Search Results (1,514)

Thyroid tumors rank among the most frequently occurring endocrine cancers because early detection helps doctors deliver effective treatments that lead to better patient results. Ultrasound imaging enables the detection of thyroid nodules, yet medical professionals struggle to differentiate between benign and malignant nodules through their diagnostic tests. This study introduces a new medical framework that enables thyroid nodule diagnosis through ultrasound imaging. The proposed model combines advanced segmentation with feature extraction, classification, and reasoning components to create a complete system. The specialized segmentation method shows accurate results when it detects nodule boundaries, which leads to better analysis of specific regions. The Hybrid Vision Transformer (HVT) operates to capture detailed textural information together with complete environmental patterns, which boosts its ability to classify different elements. The proposed framework incorporates a Large Language Model (LLM), specifically Med-PaLM, to provide context-aware clinical reasoning and interpretation. The structured evaluation process uses Thyroid Imaging Reporting and Data System (TI-RADS)-based feature scoring to compare model results with designated clinical standards. The diagnostic process is enhanced through the use of a language model, which delivers contextual understanding and produces valuable information from features that have been extracted. The proposed model achieves excellent performance with accuracy at 98.5%, precision at 98.7%, recall at 98.4%, and F1-score at 98.5%, which demonstrates its capacity for accurate and equivalent performance across different classifications. The experimental results demonstrate that the model achieves better results than existing methods. The combination of multimodal data with clinical reasoning improves both the accuracy and the user experience of the system. The proposed framework provides an efficient, interpretable, and scalable solution for thyroid nodule diagnosis. Full article

Mass-based circularity indicators, such as ISO 59020:2024, quantify material recovery as a share of total throughput but do not account for chemical composition or functional performance, as a consequence of their sector-agnostic design. In copper metallurgical systems, trace tramp elements (e.g., As, Sb, Bi, Fe, Sn, Ni) present in WEEE-derived scrap, anode slimes, and refinery residues can significantly reduce electrical conductivity. Even at nominal purities of ≥99.7 wt.% Cu, conductivity may drop to 85.0–88.0% IACS, as illustrated by selected reported cases—a level of functional degradation that remains undetected by mass-based accounting. Analysis of Grade A cathode standards (EN 1978:2022, LME Cu-CATH-1, ASTM B115-10:2021) shows that impurity limits as low as 2 ppm (Bi) constrain the achievable share of secondary feed in closed-loop recycling. For a specific flash-smelting–refinery configuration, modeling indicates that secondary feed shares above approximately 30% may lead to impurity accumulation beyond the stated specification constraints unless low-impurity primary copper is introduced. This study introduces the Quality-Adjusted Circularity Indicator (QACI), a conceptual, specification-constrained indicator framework that applies a dilution factor f_dil derived from a binary blending mass balance to adjust ISO 59020:2024 inflow-based circularity indicators using a feed-composition blending constraint anchored to Grade A specification limits. The QACI functions as a feed-composition screening indicator operating at the anode blending stage and does not represent a correction of the full electrorefining system. Parametric scenario analysis across six stylized impurity configurations shows that, at identical mass-based circularity (C_mass = 25%), the QACI ranges from 7.1% to 25.0%. This corresponds to a 1.3- to 3.5-fold difference between the mass-based and quality-adjusted indicator values under the stated feed-composition assumptions, illustrating the potential overestimation introduced when feed-quality constraints are not considered. This ratio quantifies the divergence between two indicator values under stylized conditions and should not be interpreted as a directly measured fold-difference in actual loop-closure performance. Positioned within the ISO 59020:2024 Annex C complementary method space, the QACI is positioned as a first-order screening approach of existing circularity metrics that may inform future research discussion of quality-differentiated approaches in EU secondary metals policy. Full article

