Search results for: combined therapy

Authors: Min-Chien Su, Tzu-Hsuan Hsu, Guan-Xuan Wu, Shyh-Ming Kuo

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Lung cancer is one of the clinically challenging malignant diseases worldwide. For efficient therapeutics in cancer, combination therapy has developed to acquire a better outcome. PLK-1 was one of the major factors affecting cell mitosis in cancer cells, its inhibitor Bi6727 was proven effective in treating several different cancers namely oral cancer, colon cancer and lung cancer. Despite its low toxicity toward normal cells compared to traditional chemotherapy, it is still yet to be evaluated in detail. Livistona Chinensis (LC) is a Chinese herb that used as a traditional prescription to treat lung cancer. Due to the uncertainty of the efficacy of LC, we utilized a water extraction method to extract the Livistona Chinensis and then lyophilized into powder for further study. In this study we investigated the antiproliferation activities of Bi6727 and LC extracts (LCE) on A549 non-small lung cancer cells. The IC50 of Bi6727 and LCE on A549 are 60 nM and 0.8 mg/mL, respectively. The fluorescent staining images shown nucleolus damage in cells treated with Bi6727 and mitochondrial damage after treated with LCE. A549 cells treated with Bi6727 and LCE showed increased expression of Bax, Caspase-3 and Caspase-9 proteins from Western blot assay. LCE also inhibited A549 cells growth keeping cells at G2-M phase from cell cycle assay. Apoptosis assay results showed that LCE induced late apoptosis of A549 cells. JC-1 assay showed that the mitochondria damaged at the LCE concentration of 0.4 mg/mL. In our preliminary anti-proliferation test of combined LCE and Bi-6727 on A549 cells, we found a dramatically decrease in proliferation after treated with LCE first for 24-h and then Bi-6727 for extra 24-h. This was an important finding regarding synergistic anti-proliferation effect of these drugs, However, the usage, the application sequence of LCE and Bi-6727 on A549 cells and their related mechanisms still need to be evaluated. In summary, the drugs exerted anti-proliferation effect on A549 cells independently. We hopefully combine the usage of these two drugs will bring a different and potential outcome in treating lung cancer.

Keywords: anti-proliferation, A549, Livistona Chinensis fruit extracts, PLK-1 inhibitor

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Authors: Pachawo Bisani, Goodall Nyirenda

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The Malawi National Antiretroviral Therapy (NART) Electronic Medical Record (EMR) system was designed and developed with guidance from the Ministry of Health through the Department of HIV and AIDS (DHA) with the aim of supporting the management of HIV patient data and reporting in high prevalence ART clinics. As of 2021, the system has been scaled up to over 206 facilities across the country. The system is integrated with the clinical decision support system (CDSS) to assist healthcare providers in making a decision about an individual patient at a particular point in time. Despite NART EMR undergoing several evaluations and assessments, little has been done to evaluate the clinical decision support system in the NART EMR system. Hence, the study aimed to evaluate the use of CDSS in the NART EMR system in Malawi. The study adopted a mixed-method approach, and data was collected through interviews, observations, and questionnaires. The study has revealed that the CDSS tools were integrated into the ART clinic workflow, making it easy for the user to use it. The study has also revealed challenges in system reliability and information accuracy. Despite the challenges, the study further revealed that the system is effective and efficient, and overall, users are satisfied with the system. The study recommends that the implementers focus more on the logic behind the clinical decision-support intervention in order to address some of the concerns and enhance the accuracy of the information supplied. The study further suggests consulting the system's actual users throughout implementation.

Keywords: clinical decision support system, electronic medical record system, usability, antiretroviral therapy

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Authors: Shweh Fern Loo, Jun Yin Ong, Than Zaw Oo

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Acute respiratory distress syndrome (ARDS) is a common serious condition of bilateral lung infiltrates that develops secondary to various underlying conditions such as diseases or injuries. ARDS with severe hypercapnia is associated with higher ICU mortality and morbidity. Venovenous Extracorporeal membrane oxygenation (VV-ECMO) support has been established to avert life-threatening hypoxemia and hypercapnic respiratory failure despite optimal conventional mechanical ventilation. However, VV-ECMO is relatively not advisable in particular groups of patients, especially in multi-organ failure, advanced age, hemorrhagic complications and irreversible central nervous system pathology. We presented a case of a 79-year-old Chinese lady without any pre-existing lung disease admitted to our hospital intensive care unit (ICU) after acute presentation of breathlessness and chest pain. After extensive workup, she was diagnosed with rapidly progressing acute interstitial pneumonia with ARDS and hypercapnia respiratory failure. The patient received lung protective strategies of mechanical ventilation and neuromuscular blockage therapy as per clinical guidelines. However, hypercapnia respiratory failure was refractory, and she was deemed not a good candidate for VV-ECMO support given her advanced age and high vasopressor requirements from shock. Alternative therapy with extracorporeal CO2 removal (ECCO2R) was considered and implemented. The patient received 12 days of ECCO2R paired with muscle paralysis, optimization of lung-protective mechanical ventilation and dialysis. Unfortunately, the patient still had refractory hypercapnic respiratory failure with dual vasopressor support despite prolonged therapy. Given failed and futile medical treatment, the family opted for withdrawal of care, a conservative approach, and comfort care, which led to her demise. The effectivity of extracorporeal CO2 removal may depend on disease burden, involvement and severity of the disease. There is insufficient data to make strong recommendations about its benefit-risk ratio for ECCO2R devices, and further studies and data would be required. Nonetheless, ECCO2R can be considered an alternative treatment for refractory hypercapnic respiratory failure patients who are unsuitable for initiating venovenous ECMO.

