Search results for: median sacral crest

Authors: Mai A. Ibrahim, Mohammed El-Beltagy, Motaz Khorshid

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Emerging Markets return distributions have shown significance departure from normality were they are characterized by fatter tails relative to the normal distribution and exhibit levels of skewness and kurtosis that constitute a significant departure from normality. Therefore, the classical Markowitz Mean-Variance is not applicable for emerging markets since it assumes normally-distributed returns (with zero skewness and kurtosis) and a quadratic utility function. Moreover, the Markowitz mean-variance analysis can be used in cases of moderate non-normality and it still provides a good approximation of the expected utility, but it may be ineffective under large departure from normality. Higher moments models and median models have been suggested in the literature for asset allocation in this case. Higher moments models have been introduced to account for the insufficiency of the description of a portfolio by only its first two moments while the median model has been introduced as a robust statistic which is less affected by outliers than the mean. Tail risk measures such as Value-at Risk (VaR) and Conditional Value-at-Risk (CVaR) have been introduced instead of Variance to capture the effect of risk. In this research, higher moment models including the Mean-Variance-Skewness (MVS) and Mean-Variance-Skewness-Kurtosis (MVSK) are formulated as single-objective non-linear programming problems (NLP) and median models including the Median-Value at Risk (MedVaR) and Median-Mean Absolute Deviation (MedMAD) are formulated as a single-objective mixed-integer linear programming (MILP) problems. The higher moment models and median models are compared to some benchmark portfolios and tested on real financial data in the Egyptian main Index EGX30. The results show that all the median models outperform the higher moment models were they provide higher final wealth for the investor over the entire period of study. In addition, the results have confirmed the inapplicability of the classical Markowitz Mean-Variance to the Egyptian stock market as it resulted in very low realized profits.

Keywords: Egyptian stock exchange, emerging markets, higher moment models, median models, mixed-integer linear programming, non-linear programming

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Authors: A. Nabhan, Mohamed R. El-Sharkawy, A. Rashed

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The main aim of this paper is to dedicate the belt drive system faults like cogs missing, misalignment and belt worm using vibration analysis technique. Experimentally, the belt drive test-rig is equipped to measure vibrations signals under different operating conditions. Finite element 3D model of belt drive system is created and vibration response analyzed using commercial finite element software ABAQUS/CAE.  Root mean square (RMS) and Crest Factor will serve as indicators of average amplitude of envelope analysis signals. The vibration signals pattern obtained from the simulation model and experimental data have the same characteristics. It can be concluded that each case of the RMS is more effective in detecting the defect for acceleration response. While Crest Factor parameter has a response with the displacement and velocity of vibration signals. Also it can be noticed that the model has difficulty in completing the solution when the misalignment angle is higher than 1 degree.

Keywords: simulation model, misalignment, cogs missing, vibration analysis

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Authors: H. Ben Salah, A. Gannoun, C. de Peretti, A. Trabelsi

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The Downside Risk (DSR) model for portfolio optimisation allows to overcome the drawbacks of the classical mean-variance model concerning the asymetry of returns and the risk perception of investors. This model optimization deals with a positive definite matrix that is endogenous with respect to portfolio weights. This aspect makes the problem far more difficult to handle. For this purpose, Athayde (2001) developped a new recurcive minimization procedure that ensures the convergence to the solution. However, when a finite number of observations is available, the portfolio frontier presents an appearance which is not very smooth. In order to overcome that, Athayde (2003) proposed a mean kernel estimation of the returns, so as to create a smoother portfolio frontier. This technique provides an effect similar to the case in which we had continuous observations. In this paper, taking advantage on the the robustness of the median, we replace the mean estimator in Athayde's model by a nonparametric median estimator of the returns. Then, we give a new version of the former algorithm (of Athayde (2001, 2003)). We eventually analyse the properties of this improved portfolio frontier and apply this new method on real examples.

Keywords: Downside Risk, Kernel Method, Median, Nonparametric Estimation, Semivariance

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Authors: B. Kenny, M. Dixon, A. Boshell

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The use of alcoholic surgical prep was recently introduced into the Royal Newcastle Center for elective procedures. In the past 3 months there have been a significant number of burns believed to be related to ‘pooling’ of this surgical prep in patients undergoing procedures where they are placed in the lateral position with hip bolsters. The aim of the audit was to determine the reason for the burns, analyze what pre-existing factors may contribute to the development of the burns and what can be changed to prevent further burns occurring. All patients undergoing a procedure performed on the hip who were placed in the lateral position with sacral and anterior, superior iliac spine (ASIS) support with ‘bolsters’ were included in the audit. Patients who developed a ‘burn’ were recorded, details of the surgery, demographics, surgical prep used and length of surgery were obtained as well as photographs taken to document the burn. Measures were then taken to prevent further burns and the efficacy was documented. Overall 14 patients developed burns over the ipsilateral ASIS. Of these, 13 were Total Hip Arthroplasty (THA) and 1 was a removal of femoral nail. All patients had Chlorhexidine 0.5% in Alcohol 70% Tinted Red surgical preparation or Betadine Alcoholic Skin Prep (70% etoh). Patients were set up in the standard lateral decubitus position with sacral and bilateral ASIS bolsters with a valband covering. 86% of patients were found to have pre-existing hypersensitivities to various substances. There is very little literature besides a few case reports on surgical prep-related burns. The case reports that do exist are related to the use of tourniquet-related burns and there is no mention in the literature examining ‘bolster’ related burns. The burns are hypothesized to be caused by pooling of the alcoholic solution which is amplified by the use of Valband.

Keywords: arthroplasty, chemical burns, wounds, rehabilitation

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Authors: Mahmoud I. Syam

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Stratified double median ranked set sampling (SDMRSS) method is suggested for estimating the population mean. The SDMRSS is compared with the simple random sampling (SRS), stratified simple random sampling (SSRS), and stratified ranked set sampling (SRSS). It is shown that SDMRSS estimator is an unbiased of the population mean and more efficient than SRS, SSRS, and SRSS. Also, by SDMRSS, we can increase the efficiency of mean estimator for specific value of the sample size. SDMRSS is applied on real life examples, and the results of the example agreed the theoretical results.

