In the German healthcare system, the legislator has established various concepts of data-based quality assurance. The Federal Joint Committee (G-BA) regulates external quality assurance procedures through the Directive on Data-Based Cross-Institutional Quality Assurance (DeQS-RL) to improve the quality of care and enable transparent, publicly accessible comparisons between providers. The nationwide implementation of clinical cancer registries (CCRs) was intended to strengthen, in particular, oncological quality assurance and reporting. This article compares the quality assurance concepts of the DeQS-RL and CCRs regarding the consistency of data collection, data quality and analysis, the use of quality indicators, the handling of deviant quality results to address deficiencies, and the publication of outcomes. Under the DeQS-RL, data collection, analysis, and the handling of results are standardized nationwide and mandatory for all providers. In case of deviant quality results, targeted improvement measures are initiated with providers to ensure minimum quality standards across all facilities. CCRs operate largely under state regulations and focus primarily on their respective catchment areas. The responsibility for addressing deviant quality results lies with individual facilities. Comparative results are published exclusively by the G-BA. Unlike CCRs, the G-BA uses three data sources (quality assurance documentation, health insurance data, and patient surveys). Due to binding national specifications and data delivery deadlines, DeQS data demonstrate high completeness, comprehensiveness, and timeliness. Since medical providers do not always comply with their legal obligation to report to CCRs in a timely manner, case histories are often incomplete, impairing quality results and the depiction of care processes. CCRs can make important contributions to oncological quality assurance; however, due to their organization under state law, limited binding nature, and lack of authority to enforce quality standards, they do not constitute an independent alternative to DeQS. Nevertheless, there are synergies between the two approaches, which will soon be utilized in an upcoming DeQS procedure of the G-BA.
This study aims to describe the legal basis and operational framework of a pan-government interagency committee that supports the introduction of vaccines during emerging infectious disease pandemics and examine the institutional implications of the Prime Minister's directive. As a policy report on regulatory enactment, we reviewed the key provisions of the "Regulations on the Establishment and Operation of the Pan-government Interagency Committee for Vaccine Introduction," enacted on January 7, 2026, after inter-ministerial consultations, public notice, and legal review. The directive states that when a crisis alert of "Alert" or higher is issued under the Framework Act on the Management of Disasters and Safety, an interagency committee is convened within the Korea Disease Control and Prevention Agency (KDCA). Chaired by the KDCA Commissioner, senior officials from relevant ministries coordinate for vaccine supply planning, regulatory information sharing, global supply monitoring, and ministry-specific action plans. The directive also provides for a working-level committee, interagency cooperation requests, and consultation with external experts. By formalizing interministerial coordination for vaccine introduction, the directive creates an institutional platform that can support sustained preparedness and policy continuity in future infectious disease emergencies.
Chronic insomnia is a highly prevalent sleep disorder that adversely affects quality of life and mental health. Cognitive behavioral therapy for insomnia (CBT-I) is internationally recommended as the first-line treatment, and digital CBT-I (dCBT-I) has been developed to improve accessibility and scalability. While existing dCBT-I systems effectively support structured behavioral training through standardized protocols, they provide relatively limited support for users' cognitive exploration and meaning-making processes, particularly in helping users reflect on and internalize the rationale behind CBT-I practices in daily life. These limitations may contribute to challenges in sustained engagement and long-term adherence. This study aimed to examine the usability and feasibility of SleepPathfinder, a conversational CBT-I support chatbot that integrates Socratic questioning and a self-decision mechanism to support users' understanding of and engagement with CBT-I practices. SleepPathfinder was designed around a 4-stage conversational flow: education on CBT-I techniques, Socratic cognitive exploration, self-decision, and advice provision. We conducted (1) a single-session pilot usability study (n=45) to assess system stability and user experience and (2) a 5-day condition-based comparative experiment (n=30) consisting of daily sessions, comparing an exploratory dialogue condition with a directive, protocol-guided dialogue condition. Quantitative measures assessed usability, cognitive appraisals related to sleep problems, autonomy-related experiences, and behavioral readiness, while qualitative feedback and conversational log analyses were used to examine interaction patterns and engagement characteristics. In the comparative experiment, the exploratory dialogue condition showed a tendency toward reduced perceived threat and severity appraisal of sleep problems compared with the directive condition, accompanied by moderate effect sizes in cognitive perception measures. Autonomy-related experiences, including perceived choice and engagement, demonstrated suggestive upward trends in the exploratory condition. Behavioral intention changes were comparable across conditions, while overall readiness for change increased across participants. Conversational log analyses indicated that greater depth and volume of user self-narrative were associated with larger shifts in cognitive appraisals, whereas the frequency of chatbot questions alone was not. The pilot usability study indicated generally positive evaluations of system usability and content credibility, while identifying areas for improvement in emotional responsiveness and conversational naturalness. These findings suggest that a Socratic questioning-based and self-decision-based conversational structure is usable and feasible as a supportive interaction layer within dCBT-I systems. Rather than altering the directive behavioral structure of CBT-I, such an approach may complement existing protocols by facilitating cognitive exploration and supporting user-perceived autonomy. This study provides design-oriented evidence to inform the refinement of dialogue-supported digital CBT-I systems aimed at enhancing user engagement with CBT-I practices.
