Search Results (4,215)

This study examines the operational resilience of Limassol Port, Cyprus’s primary maritime hub, amid disruptions caused mainly by the COVID-19 pandemic. Utilizing high-resolution port-level data from 2018 to 2025, we evaluate performance across five key performance indicators: port calls, anchorage utilization, berth utilization, waiting times, and arrival punctuality. The analysis adopts a longitudinal approach, spanning pre-pandemic, peak-pandemic, post-pandemic, and recent phases, while differentiating impacts across vessel categories. Unlike many regional ports, Limassol’s cruise sector exhibited unique counter-cyclical growth, with calls doubling during the pandemic as the port transitioned into a strategic safe haven and repositioning base. This surge normalized over the 2024–2025 period as temporary operational disruptions resolved. Conversely, container and Ro-Ro (roll-on/roll-off) segments demonstrated robust stability, achieving rapid post-pandemic normalization, while bulk and tanker operations exhibited higher volatility linked to shifting commodity demands. These findings, validated through one-way analysis of variance (ANOVA) and Cohen’s d effect sizes, underscore the adaptive capacity of mid-sized Mediterranean hubs. The study concludes that operational flexibility, coupled with enhanced digital coordination and strategic capacity planning, is essential for maintaining the resilience of short sea shipping networks during global crises. Full article

Background/Objectives: Following the COVID-19 pandemic, pertussis resurged sharply across Europe, with 209,674 cases reported in the EU/EEA in 2024. This study characterises the epidemiology of the 2024 pertussis resurgence across five counties of southeastern Romania, with emphasis on vaccination status, clinical severity, and regional surveillance performance. Methods: A retrospective, population-based analysis was conducted on 452 cases notified between February 2024 and January 2025, extracted from the national surveillance database. A pre-specified reclassification of PCR-positive cases yielded 326 confirmed cases. Categorical, non-parametric, correlation, and multivariate logistic regression analyses were performed. Results: The epidemic peaked in September 2024, with 56.0% of cases occurring between August and October. Children under five years accounted for 63.2% of confirmed cases, and 72.1% were not vaccinated according to age-appropriate schedule, predominantly due to parental refusal (43.0%) and non-attendance (36.6%). Pneumonia affected 36.8% of confirmed cases, ranging from 81.0% in infants under two months to 0% in adolescents. Age-appropriate vaccination was independently protective against pneumonia (adjusted OR = 0.53, 95% CI 0.29 to 0.96, p = 0.035; population attributable risk 37.3%). Significant inter-county heterogeneity was identified in PCR implementation (72 to 100%) and reporting delays. Conclusions: Vaccination gaps were the principal modifiable driver of the resurgence, supporting targeted coverage improvement and the introduction of a national maternal Tdap programme. Full article

Since 2020, recurrent waves of SARS-CoV-2 infection have persisted globally. Despite the advancements in vaccines and pharmacological treatments, a subset of patients still exhibits an aggressive form of COVID-19 requiring prolonged stays in the intensive care unit (ICU) or experiences major acute infections (or reinfections) and long-term symptoms. Endothelial dysfunction is one of the key events contributing to both the severity of acute COVID-19 and the development of long COVID (LC)/post-acute sequelae of SARS-CoV-2 infection (PASC) syndrome. Since the beginning of the pandemic, the efficacy of nutraceuticals, particularly essential micronutrients, has been investigated as a complementary treatment to prevent disease onset and improve clinical outcomes. One such bioactive molecule is folate (vitamin B9), a member of the B-vitamin family involved in the pathogenesis of multiple diseases, including viral infections and vascular disorders. This review examines the role of folic acid in COVID-19 and its interaction with homocysteine metabolism, which is frequently dysregulated in inflammatory endothelial diseases. It further discusses the potential benefits of folic acid supplementation for the prevention and treatment of COVID-19 in both the acute and long-term phases of the disease, alongside the therapeutic role of vitamin B12 supplementation in LC syndrome. Full article

