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Low-value practices, defined as tests or treatments that are used in practice despite not being supported by evidence, account for 20%-30% of healthcare expenditure; moreover, some identified low-value practices represent 16%-26% of primary care clinical services. Given the growing financial constraints healthcare systems face, evaluating the cost-effectiveness of interventions designed to reduce these practices is becoming urgent. We aimed to synthesise data on the economic value of deimplementation interventions. We evaluated the cost-effectiveness of interventions targeting the deimplementation of low-value practices among healthcare professionals and organisations (clinicians, hospitals and medical centres). Our comparator was either no intervention or a deimplementation intervention limited to a subset of the intervention components. Outcomes were incremental cost-effectiveness ratios, incremental cost-utility ratios and benefit-to-cost ratios. Studies where the intervention was dominant or dominated by the comparator were also considered. We developed search strategies for Cochrane, EMBASE, MEDLINE, CINAHL and Web of Science to February 2025. Pairs of independent reviewers sequentially screened titles, abstracts and full texts for eligibility and extracted data using a prepiloted extraction sheet. Methodological quality was assessed by two reviewers using the 19-item Consensus on Health Economic Criteria (CHEC), and results were synthesised visually using permutation matrices globally and for predefined subgroups. Of the 35 575 unique records identified, 19 met our eligibility criteria. Deimplementation interventions were found to be dominant (ie, effective with lower cost) in 10 evaluations (53%), potentially favourable (more effective with higher cost) in 8 (42%) and unfavourable in 1 (5%). Deimplementation interventions were more likely to be economically favourable in studies accounting for both medical and intervention costs, those targeting healthcare professionals and those with high methodological quality. Our findings suggest that deimplementation interventions targeting low-value practices are highly likely to be cost-effective. However, the results should be interpreted with caution due to the low methodological quality of the studies and the lack of consideration of the societal perspective.

This retrospective cohort study evaluated annual marginal bone level change and identified patient-, implant-, and treatment-level determinants in posterior maxillary implants. Records of patients who received posterior maxillary implants between 2014 and 2024 were retrospectively reviewed. Marginal bone level changes were measured on standardized periapical radiographs obtained at implant placement and at the latest follow-up. Annual marginal bone change (mm/year) was calculated to account for heterogeneous follow-up durations. Multivariable generalized estimating equation models with robust standard errors were used to evaluate independent associations while accounting for clustering of multiple implants within patients. A total of 115 implants placed in 78 patients were included, with a mean follow-up of 5.25 &#xb1; 2.49 years. Mean annual marginal bone level change was -0.04 &#xb1; 0.28 mm/year. After multivariable adjustment, free-hand surgery (&#x3b2;&#x202f;=&#x202f;0.179 mm/year; 95% CI 0.039, 0.319) and static guided surgery (&#x3b2;&#x202f;=&#x202f;0.221 mm/year; 95% CI 0.092, 0.350) were associated with lower annual marginal bone loss than navigation-assisted surgery. In contrast, osteotome and sinus augmentation procedures were associated with greater annual marginal bone loss compared with implants placed without adjunctive procedures (&#x3b2;&#x202f;=&#x202f;-0.176 mm/year; 95% CI -0.347, -0.006) (all p < 0.05). Marginal bone loss in the posterior maxilla was modest during long-term follow-up. Surgical methods and adjunctive procedures were associated with annual marginal bone level change in this cohort. However, given the observational nature of the study, these findings should be interpreted as exploratory associations rather than clinically predictive factors or definitive evidence to support specific treatment choices.

