Search results for: Pediatric intensive care unit

Authors: Rukiye Pinar Boluktas

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According to 2015 statistics, in Turkey, 46% of older people live alone in their homes, 55% have poor health perceptions, 18% face poverty, and 43% are unhappy. Prevalence of depression is between 14% and 20%. In 2013, rate of suicide was 6.5. However, the most of older people prefer to live in their community although they are lonely, they face poverty, and face limitations as a result of chronic diseases and disabilities. Community based care for older people is also encouraged by Ministry of Health as it is more cost-effective. Music therapy is a simple, effective, safe, and nonpharmacologic intervention that may be used to decrease depression and to improve cognition, and health related quality of life (HRQOL). In Turkish culture, music is typically described as ‘food for soul’. This study aimed to investigate the effect of Turkish classical music songs in 32 community dwelling older people. Participants were received interventions two or three times per week, 50-60 min per session, for 8 weeks at a day health center. Each intervention session started listening music for 15-20 min to get remember songs, then followed singing songs as a group. Participants were assessed at baseline (week 0), and two follow-up at month 1 and month 2. Compared to baseline, at two follow-up, we observed that cognition improved, depression decreased, and SF-36 scores, including 8 domains and two summary scores increased. We conclude that an intervention comprising listening and singing Turkish classical music improve cognition, depression and HRQOL in older people.

Keywords: cognitive function, depression, elderly, quality of life, Turkish classical music

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Authors: K. O. Ogbedeh, T. T. Epidi, E. U. Onweremadu, E. E. Ihem

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Apart from the devastating nature of termites as pest of cassava, nearly all termite species have been implicated in soil fertility modifications. Elasticity of soil fertility indicators and pH in termite infested cassava field as influenced by tillage and organic manure sources in Owerri, Southeast, Nigeria was investigated in this study. Three years of of field trials were conducted in 2007, 2008 and 2009 cropping seasons respectively at the Teaching and Research Farm of the Federal University of Technology, Owerri. The experiments were laid out in a 3x6 split-plot factorial arrangement fitted into a randomized complete block design (RCBD) with three replications. The TMS 4 (2)1425 was the cassava cultivar used. Treatments consists three tillage methods (zero, flat and mound), two rates of municipal waste (1.5 and 3.0tonnes/ha), two rates of Azadirachta indica (neem) leaves (20 and 30tonnes/ha), control (0.0 tonnes/ha) and a unit dose of carbofuran (chemical check). Data were collected on pre-planting soil physical and chemical properties, post-harvest soil pH (both in water and KCl) and residual total exchangeable bases (Ca, K, Mg and Na). These were analyzed using a Mixed-model procedure of Statistical Analysis Software (SAS). Means were separated using Least Significant Difference (LSD.) at 5% level of probability. Result shows that the native soil fertility status of the experimental site was poor. However soil pH increased substantially in plots where mounds, A.indica leaves at 30t/ha and municipal waste (1.5 and 3.0t/ha) were treated especially in 2008 and 2009. In 2007 trial, highest soil pH was maintained with flat (5.41 in water and 4.97 in KCl). Control on the other hand, recorded least soil pH especially in 2009 with values of 5.18 and 4.63 in water and KCl respectively. Equally, mound, A. indica leaves at 30t/ha and municipal waste at 3.0t/ha consistently increased organic matter content of the soil than other treatments. Finally, mound and A. indica leaves at 30t/ha linearly and consistently increased residual total exchangeable bases of the soil.

Keywords: elasticity, fertility, indicators, termites, tillage, cassava and manure sources

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Authors: Sameh El Mahdy

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Recording and documenting archaeological collections, especially photographic documentation, is considered one of the very important matters that museums care about and give great priority, as photographic documentation is of great importance. We monitor some of them for example, Photographs of collectibles are considered evidence and an archival record that proves the condition of the collectibles at various stages. A photo of the possessions is placed on the paper record of the possessions registration. These photos are used in inventorying archaeological collections. These pictures are viewed by researchers and scholars interested in studying these collections. These images are used in advertising campaigns for museum displays of archaeological collections. The Grand Egyptian Museum is considered one of the museums that is a unique model in terms of establishing a specific system that is used when photographing archaeological collections. The Grand Egyptian Museum sets standards for the photos that are taken inside the Grand Egyptian Museum. We mention some of them for example, Pictures must be of high quality. It is necessary to set a color scale for the drawing in order to clarify the dimensions of the collectibles in the picture and also in order to clarify the natural colors of the collectibles without any additions. Putting the numbers of the collectibles in the pictures, especially the number of the Grand Egyptian Museum. To take a good photo of the artifacts in the Grand Egyptian Museum, there are many steps: (1) Create a good location, (2) How to handle the Artifacts. (3) Choose the best position for the artifact, (4) Make the light to create a good photo without shadows to make the photo represent all the artifact details. (5) Be sure of the camera settings, and their quality. All of these steps and other ones are the best criteria for taking the best photo, which helps us in the database to represent the details of the artifact in our interface.

Keywords: grand egyptian museum, photographing, museum collections, registration and documentation

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Authors: Latifa Alenezi, Liz Croot, Janet Harris

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Chronic Low Back Pain (CLBP) is one of the most common and recurrent musculoskeletal problems that causes patients to access health care services frequently. The Bio-psychosocial Model emphasises that psychological, behavioural and social factors contribute to the development and persistence of CLBP. Cognitive behavioural therapy (CBT) is a psychological pain management strategy that can be used by physiotherapists treating chronic low back pain. However, evidence of the effectiveness of CBT for CLBP varies between different studies. The proposed study was preceded by a mixed methods systematic review that found that CBT has a beneficial effect for CLBP patients when compared to waiting list or other treatments; however, there is variation in effectiveness across different settings. Little is known about how CBT is applied by physiotherapists in physiotherapy settings. The interest of this study is directed towards generating an explanation and understanding of why, when, and how some physiotherapists make decisions and choose to apply CBT for CLBP patients, whereas others do not. Also, how and for what type of CLBP patients does CBT work, and for whom might CBT not work? Therefore, the study will take a qualitative approach to explore CLBP patients’, physiotherapists’ and managers’ perceptions of CBT and how it is used in physiotherapy to enable a deeper understanding and richer explanation of CBT effectiveness and help to inform research and practice. The study will use grounded theory approach to generate an explanatory theory of the clinical application of CBT for CLBP in physiotherapy settings. Physiotherapists, patients and managers of physiotherapy services will be interviewed. Grounded theory techniques will be used to analyse the data. The presentation will describe findings from the interviews and the emerging theory. This research will help to further inform RCTs about the effectiveness of CBT for CLBP in physiotherapy.

