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We examine the heterogeneity of experts in a credence goods setting. In our analytical model, clients are uncertain about how much effort experts need to provide to solve their problem, which is either simple or difficult. Experts have varying degrees of expertise. Less qualified experts are equally effective at solving simple problems but less effective at solving difficult ones. We show that clients pay a fee premium to more qualified experts, even for simple problems. This premium increases with the probability that the client has a difficult problem. We empirically test the model predictions in the context of partner industry expertise for the U.S. operations of the Big Four audit firms. We find, consistent with the model, a positive association between partner industry specialization and audit fees, even for simple audits, and a negative association between partner specialization and the client’s probability of restatements only for difficult audits. The industry specialization premium is higher in industries with higher proportions of difficult audits. Consistent with credence good agency issues, the specialization premium for simple audits is mitigated when information asymmetry between client and auditor is lower.

Background Policing shapes the health risks of people who use drugs (PWUD), but little is understood about interventions that can align officer practices with PWUD health. This study deploys the Theory of Planned Behavior (TPB) to understand what influences police intentions to make discretionary referrals to treatment and harm reduction resources rather than arrest on less serious charges. Methods On-line surveys integrating TPB constructs and adapting an instrument measuring police intentions to make mental health treatment referrals were completed by police employees in Indiana, Massachusetts, and Missouri. They also included items about stigma towards PWUD and attitudes and beliefs about opioid addiction, treatment, and recovery. Findings Across the sites, 259 respondents perceived control over their decision to arrest for misdemeanors (69%) and confiscate items such as syringes (56%). Beliefs about others’ approval of referrals to treatment, its ability to reduce future arrests, and to increase trust in police were associated with stated practices of nonarrest for drug and possession and making referrals ( p  ≤ .001), and nonarrest for syringe possession ( p  ≤ .05). Stigma a towards PWUD was negatively associated with stated practices of nonarrest ( p  ≤ .05). Respondents identified supervisors as having the most influence over use of discretion, seriousness of the offense as the most influential value, and attitude of the suspect as the most important situational factor. The 17 Likert scale items analyzed had a Cronbach’s alpha of 0.81. Conclusion The TPB offers untapped potential to better understand and modify police practices. In designing interventions to improve the health outcomes of police encounters with PWUD, further research should validate instruments that measure the relationship between these variables and discretionary intentions, and that measure role-relevant police stigma towards PWUD.

Background First responders [law enforcement officers (LEO) and Fire/Emergency Medical Services (EMS)] can play a vital prevention role, connecting overdose survivors to treatment and recovery services. This study was conducted to examine the effect of occupational safety and harm reduction training on first responders’ intention to refer overdose survivors to treatment, syringe service, naloxone distribution, social support, and care-coordination services, and whether those intentions differed by first responder profession. Methods First responders in Missouri were trained using the Safety and Health Integration in the Enforcement of Laws on Drugs (SHIELD) model. Trainees’ intent to refer (ITR) overdose survivors to prevention and supportive services was assessed pre- and post-training (1–5 scale). A mixed model analysis was conducted to assess change in mean ITR scores between pre- and post-training, and between profession type, while adjusting for random effects between individual trainees and baseline characteristics. Results Between December 2020 and January 2023, 742 first responders completed pre- and post-training surveys. SHIELD training was associated with higher first responders’ intentions to refer, with ITR to naloxone distribution (1.83–3.88) and syringe exchange (1.73–3.69) demonstrating the greatest changes, and drug treatment (2.94–3.95) having the least change. There was a significant increase in ITR score from pre- to post-test ( β  = 2.15; 95% CI 1.99, 2.30), and LEO—relative to Fire/EMS—had a higher score at pre-test (0.509; 95% CI 0.367, 0.651) but a lower score at post-test (0.148; 95% CI − 0.004, 0.300). Conclusion Training bundling occupational safety with harm reduction content is immediately effective at increasing first responders’ intention to connect overdose survivors to community substance use services. When provided with the rationale and instruction to execute referrals, first responders are amenable, and their positive response highlights the opportunity for growth in increasing referral partnerships and collaborations. Further research is necessary to assess the extent to which ITR translates to referral behavior in the field.

