Search results for: elderly falls

Authors: Delana Theiventhiran, Wally J. Bartfay

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Background and Significance: As the Internet is becoming the epitome of modern communications, there are many pragmatic reasons why the digital divide matters in terms of accessing and using E-health based technologies. With the rise of technology usage globally, those in the older adult generation may not be as familiar and comfortable with technology usage and are thus put at a disadvantage compared to other generations such as millennials when examining and using E-health based platforms and technology. Currently, little is known about how older adults and millennials access and use e-health based technologies. Methods: A systemic review of the literature was undertaken employing the following three databases: (i) PubMed, (ii) ERIC, and (iii) CINAHL; employing the search term 'digital divide and generations' to identify potential articles. To extract required data from the studies, a data abstraction tool was created to obtain the following information: (a) author, (b) year of publication, (c) sample size, (d) country of origin, (e) design/methods, (f) major findings/outcomes obtained. Inclusion criteria included publication dates between the years of Jan 2009 to Aug 2018, written in the English language, target populations of older adults aged 65 and above and millennials, and peer reviewed quantitative studies only. Major Findings: PubMed provided 505 potential articles, where 23 of those articles met the inclusion criteria. Specifically, ERIC provided 53 potential articles, where no articles met criteria following data extraction. CINAHL provided 14 potential articles, where eight articles met criteria following data extraction. Conclusion: Practically speaking, identifying how newer E-health based technologies can be integrated into society and identifying why there is a gap with digital technology will help reduce the impact on generations and individuals who are not as familiar with technology and Internet usage. The largest concern of all is how to prepare older adults for new and emerging E-health technologies. Currently, there is a dearth of literature in this area because it is a newer area of research and little is known about it. The benefits and consequences of technology being integrated into daily living are being investigated as a newer area of research. Several of the articles (N=11) indicated that age is one of the larger factors contributing to the digital divide. Similarly, many of the examined articles (N=5) identify that privacy concerns were one of the main deterrents of technology usage for elderly individuals aged 65 and above. The older adult generation feels that privacy is one of the major concerns, especially in regards to how data is collected, used and possibly sold to third party groups by various websites. Additionally, access to technology, the Internet, and infrastructure also plays a large part in the way that individuals are able to receive and use information. Lastly, a change in the way that healthcare is currently used, received and distributed would also help attribute to the change to ensure that no generation is left behind in a technologically advanced society.

Keywords: digital divide, e-health, millennials, older adults

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Authors: Marilena Fatigante

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Contemporary psychoanalysis is increasingly acknowledging the existential demands of clients in psychotherapy. A significant aspect of the personal crises that patients face today is often rooted in the difficulty to find meaning in their own existence, even after working through or resolving traumatic memories and experiences. Tracing back to the correspondence between Freud and Romain Rolland (1927), psychoanalysis could not ignore that investigation of the psyche also encompasses the encounter with deep, psycho-sensory experiences, which involve a sense of "being one with the external world as a whole", the well-known “oceanic feeling”, as Rolland posed it. Despite the recognition of Non-ordinary States of Consciousness (NSC) as catalysts for transformation in clinical practice, highlighted by neuroscience and results from psychedelic-assisted therapies, there is few research on how psychoanalytic knowledge can integrate with other treatment traditions. These traditions, commonly rooted in non -Western, unconventional, and non-formal psychological knowledge, emphasize the individual’s innate tendency toward existential integrity and transcendence of self-boundaries. Inspired by an autobiographical account, this paper examines narratives of 12 individuals, who engaged in psychoanalytic therapy and also underwent treatment involving a non-formal helping relationship with an expert guide in consciousness, which included experience of this nature. The guide relies on 35 yrs of experience in Psychological, multidisciplinary studies in Human Sciences and Art, and demonstrates knowledge of many wisdom traditions, ranging from Eastern to Western philosophy, including Psychoanalysis and its development in cultural perspective (e.g, Ethnopsychiatry). Analyses focused primarily on two dimensions that research has identified as central in assessing the degree of treatment “success” in the patients’ narrative accounts of their therapies: agency and coherence, defined respectively as the increase, expressed in language, of the client’s perceived ability to manage his/her own challenges and the capacity, inherent in “narrative” itself as a resource for meaning making (Bruner, 1990), to provide the subject with a sense of unity, endowing his /her life experience with temporal and logical sequentiality. The present study reports that, in all narratives from the participants, agency and coherence are described differently than in “common” psychotherapy narratives. Although the participants consistently identified themselves as responsible agentic subject, the sense of agency derived from the non-conventional guidance pathway is never reduced to a personal, individual accomplishment. Rather, the more a new, fuller sense of “Life” (more than “Self”) develops out of the guidance pathway they engage with the expert guide, the more they “surrender” their own sense of autonomy and self-containment. Something, which Safran (2016) identified as well talking about the sense of surrender and “grace” in psychoanalytic sessions. Secondly, narratives of individuals engaging with the expert guide describe coherence not as repairing or enforcing continuity but as enhancing their ability to navigate dramatic discontinuities, falls, abrupt leaps and passages marked by feelings of loss and bereavement. The paper ultimately explores whether valid criteria can be established to analyze experiences of non-conventional paths of self-evolution. These paths are not opposed or alternative to conventional ones, and should not be simplistically dismissed as exotic or magical.

Keywords: oceanic feeling, non conventional guidance, consciousness, narratives, treatment outcomes

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Authors: Wai Yan Shih, Sau Man Wong, Wing Chung Chang, Wai Chi Chan

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Background: Late-life depression is associated with significant consequences. Although symptomatic reduction is achievable through pharmacological interventions, older adults are more vulnerable to the side effects than their younger counterparts. In addition, drugs do not address underlying cognitive dysfunctions such as rumination and reduced autobiographical memory specificity (AMS), both shown to be maladaptive coping styles that are associated with a poorer prognosis in depression. Considering how aging is accompanied by cognitive, psychological and physical changes, the interplay of these age-related factors may potentially aggravate and interfere with these depressive cognitive dysfunctions in late-life depression. Special care should, therefore, be drawn to ensure these cognitive dysfunctions are adequately addressed. Aim: This randomized controlled trial aims to examine the effect of mindfulness-based cognitive therapy (MBCT) on depressed older adults, and whether the potential benefits of MBCT are mediated by improvements in rumination and AMS. Method: Fifty-seven participants with an average age of 70 years old were recruited from multiple elderly centers and online mailing lists. Participants were assessed with: (1) Hamilton depression scale, (2) ruminative response scale, (3) autobiographical memory test, (4) mindful attention awareness scale, and (5) Montreal cognitive assessment. Eligible participants with mild to moderate depressive symptoms and normal cognitive functioning were randomly allocated to an 8-week MBCT group or active control group consisting of a low-intensity exercise program and health education. Post-intervention assessments were conducted after the 8-week program. Ethics approval was given by the Institutional Review Board of the University of Hong Kong/Hospital Authority. Results: Mixed-factorials ANOVAs demonstrated significant time x group interaction effects for depressive symptoms, AMS, and dispositional mindfulness. A marginally significant interaction effect was found for rumination. Simple effect analyses revealed a significant reduction in depressive symptoms for the both the MBCT group (mean difference = 7.1, p = .000), and control group (mean difference = 2.7, p = .023). However, only participants in the MBCT group demonstrated improvements in rumination, AMS, and dispositional mindfulness. Bootstrapping-based mediation analyses showed that the effect of MBCT in alleviating depressive symptoms was only mediated by the reduction in rumination. Conclusions: The findings support the use of MBCT as an effective intervention for depressed older adults, considering the improvements in depressive symptoms, rumination, AMS and dispositional mindfulness despite their age. Reduction in ruminative tendencies plays a major role in the cognitive mechanism of MBCT.

Keywords: mindfulness-based cognitive therapy, depression, older adults, rumination, autobiographical memory specificity

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Authors: Beth Vale

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Academic research has often neglected the city after dark. Surprisingly little consideration has been given to the every night life of cities: the spatial tactics and creative insurgencies of urban residents when night falls. The focus on ‘pleasure’ in the nocturnal city has often negated the subtle politics of night-time play, embedded in expressions of identity, attachment and resistance. This paper investigates Johannesburg nightclubs as sites of quotidian political labour, through which young people contest social space and their place in it, thereby contributing to the city’s effective and socio-political cartography. The tactical remodelling of the nocturnal city through nightclubbing traces lines of desire (material, emotional, sexual), affiliation, and fear. These in turn map onto young people’s expressions of their social and political identities, as well as their attempts at place-making in a ‘post-apartheid’ context. By examining the micro-politics of the cities' nightclubs, this paper speaks back to an earlier post-94 literature, which regularly characterised Johannesburg youth as superficial, individualist and idealistic. Similarly, some might position nightclubs as sites of frivolous consumption or liberatory permissiveness. Yet because nightclub spaces are racialised, classed and gendered, historically-signified and socially regulated, they are also profoundly political. Through ordinary encounters on the cities' dancefloors, young Jo’burgers are imagining, contesting and negotiating their socio-political identities and indeed their claims to the city. Meanwhile, the politics of this generation of youth, who are increasingly critical of the utopian post-apartheid city, are being increasingly inserted and coopted into night-time cultures. Data for this study was gathered through five months of ethnographic fieldwork in Johannesburg nightclubs, including over 120 hours of participant observation and in-depth interviews with organisers and partygoers. Interviewees recognised that parties, rather than being simple frivolity, are a cacophony of celebration, mourning, worship, rage, rebellion and attachment. Countering standard associations between partying and escapism, party planners, venue owners and nightclub audiences were infusing night-time infrastructures with the aesthetics of politics and protest. Not unlike parties, local political assemblies so often rely on music, dance, the occupation of space, and a heaving crowd. References to social movements, militancy and anti-establishment emerged in nightclub themes, dress codes and décor. Metaphors of fire crossed over between party and protest, both of which could be described as having ‘been lit’ or having ‘brought flames’. More so, young people’s articulations of the city’s night-time geography, and their place in it, reflected articulations of race, class and ideological affiliation. The location, entrance fees and stylistic choices of one’s chosen club destination demarcated who was welcome, while also signalling membership to a particular politics (whether progressive or materialistic, inclusive or elitist, mainstream or counter-culture). Because of their ability to divide and unite, aggravate and titillate, mask and reveal, club cultures might offer a mirror to the complex socialities of a generation of Jo’burg youth, as they inhabit, and bring into being, a contemporary South African city.

