Search results for: philosophy of care

Authors: Omer Zvi Shaked, Amir Tirosh

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Type 1 Diabetes (T1DM) is an incurable chronic illness with no known preventive measures. Excess to insulin therapy can lead to hypoglycemia with neuro-glycogenic symptoms such as shakiness, nausea, sweating, irritability, fatigue, excessive thirst or hunger, weakness, seizure, and coma. Severe Hypoglycemia (SH) is also considered a most aversive event since it may put patients at risk for injury and death, which matches the criteria of a traumatic event. SH has a ranging prevalence of 20%, which makes it a primary medical Issue. One of the results of SH is an intense emotional fear reaction resembling the form of post-traumatic stress symptoms (PTS), causing many patients to avoid insulin therapy and social activities in order to avoid the possibility of hypoglycemia. As a result, they are at risk for irreversible health deterioration and medical complications. Fear of Hypoglycemia (FOH) is, therefore, a major disturbance for T1DM patients. FOH differs from prevalent post-traumatic stress reactions to other forms of traumatic events since the threat to life continuously exists in the patient's body. That is, it is highly probable that orthodox interventions may not be sufficient for helping patients after SH to regain healthy social function and proper medical treatment. Accordingly, the current presentation will demonstrate the results of a study conducted among T1DM patients after SH. The study was designed in two stages. First, a preliminary qualitative phenomenological study among ten patients after SH was conducted. Analysis revealed that after SH, patients confuse between stress symptoms and Hypoglycemia symptoms, divide life before and after the event, report a constant sense of fear, a loss of freedom, a significant decrease in social functioning, a catastrophic thinking pattern, a dichotomous split between the self and the body, and internalization of illness identity, a loss of internal locus of control, a damaged self-representation, and severe loneliness for never being understood by others. The second stage was a two steps study of intervention among five patients after SH. The first part of the intervention included three months of therapeutic 3rd wave CBT therapy. The contents of the therapeutic process were: acceptance of fear and tolerance to stress; cognitive de-fusion combined with emotional self-regulation; the adoption of an active position relying on personal values; and self-compassion. Then, the intervention included a one-week practical real-time 24/7 support by trained medical personnel, alongside a gradual exposure to increased insulin therapy in a protected environment. The results of the intervention are a decrease in stress symptoms, increased social functioning, increased well-being, and decreased avoidance of medical treatment. The presentation will discuss the unique emotional state of T1DM patients after SH. Then, the presentation will discuss the effectiveness of the intervention for patients with chronic conditions after a traumatic event. The presentation will make evident the unique situation of illness-related PTSD. The presentation will also demonstrate the requirement for multi-professional collaboration between social work and medical care for populations with chronic medical conditions. Limitations of the study and recommendations for further research will be discussed.

Keywords: type 1 diabetes, chronic illness, post-traumatic stress, illness-related PTSD

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Authors: Anzal Abbas Jaffari, Wajiha Javed, Naseem Salahuddin

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Rationale: Rabies, a vaccine preventable disease, continues to be a critical public health issue as it kills around 2000-5000 people annually in Pakistan. Along with the disease spread among animals, the dog population remains a victim of brutal culling practices by the local authorities, which adversely affects ecosystem (sinking of poison in the soil – affecting vegetation & contaminating water) and the disease spread. The dog population has been exponentially rising primarily because a lack of a consolidated nationwide Animal Birth Control program and awareness among the local communities in general and children in particular. This is reflected in Pakistan’s low SARE score - 1.5, which makes the country trails behind other developing countries like Bangladesh (2.5) and Philippines (3.5).According to an estimate, the province of Sindh alone is home to almost 2.5 million dogs. The clustering of dogs in Peri-Urban areas and inner cities localities leads to an increase of reported dog bite cases in these areas specifically. Objective: Rabies Free Pakistan (RFP), which is a joint venture of Getz Pharma Private Limited and Indus Hospital & Health Network (IHHN); it was established in 2018 to eliminate Rabies from Pakistan by 2030 using the One Health Approach. Methodology: The RFP team is actively working on advocacy and policy front with both the Federal & Provincial government to ensure that all stakeholders currently involved in dog culling in Pakistan have a paradigm shift towards humane methods of vaccination and ABC. Along with the federal government, RFP aims to declare Rabies as a notifiable disease. Whereas RFP closely works with the provincial government of Sindh to initiate a province wide Rabies Control Program.RFP program follows international standards and WHO approved protocols for this program in Pakistan.RFP team has achieved various milestones in the fight against Rabies after successfully scaling up project operations and has vaccinated more than 30,000 dogs and neutered around 7,000 dogs since 2018. Recommendations: Effective implementation of Rabies program (MDV and ABC) requires a concentrated effort to address a variety of structural and policy challenges. This essentially demands a massive shift in the attitude of individuals towards rabies. The two most significant challenges in implementing a standard policy at the structural level are lack of institutional capacity, shortage of vaccine, and absence of inter-departmental coordination among major stakeholders: federal government, provincial ministry of health, livestock, and local bodies (including local councils). The lack of capacity in health care workers to treat dog bite cases emerges as a critical challenge at the clinical level. Conclusion: Pakistan can learn from the successful international models of Sri Lanka and Mexico as they adopted the One Health Approach to eliminate rabies like RFP. The WHO advised One Health approach provides the policymakers with an interactive and cross-sectoral guide, which involves all the essential elements of the eco system (including animals, humans, and other components).

Keywords: animal birth control, dog population, mass dog vaccination, one health, rabies elimination

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Authors: Awatef Ahmed Ben Ramadan, Aqsa Arshad

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Background: There is a huge Muslim migration movement to North America and Europe for several reasons, primarily refuge from war areas and partly to search for better work and educational chances. There are always concerns regarding first-Generation Immigrant women's health and computer literacy, an adequate understanding of the health systems, and the use of the existing healthcare technology and services effectively and efficiently. Language proficiency level, preference for cultural and traditional remedies, socioeconomic factors, fear of stereotyping, limited accessibility to health services, and general unfamiliarity with the existing health services and resources are familiar variables among these women. Aims: The current study aims to assess the health and digital literacy of first-generation Muslim women in Atlanta city. Also, the study aims to examine how the COVID-19 pandemic has encouraged the use of health information technology and increased technology awareness among the targeted women. Methods: The study design is cross-sectional correlational research. The study will be conducted to produce preliminary results that the investigators want to have to supplement an NIH grant application about leveraging information technology to reduce the health inequalities amongst the first-generation immigrant Muslim women in Atlanta City. The investigators will collect the study data in two phases using different tools. Phase one was conducted in June 2022; the investigators used tools to measure health and digital literacy amongst 42 first-generation immigrant Muslim women. Phase two was conducted in November 2022; the investigators measured the Knowledge, Attitude, and Practice (KAP) of using health information technology such as telehealth from a sample of 45 first-generation Muslim immigrant women in Atlanta; in addition, the investigators measured how the current pandemic has affected their KAP to use telemedicine and telehealth services. Both phases' study participants were recruited using convenience sampling methodology. The investigators collected around 40 of 18 years old or older first-generation Muslim immigrant women for both study phases. The study excluded Immigrants who hold work visas and second-generation immigrants. Results: At the point of submitting this abstract, the investigators are still analyzing the study data to produce preliminary results to apply for an NIH grant entitled "Leveraging Health Information Technology (Health IT) to Address and Reduce Health Care Disparities (R01 Clinical Trial Optional)". This research will be the first step of a comprehensive research project to assess and measure health and digital literacy amongst a vulnerable community group. The targeted group might have different points of view from the U.S.-born inhabitants on how to: promote their health, gain healthy lifestyles and habits, screen for diseases, adhere to health treatment and follow-up plans, perceive the importance of using available and affordable technology to communicate with their providers and improve their health, and help in making serious decisions for their health. The investigators aim to develop an educational and instructional health mobile application considering the language and cultural factors that affect immigrants' ability to access different health and social support sources, know their health rights and obligations in their communities, and improve their health behavior and behavior lifestyles.

Keywords: first-generation immigrant Muslim women, telehealth, COVID-19 pandemic, health information technology, health and digital literacy

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Authors: Md. Nuru Miah, A. F. M. Akhter Uddin

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Medicinal plants are grown naturally in a tropical environment in Bangladesh and used as drug and therapeutic agents in the health care system. According to Bangladesh Agricultural Research Institute (BARI), there are 722 species of medicinal plants in the country. Of them, 255 plants are utilized by the manufacturers of Ayurvedic and Unani medicines. Medicinal plants like Aloevera, Ashwagonda, shotomul,Tulsi, Vuikumra, Misridana are extensively cultivated in some selected areas as well; where Aloevera scored the highest position in production. In the early 1980, Ayurvedic and Unani companies procured 80 percent of medicinal plants from natural forests, and the rest 20 percent was imported. Now the scenario has changed; 80 percent is imported, and the rest 20 percent is collected from local products(Source: Astudy on sectorbased need assessment of Business promotion council-Herbal products and medicinal plants, page-4). Uttara Development Program Society, a leading Non- Government development organization in Bangladesh, has been implementing a value chain development project under promoting Agricultural commercialization and Enterprises of Pally Karma Sahayak Foundation (PKSF) funded by the International Fund for Agricultural Development (IFAD) in Natore Sadar Upazila from April 2017 to sustainably develop the technological interventions for products and market development. The ultimate goal of the project is to increase income, generate employment and develop this sector as a sustainable business enterprise. Altogether 10,000 farmers (Nursery owners, growers, input supplier, processors, whole sellers, and retailers) are engaged in different activities of the project. The entrepreneurs engaged in medicinal plant cultivation did not know and follow environmental and good agricultural practices. They used to adopt traditional methodology in production and processing. Locally the farmers didn’t have any positive initiative to expand their business as well as developvalue added products. A lot of diversified products could be possible to develop and marketed with the introduction of post-harvest processing technology and market linkage with the local and global buyer. Training is imparted to the nursery owners and herbal growers on production technologies, sowing method, use of organic fertilizers/compost/pesticides, harvesting procedures, and storage facilities. Different types of herbal tea like Rosella, Moringa, Tulshi, and Basak are being produced and packed locally with a good scope of its marketing in different cities of the country. The project has been able to achieve a significant impact in the development of production technologies, but still, there is room for further improvement in processing, packaging, and marketing level. The core intervention of the current project to develop some entrepreneurs for branding, packaging, promotion, and marketing while considering environment friendly practices. The present strategies will strengthen the knowledge and skills of the entrepreneurs for the production and marketing of their products, maintaining worldwide accepted compliance system for easy access to the global market.