Background There is a strong association between stillbirth and fetal growth restriction. Early detection and management of IUGR can lead to reduce related morbidity and mortality. In this paper we have reviewed effectiveness of fetal movement monitoring and Doppler velocimetry for the detection and surveillance of high risk pregnancies and the effect of this on prevention of stillbirths. We have also reviewed effect of maternal body mass index (BMI) screening, symphysial-fundal height measurement and targeted ultrasound in detection and triage of IUGR in the community. Methods We systematically reviewed all published literature to identify studies related to our interventions. We searched PubMed, Cochrane Library, and all World Health Organization Regional Databases and included publications in any language. Quality of available evidence was assessed using GRADE criteria. Recommendations were made for the Lives Saved Tool (LiST) based on rules developed by the Child Health Epidemiology Group. Given the paucity of evidence related to the effect of detection and management of IUGR on stillbirths, we undertook Delphi based evaluation from experts in the field. Results There was insufficient evidence to recommend against or in favor of routine use of fetal movement monitoring for fetal well being. (1) Detection and triage of IUGR with the help of (1a) maternal BMI screening, (1b) symphysial-fundal height measurement and (1c) targeted ultrasound can be an effective method of reducing IUGR related perinatal morbidity and mortality. Pooled results from sixteen studies shows that Doppler velocimetry of umbilical and fetal arteries in ‘high risk’ pregnancies, coupled with the appropriate intervention, can reduce perinatal mortality by 29 % [RR 0.71, 95 % CI 0.52-0.98]. Pooled results for impact on stillbirth showed a reduction of 35 % [RR 0.65, 95 % CI 0.41-1.04]; however, the results did not reach the conventional limits of statistical significance. This intervention could be potentially recommended for high income settings or middle income countries with improving rates and standards of facility based care. Based on the Delphi, a combination of screening with maternal BMI, Symphysis fundal height and targeted ultrasound followed by the appropriate management could potentially reduce antepartum and intrapartum stillbirth by 20% respectively. This estimate is presently being recommended for inclusion in the LiST. Conclusion There is insufficient evidence to recommend in favor or against fetal movement counting for routine use for testing fetal well being. Doppler velocimetry of umbilical and fetal arteries and appropriate intervention is associated with 29 % (95 % CI 2% to 48 %) reduction in perinatal mortality. Expert opinion suggests that detection and management of IUGR with the help of maternal BMI, symphysial-fundal height measurement and targeted ultrasound could be effective in reducing IUGR related stillbirths by 20%.

All wounds that cannot be closed primarily needs skin coverage earliest to prevent form infections. Skin graft provides earliest and easiest wound coverage, but produces another wound, i.e. donor site wound. This study was conducted to see healing time efficacy in donor site wounds. Study was designed as prospective and randomized control study, in the Department of Plastic and Reconstructive Surgery at Civil Hospital Karachi, included 60 patients who underwent split thickness skin grafting. From the next day of surgery heparin and conventional dressings groups were made and dressing was done daily till seventh postoperative day. Data in form of questionnaire and photographs were recorded. This study was a self-controlled trial, therefore every trial participant served as his/her own control. The results of the analysis showed a decrease in soakage of dressing and a reduction in itching at intervention site. In regard to wound size, 40% of participants showed a reduction in wound size and only 20% showed no improvement at interventional half. During 7days, 81.67% of participants showed improvement in edema at intervention half. The study showed heparin irrigation resulted in better wound healing by reducing pain, edema, faster healing and reducing soakage of dressings. Trial registration The study was approved by Institutional Review Board of Dow University of Health Sciences and was registered at Clinical Trials.gov (ID NCT04613336) on 13/07/2021.

