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Abstract Background Substantial inequalities in the overall prevalence and patterns of multimorbidity have been widely reported, but the causal mechanisms are complex and not well understood. This study aimed to identify common patterns of multimorbidity in Serbia and assess their relationship with air pollutant concentrations and water quality indicators. Methods This ecological study was conducted on a nationally representative sample of the Serbian population. Data were obtained from the European Health Interview (EHIS) Survey, a periodic study designed to assess population health using widely recognized standardized instruments. The study included 13,069 participants aged 15 and older, randomly selected through a multistage stratified sampling design. Multimorbidity was defined as having two or more self-reported diagnoses of chronic non-communicable diseases. Latent class analysis (LCA) was performed to identify clusters of multimorbidity. Concentrations of particulate matter (PM10), sulfur dioxide (SO2), nitrogen dioxide (NO2), carbon monoxide (CO), and ozone (O3), as well as water quality indicators, were obtained from the Serbian Environmental Protection Agency. Results The overall prevalence of multimorbidity was 33.4% [32.6%—34.2%]. Six latent classes of multimorbidity were identified: Healthy, Multicondition, Cardiovascular, Metabolic syndrome, Respiratory, and Musculoskeletal. Annual increases in PM10 and SO2 concentrations, as well as daily increases in O3 concentrations, significantly raised the odds of having multimorbidity (OR = 1.02, 95% CI 1.02–1.03; OR = 1.01, 95% CI 1.00–1.02 and OR = 1.03, 95% CI 1.02–1.03, respectively). A pattern of increased risk was observed with rising levels of water contamination. Exposure to physico-chemical, microbiological and combined contamination was associated with a 3.92%, 5.17% and 5.54% higher probability, respectively, of having multiple chronic conditions. There was strong evidence that air pollutants, as well as chemical and microbial water contamination, were significantly associated with higher odds of the most common clusters of multimorbidity identified by LCA. Conclusion There is compelling evidence of an association between multimorbidity and environmental pollution, suggesting that exposure to air pollutants and water contaminants may contribute to disease accumulation and help explain geographically and socioeconomically patterned inequalities. These findings underscore the need for extensive studies that simultaneously measure both multimorbidity and pollution to explore their complex interrelationships.

Abstract Background In the United States (US), hepatitis C virus (HCV) screening is not covered by payers in settings outside of primary care. A non-traditional, emergency department (ED)-based HCV screening program can be cost-effective and identify infection in vulnerable populations with a high HCV risk. This study examined the long-term cost-effectiveness of routine HCV screening and linkage-to-care for high-risk patients in the ED from the payer’s perspective. Methods The University of Illinois Hospital and Health Sciences System (UIH) implemented Project HEAL (HIV & HCV Screening, Education, Awareness, Linkage-to-Care). Under this initiative, patients who presented to the ED received opt-out HCV screening if they were at high risk for HCV infection (birth cohort between 1945 and 1964, persons who inject drugs, and HIV infection) with subsequent linkage-to-care if infected. Using the summary data from Project HEAL, a hybrid decision-analytic Markov model was developed based on the HCV screening procedure in the ED and the natural history of HCV. A 30-year time horizon and 1-year cycle length were used. All patients who received the ED-based HCV screening were referred for treatment with direct-acting antiviral (DAA) regardless of their fibrosis stage. Results When unscreened/untreated patients received DAA treatment at F1, F2, F3, and compensated cirrhosis stages, the incremental cost-effectiveness ratio (ICER) ranged from $6,084 to $77,063 per quality-adjusted life year (QALY) gained. When unscreened/untreated patients received DAA treatment at the decompensated cirrhosis stage, no HCV screening was dominated. Conclusion ED-based HCV screening and linkage-to-care was cost-effective at the willingness-to-pay (WTP) threshold of $100,000/QALY in all scenarios. A reduction in infected persons in the community may provide additional benefits not evaluated in this study.

