Search results for: ante natal care

Authors: Katie Jerram, Jacqui Nevols, Rebecca Howes, Hayley Richardson, Debbie Suso, Thomas Batten, Reny Mathai

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Pyomyositis is an uncommon acute purulent skeletal muscle infection, usually caused by Staphylococcus aureus, occurring either spontaneously or following local trauma. Immunocompromise is a risk factor. It presents with pyrexia, pain, and tenderness of the affected muscle, which may have a firm ‘woody’ feel. Management usually involves surgery and prolonged courses of antibiotics, but alongside these active treatments, palliation of symptoms such as pain is also a priority. A short case series of diabetic inpatients under the care of the Renal Medicine team with pyomyositis is presented, demonstrating that Hospital Palliative Care Teams may be well placed to provide symptom management advice by working jointly with the patient’s medical or surgical team. A review of the literature on the management of pain in pyomyositis is also presented, and there was no clear consensus on the best strategy. It may be that a combination of analgesics and adjuncts is the most effective strategy, perhaps combined with the holistic approach used within palliative care.

Keywords: pyomyositis, pain, palliation, analgesia

Procedia PDF Downloads 140

Authors: Hsin-Yi Lo, Huang-Ju Jiun, Yu-Chiao Chu

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Hemodynamic monitoring is an important in the intensive care unit. Advances in medical technology in recent years, more diversification of intensive care equipment, there are many kinds of instruments available for monitoring of hemodynamics, Edwards Lifesciences Hemodynamic Monitoring (FloTrac) is one of them. The recent medical safety incidents in parameters were changed, nurses have not to notify doctor in time, therefore, it is hoped to analyze the current problems and find effective improvement strategies. In August 2021, the survey found that only 74.0% of FloTrac correctness of operation, reasons include lack of education, the operation manual is difficulty read, lack of audit mechanism, nurse doesn't know those numerical changes need to notify doctor, work busy omission, unfamiliar with operation and have many nursing records then omissions. Improvement methods include planning professional nurse education, formulate the secret arts of FloTrac, enacting an audit mechanism, establish FloTrac action learning, make「follow the sun」care map, hold simulated training and establish monitoring data automatically upload nursing records. After improvement, FloTrac correctness of operation increased to 98.8%. The results are good, implement to the ICU of the hospital.

Keywords: hemodynamic monitoring, edwards lifesciences hemodynamic monitoring, multiple strategies, intensive care

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Authors: Vera Lúcia Raposo

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The right to health care – usually known as the right to health – is recognized in many national laws and Constitutions, as well as in international human rights documents. The kind of health care that citizens are entitled to receive, especially in the framework of the National Health Service, is usually identified with conventional medicine. However, since ancient times that a different form of medicine – alternative, traditional or nonconventional medicine – exists. In recent times it is attracting increasing interest, as it is demonstrated by the use of its specific knowledge either by pharmaceutical companies either by modern health technologies. Alternative medicine refers to a holistic approach to body and mind using herbal products, animal parts and minerals instead of technology and pharmaceutical drugs. These notes contributed to a sense of distrust towards it, accusing alternative medicine of being based on superstition and ignorance. However, and without denying that some particular practices lack indeed any kind of evidence or scientific grounds, the fact is that a substantial part of alternative medicine can actually produce satisfactory results. The paper will not advocate the substitution of conventional medicine by alternative medicine, but the complementation between the two and their specific knowledge. In terms of the right to health, as a fundamental right and a human right, this thesis leads to the implementation of a wider range of therapeutic choices for patients, who should be entitled to receive different forms of health care that complement one another, both in public and private health facilities. This scenario would demand a proper regulation for alternative medicine, which nowadays does not exist in most countries, but it is essential to protect patients and public health in general and to reinforce confidence in alternative medicine.

Keywords: alternative medicine, conventional medicine, patient’s rights, right to health

Procedia PDF Downloads 385

Authors: Hsin-Yi Lo, Chia-Yu Hsu

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This article is the nursing experience of a multiple trauma case using Swanson's theory of caring, the nursing period is from May 31 to June 4, 2021, collect data through observation, written talks, interviews, listening, direct care and physical assessment, established cases with health problems such as acute pain, impaired tissue integrity, and anxiety. Nursing process including, evaluate the pain index with the pain assessment scale, assist in acupoint massage, use a corset to fix the wound, and give the patient listening to favorite radio programs to divert attention and relieve pain problems; promote wound healing and avoid infection by assessing wound condition and exudation, changing dressings with aseptic technique, and providing appropriate dressings; encourage patients to express their feelings, provide companionship, and assist in self-care and participation in treatment plans, to enable the case to overcome the anxiety caused by being admitted to the intensive care unit for the first time and not knowing about the disease, and assist the case to overcome the injury caused by the accident and return to normal life. There is no video equipment in the intensive care unit during the nursing period. In response to the problem that family visits cannot be opened during the epidemic, it is a limitation this time. It is recommended that the hospital take this into consideration in the future. In the post-epidemic era, it can reduce the risk of various infections for patients and family members. Traveling between home and hospital, improving the quality of high-quality and technological care.

Keywords: swanson's theory of caring, multiple trauma, anxiety, nursing experience

Procedia PDF Downloads 79

Authors: Emily Saurman, David Lyle

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In Australia, a well serviced rural town might have a psychiatrist visit once-a-month with more frequent visits from a psychiatric nurse, but many have no resident access to mental health specialists. Access to specialist care, would not only reduce patient distress and benefit outcomes, but facilitate the effective use of limited resources. The Mental Health Emergency Care-Rural Access Program (MHEC-RAP) was developed to improve access to specialist emergency mental health care in rural and remote communities using telehealth technologies. However, there has been no current benchmark to gauge program efficiency or capacity; to determine whether the program activity is justifiably sufficient. The evaluation of MHEC-RAP used multiple methods and applied a modified theory of access to assess the program and its aim of improved access to emergency mental health care. This was the first evaluation of a telepsychiatry service to include a time and motion study design examining program time expenditure, efficiency, and capacity. The time and motion study analysis was combined with an observational study of the program structure and function to assess the balance between program responsiveness and efficiency. Previous program studies have demonstrated that MHEC-RAP has improved access and is used and effective. The findings from the time and motion study suggest that MHEC-RAP has the capacity to manage increased activity within the current model structure without loss to responsiveness or efficiency in the provision of care. Enhancing program responsiveness and efficiency will also support a claim of the program’s value for money. MHEC-RAP is a practical telehealth solution for improving access to specialist emergency mental health care. The findings from this evaluation have already attracted the attention of other regions in Australia interested in implementing emergency telepsychiatry programs and are now informing the progressive establishment of mental health resource centres in rural New South Wales. Like MHEC-RAP, these centres will provide rapid, safe, and contextually relevant assessments and advice to support local health professionals to manage mental health emergencies in the smaller rural emergency departments. Sharing the application of this methodology and research activity may help to improve access to and future evaluations of telehealth and telepsychiatry services for others around the globe.

