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Abstract Background Spectral imaging of photon-counting detector CT (PCD-CT) scanners allows for generating virtual non-contrast (VNC) reconstruction. By analyzing 12 abdominal organs, we aimed to test the reliability of VNC reconstructions in preserving HU values compared to real unenhanced CT images. Methods Our study included 34 patients with pancreatic cystic neoplasm (PCN). The VNC reconstructions were generated from unenhanced, arterial, portal, and venous phase PCD-CT scans using the Liver-VNC algorithm. The observed 11 abdominal organs were segmented by the TotalSegmentator algorithm, the PCNs were segmented manually. Average densities were extracted from unenhanced scans (HUunenhanced), postcontrast (HUpostcontrast) scans, and VNC reconstructions (HUVNC). The error was calculated as HUerror=HUVNC–HUunenhanced. Pearson’s or Spearman’s correlation was used to assess the association. Reproducibility was evaluated by intraclass correlation coefficients (ICC). Results Significant differences between HUunenhanced and HUVNC[unenhanced] were found in vertebrae, paraspinal muscles, liver, and spleen. HUVNC[unenhanced] showed a strong correlation with HUunenhanced in all organs except spleen (r = 0.45) and kidneys (r = 0.78 and 0.73). In all postcontrast phases, the HUVNC had strong correlations with HUunenhanced in all organs except the spleen and kidneys. The HUerror had significant correlations with HUunenhanced in the muscles and vertebrae; and with HUpostcontrast in the spleen, vertebrae, and paraspinal muscles in all postcontrast phases. All organs had at least one postcontrast VNC reconstruction that showed good-to-excellent agreement with HUunenhanced during ICC analysis except the vertebrae (ICC: 0.17), paraspinal muscles (ICC: 0.64–0.79), spleen (ICC: 0.21–0.47), and kidneys (ICC: 0.10–0.31). Conclusions VNC reconstructions are reliable in at least one postcontrast phase for most organs, but further improvement is needed before VNC can be utilized to examine the spleen, kidneys, and vertebrae.

Abstract Background Mesenteric arterial thrombosis is an extremely rare thrombotic event, especially during pregnancy, that can cause rapid fatal consequences unless the patient receives early definitive treatment. Case presentation We report the case of a 34-year-old female presenting in her seventh week of gestation with severe abdominal pain who was promptly diagnosed with mesenteric artery occlusion amidst incipient miscarriage. The patient underwent a successful mesentery artery embolectomy, recovered and was later diagnosed with elevated factor VIII activity. Conclusion The diagnosis of mesenteric ischemia should be considered in pregnant women presenting with severe abdominal pain and any prior predisposing factors. Our case highlights the pivotal role of the emergency physician in maintaining a high index of suspicion coupled with timely and determined action. The prognosis of this high mortality condition depends on prompt diagnosis, early definite management and successful multidisciplinary cooperation.

(Series Information) European Papers - A Journal on Law and Integration, 2023 8(3), 1575-1597 | Article | (Table of Contents) I. Introduction. – II. New formulas in the regime of mutual recognition in the EIO. – III. The question of defining investigative measures and having recourse to a different one. – III.1. The applicability of the corrective mechanism in other cooperation systems. – IV. An increased extent of direct communication between the issuing and the executing authorities. – IV.1. Regulating greater communication between issuing and executing authorities as a form of institutionalised distrust. – V. The fundamental rights-based refusal ground and the question of its applicability. – V.1. Making the fundamental rights-based refusal ground the norm instead of it being the exception. – VI. Conclusion. | (Abstract) This Article concerns the European Investigation Order (EIO) and its relations to the principle of mutual recognition. The principle has been the engine of judicial cooperation in criminal matters between Member States of the European Union since the adoption of the Tampere conclusions in 1999. Member States rely on the principle in creating cooperation systems, thereby facilitating interaction among their criminal justice systems. Since Member States refrain from extensive criminal law harmonisation, the principle is of utmost importance. As such, a common regulatory technique was developed through which the principle is given effect in every cooperation system created so far. Although this regulatory technique was mostly followed in the directive establishing the EIO, it also introduced several novelties in the regime, notably the option to have recourse to another investigative measure, the possibility for a greater extent of communication, and the fundamental rights-based refusal ground. This Article argues that these rules make the EIO directive more protective of fundamental rights and show a new trend in the cooperation systems based on the principle of mutual recognition. In addition, while reviewing the applicability of these rules in other cooperation systems, it provides a proposal on how to apply them to enhance mutual trust between Member States through legislation.