Groundwater nitrate contamination in intensive croplands often persists despite strong short-term weather variability, suggesting that near-surface signals may not translate directly to aquifers. We tested this across a four-site south-to-north transect in Henan Province, China, under a wheat-maize rotation. For each sampling event, we quantified antecedent hydroclimatic windows from daily meteorological data, and measured depth-integrated (0-50 cm) soil inorganic N stocks, soil N-cycling enzyme activities, groundwater NO3--N, and nitrate isotopes (&#x3b4;15N-NO3- and &#x3b4;18O-NO3-). Principal component analysis summarized hydroclimatic variability into two dominant gradients: a dry-frequency axis (PC1) and an evaporative-demand axis (PC2). Drier antecedent conditions (higher dry-frequency scores) were consistently associated with greater 0-50 cm soil NO3- storage and coordinated changes in enzyme indices related to N turnover; the dry-frequency gradient accounted for 41% of the variance in soil NO3--N stocks. In contrast, groundwater nitrate showed weak short-term coupling across all window lengths, with only 19% of NO3- variability explained and no significant contemporaneous associations with short-term soil indicators or hydroclimate axes. Isotope patterns showed strong site- and stage-dependent scatter: groundwater &#x3b4;15N-NO3- varied widely (3.5-17.5&#x2030;) while &#x3b4;18O-NO3- remained narrow (7.0-8.9&#x2030;), consistent with mixing among multiple nitrate sources and transport lags that buffer legacy signals in the aquifer. These results help explain why groundwater nitrate remains poorly predictable from short-term surface indicators, and they support management strategies that prioritize sustained reductions in long-term N surplus and monitoring designs that account for subsurface storage and time lags.

Avian leukosis virus (ALV) causes immunosuppression and tumors, resulting in considerable economic losses in the poultry industry. However, the genetic basis of ALV susceptibility in indigenous breeds remains elusive. Herein, we conducted a genome-wide association study for ALV susceptibility in 259 Wuhua yellow chickens, an indigenous Chinese breed with known disease resistance. ALV infection status was determined by p27 antigen ELISA at 46 weeks of age, with 10 individuals (3.9%) classified as positive. We identified 58 significant SNPs, all located on chromosome 12 and concentrated within a 1.03-Mb region (12.19-13.22 Mb), using SAIGE to account for extreme case&#x2011;control imbalance. Gene annotation demonstrated 11 candidate genes, among which FHIT accounted for 44 of the 58 significant SNPs (76%). Additionally, PDHB, PTPRG, FAM3D, and FAM107A were identified as potential candidate genes associated with ALV susceptibility. Notably, conditional analysis confirmed that the lead SNP in FHIT (chr12:12,650,715) is the main driver of this cluster, given that its inclusion as a covariate eliminated all neighboring signals. Functional enrichment showed the citrate cycle as the most considerably enriched pathway, highlighted by PDHB, alongside pyruvate and carbon metabolism. The convergence of tumor suppression (FHIT, FAM107A), metabolic reprogramming (PDHB), and immune/signaling (PTPRG, FAM3D) genes within a single genomic region suggests a potential resistance-associated haplotype block. Our study provides promising candidate genetic markers for breeding ALV-resistant lines and offers novel insights into host-retrovirus interactions beyond traditional immune signaling.

Radiotherapy outcome analyses involve heterogeneous fractionation schemes and treatment times, complicating direct dose comparisons. This is particularly relevant for dose de-escalation in elective lymphatic drainage volumes, where schedules and durations may vary. This study presents the application of repopulation-corrected dose metrics, focusing on the use and limitations of biologically effective dose (BED) and equivalent dose in 2-Gy fractions (EQD2) for heterogeneous radiotherapy schedules in nasopharyngeal carcinoma (NPC). A retrospective cohort of NPC patients was analysed. BED values were calculated using a time-inclusive approach accounting for tumor repopulation. Corresponding EQD2 values were derived as proposed by Dale et al. This method systematically accounts for repopulation effects that may occur in the derived schedule. Dose metrics were analysed in relation to overall survival using exploratory statistical analyses, assessing sensitivity to model assumptions and parameter choices. Repopulation-corrected dose metrics (i.e. BEDs and EQD2s calculated by the method of Dale et al.) showed improved internal consistency across heterogeneous treatment schedules compared with cumulative absorbed dose and non-repopulation-adjusted EQD2. Within a limited range of repopulation-corrected doses, an apparent transition in overall survival was observed; however, this effect was sensitive to radiobiological assumptions, treatment time, and cohort size. Repopulation-corrected dose metrics provide a practical framework for comparing heterogeneous radiotherapy schedules while highlighting methodological limitations. Transparent reporting of treatment parameters and cautious interpretation of threshold-like effects are essential. Although not establishing definitive dose-outcome relationships, this framework may inform future studies on dose de-escalation of elective lymphatic drainage volumes in NPC.

