Search Results (485)

Cardiovascular diseases (CVDs) are the leading cause of mortality in Italy. This study aims to describe the setting of death of patients dying from cardiovascular diseases in Italy and to explore potential changes during the COVID-19 pandemic (years 2020 and 2021) in comparison to the previous five years and the first post-pandemic year, 2022. Data from the Italian National Cause of Death Registry were analyzed to identify deaths due to cardiovascular diseases between 2015 and 2022. To evaluate potential changes associated with the COVID-19 pandemic, deaths occurring during the pandemic years (2020–2021) were compared with those recorded in the pre-pandemic period (2015–2019). The year 2022 was included as a post-pandemic descriptive reference year. A total of 221,653 deaths due to CVD occurred in 2022, compared with 217,523 in 2021, 227,350 in 2020, and a mean of 227,468 deaths per year during the five-year period of 2015–2019. Home was the primary setting of death, accounting for 44.3% of CVD deaths in 2022, compared with 46.1% in 2021, 45.8% in 2020, and 42.3% during 2015–2019. This was followed by hospitals, where 35.8% of CVD deaths occurred in 2022, slightly higher than the 35.4% in 2021 and 34.5% in 2020, but still below the 39.3% observed during 2015–2019. Long-term care facilities accounted for 12.9% of deaths in 2022, an increase from 11.5% in 2021, and broadly consistent with the 13.2% reported in 2020 and 11.2% in the previous five-year period. CVD deaths occurring in hospice facilities continued to rise modestly, from 1.2% during 2015–2019, to 1.4% in 2020, 1.8% in 2021, and 1.9% in 2022. Home is the main setting of death for patients with cardiovascular diseases, underscoring the need to implement support and palliative care and improve targeted interventions for home-based CVD patients to enhance quality of life and care at the end of life. Full article

As populations age, micronutrient deficiencies increase and are linked to frailty, functional decline, cognitive impairment, anemia, and a higher healthcare burden. This review synthesizes evidence from the past five years on adults ≥65 years, comparing residents of nursing homes/assisted-living facilities with community-dwelling peers. Community-dwelling older adults show high prevalence of deficiencies—particularly vitamin D, calcium, magnesium, folate, and zinc—while vitamin B12 deficiency is less common overall but increases with age due to malabsorption. Institutionalized adults face higher risk, driven by limited dietary variety, reduced sunlight exposure, greater multimorbidity, and polypharmacy. Reported rates include vitamin D deficiency in 70–94% of institutionalized adults (≈6.3-fold higher odds), zinc deficiency in 50–66% (vs. 31–49% in the community), iodine deficiency in 67–78% (vs. 22% in the community), and a Mini Nutritional Assessment classification of severe malnutrition/at risk in 67.9% (vs. 28% in the community). Consequences encompass frailty, falls, infections, higher costs, and increased institutionalization. Recommended actions include routine biomarker screening, improving access to vitamin D (supplementation/fortification), individualized care for micronutrient deficiencies—including vitamin B12 when relevant—multidisciplinary nutrition support, and long-term targeted research to guide best practices for healthy aging and equity. Full article

Background: Caregiver and resident interactions are important to resident satisfaction with long-term care (LTC). However, these are variously operationalized, and caregiver–resident interactions of “spending time” (activity and autonomy) and environmental quality are less well investigated modifiable factors to inform LTC resident support policies for health aging. Methods: This quantitative, cross-sectional study analyzed secondary survey data from 326 long-term care facility (LTCF) residents (aged ≥60) across Shanghai, Nanjing, and Changsha, China. Satisfaction was measured using the Chinese version of the Ohio Long-Term Care Resident Satisfaction Survey. Caregiver Qualities served as the primary predictor, with spending time and environment as parallel mediators. Analysis adjusted for age cohort, functional independence, and length of stay. Results: Caregiver qualities were positively associated with overall satisfaction (β = 0.30, p < 0.01). Spending time (effect = 0.14, 95% CI: −0.01 to 0.30) and environment quality (effect = 0.05, 95% CI: −0.03 to 0.15) showed non-significant mediated pathways between caregiver qualities and satisfaction, but the combined indirect effect of these domains was statistically significant (effect = 0.19, 95% CI: 0.04 to 0.36). The direct association between caregiver qualities and satisfaction remained significant after accounting for these mediators (effect = 0.36, 95% CI: 0.11 to 0.61). Conclusions: These findings clarify how caregiver interactions are important to resident satisfaction both directly and indirectly through spending time, activity engagement, and environmental perceptions. To promote longevity and healthy aging in LTCFs, providers should prioritize caregiver training that fosters resident autonomy, supports daily activity, and maintains age-responsive care environments. Full article