Keywords: extracorporeal CO2 removal (ECCO2R), acute respiratory distress syndrome (ARDS), acute interstitial pneumonia (AIP), hypercapnic respiratory failure

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Authors: Yiyuan David Hu, Alex Lindqwister, Samuel B. Klein, Karen Moodie, Norman A. Paradis

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Introduction: Pseudo-Pulseless Electrical Activity (p-PEA) is a lifeless form of profound cardiac shock characterized by measurable cardiac mechanical activity without clinically detectable pulses. Patients in pseudo-PEA carry different prognoses than those in true PEA and may require different therapies. End-tidal carbon dioxide (ET-CO2) has been studied in ventricular fibrillation and true PEA but in p-PEA. We utilized an hypoxic porcine model to characterize the performance of ET-CO2 in resuscitation from p-PEA. Hypothesis: Capnography correlates to the number of required interventions for resuscitation from p-PEA. Methods: Female swine (N = 14) under intravenous anesthesia were instrumented with aortic and right atrial micromanometer pressure. ECG and ET-CO2 were measured continuously. p-PEA was induced by ventilation with 6% oxygen in 94% nitrogen and was defined as a systolic aortic (Ao) pressure less than 40 mmHg. Pigs were grouped based on the interventions required to achieve ROSC: 100%O2, 100%O2 + CPR, 100%O2 + CPR + epinephrine. Results: End tidal CO2 reliably predicted O2 therapy vs CPR-based interventions needed for resuscitation (Figure 1). Pigs who would recover with 100%O2 only had a mean ET-CO2 slope of 0.039 ± 0.013 [ R2 = 0.68], those requiring oxygen + CPR had a slope of -0.15 ± 0.016 [R2 = 0.95], and those requiring oxygen + CPR + epinephrine had a slope of -0.12 ± 0.031 [R2 = 0.79]. Conclusions: In a porcine model of hypoxic p-PEA, measured ET-CO2 appears to be strongly correlated with the required interventions needed for ROSC. If confirmed clinically, these results indicate that ET-CO2 may be useful in guiding therapy in patients suffering p-PEA cardiac arrest.

Keywords: pseudo-PEA, resuscitation, capnography, hypoxic pseudo-PEA

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Authors: Hesham Hamdy Abdelmohsen, Ahmed Shawky Abdul Azizb, Mona Fawzy Aldaghma

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Helical piles have earned considerable attention as an effective deep foundation alternative due to their rapid installation process and their dual purpose in compression and tension. These piles find common uses as foundations for structures like solar panels, wind turbines, offshore platforms, and some kinds of retaining walls. These structures usually transfer different combinations of loads to their helical-pile foundations in the form of axial and lateral loads. Extensive research has been conducted to investigate and understand the behavior of these piles under the influence of either axial or lateral loads. However, the impacts of loading patterns that may act on the helical piles as combinations of axial compression and lateral loads still need more efforts of research work. This paper presents the results of an experimental (Lab tests) and numerical (PLAXIS-3D) study performed on vertical helical-pile groups under the action of combined loads as axial compression (bearing loads), acting successively with lateral (horizontal) loads. The study aims to clarify the effects of key factors, like helix location and direction of lateral load, on the lateral capacity of helical-pile groups and, consequently, on group efficiency. Besides the variation of helix location and lateral load direction, three patterns of successive bearing combined loads were considered, in which the axial vertical compression load was either zero, V1 or V2, whereas the lateral horizontal loads were varied under each vertical compression load. The study concluded that the lateral capacity of the helical-pile group is significantly affected by helix location within the length of the pile shaft. The optimal lateral performance is achieved with helices at a depth ratio of H/L = 0.4. Furthermore, groups of rectangular plan distribution exhibit greater lateral capacity if subjected to lateral horizontal load in the direction of its long axis. Additionally, the research emphasizes that the presence of vertical compression loading can enhance the lateral capacity of the group. This enhancement depends on the value of the vertical compression load, lateral load direction, and helix location, which highlights the complex interaction effect of these factors on the efficiency of helical-pile groups.

Keywords: helical piles, experimental, numerical, lateral loading, group efficiency

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Authors: Jawad Arshad

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Back and neck pain result in more than 3 million Emergency Department (ED) visits per year. Approximately 10-20% of patients with acute low back pain will continue to have moderate to severe pain after 3 months and 30% will develop chronic functional impairment. Strategies for analgesia for musculoskeletal pain upon ED discharge have been shown to be highly variable and provider dependent. The American College of Physicians, United Kingdom and Danish treatment guidelines all recommend exercise as the first line treatment for low back pain present >12 weeks and as an adjunctive treatment to education and encouraging continued mobility in acute low back pain. URL links and QR codes were embedded in Epic’s Electronic Medical Record (EMR) for seamless integration into discharge instructions. To our knowledge, this is the first time QR codes have been embedded and used as an adjunct to computer generated discharge instructions into an EMR nationwide. Materials and Methods: Eleven two-minute physical therapy (PT) videos treating a variety of common painful musculoskeletal conditions were prepared in collaboration between the Pain Management and Physical Therapy departments of a large academic center. The videos were hosted and made available on Vimeo for free public access. Dynamic QR codes and URL links were created for each video and integrated into the EPIC Electronic Medical Record discharge instructions. Both data from physician prescribed PT videos and results of public searches are included. As the case report is devoid of patient identifiable information, it is exempt from IRB review requirements as per IRB policy. Results/Case Report: From 2/6/2021 to 5/19/21, the videos were prescribed on Epic a total of 76 times, the dynamic QR codes were scanned a total of 84 times. Low back (n=32) followed by neck (n=8), shoulder (n=7) and radicular low back pain (n=7) were the most common painful complaints prescribed a PT video. The videos were played on Vimeo 790 times with 83% (n=656) being unique views and 17% returning users. Shoulder pain (n=489) followed by neck (n=36) and low back pain (n=37) were the most commonly played videos. Discussion: Patients are viewing their physical therapy videos via QR codes provided by their physicians. The large number of public views of the physical therapy videos are either from patients sharing the link/QR code or patients not affiliated with our institution are searching for videos to treat their painful complaints. The data suggests there is a need for reputable home PT videos to treat commonly encountered painful complaints with 17% of viewers returning for repeat view. The shoulder pain video was played significantly more than the others despite not being given to patients more frequently, which raised suspicion it may have received increased traffic via an outside affiliate, website or influencer. When eliminating shoulder pain from the data, individuals watched 67% of the entire video on average, indicating high engagement.

