Public Health and Healthcare

Abstract:

Background: Diabetic retinopathy (DR) is one of the most prevalent microvascular complications of diabetes mellitus and a leading cause of visual impairment worldwide. However, clinically available, minimally invasive, and convenient tools for early DR screening and disease stage stratification remain inadequate. This study aimed to identify serum metabolic biomarkers for DR stage discrimination and to characterize metabolic alterations associated with DR onset and progression. Methods: Serum samples from four groups—healthy controls (HC), diabetic patients without retinopathy (NDR), patients with mild nonproliferative DR (NPDR), and patients with moderate-to-advanced DR (MADR)—were analyzed using untargeted metabolomics. Three pairwise comparisons were designed to identify key transition points in DR progression. Candidate biomarkers were screened by identifying differential metabolites and further optimized using logistic regression analysis. Results: Stage-specific metabolic reprogramming occurred during DR progression, and lipid metabolism dysregulation persisted throughout the disease course. The candidate biomarker panels achieved cross-validated area under the curve (AUC) values of 0.918, 0.800, and 0.893 for distinguishing NPDR from HC, NPDR from NDR, and MADR from NDR, respectively, demonstrating stable and robust diagnostic performance. Moreover, the identified biomarkers were significantly correlated with key clinical parameters of DR. Conclusions: This study provides promising blood-based candidate biomarkers and novel metabolic insights for early screening and progression monitoring of DR.

Abstract: Aptamers, short single-stranded oligonucleotides selected to bind a chosen target, have for three decades been presented as programmable substitutes for antibodies. The past five years have changed the terms of that comparison. Selection can now be performed inside living cells, generative models propose binders that were never present in the starting library, and electrochemical aptamer switches report drug concentrations in human interstitial fluid with minute resolution over a day. In parallel, population-scale aptamer proteomics has made the aptamer a workhorse of biomarker discovery rather than a curiosity of the assay laboratory. Clinical adoption nevertheless remains uneven, and the reasons are mechanistic rather than merely engineering-related. An aptamer is a conformational ensemble whose binding equilibrium is re-weighted by ions, competing proteins and surface chemistry, so an affinity measured in selection buffer is a poor predictor of behaviour in blood. Here we examine the molecular principles that govern aptamer recognition, the device architectures that convert binding into a clinical readout, and the clinical evidence accumulated since 2021. We argue that the rate-limiting step has moved from molecular discovery to the construction of evidence that regulators, payers and clinicians can audit, and we propose a framework for generating it.

Abstract: Transmission models of sexually transmitted infections (STIs) are usually calibrated to national surveillance and are rarely tested against the case history of the individual states that run prevention programs. We assembled an open, documented panel of reported chlamydia and syphilis (primary and secondary, early non-primary non-secondary, unknown duration or late, and congenital) for the 50 U.S. states and the District of Columbia, 2000–2023, and for the nation, 2000–2024, by sex and age group, joined to a single consistent series of Census Bureau population estimates (262,958 rows). The panel reproduces the national totals exactly, and 21 of 22 named values match CDC’s published tables. We then calibrated two published compartmental models, a syphilis model with reinfection, two-stage treatment and treatment failure, and a chlamydia model with behavioral heterogeneity, to each jurisdiction’s 2011–2020 cases. We scored every fit on 2021–2023, years it never saw. With its published fixed settings, and the behavior-response strength scaled per capita to each state, the syphilis model had a median held-out mean absolute percentage error (MAPE) of 41.3%. It under-predicted in 44 of 51 jurisdictions (median bias-40.6%), because its prevalence-dependent behavior term capped incidence growth. Estimating the behavior-response strength reduced the median error to 17.6% (bias-1.2%; Wilcoxon p = 7.7 × 10−6). The fitted state values clustered around the published absolute value, not the per-capita one. The chlamydia model had a median held-out MAPE of 20.6% with a one-year infectious period, and 10.1% with the one-week period implied by treatment alone. In every fit, several parameters were not identifiable from annual counts. The panel, parameter sets with uncertainty ranges, validation scorecard, code, and an assumption register are openly released (DOIs 10.5281/zenodo.23742262 and 10.5281/zenodo.23742264).

