Search results for: antiracist healthcare delivery

Authors: Jocelyne Uwibambe, Ange Thaina Ndizeye, Dinah Ishimwe, Emmanuel Mugabo Byakagaba

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Background: In low- and middle-income countries (LMICs), the use of modern contraceptive methods among women, including adolescents, is still low despite the desire to avoid pregnancy. In addition, countries have set a minimum age for marriage, which is 21 years for most countries, including Rwanda. The Rwandan culture, to a certain extent, and religion, to a greater extent, however, limit the freedom of young women to use contraceptive services because it is wrongly perceived as an encouragement for premarital sexual intercourse. In the end, what doesn’t change is that denying access to contraceptives to either male or female adolescents does not translate into preventing them from sexual activities, hence leading to an ever-increasing number of unwanted pregnancies, possible STIs, HIV, Human Papilloma Virus, and subsequent unsafe abortion followed by avoidable expensive complications. The purpose of this study is to evaluate the perception of healthcare providers regarding contraceptive use among adolescents. Methodology: This was a qualitative study. Interviews were done with different healthcare providers, including doctors, nurses, midwives, and pharmacists, through focused group discussions and in-depth interviews, then the audio was transcribed, translated and thematic coding was done. Results: This study explored the perceptions of healthcare workers regarding the provision of modern contraception to adolescents in Rwanda. The findings revealed that while healthcare providers had a good understanding of family planning and contraception, they were hesitant to provide contraception to adolescents. Sociocultural beliefs played a significant role in shaping their attitudes, as many healthcare workers believed that providing contraception to adolescents would encourage promiscuous behavior and go against cultural norms. Religious beliefs also influenced their reluctance, with some healthcare providers considering premarital sex and contraception as sinful. Lack of knowledge among parents and adolescents themselves was identified as a contributing factor to unwanted pregnancies, as inaccurate information from peers and social media influenced risky sexual behavior. Conditional policies, such as the requirement for parental consent, further hindered adolescents' access to contraception. The study suggested several solutions, including comprehensive sexual and reproductive health education, involving multiple stakeholders, ensuring easy access to contraception, and involving adolescents in policymaking. Overall, this research highlights the need for addressing sociocultural beliefs, improving healthcare providers' knowledge, and revisiting policies to ensure adolescents' reproductive health rights are met in Rwanda. Conclusion: The study highlights the importance of enhancing healthcare provider training, expanding access to modern contraception, implementing community-based interventions, and strengthening policy and programmatic support for adolescent contraception. Addressing these challenges is crucial for improving the provision of family planning services to adolescents in Rwanda and achieving the Sustainable Development Goals related to sexual and reproductive health. Collaborative efforts involving various stakeholders and organizations can contribute to overcoming these barriers and promoting the well-being of adolescents in Rwanda.

Keywords: adolescent, health care providers, contraception, reproductive health

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Authors: Bei Shan Lin, Chun Mei Lu, Ya Ping Chen, Li Chen Lu

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This study explores the ethical issues concerning the use of physical restraint in geriatric care. Physical restraint use in a medical care setting is seen as a controversial form of treatment that has occurred over decades. There is no doubt that people nowadays are living longer than previous generations. The ageing process is inevitable. Common disease such as impaired comprehension, memory loss, and trouble expressing one’s self contribute to the difficulty that these older patients have in adapting to medical institution. For these reasons, physical restraint is often used in reducing the risk of falling, managing wandering behaviour, preventing agitation, and promoting patient compliance in geriatric care. It can mean that physical restraints are considered as a common practice that is used in the care of older patients. It is most commonly used for three specific purposes, including procedural restraint, restraint to prevent falls, and behavioural restraints. Although there have been well documented instances of morbidity and mortality recognised as being potential risks associated with physical restraint use, it continues to be permitted and used in healthcare, often in the name of safety. However, there is insufficient evidence supporting the effectiveness of physical restraint use reducing injuries from falls and controlling challenging behaviour in geriatric care settings. There is barely any empirical evidence of either a scientific basis or clinical trials have evaluated the improvement in patient safety following physical restraint. In difficult clinical situations, guidelines and practical suggestions for Healthcare professionals to comply requirements can help those making appropriate decisions and to facilitate better judgement regarding physical restraint use. The following recommendations are given for physical restraint use in long-term care settings: an interdisciplinary team approach to assess, evaluate, and treat underlying diseases to determine if treatment can ease issues precipitating physical restraint use; a clearly stated purpose of treatment plan should be made after weighing up the risk of physical restraint use against the risk of without physical restraint use; a care plan for physical restraint has to include individualised treatment planning, informed consent, identification and remedial action to avoid negative consequences, regular assessment and modification, reduction and removal of risks; patients and their families must have the opportunity to consider and give voluntary informed consent prior to physical restraint utilisation; patients, family members, and Healthcare professionals should be educated on use and adverse consequences of physical restraints in order to make raise awareness of potential risks and to take appropriate steps to prevent unnecessary harm; after physical restraint removal, Healthcare professionals should discuss with patients and family members about their experience, feelings, and any anxieties regarding the treatment. Physical restraint should always be considered a last resort as deprive patient’s freedom, control, and individuality. Healthcare professionals should emphasise on providing individualized care, interdisciplinary decision-making process, and creative and collaborative alternatives to promote older patient’s rights, dignity and overall well-being as much as possible.

Keywords: ethics healthcare, geriatric care, healthcare, physical restraint

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Authors: Ivy Rose Mathew

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The purpose of this study is to outline the efficacy of technology and the opportunities it can bring to implement a successful delivery model in Distance Learning. Distance Learning has proliferated over the past few years across the world. Some of the current challenges faced by current students of distance education include lack of motivation, a sense of isolation and a need for greater and improved communication. Hence the author proposes a creative technology supported model for distance learning exactly mirrored on the traditional face to face learning that can be adopted by distance learning providers. This model suggests the usage of a range of technologies and social networking facilities, with the aim of creating a more engaging and sustaining learning environment to help overcome the isolation often noted by distance learners. While discussing the possibilities, the author also highlights the complexity and practical challenges of implementing such a model. Design/methodology/approach: Theoretical issues from previous research related to successful models for distance learning providers will be considered. And also the analysis of a case study from one of the largest private tertiary institution in Botswana, Botho University will be included. This case study illustrates important aspects of the distance learning delivery model and provides insights on how curriculum development is planned, quality assurance is done, and learner support is assured for successful distance learning experience. Research limitations/implications: While some of the aspects of this study may not be applicable to other contexts, a number of new providers of distance learning can adapt the key principles of this delivery model.