Keywords: efficiency, double ranked set sampling, median ranked set sampling, ranked set sampling, stratified

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Authors: Fatma Abdel Moneim Al Tawil

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This study was undertaken to evaluate an educational program regarding scientific writing and presentation skills among university students. This interventional study used a one-group, pretest/posttest design and was conducted in Al Jouf University among four colleges in Saudi Arabia. Baseline students’ assessment was conducted for developing educational program. Interventional, one group, pretest/posttest study was designed to evaluate the effectiveness of the educational program. Three parts evaluation sheet with total scores of 30 was used for 113 students for the development of the program and 52 students for test pretest phase. Wilcoxon signed ranks showed statistically significant improvement in the combined overall program skills score from a median of 56.7 pre to a median of 86.7 post, (z = 6.231, p < 0.001). When compared to preprogram intervention, post interventions 51.9 % of students achieve excellent performance. While pre intervention no students (0.0 %) achieve this score. Regarding to scientific writing skills, Wilcoxon signed ranks showed statistically significant improvement in the score from a median of 60 pre to a median of 90 post, (z = 6.122, p < 0.001). None of students had excellent performance changed to 73.1%. Regarding to oral presentation skills, Wilcoxon signed ranks showed statistically significant improvement in the score from a median of 50 pre to a median of 80 post, (z = 6.153, p < 0.001). None of students had excellent performance changed to 48.1%. Such educational program needs to be incorporated into classroom delivery of the students’ curriculum. Scientific writing skills book needed to be developed to be recommended as a basic educational strategy for all university faculties.

Keywords: scientific writing, presentation skills, university students, educational program

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Authors: A. M. Prasad

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Knowledge of variations of nerves of gluteal region is important for clinicians administering intramuscular injections, for orthopedic surgeons dealing with the hip surgeries, possibly for physiotherapists managing the painful conditions and paralysis of this region. Herein, we report multiple variations of the nerves of gluteal region. In the current case, the sciatic nerve was absent. The common peroneal and tibial nerves arose from sacral plexus and reached the gluteal region through greater sciatic foramen above and below piriformis respectively. The common peroneal nerve gave a muscular branch to the gluteus maximus. The inferior gluteal nerve and posterior cutaneous nerve of the thigh arose from a common trunk. The common trunk was formed by three roots. Upper and middle roots arose from sacral plexus and entered gluteal region through greater sciatic foramen respectively above and below piriformis. The lower root arose from the pudendal nerve and joined the common trunk. These variations were seen in the right gluteal region of an adult male cadaver aged approximately 70 years. Innervation of gluteus maximus by common peroneal nerve and presence of a common trunk of inferior gluteal nerve and posterior cutaneous nerve of the thigh make this case unique. The variant nerves may be subjected to iatrogenic injuries during surgical approach to the hip. They may also get compressed if there is a hypertrophy of the piriformis syndrome. Hence, the knowledge of these variations is of importance to clinicians, orthopedic surgeons and possibly for physiotherapists.

Keywords: gluteal region, multiple variations, nerve injury, sciatic nerve

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Authors: Tathagatha Khan, Smruti Sourava Mohapatra

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Median openings are provided in raised median of multilane roads to facilitate U-turn movement. The U-turn movement is a highly complex and risky maneuver because U-turning vehicle (minor stream) makes 180° turns at median openings and merge with the approaching through traffic (major stream). A U-turning vehicle requires a suitable gap in the major stream to merge, and during this process, the possibility of merging conflict develops. Therefore, these median openings are potential hot spot of conflict and posses concern pertaining to safety. The traffic at the median openings could be managed efficiently with enhanced safety when the capacity of a traffic facility has been estimated correctly. The capacity of U-turns at median openings is estimated by Harder’s formula, which requires three basic parameters namely critical gap, follow up time and conflict flow rate. The estimation of conflicting flow rate under mixed traffic condition is very much complicated due to absence of lane discipline and discourteous behavior of the drivers. The understanding of placement of major stream vehicles at median opening is very much important for the estimation of conflicting traffic faced by U-turning movement. The placement data of major stream vehicles at different section in 4-lane and 6-lane divided multilane roads were collected. All the test sections were free from the effect of intersection, bus stop, parked vehicles, curvature, pedestrian movements or any other side friction. For the purpose of analysis, all the vehicles were divided into 6 categories such as motorized 2W, autorickshaw (3-W), small car, big car, light commercial vehicle, and heavy vehicle. For the collection of placement data of major stream vehicles, the entire road width was divided into sections of 25 cm each and these were numbered seriatim from the pavement edge (curbside) to the end of the road. The placement major stream vehicle crossing the reference line was recorded by video graphic technique on various weekdays. The collected data for individual category of vehicles at all the test sections were converted into a frequency table with a class interval of 25 cm each and the placement frequency curve. Separate distribution fittings were tried for 4- lane and 6-lane divided roads. The variation of major stream traffic volume on the placement characteristics of major stream vehicles has also been explored. The findings of this study will be helpful to determine the conflict volume at the median openings. So, the present work holds significance in traffic planning, operation and design to alleviate the bottleneck, prospect of collision and delay at median opening in general and at median opening in developing countries in particular.

Keywords: median opening, U-turn, conflicting traffic, placement, mixed traffic

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Authors: Mohamed Wahba

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Objective: To build a comparative arm for product (X) in specific gene mutated advanced gastrointestinal cancer using real world evidence to fulfill HTA requirements in drug evaluation. Methods: Data for product (X) were collected from phase II clinical trial while real world data for (Y) and (Z) were collected from US database. Real-world (RW) cohorts were matched to clinical trial base line characteristics using weighting by odds method. Outcomes included progression-free survival (PFS) and overall survival (OS) rates. Study location and participants: Internationally (product X, n=80) and from USA (Product Y and Z, n=73) Results: Two comparisons were made: trial cohort 1 (X) versus real-world cohort 1 (Z), trial cohort 2 (X) versus real-world cohort 2 (Y). For first line, the median OS was 9.7 months (95% CI 8.6- 11.5) and the median PFS was 5.2 months (95% CI 4.7- not reached) for real-world cohort 1. For second line, the median OS was 10.6 months (95% CI 4.7- 27.3) for real-world cohort 2 and the median PFS was 5.0 months (95% CI 2.1- 29.3). For OS analysis, results were statistically significant but not for PFS analysis. Conclusion: This study provided the clinical comparative outcomes needed for HTA evaluation.

