Search Results (1,639)

Background: Acute bronchiolitis is among the most common causes of lower-respiratory-tract infection in infancy and remains a clinically heterogeneous syndrome. Current international guidelines recommend supportive management and generally discourage routine bronchodilator administration; however, a subset of patients may be physiologically responsive. Tidal-breathing analysis (TBA) is a non-invasive, bedside method for objectively assessing respiratory mechanics and may objectively quantify physiological changes following bronchodilator administration in older children. Case Presentation: We report the case of a 23-month-old boy presenting with a severe RSV bronchiolitis-like wheezing illness complicated by acute respiratory failure. Bronchodilator responsiveness was evaluated using predefined TBA parameters before and after administration of an inhaled bronchodilator. Following treatment, the patient’s time to peak tidal expiratory flow (tPTEF) increased from 0.17 to 0.33 s (+94%), while his tPTEF/TE ratio increased from 0.12 to 0.27 (+125%). Expiratory time (TE) and total respiratory cycle duration (Ttot) decreased by 12.6% and 5.1%, respectively, whereas tidal volume (VT) and minute ventilation (MV) increased by 12.1% and 18.3%. Peak expiratory flow remained unchanged (0.14 L/s before and after bronchodilator administration). Discussion: To the best of our knowledge, this is among the first reports of using bedside TBA to characterize acute bronchodilator responsiveness in a severe bronchiolitis-like illness. The improvement in expiratory timing indices, along with the shorter expiratory time without changes in peak expiratory flow, is consistent with improved expiratory flow dynamics following bronchodilator administration. These findings could support the hypothesis that a bronchodilator-responsive physiological phenotype may exist. Previous studies have demonstrated an association between severe bronchiolitis during infancy and subsequent recurrent wheezing or asthma; however, whether acute bronchodilator responsiveness, measured objectively via TBA, is an indication of this phenotype represents a testable hypothesis for future longitudinal studies. Conclusions: This case illustrates the feasibility of bedside TBA for identifying physiological bronchodilator responsiveness in severe bronchiolitis-like illness. Prospective longitudinal studies should be conducted to determine whether TBA-defined responsiveness represents an early physiological marker requiring prospective validation and whether such physiological stratification may support individualized follow-up strategies. Full article

The building sector is one of the largest contributors to global energy demand and carbon emissions, making the transition to net-zero buildings (NZBs) a critical component of climate change mitigation strategies. However, the persistent building energy performance gap (BEPG), defined as the discrepancy between predicted and actual energy consumption, continues to hinder the achievement of net-zero operational performance. Accordingly, this review examines the role of artificial intelligence (AI) in enabling NZBs through the integration of energy-efficient building systems, renewable energy technologies, and intelligent operational control. A comprehensive review of the literature published between 2018 and 2025 was conducted, focusing on three complementary domains: heating, ventilation, and air conditioning (HVAC) system efficiency as the demand-side pillar, renewable energy integration as the supply-side pillar, and AI as the enabling layer connecting both domains. Synthesis of the reviewed literature reveals that demand-side HVAC technologies achieve energy savings ranging from 20% to 67%, while supply-side renewable energy integration increases photovoltaic (PV) self-consumption by 11–13%. Furthermore, AI-driven optimization, particularly through reinforcement learning (22.3% ± 8.4% energy savings) and digital twins (up to 70% renewable energy utilization), substantially enhances building performance within integrated energy management frameworks. The reviewed studies further demonstrate that AI techniques, including machine learning, deep learning, reinforcement learning, and digital twins, enable accurate energy forecasting (R² > 0.90), intelligent operational control, and effective coordination of integrated PV–battery energy storage system–electric vehicle systems, improving building energy flexibility and reducing grid fluctuations by up to 12.78%. Despite these advances, challenges related to data quality, interoperability, model explainability, cybersecurity, and limited large-scale real-world validation remain significant barriers to widespread adoption. Overall, the evidence indicates that AI serves as a key enabler for reducing the BEPG and improving the reliability, resilience, and operational efficiency of NZBs, thereby supporting the transition toward intelligent, low-carbon built environments. Full article

