ABSTRACT Teachers are at high-risk of poor sleep. Teachers face many individual factors (e.g. teacher self-efficacy) and organisational factors (e.g. stressful milestones of the school year) that may influence their sleep. This study explores the impact of individual and organisational factors on the sleep of Australian teachers. An online survey was completed by 775 (89% female, 52.6% 35–55 years old) Australian school teachers. Questions included demographics, school milestones, organisational support, and the Pittsburgh Sleep Quality Index (PSQI). Descriptive statistics determined the milestones of the school year where the poorest sleep was reported. A binomial logistic regression model was used to model the likelihood of experiencing poor sleep quality as a function of demographic variables. A majority of teachers (59%) reported less than 7 hours of sleep per night, and poor sleep quality (79%). During stressful times of the school year, such as report writing, 35% of teachers believed their sleep to be less than 5 hours. To improve sleep, these individual and organisational factors should be incorporated into sleep education provided to teachers and organisations.

This research evaluates the technical and financial feasibility of green hydrogen production in Colombia using Small Hydropower Plants (SHPs), positioning them as a strategic complement to intermittent sources such as solar and wind. To address an underexplored niche in the national hydrogen roadmap, the study applies a Real Options framework, specifically using a binomial tree model, and incorporates the Weibull distribution to estimate risk-adjusted discount rates. This methodological combination allows for the modeling of operational flexibility under uncertainty, particularly through the analysis of an American-style abandonment option. The results indicate that SHPs provide continuous power generation, enhance electrolyzer efficiency, lower the Levelized Cost of Hydrogen (LCOH), and improve cash flow. However, fiscal incentives and high initial capital costs remain limiting factors. The study proposes extending the evaluation horizon to 15 years and implementing mechanisms such as Capital Expenditures (CAPEX) subsidies to improve project viability. Overall, the research contributes to the diversification of Colombia’s energy matrix, encourages regional development, and supports the positioning of green hydrogen as a viable financial asset within the country’s energy transition framework.

The perinatal period is considered protective against suicide among women of reproductive age. However, it is unclear if this applies to nonfatal suicidal behavior. This study compared rates and determinants of suicidal behavior during pregnancy/delivery, postpartum, and nonpregnancy/nonpostpartum. A repeated cross-sectional study was performed using 2006-2019 Florida hospital discharge records. Trends in hospitalization rates were assessed for suicidal ideation and intentional self-harm by pregnancy period, and adjusted rate ratios (aRRs) were estimated using negative binomial regression models to compare pregnancy/delivery and postpartum to nonpregnancy/nonpostpartum. Determinants were also compared across pregnancy periods. Hospitalization rates for suicidal ideation in 2018-2019 versus 2006-2007 were 3.5, 5.9, and 5.1 times higher during pregnancy/delivery, postpartum, and nonpregnancy/nonpostpartum, respectively. In contrast, rates for intentional self-harm declined during nonpregnancy/nonpostpartum (RR = 0.85), with no significant change during pregnancy/delivery or postpartum. Compared with nonpregnancy/nonpostpartum, aRRs for suicidal ideation were significantly lower during pregnancy/delivery (aRR = 0.08) and postpartum (aRR = 0.13). Similar findings were observed for intentional self-harm (aRRs = 0.08 and 0.14, respectively). Determinants varied slightly by behavior and period. During pregnancy/delivery and postpartum, younger age, non-Hispanic Black race (pregnancy/delivery only), and Medicaid/Medicare or "Other" payer were positively associated with both behaviors, whereas Hispanic ethnicity and Medicaid/Medicare or "Other" payer were positively associated with both behaviors during nonpregnancy/nonpostpartum. Suicidal behavior is a significant concern during the reproductive period. Increasing access to mental healthcare and tailoring interventions to high-risk populations are important to reducing hospitalization rates.