Background/Objectives: Healthcare-associated infections (HAIs) are a major and preventable threat to patient safety, yet reported figures in Central and Eastern Europe are widely affected by under-reporting, which can distort both the apparent infection profile and the perceived burden of disease. Patient-level regional surveillance data were analysed to characterise the reported HAI profile, the determinants of in-hospital mortality, and between-hospital surveillance quality in post-pandemic Southeast Romania. Methods: This was a retrospective, cross-sectional analysis of 2878 HAI cases reported across a five-county, multicentre network of 32 hospitals during 2024. Infections were grouped as Clostridioides difficile infection (CDI) versus non-CDI. Logistic regression was applied for in-hospital mortality, Cox and competing-risks models for time to death, negative binomial regression for length of stay, and a Spiegelhalter funnel plot for between-hospital variation. Results:Clostridioides difficile infection accounted for 56.3% of reported cases, a markedly higher proportion than that described in European point-prevalence surveys, although differences in design and denominator preclude direct comparison. CDIs and non-CDIs formed distinct clinical phenotypes. In-hospital mortality was lower in CDI than in non-CDIs (14.9% versus 26.1%) and was independently associated with intensive care admission, age, and immunosuppression, while CDI remained associated with lower mortality. The reported CDI proportion ranged from approximately 1% to 93% between hospitals, with most institutions lying outside the funnel control limits. Conclusions: The predominance of CDI among reported HAIs is best interpreted as a signal of selective ascertainment rather than as direct evidence of a genuinely higher CDI burden. Because the dataset lacked admission or patient-day denominators, the CDI-to-total ratio should be regarded as a simple screening indicator of potential surveillance imbalance, useful for identifying hospitals where non-CDIs may be under-detected. Full article

Background: Respiratory failure (RF) is a frequently fatal complication of chronic liver disease (CLD), yet population-level data on RF-related mortality trends among adults with CLD are lacking. This study characterized temporal trends and demographic disparities in RF-related mortality among U.S. adults with CLD from 1999 to 2024. Methods: Death certificate data were obtained from the CDC WONDER database for adults aged ≥25 years with both RF (ICD-10: J96) and CLD (ICD-10: K70–K76) listed as an underlying or contributing cause of death. Age-adjusted mortality rates (AAMRs) per 100,000 were calculated using the 2000 U.S. standard population. Joinpoint regression identified temporal inflection points and annual percentage change (APC). Results: Among 241,075 deaths, the overall AAMR increased 3.2-fold from 2.237 (1999) to 7.162 (2021) per 100,000, then declined to 6.132 by 2024. Joinpoint analysis identified four segments: moderate increase (1999–2006; APC +2.40%), accelerated increase (2006–2018; APC +5.37%), late acceleration period (2018–2021; APC +13.10%), and post-pandemic decline (2021–2024; APC −4.32%; all p < 0.001). The 2024 AAMR remained 174.2% above baseline. The male-to-female rate ratio narrowed from 2.02 to 1.50, with females showing steeper acceleration (+14.38% vs. +12.36%). American Indian or Alaska Native individuals had the highest AAMRs and the most dramatic surge (APC +26.90%). Rural areas surpassed urban AAMRs by 2020, with steeper post-2007 acceleration (+8.74% vs. +5.51%). The Western U.S. consistently had the highest regional rates. Younger adults aged 25–34 and 35–44 showed 2.96-fold and 2.37-fold increases in crude mortality rates, respectively. Approximately 80% of deaths occurred in inpatient settings. Conclusions: RF-related mortality among U.S. adults with CLD increased more than threefold from 1999 to 2021, with a dramatic surge followed by incomplete decline. Persistent disparities by sex, race/ethnicity, urbanization, and region highlight the need for targeted interventions, including expanded screening for alcohol-associated and metabolic liver disease and improved access to hepatology services in underserved communities. Full article

The post-COVID-19 tourism recovery exposes a structural divergence between economic resilience and environmental sustainability. Traditional tourism planning metrics consistently fail to diagnose how macroeconomic growth dynamics decouple from environmental pressures, leaving policymakers without empirical tools to identify structural vulnerabilities or prevent carbon-intensive recoupling during post-crisis transitions. This study integrates macroeconomic, environmental, and digital data across a global panel to map actionable pathways for sustainable tourism transitions. Employing a multi-stage methodology, the analysis first utilizes K-Means clustering (n = 80) to isolate the structural fixed effects of baseline destination archetypes driving a K-shaped recovery. Second, using a synchronized environmental panel (n = 41), a Decoupling Index evaluates eco-efficiency elasticity to test the alignment between tourism value recovery and aviation-induced CO₂ emissions. Third, regression analysis of an elite digital cohort (n = 18) measures dynamic exogenous catalysts, revealing that digital attractiveness, proxied by the global digital nomad market share, is a significantly stronger accelerator of recovery (β = 55.59, p = 0.019) than traditional physical air connectivity (β = −46.48, p = 0.036). Synthesizing these insights, a 2 × 2 Strategic Decision Matrix (n = 41) classifies destinations into Sustainable Leaders, Mass-Market Traps, Value Pivoters, and Vulnerable Laggards. The empirical results demonstrate that pre-pandemic structures do not deterministically dictate recovery (p > 0.05, Partial η² ≤ 0.077), yet rapid financial recovery often masks deep atmospheric vulnerabilities, with specific absolute decoupling leaders achieving exceptional value expansion alongside strict carbon contraction (e.g., Saudi Arabia, DE = −0.35; El Salvador, DE = −0.26). This framework provides a data-driven roadmap for policymakers to utilize “soft” digital infrastructure to transition from carbon-intensive, volume-dependent models toward value-optimized, low-emission ecosystems. Full article

