Lay mental health workers play a central role in implementing and sustaining mental health interventions across East Africa. However, limited research exists on how these workers are trained and supervised, an important gap given their role in addressing the region's severe treatment shortage, where up to 85% of individuals with mental disorders receive little or no evidence-based care. Task-sharing, which involves training non-specialist workers to deliver psychological interventions under supervision, has become a key strategy over the past two decades. Yet, the processes that ensure LMHW competence, fidelity, and wellbeing, particularly training and supervision, remain underexplored. Guided by Arksey and O'Malley's five-stage framework, this scoping review maps and synthesizes literature on training and supervision practices for LMHWs delivering community-based mental health interventions in East Africa. Systematic searches of five databases (Web of Science, Embase, Scopus, PubMed, and ProQuest) yielded records that, after screening and eligibility assessment, resulted in 18 included studies from five of the seven East African countries. Data were charted and thematically analyzed to describe training methods, supervision strategies, outcomes, and implementation challenges. Findings revealed wide variations in training duration and pedagogy, from brief workshops to multi-module or apprenticeship models, and diverse supervision formats, including hierarchical, peer, hybrid, and digital approaches. Evidence showed improvements in client outcomes, provider competence, and service delivery, but highlighted persistent gaps in standardized supervision, sustainability, and workforce support. This review informs policy and implementation efforts to strengthen LMHW training and supervision systems, contributing to narrowing the mental health treatment gap in East Africa. Main finding: Training and supervision of lay mental health workers across East Africa vary widely in duration, content, and structure, yet remain central to improving community mental health service delivery.Added knowledge: This review maps, for the first time, how lay mental health workers in East Africa are trained and supervised, highlighting gaps in standardization, long-term support, and sustainability.Global health impact for policy and action: Strengthening and harmonizing training and supervision systems for lay mental health workers can enhance mental health workforce capacity, reduce treatment gaps, and inform global task-sharing policies in low-resource settings.
Heavy metals (HMs) toxicity, such as nickel (Ni), has significantly reduced crop productivity and threatens human health, while efficient and widely applicable mitigation techniques remain underexplored. Vermicompost is an effective organic amendment to improve soil fertility and increase crop growth under HMs contamination; however, its derived biochar has not been extensively used to remediate Ni phytotoxicity. Hence, this study evaluated the ability of vermicompost (VC) and its derived biochar (VCB) in restricting nickel (Ni) bioaccumulation and growth improvement of wheat.The Ni toxicity decreased plant growth, physiological functions, and antioxidant capacity, along with yield parameters. Moreover, soil DTPA extractable Ni, Ni concentration in root and shoot and bioaccumulation factors significantly increase in Ni-contaminated soil (100 and 200 mg Ni kg-1) compared with control (0 mg Ni kg⁻1) soil. In contrast, the application of VC and VCB to soils containing 100 and 200 mg Ni kg⁻1 significantly increased dry biomass (17%-25%), chlorophyll a and b (24%-43%), carotenoids (15%-30%), root volume (17%-35%), and 100-grain yield (15%-29%) compared with their corresponding Ni-only treatments. Among VC and VCB, VCB showed more prominent results in decreasing proline (12%) and H₂O₂ (44%) contents and enhancing CAT (45%) and POD (53%) activities under both 100 and 200 mg Ni kg⁻1 levels, along with improving soil chemical properties and significantly increasing soil fertility. Further, the VCB application to Ni contaminated soils (100 and 200 mg Kg-1) has significantly decreased soil-DTPA extractable Ni (59% and 44%), root and shoot Ni contents (56%, 65%, 56% and 53%), bioaccumulation factor (8% and 16%), respectively, compared with their corresponding Ni-only treatments. The VCB demonstrated a lower reduction in Ni translocation under Ni1 levels, whereas a significant reduction was found under Ni2 stress. The heatmap correlation and biplot PCA analysis confirmed that VC and VCB, particularly VCB, decreased soil and plant Ni, oxidative stress indicators, and metal accumulation factors and promoted growth, photosynthetic pigments and antioxidant variables through improved soil fertility compared to un-amended soil. This study provides a scientific basis and a practical solution for managing Ni-contaminated soils under diverse agroclimate conditions.
Very little research exists on genitopelvic pain in racially/ethnically, sexually, and gender/sex minoritized samples despite its high prevalence among these groups. Existing frameworks of genitopelvic pain are based largely on White, heterosexual, cisgender women samples; applying these frameworks to minoritized samples may be prone to inaccuracies, as they do not account for minority stress and strength, social safety, and broader social determinants of health that structure exposure to pain, access to care, and health outcomes among marginalized populations. The main purpose of this scoping review was to synthesize findings of genitopelvic pain research published on racially/ethnically, sexually, and gender/sex minoritized samples in Canada and the United States. After removal of duplicates, the abstracts of 1330 articles were independently screened for eligibility for full-text review, of which 974 were excluded. Of the remaining 356, 59 studies were included for data extraction and synthesis. Results were organized according to the underrepresented sample of interest (racially/ethnically, sexually, or gender/sex minoritized) and subcategorized according to study aims focusing on prevalence, pain characteristics and experiences, minority stressors and strengths (eg, stigma, coping, resilience), social safety (eg, relational and healthcare contexts), and social determinants of health. Results indicated that genitopelvic pain is prevalent, there are similarities and differences in pain characteristics and experiences, and variables related to minority stress and strength, social safety, and social determinants of health-when examined-were associated with pain prevalence, severity, coping, and care trajectories in racially/ethnically, sexually, and gender/sex minoritized samples. Genitopelvic pain is common in racially/ethnically, sexually, and gender/sex minoritized individuals and is meaningfully shaped by minority stress processes, minority strength adaptations, social safety, and social determinants of health, underscoring the need for theory-informed and equity-oriented pain frameworks.
