Abstract: Global environmental governance has expanded significantly, yet it remains politically inadequate to address planetary crises in the Anthropocene. Despite the proliferation of multilateral environmental agreements, governance arrangements continue to suffer from fragmentation, weak authority, limited accountability, and a sovereignty-bound logic that constrains collective action. This article critically examines these limitations through an assessment of polycentric and Nested Systemic Governance approaches. While nested governance can reduce fragmentation and enhance participation, it remains dependent on voluntarism and lacks the political authority and democratic anchoring required for durable coordination. Drawing on debates in environmental politics and global governance, the article advances a longer-term institutional perspective that conceptualises a gradual evolution toward a federative framework combining multilevel participation with enforceable authority and democratic legitimacy.

Abstract: Objective: This study aimed to compare thromboangiitis obliterans (TAO) and diabetic peripheral vascular disease (DPVD), the two major causes of distal limb ischemia, within a single analytical framework. The comparison was not limited to practical biomarkers that could support differential diagnosis; it was based on multidimensional parameters that determine the clinical spectrum and prognosis. The two cohorts were systematically evaluated in terms of demographics and comorbidity burden, clinical presentation and limb involvement pattern, ulcer prevalence and localization, real-life treatment strategies (medical, endovascular, and surgical), and hard clinical endpoints (major/minor amputation, hospitalization, and all-cause mortality). DPVD was phenotyped according to the lesion level as isolated distal, isolated proximal, or multilevel. Within this framework, the isolated distal diabetic peripheral vascular disease (d-DPVD) subgroup was analyzed to determine how it differs from TAO in terms of clinical course, treatment patterns, and outcomes, despite the distal anatomical similarity. Methods: In this single-center retrospective cohort study, 120 non-diabetic patients who met the angiographic TAO criteria were compared with 395 patients with DPVD with infrapopliteal/pedal atherosclerotic involvement. The clinical characteristics, ulcer topography, treatment strategies, and outcomes were recorded. The discriminatory value of blood count and lipid-based inflammatory/atherogenic indices was evaluated using logistic regression and receiver operating characteristic (ROC) curve analyses. Additionally, a separate subgroup analysis was performed for the d-DPVD subgroup, which was considered the closest to the TAO phenotype in this study. Results: DPVD was characterized by older age, higher cardiometabolic comorbidity burden, and higher inflammatory and atherogenic indices than TAO. While ulcer prevalence was similar, the distribution differed: DPVD predominantly involved plantar/proximal ulcers in a single extremity, whereas TAO more frequently involved bilateral/multiple extremities and distal acral ulcers. Antiplatelet/statin use and revascularization were more common in patients with DPVD, and major amputation, all-cause mortality, and hospitalization rates were also higher. In multivariate analyses, age, cumulative smoking exposure, SIRI, and CRI-I distinguished DPVD from TAO independently. In the d-DPVD (isolated distal) subgroup, despite a similar distal anatomical distribution, the inflammatory/atherogenic burden and clinical risk were more unfavorable. Conclusion: TAO and DPVD are two distinct phenotypes with different pathobiologies and prognoses, despite similar distal ischemia presentations. Simple inflammatory and atherogenic composite indices, evaluated in conjunction with clinical/ulcer patterns, may support differential diagnosis and risk stratification in patients with PAD. However, prospective multicenter validation of these findings is required to confirm our results.

