Search results for: clinical isolates

Authors: Aaron Samuels, Ahmad Badeghiesh, Haitham Baghlaf, Michael H. Dahan

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Importance: Cervical cancer is the fourth most common cancer among women globally and a significant cause of cancer-related deaths. Understanding the impact of cervical cancer diagnosed during pregnancy on maternal, delivery, and neonatal outcomes is crucial for improving clinical management and outcomes for affected women and their children. Objective: The goal is to determine the effects of cervical cancer diagnosed during pregnancy on maternal, delivery, and neonatal outcomes using a population-based American database. Design: This study is a retrospective analysis of the Healthcare Cost and Utilization Project Nationwide Inpatient Sample (HCUP-NIS) database. The study period spans between 2004-2014, and the analysis was conducted in 2023. Setting: The study used the HCUP-NIS database, which includes data from hospital stays across the United States, covering 48 states and the District of Columbia. Participants: The study included all women who delivered a child or had a maternal death from 2004-2014, with pregnancies at 24 weeks or above. The population was comprised of 9,096,788 pregnant women, including 222 diagnosed with cervical cancer prior to delivery. Exposures: The exposure was a diagnosis of cervical cancer during pregnancy, identified using International Classification of Diseases 9th Revision codes 180.0, 180.1, 180.8, and 180.9. Main Outcomes and Measures: Primary outcomes included maternal, delivery, and neonatal complications including preterm delivery, cesarean section, hysterectomy, blood transfusion, deep venous thrombosis, pulmonary embolism, congenital anomalies, intrauterine fetal demise, and small-for-gestational-age neonates. Logistic regression analyses were conducted to evaluate the association between cervical cancer diagnosis and these outcomes, adjusting for potential confounding factors. Results: Women with cervical cancer were older (25.2% ≥35 years vs. 14.7%, p=0.001, respectively); more likely to have Medicare insurance (1.4% vs. 0.6%, p=0.005, respectively); use illicit drugs (4.1% vs. 1.4%, p=0.001, respectively); smoke tobacco during pregnancy (14.9% vs. 4.9%, p=0.001, respectively); and have chronic hypertension (3.6% vs. 1.8%, p=0.046, respectively). These women also had higher rates of preterm delivery (OR = 4.73, 95% CI (3.53-6.36), p=0.001); cesarean section (OR = 5.40, 95% CI (4.00-7.30), p=0.001); hysterectomy (OR = 390.23, 95% CI (286.43-531.65), p=0.001); blood transfusions (OR = 19.23, 95% CI (13.57-27.25), p=0.001); deep venous thrombosis (OR = 9.42, 95% CI (1.32-67.20), p=0.025); and pulmonary embolism (OR = 20.22, 95% CI (2.83-144.48), p=0.003). Neonatal outcomes, including congenital anomalies, intrauterine fetal demise, and small-for-gestational-age neonates, were comparable between groups. Conclusions and Relevance: Cervical cancer during pregnancy is associated with significant maternal and delivery risks; however, neonatal outcomes are largely unaffected. These findings highlight the need for a multidisciplinary approach to managing pregnant cervical cancer patients involving oncological, obstetrical, and neonatal care specialists.

Keywords: cervical cancer, maternal outcomes, neonatal outcomes, delivery outcomes

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Authors: Vanessa Bennemann, Gabriela Laste, Márcia Inês Goettert

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The gestational period is a phase in which the pregnant woman undergoes constant physiological and hormonal changes, which are part of the woman’s biological cycle, the development of the fetus, childbirth, and lactation. These are factors of response to the immunological adaptation of the human reproductive process that is directly related to the pregnancy’s well-being and development. Although most pregnancies occur without complications, about 15% of pregnant women will develop potentially fatal complications, implying maternal and fetal risk. Therefore, requiring specialized care for high-risk pregnant women (HRPW) with obstetric interventions for the survival of the mother and/or fetus. Among the risk factors that characterize HRPW are the women's age, gestational diabetes mellitus (GDM), autoimmune diseases, infectious diseases such as syphilis and HIV, hypertension (SAH), preeclampsia, eclampsia, HELLP syndrome, uterine contraction abnormalities, and premature placental detachment (PPD), thyroid disorders, among others. Thus, pregnancy has an impact on the thyroid gland causing changes in the functioning of the mother's thyroid gland, altering the thyroid hormone (TH) profiles and production as pregnancy progresses. Considering, throughout the gestational period, the interpretation of the results of the tests to evaluate the thyroid functioning depends on the stage in which the pregnancy is. Thyroid disorders are directly related to adverse obstetric outcomes and in child development. Therefore, the adequate release of TH is important for a pregnancy without complications and optimal fetal growth and development. Objective: Investigate the physiological effects caused by thyroid disorders in the gestational period. Methods: A search for articles indexed in PubMed, Scielo, and MDPI databases, was performed using the term “AND”, with the descriptors: Pregnancy, Thyroid. With several combinations that included: Melatonin, Thyroidopathy, Inflammatory processes, Cytokines, Anti-inflammatory, Antioxidant, High-risk pregnancy. Subsequently, the screening was performed through the analysis of titles and/or abstracts. The criteria were: including clinical studies in general, randomized or not, in the period of 10 years prior to the research, in the English literature; excluded: experimental studies, case reports, research in the development phase. Results: In the preliminary results, a total of studies (n=183) were found, (n=57) excluded, such as studies of cancer, diabetes, obesity, and skin diseases. Conclusion: To date, it has been identified that thyroid diseases can impair the fetus’s brain development. Further research is suggested on this matter to identify new substances that may have a potential therapeutic effect to aid the gestational period with thyroid diseases.

Keywords: pregnancy, thyroid, melatonin, high-risk pregnancy

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Authors: Wei-Chih Huang, Pei-Lung Chung, Ching-Heng Lin, Hsuan-Chia Yang, Der-Ming Liou

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Background: In-Hospital Cardiac Arrest (IHCA) threaten life of the inpatients, cause serious effect to patient safety, quality of inpatients care and hospital service. Health providers must identify the signs of IHCA early to avoid the occurrence of IHCA. This study will consider the potential association between early signs of IHCA and the essence of patient care provided by nurses and other professionals before an IHCA occurs. The aim of this study is to identify significant associations between nursing interventions and abnormal early evaluation results of IHCA that can assist health care providers in monitoring inpatients at risk of IHCA to increase opportunities of IHCA early detection and prevention. Materials and Methods: This study used one of the data mining techniques called association rules mining to compute associations between nursing interventions and abnormal early evaluation results of IHCA. The nursing interventions and abnormal early evaluation results of IHCA were considered to be co-occurring if nursing interventions were provided within 24 hours of last being observed in abnormal early evaluation results of IHCA. The rule based methods were utilized 23.6 million electronic medical records (EMR) from a medical center in Taipei, Taiwan. This dataset includes 733 concepts of nursing interventions that coded by clinical care classification (CCC) codes and 13 early evaluation results of IHCA with binary codes. The values of interestingness and lift were computed as Q values to measure the co-occurrence and associations’ strength between all in-hospital patient care measures and abnormal early evaluation results of IHCA. The associations were evaluated by comparing the results of Q values and verified by medical experts. Results and Conclusions: The results show that there are 4195 pairs of associations between nursing interventions and abnormal early evaluation results of IHCA with their Q values. The indication of positive association is 203 pairs with Q values greater than 5. Inpatients with high blood sugar level (hyperglycemia) have positive association with having heart rate lower than 50 beats per minute or higher than 120 beats per minute, Q value is 6.636. Inpatients with temporary pacemaker (TPM) have significant association with high risk of IHCA, Q value is 47.403. There is significant positive correlation between inpatients with hypovolemia and happened abnormal heart rhythms (arrhythmias), Q value is 127.49. The results of this study can help to prevent IHCA from occurring by making health care providers early recognition of inpatients at risk of IHCA, assist with monitoring patients for providing quality of care to patients, improve IHCA surveillance and quality of in-hospital care.

Keywords: in-hospital cardiac arrest, patient safety, nursing intervention, association rule mining

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Authors: Suman Som, Abhijit Maity, Sunil B. Daschakraborty, Sujit Chaudhuri, Manik Pradhan

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Background: Helicobacter pylori is a common and important human pathogen and the primary cause of peptic ulcer disease and gastric cancer. Currently H. pylori infection is detected by both invasive and non-invasive way but the diagnostic accuracy is not up to the mark. Aim: To set up an optimal diagnostic cut-off value of 13C-Urea Breath Test to detect H. pylori infection and evaluate a novel c-PDR methodology to overcome of inconclusive grey zone. Materials and Methods: All 83 subjects first underwent upper-gastrointestinal endoscopy followed by rapid urease test and histopathology and depending on these results; we classified 49 subjects as H. pylori positive and 34 negative. After an overnight, fast patients are taken 4 gm of citric acid in 200 ml water solution and 10 minute after ingestion of the test meal, a baseline exhaled breath sample was collected. Thereafter an oral dose of 75 mg 13C-Urea dissolved in 50 ml water was given and breath samples were collected upto 90 minute for 15 minute intervals and analysed by laser based high precisional cavity enhanced spectroscopy. Results: We studied the excretion kinetics of 13C isotope enrichment (expressed as δDOB13C ‰) of exhaled breath samples and found maximum enrichment around 30 minute of H. pylori positive patients, it is due to the acid mediated stimulated urease enzyme activity and maximum acidification happened within 30 minute but no such significant isotopic enrichment observed for H. pylori negative individuals. Using Receiver Operating Characteristic (ROC) curve an optimal diagnostic cut-off value, δDOB13C ‰ = 3.14 was determined at 30 minute exhibiting 89.16% accuracy. Now to overcome grey zone problem we explore percentage dose of 13C recovered per hour, i.e. 13C-PDR (%/hr) and cumulative percentage dose of 13C recovered, i.e. c-PDR (%) in exhaled breath samples for the present 13C-UBT. We further explored the diagnostic accuracy of 13C-UBT by constructing ROC curve using c-PDR (%) values and an optimal cut-off value was estimated to be c-PDR = 1.47 (%) at 60 minute, exhibiting 100 % diagnostic sensitivity , 100 % specificity and 100 % accuracy of 13C-UBT for detection of H. pylori infection. We also elucidate the gastric emptying process of present 13C-UBT for H. pylori positive patients. The maximal emptying rate found at 36 minute and half empting time of present 13C-UBT was found at 45 minute. Conclusions: The present study exhibiting the importance of c-PDR methodology to overcome of grey zone problem in 13C-UBT for accurate determination of infection without any risk of diagnostic errors and making it sufficiently robust and novel method for an accurate and fast non-invasive diagnosis of H. pylori infection for large scale screening purposes.