In a quantitative study, the promotion of officials in seven counties of the Kingdom of Hungary is investigated. In the 18th century, some noble office-holders of humbler origins seem to have met difficulties being elected to the office of ordinarius judex nobilium, the lowest of the really important positions, while the most elevated gentry families did not even bother to serve in the county administration – or if so, then only for that of the ordinarius vicecomes, the leading office-holder. We can even get a glimpse of signs of professionalization among the county officials. An important fact is that the gate was open for some of the leading officials the counties to be appointed by the king to offices with nationwide authority, what testifies for an important link of the central royal bureaucracy and the county administration, the two rival elites of the age.

Abstract Choosing the optimal device during cardiac resynchronization therapy (CRT) upgrade can be challenging. Therefore, we sought to provide a solution for identifying patients in whom upgrading to a CRT-defibrillator (CRT-D) is associated with better long-term survival than upgrading to a CRT-pacemaker (CRT-P). To this end, we first applied topological data analysis to create a patient similarity network using 16 clinical features of 326 patients without prior ventricular arrhythmias who underwent CRT upgrade. Then, in the generated circular network, we delineated three phenogroups exhibiting significant differences in clinical characteristics and risk of all-cause mortality. Importantly, only in the high-risk phenogroup was upgrading to a CRT-D associated with better survival than upgrading to a CRT-P (hazard ratio: 0.454 (0.228–0.907), p = 0.025). Finally, we assigned each patient to one of the three phenogroups based on their location in the network and used this labeled data to train multi-class classifiers to enable the risk stratification of new patients. During internal validation, an ensemble of 5 multi-layer perceptrons exhibited the best performance with a balanced accuracy of 0.898 (0.854–0.942) and a micro-averaged area under the receiver operating characteristic curve of 0.983 (0.980–0.986). To allow further validation, we made the proposed model publicly available ( https://github.com/tokmarton/crt-upgrade-risk-stratification ).

In the original publication [...]

Robot-Assisted Minimally Invasive Surgery (RAMIS) marks a paradigm shift in surgical procedures, enhancing precision and ergonomics. Concurrently it introduces complex stress dynamics and ergonomic challenges regarding the human–robot interface and interaction. This study explores the stress-related aspects of RAMIS, using the da Vinci XI Surgical System and the Sea Spikes model as a standard skill training phantom to establish a link between technological advancement and human factors in RAMIS environments. By employing different physiological and kinematic sensors for heart rate variability, hand movement tracking, and posture analysis, this research aims to develop a framework for quantifying the stress and ergonomic loads applied to surgeons. Preliminary findings reveal significant correlations between stress levels and several of the skill-related metrics measured by external sensors or the SURG-TLX questionnaire. Furthermore, early analysis of this preliminary dataset suggests the potential benefits of applying machine learning for surgeon skill classification and stress analysis. This paper presents the initial findings, identified correlations, and the lessons learned from the clinical setup, aiming to lay down the cornerstones for wider studies in the fields of clinical situation awareness and attention computing.

Objectives Melanoma is the deadliest form of skin cancer, but it can be fully cured through early detection and treatment in 99% of cases. Our aim was to develop a non-invasive machine learning system that can predict the thickness of a melanoma lesion, which is a proxy for tumor progression, through dermoscopic images. This method can serve as a valuable tool in identifying urgent cases for treatment. Methods A modern convolutional neural network architecture (EfficientNet) was used to construct a model capable of classifying dermoscopic images of melanoma lesions into three distinct categories based on thickness. We incorporated techniques to reduce the impact of an imbalanced training dataset, enhanced the generalization capacity of the model through image augmentation, and utilized five-fold cross-validation to produce more reliable metrics. Results Our method achieved 71% balanced accuracy for three-way classification when trained on a small public dataset of 247 melanoma images. We also presented performance projections for larger training datasets. Conclusions Our model represents a new state-of-the-art method for classifying melanoma thicknesses. Performance can be further optimized by expanding training datasets and utilizing model ensembles. We have shown that earlier claims of higher performance were mistaken due to data leakage during the evaluation process.