Keywords: aloe vera, herbs and shrubs, market, interventions

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Authors: Melanie Grier, Adam Murry

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Objective: Worldwide, Indigenous Peoples experience underemployment and poverty at disproportionately higher rates than non-Indigenous people, despite similar rates of employment seeking. Euro-colonial conquest and genocidal assimilation policies are implicated as perpetuating poverty, which research consistently links to health and wellbeing disparities. Many of the contributors to poverty, such as inadequate income and lack of access to medical care, can be directly or indirectly linked to underemployment. Calls have been made to prioritize Indigenous perspectives in Industrial-Organizational (I/O) psychology research, yet the literature on Indigenous employment remains scarce. What does exist is disciplinarily diverse, topically scattered, and lacking evidence of community-based participatory research (CBPR) practices, a research project approach which prioritizes community leadership, partnership, and betterment and reduces the potential for harm. Due to the harmful colonial legacy of extractive scientific inquiry "on" rather than "with" Indigenous groups, Indigenous leaders and research funding agencies advocate for academic researchers to adopt reparative research methodologies such as CBPR to be used when studying issues pertaining to Indigenous Peoples or individuals. However, the frequency and consistency of CBPR implementation within scholarly discourse are unknown. Therefore, this project’s goal is two-fold: (1) to understand what comprises CBPR in Indigenous research and (2) to determine if CBPR has been historically used in Indigenous employment research. Method: Using a systematic literature review process, sixteen articles about CBPR use with Indigenous groups were selected, and content was analyzed to identify key components comprising CBPR usage. An Indigenous CBPR components framework was constructed and subsequently utilized to analyze the Indigenous employment empirical literature. A similar systematic literature review process was followed to search for relevant empirical articles on Indigenous employment. A total of 120 articles were identified in six global regions: Australia, New Zealand, Canada, America, the Pacific Islands, and Greenland/Norway. Each empirical study was procedurally examined and coded for criteria inclusion using content analysis directives. Results: Analysis revealed that, in total, CBPR elements were used 14% of the time in Indigenous employment research. Most studies (n=69; 58%) neglected to mention using any CBPR components, while just two studies discussed implementing all sixteen (2%). The most significant determinant of overall CBPR use was community member partnership (CP) in the research process. Studies from New Zealand were most likely to use CBPR components, followed by Canada, Australia, and America. While CBPR use did increase slowly over time, meaningful temporal trends were not found. Further, CBPR use did not directly correspond with the total number of topical articles published that year. Conclusions: Community-initiated and engaged research approaches must be better utilized in employment studies involving Indigenous Peoples. Future research efforts must be particularly attentive to community-driven objectives and research protocols, emphasizing specific areas of concern relevant to the field of I/O psychology, such as organizational support, recruitment, and selection.

Keywords: community-based participatory research, content analysis, employment, indigenous research, international, reconciliation, recruitment, reparative research, selection, systematic literature review

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Authors: Xu Qian

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This abstract explores the importance of building resilience within families and offers evidence-based strategies for promoting positive parenting and enhancing emotional well-being. It emphasizes the role of effective communication, conflict resolution, and fostering a supportive environment to strengthen family bonds and promote healthy child development. Introduction: The well-being and resilience of families play a crucial role in fostering healthy child development and promoting overall emotional well-being. This abstract highlights the significance of nurturing resilient families and provides evidence-based strategies for positive parenting. By focusing on effective communication, conflict resolution, and creating a supportive environment, families can strengthen their bonds and enhance emotional well-being for both parents and children. Methods: This abstract draws upon a comprehensive review of existing research and literature on resilient families, positive parenting, and emotional well-being. The selected studies employ various methodologies, including surveys, interviews, and longitudinal observations, to investigate the factors contributing to family resilience and the strategies that promote positive parenting practices. The findings from these studies serve as the foundation for the strategies discussed in this abstract. Results: The results of the reviewed studies demonstrate that effective communication within families is a key factor in building resilience and promoting emotional well-being. Open and honest communication allows family members to express their thoughts, feelings, and concerns, fostering trust and understanding. Conflict resolution skills, such as active listening, compromise, and problem-solving, are vital in managing conflicts constructively and preventing negative consequences on family dynamics and children's well-being. Creating a supportive environment that nurtures emotional well-being is another critical aspect of promoting resilient families. This includes providing emotional support, setting clear boundaries, and promoting positive discipline strategies. Research indicates that consistent and responsive parenting approaches contribute to improved self-regulation skills, emotional intelligence, and overall mental health in children. Discussion: The discussion centers on the implications of these findings for promoting positive parenting and emotional well-being. It emphasizes the need for parents to prioritize self-care and seek support when facing challenges. Parental well-being directly influences the quality of parenting and the overall family environment. By attending to their own emotional needs, parents can better meet the needs of their children and create a nurturing atmosphere. Furthermore, the importance of fostering resilience in children is highlighted. Resilient children are better equipped to cope with adversity, adapt to change, and thrive in challenging circumstances. By cultivating resilience through supportive relationships, encouragement of independence, and providing opportunities for growth, parents can foster their children's ability to bounce back from setbacks and develop essential life skills. Conclusion: In conclusion, nurturing resilient families is crucial for positive parenting and enhancing emotional well-being. This abstract presents evidence-based strategies that emphasize effective communication, conflict resolution, and creating a supportive environment. By implementing these strategies, parents can strengthen family bonds, promote healthy child development, and enhance overall family resilience. Investing in resilient families not only benefits individual family members but also contributes to the well-being of the broader community.

Keywords: childrearing families, family education, children's mental health, positive parenting, emotional health

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Authors: Evgenia Iakovleva, Juha Koivisto, Pasi Karppinen, J. Inkinen, Mikko Alava

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Preventing the spread of infectious diseases throughout the worldwide is one of the most important tasks of modern health care. Infectious diseases not only account for one fifth of the deaths in the world, but also cause many pathological complications for the human health. Touch surfaces pose an important vector for the spread of infections by varying microorganisms, including antimicrobial resistant organisms. Further, antimicrobial resistance is reply of bacteria to the overused or inappropriate used of antibiotics everywhere. The biggest challenges in bacterial detection by existing methods are non-direct determination, long time of analysis, the sample preparation, use of chemicals and expensive equipment, and availability of qualified specialists. Therefore, a high-performance, rapid, real-time detection is demanded in rapid practical bacterial detection and to control the epidemiological hazard. Among the known methods for determining bacteria on the surfaces, Hyperspectral methods can be used as direct and rapid methods for microorganism detection on different kind of surfaces based on fluorescence without sampling, sample preparation and chemicals. The aim of this study was to assess the relevance of such systems to remote sensing of surfaces for microorganisms detection to prevent a global spread of infectious diseases. Bacillus subtilis and Escherichia coli with different concentrations (from 0 to 10x8 cell/100µL) were detected with hyperspectral camera using different filters as visible visualization of bacteria and background spots on the steel plate. A method of internal standards was applied for monitoring the correctness of the analysis results. Distances from sample to hyperspectral camera and light source are 25 cm and 40 cm, respectively. Each sample is optically imaged from the surface by hyperspectral imaging system, utilizing a JAI CM-140GE-UV camera. Light source is BeamZ FLATPAR DMX Tri-light, 3W tri-colour LEDs (red, blue and green). Light colors are changed through DMX USB Pro interface. The developed system was calibrated following a standard procedure of setting exposure and focused for light with λ=525 nm. The filter is ThorLabs KuriousTM hyperspectral filter controller with wavelengths from 420 to 720 nm. All data collection, pro-processing and multivariate analysis was performed using LabVIEW and Python software. The studied human eye visible and invisible bacterial stains clustered apart from a reference steel material by clustering analysis using different light sources and filter wavelengths. The calculation of random and systematic errors of the analysis results proved the applicability of the method in real conditions. Validation experiments have been carried out with photometry and ATP swab-test. The lower detection limit of developed method is several orders of magnitude lower than for both validation methods. All parameters of the experiments were the same, except for the light. Hyperspectral imaging method allows to separate not only bacteria and surfaces, but also different types of bacteria, such as Gram-negative Escherichia coli and Gram-positive Bacillus subtilis. Developed method allows skipping the sample preparation and the use of chemicals, unlike all other microbiological methods. The time of analysis with novel hyperspectral system is a few seconds, which is innovative in the field of microbiological tests.

Keywords: Escherichia coli, Bacillus subtilis, hyperspectral imaging, microorganisms detection

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Authors: Jawaad Saleem, Hannah Wright, Peter Sommerville, Adrian Hopper

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Introduction: Inpatient falls are the most commonly reported patient safety incidents, and carry a significant burden on resources, morbidity, and mortality. Ensuring adequate post falls management of patients by staff is therefore paramount to maintaining patient safety especially in out of hours and resource stretched settings. Aims: This quality improvement project aims to improve the current practice of falls management at Guys St Thomas Hospital, London as compared to our 2016 Quality Improvement Project findings. Furthermore, it looks to increase current junior doctors confidence in managing falls and their use of new guidance protocols. Methods: Multifaceted Interventions implemented included: the development of new trust wide guidelines detailing management pathways for patients post falls, available for intranet access. Furthermore, the production of 2000 lanyard cards distributed amongst junior doctors and staff which summarised these guidelines. Additionally, a ‘safety signal’ email was sent from the Trust chief medical officer to all staff raising awareness of falls and the guidelines. Formal falls teaching was also implemented for new doctors at induction. Using an established incident database, 189 consecutive falls in 2017were retrospectively analysed electronically to assess and compared to the variables measured in 2016 post interventions. A separate serious incident database was used to analyse 50 falls from May 2015 to March 2018 to ascertain the statistical significance of the impact of our interventions on serious incidents. A similar questionnaire for the 2017 cohort of foundation year one (FY1) doctors was performed and compared to 2016 results. Results: Questionnaire data demonstrated improved awareness and utility of guidelines and increased confidence as well as an increase in training. 97% of FY1 trainees felt that the interventions had increased their awareness of the impact of falls on patients in the trust. Data from the incident database demonstrated the time to review patients post fall had decreased from an average of 130 to 86 minutes. Improvement was also demonstrated in the reduced time to order and schedule X-ray and CT imaging, 3 and 5 hours respectively. Data from the serious incident database show that ‘the time from fall until harm was detected’ was statistically significantly lower (P = 0.044) post intervention. We also showed the incidence of significant delays in detecting harm ( > 10 hours) reduced post intervention. Conclusions: Our interventions have helped to significantly reduce the average time to assess, order and schedule appropriate imaging post falls. Delays of over ten hours to detect serious injuries after falls were commonplace; since the intervention, their frequency has markedly reduced. We suggest this will lead to identifying patient harm sooner, reduced clinical incidents relating to falls and thus improve overall patient safety. Our interventions have also helped increase clinical staff confidence, management, and awareness of falls in the trust. Next steps include expanding teaching sessions, improving multidisciplinary team involvement to aid this improvement.

