Search results for: Rachel Buchanan

Authors: Rachel Byrne

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Background: Due to patient and student safety concerns, combined with clinical teachers being redeployed to clinical practice, COVID-19 has resulted in a reduction in face-to-face teaching sessions for medical students. Traditionally such sessions are particularly important for final year medical students, especially in preparing for their final practical exams. A reduced student presence on the wards has also resulted in fewer opportunities for junior doctors to provide teaching sessions. This has implications for junior doctors achieving their own curriculum outcomes for teaching, as well as potentially hindering the development of a future interest in medical education. Aims: The aims of the study are 1) To create a safe face-to-face teaching environment during COVID-19 which focussed on exam preparation for final year medical students, 2) To provide a platform for doctors to gain teaching experience, 3 ) to enable doctors to gain feedback or assessments on their teaching, 4) To create beginners guide to designing a new teaching program for future junior doctors. Methods: We created a program of timed clinical stations consisting of four sessions every five weeks during the student’s medicine attachment. Each session could be attended by 6 students and consisted of 6 stations ran by junior doctors, with each station following social distancing and personal protective equipment requirements. Junior doctors were asked to design their own stations. The sessions ran out-of-hours on weekday evenings and were optional for the students. Results: 95/95 students and 20/40 doctors involved in the programme completed feedback. 100% (n=95) of students strongly agreed/agreed that sessions were aimed at an appropriate level and provided constructive feedback. 100% (n=95) of students stated they felt more confident in their abilities and would recommend the session to peers. 90% (n=18) of the teachers strongly agreed/agreed that they felt more confident in their teaching abilities and that the sessions had improved their own medical knowledge. 85% (n=17) of doctors had a teaching assessment completed, and 83% (n=16) said the program had made them consider a career in medical education. The difficulties of creating such a program were highlighted throughout, and a beginner’s guide was created with the hopes of helping future doctors who are interested in teaching address the common obstacles.

Keywords: COVID-19, education, safety, medical

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Authors: Rachel Falconer

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Background: The United Nations Convention on the Rights of the Child sets out the duties placed on signatory nations to take measures to protect children from all forms of violence, abuse, neglect and maltreatment. The systems for ensuring this protection vary globally, shaped by national welfare policies. In England and Finland, past research has highlighted differences in how child protection issues are framed and how state agencies respond. However, less is known about how such differences impact processes of social work judgment and decision making in practice. Method: Data was collected as part of a wider PhD project in three stages. First, social workers in sites across England and Finland were asked to complete a short questionnaire. Participants were then asked to comment on two constructed case vignettes, and were interviewed about their experiences of child protection decision making at the point of referral. Interviews were analyzed using NVivo to draw out key themes. Findings: There were similarities in how the English and Finnish social workers responded to the case vignettes; for example, participants in both countries expressed concerns about similar risk factors and all felt further assessment was needed. Differences were observed, in particular, in regard to the sources of support and guidance participants referred to, with the English social workers appearing to rely more upon managerial input for their decisions than the Finnish social workers. These findings suggest evidence for two distinct decision making approaches: ‘supervised’ and ‘supported’ judgement. Implications for practice: The findings have relevance to the conference theme of research and evaluation of social work practice, and support the findings of previous studies that have emphasized the significance of organizational factors in child protection decision making. The comparative methodology has also helped to demonstrate how organizational factors can influence practice in different child protection system ‘orientations’. The presentation will discuss the potential practice implications of ‘supervised’, manager-led approaches to decision making as contrasted with ‘supported’, team-led approaches, inviting discussion about the relevance of these findings for social work in other countries.

Keywords: child protection, comparative research, decision making, social work, vignettes

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Authors: Hansraj Bookun, Angela Tan, Rachel Xuan, Linheng Zhao, Kejia Wang, Animesh Singla, David Kim, Christopher Loupos

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Introduction: Incisional wound complications in vascular surgery patients represent a significant clinical and econometric burden of morbidity and mortality. The objective of this study was to trial the feasibility of applying the Prevena negative pressure incision management system as a routine dressing in patients who had undergone arterial surgery. Conventionally, Prevena has been applied to groin incisions, but this study features applications on multiple wound sites such as the thigh or major amputation stumps. Method: This was a cross-sectional observational, single-centre case series of 12 patients who had undergone major vascular surgery. Their wounds were managed with the Prevena system being applied either intra-operatively or on the first post-operative day. Demographic and operative details were collated as well as the length of stay and complication rates. Results: There were 9 males (75%) with mean age of 66 years and the comorbid burden was as follows: ischaemic heart disease (92%), diabetes (42%), hypertension (100%), stage 4 or greater kidney impairment (17%) and current or ex-smoking (83%). The main indications were acute ischaemia (33%), claudication (25%), and gangrene (17%). There were single instances of an occluded popliteal artery aneurysm, diabetic foot infection, and rest pain. The majority of patients (50%) had hybrid operations with iliofemoral endarterectomies, patch arterioplasties, and further peripheral endovascular treatment. There were 4 complex arterial bypass operations and 2 major amputations. The mean length of stay was 17 ± 10 days, with a range of 4 to 35 days. A single complication, in the form of a lymphocoele, was encountered in the context of an iliofemoral endarterectomy and patch arterioplasty. This was managed conservatively. There were no deaths. Discussion: The Prevena wound management system shows that in conjunction with safe vascular surgery, absolute wound complication rates remain low and that it remains a valuable adjunct in the treatment of vasculopaths.

Keywords: wound care, negative pressure, vascular surgery, closed incision

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Authors: Fereshteh Ganjavi, Rachel Schaffer, Varsha Jorawar

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Elena’s Light is a non-profit organization focused on building brighter futures for refugees, especially women and children. Our mission is to empower refugee women and children by addressing social, legal, and public health issues that predominantly concern them. Elena’s Light offers a range of services that support refugees from structural disadvantages, cultural and social stress, marginalization, and other stressors related to migration. Using a three-pronged approach, our programs focus on legal advocacy, English language acquisition, and health and wellness. Following the Afghan humanitarian crisis, Elena’s Light has developed and intensified advocacy efforts in the legal realm to address the influx of refugees who desperately need assistance. We developed and hosted a Know Your Rights presentation with local immigration lawyers and professionals in February 2022 on the Afghan Humanitarian Parole, which was very successful with over 100 attendees. Elena’s Light is hosting the second Know Your Rights session in early August 2022 on immigration options for Afghans, including Temporary Protected Status (TPS), asylum, Special Immigrant Visa (SIV), and humanitarian parole. Lastly, EL is also leading the local initiative to develop a pro-bono committee to respond to the overwhelming need for lawyers to work on legal cases for Afghan during this crisis. Furthermore, through our other services, we provide free, in-home customizable ESL tutoring sessions to refugee women with a focus on driver’s education, facilitating acculturation, and improving employment opportunities. We also provide in-home maternal, pediatric, and mental health education and wellness services that are aimed at addressing the explicit and implicit barriers to healthcare for refugee populations. Elena’s Light’s diverse community aims to counter the structural disadvantages and anxiety-inducing emotions and experiences related to being a refugee. We would like to join this International Conference on Refugee Law since protecting refugee rights is our mission. We would like to share what we have learned from our legal initiatives for refugee rights. We would also like to listen, learn from, and discuss with experts and researchers how to better understand and advocate for refugee rights. We hope to improve our understanding of how to provide better legal aid for our clients through this conference.