Abstract: Background/Objectives: Spread through air spaces (STAS) represents an aggressive invasion pattern in lung cancer and is associated with adverse oncologic outcomes. However, STAS is conventionally identified only after surgical resection, highlighting the need for reliable preoperative, noninvasive predictive approaches. Methods: In this retrospective study, patients who underwent surgical resection for lung cancer and had available preoperative ^18F-FDG PET/CT imaging were analyzed. Radiomic features were extracted from both intratumoral and peritumoral regions, the latter intended to reflect tumor microenvironment–related characteristics. Radiomic-only and clinicoradiomic models integrating clinical variables were developed using feature selection and multivariable modeling strategies, and their performance was evaluated using discrimination, calibration, and decision curve analyses. Results: Radiomic features derived from intratumoral metabolism and peritumoral tissue heterogeneity were associated with the presence of STAS. Integration of radiomic features with clinical parameters resulted in improved predictive performance compared with clinical models alone. The combined clinicoradiomic model demonstrated acceptable discrimination, calibration, and clinical utility across a range of threshold probabilities. Conclusions: Preoperative prediction of STAS in lung cancer is feasible using PET/CT-based radiomic analysis incorporating both intratumoral and peritumoral features. This noninvasive approach may provide biologically relevant information beyond anatomy-based assessment and supports further prospective validation of radiomic and clinicoradiomic models for STAS-oriented risk stratification.

Abstract: This research answers the knowledge gap regarding the explanation of the quantum jump of the electron. This scientific paper aims to complete Einstein’s research regarding general relativity and attempt to link general relativity to quantum laws.

Abstract: Critical slowing down and topological freezing in lattice gauge theory can be aggravated by thegauge-redundant link representation, which obscures simpler geometric structure available in al-ternative variables. We introduce Flux-Space Flow Matching (FFM), a generative samplingframework for 2D compact U(1) theory that operates directly on gauge-invariant flux (plaquette-angle) variables. By formulating the dynamics in flux space, the Wilson action is locally factorized,allowing us to train a continuous-time Neural ODE to approximate the equilibrium distributionwithout suffering from the stiff curvature typical of the coupled link formulation. We impose theglobal topological sector constraint via a deterministic “Relax-and-Project” mechanism and applyan independent Metropolis–Hastings accept/reject step as a bias-control procedure. Validated onL∈{48,64}lattices, FFMachievesacceptanceratesof50–70% atL= 48 andreducestheintegratedautocorrelation time of the topological charge by over 500×compared to Hybrid Monte Carlo atβ = 6.0 (on our run lengths). We validate model fidelity against thermodynamic observables, Wilsonloops, and Creutz ratios, finding agreement with the expected non-perturbative confinement scalingwithinthetestedregime. Furthermore, wedemonstratethatSpatialβ-Conditioningenableszero-shot approximation of inhomogeneous thermodynamics, spontaneously nucleating vortex–antivortexpairs in response to spatially varying coupling profiles. These results suggest that identifying theappropriate geometric degrees of freedom can be a more effective path to scalable neural samplingthan architectural complexity alone.

Abstract: Background: Localized lower respiratory tract infection including unilobar and round pneumonia can be associated with hypoxia and oxygen requirements. This is unexplained. Hypothesis: Spread of fluid absorption inhibiting cytokines in the alveolar spaces of the inflamed lung is cause of hypoxia in localized lower respiratory tract infection by spread of CFTR dysfunction in alveolar epithelial cells to more areas including those not infected. Evidence supporting the hypothesis: There is no evidence of pulmonary shunting to explain hypoxia in localized pneumonia. Systemic inflammatory response syndrome (SIRS) related generalized increase in alveolar capillary barrier or pulmonary vasoconstriction not visible on a chest x-ray cannot explain the hypoxia detected. Testing the hypothesis: Confirmation of the hypothesis could be achieved using pulmonary MRI or high resolution CT to confirm spread of alveolar fluid accumulation from the localized pneumonia focus as opposed to generalized SIRS related pulmonary oedema together with cytokine and chloride measurement in bronchoalveolar lavage samples from the lung segments near the affected lung segment and unaffected contralateral lung. Ventilation/perfusion scintigraphy could investigate for involvement of vasoconstriction or microemboli from intravascular coagulation. Implications of a confirmation of the hypothesis: Should the posed hypothesis be confirmed adjuvant strategies including small molecule CFTR activators and CFTR activating combination of beta-agonists, phosphodiesterase inhibitors and steroids could be used to treat hypoxia.