Keywords: patient safety, quality improvement, serious incidents, falls, clinical care

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Authors: Özge Çeliker Tosun, Melda Başer Secer, İsmail Düşmez, Sedat Çapar, İlkay Kozak, Melahat Aktaş, Furkan Can Şimşek, Gökhan Tosun

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Purpose: Portable innovative balance room system with digital game program; It was created to be able to be divided into small areas, such as inside the house, garden, balcony, to enable the person to enter and perform both evaluation and exercise safely, and to ensure that these results can be stored and sent to the therapist live or later when desired. The aim is to compare the effectiveness of the exercise program applied by the elderly within this system and the exercise program implemented under the supervision of a physiotherapist on balance and urinary incontinence symptoms. Materials and Methods: The study was conducted in a randomized controlled manner on 63 people with urinary incontinence (mean age: 75.5 years) at Narlıdere Nursing Home Elderly Care and Rehabilitation Center. Elderly people participating in the study were divided into 3 groups: 1. Group, an exercise program consisting of pelvic floor muscle training and OTOGA exercises, 2. Group, only pelvic floor muscle training, and 3. Group, pelvic floor muscle training and Otoga exercises in the form of a digital game program in a portable balance room system. (self-administered) for 12 weeks. Pelvic floor distress inventory (PTDE-20) and bladder diary were used to evaluate the incontinance symptoms of the cases. Pelvic floor muscle function was evaluated with superficial EMG. Berg, Fall Effectiveness Scale (FES) and Functional Status Evaluations (Chair Stand Test, Eight (8) Food Up and Go Test, Chair Sit and Reach Test, Two Minutes Step Test) were used to evaluate balance. The existence of differences between groups was analyzed using Krusskal Wallis analysis of variance, and the difference between before and after exercise was analyzed with Wilcoxon tests. Results: After treatment, PTDE-20, daily urinary incontinence and toilet visits values decreased significantly in all three groups (p < 0.001). While there was a statistically significant increase in pelvic floor muscle EMG values in the 2nd and third groups after treatment, there was no change in the other group (2nd Group PFM average EMG before-after: 5.5 (4.15-10.95) - 10.95 (8.68-13.68), P=0.05, 3 Group PFM average EMG before-after: 6.5 (4.28-11.55) - 11.75 (8.67-14.26), p=0.04). While BERG score, Chair Stand Test, Eight (8) Food Up and Go Test, and Two Minutes Step Test values increased in all groups (p<0.05), Fall Effectiveness Scale (FES) values did not change after treatment. Conclusion: Although pelvic floor muscle training combined with balance exercises reduces symptoms, it may not lead to a positive improvement in the functions of the pelvic floor muscles. For this reason, recovery lasts for a short time, and then symptoms may reoccur in the future. However, thanks to the new system, when balance exercises are combined with a game program for the pelvic floor muscles, a double effect can be achieved with a single application and both incontinence and balance problems can be treated in a safe environment where the person can do it himself. But more work needs to be done on this subject. However, thanks to the new system, a double effect can be achieved with a single application, and both incontinence and balance problems can be treated in a safe environment where the person can do it himself. But more work needs to be done on new system

Keywords: fall, urinary incontinance, balance, elderly

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Authors: Terryann Clark, Kabir Dasgupta, Sonia Lewycka, Gail Pacheco, Alexander Plum

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This paper focused on two main research aims using data from the Growing Up in New Zealand (GUINZ) birth cohort: 1. To examine ethnic differences in life-course trajectories in the use and experience of healthcare services in early childhood years (namely immunisation, dental checks and use of General Practitioners (GPs)) 2. To quantify the contribution of relevant explanatory factors to ethnic differences. Current policy in New Zealand indicates there should be, in terms of associated direct costs, equitable access by ethnicity for healthcare services. However, empirical evidence points to persistent ethnic gaps in several domains. For example, the data highlighted that Māori have the lowest immunisation rates, across a number of time points in early childhood – despite having a higher antenatal intention to immunise relative to NZ European. Further to that, NZ European are much more likely to have their first-choice lead maternity caregiver (LMC) and use child dental services compared to all ethnicities. Method: This research explored the underlying mechanisms behind ethnic differences in the use and experience of child healthcare services. First, a multivariate regression analysis was used to adjust raw ethnic gaps in child health care utilisation by relevant covariates. This included a range of factors, encompassing mobility, socio-economic status, mother and child characteristics, household characteristics and other social aspects. Second, a decomposition analysis was used to assess the proportion of each ethnic gap that can be explained, as well as the main drivers behind the explained component. The analysis for both econometric approaches was repeated for each data time point available, which included antenatal, 9 months, 2 years and 4 years post-birth. Results: The following findings emerged: There is consistent evidence that Asian and Pacific peoples have a higher likelihood of child immunisation relative to NZ Europeans and Māori. This was evident at all time points except one. Pacific peoples had a lower rate relative to NZ European for receiving all first-year immunisations on time. For a number of potential individual and household predictors of healthcare service utilisation, the association is time-variant across early childhood. For example, socio-economic status appears highly relevant for timely immunisations in a child’s first year, but is then insignificant for the 15 month immunisations and those at age 4. Social factors play a key role. This included discouragement or encouragement regarding child immunisation. When broken down by source, discouragement by family has the largest marginal effect, followed by health professionals; whereas for encouragement, medical professionals have the largest positive influence. Perceived ethnically motivated discrimination by a health professional was significant with respect to both reducing the likelihood of achieving first choice LMC, and also satisfaction levels with child’s GP. Some ethnic gaps were largely unexplained, despite the wealth of factors employed as independent variables in our analysis. This included understanding why Pacific mothers are much less likely to achieve their first choice LMC compared to NZ Europeans; and also the ethnic gaps for both Māori and Pacific peoples relative to NZ Europeans concerning dental service use.

Keywords: child health, cohort analysis, ethnic disparities, primary healthcare

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Authors: Nervana Elbakary, Sami Ouanes, Sadaf Riaz, Oraib Abdallah, Islam Mahran, Noriya Al-Khuzaei, Yassin Eltorki

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Major Depressive Disorder (MDD) requires therapeutic interventions during the initial month after being diagnosed for better disease outcomes. International guidelines recommend a duration of 4–12 weeks for an initial antidepressant (IAD) trial at an optimized dose to get a response. If depressive symptoms persist after this duration, guidelines recommend switching, augmenting, or combining strategies as the next step. Most patients with MDD in the mental health setting have been labeled incorrectly as treatment-resistant where in fact they have not been subjected to an adequate trial of guideline-recommended therapy. Premature discontinuation of IAD due to ineffectiveness can cause unfavorable consequences. Avoiding irrational practices such as subtherapeutic doses of IAD, premature switching between the ADs, and refraining from unjustified polypharmacy can help the disease to go into a remission phase We aimed to determine the prevalence and the patterns of strategies applied after an IAD was changed because of a suboptimal response as a primary outcome. Secondary outcomes included the median survival time on IAD before any change; and the predictors that were associated with IAD change. This was a retrospective cross- sectional study conducted in Mental Health Services in Qatar. A dataset between January 1, 2018, and December 31, 2019, was extracted from the electronic health records. Inclusion and exclusion criteria were defined and applied. The sample size was calculated to be at least 379 patients. Descriptive statistics were reported as frequencies and percentages, in addition, to mean and standard deviation. The median time of IAD to any change strategy was calculated using survival analysis. Associated predictors were examined using two unadjusted and adjusted cox regression models. A total of 487 patients met the inclusion criteria of the study. The average age for participants was 39.1 ± 12.3 years. Patients with first experience MDD episode 255 (52%) constituted a major part of our sample comparing to the relapse group 206(42%). About 431 (88%) of the patients had an occurrence of IAD change to any strategy before end of the study. Almost half of the sample (212 (49%); 95% CI [44–53%]) had their IAD changed less than or equal to 30 days. Switching was consistently more common than combination or augmentation at any timepoint. The median time to IAD change was 43 days with 95% CI [33.2–52.7]. Five independent variables (age, bothersome side effects, un-optimization of the dose before any change, comorbid anxiety, first onset episode) were significantly associated with the likelihood of IAD change in the unadjusted analysis. The factors statistically associated with higher hazard of IAD change in the adjusted analysis were: younger age, un-optimization of the IAD dose before any change, and comorbid anxiety. Because almost half of the patients in this study changed their IAD as early as within the first month, efforts to avoid treatment failure are needed to ensure patient-treatment targets are met. The findings of this study can have direct clinical guidance for health care professionals since an optimized, evidence-based use of AD medication can improve the clinical outcomes of patients with MDD; and also, to identify high-risk factors that could worsen the survival time on IAD such as young age and comorbid anxiety

Keywords: initial antidepressant, dose optimization, major depressive disorder, comorbid anxiety, combination, augmentation, switching, premature discontinuation

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Authors: Kiran Datta, Daniella Holland-Hart, Anthony Byrne

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Introduction: Oesophago-gastric (OG) cancers are the fifth commonest in the UK, accounting for over 12,000 deaths each year. Most patients will present at later stages of the disease, with only 21% of patients with stage 4 disease surviving longer than a year. As a result, many patients are unsuitable for curative surgery and instead receive palliative treatment to improve prognosis and symptom burden. However, palliative chemotherapy can result in significant toxicity: almost half of the patients are unable to complete their chemotherapy regimen, with this proportion rising significantly in older and frailer patients. In addition, clinical trials often exclude older and frailer patients due to strict inclusion criteria, meaning there is limited evidence to guide which patients are most likely to benefit from palliative chemotherapy. Inappropriate chemotherapy administration is at odds with the goals of palliative treatment and care, which are to improve quality of life, and this also represents a significant resource expenditure. This literature review aimed to examine and appraise evidence regarding treatment resilience in order to guide clinicians in identifying the most suitable candidates for palliative chemotherapy. Factors influencing treatment resilience were assessed, as measured by completion rates, dose reductions, and toxicities. Methods: This literature review was conducted using rapid review methodology, utilising modified systematic methods. A literature search was performed across the MEDLINE, EMBASE, and Cochrane Library databases, with results limited to papers within the last 15 years and available in English. Key inclusion criteria included: 1) participants with either oesophageal, gastro-oesophageal junction, or gastric cancers; 2) patients treated with palliative chemotherapy; 3) available data evaluating the association between baseline participant characteristics and treatment resilience. Results: Of the 2326 papers returned, 11 reports of 10 studies were included in this review after excluding duplicates and irrelevant papers. Treatment resilience factors that were assessed included: age, performance status, frailty, inflammatory markers, and sarcopenia. Age was generally a poor predictor for how well patients would tolerate chemotherapy, while poor performance status was a better indicator of the need for dose reduction and treatment non-completion. Frailty was assessed across one cohort using multiple screening tools and was an effective marker of the risk of toxicity and the requirement for dose reduction. Inflammatory markers included lymphopenia and the Glasgow Prognostic Score, which assessed inflammation and hypoalbuminaemia. Although quick to obtain and interpret, these findings appeared less reliable due to the inclusion of patients treated with palliative radiotherapy. Sarcopenia and body composition were often associated with chemotherapy toxicity but not the rate of regimen completion. Conclusion: This review demonstrates that there are numerous measures that can estimate the ability of patients with oesophago-gastric cancer to tolerate palliative chemotherapy, and these should be incorporated into clinical assessments to promote personalised decision-making around treatment. Age should not be a barrier to receiving chemotherapy and older and frailer patients should be included in future clinical trials to better represent typical patients with oesophago-gastric cancers. Decisions regarding palliative treatment should be guided by these factors identified as well as patient preference.