There is a substantial demand for lightweight, low-profile, and conformal antenna integration on the wing platforms of unmanned aerial vehicles (UAVs). This paper presents an S-band (2-4 GHz) flexible conformal metasurface array antenna based on a highly conductive graphene-assembled film (GAF). The main contributions of this work are twofold. First, flexible and highly conductive GAF is used as the conductor together with a flexible polyimide (PI) dielectric substrate to form a GAF-based wing-conformal antenna configuration with a low-profile, lightweight, and easily conformal performance. Second, a GAF conformal antenna element is developed by combining a dipole antenna with a directive and reflective frequency selective surface (FSS), achieving effective control of the beam and stable directional radiation at 2.4 GHz. Full-wave simulations using CST Studio Suite show that the directive FSS narrows the feed beam, whereas the reflective FSS redirects and narrows the H-plane radiation. The simulated results show that the integrated wing-conformal antenna operates over 2.19-2.65 GHz and achieves a gain of 4.65 dBi at 2.4 GHz. The measurement results indicate that the GAF conformal antenna and 1 × 4 GAF conformal array antenna shows measured reflection coefficients below -10 dB at 2.4 GHz and effective adjacent-element isolation. In addition, simulated results indicate that the GAF array antenna can perform beam scanning within the ±40° range, verifying the beam-control capability of this structure for UAV forward communication. Overall, this work highlights the feasibility of using GAF as a conductive material for both a high-efficiency radiator and an FSS beamforming structure, offering a practical material and design approach for lightweight, low-profile, and wing-conformal airborne array antennas.
European Union (EU) legislation supports the conservation of endangered freshwater species through the Habitats Directive (HD, 92/43/EEC) and the Water Framework Directive (WFD, 2000/60/EC), and the eradication of Invasive Alien Species (IAS) through the Regulation 1143/2014. Periodic monitoring and reporting on the species listed in these regulations are mandatory for EU Member States. Quantitative PCR environmental DNA (qPCR eDNA) based approaches offer a new cost-effective and sensitive tool that could contribute to these monitoring obligations and to spatial conservation planning. We analysed the results from a qPCR eDNA simultaneous survey of 11 endangered species, four IAS, one pathogen fungus and one translocated fish at 53 central-Italian freshwater sites to produce three scores that could be used to prioritize areas of intervention based on the cumulative presence of native and alien species and their prevalence and co-occurrence. For each site, we proposed a Prioritizing Protection Score (PPS), a Prioritizing Eradication Score (PES), and a Benthic Invertebrates and Fish Score (BIFS) in accordance with HD, Regulation 1143/2014, and WFD. PPS prioritized 39 sites eligible for Natura 2000 designation to achieve the EU target of 30% protected land, PES identified 22 sites for IAS eradication and management, whereas BIFS highlighted 33 sites where freshwater evaluations can benefit from eDNA surveys. Results from the qPCR eDNA survey also revealed 53 new grid cells of occurrence of IAS and species listed in Annexes II, IV and V of HD that will contribute to the next reporting for both the HD and the IAS Regulation.
The sensitive nature of mortality has hindered the death education. However, post-pandemic existential anxiety has drawn significant attention, offering a critical opportunity for disciplinary advancement. Despite this momentum, the field's interdisciplinary nature lacks a unified theoretical framework, urgently necessitating clear development directions. Furthermore, given the profound cultural divergences between Chinese and Western death education paradigms, analyzing these two contexts both independently and comparatively is essential to comprehensively guide the field's future development. Comparative bibliometric analysis. 2,311 publications were included. This study aims to analyze and compare the evolutionary trajectories, thematic distributions, and emerging frontiers of death education research in international and Chinese contexts. By synthesizing their characteristic data, it delineates the developmental trends in the post-pandemic era and the cultural divergences between Eastern and Western paradigms, thereby providing reference and guidance for the field's future directions from a bibliometric perspective. Literature was retrieved from international databases (Web of Science, PubMed, Scopus; timspan: 1971-2025), and a Chinese database (China National Knowledge Infrastructure; timespan: 1980-2025). Utilizing CiteSpace with one-year time slices, we performed co-occurrence, cluster, timeline, burst detection analyses across each bibliometric data fields. Node selection parameters were individually configured based on data density to ensure optimal network visualization. Finally, the meaningful resulting characteristic data were compared and synthesized. Analysis of 2,311 publications identifies 2020 as a pivotal turning point for significant growth in both international and Chinese death education research. Post-2023, international publication volume continues to accelerate, whereas Chinese research exhibits a downtown trend. Bibliometric results show that the highest betweenness centrality in international research remains anchored in early foundation literature. In contrast, Chinese research displays a marked preference regarding research subjects and reveals that "life education" has superseded "death education" as the primary thematic cluster. Following a post-2020 surge, international research has maintained sustained growth, whereas Chinese publications experienced a decline post-2023. Distinctively, Chinese studies show a preference for convenience sampling, while international co-citation networks reveal a persistent reliance on early foundational research. To ensure sustainable development, the field must refine theoretical frameworks globally. Furthermore, reversing the decline in China requires leveraging culturally positive semantics and policy directives to position death education as a systemic public health intervention. Research intensity of death education in both regions exhibited high synchrony with major public emergencies. International research showed sustained post-pandemic growth but a paucity of theoretical innovation, while Chinese research faced significant localization bottlenecks, characterized by reliance on convenience sampling and a tendency to reframe death discourse through the indirect lens of "life education."
