Search results for: chronic mechanical
Commenced in January 2007
Frequency: Monthly
Edition: International
Paper Count: 5065

Search results for: chronic mechanical

4255 Non-Cytotoxic Natural Sourced Inorganic Hydroxyapatite (HAp) Scaffold Facilitate Bone-like Mechanical Support and Cell Proliferation

Authors: Sudip Mondal, Biswanath Mondal, Sudit S. Mukhopadhyay, Apurba Dey

Abstract:

Bioactive materials improve devices for a long lifespan but have mechanical limitations. Mechanical characterization is one of the very important characteristics to evaluate the life span and functionality of the scaffold material. After implantation of scaffold material the primary stage rejection of scaffold occurs due to non biocompatible effect of host body system. The second major problems occur due to the effect of mechanical failure. The mechanical and biocompatibility failure of the scaffold materials can be overcome by the prior evaluation of the scaffold materials. In this study chemically treated Labeo rohita scale is used for synthesizing hydroxyapatite (HAp) biomaterial. Thermo-gravimetric and differential thermal analysis (TG-DTA) is carried out to ensure thermal stability. The chemical composition and bond structures of wet ball-milled calcined HAp powder is characterized by Fourier Transform Infrared spectroscopy (FTIR), X-ray Diffraction (XRD), Field Emission Scanning Electron Microscopy (FE-SEM), Transmission Electron Microscopy (TEM), Energy Dispersive X-ray (EDX) analysis. Fish scale derived apatite materials consists of nano-sized particles with Ca/P ratio of 1.71. The biocompatibility through cytotoxicity evaluation and MTT assay are carried out in MG63 osteoblast cell lines. In the cell attachment study, the cells are tightly attached with HAp scaffolds developed in the laboratory. The result clearly suggests that HAp material synthesized in this study do not have any cytotoxic effect, as well as it has a natural binding affinity for mammalian cell lines. The synthesized HAp powder further successfully used to develop porous scaffold material with suitable mechanical property of ~0.8GPa compressive stress, ~1.10 GPa a hardness and ~ 30-35% porosity which is acceptable for implantation in trauma region for animal model. The histological analysis also supports the bio-affinity of processed HAp biomaterials in Wistar rat model for investigating the contact reaction and stability at the artificial or natural prosthesis interface for biomedical function. This study suggests the natural sourced fish scale-derived HAp material could be used as a suitable alternative biomaterial for tissue engineering application in near future.

Keywords: biomaterials, hydroxyapatite, scaffold, mechanical property, tissue engineering

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4254 Material Flow Modeling in Friction Stir Welding of AA6061-T6 Alloy and Study of the Effect of Process Parameters

Authors: B. SahaRoy, T. Medhi, S. C. Saha

Abstract:

To understand the friction stir welding process, it is very important to know the nature of the material flow in and around the tool. The process is a combination of both thermal as well as mechanical work i.e it is a coupled thermo-mechanical process. Numerical simulations are very much essential in order to obtain a complete knowledge of the process as well as the physics underlying it. In the present work a model based approach is adopted in order to study material flow. A thermo-mechanical based CFD model is developed using a Finite Element package, Comsol Multiphysics. The fluid flow analysis is done. The model simultaneously predicts shear strain fields, shear strain rates and shear stress over the entire workpiece for the given conditions. The flow fields generated by the streamline plot give an idea of the material flow. The variation of dynamic viscosity, velocity field and shear strain fields with various welding parameters is studied. Finally the result obtained from the above mentioned conditions is discussed elaborately and concluded.

Keywords: AA6061-T6, CFD modelling, friction stir welding, material flow

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4253 Numerical Study of Two Mechanical Stirring Systems for Yield Stress Fluid

Authors: Amine Benmoussa, Mebrouk Rebhi, Rahmani Lakhdar

Abstract:

Mechanically agitated vessels are commonly used for various operations within a wide range process in chemical, pharmaceutical, polymer, biochemical, mineral, petroleum industries. Depending on the purpose of the operation carried out in mixer, the best choice for geometry of the tank and agitator type can vary widely. In this paper, the laminar 2D agitation flow and power consumption of viscoplastic fluids with straight and circular gate impellers in a stirring tank is studied by using computational fluid dynamics (CFD), where the velocity profile, the velocity fields and power consumption was analyzed.

Keywords: CFD, mechanical stirring, power consumption, yield stress fluid

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4252 Accelerated Ageing of Unidirectional Flax Fibers Reinforced Recycled Polypropylene Composites

Authors: Lara Alam, Laetitia Van-Schoors, Olivier Sicot, Benoit Piezel, Shahram Aivazzadeh

Abstract:

Over the last decades, worldwide environmental awareness has grown due to the depletion of raw material resources and global warming. This awareness has prompted the development of new products more environmentally friendly. Among these products are biocomposite materials reinforced with natural fibers. The main challenge in developing the use of biocomposites in exterior applications is the lack of knowledge about their durability and the evolution of their mechanical and physico-chemical properties in the long term. Few studies have been carried out on the photooxidation of unidirectional (UD) composites based on recycled matrix, which is the aim of this work. For this purpose, UD flax fiber composites based on recycled polypropylene were prepared by thermocompression. An accelerated aging test was carried out using a xenon arc WeatherOmeter. The consequences of UV exposure on the chemical composition and morphology of the surface of composites as well as on their tensile mechanical properties have been reported. The results showed that accelerated aging had a significant effect on the surface of these composites while it had little impact on their mechanical properties.

Keywords: flax fiber, photooxidation, physico-chemical properties, recycled polypropylene, tensile properties

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4251 Study of Biocomposites Based of Poly(Lactic Acid) and Olive Husk Flour

Authors: Samra Isadounene, Amar Boukerrou, Dalila Hammiche

Abstract:

In this work, the composites were prepared with poly(lactic acid) (PLA) and olive husk flour (OHF) with different percentages (10, 20 and 30%) using extrusion method followed by injection molding. The morphological, mechanical properties and thermal behavior of composites were investigated. Tensile strength and elongation at break of composites showed a decreasing trend with increasing fiber content. On the other hand, Young modulus and storage modulus were increased. The addition of OHF resulted in a decrease in thermal stability of composites. The presence of OHF led to an increase in percentage of crystallinity (Xc) of PLA matrix.