Keywords: frailty, oesophago-gastric cancer, palliative chemotherapy, treatment resilience

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Authors: Lizinis Cassendra Frederick Dony, Jirom Jeremy Frederick Dony, Andrew Nicholas, Dewi Binti Tajuddin

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Starting and surviving a business is influenced by various entrepreneurship socio-economics activities. The study revealed that some of the entrepreneurs are not registered under SME but running own business as an intermediary with the private organization entrusted as “Self-Employed.” SME is known as “Small Medium Enterprise” contributes growth in Malaysia. Therefore, the entrepreneurialism business interest and entrepreneurial intention enhancing new spurring production, expanding employment opportunities, increasing productivity, promoting exports, stimulating innovation and providing new avenue in the business market place. This study has identified the unique contribution to the full understanding of complex mechanisms through entrepreneurship obstacles and education impacts on happiness and well-being to society. Moreover, “Ethnic” term has defined as a curious meaning refers to a classification of a large group of people customs implies to ancestral, racial, national, tribal, religious, linguistic and cultural origins. It is a social phenomenon.1 According to Sabah data population is amounting to 2,389,494 showed the predominant ethnic group being the Kadazan Dusun (18.4%) followed by Bajau (17.3%) and Malays (15.3%). For the year 2010, data statistic immigrants population report showed the amount to 239,765 people which cover 4% of the Sabahan’s population.2 Sabah has numerous group of talented entrepreneurs. The business environment among the minority ethnics are influenced with the business sentiment competition. The literature on ethnic entrepreneurship recognizes two main type entrepreneurships: the middleman and enclave entrepreneurs. According to Adam Smith,3 there are evidently some principles disposition to admire and maintain the distinction business rank status and cause most universal business sentiments. Due to credit barriers competition, the minority ethnics are losing the business market and since 2014, many illegal immigrants have been found to be using permits of the locals to operate businesses in Malaysia.4 The development of small business entrepreneurship among the minority ethnics in Sabah evidenced based variety of complex perception and differences concepts. The studies also confirmed the effects of heterogeneity on group decision and thinking caused partly by excessive pre-occupation with maintaining cohesiveness and the presence of cultural diversity in groups should reduce its probability.5 The researchers proposed that there are seven success determinants particularly to determine the involvement of minority ethnics comparing to the involvement of the immigrants in Sabah. Although, (SMEs) have always been considered the backbone of the economy development, the minority ethnics are often categorized it as the “second-choice.’ The study showed that illegal immigrants entrepreneur imposed a burden on Sabahan social programs as well as the prison, court and health care systems. The tension between the need for cheap labor and the impulse to protect Malaysian in Sabah workers, entrepreneurs and taxpayers, among the subjects discussed in this study. This is clearly can be advantages and disadvantages to the Sabah economic development.

Keywords: entrepreneurial firms, self-employed, immigrants, minority ethnic, economic impacts

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Authors: Maria Karnachoriti, Ellas Spyratou, Dimitrios Lykidis, Maria Lambropoulou, Yiannis S. Raptis, Ioannis Seimenis, Efstathios P. Efstathopoulos, Athanassios G. Kontos

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Colorectal cancer is the third most common cancer diagnosed in Europe, according to the latest incidence data provided by the World Health Organization (WHO), and early diagnosis has proved to be the key in reducing cancer-related mortality. In cases where surgical interventions are required for cancer treatment, the accurate discrimination between healthy and cancerous tissues is critical for the postoperative care of the patient. The current study focuses on the ex vivo handling of surgically excised colorectal specimens and the acquisition of their spectral fingerprints using Raman spectroscopy. Acquired data were analyzed in an effort to discriminate, in microscopic scale, between healthy and malignant margins. Raman spectroscopy is a spectroscopic technique with high detection sensitivity and spatial resolution of few micrometers. The spectral fingerprint which is produced during laser-tissue interaction is unique and characterizes the biostructure and its inflammatory or cancer state. Numerous published studies have demonstrated the potential of the technique as a tool for the discrimination between healthy and malignant tissues/cells either ex vivo or in vivo. However, the handling of the excised human specimens and the Raman measurement conditions remain challenging, unavoidably affecting measurement reliability and repeatability, as well as the technique’s overall accuracy and sensitivity. Therefore, tissue handling has to be optimized and standardized to ensure preservation of cell integrity and hydration level. Various strategies have been implemented in the past, including the use of balanced salt solutions, small humidifiers or pump-reservoir-pipette systems. In the current study, human colorectal specimens of 10X5 mm were collected from 5 patients up to now who underwent open surgery for colorectal cancer. A novel, non-toxic zinc-based fixative (Z7) was used for tissue preservation. Z7 demonstrates excellent protein preservation and protection against tissue autolysis. Micro-Raman spectra were recorded with a Renishaw Invia spectrometer from successive random 2 micrometers spots upon excitation at 785 nm to decrease fluorescent background and secure avoidance of tissue photodegradation. A temperature-controlled approach was adopted to stabilize the tissue at 2 °C, thus minimizing dehydration effects and consequent focus drift during measurement. A broad spectral range, 500-3200 cm-1,was covered with five consecutive full scans that lasted for 20 minutes in total. The average spectra were used for least square fitting analysis of the Raman modes.Subtle Raman differences were observed between normal and cancerous colorectal tissues mainly in the intensities of the 1556 cm-1 and 1628 cm-1 Raman modes which correspond to v(C=C) vibrations in porphyrins, as well as in the range of 2800-3000 cm-1 due to CH2 stretching of lipids and CH3 stretching of proteins. Raman spectra evaluation was supported by histological findings from twin specimens. This study demonstrates that Raman spectroscopy may constitute a promising tool for real-time verification of clear margins in colorectal cancer open surgery.

Keywords: colorectal cancer, Raman spectroscopy, malignant margins, spectral fingerprints

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Authors: Rubaiat S. Ahmed, Jemer Garrido, Sergey M. Motov

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Clinical informatics (CI) enables the transformation of data into a systematic organization that improves the quality of care and the generation of positive health outcomes.Innovative technology through informatics that compiles accurate data on analgesic utilization in the emergency department can enhance pain management in this important clinical setting. We aim to establish a simplified reporting system through CI to examine and assess the analgesic prescribing practices in the EDthrough executing a U.S. federal grant project on opioid reduction initiatives. Queried data points of interest from a level-one trauma ED’s electronic medical records were used to create data sets and develop informational/visual reporting dashboards (on Microsoft Excel and Google Sheets) concerning analgesic usage across several pre-defined parameters and performance metrics using CI. The data was then qualitatively analyzed to evaluate ED analgesic prescribing trends by departmental clinicians and leadership. During a 12-month reporting period (Dec. 1, 2020 – Nov. 30, 2021) for the ongoing project, about 41% of all ED patient visits (N = 91,747) were for pain conditions, of which 81.6% received analgesics in the ED and at discharge (D/C). Of those treated with analgesics, 24.3% received opioids compared to 75.7% receiving opioid alternatives in the ED and at D/C, including non-pharmacological modalities. Demographics showed among patients receiving analgesics, 56.7% were aged between 18-64, 51.8% were male, 51.7% were white, and 66.2% had government funded health insurance. Ninety-one percent of all opioids prescribed were in the ED, with intravenous (IV) morphine, IV fentanyl, and morphine sulfate immediate release (MSIR) tablets accounting for 88.0% of ED dispensed opioids. With 9.3% of all opioids prescribed at D/C, MSIR was dispensed 72.1% of the time. Hydrocodone, oxycodone, and tramadol usage to only 10-15% of the time, and hydromorphone at 0%. Of opioid alternatives, non-steroidal anti-inflammatory drugs were utilized 60.3% of the time, 23.5% with local anesthetics and ultrasound-guided nerve blocks, and 7.9% with acetaminophen as the primary non-opioid drug categories prescribed by ED providers. Non-pharmacological analgesia included virtual reality and other modalities. An average of 18.5 ED opioid orders and 1.9 opioid D/C prescriptions per 102.4 daily ED patient visits was observed for the period. Compared to other specialties within our institution, 2.0% of opioid D/C prescriptions are given by ED providers, compared to the national average of 4.8%. Opioid alternatives accounted for 69.7% and 30.3% usage, versus 90.7% and 9.3% for opioids in the ED and D/C, respectively.There is a pressing need for concise, relevant, and reliable clinical data on analgesic utilization for ED providers and leadership to evaluate prescribing practices and make data-driven decisions. Basic computer software can be used to create effective visual reporting dashboards with indicators that convey relevant and timely information in an easy-to-digest manner. We accurately examined our ED's analgesic prescribing practices using CI through dashboard reporting. Such reporting tools can quickly identify key performance indicators and prioritize data to enhance pain management and promote safe prescribing practices in the emergency setting.

