BMC Research Notes

BackgroundTamoxifen is a cornerstone of endocrine treatment for hormone receptor-positive breast cancer, reducing recurrence and breast cancer-specific mortality. However, its use is associated with a small, yet clinically relevant, increase in uterine cancer. As diagnosis of this cancer remains symptom-triggered, it is essential for patients to be aware of this risk and report symptoms promptly for optimal outcomes. We therefore assessed risk awareness among breast cancer survivors while exploring their attitudes towards potential future endometrial surveillance strategies. MethodsOver a 10-month period, a web-based survey was conducted among breast cancer survivors with/without tamoxifen treatment. The mixed-format questionnaire included closed-ended questions and optional free-text comments. Quantitative data were summarized descriptively and analyzed statistically; qualitative responses were reviewed thematically to contextualize survey findings. ResultsOf 163 respondents, 154 breast cancer survivors were included in the analysis, 128 of whom had received tamoxifen. Among tamoxifen-associated participants, 60% reported insufficient awareness of the associated uterine cancer risk, and half expressed uncertainty about the adequacy of the current symptom-triggered endometrial evaluation. Despite this, acceptance of tamoxifen therapy was high; only one patient declined treatment over concerns about side effects. Almost all participants (96%) were willing to adopt endometrial surveillance methods, if developed and validated. ConclusionAs evaluation of tamoxifen-associated uterine pathology is symptom-triggered, our data highlight the need for improved and standardized risk communication to promote timely symptom recognition, reporting, and diagnostic evaluation. Moreover, our findings support incorporating patient-reported preferences into the development of future endometrial detection strategies to improve survivorship care.

ObjectiveThe objective of this analysis was to explore temporal and regional trends in breast pump prescription claims in outpatient settings in Germany, and to characterize the types of pumps covered. Study designWe conducted a nationwide secondary analysis of outpatient statutory health insurance billing data for breast pump prescriptions from 2011 to 2024, covering nearly 90% of the German population. Billing data from community pharmacies were scaled to full national coverage using regional extrapolation factors and subsequently linked with national and state-level live birth statistics to adjust for birth rates and population size across federal states. A list of breast pumps covered by German national statutory health insurance funds was queried for information on their characteristics. ResultsPrescription of electric pumps dominate outpatient statutory health insurance breast pump claims in Germany, with national statutory health insurance funds covering {euro}15.3 million for pump rentals. Manual pumps dispensed through community pharmacies accounted for {euro}27 thousand in 2024. Between 2011 and 2024, electric pump claims increased by a factor of 2.57, rising from 235.4 to 605.2 claims per 1000 infants newly enrolled in statutory health insurance (average annual growth rate 8.24%). Claims varied substantially across federal states but increased overall. ConclusionsThis is the first epidemiological analysis of statutory health insurance prescription claims for breast pumps in Germany. We found that electric breast pumps are important medical devices supporting outpatient human milk expression in Germany. Prescription claims appear to be very common and have shown an increase over the past 13 years.

BackgroundDengue outbreaks have become a severe threat to Bangladesh as the infections and mortality numbers are skyrocketing in recent years. Favorable environmental and anthropogenic conditions have established the capital of Bangladesh, Dhaka city as the epicenter of dengue outbreak. Studies have showed that climate change induced extreme weather events are exacerbating Aedes mosquito breeding and dengue virus transmission conditions. Methodology/Principal FindingsIn this study, short-term (0-6 weeks) associations of maximum temperature and heatwave days on dengue cases in Dhaka city were examined through Distributed Lag Non-linear Model (DLNM) methodology for weekly measurement of 2016-2024, taking into account relative humidity, cumulative rainfall, seasonality and hospital closure effect. Two separate negative binomial models were constructed. The maximum temperature model rendered an overall inverted U-shaped association, where the maximum temperature range of 31.5-33.2{degrees}C showed a sustained elevated dengue risk, with highest risk estimate at 33.2{degrees}C [relative risk (RR): 1.186, 95% CI: 1.002, 1.403]. Whereas, results of weekly heatwave days showed an overall protective effect (RR<1) for dengue cases. The lowest risk of infection was found at 3 heatwave days per week, with RR 0.275 (95% CI: 0.178, 0.423). Multiple sensitivity analyses were conducted for both models to evaluate their robustness. Lastly, the optimized models were analyzed under three distinct sub-periods, to capture the association of exposure variables with predominant circulating serotypes. Conclusions/SignificanceThe findings of the study aim to support public health policymakers and healthcare authorities in designing and implementing effective vector control interventions under emerging climatic emergencies. Author SummaryDengue disease is one of the most buringing issue in Bangladesh in recent years. This vector-borne disease is inherently influenced by climatic variables, i.e., temperature, rainfall, humidity, etc. Moreover, these relations are complex and non-linearly associated. Due to shift in climatic conditions, the occurance of extreme weather events are becoming frequent, with increased magnitude and longer duration. In this study, the nonlinear and delayed association of dengue infections due to the exposure of extreme temperature events were assessed in climate-change vulnerable Dhaka city. To do this, a statistical method was used, called distributed lag nonlinear methodology (DLNM). The results showed that dengue infections had an inverted U-shaped (parabolic) relationship with maximum temperature, while compared to mean maximum temperature, and a suppressive association with heatwaves relative to days without heatwaves. The findings aim to work as an early warning system, and support to policymakes and healthcare authorities to tackle the dengue surge in the changing climate.