Abstract: Aiming to develop strategies and infrastructure for close collaboration between healthcare and research, the Medical Informatics Initiative (MII) established a common infrastructure connecting German university hospitals and their partners. To foster interoperability across the heterogeneous sites, a health data specification was created, the MII Core Data Set (CDS), standardising the representation of clinical routine data intended for reuse in research. Findable, accessible, interoperable and reusable (FAIR) specifications are applied more efficiently. Exemplified by MII CDS modules, we demonstrate how health data specifications can be made FAIR and discuss benefits and costs involved. As the CDS defines how clinical routine data is exchanged in Germany, we implemented a multi-step FAIRifciation workflow and extended the MII CDS module implementation guide accordingly. We summarised lessons learned in a guideline and propose to reduce the number of FAIR indicators when assessing health data specifications. In summary, our results ease future FAIRification of MII CDS modules and similar health data specifications, thus contributing to the generation of FAIR health research data from those specifications.

Abstract: Clinical healthcare data in many countries is stored and exchanged using the international interoperability HL7 FHIR (Health Level 7 Fast Healthcare Interoperability Resources) standard. In Germany, for example, clinical routine data is provided in FHIR for reuse in research by the data integration centres of the Network University Medicine (NUM-DIZ). The goal of this work was to build on the FHIR format and graph database (GDB) technology to create a knowledge graph (KG) representation of the data that would make it more accessible, interpretable and available for efficient exploration and complex analysis, providing a convenient way to engage with the data for both researchers and medical professionals. We present the MeDaX pipeline, a tool that takes FHIR-formatted clinical data as input, maps it to a graph, optimizes its structure, provides options for semantically enriching it and results in a GDB representation of the data. The resulting GDB supports interactive visual exploration as well as graph-based querying and analysis. By providing a structurally optimised KG, MeDaX simplifies navigation between heterogeneous clinical resources and provides a connected view of the data, while remaining compatible with established FHIR-based infrastructures.

Abstract: Background/Objectives. Efforts to curb the obesity epidemic necessarily include policy, systems, and environmental (PSE) changes to mitigate obesity-promoting influences in food, nutrition, and physical activity environments. This study identifies learnings from applications of the Getting to Equity in obesity prevention framework (GTE), which was designed to inform such PSE approaches with a focus on reaching those at greatest need in marginalized and underserved populations. We analyzed published GTE applications to assess contributions to the field in the 9 years since initial publication. Materials and Methods: A citation-based search from January 2017 through January 2026 identified 257 articles citing a GTE description. Articles citing the framework without an application (n=230) were excluded. Qualitative, study-level analyses prioritized articles that applied the GTE during the research process. Results: Analyses included 23 studies (empirical research, reviews, policy analyses, and curricular). Most focused on community-level actions related to childhood obesity prevention (n=4) or aspects of programs and policies related to food access and nutrition security (n=16). We identified examples of GTE applications across all research phases, often complementary to other theories, models, or frameworks. Systems science approaches were used in three empirical studies. Analysis also generated insights about equity considerations related to the respective PSE topics. Conclusions: Unique contributions of the GTE were most evident for structuring qualitative inquiry and interpretation within and across the diverse topics and settings. Findings provided both methodological and content guidance for how to incorporate equity considerations in generating and translating findings to research, policy, and practice recommendations.

Abstract: Large biobanks linking genetic data with electronic health records have transformed human genetics research. Because most biobanks enroll by convenience rather than probability sampling, recruitment, consent, and participation processes shape whose data are analyzed. We review bias arising from non-probability sampling across the biobank landscape and methods for detecting and reducing it. We then examine its consequences for common genetic analyses: descriptive assessment, population substructure, genetic association, Mendelian randomization, and risk prediction. The impact is not uniform: descriptive quantities and analyses of disease-ascertained samples are especially vulnerable, whereas genetic association tests and risk prediction are often more robust. When the goal is estimating effect sizes rather than testing null hypotheses, bias-reduction tools should be considered. We conclude with recommendations for reporting biobank sampling strategies, defining source and target populations, stating bias detection and reduction approaches, and outline related open challenges for the biobank research community.