Keywords: access, emergency, mental health, rural, time and motion

Procedia PDF Downloads 234

Authors: S. Mantzoukis, M. Gerasimou, P. Christodoulou, N. Varsamis, G. Kolliopoulou, N. Zotos

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Purpose: Patients in Intensive Care Units (ICU) are exposed to a different spectrum of microorganisms relative to the hospital. Due to the fact that the majority of these patients are intubated, bronchial secretions should be examined. Material and Method: Bronchial secretions should be taken with care so as not to be mixed with sputum or saliva. The bronchial secretions are placed in a sterile container and then inoculated into blood, Mac Conkey No2, Chocolate, Mueller Hinton, Chapman and Saboureaud agar. After this period, if any number of microbial colonies are detected, gram staining is performed and then the isolated organisms are identified by biochemical techniques in the automated Microscan system (Siemens) followed by a sensitivity test in the same system using the minimum inhibitory concentration MIC technique. The sensitivity test is verified by a Kirby Bauer test. Results: In 2017 the Laboratory of Microbiology received 365 samples of bronchial secretions from the Intensive Care Unit. 237 were found positive. S. epidermidis was identified in 1 specimen, A. baumannii in 60, K. pneumoniae in 42, P. aeruginosa in 50, C. albicans in 40, P. mirabilis in 4, E. coli in 4, S. maltophilia in 6, S. marcescens in 6, S. aureus in 12, S. pneumoniae in 1, S. haemolyticus in 4, P. fluorescens in 1, E. aerogenes in 1, E. cloacae in 5. Conclusions: The majority of ICU patients appear to be a fertile ground for the development of infections. The nature of the findings suggests that a significant part of the bacteria found comes from the unit (nosocomial infection).

Keywords: bronchial secretions, cultures, infections, intensive care units

Procedia PDF Downloads 185

Authors: Diane Ghanem, Whitney Kagabo, Rebecca Engels, Uma Srikumaran, Babar Shafiq

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Hospitalist co-management of orthopaedic surgery patients is a growing trend across the country. It was created as a collaborative effort to provide overarching care to patients with the goal of improving their postoperative care and decreasing in-hospital medical complications. The aim of this project is to provide a guide for implementing and optimizing a hospitalist co-management service in orthopaedic surgery. Key leaders from the hospitalist team, orthopaedic team and quality, safety and service team were identified. Multiple meetings were convened to discuss the comanagement service and determine the necessary building blocks behind an efficient and well-designed co-management framework. After meticulous deliberation, a consensus was reached on the final service agreement and a written guide was drafted. Fundamental features of the service include the identification of service stakeholders and leaders, frequent consensus meetings, a well-defined framework, with goals, program metrics and unified commands, and a regular satisfaction assessment to update and improve the program. Identified pearls for co-managing orthopaedic surgery patients are standardization, timing, adequate patient selection, and two-way feedback between hospitalists and orthopaedic surgeons to optimize the protocols. Developing a service agreement is a constant work in progress, with meetings, discussions, revisions, and multiple piloting attempts before implementation. It is a partnership created to provide hospitals with a streamlined admission process where at-risk patients are identified early, and patient care is optimized regardless of the number or nature of medical comorbidities. A wellestablished hospitalist co-management service can increase patient care quality and safety, as well as health care value.

Keywords: co-management, hospitalist co-management, implementation, orthopaedic surgery, quality improvement

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Authors: A. Zurraini, Syed Alwi Sar, H. Helmy, H. Nazeefah

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Early Dementia Questionnaire (EDQ) was developed as a screening tool to detect patients with early dementia in primary care. It was developed based on 20 symptoms of dementia. From a preliminary study, EDQ had been shown to be a promising alternative for screening of early dementia. This study was done to further test on EDQ’s reliability and validity. Using a systematic random sampling, 200 elderly patients attending primary health care centers in Kuching, Sarawak had consented to participate in the study and were administered the EDQ. Geriatric Depression Scale (GDS) was used to exclude patients with depression. Those who scored >21 MMSE, were retested using the EDQ. Reliability was determined by Cronbach’s alpha for internal consistency and construct validity was assessed using confirmatory factor analysis (principle component with varimax rotation). The result showed that the overall Cronbach’s alpha coefficient was good which was 0.874. Confirmatory factor analysis on 4 factors indicated that the Cronbach’s alpha for each domain were acceptable with memory (0.741), concentration (0.764), emotional and physical symptoms (0.754) and lastly sleep and environment (0.720). Pearson correlation coefficient between the first EDQ score and the retest EDQ score among those with MMSE of >21 showed a very strong, positive correlation between the two variables, r = 0.992, N=160, P <0.001. The results of the validation study showed that Early Dementia Questionnaire (EDQ) is a valid and reliable tool to be used as a screening tool to detect early dementia in primary care.

Keywords: Early Dementia Questionnaire (EDQ), screening, primary care, construct validity

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Authors: Deirdre Mc Grath, Joanne Reid