ObjectiveWe aimed to prospectively validate and compare published prediction models and clinician-assigned triage categories for early trauma care. DesignProspective multicentre cohort study. SettingThree public hospitals in urban India: one secondary care hospital in Mumbai and one tertiary care teaching hospitals in Delhi and Kolkata each. ParticipantsAdult patients aged over 18 years presenting to the emergency department with a history of trauma between 2016 and 2022. A total of 13,041 patients were included in the final analysis. MethodsWe externally validated five published trauma prediction models (GAP, Gerdin, KTS, MGAP, and RTS) and clinician-assigned triage categories based on initial assessment. The primary outcome was 30-day all-cause mortality. Models were recalibrated using a separate updating sample prior to evaluation, and model performance was assessed in terms of discrimination (AUC), calibration (calibration slope and plots), and decision curve analysis. ResultsAll models and clinician gestalt-based triage demonstrated excellent discrimination (AUC range: 0.90-0.96) and good calibration after updating. The GAP model achieved the highest AUC (0.96, 95% 0.94-0.97), and RTS demonstrated the highest sensitivity (0.70). ConclusionSimple, physiology-based prediction models and clinician gestalt both demonstrated excellent performance in predicting 30-day mortality among adult trauma patients in Indian emergency departments. These findings provide a practical foundation for further development of trauma triage systems.

BackgroundThe management of residual axillary disease after neoadjuvant therapy (NAT) remains controversial, as current recommendations often treat ypN1 breast cancer as a homogeneous entity despite potential prognostic heterogeneity. Evidence supporting uniform axillary surgical strategies across different levels of residual nodal burden is limited. We investigated whether survival associations related to axillary surgical evaluation differ according to residual nodal burden in ypN1 disease, using an adjuvant cohort to validate a SEER-based proxy for surgical extent. MethodsPatients with 1-3 positive lymph nodes were identified in the SEER database (2000-2022) and stratified into neoadjuvant (NAT; n=30,560) and adjuvant (AT; n=197,586) cohorts. Axillary surgical evaluation was categorized as limited (2-3 examined nodes) or extensive ([&ge;]10 examined nodes). Survival was analyzed using Kaplan-Meier methods and log-logistic accelerated failure-time models, adjusted with inverse probability of treatment weighting. ResultsIn the ypN1 cohort, limited axillary evaluation was not associated with inferior overall survival among patients with a single residual positive node (IPTW-adjusted HR: 1.15, p=0.134; time ratio [TR]: 0.86, p=0.184). In contrast, limited evaluation was associated with worse survival in patients with two positive nodes (HR: 1.70, 95%CI 1.54-1.87; TR: 0.58, 95%CI 0.53-0.64). The findings were similar when using breast cancer-specific survival as the endpoint. ConclusionsSurvival associations related to axillary surgical evaluation after NAT vary according to residual nodal burden. Axillary de-escalation appears feasible in patients with a single residual positive node but cannot be extrapolated to those with multiple residual nodes, underscoring heterogeneity within ypN1 disease.

