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OBJECTIVES: Given the uncertainty regarding the optimal approach to laryngoscopy for the intubation of critically ill adult patients, we conducted a systematic review and meta-analysis to compare video laryngoscopy (VL) vs. direct laryngoscopy (DL) for intubation in emergency department and ICU patients. DATA SOURCES: We searched MEDLINE, PubMed, Embase, Cochrane Library, and unpublished sources, from inception to February 27, 2024. STUDY SELECTION: We included randomized controlled trials (RCTs) of critically ill adult patients randomized to VL compared with DL for endotracheal intubation. DATA EXTRACTION: Reviewers screened abstracts, full texts, and extracted data independently and in duplicate. We pooled data using a random-effects model, assessed risk of bias using the modified Cochrane tool and certainty of evidence using the Grading Recommendations Assessment, Development, and Evaluation approach. We pre-registered the protocol on PROSPERO (CRD42023469945). DATA SYNTHESIS: We included 20 RCTs (n = 4569 patients). Compared with DL, VL probably increases first pass success (FPS) (relative risk [RR], 1.13; 95% CI, 1.06-1.21; moderate certainty) and probably decreases esophageal intubations (RR, 0.47; 95% CI, 0.27-0.82; moderate certainty). VL may result in fewer aspiration events (RR, 0.74; 95% CI, 0.51-1.09; low certainty) and dental injuries (RR, 0.46; 95% CI, 0.19-1.11; low certainty) and may have no effect on mortality (RR, 0.97; 95% CI, 0.88-1.07; low certainty) compared with DL. CONCLUSIONS: In critically ill adult patients undergoing intubation, the use of VL, compared with DL, probably leads to higher rates of FPS and probably decreases esophageal intubations. VL may result in fewer dental injuries as well as aspiration events compared with DL with no effect on mortality. [ABSTRACT FROM AUTHOR]

Background: Nosocomial infections contribute significantly to mortality and morbidity in burn patients. Selective decontamination of the digestive tract is an infection prevention measure that has been shown to improve survival in mechanically ventilated intensive care unit (ICU) patients. It has been hypothesized that burn patients may benefit from selective decontamination of the digestive tract. Methods/Design: We will conduct a systematic review with meta‐analysis and trial sequential analysis of randomized clinical trials (RCTs) assessing the patient‐important effects of selective decontamination of the digestive tract in burn patients, as compared with placebo or no intervention/standard of care. The primary outcome will be 30‐day mortality. Secondary outcomes include serious adverse events, anti‐microbial resistance, pneumonia, blood stream infections, ICU‐ and hospital‐free days and 90‐day mortality. We will search the following databases: CENTRAL, MEDLINE, EMBASE, BIOSIS, Web of Science and CINAHL and follow the recommendations provided by the Cochrane Collaboration and the Preferred Reporting Items for Systematic Reviews and Meta‐Analyses guidelines. The certainty of evidence will be assessed according to the GRADE approach: Grading of Recommendations Assessment, Development and Evaluation. Discussion: There is clinical equipoise about the use of selective decontamination of the digestive tract in burn patients. In the outlined systematic review and meta‐analysis, we will assess the desirable and undesirable effects of selective decontamination of the digestive tract in burn patients. [ABSTRACT FROM AUTHOR]

This study presents a novel framework for the optimal design of compliant mechanisms, specifically addressing the structural drawbacks of conventional single-point or de facto hinges. The hinges often lead to structural instability and stress concentration while deriving maximum motion. To overcome these issues, we introduce a new method that can design stable and elastic domains connected by either revolute or prismatic joints. The new method, called sequential analysis based on the reaction force, can successfully eliminate weak hinge points while optimizing joint locations. The efficiency of developed methodology is validated through several numerical examples, yielding compliant mechanisms with suppressed hinges. [ABSTRACT FROM AUTHOR]

Several investigations have been carried out to explore the genetic association of TLR4 codon variants, specifically Asp299Gly and Thr399Ile, and susceptibility to sepsis, but the results have been contradictory. The present study aimed to conduct a meta‐analysis to draw a definitive conclusion regarding the role of TLR4 genetic variants (Asp299Gly and Thr399Ile) in sepsis. A thorough literature search was conducted using the PubMed, Scopus, and Science Direct databases. The inclusion and exclusion criteria were established to ensure the accuracy of the data. The Comprehensive Meta‐Analysis Software v4 was utilized to perform the meta‐analysis and related analyses. A total of 13 studies were analyzed, including 2328 sepsis cases and 2495 healthy controls for the TLR4 Asp299Gly variant. Eight studies provided genotype data for the rs4986791 polymorphism. The Asp299Gly variant showed a marginal protective effect in the allele (p = 0.08, odds ratio = 0.71) and dominant (p = 0.09, odds ratio = 0.71) genetic models, although it was not statistically significant. The trial sequential analysis indicated that further case–control studies are necessary to draw definitive conclusions about the TLR4 polymorphisms in sepsis. The TLR4 Asp299Gly variant may have a protective effect against sepsis. However, additional research with larger sample sizes across diverse populations is required to validate this finding. [ABSTRACT FROM AUTHOR]

Introduction: Distal hypospadias accounts for the majority of hypospadias. Mathieu and Snodgrass techniques are widely used for repair of distal hypospadias but their comparative efficacy and reported outcomes are still debated. We conducted a systematic review and meta-analysis to compare the outcomes of these two techniques. Methods: Electronic databases and trial registries were searched for randomized controlled trials (RCTs) comparing Mathieu and Snodgrass techniques for primary distal hypospadias repair. Outcome measures included complication rates and cosmetic outcomes. Risk of bias assessment was performed using the ROB2. Data was analyzed using Review Manager 5.4; Trial Sequential Analysis (TSA) also was conducted for important outcomes. Results: Twelve RCTs were eligible for inclusion. The Snodgrass technique showed a significantly lower incidence of urethrocutaneous fistula (UCF) (RR 0.48, 95% CI [0.30–0.77]). However, there was no significant difference in the incidence of meatal stenosis (MS) between the two (RR 1.64, 95% CI [0.85–3.15]). TSA supports the findings for outcome UCF but not for MS. Operative time was shorter with the Snodgrass technique. Conclusion: This SRMA indicates a lower incidence of UCF with Snodgrass technique compared to the Mathieu technique in distal hypospadias repair. However, there was no significant difference in the risk of MS. [ABSTRACT FROM AUTHOR]

Understanding older adults' driving behavior based on their personal assessment, along with challenges they encounter when driving will support community leaders and policymakers to develop effective supportive strategies for their safety on the road. This study uses a mixed methodology approach, including a survey and an interview to examine older drivers' perceptions and concerns regarding their driving habits. Collecting data from cities in Texas and Nevada, to achieve diverse perspectives on older adults who live in environments with different land use patterns and road geometry. Using the survey to understand the older adults' self-evaluated driving skills, where most consider themselves very good drivers even though they have some challenges, based on the roads, their reflexes changing over the years, and the impact of their physical and cognitive health. Supplementing the survey results with the interview allows the study to identify older drivers' major challenges including adverse weather, construction sites, and in-vehicle distractions. Supporting that visual and cognitive challenges are limiting older adults' driving patterns (e.g., not driving at night). To avoid any conflicts with aggressive drivers, the older adults are passively driving, and if accessible, utilizing in-vehicle technologies to increase their safety. However, older drivers suggested that all drivers, particularly younger drivers, should have access to more educational materials. They recommended that older adults' licensing requirements should be evaluated based on their health condition rather than age. Participants' concern regarding roadway infrastructure elements and driver behavior can be resolved through improvements in road design and driver education. [ABSTRACT FROM AUTHOR]

Intraoperative controlled hypotension improves surgical field visibility by reducing blood loss (efficacy) but poses potential risks linked to organ hypoperfusion (safety). The use of controlled hypotension persists despite increasing evidence of associations between intraoperative inadvertent hypotension and adverse outcomes. Therefore, we tested the hypothesis that the focus and results of intraoperative controlled hypertension research differ across anaesthesia and surgery investigators because of differing priorities. We systematically reviewed randomised trials comparing controlled hypotension with usual care with trials categorised by investigators' affiliation. We identified 48 eligible trials, of which 37 were conducted by anaesthesia investigators and 11 by surgery investigators. For the primary outcome, 54% of the anaesthesia-led trials focused on safety, whereas all (100%) surgery-led trials focused on efficacy (P =0.004). Compared with usual care, mean arterial pressure in controlled hypotension was 23% (95% confidence interval [CI] 17–29%) lower in anaesthesia trials and 30% (95% CI 14–37%) lower in surgery trials; estimated blood loss was 44% (95% CI 30–55%) less in anaesthesia trials and 38% (95% CI 30–49%) less in surgery trials. Overall, blood loss was reduced by 43% (95% CI 32–53%), and trial sequential analysis supported an efficacy conclusion. Mean arterial pressure and estimated blood loss reductions were associated (R2=0.41, P =0.002). All trials were underpowered for safety outcomes, and none adequately evaluated myocardial or renal injury. Anaesthesia researchers prioritised safety outcomes, whereas surgery researchers emphasised efficacy in controlled hypotension trials. Controlled hypotension significantly reduces blood loss. In contrast, safety outcomes were poorly studied. Given increasing observational evidence linking inadvertent hypotension to myocardial and renal injury, the safety of controlled hypotension remains to be addressed. PROSPERO (CRD42023450397). [ABSTRACT FROM AUTHOR]

