Search results for: balance in patient

Authors: Butta Singh

Abstract:

This paper presents a chaotic map based approach for secured embedding of patient’s confidential data in electrocardiogram (ECG) signal. The chaotic map generates predefined locations through the use of selective control parameters. The sample value difference method effectually hides the confidential data in ECG sample pairs at these predefined locations. Evaluation of proposed method on all 48 records of MIT-BIH arrhythmia ECG database demonstrates that the embedding does not alter the diagnostic features of cover ECG. The secret data imperceptibility in stego-ECG is evident through various statistical and clinical performance measures. Statistical metrics comprise of Percentage Root Mean Square Difference (PRD) and Peak Signal to Noise Ratio (PSNR). Further, a comparative analysis between proposed method and existing approaches was also performed. The results clearly demonstrated the superiority of proposed method.

Keywords: chaotic maps, ECG steganography, data embedding, electrocardiogram

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Authors: R. Hassan, J. Duncombe, E. Darke, A. Dias, K. Anderson, R. G. Middleton

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Background: NHS England has set itself the task of delivering a “Net Zero” National Health service by 2040. It is incumbent upon all health care practioners to work towards this goal. Orthopaedic surgeons are no exception. Distal radial fractures are the most common fractures sustained by the adult population. However, studiesare shortcoming on individual patient experience. The aim of this study was to assess the patient’ssatisfaction and outcomes with woodcast used in the conservative management of distal radius fractures. Methods: For all patients managed with woodcast in our unit, we undertook a structured questionnairethat included the Patient Rated Wrist Evaluation (PRWE) score, The EQ-5D-5L score, and the pain numerical score at the time of injury and six weeks after. Results: 30 patients were initially managed with woodcast.80% of patients tolerated woodcast for the full duration of their treatment. Of these, 20% didn’t tolerate woodcast and had their casts removed within 48 hours. Of the remaining, 79.1% were satisfied about woodcast comfort, 66% were very satisfied about woodcast weight, 70% were satisfied with temperature and sweatiness, 62.5% were very satisfied about the smell/odour, and 75% were satisfied about the level of support woodcast provided. During their treatment, 83.3% of patients rated their pain as five or less. Conclusion: For those who completed their treatment in woodcast, none required any further intervention or utilised the open appointment because of ongoing wrist problems. In conclusion, when woodcast is tolerated, patients’ satisfaction and outcome levels were good. However, we acknowledged 20% of patients in our series were not able to tolerate woodacst, Therefore, we suggest a comparison between the widely used synthetic plaster of Pariscasting and woodcast to come in order.

Keywords: distal radius fractures, ecological cast, sustainability, woodcast

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Authors: Erika Humphreys

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The effectiveness of treating anxiety with Reiki is explored within ten quantitative studies. The methodology utilized for a critical appraisal and systematic review of the literature is explained with inclusion and exclusion criteria. The theoretical framework for the project is grounded in the work of Hildegard Peplau, whose nursing theory based on the therapeutic use of self is foundational for Reiki implementation. A thorough critique of the literature is conducted for key components of robustness and believability. This critique is conducted using a structured guide addressing synthesized strengths and weaknesses of the body of literature. A synthesis of the literature explores the findings of the studies. This synthesis reports on Reiki’s effectiveness in treating anxiety within a variety of patient settings and populations, its effect on subscales of anxiety, physiological manifestations of anxiety, and pain associated with anxiety. Cultural considerations affecting Reiki’s potential effectiveness are discussed. Gaps in the literature are examined, including the studies’ narrow sample population, lack of participant exclusionary factors for controlled outcome data, and the lack of studies across time. Implications for future research are discussed with recommendations for expanded research that includes a broader variety of settings, age groups, and patient diagnoses, including anxiety disorders, for research data that is transferable. Implications for further practice for the advanced practice registered nurse (APRN) are explored, with the potential benefits for both providers and patients, including improved patient satisfaction and expansion of provider treatment modalities.

Keywords: Reiki, anxiety, complementary alternative medicine, pandemic

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Authors: Sarah Hazelwood, Janice Hay

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Methoxyflurane is an inhaled analgesic administered via a disposable inhaler, which has been used in Australia for 40 years for the management of pain in children & adults. However, there is a lack of data for methoxyflurane as a frontline analgesic medication within the emergency department (ED). This study will investigate the usefulness of methoxyflurane in a private inner-city ED. The study concluded that the inclusion of all key stakeholders in the prescribing, administering & use of this new process led to comprehensive uptake & vastly positive outcomes for consumer & health professionals. Method: A 12-week prospective pilot study was completed utilizing patients presenting to the ED in pain (numeric pain rating score > 4) that fit the requirement of methoxyflurane use (as outlined in the Australian Prescriber information package). Nurses completed a formatted spreadsheet for each interaction where methoxyflurane was used. Patient demographics, day, time, initial numeric pain score, analgesic response time, the reason for use, staff concern (free text), & patient feedback (free text), & discharge time was documented. When clinical concern was raised, the researcher retrieved & reviewed patient notes. Results: 140 methoxyflurane inhalers were used. 60% of patients were 31 years of age & over (n=82) with 16% aged 70+. The gender split; 51% male: 49% female. Trauma-related pain (57%) saw the highest use of administration, with the evening hours (1500-2259) seeing the greatest numbers used (39%). Tuesday, Thursday & Sunday shared the highest daily use throughout the study. A minimum numerical pain score of 4/10 (n=13, 9%), with the ranges of 5 - 7/10 (moderate pain) being given by almost 50% of patients. Only 3 instances of pain scores increased post use of methoxyflurane (all other entries showed pain score < initial rating). Patients & staff noted obvious analgesic response within 3 minutes (n= 96, 81%, of administration). Nurses documented a change in patient vital signs for 4 of the 15 patient-related concerns; the remaining concerns were due to “gagging” on the taste, or “having a coughing episode”; one patient tried to leave the department before the procedure was attended (very euphoric state). Upon review of the staff concerns – no adverse events occurred & return to therapeutic vitals occurred within 10 minutes. Length of stay for patients was compared with similar presentations (such as dislocated shoulder or ankle fracture) & saw an average 40-minute decrease in time to discharge. Methoxyflurane treatment was rated “positively” by > 80% of patients – with remaining feedback related to mild & transient concerns. Staff similarly noted a positive response to methoxyflurane as an analgesic & as an added tool for frontline analgesic purposes. Conclusion: Methoxyflurane should be used on suitable patient presentations requiring immediate, short term pain relief. As a highly portable, non-narcotic avenue to treat pain this study showed obvious therapeutic benefit, positive feedback, & a shorter length of stay in the ED. By partnering with key stake holders, this study determined methoxyflurane use decreased work load, decreased wait time to analgesia, and increased patient satisfaction.