Keywords: CBT, CLBP, perception, physiotherapy, theory

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Authors: Azariah Sosa, Carlos Renedo Sanchez

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The development of a new motorway north of Auckland (New Zealand) includes steep rock cuts, from 63 up to 85 degrees, in an interbedded sandstone and siltstone rock mass of the geological unit Waitemata Group (Pakiri Formation), which shows sub-horizontal bedding planes, various sub-vertical joint sets, and a diverse weathering profile. In this kind of rock mass -that can be classified as a weak rock- the definition of the stable maximum geometry is not only governed by discontinuities and defects evident in the rock but is important to also consider the global stability of the rock slope, including (in the analysis) the rock mass characterisation, influence of the groundwater, the geological evolution, and the weathering processes. Depending on the weakness of the rock and the processes suffered, the global stability could, in fact, be a more restricting element than the potential instability of individual blocks through discontinuities. This paper discusses those elements that govern the stability of the rock slopes constructed in a rock formation with favourable bedding and distribution of discontinuities (horizontal and vertical) but with a weak behaviour in terms of global rock mass characterisation. In this context, classifications as Q-Slope and slope stability assessment methodology (SSAM) have been demonstrated as important tools which complement the assessment of the global stability together with the analytical tools related to the wedge-type failures and limit equilibrium methods. The paper focuses on the applicability of these two new empirical classifications to evaluate the slope stability in 18 already excavated rock slopes in the Pakiri formation through comparison between the predicted and observed stability issues and by reviewing the outcome of analytical methods (Rocscience slope stability software suite) compared against the expected stability determined from these rock classifications. This exercise will help validate such findings and correlations arising from the two empirical methods in order to adjust the methods to the nature of this specific kind of rock mass and provide a better understanding of the long-term stability of the slopes studied.

Keywords: Pakiri formation, Q-slope, rock slope stability, SSAM, weak rock

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Authors: Anela Lupuwana

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The main objective of this paper is to develop an ethnobotanical survey that documents medicinal plants used to treat diarrhea among infants in the Eastern Cape province of South Africa. In South Africa’s pluralistic healthcare system, medicinal plants are an integral part of healing and treating an array of diseases. This is also the case in rural areas of South Africa, where healthcare facilities are hard to access. There is a lack of literature on the use of medicinal plants to cure ailments common to children, and this paper fills this gap. A total of 18 participants were interviewed using semi-structured interviews. A purposive approach was used to sample the study cohorts. A total of 28 medicinal plants representing 19 different families were recorded, with the family Asteraceae (11%) having the most medicinal plants. The remaining plants (82%) were distributed equally among the following families: Rubiaceae, Canellaceae, Aloaceae, Rutaceae, Thymeleaceae, Myrinaceae, Olinaceae, Iradeceae, Zingiberaceae, Capparaceae, Aizoaceae, Fabaceae, Geraniaceae, Cornaceae, Monimiaceae, Talinaceae, Chrysobalanaceae, and Icacinaceae. Oral administration was the most common mode of administration, with 82% of plants taken orally. Healing was proven to be holistic; it was more than just treating physical ailments as such; infants were protected from evil spirits that made them vulnerable to illnesses. There was also evidence of the assimilation of Dutch medicine and animal products into traditional healing methods. In order to mitigate the prevalence of disease and illness in South Africa, I recommend that diversity in healing practices should be acknowledged and appreciated.

Keywords: infants, traditional healers, primary care givers, traditional medicine

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Authors: Mona Afifi, Yara Al Qahtani, Afnan Al Dosari, Amnah Hamdi

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Background: First aid is the care provided outside the hospital. It is important in saving lives. Delay in helping the victims may result in serious complication or even death. Many people die in Saudi Arabia because they don’t get proper first aid interventions. According to Traffic Safety council in KSA (2012), in the year of 2011 there was 7153 deaths from car accident in KAS. Subjects and method: Quasi-experimental research design was utilized to assess the effect of a structured 45-minute educational session on 82 undergraduate nursing students’ knowledge about first aid. Two tools were developed for the purpose of the current study. First tool containing the sociodemographic data including age, gender, level, and previous participation in a first aid course, and 55 statements specific to different situations that requires first aid. Concept and Knowledge of First Aid has 9 questions, cardiopulmonary resuscitation has 12 questions, Bleeding and Shock have 7 questions, Road Traffic Accidents has 5 questions, Fracture and Trauma have 4 questions, wound has 5 questions, sunstroke has 4 questions, bits and stings has 4 questions and burn has 5 questions. The second tool was to evaluate the campaign session. Result: The overall knowledge score showed significant difference between the pre and post awareness session (59.58 and 93.00 respectively, p=.000). Mean score shows significant difference in pre-tests between third and fourth year nursing students indicating that knowledge of fourth year students is higher compared to third year students with the mean knowledge scores of 69.56 and 60.88 respectively (p=0.006). Conclusion: Results of the current study indicate that the level of the knowledge in the post test session was higher than in the pre session. Also results showed that the fourth year student`s knowledge in pre-test was better compared to previous year.

Keywords: first aid, awareness campaign, undergraduate nursing students, knowledge

