Search results for: elderly hip fracture patients

Authors: Nima Shafaghi, Gunay Anlaş, C. Can Aydiner

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A realistic understanding of martensitic phase transition under complex stress states is key for accurately describing the mechanical behavior of shape memory alloys (SMAs). Particularly regarding the sharply changing stress fields at the tip of a crack, the size, nature and shape of transformed zones are of great interest. There is significant variation among various analytical models in their predictions of the size and shape of the transformation zone. As the fully transformed region remains inside a very small boundary at the tip of the crack, experimental validation requires microscopic resolution. Here, the crack tip vicinity of NiTi compact tension specimen has been monitored in situ with microscopic image correlation with 20x magnification. With nominal 15 micrometer grains and 0.2 micrometer per pixel optical resolution, the strains at the crack tip are mapped with intra-grain detail. The transformation regions are then deduced using an equivalent strain formulation.

Keywords: digital image correlation, fracture, martensitic phase transition, mode I, NiTi, transformation zone

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Authors: Marzieh Moattari Mitra Abbasi, Masoud Mousavinasab, Poorahmad

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Background: Nurses in their daily practice need to communicate with patients and their families as well as health professional team members. Effective communication contributes to patients’ satisfaction which is a fundamental outcome of nursing practice. There are some evidences in support of patients' dissatisfaction with nurses’ performance in communication process. Therefore improving nurses’ communication skills is a necessity for nursing scholars and nursing administrators. Objective: The aim of the present study was to evaluate the effect of a 2-days workshop on nurses’ competencies and performances in communication in a central hospital located in the sought of Iran. Materials and Method: This is a randomized controlled trial which comprised of a convenient sample of 70 eligible nurses, working in a central hospital. They were randomly divided into 2 experimental and control groups. Nurses’ competencies was measured by an Objective Structured Clinical Examination (OSCE) and their performance was measured by asking eligible patients hospitalized in the nurses work setting during a one month period to evaluate nurses' communication skills before and 2 months after intervention. The experimental group participated in a 2 day workshop on communication skills. Content included in this workshop were: the importance of communication (verbal and non verbal), basic communication skills such as initiating the communication, active listening and questioning technique. Other subjects were patient teaching, problem solving, and decision making, cross cultural communication and breaking bad news. Appropriate teaching strategies such as brief didactic sessions, small group discussion and reflection were applied to enhance participants learning. The data was analyzed using SPSS 16. Result: A significant between group differences was found in nurses’ communication skills competencies and performances in the posttest. The mean scores of the experimental group was higher than that of the control group in the total score of OSCE as well as all stations of OSCE (p<0.003). Overall posttest mean scores of patient satisfaction with nurse's communication skills and all of its four dimensions significantly differed between the two groups of the study (p<0.001). Conclusion: This study shows that the education of nurses in communication skills, improves their competencies and performances. Measurement of Nurses’ communication skills as a central component of efficient nurse patient relationship by valid and reliable methods of evaluation is recommended. Also it is necessary to integrate teaching of communication skills in continuing nursing education programs. Trial Registration Number: IRCT201204042621N11

Keywords: communication skills, simulation, performance, competency, objective structure, clinical evaluation

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Authors: Rahul Jain, Jagdish Chander, Anish Gupta

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Introduction: Laparoscopic common bile duct exploration (LCBDE) allows cholecystectomy and the removal of common bile duct (CBD) stones to be performed during the same sitting, thereby decreasing hospital stay. CBD exploration through choledochotomy can be closed primarily with an absorbable suture material, but can lead to biliary leakage postoperatively. In this study we tried to find a solution to further lower the incidence of bile leakage by using fibrin glue to reinforce the sutures put on choledochotomy suture line. It has haemostatic and sealing action, through strengthening the last step of the physiological coagulation and biostimulation, which favours the formation of new tissue matrix. Methodology: This study was conducted at a tertiary care teaching hospital in New Delhi, India, from 2011 to 2013. 20 patients with CBD stones documented on MRCP with CBD diameter of 9 mm or more were included in this study. Patients were randomized into two groups namely Group A in which choledochotomy was closed with polyglactin 4-0 suture and suture line reinforced with fibrin glue, and Group ‘B’ in which choledochotomy was closed with polyglactin 4-0 suture alone. Both the groups were evaluated and compared on clinical parameters such as operative time, drain content, drain output, no. of days drain was required, blood loss & transfusion requirements, length of postoperative hospital stay and conversion to open surgery. Results: The operative time for Group A ranged from 60 to 210 min (mean 131.50 min) and Group B 65 to 300 min (mean 140 minutes). The blood loss in group A ranged from 10 to 120 ml (mean 51.50 ml), in group B it ranged from 10 to 200 ml (mean 53.50 ml). In Group A, there was no case of bile leak but there was bile leak in 2 cases in Group B, minimum 0 and maximum 900 ml with a mean of 97 ml and p value of 0.147 with no statistically significant difference in bile leak in test and control groups. The minimum and maximum serous drainage in Group A was nil & 80 ml (mean 11 ml) and in Group B was nil & 270 ml (mean 72.50 ml). The p value came as 0.028 which is statistically significant. Thus serous leakage in Group A was significantly less than in Group B. The drains in Group A were removed from 2 to 4 days (mean: 3 days) while in Group B from 2 to 9 days (mean: 3.9 days). The patients in Group A stayed in hospital post operatively from 3 to 8 days (mean: 5.30) while in Group B it ranged from 3 to 10 days with a mean of 5 days. Conclusion: Fibrin glue application on CBD decreases bile leakage but in statistically insignificant manner. Fibrin glue application on CBD can significantly decrease post operative serous drainage after LCBDE. Fibrin glue application on CBD is safe and easy technique without any significant adverse effects and can help less experienced surgeons performing LCBDE.