Abstract With the changing epidemiology of COVID-19 and its impact on our daily lives, there is still an unmet need of COVID-19 therapies treating early infections to prevent progression. The current study was a randomized, parallel, double-blind, placebo-controlled trial. Ninety SARS-CoV-2 positive patients were randomized into 3 groups receiving placebo, 0.02% or 0.1% azelastine nasal spray for 11 days, during which viral loads were assessed by quantitative PCR. Investigators assessed patients’ status throughout the trial including safety follow-ups (days 16 and 60). Symptoms were documented in patient diaries. Initial viral loads were log10 6.85 ± 1.31 (mean ± SD) copies/mL (ORF 1a/b gene). After treatment, virus load was reduced in all groups (p

The focus of the present study is the sustainability of the settlements in the Lake Velence area, especially Velence and Gardony, which are at the center of pressure by tourism in the area. At the beginning of the study, immediately after the introduction of the concepts of sustainability and tourism destination management and the characterization of Lake Velence and its tourism, a comparative assessment of the Integrated Settlement Development Strategies of the cities of Velence and Gárdony is presented. Gárdony’s strategy focuses on the sustainability of the economy and the urban and natural environment, while Velence has a stronger social aspect. The study determined the strengths and weaknesses, which are in line with the results of the indicator-based research presented in the second part of the study that aimed to establish the sustainability ranking of the region. We considered the direction and extent of changes between 2010 and 2018 and compared it with the absolute data series for 2018. Velence and Gárdony are in the middle category in the sustainability rankings, while Velence is among the best in the latter.

Abstract Background Recent studies put under scrutiny the prevailing hand hygiene guidelines, which incorporate quantitative parameters regarding handrub volume and hand size. Understanding the criticality of complete (i.e., efficient) hand hygiene in healthcare, objectivization of hand hygiene related parameters are paramount, including the formulation of the ABHR. Complete coverage can be achieved with optimal Alcohol-Based Hand Rub (ABHR) provided. The literature is limited regarding ABHR formulation variances to antimicrobial efficiency and healthcare workers’ preference, while public data on clinically relevant typical application differences is not available. This study was designed and performed to compare gel and liquid format ABHRs (the two most popular types in Europe) by measuring several parameters, including application time, spillage and coverage. Methodology Senior medical students were invited, and randomly assigned to receive pre-determined ABHR volumes (1.5 or 3 ml). All the 340 participants were given equal amounts of gel and liquid on two separate hand hygiene occasions, which occurred two weeks apart. During the hand hygiene events, by employing a digital, fully automated system paired with fluorescent-traced ABHRs, disinfectant hand coverage was objectively investigated. Furthermore, hand coverage in relation to the participants’ hand sizes was also calculated. Additional data collection was performed regarding volume differences and their effect on application time, participants’ volume awareness (consciousness) and disinfectant spillage during the hand hygiene events. Results The 1.5 ml ABHR volume (commonly applied in healthcare settings) is insufficient in either formulation, as the non-covered areas exceeded significant (5%+) of the total hand surface area. 3 ml, on the contrary, resulted in almost complete coverage (uncovered areas remained below 1.5%). Participants typically underestimated the volume which they needed to apply. While the liquid ABHR spreads better in the lower, 1.5 ml volume compared to the gel, the latter was easier handled at larger volume. Drying times were 30/32 s (gel and liquid formats, respectively) when 1.5 ml handrub was applied, and 40/42 s when 3 ml was used. As the evaporation rates of the ABHR used in the study are similar to those available on the market, one can presume that the results presented in the study apply for most WHO conform ABHRs. Conclusion The results show that applying 1.5 ml volume was insufficient, as large part of the hand surface remained uncovered (7.0 ± 0.7% and 5.8 ± 1.0% of the hand surface in the case of gel and liquid, respectively) When 3 ml handrub was applied drying times were 40 and 42 s (gel and liquid, respectively), which is a very long time in daily clinical practice. It looks like we cannot find a volume that fits for everyone. Personalized, hand size based ABHR volumes may be the solution to find an optimal balance between maximize coverage and minimise spillage and drying time. 3 ml can be a good volume for those who have medium size hands. Large handed people should use more handrub to reach appropriate coverage, while small-handed ones may apply less to avoid massive spillage and not to take unrealistically long to dry.