Background/Objectives: Computer-aided surgical planning (CASP) technologies, including virtual surgical planning (VSP), 3D printed cutting guides, and patient-specific implants, have been increasingly applied to deep circumflex iliac artery (DCIA) free flap reconstruction of maxillofacial defects. Despite growing adoption, no systematic review has specifically evaluated their accuracy and clinical outcomes. This study aimed to comprehensively assess the impact of CASP on reconstruction accuracy, operative efficiency, flap survival, and implant rehabilitation in DCIA flap surgery. Methods: A systematic search of PubMed, Web of Science, and Google Scholar was conducted following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 guidelines. Studies reporting CASP-assisted DCIA free flap reconstruction with three or more patients were included. Methodological quality was assessed using the Methodological Index for Non-Randomized Studies (MINORS) checklist and the Cochrane Risk of Bias 2.0 tool for the randomized controlled trial (RCT). Results: Thirty studies (1 RCT, 13 comparative, and 16 non-comparative) involving 844 patients were included. VSP with 3D-printed cutting guides was the most frequently used technology (n = 22). Mean linear deviations between planned and actual outcomes ranged from 0.40 to 4.4 mm, with most studies reporting 0.7–2.7 mm. The sole RCT demonstrated significantly better accuracy (1.3 vs. 5.5 mm, p < 0.001) and shorter reconstruction time (16 vs. 39 min, p < 0.001) with CASP. Flap survival ranged from 90% to 100%. Conclusions: CASP technologies, particularly VSP with 3D-printed cutting guides, appear to improve the accuracy and predictability of DCIA flap reconstruction. However, the evidence base is predominantly retrospective and heterogeneous; prospective multicenter studies with standardized outcome measures are needed before definitive clinical guidelines can be established. Full article

In recent years, non-financial reporting has become a central regulatory instrument for integrating environmental considerations into corporate accountability frameworks in the European Union. This study examines regional variation in mandatory environmental disclosures contained in corporate sustainability reports prepared under the Non-Financial Reporting Directive (NFRD) and the Corporate Sustainability Reporting Directive (CSRD). The analysis adopts a regional perspective, assuming that more economically developed regions are associated with greater environmental pressures and therefore exhibit more comprehensive environmental reporting practices. Regions are classified at the NUTS 2 level using GDP per capita in purchasing power standards (PPSs), enabling a systematic comparison between more and less developed regions across the EU. The empirical analysis relies exclusively on publicly available corporate sustainability reports and is deliberately limited to legally mandated environmental disclosures. A structured qualitative content analysis is applied to 20 companies operating across multiple EU Member States, with firms assigned to regions based on the location of their registered headquarters. The results provide exploratory evidence of a positive association between regional economic development (GDP per capita at the NUTS 2 level) and the comprehensiveness of mandatory environmental disclosures. The results provide empirically grounded insights into the strengths and limitations of mandatory sustainability reporting as a governance mechanism and contribute to ongoing debates on the capacity of the CSRD to enhance sustainability-oriented corporate accountability across diverse regional contexts within the EU. Full article

The energy recovery of biomass is frequently implemented through single-output systems or passive management schemes, resulting in underutilization of its thermodynamic potential and losses in economic value, climate benefits, and useful co-products. This study formalizes the concept of biopolygeneration as a diagnostic principle aimed at maximizing biomass utilization through the simultaneous production of multiple energy services and the valorization of secondary streams. A dimensionless metric, the Biopolygeneration Diagnostic Index (BDI), is proposed to quantify this concept. The index is bounded within $[0,1]$ and integrates five sub-indices: energy efficiency ($I_E$), thermal integration ($I_T$), energy self-sufficiency ($I_A$), exergetic quality of outputs ($I_Q$), and co-product valorization ($I_V$). Weights were determined using the Analytic Hierarchy Process ($w_1=0.40$, $w_2=0.24$, $w_3=w_4=0.14$, $w_5=0.08$; $\mathrm{CR}=0.007$). The BDI was evaluated using six cases, including five operating plants and one validated computational model representing five biomass conversion technologies in four countries. Results ranged from 0.453 for an engine without combined heat and power (CHP) to 0.733 for a cascade trigeneration system. Under identical feed conditions, the incorporation of CHP ($C1\to C2$) increased the BDI from 0.453 to 0.715, representing a 57.7% improvement attributable solely to heat recovery. Current limitations include the small validation sample ($n=6$) and the reconstruction of $I_A$ and $I_V$ from technological characteristics due to the absence of standardized reporting in the literature. Although these sub-indices account for only 22% of the total weighting ($w_{I_A}+w_{I_V}=0.22$), the present results should be considered a proof of concept rather than a fully empirical validation. The BDI provides a thermodynamically consistent framework for comparing bioenergy systems across technologies and supports technical, regulatory, and investment decision making. Broader validation using larger measurement-based datasets is required before claims of universality can be established. Full article