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Background: Ovarian cancer is the leading cause of mortality among gynaecologic cancers in developed countries and the seventh most common cancer worldwide, with nearly 240,000 women diagnosed each year. Although it is recognized engaging in exercise results in positive health care outcomes, women with ovarian cancer are reluctant to participate. No evidence currently exists focusing on how to successfully implement an exercise intervention program for patients with ovarian cancer, using a realist approach. There is a requirement for the implementation of exercise programmes within the oncology health care setting as engagement in such interventions has positive health care outcomes for women with ovarian cancer both during and following treatment. Aim: To co-design the implementation of an exercise intervention for women following treatment for ovarian cancer. Methods: This study is a realist evaluation using quantitative and qualitative methods of data collection and analysis. Realist evaluation is well-established within the health and social care setting and has, in relation to this study, enabled a flexible approach to investigate how to optimise implementation of an exercise intervention for this patient population. This single centre study incorporates three stages in order to identify the underlying contexts and mechanisms which lead to the successful implementation of an exercise intervention for women who have had treatment for ovarian cancer. Stage 1 - A realist literature review. Stage 2 -Co-design of the implementation of an exercise intervention with women following treatment for ovarian cancer, their carer’s, and health care professionals. Stage 3 –Implementation of an exercise intervention with women following treatment for ovarian cancer. Evaluation of the implementation of the intervention from the perspectives of the women who participated in the intervention, their informal carers, and health care professionals. The underlying programme theory initially conceptualised before and during the realist review was developed further during the co-design stage. The evolving programme theory in relation to how to successfully implement an exercise for these women is currently been refined and tested during the final stage of this realist evaluation which is the implementation and evaluation stage. Results: This realist evaluation highlights key issues in relation to the implementation of an exercise intervention within this patient population. The underlying contexts and mechanisms which influence recruitment, adherence, and retention rates of participants are identified. Conclusions: This study will inform future research on the implementation of exercise interventions for this patient population. It is anticipated that this intervention will be implemented into practice as part of standard care for this group of patients.

Keywords: exercise, ovarian cancer, co-design, implementation

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Authors: Bill D. Geis

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Suicide wrongful death forensic cases are the fastest rising tort in mental health law. It is estimated that suicide-related cases have accounted for 15% of U.S. malpractice claims since 2006. Most suicide-related personal injury claims fall into the legal category of “wrongful death.” Though mental health experts may be called on to address a range of forensic questions in wrongful death cases, the central consultation that most experts provide is about the negligence element—specifically, the issue of whether the clinician met the clinical standard of care in assessing, treating, and managing the deceased person’s mental health care. Standards of care, varying from U.S. state to state, are broad and address what a reasonable clinician might do in a similar circumstance. This fact leaves the issue of the suicide standard of care, in each case, up to forensic experts to put forth a reasoned estimate of what the standard of care should have been in the specific case under litigation. Because the general state guidelines for standard of care are broad, forensic experts are readily retained to provide scientific and clinical opinions about whether or not a clinician met the standard of care in their suicide assessment, treatment, and management of the case. In the past and in much of current practice, the assessment of suicide has centered on the elicitation of verbalized suicide ideation. Research in recent years, however, has indicated that the majority of persons who end their lives do not say they are suicidal at their last medical or psychiatric contact. Near-term risk assessment—that goes beyond verbalized suicide ideation—is needed. Our previous research employed structural equation modeling to predict lethal suicide risk--eight negative thought patterns (feeling like a burden on others, hopelessness, self-hatred, etc.) mediated by nine transdiagnostic clinical factors (mental torment, insomnia, substance abuse, PTSD intrusions, etc.) were combined to predict acute lethal suicide risk. This structural equation model, the Lethal Suicide Risk Pattern (LSRP), Acute model, had excellent goodness-of-fit [χ2(df) = 94.25(47)***, CFI = .98, RMSEA = .05, .90CI = .03-.06, p(RMSEA = .05) = .63. AIC = 340.25, ***p < .001.]. A further SEQ analysis was completed for this paper, adding a measure of Acute Suicide Ideation to the previous SEQ. Acceptable prediction model fit was no longer achieved [χ2(df) = 3.571, CFI > .953, RMSEA = .075, .90% CI = .065-.085, AIC = 529.550].This finding suggests that, in this additional study, immediate verbalized suicide ideation information was unhelpful in the assessment of lethal risk. The LSRP and other dynamic, near-term risk models (such as the Acute Suicide Affective Disorder Model and the Suicide Crisis Syndrome Model)—going beyond elicited suicide ideation—need to be incorporated into current clinical suicide assessment training. Without this training, the standard of care for suicide assessment is out of sync with current research—an emerging dilemma for the forensic evaluation of suicide wrongful death cases.

Keywords: forensic evaluation, standard of care, suicide, suicide assessment, wrongful death

Procedia PDF Downloads 68

Authors: Zemenu Yohannes

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Introduction: The pandemic overstretched the weak health systems in developing countries, including Ethiopia. This study aims to assess and explore the effect of COVID-19 on antenatal care (ANC) provision. Methods: A concurrent mixed methods study was applied. An interrupted time series design was applied for the quantitative study, and in-depth interviews were implemented for the qualitative research to explore maternity care providers' perceptions of ANC provision during COVID-19. We used routine monthly collected data from the health management information system (HMIS) in fifteen hospitals in the Sidama region, Ethiopia, from March 2019 to February 2020 (12 months) before COVID-19 and from March to August 2020 (6 months) during COVID-19. We imported data into STATA V.17 for analysis. ANC provision's mean monthly incidence rate ratio (IRR) was calculated using Poisson regression with a 95% confidence interval. The qualitative data were analysed using thematic analysis. Findings from quantitative and qualitative elements were integrated with a contiguous approach. Results: Our findings indicate the rate of ANC provision significantly decreased in the first six months of COVID-19. This study has three identified main themes: barriers to ANC provision, inadequate COVID-19 prevention approach, and delay in providing ANC. Conclusion and recommendation: Based on our findings, the pandemic affected ANC provision in the study area. The health bureau and stakeholders should take a novel and sustainable approach to prevent future pandemics. The health bureau and hospital administrators should establish a task force that relies on financial self-reliance to close gaps in future pandemics of medical supply shortages. Pregnant women should receive their care promptly from maternity care providers. In order to foster contact and avoid discrimination the future pandemics, hospital administrators should set up a platform for community members and maternity care providers.