Keywords: distance learning, efficacy, learning experience, technology supported model

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Authors: Shailender Kumar

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Current health policy pronouncements in India advocate for insurance-based financing mechanism to achieve universal health coverage (UHC), while undermine the role of comprehensive healthcare provision system. UHC is achieved when all people receive the health services they need without suffering financial hardship. This study, using 68th & 71st NSS rounds data, examines their relative and combined strength in achieving the above objective. Health-insurance has been unsuccessful in reducing prevalence and catastrophic effects of out-of-pocket payment and even dismantle the effectiveness of traditional way of health financing system. Healthcare provision is the best way forward to enhance health and well-being of households in condition if India removes existing inadequacies and inequalities in service provision across districts/states and ensure free/low cost medicines/diagnostics to the citizens.

Keywords: health policy, demand-side financing, supply-side financing, incidence of health payment

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Authors: T. Iakovleva

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Present paper suggests a theoretical model that describes the process of the development of responsible innovations on the firm level in health and welfare sectors. There is a need to develop new firm strategies in these sectors. This paper suggests to look on the concept of responsible innovation that was originally developed on the social level and to apply this new concept to the new area of firm strategy. The rapid global diffusion of information and communication technologies has greatly improved access to knowledge. At the same time, communication is cheap, information is a commodity, and global trade increases technological diffusion. As a result, firms and users, including those outside of industrialized nations, get early exposure to the latest technologies and information. General-purpose technologies such as mobile phones and 3D printers enable individuals to solve local needs and customize products. The combined effect of these changes is having a profound impact on the innovation landscape. Meanwhile, the healthcare sector is facing unprecedented challenges, which are magnified by budgetary constraints, an aging population and the desire to provide care for all. On the other hand, patients themselves are changing. They are savvier about their diseases, they expect their relation with the healthcare professionals to be open and interactive, but above all they want to be part of the decision process. All of this is a reflection of what is already happening in other industries where customers have access to large amount of information and became educated buyers. This article addresses the question of how ICT research and innovation may contribute to developing solutions to grand societal challenges in a responsible way. A broad definition of the concept of responsibility in the context of innovation is adopted in this paper. Responsibility is thus seen as a collective, uncertain and future-oriented activity. This opens the questions of how responsibilities are perceived and distributed and how innovation and science can be governed and stewarded towards socially desirable and acceptable ends. This article addresses a central question confronting politicians, business leaders, and regional planners.

Keywords: responsible innovation, ICT, healthcare, welfare sector

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Authors: Gracie Tredget, Raymond McGrath, Karen Ang, Julie Williams, Nick Sevdalis, Fiona Gaughran, Jorge Aria de la Torre, Ioannis Bakolis, Andy Healey, Zarnie Khadjesari, Euan Sadler, Natalia Stepan

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Background: Preventable physical health problems have been found to increase morbidity rates amongst adults living with serious mental illness (SMI). Community mental health clinicians have a role in identifying, and preventing physical health problems worsening, and supporting primary care services to administer routine physical health checks for their patients. However, little is known about how mental health staff perceive and approach their role when providing physical healthcare amongst patients with SMI, or the impact these attitudes have on routine practice. Methods: The present study involves a prospective service evaluation specific to Adult Community Mental Health Services at South London and Maudsley NHS Foundation Trust (SLaM). A qualitative methodology will use semi-structured interviews, focus groups and observations to explore attitudes, perceptions and experiences of staff, patients, and carers (n=64) towards physical healthcare, and barriers or facilitators that impact upon it. 1South London and Maudsley NHS Foundation Trust, London, SE5 8AZ, UK 2 Centre for Implementation Science, King’s College London, London, SE5 8AF, UK 3 Psychosis Studies, King's College London, London, SE5 8AF, UK 4 Department of Biostatistics and Health Informatics, King’s College London, London, SE5 8AF, UK 5 Kings Health Economics, King's College London, London, SE5 8AF, UK 6 Behavioural and Implementation Science (BIS) research group, University of East Anglia, Norwich, UK 7 Department of Nursing, Midwifery and Health, University of Southampton, Southampton, UK 8 Mind and Body Programme, King’s Health Partners, Guy’s Hospital, London, SE1 9RT *[email protected] Analysis: Data from across qualitative tasks will be synthesised using Framework Analysis methodologies. Staff, patients, and carers will be invited to participate in co-development of recommendations that can improve routine physical healthcare within Adult Community Mental Health Teams at SLaM. Results: Data collection is underway at present. At the time of the conference, early findings will be available to discuss. Conclusions: An integrated approach to mind and body care is needed to reduce preventable deaths amongst people with SMI. This evaluation will seek to provide a framework that better equips staff to approach physical healthcare within a mental health setting.

Keywords: severe mental illness, physical healthcare, adult community mental health, nursing

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Authors: S. S. Pati, L. Herojit Singh, A. C. Oliveira, V. K. Garg

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Chitosan functionalized Fe3O4-Au core shell nanoparticles have been prepared using a two step wet chemical approach using NaBH4 as reducing agent for formation of Au inethylene glycol. X-ray diffraction studies shows individual phases of Fe3O4 and Au in the as prepared samples with crystallite size of 5.9 and 11.4 nm respectively. The functionalization of the core-shell nanostructure with Chitosan has been confirmed using Fourier transform infrared spectroscopy along with signatures of octahedral and tetrahedral sites of Fe3O4 below 600cm-1. Mössbauer spectroscopy shows decrease in particle-particle interaction in presence of Au shell (72% sextet) than pure oleic coated Fe3O4 nanoparticles (88% sextet) at room temperature. At 80K, oleic acid coated Fe3O4 shows only sextets whereas the Chitosan functionalized Fe3O4 and Chitosan functionalized Fe3O4@Au core shell show presence of 5 and 11% doublet, respectively.