Keywords: 13C-Urea breath test, c-PDR methodology, grey zone, Helicobacter pylori

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Authors: M. Karzhauov, А. Mukhambetova, M. Sarsenova, E. Raimagambetov, V. Ogay

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Regeneration of injured articular cartilage remains one of the most difficult and unsolved problems in traumatology and orthopedics. Currently, for the treatment of cartilage defects surgical techniques for stimulation of the regeneration of cartilage in damaged joints such as multiple microperforation, mosaic chondroplasty, abrasion and microfractures is used. However, as shown by clinical practice, they can not provide a full and sustainable recovery of articular hyaline cartilage. In this regard, the current high hopes in the regeneration of cartilage defects reasonably are associated with the use of tissue engineering approaches to restore the structural and functional characteristics of damaged joints using stem cells, growth factors and biopolymers or scaffolds. The purpose of the present study was to investigate the effects of chondroinductive growth factors and synovium-derived mesenchymal stem cells (SD-MSCs) on the regeneration of cartilage defects in rabbits. SD-MSCs were isolated from the synovium membrane of Flemish giant rabbits, and expanded in complete culture medium α-MEM. Rabbit SD-MSCs were characterized by CFU-assay and by their ability to differentiate into osteoblasts, chondrocytes and adipocytes. The effects of growth factors (TGF-β1, BMP-2, BMP-4 and IGF-I) on MSC chondrogenesis were examined in micromass pellet cultures using histological and biochemical analysis. Articular cartilage defect (4mm in diameter) in the intercondylar groove of the patellofemoral joint was performed with a kit for the mosaic chondroplasty. The defect was made until subchondral bone plate. Delivery of SD-MSCs and growth factors was conducted in combination with hyaloronic acid (HA). SD-MSCs, growth factors and control groups were compared macroscopically and histologically at 10, 30, 60 and 90 days aftrer intra-articular injection. Our in vitro comparative study revealed that TGF-β1 and BMP-4 are key chondroinductive factors for both the growth and chondrogenesis of SD-MSCs. The highest effect on MSC chondrogenesis was observed with the synergistic interaction of TGF-β1 and BMP-4. In addition, biochemical analysis of the chondrogenic micromass pellets also revealed that the levels of glycosaminoglycans and DNA after combined treatment with TGF-β1 and BMP-4 was significantly higher in comparison to individual application of these factors. In vivo study showed that for complete regeneration of cartilage defects with intra-articular injection of SD-MSCs with HA takes time 90 days. However, single injection of SD-MSCs in combiantion with TGF-β1, BMP-4 and HA significantly promoted regeneration rate of the cartilage defects in rabbits. In this case, complete regeneration of cartilage defects was observed in 30 days after intra-articular injection. Thus, our in vitro and in vivo study demonstrated that combined application of rabbit SD-MSC with chondroinductive growth factors and HA results in strong synergistic effect on the chondrogenesis significantly enhancing regeneration of the damaged cartilage.

Keywords: Mesenchymal stem cells, synovium, chondroinductive factors, TGF-β1, BMP-2, BMP-4, IGF-I

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Authors: Halimat M. Ajose-Adeogun, Zaynab A. Bello

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Artificial Intelligence (AI) and Natural Language Processing (NLP) have transformed computer language comprehension, allowing computers to comprehend spoken and written language with human-like cognition. NLP, a multidisciplinary area that combines rule-based linguistics, machine learning, and deep learning, enables computers to analyze and comprehend human language. NLP applications in medicine range from tackling issues in electronic health records (EHR) and psychiatry to improving diagnostic precision in orthopedic surgery and optimizing clinical procedures with novel technologies like chatbots. The technology shows promise in a variety of medical sectors, including quicker access to medical records, faster decision-making for healthcare personnel, diagnosing dysplasia in Barrett's esophagus, boosting radiology report quality, and so on. However, successful adoption requires training for healthcare workers, fostering a deep understanding of NLP components, and highlighting the significance of validation before actual application. Despite prevailing challenges, continuous multidisciplinary research and collaboration are critical for overcoming restrictions and paving the way for the revolutionary integration of NLP into medical practice. This integration has the potential to improve patient care, research outcomes, and administrative efficiency. The research methodology includes using NLP techniques for Sentiment Analysis and Emotion Recognition, such as evaluating text or audio data to determine the sentiment and emotional nuances communicated by users, which is essential for designing a responsive and sympathetic chatbot. Furthermore, the project includes the adoption of a Personalized Intervention strategy, in which chatbots are designed to personalize responses by merging NLP algorithms with specific user profiles, treatment history, and emotional states. The synergy between NLP and personalized medicine principles is critical for tailoring chatbot interactions to each user's demands and conditions, hence increasing the efficacy of mental health care. A detailed survey corroborated this synergy, revealing a remarkable 20% increase in patient satisfaction levels and a 30% reduction in workloads for healthcare practitioners. The poll, which focused on health outcomes and was administered to both patients and healthcare professionals, highlights the improved efficiency and favorable influence on the broader healthcare ecosystem.

Keywords: natural language processing, artificial intelligence, healthcare communication, electronic health records, patient care

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Authors: Wenhsuan Lee, Yachi Chang, Yingyih Shih

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In clinical practices, it is common that while facing the unknown progress of their disease, palliative care patients may easily feel anxious and depressed. These types of reactions are a cause of psychosomatic diseases and may also influence treatment results. However, the purpose of palliative care is to provide relief from all kinds of pains. Therefore, how to make patients more comfortable is an issue worth studying. This study adopted the “bio-psycho-social model” proposed by Engel and applied spontaneous breathing training, in the hope of seeing patients’ psychological state changes caused by their physiological state changes, improvements in their anxious conditions, corresponding adjustments of their cognitive functions, and further enhancement of their social functions and the social support system. This study will be a one-year study. Palliative care outpatients will be recruited and assigned to the experimental group or the control group for six outpatient visits (once a month), with 80 patients in each group. The patients of both groups agreed that this study can collect their physiological quantitative data using an HRV device before the first outpatient visit. They also agreed to answer the “Beck Anxiety Inventory (BAI)”, the “Taiwanese version of the WHOQOL-BREF questionnaire” before the first outpatient visit, to fill a self-report questionnaire after each outpatient visit, and to answer the “Beck Anxiety Inventory (BAI)”, the “Taiwanese version of the WHOQOL-BREF questionnaire” after the last outpatient visit. The patients of the experimental group agreed to receive the breathing training under HRV monitoring during the first outpatient visit of this study. Before each of the following three outpatient visits, they were required to fill a self-report questionnaire regarding their breathing practices after going home. After the outpatient visits, they were taught how to practice breathing through an HRV device and asked to practice it after going home. Later, based on the results from the HRV data analyses and the pre-tests and post-tests of the “Beck Anxiety Inventory (BAI)”, the “Taiwanese version of the WHOQOL-BREF questionnaire”, the influence of the breathing training in the bio, psycho, and social aspects were evaluated. The data collected through the self-report questionnaires of the patients of both groups were used to explore the possible interfering factors among the bio, psycho, and social changes. It is expected that this study will support the “bio-psycho-social model” proposed by Engel, meaning that bio, psycho, and social supports are closely related, and that breathing training helps to transform palliative care patients’ psychological feelings of anxiety and depression, to facilitate their positive interactions with others, and to improve the quality medical care for them.

