Search Results (436)

Background: Regional anesthesia is a fundamental aspect of contemporary perioperative care. However, variability in practice, incomplete documentation, and inconsistent safety protocols continue to pose preventable risks. Although there are international checklist models for regional anesthesia and perioperative safety such as those developed by ASRA, ESAIC, and the WHO, Italy does not have a nationally endorsed checklist that is consensus-based and specifically tailored to local terminology, workflows, and legal requirements. Methods: To address this gap, we developed an evidence-based Locoregional Anesthesia Checklist (LRA Checklist) using established frameworks for healthcare checklist design. The development process included a needs assessment through a national survey of ESRA Italy members, a review of existing models, item drafting, expert consensus, and endorsement by the Board. We assessed content validity through a modified Delphi process involving 15 experts from the ESRA Italian Chapter Board. Additionally, we created a theoretical impact model to estimate the potential organizational and economic effects of implementing the checklist, using baseline institutional parameters. Results: Consensus was achieved for all checklist domains after two Delphi rounds, with minor edits to improve clarity, usability, and clinical relevance. The theoretical model indicates that adopting checklists may help reduce preventable complications, improve workflow, enhance documentation and traceability, and provide overall benefits to institutions in various scenarios. Conclusions: In conclusion, the LRA Checklist is a structured, consensus-based tool tailored for the Italian context, aimed at promoting safer and more standardized practices in regional anesthesia. To our knowledge, no prior Italian national consensus or checklist specifically dedicated to regional anesthesia has been formally published. Prospective multicenter studies are necessary to confirm its effectiveness in real-world settings and to quantify both clinical and economic outcomes. Full article

Objective: Nutrition is a key determinant of women’s health across all life stages. Clinical practice remains heterogeneous because of lack of evidence and non-homogeneous guidelines. Despite growing research on micronutrient supplementation, skeptical opinions persist around universal versus individualized approaches, optimal dosages, and life-stage-specific recommendations. Material and methods: This is a modified Delphi process conducted under the supervision of the Italian Association of University Gynecologists and Obstetricians (AGUI). Thirteen Italian experts in gynecology and obstetrics completed two rounds of anonymous online surveys (September–November 2025). The questionnaire, developed through a scoping review, covered six domains: pre-/periconception, pregnancy, postpartum, routine supplementation in non-pregnant women, nutrition in gynecological conditions, and menopause. Consensus was defined as ≥75% agreement on a 10-point Likert scale. Quantitative data were summarized descriptively, and qualitative comments contextualized findings. Results: Experts strongly supported personalized nutritional strategies across all life stages. Consensus was reached on individualized micronutrient supplementation in the preconception period and on the prescription of active folates for women undergoing assisted reproduction. In pregnancy, agreement emerged for universal DHA supplementation (200–300 mg/day); however, universal vitamin D supplementation lacked consensus except in gestational diabetes. In the postpartum period, iron supplementation for non-breastfeeding women reached consensus, while micronutrient recommendations for breastfeeding women remained uncertain. Strong agreement supported personalized dietary approaches for PCOS, endometriosis, and gestational diabetes, including inositol use, while evidence for interventions in severe premenstrual syndrome remained insufficiently supported. In menopause, consensus was reached for macronutrient adjustments and universal calcium and vitamin D supplementation. Conclusions: This Delphi consensus highlights shared expert perspectives on nutritional care in women and identifies key evidence gaps, particularly regarding vitamin D in physiological pregnancy, postpartum micronutrient needs during breastfeeding, and nutritional strategies for premenstrual disorders. Unified life-course guidelines and future research on standardized nutritional assessments are necessary for nutritional approach management. Full article