Patulous Eustachian Tube (PET) is a rare otologic disorder, which is caused by abnormal patency of the Eustachian tube. Rapid weight loss is a recognized predisposing factor for PET potentially because of the reduction in peritubal adipose tissue that contributes to normal tubal closure. Although there is increasing awareness of this association, the best treatment of PET is still debated with several conservative, medical and surgical operations reported in the literature. This narrative review summarizes the available evidence regarding conservative, medical, minimally invasive, and surgical management of PET, with particular consideration of PET associated with rapid weight loss. Relevant literature was identified through searches of PubMed/MEDLINE, Embase, Web of Science, and the Cochrane Library, with attention to studies using standardized diagnostic criteria and outcome measures. Conservative approaches, including hydration, nasal saline instillation, and behavioral modifications such as cessation of habitual sniffing, have been associated with symptomatic improvement and considered as initial options because of their accessibility and low procedural burden. Medical therapies, such as topical irritants, estrogen-based preparations, and mucosal-thickening agents, may provide temporary symptom relief, although their long-term effects require further evaluation. Among interventional strategies, silicone (Kobayashi) plug insertion has demonstrated encouraging symptom improvement and reductions in symptom scores in selected patients with refractory PET. Minimally invasive techniques, including autologous fat injection, cartilage augmentation, and soft tissue bulking procedures, have also demonstrated encouraging outcomes. Trans-tympanic interventions, including ventilation-tube insertion and catheter-based techniques, provided additional options with variable reported outcomes. Management of PET remains heterogeneous and largely individualized. Conservative and medical therapies are considered reasonable first-line options, while surgical and minimally invasive approaches may be considered for selected patients with persistent symptoms. Full article

Near-surface temperature inversions are prevalent during the cold months in Ulaanbaatar city, Mongolia, and significantly degrade urban air quality by trapping hazardous pollutants within a shallow atmospheric boundary layer. This study investigates spatiotemporal variability, physical mechanisms, and long-term evolution of near-surface temperature inversions over Ulaanbaatar by integrating 25 years (2000–2024) of ground-based meteorological and radiosonde observations, with high-resolution Weather Research and Forecasting (WRF) model simulations for 2012–2023. Our results demonstrate the four-dimensional data assimilation (FDDA) grid nudging effectively captures localized topographic influences in the WRF simulations, showing a strong agreement with radiosonde observations (R² = 0.783, p < 0.000). Near-surface temperature inversions are strongly controlled by the Siberian High, with the highest frequency occurring from December to February, when up to 67% of morning observations exhibit inversion conditions. A pronounced diurnal cycle was identified, with inversion intensity peaking at 5.6–6.8 °C during the early morning hours (02:00–08:00 LST) before reaching a minimum around 14:00 LST. Spatially, the strongest inversions occur along the low-lying Tuul River valley, where the planetary boundary layer is compressed to below 350 m and wind speeds decrease to less than 2.4 m·s⁻¹, creating persistent atmospheric stagnation. Despite these favorable conditions for inversion formation, long-term observations indicate that regional warming (+2.0 °C) and the urban heat island effects have reduced inversion frequency by 31%, inversion thickness by 170 m, and inversion intensity by 0.9 °C over the past 25 years. These findings demonstrate the strong coupling between regional complex terrain, and boundary layer thermodynamics, highlighting the need to incorporate urban ventilation corridors and topography-informed planning into climate adaptation and winter air-quality management strategies. Full article

