Table of Contents

Background: Noma can be a lethal disease and causes disfigurement in young children in low-resource countries, particularly in Africa. In these settings, 80% of the population mainly consult traditional healers for healthcare problems. Our study aimed to describe the sociodemographic characteristics of traditional healers and to assess their knowledge of noma. Methods: We conducted a survey among traditional healers in three Malian regions from May 2015 to January 2016 and collected data on sociodemographic characteristics, professional activity, knowledge, and experience of noma and collaboration with modern medicine. Results: Among 770 traditional healers invited to participate, 732 responded (95%) (mean age, 54.5 years). Most were illiterate (66.3%), which was associated with older age (p < 0.001). Although they treated all types of disease, only 10.5% had some knowledge of noma, with regional differences (p < 0.001). Conclusion: Noma is poorly known among traditional healers, especially in remote areas. Our findings suggest a lack of interest among young people for traditional medicine, implying an imminent decrease of healers, and thus the need for national health systems to strengthen and promote access to modern health care. Training programmes to improve the early diagnosis referral of noma patients should include all types of primary health workers. Full article

More and more people will experience thermal stress in the future as the global temperature is increasing at an alarming rate and the risk for extreme weather events is growing. The increased exposure to extreme weather events poses a challenge for societies around the world. This literature review investigates the feasibility of making advanced human thermal models in connection with meteorological data publicly available for more versatile practices and a wider population. By providing society and individuals with personalized heat and cold stress warnings, coping advice and educational purposes, the risks of thermal stress can effectively be reduced. One interesting approach is to use weather station data as input for the wet bulb globe temperature heat stress index, human heat balance models, and wind chill index to assess heat and cold stress. This review explores the advantages and challenges of this approach for the ongoing EU project ClimApp where more advanced models may provide society with warnings on an individual basis for different thermal environments such as tropical heat or polar cold. The biggest challenges identified are properly assessing mean radiant temperature, microclimate weather data availability, integration and continuity of different thermal models, and further model validation for vulnerable groups. Full article

Prescription-opioid misus e continues to be a significant health concern in the United States. The relationship between marijuana use and prescription-opioid misuse is not clear from the extant literature. This study examined national trends in prescription-opioid misuse among marijuana users and non-users using the 2007–2017 National Survey on Drug Use and Health. Cochran–Armitage tests were used to assess the statistical significance of changes in the yearly prevalence of prescription-opioid misuse and marijuana use. Multivariable logistic regression was used to examine the association between prescription-opioid and marijuana use adjusting for sociodemographic characteristics. From 2007 to 2017, marijuana use increased, while prescription-opioid misuse declined. Larger declines in prescription-opioid misuse were found among marijuana users than non-users. Marijuana ever-use was significantly associated with prescription-opioid misuse. Specifically, marijuana ever-users had higher odds of prescription-opioid misuse (ever-misuse [OR: 3.04; 95% CI, 2.68–3.43]; past-year misuse [OR: 3.44; 95% CI, 3.00–3.94]; and past-month misuse [OR: 4.50; 95% CI, 3.35–6.05]) compared to marijuana never-users. Similar results were found for the association of past-year and past-month marijuana use with prescription-opioid misuse. This study provides data on trends and associations about opioid misuse among marijuana users and non-users in a changing social environment of drug use in the United States. Future research should consider whether there is a causal relationship between marijuana use and prescription opioid misuse. Full article

Low-level wind shear, i.e., sudden changes in wind speed and/or wind direction up to altitudes of 1600 ft (500 m) above-ground is a hazardous meteorological phenomenon in aviation. It may radically change the aerodynamic circumstances of the flight, particularly during landing and take-off and consequently, it may threaten human lives and the health of passengers, people at the airport and its surrounding areas. The Bratislava Airport, the site of this case study, is one of the few airports worldwide and the first in Central Europe that is equipped with a Doppler lidar system, a perspective remote sensing tool for detecting low-level wind shear. The main objective of this paper was to assess the weather events collected over a period of one year with the occurrences of low-level wind shear situations, such as vertical discontinuities in the wind field, frontal passages and gust fronts to increase the level of flight safety and protect human lives and health. The lidar data were processed by a computer algorithm with the main focus on potential wind shear alerts and microburst alerts, guided by the recommendations of the International Civil Aviation Organisation. In parallel, the selected weather events were analyzed by the nearby located meteorological radar to utilize the strengths of both approaches. Additionally, an evaluation of the lidar capability to scan dynamics of aerosol content above the airport is presented. Full article