In this study, we explore how to balance the preservation of the original appearance of ancient villages with their development within the framework of World Heritage protection. We applied resilience theory and constructed a simple checklist, taking cultural ecosystem services into consideration, and selected the Zuojiang Huashan Rock Art Heritage Area in China for field investigation, as well as conducted in-depth interviews, the distribution of short questionnaires, and two rounds of Delphi surveys. This comprehensive approach enabled us to discover the key cultural ecosystem services that villagers rely on for their livelihoods. Then, we tracked how these services enhanced buffering capacity, helped people self-organize, and promoted adaptive learning. The results show that cultural ecosystem services constitute the core framework of the social–ecological resilience of the villages. The quantity and combination of the services directly determine the resilience score, and the resilience of villages within the heritage area shows significant spatial differentiation. High-resilience villages have diverse and mutually reinforcing cultural ecosystem services and local community rules, while low-resilience villages face service loss, weakened social connections, and single development options. Through this study, we aim to further enrich the cultural connotation of resilience theory, provide a practical assessment tool for practitioners of the method, and offer practical guidance and suggestions for transforming heritage protection from static protection to a dynamic, vibrant system that promotes vitality and resilience in practice. Full article

The growing demand for sustainable development has exposed significant limitations in how Higher Education Institutions (HEIs) evaluate sustainability-oriented research, particularly due to fragmented indicators, descriptive approaches, and the absence of robust data-driven assessment frameworks. This study proposes a comprehensive framework for evaluating the sustainability orientation of university research models, integrating validated measurement instruments with advanced analytical and predictive techniques to support evidence-based decision-making in higher education governance. The framework is based on a multidimensional instrument comprising 26 indicators across environmental, social, economic, and institutional dimensions, developed through expert judgment using the Delphi method and statistically validated through Confirmatory Factor Analysis (CFA). The instrument was applied to 260 researchers from four public HEIs located in the Colombia–Ecuador border region, and perceived performance was contrasted with actual institutional indicators, revealing significant nonlinear discrepancies. To address this complexity, an artificial neural network model was developed to estimate real sustainability performance based on survey data, achieving a predictive accuracy of 90.92%. Beyond institutional diagnosis, the proposed framework functions as a decision-support tool that enables HEIs to identify critical gaps, prioritize interventions, and guide continuous improvement strategies in research management. Due to its methodological rigor, scalability, and transferability, the framework can be adapted to diverse higher education contexts, contributing to the advancement of sustainability assessment methods and governance practices in universities. Full article

Against the backdrop of intensified global talent competition, the return of overseas talents has become a key engine driving the enhancement of core competitiveness in developing countries. Accurately identifying its critical driving factors is essential for China to address the challenges of talent introduction. This study constructs a hybrid multiple-criteria decision-making framework to systematically explore the influence mechanism of overseas talent return: first, a 15-criterion decision structure covering economic, policy, educational, technological, and social aspects is established via systematic literature review and two-round Delphi expert surveys; second, the grey DEMATEL-ANP technique is adopted to quantify the inter-relationships and relative weights of the criteria and screen and rank the critical driving factors accurately. Empirical results show that the six core driving factors ranked by importance are talent policy support, economic development level, scientific and technological development strength, public service quality, educational resource supply, and attention to science and technology, with significant synergistic interaction effects among these factors. This research provides a scientific decision-making framework and empirical support for developing countries to formulate targeted talent introduction policies and optimize the talent development ecosystem. Full article

There has been an increasing need to manage the water, energy, and food (WEF) Nexus in an integrated and sustainable way using Industry 4.0 (4IR) technologies. While 4IR technologies can significantly improve resource management and sustainability in the Nexus, their uptake across the WEF Nexus has been uneven due to institutional fragmentation and limited digital capability. This study assessed a multi-level human capital framework developed to facilitate the structured integration of 4IR technologies into the WEF Nexus. The study leveraged human capital theory and Strategic Human Resource Management to frame capability development as a multi-level process. The study employed a mixed-methods approach, initially surveying 262 professionals in the WEF Nexus to assess essential skill capabilities. This was followed by a two-round Delphi procedure involving 12 experts to refine and validate the multi-level framework. The findings reveal that digital transformation in the WEF Nexus is dependent on the synchronisation of national policy frameworks, organisational learning cultures, and individual skill sets. These levels do not work as separate enablers; instead, they work together as an integrated capacity ecosystem in which misalignment at any point will hinder the effective integration of 4IR technologies. The validated framework provides a systematic approach to understanding the interplay of human capital processes within socio-technical systems and provides a structured approach for designing comprehensive strategies that strengthen digital readiness across sectors. The study advocates for a system-embedded human capital (SEHC) approach and contributes to ongoing discussions on innovation in the public sector by highlighting the systemic nature of human capital development in sustainability- and resource-critical sectors. Full article

