Search results for: integrated care delivery

Authors: Mini P. Singh, Jagat Ram, Archit Kumar, Tripti Rungta, Jasmine Khurana, Amit Gupta, R. K. Ratho

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Introduction: Human adenovirus is the most common agent involved in viral conjunctivitis. The clinical manifestations vary with different serotypes. The identification of the circulating strains followed by phylogenetic analysis can be helpful in understanding the origin and transmission of the disease. The present study aimed to carry out molecular epidemiology of the adenovirus types in the patients with conjunctivitis presenting to the eye centre of a tertiary care hospital in North India. Materials and Methods: The conjunctival swabs were collected from 23 suspected adenoviral conjunctivitis patients between April-August, 2014 and transported in viral transport media. The samples were subjected to nested PCR targeting hexon gene of human adenovirus. The band size of 956bp was eluted and 8 representative positive samples were subjected to sequencing. The sequences were analyzed by using CLUSTALX2.1 and MEGA 5.1 software. Results: The male: female ratio was found to be 3.6:1. The mean age of presenting patients was 43.95 years (+17.2). Approximately 52.1% (12/23) of patients presented with bilateral involvement while 47.8% (11/23) with unilateral involvement of the eye. Human adenovirus DNA could be detected in 65.2% (15/23) of the patients. The phylogenetic analysis revealed presence of serotype 8 in 7 patients and serotype 4 in one patient. The serotype 8 sequences showed 99-100% identity with Tunisian, Indian and Japanese strains. The adenovirus serotype 4 strains had 100% identity with strains from Tunisia, China and USA. Conclusion: Human adenovirus was found be an important etiological agent for conjunctivitis in our set up. The phylogenetic analysis showed that the predominant circulating strains in our epidemic keratoconjunctivitis were serotypes 8 and 4.

Keywords: conjunctivitis, human adenovirus, molecular epidemiology, phylogenetics

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Authors: Emmanuel Olasope Bamigboye, Ismail Oladeji Oladosu

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Local people of south-western Nigeria like in other climes, continue to be confronted with the vagaries of changing environments. Through the modification of existing practice and shifting resource base, their strategies for coping with change have enabled them to successfully negotiate the shifts in climate change and the environment. This article analyses indigenous adaptation strategies for climate change with a view to enhancing sustainable crop farming in south –western Nigeria. Multi-stage sampling procedure was used to select 340 respondents from the two major ecological zones (Forest and Derived Savannah) for good geographical spread. The article draws on mixed methods of qualitative research, literature review, field observations, informal interview and multinomial logit regression to capture choice probabilities across the various options of climate change adaptation options among arable crop farmers. The study revealed that most 85.0% of the arable crop farmers were males. It also showed that the use of local climate change adaptation strategies had no relationship with the educational level of the respondents as 77.3% had educational experiences at varying levels. Furthermore, the findings showed that seven local adaptation strategies were commonly utilized by arable crop farmers. Nonetheless, crop diversification, consultation with rainmakers and involvement in non-agricultural ventures were prioritized in the order of 1-3, respectively. Also, multinomial logit analysis result showed that at p ≤ 0.05 level of significance, household size (P<0.08), sex (p<0.06), access to loan(p<0.16), age(p<0.07), educational level (P<0.17) and functional extension contact (P<0.28) were all important in explaining the indigenous climate change adaptation utilized by the arable crops farmers in south-western Nigeria. The study concluded that all the identified local adaptation strategies need to be integrated into the development process for sustainable climate change adaptation.

Keywords: crop diversification, climate change, adaptation option, sustainable, small farmers

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Authors: Pagadaplly Girish, P. V. Manohar

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Introduction: Management of distal femur fractures is challenging. Recently, treatment has evolved towards indirect reduction and minimally invasive techniques. Objectives: To assess the fracture union and functional outcome following open reduction and internal fixation of distal femur fractures with locking compression plate and to achieve restoration of the anatomical alignment of fracture fragments and stable internal fixation. Methodology: Patients with distal femur fracture treated by locking compression during Oct 2011 to April 2013 were assessed prospectively. Patients below 18 years and those with neuro-vascular deficits were excluded. Age, sex of the patient, type of fracture, mechanism of injury, type of implant used, operative time and postoperative complications were analysed. The Neer’s scale was used to assess the outcome of the patients. Results: The total number of patients was 30; 28 males and 2 females; mean age was 41.53 years. Road traffic accidents were the major causes of injury followed by falls. The average duration of hospital stay was 21.3 days. The overall complication rate note was 23.33%. The mean range of movement around the knee joint after 6 months of follow-up was 114.330. The average time for the radiological union was 14 weeks. Excellent to good results were noted in 26 patients (86.6%) and average to poor results were observed in 4 (13.33%) patients. Conclusions: The locking compression plate gives a rigid fixation for the fracture. It also provides a good purchase in osteoporotic bones. LCP is simple and a reliable implant appropriate for fixation of femoral fractures with promising results.

Keywords: distal femur fractures, locking compression plate, Neer’s criteria, neuro-vascular deficits

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Authors: Barsharani Maharana

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India is the country that shelters the largest number of poor. One of the major areas of concern in India is the unsatisfactory situation of the poor in social developmental and health parameters, not only in rural areas which are partly devoid of the facilities but also in the urban areas where the facilities are insufficient to provide services of a satisfactory quality. Objectives: 1) to examine the association between the environmental condition and health condition among poor women in urban areas. 2) to find out the significance of the effect of environment on the child health among the poor children. 3) to present the scenario of poor among highly urbanized and less urbanized states with respect to the health and environment. Data: data from National Family Health survey-3 and census are used to fulfill the objectives. Methodology: In this study, the standard of living condition of people living in urban areas is computed by taking some household characteristics and assets. People possessing low standard of living are considered as poor. Bivariate and multivariate analysis are employed to examine the effect of environment on poor women and children. A geographical information system is used to present the health and environmental condition of poor in highly and less urbanized states. Results: The findings reveal that the poor women who are not accessed to improved source of water, and sanitation facility are facing more health problems. Children who are living in a dirty environment and are not accessed to improved source of drinking water, among them prevalence of diarrhea and fever is found to be high. As well, the health condition of poor in highly urbanized states is dreadful. Policy implications: Government should emphasize on the implementation of programs regarding the improvement in the infrastructural facilities and health care treatment of urban poor.