Disinfection and sterilization are needed for guaranteeing that medical and surgical instruments do not spread contagious microorganisms to patients. The aim of this study was to evaluate the efficacy of a simple manual technique of high-level disinfection (HLD) of flexible fiberoptic nasofibroscopes (FFNs) with wipes impregnated with a chlorine dioxide solution (Tristel Trio Wipes System—TTW) against a conventional automated washer machine (Soluscope ENT, Cimrex 12—AW). FFNs used in 62 patients undergoing endoscopy at an ENT clinic were sampled according to an aseptic procedure. For each nasoendoscopy, microbiological samples were taken at two times: (1) after a patient’s nasoendoscopy and (2) immediately after high-level disinfection. Ten microliters of each prepared sample were inoculated onto specific culture media for the detection of nasopharyngeal flora microorganisms. The microbiological results obtained from 62 post-disinfection samples revealed bacterial growth on two FFNs disinfected with AW, and five FFNs disinfected with TTW, but this difference is not statistically significant. None of the isolates were pathogenic bacteria. Our results are different than the results obtained by two previously published studies on the TTW system. In both studies, sampling was carried out by swabbing the tip and the handle surface of FFNs. This sampling method was the least effective method means of detecting bacteria on a surface. It can be concluded that the two disinfection systems allow providers to obtain a reduction of the saprophytic and pathogenic microbial load. Full article

Chlorine dioxide (ClO₂) has been widely used as a disinfectant in drinking water in the past but its effects on water pipes have not been investigated deeply, mainly due to the difficult experimental set-up required to simulate real-life water pipe conditions. In the present paper, four different kinds of water pipes, two based on plastics, namely random polypropylene (PPR) and polyethylene of raised temperature (PERT/aluminum multilayer), and two made of metals, i.e., copper and galvanized steel, were put in a semi-closed system where ClO₂ was dosed continuously. The semi-closed system allowed for the simulation of real ClO₂ concentrations in common water distribution systems and to simulate the presence of pipes made with different materials from the source of water to the tap. Results show that ClO₂ has a deep effect on all the materials tested (plastics and metals) and that severe damage occurs due to its strong oxidizing power in terms of surface chemical modification of metals and progressive cracking of plastics. These phenomena could in turn become an issue for the health and safety of drinking water due to progressive leakage of degraded products in the water. Full article

Objective: This meta-analysis aimed to estimate the global lifetime and 12-month prevalence of suicidal behavior, deliberate self-harm and non-suicidal self-injury in children and adolescents. Methods: A systematic search for relevant articles published between 1989 to 2018 was performed in multiple electronic databases. The aggregate 12-month and lifetime prevalence of suicidal behavior, deliberate self-harm, and non-suicidal self-injury were calculated based on the random-effects model. Subgroup analyses were performed to compare the prevalence according to school attendance and geographical regions. Results: A total of 686,672 children and adolescents were included. The aggregate lifetime and 12-month prevalence of suicide attempts was 6% (95% CI: 4.7–7.7%) and 4.5% (95% CI: 3.4–5.9%) respectively. The aggregate lifetime and 12-month prevalence of suicidal plan was 9.9% (95% CI: 5.5–17%) and 7.5% (95% CI: 4.5–12.1%) respectively. The aggregate lifetime and 12-month prevalence of suicidal ideation was 18% (95% CI: 14.2–22.7%) and 14.2% (95% CI: 11.6–17.3%) respectively. The aggregate lifetime and 12-month prevalence of non-suicidal self-injury was 22.1% (95% CI: 16.9–28.4%) and 19.5% (95% CI: 13.3–27.6%) respectively. The aggregate lifetime and 12-month prevalence of deliberate self-harm was 13.7% (95% CI: 11.0–17.0%) and 14.2% (95% CI: 10.1–19.5%) respectively. Subgroup analyses showed that full-time school attendance, non-Western countries, low and middle-income countries, and geographical locations might contribute to the higher aggregate prevalence of suicidal behaviors, deliberate self-harm, and non-suicidal self-injury. Conclusions: This meta-analysis found that non-suicidal self-injury, suicidal ideation, and deliberate self-harm were the three most common suicidal and self-harm behaviors in children and adolescents. Full article

The removal of tetracycline (TC) from solution is an important environmental issue. Here we prepared an adsorbent hydrous ferric oxide (HFO) by adjusting a FeCl₃·6H₂O solution to neutral pH. HFO was characterized by a surface area analyzer, X-ray diffraction (XRD), Fourier transform infrared spectroscopy (FTIR), and X-ray photoelectron spectroscopy (XPS), and was used to remove TC from solution. The influence of pH, solid-to-liquid ratio, ionic type, and strength on TC removal was investigated. Adsorption kinetics and isotherms were also determined. HFO after adsorption of TC was analyzed by FTIR and XPS to investigate the adsorption mechanism. The results showed that the adsorption of TC increased from 88.3% to 95% with increasing pH (3.0–7.0) and then decreased. K⁺ ions had little effect on TC adsorption by HFO. However, Ca²⁺ and Mg²⁺ reduced the adsorption of TC on HFO. When the concentrations of Ca²⁺ and Mg²⁺ were increased, the inhibitory effect was more obvious. Pseudo-second-order kinetics and the Langmuir model fitted the adsorption process well. The maximum adsorption capacity of TC on HFO reached 99.49 mg·g⁻¹. The adsorption process was spontaneous, endothermic, and increasingly disordered. Combination analysis with FTIR and XPS showed that the mechanism between TC and HFO involved electrostatic interactions, hydrogen interactions, and complexation. Therefore, the environmental behavior of TC could be affected by HFO. Full article