This study aimed to examine the mediating role of health anxiety in the relationship between illness perception and self-management behavior among individuals with inflammatory bowel disease(IBD). A total of 326 patients with IBD who were treated at our hospital between June 2023, and June 2025 were enrolled. Data were collected using a general information questionnaire, the Brief Illness Perception Questionnaire (BIPQ), the Short Health Anxiety Inventory (SHAI), and the IBD Self-Management Behavior Scale. Among the 326 participants, the mean BIPQ, SHAI, and self-management scores were 47.31 (SD&#x2009;=&#x2009;12.71), 28.89 (SD&#x2009;=&#x2009;8.81), and 67.79 (SD&#x2009;=&#x2009;20.48), respectively. Self-management scores were significantly lower among patients older than 60 years and those with a disease duration of more than five years, whereas higher scores were observed among patients with a monthly income greater than 5,000 yuan (all P&#x2009;<&#x2009;0.05). BIPQ scores were negatively correlated with self-management behavior (r = -0.660) and positively correlated with SHAI scores (r&#x2009;=&#x2009;0.417). SHAI scores were negatively correlated with self-management behavior (r = -0.501). Mediation analysis showed that the BIPQ scores had both a direct negative association with self-management behavior (coefficient = -1.180, accounting for 82.69% of the total effect) and an indirect association mediated through health anxiety (coefficient = -0.246, accounting for 17.31% of the total effect). The 95% bias-corrected bootstrap confidence interval for the indirect effect did not include zero. Patients with IBD in this cohort exhibited predominantly negative illness perceptions, elevated health anxiety, and suboptimal self-management behaviors. The findings suggest that illness perception is associated with self-management behavior both directly and indirectly through the mediating role of health anxiety. These cross-sectional findings suggest the potential value of integrating psychological assessment and intervention into routine IBD care to improve patient self-management and long-term health outcomes. However, causal inferences cannot be drawn from the present data.

Digital health technologies have untapped potential to transform community health systems, and they are underutilized for chronic HIV care and electronic data management in low- and middle-income countries. We describe the design, development, and use of a mobile health application in community-based HIV prevention, care, and treatment programs implemented in Ethiopia since 2017. Initially, these programs utilized aggregate data collection methods, which were fragmented, non-uniform, and largely paper-based, posing challenges to data quality and data use. Local software developers applied user-centered methods to build a Unified Data System (UDS), an innovative digital health solution aimed at standardizing case management and routine data collection procedures. Developers involved end-users, including frontline community health workers (CHWs) and program managers, in the design and development process. They also conducted field visits to understand and assess user activities and needs. Developers and program staff conducted field testing, and they made design changes iteratively to incorporate user feedback. Local implementing partners deployed 950 CHWs to use the UDS for HIV service delivery and client-level data collection offline. Data were stored centrally in the CommCare HQ web service backed by a local analytics server. The UDS was linked to Power BI for advanced data analytics and visualization. Data validation tests were performed prior to indicator computation and reporting to the next level. 1,766 mobile accounts were opened for CHWs, of which 1,628 (92.2%; 95% confidence interval [CI]=90.8%, 93.4%) have submitted data. An additional 368 of 392 web accounts (93.9%; 95% CI=91.0%, 96.0%) have been used by program managers and monitoring and evaluation experts to access the dashboard. The UDS has eliminated the tedious, manual, paper-based work associated with data (dis)aggregation and reporting by frontline CHWs and local implementing partners. Hence, the number of days to access client-level data by the local partners was reduced from 1 month to just 1 day, and the time to report on activity performance was shortened from 5 days to a half-day. Data completeness was nearly 100% and data validation tests demonstrated no invalid data elements or errors. Generally, there was a high degree of digital health technology utilization by frontline CHWs and local implementing partners for standardized HIV care, high-quality data collection, and making data-informed decisions. Lessons learned from the UDS implementation could be adapted not only to support community HIV programming but also to strengthen national electronic community health information systems.