Keywords: environment, urban poor, health, sanitation

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Authors: Ryan Houser

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Introduction: Previous studies have found that public health systems within the United States are inadequately prepared for an act of biological terrorism. As the COVID-19 pandemic continues, few studies have evaluated bioterrorism preparedness of Emergency Medical Services, even in the accelerating environment of biothreats. Methods: This study utilized an Internet-based survey to assess the level of preparedness and willingness to respond to a bioterrorism attack and identify factors that predict preparedness and willingness among Nebraska EMS (Emergency Medical Services ) providers. The survey was available for one month in 2021, during which 190 EMS providers responded to the survey. Results: Only 56.8% of providers were able to recognize an illness or injury as potentially resulting from exposure to a CBRN agent. The provider Clinical Competency levels range from a low of 13.6% (ability to initiate patient care within his/her professional scope of practice and arrange for prompt referral appropriate to the identified condition(s)) to a high of 74% (the ability to respond to an emergency within the emergency management system of his/her practice, institution and community). Only 10% of the respondents are both willing and able to effectively function in a bioterror environment. Discussion: In order to effectively prepare for and respond to a bioterrorist attack, all levels of the healthcare system need to have the clinical skills, knowledge, and abilities necessary to treat patients exposed. Policy changes and increased focus on training and drills are needed to ensure a prepared EMS system which is crucial to a resilient state. EMS entities need to be aware of the extent of their available workforce so that the country can be prepared for the increasing threat of bioterrorism or other novel emerging infectious disease outbreaks. A resilient nation relies on a prepared set of EMS providers who are willing to respond to biological terrorism events.

Keywords: bioterrorism, prehospital, EMS, disaster, emergency, medicine, preparedness, policy

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Authors: Fengqing Li, Petra Schneider

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Failure of tailings management facilities (TMF) of radioactive residues is an enormous challenge worldwide and can result in major catastrophes. Particularly in transboundary regions, such failure is most likely to lead to international conflict. This risk occurs in Kyrgyzstan and Uzbekistan, where the current major challenge is the quantification of impacts due to pollution from uranium legacy sites and especially the impact on river basins after natural hazards (i.e., landslides). By means of GoldSim, a probabilistic simulation model, the amount of tailing material that flows into the river networks of Mailuu Suu in Kyrgyzstan after pond failure was simulated for three scenarios, namely 10%, 20%, and 30% of material inputs. Based on Muskingum-Cunge flood routing procedure, the peak value of uranium flood wave along the river network was simulated. Among the 23 TMF, 19 ponds are close to the river networks. The spatiotemporal distributions of uranium along the river networks were then simulated for all the 19 ponds under three scenarios. Taking the TP7 which is 30 km far from the Kyrgyzstan-Uzbekistan border as one example, the uranium concentration decreased continuously along the longitudinal gradient of the river network, the concentration of uranium was observed at the border after 45 min of the pond failure and the highest value was detected after 69 min. The highest concentration of uranium at the border were 16.5, 33, and 47.5 mg/L under scenarios of 10%, 20%, and 30% of material inputs, respectively. In comparison to the guideline value of uranium in drinking water (i.e., 30 µg/L) provided by the World Health Organization, the observed concentrations of uranium at the border were 550‒1583 times higher. In order to mitigate the transboundary impact of a radioactive pollutant release, an integrated framework consisting of three major strategies were proposed. Among, the short-term strategy can be used in case of emergency event, the medium-term strategy allows both countries handling the TMF efficiently based on the benefit-sharing concept, and the long-term strategy intends to rehabilitate the site through the relocation of all TMF.

Keywords: Central Asia, contaminant transport modelling, radioactive residue, transboundary conflict

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Authors: Mohammad H. Yarmohammadian, Reza Safdari, Mahmoud Keyvanara, Nahid Tavakoli

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One of the greatest challenges in disaster and emergencies is patient tracking. The concept of tracking has different denotations. One of the meanings refers to tracking patients’ physical locations and the other meaning refers to tracking patients ‘medical needs during emergency services. The main goal of patient tracking is to provide patient safety during disaster and emergencies and manage the flow of patient and information in different locations. In most of cases, there are not sufficient and accurate data regarding the number of injuries, medical conditions and their accommodation and transference. The objective of the present study is to survey on patient tracking issue in natural disaster and emergencies. Methods: This was a narrative study in which the population was E-Journals and the electronic database such as PubMed, Proquest, Science direct, Elsevier, etc. Data was gathered by Extraction Form. All data were analyzed via content analysis. Results: In many countries there is no appropriate and rapid method for tracking patients and transferring victims after the occurrence of incidents. The absence of reliable data of patients’ transference and accommodation, even in the initial hours and days after the occurrence of disasters, and coordination for appropriate resource allocation, have faced challenges for evaluating needs and services challenges. Currently, most of emergency services are based on paper systems, while these systems do not act appropriately in great disasters and incidents and this issue causes information loss. Conclusion: Patient tracking system should update the location of patients or evacuees and information related to their states. Patients’ information should be accessible for authorized users to continue their treatment, accommodation and transference. Also it should include timely information of patients’ location as soon as they arrive somewhere and leave therein such a way that health care professionals can be able to provide patients’ proper medical treatment.

Keywords: patient tracking, challenges, disaster, emergency

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Authors: Arul Ayyaswami, Vidhya Ramalingam

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Per- and polyfluoroalkyl substances (PFAS) have emerged as a significant environmental concern due to their ubiquity and persistence in the environment. Their chemical characteristics and adverse effects on human health demands more effective and sustainable solutions in remediation of the PFAS. The work presented here encompasses an overview of treatment technologies with two case studies that utilize effective approaches in addressing PFAS contaminated media. Currently the options for treatment of PFAS compounds include Activated carbon adsorption, Ion Exchange, Membrane Filtration, Advanced oxidation processes, Electrochemical treatment, and Precipitation and Coagulation. In the first case study, a pilot study application of colloidal activated carbon (CAC) was completed to address PFAS from aqueous film-forming foam (AFFF) used to extinguish a large fire. The pilot study was used to demonstrate the effectiveness of a CAC in situ permeable reactive barrier (PRB) in effectively stopping the migration of PFOS and PFOA, moving from the source area at high concentrations. Before the CAC PRB installation, an injection test using - fluorescein dye was conducted to determine the primary fracture-induced groundwater flow pathways. A straddle packer injection delivery system was used to isolate discrete intervals and gain resolution over the 70 feet saturated zone targeted for treatment. Flow rates were adjusted, and aquifer responses were recorded for each interval. The results from the injection test were used to design the pilot test injection plan using CAC PRB. Following the CAC PRB application, the combined initial concentration 91,400 ng/L of PFOS and PFOA were reduced to approximately 70 ng/L (99.9% reduction), after only one month following the injection event. The results demonstrate the remedy's effectiveness to quickly and safely contain high concentrations of PFAS in fractured bedrock, reducing the risk to downgradient receptors. The second study involves developing a reductive defluorination treatment process using UV and electron acceptor. This experiment indicates a significant potential in treatment of PFAS contaminated waste media such as landfill leachates. The technology also shows a promising way of tacking these contaminants without the need for secondary waste disposal or any additional pre-treatments.

