It reports no new data and conducts no new analyses. The original study examined a population for which suicide is described as a leading cause of death, placing the findings within a broader concern about the mental health of university students. Its framework combines family dynamics with cognitive vulnerability: parental psychological control represents the family-related component, socially prescribed perfectionism represents the cognitive component and depression is positioned as a possible intervening state.

The researchers reported significant indirect associations connecting parental psychological control to suicidal ideation through socially prescribed perfectionism and depression. This observational pattern is potentially informative, but it does not show that control produces perfectionistic beliefs, that those beliefs cause depression or that any of these factors cause suicidal thoughts. That distinction is central to the commentary’s first concern.

In a cross-sectional design, participants report conditions at the same time, so the study cannot establish which factor preceded another. Terms such as “causes,” “leads to” and similar formulations therefore imply temporal precedence and direction that the data did not demonstrate. Alternative sequences remain possible, including a pathway running from depressive symptoms to perfectionistic thinking.

The commentary illustrates this reverse-direction problem with two lines of evidence. A cognitive vulnerability model of depression also proposes that depressive cognitions can activate maladaptive perfectionistic thought patterns. Neither cited line proves that the same sequence operates in the 852-student sample, but both make it inappropriate to treat the proposed order as settled.

A cross-sectional mediation model can organize the observed covariation and test whether indirect paths are statistically supported; it cannot, by itself, turn that organization into a temporal or causal mechanism. Measurement raises a second challenge. The original study used the Positive and Negative Suicidal Ideation Inventory, known by the acronym PANSI, which contains two distinct subscales.

Negative Ideation measures active suicidal cognitions, whereas Positive Ideation captures reasons for living and protective cognitions. By reverse-scoring the positive items and combining both sets into one composite, the analysis treats protection and danger as opposite ends of a single continuum. The commentary notes that previous research has shown these subscales can have different relationships with risk and protective factors, including distinct associations among perfectionistic people.

That methodological choice may conceal an important result. If parental psychological control or socially prescribed perfectionism is associated more strongly with increased negative ideation, weaker protective positive ideation, or both, a composite score would not reveal the pattern. The same concern applies to perfectionism: mechanisms involving risk and protection may not operate at identical levels.

The commentary therefore asks for analyses that keep the two subscales separate or, at minimum, for clearer justification of the decision to combine them. Such analyses would not prove causation, but they could clarify whether the statistical relationship is concentrated in thoughts of death, reduced reasons for living, or a combination of the two. The commentary also finds that the original article devoted less discussion to one prominent part of the model than to the more elaborate mediation chain.

The direct association between parental psychological control and suicidal ideation reportedly accounted for 58.8% of the total relationship, whereas the partial serial mediation through socially prescribed perfectionism and depression accounted for 13.6%. The indirect path is scientifically interesting, especially because it links family influence, perfectionistic cognition and depressive symptoms within one model. Still, the larger direct share means that most of the observed association remained outside the proposed indirect sequence.

The commentary argues that this unaccounted portion deserved more attention in the discussion rather than being overshadowed by the chain mediation. A further reporting issue arises because the standardized coefficient for the indirect path through socially prescribed perfectionism was identical to that of the full serial chain, both given as β = 0.035 and 13.6% of the association. This creates uncertainty about how much the addition of depression contributes beyond the simpler pathway.

The commentary recommends comparing the competing models with a fit measure such as the Akaike Information Criterion, or AIC, which can help readers assess whether the more complex chain provides enough additional explanatory value to justify its greater complexity. Equal coefficients do not by themselves show that depression is irrelevant, but they make direct model comparison important for interpreting the incremental contribution of the serial pathway. The original data collection included several potential moderators, including gender, academic year, family economic condition and parental education level.

The commentary proposes examining whether these characteristics alter the relationships among psychological control, perfectionism, depression and suicidal ideation. Gender receives particular attention because prior work cited in the commentary found that it moderated depression through distinct affective and cognitive routes, with parental psychological control and suicidal ideation representing one route and socially prescribed perfectionism another. Moderation analyses could therefore test whether the same pattern applies across groups or differs meaningfully among students.

The commentary presents this as a way to enrich the findings, not as evidence that any subgroup has already been shown to experience a different pathway. Overall, the original study is described as a genuine contribution because it examines a consequential mental-health outcome in a large student sample and brings family relationships and perfectionistic cognition into a single, theoretically coherent framework. The commentary’s recommended changes—more consistently associational language, separate analysis of positive and negative suicidal ideation, fuller treatment of the large direct association and stronger comparison of nested models—would narrow the gap between what the data show and what the conclusions claim.

The results are best read as evidence of interconnected variables in one cross-sectional sample, not as proof of an inevitable progression from parental control to perfectionism, depression and suicidal thoughts. The study therefore offers a useful map of statistical relationships while leaving the direction, mechanisms and boundary conditions of those relationships unresolved.

Subject of Research: Cross-sectional associations among parental psychological control, perfectionism, depression and suicidal ideation in Chinese university students

Article Title: Considerations regarding article on parental psychological control, socially prescribed perfectionism, depression, and suicidal ideation among university students

Article References: Williamson, A., Debruille, J. B., & Dunkley, D. M. (2026). Considerations regarding article on parental psychological control, socially prescribed perfectionism, depression, and suicidal ideation among university students. BMC Psychology, 14(1), Article 1336. https://doi.org/10.1186/s40359-026-05389-2

Image Credits: AI Generated

DOI: 10.1186/s40359-026-05389-2

Keywords: parental psychological control, socially prescribed perfectionism, suicidal ideation, depression, university students, cross-sectional study, mediation analysis, PANSI, mental health, causal inference, Considerations, regarding

The survey was conducted in March 2025 using convenience sampling and a self-designed questionnaire. Investigators used latent profile analysis to identify distinct profiles among participating nurses. Univariate analysis and binary logistic regression were then used to examine factors associated with membership in the two profiles.

The median scores were 35 points for knowledge, with an interquartile range of 29 to 39; 24 points for attitudes, with an interquartile range of 22 to 28; and 11 points for practices, with an interquartile range of 8 to 14. Regression analysis found that the number of years worked, experience caring for patients with severe pneumonia who developed delirium, and previous training related to cognitive impairment were associated with profile membership, with all reported p-values below 0.01. These statistical associations do not establish that the factors caused the profiles or demonstrate changes in knowledge, attitudes or practices.

The authors concluded that the presence of a lower-profile group representing more than one-third of respondents indicates a need for targeted professional training and standardized cognitive assessment and management procedures. The findings are based on a cross-sectional, convenience-sampled questionnaire study, so they cannot establish temporal relationships or causal effects and may not represent all ICU nurses in China or other settings. In addition, the supplied source is an abstract of an early open-access article marked for later replacement by the final version, limiting assessment of the full methods and results.