Background/Objectives: The acute complications of COVID-19 have been well characterized and are frequently associated with increased mortality. Although substantial knowledge regarding long COVID has accumulated since the beginning of the pandemic, important uncertainties remain regarding the long-term clinical, functional, radiological, and metabolic consequences of SARS-CoV-2 infection. Identification of post-COVID-19 complications is therefore essential for appropriate recognition and management. This study aimed to evaluate the long-term complications of COVID-19 at 3 and 9 months after infection. Methods: This prospective study was conducted at Inonu University Turgut Ozal Medical Center. Patients who presented with active post-COVID-19 complaints or for routine follow-up were enrolled. Participants were evaluated at the pulmonology outpatient clinic at 3 and 9 months. At each visit, persistent or new-onset symptoms were assessed, and pulmonary function tests (PFT), the six-minute walk test (6MWT), echocardiography (ECHO), and thoracic computed tomography (CT) were performed as clinically indicated. Patients were stratified into three groups according to the severity of acute illness: outpatient, ward-hospitalized, and ICU-hospitalized. Results: A total of 205 patients (120 male, 85 female) were included. Male patients had significantly higher rates of ward and ICU hospitalization than female patients (p = 0.006). At 9 months, 85.3% of patients had at least one persistent symptom; dyspnea (69.6%), cough (35.6%), and chest pain (32.5%) were the most common. FVC showed a statistically significant increase between months 3 and 9 (p = 0.014), and the 6MWT distance improved significantly (423.56 m vs. 464.10 m; p = 0.008). Ground-glass opacity, present in 90.2% of patients at admission, persisted in 44.3% at 9 months (p < 0.001). Reticular opacities, pleuroparenchymal bands, and mosaic perfusion patterns increased over time. ICU patients had significantly lower ejection fraction values compared with ward and outpatient groups at 9 months (p = 0.046). During follow-up, 13 patients developed pulmonary embolism and 7 developed new-onset diabetes mellitus. Conclusions: Despite the well-characterized acute phase, the long-term sequelae of COVID-19 remain a significant clinical challenge. Identification of late complications is critical for reducing morbidity and understanding the long-term societal and healthcare burden of the pandemic. Multidisciplinary long-term follow-up is warranted, particularly for patients who experienced severe acute illness. Full article

Background: European health systems face growing pressure from population ageing, post-pandemic service backlogs, and fiscal constraints. Yet substantial cross-country differences in health outcomes persist despite comparable levels of healthcare expenditure. This study evaluated the relative efficiency of European health systems using a multidimensional framework that integrates expenditure, prevention, and population health outcomes. Methods: A cross-sectional analysis was conducted on 25 European countries using 2022 data or the nearest available year. An output-oriented constant returns to scale Data Envelopment Analysis (DEA) model was estimated with two inputs, public and private healthcare expenditure per capita, and five outputs, life expectancy at birth, inverse infant mortality, healthy life years at birth, breast cancer screening coverage, and poliomyelitis vaccination coverage. A robustness specification added physician density as an additional input. Bootstrap bias correction with 1000 replications was applied to the baseline model. A second-stage Simar–Wilson truncated regression with 2000 bootstrap replications examined the association between inefficiency and selected contextual variables, including GDP per capita, population ageing, obesity prevalence, and tobacco use prevalence. Results: In the baseline DEA model, 8 of 25 countries were located on the technical efficiency frontier (Croatia, Czechia, Estonia, Greece, Hungary, Latvia, Lithuania, and Poland; output-oriented DEA inefficiency score = 1.000 for each country), while inefficiency scores among the remaining countries ranged from 1.042 to 2.617. The highest inefficiency scores were observed for Germany (2.617), Austria (2.283), Belgium (2.230), Ireland (2.219), and France (2.167). When physician density was added as an additional input, 12 countries were located on the estimated frontier. Bootstrap correction of the baseline model increased the estimated output-oriented inefficiency scores, with bias-corrected values ranging from 1.100 to 2.941. In the second-stage analysis, higher log GDP per capita was positively associated with bias-corrected inefficiency (coefficient 1.993; 95% bootstrap CI 0.219 to 4.197), whereas population ageing, adult obesity prevalence, and tobacco use prevalence were not statistically associated with bias-corrected inefficiency. Conclusions: In this cross-sectional sample of 25 European countries, higher healthcare expenditure was not consistently associated with frontier performance when health outcomes and preventive coverage were considered jointly. The results were sensitive to the inclusion of physician density and to bootstrap correction, supporting the interpretation of Data Envelopment Analysis as an exploratory benchmarking tool rather than a definitive ranking of health systems. These findings highlight the importance of assessing how financial and workforce resources are converted into measurable health and prevention-related outputs. Full article