Keywords: per- and polyfluoroalkyl substances (PFAS), colloidal activated carbon (CAC), destructive PFAS treatment technology, aqueous film-forming foam (AFFF)

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Authors: Patrick Ebong Ebewo

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The trend of high unemployment levels globally is a growing concern, which suggests that university students especially those studying the creative industries are most likely to face unemployment upon completion of their studies. Therefore the effort of university in fostering entrepreneurial knowledge is equally important to the development of student’s soft skill. The purpose of this paper is to assess the significance of perceived university environment and perceived educational support that influencing University students’ intention in starting their own business in the future. Thus, attempting to answer the question 'How does perceived university environment affect students’ attitude towards entrepreneurship as a career option, perceived entrepreneurial abilities, subjective norm and entrepreneurial intentions?' The study is based on the Theory of Planned Behaviour model adapted from previous studies and empirically tested on graduates at the Tshwane University of Technology. A sample of 150 graduates from the Arts and Design graduates took part in the study and data collected were analysed using structural equation modelling (SEM). Our findings seem to suggest the indirect impact of perceived university environment on entrepreneurial intention through perceived environment support and perceived entrepreneurial abilities. Thus, any increase in perceived university environment might influence students to become entrepreneurs. Based on these results, it is recommended that: (a) Tshwane University of Technology and other universities of technology should establish an ‘Entrepreneurship Internship Programme’ as a tool for stimulated work integrated learning. Post-graduation intervention could be implemented by the development of a ‘Graduate Entrepreneurship Program’ which should be embedded in the Bachelor of Technology (B-Tech now Advance Diploma) and Postgraduate courses; (b) Policymakers should consider the development of a coherent national policy framework that addresses entrepreneurship for the Arts/creative industries sector. This would create the enabling environment for the evolution of Higher Education Institutions from merely Teaching, Learning & Research to becoming drivers for creative entrepreneurship.

Keywords: business venture, entrepreneurship education, entrepreneurial intent, university environment

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Authors: Tiantian Feng

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There is a dearth of research on the literary circle as a teaching strategy in English as a Foreign Language (EFL) classes in Chinese colleges and universities and even fewer empirical studies on its impacts. In this one-quarter, design-based project, the researcher aims to increase students’ engagement, cooperation, and, on top of that, reading comprehension performance by utilizing a researcher-developed, adapted reading circle model in an EFL reading course at a Chinese college. The model also integrated team-based learning and portfolio assessment, with an emphasis on the specialization of individual responsibilities, contributions, and outcomes in reading projects, with the goal of addressing current issues in EFL classes at Chinese colleges, such as passive learning, test orientation, ineffective and uncooperative teamwork, and lack of dynamics. In this quasi-experimental research, two groups of students enrolled in the course were invited to participate in four in-class team projects, with the intervention class following the adapted literature circle model and team members rotating as Leader, Coordinator, Brain trust, and Reporter. The researcher/instructor used a sequential explanatory mixed-methods approach to quantitatively analyze the final grades for the pre-and post-tests, as well as individual scores for team projects and will code students' artifacts in the next step, with the results to be reported in a subsequent paper(s). Initial analysis showed that both groups saw an increase in final grades, but the intervention group enjoyed a more significant boost, suggesting that the adapted reading circle model is effective in improving students’ reading comprehension performance. This research not only closes the empirical research gap of literature circles in college EFL classes in China but also adds to the pool of effective ways to optimize reading comprehension performance and class performance in college EFL classes.

Keywords: literature circle, EFL teaching, college english reading, reading comprehension

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Authors: A. S. Strait, J. A. Bryk-Lucy, L. M. Ritchie

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Thrush is a common disease of ungulates primarily affecting the frog and sulci, caused by the anaerobic bacteria Fusobacterium necrophorum. Thrush accounts for approximately 45.0% of hoof disorders in horses. Prevention and treatment of thrush are essential to prevent horses from developing severe infections and becoming lame. Proper knowledge of hoof care and thrush treatments is crucial to avoid financial costs, unsoundness and lost training time. Research on the effectiveness of numerous commercial and homemade thrush treatments is limited in the equine industry. The objective of this study was to compare the effectiveness of three common thrush treatments for horses: weekly application of Thrush Buster, daily dilute bleach solution spray, or Metronidazole pastes every other day. Cases of thrush diagnosed by a veterinarian or veterinarian-trained researcher were given a score, from 0 to 4, based on the severity of the thrush in each hoof (n=59) and randomly assigned a treatment. Cases were rescored each week of the three-week treatment, and the final and initial scores were compared to determine effectiveness. The thrush treatments were compared with Thrush Buster as the reference at a significance level of α=.05. Binomial Logistic Regression Modeling was performed, finding that the odds of a hoof treated with Metronidazole to be thrush-free was 6.1 times greater than a hoof treated with Thrush Buster (p=0.001), while the odds of a hoof that was treated with bleach to be thrush-free was only 0.97 times greater than a hoof treated with Thrush Buster (p=0.970), after adjustment for treatment week. Of the three treatments utilized in this study, Metronidazole paste applied to the affected areas every other day was the most effective treatment for thrush in horses. There are many other thrush remedies available, and further research is warranted to determine the efficacy of additional treatment options.