Service robots have the potential to support cognitive and social well-being in long-term care facilities, yet their widespread adoption depends on intuitive interaction modalities that minimize user learning effort and the need for a technical expert on-ground. Spoken dialogue is a natural interface, and recent advances in large language models (LLMs) promise more flexible and engaging exchanges than traditional scripted systems. In this study, we implemented a modular speech-based architecture combining automatic speech recognition, text-to-speech synthesis, and a conversational agent capable of switching between a fully scripted and LLM-driven dialogue. The implemented architecture was embodied in a TIAGo robot (PAL Robotics) and tested to compare three conversational strategies: (1) scripted, pre-defined dialogue, (2) LLM-based free-form conversation, and (3) LLM-based conversation augmented with personal information provided through the prompt. Eighteen younger adults and eighteen older adults engaged in a five-minute interaction with the robot under all three conditions in a within-subject design, and subsequently completed the Almere model questionnaire. Across all subscales and both participant groups, differences between dialogue strategies were small and statistically non-significant, despite informal comments from several older participants indicating a perceived increase in intelligence or naturalness for the LLM conditions. The findings suggest that generative dialogue and basic personalization alone do not meaningfully shift perceived acceptance in brief, task-neutral encounters, underscoring the importance of longer-term deployment and functionally meaningful robot roles in future evaluations. Full article

Background: Value-based healthcare (VBHC) has emerged as a promising approach for improving quality while reducing costs. While evidence from tertiary hospitals suggests that outsourcing to VBHC networks can improve safety, efficiency, and satisfaction, less is known about its impact in low- and intermediate-complexity hospitals. The Madrid Regional Health System (RMHS), which stratifies hospitals by complexity, provides a unique opportunity to compare performance across management models. The objective of this study was to compare outcomes between low and intermediate-complexity hospitals outsourced to a VBHC network with those operating under public management and outsourced to traditional for-profit organizations. Methods: The researchers conducted a cross-sectional analysis using the RMHS 2024 annual audit report. Sixteen low- and intermediate-complexity hospitals were included: three outsourced to the VBHC network Quirónsalud and thirteen under public management and outsourced to a traditional private for-profit network. Monographic and long-term facilities were excluded. Variables included case mix complexity, quality and safety indicators (inpatient complications, hospital-acquired infections, low-risk cesarean sections), efficiency metrics (average and case-mix-adjusted length of stay), and patient satisfaction measures (survey scores and patient transfers under the Free Choice of Care Mandate). Continuous variables were compared using Mann–Whitney U tests and categorical variables with Chi-square tests. Results: Study hospitals managed more complex patients (median case-mix 1.06 vs. 0.88, p = 0.007). Despite this, no differences were found in complication rates. Hospital-acquired infections (3.47% vs. 5.46%, p < 0.001) and low-risk cesarean sections (16.1% vs. 19.3%, p < 0.001) were significantly lower in VBHC hospitals. Efficiency was improved, with shorter average length of stay (4.26 vs. 5.03 days, p = 0.031) and all study hospitals demonstrating lower-than-expected case-mix-adjusted stay, unlike several controls. Patient satisfaction was higher (0.91 vs. 0.87, p = 0.007), as were recommendation scores (0.96 vs. 0.92, p = 0.003). Patient transfers favored outsourced hospitals, with more patients choosing them and fewer leaving compared with controls. Conclusions: Low- and intermediate-complexity hospitals managed by a value-based network in Madrid achieved superior performance across safety, efficiency, and satisfaction indicators, despite treating more complex patients. These findings extend evidence for VBHC outsourcing beyond tertiary hospitals, highlighting potential for improved system-wide performance where universal coverage and hospital stratification ensure comparability. VBHC outsourcing may represent a viable strategy to enhance patient outcomes and optimize resource use in regional healthcare systems. Full article