While conventional theories posit that stronger institutions buffer economies against crises, the COVID-19 pandemic presents a puzzle: despite substantial variation in institutional capacity, the global economic contraction of 2020 was both severe and widespread. Motivated by this puzzle, we constructed a global panel dataset from 2014 to 2024 and employed two-way fixed-effect estimation with Driscoll–Kraay robust standard errors to examine the differential role of state capacity across COVID-19 crisis phases. The results confirm that the shock caused by the pandemic reduced GDP per capita growth across countries, with the Americas experiencing disproportionately deeper contractions and stronger rebounds relative to other regions. Most importantly, the findings reveal a temporal asymmetry in institutional effectiveness: our constructed composite resource-based measure of state capacity does not mitigate the initial economic contraction but exerts a positive, statistically significant effect on post-pandemic recovery. Unsurprisingly, model re-estimation with the conventional perception-based measure of state capacity fails to replicate this dynamic, underscoring the importance of measurement strategy in institutional research. These results challenge the assumption that institutions uniformly buffer shocks, demonstrating instead that state capacity is more consequential for recovery than crisis prevention. Full article

Six years into the COVID-19 pandemic, evidence is increasingly clear that long COVID affects women disproportionately, with higher rates of persistent cognitive and neurological symptoms. Yet, the biological mechanisms underlying this sex-dimorphic impact remain elusive. We investigated whether the immune storm of acute COVID-19 leaves a silent yet sex-specific scar on white matter integrity that shapes long-term cognitive health. In 60 previously hospitalized COVID-19 survivors, we combined an inflammatory snapshot at admission proxied by the systemic immune-inflammation index (SII) with 3T diffusion MRI and a comprehensive cognitive battery (BACS) acquired three months after recovery. Sex reshaped the inflammation–brain relationship: a higher SII predicted a diffuse alteration pattern within core associative and inter-hemispheric fibres in females only, sparing the male architecture despite a comparable inflammatory burden. In women, white matter damage coupled with poorer psychomotor coordination, and mean diffusivity fully mediated the link, unveiling a female-specific pathway from systemic inflammation to cognitive slowdown. COVID-19 inflammation imprints a durable, sex-sensitive footprint on white matter that selectively undermines psychomotor coordination in female survivors, despite a clinical recovery. This work positions women’s white matter as a critical target of post-COVID neuroinflammation and argues for sex-informed monitoring and interventions that explicitly tackle immune–brain crosstalk in long COVID. Full article

The pandemic resulted in a proliferation of job-related and family stressors for many working mothers. The purpose of the current study is to explore working mothers’ career aspirations and priorities in the aftermath of the COVID-19 pandemic. The current sample consisted of 168 working mothers in the United States who responded to open-ended questions developed to understand how they perceived that the COVID-19 pandemic affected their career progression, career aspirations, and priorities. Thematic analysis of these open-ended questions revealed a change in career aspirations for many working mothers as a result of the COVID-19 pandemic. Additionally, thematic analysis also indicated that some working mothers shifted their priorities away from their career trajectory and towards family, health, and stability. Three subthemes emerged from working mothers’ descriptions of placing greater priority on family following the pandemic: shifting priorities away from work concerns to family needs, increased focus on time spent with family, and recognition that family should not be taken for granted. The findings of the present study attempt to gain a more nuanced understanding of the pandemic’s effect on working mothers’ attitudes towards their career trajectories, priorities, and families in a post-pandemic worker landscape. Full article

Background: The COVID-19 pandemic was accompanied by an infodemic that promoted the use of so-called “miracle products” lacking scientific evidence, posing significant public health risks. Despite increasing concern, evidence on effective educational strategies to counteract this misinformation remains limited, particularly in Latin America. Methods: A quasi-experimental pre–post study without a control group was conducted among university students in Mexico City between February and June 2021. Participants were recruited via Facebook using a snowball sampling approach. A validated nine-item questionnaire assessed knowledge about miracle products before and after exposure to an educational video intervention. Paired statistical analyses were performed to evaluate changes in knowledge. Results: A total of 157 participants completed the pre-test, and 103 completed the post-test. The intervention resulted in a significant increase in knowledge scores, from a mean of 5.98 (SD = 1.73) to 9.05 (SD = 1.54) (p < 0.001). Significant improvements were observed in eight of nine items, with the largest increases in knowledge related to high-risk substances and reporting mechanisms. No significant baseline differences were found between participants who completed and those who did not complete the post-test. Conclusions: The video-based educational intervention was effective in improving knowledge about miracle products during COVID-19. These findings support the use of digital health education strategies as scalable tools to combat misinformation, particularly in resource-constrained settings. However, further research using controlled designs is needed to assess long-term effects and behavioral outcomes. Full article