Abstract: Background: Abrupt cessation of deep brain stimulation (DBS) in Parkinson’s disease (PD), most commonly due to implantable pulse generator (IPG) depletion, may lead to DBS withdrawal syndrome (DBS-WDS). However, withdrawal does not occur in all patients following stimulation cessation.Methods: We retrospectively analyzed 210 PD patients treated with DBS. Patients with documented stimulation cessation were evaluated for the presence of withdrawal syndrome based on clinical criteria. Demographic, disease-related, and treatment characteristics were assessed, with descriptive analysis of severe cases requiring intensive care.Results: DBS battery shutdown occurred in 28 patients (13.3%). Most patients did not develop withdrawal syndrome and experienced only transient motor worsening. Severe DBS-WDS requiring intensive care was rare, occurring in only three patients (1.4%). Battery shutdown alone did not predict withdrawal, and preoperative levodopa equivalent daily dose was not associated with withdrawal risk.Conclusions: DBS battery shutdown is usually not accompanied by withdrawal syndrome, and severe DBS-WDS is uncommon. Proactive battery management may help prevent this rare but serious complication.

Abstract: Plug-in hybrid electric vehicles (PHEVs) are critical to the EU's decarbonization strategy, yet their real-world climate benefits remain uncertain. This study presents a large-scale analysis of real-world PHEV performance using on-board monitoring data from 457,303 vehicles (2021-2023). The results reveal a profound discrepancy between official test values and actual use. The mean real-world CO₂ emissions were 138 g/km, compared to a test-cycle average of 46 g/km, resulting in a regulatory gap of approximately 300%—significantly higher than for other vehicle types. Performance varied substantially across manufacturers, with gaps ranging over 200 percentage points. Contrary to expectations, larger battery capacity was correlated with a wider performance gap. Real-world electric driving averaged only 45.5% of distance, far below regulatory assumptions. This gap has grown wider each year, indicating test-cycle optimization is outpacing real-world efficiency gains. Policy analysis shows that closing this gap could achieve major CO₂ savings, underscoring the urgent need for regulatory reform, including real-world emissions monitoring and updated test procedures, to ensure PHEVs deliver their promised environmental impact.

Abstract: Cellular dynamics rely on numerous physical processes, including phase separation, membrane remodeling, stress relaxation, transport and stochastic fluctuation control, which are commonly treated as passive consequences of thermodynamics, mechanics or statistical physics. Here we advance the hypothesis that living systems can actively regulate such processes through biologically produced, reusable agents that act analogously to enzymes, but target physical state transitions rather than chemical reactions. We introduce the concept of enzymatic-like control, defined as the localized and saturable lowering of kinetic, topological or statistical barriers in configuration space by endogenous cellular components. Among the many cellular physical phenomena to which this concept may apply, we focus on biomolecular condensate nucleation and dissolution as a concrete and analytically tractable example. Condensate dynamics are conceived as barrier-limited physical reactions whose kinetic rates can be selectively modulated by putative enzyme-like Phase-Kinetases without altering equilibrium phase behavior. Using hazard-based inference and survival analysis, we present simulations demonstrating how these putative enzyme-like agents could generate small effective free-energy shifts on the order of a few kT, resulting in orders-of-magnitude changes in nucleation rates and yielding explicit, falsification-oriented criteria.Our framework complements existing biochemical and mechanical models by providing a testable perspective on the active regulation of physical dynamics without invoking new chemistry or nonstandard physics. It reframes cellular organization as the selective control of physical state transitions, rather than their passive accommodation within fixed physical laws.