Keywords: core shell, drug delivery, gold nanoparticles, magnetic nanoparticles

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Authors: M. D. Antoine

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When a child is diagnosed with an illness, condition, or developmental disorder, the process involved in understanding and accepting this diagnosis can be a very stressful and isolating experience for parents and families. The healthcare providers’ ability to effectively communicate in such situations represents a vital lifeline for parents. In this context, communication becomes a crucial element not only for getting through the period of grief but also for the future. We mobilized the five stages of grief model to summarize existing literature regarding the ways in which the experience ofan autism spectrum disorder diagnosis disclosurealigns with the experience of grief to explore how this can inform best practices for effective communication with parents through the diagnosis disclosure. Fifteen publications met inclusion criteria. Findings from the scoping review of empirical studies show that parents/families experience grief-like emotions during the diagnosis disclosure. However, grief is not an outcome of the encounter itself. In fact, the experience of the encounter can help mitigate the grief experience. The way parents/families receive and react to the ‘news’ depends on their preparedness, knowledge, and the support received through the experience. Individual communication skills, as well as policies and regulations, should be examined to alleviate adverse reactions in this context. These findings highlight the importance of further research into effective parent-provider communication strategies and their place in supporting quality autism care.

Keywords: autism spectrum disorder, autism spectrum disorder diagnosis, diagnosis disclosure, parent-provider communication, parental grief

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Authors: Kaous Samira

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The lack of hand hygiene can contribute to nosocomial infections, including Central-venous-catheter-related bloodstream infections (CRBSI). An investigation from severally hospitals examined the frequency of hand hygiene in an OR among perioperative staff members who did not perform a surgical scrub. Among 50 operations (120 hours) that were observed, only 2% of staff members performed hand hygiene practices upon entering the OR, and 8.4% of staff performed hand hygiene upon leaving the OR. In addition, when performing radial arterial catheter placement, 0% of staff members wore gloves. Another study (A1170) surveyed healthcare providers regarding hand hygiene compliance. All of the 107 providers surveyed agreed that they should maintain hand hygiene, and most respondents believed that their own compliance was high. The author suggests that the low compliance problem associated with hand hygiene worldwide is a behavioral one among healthcare providers that requires acknowledgment and change.

Keywords: aneshesia, investigation, IOP, SBP

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Authors: Yihenew Simegniew Birhan, Hsieh Chih Tsai

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The recent advancements in synthetic chemistry and nanotechnology fostered the development of different nanocarriers for enhanced intracellular delivery of pharmaceutical agents to tumor cells. Polymeric micelles (PMs), characterized by small size, appreciable drug loading capacity (DLC), better accumulation in tumor tissue via enhanced permeability and retention (EPR) effect, and the ability to avoid detection and subsequent clearance by the mononuclear phagocyte (MNP) system, are convenient to improve the poor solubility, slow absorption and non-selective biodistribution of payloads embedded in their hydrophobic cores and hence, enhance the therapeutic efficacy of chemotherapeutic agents. Recently, redox-responsive polymeric micelles have gained significant attention for the delivery and controlled release of anticancer drugs in tumor cells. In this study, we synthesized redox-responsive diselenide bond containing amphiphilic polymer, Bi(mPEG-PLGA)-Se₂ from mPEG-PLGA, and 3,3'-diselanediyldipropanoic acid (DSeDPA) using DCC/DMAP as coupling agents. The successful synthesis of the copolymers was verified by different spectroscopic techniques. Above the critical micelle concentration, the amphiphilic copolymer, Bi(mPEG-PLGA)-Se₂, self-assembled into stable micelles. The DLS data indicated that the hydrodynamic diameter of the micelles (123.9 ± 0.85 nm) was suitable for extravasation into the tumor cells through the EPR effect. The drug loading content (DLC) and encapsulation efficiency (EE) of DOX-loaded micelles were found to be 6.61 wt% and 54.9%, respectively. The DOX-loaded micelles showed initial burst release accompanied by sustained release trend where 73.94% and 69.54% of encapsulated DOX was released upon treatment with 6mM GSH and 0.1% H₂O₂, respectively. The biocompatible nature of Bi(mPEG-PLGA)-Se₂ copolymer was confirmed by the cell viability study. In addition, the DOX-loaded micelles exhibited significant inhibition against HeLa cells (44.46%), at a maximum dose of 7.5 µg/mL. The fluorescent microscope images of HeLa cells treated with 3 µg/mL (equivalent DOX concentration) revealed efficient internalization and accumulation of DOX-loaded Bi(mPEG-PLGA)-Se₂ micelles in the cytosol of cancer cells. In conclusion, the intelligent, biocompatible, and the redox stimuli-responsive behavior of Bi(mPEG-PLGA)-Se₂ copolymer marked the potential applications of diselenide-linked mPEG-PLGA micelles for the delivery and on-demand release of chemotherapeutic agents in cancer cells.

Keywords: anticancer drug delivery, diselenide bond, polymeric micelles, redox-responsive

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Authors: Stephanie Giordano, Rosa Plasencia

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In the USA, in 2013, public service systems such as Medicaid, aging, and disability systems undertook an effort to measure the quality of service delivery by examining the experiences and outcomes of those receiving public services. The goal of this effort was to develop a survey to measure the experiences and outcomes of those receiving public services, with the goal of measuring system performance for quality improvement. The performance indicators were developed through with input from directors of state aging and disability service systems, along with experts and stakeholders in the field across the United States. This effort, National Core Indicators –Aging and Disabilities (NCI-AD), grew out of National Core Indicators –Intellectual and Developmental Disabilities, an effort to measure developmental disability (DD) systems across the States. The survey tool and administration protocol underwent multiple rounds of testing and revision between 2013 and 2015. The measures in the final tool – called the Adult Consumer Survey (ACS) – emphasize not just important indicators of healthcare access and personal safety but also includes indicators of system quality based on person-centered outcomes. These measures indicate whether service systems support older adults and people with disabilities to live where they want, maintain relationships and engage in their communities and have choice and control in their everyday lives. Launched in 2015, the NCI-AD Adult Consumer Survey is now used in 23 states in the US. Surveys are conducted by NCI-AD trained surveyors via direct conversation with a person receiving public long-term services and supports (LTSS). Until 2020, surveys were only conducted in person. However, after a pilot to test the reliability of videoconference and telephone survey modes, these modes were adopted as an acceptable practice. The nature of the survey is that of a “guided conversation” survey administration allows for surveyor to use wording and terminology that is best understand by the person surveyed. The survey includes a subset of questions that may be answered by a proxy respondent who knows the person well if the person is receiving services in unable to provide valid responses on their own. Surveyors undergo a standardized training on survey administration to ensure the fidelity of survey administration. In addition to the main survey section, a Background Information section collects data on personal and service-related characteristics of the person receiving services; these data are typically collected through state administrative record. This information is helps provide greater context around the characteristics of people receiving services. It has also been used in conjunction with outcomes measures to look at disparity (including by race and ethnicity, gender, disability, and living arrangements). These measures of quality are critical for public service delivery systems to understand the unique needs of the population of older adults and improving the lives of older adults as well as people with disabilities. Participating states may use these data to identify areas for quality improvement within their service delivery systems, to advocate for specific policy change, and to better understand the experiences of specific populations of people served.