Keywords: real world evidence, pharmacoeconomics, HTA agencies, oncology

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Authors: Ossama Salman

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Background and objective: Sacroiliac joint pain is a common cause for chronic axial low back pain, with up to 20% prevalence rate. To date, no effective long-term treatment intervention has been embarked on yet. The aim of our study was to compare steroid block to radiofrequency ablation for SIJ pain conditions. Methods: A randomized, blind, study was conducted in 30 patients with sacroiliac joint pain. Fifteen patients received radiofrequency denervation of L4-5 primary dorsal rami and S1-3 lateral sacral branch, and 15 patients received steroid under fluoroscopy. Those in the steroid group who did not respond to steroid injections were offered to cross over to get radiofrequency ablation. Results: At 1-, 3- and 6-months post-intervention, 73%, 60% and 53% of patients, respectively, gained ≥ 50 % pain relief in the radiofrequency (RF) ablation group. In the steroid group, at one month post intervention follow up, only 20% gained ≥ 50 % pain relief, but failed to show any improvement at 3 months and 6 months follow up. Conclusions: Radiofrequency ablation at L4 and L5 primary dorsal rami and S1-3 lateral sacral branch may provide effective and longer pain relief compared to the classic intra-articular steroid injection, in properly selected patients with suspected sacroiliac joint pain. Larger studies are called for to confirm our results and lay out the optimal patient selection and treatment parameters for this poorly comprehended disorder.

Keywords: lateral branch denervation, LBD, radio frequency, RF, sacroiliac joint, SIJ, visual analogue scale, VAS

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Authors: Juan P. Silva, T. R. Canchala, H. J. Lubberding, E. J. Peña, H. J. Gijzen

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This study measured the fluxes of greenhouse gases (GHGs) i.e. CO₂, CH₄ and N₂O from a tropical eutrophic freshwater wetland (“Sonso Lagoon”) which receives input loading nutrient from several sources i.e. agricultural run-off, domestic sewage, and a polluted river. The flux measurements were carried out at four different points using the static chamber technique. CO₂ fluxes ranged from -8270 to 12210 mg.m^-2.d^-1 (median = 360; SD = 4.11; n = 50), CH₄ ranged between 0.2 and 5270 mg.m^-2.d^-1 (median = 60; SD = 1.27; n = 45), and N₂O ranged from -31.12 to 15.4 mg N₂O m^-2.d^-1 (median = 0.05; SD = 9.36; n = 42). Although some negative fluxes were observed in the zone dominated by floating plants i.e. Eichornia crassipes, Salvinia sp., and Pistia stratiotes L., the mean values indicated that the Sonso Lagoon was a net source of CO₂, CH₄ and N₂O. In addition, an effect of the eutrophication on GHG emissions could be observed in the positive correlation found between CO₂, CH₄ and N₂O generation and COD, PO₄^-3, NH₃-N, TN and NO₃^-N. The eutrophication impact on GHG production highlights the necessity to limit the anthropic activities on freshwater wetlands.

Keywords: eutrophication, greenhouse gas emissions, freshwater wetlands, climate change

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Authors: Deepthinath Reghunathan, Satheesha Nayak, Sudarshan S., Prasad Alathady Maloor, Prakash Shetty

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Lumbar plexus is formed by the union of ventral rami of T12, L1, L2, L3 spinal nerves and the larger upper division of L4 lumbar spinal nerves. Variations in the normal anatomy of the lumbar and sacral plexus might be seen in some cases and are reported in the literature, but finding such an unusual case comprising of multiple variations which is normally not expected in a clinical setup, proves to be a vital piece of information for clinicians and medical practitioners. During the dissection of the abdomen and pelvis of an approximately 70 year old cadaver, we observed the following variations in the formation of the lumbar and sacral nerves. 1. The genitofemoral nerve bifurcated at a higher level; genital branch of genitofemoral nerve gave branches to the anterior abdominal wall muscles, 2. A communicating branch was given from the lateral cutaneous nerve of thigh to the medial cutaneous nerve of thigh, 3. A muscular branch was given from femoral nerve to psoas major, 4. There was absence of contribution of L4 spinal nerve in the formation of the lumbosacral trunk and 5. Lumbosacral trunk gave communicating branches to the femoral and obturator nerves. Most of the variations found were rare and finding all the above said variations in a single cadaver is even rare. Documentation of such rare cases with multiple variations in the formation of nerves from the lumbar plexus provides vital information on such occurrences. This information would in turn improve the knowledge of clinicians and surgeons dealing with this region. Emphasizing such knowledge of this region would prevent accidental damage to the structures with a variant anatomy.

Keywords: femoral nerve, genitofemoral nerve, lumbar plexus, lumbosacral trunk

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Authors: Daeung Jung

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Background: In case of patients with missing teeth, multiple implant restoration has been widely used and is inevitable. To increase its survival rate, it is important to understand the influence of different implant designs on inter-implant crestal bone resorption. There are several implant systems designed to minimize loss of crestal bone, and the Astra Tech and Brånemark Implant are two of them. Aim/Hypothesis: The aim of this 10-year study was to compare the height of inter-implant bone crest in two implant systems; the Astra Tech and the Brånemark implant system. Material and Methods: In this retrospective study, 40 consecutively treated patients were utilized; 23 patients with 30 sites for Astra Tech system and 17 patients with 20 sites for Brånemark system. The implant restoration was comprised of splinted crown in partially edentulous patients. Radiographs were taken immediately after 1st surgery, at impression making, at prosthetics setting, and annually after loading. Lateral distance from implant to bone crest, inter-implant distance was gauged, and crestal bone height was measured from the implant shoulder to the first bone contact. Calibrations were performed with known length of thread pitch distance for vertical measurement, and known diameter of abutment or fixture for horizontal measurement using ImageJ. Results: After 10 years, patients treated with Astra Tech implant system demonstrated less inter-implant crestal bone resorption when implants had a distance of 3mm or less between them. In cases of implants that had a greater than 3 mm distance between them, however, there appeared to be no statistically significant difference in crestal bone loss between two systems. Conclusion and clinical implications: In the situation of partially edentulous patients planning to have more than two implants, the inter-implant distance is one of the most important factors to be considered. If it is impossible to make sure of having sufficient inter-implant distance, the implants with less micro gap in the fixture-abutment junction, less traumatic 2nd surgery approach, and the adequate surface topography would be choice of appropriate options to minimize inter-implant crestal bone resorption.