This study explores the effect that the adoption of International Financial Reporting Standards (IFRS) 9 has on credit risk in commercial banks in Cambodia, focused primarily on non-performing loans (NPLs) as a significant indicator. In the static and dynamic panel estimations, the analysis shows that the NPL behavior is best characterized using a dynamic specification, which passes relevant diagnostic tests and leads to evidence of persistence and endogeneity, which has not been conducted in Cambodia yet. The study covered the period from 2013 to 2024. During this period, 26 commercial banks had complete datasets. Combining time-series and cross-sectional data, the total sample size was 312 observations. The results show substantial path dependence in NPLs, suggesting credit deterioration is persistent and that early measures are needed. We find evidence that the adoption of IFRS 9 is positively and significantly associated with increased measures of NPLs, though we interpret this as consistent with improved transparency and forward-looking recognition of expected credit losses—and not indicative of deterioration in underlying asset quality. Bank-specific determinants such as profitability, size, leverage, and liquidity emerge as key predictors of credit risk; banks with stronger financial fundamentals experience improved asset quality. Macroeconomic factors like economic growth are key to decreasing NPLs in the dynamic framework as well. The results highlight the need for forward-looking accounting standards, prudent bank-level practices, and macroeconomic stability. Policy issues include increased supervisory vigilance, legal conservatism when assessing IFRS 9-related indicators, a revision of the capital and liquidity regulatory framework in relation to counterparties operating with them, as well as coordinated macroeconomic policies aiming at boosting the financial system—economy arterial connection. Full article

Background/Objectives: Arboviruses including dengue virus (DENV), Zika virus (ZIKV), chikungunya virus (CHIKV), yellow fever virus (YFV), and West Nile virus (WNV) co-circulate across the Americas, generating overlapping febrile syndromes that challenge etiological diagnosis based solely on clinical criteria. Cartridge-based multiplex molecular platforms offer potential for decentralized testing in hyperendemic settings, yet independent real-world evaluations of their clinical and analytical performance remain limited. Methods: A retrospective two-phase analytical study was conducted. Phase 1 assessed clinical diagnostic accuracy for dengue using 163 de-identified serum samples classified using a composite reference standard consisting of Panbio NS1 ELISA reactivity (≥11 Panbio units) combined with compatible clinical and epidemiological data, operationalized in accordance with the PAHO 2023 laboratory confirmation algorithm for dengue; RT-qPCR was not routinely available for all archived samples, and reported sensitivity should therefore be interpreted as a conservative lower-bound estimate; Phase 2 evaluated analytical sensitivity across all eight panel targets using characterized arboviral reference strains in serial dilution experiments, with reference RT-qPCR assays as the comparator; this phase was incorporated to characterize detection thresholds for targets not represented by clinical specimens. Results: In Phase 1, the M10 demonstrated sensitivity of 96.0% (96/100), specificity of 100% (63/63), overall accuracy of 97.5%, and near-perfect agreement with the reference standard (Cohen’s κ = 0.95). DENV-3 was the predominant serotype (74/96; 77.1%), followed by DENV-1 (16.7%) and DENV-4 (6.3%); DENV-2 was not detected. In Phase 2, operational LoDs (defined as the lowest concentration yielding a detectable Ct in all triplicate reactions for the RT-qPCR, and from a single cartridge per dilution point for the STANDARD M10) were equivalent or superior to reference RT-qPCR for six targets (DENV-1, DENV-3, DENV-4, ZIKV, WNV, YFV; range 1–5 PFU/mL), while DENV-2 and CHIKV showed 20-fold higher operational LoDs (20 PFU/mL vs. 1 PFU/mL for the reference RT-qPCR); formal LoD₉₅ estimates were not determined. Conclusions: The STANDARD M10 Arbovirus Panel shows high clinical accuracy for dengue and adequate analytical sensitivity for most targets, supporting its use as a complementary decentralized molecular tool. Reduced sensitivity for DENV-2 and CHIKV and the absence of formal LoD₉₅ estimates remain key limitations to be addressed in future validation studies. Full article