Keywords: pain, EMR, emergency medicine, discharge

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Authors: N. Dlamini, Mpumelelo G. Ndlela, Philisiwe Dlamini, Nicholus Kisyeri, Bhekizitha Sithole

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Accessing health services during the COVID-19 pandemic have exacerbated scarcity to routine medication. To ensure continuous accessibility to services, Eswatini launched Community Health Commodities Distribution (CHCD). Eligible Antiretroviral Therapy(ART) stable clients (VL<1,000) and patients on Non-Communicable Disease (NCD) medications were attended at community pick up points (PUP) based on distance between clients’ residence and the public health facility. Services provided includes ART and Pre-Exposure prophylaxis (PrEP) refills and NCD drug refills). The number of community PUP was 14% higher than health facility visits. Among all medications and commodities distributed between April and October 2020 at the PUP, 64% were HIV-related (HIV rapid test, HIVST, VL test, PrEP meds), and 36% were NCD related. The rapid roll out of CHCD during COVID-19 pandemic reduced the risk of COVID-19 transmission to clients as travel to health facilities was eliminated. It Additionally increased access to commodities during COVID-19-driven lockdown, decongested health facilities, integrated model of care, and increase service coverage. It was also noted that CHCD added different curative and HIV related services based on client specific needs and availability of the commodities.

Keywords: community health commodities distribution, pick up points, antiretroviral therapy, pre-exposure prophylaxis

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Authors: M. Manzoor, J. N. Ahmad, R. M. Giblin Davis, N. Javed, M. S. Haider

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The invasive Red Palm Weevil (RPW) (Rhynchophorus ferrugineus [Olivier] (Coleoptera: Curculionidae) is one of the most destructive palm pests in the world. Synthetic pesticides are environmentally hazardous pest control strategies being used in the past with emerging need of eco-friendly biological approaches including microbial entomopathogens for RPW management. The sublethal effects of a single entomopathogenic fungus (EPF) Beauveria bassiana (WG-11) (Ascomycota: Hypocreales) and two entomopathogenic nematode (EPN) species Heterorhabditis bacteriophora (Poinar) and Steinernema carpocapsae (Weiser) (Nematoda: Rhabditida) were evaluated in various combinations against laboratory-reared 3rd, 5th and 8th instar larvae of RPW in laboratory assays. Individual and combined effects of both entomopathogens (EP) were observed after the pre-application of B. bassiana fungus at 1-2-week intervals. A number of parameters were measured after the application of sub-lethal doses of EPF such as diet consumption, development, frass production, mortality, and weight gain. Combined treatments were tested for additive and synergistic effects. Synergism was more frequently observed in B. bassiana and S. carpocapsae combined treatments than in B. bassiana and H. bacteriophora combinations. Early instar larvae of RPW were more susceptible than older instars. Synergistic effects were observed in the 3rd and 5th instars exposed to B. bassiana and S. carpocapsae at 0, 7 and 14-day intervals. Whereas, in 8th instar larvae, the synergistic effect was observed only in B. bassiana and S. carpocapsae treatments after 0 and 7 days intervals. EPN treatments decreased pupation, egg hatching and emergence of adults. Lethal effects of nematodes were also observed in all growth stages of R. ferrugineus. Reduced larval weight, increased larval, pre-pupal and pupal duration, reduced adult weight and life span were observed. Sub-lethal concentrations of both entomopathogens induced variations in the different developmental stages and reduced food consumption, frass production, growth, and weight gain. So, on the basis of results, it is concluded that synthetic pesticides should be replaced with environmentally friendly sustainable biopesticides.

Keywords: H. bacteriophora, S. carpocapsae, B. bassiana, mortality

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Authors: Noor Ayuni Che Zakaria, Takashi Komeda, Cheng Yee Low, Kaoru Inoue, Fazah Akhtar Hanapiah

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Previous studies have shown that there are arguments regarding the reliability and validity of the Ashworth and Modified Ashworth Scale towards evaluating patients diagnosed with upper limb disorders. These evaluations depended on the raters’ experiences. This initiated us to develop an upper limb disorder part-task trainer that is able to simulate consistent upper limb disorders, such as spasticity and rigidity signs, based on the Modified Ashworth Scale to improve the variability occurring between raters and intra-raters themselves. By providing consistent signs, novice therapists would be able to increase training frequency and exposure towards various levels of signs. A total of 22 physiotherapists and occupational therapists participated in the study. The majority of the therapists agreed that with current therapy education, they still face problems with inter-raters and intra-raters variability (strongly agree 54%; n = 12/22, agree 27%; n = 6/22) in evaluating patients’ conditions. The therapists strongly agreed (72%; n = 16/22) that therapy trainees needed to increase their frequency of training; therefore believe that our initiative to develop an upper limb disorder training tool will help in improving the clinical education field (strongly agree and agree 63%; n = 14/22).

Keywords: upper limb disorder, clinical education tool, inter/intra-raters variability, spasticity, modified Ashworth scale

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Authors: A. Dionísio, L. Roseiro, J. Fonseca, P. Nicolau

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Thermography is a non-radiating and contact-free technology which can be used to monitor skin temperature. The efficiency and safety of thermography technology make it a useful tool for detecting and locating thermal changes in skin surface, characterized by increases or decreases in temperature. This work intends to be a contribution for the use of thermography as a methodology for evaluation of skin temperature in the context of orofacial biomechanics. The study aims to identify the oscillations of skin temperature in the left and right hemiface regions of the masseter muscle, during and after thermal stimulus, and estimate the time required to restore the initial temperature after the application of the stimulus. Using a FLIR T430sc camera, a data acquisition protocol was followed with a group of eight volunteers, aged between 22 and 27 years. The tests were performed in a controlled environment with the volunteers in a comfortably static position. The thermal stimulus involves the use of an ice volume with controlled size and contact surface. The skin surface temperature was recorded in two distinct situations, namely without further stimulus and with the additions of a stimulus obtained by a chewing gum. The data obtained were treated using FLIR Research IR Max software. The time required to recover the initial temperature ranged from 20 to 52 minutes when no stimulus was added and varied between 8 and 26 minutes with the chewing gum stimulus. These results show that recovery is faster with the addition of the stimulus and may guide clinicians regarding the pre and post-operative times with ice therapy, in the presence or absence of mechanical stimulus that increases muscle functions (e.g. phonetics or mastication).

