Search results for: medical service

Authors: Sharat Chandra, Zilong Wang, Ru-Rong Ji, Andrey Bortsov

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Chronic pain (CP) therapeutic approaches have limited efficacy. As a result, doctors are prescribing opioids for chronic pain, leading to opioid overuse, abuse, and addiction epidemic. Therefore, the development of effective and safe CP drugs remains an unmet medical need. Voltage-gated sodium (Nav) channels act as cardiovascular and neurological disorder’s molecular targets. Nav channels selective inhibitors are hard to design because there are nine closely-related isoforms (Nav1.1-1.9) that share the protein sequence segments. We are targeting the Nav1.7 found in the peripheral nervous system and engaged in the perception of pain. The objective of this project was to screen a 1.5 million compound library for identification of inhibitors for Nav1.7 with analgesic effect. In this study, we designed a protocol for identification of isoform-selective inhibitors of Nav1.7, by utilizing the prior information on isoform-selective antagonists. First, a similarity search was performed; then the identified hits were docked into a binding site on the fourth voltage-sensor domain (VSD4) of Nav1.7. We used the FTrees tool for similarity searching and library generation; the generated library was docked in the VSD4 domain binding site using FlexX and compounds were shortlisted using a FlexX score and SeeSAR hyde scoring. Finally, the top 25 compounds were tested with molecular dynamics simulation (MDS). We reduced our list to 9 compounds based on the MDS root mean square deviation plot and obtained them from a vendor for in vitro and in vivo validation. Whole-cell patch-clamp recordings in HEK-293 cells and dorsal root ganglion neurons were conducted. We used patch pipettes to record transient Na⁺ currents. One of the compounds reduced the peak sodium currents in Nav1.7-HEK-293 stable cell line in a dose-dependent manner, with IC50 values at 0.74 µM. In summary, our computer-aided analgesic discovery approach allowed us to develop pre-clinical analgesic candidate with significant reduction of time and cost.

Keywords: chronic pain, voltage-gated sodium channel, isoform-selective antagonist, similarity search, virtual screening, analgesics development

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Authors: Bahaa Eldin A. Fouda, Khaled N. Yossef, Mohamed Elhosseny, Ahmed Lotfy, Mohamed Salama, Mohamed Sobh

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Developmental neurotoxicity (DNT) entails the toxic effects imparted by various chemicals on the brain during the early childhood period. As human brains are vulnerable during this period, various chemicals would have their maximum effects on brains during early childhood. Some toxicants have been confirmed to induce developmental toxic effects on CNS e.g. lead, however; most of the agents cannot be identified with certainty due the defective nature of predictive toxicology models used. A novel alternative method that can overcome most of the limitations of conventional techniques is the use of 3D neurospheres system. This in-vitro system can recapitulate most of the changes during the period of brain development making it an ideal model for predicting neurotoxic effects. In the present study, we verified the possible DNT of epoxomicin which is a naturally occurring selective proteasome inhibitor with anti-inflammatory activity. Rat neural progenitor cells were isolated from rat embryos (E14) extracted from placental tissue. The cortices were aseptically dissected out from the brains of the fetuses and the tissues were triturated by repeated passage through a fire-polished constricted Pasteur pipette. The dispersed tissues were allowed to settle for 3 min. The supernatant was, then, transferred to a fresh tube and centrifuged at 1,000 g for 5 min. The pellet was placed in Hank’s balanced salt solution cultured as free-floating neurospheres in proliferation medium. Two doses of epoxomicin (1µM and 10µM) were used in cultured neuropsheres for a period of 14 days. For proliferation analysis, spheres were cultured in proliferation medium. After 0, 4, 5, 11, and 14 days, sphere size was determined by software analyses. The diameter of each neurosphere was measured and exported to excel file further to statistical analysis. For viability analysis, trypsin-EDTA solution were added to neurospheres for 3 min to dissociate them into single cells suspension, then viability evaluated by the Trypan Blue exclusion test. Epoxomicin was found to affect proliferation and viability of neuropsheres, these effects were positively correlated to doses and progress of time. This study confirms the DNT effects of epoxomicin on 3D neurospheres model. The effects on proliferation suggest possible gross morphologic changes while the decrease in viability propose possible focal lesion on exposure to epoxomicin during early childhood.

Keywords: neural progentor cells, epoxomicin, neurosphere, medical and health sciences

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Authors: Gabrielle Brand, Christopher Etherton-Beer

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The learning landscape of higher education environment is changing, with an increased focus over the past decade on how educators might begin to cultivate reflective skills in health professions students. In addition, changing professional requirements demand that health professionals are adequately prepared to practice in today’s complex Australian health care systems, including responding to changing demographics of population ageing. To counteract a widespread perception of health professions students’ disinterest in caring for older persons, the authors will report on an exploratory, mixed method research study that used photographs, narrative and small group work to enhance medical and nursing students’ reflective learning experience. An innovative photo-elicitation technique and reflective questioning prompts were used to increase engagement, and challenge students to consider new perspectives (around ageing) by constructing shared storylines in small groups. The qualitative themes revealed how photographs, narratives and small group work created learning spaces for reflection whereby students could safely explore their own personal and professional values, beliefs and perspectives around ageing. By providing the space for reflection, the students reported how they found connection and meaning in their own learning through a process of self-exploration that often challenged their assumptions of both older people and themselves as future health professionals. By integrating cognitive and affective elements into the learning process, this research demonstrates the importance of embedding visual methodologies that enhance reflection and transformative learning. The findings highlight the importance of integrating the arts into predominantly empirically driven health professional curricula and can be used as a catalyst for individual and/or collective reflection which can potentially enhance empathy, insight and understanding of the lived experiences of older patients. Based on these findings, the authors have developed ‘Depth of Field: Exploring Ageing’ an innovative, interprofessional, digital reflective learning resource that uses Prezi Inc. software (storytelling tool that presents ideas on a virtual canvas) to enhance students’ reflective capacity in the higher education environment.

Keywords: narrative, photo-elicitation, reflective learning, qualitative research

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Authors: Titir Bhattacharya, Tanika Chakraborty, Prabal K. De

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Maternal and child health continue to be a significant policy focus in developing countries, including India. An emerging model in health care is the creation of public and private partnerships. Since the construction of physical infrastructure is costly, governments at various levels have tried to implement social health insurance schemes where a trust calculates insurance premiums and medical payments. Typically, qualifying families get full subsidization of the premium and get access to private hospitals, in addition to low cost public hospitals, for their tertiary care needs. We analyze one such pioneering social insurance scheme in the Indian state of Andhra Pradesh (AP). The Rajiv Aarogyasri program (RA) was introduced by the Government of AP on a pilot basis in 2007 and implemented in 2008. In this paper, we first examine the extent to which access to reproductive health care changed. For example, the RA scheme reimburses hospital deliveries leading us to expect an increase in institutional deliveries, particularly in private hospitals. Second, we expect an increase in institutional deliveries to also improve child health outcomes. Hence, we estimate if the program improved infant and child mortality. We use District Level Health Survey data to create annual birth cohorts from 2000-2015. Since AP was the only state in which such a state insurance program was implemented, the neighboring states constituted a plausible control group. Combined with the policy timing, and the year of birth, we employ a difference-indifference strategy to identify the effects of RA on the residents of AP. We perform several checks against threats to identification, including testing for pre-treatment trends between the treatment and control states. We find that the policy significantly lowered infant and child mortality in AP. We also find that deliveries in private hospitals increased, and government hospitals decreased, showing a substitution effect of the relative price change. Finally, as expected, out-of-pocket costs declined for the treatment group. However, we do not find any significant effects for usual preventive care such as vaccination, showing that benefits of insurance schemes targeted at the tertiary level may not trickle down to the primary care level.

