PLOS https://journals.plos.org/plosone/ customercare@plos.org https://journals.plos.org/plosone/feed/atom All PLOS articles are Open Access. https://journals.plos.org/plosone/resource/img/favicon.ico https://journals.plos.org/plosone/resource/img/favicon.ico 2026-09-22T13:09:23Z Wangbing Liang Haoyu Song 10.1371/journal.pone.0358987 2026-09-21T14:00:00Z 2026-09-21T14:00:00Z <p>by Wangbing Liang, Haoyu Song</p> Intangible cultural heritage tourism plays an important role in cultural sustainability, yet how tourists’ experiential perceptions are associated with their willingness to support ICH inheritance remains insufficiently understood. Taking Gansu Shehuo, a representative form of Chinese folk intangible cultural heritage, as the empirical context, this study investigates how ritualized experiences and perceived authenticity are associated with tourists’willingness to support ICH inheritance.Based on 390 valid questionnaires, the study further explores both the independent effects and configurational pathways underlying tourists’ willingness to support ICH inheritance.The results show that uniqueness, ceremoniality, non-functionality, objective authenticity, and existential authenticity are significantly and positively associated with tourists’ willingness to support ICH inheritance, whereas commitment and constructive authenticity have no significant direct effects. The necessity analysis indicates that no single antecedent condition is necessary for either high or low willingness. The configurational analysis further identifies six configurations leading to high willingness and one configuration leading to low willingness, demonstrating equifinality and causal asymmetry. The findings suggest that sustainable ICH revitalization may benefit from the coordinated development of ritual distinctiveness, symbolic order, historical credibility, and lived authenticity rather than from isolated experiential attributes. Balram Yelamasetti Abhishek Agarwal Mahender Thotakuri I. Sri Phani Sushma Jamyang Choden Naveen Kumar P Harikishor Kumar 10.1371/journal.pone.0358969 2026-09-21T14:00:00Z 2026-09-21T14:00:00Z <p>by Balram Yelamasetti, Abhishek Agarwal, Mahender Thotakuri, I. Sri Phani Sushma, Jamyang Choden, Naveen Kumar P, Harikishor Kumar</p> Lightweight sandwich structures produced by fused filament fabrication (FFF) require geometric designs that provide adequate mechanical performance without excessive material usage. However, the geometric parameters governing flexural response and structural mass can favour different design configurations, making response-specific parameter selection unsuitable when both requirements must be considered simultaneously. This study experimentally investigates the effects of honeycomb cell size (HCS), honeycomb cell-wall thickness (HCT), top face-sheet thickness (TFS), and bottom face-sheet thickness (BFS) on the flexural strength and mass of FFF-printed polylactic acid (PLA) honeycomb sandwich panels. Eighteen geometric configurations were fabricated according to a mixed-level Taguchi L18 orthogonal array and evaluated by three-point bending and mass measurement. Analysis of means (ANOM) was used to identify response-specific factor levels, while analysis of variance (ANOVA) quantified the relative contributions of the geometric parameters. HCS and HCT accounted for 45.9% and 34.1% of the modelled variation in flexural strength, respectively, whereas HCT and HCS accounted for 50.9% and 34.0% of the modelled variation in panel mass. Because the parameter settings favoured by maximum flexural strength differed from those favoured by minimum mass, the ANOM factor levels were combined with normalized ANOVA contributions in a contribution-weighted multi-response selection procedure. The resulting configuration, HCS = 6 mm, HCT = 1.08 mm, TFS = 1.18 mm, and BFS = 1 mm, produced a flexural strength of 13.21 MPa and a mass of 34.367 g in the validation experiment. Compared with the highest-strength L18 configuration, the selected design retained 90.54% of the measured flexural strength while reducing panel mass by 50.29%. The results indicate that the core-related variables accounted for most of the modelled variation in the two measured responses. Within the investigated design space, the contribution-weighted procedure was used as a study-specific means of reconciling the response-specific factor settings and selecting a candidate strength–mass compromise for experimental evaluation. Jae Shin Song Min Seok Kim 10.1371/journal.pone.0358964 2026-09-21T14:00:00Z 2026-09-21T14:00:00Z <p>by Jae Shin Song, Min Seok Kim</p> Smoking has been suggested to influence choroidal circulation and structure, but population-based evidence regarding its association with choroidal thickness remains limited. This cross-sectional, population-based study investigated the association between smoking status and subfoveal choroidal thickness (SFCT) in a nationally representative Korean population, using data from the Korea National Health and Nutrition Examination Survey (KNHANES) 2017–2021. A total of 22,130 participants from KNHANES who had gradable optical coherence tomography images and without ocular pathologies affecting choroidal thickness were included. Smoking status was categorized as never, former, and current smoking based on standardized KNHANES questionnaires. Weighted mean SFCT across smoking groups was compared, and association between smoking status and SFCT were estimated using survey-weighted multivariate linear regression. Mean SFCT showed a stepwise increase from never to former to current smokers in both eyes (right eye: 297.3 ± 1.3 µm, 307.0 ± 2.1 µm, and 330.6 ± 2.3 µm, respectively; left eye: 297.2 ± 1.3 µm, 305.5 ± 2.2 µm, and 330.1 ± 2.2 µm, respectively; all p < 0.001). In multivariate analysis, current smoking was associated with thicker SFCT (right eye: β = 17.55 ± 3.45 µm, left eye: β = 20.47 ± 3.40 µm; both p < 0.001). Older age, female sex, longer axial length, greater central macular thickness, and the presence of cardiovascular disease were independently associated with thinner SFCT in both eyes (all p < 0.05). Current smoking was independently associated with greater SFCT, providing large-scale population-based evidence of the association between smoking status and choroidal structural changes. Beibei Zhang Shizhu Gou Deqiang Wang Xingjian Zhu Yuhui Han Yaqi Sun Ying Li Qinglei Hu Xueying Liu 10.1371/journal.pone.0358951 2026-09-21T14:00:00Z 2026-09-21T14:00:00Z <p>by Beibei Zhang, Shizhu Gou, Deqiang Wang, Xingjian Zhu, Yuhui Han, Yaqi Sun, Ying Li, Qinglei Hu, Xueying Liu</p> Professional observation ability is a foundational skill for preschool teachers, yet its cultivation has long faced the challenge of bridging theory and practice. Virtual simulation and authentic video offer new technological pathways to address this gap, but research on their sequential integration remains limited. This study adopted a design-based research-informed intervention approach, conducting four sequential workshops over six weeks with one natural class of 46 preschool teacher candidates. A mixed-methods design was employed, integrating group observation assignment scores (32 valid samples), questionnaires (34 students), and semi-structured interviews (9 students). In the initial skill acquisition phase, virtual simulation and authentic video demonstrated functional complementarity: virtual simulation was more conducive to stimulating active thinking (purposefulness dimension, p = 0.006), while authentic