Keywords: biopolymers, composites, mechanical properties, poly(lactic acid)

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4250 Murine Pulmonary Responses after Sub-Chronic Exposure to Environmental Ultrafine Particles

Authors: Yara Saleh, Sebastien Antherieu, Romain Dusautoir, Jules Sotty, Laurent Alleman, Ludivine Canivet, Esperanza Perdrix, Pierre Dubot, Anne Platel, Fabrice Nesslany, Guillaume Garcon, Jean-Marc Lo-Guidice

Abstract:

Air pollution is one of the leading causes of premature death worldwide. Among air pollutants, particulate matter (PM) is a major health risk factor, through the induction of cardiopulmonary diseases and lung cancers. They are composed of coarse, fine and ultrafine particles (PM10, PM2.5, and PM0.1 respectively). Ultrafine particles are emerging unregulated pollutants that might have greater toxicity than larger particles, since they are more abundant and consequently have higher surface area per unit of mass. Our project aims to develop a relevant in vivo model of sub-chronic exposure to atmospheric particles in order to elucidate the specific respiratory impact of ultrafine particles compared to fine particulate matter. Quasi-ultrafine (PM0.18) and fine (PM2.5) particles have been collected in the urban industrial zone of Dunkirk in north France during a 7-month campaign, and submitted to physico-chemical characterization. BALB/c mice were then exposed intranasally to 10µg of PM0.18 or PM2.5 3 times a week. After 1 or 3-month exposure, broncho alveolar lavages (BAL) were performed and lung tissues were harvested for histological and transcriptomic analyses. The physico-chemical study of the collected particles shows that there is no major difference in elemental and surface chemical composition between PM0.18 and PM2.5. Furthermore, the results of the cytological analyses carried out show that both types of particulate fractions can be internalized in lung cells. However, the cell count in BAL and preliminary transcriptomic data suggest that PM0.18 could be more reactive and induce a stronger lung inflammation in exposed mice than PM2.5. Complementary studies are in progress to confirm these first data and to identify the metabolic pathways more specifically associated with the toxicity of ultrafine particles.

Keywords: environmental pollution, lung affect, mice, ultrafine particles

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4249 Studying the Effect of Nanoclays on the Mechanical Properties of Polypropylene/Polyamide Nanocomposites

Authors: Benalia Kouini, Aicha Serier

Abstract:

Nanocomposites based on polypropylene/polyamide 66 (PP/PA66) nanoblends containing organophilic montmorillonite (OMMT) and maleic anhydride grafted polypropylene (PP-g-MAH) were prepared by melt compounding method followed by injection molding. Two different types of nanoclays were used in this work. DELLITE LVF is the untreated nanoclay and DELLITE 67G is the treated one. The morphology of the nanocomposites was studied using the XR diffraction (XRD). The results indicate that the incorporation of treated nanoclay has a significant effect on the impact strength of PP/PA66 nanocomposites. Furthermore, it was found that XRD results revealed the intercalation, exfoliation of nanaclays of nanocomposites.

Keywords: nNanoclay, Nanocomposites, Polypropylene, Polyamide, melt processing, mechanical properties.

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4248 Analysis of Impact of Flu Vaccination on Acute Respiratory Viral Infections (ARVI) Morbidity among Population in South Kazakhstan Region, 2010-2015

Authors: Karlygash Tulendieva

Abstract:

Presently vaccination is the most effective method of prevention of flu and its complications. The purpose of this study was to analyze the impact of the increase of coverage of the population of South Kazakhstan region with flu vaccination and decrease of the ARVI morbidity. The analysis was performed on the data of flu vaccination of risk groups, including children under one year and pregnant women. Data on ARVI morbidity during 2010-2015 and data on vaccination were taken from the reports of the Epidemiological Surveillance Unit of Department of Consumers’ Rights Protection of South Kazakhstan region. Coverage with flu vaccination of the risk groups was annually increasing and in 2015 it reached 16% (450,000/2,800,682) from the total population. The ARVI morbidity rate in the entire population in 2010 was 2,010.4 per 100,000 of the population and decreased 3.2 times to 609.9 per 100,000 of the population in 2015. Annual growth was observed from 2010 to 2015 of specific weight of the vaccinated main risk groups: healthcare workers by 51% (from 17,331 in 2010 to 33,538 in 2015), children with chronic pulmonary and cardio-vascular diseases, immune deficiency, weak and sickly children above six months by 39% (from 63,122 in 2010 to 158,023 in 2015), adults with chronic co-morbidities by 27% (from 44,271 in 2010 to 162,595 in 2015), persons above 65 by 17% (from 10,276 in 2010 to 57,875 in 2015), and annual coverage of pregnant women on second or third trimester from 34,443 in 2010 to 37,969 in 2015. Starting from 2013 and until 2015 vaccination was performed in the region with coverage of at least 90% of children from 6 months to one year. The ARVI morbidity in this age group decreased 3.3 times from 8,687.8 per 100,000 of the population in 2010 to 2,585.8 per 100,000 of the population in 2015. Vaccination of pregnant women on 2-3 trimester was started in the region in 2012. Annual increase of vaccination coverage of pregnant women from 86.1% (34,443/40,000) in 2012 to 95% (37,969/40,000) in 2015 decreased the morbidity 1.5 times from 4,828.8 per 100,000 of population in 2012 to 3,022.7 per 100,000 of population in 2015. Following the increase of vaccination coverage of the population in South Kazakhstan region, the trend was observed of decrease of ARVI morbidity rates among the population and main risk groups, among pregnant women and children under one year.

Keywords: acute respiratory viral infections, flu, risk groups, vaccination

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4247 Impact Tensile Mechanical Properties of 316L Stainless Steel at Different Strain Rates

Authors: Jiawei Chen, Jia Qu, Dianwei Ju

Abstract:

316L stainless steel has good mechanical and technological properties, has been widely used in shipbuilding and aerospace manufacturing. In order to understand the effect of strain rate on the yield limit of 316L stainless steel and the constitutive relationship of the materials at different strain rates, this paper used the INSTRON-4505 electronic universal testing machine to study the mechanical properties of the tensile specimen under quasi-static conditions. Meanwhile, the Zwick-Roell RKP450 intelligent oscillometric impact tester was used to test the tensile specimens at different strain rates. Through the above two kinds of experimental researches, the relationship between the true stress-strain and the engineering stress-strain at different strain rates is obtained. The result shows that the tensile yield point of 316L stainless steel increases with the increase of strain rate, and the real stress-strain curve of the 316L stainless steel has a better normalization than that of the engineering stress-strain curve. The real stress-strain curves can be used in the practical engineering of impact stretch to improve its safety.

