Introduction. Effective communication between patients and healthcare workers (HCW) is central to the healthcare process; it affects the quality of care, safety, outcomes, and satisfaction of both patients and HCW. Visual aids (VAs) facilitate communication by reducing anxiety and promoting more tolerable experiences within the hospital. Objective. To describe the acceptance of the use of VAs to anticipate medical procedures in a pediatric hospital by families and HCWs. Population and methods. Descriptive, cross-sectional, and qualitative-quantitative study. Frequent medical procedures and their corresponding VAs were selected, and HCWs were trained in their use. Acceptance of the VAs was assessed among caregivers and HCWs through semi-structured surveys and qualitative analysis of field notes. Results. Seventy-two surveys were collected from caregivers and 24 from healthcare providers. All healthcare providers used VAs at least once; 23/24 reported that patients understood the situation better, and 18/24 reported reduced stress and a simplified procedure. Among caregivers, 69/72 reported some degree of improvement in understanding the procedure, reduced stress, and greater tolerance of the experience. Qualitative analysis revealed strong acceptance of VAs, greater patient participation, and difficulties due to time constraints and organizational challenges. Conclusion. The findings suggest good acceptance and provide preliminary information to guide future studies in other institutional settings.

Experiential avoidance, engaged living, and burnout in medical students, residents and fellows.

The rapid expansion of healthcare infrastructure may exert increasing pressure on the sustainability of social health insurance. China's concurrent pursuit of universal coverage, coupled with extensive hospital construction, offers a valuable context for examining whether the patterns observed in China align with Roemer's Law (1961), which is often summarized as 'a hospital bed built is a bed filled' within an insured population. This study investigates the relationship between hospital bed density and insurance expenditure to deepen our understanding of the factors associated with the growth of healthcare costs. We compiled a panel dataset encompassing 31 Chinese provinces covering the period from 2011 to 2024. To strengthen identification and address potential endogeneity concerns, we employed two-way fixed effects models alongside instrumental variable (IV-2SLS) estimation. Mediation analysis was employed to investigate potential pathways, while panel threshold regression was utilized to examine nonlinear patterns in the relationship between supply and expenditure. The baseline estimates indicated a positive association, suggesting that higher provincial bed density correlates with increased province-level insurance spending. Mediation analysis revealed that the Average Length of Stay may serve as a potential aggregate pathway, accounting for 17.8% of the estimated relationship. Furthermore, threshold regression analysis indicated a possible nonlinear pattern, with an estimated threshold of 7.271 beds per 1,000 population. Below this threshold, hospital bed density is positively related to insurance spending (β = 0.217); however, above this threshold, the association loses statistical significance. Regional analysis demonstrated that the positive association was most pronounced in the western region, while no statistically significant association was observed in the northeastern region. Our findings support a conditional, province-level interpretation of Roemer's Law within the Chinese context, indicating that the association between bed density and insurance expenditure varies across institutional and capacity settings. Specifically, higher provincial bed density is more strongly associated with a longer average length of stay at the provincial level than with increased admission volumes. Beyond the exploratory threshold estimate, the marginal association between additional bed supply and insurance expenditure appears to weaken. These results suggest that payment reform, length-of-stay management, and regulatory oversight should be prioritized alongside careful capacity planning.