Keywords: analgesia, benefits, emergency, methoxyflurane

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Authors: Chia-Ying Lin

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This paper explains how to enhance doctor-patient communication and nurse-patient communication through multiple intelligence signing methods and user-centered. It is hoped that through the implementation of the "electronic consent", the problems faced by the paper consent can be solved: storage methods, resource utilization, convenience, correctness of information, integrated management, statistical analysis and other related issues. Make better use and allocation of resources to provide better medical quality. First, invite the ｍedical records department to assist in the inventory of paper consent in the hospital: organising, classifying, merging, coding, and setting. Second, plan the electronic consent configuration file: set the form number, consent form group, fields and templates, and the corresponding doctor's order code. Next, Summarize four types of rapid methods of electronic consent: according to the doctor's order, according to the medical behavior, according to the schedule, and manually generate the consent form. Finally, system promotion and adjustment: form an "electronic consent promotion team" to improve, follow five major processes: planning, development, testing, release, and feedback, and invite clinical units to raise the difficulties faced in the promotion, and make improvements to the problems. The electronic signature rate of the whole hospital will increase from 4% in January 2022 to 79% in November 2022. Use the saved resources more effectively, including: reduce paper usage (reduce carbon footprint), reduce the cost of ink cartridges, re-plan and use the space for paper medical records, and save human resources to provide better services. Through the introduction of information technology and technology, the main spirit of "lean management" is implemented. Transforming and reengineering the process to eliminate unnecessary waste is also the highest purpose of this project.

Keywords: smart signature, electronic consent, electronic medical records, user-centered, doctor-patient communication, nurse-patient communication

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Authors: Kulvinder Singh Mann

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The usability and simulation of information systems, known as Hospital Information System (HIS), Radiology Information System (RIS), and Picture Archiving, Communication System, for electronic medical records has shown a good impact for actors in the hospital. The objective is to help and make their work easier; such as for a nurse or administration staff to record the medical records of the patient, and for a patient to check their bill transparently. However, several limitations still exists on such area regarding the type of data being stored in the system, ability for data transfer, storage and protocols to support communication between medical devices and digital images. This paper reports the simulation result of integrating several systems to cope with those limitations by using the Modality Worklist and DICOM standard. It succeeds in documenting the reason of that failure so future research will gain better understanding and be able to integrate those systems.

Keywords: HIS, RIS, PACS, modality worklist, DICOM, digital images

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Authors: Zainab Elazab, Azhar Aziz

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Background: Spontaneous Splenic artery pseudoaneurysm rupture is a rare condition which is potentially life threatening, if not detected and managed early. We report a case of abdominal pain with intraperitoneal free fluid, which turned out to be spontaneous rupture of a splenic artery pseudoaneurysm, and was treated with arterial embolization. Case presentation: A 28-year old, previously healthy male presented to the ED with a history of sudden onset upper abdominal pain and fainting attack. The patient denied any history of trauma or prior similar attacks. On examination, the patient had tachycardia and a low-normal BP (HR 110, BP 106/66) but his other vital signs were normal (Temp. 37.2, RR 18 and SpO2 100%). His abdomen was initially soft with mild tenderness in the upper region. Blood tests showed leukocytosis of 12.3 X109/L, Hb of 12.6 g/dl and lactic acid of 5.9 mmol/L. Ultrasound showed trace of free fluid in the perihepatic and perisplenic areas, and a splenic hypoechoic lesion. The patient remained stable; however, his abdomen became increasingly tender with guarding. We made a provisional diagnosis of a perforated viscus and the patient was started on IV fluids and IV antibiotics. An erect abdominal x-ray did not show any free air under the diaphragm so a CT abdomen was requested. Meanwhile, bedside ultrasound was repeated which showed increased amount of free fluid, suggesting intra-abdominal bleeding as the most probable etiology for the condition. His CT abdomen revealed a splenic injury with multiple lacerations, a focal intrasplenic enhancing area on venous phase scan (suggesting a pseudoaneurysm with associated splenic intraparenchymal, sub capsular and perisplenic hematomas). Free fluid in the subhepatic and intraperitoneal regions along the small bowel was also detected. Angiogram was done which confirmed a diagnosis of pseudoaneurysm of intrasplenic arterial branch, and angio-embolization was done to control the bleeding. The patient was later discharged in good condition with a surgery follow-up. Conclusion: Splenic artery pseudoaneurysm rupture is a rare cause of abdominal pain which should be considered in any case of abdominal pain with intraperitoneal bleeding. Early management is crucial as it carries a high mortality. Bedside ultrasound is a useful tool to help for early diagnosis of such cases.

Keywords: abdominal pain, pseudo aneurysm, rupture, splenic artery

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Authors: E. Tugba Topcu

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The emergency services are usually the first places to encounter forensic cases. Hence, it is important to consider forensics from the perspective of the emergency services staff and the physiological and psychological consequences that may arise as a result of behaviour by itself or another person. Accurate and detailed documentation of the situation in which the patient first arrives at the emergency service and preservation of the forensic findings is pivotal for the subsequent forensic investigation. The first step in determining whether or not a forensic case exists is to perform a medical examination of the patient. For each individual suspected to be part of a forensic case, police officers should be informed at the same time as the medical examination is being conducted. Violent events are increasing every year and with an increase in the number of forensic cases, emergency service workers have increasing responsibility and consequently play a key role in protecting, collecting and arranging the forensic evidence. In addition, because the emergency service workers involved in forensic events typically have information about the accused and/or victim, as well as evidence related to the events and the cause of injuries, police officers often require their testimony. However, both nurses and other health care personnel do not typically have adequate expertise in forensic medicine. Emergency nurses should take an active role for determining that whether any patient admitted to the emergency services is a clinical forensic patient the emergency service with injury and requiring possible punishment and knowing of their roles and responsibilities in this area provides legal protection as well as the protection of the judicial affair. Particularly, in emergency services, where rapid patient turnover and high workload exists, patient registration and case reporting may not exist. In such instances, the witnesses, typically the nurses, are often consulted for information. Knowledge of forensic medical matters plays a vital role in achieving justice. According to the Criminal Procedure Law, Article 75, Paragraph 3, ‘an internal body examination or the taking of blood or other biological samples from the body can be performed only by a doctor or other health professional member’. In favour of this item, the clinic nurse and doctor are mainly responsible for evaluating forensic cases in emergency departments, performing the examination, collecting evidence, and storing and reporting data. The courts place considerable importance on determining whether a suspect is the victim or accused and, thus, in terms of illuminating events, it is crucial that any evidence is gathered carefully and appropriately. All the evidence related to the forensic case including the forensic report should be handed over to the police officers. In instances where forensic evidence cannot be collected and the only way to obtain the evidence is the hospital environment, health care personnel in emergency services need to have knowledge about the diagnosis of forensic evidence, the collection of evidence, hiding evidence and provision of the evidence delivery chain.