This paper develops a region-specific technological transformation strategy for the automotive and mobility sector in Southeast Lower Saxony (SON) under conditions of high uncertainty driven by electrification, digitalization, and automation. The study integrates three analytical components: (i) a SWOT-based baseline assessment of SON’s current strengths, weaknesses, opportunities, and threats; (ii) a scenario-technique framework describing alternative German mobility futures toward 2035; and (iii) a two-round Delphi survey with experts from the Institutes of Automotive Engineering and Engineering Design to evaluate actionable transformation measures. SWOT factors are mapped to scenario key-factor projections and assessed using a trinary impact scale (−1/0/+1), followed by aggregation and normalization to derive scenario-specific change factors. Delphi-rated measures are then prioritized using scenario-overarching performance and SWOT relevance, yielding a tiered strategy concept. The resulting strategy is organized around five interdependent pillars: strengthening industry–research cooperation, advancing research in modern mobility, developing key mobility-support technologies (battery technology, AI, circular economy), expanding digital infrastructure, and upgrading R&D infrastructure and talent capacity, supported by enabling regulatory and workforce measures. The paper provides focus points from regional diagnosis to prioritized action, supporting robust strategic decision-making and adaptive capability building in SON. Full article

Background/Objectives: Early Childhood Intervention (ECI) services are critical for supporting children with developmental needs and their families. Despite an established legislative framework, challenges related to accessibility, equity, resources, and standardization of practices persist. This study aimed to describe the perspectives of early intervention professionals in Portugal regarding current barriers, facilitators, and priority areas for improvement within the system. Methods: A descriptive study was conducted involving 82 professionals working in early intervention in Portugal. Data were collected using a survey specifically developed by the research team, grounded in a comprehensive literature review and professional expertise. The instrument was validated through a Delphi Panel with two rounds involving six experts in ECI. Data from open-ended questions were analyzed using content analysis, identifying categories and sub-categories to describe the responses, and descriptive statistics for the closed-ended questions. Results: Professionals highlighted the need to update the National ECI System (SNIPI), improve accessibility, and ensure equitable access to early intervention services. Participants reported limited resources, a lack of standardization in practices, and emphasized the importance of professional training and continuous professional development. The findings also pointed to the urgent need for investment and functional and structural restructuring of early intervention services. Various barriers and facilitators were identified. Conclusions: The study provides valuable insights into the perspectives of early intervention professionals, identifying critical areas for policy improvement, resource allocation, and practice standardization. Full article

Education on the Big Food Concept, as a strategic framework for ensuring national food security and promoting high-quality agricultural development, represents a key nexus between ideological and political education and quality-oriented education for college students. Based on survey data from 1268 students across six provinces in China, this study utilized the Delphi method, the analytic hierarchy process (AHP), and structural equation modeling (SEM) to develop a four-dimensional evaluation system encompassing cognitive, affective, value, and behavioral dimensions. It examined the relationship and underlying mechanism through which Big Food Concept education influences student behavior. The results indicate that college students’ overall understanding of the Big Food Concept remains at a moderate level, with particularly limited awareness of diversified food supply systems. The weights of the dimensions in the educational evaluation system were as follows: behavioral dimension (0.342) > cognitive dimension (0.287) > value dimension (0.221) > affective dimension (0.150). Big Food Concept education shapes student behavior through the sequential pathway of cognitive enlightenment, affective resonance, and value internalization, with value internalization demonstrating the strongest mediating effect (β = 0.413, p < 0.001). The evaluation system developed in this study is a practical tool for assessing the effectiveness of Big Food Concept education in higher institutions, while the identified mechanism provides a theoretical basis for implementing targeted educational practices. Full article