Keywords: clinical informatics, dashboards, emergency department, health informatics, healthcare informatics, medical informatics, opioids, pain management, technology

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Authors: Andrew Read, Alice Parry, Kate Woods

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Since the advent of the SARS-CoV-2 pandemic, the search for medications that can reduce mortality and morbidity has been a global research priority. Several multi-center trials have recently demonstrated improved mortality associated with the use of Tocilizumab, an interleukin-6 receptor antagonist, in patients with severe SARS-CoV-2 pneumonia. Initial data supported the administration in patients requiring respiratory support (non-invasive or invasive ventilation), but more recent data has shown benefit in all hypoxic patients. At the height of the second wave of COVID-19 infections in London, our hospital introduced the use of Tocilizumab for patients with severe COVID-19. Tocilizumab is licensed for use in chronic inflammatory conditions and has been associated with an increased risk of severe bacterial and fungal infections, as well as reactivation of chronic viral infections (e.g., hepatitis B). It is a specialist drug that suppresses the formation of C-reactive protein (CRP) for 6 – 12 weeks. It is not widely used by the general medical community. We aimed to assess Tocilizumab use in our hospital and to implement changes to the protocol as required to ensure administration was safe and appropriate. A retrospective study design was used to assess prescriptions over an initial 3-week period in both intensive care and on the medical wards. This amounted to a total of 13 patients. The initial data collection identified four key areas of concern: adherence to national and local inclusion & exclusion criteria; a collection of appropriate screening blood prior to administration; documentation of informed consent or best interest decision and documentation of Tocilizumab administration on patient discharge information, to alert future healthcare providers that typical measures of inflammation and infection, such as CRP, are unreliable for up to 3-months. Data were collected from electronic notes, blood results and observation charts, and cross referenced with pharmacy data. Initial results showed that all four key areas were completed in approximately 50% of cases. Of particular concern was adherence to exclusion criteria, such as current evidence of bacterial infection, and ensuring the correct screening blood was sent to exclude infections such as hepatitis. To remedy this and improve patient safety, the initial data was presented to relevant healthcare professionals. Subsequently, three interventions were introduced and education on each provided to hospital staff. An electronic ‘order set’ collating the appropriate screening blood was created simplifying the screening process. Pre-formed electronic documentation which can be inserted into the notes was created to provide a framework for consent discussions and reduce the time needed for junior doctors to complete this task. Additionally, a ‘Tocilizumab’ administration card was created and administered via pharmacy. This was distributed to each patient on discharge to ensure future healthcare professionals were aware of the potential effects of Tocilizumab administration, including suppression of CRP. Following these changes, repeat data collection over two months illustrated that each of the 4 safety aspects was met with a 100% success rate in every patient. Although this demonstrates good progress and effective interventions the challenge will be to maintain this progress. The audit data collection is ongoing

Keywords: education, patient safety , SARS-CoV-2, Tocilizumab

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Authors: Rocio Murad, Marcela Sanchez, Mariana Calderon Jaramillo, Danny Rivera, Angela Cifuentes, Daniela Roldán, Juan Carlos Rivillas

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Women and girls have specific health needs, but during health pandemics such as COVID19 they are less likely to have access to quality essential health information, commodities and services, or insurance coverage for routine and catastrophic health expenses, especially in rural and marginalized communities. This is compounded by multiple or intersecting inequalities, such as ethnicity, socioeconomic status, disability, age, geographic location, and sexual orientation, among others. Despite concerted collective action, there is a lack of information on the situation of women, adolescents and youth, including gender inequalities exacerbated by the pandemic. Much more needs to be done to amplify the lived realities of women and adolescents in global and national advocacy and policy responses. The COVID 19 pandemic reflects the need for systematic advocacy policies based on the lived experiences of women and adolescents, underpinned by human rights. This research is part of the initiative of Profamilia Association (Solidarity Study), and its objective is twofold: i) to analyze the behavioral changes and immediate expectations of Colombians during the stage of relaxation of the confinement measures decreed by the national government; and ii) to identify the needs, experiences and resilient practices of adolescents and young women during the COVID-19 crisis in Colombia. Descriptive analysis of data collected by Profamilia through the Solidaridad study, an exploratory cross-sectional descriptive study that used subnational level data from a nonprobabilistic sample survey conducted to 1735 adults, between September 01 and 11, 2020. Interviews were conducted with key stakeholders about their experiences during COVID19, under three key axes: i) main challenges for adolescents and young women; ii) examples of what has worked well in responding to the challenge; and iii) how/what services are/should be provided during COVID-19 (and beyond) to address the challenge. Interviewees were selected based on prior mapping of social groups of interest. In total, 23 adolescents and young women participated in the interviews. The results show that people adopted behavioral changes such as wearing masks, avoiding people with symptoms, and reducing mobility, but there was also a doubling of concerns for many reasons, from effects on mental health, sexual health, and unattended reproductive health to the burden of care and working at home. The favorable perception that people had at the beginning of the quarantine about the response and actions of the national and local government to control Covid-19 decreased over the course of the quarantine. The challenges and needs of adolescents and young women were highlighted during the most restrictive measures to contain the COVID-19 pandemic, which resulted in disruptions to daily activities, education and work, as well as restrictions to mobility and social interaction. Concerns raised by participants included: impact on mental health and wellbeing due to disruption of daily life; limitations in access to formal and informal education; food insecurity; migration; loss of livelihoods; lack of access to health information and services; limitations to sexual and reproductive health and rights; insecurity problems; and problems in communication and treatment among household members.

Keywords: COVID-19, changes in behavior, adolescents, women

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Authors: Abdulaziz Alakeel, Abdulrahman Alomair, Mohammed Fouda

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Introduction: Methotrexate (MTX) is an antimetabolite used to treat multiple conditions, including neoplastic diseases, severe psoriasis, and rheumatoid arthritis. Skin cancer is the out-of-control growth of abnormal cells in the epidermis, the outermost skin layer, caused by unrepaired DNA damage that triggers mutations. These mutations lead the skin cells to multiply rapidly and form malignant tumors. The aim of this review is to evaluate the risk of skin cancer associated with the use of methotrexate and to suggest regulatory recommendations if required. Methodology: Signal Detection team at Saudi Food and Drug Authority (SFDA) performed a safety review using National Pharmacovigilance Center (NPC) database as well as the World Health Organization (WHO) VigiBase, alongside with literature screening to retrieve related information for assessing the causality between skin cancer and methotrexate. The search conducted in July 2020. Results: Four published articles support the association seen while searching in literature, a recent randomized control trial published in 2020 revealed a statistically significant increase in skin cancer among MTX users. Another study mentioned methotrexate increases the risk of non-melanoma skin cancer when used in combination with immunosuppressant and biologic agents. In addition, the incidence of melanoma for methotrexate users was 3-fold more than the general population in a cohort study of rheumatoid arthritis patients. The last article estimated the risk of cutaneous malignant melanoma (CMM) in a cohort study shows a statistically significant risk increase for CMM was observed in MTX exposed patients. The WHO database (VigiBase) searched for individual case safety reports (ICSRs) reported for “Skin Cancer” and 'Methotrexate' use, which yielded 121 ICSRs. The initial review revealed that 106 cases are insufficiently documented for proper medical assessment. However, the remaining fifteen cases have extensively evaluated by applying the WHO criteria of causality assessment. As a result, 30 percent of the cases showed that MTX could possibly cause skin cancer; five cases provide unlikely association and five un-assessable cases due to lack of information. The Saudi NPC database searched to retrieve any reported cases for the combined terms methotrexate/skin cancer; however, no local cases reported up to date. The data mining of the observed and the expected reporting rate for drug/adverse drug reaction pair is estimated using information component (IC), a tool developed by the WHO Uppsala Monitoring Centre to measure the reporting ratio. Positive IC reflects higher statistical association, while negative values translated as a less statistical association, considering the null value equal to zero. Results showed that a combination of 'Methotrexate' and 'Skin cancer' observed more than expected when compared to other medications in the WHO database (IC value is 1.2). Conclusion: The weighted cumulative pieces of evidence identified from global cases, data mining, and published literature are sufficient to support a causal association between the risk of skin cancer and methotrexate. Therefore, health care professionals should be aware of this possible risk and may consider monitoring any signs or symptoms of skin cancer in patients treated with methotrexate.

Keywords: methotrexate, skin cancer, signal detection, pharmacovigilance

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Authors: Grace Scaplehorn, Muhammad Adeel Akhtar, Jane Gibson

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Background: Canoe Slalom entails the skilful navigation of a carbon composite canoe or kayak through a series of 18-25 hanging gates, strategically positioned along the course, either upstream or downstream, amidst currents of whitewater rapids in natural and man-made river settings. Athletes compete individually in timed trials, competing for the fastest course time, typically around 80 to 120 seconds. In the new discipline of Kayak Cross, descents of the course are initiated by groups of four athletes freefalling simultaneously from a starting platform situated 3m above the river. Kayak Cross athletes, in contrast to Canoe Slalom, can make physical contact with suspended gates without incurring time penalties and are required to perform a kayak roll half way down the course. The Canoe Slalom World Championships were held at Lee Valley Whitewater Centre, London, from 19th to 24th September 2023. The event comprised 299 international athletes competing for 10 World Championship titles in Canoe/Kayak Slalom events (Olympic Debut Munich 1972), and the new Kayak Cross discipline (Olympic Debut Paris 2024). The inaugural appearance of Kayak Cross at the World Championships occurred in 2017, in Pau, France. There is limited literature surrounding Kayak Cross and the incidence of athlete injuries compared to traditional Canoe Slalom, hence it was felt important to undertake this review to address the perception that the event is dangerous. Aim: The study aimed to quantify and collate data collected from athletes presenting to the event medical centre. Methods: Athletes’ details were collected at initial assessments from the start of the practice period (16th–18th September) and throughout the event. Demographics such as age, sex and nationality were recorded along with presenting complaints, treatment, medication administered and outcome. Specifically, injuries were then sub-classified into body regions. The data does not include athletes who sought medical attention from their own governing body’s medical team. Results: During the 8-day period, there were 11 individual presentations to the medical centre, 3.7% of the athlete population (n=299). The mean age was 23.9 years (n=7), 6 were male (n=10). The most common presentation was minor injury (n=9), with 6 being musculoskeletal and 3 comprising skin damage, followed by insect sting/allergy (n=1) and pain relief requests (n=1). Five presentations were event-related, all being musculoskeletal injuries; 2 shoulder/arm, 1 head/neck, 1 hand/wrist and 1 other (data was not recorded). Of these injuries, the only intervention was 2 cases of 400mg Ibuprofen, which was given to both shoulder/arm injuries. Four of the 11 presentations were pre-existing injuries, which had been exacerbated due to increased intensity of practice. Two patients were advised to return for review, with 100% compliance. There were no unplanned re-presentations, and no emergency transfers to secondary care. Both the Kayak Cross and Canoe Slalom competitions resulted in 1 new event-related athlete presentation each. Conclusion: The event resulted in a negligible incidence of presentations at the medical centre, for both Kayak Cross and Canoe Slalom. This data holds significance in informing risk assessments and medical protocols necessary for the organisation of canoe slalom events.