Keywords: thermography, orofacial biomechanics, skin temperature, ice therapy

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Authors: Maria Debora Braga, Luigi Riso, Maria Grazia Zoia

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Risk-based approaches to asset allocation are portfolio construction methods that do not rely on the input of expected returns for the asset classes in the investment universe and only use risk information. They include the Minimum Variance Strategy (MV strategy), the traditional (volatility-based) Risk Parity Strategy (SRP strategy), the Most Diversified Portfolio Strategy (MDP strategy) and, for many, the Equally Weighted Strategy (EW strategy). All the mentioned approaches were based on portfolio volatility as a reference risk measure but in 2023, the Kurtosis-based Risk Parity strategy (KRP strategy) and the Minimum Kurtosis strategy (MK strategy) were introduced. Understandably, they used the fourth root of the portfolio-fourth moment as a proxy for portfolio kurtosis to work with a homogeneous function of degree one. This paper contributes mainly theoretically and methodologically to the framework of risk-based asset allocation approaches with two steps forward. First, a new and more flexible objective function considering a linear combination (with positive coefficients that sum to one) of portfolio volatility and portfolio kurtosis is used to alternatively serve a risk minimization goal or a homogeneous risk distribution goal. Hence, the new basic idea consists in extending the achievement of typical risk-based approaches’ goals to a combined risk measure. To give the rationale behind operating with such a risk measure, it is worth remembering that volatility and kurtosis are expressions of uncertainty, to be read as dispersion of returns around the mean and that both preserve adherence to a symmetric framework and consideration for the entire returns distribution as well, but also that they differ from each other in that the former captures the “normal” / “ordinary” dispersion of returns, while the latter is able to catch the huge dispersion. Therefore, the combined risk metric that uses two individual metrics focused on the same phenomena but differently sensitive to its intensity allows the asset manager to express, in the context of an objective function by varying the “relevance coefficient” associated with the individual metrics, alternatively, a wide set of plausible investment goals for the portfolio construction process while serving investors differently concerned with tail risk and traditional risk. Since this is the first study that also implements risk-based approaches using a combined risk measure, it becomes of fundamental importance to investigate the portfolio effects triggered by this innovation. The paper also offers a second contribution. Until the recent advent of the MK strategy and the KRP strategy, efforts to highlight interesting properties of risk-based approaches were inevitably directed towards the traditional MV strategy and SRP strategy. Previous literature established an increasing order in terms of portfolio volatility, starting from the MV strategy, through the SRP strategy, arriving at the EQ strategy and provided the mathematical proof for the “equalization effect” concerning marginal risks when the MV strategy is considered, and concerning risk contributions when the SRP strategy is considered. Regarding the validity of similar conclusions when referring to the MK strategy and KRP strategy, the development of a theoretical demonstration is still pending. This paper fills this gap.

Keywords: risk parity, portfolio kurtosis, risk diversification, asset allocation

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Authors: T. Mcgraw, F. N. Morin, N. Desai

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Background: Antimicrobial resistance is a critical issue in global health care and a significant contributor to increased patient morbidity and mortality. Suspected urinary tract infection (UTI) is a key area of inappropriate antibiotic prescription in pediatrics. Management patterns of infectious diseases have been shown to vary by provider type within a single setting. The aim of this study was to assess compliance with national UTI management guidelines by nurse practitioners in a pediatric emergency department (ED). Methods: This was a post-hoc analysis of a retrospective cohort study to review and evaluate visits to a tertiary care freestanding pediatric emergency department. Patients were included if they were 60 days to 36 months old and discharged with a diagnosis of UTI or ‘rule-out UTI’ between July 2015 and July 2020. Primary outcome measure was proportion of visits seen by Nurse Practitioners (NP) which were associated with national guideline compliance in the diagnosis and treatment of suspected UTI. We performed descriptive statistics and comparative analyses to determine differences in practice patterns between NPs, and physicians. Results: A total of 636 charts were reviewed, of which 402 patients met inclusion criteria. 17 patients were treated by NPs, 385 were treated by either Pediatric Emergency Medicine physicians (PEM) or non-PEM physicians. Overall, the proportion of infants receiving guideline-compliant care was 25.9% (21.8-30.4%). Of those who were prescribed antibiotics, 79.6% (74.7-83.8%) received first line guideline recommended therapy and 58.9% (53.8-63.8%) received fully compliant therapy with respect to age, dose, duration, and frequency. In patients treated by NPs, 16/17 (94%(95% CI:73.0-99.0)) required antibiotics, 15/16 (93%(95% CI: 71.7-98.9)) were treated with first line agent (cephalexin), 8/16 (50%(95% CI:28-72)) were guideline compliant of dose and duration. 5/8 (63%(95% CI:30.6-86.3)) were noncompliant for dose being too high. There was no difference in receiving guideline compliant empiric antibiotic therapy between physicians and nurse practitioners (OR: 0.837 CI: 0.302-2.69). Conclusion: In this post-hoc analysis, guideline noncompliance by nurse practitioners is common in children tested and treated for UTIs in a pediatric emergency department. Care by a Nurse Practitioner was not associated with greater rate of noncompliance than care by a Pediatric Emergency Medicine physician. Future appropriately powered studies may focus on confirming these results.

Keywords: antibiotic stewardship, infectious disease, nurse practitioner, urinary tract infection

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Authors: Jennifer Bradley

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With opportunities to live and work abroad on the rise, effective preparation and support for international employees needs to be addressed within the work-site. International employees must build new habits, routines and social networks in an unfamiliar culture. Culture shock typically occurs within the first year and can affect both physical and psychological health. Employers have the opportunity to support staff through the adaptation process and foster healthy habits and routines. Cross-cultural training that includes a combination of instructional teaching, cultural experiences, and practice, is shown to increase the international employee adaptation process. However, little evidence demonstrates that organizations provide all of these aspects for international employees. The occupational therapy practitioner (OTP) offers a unique perspective focusing on the employee transactional relationship and engagement of meaningful occupations to enhance and enable participation in roles, habits and routines within new cultural contexts. This paper examines one such program developed and implemented by an OTP at the New England Center for Children, in Abu Dhabi, United Arab Emirates. The effectiveness of the program was assessed via participant feedback and concluded that an international employee support program that focuses on a variety of meaningful experiences and knowledge can empower employees to navigate healthy practices, develop habits and routines, and foster positive inter-cultural relationships in the organization and community.

Keywords: occupational therapy practitioner, cross cultural training, international employee health, international employee support

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Authors: Florian Engel

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Only with a radical change to an intrinsically motivated project team, through giving the employees the freedom for autonomy, mastery and purpose, it is then possible to develop excellent products. With these changes, combined with using a rapid application development approach, the group of users serves as an important indicator to test the market needs, rather than only as the stakeholders for requirements.