Keywords: implant design, crestal bone loss, inter-implant distance, 10-year retrospective study

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Authors: Regis Pochon, Nicolas Stefaniak, Veronique Baltazart, Pamela Gobin

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Anxiety is known to have an impact on working memory. In reasoning or memory tasks, individuals with anxiety tend to show longer response times and poorer performance. Furthermore, there is a memory bias for negative information in anxiety. Given the crucial role of working memory in lexical learning, anxious students may encounter more difficulties in learning to read and spell. Anxiety could even affect an earlier learning, that is the activation of phonological representations, which are decisive for the learning of reading and writing. The aim of this study is to compare the access to phonological representations of beginning readers and writers according to their level of anxiety, using an auditory lexical decision task. Eighty students of 6- to 9-years-old completed the French version of the Revised Children's Manifest Anxiety Scale and were then divided into four anxiety groups according to their total score (Low, Median-Low, Median-High and High). Two set of eighty-one stimuli (words and non-words) have been auditory presented to these students by means of a laptop computer. Stimuli words were selected according to their emotional valence (positive, negative, neutral). Students had to decide as quickly and accurately as possible whether the presented stimulus was a real word or not (lexical decision). Response times and accuracy were recorded automatically on each trial. It was anticipated a) longer response times for the Median-High and High anxiety groups in comparison with the two others groups, b) faster response times for negative-valence words in comparison with positive and neutral-valence words only for the Median-High and High anxiety groups, c) lower response accuracy for Median-High and High anxiety groups in comparison with the two others groups, d) better response accuracy for negative-valence words in comparison with positive and neutral-valence words only for the Median-High and High anxiety groups. Concerning the response times, our results showed no difference between the four groups. Furthermore, inside each group, the average response times was very close regardless the emotional valence. Otherwise, group differences appear when considering the error rates. Median-High and High anxiety groups made significantly more errors in lexical decision than Median-Low and Low groups. Better response accuracy, however, is not found for negative-valence words in comparison with positive and neutral-valence words in the Median-High and High anxiety groups. Thus, these results showed a lower response accuracy for above-median anxiety groups than below-median groups but without specificity for the negative-valence words. This study suggests that anxiety can negatively impact the lexical processing in young students. Although the lexical processing speed seems preserved, the accuracy of this processing may be altered in students with moderate or high level of anxiety. This finding has important implication for the prevention of reading and spelling difficulties. Indeed, during these learnings, if anxiety affects the access to phonological representations, anxious students could be disturbed when they have to match phonological representations with new orthographic representations, because of less efficient lexical representations. This study should be continued in order to precise the impact of anxiety on basic school learning.

Keywords: anxiety, emotional valence, childhood, lexical access

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Authors: Maria Melania Muda, Retno Wibawanti, Retno Asti Werdhani

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Background: Flight attendant (FA) is a job that is often exposed to ergonomic stressors; thus, they are very susceptible to symptoms of musculoskeletal disorders (MSDs). One of the ways to overcome musculoskeletal complaints is by stretching. This study aimed to examine the prevalence of MSDs and the effect of a 2-week stretching exercise program using the Indonesian Ministry of Health's stretching video on changes in musculoskeletal pain intensity in FA on commercial aircraft in Indonesia. Methods: A pre-post study was conducted using Nordic Musculoskeletal Questionnaire (NMQ) for MSDs’ identification and Visual Analog Scale (VAS) as pain intensity measurement. Data was collected and then analyzed using SPSS with Wilcoxon test. The change in pain intensity was considered significant if the p value was less than 0.05. Results: The results showed that 92% of the FA (n=75) had MSDs in at least 1 area of the body in the last 12 months. Thirty-four respondents participated as subjects. The complaint level score in 28 body areas before intervention was a median of 34 (29-84), with pain intensity of a median of 6 (2-9) became a median of 32 (28-67) and a median of 3 (0-9) after the intervention, respectively, with p-value <0.001. Conclusion: The stretching exercise program showed significant changes in the complaint level scores in 28 body areas (p < 0.001) and pain intensity before and after the stretching exercise intervention (p < 0.001).

Keywords: flight attendant, MSDs, Nordic Musculoskeletal Questionnaire, stretching exercise program, visual analog scale

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Authors: Amir Mahyar Khorasani, Ian Gibson, Moshe Goldberg, Mohammad Masoud Movahedi, Guy Littlefair

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One of the important factors in manufacturing processes especially machining operations is surface quality. Improving this parameter results in improving fatigue strength, corrosion resistance, creep life and surface friction. The reliability and clearance of removable joints such as thread and nuts are highly related to the surface roughness. In this work, the effect of different cutting parameters such as cutting fluid pressure, feed rate and cutting speed on the surface quality of the crest of thread in the high-speed milling of Brass C3600 have been determined. Two popular neural networks containing MLP and RBF coupling with Taguchi L32 have been used to model surface roughness which was shown to be highly adept for such tasks. The contribution of this work is modelling surface roughness on the crest of the thread by using precise profilometer with nanoscale resolution. Experimental tests have been carried out for validation and approved suitable accuracy of the proposed model. Also analysing the interaction of parameters two by two showed that the most effective cutting parameter on the surface value is feed rate followed by cutting speed and cutting fluid pressure.

Keywords: artificial neural networks, cutting conditions, high-speed machining, surface roughness, thread milling

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Authors: Christophe Spaas, Lies Pottel, Joke De Ceulaer, Johan Abeloos, Philippe Lamoral, Tom De Backer, Calix De Clercq

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We aimed to evaluate the accuracy of an in-house developed low-cost computer-assisted surgery (CAS) protocol for osseous free flap mandibular reconstruction. All patients who underwent primary or secondary mandibular reconstruction with a free (solely or composite) osseous flap, either a fibula free flap or iliac crest free flap, between January 2014 and December 2017 were evaluated. The low-cost protocol consisted out of a virtual surgical planning, a prebend custom reconstruction plate and an individualized free flap positioning guide. The accuracy of the protocol was evaluated through comparison of the postoperative outcome with the 3D virtual planning, based on measurement of the following parameters: intercondylar distance, mandibular angle (axial and sagittal), inner angular distance, anterior-posterior distance, length of the fibular/iliac crest segments and osteotomy angles. A statistical analysis of the obtained values was done. Virtual 3D surgical planning and cutting guide design were performed with Proplan CMF® software (Materialise, Leuven, Belgium) and IPS Gate (KLS Martin, Tuttlingen, Germany). Segmentation of the DICOM data as well as outcome analysis were done with BrainLab iPlan® Software (Brainlab AG, Feldkirchen, Germany). A cost analysis of the protocol was done. Twenty-two patients (11 fibula /11 iliac crest) were included and analyzed. Based on voxel-based registration on the cranial base, 3D virtual planning landmark parameters did not significantly differ from those measured on the actual treatment outcome (p-values >0.05). A cost evaluation of the in-house developed CAS protocol revealed a 1750 euro cost reduction in comparison with a standard CAS protocol with a patient-specific reconstruction plate. Our results indicate that an accurate transfer of the planning with our in-house developed low-cost CAS protocol is feasible at a significant lower cost.