Compassion fatigue is a well-documented hazard among healthcare and veterinary professionals, yet the psychological toll on informal caregivers of feral cat colonies, likely numbering several tens of thousands in Portugal, remains largely unexplored. This cross-sectional study examines internal and external factors associated with the secondary traumatic stress component of compassion fatigue among 172 informal caregivers in Portugal. Secondary traumatic stress refers to work-related secondary exposure to individuals who have experienced extremely stressful or traumatic events. Structured telephone interviews assessed sociodemographics, colony management, compassion satisfaction, resilience, spiritual well-being, and perceived social support. Univariate and multivariable linear regression identified predictors of compassion fatigue. Results indicate that 47% of participants experienced moderate compassion fatigue, and 10% reported high levels. Multivariable analysis revealed that caring for large colonies (more than 25 cats) and being unemployed were significantly associated with higher fatigue. Conversely, older age, higher perceived family support, and the resilience dimension of serenity served as protective factors. Interestingly, finding meaning in life was positively correlated with fatigue, suggesting that caregivers who perceive their role as central to their life purpose may become more emotionally invested, increasing vulnerability to distress when unable to help animals. Official colony registration and formal institutional support did not significantly alleviate fatigue. These findings highlight that institutional support alone is insufficient to mitigate fatigue among informal caregivers, who experience significant distress driven by both practical burdens and profound emotional involvement. The most frequently reported concern among caregivers was the inability to cover the costs of feeding and veterinary care for the cats. Interventions must address both external needs (e.g., support to cover veterinary and feeding expenses for the cats) and internal coping mechanisms. Implementing psychosocial support alongside trap-neuter-return programs may also improve caregiver well-being and foster sustainable urban feral cat management. This underscores a One Health perspective, demonstrating that animal health is closely interconnected with human well-being and environmental health.

BackgroundApproximately 300 million people worldwide live with a rare disease, and the majority of rare diseases manifest in childhood. For families, the period before diagnosis is often protracted and distressing, marked by repeated consultations, inconclusive investigations, conflicting medical opinions, and the absence of a recognisable name for their childs condition. While the clinical and epidemiological dimensions of the diagnostic odyssey have been documented, the narrative and experiential dimensions of how parents live through and make sense of prolonged diagnostic uncertainty remain underexplored, particularly in low- and middle-income country contexts. AimTo explore the narrative experiences of parents navigating diagnostic uncertainty for children with rare diseases in Brazil. MethodsA narrative inquiry informed by the three-dimensional narrative space framework of Clandinin and Connelly was conducted. Sixteen parents (twelve mothers and four fathers) of children who had experienced a diagnostic delay of at least two years were recruited from two rare disease referral centres in Sao Paulo and Belo Horizonte. Data were collected through two narrative interviews per participant, supplemented by participant-produced timelines and family photographs. Analysis followed a narrative analytical approach attending to temporality, sociality, and place. FindingsThree narrative threads were woven across the parents stories: (a) "Living in the space before the name," capturing the disorienting experience of caring for a child whose suffering could not be categorised, explained, or predicted; (b) "Fighting to be believed," describing the relentless advocacy required to sustain medical attention in a system that struggled to accommodate conditions falling outside familiar diagnostic categories; and (c) "Rewriting the story," illuminating how the eventual arrival (or non-arrival) of a diagnosis reshaped parents understanding of their child, their family, and themselves. ConclusionDiagnostic uncertainty for parents of children with rare diseases is not a passive waiting period but an active, effortful, and identity-transforming experience. The findings highlight the need for healthcare systems to provide structured psychosocial support during the pre-diagnostic period and for clinicians to develop communication practices that acknowledge, rather than dismiss, the legitimacy of undiagnosed suffering.

BackgroundThe COVID-19 pandemic required South African public sector HIV viral load (VL) laboratories to scale up Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) testing while maintaining essential HIV services. This placed additional pressure on diagnostic services. This dual mandate introduced significant occupational and environmental challenges (OEC) for staff that remain underexplored. ObjectiveThis study aimed to investigate the OEC and effects that staff experienced during the implementation of COVID-19 testing at public sector VL laboratories in South Africa. MethodsA quantitative, cross-sectional study utilised a census approach among technical and support staff. Data were collected via a structured REDCap questionnaire using 5-point Likert scales. Pre- and post-implementation challenges were assessed across four domains: workload, environmental conditions (space, ventilation, waste), communication, and PPE availability. Statistical analyses included the Wilcoxon Signed-Rank and Spearmans correlation tests. ResultsPerceived occupational challenges increased significantly across all domains post-implementation. Staff workload saw the highest rise (mean score 3.02 to 3.53). Adverse health effects were pervasive; 80.2% of staff reported burnout/fatigue, and 76.5% reported increased anxiety/stress. A strong positive correlation was observed between post-COVID-19 challenges and adverse mental and physical health outcomes (rho = 0.449, p < 0.001). Furthermore, 35.8% of staff considered resigning due to increased job demands. ConclusionIntegrating COVID-19 testing exacerbated systemic weaknesses, causing measurable psychological injury and threatening workforce retention. Findings suggest that the diagnostic workforce requires formal crisis surge staffing models and institutionalised mental health support to safeguard personnel and maintain essential services during future health emergencies.