Keywords: legal, advocacy, Afghan humanitarian crisis, policy, pro-bono

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Authors: Ingrid van der Heijden, Kristen Dunkle, Rachel Jewkes

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Background: Emerging literature on prevalence shows that men with disabilities are four more times likely than men without disabilities to experience sexual violence during their lifetime. However, compared to women with disabilities, men with disabilities still have lesser experiences of violence. While empirical evidence on the prevalence of victimization of men with disabilities is emerging, there is scarcer evidence highlighting disabled men’s perpetration of different forms of violence, particularly intimate partner violence. We can assume that men are likely to be both perpetrators and victims of violence, making more complex the causes and risks of violence. Gender norms and disability stigma play important roles in men’s experiences of violence. Men may be stigmatized because of their inability to attain hegemonic masculine ideals of strength, control over women and sexual conquest, which makes them more susceptible to emotional, physical and sexual abuse. Little to no evidence exists of men with disabilities’ experiences of perpetration of intimate partner violence, family violence or community violence. So far studies on male victimization do not succeed to offer contextual evidence that would highlight why and how men with disabilities perpetrate and/or are victims of sexual or other forms of violence. Objective: The overall aim to highlight men with disabilities’ experiences of both victimization and perpetration, and how living up to normative and hegemonic ideals of masculinity and ‘ability’ shape their experiences. It will include: identifying how gender and impairments intersect and shape their experiences of violence; identifying the contexts of and risks for violence; identifying the impacts and consequences of violence on their lives (including mental health impacts), and identifying obstacles and enablers to support and interventions to prevent violence. Methodology: In-depth qualitative interviews with 20 men with disabilities participating in interventions conducted by the What Works Global Programme for violence prevention (DIFD) in Africa and Asia. Men with a range of disabilities will be invited to share their lifetime experiences of violence. Implications for Practice: The data from this study will be used to start thinking about strategies to include men with disabilities in violence prevention strategies for both men and women. Limitations: Because men will be participating in interventions, it is assumed that they will not have severe impairments that hamper their cognitive or physical ability to participate in the intervention activities - and therefore will be able to participate in the in-depth interviews. Of course, this is a limitation of the study as it does not include those men with severe disabilities – measured by the World Health Organization’s International Classification of Functioning - who may be more vulnerable and at higher risk of experiencing violence, and who are less likely to be able to access services and interventions.

Keywords: gender, men with disabilities, perpetration of violence, victimization

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Authors: Rachel Cherner

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Introduction: The current study investigates several user characteristics that may predict the adoption of digital mental health supports. The extent to which individual characteristics predict preferences for functional elements of computer-mediated social support (CMSS) platforms and mental health (MH) apps is relatively unstudied. Aims: The present study seeks to illuminate the relationship between broad user characteristics and perceived attraction to CMSS platforms and MH apps. Methods: Participants (n=353) were recruited using convenience sampling methods (i.e., digital flyers, email distribution, and online survey forums). The sample was 68% male, and 32% female, with a mean age of 29. Participant racial and ethnic breakdown was 75% White, 7%, 5% Asian, and 5% Black or African American. Participants were asked to complete a 25-minute self-report questionnaire that included empirically validated measures assessing a battery of characteristics (i.e., subjective levels of anxiety/depression via PHQ-9 (Patient Health Questionnaire 9-item) and GAD-7 (Generalized Anxiety Disorder 7-item); attachment style via MAQ (Measure of Attachment Qualities); personality types via TIPI (The 10-Item Personality Inventory); growth mindset and mental health-seeking attitudes via GM (Growth Mindset Scale) and MHSAS (Mental Help Seeking Attitudes Scale)) and subsequent attitudes toward CMSS platforms and MH apps. Results: A stepwise linear regression was used to test if user characteristics significantly predicted attitudes towards key features of CMSS platforms and MH apps. The overall regression was statistically significant (R² =.20, F(1,344)=14.49, p<.000). Conclusion: This original study examines the clinical and sociocultural factors influencing decisions to use CMSS platforms and MH apps. Findings provide valuable insight for increasing adoption and engagement with digital mental health support. Fostering a growth mindset may be a method of increasing participant/patient engagement. In addition, CMSS platforms and MH apps may empower under-resourced and minority groups to gain basic access to mental health support. We do not assume this final model contains the best predictors of use; this is merely a preliminary step toward understanding the psychology and attitudes of CMSS platform/MH app users.

Keywords: computer-mediated social support platforms, digital mental health, growth mindset, health-seeking attitudes, mental health apps, user characteristics

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Authors: Erica Siqueira, Adriana Bin, Rachel Stefanuto

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The paper aims to identify and to discuss the impact and results of ex-ante, mid-term and ex-post evaluation initiatives in Brazilian Social Enterprises from the point of view of the entrepreneurs and investors, highlighting the processes involved in these activities and their aftereffects. The study was conducted using a descriptive methodology, primarily qualitative. A multiple-case study was used, and, for that, semi-structured interviews were conducted with ten entrepreneurs in the (i) social finance, (ii) education, (iii) health, (iv) citizenship and (v) green tech fields, as well as three representatives of various impact investments, which are (i) venture capital, (ii) loan and (iii) equity interest areas. Convenience (non-probabilistic) sampling was adopted to select both businesses and investors, who voluntarily contributed to the research. The evaluation is still incipient in most of the studied business cases. Some stand out by adopting well-known methodologies like Global Impact Investing Report System (GIIRS), but still, have a lot to improve in several aspects. Most of these enterprises use nonexperimental research conducted by their own employees, which is ordinarily not understood as 'golden standard' to some authors in the area. Nevertheless, from the entrepreneur point of view, it is possible to identify that most of them including those routines in some extent in their day-by-day activities, despite the difficulty they have of the business in general. In turn, the investors do not have overall directions to establish evaluation initiatives in respective enterprises; they are funding. There is a mechanism of trust, and this is, usually, enough to prove the impact for all stakeholders. The work concludes that there is a large gap between what the literature states in regard to what should be the best practices in these businesses and what the enterprises really do. The evaluation initiatives must be included in some extension in all enterprises in order to confirm social impact that they realize. Here it is recommended the development and adoption of more flexible evaluation mechanisms that consider the complexity involved in these businesses’ routines. The reflections of the research also suggest important implications for the field of Social Enterprises, whose practices are far from what the theory preaches. It highlights the risk of the legitimacy of these enterprises that identify themselves as 'social impact', sometimes without the proper proof based on causality data. Consequently, this makes the field of social entrepreneurship fragile and susceptible to questioning, weakening the ecosystem as a whole. In this way, the top priorities of these enterprises must be handled together with the results and impact measurement activities. Likewise, it is recommended to perform further investigations that consider the trade-offs between impact versus profit. In addition, research about gender, the entrepreneur motivation to call themselves as Social Enterprises, and the possible unintended consequences from these businesses also should be investigated.

Keywords: evaluation practices, impact, results, social enterprise, social entrepreneurship ecosystem

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Authors: Martin Wiseman, Rachel Thompson, Panagiota Mitrou, Kate Allen

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Since 1997 World Cancer Research Fund (WCRF) International and the American Institute for Cancer Research (AICR) have been at the forefront of synthesising and interpreting the accumulated scientific literature on the link between diet, nutrition, physical activity and cancer, and deriving evidence-based Cancer Prevention Recommendations. The 2007 WCRF/AICR 2nd Expert Report was a landmark in the analysis of evidence linking diet, body weight and physical activity to cancer and led to the establishment of the Continuous Update Project (CUP). In 2018, as part of the CUP, WCRF/AICR will publish a new synthesis of the current evidence and update the Cancer Prevention Recommendations. This will ensure that everyone - from policymakers and health professionals to members of the public - has access to the most up-to-date information on how to reduce the risk of developing cancer. Overweight and obesity play a significant role in cancer risk, and rates of both are increasing in many parts of the world. This session will give an overview of new evidence relating obesity to cancer since the 2007 report. For example, since the 2007 Report, the number of cancers for which obesity is judged to be a contributory cause has increased from seven to eleven. The session will also shed light on the well-established mechanisms underpinning obesity and cancer links. Additionally, the session will provide an overview of diet and physical activity related factors that promote positive energy imbalance, leading to overweight and obesity. Finally, the session will highlight how policy can be used to address overweight and obesity at a population level, using WCRF International’s NOURISHING Framework. NOURISHING formalises a comprehensive package of policies to promote healthy diets and reduce obesity and non-communicable diseases; it is a tool for policymakers to identify where action is needed and assess if an approach is sufficiently comprehensive. The framework brings together ten policy areas across three domains: food environment, food system, and behaviour change communication. The framework is accompanied by a regularly updated database providing an extensive overview of implemented government policy actions from around the world. In conclusion, the session will provide an overview of obesity and cancer, highlighting the links seen in the epidemiology and exploring the mechanisms underpinning these, as well as the influences that help determine overweight and obesity. Finally, the session will illustrate policy approaches that can be taken to reduce overweight and obesity worldwide.