Keywords: palliative care, breathing training, bio-psycho-social model, heart rate variability

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Authors: Magdalena B. Kaziuk, Waldemar Kosiba, Marek J. Kuzniewski

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Introduction: Adipose tissue is a typical place for storage water-insoluble toxins in the body. It's connective tissue, where the intercellular substance consist of fat, which level in people with low physical activity should be 18-25% for women and 13-18% for men. Due to the fat distribution in the body we distinquish two types of obesity: android (visceral, abdominal) and gynoidal (gluteal-femoral, peripheral). Abdominal obesity increases the risk of complications of the cardiovascular system diseases, and impaired renal and liver function. Through the influence on disorders of metabolism, lipid metabolism, diabetes and hypertension, leading to emergence of the metabolic syndrome. So thus, obesity will especially overload kidney function in patients after transplantation. Aim: An attempt was made to estimate the impact of amount fat tissue on transplanted kidney function and excretory function of the liver in patients after Ktx. Material and Methods: The study included 108 patients (50 females, 58 male, age 46.5 +/- 12.9 years) with active kidney transplant after more than 3 months from the transplantation. An analysis of body composition was done by using electrical bioimpedance (BIA) and anthropometric measurements. Estimated basal metabolic rate (BMR), muscle mass, total body water content and the amount of body fat. Information about physical activity were obtained during clinical examination. Nutritional status, and type of obesity were determined by using indicators: Waist to Height Ratio (WHR) and Waist to Hip Ratio (WHR). Excretory functions of the transplanted kidney was rated by calculating the estimated renal glomerular filtration rate (eGFR) using the MDRD formula. Liver function was rated by total bilirubin and alanine aminotransferase levels ALT concentration in serum. In our patients haemolitic uremic syndrome (HUS) was excluded. Results: In 19.44% of patients had underweight, 22.37% of the respondents were with normal weight, 11.11% had overweight, and the rest were with obese (49.08%). People with android stature have a lower eGFR compared with those with the gynoidal stature (p = 0.004). All patients with obesity had higher amount of body fat from a few to several percent. The higher amount of body fat percentage, the lower eGFR had patients (p <0.001). Elevated ALT levels significantly correlated with a high fat content (p <0.02). Conclusion: Increased amount of body fat, particularly in the case of android obesity can be a predictor of kidney and liver damage. Due to that obese patients should have more frequent control of diagnostic functions of these organs and the intensive dietary proceedings, pharmacological and regular physical activity adapted to the current physical condition of patients after transplantation.

Keywords: obesity, body fat, kidney transplantation, glomerular filtration rate, liver function

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Authors: Anuj Pathare, Aleksandra Birn-Jeffery

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Background: The Anterior Cruciate Ligament(ACL) helps stabilize the knee joint minimizing tibial anterior translation. Anterior Cruciate Ligament (ACL) injury is common in racquet sports and often occurs due to sudden acceleration, deceleration or changes of direction. This mechanism in badminton most commonly occurs during landing after an overhead stroke. Knee biomechanics during dynamic movements such as walking, running and stair negotiation, do not return to normal for more than a year after an ACL reconstruction. This change in the biomechanics may lead to re-injury whilst performing non-steady movements during sports, where these injuries are most prevalent. Aims: To compare if the knee kinetics and kinematics in ACL injury recovered athletes return to the same level as those from an uninjured cohort during standard movements used for clinical assessment and badminton shots. Objectives: The objectives of the study were to determine: Knee valgus during the single leg squat, vertical drop jump, net shot and drop shot; Degree of internal or external rotation during the single leg squat, vertical drop jump, net shot and drop shot; Maximum knee flexion during the single leg squat, vertical drop jump and net shot. Methods: This case-control study included 14 participants with three ACL injury recovered athletes and 11 uninjured participants. The participants performed various functional tasks including vertical drop jump, single leg squat; the forehand net shot and the forehand drop shot. The data was analysed using the two-way ANOVA test, and the reliability of the data was evaluated using the Intra Class Coefficient. Results: The data showed a significant decrease in the range of knee rotation in ACL injured participants as compared to the uninjured cohort (F₇,₅₅₆=2.37; p=0.021). There was also a decrease in the maximum knee flexion angles and an increase in knee valgus angles in ACL injured participants although they were not statistically significant. Conclusion: There was a significant decrease in the knee rotation angles in the ACL injured participants which could be a potential cause for re-injury in these athletes in the future. Although the results for decrease in maximum knee flexion angles and increase in knee valgus angles were not significant, this may be due to a limited sample of ACL injured participants; there is potential for it to be identified as a variable of interest in the rehabilitation of ACL injuries. These changes in the knee biomechanics could be vital in the rehabilitation of ACL injured athletes in the future, and an inclusion of sports based tasks, e.g., Net shot along with standard protocol movements for ACL assessment would provide a better measure of the rehabilitation of the athlete.

Keywords: ACL, biomechanics, knee injury, racquet sport

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Authors: Alessandra Turini Bolsoni Silva, Nilson Rogério Da Silva

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The hospitalization process for long periods and the experience of invasive and painful clinical procedures can trigger a set of stressors in children, family members and professionals, leading to stress. Mothers are, in general, the main caregivers and, therefore, have a high degree of sadness and stress with an impact on mental health. However, the father, in the face of the mother's absence, needs to assume other responsibilities such as domestic activities and healthy children in addition to work activities. In addition, he has to deal with changes in family and work relationships during the child's hospitalization, with disagreements and changes in the relationship with the partner, changes in the relationship with the children, and finding it difficult to reconcile the new tasks as a caregiver and work. A consequence of the hospitalization process is the interruption of the routine activities of both the child and the family members responsible for the care, who can go through stressful moments due to the consequences of family breakdown, attention focused only on the child and sleepless nights. In this sense, both the mother and the father can have their health affected by their child's hospitalization. The present study aims to compare the prevalence of stress and overload in mothers and fathers of hospitalized children, as well as possible associations with activities related to care. The participants were 10 fathers and 10 mothers of children hospitalized in a hospital located in a medium-sized city in the interior of São Paulo. Three instruments were used for data collection: 1) Script to characterize the participants; 2) The Lipp Stress Symptom Inventory (ISSL, 2000) 3) Zarit Burden Interview Protocol – ZBT. Contact was made with the management of the hospital in order to present the objectives of the project, then authorization was requested for the participation of the parents; after an agreement, the time and place were convenient for the participant to carry out the interview. Thus, they signed the Free and Informed Consent Term. Data were analyzed according to the instrument application manuals and organized in Figures and Tables. The results revealed that fathers and mothers have their family and professional routine affected by the hospitalization of their children, with the consequent presence of stress and overload indicators. However, the study points to a greater presence of stress and overload in mothers due to their role as the main caregiver, often interrupting their professional life to exercise care. In the case of the father, the routine is changed due to taking on household chores and taking care of the other children, with the professional life being less affected. It is hoped that the data can guide future interventions that promote and develop strategies that favor care and, at the same time, preserve the health of caregivers and that include mothers and fathers, considering that both are affected, albeit in a different way.

Keywords: stress, overload, caregivers, parents

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Authors: E. Tugba Topcu

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The emergency services are usually the first places to encounter forensic cases. Hence, it is important to consider forensics from the perspective of the emergency services staff and the physiological and psychological consequences that may arise as a result of behaviour by itself or another person. Accurate and detailed documentation of the situation in which the patient first arrives at the emergency service and preservation of the forensic findings is pivotal for the subsequent forensic investigation. The first step in determining whether or not a forensic case exists is to perform a medical examination of the patient. For each individual suspected to be part of a forensic case, police officers should be informed at the same time as the medical examination is being conducted. Violent events are increasing every year and with an increase in the number of forensic cases, emergency service workers have increasing responsibility and consequently play a key role in protecting, collecting and arranging the forensic evidence. In addition, because the emergency service workers involved in forensic events typically have information about the accused and/or victim, as well as evidence related to the events and the cause of injuries, police officers often require their testimony. However, both nurses and other health care personnel do not typically have adequate expertise in forensic medicine. Emergency nurses should take an active role for determining that whether any patient admitted to the emergency services is a clinical forensic patient the emergency service with injury and requiring possible punishment and knowing of their roles and responsibilities in this area provides legal protection as well as the protection of the judicial affair. Particularly, in emergency services, where rapid patient turnover and high workload exists, patient registration and case reporting may not exist. In such instances, the witnesses, typically the nurses, are often consulted for information. Knowledge of forensic medical matters plays a vital role in achieving justice. According to the Criminal Procedure Law, Article 75, Paragraph 3, ‘an internal body examination or the taking of blood or other biological samples from the body can be performed only by a doctor or other health professional member’. In favour of this item, the clinic nurse and doctor are mainly responsible for evaluating forensic cases in emergency departments, performing the examination, collecting evidence, and storing and reporting data. The courts place considerable importance on determining whether a suspect is the victim or accused and, thus, in terms of illuminating events, it is crucial that any evidence is gathered carefully and appropriately. All the evidence related to the forensic case including the forensic report should be handed over to the police officers. In instances where forensic evidence cannot be collected and the only way to obtain the evidence is the hospital environment, health care personnel in emergency services need to have knowledge about the diagnosis of forensic evidence, the collection of evidence, hiding evidence and provision of the evidence delivery chain.

Keywords: emergency department, emergency nursing, forensic cases, forensic nursing

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Authors: Souradip Paul, Arijit Paramanick, M. Suheshkumar Singh

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Traumatic injury is the leading worldwide health problem. Annually, millions of surgical wounds are created for the sake of routine medical care. The healing of these unintended injuries is always monitored based on visual inspection. The maximal restoration of tissue functionality remains a significant concern of clinical care. Although minor injuries heal well with proper care and medical treatment, large injuries negatively influence various factors (vasculature insufficiency, tissue coagulation) and cause poor healing. Demographically, the number of people suffering from severe wounds and impaired healing conditions is burdensome for both human health and the economy. An incomplete understanding of the functional and molecular mechanism of tissue healing often leads to a lack of proper therapies and treatment. Hence, strong and promising medical guidance is necessary for monitoring the tissue regeneration processes. Photoacoustic imaging (PAI), is a non-invasive, hybrid imaging modality that can provide a suitable solution in this regard. Light combined with sound offers structural, functional and molecular information from the higher penetration depth. Therefore, molecular and structural mechanisms of tissue repair will be readily observable in PAI from the superficial layer and in the deep tissue region. Blood vessel formation and its growth is an essential tissue-repairing components. These vessels supply nutrition and oxygen to the cell in the wound region. Angiogenesis (formation of new capillaries from existing blood vessels) contributes to new blood vessel formation during tissue repair. The betterment of tissue healing directly depends on angiogenesis. Other optical microscopy techniques can visualize angiogenesis in micron-scale penetration depth but are unable to provide deep tissue information. PAI overcomes this barrier due to its unique capability. It is ideally suited for deep tissue imaging and provides the rich optical contrast generated by hemoglobin in blood vessels. Hence, an early angiogenesis detection method provided by PAI leads to monitoring the medical treatment of the wound. Along with functional property, mechanical property also plays a key role in tissue regeneration. The wound heals through a dynamic series of physiological events like coagulation, granulation tissue formation, and extracellular matrix (ECM) remodeling. Therefore tissue elasticity changes, can be identified using non-contact photoacoustic elastography (PAE). In a nutshell, angiogenesis and biomechanical properties are both critical parameters for tissue healing and these can be characterized in a single imaging modality (PAI).