video showed an advantage in honing detail-capturing abilities (acuity dimension, p = 0.048) and higher-order cognitive skills (analysis and support dimensions, p < 0.05). During sequential exposure to authentic videos, analytical ability showed a “leap-plateau” pattern, supportive ability displayed continuous growth, while basic observation ability remained stable. Learners’ experiences followed a trajectory from cognitive conflict to support seeking and then to metacognitive growth. This study provides preliminary support for the sequential integration model in enhancing preschool teacher candidates’ observational skills, offering empirical insights for technology-enhanced teacher education. The findings suggest that teacher training programs should consider the complementary roles of different technological media across skill development stages. Qiu Zhu Zijing Duan Yi Dai Junting Chi Wangao Guan Lixuan Dong Qingjiao Lin Yingying Fu 10.1371/journal.pone.0358940 2026-09-21T14:00:00Z 2026-09-21T14:00:00Z <p>by Qiu Zhu, Zijing Duan, Yi Dai, Junting Chi, Wangao Guan, Lixuan Dong, Qingjiao Lin, Yingying Fu</p> Objective <p>To map evidence on symptom network analysis in patients with gastric cancer by summarizing study characteristics, commonly used assessment tools, central and bridge symptoms, temporal symptom relationships, and associated factors, and to provide a basis for precision symptom management.</p> Methods <p>This scoping review was guided by the Arksey and O’Malley framework and reported in accordance with the PRISMA extension for Scoping Reviews (PRISMA-ScR). PubMed, Web of Science, CINAHL, Cochrane Library, Embase, CNKI, Wanfang Data, VIP, and CBM were systematically searched from database inception to April 1, 2026. Original studies published in Chinese or English that applied symptom network analysis to gastric cancer populations, including eligible mixed cancer populations with gastric cancer patients, during the perioperative period or chemotherapy were included. Literature screening, data extraction, and narrative synthesis were performed.</p> Results <p>A total of 9 studies were included. Six symptom assessment tools were identified, with the Chinese version of the MD Anderson Symptom Inventory–Gastrointestinal Cancer Module (MDASI-GI-C) being the most frequently used tool (reported in 7 studies). Nine core symptoms were identified across the included studies, with fatigue being the most frequently reported core symptom (identified in 5 studies). Ten bridge symptoms were identified; however, considerable variation was observed in the identification of bridge symptoms across studies. Longitudinal analyses suggested that phlegm-dampness constitution was associated with subsequent changes in taste, while changes in taste were associated with subsequent appetite loss.</p> Conclusions <p>The symptom profiles of patients with gastric cancer are characterized by complexity, dynamic changes across treatment stages, and population heterogeneity. Symptom management strategies may benefit from individualized and stage-specific approaches targeting core symptoms, bridge symptoms, and key symptom pathways. Future research should focus on standardizing symptom assessment tools and assessment time points, conducting multicenter longitudinal studies, and supporting the development and evaluation of interventions for clinical practice.</p> Trial registration <p>OSF Registration DOI: https://doi.org/10.17605/OSF.IO/MJAZ3</p> Hunter Parsons David G. Behm 10.1371/journal.pone.0358885 2026-09-21T14:00:00Z 2026-09-21T14:00:00Z <p>by Hunter Parsons, David G. Behm</p> This study compared the immediate effects of a single 30-second stretching bout on local (stretched) and non-local (non-stretched) range of motion (ROM), pain sensitivity/onset, strength, and endurance. Fourteen participants were involved with this within-subjects, repeated-measures study, consisting of four conditions: 30-seconds of static (SS), proprioceptive neuromuscular facilitation (PNF), dynamic (DS) stretching, and a no-stretch control condition. Passive hip flexion and shoulder extension ROM, pain pressure thresholds (PPT), knee flexors and right shoulder extension maximum voluntary isometric contraction force (MVIC), 30-s MVIC fatigue index and muscle activation (electromyography: EMG) were measured pre- and post-intervention. The primary findings were that 30-seconds of SS elicited greater moderate magnitude ROM improvements in the stretched limb (p < 0.001, 8.1%) compared to control. Non- significant (p = 0.08) SS-induced ROM gains were observed with the contralateral leg inferring the possibility of crossover effects in some individuals. There were no significant effects on the shoulder with any intervention. All conditions including control experienced MVIC force decreases with the stretched limb (p = 0.007). However, there were no significant PPT interactions. Women demonstrated greater ROM whereas men exhibited greater force, EMG activity, and fatigue indices. In conclusion, while passive ROM improved across all conditions, these gains can be accompanied by declines in MVIC force. Overall, 30-seconds elicited significant increases in ROM of the stretched leg respectively; however, it failed to produce any significant effects on the contralateral leg and shoulder. Jiahui Ding Xiaojin Hu Meiling Sun Shanshan Ge 10.1371/journal.pone.0358879 2026-09-21T14:00:00Z 2026-09-21T14:00:00Z <p>by Jiahui Ding, Xiaojin Hu, Meiling Sun, Shanshan Ge</p> Objective <p>To investigate the associations of metabolic score for insulin resistance (METS-IR) and uric acid (UA) with the odds of prevalent thyroid nodules, including nonlinear associations across C-TIRADS categories; to explore SBP-related indirect associations; and to evaluate the joint association and statistical interaction of METS-IR and UA.</p> Methods <p>Among 12,256 individuals initially screened at the Health Management Center of the First Hospital of Shanxi Medical University between January 2018 and December 2021, 5,232 participants were included in the final complete-case analysis. Data were retrieved from the hospital health examination database on January 25, 2026. METS-IR and UA were categorized into quartiles. Multivariable logistic regression, restricted cubic spline (RCS) regression, exploratory mediation analysis, joint classification analysis, and interaction analyses were performed.</p> Results <p>Compared with the lowest quartile, the highest quartiles of METS-IR and UA were associated with higher odds of prevalent thyroid nodules in the fully adjusted models (METS-IR: <i>OR</i>=3.928, 95% <i>CI</i>: 3.120 to 4.946; UA: <i>OR</i>=3.627, 95% <i>CI</i>: 2.839 to 4.634; both <i>P</i> < 0.001). RCS analyses showed nonlinear associations of METS-IR and UA with C-TIRADS 2–3 and C-TIRADS 4 thyroid nodules (all <i>P</i> for overall association <0.001; all <i>P</i> for nonlinearity ≤0.049). Exploratory mediation analyses yielded outcome-dependent findings: in the overall analysis, the estimated proportions mediated through SBP were 6.62% for METS-IR and 1.44% for UA; no significant indirect associations were observed for C-TIRADS 2–3 nodules, whereas only the indirect association for METS-IR was significant for C-TIRADS 4 nodules. Participants with concurrently elevated METS-IR and UA had the highest adjusted odds of prevalent thyroid nodules (<i>OR</i>, 4.562; 95% <i>CI</i>, 3.753–5.544; <i>P</i> < 0.001); however, interaction analyses indicated a submultiplicative joint association and no evidence of positive additive interaction.