Keywords: ANC provision, COVID-19, mixed methods study, Ethiopia

Procedia PDF Downloads 74

Authors: Neeti Rustagi, Naveen Dutt, Arvind Sinha, Mahaveer S. Rhodha, Pankaja R. Raghav

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Background: Pre-hospital trauma care services are in developing stage in fast-urbanizing cities of India including Jodhpur. Training of health professionals in providing necessary pre-hospital trauma care is an essential step in decreasing accident related morbidity and mortality. The current study explores the response of a medical graduate toward helping an accident victim in a pre-hospital setting before patient can be transferred to definitive trauma facility. Methodology: This study examines the perceived competence in predicting response to an accident victim by medical graduates in Jodhpur, Rajasthan. Participants completed measures of attitude, normative influence and perceived behavior control toward providing pre-hospital care to an accident victim. Likert scale was used to measure the participant responses. Preliminary and descriptive analysis were used using SPSS 21.0. Internal consistency of the responses received was measured using Cronbach’s alpha. Results: Almost all medical graduates agreed that road accidents are common in their area (male: 92%; female: 78%). More male medical graduates (28%) reported helping an accident victim as compared to female physicians (9%) in the previous three months. Majority of study participants (96%) reported that providing immediate care to an accident victim is essential to save the life of an individual. Experience of helping an accident victim was considered unpleasant by the majority of female participants (70%) as compared to male participants (36%). A large number of participants believed that their friends (80%) and colleagues (96%) would appreciate them helping an accident victim in a pre-hospital setting. A large number of participants also believed that they possess the necessary skills and competencies (80%) towards helping a roadside accident victim in the pre-hospital care environment. Perceived competence of helping a roadside accident victim until they are transferred to a health facility was reported by less than half of the participants (male: 56%; female: 43%). Conclusion: Medical graduates have necessary attitude, competencies, and intention of helping a roadside accident victim. The societal response towards helping a road side accident victim is also supportive. In spite of positive determinants, a large proportion of medical graduates have perceived lack of competence in helping a roadside accident victim. This is essential to explore further as providing pre-hospital care to a roadside accident victim is an essential step in establishing the continuum of care to an accident victim especially in countries where pre-hospital services are in developing phase.

Keywords: prehospital care, perceived behavior, perceived competence, medical graduates

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Authors: Huda Al-Awisi, Mohammed Al-Azri, Samira Al-Rasbi, Mansour Al-Moundhri

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Cancer diagnosis is invariably a profound and catastrophic life-changing experience for individuals and their families. It has been found that cancer patients and survivors are distressed with the fragility of their life and their mortality. Based on the literature, cancer patients /survivors value their spiritual experience and connecting with unknown power either related to religious belief or not as an important coping mechanism. Health care professionals including nurses are expected to provide spiritual care for cancer patients as holistic care. Yet, nurses face many challenges in providing such care mainly due to lack of clear definition of spirituality. This study aims to explore coping mechanisms of Omani women diagnosed with breast cancer throughout their cancer journey including spirituality using a qualitative approach. A purposive sample of 19 Omani women diagnosed with breast cancer at different stages of cancer treatment modalities were interviewed. Interviews were tape recorded and transcribed verbatim. The framework approach was used to analyze the data. One main theme related to spirituality was identified and called “The power of faith”. For the majority of participants, faith in God (the will of God) was most important in coping with all stages of their breast cancer experience. Some participants thought that the breast cancer is a test from God which they have to accept. Participants also expressed acceptance of death as the eventual end and reward from God. This belief gives them the strength to cope with cancer and seek medical treatment. In conclusion, women participated in this study believed faith in God imposed spiritual power for them to cope with cancer. They connected spirituality with religious beliefs. Therefore, regardless of nurses’ faith in spirituality, the spiritual care needs to be tailored and provided according to each patient individual need.

Keywords: breast cancer, spiritual, religion, coping, diagnosis, oman, women

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Authors: Philip Eappen, Narasimha Rao Vajjhala

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This chapter examines how healthcare organizations harnessed innovative healthcare informatics to navigate the challenges posed by the COVID-19 pan-demic, addressing critical needs and improving care delivery. The pandemic's un-precedented demands necessitated the adoption of new and advanced tools to manage healthcare operations more effectively. Informatics solutions played a crucial role in facilitating the smooth functioning of healthcare systems during this crisis and are anticipated to remain central to future healthcare management. Technologies such as telemedicine helped healthcare professionals minimize ex-posure to COVID-19 patients, thereby reducing infection risks within healthcare facilities. This chapter explores a range of informatics applications utilized worldwide, including telemedicine, AI-driven solutions, big data analytics, drones, robots, and digital platforms for drug delivery, all of which enabled re-mote patient care and enhanced healthcare accessibility and safety during the pan-demic.

Keywords: healthcare informatics, COVID-19 Pandemic, telemedicine, AI-driven healthcare, big data analytics, remote patient care, digital health platforms

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Authors: Aimen Batool Bint-E-Rashid, Syed Muhammad Dawood Ali Shah, Muhammad Usman Farooq, Mahgul Anwar

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As the world is progressing, the needs and demands of the consumer market are also changing. Nowadays the trends of consumer purchase decisions are dependent upon multiple factors. This study aims to identify the influential impact of country of origin over the perception and devotion towards daily personal care products specifically in reference to the knowledge and awareness regarding that particular brand in Pakistan. To corroborate this study, a 30-item brand origin questionnaire has been used with 300 purchase decision makers belonging to different age groups. To illustrate this study, a model has been developed based on brand origin, brand awareness and brand loyalty. Correlation and regression analysis have been used to find out the results which conclude the findings on the perspective of Pakistan’s consumer market as that brand origin has a direct relationship with brand loyalty provided that the consumer has a positive brand awareness. Support for the fact that brand origin impacts brand loyalty through brand awareness has been presented in this study.

Keywords: brand awareness, brand loyalty, brand origin, personal care products, P&G, Unilever

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Authors: Shannon Hearney, Jeffrey Hoch

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While all cancers are costly to treat, pancreatic cancer is a notoriously costly and deadly form of cancer. Across the world there are a variety of treatment centers ranging from small clinics to large, high-volume hospitals as well as differing structures of payment and access. It has been noted that centers that treat a high volume of pancreatic cancer patients have higher quality of care, it is unclear if that care is cost-effective. In the US there is no clear consensus on the cost-effectiveness of high-volume centers for the surgical care of pancreatic cancer. Other European countries, like Finland and Italy have shown that high-volume centers have lower mortality rates and can have lower costs, there however, is still a gap in knowledge about these centers cost-effectiveness globally. This paper seeks to review the current literature in Europe and the US to gain a better understanding of the state of high-volume pancreatic surgical centers cost-effectiveness while considering the contextual differences in health system structure. A review of major reference databases such as Medline, Embase and PubMed will be conducted for cost-effectiveness studies on the surgical treatment of pancreatic cancer at high-volume centers. Possible MeSH terms to be included, but not limited to, are: “pancreatic cancer”, “cost analysis”, “cost-effectiveness”, “economic evaluation”, “pancreatic neoplasms”, “surgical”, “Europe” “socialized medicine”, “privatized medicine”, “for-profit”, and “high-volume”. Studies must also have been available in the English language. This review will encompass European scientific literature, as well as those in the US. Based on our preliminary findings, we anticipate high-volume hospitals to provide better care at greater costs. We anticipate that high-volume hospitals may be cost-effective in different contexts depending on the national structure of a healthcare system. Countries with more centralized and socialized healthcare may yield results that are more cost-effective. High-volume centers may differ in their cost-effectiveness of the surgical care of pancreatic cancer internationally especially when comparing those in the United States to others throughout Europe.