IntroductionDespite the significant contribution of circumferential shortening to the global ventricular function, data are scarce concerning its prognostic value on long-term mortality. Accordingly, our study aimed to assess both left (LV) and right ventricular (RV) global longitudinal (GLS) and global circumferential strain (GCS) using three-dimensional echocardiography (3DE) to determine their prognostic importance.MethodsThree hundred fifty-seven patients with a wide variety of left-sided cardiac diseases were retrospectively identified (64 ± 15 years, 70% males) who underwent clinically indicated 3DE. LV and RV GLS, and GCS were quantified. To determine the prognostic power of the different patterns of biventricular mechanics, we divided the patient population into four groups. Group 1 consisted of patients with both LV GLS and RV GCS above the respective median values; Group 2 was defined as patients with LV GLS below the median while RV GCS above the median, whereas in Group 3, patients had LV GLS values above the median, while RV GCS was below median. Group 4 was defined as patients with both LV GLS and RV GCS below the median. Patients were followed up for a median of 41 months. The primary endpoint was all-cause mortality.ResultsFifty-five patients (15%) met the primary endpoint. Impaired values of both LV GCS (HR, 1.056 [95% CI, 1.027–1.085], p < 0.001) and RV GCS (1.115 [1.068–1.164], p < 0.001) were associated with increased risk of death by univariable Cox regression. Patients with both LV GLS and RV GCS below the median (Group 4) had a more than 5-fold increased risk of death compared with those in Group 1 (5.089 [2.399–10.793], p < 0.001) and more than 3.5-fold compared with those in Group 2 (3.565 [1.256–10.122], p = 0.017). Interestingly, there was no significant difference in mortality between Group 3 (with LV GLS above the median) and Group 4, but being categorized into Group 3 versus Group 1 still held a more than 3-fold risk (3.099 [1.284–7.484], p = 0.012).DiscussionThe impaired values of both LV and RV GCS are associated with long-term all-cause mortality, emphasizing the importance of assessing biventricular circumferential mechanics. Reduced RV GCS is associated with significantly increased risk of mortality even if LV GLS is preserved.

Simple Summary: Tumor budding (TB), poorly differentiated clusters (PDCs), and the Stroma AReactive Invasion Front Area (SARIFA) are emerging biomarkers offering fast and cost-effective ways of assisting the clinical therapeutic decision. However, in esophageal cancers, their applicability has not been fully elucidated. In our retrospective study, we examined these invasion markers in a cohort of esophageal squamous cell cancers and adenocarcinomas, with a special focus on lymphatic spread. According to our results, different invasive patterns are prognostic in histological subtypes of esophageal cancer, namely, SARIFA in adenocarcinomas and TB in squamous cell carcinomas. However, only in squamous cell cancers were TB and PDC useful for the prediction of overall survival. In adenocarcinomas, neither of the aforementioned markers were significant regarding survival prediction, possibly due to the small cohort size. Both esophageal squamous cell carcinoma (ESQCC) and adenocarcinoma (EAC) are known to have poor prognosis. We aimed to investigate the invasion front areas of 57 ESQCC and 43 EAC cases to find histological signs of metastatic progression. Tumor cell clusters with different cell counts, including tumor buds (TBs) and poorly differentiated clusters (PDCs), were assessed. The presence of the recently described Stroma AReactive Invasion Front Area (SARIFA) phenomenon, which defines a direct contact between tumor cells and adipocytes, was more frequently observed in EAC than in ESQCC (p = 0.004). In adenocarcinomas, a higher prevalence of SARIFA was observed in tumors with a higher number of small clusters (TBs and small PDCs; p < 0.001); furthermore, both the high number of TBs (p = 0.016) and the presence of SARIFA (p = 0.001) correlated with a higher pT stage. SARIFA positivity in EAC (p = 0.011) and high TB in ESQCC (p = 0.0006) were found to be independent prognostic factors for lymph node metastases. Moreover, in ESQCC, the higher absolute number of both TBs and PDCs was associated with shorter overall survival (p = 0.0269 and p = 0.0377, respectively). Our results suggest that the histological subtypes of esophageal cancer behave differently, namely, that different features of the invasion front are of prognostic significance. [ABSTRACT FROM AUTHOR]