Keywords: emergency department, emergency nursing, forensic cases, forensic nursing

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Authors: Samira K. Al-Nasser, Siamak Noroozi, Roya Haratian, Adrian Harvey

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A total knee replacement (TKR) is a surgical procedure necessary when there is severe pain and/or loss of function in the knee. Surgeons balance the load in the knee and the surrounding soft tissue by feeling the tension at different ranges of motion. This method can be unreliable and lead to early failure of the joint. The ideal kinematics and load distribution have been debated significantly based on previous biomechanical studies surrounding both TKRs and normal knees. Intraoperative sensors like VERASENSE and eLibra have provided a method for the quantification of the load indicating a balanced knee. A review of the literature written about intraoperative sensors and tension/stability of the knee was done. Studies currently debate the quantification of the load in medial and lateral compartments specifically. However, most research reported that following a TKR the medial compartment was loaded more heavily than the lateral compartment. In several cases, these results were shown to increase the success of the surgery because they mimic the normal kinematics of the knee. In conclusion, most research agrees that an intercompartmental load differential of between 10 and 20 pounds, where the medial load was higher than the lateral, and an absolute load of less than 70 pounds was ideal. However, further intraoperative sensor development could help improve the accuracy and understanding of the load distribution on the surgical outcomes in a TKR. A reduction in early revision surgeries for TKRs would provide an improved quality of life for patients and reduce the economic burden placed on both the National Health Service (NHS) and the patient.

Keywords: intraoperative sensors, joint load forces, kinematics, load balancing, and total knee replacement

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Authors: Jac J. W. Andrews, James B. Hale

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Effective practicing psychologists require ongoing skill development that is constructivist and recursive in nature, with mentor, colleague, co-worker, and patient feedback critical to successful acquisition and maintenance of professional competencies. This paper will provide an overview of the nature and scope of psychologist skill development through multisource feedback (MSF) or 360 degree evaluation, present a rationale for its use for assessing practicing psychologist performance, and advocate its use in psychology given the demonstrated model utility in other health professions. The paper will conclude that an international research design is needed to assess the feasibility, reliability, and validity of MSF system ratings intended to solicit feedback from mentors, colleagues, coworkers, and patients about psychologist competencies. If adopted, the MSF model could lead to enhanced skill development that fosters patient satisfaction within and across countries.

Keywords: psychologist, multisource feedback, psychologist competency, professionalism

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Authors: Muhammad Waleed Asfandyar, Akhtar Ahmed, Syed Adib-ul-Hasan Rizvi

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Objective: To evaluate the ability of serum concentration of prostate specific antigen between two cutting points considering it as a predictor of skeletal metastasis on bone scintigraphy in men with prostate cancer. Settings: This study was carried out in department of Nuclear Medicine at Sindh Institute of Urology and Transplantation (SIUT) Karachi, Pakistan. Materials and Method: From August 2013 to November 2013, forty two (42) consecutive patients with prostate cancer who underwent technetium-99m methylene diphosphonate (Tc-99mMDP) whole body bone scintigraphy were prospectively analyzed. The information was collected from the scintigraphic database at a Nuclear medicine department Sindh institute of urology and transplantation Karachi Pakistan. Patients who did not have a serum PSA concentration available within 1 month before or after the time of performing the Tc-99m MDP whole body bone scintigraphy were excluded from this study. A whole body bone scintigraphy scan (from the toes to top of the head) was performed using a whole-body Moving gamma camera technique (anterior and posterior) 2–4 hours after intravenous injection of 20 mCi of Tc-99m MDP. In addition, all patients necessarily have a pathological report available. Bony metastases were determined from the bone scan studies and no further correlation with histopathology or other imaging modalities were performed. To preserve patient confidentiality, direct patient identifiers were not collected. In all the patients, Prostate specific antigen values and skeletal scintigraphy were evaluated. Results: The mean age, mean PSA, and incidence of bone metastasis on bone scintigraphy were 68.35 years, 370.51 ng/mL and 19/42 (45.23%) respectively. According to PSA levels, patients were divided into 5 groups < 10ng/mL (10/42), 10-20 ng/mL (5/42), 20-50 ng/mL (2/42), 50-100 (3/42), 100- 500ng/mL (3/42) and more than 500ng/mL (0/42) presenting negative bone scan. The incidence of positive bone scan (%) for bone metastasis for each group were O1 patient (5.26%), 0%, 03 patients (15.78%), 01 patient (5.26%), 04 patients (21.05%), and 10 patients (52.63%) respectively. From the 42 patients 19 (45.23%) presented positive scintigraphic examination for the presence of bone metastasis. 1 patient presented bone metastasis on bone scintigraphy having PSA level less than 10ng/mL, and in only 1 patient (5.26%) with bone metastasis PSA concentration was less than 20 ng/mL. therefore, when the cutting point adopted for PSA serum concentration was 10ng/mL, a negative predictive value for bone metastasis was 95% with sensitivity rates 94.74% and the positive predictive value and specificities of the method were 56.53% and 43.48% respectively. When the cutting point of PSA serum concentration was 20ng/mL the observed results for Positive predictive value and specificity were (78.27% and 65.22% respectively) whereas negative predictive value and sensitivity stood (100% and 95%) respectively. Conclusion: Results of our study allow us to conclude that serum PSA concentration of higher than 20ng/mL was the most accurate cutting point than a serum concentration of PSA higher than 10ng/mL to predict metastasis in radionuclide bone scintigraphy. In this way, unnecessary cost can be avoided, since a considerable part of prostate adenocarcinomas present low serum PSA levels less than 20 ng/mL and for these cases radionuclide bone scintigraphy could be unnecessary.