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Authors: Igor Jerkovic

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Owing to the attractive sensory properties and low odour thresholds, norisoprenoids (degraded carotenoid-like structures with 3,5,5-trimethylcyclohex-2-enoic unit) have been identified as aroma contributors in a number of different matrices. C₁₃-Norisoprenoids have been found among volatile organic compounds of various honey types as well as C₉//C₁₀-norisoprenoids or C₁₄/C₁₅-norisoprenoids. Besides degradation of abscisic acid (which produces, e.g., dehydrovomifoliol, vomifoliol, others), the cleavage of the C(9)=C(10) bond of other carotenoid precursors directly generates nonspecific C₁₃-norisoprenoids such as trans-β-damascenone, 3-hydroxy-trans-β-damascone, 3-oxo-α-ionol, 3-oxo-α-ionone, β-ionone found in various honey types. β-Damascenone and β-ionone smelling like honey, exhibit the lowest odour threshold values of all C₁₃-norisoprenoids. The presentation is targeted on two uncommon C₁₃-norisoprenoids in the honey flavor that could be used as specific or nonspecific chemical markers of the botanical origin. Namely, after screening of different honey types, the focus was directed on Centaruea cyanus L. and Allium ursinum L. honey. The samples were extracted by headspace solid-phase microextraction (HS-SPME) and ultrasonic solvent extraction (USE) and the extracts were analysed by gas chromatography and mass spectrometry (GC-MS). SPME fiber with divinylbenzene/carboxen/polydimethylsiloxane (DVB/CAR/PDMS) coating was applied for the research of C. cyanus honey headspace and predominant identified compound was 3,4-dihydro-3-oxoedulan (2,5,5,8a-tetramethyl-2,3,5,6,8,8a-hexahydro-7H-chromen-7-one also known as 2,3,5,6,8,8a-hexahydro-2,5,5,8a-tetramethyl-7H-1-benzo-pyran-7-one). The oxoedulan structure contains epoxide and it is more volatile in comparison with its hydroxylated precursors. This compound has not been found in other honey types and can be considered specific for C. cyanus honey. The dichloromethane extract of A. ursinum honey contained abundant (E)-4-(r-1',t-2',c-4'-trihydroxy-3',6',6'-trimethylcyclohexyl)-but-3-en-2-one that was previously isolated as dominant substance from the ether extracts of New Zealand thyme honey. Although a wide variety of degraded carotenoid-like substances have been identified from different honey types, this appears to be rare situation where 3,4-dihydro-3-oxoedulan and (E)-4-(r-1',t-2',c-4'-trihydroxy-3',6',6'-trimethylcyclohexyl)-but-3-en-2-one have been found that is of great importance for chemical fingerprinting and identification of the chemical biomarkers that can complement the pollen analysis as the major method for the honey classification.

Keywords: 3, 4-dihydro-3-oxoedulan, (E)-4-(r-1', t-2', c-4'-trihydroxy-3', 6', 6'-trimethylcyclohexyl)-but-3-en-2-one, honey flavour, C₁₃-norisoprenoids

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Authors: Giorgio Visentin, Alexei A. Buchachenko

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Recent proposals to use Yb dimer as an optical clock and as a sensor for non-Newtonian gravity imply the knowledge of its interaction potential. Here, the ground-state Born-Oppenheimer Yb₂ potential energy curve is represented by a semi-analytical function, consisting of short- and long-range contributions. For the former, the systematic ab initio all-electron exact 2-component scalar-relativistic CCSD(T) calculations are carried out. Special care is taken to saturate diffuse basis set component with the atom- and bond-centered primitives and reach the complete basis set limit through n = D, T, Q sequence of the correlation-consistent polarized n-zeta basis sets. Similar approaches are used to the long-range dipole and quadrupole dispersion terms by implementing the CCSD(3) polarization propagator method for dynamic polarizabilities. Dispersion coefficients are then computed through Casimir-Polder integration. The semiclassical constraint on the number of the bound vibrational levels known for the ¹⁷⁴Yb isotope is used to scale the potential function. The scaling, based on the most accurate ab initio results, bounds the interaction energy of two Yb atoms within the narrow 734 ± 4 cm⁻¹ range, in reasonable agreement with the previous ab initio-based estimations. The resulting potentials can be used as the reference for more sophisticated models that go beyond the Born-Oppenheimer approximation and provide the means of their uncertainty estimations. The work is supported by Russian Science Foundation grant # 17-13-01466.

Keywords: ab initio coupled cluster methods, interaction potential, semi-analytical function, ytterbium dimer

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Authors: Md. Shakhawat Hossain, Jimma Hossain, Md. Naushad Ali

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Acute pancreatitis is a dangerous medical emergency in the practice of gastroenterology. Management of acute pancreatitis needs multidisciplinary approach with support starts from emergency to ICU. So, there is a chance of mismanagement in every steps, especially in low resource settings. Other factors such as patient’s financial condition, education, social custom, transport facility, referral system from periphery may also challenge the current guidelines for management. The present study is intended to determine the clinico-pathological profile, severity assessment and challenges of management of acute pancreatitis in a government laid tertiary care hospital to image the real scenario of management in a low resource place. A total 100 patients of acute pancreatitis were studied in this prospective study, held in the Department of Gastroenterology, Rangpur medical college hospital, Bangladesh from July 2017 to July 2018 within one year. Regarding severity, 85 % of the patients were mild, whereas 13 were moderately severe, and 2 had severe acute pancreatitis according to the revised Atlanta criteria. The most common etiologies of acute pancreatitis in our study were gall stone (15%) and biliary sludge (15%), whereas 54% were idiopathic. The most common challenges we faced were delay in hospital admission (59%) and delay in hospital diagnosis (20%). Others are non-adherence of patient party, and lack of investigation facility, physician’s poor knowledge about current guidelines. We were able to give early aggressive fluid to only 18% of patients as per current guideline. Conclusion: Management of acute pancreatitis as per guideline is challenging when optimum facility is lacking. So, modified guidelines for assessment and management of acute pancreatitis should be prepared for low resource setting.

Keywords: acute pancreatitis, challenges of management, severity, prognosis

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Authors: Suruchi Shukla, Shantanu Prakash, Amita Jain

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Introduction: Arboviral diseases are one of the most common causes of viral hemorrhagic fever (VHF). Of which, Dengue and Chikungunya pose a significant health problem in India. Arbovirus has a tendency to cross the territories and emerge in the new region. Considering the above issues, in the current study active surveillance was conducted among viral hemorrhagic fever (VHF) cases reported from Uttar Pradesh (UP), India. We studied the arboviral etiology of VHF; mainly Dengue, Chikungunya, and ZIKA. Methods: Clinical samples of 465 suspected VHF cases referred to tertiary care referral center of UP, India were enrolled in the study during a period from 15th May 2016 to 9th March 2018. Serum specimens were collected and analyzed for the presence of Dengue, Chikungunya, and ZIKA either by serology and/or by molecular assays. Results: Of all tested, 165 (35.4%) cases were positive for either Dengue or Chikungunya. Dengue (21.2%) was found to be the most prevalent, followed by Chikungunya, (6.6%). None of the cases tested positive for ZIKA virus. Serum samples of 35 (7.5%) cases were positive for both Dengue and Chikungunya. DEN-2 serotype was the most predominant serotype. Phylogenetic and sequence analysis of DEN-2 strains showed 100% clustering with the Cosmopolitan genotype strain. Bleeding from several sites, jaundice, abdominal pain, arthralgia, haemoconcentration, and thrombocytopenia were significantly higher in dengue hemorrhagic cases. However, the rash was significantly more common in Chikungunya patients. Most of the Dengue and Chikungunya positive cases (Age group 6-40 years) were seen in post monsoon season (September to November). Conclusion: Only one-third of total VHF cases are positive for either Dengue/Chikungunya or both. This necessitates the screening of other etiologies capable of causing hemorrhagic manifestations.