Keywords: impact stretch, 316L stainless steel, strain rate, real stress-strain, normalization

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4246 Mycobacterium Genome Extraction from Lymph Nodes of Sarcoidosis Cases Using Transbronchial Needle Aspiration: A Cross-Sectional Descriptive Essay On 1223 Patients

Authors: Atefeh Abedini, Pegah Soltani, Arda Kiani

Abstract:

Background: Sarcoidosis and Tuberculosis are both considered granulomatous chronic diseases with some similar pulmonary and extra-pulmonary manifestations. It is hypothesized that given these morphological similarities, the genome of mycobacterium could have an impact on the development of Sarcoidosis. Identifying the potential correlation of these diseases may assist in the management of sarcoidosis. Herein, we aimed to inspect the lymph node biopsy of sarcoidosis patients for the existence of the HSP-65 mycobacterium DNA sequence. Methods: This cross-sectional survey was conducted on 1188 Sarcoidosis patients without active/latent tuberculosis infection who were diagnosed in Masih Daneshvari Hospital in Tehran, Iran, from January 2020 to January 2022. Trans-bronchial needle aspiration (TBNA) was performed due to bilateral hilar lymphadenopathy to take a specimen. Results: The under-evaluated patients were mainly women (N=815 (68.6%)), none-smoker (N=1016 (85.5%)), and middle-aged (50.1 (SD=4.22)) with average angiotensin-converting enzyme (ACE) index of 75.6 (SD=6.42). Dyslipidemias (n=314 (26.4%), Hypertension (n=295 (24.8%)), Diabetes mellitus (n=131 (11.0%)), and chronic heart diseases (n=97 (8.2%)) had the highest prevalence between comorbidities. Skin lesions (n= 655 (55.1%)), ophthalmic (n=341 (28.7%)), and cardiac involvement (n=229 (19.3%)) were obtained as the most common extra-pulmonary characteristics of the patients. Amongst 1188 enrolled patients who were not afflicted with Mycobacterium tuberculosis based on smear/culture essay, clinical symptoms, and Chest x-ray screening, 121 (10.2%) cases had detectable amplified DNA for Mycobacterium Tuberculosis extracted from mediastinal lung lymph nodes. Conclusion: In this survey, the mycobacterium genome was detected in almost 1 per 10 case biopsies of sarcoidosis. The remarkable number of cases (n=1188) evaluated in this study was the strength of this study which supported the hypothesis regarding sarcoidosis and mycobacterium genome correlation. Further investigation, such as case-control surveys, is required to better clarify this association.

Keywords: mycobacterium tuberculosis, sarcoidosis, genome, DNA, trans-bronchial needle aspiration

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4245 Influence of Urban Design on Pain and Disability in Women with Chronic Low Back Pain in Urban Cairo

Authors: Maha E. Ibrahim, Mona Abdel Aziz

Abstract:

Background: Chronic low back pain (CLBP) in urban communities represents a challenge to healthcare systems worldwide. The traditional biomedical approach to back pain has been particularly inadequate. Failure of the biomedical model to explain the poor correlation between pain and disability on the one hand, and biological and physical factors that explain those symptoms on the other has led to the adoption of the biopsychosocial model, to recognize the reciprocal influence of physical, social and psychological factors implicated in CLBP, a condition that shows higher prevalence among women residing in urban areas. Urban design of the built community has been shown to exert a significant influence on physical and psychological health. However, little research has investigated the relationship between elements of the built environment, and the level of pain and disability of women with CLBP. As Egypt embarks on building a new capital city, and new settlements proliferate, better understanding of this relationship could greatly reduce the economic and human costs of this widespread medical problem for women. Methods: This study was designed as an exploratory mixed qualitative and quantitative study. Twenty-Six women with CLBP living in two neighborhoods in Cairo, different in their urban structure, but adjacent in their locations (Old Maadi and New Maadi) were interviewed using semi-structured interviews (8 from Old Maadi and 18 from New Maadi). Located in the South of Cairo, New Maadi is a neighborhood with the characteristic modern urban style (narrow streets and tall, adjacent buildings), while Old Maadi is known for being greener, quieter and more relaxed than the usual urban districts of Cairo. The interviews examined their perceptions of the built environment, including building shapes and colors and street light, as well as their sense of safety and comfort, and how it affects their physical and psychological health in general, and their back condition in particular. In addition, they were asked to rate their level of pain and to fill the Oswestry Disability Index (ODI), and the General Health Questionnaire (GHQ-12) to rate their level of disability and psychological status, respectively. Results: Women in both districts had moderate to severe pain and moderate disability with no significant differences between the two districts. However, those living in New Maadi had significantly worse scores on the GHQ-12 than those living in Old Maadi. Most women did not feel that specific elements of the built environment affected their back pain, however, they expressed distress of the elements that were ugly, distorted or damaged, especially where there were no ways of avoiding or fixing them. Furthermore, most women affirmed that the unsightly and uncomfortable elements of their neighborhoods affected their mood states and were a constant source of stress. Conclusion: This exploratory study concludes that elements of the urban built environment do not exert a direct effect on CLBP. However, the perception of women regarding these elements does affect their mood states, and their levels of stress, making them a possible indirect cause of increased suffering in these women.

Keywords: built environment, chronic back pain, disability, urban Cairo

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4244 Effectiveness of Office-Based Occupational Therapy for Office Workers with Low Back Pain: A Public Health Approach

Authors: Dina Jalalvand, Joshua A. Cleland

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This double-blind, randomized control trial with parallel groups aimed to examine the effectiveness of office-based occupational therapy for office workers with low back pain on the intensity of pain and range of motion. Seventy-two male office workers (age: 20-50 years) with chronic low back pain (more than three months with at least two symptoms of chronic low back pain) satisfied eligibility criteria and agreed to participate in this study. The absence of joint burst following magnetic resonance imagining (MRI) was considered as an important inclusion criterion as well. Subjects were randomly assigned to a control or experimental group. The experimental group received the modified package of exercise-based occupational therapy, which included 11 simple exercise movements (derived from Williams and McKenzie), and the control group just received the conventional therapy, which included their routine physiotherapy sessions. The subjects completed the exercises three times a week for a duration of six weeks. Each exercise session was 10-15 minutes. Pain intensity and range of motion were the primary outcomes and were measured at baseline, 6 weeks, and 12 weeks after the end of the intervention using the numerical rating scale (NRS) and goniometer accordingly. Repeated measure ANOVA was used for analyzing data. The results of this study showed that significant decreases in pain intensity (p ≤ 0.05) and an increase in range of motion (p ≤ 0.001) in the experimental group in comparison with the control group after 6 and 12 weeks of intervention (between-group comparisons). In addition, there was a significant decrease in intensity of the pain (p ≤ 0.05) and an increase (p ≤ 0.001) in range of motion in the intervention group in comparison with baseline after 6 and 12 weeks (within-group comparison). This showed a positive effect of exercise-based occupational therapy that could potentially be used with low cost among office workers who suffer from low back pain. In addition, it should be noted that the introduced package of exercise training is easy to do, and there is not a need for a specific introduction.