Population ageing increases the need to understand psychosocial determinants of emotional well-being in later life. Loneliness is a key predictor of depression and anxiety in older adults, yet other emotions such as anger-less frequently investigated in gerontological research-may also contribute to distress when social needs are unmet. Although residential context has been linked to emotional health, the extent to which loneliness helps explain this relationship remains unclear. This study aimed to (1) explore differences in depression, anxiety, anger, and loneliness between institutionalized and community-dwelling older adults, and (2) examine the role of loneliness in the relationship between residential status, age, and emotional outcomes. A cross-sectional study was conducted with 190 participants aged 60 years and older (M = 79.0, SD = 9.15). Participants were recruited from nursing homes, senior centers, and community settings in Spain through institutional collaboration and snowball sampling. Measures included the Geriatric Depression Scale (GDS-15), Geriatric Anxiety Inventory (GAI), State-Trait Anger Expression Inventory (STAXI-2, trait anger scale), and the UCLA Loneliness Scale (10-item version). Data analyses comprised ANCOVAs controlling for age and three explanatory models estimated with Jamovi (GLM Mediation, version 2.6.24). Institutionalized participants reported significantly higher depression scores, with mean scores at the commonly used GDS-15 screening threshold. They also showed a tendency toward greater anger and loneliness, while no group differences were found in anxiety. The models indicated that loneliness was a consistent and robust factor associated with depression, anxiety, and anger. However, neither age nor residential status showed significant indirect effects through loneliness. The total effect of residential status on depression was significant, whereas no significant direct or indirect effects of residential status or age were observed for anxiety and anger. The models explained 27.4% of the variance in depression, 23.4% in anxiety, and 17.7% in anger. Loneliness emerged as the factor most consistently associated with emotional distress in older adults. These findings underscore the importance of designing public policies and psychosocial interventions focused on reducing unwanted loneliness and strengthening social connectedness in both institutional and community settings.

Innovations in economic assessment of drought management: Application to crops and river basins of New Mexico.

Purpose This study aims to examine the moderating role of product market competition (PMC) in the relationship between corporate governance (CG) and firm value from the perspective of agency theory in Pakistan. Design/methodology/approach This study applied a fixed-effect model, instrumental variable two-stage least squares estimator and the system generalized method of moments to analyze panel data, collected from 369 firms listed on the Pakistan Stock Exchange between 2010 and 2023. Findings The findings indicate that CG increases firm value only in highly competitive industries through a complementary effect, whereas it diminishes firm value in less competitive industries through a substitutive effect. The results further demonstrate that this impact is more pronounced in state-owned enterprises (SOEs) than in non-SOEs. The robustness of the findings is confirmed through consistent results across alternative sample divisions, variable measurements, governance structures and regression estimations. Research limitations/implications Policymakers and regulatory authorities in developing countries like Pakistan should consider diversifying CG structures based on varying levels of competition to improve firm value. Given the strong complementarity between PMC and CG in SOEs, regulatory reforms should prioritize aligning governance practices in SOEs with the best practices observed in non-SOEs to maximize performance outcomes. Originality/value This study grasps critical research gaps in the literature, theory and methodology by investigating how external governance (i.e. PMC) shapes the relationship between internal CG and firm value through the lens of agency theory. Besides, it offers insights into how the CG structures of SOEs and non-SOEs respond to competitive pressures within the unique institutional context of Pakistan. Moreover, the findings support the view that the moderating role of PMC in the nexus of CG with firm value or performance diverges from patterns observed in other institutional settings.

Access to culturally relevant foods is essential to aging well, particularly for Canadians from ethno-cultural minority groups, including African, Caribbean, and Black communities. Food insecurity is defined as inadequate or unreliable access to affordable, safe, and nutritious food that meets one's needs and preferences. While food insecurity is often framed primarily in economic terms, with limited attention to culturally appropriate food access, it is also closely linked to systemic inequities shaped by policy-making and institutional barriers that ultimately affect dietary intake, mealtime experiences, and overall health among ethnocultural minority groups. In the Canadian long-term care sector, food insecurity is exacerbated among African, Caribbean, and Black residents due to limited access to culturally congruent food options within care environments designed to accommodate the ethnic majority. This project will develop roadmaps to promote healthy aging among African, Caribbean, and Black residents in long-term care homes through culturally relevant food provision as part of resident-centered care. We will use a community-based research approach guided by an intersectionality framework and a Community Advisory Council. The study includes a policy analysis of legislation, policies, and regulations shaping food provision in long-term care homes, supplemented by interviews with policy and decision-makers. Focus groups with key informants in food, aging, or long-term care will identify opportunities for change at organizational and governance levels. Ethnographic site visits to community-based food programs in three Canadian provinces-Alberta, Ontario, and Quebec-will explore how social and cultural factors influence food sourcing, preparation, and provision. Interviews with long-term care stakeholders will examine how promising community practices may be adapted to institutional settings. Finally, we will co-create and share roadmaps to support culturally safe food services and programming for African, Caribbean, and Black residents in long-term care. This equity-focused project aims to increase access to culturally relevant foods in long-term care as part of resident-centered care for African, Caribbean, and Black communities, and contributes to broader efforts to decolonize long-term care through culturally safer and more responsive care for people living in institutional settings.