Background: Oral health (OH) is integral to general health, well-being, and quality of life; however, in long-term care (LTC) settings, it is often neglected due to residents’ functional limitations, high care dependency, and the prioritization of underlying medical conditions by healthcare staff. Previous studies have highlighted this issue and identified multiple barriers to OH promotion in institutional settings. Objectives: To assess OH practices among nurses (NUR) and nursing assistants (NA) in LTC units and to identify barriers compromising effective oral care delivery. Methods: An observational, cross-sectional, descriptive study was conducted across five LTC facilities in Porto, Portugal. A structured survey was administered to 145 healthcare workers out of a total of 259 eligible participants, yielding a response rate of 55.98%. Data were collected via Google Forms and analyzed using IBM SPSS Statistics v.26. Descriptive statistics, analysis of variance, the Mann–Whitney U test, and Chi-square tests were applied, with a significance level of 0.05. Results: The main primary barriers to OH promotion included poor patient cooperation (74.6%), lack of dentists (74.6%), insufficient material (62.7%), limited time (45.8%) and inadequate staffing (40.7%). Chlorhexidine (94.50%) and oral sponges (70%) were the most frequently used resources, whereas other methods were underutilized. No statistically significant differences were observed between professional groups, irrespective of prior training. Although 48.5% of NUR and 51.5% of NA reported not perceiving barriers, substantial gaps in practice were identified. Only 1.9% of untrained NA reported consulting evidence-based scientific sources, compared with 44.7% of untrained NUR. Conclusions: Despite limited perceived barriers, significant deficiencies in OH practices persist in LTC settings, highlighting the need for structured, interdisciplinary training programs to improve oral care delivery. Full article

Background: Proton beam therapy (PBT) is a valuable alternative to photon radiotherapy of CNS tumors in children and adolescents. While most recent studies deal with the outcome or long-term side effects of PBT, the aim of this study was to investigate the feasibility of PBT with a particular focus on the acute toxicity of a simultaneous radiochemotherapy (sPBCT). Patients and methods: We enrolled 199 children [median age 7.4 years (range, 0.9–17.9)], who received altogether 200 courses of PBT/sPBCT at initial diagnosis (n = 121) or at relapse (n = 79) with sPBCT in 52 (26%) courses. Data collection to PBT/sPBCT was based on the medical records and the KiProReg (Registry study of Standard Proton Therapy in Children at West German Proton Therapy Center) with a primarily descriptive-statistical and logistic regression analysis. Results: During PBT/sPBCT a total of n = 704 adverse events (AEs, mean 3.4 per course) were observed. Eighty-seven of them were graded as high-grade adverse events (HGAEs, Common Terminology Criteria for Adverse Eventº ≥3 (CTCAE)) which occurred in 67 (33.5%) PBT/sPBCT courses. HGAEs were in particular hematotoxicity (n = 43; 64.1%) and infections (n = 18; 26.8%). A significantly higher rate of HGAEs was documented in patients treated with sPBCT (n = 33/52; 63.5%) compared to those with PBT only (n = 34/148; 23.0%) (p = 0.001). In children with sPBCT, 15 (28.8%) patients could not receive the recommended dose or schedule of the planned chemotherapy (CTx) due to HGAEs, with the rate of planned CTx courses performed being significantly lower in patients receiving intensive intravenous CTx (p < 0.001). Interruptions of PBT and of simultaneous CTx were both significantly associated with the occurrence of infections [Odds ratios 3.002 (95% CI 1.005–8.971, p = 0.049) and 3.905 (95% CI 1.005–15.174, p = 0.049)]. Total discontinuation of treatment did not occur. Conclusions: Concurrent CTx during proton therapy is associated with a significant increased risk for HGAE occurrence and therapy interruptions requiring individual dose and schedule adjustments dependent on CTx intensity, very experienced interdisciplinary teams as well as intensive care and in-/out-patient oncology facilities on site. Full article

