding and identify factors associated with accurate coding practices in a major teaching hospital in Malaysia. Methods: A cross-sectional study was conducted using 445 inpatient discharge records from Hospital Canselor Tuanku Muhriz from January 2023 to December 2023. Stratified random sampling was applied across 4 departments. Coding accuracy was determined by comparing electronic medical record entries to a gold-standard set by trained coders and specialists. Descriptive and bivariate analyses were performed accordingly. Results: This study found that the overall clinical coding accuracy was 76.4% (340/445). Documentation completeness (<.001) and coding turnaround time (=.02) were significantly associated with coding accuracy. Other variables such as patients’ sex, patient age, department, and coder experience were not significantly associated. Clinical coding accuracy in this setting was suboptimal. Conclusions: Continuous training and regular audits are recommended to improve coding quality and ensure reliable casemix data for policy and funding decisions.

Comparative Analysis of Cardiometabolic Risk Profiles Among Hypertensive and Normotensive Adults: Cross-Sectional Study

2026-09-10T15:30:03-04:00

Background: Hypertension is a significant modifiable risk factor for cardiometabolic syndrome, leading to increased morbidity and premature mortality. Understanding the differences in cardiometabolic risk profiles between hypertensive and normotensive adults is essential for effective prevention strategies. Objective: This study examined cardiometabolic risk profiles among adults in Johannesburg South, Gauteng Province, South Africa. Methods: A cross-sectional study was conducted with 209 adults aged 25 to 65 years who were recruited from 3 Johannesburg townships in Region G. Anthropometric measures (BMI and waist circumference), blood pressure, and biochemical indexes (random glucose, total cholesterol, high-density lipoprotein cholesterol, low-density lipoprotein cholesterol, and triglycerides) were assessed. Statistical analyses were performed using Stata (version 19), with statistical significance set at P<.05. Results: Hypertension prevalence increased significantly with BMI (P<.001) and waist circumference (P=.003). In multivariable analysis, age and elevated glucose levels were independently associated with hypertension, whereas obesity and central adiposity were not significantly associated after adjustment. Conclusions: Hypertension was independently associated with advancing age and elevated glucose levels in this population. Although obesity and central adiposity showed significant associations in unadjusted analyses, they were not independently associated with hypertension after adjustment. These findings highlight the importance of early screening and targeted interventions to address cardiometabolic risk in underserved South African communities.

Enhancing Healthy Longevity: Scoping Review of Practices and Interventions

2026-09-08T16:15:13-04:00

Background: Over the past 2 decades, concerns have arisen about the distinction between health span and lifespan, highlighting that longevity does not necessarily equate to good health, a concept often referred to as “healthy longevity.” While various strategies have been explored to promote healthy aging and achieve healthy longevity, it remains uncertain which practices are most effective. Objective: This scoping review identifies the existing and emerging practices and interventions that promote healthy longevity, identifies the key components of these practices and interventions, and considers how stakeholders contribute to these practices and interventions. Methods: A scoping review of the literature was conducted using Arksey and O’Malley’s 6-stage framework. The Joanna Briggs Institute Population-Concept-Context framework was used to define the eligibility criteria and select studies reporting practices or interventions aimed at achieving a long health span or promoting healthy longevity carried out in the community. Data were manually extracted by 2 independent reviewers to detail the characteristics of these practices and interventions and guide the data charting process and narrative synthesis. Six databases (PubMed, Web of Science, Embase, Scopus, CINAHL, and Google Scholar) were searched for academic papers published between January 2010 and February 2025. Results: A total of 21 studies met the inclusion criteria. Most studies (n=15, 71%) were published after 2020 and were predominantly conducted in high-income settings (n=17, 81%) across North America, Europe, and Asia. Four study types were identified: interventional (n=7, 33%), intervention development (n=4, 19%), association (n=5, 24%), and descriptive (n=5, 24%). Interventional and intervention development studies primarily described multicomponent programs targeting individual and social determinants of health and generally reported beneficial effects on physical, cognitive, and psychosocial outcomes. Association studies linked micro-, meso-, and macro-level factors (eg, nutrition, household expenditure, housing quality, health insurance, and public financing policy) to healthy longevity indicators. Descriptive studies highlighted themes across the micro and meso levels, including finance, physical activity, mental and spiritual health, digital literacy, independent living, safety, social support, and health care support. Conclusions: The identified community-based strategies, practices, and policies that extend health span represent the joint efforts of multiple stakeholders and disciplines. The implementation of these practices and policies is worthy of being supported. More studies in diverse socioeconomic contexts are needed.