</p> Conclusion <p>METS-IR and UA were associated with higher odds of prevalent thyroid nodules, with nonlinear associations observed across the exposure distributions. Concurrent elevations in METS-IR and UA identified a subgroup with the highest observed odds of thyroid nodules, although interaction analyses did not support positive synergy. Exploratory mediation analyses provided limited and outcome-dependent evidence of SBP-related indirect associations. The cross-sectional design precludes conclusions regarding temporal ordering or causal mediation.</p> Md Parvej Hussain Mohammod Mahmudur Rahman Md Rezaul Kader Md Robiul Islam Talukder Md Tareq Ferdous Khan Foyez Ahmmed 10.1371/journal.pone.0358877 2026-09-21T14:00:00Z 2026-09-21T14:00:00Z <p>by Md Parvej Hussain, Mohammod Mahmudur Rahman, Md Rezaul Kader, Md Robiul Islam Talukder, Md Tareq Ferdous Khan, Foyez Ahmmed</p> This study investigated the association between low birth weight (LBW) and various forms of child malnutrition across five South Asian countries (Bangladesh, India, Pakistan, Nepal, and the Maldives). Data from the most recent demographic and health surveys were analyzed. Propensity score matching was applied to evaluate the association between LBW and five forms of child malnutrition: stunting, wasting, underweight, at least one form of child malnutrition (AOFOCM), and multiple concurrent forms of child malnutrition (MCFOCM). Subgroup analyses were performed to assess variability in effects across the countries studied. Analysis of 147,332 complete cases revealed an overall LBW prevalence of 16.23%, with country-specific prevalences of 13.67% (Bangladesh), 16.32% (India), 18.97% (Pakistan), 11.94% (Nepal), and 12.86% (Maldives). Regression analyses of matched samples revealed significant associations between LBW and all five forms of malnutrition. Subgroup analyses also revealed a significant association between LBW and all five forms of malnutrition across the five countries, with the exception of wasting, for which no statistically significant association was observed in Bangladesh and the Maldives. These findings emphasize the importance of context-specific interventions targeting LBW to reduce child malnutrition in South Asia, while taking the observational design and cross-country variability into consideration. Michele Conconi Raphael Dumas Nicola Sancisi 10.1371/journal.pone.0358863 2026-09-21T14:00:00Z 2026-09-21T14:00:00Z <p>by Michele Conconi, Raphael Dumas, Nicola Sancisi</p> To provide reliable results, musculoskeletal models must accurately represent human anatomy and be consistent with anatomical function. While considerable effort has been made to improve the muscular modeling, the same is often not true for the kinematic chain representing skeletal mobility. The aim of this work is therefore to take one of the most comprehensive musculoskeletal models, the TLEM 2.0, and improve its articular representation. Based on bone morphology, 3D articular kinematics of the tibio-femoral, patella-femoral, talo-tibial, and calcaneo-talar joints have been reconstructed by joint congruence maximization. Given these reference motions: the most isometric fibers for the main ligaments at the knee and the ankle have been identified; contact points and normals have been defined; the neutral configuration of the model has been defined. With respect to the original kinematic chain based on revolute joints, the one here proposed presents no joint distraction nor copenetration between the bones, together with a more physiological ligament elongation during joint motion, resulting in an articular representation more consistent with the TLEM 2.0 anatomy. These improvements substantially strengthen the anatomical fidelity of TLEM 2.0 and provide a robust foundation for next-generation MSK models. The updated dataset enables more reliable estimation of ligament and contact forces, supports the development of advanced rigid or deformable joint mechanisms, and offers a generalizable framework for subject-specific personalization whenever joint geometry is available. This represents a significant step toward MSK models capable of reliably capturing articular function under load. Rajitra Nawawonganun Kittipong Sornlorm Roshan Kumar Mahato 10.1371/journal.pone.0358849 2026-09-21T14:00:00Z 2026-09-21T14:00:00Z <p>by Rajitra Nawawonganun, Kittipong Sornlorm, Roshan Kumar Mahato</p> Urban air pollution is increasingly recognized as a mental-health risk, yet its impact on parents of schoolchildren remains understudied, particularly in rapidly urbanizing Southeast Asian cities. This study examined the prevalence of, and factors associated with, psychological distress related to traffic-related air pollution (TRAP) awareness and exposure among parents of urban schoolchildren in Khon Kaen Municipality, a major urban center in northeastern Thailand. A cross-sectional study surveyed 557 parents from two primary schools in high-traffic areas during March–May 2025, Thailand’s hot/dry high-pollution season. Structured interviews assessed sociodemographic characteristics, air pollution awareness and exposure, health behaviors, physical symptoms, and psychological distress using a validated 10-item questionnaire. Data were analyzed by bivariate and multivariable logistic regression with backward elimination (α = 0.05). Moderate-to-high psychological distress affected 61.94% of parents (95% confidence interval [CI]: 57.87–65.85). Higher air pollution awareness showed the strongest association with distress, following a graded pattern (moderate: adjusted odds ratio [AOR] = 2.41, 95%CI: 1.56–3.72; high: AOR = 4.39, 95%CI: 2.33–8.30). Other significant factors were moderate-to-appropriate health behaviors (AOR = 3.36, 95%CI: 2.14–5.26), air quality monitoring app use (AOR = 1.79, 95%CI: 1.17–2.74), and four to five affected body systems (AOR = 2.16, 95%CI: 1.32–3.53). A cross-sectional awareness–distress pattern was identified, whereby greater air pollution awareness was associated with higher psychological distress; the design does not permit conclusions about direction of effect. School-based air-quality communication in traffic-exposed urban settings should pair risk information with practical protective guidance and mental-health support for caregivers, relevant to rapidly urbanizing cities across Southeast Asia and beyond. Sophie Merrick Annabelle South Elena Frangou Hannah L. Rush Grisma Patel Jemima Thompson Hannah Plant Lisa Pickering Ruth E. Langley Duncan C. Gilbert Thomas Powles James Larkin Angela Meade 10.1371/journal.pone.0358789 2026-09-21T14:00:00Z 2026-09-21T14:00:00Z <p>by Sophie Merrick, Annabelle South, Elena Frangou, Hannah L. Rush, Grisma Patel, Jemima Thompson, Hannah Plant, Lisa Pickering, Ruth E. Langley, Duncan C. Gilbert, Thomas Powles, James Larkin, Angela Meade</p> Introduction <p>RAMPART is an international phase III trial evaluating adjuvant immune checkpoint inhibitors (ICIs) after nephrectomy for renal cell carcinoma. ICIs have a distinct toxicity profile that can significantly impact health-related quality of life (HRQoL); however existing HRQoL questionnaires were developed in a pre-ICI era and may not fully capture the patient experience. To address this, we embedded a qualitative interview sub-study within RAMPART among UK participants to explore the impact of ICIs on HRQoL in depth.