Search Results (35,835)

Background: Gastrointestinal (GI) cancers remain a major global health concern, where timely and accurate interpretation of endoscopic findings plays a decisive role in patient outcomes. In recent years, deep learning–based decision support systems have shown considerable potential in assisting GI diagnosis; however, their broader adoption is often limited by patient privacy regulations, uneven data availability, and the fragmented nature of clinical data across institutions. Federated learning (FL) offers a practical solution by enabling collaborative model training while keeping patient data local to each hospital. Methods: Vision Transformers (ViTs) are particularly well suited for endoscopic image analysis due to their ability to capture long-range contextual information. Nevertheless, their high computational and communication costs pose a significant challenge in federated settings, especially when data distributions vary across clients. To address this issue, we propose a privacy-preserving federated framework that combines ViTs with a Clinical-Entropy Guided Quantum Evolutionary Algorithm (CEQEA) for adaptive token pruning. The CEQEA leverages the diagnostic diversity of each client’s local dataset to guide population initialization, evolutionary updates, and mutation strength, allowing the pruning strategy to adapt naturally to different clinical profiles. Results: The proposed framework was evaluated on curated upper- and lower-GI tract subsets of the HyperKVASIR dataset under realistic non-IID federated conditions. On the final test sets, the model achieved a mean micro-averaged accuracy of 92.33% for lower-GI classification and 90.19% for upper-GI classification, while maintaining high specificity across all diagnostic classes. At the same time, the adaptive pruning strategy reduced the number of tokens processed by approximately 40% and decreased the number of required federated communication rounds by 33% compared to ViT-based federated baselines. Conclusions: Overall, these results indicate that entropy-aware, quantum-inspired evolutionary optimization can effectively balance diagnostic performance and efficiency, making transformer-based models more practical for privacy-preserving, multi-institutional gastrointestinal endoscopy. Full article

The rapid digitalization of cities is reshaping urban planning practices; however, significant gaps persist between technological investments and institutional governance capacity, particularly in transition economies. This study investigates how digital tools can be systematically embedded within planning processes to improve decision-making quality, coordination, and administrative efficiency. Drawing on urban governance theory and an empirical implementation study conducted in Yerevan, Armenia (population 1.1 million) between 2019 and 2023, the paper develops and operationalizes a multi-layer governance framework that aligns digital instruments—including geospatial information systems, performance dashboards, and decision-support platforms—with strategic, tactical, and operational levels of city management. The framework is evaluated through institutional analysis of municipal policy documents, planning databases, and semi-structured interviews with planning officials. The results reveal substantial governance barriers, including data fragmentation, organizational silos, and limited digital capacity. Framework-based implementation produced measurable improvements: planning decision cycles shortened by 43%, GIS utilization increased from 18% to 68% of eligible projects, inter-agency data sharing rose sixfold, and annual cost savings of approximately $1.2 million were achieved through reduced duplication and faster approvals. By combining conceptual design with empirical validation, the study advances digital urban governance research and offers a transferable, evidence-based model for implementing resilient and efficient data-driven planning systems in resource-constrained contexts. Full article