The purpose of the study is to identify a set of key indicators with weightings for health tourism destinations by using an advanced analytic hierarchy process (AHP) method, derived from the official, academic, and professional opinions of the experts. The AHP method allocated weightings to the evaluation criteria selected by the fifteen experts. After expert evaluations were conducted, the three dimensions and eleven sub-dimensions of the initial health tourism destination were obtained as follows: (1) special demands and indications—medical care, health promotion, and tourism and leisure; (2) natural environment—climate, air, water, and light; (3) leisure activities and general demands—sports, therapeutic activities, interactions with animals and plants, and diet. The results revealed that the dimensions of special demands and indications were given the most attention and that the sub-dimensions of sports promotion were the highest ranked by expert groups. The official and academic opinions suggested that health tourism destinations should focus on special demands and indications, while professionals tended to consider the natural environment as a primary concern. In particular, they considered that good air quality can help people release pressure, relax, activate lymphocytes, improve immune function, and enhance disease immunity. The health tourism destination index can contribute to the overall strategic planning process by identifying improvements in activities and enhancing competitiveness in health tourism management by using benchmarking to further improve tourists’ experience and satisfaction. Full article

Background: Hypertension is one of the most significant and common risk factors for cardiovascular disease, yet it remains poorly controlled in China. This study aims to examine trends and socioeconomic inequalities in the management of hypertension between 2011 and 2015 in China and to investigate the association between antihypertensive medication treatment and reduction of blood pressure, using nationally representative data. Methods: Concentration curve and concentration index were used to assess socioeconomic-related inequalities in hypertension care and health service utilisation. The fixed-effects analysis was performed to measure the impact of medication treatment on reduction of blood pressure among people with hypertension by using linear regression models. Results: Among hypertensive individuals, there were growing trends in the rates of awareness and treatment from 55.87% and 48.44% in 2011, to 68.31% in 2013 and 61.97% in 2015, respectively. The proportion of hypertension control was still below 30%. The fixed-effects models indicated that medication treatment was statistically significant and associated with the patients’ systolic blood pressure (β: −13.483; 95% CI: −15.672, −11.293) and diastolic blood pressure (β: −5.367; 95% CI: −6.390, −4.344). Conclusions: China has made good progress in the hypertension diagnosis, medication treatment and coverage of health services over the last 10 years; however, pro-rich inequalities in hypertension care still exist, and there is considerable progress to be made in the prevention, treatment and effective control of hypertension. Full article

To understand how the sustainable development goals (SDGs) are involved and cited in different fields, the current study aimed to explore the key SDGs and SDG-pairs from the viewpoints of academia and the media. The academic publications with SDG(s)-related keywords in the Scopus database and the entry videos of the “2018 SDG Lions” were collected and analyzed through content and network analysis. It was found that SDG 3 and SDG 10 shared the highest preferences in both industries, but apparent gaps happened to SDG 5. The tied frequencies of the possible SDG pairs were also examined, and SDG 3-10 was identified taking the lead in both industries. Network analysis using degree centrality as the vital parameter demonstrated that SDG 8 and SDG 5 has strong connections with several SDGs for the academia and the media, respectively. The SDG-2-6-7 combination or “water-energy-food” nexus was also found the most frequent combination of three SDGs in the academia. Overall, SDG 3 can be treated as a unifying theme when seeking to acquire evidence-based knowledge for integrated implementation of the SDGs. Important implications for policy-making of the SDGs were also discussed. Full article

The circulating pellet fluidized bed (CPFB) softening method is a highly efficient and environmentally friendly softening technology that can be used to reduce water hardness during the pretreatment process of circulating water in thermal power plants. The performance of chemical crystallization CPFB reactors was tested for increasing the concentration ratio and softening the circulating water in a thermal power plant in Dingzhou, Hebei. The results show that usage of CPFB reactors removed water hardness and Ca²⁺ ions with efficiencies exceeding 60% and 90%, respectively. The size of the particles discharged from the reactors was approximately 1–3 mm, and the content of CaO in these particles was found to be greater than 50%. All the discharged particles were reused in the desulfurization system in the power plant. The operational cost of the CPFB system is US$0.074 per cubic meter of water. After adopting the proposed CPFB softening method in the Dingzhou Power Plant, the concentration ratio of the circulation cooling water was increased from 4.5 to more than 9. In addition, the amount of replenished water and sewage discharge were both reduced by 150 m³/h, and the amount of scale inhibitor used in the system was reduced by more than 30%. These improvements contribute to approximately US$200,000 in annual savings in the power plant. In summary, the CPFB softening method demonstrated a high hardness removal rate, strong economic benefits, and remarkable environmental and social benefits. Therefore, this method seems ideal for softening replenished circulating cooling water, increasing the concentration ratio of the water and achieving zero liquid discharge (ZLD) in thermal power plants. Full article