Extreme hydro-meteorological events are intensifying under climate change, disproportionately disrupting last-mile healthcare in flood-prone geographies. In this study, flood-adaptive primary care clinics (FAPCCs) integrated with islandable smart microgrids and a rapid-deploy medical technology stack (MedTech) are developed and evaluated to ensure continuity of essential services (triage, maternal and child health, vaccination cold-chain, minor procedures, diagnostics, and telemedicine) during fluvial, pluvial, and coastal flooding. Evidence on resilient health facilities, microgrid architectures, distributed energy resources, and modular clinical systems is presented in a multi-layer systems design: (1) a modular, amphibious, and elevatable clinic chassis; (2) a photovoltaic–battery–diesel hybrid system with demand-aware energy management; (3) redundant connectivity long-term evolution/fifth-generation, satellite, and very high frequency; (4) a rapid-deploy MedTech kit including point-of-care diagnostics, low-temperature cold-chain, negative-pressure isolation, and sterilization modules; and (5) flood-aware logistics using unmanned aerial vehicle/unmanned surface vehicle. A mixed-integer linear programming sizing is formulated and dispatched with a continuity-of-care reliability metric that couples energy availability to clinical throughput. Simulation across three archetypal sites (peri-urban delta, inland riverine, coastal estuary) shows that FAPCCs achieve the service availability of higher than 99.5% across 7-day grid outage scenarios while reducing fuel use by 62–81% relative to diesel-only baselines, maintaining vaccine temperatures within 2–8 °C with <0.1% thermal excursion time, and sustaining telemedicine quality of service with <150 ms median uplink latency in hybrid networks. A life-cycle cost analysis indicates a 7.1–9.8 year discounted payback from fuel displacement and avoided service loss. Deployment playbooks and policy guidance are also proposed for Ministries of Health and Disaster Agencies in monsoon-impacted regions. Full article

Introduction: Patients undergoing surgery are exposed to various stressors that may increase psychological distress during the perioperative period. These repercussions may be substantial, affecting both physical and mental health, as well as the ability to resume regular activities and overall quality of life. Aim: This study aimed to compare the preoperative psychological distress levels of patients admitted to long-term preoperative hospitalization (LONG) to those of patients admitted to day care (DC) facilities for ambulatory surgery within an oncology hospital and to examine potential sociodemographic predictors. Methods: This was a prospective observational study that included 176 individuals who underwent surgery in two cohorts. Patients in the DC cohort (n = 88) were treated in a day care surgery clinic, whereas patients in the LONG cohort (n = 88) were treated in a long-term oncology hospital. Demographic and clinical data were collected. Patients’ psychological distress (depression, anxiety, and stress) was preoperatively evaluated using the DASS-42. Univariate and multivariate logistic regression analyses were performed. Results: The DASS-42 scale’s Cronbach’s alpha was 0.923. There was no significant difference between the cohorts in terms of age; however, waiting time before surgery differed significantly (U = 2884, p = 0.002). Stress levels differed significantly between the two cohorts (p = 0.05). Conclusions: Health managers and health care providers should consider gender, surgical severity, and rural/urban residence as factors associated with preoperative psychological distress. Studies assessing gender-specific dynamics, as well as mixed-methods approaches, could provide deeper insights into patients’ experiences and the correlations of distress and highlight implications for oncology nursing practice across different hospitalization models. Full article

Background: Urothelial carcinoma (UC) is characterized by high recurrence rates and the need for long-term surveillance. Cystoscopy remains the diagnostic gold standard but is invasive, costly, and burdensome for patients. Urine, as a tumor-proximal and non-invasive biospecimen, represents an attractive source for biomarkers enabling screening, diagnosis, risk stratification, and follow-up. Objective: This review summarizes current and emerging urine-based diagnostic approaches for UC, ranging from conventional cytology to advanced molecular technologies, and discusses their clinical utility, limitations, and future perspectives. Methods: A narrative review of the literature was conducted focusing on urine-based diagnostics for UC, including urinary cytology, FDA-approved and investigational protein and DNA/RNA biomarkers, next-generation sequencing (NGS), cell-free DNA (cfDNA), exosomes, and microRNAs. Evidence from clinical validation studies, meta-analyses, and translational research was evaluated. Results: Urinary cytology remains highly specific for high-grade disease but has limited sensitivity for low-grade tumors. Protein- and DNA-based biomarkers have improved sensitivity but often lack sufficient specificity for standalone use. Recent advances in NGS-based assays enable comprehensive detection of tumor-specific genomic alterations in urinary cfDNA, offering high sensitivity for both initial diagnosis and disease monitoring. Exosomes and microRNAs represent promising biomarkers reflecting tumor biology, though standardization and large-scale validation are ongoing challenges. Overall, multimodal approaches combining cytology with molecular assays appear most promising for clinical implementation. Conclusions: Urine-based diagnostics are rapidly evolving toward integrated liquid biopsy platforms capable of transforming UC management. While several assays show strong potential to reduce reliance on cystoscopy, robust prospective validation, cost-effectiveness analyses, and clinical integration strategies are required before widespread adoption. Full article