Keywords: cost-effectiveness analysis, economic evaluation, pancreatic cancer, scientific literature review

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Authors: Harmeet Pal Singh Dhooria, Deepinder Chinna, UPS Sidhu, Alok Jain

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Serious infections caused by gram-negative bacteria are a significant cause of mortality and morbidity in the hospital setting. In acute care facilities like in intensive care units (ICUs), the intensity of antimicrobial use together with a population highly susceptible to infection, creates an environment, which facilitates both emergence and transmission of Extended Spectrum -lactamase (ESBL) producing Enterobacteriaceae species. The study was conducted in the Medical Intensive Care Unit (MICU) and the Pulmonary Critical Care Unit (PCCU) of the Department of Medicine, Dayanand Medical College and Hospital, Ludhiana, Punjab, India. Out of a total of 1108 samples of urine, blood and respiratory tract secretions received for culture and sensitivity analysis from Medical Intensive Care Unit and Pulmonary Critical Care Unit, a total of 170 isolates of Enterobacteriaceae species were obtained which were then included in our study. Out of these 170 isolates, confirmed ESBL production was seen in 116 (68.24%) cases. E.coli was the most common species isolated (56.47%) followed by Klebsiella (32.94%), Enterobacter (5.88%), Citrobacter (3.53%), Enterobacter (0.59%) and Morganella (0.59%) among the total isolates. The rate of ESBL production was more in Klebsiella (78.57%) as compared to E.coli (60.42%). ESBL producers were found to be significantly more common in patients with prior history of hospitalization, antibiotic use, and prolonged ICU stay. Also significantly increased the prevalence of ESBL related infections was observed in patients with a history of catheterization or central line insertion but not in patients with the history of intubation. Patients who had an underlying malignancy had significantly higher prevalence of ESBL related infections as compared to other co-morbid illnesses. A slightly significant difference in the rate of mortality/LAMA was observed in the ESBL producer versus the non-ESBL producer group. The rate of mortality/LAMA was significantly higher in the ESBL related UTI but not in the ESBL related respiratory tract and bloodstream infections. ESBL producing isolates had significantly higher rates of resistance to Cefepime and Piperacillin/Tazobactum, and to non β-lactum antibiotics like Amikacin and Ciprofloxacin. The level of resistance to Imipenem was lower as compared to other antibiotics. However, it was noted that ESBL producing isolates had higher levels of resistance to Imipenem as compared to non-ESBL producing isolates. Conclusion- The prevalence of ESBL producing organisms was found to be very high (68.24%) among Enterobacteriaceae isolates in our ICU setting as among other ICU care settings around the world.

Keywords: enterobacteriaceae, extended spectrum B-lactamase (ESBL), ICU, antibiotic resistance

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Authors: R. Pääkkönen, L. Korpinen, T. Kava, I. Salmi

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This study evaluates obstructive sleep apnea treatment through a case study involving a 67-year-old male driver who had a successful continuous positive airway pressure (CPAP) treatment at home but experienced difficulties with traveling and dental care. There are many cheap sleep apnea and snoring devices available, but there is little professional advice on what kind of devices can help. Professional drivers receive yearly specialized medical care follow-up.

Keywords: sleep, apnea patient, CPAP, professional driver

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Authors: Samantha Ramachandra, Avanthi Rupasinghe

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Demographic transition from lower to higher percentage of elderly population eventually coupled with epidemiological transition from communicable to non-communicable diseases (NCD). Higher percentage of NCD overload the health system as NCD survivors claims continuous health care. The demands are challenging to a resource constrained setting but reorganizing the system may find solutions. The study focused on the facilities available and their utilization at outpatient department (OPD) setting of the public hospitals of Sri Lanka for continuous medical care. This will help in identifying steps of reorganizing the system to provide better care with the maximum utilization of available facilities. The study was conducted as a situation analysis with secondary data at hospital planning units. Variable were identified according to the world health organization (WHO) recommendation on continuous health care for elders in “age-friendly primary health care toolkit”. Data were collected from secondary and tertiary care hospitals of Sri Lanka where most of the continuous care services are available. Out of 58 secondary and tertiary care hospitals, 16 were included in the study to represent each hospital categories. Average number of patient attending for episodic treatment at OPD and Clinical follow-up of chronic conditions shows vast disparity according to the category of the hospital ranging from 3750 – 800 per day at OPD and 1250 – 200 per clinic session. Average time spent per person at OPD session is low, range from 1.54 - 2.28 minutes, the time was increasing as the hospital category goes down. 93.7% hospitals had special arrangements for providing acute care on chronic conditions such as catheter, feeding tube and wound care. 25% hospitals had special clinics for elders, 81.2% hospitals had healthy lifestyle clinics (HLC), 75% hospitals had physical rehabilitation facilities and 68.8% hospitals had facilities for counselling. Elderly clinics and HLC were mostly available at lower grade hospitals where as rehabilitation and counselling facilities were mostly available at bigger hospitals. HLC are providing health education for both patients and their family members, refer patients for screening of complication but not provide medical examinations, investigations or treatments even though they operate in the hospital setting. Physical rehabilitation is basically offered for patients with rheumatological conditions but utilization of centers for injury rehabilitation and rehabilitation of survivors following major illness such as myocardial infarctions, stroke, cancer is not satisfactory (12.5%). Human Resource distribution within hospital shows vast disparity and there are 103 physiotherapists in the biggest hospital where only 36 physiotherapists available at the next level hospital. Counselling facilities also provided mainly for the patient with psychological conditions (100%) but they were not providing counselling for newly diagnosed patients with major illnesses (0%). According to results, most of the public-sector hospitals in Sri Lanka have basic facilities required in providing continuous care but the utilization of services need more focus. Hospital administration or the government need to have initial steps in proper utilization of them in improving continuous health care incorporating team approach of rehabilitation. The author wishes to acknowledge that this paper was made possible by the support and guidance given by the “Australia Awards Fellowships Program for Sri Lanka – 2017,” which was funded by the Department of Foreign Affairs and Trade, Australia, and co-hosted by Monash University, Australia and the Sri Lanka Institute of Development Administration.