The advancements made in Software-Defined Networking (SDN) technology seem quite promising, with potential wide application in managing and controlling the latest network infrastructures. SDN technology decouples the control plane from the data plane, enabling effective and flexible network management. However, this dynamic phenomenon brings new security challenges. With the increasing dynamism and programmable nature of networks, conventional security protocols may not sufficient to protect against advanced and sophisticated attacks. Although Intrusion Detection Systems (IDSs) have been extensively applied for identifying and preventing security threats in traditional network environments, IDS models designed specifically for traditional network requirements may not be adequate for SDN environments. These issues may stem from the static nature of conventional networks, contrasting with the dynamicity of advanced SDN networks, and the traditional IDS’s inability to adapt to the dynamic nature of SDN. To address these challenges, the current research proposes a novel Deep Hybrid IDS model to enhance network security in SDN environments and prevent attacks using Scapy. The proposed model detects signature-based attacks by integrating Gated Recurrent Units (GRU) and Long Short-Term Memory (LSTM) for real-time simulated datasets, achieving an accuracy of 97.8%, which is comparatively better than existing models.

Background: The world economy is significantly impacted by floods. Identifying flood risk is essential to flood mitigation techniques. AIM: The primary goal of this study is to create a geographic information system (GIS)-based flood susceptibility map for the study area. Methods: Ten flood-influencing factors from a geospatial database were taken into account when mapping the flood-prone areas. Every element demonstrated a robust relationship with the probability of flooding. Results: The highest contributing elements for the flood disaster in the study region were drainage density, distance, and the curvature. Flood susceptibility models’ performance was validated using standard statistical measures and AUC. The ROC curves demonstrated that all ensemble models had good performance on the validation data sets (AUC = >0.97) with high accuracy scores of 0.80. Based on the flood susceptibility maps, most of the northwest regions of the study area are more likely to flood because of low land areas, areas with a lower gradient slope, linear and concave shape curvature, high drainage density with high rainfall, more “water bodies,” “crops land,” and “built areas,” abundance on sea and surface water, and Quaternary types of soil feature and so on. The very high flood susceptibility class accounts for 18.2% of the study area, according to the RF-embedding model, whereas the high, moderate, low, and very low susceptibility classes were found at about 20.0%, 24.6%, 24.3%, and 12.9%, respectively. Conclusion: In comparison with other commonly used applied approaches, this research presents a novel modeling approach for flood susceptibility that integrates machine learning and geospatial data. It has been found to be stronger and more efficient, highly accurate, has good prediction performance, and is less biased. Overall, our research into machine learning-based solutions points in a positive path technologically and can serve as a reference manual for future research and applications for academic specialists and decision-makers.

Abstract Background The PedsQL™ 4.0 Generic Core Scales (GSC) have been translated into over 60 languages, but use in the sub-Saharan African region is limited. This study aimed to cross-culturally adapt and validate the PedsQL™ 4.0 GCS child self-report and teen self-report versions into the Chichewa language for Malawi. Methods The English (USA) versions were adapted (translation, back translation and cognitive interviews to evaluate conceptual equivalence) into Chichewa. We recruited 289 children (8–17 years) in Blantyre, Malawi. Classical psychometrics at the item level (missing data, endorsement frequencies, item redundancy) and scale level (internal consistency, convergent, discriminant and known groups validity) was used to evaluate the new Chichewa versions. Results Six items were found to need cultural adaptation for Malawi. There were problems with missing data ( 0.7). Convergent validity was generally strong (correlations > 0.4). Discriminant validity (p > 0.05) was evident with respect to gender and age, but not for school grade (p