Background Psychological stress is linked to elevated salivary cortisol levels, potentially worsening periodontitis by exacerbating inflammation. This study examines the impact of stress on cortisol levels in periodontitis patients, aiming to explore salivary cortisol as a biomarker for disease severity and its role in improving management strategies. Methods This case-control study, conducted at Dow University of Health Sciences in Karachi from January to December 2022, involved 120 dental clinic patients aged 30–60. Participants were selected based on the presence (cases) or absence (controls) of periodontitis, excluding those with systemic diseases, taking hydrocortisone, immunosuppressives, antidepressants, systemic antibiotics, having oral ulcers and pregnancy or lactation. Periodontal parameters, stress levels (using the Perceived Stress Scale), and morning salivary cortisol (measured via ELISA) were assessed. Statistical analyses were performed using SPSS version 23, including descriptive statistics, independent t-tests, ANOVA, and odds ratio calculations with a 95% confidence interval at 0.05. Results The study cohort comprised 120 subjects, equally divided between periodontitis patients and healthy controls. Predominantly male (63%) with a mean age of 41.75 years, participants were subjected to comprehensive evaluations. Oral health indices (Gingival index, Plaque index, Clinical attachment loss, Periodontal probing depth, Tooth mobility) and stress markers (Perceived Stress Score, Salivary cortisol levels [SCLs]) were significantly higher in cases compared to controls ( p  < 0.001). Majority of cases (58.3%) had stage II periodontitis. Notably, cases exhibited significantly higher stress levels (2.05 ± 0.59 vs. 1.38 ± 0.52; p  < 0.001) and elevated salivary cortisol levels (6.67 ± 1.64 vs. 2.54 ± 0.88; p  < 0.001) compared to controls. The odds ratio (OR) of 3.73 (95% CI [1.75, 7.93], p  = 0.0006) indicated that periodontitis patients were over 3.5 times more likely to have elevated SCLs. Stress prevalence was 42.5% in periodontitis patients compared to 18.33% in controls. Conclusions This study highlights a potential link between stress, cortisol levels, and periodontitis, suggesting that salivary cortisol could be a valuable biomarker. Incorporating cortisol measurements into routine dental evaluations may enable personalized treatment plans, addressing both biological and psychological contributors to periodontitis. Further research is needed to explore the long-term effects of stress on cortisol levels and periodontal disease progression, as well as the role of stress management in managing periodontitis.

We executed this study to determine if chemerin‐like receptor 1 (CMKLR1), a G i/o protein‐coupled receptor expressed by leukocytes and non‐leukocytes, contributes to the development of phenotypic features of non‐atopic asthma, including airway hyperresponsiveness (AHR) to acetyl‐β‐methylcholine chloride, lung hyperpermeability, airway epithelial cell desquamation, and lung inflammation. Accordingly, we quantified sequelae of non‐atopic asthma in wild‐type mice and mice incapable of expressing CMKLR1 (CMKLR1‐deficient mice) following cessation of acute inhalation exposure to either filtered room air (air) or ozone (O 3 ), a criteria pollutant and non‐atopic asthma stimulus. Following exposure to air, lung elastic recoil and airway responsiveness were greater while the quantity of adiponectin, a multi‐functional adipocytokine, in bronchoalveolar lavage (BAL) fluid was lower in CMKLR1‐deficient as compared to wild‐type mice. Regardless of genotype, exposure to O 3 caused AHR, lung hyperpermeability, airway epithelial cell desquamation, and lung inflammation. Nevertheless, except for minimal genotype‐related effects on lung hyperpermeability and BAL adiponectin, we observed no other genotype‐related differences following O 3 exposure. In summary, we demonstrate that CMKLR1 limits the severity of innate airway responsiveness and lung elastic recoil but has a nominal effect on lung pathophysiology induced by acute exposure to O 3 .