Keywords: fusobacterium necrophorum, thrush, equine, horse, lameness

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Authors: Sedigheh Kalantari, Yaping Huang

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The historic area of cities has experienced different phases of transformation. The beginning of the twentieth century, modernism, and modern development changed the integrated pattern of change and the historic urban quarter were regarded as subject comprehensive redevelopment. In this respect, historic area of Iranian cities have not been safe from these changes and affected by widespread evolutions; in particular after Islamic Revolution eras (1978) cities have traveled through an evolution in conservation and development policies and practices. Moreover, moving toward a specific approach and specific attention paid to the regeneration of the historical urban centers in Iran has started since the 1990s. This reveals the great importance attached to the historical centers of cities. This paper is an approach to examine an experience on urban regeneration in Iran through a case study. The study relies on multiple source of evidence. The use of multiple sources of evidence can help substantially improve the validity and reliability of the research. The empirical core of this research, therefore, rests in the process of urban revitalization of the old square in Isfahan. Isfahan is one of the oldest city of Persia. The historic area of city encompasses a large number of valuable buildings and monuments. One of the cultural and historical region of Isfahan is Atiq Square (Old Square). It has been the backbone node of the city that in course of time has being ignored more and more and transformed negatively. The complex had suffered from insufficiencies especially with respect to social and spatial aspects. Therefore, reorganization of that complex as the main and most important urban center of Isfahan became an inevitable issue; So this paper except from reminding the value of such historic-cultural heritage and review of its transformation, focused on an experience of urban revitalization project in this heritage site. The outcome of this research shows that situated in different socio-economic political and historical contexts and in face of different urban regeneration issues, Iran have displayed significant differences in the way of urban regeneration.

Keywords: historic area, Iran, urban regeneration, revitalization

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Authors: R. Botrugno, S Basyuni, G. Nugent, I. Jenkyn, A. Ferro, H. Bennett, C. Hjalmarsson, J. Chu, V. Santhanam

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This trainee led randomised controlled trial (RCT) aims to assess various outcomes for resorbable versus non-resorbable sutures for traumatic lacerations to the face. Within this trial of resorbable versus non-resorbable sutures for traumatic lacerations of the face (TORNFace), patient recruitment was facilitated by trainees who were employed at an NHS University Teaching Hospital in the United Kingdom. The trainees received appropriate training prior to recruiting patients for the trial. This included the completion of a national research e-learning module and face-to-face training that was provided locally. The locally delivered training provided an understanding of the eligibility criteria for the trial and the consent process. Existing trainee skills were utilised involving clinical photography to record baseline data and delivering the intervention based on the treatment arm selected. Eligible patients who required primary closure of traumatic lacerations of the face were randomised into one of two treatment arms. These comprised of resorbable (vicryl rapide) or non-resorbable sutures (ethilon). Primarily the cosmetic outcome was assessed. Secondary outcomes included: complications rates, health care economics, and patient-reported outcomes. Remote follow-up of recruited patients utilised photographs of the facial laceration which had received the intervention. These took place at 1 week, 3 months and 6 months post-intervention. This study aims to demonstrate an example of trainee-led research within the specialty of oral and maxillofacial surgery. The available data for the randomised controlled trial will also be presented.

Keywords: laceration, suture, trauma, trial

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Authors: Asmamaw Yehun, Tsegaye Gogie, Martin Vermeer, Addisu Hunegnaw

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The Global Positioning System (GPS) is a space-based radio positioning system, which is capable of providing continuous position, velocity, and time information to users anywhere on or near the surface of the Earth. The main objective of this work was to estimate the integrated precipitable water vapour (IPWV) using ground GPS and Low Earth Orbit (LEO) Radio Occultation (RO) to study spatial-temporal variability. For LEO-GPS RO, we used Constellation Observing System for Meteorology, Ionosphere, and Climate (COSMIC) datasets. We estimated the daily and monthly mean of IPWV using six selected ground-based GPS stations over a period of range from 2012 to 2016 (i.e. five-years period). The main perspective for selecting the range period from 2012 to 2016 is that, continuous data were available during these periods at all Ethiopian GPS stations. We studied temporal, seasonal, diurnal, and vertical variations of precipitable water vapour using GPS observables extracted from the precise geodetic GAMIT-GLOBK software package. Finally, we determined the cross-correlation of our GPS-derived IPWV values with those of the European Centre for Medium-Range Weather Forecasts (ECMWF) ERA-40 Interim reanalysis and of the second generation National Oceanic and Atmospheric Administration (NOAA) model ensemble Forecast System Reforecast (GEFS/R) for validation and static comparison. There are higher values of the IPWV range from 30 to 37.5 millimetres (mm) in Gambela and Southern Regions of Ethiopia. Some parts of Tigray, Amhara, and Oromia regions had low IPWV ranges from 8.62 to 15.27 mm. The correlation coefficient between GPS-derived IPWV with ECMWF and GEFS/R exceeds 90%. We conclude that there are highly temporal, seasonal, diurnal, and vertical variations of precipitable water vapour in the study area.

Keywords: GNSS, radio occultation, atmosphere, precipitable water vapour

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Authors: Vinay Kumar, M. Kishor, Sathyanarayana Rao Ts

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Background: Growth of elderly people in the general population in recent years is termed as ‘greying of the world’ where there is a shift from high mortality & fertility to low mortality and fertility, resulting in an increased proportion of older people as seen in India. Improved health care promises longevity but socio-economic factors like poverty, joint families and poor services pose a psychological threat. Epidemiological data regarding the prevalence of mental disorders in geriatric population with physical illness is required for proper health planning. Methods: Sixty consecutive elderly patients aged 60 years or above of both sexes, reporting with physical illness to general outpatient registration counter of JSS Medical College and Hospital, Mysore, India, were considered for the Study. With informed consent, they were screened with General Health Questionnaire (GHQ-12) and were further evaluated for diagnosing mental disorders according to WHO International Classification of Diseases (ICD-10) criteria. Results: Mental disorders were detected in 48.3%, predominantly depressive disorders, nicotine dependence, generalized anxiety disorder, alcohol dependence and least was dementia. Most common physical illness was cardiovascular disease followed by metabolic, respiratory and other diseases. Depressive disorders, substance dependence and dementia were more associated with cardiovascular disease compared to metabolic disease and respiratory diseases were more associated with nicotine dependence. Conclusions: Depression and Substance use disorders among elderly population is of concern, which needs to be further studied with larger population. Psychiatric morbidity will adversely have an impact on physical illness which needs proper assessment and management. This will enhance our understanding and prioritize our planning for future.