Keywords: bile leak, fibrin glue, LCBDE, serous leak

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Authors: Irene Kretchy, Frances Owusu-Daaku, Samuel Danquah

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Hypertension is the leading risk factor for cardiovascular diseases, and a major cause of death and disability worldwide. This study examined whether psychosocial variables influenced patients’ perception and experience of side effects of their medicines, how they coped with these experiences and the impact on mental health and medication adherence to conventional hypertension therapies. Methods: A hospital-based mixed methods study, using quantitative and qualitative approaches was conducted on hypertensive patients. Participants were asked about side effects, medication adherence, common psychological symptoms, and coping mechanisms with the aid of standard questionnaires. Information from the quantitative phase was analyzed with the Statistical Package for Social Sciences (SPSS) version 20. The interviews from the qualitative study were audio-taped with a digital audio recorder, manually transcribed and analyzed using thematic content analysis. The themes originated from participant interviews a posteriori. Results: The experiences of side effects – such as palpitations, frequent urination, recurrent bouts of hunger, erectile dysfunction, dizziness, cough, physical exhaustion - were categorized as no/low (39.75%), moderate (53.0%) and high (7.25%). Significant relationships between depression (x 2 = 24.21, P < 0.0001), anxiety (x 2 = 42.33, P < 0.0001), stress (x 2 = 39.73, P < 0.0001) and side effects were observed. A logistic regression model using the adjusted results for this association are reported – depression [OR = 1.9 (1.03 – 3.57), p = 0.04], anxiety [OR = 1.5 (1.22 – 1.77), p = < 0.001], and stress [OR = 1.3 (1.02 – 1.71), p = 0.04]. Side effects significantly increased the probability of individuals to be non-adherent [OR = 4.84 (95% CI 1.07 – 1.85), p = 0.04] with social factors, media influences and attitudes of primary caregivers further explaining this relationship. The personal adoption of medication modifying strategies, espousing the use of complementary and alternative treatments, and interventions made by clinicians were the main forms of coping with side effects. Conclusions: Results from this study show that contrary to a biomedical approach, the experience of side effects has biological, social and psychological interrelations. The result offers more support for the need for a multi-disciplinary approach to healthcare where all forms of expertise are incorporated into health provision and patient care. Additionally, medication side effects should be considered as a possible cause of non-adherence among hypertensive patients, thus addressing this problem from a Biopsychosocial perspective in any intervention may improve adherence and invariably control blood pressure.

Keywords: biopsychosocial, hypertension, medication adherence, psychological disorders

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Authors: Nicole Selvi Hill, Archchana Radhakrishnan

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Introduction: Traumatic brain injury (TBI) is a leading cause of mortality among trauma patients. In the management of TBI, the main principle is avoiding cerebral ischemia, as this is a strong determiner of neurological outcomes. The use of vasoactive drugs, such as vasopressin, has an important role in maintaining cerebral perfusion pressure to prevent secondary brain injury. Current guidelines do not suggest a preferred vasoactive drug to administer in the management of TBI, and there is a paucity of information on the therapeutic potential of vasopressin following TBI. Vasopressin is also an endogenous anti-diuretic hormone (AVP), and pathways mediated by AVP play a large role in the underlying pathological processes of TBI. This creates an overlap of discussion regarding the therapeutic potential of vasopressin following TBI. Currently, its popularity lies in vasodilatory and cardiogenic shock in the intensive care setting, with increasing support for its use in haemorrhagic and septic shock. Methodology: This is a review article based on a literature review. An electronic search was conducted via PubMed, Cochrane, EMBASE, and Google Scholar. The aim was to identify clinical studies looking at the therapeutic administration of vasopressin in severe traumatic brain injury. The primary aim was to look at the neurological outcome of patients. The secondary aim was to look at surrogate markers of cerebral perfusion measurements, such as cerebral perfusion pressure, cerebral oxygenation, and cerebral blood flow. Results: Eight papers were included in the final number. Three were animal studies; five were human studies, comprised of three case reports, one retrospective review of data, and one randomised control trial. All animal studies demonstrated the benefits of vasopressors in TBI management. One animal study showed the superiority of vasopressin in reducing intracranial pressure and increasing cerebral oxygenation over a catecholaminergic vasopressor, phenylephrine. All three human case reports were supportive of vasopressin as a rescue therapy in catecholaminergic-resistant hypotension. The retrospective review found vasopressin did not increase cerebral oedema in TBI patients compared to catecholaminergic vasopressors; and demonstrated a significant reduction in the requirements of hyperosmolar therapy in patients that received vasopressin. The randomised control trial results showed no significant differences in primary and secondary outcomes between TBI patients receiving vasopressin versus those receiving catecholaminergic vasopressors. Apart from the randomised control trial, the studies included are of low-level evidence. Conclusion: Studies favour vasopressin within certain parameters of cerebral function compared to control groups. However, the neurological outcomes of patient groups are not known, and animal study results are difficult to extrapolate to humans. It cannot be said with certainty whether vasopressin’s benefits stand above usage of other vasoactive drugs due to the weaknesses of the evidence. Further randomised control trials, which are larger, standardised, and rigorous, are required to improve knowledge in this field.

Keywords: catecholamines, cerebral perfusion pressure, traumatic brain injury, vasopressin, vasopressors

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Authors: Sayna Bahraini, Wendy Gifford, Ian Graham, Liquaa Wazni, Suzettee Bremault-Phillips, Rebekah Hackbusch, Catrine Demers, Mary Egan

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Objective: Guidelines for palliative and spiritual care emphasize the importance of screening patients for spiritual suffering. The aim of this review was to synthesize the research evidence on the accuracy of measures used to screen adults for spiritual suffering. Methods: A systematic review has been conducted. We searched five scientific databases to identify relevant articles. Two independent reviewers screened extracted data and assessed study methodological quality. Results: We identified five articles that yielded information on 24 spiritual screening measures. Among all identified measures, the 2-item Meaning/Joy & Self-Described Struggle has the highest sensitivity (82-87%), and the revised Rush protocol has the highest specificity (81-90%). The methodological quality of all included studies was low. Significance of Results: While most of the identified spiritual screening measures are brief (comprise 1 to 12 number of items), few have sufficient accuracy to effectively screen patients for spiritual suffering. We advise clinicians to use their critical appraisal skills and clinical judgment when selecting and using any of the identified measures to screen for spiritual suffering.

Keywords: screening, suffering, spirituality, diagnostic test accuracy, systematic review

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Authors: Kenji Gwee

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The Mental Capacity Act is a new legislation that allows for lasting powers of attorney and court-appointed deputies, in respect of people who lack legal capacity. While the UK Act, after which the Singapore Act is modeled, has been shown to be therapeutic to donors, the Singapore Act differs from its UK counterpart and it is unclear if the Singapore Act can be beneficial to donors as purported. The purpose of this study was to determine what the perceptions of three groups of stakeholders (patients, caregivers and psychiatrists) are about the aspects of the Mental Capacity Act that are therapeutic to donors. In addition, ways to increase the therapeutic value of the Act to donors are sought. A qualitative methodology was used and the research was guided by two theoretical frameworks: therapeutic jurisprudence and an interpretive constructive framework. Interviews with 12 psychiatrists, and focus groups with twenty three patients and seven caregivers showed agreement that, allowing donors to nominate more than one decision- maker, and whistle-blowing mechanisms for recourse for abuse, were therapeutic to donors. To further increase the therapeutic value of the Act, 2 suggestions were made: the Act should provide for (i) advanced healthcare directives- allowing donors to make advance decisions to refuse treatment, or cease existing treatment, and (ii) independent advocacy services- to have a case worker to represent people who have no family or friends and are thus unable to find suitable donees.

