Search Results (1,394)

Background/Objectives: The management of ventricular arrhythmias (VAs) within cardiac intensive care units (CICUs) is undergoing a significant transformation. This review aims to analyze the historical transition from a narrow focus on arrhythmia-specific treatments toward on the multidisciplinary heart rhythm team. Methods: A narrative revies was conducted. Results: Effective management of electrical storm (ES) requires prompt attenuation of sympathetic hyperactivity, with a preference for non-selective beta-blockers and the implementation of deep sedation. The use of mechanical circulatory support (MCS) has emerged as a mechanical antiarrhythmic strategy by facilitating ventricular unloading and reducing myocardial wall stress. Furthermore, early catheter ablation, guided by 3D electroanatomical mapping and advanced imaging, has proven superior to salvage procedures for stabilizing the arrhythmic substrate. Finally, the integration of palliative care ensures ethical stewardship during refractory shock. Conclusions: Modern VAs management in the CICUs represents a convergence of technology, biology, and multidisciplinary coordination. Full article

Patients with left ventricular dysfunction undergoing cardiac surgery face a heightened risk of perioperative complications, including postcardiotomy shock (PCS). Conventional management with inotropes and vasopressors can exacerbate end-organ dysfunction, underscoring the need for alternative strategies. The planned use of mechanical circulatory support (MCS) devices, such as the Impella, offers a proactive approach to mitigating PCS in high-risk patients. This study presents our early experience at Johns Hopkins with planned Impella utilization in high-risk cardiac surgery. We detail our risk stratification methodology, patient selection criteria, and perioperative management strategies. Our proposed risk stratification scoring system incorporates surgical intent, preoperative myocardial function, anticipated postoperative course, and exit strategy to identify optimal candidates for perioperative MCS. We describe the intraoperative central placement technique for the Impella 5.5, perioperative management protocols—including anticoagulation strategies and weaning protocols—and postoperative device extraction. A retrospective review of our first 11 consecutive patients with severely reduced left ventricular ejection fraction (< 30%) who underwent Impella-assisted cardiac surgery demonstrated favorable outcomes, with no postoperative mortality and a two-year follow-up. Our findings suggest that planned Impella use in high-risk cardiac surgery is both feasible and beneficial. However, further studies are necessary to validate these results, assess long-term outcomes, and evaluate cost-effectiveness. Full article

Japan’s import market for wood pellets has expanded rapidly since the introduction of the feed-in tariff (FIT) scheme in 2012, with imports exceeding six million tonnes in 2024, positioning Japan as the world’s second-largest wood pellet importer. Despite this expansion, empirical evidence on its demand structure remains limited. This study employs a Dynamic Linear Approximate Almost Ideal Demand System (Dynamic LA-AIDS) model incorporating demand inertia stemming from long-term fuel supply contracts to analyze Japan’s wood pellet import demand from 2012Q1 to 2025Q3. The results reveal a distinct two-tiered structure: North American pellets behave as a strategic necessity, exhibiting price-inelastic demand and a tendency toward a stable long-run procurement pattern following price and expenditure shocks, suggesting procurement practices that prioritize supply security under long-term contracts. In contrast, Vietnamese pellets behave as a price-sensitive commodity, displaying price-elastic demand and relatively sustained responsiveness following such shocks. These results indicate a dual procurement strategy under the FIT scheme that balances stability and cost flexibility. Importantly, the Japanese demand structure differs from the more uniformly price-inelastic patterns observed in the EU and South Korean markets, providing new insights into how institutional frameworks shape biomass allocation and market responsiveness in renewable energy systems. Full article