Keywords: intrinsic motivation, requirements elicitation, self-directed work, stakeholder participation

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Authors: Arpit Gite

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Purpose: We have evaluated the role of Total Neoadjuvant Therapy in patients with Locally Advanced Rectal cancer by giving Chemoradiotherapy followed by consolidation chemotherapy (CRT-CNCT) and, after that, the strategy of wait and watch. Methods: In this prospective case series, we evaluated the results of three locally advanced Rectal cancers, two cases Stage II (cT3N0) and one case Stage III ( cT4aN2). All three patients' growth was 4-6 cm from the anal verge. We have treated with Chemoradiotherapy to dose of 45Gy/25 Fractions to elective nodal regions (Inguinal node in anal canal Involvement)and Primary and mesorectum (Phase I) followed by 14.4Gy/8 Fractions to Primary and Mesorectum(Phase II) to a total dose of 59.4Gy/33 Fractions with concurrent chemotherapy Tab Capecitabine 825mg/m2 PO BD with Radiation therapy. After 6 weeks of completion of Chemoradiotherapy, advised six cycles of consolidative chemotherapy, CAPEOX regimen, Oxaliplatin 130mg/m2 on day 1 and Capecitabine 1000mg/m2 PO BD on days 1-14 repeated on a 21-day cycle for a total of six cycles. The primary endpoint is Disease-free survival (DFS); the secondary endpoint is adverse events related to chemoradiotherapy. Radiation toxicity is assessed by RTOG criteria, and chemotherapy toxicity is assessed by Common Terminology Criteria for Adverse Events (CTCAE) Version 5.0. Results: After 6 weeks of completion of Chemoradiotherapy, we did PET-CT of all three patients; all three patients had a clinically complete response and we advised 6 cycles of consolidative chemotherapy. After completion of consolidative chemotherapy, again PET-CT and sigmoidoscopy, all three patients had complete response on PET-CT and no lesions on sigmoidoscopy and kept all three patients on wait and watch.2 patients had Grade 2 skin toxicities,1 patient had Grade 1 skin toxicity, .2 patients had Grade 2 lower GI toxicities, and 1 patient had Grade lower GI toxicity, both according to RTOG criteria. 3 patients had Grade 2 diarrhea due to capecitabine, and 1 patient had Grade 1 thrombocytopenia due to oxaliplatin assessed by Common Terminology Criteria for Adverse Events (CTCAE) Version 5.0. Conclusion: Sphincter Preservation is possible with this regimen in those who don’t want to opt for surgery or in case of low-lying rectal cancer.

Keywords: locally advanced rectal cancer, sphincter preservation, chemoradiotherapy, consolidative chemotherapy

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Authors: Marin Kanarev, Delyan Stoyanov, Ivanna Popova, Nadezhda Petrova

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Thanks to increased survival rates in patients bearing oncological malignancies due to recent developments in anti-cancer therapies and diagnostic techniques, observation of clinical cases of metachronous cancers is more common and can provide more in-depth knowledge of their development and, as a result, help clinicians apply suitable therapy. This unusual case of three metachronous tumors presented the opportunity to follow their occurrence, progression, and treatment thoroughly. A 77-year-old male presented with carcinoma ventriculi of the pylorus region, which was surgically removed via upper subtotal stomach resection, a lateral antecolical gastro-enteroanastomosis, and a subsequent Braun anastomosis. An EOX chemotherapy regimen followed. A CT scan four months later showed no indication of recurrence or dissemination. The same scan, performed as a part of the follow-up plan two years later, showed an indication of neoplastic growth in the urinary bladder. After the patient had been directed to a urologist, the suspicion was confirmed, and the growth was histologically diagnosed as a carcinoma of the urinary bladder. An immunohistochemistry test showed an expression of PDL1 of less than 5%, which resulted in treatment with GemCis chemotherapy regimen that led to full remission. Two years and seven months after the first surgery, a CT scan showed again that the two carcinomas were gone. However, four months later, elevated tumor markers prompted a PET/CT scan, which showed data indicative of recurring neoplastic growth in the region of the stomach cardia. It was diagnosed as an adenocarcinoma infiltrating the esophagus. Preoperative chemotherapy with the ECF regimen was completed in four courses, and a CT scan showed no progression of the disease. In less than a month after therapy, the patient underwent laparotomy, debridement, gastrectomy, and a subsequent mechanical terminal-lateral esophago-jejunoanasthomosis. It was verified that the tumor originated from metastasis from the carcinoma ventriculi, which was located in the pylorus. In conclusion, this case report highlights the importance of patient follow-up and studying recurring neoplastic growth. Despite the absence of symptoms, clinicians should maintain a high level of suspicion when evaluating the patient data and choosing the most suitable therapy.

Keywords: carcinoma, follow-up, metachronous, neoplastic growth, recurrence

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Authors: Runliang Wang, Jianhua Liu, Duo Jia, Xiaoyu Ding

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The contact between sealing surfaces plays a vital role in guaranteeing the sealing performance of various seals. To date, analyses of sealing structures have rarely considered both structural parameters (macroscale) and surface roughness information (microscale) of sealing surfaces due to the complex modeling process. Meanwhile, most of the contact analyses applied to seals were conducted only under normal loading, which still existssome distance from real loading conditions in engineering. In this paper, a multiscale rough contact model, which took both macrostructural parameters of seals and surface roughness information of sealing surfaces into consideration for the cone-cone seal, was established. By using the finite element method (FEM), the combined normal and tangential loading was applied to the model to simulate the assembly process of the cone-cone seal. The evolution of the contact behaviors during the assembly process, such as the real contact area (RCA), the distribution of contact pressure, and contact status, are studied in detail. The results showed the non-linear relationship between the RCA and the load, which was different from the normal loading cases. In addition, the evolution of the real contact area of cone-cone seals with isotropic and anisotropic rough surfaces are also compared quantitatively.