Abstract Objective To review HIV testing services (HTS) costs in sub-Saharan Africa. Design A systematic literature review of studies published from January 2006 to October 2020. Methods We searched ten electronic databases for studies that reported estimates for cost per person tested ($pptested) and cost per HIV-positive person identified ($ppositive) in sub-Saharan Africa. We explored variations in incremental cost estimates by testing modality (health facility-based, home-based, mobile-service, self-testing, campaign-style, and stand-alone), by primary or secondary/index HTS, and by population (general population, people living with HIV, antenatal care male partner, antenatal care/postnatal women and key populations). All costs are presented in 2019US$. Results Sixty-five studies reported 167 cost estimates. Most reported only $pptested (90%), while (10%) reported the $ppositive. Costs were highly skewed. The lowest mean $pptested was self-testing at $12.75 (median = $11.50); primary testing at $16.63 (median = $10.68); in the general population, $14.06 (median = $10.13). The highest costs were in campaign-style at $27.64 (median = $26.70), secondary/index testing at $27.52 (median = $15.85), and antenatal male partner at $47.94 (median = $55.19). Incremental $ppositive was lowest for home-based at $297.09 (median = $246.75); primary testing $352.31 (median = $157.03); in the general population, $262.89 (median: $140.13). Conclusion While many studies reported the incremental costs of different HIV testing modalities, few presented full costs. Although the $pptested estimates varied widely, the costs for stand-alone, health facility, home-based, and mobile services were comparable, while substantially higher for campaign-style HTS and the lowest for HIV self-testing. Our review informs policymakers of the affordability of various HTS to ensure universal access to HIV testing.

Abstract To investigate solar activity dependence of the coupling between medium-scale traveling ionosphere disturbance (MSTID) and sporadic E (Es) layer, we analyzed the total electron content (TEC) obtained from a Japanese global positioning system (GPS) receivers and ionosonde at Kokubunji (35.7° N, 139.5° E) in Japan during the summer period of May–August from 1998 to 2019. To obtain perturbation TEC caused by MSTIDs, the detrended TEC is calculated by subtracting 1-h moving averages from the measured TEC for each pair of GPS satellite and receiver. The detrended TEC data are mapped on to the geographical coordinates to make detrended 2-D maps with spatial resolution of 0.15° × 0.15° in longitude and latitude. The MSTID activity is defined as a ratio of the standard deviation to the background TEC over Kokubunji in Japan. Day-to-day variations of the MSTID activity during summer nights was compared to Es layer parameters [critical frequency ( $${f}_{o}Es$$ f o E s ) and $${\Delta f}_{o-b}\equiv {f}_{o}Es-{f}_{b}E$$ Δ f o - b ≡ f o E s - f b E , where $${f}_{{\text{b}}}Es$$ f b E s is blanketing frequency] derived from ionosonde station at Kokubunji. We have found that the correlation coefficient between the MSTID activity and $${f}_{o}Es$$ f o E s ( $${\Delta f}_{o-b}$$ Δ f o - b ) between 1998 and 2019 is 0.5 3 (0.46) on average, suggesting that there is an electrodynamical coupling between the Es layer and F region could generate nighttime MSTIDs. We also have found that the correlation coefficient positively correlates with solar activity. This finding indicates that in the high solar activity conditions, when the growth rate of Perkins instability is relatively low, generation of the polarization electric fields in the $$Es$$ Es layer could play a more important role to grow MSTIDs than in the low solar activity conditions. Graphical Abstract

Abstract This study aimed to register and analyse outcomes after iatrogenic ureteral injuries (IUI) with special emphasis on potential consequences of a delayed diagnosis, and further to analyse if the incidence of IUI has changed during the study period. 108 patients treated for an IUI during 2001–2021 were included. Injuries due to endourological procedures, planned tumour resection and traumatic injuries were excluded. All relevant information to answer the research questions were entered into a database. Chi-square and t-tests were used for categorical and continuous variables respectively. Regression analysis was used to evaluate potential change of incidence in IUIs over time. Our results showed that most IUIs (74, 69%) were caused by gynaecological surgery. 49 (45%) had a delayed diagnosis (not diagnosed intraoperatively). Younger age (mean 50 vs 62 years, p