Background/Objectives: Severe hemorrhagic shock progressing to clinical death remains a major cause of mortality and long-term neurological morbidity despite advances in trauma care. While current resuscitation strategies restore circulation, their ability to preserve brain structure and function following global ischemia–reperfusion injury remains limited. Hemorrhagic shock induces widespread neuronal vulnerability, particularly within the hippocampus and prefrontal cortex, contributing to persistent cognitive and behavioral deficits among survivors. Methods: Using a rat model of hemorrhagic shock-induced clinical death, we evaluated whether resuscitation with VBI-1, a phospholipid nanoparticle-based colloid, supports neurological recovery compared with whole blood-based resuscitation. Animals underwent controlled exsanguination to the point of clinical death, followed by rapid intra-arterial reanimation with either shed whole blood or VBI-1. Two phases of study were performed: histological evaluation of tissues 12 h after resuscitation and, in a separate cohort of animals, longitudinal behavioral recovery over 30 days. Histology focused on evaluating neuronal integrity in the hippocampal CA1 region and prefrontal cortex, neuronal functional status, and microglial responses. Sex was analyzed as a biological variable. Results: Resuscitation with VBI-1 is associated with sustained behavioral recovery, with pronounced sex-dependent effects favoring females during the subacute-to-chronic recovery phase. VBI-1 preserved neuronal density, laminar organization, and neuronal functional integrity in ischemia-vulnerable brain regions. This, and neuronal preservation, correlated with hippocampal-dependent working memory performance. Importantly, resuscitation with VBI-1 did not increase microglial density, coverage, or spatial organization, exacerbating the neuroinflammatory burden. Conclusions: These findings demonstrate that phospholipid nanoparticle-based resuscitation confers meaningful neurological recovery following profound circulatory collapse, highlighting the importance of evaluating resuscitation agents based on long-term brain outcomes. Full article

This paper presents a new type of ultrasonic gyroscopic sensor based on a solid-state standing-wave vibrator, which is promising for shock-resistant applications. A theoretical model of the proposed design, which is a layered structure, and the numerical simulation of its frequency response using the developed software are presented. A test sample of the novel sensing element was made and experimental studies of its frequency response were conducted. The results showed a high correlation between the resonant frequencies both for the real sample research and numerical modeling; thus, the validity of the theoretical model was confirmed. The laboratory investigation of the developed sensing element on a test bench under rotating conditions was carried out and a shift in the standing-wave amplitude proportional to the angular velocity of rotation was revealed; thus, an informative signal for this type of gyroscopic sensor was found. It is shown that the amplitude of the output signal of the new sensor on standing waves compares favorably with the signal levels reported for similar traveling-wave solutions in previous studies. The optimization strategies for the new sensor’s design and operating mode to increase signal to noise ratio are also identified. Thus, the potential of using the developed solid-state standing-wave vibrator as a shock-resistant ultrasonic gyroscopic sensor is supported. Full article

This study examines how manufacturing SMEs can structure digital transformation as a strategic, risk-managed process under demand uncertainty and resource constraints. Integrating digital maturity assessment with cost–benefit analysis (D3A–CBA framework), the study evaluates a phased investment strategy at a Turkish metal processing SME, grounding the analysis in real production order data and firm-level financial records. The phased structure—informed by real options reasoning—conditions capacity expansion on measurable Phase-1 performance thresholds, thereby limiting downside risk while preserving strategic flexibility. Under the base scenario (10% real discount rate), Phase-1 yields an NPV of TRY 3,830,738 and an IRR of 12.4%; the combined portfolio reaches TRY 17,365,066. However, a 10,000-iteration Monte Carlo simulation reveals a 29.8–33.0% probability of negative NPV, and sensitivity analysis exposes an asymmetric risk profile in which moderate demand shocks—rather than cost shocks—drive non-viability. The findings demonstrate that digital transformation in resource-constrained SMEs requires not only positive financial returns but also strategic mechanisms to manage demand uncertainty, exchange rate volatility, and organizational adaptation. The proposed framework offers SME managers a reproducible, evidence-based approach to aligning investment decisions with strategic objectives while containing capital risk. Full article