The opioid epidemic remains a public health crisis in the United States. Naloxone is a cornerstone of overdose reversal, and its increasing availability to bystanders has improved immediate survival. However, little is known about how bystander naloxone administration influences use of emergency medical services (EMS), particularly patient refusal of transport. Understanding these dynamics is critical for development of EMS protocol and harm reduction strategies. We performed a retrospective cohort study of suspected opioid overdoses reported to the Connecticut Statewide Opioid Reporting Directive (SWORD) between November 1, 2019-June 30, 2024. The primary outcome was EMS transport refusal, defined as non-transport after naloxone administration. The primary exposure was initial naloxone administrator (bystander vs first responder). Secondary variables included naloxone dose frequency, patient demographics, and time. Bivariate tests compared group differences. We used multivariable logistic regression to assess the association between bystander naloxone and refusal, adjusting for covariates. To evaluate temporal trends, we performed separate logistic regression models with calendar quarter (Q) modeled as a continuous variable (Q1 2020-Q2 2024). Among 15,025 nonfatal suspected overdoses involving naloxone in Connecticut, bystanders were initial administrators in 18%. Transport refusal occurred more often after bystander administration compared to first responder administration (16.1% vs 6.2%). In adjusted analyses, bystander administration was associated with nearly threefold higher odds of refusal (adjusted odds ratio [aOR] 2.90; 95% CI, 2.53-3.31). Multiple-dose incidents were associated with decreased refusal (aOR 0.83; 0.72-0.93). During the study period, bystander administration increased from 15% in Q4 2019 to 24% in Q2 2024, corresponding to a 3.8% increase in odds per quarter (OR 1.04; 95% CI 1.03-1.05, P < .001). Refusal more than doubled from 4% to 12%, with odds increasing 4.5% per quarter (OR 1.05; 1.04-1.06, P < .001). Bystander-administered naloxone is increasingly common and strongly associated with higher odds of EMS transport refusal. While refusal does not always equate to unsafe outcomes, it represents missed opportunities for initiation of medications for opioid use disorder, harm reduction counseling, and linkage to care. Emergency medical services agencies should consider strategies such as leave-behind naloxone, peer recovery coach deployment, and EMS-initiated buprenorphine to capitalize on these encounters.
Artificial intelligence can substantially enhance law-enforcement capabilities, but its use in security research domains, including Fight Crime Terrorism, Border Management, INFRA, and DRS, raises significant legal, ethical, and operational challenges. Access to operational case data is typically restricted, making it unavailable for continuous ingestion or model training, while the adoption of third-party models, datasets and software artefacts introduces intellectual-property and licensing constraints. At the same time, EU regulations, notably the GDPR, the Law Enforcement Directive (LED), and the EU AI Act, impose procedural and technical safeguards that must be embedded throughout the development lifecycle . To address these challenges, this paper presents a practical, EU-centric lifecycle framework for developing AI systems in security-sensitive contexts. The methodology is structured into five stages: Matchmaking, Definition & Design, Development, Validation, and Monitoring. By mapping legal and ethical obligations to concrete engineering checkpoints, the framework supports data provenance, reproducibility, and software supply-chain assurance through artefacts such as dataset registries, Model Cards, and SBOMs. To address restricted access to operational data, the methodology also defines validation patterns for end-user evaluation, including on-premises bring-solution-to-data assessment. The main contributions of the paper are a tailored lifecycle methodology, a compliance mapping linking EU obligations to lifecycle evidence, and a practical assurance package for traceable and auditable development. The methodology is further illustrated through a worked example derived from the STARLIGHT ( https://starlight-h2020.eu/) European project, showing how operational validation can be conducted without exposing raw law-enforcement data. This paper provides a step-by-step guide for building Artificial Intelligence (AI) systems for security and law enforcement projects in the European Union (EU). Because AI systems in these high-stakes areas must be safe, ethical, and legally compliant, developers must follow strict rules like the EU AI Act and the General Data Protection Regulation (GDPR). The major challenges in building these systems are that law enforcement agencies cannot easily share highly sensitive, real-world data with developers, the compliance with the legal and ethical European framework and the intellectual-property and licensing constraints. To solve this, our paper proposes a five-stage methodology that allows developers to build, test, and monitor AI models reliably without needing direct access to private operational data and is compliant with both licensing and legal and ethical frameworks. Instead of treating the law as an afterthought or a final checklist, this framework builds legal and ethical checks directly into the daily work of writing code and managing data. By adopting this approach, technical teams and law enforcement agencies can work together to create AI tools that are effective, trustworthy, and fully aligned with EU regulations, ultimately protecting both the users of the technology and the public.