Subject of Research: Latent profiles of ICU nurses’ knowledge, attitudes and practices regarding post-delirium cognitive impairment in severe pneumonia

Article Title: ICU nurses’ knowledge, attitudes, and practices regarding post-delirium cognitive impairment in patients with severe pneumonia: a latent profile analysis

Article References: Luo, Y., Deng, X., Liu, C., Zhang, W., & Mi, J. (2026). ICU nurses’ knowledge, attitudes, and practices regarding post-delirium cognitive impairment in patients with severe pneumonia: a latent profile analysis. BMC Nursing. https://doi.org/10.1186/s12912-026-05315-2

Image Credits: AI Generated

DOI: 10.1186/s12912-026-05315-2

Keywords: ICU nurses, severe pneumonia, post-delirium cognitive impairment, knowledge, attitudes, practices, latent profile analysis, cross-sectional survey, China, professional training, nurses, regarding

A recent cross-sectional study conducted in Osun State, Nigeria, provides critical insights into the knowledge, attitudes, and practices regarding antimicrobial use among local poultry farmers. Published in the journal Discover Animals, the research was led by Sunday Charles Adeyemo and colleagues from Osun State University and other institutions. The study aimed to assess the awareness, knowledge, attitudes, and practices related to antimicrobial resistance among actively practicing poultry farmers in the state. By identifying specific gaps and barriers to responsible antibiotic use, the findings offer actionable evidence for Nigeria’s National Action Plan on Antimicrobial Resistance at the sub-national level, highlighting the complex interplay between education, access to veterinary services, and farming practices.

The study employed a rigorous multistage sampling procedure to select 289 poultry farmers across the three agricultural zones of Osun State: Osogbo, Ife/Ilesha, and Iwo. Data were collected between July and August 2025 using a pre-tested, structured, interviewer-administered questionnaire. The sample size was calculated using the Leslie Fisher formula, adjusted for an 11.5% non-response rate, ensuring statistical robustness. The questionnaire covered socio-demographics, awareness and knowledge of antimicrobial resistance, antibiotic use practices, attitudes toward stewardship, and barriers to responsible use. Reliability was established through test-retest methodology, yielding a Pearson correlation coefficient of 0.84, while internal consistency was assessed using Cronbach’s alpha, with values ranging from 0.74 to 0.82 for different sections of the survey.

The results revealed a high level of awareness among the surveyed farmers, with 89.6% reporting that they had heard of antimicrobial resistance. Notably, 92.3% of those aware cited veterinary doctors as their primary source of information, underscoring the critical role of veterinary professionals as educators and gatekeepers in antimicrobial stewardship. Overall, 77.2% of respondents demonstrated good knowledge of antimicrobial resistance, defined as scoring at least 70% on a 12-item knowledge scale. However, the most commonly misunderstood concepts were antimicrobial stewardship and the role of the environment in resistance transmission, indicating specific areas where educational efforts may need to be targeted to improve understanding among the farming community.

Despite this high level of awareness and knowledge, significant discrepancies emerged in actual farming practices. Among the 89.6% of farmers who used antimicrobials within the last 12 months, 64.5% relied on personal experience rather than veterinary advice to select antibiotics. Only 32.0% reported following veterinary prescriptions, while others used antimicrobials for growth promotion or disease prevention without professional guidance. This reliance on informal knowledge systems is a persistent challenge in low- and middle-income countries, where limited access to affordable veterinary services often leads farmers to prioritize experiential learning over professional consultation, thereby accelerating the selection of resistant bacterial strains.

The study also examined the attitudes of farmers toward antimicrobial stewardship, finding that 84.4% held a positive attitude, with 57.8% considering the reduction of antimicrobial use very important. Approximately 71.6% of farmers implemented biosecurity measures, such as restricted farm access, foot baths, and regular disinfection of coops, which are essential for reducing disease incidence and the subsequent need for antibiotics. However, persistent challenges such as bird mortality, the cost of drugs, and the prevalence of fake medicines remained significant barriers to responsible antibiotic use. These structural and economic constraints highlight the need for a multi-pronged approach that addresses not only behavioral factors but also the systemic issues affecting poultry production in the region.

Statistical analysis revealed strong associations between knowledge, attitude, and practice. Chi-square tests indicated significant relationships between knowledge and practice, as well as between attitude and practice, with Cramer’s V values of 0.59 and 0.63, respectively. Multivariable logistic regression identified good knowledge, positive attitude, and prior antimicrobial resistance training as independent predictors of good practice. Specifically, farmers with good knowledge were 4.21 times more likely to demonstrate good practice, while those with a positive attitude were 5.63 times more likely. Prior training was also a significant predictor, with an adjusted odds ratio of 2.45, suggesting that targeted educational programs can effectively promote responsible antimicrobial use among poultry farmers.

The findings underscore the critical importance of targeted educational interventions and improved veterinary oversight in mitigating antimicrobial resistance risks in poultry farming. The study highlights a clear policy opportunity, as all farmers who had never received antimicrobial resistance training expressed interest in participating in such programs. This universal interest suggests that agricultural extension programs and veterinary-led training workshops could be rapidly deployed to reach a receptive audience. Furthermore, the results emphasize the need for stricter regulatory enforcement, including the prohibition of over-the-counter antibiotic sales and the requirement of veterinary prescriptions for antimicrobials, to ensure that farmers have access to professional guidance and are held accountable for responsible use.

As Nigeria continues to grapple with the challenges of antimicrobial resistance, this study provides valuable insights into the behavioral and socio-cultural dimensions of antibiotic use in the poultry sector. The data suggest that while awareness is high, translating this knowledge into consistent, responsible practice requires addressing the underlying structural barriers and enhancing access to veterinary services. By integrating poultry farmers into national surveillance systems and promoting alternatives to antimicrobials for disease prevention and growth promotion, Nigeria can better protect the health of its animals and people. The study’s findings contribute to the broader One Health framework, which recognizes the interconnectedness of human, animal, and environmental health, and offers a roadmap for sustainable poultry production in the face of growing antimicrobial resistance threats.

Subject of Research: Knowledge, attitudes, and practices regarding antimicrobial use, resistance and stewardship among poultry farmers in Osun state, Nigeria

Article Title: Knowledge, attitudes, and practices regarding antimicrobial use, resistance and stewardship among poultry farmers in Osun state, Nigeria

Article References: Adeyemo, S. C., Olarewaju, S. O., Faramade, I. O., Awodele, K., Olabode, E. D., Towoju, O. P., Adeoye, O. E., Are-Daniel, O., Ajayi, A. R., & Opeyemi, O. (2026). Knowledge, attitudes, and practices regarding antimicrobial use, resistance and stewardship among poultry farmers in Osun state, Nigeria. Discover Animals, 3(1), 104. https://doi.org/10.1007/s44338-026-00260-5

Image Credits: AI Generated

DOI: 10.1007/s44338-026-00260-5

Keywords: Knowledge, attitudes, practices, regarding, antimicrobial, resistance, stewardship, poultry, farmers, Osun, state, Nigeria

The cross-sectional study, led by Fang Pei of the Civil Aviation Flight University of China and colleagues, enrolled 4,133 students from 10 universities in Sichuan Province between October and December 2020. All of the participating institutions were located in Sichuan, which carries the highest burden of HIV infection of any province in China. According to the Chinese Center for Disease Control and Prevention, the number of newly diagnosed college students nationwide has been growing at an annual rate of 30 to 50 percent over the past several years, a trajectory that transforms the dense, socially dynamic environment of a university campus into a critical setting for infectious disease preparedness.