Keywords: Mental Capacity Act, therapeutic jurisprudence, qualitative methodology, the UK Act

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Authors: Shradha Parsekar, Suma Nair, Ajay Bailey, Binu V. S.

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Background: Concealing of cancer-related information is seen in many low-and-middle-income countries and may be associated with multiple factors. Comparatively, there is lack of information about, how breast cancers diagnosed women disclose cancer-related information to their social contacts and vice versa. To get more insights on the participant’s experience, opinions, expectations, and attitudes, a qualitative study is a suitable approach. Therefore, this study involving in-depth interviews was planned to lessen this gap. Methods: Interviews were conducted separately among breast cancer patients and their caregivers with semi-structured qualitative interview guide. Purposive and convenient sampling was being used to recruit patients and caregivers, respectively. Ethical clearance and permission from the tertiary hospital were obtained and participants were selected from the Udupi district, Karnataka, India. After obtaining a list of breast cancer diagnosed cases, participants were contacted in person and their willingness to take part in the study was taken. About 39 caregivers and 35 patients belonging to different breast cancer stages were recruited. Interviews were recorded with prior permission. Data was managed by Atlas.ti 8 software. The recordings were transcribed, translated and coded in two cycles. Most of the patients belonged to stage II and III cancer. Codes were grouped together into to whom breast cancer status was concealed to and underneath reason for the same. Main findings: followings are the codes and code families which emerged from the data. 1) Concealing the breast cancer status from social contacts other than close family members (such as extended family, neighbor and friends). Participants perceived the reasons as, a) to avoid questions which people probe (which doesn’t have answers), b) to avoid people paying courtesy visit (to inquire about the health as it is Indian culture to visit the sick person) making it inconvenient for patient and caregivers have to offer something and talk to them, c) to avoid people getting shocked (react as if cancer is different from other diseases) or getting emotional/sad, or getting fear of death d) to avoid getting negative suggestion or talking anything in front of patient as it may affect patient negatively, e) to avoid getting stigmatized, f) to avoid getting obstacle in child’s marriage. 2) Participant concealed the breast cancer status of young children as they perceived that it may a) affect studies, b) affect emotionally, c) children may get scared. 3) Concealing the breast cancer status from patients as the caregivers perceived that they have fear of a) worsening patient’s health, b) patient getting tensed, c) patient getting shocked, and d) patient getting scared. However, some participants stressed important in disclosing the cancer status to social contact/patient to make the people aware of the disease. Conclusion: The news of breast cancer spreads like electricity in the wire, therefore, patient or family avoid it for many reasons. Although, globally, due to physicians’ ethical obligations, there is an inclination towards more disclosure of cancer diagnosis and status of prognosis to the patient. However, it is an ongoing argument whether patient/social contacts should know the status especially in a country like India.

Keywords: breast cancer, concealing cancer status, India, qualitative study

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Authors: Khalid Ahmed Eldwaib

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In this study, Al-Mg alloy 5052 was used as the testing material. Corrosion fatigue life was studied for the alloy in 3.5% NaCl (pH=1, 3, 5, 7, 9, and 11), and 3.5% NaCl (pH=1) with inhibitors. The compound inhibitors were composed mainly of phosphate (PO4³-), adding a certain proportion of other nontoxic inhibitors so as to select alternatives to environmentally hazardous chromate (Cr2O7²-). The inhibitors were sodium dichromate Na2Cr2O7, sodium phosphate Na3PO4, sodium molybdate Na2MoO4, and sodium citrate Na3C6H5O7. The total amount of inhibiting pigments was at different concentrations (250,500,750, and 1000 ppm) in the solutions. Corrosion fatigue behavior was studied by using plane-bending corrosion fatigue machine with stress ratio R=0.5 and under the constant frequency of 13.3 Hz. Results show that in 3.5% NaCl the highest fatigue life (number of cycles to failure Nf) is obtained at pH=5 where the oxide film on aluminum has very low solubility, and the lowest number of cycles is obtained at pH=1, where the media is too aggressive (extremely acidic). When the concentration of inhibitor increases the cycles to failure increase. The surface morphology and fracture section of the specimens had been characterized through scanning electron microscope (SEM).

Keywords: Al-Mg alloy 5052, corrosion, fatigue, inhibitors

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Authors: Francisco Alvarado, Luz Ramírez

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Corneal diseases are one of the main causes of visual impairment and affect almost 4 million, and this study assesses the effects of deep anterior lamellar keratoplasty (DALK) with porcine corneal stroma and postoperative topical treatment with tacrolimus in patients with infectious keratitis. No patient was observed with clinical graft rejection. Among the cases: 2 were positive to fungal culture, 2 with Aspergillus and the other 8 cases were confirmed by bacteriological culture. Corneal diseases are one of the main causes of visual impairment and affect almost 4 million. This study assesses the effects of deep anterior lamellar keratoplasty (DALK) with porcine corneal stroma and postoperative topical treatment with tacrolimus in patients with infectious keratitis. Receiver bed diameters ranged from 7.00 to 9.00 mm. No incidents of Descemet's membrane perforation were observed during surgery. During the follow-up period, no corneal graft splitting, IOP increase, or intolerance to tacrolimus were observed. Deep anterior lamellar keratoplasty seems to be the best option to avoid xenograft rejection, and it could help new surgical techniques in humans.