To compare the clinical characteristics, biochemical presentation, and short- and long-term outcomes of DKA in hospitalized adults with T1DM and T2DM, including the impact of SGLT2 inhibitor therapy. A retrospective cohort of 2283 adults (838 with T1DM; 1445 with T2DM) hospitalized with DKA between 2013 and 2023 across Clalit Health Services hospitals was analyzed. Patients were stratified by SGLT2 inhibitor use within 4 months before admission. Outcomes included AKI, 30-day mortality, 1-year mortality, and readmissions. One-year mortality was assessed using Cox proportional hazards regression, 30-day mortality using logistic regression, and recurrent readmissions using a negative binomial model. 2.3% (N = 19) of T1DM and 16% (235) of T2DM patients were treated with SGLT-2 inhibitors. A total of 115 patients from all cohorts presented with eu DKA, characterized by lower glucose and bicarbonate levels. In T2DM, the incidence of AKI was higher among SGLT2 users (26% vs. 17%; p = 0.030) but lower in euDKA cases (9.6% vs. 19%; p = 0.020). In Cox regression analysis, treatment with SGLT2 inhibitors was independently associated with reduced 1-year mortality (HR 0.55, 95% CI 0.36-0.82; p = 0.004). Predictors of increased 1-year mortality included older age, higher HbA1c, cardiovascular disease, CKD and insulin therapy. In the negative binomial model, higher readmission rates were independently associated with T1DM, higher HbA1c, higher BMI, CKD and pre-admission insulin use, while SGLT2 inhibitor use was not linked to increased readmissions. Pre-hospital SGLT2 inhibitor therapy in patients presenting with DKA was associated with substantially lower long-term mortality and no increase in short-term mortality or readmissions, supporting the safety of these agents when appropriate monitoring is in place. Pre-hospital SGLT2 inhibitor therapy in patients presenting with DKA was associated with improved long-term survival and no increase in short-term mortality, supporting their continued use with appropriate clinical monitoring.

Traditional medicines can contribute to achieving universal health coverage, particularly in low- and middle-income countries where access to conventional treatments is limited. International collaboration is crucial to bridge the lag in modernised research and promote access to traditional medicines. This study focused on China's global collaborative research and development (R&D) efforts on traditional medicine, in the hope of improving global recognition for traditional medicine. We conducted a cross-sectional study to analyse collaborative R&D outputs on Chinese patent medicines from 1996 to 2022. The study cohort included the collaborative outputs of scientific research, patent applications, and clinical trials between China and other countries. We analysed the outputs using data from the Web of Science, Worldwide Patent Statistical Database, and the International Clinical Trials Registry Platform. The Zero Inflated Negative Binomial regression model was employed to investigate the association between outputs and the characteristics of participating countries. The majority of collaborative outputs (n = 964, 92.4%) originated from collaborations with high-income countries, with only 7.6% involving low- and middle- income countries (LMICs). The percentage of R&D collaborations with LMICs showed an increasing trend from 0% in 1996 to 11.7% in 2022. Most collaborations focused on non-communicable diseases (n = 912, 87.4%). Low-income countries accounted for a larger share of collaborative R&D on communicable diseases (14.3%) compared with high-income countries (1.4%). The total number of outputs was positively associated with the degree of cooperative institutionalisation and the collaborator's traditional medicine development score. Gaps still remain in the involvement of low- and middle-income members compared with high income countries. Findings highlight the importance of encouraging greater engagement of low- and middle- income countries in global R & D collaboration on traditional medicine, particularly through South-South partnerships. Such collaborations should prioritise research agendas that address local health priorities, especially those related to communicable diseases.

Team-based care is a primary care model that involves collaborative care between primary care providers and other professional providers. In Ontario Canada, this model is delivered through Community Health Centres. The study objective was to identify if visits to different providers within Community Health Centres were associated with fewer emergency department visits. We conducted a retrospective population-based, nested case-control study using healthcare data at ICES. We included adults receiving primary care at a Community Health Centre in Ontario between 2016 and 2018 and captured the outcome of emergency department visits between 2019 and 2020. Using the Generalized Estimating Equation (GEE) extension of the negative binomial regression model, we estimated the association between number of visits to seven different provider types within a Community Health Centre and number of emergency department visits, with adjustment for potential confounders. We defined team-based care as a visit to one of the providers in a group other than a primary care physician or nurse practitioner (i.e., mental health, diet and lifestyle education, community workers/ lay patient support, physical therapy, health promotion system navigation, foot care). We also calculated the ratio of observed-to-expected average emergency department visits per person. We identified 138,324 patients across 71 Community Health Centres, with 43% who received team-based care. We found that increased number of visits to any provider was associated with more emergency department visits. However, there were no significant differences between observed and expected number of emergency department visits for people who received care from different providers. Almost half of the adult Community Health Centre population received team-based care. Although some benefits of team-based care have been established in the literature, we did not find any associations between care received from individual team-based provider types with lower emergency department visits.