Participants, aged 16 to 28 with a mean age of 19.45 years, completed a standardized self-administered questionnaire covering demographics, HIV knowledge, HIV stigma, self-esteem, sexual behavior, and testing history. The survey achieved a 99 percent response rate. HIV knowledge was assessed with eight items developed by the National Center for AIDS/STD Control and Prevention of the China CDC, with students answering more than six items correctly classified as having a high knowledge level. Stigma was measured with the Chinese version of Zelaya’s HIV-related stigma scale, which probes four distinct dimensions: fear of casual transmission, moral judgment, personal stigma, and perceived community stigma. Self-esteem was evaluated with the Rosenberg self-esteem scale.

The headline knowledge figure of 74.2 percent conceals significant gaps in understanding. The highest awareness rate, 92.4 percent, was for the item stating that after high-risk behavior one should actively seek AIDS counseling and testing. The lowest, 62.8 percent, concerned the recognition that the main mode of HIV transmission among China’s students is male homosexual sex. Only 69.3 percent knew that HIV is a serious incurable infectious disease, and 74.3 percent understood that an HIV-infected person cannot be identified from appearance. Notably, 92.6 percent of participants had never been tested for HIV, and only 15.2 percent were aware of the HIV/AIDS epidemic in their own region, indicating that even free testing services available as part of China’s prevention campaign are reaching only a small fraction of the student population.

Stigma proved even more widespread than knowledge deficits. Fear of casual transmission was reported by 79.8 percent of respondents, moral judgment by 71.1 percent, personal stigma by 72.2 percent, and perceived community stigma by 71.8 percent. In practical terms, this means that most students surveyed either feared that HIV could be spread through everyday contact, held negative moral views about people living with HIV, personally endorsed discriminatory attitudes, or believed their community would stigmatize those with the virus. Previous research has consistently linked HIV-related stigma to decreased testing uptake and reduced efficacy of preventive behaviors such as condom use, making these attitudes a direct barrier to the very interventions that campus prevention strategies depend upon.

To untangle the factors driving both knowledge and stigma, the researchers applied multivariate logistic regression, calculating adjusted odds ratios with 95 percent confidence intervals. Six variables emerged as significantly associated with HIV knowledge: gender, ethnicity, grade, sexual orientation, awareness of the regional HIV/AIDS epidemic, and self-esteem. Female students had 0.85 times the odds of high knowledge compared to males, while students of non-Han ethnicity had 0.71 times the odds. Non-freshmen showed 1.37 times the odds of high knowledge relative to freshmen, and students aware of the regional epidemic had 1.76 times the odds. Those with high self-esteem showed 1.41 times the odds of robust HIV knowledge, a finding that underscores the psychological dimension of health literacy.

When the analysis turned to stigma, the most striking result was the consistency of the knowledge effect. Students with high HIV knowledge had significantly lower stigma across all four dimensions, with adjusted odds ratios of 0.50 for fear of casual transmission, 0.61 for moral judgment, 0.37 for personal stigma, and 0.43 for perceived community stigma, all statistically significant at the p < 0.001 level. This uniform association suggests that closing knowledge gaps could yield broad reductions in discriminatory attitudes, though the researchers caution that knowledge alone may not ultimately change risky behavior or prevention strategy utilization.

Beyond knowledge, seven variables played differentiated roles across the stigma dimensions. Female students showed less discriminatory attitudes than males in three dimensions, with adjusted odds ratios of 0.58 for moral judgment, 0.77 for personal stigma, and 0.65 for perceived community stigma, a pattern the researchers attribute partly to gender roles and increased compassion. Students of non-Han ethnicity expressed more fear of casual transmission, more negative judgment, and more personal stigma than Han students. Non-freshmen consistently showed higher stigma across fear, personal, and community dimensions than freshmen, possibly because older undergraduates are more likely to engage in unsafe sex despite their greater knowledge and may express stigma as a way of reducing discomfort associated with their own behavior. Non-heterosexual students showed less moral judgment, which the researchers suggest may reflect intersectional connections with HIV infection in social identification.

Self-esteem emerged as a powerful protective factor. Students with high self-esteem had lower stigma in three dimensions, with adjusted odds ratios of 0.81 for fear of casual transmission, 0.79 for personal stigma, and 0.62 for perceived community stigma. Being an only child also reduced personal stigma, with an adjusted odds ratio of 0.82, a surprising finding the researchers explain by noting that only children typically have higher self-ratings, which may result in more accurate perception of personal risk. Awareness of the regional HIV/AIDS epidemic reduced fear of casual transmission and perceived community stigma, consistent with the knowledge-attitude-belief-practice model, which holds that increased knowledge and self-esteem can reduce misunderstandings about transmission and ultimately diminish stigma.

The researchers conclude that college students in southwest China have a low level of HIV knowledge and a high degree of HIV stigma, characteristics that directly compromise institutional capacity for effective infectious disease emergency management. They argue that addressing HIV on campuses must incorporate deliberate efforts to reduce stigma, and that the four dimensions of stigma, being influenced by different factors, should be addressed independently when developing new interventions. For emergency preparedness, the study underscores the necessity of integrating stigma-reduction strategies into institutional plans, since stigma acts as a barrier to risk communication, intervention uptake, and response efficacy during public health emergencies. The researchers call for multilayered interventions at the individual, interpersonal, community, institutional, and structural levels, along with targeted learning and practice opportunities to improve student self-esteem, as personal self-esteem heavily influenced both HIV knowledge and stigma. Further studies, they note, are required to identify effective ways to raise knowledge levels and decrease stigma among college students if the global goal of ending the AIDS epidemic by 2030 is to be achieved.

Subject of Research: Fundamental data regarding the emergency management of infectious diseases in higher education institutions: HIV knowledge and stigma among college students in Southwest China

Article Title: Fundamental data regarding the emergency management of infectious diseases in higher education institutions: HIV knowledge and stigma among college students in Southwest China

Article References: Pei, F., Li, X., Yao, H., & Pei, R. (2026). Fundamental data regarding the emergency management of infectious diseases in higher education institutions: HIV knowledge and stigma among college students in Southwest China. Frontiers in Public Health, 14, Article 1970246. https://doi.org/10.3389/fpubh.2026.1970246

Image Credits: AI Generated

DOI: 10.3389/fpubh.2026.1970246

Keywords: Fundamental, data, regarding, emergency, management, infectious, diseases, higher, education, institutions, knowledge, stigma

The study, conducted from June to November 2025, used a structured online questionnaire distributed through pharmacy-related social media groups and professional pages across Kosova. Participants included pharmacists and pharmacy technicians directly involved in dispensing medicines and counseling patients. The 29-item instrument covered demographic and professional background, awareness of opioid abuse and misuse, attitudes toward counseling and harm reduction, reported practices, and self-reported confidence related to naloxone administration. Most participants were female (75.8 percent), aged 19 to 30 (57.7 percent), and held a Master of Pharmacy degree (65.4 percent). More than half reported one to four years of work experience, and most worked full time in urban pharmacies.