Emerging evidence indicates that the health effects of transportation noise are broader than cardiometabolic disease in adults and neurodevelopment in children. We aimed to evaluate the evidence for a link between transportation noise and the risk of depression and dementia and to quantify the corresponding burden of disease for Europe. Following an Umbrella+ approach, the most recent high-quality systematic review was identified, which was then combined with relevant original studies published after the selected review. Subsequently, a meta-analysis was conducted to derive up-to-date exposure-response functions, which in turn served as the basis to calculate the burden of disease from transportation noise. Exposure distribution was derived from the data reported under the Environmental Noise Directive and baseline health data were taken from the Global Burden of Disease database. The pooled relative risk for depression and dementia were 1.059 (95%-confidence interval (CI): 1.018 to 1.103) and 1.045 (95%-CI: 1.023 to 1.067) per 10 dB Lden increase in transportation noise, respectively. This translates to an estimated annual burden of disease of 563,600 (95%-CI: 176,200 to 958,900) cases of depression and 28,200 (95%-CI: 14,600 to 41,500) cases of dementia in Europe. The respective disability-adjusted life years were 89,700 (95%-CI: 28,000 to 152,700) for depression and 113,200 (95%-CI: 58,600 to 166,300) for dementia. We found substantial burden of depression and dementia attributable to transportation noise. However, the body of evidence for these outcomes is still considered scarce, and further research is needed to corroborate these findings.
The Italian grey partridge (Perdix perdix italica Hartert, 1917) is a subspecies endemic to the Italian peninsula, considered extinct in the wild, and it is included in Annex I of the EU Bird Directive. The aim of our project is to reintroduce a viable population of the endemic taxon into a protected area in north-east Italy, using genetically selected founder birds belonging to the original Italian genetic lineage. From 2021 to 2023, a total of 30,078 partridges were reintroduced to Valle del Mezzano using a soft-release method, and 241 of them were equipped with VHF transmitters to evaluate survival, dispersal and spacing behaviour of the released birds. Furthermore, male spring counts using the playback method were performed to assess the number of reproductive pairs. The overall survival was 21.86%; the Cox proportional hazards model, including time-dependent effects, showed that neither sex (HR = 1.20, p = 0.28) nor body mass significantly influenced survival. The release year was included as a stratification factor, and site-level heterogeneity was negligible. These results show that survival dynamics were not explained solely by individual traits. Dispersal distance and spatial behaviour were affected by the release year, while sex had only a minor effect and body mass had no impact. Local heterogeneity contributed to variability but did not override the strong temporal pattern. The number of calling males in spring ranged from 152 to 267, with variations between years. Overall, our findings suggest that post-release performance in reintroduced individuals is influenced more by environmental factors than by inherent individual traits. In conclusion, despite high mortality rates among reintroduced birds, the first breeding nucleus of Italian partridges since their extinction in the wild has been observed.
Incident Learning Systems (ILSs) are central to patient safety in radiotherapy, enabling learning from adverse events and near misses. Despite EU regulatory requirements, substantial variability persists across Europe in the implementation and effectiveness of ILSs in radiotherapy. This paper presents radiotherapy-specific recommendations derived from the MARLIN study to support harmonised, risk-informed implementation of ILSs. The 24-month MARLIN study, conducted under the SAMIRA Action Plan, employed a structured literature review, an online European survey of clinical facilities, competent authorities and professional societies, expert interviews, and a multi-stakeholder consensus workshop. Survey data from 172 respondents in 28 countries were analysed to identify current practices, barriers and enabling factors for ILS implementation in radiotherapy. Although all responding countries reported transposition of the Directive, substantial variability was observed in criteria for reporting significant radiotherapy events, feedback mechanisms and use of international databases. Fear of punitive actions, limited resources, lack of training in incident analysis, and insufficient dissemination of lessons learned were identified as key barriers. External-beam radiotherapy showed more mature ILS implementation than brachytherapy. Findings from the MARLIN study informed recommendations on category-based event classification, radiotherapy-specific taxonomies, multidisciplinary incident-learning committees, and collaboration between clinical facilities, competent authorities and professional societies. The MARLIN recommendations provide a practical framework to strengthen ILS implementation in radiotherapy, promote a just culture, enhance learning from incidents and support regulatory compliance, ultimately improving patient safety and quality of care across Europe, while the broader RP-208 report extends these principles to all medical fields using ionising radiation, supporting cross-disciplinary harmonisation.