Keywords: public health insurance, maternal and child health, public-private choice

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Authors: Angelis P. Barlampas

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Objective: The confusion of terms is a common practice in many situations of the everyday life. But, in some circumstances, such as in medicine, the precise meaning of a word curries a critical role for the health of the patient. Fahr disease and Fahr syndrome are often falsely used interchangeably, but they are two different conditions with different physical histories of different etiology and different medical management. A case of the seldom Fahr disease is presented, and a comparison with the more common Fahr syndrome follows. Materials and method: A 72 years old patient came to the emergency department, complaining of some kind of non specific medal disturbances, like anxiety, difficulty of concentrating, and tremor. The problems had a long course, but he had the impression of getting worse lately, so he decided to check them. Past history and laboratory tests were unremarkable. Then, a computed tomography examination was ordered. Results: The CT exam showed bilateral, hyperattenuating areas of heavy, dense calcium type deposits in basal ganglia, striatum, pallidum, thalami, the dentate nucleus, and the cerebral white matter of frontal, parietal and iniac lobes, as well as small areas of the pons. Taking into account the absence of any known preexisting illness and the fact that the emergency laboratory tests were without findings, a hypothesis of the rare Fahr disease was supposed. The suspicion was confirmed with further, more specific tests, which showed the lack of any other conditions which could probably share the same radiological image. Differentiating between Fahr disease and Fahr syndrome. Fahr disease: Primarily autosomal dominant Symmetrical and bilateral intracranial calcifications The patient is healthy until the middle age Absence of biochemical abnormalities. Family history consistent with autosomal dominant Fahr syndrome :Earlier between 30 to 40 years old. Symmetrical and bilateral intracranial calcifications Endocrinopathies: Idiopathic hypoparathyroidism, secondary hypoparathyroidism, hyperparathyroidism, pseudohypoparathyroidism ,pseudopseudohypoparathyroidism, e.t.c The disease appears at any age There are abnormal laboratory or imaging findings. Conclusion: Fahr disease and Fahr syndrome are not the same illness, although this is not well known to the inexperienced doctors. As clinical radiologists, we have to inform our colleagues that a radiological image, along with the patient's history, probably implies a rare condition and not something more usual and prompt the investigation to the right route. In our case, a genetic test could be done earlier and reveal the problem, and thus avoiding unnecessary and specific tests which cost in time and are uncomfortable to the patient.

Keywords: fahr disease, fahr syndrome, CT, brain calcifications

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Authors: D. Signore, M. Ferraiuolo, P. Caramuta, O. Petrella, C. Toscano

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The Digital Image Correlation (DIC) is a newly developed optical technique that is spreading in all engineering sectors because it allows the non-destructive estimation of the entire surface deformation without any contact with the component under analysis. These characteristics make the DIC very appealing in all the cases the global deformation state is to be known without using strain gages, which are the most used measuring device. The DIC is applicable to any material subjected to distortion caused by either thermal or mechanical load, allowing to obtain high-definition mapping of displacements and deformations. That is why in the civil and the transportation industry, DIC is very useful for studying the behavior of metallic materials as well as of composite materials. DIC is also used in the medical field for the characterization of the local strain field of the vascular tissues surface subjected to uniaxial tensile loading. DIC can be carried out in the two dimension mode (2D DIC) if a single camera is used or in a three dimension mode (3D DIC) if two cameras are involved. Each point of the test surface framed by the cameras can be associated with a specific pixel of the image, and the coordinates of each point are calculated knowing the relative distance between the two cameras together with their orientation. In both arrangements, when a component is subjected to a load, several images related to different deformation states can be are acquired through the cameras. A specific software analyzes the images via the mutual correlation between the reference image (obtained without any applied load) and those acquired during the deformation giving the relative displacements. In this paper, a metrological characterization of the digital image correlation is performed on aluminum and composite targets both in static and dynamic loading conditions by comparison between DIC and strain gauges measures. In the static test, interesting results have been obtained thanks to an excellent agreement between the two measuring techniques. In addition, the deformation detected by the DIC is compliant with the result of a FEM simulation. In the dynamic test, the DIC was able to follow with a good accuracy the periodic deformation of the specimen giving results coherent with the ones given by FEM simulation. In both situations, it was seen that the DIC measurement accuracy depends on several parameters such as the optical focusing, the parameters chosen to perform the mutual correlation between the images and, finally, the reference points on image to be analyzed. In the future, the influence of these parameters will be studied, and a method to increase the accuracy of the measurements will be developed in accordance with the requirements of the industries especially of the aerospace one.

Keywords: accuracy, deformation, image correlation, mechanical analysis

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Authors: Maris Eugênia Dela Rosa, Ana Luiza Menegatti Pavan, Marcela De Oliveira, Diana Rodrigues De Pina, Luis Carlos Vulcano

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In medical veterinary as well as in human medicine, radiological study is essential for a safe diagnosis in clinical practice. Thus, the quality of radiographic image is crucial. In last year’s there has been an increasing substitution of image acquisition screen-film systems for computed radiology equipment (CR) without technical charts adequacy. Furthermore, to carry out a radiographic examination in veterinary patient is required human assistance for restraint this, which can compromise image quality by generating dose increasing to the animal, for Occupationally Exposed and also the increased cost to the institution. The image optimization procedure and construction of radiographic techniques are performed with the use of homogeneous phantoms. In this study, we sought to develop a homogeneous phantom of canine chest to be applied to the optimization of these images for the CR system. In carrying out the simulator was created a database with retrospectives chest images of computed tomography (CT) of the Veterinary Hospital of the Faculty of Veterinary Medicine and Animal Science - UNESP (FMVZ / Botucatu). Images were divided into four groups according to the animal weight employing classification by sizes proposed by Hoskins & Goldston. The thickness of biological tissues were quantified in a 80 animals, separated in groups of 20 animals according to their weights: (S) Small - equal to or less than 9.0 kg, (M) Medium - between 9.0 and 23.0 kg, (L) Large – between 23.1 and 40.0kg and (G) Giant – over 40.1 kg. Mean weight for group (S) was 6.5±2.0 kg, (M) 15.0±5.0 kg, (L) 32.0±5.5 kg and (G) 50.0 ±12.0 kg. An algorithm was developed in Matlab in order to classify and quantify biological tissues present in CT images and convert them in simulator materials. To classify tissues presents, the membership functions were created from the retrospective CT scans according to the type of tissue (adipose, muscle, bone trabecular or cortical and lung tissue). After conversion of the biologic tissue thickness in equivalent material thicknesses (acrylic simulating soft tissues, bone tissues simulated by aluminum and air to the lung) were obtained four different homogeneous phantoms, with (S) 5 cm of acrylic, 0,14 cm of aluminum and 1,8 cm of air; (M) 8,7 cm of acrylic, 0,2 cm of aluminum and 2,4 cm of air; (L) 10,6 cm of acrylic, 0,27 cm of aluminum and 3,1 cm of air and (G) 14,8 cm of acrylic, 0,33 cm of aluminum and 3,8 cm of air. The developed canine homogeneous phantom is a practical tool, which will be employed in future, works to optimize veterinary X-ray procedures.

Keywords: radiation protection, phantom, veterinary radiology, computed radiography

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Authors: Mohamed Mamdouh Al-Banna, Warda Youssef Mohamed Morsy, Hanaa Ali El-Feky, Ashraf Hussein Abdelmohsen

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Background: The mechanically ventilated patients need a special nursing care with continuous closed observation. The patients’ body mass index may affect their prognosis or outcomes. Aim of the study: to investigate the relationship between BMI and selected outcomes of critically ill mechanically ventilated patients. Research Design: A descriptive correlational research design was utilized Research questions: a) what is the BMI profile of mechanically ventilated patients admitted to critical care units over a period of six months? b) What is the relationship between body mass index and frequency of organ dysfunction, length of ICU stay, weaning from mechanical ventilation, and the mortality rate among adult critically ill mechanically ventilated patients? Setting: different intensive care units of Cairo University Hospitals. Sample: A convenience sample of 30 mechanically ventilated patients for at least 72 hours. Tools of data collection: Three tools were utilized to collect data pertinent to the current study: tool 1: patients’ sociodemographic and medical data sheet, tool 2: BURNS Wean Assessment Program (BWAP) checklist, tool 3: Sequential organ failure assessment (SOFA score) sheet. Results: The majority of the studied sample (77%) was males, and (26.7 %) of the studied sample were in the age group of 18-28 years old, and (26.7 %) were in the age group of 40-50 years old. Moreover, two thirds (66.7%) of the studied sample were within normal BMI. No significant statistical relationship between BMI category and ICU length of stay or the mortality rate among the studied sample, (X² = 11.31, P value = 0.79), (X² = 0.15, P value = 0.928) respectively. No significant statistical relationship between BMI category and the weaning trials from mechanical ventilation among the studied sample, (X² = 0.15, P value = 0.928). No significant statistical relationship was found between BMI category and the occurrence of organ dysfunction among the studied sample, (X² = 2.54, P value = 0.637). Conclusion: No relationship between the BMI categories and the selected patients’ outcomes (weaning from MV, length of ICU stay, occurrence of organ dysfunction, mortality rate). Recommendations: Replication of this study on a larger sample from different geographical locations in Arab Republic of Egypt, conducting farther studies to assess the effect of the quality of nursing care on the mechanically ventilated patients’ outcomes.