Aim: The aim of this analysis was to assess the cost–effectiveness of the EmboTrap Revascularization Device compared with the Solitaire™ Revascularization Device and Trevo Retriever for the treatment of acute ischemic stroke (AIS) from the perspective of the Chinese healthcare system. Methods: According to MASTRO I, a recent living systematic literature review and meta-analysis, mechanical thrombectomy (MT) with EmboTrap in the treatment of AIS resulted in better functional outcomes compared with the use of Solitaire or Trevo. Based on the proportion of patients that achieved 90-day modified Rankin Scale (mRS) scores of 0–2, 3–5 and 6 reported in MASTRO I, a combined 90-day short-term decision tree and Markov model with a 10-year time horizon was used to compare the cost–effectiveness of the three devices. The primary outcome was the incremental cost–effectiveness ratio (ICER), representing the incremental cost (in 2022 Chinese Yuan [CNY]) per incremental quality-adjusted life-year (QALY). The ICERs were compared against willingness-to-pay (WTP) thresholds of 1, 1.5 and 3-times the 2022 national gross domestic product (GDP) per capita in China. Results: Treatment with EmboTrap resulted in total QALYs of 3.28 and total costs of 110,058 CNY per patient. Treatment with Trevo resulted in total QALYs of 3.05 and total costs of 116,941 CNY per patient. Treatment with Solitaire resulted in total QALYs of 2.81 and total costs of 99,090 CNY per patient. Trevo was dominated by EmboTrap as it was a more costly and less effective intervention. As such, Trevo was not cost-effective at any WTP threshold. Compared with Solitaire, EmboTrap was more effective and more costly, with an ICER of 23,615 CNY per QALY. This result suggests that EmboTrap is cost-effective when compared with Solitaire since the ICER was lower than all WTP thresholds assessed. Conclusion: EmboTrap dominated Trevo and is cost-effective for the treatment of patients with AIS compared with Solitaire when assessed from the perspective of the Chinese healthcare system and based on the devicelevel meta-analysis MASTRO I. Selecting a stent retriever (SR) that optimizes 90-day mRS score is an important consideration from both a clinical and healthcare payer perspective in China as it is associated with reduced long-term costs and increased quality of life.

The prediction of final semester grades is a crucial undertaking in education, offering insights into student performance and enabling timely interventions to support their academic journey. This paper employs a deep learning approach, specifically gated recurrent unit (GRU), in conjunction with feature optimization using analysis of variance (ANOVA), to forecast final semester grades. The predictive model is trained and evaluated on a handcrafted grade prediction dataset, which contains the academic performance of the students during Plus 2 and from Semester 1 to Semester 4 of a group of Computer science and Engineering majors in Kerala. By processing historical academic records and contextual information, the GRU model learns to predict future performance accurately. To enhance the model's efficacy and interpretability, ANOVA is applied to optimize the feature selection process. This statistical technique identifies the most influential factors contributing to final grades, refining the model's predictive power while reducing dimensionality. The experimental results showcase the model's effectiveness in predicting final semester grades, demonstrating superior accuracy and performance compared to grade prediction using CNN with Bayesian optimization and LSTM with L1-Norm optimization.

Zinc oxide nanoparticles (ZnO NPs) have become a highly regarded substance in various industries especially biologically synthesized ZnO NPs due to their adherence to the principles of green chemistry. However, concerns have been raised regarding the potential cytotoxic effects of ZnO NPs on biological systems. This study aimed to investigate and compare the cytotoxicity of ZnO NPs that were synthesized through chemical (C–ZnO NPs) and green approach using Musa acuminata leaf aqueous extract (Ma-ZnO NPs) on Vero cells.Characterization of ZnO NPs through Uv–Vis, FESEM, EDX, XRD, FTIR and XPS confirmed the successful synthesis of C- and Ma-ZnO NPs. MTT and ROS assays revealed that C- and Ma-ZnO NPs induced a concentration- and time-dependent cytotoxic effect on Vero cells. Remarkably, Ma-ZnO NPs showed significantly higher cell viability compared to C–ZnO NPs. The corelation of ROS and vell viability suggest that elevated ROS levels can lead to cell damage and even cell death. Flow cytometry analysis indicated that Ma-ZnO NPs exposed cells had more viable cells and a smaller cell population in the late and early apoptotic stage. Furthermore, more cells were arrested in the G1 phase upon exposure to C–ZnO NPs, which is associated with oxidative stress and DNA damage caused by ROS generation, proving its higher cytotoxicity than Ma-ZnO NPs. Similarly, time-dependent cytotoxicity and morphological alterations were observed in C- and Ma-ZnO NPs treated cells, indicating cellular damage. Furthermore, fluorescence microscopy also demonstrated a time-dependent increase in ROS formation in cells exposed to C- and Ma-ZnO NPs.In conclusion, the findings suggest that green ZnO NPs possess a favourable biocompatibility profile, exhibiting reduced cytotoxicity compared to chemically synthesized ZnO NPs on Vero cells. These results emphasize the potential of green synthesis methods for the development of safer and environmentally friendly ZnO NPs.