We describe a fast, noninvasive, low-cost survey method designed to understand the mode of transmission of an emerging pathogen. It is inspired from the standard household prevalence survey consisting in sampling households and counting the total number of people infected in each household, but refines it with the aim of improving diagnosis and estimating more parameters of the model of intra-household transmission. The survey was carried out in May-June 2020, during part of the first national French lockdown and received responses from more than 6,000 households involving a total of 20,000 people. We explain how we conceived the questionnaire, how we disseminated it, to the public through an open website hosted by CNRS, marketed through media and social media, and to a socially representative panel hosted by two survey institutes (BVA, Bilendi). We used the data obtained from the representative panel to correct for sampling biases in the CNRS survey using a classical raking procedure. Our results indicate that raking correctly canceled statistical biases between the two populations. We obtain the empirical distribution in households of the number and nature of symptoms. The main factors affecting the presence of symptoms are age, gender, body mass index (BMI), household size, but not necessarily in the expected direction. Our study shows that combining self-reporting and representative surveys allows investigators to obtain information on prevalence and household transmission mechanisms on emerging diseases at low cost.

BackgroundQuality-of-life (QoL) assessment is essential in breast cancer care, yet limited evidence describes how interrelated QoL domains change during pharmacotherapy. This study aimed to evaluate correlations among functional and symptom scales using the EORTC QLQ-C30 and QLQ-BR23, highlighting their ability to reveal multidimensional QoL patterns. MethodsA prospective observational study was conducted in two second-referral hospitals in Indonesia, enrolling 106 female breast cancer patients. QoL was assessed before and after pharmacotherapy using QLQ-C30 and QLQ-BR23. Changes in scores ({Delta}) were computed, and interdomain relationships were analyzed using Spearmans rho. ResultsPhysical functioning correlated with role functioning ({rho} = 0.55, p <0.001), emotial functioning ({rho} = 0.33, p <0.001), and social functioning ({rho} = 0.31, p = 0.002). Role and social functioning were likewise correlated ({rho} = 0.32, p = 0.001), indicating that improvements across functional domains tended to occur in parallel. Symptom scales showed strong positive clustering, including fatigue with pain ({rho} = 0.37, p <0.001), insomnia ({rho} = 0.35, p <0.001), and systemic side effects ({rho} = 0.48, p <0.001). Functional and symptom domains generally exhibited inverse relationships: physical functioning negatively correlated with fatigue ({rho} = -0.40), pain ({rho} = -0.43), both p <0.001, and systemic side effects ({rho} = -0.26; p = 0.01). ConclusionThe QLQ-C30 and QLQ-BR23 instruments effectively captured structured, clinically meaningful interdependencies. Functional improvements consistently aligned with symptom reductions, revealing coherent functional-symptom clustering. These findings underscore the sensitivity of QoL instruments to detect multidimensional patient-reported changes during breast cancer pharmacotherapy.

Food costs are more significantly impacted by climate change as countries grow. It is well known that climate change has an impact on the productivity of most agricultural goods, but it is unclear how specifically it will affect food costs. The present research explores how the North Atlantic Oscillation (NAO) index, a widely used climate indicator, affects food prices around the world. This is achieved by applying a robust bivariate Hurst exponent (robust bHe). The research creates a color map of this coefficient using a window-sliding technique over various intervals of time, displaying an illustration that changes overtime. Additionally, the NAO index and global food prices are examined for causal connections using variable-lag transfer entropy using a window-sliding technique. The results show that notable rises in a number of international food prices for long as well as short periods are associated with significant increases in the NAO index. Furthermore, the causative function of the NAO index in influencing global food costs is confirmed by variable-lag transfer entropy. Is highly recommended as it directly connects the research to actionable outcomes for policymakers and the overarching goal of sustainability and food security. This study provides the first direct evidence of a robust, long-range cross-correlation and causal link between the North Atlantic Oscillation (NAO) index and key global food prices. It introduces a novel, robust methodological framework to visualize this time-varying relationship, offering a critical tool for policymakers and forecasting models.