Tooth loss remains a public health problem in Brazil, reflecting social inequality, population aging, and limited access to oral rehabilitation. For many individuals, complete dentures (CD) are the only option available free of charge through the Brazilian Unified Health System (Sistema Único de Saúde, SUS). However, nationwide assessments of service delivery and regional equity in prosthetic rehabilitation are limited. To quantify national trends and regional disparities in CD production within the SUS and examine how prosthetic output relates to demographic, socioeconomic, and infrastructure indicators using the most recent data available. This ecological-analytical time-series study used open data from the SUS Outpatient Information System (SIA/SUS). The analysis included maxillary and mandibular CD procedures recorded between 2000 and 2022, representing the most recent consolidated period for temporal modeling, and a state-level snapshot for 2023 to describe the latest correlational scenario. Production rates were standardized per 100,000 inhabitants. Temporal trends were analyzed using segmented linear regression to estimate the average annual percent change (AAPC), which summarizes overall long-term changes in complete denture production, and to identify inflection points. Correlations between CD production and demographic or socioeconomic indicators were tested using Spearman's rho (α = 0.05). Between 2000 and 2022, a total of 5,239,089 complete dentures were delivered through the Brazilian Unified Health System. CD production increased significantly nationwide from 2000 to 2022 (AAPC = 9.7%; 95% CI: 4.8-14.9), a relatively high annual growth rate for public health service expansion, with the steepest rise between 2006 and 2014 (AAPC = 29.2%; 95% CI: 18.6-40.7). Regional trends varied across the country, with the highest growth observed in the Northeast (AAPC = 16.4%; 95% CI: 11.7-21.3), followed by the North (AAPC = 14.3%; 95% CI: 10.9-17.7), Central-West (AAPC = 13.4%; 95% CI: 4.9-22.5), and South (AAPC = 12.8%; 95% CI: 9.0-16.7), whereas the Southeast showed the smallest expansion (AAPC = 8.0%; 95% CI: -1.7-18.8). In 2023, the SUS network included 2,903 prosthetic laboratories, highlighting the organizational infrastructure supporting prosthetic rehabilitation services. In 2023, São Paulo (Southeast region) produced 111,396 dentures, and Piauí (Northeast region) recorded the highest production rate (833.36 per 100,000 inhabitants). Strong correlations were observed between CD production and population size (ρ = 0.742, p < 0.001) and number of municipalities (ρ = 0.938, p < 0.001). Over the past two decades, complete denture production within the SUS expanded substantially, reflecting the consolidation of Brazil's public oral health policies. However, persistent regional disparities and heterogeneous production rates indicate that service expansion has not translated into equitable coverage nationwide. These findings highlight the importance of demographic and organizational factors in shaping prosthetic service provision and underscore the need for targeted planning and resource allocation to reduce inequalities in access to oral rehabilitation.
Occupational health and safety (OHS) practices witnessed profound changes worldwide during the COVID-19 pandemic. The pandemic exposed critical vulnerabilities in workplace preparedness, particularly among workers in high-exposure and essential service sectors. A systematic review was conducted following PRISMA guidelines using PubMed, Google Scholar, DOAJ, ResearchGate, and gray literature sources. Studies published between January 2020 and December 2024 focusing on occupational exposure, workplace transmission, OHS guidelines, and workforce health during COVID-19 were included. Healthcare workers experienced the highest occupational risk due to sustained patient contact and aerosol-generating procedures, accompanied by significant psychological distress and burnout. Essential workers, manufacturing sectors, retail workers, educators, and informal sector workers also faced substantial occupational and socioeconomic challenges. Workplace interventions including engineering controls, administrative controls, PPE use, vaccination strategies, and digital surveillance tools reduced workplace transmission. Remote-enabled sectors demonstrated lower infection risk but increased mental health concerns. The COVID-19 pandemic transformed traditional OHS frameworks by integrating infectious disease preparedness, vaccination strategies, mental health support, and workplace surveillance into occupational safety systems. The findings emphasize the need for integrated, adaptive, and equitable OHS frameworks aligned with public health preparedness to strengthen workforce resilience against future pandemics.