Objectives: Exploring determinants underlying disparities in full vaccination coverage (FVC) can contribute to improved immunization interventions. FVC and its risk factors in Zhejiang province have been studied, yet the determinants explaining the rural–urban disparity in FVC have not been studied. This study aimed to disentangle the factors explaining rural–urban disparities in FVC of vaccine doses scheduled during the first year of life in Zhejiang province. Methods: We used data from a vaccination coverage survey among children aged 24–35 months conducted in 2016. The outcome measure was full vaccination status, and the grouping variable was the area of residence. Descriptive statistics were used to analyze the FVC and rural–urban residence across the exposure variables. The Fairlie decomposition technique was used to decompose factors contributing to explaining the FVC disparity. Results: There were 847 children included in this study, of which 49.6% lived in a rural area. FVC was 94% in rural areas and 85% in urban areas. A disparity of 9% to the advantage of the rural areas and the exposure variables explained 81.1% of the disparity. Maternal factors explained 49.7% of the explained disparity with education, occupation, and ethnicity being the significant contributors to the explained disparity. Children’s birth order and immigration status contributed somewhat to the explained inequality. Conclusion: There was a significant disparity in FVC in Zhejiang province, a disadvantage to the urban areas. Policy recommendations or health interventions to reduce the inequality should be focused on eliminating poverty and women’s illiteracy, targeted at migrant children or children from minority ethnicities. Full article

Background: Environmental tax has been implemented by the government in response to the demands of the residents to control environmental pollution. However, a tax has a wide effect on many interacting aspects of the society. It remains unknown whether enacting an environmental tax for the government can improve the residents’ happiness. This study aimed to examine the impact of air and water pollution on residents’ happiness and evaluate whether an environmental tax can alleviate the impact of air and water pollution on residents’ happiness. Methods: Based on the 2015 Chinese General Social Survey Data, 28 provinces in China were divided into two categories according to their environmental tax rates: baseline-tax areas (n = 13) and high-tax areas (n = 15). The ordered probit model was used to analyze the impact of air and water pollution on the residents’ happiness in baseline-tax areas and high-tax areas, respectively. The Chow Test was used to test whether the impact of environmental pollution on happiness was different between baseline-tax areas and high-tax areas. Results: The impact of air pollution on residents’ happiness was statistically significant in the baseline-tax areas (coefficient −0.162, 95% confidence interval (CI) −0.239, −0.086, p < 0.001), but the significance was weakened in the high-tax areas (coefficient −0.030, 95% CI −0.060, 0.000, p = 0.051). The Chow Test showed that the absolute value of the regression coefficient in the baseline-tax areas was significantly higher than the value in the high-tax areas (F = 12.712, p < 0.001). Similarly, the impact of water pollution on residents’ happiness was statistically significant (coefficient −0.264, 95% CI −0.353, −0.174, p < 0.001) in the baseline-tax areas and in the high-tax areas (coefficient −0.063, 95% CI −0.091, −0.035, p < 0.001), but the Chow Test showed that the absolute value of the regression coefficient in the baseline-tax areas was significantly higher than the value in the high-tax areas (F = 13.758, p < 0.001). Conclusions: Both air and water pollution impair residents’ happiness. The present study shows for the first time that enacting an environmental tax significantly alleviates the negative effect of air and water pollution on residents’ happiness. The findings of the present study provide empirical evidence for the government to levy environmental tax. Full article

The purpose of this study is to identify the willingness of pensioners to move from an apartment/house to an apartment/house located in a housing estate specifically designed for senior citizens. As such, this article forms part of the discussion of the housing needs of senior citizens, their preferences and willingness to change their place of residence. The research covers a group of post-working-age people residing in the region of Lower Silesia in south-western Poland. Various research methods were used in the study, including a written questionnaire and its statistical analysis. The research focuses on analysing both the preferences of potential buyers of apartments for seniors and seniors’ willingness to change their place of residence in order to purchase an apartment adapted to their mobility needs (free from architectural and technical barriers), taking into account the respondent’s age and housing situation. The research indicates that city residents are significantly more often willing to change their current place of residence for one adapted to the needs of persons with disabilities than residents of rural areas. In turn, those living with their husband or wife are significantly more likely to state that special offers for seniors do not need to be developed than those living alone or with other family members or in a social care home. No relationship was found between the age of a respondent and the desire to move to a new house. However, younger seniors are more open to moving to housing estates offering facilities for the elderly who require additional care. Full article