Abstract: Rapid blood culture identification panels report resistance genes (mecA/mecC, vanA/vanB, KPC, NDM, OXA-48-like, VIM, IMP and CTX-M) hours to days before growth-based antimicrobial susceptibility testing (AST) is complete, and laboratories and prescribers act on that early result. We built an open, versioned, isolate-level benchmark that measures how often each panel target predicts the AST result that follows, using public data only. From 26,886 NCBI BioSample records carrying a submitted antibiogram for Staphylococcus aureus, Enterococcus faecalis, Enterococcus faecium and the Enterobacterales, we joined AMRFinderPlus gene calls from NCBI Pathogen Detection, kept U.S. human clinical isolates, mapped genes to panel targets through NCBI’s Reference Gene Hierarchy, and reinterpreted 19,741 isolate-drug MICs and zone diameters against CLSI M100 (35th edition) breakpoints. The benchmark contains 5,168 isolates (731 from blood or other sterile sites). mecA predicted oxacillin or cefoxitin resistance in 215/220 S. aureus (positive predictive value, PPV, 97.7%; 95% CI 94.8%–99.0%), and its absence predicted susceptibility in 329/330 (NPV 99.7%). Any panel carbapenemase predicted resistance to at least one carbapenem in 272/278 Enterobacterales (PPV 97.8%) but to meropenem in only 241/275 (PPV 87.6%), with OXA-48-like and IMP enzymes most often leaving meropenem susceptible. CTX-M predicted ceftriaxone resistance with PPV 97.7% across Enterobacterales, but a CTX-M-negative result was a weak predictor of susceptibility outside E. coli (NPV 94.2% in E. coli, 37.3% in K. pneumoniae complex, and below 10% in chromosomal AmpC species). In a secondary analysis, CTX-M-1-group enzymes conferred ceftazidime resistance in 64.2% of E. coli versus 14.5% for CTX-M-9-group enzymes. vanA predicted vancomycin resistance in 26/29 enterococci; no vanB or mecC was present. All 970 discordant isolate-target pairs are released with a rule-based likely cause; most gene-negative resistant isolates carried a non-panel ESBL or AmpC, a panel carbapenemase, or belonged to a chromosomal AmpC species. The data, gene-to-target crosswalk, discordance collection, code and a public lookup page are openly released for reuse and annual update.

Abstract: Wearable eye-tracking systems enable the assessment of ocular and oculomotor dy-namics during natural motor activities, although their temporal variation and rela-tionship with performance remain insufficiently understood. This study investigated ocular characteristics during repeated basketball free throws and their association with individual shooting outcomes. Thirty-three basketball players performed 30 free throws while wearing a Pupil Labs Neon eye-tracking system. Following quality con-trol, 936 attempts from 32 athletes were analysed. Pupil diameter, eyelid aperture, blink occurrence, saccade rate, and fixation rate were extracted from pre-release in-tervals. Mixed-effects models examined temporal changes and within-athlete associa-tions with shooting success, applying false discovery rate (FDR) correction. Modest temporal changes were observed: eyelid aperture increased across successive attempts (β = 0.0069 mm/attempt; FDR-adjusted p = 0.047), whereas saccade rate (β = −0.0129 events·s⁻¹/attempt; FDR-adjusted p = 0.007) and fixation rate (β = −0.0112 events·s⁻¹/attempt; FDR-adjusted p = 0.028) decreased. Pupil diameter and blink occur-rence showed no significant temporal changes. None of the five ocular measures was significantly associated with individual shooting success after FDR correction. These findings indicate that wearable eye tracking can detect temporal changes in ocular behaviour during repeated motor performance, although their physiological signifi-cance and potential applications in human monitoring require further investigation.

Abstract: Extracellular vesicles (EVs) mediate communication between Leishmania parasites and their hosts through the transfer of proteins, lipids and nucleic acids that influence immune responses, parasite persistence and disease progression. Despite more than a decade of investigation, translation of EV-associated discoveries into clinical, veterinary and public-health applications remains limited. Methodological heterogeneity, inconsistent reporting practices and insufficient validation continue to impede the development of clinically actionable biomarkers. Concurrently, the evolution from MISEV2018 to MISEV2023 reflects the broader maturation of extracellular-vesicle science, shifting the field from descriptive characterisation towards greater emphasis on reproducibility, functional validation and translational relevance. Here, we revisit the Leishmania 360° concept through the complementary lenses of MISEV2023, translational medicine and One Health. We argue that the principal challenge is no longer the identification of vesicular cargo, but the establishment of evidence-based frameworks capable of determining whether EV-associated signals are sufficiently validated to support clinical, veterinary or public-health decision-making. A central conceptual advance is the Dual-Compartment Liquid Biopsy Paradigm, whereby parasite-derived and host-response EVs are interpreted as complementary indicators of pathogen biology and host pathophysiology, providing a multidimensional framework for diagnosis, prognosis, treatment monitoring and surveillance. Building upon this concept, we introduce LEV-MISEV, a claim-to-evidence framework that extends MISEV2023 principles beyond methodological reporting by linking biological, clinical and public-health claims to proportional evidentiary requirements. We further propose a staged translational framework comprising the Translational Readiness Level for Extracellular Vesicles (TRL-EV) and the Leishmania 360° Translational Evidence Matrix. Whereas TRL-EV evaluates biomarker maturity along the pathway from discovery to implementation, the Translational Evidence Matrix assesses the overall strength of evidence across biological, analytical, clinical, operational and One Health domains. Together, these complementary frameworks identify translational bottlenecks, prioritise validation efforts and support evidence-based implementation planning. Finally, we position EV signatures as a molecular intelligence layer within climate-informed One Health surveillance systems integrating human, canine, vector and environmental data. Application of these frameworks indicates that no EV-based application in leishmaniasis has yet progressed beyond the stage of clinically associated biomarker candidates. We therefore propose a translational roadmap that integrates biological plausibility, analytical validity, clinical validity, implementation readiness and One Health utility. Collectively, these concepts reposition EVs not merely as sources of candidate biomarkers, but as components of a translational platform capable of supporting precision diagnostics, therapeutic monitoring, risk assessment and integrated surveillance. More broadly, the proposed framework may provide a transferable model for evidence-based biomarker development across infectious, parasitic and vector-borne diseases beyond leishmaniasis.