Keywords: viral hemorrhagic fever, dengue, chikungunya, zika, India

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Authors: Pedro Gomes, Lia Ferreira, Sofia Garcia, Jaime Babulal, Luís Costa, Luís Castelo, José Muras, Isabel Gonçalves, Rui Carvalho

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Introduction: Foot ulcers and their complications are an important cause of morbidity and mortality in diabetes. Objectives: The present study aims to evaluate the outcomes in terms of need for hospitalization, amputation, healing time and mortality in patients with new-onset diabetic foot ulcers in subgroups stratified by etiology. Methods: A retrospective study based on clinical assessment of patients presenting with new ulcers to a multidisciplinary diabetic foot consult during 2012. Outcomes were determined until September 2014, from hospital registers. Baseline clinical examination was done to classify ulcers as neuropathic, ischemic or neuroischemic. Results: 487 patients with new diabetic foot ulcers were observed; 36%, 15% and 49% of patients had neuropathic, ischemic and neuroischemic ulcers, respectively. For analysis, patients were classified as having predominantly neuropathic (36%) or ischemic foot (64%). The mean age was significantly higher in the group with ischemic foot (70±12 vs 63±12 years; p <0.001), as well as the duration of diabetes (18±10 vs 16 ± 10years, p <0.05). A history of previous amputation was also significantly higher in this group (24.7% vs 15.6%, p <0.05). The evolution of ischemic ulcers was significantly worse, with a greater need for hospitalization (27.2% vs 18%, p <0.05), amputation (11.5% vs 3.6% p <0.05) mainly major amputation (3% vs. 0%; p <0.001) and higher mean healing time (151 days vs 89 days, p <0.05). The mortality rate at 18 months, was also significantly higher in the ischemic foot group (7.3% vs 1.8%, p <0.05). Conclusions: All types of diabetic foot ulcers are associated with high morbidity and mortality, however, the presence of arterial disease confers a poor prognosis. Diabetic foot can be successfully treated only by the multidisciplinary team which can provide more comprehensive and integrated care.

Keywords: diabetes, foot ulcers, etiology, outcome

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Authors: Elyas Palantei, Dewiani, Farid Armin, Ardiansyah

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High precision of printed microwave sensor utilized for sensing and monitoring the potential breast cancer existed in women breast tissue was optimally computed. The single element of UWB printed sensor that successfully modeled through several numerical optimizations was multiple fabricated and incorporated with woman bra to form the spherical sensors array. One sample of UWB microwave sensor obtained through the numerical computation and optimization was chosen to be fabricated. In overall, the spherical sensors array consists of twelve stair patch structures, and each element was individually measured to characterize its electrical properties, especially the return loss parameter. The comparison of S11 profiles of all UWB sensor elements is discussed. The constructed UWB sensor is well verified using HFSS programming, CST programming, and experimental measurement. Numerically, both HFSS and CST confirmed the potential operation bandwidth of UWB sensor is more or less 4.5 GHz. However, the measured bandwidth provided is about 1.2 GHz due to the technical difficulties existed during the manufacturing step. The configuration of UWB microwave sensing and monitoring system implemented consists of 12 element UWB printed sensors, vector network analyzer (VNA) to perform as the transceiver and signal processing part, the PC Desktop/Laptop acting as the image processing and displaying unit. In practice, all the reflected power collected from whole surface of artificial breast model are grouped into several numbers of pixel color classes positioned on the corresponding row and column (pixel number). The total number of power pixels applied in 2D-imaging process was specified to 100 pixels (or the power distribution pixels dimension 10x10). This was determined by considering the total area of breast phantom of average Asian women breast size and synchronizing with the single UWB sensor physical dimension. The interesting microwave imaging results were plotted and together with some technical problems arisen on developing the breast sensing and monitoring system are examined in the paper.

Keywords: UWB sensor, UWB microwave imaging, spherical array, breast cancer monitoring, 2D-medical imaging

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Authors: Ilana Margalith, Yaron Niv

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One of the most important factors of professional health treatment is teamwork, in which each discipline contributes its expert knowledge, thus ensuring quality and a high standard of care as well as efficient communication (one of the International Patient Safety Goals). However, in most countries, students are educated separately by each health discipline. They are exposed to teamwork only during their clinical experience, which in some cases is short and skill-oriented. In addition, health organizations in most countries are hierarchical and although changes have occurred in the hierarchy of the medical system, there are still disciplines that underrate the unique contributions of other health professionals, thus, young graduates of health professions develop and base their perception of their peers from other disciplines on insufficient knowledge. In order to establish a wide-ranging perception among nursing students as to the contribution of different health professionals to the health of their patients, students at the Clalit Nursing Academy, Rabin Campus (Dina), Israel, participated in an interdisciplinary clinical discussion with students from several different professions, other than nursing, who were completing their clinical experience at Rabin Medical Center in medicine, health psychology, social work, audiology, physiotherapy and occupational therapy. The discussion was led by a medical-surgical nursing instructor. Their tutors received in advance, a case report enabling them to prepare the students as to how to present their professional theories and interventions regarding the case. Mutual stimulation and acknowledgment of the unique contribution of each part of the team enriched the nursing students' understanding as to how their own nursing interventions could be integrated into the entire process towards a safe and speedy recovery of the patient.

Keywords: health professions' students, interdisciplinary clinical discussion, nursing education, patient safety

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Authors: Haripriya Chakraborty

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The healthcare system in the United States is considered to be one of the most inefficient and expensive systems when compared to other developed countries. Consequently, there are persistent concerns regarding the overall functioning of this system. For instance, the large number of uninsured individuals and high premiums are pressing issues that are shown to have a negative effect on health outcomes with possible life-threatening consequences. The Affordable Care Act (ACA), which was signed into law in 2010, was aimed at improving some of these inefficiencies. This paper aims at providing a computational mechanism to examine some of these inefficiencies and the effects that policy proposals may have on reducing these inefficiencies. Agent-based modeling is an invaluable tool that provides a flexible framework to model complex systems. It can provide an important perspective into the nature of some interactions that occur and how the benefits of these interactions are allocated. In this paper, we propose a novel and versatile agent-based model with realistic assumptions to simulate the dynamics of a health insurance marketplace that contains a mixture of private and public insurers and individuals. We use this model to analyze the characteristics, motivations, payoffs, and strategies of these agents. In addition, we examine the effects of certain policies, including some of the provisions of the ACA, aimed at reducing the uninsured rate and the cost of premiums to move closer to a system that is more equitable and improves health outcomes for the general population. Our test results confirm the usefulness of our agent-based model in studying this complicated issue and suggest some implications for public policies aimed at healthcare reform.