Abstract: Trace dynamics is a matrix-valued Lagrangian/Hamiltonian dynamics whose equilibrium statistical mechanics yields quantum theory via the Adler--Millard conserved charge. A persistent conceptual gap is a canonical (Noether--Hamiltonian) definition of spin: since trace dynamics is fundamentally pre-spacetime (in the sense that classical spacetime geometry is emergent), the conventional interpretation of spin as an ``internal'' angular momentum requires a precise identification of the relevant configuration ``angle'' variable and the space in which it lives. Building on earlier phase-amplitude constructions of complexified trace-dynamical variables, we propose a mathematically sharpened definition: \emph{spin is the canonical momentum conjugate to an orientation variable valued in an appropriate spin group} (e.g.\ $\Spin(3,1)$ on an emergent Lorentzian leaf, or $\Spin(3,3)$ at the 6D pre-localisation stage). This reformulation upgrades the abelian phase $\theta$ to a nonabelian group element $U(\tau)$, with angular velocity $\Omega=U^{-1}\dot U$ and intrinsic spin tensor $S=\delta\,\Tr L/\delta\Omega\in\mathfrak{spin}(p,q)$. We show (i) how the earlier $\theta$-momentum definition arises as a restriction to a one-parameter subgroup; (ii) how quantisation of spin follows from the emergent canonical (anti)commutators induced by equipartition of the Adler--Millard charge together with the topology of the true orientation manifold ($\SU(2)$ double cover); (iii) how the Pauli--Lubanski invariant is recovered and how a 6D $(3,3)$-signature generalisation naturally appears as a 3-form; and (iv) how division-algebra geometry (octonions, split bioctonions) provides a concrete scaffolding for the relevant spin groups, including the $\SO(3,3)\to \SO(3,1)\times \SO(2)$ leaf selection and the $\SU(3)_{\mathrm{geom}}$-induced internal $\mathrm{Spin}^c$ structure on $\mathbb{CP}^2$-type fibres. We also clarify the relation between Poincar\'e-mass as the translation Casimir and ``square-root mass'' charges that can arise from geometric $U(1)$ factors.

Abstract: In acidic tea soil, boron (B) adsorption and desorption processes are dominated by the complex relationship between soil acidity, mineralogy, and organic matter. This study investigated B adsorption–desorption behavior in five acidic tea soils (pH 3.8–5.6) col-lected from the Eastern Black Sea region of Türkiye and evaluated the potential of machine learning (ML) algorithms to predict B desorption. Laboratory batch experi-ments were conducted using five initial B concentrations, and adsorption data were interpreted using the Langmuir isotherm model. Adsorption experiments indicated that B interacted with Fe/Al-oxide-containing clay minerals, which had low but fa-vorable binding affinity, as indicated by Langmuir maximum adsorption capacities (Qmax) ranging from 46.5 to 181.8 mg kg⁻¹. Desorption experiments revealed a high degree of reversibility, particularly in soils with lower adsorption capacities, ensuring potential B leaching. To capture the non-linear relationships governing B desorption, six ML algorithms were trained on 75 data points. Among the tested models, Extreme Gradient Boosting (XGBoost) showed the highest predictive accuracy (R² = 0.963), fol-lowed by Gaussian Process Regression and Random Forest. Variable importance anal-yses consistently highlighted soil pH, organic matter content, and clay fraction as the dominant factors. The results demonstrate that integrating laboratory experiments with machine learning provides an effective framework for predicting B mobility in acidic tea soils, offering a practical tool for improving boron management strategies.

Abstract: Coastal salt marshes are essential for climate change mitigation due to their high carbon storage capacity, which is influenced by soil type, hydrology, and floristic composition. Over the past century, invasive Phragmites australis has displaced native Sporobolus alterniflorus (formerly Spartina alterniflora) across salt marshes on the Long Island Sound, and it is widely hypothesized that its larger biomass and rapid growth enhance soil carbon sequestration. This study tested that hypothesis by comparing total organic carbon stocks and physical soil properties in two southern Connecticut marshes over multiple seasons. Our results show that mean soil bulk density was significantly higher under P. australis than S. alterniflorus at both locations. However, this did not translate to superior carbon storage. Analysis showed significant seasonal effect but no significant overall difference in median TOC between species, indicating that P. australis is competitive in total mass only due to its higher soil density. Notably, Levene’s test for homogeneity of variance was significant (P = 0.039), revealing that P. australis creates highly heterogeneous "hot spots" of carbon storage compared to the relatively uniform distribution found in native stands. These findings suggest that while P. australis invasion results in a more physically dense and potentially resilient marsh platform—relevant for surviving sea-level rise and filtering nutrient runoff—it may simultaneously compromise the stability and uniformity of regional carbon sinks. Management strategies should consider these tradeoffs when prioritizing the protection of native S. alterniflorus for consistent carbon sequestration.