Feeling lonely defined as a subjective dissatisfaction with social relationships, is associated with an increased risk of functional and cognitive decline well-known factors for institutionalization. The objective was to evaluate the predictive role of feeling lonely on admission to nursing homes among elderly people hospitalized via emergency departments. This was an observational, longitudinal, prospective, multicenter study. Participants were recruited over a period of ten months. Patients were eligible if they were aged 75 years or older and hospitalized in a medical ward of the same hospital as the emergency department (ED) where they were initially admitted. The assessment included the collection of sociodemographic data-age, sex, level of education, available support (particularly the presence of a primary caregiver), number of children, and living arrangements (home or institutional setting)-as well as clinical variables, including presence of dementia or delirium, mood disorders, comorbidities, nutritional status, dependence in activities of daily living (ADL), mobility, risk of falls, and risk of pressure ulcers. The assessment included the collection of sociodemographic (age, sex, level of education, available support (in particular the presence of a primary caregiver), number of children, living conditions (e.g., at home or in an institution) Loneliness was assessed using item 14 of the CES-D (Center for Epidemiologic Studies Depression) scale. Univariate and multivariate analyses were performed using a Cox model that took death into account as a competing risk, using a Fine & Gray model. The mean age was 84.4 ± 5.9 years, and 55% were women. In this population, 40% reported feeling lonely, 41% were at risk of depression, 78% had at least one child, 67% had at least one family caregiver, and 79% (n = 833) lived alone. Over the 36-month follow-up period, 31.46% of patients entered nursing homes. Independent risk factors for institutionalization included social determinants specifically feeling lonely, which was independently associated with an increased risk of placement at 12, 24, and 36 months. Individuals reporting loneliness showed an increased risk of functional and cognitive decline. This study regarding hospitalized elderly after admission to an Emergency Department shows that feeling lonely is not merely a marker of social vulnerability but is independently associated with of nursing home admission.

Depression and loneliness are highly prevalent among older adults, yet access to timely and adequate mental health care remains limited in this population. Artificial intelligence-based conversational and socially assistive agents have emerged as a potentially scalable and cost-effective intervention; however, their effectiveness in alleviating depression and loneliness among older adults has not been comprehensively established. This systematic review and meta-analysis aimed to synthesize evidence from randomized controlled trials (RCTs) examining the effects of AI-based conversational and socially assistive agent interventions on depressive symptoms and loneliness in older adults. A systematic search of five electronic databases was conducted from inception to November 15, 2025, to identify RCTs evaluating AI-based conversational and socially assistive agent interventions targeting depression and/or loneliness in older adults. Random-effects meta-analyses were performed using standardized mean differences. Statistical heterogeneity was assessed using the I² statistic and further explored through subgroup analyses. Risk of bias was evaluated using the Cochrane Risk of Bias 2 tool, and the certainty of evidence was appraised using the GRADE framework. Eight RCTs comprising 611 participants met the inclusion criteria. Compared with control conditions, AI-based conversational and socially assistive agent interventions were associated with a statistically significant reduction in depressive symptoms (Hedges' g = - 0.25, 95% CI - 0.48 to - 0.02; I² = 10.7%). In contrast, no significant effect was observed for loneliness, and substantial heterogeneity was detected across studies (Hedges' g = - 0.67, 95% CI - 2.57 to 1.23; I² = 89%). Subgroup analyses suggested that interventions with a cognitive focus yielded more consistent effects than companionship-focused approaches, while no clear differences were observed between home-based and institutional settings. AI-based conversational and socially assistive agent interventions appear to be effective in reducing depressive symptoms among older adults, whereas current evidence does not support a significant effect on loneliness. The effectiveness of these interventions may depend on their theoretical orientation and implementation characteristics. AI-based conversational and socially assistive agents may serve as a promising adjunct to conventional mental health care for older adults; however, further high-quality trials are needed to clarify their role in addressing loneliness and to optimize intervention design. The protocol for this systematic review was registered in International Prospective Register of Systematic Reviews (PROSPERO identifier: CRD420261283098).