Keywords: overweight, obesity, nutrition, cancer, mechanisms, policy

Procedia PDF Downloads 157

Authors: Cristina Fernandez, Felix Amparano, John Tumberger, Stephani Stancil, Sarah Hampl, Brooke Sweeney, Amy R. Beck, Helena H Laroche, Jared Tucker, Eileen Chaves, Sara Gould, Matthew Lindquist, Lora Edwards, Renee Arensberg, Meredith Dreyer, Jazmine Cedeno, Alleen Cummins, Jennifer Lisondra, Katie Cox, Kelsey Dean, Rachel Perera, Nicholas A. Clark

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Background: Adolescents with obesity are at higher risk of disordered eating than the general population. Detection of eating disorders (ED) is difficult. Screening questionnaires may aid in early detection of ED. Our team’s prior efforts focused on increasing ED screening rates to ≥90% using a validated 10-question adolescent binge eating disorder screening questionnaire (ADO-BED). This aim was achieved. We then aimed to improve treatment plan initiation of patients ≥12 years of age who screen positive for BED within our WMC from 33% to 70% within 12 months. Methods: Our WMC is within a tertiary-care, free-standing children’s hospital. A3, an improvement framework, was used. A multidisciplinary team (physicians, nurses, registered dietitians, psychologists, and exercise physiologists) was created. The outcome measure was documentation of treatment plan initiation of those who screen positive (goal 70%). The process measure was ADO-BED screening rate of WMC patients (goal ≥90%). Plan-Do-Study-Act (PDSA) cycle 1 included provider education on current literature and treatment plan initiation based upon ADO-BED responses. PDSA 2 involved increasing documentation of treatment plan and retrain process to providers. Pre-defined treatment plans were: 1) repeat screen in 3-6 months, 2) resources provided only, or 3) comprehensive multidisciplinary weight management team evaluation. Run charts monitored impact over time. Results: Within 9 months, 166 patients were seen in WMC. Process measure showed sustained performance above goal (mean 98%). Outcome measure showed special cause improvement from mean of 33% to 100% (n=31). Of treatment plans provided, 45% received Plan 1, 4% Plan 2, and 46% Plan 3. Conclusion: Through a multidisciplinary improvement team approach, we maintained sustained ADO-BED screening performance, and, prior to our 12-month timeline, achieved our project aim. Our efforts may serve as a model for other multidisciplinary WMCs. Next steps may include expanding project scope to other WM programs.

Keywords: obesity, pediatrics, clinic, eating disorder

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Authors: Rachel S. E. Lim, Winnie L. C. Tan

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Visual literacy is about making meaning through the interaction of images, words, and sounds. Graphic communication students typically develop visual literacy through critique and production of studio-based projects for their portfolios. However, the abrupt switch to online learning during the COVID-19 pandemic has made it necessary to consider new strategies of visualization and planning to scaffold teaching and learning. This study, therefore, investigated how MIRO, a cloud-based visual collaboration platform, could be used to develop the visual literacy confidence of 30 diploma in graphic communication students attending a graphic design course at a Singapore arts institution. Due to COVID-19, the course was taught fully online throughout a 16-week semester. Guided by Kolb’s Experiential Learning Cycle, the two lecturers developed students’ engagement with visual literacy concepts through different activities that facilitated concrete experiences, reflective observation, abstract conceptualization, and active experimentation. Throughout the semester, students create, collaborate, and centralize communication in MIRO with infinite canvas, smart frameworks, a robust set of widgets (i.e., sticky notes, freeform pen, shapes, arrows, smart drawing, emoticons, etc.), and powerful platform capabilities that enable asynchronous and synchronous feedback and interaction. Students then drew upon these multimodal experiences to brainstorm, research, and develop their motion design project. A survey was used to examine students’ perceptions of engagement (E), confidence (C), learning strategies (LS). Using multiple regression, it¬ was found that the use of MIRO helped students develop confidence (C) with visual literacy, which predicted performance score (PS) that was measured against their application of visual literacy to the creation of their motion design project. While students’ learning strategies (LS) with MIRO did not directly predict confidence (C) or performance score (PS), it fostered positive perceptions of engagement (E) which in turn predicted confidence (C). Content analysis of students’ open-ended survey responses about their learning strategies (LS) showed that MIRO provides organization and structure in documenting learning progress, in tandem with establishing standards and expectations as a preparatory ground for generating feedback. With the clarity and sequence of the mentioned conditions set in place, these prerequisites then lead to the next level of personal action for self-reflection, self-directed learning, and time management. The study results show that the affordances of MIRO can develop visual literacy and make up for the potential pitfalls of student isolation, communication, and engagement during online learning. The context of how MIRO could be used by lecturers to orientate students for learning in visual literacy and studio-based projects for future development are discussed.

Keywords: design education, graphic communication, online learning, visual literacy

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Authors: Noa Nelson, Orit Appel, Rachel Ben-ari

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Organizational Citizenship Behavior (OCB) is voluntary employee behavior that contributes to the organization beyond formal job requirements. It can take different forms, such as helping teammates (OCB toward individuals; hence, OCB-I), or staying after hours to attend a task force (OCB toward the organization; hence, OCB-O). Generally, OCB contributes substantially to organizational climate, goals, productivity, and resilience, so organizations need to understand what encourages it. This is particularly challenging in security organizations. Security work is characterized by high levels of stress and burnout, which is detrimental to OCB, and security organizational design emphasizes formal rules and clear hierarchies, leaving employees with less freedom for voluntary behavior. The current research explored the role of Perceived Procedural Justice (PPJ) in enhancing OCB in a security organization. PPJ refers to how fair decision-making processes are perceived to be. It involves the sense that decision makers are objective, attentive to everyone's interests, respectful in their communications and participatory - allowing individuals a voice in decision processes. Justice perceptions affect motivation, and it was specifically suggested that PPJ creates an attachment to one's organization and personal interest in its success. Accordingly, PPJ had been associated with OCB, but hardly any research tested their association with security organizations. The current research was conducted among prison guards in the Israel Prison Service, to test a correlational and a causal association between PPJ and OCB. It differentiated between perceptions of direct commander procedural justice (CPJ), and perceptions of organization procedural justice (OPJ), hypothesizing that CPJ would relate to OCB-I, while OPJ would relate to OCB-O. In the first study, 336 prison guards (305 male) from 10 different prisons responded to questionnaires measuring their own CPJ, OPJ, OCB-I, and OCB-O. Hierarchical linear regression analyses indicated the significance of commander procedural justice (CPJ): It associated with OCB-I and also associated with OPJ, which, in turn, associated with OCB-O. The second study tested CPJ's causal effects on prison guards' OCB-I and OCB-O; 311 prison guards (275 male) from 14 different prisons read scenarios that described either high or low CPJ, and then evaluated the likelihood of that commander's prison guards performing OCB-I and OCB-O. In this study, CPJ enhanced OCB-O directly. It also contributed to OCB-I, indirectly: CPJ enhanced the motivation for collaboration with the commander, which respondents also evaluated after reading scenarios. Collaboration, in turn, associated with OCB-I. The studies demonstrate that procedural justice, especially commander's PJ, promotes OCB in security work environments. This is important because extraordinary teamwork and motivation are needed to deal with emergency situations and with delicate security challenges. Following the studies, the Israel Prison Service implemented personal procedural justice training for commanders and unit level programs for procedurally just decision processes. From a theoretical perspective, the studies extend the knowledge on PPJ and OCB to security work environments and contribute evidence on PPJ's causal effects. They also call for further research, to understand the mechanisms through which different types of PPJ affect different types of OCB.