Coronary autoregulation maintains relatively constant myocardial blood flow over a wide range of perfusion pressures through myogenic, shear-dependent and metabolic control mechanisms. Understanding this phenomenon is challenging due to the coupled nature of these mechanisms and their heterogeneous effects throughout the coronary tree. In this study, we developed a framework to study coronary autoregulation based on constrained mixture theory. The framework simulates autoregulation at three myocardial depths (subepicardium, midwall and subendocardium), calibrated using extensive literature data. Coronary trees at each myocardial depth are constructed via a homeostatic optimization approach to determine morphological and haemodynamic characteristics. Each vessel is endowed with passive and active mechanical properties, governed by a microstructurally motivated wall model. Autoregulatory stimuli from myogenic, metabolic and shear-dependent mechanisms modulate vascular smooth muscle tone, enabling the framework to reproduce autoregulatory responses, experimentally measured transmural flow ratios and vessel diameter changes with variations in perfusion pressure. The framework also incorporates phasic dynamics by extending Womersley's theory to account for time-varying intramyocardial pressures, successfully capturing key features of coronary flow waveforms. Sensitivity analysis highlights metabolic mechanisms as primary contributors to autoregulatory function, with the myogenic response playing an important role and shear-dependent control having minimal contribution. Additionally, the framework demonstrates how changes in vessel microstructure (e.g. collagen stiffening or impaired smooth muscle contractility) affect autoregulatory capacity, providing mechanistic insight into pathophysiological states. This microstructurally motivated framework offers a novel approach for hypothesis testing in coronary autoregulation while providing a unified platform for describing processes spanning short-term tone regulation and long-term vascular remodelling. KEY POINTS: Coronary autoregulation is defined as the capability of the coronary circulation to maintain the blood supply to the heart over a range of perfusion pressures. This phenomenon is facilitated through intrinsic mechanisms that control the vascular resistance by regulating the function of smooth muscle cells. This paper presents a microstructurally motivated coronary autoregulation framework that uses a non-linear continuum mechanics approach to account for the morphometry and vessel wall composition in three coronary trees in the subepicardial, midwall and subendocardial layers of the myocardium. The model is calibrated against diverse experimental data from the literature and is used to study heterogeneous autoregulatory response in the coronary trees. This model drastically differs from previous models and is suited to the study of long-term pathophysiological growth and remodelling phenomena in coronary vessels.

In men presenting with erectile dysfunction, reduced sexual desire, or suspected hypogonadism, laboratory work-up frequently oscillates between indiscriminate hormone panels and underuse of high-yield metabolic testing. From a clinical biochemistry perspective, the key question is not how many biomarkers can be ordered, but which tests are analytically fit for purpose and likely to change management. This evidence-informed narrative review examines biomarkers commonly used in erectile dysfunction and androgen-deficiency phenotypes, with emphasis on glycemic biomarkers, lipids, testosterone, sex hormone-binding globulin (SHBG), calculated free testosterone, prolactin, thyroid function tests, and selectively indicated estradiol. The review focuses on preanalytical control, assay limitations, interpretative pitfalls, and laboratory stewardship. In most men with erectile dysfunction, the highest-value initial laboratory panel consists of fasting glucose and/or hemoglobin A1c (HbA1c), a lipid profile, and early-morning fasting testosterone, provided recent results are unavailable. Low or borderline testosterone should be confirmed on a second independent early-morning fasting sample before biochemical classification, with attention to assay performance and to SHBG with calculated free testosterone when indicated. Prolactin testing is reserved for selected endocrine phenotypes and must account for medication use, macroprolactin, and the hook effect. Thyroid tests and estradiol should be phenotype driven rather than routine. A selective, analytically robust testing strategy can reduce misclassification, support cardiovascular and endocrine phenotyping, and better align biomarker results with clinically actionable decisions.