Objective: The aim of this case series was to investigate the safety and efficacy of vancomycin–gentamicin embedded PMMA beads (VGPB) in the setting of acute pyogenic soft tissue infections (STIs) of the extremities. Materials and Methods: A retrospective study of 19 cases diagnosed with pyogenic STIs of the lower or upper extremity in two academic institutions was conducted between January 2017 and December 2023. All patients underwent surgical debridement, systemic antibiotics and intrawound deposition of vancomycin and gentamicin embedded cement beads (2 g of vancomycin plus 1 g of gentamicin diluted in 40 g of PMMA). Upon second look (4th–7th day post-index surgery) the cement beads were removed, serum samples from the surgical site of infection and from peripheral blood were obtained and the concentration of eluted vancomycin and gentamicin was measured. Furthermore, the white blood cell count (WBC), C reactive protein serum levels (CRP) and erythrocyte sedimentation rate (ESR) were measured before the surgical debridement and after the end of the bead therapy. All patients were reevaluated after discharge with a mean follow-up of 4.4 years (range, 1 to 7.6). Results: Wound vancomycin and gentamicin levels were significantly higher than those measured in the serum (34.01 ± 4.47 μg/mL versus 11.96 ± 2.79 μg/mL, p < 0.001 and 5.75 ± 1.22 μg/mL versus 0.51 ± 0.14 μg/mL, p < 0.001 respectively). Serum vancomycin and gentamicin concentrations were below the level of toxicity and no adverse events related to antibiotic-embedded bead treatment were documented. Serum WBC, ESR and CRP levels before debridement (13,446 ± 935.7 c/μL, 42.3 ± 18.7 mm/h and 113.9 ± 20.26 mg/L respectively) were significantly higher than those after the end of treatment (7889 ± 1203.6 c/μL, p < 0.001; 30.3 ± 9.14 mm/h, p = 0.017; and 22.7 ± 6.68 mg/L, p < 0.001 respectively). Two cases (10.5%) had a local recurrence of their STIs. Both of them relapsed within 4 months after their treatment and both had Gram-negative pathogens. Conclusions: Vancomycin–gentamicin PMMA bead pouch therapy appears to be a safe and effective adjuvant treatment for pyogenic soft tissue infections, offering high local antibiotic availability without systemic adverse effects. Full article

Background: Public satisfaction with public transport infrastructure is a factor in the social legitimacy of infrastructure investment policies. Methods: This study analyzes the determinants of citizen satisfaction with toll roads in Mexico using a hierarchical regression model applied to a nationally representative survey. Results: Satisfaction does not depend primarily on sociodemographic factors, but rather on users’ overall perception of the quality, safety, and management of the road system as a whole. Furthermore, the pattern of predictors varies according to usage experience, suggesting that satisfaction is influenced by different factors among users and non-users of these facilities. These findings support a contextual evaluation model, in which citizen assessments are based more on systemic interpretations than on isolated experiences. Conclusions: The study has direct implications for public policy design and infrastructure management in contexts where the use of toll roads responds to structural constraints rather than voluntary decisions. Although the study focuses on the Mexican case, its contributions offer useful interpretative insights for other countries with similar challenges in terms of mobility and institutional legitimacy. Full article

Background: Extrinsic compression of the left atrium (LA) is a rare and underrecognized condition that may result in significant hemodynamic compromise and atrial arrhythmias. The available evidence has been largely limited to isolated case reports and small case series, and clinical awareness has remained low. Methods: We performed a structured review of published case reports and case series indexed in PubMed between 2016 and 2026 describing extracardiac LA compression. A predefined and reproducible literature search strategy with explicit eligibility criteria was applied. The structured review included 22 publications reporting 23 individual cases of LA compression; in addition, two institutional cases with distinct etiologies were presented separately. Demographic characteristics, presenting symptoms, diagnostic modalities, complications, management strategies, and outcomes were synthesized descriptively. Results: The structured review identified gastroesophageal disorders, particularly hiatal hernia, as the most frequent etiology, followed by vascular, mediastinal, malignant, and musculoskeletal causes. Dyspnea was the most common presenting symptom, while hemodynamic compromise, pulmonary edema, and atrial arrhythmia represented the most frequent complications. Transthoracic echocardiography was the initial diagnostic modality in all reported cases, with computed tomography required for definitive etiological diagnosis. The two institutional cases illustrated both a common cause, hiatal hernia mimicking intracardiac mass, and a rare, aggressive malignant cause with extensive mediastinal involvement. Conclusions: Extrinsic LA compression arises from diverse extracardiac pathologies and may be clinically severe. Transthoracic echocardiography can serve as a pivotal first-line tool for early recognition and differentiation from intracardiac masses, while cross-sectional imaging is essential for etiological clarification. By integrating institutional experience with a structured synthesis of published cases, this review can provide practical insights to support timely diagnosis and management of this potentially life-threatening condition. Full article