Keywords: mechanical ventilation, body mass index, outcomes of mechanically ventilated patient, organ failure

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Authors: Ankush Raina, Ankush Anand

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Plyometric training is a form of specialised strength training that uses fast muscular contractions to improve power and speed in sports conditioning by coaches and athletes. Despite its useful role in sports conditioning programme, the information about plyometric training on the athletes cardiovascular health especially Electrocardiogram (ECG) has not been established in the literature. The purpose of the study was to determine the effects of lower and upper body plyometric training on ECG of athletes. The study was guided by three null hypotheses. Quasi–experimental research design was adopted for the study. Seventy-two university male athletes constituted the population of the study. Thirty male athletes aged 18 to 24 years volunteered to participate in the study, but only twenty-three completed the study. The volunteered athletes were apparently healthy, physically active and free of any lower and upper extremity bone injuries for past one year and they had no medical or orthopedic injuries that may affect their participation in the study. Ten subjects were purposively assigned to one of the three groups: lower body plyometric training (LBPT), upper body plyometric training (UBPT), and control (C). Training consisted of six plyometric exercises: lower (ankle hops, squat jumps, tuck jumps) and upper body plyometric training (push-ups, medicine ball-chest throws and side throws) with moderate intensity. The general data were collated and analysed using Statistical Package for Social Science (SPSS version 22.0). The research questions were answered using mean and standard deviation, while paired samples t-test was also used to test for the hypotheses. The results revealed that athletes who were trained using LBPT had reduced ECG parameters better than those in the control group. The results also revealed that athletes who were trained using both LBPT and UBPT indicated lack of significant differences following ten weeks plyometric training than those in the control group in the ECG parameters except in Q wave, R wave and S wave (QRS) complex. Based on the findings of the study, it was recommended among others that coaches should include both LBPT and UBPT as part of athletes’ overall training programme from primary to tertiary institution to optimise performance as well as reduce the risk of cardiovascular diseases and promotes good healthy lifestyle.

Keywords: boundary lubrication, copper oxide, friction, nano diamond

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Authors: Takashi Mitsuishi

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Fuzzy logic has gained acceptance in the recent years in the fields of social sciences and humanities such as psychology and linguistics because it can manage the fuzziness of words and human subjectivity in a logical manner. However, the major field of application of the fuzzy logic is control engineering as it is a part of the set theory and mathematical logic. Mamdani method, which is the most popular technique for approximate reasoning in the field of fuzzy control, is one of the ways to numerically represent the control afforded by human language and sensitivity and has been applied in various practical control plants. Fuzzy logic has been gradually developing as an artificial intelligence in different applications such as neural networks, expert systems, and operations research. The objects of inference vary for different application fields. Some of these include time, angle, color, symptom and medical condition whose fuzzy membership function is a periodic function. In the defuzzification stage, the domain of the membership function should be unique to obtain uniqueness its defuzzified value. However, if the domain of the periodic membership function is determined as unique, an unintuitive defuzzified value may be obtained as the inference result using the center of gravity method. Therefore, the authors propose a method of circular-polar-coordinates transformation and defuzzification of the periodic membership functions in this study. The transformation to circular polar coordinates simplifies the domain of the periodic membership function. Defuzzified value in circular polar coordinates is an argument. Furthermore, it is required that the argument is calculated from a closed plane figure which is a periodic membership function on the circular polar coordinates. If the closed plane figure is continuous with the continuity of the membership function, a significant amount of computation is required. Therefore, to simplify the practice example and significantly reduce the computational complexity, we have discretized the continuous interval and the membership function in this study. In this study, the following three methods are proposed to decide the argument from the discrete polygon which the continuous plane figure is transformed into. The first method provides an argument of a straight line passing through the origin and through the coordinate of the arithmetic mean of each coordinate of the polygon (physical center of gravity). The second one provides an argument of a straight line passing through the origin and the coordinate of the geometric center of gravity of the polygon. The third one provides an argument of a straight line passing through the origin bisecting the perimeter of the polygon (or the closed continuous plane figure).

Keywords: defuzzification, fuzzy membership function, periodic function, polar coordinates transformation

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Authors: José Ramón López-Mínguez, Estrella Suárez-Corchuelo, Sergio López-Tejero, Luis Nombela-Franco, Xavier Freixa-Rofastes, Guillermo Bastos-Fernández, Xavier Millán-Álvarez, Raúl Moreno-Gómez, José Antonio Fernández-Díaz, Ignacio Amat-Santos, Tomás Benito-González, Fernando Alfonso-Manterola, Pablo Salinas-Sanguino, Pedro Cepas-Guillén, Dabit Arzamendi, Ignacio Cruz-González, Juan Manuel Nogales-Asensio

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Background and objectives: The treatment of patients with non-valvular atrial fibrillation (NVAF) who need coronary stenting is challenging. The objective of the study was to determine whether left atrial appendage occlusion (LAAO) could be a feasible option and benefit these patients. To this end, we studied the impact of LAAO plus antiplatelet drugs vs oral anticoagulants (OAC) (including direct OAC) plus antiplatelet drugs in these patients’ long-term outcomes. Methods: The results of 207 consecutive patients with NVAF who underwent coronary stenting were analyzed. A total of 146 patients were treated with OAC (75 with acenocoumarol, 71 with direct OAC) while 61 underwent LAAO. The median follow-up was 35 months. Patients also received antiplatelet therapy as prescribed by their cardiologist. The study received the proper ethical oversight. Results: Age (mean 75.7 years), and the past medical history of stroke were similar in both groups. However, the LAAO group had more unfavorable characteristics (history of coronary artery disease [CHA2DS2-VASc], and significant bleeding [BARC ≥ 2] and HAS-BLED). The occurrence of major adverse events (death, stroke/transient ischemic events, major bleeding) and major cardiovascular events (cardiac death, stroke/transient ischemic attack, and myocardial infarction) were significantly higher in the OAC group compared to the LAAO group: 19.75% vs 9.06% (HR, 2.18; P = .008) and 6.37% vs 1.91% (HR, 3.34; P = .037), respectively. Conclusions: In patients with NVAF undergoing coronary stenting, LAAO plus antiplatelet therapy produced better long-term outcomes compared to treatment with OAC plus antiplatelet therapy despite the unfavorable baseline characteristics of the LAAO group.

Keywords: stents, atrial fibrillation, anticoagulants, left atrial appendage occlusion

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Authors: Sameh S. Namnqani, Yaqoob Y. Abobakar, Ahmed M. Alsewehri, Khaled M. AlQethami

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The main objective of this research is to know the impact of the application of the electronic supply system on the performance of the supply department of health organizations. To reach this goal, the study adopted independent variables to measure the dependent variable (performance of the supply department), namely: integration with suppliers, integration with intermediaries and distributors and knowledge of supply size, inventory, and demand. The study used the descriptive method and was aided by the questionnaire tool that was distributed to a sample of workers in the Supply Chain Management Department of King Abdullah Medical City. After the statistical analysis, the results showed that: The 70 sample members strongly agree with the (electronic integration with suppliers) axis with a p-value of 0.001, especially with regard to the following: Opening formal and informal communication channels between management and suppliers (Mean 4.59) and exchanging information with suppliers with transparency and clarity (Mean 4.50). It also clarified that the sample members agree on the axis of (electronic integration with brokers and distributors) with a p-value of 0.001 and this is represented in the following elements: Exchange of information between management, brokers and distributors with transparency, clarity (Mean 4.18) , and finding a close cooperation relationship between management, brokers and distributors (Mean 4.13). The results also indicated that the respondents agreed to some extent on the axis (knowledge of the size of supply, stock, and demand) with a p-value of 0.001. It also indicated that the respondents strongly agree with the existence of a relationship between electronic procurement and (the performance of the procurement department in health organizations) with a p-value of 0.001, which is represented in the following: transparency and clarity in dealing with suppliers and intermediaries to prevent fraud and manipulation (Mean 4.50) and reduce the costs of supplying the needs of the health organization (Mean 4.50). From the results, the study recommended several recommendations, the most important of which are: that health organizations work to increase the level of information sharing between them and suppliers in order to achieve the implementation of electronic procurement in the supply management of health organizations. Attention to using electronic data interchange methods and using modern programs that make supply management able to exchange information with brokers and distributors to find out the volume of supply, inventory, and demand. To know the volume of supply, inventory, and demand, it recommended the application of scientific methods of supply for storage. Take advantage of information technology, for example, electronic data exchange techniques and documents, where it can help in contact with suppliers, brokers, and distributors, and know the volume of supply, inventory, and demand, which contributes to improving the performance of the supply department in health organizations.