Keywords: canoe slalom, kayak cross, athlete injuries, event injuries

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Authors: Sonia Butalia, Huong Luu, Alexis Guigue, Karen J. B. Martins, Khanh Vu, Scott W. Klarenbach

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Obesity is associated with significant personal impacts on health and has a substantial economic burden on payers due to increased healthcare use. A contemporary estimate of the healthcare costs associated with obesity at the population level are lacking. This evidence may provide further rationale for weight management strategies. Methods: Adults who underwent a medical procedure between 2012 and 2019 in Alberta, Canada were categorized into the investigational cohort (had body mass index [BMI]-defined class 2 or 3 obesity based on a procedure-associated code) and the control cohort (did not have the BMI procedure-associated code); those who had bariatric surgery were excluded. Characteristics were presented and healthcare costs ($CDN) determined over a 1-year observation period (2019/2020). Logistic regression and a generalized linear model with log link and gamma distribution were used to assess total healthcare costs (comprised of hospitalizations, emergency department visits, ambulatory care visits, physician visits, and outpatient prescription drugs); potential confounders included age, sex, region of residence, and whether the medical procedure was performed within 6-months before the observation period in the partial adjustment, and also the type of procedure performed, socioeconomic status, Charlson Comorbidity Index (CCI), and seven obesity-related health conditions in the full adjustment. Cost ratios and estimated cost differences with 95% confidence intervals (CI) were reported; incremental cost differences within the adjusted models represent referent cases. Results: The investigational cohort (n=220,190) was older (mean age: 53 standard deviation [SD]±17 vs 50 SD±17 years), had more females (71% vs 57%), lived in rural areas to a greater extent (20% vs 14%), experienced a higher overall burden of disease (CCI: 0.6 SD±1.3 vs 0.3 SD±0.9), and were less socioeconomically well-off (material/social deprivation was lower [14%/14%] in the most well-off quintile vs 20%/19%) compared with controls (n=1,955,548). Unadjusted total healthcare costs were estimated to be 1.77-times (95% CI: 1.76, 1.78) higher in the investigational versus control cohort; each healthcare resource contributed to the higher cost ratio. After adjusting for potential confounders, the total healthcare cost ratio decreased, but remained higher in the investigational versus control cohort (partial adjustment: 1.57 [95% CI: 1.57, 1.58]; full adjustment: 1.21 [95% CI: 1.20, 1.21]); each healthcare resource contributed to the higher cost ratio. Among urban-dwelling 50-year old females who previously had non-operative procedures, no procedures performed within 6-months before the observation period, a social deprivation index score of 3, a CCI score of 0.32, and no history of select obesity-related health conditions, the predicted cost difference between those living with and without obesity was $386 (95% CI: $376, $397). Conclusions: If these findings hold for the Canadian population, one would expect an estimated additional $3.0 billion per year in healthcare costs nationally related to BMI-defined obesity (based on an adult obesity rate of 26% and an estimated annual incremental cost of $386 [21%]); incremental costs are higher when obesity-related health conditions are not adjusted for. Results of this study provide additional rationale for investment in interventions that are effective in preventing and treating obesity and its complications.

Keywords: administrative data, body mass index-defined obesity, healthcare cost, real world evidence

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Authors: Charalabos Antonatos, Mariza Panoutsopoulou, Georgios K. Georgakilas, Evangelos Evangelou, Yiannis Vasilopoulos

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The extended tissue damage and severe clinical outcomes of autoimmune diseases, accompanied by the high annual costs to the overall health care system, highlight the need for an efficient therapy. Increasing knowledge over the pathophysiology of specific chronic inflammatory diseases, namely Psoriasis (PsO), Inflammatory Bowel Diseases (IBD) consisting of Crohn’s disease (CD) and Ulcerative colitis (UC), and Rheumatoid Arthritis (RA), has provided insights into the underlying mechanisms that lead to the maintenance of the inflammation, such as Tumor Necrosis Factor alpha (TNF-α). Hence, the anti-TNFα biological agents pose as an ideal therapeutic approach. Despite the efficacy of anti-TNFα agents, several clinical trials have shown that 20-40% of patients do not respond to treatment. Nowadays, high-throughput technologies have been recruited in order to elucidate the complex interactions in multifactorial phenotypes, with the most ubiquitous ones referring to transcriptome quantification analyses. In this context, a random effects meta-analysis of available gene expression cDNA microarray datasets was performed between responders and non-responders to anti-TNFα therapy in patients with IBD, PsO, and RA. Publicly available datasets were systematically searched from inception to 10th of November 2020 and selected for further analysis if they assessed the response to anti-TNFα therapy with clinical score indexes from inflamed biopsies. Specifically, 4 IBD (79 responders/72 non-responders), 3 PsO (40 responders/11 non-responders) and 2 RA (16 responders/6 non-responders) datasetswere selected. After the separate pre-processing of each dataset, 4 separate meta-analyses were conducted; three disease-specific and a single combined meta-analysis on the disease-specific results. The MetaVolcano R package (v.1.8.0) was utilized for a random-effects meta-analysis through theRestricted Maximum Likelihood (RELM) method. The top 1% of the most consistently perturbed genes in the included datasets was highlighted through the TopConfects approach while maintaining a 5% False Discovery Rate (FDR). Genes were considered as Differentialy Expressed (DEGs) as those with P ≤ 0.05, |log2(FC)| ≥ log2(1.25) and perturbed in at least 75% of the included datasets. Over-representation analysis was performed using Gene Ontology and Reactome Pathways for both up- and down-regulated genes in all 4 performed meta-analyses. Protein-Protein interaction networks were also incorporated in the subsequentanalyses with STRING v11.5 and Cytoscape v3.9. Disease-specific meta-analyses detected multiple distinct pro-inflammatory and immune-related down-regulated genes for each disease, such asNFKBIA, IL36, and IRAK1, respectively. Pathway analyses revealed unique and shared pathways between each disease, such as Neutrophil Degranulation and Signaling by Interleukins. The combined meta-analysis unveiled 436 DEGs, 86 out of which were up- and 350 down-regulated, confirming the aforementioned shared pathways and genes, as well as uncovering genes that participate in anti-inflammatory pathways, namely IL-10 signaling. The identification of key biological pathways and regulatory elements is imperative for the accurate prediction of the patient’s response to biological drugs. Meta-analysis of such gene expression data could aid the challenging approach to unravel the complex interactions implicated in the response to anti-TNFα therapy in patients with PsO, IBD, and RA, as well as distinguish gene clusters and pathways that are altered through this heterogeneous phenotype.

Keywords: anti-TNFα, autoimmune, meta-analysis, microarrays

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Authors: Chia-Pei Chen, Yu-Ju Chen, Yu-Juei Hsu

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The prevalence and incidence of end-stage renal disease in Taiwan ranks the highest in the world. According to the statistical survey of the Ministry of Health and Welfare in 2019, kidney disease is the ninth leading cause of death in Taiwan. It leads to autonomic dysfunction, inflammatory response and symptom distress, and further increases the damage to the structure and function of the kidneys, leading to increased demand for renal replacement therapy and risks of cardiovascular disease, which also has medical costs for the society. If we can intervene in a feasible manual to effectively regulate the autonomic nerve function of CKD patients, reduce the inflammatory response and symptom distress. To prolong the progression of the disease, it will be the main goal of caring for CKD patients. This study aims to test the effect of heart rate variability biofeedback (HRVBF) on improving autonomic nerve function (Heart Rate Variability, HRV), inflammatory response (Interleukin-6 [IL-6], C reaction protein [CRP] ), symptom distress (Piper fatigue scale, Pittsburgh Sleep Quality Index [PSQI], and Beck Depression Inventory-II [BDI-II] ) in patients with chronic kidney disease. This study was experimental research, with a convenience sampling. Participants were recruited from the nephrology clinic at a medical center in northern Taiwan. With signed informed consent, participants were randomly assigned to the HRVBF or control group by using the Excel BINOMDIST function. The HRVBF group received four weekly hospital-based HRVBF training, and 8 weeks of home-based self-practice was done with StressEraser. The control group received usual care. We followed all participants for 3 months, in which we repeatedly measured their autonomic nerve function (HRV), inflammatory response (IL-6, CRP), and symptom distress (Piper fatigue scale, PSQI, and BDI-II) on their first day of study participation (baselines), 1 month, and 3 months after the intervention to test the effects of HRVBF. The results were analyzed by SPSS version 23.0 statistical software. The data of demographics, HRV, IL-6, CRP, Piper fatigue scale, PSQI, and BDI-II were analyzed by descriptive statistics. To test for differences between and within groups in all outcome variables, it was used by paired sample t-test, independent sample t-test, Wilcoxon Signed-Rank test and Mann-Whitney U test. Results: Thirty-four patients with chronic kidney disease were enrolled, but three of them were lost to follow-up. The remaining 31 patients completed the study, including 15 in the HRVBF group and 16 in the control group. The characteristics of the two groups were not significantly different. The four-week hospital-based HRVBF training combined with eight-week home-based self-practice can effectively enhance the parasympathetic nerve performance for patients with chronic kidney disease, which may against the disease-related parasympathetic nerve inhibition. In the inflammatory response, IL-6 and CRP in the HRVBF group could not achieve significant improvement when compared with the control group. Self-reported fatigue and depression significantly decreased in the HRVBF group, but they still failed to achieve a significant difference between the two groups. HRVBF has no significant effect on improving the sleep quality for CKD patients.