Background/Objectives: Dominant models of successful aging emphasize health, autonomy, and active engagement, often excluding older adults belonging to vulnerable groups, such as those living in long-term care facilities (LTCFs). This study aims to address this limitation by exploring how LTCF residents define “aging well” and by examining whether they perceive themselves as aging well according to their own criteria. Methods: A qualitative design was employed using semi-structured interviews with 30 residents aged 67–95 living in three long-term care facilities located in Barcelona, Spain. Interview transcripts were analyzed using inductive thematic analysis. Results: Five core themes emerged in the participants’ definitions of aging well: health, attitude, social ties, security, and activities. Health was the most frequently mentioned domain but was conceptualized in undemanding terms, focusing on basic autonomy and cognitive functioning. Psychological attitudes and meaningful social relationships were also key, alongside contextual factors, such as security and access to activities. Two-thirds of the participants perceived themselves as aging well, with justifications closely aligned with their personal definitions; negative self-perceptions were mainly associated with poor health, loss of autonomy, or loneliness. Conclusions: The findings suggest that, in contrast with academic definitions, LTCF residents define aging well in a broader, more context-sensitive manner, which allows them to view themselves positively despite their limitations. Person-centered care environments may play a crucial role in supporting aging well in institutional settings. Full article

Taiwan’s rapid demographic shift toward a super-aged society has heightened demand for long-term care, yet limited staffing creates safety risks from fires; heating, ventilation, and air conditioning failures; and health incidents. To address this, we propose an IoT-based intelligent environmental monitoring and early-warning system designed for care facilities. The three-layer architecture integrates sensors for temperature, humidity, light, air quality, and noise; employs ESP-NOW and wireless fidelity mesh for reliable networking; and supports user interfaces with real-time anomaly alerts. Using PCA and Isolation Forest for efficient anomaly detection, the modular, node-based design enhances safety, reduces manpower burden, and enables scalable smart services. Full article

Background/Objectives: Older adults living in long-term care facilities (LTCFs) are at high risk of undernutrition. This study evaluated the adequacy of planned energy intake (PEI) by comparing prescribed diets with individual requirements measured using indirect calorimetry (IC) and by modelling how different levels of food consumption affect energy adequacy. Methods: In this cross-sectional study, 169 adults aged ≥ 65 years living in LTCFs underwent anthropometric assessment and IC-based measurement of resting energy expenditure. Total energy expenditure (TEE) was derived using activity-specific PAL factors. PEI was calculated from 7-day menu records (oral diets) or enteral feeding prescriptions. Scenario analyses assumed intake levels from 100% to 50% of PEI and applied BMI-specific adequacy thresholds. Results: Mean TEE was 1447 ± 359 kcal/day (25 ± 6 kcal/kg), whereas mean PEI was 1999 ± 400 kcal/day, yielding an average surplus of 552 ± 496 kcal/day and a TEE/PEI ratio of 0.76. PEI did not differ across sex, BMI, or activity groups despite significant differences in measured TEE. Individuals receiving enteral nutrition demonstrated close agreement between intake and expenditure. Fewer than half of residents consumed > 75% of their served portion, about one third consumed 51–75%, and approximately one fifth consumed ≤ 50%, based on caregiver reports. Scenario modelling showed that the proportion of adults meeting adequacy criteria remained relatively stable at intake levels of 100–70% of PEI but declined significantly below 70%. Conclusions: Planned dietary energy provision exceeded measured requirements, yet underweight remained frequent, indicating a gap between prescribed and consumed energy. Monitoring actual intake and adjusting provision to individual needs are essential in LTCFs. Full article