The adoption of neoadjuvant immune checkpoint inhibitor (ICI)-based chemoimmunotherapy has fundamentally transformed the operative landscape of resectable non-small cell lung cancer (NSCLC). Surgeons are now routinely confronted with ICI-altered tissue planes characterized by hilar fibrosis, vascular friability, and disrupted lymph node architecture. Simultaneously, robotic-assisted thoracic surgery (RATS) has consolidated its position as the dominant minimally invasive platform for pulmonary resection, accounting for the majority of lobectomies and segmentectomies performed at high-volume centers in 2023. Whether RATS confers specific technical advantages in this increasingly complex operative context remains incompletely characterized. We conducted a structured narrative review of published evidence, synthesizing data from randomized controlled trials, prospective cohorts, national registry analyses, and emerging technology reports addressing RATS in the setting of neoadjuvant ICI-based therapy for NSCLC. A systematic literature search was conducted across PubMed and EMBASE using predefined search terms. Available evidence, though largely retrospective and limited by small sample sizes, consistently demonstrates that RATS after neoadjuvant chemoimmunotherapy is technically feasible and oncologically sound, with R0 resection achievable in virtually all cases. The enhanced three-dimensional visualization, tremor filtration, and instrument degrees of freedom afforded by robotic platforms appear particularly advantageous in the setting of dense hilar adhesions and fragile pulmonary vasculature. Lymph node yield, a recognized robotic advantage, is preserved or enhanced despite post-ICI fibrosis. Pooled conversion rates to thoracotomy, derived from post hoc surgical analyses of ICI trial populations rather than trials designed to measure conversion, are higher than for upfront resection; available retrospective single-center data, including one direct RATS-versus-VATS comparison, suggest lower conversion rates with RATS in experienced hands, though this conclusion requires prospective validation. Emerging platform integrations, including combined robotic bronchoscopy and thoracoscopic surgery, single-port systems, and artificial intelligence-assisted anatomical navigation, are poised to further extend the reach of minimally invasive surgery in this challenging clinical scenario. In experienced centers, RATS appears to offer a technically favorable minimally invasive platform for pulmonary resection after neoadjuvant ICI-based therapy, with potential advantages over VATS in managing immunotherapy-altered anatomy; however, this conclusion is derived from retrospective series and should be interpreted cautiously pending prospective comparative data. Prospective multicenter trials with standardized surgical endpoints are urgently needed. Full article

Background/Objectives: Epidermolysis bullosa (EB) comprises a heterogeneous group of rare inherited skin-fragility disorders in which even minimal trauma can cause blistering, chronic wounds, scarring, and functional impairment. After surgical release of EB hand deformities, wound coverage is challenging because autologous split-thickness skin grafting creates an additional donor-site wound in already fragile tissue. This preliminary case series reports our single-center pediatric experience using intact fish skin grafting (iFSG) as an adjunct after EB hand surgery. Methods: We conducted an observational case series of five pediatric patients with dystrophic EB, including eight operated hands, treated between December 2022 and December 2025. iFSG was applied after the release of contractures and/or pseudosyndactyly. Primary outcomes were time to complete re-epithelialization, need for re-application, need for autologous grafting, and early complications. Secondary outcomes included dressing-related pain assessed with an age-appropriate visual analog scale during awake dressing care, dressing burden, and early recurrence signals. Results: The iFSG application was feasible in all cases. One localized second application was required, and no patient required autologous split-thickness skin grafting. Mean dressing-related pain was 1.6 on the visual analog scale, and mean time to complete re-epithelialization was 47.6 days. No allergic reactions occurred. Healing was slower in the two most severe bilateral mitten-hand cases, and one patient developed limited dorsal disepithelialization attributed to prolonged dressing contact on extremely fragile skin. One partial recurrence of pseudosyndactyly was observed during follow-up without the need for revision surgery. Conclusions: iFSG was feasible in this small preliminary pediatric dystrophic EB hand surgery series and may provide a biologically active scaffold that supports secondary closure while avoiding autologous donor-site creation. Because of the rarity of the disease, the limited sample size, the absence of a comparator group, and the limited follow-up, these findings should be interpreted cautiously. Larger multicenter studies with standardized functional, pain, recurrence, and caregiver-reported outcomes are needed to define the role of iFSG in EB hand reconstruction. ABILHAND-Kids was also administered to patients/caregivers and suggested encouraging perceived improvement in postoperative hand use and independence in daily activities. Full article