Worldwide Survey on Interventional Pulmonology Training Programs.

Comprehensive preoperative CT assessment is essential for ventral hernia repair, yet no standardized reporting framework exists. This study evaluated the completeness of preoperative abdominal CT reports and developed an evidence-based protocol to guide standardized reporting for abdominal wall reconstruction (AWR). We conducted a systematic evaluation of CT reporting completeness in 834 patients who underwent elective transversus abdominis release (TAR) at the Cleveland Clinic Center for Abdominal Core Health between January 2020 and December 2024. A panel of AWR experts defined 16 CT-based parameters deemed essential for surgical planning, and their clinical relevance was validated through a global survey of 61 AWR surgeons. Radiologic reports were assessed for documentation of these parameters and compared with intraoperative findings and registry data from the Abdominal Core Health Quality Collaborative (ACHQC). Parameters were classified as either generalizable or patient specific. A Multi-Criteria Decision Analysis using the Analytic Hierarchy Process was applied to prioritize features for standardized reporting. Overall documentation completeness was limited, with a median of 34.4%. Although surgeons rated defect width as the most critical parameter for operative planning, it was documented in only 32.6% of CT reports. Patient-specific findings demonstrated higher overall reporting rates (median 87.8%), though key features such as mesh presence and anatomical mesh plane were documented in only 36.2% and 1.7% of applicable cases, respectively. Multi-Criteria Decision Analysis identified defect Size, Tanaka index, Anatomical hernia location, presence of prior Mesh, old mesh Plane and Concurrent inguinal or stomal site hernia as the most critical parameters for preoperative evaluation. Substantial gaps exist between CT reporting and the informational needs of AWR surgeons. We propose the "STAMP-C" framework as a pragmatic, consensus-driven model to standardize ventral hernia CT assessment and improve multidisciplinary alignment in preoperative planning. Prospective validation of this framework across diverse institutional settings and hernia subtypes is needed before universal adoption can be recommended.

Purpose For pre-digital organizations, an important aspect likely to be transformed in their digital transformation (DT) is the business process. This study explores the challenges and coping practices underlying DT of business process in pre-digital organizations. Design/methodology/approach A seven-year canonical action research (CAR) study was conducted in SD Energy (a pseudonym), one of the largest new energy companies in China. Following the principle of CAR, we chose the inductive research approach as our instrumental theory in the diagnostic phase and empowerment theory as our focal theory in the action planning and intervention phase. Findings Our diagnosis phase revealed four groups of challenges encountered by SD Energy in its DT of business processes, namely, process challenges, system challenges, data challenges and people-related challenges. In the action planning and intervention phase, we developed three practices, process redesign, system integration and data governance, to tackle the process, system and data challenges. The implementation of the three practices further empowered organizational members of SD Energy to overcome the people-related challenges. Research limitations/implications The study's single-case, China-specific energy context limits generalizability. Future research should test the sequential process-system-data framework and empowerment mechanisms in other industries and institutional settings. Practitioners should prioritize process redesign before system integration and data governance, adapting leadership from co-creation to top-down mandates for cultural change. Originality/value The findings of our CAR study provide important theoretical contributions to research on DT and practical implications for pre-digital organizations that pursue DT of business process.