Keywords: healthcare supply chain, performance, electronic system, ERP

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Authors: Vivek Rangarajan, Kim G. Clarke

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Bacillus lipopeptides are biosurfactants with wide ranging applications in the medical, food, agricultural, environmental and cosmetic industries. They are produced as a mix of three families, surfactin, iturin and fengycin, each comprising a large number of homologues of varying functionalities. Consequently, the method and degree of purification of the lipopeptide cocktail becomes particularly important if the functionality of the lipopeptide end-product is to be maximized for the specific application. However, downstream processing of Bacillus lipopeptides is particularly challenging due to the subtle variations observed in the different lipopeptide homologues and isoforms. To date, the most frequently used lipopeptide purification operations have been acid precipitation, solvent extraction, membrane ultrafiltration, adsorption and size exclusion. RP-HPLC (reverse phase high pressure liquid chromatography) also has potential for fractionation of the lipopeptide homologues. In the studies presented here, membrane ultrafiltration and RP-HPLC were evaluated for lipopeptide purification to different degrees of purities for maximum functionality. Batch membrane ultrafiltration using 50 kDa polyether sulphone (PES) membranes resulted in lipopeptide recovery of about 68% for surfactin and 82 % for fengycin. The recovery was further improved to 95% by using size-conditioned lipopeptide micelles. The conditioning of lipopeptides with Ca2+ ions resulted in uniformly sized micelles with average size of 96.4 nm and a polydispersity index of 0.18. The size conditioning also facilitated removal of impurities (molecular weight ranging between 2335-3500 Da) through operation of the system under dia-filtration mode, in a way similar to salt removal from protein by dialysis. The resultant purified lipopeptide was devoid of macromolecular impurities and could ideally suit applications in the cosmetic and food industries. Enhanced purification using RP-HPLC was carried out in an analytical C18 column, with the aim to fractionate lipopeptides into their constituent homologues. The column was eluted with mobile phase comprising acetonitrile and water over an acetonitrile gradient, 35% - 80%, over 70 minutes. The gradient elution program resulted in as many as 41 fractions of individual lipopeptide homologues. The efficacy test of these fractions against fungal phytopathogens showed that first 21 fractions, identified to be homologues of iturins and fengycins, displayed maximum antifungal activities, suitable for biocontrol in the agricultural industry. Thus, in the current study, the downstream processing of lipopeptides leading to tailor-made products for selective applications was demonstrated using two major downstream unit operations.

Keywords: bacillus lipopeptides, membrane ultrafiltration, purification, RP-HPLC

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Authors: Scott Cavinder

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Surgical site infections (SSI) are a known complication to any surgical procedure and are one of the most common nosocomial infections. Globally it is estimated 300 million surgical procedures take place annually, with an incidence of SSI’s estimated to be 11 of 100 surgical patients developing an infection within 30 days after surgery. The specific purpose of the project is to address the PICOT (Problem, Intervention, Comparison, Outcome, Time) question: In patients who have undergone cardiothoracic or vascular surgery (P), does implementation of a post-operative care bundle based on current EBP (I) as compared to current clinical agency practice standards (C) result in a decrease of SSI (O) over a 12-week period (T)? Synthesis of Supporting Evidence: A literature search of five databases, including citation chasing, was performed, which yielded fourteen pieces of evidence ranging from high to good quality. Four common themes were identified for the prevention of SSI’s including use and removal of surgical dressings; use of topical antibiotics and antiseptics; implementation of evidence-based care bundles, and implementation of surveillance through auditing and feedback. The Iowa Model was selected as the framework to help guide this project as it is a multiphase change process which encourages clinicians to recognize opportunities for improvement in healthcare practice. Practice/Implementation: The process for this project will include recruiting postsurgical participants who have undergone cardiovascular or thoracic surgery prior to discharge at a Northwest Indiana Hospital. The patients will receive education, verbal instruction, and return demonstration. The patients will be followed for 12 weeks, and wounds assessed utilizing the National Healthcare Safety Network//Centers for Disease Control (NHSN/CDC) assessment tool and compared to the SSI rate of 2021. Key stakeholders will include two cardiovascular surgeons, four physician assistants, two advance practice nurses, medical assistant and patients. Method of Evaluation: Chi Square analysis will be utilized to establish statistical significance and similarities between the two groups. Main Results/Outcomes: The proposed outcome is the prevention of SSIs in the post-op cardiothoracic and vascular patient. Implication/Recommendation(s): Implementation of standardized post operative care bundles in the prevention of SSI in cardiovascular and thoracic surgical patients.

Keywords: cardiovascular, evidence based practice, infection, post-operative, prevention, thoracic, surgery

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Authors: Mohammad Khatib, Salam Hadid

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Introduction: Developing nurses' cultural competence begins in their basic training and requires them to participate in an array of activities which raise their awareness and stimulate their interest, desire and curiosity about different cultures, by creating opportunities for intercultural meetings promoting the concept of 'culture' and its components, including recognition of cultural diversity and the legitimacy of the other. Importantly, professionals need to acquire specific cultural knowledge and thorough understanding of the values, norms, customs, beliefs and symbols of different cultures. Similarly, they need to be given opportunities to practice the verbal and non-verbal communication skills of other cultures according to their cultural codes. Such a system is being implemented as part of nursing studies at Zefat Academic College in two study frameworks; firstly, a course integrating nursing theory and practice in multicultural nursing; secondly, a course in learning the languages spoken in Israel focusing on medical and nursing terminology. Methods: Students participating in the 'Transcultural Nursing' course come from a variety of backgrounds: Jews, or Arabs, religious, or secular; Muslim, Christian, new immigrants, Ethiopians or from other cultural affiliations. They are required to present and discuss cultural practices that affect health. In addition, as part of the language course, students learn and teach their friends 5 spoken languages (Arabic, Russian, Amharian, Yidish, and Sign language) focusing on therapeutic interaction and communication using the vocabulary and concepts necessary for the therapeutic encounter. An evaluation of the process and the results was done using a structured questionnaire which includes series of questions relating to the contributions of the courses to their cultural knowledge, awareness and skills. 155 students completed the questionnaire. Results: A preliminary assessment of this educational system points an increase in cultural awareness and knowledge among the students as well as in their willingness to recognize the other's difference. A positive atmosphere of multiculturalism is reflected in students' mutual interest and respect was created. Students showed a deep understanding of cultural issues relating to health and care (consanguinity and genetics, food customs; cultural events, reincarnation, traditional treatments etc.). Most of the students were willing to recommend the courses to others and suggest some changes relating learning methods (more simulations, role playing and activities).

Keywords: cultural competence, nursing education, culture, language

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Authors: Yi-Fung Lin, Shiow-Ching Shun, Wen-Yu Hu

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Background: A skill mix model is regarded as one of the most effective methods of reducing nursing shortages, as well as easing nursing staff workloads and labor costs. Although this model shows several benefits for the health workforce, the relationship between the optimal model of skill mix and the patient mortality rate remains to be discovered. Objectives: This review aimed to explore the relationship between the skill mix model and patient mortality rate in acute care hospitals. Data Sources: A systematic search of the PubMed, Web of Science, Embase, and Cochrane Library databases and researchers retrieved studies published between January 1986 and March 2022. Review methods: Two independent reviewers screened the titles and abstracts based on selection criteria, extracted the data, and performed critical appraisals using the STROBE checklist of each included study. The studies focused on adult patients in acute care hospitals, and the skill mix model and patient mortality rate were included in the analysis. Results: Six included studies were conducted in the USA, Canada, Italy, Taiwan, and European countries (Belgium, England, Finland, Ireland, Spain, and Switzerland), including patients in medical, surgical, and intensive care units. There were both nurses and nursing assistants in their skill mix team. This main finding is that three studies (324,592 participants) show evidence of fewer mortality rates associated with hospitals with a higher percentage of registered nurse staff (range percentage of registered nurse staff 36.1%-100%), but three articles (1,122,270 participants) did not find the same result (range of percentage of registered nurse staff 46%-96%). However, based on appraisal findings, those showing a significant association all meet good quality standards, but only one-third of their counterparts. Conclusions: In light of the limited amount and quality of published research in this review, it is prudent to treat the findings with caution. Although the evidence is not insufficient certainty to draw conclusions about the relationship between nurse staffing level and patients' mortality, this review lights the direction of relevant studies in the future. The limitation of this article is the variation in skill mix models among countries and institutions, making it impossible to do a meta-analysis to compare them further.