Keywords: PAT, wound healing, tissue coagulation, angiogenesis

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Authors: Parvesh Singh, Vipan Kumar, Vishu Mehra

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Quinoline-4-ones represent an important class of heterocyclic scaffolds that have attracted significant interest due to their various biological and pharmacological activities. This heterocyclic unit also constitutes an integral component in drugs used for the treatment of neurodegenerative diseases, sleep disorders and in antibiotics viz. norfloxacin and ciprofloxacin. The synthetic accessibility and possibility of fictionalization at varied positions in quinoline-4-ones exemplifies an elegant platform for the designing of combinatorial libraries of functionally enriched scaffolds with a range of pharmacological profles. They are also considered to be attractive precursors for the synthesis of medicinally imperative molecules such as non-steroidal androgen receptor antagonists, antimalarial drug Chloroquine and martinellines with antibacterial activity. 2-Aryl-2,3-dihydroquinolin-4(1H)-ones are present in many natural and non-natural compounds and are considered to be the aza-analogs of favanones. The β-lactam class of antibiotics is generally recognized to be a cornerstone of human health care due to the unparalleled clinical efficacy and safety of this type of antibacterial compound. In addition to their biological relevance as potential antibiotics, β-lactams have also acquired a prominent place in organic chemistry as synthons and provide highly efficient routes to a variety of non-protein amino acids, such as oligopeptides, peptidomimetics, nitrogen-heterocycles, as well as biologically active natural and unnatural products of medicinal interest such as indolizidine alkaloids, paclitaxel, docetaxel, taxoids, cyptophycins, lankacidins, etc. A straight forward route toward the synthesis of quinoline-4-ones via the triflic acid assisted Fries rearrangement of N-aryl-βlactams has been reported by Tepe and co-workers. The ring expansion observed in this case was solely attributed to the inherent ring strain in β-lactam ring because -lactam failed to undergo rearrangement under reaction conditions. Theabovementioned protocol has been recently extended by our group for the synthesis of benzo[b]-azocinon-6-ones via a tandem Michael addition–Fries rearrangement of sorbyl anilides as well as for the single-pot synthesis of 2-aryl-quinolin-4(3H)-ones through the Fries rearrangement of 3-dienyl-βlactams. In continuation with our synthetic endeavours with the β-lactam ring and in view of the lack of convenient approaches for the synthesis of C-3 functionalized quinolin-4(1H)-ones, the present work describes the single-pot synthesis of C-3 functionalized quinolin-4(1H)-ones via the trific acid promoted Fries rearrangement of C-3 vinyl/isopropenyl substituted β-lactams. In addition, DFT calculations and MD simulations were performed to investigate the stability profles of synthetic compounds.

Keywords: dihydroquinoline, fries rearrangement, azetidin-2-ones, quinoline-4-ones

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Authors: Shamsa Al Sharji, Athar Al Jabri, Haitham Al Dughaishi, Mirfat Al Barwani, Raja Al Rawahi, Raiya Al Rajhi, Shurooq Al Ruqaishi, Thamreen Al Zadjali, Iman Al Humaidi

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Background: External Ventricular Drains (EVDs) are critical in managing traumatic brain injuries and hydrocephalus by controlling intracranial pressure, but they carry a high risk of infection. Infection rates vary globally, ranging from 5% to 45%, leading to increased morbidity, prolonged hospital stays, and higher healthcare costs. Nursing protocols play a pivotal role in reducing these infection rates. This study investigates the impact of a structured nursing protocol on EVD-associated infections in adult neurosurgery patients at the Directorate General of Khoula Hospital, Oman, from January to September 2024. Methods: A cluster-randomized trial was conducted across neurosurgery wards and the ICU. The intervention group followed a comprehensive nursing protocol, including strict sterile insertion, standardized dressing changes, infection control training, and regular clinical audits. The control group received standard care. The primary outcome was the incidence of EVD-associated infections, with secondary outcomes including protocol compliance, infection severity, recovery times, length of stay, and 30-day mortality. Statistical analysis was conducted using Chi-square tests, paired t-tests, and logistic regression to assess the differences between groups. Results: The study involved 75 patients, with an overall infection rate of 13.3%. The intervention group showed a reduced infection rate of 8.9% compared to 20% in the control group. Compliance rates for key nursing actions were high, with 89.7% for hand hygiene and 86.2% for wound dressing. The relative risk of infection was 0.44 in the intervention group, reflecting a 55.6% reduction. Logistic regression identified obesity as a significant predictor of EVD infections. Although mortality rates were slightly higher in the intervention group, the number needed to treat (NNT) of 9 suggests that the nursing protocol may improve survival outcomes. Conclusion: This study demonstrates that structured nursing protocols can reduce EVD-related infections and improve patient outcomes in neurosurgery. While the findings are promising, further research with larger sample sizes is needed to confirm these results and optimize infection control strategies in neurosurgical care.

Keywords: EVD, CSF, nursing protocol, EVD infection

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Authors: Kathrina Aseanne Acapulco-Gomez, Shayne Julieane Morales, Tzar Francis Verame

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Mean platelet volume (MPV) is the most accurate measure of the size of platelets and is routinely measured by most automated hematological analyzers. Several studies have shown associations between MPV and cardiovascular risks and outcomes. Although its measurement may provide useful data, MPV remains to be a diagnostic tool that is yet to be included in routine clinical decision making. The aim of this systematic review and meta-analysis is to determine summary estimates of the diagnostic accuracy of mean platelet volume for the diagnosis of myocardial infarction among adult patients with angina and/or its equivalents in terms of sensitivity, specificity, diagnostic odds ratio, and likelihood ratios, and to determine the difference of the mean MPV values between those with MI and those in the non-MI controls. The primary search was done through search in electronic databases PubMed, Cochrane Review CENTRAL, HERDIN (Health Research and Development Information Network), Google Scholar, Philippine Journal of Pathology, and Philippine College of Physicians Philippine Journal of Internal Medicine. The reference list of original reports was also searched. Cross-sectional, cohort, and case-control articles studying the diagnostic performance of mean platelet volume in the diagnosis of acute myocardial infarction in adult patients were included in the study. Studies were included if: (1) CBC was taken upon presentation to the ER or upon admission (within 24 hours of symptom onset); (2) myocardial infarction was diagnosed with serum markers, ECG, or according to accepted guidelines by the Cardiology societies (American Heart Association (AHA), American College of Cardiology (ACC), European Society of Cardiology (ESC); and, (3) if outcomes were measured as significant difference AND/OR sensitivity and specificity. The authors independently screened for inclusion of all the identified potential studies as a result of the search. Eligible studies were appraised using well-defined criteria. Any disagreement between the reviewers was resolved through discussion and consensus. The overall mean MPV value of those with MI (9.702 fl; 95% CI 9.07 – 10.33) was higher than in those of the non-MI control group (8.85 fl; 95% CI 8.23 – 9.46). Interpretation of the calculated t-value of 2.0827 showed that there was a significant difference in the mean MPV values of those with MI and those of the non-MI controls. The summary sensitivity (Se) and specificity (Sp) for MPV were 0.66 (95% CI; 0.59 - 0.73) and 0.60 (95% CI; 0.43 – 0.75), respectively. The pooled diagnostic odds ratio (DOR) was 2.92 (95% CI; 1.90 – 4.50). The positive likelihood ratio of MPV in the diagnosis of myocardial infarction was 1.65 (95% CI; 1.20 – 22.27), and the negative likelihood ratio was 0.56 (95% CI; 0.50 – 0.64). The intended role for MPV in the diagnostic pathway of myocardial infarction would perhaps be best as a triage tool. With a DOR of 2.92, MPV values can discriminate between those who have MI and those without. For a patient with angina presenting with elevated MPV values, it is 1.65 times more likely that he has MI. Thus, it is implied that the decision to treat a patient with angina or its equivalents as a case of MI could be supported by an elevated MPV value.