Background/Objectives: Placenta accreta spectrum (PAS) disorders are a major cause of life-threatening obstetric hemorrhage and frequently necessitate cesarean hysterectomy. Abdominal aorta balloon occlusion (AABO) has been increasingly adopted as a strategy to reduce intraoperative blood loss during cesarean section. This study aims to evaluate the effectiveness and safety of AABO during cesarean delivery in women with PAS disorders. Materials and Methods: A systematic review and meta-analysis of studies published in English from 2015 to April 2025 was conducted using the following databases: Embase, Scopus, PubMed, Google Scholar, and Web of Science. Articles that met inclusion criteria focused on human participants, original studies, female participants, and studied the efficacy of AABO on blood loss during cesarean delivery for PAS. Articles that were reviews, case reports, other occlusion procedures, and animal studies were excluded. Risk of bias was evaluated using the Newcastle-Ottawa Scale. Results: Twenty-four studies comprising 1958 cesarean deliveries with AABO and 1791 without AABO met the inclusion criteria. Data on blood loss, transfusion, hysterectomy, maternal complications, and neonatal outcomes were extracted, synthesized, and analyzed. The majority of studies (91.6%) applied the balloon at the infrarenal level. Cesarean delivery with AABO resulted in substantially lower mean blood loss (1231 ± 688 mL vs. 2253 ± 857 mL, p < 0.001) and reduced requirements for blood transfusion compared with cesarean delivery alone. Hysterectomy rates were threefold lower with AABO (7.8% vs. 25.8%, p < 0.001), and the incidence of hemorrhagic shock and re-laparotomy were markedly reduced. Complications associated with AABO, including lower limb arterial thrombosis and fever, were uncommon and generally manageable. Conclusions: AABO during cesarean delivery for PAS disorders is associated with reduced intraoperative blood loss, lower transfusion requirements, and decreased hysterectomy rates, suggesting improved maternal hemodynamic stability. Although the procedure is generally safe, vigilance for vascular and thromboembolic complications is essential, and preventive strategies should be incorporated into perioperative care. These findings support the integration of AABO into multidisciplinary management protocols for women with PAS disorders. Future randomized prospective studies should be performed to improve patient selection criteria, standardize the protocols, and further evaluate the long-term maternal and neonatal safety/outcomes of the procedure. Full article

Background and Clinical Significance: Alpha-1 antitrypsin deficiency (AATD) is an autosomal codominant disorder caused by pathogenic variants in the SERPINA1 gene, resulting in reduced circulating alpha-1 antitrypsin (AAT) or production of dysfunctional protein. AAT is the principal inhibitor of neutrophil elastase, and its deficiency leads to unchecked proteolytic activity, progressive destruction of lung parenchyma, and increased susceptibility to infections. Severe deficiency, particularly in individuals homozygous for the Z allele (PI*ZZ), predisposes to early-onset panacinar emphysema, chronic airflow obstruction, and liver disease. Despite its clinical relevance, AATD remains markedly underdiagnosed and is frequently misclassified as smoking-related chronic obstructive pulmonary disease (COPD), delaying access to disease-modifying therapy, genetic counselling, and preventive strategies. Early recognition is therefore essential to improve outcomes. Case Presentation: We report the case of a 68-year-old ex-smoker with a long-standing diagnosis of “COPD” who presented with acute-on-chronic type 2 respiratory failure and community-acquired pneumonia. Spirometry revealed severe airflow obstruction, and high-resolution computed tomography demonstrated extensive basilar panlobular emphysema, raising suspicion for AATD. Serum AAT concentration was critically low at 26.8 mg·dL⁻¹, and isoelectric focusing confirmed a PI*ZZ phenotype. Next-generation sequencing identified homozygosity for the SERPINA1 c.1096G>A (Z) variant, with no additional pathogenic alleles. Cascade family screening revealed multiple heterozygous PI*MZ relatives. Before augmentation therapy could be initiated, the patient developed severe Legionella pneumophila pneumonia with secondary bacterial superinfection, progressing to refractory septic shock and death. Conclusions: This case illustrates how AATD can masquerade as smoking-related COPD for years, leading to missed opportunities for timely intervention. It underscores the importance of testing all adults with COPD or refractory asthma at least once, regardless of age or smoking history. Early diagnosis enables initiation of augmentation therapy, targeted vaccination, lifestyle modification, and genetic counselling, ultimately improving prognosis and reducing preventable morbidity and mortality. Full article

The use of hydrogen direct injection (DI) plays a crucial role in decarbonizing internal combustion engine (ICE) technology. However, a suitable characterization of the injection process is required to control the mixture preparation before combustion, especially in the case of late injection timing. CFD modeling represents a useful tool to support experiments in addressing this goal. This study presents a numerical investigation of hydrogen DI using a swirled-type injector, seated in a constant-volume vessel. First, the selected numerical setup is validated against optical measurements of the jet penetration, demonstrating the reliability of the approach. Then, the analysis compares swirling and non-swirling configurations under different nozzle pressure ratios (nPRs) to evaluate the interaction between swirl-induced mixing and under-expanded jet structures. Results show that at lower nPR, swirl significantly alters the momentum distribution, reducing axial penetration. Instead, at higher nPR, where the H2 jets exhibit strong shock structures, the effects of swirl become negligible, with penetration and plume morphology nearly identical to non-swirling conditions. Analysis of the scalar dissipation rate showed the presence of a redistribution of mixing characteristics at low nPR due to swirl, while shock structures dominate at high nPR. This could have a significant impact on combustion and NO_x emissions in ICE operated with late injection strategies, where lower nPR are found. Full article