</p> Methods <p>Eligible participants were enrolled in RAMPART at UK sites and randomised to Arm B (durvalumab q4w for 1 year) or C (durvalumab q4w for 1 year plus tremelimumab at day 1 and week 4). Participants were purposively selected to ensure representation across baseline characteristics, treatment tolerance, toxicity development, and recurrence status. Interviews were conducted online, via telephone and in person, with transcripts analysed using the framework method.</p> Results <p>Of 220 eligible participants, 71 were invited; with recruitment closing early due to a high response rate. 37 expressed interest, and 23 were interviewed. Two themes were generated based on participant insights: <i>Living in a Changed Body and Mind</i> and <i>It Depends on Your Life: How Context Shapes the Impact of Immune Related Adverse Events (irAEs)</i>. The findings suggest that participants often placed greater importance on the duration and chronicity of irAEs than their severity when describing impacts on HRQoL. Persistent toxicities, including fatigue, arthralgia, and diarrhoea, disrupted daily functioning, while cognitive changes and emotional strain were common. Employment, financial security, and caregiving responsibilities influenced the impact of irAEs, whereas supportive relationships and structured follow-up mitigated their burden.</p> Conclusions <p>Chronic irAEs can negatively affect HRQoL, mental health, and the ability to work. Clinical trials evaluating ICIs should report toxicity grade, duration, and resolution to better inform patient decision-making. Development of ICI-specific HRQoL tools that capture the impact of persistent irAEs is needed, alongside clear care pathways for management of chronic irAEs.</p> Shi Chen Xin Chen Rui Feng Guihua Chen Chunyun Lu Donghui Zhao Zhaoqian Wang Dee Yu 10.1371/journal.pone.0358788 2026-09-21T14:00:00Z 2026-09-21T14:00:00Z <p>by Shi Chen, Xin Chen, Rui Feng, Guihua Chen, Chunyun Lu, Donghui Zhao, Zhaoqian Wang, Dee Yu</p> Men who have sex with men (MSM) have historically been a high-risk group for sexually transmitted diseases. In Hainan, the incidence of HIV and syphilis among MSM has increased rapidly. Additionally, there is a growing number of young students being diagnosed with HIV, with MSM identified as the primary demographic affected. However, the size and distribution of the MSM population within colleges and universities in Hainan Province remains unknown. In this study, the Blued App was employed to collect data on users within Hainan colleges and universities from May 9 to May 18, 2023. Using the users information and questionnaire survey data, we applied the multiplier method to estimate the population size of student MSM. Multivariate and geographic density analyses integrating survey data were conducted to identify regional disparities. A questionnaire survey revealed that 89.28% of student MSM reported using the Blued App, and 76.00% of the individuals utilized it for seeking sexual partners. The estimated population size of MSM in colleges across Hainan Province was 3504 (95%CI: 3464–3544), with Haikou and Sanya identified as hotspots. The proportion of active users was 33.13% (860/2596). Notably, Danzhou and Wenchang, relatively small urban areas with limited Blued registrants, exhibited high proportion of active users (42.22% and 41.30%). These findings suggest that particular attention should be directed towards sexual health education, and sexually transmitted disease surveillance in specific colleges. Lin Qin Jie Li Fusheng Zha Long Xu Bo Kang 10.1371/journal.pone.0358749 2026-09-21T14:00:00Z 2026-09-21T14:00:00Z <p>by Lin Qin, Jie Li, Fusheng Zha, Long Xu, Bo Kang</p> Conventional binders to treat expansive soil commonly present challenges of high cost and significant environmental burdens. To address these limitations, this study proposes an environmentally sustainable binder termed LSP (lime-sodium silicate amended phosphogypsum) based on the valorization of phosphogypsum (PG). Systematic laboratory tests were conducted to evaluate the engineering performance of LSP stabilized soil under drying-wetting cycles. Results indicate that the expansive soil stabilized with LSP obtains a higher maximum dry density and a lower optimum moisture content. The swelling-shrink potential is weakened as well. However, the successive D-W cycles imposes detrimental impacts on the development of all the geotechnical indexes, including free swelling index, unconfined compressive strength (UCS), shear strength, compressibility and permeability. LSP reduces FSI from 58.6% to 32.1%; UCS decreases by 26.5% after 15 cycles; permeability increases 1.65-fold. XRD and MIP analyses reveal that physical filling by PG powder constitutes the primary mechanism for the improvement of soil engineering properties, while micro-crack development is the controlled mechanism for the deterioration induced by D-W cycles. Wenwei Liu Jinyu Xu Guoao Wang Shuo Ding Yuanbo Zhang Runze Tian Zejiang Li Yuanzhe Ji Li Zhang 10.1371/journal.pone.0358742 2026-09-21T14:00:00Z 2026-09-21T14:00:00Z <p>by Wenwei Liu, Jinyu Xu, Guoao Wang, Shuo Ding, Yuanbo Zhang, Runze Tian, Zejiang Li, Yuanzhe Ji, Li Zhang</p> Precise flower grading in modern agriculture is critical for determining market value but remains hindered by inefficient manual labor and the computational constraints of edge devices. To address these challenges, this paper introduces Flora-YOLO, a lightweight and robust detection framework built upon the YOLO11n architecture. To overcome the inherent bottlenecks of agricultural vision, the framework incorporates four targeted optimizations, explicitly distinguishing novel components from adapted architectures: (1) an adapted C3k2-based Sandglass-Gated Bottleneck (C3k2_SGB) module to extract and amplify minute floral textures; (2) an integrated Adaptive Downsampling (ADown) module to preserve critical high-frequency spatial cues under severe foliage occlusion; (3) a newly proposed CSP-based Variance-Gated Attention (C2VGA) hybrid attention mechanism to amplify the weak semantic signals of early-stage buds while suppressing background noise; and (4) a novel Focused Shape-Intersection over Union (FSIoU) loss function to provide shape-aware gradient guidance for the precise bounding-box regression of irregular, non-rigid floral boundaries. Evaluated via 5-fold cross-validation on a custom dataset, the model achieves a stable 86.7% mAP@0.5 and 50.4% mAP@0.5:0.95. This represents a 3.4% accuracy improvement over the baseline, achieved alongside a 28.6% reduction in computational load, requiring only 1.73 M parameters and 4.5 GFLOPs. Furthermore, out-of-domain testing and evaluation on public agricultural datasets confirm the model’s cross-species generalization. Finally, hardware deployment on both Android terminals and an NPU-accelerated NXP i.MX 8M Plus platform yields a real-time inference speed of 11.05 FPS with a 90.5 ms latency. These results establish Flora-YOLO as a highly efficient, accurate, and scalable solution for automated, edge-based sorting in precision floriculture. İsmail Yaşartürk Halil İbrahim Öksüz Ramazan Deniz Mustafa Öztürk 10.1371/journal.pone.0358694 2026-09-21T14:00:00Z 2026-09-21T14:00:00Z <p>by İsmail Yaşartürk, Halil İbrahim Öksüz, Ramazan Deniz, Mustafa Öztürk</p> The purpose of this study is to evaluate the legibility of fourth-grade elementary school students’ handwriting and to examine the differences and relationships between two evaluators: a human researcher and artificial intelligence (ChatGPT). To this end, the study was conducted using the descriptive survey model, one of the quantitative