Leishmaniasis is a neglected tropical disease that primarily occurs in developing countries. This disease is caused by more than 20 species of the genus Leishmania. To face this problem, Brazil's health authorities establish control of the canine reservoir through serological surveys and sacrifice of seropositive dogs. This study aimed to evaluate the serodiagnosis process and registration of canine visceral leishmaniasis (CVL) cases by the Environmental Health Surveillance Directorate (EHSD) of Federal District, Brasilia, the capital city of Brazil. We analyzed the EHSD database from 2005 to 2022. The database contained 52,266 records, with an overall positivity of 15.78%. The results indicated a risk association between the variables sex, age, fur size, and symptomatic state with CVL seropositivity. In the binomial logistic regression model, being male, being older than 6 years, and having a short fur increased the odds of a positive diagnosis. Among the clinical signs recorded, skin lesions were the most sensitive in indicating the presence of CVL (62.4%). The factor with the highest specificity was alopecia around the eyes (83.6%). The administrative regions with an incidence of human cases were the same as those with a high seroprevalence of CVL between 2011 and 2022.

Opioid agonist treatment (OAT) is an evidence-based intervention that reduces harms associated with heroin use. Ambulance services often serve as the first point of contact for people experiencing these acute harms. OAT access relies on dosing points and prescribers, which may be unevenly distributed geographically. This study examines the geographical distribution of heroin-related ambulance attendances across Victoria and assesses whether the presence, availability, and number of OAT service providers are associated with these harms. We merged 2023/24 Victorian heroin-related ambulance attendance from the National Ambulance Surveillance System with Victorian OAT service availability data from a statewide helpline. Three negative binomial regression models tested associations between OAT availability and heroin-related ambulance attendances at the local government area (LGA) level. Fourteen LGAs had higher than average, population-adjusted, heroin-related ambulance attendances. In Model 2, LGAs with more pharmacies offering OAT vacancies than those without had a 50% lower risk of heroin-related harms (IRR = 0.52, p = 0.014). Model 3 found that every 10% increase in the proportion of OAT doctors with current availability was associated with a 9% reduction in heroin harms (IRR = 0.91, p = 0.04). A similar trend was observed for pharmacists (IRR = 0.90, p = 0.08). All models found heroin harms to be approximately 70% lower in regional versus metropolitan LGAs. The availability and geographic distribution of OAT providers-especially those with current capacity-are linked to reduced heroin-related ambulance attendances. Strategic placement and resourcing of OAT services could better align with population need and target hotspots. The metropolitan-regional differences warrant further investigation.

We developed a Suitable Conditions Index (SCI) to predict dengue transmission in our prior work. However, the initial SCI was not refined with other important abiotic parameters. Therefore, in this study we refined the index by calculating three variants: temperature-based baseline daily average SCI (BDA-SCI), precipitation-weighted daily average SCI (PWDA-SCI), and waterbody-weighted daily average SCI (WWDA-SCI). We used the district-wise data for two South Asian dengue-endemic countries: Bangladesh and Sri Lanka. Temperature-suitable days specific to Aedes aegypti (17.05-34.61℃) and Aedes albopictus (15.84-31.51℃) were averaged (BDA-SCI) and weighted by district-level precipitation (PWDA-SCI) and waterbody data (WWDA-SCI). We assessed the association between dengue incidence and each SCI, along with other covariates using negative binomial regression models. Furthermore, a binomial logistic regression model (BLR) was used to measure the predictive accuracy of each SCI. The BDA-SCI for Ae. aegypti was highest in Sri Lanka at 0.96 (Standard deviation [SD] 0.04, range 0.85-1.00), compared to Bangladesh 0.68 (SD 0.06, range 0.61-0.87). For Ae. aegypti, WWDA-SCI (Relative risk [RR]aegypti = 1.06, p = 0.056, Akaike Information Criteria [AIC] 1218.6) and BDA-SCI (RRaegypti = 1.05, p = 0.008, AIC 1214.2) had a stronger association with dengue incidence in Bangladesh than PWDA-SCI (RRaegypti = 1.06, p = 0.056, AIC 1232.2), whereas in Sri Lanka, PWDA-SCI (RRaegypti = 1.06, p = 0.056, AIC 472.63) performed better (AICBDA-SCI: 481.36, AICWWDA-SCI: 475.89) in the multivariable model, similar to the findings for Ae. albopictus. The BLR model predicted districts with above-median dengue incidence, and model performance indicated that BDA-SCI achieved highest accuracy for Bangladesh, while WWDA-SCI performed best for Sri Lanka, based on higher sensitivity and the Area Under the Curve value. Overall, the SCI method demonstrated a practical approach for identifying dengue vector suitability and transmission risk. Refining this index with location-specific climatic and environmental variables may enhance the model accuracy and may be used for future predictions under climate change scenarios. Thus, our refined SCI will assist in creating a reliable early warning system and inform the policymakers to initiate vector control strategies, including monitoring and eliminating dengue breeding sites and implementing biocontrol strategies within hotspots.

