Search Results (375)

Lateral epicondylitis (LE), commonly referred to as tennis elbow, remains a frequent cause of lateral elbow pain, yet its optimal management and risk profile are still debated. Therefore, this review aimed to summarize current evidence on its definition, diagnosis, and treatment while addressing common misconceptions. A non-systematic review of major medical databases, including PubMed, Cochrane Library, and Google Scholar, was conducted using predefined inclusion criteria to identify relevant review articles. The analyzed literature highlights that LE is primarily diagnosed clinically and managed through a spectrum of conservative and interventional approaches. Evidence suggests that structured physiotherapy and load modification remain the cornerstones of treatment, while modalities such as platelet-rich plasma and autologous blood injections may offer longer-term benefits compared with corticosteroids, which are effective mainly for short-term symptom relief. In contrast, interventions such as acupuncture and shock wave therapy show limited or inconsistent efficacy. Identified risk factors include female sex, smoking history, repetitive or forceful manual work, and higher cardiovascular risk burden. Overall, conservative management should be the first-line approach, with biologic therapies considered in refractory cases and surgery reserved as a last option; however, further high-quality randomized controlled trials are required to establish optimal treatment algorithms and clarify long-term outcomes. Full article

Cold-chain supply systems depend on a sequence of linked production and logistics decisions. In prepared-food cold chains, quality may deteriorate not because one visible failure occurs, but because testing, traceability records, temperature monitoring, and abnormal-condition reporting are gradually weakened under cost pressure. Once such hidden effort reduction accumulates, external disturbances may push the system from strict assurance to weakened governance. To explain this nonlinear process, an asymmetric evolutionary game is built between prepared-food producers and cold-chain logistics providers, each choosing between strict and weakened quality assurance. White Gaussian noise is introduced to represent random operating shocks, and the two-population strategy system is projected onto a system-level quality-governance coordinate, $q$. This projection is used as a transparent baseline coordinate rather than as an assumption of linear system evolution. The reduced system is then transformed into a stochastic cusp catastrophe model, with a resilience indicator used to measure the distance from critical transition conditions. Numerical simulations show that quality assurance costs and short-term cost-saving benefits move the system toward a weakened-governance basin, whereas external incentives, coordination degree, and credible accountability mechanisms support recovery toward strict collaboration. The framework offers a scenario-based resilience diagnosis approach for identifying threshold effects in cold-chain quality governance. Digital traceability, temperature-data sharing, incentive alignment, and accountability rules are further interpreted as operational innovations that improve resilience and reduce avoidable quality losses in sustainable cold-chain operations. Full article

Multivessel coronary artery disease is observed in a substantial proportion of patients presenting with ST-segment elevation myocardial infarction (STEMI) and identifies a higher-risk phenotype characterized by larger atherosclerotic burden, recurrent ischemic events, and greater need for subsequent revascularization. Over the past decade, randomized evidence has progressively shifted the interventional paradigm from culprit-lesion-only primary percutaneous coronary intervention (PCI) toward complete revascularization in hemodynamically stable STEMI patients with suitable non-culprit lesions. Nevertheless, several clinically relevant questions remain unresolved, including the optimal criteria for selecting non-culprit lesions, the relative value of angiography, coronary physiology, and intracoronary imaging, the timing of complete revascularization, and the management of patients presenting with cardiogenic shock. Angiography-guided complete revascularization has the strongest evidence base, while physiology-guided approaches may reduce unnecessary PCI but have not demonstrated superiority over angiography-guided strategies in direct randomized comparisons. Intracoronary imaging offers unique information on plaque vulnerability and PCI optimization, although dedicated outcome trials in STEMI remain limited. The timing of complete revascularization has also evolved, with contemporary trials supporting early treatment in selected stable patients but not establishing a universal immediate strategy. This review summarizes current evidence, unresolved controversies, and emerging directions regarding strategies and timing of complete revascularization in STEMI patients with multivessel disease. Full article