Keywords: public health, office workers, low back pain, occupational therapy

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4243 A Numerical Study on Micromechanical Aspects in Short Fiber Composites

Authors: I. Ioannou, I. M. Gitman

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This study focused on the contribution of micro-mechanical parameters on the macro-mechanical response of short fiber composites, namely polypropylene matrix reinforced by glass fibers. In the framework of this paper, an attention has been given to the glass fibers length, as micromechanical parameter influences the overall macroscopic material’s behavior. Three dimensional numerical models were developed and analyzed through the concept of a Representative Volume Element (RVE). Results of the RVE-based approach were compared with analytical Halpin-Tsai’s model.

Keywords: effective properties, homogenization, representative volume element, short fiber reinforced composites

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4242 Investigation of Film and Mechanical Properties of Poly(Lactic Acid)

Authors: Reyhan Özdoğan, Özgür Ceylan, Mehmet Arif Kaya, Mithat Çelebi

Abstract:

Food packaging is important for the food industry. Bioplastics have been used as food packaging materials. According to the European Bioplastics organization, bioplastics can be defined as plastics based on renewable resources (bio-based) or as plastics which are biodegradable and/or compostable. Poly(lactic acid) (PLA) has an industrially importance of bioplastic polymers. PLA is a family of biodegradable thermoplastic polyester made from renewable resources. It is produced by conversion of corn, or other carbohydrate sources, into dextrose, followed by fermentation into lactic acid through direct polycondensation of lactic acid monomers or through ring-opening polymerization of lactide. The processing possibilities of this transparent material are very wide, ranging from injection molding and extrusion over cast film extrusion to blow molding and thermoforming. In this study, PLA films were prepared by solution casting method. PLAs which are different molecular weights were plasticized with glycerol and the morphology of films was monitored by optical microscopy. Properties of mechanical and film of PLA were researched with the mechanical testing machine.

Keywords: biodegradable, bioplastics, morphology, solution casting, poly(lactic acid)

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4241 Effects of Different Mechanical Treatments on the Physical and Chemical Properties of Turmeric

Authors: Serpa A. M., Gómez Hoyos C., Velásquez-Cock J. A., Ruiz L. F., Vélez Acosta L. M., Gañan P., Zuluaga R.

Abstract:

Turmeric (Curcuma Longa L) is an Indian rhizome known for its biological properties, derived from its active compounds such as curcuminoids. Curcumin, the main polyphenol in turmeric, only represents around 3.5% of the dehydrated rhizome and extraction yields between 41 and 90% have been reported. Therefore, for every 1000 tons of turmeric powder used for the extraction of curcumin, around 970 tons of residues are generated. The present study evaluates the effect of different mechanical treatments (waring blender, grinder and high-pressure homogenization) on the physical and chemical properties of turmeric, as an alternative for the transformation of the entire rhizome. Suspensions of turmeric (10, 20 y 30%) were processed by waring blender during 3 min at 12000 rpm, while the samples treated by grinder were processed evaluating two different Gaps (-1 and -1,5). Finally, the process by high-pressure homogenization, was carried out at 500 bar. According to the results, the luminosity of the samples increases with the severity of the mechanical treatment, due to the stabilization of the color associated with the inactivation of the oxidative enzymes. Additionally, according to the microstructure of the samples, the process by grinder (Gap -1,5) and by high-pressure homogenization allowed the largest size reduction, reaching sizes up to 3 m (measured by optical microscopy). This processes disrupts the cells and breaks their fragments into small suspended particles. The infrared spectra obtained from the samples using an attenuated total reflectance accessory indicates changes in the 800-1200 cm⁻¹ region, related mainly to changes in the starch structure. Finally, the thermogravimetric analysis shows the presence of starch, curcumin and some minerals in the suspensions.

Keywords: characterization, mechanical treatments, suspensions, turmeric rhizome

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4240 Total Plaque Area in Chronic Renal Failure

Authors: Hernán A. Perez, Luis J. Armando, Néstor H. García

Abstract:

Background and aims Cardiovascular disease rates are very high in patients with renal failure (CRF), but the underlying mechanisms are incompletely understood. Traditional cardiovascular risk factors do not explain the increased risk, and observational studies have observed paradoxical or absent associations between classical risk factors and mortality in dialysis patients. A large randomized controlled trial, the 4D Study, the AURORA and the ALERT study found that statin therapy in CRF do not reduce cardiovascular events. These results may be the results of ‘accelerated atherosclerosis’ observed on these patients. The objective of this study was to investigate if carotid total plaque area (TPA), a measure of carotid plaque burden growth is increased at progressively lower creatinine clearance in patients with CRF. We studied a cohort of patients with CRF not on dialysis, reasoning that risk factor associations might be more easily discerned before end stage renal disease. Methods: The Blossom DMO Argentina ethics committee approved the study and informed consent from each participant was obtained. We performed a cohort study in 412 patients with Stage 1, 2 and 3 CRF. Clinical and laboratory data were obtained. TPA was determined using bilateral carotid ultrasonography. Modification of Diet in Renal Disease estimation formula was used to determine renal function. ANOVA was used when appropriate. Results: Stage 1 CRF group (n= 16, 43±2yo) had a blood pressure of 123±2/78±2 mmHg, BMI 30±1, LDL col 145±10 mg/dl, HbA1c 5.8±0.4% and had the lowest TPA 25.8±6.9 mm2. Stage 2 CRF (n=231, 50±1 yo) had a blood pressure of 132±1/81±1 mmHg, LDL col 125±2 mg/dl, HbA1c 6±0.1% and TPA 48±10mm2 ( p< 0.05 vs CRF stage 1) while Stage 3 CRF (n=165, 59±1 yo) had a blood pressure of 134±1/81±1, LDL col 125±3 mg/dl, HbA1c 6±0.1% and TPA 71±6mm2 (p < 0.05 vs CRF stage 1 and 2). Conclusion: Our data indicate that TPA increases along the renal function deterioration, and it is not related with the LDL cholesterol and triglycerides levels. We suggest that mechanisms other than the classics are responsible for the observed excess of cardiovascular disease in CKD patients and finally, determination of total plaque area should be used to measure effects of antiatherosclerotic therapy.