The results paint a picture of a workforce that is well informed on paper. A striking 93.5 percent of respondents reported understanding the difference between opioid abuse and opioid misuse, terms that carry distinct clinical meanings: misuse refers to using prescription opioids in a manner other than prescribed, while abuse refers more broadly to harmful or non-medical opioid use. Familiarity with naloxone and its mechanism of action was reported by 81.5 percent of participants. Internal consistency of the awareness items was good, with a Cronbach’s alpha of 0.81, suggesting the questions reliably captured a coherent construct of self-reported knowledge.

Attitudes toward professional involvement were similarly encouraging. Three quarters of respondents (75.8 percent) agreed that pharmacies are appropriate settings for counseling individuals suspected of opioid abuse, and 75.1 percent said they were willing to provide such counseling. Support for dispensing opioids only with a valid medical prescription was nearly universal at 93.5 percent, and 94.6 percent agreed that pharmacy professionals should not sell medications to individuals who appear to be abusing them. Almost all respondents (95.0 percent) agreed that pharmacy staff should be trained to recognize individuals with substance misuse, and 98.5 percent said staff should be informed about medications with abuse potential. The attitude scale showed acceptable internal consistency with a Cronbach’s alpha of 0.76.

Yet beneath these positive surface indicators, the survey exposed significant vulnerabilities. Only 56.2 percent of participants reported feeling either confident enough or very confident in administering naloxone in their pharmacy setting, while 43.8 percent reported not feeling confident at all. This is a substantial proportion of a workforce that, in many countries, is increasingly expected to serve as a frontline response to opioid overdose. More than half of respondents (54.2 percent) also expressed concern that administering naloxone would require more time than they could provide in routine pharmacy practice, pointing to workflow pressures as an additional barrier beyond knowledge alone.

Work experience emerged as a meaningful variable across multiple measures. Chi-square tests revealed statistically significant associations between years of practice and several responses, including views on prescription-only opioid dispensing (p = 0.013), training in recognizing substance misuse (p = 0.040), naloxone-related education (p = 0.001), and time constraints around naloxone administration (p = 0.027). Most notably, self-reported confidence in administering naloxone was significantly associated with work experience (p = 0.017), and familiarity with naloxone showed an even stronger association (p = 0.001). These findings align with previous international research suggesting that more experienced pharmacists often report greater comfort when addressing opioid-related situations and engaging in patient counseling.

The regulatory context in Kosova adds a layer of complexity that the authors emphasize. Although national legislation governs medicinal products and retail pharmacy services, the current framework does not explicitly provide community pharmacists or pharmacy technicians with the authority to administer naloxone. This means that participants’ responses regarding confidence in naloxone administration should be understood as perceptions of a potential role rather than reflections of established practice. The authors note that this regulatory uncertainty is particularly relevant when assessing pharmacy professionals’ willingness and confidence to participate in opioid overdose management, and that clearer professional and regulatory guidance may be needed to address the gap.

Not all findings were uniformly positive. While 78.1 percent of respondents reported suggesting safer alternatives when misuse was suspected, only 31.9 percent reported contacting nearby pharmacies to inform them of an individual suspected of opioid misuse. This pattern, in which pharmacists feel comfortable with individual counseling but hesitate when broader professional collaboration is required, has been observed in other studies and may reflect barriers to inter-professional communication that were not directly examined in the present research. Additionally, 38.5 percent of participants agreed that the sale of controlled medications without a prescription represents an important source of pharmacy income, a finding the authors say should be interpreted cautiously as it reflects perceptions rather than dispensing practices.

The study has several limitations that shape how the results should be read. The cross-sectional design captures attitudes at a single point in time and cannot establish causality. Responses were self-reported rather than directly observed, meaning actual behavior and practical competence may differ from what participants described. Social desirability bias may have influenced answers to questions about professional responsibility and ethical practice. The voluntary online recruitment through social media may have attracted pharmacy professionals with a stronger interest in public health, potentially skewing responses toward more positive attitudes. The questionnaire was developed specifically for this study without formal pilot testing, and confidence in naloxone administration was assessed using a single item. Pharmacists and pharmacy technicians were also analyzed together without separate analysis by professional qualification.

Despite these limitations, the findings carry practical weight for a region where empirical evidence on pharmacy involvement in opioid harm reduction has been scarce. The authors conclude that strengthening the role of community pharmacy professionals in opioid abuse prevention will require more than awareness alone. Practice-oriented training, clear professional guidance, and supportive regulatory frameworks are needed to translate positive attitudes and self-reported knowledge into genuine confidence at the counter. International evidence suggests that successful pharmacist involvement in opioid harm reduction is most likely when training, regulatory clarity, and institutional support are aligned, and in settings where access to specialized addiction services is limited, community pharmacies may represent one of the most promising settings for early identification of opioid-related concerns and overdose prevention.

Subject of Research: Community pharmacists' awareness, attitudes, and confidence regarding opioid abuse and naloxone use in Kosova

Article Title: Community pharmacists’ awareness, attitudes, and confidence regarding opioid abuse and naloxone use in Kosova: A cross-sectional survey

Article References: Ibraimi, Z., Haxhiu, A., Shabani, D., Qeriqi, V., Bresa, A., & Haliti, D. (2026). Community pharmacists’ awareness, attitudes, and confidence regarding opioid abuse and naloxone use in Kosova: A cross-sectional survey. Pharmacia, 73, Article e204449. https://doi.org/10.3897/pharmacia.73.e204449

Image Credits: AI Generated

DOI: 10.3897/pharmacia.73.e204449

Keywords: opioid abuse, naloxone, community pharmacists, Kosova, harm reduction, cross-sectional survey, Community, pharmacists, awareness, attitudes, confidence, regarding

The distinction between recognizing that neonates feel pain and acting on that recognition through systematic assessment is a recurring theme in implementation research on pediatric pain. Knowledge alone has rarely proven sufficient to change clinical behavior; guidelines published in high-income settings have repeatedly documented similar gaps between awareness and practice, even where resources are comparatively abundant. What makes the Kinshasa findings notable is the magnitude of the discrepancy: recognition of neonatal pain was nearly universal among respondents, yet the reported use of standardized assessment tools was an order of magnitude lower. This pattern suggests that the barrier is not denial of neonatal pain capacity, which was a historical problem in twentieth-century practice, but rather the absence of practical tools, training, and institutional routines that translate belief into measurable action.

