Search Results (6,972)

Background: The U.S. Medicare Annual Wellness Visit (AWV) offers a structured opportunity for cognitive screening and personalized prevention planning among older adults. Yet, implementation of AWVs, particularly for individuals with cognitive impairment, remains inconsistent across primary care or other diverse care settings. Methods: We conducted a scoping review using the Consolidated Framework for Implementation Research (CFIR) to explore multilevel factors influencing the implementation of the Medicare AWV’s cognitive screening component, with a focus on how these processes support the detection and management of cognitive impairment among older adults. We searched four databases and screened peer-reviewed studies published between 2011 and March 2025. Searches were conducted in Ovid MEDLINE, PubMed, EBSCOhost, and CINAHL databases. The initial search was completed on 3 January 2024 and updated monthly through 30 March 2025. All retrieved citations were imported into EndNote 21, where duplicates were removed. We screened titles and abstracts for relevance using the predefined inclusion criteria. Full-text articles were then reviewed and scored as either relevant (1) or not relevant (0). Discrepancies were resolved through consensus discussions. To assess the methodological quality of the included studies, we used the Joanna Briggs Institute critical appraisal tools appropriate to each study design. These tools evaluate rigor, trustworthiness, relevance, and risk of bias. We extracted the following data from each included study: Author(s), year, title, and journal; Study type and design; Data collection methods and setting; Sample size and population characteristics; Outcome measures; Intervention details (AWV delivery context); and Reported facilitators, barriers, and outcomes related to AWV implementation. The first two authors independently coded and synthesized all relevant data using a table created in Microsoft Excel. The CFIR guided our data analysis, thematizing our findings into facilitators and barriers across its five domains, viz: (1) Intervention Characteristics, (2) Outer Setting, (3) Inner Setting, (4) Characteristics of Individuals, and (5) Implementation Process. Results: Among 19 included studies, most used quantitative designs and secondary data. Our CFIR-based synthesis revealed that AWV implementation is shaped by interdependent factors across five domains. Key facilitators included AWV adaptability, Electronic Health Record (EHR) integration, team-based workflows, policy alignment (e.g., Accountable Care Organization participation), and provider confidence. Barriers included vague Centers for Medicare and Medicaid Services (CMS) guidance, limited reimbursement, staffing shortages, workflow misalignment, and provider discomfort with cognitive screening. Implementation strategies were often poorly defined or inconsistently applied. Conclusions: Effective AWV delivery for older adults with cognitive impairment requires more than sound policy and intervention design; it demands organizational readiness, structured implementation, and engaged providers. Tailored training, leadership support, and integrated infrastructure are essential. These insights are relevant not only for U.S. Medicare but also for global efforts to integrate dementia-sensitive care into primary health systems. Our study has a few limitations that should be acknowledged. First, our scoping review synthesized findings predominantly from quantitative studies, with only two mixed-method studies and no studies using strictly qualitative methodologies. Second, few studies disaggregated findings by race, ethnicity, or geography, reducing our ability to assess equity-related outcomes. Moreover, few studies provided sufficient detail on the specific cognitive screening instruments used or on the scope and delivery of educational materials for patients and caregivers, limiting generalizability and implementation insights. Third, grey literature and non-peer-reviewed sources were not included. Fourth, although CFIR provided a comprehensive analytic structure, some studies did not explicitly fit in with our implementation frameworks, which required subjective mapping of findings to CFIR domains and may have introduced classification bias. Additionally, although our review did not quantitatively stratify findings by year, we observed that studies from more recent years were more likely to emphasize implementation facilitators (e.g., use of templates, workflow integration), whereas earlier studies often highlighted systemic barriers such as time constraints and provider unfamiliarity with AWV components. Finally, while our review focused specifically on AWV implementation in the United States, we recognize the value of comparative analysis with international contexts. This work was supported by a grant from the National Institute on Aging, National Institutes of Health (Grant No. 1R01AG083102-01; PIs: Tzeng, Kuo, & Raji). Full article