Keywords: affect, Johannesburg, nightclub, nocturnal city, politics

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Authors: Jessica Cecchinelli, Amer Ali

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The continuing growth in road traffic and the resultant impact on the level of pollution and safety especially in urban areas have led local and national authorities to reduce traffic speed and flow in major towns and cities. Various boroughs of London have recently reduced the in-city speed limit from 30mph to 20mph mainly to calm traffic, improve safety and reduce noise and vibration. This paper reports the detailed field measurements using noise sensor and analyser and the corresponding theoretical calculations and analysis of the noise levels on a number of roads in the central London Borough of Camden where speed limit was reduced from 30mph to 20mph in all roads except the major routes of the ‘Transport for London (TfL)’. The measurements, which included the key noise levels and scales at residential streets and main roads, were conducted during weekdays and weekends normal and rush hours. The theoretical calculations were done according to the UK procedure ‘Calculation of Road Traffic Noise 1988’ and with conversion to the European L-day, L-evening, L-night, and L-den and other important levels. The current study also includes comparable data and analysis from previously measured noise in the Borough of Camden and other boroughs of central London. Classified traffic flow and speed on the roads concerned were observed and used in the calculation part of the study. Relevant data and description of the weather condition are reported. The paper also reports a field survey in the form of face-to-face interview questionnaires, which was carried out in parallel with the field measurement of noise, in order to ascertain the opinions and views of local residents and workers in the reduced speed zones of 20mph. The main findings are that the reduction in speed had reduced the noise pollution on the studied zones and that the measured and calculated noise levels for each speed zone are closely matched. Among the other findings was that of the field survey of the opinions and views of the local residents and workers in the reduced speed 20mph zones who supported the scheme and felt that it had improved the quality of life in their areas giving a sense of calmness and safety particularly for families with children, the elderly, and encouraged pedestrians and cyclists. The key conclusions are that lowering the speed limit in built-up areas would not just reduce the number of serious accidents but it would also reduce the noise pollution and promote clean modes of transport particularly walking and cycling. The details of the site observations and the corresponding calculations together with critical comparative analysis and relevant conclusions will be reported in the full version of the paper.

Keywords: noise calculation, noise field measurement, road traffic noise, speed limit in london, survey of people satisfaction

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Authors: Kristine Demilou D. Santiago

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An access to a high-quality health care system is what sets apart industrialized nations, such as the United States from other developing countries, which in this case is specifically pertaining to their older population. But what was the underrated factor in the sphere of quality healthcare rendered to elderly people in the Western context? Will this salient factor could push conviction to prorogue the existing gaps between self-denial patient-client and cheek by jowl medications? Are the natural socio-environmental approaches of caregiving the protracted remedy to healthcare disparities for aging population considering their day to day living? The conceptual framework of this model is primarily associated with addressing health and illness of human beings considering the biological, psychological and socio-environmental factors around them. The relevance of biopsychosocial formulation advancing each of the characteristics in the Biopsychosocial (BPS) model in a balance contemplation is the tumult of this study in an attempt to respond to prevailing disparities in caregiving services for old-aged patients on a day to day living. Caregiving services have been the medium path connecting between the patient and its prescribed medications. Moreover, caregivers serve as positive reinforcers in a patient’s environment. Therefore, caregivers play an important role in healthcare delivery to patients. They are considered significant people whom their acts will give an impact to a patient’s view in life. This research study intends to present the supreme importance of biopsychosocial assessment to old-aged patients with mental health illness and conditions. Biopsychosocial assessment will secure the quality of full medication to an old-aged adult suffering from a mental illness. This is because it offers a recognizably wholesome approach to medical healing of old-aged adult patients. The principle of biopsychosocial supersedes the biomedicine being offered to old-aged adults having mental illness, but it does not take away the high relevance of scientific biomedicine in healing patients. The framework presented an overlapping participation of each of its factors in its BPS model that affects in general a person’s health. The correlation between the biological (physiological), psychological (mental) and social (environment) in a person’s health condition requires equal attention according to BPS, and it always coexist with each other. Indisputably said, bio-medicine has been and is being in its unceasing endeavor to provide scientifically proven health care medications for every individual seeking medical treatments. As we grow older and eventually reach the other side of the median population, not only our physiological aspects change, our psychological and socio-environmental changes happen too. Caregiving is a salient responsibility taking place on these inevitable changes.

Keywords: biopsychosocial formulation, caregiving through natural approaches, US health care, BPS in caregiving, caregiving for aging population

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Authors: Stefan Fuchs

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Against the backdrop of the proliferation of shopping malls in Japan during the last two decades, this paper presents the results of an ethnography conducted at a recently built suburban shopping mall in Western Tokyo. Through the analysis of the lived experiences of local residents, mall customers and the mall management this paper evaluates the benefits and disadvantages of the Business Improvement District (BID) model, which was implemented as urban redevelopment strategy in the area surrounding the shopping mall. The results of this research project show that while the BID model has in some respects contributed to the economic prosperity and to the perceived convenience of the area, it has led to gentrification and the redevelopment shows some deficiencies with regard to the inclusion of the elderly population as well as to the democratization of the decision-making process within the area. In Japan, shopping malls have been steadily growing both in size and number since a series of deregulation policies was introduced in the year 2000 in an attempt to push the domestic economy and to rejuvenate urban landscapes. Shopping malls have thereby become defining spaces of the built environment and are arguably important places of social interaction. Notwithstanding the vital role they play as factors of urban transformation, they have been somewhat overlooked in the research on Japan; especially with respect to their meaning for people’s everyday lives. By examining the ways, people make use of space in a shopping mall the research project presented in this paper addresses this gap in the research. Moreover, the research site of this research project is one of the few BIDs of Japan and the results presented in this paper can give indication on the scope of the future applicability of this urban redevelopment model. The data presented in this research was collected during a nine-months ethnographic fieldwork in and around the shopping mall. This ethnography includes semi-structured interviews with ten key informants as well as direct and participant observations examining the lived experiences and perceptions of people living, shopping or working at the shopping mall. The analysis of the collected data focused on recurring themes aiming at ultimately capturing different perspectives on the same aspects. In this manner, the research project documents the social agency of different groups within one communal network. The analysis of the perceptions towards the urban redevelopment around the shopping mall has shown that mainly the mall customers and large businesses benefit from the BID redevelopment model. While local residents benefit to some extent from their neighbourhood becoming more convenient for shopping they perceive themselves as being disadvantaged by changing demographics due to rising living expenses, the general noise level and the prioritisation of a certain customer segment or age group at the shopping mall. Although the shopping mall examined in this research project is just an example, the findings suggest that in future urban redevelopment politics have to provide incentives for landowners and developing companies to think of other ways of transforming underdeveloped areas.

Keywords: business improvement district, ethnography, shopping mall, urban redevelopment

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Authors: Yuanyuan Fu

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Background and Purpose: Along with the change of society and economy, the traditional home function of old people has gradually weakened in the contemporary China. Acknowledging these situations, to better meet old people’s needs on formal services and improve the quality of later life, this study seeks to identify patterns of intended service use among frail old people living in the communities and examined determinants that explain heterogeneous variations in old people’s intended service use patterns. Additionally, this study also tested the relationship between culture value and intended service use patterns and the mediating role of enabling factors in terms of culture value and intended service use patterns. Methods：Participants were recruited from Haidian District, Beijing, China in 2015. The multi-stage sampling method was adopted to select sub-districts, communities and old people aged 70 years old or older. After screening, 577 old people with limitations in daily life, were successfully interviewed. After data cleaning, 550 samples were included for data analysis. This study establishes a conceptual framework based on the Anderson Model (including predisposing factors, enabling factors and need factors), and further developed it by adding culture value factors (including attitudes towards filial piety and attitudes towards social face). Using a latent class analysis (LCA), this study classifies overall patterns of old people’s formal service utilization. Fourteen types of formal services were taken into account, including housework, voluntary support, transportation, home-delivered meals, and home-delivery medical care, elderly’s canteen and day-care center/respite care and so on. Structural equation modeling (SEM) was used to examine the direct effect of culture value on service use pattern, and the mediating effect of the enabling factors. Results: The LCA classified a hierarchical structure of service use patterns: multiple intended service use (N=69, 23%), selective intended service use (N=129, 23%), and light intended service use (N=352, 64%). Through SEM, after controlling predisposing factors and need factors, the results showed the significant direct effect of culture value on older people’s intended service use patterns. Enabling factors had a partial mediation effect on the relationship between culture value and the patterns. Conclusions and Implications: Differentiation of formal services may be important for meeting frail old people’s service needs and distributing program resources by identifying target populations for intervention, which may make reference to specific interventions to better support frail old people. Additionally, culture value had a unique direct effect on the intended service use patterns of frail old people in China, enriching our theoretical understanding of sources of culture value and their impacts. The findings also highlighted the mediation effects of enabling factors on the relationship between culture value factors and intended service use patterns. This study suggests that researchers and service providers should pay more attention to the important role of culture value factors in contributing to intended service use patterns and also be more sensitive to the mediating effect of enabling factors when discussing the relationship between culture value and the patterns.