Keywords: ophthalmology, cornea, corneal transplant, xenografts, surgical innovations

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Authors: Ssembatya Joseph Mary

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Introduction: Cryptococcal infection in the Central Nervous System (CNS) is frequently seen in human immunodeficiency virus (HIV) patients and others with low immunity as an opportunistic fungal infection. However, CNS cryptococcal granuloma (cryptococcoma) in immunocompetent patients is rare. We present a case of CNS cryptococcoma in an immunocompetent patient and review the literature to illustrate the diagnosis and treatment of such lesions. Case presentation: A 62-year-old, HIV-negative, immunocompetent female patient with no known chronic illness presented with 5 months history of a progressive headache associated with on and off episodic generalized tonic-clonic convulsions. She had been to several hospitals before she was referred to our center with a diagnosis of a brain tumor. Before referral and despite a negative CSF analysis result, she had received treatment for bacterial meningitis with no success. At Mbarara Regional Referral Hospital (MRRH), she had surgery with an excision biopsy which showed features consistent with cryptococcosis on histology. The patient had a successful adjuvant treatment with antifungal drugs following surgery. Conclusion: The diagnosis of a parasitic CNS infection, particularly cryptococcal infection mimicking neoplastic lesions in an immunocompetent patient, was unusual. Surgical management of such lesions from different reports has a bad outcome and management remains totally conservative.

Keywords: Cryptococcal meningitis, immunocompetent patient, Uganda, low resource setting

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Authors: Mohammad Hossain Validad

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Background and Aim: Epidemic keratoconjunctivitis is a type of conjunctivitis caused by adenoviruses that can spread rapidly through direct and indirect contact. The aim of this study was to evaluate the therapeutic effects of Povidone-Iodine 0.4% and 0.2% in improving the symptoms and signs of patients with epidemic keratoconjunctivitis. Materials and Methods: In this clinical trial study, 60 patients with a mean age of 27.8±8.4 years who were eligible for inclusion criteria were randomly divided into three groups. The first group received eye drops of Povidone-Iodine 0.4% and betamethasone 0.1%, the second group received PovidoneIodine 0.2% and betamethasone 0.1% and the third group received betamethasone 0.1%. Follow-ups were on the first, fourth, seventh and tenth days after starting treatment. Parameters examined at each examination were hyperaemia, mucopurulent discharge, eyelid edema, hemorrhage, and subepithelial infiltration. Results: The results showed that mucopurulent discharge on the fourth day of the examination (P = 0.005) and the seventh day of the examination (P = 0.001) were significantly different in the three treatment groups. Sub-epithelial infiltration on the tenth day after treatment did not show a significant difference in the 3 groups (P = 0.287). Conclusion: Based on the results of this study, Povidone-Iodine is more effective in relieving some of signs of EKC, such as reduced mucopurulent discharge than steroids alone.

Keywords: EKC, topical bethadine, adenovirus, sub epithelial opacity

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Authors: A. C. Facin, M. C. Maronezi , M. P. Menezes, G. L. Montanhim, L. Pavan, M. A. R. Feliciano, R. P. Nociti, R. A. R. Uscategui, P. C. Moraes

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The incidence of brachycephalic syndrome (BS) in the clinical routine of small animals has increased significantly giving the higher proportion of brachycephalic pets in the last years and has been considered as an animal welfare problem. The treatment of BS is surgical and the clinical signs related can be considerably attenuated. Nevertheless, the systemic effects of the BS are still poorly reported and little is known about these when the surgical correction is not performed early. Affected dogs are more likely to develop cardiopulmonary, gastrointestinal and sleep disorders in which the chronic hypoxemia plays a major role. This syndrome is compared with the obstructive sleep apnea (OSA) in humans, both considered as causes of systemic and metabolic dysfunction. Among the several consequences of the BS little is known if the syndrome also affects the hepatic tissue of brachycephalic patients. Elastography is a promising ultrasound technique that evaluates tissue elasticity and has been recently used with the purpose of diagnosis of liver fibrosis. In medicine, it is a growing concern regarding the hepatic injury of patients affected by OSA. This prospective study hypothesizes if there is any consequence of BS in the hepatic parenchyma of brachycephalic dogs that don’t receive any surgical treatment. This study was conducted following the approval of the Animal Ethics and Welfare Committee of the Faculdade de Ciências Agrárias e Veterinárias, UNESP, Campus Jaboticabal, Brazil (protocol no 17944/2017) and funded by Sao Paulo Research Foundation (FAPESP, process no 2017/24809-4). The methodology was based in ARFI elastography using the ACUSON S2000/SIEMENS device, with convex multifrequential transducer and specific software as well as clinical evaluation of the syndrome, in order to determine if they can be used as a prognostic non-invasive tool. On quantitative elastography, it was collected three measures of shear wave velocity (meters per second) and depth in centimeters in the left lateral, left medial, right lateral, right medial and caudate lobe of the liver. The brachycephalic patients, 16 pugs and 30 french bulldogs, were classified using a previously established 4-point functional grading system based on clinical evaluation before and after a 3-minute exercise tolerance test already established and validated. The control group was based on the same features collected in 22 beagles. The software R version 3.3.0 was used for the analysis and the significance level was set at 0.05. The data were analysed for normality of residuals and homogeneity of variances by Shapiro-Wilks test. Comparisons of parametric continuous variables between breeds were performed by using ANOVA with a post hoc test for pair wise comparison. The preliminary results show significant statistic differences between the brachycephalic groups and the control group in all lobes analysed (p ≤ 0,05), with higher values of shear wave velocities in the hepatic tissue of brachycephalic dogs. In this context, the results obtained in this study contributes to the understanding of BS as well as its consequences in our patients, reflecting in evidence that one more systemic consequence of the syndrome may occur in brachycephalic patients, which was not related in the veterinary literature yet.

Keywords: airway obstruction, brachycephalic airway obstructive syndrome, hepatic injury, obstructive sleep apnea

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Authors: Denise Schrama, Claudia Raposo, Pedro Rodrigues

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Background: Food allergies are conducted by a hypersensitive response of the immune system. These allergies are a global concern for the public health. Consumption of fish is increasing worldwide as it is a healthy meat with high nutritional value. Unfortunately, fish can cause adverse immune-mediate reactions, affecting part of the population with higher incidence in children. β-parvalbumin, a small, highly conserved stable, calcium or magnesium binding muscle protein is the main fish allergen. In fish-allergic patients, cross-reactivity between different fish species exist due to recognition of highly identical protein regions. Enolases, aldolases, or fish gelatin are other identified fish allergens in some fish species. With no available cure for fish allergies, clinical management is only based on an avoidance diet aiming at the total exclusion of offending food. Methods: Mediterranean fish (S. aurata and D. labrax) were fed specifically designed diets, enriched in components that target the expression or inactivation of parvalbumin (creatine and EDTA, respectively). After 90 days fish were sampled and biological tissues were excised. Proteomics was used to access fish allergens characterization and expression in muscle while IgE assays to confirm the lower allergenic potential are conducted in patients with history of fish allergies. Fish welfare and quality of flesh were established with biochemical, texture and sensorial analysis. Results: Fish welfare shows no major impact between diets. In case of creatine supplementation in D. labrax proteomic analysis show a slight decrease in parvalbumin expression. No accumulation of this compound was found in muscle. For EDTA supplementation in S. aurata IgE assay show a slight decrease in allergenicity when using sera of fish allergic patients. Conclusion: Supplementation with these two compounds seems to change slightly the allergenicity of the two mean Mediterranean species.