To estimate the pooled prevalence and associated factors of gastro-oesophageal reflux disease (GERD) in Saudi Arabia and other Gulf Cooperation Council (GCC) countries. Systematic review and meta-analysis DATA SOURCES: Searches were carried out in Web of Science, Scopus, PubMed, Google Scholar and Dimensions AI with no date or language filters. Cross-sectional studies that reported estimates of GERD prevalence from Saudi Arabia and other GCC countries were included. Two reviewers independently extracted the data, and the accuracy and clarity of the final extracted data were cross-checked by another two reviewers. Study quality was assessed using JBI Critical Appraisal Tool for Prevalence Studies. Random-effects model was used for meta-analyses. Fourteen studies from Saudi Arabia met the inclusion criteria (total participants=17 927); from the other GCC countries, only one study from Bahrain and none from Qatar, United Arab Emirates, Kuwait or Oman met the inclusion criteria, and thus were not included in the pooled analysis. The pooled prevalence of GERD from Saudi Arabia was 32% (95% CI 22% to 44%); however, there was substantial heterogeneity (I&#xb2; = 99.4%). In subgroup analysis to account for heterogeneity, the prevalence was found to be significantly lower when endoscopy findings were used as the diagnostic criteria (13% (95% CI 10% to 16%); &#x3c4; 2=0.028; I&#xb2; = 93.4%) compared with Gerd-Q questionnaire (33% (95% CI 24% to 43%); &#x3c4; 2=0.54; I&#xb2; = 98.6%) (p<0.0001). Similar findings were noted based on study quality: high, 26% (95% CI 17% to 36%); moderate, 49% (95% CI 32% to 66%) (&#x3c4; 2=0.87, I&#xb2; = 99.3%) (p=0.0185). Factors that increased the odds of GERD were non-steroidal anti-inflammatory drugs/analgesics use (OR: 1.78, 95% CI 1.14 to 2.79; p=0.01; &#x3c4; 2=0.09, I&#xb2; = 59%) and smoking (OR: 1.59, 95% CI 1.28 to 1.99; p<0.0001; &#x3c4; 2=0.03, I&#xb2; = 33%). The pooled prevalence of GERD in Saudi Arabia is 32%. However, given the high heterogeneity, there is a need to standardise methods for better contextualisation of such epidemiological data. Notably, GERD prevalence was significantly lower in high-quality studies and when endoscopy findings were used as the diagnostic criteria. Finally, the lack of GERD prevalence studies from other GCC countries highlights the need for studies to fill this gap. PROSPERO (ID: CRD42023453031).

In situ capping is a widely used contaminated sediment treatment technology to mitigate risks to human health and the environment resulting from contaminated sediments. Regulatory agencies typically require long-term effectiveness monitoring (LTM) of sediment caps to ensure that contaminants are contained by the cap, with monitoring typically in perpetuity well beyond a typical LTM duration for other remedy types. An implicit assumption behind the LTM requirement is that organic contaminants persist in anaerobic sediment environments below the cap, and cap design and associated performance monitoring typically do not account for biodegradation of residual contaminated sediments under the cap. However, the colonization of capping materials by microorganisms capable of transforming organic contaminants has been documented in numerous studies, with enhanced degradation of some organic contaminants via biostimulation or bioaugmentation. Given the regulatory focus on assessing the potential for sediment-water contaminant release, the long-term impact of in situ degradation under sediment caps, including the effectiveness of cap amendments at encouraging biodegradation, is poorly documented. This analysis evaluates the pathways of anaerobic biodegradation for common organic contaminant classes, conservative assumptions that neglect consideration of anaerobic biodegradation in sediment cap design, and LTM; compiles degradation rates for polycyclic aromatic hydrocarbons (PAHs) under anaerobic conditions; and identifies implications for future research, regulatory frameworks, and cap design. This review focuses on PAHs due to the robust body of data on anerobic degradation rate kinetics, but the underlying concepts and resulting recommendations are broadly applicable to other organic contaminant classes managed using capping technology. Current understanding and quantification of anaerobic degradation rates are largely based on controlled laboratory studies, which limits the reliable application of these findings to field-scale remedial design. This literature review presents recommendations to improve understanding of in situ anaerobic biodegradation with specific consideration for LTM planning and cap modeling.