Keywords: mean platelet volume, MPV, myocardial infarction, angina, chest pain

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Authors: Masih Nikgou

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ICU nurses or intensive care nurses are highly specialized and trained healthcare personnel. These nurses provide nursing care for patients with life-threatening illnesses or conditions. They provide the experience, knowledge and specialized skills that patients need to survive and recover. Intensive care nurses (ICU) are trained to make momentary decisions and act quickly when the patient's condition changes. Their primary work environment is in the hospital in intensive care units. Typically, ICU patients require a high level of care. ICU nurses work in challenging and complex fields in their nursing profession. They have the primary duty of caring for and saving patients who are fighting for their lives. Intensive care (ICU) nurses are highly trained to provide exceptional care to patients who depend on 24/7 nursing care. A patient in the ICU is often equipped with a ventilator, intubated and connected to several life support machines and medical equipment. Intensive Care Nurses (ICU) have full expertise in considering all aspects of bringing back their patients. Some of the specific responsibilities of ICU nurses include (a) Assessing and monitoring the patient's progress and identifying any sudden changes in the patient's medical condition. (b) Administration of drugs intravenously by injection or through gastric tubes. (c) Provide regular updates on patient progress to physicians, patients, and their families. (d) According to the clinical condition of the patient, perform the approved diagnostic or treatment methods. (e) In case of a health emergency, informing the relevant doctors. (f) To determine the need for emergency interventions, evaluate laboratory data and vital signs of patients. (g) Caring for patient needs during recovery in the ICU. (h) ICU nurses often provide emotional support to patients and their families. (i) Regulating and monitoring medical equipment and devices such as medical ventilators, oxygen delivery devices, transducers, and pressure lines. (j) Assessment of pain level and sedation needs of patients. (k) Maintaining patient reports and records. As the name suggests, critical care nurses work primarily in ICU health care units. ICUs are completely healthy and have proper lighting with strict adherence to health and safety from medical centers. ICU nurses usually move between the intensive care unit, the emergency department, the operating room, and other special departments of the hospital. ICU nurses usually follow a standard shift schedule that includes morning, afternoon, and night schedules. There are also other relocation programs depending on the hospital and region. Nurses who are passionate about data and managing a patient's condition and outcomes typically do well as ICU nurses. An inquisitive mind and attention to processes are equally important. ICU nurses are completely compassionate and are not afraid to advocate for their patients and family members. who are distressed.

Keywords: nursing, intensive care unit, pediatric intensive care unit, mobile intensive care unit, surgical intensive care unite

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Authors: Simona Perga, Chiara Beltramo, Floriana Fruscione, Isabella Martini, Federica Cavallo, Federica Riccardo, Paolo Buracco, Selina Iussich, Elisabetta Razzuoli, Katia Varello, Lorella Maniscalco, Elena Bozzetta, Angelo Ferrari, Paola Modesto

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Introduction: Human and canine melanoma have common clinical, histologic characteristics making dogs a good model for comparative oncology. The identification of specific genes and a better understanding of the genetic landscape, signaling pathways, and tumor–microenvironmental interactions involved in the cancer onset and progression is essential for the development of therapeutic strategies against this tumor in both species. In the present study, the differential expression of genes in spontaneously occurring canine melanoma and in paired normal tissue was investigated by targeted RNAseq. Material and Methods: Total RNA was extracted from 17 canine malignant melanoma (CMM) samples and from five paired normal tissues stored in RNA-later. In order to capture the greater genetic variability, gene expression analysis was carried out using two panels (Qiagen): Human Immuno-Oncology (HIO) and Mouse-Immuno-Oncology (MIO) and the miSeq platform (Illumina). These kits allow the detection of the expression profile of 990 genes involved in the immune response against tumors in humans and mice. The data were analyzed through the CLCbio Genomics Workbench (Qiagen) software using the Canis lupus familiaris genome as a reference. Data analysis were carried out both comparing the biologic group (tumoral vs. healthy tissues) and comparing neoplastic tissue vs. paired healthy tissue; a Fold Change greater than two and a p-value less than 0.05 were set as the threshold to select interesting genes. Results and Discussion: Using HIO 63, down-regulated genes were detected; 13 of those were also down-regulated comparing neoplastic sample vs. paired healthy tissue. Eighteen genes were up-regulated, 14 of those were also down-regulated comparing neoplastic sample vs. paired healthy tissue. Using the MIO, 35 down regulated-genes were detected; only four of these were down-regulated, also comparing neoplastic sample vs. paired healthy tissue. Twelve genes were up-regulated in both types of analysis. Considering the two kits, the greatest variation in Fold Change was in up-regulated genes. Dogs displayed a greater genetic homology with humans than mice; moreover, the results have shown that the two kits are able to detect different genes. Most of these genes have specific cellular functions or belong to some enzymatic categories; some have already been described to be correlated to human melanoma and confirm the validity of the dog as a model for the study of molecular aspects of human melanoma.

Keywords: animal model, canine melanoma, gene expression, spontaneous tumors, targeted RNAseq

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Authors: Tiffanie-Marie Borg, Yasmin Zeinolabediny, Nima Heidari, Ali Noorani, Mark Slevin, Angel Cullen, Stefano Olgiati, Alberto Zerbi, Alessandro Danovi, Adrian Wilson

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Knee Osteoarthritis (OA) is a critical cause of disability globally. In recent years, there has been growing interest in non-invasive treatments, such as intra-articular injection of micro-fragmented fat (MFAT), showing great potential in treating OA. Mesenchymal stem cells (MSCs), originating from pericytes of micro-vessels in MFAT, can differentiate into mesenchymal lineage cells such as cartilage, osteocytes, adipocytes, and osteoblasts. Secretion of growth factor and cytokines from MSCs have the capability to inhibit T cell growth, reduced pain and inflammation, and create a micro-environment that through paracrine signaling, can promote joint repair and cartilage regeneration. Here we have shown, for the first time, data supporting the hypothesis that women respond better in terms of improvements in pain and function to MFAT injection compared to men. Historically, women have been underrepresented in studies, and studies with both sexes regularly fail to analyse the results by sex. To mitigate this bias and quantify it, we describe a technique using reproducible statistical analysis and replicable results with Open Access statistical software R to calculate the magnitude of this difference. Genetic, hormonal, environmental, and age factors play a role in our observed difference between the sexes. This observational, intention-to-treat study included the complete sample of 456 patients who agreed to be scored for pain (visual analogue scale (VAS)) and function (Oxford knee score (OKS)) at baseline regardless of subsequent changes to adherence or status during follow-up. We report that a significantly larger number of women responded to treatment than men: [90% vs. 60% change in VAS scores with 87% vs. 65% change in OKS scores, respectively]. Women overall had a stronger positive response to treatment with reduced pain and improved mobility and function. Pre-injection, our cohort of women were in more pain with worse joint function which is quite common to see in orthopaedics. However, during the 2-year follow-up, they consistently maintained a lower incidence of discomfort with superior joint function. This data clearly identifies a clear need for further studies to identify the cell and molecular biological and other basis for these differences and be able to utilize this information for stratification in order to improve outcome for both women and men.

Keywords: gender differences, micro-fragmented adipose tissue, knee osteoarthritis, stem cells

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Authors: Taurino S. R. Neto, Epitácio D. S. Neto, Flávio Signorelli, Gustavo G. M. Balbi, Alex H. Higashi, Mário Luiz R. Monteiro, Eloisa Bonfá, Danieli C. O. Andrade, Leandro C. Zacharias

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Purpose: To perform a multimodal evaluation, including the use of Optical Coherence Angiotomography (OCTA), in patients with primary antiphospholipid syndrome (PAPS) without ocular complaints and to compare them with healthy individuals. Methods: A complete structural and functional ophthalmological evaluation using OCTA and microperimetry (MP) exam in patients with PAPS, followed at a tertiary rheumatology outpatient clinic, was performed. All ophthalmologic manifestations were recorded and then statistical analysis was performed for comparative purposes; p <0.05 was considered statistically significant. Results: 104 eyes of 52 subjects (26 patients with PAPS without ocular complaints and 26 healthy individuals) were included. Among PAPS patients, 21 were female (80.8%) and 21 (80.8%) were Caucasians. Thrombotic PAPS was the main clinical criteria manifestation (100%); 65.4% had venous and 34.6% had arterial thrombosis. Obstetrical criteria were present in 34.6% of all thrombotic PAPS patients. Lupus anticoagulant was present in all patients. 19.2% of PAPS patients presented ophthalmologic findings against none of the healthy individuals. The most common retinal change was paracentral acute middle maculopathy (PAMM) (3 patients, 5 eyes), followed by drusen-like deposits (1 patient, 2 eyes) and pachychoroid pigment epitheliopathy (1 patient, 1 eye). Systemic hypertension and hyperlipidaemia were present in 100% of the PAPS patients with PAMM, while only six patients (26.1%) with PAPS without PAMM presented these two risk factors together. In the quantitative OCTA evaluation, we found significant differences between PAPS patients and controls in both the superficial vascular complex (SVC) and deep vascular complex (DVC) in the high-speed protocol, as well as in the SVC in the high-resolution protocol. In the analysis of the foveal avascular zone (FAZ) parameters, the PAPS group had a larger area of FAZ in the DVC using the high-speed method compared to the control group (p=0.047). In the quantitative analysis of the MP, the PAPS group had lower central (p=0.041) and global (p<0.001) retinal sensitivity compared to the control group, as well as in the sector analysis, with the exception of the inferior sector. In the quantitative evaluation of fixation stability, there was a trend towards worse stability in the PAPS subgroup with PAMM in both studied methods. Conclusions: PAMM was observed in 11.5% of PAPS patients with no previous ocular complaints. Systemic hypertension concomitant with hyperlipidemia was the most commonly associated risk factor for PAMM in patients with PAPS. PAPS patients present lower vascular density and retinal sensitivity compared to the control group, even in patients without PAMM.