With the accelerated commercialization of autonomous vehicles, new accident types and complex risk factors have emerged beyond the scope of existing traffic safety management systems. This study aims to contribute to sustainable safety by establishing a quantitative basis for early recognition and response to high-risk situations in urban traffic environments where autonomous and conventional vehicles coexist. To this end, high-risk factors were identified through a combination of literature meta-analysis, accident history and image analysis, autonomous driving video review, and expert seminars. For analytical structuring, the six-layer scenario framework from the PEGASUS project was redefined. Using the analytic hierarchy process (AHP), 28 high-risk factors were identified. A risk prediction model framework was then developed, incorporating observational indicators derived from expert rankings. These indicators were structured as input variables for both road segments and autonomous vehicles, enabling spatial risk assessment through agent-based strategies. This space–object integration-based prediction model supports the early detection of high-risk situations, the designation of high-enforcement zones, and the development of preventive safety systems, infrastructure improvements, and policy measures. Ultimately, the findings offer a pathway toward achieving sustainable safety in mixed traffic environments during the initial deployment phase of autonomous vehicles. Full article

Obstructive sleep apnea (OSA) is a highly prevalent and underdiagnosed sleep disorder with significant cardiovascular implications, namely in atrial fibrillation (AF) patients. Despite its clinical relevance, OSA prevalence among AF patients and the diagnostic strategies used remain heterogeneous across studies, complicating screening, and treatment pathways. Our aim was to synthesize recent evidence on OSA prevalence in AF populations and to critically evaluate the diagnostic methods and screening strategies employed in clinical studies, by conducting a systematic review using PubMed and Google Scholar to identify original clinical studies published between January-2019 and December-2024. Inclusion criteria targeted adult AF populations assessed for OSA or sleep-disordered breathing. The results were analyzed by two independent reviewers. Non-concordances were resolved by consensus. Data extracted included study characteristics, population profiles, diagnostic approaches, prevalence rates, symptom profiles, and clinical correlates. Thirty-eight studies were included, comprising predominantly observational studies. Prevalence estimates of OSA in AF populations ranged from 5% to 90%, with most studies reporting rates >60%. A consistent burden of moderate-to-severe OSA was observed. Diagnostic methods varied widely, from polysomnography (PSG) and home sleep apnea testing to pacemaker-derived monitoring and questionnaires such as STOP-Bang and Epworth Sleepiness Scale (ESS). Underdiagnosis was attributed to minimal symptomatology, lack of physician awareness, and reliance on subjective tools. Several studies highlighted the limited sensitivity of standard screening instruments in AF populations and advocated for objective testing even in asymptomatic patients. Marked heterogeneity in study designs, diagnostic methods, and populations precluded quantitative synthesis and limited direct comparisons. Objective diagnostic testing, particularly PSG, is essential to improve OSA detection rates and guide individualized management. Integration of structured screening protocols into AF care—especially for high-risk patients—and interdisciplinary collaboration are critical. Full article

Background: Evidence on the humoral and cellular immune responses to SARS-CoV-2 following COVID-19 vaccination in older adults is warranted. Aims: To synthesize and analyze the current evidence on humoral and cellular immune responses to both standard and booster COVID-19 vaccination in individuals aged 60 years and older. Methods: Clinical trials and observational studies were included. Reviews, case series, letters to the editor, and similar publications were excluded. A selective literature search was conducted in the following databases: PubMed, Scopus, EMBASE, and Web of Science. The risk of bias and methodological quality of the included studies were assessed using the Newcastle–Ottawa Scale (NOS) and the Risk of Bias 2.0 (RoB 2) tool. Statistical analysis was conducted using Stata version 18 and Review Manager version 5.4.1. Results: Thirteen studies were included: eleven observational studies and two randomized clinical trials, evaluating humoral and cellular immune responses in 782 older adults. Messenger RNA vaccines were the most administered, particularly Pfizer-BioNTech (76.9%) and Moderna mRNA-1273 (23%). In most cases, immune responses were assessed after the second dose and booster doses. Most studies (61.5%) reported increased IgG titers specific to the SARS-CoV-2 Spike protein, while 23.1% reported a decrease. Regarding cellular immunity, 46.2% of the studies reported low interferon-gamma (IFN-γ) levels post-vaccination, whereas 38.5% showed increases. These findings highlight the need for tailored vaccination strategies to address emerging variants, particularly in vulnerable populations such as older adults. Conclusions: In older adults receiving COVID-19 vaccination, humoral immunity tends to increase, whereas cellular responses are frequently diminished, reflecting age-related immunosenescence that may limit the durability and breadth of protection following vaccination in older adults. Full article