Keywords: frail old people, intended service use pattern, culture value, enabling factors, contemporary China, latent class analysis

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Authors: Dessy Pinem, Rahmadian Sembiring, Adanil Bushra

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Medan Belawan is one of the subdistricts of 21 districts in Medan. Medan Belawan Sub-district is directly adjacent to the Malacca Strait in the North. Due to its direct border with the Malacca Strait, the problem in this sub-district, which has continued for many years, is a flood of rob. In 2015, rob floods inundated Sicanang urban village, Belawan I urban village, Belawan Bahagia urban village and Bagan Deli village. The extent of inundation in the flood of rob that occurred in September 2015 reached 540, 938 ha. Rob flood is a phenomenon where the sea water is overflowing into the mainland. Rob floods can also be interpreted as a puddle of water on the coastal land that occurs when the tidal waters. So this phenomenon will inundate parts of the coastal plain or lower place of high tide sea level. Rob flood is a daily disaster faced by the residents in the district of Medan Belawan. Rob floods can happen every month and last for a week. The flood is not only the residents' houses, the flood also soaked the main road to Belawan Port reaching 50 cm. To deal with the problems caused by the flood and to prepare coastal communities to face the character of coastal areas, it is necessary to know the vulnerability of the people who are always the victims of the rob flood. Are the people of Medan Belawan sub-district, especially in the flood-affected villages, able to cope with the consequences of the floods? To answer this question, it is necessary to assess the vulnerability of the Belawan District community in the face of the flood disaster. This research is descriptive, qualitative and quantitative. Data were collected by observation, interview and questionnaires in 4 urban villages often affected by rob flood. The vulnerabilities measured are physical, economic, social, environmental, organizational and motivational vulnerabilities. For vulnerability in the physical field, the data collected is the distance of the building, floor area ratio, drainage, and building materials. For economic vulnerability, data collected are income, employment, building ownership, and insurance ownership. For the vulnerability in the social field, the data collected is education, number of family members, children, the elderly, gender, training for disasters, and how to dispose of waste. For the vulnerability in the field of organizational data collected is the existence of organizations that advocate for the victims, their policies and laws governing the handling of tidal flooding. The motivational vulnerability is seen from the information center or question and answer about the rob flood, and the existence of an evacuation plan or path to avoid disaster or reduce the victim. The results of this study indicate that most people in Medan Belawan sub-district have a high-level vulnerability in physical, economic, social, environmental, organizational and motivational fields. They have no access to economic empowerment, no insurance, no motivation to solve problems and only hope to the government, not to have organizations that support and defend them, and have physical buildings that are easily destroyed by rob floods.

Keywords: disaster, rob flood, Medan Belawan, vulnerability

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Authors: M. Attavanich, H. Kobayashi

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Moklen is a sub-group of ethnic minority in Thailand. In the past, they were vagabonds of the sea. Their livelihood relied on the sea but they built temporary shelters to avoid strong wind and waves during monsoon season. Recently, they have permanently settled on land along coastal area and mangrove forest in Phang Nga and Phuket Province, Southern Thailand. Moklen people have their own housing culture: the Moklen ethnic house was built from local natural materials, indicating a unique structure and design. Its wooden structure is joined by rattan ropes. The construction process is very unique because of using body-based unit of measurement for design and construction. However, there are several threats for those unique structures. One of the most important threats on Moklen ethnic house is tsunami. Especially the 2004 Indian Ocean Tsunami caused widely damage to Southern Thailand and Phang Nga province was the most affected area. In that time, Moklen villages which are located along the coastal area also affected calamitously. In order to recover the damage in affected villages, mostly new modern style houses were provided by aid agencies. This process has caused a significant impact on Moklen housing culture. Not only tsunami, but also modernization has an influence on the changing appearance of the Moklen houses and the effect of modernization has been started to experience before the tsunami. As a result, local construction knowledge is very limited nowadays because the number of elderly people in Moklen has been decreasing drastically. Last but not the least, restrictions of construction materials which are originally provided from accessible mangroves, create limitations in building a Moklen house. In particular, after the Reserved Forest Act, wood chopping without any permission has become illegal. These are some of the most important reasons for Moklen ethnic houses to disappear. Nevertheless, according to the results of field surveys done in 2013 in Phang Nga province, it is found out that some Moklen ethnic houses are still available in Tubpla Village, but only a few. Next survey in the same area in 2014 showed that number of Moklen houses in the village has been started to increase significantly. That proves that there is a high potential to conserve Moklen houses. Also the project of our research team in February 2014 contributed to continuation of Moklen ethnic house. With the cooperation of the village leader and our team, it was aimed to construct a Moklen house with the help of local participants. For the project, villagers revealed the building knowledge and techniques, and in the end, project helped community to understand the value of their houses. Also, it was a good opportunity for Moklen children to learn about their culture. In addition, NGOs recently have started to support ecotourism projects in the village. It not only helps to preserve a way of life, but also contributes to preserve indigenous knowledge and techniques of Moklen ethnic house. This kind of supporting activities are important for the conservation of Moklen ethnic houses.

Keywords: conservation, construction project, Moklen Ethnic House, 2004 Indian Ocean tsunami

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Authors: Bing Chen, Xiang Ni, Eric Li

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With the population ageing, the number of patients suffering from chronic diseases is increasing, among which stroke is a high incidence for the elderly. In addition, there is a gradual increase in the number of patients with orthopedic or neurological conditions such as spinal cord injuries, nerve injuries, and other knee injuries. These diseases are chronic, with high recurrence and complications, and normal walking is difficult for such patients. Nowadays, robotic knee exoskeletons have been developed for individuals with knee impairments. However, the currently available robotic knee exoskeletons are generally developed with heavyweight, which makes the patients uncomfortable to wear, prone to wearing fatigue, shortening the wearing time, and reducing the efficiency of exoskeletons. Some lightweight materials, such as carbon fiber and titanium alloy, have been used for the development of robotic knee exoskeletons. However, this increases the cost of the exoskeletons. This paper illustrates the design of a new ultra-light and ultra-stiff truss type of lattice structure. The lattice structures are arranged in a fan shape, which can fit well with circular arc surfaces such as circular holes, and it can be utilized in the design of rods, brackets, and other parts of a robotic knee exoskeleton to reduce the weight. The metamaterial is formed by continuous arrangement and combination of small truss structure unit cells, which changes the diameter of the pillar section, geometrical size, and relative density of each unit cell. It can be made quickly through additive manufacturing techniques such as metal 3D printing. The unit cell of the truss structure is small, and the machined parts of the robotic knee exoskeleton, such as connectors, rods, and bearing brackets, can be filled and replaced by gradient arrangement and non-uniform distribution. Under the condition of satisfying the mechanical properties of the robotic knee exoskeleton, the weight of the exoskeleton is reduced, and hence, the patient’s wearing fatigue is relaxed, and the wearing time of the exoskeleton is increased. Thus, the efficiency and wearing comfort, and safety of the exoskeleton can be improved. In this paper, a brief description of the hardware design of the prototype of the robotic knee exoskeleton is first presented. Next, the design of the ultra-light and ultra-stiff truss type of lattice structures is proposed, and the mechanical analysis of the single-cell unit is performed by establishing the theoretical model. Additionally, simulations are performed to evaluate the maximum stress-bearing capacity and compressive performance of the uniform arrangement and gradient arrangement of the cells. Finally, the static analysis is performed for the cell-filled rod and the unmodified rod, respectively, and the simulation results demonstrate the effectiveness and feasibility of the designed ultra-light and ultra-stiff truss type of lattice structures. In future studies, experiments will be conducted to further evaluate the performance of the designed lattice structures.

Keywords: additive manufacturing, lattice structures, metamaterial, robotic knee exoskeleton

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Authors: Huseyin Apdik, Aysegul Dogan, Selami Demirci, Ezgi Avsar Apdik, Fikrettin Sahin

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Mesenchymal stem cells (MSCs) are crucial cell types for bone maintenance and growth along with resident bone progenitor cells providing bone tissue integrity during osteogenesis and skeletal growth. Any deficiency in this regulation would result in vital bone diseases. Of those, osteoporosis, characterized by a reduction in bone mass and mineral density, is a critical skeletal disease for especially elderly people. The commonly used drugs for the osteoporosis treatment are bisphosphonates (BPs). The most prominent role of BPs is to prevent bone resorption arisen from high osteoclast activity. However, administrations of bisphosphonates may also cause bisphosphonate-induced osteonecrosis of the jaw (BIONJ). Up to the present, the researchers have proposed several circumstances for BIONJ. However, effects of long-term and/or high dose usage of BPs on stem cell’s proliferation, survival, differentiation or maintenance capacity have not been evaluated yet. The present study will be held to; figure out BPs’ effects on MSCs in vitro in the aspect of cell proliferation and toxicity, migration, angiogenic activity, lineage specific gene and protein expression levels, mesenchymal stem cell properties and potential signaling pathways affected by BP treatment. Firstly, mesenchymal stem cell characteristics of Dental Pulp Stem Cells (DPSCs) and Periodontal Ligament Stem Cells (PDLSCs) were proved using flow cytometry analysis. Cell viability analysis was completed to determine the cytotoxic effects of BPs (Zoledronate (Zol), Alendronate (Ale) and Risedronate (Ris)) on DPSCs and PDLSCs by the 3-(4,5-di-methyl-thiazol-2-yl)-5-(3-carboxymethoxy-phenyl)-2-(4-sulfo-phenyl)-2H-tetrazolium (MTS) assay. Non-toxic concentrations of BPs were determined at 24 h under growth condition, and at 21 days under osteogenic differentiation condition for both cells. The scratch assay was performed to evaluate their migration capacity under the usage of determined of BPs concentrations at 24 h. The results revealed that while the scratch closure is 70% in the control group for DPSCs, it was 57%, 66% and 66% in Zol, Ale and Ris groups, respectively. For PDLSs, while wound closure is 71% in control group, it was 65%, 66% and 66% in Zol, Ale and Ris groups, respectively. As future experiments, tube formation assay and aortic ring assay will be done to determinate angiogenesis abilities of DPSCs and PDLSCs treated with BPs. Expression levels of osteogenic differentiation marker genes involved in bone development will be determined using real time-polymerase change reaction (RT-PCR) assay and expression profiles of important proteins involved in osteogenesis will be evaluated using western blotting assay for osteogenically differentiated MSCs treated with or without BPs. In addition to these, von Kossa staining will be performed to measure calcium mineralization status of MSCs.