Background: An outbreak of fever and cough was notified to public health authorities by the management of school X among their students, Kozhikode district, Kerala, on Jan 1, 2020. We conducted an outbreak investigation to confirm the diagnosis, describe the case patients by time, place, and person, and propose appropriate recommendations. Materials and Methods: We defined a probable case of influenza as any student or staff of school X, Kozhikode district with a fever and cough between Dec 30, 2019, and Jan 14, 2020. We conducted an active case search and contact tracing in the school. We described the cases by date of symptom onset using an Epicurve, plotted cases by their classroom, and calculated the attack rate by age, and gender. Results: We identified 270 cases of influenza; among them, 264 (98%) were students, and 6 (2%) were the staff. The overall attack rate was 36%. The attack rate was higher among the students (39%) than the staff (12%, 6/49, P < 0.0003). The attack rate was higher among students of class 10E (90%, 37/41) and class 10A (80%, 33/41), where the index case had contact with the students during the symptomatic phase. Conclusion: An outbreak of influenza A (H1N1) occurred among students and staff, predominantly affecting the 10th division. School and health authorities implemented several interventions to limit the outbreak, including training students on personal hygiene. We recommended conducting surveillance of influenza, maintaining adequate spacing of benches, self-hygiene practices, and classroom ventilation.

Constipation, which refers to difficulties in defecation and infrequent bowel movement in emptying the gastrointestinal system that ultimately produces hardened fecal matters, is a health concern in livestock and aging animals. The present study aimed to evaluate the potential effects of dairy-isolated lactic acid bacteria (LAB) strains to alleviate constipation as an alternative therapeutic intervention for constipation treatment in the aging model. Rats were aged via daily subcutaneous injection of D-galactose (600 mg/body weight [kg]), prior to induction of constipation via oral administration of loperamide hydrochloride (5 mg/body weight [kg]). LAB strains (L. fermentum USM 4189 or L. plantarum USM 4187) were administered daily via oral gavage (1 × 10 Log CFU/day) while the control group received sterile saline. Aged rats as shown with shorter telomere lengths exhibited increased fecal bulk and soften fecal upon administration of LAB strains amid constipation as observed using the Bristol Stool Chart, accompanied by a higher fecal moisture content as compared to the control (p < 0.05). Fecal water-soluble metabolite profiles showed a reduced concentration of threonine upon administration of LAB strains compared to the control (p < 0.05). Histopathological analysis also showed that the administration of LAB strains contributed to a higher colonic goblet cell count as compared to the control (p < 0.05). The present study illustrates the potential of dairy-sourced LAB strains as probiotics to ameliorate the adverse effect of constipation amid aging, and as a potential dietary intervention strategy for dairy foods including yogurt and cheese.