Keywords: fish allergies, fish nutrition, proteomics, aquaculture

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Authors: Sirilak Kongkaew, Pathumwadee Yodmanee, Nopporn Kaiyawet, Arthitaya Meeprasert, Thanyada Rungrotmongkol, Toshikatsu Kaburaki, Hiroshi Noguchi, Fujio Takeuch, Nawee Kungwan, Supot Hannongbua

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Behçet’s disease (BD) is a genetic autoimmune expressed by multisystemic inflammatory disorder mostly occurred at the skin, joints, gastrointestinal tract, and genitalia, including ocular, oral, genital, and central nervous systems. Most BD patients in Japan and Korea were strongly indicated by the genetic factor namely HLA-B*51 (especially, HLA-B*51:01) marker in HMC class I, while HLA-A*26:01 allele has been detected from the BD patients in Greek, Japan, and Taiwan. To understand the selective binding of the MICA-TM peptide towards the HLAs associated with BD, the molecular dynamics simulations were applied on the four HLA alleles (B*51:01, B*35:01, A*26:01, and A*11:01) in complex with such peptide. As a result, the key residues in the binding groove of HLA protein which play an important role in the MICA-TM peptide binding and stabilization were revealed. The Van der Waals force was found to be the main protein-protein interaction. Based on the binding free energy prediction by MM/PBSA method, the MICA-TM peptide interacted stronger to the HLA alleles associated to BD in the identical class by 7-12 kcal/mol. The obtained results from the present study could help to differentiate the HLA alleles and explain a source of Behçet’s disease.

Keywords: Behçet’s disease, MD simulations, HMC class I, autoimmune

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Authors: Mrinalini Ranjan, Sudheesh Chethil

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Epilepsy is a common neurological disorder characterised by the recurrence of seizures. Electroencephalogram (EEG) signals are complex biomedical signals which exhibit nonlinear and nonstationary behavior. We use two methods 1) Detrended Fluctuation Analysis (DFA) and 2) Recurrence Plots (RP) to capture this complex behavior of EEG signals. DFA considers fluctuation from local linear trends. Scale invariance of these signals is well captured in the multifractal characterisation using detrended fluctuation analysis (DFA). Analysis of long-range correlations is vital for understanding the dynamics of EEG signals. Correlation properties in the EEG signal are quantified by the calculation of a scaling exponent. We report the existence of two scaling behaviours in the epileptic EEG signals which quantify short and long-range correlations. To illustrate this, we perform DFA on extant ictal (seizure) and interictal (seizure free) datasets of different patients in different channels. We compute the short term and long scaling exponents and report a decrease in short range scaling exponent during seizure as compared to pre-seizure and a subsequent increase during post-seizure period, while the long-term scaling exponent shows an increase during seizure activity. Our calculation of long-term scaling exponent yields a value between 0.5 and 1, thus pointing to power law behaviour of long-range temporal correlations (LRTC). We perform this analysis for multiple channels and report similar behaviour. We find an increase in the long-term scaling exponent during seizure in all channels, which we attribute to an increase in persistent LRTC during seizure. The magnitude of the scaling exponent and its distribution in different channels can help in better identification of areas in brain most affected during seizure activity. The nature of epileptic seizures varies from patient-to-patient. To illustrate this, we report an increase in long-term scaling exponent for some patients which is also complemented by the recurrence plots (RP). RP is a graph that shows the time index of recurrence of a dynamical state. We perform Recurrence Quantitative analysis (RQA) and calculate RQA parameters like diagonal length, entropy, recurrence, determinism, etc. for ictal and interictal datasets. We find that the RQA parameters increase during seizure activity, indicating a transition. We observe that RQA parameters are higher during seizure period as compared to post seizure values, whereas for some patients post seizure values exceeded those during seizure. We attribute this to varying nature of seizure in different patients indicating a different route or mechanism during the transition. Our results can help in better understanding of the characterisation of epileptic EEG signals from a nonlinear analysis.

Keywords: detrended fluctuation, epilepsy, long range correlations, recurrence plots

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Authors: Charn Loong Ng, Mamun Bin Ibne Reaz

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As elderly population grows globally, the percentage of people diagnosed with musculoskeletal disorder (MSD) increase proportionally. Electromyography (EMG) is an important biosignal that contributes to MSD’s clinical diagnose and recovery process. Conventional conductive electrode has many disadvantages in the continuous EMG measurement application. This research has design a new surface EMG biosensor based on the parallel-plate capacitive coupling principle. The biosensor is developed by using a double-sided PCB with having one side of the PCB use to construct high input impedance circuitry while the other side of the copper (CU) plate function as biosignal sensing metal plate. The metal plate is insulated using kapton tape for contactless application. The result implicates that capacitive biosensor is capable to constantly capture EMG signal without having galvanic contact to human skin surface. However, there are noticeable noise couple into the measured signal. Post signal processing is needed in order to present a clean and significant EMG signal. A complete design of single ended, non-contact, high input impedance, front end EMG biosensor is presented in this paper.

Keywords: contactless, capacitive, biosensor, electromyography

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Authors: Atitallah Sofien, Bouyahia Olfa, Hadj Salah Ibrahim, Ben Saleh Foued, Missaoui Nada, Ben Rabeh Rania, Yahyaoui Salem, Mazigh Sonia, Boukthir Samir

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Introduction: Carbon monoxide (CO) poisoning is a common pathology responsible for high morbidity and mortality worldwide. Aim: The purpose of this study was to determine the epidemiological profile of CO poisoning as well as its clinical, paraclinical, therapeutic, and evolutionary aspects. Methods: Our study included observations of CO poisoning in children hospitalized in the pediatric department C of the Children's Hospital in Tunis over a period of 3 years. Results: We have collected 199 cases of CO poisoning in children. The average age was 5.43 years, with a sex ratio of 0.98. The source of CO was inside the home in 73.2% of cases, and it was the gas bath heater in 68.8% of cases. The intoxication was collective in 93.5% of the cases, and it occurred during the month of January in 35.8% of the cases. The clinical manifestations were headaches in 69.5% of cases. The rate of carboxyhemoglobin was pathological in 73.9% of cases. All patients received normobaric oxygen therapy, and only 3.6% of patients had a hyperbaric oxygen therapy session. We did not deplore any case of death in our study. Conclusion: CO poisoning remains a public health problem in Tunisia with high morbidity. The risk of secondary complications, particularly neuropsychiatric, requires clinical and possibly neuroradiological monitoring of these victims.