The statistical approach taken by the researchers merits some explanation for readers less familiar with survey methodology. Because participants were drawn from only ten hospitals, individuals within the same hospital share institutional characteristics such as staffing levels, available protocols, and local leadership priorities. Ignoring this clustering would artificially inflate the precision of the estimates, so the investigators used cluster-robust standard errors at the hospital level in their multivariable logistic regression. This technique adjusts the confidence intervals to account for the correlation of responses within each facility, producing more honest uncertainty estimates. The adjusted odds ratio of 4.90 for the association between higher knowledge and reported standardized tool use should therefore be interpreted with this design feature in mind, as should the sensitivity analysis, which demonstrated that the strength of the association depended partly on whether scale recognition was counted as a knowledge item.

That sensitivity analysis is methodologically informative in its own right. When the investigators removed the item asking whether participants could recognize a validated pain scale from the composite knowledge score, the association between knowledge and tool use weakened considerably, dropping from an adjusted odds ratio of 4.90 to 1.93. This attenuation suggests that a substantial portion of the observed relationship was driven by familiarity with the existence of such instruments rather than by deeper conceptual knowledge about neonatal pain physiology or assessment principles. In practical terms, this could mean that simply making clinicians aware that validated neonatal pain scales exist, and showing them what these tools look like, might move a meaningful fraction of the workforce toward adoption. It also underscores a caution for future research: composite knowledge scores are sensitive to which items are included, and findings built on such scores should be stress-tested in the way these investigators did.

The context of postoperative care specifically deserves emphasis. Neonates undergoing surgery represent a population in which pain is predictable, sustained, and amenable to planned management, in contrast to the episodic pain of routine procedures such as heel lances or venipuncture. International guidance on neonatal surgical care generally assumes that scheduled assessment of pain using a validated instrument is a basic component of postoperative nursing care, alongside monitoring of vital signs and wound inspection. The finding that only about one in seven respondents reported assessing postoperative pain at regular intervals indicates that this assumption cannot be made in the settings studied. Regular, scheduled assessment is the mechanism by which analgesic dosing is titrated and by which complications such as inadequate analgesia or excessive sedation are detected; without it, even medications that are physically available in the pharmacy may be underused or applied without a rational basis for dose adjustment.

The ten hospitals included in the survey spanned both tertiary and secondary levels of care, which strengthens the representativeness of the findings for the urban Kinshasa setting. Because the investigators approached the exhaustive set of hospitals providing pediatric surgical activity in the city during the study period, the sample is not subject to the selection biases that arise when only flagship institutions participate. At the same time, the findings describe one major African metropolis and should not be generalized automatically to rural facilities, to other countries, or to non-surgical neonatal units such as intensive care nurseries without surgical services. Neonatal care in district hospitals, mission facilities, and community health centers may face different constraints, including even scarcer access to analgesic formulations suitable for newborns and fewer staff per bed.

The high response rate achieved in the survey, with 536 of 580 approached professionals returning the questionnaire and only six excluded for excessive missing data, reduces concern about nonresponse bias, which is often the Achilles heel of cross-sectional surveys in busy clinical environments. However, the study measured self-reported practices rather than directly observed behavior, and a substantial literature has documented that clinicians tend to overestimate their adherence to recommended practices when asked retrospectively. Social desirability may also have influenced responses, particularly on questions touching on the adequacy of one’s own professional practice. The true prevalence of standardized tool use could therefore be even lower than the 10.0% figure reported, or the relationship between knowledge and practice could differ from what self-reports suggest. Studies combining direct observation, chart review, or audit of nursing records with questionnaire data would help triangulate the true state of practice.

The neurodevelopmental rationale for aggressive neonatal pain management has accumulated steadily over recent decades. Animal and human studies have shown that early nociceptive experience can shape the developing somatosensory system, with implications for subsequent pain sensitivity, stress regulation, and possibly long-term neurobehavioral outcomes. Repeated untreated painful exposure in preterm infants has been associated in some cohorts with altered brain development on imaging and with differences in developmental scores during follow-up. While the precise clinical significance of these associations continues to be investigated, the direction of the evidence supports the principle that preventing and treating neonatal pain is not merely a matter of immediate comfort but may influence trajectories that extend well beyond the hospital stay. This framing gives the gaps documented in Kinshasa a significance that reaches beyond the perioperative period itself.

Non-pharmacological comfort measures, which the source study situates within a broader assessment framework, occupy an interesting position in resource-limited settings. Interventions such as breastfeeding, skin-to-skin contact, swaddling, facilitated tucking, and oral glucose administration require little in the way of material resources and have demonstrated benefit primarily for procedural pain in neonates. Their accessibility makes them attractive options where opioid supplies are unreliable or where trained pediatric anesthesiologists are scarce. However, the evidence base for these measures is strongest for brief procedural pain, and they are not substitutes for systemic analgesia after major surgery. The study’s careful framing of these approaches as complementary rather than equivalent to postoperative analgesia reflects an important distinction that is sometimes blurred in discussions of pain management in low-resource contexts, where non-drug measures are occasionally presented as a full alternative when pharmacological options are constrained.

The choice of the DAN scale in earlier Congolese work on procedural neonatal pain illustrates that validated instruments have already been deployed in the country’s clinical research environment, which is a relevant precedent for implementation efforts. French-language instruments are particularly relevant in the DRC, where francophone medical education means that tools and training materials developed in French-speaking research communities can be adapted more readily than those available only in English. The EDIN scale, the NFNS, DAN, and other instruments each have different intended contexts, and the recent systematic evidence cited by the investigators emphasizes that no single scale suits every population and pain type. Selecting an instrument for widespread implementation in Kinshasa would therefore involve matching the tool to the predominant clinical scenarios, the literacy and staffing realities of the units, and the feasibility of routine scoring during busy postoperative care.

From a health systems perspective, the association between knowledge and reported tool use points toward educational interventions as one plausible lever, but the near-total absence of prior training also implies that such interventions would be starting from a very low baseline. Continuing education formats that have shown promise in other settings include structured in-service workshops, integration of pain scales into nursing documentation forms so that assessment becomes part of the routine charting workflow, and audit-and-feedback cycles in which units review their own assessment rates. Embedding a pain score in the vital signs chart is a particularly low-cost structural intervention, because it converts assessment from an optional cognitive task into a required documentation step. Whether such approaches are effective in the specific conditions of Congolese hospitals would need local evaluation, but the underlying logic of making the desired behavior the path of least resistance is well established in implementation science.

The cross-sectional design of the study, which the investigators themselves flag as precluding causal interpretation, leaves open the direction of the relationship between knowledge and tool use. It is plausible that clinicians who use standardized scales become more knowledgeable through practice, rather than the reverse, or that a third factor such as working in a hospital with an engaged leadership or access to continuing education drives both. Longitudinal designs, or before-and-after evaluations of training programs, would be needed to establish whether improving knowledge leads to increased tool adoption. Nevertheless, the consistency of the association after adjustment for professional characteristics, and its persistence in attenuated form through the sensitivity analysis, makes knowledge a credible target for intervention even in the absence of proof of causation.