Keywords: CAD/CAM, computer-assisted surgery, low-cost, mandibular reconstruction

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Authors: Andreas Aceranti, Stefano Costa

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The aim of this study was to demonstrate that manipulative treatment combined with therapeutic exercisetherapywas more effective than isolated therapeutic exercise in the short-term treatment of eye convergence disorders in boxers. A randomized controlled trial (RCT) pilot trial was performed at our physiotherapy practices. 30 adult subjects who practice the discipline of boxing were selected after an initial skimming defined by the Convergence Insufficiency Symptom Survey (CISS) test (results greater than or equal to 10) starting from the initial sample of 50 subjects; The 30 recruits were evaluated by an orthoptist using prisms to know the diopters of each eye and were divided into 2 groups (experimental group and control group). The members of the experimental group were subjected to manipulation of the lateral strain of sphenoid from the side contralateral to the eye that had fewer diopters and were subjected to a sequence of 3 ocular motor exercises immediately after manipulation. The control group, on the other hand, received only ocular motor treatment. A secondary outcome was also drawn up that demonstrated how changes in ocular motricity also affected cervical rotation. Analysis of the data showed that the experimental treatment was in the short term superior to the control group to astatistically significant extent both in terms of the prismatic delta of the right eye (0 OT median without manipulation and 10 OT median with manipulation) and that of the left eye (0 OT median without manipulation and 5 OT median with manipulation). Cervical rotation values also showed better values in the experimental group with a median of 4° in the right rotation without manipulation and 6° with thrust; the left rotation presented a median of 2° without manipulation and 7° with thrust. From the results that emerged, the treatment was effective. It would be desirable to increase the sample number and set up a timeline to see if the net improvements obtained in the short term will also be maintained in the medium to long term.

Keywords: boxing, basilar spheno synchondrosis, ocular convergence deficit, osteopathic treatment

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Authors: Walid Ibrahim, Abdul Kasem, Sudeendra Doddi, Ilaria Giono, Tareq Sabagh, Muhammad Ammar, Nermin Osman

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Background: wire-guided localization (WL) is the most widely used method for the localization of non-palpable breast lesions. SAVI SCOUT occult lesion localization (SSL) is a new technique in breast-conservative surgery. SSL has the potential benefit of improving radiology workflow as well as accurate localization. Purpose: The purpose of this study is to compare the breast tissue specimen volume and weight and margin excision between WL and SSL. Materials and methods: A single institution retrospective analysis of 377 female patients who underwent wide local breast excision with SAVI SCOUT and or wire-guided technique between 2018 and 2021 in a UK University teaching hospital. Breast department. Breast tissue specimen volume and weight, and margin excision have been evaluated in the three groups of different localization. Results: Three hundred and seventy-seven patients were studied. Of these, 261 had wire localization, 88 had SCOUT and 28 had dual localization techniques. Tumor size ranged from 1 to 75mm (Median 20mm). The pathology specimen weight ranged from 1 to 466gm (Median 46.8) and the volume ranged from 1.305 to 1560cm³ (Median 106.32 cm³). SCOUT localization was associated with a significantly low specimen weight than wire or the dual technique localization (Median 41gm vs 47.3gm and 47gm, p = 0.029). SCOUT was not associated with better specimen volume with a borderline significance in comparison to wire and combined techniques (Median 108cm³ vs 105cm³ and 105cm³, p = 0.047). There was a significant correlation between tumor size and pathology specimen weight in the three groups. SCOUT showed a better >2mm safety margin in comparison to the other 2 techniques (p = 0.031). Conclusion: Preoperative SCOUT localization is associated with better specimen weight and better specimen margin. SCOUT did not show any benefits in terms of specimen volume which may be due to difficulty in getting the accurate specimen volume due to the irregularity of the soft tissue specimen.

Keywords: scout, wire, localization, breast

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Authors: Jakub Młoźniak, Adam Szymański, Gabriela Stondzik, Dagny Krankowska, Tomasz Mikuła

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Nontuberculous mycobacteria (NTM) are bacterial species that cause diversely manifesting diseases mainly in immunocompromised patients. In people with HIV, NTM infection is an AIDS-defining disease and usually appears when the lymphocyte T CD4 count is below 50 cells/μl. The usage of antiretroviral therapy has decreased the prevalence of NTM among people with HIV, but the disease can still be observed especially among patients with late HIV diagnosis. Common presence in environment, human colonization, clinical similarity with tuberculosis and slow growth on culture makes NTM especially hard to diagnose. The study aimed to analyze the epidemiology and clinical course of NTM among patients with HIV. This study included patients with NTM and HIV admitted to our department between 2017 and 2023. Medical records of patients were analyzed and data on age, sex, median time from HIV diagnosis to identification of NTM infection, median CD4 count at NTM diagnosis, methods of determining NTM infection, type of species of mycobacteria identified, clinical symptoms and treatment course were gathered. Twenty-four patients (20 men, 4 women) with identified NTM were included in this study. Among them, 20 were HIV late presenters. The patients' median age was 40. The main symptoms which patients presented were fever, weight loss and cough. Pulmonary disease confirmed with positive cultures from sputum/bronchoalveolar lavage was present in 18 patients. M. avium was the most common species identified. M. marinum caused disseminated skin lesions in 1 patient. Out of all, 5 people were not treated for NTM caused by lack of symptoms and suspicion of colonization with mycobacterium. Concomitant tuberculosis was present in 6 patients. The median diagnostic time from HIV to NTM infections was 3.5 months. The median CD4 count at NTM identification was 69.5 cells/μl. Median NTM treatment time was 16 months but 7 patients haven’t finished their treatment yet. The most commonly used medications were ethambutol and clarithromycin. Among analyzed patients, 4 of them have died. NTM infections are still an important disease among patients who are HIV late presenters. This disease should be taken into consideration during the differential diagnosis of fever, weight loss and cough in people with HIV with lymphocyte T CD4 count <100 cells/μl. Presence of tuberculosis does not exclude nontuberculous mycobacterium coinfection.