Background: The use of prehospital tranexamic acid (TXA) in patients with trauma has attracted considerable attention. This systematic review and meta-analysis aimed to provide the best evidence for clinicians. Methods: All related literature in PubMed, Embase, and the Cochrane Central Register of Controlled Trials (Central) databases were searched systematically from their establishment to July 1, 2023. The outcome measures included 24-hour and 28–30-day mortality and adverse events (multiple organ dysfunction syndrome, acute respiratory distress syndrome, thrombotic events, and infection events). The Revised Cochrane Risk of Bias Tool for Randomized Trials was used to evaluate the quality of the randomized controlled trials (RCTs). The Methodological Index for Nonrandomized Studies (MINORS) was used to evaluate the risk of bias in non-RCTs. The required information size was estimated using trial sequential analysis. The Grading of Recommendations, Assessment, Development, and Evaluation approach was used to evaluate the evidence quality. Results: Eleven studies (comprising 11,259 patients) were included; two of these were RCTs. The overall risks of bias were low in the RCTs. ROBINS-I risk of bias was Moderate in 3 studies, serious in 5 studies, and critical in 1 study. A significant reduction in 24-hour mortality was observed (odds ratio [OR], 0.82; 95% confidence interval [CI], 0.71–0.94). A subgroup analysis that included only RCTs revealed that prehospital TXA was associated with reduced 28–30-day mortality (OR, 0.80; 95% CI, 0.66–0.97) and increased risks of thromboembolism (OR, 1.22; 95% CI, 1.03–1.44) and infection (OR, 1.13; 95% CI, 1.00–1.28) events. The blood products for transfusion decreased by 2.3 units on average (weighted mean difference [WMD], − 2.30; 95%CI, − 3.59 to − 1.01). Conclusions: This updated systematic review showed that prehospital TXA reduced the 24-hour and 28–38-day mortality and blood transfusion but increased the risks of infection and thromboembolism in patients with trauma. Future RCTs with larger and more homogeneous samples will help verify our results. [ABSTRACT FROM AUTHOR]

ABSTRACT We propose a semiparametric approach to Bayesian modeling of dynamic treatment regimes that is built on a Bayesian likelihood‐based regression estimation framework. Methods based on this framework exhibit a probabilistic coherence property that leads to accurate estimation of the optimal dynamic treatment regime. Unlike most Bayesian estimation methods, our proposed method avoids strong distributional assumptions for the intermediate and final outcomes by utilizing empirical likelihoods. Our proposed method allows for either linear, or more flexible forms of mean functions for the stagewise outcomes. A variational Bayes approximation is used for computation to avoid common pitfalls associated with Markov Chain Monte Carlo approaches coupled with empirical likelihood. Through simulations and analysis of the STAR*D sequential randomized trial data, our proposed method demonstrates superior accuracy over Q‐learning and parametric Bayesian likelihood‐based regression estimation, particularly when the parametric assumptions of regression error distributions may be potentially violated. [ABSTRACT FROM AUTHOR]

Currently, generative AI has undergone rapid development. Numerous studies have attested to the benefits of Gen AI in programming, mathematics and other disciplines. However, since Gen AI mostly uses English as the intrinsic training parameter, it is more effective in facilitating the teaching of courses that use international common notation, but few scholars have researched the fitness of Gen AI-assisted teaching of humanities courses in Chinese-language environments. To address these gaps, this study examined the learning behaviours of 30 students using Gen AI to help them answer questions on economic law tests using the Lag Sequential Analysis. The results show that the following: (1) The use of Gen AI to aid learning in an economic law course did not significantly improve the cognitive level of academics from the perspective of knowledge construction. (2) According to the characteristics of students’ behavioural paths via Gen AI-assisted learning, their behavioural patterns can be classified into autonomous and innovative, moderate, and lacking innovation. (3) Different learning modes when Gen AI-assisted teaching was used affected the final results, which were as follows: High-performing students favoured the autonomous and innovative pattern, medium-performing students favoured the moderate pattern, and low-performing students favoured the lacking innovation pattern. [ABSTRACT FROM AUTHOR]

Attraction to the target culture can be a reason to study the language, especially in the case of languages other than English (LOTEs). Recently, the number of Korean language learners has surged alongside the growing popularity of Korean pop culture (K‐pop). However, it is unknown whether the initial attraction to the culture and the first steps in that direction shape foreign language (FL) emotions in the longer term. To fill this gap, this mixed‐methods study examined to what extent the attractiveness of the Korean Culture (K‐culture) predicts foreign language enjoyment (FLE) after controlling for other established learner variables (i.e., the length of FL study, FL proficiency, frequency of FL use outside of class, and attitudes toward the teacher and FL) through sequential regression analysis. The quantitative findings are complemented by the open‐ended responses to the sources of FLE using the American Council on Teaching of Foreign Languages 3Ps framework (products, practices, and perspectives) through NVivo. A total of 782 university students studying Korean as FL completed an online survey on the attractiveness of K‐culture and FLE. The results showed that the attitude toward the teacher and attractiveness of K‐culture are the strongest predictors of FLE. [ABSTRACT FROM AUTHOR]

Background Methods Results Conclusions The anterior quadratus lumborum (QL) block may be used for postoperative pain management for intra‐abdominal surgeries, but the evidence is uncertain. We aimed to investigate the benefit and harm of the anterior QL block compared to placebo/no block for intra‐abdominal surgery.We searched Medline, Embase, and CENTRAL for randomized controlled trials investigating anterior QL block for postoperative pain management for adult patients undergoing any intra‐abdominal surgery. The two co‐primary outcomes were cumulative 24‐h opioid consumption and serious adverse events. We performed meta‐analysis, trial sequential analysis (TSA), assessed the risk of bias, and present the certainty of evidence with the Grading of Recommendations, Assessment, Development and Evaluation approach.Thirty‐five trials randomizing 2418 patients were included in the meta‐analyses. Anterior QL block may reduce cumulative 24‐h intravenous opioid consumption compared to placebo/no block (MD −10.42 mg, 96.7% CI −14.83 to −6.01, TSA‐adjusted CI −17.03 to −3.82, p < .01). Two trials reported on SAEs. Anterior QL block may have little to no effect on the number of serious adverse events compared to placebo (RR 1.49, 96.7% CI 0.19 to 11.47, p = .68), but the evidence is very uncertain. All trial results were assessed as being high risk of bias.The anterior QL block may reduce cumulative 24‐h opioid consumption. Reported serious adverse events were few and the anterior QL block may have little to no effect on the number of SAEs, but the evidence was very uncertain. [ABSTRACT FROM AUTHOR]

Objective: This meta-analysis aims to compare the clinical efficacy of mesh non-fixation and fixation in laparoscopic transabdominal preperitoneal (TAPP) inguinal hernia repair, systematically evaluating the application value of the mesh non-fixation technique in clinical settings. Methods: A computerized search of PubMed, Embase, Cochrane Library, Web of Science, and ClinicalTrials.gov databases was conducted to identify randomized controlled trials (RCTs) comparing mesh non-fixation and fixation in TAPP inguinal hernia repair. Meta-analysis was performed using RevMan 5.3 software, and the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) evidence grading system was employed for outcome quality assessment. Publication bias analysis was performed using Begg's test. A trial sequential analysis (TSA) was performed using TSA 0.9.5.10 Beta software. Results: A total of nine RCTs involving 1,879 inguinal hernia patients were included. Meta-analysis results demonstrated that, compared to the fixation group, the non-fixation group exhibited significantly lower seroma occurrence rate [RR = 0.43, 95% CI (0.20, 0.89), P = 0.02, heterogeneity P = 0.28, I²=22%], Visual Analog Scale (VAS) pain score at 6 months postoperatively [MD=-0.21, 95% CI (-0.29, -0.12), P < 0.00001, heterogeneity P = 0.34, I²=0%], and cost [MD=-3.23 thousand yuan, 95% CI (-4.26, -2.19), P < 0.00001, heterogeneity P = 0.0003, I²=92%]. There were no statistically significant differences in overall complication rate [RR = 0.88, 95% CI (0.62, 1.23), P = 0.45, heterogeneity P = 0.11, I²=44%], overall infection event rate [RR = 0.96, 95% CI (0.36, 2.56), P = 0.93, heterogeneity P = 0.62, I²=0%] and recurrence rate [RR = 0.75, 95% CI (0.28, 1.99), P = 0.56, heterogeneity P = 0.44, I²=0%] between the two groups. The results of the TSA indicated that the observed lower seroma occurrence rate in the non-fixation group compared to the fixation group requires further validation through the inclusion of additional RCTs. Conclusion: Mesh non-fixation in TAPP inguinal hernia repair is deemed safe and does not elevate the risk of hernia recurrence. However, given certain limitations in this study, future comprehensive and reliable validation will require further multicenter, high-quality, large-sample double-blind RCTs. [ABSTRACT FROM AUTHOR]