Intelligent ankle-foot orthoses (AFOs) have emerged as a promising assistive technology for improving mobility in children with cerebral palsy (CP). However, their effective development and implementation require a comprehensive understanding of user needs from multiple stakeholders, particularly in resource-limited regions. To systematically investigate the demand characteristics for intelligent AFOs among families of children with CP and medical professionals in Sichuan Province, and to identify key determinants influencing these demands. A multicenter cross-sectional survey was conducted, including 95 families of children with CP and 39 medical professionals. Structured questionnaires were used to assess functional demands, usage experiences, and perceived barriers. Data were collected from multiple hospitals and rehabilitation centers across different administrative regions in Sichuan Province to enhance representativeness. Group differences were analyzed using non-parametric tests, and multivariate logistic regression was applied to identify independent determinants of demand. Families demonstrated the highest demand for practical and usability-oriented functions, particularly walking stability (93.69%) and ease of donning and doffing (83.16%). In contrast, medical professionals prioritized clinically oriented functions, including gait monitoring and predictive fall prevention (both 87.18%). Significant inter-group differences were observed in data monitoring (p < 0.001) and adaptive adjustment (p = 0.012). Multivariate analysis revealed that higher household income was significantly associated with increased demand for both data monitoring functions (OR = 3.13, 95% CI: 1.15-8.58, p = 0.026) and usability-related features (OR = 3.00, p = 0.033). Demand for intelligent AFOs exhibits clear stakeholder-specific patterns, reflecting a divergence between practicality-driven needs among families and clinically oriented expectations among medical professionals. Safety, comfort, and indoor scenario adaptability represent shared priorities, while economic constraints and prior technology exposure further shape demand. These findings highlight the necessity of integrating multi-stakeholder perspectives into device design and support the development of context-specific strategies to improve accessibility and adoption in resource-limited settings.
Major public health emergencies often trigger severe imbalances between the supply and demand of medical supplies, resulting in substantial price fluctuations and reduced allocation efficiency. The rapid entry of converted and capacity-expanding enterprises into medical supply production further complicates pricing dynamics, particularly under government intervention policies. To investigate optimal pricing decisions under emergency conditions, this study integrates an epidemiological SEIR framework with an economic decision model and develops a Stackelberg game involving converted and expanded manufacturers under government subsidy schemes. Pricing strategies are compared under decentralized competitive and centralized cooperative scenarios to evaluate differences in market outcomes and welfare performance. The data suggest that decentralized competition among businesses results in inflated prices and diminished efficiency in resource allocation. Conversely, collaborative pricing and resource integration demonstrably enhance firm profitability and contribute to greater overall social welfare. Furthermore, when production costs rise for manufacturers that have undergone conversion, the adverse impacts of cost escalation can be mitigated through the redistribution of demand among enterprises. This research furnishes a theoretical basis for pricing strategies concerning medical supplies during significant public health crises. The findings offer practical guidance for policymakers in the formulation of effective subsidy mechanisms and price regulation policies, thereby fortifying emergency medical supply systems. This study provides a theoretical foundation for pricing strategies of medical supplies during major public health emergencies. The results offer practical insights for policymakers in designing effective subsidy mechanisms and price regulation policies, thereby strengthening emergency medical supply.
This study aims to systematically investigate the effects, mechanisms, and demographic heterogeneity of physical exercise on reemployment among older adults. To address the gaps in current studies, i.e., the lack of exploration of mediating mechanisms and the scarcity of large-sample empirical evidence, this paper provides empirical evidence and practical guidance for activating the human resources of older adults and advancing active aging strategies. Data were derived from the 2023 China Longitudinal Aging Social Survey, yielding a sample of 4,597 retired individuals aged 60 and older with complete data. The study treated reemployment as the dependent variable and physical exercise behavior as the primary independent variable, with physical health, cognitive function, and social participation selected as mediating variables. Control variables included factors related to individual and household sociodemographic characteristics. A binary logistic regression model was used to analyze main effects, and the propensity score matching method was employed to address potential endogeneity. Robustness tests were conducted using multiple methods, and the mediating effects were examined using the bias-corrected Bootstrap method, while heterogeneity analysis was also performed. The baseline regression results revealed that physical exercise has a significant positive effect on reemployment among Chinese older adults. This effect remained stable and reliable after undergoing several robustness checks, including propensity score matching and other regression models. Tests of the mediating effects confirmed that physical exercise could promote reemployment among older adults through three pathways: first, by improving physical health, with an indirect effect accounting for approximately 10.3% of the total effect; second, by enhancing cognitive functions, with an indirect effect accounting for approximately 4.9% of the total effect; third, by increasing social participation, with an indirect effect accounting for approximately 11.3% of the total effect, which serves as the core mediating pathway. Heterogeneity analysis revealed significant group differences in this promotional effect. The promotional effect of physical exercise was particularly pronounced among older adults in rural areas, the eastern region, those aged 60-70 years, those with a junior middle school education or above, and those who were ordinary workers, clerks, or other before retirement. Physical exercise was and significantly positively associated with reemployment among older adults. This association may operate through several parallel pathways: physical exercise was associated with higher reemployment likelihood partially via improving physical health, enhancing cognitive functions, and increasing social participation, with social participation serving as the most critical mediating pathway.