Keywords: heart rate variability biofeedback, autonomic nerve function, inflammatory response, symptom distress, chronic kidney disease

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Authors: Saraswati Kerketta

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Tea industry is one of the oldest organised sector of India. It employs roughly 1.5 million people directly. Since the last decade Indian tea industry, especially in the northern region is experiencing worst crisis in the post-independence period. Due to many reason the prices of tea show steady decline. The workers are paid one of the lowest wage in tea industry in the world (1.5$ a day) below the UN's $2 a day for extreme poverty. The workers rely on addition benefits from plantation which includes food, housing and medical facilities. These have been effective means of enslavement of generations of labourers by the owners. There is hardly any change in the tea estates where the owners determine the fate of workers. When the tea garden is abandoned or is closed all the facilities disappear immediately. The workers are the descendants of tribes from central India also known as 'tea tribes'. Alienated from their native place, the geographical and social isolation compounded their vulnerability of these people. The economy of the region being totally dependent on tea has resulted in absolute unemployment for the workers of these tea gardens. With no other livelihood and no land to grow food, thousands of workers faced hunger and starvation. The Plantation Labour Act which ensures the decent working and living condition is violated continuously. The labours are forced to migrate and are also exposed to the risk of human trafficking. Those who are left behind suffers from starvation, malnutrition and disease. The condition in the sick tea plantation is no better. Wage are not paid regularly, subsidised food, fuel are also not supplied properly. Health care facilities are in very bad shape. Objectives: • To study the socio-cultural and demographic characteristics of the tea garden labourers in the study area. • To examine the social situation of workers in sick estates in dooars region. • To assess the magnitude of deprivation the impact of economic crisis on abandoned and closed tea estates in the region. Data Base: The study is based on data collected from field survey. Methods: Quantative: Cross-Tabulation, Regression analysis. Qualitative: Household Survey, Focussed Group Discussion, In-depth interview of key informants. Findings: Purchasing power parity has declined since in last three decades. There has been many fold increase in migration. Males migrates long distance towards central and west and south India. Females and children migrates both long and short distance. No one has reported to migrate back to the place of origin of their ancestors. Migrant males work mostly as construction labourers and as factory workers whereas females and children work as domestic help and construction labourers. In about 37 cases either they haven't contacted their families in last six months or are not traceable. The families with single earning members are more likely to migrate. Burden of disease and the duration of sickness, abandonment and closure of plantation are closely related. Death tolls are likely to rise 1.5 times in sick tea gardens and three times in closed tea estates. Sixty percent of the people are malnourished in the sick tea gardens and more than eighty five per cent in abandoned and sick tea gardens.

Keywords: migration, trafficking, starvation death, tea garden workers

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Authors: Nitika Sharma, Yogesh Jain

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Introduction: An efficient Information System helps in improving the service delivery as well provides the foundation for policy and regulation of other building blocks of Health System. Health care organizations require an integrated working of its various sub-systems. An efficient EMR software boosts the teamwork amongst the various sub-systems thereby resulting in improved service delivery. Although there has been a huge impetus to EMR under the Digital India initiative, it has still not been mandated in India. It is generally implemented in huge funded public or private healthcare organizations only. Objective: The study was conducted to understand the factors that lead to the successful adoption of an affordable EMR in the low level healthcare organization. It intended to understand the design of the EMR and address the solutions to the challenges faced in adoption of the EMR. Methodology: The study was conducted in a non-profit registered Healthcare organization that has been providing healthcare facilities to more than 2500 villages including certain areas that are difficult to access. The data was collected with help of field notes, in-depth interviews and participant observation. A total of 16 participants using the EMR from different departments were enrolled via purposive sampling technique. The participants included in the study were working in the organization before the implementation of the EMR system. The study was conducted in one month period from 25 June-20 July 2018. The Ethical approval was taken from the institute along with prior approval of the participants. Data analysis: A word document of more than 4000 words was obtained after transcribing and translating the answers of respondents. It was further analyzed by focused coding, a line by line review of the transcripts, underlining words, phrases or sentences that might suggest themes to do thematic narrative analysis. Results: Based on the answers the results were thematically grouped under four headings: 1. governance of organization, 2. architecture and design of the software, 3. features of the software, 4. challenges faced in adoption and the solutions to address them. It was inferred that the successful implementation was attributed to the easy and comprehensive design of the system which has facilitated not only easy data storage and retrieval but contributes in constructing a decision support system for the staff. Portability has lead to increased acceptance by physicians. The proper division of labor, increased efficiency of staff, incorporation of auto-correction features and facilitation of task shifting has lead to increased acceptance amongst the users of various departments. Geographical inhibitions, low computer literacy and high patient load were the major challenges faced during its implementation. Despite of dual efforts made both by the architects and administrators to combat these challenges, there are still certain ongoing challenges faced by organization. Conclusion: Whenever any new technology is adopted there are certain innovators, early adopters, late adopters and laggards. The same pattern was followed in adoption of this software. He challenges were overcome with joint efforts of organization administrators and users as well. Thereby this case study provides a framework of implementing similar systems in public sector of countries that are struggling for digitizing the healthcare in presence of crunch of human and financial resources.

Keywords: EMR, healthcare technology, e-health, EHR

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Authors: Sophia El Ouazzani, Amer M. Burhan, Mary Wickenden

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Background: Despite improvements in recent years, the Moroccan mental healthcare system still face disparity between available resources and the current population’sneeds. The societal stigma, and limited economic, political, and human resources are all factors in shaping the psychiatric system, exacerbating the discontinuity of services for users after discharged from the hospital. As a result, limited opportunities for social inclusion and meaningful community engagement undermines human rights and recovery potential for people with mental health problems, especially those with psychiatric disabilities from serious mental illness (SMI). Recovery-oriented practice, such as mental health rehabilitation, addresses the complex needs of patients with SMI and support their community inclusion. The cultural acceptability of recovery-oriented practice is an important notion to consider for a successful implementation. Exploring the extent to which recovery-oriented practices are used in Morocco is a necessary first step to assess the cultural relevance of such a practice model. Aims: This study aims to explore understanding and knowledge, perception, and perspective about core concepts in mental health rehabilitation, including psychiatric disability, recovery, and engagement in meaningful occupations for people with SMI in Morocco. Methods: A pilot qualitative study was undertaken. Data was collected via semi-structured interviews and focusgroup discussions with healthcare professional students. Questions were organised around the following themes: 1) students’ perceptions, understanding, and expectations around concepts such as SMI, mental health disability, and recovery, and 2) changes in their views and expectations after starting their professional training. Further analysis of students’ perspectives on the concept of ‘meaningful occupation’ and how is this viewed within the context of the research questions was done. The data was extracted using an inductive thematic analysis approach. This is a pilot stage of a doctoral project, further data will be collected and analysed until saturation is reached. Results: A total of eight students were included in this study which included occupational therapy and mental health nursing students receiving training in Morocco. The following themes emerged as influencing students’ perceptions and views around the main concepts: 1) Stigma and discrimination, 2) Fatalism and low expectations, 3) Gendered perceptions, 4) Religious causation, 5) Family involvement, 6) Professional background, 7) Inaccessibility of services and treatment. Discussion/Contribution: Preliminary analysis of the data suggests that students’ perceptions changed after gaining more clinical experiences and being exposed to people with psychiatric disabilities. Prior to their training, stigma shaped greatly how they viewed people with SMI. The fear, misunderstanding, and shame around SMI and their functional capacities may contribute to people with SMI being stigmatizedand marginalised from their family and their community. Religious causations associated to SMIsare understood as further deepening the social stigma around psychiatric disability. Perceptions are influenced by gender, with women being doubly discriminated against in relation to recovery opportunities. Therapeutic pessimism seems to persist amongst students and within the mental healthcare system in general and regarding the recovery potential and opportunities for people with SMI. The limited resources, fatalism, and stigma all contribute to the low expectations for recovery and community inclusion. Implications and future directions will be discussed.

Keywords: disability, mental health rehabilitation, recovery, serious mental illness, transcultural psychiatry

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Authors: Betül Gelengül Eki̇mci̇, Semra Günay Aktaş

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Festive, habitual activities celebrated on the specified date by a local community, are conducive to recognition of the region. The main function of festive events is to help gathering people via an annual celebration to create an atmosphere of understanding and the opportunity to participate in the joy of life. At the same time, festive events may serve as special occasions on which immigrants return home to celebrate with their family and community, reaffirming their identity and link to the community’s traditions. Festivals also support the local economy by bringing in different visitors to the region. The tradition of “Beet Brewing-Molasses Production,” which is held in İdrisyayla Village is an intangible cultural heritage with customs, traditions, and rituals carrying impacts of cuisine culture of Rumelian immigrants in the Ottoman. After the harvest of the beet plant in the autumn season of the year, Beet Brewing Molasses syrup is made by traditional production methods with co-op of the local community. Festive occurring brewing paste made process provided transmission of knowledge and experience to the young generations. Making molasses, which is a laborious process, is accompanied by folk games such as "sayacı," which is vital element of the festive performed in İdrisyayla. Performance provides enjoyable time and supporting motivation. Like other forms of intangible cultural heritage, “Beet Brewing-Molasses Festive in İdrasyayla is threatened by rapid urbanisation, young generation migration, industrialisation and environmental change. The festive events are threatened with gradual disappearance due to changes communities undergo in modern societies because it depends on the broad participation of practitioners. Ensuring the continuity of festive events often requires the mobilization of large numbers of individuals and the social, political and legal institutions and mechanisms of society. In 2015, Intangible cultural heritage research project with the title of "İdrisyayla Molasses Process" managed by the Eskişehir Governorship, City Directorate of Culture and Tourism and Anadolu University, project members took part in the festival organization to promote sustainability, making it visible, to encourage the broadest public participation possible, to ensure public awareness on the cultural importance. To preserve the originality of and encourage participation in the festive İdrisyayla, local associations, researchers and institutions created foundation and supports festive events, such as "sayacı" folk game, which is vital element of the festive performed in İdrisyayla. Practitioners find new opportunity to market İdrisyayla Molasses production. Publicity program through the press and exhibition made it possible to stress the cultural importance of the festive in İdrisyayla Village. The research reported here used a survey analysis to evaluate an affect of the festive after the spirit of the 2015 Festive in İdrisyayla Village. Particular attention was paid to the importance of the cultural aspects of the festival. Based on a survey of more than a hundred festival attendees, several recommendations are made to festival planners. Results indicate that the variety of festive activities and products offered for sale very important to attendees. The local participants care product sales rather than cultural heritage.