Introduction: The educational system in Costa Rica, as regulated by Law #7727, which governs Alternative Conflict Resolution and Promotion of Social Peace must consider the interplay of various factors influencing classroom conflicts and the management strategies employed by teachers. Consequently, it becomes imperative to identify the most effective conflict resolution practices applicable within this context. To achieve this, a thorough procedure based on mixed methods was employed to analyze and interpret both classroom conflict behaviors and teachers' strategic responses. Method: This study employed an indirect observational methodology, from a mixed methods approach. Data was collected through a focus group comprised of teachers. Following the connect framework, the procedure was conducted in three phases: QUAL-QUAN-QUAL. Two analytical techniques were implemented. A lag sequential analysis was used to explore potential behavioral patterns. The results of this analysis informed a polar coordinate analysis, which generated a visual representation of the relationships between codes. Results and discussion: A focus group addressed four questions, yielding satisfactory data quality control results (kappa values: 0.80, 0.77, 0.76, 0.82). In polar coordinate analysis, the 37 observational instrument categories were designated as focal behaviors. Each of the 37 analyses treated all categories as conditioned behaviors. The analysis identified 342 activation/inhibition relationships between focal and conditioned behaviors. Of these, 195 were statistically highly significant, distributed across quadrants: Quadrant I (106), Quadrant II (36), Quadrant III (16), Quadrant IV (36). Significant gaps in understanding of conflict were identified, along with disparities in the resources and competencies necessary for successful conflict resolution among the observed educators. Specifically, teachers frequently employed techniques informed by intuition rather than deliberate strategy learned in their training. Consequently, the study advocates for enhancing teachers' cognitive and emotional competencies to optimize conflict management within the classroom and bolster their adaptive coping mechanisms. [ABSTRACT FROM AUTHOR]

Objective: This meta-analysis aimed to compare videolaryngoscope (VL)-assisted transesophageal echocardiography (TEE) probe insertion with conventional methods in terms of efficacy and safety. Methods: Several major databases such as Medline and Embase were systematically searched to identified relevant studies from inception to June 2024. The primary outcome was complication rate, defined as the proportion of patients experiencing complications related to TEE probe insertion. Injuries at specific sites (e.g., posterior hypopharyngeal wall) from both groups were also analyzed. The secondary outcomes included the first-attempt success rate and total insertion time of VL and conventional methods. Results: Seven trials involving 716 participants were identified. The use of VL was found to significantly reduce the complication rate (risk ratio[RR]:0.28, 95% confidence interval[CI]:0.17–0.46, P < 0.00001) and increased the first-attempt success rate [FASR] (RR:1.33, 95%CI: 1.10–1.60, P = 0.003) compared with conventional methods. These findings were confirmed by trial sequential analysis. No significant difference was found in the TEE insertion time among the two techniques (mean difference: −2.94s, 95%CI: −10.28–4.4, P = 0.43). VL significantly reduced the risk of trauma to the hypopharyngeal wall but showed no significant benefits in other areas (e.g., pyriform sinus). The certainty of evidence was moderate for the complication rate, very low for the FAS rate, and low for the TEE insertion time. Conclusion: The use of VL for TEE probe insertion is associated with a significantly lower complication rate and higher FAS rate than conventional methods. These findings suggest that VL enhances patient safety and improves the efficiency of TEE probe insertion. [ABSTRACT FROM AUTHOR]

Background: The effectiveness and safety of endovascular treatment compared with medical management alone regarding outcomes for patients with a large infarct core remain uncertain. Objectives: To juxtapose the clinical outcomes of thrombectomy versus the best medical care in patients with a large infarct core. Design: Systematic review and meta-analysis. Data sources and methods: We conducted searches in PubMed, Cochrane, and Embase for articles published up until November 8, 2023. Randomized trials were selected for inclusion if they encompassed patients with large vessel occlusion and sizable strokes receiving thrombectomy. The primary outcome was functional outcomes at 3 months after pooling data using random-effects modeling. Safety outcomes included mortality at 3 months, symptomatic intracranial hemorrhage (SICH), and decompressive craniectomy. We performed a trial sequential analysis to balance type I and II errors. Results: From 904 citations, we identified six randomized trials, involving a cohort of 1897 patients with a large ischemic region. Of these, 953 individuals underwent endovascular thrombectomy. At 3 months, thrombectomy was significantly correlated with better neurological prognosis, as evidenced by the increased odds of good functional outcomes (odds ratio (OR), 2.90; 95% confidence interval (CI), 2.08–4.05) and favorable functional outcomes (OR, 2.40; 95% CI, 1.86–3.09). Mortality rates did not demonstrably diminish as a consequence of the endovascular management (OR, 0.78; 95% CI, 0.58–1.06). However, the incidence of SICH was greater in the thrombectomy group compared to those with only medical treatment (5.5% vs 3.2%; OR, 1.77; 95% CI, 1.11–2.83). The application of trial sequential analysis yielded definitive evidence regarding favorable function outcomes and a shift in the distribution of modified Rankin scale scores at 3 months; however, others remained inconclusive. Conclusion: The results from most of the included trials display consistency. Meta-analysis of these six randomized trials offers high-quality evidence that thrombectomy significantly mitigates disability in patients with a large infarction, while also increasing the risk of SICH. Trial registration: PROSPERO, CRD42023480359. [ABSTRACT FROM AUTHOR]

BACKGROUND: Difficulty attracting physicians to work in rural and remote areas is a worldwide problem. Specific to pediatrics, barriers to recruitment include burdensome on-call rosters, a lack of career opportunities for partners and professional isolation. METHODS: To examine attitudes to working in a community hospital in Ireland, a mixed-methods sequential analysis approach was undertaken. Pediatricians-in training (70) and attending community pediatricians (25) completed surveys. Six semistructured interviews were used to triangulate survey results. RESULTS: Most trainees planned to stay in Ireland (66/70), with five (eight%) stating that a career in a community hospital was their first preference. Personal factors such as a partner's career prospects and closeness to family and friends were the most important deterrents to working in a community hospital for trainees. Both trainees and attendings were concerned regarding professional isolation. Trainees were concerned about the poor reputation of community units. This converged with attendings feeling their role was not adequately respected, even though their job had more variability and exposure to emergencies, with less support, than working in a large center. Both groups agreed that targeted postgraduate training pathways and better training opportunities within Ireland were the best way to improve recruitment. Financial bonuses were not highly ranked as potential incentives. Motivators for considering a career in community units included the desire to make an impact and to build something new. Concerns about job satisfaction, professional recognition, and limited support for service development were prevalent. CONCLUSION: This study reveals critical challenges and motivators influencing the shortage of pediatricians in Irish community units. Addressing these issues requires a multifaceted approach, incorporating targeted training, support structures, and recognition to enhance recruitment and retention in these underserved areas. Insights from the Irish context could be applied to improve recruitment and retention of pediatricians in regions with similar contexts. [ABSTRACT FROM AUTHOR]

Simple Summary: We review the existing research on social play in humans and other mammals to highlight the complex nature of this behaviour, which is regulated by various hormones and neural circuits. Play can swing from cooperation to competition. Contrary to what has been previously thought, when animals (including humans) play, they might not always be in a positive emotional state or in a relaxed context. By checking examples from human and non-human mammals, we aim to examine current tools and methodological approaches that can give information about the different individual emotional states possibly driving playful interactions and about the individual, socio-ecological, and structural factors potentially revealing the emotional nature of the play. We discuss the context in which play occurs (relaxed/not relaxed) and the structural similarities between play fighting and aggressive behaviour, considering how more competitive forms of play can serve as alternatives to aggression. Additionally, we look at the postures/movements and facial expressions (e.g., play faces) used as signals to indicate the player's intent and at copying behaviours, like rapid motor mimicry, which can enhance synchronization, non-agonistic competition, and possibly emotional sharing between players. This review focuses on social play, a complex behaviour that is often difficult to categorize. Although play has been typically associated with positive emotional states, a thorough examination of the literature indicates that it may relate to different emotional systems, from attachment to conflict. Play oscillates between competition and cooperation, and includes a spectrum in between; thus, quantitatively identifying and demonstrating the emotional nature of play remains challenging. We considered examples from human and non-human animal studies and explored the emotional and neuro-hormonal systems involved in play. We assessed ethological data possibly indicating the emotional states underlying play, and we focused on the cooperative and competitive elements of play. We investigated the relationship between play and affiliative/aggressive behaviours, the communicative meaning of play signals (especially primate play faces), and the motor and possibly emotional contagion function of rapid motor mimicry during play. From all the literature on play, this review selects and combines studies in an innovative way to present the methods (e.g., play indices and social network analysis), tools (e.g., sequential analysis and facial coding software), and evidence indicative of the emotional states underlying play, which is much more complex than previously thought. [ABSTRACT FROM AUTHOR]

Brain–computer interface (BCI) offers a novel means of communication and control for individuals with disabilities and can also enhance the interactions between humans and machines for the broader population. This paper explores the brain neural signatures of unmanned aerial vehicle (UAV) operators in emergencies and develops an operator's electroencephalography (EEG) signals-based detection method for UAV emergencies. We found regularity characteristics similar to classic event-related potential (ERP) components like visual mismatch negativity (vMMN) and contingent negative variation (CNV). Source analysis revealed a sequential activation of the occipital, temporal, and frontal lobes following the onset of emergencies, corresponding to the processing of attention, emotion, and motor intention triggered by visual stimuli. Furthermore, an online detection system was implemented and tested. Experimental results showed that the system achieved an average accuracy of over 88% in detecting emergencies with a detection latency of 431.95 ms from the emergency onset. This work lays a foundation for understanding the brain activities of operators in emergencies and developing an EEG-based detection method for emergencies to assist UAV operations. [ABSTRACT FROM AUTHOR]