Pluvial flooding is intensifying in fast-growing coastal cities as rapid urbanization increases impervious surfaces and reduces natural infiltration, challenging planners to identify scalable and site-level mitigation strategies. Although statutory setbacks around institutional buildings are widely mandated for ventilation, safety, and accessibility, their contribution to urban flood resilience remains largely unexplored. This study develops the Flood Setback Performance Index (FSPI), a dimensionless indicator that integrates setback permeability and area-weighted runoff coefficients to quantify the flood-mitigation potential of mandatory setbacks. The framework was demonstrated using eight government school campuses in the Chennai, Chengalpattu, and Thiruvallur regions, which are part of a flood-prone coastal metropolis in India, following the extreme rainfall event of December 2025. Flood conditions were verified through post-event field surveys and visual evidence, while setback characteristics were extracted from satellite imagery and classified into permeable and impervious surfaces. The permeable fraction of setbacks and the FSPI values exhibited a strong inverse relationship with flood severity (Spearman’s ρ = −0.87, exact permutation p = 0.011). Ordinal logistic regression confirmed this gradient (likelihood-ratio χ² = 9.3–10.3, p ≤ 0.002, McFadden’s R² = 0.54–0.60), and campus rankings were made under saturated runoff coefficients. The findings demonstrate that statutory setbacks can function as nature-based flood-mitigation infrastructure with measurable hydrological benefits. Beyond the case study, the FSPI provides a simple, transferable, evidence-based tool for screening institutional sites by flood-mitigation performance and prioritizing where adaptation measures, such as increasing permeable-surface cover within statutory setbacks are needed, supporting climate-resilient urban planning and providing a regulatory reform decision-support tool with three applications: prioritizing the campus-level retrofit of permeable surfaces; screening building applications against setback surface standards; and identifying shelter-designated schools that require drainage upgrades. It thereby supports climate-resilient urban planning, regulatory reform, and progress toward Sustainable Development Goals 11 and 13. Full article

Background/Objectives: Cardiac comorbidities are increasingly common among liver transplant candidates, particularly those with metabolic dysfunction-associated steatohepatitis (MASH)-related cirrhosis. Although the Liver Transplant Comorbidity Index identifies coronary artery disease (CAD) as a predictor of post-transplant mortality, the impact of overall cardiac comorbidity burden on early outcomes after liver transplantation remains unclear. We evaluated the association between pre-transplant cardiac comorbidities and early post-transplant outcomes, with emphasis on MASH-related cirrhosis. Methods: We performed a retrospective cohort study using the TriNetX US Collaborative Research Network. Adults undergoing first-time isolated liver transplantation through May 2026 were included. Pre-transplant CAD, heart failure (HF), and atrial fibrillation (AF) documented within 12 months before transplantation were identified using ICD-10-CM codes. Patients were categorized by cardiac comorbidity burden (0–3 conditions). Recipients with any cardiac comorbidity underwent 1:1 propensity score matching to those without cardiac disease using 16 baseline demographic, clinical, and laboratory variables, including MELD-Na. The estimand was the average treatment effect in the treated patients. Primary outcomes comprised 30- and 90-day all-cause mortality. Secondary outcomes included a prespecified restricted major adverse cardiac event (MACE) composite, limited to hard endpoints (death, myocardial infarction, cardiac arrest, ischemic stroke), and a broader composite, i.e., acute kidney injury, prolonged mechanical ventilation, vasopressor requirement, renal replacement therapy, ICU and hospital length of stay, and 90-day readmission. Results: Among 5124 recipients, 986 (19.2%) exhibited at least one cardiac comorbidity. After matching, 974 patients remained in each group. Pre-transplant cardiac comorbidity was associated with higher 30- and 90-day mortality and increased risks of all secondary outcomes. The association with MACE persisted but was attenuated when restricted to hard endpoints (90-day RR 1.55; 95% CI 1.19–2.03) when compared with the broad composite (RR 1.75; 95% CI 1.40–2.18). MASH recipients with cardiac comorbidities experienced numerically higher event rates than did non-MASH recipients, but interaction estimates were imprecise and non-significant. In separate matched analyses, AF was most strongly associated with MACE, whereas CAD showed the strongest association with mortality. Conclusions: Pre-transplant cardiac comorbidity burden is associated with worse early post-transplant outcomes. Although MASH-cirrhosis recipients experienced numerically higher event rates, exploratory subgroup analyses did not demonstrate statistically significant differences from the non-MASH recipients. These findings may help refine cardiac risk prediction and perioperative planning, but they do not establish that intensified cardiac risk stratification or perioperative optimization improve outcomes. Prospective studies incorporating detailed cardiac, donor, operative, frailty, and medication data are needed to validate these associations and determine whether targeted risk-stratification and perioperative strategies can improve post-transplant outcomes. Full article