Keywords: contact mechanics, FEM, randomly rough surface, real contact area, sealing

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Authors: Leonor Varandas, Pedro D. Gaspar, Martim L. Aguiar

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One of the biggest concerns in the field of agriculture is around the energy efficiency of robots that will perform agriculture’s activity and their charging methods. In this paper, two different charging methods for agricultural standalone docking stations are shown that will take into account various variants as field size and its irregularities, work’s nature to which the robot will perform, deadlines that have to be respected, among others. Its features also are dependent on the orchard, season, battery type and its technical specifications and cost. First charging base method focuses on wireless charging, presenting more benefits for small field. The second charging base method relies on battery replacement being more suitable for large fields, thus avoiding the robot stop for recharge. Existing many methods to charge a battery, the CC CV was considered the most appropriate for either simplicity or effectiveness. The choice of the battery for agricultural purposes is if most importance. While the most common battery used is Li-ion battery, this study also discusses the use of graphene-based new type of batteries with 45% over capacity to the Li-ion one. A Battery Management Systems (BMS) is applied for battery balancing. All these approaches combined showed to be a promising method to improve a lot of technical agricultural work, not just in terms of plantation and harvesting but also about every technique to prevent harmful events like plagues and weeds or even to reduce crop time and cost.

Keywords: agricultural mobile robot, charging methods, battery replacement method, wireless charging method

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Authors: Atoui Oussama, Maazoun Azer, Belkassem Bachir, Pyl Lincy, Lecompte David

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For many decades, researchers have been focused on understanding the dynamic behavior of different structures and materials subjected to fragment impact or blast loads separately. The explosion mechanics, as well as the impact physics studies dealing with the numerical modeling of the response of protective structures under the synergistic effect of a blast wave and the impact of fragments, are quite limited in the literature. This article numerically evaluates the nonlinear dynamic behavior and damage mechanisms of Aluminum plates EN AW-1050A- H24 under different combined loading scenarios varied by the sequence of the applied loads using the commercial software LS-DYNA. For one hand, with respect to the terminal ballistic field investigations, a Lagrangian (LAG) formulation is used to evaluate the different failure modes of the target material in case of a fragment impact. On the other hand, with respect to the blast field analysis, an Arbitrary Lagrangian-Eulerian (ALE) formulation is considered to study the fluid-structure interaction (FSI) of the shock wave and the plate in case of a blast loading. Four different loading scenarios are considered: (1) only blast loading, (2) only fragment impact, (3) blast loading followed by a fragment impact and (4) a fragment impact followed by blast loading. From the numerical results, it was observed that when the impact load is applied to the plate prior to the blast load, it suffers more severe damage due to the hole enlargement phenomenon and the effects of crack propagation on the circumference of the damaged zone. Moreover, it was found that the hole from the fragment impact loading was enlarged to about three times in diameter as compared to the diameter of the projectile. The validation of the proposed computational model is based in part on previous experimental data obtained by the authors and in the other part on experimental data obtained from the literature. A good correspondence between the numerical and experimental results is found.

Keywords: computational analysis, combined loading, explosion mechanics, hole enlargement phenomenon, impact physics, synergistic effect, terminal ballistic

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Authors: Eri Sulyanti, Trimurti Habazar, Eti Farda Husen, Abdi Dharma, Nasril Nasir

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In this study, combination of some biocontrol agents with different mechanisms was an alternative to improve the effectiveness of the biological control agents. Single and combined applications of indigenous Pseudomonas fluorescens and Arbuscular Mychorrhizae Fungi (AM Fungi) isolates were tested to induce the resistance on susceptible Cavendish banana against F.oxysporum f. sp. cubense race 4 under greenhouse conditions. These isolates originally isolated from healthy banana rhizosphere at endemic Fusarium wilt areas in the centre of production banana in West Sumatra. These researches were conducted with Randomized Block Design with 16 treatments and 10 replications. The treatments were three indigenous isolates of Pseudomonas fluorescens (Par1-Cv, Par4-Rj1, Par2-Jt1) and 3 isolates of AM Fungi (Gl1BuA4, Gl2BuA6, and Gl1KeP3. The biocontrol agents were applied as single agents and combination two of them. This study demonstrated that the application of combination biocontrol organisms Pseudomonas fluorescens and AM Fungi provided were more effective than single application. The combination of Par1-Cv and Gl1BuA4 isolates was the most effective to control Fusarium wilt and followed by the combination of Par1-Cv and Gl2BuA6 and Par2-Jt1 and Gl1P3.

Keywords: pseudomonad fluorescens (Pf), arbuscular mychorrhizae fungi (AM Fungi) indigenous isolates, fusarium oxysporum f. sp. cubense, soil rhizosphere

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Authors: Yerbolat Iztleuov

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Stochastic effects, which are currently largely associated with exposure to ionizing radiation or a combination of ionizing radiation with other chemical, physical, and biological agents, are expressed in the form of various mutations. In the first stage of the study, rats of both sexes were divided into 3 groups. 1st - control group, animals of the 2nd group were exposed to gamma radiation at a dose of 0.2 Gy. The third group received hexavalent chromium in a dose of 180 mg/ l with drinking water for a month before irradiation and a day after the end of chromium consumption and was subjected to total gamma irradiation at a dose of 0.2 Gy. The second stage of the experiment. After 3 days, the males were mated with the females. The obtained offspring were studied for peroxidation, cytokine profile and micronucleus in the nuclei. This study shows that 5-month-old offspring whose parents were exposed to combined exposure to chromium and γ-irradiation exhibit hereditary instability of the genome, decreased activity of antioxidant enzymes and sulfhydryl blood groups, and increased levels of lipid peroxidation. There is also an increase in the level of inflammatory markers (IL-6 and TNF) in the blood plasma against the background of a decrease in anti-inflammatory cytokine (IL-10). Thus, the combined effect of hexavalent chromium and ionizing radiation can lead to the development of an oncological process.

Keywords: hexavalent chromium, ionizing radiation, first generation, oxidative stress, cytokines, mutagenesis, cancer

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Authors: Hilman Agil Satria, Rezky Naufan Hendrawan

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Indonesia is vulnerable to geological hazard because of its location in subduction zone and have tropical climate. Landslide is one of the most happened geological hazard in Indonesia, based on Indonesia Geospasial data, at least 194 landslides recorded in 2013. In fact, research location is placed as the third city that most happened landslide in Indonesia. Landslide caused damage of many houses and wrecked the road. The purpose of this research is to make a landslide zone therefore can be used as one of mitigation consideration. The location is in Bruno, Porworejo district Central Java Province Indonesia at 109.903 – 109.99 and -7.59 – -7.50 with 10 Km x 10 Km wide. Based on geological mapping result, the research location consist of Late Miocene sandstone and claystone, and Pleistocene volcanic breccia and tuff. Those landslide happened in the lithology that close with fault zone. This location has so many geological structures: joints, faults and folds. There are 3 thrust faults, 1 normal faults, 4 strike slip faults and 6 folds. This geological structure movement is interpreted as the main factor that has triggered landslide in this location. This research use field data as well as samples of rock, joint, slicken side and landslide location which is combined with DEM SRTM to analyze geomorphology. As the final result of combined data will be presented as geological map, geological structure map and landslide zone map. From this research we can assume that there is correlation between geological structure and landslide locations.