The case for early vasopressor initiation in septic shock has been argued in detail in physiologic reviews and randomized trials. The evidence base is no longer the limiting factor. What remains limiting is delivery. Across most U.S. emergency departments and many international settings, patients with septic shock still do not reliably receive norepinephrine within the first hour of recognition. This review reframes the early-vasopressor question from a physiologic argument into an implementation problem and identifies three structural barriers that operate independently of any individual clinician’s understanding of the underlying evidence. The first is regulatory: the SEP-1 quality measure, despite a documented physician exception for the fluid requirement, continues to incentivize a fluids-first sequence as the institutional default. The second is cultural: the gap between policies that permit peripheral norepinephrine administration and the workflows, scope-of-practice arrangements, and standing orders required to actually start it at the bedside. The third is upstream: time-to-vasopressor is partly a downstream surrogate for time-to-recognition, and interventions that target only the pressor decision miss the larger source of delay. We propose a parallel resuscitation framework with explicit protocolized triggers and stratify implementation considerations across U.S. academic centers, U.S. community emergency departments, and resource-limited international settings. Closing the gap means stopping the physiology argument and rebuilding the operational architecture. Full article

This study investigates broadband vibration and mechanical shock mitigation for an aluminum (AlSi10Mg) battery pack casing by integrating mechanical metamaterial wall modifications and add-on damping structures. A 12.432 kWh underbody-type casing is designed. Two wall architectures, i.e., the star-triangular honeycomb (STH) and a novel hybrid auxetic (NHA), are implemented on three walls (top, front, and rear) of the battery pack casing. A mechanical damping (DSMS) and three biomimetic damping concepts (BWBIS, BPPIS and BBIGPS) are further compared. All designs are evaluated through simulation using random vibration analysis based on ISO 12405-2 standard, followed by shaker-based shock and random vibration experiments. Simulations show that both modified casings suppress the casing vibration by approximately ${10}^2$–${10}^6$ relative to the solid casing, and their dominant peaks shift to above 150 Hz. The NHA casing provides higher overall vibration mitigation than the STH casing (98.07% longitudinal, 95.09% vertical, and 93.60% transverse versus 97.64%, 94.00%, and 91.51%). Thus, the NHA casing is selected for fabrication. In addition, BPPIS and BBIGPS outperform BWBIS and DSMS, and thus, BPPIS is selected for fabrication due to its simpler geometry and lower mass. Experimentally, the solid-BPPIS configuration achieves the most robust random vibration attenuation across all measurement points, with average root mean square (RMS) reductions of 26.82% (vertical), 87.34% (longitudinal), and 83.60% (transverse). Shock tests reveal strong direction dependence; adding damping structures improves longitudinal and transverse shock mitigation, while vertical shock mitigation remains limited. The results provide design-level guidance on selecting wall architectures and damping layouts for practical vibration and shock protection of electric vehicle (EV) battery pack casings. Full article

Background/Objectives: Methylene blue (MB) has re-emerged as an adjunctive vasopressor-sparing therapy in vasoplegic shock states, with emerging evidence supporting its hemodynamic benefits; however, its effect on mortality remains uncertain. We systematically evaluated the effectiveness of MB versus standard therapy in adults with circulatory shock. Methods: We performed a systematic review and meta-analysis of randomized controlled trials registered in PROSPERO (CRD420261326534) and reported according to PRISMA. MEDLINE, Embase, and the Cochrane Library were searched through February 2026. An additional AI-assisted supplementary search was conducted to minimize the risk of missing eligible studies. Eligible studies enrolled adults with shock and compared MB with standard therapy or placebo. The primary outcome was 28–30-day all-cause mortality. Secondary outcomes were renal replacement therapy (RRT), hospital length of stay, and intensive care unit (ICU) length of stay. Risk of bias was assessed with RoB 2. Results: Nine randomized trials involving 535 participants met the eligibility criteria; most evaluated septic shock, while one trial included post-cardiac surgery vasoplegic shock. Eight trials contributed to the quantitative synthesis of mortality. MB was not associated with a statistically significant reduction in short-term mortality. Secondary analyses also did not demonstrate significant pooled effects for RRT, hospital length of stay, or ICU length of stay, although several individual trials reported faster hemodynamic improvement and reduced vasopressor exposure with MB. Overall confidence in the pooled estimates was limited by small sample sizes, clinical heterogeneity, imprecision, and risk-of-bias concerns in some studies. Conclusions: Current randomized evidence does not demonstrate a clear mortality or resource use benefit of MB in adult shock, despite signals of hemodynamic improvement. MB appears promising as an adjunctive therapy, but adequately powered, methodologically rigorous trials are required before its routine early use can be recommended. Full article