To investigate the relationship between active commuting and atherosclerosis in middle age using state-of-the-art coronary CT angiography (CCTA). This cross-sectional study used data from the Swedish CArdioPulmonary bioImage Study (SCAPIS) and included 23 722 randomly recruited individuals aged 50-64 years from six different regions in Sweden. The exposure was commuting mode, assessed using self-reported questionnaires and categorised as year-round walking and/or cycling (active commuting), commuting by bus/train, commuting by car or mixed commuting patterns. The outcome was atherosclerosis, evaluated using CCTA for coronary stenosis and coronary artery calcium (CAC) score and ultrasound for carotid plaques. Associations were analysed using multivariate binomial logistic regression models. After adjusting for confounders (age, sex, SCAPIS site, education, occupational physical activity and leisure time exercise habits, sleep, diet and smoking habits), active commuting was associated with lower odds of coronary stenosis (OR 0.87; 95% CI 0.80 to 0.94) and a CAC score ≥1 Agatston units (OR 0.93; 95% CI 0.86 to 1.00), as compared with car commuting. No associations were observed between active commuting and the presence of carotid plaques (OR 0.97; 95% CI 0.90 to 1.03). When stratified, the inverse association with coronary stenosis appeared to be somewhat stronger for cycling (OR 0.86; 95% CI 0.78 to 0.95) than for walking (OR 0.89; 95% CI 0.79 to 1.01). Using advanced CCTA imaging in a large, randomly selected sample of middle-aged adults, we show for the first time that coronary atherosclerosis is less common in active commuters, particularly those cycling, compared with car commuters. While this indicates that active commuting might be a potential preventive measure to reduce atherosclerosis and subsequent cardiovascular disease, further causal analyses are needed to confirm our findings.

Widening Gaps in Episode of Care Markers between Medicare Managed Care and Medicare Fee-for-Service in Spinal Fusion.

In contrast to methadone, buprenorphine is susceptible to precipitated withdrawal complicated by fentanyl in the unregulated opioid supply. The objective of this study was to examine associations between drug supply characteristics and the prevalence of precipitated withdrawal. We conducted a cross-sectional analysis of a cohort study during 2023-2025 among people with a lifetime history of buprenorphine or methadone treatment currently using a drug checking program. Explanatory variables included drug supply, health care, and treatment characteristics. The primary outcome was a self-reported lifetime history of precipitated withdrawal during a buprenorphine induction. Binomial linear regression models were used to calculate prevalence ratios with 95% CIs. Among 234 people, 64% were men, 67% were non-Hispanic white, 41 was the median age, 94% reported a history of fentanyl use, 92% had a history of methadone treatment, and 68% had a history of buprenorphine treatment. Among those with a history of buprenorphine treatment, 29% reported precipitated withdrawal during buprenorphine inductions, of which 67% occurred when starting via outpatient pathways. Buprenorphine-associated precipitated withdrawal was slightly higher among those with recent xylazine use compared with those without (32% vs 22%, prevalence ratio: 2.10, 95% CI: 0.94, 4.67). People with recent buprenorphine inductions commonly started without clinical or social support (63%) or used standard dosing (53%). Buprenorphine-associated precipitated withdrawal was commonly reported. Improved guidance and treatment approaches should be prioritized to minimize these complications, particularly in outpatient settings.