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A sero-epidemiology study was conducted in Dhaka, Bangladesh between January 2020 and February 2021 to assess the immune responses to ETEC infection in adults and children. (1) Background: Enterotoxigenic Escherichia coli infection is a main cause of diarrheal disease in endemic countries. The characterization of the immune responses evoked by natural infection can guide vaccine development efforts. (2) Methods: A total of 617 adult and 480 pediatric diarrheal patients were screened, and 43 adults and 46 children (below 5 years of age) with an acute ETEC infection completed the study. The plasma samples were analyzed for antibody responses against the ETEC toxins. (3) Results: Heat-stable toxin (ST)-positive ETEC is the main cause of ETEC infection in adults, unlike in children in an endemic setting. We detected very low levels of anti-ST antibodies, and no ST-neutralizing activity. However, infection with ETEC strains expressing the heat-labile toxin (LT) induced systemic antibody responses in less than 25% of subjects. The antibody levels against LTA and LTB, as well as cholera toxin (CT), correlated well. The anti-LT antibodies were shown to have LT- and CT- neutralizing activity. The antibody reactivity against linear LT epitopes did not correlate with toxin-neutralizing activity. (4) Conclusions: Unlike LT, ST is a poor antigen and even adults have low anti-ST antibody levels that do not allow for the detection of toxin-neutralizing activity.

Climate change and increasing human impacts are more emphasised in recharge regions, where the main flow direction is downward, resulting in negative water balance. Two wetlands located in the recharge position of regional groundwater flow systems were investigated in the Nyírség region, Hungary, as pilot areas for representing wetlands in similar hydraulic positions. Hydraulic data processes, chemical data evaluations, and numerical simulations revealed that the wetlands are fed via local flow systems, superimposing regional-scale recharge conditions in the area. The wetlands are discharge and flow-through types in connection with local flow systems. Nevertheless, in the case of significant regional water table decline—due to the high vulnerability of recharge areas to climate change—local flows are degraded, so they are not able to sustain the wetlands. To preserve the groundwater-dependent ecosystems in the areas, water retention at the local recharge areas of the wetlands may help in the mitigation of water level decline under present-day conditions. If the regional water table continues to decline, comprehensive water retention solutions are needed in the whole region. The results highlight that understanding the natural wetland–groundwater interactions at different scales is crucial for the preservation of wetlands and for successful water retention planning.

This paper focuses on the complexity of socio-economic governance in the European Union. We define socio-economic governance as the process of governing societies in a situation where no single actor can claim absolute dominance thus socio-economic governance is the outcome of the interaction between European Union institutions (European Union decision-makers) and member states (national policy-makers). Since the onset of the global financial crisis and the euro crisis a decade ago, social issues have become substantially prominent in EU governance and policy debate. Furthermore, the Covid-19 crisis brought again social issues to the fore. There is no dedicated social governance framework in the European Union but there are several mechanisms (strategies, initiatives and regulations) through which social governance is practiced. At the same time, the framework for European economic governance has substantially been strengthened as a consequence of the global financial crisis and the euro crisis and can be characterised by a matured but incomplete framework. On the one hand, this paper aims to collect and investigate all governance tools related to economic and social issues in the European Union, and on the other hand, this research examines the impacts of those governance tools on member states.