Background: Hepatocellular carcinoma (HCC) remains a major cause of cancer-related mortality worldwide, with survival outcomes influenced by a range of demographic and pathological factors. While cirrhosis is a well-established risk factor, recent evidence shows that HCC can also develop in patients with only mild to moderate liver fibrosis. However, there is limited understanding of how fibrosis severity interacts with other clinical variables, such as patient age, to affect mortality. This study aims to explore how fibrosis scores relate to both overall and cancer-specific mortality in US HCC patients, with an emphasis on how this relationship may shift across different age groups. Methods: We utilized data from the Surveillance, Epidemiology, and End Results (SEER) database to identify 15,796 adult patients diagnosed with HCC between 2010 and 2021. Baseline demographics, disease characteristics, and treatment variables were examined. Mortality outcomes were evaluated using Cox proportional hazard regression. Variables significant at p < 0.1 in univariate analysis were included in multivariate models to identify independent predictors of mortality (with hazard ratios [HRs] > 1 signifying increased risk). A secondary analysis assessed how age modifies the association between fibrosis score and mortality. Results: The study population was predominantly male (77.2%), with most patients aged 60–79 (59.6%) and presenting with localized disease (61%). A majority had advanced liver fibrosis or cirrhosis (81.7%) and lived in large urban areas (62.9%). Crude comparisons indicated that male sex, older age, single status, advanced tumor stage, lower income, and cirrhosis were linked to worse outcomes. In adjusted models, independent predictors of increased mortality included male sex, older age, unmarried status, and more advanced disease stage. Receipt of surgery or chemotherapy was associated with a lower risk of death. Notably, the influence of fibrosis on mortality was found to be greater in older patients than in their younger counterparts. Conclusions: This analysis identifies key prognostic indicators in HCC and suggests that the relationship between fibrosis and survival is not uniform across age groups. These findings support the need for age-specific clinical management strategies and highlight the potential benefit of early detection and appropriate interventions, even in non-cirrhotic patients. Full article

Background: Spontaneous intracerebral hemorrhage (ICH) has the highest case fatality of all stroke types, yet recent epidemiological and outcome data from Central and Eastern Europe remain limited. Methods: We retrospectively analyzed prospectively collected data for 601 consecutive adults with primary ICH admitted to Sibiu County Clinical Emergency Hospital, Romania (2017–2023). Demographics, Glasgow Coma Scale (GCS), CT-derived hematoma volume (ABC/2), anatomical site, intraventricular extension (IVH), treatment, comorbidities, and in-hospital death were reported with exact counts and percentages; no imputation was performed. Results: Mean age was 68.4 ± 12.9 years, and 59.7% were male. Mean hematoma volume was 30.4 mL, and 23.0% exceeded 30 mL. IVH occurred in 40.1% and doubled mortality (50.6% vs. 16.7%). Overall case fatality was 29.6% and climbed to 74.5% for brain-stem bleeds. Men, although younger than women (66.0 vs. 71.9 years), died more often (35.4% vs. 21.1%; risk ratio 1.67, 95% CI 1.26–2.21). Systemic hazards amplified death risk: Oral anticoagulation, 44.2%; chronic alcohol misuse, 51.4%; thrombocytopenia, 41.0%; chronic kidney disease, 42.3%. Conservative management (74.9%) yielded 27.8% mortality overall and ≤15 for small-to-mid lobar or capsulo-lenticular bleeds; lobar surgery matched this (13.4%) only in large clots. Thalamic evacuation was futile (82.3% mortality), and cerebellar decompression performed late still carried 54.5% mortality versus 16.6% medically. Multivariable analysis confirmed that low GCS, IVH, large hematoma volume, thrombocytopenia, and chronic alcohol use independently predicted in-hospital mortality. Limitations: This retrospective study lacked post-discharge functional outcome data (e.g., mRS at 90 days). Conclusions: This study presents the largest Romanian single-center ICH cohort, establishing national benchmarks and underscoring modifiable risk factors. Early ICH lethality aligns with Western data but is amplified by exposures such as alcohol misuse, anticoagulation, thrombocytopenia, and CKD. Priorities include preventive strategies, timely surgical access, wider adoption of minimally invasive techniques, and development of a prospective regional registry. Full article