Bisphenol A (BPA) is a high-production industrial chemical used in polycarbonate plastics and epoxy resins. Dietary intake is a major exposure pathway for the general population due to BPA migration from food-contact materials. Using nationally representative data from the Korean National Environmental Health Survey (KoNEHS; Cycles 1-4, 2009-2020), we evaluated temporal trends in urinary BPA concentrations among 18,050 adults and assessed associations with processed food consumption. Analyses accounted for the complex survey design, and urinary BPA concentrations were adjusted for creatinine. In pooled analyses adjusting for demographic and lifestyle factors, frequent consumption of processed foods-particularly canned foods (&#x3b2;=0.134), instant noodles (&#x3b2;=0.180), and burgers (&#x3b2;=0.116)-was associated with higher urinary BPA concentrations. Urinary BPA concentrations increased during 2012-2017 and declined from 2018 onward, a temporal pattern consistent with strengthened national regulations related to food-contact materials and plastic waste management in South Korea. These findings identify processed food consumption as an important dietary correlate of BPA exposure and support continued biomonitoring to inform exposure-reduction strategies and risk management for food-contact materials.

This study aims to explore the critical risk factors associated with surgical site infection (SSI) in patients with type 2 diabetes mellitus (T2DM) undergoing oral and maxillofacial surgery, and to develop a predictive model to support early risk stratification and guide targeted preventive approaches. This retrospective, case-control study enrolled patients with T2DM who underwent oral surgery at Nanjing Stomatological Hospital, Nanjing University between June 2022 and June 2025. A total of 110 patients who developed postoperative SSI were included in the infection group. A total of 110 patients without SSI were selected as the control group, matched 1:1 according to age and sex. Detailed demographic and clinical data, including patient history, perioperative blood glucose control levels, surgical type, oral environment, and antibiotic usage, were collected from both groups. Risk factors associated with SSI were analyzed and compared between groups, and a nomogram prediction model was developed. Internal validation was performed using 5000 bootstrap resamples, and model performance was assessed via the area under the receiver operating characteristic (ROC) curve (AUC) and calibration plots. Among the 110 patients who developed SSI after oral surgery, microbiological assessment identified Gram-negative bacteria as the predominant pathogens (62.73%), with Pseudomonas aeruginosa accounting for 18.18% and Klebsiella pneumoniae for 14.55% of the isolates. This was followed by Gram-positive organisms, which account for 34.55% of the pathogens, predominantly Staphylococcus aureus (10.91%). Multivariable logistic regression analysis showed that a surgical incision classified as Type II or III (vs Type I; Odds Ratio [OR] = 3.789), severe periodontal calculus in the oral environment (Grade III vs Grade I-II; OR = 4.092), poor blood glucose control (vs good; OR = 3.347), and elevated serum C&#x2011;reactive protein (CRP) levels (per unit increase; OR = 1.627) were independently associated with postoperative surgical site infection. A nomogram was constructed based on the equation: Logit (P) = 1.402 + 1.332 &#xd7; (incision type) + 1.409 &#xd7; (oral environment) + 1.208 &#xd7; (blood glucose control) + 0.487 &#xd7; (CRP). The maximum total score on the nomogram was 225 points, corresponding to a 90% predicted probability of postoperative SSI. The Hosmer-Lemeshow test (&#x3c7;2 = 2.088, p = 0.230 > 0.05) demonstrated no significant difference between the observed and predicted outcomes of the nomogram model. The nomogram demonstrated excellent predictive performance, with an AUC of 0.897 (95% Confidence Interval [CI]: 0.855 to 0.939). The oral environment, perioperative glycemic control, CRP levels, and surgical incision type are independent risk factors associated with postoperative SSI. Establishing a prediction model based on these factors and implementing targeted interventions can effectively reduce infection in this high-risk cohort.

Energy requirements in the human body are met by fuel mobilization stored in the form of fat, protein and carbohydrate. Fat depots and glycogen storage in muscle and liver represent the largest contributors that sustain essential organic functions and mobility. Protein reserves are intended primarily for structural, biochemical and physiological purposes and are, thus, spared as substrate for oxidation, except under conditions of prolonged starvation. Extracellular free FFA, triglycerides and glucose account for only a minor fraction of the total energy storage, but they are essential sources of energy to organs and tissues in times of need. Therefore, maintenance of appropriate circulating levels of these substrates, particularly glucose, is an important component of fuel homeostasis. In this review, we focus on those mechanisms responsible for maintaining adequate blood glucose concentrations, with an emphasis on the role of the kidney. Renal adaptations to changes in the metabolic milieu, both in healthy and diabetic conditions, will be examined. We will provide a comprehensive description of the pharmacology and therapeutic actions of the sodium-glucose co-transporter 2 inhibitor [SGLT2i] class of drugs, which target the kidney and inhibit the reabsorption of glucose. The renal and cardiovascular benefits of the SGLT2i will be reviewed.