Commercial greenhouses are becoming significant, controllable, and weather-dependent electricity loads in regions pursuing controlled environment agriculture (CEA). Their electrical demands—such as supplemental lighting, heating, ventilation/cooling, irrigation pumps, and CO₂ enrichment—exhibit substantial intra-day flexibility. This flexibility stems from the fact that plant productivity depends on time-integrated agronomic variables (e.g., Daily Light Integral, accumulated thermal time, and mean vapor pressure deficit) rather than instantaneous environmental setpoints. However, existing studies have predominantly focused on greenhouse thermal modeling and energy conservation, while decision-making models that integrate crop physiological characteristics into day-ahead (DA) market bidding remain limited. To bridge this gap, this paper develops a scenario-based stochastic DA bidding framework for a load aggregator, representing multiple smart greenhouses in a wholesale electricity market. In the DA stage, the aggregator submits hourly demand–price bidding curves based on price-conditional schedules of heating and lighting demand while satisfying coupled thermal–photon balance constraints. Fifty representative scenarios generated from 2023 to 2024 historical price and weather data through cGAN-based scenario generation and K-means scenario reduction are used for stochastic bid construction and feasibility analysis. A separate 30-day historical dataset from January 2025 is used for benchmark comparison. The aggregator portfolio consists of 100 greenhouses divided into five LAI-based crop groups, with 20 greenhouses in each group. Relative to the 15–25 °C trapezoidal temperature baseline, which is adopted as the primary practical benchmark, the proposed strategy reduces the mean daily electricity procurement cost by 15.80%. A reduction of 18.89% is also observed relative to the rigid 20 °C thermostat case, which is retained as a capacity-intensive reference. These results represent simulation-based operating-cost comparisons under a common equipment configuration and do not include equipment capital costs. Full article

Courtyard-cluster layouts are common in rural public buildings in hot-humid regions, but their open-space types remain poorly quantified. We assessed a completed elderly-care center in Shaoguan, South China, using steady-state RANS CFD (simpleFoam, standard k–ε, OpenFOAM 8), porous-media vegetation, Solar Cal-based mean radiant temperature (MRT), and pedestrian-level Universal Thermal Climate Index (UTCI). Published component-level validation was used to assess toolchain reliability. Simulations represented peak heat stress at noon on 24 July (air temperature 30.3 °C, relative humidity 69%, southwesterly wind 2.9 m/s). Relative to an unobstructed reference (MRT 60.1 °C; UTCI 40.0 °C), architectural open spaces reduced mean MRT by 21.2 °C (35%) and UTCI by 5.3 °C (13%). Covered, laterally open grey spaces were coolest (mean MRT 34.63 °C; UTCI 33.61 °C), whereas open courtyards were warmer (41.79 °C; 35.34 °C) but 18% better ventilated (0.87 versus 0.74 m/s) and served as ventilation nodes. With uniform air temperature and humidity, UTCI variation was strongly associated with MRT (R = 0.989) and weakly with wind speed (R = −0.182). These scenario-bounded results support a shade-first strategy in which courtyards supply ventilation to adjacent covered spaces. Full article