Keywords: continuous care, outpatient department, non communicable diseases, rehabilitation

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Authors: Arezoo Fallahi, Fateme Aslibigi, Parvaneh Taymoori, Babak Nematshahrbabaki

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Background and Aims: Cancer of the cervix, one of cancer-related death, is the second most common cancer in women worldwide. It develops over time but it is one of the most preventable types of cancer and there is the available proper screening program for its preventing. Since Pap smear test is vital to prevent and control of disease but women do not accomplish it regularly. Therefore, this study was aimed to explore women's needs referring to health care centers for doing Pap smear test. Material and methods: In this study, an inductive qualitative method with content analysis approach was used. This survey was done in varamin city (is located capital of Iran) in year 2014. Through the purposive sampling 15 women's view of point referring to health care centers of for doing Pap smear test was surveyed. Inclusion criteria were: 20-50 years old married women, having experience Pap smear test and attendance to participate in the Study. Recorded semi- structured interviews were typed and analyzed through of content analysis method. To obtain trustworthiness and rigor of the data, the criteria of credibility, dependability, confirmability and transferability was used. Results: During the data analysis, four main categories of “role of health care team”, “role of organizations”, “social support” and “policies and administration system” were developed. The participants emphasized on making motivational rules and coordination among organizations to do behaviors related to women health. Conclusion: The findings of study showed that doing Pap smear test are attributed to appropriate and intimate interactions with health professionals, family support, encouraging legislation and policies and coordination and notification of organizations. Therefore, designers and stockholders of policies and health system should more consider to growth and involve other organizations toward women's health.

Keywords: qualitative approach, pap smear test, women, health care centers

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Authors: Danielle A. Walker, Kyle L. Johnson, Tara B. Thomas, Sandor Dorgo, Jacen S. Moore

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Approximately 37 million people worldwide are infected with the Human Immunodeficiency Virus (HIV), with the majority located in sub-Saharan Africa. The relationship existing between HIV incidence and socioeconomic inequity confirms the critical need for programs promoting HIV education, prevention and treatment access. This literature review analyzed 36 sources with a specific focus on the Democratic Republic of Congo, whose critically low socioeconomic status and education rate have resulted in a drastically high HIV rates. Relationships between HIV testing and treatment and barriers to care were explored. Cultural and religious considerations were found to be vital when creating and implementing HIV education and testing programs. Partnerships encouraging active support from community-based spiritual leaders to implement HIV educational programs were also key mechanisms to reach communities and individuals. Gender roles were highlighted as a key component for implementation of effective community trust-building and successful HIV education programs. The efficacy of added support by hospitals and clinics in rural areas to facilitate access to HIV testing and care for people living with HIV/AIDS (PLWHA) was discussed. This review highlighted the need for healthcare providers to provide a network of continued education for PLWHA in clinical settings during disclosure and throughout the course of treatment to increase retention in care and promote medication adherence for viral load suppression. Implementation of culturally sensitive models that rely on community familiarity with HIV educators such as ‘train-the-trainer’ were also proposed as efficacious tools for educating rural communities about HIV. Further research is needed to promote community partnerships for HIV education, understand the cultural context of gender roles as barriers to care, and empower local health care providers to be successful within the HIV Continuum of Care.

Keywords: cultural sensitivity, Democratic Republic of the Congo, education, HIV

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Authors: Danny Hjeij, Karine Bilodeau, Caroline Arbour

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Background: Chemotherapy infusions often lead to a cluster of co-occurring and difficult-to-treat symptoms (nausea, tingling, etc.), which may negatively impact the treatment experience at the outpatient clinic. Although several complementary approaches have shown beneficial effects for chemotherapy-induced symptom management, they are not easily implementable during chemotherapy infusion. In response to this limitation, comfort talk (CT), a simple, fast conversational method inspired by the language principles of clinical hypnosis, is known to optimize the management of symptoms related to antineoplastic treatments. However, the perception of nurses who have had to integrate this practice into their care has never been documented. Study design: A qualitative descriptive study with iterative content analysis was conducted among oncology nurses working in a chemotherapy outpatient clinic who had previous experience with CT. Semi-structured interviews were conducted by phone, using a pre-tested interview guide and a sociodemographic survey to document their perception of CT. The conceptual framework. Results: A total of six nurses (4 women, 2 men) took part in the interviews (N=6). The average age of participants was 49 years (36-61 years). Participants had an average of 24 years of experience (10-38 years) as a nurse, including 14.5 years in oncology (5-32 years). Data saturation (i.e., redundancy of words) was observed around the fifth interview. A sixth interview was conducted as confirmation. Six themes emerged: two addressing contextual and organizational obstacles at the chemotherapy outpatient clinic, and three addressing the added value of CT for oncology nursing care. Specific themes included: 1) the outpatient oncology clinic, a saturated care setting, 2) the keystones that support the integration of CT into care, 3) added value for patients, 4) a positive and rewarding experience for nurses, 5) collateral benefits, and 6) CT an approach to consider during the COVID-19 pandemic. Conclusion: For the first time, this study describes nurses' perception of the integration of CT into the care surrounding the administration of chemotherapy at the outpatient oncology clinic. In summary, contextual and organizational difficulties, as well as the lack of training, are among the main obstacles that could hinder the integration of CT in oncology. Still, the experience was reported mostly as positive. Indeed, nurses saw HC as an added value to patient care and meeting their need for holistic care. HC also appears to be beneficial for patients on several levels (for pain management in particular). Results will be used to inform future knowledge transfer activities related to CT in oncology nursing.

Keywords: cancer, chemotherapy, comfort talk, oncology nursing role

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Authors: Robyn L. Curran, Joanne R. Naidoo, Gugu Mchunu

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Along with the increasing awareness of human trafficking, is the acknowledgement that it is no longer just a social problem but also a significant public health problem that requires both increased knowledge and the specialist equipping of aftercare providers such as nurses who care for human trafficking survivors. Current discourse regarding aftercare of human trafficking survivors, is that approaches do not clearly explain the function or content of aftercare and what aftercare entails. Although psychological and medical aftercare are emphasized as important components, little practical attention is devoted to what these components actually involve and the effectiveness of current practice in aftercare. Review of the literature on the processes that take place from aftercare to empowerment, revealed the need for emphasis to be placed on the voices of survivors concerning their liberation from oppression. The aim of the study was to develop a theory for aftercare of human trafficking survivors, through analyzing the experiences of survivors and aftercare providers in shelters in three provinces in South Africa. Through using a Straussian grounded theory approach, the researcher developed a theory to inform care of human trafficking survivors in low resource settings using the voice of the survivors and those experienced in direct care of human trafficking survivors. Four human trafficking survivors and three aftercare providers from three shelters in three provinces in South Africa were individually interviewed in order for the theory to emerge. The findings of the study elicited a theoretical model of the renewed self, and the conditions that facilitate this process in care of human trafficking survivors. The process that human trafficking survivors navigate to empowerment require mutual collaboration of the aftercare provider and survivor as the survivor awakens vision, confronts reality, re-salvages autonomy and liberates self. Psychological resilience of the survivor facilitates the transition to renewed self. The recommendations of this study may improve the nursing care provided to human trafficking survivors and equip professionals with knowledge and skills to promote the process of renewing self for survivors.