Finally, the study contributes to a slowly growing literature on pediatric pain in sub-Saharan Africa, a field the investigators describe as limited and heterogeneous. Multicenter surveys of this kind provide the baseline data against which future interventions can be measured, and the exhaustive sampling of eligible hospitals in Kinshasa offers a model that could be replicated in other cities of the region. If subsequent efforts build on this foundation, whether through training initiatives, documentation reforms, or the local validation and adoption of specific neonatal pain scales, the present survey will serve as the reference point for judging whether practice has moved. The gap it documents between near-universal recognition of neonatal pain and minimal use of standardized assessment is a measurable starting line for that work.

Subject of Research: Knowledge and practices regarding postoperative neonatal pain assessment among healthcare professionals in Kinshasa: a multicenter cross-sectional survey

Article Title: Knowledge and practices regarding postoperative neonatal pain assessment among healthcare professionals in Kinshasa: a multicenter cross-sectional survey

Article References: Landu, E., Nsiala, J., Makembi Bunkete, A., Mbombo, W., Mutombo, S., Mukuna, P., Lemba, C., Nantulu, C., Kabuni, P., Mosolo, A., Ilunga, J.-P., Kabwe, B., Bulabula, M., & Barhayiga, B. (2026). Knowledge and practices regarding postoperative neonatal pain assessment among healthcare professionals in Kinshasa: a multicenter cross-sectional survey. Frontiers in Pain Research, 7, Article 1968968. https://doi.org/10.3389/fpain.2026.1968968

Image Credits: AI Generated

DOI: 10.3389/fpain.2026.1968968

Keywords: Knowledge, practices, regarding, postoperative, neonatal, pain, assessment, healthcare, professionals, Kinshasa, multicenter, cross-sectional

The proposal landed at a moment when the field is hungry for exactly this kind of synthesis. For decades, decompression safety has rested on statistical models built from population averages, dive tables, and ascent profiles that treat every diver as roughly equivalent. Yet anyone who has spent time around operational diving knows the reality is messier. Some individuals develop venous gas emboli, bubbles detectable in the bloodstream, after dives that leave others untouched, and the same person can respond differently on different days. If part of that variability is written into the genome, the argument goes, then genomic screening could one day identify who needs more conservative profiles before they ever enter the water. The review’s authors deserve credit, as a group of researchers led by Emmanuel Dugrenot of University Brest and the Lampe Joint Department of Biomedical Engineering at the University of North Carolina and North Carolina State University acknowledged, for tackling such a timely and important topic.

But the acknowledgment came with a warning. In a letter to the editor published in the same journal on 16 October 2026, Dugrenot and colleagues, including Emmanuel Gouin of Divers Alert Network, Clément Lévêque, Jérémy Orsat, and Frauke Tillmans, reported that they had identified several conceptual misattributions, literature inaccuracies, and improper terminology in the review. The letter’s authors suggested these problems may stem from automated text-generation or reference-management tools used without supplementary expert review. The observation matters far beyond one manuscript. Comprehensive review papers serve as foundational benchmarks for the hyperbaric medicine community, and if the primary literature they synthesize is misrepresented, the errors propagate into every downstream citation, guideline, and training document that relies on them.

The technical details of the dispute illustrate how easily misattribution can distort the scientific record. The review had cited a 2020 study by Lautridou and colleagues, published in the Journal of Applied Physiology, which examined physiological characteristics associated with increased resistance to decompression sickness in male and female rats. According to the letter, the review stated that females exhibited greater decompression sickness resistance associated with estrogen-mediated differences in anti-inflammatory cytokine profiles. The cited publication, however, reported no statistically significant difference in decompression sickness incidence between sexes, with a p-value of 0.29, and focused instead on specific single nucleotide polymorphisms, hematological parameters, vascular reactivity, and mitochondrial functions. The rat study did not measure estrogen levels or anti-inflammatory cytokine profiles at all. In other words, the review attributed a finding and a mechanism to a study that explicitly reported neither.

The misattributions extended to the study’s methods. The review credited Lautridou and colleagues with physiological assessments involving lung function and cardiac structure measurements, tests that were not performed in that particular rat study. Such systemic errors, the letter’s authors wrote, illustrate the significant risk of relying on automated tools for literature reviews, which could inadvertently introduce bibliographical misattributions. Their conclusion was blunt: line-by-line human expert verification remains indispensable to ensure the accuracy and integrity of all cited primary sources. For a field in which review articles may influence clinical practice and operational safety guidelines, the stakes of getting the underlying evidence right could hardly be higher.

A second dispute concerns venous gas emboli, the bubbles that form in the venous circulation during or after decompression and serve as one of the most widely used proxies for decompression stress in diving research. The review claimed that intra-individual variability in venous gas emboli is significantly lower than inter-individual variability, citing a 2023 study by David Doolette and Fiona Murphy published in Diving and Hyperbaric Medicine. That claim, the letter states, directly contradicts the cited study’s explicit conclusions. The distinction is not pedantic. Inter-individual variability, differences between divers, is precisely the signal that genomic screening would need to exploit; intra-individual variability, differences within the same diver across dives, is the noise that would undermine it. If the cited work actually found substantial within-diver variability following repeated dives, then the assumption that a diver’s bubble response is a stable personal trait is called into question, and with it the entire logic of precision prevention based on a single genomic profile.

The letter’s authors were careful to separate the critique of evidence from the vision itself. The goal of applying precision medicine to decompression physiology, they wrote, is inspiring and valuable and may ultimately improve operational diving and spaceflight safety. Their concern is narrower and more concrete: because translational review articles may influence clinical practice and operational safety guidelines, promoting precision prevention and genomic screening strategies based on misattributed evidence carries significant operational risks for human dives and spaceflight. A diver who trusts a screening strategy built on a misread study, or an astronaut selection protocol that weights a genetic variant whose association was overstated, faces consequences that no automated citation tool can repair after the fact.

The episode arrives as artificial intelligence tools are increasingly woven into the research workflow, from literature searches to drafting assistance to reference management. The failure mode the letter describes, plausible-sounding claims attached to real citations that say something different, is among the most dangerous because it defeats the usual defenses. A fabricated reference can be caught by checking whether it exists; a misattributed one survives because it does exist, and only a reader who goes back to the primary source and compares the actual findings with the review’s characterization will notice the gap. The letter’s authors offered their observations as representative examples rather than a comprehensive catalog, suggesting the issues may benefit from further clarification and refinement.

Their recommendation was constructive rather than dismissive. The letter was offered, the authors wrote, in the spirit of strengthening what is otherwise a promising and ambitious review, and they respectfully suggested that the authors undertake a comprehensive audit of their manuscript to align it with their bibliography. Careful refinement, they argued, will improve the manuscript’s clarity and accuracy and safeguard the academic rigor of the journal. The underlying scientific questions remain open and genuinely important. Whether genetic variants influence bubble formation, inflammatory responses to decompression, or the threshold at which asymptomatic emboli become symptomatic illness are questions worth answering with rigorous evidence, and the omics framework the review proposed could yet prove valuable if rebuilt on accurately cited foundations.