Keywords: poisoning, carbon monoxide, children, hyperbaric oxygenation

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Authors: Abdulrahman H. Alrashidi

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Kuwait Oil Company provides health care services through Ahmadi hospital for oil sector employee and their families. Due to increasing number of entitled patients in Ahmadi hospital, the company starts health insurance option in 2010. In addition, a new Ahmadi hospital decided to build to accumulate all entitled patients. Operation and management of new Ahmadi hospital investigated in this research. In order to maintain the high quality of medical services and satisfaction rate among oil sector community and reducing the operation cost. Six operation and management options evaluated in order to implement in new Ahmadi hospital. Qualitative Risk assessment method used to investigate proposed options for operation and management of new Ahmadi hospital. Evaluation criteria consist of quality of medical services, operation cost and satisfaction rate among oil sector community. Results show that using the same operation and management system in existing Ahmadi hospital with new Ahmadi hospital will bring cost higher. This approach brings risk to KOC. Results from risk assessment show that partially operated new Ahmadi hospital is the best opportunity to meet the objectives of KOC’s medical group.

Keywords: Kuwait Oil Company, new Ahmadi hospital, operation and management, risk assessment

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Authors: Sangeeta Girdhar, Amanat Grewal, Nahush Bansal

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Introduction: There is an increasing burden of hypertension in India. The morbidity and mortality arising from complications are mainly due to non-adherence to medication, unhealthy dietary habits, and lack of physical activity. Non-adherence is a well-recognised factor contributing to inadequate control of high blood pressure. Adherence to pharmacotherapy for hypertension varies from 43% to 88%. Non-adherence is influenced by various socio-demographic factors. Understanding these factors is useful in managing non-adherence. Therefore, the study was planned to determine adherence among hypertensives and factors associated with non-adherence to treatment. Methodology: A cross-sectional study was conducted at Urban Health Training Centre of Dayanand Medical College and Hospital Ludhiana. Patients attending the OPD over a period of 3 months were included in the study. Prior ethical approval was obtained, and informed consent was taken from subjects. A predesigned semi-structured questionnaire was applied, which included socio-demographic profile, treatment-seeking behaviour, adherence to the antihypertensive medication, lifestyle factors (intake of alcohol, smoking, consumption of junk food, high salt intake) contributing to the development of the disease. Reasons for non-adherence to the therapy were also explored. Data was entered into excel, and SPSS 26 version was used for analysis. Results: A total of 186 individuals were interviewed. Out of these, 113 females (60.8%) and 73 males (39.2%) participated in the study. Mean age of participants was 60.9 ± 10.7 years. Adherence to anti-hypertensive treatment was found in 68.3% of the participants. It was observed that adherence was more in literate individuals as compared to illiterate (p value- 0.78). Adherence was lower among smokers (33.3%) and alcohol consumers (53.8%) as compared to non-users (69.4% and 70.6%, respectively). The predominant reasons for skipping medications were discontinuing medication when feeling well, forgetfulness and unawareness. Conclusion: There is a need to generate awareness regarding the importance of adherence to therapy among patients. Intensive health education and counselling of the patients is the need of the hour.

Keywords: hypertension, anti-hypertensive, adherence, counselling

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Authors: Natalia Wojarnik

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The paper aims to present the analysis of a Reddit confessions corpus. The interpretation focuses on the use of emotional language, in particular emotive verbs, in the context of personal pronouns. The analysis of the linguistic properties answers the question of what the Reddit users confess about and who is the subject of confessions. The study reveals that the specific language patterns used in Reddit confessions reflect the language of depression and the language used by patients during different stages of their psychotherapy sessions. The paper concludes that Reddit users are more willing to confess about their own experiences, not rarely very private and intimate, extensively using the first person singular pronoun I. It indicates that the Reddit users use the language of depression and the language used by psychotherapy patients. The language they use is very emotionally impacted and includes many emotive verbs such as want, feel, need, hate, love. This finding in Reddit confessions correlates with the extensive use of stative affective verbs in the first stages of the psychotherapy sessions. Lastly, the paper refers to the positive and negative lexicon and helps determine how online posts can serve as a depression detector and “talking cure” for the users.

Keywords: confessions, emotional language, emotive verbs, pronouns, first person pronoun, language of depression, depression detection, psychotherapy language

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Authors: Taisuke Sakaki, Toshihiko Shimokawa, Nobuhiro Ushimi, Koji Murakami, Yong-Kwun Lee, Kazuhiro Tsuruta, Kanta Aoki, Kaoru Fujiie, Ryuji Katamoto, Atsushi Sugyo

Abstract:

Recently attention has been focused on incomplete spinal cord injuries (SCI) to the central spine caused by pressure on parts of the white matter conduction pathway, such as the pyramidal tract. In this paper, we focus on a training robot designed to assist with primary walking-pattern training. The target patient for this training robot is relearning the basic functions of the usual walking pattern; it is meant especially for those with incomplete-type SCI to the central spine, who are capable of standing by themselves but not of performing walking motions. From the perspective of human engineering, we monitored the operator’s actions to the robot and investigated the movement of joints of the lower extremities, the circumference of the lower extremities, and exercise intensity with the machine. The concept of the device was to provide mild training without any sudden changes in heart rate or blood pressure, which will be particularly useful for the elderly and disabled. The mechanism of the robot is modified to be simple and lightweight with the expectation that it will be used at home.