Keywords: quality of life, long term services and supports, person-centered practices, aging and disability research, survey methodology

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Authors: Daniel Klimovský

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Slovakia belongs to the most fragmented countries if one looks at its local government structure. The Slovak central governments implemented both broad devolution and fiscal decentralization some decades ago. However, neither territorial consolidation nor size categorization of local competences and powers has been implemented yet. Taking this fact into account, it is clear that the local governments are challenged not only by their citizens as customers but also by effectiveness as well as efficiency of delivered services. The paper is focused on behavior of the local governments in Slovakia and their approaches towards other local partners, including other local governments. Analysis of set of interviews shows that inter-municipal cooperation is the most common local partnership in Slovakia, but due to diversity of the local governments, this kind of cooperation leads to both intended and unintended outcomes. While in many cases the local governments are more efficient as well as effective in delivery of local services thanks to inter-municipal cooperation, there are many cases where inter-municipal cooperation fails, and it brings rather questionable or even negative outcomes.

Keywords: local governments, local partnerships, inter-municipal cooperation, delivery of local services

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Authors: Pankaj Kumar Kalita

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Ineffectiveness of formal institutional mechanisms such as official audit to improve public service delivery has been a serious concern to scholars working on governance reforms in developing countries. Scholars argue that public service delivery in local self-governing institutions can be improved through application of informal mechanisms such as social accountability. Social accountability has been reinforced with the engagement of citizens and civic organizations in the process of service delivery to reduce the governance gap in developing countries. However, there are challenges that may impede the scope of establishing social accountability initiatives in the performance of local self-governing institutions. This study makes an attempt to investigate the factors that may impede the scope of establishing social accountability, particularly in culturally heterogeneous societies like India. While analyzing the implementation of two rural development schemes by Panchayats, the local self-governing institutions functioning in rural Assam in India, this study argues that the scope of establishing social accountability in the performance of local self-governing institutions, particularly in culturally heterogeneous societies in developing countries will be impeded by the absence of inter-caste and inter-religion networks. Data has been collected from five selected districts of Assam using in-depth interview method and survey method. The study further contributes to the debates on 'good governance' and citizen-centric approaches in developing countries.

Keywords: citizen engagement, local self-governing institutions, networks, social accountability

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Authors: Rania Albsoul, Muhammad Ahmed Alshyyab, Baraa Ayed Al Odat, Nermeen Borhan Al Dwekat, Batool Emad Al-masri, Fatima Abdulsattar Alkubaisi, Salsabil Awni Flefil, Majd Hussein Al-Khawaldeh, Ragad Ayman Sa’ed, Maha Waleed Abu Ajamieh, Gerard Fitzgerald

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Purpose: The purpose of this paper is to explore the perceptions of operating room staff towards the use of the World Health Organization Surgical Safety Checklist in a tertiary hospital in Jordan. Design/methodology/approach: This was a qualitative descriptive study. Semi-structured interviews were conducted with a purposeful sample of 21 healthcare staff employed in the operating room (nurses, residents, surgeons, and anaesthesiologists). The interviews were conducted in the period from October to December 2021. Thematic analysis was used to analyse the data. Findings: Three main themes emerged from data analysis, namely compliance with the surgical safety checklist, the impact of the surgical safety checklist, and barriers and facilitators to the use of the surgical safety checklist. The use of the checklist was seen as enabling staff to communicate effectively and thus accomplish patient safety and positive outcomes. The perceived barriers to compliance included excessive workload, congestion, and lack of training and awareness. Enhanced training and education were thought to improve the utilization of the surgical safety checklist and help enhance awareness about its importance. Originality/value: While steps to utilize the surgical safety checklist by the operation room personnel may seem simple, the quality of its administration is not necessarily robust. There are several challenges to consistent, complete, and effective administration of the surgical safety checklist by the surgical team members. Healthcare managers must employ interventions to eliminate barriers to and offer facilitators of adherence to the application of the surgical safety checklist, therefore promoting quality healthcare and patient safety.

Keywords: patient safety, surgical safety checklist, compliance, utility, operating room, quality healthcare, communication, teamwork

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Authors: Asma Ammar, Nabiha Bouafia , Asma BenCheikh, Mohamed Mahjoub, Olfa Ezzi, Wadiaa Bannour, Radhia Helali, Mansour Njah

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Background: The objective of the present study was to identify factors associated with vaccination against Hepatitis B virus (HBV) among healthcare workers (HWs) in the University Hospital Center (UHC) Farhat Hached Sousse, Tunisia. Methods: We conducted a descriptive cross-sectional study all licensed physicians (n= 206) and a representative sample of paramedical staff (n= 372) exercising at UHC Hached Sousse (Tunisia) during two months (January and February 2014). Data were collected using a self-administered and pre-tested questionnaire, which composed by 21 questions. In order to determinate factors associated with vaccination against hepatitis B among HWs, this questionnaire was based on the Health Belief Model, one of the most classical behavior theories. Logistic regression with the stepwise method of Hosmer and Lemeshow was used to identify the determinants of the use of vaccination against HBV. Results: The response rates were 79.8%. Fifty two percent believe that HBV is frequent in our healthcare units and 60.6% consider it a severe infection. The prevalence of HWs vaccination was 39%, 95% CI [34.49%; 43.5%]. In multivariate analysis, determinants of the use of vaccination against HBV among HWs were young age (p=10-4), male gender (p = 0. 006), high or very high importance accorded to health (p = 0.035), perception membership in a risk group for HBV infection (p = 0.038) and very favorable or favorable opinion about vaccination against HVB (p=10-4). Conclusion: The results of our study should be considered in any strategy for preventing VHB infection in HWs. In the mean time, coverage with standard vaccines should be improved also by supplying complete information on the risks of VHB infection and on the safety and efficacy of vaccination.