Keywords: Geriatric, mental disorders, physical illness, psychiatry

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Authors: Stela Doncheva

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Postpartum distress, encompassing depressive symptoms, obsessions, and anxiety, remains a subject of significant scientific interest due to its prevalence among individuals giving birth. This critical and transformative period presents a multitude of factors that impact women's health. On the one hand, variables such as social support, satisfaction in romantic relationships, shared newborn care, and birth satisfaction directly affect the mental well-being of new mothers. On the other hand, the interplay of hormonal changes, personality characteristics, emotional difficulties, and the profound life adjustments experienced by mothers can profoundly influence their self-esteem and overall physical and emotional well-being. This paper extensively explores the factors of alexithymia, social support, partners' support, and birth satisfaction to gain deeper insights into their impact on postpartum distress. Utilizing a qualitative survey consisting of six self-reflective questionnaires, this study collects valuable data regarding the individual postpartum experiences of Bulgarian mothers. The primary objective is to enrich our understanding of the complex factors involved in the development of postpartum distress during this crucial period. The results shed light on the intricate nature of the problem and highlight the significant influence of bio-psycho-social elements. By contributing to the existing knowledge in the field, this research provides valuable implications for the development of interventions and support systems tailored to the unique needs of mothers in the postpartum period. Ultimately, this study aims to improve the overall well-being of new mothers and promote optimal maternal health during the postpartum journey.

Keywords: maternal mental health, postpartum distress, postpartum depression, postnatal mothers

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Authors: Asma AlQahtani, Jumana AlHadad, Maryam AlQallaf, Shoug AlHasan

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New product development (NPD) is the complete process of bringing a new product to the customer by integrating the two broad divisions; one involving the idea generation, product design and detail engineering; and the other involving market research and marketing analysis. It is a common practice for companies to undertake some of these tasks simultaneously (concurrent engineering) and also consider them as an ongoing process (continuous development). The current study explores the framework and methodology for a new product development process utilizing the Quality Function Deployment (QFD) tool for bringing the customer opinion into the product development process. An elaborate customer survey with focus groups in the region was carried out to ensure that customer requirements are integrated into new products as early as the design stage including identifying the recognition of need for the new product. A QFD Matrix (House of Quality) was prepared that links customer requirements to product engineering requirements and a feasibility study and risk assessment exercise was carried out for a Small and Medium Enterprise (SME) in Kuwait for development of the new product. SMEs in Kuwait, particularly in manufacturing sector are mainly focused on serving the local demand, and often lack of product quality adversely affects the ability of the companies to compete on a regional/global basis. Further, lack of focus on identifying customer requirements often deters SMEs to envisage the idea of a New Product Development. The current study therefore focuses in utilizing QFD Matrix right from the conceptual design to detail design and to some extent, extending the link this to design of the manufacturing system. The outcome of the project resulted in a development of the prototype for a new molded product which can ensure consistency between the customer’s requirements and the measurable characteristics of the product. The Engineering Economics and Cost studies were also undertaken to analyse the viability of the new product, the results of which was also linked to the successful implementation of the initial QFD Matrix.

Keywords: Quality Function Deployment, QFD Matrix, new product development, NPD, Kuwait SMEs, prototype development

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Authors: Melek Göregenli, Pelin Karakuş

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This present study explored the acculturation strategies and urban related identity of Turk and Kurd internal migrants from different regions of Turkey who resettled in three big cities in the west. Besides we aimed at a comparative analysis of acculturation strategies and urban-related identity of voluntary and internally displaced Kurd migrants. Particularly we explored the role of migration type, satisfaction with migration decision, urban-related identity and several socio demographic variables as predictors of Kurds’ integration strategy preference. The sample consisted of 412 adult participants from Izmir (64 females, 86 males); Ankara (76 females, 75 males); and Istanbul (43 females, 64 males and four unreported). In terms of acculturation strategies, assimilation was found to be the most preferred acculturation attitude among Turks whereas separation was found to be most endorsed acculturation attitude among Kurds. The migrants in Izmir were found to prefer assimilation whereas the migrants in Ankara prefer separation. Concerning urban-related identity mean scores, Turks reported higher urban-related identity scores than Kurds. Furthermore the internal migrants in Izmir were found to score higher in urban-related identity than the migrants living in Istanbul and Ankara. The results of the regression analysis revealed that gender, length of residence and migration type were the significant predictors of integration preference of Kurds. Thus, whereas gender and migration type had significant negative associations; length of residence had positive significant associations with Kurds integration preference. Compared to female Kurds, male Kurds were found to be more integrated. Furthermore, voluntary Kurd migrants were more favour of integration than internally displaced Kurds. The findings supported the significant associations between acculturation strategies and urban-related identity with either group.

Keywords: acculturation, forced migration, internal displacement, internal migration, Turkey, urban-related identity

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Authors: Mingxia Zhu, Matthew Tingchi Liu

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AI grows gradually in the market with its efficiency and accuracy, influencing people’s perceptions, attitude, and even consequential behaviors. Current study extends prior research by focusing on AI’s impact on consumers’ morality. First, study 1 tested individuals’ believes about AI and human’s moral perceptions and people’s attribution of moral worth to AI and human. Moral perception refers to a computational system an entity maintains to detect and identify moral violations, while moral worth here denotes whether individual regard an entity as worthy of moral treatment. To identify the effect of AI on consumers’ morality, two studies were employed. Study 1 is a within-subjects survey, while study 2 is an experimental study. In the study 1, one hundred and forty participants were recruited through online survey company in China (M_age = 27.31 years, SD = 7.12 years; 65% female). The participants were asked to assign moral perception and moral worth to AI and human. A paired samples t-test reveals that people generally regard that human has higher moral perception (M_Human = 6.03, SD = .86) than AI (M_AI = 2.79, SD = 1.19; t(139) = 27.07, p < .001; Cohen’s d = 1.41). In addition, another paired samples t-test results showed that people attributed higher moral worth to the human personnel (M_Human = 6.39, SD = .56) compared with AIs (M_AI = 5.43, SD = .85; t(139) = 12.96, p < .001; d = .88). In the next study, two hundred valid samples were recruited from survey company in China (M_age = 27.87 years, SD = 6.68 years; 55% female) and the participants were randomly assigned to two conditions (AI vs. human). After viewing the stimuli of human versus AI, participants are informed that one insurance company would determine the price purely based on their declaration. Therefore, their open-ended answers were coded into ethical, honest behavior and unethical, dishonest behavior according to the design of prior literature. A Chi-square analysis revealed that 64% of the participants would immorally lie towards AI insurance inspector while 42% of participants reported deliberately lower mileage facing with human inspector (χ^2 (1) = 9.71, p = .002). Similarly, the logistic regression results suggested that people would significantly more likely to report fraudulent answer when facing with AI (β = .89, odds ratio = 2.45, Wald = 9.56, p = .002). It is demonstrated that people would be more likely to behave unethically in front of non-human agents, such as AI agent, rather than human. The research findings shed light on new practical ethical issues in human-AI interaction and address the important role of human employees during the process of service delivery in the new era of AI.