Keywords: agritourism, cultural tourism, festival, sustainable cultural heritage

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Authors: Kaaryn Cater

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People vary in how they perceive, process, and react to internal, external, social, and emotional environmental factors; some are more sensitive than others. Compassionate people have a highly reactive nervous system and are more impacted by positive and negative environmental conditions (Differential Susceptibility). Further, some sensitive individuals are disproportionately able to benefit from positive and supportive environments without necessarily suffering negative impacts in less supportive environments (Vantage Sensitivity). Environmental sensitivity is underpinned by physiological, genetic, and personality/temperamental factors, and the phenotypic expression of high sensitivity is Sensory Processing Sensitivity. The hallmarks of Sensory Processing Sensitivity are deep cognitive processing, emotional reactivity, high levels of empathy, noticing environmental subtleties, a tendency to observe new and novel situations, and a propensity to become overwhelmed when over-stimulated. Several educational advantages associated with high sensitivity include creativity, enhanced memory, divergent thinking, giftedness, and metacognitive monitoring. High sensitivity can also lead to some educational challenges, particularly managing multiple conflicting demands and negotiating low sensory thresholds. A mixed methods study was undertaken. In the first quantitative study, participants completed the Perceived Success in Study Survey (PSISS) and the Highly Sensitive Person Scale (HSPS-12). Inclusion criteria were current or previous postsecondary education experience. The survey was presented on social media, and snowball recruitment was employed (n=365). The Excel spreadsheets were uploaded to the statistical package for the social sciences (SPSS)26, and descriptive statistics found normal distribution. T-tests and analysis of variance (ANOVA) calculations found no difference in the responses of demographic groups, and Principal Components Analysis and the posthoc Tukey calculations identified positive associations between high sensitivity and three of the five PSISS factors. Further ANOVA calculations found positive associations between the PSISS and two of the three sensitivity subscales. This study included a response field to register interest in further research. Respondents who scored in the 70th percentile on the HSPS-12 were invited to participate in a semi-structured interview. Thirteen interviews were conducted remotely (12 female). Reflexive inductive thematic analysis was employed to analyse data, and a descriptive approach was employed to present data reflective of participant experience. The results of this study found that compassionate students prioritize work-life balance; employ a range of practical metacognitive study and self-care strategies; value independent learning; connect with learning that is meaningful; and are bothered by aspects of the physical learning environment, including lighting, noise, and indoor environmental pollutants. There is a dearth of research investigating sensitivity in the educational context, and these studies highlight the need to promote widespread education sector awareness of environmental sensitivity, and the need to include sensitivity in sector and institutional diversity and inclusion initiatives.

Keywords: differential susceptibility, highly sensitive person, learning, neurosensitivity, sensory processing sensitivity, vantage sensitivity

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Authors: Caroline Seo, Jennifer Stephens, Kirstin H. Heinrich

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Background: Clostridiodes (formerly Clostridium) difficile infection (CDI) is an anaerobic, spore-forming bacterium with manifestations including diarrhea, pseudomembranous colitis and toxic megacolon. Despite general understanding that CDI may be associated with marked burden on patients’ health, there has been limited information available on the humanistic burden of CDI. The objective of this literature review was to summarize the published data on the humanistic burden of CDI globally, in order to better inform future research efforts and increase awareness of the patient perspective in this disease. Methods: A comprehensive literature review of the past 15 years (2002-2017) was conducted using MEDLINE, Embase and Cumulative Index of Nursing and Allied Health Literature. Additional searches were conducted from conference proceedings (2015-2017). Articles selected were studies specifically designed to examine the humanistic burden of illness associated with adult patients with CDI. Results: Of 3,325 articles or abstracts identified, 33 remained after screening and full text review. Sixty percent (60%) were published in 2016 or 2017. Data from the United States or Western Europe were most common. Data from Brazil, Canada, China and Spain also exist. Thirteen (13) studies used validated patient-reported outcomes instruments, mostly EQ-5D utility and SF-36 generic instruments. Three (3) studies used CDI-specific instruments (CDiff32, CDI-DaySyms). The burden of CDI impacts patients in multiple health-related quality of life (HRQOL) domains. SF-36 domains with the largest decrements compared to other GI diarrheal diseases (IBS-D and Crohn’s) were role physical, physical functioning, vitality, social functioning, and role emotional. Reported EQ-5D utilities for CDI ranged from 0.35-0.42 compared to 0.65 in Crohn’s and 0.72 in IBS-D. The majority of papers addressed physical functioning and mental health domains (67% for both). Across various studies patients reported weakness, lack of appetite, sleep disturbance, functional dependence, and decreased activities of daily lives due to the continuous diarrhea. Due to lack of control over this infection, CDI also impacts the psychological and emotional quality of life of the patients. Patients reported feelings of fear, anxiety, frustration, depression, and embarrassment. Additionally, the type of disease (primary vs. recurrent) may impact mental health. One study indicated that there is a decrement in SF-36 mental scores in patients with recurrent CDI, in comparison to patients with primary CDI. Other domains highlighted by these studies include pain (27%), social isolation (27%), vitality and fatigue (24%), self-care (9%), and caregiver burden (0%). Two studies addressed work productivity, with 1 of these studies reporting that CDI patients had the highest work productivity and activity impairment scores among the gastrointestinal diseases. No study specifically included caregiver self-report. However, 3 studies did provide mention of patients’ worry on how their diagnosis of CDI would impact family, caregivers, and/or friends. Conclusions: Despite being a serious public health issue there has been a paucity of research on the HRQOL among those with CDI. While progress is being made, gaps exist in understanding the burden on patients, caregivers, and families. Future research is warranted to aid understanding of the CDI patient perspective.

Keywords: burden, Clostridiodes, difficile, humanistic, infection

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Authors: Francesca Crivellari, Nicholas Mavrogiannis, Zachary Gagnon

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Portable diagnostic methods have become increasingly important for a number of different purposes: point-of-care screening in developing nations, environmental contamination studies, bio/chemical warfare agent detection, and end-user use for commercial health monitoring. The cheapest and most portable methods currently available are paper-based – lateral flow and dipstick methods are widely available in drug stores for use in pregnancy detection and blood glucose monitoring. These tests are successful because they are cheap to produce, easy to use, and require minimally invasive sampling. While adequate for their intended uses, in the realm of blood-borne pathogens and numerous cancers, these paper-based methods become unreliable, as they lack the nM/pM sensitivity currently achieved by clinical diagnostic methods. Clinical diagnostics, however, utilize techniques involving surface plasmon resonance (SPR) and enzyme-linked immunosorbent assays (ELISAs), which are expensive and unfeasible in terms of portability. To develop a better, competitive biosensor, we must reduce the cost of one, or increase the sensitivity of the other. Electric fields are commonly utilized in microfluidic devices to manipulate particles, biomolecules, and cells. Applications in this area, however, are primarily limited to interfaces formed between immiscible interfaces. Miscible, liquid-liquid interfaces are common in microfluidic devices, and are easily reproduced with simple geometries. Here, we demonstrate the use of electrical fields at liquid-liquid electrical interfaces, known as fluidic dielectrophoresis, (fDEP) for biodetection in a microfluidic device. In this work, we apply an AC electric field across concurrent laminar streams with differing conductivities and permittivities to polarize the interface and induce a discernible, near-immediate, frequency-dependent interfacial tilt. We design this aqueous electrical interface, which becomes the biosensing “substrate,” to be intelligent – it “moves” only when a target of interest is present. This motion requires neither labels nor expensive electrical equipment, so the biosensor is inexpensive and portable, yet still capable of sensitive detection. Nanoparticles, due to their high surface-area-to-volume ratio, are often incorporated to enhance detection capabilities of schemes like SPR and fluorimetric assays. Most studies currently investigate binding at an immobilized solid-liquid or solid-gas interface, where particles are adsorbed onto a planar surface, functionalized with a receptor to create a reactive substrate, and subsequently flushed with a fluid or gas with the relevant analyte. These typically involve many preparation and rinsing steps, and are susceptible to surface fouling. Our microfluidic device is continuously flowing and renewing the “substrate,” and is thus not subject to fouling. In this work, we demonstrate the ability to electrokinetically detect biomolecules binding to functionalized nanoparticles at liquid-liquid interfaces using fDEP. In biotin-streptavidin experiments, we report binding detection limits on the order of 1-10 pM, without amplifying signals or concentrating samples. We also demonstrate the ability to detect this interfacial motion, and thus the presence of binding, using impedance spectroscopy, allowing this scheme to become non-optical, in addition to being label-free.

Keywords: biodetection, dielectrophoresis, microfluidics, nanoparticles

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Authors: Michael Josef Schwerer

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Background: Analyzing any aircraft accident is mandatory based on the regulations of the International Civil Aviation Organization and the respective country’s criminal prosecution authorities. Legal medicine investigations are unavoidable when fatalities involve the flight crew or when doubts arise concerning the pilot’s aeromedical health status before the event. As a result of frequently tremendous blunt and sharp force trauma along with the impact of the aircraft to the ground, consecutive blast or fire exposition of the occupants or putrefaction of the dead bodies in cases of delayed recovery, relevant findings can be masked or destroyed and therefor being inaccessible in standard pathology practice comprising just forensic autopsy and histopathology. Such cases are of considerable risk of remaining unsolved without legal consequences for those responsible. Further, no lessons can be drawn from these scenarios to improve flight safety and prevent future mishaps. Aims and Methods: To learn from previously unsolved aircraft accidents, re-evaluations of the investigation files and modern molecular pathology studies were performed. Genetic testing involved predominantly PCR-based analysis of gene regulation, studying DNA promotor methylations, RNA transcription and posttranscriptional regulation. In addition, the presence or absence of infective agents, particularly DNA- and RNA-viruses, was studied. Technical adjustments of molecular genetic procedures when working with archived sample material were necessary. Standards for the proper interpretation of the respective findings had to be settled. Results and Discussion: Additional molecular genetic testing significantly contributes to the quality of forensic pathology assessment in aviation mishaps. Previously undetected cardiotropic viruses potentially explain e.g., a pilot’s sudden incapacitation resulting from cardiac failure or myocardial arrhythmia. In contrast, negative results for infective agents participate in ruling out concerns about an accident pilot’s fitness to fly and the aeromedical examiner’s precedent decision to issue him or her an aeromedical certificate. Care must be taken in the interpretation of genetic testing for pre-existing diseases such as hypertrophic cardiomyopathy or ischemic heart disease. Molecular markers such as mRNAs or miRNAs, which can establish these diagnoses in clinical patients, might be misleading in-flight crew members because of adaptive changes in their tissues resulting from repeated mild hypoxia during flight, for instance. Military pilots especially demonstrate significant physiological adjustments to their somatic burdens in flight, such as cardiocirculatory stress and air combat maneuvers. Their non-pathogenic alterations in gene regulation and expression will likely be misinterpreted for genuine disease by inexperienced investigators. Conclusions: The growing influence of molecular pathology on legal medicine practice has found its way into aircraft accident investigation. As appropriate quality standards for laboratory work and data interpretation are provided, forensic genetic testing supports the medico-legal analysis of aviation mishaps and potentially reduces the number of unsolved events in the future.

Keywords: aviation medicine, aircraft accident investigation, forensic pathology, molecular pathology

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