Keywords: mycobacteriosis, HIV, late presenter, epidemiology

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Authors: Roozbeh Aghamajidi

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Shaft spillways are circling spillways used generally for emptying unexpected floods on earth and concrete dams. There are different types of shaft spillways: Stepped and Smooth spillways. Stepped spillways pass more flow discharges through themselves in comparison to smooth spillways. Therefore, awareness of flow behavior of these spillways helps using them better and more efficiently. Moreover, using vortex breaker has great effect on passing flow through shaft spillway. In order to use more efficiently, the risk of flow pressure decreases to less than fluid vapor pressure, called cavitations, should be prevented as far as possible. At this research, it has been tried to study different behavior of spillway with different vortex shapes on spillway crest on flow. From the viewpoint of the effects of flow regime changes on spillway, changes of step dimensions, and the change of type of discharge will be studied effectively. Therefore, two spillway models with three different vortex breakers and three arrangements have been used to assess the hydraulic characteristics of flow. With regard to the inlet discharge to spillway, the parameters of pressure and flow velocity on spillway surface have been measured at several points and after each run. Using these kinds of information leads us to create better design criteria of spillway profile. To achieve these purposes, optimization has important role and genetic algorithm are utilized to study the emptying discharge. As a result, it turned out that the best type of spillway with maximum discharge coefficient is smooth spillway with ogee shapes as vortex breaker and 3 number as arrangement. Besides it has been concluded that the genetic algorithm can be used to optimize the results.

Keywords: shaft spillway, vortex breaker, flow, genetic algorithm

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Authors: Ashish Sinha, Pushpend Agrawal

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Background: Patients with undiagnosed pulmonary TB predominantly act as reservoirs for its transmission through 10-15 secondary infections in the next 1-5 Yrs. Delays in the diagnosis and treatment may worsen the disease with increase the risk of death. Factors responsible for such delays by tracking patient pathways to treatment may help in planning better interventions. The provision of ‘free diagnosis and treatment’ forms the cornerstone of the National Tuberculosis Elimination Programme (NTEP). OOPE is defined as the money spent by the patient during TB care other than public health facilities. Free TB care at all health facilities could reduce out-of-pocket expenses to the minimum possible levels. Material and Methods: This cross-sectional study was conducted among randomly selected 252 TB patients from Nov – Oct 2022 by taking in-depth interviews following informed verbal consent. We documented their journey from initial symptoms until they reached the public health facility, along with their ‘out-of-pocket expenditure’ (OOPE) pertaining to TB care. Results: Total treatment delay was 91±72 days on average (median: 77days, IQR: 45-104 days), while the isolated patient delay was 31±45 days (median: 15 days, IQR: 0 days to 43 days); diagnostic delay; 57±60 days (median: 42days, IQR 14-78 days), treatment delay 19 ± 18 days (median: 15days, IQR: 11-19 days). A patient delay (> 30 days) was significantly associated with ignorance about classic symptoms of pulmonary TB, adoption of self-medication, illiteracy, and middle and lower social class. Diagnostic delay was significantly higher among those who contacted private health facilities, were unaware of signs and symptoms, had >2 consultations, and not getting an appropriate referral for TB care. Most (97%) of the study participants interviewed claimed to have incurred some expenditure.Median total expenses were 6155(IQR: 2625-15175) rupees. More than half 141 (56%) of the study participants had expenses >5000 rupees. Median transport expenses were 525(IQR: 200-1012) rupees; Median consultation expenses were 700(IQR: 200-1600) rupees; Median investigation expenses were 1000(IQR: 0-3025) rupees and the Median medicine expenses were 3350(IQR: 1300-7525).OOPE for consultation, investigation, and medicine was observed to be significantly higher among patients who ignored classical signs& symptoms of TB, repeated visits to private health facilities, and due to self-medication practices. Transport expenses and delays in seeking care at facilities were observed to have an upward trend with OOP Expenses (r =1). Conclusion: Delay in TB care due to low awareness about signs and symptoms of TB and poor seeking care, lack of proper consultation, and appropriate referrals reported by the study subjects indicate the areas which need proper attention by the program managers. Despite a centrally sponsored programme, the financial burden on TB patients is still in the unacceptable range. OOPE could be reduced as low as possible by addressing the responsible factors linked to it.

Keywords: patient pathway, delay, pulmonary tuberculosis, out of pocket expenses

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Authors: Malte Schilling, Mahmoud M. Rabah, Sven Liebisch

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Wave run-up and overtopping are the relevant parameters for the dimensioning of the crest height of dikes. Various experimental as well as numerical studies have investigated these parameters under different boundary conditions (e.g. wave conditions, structure type). Particularly for the dike design in Europe, a common approach is formulated where wave and structure properties are parameterized. However, this approach assumes equal run-up heights and overtopping discharges along the longitudinal axis. However, convex dikes have a heterogeneous crest by definition. Hence, local differences in a convex dike line are expected to cause wave-structure interactions different to a straight dike. This study aims to assess both run-up and overtopping at convexly curved dikes. To cast light on the relevance of curved dikes for the design approach mentioned above, physical model tests were conducted in a 3D wave basin of the Ludwig-Franzius-Institute Hannover. A dike of a slope of 1:6 (height over length) was tested under both regular waves and TMA wave spectra. Significant wave heights ranged from 7 to 10 cm and peak periods from 1.06 to 1.79 s. Both run-up and overtopping was assessed behind the curved and straight sections of the dike. Both measurements were compared to a dike with a straight line. It was observed that convex curvatures in the longitudinal dike line cause a redirection of incident waves leading to a concentration around the center point. Measurements prove that both run-up heights and overtopping rates are higher than on the straight dike. It can be concluded that deviations from a straight longitudinal dike line have an impact on design parameters and imply uncertainties within the design approach in force. Therefore, it is recommended to consider these influencing factors for such cases.