In May 2018, the non-governmental organization (NGO) Doctors with Africa CUAMM began to implement an intervention to strengthen Chiulo Hospital’s public health section to deliver immunization services in Mucope Comuna, Ombadja District. We aimed to evaluate the effect of this intervention. During the intervention period, actions such as staff training, improvement in the monitoring of vaccine stockpile, and the involvement of Community Health Workers were performed. The effects of the intervention on the number of vaccine doses administered were examined using negative binomial regression. Doses administered were 14,221 during the intervention period and 11,276 in the pre-intervention one. The number of administered doses was 26% higher (95% CI 9%–45%) in the intervention period than in the pre-intervention period. This was driven by vaccine doses administered during outreach sessions, where a statistically significant increase of 62% (95% CI 28%–107%) was observed. Regarding individual vaccines, statistically significant increases in the number of doses were observed for OPV2 (76%), OPV3 (100%), Penta3 (53%), PCV3 (53%), and Rota2 (43%). The NGO interventions led to improved delivery of immunization services in the study area. Greater increases were observed for vaccine doses that are more likely to be missed by children. Full article

In gymnastics, coaches are constantly searching for efficient training methods in order to improve the athletes’ performance. Therefore, in this study we aimed to investigate the effects of a novel, four-week, gymnastic-specific, eccentric–isokinetic (0.1 m/s) cluster training on a computer-controlled training device on the improvement of two static strength elements on rings (swallow and support scale). Nine elite male gymnasts participated in this study. Outcome parameters were maximum strength and strength endurance in maintaining the static position of both elements. After four weeks of training, specific maximum strength increased significantly (swallow: +4.1%; d = 0.85; p = 0.01; support scale: +3.6%; d = 2.47; p = 0.0002) and strength endurance tended to improve (swallow: +104.8%; d = 0.60; p = 0.07; support scale: +26.8%; d = 0.27; p = 0.19). Our results demonstrate that top athletes can considerably improve ring-specific strength and strength endurance in only four weeks. We assumed that the high specificity but also the unfamiliar stimulus of slow eccentric movements with very long times under maximal muscle tension led to these improvements. We suggest to use this type of training periodically and during phases in which the technical training load is low. Full article

In the European Union, the Environmental Impact Assessment (EIA) Directive (2014/52/EU) and Strategic Environmental Assessment (SEA) Directive (2011/92/EU) emphasise the assessment of population and human health. The directives require health to be considered within Environmental Impact Assessment (EIA) and Strategic Environmental Assessment (SEA). To date, health is mainly considered in connection with negative environmental factors and in terms of risk assessments. The integration of health in EIA as well as SEA has not been investigated in a Danish context, and this study aims to address the missing knowledge. There is a need for a more comprehensive health assessment within EIA and SEA to comply with the EIA and SEA directives. An integration of health into EIA and SEA will ensure a sound examination of health determinants which can improve decision making and thus comprehensively promote and protect health. To establish the status of the inclusion of the assessment of impacts on health into EIA and SEA, a literature review was performed. In addition, a survey addressed to researchers and practitioners was conducted and analysed through a comparative analysis. The survey examined the needs of practitioners and researchers, focusing on the Danish context, regarding the inclusion of health into EIA and SEA. Enhanced intersectoral cooperation of the health and environmental sectors, more specific guidance documents, and underlying this, stronger political support, were identified among needs for more comprehensive health assessments. Full article

Respiratory tract infection (RTI) is a major public health challenge during the Muslim pilgrimage to Makkah. This study aims to evaluate the knowledge, attitude, and practice of Malaysian Hajj and Umrah pilgrims towards the prevention of RTIs in 2018 and determine correlations among three domains. A cross-sectional study was conducted among 225 Umrah and Hajj pilgrims. Knowledge, attitude, and practice (KAP) towards RTI prevention was assessed by using a validated self-administered questionnaire among pilgrims attending a weekly orientation course organized by private Hajj/Umrah companies. Out of 225 participants, 65.9% of respondents were female with the mean (SD) age of 46.74 (13.38) years. The interquartile range (IQR) score for knowledge is 18.0 (6.0), the mean scores of attitude and practice are 32.65 (4.72) and 25.30 (4.9). respectively. Significant and negative linear correlations between knowledge and practice (r = −0.232, p < 0.001), and attitude and practice (r = 0.134, p = 0.045) were observed. Results from the current study showed good knowledge of RTIs among Malaysian pilgrims. However, a poor attitude was reflected in their preventive practice behaviors. This will further help in the prevention and management of RTIs during Hajj and Umrah. Therefore, an extensive educational health campaign should be provided to pilgrims to create awareness. Full article