Keywords: agent-based modeling, healthcare reform, insurance markets, public policy

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Authors: Mahmoud Nabilu

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The present study explored the effect of using Mobile listening applications on developing listening skills by Iranian intermediate EFL learners. Fifty male intermediate English learners whose age range was between 15 and 20, participated in the study. The participants were placed in two groups on the basis of their scores on a placement test. Therefore, the participants of the study were homogenized in terms of general proficiency, and groups were assigned as one experimental group and one control group. The experimental group was instructed by the treatment which was using mobile applications to develop their listening skills while the control group received traditional methods. The research data were obtained from the 40-item multiple-choice tests as a pre-test and a post-test. The results of the t-test clearly revealed that the learners in the experimental group performed better in the post-test than the pre-test. This implies that using a mobile application for developing listening skills as a treatment was effective in helping the language learners perform better on post-test. However, a statistically significant difference was found between the post-tests scores of the two groups. The mean of the experimental group was greater compared to the control group. The participants were Iranian and from an Iranian Language Institute, so care should be taken while generalizing the results to the learners of other nationalities. However, in the researcher's view, the findings of this study have valuable implications for teachers and learners, methodologists and syllabus designers, linguists and MALL/CALL (mobile/computer-assisted language learning) experts. Using the result of the present paper is an aim of raising the consciousness of a better technique of developing listening skills in order to make language learning more efficient for the learners.

Keywords: Mobile listening applications, intermediate EFL learners, MALL, CALL

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Authors: Milad Gholizadeh

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Asthma and chronic obstructive pulmonary disease (COPD) are very shared inflammatory diseases of the airlines. They togethercause airway tapering and are cumulative in occurrence throughout the world, imposing huge burdens on health care. It is currently recognized that some asthmatic inflammation is neutrophilic, controlled by the TH17 subset of helper T cells, and that some eosinophilic inflammation is controlled by type 2 innate lymphoid cells (ILC2 cells) temporary together with basophils. Patients who have plain asthma or are asthmatic patients who smoke with topographies of COPD-induced inflammation and might advantage from treatments targeting neutrophils, countingmacrolides, CXCR2 antagonists, phosphodiesterase 4 inhibitors, p38 mitogen-activating protein kinase inhibitors, and antibodies in contradiction of IL-1 and IL-17.Viral and bacterial infections, not only reason acute exacerbations of COPD, but also intensify and continue chronic inflammation in steady COPD through pathogen-associated molecular patterns. Present treatment plans are absorbed on titration of inhaled therapies such as long-acting bronchodilators, with cumulative interest in the usage of beleaguered biologic therapies meant at the underlying inflammatory devices. Educationssuggest that the mucosal IgA reply is abridged in COPD, and a lacking conveyance of IgA across the bronchial epithelium in COPD has been recognized, perhaps involving neutrophil proteinases, which may damage the Ig receptor mediating this transepithelialdirection-finding. Future instructions for investigation will emphasis elucidating the diverse inflammatory signatures foremost to asthma and chronic obstrucive, the development of reliable analytic standards and biomarkers of illness, and refining the clinical organization with an eye toward targeted therapies.

Keywords: imminology, asthma, COPD, CXCR2 antagonists

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Authors: Ndukwe, Chinedu O.

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Background: There are only a few epidemiological studies published on skin disorders in the elderly within the Nigerian context and none from the Southeast Region of the country. In addition, none of these studies has considered the pattern and frequency of histopathologically diagnosed geriatric skin lesions. Hence, we attempted to determine the frequency as well as the age and gender distributions of histologically diagnosed dermatological diseases in the geriatric population from skin biopsies submitted to the histopathology department of a tertiary care hospital in Southeast Nigeria. Material and methods: This is a cross-sectional retrospective hospital-based study involving all skin biopsies of patients 60 years and above, received at the Department of Histopathology, Nnamdi Azikiwe University Teaching Hospital, Nnewi, Nigeria from January 2004 to December 2019. Results: During the study period, 751 skin biopsies were received in the histopathology department. Of these, 142 were from patients who were older than 60 years. Thus, the overall share of geriatric patients was 18.9%. The mean age at presentation was 71.1 ± 8.6 years. The M: F was 1:1 and most of the patients belonged to the age group of 60–69 years (69 cases, 48.6%). The mean age of the male patients was 72.1±9.5 years. In the female patients, it was 70.1±7.5 years. The commonest disease category was neoplasms (91, 64.1%). Most neoplasms were malignant. There were 67/142 (47.2%) malignant lesions. Commonest was Squamous cell carcinoma (SCC) (30 cases) which is 21.1% of all geriatric skin biopsies and 44.8% of malignant skin biopsies. This is closely followed by melanoma (29 cases). Conclusion: Malignant neoplasms, benign neoplasms and papulosquamous disorders are the three commonest histologically diagnosed skin lesions in our geriatric population. The commonest skin malignancies in this group of patients are squamous cell carcinoma and malignant melanoma.

Keywords: geriatric, skin, Nigeria, histopathology

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Authors: Enido Fabiano de Ramos, Ieda Kanashiro Makiya, Francisco I. Giocondo Cesar

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This study investigates the application of Digital Twins (DT) in Smart Hospital Environments (SHE), through a bibliometric study and literature review, including comparison with the principles of Industry 4.0. It aims to analyze the current state of the implementation of digital twins in clinical and non-clinical operations in healthcare settings, identifying trends and challenges, comparing these practices with Industry 4.0 concepts and technologies, in order to present a basic framework including stages and maturity levels. The bibliometric methodology will allow mapping the existing scientific production on the theme, while the literature review will synthesize and critically analyze the relevant studies, highlighting pertinent methodologies and results, additionally the comparison with Industry 4.0 will provide insights on how the principles of automation, interconnectivity and digitalization can be applied in healthcare environments/operations, aiming at improvements in operational efficiency and quality of care. The results of this study will contribute to a deeper understanding of the potential of Digital Twins in Smart Hospitals, in addition to the future potential from the effective integration of Industry 4.0 concepts in this specific environment, presented through the practical framework, after all, the urgent need for changes addressed in this article is undeniable, as well as all their value contribution to human sustainability, designed in SDG3 – Health and well-being: ensuring that all citizens have a healthy life and well-being, at all ages and in all situations. We know that the validity of these relationships will be constantly discussed, and technology can always change the rules of the game.