Background: We aimed to verify the effectiveness of electroacupuncture on postoperative ileus prevention after abdominal surgery by meta‐analysis and trial sequential analysis (TSA). Methods: From inception to May 14, 2024, PubMed, the Cochrane Library, Web of Science, and Embase databases were searched. TSA was used to determine an optimal sample size and control false‐positive findings. The primary outcome was the time to first defecation (hours). Results: Fourteen studies were included, with 1105 participants. Meta‐analysis and TSA revealed firm evidence for benefits that electroacupuncture shorted the time to first defecation (mean difference [MD] −12.73 h, I2 = 22%, P < 0.01), the time to first flatus (MD −7.03 h, I2 = 25%, P < 0.01), the time to start of sips of water (MD −12.02 h, I2 = 0%, P < 0.01), and the time to start of liquid diet (MD −12.97 h, I2 = 0%, P < 0.01) compared with usual care. While compared with sham electroacupuncture, meta‐analysis and TSA also confirmed that electroacupuncture shortened the time to first defecation (MD −10.81 h, I2 = 31%, P = 0.02) and the time to first flatus (MD −10.81 h, I2 = 0%, P < 0.01). However, TSA revealed that firm evidence for benefit or futility was not reached for the length of hospital stay and the rates of postoperative prolonged ileus. Conclusions: Electroacupuncture shortened the duration of postoperative ileus in patients undergoing abdominal surgery, and the adverse events related to electroacupuncture were minor. Further investigation of the effect of electroacupuncture on the risk of prolonged postoperative ileus is warranted in the future. [ABSTRACT FROM AUTHOR]

Background and Aim: We aimed to evaluate comparative outcomes of aggressive versus non‐aggressive intravenous fluid (IVF) therapy in patients with acute pancreatitis. Methods: A systematic search of electronic data sources and bibliographic reference lists were conducted. All randomized controlled trials (RCTs) reporting outcomes of aggressive versus non‐aggressive IVF therapy in acute pancreatitis were included and their risk of bias were assessed. Effect sizes were determined for overall mortality, systemic inflammatory response syndrome (SIRS), sepsis, respiratory failure, pancreatic necrosis, severe pancreatitis, clinical improvement, AKI, and length of stay using random‐effects modeling. Trial sequential analysis was conducted to determine risk of types 1 or 2 errors. Results: We included 10 RCTs reporting 993 patients with acute pancreatitis who received aggressive (n = 475) or non‐aggressive (n = 518) IVF therapy. Aggressive IVF therapy was associated with significantly higher rate of sepsis (OR: 2.68, P = 0.0005) and longer length of stay (MD: 0.94, P < 0.00001) compared with the non‐aggressive approach. There was no statistically significant difference in mortality (RD: 0.02, P = 0.31), SIRS (OR: 0.93, P = 0.89), respiratory failure (OR: 2.81, P = 0.07), pancreatic necrosis (OR: 1.98, P = 0.06), severe pancreatitis (OR: 1.31, P = 0.38), clinical improvement (OR: 1.12, P = 0.83) or AKI (OR: 1.06, P = 0.91) between the two groups. Sub‐group analysis demonstrated higher morbidity and mortality associated with the aggressive approach in more severe disease. Trial sequential analysis detected risk of type 2 error. Conclusions: Aggressive IVF therapy may be associated with higher morbidity in patients with acute pancreatitis compared with the non‐aggressive approach, particularly in patients with more severe disease. It may also prolong length of hospital stay. The available evidence is subject to type 2 error indicating the need for adequately powered RCTs. [ABSTRACT FROM AUTHOR]

This study aimed to use a game-based learning (GBL) module with multi-scaffolding and mobile technology for high school students with mild intellectual disabilities (MID) to assist them in learning career education knowledge. This study used a quasi-experimental method to investigate the participants’ learning effectiveness, motivation, flow state, game acceptance, and learning behavior patterns (LBP). The differences in the LBP of the high and low learning effectiveness groups and the high and low flow state groups were also investigated. In total, 32 high school students with MID participated in this study. The results show that the GBL module with the multi-scaffolding mechanism could improve their learning effectiveness, motivation, flow state, game acceptance, and LBP and reduce their distraction behavior in the learning activities. The results of the sequential analysis indicated the significance of the behavior of reflection and discussions in the high learning effectiveness group. Additionally, the high-flow state group tended to try multiple strategies to complete the learning tasks. Furthermore, the game mechanism embodied collaborative peer interaction; even when the high-flow group became distracted, they returned to the tasks and continued the discussions with peers. [ABSTRACT FROM AUTHOR]

Background: There are multiple antibiotic regimens for the treatment of carbapenem-resistant Acinetobacter baumannii (CRAB) in clinical practice. We conducted this meta-analysis to compare the efficacy and safety of cefiderocol-based regimens and colistin-based regimens in the treatment of CRAB infections. Methods: Two authors independently searched the PubMed, Web of Science, Embase, and Cochrane databases from their establishment to April 15, 2024, to search for randomized controlled trials (RCTs) or cohort studies, and compared the clinical efficacy and safety of cefiderocol-based regimens and colistin-based regimens in the treatment of CRAB infections. The Newcastle Ottawa Scale (NOS) checklist was used to evaluate the quality of the included studies. The primary outcome was all-cause mortality, and subgroup analysis was conducted on the basis of the site of infection and the risk of bias in the studies. Trial sequential analysis (TSA) was then conducted. Results: Six observational studies were included, with 251 cases in the cefiderocol-based group and 372 cases in the colistin-based group. Compared to the colistin-based group, the cefiderocol-based group had lower all-cause mortality (RR = 0.71, 95% CI: 0.54–0.92, P = 0.01) and 30-day mortality (RR = 0.64, 95% CI: 0.43–0.95, P = 0.03). However, for the 14-day and 28-day mortality rates, there was no statistically significant difference between two groups. According to the subgroup analysis, among patients with bloodstream infection (BSI), the cefiderocol-based group had lower all-cause mortality, but it did not reduce the mortality of ventilator-associated pneumonia (VAP) patients. The result of TSA showed that our conclusions are reliable. There was no significant statistical difference in the microbiological cure rate, clinical cure rate, or duration of hospitalization. In addition, the cefiderocol-based group did not have an increased incidence of acute kidney injury (AKI). Conclusions: Compared with the colistin-based regimens, the cefiderocol-based regimens were significantly associated with a lower risk of mortality in CRAB-infected patients, especially for patients with BSI. However, they did not show any advantages in terms of the clinical cure rate or microbiological cure rate, nor did they reduce the incidence of AKI. PROSPERO registration number: CRD42023487213. [ABSTRACT FROM AUTHOR]

Digital game-based learning (DGBL) and electronic books (E-books) can provide students with different benefits. Accordingly, one aim of this study was to incorporate an E-book into DGBL to develop a Digital Entertaining English Learning (DEEL). However, individual differences exist among learners, especially prior knowledge. To this end, the other aim of this study was to provide a complete understanding of the effects of prior knowledge on student learning in the context of DEEL. Hence, we conducted empirical investigation, where learners' reactions to the DEEL were analyzed with quantitative methods and the lag sequential analyses. An independent variable was prior knowledge while dependent variables were test performance, task performance and learning behavior. Regardless of test performance or task performance, results indicated that high prior knowledge learners (HPK) performed better than low prior knowledge learners (LPK). Regarding learning behavior, LPK more frequently used the grammar E-book than HPK, especially pictorial illustration. Additionally, LPK moved between the text description and pictorial illustration with a bidirectional approach while HPK viewed the text description and pictorial illustration with a unidirectional approach. Based on these findings, we developed a framework, which can be applied to personalize the DEEL so that learners' learning experience can be improved. [ABSTRACT FROM AUTHOR]

OBJECTIVES: To assess the effects of antibiotics delivered via the respiratory tract in preventing ventilator-associated pneumonia (VAP). DATA SOURCES: We searched PubMed, Scopus, the Cochrane Library, and ClinicalTrials.gov for studies published in English up to October 25, 2023. STUDY SELECTION: Adult patients with mechanical ventilation of over 48 h and receiving inhaled or instilled antibiotics (with control group) to prevent VAP were included. DATA EXTRACTION: Two independent groups screened studies, extracted the data, and assessed the risk of bias. The Grading of Recommendations Assessment, Development, and Evaluation approach was used to assess the certainty/quality of the evidence. Results of a random-effects model were reported for overall and predefined subgroup meta-analyses. The analysis was primarily conducted on randomized controlled trials, and observational studies were used for sensitivity analyses. DATA SYNTHESIS: Seven RCTs with 1445 patients were included, of which six involving 1283 patients used nebulizers to deliver antibiotics. No obvious risk of bias was found among the included RCTs for the primary outcome. Compared with control group, prophylactic antibiotics delivery via the respiratory tract significantly reduced the risk of VAP (risk ratio [RR], 0.69 [95% CI, 0.53-0.89]), particularly in subgroups where aminoglycosides (RR, 0.67 [0.47-0.97]) or nebulization (RR, 0.64 [0.49-0.83]) were used as opposed to other antibiotics (ceftazidime and colistin) or intratracheal instillation. No significant differences were observed in mortality, mechanical ventilation duration, ICU and hospital length of stay, duration of systemic antibiotics, need for tracheostomy, and adverse events between the two groups. Results were confirmed in sensitivity analyses. CONCLUSIONS: In adult patients with mechanical ventilation for over 48 h, prophylactic antibiotics delivered via the respiratory tract reduced the risk of VAP, particularly for those treated with nebulized aminoglycosides. [ABSTRACT FROM AUTHOR]