Point-of-care electroencephalography (POC-EEG) has emerged as a practical tool for the rapid detection of non-convulsive seizures (NCS) and non-convulsive status epilepticus (NCSE) in acute neurological settings where access to conventional EEG is often delayed. This narrative review synthesizes current evidence on the clinical applications, tech-no-logical evolution, and limitations of POC-EEG systems across adult and pediatric populations. Available data suggest that POC-EEG is associated with earlier seizure identification, more timely antiseizure treatment decisions, and reduced dependence on inter-facility transfers in selected healthcare settings. Beyond seizure detection, POC-EEG has shown potential utility in the assessment of acute encephalopathy due to conditions such as stroke, traumatic brain injury, delirium, and post-cardiac arrest states. Recent advances in device portability and artificial intelligence-assisted interpretation have expanded accessibility, enabling use by non-specialist clinicians; however, reduced spatial resolution, artifact susceptibility, and variable performance in focal or low-burden epileptiform activity remain important limitations. Automated detection algorithms show high accuracy for sustained seizure burden but require cautious interpretation and further prospective validation. Ethical and health-system considerations, including equitable access, diagnostic stewardship, and data governance, are increasingly relevant as adoption grows. Overall, POC-EEG represents a promising adjunct to conventional EEG that may improve early diagnostic workflows in acute neurological care, while definitive impacts on long-term outcomes warrant further study. Full article

The rapid development of medical technologies requires architects to implement a future-proofing approach while designing medical facilities, despite the inherent uncertainty of long-term change. This challenge is particularly visible within hospital emergency departments (HEDs), which play a critical role as first-contact units and life-saving infrastructures. Due to their specific function, HEDs are a challenging environment for implementing new solutions, as they rely on proven frameworks designed to ensure continuity of care and operational efficiency. This raises the key question: how can modern technologies and architectural strategies streamline workflows in HEDs without overwhelming medical staff? Considering current challenges, an equally important factor in the development of emergency departments is their preparedness for crisis situations, such as pandemics, war threats and natural disasters. How can architectural design enable the implementation of given design strategies, aiming to ensure opportunities for development while simultaneously preparing for all-hazard scenarios? The authors gathered existing trends and solutions aimed at preparing hospital emergency departments for future challenges: positive/neutral, such as technological development, but also negative, such as currently ongoing war threats or risk of the next pandemic. Despite the apparent thematic extremity, certain systematic architectural solutions using a transdisciplinary approach may be the answer to these occurrences. The mentioned architectural solutions and factors were synthesized and subjected to design-oriented review based on existing case studies of a few Polish hospitals, which are simultaneously studied as case studies for broader doctoral research in the field of effectiveness assessment. The selected Polish hospital emergency departments are used as an illustrative, analytical reference to support the interpretation and synthesis of the reviewed literature. The contextual analysis enables the identification of transferable, design-oriented strategies relevant to broader emergence medicine architecture and applicable within European units. Examples from Polish units in particular are used as reference and background for discussion, rather than as empirical case studies. The study provides an overview of contemporary and future-oriented solutions in hospital architecture, focusing on the impact and feasibility within the hospital emergency departments. The synthesis highlights the importance of designing flexible spaces prepared for future technological advances, such as oversized service shafts, increased floor heights, and modular layouts. Additionally, the study focuses on the spatial connotations of emerging technologies like medical robotics, their maintenance areas and possible challenges. All of this is interrelated to social, demographic, and economic trends. These include the development of hospital networks, the evolving patient profile, inter-hospital information flow, and the growing role of highly specialized medical units. In terms of rapid challenges like wars or armed threats, factors revealed within the review indicate levels of HED readiness to face the conflict, mainly in terms of surge capacity but also structural durability and reserve resources. The post-pandemic context, in turn, assumes rapid expansion of the hospital into temporary and flexible structures and reversible zoning allowing for patient segregation and separation. Together, these insights outline pathways for creating resilient, adaptable, and efficient emergency care environments resilient to unforeseen challenges. Considering future scenarios of emergency departments, two main scenarios were identified: “the hospital of the future”, continuing overall development and adapting to rapid technological innovations, and “the crisis-resilient hospital”, resistant to various crisis scenarios, such as pandemics or war threats. The optimal development of the unit assumes both openness to technological changes and preparation of key zones for all-hazard scenarios. This review aims to synthesize architectural implications of technological and socio-demographic changes, not to provide a full empirical study. Adopting an exploratory framework, the review refers to technological innovations and crisis preparedness as external drivers shaping the spatial organization of hospital emergency departments and their adaptability to future challenges. Because of various inhibitors (economic, political, hierarchical), not all hospitals can introduce the described improvements, but the synthesis may serve as a knowledge source for future investments. The review was also conducted to support design decisions under conditions of uncertainty. The choice to address all the external factors collectively was induced to provide transferability of solutions and coherence of possible scenarios, which may happen simultaneously. Full article