The rapid expansion of high-speed railway networks has increased the operational energy demand and indoor overheating risk of large-scale, high-volume railway station buildings. Natural ventilation is a climate-responsive passive strategy that can improve indoor environmental quality and reduce reliance on mechanical cooling. However, its contribution to the operational sustainability of large transportation buildings remains insufficiently quantified, particularly in hot-summer and cold-winter regions. This study investigates a seasonally adaptive window-opening strategy for Chengdu Station, with particular attention to major functional spaces such as waiting halls and commercial areas. A DesignBuilder model was used to simulate six ventilation scenarios, ranging from doors-only operation to fully open doors and windows. The effects of different window-opening ratios on hourly indoor temperature, relative humidity, adaptive thermal comfort, and annual building energy use were systematically evaluated. The simulation approach was further assessed against field measurements obtained from a comparable large railway station. The results reveal a pronounced nonlinear and seasonal response to the window-opening ratio. In winter, maintaining a very low opening ratio or keeping only the entrance doors open limits unnecessary heat loss. During the transitional seasons, opening ratios of 40–60% are sufficient to remove residual indoor heat while maintaining acceptable thermal conditions. In summer, the marginal improvement in ventilation performance becomes limited when the side-window opening ratio exceeds approximately 80%; therefore, an opening ratio of 80% was selected as a practical operating threshold rather than an absolute thermal optimum. Based on these seasonal characteristics, a month-by-month window-opening strategy was developed. Compared with the doors-only baseline, the proposed strategy reduced the annual high-temperature-hour ratio from 33.4% to 16.36%, corresponding to a decrease of 17.04 percentage points and a relative reduction of approximately 51.0%. Total annual building energy use decreased from 32,238.8 MWh to 25,923.8 MWh, representing an energy saving of 19.6%. These findings demonstrate that seasonally adaptive natural ventilation can simultaneously reduce overheating risk and operational energy demand while maintaining acceptable indoor thermal conditions. The proposed strategy provides a quantitative basis for the sustainable, energy-efficient, and intelligently managed operation of large-space railway stations in hot-summer and cold-winter regions. Full article

Early detection of acute lung injury (ALI) remains challenging, as conventional diagnostics rarely capture initial molecular changes. We therefore examined whether extracellular vesicles (EVs) in bronchoalveolar lavage fluid (BALF) can detect early regional injury and distinguish initial stress mechanisms in a porcine ALI model. Unilateral ALI was induced using Triton X-100, followed by six hours of mechanical ventilation with either fixed positive end-expiratory pressure (PEEP) at 5 cmH₂O or transpulmonary-pressure (TPP)-guided PEEP. Spatially separated BALF sampling allowed direct comparison between injured and contralateral mechanically stressed lungs. EV concentration and size distribution were quantified by nano-flow cytometry, while vesicular identity was confirmed by transmission electron microscopy and tetraspanin dot blot analyses. Furthermore, EV metrics were related to corresponding histologic injury scores. Across both PEEP strategies, EV concentration was markedly higher in both directly injured and contralateral mechanically stressed lungs compared with sham controls, indicating alveolar stress beyond the primary injury site. Median EV size differed significantly by injury type and correlated inversely with histologic injury, particularly with alveolar neutrophil infiltration. BALF-derived EV concentration and size may therefore provide complementary, spatially resolved molecular readouts of early ALI. Full article

Pressure losses in heating, ventilation, and air-conditioning (HVAC) duct elbows significantly increase fan power requirements and reduce overall system efficiency. This study presents a comprehensive computational fluid dynamics (CFD) investigation aimed at identifying effective strategies for reducing pressure losses in 90° HVAC duct elbows. The numerical methodology was first validated against published experimental measurements, demonstrating excellent agreement and providing confidence in the predictive capability of the CFD model. The validated model was then employed to evaluate the influence of duct geometry, inlet velocity, guide vane configuration, inter-vane spacing, perforated guide vanes, and duct material roughness on aerodynamic performance using the SST k–ω turbulence model. The results show that round elbows reduce pressure losses by approximately 50% compared with hydraulically equivalent rectangular elbows, highlighting the strong influence of duct geometry on flow separation. Among the flow-control strategies investigated, curved guide vanes produced the greatest improvement, with an optimized three-vane arrangement and a non-dimensional spacing of $\mathrm{s}/{\mathrm{D}}_{\mathrm{h}}\approx 0.15$ (corresponding to 150 mm for the specific geometry tested) reducing pressure losses by approximately 31% relative to the baseline elbow without guide vanes. In contrast, the investigated perforated guide vane provided only marginal improvement, indicating that its geometry requires further optimization to minimize blockage and mixing losses. The material roughness study showed that smooth, rigid duct materials produced only minor differences in pressure loss, whereas flexible ducts generated noticeably higher losses because of their increased surface roughness. These findings demonstrate that optimizing elbow geometry and guide vane design is considerably more effective than modifying duct material or using the investigated perforated vane configuration. The study provides practical design recommendations for improving the aerodynamic performance and energy efficiency of HVAC duct systems. Full article