The etiology of Rheumatoid Arthritis (RA) development remained unclear, and several factors, such as environmental, genetic, and immune system dysfunction, have been attributed to the susceptibility. Interleukin 23 (IL23) induces expansion of the Th17 cells through the IL-23 receptor (IL-23R) and believes in playing a major role in RA pathogenesis. Various genetic mutants in the IL23R gene (rs10489629, rs1343151, rs2201841, rs7517847, rs1004819, rs10889677, rs11209026, rs7530511) have been associated with the susceptibility RA, but results are contradictories. We performed a meta-analysis to establish the association of IL23R polymorphisms with susceptibility RA. For the meta-analysis, a detailed search of databases like Google Scholar, PubMed, Scopus, Web of Science, and Science Direct was conducted, and data were extracted from the included reports. The meta-analysis was performed by the Comprehensive Meta-Analysis v3 software. A significant association of IL-23R rs11209026 (AA vs. GG: Odds ratio = 2.250, p-value = 0.01; AA vs. GG+GA: Odds ratio = 2.271, p-value = 0.01), rs1343151 (A vs. G: Odds ratio = 1.091, p-value = 0.001; AA vs. GG: Odds ratio = 1.209, p-value = 0.001; GA vs. GG: Odds ratio = 1.116, p-value = 0.004; AA+GA vs. GG: Odds ratio = 1.135, p-value = 0.000; AA vs. GG+GA: Odds ratio = 1.144, p-value = 0.012) and rs10889677 (CA vs. CC: Odds ratio = 1.375, p-value = 0.041) polymorphisms were observed with increased susceptibility for the development of RA. In contrast, IL-23R rs10489629 (G vs. A: odds ratio = 0.901, p-value = 0.047, GG vs. AA: Odds ratio = 0.763, p-value = 0.022, GG vs. AA+AG: Odds ratio = 0.852, p-value = 0.00) and IL23R rs2201841 (CC vs. TT+TC: Odds ratio = 0.826, p-value = 0.026) variants were linked with protection against the development of RA. In addition, the trial sequential analysis revealed the inclusion of a sufficient number of studies in the present meta-analysis, and no further additional studies are required. IL-23R variants are associated with genetic susceptibility or resistance against the development of RA. [ABSTRACT FROM AUTHOR]

Systemic Lupus Erythematosus (SLE) is an autoimmune disorder characterized by autoantibody production and organ involvement. The role of toll-like receptor-7 in SLE is well established. Although genetic variations in the TLR-7 gene have been associated with an increased risk of developing SLE, the findings are not consistent. We performed a meta-analysis of previously published articles on four important single nucleotide polymorphisms in the TLR-7 gene (rs3853839, rs179008, rs179019, and rs179010) to reach a valid conclusion. Various literature databases, including PubMed, Science Direct, and Scopus, were scoured for eligible reports until May 10, 2023. GPower software v.3 was used to assess the power of individual reports included in the meta-analysis. Comprehensive Meta-analysis v3 software was used to perform all statistics. The publication biases in each genetic comparison model were investigated using funnel plots and Egger's regression test. To test heterogeneity, Cochrane Q statistics, probability value and I2 were used. Considering the predefined inclusion and exclusion criteria, the current study included a total of 10 eligible studies that included 15,472 SLE cases and 16,721 healthy controls. The meta-analysis revealed a significant association between TLR7 polymorphisms (rs179019 and rs179010) and susceptibility to SLE development. Other TLR7 polymorphisms (rs3853839 and rs179008), on the other hand, showed no significant association. Furthermore, the trial sequential analysis identified the need for additional case control studies for TLR-7 polymorphisms (rs3853839, rs179008, and rs179019) other than the rs179010 polymorphism. TLR7 variants for rs179010 and rs179019 are risk factor for the development of SLE. Further investigations are required to reach a valid conclusion. [ABSTRACT FROM AUTHOR]

Introduction: Knee pain is a major cause of disability worldwide, particularly among the elderly. Current treatments, including nonsteroidal anti-inflammatory drugs and analgesics, often lead to adverse effects. Krill oil is being explored as a potential alternative, however its efficacy in managing knee symptoms remains unclear. Methods: MEDLINE, Embase, and Cochrane databases were searched until May 2024 for studies comparing krill oil and placebo in knee pain patients. Endpoints included knee pain, stiffness, physical function, and lipid profiles (HDL-C, LDL-C, triglycerides, and total cholesterol). A restricted maximum likelihood random-effects model with standardized mean differences (SMD) and 95% confidence intervals (CI) was used. A trial sequential analysis was conducted to evaluate further research implications. Results: We included five trials with 700 patients using krill oil for knee pain. Results showed no significant difference between krill oil and placebo for knee pain, knee stiffness, and lipid profiles. However, krill oil demonstrated a significant small effect in improving knee physical function (SMD -0.24, 95% CI [-0.41; -0.08], I2 = 0%).Trial sequential analysis provided certainty that krill oil enhances knee physical function compared to placebo and indicated no improvement in knee pain, but the findings for knee stiffness need to be confirmed by further research. Conclusion: This study found that krill oil supplementation did not significantly improve knee pain, stiffness, or lipid profile, although it may help knee physical function. Based on these findings, krill oil supplementation is not yet justified for knee pain. [ABSTRACT FROM AUTHOR]

Sequential change-point analysis, which identifies a change of probability distribution in an infinite sequence of random observations, has important applications in many fields. A good method should detect a change point as soon as possible, and keep a low amount of false alarms. As one of the most popular methods, Shiryaev-Roberts (SR) procedure holds many optimalities. However, its implementation requires the pre-change and post-change distributions to be known, which is not achievable in practice. In this paper, we construct a nonparametric version of the SR procedure by embedding different versions of empirical likelihood, assuming two training samples, before and after change, are available for parameter estimations. Simulations are conducted to compare the performance of the proposed method with existing methods. The results show that when the underlying distribution is unknown, and training sample sizes are small, the proposed modified procedure shows advantage by giving a smaller delay of detection. [ABSTRACT FROM AUTHOR]

Summary: Background: Intrathecal diamorphine is believed to provide postoperative analgesia but is associated with adverse effects such as nausea and vomiting. There is little evidence of synthesis regarding intrathecal diamorphine in the contemporary literature. We performed a systematic review, meta‐analysis with meta‐regression and trial sequential analysis to determine the magnitude of intrathecal diamorphine efficacy and safety. Methods: We systematically searched the literature for trials comparing intrathecal diamorphine with a control group in patients undergoing all types of surgery. The primary efficacy and safety outcomes were intravenous morphine consumption and incidence of postoperative nausea and vomiting at 24 h following surgery, respectively. Results: Twelve trials were identified, which included data for 712 patients. Intrathecal doses of diamorphine ranged from 100 μg to 2500 μg. Intravenous morphine consumption at 24 h postoperatively was significantly reduced in the intrathecal diamorphine group, with a mean difference (95%CI) of ‐8 mg (‐11 to ‐6), I2 = 93%, p < 0.001. There was a significant difference between three intrathecal diamorphine dosing subgroups but without correlation: mean differences (95%CI) ‐1 mg (‐3–0), ‐26 mg (‐40 to ‐11) and ‐6 mg (‐15–4) in patients receiving doses of 0–200 μg, 201–400 μg and > 400 μg, respectively (p = 0.003). Intrathecal diamorphine increased postoperative nausea and vomiting with a risk ratio (95%CI) of 1.37 (1.19–1.58), I2 = 7%, p < 0.001. There were no differences in postoperative nausea and vomiting between the three intrathecal diamorphine dosing subgroups. There was no correlation observed with meta‐regression of the primary efficacy and safety outcomes. The quality of evidence for all outcomes was very low. Conclusion: There is very low level of evidence that intrathecal diamorphine provides effective analgesia after surgery, while increasing postoperative nausea and vomiting with doses > 200 μg. [ABSTRACT FROM AUTHOR]

This study explored the sequential interplay between challenges and regulatory processes in high- and low-performing collaborative groups. 66 students from a Finnish higher education institution participated in a collaborative task in groups of three. Approximately 34 h of video data were coded. The sequential analysis revealed that both groups had higher sequential transitions between cognitive regulation and emotional/motivational regulation, rather than cognitive challenges. The high-performing groups demonstrated a stronger sequential link between emotional/motivational regulation and cognitive regulation than the low-performing groups did when faced with cognitive challenges. The study establishes a theoretical grounding and advances our understanding of regulated learning. Since collaborative learning tasks are highly adopted in the higher education context, especially in the Nordic region, this study has practical implications for higher education in these countries and beyond as they seek to develop pedagogical methodologies and customised support to help collaborative groups resolve challenges by initiating regulatory processes. [ABSTRACT FROM AUTHOR]

Little attention has been paid to describing the ways early childhood education (ECE) teachers implement interactive strategies and the use of Spanish and English, in real time, to support Spanish–English emergent bilingual children's contributions to shared book reading interactions. Video recordings from 19 ECE classrooms during shared book reading were used to conduct sequential analysis to examine the different types of interactive strategies (e.g., questions, extensions) implemented by bilingual ECE teachers and emergent bilinguals' responses to these strategies. This study found that teachers' interactive strategies may reflect a degree of reciprocity, with teachers and children sensitively attuned to one another's contributions in real time. Teachers' questions in English and Spanish were related to emergent bilinguals' responses across a wide range of language complexity. Similarly, teachers and emergent bilinguals tended to respond to one another in the language of the prior utterance, suggesting teachers and emergent bilinguals are attuned to the contributions of one another. By examining teacher–child dynamics, this study produced results that can address issues that may have direct, translatable implications for ECE practice and intervention efforts. [ABSTRACT FROM AUTHOR]