Abstract: Background: Point-of-care (POC) diagnostics could improve timely diagnosis of skin neglected tropical diseases (skin NTDs) in settings with limited access to laboratory services. However, evidence on their diagnostic performance, operational feasibility and readiness for decentralized implementation remains fragmented. Methods: We systematically searched PubMed, Web of Science, Google Scholar, and grey literature sources for studies evaluating POC diagnostic technologies for skin NTDs. Diagnostic performance, evidence maturity and operational characteristics were synthesized narratively because of heterogeneity across technologies, populations, reference standards, and reported outcomes. Diagnostic-accuracy studies were assessed using the Quality Assessment of Diagnostic Accuracy Studies-2 (QUADAS-2). Results: A short summary of the article’s main findings. Conclusions: POC diagnostics for skin NTDs show promising technological development but uneven evidence of maturity. Molecular technologies have generally progressed further in analytical development than in clinical and field validation, while simpler rapid tests have greater field experience but variable performance. Future research should prioritize prospective clinical and implementation-focused evaluation of complete diagnostic workflows in representative endemic settings.

Abstract: Before a model can screen a citation, the review team must decide what satisfies each eligibility criterion and which combinations of findings justify exclusion. PANNER makes these decisions explicit through interactive protocol compilation. A host agent works with the team to turn the criteria into atomic signal questions, answer conditions and rules for combining the answers. After the team reviews and freezes the protocol, a calibrated decision model answers the questions for each citation, and a fixed rule engine derives the retain or exclude decision. Records are retained for further assessment whenever no exclusion rule is satisfied. Implemented as a local Model Context Protocol (MCP) server, PANNER preserves the source criteria, protocols, answers and run configurations for inspection and recomputation. In four worked examples, it screened 26,195 deduplicated citations and excluded 21,768 (83.1%), leaving 4,427 for downstream screening. All 67 supplied reference reports were retained; these records also informed protocol calibration. Jev screening cost US$3.39, with approximately US$0.54 in estimated agent compilation costs. The examples illustrate how an explicit screening protocol can guide inexpensive batch judgements and reduce the number of records requiring further assessment.

Abstract: Female pelvic organ prolapse (POP) is a gynecological disorder characterized by pelvic organ descent that significantly impacts quality of life. With increasing global burden, approaches for early diagnosis are essential. This study illustrates a patient-specific computational model of the pelvic cavity, updating the uterine and cervical geometric model and assigning cervical tissue properties. Three distinct uterine geometric models were assembled, based on literature measurements and magnetic resonance images for comparison and validation. Human cervical properties were extrapolated from biomechanical testing of ovine pelvic tissues. Finite elements simulations of the Valsalva maneuver were conducted to analyze the biomechanical effects of varying uterine morphology and tissue properties on the pelvic cavity, including the bladder neck, vagina, and uterosacral ligaments (USLs). Results show that a uterus with softer properties assigned exhibits less vertical displacement and relies more on USLs support than a stiffer one. Furthermore, uterine volume and morphology significantly influence pelvic dynamics: a larger uterus tends toward anteversion, while a smaller uterus increases vertical vaginal displacement (10.57 mm vs 6.04 mm) and requires greater USLs support. Anatomical variations directly constrain bladder neck displacement. These computational advancements aim to enhance patient-specific modeling, assisting clinical decision-making.