Background Temporomandibular joint disorders (TMDs) are a variety of conditions that affect different parts of the temporomandibular joints (TMJ) and can cause orofacial pain and functional impairment. This study aims to investigate dental practitioners’ knowledge and management of Temporomandibular Joint Disorders (TMDs), particularly their knowledge of the role physical therapy plays in TMD treatment. Methods A mixed-methods approach was adopted to provide a comprehensive view of current knowledge, management practices, and attitudes toward collaboration among dental practitioners in treating TMD. Data were collected from a convenience sample of 335 dentists in Karachi using a detailed questionnaire to assess their knowledge of the role of physical therapy in the treatment of TMD. Twenty dentists were chosen for face-to-face, in-depth interviews to explore their experiences and challenges in managing TMDs based on their responses to the administered questionnaire. Results The cumulative quantitative and qualitative findings of the study revealed a landscape marked by individualized approaches to referral practices and significant gaps in interdisciplinary collaboration. Most practitioners holding a bachelor’s degree predominantly used medication (65.2%) and cause-specific treatment (65.3%) for TMD treatment. Thematic analysis of clinical efficacy and practitioner challenges in managing TMD revealed significant issues faced by dental professionals. Conclusions The study successfully validated a questionnaire to understand dental practitioners’ knowledge regarding physical therapy in TMD treatment. The study identified significant gaps in knowledge and a lack of collaboration between dentists and physiotherapists. The limited referral practices highlighted in the study, along with insights from dentist interviews, emphasize the need for improved interdisciplinary approaches to managing TMDs within dental practice.

The demographic transition in South Asia coupled with unplanned urbanization and lifestyle changes are increasing the burden of non-communicable disease (NCD) where infectious diseases are still highly prevalent. The true magnitude and impact of this double burden of disease, although predicted to be immense, is largely unknown due to the absence of recent, population-based longitudinal data. The present study was designed as a unique 'Framingham-like' Pakistan cohort with the objective of measuring the prevalence and risk factors for hypertension, obesity, diabetes, coronary artery disease and hepatitis B and C infection in a multi-ethnic, middle to low income population of Karachi, Pakistan. We selected two administrative areas from a private charitable hospital's catchment population for enrolment of a random selection of cohort households in Karachi, Pakistan. A baseline survey measured the prevalence and risk factors for hypertension, obesity, diabetes, coronary artery disease and hepatitis B and C infection. Six hundred and sixty-seven households were enrolled between March 2010 and August 2011. A majority of households lived in permanent structures (85%) with access to basic utilities (77%) and sanitation facilities (98%) but limited access to clean drinking water (68%). Households had high ownership of communication technologies in the form of cable television (69%) and mobile phones (83%). Risk factors for NCD, such as tobacco use (45%), overweight (20%), abdominal obesity (53%), hypertension (18%), diabetes (8%) and pre-diabetes (40%) were high. At the same time, infectious diseases such as hepatitis B (24%) and hepatitis C (8%) were prevalent in this population. Our findings highlight the need to monitor risk factors and disease trends through longitudinal research in high-burden transition communities in the context of rapid urbanization and changing lifestyles. They also demonstrate the urgency of public health intervention programs tailored for these transition communities.

Objectives We examined the nationwide geographic variation of overweight and obesity in India, as well as a range of potential correlates of excess body fat. Methods We conducted cross-sectional analyses of the 2005–2006 Indian Demographic Health Survey (IDHS), based on 161,050 individuals (age range 18–54 years). Multivariate logistic regression models were used to determine odds ratios (OR) of overweight and obesity compared to normal weight with associated correlates. Results The overall prevalence was 12.4 % for overweight, 3.2 % for obesity, and 26.5 % for underweight. After multivariate adjustment, obesity was nearly thrice more likely in urban areas than in rural (OR 2.73, 95 % CI 2.53–2.94). Women were 2.71 times more likely to be obese than men (95 % CI 2.50–2.95). Better socioeconomic status was significantly associated with overweight and obesity. Overweight (OR 1.38, 95 % CI 1.31–1.47) and obesity (OR 1.46, 95 % CI 1.32–1.61) were most likely to occur in India’s Southern zone, when controlled for confounding factors. Conclusions High-risk estimates for overweight/obesity in urban settings, along with socioeconomic prowess in India and the resulting nutritional transition make a compelling case for public health policy on healthy lifestyles to avert the growing burden of non-communicable diseases associated with overweight/obesity.