Keywords: AI agent, consumer morality, ethical behavior, human-AI interaction

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Authors: Vistorina Amputu, Katja Tielboerger, Nichola Knox

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Primary productivity in dry savannahs is constraint by moisture availability and under increasing anthropogenic pressure. Thus, considering climate change and the unprecedented pace and scale of rangeland deterioration, methods for assessing the status of such rangelands should be easy to apply, yield reliable and repeatable results that can be applied over large spatial scales. Global and local scale monitoring of rangelands through satellite data and labor-intensive field measurements respectively, are limited in accurately assessing the spatiotemporal heterogeneity of vegetation dynamics to provide crucial information that detects degradation in its early stages. Fortunately, newly emerging techniques such as unmanned aerial vehicles (UAVs), associated miniaturized sensors and improving digital photogrammetric software provide an opportunity to transcend these limitations. Yet, they have not been extensively calibrated in natural systems to encompass their complexities if they are to be integrated for long-term monitoring. Limited research using drone technology has been conducted in arid savannas, for example to assess the health status of this dynamic two-layer vegetation ecosystem. In our study, we fill this gap by testing the relationship between UAV-estimated cover of rangeland functional attributes and field data collected in discrete sample plots in a Namibian dryland savannah along a degradation gradient. The first results are based on a supervised classification performed on the ultra-high resolution multispectral imagery to distinguish between rangeland functional attributes (bare, non-woody, and woody), with a relatively good match to the field observations. Integrating UAV-based observations to improve rangeland monitoring could greatly assist in climate-adapted rangeland management.

Keywords: arid savannah, degradation gradient, field observations, narrow-band sensor, supervised classification

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Authors: J. Ritonja, R. Brezovnik, M. Petrun, B. Polajžer

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Many modern synchronous generators in power systems are extremely weakly damped. The reasons are cost optimization of the machine building and introduction of the additional control equipment into power systems. Oscillations of the synchronous generators and related stability problems of the power systems are harmful and can lead to failures in operation and to damages. The only useful solution to increase damping of the unwanted oscillations represents the implementation of the power system stabilizers. Power system stabilizers generate the additional control signal which changes synchronous generator field excitation voltage. Modern power system stabilizers are integrated into static excitation systems of the synchronous generators. Available commercial power system stabilizers are based on linear control theory. Due to the nonlinear dynamics of the synchronous generator, current stabilizers do not assure optimal damping of the synchronous generator’s oscillations in the entire operating range. For that reason the use of the robust power system stabilizers which are convenient for the entire operating range is reasonable. There are numerous robust techniques applicable for the power system stabilizers. In this paper the use of sliding mode control for synchronous generator stability improvement is studied. On the basis of the sliding mode theory, the robust power system stabilizer was developed. The main advantages of the sliding mode controller are simple realization of the control algorithm, robustness to parameter variations and elimination of disturbances. The advantage of the proposed sliding mode controller against conventional linear controller was tested for damping of the synchronous generator oscillations in the entire operating range. Obtained results show the improved damping in the entire operating range of the synchronous generator and the increase of the power system stability. The proposed study contributes to the progress in the development of the advanced stabilizer, which will replace conventional linear stabilizers and improve damping of the synchronous generators.

Keywords: control theory, power system stabilizer, robust control, sliding mode control, stability, synchronous generator

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Authors: Milad Pirali, Sohrab Keyhani, Mohhamad Ali Sanjari, Ali Ashraf Jamshidi

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Purpose: The effect of hamstring antagonist activity on the knee extensors torque of the Anterior Cruciate Ligament reconstruction (ACLR) is not clear and persistent muscle weakness is common after ACLR. Hamstring activation when acting as antagonist is considered very important for knee strengths. Therefore the purpose of this study was to examine hamstring antagonist coactivation during maximal effort of the isokinetic knee extension in ACLR athletes with hamstring autograft. Materials and Methods: We enrolled 20 professional athletes who underwent primary ACLR (hamstring tendon autograft)with 6-24 months postoperative and 20 healthy subjects as control group. Each subjects performed maximal effort isokinetic knee extension and flexion in 60/˚ s and 180/˚ s velocities for the involved and uninvolved limb. Synchronously, surface electromyography (EMG) was recorded of vastus medialis (VM), vastus lateralis (VL), rectus femoris (RF) and biceps femoris (BF). The antagonist integrated EMG (IEMG) values were normalized to the IEMG of the same muscle during maximal isokinetic eccentric effort at the same velocities and ROM. Results: A one-way analysis of variance designs shows significantly greater IEMG coactivation of hamstring and decreased activation of Vm in ACLR when compared to uninvolved and control group leg in 60/˚ s and 180/˚ s velocities. Likewise peak torque to body weight was decreased in ACLR compared to uninvolved and control group during knee extension in both velocities (p < 0.05). Conclusions: Decreased extensors moment caused by decreased quadriceps inhibition and increased hamstring coactivation. In addition, these result indicated to decrease of motor unit recruitment in the VM (as a kinesiologicmonitore of the knee). It is appearing that strengthening of the quadriceps to be an important for rehabilitation program after ACLR for preparation in athletes endeavors. Therefore, we suggest that having more emphasis and focus on quadriceps strength and less emphasis on hamstring following ACLR.