Abstract: Background/Objectives: Familial resilience is essential for the well-being of households raising children with Autism Spectrum Disorder (ASD), yet its determinants remain insufficiently understood in Greece. Methods: A cross-sectional study of 517 mothers used validated self-report measures, including the Family Resilience Scale. Descriptive statistics, correlation analyses, and multivariate linear regression models were applied to identify factors associated with Family Pride and Family Cohesion. Results: Families reported high Family Pride and average Family Cohesion. Family composition, maternal age, and birth order predicted Family Pride, while paternal family history and child functional level predicted Family Cohesion. Conclusions: Findings show that resilience in ASD families is multidimensional and shaped by structural and child-related factors, highlighting the need for targeted family-centered supports.

Abstract: The increasing prevalence of neurodegenerative diseases (NDs), especially Alzheimer's and Parkinson's, is a major public health concern in the Gulf countries (GCs) due to the rapid increase in life expectancy and population aging. This research explores the impact of radio, podcasts, and YouTube on raising awareness about NDs and publicizing media's focus on policy in four GCs: Oman, Qatar, the UAE, and Saudi Arabia, in light of media and technological limitations and restrictions, alongside cultural and religious contexts. It is observed that while radio would help to engage elderly people and rural populations, podcasts enable in-depth health education. YouTube provides an effective channel for visually clear communication of health-related information, the evidence for media to communicate specific knowledge about NDs is not strong. The lack of evidence and normalization of cognitive decline have remained an obstacle. It concludes that effective communication channels that build on existing cultural and social factors show promise for informing and increasing health awareness of NDs, but evidence is still lacking to show that receiving information alone affects health or policy. It emphasizes the necessity for future study into whether improved knowledge at the community level leads to earlier help-seeking, improved caregiver support, and access to services.

Abstract: Shamonda virus (SHAV), an emerging orthobunyavirus recently detected in Europe, was investigated in dairy water buffaloes (Bubalus bubalis) following reports of reduced milk production in Campania, southern Italy. In September 2026, 23 buffaloes from four farms in Salerno province were sampled, including EDTA blood from 15 animals and individual milk from eight. Samples were tested by RT-qPCR for SHAV and, in parallel, for Schmallenberg virus, bluetongue virus and epizootic haemorrhagic disease virus. SHAV RNA was detected in 10 of 15 blood samples and in all eight milk samples examined, whereas the other viruses were not detected. Three samples with the lowest Cq values were subjected to whole-genome sequencing. Phylogenetic analysis of the L, M and S segments showed that all three strains clustered within the SHAV-EU1 clade and were closely related to viruses detected in cattle in France, Germany and Switzerland in 2026. Although detection of viral RNA in milk does not demonstrate the presence of infectious virus or replication in the mammary gland, these findings document SHAV infection in water buffaloes and support the inclusion of this species in surveillance during the ongoing European emergence of SHAV.

Abstract: Non-invasive aesthetic technologies, such as cryolipolysis (CLL), radiofrequency (RF), and ultrasound cavitation, have become standard therapeutic approaches for the management of localized adiposity and gynoid lipodystrophy (cellulite). While these technologies effectively induce adipocyte apoptosis or lipolysis, the subsequent clearance of cellular debris and free fatty acids (FFAs) heavily relies on the body’s lymphatic and metabolic pathways. This article explores the therapeutic synergy between applied physical activity and non-invasive body contouring. We hypothesize that integrating targeted exercise—specifically aerobic training and targeted muscle contractions—may act as a therapeutic adjunct to aesthetic sections. Physiologically, exercise-induced muscle pumps accelerate lymphatic drainage, facilitating the rapid removal of metabolic byproducts, while increased energy expenditure promotes the oxidation of released FFAs, preventing their re-esterification. By bridging aesthetic science and applied physical activity, this paper proposes a theoretical framework for combined protocols, intended to guide future clinical investigation and offer a holistic, therapeutic approach to body sculpting.