Keywords: Hepatitis B virus, healthcare workers, prevalence, vaccination

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Authors: Sinead Impey, Damon Berry, Selma Furtado, Miriam Galvin, Loretto Grogan, Orla Hardiman, Lucy Hederman, Mark Heverin, Vincent Wade, Linda Douris, Declan O'Sullivan, Gaye Stephens

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Healthcare is a knowledge-rich environment. This knowledge, while valuable, is not always accessible outside the borders of individual clinics. This research aims to address part of this problem (at a study site) by constructing a maximal data set (knowledge artefact) for motor neurone disease (MND). This data set is proposed as an initial knowledge base for a concurrent project to develop an MND patient data platform. It represents the domain knowledge at the study site for the duration of the research (12 months). A knowledge elicitation method was also developed from the lessons learned during this process - the WICKED method. WICKED is an anagram of the words: eliciting and confirming data, information, knowledge, wisdom. But it is also a reference to the concept of wicked problems, which are complex and challenging, as is eliciting expert knowledge. The method was evaluated at a second site, and benefits and limitations were noted. Benefits include that the method provided a systematic way to manage data, information, knowledge and wisdom (DIKW) from various sources, including healthcare specialists and existing data sets. Limitations surrounded the time required and how the data set produced only represents DIKW known during the research period. Future work is underway to address these limitations.

Keywords: healthcare, knowledge acquisition, maximal data sets, action design science

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Authors: Merve Kadioğlu, Nevin H. Şahin

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Purpose: This research is organized to determine the influence of the web-based learning program. The program has been developed to gain information about normal delivery skill that is one of the topics of nursing students who take the woman health and illness. Material and Methods: The methodology of this study was applied as pre-test post-test single-group quasi-experimental. The pilot study consisted of 28 nursing student study groups who agreed to participate in the study. The findings were gathered via web-based technologies: student information form, information evaluation tests, Web Based Training Material Evaluation Scale and web-based learning environment feedback form. In the analysis of the data, the percentage, frequency and Wilcoxon Signed Ranks Test were used. The Web Based Instruction Program was developed in the light of full learning model, Mayer's research-based multimedia development principles and Gagne's Instructional Activities Model. Findings: The average scores of it was determined in accordance with the web-based educational material evaluation scale: ‘Instructional Suitability’ 4.45, ‘Suitability to Educational Program’ 4.48, ‘Visual Adequacy’ 4.53, ‘Programming Eligibility / Technical Adequacy’ 4.00. Also, the participants mentioned that the program is successful and useful. A significant difference was found between the pre-test and post-test results of the seven modules (p < 0.05). Results: According to pilot study data, the program was rated ‘very good’ by the study group. It was also found to be effective in increasing knowledge about normal labor.

Keywords: normal delivery, web-based learning, nursing students, e-learning

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Authors: Deepak Kakde, Steve Howdle, Derek Irvine, Cameron Alexander

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The poor aqueous solubility is one of the major obstacles in the formulation development of many drugs. Around 70% of drugs are poorly soluble in aqueous media. In the last few decades, micelles have emerged as one of the major tools for solubilization of hydrophobic drugs. Micelles are nanosized structures (10-100nm) obtained by self-assembly of amphiphilic molecules into the water. The hydrophobic part of the micelle forms core which is surrounded by a hydrophilic outer shell called corona. These core-shell structures have been used as a drug delivery vehicle for many years. Although, the utility of micelles have been reduced due to the lack of sustainable materials. In the present study, a novel methoxy poly(ethylene glycol)-b-poly(ε-decalactone) (mPEG-b-PεDL) copolymer was synthesized by ring opening polymerization (ROP) of renewable ε-decalactone (ε-DL) monomers on methoxy poly(ethylene glycol) (mPEG) initiator using 1,5,7-triazabicyclo[4.4.0]dec-5-ene (TBD) as a organocatalyst. All the reactions were conducted in bulk to avoid the use of toxic organic solvents. The copolymer was characterized by nuclear magnetic resonance spectroscopy (NMR), gel permeation chromatography (GPC) and differential scanning calorimetry (DSC).The mPEG-b-PεDL block copolymeric micelles containing indomethacin (IND) were prepared by nanoprecipitation method and evaluated as drug delivery vehicle. The size of the micelles was less than 40nm with narrow polydispersity pattern. TEM image showed uniform distribution of spherical micelles defined by clear surface boundary. The indomethacin loading was 7.4% for copolymer with molecular weight of 13000 and drug/polymer weight ratio of 4/50. The higher drug/polymer ratio decreased the drug loading. The drug release study in PBS (pH7.4) showed a sustained release of drug over a period of 24hr. In conclusion, we have developed a new sustainable polymeric material for IND delivery by combining the green synthetic approach with the use of renewable monomer for sustainable development of polymeric nanomedicine.

Keywords: dopolymer, ε-decalactone, indomethacin, micelles

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Authors: Karim Hajjar, Luis Lillo, Diego Martinez, Manuel Hermosilla, Nicholas Risko

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Objectives: This study examines the relationship between universal health coverage (UCH) and the burden of emergency diseases at a global level. Methods: Data on Disability-Adjusted Life Years (DALYs) from emergency conditions were extracted from the Institute for Health Metrics and Evaluation (IHME) database for the years 2015 and 2019. Data on UHC, measured using two variables, 1) coverage of essential health services and 2) proportion of population spending more than 10% of household income on out-of-pocket health care expenditure, was extracted from the World Bank Database for years preceding our outcome of interest. Linear regression was performed, analyzing the effect of the UHC variables on the DALYs of emergency diseases, controlling for other variables. Results: A total of 133 countries were included. 44.4% of the analyzed countries had coverage of essential health services index of at least 70/100, and 35.3% had at least 10% of their population spend greater than 10% of their household income on healthcare. For every point increase in the coverage of essential health services index, there was a 13-point reduction in DALYs of emergency medical diseases (95% CI -16, -11). Conversely, for every percent decrease in the population with large household expenditure on healthcare, there was a 0.48 increase in DALYs of emergency medical diseases (95% CI -5.6, 4.7). Conclusions: After adjusting for multiple variables, an increase in coverage of essential health services was significantly associated with improvement in DALYs for emergency conditions. There was, however, no association between catastrophic health expenditure and DALYs.