Artisanal and small-scale gold mining has rapidly reshaped southeastern Senegal's Kédougou region from a sparsely populated savanna-forest landscape into a highly connected frontier marked by land-use change, intense population mobility, and fragile basic services. Over the past decade, this corridor has recorded clustered outbreaks and warning signals involving mosquito-borne, tick-borne, and water-associated infections, including sylvatic dengue, yellow fever, chikungunya, Crimean-Congo haemorrhagic fever, and hepatitis E. These events suggest that mining settlements can function both as amplification sites, where ecological disruption, mobility, and weak services increase transmission risk, and as detection nodes, where clustered febrile illness may reveal emerging threats early. Using Kédougou as a case example, this Conceptual Analysis synthesizes outbreak experience, operational lessons, and published evidence to propose an evidence-informed One Health operational framework for mining corridors. The framework brings together fever triage and specimen referral, targeted vaccination for mobile populations, frontier-adapted mosquito and tick surveillance and control, minimum water and sanitation standards, community engagement, and joint One Health investigations supported by selective genomic sequencing when operationally useful. Rather than reporting an implemented intervention, this paper offers a structured prevention model for prospective adaptation, implementation, and evaluation in mining-affected frontier settings. The framework is intended to help districts strengthen routine services, support prevention of spillover and amplification, and improve cross-border preparedness in ecologically and socially dynamic mining corridors.
Diabetes-related stigma can negatively affect self-management, psychological well-being, and health outcomes among people living with diabetes; however, its correlates in Middle Eastern populations remain insufficiently explored. Type 1 diabetes (T1D) is highly prevalent in Saudi Arabia and imposes substantial clinical, emotional, and social burdens, including stigma that may interfere with optimal care. Limited evidence from the Eastern Mediterranean Region highlights the need for context-specific research. This study assessed the prevalence of stigma among adults with T1D in Jazan, Saudi Arabia, and examined associated sociodemographic and clinical factors. A cross-sectional survey was conducted among 299 adults attending the Endocrinology and Diabetes Centre. Participants completed a structured questionnaire on sociodemographic and clinical characteristics and the Arabic Diabetes Type 1 Stigma Assessment Scale (DSAS-1), covering Treated Differently, Blame and Judgment, and Identity Concerns domains. Items were rated on a five-point Likert scale. Associations were examined using Spearman correlations, Mann-Whitney U, and Kruskal-Wallis tests, and hierarchical linear regression with sociodemographic factors entered first and clinical variables added in the second model. Participants had a mean age of 30.4 ± 13.4 years (range: 18-87 years); most were females (59.2%) and urban residents (52.8%). Problematic stigma was observed across DSAS-1 domains, particularly Treated Differently and overall stigma. Higher stigma was associated with more recent diagnosis, poorer glycemic control and with more frequent episodes of hypoglycemia, hyperglycemia, and ketoacidosis. Stigma was also more common among females, urban residents, unemployed participants, and those with lower income or education. Regression models showed that clinical factors substantially improved explained variance of stigma. Diabetes-related stigma is common among adults with T1D in Jazan and is closely linked to adverse glycemic outcomes and sociodemographic disadvantage. Integrating strategies that reduce stigma into routine T1D care, particularly for individuals with poor glycemic control or recent diagnosis, may improve psychosocial well-being and clinical outcomes overall.
Cerebrocardiac health advisors (CHAs) play a pivotal role in coordinating neuro-cardiovascular care. However, systematic trainee-centered evaluations of training programs remain scarce. Understanding their experiences and expectations is essential for evidence-based program optimization and strengthening the frontline public health workforce. A convergent parallel mixed-methods study was conducted in Hubei Province, China, including 126 survey respondents and 11 interviewees. Quantitative data were collected using a validated cross-sectional survey (content validity index = 0.96) to assess training necessity, content needs, and acceptability. Qualitative data were collected via semi-structured interviews with purposively sampled trainees and analyzed using conventional content analysis. Most trainees recognized training as necessary (98.41%, 124/126) and were willing to participate (97.62%, 123/126). Stroke screening and prevention was rated the most essential curriculum component, whereas stroke research received the lowest priority. Although 97.62% (n = 123) rated the program highly, key areas for improvement were identified. Qualitatively, four themes emerged: training duration should be more reasonable, training content should be more comprehensive, training should be stratified, and training methodology should be more interactive and diverse. This study reveals strong trainee demand for professional development while identifying critical gaps in current CHA training. Evidence-based recommendations include extending training duration, expanding curricular scope, implementing competency-tiered instruction, and integrating interactive pedagogies. These findings provide policymakers with actionable insights to align CHA training with frontline practice needs, which may ultimately improve the quality of cerebrocardiovascular care coordination.