Background: Right-to-left shunting through a patent foramen ovale (PFO) is an underrecognized yet potentially reversible cause of refractory hypoxemia, particularly in patients with right ventricular dysfunction. This case report describes heart-rate-dependent right-to-left shunting through a PFO causing refractory hypoxemia in a patient with inflammatory cardiomyopathy and severe right ventricular dysfunction, presumably arising from biventricular output mismatch. Case Presentation: We report the case of a 41-year-old male with inflammatory cardiomyopathy and a recently implanted single-chamber pacemaker (VVI mode, lower rate limit 50 bpm), admitted for decompensated heart failure. After initial clinical improvement with guideline-directed therapy, the patient’s intrinsic heart rate declined, and ventricular pacing at 50 bpm became the dominant rhythm. He subsequently developed refractory hypoxemia unresponsive to mechanical ventilation. Systematic hemodynamic assessment was performed using transthoracic echocardiography and thoracic electrical bioimpedance (TEB) monitoring at different pacing rates. Results: Echocardiographic evaluation revealed dynamic interatrial shunting through a PFO with the following characteristics: left-to-right at a pacing rate of 80 bpm and right-to-left at 50 bpm. Hemodynamic and echocardiographic data suggested that bradycardia induced biventricular output mismatch—left ventricular outflow tract velocity–time integral (VTI) increased by approximately 38% (from 17.5 cm to 24.1 cm), whereas right ventricular outflow tract VTI increased by only approximately 4% (13.3 cm vs. 13.8 cm). This mismatch likely resulted in relative elevation of right atrial pressure, thereby driving right-to-left shunting through the PFO. Increasing the pacing rate to 80 bpm reversed the shunt direction, normalized oxygenation, and facilitated successful extubation. Conclusions: This case suggests that in patients with severe right ventricular dysfunction, bradycardia may induce biventricular output mismatch with substantially greater left than right ventricular stroke volume augmentation, and presumably relative elevation of right atrial pressure, potentially leading to dynamic right-to-left shunting through a PFO. For such patients with unexplained hypoxemia, the possibility of dynamic PFO shunting should be considered. Appropriately increasing the pacing rate may help restore biventricular output matching, reverse shunt direction, and improve oxygenation; individualized heart rate management strategies warrant clinical consideration. Full article

Background/Objectives: Retained airway secretions are a common complication of mechanical ventilation and a major contributor to ventilator-associated pneumonia. Airway Pressure Release Ventilation following a Time-Controlled Adaptive Ventilation protocol (APRV-TCAV) has been anecdotally observed to improve secretion clearance, but the mechanism is not well established. Because TCAV sets the release time (TLow) from each patient’s own expiratory flow decay, we hypothesized that the resulting expiratory-dominant flow profile would generate a net antegrade force on secretions. This bench study compared secretion movement between APRV-TCAV and conventional Volume-Control Continuous Mandatory Ventilation (VC-CMV), with and without an in-line oscillatory device. Methods: A critical care ventilator was connected to a 3 L test lung via a 7 mm endotracheal tube (ETT). Simulated mucus (1% guar gum) was instilled into the ETT, and secretion movement was measured under VC-CMV (positive end-expiratory pressure (PEEP) 5, 10, 15 cmH₂O) and APRV-TCAV (PHigh 20, 25, 30 cmH₂O; PLow 0 cmH₂O). Each condition was repeated with an in-line oscillatory device. Results: All VC-CMV settings produced retrograde secretion movement toward the test lung; all APRV-TCAV settings produced antegrade movement. The largest antegrade movement was observed at the widest PHigh-to-PLow differential. Adding the oscillatory device raised peak expiratory flow above peak inspiratory flow in every condition, yet abolished antegrade movement under APRV-TCAV. Conclusions: In this bench study, APRV-TCAV reversed the direction of secretion movement within the ETT, with larger antegrade movement at wider PHigh-to-PLow differentials. This suggests a potential mechanism by which the ventilator flow profile itself may influence secretion movement. The directional effect depended on the intact release-phase waveform and was abolished by in-line oscillatory therapy despite preserved peak flow asymmetry. Full article