Abstract: Ethiopian finches (Fringillidae) provide a continental-scale system for examining how environmental gradients shape functional trait evolution. This review synthesizes current knowledge on the evolution of beak traits in Ethiopian finches across the country’s highlands, integrating evidence from diet composition, habitat heterogeneity, thermoregulatory demands, and human-mediated environmental change. Beak diversification reflects the interaction of lineage-specific phylogenetic constraints, functional trade-offs, and plastic responses, producing adaptive divergence comparable in magnitude to classic island radiations despite ongoing gene flow. Anthropogenic pressures, including agricultural expansion, habitat fragmentation, and urbanization, interact with natural gradients to favor generalized morphologies while eroding specialized traits. Genetic analyses highlight key loci, such as BMP4 and ALX1, that may enable rapid adaptation to environmental and anthropogenic pressures. This synthesis emphasizes the need for empirical research to test trait-environment relationships and clarifies gaps in current knowledge, providing a framework for future ecological and evolutionary studies in Ethiopian finches, with implications for conservation and management of finch populations in rapidly changing landscapes.

Abstract: Cancer is one of the most significant global health problems and a leading cause of death worldwide. The origins of cancer are diverse and may stem from natural biological processes over time or directly result from anthropogenic activities. The complete elimination of all cancer-causing events within a living organism is highly unlikely. A more promising strategy would be to prevent tumors entirely by making the organism an unlivable environment where cancerous cells cannot survive. Surprisingly, this plausible alternative remains virtually unexplored. For the most part, it is not about the odds of cancer cells emerging in a hostile environment, rather than about their ability to adapt and persist within it. Plants have a broad-spectrum mechanism of defense against pathogens called non-host resistance (NHR), when an entire plant species is resistant to all isolates of a microbial species. While the NHR is effective against pathogens whereas cancer cells are perceived by an organism as “self” or “altered self”, they are still de facto “foreign intruders” since they generate neoantigens, novel proteins absent from normal tissues. Considering this, what are the theoretical possibilities of making a human organism an absolute non-host for cancer? As nearly all basic mechanisms and components of the NHR in plants have similarities to cancer responses in vertebrates, the task might be more feasible than it appears.

Abstract: Background: Urothelial carcinoma (UC) of the bladder exhibits low- and high-grade papillary forms with distinct prognoses. High mobility group proteins (HMGA1, HMGA2, HMGB1) and miR‑106a‑5p are involved in tumor progression, but their interplay in UC remains incompletely understood. The aim of this study was to compare the expression of these parameters in low- and high-grade papillary UC. Methods: Tissue samples from 80 patients (40 low-grade and 40 high-grade) undergoing transurethral resection or cystectomy were analyzed, with control samples consisting of tumor-adjacent tissues without histopathological alterations obtained from the same patients. HMGA1, HMGA2, and HMGB1 protein expression was assessed immunohistochemically. Gene expression was quantified by real-time PCR, and miR‑106a‑5p levels were measured by droplet digital PCR. Statistical analysis was conducted using Statistica 13.3, applying one-way ANOVA with Tukey’s post hoc test and correlation analysis, with p < 0.05 considered significant. Results: Expression of HMGA1 and HMGB1 was reduced in low-grade papillary urothelial carcinoma compared to control tissues, whereas both proteins were significantly increased in high-grade lesions. HMGA2 expression was minimal in low-grade tumors but partially restored in high-grade tumors. Analysis revealed the highest levels of miR-106a-5p in normal urothelium, slightly decreaseed in low-grade tumors, and significantly reduced in high-grade carcers. Conclusions: HMG proteins and miR‑106a‑5p demonstrate distinct expression patterns in low- versus high-grade papillary UC, which correlates with tumor aggressiveness. These molecules may serve as diagnostic and prognostic biomarkers and potential therapeutic targets. Further research is needed to clarify the underlying mechanisms and validate clinical applicability.