Structured AbstractO_ST_ABSObjectiveC_ST_ABSThis mixed-methods study investigated the lived-experience perspectives of receiving a novel, brief digital mental health intervention after psychological trauma. The online gamified imagery-competing task intervention (ICTI) involves one researcher-guided session followed by self-use. Tested in two randomised controlled trials (GAINS-01; GAINS-02), ICTI led to fewer intrusive memories at week-4, with the reduction sustained over 24 weeks, alongside reductions in post-traumatic stress. Here, we contrasted user experiences of ICTI with an Active Control (AC; music-listening task), and explored longer-term impact in qualitative interviews to contextualise GAINS-02 findings. Methods and AnalysisThe GAINS-02 trial randomised healthcare staff experiencing intrusive memories after work-related trauma to ICTI (N=40), AC (N=39), or treatment-as-usual (TAU; N=20). Expectancy was assessed before the researcher-guided session (Day 0), acceptability at week-4, and usage tracked for 24-weeks. Semi-structured interviews (N=27) were conducted in ICTI and AC arms only (15 at week-4; 12 during 12-24-weeks). Interviews were analysed using reflexive thematic analysis. ResultsPrior to use, many trial participants did not think the intervention would work, favouring AC over ICTI. However, after completing the tasks, participants found ICTI more acceptable and relevant to intrusive memories than AC. After the one guided session, median ICTI usage the next four weeks was 4.00 times with little additional use (once more) over the next 20 weeks because of lack of need. Potential implementation facilitators included ease of use, and advantages over existing interventions due to not needing to talk about the trauma, brevity, and lesser resource commitment. Perceived barriers included a lack of staff and manager education about the nature and consequences of intrusive memories, with a need for workplace buy-in and demonstration of organisational benefits. ConclusionHealthcare staff experiencing workplace-related trauma found ICTI to be acceptable and effective for reducing intrusive memories with low effort and emotional burden, even among participants who initially expressed scepticism. Participants highlighted implementation considerations including offering ICTI both within and outside the workplace, and providing a self-guided version of ICTI with optional support. Future work should assess cost-effectiveness, impacts on presenteeism and retention, and real-world implementation including the feasibility and effectiveness of a self-guided ICTI. Summary BoxO_ST_ABSWhat is already known on this topicC_ST_ABSIn a previous randomised controlled trial (GAINS-01) with Intensive Care Unit (ICU) staff exposed to work-related trauma, a brief online gamified imagery-competing task intervention (ICTI) reduced intrusive memories compared to usual care at four-weeks. What this study addsThe GAINS-02 randomised controlled trial replicated GAINS-01 and extended results by comparing ICTI to an active control (AC; music listening) task, enrolling hospital staff from outside ICU, and a follow-up period of 24-weeks. Qualitative interviews found that, despite initial scepticism from healthcare staff prior to using the intervention, ICTI was more acceptable than an AC due to specific effects on swiftly reducing intrusive memories and requiring minimal support or usage after an initial researcher-guided session. After one guided session, ICTI was used 4 more times in the first four weeks, with little additional usage (once) thereafter because of lack of need (i.e., no longer experiencing intrusive memories). How this study might affect research, practice or policyICTI is an efficacious scalable intervention to relieve staff of intrusive memories with effects sustained for at least 6-months. It was found to be more acceptable to participants than alternatives, requiring less time commitment than standard psychological treatments.

A concern in infectious disease modelling is how accurately population mixing is incorporated, as it shapes the type and frequency of contacts through which infection spreads, and consequently, estimated intervention effectiveness. Although synthesizing mixing patterns from diary-based surveys is an established framework, geographical information is poorly or sparsely captured. Here we propose a generalizable workflow to quantify geographical connectivity from job registry data covering over 8 million Dutch working population. The derived colleague connectedness shows heterogeneous spatial patterns, quantified from the number of connections per municipality triplet, two residential municipalities and one shared workplace municipality. We demonstrate the utility of this spatial connectivity in signalling regions with elevated outbreak risks. Using SARS-CoV-2 Omicron as an example: a ten-fold increase in within-province connections is associated with a 12-day earlier (95% CI: 2 to 22 days) Omicron onset, and between-province connections associated with an 8-day earlier (95% CI: - 4 to 21 days) onset. These results suggest that the impact of regional interventions shifting spatial connectivity patterns should be expected to vary by region and type of intervention. Together, our findings draw attention of using this highly fine-grained spatial connectivity to enable more regionally tailored and network-targeted policy measures.