Keywords: organizational citizenship behavior, perceived procedural justice, prison guards, security organizations

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Authors: J. Waita, S. Wamuhu, J. Makoyo, M. Rachel, T. Ngangari, W. Christine, M. Zipporah

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Contraceptive use is one of the key global strategies to alleviate maternal mortality. Global efforts through advocating for contraceptive uptake and service provision has led improved contraceptive prevalence. In Kenya maternal mortality rate has remained a challenged despites efforts by government and non-governmental organizations. Objective: To describe the uptake of contraceptives among women in Tunza Clinics, Kenya. Design and Methods: Ps Kenya through health care marketing fund is implementing a family planning program among its 350 Tunza fractional franchise facilities. Through private partnership, private owned facilities in low socio-economic areas are recruited and trained on contraceptive technology update. The providers are supported through facilitative supervision through a mobile based application Health Network Quality Improvement System (HNQIS) and interpersonal communication through 150 community based volunteers. The data analyzed in this paper was collected between January to July 2017 to show the uptake of modern Contraceptives among women in the Tunza franchise, method mix, age and distribution among the age bracket. Further analysis compares two different service delivery strategies; outreach and walk ins. Supportive supervision HNQIS scores was analyzed. Results: During the time period, a total of 132121 family planning clients were attended in 350 facilities. The average age of clients was 29.6 years. The average number of clients attended in the facilities per month was 18874. 73.7 %( n=132121) of the clients attended in the Tunza facilities were aged above 25 years while 22.1% 20-24 years and 4.2% 15-19 years. On contraceptive method mix, intra uterine device insertions clients contributed to 7.5%, implant insertions 15.3%, pills 11.2%, injections 62.7% while condoms and emergency pills had 2.7% and 0.6% respectively. Analysis of service delivery strategy indicated more than 79% of the clients were walk ins while 21% were attended to during outreaches. Uptake of long term contraceptive methods during outreaches was 73% of the clients while short term modern methods were 27%. Health Network Quality Improvement system assessment scores indicated 51% of the facilities scored over 90%, 25% scoring 80-89% while 21% scored below 80%. Conclusion: Preference for short term methods by women is possibly associated to cost as they are cheaper and easy to administer. When the cost of intra uterine device Implants is meant affordable during outreaches, the uptake is observed to increase. Making intra uterine device and implants affordable to women is a key strategy in increasing contraceptive prevalence hence averting maternal mortality.

Keywords: contraceptives, contraceptive uptake, low socio economic, supportive supervision

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Authors: Navah Z. Ratzon, Rachel Shichrur

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Background: Many studies have assessed and identified the risk factors of safe driving, but there is relatively little research-based evidence concerning the ability to improve the driving skills of drivers in general and in particular of bus drivers, who are defined as a population at risk. Accidents involving bus drivers can endanger dozens of passengers and cause high direct and indirect damages. Objective: To examine the effectiveness of a metacognitive-functional intervention program for the reduction of risk factors among professional drivers relative to a control group. Methods: The study examined 77 bus drivers working for a large public company in the center of the country, aged 27-69. Twenty-one drivers continued to the intervention stage; four of them dropped out before the end of the intervention. The intervention program we developed was based on previous driving models and the guiding occupational therapy practice framework model in Israel, while adjusting the model to the professional driving in public transportation and its particular risk factors. Treatment focused on raising awareness to safe driving risk factors identified at prescreening (ergonomic, perceptual-cognitive and on-road driving data), with reference to the difficulties that the driver raises and providing coping strategies. The intervention has been customized for each driver and included three sessions of two hours. The effectiveness of the intervention was tested using objective measures: In-Vehicle Data Recorders (IVDR) for monitoring natural driving data, traffic accident data before and after the intervention, and subjective measures (occupational performance questionnaire for bus drivers). Results: Statistical analysis found a significant difference between the degree of change in the rate of IVDR perilous events (t(17)=2.14, p=0.046), before and after the intervention. There was significant difference in the number of accidents per year before and after the intervention in the intervention group (t(17)=2.11, p=0.05), but no significant change in the control group. Subjective ratings of the level of performance and of satisfaction with performance improved in all areas tested following the intervention. The change in the ‘human factors/person’ field, was significant (performance : t=- 2.30, p=0.04; satisfaction with performance : t=-3.18, p=0.009). The change in the ‘driving occupation/tasks’ field, was not significant but showed a tendency toward significance (t=-1.94, p=0.07,). No significant differences were found in driving environment-related variables. Conclusions: The metacognitive-functional intervention significantly improved the objective and subjective measures of safety of bus drivers’ driving. These novel results highlight the potential contribution of occupational therapists, using metacognitive functional treatment, to preventing car accidents among the healthy drivers population and improving the well-being of these drivers. This study also enables familiarity with advanced technologies of IVDR systems and enriches the knowledge of occupational therapists in regards to using a wide variety of driving assessment tools and making the best practice decisions.

Keywords: bus drivers, IVDR, human risk factors, metacognitive-functional intervention

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Authors: Hansraj Bookun, Rachel Xuan, Angela Tan, Kejia Wang, Animesh Singla, David Kim, Christopher Loupos, Jim Iliopoulos

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Introduction: Complex endovascular aortic aneursymal repairs with fenestrated and branched endografts require customised devices to exclude the pathology while reducing morbidity and mortality, which was historically associated with open repair of complex aneurysms. Such endovascular procedures have predominantly been performed in a large volume dedicated tertiary centres. We present here our nine year multidisciplinary experience with this technology in an Australian tertiary centre. Method: This was a cross-sectional, single-centre observational study of 670 patients who had undergone complex endovascular aortic aneurysmal repairs with conventional endografts, fenestrated endografts, and iliac-branched devices from January 2010 to July 2019. Descriptive statistics were used to characterise our sample with regards to demographic and perioperative variables. Homogeneity of the sample was tested using multivariant regression, which did not identify any statistically significant confounding variables. Results: 670 patients of mean age 74, were included (592 males) and the comorbid burden was as follows: ischemic heart disease (55%), diabetes (18%), hypertension (90%), stage four or greater kidney impairment (8%) and current or ex-smoking (78%). The main indications for surgery were elective aneurysms (86%), symptomatic aneurysms (5%), and rupture aneurysms (5%). 106 patients (16%) underwent fenestrated or branched endograft repairs. The mean length of stay was 7.6 days. 2 patients experienced reactionary bleeds, 11 patients had access wound complications (6 lymph fistulae, 5 haematoms), 11 patients had cardiac complications (5 arrhythmias, 3 acute myocadial infarctions, 3 exacerbation of congestive cardiac failure), 10 patients had respiratory complications, 8 patients had renal impairment, 4 patients had gastrointestinal complications, 2 patients suffered from paraplegia, 1 major stroke, 1 minor stroke, and 1 acute brain syndrome. There were 4 vascular occlusions requiring further arterial surgery, 4 type I endoleaks, 4 type II endoleaks, 3 episodes of thromboembolism, and 2 patients who required further arterial operations in the setting of patient vessels. There were 9 unplanned returns to the theatre. Discussion: Our numbers of 10 years suggest that we are not a dedicated high volume centre focusing on aortic repairs. However, we have achieved significantly low complication rates. This can be attributed to our multidisciplinary approach with the intraoperative involvement of skilled interventional radiologists and vascular surgeons as well as postoperative protocols with particular attention to spinal cord protection. Additionally, we have a ratified perioperative pathway that involves multidisciplinary team discussions of patient-related factors and lesion-centered characteristics, which allows for holistic, patient-centered care.