For the diving and spaceflight communities, the practical takeaway is a reminder that the path from genome to dive profile runs through the unglamorous work of verification. Precision prevention in decompression sickness is an idea whose time may come, but only if the evidence supporting it is what the literature actually says. Until then, the letter stands as a case study in why the human expert, reading the primary source line by line, remains the last and most important checkpoint between an automated draft and a published claim that divers, aviators, and astronauts may one day be asked to trust with their lives.

Subject of Research: Decompression Sickness Genetics

Article Title: Letter to the Editor regarding “Genetic susceptibility to decompression sickness: molecular mechanisms, genomic advances, and precision prevention strategies”

Article References: Dugrenot, E., Gouin, E., Lévêque, C., Orsat, J., & Tillmans, F. (2026). Letter to the Editor regarding “Genetic susceptibility to decompression sickness: molecular mechanisms, genomic advances, and precision prevention strategies”. Journal of Translational Medicine, 24(1), Article 1312. https://doi.org/10.1186/s12967-026-08937-x

Image Credits: AI Generated

DOI: 10.1186/s12967-026-08937-x

Keywords: decompression sickness, genetic susceptibility, venous gas emboli, hyperbaric medicine, precision prevention, automated literature review, diving safety, spaceflight medicine, Letter, Editor, regarding, Genetic

The research team, led by midwifery and nursing researchers at Istanbul Esenyurt University and partner institutions, interviewed 21 parents who reported using oils during infant massage. Participants were recruited through criterion-based purposive sampling, meaning the researchers deliberately sought out parents with direct experience of the practice rather than a random sample of the general population. Data were collected through semi-structured, face-to-face interviews and analyzed using Braun and Clarke’s six-phase thematic analysis approach, supported by MAXQDA 24 software. The study was reported in accordance with the Consolidated Criteria for Reporting Qualitative Research, or COREQ, a guideline designed to make qualitative studies more transparent and reproducible.

One of the study’s most important methodological choices was its use of the term aromatic oils as an umbrella category. In everyday parenting conversations, people rarely distinguish between essential oils, which are highly concentrated plant extracts, and carrier oils such as almond or olive oil, which are used to dilute them or applied on their own. The researchers deliberately grouped both under one term to capture the full range of products parents discussed. However, the authors themselves caution that this grouping was an analytical decision, not necessarily a reflection of how parents mentally categorize these products in daily life.

The analysis generated three major themes. The first, which the researchers described as meaning-making within the framework of natural and relaxing, captured how parents perceived oils as plant-based and calming. Parents described obtaining information or advice from other parents, friends, and, in one account, from social media and healthcare professionals. This pattern is consistent with a well-documented phenomenon in health psychology: when formal medical guidance is sparse, informal networks become the primary information infrastructure. Parents are not simply applying oils; they are participating in a social exchange of caregiving knowledge.

The second theme, from need to routine, described how oil use typically began in response to a specific infant complaint, such as restlessness, gas-related discomfort, or skin dryness. Over time, however, many parents described incorporating oil use into a regular massage practice, transforming a reactive remedy into a proactive ritual. This transition from targeted intervention to embedded routine is a common pattern in complementary care adoption and helps explain why such practices persist across generations even in the absence of clinical evidence.

Participants also reported taking precautions such as diluting oils, testing them on a small area of skin before broader application, and carefully selecting products. These self-directed safety behaviors suggest that parents are not blindly trusting of natural products. Instead, they operate with an intuitive risk framework, one that balances faith in nature with an awareness that even plant-derived substances can cause harm, particularly on the delicate skin of newborns.

The third theme, balancing expected benefits and risk concerns, encompassed parents’ perceived changes in relaxation, sleep, and skin condition, alongside concerns about allergies, misinformation, and product safety. Parents expressed conditional willingness to recommend oil use to other parents, meaning they would do so only if certain safety conditions were met. This nuance is significant: parents are not uncritical evangelists of natural remedies but thoughtful decision-makers navigating uncertainty with limited formal guidance.

Crucially, the study’s authors emphasize that these were parents’ reported perceptions, not measured infant outcomes. The interviews captured what parents believed and observed, not what clinical trials would recognize as verified effects. This distinction matters enormously for how the findings should be interpreted and applied. The study cannot establish that aromatic oils cause improved sleep, reduced gas discomfort, or better skin condition in infants. What it can establish is how parents think, decide, and act, which is itself valuable knowledge for healthcare providers.

The practical implications are directed squarely at healthcare professionals. The authors recommend that providers identify the specific product a parent is using and how it is being applied, particularly for neonates, whose skin is thinner, more permeable, and less mature than that of older infants. They also suggest discussing the reliability of the advice parents receive, given that much of it originates from informal sources rather than clinical guidelines. This approach respects parental autonomy while introducing evidence-based safety considerations into the conversation.

Published on 15 October 2026 as an open-access article, the study received no external funding and was approved by the Ethics Committee of Istanbul Gelisim University in April 2025. All participants provided written informed consent, and the research was conducted in accordance with the Declaration of Helsinki. The authors declare no competing interests. As a qualitative descriptive study with 21 participants recruited purposively in Türkiye, its findings are context-specific and cannot be generalized to all populations. Nevertheless, it adds an important layer to the growing body of research on complementary care in early childhood, illuminating the beliefs, routines, and risk calculations that shape one of parenting’s most intimate practices.

Subject of Research: Parents’ experiences, risk perceptions and decision-making regarding aromatic oil use during infant massage in Türkiye: a qualitative study

Article Title: Parents’ experiences, risk perceptions and decision-making regarding aromatic oil use during infant massage in Türkiye: a qualitative study

Article References: Aslan, M., Nart, A., Alpaydın, M., Nıgız, Ş., Say, C., Kuroğlu, Z. Ö., & Navruz, H. E. (2026). Parents’ experiences, risk perceptions and decision-making regarding aromatic oil use during infant massage in Türkiye: a qualitative study. BMC Complementary Medicine and Therapies. https://doi.org/10.1186/s12906-026-05636-4

Image Credits: AI Generated

DOI: 10.1186/s12906-026-05636-4

Keywords: aromatherapy, infant massage, qualitative research, parental decision-making, complementary medicine, Türkiye, Parents, experiences, risk, perceptions, decision-making, regarding

The technical foundation of the dispute lies in two biomarkers. Ethylene is a simple gaseous molecule that humans both produce internally and inhale from the environment, including from combustion sources and ripening fruit. Inside the body, a fraction of inhaled ethylene is converted by cytochrome P450 enzymes into ethylene oxide, a more reactive epoxide that can bind to hemoglobin and DNA. The specific biomarker used to track this chemistry is N-(2-hydroxyethyl)valine, abbreviated HEV, an adduct formed when ethylene oxide reacts with the N-terminal valine residue of hemoglobin proteins. Because red blood cells circulate for roughly four months, HEV provides an integrated record of ethylene oxide exposure over time. Lin and colleagues compiled a database of breath ethylene measurements and, using physiologically based pharmacokinetic modeling, sought to estimate how much endogenous ethylene oxide production contributes to total HEV burdens in the general population.