Keywords: bisphosphonates, bisphosphonate-induced osteonecrosis of the jaw, mesenchymal stem cells, osteogenesis

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Authors: Christian Bruss, Simona Gamba, Davide Azzolini, Federico Podestà

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In this paper, the authors assess the impact of different political and environmental shocks on the size and on the age and gender composition of asylum-related migration flows to Europe. With this paper, the authors contribute to the literature by looking at the impact of different political and environmental shocks on the gender and age composition of migration flows in addition to the size of these flows. Conflicting theories predict different outcomes concerning the relationship between political and environmental shocks and the migration flows composition. Analyzing the relationship between the causes of migration and the composition of migration flows could yield more insights into the mechanisms behind migration decisions. In addition, this research may contribute to better informing national authorities in charge of receiving these migrant, as women and children/the elderly require different assistance than young men. To be prepared to offer the correct services, the relevant institutions have to be aware of changes in composition based on the shock in question. The authors analyze the effect of different types of shocks on the number, the gender and age composition of first time asylum seekers originating from 154 sending countries. Among the political shocks, the authors consider: violence between combatants, violence against civilians, infringement of political rights and civil liberties, and state terror. Concerning environmental shocks, natural disasters (such as droughts, floods, epidemics, etc.) have been included. The data on asylum seekers applying to any of the 32 Schengen Area countries between 2008 and 2015 is on a monthly basis. Data on asylum applications come from Eurostat, data on shocks are retrieved from various sources: georeferenced conflict data come from the Uppsala Conflict Data Program (UCDP), data on natural disasters from the Centre for Research on the Epidemiology of Disasters (CRED), data on civil liberties and political rights from Freedom House, data on state terror from the Political Terror Scale (PTS), GDP and population data from the World Bank, and georeferenced population data from the Socioeconomic Data and Applications Center (SEDAC). The authors adopt a Difference-in-Differences identification strategy, exploiting the different timing of several kinds of shocks across countries. The highly skewed distribution of the dependent variable is taken into account by using count data models. In particular, a Zero Inflated Negative Binomial model is adopted. Preliminary results show that different shocks - such as armed conflict and epidemics - exert weak immediate effects on asylum-related migration flows and almost non-existent effects on the gender and age composition. However, this result is certainly affected by the fact that no time lags have been introduced so far. Finding the correct time lags depends on a great many variables not limited to distance alone. Therefore, finding the appropriate time lags is still a work in progress. Considering the ongoing refugee crisis, this topic is more important than ever. The authors hope that this research contributes to a less emotionally led debate.

Keywords: age, asylum, Europe, forced migration, gender

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Authors: Kristina Gordon

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One in three children in the United States is a victim of a maltreatment investigation, and about one in nine children has a substantiated investigation. Home visiting is one of several preventative strategies rooted in an early childhood approach that fosters maternal, infant, and early childhood health, protection, and growth. In the United States, 88% of states report administering home visiting programs or state-designed models. The purpose of this study was to conduct a systematic review on home visiting programs in the United States focused on the prevention of child abuse and neglect. This systematic review included 17 articles which found that most of the studies reported optimistic results. Common across studies was program content related to (1) typical child development, (2) parenting education, and (3) child physical health. Although several factors common to home visiting and parenting interventions have been identified, no research has examined the common components of manualized home visiting programs to prevent child maltreatment. Child maltreatment can be addressed with home visiting programs with evidence-based components and cultural adaptations that increase prevention by assisting families in tackling the risk factors they face. An innovative approach to child maltreatment prevention is bringing together at-risk families with the aging community. This innovative approach was prompted due to existing home visitation programs only focusing on improving skillsets and providing temporary relationships. This innovative approach can provide the opportunity for families to build a relationship with an aging individual who can share their wisdom, skills, compassion, love, and guidance, to support families in their well-being and decrease child maltreatment occurrence. Families would be identified if they experience any of the risk factors, including parental substance abuse, parental mental illness, domestic violence, and poverty. Families would also be identified as at risk if they lack supportive relationships such as grandparents or relatives. Families would be referred by local agencies such as medical clinics, hospitals, schools, etc., that have interactions with families regularly. The aging community would be recruited at local housing communities and community centers. An aging individual would be identified by the elderly community when there is a need or interest in a relationship by or for the individual. Cultural considerations would be made when assessing for compatibility between the families and aging individuals. The pilot program will consist of a small group of participants to allow manageable results to evaluate the efficacy of the program. The pilot will include pre-and post-surveys to evaluate the impact of the program. From the results, data would be created to determine the efficacy as well as the sufficiency of the details of the pilot. The pilot would also be evaluated on whether families were referred to Child Protective Services during the pilot as it relates to the goal of decreasing child maltreatment. The ideal findings will display a decrease in child maltreatment and an increase in family well-being for participants.

Keywords: child maltreatment, home visiting, neglect, preventative, abuse

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Authors: Hsin-Yi Kathy Cheng, Yan-Ying JU, Wann-Yun Shieh, Chin-Man Wang

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Although the coordination of swallowing and respiration has been discussed widely, the influence of the positioning angle on swallowing and respiration during feeding has rarely been investigated. This study aimed to investigate the timing and coordination of swallowing and respiration in different seat inclination angles, with liquid and bolus, to provide suggestions and guidelines for the design and develop a feedback-controlled seat angle adjustment device for the back-adjustable wheelchair. Twenty-six participants aged between 15-30 years old without any signs of swallowing difficulty were included. The combination of seat inclinations and food types was randomly assigned, with three repetitions in each combination. The trunk inclination angle was adjusted by a commercialized positioning wheelchair. A total of 36 swallows were done, with at least 30 seconds of rest between each swallow. We used a self-developed wearable device to measure the submandibular muscle surface EMG, the movement of the thyroid cartilage, and the respiratory status of the nasal cavity. Our program auto-analyzed the onset and offset of duration, and the excursion and strength of thyroid cartilage when it was moving, coordination between breathing and swallowing were also included. Variables measured include the EMG duration (DsEMG), swallowing apnea duration (SAD), total excursion time (TET), duration of 2nd deflection, FSR amplitude, Onset latency, DsEMG onset, DsEMG offset, FSR onset, and FSR offset. These measurements were done in four-seat inclination angles (5。, 15。, 30。, 45。) and three food contents (1ml water, 10ml water, and 5ml pudding bolus) for each subject. The data collected between different contents were compared. Descriptive statistics were used to describe the basic features of the data. Repeated measure ANOVAs were used to analyze the differences for the dependent variables in different seat inclination and food content combinations. The results indicated significant differences in seat inclination, mostly between 5。 and 45。, in all variables except FSR amplitude. It also indicated significant differences in food contents almost among all variables. Significant interactions between seat inclination and food contents were only found in FSR offsets. The same protocol will be applied to participants with disabilities. The results of this study would serve as clinical guidance for proper feeding positions with different food contents. The ergonomic data would also provide references for assistive technology professionals and practitioners in device design and development. In summary, the current results indicated that it is easier for a subject to lean backward during swallowing than when sitting upright and swallowing water is easier than swallowing pudding. The results of this study would serve as the clinical guidance for proper feeding position (such as wheelchair back angle adjustment) with different food contents. The same protocol can be applied to elderly participants or participants with physical disabilities. The ergonomic data would also provide references for assistive technology professionals and practitioners in device design and development.

Keywords: swallowing, positioning, assistive device, disability

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Authors: Sonia P. Marrero Duran, Lilian Noya Dominguez, Lisandra Quintana Alvarez, Evert Martinez Perez, Ana Julia Acevedo Urquiaga

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Cuban business and economic policy are in the constant update as well as facing a client ever more knowledgeable and demanding. For that reason become fundamental for companies competitiveness through the optimization of its processes and services. One of the Cuban’s pillars, which has been sustained since the triumph of the Cuban Revolution back in 1959, is the free health service to all those who need it. This service is offered without any charge under the concept of preserving human life, but it implied costly management processes and logistics services to be able to supply the necessary medicines to all the units who provide health services. One of the key actors on the medicine supply chain is the Havana Distribution Center (HDC), which is responsible for the delivery of medicines in the province; as well as the acquisition of medicines from national and international producers and its subsequent transport to health care units and pharmacies in time, and with the required quality. This HDC also carries for all distribution centers in the country. Given the eminent need to create an actor in the supply chain that specializes in the medicines supply, the possibility of centralizing this operation in a logistics service provider is analyzed. Based on this decision, pharmacies operate as clients of the logistic service center whose main function is to centralize all logistics operations associated with the medicine supply chain. The HDC is precisely the logistic service provider in Havana and it is the center of this research. In 2017 the pharmacies had affectations in the availability of medicine due to deficiencies in the distribution routes. This is caused by the fact that they are not based on routing studies, besides the long distribution cycle. The distribution routs are fixed, attend only one type of customer and there respond to a territorial location by the municipality. Taking into consideration the above-mentioned problem, the objective of this research is to optimize the routes system in the Havana Distribution Center. To accomplish this objective, the techniques applied were document analysis, random sampling, statistical inference and tools such as Ishikawa diagram and the computerized software’s: ArcGis, Osmand y MapIfnfo. As a result, were analyzed four distribution alternatives; the actual rout, by customer type, by the municipality and the combination of the two last. It was demonstrated that the territorial location alternative does not take full advantage of the transportation capacities or the distance of the trips, which leads to elevated costs breaking whit the current ways of distribution and the currents characteristics of the clients. The principal finding of the investigation was the optimum option distribution rout is the 4th one that is formed by hospitals and the join of pharmacies, stomatology clinics, polyclinics and maternal and elderly homes. This solution breaks the territorial location by the municipality and permits different distribution cycles in dependence of medicine consumption and transport availability.