research approaches. The study sample consisted of 67 fourth-grade students attending a public elementary school. The students’ handwriting was evaluated using the Multidimensional Legibility Scale. Writing samples were collected from each student, including copying samples, dictated samples, and free writing samples. One class period was allocated for each writing task. The 201 handwriting samples obtained from the 67 students were evaluated by a researcher (the second author) and artificial intelligence (ChatGPT). According to the findings, no significant differences were detected between the artificial intelligence and the researcher in any writing type or subdimension, except for the slant subdimension of free writing. However, a high level of positive and significant correlation was identified between the two raters. Findings indicate that artificial intelligence can produce results comparable to those of expert raters when evaluating handwriting legibility. The fact that differences among raters are not statistically significant suggests that AI-based handwriting evaluations could serve as an objective and reliable alternative. Karen A. Sullivan Keeley Lappin 10.1371/journal.pone.0358688 2026-09-21T14:00:00Z 2026-09-21T14:00:00Z <p>by Karen A. Sullivan, Keeley Lappin</p> Sport-concussion is widely reported in the mass media. This reporting includes live sport broadcasts that reach, and influence, widespread audiences. From a public health perspective, broadcast information about concussion should be accurate. An understanding of public perceptions of sport-concussion coverage is needed to understand potential impacts. One-hundred and sixty-three people completed an online cross-sectional survey. The survey comprised structured and open-ended questions to gather perceptions about the media portrayal of sport-concussions (portrayal-perceptions) in sport broadcasts, and recommendations to improve it (recommendations). Twelve of 30 portrayal-perceptions were endorsed (agreed or disagreed) by >50% of respondents, including that the portrayal should be improved. Ten of 12 recommendations were agreed, including that the portrayal should prioritise player health. No statistically significant differences in perceptions were found based on participant background (e.g., their concussion history). This research, through considering the way people experience sport-concussion coverage, elucidates its potential to shape understanding about sport-concussion and its management. Community members support changes to the media portrayal of sport-concussion to increase its informative value for audiences. Fukai Zhao Zekun Pang Haoran Guo Yue Chen Jiao Wang Bailing Hsu Jianming Li 10.1371/journal.pone.0358657 2026-09-21T14:00:00Z 2026-09-21T14:00:00Z <p>by Fukai Zhao, Zekun Pang, Haoran Guo, Yue Chen, Jiao Wang, Bailing Hsu, Jianming Li</p> Background <p>In patients with ischemic cardiomyopathy (ICM), accurate preoperative identification of viable myocardium is clinically important to identify those who are likely to benefit from coronary artery bypass grafting (CABG). Although the PET perfusion–metabolism mismatch index has long been used to assess myocardial viability, its value in predicting contractile recovery remains controversial. Quantitative metabolic indices based on standardized uptake value (SUV) may provide complementary prognostic information.</p> Methods <p>This single-center retrospective cohort study included 53 patients with ICM who underwent preoperative [¹³N]ammonia/[¹⁸F]FDG PET/CT followed by isolated CABG. Conventional perfusion–metabolism indices were compared with SUV-based indices. The evaluated outcomes were postoperative increases in left ventricular ejection fraction (ΔLVEF) of ≥5% and ≥10% on follow-up echocardiography, and time to first major adverse cardiovascular event (MACE). Each PET parameter was evaluated in a separate multivariable Firth-penalized logistic regression model adjusted a priori for age, baseline LVEF, history of coronary artery disease, and diabetes. The predictive performance was assessed by receiver operating characteristic analysis, and time to MACE by Cox regression with the adjustment of multiple testing and model optimism.</p> Results <p>Of the 53 patients, 32 (60.4%) achieved ΔLVEF ≥5% and 25 (47.2%) achieved ΔLVEF ≥10%. The infarct-to-non-infarct SUV ratio (SUVR) was associated with ΔLVEF ≥5% (odds ratio [OR] 1.94 per 0.1-unit increase, 95% confidence interval [CI] 1.28–3.25; <i>P</i> < 0.001; <i>q</i> = 0.003) and ΔLVEF ≥10% (OR 1.53, 95% CI 1.11–2.29; <i>P</i> = 0.004; <i>q</i> = 0.035). For the prediction of ΔLVEF ≥5%, SUVR had a higher area under the curve (AUC) than the mismatch index (0.83 vs 0.62; DeLong <i>P</i> = 0.0049; <i>q</i> = 0.0147). For the prediction of ΔLVEF ≥10%, the AUCs did not differ (0.73 and 0.63; DeLong <i>P</i> = 0.200; <i>q</i> = 0.383). No individual PET parameter was associated with time to first MACE in adjusted Cox models.</p> Conclusions <p>SUVR showed greater discrimination for postoperative ΔLVEF ≥5% than the conventional perfusion–metabolism mismatch index. This finding supports SUVR as a quantitative adjunct to conventional PET viability assessment and warrants further multicenter validation.</p> Konstantinos G. Baroutis Victor San Martin C. Corrêa Dimitrios Ntentakis Toshio Narimatsu Evangelos S. Gragoudas Joan W. Miller Lucy H. Young Demetrios G. Vavvas 10.1371/journal.pone.0358654 2026-09-21T14:00:00Z 2026-09-21T14:00:00Z <p>by Konstantinos G. Baroutis, Victor San Martin C. Corrêa, Dimitrios Ntentakis, Toshio Narimatsu, Evangelos S. Gragoudas, Joan W. Miller, Lucy H. Young, Demetrios G. Vavvas</p> Verteporfin (VP) is widely used as a light-independent pharmacologic inhibitor of the YAP-TEAD transcriptional complex, despite its potent photosensitizing properties. Here we show that VP-associated high–molecular–weight complexes and apparent depletion of key proteins on immunoblots can be substantially driven by ambient-light exposure during post-lysis handling, more than by light during cellular treatment. In this study, the hypothesis is tested independently using MEL270, HEK293, and MCF-7 cells treated with therapeutic and supra-therapeutic concentrations of VP under four systematically varied light/dark conditions. The results demonstrate that high-molecular-weight complex (HMWC) formation for p62, DIAP1, ROCK1, YAP, and phospho-YAP is driven principally by light exposure during sample processing rather than during cell treatment, occurs in cell-free lysates within 1 hour of ambient-light exposure, and is markedly attenuated by both N-acetylcysteine and L-histidine, consistent with contributions from both radical-mediated and singlet oxygen-mediated photochemistry. Notably, YAP and phospho-YAP are highly susceptible to photo-cross-linking, whereas transcription enhancer factor 1 (TEF1)/TEAD1 remains comparatively resistant, a pattern that mimics selective YAP-TEAD inhibition on standard immunoblots. In a single-experiment CCK-8 assay, viability was markedly lower under light than in darkness at 24 hours, an observation consistent with the immunoblot findings but requiring independent replication. These findings support the light-artifact hypothesis and may have implications for how preclinical data on VP are interpreted in the design of clinical investigations. Fitri Ariyanti Abidin Evi Eliyanah Fredrick Dermawan Purba Anissa Lestari Kadiyono Grace Natasha Sunardy Syipa Husni Fadilah Joeri K. Tijdink 10.1371/journal.pone.0358652 2026-09-21T14:00:00Z 