Defining architectural space comes with multiple and diverse aspects. Our theoretical reflection aims at establishing the base for a new definition, in the sense that theoretical topology, like geometry, is an effective means to define the form of architectural spatiality based on the notion of ambiences. Topological definitions already developed by several renowned architects allow us to build a better understanding of route and sequence and thereby help the development of our analytical model. This research is focused on the museum, which is a public-facing architectural construction. According to the approach, thirty European museums were examined. The data collected for these museums were statistically analysed. Based, on the ambience discontinuities, the sequential analysis allowed us to create ambient topologies by transforming them into ambient events that are linked to the displacement of the user in connection with ambiance change. We endeavor to develop a micro study to reflect on the interaction between different environmental sources as a means to comprehend the influence on the future spatial-energetic behavior. This study lays the groundwork for a novel approach of defining architectural space based on differences in users' perceptions and the environment of a given space. [ABSTRACT FROM AUTHOR]

Purpose: This study aims to establish an evaluation method for cross-regional major infrastructure project (CRMIP) supportability. The focus is to identify evaluation indicators from a complexity perspective and develop an evaluation model using qualitative and quantitative methods. Case studies are carried out to verify the reliability of the evaluation model, thereby providing theoretical and practical guidance for CRMIP operations and maintenance (O&M). Design/methodology/approach: Guided by the idea of complexity management, the evaluation indicators of CRMIP supportability are determined through literature analysis, actual O&M experience and expert interviews. A combination of qualitative and quantitative methods, consisting of sequential relationship analysis, entropy weighting, game theory and cloud model, is developed to determine the indicator weights. Finally, the evaluation model is used to evaluate the supportability of the Hong Kong–Zhuhai–Macao Bridge (HZMB), which tests the rationality of the model and reveals its supportability level. Findings: The results demonstrate that CRMIPs' supportability is influenced by 6 guideline-level and 18 indicator-level indicators, and the priority of the influencing factors includes "organization," "technology," "system," "human resources," "material system," and "funding." As for specific indicators, "organizational objectives," "organizational structure and synergy mechanism," and "technical systems and procedures" are critical to CRMIPs' O&M supportability. The results also indicate that the supportability level of the HZMB falls between good and excellent. Originality/value: Under the guidance of complexity management thinking, this study proposes a supportability evaluation framework based on the combined weights of game theory and the cloud model. This study provides a valuable reference and scientific judgment for the health and safety of CRMIPs' O&M. [ABSTRACT FROM AUTHOR]

In the area of online teacher training, asynchronous collaboration faces several challenges such as limited learner engagement and low interaction quality, thereby hindering its overall effectiveness. Drawing on social comparison theory, providing social comparison feedback to teacher-learners in online asynchronous collaborative learning offers benefits, but also has drawbacks. While social comparison has been explored in diverse fields, its role in education remains unclear. In this study, we selected 95 primary and secondary school teachers participating in an online training course. Using randomized controlled trial design, we provided the experimental group with social comparison feedback, while the control group received only self-referential feedback. We used epistemic network analysis, lag sequential analysis, and social network analysis to identify the impact of social comparison feedback on group-regulated focus, group-interactive behaviors, and social network structures. The results showed that social comparison feedback significantly enhanced teachers' online asynchronous collaborative learning. [ABSTRACT FROM AUTHOR]

Background: Dengue, a viral infection transmitted by Aedes species mosquitoes, presents a substantial global public health concern, particularly in tropical regions. In Bangladesh, where dengue prevalence is noteworthy, accurately mapping the distribution of high-risk and low-risk areas and comprehending the clustering of dengue cases throughout the year is essential for the development of effective risk-based prevention and control strategies. Our objective was to identify dengue hotspots and temporal patterns over the years across Bangladesh in the years 2019–2023 excluding year 2020. Methods: A sequential spatial analysis was employed for each year to identify high-risk areas for dengue cases. Choropleth graphs were used to visualize the geographic distribution of dengue incidence rates per million population across the areas. Monthly distribution analysis was performed to identify temporal trends over the year 2022 and 2023. Additionally, the global Moran's I test was used to assess the overall geographical pattern. Subsequently, Anselin local Moran's I test was employed to identified clustering and hotspots of dengue incidences. Results: Dengue cases in Bangladesh exhibited a significant increase from 2019 to 2023 (excluding 2020 data), with a cumulative total of 513,344 reported cases. Dhaka city initially bore substantial burden, accounting for over half (51%) of the 101,354 cases in 2019. The case fatality rate also demonstrated a steadily rise, reaching 0.5% in 2023 with 321,179 cases (a five-fold increase compare to 2022). Interestingly, the proportion of cases in Dhaka decreased from 51% in 2019 to 34% in 2023. Notably, the southeast and central regions of Bangladesh showed the highest dengue rates, persisting throughout the study period. Cases were concentrated in urban regions, with Dhaka City exhibiting the highest caseload in most years, followed by Manikganj in 2023. A distinct temporal shift in dengue transmission was observed in 2023, when the peak incidence occurred three months earlier in July with complete geographic coverage (all the 64 districts) compared to the peak in October 2022 (covering 95%, 61 districts). Positive global autocorrelation analysis revealed spatial dependence, with more stable trends in 2023 compared to previous years. Several districts like, Bagerhat, Barisal, and Faridpur remained persistent hotspots or emerged as new hotspots in 2023. Conversely, districts like Dinajpur, Gaibandha, Nilphamari, Rangpur and Sylhet consistently exhibited low caseloads, categorized as dengue coldspots throughout most of the years. Jhalokati in 2019 and Gopalganj in 2022, both initially classified as low-incidence district surrounded by high-incidence districts, emerged as hotspots in 2023. Conclusion: This study sheds light on the spatiotemporal dynamics of dengue transmission in Bangladesh, particularly by identifying hotspots and clustering patterns. These insights offer valuable information for designing and implementing targeted public health interventions and control strategies. Furthermore, the observed trends highlight the need for adaptable strategies to address the region's evolving nature of dengue transmission effectively. Author summary: Dengue poses a serious global health threat, particularly in tropical regions like Bangladesh. Effective prevention and control depend on accurately mapping high-risk (hotspots) and low-risk (coldspots) areas. Using sequential spatial analysis, this study revealed a concerning rise in dengue cases, with a total of 513,344 reported of the study periods. The case fatality rate also increased, rising from 0.16% in 2019 to 0.5% in 2023. Initially, Dhaka city bore the highest burden, accounting for over half of the cases in 2019. However, a worrying shift emerged in 2023. Cases surged nationwide, with geographical coverage peaking in July–three months earlier than the typical October peak observed in 2022. This surge achieved complete geographic coverage, unlike the previous year. Spatial analysis indicated a strong spatial dependence of the disease, with trends stabilizing in 2023 compared to previous years. The study identified persistent hotspots in Bagerhat, Barisal, and Faridpur districts, while Dinajpur, Gaibandha, Nilphamari, Rangpur, and Sylhet districts emerged as coldspots. The southeast and central regions consistently showed high dengue rates. These findings underscore the dynamic nature of dengue transmission in Bangladesh, emphasizing the need for adaptable public health strategies and targeted interventions. [ABSTRACT FROM AUTHOR]

Background: Although electronic alerts are being increasingly implemented in patients with acute kidney injury (AKI), their effect remains unclear. Therefore, we conducted this meta-analysis aiming at investigating their impact on the care and outcomes of AKI patients. Methods: PubMed, Embase, Cochrane Library, and Clinical Trial Registries databases were systematically searched for relevant studies from inception to March 2024. Randomized controlled trials comparing electronic alerts with usual care in patients with AKI were selected. Results: Six studies including 40,146 patients met the inclusion criteria. The pooled results showed that electronic alerts did not improve mortality rates (relative risk (RR) = 1.02, 95% confidence interval (CI) = 0.97–1.08, P = 0.44) or reduce creatinine levels (mean difference (MD) = − 0.21, 95% CI = − 1.60–1.18, P = 0.77) and AKI progression (RR = 0.97, 95% CI = 0.90–1.04, P = 0.40). Instead, electronic alerts increased the odds of dialysis and AKI documentation (RR = 1.14, 95% CI = 1.05–1.25, P = 0.002; RR = 1.21, 95% CI = 1.01–1.44, P = 0.04, respectively), but the trial sequential analysis (TSA) could not confirm these results. No differences were observed in other care-centered outcomes including renal consults and investigations between the alert and usual care groups. Conclusions: Electronic alerts increased the incidence of AKI and dialysis in AKI patients, which likely reflected improved recognition and early intervention. However, these changes did not improve the survival or kidney function of AKI patients. The findings warrant further research to comprehensively evaluate the impact of electronic alerts. [ABSTRACT FROM AUTHOR]