Keywords: computerized geographic software, distribution, distribution routs, vehicle problem routing (VPR)

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Authors: Hsiang-Yu Yuan, Marc Baguelin, Kin O. Kwok, Nimalan Arinaminpathy, Edwin Leeuwen, Steven Riley

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Traditional syndromic surveillance for influenza has substantial public health value in characterizing epidemics. Because the relationship between syndromic incidence and the true infection events can vary from one population to another and from one year to another, recent studies rely on combining serological test results with syndromic data from traditional surveillance into epidemic models to make inference on epidemiological processes of influenza. However, despite the widespread availability of serological data, epidemic models have thus far not explicitly represented antibody titre levels and their correspondence with immunity. Most studies use dichotomized data with a threshold (Typically, a titre of 1:40 was used) to define individuals as likely recently infected and likely immune and further estimate the cumulative incidence. Underestimation of Influenza attack rate could be resulted from the dichotomized data. In order to improve the use of serosurveillance data, here, a refinement of the concept of the stratified immunity within an epidemic model for influenza transmission was proposed, such that all individual antibody titre levels were enumerated explicitly and mapped onto a variable scale of susceptibility in different age groups. Haemagglutination inhibition titres from 523 individuals and 465 individuals during pre- and post-pandemic phase of the 2009 pandemic in Hong Kong were collected. The model was fitted to serological data in age-structured population using Bayesian framework and was able to reproduce key features of the epidemics. The effects of age-specific antibody boosting and protection were explored in greater detail. RB was defined to be the effective reproductive number in the presence of stratified immunity and its temporal dynamics was compared to the traditional epidemic model using use dichotomized seropositivity data. Deviance Information Criterion (DIC) was used to measure the fitness of the model to serological data with different mechanisms of the serological response. The results demonstrated that the differential antibody response with age was present (ΔDIC = -7.0). The age-specific mixing patterns with children specific transmissibility, rather than pre-existing immunity, was most likely to explain the high serological attack rates in children and low serological attack rates in elderly (ΔDIC = -38.5). Our results suggested that the disease dynamics and herd immunity of a population could be described more accurately for influenza when the distribution of immunity was explicitly represented, rather than relying only on the dichotomous states 'susceptible' and 'immune' defined by the threshold titre (1:40) (ΔDIC = -11.5). During the outbreak, RB declined slowly from 1.22[1.16-1.28] in the first four months after 1st May. RB dropped rapidly below to 1 during September and October, which was consistent to the observed epidemic peak time in the late September. One of the most important challenges for infectious disease control is to monitor disease transmissibility in real time with statistics such as the effective reproduction number. Once early estimates of antibody boosting and protection are obtained, disease dynamics can be reconstructed, which are valuable for infectious disease prevention and control.

Keywords: effective reproductive number, epidemic model, influenza epidemic dynamics, stratified immunity

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Authors: Christabel Ihedike, John Mooney, Monica Price

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Summary: This study aims to critically evaluate effect of photochemical smog on respiratory health in Nigeria. Cohort of chronic obstructive pulmonary disease (COPD) patients was recruited from two large hospitals in Abuja Nigeria. Respiratory health questionnaires, daily diaries, dyspnoea scale and lung function measurement were used to obtain health data and investigate the relationship with air quality data (principally ozone, NOx and particulate pollution). Concentrations of air pollutants were higher than WHO and Nigerian air quality standard. The result suggests a correlation between measured air quality and exacerbation of respiratory illness. Introduction: Photochemical smog is a significant health challenge in most cities and its effect on respiratory health is well acknowledged. This type of pollution is most harmful to the elderly, children and those with underlying respiratory disease. This study aims to investigate impact of increasing temperature and photo-chemically generated secondary air pollutants on respiratory health in Abuja Nigeria. Method and Result: Health data was collected using spirometry to measure lung function on routine attendance at the clinic, daily diaries kept by patients and information obtained using respiratory questionnaire. Questionnaire responses (obtained using an adapted and internally validated version of St George’s Hospital Respiratory Questionnaire), shows that ‘time of wheeze’ showed an association with participants activities: 30% had worse wheeze in the morning: 10% cannot shop, 15% take long-time to get washed, 25% walk slower, 15% if hurry have to stop and 5% cannot take-bath. There was also a decrease in Forced expiratory volume in the first second and Forced Vital Capacity, and daily change in the afternoon–morning may be associated with the concentration level of pollutants. Also, dyspnoea symptoms recorded that 60% of patients were on grade 3, 25% grade 2 and 15% grade 1. Daily frequency of the number of patients in the cohort that cough /brought sputum is 78%. Air pollution in the city is higher than Nigerian and WHO standards with NOx and PM10 concentrations of 693.59ug/m-3 and 748ugm-3 being measured respectively. The result shows that air pollution may increase occurrence and exacerbation of respiratory disease. Conclusion: High temperature and local climatic conditions in urban Nigeria encourages formation of Ozone, the major constituent of photochemical smog, resulting also in the formation of secondary air pollutants associated with health challenges. In this study we confirm the likely potency of the pattern of secondary air pollution in exacerbating COPD symptoms in vulnerable patient group in urban Nigeria. There is need for better regulation and measures to reduce ozone, particularly when local climatic conditions favour development of photochemical smog in such settings. Climate change and likely increasing temperatures add impetus and urgency for better air quality standards and measures (traffic-restrictions and emissions standards) in developing world settings such as Nigeria.

Keywords: Abuja-Nigeria, effect, photochemical smog, respiratory health

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Authors: Carolina L. Cerdeira, Julia V. F. Cortes, Maria E. V. Amarante, Gersika B. Santos

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Skin cancer is the most common cancer in several parts of the world; in a tropical country like Brazil, the situation isn’t different. The Brazilian population is exposed to high levels of solar radiation, increasing the risk of developing cutaneous carcinoma. Aimed at encouraging prevention measures and the early diagnosis of these tumors, a study was carried out that analyzed data on cutaneous melanomas, basal cell, and epidermoid carcinomas, using as primary data source the medical records of 161 patients registered in one pathology service, which performs skin biopsies in a city of Minas Gerais, Brazil. All patients diagnosed with skin cancer at this service from January 2015 to December 2019 were included. The incidence of skin carcinoma cases was correlated with the identification of histological type, sex, age group, and topographic location. Correlation between variables was verified by Fisher's exact test at a nominal significance level of 5%, with statistical analysis performed by R® software. A significant association was observed between age group and type of cancer (p=0.0085); age group and sex (0.0298); and type of cancer and body region affected (p < 0.01). Those 161 cases analyzed comprised 93 basal cell carcinomas, 66 epidermoid carcinomas, and only two cutaneous melanomas. In the group aged 19 to 30 years, the epidermoid form was most prevalent; from 31 to 45 and from 46 to 59 years, the basal cell prevailed; in 60-year-olds or over, both types had higher frequencies. Associating age group and sex, in groups aged 18 to 30 and 46 to 59 years, women were most affected. In the 31-to 45-year-old group, men predominated. There was a gender balance in the age group 60-year-olds or over. As for topography, there was a high prevalence in the head and neck, followed by upper limbs. Relating histological type and topography, there was a prevalence of basal cell and epidermoid carcinomas in the head and neck. In the chest, the basal cell form was most prevalent; in upper limbs, the epidermoid form prevailed. Cutaneous melanoma affected only the chest and upper limbs. About 82% of patients 60-year-olds or over had head and neck cancer; from 46 to 59 and 60-year-olds or over, the head and neck region and upper limbs were predominantly affected; the distribution was balanced in the 31-to 45-year-old group. In conclusion, basal cell carcinoma was predominant, whereas cutaneous melanoma was the rarest among the types analyzed. Patients 60-year-olds or over were most affected, showing gender balance. In young adults, there was a prevalence of the epidermoid form; in middle-aged patients, basal cell carcinoma was predominant; in the elderly, both forms presented with higher frequencies. There was a higher incidence of head and neck cancers, followed by malignancies affecting the upper limbs. The epidermoid type manifested significantly in the upper limbs. Body regions such as the thorax and lower limbs were less affected, which is justified by the lower exposure of these areas to incident solar radiation.