Keywords: nurse staffing level, nursing assistants, mortality, skill mix

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Authors: Maysoon Nasser Samhan, Somaya Alkiswani, Abdullah Alzibdeh

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Background: Routine lumbar MRIs for back pain may yield normal results despite persistent symptoms, which means the possibility of other causes for this pain, which was not shown on the routine images. Research suggests including coronal STIR imaging to detect additional pathologies like sacroiliitis. Objectives: This study aims to enhance diagnostic accuracy and aid in determining treatment processes for patients with persistent back pain who have normal routine lumbar MRI (T1 and T2 images) by incorporating coronal STIR into the examination. Methods: A prospectively conducted study involving 274 patients, 115 males and 159 females, with an age range of 6–92 years, reviewed their medical records and imaging data following a lumbar spine MRI. This study included patients with back pain and sciatica as their primary complaints, all of whom underwent lumbar spine MRIs at our hospital to identify potential pathologies. Using a GE Signa HD 1.5T MRI System, each patient received a standard MRI protocol that included T1 and T2 sagittal and axial sequences, as well as a coronal STIR sequence. We collected relevant MRI findings, including abnormalities and structural variations, from radiology reports. We classified these findings into tables and documented them as counts and percentages, using Fisher’s exact test to assess differences between categorical variables. We conducted a statistical analysis using Prism GraphPad software version 10.1.2. The study adhered to ethical guidelines, institutional review board approvals, and patient confidentiality regulations. Results: Exclusion of the coronal STIR sequence led to 83 subjects (30.29%) being classified as within normal limits on MRI examination. 36 patients without abnormalities on T1 and T2 sequences showed abnormalities on the coronal STIR sequence, with 26 cases attributed to spinal pathologies and 10 to non-spinal pathologies. In addition to that, Fisher's exact test demonstrated a significant association between sacroiliitis diagnosis and abnormalities identified solely through the coronal STIR sequence (P < 0.0001). Conclusion: Implementing coronal STIR imaging as part of routine lumbar MRI protocols has the potential to improve patient care by facilitating a more comprehensive evaluation and management of persistent back pain.

Keywords: magnetic resonance imaging, lumber MRI, radiology, neurology

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Authors: Padma Chutoo, Elena Kulinskaya, Ilyas Bakbergenuly, Nicholas Steel, Dmitri Pchejetski

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Transient ischaemic attacks (TIAs) are warning signs for future strokes. TIA patients are at increased risk of stroke and cardio-vascular events after a first episode. A majority of studies on TIA focused on the occurrence of these ancillary events after a TIA. Long-term mortality after TIA received only limited attention. We undertook this study to determine the long-term hazards of all-cause mortality following a first episode of a TIA using anonymised electronic health records (EHRs). We used a retrospective case-control study using electronic primary health care records from The Health Improvement Network (THIN) database. Patients born prior to or in year 1960, resident in England, with a first diagnosis of TIA between January 1986 and January 2017 were matched to three controls on age, sex and general medical practice. The primary outcome was all-cause mortality. The hazards of all-cause mortality were estimated using a time-varying Weibull-Cox survival model which included both scale and shape effects and a random frailty effect of GP practice. 20,633 cases and 58,634 controls were included. Cases aged 39 to 60 years at the first TIA event had the highest hazard ratio (HR) of mortality compared to matched controls (HR = 3.04, 95% CI (2.91 - 3.18)). The HRs for cases aged 61-70 years, 71-76 years and 77+ years were 1.98 (1.55 - 2.30), 1.79 (1.20 - 2.07) and 1.52 (1.15 - 1.97) compared to matched controls. Aspirin provided long-term survival benefits to cases. Cases aged 39-60 years on aspirin had HR of 0.93 (0.84 - 1.00), 0.90 (0.82 - 0.98) and 0.88 (0.80 - 0.96) at 5 years, 10 years and 15 years, respectively, compared to cases in the same age group who were not on antiplatelets. Similar beneficial effects of aspirin were observed in other age groups. There were no significant survival benefits with other antiplatelet options. No survival benefits of antiplatelet drugs were observed in controls. Our study highlights the excess long-term risk of death of TIA patients and cautions that TIA should not be treated as a benign condition. The study further recommends aspirin as the better option for secondary prevention for TIA patients compared to clopidogrel recommended by NICE guidelines. Management of risk factors and treatment strategies should be important challenges to reduce the burden of disease.

Keywords: dual antiplatelet therapy (DAPT), General Practice, Multiple Imputation, The Health Improvement Network(THIN), hazard ratio (HR), Weibull-Cox model

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Authors: Najmeh Hamid, Vajiheh Hamedy , Zahra Rostamianasl

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Background: Cancer is one of the medical problems that have been associated with pain. Moreover, the pain is combined with negative emotions such as anxiety, depression and anger. Poor pain management causes negative effects on the quality of life, which results in negative effects that continue a long time after the painful experiences. Objectives: The aim of this research was to compare the effectiveness of Common Cognitive Behavioral Therapy for Pain and its computerized version on the reduction of pain intensity, depression, anger and anxiety in children with cancer. Methods: The research method of this “Randomized Controlled Clinical Trial” was a pre, post-test and follow-up with a control group. In this research, we have examined the effectiveness of Common Cognitive Behavioral Therapy for Pain and its computerized version on the reduction of pain intensity, anxiety, depression and anger in children with cancer in Ahvaz. Two psychological interventions (cognitive behavioral therapy for pain and the computerized version) were compared with the control group. The sample consisted of 60 children aged 8 to 12 years old with different types of cancer at Shafa hospital in Ahwaz. According to the including and excluding criteria such as age, socioeconomic status, clinical diagnostic interview and other criteria, 60 subjects were selected. Then, randomly, 45 subjects were selected. The subjects were randomly divided into three groups of 15 (two experimental and one control group). The research instruments included Spielberger Anxiety Inventory (STAY-2) and International Pain Measurement Scale. The first experimental group received 6 sessions of cognitive-behavioral therapy for 6 weeks, and the second group was subjected to a computerized version of cognitive-behavioral therapy for 6 weeks, but the control group did not receive any interventions. For ethical considerations, a version of computerized cognitive-behavioral therapy was provided to them. After 6 weeks, all three groups were evaluated as post-test and eventually after a one-month follow-up. Results: The findings of this study indicated that both interventions could reduce the negative emotions (pain, anger, anxiety, depression) associated with cancer in children in comparison with a control group (p<0.0001). In addition, there were no significant differences between the two interventions (p<0.01). It means both interventions are useful for reducing the negative effects of pain and enhancing adjustment. Conclusion: we can use CBT in situations in which there is no access to psychologists and psychological services. In addition, it can be a useful alternative to conventional psychological interventions.

Keywords: pain, children, psychological intervention, cancer, anger, anxiety, depression

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Authors: Ashutosh Biswas, Poonam Coushic, Kalpana Baruah, Paras Singla, A. C. Dhariwal, Pawana Murthy