Keywords: emergency medicine, universal healthcare, global health, health economics

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Authors: Sheldon McCall, Miao Yu, Liyun Gong, Shigang Yue, Stefanos Kollias

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Falls are a significant health concern for older adults globally, and prompt identification is critical to providing necessary healthcare support. Our study proposes a new fall detection method using computer vision based on modern deep learning techniques. Our approach involves training a trans- former model on a large 2D pose dataset for general action recognition, followed by transfer learning. Specifically, we freeze the first few layers of the trained transformer model and train only the last two layers for fall detection. Our experimental results demonstrate that our proposed method outperforms both classical machine learning and deep learning approaches in fall/non-fall classification. Overall, our study suggests that our proposed methodology could be a valuable tool for identifying falls.

Keywords: healthcare, fall detection, transformer, transfer learning

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Authors: Fei Ye, Åsa Barrefelt, Manuchehr Abedi-Valugerdi, Khalid M. Abu-Salah, Salman A. Alrokayan, Mamoun Muhammed, Moustapha Hassan

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With appropriate encapsulation in functional nanoparticles drugs are more stable in physiological environment and the kinetics of the drug can be more carefully controlled and monitored. Furthermore, targeted drug delivery can be developed to improve chemotherapy in cancer treatment, not only by enhancing intracellular uptake by target cells but also by reducing the adverse effects in non-target organs. Inorganic imaging agents, delivered together with anti-cancer drugs, enhance the local imaging contrast and provide precise diagnosis as well as evaluation of therapy efficacy. We have developed biodegradable polymeric vesicles as a nanocarrier system for multimodal bio-imaging and anticancer drug delivery. The poly (lactic-co-glycolic acid) PLGA) vesicles were fabricated by encapsulating inorganic imaging agents of superparamagnetic iron oxide nanoparticles (SPION), manganese-doped zinc sulfide (MN:ZnS) quantum dots (QDs) and the anticancer drug busulfan into PLGA nanoparticles via an emulsion-evaporation method. T2-weighted magnetic resonance imaging (MRI) of PLGA-SPION-Mn:ZnS phantoms exhibited enhanced negative contrast with r2 relaxivity of approximately 523 s-1 mM-1 Fe. Murine macrophage (J774A) cellular uptake of PLGA vesicles started fluorescence imaging at 2 h and reached maximum intensity at 24 h incubation. The drug delivery ability PLGA vesicles was demonstrated in vitro by release of busulfan. PLGA vesicles degradation was studied in vitro, showing that approximately 32% was degraded into lactic and glycolic acid over a period of 5 weeks. The biodistribution of PLGA vesicles was investigated in vivo by MRI in a rat model. Change of contrast in the liver could be visualized by MRI after 7 min and maximal signal loss detected after 4 h post-injection of PLGA vesicles. Histological studies showed that the presence of PLGA vesicles in organs was shifted from the lungs to the liver and spleen over time.

Keywords: biodegradable polymers, multifunctional nanoparticles, quantum dots, anticancer drugs

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Authors: H. S. Kumara

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The rapid process of urbanization and the growing number of the metropolitan cities and its region call for better governance in India. This article attempts to argue that spatial planning really matters for measuring the governance at metropolitan scale. These study explore to metropolitan governance and spatial planning and its interrelationship issues, concepts and evolution of spatial planning in India and critically examines the multi actors’ scenario for measuring metropolitan governance by means of spatial planning in context with reviewing various master plans, concept of multi-actors viewpoint on role of spatial planning related to zoning regulations, master plan implementations and effective service delivery issues. This paper argues and concludes that the spatial planning of Bangalore directly impact on measuring metropolitan governance.

Keywords: metropolitan governance, spatial planning, service delivery, multi-actors’, opinion survey, master plan

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Authors: Gulhan Sen

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Disasters could result in many deaths and injuries. In these difficult times, accessible resources are limited, demand and supply balance is distorted, and there is a need to make urgent interventions. Disproportionateness between accessible resources and intervention capacity makes triage a necessity in every stage of disaster response. Healthcare professionals, who are in charge of triage, have to evaluate swiftly and make ethical decisions about which patients need priority and urgent intervention given the limited available resources. For such critical times in disaster triage, 'doing the greatest good for the greatest number of casualties' is adopted as a code of practice. But there is no guide for healthcare professionals about ethical decision-making during disasters, and this study is expected to use as a source in the preparation of the guide. This study aimed to examine whether the qualities healthcare professionals in Izmir related to disaster triage were adequate and whether these qualities influence their capacity to make ethical decisions. The researcher used a survey developed for data collection. The survey included two parts. In part one, 14 questions solicited information about socio-demographic characteristics and knowledge levels of the respondents on ethical principles of disaster triage and allocation of scarce resources. Part two included four disaster scenarios adopted from existing literature and respondents were asked to make ethical decisions in triage based on the provided scenarios. The survey was completed by 215 healthcare professional working in Emergency-Medical Stations, National Medical Rescue Teams and Search-Rescue-Health Teams in Izmir. The data was analyzed with SPSS software. Chi-Square Test, Mann-Whitney U Test, Kruskal-Wallis Test and Linear Regression Analysis were utilized. According to results, it was determined that 51.2% of the participants had inadequate knowledge level of ethical principles of disaster triage and allocation of scarce resources. It was also found that participants did not tend to make ethical decisions on four disaster scenarios which included ethical dilemmas. They stayed in ethical dilemmas that perform cardio-pulmonary resuscitation, manage limited resources and make decisions to die. Results also showed that participants who had more experience in disaster triage teams, were more likely to make ethical decisions on disaster triage than those with little or no experience in disaster triage teams(p < 0.01). Moreover, as their knowledge level of ethical principles of disaster triage and allocation of scarce resources increased, their tendency to make ethical decisions also increased(p < 0.001). In conclusion, having inadequate knowledge level of ethical principles and being inexperienced affect their ethical decision-making during disasters. So results of this study suggest that more training on disaster triage should be provided on the areas of the pre-impact phase of disaster. In addition, ethical dimension of disaster triage should be included in the syllabi of the ethics classes in the vocational training for healthcare professionals. Drill, simulations, and board exercises can be used to improve ethical decision making abilities of healthcare professionals. Disaster scenarios where ethical dilemmas are faced should be prepared for such applied training programs.