2026-09-21T14:00:00Z <p>by Fitri Ariyanti Abidin, Evi Eliyanah, Fredrick Dermawan Purba, Anissa Lestari Kadiyono, Grace Natasha Sunardy, Syipa Husni Fadilah, Joeri K. Tijdink</p> University academics are central to advancing higher education through teaching, research, and community engagement. However, mental-health challenges in this population have risen in recent years, partially driven by systemic pressures such as hypercompetition, heavy workloads, job insecurity, and escalating expectations for research productivity and publication output. This national survey included 1,380 academics (37.1% men, 62.7% women; M = 40.09 years) from 32 of Indonesia’s 38 provinces, representing both public and private institutions and all academic ranks from lecturer to full professor. The findings showed that nearly half of the participants (40.5%) reported working more than 40 hours per week, exceeding the standard legal working hours in Indonesia, with work often extending into evenings, weekends, and holidays. Most participants reported low/minimal anxiety (63.1%) and moderate stress (63.8%), while depression was mostly low/minimal (43.3%) or mild (36.3%). Female, younger age, academics without children, and those in lower ranks with lower income were the groups most vulnerable to poorer mental health outcomes. Across the risk and protective factors examined, higher publication stress and greater experience of unwanted behavior at the workplace were consistently associated with lower levels of well-being and higher psychological distress (<i>β</i> = −.19 to.20 and −.15 to.16, respectively; all <i>p</i>s < .001). In contrast, higher personal mastery was consistently associated with better mental-health (<i>β</i> = .39), greater work satisfaction (<i>β</i> = .33), higher happiness at work (<i>β</i> = .37), and lower stress (<i>β</i> = −.50), anxiety (<i>β</i> = −.40), depression (<i>β</i> = −.41), and emotional exhaustion (<i>β</i> = −.31) (all <i>p</i>s < .001). These findings suggest that academic mental health is shaped by intersecting individual capacities, institutional climates, and global publication pressures. Interventions should therefore move beyond individual-focused strategies and include institutional policies that prevent and address unwanted behavior in the workplace, reduce publication stress, and promote healthier work practices. Jian Zhang Khalid Usman Hongmei Yang Qianqian Yan 10.1371/journal.pone.0358648 2026-09-21T14:00:00Z 2026-09-21T14:00:00Z <p>by Jian Zhang, Khalid Usman, Hongmei Yang, Qianqian Yan</p> Drawing on the resource-based view, constructivist learning theory, and the theory of planned behavior, this study develops a process-oriented framework conceptualized as “resource input-cognitive construction-behavioral engagement” to examine how integrated learning outcomes in professional and entrepreneurship education are associated with multiple educational factors. Using survey data from 584 university students, the empirical analysis indicates that teaching content, teacher competence, student engagement, and university-enterprise resources are all positively associated with integrated learning outcomes. These associations are primarily reflected through instructional practice effectiveness as a key process variable. In contrast, policy support shows no significant direct association with learning outcomes but appears to be related through indirect pathways. By adopting a process perspective, this study highlights how educational resources, instructional practices, and student engagement jointly relate to learning outcomes in integrated education contexts. The findings offer implications for improving curriculum design, strengthening practice-oriented teaching, enhancing teacher competence, and promoting university enterprise collaboration in higher education. Jingcong Li Yu Liao Ximeng Wang Jie Deng 10.1371/journal.pone.0358646 2026-09-21T14:00:00Z 2026-09-21T14:00:00Z <p>by Jingcong Li, Yu Liao, Ximeng Wang, Jie Deng</p> The solution of partial differential equations (PDEs) remains a significant problem in scientific computing. Although physics-informed neural networks (PINNs) provide a mesh-free paradigm, pointwise constraints offer limited supervision between collocation points and uniform training can under-resolve regions with greater learning difficulty. To address these coupled limitations, this paper introduces Cognitive Region Optimized Physics-Informed Neural Networks (CoRoPINN). Rather than treating region optimization and cognitive learning as independent additions, CoRoPINN forms a closed feedback loop. Gradient-stability statistics calibrate a globally stable baseline radius, PDE residuals estimate pointwise learning difficulty, and the same difficulty signal jointly adjusts sample-specific neighborhoods and cognitive weights. This coupling expands continuous physical constraints around under-resolved collocation points while progressively reallocating optimization from easier to more difficult regions. We evaluate CoRoPINN on three one-dimensional PDEs with five backbone architectures, Poisson equations in two, three, and five dimensions, and Burgers2D. Across the five backbones, CoRoPINN achieves the lowest geometric-mean relative mean absolute error (rMAE) on all three one-dimensional benchmarks, reducing the aggregate error relative to the second-best method by 21.0%, 61.6%, and 52.9% on 1D-Reaction, 1D-Wave, and Convection, respectively. It also ranks first in both metrics for 2D and 5D Poisson, remains second in 3D, and attains the lowest rMAE and relative root mean square error (rMSE) among all four methods on Burgers2D. These results establish a clear overall accuracy advantage for CoRoPINN among the evaluated baselines. Denise Fuchten Kelly K. S. Assouly Inge Stegeman Adriana L. Smit 10.1371/journal.pone.0358644 2026-09-21T14:00:00Z 2026-09-21T14:00:00Z <p>by Denise Fuchten, Kelly K. S. Assouly, Inge Stegeman, Adriana L. Smit</p> Introduction <p>The experience of tinnitus varies considerably among individuals, particularly in terms of perceived distress. Psychological factors play a major role in this variability, and numerous studies have demonstrated a correlation between symptoms of depression and tinnitus distress. Both constructs are commonly assessed through self-report questionnaires. However, content overlap between these questionnaires can make it challenging to differentiate the constructs and interpret their relationship. Given the variation in content among questionnaires assessing tinnitus distress and depressive symptoms, a comprehensive examination of their similarities and differences is needed. This study therefore aims to systematically assess the content overlap of tinnitus distress and depressive symptom questionnaires using the International Classification of Functioning, Disability and Health (ICF) framework.</p> Methods and analysis <p>Six validated, multi-item, self-report questionnaires measuring tinnitus distress (THI, TQ, mTQ, THQ, TRQ, TFI) and seven validated, multi-item, self-report depressive symptom questionnaires (BDI-II, HADS-D, SDS, PHQ-9, CES-D, SCL-90-R depression subscale, DASS-42 depression subscale) were included in the content analysis. The underlying concepts of all items of these questionnaires were linked to the most specific ICF categories based on established linking rules. The overlap between the tinnitus distress and depressive symptom questionnaires was analyzed based on the assigned second-level ICF categories.