Keywords: aneurysm, aortic, endovascular, fenestrated

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Authors: Rachel M. Edelstein, John D. Van Horn, Karen M. Schmidt, Sydney N. Cushing

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As a consequence of sports-related concussions, female athletes have been documented as reporting more symptoms than their male counterparts, in addition to incurring longer periods of recovery. However, the role of sex and its potential influence on symptom reporting and recovery outcomes in concussion management has not been completely explored. The present aims to investigate the relationship between female concussion symptom severity and the presence of assessment bias. The Sport Concussion Assessment Tool 3 (SCAT3), collected by the NCAA and DoD CARE Consortium, was quantified at five different time points post-concussion. N= 1,258 NCAA athletes, n= 473 female (soccer, rugby, lacrosse, ice hockey) and n=785 male athletes (football, rugby, lacrosse, ice hockey). A polytomous Item Response Theory (IRT) Graded Response Model (GRM) was used to assess the relationship between sex and symptom reporting. Differential Item Functioning (DIF) and Differential Group Functioning (DGF) were used to examine potential group-level bias. Interactions for DIF were utilized to explore the impact of sex on symptom reporting among NCAA male and female athletes throughout and after their concussion recovery. DIF was significantly detected after B-H corrections displayed in limited items; however, one symptom, “Pressure in Head” (-0.29, p=0.04 vs -0.20, p =0.04), was statistically significant at both < 6 hours and 24-48 hours. Thus, implies that at < 6 hours, males were 29% less likely to indicate “Pressure in the Head” compared to female athletes and 20% less likely at 24-48 hours. Overall, the DGF suggested significant group differences, suggesting that male athletes might be at a higher risk for returning to play prematurely (logits = -0.38, p < 0.001). However, after analyzing the SCAT 3, a clinically relevant trend was discovered. Twelve out of the twenty-two symptoms suggest higher difficulty in female athletes within three or more of the five-time points. These symptoms include Balance Problems, Blurry Vision, Confusion, Dizziness, Don’t Feel Right, Feel in Fog, Feel Slow Down, Low Energy, Neck Pain, Sensitivity to Light, Sensitivity to Noise, Trouble Falling Asleep. Despite a lack of statistical significance, this tendency is contrary to current literature stating that males may be unclear on symptoms, but females may be more honest in reporting symptoms. Further research, which includes possible modifying socioecological factors, is needed to determine whether females may consistently experience more symptoms and require longer recovery times or if, parsimoniously, males tend to present their symptoms and readiness for play differently than females. Such research will help to improve the validity of current assumptions concerning male as compared to female head injuries and optimize individualized treatments for sports-related head injuries.

Keywords: female athlete, sports-related concussion, item response theory, concussion assessment

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Authors: Egemen Sert, Leila Hedayatifar, Rachel A. Rigg, Amir Akhavan, Olha Buchel, Dominic Elias Saadi, Aabir Abubaker Kar, Alfredo J. Morales, Yaneer Bar-Yam

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The complexity of providing timely and cost-effective distribution of finished goods from industrial facilities to customers makes effective operational coordination difficult, yet effectiveness is crucial for maintaining customer service levels and sustaining a business. Logistics planning becomes increasingly complex with growing numbers of customers, varied geographical locations, the uncertainty of future orders, and sometimes extreme competitive pressure to reduce inventory costs. Linear optimization methods become cumbersome or intractable due to a large number of variables and nonlinear dependencies involved. Here we develop a complex systems approach to optimizing logistics networks based upon dimensional reduction methods and apply our approach to a case study of a manufacturing company. In order to characterize the complexity in customer behavior, we define a “customer space” in which individual customer behavior is described by only the two most relevant dimensions: the distance to production facilities over current transportation routes and the customer's demand frequency. These dimensions provide essential insight into the domain of effective strategies for customers; direct and indirect strategies. In the direct strategy, goods are sent to the customer directly from a production facility using box or bulk trucks. In the indirect strategy, in advance of an order by the customer, goods are shipped to an external warehouse near a customer using trains and then "last-mile" shipped by trucks when orders are placed. Each strategy applies to an area of the customer space with an indeterminate boundary between them. Specific company policies determine the location of the boundary generally. We then identify the optimal delivery strategy for each customer by constructing a detailed model of costs of transportation and temporary storage in a set of specified external warehouses. Customer spaces help give an aggregate view of customer behaviors and characteristics. They allow policymakers to compare customers and develop strategies based on the aggregate behavior of the system as a whole. In addition to optimization over existing facilities, using customer logistics and the k-means algorithm, we propose additional warehouse locations. We apply these methods to a medium-sized American manufacturing company with a particular logistics network, consisting of multiple production facilities, external warehouses, and customers along with three types of shipment methods (box truck, bulk truck and train). For the case study, our method forecasts 10.5% savings on yearly transportation costs and an additional 4.6% savings with three new warehouses.

Keywords: logistics network optimization, direct and indirect strategies, K-means algorithm, dimensional reduction

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Authors: Rachel Jones

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Systemic Family therapy in the Queensland Foster Care System is the implementation of Integrative Practice as a purposeful intervention implemented with complex ‘family’ systems (by expanding the traditional concept of family to include all relevant stakeholders for a child) and is shown to improve the overall wellbeing of children (with developmental delays and trauma) in Queensland out of home care contexts. The importance of purposeful integrative practice in the field of systemic family therapy has been highlighted in achieving change in complex family systems. Essentially, it is the purposeful use of multiple interventions designed to meet the myriad of competing needs apparent for a child (with developmental delays resulting from early traumatic experiences - both in utero and in their early years) and their family. In the out-of-home care context, integrative practice is particularly useful to promote positive change for the child and what is an extended concept of whom constitutes their family. Traditionally, a child’s family may have included biological and foster care family members, but when this concept is extended to include all their relevant stakeholders (including biological family, foster carers, residential care workers, child safety, school representatives, Health and Allied Health staff, police and youth justice staff), the use of integrative family therapy can produce positive change for the child in their overall wellbeing, development, risk profile, social and emotional functioning, mental health symptoms and relationships across domains. By tailoring therapeutic interventions that draw on systemic family therapies from the first and second-order schools of family therapy, neurobiology, solution focussed, trauma-informed, play and art therapy, and narrative interventions, disability/behavioural interventions, clinicians can promote change by mixing therapeutic modalities with the individual and their stakeholders. This presentation will unpack the implementation of systemic family therapy using this integrative approach to formulation and treatment for a child in out-of-home care in Queensland (experiencing developmental delays resulting from trauma). It considers the need for intervention for the individual and in the context of the environment and relationships. By reviewing a case example, this study aims to highlight the simultaneous and successful use of pharmacological interventions, psychoeducational programs for carers and school staff, parenting programs, cognitive-behavioural and trauma-informed interventions, traditional disability approaches, play therapy, mapping genograms and meaning-making, and using family and dyadic sessions for the system associated with the foster child. These elements of integrative systemic family practice have seen success in the reduction of symptoms and improved overall well-being of foster children and their stakeholders. Accordingly, a model for best practice using this integrative systemic approach is presented for this population group and preliminary findings for this approach over four years of local data have been reviewed.

Keywords: systemic family therapy, treating families of children with delays, trauma and attachment in families systems, improving practice and functioning of children and families