BackgroundCommunity safety is a key determinant of mental well-being, yet racially and ethnically minoritised communities in the UK often face higher exposure to violence alongside barriers to formal protection and support. In these contexts, informal support networks may play a critical role in shaping how safety is experienced and how distress is managed. Although such networks are widely recognised as protective for mental well-being, there is limited qualitative research examining how they operate in relation to community safety in settings shaped by structural inequality. This study explores how informal support networks influence experiences of community safety and mental well-being among racially and ethnically minoritised groups in South East London. MethodsThis qualitative study draws on semi-structured interviews (n = 31) with racially and ethnically minoritised participants aged 16+ living or working in Lambeth and Southwark [South East London]. Using a co-produced qualitative design, community consultations informed the development of interview topics. Interviews explored informal support networks, experiences of community safety and their intersections with mental well-being. Audio-recorded interviews were transcribed verbatim and analysed using inductive thematic analysis. ResultsFour themes were identified: (1) experiences of community safety and their mental health impacts; (2) gendered experiences of safety and responsibility; (3) formal support and its barriers; and (4) community and peer-led initiatives as a response to institutional distrust. ConclusionInformal support networks are central to everyday safety and emotional well-being, yet they cannot substitute for adequately resourced, culturally informed public provisions. Strengthening public infrastructure must involve meaningful collaboration with trusted community networks and address the intersectional needs of racially and ethnically minoritised groups.

BackgroundGynecological cancers and their treatments can compromise fertility, with profound psychosocial consequences for women of reproductive age. Yet, womens lived experiences of cancer-related infertility remain underexplored in low-resource settings, including Ghana. This study examined the impact of gynecological cancers on fertility among reproductive-aged women receiving care at Ho Teaching Hospital, Ghana. MethodsA qualitative descriptive design was used. Fourteen women aged 15-49 years with gynecological cancers who had completed or were undergoing treatment were purposively recruited until saturation. Semi-structured interviews (30-45 minutes) were conducted face-to-face or by telephone in English, Twi, or Ewe, audio-recorded, transcribed verbatim, and analyzed using thematic analysis. Strategies to enhance rigor included independent coding, member checking, reflexivity, and peer debriefing. ResultsFive themes and eighteen subthemes emerged. Participants described infertility as a threat to womanhood and future life plans, expressed as a sense of incompleteness, fear of rejection, denial, and shattered aspirations. Social consequences included stigma and impaired intimate relationships. Treatment-related burdens, menstrual changes, pain, fatigue, and anxiety compounded distress. Economic hardship and educational disruption were common. Women also demonstrated resilience through adherence to treatment, dietary and lifestyle modifications, faith-based coping, and family support. ConclusionGynecological cancer-related infertility is a multidimensional survivorship burden. Integrating fertility counseling, psychosocial support, symptom management, and financial/social protection into cancer care is critical in Ghanaian settings.