Cardiogenic shock (CS) is the most lethal complication of acute myocardial infarction (AMI), with a 30-day mortality of approximately 40–50% despite early revascularization. Temporary mechanical circulatory support (tMCS) devices, including the intra-aortic balloon pump (IABP), microaxial flow pumps (MAFP) and veno-arterial extracorporeal membrane oxygenation (VA-ECMO), are used as adjunctive therapy in refractory shock, but evidence of a survival benefit is limited and often conflicting. The IABP-SHOCK II trial found no 30-day mortality reduction with IABP, supporting a Class III (no benefit) recommendation, whereas the DanGer Shock trial reported a 12.7% absolute mortality reduction at 180 days with the MAFP Impella CP in highly selected patients. In contrast, the ECLS-SHOCK and ECMO-CS trials showed no improvement in survival with early VA-ECMO and noted high complication rates. Real-world data reveal significant disparities between trial populations and clinical practice, highlighting limitations of current evidence, since many AMI-CS patients are older, in more advanced shock or have multiple comorbidities and would not meet typical randomized controlled trial (RCT) inclusion criteria. In clinical practice, in-hospital mortality with IABP or VA-ECMO often exceeds 50–60%. Given the heterogeneity of AMI-CS, rapid identification of appropriate tMCS candidates and personalized therapy are essential. Management guided by individual patient profile, hemodynamic stage and neurological status, supported by multidisciplinary shock teams, may improve timely triage, device selection and outcomes. This review emphasizes the need for individualized, protocol-driven care within structured shock systems to optimize tMCS use in AMI-CS. Full article

This study presents a new version of the ZLindly (ZL) model that improves modeling flexibility while maintaining ease of analysis, allowing for the simultaneous accommodation of redundant zeros, thick-tailed behavior, and complex failure rate dynamics within a unified probabilistic framework. Marshall–Olkin (MO) theory facilitates this advancement. The MOZL hazard rate can exhibit several patterns, including increasing, decreasing, bathtub, or upside-down bathtub-shaped. These features enable the model to capture diverse reliability phenomena such as early-life failures, random shocks, and wear-out effects. Comprehensive theoretical investigations were conducted and shown to be governed by an interpretable dual-parameter mechanism, where the Marshall–Olkin parameter controls tail behavior and dispersion, while the scale parameter regulates skewness and hazard evolution. A likelihood-based approach was developed under Type-II censoring conditions, and rigorous evidence is provided for the existence and uniqueness. To address inferential uncertainty, both classical asymptotic confidence intervals and log-normal approximations were constructed. Within a Bayesian framework, independent gamma priors were assumed, and posterior inference was performed via an efficient Metropolis–Hastings algorithm. Bayesian point and credible estimators were obtained and compared with their classical counterparts. An extensive simulation study demonstrates that Bayesian estimators, particularly with informative priors, consistently outperform likelihood-based estimators in terms of bias, mean squared error, interval length, and coverage probability, especially for moderate sample sizes and higher censoring levels. Three engineering applications are provided to assess the practical utility of the MOZL model, where it provides superior goodness-of-fit relative to 15 competing models, including MO–Exponential, MO–Gompertz, MO–Nadarajah–Haghighi, MO–Exponentiated Weibull, and Birnbaum–Saunders, among others. Overall, the proposed MOZL distribution emerges as a flexible, interpretable, and computationally efficient lifetime model whose structurally meaningful parameter interactions enhance distributional balance and flexible hazard behavior, thereby contributing to modern symmetry-oriented distribution theory while offering valuable applications in reliability engineering, survival analysis, and applied statistical modeling. Full article