Rice (Oryza sativa L.) is a staple crop for over half of the global population; however, pathogenic infections pose significant threats to its sustainable production. Although chemical pesticides are commonly employed for disease control, their prolonged usage has led to pathogen resistance, reduced effectiveness, and non-target toxicity, rendering them unsustainable for agricultural practices. Nanomaterials (NMs) present a promising alternative due to their small size, tunable release properties, and diverse mechanisms for disease resistance. This review examines how NMs can enhance rice disease management through (1) direct pathogen suppression; (2) the activation of plant defense pathways; (3) the formation of nanoscale barriers on leaves to obstruct pathogens; (4) targeted delivery and controlled release of fungicides; and (5) modulation of the microbiome to bolster resilience. Moreover, we critically analyze the agricultural potential and environmental implications of NMs, develop optimized application strategies, and, for the first time, propose the innovative ‘NMs-Rice-Soil’ Ternary System framework. This groundbreaking approach integrates nanotechnology, plant physiology, and soil ecology. The pioneering framework offers transformative solutions for sustainable crop protection, illustrating how strategically engineered NMs can synergistically enhance rice productivity, grain quality, and global food security through science-based risk management and interdisciplinary innovation. Full article

Based on SWOT and TOWS analyses and combined with expert interviews, this study proposes a series of marketing strategies to enhance consumers’ willingness to purchase used electric vehicles (UEVs). In terms of the strengths and opportunities (SO) strategy, it is recommended that enterprises strengthen marketing and brand building, customize services and special features, use price advantages and environmental awareness to attract specific groups, provide convenient charging services, give full play to technical support advantages, and expand channels through cooperation with the government and manufacturers. The strategies for the strengths and threats (ST) scenario include establishing a government relations department, improving product quality and brand image, enhancing information transparency and quality assurance, and building a partner network and customer relationships. In terms of weaknesses and opportunities (WO), it is proposed to transform corporate weaknesses into opportunities by investing in evaluation technology and expanding charging facilities, strengthening market promotion and consumer education, and providing personalized car purchase advice and high-quality after-sales services. In the face of weaknesses and threats (WT), the emphasis is on reducing risks and improving competitiveness by improving quality management, internal management, and providing long-term after-sales and warranty services. The main innovation of this study lies in integrating SWOT-TOWS strategic frameworks with qualitative expert insights to develop actionable and scenario-specific marketing strategies for the UEV market—an area previously underexplored in existing literature. The comprehensive strategy proposed in this study provides a practical path for UEV companies to enhance consumer trust and purchase willingness and promote the industry’s sustainable development. Full article

Background: Rib fractures are among the most common thoracic injuries following blunt trauma and are associated with significant morbidity, particularly in elderly and polytrauma populations. Historically managed non-operatively, recent advances have redefined the role of surgical stabilization of rib fractures (SSRF) in improving patient outcomes. The objective of this narrative review is to evaluate current evidence surrounding the management of rib fractures, with a focus on indications for SSRF, surgical techniques, special populations, and future directions in care. Methods: A narrative review of the literature was conducted, incorporating relevant randomized controlled trials, cohort studies, clinical guidelines, and expert consensus statements. Emphasis was placed on patient selection criteria, surgical strategies, multimodal analgesia, and emerging technologies. Results: SSRF has demonstrated benefits in short- and long-term outcomes, including improved pain control, reduced ventilator dependence, shorter ICU and hospital stays, and better functional recovery. These outcomes are most evident in patients with flail chest, severe displacement, or failure of conservative therapy. Minimally invasive techniques and 3D-printed implants represent promising innovations. Despite growing evidence, SSRF remains underutilized due to variability in institutional protocols and access to trained personnel. Conclusions: The management of rib fractures continues to evolve with increasing support for surgical intervention in select patients. Wider implementation of SSRF, guided by standardized protocols and advanced technologies, may improve outcomes and reduce complications in this high-risk trauma population. Full article