Background/Objectives: Propofol is effective for pediatric endoscopy but can depress ventilation. We compared three induction regimens in school-aged children undergoing bidirectional gastrointestinal endoscopy. Methods: This single-center, assessor-blinded randomized trial allocated children aged 6–12 years (1:1:1) to propofol 3 mg/kg (P), remimazolam 0.2 mg/kg plus propofol 1 mg/kg (R1), or remimazolam 0.4 mg/kg plus propofol 1 mg/kg (R2). All groups received sufentanil and standardized propofol maintenance. Respiratory depression was a respiratory rate < 10 breaths/min or peripheral oxygen saturation < 90% for >1 min. The trial was prospectively registered (ChiCTR2500096218), and analysis followed assigned groups. Results: The analysis included 120 children (40 per group). Respiratory depression occurred in 32/40 (80.0%) in P, 6/40 (15.0%) in R1, and 14/40 (35.0%) in R2 (overall p < 0.001). Compared with P, the risk difference was −65.0 percentage points for R1 (95% confidence interval [CI], −77.4 to −44.6; risk ratio, 0.19; 95% CI, 0.09–0.37) and −45.0 percentage points for R2 (95% CI, −61.0 to −23.6; risk ratio, 0.44; 95% CI, 0.27–0.66); both Holm-adjusted p values were <0.001. Mean time to eye opening was 12.7, 11.2, and 16.9 min, respectively. In the exploratory R1-versus-R2 comparison, time to eye opening was 5.75 min shorter with R1 (95% CI, 4.28–7.20). Conclusions: Both remimazolam–propofol regimens reduced monitor-defined respiratory depression compared with propofol 3 mg/kg. The 0.2 mg/kg remimazolam–propofol regimen combined this respiratory benefit with faster recovery than the 0.4 mg/kg regimen in exploratory analysis, supporting its further evaluation as an induction strategy for pediatric bidirectional endoscopy. Full article

The twentieth (20th) century represents a radical transformation in architectural history. Unlike previous centuries, characterized by gradual stylistic continuity, it witnessed a succession of theoretical ruptures, technological innovations, material discoveries, and experimental design paradigms. Each movement emerged by questioning the assumptions of its predecessors, generating an experimentation laboratory that transformed the relationship between buildings, resources, climate, and society. Despite this exceptional intellectual and technological legacy, 20th-century architecture is still predominantly interpreted through its technological shortcomings, while the historical evolution of its contributions to environmental sustainability and energy efficiency is still lacking. This study reconstructs the historical genealogy of environmental sustainability and energy efficiency across the principal architectural movements of the 20th century. Through a comparative analysis of design theories and architectural principles, it identifies environmental and energy paradigms, drawbacks, and design lessons. Environmental sustainability evolved around material durability, adaptability, resource optimization, contextual integration, and life cycle thinking, whereas energy efficiency developed through passive climatic strategies, building morphology, envelope performance, daylight, natural ventilation, and environmental control. The study demonstrates that many of the principles underpinning contemporary sustainable and energy-efficient architecture originated during the 20th century. Approaches such as Parametricism, Computational Design, Biomimetic Architecture, Climate-Responsive Design, Circular Architecture, and Regenerative Design extend these concepts through new scientific understanding, digital technologies, and environmental performance objectives. Full article