Forest litter strongly affects wildfire ignition, heat release, smoke generation, and post-fire carbon cycling, but species-specific leaf-level combustion data remain limited for subtropical green-space management. This study investigated the combustion behavior, carbon emission characteristics, and biochar properties of Liriodendron, Rhododendron, and Camphor litter collected from a managed subtropical green-space environment in East China. Leaf specimens were tested under external heat fluxes of 35, 55, and 75&#x202f;kW/m2 using CONE tests, combined with proximate and ultimate analyses, carbon emission measurements, FESEM-EDS characterization, and Monte Carlo uncertainty analysis. The results showed clear interspecific differences. Rhododendron exhibited the highest PHRR, indicating strong short-term fire-growth potential, whereas Camphor showed the highest THR, ICF, and CO/CO2 ratio, suggesting greater sustained-burning, CO2-emission, and smoke-exposure risks. In contrast, Liriodendron generally showed lower heat-release and emission potential. Biochar analysis indicated that approximately 14.03% of the initial dry leaf mass was stored as CO2-equivalent carbon over a 100-year timescale, with a Monte Carlo 95% uncertainty interval of 11.2%-17.5%. These findings provide laboratory scale evidence for species-specific litter-risk classification and support differentiated litter management, vegetation planning, and carbon-accounting strategies in subtropical urban forests and wildland-urban interface environments.

Alcohol adversely affects cognitive and motor functions that are critical for surgical performance. Although its general physiological and neurocognitive effects are well documented, evidence regarding its impact on complex, high-precision tasks-such as surgical procedures-remains limited. In this study, nine neurosurgeons performed a series of standardized surgical tasks assessing fine motor skills, gross motor control, and hand-eye coordination under three conditions: sober, acutely influenced (blood alcohol concentration [BAC]&#x2009;~&#x2009;1.0 g/kg), and during the elimination phase several hours after alcohol consumption (BAC&#x2009;~&#x2009;0.6 g/kg), with blood samples collected in each condition for BAC determination in accordance with German forensic standards. Across all nine participants, a total of 189 tests were conducted and evaluated, taking into account both the time required to complete each task and the quality of task performance. Task quality declined in both the acutely influenced and elimination phases. Significant impairments in quality were observed in almost all tasks. During acute influence, tasks such as suturing took longer to complete, whereas others like drilling were performed more quickly. In the elimination phase, all tasks were completed faster than at baseline. These findings suggest that even moderate alcohol intake can have lasting effects on surgical precision and may have implications for patient safety in operative settings.

Escalating health-care costs and increasing patient complexity underscore the need for standardized, comparable measures of surgical value. Despite numerous proposed indices, methodological heterogeneity limits cross-specialty comparison. This scoping review aims to (1) characterize trends in value index utilization, (2) assess variability in index components, (3) identify specialty-specific and bibliometric patterns, and (4) propose a preliminary conceptual model to guide index selection. A Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews-guided scoping review of PubMed, Embase, and Google Scholar (July 2025) identified 2015-2025 studies evaluating surgical value. Eligible English-language, peer-reviewed studies applied quantitative value indices, while reviews, case reports, and nonoperative studies were excluded. Two reviewers screened independently, and data on specialty, index type, and components were extracted. Bibliometric analysis mapped keyword clusters and citation trends. Of 342 included studies, 11 distinct indices were identified. The most frequently reported indices were incremental cost-effectiveness ratio (n = 189, 55.3%), time-driven activity-based costing (n = 93, 27.2%), and net monetary benefit (n = 27, 7.9%), followed by return on investment (n = 23, 6.7%) and operative value index (n = 6, 1.8%); net health benefit, net present value, and procedure value index each accounted for under 1% of studies (n &#x2264; 6). General, orthopedic, and cardiothoracic surgery were the most represented specialties. Bibliometric analysis identified orthopedic-predominant keyword clusters and citation bursts in replacement and quality of life. Substantial heterogeneity in index selection across specialties motivated development of a preliminary conceptual model for index selection. This first scoping review of surgical value metrics reveals pervasive heterogeneity and introduces a preliminary conceptual model intended to organize index selection and motivate future validation efforts toward comparable, evidence-based value assessment.