Keywords: bone scan, cut off value, prostate specific antigen value, scintigraphy

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Authors: Ahmed Elreedy, Ahmed Tawfik

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This investigation aims to assess the effect of inoculum to substrate ratio (ISR) and nitrogen to phosphorous balance on simultaneous biohydrogen and methane production from anaerobic decomposition of mono-ethylene glycol (MEG). Different ISRs were applied in the range between 2.65 and 13.23 gVSS/gCOD, whereas the tested N/P ratios were changed from 4.6 to 8.5; both under thermophilic conditions (55°C). The maximum obtained methane and hydrogen yields (MY and HY) of 151.86±10.8 and 22.27±1.1 mL/gCODinitial were recorded at ISRs of 5.29 and 3.78 gVSS/gCOD, respectively. Unlikely, the ammonification process, in terms of net ammonia produced, was found to be ISR and COD/N ratio dependent, reaching its peak value of 515.5±31.05 mgNH4-N/L at ISR and COD/N ratio of 13.23 gVSS/gCOD and 11.56. The optimum HY was enhanced by more than 1.45-fold with declining N/P ratio from 8.5 to 4.6; whereas, the MY was improved (1.6-fold), while increasing N/P ratio from 4.6 to 5.5 with no significant impact at N/P ratio of 8.5. The results obtained revealed that the methane production was strongly influenced by initial ammonia, compared to initial phosphate. Likewise, the generation of ammonia was markedly deteriorated from 535.25±41.5 to 238.33±17.6 mgNH4-N/L with increasing N/P ratio from 4.6 to 8.5. The kinetic study using Modified Gompertz equation was successfully fitted to the experimental outputs (R2 > 0.9761).

Keywords: mono-ethylene glycol, biohydrogen and methane, inoculum to substrate ratio, nitrogen to phosphorous balance, ammonification

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Authors: Hannah Riva, Sarah Mazal, Jessica L. Marquez, Michael Rains

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A 70-year-old female with a Fitzpatrick skin phenotype II presented with a 13-year history of a scaly rash located on the left breast and bilateral pretibial regions. The patient’s past medical history was otherwise unremarkable, with the exception of surgery involving the left breast. Physical examination revealed infiltrative hyperpigmented scaly plaques and nodules located on the left breast and pretibial regions bilaterally. A negative systemic workup excluded organ involvement. A clinical diagnosis of cutaneous sarcoidosis was made. Prior treatments included triamcinolone 0.1% topical cream and clobetasol 0.05% ointment, which failed to show improvement. Full-body narrow-band UVB (NBUVB) treatment was performed on a tri-weekly basis for eight months. NBUVB dosage was slowly titrated from 300 mJ/cm2 to a final dose of 1800 mJ/cm2 to prevent discomfort and burning sensations. Throughout the duration of her treatment, the patient adhered to a regimen of clobetasol 0.05% topical ointment applied twice daily in two-week intervals. Improvement was noticed after two months, with continued improvement up to eight months. The patient is continuing NBUVB phototherapy treatments for maintenance. In our case, NBUVB phototherapy treatment demonstrated promising results with improvement after two months of treatment. Physicians should consider NBUVB phototherapy as an effective option for patients presenting with cutaneous sarcoidosis.

Keywords: dermatology, sarcoidosis, phototherapy, ultraviolet

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Authors: Ihab Saad Ahmed

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Background For Siewert type I and II gastroesophageal junction tumor (GEJ) laparoscopic proximal gastrectomy can be performed. It is associated with several perioperative benefits compared with open proximal gastrectomy. The use of laparoscopic proximal gastrectomy (LPG) has become an increasingly popular approach for select tumors Methods We describe our technique for LPG, including the preoperative work-up, illustrated images of the main principle steps of the surgery, and our postoperative course. Results Thirteen pts (nine males, four female) with type I, II (GEJ) adenocarcinoma had laparoscopic radical proximal gastrectomy and D2 lymphadenectomy. All of our patient received neoadjuvant chemotherapy, eleven patients had intrathoracic anastomosis through mini thoracotomy (two hand sewn end to end anastomoses and the other 9 patient end to side using circular stapler), two patients with intrathoracic anastomosis had flap and wrap technique, two patients had thoracoscopic esophageal and mediastinal lymph node dissection with cervical anastomosis The mean blood loss 80ml, no cases were converted to open. The mean operative time 250 minute Average LN retrieved 19-25, No sever complication such as leakage, stenosis, pancreatic fistula ,or intra-abdominal abscess were reported. Only One patient presented with empyema 1.5 month after discharge that was managed conservatively. Conclusion For carefully selected patients, LPG in GEJ tumour type I and II is a safe and reasonable alternative for open technique , which is associated with similar oncologic outcomes and low morbidity. It showed less blood loss, respiratory infections, with similar 1- and 3-year survival rates.

Keywords: LPG(laparoscopic proximal gastrectomy, GEJ( gastroesophageal junction tumour), d2 lymphadenectomy, neoadjuvant cth

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Authors: Mehaiguene Madjid, Meddi Mohamed

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The results of applying the model WEAP 21 or 'Water Evaluation and Planning System' in Upper and Middle Cheliff are presented in cartographic and graphic forms by considering two scenarios: -Reference scenario 1961-1990, -Climate change scenarios (low and high) for 2020 and 2050. These scenarios are presented together in the results and compared them to know the impact on aquatic systems and water resources. For the low scenario for 2050, a decrease in the rate of runoff / infiltration will be 81.4 to 3.7 Hm3 between 2010 and 2050. While for the high scenario for 2050, the reduction will be 87.2 to 78.9 Hm3 between 2010 and 2050. Comparing the two scenarios, shows that the water supplied will increase by 216.7 Hm3 to 596 Hm3 up to 2050 if we do not take account of climate change. Whereas, if climate change will decrease step by step: from 2010 to 2026: for the climate change scenario (high scenario) by 2050, water supplied from 346 Hm3 to 361 Hm3. That of the reference scenario (1961-1990) will increase to 379.7 Hm3 in 2050. This is caused by the increased demand (increased population, irrigated area, etc ). The balance water management basin is positive for the different Horizons and different situations. If we do not take account of climate change will be the outflow of 5881.4 Hm3. This excess at the basin can be used as part of a transfer for example.