Keywords: hypertension, chronic renal failure, atherosclerosis, cholesterol

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4239 Healthcare Utilization and Costs of Specific Obesity Related Health Conditions in Alberta, Canada

Authors: Sonia Butalia, Huong Luu, Alexis Guigue, Karen J. B. Martins, Khanh Vu, Scott W. Klarenbach

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Obesity-related health conditions impose a substantial economic burden on payers due to increased healthcare use. Estimates of healthcare resource use and costs associated with obesity-related comorbidities are needed to inform policies and interventions targeting these conditions. Methods: Adults living with obesity were identified (a procedure-related body mass index code for class 2/3 obesity between 2012 and 2019 in Alberta, Canada; excluding those with bariatric surgery), and outcomes were compared over 1-year (2019/2020) between those who had and did not have specific obesity-related comorbidities. The probability of using a healthcare service (based on the odds ratio of a zero [OR-zero] cost) was compared; 95% confidence intervals (CI) were reported. Logistic regression and a generalized linear model with log link and gamma distribution were used for total healthcare cost comparisons ($CDN); cost ratios and estimated cost differences (95% CI) were reported. Potential socio-demographic and clinical confounders were adjusted for, and incremental cost differences were representative of a referent case. Results: A total of 220,190 adults living with obesity were included; 44% had hypertension, 25% had osteoarthritis, 24% had type-2 diabetes, 17% had cardiovascular disease, 12% had insulin resistance, 9% had chronic back pain, and 4% of females had polycystic ovarian syndrome (PCOS). The probability of hospitalization, ED visit, and ambulatory care was higher in those with a following obesity-related comorbidity versus those without: chronic back pain (hospitalization: 1.8-times [OR-zero: 0.57 [0.55/0.59]] / ED visit: 1.9-times [OR-zero: 0.54 [0.53/0.56]] / ambulatory care visit: 2.4-times [OR-zero: 0.41 [0.40/0.43]]), cardiovascular disease (2.7-times [OR-zero: 0.37 [0.36/0.38]] / 1.9-times [OR-zero: 0.52 [0.51/0.53]] / 2.8-times [OR-zero: 0.36 [0.35/0.36]]), osteoarthritis (2.0-times [OR-zero: 0.51 [0.50/0.53]] / 1.4-times [OR-zero: 0.74 [0.73/0.76]] / 2.5-times [OR-zero: 0.40 [0.40/0.41]]), type-2 diabetes (1.9-times [OR-zero: 0.54 [0.52/0.55]] / 1.4-times [OR-zero: 0.72 [0.70/0.73]] / 2.1-times [OR-zero: 0.47 [0.46/0.47]]), hypertension (1.8-times [OR-zero: 0.56 [0.54/0.57]] / 1.3-times [OR-zero: 0.79 [0.77/0.80]] / 2.2-times [OR-zero: 0.46 [0.45/0.47]]), PCOS (not significant / 1.2-times [OR-zero: 0.83 [0.79/0.88]] / not significant), and insulin resistance (1.1-times [OR-zero: 0.88 [0.84/0.91]] / 1.1-times [OR-zero: 0.92 [0.89/0.94]] / 1.8-times [OR-zero: 0.56 [0.54/0.57]]). After fully adjusting for potential confounders, the total healthcare cost ratio was higher in those with a following obesity-related comorbidity versus those without: chronic back pain (1.54-times [1.51/1.56]), cardiovascular disease (1.45-times [1.43/1.47]), osteoarthritis (1.36-times [1.35/1.38]), type-2 diabetes (1.30-times [1.28/1.31]), hypertension (1.27-times [1.26/1.28]), PCOS (1.08-times [1.05/1.11]), and insulin resistance (1.03-times [1.01/1.04]). Conclusions: Adults with obesity who have specific disease-related health conditions have a higher probability of healthcare use and incur greater costs than those without specific comorbidities; incremental costs are larger when other obesity-related health conditions are not adjusted for. In a specific referent case, hypertension was costliest (44% had this condition with an additional annual cost of $715 [$678/$753]). If these findings hold for the Canadian population, hypertension in persons with obesity represents an estimated additional annual healthcare cost of $2.5 billion among adults living with obesity (based on an adult obesity rate of 26%). Results of this study can inform decision making on investment in interventions that are effective in treating obesity and its complications.

Keywords: administrative data, healthcare cost, obesity-related comorbidities, real world evidence

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4238 Alpha-To-Omega Phase Transition in Bulk Nanostructured Ti and (α+β) Ti Alloys

Authors: Askar Kilmametov, Julia Ivanisenko, Boris Straumal, Horst Hahn

Abstract:

The high-pressure α- to ω-phase transition was discovered in elemental Ti and Zr fifty years ago using static high pressure and then observed to appear between 2 and 12 GPa at room temperature, depending on the experimental technique, the pressure environment, and the sample purity. The fact that ω-phase is retained in a metastable state in ambient condition after the removal of the pressure has been used to check the changes in magnetic and superconductive behavior, electron band structure and mechanical properties. However, the fundamental knowledge on a combination of both mechanical treatment and high applied pressure treatments for ω-phase formation in Ti alloys is currently lacking and has to be studied in relation to improved mechanical properties of bulk nanostructured states. In the present study, nanostructured (α+β) Ti alloys containing β-stabilizing elements such as Co, Fe, Cr, Nb were performed by severe plastic deformation, namely high pressure torsion (HPT) technique. HPT-induced α- to ω-phase transformation was revealed in dependence on applied pressure and shear strains by means of X-ray diffraction, transmission electron microscopy, and differential scanning calorimetry. The transformation kinetics was compared with the kinetics of pressure-induced transition. Orientation relationship between α-, β- and ω-phases was taken into consideration and analyzed according to theoretical calculation proposed earlier. The influence of initial state before HPT appeared to be considerable for subsequent α- to ω-phase transition. Thermal stability of the HPT-induced ω-phase was discussed as well in the frame of mechanical behavior of Ti and Ti-based alloys produced by shear deformation under high applied pressure.