Keywords: aftercare, aftercare providers, grounded theory, human trafficking survivors

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Authors: Cátia Regina Branco da Fonseca, Maria Wany Louzada Strufaldi, Lídia Raquel de Carvalho, Rosana Fiorini Puccini

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Background: Birth weight reflects gestational conditions and development during the fetal period. Low birth weight (LBW) may be associated with antenatal care (ANC) adequacy and quality. The purpose of this study was to analyze ANC adequacy and its relationship with LBW in the Unified Health System in Brazil. Methods: A case-control study was conducted in Botucatu, São Paulo, Brazil, 2004 to 2008. Data were collected from secondary sources (the Live Birth Certificate), and primary sources (the official medical records of pregnant women). The study population consisted of two groups, each with 860 newborns. The case group comprised newborns weighing less than 2,500 grams, while the control group comprised live newborns weighing greater than or equal to 2,500 grams. Adequacy of ANC was evaluated according to three measurements: 1. Adequacy of the number of ANC visits adjusted to gestational age; 2. Modified Kessner Index; and 3. Adequacy of ANC laboratory studies and exams summary measure according to parameters defined by the Ministry of Health in the Program for Prenatal and Birth Care Humanization. Results: Analyses revealed that LBW was associated with the number of ANC visits adjusted to gestational age (OR = 1.78, 95% CI 1.32-2.34) and the ANC laboratory studies and exams summary measure (OR = 4.13, 95% CI 1.36-12.51). According to the modified Kessner Index, 64.4% of antenatal visits in the LBW group were adequate, with no differences between groups. Conclusions: Our data corroborate the association between inadequate number of ANC visits, laboratory studies and exams, and increased risk of LBW newborns. No association was found between the modified Kessner Index as a measure of adequacy of ANC and LBW. This finding reveals the low indices of coverage for basic actions already well regulated in the Health System in Brazil. Despite the association found in the study, we cannot conclude that LBW would be prevented only by an adequate ANC, as LBW is associated with factors of complex and multifactorial etiology. The results could be used to plan monitoring measures and evaluate programs of health care assistance during pregnancy, at delivery and to newborns, focusing on reduced LBW rates.

Keywords: low birth weight, antenatal care, prenatal care, adequacy of health care, health evaluation, public health system

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Authors: Josephine Aikpitanyi, Friday Okonofua, Lorrettantoimo, Sandy Tubeuf

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Every day, 800 women die from conditions related to pregnancy and childbirth, resulting in an estimated 300,000 maternal deaths worldwide per year. Over 99 percent of all maternal deaths occur in developing countries, with more than half of them occurring in sub-Saharan Africa. Nigeria being the most populous nation in sub-Saharan Africa bears a significant burden of worsening maternal and child health outcomes with a maternal mortality rate of 917 per 100,000 live births and child mortality rate of 117 per 1,000 live births. While several studies have documented that financial barriers disproportionately discourage poor women from seeking needed maternal and child healthcare, other studies have indicated otherwise. Evidence shows that there are instances where health facilities with skilled healthcare providers exist, and yet maternal, and child health outcomes remain abysmally low, indicating the presence of non-cognitive and behavioural factors that may affect the utilization of healthcare services. This study investigated the influence of locus of control and self-esteem on utilization of maternal and child healthcare services in Nigeria. Specifically, it explored the differences in utilization of antenatal care, skilled birth care, postnatal care, and child vaccination by women having an internal and external locus of control and women having high and low self-esteem. We collected information on non-cognitive traits of 1411 randomly selected women, along with information on utilization of the various indicators of maternal and child healthcare. Estimating logistic regression models for various components of healthcare services utilization, we found that women’s internal locus of control was a significant predictor of utilization of antenatal care, skilled birth care, and completion of child vaccination. We also found that having high self-esteem was a significant predictor of utilization of antenatal care, postnatal care, and completion of child vaccination after adjusting for other control variables. By improving our understanding of non-cognitive traits as possible barriers to maternal and child healthcare utilization, our findings offer important insights for enhancing participant engagement in intervention programs that are initiated to improve maternal and child health outcomes in low-and-middle-income countries.

Keywords: behavioural economics, health-seeking behaviour, locus of control and self-esteem, maternal and child healthcare, non-cognitive traits, and healthcare utilization

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Authors: Erin Lynne Plettenberg, Jeremy Vickery

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In an access-control situation, the role of a user determines whether a data request is appropriate. This paper combines vetted web mining and logic modeling to build a lightweight system for determining the role of a health care provider based only on their prior authorized requests. The model identifies provider roles with 100% recall from very little data. This shows the value of vetted web mining in AI systems, and suggests the impact of the ICD classification on medical practice.