Keywords: balance water, management basin, climate change scenario, Upper and Middle Cheliff

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Authors: Ravija Gunawardana, Banuka Athuraliya

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Machine learning has emerged as a powerful tool for disease diagnosis and prediction. The use of machine learning algorithms has the potential to improve the accuracy of disease prediction, thereby enabling medical professionals to provide more effective and personalized treatments. This study focuses on developing a machine-learning model for disease prediction using symptoms and X-ray images. The importance of this study lies in its potential to assist medical professionals in accurately diagnosing diseases, thereby improving patient outcomes. Respiratory diseases are a significant cause of morbidity and mortality worldwide, and chest X-rays are commonly used in the diagnosis of these diseases. However, accurately interpreting X-ray images requires significant expertise and can be time-consuming, making it difficult to diagnose respiratory diseases in a timely manner. By incorporating machine learning algorithms, we can significantly enhance disease prediction accuracy, ultimately leading to better patient care. The study utilized the Mask R-CNN algorithm, which is a state-of-the-art method for object detection and segmentation in images, to process chest X-ray images. The model was trained and tested on a large dataset of patient information, which included both symptom data and X-ray images. The performance of the model was evaluated using a range of metrics, including accuracy, precision, recall, and F1-score. The results showed that the model achieved an accuracy rate of over 90%, indicating that it was able to accurately detect and segment regions of interest in the X-ray images. In addition to X-ray images, the study also incorporated symptoms as input data for disease prediction. The study used three different classifiers, namely Random Forest, K-Nearest Neighbor and Support Vector Machine, to predict diseases based on symptoms. These classifiers were trained and tested using the same dataset of patient information as the X-ray model. The results showed promising accuracy rates for predicting diseases using symptoms, with the ensemble learning techniques significantly improving the accuracy of disease prediction. The study's findings indicate that the use of machine learning algorithms can significantly enhance disease prediction accuracy, ultimately leading to better patient care. The model developed in this study has the potential to assist medical professionals in diagnosing respiratory diseases more accurately and efficiently. However, it is important to note that the accuracy of the model can be affected by several factors, including the quality of the X-ray images, the size of the dataset used for training, and the complexity of the disease being diagnosed. In conclusion, the study demonstrated the potential of machine learning algorithms for disease prediction using symptoms and X-ray images. The use of these algorithms can improve the accuracy of disease diagnosis, ultimately leading to better patient care. Further research is needed to validate the model's accuracy and effectiveness in a clinical setting and to expand its application to other diseases.

Keywords: K-nearest neighbor, mask R-CNN, random forest, support vector machine

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Authors: Le Nguyen Binh, Luong Xuan Binh, Le Van Tuan, Tran Binh Duong, Truong Nguyen Khanh Hung, Do Le Hoang Son, Pham Quang Vinh, Hoang Quoc Huy, Nguyen Bach, Nguyen Quoc Khanh Le, Jiunn Horng Kang

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Introduction: Traumatic hip dislocation is an emergency in young adult which can cause avascular necrosis of femoral head or osteoarthritis of hip joint. The reasons for these may be the loose body of bony or chondral fragments, which are difficult to be detected on CT scan or MRI. In those cases, Hip arthroscopy may be the method of choice for diagnosis and treatment of loose bodies in hip joint after traumatic dislocation. Methods: A case report is performed. A 55-year-old male patient was under hip arthroscopy to retrieve the loose body in the right hip joint. Results: The patient’s hip was reduced under anesthesia in the opeation room. Xray and CT scan post-reduction showed that his right hip was wide and a small fragment of femoral head (< 5mm) locking inside the joint. A hip arthroscopy was done to take the fragment out. Post-operation, the patient went under rehabilition. After 6 months, he can walk with full-weight bearing; no further dislocaion was noted, and the Harris score was 84 points. Conclusions: Although acute traumatic injury of hip joint is usually treated with open surgeries, these methods have many drawbacks, such as soft tissue destruction, blood-loss,….Despite its technical requirement, hip arthroscopy is less invasive and effective treatment. Therefore, it may be an alternative treatment for a traumatic hip injury and can be applied frequently in the near future.

Keywords: hip dislocation, hip arthroscopy, hip osteoarthritis, acute hip trauma

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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: K. Jagannath, Akhilesh Kotian, S. S. Sharma, Achutha Kini U., P. R. Prabhu

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Boiling process is characterized by the rapid formation of vapour bubbles at the solid–liquid interface (nucleate boiling) with pre-existing vapour or gas pockets. Computational fluid dynamics (CFD) is an important tool to study bubble dynamics. In the present study, CFD simulation has been carried out to determine the bubble detachment diameter and its terminal velocity. Volume of fluid method is used to model the bubble and the surrounding by solving single set of momentum equations and tracking the volume fraction of each of the fluids throughout the domain. In the simulation, bubble is generated by allowing water-vapour to enter a cylinder filled with liquid water through an inlet at the bottom. After the bubble is fully formed, the bubble detaches from the surface and rises up during which the bubble accelerates due to the net balance between buoyancy force and viscous drag. Finally when these forces exactly balance each other, it attains a constant terminal velocity. The bubble detachment diameter and the terminal velocity of the bubble are captured by the monitor function provided in FLUENT. The detachment diameter and the terminal velocity obtained is compared with the established results based on the shape of the bubble. A good agreement is obtained between the results obtained from simulation and the equations in comparison with the established results.

Keywords: bubble growth, computational fluid dynamics, detachment diameter, terminal velocity

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Authors: Yunhe Chen, Xinyun Liu, Qian Wang, Jianan Li

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Background Cochlear implants (CIs) are currently the primary effective treatment for severe or profound sensorineural hearing loss. As China's population ages and the number of young children rises, the demand for MRI for CI patients is expected to increase. Methods Reviewed MRI cases of 25 CI patients between 2015 and 2024, assessed imaging auditory outcomes and adverse reactions. Use the adverse event record sheet and accompanying medication sheet to record follow-up measures. Results Most CI patients undergoing MRI may face risks such as artifacts, pain, redness, swelling, tissue damage, bleeding, and magnet displacement or demagnetization. Twenty-five CI patients in our hospital were reviewed. Seven patient underwent 3.0 T MR, the others underwent 1.5 T MR. The manufacturers are 18 cases in Austria, 5 cases in Australia and 2 cases in Nurotron. Among them, one patient with bilateral CI underwent 1.5 T MR examination after head pressure bandaging, and the left magnet was displaced (CI24RE Series, Australia). This patient underwent surgical replacement of the magnet under general anesthesia. Six days after the operation, the patient's feedback indicated that the performance of the cochlear implant was consistent with the previous results following the reactivation of the external device. Based on the experience of our hospital, we proposed the feasible management scheme of MRI examination procedure for CI patients. This plan should include a module for confirming MRI imaging parameters, informed consent, educational materials for patients, and other safety measures to ensure that patients receive imaging results safely and effectively, implify clinical. Conclusion As indications for both MRI and cochlear implantation expand，the number of MRI studies recommended for patients with cochlear implants will also increase. The process and management scheme proposed in this study can help to obtain imaging results safely and effectively, and reduce clinical stress.