Keywords: disaster triage, medical ethics, ethical principles of disaster triage, ethical decision-making

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Authors: Lena Ernstgård, Aishwarya M. Dwivedi, Johan Lundström, Gunnar Johanson

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A simple inexpensive olfactometer was constructed to enable valid measures of detection threshold of low concentrations of vapours of chemicals. The delivery system consists of seven syringe pumps, each connected to a Tedlar bag containing a predefined concentration of the test chemical in the air. The seven pumps are connected to a 8-way mixing valve which in turn connects to a birhinal nose piece. Chemical vapor of known concentration is generated by injection of an appropriate amount of the test chemical into a Tedlar bag with a known volume of clean air. Complete vaporization is assured by gentle heating of the bag from the outside with a heat flow. The six test concentrations are obtained by adding different volumes from the starting bag to six new Tedlar bags with known volumes of clean air. One bag contains clean air only. Thus, six different test concentrations and clean air can easily be tested in series by shifting the valve to new positions. Initial in-line measurement with a photoionization detector showed that the delivery system quickly responded to a shift in valve position. Thus 90% of the desired concentration was reached within 15 seconds. The concentrations in the bags are verified daily by gas chromatography. The stability of the system in terms of chemical concentration is monitored in real time by means of a photo-ionization detector. To determine lateralization thresholds, an additional pump supplying clean air is added to the delivery system in a way so that the nostrils can be separately and interchangeably be exposed to clean air and test chemical. Odor and lateralization thresholds were determined for three aldehydes; acrolein, crotonaldehyde, and hexanal in 20 healthy naïve individuals. Aldehydes generally have a strong odour, and the selected aldehydes are also considered to be irritating to mucous membranes. The median odor thresholds of the three aldehydes were 0.017, 0.0008, and 0.097 ppm, respectively. No lateralization threshold could be identified for acrolein, whereas the medians for crotonaldehyde and hexanal were 0.003 and 0.39 ppm, respectively. In conclusion, we constructed a simple, inexpensive olfactometer that allows for stable and easily measurable concentrations of vapors of the test chemical. Our test with aldehydes demonstrates that the system produces valid detection among volunteers in terms of odour and lateralization thresholds.

Keywords: irritation, odour delivery, olfactometer, smell

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Authors: Songul Aktas, Turkan Pasinlioglu, Kiymet Yesilcicek Calik

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Introduction: Emphatic approach during labor increases both quality of care and birth satisfaction of mothers. Besides; maternal satisfaction statements and expressions about midwives who assist labor contribute to a positive birth perception and wish to give vaginal delivery again. Aim: The study aimed at investigating the effect of empathy training given to midwives on mothers’ satisfaction with midwives and their birth perception. Material/Method: This experimental study was undertaken between February 2013 and January 2014 at a public hospital in Trabzon Province. The population of the study was composed of mothers who gave vaginal delivery and the sample was composed of 222 mothers determined with power analyzes. Ethical approval and written informed consents were obtained. Mothers who were assisted by midwives during 1st, 2nd and 3rd phases of delivery and first two postpartum hours were included. Empathy training given to midwives included didactic narration, creative drama, psychodrama techniques and lasted 32 hours. The data were collected before the empathy training (BET), right after empathy training (RAET) and 8 weeks later after birth (8WLAB). Mothers were homogenous in terms of socio-demographic, obstetric characteristics. Data were collected with a questionnaire and were analyzed with Chi-square tests. Findings: Rate of mother’s satisfaction with midwives was 36.5% in BET, 81.1% in RAET and 75.7% in 8WLAB. Key mother’s satisfaction with midwives were as follows: 27.6% of mothers told that midwives were “smiling-kind” in BET, 39.6% of them in RAET and 33.7% of them in 8WLAB; 31% of mothers told that midwives were “understanding” in BET, 38.2% of them in RAET and 33.7% of them in 8WLAB; 15.7% of mothers told that midwives were “reassuring” in BET, 44.9% of them in RAET and 39.3% of them in 8WLAB;19.5% of mothers told that midwives were “encouraging and motivating” in BET, 39.8% of them in RAET and 19.8% of mothers told that midwives were “informative” in BET, 45.6% of them in RAET and 35.1% of them in 8WLAB (p<0.05). Key mother’s dissatisfaction with midwives were as follows: 55.3% of mothers told that midwives were “poorly-informed” in BET, 17% of them in RAET and 27.7% of them in 8WLAB; 56.9% of mothers told that midwives were “poorly-listening” in BET, 17.6% of them in RAET and 25.5% of them in 8WLAB; 53.2% of mothers told that midwives were “judgmental-embarrassing” in BET, 17% of them in RAET and 29.8% of them in 8WLAB; 56.2% of mothers told that midwives had “fierce facial expressions” in BET, 15.6% of them in RAET and 28.1% of them in 8WLAB. Rates of mothers’ perception that labor was “easy” were 8.1% in BET, 21.6% in RAET and 13.5% in 8WLAB and rates of mothers’ perception that labor was “very difficult and tiring” were 41.9% in BET, 5.4% in RAET and 13.5% in 8WLAB (p<0.05). Conclusion: The effect of empathy training given to midwives upon statements that described mothers’ satisfaction with midwives and their birth perception was positive. Note: This study was financially funded by TUBİTAK project with number 113S672.

Keywords: empathy training, labor perception, mother’s satisfaction with midwife, vaginal delivery

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Authors: Ankita Singh, Chandan Gorain, Amirul I. Mallick

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Successful adherence of the mucosal epithelial cells is the key early step for Campylobacter jejuni pathogenesis (C. jejuni). A set of Surface Exposed Colonization Proteins (SECPs) are among the major factors involved in host cell adherence and invasion of C. jejuni. Among them, constitutively expressed surface-exposed lipoprotein adhesin of C. jejuni, JlpA, interacts with intestinal heat shock protein 90 (hsp90α) and contributes in disease progression by triggering pro-inflammatory response via activation of NF-κB and p38 MAP kinase pathway. Together with its ability to express in the bacterial surface, higher sequence conservation and predicted predominance of several B cells epitopes, JlpA protein reserves its potential to become an effective vaccine candidate against wide range of Campylobacter sps including C. jejuni. Given that chickens are the primary sources for C. jejuni and persistent gut colonization remain as major cause for foodborne pathogenesis to humans, present study explicitly used chickens as model to test the immune-protective efficacy of JlpA protein. Taking into account that gastrointestinal tract is the focal site for C. jejuni colonization, to extrapolate the benefit of mucosal (intragastric) delivery of JlpA protein, a food grade Nisin inducible Lactic acid producing bacteria, Lactococcus lactis (L. lactis) was engineered to express recombinant JlpA protein (rJlpA) in the surface of the bacteria. Following evaluation of optimal surface expression and functionality of recombinant JlpA protein expressed by recombinant L. lactis (rL. lactis), the immune-protective role of intragastric administration of live rL. lactis was assessed in commercial broiler chickens. In addition to the significant elevation of antigen specific mucosal immune responses in the intestine of chickens that received three doses of rL. lactis, marked upregulation of Toll-like receptor 2 (TLR2) gene expression in association with mixed pro-inflammatory responses (both Th1 and Th17 type) was observed. Furthermore, intragastric delivery of rJlpA expressed by rL. lactis, but not the injectable form, resulted in a significant reduction in C. jejuni colonization in chickens suggesting that mucosal delivery of live rL. lactis expressing JlpA serves as a promising vaccine platform to induce strong immune-protective responses against C. jejuni in chickens.