The primary objective of this study was to evaluate the bound fractions of mercury (Hg), physicochemical parameters, and mineral composition of coal. Coal samples were collected from various depths within Block-VII of the Thar coalfield in Pakistan. The Hg associated with different chemical fractions of coal was extracted using a sequential extraction scheme as per the community bureau of reference (BCR) protocol. This study utilized both the BCR-sequential extraction method (BCR-SEM) and a single-step sequential extraction based on an ultrasonic-assisted method (SSE-UAM) for the fractionation analysis of Hg in coal. The extraction methodologies, BCR-SEM and SSE-UAM, were specifically designed for analyzing Hg fractionation in coal samples. The SSE-UAM offers an operational advantage, requiring only 2 h compared to the 51 h needed for BCR-SEM. The analyses were validated using standard reference material (SRM-1635a) and the spiking addition method, achieving a recovery percentage of 97.1% for total Hg concentrations using the pseudo-extraction method in SRM-1635A. Total Hg content in the coal samples ranged from 0.60 to 2.34 µg g−1 across four different coal seams from Block-VII of the Thar coalfield. Additionally, Hg concentration was observed to decrease with increasing depth, attributed to changes in mineralogical composition. The highest concentration of Hg was detected at a depth of 200–203 m, while the lowest concentration was at a depth of 152–154 m. The concentration of Hg in various fractions was 32–60% in the acid-soluble fraction, 1.72–4.92% in the reducible fraction, and 9.58–50.8% in the oxidizable fractions. The coal sample characteristics were analyzed using an elemental analyzer and scanning electron microscopy with energy-dispersive spectroscopy. Cold vapor atomic absorption spectrometry (CV-AAS) was used to measure the extracted fractional concentration of Hg in coal. [ABSTRACT FROM AUTHOR]

Background: The aim of this study is to evaluate the efficacy and safety of faecal microbiota transplantation (FMT) for the treatment of irritable bowel syndrome (IBS). Methods: We searched four databases for randomised controlled trials (RCTs) that compared FMT with a control intervention in patients with IBS. The revised Cochrane risk-of-bias (RoB) tool was chosen for appraisal. Meta-analysis with trial sequential analysis (TSA) was conducted. Grading of Recommendations Assessment Development and Evaluation (GRADE) methodology was used to assess the certainty of evidence (CoE). Results: We included 12 RCTs with a total of 615 participants. Meta-analyses showed no significant difference between the FMT and control groups in terms of clinical responses (relative risk [RR] = 1.44, 95% confidence interval [CI] 0.88–2.33) and changes in IBS Severity Scoring System (IBS-SSS) scores (standardised mean difference [SMD] = − 0.31, 95% CI − 0.72 to 0.09) and IBS Quality of Life (IBS-QOL) scores (SMD = 0.30, 95% CI − 0.09 to 0.69). Subgroup analysis revealed that in studies with low RoB and using endoscopy, nasojejunal tube and rectal enema delivery, FMT led to a significant improvement in clinical responses and changes in IBS-SSS and IBS-QOL scores. TSA suggested that the current evidence is inconclusive and that the CoE is very low. Conclusion: This study suggests that patients with IBS may benefit from FMT especially when it is administered via endoscopy, nasojejunal tube or rectal enema. However, the certainty of evidence is very low. Further research is needed to confirm the efficacy and safety of FMT for IBS treatment. Trial Registration: PROSPERO registration number CRD42020211002. [ABSTRACT FROM AUTHOR]

Background Aims Sample Methods Results Conclusions Students often harbour negative attitudes towards research methods and statistics courses, and such attitudes may be associated with harmful cognitive and behavioural responses. Research on these effects has been restricted to the investigation of direct links between attitudes towards statistics, statistics anxiety, academic procrastination, and course performance.This study sought to examine the interconnected impact of attitudes towards statistics, statistics anxiety, and procrastination, on course performance in a cohesive model. It was predicted that attitudes towards statistics would indirectly affect statistical performance via statistics anxiety and procrastination in a sequential manner.The sample comprised 171 undergraduate psychology students from Australian universities.An online questionnaire collected information on participant demographics, attitudes towards statistics, statistics anxiety, procrastinatory behaviours, and performance in participants most recently completed statistics course. Data were collected cross‐sectionally. All responses were anonymous.A sequential mediation analysis revealed a significant indirect effect of statistics anxiety and procrastination, controlling for age and gender. The results showed that more negative attitudes towards statistics are associated with greater statistics anxiety, which is in turn associated with greater procrastination, and finally with lower statistical performance.It was concluded that students who view their statistics courses as a threatening experience may fail to see value in their statistical education, which is associated with heightened statistics anxiety, increased avoidance of course‐related activities, and in turn poorer course performance. Practical implications of the findings are also discussed. [ABSTRACT FROM AUTHOR]

Lenalidomide, bortezomib, and dexamethasone (RVd) have previously been established as standard-of-care induction therapy for newly diagnosed multiple myeloma (NDMM). More recently, randomized phase 3 data have demonstrated the benefit of the addition of daratumumab (Dara-RVd) to the RVd backbone in terms of improved both depth of response and long-term survival benefit as measured by progression-free survival (PFS). Our group has previously published on a historical cohort of 1000 NDMM patients uniformly treated with RVd induction with impressive both PFS and overall survival. Here, we present a comparative analysis of our RVd cohort with a recent cohort of 326 patients induced with Dara-RVd at our institution with intent to transplant. This analysis demonstrates the utility of this regimen in real-world clinical practice and provides additional insights into D-RVd performance in patient subsets often underrepresented in clinical trials, as well as the impact of daratumumab in maintenance for NDMM patients. [ABSTRACT FROM AUTHOR]

AbstractUnderstanding the pedagogical dynamics that occur when teachers interact with digital textbook devices (DTDs) in the artificial intelligence (AI)–enhanced teaching environment is critical for education success. Previous research on the use of DTDs has primarily focused on subjective and intrusive questionnaire surveys, with little attention paid to the accompanying data when teachers use AI tools. This study aims to mine teachers’ behaviors from a data-driven perspective, exploring actual practices as they integrate DTDs into their teaching. We collected teachers’ behavioral data from a cloud-based curriculum platform, covering four subjects over a four-month period. Then, we used the lag sequential analysis (LSA) technique to investigate state-change patterns and the motif discovery technique to uncover hidden sequential patterns in teachers’ behaviors. Furthermore, using two mutually dependent recurrent neural networks, we predicted teachers’ future behaviors while operating DTDs, providing a more complete understanding of their pedagogical dynamics. Our findings show significant behavioral patterns when teachers use AI–embedded digital devices in the smart teaching environment. Additionally, the predictive model performed well in predicting teachers’ future behaviors, which can be used to improve the design of human–computer interaction in digital textbooks. [ABSTRACT FROM AUTHOR]

Background: There has been a significant surge in animal studies of stem cell-derived extracellular vesicles (EVs) therapy for the treatment of premature ovarian failure (POF) but its efficacy remains unknown and a comprehensive and up-to-date meta-analysis is lacking. Before clinical translation, it is crucial to thoroughly understand the overall impact of stem cell-derived EVs on POF. Methods: PubMed, EMBASE, Cochrane Library, Web of Science were searched up to February 18, 2024. The risk of bias was evaluated according to Cochrane Handbook criteria, while quality of evidence was assessed using the SYRCLE system. The PRISMA guidance was followed. Trial sequential analysis was conducted to assess outcomes, and sensitivity analysis and publication bias analysis were performed using Stata 14. Results: Data from 25 studies involving 339 animals were extracted and analyzed. The analysis revealed significant findings: stem cell-derived EVs increase ovary weight (SMD = 3.88; 95% CI: 2.50 ~ 5.25; P < 0.00001; I2 = 70%), pregnancy rate (RR = 3.88; 95% CI: 1.94 ~ 7.79; P = 0.0001; I2 = 0%), count of births (SMD = 2.17; 95% CI: 1.31 ~ 3.04; P < 0.00001; I2 = 69%) and counts of different types of follicles. In addition, it elevates the level of AMH (SMD = 4.15; 95% CI: 2.75 ~ 5.54; P < 0.00001; I2 = 88%) and E2 (SMD = 2.88; 95% CI: 2.02 ~ 3.73; P < 0.00001; I2 = 80%) expression, while reducing FSH expression (SMD = -5.05; 95% CI: -6.60 ~ -3.50; P < 0.00001; I2 = 90%). Subgroup analysis indicates that the source of EVs, animal species, modeling method, administration route, and test timepoint affected efficacy. Trial sequential analysis showed that there was sufficient evidence to confirm the effects of stem cell-derived EVs on birth counts, ovarian weights, and follicle counts. However, the impact of stem cell-derived EVs on pregnancy rates needs to be further demonstrated through more animal experimental evidence. Conclusions: Stem cell-derived EVs demonstrate safety and efficacy in treating POF animal models, with potential improvements in fertility outcomes. Trial registration: PROSPERO registration number: CRD42024509699. [ABSTRACT FROM AUTHOR]