Keywords: cochlear implantation, MRI, magnet, displacement

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Authors: Elsa Lamy, Marília Prada, Ada Rocha, Cláudia Viegas

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The traditional and widely used nutrition-focused approach to communicate with consumers is reductionist and makes it difficult for consumers to assess their food intake. Without sufficient nutrition knowledge and understanding, it would be difficult to choose a healthful diet based only on nutritional recommendations. This study aimed to evaluate the understanding of how food/nutritional information is presented in menus to Portuguese consumers, comparing the nutrient-focused approach (currently used Nutrition Declaration) and the new food-focused approach (the infographic). For data collection, a questionnaire was distributed online using social media channels. A main effect of format on ratings of meal balance and completeness (Fbalance(1,79) = 18.26, p < .001, ηp2 = .188; Fcompleteness(1,67) = 27.18, p < .001, ηp2 = .289). Overall, dishes paired with the nutritional information were rated as more balanced (Mbalance= 3.70, SE = .11; Mcompleteness = 4.00, SE = .14) than meals with the infographic representation (Mbalance = 3.14, SE = .11; Mcompleteness = 3.29, SE = .13). We also observed a main effect of the meal, F(3,237) = 48.90, p < .001, ηp2 = .382, such that M1 and M2 were perceived as less balanced than the M3 and M4, all p < .001. The use of a food-focused approach (infographic) helped participants identify the lack of balance in the less healthful meals (dishes M1 and M2), allowing for a better understanding of meals' compliance with recommendations contributing to better food choices and a healthier lifestyle.

Keywords: food labelling, food and nutritional recommendations, infographics, portions based information

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Authors: Soumaya Mrabet, Taieb Ach, Imen Akkari, Amira Atig, Neirouz Ghannouchi, Koussay Ach, Elhem Ben Jazia

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Introduction: Celiac disease (CD) is an immune-mediated small intestinal disorder that occurs in genetically susceptible people. It is significantly associated with other autoimmune disorders represented mainly by type 1 diabetes and autoimmune dysthyroidism. The aim of our study is to determine the prevalence and the type of the various autoimmune diseases associated with CD in adult patients. Material and methods: This is a retrospective study including patients diagnosed with CD, explored in Internal Medicine, Gastroenterology and Endocrinology and Diabetology Departments of the Farhat Hached University Hospital, between January 2005 and January 2016. The diagnosis of CD was confirmed by serological tests and duodenal biopsy. The screening of autoimmune diseases was based on physical examination, biological and serological tests. Results: Sixty five patients with a female predominance were included, 48women (73.8%) and 17 men (26.2%). The mean age was 31.8 years (17-75). A family history of CD or other autoimmune diseases was present in 5 and 10 patients respectively. Clinical presentation of CD was made by recurrent abdominal pain in 49 cases, diarrhea in 29 cases, bloating in 17 cases, constipation in 25 cases and vomiting in 8 cases. Autoimmune diseases associated with CD were found in 30 cases (46.1%): type 1 diabetes in 15 patients attested by the positivity of anti-GAD antibodies in 11 cases and anti-IA2 in 4 cases, Hashimoto thyroiditis in 8 cases confirmed by the positivity of anti-TPO antibodies, Addison's disease in 2 patients, Anemia of Biermer in 2 patients, autoimmune hepatitis, Systemic erythematosus lupus, Gougerot Sjögren syndrome, rheumatoid arthritis, Vitiligo and antiphospholipid syndrome in one patient each. CD was associated with more than one autoimmune disease defining multiple autoimmune syndrome in 2 female patients. The first patient had Basedow disease, Addison disease and type 1 diabetes. The second patient had systemic erythematosus lupus and Gougerot Sjögren syndrome. Conclusion: In our study autoimmune diseases were associated with CD in 46.1% of cases and were dominated by diabetes and dysthroidism. After establishing the diagnosis of CD the search of associated autoimmune diseases is necessary in order to avoid any therapeutic delay which can alter the prognosis of the patient.

Keywords: association, autoimmune thyroiditis, celiac disease, diabetes

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Authors: Mohamed Majrashi, Patricia Connolly, Terry Gourlay

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Cardiopulmonary bypass is known to cause inflammatory response during open heart surgery. It includes the initiation of different cascades such as coagulation, complement system and cytokines. Although the immune system is body’s key defense mechanism against external assault, when overexpressed, it can be injurious to the patient, particularly in a cohort of patients in which there is a heightened and uncontrolled response. The inflammatory response develops in these patients to an exaggerated level resulting in an autoimmune injury and may lead to poor postoperative outcomes (systemic inflammatory response syndrome and multi-organs failure). Previous studies by this group have suggested a correlation between the level of IL6 measured in patient’s blood before surgery and after polymeric activation and the observed inflammatory response during surgery. Based upon these findings, the present work is aimed at using this response to develop a test which can be used prior to the open heart surgery to identify the high-risk patients before their operation. The work will be accomplished via three main clinical phases including some pilot in-vitro studies, device development and clinical investigation. Current findings from studies using animal blood, employing DEHP and DEHP plasticized PVC materials as the activator, support the earlier results in patient samples. Having established this relationship, ongoing work will focus on developing an activated lateral flow strip technology as a screening device for heightened inflammatory propensity.