End-of-life (EOL) conversations offer individuals opportunities for consideration of future treatment options with accordance to their values and wishes, helping maintain autonomy and dignity in the eventual dying process. While there exists multiple reports in the international literature focusing on community-based interventions for initiating early advanced care planning (ACP) conversations and EOL planning behaviors in non-terminally ill adults, the effects of these interventions are poorly understood. We conducted a systematic review and meta-analysis to provide a comprehensive summary of community-based interventions for the initiation of early ACP conversations and EOL planning behaviors that may aid other countries and societies in adopting such implementations. A total of 30,869 abstracts were identified from CINAHL, Cochrane Central Register of Controlled Trials, Embase, PsycINFO and PubMed from their respective dates of inception to 20 July 2025, of which 71 articles were included in the final analysis. The population of interest were non-terminally ill adults above the age of 18 who were residing in the community at the time of study. The intervention of interest was any community-based intervention with the objective of promoting or educating on EOL and ACP related topics. The comparator was any ongoing education or outreach on EOL and ACP in the community or no intervention at all. The outcome was (1) rate of completion of EOL and ACP-related behaviors and (2) self-reported scores of knowledge, attitudes and perceptions of EOL and ACP. Two investigators independently extracted data for each study, pertaining to the study design, intervention design, baseline characteristics, EOL and ACP-related knowledge, attitude. The quality of studies was appraised in reference to the National Institute for Health and Care Excellence checklist. A meta-analysis of standardized mean difference (SMD) was conducted to assess the effectiveness of interventions in improving (1) uptake of EOL and ACP-related behaviors and (2) knowledge, attitudes and perceptions (KAP) towards EOL and ACP. 83 studies consisting of interventions using workshops, 1-to-1 counselling, discussion groups, modified AD, complex methods, distribution of printed or online materials, were included in this study. Community-based EOL interventions were significantly associated with carrying out EOL or ACP-related behaviors (n = 71,489 participants in 19 studies, RR = 2.24, 95% CI: 1.42 to 3.53, I2 = 97%) and more positive perceptions towards EOL and ACP (n = 1,766 participants across 12 studies, SMD = 1.24, 95% CI: 0.42 to 2.06, I2 = 87%) as compared to usual care. Similar findings were reported for single-arm studies and remained robust on sensitivity analysis of studies with low risk-of-bias only. Subgroup and meta-regression analyses showed that discussion group and workshop-based interventions were relatively more effective in promoting EOL and ACP compared to other interventions. Community-based interventions were shown to be effective in improving uptake of EOL and ACP-related behaviors and perceptions towards EOL and ACP amongst the nonterminally ill. Further studies investigating interventions for promotion of EOL and ACP should consider appropriate right-siting in the community and co-creation with key community figures to improve contextualization and generalizabilty. There is moderate evidence for community-based evidence in promoting end-of-life (EOL) and advanced care planning (ACP)-related behaviors and attitudes amongst a non-terminally ill population. The review in brief: We demonstrated the effectiveness of community-interventions in increasing knowledge, attitudes and perceptions towards EOL and ACP-related topics (SMD = 1.24, 95% CI: 0.42 to 2.06) and uptake of EOL and ACP-related behaviors (RR = 2.24, 95% CI: 1.42 to 3.53) compared to usual care protocols. The current landscape of community-based interventions that promote ACP and EOL-related topics is highly heterogeneous, of which EOL discussion groups and EOL workshops were the most effective. Thus, by right-siting interventions promoting EOL and ACP away from institutions and into the community with input from key communal figures, the non-terminally ill in the community can be more engaged in the ACP process. What is this review about? The review evaluates the effects of community interventions on ACP and EOL-related perceptions and behaviors amongst nonterminally-ill individuals. What is the aim of this review?: This review aims to evaluate the effectiveness of community-based interventions in (1) increasing the uptake of EOL and ACP-related behaviors as measured by self-reported rates of completion and (2) improving knowledge, attitudes and perceptions of EOL and ACP as measured by self-reported questionnaires such as the Advanced Care Planning Engagement Survey, amongst individuals who are not terminally ill. What Studies Are Included: Studies reporting outcomes of community-based interventions for educating and promoting EOL and ACP were included. This included evaluation reports commissioned by governments, public health institutions and private companies such as health technology assessments. 