Keywords: chickens, lipoprotein adhesion of Campylobacter jejuni, immuno-protection, Lactococcus lactis, mucosal delivery

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Authors: Syed Abdul Rehman Khan

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In today’s world, information sharing plays a vital role in successful operations of supply chain; and boost to the profitability of the organizations (end-to-end supply chains). Many researches have been completed over the role of information sharing in supply chain. In this research article, we will investigate the ‘how information sharing can boost profitability & productivity of the organization; for this purpose, we have developed one conceptual model and check to that model through collected data from companies. We sent questionnaire to 369 companies; and will filled form received from 172 firms and the response rate was almost 47%. For the data analysis, we have used Regression in (SPSS software) In the research findings, our all hypothesis has been accepted significantly and due to the information sharing between suppliers and manufacturers ‘quality of material and timely delivery’ increase and also ‘collaboration & trust’ will become more stronger and these all factors will lead to the company’s profitability directly and in-directly. But unfortunately, companies could not avail the all fruitful benefits of information sharing due to the fear of ‘compromise confidentiality or leakage of information’.

Keywords: collaboration, information sharing, risk factor, timely delivery

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Authors: Anil Bhandari, Imran Khan Pathan, Peeyush K. Sharma, Rakesh K. Patel, Suresh Purohit

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The purpose of this study was to prepare time and pH dependent release tablets of Ayurvedic Churna formulation and evaluate their advantages as colon targeted drug delivery system. The Vidangadi Churna was selected for this study which contains Embelin and Gallic acid. Embelin is used in Helminthiasis as therapeutic agent. Embelin is insoluble in water and unstable in gastric environment so it was formulated in time and pH dependent tablets coated with combination of two polymers Eudragit L100 and ethyl cellulose. The 150mg of core tablet of dried extract and lactose were prepared by wet granulation method. The compression coating was used in the polymer concentration of 150mg for both the layer as upper and lower coating tablet was investigated. The results showed that no release was found in 0.1 N HCl and pH 6.8 phosphate buffers for initial 5 hours and about 98.97% of the drug was released in pH 7.4 phosphate buffer in total 17 hours. The in vitro release profiles of drug from the formulation could be best expressed first order kinetics as highest linearity (r2= 0.9943). The results of the present study have demonstrated that the time and pH dependent tablets system is a promising vehicle for preventing rapid hydrolysis in gastric environment and improving oral bioavailability of Embelin and Gallic acid for treatment of Helminthiasis.

Keywords: embelin, gallic acid, Vidangadi Churna, colon targeted drug delivery

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Authors: Anna Paola Micheli, Carmelo Intrisano, Anna Maria Calce

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This research focused on the capability of health tourism to improve the economic and financial performance of healthcare companies. It is assumed that health tourism companies have better profitability and financial efficiency because they can also count on cross-border demand differently from no health tourism companies. A three-level gap analysis was conducted: the first concerns health tourism companies located in Italy and in the other EU28 states; in the second Italian and EU28, no health tourism companies were compared; the third level is about the Italian system with a comparison between health tourism and no health tourism companies. Findings highlighted that Italian healthcare companies have better profitability performance if compared to European ones, but they present weaknesses in the financial position given the illiquidity and excessive leverage. Furthermore, studying the Italian system, we found that health tourism companies are more profitable than no health tourism companies.

Keywords: financial performance, gap analysis, health tourism, profitability performance, value creation

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Authors: Rosemary Saunders, Courtney Glass, Karla Seaman, Karen Gullick, Julie Andrew, Anne Wilkinson, Ashwini Davray

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Current literature demonstrates that most Australians receive end-of-life care in a hospital setting, despite most hoping to die within their own home. The necessity for high quality end-of-life care has been emphasised by the Australian Commission on Safety and Quality in Health Care and the National Safety and Quality in Health Services Standards depict the requirement for comprehensive care at the end of life (Action 5.20), reinforcing the obligation for continual organisational assessment to determine if these standards are suitably achieved. Limited research exploring clinical staff perspectives of end-of-life care delivery has been conducted within an Australian private health context. This study aimed to investigate clinical staff member perceptions of end-of-life care delivery at a private hospital in Western Australia. The study comprised of a multi-faceted mixed-methods methodology, part of a larger study. Data was obtained from clinical staff utilising surveys and focus groups. A total of 133 questionnaires were completed by clinical staff, including registered nurses (61.4%), enrolled nurses (22.7%), allied health professionals (9.9%), non-palliative care consultants (3.8%) and junior doctors (2.2%). A total of 14.7% of respondents were palliative care ward staff members. Additionally, seven staff focus groups were conducted with physicians (n=3), nurses (n=26) and allied health professionals including social workers (n=1), dietitians (n=2), physiotherapists (n=5) and speech pathologists (n=3). Key findings from the surveys highlighted that the majority of staff agreed it was part of their role to talk to doctors about the care of patients who they thought may be dying, and recognised the importance of communication, appropriate training and support for clinical staff to provide quality end-of-life care. Thematic analysis of the qualitative data generated three key themes: creating the setting which highlighted the importance of adequate resourcing and conducive physical environments for end-of-life care and to support staff and families; planning and care delivery which emphasised the necessity for collaboration between staff, families and patients to develop care plans and treatment directives; and collaborating in end-of-life care, with effective communication and teamwork leading to achievable care delivery expectations. These findings contribute to health professionals better understanding of end-of-life care provision and the importance of collaborating with patients and families in care delivery. It is crucial that health care providers implement strategies to overcome gaps in care, so quality end-of-life care is provided. Findings from this study have been translated into practice, with the development and implementation of resources, training opportunities, support networks and guidelines for the delivery of quality end-of-life care.

Keywords: clinical staff, end-of-life care, mixed-methods, private hospital.

Procedia PDF Downloads 155