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Burden of Dengue in Northern India Ashutosh Biswas, Poonam Coushic, Kalpana Baruah, Paras Singla, AC Dhariwal, Pawana Murthy. All India Institute of Medical Sciences, NVBDCP,WHO New Delhi, India Aim: This study was conducted to estimate the burden of dengue in capital region of India. Methodology:Seropositivity of Dengue for IgM Ab, NS1 Ag and IgG Ab were performed among the blood donors’ samples from blood bank, those who were coming to donate blood for the requirement of blood for the admitted patients in hospital. Blood samplles were collected through out the year to estimate seroprevalance of dengue with or without outbreak season. All the subjects were asymptomatic at the time of blood donation. Results: A total of 1558 donors were screened for the study. On the basis of inclusion/ exclusion criteria, we enrolled 1531subjects for the study.Twenty seven donors were excluded from the study, out of which 6 were detected HIV +ve, 11 were positive for HBsAg and 10 were found positive for HCV.Mean age was 30.51 ± 7.75 years.Of 1531subjects, 18 (1.18%) had a past history of typhoid fever, 28 (1.83%) had chikungunya fever, 9 (0.59%) had malaria and 43 subjects (2.81%) had a past history of symptomatic dengue infection.About 2.22% (34) of subjects were found to have sero-positive for NS1 Ag with a peak point prevalence of 7.14% in the month of October and sero-positive of IgM Ab was observed about 5.49% (84)with a peak point prevalence of 14.29% in the month of October. Sero-prevalnce of IgGwas detected in about 64.21% (983) of subjects. Conclusion: Acute asymptomatic dengue (NS1 Ag+ve) was observed in 7.14%, as the subjects were having no symptoms at the time of sampling. This group of subjects poses a potential public health threat for transmitting dengue infection through blood transfusion (TTI) in the community as evident by presence of active viral infection due to NS1Ag +VE. Therefore a policy may be implemented in the blood bank for testing NS1 Ag to look for active dengue infection for preventing dengue transmission through blood transfusion (TTI). Acute or Subacute dengue infection ( IgM Ab+ve) was observed from 5.49% to 14.29% which is a peak point prevalence in the month of October. About 64.21% of the population were immunized by natural dengue infection ( IgG Ab+ve) in theNorthern province of India. This might be helpful for implementing the dengue vaccine in a region. Blood samples in blood banks should be tested for dengue before transfusion to any other person to prevent transfusion transmitted dengue infection as we estimated upto 7.14% positivity of NS1 Ag in our study which indicates presence of dengue virus in blood donors’ samples.

Keywords: Dengue Burden, Seroprevalance, Asymptomatic dengue, Dengue transmission through blood transfusion

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Authors: Fateme Aysin Anka, Farzad Kiani

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Forced migration is a situation in which people are forced to leave their homes against their will due to political conflicts, wars and conflicts, natural disasters, climate change, economic crises, or other emergencies. This type of migration takes place under conditions where people cannot lead a sustainable life due to reasons such as security, shelter and meeting their basic needs. This type of migration may occur in connection with different factors that affect people's living conditions. In addition to these general and widespread reasons, water security and resources will be one that is starting now and will be encountered more and more in the future. Forced migration may occur due to insufficient or depleted water resources in the areas where people live. In this case, people's living conditions become unsustainable, and they may have to go elsewhere, as they cannot obtain their basic needs, such as drinking water, water used for agriculture and industry. To cope with these situations, it is important to minimize the causes, as international organizations and societies must provide assistance (for example, humanitarian aid, shelter, medical support and education) and protection to address (or mitigate) this problem. From the international perspective, plans such as the Green New Deal (GND) and the European Green Deal (EGD) draw attention to the need for people to live equally in a cleaner and greener world. Especially recently, with the advancement of technology, science and methods have become more efficient. In this regard, in this article, a multidisciplinary case model is presented by reinforcing the water problem with an engineering approach within the framework of the social dimension. It is worth emphasizing that this problem is largely linked to climate change and the lack of a sustainable water management perspective. As a matter of fact, the United Nations Development Agency (UNDA) draws attention to this problem in its universally accepted sustainable development goals. Therefore, an artificial intelligence-based approach has been applied to solve this problem by focusing on the water management problem. The most general but also important aspect in the management of water resources is its correct consumption. In this context, the artificial intelligence-based system undertakes tasks such as water demand forecasting and distribution management, emergency and crisis management, water pollution detection and prevention, and maintenance and repair control and forecasting.

Keywords: water resource management, forced migration, multidisciplinary studies, artificial intelligence

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Authors: Chana Pavneet

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Background: In more recent years in dentistry, a greater emphasis has been placed on competency-based education (CBE) programmes. Undergraduate and postgraduate curriculums have been reformed to reflect these changes, and adopting a CBE approach has shown to be beneficial to trainees and places an emphasis on continuous lifelong learning. The literature is vast; however, very little work has been done specifically to the assessment of competence in dentistry and even less so in oral surgery. The majority of the literature tends to opinion pieces. Some small-scale studies have been undertaken in this area researching assessment tools which can be used to assess competence in oral surgery. However, there is a lack of general consensus on the preferable assessment methods. The aim of this review is to identify the assessment methods available and their usefulness. Methods: Electronic databases (Medline, Embase, and the Cochrane Database of systematic reviews) were searched. PRISMA guidelines were followed to identify relevant papers. Abstracts of studies were reviewed, and if they met the inclusion criteria, they were included in the review. Papers were reviewed against the critical appraisal skills programme (CASP) checklist and medical education research quality instrument (MERQSI) to assess their quality and identify any bias in a systematic manner. The validity and reliability of each assessment method or tool were assessed. Results: A number of assessment methods were identified, including self-assessment, peer assessment, and direct observation of skills by someone senior. Senior assessment tended to be the preferred method, followed by self-assessment and, finally, peer assessment. The level of training was shown to affect the preferred assessment method, with one study finding peer assessment more useful in postgraduate trainees as opposed to undergraduate trainees. Numerous tools for assessment were identified, including a checklist scale and a global rating scale. Both had their strengths and weaknesses, but the evidence was more favourable for global rating scales in terms of reliability, applicability to more clinical situations, and easier to use for examiners. Studies also looked into trainees’ opinions on assessment tools. Logbooks were not found to be significant in measuring the competence of trainees. Conclusion: There is limited literature exploring the methods and tools which assess the competence of oral surgery trainees. Current evidence shows that the most favourable assessment method and tool may differ depending on the stage of training. More research is required in this area to streamline assessment methods and tools.

Keywords: competence, oral surgery, assessment, trainees, education

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Authors: Sharib Ahmed, Mansoor Rafi, Kamran Ali Awan, Faraz Khaskhali, Amir Maqbool, Altaf Hashmi

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Medical linear accelerators (LINAC’s) used in radiotherapy treatments produce undesired neutrons when they are operated at energies above 8 MeV, both in electron and photon configuration. Neutrons are produced by high-energy photons and electrons through electronuclear (e, n) a photonuclear giant dipole resonance (GDR) reactions. These reactions occurs when incoming photon or electron incident through the various materials of target, flattening filter, collimators, and other shielding components in LINAC’s structure. These neutrons may reach directly to the patient, or they may interact with the surrounding materials until they become thermalized. A work has been set up to study the effect of different parameter on the production of neutron around the room by photonuclear reactions induced by photons above ~8 MeV. One of the commercial available neutron detector (Ludlum Model 42-31H Neutron Detector) is used for the detection of thermal and fast neutrons (0.025 eV to approximately 12 MeV) inside and outside of the treatment room. Measurements were performed for different field sizes at 100 cm source to surface distance (SSD) of detector, at different distances from the isocenter and at the place of primary and secondary walls. Other measurements were performed at door and treatment console for the potential radiation safety concerns of the therapists who must walk in and out of the room for the treatments. Exposures have taken place from Elekta Synergy® linear accelerators for two different energies (10 MV and 18 MV) for a given 200 MU’s and dose rate of 600 MU per minute. Results indicates that neutron doses at 100 cm SSD depend on accelerator characteristics means jaw settings as jaws are made of high atomic number material so provides significant interaction of photons to produce neutrons, while doses at the place of larger distance from isocenter are strongly influenced by the treatment room geometry and backscattering from the walls cause a greater doses as compare to dose at 100 cm distance from isocenter. In the treatment room the ambient dose equivalent due to photons produced during decay of activation nuclei varies from 4.22 mSv.h−1 to 13.2 mSv.h−1 (at isocenter),6.21 mSv.h−1 to 29.2 mSv.h−1 (primary wall) and 8.73 mSv.h−1 to 37.2 mSv.h−1 (secondary wall) for 10 and 18 MV respectively. The ambient dose equivalent for neutrons at door is 5 μSv.h−1 to 2 μSv.h−1 while at treatment console room it is 2 μSv.h−1 to 0 μSv.h−1 for 10 and 18 MV respectively which shows that a 2 m thick and 5m longer concrete maze provides sufficient shielding for neutron at door as well as at treatment console for 10 and 18 MV photons.