In the 1950s, Alan Durrant of the University College Wales began a series of experiments to investigate the inheritance of environmental effects in plants, forging an unexpected connection to the controversial hereditary theories of Trofim Denisovich Lysenko. Durrant's work relied heavily on a specific fibre flax variety, Stormont Cirrus, developed in the interwar period in the UK for linen production. I investigate how the exigencies of the UK linen industry, along with Durrant's training and institutional setting, formed the milieu that generated an unexpected outlier in British genetic scholarship during the Cold War. I supplement my text-based historical analysis by conducting experiments to re-examine the genetic constitution of the original Stormont Cirrus cultivar. These findings suggest that Durrant's creation of alternative 'genotroph' derivatives by treating Stormont Cirrus plants with different soil nutrient regimes likely resulted from selection of pre-existing genetic variation present in the incompletely inbred parental strain, rather than being an example of inherited environmental effects. Inverting Durrant's intention to interpret his results in the context of Lysenko's work, my historical analysis of Durrant's flax genotroph findings informs a reappraisal of one of the key experimental claims supporting Lysenko's environmentalist concepts of inheritance.

Background: Interprofessional education (IPE) and interprofessional collaboration (IPC) are globally recognized as strategies for strengthening health systems and improving patient outcomes. Although frameworks and evidence have been well established in high-income countries, insights from low- and middle-income contexts remain limited. In the Philippines, studies on IPE and IPC are emerging but remain fragmented across disciplines and institutions. Objectives: This review aimed to synthesize international and Philippine literature on IPE and IPC, identify key frameworks, experiences, and challenges, and discuss implications for education, practice, and policy development in the Philippine context. Materials and methods: A narrative review approach was used to integrate diverse forms of evidence on IPE and IPC. Sources were identified through PubMed, Scopus, Google Scholar, and relevant organizational reports using the keywords “interprofessional education,” “interprofessional collaboration,” “health professions,” and “Philippines.” Articles published in English between 2000 and 2024 were included if they discussed definitions, frameworks, implementation strategies, challenges, or outcomes. Extracted data were synthesized thematically to operationalize the review objectives, focusing on conceptual and policy foundations of IPE and IPC, evidence of effectiveness, international experiences, the Philippine context and local evidence, and challenges, barriers, and sustainability. Results: Global literature shows that IPE enhances teamwork, communication, and, in some cases, patient outcomes, though findings are often constrained by methodological heterogeneity. International frameworks from Australia, Canada, the United Kingdom, and the United States establish shared competency domains but highlight challenges in assessment and curriculum integration. Philippine studies demonstrate readiness among students and professionals, pilot initiatives in community and institutional settings, and recurring barriers such as faculty shortages, professional hierarchies, and limited policy support. Sustainability emerged as a major concern in both global and local contexts. Conclusion: IPE and IPC hold significant potential to advance collaborative health professions education in the Philippines and similar low- and middleincome countries. To strengthen sustainability, contextual adaptation of global frameworks, investment in faculty development, alignment of accreditation and policy standards, and longitudinal research are essential to building enduring models that enhance interprofessional collaboration and health system outcomes.

Medical practitioners' experiences of and attitudes towards goals of patient care discussions: A cross-sectional survey.

Developmental needs in institutional settings: How children experience and imagine better residential youth care

This study aimed to investigate the pathophysiological changes of urban sanitation workers caused by potentially toxic element (PTE) exposure with a network analysis approach. Ninety urban sanitation workers from Bushehr Municipal Organization (exposed group) and 90 janitorial staff members from academic, administrative, and institutional settings (control group) were included. The PTE levels in serum samples were quantified using inductively coupled plasma mass spectrometry (ICP-MS; Agilent 7500). Cytoscape software, version 3.10.3, was employed for network analysis and visualization. The concentration levels of PTEs in the exposed and control groups ranged from 0.65 (Co) to 1345 (Fe) and 0.23 (Cd) to 1287 (Fe) μg/L, respectively. The concentration levels of ∑PTEs in the exposed and control groups were 2986 ± 1655 and 2664 ± 1240μg/L, respectively. The levels of some blood indices, such as white blood cell (WBC), red blood cell (RBC), hemoglobin (HB), mean corpuscular hemoglobin concentration (MCHC), lymphocytes, and eosinophils, were statistically different between the exposed and control groups (p < 0.001). The direct and weighted network analysis to visualize interactions between PTEs and biomarkers showed that As, Cd, and Pb emerged as the most influential PTEs, affecting multiple biomarkers with robust connections. The network analysis showed that oxidative stress/inflammatory markers, particularly 8-OHdG and TNF-α, act as key triggers mediating the adverse effects of PTEs on liver function (ALT, AST) and other physiological systems. The elevated exposure to hazardous elements among solid waste collectors poses a clear public health concern, and a comprehensive approach combining engineering controls, personal protective equipment (PPE), health monitoring, education, and policy enforcement is essential to protect workers' health.