The Middle East and North Africa (MENA) region has experienced a notable increase in HIV infections in recent years, with limited epidemiological and behavioral data from Gulf Cooperation Council (GCC) countries, including Saudi Arabia. This study aimed to address the critical knowledge gaps by examining HIV-related knowledge, attitudes, and testing behaviors among adults in Saudi Arabia to inform culturally appropriate public health interventions. A cross-sectional survey was conducted among adults from various regions of Saudi Arabia. Data were collected using a validated electronic Arabic-language questionnaire that assessed socio-demographic characteristics, objective HIV knowledge, self-perceived knowledge, attitudes towards people living with HIV (PLWHIV), history of testing, exposure to health education, and perceptions of societal stigma. A total of 475 eligible respondents were considered in the analyses. The overall mean HIV knowledge score was 6.62 ± 2.44. Although 364 (76.6%) of participants identified the primary modes of HIV transmission, 209 (44.0%) perceived HIV as a fatal disease. Furthermore, 258 (54.3%) of respondents perceived Saudi society as "not accepting" of people living with HIV (PLWHIV), and 285 (60.0%) considered discussions about HIV to be culturally sensitive. The rate of voluntary HIV testing was low. The predominant reason cited was "testing was unnecessary". However, among those who had never been tested, 177 (54.5%) expressed willingness to undergo testing if it were provided free of charge and confidential. Majorities of respondents supported the integration of HIV-related information into educational curricula (93.5%). Higher educational attainment (p = 0.003), prior HIV testing (p < 0.001), and exposure to health education (p < 0.001) were significantly associated with higher HIV knowledge scores. Interestingly, 99 (66.0%) of individuals who had previously undergone HIV testing, compared with 159 (48.9%) of those who had never been tested, perceived society as non-accepting of PLWHIV. This study confirms substantial gaps in comprehensive HIV knowledge, persistent societal stigma, and low uptake of voluntary HIV testing among adults in Saudi Arabia. Despite these challenges, there is a considerable public support for expanding HIV education and improving access to testing services. The findings highlight the urgent need for culturally sensitive, evidence-based public health strategies that address knowledge deficits, reduce stigma, and promote widely accessible HIV testing services. Strengthening these efforts is essential to accelerate Saudi Arabia's progress toward achieving the UNAIDS 95-95-95 targets.
Ketamine exerts rapid antidepressant effects. However, currently available ketamine-based treatments are associated with dissociative and cardiovascular adverse effects. To evaluate the antidepressant efficacy and tolerability of KET01, a novel, oral, prolonged-release racemic ketamine tablet formulation. KET01-03 was an active-comparator, double-blind, double-dummy, crossover phase 1 randomized clinical trial (RCT) conducted among healthy adult male volunteers (aged ≥18 years) between July and August 2023 at a single trial site in Germany. KET01-02 was a placebo-controlled, double-blind phase 2 RCT conducted between May 2022 and May 2023 among adult outpatients (aged ≥18 years) with treatment-resistant depression across 29 trial sites in the Czech Republic, Germany, and Poland. KET01-02 data were analyzed from May to October 2023 and KET01-03 data from August to October 2024. KET01-03 investigated a single dose of KET01 (240 mg) vs intranasal esketamine (84 mg), and KET01-02 evaluated KET01 dosages of 120 or 240 mg/d (adjunctive to ongoing standard therapy) against placebo for 3 weeks. The primary end points were the difference in mean maximum change in Clinician-Administered Dissociative States Scale (CADSS) score between KET01 and intranasal esketamine within the first 24 hours in KET01-03 and the least squares (LS) mean change in Montgomery-Åsberg Depression Rating Scale (MADRS) score from baseline to day 21 for 240 mg/d of KET01 vs placebo in KET01-02. KET01-03 randomized 26 males (median age, 32 years [range, 21-45 years]), and KET01-02 randomized 122 outpatients with treatment-resistant depression (72 [59.0%] female; median age, 41 years [range, 19-65 years]). In KET01-03, intranasal esketamine but not KET01 induced significant dissociation within 24 hours after dosing (mean [SD] maximum change in CADSS score, 29.6 [12.5] points vs 0.7 [1.7] points; P < .001). The maximum plasma concentration was lower for KET01 (39.1 ng/mL) than esketamine (104.1 ng/mL); conversely, exposure to metabolites was higher for KET01 (eg, area under the curve [AUC] from baseline to last measurement for norketamine was 3.5 µg × h/mL) than esketamine (AUC for [S]-norketamine, 1.4 µg × h/mL). Pulse and blood pressure did not change markedly in the KET01 group in both trials, in contrast to rapid increases after intranasal esketamine in KET01-03. In KET01-02, the primary efficacy end point at day 21 was not met: LS mean MADRS score difference for 240 mg/d of KET01 vs placebo was -1.82 points (95% CI, -6.21 to 2.57 points; P = .41). However, a reduction in MADRS scores was observed 7 hours after administering the first 240 mg dose of KET01, with an LS mean difference vs placebo at day 4 (-3.66 [95% CI, -6.74 to -0.59] points; nominal P = .02) and day 7 (-3.95 [95% CI, -7.75 to -0.15] points; nominal P = .04). During follow-up, the LS mean MADRS point difference vs placebo at 4 weeks was -3.35 (95% CI, -7.62 to 0.93; nominal P = .13). The antidepressant properties and tolerability profile of KET01 in these RCTs, including minimal dissociation and cardiovascular effects, support further development of oral KET01 formulation for at-home administration. EU Clinical Trials Register Identifiers: 2023-503971-45-00 and 2021-004927-34.