83 studies were included in this review, of which 28 were randomized controlled trials, 24 were quasi-experimental, 14 were cross-sectional, 16 were prospective observational and 1 was a retrospective observational study. The studies were published between 1992 to 2025. What are the main findings of this review? The range of community-based interventions is diverse, which include workshops, discussion groups, one-to-one counselling, distribution of education materials, modified advanced directive initiatives and public education initiatives. We found moderate evidence supporting an association between community-based interventions and improved ACP and EOL-related attitudes and behaviors compared to usual care protocols for a non-terminally ill population. Community-based interventions were found to be effective in increasing knowledge, attitudes and perceptions towards EOL and ACP-related topics (SMD = 1.24, 95% CI: 0.42 to 2.06) and uptake of EOL and ACP-related behaviors (RR = 2.24, 95% CI: 1.42 to 3.53) compared to usual care protocols. Our findings remain robust on sensitivity analysis by including only randomized controlled trials. Meta-regression by way of mixed effects modelling showed that discussion group and workshop-based interventions were relatively more effective than other types of interventions. How Has This Intervention Worked? Community-based interventions work by changing the health beliefs and behaviors of nonterminally ill adults in the community to nudge them towards early ACP discussions and EOL planning. One way which this can be described is by the Health Belief Model (HBM), comprising six domains: risk susceptibility, risk severity, benefits to action, barriers to action, self-efficacy, and cues to action. In the context of EOL and ACP, the mechanisms by which such interventions change beliefs and behaviors include reducing perceived barriers by clarifying misconceptions, increasing perceived control of participants over their EOL care and enhancing awareness and acceptability of EOL and ACP-related behaviors. In practice, these interventions first consider the inputs of community leaders and figures in order to incorporate culturally-relevant beliefs and values to contextualize the intervention to the community. Physical right-siting is done by carrying out these interventions in a trusted community space. These interventions then involve community members as volunteers and facilitators to engage the population effectively and outcome measures are assessed afterwards through follow-up surveys. What do the findings of this review mean? There is moderate evidence for the effectiveness of community-based interventions in promoting ACP and EOL-related attitudes and behaviors amongst a healthy population. We recommend that EOL discussion groups and EOL workshops situated in the community and co-designed with community members be implemented to best educate and engage members of the public. More work is needed to ascertain the persistence of effectiveness over a long period of time and amongst ethnic minorities and other vulnerable communities. How up-to-date is this review? The review authors searched for studies up to 20 July 2025.
Femicide represents an unparalleled criminal phenomenon both in Italy and worldwide, characterized by tolerance and substantial impunity rooted in a culture shared even by institutions. With Law No. 181 of 2025, Italy stands among the few European countries to have included the crime of femicide into the penal code, clearly defining the discriminatory structure of a crime too often romanticized and reduced to a private matter. Article 577-bis punishes anyone who causes the death of a woman with life imprisonment when the crime is committed as an act of hatred, discrimination, abuse, control, possession or domination on a woman. WHO data show that 35% of women experience violence, especially within the family, and that the leading cause of death for women aged 16 to 44 is murder by their partner or ex-partner. Globally, 137 femicides occur every day, approximately 50,000 per year. Only 10.5% of victims report to authorities. The Italian Commission of Inquiry found that 90% of 211 femicides were committed in an affective and familial context, and only in 15% of cases women had previously reported abuse. Male violence against women is systematic and discriminatory in every social, cultural and economic context. Binding supranational sources (CEDAW, ECHR, Istanbul Convention, EU Directives) are based on the assumption that these crimes are rooted in unequal relations between the sexes. The psychiatrisation of femicide perpetrators represents an interpretive distortion that makes invisible the discriminatory nature of the crime. International scientific evidence confirms that only a small percentage of femicides are committed by subjects with diagnosed mental disorders.