Over the past several decades, Medicaid's expansion of home- and community-based services (HCBS) has facilitated a shift in the direct care workforce from institutional settings to home care settings. Although this shift is well documented, less is known about its impact on the hourly wages of direct care workers. This study examines how the rising proportion of home care workers in the direct care workforce has been associated with wages of the 2 groups that constitute this workforce-home care and institutional care workers-and the overall direct care worker wages. An observational study using pooled data from the 2008-2012 and 2018-2022 American Community Survey. The sample includes direct care workers-personal care aides, home health aides, and nursing assistants-in 50 states and Washington, DC. We adopt first-difference models at the state level to analyze trends in the direct care worker composition and wages over the recent decade. Increases in the share of home care workers are associated with a decline in direct care worker wages but no changes in the wages of home care or institutional care workers. This decline appears to be driven by the growing share of lower-paid home care jobs. These findings extend prior studies that have largely focused on the shift in the long-term services and supports (LTSS) toward HCBS with respect to Medicaid expenditures and worker supply, with less attention to worker compensation. By doing so, we highlight a critical policy challenge: without improving compensation for home care workers, continued rebalancing of LTSS toward home-based settings may worsen workforce shortages.

Hospice is designed to support comfort-focused care at the end of life, yet enrollment often depends on whether supportive caregiving infrastructures are in place. Prior studies rely on single indicators such as living arrangements, offering limited insight into the structural care environments that shape hospice feasibility. This study conceptualizes end-of-life care environments as graded structural positions: care formalization (how care is organized across household and institutional settings) and care scarcity (the availability of hands-on support) and examines their associations with hospice use among older decedents, including gender differences shaped by gendered life-course trajectories. Using nationally representative data from the HRS Harmonized End-of-Life Interview (1994-2021; N = 12,477), we estimated multivariable logistic regression models of hospice use in the last year of life. Occupying more formalized structural care positions was associated with greater odds of hospice use (OR = 1.39), whereas greater care scarcity was associated with lower odds (OR = 0.69). Gender moderated both associations: the facilitating effect of formalization was weaker for women (OR = 0.87), while the constraining effect of scarcity was attenuated for women (OR = 1.20), indicating steeper structural gradients among men. Hospice use is embedded within structurally patterned caregiving ecologies rather than driven solely by clinical trajectories or preferences. Erosion of support may constrain hospice access, whereas more formalized care settings may enhance referral and coordination. Strengthening caregiving infrastructures and targeting older adults experiencing care scarcity may promote more equitable end-of-life care.

The disablement process model identifies institutional environments as modifiers of the pathway from pathology to disability, yet has not specified the mechanisms through which they accelerate or interrupt disablement. This article proposes institutional attention ecology as a theoretical construct addressing this gap: the patterned distribution of organizational vigilance, investigation, and accountability across outcome domains within care institutions. In post-acute skilled nursing facilities, this ecology has become asymmetric, intensely organized around discrete safety events while leaving functional recovery largely outside institutional response. Drawing on the disablement process, relational autonomy theory, and qualitative evidence, we trace how this asymmetry reshapes functional trajectories and the conditions for authentic agency in later life. We propose attention ecology as a meso-level extension linking institutional context to resident-level outcomes. Nationally representative facility-level data (N = 13,713) support the predicted dissociation: safety performance and functional outcomes are essentially uncorrelated (Pearson r = 0.018). We advance three propositions: attention ecology operates as a formal extra-individual modifier in the disablement process; attention asymmetry produces structurally imposed dependency distinguishable from chosen dependency; and the disablement process in institutional settings is embedded in a moral ecology shaping which forms of diminishment are recognized as problems and which are normalized as aging.