Keywords: electronic medical records, information extraction, logic modeling, ontology, vetted web mining

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Authors: Nermeen Saad Elbeltagy, Hoda Ghareeb, Hesham Adel Elsheshtawy, Nadim Hamed, Amany Ibrahim Mostafa, Sara Hazem Hassan

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Introduction: Depression is one of the most common mental health problems occurring in women during their child bearing years. Perinatal depression refers to major and minor depressive episodes that occur either during pregnancy or aer delivery. Although perinatal depression is common in developing countries, it is under-recognized in low and middle income countries making a substantial contribution to maternal and infant morbidity and mortality. About 12.5 - 42% of pregnant women and, 12 - 50% of post natal mothers in low and middle income countries such as Ethiopia had depression AIM OF THE WORK: To study prevalence, associated factors and impact of maternal perinatal depression in Alexandria. Patients and method: This study was conducted on 300 mothers at the postnatal ward in ElShatby Maternity Hospital from April 2022 unl October 2022. Females with past history of depression before pregnancy or females who receive medications inducing depression were excluded. The participants were asked to complete the questionnaire that includes the Edinburgh Postnatal Depression Scale (EPDS) as a screening test to obtain information concerning the current frame of mind at antepartum, partum and postpartum periods Results: The prevalence of perinatal depression was 22.3%. It was found that there is a significant negave moderate correlation between socioeconomic status and perinatal depression(r=-0.42). The present study revealed that about two thirds (60.7%) of postpartum women had low socioeconomic level. Also, less than one fourth (20%) of parents had high education and only one fourth (25.3%) of postpartum women were working. There was a statically significance difference between the number of previous abortions and perinatal depression (p=0.04). There was a significant moderate correlation between the amount of blood lost during delivery and an increased risk of developing postpartum depression. The prevalence of perinatal depression was high in cases of female neonates more than male ones. Conclusion: the prevalence of perinatal depression among the studied women was 22.3% of studied group. The significant factors identified in this study can be targeted to reduce the occurrence of perinatal depression among pregnant women in Alexandria through appropriate health interventions which includes perinatal depression screening, counseling, and the provision of support for pregnant women during antenatal care as well as lifestyle modification.

Keywords: mental health, depression in pregnancy, mental disorders, psychology in pregnancy

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Authors: Elisenda Camprecios, Alicia Macarrila, Montse Albiol, Neus Garriga Garriga

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The loss of a child during pregnancy, or shortly after birth, is not a common occurrence, but it is a prevalent fact in our society. When this loss happens, life and death walk together. The grief that parents experience following a perinatal loss is a devastating experience. Professionals are aware that the quality of care offered during this first period is crucial to support the families experiencing a perinatal loss and meet their needs. However, it is not always easy for the health care professionals to know what to say and what to do in these difficult circumstances. Given the complexity of the Health, painful process that a family must face when is affected by such loss, we believe that the creation of a protocol that pays special attention to the emotional needs of those couples can be a very valuable tool for the professionals. The short documentary named ‘When the illusion vanished’ was created as part of the material of this protocol, which focuses on the emotional needs of the families who have suffered a perinatal loss. This video is designed to see what impact has a perinatal death and to raise awareness among professionals working in this field. The methodology is based on interviews with couples who have experienced perinatal death and to professionals who accompany families suffering from perinatal loss. The use of sensitive and empathized words, being encouraged to express feelings, respect the time, appropriate training for the professionals are some of the issues reflected in this documentary. We believe that this video has contributed to help health care professionals to empathize and understand the need to be able to accompany these families with the appropriate care, respectful, empathetic attitude and professionalism so that they can start the path to a ‘healthy’ mourning.

Keywords: neonatal loss, midwifery, perinatal bereavement, perinatal loss

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Authors: V. Karuppaiah, J. C. Padaria, C. Srivastava

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The tobacco caterpillar, Spodoptera litura Fab (Lepidoptera: Noctuidae) is a polyphagous pest various field and horticulture crops in India. Pest had virtually developed resistance to all commonly used insecticides. Enhanced detoxification is the prime mechanism that is dictated by detoxification different enzymes and carboxylesterase is one of the major enzyme responsible development of resistance. In India, insecticide resistance studies on S. litura are mainly deployed on detoxification enzymes activity and investigation at gene level alteration i.e. at nucleotide level is very merger. In the present study, we collected the S. litura larvae from three different cauliflower growing belt viz., IARI, New Delhi (Delhi), Palari, Sonepat (Haryana) and Varanasi (Uttar Pradesh) to study the role of carboxylesterase activity and its gene level variation The CarE activity was measured using UV-VIS spectrophotometer with 3rd instar larvae of S. litura. The elevated activity of CarE was observed in Sonepat strain (28.09 ± 0.09 µmol/min/mg of protein) followed by Delhi (26.72 ± 0.04 µmol/min/mg of protein) and Varanasi strain (10.00 ± 0.44 µmol/min/mg of protein) of S. litura. The genomic DNA was isolated from 3rd instar larvae and CarE gene was amplified using a primer sequence, F:5’tccagagttccttgtcaggcac3’; R:5’ctgcatcaagcatgtctc3. CarE gene, about 500bp was partially amplified, sequenced and submitted to NCBI (Accession No. KF835886, KF835887 and KF835888). The sequence data revealed polymorphism at nucleotide level in all the three strains and gene found to have 88 to 97% similarity with previous available nucleotide sequences of S. litura, S. littoralis and S. exiqua. The polymorphism at the nucleotide level could be a reason for differential activity of carboxylesterase enzymes among the strains. However, investigation at gene expression level would be useful to analyze the overproduction of carboxylesterase enzyme.

Keywords: carboxylesterase, CarE gene, nucleotide polymorphism, insecticide resistance, spodoptera litura

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Authors: Sasiwan Tassana-iem, Sumattana Glangkarn

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Diabetic nephropathy is a major complication in diabetic patients whom as the glomerular filtration rate falls. The affects their quality of life and results in loss of money for kidney replacement therapy costs. There is an existing intervention, but the prevalence remains high, thus this research aims to study lessons learned in implementing programs to delay diabetic nephropathy management in primary health care. Method: The target settings are, 24 sub-district health promoting hospital in Sakon Nakhon province. Participants included the health care professionals, head of the sub-district health promoting hospital and the person responsible for managing diabetic nephropathy in each hospital (n= 50). There are 400 patients with diabetes mellitus in an area. Data were collected using questionnaires, patient records data, interviews and focus groups and analyzed by statistics and content analysis. Result: Reflection of participants that the interventions to delay diabetic nephropathy management in each area, the Ministry of Public Health has a policy to screen and manage this disease. The implementing programs aimed to provide health education, innovative teaching media used in communication to educate. Patients and caregivers had misunderstanding about the actual causes and prevention of this disease and how to apply knowledge suitable for daily life. Conclusion: The obstacles to the success of the implementing programs to delay diabetic nephropathy management in primary health care were most importantly, the patient needs self-care and should be evaluated for health literacy. This is crucial to promote health literacy; to access and understand health information as well to decide their health-related choices based on health information which will promote and maintain a good health. This preliminary research confirms that situation of diabetic nephropathy still exists. The results of this study will lead to the development of delay in diabetic nephropathy implementation among patients in the province studied.

Keywords: diabetic nephropathy, chronic kidney disease, primary health care, implementation

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