People with heart failure (HF) have unmet palliative care (PC) needs, particularly in rural areas. Collaborative care models may meet these needs by connecting primary care teams with urban palliative care specialists. We aimed to evaluate the feasibility and acceptability of the Rural Palliative Care for Patients with Heart Failure (RuPAL-HF) intervention. We recruited patients with HF from a rural Maine primary care clinic. A complex care team embedded in primary care was trained in PC. Specialty PC clinicians supported the team through weekly collaborative care meetings, providing coaching and case-specific guidance. Specialty palliative care clinicians also provided tele-PC when needed. Feasibility was assessed via recruitment, referral-to-completion rates, completion of advance care planning and surveys as well as collaborative care meeting attendance. Acceptability was assessed using qualitative methods through semi-structured interviews with patients, clinicians, and complex care team members. The intervention was feasible and acceptable to patients, clinicians, and complex care team members. 31 patients were approached, 13 enrolled, and 12 (92.3%) completed all intervention components. All patients completed a serious illness conversation with the complex care team and 11 (84.6%) with the specialty PC physician. 12 patients (92.3%) completed an advance directive and 8 (61.5%) a Portable Medical Orders Form. Patients reported that goals-of-care conversations were not overly emotionally challenging, and they valued the telehealth option. All care team members attended trainings, completed surveys, and participated in ≥90% of collaborative care meetings. Complex care team members reported increased confidence and skills after trainings. The RuPAL-HF intervention was feasible and acceptable for patients, clinicians, and complex care team members. Telehealth appeared feasible as a mechanism to support access to specialty PC. Further research is needed to evaluate this intervention in other rural sites, care teams, and health conditions.
Recommendations for safe anaesthesia are common in medical practice, have been formulated for traditional laboratory species, i.e. rodents, but do not exist for laboratory pigs, sheep, goats and cattle. The guidelines presented here were commissioned by the Federation of European Laboratory Animal Science Associations (FELASA) and serve to underscore EU Directive 2010/63/EU (Article 14) which require that, 'procedures are carried out with general or local anaesthesia and analgesia or another appropriate method to ensure pain, suffering and distress are kept to a minimum'. The guidelines are based on a review of: (i) medical and veterinary medical guidelines promoting safe anaesthetic practice; (ii) scientific literature pertaining to anaesthesia and analgesia in pigs, sheep, goats and cattle; and (iii) a consideration of the ethical, legal and scientific requirements when anaesthetizing laboratory animals. The guidelines aim to make recommendations for the provision of safe, practical and effective anaesthesia and analgesia to laboratory pigs and ruminants. Recommended standards for sedation and restraint (I), general principles of anaesthesia (II), monitoring anaesthesia (III) and pain assessment (IV) in the same species have been described by this working group (WG) and are set out in four parts in this document.
Decellularized tissue scaffolds may provide a substrate for cell delivery, yet their impact on stem cell function remains unclear. We evaluated a decellularized pericardium bioscaffold (CardioCel®) as a platform for mesenchymal stromal cells (MSC), testing whether it maintains multipotency without enforcing lineage commitment. Human adipose- and bone marrow-derived MSC adhered, proliferated, and differentiated under appropriate stimuli when cultured on the scaffold. Transcriptome analysis showed most genes retained their expression levels, with only 57 differentially expressed, mainly in pathways related to adhesion, oxygen response, and endogenous stimuli. Genes encoding regenerative paracrine factors were preserved, indicating that the scaffold provides a supportive but non-directive environment. These findings suggest MSC assays can serve as a screening approach to predict scaffold compatibility with endogenous progenitor cells, supporting the broader application of pericardium scaffolds in regenerative medicine.
Background/Objectives: In-hospital cardiac arrest (IHCA) remains a devastating event associated with high morbidity and mortality among general ward patients. While Rapid Response Systems (RRS) can help identify deteriorating patients, maintaining these systems in secondary hospitals is frequently hindered by severe fiscal and personnel constraints. Consequently, evidence regarding the real-world clinical effectiveness of artificial intelligence software as a medical device (AI-SaMD) for predicting deterioration in such resource-constrained settings remains limited. Methods: We conducted a retrospective analysis on a multicenter, staggered-implementation study evaluating 164,761 eligible adult general ward admissions across three secondary hospitals in South Korea. The intervention involved deploying an AI-SaMD (DeepCARS), which utilizes four routine vital signs to predict ward IHCA within 24 h. The primary outcome was ward IHCA. Secondary outcomes included in-hospital mortality and length of stay (LOS). Exploratory analyses investigated the mechanisms of clinical outcomes by evaluating lead-times to interventions, outcomes in sepsis subgroups, changes in care directives, and post-arrest neurological outcomes. Results: AI-SaMD implementation was associated with a 21% reduction in ward IHCA incidence (adjusted rate ratio 0.79; 95% CI, 0.65-0.96; p = 0.016) and a 15% reduction in in-hospital mortality (aRR 0.85; 95% CI, 0.79-0.90; p < 0.001), alongside significantly shorter hospital and intensive care unit LOS. These associations were also observed in patients with sepsis (IHCA aRR 0.71; 95% CI, 0.54-0.93; p = 0.013). Lead-times to critical care intervention and to antibiotic escalation were numerically shorter in the AI-SaMD group by 16.3 h (p = 0.066) and 2.6 h (p = 0.523); poor neurological outcome at discharge among ward IHCA cases was 85/108 (78.7%) in the AI-SaMD group versus 63/102 (61.8%) in the standard-care group (aRR 1.13; 95% CI, 0.99-1.33; p = 0.058); and the full-code death rate did not differ between groups (aRR 0.94; 95% CI, 0.76-1.15)-none of these additional analyses reached statistical significance. Conclusions: In secondary hospitals unable to operate an RRS due to fiscal limitations, implementation of an AI-SaMD as an additional informational layer was associated with lower ward IHCA and in-hospital mortality. The AI-SaMD may serve as an actionable and scalable additional safety layer for general-ward patients in resource-constrained environments where RRS infrastructure is not feasible. Although this was a multicenter, large-scale study, the present analysis was retrospective and quasi-experimental in design; rigorous randomized studies are needed to confirm these associations.