Fourth-generation immunoassays are widely used for HIV and syphilis screening; however, false-reactive results may increase confirmatory testing and operational burden in high-throughput laboratories. This study evaluated the comparative performance of automated chemiluminescent immunoassays (MAGLUMI^® HIV Ab/Ag Combi (Snibe Diagnostics Co. Ltd., Shenzhen, China), VITROS^® ECiQ HIV Combo (Ortho Clinical Diagnostics, Raritan, NJ, USA), MAGLUMI^® Syphilis (Snibe Diagnostics Co. Ltd., Shenzhen, China), and ARCHITECT^® Syphilis TP (Abbott Diagnostics, Abbott Park, IL, USA) within a routine diagnostic algorithm, incorporating antibody differentiation immunoassays (INNO-LIA^® HIV I/II Score (Fujirebio Europe N.V., Ghent, Belgium) and HIV-1 RNA PCR where applicable. A total of 240 archived serum samples for HIV testing and 180 for syphilis testing were analyzed. Agreement-based performance measures including sensitivity, specificity, overall percent agreement (OPA), and Cohen’s kappa (κ) were calculated as comparator-based estimates reflecting concordance within the routine diagnostic algorithm rather than absolute diagnostic accuracy against a universal reference standard. For comparisons with HIV-1 RNA PCR, positive and negative concordance rates are reported to reflect agreement between assays detecting different biological targets. Among samples with definitive (positive or negative) results, the MAGLUMI^® HIV Ab/Ag Combi assay showed complete agreement with INNO-LIA^® HIV I/II Score (κ = 1.00) and high agreement with PCR within the ARCHITECT^® HIV Ag/Ab Combo-reactive subset (κ = 0.90). The VITROS^® ECiQ HIV Combo assay demonstrated high agreement with INNO-LIA^® HIV I/II Score (κ = 0.916) and substantial agreement with PCR (κ = 0.715), with a lower negative concordance rate with PCR observed in the ARCHITECT-reactive subset. A parallel five-modality analysis of 11 discordant samples applying the CDC 2014 algorithm demonstrated that all three immunoassay platforms successfully detected confirmed HIV-seropositive individuals with controlled viremia despite negative PCR, while MAGLUMI^® HIV Ab/Ag Combi produced fewer false-reactive results than both ARCHITECT^® and VITROS^® in this discordant subset. Additionally, two cases showed INNO-LIA^® indeterminate results with positive PCR, consistent with acute HIV infection during the early seroconversion stage; all three immunoassay platforms produced signals above the non-reactive threshold in both cases. For syphilis testing, both MAGLUMI^® Syphilis and ARCHITECT^® Syphilis TP assays showed complete agreement with INNO-LIA^® Syphilis Score among samples with definitive results (κ = 1.00). In contrast, the RPR assay showed reduced positive predictive value (49.4%) and moderate agreement with INNO-LIA^® Syphilis Score (κ = 0.52). Automated chemiluminescent immunoassay (CLIA) platforms demonstrated high agreement within a structured diagnostic algorithm in a high-throughput screening setting. Differences in assay performance were observed across platforms, particularly with respect to discordant results in the ARCHITECT-reactive PCR-evaluated subset for HIV and non-treponemal concordance for syphilis. These platforms may support more efficient laboratory workflows; however, findings should be interpreted within the context of comparator-based classification rather than absolute diagnostic accuracy. Full article