Keywords: antiphospholipid syndrome, optical coherence angio tomography, optical coherence tomography, retina

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Authors: Prince S. Campbell, Janine B. Adams, Melusi Thwala, Opeoluwa Oyedele, Paula E. Melariri

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Schistosomiasis, often known as bilharzia, is a parasitic water-borne disease caused by trematode flatworms of the genus Schistosoma. Schistosomiasis infection and prevention have been found to be influenced by a range of socio-cultural risk factors, including human characteristics (e.g., gender, age, education, knowledge, attitude, and practices), as well as environmental and economic elements. Lack of awareness of the disease may also contribute to an individual's tendency to participate in behaviours or activities that heighten their susceptibility to infection. The current study assessed the community knowledge, attitude and practices (KAP) on schistosomiasis and implemented an educational intervention following pre-test interviews. A cross-sectional quasi-experimental research design was used in this quantitative study. Pre- and post-intervention interview format surveys were conducted using a structured questionnaire, targeting individuals aged 18–65 years residing within 5 km of select water bodies. The questionnaire contained 54 close-ended questions about schistosomiasis causes, transmission, and clinical symptoms and the participants were interviewed face-to-face in their homes. Data was captured on Question Pro and analyzed using Microsoft Office Excel 365 (2019) and R (version 4.3.1) software. Overall, 380 individuals completed the pre and post-intervention assessments; 194 and 185 were males (51.1%) and females (48.7%), respectively. A notable 91.3% of participants did not know about schistosomiasis in the pre-intervention phase; however, the mean post-intervention test score (9.4 ± 1.4) for knowledge among participants was higher than the pre-intervention test score (2.2 ± 2.1) indicating a good and improved knowledge of schistosomiasis among the participants. Furthermore, the paired samples t-test results demonstrated that the increase in knowledge levels was statistically significant (p<0.001). Also, the post-intervention improvement of both practice (p<0.001) and attitude (p<0.001) levels was statistically significant. A positive correlation (r=0.23, p<0.001) was found between knowledge and attitude in the pre-intervention stage. Knowledgeable participants had a more positive attitude towards obtaining medical assistance and disease prevention. Moreover, attitudes and practices correlated negatively (r=-0.13, p=0.013) post-intervention; hence, those with positive attitudes did not engage in risky water-related practices, which was the desired outcome. The educational intervention had a favourable impact on the KAP of the study population as the majority were able to recall the disease aetiology, symptoms, transmission pattern, and preventative measures three months post-intervention. Nevertheless, previous research has suggested that participants were unable to recall information about the disease following the intervention. Consequently, research should prioritize behavioural modification strategies that may result in a more persistent outcome in terms of the participants' knowledge, which could ultimately contribute to the development of long-term positive attitudes and practices.

Keywords: educational intervention, knowledge, attitudes and practices, schistosomiasis

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Authors: Ravija Gunawardana, Banuka Athuraliya

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Machine learning has emerged as a powerful tool for disease diagnosis and prediction. The use of machine learning algorithms has the potential to improve the accuracy of disease prediction, thereby enabling medical professionals to provide more effective and personalized treatments. This study focuses on developing a machine-learning model for disease prediction using symptoms and X-ray images. The importance of this study lies in its potential to assist medical professionals in accurately diagnosing diseases, thereby improving patient outcomes. Respiratory diseases are a significant cause of morbidity and mortality worldwide, and chest X-rays are commonly used in the diagnosis of these diseases. However, accurately interpreting X-ray images requires significant expertise and can be time-consuming, making it difficult to diagnose respiratory diseases in a timely manner. By incorporating machine learning algorithms, we can significantly enhance disease prediction accuracy, ultimately leading to better patient care. The study utilized the Mask R-CNN algorithm, which is a state-of-the-art method for object detection and segmentation in images, to process chest X-ray images. The model was trained and tested on a large dataset of patient information, which included both symptom data and X-ray images. The performance of the model was evaluated using a range of metrics, including accuracy, precision, recall, and F1-score. The results showed that the model achieved an accuracy rate of over 90%, indicating that it was able to accurately detect and segment regions of interest in the X-ray images. In addition to X-ray images, the study also incorporated symptoms as input data for disease prediction. The study used three different classifiers, namely Random Forest, K-Nearest Neighbor and Support Vector Machine, to predict diseases based on symptoms. These classifiers were trained and tested using the same dataset of patient information as the X-ray model. The results showed promising accuracy rates for predicting diseases using symptoms, with the ensemble learning techniques significantly improving the accuracy of disease prediction. The study's findings indicate that the use of machine learning algorithms can significantly enhance disease prediction accuracy, ultimately leading to better patient care. The model developed in this study has the potential to assist medical professionals in diagnosing respiratory diseases more accurately and efficiently. However, it is important to note that the accuracy of the model can be affected by several factors, including the quality of the X-ray images, the size of the dataset used for training, and the complexity of the disease being diagnosed. In conclusion, the study demonstrated the potential of machine learning algorithms for disease prediction using symptoms and X-ray images. The use of these algorithms can improve the accuracy of disease diagnosis, ultimately leading to better patient care. Further research is needed to validate the model's accuracy and effectiveness in a clinical setting and to expand its application to other diseases.

Keywords: K-nearest neighbor, mask R-CNN, random forest, support vector machine

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Authors: Doni Dermawan

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Modern sports competition as a consequence of the increase in the value of the business and entertainment in the field of sport has been demanding athletes to always have excellent physical endurance performance. Physical exercise is done in a long time, and intensive may pose a risk of muscle tissue damage caused by the increase of the enzyme creatine kinase. Branched Chain Amino Acids (BCAA) is an essential amino acid that is composed of leucine, isoleucine, and valine which serves to maintain muscle tissue, keeping the immune system, and prevent further loss of coordination and muscle pain. Pea (Pisum sativum L.) is a kind of leguminous plants that are rich in Branched Chain Amino Acids (BCAA) where every one gram of protein pea contains 82.7 mg of leucine; 56.3 mg isoleucine; and 56.0 mg of valine. This research aims to develop Branched Chain Amino Acids (BCAA) from pea extract is applied in dosage forms Gel PVP Kinesio Tape technology using Ultrasound-assisted Extraction. The method used in the writing of this paper is the Cochrane Collaboration Review that includes literature studies, testing the quality of the study, the characteristics of the data collection, analysis, interpretation of results, and clinical trials as well as recommendations for further research. Extraction of BCAA in pea done using ultrasound-assisted extraction technology with optimization variables includes the type of solvent extraction (NaOH 0.1%), temperature (20-250C), time (15-30 minutes) power (80 watt) and ultrasonic frequency (35 KHz). The advantages of this extraction method are the level of penetration of the solvent into the membrane of the cell is high and can increase the transfer period so that the BCAA substance separation process more efficient. BCAA extraction results are then applied to the polymer PVP (Polyvinylpyrrolidone) Gel powder composed of PVP K30 and K100 HPMC dissolved in 10 mL of water-methanol (1: 1) v / v. Preparations Kinesio Tape Gel PVP is the BCAA in the gel are absorbed into the muscle tissue, and joints through tensile force then provides stimulation to the muscle circulation with variable pressure so that the muscle can increase the biomechanical movement and prevent damage to the muscle enzyme creatine kinase. Analysis and evaluation of test preparation include interaction, thickness, weight uniformity, humidity, water vapor permeability, the levels of the active substance, content uniformity, percentage elongation, stability testing, release profile, permeation in vitro and in vivo skin irritation testing.

Keywords: branched chain amino acid, BCAA, Kinesio tape, pea, PVP gel, ultrasound-assisted extraction

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Authors: Dejene Ermias Mekango, Mussie Alemayehu, Gebremedhin Berhe Gebregergs, Araya Abrha Medhanye, Gelila Goba

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Background: Maternal near miss (MNM) can be used as a proxy indicator of maternal mortality ratio. There is a huge gap in life time risk between Sub-Saharan Africa and developed countries. In Ethiopia, a significant number of women die each year from complications during pregnancy, childbirth and the post-partum period. Besides, a few studies have been performed on MNM, and little is known regarding determinant factors. This study aims to identify determinants of MNM among women in Tigray region, Northern Ethiopia. Methods: a case-control study in hospital found in Tigray region, Ethiopia was conducted from January 30 - March 30, 2016. The sample included 103 cases and 205 controls recruited from women seeking obstetric care at six public hospitals. Clients having a life-threatening obstetric complication including haemorrhage, hypertensive diseases of pregnancy, dystocia, infections, and anemia or clinical signs of severe anemia in women without haemorrhage were taken as cases and those with normal obstetric outcomes were considered as controls. Cases were selected based on proportional to size allocation while systematic sampling was employed for controls. Data were analyzed using SPSS version 20.0. Binary and multiple variable logistic regression (odds ratio) analyses were calculated with 95% CI. Results: The largest proportion of cases and controls was among the ages of20–29 years, accounting for37.9 %( 39) of cases and 31.7 %( 65) of controls. Roughly 90% of cases and controls were married. About two-thirds of controls and 45.6 %( 47) of cases had gestational age between 37-41 weeks. History of chronic medical conditions was reported in 55.3 %(57) of cases and 33.2%(68) of controls. Women with no formal education [AOR=3.2;95%CI:1.24, 8.12],being less than 16 years old at first pregnancy [AOR=2.5; 95%CI:1.12,5.63],induced labor[AOR=3; 95%CI:1.44, 6.17], history of Cesarean section (C-section) [AOR=4.6; 95%CI: 1.98, 7.61] or chronic medical disorder[AOR=3.5;95%CI:1.78, 6.93], and women who traveled more than 60 minutes before reaching their final place of care[AOR=2.8;95% CI: 1.19,6.35] all had higher odds of experiencing MNM. Conclusions: The Government of Ethiopia should continue its effort to address the lack of road and health facility access as well as education, which will help reduce MNM. Work should also be continued to educate women and providers about common predictors of MNM like the history of C-section, chronic illness, and teenage pregnancy. These efforts should be carried out at the facility, community, and individual levels. The targeted follow-up to women with a history of chronic disease and C-section could also be a practical way to reduce MNM.