Assessing the phytoremediation efficiency of riparian macrophytes in natural stream systems remains challenging because plant performance is often evaluated using metal concentrations alone, without considering biomass-driven removal or spatial contamination variability. This study evaluated four macrophytes (Typha latifolia, Phragmites australis, Lythrum salicaria, and Persicaria lapathifolia) along a pollution gradient in the Riva Stream. A novel Remediation Efficiency Index (REI) was developed to integrate contamination risk with plant performance and classify species into site-specific management zones. Five sites were sampled during the 2025 vegetation season, and water and aboveground plant biomass were analyzed using ICP-OES. Results revealed clear spatial patterns. Midstream sites represented key potentially toxic element hotspots. P. lapathifolia showed the highest Cu and Fe concentrations (184.6 and 465.3 mg kg-1), while L. salicaria accumulated the highest Zn and Pb (119.5 and 2.83 mg kg-1). P. australis dominated Cr uptake (10.3 mg kg-1) and, due to its higher biomass (1145 g DW m-2), achieved the greatest total metal removal. REI classification placed P. australis in the Sustainable Remediation zone, whereas the other species fell into Adaptive Management or High-Risk Intervention zones. These findings show that integrating biomass-driven removal with spatial contamination patterns can guide phytoremediation strategies in contaminated streams. This study presents the Remediation Efficiency Index (REI), a novel decision-support tool that integrates contamination risk, species-specific performance, and biomass production into a comprehensive assessment. By combining species-specific metal accumulation, biomass production, and site-level contamination risk, the study identifies clear functional roles for riparian macrophytes. It provides a decision-ready framework for targeted remediation planning. These findings help turn field variability into a practical tool for species selection in polluted river systems and support nature-based management consistent with the aims of the EU Water Framework Directive and the UN Sustainable Development Goals.
The rapid expansion of the textile industry presents critical challenges in achieving sustainable consumption and production. In response, this study develops an integrated sustainable production model for the yarn sector. The proposed model incorporates investments in green technology and wastewater purification systems, assessing their influence on both economic performance and environmental sustainability. The average integrated total profit of the system is optimized, and the model's practicability is demonstrated through a numerical illustration. The findings reveal that upcycling old garments enhances overall profitability by an average of 5.13% under both carbon pricing policies. Furthermore, while the CCT mechanism reduces green investment costs by 3.18%, the CT policy achieves a 2.29% reduction, highlighting the superior emission mitigation efficiency of the CCT approach. The suggested model advances sustainable production-consumption in the yarn industry by repurposing banana waste for yarn, and adopting the extended producer responsibility (EPR) directive, all while maintaining system profitability.
Chronic occupational stress enters the biological systems through which workers perform their jobs, yet evidence linking diurnal cortisol dysregulation to specific professional behavioral acts in naturalistic encounters remains limited. Drawing on the Stress-Induced Deliberation-to-Intuition (SIDI) model, we predicted that HPA-axis dysregulation would covary with a shift officer behavior toward habitual, authority-oriented defaults and away from the trained relational layer requiring active top-down modulation. Community supervision officers were assessed across four waves of a longitudinal study; diurnal cortisol indices (slope, waking, evening) were linked to behavioral coding from 2126 naturalistic supervision sessions under 41 officers. Within-person multilevel models showed that elevated evening cortisol predicted increased Directive Engagement, consistent with failure of HPA recovery covarying with increased occupational authority behavior. Elevated waking and evening cortisol each independently predicted decreased Relational Engagement, consistent with a dose-sensitivity pattern in which the deliberate relational behavioral layer is associated with cortisol load from either end of the diurnal profile. Eliciting Engagement, the most trait-stable and surface-level behavioral dimension, was unaffected. All four within-person effects replicated across session-count weighting, covariate adjustment, concurrent diary covariates, and alternative centering approaches. These findings extend the SIDI framework from laboratory paradigms to naturalistic professional encounters, demonstrating that diurnal HPA dysregulation dissociates across empirically independent behavioral dimensions through partially distinct cortisol features.