Keywords: ACLR-coactivation, dynamometry, electromyography, isokinetic

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Authors: Matei Tudor Berceanu, Hema Viswambharan, Kirti Kain, Chew Weng Cheng

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Background - Obesity parameters, particularly visceral obesity as measured by the waist-to-height ratio (WHtR), correlate with insulin resistance. The metabolic microvascular changes associated with insulin resistance causes increased peripheral arteriolar resistance primarily to the lower limb vessels. We hypothesize that ankle systolic blood pressures (SBPs) are more significantly associated with visceral obesity than brachial SBPs. Methods - 1098 adults enriched in south Asians or Europeans with diabetes (T2DM) were recruited from a primary care practice in West Yorkshire. Their medical histories, including T2DM and cardiovascular disease (CVD) status, were gathered from an electronic database. The brachial, dorsalis pedis, and posterior tibial SBPs were measured using a Doppler machine. Their body mass index (BMI) and WHtR were calculated after measuring their weight, height, and waist circumference. Linear regressions were performed between the 6 SBPs and both obesity parameters, after adjusting for covariates. Results - Generally, the left posterior tibial SBP (P=4.559*10⁻¹⁵) and right posterior tibial SBP (P=1.114* 10⁻¹³ ) are the pressures most significantly associated with the BMI, as well as in south Asians (P < 0.001) and Europeans (P < 0.001) specifically. In South Asians, although the left (P=0.032) and right brachial SBP (P=0.045) were associated to the WHtR, the left posterior tibial SBP (P=0.023) showed the strongest association. Conclusion - Regardless of ethnicity, ankle SBPs are more significantly associated with generalized obesity than brachial SBPs, suggesting their screening potential for screening for early detection of T2DM and CVD. A combination of ankle SBPs with WHtR is proposed in south Asians.

Keywords: ankle blood pressures, body mass index, insulin resistance, waist-to-height-ratio

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Authors: Teka Haile, Behailu Hawulte, Solomon Alemayehu

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Background: HIV virological failure still remains a problem in HV/AIDS treatment and care. This study aimed to describe the prevalence and identify the factors associated with viral non-suppression among HIV-positive adult patients on antiretroviral therapy in Woliso Town, Oromia, Ethiopia. Methods: A retrospective cross-sectional study was conducted among 424 HIV-positive patient’s attending antiretroviral therapy (ART) in Woliso Town during the period from August 25, 2020 to August 30, 2020. Data collected from patient medical records were entered into Epi Info version 2.3.2.1 and exported to SPSS version 21.0 for analysis. Logistic regression analysis was done to identify factors associated with viral load non-suppression, and statistical significance of odds ratios were declared using 95% confidence interval and p-value < 0.05. Results: A total of 424 patients were included in this study. The mean age (± SD) of the study participants was 39.88 (± 9.995) years. The prevalence of HIV viral load non-suppression was 55 (13.0%) with 95% CI (9.9-16.5). Second-line ART treatment regimen (Adjusted Odds Ratio (AOR) = 8.98, 95% Confidence Interval (CI): 2.64, 30.58) and routine viral load testing (AOR = 0.01, 95% CI: 0.001, 0.02) were significantly associated with virological non-suppression. Conclusion: Virological non-suppression was high, which hinders the achievement of the third global 95 target. The second-line regimen and routine viral load testing were significantly associated with virological non-suppression. It suggests the need to assess the effectiveness of antiretroviral drugs for epidemic control. It also clearly shows the need to decentralize third-line ART treatment for those patients in need.

Keywords: virological non-suppression, HIV-positive, ART, Woliso town, Ethiopia

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Authors: Malgorzata Sekulowicz, Krystyna Boron-Krupinska, Paulina Morga, Blazej Cieslik

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Burnout is highly prevalent in health care employees, especially in physicians. It significantly reduces the efficiency of these employees, which can have negative consequences for both physicians and patients. Resilience and mindfulness enhancing positive emotions, leading to sustainable development and personal commitment, can have a significant impact on burnout. Therefore, the aim of this study was to determine the relationship between burnout symptoms and mindfulness and resilience among physicians. The authors conducted a cross-sectional survey study among seventy-four polish physicians. Participants filled out the following psychometric tools: the Maslach Burnout Inventory - Human Services Survey (MBI-HSS), Five Facet Mindfulness Questionnaire (FFMQ), Areas of Work-Life Survey (AWS), International Personality Item Pool (IPIP), the Resilience Assessment Scale (SPP-25) and the Mini-COPE Inventory. The relationship between burnout and resilience and mindfulness was assessed with path analysis. Analyzing the relationship between MBI-HSS components and mindfulness, a significant negative correlation of the FFMQ score with emotional exhaustion (-0.50, p < 0.05) and depersonalization (-0.43, p < 0.05) and a positive correlation with personal accomplishment (0.50, p < 0.05) was demonstrated. Analyzing resilience, a statistically significant relationship of SPP-25 with all tested components of MBI-HSS was demonstrated: emotional exhaustion (-0.54, p < 0.05), depersonalization (-0.31, p < 0.05) and personal accomplishment (0.35, p < 0.05). In the group of medical doctors, the higher the level of mindfulness and resilience, the lower the risk of burnout. Furthermore, the more frequently used active coping strategies (planning, acceptance), the lower the risk of burnout, while the use of passive, evasive strategies increases the risk of burnout. It may be worth considering implementing mindfulness intervention to effectively manage burnout symptoms in this group.

Keywords: burnout, medical doctors, mindfulness, physicians, resilience

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Authors: Geetha Baskaran, Andrzej Barjiela, Rong Qu

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Motivation: Nurse scheduling is a complex combinatorial optimization problem. It is also known as NP-hard. It needs an efficient re-scheduling to minimize some trade-off of the measures of violation by reducing selected constraints to soft constraints with measurements of their violations. Problem Statement: In this paper, we extend our novel approach to solve the nurse scheduling problem by transforming it through Information Granulation. Approach: This approach satisfies the rules of a typical hospital environment based on a standard benchmark problem. Generating good work schedules has a great influence on nurses' working conditions which are strongly related to the level of a quality health care. Domain transformation that combines the strengths of operation research and artificial intelligence was proposed for the solution of the problem. Compared to conventional methods, our approach involves judicious grouping (information granulation) of shifts types’ that transforms the original problem into a smaller solution domain. Later these schedules from the smaller problem domain are converted back into the original problem domain by taking into account the constraints that could not be represented in the smaller domain. An Integer Programming (IP) package is used to solve the transformed scheduling problem by expending the branch and bound algorithm. We have used the GNU Octave for Windows to solve this problem. Results: The scheduling problem has been solved in the proposed formalism resulting in a high quality schedule. Conclusion: Domain transformation represents departure from a conventional one-shift-at-a-time scheduling approach. It offers an advantage of efficient and easily understandable solutions as well as offering deterministic reproducibility of the results. We note, however, that it does not guarantee the global optimum.