Abstract: As a renewable energy source, solar energy holds significant potential for addressing future energy and environmental challenges. Concurrently, hydrogen (H2), as a clean and renewable energy carrier, has garnered substantial attention. Photoelectrocatalytic water splitting to produce H2 represents an emerging green technology for converting solar energy into hydrogen energy, which has been highly valued by researchers. The key to advancing this technology lies in identifying photoelectrode materials with high catalytic activity and stability. In this study, dendritic α-Fe was synthesized via electrodeposition, and the photoelectrocatalytic performance of α-Fe2O3@Fe was enhanced through partial oxidation. This approach effectively addressed the issue of the short carrier transport distance in α-Fe2O3. Specifically, dendritic α-Fe2O3 was partially oxidized after annealing at 300°C for 6 h. The resulting partially oxidized α-Fe2O3@Fe exhibited a photocurrent that was 2.23 times higher than that of the fully oxidized counterpart. The influence of deposition potential on the photoelectrocatalytic performance was systematically explored, and an optimal deposition potential was identified. Additionally, surface modification with Pt was employed to further improve the photocatalytic performance of α-Fe2O3. After continuous operation for 2 h, the photocurrent of the surface-modified sample decreased by only 6.5%, indicating a substantial enhancement in stability.

Abstract: Sub-Saharan Africa is undergoing a rapid nutritional and epidemiological transition, characterized by a rising incidence of Type 2 Diabetes (T2D) among lean populations. While the "Westernization" of the gut microbiome is well-documented globally, the specific ecological shifts driving metabolic dysfunction in the African context remain under-synthesized. This systematic review aims to catalog diet-driven taxonomic alterations and evaluate their mechanistic link to T2D. A systematic search was conducted following PRISMA guidelines using PubMed, Scopus, and Google Scholar (2015–2026). Studies were included if they compared the gut microbiomes of urban vs. rural African populations and reported metabolic outcomes. Quality was assessed using the Newcastle-Ottawa Scale. Twelve studies meeting inclusion criteria were identified, representing a pooled cohort of N=6,097 participants across 22 countries. The analysis revealed a consistent "rural signature" marked by the enrichment of fiber-degrading Treponema and Prevotella ("VANISH" taxa). Urbanization was associated with the significant depletion of these guilds and a compensatory bloom of Bacteroides and Bifidobacterium. This taxonomic shift was statistically correlated with elevated fasting blood glucose, HbA1c, and diabetes prevalence in urban cohorts. Mechanistically, the loss of Treponema likely compromises SCFA-mediated insulin signaling, while the rise of mucin-degrading Bacteroides may drive metabolic endotoxemia. Urbanization in Africa is associated with the loss of key ancestral microbes that protect metabolic health. Given that commercial probiotics often contain taxa already enriched in urban Africans (Bifidobacterium), we propose that indigenous fermented foods (e.g., Ogi, Kunu), which provide a Lactobacillus-rich acidic niche, represent a more ecologically appropriate therapeutic strategy to restore metabolic homeostasis. All identified associations are observational, and causal inferences cannot be established.