</p> Results <p>The depressive symptom questionnaires demonstrated less diversity in ICF category coverage compared to the tinnitus distress questionnaires, with 14 versus 23 second-level ICF categories. Seven second-level categories were shared between tinnitus distress and depressive symptom questionnaires; energy and drive functions, sleep functions, attention functions, emotional functions, thought functions, interpersonal interactions and relationships, and recreation and leisure. The content analysis showed that, at the second-level ICF category, the TQ had the lowest degree of overlap with the depressive symptom questionnaires (11.54–26.92%), while the TRQ exhibited the highest (61.54–73.08%). Among the depressive symptom questionnaires, the SDS showed the least overlap with the tinnitus distress questionnaires (40–60%), whereas the DASS-42 depression subscale demonstrated the most overlap (85.71–100%).</p> Conclusion <p>The overlap between tinnitus distress and depressive symptom questionnaires emphasizes the importance of carefully selecting assessment tools and interpreting their results, based on specific clinical or research goals. This content analysis can guide making decisions about this selection.</p> The PLOS One Editors 10.1371/journal.pone.0358627 2026-09-21T14:00:00Z 2026-09-21T14:00:00Z <p>by The PLOS One Editors </p> The PLOS One Editors 10.1371/journal.pone.0358617 2026-09-21T14:00:00Z 2026-09-21T14:00:00Z <p>by The PLOS One Editors </p> Yueyi Tan Jusheng Song Guangying Zhao Yunxi Bai Yan Li Xuren Wei 10.1371/journal.pone.0358597 2026-09-21T14:00:00Z 2026-09-21T14:00:00Z <p>by Yueyi Tan, Jusheng Song, Guangying Zhao, Yunxi Bai, Yan Li, Xuren Wei</p> Understanding spatial competition between retail formats is vital for sustaining urban commercial vitality. In China’s rapidly evolving urban economy, the contrast between light‑asset and capital‑intensive formats within traditional retail has been increasingly shaped by urban redevelopment and changing consumer behavior. However, prior studies largely confine themselves to linear assumptions, neglecting nonlinear dynamics and complex interdependencies. They also lack systematic comparisons between light-asset and capital-intensive formats, especially when attempting to integrate objective urban features with perceptual dimensions. This study investigates how objective urban environment indicators and human perception jointly shape the spatial density of two traditional retail formats, light‑asset (convenience stores) and capital‑intensive (large-scale supermarkets and shopping malls), in Shenzhen, China. Using multi‑source geospatial data and an integrated framework combining XGBoost, SHAP, Partial Dependence Plots (PDP), Interpretive Structural Modeling (ISM), and Bayesian Networks (BN), we quantify nonlinear effects, interaction patterns, and probabilistic association pathways. Results reveal distinct locational logics: light‑asset retail thrives through widespread penetration, responding strongly to competition intensity, service‑function proximity, and perceptual synergies; capital‑intensive retail concentrates in high‑yield hubs, driven by facility networks, accessibility, and high‑quality aesthetic environments above defined thresholds. Human perception emerges as a core determinant, accounting for up to 28.95% of explanatory importance, often exerting threshold‑dependent effects. The ISM–BN analysis uncovers multi‑entry vs. sequential pathways to spatial clustering across formats. Findings advance retail location theory by linking built‑environment metrics with street-level perceptual attributes, offering actionable guidance for urban planners to tailor format‑specific, perception‑oriented, and threshold‑sensitive strategies for sustainable retail ecosystems. Niko Kargas Mirena Dimolareva Stamatina Tsiora Anum Farooq Victoria L. Brelsford Holly Stocks Ella Doolan-Dransfield Julian Free 10.1371/journal.pone.0358595 2026-09-21T14:00:00Z 2026-09-21T14:00:00Z <p>by Niko Kargas, Mirena Dimolareva, Stamatina Tsiora, Anum Farooq, Victoria L. Brelsford, Holly Stocks, Ella Doolan-Dransfield, Julian Free</p> British Armed Forces families raising neurodivergent children must coordinate health, education, welfare and informal support within a service context characterised by mobility and deployment. This study examined how families understood, accessed and sustained support, and how these processes shaped caregiving and family life. Twelve parents and caregivers of children aged 3–17 years with diagnosed or suspected neurodevelopmental conditions participated in online semi-structured interviews. Guided by critical realism, data were analysed using reflexive thematic analysis. The analysis showed that support was experienced less as a stable entitlement than as a contingent achievement. Relocation repeatedly interrupted clinical, diagnostic and educational pathways. Parents consequently became continuity brokers who carried records, rebuilt professional relationships and repeatedly legitimised their children's needs. Military welfare and informal networks could provide meaningful practical and emotional help, but access depended heavily on local knowledge, individual champions and geographic proximity. Advocacy generated occupational, financial and emotional costs that were often gendered. Deployment further redistributed care, disrupted routines and reverberated across caregiver wellbeing, child regulation and serving personnel's work. Parents also described meaning, pride and solidarity, while resisting uses of “resilience” that shifted responsibility from systems to families. These findings identify a policy-implementation gap: commitments to avoid service-related disadvantage do not consistently translate into portable, neurodiversity-informed support. Greater continuity across postings, transparent inter-agency handovers, knowledgeable welfare provision and deployment-sensitive respite are required. Ruba Malkawi 10.1371/journal.pone.0358580 2026-09-21T14:00:00Z 2026-09-21T14:00:00Z <p>by Ruba Malkawi</p> Background <p>Baicalein (BA) is a flavonoid with significant pharmacological and antioxidant activities; however, its poor aqueous solubility and high crystallinity limit its dissolution and oral bioavailability. Liquisolid compact technology represents a promising approach for improving the dissolution behavior of poorly soluble drugs.</p> Objective <p>This study aimed to develop a sustainable liquisolid compact formulation of BA using extracted fish viscera oil as a non-volatile solvent and to evaluate its physicochemical characteristics, dissolution behavior, and antioxidant activity.</p> Methods <p>Fish oil was extracted from salmon viscera and used as a liquid vehicle for preparing BA liquisolid compacts using corn starch as a carrier and talc as a coating material. The prepared formulation was characterized using Fourier Transform Infrared Spectroscopy (FTIR), Differential Scanning Calorimetry (DSC), and Powder X-Ray Diffraction (PXRD) to evaluate drug–excipient interactions and changes in crystallinity. In vitro dissolution studies were conducted using USP apparatus II in phosphate buffer (pH 6.8). Antioxidant activity was assessed using the DPPH radical scavenging assay in a 96-well microplate reader.