Keywords: basal cell carcinoma, cutaneous melanoma, skin cancer, squamous cell carcinoma, topographic location

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Authors: Carolina Busco, Daniela Osses

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The development of digital literacy has become a fundamental element that allows for citizen inclusion, access to quality jobs, and a labor market capable of responding to the digital economy. There are no methodological instruments available in Chile to measure the workforce’s digital literacy and improve national policies on this matter. Thus, the objective of this research is to develop a survey to measure digital literacy in a sample of 200 Chilean workers. Dimensions considered in the instrument are sociodemographics, access to infrastructure, digital education, digital skills, and the ability to use e-government services. To achieve the research objective of developing a digital literacy model of indicators and a research instrument for this purpose, along with an exploratory analysis of data using factor analysis, we used an empirical, quantitative-qualitative, exploratory, non-probabilistic, and cross-sectional research design. The research instrument is a survey created to measure variables that make up the conceptual map prepared from the bibliographic review. Before applying the survey, a pilot test was implemented, resulting in several adjustments to the phrasing of some items. A validation test was also applied using six experts, including their observations on the final instrument. The survey contained 49 items that were further divided into three sets of questions: sociodemographic data; a Likert scale of four values ranked according to the level of agreement; iii) multiple choice questions complementing the dimensions. Data collection occurred between January and March 2022. For the factor analysis, we used the answers to 12 items with the Likert scale. KMO showed a value of 0.626, indicating a medium level of correlation, whereas Bartlett’s test yielded a significance value of less than 0.05 and a Cronbach’s Alpha of 0.618. Taking all factor selection criteria into account, we decided to include and analyze four factors that together explain 53.48% of the accumulated variance. We identified the following factors: i) access to infrastructure and opportunities to develop digital skills at the workplace or educational establishment (15.57%), ii) ability to solve everyday problems using digital tools (14.89%), iii) online tools used to stay connected with others (11.94%), and iv) residential Internet access and speed (11%). Quantitative results were discussed within six focus groups using heterogenic selection criteria related to the most relevant variables identified in the statistical analysis: upper-class school students; middle-class university students; Ph.D. professors; low-income working women, elderly individuals, and a group of rural workers. The digital divide and its social and economic correlations are evident in the results of this research. In Chile, the items that explain the acquisition of digital tools focus on access to infrastructure, which ultimately puts the first filter on the development of digital skills. Therefore, as expressed in the literature review, the advance of these skills is radically different when sociodemographic variables are considered. This increases socioeconomic distances and exclusion criteria, putting those who do not have these skills at a disadvantage and forcing them to seek the assistance of others.

Keywords: digital literacy, digital society, workforce digitalization, digital skills

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Authors: K. Power, M. White, B. Dunleavey, E. Comerford, C. Doherty, N. Delanty, R. Corbridge, M. Fitzsimons

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Introduction: Providing people with access to their own healthcare information and engaging them as co-authors of their health record can promote better transparency, trust, and inclusivity in the healthcare system. With the advent of electronic health records, there is a move towards involving patients as partners in their healthcare by providing them with access to their own health data via electronic patient portals (ePortal). For example, a recently developed ePortal to the Irish National Epilepsy Electronic Patient Record (EPR) provides access to summary medical records, tools for Patient Reported Outcomes (PROM), health goal-setting and preparation for clinical appointments. Aim: To determine what people with epilepsy (their families/carers) value about the Irish epilepsy ePortal. Methods: A socio-technical process was employed recruiting 30 families of people with epilepsy who also have an intellectual disability (ID). Family members who are a care partner of the person with epilepsy (PWE) were invited to co-design, develop and implement the ePortal. Family members engaged in usability and utility testing which involved a face to face meeting to learn about the ePortal, register for a user account and evaluate its structure and content. Family members were instructed to login to the portal on at least two separate occasions following the meeting and to complete a self-report evaluation tool during this time. The evaluation tool, based on a Usability Questionnaire (Lewis, 1993), consists of a short assessment of comfort using technology, instructions for using the ePortal and some tasks to complete. Tasks included validating summary record details, assessing ePortal ease of use, evaluation of information presented. Participants were asked for suggestions on how to improve the portal and make it more applicable to PWE who also have an ID. Results: Family members responded positively to the ePortal and valued the ability to share information between clinicians and care partners; use the ePortal as a passport between different healthcare settings (e.g., primary care to hospital). In the context of elderly parents of PWE, the ePortal is valued as a tool for supporting shared care between family members. Participants welcomed the facility to log lists of questions and goals to discuss with the clinician at the next clinical appointment as a means of improving quality of care. Participants also suggested further enhancements to the ePortal such as access to clinic letters which can provide an aide memoir in terms of the careplan agreed with the clinical team. For example, through the ePortal, people could see what investigations or therapies are scheduled. Conclusion: The Epilepsy Patient Portal is accessible via a range of devices such as smartphones and tablets. ePortals have the potential to help personalise care, improve patient involvement in clinical decision making, engage them as quality and safety partners, and help clinicians be more responsive to patient needs. Acknowledgement: The epilepsy ePortal project is part of PISCES, a Lighthouse Project funded by eHealth Ireland and HSE to help build an understanding of the benefits of eHealth technologies in the Irish Healthcare System.

Keywords: electronic patient portal, electronic patient record, epilepsy, intellectual disability, usability testing

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Authors: Linara Salikhova, Elmira Nizamova, Aleksandra Katasonova, Gleb Vitkov, Olga Sarapulova.

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While most European cities conduct research on heat-related risks, there is a research gap in the Caucasus region, particularly in Yerevan, Armenia. This study aims to test the method of establishing a correlation between urban heat islands (UHI) and urban greenery distribution for prioritization of heat-vulnerable areas for revegetation. Armenia has failed to consider measures to mitigate UHI in urban development strategies despite a 2.1°C increase in average annual temperature over the past 32 years. However, planting vegetation in the city is commonly used to deal with air pollution and can be effective in reducing UHI if it prioritizes heat-vulnerable areas. The research focuses on establishing such priorities while considering the distribution of urban greenery across the city. The lack of spatially explicit air temperature data necessitated the use of satellite images to achieve the following objectives: (1) identification of land surface temperatures (LST) and quantification of temperature variations across districts; (2) classification of massifs of land surface types using normalized difference vegetation index (NDVI); (3) correlation of land surface classes with LST. Examination of the heat-vulnerable city areas (in this study, the proportion of individuals aged 75 years and above) is based on demographic data (Census 2011). Based on satellite images (Sentinel-2) captured on June 5, 2021, NDVI calculations were conducted. The massifs of the land surface were divided into five surface classes. Due to capacity limitations, the average LST for each district was identified using one satellite image from Landsat-8 on August 15, 2021. In this research, local relief is not considered, as the study mainly focuses on the interconnection between temperatures and green massifs. The average temperature in the city is 3.8°C higher than in the surrounding non-urban areas. The temperature excess ranges from a low in Norq Marash to a high in Nubarashen. Norq Marash and Avan have the highest tree and grass coverage proportions, with 56.2% and 54.5%, respectively. In other districts, the balance of wastelands and buildings is three times higher than the grass and trees, ranging from 49.8% in Quanaqer-Zeytun to 76.6% in Nubarashen. Studies have shown that decreased tree and grass coverage within a district correlates with a higher temperature increase. The temperature excess is highest in Erebuni, Ajapnyak, and Nubarashen districts. These districts have less than 25% of their area covered with grass and trees. On the other hand, Avan and Norq Marash districts have a lower temperature difference, as more than 50% of their areas are covered with trees and grass. According to the findings, a significant proportion of the elderly population (35%) aged 75 years and above reside in the Erebuni, Ajapnyak, and Shengavit neighborhoods, which are more susceptible to heat stress with an LST higher than in other city districts. The findings suggest that the method of comparing the distribution of green massifs and LST can contribute to the prioritization of heat-vulnerable city areas for revegetation. The method can become a rationale for the formation of an urban greening program.

Keywords: heat-vulnerability, land surface temperature, urban greenery, urban heat island, vegetation

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Authors: Mukondi Esther Nethavhakone

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In 2020 World Health Organization announced the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), also known as Coronavirus disease 2019 (COVID-19) pandemic. To curb or contain the spread of the novel coronavirus (COVID 19), global governments implemented social distancing and lockdown regulations. Subsequently, it was no longer business as per usual, life as we knew it had changed, and so many aspects of people's lives were negatively affected, including financial and employment stability. Mainly, because companies/businesses had to put their operations on hold, some had to shut down completely, resulting in the loss of income for many people globally. Finances and employment insecurities are some of the issues that exacerbated many social issues that the world was already faced with, such as school drop-outs, teenage pregnancies, sexual assaults, gender-based violence, crime, child abuse, elderly abuse, to name a few. Expectedly the majority of the population's mental health state was threatened. This resulted in an increased number of people seeking mental healthcare services. The increasing need for mental healthcare services in Low and Middle-income countries proves to be a challenge because it is a well-known fact due to financial constraints and not well-established healthcare systems, mental healthcare provision is not as prioritised as the primary healthcare in these countries. It is against this backdrop that the researcher seeks to find viable, cost-effective, and accessible mental health solutions for low and middle-income countries amid the pressures of any pandemic. The researcher will undertake a systematic review of the technology-based mental health solutions that have been implemented/adopted by developed countries during COVID 19 lockdown and social distancing periods. This systematic review study aims to determine if low and middle-income countries can adopt the cost-effective version of digital mental health solutions for the healthcare system to adequately provide mental healthcare services during critical times such as pandemics (when there's an overwhelming diminish in mental health globally). The researcher will undertake a systematic review study through mixed methods. It will adhere to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The mixed-methods uses findings from both qualitative and quantitative studies in one review study. It will be beneficial to conduct this kind of study using mixed methods because it is a public health topic that involves social interventions and it is not purely based on medical interventions. Therefore, the meta-ethnographic (qualitative data) analysis will be crucial in understanding why and which digital methods work and for whom does it work, rather than only the meta-analysis (quantitative data) providing what digital mental health methods works. The data collection process will be extensive, involving the development of a database, table of summary of evidence/findings, and quality assessment process lastly, The researcher will ensure that ethical procedures are followed and adhered to, ensuring that sensitive data is protected and the study doesn't pose any harm to the participants.