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Authors: Nanteza Rachel

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Background: Worldwide, there were 36.7 million people living with Human Immunodeficiency Virus (HIV) in 2015, up from 35 million at the end of 2013. Wakiso district is one of the hotspots for the Human Immunodeficiency Virus (HIV)/ Acquired Immune Deficiency Syndrome (AIDS) infection in Uganda, with the prevalence of 8.1 %. Herbal medicine has gained popularity among Human Immunodeficiency Virus (HIV)/ Acquired Immune Deficiency Syndrome (AIDS) patients as adjuvant therapy to reduce the adverse effects of ART. Regardless of the subsidized and physical availability of the Anti-Retroviral Therapy (ART), majority of Africans living with Human Immunodeficiency Virus (HIV)/ Acquired Immune Deficiency Syndrome (AIDS) resort to adding to their ART traditional medicine. Result found out from a pilot observation made by the PI that indicate 13 out of 30 People Living with AIDS(PLWA) who are attending Human Immunodeficiency Virus (HIV) clinics in Wakiso district reported to be using herbal preparations despite the fact that they were taking Anti Retro Viral (ARVs) this prompted this study to be done. Purpose of the study: To determine the prevalence and factors associated with concurrent use of herbal medicine and anti-retroviral therapy among HIV/AIDS patients attending selected HIV clinics in Wakiso district. Methodology: This was a cross sectional study with both quantitative data collection (use of a questionnaire) and qualitative data collection (key informants’ interviews). A mixed method of sampling was used, that is, purposive and random sampling. Purposive sampling was based on the location in the district and used to select 7 health facilities basing on the 7 health sub districts from Wakiso. Simple random sampling was used to select one HIV clinic from each of the 7 health sub districts. Furthermore, the study units were enrolled in to the study as they entered into the HIV clinics, and 105 respondents were interviewed. Both manual and computer packages (SPSS) were used to analyze the data Results: The prevalence of concurrent use of herbal medicine and ART was 38 (36.2%). Commonly HIV symptom treated with herbs was fever 27(71.1%), diarrhea 3(7.9%) and cough 2(5.3%). Commonly used herbs for fever (Omululuza (Vernonica amydalina), Ekigagi (Aloe sp), Nalongo (Justicia betonica Linn) while for diarrhea was Ntwatwa. The side effects also included; too much pain, itchy pain of HIV, aneamia,felt sick, loss/gain appetite, joint pain and bad dreams. Herbs used to sooth the side effects were; for aneamia was avocado leaves Parea Americana mill The significant factors associated with concurrent use of herbal medicine were being familiar with herbs and conventional medicine for management HIV symptoms being expensive. The other significant factor was exhibiting hostility to patients by health personnel providing HIV care. Conclusion: Herbal medicine is widely used by clients in HIV/AIDS care. Patients being familiar with herbs and conventional medicine being expensive were associated with concurrent use of herbal medicine and ART. The exhibition of hostility to the HIV/AIDS patients by the health care providers was also associated with concurrent use of herbal medicine and ART among HIV/AIDS patients.

Keywords: HIV patients, herbal medicine, antiretroviral therapy, factors associated

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Authors: Ruth Goldschmidt, Vyacheslav Kalchenko, Lilah Agemy, Rachel Elmoalem, Avigdor Scherz

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Vascular Targeted Photodynamic therapy (VTP) is a new modality for selective cancer treatment that leads to the complete tumor ablation. A photosensitizer, a bacteriochlorophyll derivative in our case, is first administered to the patient and followed by the illumination of the tumor area, by a near-IR laser for its photoactivation. The photoactivated drug releases reactive oxygen species (ROS) in the circulation, which reacts with blood cells and the endothelium leading to the occlusion of the blood vasculature. If the blood vessels are only partially closed, the tumor may recover, and cancer cells could survive. On the other hand, excessive treatment may lead to toxicity of healthy tissues nearby. Simultaneous VTP monitoring and image processing independent of the photoexcitation laser has not yet been reported, to our knowledge. Here we present a method for blood flow monitoring, using a real-time laser speckle imaging (RTLSI) in the tumor during VTP. We have synthesized over the years a library of bacteriochlorophyll derivatives, among them WST11 and STL-6014. Both are water soluble derivatives that are retained in the blood vasculature through their partial binding to HSA. WST11 has been approved in Mexico for VTP treatment of prostate cancer at a certain drug dose, and time/intensity of illumination. Application to other bacteriochlorophyll derivatives or other cancers may require different treatment parameters (such as light/drug administration). VTP parameters for STL-6014 are still under study. This new derivative mainly differs from WST11 by its lack of the central Palladium, and its conjugation to an Arg-Gly-Asp (RGD) sequence. RGD is a tumor-specific ligand that is used for targeting the necrotic tumor domains through its affinity to αVβ3 integrin receptors. This enables the study of cell-targeted VTP. We developed a special RTLSI module, based on Labview software environment for data processing. The new module enables to acquire raw laser speckle images and calculate the values of the laser temporal statistics of time-integrated speckles in real time, without additional off-line processing. Using RTLSI, we could monitor the tumor’s blood flow following VTP in a CT26 colon carcinoma ear model. VTP with WST11 induced an immediate slow down of the blood flow within the tumor and a complete final flow arrest, after some sporadic reperfusions. If the irradiation continued further, the blood flow stopped also in the blood vessels of the surrounding healthy tissue. This emphasizes the significance of light dose control. Using our RTLSI system, we could prevent any additional healthy tissue damage by controlling the illumination time and restrict blood flow arrest within the tumor only. In addition, we found that VTP with STL-6014 was the most effective when the photoactivation was conducted 4h post-injection, in terms of tumor ablation success in-vivo and blood vessel flow arrest. In conclusion, RTSLI application should allow to optimize VTP efficacy vs. toxicity in both the preclinical and clinical arenas.

Keywords: blood vessel occlusion, cancer treatment, photodynamic therapy, real time imaging

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Authors: Thomas D. Collin, Rachel Cunningham, Bruce Jefferson, Raffaella Villa

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Fats, oils and grease (FOG) are by-products of food preparation and cooking processes. FOG enters wastewater systems through a variety of sources such as households, food service establishments, and industrial food facilities. Over time, if no source control is in place, FOG builds up on pipe walls, leading to blockages, and potentially to sewer overflows which are a major risk to the Environment and Human Health. UK water utilities spend millions of pounds annually trying to control FOG. Despite UK legislation specifying that discharge of such material is against the law, it is often complicated for water companies to identify and prosecute offenders. Hence, it leads to uncertainties regarding the attitude to take in terms of FOG management. Research is needed to seize the full potential of implementing current practices. The aim of this research was to undertake a comprehensive study to document the extent of FOG problems in sewer lines and reinforce existing knowledge. Data were collected to develop a model estimating quantities of FOG available for recovery within Thames Water wastewater catchments. Geographical Information System (GIS) software was used in conjunction to integrate data with a geographical component. FOG was responsible for at least 1/3 of sewer blockages in Thames Water waste area. A waste-based approach was developed through an extensive review to estimate the potential for FOG collection and recovery. Three main sources were identified: residential, commercial and industrial. Commercial properties were identified as one of the major FOG producers. The total potential FOG generated was estimated for the 354 wastewater catchments. Additionally, raw and settled sewage were sampled and analysed for FOG (as hexane extractable material) monthly at 20 sewage treatment works (STW) for three years. A good correlation was found with the sampled FOG and population equivalent (PE). On average, a difference of 43.03% was found between the estimated FOG (waste-based approach) and sampled FOG (raw sewage sampling). It was suggested that the approach undertaken could overestimate the FOG available, the sampling could only capture a fraction of FOG arriving at STW, and/or the difference could account for FOG accumulating in sewer lines. Furthermore, it was estimated that on average FOG could contribute up to 12.99% of the primary sludge removed. The model was further used to investigate the relationship between estimated FOG and number of blockages. The higher the FOG potential, the higher the number of FOG-related blockages is. The GIS-based tool was used to identify critical areas (i.e. high FOG potential and high number of FOG blockages). As reported in the literature, FOG was one of the main causes of sewer blockages. By identifying critical areas (i.e. high FOG potential and high number of FOG blockages) the model further explored the potential for source-control in terms of ‘sewer relief’ and waste recovery. Hence, it helped targeting where benefits from implementation of management strategies could be the highest. However, FOG is still likely to persist throughout the networks, and further research is needed to assess downstream impacts (i.e. at STW).