Keywords: convex dike, longitudinal curvature, overtopping, run-up

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Authors: P. Sathyathas, H. M. I. S. W. Herath, T. Amalraj, U. J. M. A. L. Jayasinghe

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Over two thirds of medical radiation can now be attributed to Computed Tomography (CT). There is little information on amount of radiation received from multiphase CT scan of abdomen- pelvic region in clinical practice. We sought to estimate the radiation dose and associated exposure parameters in the multiphase abdomen - pelvic scan of Multideteror Computed Tomography (MDCT) studies in clinical practice. This was a retrospective cross sectional studies describing radiation dose associated with main exposure parameters in diagnostic multiphase abdomen - pelvic scans performed on 152 consecutive patients by two different sixteen slice CT scanners. Patient information, exposure parameters of CTDI (volume), DLP, kVp, mAs and pitch were recorded for every phases of abdomen- a pelvic study from dose report of MDCT scanners (MDCTs). Age of patients range from 14 years to 87 years in both MDCT scanners. Overall CTDI (volume) median was 63.8 (±10.4) mGy for a multiphase abdominal-pelvic scan with scanner A while it was 35.4 (±15.6) mGy for scanner B. Patients' effective dose for multiphase abdomen - pelvic CT scan range from 8.2 mSv to 58 mSv. Median effective dose for patients, who underwent multiphase abdomen- pelvis scan with scanner A and B were 38.5 (± 8.2) mSv and 21.3 (± 8.6) mSv respectively. Median value of exposure parameters of mAs, kVp and pitch, were 150 (±29.7), 130 (±15.3) and 1.3 (±0.1) respectively in scanner A. In scanner B; they were 60 (±14.5), 120 and 1. The median effective dose for patients between multiphase abdomen-pelvic scan of both MDCT, a significant different (P<0.05) was observed. Multiphase abdomen – pelvic scan of clinical study shows significant different of effective dose with reference level of phantom studies (8-14mSv) and it depends on the type of vendors.

Keywords: abdomen-pelvic region, computed tomography, exposure parameters, radiation dose

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Authors: Noreen Noreen, Aamir Ijaz, Hamza Akhtar

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Background: Screening plays a major role to detect chromosomal abnormalities, Down syndrome, neural tube defects and other inborn diseases of the newborn. Serum biomarkers in the second trimester are useful in determining risk of most common chromosomal anomalies; these test include Alpha-fetoprotein (AFP), Human chorionic gonadotropin (hCG), Unconjugated Oestriol (UEȝ)and inhibin-A. Quadruple biomarkers are worth test in diagnosing the congenital pathology during pregnancy, these procedures does not form a part of routine health care of pregnant women in Pakistan, so the median value is lacking for population in Pakistan. Objective: To determine median values of biochemical maternal serum markers in local population during second trimester maternal screening. Study settings: Department of Chemical Pathology and Endocrinology, Armed Forces Institute of Pathology (AFIP) Rawalpindi. Methods: Cross-Sectional study for estimation of reference values. Non-probability consecutive sampling, 155 healthy pregnant women, of 30-40 years of age, will be included. As non-parametric statistics will be used, the minimum sample size is 120. Result: Total 155 women were enrolled into this study. The age of all women enrolled ranged from 30 to39 yrs. Among them, 39 per cent of women were less than 34 years. Mean maternal age 33.46±2.35 SD and maternal body weight were 54.98±2.88. Median value of quadruple markers calculated from 15-18th week of gestation that will be used for calculation of MOM for screening of trisomy21 in this gestational age. Median value at 15 week of gestation were observed hCG 36650 mIU/ml, AFP 23.3 IU/ml, UEȝ 3.5 nmol/L, InhibinA 198 ng/L, at 16 week of gestation hCG 29050 mIU/ml, AFP 35.4 IU/ml, UEȝ 4.1 nmol/L, InhibinA 179 ng/L, at 17 week of gestation hCG 28450 mIU/ml, AFP 36.0 IU/ml, UEȝ 6.7 nmol/L, InhibinA 176 ng/L and at 18 week of gestation hCG 25200 mIU/ml, AFP 38.2 IU/ml, UEȝ 8.2 nmol/L, InhibinA 190 ng/L respectively.All the comparisons were significant (p-Value <0.005) with 95% confidence Interval (CI) and level of significance of study set by going through literature and set at 5%. Conclusion: The median values for these four biomarkers in Pakistani pregnant women can be used to calculate MoM.

Keywords: screening, down syndrome, quadruple test, second trimester, serum biomarkers

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Authors: Usama Abdulwahab, Mohammed Wahab

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This paper presents the application of uncapacitated facility location problems (UFLP) and 1-median problems to support decision making in blood supply chain networks. A plethora of factors make blood supply-chain networks a complex, yet vital problem for the regional blood bank. These factors are rapidly increasing demand; criticality of the product; strict storage and handling requirements; and the vastness of the theater of operations. As in the UFLP, facilities can be opened at any of $m$ predefined locations with given fixed costs. Clients have to be allocated to the open facilities. In classical location models, the allocation cost is the distance between a client and an open facility. In this model, the costs are the allocation cost, transportation costs, and inventory costs. In order to address this problem the median algorithm is used to analyze inventory, evaluate supply chain status, monitor performance metrics at different levels of granularity, and detect potential problems and opportunities for improvement. The Euclidean distance data for some Ontario cities (demand nodes) are used to test the developed algorithm. Sitation software, lagrangian relaxation algorithm, and branch and bound heuristics are used to solve this model. Computational experiments confirm the efficiency of the proposed approach. Compared to the existing modeling and solution methods, the median algorithm approach not only provides a more general modeling framework but also leads to efficient solution times in general.

Keywords: approximate dynamic programming, facility location, perishable product, inventory model, blood platelet, P-median problem

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Authors: P. Donnelly, G. Mitchell

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Traumatic Brain Injury (TBI) is a major contributor to the global burden of disease; despite its ubiquity, there is significant variation in diagnosis, prognosis, and treatment between clinicians. This study aims to examine the spectrum of approaches that currently exist at a Level 1 Trauma Centre in Australasia by surveying Emergency Physicians and Neurosurgeons on those aspects of mTBI. A pilot survey of 17 clinicians (Neurosurgeons, Emergency Physicians, and others who manage patients with mTBI) at a Level 1 Trauma Centre in Brisbane, Australia, was conducted. The objective of this study was to examine the importance these clinicians place on various elements in their approach to the diagnosis, prognostication, and treatment of mTBI. The data were summarised, and the descriptive statistics reported. Loss of consciousness and post-traumatic amnesia were rated as the most important signs or symptoms in diagnosing mTBI (median importance of 8). MRI was the most important imaging modality in diagnosing mTBI (median importance of 7). ‘Number of the Previous TBIs’ and Intracranial Injury on Imaging’ were rated as the most important elements for prognostication (median importance of 9). Education and reassurance were rated as the most important modality for treating mTBI (median importance of 7). There was a statistically insignificant variation between the specialties as to the importance they place on each of these components. In this Australian tertiary trauma center, there appears to be variation in how clinicians approach mTBI. This study is underpowered to state whether this is between clinicians within a specialty or a trend between specialties. This variation is worthwhile in investigating as a step toward a unified approach to diagnosing, prognosticating, and treating this common pathology.