Roberto Bassani,1 Thibaut Galvain,2 Suzanne Battaglia,3 Hendramoorthy Maheswaran,4 George Wright,5 Ankita Kambli,5 Alessandra Piemontese3 1II Spinal Surgery Unit, IRCCS Galeazzi-Sant’Ambrogio Hospital, Milano, Italy; 2Johnson and Johnson MedTech, Issy-les-Moulineaux, France; 3Johnson and Johnson MedTech, Pomezia, Italy; 4Johnson and Johnson MedTech, London, UK; 5EVERSANA, Burlington, Ontario, CanadaCorrespondence: George Wright, EVERSANA, 113-3228 South Service Road, Burlington, Ontario, L7N 3H8, Canada, Tel +1 513-827-3035, Email george.wright@eversana.comPurpose: When traditional therapies fail to provide relief from debilitating lower back pain, surgeries such as transforaminal lumbar interbody fusion (TLIF) may be required. This budget impact analysis (BIA) compared minimally-invasive (MI)-TLIF versus open (O)-TLIF for single-level fusion from an Italian hospital perspective.Methods: The BIA compared costs of 100 MI-TLIF and 100 O-TLIF procedures from an Italian hospital perspective over a one-year time horizon. The base case included costs for length of hospital stay (LOS), blood loss, and sterilizing surgical trays. The scenario analysis also included operating room (OR) time and complication costs. Base case inputs were from the Miller et al meta-analysis; scenario analysis inputs were from the Hammad et al meta-analysis. The device costs for MI-TLIF and O-TLIF procedures were from Italian tender prices for Viper Prime™ System and Expedium™ Spine System, respectively.Results: Base case deterministic analysis results showed cost savings of € 207,370 for MI-TLIF compared with O-TLIF. MI-TLIF costs were lower for LOS (€ 215,277), transfusion for blood loss (€ 16,881), and surgical tray sterilization (€ 28,232), whereas device costs were lower for O-TLIF (€ 53,020). The probabilistic result was similar, with MI-TLIF resulting in savings of € 211,026 (95% credible interval [CR]: € 208,725 – € 213,327). All 1000 base case probabilistic sensitivity analysis runs were cost saving. Deterministic scenario analysis results showed cost savings of € 166,719 for MI-TLIF. MI-TLIF costs were lower for LOS (€ 190,813), transfusion for blood loss (€ 16,881), surgical tray sterilization (€ 28,232), and complications (€ 2076), whereas O-TLIF costs were lower for OR time (€ 18,263) and devices used (€ 53,020).Conclusion: Despite the increase incremental cost for medical device innovation and OR time, this study demonstrates the economic savings of MI-TLIF compared to O-TLIF from a European hospital perspective. The findings will be useful to policy and hospital decision makers in assessing purchasing, funding and reimbursement decisions.Keywords: spine surgery, incremental cost, budget impact analysis, Italy, medical device innovation, health economic model

The enhancement of photocatalytic reactivity through the internal electric field has received much attention. The combination of the piezoelectric effect and the photo-exiting process facilitates the segregation of the photogenerated carriers, thereby boosting the piezo-photocatalytic activity. We have constructed g-C3N4/Ag/ZnO tri-component composites; with various g-C3N4 precursors to achieve reliable photo/piezo-photocatalysis for H2 production and Rhodamine B (RhB) dye degradation. We observed that urea-based g-C3N4/Ag/ZnO (UCAZ) tri-components exhibit a superior H2 production rate of 1125.5 μmol h−1 g−1 under photocatalytic conditions. When piezoelectric-potential was introduced into the photocatalysis reaction via ultrasonic, the H2 rate increased dramatically to 1637.5 μmol h−1 g−1, which is approximately 145% greater than that light irradiation alone.Similarly, the catalytic decomposition ratio of Rhodamine B (RhB) under the coexistence of ultrasound and light, and degradation efficiency reached 99% in 120 min, which is higher than the value of (42%, 0.0031 min−1) for piezo-catalysis and (80%, 0.01 min−1) for photocatalysis condition alone. The rate constant under synergistic simulation reaches 0.021 min−1, which is 200% and 645% times higher than the sole light and ultrasonic illumination. Additionally, RhB degradation of all the tri-components was performed under solar light (Sunlight) and ultrasound irradiation, and efficiency reached 99.5% in 45 min with a rate constant of 0.06 min−1, which is 300% higher than the piezo-photocatalytic under LED source. The enhanced performance of the g-C3N4/Ag/ZnO tricomponent is attributed to the high specific surface area (168 m2 g−1) and synergetic effect of piezo catalysis and photocatalysis.