Fusarium oxysporum f. sp. cucumerium, a resilient saprophytic fungus, poses a significant risk to cucumber crops. The research investigated the suppressive impact of Bacillus velezensis dhm2 on this pathogen and the synergistic performance of its crude lipopeptide extract with synthetic fungicides. Strain dhm2 inhibited the pathogen by 52.27% in confrontation culture. Its fermentation supernatant showed peak activity at 4 h bacterial age and 60 h fermentation duration, while the crude lipopeptide extract had an EC₅₀ of 9.99 g L⁻¹. Among the six chemical fungicides, prochloraz exhibited the highest toxicity, with an EC₅₀ value of 0.03 μg mL⁻¹. In all mixed combinations of the crude lipopeptide extract and chemical fungicides, there existed synergistic mixing ratios, particularly with difenoconazole (volume ratio 7:3, synergistic ratio 5.88) and propiconazole (7:3, 3.41), as confirmed by Wadley tests. Pot experiments revealed that the combined use of the crude lipopeptide extract and difenoconazole controlled cucumber Fusarium wilt by 80.95%. The mixture showed the highest SOD (315.76 U g⁻¹ FW min⁻¹), POD (281.63 U g⁻¹ FW min⁻¹), and CAT (23.39 U g⁻¹ FW min⁻¹), with increases over single treatments. This study provides an eco-friendly strategy for managing cucumber wilt, advocating reduced fungicide use via synergistic formulations. Full article

Futures and forward contracts together offer farmers of all sizes important tools for shifting and managing production risk. This risk shifting is particularly apparent in the U.S. grain complex, where the United States also has a significant export position. Because of this international reach, we argue that the futures and forward markets play a critical role in reducing world food insecurity and thus contribute to satisfying Sustainable Development Goal #2: Zero Hunger. We further argue that the presence of investors willing to take the opposite side of the farmers’ natural short hedge helps futures markets perform their key functions of price discovery and risk management. In addition to these roles, futures markets also enable farmers to finance their crops more efficiently over the production cycle, supporting operational stability. Finally, we highlight that agricultural markets in the United States are supported by significant regulation at the county, state, and federal levels. These farming regulations, coupled with federal oversight of agricultural futures markets, provide sufficient confidence that the goal of Zero Hunger is being pursued in an appropriate and effective manner, reinforcing the case for agricultural futures as a meaningful component of a broader sustainable investment strategy. Full article

Background: Large vessel occlusion (LVO) strokes account for a significant proportion of ischemic strokes and are often cardioembolic in origin, particularly following atrial fibrillation (AF) with thrombus formation in the left atrial appendage (LAA). Although direct oral anticoagulation (DOAC) therapy reduces stroke risk in AF, anatomical and flow-related factors may still allow thrombi to form and persist, revealing the limitations of anticoagulation in high-risk patients. Examining structural and hemodynamic factors contributing to thrombus persistence is essential for optimizing patient management. Methods: We retrospectively analyzed 169 AF patients with LVO stroke who underwent cardiac CT (cCT) during acute stroke assessment. Patients were categorized based on the presence or absence of persistent LAA thrombi and further stratified by DOAC status. LAA volume, blood stasis and left ventricular (LV) diameter were measured. Thrombi were assessed using Hounsfield Unit (HU) analysis to evaluate potential differences in thrombus composition. Logistic regression analysis was performed to identify independent predictors of thrombus persistence with adjustment for DOAC therapy. Results: Persistent LAA thrombi were identified in 23 patients (13.6%). Patients with thrombi had significantly higher rates of stasis (p = 0.004), larger left ventricular diameters (p = 0.0019) and higher LAA volumes (p = 0.004). When adjusted for DOAC therapy, larger LAA volume (OR 1.05, p = 0.011), presence of LAA stasis (OR 6.14, p = 0.013) and increased LV diameter (OR 1.06, p = 0.006) were independent predictors of thrombus persistence. Thrombus size and HU values did not differ significantly between DOAC and non-DOAC groups. Notably, 30.4% of patients with persistent thrombi were on adequate DOAC therapy. Conclusions: LAA volume, stasis and LV enlargement predict thrombus persistence in the LAA of AF patients with LVO stroke, even under adequate DOAC therapy. These findings highlight the potential need for alternative antithrombotic strategies, including interventional LAA occlusion, and warrant further investigation into individualized stroke prevention in high-risk AF populations. Full article