Despite advances in septic shock management, optimal vasopressor strategies remain understudied. Norepinephrine (NE) is recommended as the first-line vasopressor for restoring arterial pressure; however, excessive catecholamine exposure has been associated with adverse events, including arrhythmias, ischemia, and poor clinical outcomes. While the early initiation of NE is increasingly recognized as important, uncertainty persists regarding the optimal starting dose and escalation strategy. In septic shock, particularly refractory septic shock, reduced vascular responsiveness may limit the effectiveness of escalating NE doses and increase the risk of dose-related complications. Vasopressin (AVP), a non-adrenergic vasopressor, provides complementary mechanisms to NE and may reduce catecholamine requirements. Randomized trials have not consistently demonstrated a survival benefit; AVP may improve hemodynamic stability and renal perfusion. Emerging evidence suggests the potential advantages of earlier AVP initiation at lower NE doses than those currently recommended. Collectively, the current evidence supports a strategy that prioritizes early and adequately dosed NE to achieve rapid hemodynamic stabilization, followed by the timely initiation of AVP once moderate NE requirements are reached, rather than the continued escalation of NE alone. Such an integrated approach may help balance efficacy and safety, and minimize catecholamine-related harm while optimizing perfusion in septic shock cases. Full article

Road infrastructure projects are frequently affected by cost overruns driven by volatility in critical construction inputs and by the uneven association between external market shocks and material price movements. However, existing studies still provide limited evidence on how comparative forecasting, temporal price-signal diagnostics and probabilistic simulation can be integrated into a contingency-oriented decision framework. This study examines how construction input price forecasting and probabilistic simulation can inform contingency estimation in a road infrastructure case study. The empirical application is based on a Peruvian bridge project and combines benchmark-oriented forecasting using Bi-GRU and Random Walk models, descriptive temporal diagnostics based on lead–lag assessment and rolling-correlation analysis, and Monte Carlo simulation. Monthly series for structural steel, construction steel, cement, and diesel were transformed into log-returns and evaluated under a strict chronological design, while oil, the exchange rate, and the consumer price index were incorporated as exogenous variables. The Random Walk model produced lower forecasting errors for most inputs, achieving lower RMSE values in seven of the eight input-period comparisons; Bi-GRU outperformed it only for diesel in the test subset, with a 7.24% lower RMSE. From a project cost-risk perspective, the P95 contingency was estimated at 3.92% under Bi-GRU and 3.96% under Random Walk, indicating a similar upper-percentile contingency envelope under both forecasting specifications. The findings support contingency as a confidence-based budgeting decision rather than a fixed percentage. Full article

Background/Objectives: Acute gastrointestinal (GI) emergencies require timely and accurate prediction of surgical necessity to avoid delayed intervention and improve patient outcomes. Traditional scoring systems offer limited accuracy and fail to integrate multimodal data. This study aimed to develop and validate an explainable machine learning model for early prediction of surgical necessity in patients presenting with GI emergencies. Methods: A retrospective cohort of 1032 consecutive adult patients admitted with acute GI emergencies at a tertiary referral center (2019–2024) was analyzed. Three predictive models were developed: logistic regression, Random Forest, and XGBoost. Features included clinical, laboratory, and contrast-enhanced CT imaging variables available within the first 24 h. Model performance was evaluated using AUC, sensitivity, specificity, PPV, NPV, and F1-score. Shapley Additive Explanations (SHAP) were applied for global and individual-level interpretability. The study followed STROBE and TRIPOD+AI reporting guidelines. Results: Surgical intervention was required in 312 patients (30.2%). The XGBoost model achieved the highest AUC (0.89; 95% CI: 0.86–0.92), outperforming Random Forest (AUC 0.86) and logistic regression (AUC 0.79), with sensitivity 0.84, specificity 0.81, and NPV 0.90. The most influential predictors were serum lactate, CT findings (free intraperitoneal air, bowel ischemia), IL-6, and shock index. Decision curve analysis confirmed net clinical benefit across threshold probabilities of 10–70%. Subgroup performance remained robust across diagnostic categories (AUC 0.87–0.91). Conclusions: An explainable XGBoost model integrating early clinical, laboratory, and imaging data accurately predicts surgical necessity in GI emergencies and outperforms traditional scoring systems. SHAP-based explainability supports clinical adoption and transparency. Prospective multicenter validation is warranted. The positive predictive value of 0.74 indicates that approximately one in four patients flagged as requiring surgery may not need operative intervention. The model should be regarded as a decision-support adjunct, rather than a standalone surgical decision tool, that is most relevant in settings where immediate experienced surgical judgment is limited. Full article