Keywords: geological structure, landslide, Porworejo, Indonesia

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Authors: Mohamed Hesham Hamdy Abdelmohsen, Ahmed Shawky Abdul Aziz, Mona Fawzy Al-Daghma

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Helical piles are widely used as axially and laterally loaded deep foundations. Once they are required to resist bearing combined loads (BCLs), as axial compression and lateral thrust, different behaviour is expected, necessitating further investigation. The objective of the present article is to clarify the behaviour of a single helical pile of different shaft rigidity embedded in cohesion-less soil and subjected to simultaneous or successive loading patterns of BCLs. The study was first developed analytically and extended numerically. The numerical analysis was further verified through a laboratory experimental program on a set of helical pile models. The results indicate highly interactive effects of the studied parameters, but it is obviously confirmed that the pile performance increases with both the increase of shaft rigidity and the change of BCLs loading pattern from simultaneous to successive. However, it is noted that the increase of vertical load does not always enhance the lateral capacity but may cause a decrement in lateral capacity, as observed with helical piles of flexible shafts. This study provides insightful information for the design of helical piles in structures loaded by complex sequence of forces, wind turbines, and industrial shafts.

Keywords: helical pile, lateral loads, combined loads, cohesion-less soil, analytical, numerical

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Authors: Upasana Bhumbla

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Background: Hepatitis C virus is a major cause of chronic hepatitis, which can further lead to cirrhosis of the liver and hepatocellular carcinoma. Worldwide the burden of Hepatitis C infection has become a serious threat to the human race. Hepatitis C virus (HCV) has population-specific genotypes and provides valuable epidemiological and therapeutic information. Genotyping and assessment of viral load in HCV patients are important for planning the therapeutic strategies. The aim of the study is to study the changing trends of prevalence and genotypic distribution of hepatitis C virus in a tertiary care hospital in Western India. Methods: It is a retrospective study; blood samples were collected and tested for anti HCV antibodies by ELISA in Dept. of Microbiology. In seropositive Hepatitis C patients, quantification of HCV-RNA was done by real-time PCR and in HCV-RNA positive samples, genotyping was conducted. Results: A total of 114 patients who were seropositive for Anti HCV were recruited in the study, out of which 79 (69.29%) were HCV-RNA positive. Out of these positive samples, 54 were further subjected to genotype determination using real-time PCR. Genotype was not detected in 24 samples due to low viral load; 30 samples were positive for genotype. Conclusion: Knowledge of genotype is crucial for the management of HCV infection and prediction of prognosis. Patients infected with HCV genotype 1 and 4 will have to receive Interferon and Ribavirin for 48 weeks. Patients with these genotypes show a poor sustained viral response when tested 24 weeks after completion of therapy. On the contrary, patients infected with HCV genotype 2 and 3 are reported to have a better response to therapy.

Keywords: hepatocellular, genotype, ribavarin, seropositive

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Authors: H.Karnezi, K. Tierney

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Childhood fears that persist over time and interfere with the children’s normal functioning may have detrimental effects on their social and emotional development. Cognitive behavior therapy is considered highly effective in treating fears and anxieties. However, given that many childhood fears are based on fantasy, the applicability of CBT may be hindered by cognitive immaturity. Furthermore, a lack of motivation to engage in therapy is another commonly encountered obstacle. The purpose of this study was to introduce and evaluate a more developmentally appropriate intervention model, specifically designed to provide phobic children with the motivation to overcome their fears. To this end, principles and techniques from cognitive and behavior therapies are incorporated into the ‘Drama in Education’ model. The Cognitive Behaviour Drama (CBD) method involves using the phobic children’s creativity to involve them in the therapeutic process. The children are invited to engage in exciting fictional scenarios tailored around their strengths and special interests. Once their commitment to the drama is established, a problem that they will feel motivated to solve is introduced. To resolve it, the children will have to overcome a number of obstacles culminating in an in vivo confrontation with the fear stimulus. The study examined the application of the CBD model in three single cases. Results in all three cases shown complete elimination of all fear-related symptoms. Preliminary results justify further evaluation of the Cognitive Behaviour Drama model. It is time and cost-effective, ensuring the clients' immediate engagement in the therapeutic process.

Keywords: phobias, autism, intervention, drama

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Authors: P. Gao, Z. Q. Li, Y. G. Jin

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In the past 10 years, computers and cellphones have become one of the most important factors in our lives, and one which has a tremendously negative impact on our muscles. Muscle tension may be one of the causes of sleep disturbance. Tension in the shoulders and neck can affect blood circulation to the muscles. This research uses a dry needling treatment to reduce muscle tension in order to determine if the strain in the head and shoulders can influence sleep duration. All 38 patients taking part in the testing suffered from tinnitus and have been experiencing disturbed sleep for at least one to five years. Even after undergoing drug therapy treatments and traditional acupuncture therapies, their sleep disturbances have not shown any improvement. After five to 10 dry needling treatments, 24 of the patients reported an improvement in their sleep duration. Five patients considered themselves to be completely recovered, while 12 patients experienced no improvement. This study investigated these pathogenic and therapeutic problems. The standard treatment for sleep disturbances is drug-based therapy; the results of most standard treatments are unfortunately negative. The result of this clinical research has demonstrated that: The possible cause of sleep disturbance for a lot of patients is the result of tensions in the neck and shoulder muscles. Blood circulation to those muscles is also influenced by the duration of sleep. Hypertonic neck and shoulder muscles are considered to impact sleeping patterns and lead to disturbed sleep. Poor posture, often adopted while speaking on the phone, is one of the main causes of hypertonic neck and shoulder muscle problems. The dry needling treatment specifically focuses on the release of muscle tension.