</p> Results <p>FTIR analysis confirmed the absence of chemical incompatibilities between BA and the formulation components. DSC and PXRD analyses demonstrated a significant reduction in the crystalline nature of BA, indicating its transformation into an amorphous or molecularly dispersed state within the liquisolid compact. The liquisolid compact showed a marked improvement in drug dissolution compared with pure baicalein and the physical mixture. Furthermore, the fish oil–BA formulation exhibited enhanced antioxidant activity compared with BA alone.</p> Conclusion <p>The developed fish oil–based liquisolid compact system significantly improved the dissolution and antioxidant performance of BA. In addition, the use of fish viscera oil provides a sustainable formulation approach by repurposing marine waste into a functional pharmaceutical excipient.</p> Shan Xu Hongjun Xie Zhao Yang Zhenkun Ma Xiaojing Bai Xiaoyu Feng Jiale An Bohan Ma 10.1371/journal.pone.0358561 2026-09-21T14:00:00Z 2026-09-21T14:00:00Z <p>by Shan Xu, Hongjun Xie, Zhao Yang, Zhenkun Ma, Xiaojing Bai, Xiaoyu Feng, Jiale An, Bohan Ma</p> p21-Activated kinase 4 (PAK4) is widely dysregulated and acts as an oncogene in multiple cancers, and the inhibition or knockout of PAK4 has shown excellent therapeutic effects in inhibiting tumor progression in combination with immunotherapy across a variety of cancers. Previously, we reported our self-developed peptide proteolysis-targeting chimera (PROTAC) drug PpD, which specifically and selectively degrades the PAK4 protein to effectively inhibit the growth of renal cancer tumors. In this study, we confirmed that the PAK4 protein is highly expressed in bladder cancer (BLCA) tissues. Moreover, we established PAK4 knockout BLCA cell lines and explored the regulatory mechanisms of PAK4 in BLCA via RNA sequencing. Our RNA sequencing results revealed that PAK4 promotes the cell cycle progression of BLCA cells and inhibits apoptosis. Comparative studies of the PAK4 knockout cell lines T-24 sg/PAK4 and 5637 sg/PAK4 with PpD drug treatment revealed that both PAK4 knockout and PpD drug treatment inhibited the ERK1/2/CDK4 pathway, thereby blocking the cell cycle transition from the G1 phase to the S phase, and both induced caspase-3-mediated apoptotic cell death. <i>In vivo</i> animal experiments also confirmed that the growth of BLCA cells was significantly inhibited in both the PAK4 knockout group and the PpD drug-treated group. Collectively, our findings indicate that PpD exhibits potent anti-tumor activity against BLCA and holds promising potential for therapeutic application in other cancers. Jakia Sultana Mim Md. Shihab Mostafa Bodrunnahar Barna Ahmed Nuzat Sadia Raisul Islam Abdullah Al Islam 10.1371/journal.pone.0358556 2026-09-21T14:00:00Z 2026-09-21T14:00:00Z <p>by Jakia Sultana Mim, Md. Shihab Mostafa, Bodrunnahar Barna, Ahmed Nuzat Sadia, Raisul Islam, Abdullah Al Islam</p> Background <p>Bangladesh has achieved notable progress in maternal and child health; however, maternal and neonatal mortality remain high, partly due to inadequate access to skilled birth attendants (SBA) during delivery. This study aims to identify key socioeconomic and demographic factors influencing SBA utilization in Bangladesh.</p> Methods <p>Data were obtained from the 2022 Bangladesh Demographic and Health Survey (BDHS), a nationally representative cross-sectional survey which was conducted from June 27 to December 12, 2022. The outcome variable was skilled birth attendants during delivery, defined as attendants provided by a doctor, nurse, or midwife. Descriptive statistics and chi-square tests were used for initial analysis, followed by binary logistic regression to identify significant determinants. Additionally, the inclusion of machine learning models provides an additional classification framework that improves classification performance and helps identify important predictors, complementing traditional regression analysis.</p> Results <p>From the study, 67.94% of women utilized skilled birth attendants during childbirth. Higher maternal education, household wealth, antenatal care utilization, and urban residence were significantly associated with greater SBA utilization. Women with higher education had substantially higher odds of using SBA than those with no education (AOR = 4.10, 95% CI: 1.94–8.66, p < 0.001), while rural women had lower odds than urban women (AOR = 0.64, 95% CI: 0.47–0.88, p = 0.006). Women who attended four or more ANC visits were also more likely to use SBA than those with no ANC visits (AOR = 2.92, 95% CI: 1.72–4.96, p < 0.001). Women from the richest households had higher odds of SBA utilization compared with those from the poorest households (AOR = 1.77, 95% CI: 1.11–2.81, p = 0.016). Among the machine-learning models, Random Forest achieved the highest numerical accuracy (0.82).</p> Conclusion <p>Education, economic status, ANC utilization, and place of residence were identified as key factors associated with skilled birth attendants during delivery in Bangladesh using the binary logistic regression model. Moreover, the machine learning models were used separately to classify SBA. Targeted interventions focusing on disadvantaged and rural populations can help improve equitable access to maternal healthcare. However, differences related to religion and region should be interpreted cautiously, as they may reflect broader socioeconomic and cultural factors rather than direct effects.</p> Chung-Fen Tsai Sung-Chun Tang Ya-Hui Wang Chih-Hao Chen Kristiina Rannikmäe Ping-Keung Yip Jiann-Shing Jeng 10.1371/journal.pone.0358545 2026-09-21T14:00:00Z 2026-09-21T14:00:00Z <p>by Chung-Fen Tsai, Sung-Chun Tang, Ya-Hui Wang, Chih-Hao Chen, Kristiina Rannikmäe, Ping-Keung Yip, Jiann-Shing Jeng</p> Background <p>East Asians have a higher incidence rate of intracerebral hemorrhage (ICH). As clinical and neuroimaging characteristics, genetic and vascular risk factors, and prognosis might vary between populations, we aimed to make comparisons between different ICH locations and etiologies, and to investigate the factors associated with early post-stroke cognition in Chinese patients in Taiwan.</p> Methods <p>We prospectively recruited acute spontaneous Chinese ICH patients from two large Hospitals in Taiwan. For included patients, we compared major vascular risk factors, APOE genotypes, clinical and neuroimaging features, and early post-stroke cognition in patients with lobar versus non-lobar ICH and in cerebral amyloid angiopathy (CAA) versus non-CAA group. Furthermore, we used generalized linear models to investigate the associated factors with early global cognitive performance after ICH.</p> Results <p>In 202 included acute spontaneous ICH patients, 65% were men. 80% were non-lobar ICH, and 20% were lobar ICH. Lobar ICH patients generally had an older age, worse conscious level, a higher 1-month case fatality, a larger ICH volume, more lobar CMBs and cortical superficial siderosis, and worse early post-stroke cognitive function, while non-lobar patients had a higher proportion of hypertension (98% vs 85%, p < 0.001). Similar findings were noted when comparing patients of CAA group with non-CAA groups. Generalized linear regression models revealed that age, education, initial conscious level, stroke severity, ICH volume and lobar CMB burden were associated with early post-stroke cognition in ICH patients.</p> Conclusion <p>Our study demonstrated the differences in clinical and imaging features, major risk factors, and early post-stroke cognitive function between different locations and etiologies in Chinese ICH patients in Taiwan. Age, education, stroke severity, ICH volume and lobar CMB burden were the associated factors for early global cognitive performance after ICH.</p>