Abstract: Introduction: Sequencing therapy in CD is currently intensively discussed due to the development of novel drugs and lack of standardized criteria for drug positioning in first and further treatment lines. The aim of this study was to compare the efficacy of a second line advanced therapy in Romanian patients with CD who have failed an anti-TNF agent. Methods: We performed a multicenter retrospective study that included adult patients with CD who had secondary loss of response after an initial response with an an-ti-TNF drug. The main outcome was clinical remission at 12 weeks of second-line treatment (CDAI < 150). Secondary outcomes included clinical response (decrease of CDAI ≥ 25%), persistence of therapy at 1 year and rates of adverse events. Results: From 2008 to 2024, 216 patients were either switched to another anti-TNF or swapped to another therapeutic class due to failure of a first anti-TNF drug. Secondary lines of treatment in-cluded infliximab (IFX), adalimumab (ADA), vedolizumab (VDZ), ustekinumab (UST). The highest rate of clinical remission (81%) was obtained with the sequence ADA-IFX in 26/32(81%) patients and ADA-UST in 62/82(76%) patients, followed by IFX-UST in 22/33(67%) and IFX-ADA 34/51(67%). Persistence on therapy at 1 year was better for the sequence ADA-UST(73%) and IFX-UST(67%) and ADA-IFX(63%) compared to IFX-ADA(59%) and IFX-VDZ(44%)(p< 0.001). Conclusions: In patients with CD who have failed a first anti-TNF, the highest rate of clinical re-mission at 12 weeks was obtained with second line IFX and UST whilst vedolizumab showed lower efficacy. UST demonstrated the most favorable long-term treatment persistence at 1 year.

Abstract: Biodiversity in Ethiopia is under mounting pressure from deforestation, agricultural expansion, climate change, and other anthropogenic pressures, yet conventional conservation approaches often fail to protect species and ecosystems effectively. Dominated by Western scientific paradigms, these approaches treat the ecosystems as isolated from human activity, relying on centralized management, protected areas, and technical interventions. In human-dominated landscapes, such models frequently overlook the adaptive capacities embedded within Indigenous Knowledge (IK) systems. Developed through generations of observation, experimentation, and social regulation, IK encodes a detailed understanding of species behavior, landscape dynamics, and sustainable resource use, functioning as a dynamic ecological system. This essay argues that integrating Indigenous knowledge into biodiversity conservation is an Ecological imperative rather than a moral preference. Evidence from Ethiopian church forests, pastoralist rangelands, and Konso terraces shows that IK sustains biodiversity, ecosystem resilience, and livelihoods. While highly effective, IK is not uniform or universally sufficient; demographic change, market pressures, and internal social inequalities can constrain its impact. Recognizing both the strengths and limits of IK, and embedding it within multi-level governance systems is essential for designing resilient, socially legitimate conservation strategies. Thoughtful integration transforms Indigenous stewardship from a cultural practice into a strategic tool for sustaining ecosystems in climatically variable, human-occupied landscapes.

Abstract:

Background: Intraoperative hypotension (IOH) is strongly associated with postoperative myocardial injury, acute kidney injury, and mortality. Current monitoring relies on reactive threshold alarms, often alerting clinicians only after hemodynamic compromise has occurred. We hypothesized that a machine learning (ML) approach utilizing engineered hemodynamic volatility features could predict IOH five minutes before its occurrence. Methods: A retrospective observational study was conducted using high-resolution intraoperative monitoring data from the VitalDB registry. The cohort included 1,750 adult patients undergoing non-cardiac surgery. We developed and compared three ML algorithms Logistic Regression (LR), Random Forest (RF), and Extreme Gradient Boosting (XGBoost) trained on physiological features including arterial pressure trends and rolling volatility indices. Performance was evaluated using the Area Under the Receiver Operating Characteristic Curve (AUROC) for discrimination and the Brier Score for calibration. Results: All models demonstrated robust predictive capability. The Random Forest model achieved the highest discrimination (AUROC 0.837), outperforming LR (0.824) and XGBoost (0.803). However, XGBoost demonstrated superior calibration with a Brier Score of 0.0825 (vs. 0.153 for RF), indicating more reliable probabilistic risk estimates. Feature importance analysis consistently identified hemodynamic volatility (rolling standard deviation of MAP) as the dominant predictor across all models. At the optimal threshold, the system demonstrated a sensitivity of 69.5% and specificity of 75.3%. Conclusions: We identified a trade-off between discrimination and calibration: Random Forest offers the best ranking for early warning, while XGBoost provides the most accurate risk probability. Crucially, hemodynamic instability was identified as a critical prodromal marker, suggesting that oscillatory variance precedes hypotension.