Small satellites provide cost-effective platforms for environmental monitoring. Open-source commercial off-the-shelf (COTS) hyperspectral payloads, such as those launched with HYPSO-1 and -2, have a ground sampling distance (GSD) of 100 m. However, detecting smaller features, such as water quality in lakes, requires a GSD below 10 m and a high signal-to-noise ratio. Terrestrial COTS Schmidt–Cassegrain telescopes lack launch-load stiffness and in-orbit refocus capability. This study presents a deployable modified COTS (MCOTS) Schmidt–Cassegrain telescope that uses the original optical COTS components, a 3D-printed high-performance polymer (HPP) structure, and a dual-lead-screw deployment and focusing mechanism. The telescope has a stowed length of 280 mm and deploys to an additional 110 mm, making integration into a 16U platform with a payload length of 290 mm feasible. The modified structure is evaluated using shock and sine-sweep vibration testing, with collimation and focus verified before and after testing. Collimation remained concentric within measurement uncertainty. Complementary random-vibration finite-element simulations predicted a $3\sigma$ von Mises stress of 26.5 MPa, yielding a safety factor of 2.8. The results demonstrate a feasible pathway for adapting COTS telescopes toward space-grade COTS (SCOTS) payloads, bridging the gap between rapid production, cost efficiency, and performance for small Earth observation missions. Full article

Standard asset pricing models treat price dynamics as a stochastic process driven by undifferentiated random noise, rendering them agnostic about the primary engine of price discovery: the arrival of economically significant information. This paper introduces ORAKULUM, a structured Information-Impact Asset Pricing Model that reconceptualises the log-price as a signed information ledger. Each market-relevant event appends a weighted entry that either permanently revises the market consensus or temporarily disturbs it before decaying exponentially toward the new equilibrium. Mathematically, ORAKULUM is a jump-diffusion process combining a Wiener component for continuous micro-uncertainty with a Poisson-driven jump component for discrete macroeconomic and geopolitical shocks. The log-price identity $x\left(t\right)=x\left(0\right)+\mu ·t+\sum A_i+\sum B_i·e^{(-\gamma \left(t-t_i\right))}+\sigma ·W\left(t\right)$ decomposes price dynamics into permanent and transient information impact, admits a natural event catalogue calibration, and supports Monte Carlo scenario simulation. We present the complete theoretical foundations, a closed-form expected path solution, a gradient-descent calibration procedure, and a fully documented Python3 reference implementation. An empirical illustration applies the model to XAU/USD and EUR/USD market data downloaded from Yahoo Finance, demonstrating ORAKULUM’s capacity to generate economically interpretable, real-time prediction clouds in response to central bank communications, inflation releases, and geopolitical shocks. Full article

This study examines the nonlinear, threshold-dependent relationship between financial leverage and firm performance in publicly traded tourism firms in Turkey, and investigates how this relationship has evolved under post-COVID-19 multi-shock conditions. The main aim of the research is to identify the thresholds at which borrowing becomes a source of financial vulnerability and to analyse how this process deepens under macroeconomic shocks. For this purpose, quarterly panel data covering the period from Q1 2012 to Q1 2025 for 22 tourism firms listed on Borsa Istanbul were used. Firm performance was measured through accounting-based indicators Return on Asset(ROA) and Return on Equity(ROE), and a market-based indicator (stock returns). In the empirical analysis, both the random-effects panel regression model and the endogenous-threshold panel regression methods were applied. The findings indicate that the relationship between financial leverage and performance is nonlinear, and a significant regime change occurs when the leverage ratio exceeds approximately 60–70%. In the post-COVID-19 period, both accounting-based and market-based performance indicators under high-leverage regimes became more sensitive to financial vulnerability. Additionally, the effects of the real effective exchange rate and the service sector price index on firm performance have strengthened in the post-crisis period. The study reveals that financial fragility in the tourism sector is a structural feature sensitive to thresholds and crisis regimes rather than temporary shocks. In this regard, the research highlights the limits of debt-based growth strategies and contributes to early warning mechanisms for policymakers, investors, and firm managers. Full article