Keywords: digital twin, smart hospital, healthcare operations, industry 4.0, SDG3, technology

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Authors: Mark Linden, Trisha Forbes, Michael Brown, Lynne Marsh, Maria Truesdale, Stuart Todd, Nathan Hughes

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Background The COVID-19 pandemic resulted in a reduction of health care services for many family carers of people with profound and multiple intellectual disabilities (PMID). Due to lack of services, family carers turned to charities for support during the pandemic. We explored the views of charity workers across the UK and Ireland who supported family carers during the COVID-19 pandemic and explored their views on effective online support programmes for family carers. Methods This was a qualitative study using online focus groups with participants (n = 24) from five charities across the UK and Ireland. Questions focused on challenges, supports, coping and resources which helped during lockdown restrictions. Focus groups were audio recorded, transcribed verbatim, and analysed through thematic analysis. Findings Four themes were identified (i) ‘mental and emotional health’, (ii) ‘they who shout the loudest’ (fighting for services), (iii) ‘lack of trust in statutory services’ and (iv) ‘creating an online support programme’. Mental and emotional health emerged as the most prominent theme and included three subthemes named as ‘isolation’, ‘fear of COVID-19’ and ‘the exhaustion of caring’. Conclusions The withdrawal of many services during the COVID-19 pandemic further isolated and placed strain on family carers. Even after the end of the pandemic family cares continue to report on the struggle to receive adequate support. There is a critical need to design services, including online support programmes, in partnership with family carers which adequately address their needs.

Keywords: intellectual disability, family carers, COVID-19, charities

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Authors: Basant H. El-Refay, Nabeel T. Faiad

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Background: The high prevalence of obesity in Egypt has a great impact on the health care system, economic and social situation. Evidence suggests that even a moderate amount of weight loss can be useful. Aim of the study: To analyze the effects of lower body positive pressure supported treadmill training, conducted with hypocaloric diet, on body composition of obese children. Methods: Thirty children aged between 8 and 14 years, were randomly assigned into two groups: intervention group (15 children) and control group (15 children). All of them were evaluated using body composition analysis through bioelectric impedance. The following parameters were measured before and after the intervention: body mass, body fat mass, muscle mass, body mass index (BMI), percentage of body fat and basal metabolic rate (BMR). The study group exercised with antigravity treadmill three times a week during 2 months, and participated in a hypocaloric diet program. The control group participated in a hypocaloric diet program only. Results: Both groups showed significant reduction in body mass, body fat mass and BMI. Only study group showed significant reduction in percentage of body fat (p = 0.0.043). Changes in muscle mass and BMR didn't reach statistical significance in both groups. No significant differences were observed between groups except for muscle mass (p = 0.049) and BMR (p = 0.042) favoring study group. Conclusion: Both programs proved effective in the reduction of obesity indicators, but lower body positive pressure supported treadmill training was more effective in improving muscle mass and BMR.

Keywords: children, hypocaloric diet, lower body positive pressure supported treadmill, obesity

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Authors: John Hardy

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The early twenty-first century national security environment has been characterized by political coercion. Despite an abundance of political commentary on the various forms of non-state coercion leveraged against the state, there is a lack of literature which distinguishes between the mechanisms and the mediums of coercion. Frequently non-state movements seeking to coerce the state are labelled by their tactics, not their strategies. Terrorists, insurgencies and social movements are largely defined by the ways in which they seek to influence the state, rather than by their political aims. This study examines the strategies of coercion used by non-state actors against states. This approach includes terrorist groups, insurgencies, and social movements who seek to coerce state politics. Not all non-state actors seek political coercion, so not all examples of different group types are considered. This approach also excludes political coercion by states, focusing on the non-state actor as the primary unit of analysis. The study applies a general theory of political coercion, which is defined as attempts to change the policies or action of a polity against its will, to the strategies employed by terrorist groups, insurgencies, and social movements. This distinguishes non-state actors’ strategic objectives from their actions and motives, which are variables that are often used to differentiate between types of non-state actors and the labels commonly used to describe them. It also allows for a comparative analysis of theoretical perspectives from the disciplines of terrorism, insurgency and counterinsurgency, and social movements. The study finds that there is a significant degree of overlap in the way that different disciplines conceptualize the mechanism of political coercion by non-state actors. Studies of terrorism and counterterrorism focus more on the notions of cost tolerance and collective punishment, while studies of insurgency focus on a contest of legitimacy between actors, and social movement theory tend to link political objectives, social capital, and a mechanism of influence to leverage against the state. Each discipline has a particular vernacular for the mechanism of coercion, which is often linked to the means of coercion, but they converge on three core theoretical components of compelling a polity to change its policies or actions: exceeding resistance to change, using political or violent punishments, and withholding legitimacy or consent from a government.

Keywords: counter terrorism, homeland security, insurgency, political coercion, social movement theory, terrorism

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Authors: Aferdita Stroka Koka, Laver Stroka, Juna Musa, Samanda Celaj

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Non-melanoma skin cancers (NMSCs) are the most common human malignancies. About 5.4 million basal and squamous cell skin cancers are diagnosed each year in the US and new cases continue to grow. About eight out of ten of these are basal cell cancers. Squamous cell cancers occur less often. NMSC usually are treatable, but treatment is expensive and can leave scars. In 2019, 167 patients of both sexes suffering from NMSC were treated by traditional medicine. Patients who have been diagnosed with Basal Cell Carcinoma were 122 cases, Squamous Cell Carcinoma 32 cases and both of them 13 cases. Of these,122 cases were ulcerated lesions and 45 unulcerated lesions. All patients were treated with the herbal solution called NILS, which contains extracts of some Albanian plants such as Allium sativum, Jugulans regia and Laurus nobilis. The treatment is done locally, on the surface of the tumor, applying the solution until the tumor mass is destroyed and, after that, giving the necessary time to the wound to make the regeneration that coincides with the complete healing of the wound. We have prepared a collection of photos for each case. Since the first sessions, a shrinkage and reduction of the tumor mass were evident, up to the total disappearance of the lesion at the end of treatment. The normal period of treatment lasted 1 to 2 weeks, depending on the size of the tumor, then take care of it until the closure of the wound, taking the whole process from 1 to 3 months. In 7 patients, the lesion failed to be dominated by treatment and they underwent standard treatment with radiotherapy or surgery, while in 10 patients, the lesion recurred and was treated again. The aim of this survey was to put in evidence the good results obtained by treatment of NMSC with Albanian traditional medicine methods.