Compression tests are widely used to characterize cereal kernels, yet the loading rate is often treated as a secondary methodological factor, despite the fact that the ASAE S368.4 procedure recommends a low crosshead speed, whereas industrial size-reduction operations involve much faster and more complex loading conditions. This mismatch limits the direct transfer of laboratory data to milling practice and makes it difficult to compare results obtained under different test settings. The aim of this study was therefore to determine how grain moisture content and loading rate (crosshead speed) affect kernel damage and selected mechanical properties of bread wheat cultivars (Bataja and Tytanika) and feed wheat cultivars classified in the Polish C quality group (Lawina and Sikorka). Before the analyses, kernels were adjusted to five moisture levels: 10%, 12%, 14%, 16%, and 18% on a wet basis (w.b.). Compression tests were conducted at six crosshead speeds: 1, 3, 5, 10, 30, and 50 mm min⁻¹. The conversion ratio of mechanical properties determined relative to 1 mm min⁻¹ and 10% moisture content ranged from 0.46 to 2.59, confirming that both factors markedly changed kernel response. Rupture force generally decreased with increasing moisture content, whereas longitudinal strain, relative strain and rupture energy increased. A distinct decrease in all mechanical parameters was observed at 10 mm min⁻¹, and this effect became more pronounced at higher moisture contents. The results indicate that the loading rate should be reported and controlled in wheat kernel compression tests and should be considered when laboratory measurements are used to support milling optimization. However, the proposed value of 10 mm min⁻¹ should be interpreted as a promising laboratory reference point rather than as a direct industrial operating standard. Full article

Background/Objectives: Establishing laparoscopic access remains a critical and complication-prone step in minimally invasive surgery. Previous work has shown that proximal vibroacoustic sensing can identify peritoneal puncture events in porcine cadavers. The present pilot study evaluated whether these findings translate to human anatomy under controlled, ex vivo conditions. Methods: A vibroacoustic sensing prototype was proximally attached to a standard Veress needle during 14 insertions into a fresh human body donor (within 48 h post-mortem). An endoscope was introduced laterally to provide visual ground truth of peritoneal entry. Vibroacoustic signals were recorded at the proximal end of the instrument. Time–frequency analyses, transient excitation detection, and statistical comparisons were performed to assess whether (1) peritoneal puncture can be identified in the vibroacoustic signal, (2) signal phases and dynamics correspond to those previously observed in porcine cadavers, and (3) peritoneal punctures can be statistically differentiated from non-peritoneal events. Results: All 14 peritoneal punctures were identifiable in the vibroacoustic signal under the experimental conditions. Characteristic signal phases previously described in porcine tissue, including transient excitation associated with cavity entry, were consistently reproduced with comparable temporal and spectral profiles. Statistical analyses demonstrated group-level differences between peritoneal and non-peritoneal events, and the peritoneal puncture was the highest-energy event of its insertion in 13 of 14 cases (92.9%). Conclusions: Under the controlled ex vivo conditions of this single-donor pilot study, vibroacoustic sensing was feasible for identifying peritoneal puncture in human tissue and reproduced signal dynamics observed in porcine models. To our knowledge, this is the first demonstration of the proximal vibroacoustic sensing concept on a human body donor and the first cross-species replication of the previously reported puncture phase structure, establishing an important translational stepping stone between animal cadaver studies and in vivo investigations. The study demonstrates feasibility rather than clinical reliability: the single-donor design and the retrospective annotation framework limit generalizability. Prospective validation in living patients, across multiple subjects and operators, is required before clinical deployment. Full article

Background: Food contamination in institutional food service settings remains a significant public health concern, particularly where large numbers of consumers are exposed daily. This study aimed to assess chemical and microbiological contamination, evaluate food handlers’ knowledge, attitudes, and practices (KAP), and identify contamination patterns in university food outlets. Methods: A cross-sectional study was conducted across all 77 food outlets within a university in northern Thailand. KAP was assessed using a structured questionnaire, while chemical and microbiological contamination were evaluated using standard screening methods. Results: Food handlers demonstrated generally high KAP scores; however, microbiological contamination was still observed, including Escherichia coli on food handlers’ hands (27.3%) and food-contact utensils (14.3%), as well as Salmonella spp. in ready-to-eat food (6.5%). In contrast, chemical contamination was rarely detected in screening tests. Moreover, cluster analysis identified four distinct contamination patterns, indicating heterogeneity in contamination risk across outlets. Conclusions: These findings suggest that reported food safety practices may not fully prevent contamination and that food safety management should incorporate both behavioral and operational controls to effectively reduce contamination risks in institutional settings. Full article