Keywords: training, rehabilitation, SCI patient, welfare, robot

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Authors: Sheng Yu Chen, Shi-Heng Wang

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Aim: Based on human, animal experiments, and genetic studies, cysteinyl leukotrienes, LTC4, LTD4, and LTE4, are inflammatory substances that are metabolized by 5-lipooxygenase from arachidonic acid, and these substances trigger asthma. In addition, the synthetic pathway of cysteinyl leukotriene is relevant to the increase in cardiovascular diseases such as myocardial ischemia and stroke. Given the situation, we aim to investigate whether cysteinyl leukotrienes receptor antagonist (LTRA), montelukast which cures those who have asthma has potential protective effects on cardiovascular diseases. Method: We conducted a cohort study, and enrolled participants which are newly diagnosed with asthma (ICD-9 CM code 493. X) between 2002 to 2011. The data source is from Taiwan National Health Insurance Research Database Patients with a previous history of myocardial infarction or ischemic stroke were excluded. Among the remaining participants, every montelukast user was matched with two randomly non-users by sex, and age. The incident cardiovascular diseases, including myocardial infarction and ischemic stroke, were regarded as outcomes. We followed the participants until outcomes come first or the end of the following period. To explore the protective effect of montelukast on the risk of cardiovascular disease, we use multivariable Cox regression to estimate the hazard ratio with adjustment for potential confounding factors. Result: There are 55876 newly diagnosed asthma patients who had at least one claim of inpatient admission or at least three claims of outpatient records. We enrolled 5350 montelukast users and 10700 non-users in this cohort study. The following mean (±SD) time of the Montelukast group is 5 (±2.19 )years, and the non-users group is 6.2 5.47 (± 2.641) years. By using multivariable Cox regression, our analysis indicated that the risk of incident cardiovascular diseases between montelukast users (n=43, 0.8%) and non-users (n=111, 1.04%) is approximately equal. [adjusted hazard ratio 0.992; P-value:0.9643] Conclusion: In this population-based study, we found that the use of montelukast is not associated with a decrease in incident MI or IS.

Keywords: asthma, inflammation, montelukast, insurance research database, cardiovascular diseases

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Authors: Sarah Beaver, Renee Bryce

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Audiograms detect hearing impairment, but missing values pose problems. This work explores imputations in an attempt to improve accuracy. This work implements Linear Regression, Lasso, Linear Support Vector Regression, Bayesian Ridge, K Nearest Neighbors (KNN), and Random Forest machine learning techniques to impute audiogram frequencies ranging from 125Hz to 8000Hz. The data contains patients who had or were candidates for cochlear implants. Accuracy is compared across two different Nested Cross-Validation k values. Over 4000 audiograms were used from 800 unique patients. Additionally, training on data combines and compares left and right ear audiograms versus single ear side audiograms. The accuracy achieved using Root Mean Square Error (RMSE) values for the best models for Random Forest ranges from 4.74 to 6.37. The R\textsuperscript{2} values for the best models for Random Forest ranges from .91 to .96. The accuracy achieved using RMSE values for the best models for KNN ranges from 5.00 to 7.72. The R\textsuperscript{2} values for the best models for KNN ranges from .89 to .95. The best imputation models received R\textsuperscript{2} between .89 to .96 and RMSE values less than 8dB. We also show that the accuracy of classification predictive models performed better with our best imputation models versus constant imputations by a two percent increase.

Keywords: machine learning, audiograms, data imputations, single imputations

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Authors: Mengjia Zhi, Xingmei Wei, Xiang Gao, Shiyang Liu, Zhiran Huang, Li Yang, Jing Sun

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Background: To understand the consumption trend of opioid analgesics and the consumption adequacy of opioid analgesic treatment for moderate to severe pain in China, as well as the pain control level of China with international perspective. Importance: To author’s best knowledge, this is the first study in China to measure the adequacy of opioid analgesic treatment for moderate to severe pain considering disease pattern and with the standardized pain treatment guideline. Methods: A retrospective analysis was carried out to show the consumption frequency (daily defined doses, DDDs) of opioid analgesics and its trend in China from 2006 to 2016. Adequacy of consumption measure (ACM) was used to measure the number of needed morphine equivalents and the overall adequacy of opioid analgesic treatment of moderate to severe pain in China, and compared with international data. Results: The consumption frequency of opioid analgesics (DDDs) in China increased from 13,200,000 DDDs in 2006 to 44,200,000 DDDs in 2016, and showed an increasing trend. The growth rate was faster at first, especially in 2013, then slowed down, decreased slightly in 2015. The ACM of China increased from 0.0032 in 2006 to 0.0074 in 2016, with an overall trend of growth. The ACM level of China has been always a very poor level during 2006-2016. Conclusion: The consumption of opioid analgesics for the treatment of moderate to severe pain in China has always been inadequate. There is a huge gap between China and the international level. There are many reasons behind this problem, which lie in different aspects, including medical staff, patients and the public, health systems and social & cultural aspects. It is necessary to strengthen the training and education of medical staff and the patients, to use mass media to disseminate scientific knowledge of pain management, to encourage communications between doctors and patients, to improve regulatory system for the controlled medicines and the overall health systems, and to balance the regulatory goal for avoidance of abuse, and the social goal of meeting the increasing needs of the people for better life.

Keywords: opioid analgesics, adequate consumption measure, pain control, China

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Authors: Dhaladhuli Pranavi, Amirtham Rajagopal

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There are various failure modes in ceramic matrix composites; notable ones are fiber breakage, matrix cracking and fiber matrix debonding. Crack nucleation and propagation in microstructure of such composites requires an understanding of interaction of crack with the multiple inclusion heterogeneous system and interfaces. In order to assess structural integrity, the material parameters especially of the interface that governs the crack growth should be determined. In the present work, a nonlocal phase field approach is proposed to model the crack interface interaction in such composites. Nonlocal approaches help in understanding the complex mechanisms of delamination growth and mitigation and operates at a material length scale. The performance of the proposed formulation is illustrated through representative numerical examples. The model proposed is implemented in the framework of the finite element method. Several parametric studies on interface crack interaction are conducted. The proposed model is easy and simple to implement and works very well in modeling fracture in composite systems.