Keywords: mild traumatic brain injury, adult, clinician, survey

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Authors: Yuzhi Cai

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In this paper, we discuss a Bayesian approach to quantile autoregressive (QAR) time series model estimation and forecasting. Together with a combining forecasts technique, we then predict USD to GBP currency exchange rates. Combined forecasts contain all the information captured by the fitted QAR models at different quantile levels and are therefore better than those obtained from individual models. Our results show that an unequally weighted combining method performs better than other forecasting methodology. We found that a median AR model can perform well in point forecasting when the predictive density functions are symmetric. However, in practice, using the median AR model alone may involve the loss of information about the data captured by other QAR models. We recommend that combined forecasts should be used whenever possible.

Keywords: combining forecasts, MCMC, predictive density functions, quantile forecasting, quantile modelling

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Authors: Amani Waheed, Mostafa Kofi, Shaymaa Attia, Soha Younis, Basma Abdel Hadi

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Background: Exposure to pesticides is one of the most important occupational risks among farmers in developing countries. Along with the wide use of pesticides in the world, the concerns over their health impacts are rapidly growing. Objective: To investigate thyroid and reproductive hormones and fasting blood glucose levels among farmers chronically exposed to pesticide from East Almnaif district, Ismailia governorate. Methods: An analytical cross-sectional study was conducted on 43 farmers with active involvement pesticides handling and 43 participants not occupationally exposed to pesticides as the control group. A structured interview questionnaire measuring the sociodemographic characteristics, pesticides exposure characteristics, and safety measures was used. General examination including measurements of height, weight, and blood pressure was done. Moreover, levels of plasma cholinesterase enzyme (PChE), glucose, as well as reproductive and thyroid hormones (TSH, T4, and testosterone) were determined. Results: There were no statistically significant differences between both groups regarding their age, educational level, smoking status, and body mass index. The mean duration of exposure was 20.60 11.06 years. Majority of farmers (76.7%) did not use any personal protective equipment (PPE) during pesticides handling. The mean systolic blood pressure among exposed farmers was greater (134.88 17.18 mm Hg) compared to control group (125 14.69 mm Hg) with statistically significant difference (p = 0.003). The mean diastolic blood pressure was higher (84.02 8.69 mm Hg) compared to control group (78.79 8.98 mm Hg) with statistically significant difference (p = 0.006). The pesticide exposed farmers had statistically significant lower level of PChE (3969.93 1841U/L) than control group (4879.29 1950.08 U/L). Additionally, TSH level was significantly higher in exposed farmers (median =1.39µIU/ml) compared to controls (median = 0.91 µIU/ml) (p=0.032). While, the exposed group had a lower T4 level (6.91 1.91 µg/dl) compared to the control group (7.79 2.10µg/dl), with the statistically significant difference between the two groups (p = 0.045). The exposed group had significantly lower level of testosterone hormone (median=3.37 ng/ml) compared to the control group (median= 6.22 ng/ml) (p=0.003). While, the exposed farmers had statistically insignificant higher level of fasting blood glucose (median =89 mg/dl) than the controls (median=88 mg/dl). Furthermore, farmers who did not use PPE had statistically significant lower level of T4 (6.57 1.81µg/dl) than farmers who used PPE during handling of pesticides (8.01 1.89 µg/dl). Conclusion: Chronic exposure to pesticides exerts disturbing action on reproductive function and thyroid function of the male farmers.

Keywords: chronic occupational pesticide exposure, Diabetes mellitus, male reproductive hormones, thyroid function

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Authors: Rodrigo Fernandes da Silva, Daniela Maira Cardozo, Paulo Cesar Martins Alves, Sophie Françoise Derchain, Fernando Guimarães

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T-reg lymphocytes are important for the control of peripheral tolerance. They control the adaptive immune system and prevent autoimmunity through its suppressive action on CD4+ and CD8+ lymphocytes. The suppressive action also includes B lymphocytes, dendritic cells, monocytes/macrophages and recently, studies have shown that T-reg are also able to inhibit NK cells, therefore they exert their control of the immune response from innate to adaptive response. Most tumors express self-ligands, therefore it is believed that T-reg cells induce tolerance of the immune system, hindering the development of successful immunotherapies. T-reg cells have been linked to the suppression mechanisms of the immune response against tumors, including ovarian cancer. The goal of this study was to disclose the sub-population of the expanded CD3+ lymphocytes reported by previous studies, using the long-term culture model designed by Carlens et al 2001, to generate effector cell suspensions enriched with cytotoxic CD3-CD56+ NK cells, from PBMC of ovarian neoplasia patients. Methods and Results: Blood was collected from 12 patients with ovarian neoplasia after signed consent: 7 benign (Bng) and 5 malignant (Mlg). Mononuclear cells were separated by Ficoll-Paque gradient. Long-term culture was conducted by a 21 day culturing process with SCGM CellGro medium supplemented with anti-CD3 (10ng/ml, first 5 days), IL-2 (1000UI/ml) and FBS (10%). After 21 days of expansion, there was an increase in the population of CD3+ lymphocytes in the benign and malignant group. Within CD3+ population, there was a significant decrease in the population of CD4+ lymphocytes in the benign (median Bgn D-0=73.68%, D-21=21.05%) (p<0.05) and malignant (median Mlg D-0=64.00%, D-21=11.97%) (p < 0.01) group. Inversely, after 21 days of expansion, there was an increase in the population of CD8+ lymphocytes within the CD3+ population in the benign (median Bgn D-0=16.80%, D-21=38.56%) and malignant (median Mlg D-0=27.12%, D-21=72.58%) group. However, this increase was only significant on the malignant group (p<0.01). Within the CD3+CD4+ population, there was a significant increase (p < 0.05) in the population of T-reg lymphocytes in the benign (median Bgn D-0=9.84%, D-21=39.47%) and malignant (median Mlg D-0=3.56%, D-21=16.18%) group. Statistical analysis inter groups was performed by Kruskal-Wallis test and intra groups by Mann Whitney test. Conclusion: The CD4+ and CD8+ sub-population of CD3+ lymphocytes shifts with the culturing process. This might be due to the process of the immune system to produce a cytotoxic response. At the same time, T-reg lymphocytes increased within the CD4+ population, suggesting a modulation of the immune response towards cells of the immune system. The expansion of the T-reg population can hinder an immune response against cancer. Therefore, an immunotherapy using this expansion procedure should aim to halt the expansion of T-reg or its immunosuppresion capability.

Keywords: regulatory T cells, CD8+ T cells, CD4+ T cells, NK cell expansion

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