Keywords: cardiopulmonary bypass, cytokines, inflammatory response, overexpression

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Authors: Inbal Zuriely, Yonit Weiss, Hilla Zaharoni, Hadas Lewkowicz, Tatiana Vander, Tarif Bader

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early active movement, along with adjusting optimal nutrition, prevents aggravation of muscle degeneracy and functional decline. Eating is a basic activity of daily life, which reflects the patient's independence. When eating and feeding are experienced successfully, they lead to a sense of pleasure and satisfaction. However, when they are experienced as a difficulty, they might evoke feelings of helplessness and frustration. This stresses the essential process of gradual weaning off the enteral feeding tube. the work describes the collaboration of a dietitian, determining the nutritional needs of patients undergoing enteral tube weaning as part of the rehabilitation process, with the suited treatment of an occupational therapist. Occupational therapy intervention regarding eating capabilities focuses on improving the required motor and cognitive components, along with environmental adjustments and aids, imparting eating strategies and training to patients and their families. The project was conducted in the long-term, ventilated patients’ department at the Herzfeld Rehabilitation Geriatric Medical Center on patients undergoing enteral tube weaning with the staff’s assistance. Establishing continuous collaboration between the dietician and the occupational therapist, starting from the beginning of the feeding-tube weaning process: 1.The dietician updates the occupational therapist about the start of the process and the approved diet. 2.The occupational therapist performs cognitive, motor, and functional assessments and treatments regarding the patient’s eating capabilities and recommends the required adjustments for independent eating according to the FIM (Functional Independence Measure) scale. 3.The occupational therapist closely follows up on the patient’s degree of independence in eating and provides a repeated update to the dietician. 4.The dietician accordingly guides the ward staff on whether and how to feed the patient or allow independent eating. The project aimed to promote patients toward independent feeding, which leads to a sense of empowerment, enjoyment of the eating experience, and progress of functional ability, along with performing active movements that will motivate mobilization. From the beginning of 2022, 26 patients participated in the project. 79% of all patients who started the weaning process from tube feeding achieved different levels of independence in feeding (independence levels ranged from supervision (FIM-5) to complete independence (FIM-7). The integration of occupational therapy and dietary treatment is based on a patient-centered approach while considering the patient’s personal needs, preferences, and goals. This interdisciplinary partnership is essential for meeting the complex needs of prolonged mechanically ventilated patients and promotes independent functioning and quality of life.

Keywords: dietary, mechanical ventilation, occupational therapy, tube feeding weaning

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Authors: Hong Mengdi, Li Jianan, Ji Fei, Chen Aiting, Wang Qian

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Objective: To overcome the communication barriers that audiologists encounter during cochlear implant mapping, particularly the challenge of eliciting subjective feedback from recipients regarding electrical stimulation, and to enhance the capabilities of existing technologies, we teamed up with software engineers to design an interactive approach for patient-audiologist communication. This approach employs a tablet (PAD) as the interface for a communication and feedback system between patients and audiologists during the mapping process, known as the Cochlear Implant Mapping Assistance System. Methods: Capitalizing on the touchscreen functionality of the PAD, the recipients' subjective feedback during cochlear implant mapping is instantly transmitted to the audiologist's mapping computer. The system acts as a platform for auditory assessment instruments, facilitating immediate evaluation of recipients' post-mapping hearing and speech discrimination capabilities. Furthermore, the system is designed to augment the visual reinforcement audiometry (VRA) process. The system consists of six modules, including three testing projects: loudness testing, hearing threshold testing, and loudness balance testing; two assessment projects: warble tone testing and digit speech testing; and one VRA animation project. It also incorporates speech-to-text and text input display functions tailored to accommodate speech communication difficulties in hearing-impaired individuals, with pre-installed common exchange content between audiologists and recipients. Audiologists can input sentences by selecting options. The system supports switching between Chinese and English versions, suitable for audiologists and recipients who use English, facilitating international application of the system. Results: The Cochlear Implant Mapping Assistance System has been in use for over a year in the Auditory Implant Center of the Department of Otology and Neurotology, Medical Center of Otology and Head & Neck Surgery, Chinese PLA General Hospital, with more than 300 recipients using this mapping system. Currently, the system operates stably, with both audiologists and recipients providing positive feedback, indicating a significant improvement over previous methods. It is particularly well-received by pediatric recipients, significantly enhancing the work efficiency of audiologists and improving the feedback efficiency and accuracy of recipients. The system enhances the comprehensibility for cochlear implant recipients, improves wearing comfort and user experience, facilitates cochlear implant auditory mapping, and increases the collection of previously challenging-to-obtain data during the existing assisted mapping process, such as loudness testing data, electrical stimulation testing data, warble tone testing data, loudness balance testing data, digit speech testing data, and visual reinforcement audiometry testing data. Real-time data recording improves the accuracy of assisted mapping. The interface design is meticulously crafted to accommodate patients of varying ages and cognitive abilities, featuring an intuitive design that allows for effortless, guidance-free use by patients.

Keywords: audiologist, subjective feedback, mapping, cochlear implant

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Authors: Muhammad Saqlain, Nazar Abbas Saqib, Muazzam A. Khan

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Heart Failure (HF) has become the major health problem in our society. The prevalence of HF has increased as the patient’s ages and it is the major cause of the high mortality rate in adults. A successful identification and progression of HF can be helpful to reduce the individual and social burden from this syndrome. In this study, we use a real data set of cardiac patients to propose a classification model for the identification and progression of HF. The data set has divided into three age groups, namely young, adult, and old and then each age group have further classified into four classes according to patient’s current physical condition. Contemporary Data Mining classification algorithms have been applied to each individual class of every age group to identify the HF. Decision Tree (DT) gives the highest accuracy of 90% and outperform all other algorithms. Our model accurately diagnoses different stages of HF for each age group and it can be very useful for the early prediction of HF.

Keywords: decision tree, heart failure, data mining, classification model

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Authors: Khalid A. Salman, Shereen Wagih, Tariq Munshi, Musaed Almalki, Safwan Zatari, Zahid Khan