Keywords: digital, mental health, covid, low and middle-income countries

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Authors: Diana Reckien

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Vulnerability assessments are increasingly used to support policy-making in complex environments, like urban areas. Usually, vulnerability studies include the construction of aggregate (sub-) indices and the subsequent mapping of indices across an area of interest. Vulnerability studies show a couple of advantages: they are great communication tools, can inform a wider general debate about environmental issues, and can help allocating and efficiently targeting scarce resources for adaptation policy and planning. However, they also have a number of challenges: Vulnerability assessments are constructed on the basis of a wide range of methodologies and there is no single framework or methodology that has proven to serve best in certain environments, indicators vary highly according to the spatial scale used, different variables and metrics produce different results, and aggregate or composite vulnerability indicators that are mapped easily distort or bias the picture of vulnerability as they hide the underlying causes of vulnerability and level out conflicting reasons of vulnerability in space. So, there is urgent need to further develop the methodology of vulnerability studies towards a common framework, which is one reason of the paper. We introduce a social vulnerability approach, which is compared with other approaches of bio-physical or sectoral vulnerability studies relatively developed in terms of a common methodology for index construction, guidelines for mapping, assessment of sensitivity, and verification of variables. Two approaches are commonly pursued in the literature. The first one is an additive approach, in which all potentially influential variables are weighted according to their importance for the vulnerability aspect, and then added to form a composite vulnerability index per unit area. The second approach includes variable reduction, mostly Principal Component Analysis (PCA) that reduces the number of variables that are interrelated into a smaller number of less correlating components, which are also added to form a composite index. We test these two approaches of constructing indices on the area of New York City as well as two different metrics of variables used as input and compare the outcome for the 5 boroughs of NY. Our analysis yields that the mapping exercise yields particularly different results in the outer regions and parts of the boroughs, such as Outer Queens and Staten Island. However, some of these parts, particularly the coastal areas receive the highest attention in the current adaptation policy. We imply from this that the current adaptation policy and practice in NY might need to be discussed, as these outer urban areas show relatively low social vulnerability as compared with the more central parts, i.e. the high dense areas of Manhattan, Central Brooklyn, Central Queens and the Southern Bronx. The inner urban parts receive lesser adaptation attention, but bear a higher risk of damage in case of hazards in those areas. This is conceivable, e.g., during large heatwaves, which would more affect more the inner and poorer parts of the city as compared with the outer urban areas. In light of the recent planning practice of NY one needs to question and discuss who in NY makes adaptation policy for whom, but the presented analyses points towards an under representation of the needs of the socially vulnerable population, such as the poor, the elderly, and ethnic minorities, in the current adaptation practice in New York City.

Keywords: vulnerability mapping, social vulnerability, additive approach, Principal Component Analysis (PCA), New York City, United States, adaptation, social sensitivity

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Authors: Majed Al Otaibi, Melissa Lessard-Beaudoin, Amel Loudghi, Raphael Chouinard-Watkins, Melanie Plourde, Frederic Calon, C. Alexandre Castellano, Stephen Cunnane, Helene Payette, Pierrette Gaudreau, Denis Gris, Rona K. Graham

Abstract:

Introduction: Alzheimer disease (AD) is a chronic disorder that affects millions of individuals worldwide. Symptoms include memory dysfunction, and also alterations in attention, planning, language and overall cognitive function. Olfactory dysfunction is a common symptom of several neurological disorders including AD. Studying the mechanisms underlying the olfactory dysfunction may therefore lead to the discovery of potential biomarkers and/or treatments for neurodegenerative diseases. Objectives: To determine if olfactory dysfunction predicts future cognitive impairment in the aging population and to characterize the olfactory system in a murine model expressing a genetic factor of AD. Method: For the human study, quantitative olfactory tests (UPSIT and OMT) have been done on 93 subjects (aged 80 to 94 years) from the Quebec Longitudinal Study on Nutrition and Successful Aging (NuAge) cohort accepting to participate in the ORCA secondary study. The telephone Modified Mini Mental State examination (t-MMSE) was used to assess cognition levels, and an olfactory self-report was also collected. In a separate cohort, olfactory cortical volume was calculated using MRI results from healthy old adults (n=25) and patients with AD (n=18) using the AAL single-subject atlas and performed with the PNEURO tool (PMOD 3.7). For the murine study, we are using Western blotting, RT-PCR and immunohistochemistry. Result: Human Study: Based on the self-report, 81% of the participants claimed to not suffer from any problem with olfaction. However, based on the UPSIT, 94% of those subjects showed a poor olfactory performance and different forms of microsmia. Moreover, the results confirm that olfactory function declines with age. We also detected a significant decrease in olfactory cortical volume in AD individuals compared to controls. Murine study: Preliminary data demonstrate there is a significant decrease in expression levels of the proform of caspase-3 and the caspase substrate STK3, in the olfactory bulb of mice expressing human APOE4 compared with controls. In addition, there is a significant decrease in the expression level of the caspase-9 proform and caspase-8 active fragment. Analysis of the mature neuron marker, NeuN, shows decreased expression levels of both isoforms. The data also suggest that Iba-1 immunostaining is increased in the olfactory bulb of APOE4 mice compared to wild type mice. Conclusions: The activation of caspase-3 may be the cause of the decreased levels of STK3 through caspase cleavage and may play role in the inflammation observed. In the clinical study, our results suggest that seniors are unaware of their olfactory function status and therefore it is not sufficient to measure olfaction using the self-report in the elderly. Studying olfactory function and cognitive performance in the aging population will help to discover biomarkers in the early stage of the AD.

Keywords: Alzheimer's disease, APOE4, cognition, caspase, brain atrophy, neurodegenerative, olfactory dysfunction

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Authors: May Bazzi, Shafik Tokmaj, Younes Saberi, Mats Geijer, Tony Jurkiewicz, Patrik Sund, Anna Bjällmark

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Mobile radiography, employing portable X-ray equipment, has become a routine procedure within hospital settings, with chest X-rays in intensive care units standing out as the most prevalent mobile X-ray examinations. This approach is not limited to hospitals alone, as it extends its benefits to imaging patients in various settings, particularly those too frail to be transported, such as elderly care residents in nursing homes. Moreover, the utility of mobile X-ray isn't confined solely to traditional healthcare recipients; it has proven to be a valuable resource for vulnerable populations, including the homeless, drug users, asylum seekers, and patients with multiple co-morbidities. Mobile X-rays reduce patient stress, minimize costly hospitalizations, and offer cost-effective imaging. While studies confirm its reliability, further research is needed, especially regarding image quality. Recent advancements in lightweight equipment with enhanced battery and detector technology provide the potential for nearly handheld radiography. The main aim of this study was to evaluate a new lightweight mobile X-ray system with two different detectors and compare the image quality with a modern stationary system. Methods: A total of 74 images of the chest (chest anterior-posterior (AP) views and chest lateral views) and pelvic/hip region (AP pelvis views, hip AP views, and hip cross-table lateral views) were acquired on a whole-body phantom (Kyotokagaku, Japan), utilizing varying image parameters. These images were obtained using a stationary system - 18 images (Mediel, Sweden), a mobile X-ray system with a second-generation detector - 28 images (FDR D-EVO II; Fujifilm, Japan) and a mobile X-ray system with a third-generation detector - 28 images (FDR D-EVO III; Fujifilm, Japan). Image quality was assessed by visual grading analysis (VGA), which is a method to measure image quality by assessing the visibility and accurate reproduction of anatomical structures within the images. A total of 33 image criteria were used in the analysis. A panel of two experienced radiologists, two experienced radiographers, and two final-term radiographer students evaluated the image quality on a 5-grade ordinal scale using the software Viewdex 3.0 (Viewer for Digital Evaluation of X-ray images, Sweden). Data were analyzed using visual grading characteristics analysis. The dose was measured by the dose-area product (DAP) reported by the respective systems. Results: The mobile X-ray equipment (both detectors) showed significantly better image quality than the stationary equipment for the pelvis, hip AP and hip cross-table lateral images with AUCVGA-values ranging from 0.64-0.92, while chest images showed mixed results. The number of images rated as having sufficient quality for diagnostic use was significantly higher for mobile X-ray generation 2 and 3 compared with the stationary X-ray system. The DAP values were higher for the stationary compared to the mobile system. Conclusions: The new lightweight radiographic equipment had an image quality at least as good as a fixed system at a lower radiation dose. Future studies should focus on clinical images and consider radiographers' viewpoints for a comprehensive assessment.

Keywords: mobile x-ray, visual grading analysis, radiographer, radiation dose

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Authors: Adam J. Bowen

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Abstract— Should robots have rights or legal protections. Often debates concerning whether robots and AI should be afforded rights focus on conditions of personhood and the possibility of future advanced forms of AI satisfying particular intrinsic cognitive and moral attributes of rights-holding persons. Such discussions raise compelling questions about machine consciousness, autonomy, and value alignment with human interests. Although these are important theoretical concerns, especially from a future design perspective, they provide limited guidance for addressing the moral and legal standing of current and near-term AI that operate well below the cognitive and moral agency of human persons. Robots and AI are already being pressed into service in a wide range of roles, especially in healthcare and biomedical contexts. The design and large-scale implementation of robots in the context of core societal institutions like healthcare systems continues to rapidly develop. For example, we bring them into our homes, hospitals, and other care facilities to assist in care for the sick, disabled, elderly, children, or otherwise vulnerable persons. We enlist surgical robotic systems in precision tasks, albeit still human-in-the-loop technology controlled by surgeons. We also entrust them with social roles involving companionship and even assisting in intimate caregiving tasks (e.g., bathing, feeding, turning, medicine administration, monitoring, transporting). There have been advances to enable severely disabled persons to use robots to feed themselves or pilot robot avatars to work in service industries. As the applications for near-term AI increase and the roles of robots in restructuring our biomedical practices expand, we face pressing questions about the normative implications of human-robot interactions and collaborations in our collective worldmaking, as well as the moral and legal status of robots. This paper argues that robots operating in public and private spaces be afforded some protections as either moral patients or legal agents to establish prohibitions on robot abuse, misuse, and mistreatment. We already implement robots and embed them in our practices and institutions, which generates a host of human-to-machine and machine-to-machine relationships. As we interact with machines, whether in service contexts, medical assistance, or home health companions, these robots are first encountered in relationship to us and our respective roles in the encounter (e.g., surgeon, physical or occupational therapist, recipient of care, patient’s family, healthcare professional, stakeholder). This proposal aims to outline a framework for establishing limiting factors and determining the extent of moral or legal protections for robots. In doing so, it advocates for a relational approach that emphasizes the priority of mapping the complex contextually sensitive roles played and the relations in which humans and robots stand to guide policy determinations by relevant institutions and authorities. The relational approach must also be technically informed by the intended uses of the biomedical technologies in question, Design History Files, extensive risk assessments and hazard analyses, as well as use case social impact assessments.