Keywords: fat, FOG, GIS, grease, oil, sewer blockages, sewer networks

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Authors: Rachel Barker

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The exponential velocity in the truly knowledge-intensive world today has increasingly bombarded organizations with unfathomable challenges. Hence organizations are introduced to strange lexicons of descriptors belonging to a new paradigm of who, what and how knowledge at individual and organizational levels should be managed. Although organizational knowledge has been recognized as a valuable intangible resource that holds the key to competitive advantage, little progress has been made in understanding how knowledge sharing at individual level could benefit knowledge use at collective level to ensure added value. The research problem is that a lack of research exists to measure knowledge sharing through a multi-layered structure of ideas with at its foundation, philosophical assumptions to support presuppositions and commitment which requires actual findings from measured variables to confirm observed and expected events. The purpose of this paper is to address this problem by presenting a theoretical approach to measure knowledge sharing in emerging knowledge organizations. The research question is that despite the competitive necessity of becoming a knowledge-based organization, leaders have found it difficult to transform their organizations due to a lack of knowledge on who, what and how it should be done. The main premise of this research is based on the challenge for knowledge leaders to develop an organizational culture conducive to the sharing of knowledge and where learning becomes the norm. The theoretical constructs were derived and based on the three components of the knowledge management theory, namely technical, communication and human components where it is suggested that this knowledge infrastructure could ensure effective management. While it is realised that it might be a little problematic to implement and measure all relevant concepts, this paper presents effect of eight critical success factors (CSFs) namely: organizational strategy, organizational culture, systems and infrastructure, intellectual capital, knowledge integration, organizational learning, motivation/performance measures and innovation. These CSFs have been identified based on a comprehensive literature review of existing research and tested in a new framework adapted from four perspectives of the balanced score card (BSC). Based on these CSFs and their items, an instrument was designed and tested among managers and employees of a purposefully selected engineering company in South Africa who relies on knowledge sharing to ensure their competitive advantage. Rigorous pretesting through personal interviews with executives and a number of academics took place to validate the instrument and to improve the quality of items and correct wording of issues. Through analysis of surveys collected, this research empirically models and uncovers key aspects of these dimensions based on the CSFs. Reliability of the instrument was calculated by Cronbach’s a for the two sections of the instrument on organizational and individual levels.The construct validity was confirmed by using factor analysis. The impact of the results was tested using structural equation modelling and proved to be a basis for implementing and understanding the competitive predisposition of the organization as it enters the process of knowledge management. In addition, they realised the importance to consolidate their knowledge assets to create value that is sustainable over time.

Keywords: innovation, intellectual capital, knowledge sharing, performance measures

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Authors: Sharon Harel, Rachel Kizony, Yoram Feldman, Gabi Zeilig, Mordechai Shani

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Multiple Sclerosis (MS) is a neurological disease that may cause restriction in participation in daily activities of young adults. Main symptoms include fatigue, weakness and cognitive decline. The appearance of symptoms, their severity and deterioration rate, change between patients. The challenge of health services is to provide long-term rehabilitation services to people with MS. The objective of this presentation is to describe a course of tele-rehabilitation service of a woman with MS. Methods; R is a 48 years-old woman, diagnosed with MS when she was 22. She started to suffer from weakness of her non-dominant left upper extremity about ten years after the diagnosis. She was referred to the tele-rehabilitation service by her rehabilitation team, 16 years after diagnosis. Her goals were to improve ability to use her affected upper extremity in daily activities. On admission her score in the Mini-Mental State Exam was 30/30. Her Fugl-Meyer Assessment (FMA) score of the left upper extremity was 48/60, indicating mild weakness and she had a limitation of her shoulder abduction (90 degrees). In addition, she reported little use of her arm in daily activities as shown in her responses to the Motor Activity Log (MAL) that were equal to 1.25/5 in amount and 1.37 in quality of use. R. received two 30 minutes on-line sessions per week in the tele-rehabilitation service, with the CogniMotion system. These were complemented by self-practice with the system. The CogniMotion system provides a hybrid (synchronous-asynchronous), the home-based tele-rehabilitation program to improve the motor, cognitive and functional status of people with neurological deficits. The system consists of a computer, large monitor, and the Microsoft’s Kinect 3D sensor. This equipment is located in the client’s home and connected to a clinician’s computer setup in a remote clinic via WiFi. The client sits in front of the monitor and uses his body movements to interact with games and tasks presented on the monitor. The system provides feedback in the form of ‘knowledge of results’ (e.g., the success of a game) and ‘knowledge of performance’ (e.g., alerts for compensatory movements) to enhance motor learning. The games and tasks were adapted for R. motor abilities and level of difficulty was gradually increased according to her abilities. The results of her second assessment (after 35 on-line sessions) showed improvement in her FMA score to 52 and shoulder abduction to 140 degrees. Moreover, her responses to the MAL indicated an increased amount (2.4) and quality (2.2) of use of her left upper extremity in daily activities. She reported high level of enjoyment from the treatments (5/5), specifically the combination of cognitive challenges while moving her body. In addition, she found the system easy to use as reflected by her responses to the System Usability Scale (85/100). To-date, R. continues to receive treatments in the tele-rehabilitation service. To conclude, this case report shows the potential of using tele-rehabilitation for people with MS to provide strategies to enhance the use of the upper extremity in daily activities as well as for maintaining motor function.

Keywords: motor function, multiple-sclerosis, tele-rehabilitation, daily activities

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Authors: Rachel S. Chang, Samuel P. Massion, Alan Z. Grusky, Heather A. Ridinger

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Introduction Health advocacy is defined as activities that improve access to care, utilize resources, address health disparities, and influence health policy. Advocacy is increasingly being recognized as a critical component of a physician’s role, as understanding social determinants of health and improving patient care are important aspects within the American Medical Association’s Health Systems Science framework. However, despite this growing prominence, educational interventions that address advocacy topics are limited and variable across medical school curricula. Furthermore, few recent studies have evaluated attitudes toward health advocacy among physicians-in-training in the United States. This study examines medical student attitudes towards health advocacy, along with perceived knowledge, ability, and current level of engagement with health advocacy during their clerkships. Methods This study employed a cross-sectional survey design using a single anonymous, self-report questionnaire to all second-year medical students at Vanderbilt University School of Medicine (n=96) in December 2020 during clerkship rotations. The survey had 27 items with 5-point Likert scale (15), multiple choice (11), and free response questions (1). Descriptive statistics and thematic analysis were utilized to analyze responses. The study was approved by the Vanderbilt University Institutional Review Board. Results There was an 88% response rate among second-year clerkship medical students. A majority (83%) agreed that formal training in health advocacy should be a mandatory part of the medical student curriculum Likewise, 83% of respondents felt that acting as a health advocate or patients should be part of their role as a clerkship student. However, a minority (25%) felt adequately prepared. While 72% of respondents felt able to identify a psychosocial need, 18% felt confident navigating the healthcare system and only 9% felt able to connect a patient to a psychosocial resource to fill that gap. 44% of respondents regularly contributed to conversations with their medical teams when discussing patients’ social needs, such as housing insecurity, financial insecurity, or legal needs. On average, respondents reported successfully connecting patients to psychosocial resources 1-2 times per 8-week clerkship block. Barriers to participating in health advocacy included perceived time constraints, lack of awareness of resources, lower emphasis among medical teams, and scarce involvement with social work teams. Conclusions In this single-institutional study, second-year medical students on clerkships recognize the importance of advocating for patients and support advocacy training within their medical school curriculum. However, their perceived lack of ability to navigate the healthcare system and connect patients to psychosocial resources, result in students feeling unprepared to advocate as effectively as they hoped during their clerkship rotations. Our results support the ongoing need to equip medical students with training and resources necessary for them to effectively act as advocates for patients.