The China–Pakistan Economic Corridor (CPEC) represents a transformative transport infrastructure initiative with the potential to reshape tourism in South Asia. However, the behavioral mechanisms through which corridor development translate into travel willingness remain insufficiently understood, particularly between domestic and cross-border tourism. This study investigated the determinants of domestic tourism willingness within Pakistan and cross-border tourism willingness toward China using a stated preference survey of 441 Pakistani respondents collected through an online questionnaire. To balance behavioral interpretation and predictive performance, this study integrated ordinal logistic regression (OLR) with multiple machine learning classifiers. The results revealed clear behavioral asymmetries between domestic and cross-border tourism decisions. Domestic tourism willingness was primarily driven by attitudinal evaluations, particularly perceived desirability, pleasantness, and comfort of travel along the CPEC. In contrast, cross-border tourism willingness was more strongly constrained by knowledge-related and institutional factors, including awareness of visa procedures, accommodation arrangements, and destination information. Comparative performance analysis indicated that machine learning models outperformed ordinal logistic regression, improving predictive accuracy by approximately 12.6 percentage points for domestic tourism (93.6% vs. 81.0%) and 1.7 percentage points for cross-border tourism (81.1% vs. 79.4%). These findings demonstrate that corridor-induced tourism demand is governed by distinct behavioral mechanisms across domestic and international contexts, highlighting the need for differentiated tourism development strategies. From a policy perspective, the results suggest that domestic tourism development along the CPEC should prioritize experiential quality and travel comfort, whereas cross-border tourism promotion should focus on reducing informational and procedural barriers such as visa knowledge, accommodation awareness, and travel facilitation. Full article

The unit costs of power generation of onshore wind and photovoltaics in China have dropped rapidly and significantly since 2010. Recent studies have indicated that the learning effect on cost reduction could have been overestimated due to the exclusion of the equipment-level installed capacity and the price of capital. To address this estimation bias, we constructed a research framework comprising a one-factor analysis model (OFAM), a two-factor analysis model (OFAM), and a multi-factor analysis model (MFAM) based on the Cobb–Douglas function and the cost minimization problem. This framework examines the determinants of unit costs in renewable energy generation in consideration of learning effects, scale effects, and price effects. This paper uses data from institutions such as IRENA and the World Bank to empirically analyze the contributions of these factors to reductions in the cost of onshore wind and photovoltaic power generation in China from 2010 to 2022. The results indicate that the learning-by-doing (LBD) effect has been overestimated, with scale effects accounting for a significant portion of the cost reduction. Moreover, the price of capital exerts a more pronounced influence on the levelized cost of electricity (LCOE) for photovoltaics. After factoring in equipment scale and capital costs, LBD continues to significantly reduce the LCOE of photovoltaics, with the LBD learning rate declining from 23.85% to 6.30%. Meanwhile, the impact of LBD on the LCOE of onshore wind technology ceases to be significant. Both technologies exhibit economies of scale, with scale effects accounting for 41.60% and 34.12% of the LCOE reductions for onshore wind and photovoltaics, respectively. Capital costs accounted for 32.50% of the LCOE reduction for photovoltaics. Therefore, future large-scale deployments of other costly renewable energy technologies may also benefit from the equipment-level scale and favorable bank interest rates in addition to learning-by-doing. Full article