Active smoking and secondhand smoke (SHS) exposure are major cardiovascular risk factors, and comprehensive smoke-free laws are a central tobacco control strategy. Although prior studies have demonstrated short-term reductions in cardiovascular morbidity following smoke-free policies, evidence regarding their long-term association with cardiovascular disease (CVD) mortality and potential differences across demographic groups remains limited. To evaluate the long-term association between comprehensive smoke-free laws and county-level CVD mortality and assess whether these associations vary by age, sex, and race and ethnicity. Comparative effectiveness research study using longitudinal county-level panel data and the generalized synthetic control method to evaluate staggered policy adoption across 38 treated counties that adopted comprehensive 100% smoke-free laws covering workplaces, restaurants, and bars between 2007 and 2018, and 103 control counties that did not implement smoke-free laws at any level during the study period from 2000 to 2018. Data were analyzed from May to August 2025. Implementation of comprehensive smoke-free laws. Annual county-level age-adjusted CVD mortality rates per 100 000 population overall and stratified by age, sex, and race and ethnicity. Average treatment effects on the treated (ATTs) were estimated with 95% CIs using parametric bootstrapping. This study included 38 treated and 103 control counties. Prepolicy mean (SD) of county-level median age was 37.5 (3.5) for treated counties vs 39.1 (5.6) years for control counties. In treated counties vs control counties, 49.3% vs 49.5% of residents were male, and 15.3% vs 20.3% were not non-Hispanic White, respectively. Implementation of comprehensive smoke-free laws was associated with a mean annual reduction of 12.0 (95% CI, -21.3 to -2.7) CVD deaths per 100 000 population over 12 postpolicy years. Larger reductions were observed among adults aged 65 years or older, male individuals, and non-Hispanic White populations, whereas the associations among younger adults, female individuals, and non-Hispanic Black populations were smaller and less precise. In this comparative effectiveness research study of county-level smoke-free laws, comprehensive smoke-free laws were associated with sustained reductions in CVD mortality. However, the magnitude of the associations varied across demographic groups, suggesting that additional strategies addressing disparities in tobacco exposure may be needed to achieve improvement in cardiovascular outcomes across all subpopulations.
Nepal faces many natural hazards, including floods, landslides, earthquakes, and extreme weather, which severely impact infrastructure, public health, and community resilience. In 2025, we conducted a formative stakeholder and community engagement exercise to inform research on strengthening local preparedness. This included consultative meetings with national agencies, local government, and community members in two hazard-affected municipalities. Field notes from the meetings were thematically analysed to identify priority themes. Findings indicated that national legal and policy frameworks exist, but implementation at municipal and ward levels remains inconsistent and hindered by limited institutional capacity. Local actions were largely focused on relief and reconstruction rather than preparedness and risk reduction. Community members and local officials described limited awareness of preventive strategies but strong willingness to engage in preparedness planning. Stakeholders identified priorities including improved coordination, legal literacy, locally tailored early-warning communication, and better data systems. These findings will inform co-development of a practical preparedness resource. Main findings: Local disaster preparedness in two Nepalese municipalities remained largely relief-oriented, despite national disaster risk management frameworks and community willingness to engage in preparedness.Added knowledge: Multi-level engagement identified practical implementation barriers, including limited legal literacy, weak coordination, low preparedness awareness, gaps in early-warning communication, and limited local loss-and-damage data systems.Global health impact for policy and action: Locally adaptable preparedness tools and inclusive community engagement can support risk reduction and strengthen disaster resilience in resource-limited settings.
With the rapid aging of China's population, so-called "Double-Aging" communities-characterized by a high proportion of older residents and relatively aged buildings-are becoming increasingly prevalent in urban areas. This study takes Shangcheng District in Hangzhou as a case, systematically examining the effects of community green space, green space activity behaviors, and community renovation on older adults' mental health across different community types, with particular focus on double-aging communities. Communities were pre-selected based on publicly available government and spatial data, followed by a questionnaire survey yielding 312 valid responses, covering individual characteristics, green space features, activity behaviors, and mental health indicators. Data were analyzed using structural equation modeling (SEM), hierarchical regression, ANOVA, and independent-sample t-tests. Results indicate that green space planning indirectly promotes older adults' mental health by enhancing overall perception, social interaction, and activity engagement, while social interaction frequency and activity participation have significant direct positive effects. Community renovation significantly improves overall perception and mental health, with pronounced benefits for middle-aged older adults (55-65 years), but limited effects for the oldest group (65 years and above). Moreover, heat-related environmental factors partially attenuate these positive effects. Overall, the findings suggest that optimizing green space planning, improving public environments, promoting social interaction and activity participation, and incorporating heat-adaptive strategies can effectively enhance older adults' mental health. The study provides theoretical and practical implications for the planning and policy-making of double-aging communities and highlights the need for future research to consider high-aged residents' adaptability, longitudinal analyses, and the integration of multidimensional environmental factors.