Background: Systematic reviews and data synthesis of randomised clinical trials play a crucial role in clinical practice, research, and health policy. Trial sequential analysis can be used in systematic reviews to control type I and type II errors, but methodological errors including lack of protocols and transparency are cause for concern. We assessed the reporting of trial sequential analysis. Methods: We searched Medline and the Cochrane Database of Systematic Reviews from 1 January 2018 to 31 December 2021 for systematic reviews and meta-analysis reports that include a trial sequential analysis. Only studies with at least two randomised clinical trials analysed in a forest plot and a trial sequential analysis were included. Two independent investigators assessed the studies. We evaluated protocolisation, reporting, and interpretation of the analyses, including their effect on any GRADE evaluation of imprecision. Results: We included 270 systematic reviews and 274 meta-analysis reports and extracted data from 624 trial sequential analyses. Only 134/270 (50%) systematic reviews planned the trial sequential analysis in the protocol. For analyses on dichotomous outcomes, the proportion of events in the control group was missing in 181/439 (41%), relative risk reduction in 105/439 (24%), alpha in 30/439 (7%), beta in 128/439 (29%), and heterogeneity in 232/439 (53%). For analyses on continuous outcomes, the minimally relevant difference was missing in 125/185 (68%), variance (or standard deviation) in 144/185 (78%), alpha in 23/185 (12%), beta in 63/185 (34%), and heterogeneity in 105/185 (57%). Graphical illustration of the trial sequential analysis was present in 93% of the analyses, however, the Z-curve was wrongly displayed in 135/624 (22%) and 227/624 (36%) did not include futility boundaries. The overall transparency of all 624 analyses was very poor in 236 (38%) and poor in 173 (28%). Conclusions: The majority of trial sequential analyses are not transparent when preparing or presenting the required parameters, partly due to missing or poorly conducted protocols. This hampers interpretation, reproducibility, and validity. Study registration: PROSPERO CRD42021273811 [ABSTRACT FROM AUTHOR]

Background: The anti-pruritic effect of placebo in patients with chronic urticaria has gained increasing attention in clinical research. However, the extent of placebo effect and its influencing factors in the treatment of chronic urticaria are not well understood. Objective: The objective of this systematic review and meta-analysis was to investigate the effect of placebo on pruritus in patients with chronic urticaria and to explore relevant influencing factors. Methods: PubMed, Embase, Web of Science, Cochrane Library, and PsycINFO were searched from inception to 10 July, 2024. Primary outcome included pruritus scores. The secondary outcomes focused on global symptoms and quality of life. Subgroup analyses and meta-regression analyses were conducted based on drug types, sample size, participants' age, and other variables. The Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system and a trial sequential analysis were employed to establish the reliability of evidence. Results: A total of 65 eligible publications (including 67 randomized controlled trials) involving 10,704 patients with chronic urticaria were included. The pruritus scores decreased following placebo treatment (moderate evidence). In addition, favorable results were observed in global symptoms (moderate evidence) and quality of life (low evidence) after placebo treatment. Subgroup analyses indicated that the type of active medication in intervention groups was an influencing factor of placebo effect of pruritus. Meta-regression analyses demonstrated that the anti-pruritic effect of placebo was inversely correlated with sample size and positively correlated with participants' age. A trial sequential analysis provided further support for the anti-pruritic effect of placebo. Conclusions: A substantial improvement of pruritus after placebo treatment was observed in patients with chronic urticaria. The anti-pruritic effect of placebo varied with sample size, participants' age, and type of active medication used. Future research should further investigate the effect size of placebo and clarify the potential mechanism. PROSPERO Registration: The protocol was registered in the International Prospective Register of Systematic Reviews (PROSPERO) as CRD42023482608. [ABSTRACT FROM AUTHOR]

We investigate the ability to discover data assimilation (DA) schemes meant for chaotic dynamics with deep learning. The focus is on learning the analysis step of sequential DA, from state trajectories and their observations, using a simple residual convolutional neural network, while assuming the dynamics to be known. Experiments are performed with the Lorenz 96 dynamics, which display spatiotemporal chaos and for which solid benchmarks for DA performance exist. The accuracy of the states obtained from the learned analysis approaches that of the best possibly tuned ensemble Kalman filter and is far better than that of variational DA alternatives. Critically, this can be achieved while propagating even just a single state in the forecast step. We investigate the reason for achieving ensemble filtering accuracy without an ensemble. We diagnose that the analysis scheme actually identifies key dynamical perturbations, mildly aligned with the unstable subspace, from the forecast state alone, without any ensemble-based covariances representation. This reveals that the analysis scheme has learned some multiplicative ergodic theorem associated to the DA process seen as a non-autonomous random dynamical system. [ABSTRACT FROM AUTHOR]

Background: The ideal timing for tracheostomy in critically ill patients is still debated. This systematic review and meta-analysis examined whether early tracheostomy improves clinical outcomes compared to late tracheostomy or prolonged intubation in critically ill patients on mechanical ventilation. Methods: We conducted a comprehensive search of randomized controlled trials (RCTs) assessing the risk of clinical outcomes in intensive care unit (ICU) patients who underwent early (within 7–10 days of intubation) versus late tracheostomy or prolonged intubation. Databases searched included PubMed, Embase, and the Cochrane Library up to June 2023. The primary outcome evaluated was mortality, while secondary outcomes included the incidence of ventilator-associated pneumonia (VAP), ICU length of stay, and duration of mechanical ventilation. No language restriction was applied. Eligible studies were RCTs comparing early to late tracheostomy or prolonged intubation in critically ill patients that reported on mortality. The risk of bias was evaluated using the Cochrane Risk of Bias Tool for RCTs, and evidence certainty was assessed via the GRADE approach. Results: This systematic review and meta-analysis included 19 RCTs, covering 3586 critically ill patients. Early tracheostomy modestly decreased mortality compared to the control (RR −0.1511 [95% CI: −0.2951 to −0.0070], p = 0.0398). It also reduced ICU length of stay (SMD −0.6237 [95% CI: −0.9526 to −0.2948], p = 0.0002) and the duration of mechanical ventilation compared to late tracheostomy (SMD −0.3887 [95% CI: −0.7726 to −0.0048], p = 0.0472). However, early tracheostomy did not significantly reduce the duration of mechanical ventilation compared to prolonged intubation (SMD −0.1192 [95% CI: −0.2986 to 0.0601], p = 0.1927) or affect VAP incidence (RR −0.0986 [95% CI: −0.2272 to 0.0299], p = 0.1327). Trial sequential analysis (TSA) for each outcome indicated that additional trials are needed for conclusive evidence. Conclusions: Early tracheostomy appears to offer some benefits across all considered clinical outcomes when compared to late tracheostomy and prolonged intubation. [ABSTRACT FROM AUTHOR]

Causal effect estimation from observational data is one of the essential problems in causal inference. However, most estimation methods rely on the strong assumption that all confounders are observed, which is impractical and untestable in the real world. We develop a mediation analysis framework inferring the latent confounder for debiasing both direct and indirect causal effects. Specifically, we introduce generalized structural equation modeling that incorporates structured latent factors to improve the goodness-of-fit of the model to observed data, and deconfound the mediators and outcome simultaneously. One major advantage of the proposed framework is that it uses the causal pathway structure from cause to outcome via multiple mediators to debias the causal effect without requiring external information on latent confounders. In addition, the proposed framework is flexible in terms of integrating powerful nonparametric prediction algorithms while retaining interpretable mediation effects. In theory, we establish the identification of both causal and mediation effects based on the proposed deconfounding method. Numerical experiments on both simulation settings and a normative aging study indicate that the proposed approach reduces the estimation bias of both causal and mediation effects. for this article are available online. [ABSTRACT FROM AUTHOR]

This paper investigates the feasibility of detecting and estimating the rate of internal hemorrhage based on continuous noninvasive hematocrit measurement. A unique challenge in hematocrit-based hemorrhage detection is that hematocrit decreases in response to hemorrhage and resuscitation with fluids, which makes hemorrhage detection during resuscitation challenging. We developed two sequential inference algorithms for detection of internal hemorrhage based on the Luenberger observer and the extended Kalman filter. The sequential inference algorithms use fluid resuscitation dose and hematocrit measurement as inputs to generate signatures to enable detection of internal hemorrhage. In the case of the extended Kalman filter, the signature is nothing but inferred hemorrhage rate, which allows it to also estimate internal hemorrhage rate. We evaluated the proof-of-concept of these algorithms based on in silico evaluation in 100 virtual patients subject to diverse hemorrhage and resuscitation rates. The results showed that the sequential inference algorithms outperformed naïve internal hemorrhage detection based on the decrease in hematocrit when hematocrit noise level was 1% (average F1 score: Luenberger observer 0.80; extended Kalman filter 0.76; hematocrit 0.59). Relative to the Luenberger observer, the extended Kalman filter demonstrated comparable internal hemorrhage detection performance and superior accuracy in estimating the hemorrhage rate. The analysis of the dependence of the sequential inference algorithms on measurement noise and plant parametric uncertainty showed that small (≤1%) hematocrit noise level and personalization of sequential inference algorithms may enable continuous noninvasive detection of internal hemorrhage and estimation of its rate. [ABSTRACT FROM AUTHOR]

The route for the development, evaluation and dissemination of personalized psychological therapies is complex and challenging. In particular, the large sample sizes needed to provide adequately powered trials of newly-developed personalization approaches means that the traditional treatment development route is extremely inefficient. This paper outlines the promise of adaptive platform trials (APT) embedded within routine practice as a method to streamline development and testing of personalized psychological therapies, and close the gap to implementation in real-world settings. It focuses in particular on a recently-developed simplified APT design, the 'leapfrog' trial, illustrating via simulation how such a trial may proceed and the advantages it can bring, for example in terms of reduced sample sizes. Finally it discusses models of how such trials could be implemented in routine practice, including potential challenges and caveats, alongside a longer-term perspective on the development of personalized psychological treatments. [ABSTRACT FROM AUTHOR]