The digitalization of maritime information and operational data has led to increasing reliance on data-driven services to support safe and efficient maritime transportation. As maritime operations become more service-oriented, data quality and interoperability play a crucial role in operational reliability and safety-related decision-making. However, most existing data quality assessment approaches treat quality characteristics as independent attributes, offering limited insight into how deficiencies interact and propagate risk across interconnected services. This study proposes a safety-oriented analytical framework that focuses on the interrelations among data quality characteristics in service-oriented maritime operations. The framework combines Delphi-inspired expert elicitation with a structured prioritization approach based on the principles of the Analytic Hierarchy Process to capture both the perceived importance of data quality characteristics and their influence relationships. An expert survey was conducted with practitioners across the maritime transportation value chain, focusing on safety-relevant services such as condition monitoring and route planning. The results indicate that data quality characteristics are perceived as interdependent rather than isolated. Timeliness is identified as a key upstream factor that strongly influences both accuracy and reliability, especially in operational services that operate under time constraints. The analysis further shows that operational services are more vulnerable to compounded data quality degradation than reporting-oriented services. By framing data quality interactions as latent safety and interoperability risk factors, this study provides a practical perspective that complements existing standards and supports more effective prioritization of data quality management in digital maritime services. Full article

Breast cancer (BC) is the most common malignant disease in women in Romania, with incidence and mortality rates among the highest in Europe. This consensus statement aims to ensure equitable access to care for human epidermal growth factor receptor 2-negative metastatic BC (HR+/HER2– mBC) and triple-negative mBC (mTNBC) in Romania. Between December 2024 and June 2025, a scientific board of 11 oncologists, in collaboration with the Romanian National Society for Medical Oncology (SNOMR), developed national recommendations based on ESMO/NCCN/ABC guidelines, clinical expertise, and local conditions. A modified Delphi survey was conducted among medical oncologists to evaluate acceptance of recommendations with greatest clinical impact. Key recommendations included: mandatory biopsy at metastasis with ER/PgR/HER2 retesting, HER2-low assessment, and molecular profiling (BRCA, PIK3CA, AKT1/PTEN, ESR1, plus PD-L1 testing in mTNBC); for HR+/HER2– mBC, first-line endocrine therapy plus CDK4/6 inhibitor, followed by targeted agents, chemotherapy, or antibody–drug conjugates based on progression and visceral crisis; for mTNBC, first-line immune checkpoint inhibitor plus chemotherapy in PD-L1-positive, PARP inhibitors in BRCA-positive patients, and sacituzumab-govitecan or trastuzumab-deruxtecan later; systematic toxicity monitoring; and integrated supportive and palliative care. Sixty-one oncologists completed the survey, with >90% overall agreement, suggesting broad acceptance of recommendations as Romania’s national standard for mBC care. Full article

Hydrotherapy tourism is a significant and long-standing area of interest, with countries worldwide employing innovative strategies to attract tourists. It not only offers desirable benefits but also plays a role in the development of tourist destinations. This research aims to identify critical success factors for tourist attraction in a prominent destination in northwest Iran, particularly in Ardabil Province (Sareyn county). It utilizes a mixed-method approach, employing the Partially Mixed Sequential Dominant Status Design methodology across three phases: qualitative, qualitative, and quantitative. The study employs sequential methods including scoping review, Delphi, and surveys to achieve its objectives. Data collection involved utilizing reputable scientific databases in the initial phase. Subsequently, 15 experts underwent purposeful selection for interviews and three rounds of Delphi surveys in the second phase. In the third phase, data collection was conducted through a questionnaire tool. Initially, approximately 141 relevant studies were identified, narrowed down to 11 primary ones using the scoping review checklist. Then, experts utilized the qualitative Delphi method to confirm and extract effective indices, resulting in 6 components and 50 indices. Finally, 61 experts provided feedback on confirming or rejecting these components and indices in the quantitative survey phase. The quantitative survey highlighted key factors influencing hydrotherapy tourism in Sareyn, such as supportive services, community backing, and smart destination management. Prioritizing healthcare, safety, reputation enhancement, and digital initiatives, like modern infrastructure, specialized apps, and social media engagement, is essential. These elements significantly impact tourist satisfaction and engagement, shaping Sareyn County’s hydrotherapy tourism. Strengthening these factors can boost its appeal, economic contribution, and status as a leading tourist destination in Ardabil Province and beyond. Full article