Keywords: bulk nanostructured materials, high pressure phase transitions, severe plastic deformation, titanium alloys

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4237 Chemical, Structural and Mechanical Optimization of Zr-Based Bulk Metallic Glass for Biomedical Applications

Authors: Eliott Guérin, Remi Daudin, Georges Kalepsi, Alexis Lenain, Sebastien Gravier, Benoit Ter-Ovanessian, Damien Fabregue, Jean-Jacques Blandin

Abstract:

Due to interesting compromise between mechanical and corrosion properties, Zr-based BMGs are attractive for biomedical applications. However, the enhancement of their glass forming ability (GFA) is often achieved by addition of toxic elements like Ni or Be, which is of course a problem for such applications. Consequently, the development of Ni-free Be-free Zr-based BMGs is of great interest. We have developed a Zr-based (Ni and Be-free) amorphous metallic alloy with an elastic limit twice the one of Ti-6Al-4V. The Zr56Co28Al16 composition exhibits a yield strength close to 2 GPa and low Young’s modulus (close to 90 GPa) [1-2]. In this work, we investigated Niobium (Nb) addition through substitution of Zr up to 8 at%. Cobalt substitution has already been reported [3], but we chose Zr substitution to preserve the glass forming ability. In this case, we show that the glass forming ability for 5 mm diameters rods is maintained up to 3 at% of Nb substitution using suction casting in cooper moulds. Concerning the thermal stability, we measure a strong compositional dependence on the glass transition (Tg). Using DSC analysis (heating rate 20 K/min), we show that the Tg rises from 752 K for 0 at% of Nb to 759 K for 3 at% of Nb. Yet, the thermal range between Tg and the crystallisation temperature (Tx) remains almost unchanged from 33 K to 35 K. Uniaxial compression tests on 2 mm diameter pillars and 3 points bending (3PB) tests on 1 mm thick plates are performed to study the Nb addition on the mechanical properties and the plastic behaviour. With these tests, an optimal Nb concentration is found, improving both plasticity and fatigue resistance. Through interpretations of DSC measurements, an attempt is made to correlate the modifications of the mechanical properties with the structural changes. The optimized chemical, structural and mechanical properties through Nb addition are encouraging to develop the potential of this BMG alloy for biomedical applications. For this purpose, we performed polarisation, immersion and cytotoxicity tests. The figure illustrates the polarisation response of Zr56Co28Al16, Zr54Co28Al16Nb2 and TA6V as a reference after 2h of open circuit potential. The results show that the substitution of Zr by a small amount of Nb significantly improves the corrosion resistance of the alloy.

Keywords: metallic glasses, amorphous metal, medical, mechanical resistance, biocompatibility

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4236 Osteoprotegerin and Osteoprotegerin/TRAIL Ratio are Associated with Cardiovascular Dysfunction and Mortality among Patients with Renal Failure

Authors: Marek Kuźniewski, Magdalena B. Kaziuk , Danuta Fedak, Paulina Dumnicka, Ewa Stępień, Beata Kuśnierz-Cabala, Władysław Sułowicz

Abstract:

Background: The high prevalence of cardiovascular morbidity and mortality among patients with chronic kidney disease (CKD) is observed especially in those undergoing dialysis. Osteoprotegerin (OPG) and its ligands, receptor activator of nuclear factor kappa-B ligand (RANKL) and tumor necrosis factor-related apoptosis-inducing ligand (TRAIL) have been associated with cardiovascular complications. Our aim was to study their role as cardiovascular risk factors in stage 5 CKD patients. Methods: OPG, RANKL and TRAIL concentrations were measured in 69 hemodialyzed CKD patients and 35 healthy volunteers. In CKD patients, cardiovascular dysfunction was assessed with aortic pulse wave velocity (AoPWV), carotid artery intima-media thickness (CCA-IMT), coronary artery calcium score (CaSc) and N-terminal pro-B-type natriuretic peptide (NT-proBNP) serum concentration. Cardiovascular and overall mortality data were collected during a 7-years follow-up. Results: OPG plasma concentrations were higher in CKD patients comparing to controls. Total soluble RANKL was lower and OPG/RANKL ratio higher in patients. Soluble TRAIL concentrations did not differ between the groups and OPG/TRAIL ratio was higher in CKD patients. OPG and OPG/TRAIL positively predicted long-term mortality (all-cause and cardiovascular) in CKD patients. OPG positively correlated with AoPWV, CCA-IMT and NT-proBNP whereas OPG/TRAIL with AoPWV and NT-proBNP. Described relationships were independent of classical and non-classical cardiovascular risk factors, with exception of age. Conclusions: Our study confirmed the role of OPG as a biomarker of cardiovascular dysfunction and a predictor of mortality in stage 5 CKD. OPG/TRAIL ratio can be proposed as a predictor of cardiovascular dysfunction and mortality.

Keywords: osteoprotegerin, tumor necrosis factor-related apoptosis-inducing ligand, receptor activator of nuclear factor kappa-B ligand, hemodialysis, chronic kidney disease, cardiovascular disease

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4235 Influence of Modified and Unmodified Cow Bone on the Mechanical Properties of Reinforced Polyester Composites for Biomedical Applications

Authors: I. O. Oladele, J. A. Omotoyinbo, A. M. Okoro, A. G. Okikiola, J. L. Olajide

Abstract:

This work was carried out to investigate comparatively the effects of modified and unmodified cow bone particles on the mechanical properties of polyester matrix composites in order to investigate the suitability of the materials as biomaterial. Cow bones were procured from an abattoir, sun dried for 4 weeks and crushed. The crushed bones were divided into two, where one part was turned to ash while the other part was pulverized with laboratory ball mill before the two grades were sieved using 75 µm sieve size. Bone ash and bone particle reinforced tensile and flexural composite samples were developed from pre-determined proportions of 2, 4, 6, and 8 %. The samples after curing were stripped from the moulds and were allowed to further cure for 3 weeks before tensile and flexural tests were performed on them. The tensile test result showed that, 8 wt % bone particle reinforced polyester composites has higher tensile properties except for modulus of elasticity where 8 wt % bone ash particle reinforced composites has higher value while for flexural test, bone ash particle reinforced composites demonstrate the best flexural properties. The results show that these materials are structurally compatible.