Background: Healthcare institutions increasingly face sustainability challenges associated with environmental governance, operational efficiency, digital transformation, and social responsibility in the post-pandemic era. However, limited studies have comprehensively examined the organizational factors influencing ESG implementation and healthcare social sustainability practices among hospitals. Objective: This study aimed to investigate the organizational determinants of ESG implementation and healthcare social sustainability practices among Taiwanese hospitals and to explore how healthcare professionals and hospital administrators perceive sustainability implementation within post-pandemic healthcare environments. Methods: A convergent mixed methods design integrating quantitative surveys and qualitative interviews was employed. Exploratory factor analysis (EFA), correlation analysis, and multiple regression analysis were performed, and qualitative data were analyzed using thematic analysis. Results: A total of 135 valid questionnaires were analyzed, and qualitative data were obtained from three semi-structured interviews. ESG sustainability support demonstrated the strongest positive influence on healthcare social sustainability practices (β = 0.481, p < 0.001), followed by operational sustainability (β = 0.276, p < 0.01) and sustainability management capability (β = 0.214, p < 0.05). Organizational resource pressure did not significantly influence healthcare social sustainability practices. The qualitative findings converged with and expanded upon the quantitative results by highlighting the importance of leadership support, digital healthcare transformation, operational coordination, and community health promotion in facilitating ESG implementation and long-term healthcare sustainability. Conclusions: The integrated findings suggest that healthcare ESG implementation increasingly functions as a comprehensive sustainability governance strategy involving operational sustainability, digital healthcare transformation, healthcare accessibility, and social responsibility practices within post-pandemic healthcare environments. Strengthening sustainability support systems, governance capability, and operational resilience may facilitate long-term healthcare social sustainability implementation. Full article

Background. Hispanic populations in the United States experienced disproportionate health and economic impacts during the COVID-19 pandemic. This study assessed relationships between social determinants of health (SDOH) and COVID-19-related health and economic outcomes among Hispanic and non-Hispanic participants in the All of Us Research Program. Methods. Descriptive analyses and logistic regression models explored associations between all variables. Iterative proportional fitting (raking) was used to align survey samples with known population margins. Results. Hispanics reported worse outcomes across all COVID-19-related variables: lower vaccination rates and higher rates of COVID-19 symptoms and experiencing hardships due to COVID-19. Final post-raking models found Hispanics had greater odds of experiencing hardships (OR = 1.81, 95% CI = 1.55, 2.11) especially among those reporting COVID-19 symptoms (OR = 2.45, 95% CI = 1.51, 3.97). The final model identified increased rates of COVID-19 vaccination among Hispanics when controlling for gender, age, and SDOH (OR = 1.22, CI = 1.09, 1.37) than have been reported nationally during the examined time period for Hispanics. Conclusions. Uptake of COVID-19 vaccination and disproportionate negative health, economic, and social impacts of COVID-19 experienced by Hispanic communities were driven by SDOH. Findings underscore the need for targeted efforts to address SDOH to achieve the best health outcomes for all. Full article

Global value chains (GVCs) are undergoing significant reconfiguration in a context of slower trade growth, rising geopolitical tensions and repeated supply chain disruptions. This article examines how these pressures have shaped the sourcing geography of Spanish apparel imports between 1999 and 2023. Drawing on a panel of the 25 main supplier countries (625 country-year observations), it analyses the changing structure of sourcing through three restructuring dynamics widely discussed in the recent literature: nearshoring, diversification and friendshoring. The results show that diversification, rather than regionalization, has been the main response to recent disruptions. While Spain’s apparel sourcing has become less concentrated, this shift has not led to a sustained shortening of supply chains or to a clear reduction in dependence on Asia. Geopolitical alignment has limited explanatory power at the aggregate level, although it becomes more relevant among semi-proximity suppliers competing on the basis of speed, flexibility and political reliability. Overall, the findings suggest that post-pandemic restructuring in Spanish apparel is better understood as a selective form of risk management within an existing buyer-driven GVC than as a broad move toward nearshoring. Full article