This review paper briefly summarizes the research results of the majority (∼70%) women team of the Hydrogeology Research Group of Eötvös Loránd University, Hungary, led by Judit Mádl-Szőnyi. The group had originally focused on basin-scale groundwater flow systems and the related processes and phenomena but extended its research activity to other geofluids in answer to global challenges such as the water crisis, climate change, and energy transition. However, the core concept of these studies remained the basin-scale system approach of groundwater flow, as these flow systems interact with the rock framework and all other geofluids resulting in a systematic distribution of the related environmental and geological processes and phenomena. The presented methodological developments and mostly general results have been and can be utilized in the future in any sedimentary basins. These cover the following fields of hydrogeology and geofluid research: carbonate and karst hydrogeology, asymmetric basin and flow pattern, geothermal and petroleum hydrogeology, radioactivity of groundwater, groundwater and surface water interaction, groundwater-dependent ecosystems, effects of climate change on groundwater flow systems, managed aquifer recharge.

Hypocalcemia is a common condition in liver cirrhosis and is associated with the severity of SARS-CoV-2 infection. However, there is a lack of data demonstrating the prognostic value of hypocalcemia in COVID-19 patients with cirrhosis. This study aimed to evaluate the prognostic value of hypocalcemia for COVID-19 severity, mortality and its associations with abnormal liver function parameters. We selected 451 COVID-19 patients in this retrospective study and compared the laboratory findings of 52 COVID-19 patients with cirrhosis to those of 399 COVID-19 patients without cirrhosis. Laboratory tests measuring albumin-corrected total serum calcium were performed on admission, and the levels were monitored during hospitalization. The total serum calcium levels were significantly lower in cirrhosis cases (2.16 mmol/L) compared to those without cirrhosis (2.32 mmol/L). Multivariate analysis showed that hypocalcemia in COVID-19 patients with cirrhosis was a significant predictor of in-hospital mortality, with an OR of 4.871 (p < 0.05; 95% CI 1.566–15.146). ROC analysis showed the AUC value of total serum calcium was 0.818 (95% CI 0.683–0.953, p < 0.05), with a sensitivity of 88.3% and a specificity of 75%. The total serum calcium levels showed a significant negative correlation with the Child–Turcette–Pugh score (r = −0.400, p < 0.05). Hypocalcemia on admission was a significant prognostic factor of disease progression in COVID-19 patients with cirrhosis.

In this paper, we provide a macro-comparative assessment of welfare state convergence. Using the welfare state regime approach, the paper analyses the development of main welfare state indicators within in the enlarged European Union. In this study we capitalize on descriptive statistics and a single convergence analysis based on standard deviation in order to capture alterations in national welfare models of 26 European countries and among acknowledged welfare regimes. Our fundamental aim is to seize on long-term processes (convergence, divergence, or persistence), so we cover almost a two-decade period starting at 2000. Our results, in general, suggest that convergence among welfare states (different indicator of social spending) of European countries is particularly weak, however convergence inside welfare regimes is significantly stronger apart from the Anglo-Saxon group. The pre-crisis period was characterized by a stronger convergence among European countries as a consequence of economic prosperity and intense EU intervention.

Background and purpose: The COVID-19 pandemic continues to pose challenges, especially with the emergence of new SARS-CoV-2 variants that are associated with higher infectivity and/or compromised protection afforded by the current vaccines. There is a high demand for additional preventive and therapeutic strategies effective against this changing virus. Repurposing of approved or clinically tested drugs can provide an immediate solution.Experimental Approach: We applied a novel computational approach to search among approved and commercially available drugs. Antiviral activity of a predicted drug, azelastine, was tested in vitro in SARS-CoV-2 infection assays with Vero E6 cells, Vero cells stably overexpressing the human TMPRSS2 and ACE2 proteins as well as on reconstituted human nasal tissue using the predominant variant circulating in Europe in summer 2020, B.1.177 (D614G variant), and its emerging variants of concern; B.1.1.7 (alpha), B.1.351 (beta) and B.1.617.2 (delta) variants. The effect of azelastine on viral replication was assessed by quantification of viral genomes by droplet digital PCR or qPCR.Key results: The computational approach identified major drug families, such as anti-infective, anti-inflammatory, anti-hypertensive, antihistamine, and neuroactive drugs. Based on its attractive safety profile and availability in nasal formulation, azelastine, a histamine 1 receptor-blocker was selected for experimental testing. Azelastine reduced the virus-induced cytopathic effect and SARS-CoV-2 copy numbers both in preventive and treatment settings upon infection of Vero cells with an EC50 of 2.2–6.5 µM. Comparable potency was observed with the alpha, beta and delta variants. Furthermore, five-fold dilution (containing 0.02% azelastine) of the commercially available nasal spray formulation was highly potent in inhibiting viral propagation in reconstituted human nasal tissue.Conclusion and Implications: Azelastine, an antihistamine available as nasal sprays developed against allergic rhinitis may be considered as a topical prevention or treatment of nasal colonization by SARS-CoV-2. A Phase 2 efficacy indicator study with azelastine-containing nasal spray that was designed based on the findings reported here has been concluded recently, confirming accelerated viral clearance in SARS-CoV-2 positive subjects.