Keywords: biomedical, composites, cow bone, mechanical properties, polyester, reinforcement

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4234 The Clinical Significance of Cutaneous Leishmaniasis in Immigrant and Refugee Populations

Authors: Promise Ufomadu, Edgar Rodriguez, Grace Lee

Abstract:

Cutaneous Leishmaniasis (CL) is an infection caused by a variety of Leishmania species which are protozoan organisms that are typically carried by sandflies found in tropical regions. The parasite causes skin lesions that may resolve spontaneously but commonly become chronic and therefore necessitate thorough clinical attention. We present a 15-year-old female patient with CL of her bilateral dorsal hands, which resolved after a 28-day course of miltefosine. This case details the significance of compiling a thorough patient history and considering CL as a possible differential in patients from endemic regions.

Keywords: leishmaniasis, infection, immigrant, parasites, pediatrics

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4233 Investigation of the Mechanical Performance of Hot Mix Asphalt Modified with Crushed Waste Glass

Authors: Ayman Othman, Tallat Ali

Abstract:

The successive increase of generated waste materials like glass has led to many environmental problems. Using crushed waste glass in hot mix asphalt paving has been though as an alternative to landfill disposal and recycling. This paper discusses the possibility of utilizing crushed waste glass, as a part of fine aggregate in hot mix asphalt in Egypt. This is done through evaluation of the mechanical properties of asphalt concrete mixtures mixed with waste glass and determining the appropriate glass content that can be adapted in asphalt pavement. Four asphalt concrete mixtures with various glass contents, namely; 0%, 4%, 8% and 12% by weight of total mixture were studied. Evaluation of the mechanical properties includes performing Marshall stability, indirect tensile strength, fracture energy and unconfined compressive strength tests. Laboratory testing had revealed the enhancement in both compressive strength and Marshall stability test parameters when the crushed glass was added to asphalt concrete mixtures. This enhancement was accompanied with a very slight reduction in both indirect tensile strength and fracture energy when glass content up to 8% was used. Adding more than 8% of glass causes a sharp reduction in both indirect tensile strength and fracture energy. Testing results had also shown a reduction in the optimum asphalt content when the waste glass was used. Measurements of the heat loss rate of asphalt concrete mixtures mixed with glass revealed their ability to hold heat longer than conventional mixtures. This can have useful application in asphalt paving during cold whether or when a long period of post-mix transportation is needed.

Keywords: waste glass, hot mix asphalt, mechanical performance, indirect tensile strength, fracture energy, compressive strength

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4232 Enhanced Mechanical Properties and Corrosion Resistance of Fe-Based Thin Film Metallic Glasses via Pulsed Laser Deposition

Authors: Ali Obeydavi, Majid Rahimi

Abstract:

This study explores the synthesis and characterization of Fe-Cr-Mo-Co-C-B-Si thin film metallic glasses fabricated using the pulsed laser deposition (PLD) technique on silicon wafer and 304 stainless steel substrates. it systematically varied the laser pulse numbers (20,000; 30,000; 40,000) and energies (130, 165, 190 mJ) to investigate their effects on the microstructural, mechanical, and corrosion properties of the deposited films. Comprehensive characterization techniques, including grazing incidence X-ray diffraction, field emission scanning electron microscopy, atomic force microscopy, and transmission electron microscopy with selected area electron diffraction, were utilized to assess the amorphous structure and surface morphology. Results indicated that increased pulse numbers and laser energies led to enhanced deposition rates and film thicknesses. Nanoindentation tests demonstrated that the hardness and elastic modulus of the amorphous thin films significantly surpassed those of the 304 stainless steel substrate. Additionally, electrochemical polarization and impedance spectroscopy revealed that the Fe-based metallic glass coatings exhibited superior corrosion resistance compared to the stainless steel substrate. The observed improvements in mechanical and corrosion properties are attributed to the unique amorphous structure achieved through the PLD process, highlighting the potential of these materials for protective coatings in aggressive environments.

Keywords: thin film metallic glasses, pulsed laser deposition, mechanical properties, corrosion resistance

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4231 Effect of Milling Parameters on the Characteristics of Nanocrystalline TiAl Alloys Synthesized by Mechanical Alloying

Authors: Jinan B. Al-Dabbagh, Rozman Mohd Tahar, Mahadzir Ishak

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TiAl alloy nano-powder was successfully produced by a mechanical alloying (MA) technique in a planetary ball mill. The influence of milling parameters, such as the milling duration, rotation speed, and balls-to-powder mass ratio, on the characteristics of the Ti50%Al powder, including the microstructure, crystallite size refinement, and phase formation, were investigated. It was found that MA of elemental Ti and Al powders promotes the formation of TiAl alloys, as Ti (Al) solid solution was formed after 5h of milling. Milling without the addition of process control agents led to a dramatic decrease in the crystallite size to 17.8 nm after 2h of milling. Higher rotation energy and a higher ball-to-powder weight ratio also accelerated the reduction in crystallite size. Subsequent heating up to 850°C resulted in the formation of a new intermetallic phase with a dominant TiAl3 phase plus minor γ-TiAl or α2-Ti3Al phase or both. A longer milling duration also exhibited a better effect on the micro-hardness of Ti50%Al powders.

Keywords: TiAl alloys, nanocrystalline materials, mechanical alloying, materials science

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4230 Utilization of Nanoclay to Reinforce Flax Fabric-Geopolymer Composites

Authors: H. S. Assaedi, F. U. A. Shaikh, I. M. Low

Abstract:

Geopolymer composites reinforced with flax fabrics and nano-clay are fabricated and studied for physical and mechanical properties using X-Ray Diffraction (XRD), Fourier Transform Infrared Spectroscopy (FTIR) and Scanning Electron Microscope (SEM). Nanoclay platelets at a weight of 1.0%, 2.0%, and 3.0% were added to geopolymer pastes. Nanoclay at 2.0 wt.% was found to improve density and decrease porosity while improving flexural strength and post-peak toughness. A microstructural analysis indicated that nanoclay behaves as filler and as an activator supporting geopolymeric reaction while producing a higher content geopolymer gel improving the microstructure of binders. The process enhances adhesion between the geopolymer matrix and flax fibres.