Background/Objectives: Gabapentinoids are first-line treatments for neuropathic pain (NP); however, real-world evidence regarding their safety and effectiveness in complex clinical populations remains limited. This study aimed to evaluate the effectiveness and safety profile of gabapentinoid therapy in patients managed within a specialized pain relief institution. Methods: A retrospective cohort study (n = 109) was conducted (January 2024 to December 2024). Effectiveness was assessed via DN4 and VAS over one year. Time to improvement was analyzed using Kaplan–Meier curves. Results: The cohort (mean age 66.2 ± 15.3 years) presented 100% comorbidity and polypharmacy (66.1% opioids; 67.9% antidepressants). Although all patients showed improvement, only 35.8% achieved “maximal improvement.” Pregabalin demonstrated faster VAS reduction than gabapentin (p = 0.029), though long-term success was comparable (p = 0.30). Significantly, 100% of patients reported at least one adverse drug event (ADE), primarily somnolence (66.1%), though no serious ADEs occurred. Lower baseline pain scores were significant predictors of therapeutic success. Conclusions: Gabapentinoids are effective for long-term NP management; however, their use is consistently associated with non-serious ADEs. In specialized settings characterized by extensive CNS-active polypharmacy, proactive pharmacovigilance and multidisciplinary oversight are essential to balance analgesic effectiveness with medication safety. Full article

Understanding the role of trust in shaping pro-ecological behaviour is essential for advancing effective environmental communication, particularly in societies characterized by low institutional credibility. This study examines how different forms of trust—scientific, institutional, mediatic, and interpersonal—predict pro-ecological behaviour in Bulgaria, a context marked by historically low levels of social and institutional trust. Drawing on a nationally representative survey of 1008 adults, participants rated their trust in six sources of environmental information (experts, public servants, politicians, media, social networks, and friends or relatives) and reported their engagement in various ecological practices. Multiple regression analysis revealed that trust in experts was the strongest positive predictor of pro-ecological behaviour, followed by trust in friends and relatives. Trust in political institutions, media, and online social networks showed no significant associations. These findings suggest that in low-trust societies, interpersonal trust and trust in experts serve as primary drivers of ecological engagement, while institutional trust alone is insufficient to mobilize collective environmental action. The study underscores the importance of fostering both scientific credibility and community-based communication to enhance public participation in sustainability initiatives. Full article

Background/Objectives: Spontaneous spinal subdural hematoma (SSSDH) is a rare and severe condition that causes rapid neurological decline. Spontaneous spinal epidural hematoma (SSEH) presents similarly but is more common, and surgical management differs because SSSDH requires an intradural approach. Few studies have assessed the reliability of magnetic resonance imaging (MRI) features used to distinguish SSSDH from SSEH in patients requiring surgery. Methods: We retrospectively reviewed 27 patients who underwent surgical evacuation of spinal hematomas at two institutions (2015–2025). Definitive hematoma location was determined intraoperatively. Four MRI features—shape (crescentic vs. biconvex), location (ventral vs. dorsal), craniocaudal length (<5 vs. ≥5 segments), and spinal region—were independently evaluated by two reviewers. Inter- and intra-rater reliability was assessed using agreement rate and Cohen’s kappa (κ) with 95% confidence intervals (95% CIs). Results: Among 27 cases, three (11.1%) were SSSDH and 24 were SSEH. Hematoma location, length, and spinal region demonstrated perfect inter- and intra-rater agreement (κ = 1.00). For hematoma shape, intra-rater agreement was good (96.2%, κ = 0.84; 95% CI 0.52–1.00), whereas inter-rater agreement was poor to fair (84.6%, κ = 0.26; 95% CI −0.25–0.77). Notably, two of the three SSSDHs demonstrated a biconvex configuration, and 83.3% of SSEHs also exhibited a biconvex morphology. Conclusions: MRI features such as hematoma location, extent, and spinal level were highly reproducible, whereas hematoma shape showed limited reliability. Although ventral hematomas most strongly suggest SSSDH, atypical SSEH presentations occur. When dorsal exposure reveals no epidural hematoma, intradural exploration should be promptly considered. Full article