This study examines how entrepreneurial ecosystem constraints shape MSME resilience in the Jakarta–Bogor–Depok Indonesia corridor using a qualitative multiple-case design. Drawing on 20 MSME case reports across food and beverage, retail, services, and small-scale manufacturing, the study addresses two questions: (1) which ecosystem domains are the most binding constraints, and (2) how MSMEs convert ecosystem resources into resilience outcomes. The analysis shows that market pressure is the most universal constraint (20/20 cases), followed by digital-managerial support infrastructure gaps (18/20), supply chain volatility (13/20), and finance, human capital, and institutional constraints (each 12/20 cases). Cross-case evidence identifies four recurrent mechanisms: market pressure is managed through digital channel orchestration and customer engagement; capital constraints are managed through internal cash discipline and partnership-based financing; input volatility is managed through supplier diversification, local sourcing, and inventory control; and skill gaps are managed through internal training and process standardization. Building on these mechanisms, the study develops a threefold resilience typology: Adaptive Leaders, Operational Survivors, and Vulnerable Traditionalists. The main theoretical contribution is to show that MSME resilience is configurational and depends on inter-domain alignment rather than on isolated ecosystem components or entrepreneur-level grit alone. The practical contribution is a typology-based policy logic that prioritizes integrated intervention bundles, which are finance, digital capability, operations, supply chain, and managerial upgrading, over fragmented support programs. Full article

Background and Objectives: Persistent quadriceps weakness, muscle atrophy, and functional deficits are common following anterior cruciate ligament (ACL) reconstruction and may compromise return to sport and increase the risk of reinjury. Eccentric-oriented strength training has been widely used to enhance muscle strength and hypertrophy in various musculoskeletal conditions; however, its specific application within ACL rehabilitation remains insufficiently explored. The aim of this scoping review was to map the existing evidence on the use of eccentric-oriented strength training in ACL rehabilitation, identify gaps in the current literature, and provide suggestions for future research. Materials and Methods: A scoping review search was conducted in PubMed, Scopus, Web of Science, and PEDro from inception to February 2026 using the following keywords and Boolean operators: (“anterior cruciate ligament”, “ACL”, “anterior cruciate ligament reconstruction”, “ACLR”) AND (“eccentric training”, “eccentric exercise”, “eccentric loading”, “flywheel training”, “isoinertial training”). Eligible studies included studies that investigated eccentric exercises as part of ACL rehabilitation and reported outcomes related to muscle strength, muscle morphology, functional performance, or return to sport. Data were extracted and synthesized descriptively in accordance with the PRISMA-ScR extension for Scoping Reviews guidelines. Methodological quality and risk of bias were evaluated using the PEDro scale (RCTs) and the ROBINS-I tool (non-randomized studies). Results: Fifteen studies met the inclusion criteria. The included literature primarily examined isokinetic eccentric exercise, eccentric cycling, early progressive eccentric resistance training, Nordic hamstring exercise, eccentric ergometry, and flywheel strength training. Most studies reported improvements in quadriceps strength and muscle morphology, with additional benefits observed in functional performance measures (i.e., hop tests), gait mechanics, and limb symmetry. Evidence was unevenly distributed across rehabilitation phases, with relatively few studies focusing on the mid-phase of ACL rehabilitation. Conclusions: Eccentric-oriented strength training represents a promising but underexplored component of ACL rehabilitation. However, the existing literature lacks standardized protocols, comprehensive outcome measures, and phase-specific guidance, particularly during the mid and late stages of rehabilitation. Further high-quality studies are needed to clarify the optimal timing, dosage, and integration of eccentric training across rehabilitation phases. Full article