Keywords: domain transformation, nurse scheduling, information granulation, artificial intelligence, simulation

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Authors: Nneka Evelyn Udeh

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Women’s economic participation and empowerment are fundamental to strengthening women’s rights and enabling women to have control over their lives and exert influence in the society. The economic empowerment of women is a prerequisite for sustainable development, pro-poor growth and the achievement of all the millennium development Goals (MDGs). For women to be in development they need to be empowered morally, socially, economically, and financially and this is why women in Udi Local Government Area of Nigeria meet every August, the eighth month of the year to discuss matters relating to the pursuit of women empowerment, community welfare, and national development. This exploratory study depicts how annual august meetings serve as a stimulator for female empowerment with a case study Udi Local Government area of Enugu state, Nigeria. The paper finds that ‘August Meeting’ is a regular annual occurrence in Udi Local Government Area, Enugu State, Nigeria particularly for married women and is designed to better the lot of women, the child, family, the church, and the Community. Through this forum, with its seminars and workshops, women have the opportunity to learn everything about womanhood and how to chart new courses of action and sources of empowerment. The gathering gives women the opportunity to be integrated into their community development projects, and having women as stakeholders and not mere observers helps guarantee a speedy and steady community and overall national development progress. Funds are raised for community development projects through annual dues, levies, donations, fines, sales, income from money-yielding ventures, endowment and investiture. Annual August meeting also known as ‘Mothers Summit’ is indeed a powerful stimulator for female empowerment. Support and invigoration of this women initiative is essential for sustainable emancipation of female gender, not just in Udi Local Government Area of Nigeria but globally.

Keywords: women empowerment, annual august meeting, Udi Lga, mothers' summit, stimulator, emancipation, sustainability, community welfare, national development, millennium development goal

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Authors: Abdulrahman M. Alajlan, Saichao Dang, Qiaoqiang Gan

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Photovoltaic (PV) cells, while pivotal for solar energy harnessing, confront a challenge due to the presence of persistent residual heat. This thermal energy poses significant obstacles to the performance and longevity of PV cells. Mitigating this thermal issue is imperative, particularly in tropical regions where solar abundance coexists with elevated ambient temperatures. In response, a sustainable and economically viable solution has been devised, incorporating water-passive cooling within a Photovoltaic-Thermoelectric (PV-TEG) hybrid system to address PV cell overheating. The implemented system has significantly reduced the operating temperatures of PV cells, achieving a notable reduction of up to 15 °C below the temperature observed in standalone PV systems. In addition, a thermoelectric generator (TEG) integrated into the system significantly enhances power generation, particularly during nighttime operation. The developed hybrid system demonstrates its capability to generate power at a density of 0.5 Wm⁻² during nighttime, which is sufficient to concurrently power multiple light-emitting diodes, demonstrating practical applications for nighttime power generation. Key findings from this research include a consistent temperature reduction exceeding 10 °C for PV cells, translating to a 5% average enhancement in PV output power compared to standalone PV systems. Experimental demonstrations underscore nighttime power generation of 0.5 Wm⁻², with the potential to achieve 0.8 Wm⁻² through simple geometric optimizations. The optimal cooling of PV cells is determined by the volume of water in the heat storage unit, exhibiting an inverse relationship with the optimal performance for nighttime power generation. Furthermore, the TEG output effectively powers a lighting system with up to 5 LEDs during the night. This research not only proposes a practical solution for maximizing solar radiation utilization but also charts a course for future advancements in energy harvesting technologies.

Keywords: photovoltaic-thermoelectric systems, nighttime power generation, PV thermal management, PV cooling

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Authors: Alexander Hedlund, Anna-Karin Stengard, Olof Björkqvist

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A step towards reducing greenhouse gases and energy consumption is to collaborate with the energy system between several industries. This work is based on a case study on integration of pulp and paper mills with a district heating system in Sundsvall, Sweden. Present research shows that it is possible to make a significant reduction in the electricity demand in the mechanical pulping process. However, the profitability of the efficiency measures could be an issue, as the excess steam recovered from the refiners decreases with the electricity consumption. A consequence will be that the fuel demand for steam production will increase. If the fuel price is similar to the electricity price it would reduce the profit of such a project. If the paper mill can be integrated with a district heating system, it is possible to upgrade excess heat from a nearby kraft pulp mill to process steam via the district heating system in order to avoid the additional fuel need. The concept is investigated by using a simulation model describing both the mass and energy balance as well as the operating margin. Three scenarios were analyzed: reference, electricity reduction and energy substitution. The simulation show that the total input to the system is lowest in the Energy substitution scenario. Additionally, in the Energy substitution scenario the steam from the incineration boiler covers not only the steam shortage but also a part of the steam produced using the biofuel boiler, the cooling tower connected to the incineration boiler is no longer needed and the excess heat can cover the whole district heating load during the whole year. The study shows a substantial economic advantage if all stakeholders act together as one system. However, costs and benefits are unequally shared between the actors. This means that there is a need for new business models in order to share the system costs and benefits.

Keywords: energy system, cooperation, simulation method, excess heat, district heating

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Authors: R. R. Dewi Rahmawaty Aktyani Putri, Earmporn Thongkrajai, Dedy Purwito

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There were many instruments have been developed to assess social support which has the different dimension in breast cancer patients. The Issue of measurement is a challenge to determining the component of dimensional concept, defining the unit of measurement, and establishing the validity and reliability of the measurement. However, the instruments where need to know how much support which obtained and perceived among women with breast cancer who undergone chemotherapy which it can help nurses to prevent of non-adherence in chemotherapy. This study aimed to measure the reliability of BC-SSAS instrument among 30 Indonesian women with breast cancer aged 18 years and above who undergone chemotherapy for six cycles in the oncological unit of Outpatient Department (OPD), Margono Soekardjo Hospital, Central Java, Indonesia. Data were collected during October to December 2015 by using modified the Breast Cancer Social Support Assessment (BC-SSAS). The Cronbach’s alpha analysis was carried out to measure internal consistency for reliability test of BC-SSAS instrument. This study used five experts for content validity index. The results showed that for content validity, I-CVI was 0.98 and S-CVI was 0.98; Cronbach’s alpha value was 0.971 and the Cronbach’s alpha coefficients for the subscales were high, with 0.903 for emotional support, 0.865 for informational support, 0.901 for tangible support, 0.897 for appraisal support and 0.884 for positive interaction support. The results confirmed that the BC-SSAS instrument has high reliability. BC-SSAS instruments were reliable and can be used in health care services to measure the social support received and perceived among women with breast cancer who undergone chemotherapy so that preventive interventions can be developed and the quality of health services can be improved.

Keywords: BC-SSAS, women with breast cancer, chemotherapy, Indonesia

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