This study examines the association between maternal education, human reproductive behavior, and fertility adaptation in Pakistan, using nationally representative data from the Pakistan Demographic and Health Survey (PDHS) 2017-2018. It aims to assess how different levels of maternal education influence fertility outcomes, particularly children ever born, while controlling for key demographic, socioeconomic, and reproductive factors. The study utilizes cross-sectional data from ever-married women aged 15-49&#x2009;years (N&#x2009;=&#x2009;14&#x2009;500). Fertility behavior is measured using children ever born (CEB) as a count variable. Maternal education is categorized into four levels: no education, primary, secondary, and higher education. Descriptive and bivariate analyses are conducted to examine fertility differentials, followed by multivariate regression models, including Poisson and Negative Binomial regression, to estimate adjusted incidence rate ratios (IRRs). Logistic regression is additionally employed to assess high fertility (CEB &#x2265;&#x2009;4). All analyses account for the complex survey design using sampling weights. The findings reveal a strong and statistically significant inverse relationship between maternal education and fertility behavior. Women with higher education have substantially lower fertility compared to those with no education. Specifically, higher education is associated with nearly a 49% reduction in children ever born (IRR&#x2009;=&#x2009;0.51, p < 0.001), while secondary education reduces fertility by approximately 28%. The results indicate a clear dose-response relationship, with stronger effects observed at higher levels of education. Additionally, age at marriage, urban residence, wealth status, and modern contraceptive use are significantly associated with reduced fertility. These findings remain robust across multiple model specifications. Maternal education emerges as a critical determinant of fertility behavior in Pakistan, operating through multiple pathways, including delayed marriage, increased contraceptive use, and enhanced reproductive autonomy. The findings highlight the importance of expanding access to secondary and higher education for women as a key strategy for lower fertility intensity and improved reproductive outcomes. The findings contribute to understanding how maternal education shapes reproductive behavior and fertility outcomes within the broader sociocultural and ecological context of a high-fertility population.

This study aimed to assess the awareness, perception, and utilization of complementary and alternative medicine (CAM) among Korean patients with cancer and their caregivers. Furthermore, it evaluated CAM information sources, the reliability of these sources, communication patterns with clinicians, and the effect of caregiver beliefs on the use of CAM and patients' attitudes toward CAM. A nationwide cross-sectional survey was conducted from September 2021 to January 2022 across 19 hospitals in South Korea. Adult patients with cancer and their accompanying caregivers were recruited via convenience sampling from outpatient oncology clinics and inpatient settings and completed a structured questionnaire. Data from 1,804 patients and 768 family members were analyzed using descriptive statistics and appropriate comparative tests. Among patients, 47.2% had heard of CAM, and 41.0% expressed belief in it. Biologically based therapies were the most commonly used form of CAM among users (55.0%). The primary sources of CAM information were family/relatives (24.8%) and television (23.8%), whereas medical professionals accounted for only 5.4% of sources, although doctors and nurses were perceived as the most reliable (mean reliability: 3.43 on a 5-point scale). A significant communication gap was observed, with 71.7% of patients not discussing CAM with their medical professionals. Common reasons for non-disclosure included a lack of patient interest (39.4% of non-disclosers), the perception that CAM was irrelevant to their doctors (27.6%), and concerns about physician disapproval. Among patients who did consult their clinicians, 60.8% were advised against CAM use. Caregivers' CAM beliefs significantly influenced patients' beliefs (odds ratio [OR], 4.242; p<0.001), although this did not translate into a statistically significant direct effect on CAM use by patients (OR, 1.449; p=0.105). CAM awareness and use are substantial among Korean patients with cancer; however, a critical communication gap with healthcare providers persists. Family members are key information sources, and caregiver beliefs influence patient beliefs regarding CAM. Proactive, empathetic, and evidence-based communication about CAM is essential to promote shared decision-making and ensure safe, patient-centered integrative cancer care.