Subway train operators face the risk of cumulative cognitive stress due to factors such as visual fatigue from prolonged high-speed tunnel driving, irregular shift patterns, and the monotony of automated operations. This can lead to cognitive decline and human error accidents. Current monitoring of cognitive stress risk predominantly relies on single-modal methods, which are susceptible to environmental interference and offer limited accuracy. This study proposes an intelligent multimodal framework for cognitive stress monitoring by leveraging the symmetry principles in physiological and behavioral manifestations. The symmetry of photoplethysmography (PPG) waveforms and the bilateral symmetry of head movements serve as critical indicators reflecting autonomic nervous system homeostasis and cognitive load. By integrating these symmetry-based features, this study constructs a spatiotemporal dynamic feature set through fusing physiological signals such as PPG and galvanic skin response (GSR) with head and facial behavioral features. Furthermore, leveraging deep learning techniques, a hybrid PSO-CNN-GRU-Attention model is developed. Within this model, the Particle Swarm Optimization (PSO) algorithm dynamically adjusts hyperparameters, and an attention mechanism is introduced to weight multimodal features, enabling precise assessment of cognitive stress states. Experiments were conducted using a full-scale subway driving simulator, collecting data from 50 operators to validate the model’s feasibility. Results demonstrate that the complementary nature of multimodal physiological signals and behavioral features effectively overcomes the limitations of single-modal data, yielding significantly superior model performance. The PSO-CNN-GRU-Attention model achieved a predictive coefficient of determination (R²) of 0.89029 and a mean squared error (MSE) of 0.00461, outperforming the traditional BiLSTM model by approximately 22%. This research provides a high-accuracy, non-invasive solution for detecting cognitive stress in subway operators, offering a scientific basis for occupational health management and the formulation of safe driving intervention strategies. Full article

Multiple sclerosis (MS) is characterized by a continuum of diverse neuroinflammatory and neurodegenerative processes that contribute to disease progression from the earliest stages. This leads to a highly heterogeneous clinical course, requiring early and accurate prognostic assessment: the identification of reliable prognostic biomarkers is crucial to support therapeutic decision-making and guide personalized disease management. In this narrative review, we critically examined the current MS literature, investigating prognostic factors associated with disease progression and irreversible disability in adult-onset MS, with a focus on different clinical, radiological, and molecular biomarkers. Particular attention is directed toward the prognostic value of baseline clinical and neuroimaging factors, emerging biomarkers of smoldering disease, and progression independent of relapse activity (PIRA) events. Additionally, we discussed the role of integrated prognostic tools and risk scores, as well as their potential impact on clinical practice. We aim to provide a comprehensive and clinically oriented synthesis of available evidence in the MS biomarkers field, supporting multifaceted prognostication strategies to improve long-term outcomes in people with MS. Full article

The escalating threat of climate-driven wildfires, land abandonment, wildland–urban interface expansion, and inadequate forest management poses an existential challenge to Mediterranean oak ecosystems, for which traditional fire suppression has proven insufficient. This paper presents a combination of integrated fire management (IFM) and closer-to-nature forest management (CTNFM) in a representative mixed Pyrenean oak (Quercus pyrenaica) forest at Quinta da França (QF), in Portugal. It is structured around three main objectives designed to evaluate this pioneer integrated approach: (1) to describe the integration of IFM and CTNFM within an agro-silvo-pastoral landscape; (2) to qualitatively assess its ecological, operational, and socio-economic outcomes; and (3) to quantitatively evaluate the effectiveness of two key nature-based solutions (NbSs), that is, prescribed burning and planned grazing, in reducing wildfire risk and enhancing forest resilience and biodiversity. By strategically combining proactive fuel reduction with biodiversity-oriented silviculture, the QF case provides a replicable model for managing analogous Mediterranean forested areas facing similar risks. This integrated approach supports forest multifunctionality, advancing both prevention and adaptation goals, and directly contributes to the ambitious targets set by the European Union’s New Forest and Biodiversity Strategies for 2030, marking a significant step towards a more sustainable and fire-resilient future for such Mediterranean landscapes. Full article