Keywords: equivalent doses, neutron contamination, neutron detector, photon energy

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Authors: T. Suleiman, C. Mchugh, H. Ranu

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Background; Asthma continues to be associated with poor patient outcomes, including mortality. An audit of the management of acute asthma admissions in our hospital in 2020 found poor compliance with National Asthma and COPD Audit Project (NACAP) standards which set out to improve inpatient asthma care. Clinical nurse specialists have been shown to improve patient care across a range of specialties. In September 2021, an asthma Nurse Specialist (ANS) was employed in our hospital. Aim; To re-audit management of acute asthma admissions using NACAP standards and assess for quality improvement post-employment of an ANS. Methodology; NACAP standards are wide-reaching; therefore, we focused on ‘specific elements of good practice’ in addition to the provision of inhaled corticosteroids (ICS) on discharge. Medical notes were retrospectively requested from the hospital coding department and selected as per NACAP inclusion criteria. Data collection and entry into the NACAP database were carried out. As this was a clinical audit, ethics approval was not required. Results; Cycle 1 (pre-ANS) and 2 (post-ANS) of the audit included 20 and 32 patients, respectively, with comparable baseline demographics. No patients had a discharge bundle completed on discharge in cycle 1 vs. 84% of cases in cycle 2. Regarding specific components of the bundle, 25% of patients in cycle 1 had their inhaler technique checked vs. 91% in cycle 2. Furthermore, 80% of patients had maintenance medications reviewed in cycle 1 vs. 97% in cycle 2. Medication adherence was addressed in 20% of cases in cycle 1 vs. 88% of cases in cycle 2. Personalized asthma action plans were not issued or reviewed in any cases in cycle 1 as compared with 84% of cases in cycle 2. Triggers were discussed in 30% of cases in cycle 1 vs. 88% of cases in cycle 2. Tobacco dependence was addressed in 44% of cases in cycle 1 vs. 100% of cases in cycle 2. No patients in cycle 1 had community follow-up requested within 2 days vs. 81% of the patients in cycle 2. Similarly, 20% of the patients in cycle 1 vs. 88% of the patients in cycle 2 had a 4-week asthma clinic follow-up requested. 75% of patients in cycle 1 were the recipient of ICS on discharge compared with 94% of patients in cycle 2. Conclusion; Our quality improvement project demonstrates the utility of an ANS in improving performance in the management of acute asthma admissions, evidenced here through concordance with NACAP standards. Asthma is a complex condition with biological, psychological, and sociological components; therefore, ANS is a suitable intervention to improve concordance with guidelines. ANS likely impacted performance directly, for example, by checking inhaler technique, and indirectly as a safety net ensuring doctors included ICS on discharge.

Keywords: asthma, nurse specialist, clinical audit, quality improvement

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Authors: B. Petrović, M. Petrović, L. Rutonjski, I. Djan, V. Ivanović

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Objective: Cardiac pacemakers are very sensitive to radiotherapy treatment from two sources: electromagnetic influence from the medical linear accelerator producing ionizing radiation- influencing electronics within the pacemaker, and the absorption of dose to the device. On the other hand, patients with cardiac pacemakers at the place of a tumor are rather rare, and single clinic hardly has experience with the management of such patients. The widely accepted international guidelines for management of radiation oncology patients recommend that these patients should be closely monitored and examined before, during and after radiotherapy treatment by cardiologist, and their device and condition followed up. The number of patients having both cancer and pacemaker, is growing every year, as both cancer incidence, as well as cardiac diseases incidence, are inevitably growing figures. Materials and methods: Female patient, age 69, was diagnozed with valvular cardiomyopathy and got implanted a pacemaker in 2005 and prosthetic mitral valve in 1993 (cancer was diagnosed in 2012). She was stable cardiologically and came to radiation therapy department with the diagnosis of right breast cancer, with the tumor in upper lateral quadrant of the right breast. Since she had all lymph nodes positive (28 in total), she had to have irradiated the supraclavicular region, as well as the breast with the tumor bed. She previously received chemotherapy, approved by the cardiologist. The patient was estimated to be with the high risk as device was within the field of irradiation, and the patient had high dependence on her pacemaker. The radiation therapy plan was conducted as 3D conformal therapy. The delineated target was breast with supraclavicular region, where the pacemaker was actually placed, with the addition of a pacemaker as organ at risk, to estimate the dose to the device and its components as recommended, and the breast. The targets received both 50 Gy in 25 fractions (where 20% of a pacemaker received 50 Gy, and 60% of a device received 40 Gy). The electrode to the heart received between 1 Gy and 50 Gy. Verification of dose planned and delivered was performed. Results: Evaluation of the patient status according to the guidelines and especially evaluation of all associated risks to the patient during treatment was done. Patient was irradiated by prescribed dose and followed up for the whole year, with no symptoms of failure of the pacemaker device during, or after treatment in follow up period. The functionality of a device was estimated to be unchanged, according to the parameters (electrode impedance and battery energy). Conclusion: Patient was closely monitored according to published guidelines during irradiation and afterwards. Pacemaker irradiated with the full dose did not show any signs of failure despite recommendations data, but in correlation with other published data.

Keywords: cardiac pacemaker, breast cancer, radiotherapy treatment planning, complications of treatment

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Authors: Jilbert Novelero, Oliver Mariano

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In a world where technological evolution and competition to create innovative products are at its peak, problems on Electronic Waste (E-Waste) are now becoming a global concern. E-waste is said to be any electrical or electronic devices that have reached the terminal of its useful life. The major issue are the volume and the raw materials used in crafting E-waste which is non-biodegradable and contains hazardous substances that are toxic to human health and the environment. The objective of this study is to gather baseline data in terms of the composition of E-waste in the solid waste stream and to determine the top 5 E-waste categories in a highly urbanized city. Recommendations in managing these wastes for its reduction were provided which may serve as a guide for acceptance and implementation in the locality. Pasig City was the chosen beneficiary of the research output and through the collaboration of the City Government of Pasig and its Solid Waste Management Office (SWMO); the researcher successfully conducted the Electronic Waste Analysis and Characterization Study (E-WACS) to achieve the objectives. E-WACS that was conducted on April 2019 showed that E-waste ranked 4th which comprises the 10.39% of the overall solid waste volume. Out of 345, 127.24kg which is the total daily domestic waste generation in the city, E-waste covers 35,858.72kg. Moreover, an average of 40 grams was determined to be the E-waste generation per person per day. The top 5 E-waste categories were then classified after the analysis. The category which ranked first is the office and telecommunications equipment that contained the 63.18% of the total generated E-waste. Second in ranking was the household appliances category with 21.13% composition. Third was the lighting devices category with 8.17%. Fourth on ranking was the consumer electronics and batteries category which was composed of 5.97% and fifth was the wires and cables category where it comprised the 1.41% of the average generated E-waste samples. One of the recommendations provided in this research is the implementation of the Pasig City Waste Advantage Card. The card can be used as a privilege card and earned points can be converted to avail of and enjoy services such as haircut, massage, dental services, medical check-up, and etc. Another recommendation raised is for the LGU to encourage a communication or dialogue with the technology and electronics manufacturers and distributors and international and local companies to plan the retrieval and disposal of the E-wastes in accordance with the Extended Producer Responsibility (EPR) policy where producers are given significant responsibilities for the treatment and disposal of post-consumer products.

Keywords: E-waste, E-WACS, E-waste characterization, electronic waste, electronic waste analysis

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Authors: Hakan Duger, Alparslan Ersoy, Canan Ersoy

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The improvement of surgical techniques in recent years has reduced the frequency of postoperative complications in kidney transplant recipients. Novel immunosuppressive agents have reduced rates of graft loss due to acute rejection to less than 1%. However, surgical complications may still lead graft loss and morbidity in recipients. Because of potent immunosuppression, impaired wound healing and complications are frequent after transplantation. We compared the frequency of post-operative surgical complications in diabetic and non-diabetic patients after kidney transplantation. Materials and Methods: This retrospective study conducted in consecutive patients (213 females, 285 males, median age 39 years) who underwent kidney transplant surgery at our center between December 2005 and October 2015. The patients were divided into two groups: diabetics (46 ± 10 year, 26 males, 16 females) and non-diabetics (39 ± 12 year, 259 males, 197 females). Characteristics of both groups were obtained from medical records. Results: We performed 225 living and 273 deceased donor transplantations. Renal replacement type was hemodialysis in 60.8%, peritoneal dialysis in 17.3% and preemptive in 12%. The mean body mass indexes of the recipients were 24 ± 4.6 kg/m², donor age was 48.6 ± 14.3 years, cold ischemic time was 11.3 ± 6.1 hours, surgery time was 4.9 ± 1.2 hours, and recovery time was 54±31 min. The mean hospitalization duration was 19.1 ± 13.5 days. The frequency of postoperative surgical complications was 43.8%. There was no significant difference between the ratios of post-operative surgical complications in non-diabetic (43.5%) and diabetic (47.4%) groups (p=0.648). Post-operative surgical complications were lymphocele (24.6% vs. 23.7%), delayed wound healing (13.2% vs. 7.6%), hematoma (7.8% vs.15.8 %), urinary leak (4.6% vs. 5.3%), hemorrhage (5.1% vs. 0%), hydronephrosis (2.2% vs. 0%), renal artery thrombosis (1.5% vs. 0%), renal vein thrombosis (1% vs. 2.6%), urinoma (0.7% vs. 0%), urinary obstruction (0.5% vs. 0%), ureteral stenosis (0.5% vs. 0%) and ureteral reflux (0.2% vs. 0%) in non-diabetic and diabetic groups, respectively (p > 0.05). Mean serum creatinine levels in non-diabetics and diabetics were 1.43 ± 0.81 and 1.61 ± 0.96 mg/dL at 1st month (p=0.198). At the 6th month, the mean graft and patient survival times in patients with post-operative surgical complications were significantly lower than in those who did not (162.9 ± 3.4 vs. 175.6 ± 1.5 days, p=0.008, and 171 ± 2.9 vs. 176.1 ± 1.6 days, p=0.047, respectively). However, patient survival durations of non-diabetic (173 ± 27) and diabetic (177 ± 13 day) groups were comparable (p=0.396). Conclusion: As a result, we concluded that surgical complications such as lymphocele and delayed wound healing were common and that frequency of these complications in diabetic recipients did not differ from non-diabetic one. All persons involved in the postoperative care of kidney transplant recipients be aware of the potential surgical complications for rapid diagnosis and treatment.