Keywords: maternal near miss, severe obstetric hemorrhage, hypertensive disorder, c-section, Tigray, Ethiopia

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Authors: Aziz Ikhlef

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Most of multi-slices CT scanners are built with detectors composed of scintillator - photodiodes arrays. The photodiodes arrays are mainly based on front-illuminated technology for detectors under 64 slices and on back-illuminated photodiode for systems of 64 slices or more. The designs based on back-illuminated photodiodes were being investigated for CT machines to overcome the challenge of the higher number of runs and connection required in front-illuminated diodes. In backlit diodes, the electronic noise has already been improved because of the reduction of the load capacitance due to the routing reduction. This translated by a better image quality in low signal application, improving low dose imaging in large patient population. With the fast development of multi-detector-rows CT (MDCT) scanners and the increasing number of examinations, the clinical community has raised significant concerns on radiation dose received by the patient in both medical and regulatory community. In order to reduce individual exposure and in response to the recommendations of the International Commission on Radiological Protection (ICRP) which suggests that all exposures should be kept as low as reasonably achievable (ALARA), every manufacturer is trying to implement strategies and solutions to optimize dose efficiency and image quality based on x-ray emission and scanning parameters. The added demands on the CT detector performance also comes from the increased utilization of spectral CT or dual-energy CT in which projection data of two different tube potentials are collected. One of the approaches utilizes a technology called fast-kVp switching in which the tube voltage is switched between 80kVp and 140kVp in fraction of a millisecond. To reduce the cross-contamination of signals, the scintillator based detector temporal response has to be extremely fast to minimize the residual signal from previous samples. In addition, this paper will present an overview of detector technologies and image chain improvement which have been investigated in the last few years to improve the signal-noise ratio and the dose efficiency CT scanners in regular examinations and in energy discrimination techniques. Several parameters of the image chain in general and in the detector technology contribute in the optimization of the final image quality. We will go through the properties of the post-patient collimation to improve the scatter-to-primary ratio, the scintillator material properties such as light output, afterglow, primary speed, crosstalk to improve the spectral imaging, the photodiode design characteristics and the data acquisition system (DAS) to optimize for crosstalk, noise and temporal/spatial resolution.

Keywords: computed tomography, X-ray detector, medical imaging, image quality, artifacts

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Authors: Sigal Gat-Lazer, Ronny Geva, Dan Ramon, Eitan Gur, Daniel Stein

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Introduction: Eating disorders (ED) are common psychopathologies which involve distorted body image and eating disturbances. Binge-purge eating disorders (B/P ED) are characterized by repetitive events of binge eating followed by purges. Patients with B/P ED behavior may be seen as impulsive especially when relate to food stimulation and affective conditions. The current study included innovative modification of the day-night task targeted to assess inhibitory control among patients with B/P ED. Methods: This prospective study included 50 patients with B/P ED during acute phase of illness (T1) upon their admission to specialized ED department in tertiary center. 34 patients repeated the study towards discharge to ambulatory care (T2). Treatment effect was evaluated by BMI and emotional questionnaires regarding depression and anxiety by the Beck Depression Inventory and State Trait Anxiety Inventory questionnaires. Control group included 36 healthy controls with matched demographic parameters who performed both T1 and T2 assessments. The current modification is based on the emotional day-night task (EDNT) which involves five emotional stimulation added to the sun and moon pictures presented to participants. In the current study, we designed the food-emotional modification day night task (F-EDNT) food stimulations of egg and banana which resemble the sun and moon, respectively, in five emotional states (angry, sad, happy, scrambled and neutral). During this computerized task, participants were instructed to push on “day” bottom in response to moon and banana stimulations and on “night” bottom when sun and egg were presented. Accuracy (A) and reaction time (RT) were evaluated and compared between EDNT and F-EDNT as a reflection of participants’ inhibitory control. Results: Patients with B/P ED had significantly improved BMI, depression and anxiety scores on T2 compared to T1 (all p<0.001). Task performance was similar among patients and controls in the EDNT without significant A or RT differences in both T1 and T2. On F-EDNT during T1, B/P ED patients had significantly reduced accuracy in 4/5 emotional stimulation compared to controls: angry (73±25% vs. 84±15%, respectively), sad (69±25% vs. 80±18%, respectively), happy (73±24% vs. 82±18%, respectively) and scrambled (74±24% vs. 84±13%, respectively, all p<0.05). Additionally, patients’ RT to food stimuli was significantly faster compared to neutral ones, in both cry and neutral emotional stimulations (356±146 vs. 400±141 and 378±124 vs. 412±116 msec, respectively, p<0.05). These significant differences between groups as a function of stimulus type were diminished on T2. Conclusion: Having to process food related content, in particular in emotional context seems to be impaired in patients with B/P ED during the acute phase of their illness and elicits greater impulsivity. Innovative modification using such procedures seem to be sensitive to patients’ illness phase and thus may be implemented during screening and follow up through the clinical management of these patients.

Keywords: binge purge eating disorders, day night task modification, eating disorders, food related stimulations

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Authors: Monika Soni, Chandra Bhattacharya, Siraj Ahmed Ahmed, Prafulla Dutta

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Dengue is now a globally important arboviral disease. Extensive vector surveillance has already established A.aegypti as a primary vector, but A.albopictus is now accelerating the situation through gradual adaptation to human surroundings. Global destabilization and gradual climatic shift with rising in temperature have significantly expanded the geographic range of these species These versatile vectors also host Chikungunya, Zika, and yellow fever virus. Biggest challenge faced by endemic countries now is upsurge in co-infection reported with multiple serotypes and virus co-circulation. To foster vector control interventions and mitigate disease burden, there is surge for knowledge on vector susceptibility and viral tolerance in response to multiple infections. To address our understanding on transmission dynamics and reproductive fitness, both the vectors were exposed to single and dual combinations of all four dengue serotypes by artificial feeding and followed up to third generation. Artificial feeding observed significant difference in feeding rate for both the species where A.albopictus was poor artificial feeder (35-50%) compared to A.aegypti (95-97%) Robust sequential screening of viral antigen in mosquitoes was followed by Dengue NS1 ELISA, RT-PCR and Quantitative PCR. To observe viral dissemination in different mosquito tissues Indirect immunofluorescence assay was performed. Result showed that both the vectors were infected initially with all dengue(1-4)serotypes and its co-infection (D1 and D2, D1 and D3, D1 and D4, D2 and D4) combinations. In case of DENV-2 there was significant difference in the peak titer observed at 16th day post infection. But when exposed to dual infections A.aegypti supported all combinations of virus where A.albopictus only continued single infections in successive days. There was a significant negative effect on the fecundity and fertility of both the vectors compared to control (PANOVA < 0.001). In case of dengue 2 infected mosquito, fecundity in parent generation was significantly higher (PBonferroni < 0.001) for A.albopicus compare to A.aegypti but there was a complete loss of fecundity from second to third generation for A.albopictus. It was observed that A.aegypti becomes infected with multiple serotypes frequently even at low viral titres compared to A.albopictus. Possible reason for this could be the presence of wolbachia infection in A.albopictus or mosquito innate immune response, small RNA interference etc. Based on the observations it could be anticipated that transovarial transmission may not be an important phenomenon for clinical disease outcome, due to the absence of viral positivity by third generation. Also, Dengue NS1 ELISA can be used for preliminary viral detection in mosquitoes as more than 90% of the samples were found positive compared to RT-PCR and viral load estimation.

Keywords: co-infection, dengue, reproductive fitness, viral quantification

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Authors: Natalia Buderatskaya, Igor Ilyin, Julia Gontar, Sergey Lavrynenko, Olga Parnitskaya, Ekaterina Ilyina, Eduard Kapustin, Yana Lakhno

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Introduction: It is known that cryopreservation of oocytes has peculiar features due to the complex structure of the oocyte. One of the most important features is that mature oocytes contain meiotic division spindle which is very sensitive even to the slightest variation in temperature. Thus, the main objective of this study is to analyse the resulting euploid embryos obtained from thawed oocytes in comparison with the data of preimplantation genetic screening (PGS) in fresh embryo cycles. Material and Methods: The study was conducted at 'Medical Centre IGR' from January to July 2016. Data were analysed for 908 donor oocytes obtained in 67 cycles of assisted reproductive technologies (ART), of which 693 oocytes were used in the 51 'fresh' cycles (group A), and 215 oocytes - 16 ART programs with vitrification female gametes (group B). The average age of donors in the groups match 27.3±2.9 and 27.8±6.6 years. Stimulation of superovulation was conducted the standard way. Vitrification was performed in 1-2 hours after transvaginal puncture and thawing of oocytes were carried out in accordance with the standard protocol of Cryotech (Japan). Manipulation ICSI was performed 4-5 hours after transvaginal follicle puncture for fresh oocytes, or after defrosting - for vitrified female gametes. For the PGS, an embryonic biopsy was done on the third or on the fifth day after fertilization. Diagnostic procedures were performed using fluorescence in situ hybridization with the study of such chromosomes as 13, 16, 18, 21, 22, X, Y. Only morphologically quality blastocysts were used for the transfer, the estimation of which corresponded to the Gardner criteria. The statistical hypotheses were done using the criteria t, x^2 at a significance levels p<0.05, p<0.01, p<0.001. Results: The mean number of mature oocytes per cycle in group A was 13.58±6.65 and in group B - 13.44±6.68 oocytes for patient. The survival of oocytes after thawing totaled 95.3% (n=205), which indicates a highly effective quality of performed vitrification. The proportion of zygotes in the group A corresponded to 91.1%(n=631), in the group B – 80.5%(n=165), which shows statistically significant difference between the groups (p<0.001) and explained by non-viable oocytes elimination after vitrification. This is confirmed by the fact that on the fifth day of embryos development a statistically significant difference in the number of blastocysts was absent (p>0.05), and constituted respectively 61.6%(n=389) and 63.0%(n=104) in the groups. For the PGS performing 250 embryos analyzed in the group A and 72 embryos - in the group B. The results showed that euploidy in the studied chromosomes were 40.0%(n=100) embryos in the group A and 41.7% (n=30) - in the group B, which shows no statistical significant difference (p>0.05). The indicators of clinical pregnancies in the groups amounted to 64.7% (22 pregnancies per 34 embryo transfers) and 61.5% (8 pregnancies per 13 embryo transfers) respectively, and also had no significant difference between the groups (p>0.05). Conclusions: The results showed that the vitrification does not affect the resulting euploid embryos in assisted reproductive technologies and are not reflected in their morphological characteristics in ART programs.