Heatwave studies typically estimate heat-related mortality and morbidity risks at the city level; few have addressed the heterogeneous risks by socioeconomic status (SES) and location within a city. This study aimed to examine the impacts of heatwaves on mortality outcomes in Memphis, Tennessee, a Mid-South metropolitan area top-ranked in morbidity and poverty rates, and to investigate the effects of SES and urbanicity. Mortality data were retrieved from the death records in 2008–2017, and temperature data from the Applied Climate Information System. Heatwave days were defined based on four temperature metrics. Heatwave effects on daily total-cause, cardiovascular, and respiratory mortality were evaluated using Poisson regression, accounting for temporal trends, sociodemographic factors, urbanicity, and air pollution. We found higher cardiovascular mortality risk (cumulative RR (relative risk) = 1.25, 95% CI (confidence interval): 1.01–1.55) in heatwave days defined as those with maximum daily temperature >95th percentile for more than two consecutive days. The effects of heatwaves on mortality did not differ by SES, race, or urbanicity. The findings of this study provided evidence to support future heatwave planning and studies of heatwave and health impacts at a coarser geographic resolution. Full article

Saturation in hospital emergency departments is one of the main safety problems for the patient, which can generate negative consequences for their health. In response to this issue, triage systems are developed to organize the flow of patients in order to allow the most urgent ones to be treated first. The Emergency Severity Index (ESI) is the most used triage system in the USA and it has been implemented in the General Hospital of La Palma since 2010. The objective of this study is the validation of the ESI adapted to our hospital through the study of its degree of reliability, as well as the criterion validity. The sample consisted of 240 randomly selected cases, with proportional representation of emergencies attended in 2015 and their fraction of urgent ones (Levels 1 and 2). Criterion validity was estimated by sensitivity, specificity, and predictive result values. For reliability, the degree of agreement among the nurses was studied by means of the adapted kappa index k_c2. Criterion validity showed a sensitivity of 89% (85–93%) and a specificity of 97% (94–99%), with a positive predictive value of 68% (62–74%) and a negative predictive value of 99% (98–100%) for the discrimination of urgent cases. The reliability analysis showed a k_c2 = 0.94 (0.84–0.99) index, a very good agreement according to Landis-Koch criteria. The results of our study have shown adequate validity and reliability in the adaptation and implementation of an ESI triage system suited to the specific conditions of a hospital emergency service in Spain. Full article

This paper constructs a dual-channel value chain composed of one altruistic manufacturer and one altruistic retailer, where the manufacturer makes green innovation input for green products and sells its green products to its customers through both the direct channel and the traditional channel, the retailer provides channel service for customers and sells green products through the traditional channel. We consider two scenarios in which the manufacturer and the retailer make decentralized and centralized decisions, respectively. We develop two dynamic game models for the two scenarios and analyze the dynamic behaviors of the two dynamic game models using bifurcation diagram, LLE (largest Lyapunov exponent) and attraction of basin, etc. We find that the stability region in decentralized decision model is greater than that of centralized decision, and narrow with increase of service value, green innovation input. In the decentralized decision model, the stability of the system decreases with the altruistic behavior increasing. With the price adjustment speed increasing, the dual-channel green value chain system enters into chaotic state through flip bifurcation or N-S bifurcation. In the stable state, the manufacturer and the retailer can obtain the maximum utility with the appropriate value of green innovation input. In the chaotic state, the utilities of the manufacturer and retailer are greatly affected and significantly reduced. This study will provide good guidance for sustainable development decision-making of dual-channel green value chain. Full article

Home-based interventions targeting children’s sedentary behaviours have had limited and inconsistent effectiveness, possibly due to a mismatch between the behaviours targeted, the behaviours actually performed, and health-risk messages parents need to initiate change. Between October 2017–February 2018, 540 parents completed an online survey indicating their own and their child’s participation in 15 home-based sedentary behaviours (child mean age 11.1 ± 2.61 years, 52% male; parent mean age 40.7 ± 6.14, 93% female). Parents also indicated which home-based sedentary behaviours they and their child could reduce, and what health-risk messages would make them change their child’s behaviours. The most prevalent sedentary behaviours among children (particularly older children) and parents were screen-based leisure-time activities, specifically TV/video/DVD use (67.5 and 62.5 min/day, respectively) and using a tablet/smart phone for leisure (53.6 and 80.8 min/day, respectively). Importantly, these were also perceived as the most feasible behaviours parents and children could reduce. Parents reported that the following messages would help them reduce their child’s sedentary behaviour: sitting may increase the risk of poor mental health (85.2% of parents) and adversely impact future health as an adult (85.1%). These findings highlight feasible behavioural targets and intervention content for programs aiming to reduce sedentary behaviours in the home environment. Further research is needed to test these strategies. Full article