Clarithromycin is a macrolide antibiotic widely used for eradication of Helicobacter pylori infection. Here, Kocsmár et al. study clarithromycin resistance and previous macrolide consumption in 4,744 H. pylori-infected patients, shedding light into the sources of primary resistant cases and the role played by prior consumption of macrolides for non-eradication purposes.

The hummocky Balaton Highland is located in western Hungary and is part of the Transdanubian Mountains, the most extensive carbonate aquifer system in Hungary. The study region also encompasses Lake Balaton, the biggest lake in central Europe, which is to the south of Balaton Highland. The surface water–groundwater interaction in the Balaton Highland–Lake Balaton region and the groundwater contribution to Lake Balaton are revisited in this paper. Hydrostratigraphic classification was performed first; then, groundwater flow directions by hydraulic head distribution were analysed, and baseflow indices of surface watercourses were calculated. Regarding hydrochemical characterisation, general hydrochemical facies were identified, natural tracers of temperature, chloride and uranium were applied, and the stable isotopic composition of oxygen and hydrogen was determined. Finally, groundwater flow and heat transport were simulated in a 2D numerical model. A high level of hydraulic interaction was evidenced between surface water and groundwater and the sub-regions of Bakony Mountains, Balaton Highland and Lake Balaton by physical and chemical parameters, numerical simulation and groundwater-flow-related natural manifestations, revealing hydraulic continuity in the study region. Based on the results, the division of legislative water bodies can be reconsidered, especially that surface water and groundwater should be regarded as interconnected, and Lake Balaton can be considered a groundwater-dependent ecosystem in any water-use planning in the region.

Managed aquifer recharge (MAR) is an increasingly popular technique; however, the significance of groundwater flow dynamics is rarely examined in detail regarding MAR systems. In general, a high hydraulic gradient is not favoured for MAR implementation, as it causes higher water loss and mixing of recharge water with native groundwater. However, during groundwater-dependent ecosystem (GDE) rehabilitation, these hydraulic gradient-driven flow processes can be taken advantage of. The aim of this research is to test this hypothesis by evaluating the effect of groundwater table inclination, topography, and other local characteristics on MAR efficiency from the perspective of GDE restoration. MAR efficiency was examined from recharge to discharge area in a simple half-basin based on theoretical flow simulations, using GeoStudio SEEP/W software. Different scenarios were compared to analyse the groundwater level increase and the infiltrated water volumes and to assess the efficiency of MAR based on these parameters in each scenario. The theoretical results were applied to a close-to-real situation of Lake Kondor, a GDE of the Danube-Tisza Interfluve (Hungary), which dried up in the past decades due to groundwater decline in the area. Based on the results, initial hydraulic head difference, model length, and hydraulic conductivity are the most critical parameters regarding water level increase at the discharge area. The water amount needed for increasing the water table is mainly influenced by the thickness of the unsaturated zone and the material properties of the aquifer. The findings can help better understand MAR efficiency in light of local groundwater flow processes and contribute to optimising MAR systems. The results of the study suggest that, if water is infiltrated at the local recharge area, the water table will also increase at the corresponding discharge area, which positively effects the connected GDEs. This approach can serve as a nature-based solution (NBS) to sustain sensitive ecosystems in changing climatic conditions.