This study investigates the dynamic impact of technological innovation and institutional governance on the value-added contribution of Malaysia’s agriculture, forestry, and fishery (AFF) sectors. This research addresses a critical literature gap by integrating Schumpeterian Innovation Theory and Institutional Theory to examine how these drivers promote the primary sector by employing the Autoregressive Distributed Lag (ARDL) approach. The empirical results revealed that while technological innovation provides a highly significant boost to sectoral productivity in the short run, its long-run effect is negative. This suggested a structural contraction consistent with Schumpeterian creative destruction notion. Additionally, governance quality exhibited an initial compliance shock before yielding positive results, though it remains prone to long-term institutional traps. These findings contribute a multi-sectoral integrated framework that challenges the traditional siloed approach to AFF research. The study offers vital implications for policymakers, emphasizing the need for adaptive governance and inclusive innovation strategies to ensure that Malaysia’s path toward modernization does not compromise national food sovereignty. Full article

COVID-19 was a prolonged public-health shock that disrupted mobility, access to services, and household spending. Although the official U.S. poverty rate declined to 11.1%, the Supplemental Poverty Measure rose to 12.9%, suggesting that material hardship persisted unevenly across places. This study asks whether pre-existing livelihood vulnerability and local epidemic burden translated into geographically concentrated consumption losses during 2020–2022. Because sustained consumption loss can erode households’ health-related spending, tracking where spending declines concentrate helps connect local social and environmental conditions to how communities withstand a health crisis. We analyze consumer expenditure, unlike prior research relying on aggregate retail sales, to capture fine-grained economic strains as a proxy for shock-absorption capacity. A Livelihood Vulnerability Index (LVI) was calculated for each U.S. county using 16 socio-economic variables, and counties were classified as high- or low-risk. A multilevel model then examined how socio-economic and COVID-19 factors at county and census tract levels shaped consumption changes. Higher-risk communities experienced greater consumption reductions. At the census tract level, the non-White ratio, vacancy rate, built year, per capita income, education level, and housing value were significant. At the county level, COVID-19 cases and deaths, crowding, public transportation use, and vehicle availability mattered most. These findings support place-targeted strategies that combine public-health response with socio-environmental interventions to reduce disparities rooted in pre-existing vulnerability. Full article

Viral internal ribosome entry sites (IRESs) are specialized RNA structures that facilitate cap-independent translation as a strategy to usurp the host translational machinery. The Type 6 IRESs are the most streamlined mechanism to date, as they adopt a three pseudoknot RNA structure to initiate factorless translation initiation by directly recruiting the ribosome and drive translation. The Halastavi árva virus (HalV) IRES represents the most minimalistic subclass identified to date, whereby the IRES lacks specific pseudoknot domains that bind to the 40S subunit but instead recruits pre-assembled 80S ribosomes via a mechanism that is not fully understood. Here, we examined cellular conditions that can support HalV IRES translation. We demonstrated that the HalV IRES is translationally active in insect Sf21 lysates and Drosophila S2 cells, but inactive in mammalian RRL and wheat germ extract. Cells treated with heat shock or serum starvation suppressed HalV IRES activity, whereas virus infection robustly enhanced HalV IRES-mediated translation. Finally, the HalV IRES can support viral translation and replication using a heterologous viral replicon. These findings highlight the context-specific cellular conditions that allow ribosome assembly and translation by a factorless minimalist IRES. Full article