Keywords: composite, interface, nonlocal, phase field

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Authors: Chiara Colarusso, Michela Terlizzi, Aldo Pinto, Rosalinda Sorrentino

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Cigarette smoking is the main cause and the most common risk factor for both COPD and lung cancer. In our previous studies, we proved that caspase-11 in mice and its human analogue, caspase-4, are involved in lung carcinogenesis and that AIM2 inflammasome might play a pro-cancerous role in lung cancer. Therefore, the aim of this study was to investigate potential crosstalk between COPD and lung cancer, focusing on AIM2 and caspase-11-dependent inflammasome signaling pathway. To mimic COPD, we took advantage of an experimental first-hand smoking mouse model and, to confirm what was observed in mice, we used human samples of lung adenocarcinoma patients stratified according to the smoking and COPD status. We demonstrated that smoke exposure led to emphysema-like features, bronchial tone impairment, and release of IL-1-like cytokines (IL-1α, IL-1β, IL-33, IL-18) in a caspase-1 independent manner in C57Bl/6N. Rather, a dysfunctional caspase-11 in smoke-exposed 129Sv mice was associated to lower bronchial inflammation, collagen deposition, and IL-1-like inflammation. In addition, for the first time, we found that AIM2 inflammasome is involved in lung inflammation in smoking and COPD, in that its expression was higher in smoke-exposed C57Bl/6N compared to 129Sv smoking mice, who instead did not show any alteration of AIM2 in both macrophages and dendritic cells. Moreover, we found that AIM2 expression in the cancerous tissue, albeit higher than non-cancerous tissue, was not statistically different according to the COPD and smoking status. Instead, the higher expression of AIM2 in non-cancerous tissue of smoker COPD patients than smokers who did not have COPD was correlated to a higher hazard ratio of poor survival rate than patients who presented lower levels of AIM2. In conclusion, our data highlight that caspase-11 in mice is associated to smoke-induced lung latent inflammation which could drive the establishment of lung cancer, and that AIM2 inflammasome plays a role at the crosstalk between smoking/COPD and lung adenocarcinoma in that its higher presence is correlated to lower survival rate of smoker COPD adenocarcinoma.

Keywords: COPD, inflammasome, lung cancer, lung inflammation, smoke

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Authors: Xie Xiaobin, Zhang Yan, Shi Yipeng, Sun Wenying, Chen Shuang, Cai Zhipeng, Zhang Hong, Zhang Lixia, Xie Like

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Objective: The objective of this research is to compare the efficacy of the late in-situ surgical revision augmented with continuous infusion and needle revision on failed trabeculectomy blebs. Methods From December 2018 to December 2021, a prospective randomized controlled trial was performed on 44 glaucoma patients with failed bleb ≥ 6months with medically uncontrolled in Eye Hospital, China Academy of Chinese Medical Sciences. They were randomly divided into two groups. 22 eyes of 22 patients underwent the late in-situ surgical revision with continuous anterior chamber infusion in the study group, and 22 of 22 patients were treated with needle revision in the control group. Main outcome measures include preoperative and postoperative intraocular pressure (IOP), the number of anti-glaucoma medicines, the operation success rate, and the postoperative complications. Results The postoperative IOP values decreased significantly from the baseline in both groups (both P<0.05). IOP was significantly lower in the study group than in the control group at one week, 1, and 3 months postoperatively (all P<0.05). IOP reductions in the study group were substantially more prominent than in the control group at all postoperative time points (all P<0.05). The complete success rate in the study group was significantly higher than in the control group (71.4% vs. 33.3%, P<0.05), while the complete failure rate was significantly lower in the study group (0% vs. 28.5%, P<0.05). According to Cox’s proportional hazards regression analysis, high IOP at baseline was independently associated with increased risks of complete failure (adjusted hazard ratio=1.141, 95% confidence interval=1.021-1.276, P<0.05). There was no significant difference in the incidence of postoperative complications between the two groups (P>0.05). Conclusion: Both in-situ surgical and needle revision have acceptable success rates and safety for the late failed trabeculectomy blebs, while the former is likely to have a higher level of efficacy over the latter. Needle revision may be insufficient for eyes with low target IOP.

Keywords: glaucoma, trabeculectomy blebs, in-situ surgical revision, needle revision

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Authors: Tedman Cheuk-Yiu Chau, Xavier Harvey, Hung Nguyen

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Defunctioning ileostomies are frequently used as an adjunct to low anterior resection in the surgical treatment of rectal cancer. Despite reducing the rate of clinically relevant anastomotic leak, the burden of defunctioning ileostomy is significant, with up to two-thirds of patients reporting stoma-related morbidity. International data have demonstrated an increased risk of bowel dysfunction and lower quality of life in patients with delayed closure (greater than six months post-surgery). While timely reversal is safe and cost-effective, the time to the reversal in Australian and New Zealand public hospitals is not described in the published literature. Thus, it is important to assess the current timeliness of ileostomy closure in the Australian regional context and examine the reasons for the delay. A retrospective analysis of ileostomy closure in Launceston General Hospital (LGH) patients treated with low/ultra low anterior resection for rectal cancer between 2012 and 2019 was undertaken. 94 cases of rectal adenocarcinoma undergoing ultralow anterior resection were examined over the years between 2012-2019. Amongst these, 21 cases (22.3%) were not reversed due to disease progress, death prior to reversal, or surgical complication. Demographics, disease status, surgical technique, and hospital inpatient events of these cases were examined. An average waiting time of 213.2 days was noted. Reasons for the delay include non-specified/prolonged hospital waiting time (54%), delayed or complicated chemotherapy course (13%), surgical complication (11%), advanced age, and frailty(5%). Complication of a delayed ileostomy reversal includes post-operation ileus and the development of an incisional hernia. We conclude that a delayed reversal of ileostomy can contribute to a higher incidence of stoma-related co-morbidities and contribute to a longer hospital stay and therefore use of public hospital resources.

Keywords: anterior resection, colorectal surgery, ileostomy reversal, rectal cancer

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Authors: Mohammadreza Mohebbi, Masoumeh Sanagou

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The ability to predict clinical outcomes is of great importance to physicians and clinicians. A number of different methods have been used in an effort to accurately predict these outcomes. These methods include the development of scoring systems based on multivariate statistical modelling, and models involving the use of classification and regression trees. The process usually consists of two consecutive phases, namely model development and external validation. The model development phase consists of building a multivariate model and evaluating its predictive performance by examining calibration and discrimination, and internal validation. External validation tests the predictive performance of a model by assessing its calibration and discrimination in different but plausibly related patients. A motivate example focuses on prediction modeling using a sample of patients undergone coronary artery bypass graft (CABG) has been used for illustrative purpose and a set of primary considerations for evaluating prediction model studies using specific quality indicators as criteria to help stakeholders evaluate the quality of a prediction model study has been proposed.

Keywords: clinical prediction models, clinical decision rule, prognosis, external validation, model calibration, biostatistics

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