IntroductionMusculoskeletal injuries (MSKIs) are ubiquitous in the U.S. military, especially among high-performing service members such as Marines. Given that female service members only started to be assigned to ground combat roles since December 2015, evaluation of sex on MSKI risk in ground combat occupations has not been possible until there was an ample population to study. The purpose of this population-level epidemiological study was to assess (1) if female sex was a salient risk factor for MSKI in Marines serving in different military occupations, including combat arms, and (2) the effects of integration period on MSKI risk among female Marines. Materials and MethodsA population-based epidemiological retrospective cohort study of all U.S. Marines was performed assessing female sex, occupation, and integration period on the prevalence of MSKI from 2011 through 2020. The Military Health System Data Repository was utilized to identify initial healthcare encounters for diagnosed ankle-foot, knee, lumbopelvic-hip, thoracocostal, cervicothoracic, shoulder, elbow, or wrist-hand complex injuries. Prevalence was calculated for female and male Marines in each occupational category (combat, combat support, aviators, aviation support, services) during the pre-integration (2011-2015) and post-integration (2016-2020) periods. ResultsDuring the pre-integration period, 520/1,000 female Marines (n=13,985) and 299/1,000 male Marines (n=142,158) incurred MSKIs. In the post-integration period, the prevalence increased to 565/1,000 female Marines (n=17,608) and 348/1,000 male Marines (n=161,429). In the multivariable evaluation of sex, occupation, integration period, and the interaction of sex and occupation on combined MSKIs, only female sex was a significant factor for injury (prevalence ratio [PR]=1.99), with service in ground combat and aviation occupations identified as protective factors when compared with services occupations (PR=0.69). When these same factors were evaluated for specific MSKI outcomes, female sex remained a robust factor in all lower quarter (PR=1.75-2.63) and upper quarter (PR=1.38-2.36) injuries except for shoulder injuries. Service in ground combat and aviation occupations was protective for all lower quarter injuries (PR=0.46-0.71). In the upper quarter, ground combat was protective for all injuries except for elbow injuries (PR=0.67-0.77). Serving as an aviator was a risk factor for cervicothoracic (PR=1.57) and thoracocostal (PR=1.22) injuries and a protective factor for shoulder (PR = 0.73) and wrist-hand (PR = 0.46) injuries. Adjusted risk for lumbopelvic-hip (PR=1.13), ankle-foot (PR=1.53), cervicothoracic (PR=1.19), thoracocostal (PR=1.14), and elbow (PR=1.48) injuries significantly increased during the post-integration period. There was a significant sex-by-period interaction for shoulder injuries alone, with female sex in the post-integration epoch found to be salient (PR=1.26). ConclusionsFemale sex was a salient factor for MSKI, with service in ground combat and aviation occupations identified as protective factors when compared with services occupations. In the evaluation of specific MSKIs, female sex remained a robust and significant factor in all lower quarter injuries and upper quarter injuries except for shoulder injuries. There was only a significant sex-by-period interaction for shoulder conditions, with an increased risk of these injuries in female Marines in the post-integration period.

ObjectiveThis study aimed to identify characteristics that define population need groups with similar mental health service needs within prisons and describe the mix of services required to meet those needs. MethodsMixed methods were used, including three iterative, semi-structured focus groups, followed by an online survey, seeking information on the characteristics that define service needs, how these can identify groups of people who require mental health care in prisons and the services required by each group. Participation was sought from prison health services, prison mental health services, non-government service partners and people with a lived experience. Focus group transcripts and free text survey responses were thematically analysed. Descriptive statistics were generated for online survey responses to Likert Scales to determine the levels of agreement with survey content. ResultsThe characteristics and service needs of four distinct population groups who require mental health care in prisons were defined: indicated prevention, mild, moderate, severe and complex. These groups were delineated using characteristics including presence of a diagnosed mental illness, level of functional impairment, presence of added complexity and service response required. The required service mix varied across need groups, however service types common across all groups included assessments, psychological therapies, peer support, lifestyle interventions and carer support. ConclusionsThe identified need groups and service descriptions will contribute to the evidence required for needs-based planning of mental health care in Australian prisons. This information can be used for planning a responsive, equitable, and needs-based mental health service system within custodial environments.

Importance: Lung cancer mortality in the United States has fallen substantially in recent decades, yet the relative influence of behavioral, environmental, socioeconomic, and therapeutic factors and their sex specific contributions remains unclear. Understanding these drivers is essential to sustain progress and reduce persistent disparities. Objective: To quantify how behavioral, environmental, socioeconomic, and therapeutic determinants collectively shaped US lung cancer mortality from 1994 to 2020, assess sex specific differences, and forecast mortality trajectories through 2030 using an integrated machine learning framework. Design, Setting, and Participants: Ecological time series study using publicly available national data from 1994 to 2020. Sex stratified analyses were conducted integrating lung cancer mortality, smoking prevalence, fine particulate matter PM2.5 exposure, Human Development Index HDI, per capita healthcare expenditure, healthcare inflation, insurance coverage, income inequality, and annual drug approvals. Exposures: Behavioral smoking, environmental PM2.5, socioeconomic HDI health expenditure inflation, uninsurance inequality, and therapeutic drug approval indicators. Main Outcomes and Measures: Age-standardized lung cancer mortality per 100000 population. Temporal changes were modeled using Joinpoint regression. Concurrent associations were assessed using multivariable and elastic net regression, and forecasts were estimated with AutoRegressive Integrated Moving Average models with exogenous variables ARIMAX. Results: From 1994 to 2020, mortality declined by 59 percent in men, from 52.9 to 21.7 per 100000, and by 40 percent in women, from 26.7 to 15.9 per 100000, with faster declines after 2015. Smoking and PM2.5 decreased by more than 45 percent but remained strongly correlated with mortality. In elastic net models, PM2.5 was the strongest predictor for men, while smoking was the strongest predictor for women. Per capita expenditure and HDI ranked higher for men, while uninsurance and income inequality were strong predictors for women. Mortality declines occurred during periods of major approvals of lung cancer drugs. Forecasts suggest continued but slower declines through 2030, with projected rates of 20.2 and 14.9 deaths per 100000 in men and women, respectively. Conclusions and Relevance: Sex specific declines in lung cancer mortality reflect different dominant correlates, with air pollution more important in men and smoking more important in women, while socioeconomic conditions and therapeutic advances also influence trends. Continued tobacco control, improved air quality, and equitable access to screening and modern treatment are essential to sustain further reductions in mortality. Keywords: Lung Neoplasms, Sex Factors, Air Pollution, Smoking, Socioeconomic Factors, Machine Learning