Abstract: Background: Dental caries is the most prevalent noncommunicable disease worldwide. Within the DCIEH framework it is a dysbiosis of the dental biofilm microbiome that is regulated by biology, modulated by behavior and conditioned by the environment. It is also a trans-complex disease whose outcome emerges from the interaction of biological, behavioral and socio-environmental factors. Behavioral sciences offer mature theories to explain and change oral health behaviors, but a persistent gap separates these theories from routine chairside care. In 2024 we proposed ELIGE/CHOOSE, a theoretical framework that integrates Social Cognitive Theory (SCT) and the Capability-Opportunity-Motivation-Behavior (COM-B) model into three clinical phases: Identify, Articulate and Plan.Objective: To report the systematic development of ELIGE AI, a clinical decision support tool that operationalizes the ELIGE/CHOOSE framework through an evidence-based, author-designed deterministic algorithm combined with a large language model (LLM).Methods: Development was guided by the Medical Research Council framework for complex interventions, the ORBIT model and the IDEAS framework for digital behavior change interventions. Reporting draws on TIDieR, DECIDE-AI and TRIPOD-LLM. Development proceeded in five phases: (1) theoretical integration of SCT, COM-B, the Transtheoretical Model, the Health Action Process Approach, motivational interviewing and Intervention Mapping; (2) translation into a stepwise clinical protocol; (3) formalization of the first author's clinical reasoning as an explicit decision algorithm, with every rule traceable to theory or evidence; (4) integration of an LLM restricted to bounded language tasks; and (5) iterative build-and-refine cycles across versions informed by clinical use.Results: ELIGE AI (v3.9) is a web application with seven screens across the three ELIGE/CHOOSE phases plus a follow-up module. In about 20 to 25 minutes it produces a specified behavior, a principal COM-B determinant with a displayed rationale, a graded goal ladder, Behaviour Change Technique Taxonomy v1 techniques matched to the determinant, rule-based referrals and personalized patient materials. At follow-up it re-measures the same constructs, behavior frequency and dental caries risk, and recommends the next step on the same behavioral route. The algorithm makes every clinical decision; the LLM only drafts and classifies; the clinician validates and can override every output.Conclusions: ELIGE AI shows how a published behavioral framework and its author's clinical reasoning can be encoded as a transparent algorithm and safely combined with generative AI. The tool now enters a three-stage evaluation of usability, feasibility and validity, and efficacy on dental caries outcomes.

Abstract: Background. This longitudinal follow-up study explored biomarkers and psychological symptoms of directly-exposed survivors of the Oklahoma City (OKC) bombing related to media coverage of the OKC bombing and the September 11, 2001 (9/11) terrorist attacks. Methods. Medically-healthy, directly-exposed Oklahoma City (OKC) bombing survivors were compared to OKC community members on cardiovascular reactivity, inflammatory biomarkers, and psychosocial outcomes in relation to the OKC bombing and 9/11 media consumption. Measures. Impact of Event Scale-Revised (IES-R) for current bombing-related and 9/11-related posttraumatic stress PTS symptoms; Beck Depression Inventory-II (BDI-II); Distress and Functioning (DAF) Scale; inflammatory IL-1β, anti-inflammatory IL-2R, cardiovascular reactivity biomarkers; and media consumption variables including associated nervousness/fear. Results. Bombing survivors had lower IL-2R and higher IL-1β, cardiovascular reactivity, and OKC bombing-related posttraumatic stress and distress/functioning problems than community controls, but no differences on 9/11 media consumption. Correlations were found among bombing survivors’ IL-2R with nervousness/fear from OKC bombing media contact. IL-1β correlated with PTSOKC levels and DAF, IL-2R with DAF, and systolic BP reactivity with DAF. Conclusions. Media consumption was associated not only with psychosocial outcomes but also with inflammatory stress biomarkers. Media coverage of both prior personally-exposed terrorist incidents and more recent attacks on others have the potential to affect psychosocial outcomes and biological stress markers of terrorism survivors.

Abstract: Background: Transgender and gender diverse people experience significant health disparities. Health professionals are generally not adequately prepared by current curricula to provide gender-affirming care. Methods: The aim of this study was to explore how medical curriculum change could enable the professional identity formation of a gender-affirming practitioner. The study used case study design and narrative inquiry as complementary methodological frameworks, with a conceptual lens of professional identity formation. Narrative interviews with six health care practitioners and nine medical students formed phase one. A narrative analysis was conducted and shared with medical educators to reflect on gender-affirming curriculum change in phase two. Findings were combined for the case study analysis using a critical lens. Results: This case study sheds light on power relations at three levels: medical school as institution, educator-student interactions as well as in the clinical encounter. A decolonized and affirming approach offers a new perspective of how these power dynamics may shift to create a more enabling environment for the development of a gender-affirming professional identity. Conclusion: The findings create the opportunity to rethink power relations. This study recommends that respect for diversity needs to be taught early in the curriculum, with awareness of epistemic justice, where student and patient voices are valued.