Accurate differentiation between malignant and benign thyroid nodules is essential. Although ultrasound serves as the primary diagnostic modality, there is a paucity of longitudinal data concerning nodule progression and limited validation of the Chinese Thyroid Imaging Reporting and Data System (C-TIRADS). This underscores the necessity for evidence-based follow-up strategies. The present study sought to assess the developmental trends of thyroid nodules over an extended follow-up period and to evaluate the diagnostic efficacy of the C-TIRADS. This was a single-center retrospective longitudinal cohort study. We included patients who underwent thyroid ultrasound between 2019 and 2024 with at least one follow-up examination. Exclusions were: (1) prior thyroid malignancy; (2) incomplete baseline data; (3) follow-up <12 months without pathology/cytology. In the primary analysis, the nodule was the statistical unit. Correlation among multiple nodules within the same patient was addressed by clustering at the patient level. A sensitivity analysis at the patient level retained only the largest or most suspicious nodule per patient. Two radiologists (≥5 years' experience) independently graded nodules using C-TIRADS and Kwak Thyroid Imaging Reporting and Data System (Kwak TI-RADS) while blinded to the reference standard. Disagreements were adjudicated by a senior radiologist. Inter-reader agreement was reported using the weighted kappa (κ). The reference standard was surgical histopathology whenever available. For non-surgical cases, cytology Bethesda V/VI was considered malignant; nodules with ≥24 months of stable imaging (no upgrade or suspicious progression) were considered benign. Indeterminate cases were excluded from the primary endpoint analysis. We reported the verification proportion and performed two sensitivity analyses: (1) surgery-only subset; (2) including nodules deemed benign after ≥24-month stable follow-up. For predefined thresholds (e.g., C-TIRADS ≥4B, Kwak ≥4), 2×2 tables were used to derive sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) with 95% CIs. Area Under the Curves (AUCs) were estimated and compared using the DeLong method. Because nodules were clustered within patients, Generalized Estimating Equations (GEE) with an exchangeable correlation structure or cluster-robust standard errors were applied. Temporal changes in sonographic features were assessed with trend tests. Missing data were handled by complete-case analysis. Ultrasonographic data from patients diagnosed with thyroid nodules in 2019 and monitored consistently until 2024 were analyzed to evaluate longitudinal changes in nodule characteristics. A retrospective analysis of 272 surgically confirmed cases (173 malignant and 99 benign) was performed to compare the diagnostic efficacy of the C-TIRADS with the Kwak TI-RADS. 1.Throughout the follow-up period, the nodules identified in the study participants were predominantly multiple and bilaterally distributed across the thyroid lobes, with their prevalence increasing annually. The majority of these nodules were round or oval in shape, with diameters less than 10 mm. However, there was a gradual increase in the proportion of nodules exceeding 10 mm in diameter, as well as those that were oval or irregularly shaped. Ultrasound characteristics such as microcalcifications, border invasion, a taller-than-wide shape (aspect ratio ≥1), and internal vascularity were largely absent in most nodules. Nonetheless, there was an upward trend in the proportion of nodules exhibiting these features. Nodules characterized by internal hypoechogenicity and lacking posterior acoustic attenuation constituted a significant proportion and did not demonstrate a notable trend of change over time. 2. The AUC for the C-TIRADS classification in the diagnosis of nodules was determined to be 0.784. A C-TIRADS category of ≥4B was identified as the optimal cutoff value for the diagnosis of malignant nodules, yielding sensitivity, specificity, PPV, NPV, and accuracy rates of 75.72%, 75.76%, 84.52%, 64.10%, and 75.74%, respectively. Furthermore, no statistically significant difference (P > 0.05) was observed in the diagnostic efficacy between the C-TIRADS classification and the Kwak TI-RADS classification for thyroid nodules. Microcalcifications, irregular margins, a taller-than-wide morphology, and internal vascularity were increasingly observed during follow-up and may be associated with malignancy, warranting closer surveillance. The C-TIRADS demonstrates diagnostic accuracy comparable to that of the Kwak TI-RADS, thereby reinforcing its clinical utility in the management of thyroid nodules.
Emergency Medical Services (EMS) play a crucial role in safeguarding public health, yet their efficiency is highly dependent on spatial accessibility and optimal facility location. Existing research often evaluates EMS spatial accessibility using total population counts, overlooking the heterogeneity of EMS risk across space and age groups. This study aims to improve EMS accessibility measurement and spatial optimization by integrating spatial and demographic variations in EMS risk. An integrated framework combining a modified two-step floating catchment area (2SFCA) model and two spatial optimization models-the Maximum Covering Location Problem (MCLP) and the P-median model-were developed. The improved models incorporate spatial and age-based EMS risk derived from 2024 EMS records in Wuhan, China. Comparative analyses were conducted between traditional and risk-integrated models to examine differences in accessibility and optimal station layouts. Findings reveal significant age-related and spatial variations in EMS risk, with older adults populations showing markedly higher risks, and high-risk areas concentrated in central and near-suburban districts. Compared to traditional 2SFCA results, the improved model produced significantly different accessibility distributions, particularly in peri-urban areas. In optimization analyses, risk-integrated MCLP and P-median models located new EMS stations closer to near-urban areas, whereas traditional models favored peripheral suburbs. Incorporating spatial and demographic variations in EMS risk substantially enhances the accuracy of accessibility measurement and optimization outcomes. The results underscore the importance of prioritizing high-risk older adults populations, strengthening EMS capacity in urban cores, and improving coverage in underserved suburbs. This framework offers a transferable tool for developing more efficient and equitable EMS systems in rapidly urbanizing and aging regions.