Keywords: clerkships, medical students, patient advocacy, social medicine

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Authors: Roland F. Karthaus, Rachel S. O'Brien

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Over the past decade, the authors have undertaken applied research aimed at enabling transformation within the prison service to improve conditions and outcomes for those living, working and visiting in prisons in the UK and the communities they serve. The research has taken place against a context of reducing resources and public discontent at increasing levels of violence, deteriorating conditions and persistently high levels of re-offending. Top-down governmental policies have mainly been ineffectual and in some cases counter-productive. The prison service is characterised by hierarchical organisation, and the research has applied design thinking at multiple levels to challenge and precipitate change: top-down, middle-out and bottom-up. The research employs three distinct but related approaches, system design (top-down): working at the national policy level to analyse the changing policy context, identifying opportunities and challenges; engaging with the Ministry of Justice commissioners and sector organisations to facilitate debate, introducing new evidence and provoking creative thinking, place-based design (middle-out): working with individual prison establishments as pilots to illustrate and test the potential for local empowerment, creative change, and improved architecture within place-specific contexts and organisational hierarchies, everyday design (bottom-up): working with individuals in the system to explore the potential for localised, significant, demonstrator changes; including collaborative design, capacity building and empowerment in skills, employment, communication, training, and other activities. The research spans a series of projects, through which the methodological approach has developed responsively. The projects include a place-based model for the re-purposing of Ministry of Justice land assets for the purposes of rehabilitation; an evidence-based guide to improve prison design for health and well-being; capacity-based employment, skills and self-build project as a template for future open prisons. The overarching research has enabled knowledge to be developed and disseminated through policy and academic networks. Whilst the research remains live and continuing; key findings are emerging as a basis for a new methodological approach to effecting change in the UK prison service. An interdisciplinary approach is necessary to overcome the barriers between distinct areas of the prison service. Sometimes referred to as total environments, prisons encompass entire social and physical environments which themselves are orchestrated by institutional arms of government, resulting in complex systems that cannot be meaningfully engaged through narrow disciplinary lenses. A scalar approach is necessary to connect strategic policies with individual experiences and potential, through the medium of individual prison establishments, operating as discrete entities within the system. A reflexive process is necessary to connect research with action in a responsive mode, learning to adapt as the system itself is changing. The role of individuals in the system, their latent knowledge and experience and their ability to engage and become agents of change are essential. Whilst the specific characteristics of the UK prison system are unique, the approach is internationally applicable.

Keywords: architecture, design, policy, prison, system, transformation

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Authors: Rachel Danielson, Brendan Bohannan, S.M. Tsai, Kyle Meyer, Jorge L.M. Rodrigues

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The Amazon Rainforest is a global diversity hotspot and crucial carbon sink, but approximately 20% of its total extent has been deforested- primarily for the establishment of cattle pasture. Understanding the impact of this large-scale disturbance on soil microbial community composition and activity is crucial in understanding potentially consequential shifts in nutrient or greenhouse gas cycling, as well as adding to the body of knowledge concerning how these complex communities respond to human disturbance. In this study, surface soils (0-10cm) were collected from three forests and three 45-year-old pastures in Rondonia, Brazil (the Amazon state with the greatest rate of forest destruction) in order to determine the impact of forest conversion on microbial communities involved in nitrogen fixation. Soil chemical and physical parameters were paired with measurements of microbial activity and genetic profiles to determine how community composition and process rates relate to environmental conditions. Measuring both the natural abundance of 15N in total soil N, as well as incorporation of enriched 15N2 under incubation has revealed that conversion of primary forest to cattle pasture results in a significant increase in the rate of nitrogen fixation by free-living diazotrophs. Quantification of nifH gene copy numbers (an essential subunit encoding the nitrogenase enzyme) correspondingly reveals a significant increase of genes in pasture compared to forest soils. Additionally, genetic sequencing of both nifH genes and transcripts shows a significant increase in the diversity of the present and metabolically active diazotrophs within the soil community. Levels of both organic and inorganic nitrogen tend to be lower in pastures compared to forests, with ammonium rather than nitrate as the dominant inorganic form. However, no significant or consistent differences in total, extractable, permanganate-oxidizable, or loss-on-ignition carbon are present between the two land-use types. Forest conversion is associated with a 0.5- 1.0 unit pH increase, but concentrations of many biologically relevant nutrients such as phosphorus do not increase consistently. Increases in free-living diazotrophic community abundance and activity appear to be related to shifts in carbon to nitrogen pool ratios. Furthermore, there may be an important impact of transient, low molecular weight plant-root-derived organic carbon on free-living diazotroph communities not captured in this study. Preliminary analysis of nitrogenase gene variant composition using NovoSeq metagenomic sequencing indicates that conversion of forest to pasture may significantly enrich vanadium-based nitrogenases. This indication is complemented by a significant decrease in available soil molybdenum. Very little is known about the ecology of diazotrophs utilizing vanadium-based nitrogenases, so further analysis may reveal important environmental conditions favoring their abundance and diversity in soil systems. Taken together, the results of this study indicate a significant change in nitrogen cycling and diazotroph community composition with the conversion of the Amazon Rainforest. This may have important implications for the sustainability of cattle pastures once established since nitrogen is a crucial nutrient for forage grass productivity.

Keywords: free-living diazotrophs, land use change, metagenomic sequencing, nitrogen fixation

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Authors: Charles W. MacQuarrie, Rachel R. Tatro Duarte

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This paper explores the representation of medieval identity within the world of games such as Dragon Age, Elden Ring, Hellblade: Senua’s sacrifice, fantasy role-playing games that draw effectively and problematically on Celtic and Norse mythologies. Focusing on tattoos, onomastics, and accent as visual and oral markers of status and ethnicity, this study analyzes how the game's interplay between mythology, character narratives, and visual storytelling enriches the themes and offers players an immersive, but sometimes baldly ahistorical, connection to ancient mythologies and contemporary digital storytelling. Dragon Age is a triple a game series, Hellblade Senua’s Sacrifice, and Elden Ring of gamers worldwide with its presentation of an idealized medieval world, inspired by the lore of Celtic and Norse mythologies. This paper sets out to explore the intricate relationships between tattoos, accent, and character narratives in the game, drawing parallels to themes,heroic figures and gods from Celtic and Norse mythologies. Tattoos as Mythic and Ethnic Markers: This study analyzes how tattoos in Dragon Age visually represent mythological elements from both Celtic and Norse cultures, serving as conduits of cultural identity and narratives. The nature of these tattoos reflects the slave, criminal, warrior associations made in classical and medieval literature, and some of the episodes concerning tattoos in the games have either close analogs or sources in literature. For example the elvish character Solas, in Dragon Age Inquisition, removes a slave tattoo from the face of a lower status elf in an episode that is reminiscent of Bridget removing the stigmata from Connallus in the Vita Prima of Saint Bridget Character Narratives: The paper examines how characters' personal narratives in the game parallel the archetypal journeys of Celtic heroes and Norse gods, with a focus on their relationships to mythic themes. In these games the Elves usually have Welsh or Irish accents, are close to nature, magically powerful, oppressed by apparently Anglo-Saxon humans and Norse dwarves, and these elves wear facial tattoos. The Welsh voices of fairies and demons is older than the reference in Shakespeare’s Merry Wives of Windsor or even the Anglo-Saxon Life of Saint Guthlac. The English speaking world, and the fantasy genre of literature and gaming, undoubtedly driven by Tolkien, see Elves as Welsh speakers, and as having Welsh accents when speaking English Comparative Analysis: A comparative approach is employed to reveal connections, adaptations, and unique interpretations of the motifs of tattoos and narrative themes in Dragon Age, compared to those found in Celtic and Norse mythologies. Methodology: The study uses a comparative approach to examine the similarities and distinctions between Celtic and Norse mythologies and their counterparts in video games. The analysis encompasses character studies, narrative exploration, visual symbolism, and the historical context of Celtic and Norse cultures. Mythic Visuals: This study showcases how tattoos, as visual symbols, encapsulate mythic narratives, beliefs, and cultural identity, echoing Celtic and Norse visual motifs. Archetypal Journeys: The paper analyzes how character arcs mirror the heroic journeys of Celtic and Norse mythological figures, allowing players to engage with mythic narratives on a personal level. Cultural Interplay: The study discusses how the game's portrayal of tattoos and narratives both preserves and reinterprets elements from Celtic and Norse mythologies, fostering a connection between ancient cultures and modern digital storytelling. Conclusion: By exploring the interconnectedness of tattoos and character narratives in Dragon Age, this paper reveals the game series' ability to act as a bridge between ancient mythologies and contemporary gaming. By drawing inspiration from Celtic heroes and Norse gods and translating them into digital narratives and visual motifs, Dragon Age offers players a multi-dimensional engagement with mythic themes and a unique lens through which to appreciate the enduring allure of these cultures.

Keywords: comparative analysis, character narratives, video games and literature, tattoos, immersive storytelling, character development, mythological influences, Celtic mythology, Norset mythology

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