Keywords: kidney transplantation, diabetes mellitus, surgery, complication

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Authors: Cemil Akcay, Goksun Yerlikaya

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Buildings are the living spaces of people with an active role in every aspect of life in today's world. While some structures have survived from the early ages, most of the buildings that completed their lifetime have not transported to the present day. Nowadays, buildings that do not meet the social, economic, and safety requirements of the age return to life with a transformation process. This transformation is called urban transformation. Urban transformation is the renewal of the areas with a risk of disaster and the technological infrastructure required by the structure. The transformation aims to prevent damage to earthquakes and other disasters by rebuilding buildings that have completed their non-earthquake-resistant economic life. It is essential to decide on other issues related to conversion and transformation in places where most of the building stock should transform into the first-degree earthquake belt, such as Istanbul. In urban transformation, property owners, local authority, and contractor must deal at a common point. Considering that hundreds of thousands of property owners are sometimes in the areas of transformation, it is evident how difficult it is to make the deal and decide. For the optimization of these decisions, the use of game theory is foreseeing. The main problem in this study is that the urban transformation is carried out in place, or the building or buildings are transport to a different location. There are many stakeholders in the Istanbul University Cerrahpaşa Medical Faculty Campus, which is planned to be carried out in the process of urban transformation, was tried to solve the game theory applications. An analysis of the decisions given on a real urban transformation project and the logical suitability of decisions taken without the use of game theory were also supervised using game theory. In each step of this study, many decision-makers are classifying according to a specific logical sequence, and in the game trees that emerged as a result of this classification, Nash balances were tried to observe, and optimum decisions were determined. All decisions taken for this project have been subjected to two significant differentiated comparisons using game theory, and as decisions are taken without the use of game theory, and according to the results, solutions for the decision phase of the urban transformation process introduced. The game theory model developed from beginning to the end of the urban transformation process, particularly as a solution to the difficulty of making rational decisions in large-scale projects with many participants in the decision-making process. The use of a decision-making mechanism can provide an optimum answer to the demands of the stakeholders. In today's world for the construction sector, it is also seeing that the game theory is a non-surprising consequence of the fact that it is the most critical issues of planning and making the right decision in future years.

Keywords: urban transformation, the game theory, decision making, multi-actor project

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Authors: K. Rajarajeswaran, Krishna Prasad

Abstract:

Introduction: Refractory shock is a typical consequence of sepsis that does not improve with standard vasopressor therapy. A possible adjuvant therapeutic option for treating refractory shock in sepsis is methylene blue. This study looked at the effects of intravenous methylene blue plus norepinephrine given as a single bolus infusion on mortality and hemodynamic improvement in patients suffering from refractory shock. Methodology: This six-month observational prospective study was carried out at an intensive care unit, teaching hospital, and medical college. It involved 112 patients who had been diagnosed with refractory septic shock and needed vasopressor medication. Group B received injection norepinephrine 0.01 µg/kg/min infusion alone, while Group A received injection methylene blue 2 mg/kg iv single bolus (fixed dose) in addition to injection norepinephrine 0.01 µg/kg/min infusion. Both groups' noradrenaline doses were titrated to reach the desired MAP of 60–75 mm Hg. The amount of norepinephrine needed to sustain a MAP of more than 60 mm Hg was the data gathered. Serum lactate, procalcitonin level, C-reactive protein, length of stay in the intensive care unit (ICU), sequential organ failure assessment (SOFA) score, and duration of mechanical ventilation, incidence of acute kidney injury (AKI), and mortality were compared. Results: A total of 112 patients with refractory shock were included in the study. With the use of IV methylene blue, 36 (59.3%) patients showed significant improvement in MAP within 2 hours (77.12 ± 8.90 vs 74.28 ± 21.84, p = 0.005). Responders were 4.009 times more likely to have vasopressor-free time within 24 hours (19.5% vs 6.1%, p = 0.022, odds ratio 5.017, 95% confidence interval, 1.110–14.283). The serum lactate was lower, and urine output was higher in group I than in group II (p <0.05). Group I had a significantly greater reduction in SOFA score in 12 hours than group II. However, there was no significant difference in terms of mortality, length of ICU stay, ventilator free days, and incidence of AKI. In the responder group, there was a significant increase in the MAP and decrease in vasopressor requirement pre- and post-infusion of methylene blue (p < 0.05). Responder had shorter vasopressor-free days as compared with non-responder (5.44 vs 6.99, p = 0.007). Conclusion: When administered as adjuvant therapy, a single-dose bolus infusion of Methylene Blue plus Norepinephrine may aid in meeting early resuscitation goals for the management of patients with septic shock. But the patients' death rate, ICU stay duration, ventilator-free days, or incidence of AKI were unchanged.

Keywords: norepinephrine, methylene blue, shock, vasopressor

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Authors: G. Natuhwera, M. Rabwoni, P. Ellis, A. Merriman

Abstract:

Aims: Health workers are likely to document patients’ care inaccurately, especially when using new and revised case tools, and this could negatively impact patient care. This study set out to; (1) assess nurses’ and clinicians’ documentation practices when using a new patients’ continuation case sheet (PCCS) and (2) explore nurses’ and clinicians’ experiences regarding documentation of patients’ information in the new PCCS. The purpose of introducing the PCCS was to improve continuity of care for patients attending clinics at which they were unlikely to see the same clinician or nurse consistently. Methods: This was a mixed methods study. The cross-sectional inquiry retrospectively reviewed 100 case notes of active patients on hospice and palliative care program. Data was collected using a structured questionnaire with constructs formulated from the new PCCS under study. The qualitative element was face-to-face audio-recorded, open-ended interviews with a purposive sample of one palliative care clinician, and four palliative care nurse specialists. Thematic analysis was used. Results: Missing patients’ biogeographic information was prevalent at 5-10%. Spiritual and psychosocial issues were not documented in 42.6%, and vital signs in 49.2%. Poorest documentation practices were observed in past medical history part of the PCCS at 40-63%. Four themes emerged from interviews with clinicians and nurses-; (1) what remains unclear and challenges, (2) comparing the past with the present, (3) experiential thoughts, and (4) transition and adapting to change. Conclusions: The PCCS seems to be a comprehensive and simple tool to be used to document patients’ information at subsequent visits. The comprehensiveness and utility of the PCCS does paper to be limited by the failure to train staff in its use prior to introducing. The authors find the PCCS comprehensive and suitable to capture patients’ information and recommend it can be adopted and used in other palliative and hospice care settings, if suitable introductory training accompanies its introduction. Otherwise, the reliability and validity of patients’ information collected by this PCCS can be significantly reduced if some sections therein are unclear to the clinicians/nurses. The study identified clinicians- and nurses-related pitfalls in documentation of patients’ care. Clinicians and nurses need to prioritize accurate and complete documentation of patient care in the PCCS for quality care provision. This study should be extended to other sites using similar tools to ensure representative and generalizable findings.

Keywords: documentation, information case sheet, palliative care, quality improvement

Procedia PDF Downloads 151