Pregnancy-associated stroke may present with nonfocal symptoms, leading to missed diagnostic opportunities (MDO). We conducted a retrospective study including patients aged 18 to 50 years and pregnant or within 1 year of delivery, treated at 5 US comprehensive stroke centers from 2012 to 2021 for confirmed arterial ischemic stroke, intracerebral hemorrhage, subarachnoid hemorrhage, or cerebral venous thrombosis. Vascular neurologists at each site reviewed cases using a validated tool, Safer Stroke-Dx. We determined the proportion of cases with MDO and estimated 95% CIs based on a binomial distribution. We identified 135 patients with pregnancy-related stroke (mean age, 32.4 [SD, 6.0] years), of whom 37 (27%) had MDO (95% CI, 20.6%-35.5%). Presenting symptoms included focal neurological deficits (57%; n=77), headache (53%; n=71), systemic symptoms (26%; n=35), and altered mental status (19%; n=25). More patients with MDO had hemorrhagic strokes (22 of 37 [59%] versus 34 of 79 [43%] patients with no MDO, and 10 of 19 [53%] with insufficient information to determine [P=0.05]). Among patients with MDO, 34 of 37 (92%) had ≥1 documented medical encounter in the month preceding stroke diagnosis compared with 47 of 79 (59%) individuals without MDO and 9 of 19 (47%) with insufficient information to determine (P<0.001). Of the 86 patients with prestroke encounters, most were evaluated by obstetricians (49%; n=42) or emergency medicine clinicians (29%; n=25). Among patients with MDO, contributing factors included failure to recognize symptoms (84%; n=31) and omission of appropriate neuroimaging studies (81%; n=30), despite that the clinical presentation was judged typical of the final stroke diagnosis in 35 of the 37 (95%) patients. In this retrospective cohort, >1 in 4 pregnant or postpartum patients with acute stroke experienced MDO. Our results suggest a need for enhanced clinician education, particularly for nonneurologists, in diagnosing stroke during pregnancy and the postpartum period.

Efficacy of amitraz acaricide footbaths against cattle and goat tick infestations on sites in Highveld and Lowveld regions of Zimbabwe

The University of Wisconsin Population Health Institute (PHI) Model of Health, grounded in models developed over a decade ago, provides a framework for prioritizing health-related investments including setting agendas, implementing policies, and sharing resources for improving community health and health equity. The model includes multiple determinants of health and two broad health outcomes (length and quality of life). We adapted the PHI Model of Health to cancer outcomes. Using county-level publicly available data, health factor summary measures were derived in three areas: health infrastructure including health promotion and clinical care, physical environment, and social and economic factors. A composite health factor z-score was calculated as the weighted (40%, 15%, and 45%, respectively) average of the summary measures for each county, and k-means clustering was used to create unequally sized county groups with lower (healthier) to higher (less healthy) z-scores. We fit age-adjusted negative binomial regression models to estimate rate ratios and 95% CI for cancer mortality in relation to county health factor cluster. Age-adjusted cancer mortality rates increased across the 10 county health factor clusters for all-cancers as well as for lung, colorectal, breast, and prostate cancers. Rate ratios generally increased across the 10 health factor clusters for all cancers combined and for specific cancer types. Compared with counties with the most favorable health factor conditions, the counties with the least favorable conditions had an all-cancer mortality rate ratio of 1.49 (95% CI, 1.39 to 1.60). The PHI model of health adapted to cancer outcomes provides an approach for linking community-specific conditions to the interventions that hold promise to directly address drivers of the cancer burden.

The effect of license plate number-based vehicle restrictions on crash frequency.

Avoidable loss of life expectancy from ambient fine particulate matter in Korea: A national assessment based on mortality data for 2010-2019 and 2023.

Limitations of Comprehensive Respiratory Viral Testing in Managing Young Infants with Fever.

Phase 2 clinical trials typically rely on a single primary endpoint, yet in many settings, treatment efficacy must be demonstrated across multiple co-primary endpoints. Such settings require intersection-union hypothesis testing, in which the global null hypothesis is rejected only when all individual component hypotheses are rejected. Existing phase 2 designs for binary endpoints are largely restricted to single-arm or single-endpoint settings, or rely on large-sample normal approximations for two-arm trials, which may be inadequate when sample sizes are small. We developed exact and simulation-based methods for designing two-arm, two-stage phase 2 trials with two co-primary binary endpoints using the bivariate binomial distribution, allowing different correlations between endpoints across treatment arms. The proposed framework identifies optimal designs that minimize the expected sample size and minimax designs that minimize the maximum sample size, while allowing early termination for futility at the first stage. For small sample sizes (approximately per arm), the exact method is computationally feasible and yields analytically exact operating characteristics under the assumed bivariate binomial distribution. For larger sample sizes, however, exact computations become intensive. To address this, we evaluated a simulation-based approach and a normal approximation by comparing their performance against the exact method. The simulation approach selected designs that closely matched those from the exact method, whereas the normal approximation often deviated. Therefore, we recommend the simulation-based method as a computationally efficient and accurate alternative for moderate-to-large sample size trials.

scUCAF: An uncertainty-aware cross-omics alignment and fusion network for single-cell multi-omics data clustering.