Keywords: local treatment, nils, NMSC, traditional medicine

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Authors: Gagandeep Kaur

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The pesticide industry is a big supplier of agricultural inputs. The uses of pesticides control weeds, fungal diseases, etc., which causes of yield losses in agricultural production. In agribusiness and agrichemical industry, Globalization of markets, competition and innovation are the dominant trends. By the tradition of increasing the productivity of agro-systems through generic, universally applicable technologies, innovation in the agrichemical industry is limited. The marketing of technology of agriculture needs to deal with some various trends such as locally-organized forces that envision regionalized sustainable agriculture in the future. Agricultural production has changed dramatically over the past century. Before World War second agricultural production was featured as a low input of money, high labor, mixed farming and low yields. Although mineral fertilizers were applied already in the second half of the 19th century, most f the crops were restricted by local climatic, geological and ecological conditions. After World War second, in the period of reconstruction, political and socioeconomic pressure changed the nature of agricultural production. For a growing population, food security at low prices and securing farmer income at acceptable levels became political priorities. Current agricultural policy the new European common agricultural policy is aimed to reduce overproduction, liberalization of world trade and the protection of landscape and natural habitats. Farmers have to increase the quality of their productivity and they have to control costs because of increased competition from the world market. Pesticides should be more effective at lower application doses, less toxic and not pose a threat to groundwater. There is a big debate taking place about how and whether to mitigate the intensive use of pesticides. This debate is about the future of agriculture which is sustainable agriculture. This is possible by moving away from conventional agriculture. Conventional agriculture is featured as high inputs and high yields. The use of pesticides in conventional agriculture implies crop production in a wide range. To move away from conventional agriculture is possible through the gradual adoption of less disturbing and polluting agricultural practices at the level of the cropping system. For a healthy environment for crop production in the future there is a need for the maintenance of chemical, physical or biological properties. There is also required to minimize the emission of volatile compounds in the atmosphere. Companies are limiting themselves to a particular interpretation of sustainable development, characterized by technological optimism and production-maximizing. So the main objective of the paper will present the trends in the pesticide industry and in agricultural production in the era of Globalization. The second objective is to analyze sustainable agriculture. Companies of pesticides seem to have identified biotechnology as a promising alternative and supplement to the conventional business of selling pesticides. The agricultural sector is in the process of transforming its conventional mode of operation. Some experts give suggestions to farmers to move towards precision farming and some suggest engaging in organic farming. The methodology of the paper will be historical and analytical. Both primary and secondary sources will be used.

Keywords: globalization, pesticides, sustainable development, organic farming

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Authors: Natalia M. Acevedo, Luis M. Jimenez, Erick Lambis

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Imperfections in the capital market are used to argue the relevance of the corporate risk management function. With corporate hedge, the value of the company is increased by reducing the volatility of the expected cash flow and making it possible to face a lower bankruptcy costs and financial difficulties, without sacrificing tax advantages for debt financing. With the propose to avoid exchange rate troubles over cash flows of Colombian exporting firms, this dissertation uses financial options, over exchange rate between Peso and Dollar, for realizing a financial hedge. In this study, a strategy of hedge is designed for an exporting company in Colombia with the objective of preventing fluctuations because, if the exchange rate down, the number of Colombian pesos that obtains the company by exports, is less than agreed. The exchange rate of Colombia is measured by the TRM (Representative Market Rate), representing the number of Colombian pesos for an American dollar. First, the TMR is modelled through the Geometric Brownian Motion, with this, the project price is simulated using Montecarlo simulations and finding the mean of TRM for three, six and twelve months. For financial hedging, currency options were used. The 6-month projection was covered with financial options on European-type currency with a strike price of $ 2,780.47 for each month; this value corresponds to the last value of the historical TRM. In the compensation of the options in each month, the price paid for the premium, calculated with the Black-Scholes method for currency options, was considered. Finally, with the modeling of prices and the Monte Carlo simulation, the effect of the exchange hedging with options on the exporting company was determined, this by means of the unit price estimate to which the dollars in the scenario without coverage were changed and scenario with coverage. After using the scenarios: is determinate that the TRM will have a bull trend and the exporting firm will be affected positively because they will get more pesos for each dollar. The results show that the financial options manage to reduce the exchange risk. The expected value with coverage is approximate to the expected value without coverage, but the 5% percentile with coverage is greater than without coverage. The foregoing indicates that in the worst scenarios the exporting companies will obtain better prices for the sale of the currencies if they cover.

Keywords: currency hedging, futures, geometric Brownian motion, options

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Authors: P. R. Chauhan, S. K. Tyagi

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Adsorption refrigeration technology offers a sustainable and energy-efficient cooling alternative over traditional refrigeration technologies for meeting the fast-growing cooling demands. With its ability to utilize natural refrigerants, low-grade heat sources, and modular configurations, it has the potential to revolutionize the cooling industry. Despite these benefits, the commercial viability of this technology is hampered by several fundamental limiting constraints, including its large size, low uptake capacity, and poor performance as a result of deficient heat and mass transfer characteristics. The primary cause of adequate heat and mass transfer characteristics and magnitude of exergy loss in various real processes of adsorption cooling system can be assessed by the entropy generation rate analysis, i. e. Second law of Thermodynamics. Therefore, this article presents the second law of thermodynamic-based investigation in terms of entropy generation rate (EGR) to identify the energy losses in various processes of the HPCC-based adsorption system using MATLAB R2021b software. The adsorption technology-based cooling system consists of two beds made up of silica gel and arranged in a single stage, while the water is employed as a refrigerant, coolant, and hot fluid. The variation in process-wise EGR is examined corresponding to cycle time, and a comparative analysis is also presented. Moreover, the EGR is also evaluated in the external units, such as the heat source and heat sink unit used for regeneration and heat dump, respectively. The research findings revealed that the combination of adsorber and desorber, which operates across heat reservoirs with a higher temperature gradient, shares more than half of the total amount of EGR. Moreover, the EGR caused by the heat transfer process is determined to be the highest, followed by a heat sink, heat source, and mass transfer, respectively. in case of heat transfer process, the operation of the valve is determined to be responsible for more than half (54.9%) of the overall EGR during the heat transfer. However, the combined contribution of the external units, such as the source (18.03%) and sink (21.55%), to the total EGR, is 35.59%. The analysis and findings of the present research are expected to pinpoint the source of the energy waste in HPCC based adsorption cooling systems.