Keywords: euploid embryos, preimplantation genetic screening, thawing oocytes, vitrification

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Authors: Hsiao-Lin Fang

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Every life is precious, and comprehensive care should be provided to individuals who are in the final stages of their lives. Hospice-shared care aims to provide optimal symptom control and palliative care to terminal (cancer) patients through the implementation of shared care, and to support patients and their families in making various physical and psychological adjustments in the face of death. This report examines a 10-year-boy diagnosed with Out-of-Hospital Cardiac Arrest (OHCA). The individual fainted when swimming at school and underwent 31 minutes of cardiopulmonary resuscitation (CPR). While receiving treatment at the hospital, the individual received extracorporeal membrane oxygenation(ECMO) due to unstable hemodynamics. Urgent cardiac catheterization found: Suspect acute fulminant myocarditis or underlying cardiomyopathy with acute decompensation, After the active rescue by the medical team, hemodynamics still showed only mean pressure value. With respect to the patient, interdepartmental hospice-shared care was implemented and a do-not-resuscitate (DNR) order was signed after family discussions were conducted. Assistance and instructions were provided as part of the comfort care process. A farewell gathering attended by the patient’s relatives, friends, teachers, and classmates was organized in an intensive care unit (ICU) in order to look back on the patient’s life and the beautiful memories that were created, as well as to alleviate the sorrow felt by family members, including the patient’s father and sister. For example, the patient was presented with drawings and accompanied to a garden to pick flowers. In this manner, the patient was able to say goodbye before death. Finally, the patient’s grandmother and father participated in the clinical hospice care and post-mortem care processes. A hospice-shared care clinician conducted regular follow-ups and provided care to the family of the deceased, supporting family members through the sorrowful period. Birth, old age, sickness, and death are the natural phases of human life. In recent years, growing attention has been paid to human-centered hospice care. Hospice care is individual holistic care provided by a professional team and it involves the provision of comprehensive care to a terminal patient. Hospice care aims to satisfy the physical, psychological, mental, and social needs of patients and their families. It does not involve the cessation of treatment but rather avoids the exacerbation or extension of the suffering endured by patients, thereby preserving the dignity and quality of life during the end-of-life period. Patients enjoy the company of others as they complete the last phase of their lives, and their families also receive guidance on how they can move on with their own lives after the patient’s death.

Keywords: hospice-shared care, extracorporeal membrane oxygenation (ECMO), hospice-shared care, child patient

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Authors: Ilija Kelepurovski, Stefan Lazorovski, Pece Petkovski, Marian Anakievski, Svetlana Petkovska

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Introduction: Benign prostatic hyperplasia (BPH) is a common condition that affects men over the age of 50 and is characterized by an enlarged prostate gland that can cause lower urinary tract symptoms (LUTS). Uroflowmetry and cystoscopy are two commonly used diagnostic tests to evaluate LUTS and diagnose BPH. While both tests can be useful, there is a risk of overusing cystoscopy and underusing uroflowmetry in the evaluation of LUTS. The aim of this study was to compare the use of uroflowmetry and cystoscopy in a prospective cohort of 100 patients with suspected BPH or other urinary tract conditions and to assess the diagnostic yield of each test. Materials and Methods: This was a prospective study of 100 male patients over the age of 50 with suspected BPH or other urinary tract conditions who underwent uroflowmetry and cystoscopy for the evaluation of LUTS at a single tertiary care center. Inclusion criteria included male patients over the age of 50 with suspected BPH or other urinary tract conditions, while exclusion criteria included previous urethral or bladder surgery, active urinary tract infection, and significant comorbidities. The primary outcome of the study was the frequency of cystoscopy in the evaluation of LUTS, and the secondary outcome was the diagnostic yield of each test. Results: Of the 100 patients included in the study, 86 (86%) were diagnosed with BPH and 14 (14%) had other urinary tract conditions. The mean age of the study population was 67 years. Uroflowmetry was performed on all 100 patients, while cystoscopy was performed on 70 (70%) of the patients. The diagnostic yield of uroflowmetry was high, with a clear diagnosis made in 92 (92%) of the patients. The diagnostic yield of cystoscopy was also high, with a clear diagnosis made in 63 (90%) of the patients who underwent the procedure. There was no statistically significant difference in the diagnostic yield of uroflowmetry and cystoscopy (p = 0.20). Discussion: Our study found that uroflowmetry is an effective and well-tolerated diagnostic tool for evaluating LUTS and diagnosing BPH, with a high diagnostic yield and low risk of complications. Cystoscopy is also a useful diagnostic tool, but it is more invasive and carries a small risk of complications such as bleeding or urinary tract infection. Both tests had a high diagnostic yield, suggesting that either test can provide useful information in the evaluation of LUTS. However, the fact that 70% of the study population underwent cystoscopy raises concerns about the potential overuse of this test in the evaluation of LUTS. This is especially relevant given the focus on patient-centered care and the need to minimize unnecessary or invasive procedures. Our findings underscore the importance of considering the clinical context and using evidence-based guidelines. Conclusion: In this prospective study of 100 patients with suspected BPH or other urinary tract conditions, we found that uroflowmetry and cystoscopy were both valuable diagnostic tools for the evaluation of LUTS. However, the potential overuse of cystoscopy in this population warrants further investigation and highlights the need for careful consideration of the optimal use of diagnostic tests in the evaluation of LUTS and the diagnosis of BPH. Further research is needed to better understand the relative roles of uroflowmetry and cystoscopy in the diagnostic workup of patients with LUTS, and to develop evidence-based guidelines for their appropriate use.

Keywords: uroflowmetry, cystoscopy, LUTS, BPH

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Authors: Rahy Farooq, Maria Ahmad Khan, Ayesha Isani Majeed

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Objective: The main aim of this research is to assess the knowledge, attitude and practices of female nursing staff and nursing students regarding breast cancer, to provide a baseline for monitoring trends of breast cancer awareness in them. Background: Healthcare professionals are a direct source of information for the patients and the general public as a whole. It is, therefore, essential that the information they convey be accurate and helps in building additional awareness. However, clinical experience does not influence the knowledge, attitude and practices regarding breast cancer. Nurses, being the prime part of the healthcare professionals, play a significant role and hence, their awareness regarding this pressing issue is pertinent. Lack of awareness regarding common presenting symptoms or breast cancer risk factors translates to poor breast cancer screening practices and late diagnosis. Methodology: A cross-sectional study of 280 female nurses was conducted at a tertiary care hospital in Islamabad, Pakistan. A pre-tested structured questionnaire with additional variables like cultural barriers to seeking medical help was used. The scores for outcome variables including knowledge, attitude and practices were pre-defined. Data was analyzed using SPSSv23. Results: Of the 280 participants with a mean age of 28.99±9.98 years, 142 (50.7%) were married, and 138 (49.3%) were unmarried. Mean scores were computed to be 6.14±2.93 (out of 12), 0.30±0.7 (out of 3) and 9.53±1.92 (out of 16) for knowledge, attitude and practice respectively. Using independent sample T-test, a statistically significant correlation was found when means for the score of Attitude was compared with age. With a p-value of 0.018, 117 nurses of age more than 30 years, faced more practical, financial, emotional and service barriers as compared to 163 women younger than 30 years of age. Knowledge of age-related lifetime risks was also significantly poor more in single women; with a p-value of 0.006 for identification of correct age as a risk factor and a p-value of 0.005 for correct identification of risk for development of breast cancer in the lifetime of women. By application of Chi-square test, there was a significant correlation between marital status and cultural barriers to seeking medical help, showing that single women (58.7%) shy away from talking about breast cancer considering it a taboo (p-value 0.028) whereas, more married nurses (59.2%) were apprehensive that they might be considered at fault by the society, as compared to 40.8% of single nurses. (p-value 0.038). Conclusion: Owing to the scarcity of awareness among nurses, this study recognizes the need for delivering effective information to the female nurses regarding breast cancer. Educating patients is likely to be effective if the female nurses play their part and have correct attitudes towards breast cancer practices. A better understanding of the knowledge and practices regarding breast cancer among the nursing population will enable high-risk patients to be recognized early. Therefore, we recommend arrangement of special courses and seminars for all healthcare professionals including the nursing staff.

Keywords: breast cancer, cultural barriers, kap, nurses

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