Keywords: flax fibres, geopolymer, mechanical properties, nanoclay

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4229 Molecular Dynamics Study on Mechanical Responses of Circular Graphene Nanoflake under Nanoindentation

Authors: Jeong-Won Kang

Abstract:

Graphene, a single-atom sheet, has been considered as the most promising material for making future nanoelectromechanical systems as well as purely electrical switching with graphene transistors. Graphene-based devices have advantages in scaled-up device fabrication due to the recent progress in large area graphene growth and lithographic patterning of graphene nanostructures. Here we investigated its mechanical responses of circular graphene nanoflake under the nanoindentation using classical molecular dynamics simulations. A correlation between the load and the indentation depth was constructed. The nanoindented force in this work was applied to the center point of the circular graphene nanoflake and then, the resonance frequency could be tuned by a nanoindented depth. We found the hardening or the softening of the graphene nanoflake during its nanoindented-deflections, and such properties were recognized by the shift of the resonance frequency. The calculated mechanical parameters in the force vs deflection plot were in good agreement with previous experimental and theoretical works. This proposed schematics can detect the pressure via the deflection change or/and the resonance frequency shift, and also have great potential for versatile applications in nanoelectromechanical systems.

Keywords: graphene, pressure sensor, circular graphene nanoflake, molecular dynamics

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4228 Exploring the Food Environments and Their Influence on Food Choices of Working Adults

Authors: Deepa Shokeen, Bani Tamber Aeri

Abstract:

Food environments are believed to play a significant role in the obesity epidemic and robust research methods are required to establish which factors or aspects of the food environment are relevant to food choice and to adiposity. The relationship between the food environment and obesity is complex. While there is little research linking food access with obesity as an outcome measure in any age group, with the help of this article we will try to understand the relationship between what we eat and the environmental context in which these food choices are made. Methods: A literature search of studies published between January 2000 and December 2013 was undertaken on computerized medical, social science, health, nutrition and education databases including Google, PubMed etc. Reports of organisations such as World Health Organisation (WHO), Centre for Chronic Disease Control (CCDC) were studied to project the data. Results: Studies show that food environments play a significant role in the obesity epidemic and robust research methods are required to establish which factors or aspects of the food environment are relevant to food choice and to adiposity. Evidence indicates that the food environment may help explain the obesity and cardio-metabolic risk factors among young adults. Conclusion: Cardiovascular disease is the ever growing chronic disease, the incidence of which will increase markedly in the coming decades. Therefore, it is the need of the hour to assess the prevalence of various risk factors that contribute to the incidence of cardiovascular diseases especially in the work environment. Research is required to establish how different environments affect different individuals as individuals interact with the environment on a number of levels. We need to ascertain the impact of selected food and nutrition environments (Information, organization, community, consumer) on food choice and dietary intake of the working adults as it is important to learn how these food environments influence the eating perceptions and health behaviour of the adults.

Keywords: food environment, prevalence, cardiovascular disease, India, worksite, risk factors

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4227 Ni-B Coating Production on Magnesium Alloy by Electroless Deposition

Authors: Ferhat Bülbül

Abstract:

The use of magnesium alloys is limited due to their susceptibility to corrosion although they have many attractive physical and mechanical properties. To increase mechanical and corrosion properties of these alloys, many deposition method and coating types are used. Electroless Ni–B coatings have received considerable interest recently due to its unique properties such as cost-effectiveness, thickness uniformity, good wear resistance, lubricity, good ductility and corrosion resistance, excellent solderability and electrical properties and antibacterial property. In this study, electroless Ni-B coating could been deposited on AZ91 magnesium alloy. The obtained coating exhibited an amorphous and rougher structure.

Keywords: magnesium, electroless Ni–B, X-ray diffraction, amorphous

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4226 Knowledge, Attitude and Beliefs Towards Polypharmacy Amongst Older People Attending Family Medicine Clinic at the Aga Khan University Hospital, Nairobi, Kenya (AKUHN) Sub-Saharan Africa-Qualitative Study

Authors: Maureen Kamau, Gulnaz Mohamoud, Adelaide Lusambili, Njeri Nyanja

Abstract:

Life expectancy has increased over the last century amongst older individuals, and in particular, those 60 years and over. The World Health Organization estimates that the world's population of persons over 60 years will rise to 22 per cent by the year 2050. Ageing is associated with increasing disability, multiple chronic conditions, and an increase in the use of health services. These multiple chronic conditions are managed with polypharmacy. Polypharmacy has numerous adverse effects including non-adherence, poor compliance to the various medications, reduced appetite, and risk of fall. Studies on polypharmacy and ageing are few and poorly understood especially in low and middle - income countries. The aim of this study was to explore the knowledge, attitudes and beliefs of older people towards polypharmacy. A qualitative study of 15 patients aged 60 years and above, taking more than five medications per day were conducted at the Aga Khan University using Semi-structured in-depth interviews. Three interviews were pilot interviews, and data analysis was performed on 12 interviews. Data were analyzed using NVIVO 12 software. A thematic qualitative analysis was carried out guided by Braun and Clarke (2006) framework. Themes identified; - knowledge of their co-morbidities and of the medication that older persons take, sources of information about medicines, and storage of the medication, experiences and attitudes of older patients towards polypharmacy both positive and negative, older peoples beliefs and their coping mechanisms with polypharmacy. The study participants had good knowledge on their multiple co-morbidities, and on the medication they took. The patients had positive attitudes towards medication as it enhanced their health and well-being, and enabled them to perform their activities of daily living. There was a strong belief among older patients that the medications were necessary for their health. All these factors enhanced compliance to the multiple medication. However, some older patients had negative attitudes due to the pill burden, side effects of the medication, and stigma associated with being ill. Cost of healthcare was a concern, with most of the patients interviewed relying on insurance to cover the cost of their medication. Older patients had accepted that the medication they were prescribed were necessary for their health, as it enabled them to complete their activities of daily living. Some concerns about the side effects of the medication arose, and brought about the need for patient education that would ensure that the patients are aware of the medications they take, and potential side effects. The effect that the COVID 19 pandemic had in the healthcare of the older patients was evident by the number of the older patients avoided coming to the hospital during the period of the pandemic. The relationship with the primary care physician and the older patients is an important one, especially in LMICs such as Kenya, as many of the older patients trusted the doctors wholeheartedly to make the best decision about their health and about their medication. Prescription review is important to avoid the use of potentially inappropriate medication.

Keywords: polypharmacy, older patients, multiple chronic conditions, Kenya, Africa, qualitative study, indepth interviews, primary care

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