While environmental awareness is crucial for ecological governance, its sociocultural foundations across different macro-institutional contexts remain underexplored. This study compares the sociocultural correlates of environmental awareness in China and Singapore—two developmental states with state-centric governance but distinct institutional configurations. Integrating Sociocultural Theory and the Theory of Planned Behavior, this exploratory study analyzes World Values Survey data Wave 7 using ordered logistic and probit models. We identify three key patterns. First, both nations exhibit a pervasive “attitude-behavior gap,” with cognitive environmentalism significantly outpacing actual civic action. Second, universally, social trust is correlated with environmental attitudes, while political action and religiosity are positively linked to actual behavior. Third, distinct institutional mechanisms emerge: China reflects a “state-dependent environmentalism” where attitudes are associated with post-materialist values and institutional deterrence, and behavioral participation is strongly related to government trust. Conversely, Singapore displays an “institutionalized civic environmentalism,” where routine political action shows a strong positive association with environmental attitudes—an association neutralized in China. These findings demonstrate that pathways to ecological sustainability in developmental states are structurally divergent, necessitating context-specific governance interventions. Full article

Background and Objectives: This study aimed to evaluate the safety and feasibility of reduced-port laparoscopic distal gastrectomy (RPLDG) in elderly patients. Materials and Methods: Electronic medical records of 226 patients who underwent RPLDG performed by a single high-volume surgeon at a single institution (Chonnam National University Hospital) between January 2015 and April 2020 were retrospectively analyzed. Among these patients, 60 were aged ≥ 75 years (elderly group), and 166 were younger than 75 years (non-elderly group). Patient characteristics, surgical outcomes, and short-term postoperative outcomes were compared between the two groups. Results: Surgical outcomes were comparable between the age groups. However, medical complication events, assessed using an event-based approach allowing multiple events per patient, were more frequent in patients aged ≥ 75 years. Compared with the non-elderly group, the elderly group demonstrated a higher frequency of overall postoperative complication events (18 [30%] vs. 29 [18%], p = 0.040), primarily attributable to medical complications (9 [15%] vs. 6 [4%], p < 0.01). The elderly group also showed a delayed time to first gas passage (3.5 [3.0–4.0] vs. 3.0 [3.0–3.0] days, p < 0.001). However, no statistically significant differences were observed in length of hospital stay (7.0 [6.0–10.0] vs. 6.0 [6.0–8.0] days, p = 0.262) or intraoperative blood loss (p = 0.831). No significant differences were found in surgical complication events (p = 0.05) or Clavien–Dindo grade ≥ 3 complication events (p = 0.13). In the risk factor analysis for complications, univariate analysis identified age ≥ 75 years as a significant factor. However, in the multivariate analysis, only respiratory comorbidities, liver disease, and poor ECOG performance status remained independent risk factors, whereas age ≥ 75 years was no longer statistically significant (p = 0.193). The finding regarding liver disease should be interpreted with caution because of the extremely small sample size. Conclusions: RPLDG appears to be a viable surgical option for patients aged ≥ 75 years, demonstrating acceptable surgical outcomes and severe complication rates comparable to those observed in non-elderly patients. Full article

Background: Direct oral anticoagulants (DOACs) have transformed antithrombotic therapy but carry significant bleeding risks requiring prompt reversal. Recent regulatory changes have altered the reversal landscape, notably with the withdrawal of andexanet alfa from the U.S. market. Anticoagulation stewardship programs (ASPs) are essential for navigating this evolving environment and optimizing safe use of anticoagulants. Methods: This narrative review synthesizes evidence from landmark clinical trials (RE-VERSE AD, ANNEXA-4, ANNEXA-I), contemporary guidelines, emerging literature on reversal agents, and critical regulatory updates including the 2025 U.S Food and Drug Administration (FDA) withdrawal of andexanet alfa. Results: Idarucizumab remains the only FDA-approved specific antidote for dabigatran. Following the withdrawal of andexanet alfa, prothrombin complex concentrates (PCCs), both 4-factor and activated are now the primary reversal options for Factor Xa inhibitors, with recent evidence demonstrating comparable hemostatic efficacy. Ciraparantag, a universal reversal agent, is currently in Phase III development. Effective ASPs must now adapt protocols to the post-andexanet era while ensuring timely access to alternative reversal strategies. Conclusions: The reversal landscape has undergone a fundamental transformation with the loss of andexanet alfa. Success in DOAC-associated bleeding management now depends on optimizing PCC-based strategies, integrating systematic stewardship approaches, and preparing for emerging universal antidotes. Institutions must urgently update algorithms, ensure PCC availability, and monitor outcomes in this new therapeutic environment. Full article