Despite abundant literature on antenatal and delivery care received by pregnant women, there is a wide knowledge gap on the prevalence of symptoms of discomfort or problems during the postpartum period and their relationship with the mode of delivery. This cross-sectional study, carried out with 3324 participants in Spain in 2017, aimed to investigate the association between the mode of delivery and self-reported postpartum symptoms of discomfort and maternal problems during the puerperium. An ad hoc online questionnaire was used to collect data on socio-demographic and obstetric variables, symptoms of discomfort, and maternal problems during the puerperium. The crude odds ratios (OR) and adjusted OR (aOR) and their 95% confidence intervals (95%CI) were calculated using binary logistic regression. In total, 3324 women participated. Compared to a normal vaginal delivery, having a cesarean section was associated with increased odds of an infected surgical wound (aOR: 11.62, 95%CI: 6.77–19.95), feeling sad (aOR: 1.31, 23 95%CI: 1.03–1.68), and symptoms of post-traumatic stress (aOR: 4.64, 95%CI: 2.94–7.32). Instrumental delivery vs. normal vaginal delivery was a risk factor for constipation (aOR: 1.35 95%CI: 25 1.10–1.66), hemorrhoids (aOR: 1.28, 95%CI: 1.04–1.57), urinary incontinence (aOR: 1.30, 95%CI: 26 1.05–1.61), and fecal incontinence (aOR: 1.94, 95%CI: 1.29–2.92) during the puerperium. Women who gave delivery via cesarean section or instrumental delivery had higher incidences of infection and psychological alterations than those who had a normal vaginal delivery. Identifying women at risk of giving birth by cesarean section and informing them about subsequent symptoms of discomfort and maternal problems during the puerperium must be included in pregnancy health program policies and protocols to allow women to make informed decisions regarding their birthing plan. Full article

This paper analyzes the choice of illness-cure combinations to estimate people’s willingness to pay (WTP) for the reduction of acute health risks correlated with air pollution caused by mining and smelting in the Jinchuan mining area, China. To improve explaining the power of choice experiment (CE), a random parameter logit model (RPL) was employed and extended by considering rank ordered choice sets and non-linear effects of health risk perception on choice behaviors. The results of this study indicated that the ordered RPL approach produced better results than the unordered alternative after comparing different modeling techniques. Perceived health risk, illness attributes, and the residents’ external characteristics: income, education, age, family health experience, work environment and proximity to pollution source are important determinants of the Jinchuan people’s choice mode for avoiding acute health risks caused by air pollution. Taking all acute illnesses investigated together, the mean Jinchuan household WTP for reducing acute health risk caused by air pollution is 146.69 RMB (abbreviation of Chinese yuan) per year (US$23.38, 0.31% of average yearly household income). On the basis of our findings, we conclude that virtually Jinchuan residents perceive air pollution as a serious health risk. To assist the residents to take appropriate preventive action, the local government should develop counseling and educational campaigns and institutionalize disclosure of air quality conditions. Full article

(1) Background: Squatting is one of the common closed-kinetic chain (CKC) exercises for knee rehabilitation. Some patients cannot perform squatting exercises on land occasionally due to knee pain. Several studies had suggested that lower limb muscle activities are lower in water than on land while performing CKC exercises. The purpose of this study is to investigate the surface electromyography (sEMG) activities of Rectus femoris (RF) and Biceps femoris (BF) muscles when doing a squatting exercise in water and on land. (2) Methods: This was a cross-sectional experimental study. A total of 20 healthy participants (10 males, 10 females) were recruited by convenience sampling. The sEMG of RF and BF muscles in water and on land were collected and the knee motions were videotaped. Participants were instructed to perform closed kinetic-chain back squatting exercises at a specific speed (30 beats per minute) in water and on land at angular speed of 45°/s. Eight repetitions of the squatting exercise (0–90° knee flexion) were performed. The mean percentage maximal voluntary contraction (%MVC) between two muscles was compared in two conditions. The %MVC of RF and BF muscles at different specific knee flexion angles (30°, 60° and 90° knee flexion) was also identified. (3) Result: Muscle activities of RF (p = 0.01) and BF (p < 0.01) muscles were significantly lower in water than on land. The %MVC of RF and BF muscles was found to be 15.01% and 10.68% lower in water than on land respectively. For different knee angle phases, the differences in %MVC between land and water had significant difference for both RF muscles and BF muscles. (4) Conclusion: This study found a difference of mean percentage MVC of RF and BF muscles between land and water in different phases of squatting. The water medium reduced the two muscles’ activities to a similar extent. The result showed that the aquatic environment allows an individual to perform squatting with less muscle activation which may serve as an alternative knee exercise option for patients who encounter difficulty in land squatting due to lower limb muscle weakness or a high level of knee pain. Full article