Keywords: biomedical robots, robot ethics, robot laws, human-robot interaction

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Authors: Petra Gergelova, Sofia Ioannidou, Davide Arcella, Alexandra Tard, Polly E. Boon, Oliver Lindtner, Christina Tlustos, Jean-Charles Leblanc

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Objectives: To assess chronic dietary exposure to food additives in different European countries and population groups. Method and Design: The European Food Safety Authority’s (EFSA) Panel on Food Additives and Nutrient Sources added to Food (ANS) estimates chronic dietary exposure to food additives with the purpose of re-evaluating food additives that were previously authorized in Europe. For this, EFSA uses concentration values (usage and/or analytical occurrence data) reported through regular public calls for data by food industry and European countries. These are combined, at individual level, with national food consumption data from the EFSA Comprehensive European Food Consumption Database including data from 33 dietary surveys from 19 European countries and considering six different population groups (infants, toddlers, children, adolescents, adults and the elderly). EFSA ANS Panel estimates dietary exposure for each individual in the EFSA Comprehensive Database by combining the occurrence levels per food group with their corresponding consumption amount per kg body weight. An individual average exposure per day is calculated, resulting in distributions of individual exposures per survey and population group. Based on these distributions, the average and 95th percentile of exposure is calculated per survey and per population group. Dietary exposure is assessed based on two different sets of data: (a) Maximum permitted levels (MPLs) of use set down in the EU legislation (defined as regulatory maximum level exposure assessment scenario) and (b) usage levels and/or analytical occurrence data (defined as refined exposure assessment scenario). The refined exposure assessment scenario is sub-divided into the brand-loyal consumer scenario and the non-brand-loyal consumer scenario. For the brand-loyal consumer scenario, the consumer is considered to be exposed on long-term basis to the highest reported usage/analytical level for one food group, and at the mean level for the remaining food groups. For the non-brand-loyal consumer scenario, the consumer is considered to be exposed on long-term basis to the mean reported usage/analytical level for all food groups. An additional exposure from sources other than direct addition of food additives (i.e. natural presence, contaminants, and carriers of food additives) is also estimated, as appropriate. Results: Since 2014, this methodology has been applied in about 30 food additive exposure assessments conducted as part of scientific opinions of the EFSA ANS Panel. For example, under the non-brand-loyal scenario, the highest 95th percentile of exposure to α-tocopherol (E 307) and ammonium phosphatides (E 442) was estimated in toddlers up to 5.9 and 8.7 mg/kg body weight/day, respectively. The same estimates under the brand-loyal scenario in toddlers resulted in exposures of 8.1 and 20.7 mg/kg body weight/day, respectively. For the regulatory maximum level exposure assessment scenario, the highest 95th percentile of exposure to α-tocopherol (E 307) and ammonium phosphatides (E 442) was estimated in toddlers up to 11.9 and 30.3 mg/kg body weight/day, respectively. Conclusions: Detailed and up-to-date information on food additive concentration values (usage and/or analytical occurrence data) and food consumption data enable the assessment of chronic dietary exposure to food additives to more realistic levels.

Keywords: α-tocopherol, ammonium phosphatides, dietary exposure assessment, European Food Safety Authority, food additives, food consumption data

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Authors: Melanie Schinnerl, Dorothea Greiling

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In the context of the 2020 strategy, poverty and its fight returned to the center of national political efforts. This served as motivation for an Austrian research grant-funded project to focus on the under-researched local government level with the aim to identify municipal best-practice cases and to derive policy implications for Austria. Designing effective poverty reduction strategies is a complex challenge which calls for an integrated multi-actor in approach. Cities are increasingly confronted to combat poverty, even in rich EU-member states. By doing so cities face substantial demographic, cultural, economic and social challenges as well as changing welfare state regimes. Furthermore, there is a low willingness of (right-wing) governments to support the poor. Against this background, the research questions are: 1. How do local governments define poverty? 2. Who are the main risk groups and what are the most pressing problems when fighting urban poverty? 3. What is regarded as successful anti-poverty initiatives? 4. What is the underlying welfare state concept? To address the research questions a multi-method approach was chosen, consisting of a systematic literature analysis, a comprehensive document analysis, and expert interviews. For interpreting the data the project follows the qualitative-interpretive paradigm. Municipal approaches for reducing poverty are compared based on deductive, as well as inductive identified criteria. In addition to an intensive literature analysis, interviews (40) were conducted in Austria since the project started in March 2018. From the other countries, 14 responses have been collected, providing a first insight. Regarding the definition of poverty the EU SILC-definition as well as counting the persons who receive need-based minimum social benefits, the Austrian form of social welfare, are the predominant approaches in Austria. In addition to homeless people, single-parent families, un-skilled persons, long-term unemployed persons, migrants (first and second generation), refugees and families with at least 3 children were frequently mentioned. The most pressing challenges for Austrian cities are: expected reductions of social budgets, a great insecurity of the central government's social policy reform plans, the growing number of homeless people and a lack of affordable housing. Together with affordable housing, old-age poverty will gain more importance in the future. The Austrian best practice examples, suggested by interviewees, focused primarily on homeless, children and young people (till 25). Central government’s policy changes have already negative effects on programs for refugees and elderly unemployed. Social Housing in Vienna was frequently mentioned as an international best practice case, other growing cities can learn from. The results from Austria indicate a change towards the social investment state, which primarily focuses on children and labour market integration. The first insights from the other countries indicate that affordable housing and labor market integration are cross-cutting issues. Inherited poverty and old-age poverty seems to be more pressing outside Austria.

Keywords: anti-poverty policies, European cities, empirical study, social investment

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Authors: Kazuhiro Tateda, Elisa Gonzalez, Shuhei Ito, Kirstin Heinrich, Kevin Sweetland, Pingping Zhang, Catia Ferreira, Michael Pride, Jennifer Moisi, Sharon Gray, Bennett Lee, Fred Angulo

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Clostridium difficile (C. difficile) is the most common cause of antibiotic-associated diarrhea and infectious diarrhea in healthcare settings. Japan has an aging population; the elderly are at increased risk of hospitalization, antibiotic use, and C. difficile infection (CDI). Little is known about the population-based incidence and disease burden of CDI in Japan although limited hospital-based studies have reported a lower incidence than the United States. To understand CDI disease burden in Japan, CLOUD (Clostridium difficile Infection Burden of Disease in Adults in Japan) was developed. CLOUD will derive population-based incidence estimates of the number of CDI cases per 100,000 population per year in Ota-ku (population 723,341), one of the districts in Tokyo, Japan. CLOUD will include approximately 14 of the 28 Ota-ku hospitals including Toho University Hospital, which is a 1,000 bed tertiary care teaching hospital. During the 12-month patient enrollment period, which is scheduled to begin in November 2018, Ota-ku residents > 50 years of age who are hospitalized at a participating hospital with diarrhea ( > 3 unformed stools (Bristol Stool Chart 5-7) in 24 hours) will be actively ascertained, consented, and enrolled by study surveillance staff. A stool specimen will be collected from enrolled patients and tested at a local reference laboratory (LSI Medience, Tokyo) using QUIK CHEK COMPLETE® (Abbott Laboratories). which simultaneously tests specimens for the presence of glutamate dehydrogenase (GDH) and C. difficile toxins A and B. A frozen stool specimen will also be sent to the Pfizer Laboratory (Pearl River, United States) for analysis using a two-step diagnostic testing algorithm that is based on detection of C. difficile strains/spores harboring toxin B gene by PCR followed by detection of free toxins (A and B) using a proprietary cell cytotoxicity neutralization assay (CCNA) developed by Pfizer. Positive specimens will be anaerobically cultured, and C. difficile isolates will be characterized by ribotyping and whole genomic sequencing. CDI patients enrolled in CLOUD will be contacted weekly for 90 days following diarrhea onset to describe clinical outcomes including recurrence, reinfection, and mortality, and patient reported economic, clinical and humanistic outcomes (e.g., health-related quality of life, worsening of comorbidities, and patient and caregiver work absenteeism). Studies will also be undertaken to fully characterize the catchment area to enable population-based estimates. The 12-month active ascertainment of CDI cases among hospitalized Ota-ku residents with diarrhea in CLOUD, and the characterization of the Ota-ku catchment area, including estimation of the proportion of all hospitalizations of Ota-ku residents that occur in the CLOUD-participating hospitals, will yield CDI population-based incidence estimates, which can be stratified by age groups, risk groups, and source (hospital-acquired or community-acquired). These incidence estimates will be extrapolated, following age standardization using national census data, to yield CDI disease burden estimates for Japan. CLOUD also serves as a model for studies in other countries that can use the CLOUD protocol to estimate CDI disease burden.

Keywords: Clostridium difficile, disease burden, epidemiology, study protocol

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