Background: Adrenocortical carcinoma (ACC) is a rare and aggressive endocrine malignancy, for which population-level evidence regarding prognostic factors and survival conditions is limited. The available data mostly represent single-institution series, limiting their applicability. This study, therefore, assesses clinicopathological features and determines independent predictive variables of overall survival (OS) in patients with ACC using a population-based cohort. Methods: This retrospective observational cohort study used data from the Surveillance, Epidemiology, and End Results (SEER) Program between 2000 and 2022, initially identifying 1176 patients with ACC. Adult patients (≥18 years) with histologically confirmed ACC were identified using ICD-O-3 histology code 8370/3 and primary site code C74.0. Cases with zero-month survival, missing survival data, or identified only through autopsy or death certificate were excluded. To ensure dataset harmonization, patients with missing or indeterminate tumor grade and unknown stage were also excluded. After applying these inclusion and exclusion criteria, the final analytic cohort consisted of 267 patients. Data on demographic factors, stage of the disease, and treatment (surgery, chemotherapy, radiotherapy) were extracted. OS was evaluated using the Kaplan–Meier method, and independent prognostic factors were identified using Cox proportional hazards regression analysis. Results: The median OS was 54 months [95% confidence intervals (CI): 36–85]. The estimated 1-, 3-, and 5-year OS rates were 77%, 57%, and 48%, respectively. Survival differed significantly according to tumor grade, stage, and surgical treatment. In multivariable Cox regression analysis, increasing age [Hazard ratio (HR): 1.03, 95% CI: 1.02–1.04; p < 0.001], high tumor grade (HR: 2.21, 95% CI: 1.43–3.41; p < 0.001), and distant-stage disease (HR: 3.24, 95% CI: 1.95–5.38; p < 0.001) were independently associated with an increased risk of mortality, whereas surgical treatment was associated with improved survival (HR 0.53, 95% CI 0.30–0.93; p = 0.028). Chemotherapy and radiotherapy were not significantly associated with mortality. Conclusion: In this SEER-based cohort of patients with adrenocortical carcinoma, older age, high tumor grade, and distant-stage disease were independently associated with worse OS, whereas documented receipt of surgery was associated with longer OS. Treatment-related associations should be interpreted cautiously in view of the inherent limitations of registry-based data. Further prospective multicenter studies are needed to confirm these findings. Full article

This paper examines the political dimension of architecture in developing and post-conflict economies by shifting the focus from representational aesthetics to the organisation of production. Drawing on critical theory and political economy, it contends that architecture is political not through explicit ideology but through its impact on relationships among labour, knowledge, material systems, and institutional authority. The paper challenges the historic divide between thinker and maker, rooted in Alberti’s ideas, and examines how frameworks such as critical regionalism often aestheticise marginality while overlooking construction labour and political economy. Empirically, the study analyses six architectural projects in post-war Sri Lanka from 2013 to 2023, employing a qualitative, practice-based case study approach. These projects are viewed as social processes, emphasising labour organisation, knowledge exchange, material choices, procurement, and tectonics. The results show how small architectural interventions can serve as civic and pedagogical infrastructures, revealing labour, redistributing expertise, and strategically engaging with state and donor systems. A normative framework is proposed to redirect architectural politics towards production rather than mere representation. Full article