ObjectivesCervical cancer is a preventable disease, and a properly implemented screening programme can reduce its incidence and mortality and potentially save resources. This study aimed to evaluate the cost-effectiveness of options for potential transformation of the nationwide screening programme in the Czech Republic, especially considering recent changes in HPV DNA testing recommendations. MethodsA microsimulation model was developed to assess the cost-effectiveness and health benefits of alternative screening strategies in the Czech Republic. The model simulated annual life cycles of women from age 15, comparing combinations of cytology and HPV testing. Input parameters used were obtained from national registries in the Czech Republic and from published literature. The analysis was conducted from the perspective of healthcare payers. Costs (2025 EUR) and LYs were discounted at a rate of 3% annually. Probabilistic sensitivity analysis was conducted. ResultsThe CEA showed that, compared to the current setting (annual cytology with co-test at 35, 45, 55), only specific co-testing strategies lead to a decrease in incidence and mortality but differ in benefits and economic efficiency. The lowest ICER was reported for a strategy combining cytology at two-year intervals and co-testing at four-year intervals from ages 30 to 65. Sensitivity analysis showed that the current strategy has the highest probability of cost-effectiveness at {euro}31,000 per LY gained. At higher values, this is replaced by a strategy with a 3-year interval co-test. ConclusionsBased on the models presented, co-testing appears to be cost-effective. The actual willingness to pay threshold will facilitate selection of the most-appropriate strategy.

Purpose: The GIG-OSH cohort was established to investigate the impact of digital platform work on occupational safety and health (OSH), working and employment conditions, and health in seven countries in Europe. Participants: The cohort comprises 3,945 digital platform workers from seven European countries. The sample includes both web-based workers (e.g., micro-tasking, freelance design) and on-location workers (e.g., delivery, transport). Participants were recruited using non-probabilistic sampling strategies tailored to national contexts, including social media advertising, recruitment through micro-task platforms, and on-site field outreach. Multidimensional data have been collected through online surveys (implemented via REDCap) covering sociodemographic characteristics, working and employment conditions, psychosocial risks, algorithmic management, and physical and mental health indicators. Findings to date: Participants had a mean age of 32.6 years at baseline (SD 10.4), and the majority are male (58.8%), with a higher concentration of migrants in on-location tasks (62.2%) compared to web-based tasks (48.8%). Regarding educational attainment, 55.4% of the total cohort holds a tertiary degree, reaching 64.4% among web-based workers. Platform work intensity varies significantly: on-location workers averaged 85.4 hours of work in the last month, while web-based workers averaged 47.0 hours. Mean income from platform work as a percentage of the national median was 20.6% (SD 22.2). The mean WHO-5 Well-Being Index score was 58.7 (SD 20.3), which is notably lower than the European general population average (69.4), indicating poorer mental health outcomes among cohort members. Future plans: The GIG-OSH cohort represents the first large-scale, longitudinal study examining occupational safety and health among digital platform workers across multiple European countries. Future waves will prioritize developing precise tools to measure hourly earnings and unpaid waiting time. Future research should aim to include underrepresented subgroups, such as medical and domestic care workers, and explore potential linkage with administrative records to evaluate long-term health trajectories and the impact of new EU labour regulations.