There is increasing concern in many advanced economies about the risks of disruption and crises in agri-food systems. Government departments and non-governmental organisations are working to identify and understand specific risks but struggle to take broad, holistic perspectives and therefore underestimate the potential for civil unrest. In the interests of helping move from understanding to action, we convened a group of experts through a Delphi process to map out potential pathways to acute UK food system crises and identify interventions that would build resilience and sustainability. To this end, we consulted 31 experts, carrying out 15 expert interviews, followed by three surveys and two workshops with a further 16 experts. The experts highlighted the many existing chronic issues creating a tinderbox for an acute risk to lead to a food crisis in the UK. These chronic issues include climate change, poor policy implementation, rising inequality, food supply chain consolidation and the risks from just-in-time supply of food. They voted to include three acute triggers—(a) cyber-attack, (b) a major extreme weather event and (c) a major new international conflict—and described how any combination of these could lead to (d) a UK food availability and/or price shock that could result in widespread fear of unsafe or inadequate food, leading to violence. A total of 7 system-wide interventions were prioritised to help address these pathway elements together and build sustainability, and a further 21 were identified to address elements individually. Full article

Background: Spasticity, which occurs with certain neurological conditions, substantially affects quality of life, function, and social participation. Despite widespread botulinum toxin use, variability persists in patient information, access to specialized rehabilitation, and follow-up models. Methods: This two-phase Delphi-Dialogue Patients–Professionals study (DDPP), promoted by SERMEF, integrated perspectives from 77 patients and 141 rehabilitation professionals. Phase 1 used parallel surveys to assess satisfaction, perceived effectiveness of botulinum toxin, communication preferences, and rehabilitation follow-up. Phase 2 applied Real-Time Delphi with 38 experts to generate consensus recommendations to improve spasticity management. Results: Patients and professionals agreed on botulinum toxin benefits, the importance of ongoing rehabilitation, and the value of hybrid (in-person/remote) follow-up. Key gaps concerned access to Physical Medicine and Rehabilitation services, clarity and timing of information, and shared goal setting. Experts translated these misalignments into 10 prioritized recommendations, with highest feasibility for actions standardizing access pathways, optimizing botulinum toxin use, reinforcing structured education, and consolidating hybrid rehabilitation models. Conclusions: The DDPP approach offers a reproducible framework to align stakeholder perspectives by converting quantified divergence into consensus-based innovation priorities. Implementing the recommendations—particularly those strengthening communication, education, and hybrid pathways regarding botulinum toxin treatment—may support more accessible, personalized, patient-centered spasticity care. Full article

Rising rates of mental health concerns worldwide highlight the need for accessible and effective support. Music wellness, defined as “interacting with music in a way that contributes to holistic health and flourishing,” may help address this gap when integrated into education. In 2024, this research team conducted a Delphi study to establish this definition and propose a four-dimensional music wellness model (catalyst, act, outcome, and skill). The present study builds on that work by evaluating the model’s clarity, relevance, and real-world applicability through a mixed-methods validation study. Semi-structured interviews with five experts assessed conceptual coherence and clarity, and a survey of 160 adults examined whether the model reflected everyday uses of music for well-being. Experts confirmed the model’s logic and utility while suggesting refinements to improve clarity. Survey responses showed high overall agreement (mean = 85.6%) across items representing all four dimensions, and all participants reported daily engagement with music and positive emotional effects. These findings support the model’s validity and applicability, providing an evidence-based foundation for integrating music wellness into curricula that promote lifelong health and flourishing. Full article