This paper describes a consultation exercise to explore the acceptability of adapting digital social prescribing (DSP) for suicide bereavement support. Bereavement by suicide increases the risk of suicide and mental health issues. Social prescribing improves connectedness and empowerment and can provide digital outcomes-based reporting to improve the capacity for measuring the effectiveness of interventions. Our aim was to consult on the acceptability and potential value of DSP for addressing the complexities of suicide bereavement support. Our approach was underpinned by implementation science and a co-design ethos. We reviewed the literature and delivered DSP demonstrations as part of our engagement process with commissioners and service providers (marrying evidence and context) and identified key roles for stakeholders (facilitation). Stakeholders contributed to a co-designed workshop to establish consensus on the challenges of providing postvention support. We present findings on eight priority challenges, as well as roles and outcomes for testing the feasibility of DSP for support after suicide. There was a consensus that DSP could potentially improve access, reach, and monitoring of care and support. Stakeholders also recognised the potential for DSP to contribute substantially to the evidence base for postvention support. In conclusion, the consultation exercise identified challenges to facilitating DSP for support after suicide and parameters for feasibility testing to progress to the evaluation of this innovative approach to postvention. Full article

In the present study, trace elements (TE) levels were evaluated in scalp hair along the continuum from healthy subjects (HS) to patients suffering from subjective memory concerns (SMC), and/or mild cognitive impairment (MCI), and those with already installed dementia (DEM) in order to: (i) assess the effects of environmental and lifestyle factors on TE concentrations and (ii) evaluate the analyzed elements as possible diagnostic biomarkers for the disease. The study involved 79 mainly permanent residents, >55 years old, from the city of Estarreja (northern Portugal), a former industrial area. The health status of the participants was assessed by means of a complete socio-demographic questionnaire and through cognitive screening tests, namely the Mini-Mental State Examination (MMSE). The test scores were categorized and used in the statistical analysis. Hair samples were collected and analyzed by inductively coupled plasma-mass spectrometry (ICP-MS) ICP-MS for selected TE. Dementia appears to be associated with higher age, the female gender, lower education level, and longer residence time in the study area. In addition, most of the participants diagnosed with dementia frequently consume home-grown foodstuffs, some irrigated with contaminated well water. The calculation of the TE enrichment factors of soil samples collected in kitchen gardens/small farms in the vicinity of the Estarreja Chemical Complex (ECC) reinforces the degree of Hg soil contamination in the area, due to anthropogenic sources that can be a source for the population Hg exposure route among others. Mercury levels in hair differed significantly between the four individual groups (HS, SMC, MCI, and DEM), increasing from healthy to dementia participants. Improved diagnostic results can be obtained using hair TE signatures coupled with MMSE scores. This strategy may prove useful for predictive diagnosis in population screening for cognitive impairment. Full article

Limited research in the area of the triple bottom line (TBL) mediation effect on the relationship between organizational strategic performance (OSP) and corporate social responsibility performance (CSRP) has motivated this study. The objective of this study is to investigate how OSP affects CSRP and the mediation impact of TBL elements through the decision-making process of business management. Considering a sample of 250 employees from Bangladesh, this study used structural equation modelling (SEM) to test the relevant research hypotheses. Through the lens of stakeholder, institutional, legitimacy and resource-based view theories along with rigorous statistical techniques, this study has found that OSP is positively related to CSRP. In terms of the mediation effect, this study has found that economic responsibility has no intervening role while environmental and social responsibility significantly mediated the relationship between OSP and CSRP. Finally, the full mediation power of the model suggests that OSP affects a firm’s strategic decision and CSR outcomes directly as well as indirectly through TBL. Full article

Background. The world population is aging. This phenomenon is accompanied by an increase in the number of elderly with dementia, whose oral hygiene care is a challenge. Objective. This paper presents a literature review of oral health status and the need for oral care in people with dementia, as compared to people without dementia and also of the relationship between periodontal disease and cognitive impairment. Methods. A systematic review was conducted in PubMed, CINAHL, and the Cochrane Library. Fifty-six articles met the inclusion criteria and were consequently included for quality assessment and data extraction. Results. No significant differences were found between both groups with regard to the number of present teeth, DMFT Index, edentulousness/use of denture, and orofacial pain. Coronal/root caries and retained roots were more common in people with dementia than in those without dementia. Most of the participants with dementia presented gingival bleeding or inflammation and they suffered from the periodontal disease more than people without dementia. Conclusions. Poor oral health is a common condition among the elderly with dementia. The education process of caregivers might improve the oral health status of people with dementia. Finally, periodontal disease might contribute to the onset or progression of dementia. Full article