Keywords: adsorption cooling cycle, heat transfer, mass transfer, entropy generation, silica gel-water

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Authors: Maryam Kamali Nezhad

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The Robert-Bourassa development (LG-2), the first to be built on the Grande Rivière, comprises two sets of eight turbines- generator units each, the East and West powerhouses. Each powerhouse has two tailrace tunnels with an average length of about 1178 m. The LG-2A powerhouse houses 6 turbine-generator units. The water is discharged through two tailrace tunnels with a length of about 1330 m. The objective of this work, at RB (LG-2), is; 1) to establish a new maximum transient level in the surge chamber, 2) to define the new maximum equipment flow rate for the future turbine-generator units, 3) to ensure safe access to various intervention locations in the surge chamber. The transient levels under normal operating conditions at the RB plant were determined in 2001 by the Hydraulics Unit of HQE using the "Chamber" software. It is a one-dimensional mass oscillation calculation software; it is used to determine the variation of the water level in the equilibrium chamber located downstream of a power plant during the load shedding of the power plant units; it can also be used in the case of an equilibrium stack upstream of a power plant. The RB (LG-2) plant study is based on the theoretical nominal geometry of the chamber and the tailrace tunnels and the flow-level relationship at the outlet of the galleries established during design. The software is used in such a way that the results have an acceptable margin of safety, especially with respect to the maximum transient level (e.g., resumption of flow at an inopportune time), to take into account the turbulent and three-dimensional aspects of the actual flow in the chamber. Note that the transient levels depend on the water levels in the river and in the steady-state equilibrium chambers. These data are established in the HQP CRP database and updated from time to time. The maximum transient levels in the RB-East and RB-West powerhouses surge chamber were revised based on the latest update (set 4) of in-river rating curves and steady-state surge chamber water levels. The results of the revision were also used to update the technical advice on the operating conditions for the aforementioned surge chamber access while considering revisions to the calculated water levels.

Keywords: generating station, surge chamber, maximum transient level, hydroelectric power station, turbine-generator, reservoir

Procedia PDF Downloads 86

Authors: Bonnie Pollak

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As the world continues to suffer grievous injuries, future generations will suffer from trauma that was inflicted on innocent victims. Trauma can result from refugees fleeing their homes, exposure to warfare, loss of loved ones, and lack of shelter and basic necessities. The Holocaust continues to cause pain even though WWII ended nearly 80 years ago. One cannot forget the inhumane treatment and murder of relatives. The pain and trauma may continue for generations. The purpose of the Final Solution was to eliminate Jews in totality. Though Hitler’s plan was not successful, he managed to cause trauma that will continue with no end date in sight. “The Effects of Trauma and Secondary Trauma,” Trauma can cause life-long challenges, eating disorders, cardiovascular disease, cancer, sleeping difficulties, fear of going outside, guilt, separation problems, and epigenetic changes. Secondary Trauma, witnessing a loved one in danger or hearing about the danger, can cause similar symptoms as seen in primary trauma. The transmission of trauma was demonstrated in children of Holocaust survivors and in communities where oppression was commonplace. We are witnessing a repeat of widescale death and horrific injuries today in Ukraine and in other parts of the world, where concern for pain and trauma is not acknowledged by perpetrators. Lessons from the Holocaust can be applied to help others who have been traumatized by widescale terrorism resulting in death of loved ones, loss of home and shelter, food and other life-sustaining measures. The world must help victims by providing basic necessities but also by using trauma-informed care, focusing on strength and resilience, and helping individuals to feel pride in their identity.

Keywords: transmission of intergenerational trauma, impact on religious beliefs and practices, 2nd generation, identity

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Authors: Kvnkc Sharma

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Globalization, coupled with increase in competition is compelling organizations to adopt innovative strategies and identify core competencies in order to distinguish themselves from the competition. The capability of an organization is no longer determined by their products or services alone. The intellectual assets and quality of the human resource are fast emerging as key differentiators. Corporations are now positioning themselves as ‘brands’ not solely to market their products and services, but also to lure and to retain the best talent in the business. This paper identifies leadership as the ‘key element’ in developing an organization’s brand, which has a significant influence on the employee’s eventual perception of this external brand as portrayed by the organization. External branding incorporates innovation, consumer concern, trust, quality and sustainability. The paper contends that employees are indeed an organization’s ‘brand ambassadors. Internal branding involves taking care of these ambassadors of corporate brand i.e. human resource. If employees of an organization are not exposed to the organization’s branding (an ongoing process that functionally aligns, motivates and empower employees at all levels to consistently provide a satisfying customer experience), the external brand could be jeopardized. Internal branding, on the other hand, refers to employee’s perception of the organization’s brand. The current business environment can at best, be termed as volatile. Employees with the right technical and behavioral skills remain a scarce resource and the employers need to be ready to capture the attention, interest and commitment of the best and brightest candidates. This paper attempts to review and understand the relationship between employer branding and employee retention. The paper also seeks to identify potential impact of employer branding across all the factors affecting employees.

Keywords: external branding, human resource, internal branding, leadership

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Authors: Ling-Lang Huang

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Research Background: Historically, the evolution of medicine has not only aimed to extend life but has also inadvertently introduced suffering in the process of maintaining life, presenting a contemporary challenge. We must carefully assess the conflict between the length of life and the quality of living. Evidence-Based Medicine (EBM) exists primarily to ensure the quality of cures. However, EBM alone does not fulfill our ultimate medical goals; we must also evaluate Value-Based Medicine (VBM) to find the best treatment for patients. Research Methodology: We can attempt to integrate EBM with VBM. Within the five steps of EBM, the first three steps (Ask—Acquire—Appraise) focus on the physical aspect of humans. However, in the fourth and fifth steps (Apply—Assess), the focus shifts from the physical to applying evidence-based treatment to the patient and assessing its effectiveness, considering a holistic approach to the individual. To consider VBM for patients, we can divide the process into three steps: The first step is "awareness," recognizing that each patient inhabits a different life-world and possesses unique differences. The second step is "integration," akin to the hermeneutic concept of the Fusion of Horizons. This means being aware of differences and also understanding the origins of these patient differences. The third step is "respect," which involves setting aside our adherence to medical objectivity and scientific rigor to respect the ultimate healthcare decisions made by individuals regarding their lives. Discussion and Conclusion: After completing these three steps of VBM, we can return to the fifth step of EBM: Assess. Our assessment can now transcend the physical treatment focus of the initial steps to align with a holistic care philosophy.

Keywords: shared decision-making, evidence-based medicine, values-based medicine, holistic healthcare

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