Few studies have evaluated whether modifiable aspects of red blood cell (RBC) transfusions are associated with recipient outcomes in very-low-birth-weight (VLBW) infants. To determine whether blood donor, RBC modifications and storage, or transfusion thresholds and characteristics are associated with serious adverse outcomes in VLBW infants undergoing transfusion. Transfusion in Preterm Infants was a prospective birth cohort study that recruited VLBW infants (<1500 g at birth) between April 1, 2019, and December 31, 2023, at 5 university-affiliated and 3 community birth hospitals in the US. Electronic medical record data linking blood donor and component data to infants were obtained and linked with Vermont Oxford Network outcome data, with additional outcome review by site. The analysis was completed in January 2026. RBC transfusion and transfusion characteristics, evaluated up to the first outcome event. The primary outcome was a composite outcome of severe intraventricular hemorrhage (IVH), necrotizing enterocolitis (NEC), late-onset sepsis, severe bronchopulmonary dysplasia (BPD), retinopathy of prematurity, or death (and secondary individual outcomes), with follow-up through 90 days or death. Blood donor characteristics (sex, age, and hemoglobin), anticoagulant preservative solution and/or unit characteristics, transfused volumes, transfusion number, and infants' pretransfusion hemoglobin values were evaluated using multivariable generalized estimating equation regression models to account for correlation within hospital, adjusted for illness severity. The study enrolled 2605 VLBW infants, and 1283 (586 [45.7%] female; 713 [55.6%] <27 weeks' gestational age) received RBC transfusion. Median pretransfusion hemoglobin level was associated with higher odds of the composite outcome (odds ratio [OR] per 1 g/dL increase, 1.15; 95% CI, 1.07-1.25; P < .001). In contrast, use of additive solution (AS)-1 or AS-5 vs the reference of citrate phosphate dextrose adenine or citrate phosphate dextrose as the anticoagulant preservative solution was associated with lower odds of the composite outcome (OR, 0.72; 95% CI, 0.53-0.97; P = .03). There were no significant associations with other examined modifiable factors and the composite outcome. Among secondary outcomes, anticoagulant preservative solution was associated with lower risk of BPD (AS-1 and AS-5, OR, 0.48; 95% CI, 0.33-0.69; AS-3, OR, 0.65; 95% CI, 0.56-0.77) and higher risk of NEC (AS-3, hazard ratio [HR], 5.33; 95% CI, 1.22-23.29). Transfusion dose was associated with higher risk of mortality (HR per 5 mL/kg, 1.25; 95% CI, 1.17-1.35), and donor age was associated with a lower risk of mortality (HR for age ≥60 years, 0.63; 95% CI, 0.44-0.92). Shorter postirradiation storage duration (<1 day) was associated with lower risk of NEC (HR, 0.44; 95% CI, 0.22-0.89). Female donor sex was associated with lower risk of IVH (HR, 0.60; 95% CI, 0.36-0.99). In this cohort study of VLBW infants, pretransfusion hemoglobin and anticoagulant preservative solution were associated with a composite of morbidities and mortality, unlike other modifiable blood banking practices. For individual outcomes, select donor and blood banking factors were identified that may be modifiable targets for further evaluation.
To compare symptom burden, functional impact, emotional well-being, and health-related quality of life (HRQoL) between patients with chronic unilateral vestibular hypofunction (UVH) and bilateral vestibulopathy (BVP). This cross-sectional study included 100 patients with chronic UVH and 148 patients with BVP from a tertiary referral center. Symptom burden and functional impact were assessed using the Bilateral Vestibulopathy Questionnaire, Dizziness Handicap Inventory, and Oscillopsia Severity Questionnaire (OSQ). Emotional well-being was evaluated with the Hospital Anxiety and Depression Scale, and HRQoL with the EuroQol 5-Dimension 5-Level and Health Utility Index Mark 3. Total scores were compared across groups. Standardized mean differences (SMDs) were calculated to quantify the differences across all patient-reported outcome measures. Bilateral vestibulopathy patients reported significantly greater symptom burden and functional limitations than chronic UVH patients (P < .05). No significant group differences were found in emotional well-being or generic HRQoL. Both patient groups showed significantly worse outcomes than healthy controls across most domains (P < .05). Standardized mean difference analysis showed that when effect sizes between groups were large or moderate, the differences were statistically significant. Conversely, when effect sizes were very low or small, there were no statistically significant differences (except for the OSQ, which remained significant despite a small effect size). Chronic UVH and BVP are associated with significantly reduced QoL. Bilateral vestibulopathy patients report a greater symptom burden and functional limitations compared to patients with chronic UVH. These findings demonstrate the need for tailored assessments and targeted rehabilitation strategies for vestibular patients.