Keywords: dry needling, muscle tension, sleep duration, hypertonic muscles

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Authors: Sajida Saqira, Anthony Chariton, Grant C. Hose

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The Anthropocene has seen dramatic environmental changes which are affecting every ecosystem on earth. Freshwater ecosystems are particularly vulnerable as they are at risk from the many activities that go on and contaminants that are released in catchments. They are thus subject to many stressors simultaneously. Freshwater ecosystems respond to stress at all levels of biological organization, from subcellular to community structure and ecosystem functioning. The aim of this study was to examine the resistance and resilience of freshwater ecosystems to multiple stressors. Here we explored the individual and combined effects of copper as a chemical stressor and common carp (Cyprinus carpio) as a biological stressor on the health, functioning, and recovery of outdoor experimental pond ecosystems in a long-term, controlled, factorial experiment. Primary productivity, decomposition, and water and sediment quality were analysed at regular intervals for one year to understand the health and functioning of the ecosystems. Changes to benthic biota were quantified using DNA-based and traditional microscopy-based counts of invertebrates. Carp were added to the ponds to copper contaminated sediments (with controls) to explore the combined effects of copper and carp and removed after six months to explore the resilience and recovery of the system. The outcomes of this study will advance our understanding of the impacts of multiple stressors on freshwater ecosystems, and the resilience of these systems to copper and C. carpio, which are both globally significant stressors in freshwater systems.

Keywords: carp, copper, ecosystem health, freshwater ecosystem, multiple stressors

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Authors: Hajer Chaker Ben Hadj Kacem, Thouraya Slama, Néjiba El Yetim Zribi

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This paper analyzes the effects of gender, affiliation, prior work experience, social work, and vicarious learning through family role models on entrepreneurial skills development by students when they have learned through the entrepreneurship method in Tunisia. Authors suggest that these variables enhance the development of students’ entrepreneurial skills when combined with teaching through entrepreneurship. The article assesses the impact of these combinations by comparing their effects on the development of thirteen students’ entrepreneurial competencies, namely entrepreneurial mindset, core self-evaluation, entrepreneurial attitude, entrepreneurial knowledge, creativity, financial literacy, managing ambiguity, marshaling of resources, planning, teaching methods, entrepreneurial teachers, innovative employee, and Entrepreneurial intention. Authors use a two-sample independent t-test to make the comparison, and the results indicate that, when combined with teaching through the entrepreneurship method, students with prior work experience developed better six entrepreneurial skills; students with social work developed better three entrepreneurial skills, men developed better four entrepreneurial skills than women. However, all students developed their entrepreneurial skills through this practical method regardless of their affiliation and their vicarious learning through family role models.

Keywords: affiliation, entrepreneurial skills, gender, role models, social work, teaching through entrepreneurship, vicarious learning, work experience

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Authors: Emil Iskandarov, Nazrin Agayeva

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Background: The effectiveness of hormone suppressive therapy (HST) in patients with nodular goiter (NG) is controversial. The aim of this study was to identify the impact of long-time HST on the Quality of Life (QoL) of patients with NG. Material and Methods: A retrospective analysis of 146 patients with NG showed treated with HST showed that in 38,4% of cases, HST was not effective. Nodules were increased in size and moreover, and new nodules were developed. Statistical procedure identified the predictors of resistant nodules: only one nodule in the left lobe; nodule size >17mm; calcinate within the nodule. 174 patients with NG, by whom predictors of resistant nodules were established, were informed about the results of previous research and surgery was suggested. Eighty-eight patients (the basic group) agreed with surgery and thyroidectomy was led. 86 patients (control group) ignored the suggestion and wished to receive HST. 3, 6 and 12 months after starting HST; control group patients were examined. HST was non-effective and patients, due to developing symptoms, were operated on. Patients in both groups were followed up 3, 6 and 12 months after thyroidectomy. Quality of Life was checked with the SF-36 survey form and compared between groups. The statistical analysis was performed with the non-parametric Mann–Whitney U test and with the Student t-test. P values ＜0.05 were considered statistically significant. Results and Discussions: QoL of patients in the basic and control groups 3 months after surgery was almost the same. However, Emotional problems severely interfered with patients in a control group with normal social activities with family, friends, and neighbors. The causes were related to the non-effective HST treatment before surgery: stress for forgetting to take drugs timely every day for a long time; blood tests for thyroid hormone level; needle biopsies of nodules for cancer screening and regular ultrasound investigations, which showed that nodules not diminished in size. Changing the treatment method after 1-year non-effective HST and delayed surgery negatively impacted patient's QoL. Social role functioning and mental health in the control group were also impaired and the difference between the results in the basic group was statistically significant (p <0.05). Conclusion: Predictors, such as only one nodule, the width of nodules more than 17mm, and the existence of calcinate within the nodule, are able to forecast the resistant nodules. HST in patients with resistant nodules is non-effective and surgery is suggested in patients with resistant nodules in the thyroid gland. Long time HST has a negative impact on the QoL patient after surgery.

Keywords: thyroid gland, nodule, hormone suppressive therapy, quality of life

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Authors: Tao Lin, Hongzhi Song, Zhongtao Yuan, Shanshan Lin, Chunyue Tong

Abstract:

Offshore heavy oil in the production of thick oil fields, old wells of low production and low efficiency are mainly caused by plugging, heavy oil, insufficient stratigraphic energy, etc., the use of heat - gas - chemical and other composite production enhancement role, can be better to achieve the purpose of unblocking and increase the efficiency of the production. Through indoor physical simulation experiments, comprehensive grey correlation analysis, combined with theoretical methods to analyze the composite production enhancement effect of heat-gas-chemical and other factors was in the order of heat>gas>chemical agent; and quantitative analysis of the data shows that the contribution of heat is the highest in the range of 68.5%-82.8%, the gas role in the range of 9.3%-11.3%, and the contribution of the chemical agent in the range of 6.0%-22.2%. Combined with indoor physical simulation experiments and reservoir engineering calculations, it shows that the production capacity is restored and increased by about 50%, and numerical simulation calculations show that the cumulative increase in production by using thermal-gas-chemical decongestion process measures can be up to 40%. Through the optimization of this kind of compound production enhancement technology, it can meet the requirements of original production string operation, and this technology has the advantages of short, flat and fast operation and has good application prospects.

Keywords: MCTF, old heavy oil wells, low production and low efficiency, immobile tubular column, composite production increase

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