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Aim: To measure exposure levels to family members and caregivers of Saudi patients treated with low dose I131 therapy, and household radiation exposure rate to predict different factors that can affect radiation exposure. Patients and methods: All adult self dependent patients with hyperthyroidism or cancer thyroid referred for low dose radioactive I131 therapy on outpatient basis are included. Radiation protection procedures are given to the participant and family members in details. TLD’s were dispensed to each participant in sufficient quantity for his/her family members living in the household. TLD’s are collected at fifth days post-dispense from patients who agreed to have a home visit during which the household is inspected and level of radiation contamination of surfaces was measured. Results: Thirty-two patients were enrolled in the current study, with a mean age of 43.1± 17.1 years Out of them 25 patients (78%) are females. I131 therapy was given in twenty patients (63%) for cancer thyroid of and for toxic goiter in the remaining twelve patients (37%), with an overall mean I131 dose of 24.1 ± 7.5mCi that is relatively higher in the former. The overall number of household family members and helpers of patients are 139, out of them77 are females (55.4%) & 62 are males (44.6%) with a mean age of 29.8± 17.6. The mean period of contact with the patient is 7.6 ±5.6hours. The cumulative radiation exposure shows that radiation exposure to all family members is below the exposure constraint (1mSv), with a range of 109 to 503uSv, and a mean value of 220.9±91 uSv. Numerical data shows a little higher exposure rate for family members of those who receive higher dose of I131 (patients with thyroid cancer) and household members who spent longer time with the patient, yet, the difference is statistically insignificant (P>0.05). Besides, no significant correlation was found between the degree of cumulative exposure of the family members to their gender, age, socioeconomic standard, educational level and residential factors. In the 21 home visits all data from bedrooms, reception areas and kitchens are below hazardous limits (0.5uSv/h) apart from bathrooms that give a slightly higher reading of 0.57±0.39 uSv/h in those with cancer thyroid who receive a higher radiation dose. A statistically significant difference was found between radiation exposure rate in bathrooms used by the patient versus those used by family members only, with a mean value of exposure rate of 0.701±0.21 uSv/h and 0.17±0.82 uSv/h respectively, with a p-value of 0.018 (<0.05). Conclusion: Family members of patients treated with low dose I131 on outpatient basis have a good compliance to radiation protection instruction if given properly with a cumulative radiation exposure rate evidently beyond the radiation exposure constraints of 1 mSv. Given I131 dose, hours spent with the patient, age, gender, socioeconomic standard, educational level and residential factors have no significant correlation with the cumulative radiation exposure. The patient bathroom exhibits more radiation exposure rate, needing more strict instructions for patient bathroom use and health hygiene.

Keywords: family members, radiation exposure, radioactive iodine therapy, radiation safety

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Authors: Ebtisam A. Benomran, Abdurrauf M. Gusbi, Malak S. Elazarg, M. Sultan, Layla M. Kafu, Arwa M. Matoug, Esra E. Benamara

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Normal pregnancy is associated with metabolic changes leading to decreased insulin sensitivity and reduced glucose tolerance, however, 3-5% of pregnant women proceed to develop gestational diabetes mellitus (GDM). Researcher studied the use of metformin in many fields and the benefit to risk balance of using metformin during pregnancy and the risk of fetotoxic. In this study we examined the use of Metformin to control Glucose in pregnant Women with gestational diabetes mellitus (GDM) and evaluate its safety use during the first trimester of pregnancy.A group of pregnant patients with gestational diabetes mellitus from the first trimester of pregnancy, non smoking with no family history of congenital malformation disease, aged between (20-45 years) and have no liver diseases and who had indicating good compliance at more than one visit over several month until delivery put on Metformin were participated in this trial. Our study shown that all the studied group of pregnant women using metformin 500 mg daily delivered a healthy babies. Meta-analysis by mother risk program showed no increase in incidence of malformations by use Metformin during the first trimester of pregnancy. A hundred outpatients were participated in the survey on the general knowledge and awareness of diabetic patients to their illness and medication used their aged between 20-40 years old. In this survey we realize that 90% of the doctors are not giving the patient full information about their illness and the use of metformin during pregnancy, also about 65% of the patients did not know about the nutritionist in the hospital and the right control diet for diabetes. Courses on first aid, rapid diagnosis of poisoning and follow the written procedures to dealing with such cases.

Keywords: gestational diabetes, malformations, metformin, pregnancy

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Authors: Daniela Monteiro

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Considering the entry into force of the new EU audit reform regarding statutory auditors, in effect in all member states since 2016, this research aims to identify which audit regulation rules are associated with a high-level audit quality on both its dimensions, i.e., the actual quality and the perceived quality, in relation to public interest entities, within the European Union, and whether those rules have the same impact on both dimensions. Its measurement was based on the following proxies: the quality of financial information through earnings management and the impact of qualified opinions on financial costs. We considered in the research regulation subjects such as auditors’ rotation and provision of services (NAS) and also the level of market concentration. The criteria to include these issues in the research was its contemplation of the new rules. We studied the period before the audit reform (2009-2015) when the regulation measures were less uniform. Besides the consideration of both dimensions of audit quality and several regulation measures, we believe our conclusions configure an important contribution to this research field, considering the involvement of the first 15 member states of the European Union. The results consolidate the assumption that the balance between competence and independence is not the only challenge related to the regulation of the audit profession. The evidence demonstrates that the balance between actual and perceived quality is also a relevant matter. The major conclusion is that the challenge is to keep balanced both actual and perceived audit quality whilst ensuring the independence and competence of auditors.

Keywords:

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Authors: Pablo Cid Galache, Laura Zamorano Bonilla

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Mauriac syndrome (MS) is a rare complication of type 1 diabetes mellitus (DM1). It is rela-ted to low insulin concentrations. Therefore is a complication mainly found in developing countries. The main clinical features are hepatomegaly, edema, growth and puberty delay, and the presence of elevated transaminases and serum lipids. The MS incidence is de-creasing due to the new types of insulin and intensive glycemic control. Therefore is a rare diagnosis in Europe nowadays, being described mainly in developing countries or with so-cioeconomic limitations to guarantee an adequate management of diabetes. Edema secondary to fluid retention is a rare complication of insulin treatment, especially in young patients. Its severity is variable and is mainly related to the start of a proper treatment and the improvement in glycemic control after diagnosis or after periods of poor metabolic control. Edema resolves spontaneously without requiring treatment in most cases. The Pediatric Endocrinology Unit of Hospital Motril could diagnose a 14-year-old girl who presented very poor metabolic control during the last 3 years as a consequence of the socioeconomic conditions of the country of origin during the last years. Presents up to 4 admissions for ketoacidosis during the last 12 months. After the family moved to Spain our patient began to be followed up in our Hospital. Initially presented glycated hemoglobin figures of 11%. One week after the start of treatment, the patient was admitted in the emergency room due to the appearance of generalized edema and pain in the limbs. The main laboratory abnormalities include: blood glucose 225mg/dl; HbA1C 10.8% triglycerides 543 mg/dl, total cholesterol 339 mg/dl (LDL 225) GOT 124 U/l, GPT 89U/l. Abdominal ultrasound shows mild hepatomegaly and no signs of ascites were shown. The patient presented a progressive improvement with resolution of the edema and analitical abnormalities during the next two weeks. During admission, the family received diabetes education, achieving adequate glycemic control at discharge. Nowadays the patient has a good glycemic control having glycated hemoglobin levels around 7%.

Keywords: Mauriac, diabetes, complication, developing countries

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