What Kirman and Bus highlight in their correspondence is a fundamental analytical problem embedded in that database. Breath ethylene concentrations reported across the literature are extraordinarily variable, and the variability appears to track with the measurement technology rather than with genuine differences between study populations. Studies employing laser-based photoacoustic spectrometry, a technique that detects gas absorption of laser light, reported mean ethylene concentrations of roughly 61 parts per billion with a standard deviation of 130 ppb, an enormous spread. By contrast, studies relying on gas chromatography reported a mean of approximately 20 ppb with a standard deviation of 16 ppb, far tighter and consistently lower. Even within the subset of studies that Lin and colleagues designated as high confidence, mean ethylene levels hovered around just 0.5 ppb, orders of magnitude below the values coming from the laser-based literature.

This is not a new concern, and Kirman and Bus invoke a striking historical precedent. More than two decades ago, Berkelmans and colleagues, working with online laser photoacoustic detection, observed that endogenous ethylene production rates derived from laser-based studies were significantly lower than published values based on gas chromatography, an inconsistency they attributed to fundamental differences between the two analytical approaches. When Berkelmans’s team attempted to fit a physiologically based pharmacokinetic model to their laser-derived data, they found they had to modify measured physiological and biochemical parameters to make the model work, indicating that the laser measurements were inconsistent with the well-established understanding of ethylene toxicokinetics built on gas chromatography. Kirman and Bus argue that this methodological fault line has not been resolved, and that Lin and colleagues’ database largely inherits the problem rather than correcting it.

The PBPK modeling itself is the second pillar of the critique. Physiologically based pharmacokinetic models are mathematical descriptions of how a chemical moves through the body, incorporating blood flow, tissue partitioning, metabolic rates, and ventilation. The model used by Lin and colleagues traces back to the foundational work of Filser and Klein, who developed a toxicokinetic model for inhaled ethylene and ethylene oxide across mouse, rat, and human species, and to earlier work by Csanády and colleagues, who modeled the formation of 2-hydroxyethyl adducts with hemoglobin and DNA from both exogenous and endogenous sources. Running the model with the breath ethylene data, Lin’s team concluded that endogenous production pathways account for less than 20 percent of total HEV in nonsmokers, leaving more than 80 percent unexplained. Kirman and Bus point out that this large unexplained fraction is itself a signal that something in the exposure reconstruction may be missing, whether it be analytical bias in breath measurements, unrecognized internal sources, or contributions from pathways not captured by the model.

Exogenous exposure, meaning ethylene and ethylene oxide inhaled from outside sources such as ambient and indoor air, is the other candidate explanation for the unaccounted adduct burden. Here, Kirman and Bus note that available air monitoring data, including large-scale studies such as Health Canada’s Windsor Exposure Assessment Study, indicate that environmental contributions to total ethylene oxide body burden are expected to be small for the general population. This conclusion aligns with their own prior publications, including a 2021 comprehensive review characterizing total ethylene oxide exposure from endogenous and exogenous pathways and a 2025 assessment of background exposures in the United States that questioned theoretical health risks for populations living near industrial sources. The implication is that the apparent gap between modeled endogenous production and measured HEV cannot simply be closed by invoking ambient air pollution, contrary to some popular narratives about ethylene oxide risk.

The broader context makes this technical disagreement consequential beyond the laboratory. Ethylene oxide is used industrially to sterilize roughly half of all medical devices in the United States, and the Environmental Protection Agency’s recent regulatory actions targeting sterilization facilities have relied on risk estimates derived from inhalation unit risk values. If a substantial fraction of the population’s hemoglobin adduct burden derives from endogenous biology rather than industrial emissions, then the margin between background internal exposure and levels associated with elevated cancer risk is narrower than many assume, and any risk assessment that fails to account for endogenous background risks mischaracterizing the true incremental danger of industrial emissions. Kirman and Bus have argued elsewhere that recognizing endogenous ethylene oxide formation is essential for a coherent risk management framework, since regulatory limits that ignore the body’s own production of the chemical cannot meaningfully protect public health in proportion to actual incremental exposure.

They also point to emerging molecular dosimetry work that helps interpret HEV data. Recent studies by Liu and colleagues on hemoglobin adduct formation in mice exposed to ethylene oxide, and Lin’s own companion work integrating PBPK modeling with tobacco biomarkers to interpret HEV levels in the U.S. population, demonstrate that smoking contributes substantially to measured adduct burdens, since tobacco smoke contains both ethylene and ethylene oxide directly. In nonsmokers, however, the origin of the remaining adduct burden remains contested. Classical biomonitoring studies from the 1990s and 2000s, including molecular dosimetry work by Walker, Fennell, Upton, and Swenberg in rodents exposed to ethylene oxide, established the dose-response framework that still underpins modern interpretation, and those studies consistently emphasized the importance of distinguishing background from incremental exposure when translating adduct measurements into cancer risk.

Neither the correspondence nor the original analysis settles the question of how much endogenous metabolism contributes to human ethylene oxide body burdens, but the exchange underscores a lesson that resonates across exposure science: the quality of a risk assessment is bounded by the quality of the exposure data fed into it. When two analytical technologies applied to the same biological matrix differ by more than an order of magnitude, as laser-based photoacoustic spectrometry and gas chromatography evidently do for breath ethylene, downstream models, no matter how sophisticated, inherit that uncertainty. Kirman and Bus contend that progress requires reconciling the methodological discrepancy, validating breath ethylene measurements against gas-chromatographic benchmarks, and ensuring that PBPK models are fit to data consistent with established toxicokinetics. Until that reconciliation occurs, estimates of how much ethylene oxide in the average person’s blood comes from industry versus biology will remain contested, and the regulatory debate over one of the world’s most widely used sterilants will continue to be fought on contested ground.

Subject of Research: Human exposure to ethylene and endogenous ethylene oxide assessed through breath biomarkers and pharmacokinetic modeling

Article Title: Regarding ethylene exposure and endogenous ethylene oxide levels in humans (Lin et al., 2025)

Article References: Kirman, C. R., & Bus, J. S. (2026). Regarding ethylene exposure and endogenous ethylene oxide levels in humans (Lin et al., 2025). Journal of Exposure Science &amp; Environmental Epidemiology. https://doi.org/10.1038/s41370-026-00967-3

Image Credits: AI Generated

DOI: 10.1038/s41370-026-00967-3

Keywords: ethylene, ethylene oxide, hemoglobin adducts, PBPK modeling, breath analysis, biomonitoring, exposure science, risk assessment, photoacoustic spectrometry, gas chromatography, environmental epidemiology, Regarding