In the digital era, online attention has become a key indicator of tourism competitiveness and destination visibility. This study proposes a two-dimensional framework to evaluate the competitive state of online attention by combining its current magnitude and growth dynamics. Using Baidu Index data, the study applies the Boston Consulting Group (BCG) matrix and the coefficient of variation to analyze online attention patterns of Beijing’s 5A–level tourist attractions from 2011 to 2025. The results show clear polarization in online attention. A small number of iconic attractions consistently dominate digital visibility, while many other sites exhibit unstable and uneven attention trajectories. These patterns reflect the cumulative effects of consumer behavior, information-seeking preferences, and algorithmically mediated content environments, which reinforce attention concentration and competitive inequality over time. External shocks, particularly the COVID–19 pandemic, caused sharp declines in online attention in 2020, followed by an uneven recovery in subsequent years, highlighting the volatility of digital attention systems. The study also demonstrates the managerial value of the proposed framework. By classifying attractions according to attention levels and growth potential, the framework supports differentiated marketing and demand–redistribution strategies. For instance, increasing the visibility of high-potential but under-visited attractions can help redirect visitors away from overcrowded “Star/GC” sites and encourage more balanced spatial and temporal visitation. Overall, this study proposes a quantitative and replicable framework that integrates digital attention dynamics, algorithmic filtering, and consumer behavior into destination competitiveness analysis. The framework supports evidence-based and sustainability-oriented destination management by informing adaptive marketing and demand management strategies that can help alleviate overtourism and balance visitor flows. However, the study relies on a single digital platform and lacks direct sustainability indicators. Future research should integrate multi-platform data and link online attention metrics to measurable environmental, social, and economic sustainability outcomes. Full article

This research article explores whether the climate transition risk (CTR) and climate physical risk (CPR) transmit greater shocks towards the sustainable, gold-backed, energy-related and Sharia-compliant cryptocurrencies during bullish market conditions as compared with the normal and bearish market conditions. We employ the novel quantile vector auto-regression (QVAR)-based connectivity framework. Overall findings suggested that CPR and CTR transmitted greater shocks towards cryptocurrency classes during extremely high and lower quantiles as compared with the median quantile. This U-shaped and non-linear climate risks shock transmission indicates that Sharia-compliant, energy-related and gold-backed cryptocurrencies become more vulnerable during extreme market conditions (higher and lower quantiles) and may not consistently serve as reliable hedging or diversification instruments, particularly during periods of heightened climate uncertainty. Overall findings suggested that both the CPR and CTR transmitted greater shocks towards energy-related, gold-backed, and Sharia-compliant cryptocurrencies as compared with the sustainable cryptocurrencies, across all the quantiles. Therefore, sustainable cryptocurrencies, particularly those with energy-efficient consensus mechanisms such as Stellar, Cardano and Ripple, exhibited resilience to climate risks and can therefore function as stabilizing core holdings in diversified portfolios. Fund managers should incorporate a rebalancing strategy that increases allocation to these climate-resilient, sustainable digital assets during periods of elevated climate risk. Fund managers should integrate CPR and CTR into the quantile-domain forecasting frameworks for predicting digital asset market returns to enhance financial stability. Portfolio managers should undertake dynamic and quantile-contingent climate risk hedging strategies that account for tail-risk exposure rather than relying on average market behavior. Full article

Upper tract urothelial carcinoma (UTUC) is a rare and aggressive malignancy, accounting for only 5–10% of all urothelial carcinomas (UCs). Lung, bone, liver, and distant lymph nodes are common sites of metastasis, while gastrointestinal metastasis is extremely rare. We present a case of a 63-year-old female who developed a descending colon lesion 19 months after left radical nephroureterectomy for high-grade ureteral UC. The diagnosis was established by computed tomography (CT), magnetic resonance imaging (MRI), colonoscopy, and biopsy, which excluded primary colorectal malignancy. First-line therapy consisted of six 21-day cycles of gemcitabine plus cisplatin, followed by two cycles of tislelizumab maintenance immunotherapy. Restaging with contrast-enhanced CT and positron emission tomography/computed tomography (PET/CT) demonstrated disease progression. Despite switching to second-line nab-paclitaxel, the patient rapidly deteriorated from tumor cachexia and ultimately succumbed to septic shock secondary to severe pulmonary infection. This represents the first reported case of descending colon metastasis from primary ureteral UC. It highlights the colon as a potential metastatic site where biopsy is essential for definitive diagnosis. Notably, although the patient initially responded to platinum-based therapy, the subsequent rapid progression underscores the need for vigilant monitoring and timely adjustment of therapeutic strategies in managing such high-risk presentations. Full article