Search results for: private hospital.

Authors: Jared Abuga, Wesley Too

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Medical error is the third leading cause of death in US, with approximately 98,000 deaths occurring every year as a result of medical errors. The world financial burden of medication errors is roughly USD 42 billion. Medication errors may lead to at least one death daily and injure roughly 1.3 million people every year. Medical error reporting is essential in creating a culture of accountability in our healthcare system. Studies have shown that attitudes and practice of healthcare workers in reporting medical errors showed that the major factors in under-reporting of errors included work stress and fear of medico-legal consequences due to the disclosure of error. Further, the majority believed that increase in reporting medical errors would contribute to a better system. Most hospitals depend on nurses to discover medication errors because they are considered to be the sources of these errors, as contributors or mere observers, consequently, the nurse’s perception of medication errors and what needs to be done is a vital feature to reducing incidences of medication errors. We sought to explore knowledge among nurses on medical errors and factors affecting or hindering reporting of medical errors among nurses working at the emergency unit, KNH. Critical care nurses are faced with many barriers to completing incident reports on medication errors. One of these barriers which contribute to underreporting is a lack of education and/or knowledge regarding medication errors and the reporting process. This study, therefore, sought to determine the availability and the use of reporting systems for medical errors in critical care unity. It also sought to establish nurses’ perception regarding medical errors and reporting and document factors facilitating timely identification and reporting of medical errors in critical care settings. Methods: The study used cross-section study design to collect data from 76 critical care nurses from Kenyatta Teaching & Research National Referral Hospital, Kenya. Data analysis and results is ongoing. By October 2022, we will have analysis, results, discussions, and recommendations of the study for purposes of the conference in 2023

Keywords: errors, medical, kenya, nurses, safety

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Authors: Balasooriya B. M. C. M., Sujeeva N., Thowfeek Z., Siddiqa Omo, Liyanagunawardana J. E., Jayawardana Saiu, Manathunga S. S., Katulanda G. W.

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Introduction and objectives: Adrenal venous sampling (AVS) is the gold standard to discriminate unilateral primary aldosteronism (UPA) from bilateral disease (BPA). AVS is technically demanding and only performed in a limited number of centers worldwide. To the best of our knowledge, Except for one study conducted in India, no other research studies on this area have been conducted in South Asia. This study aimed to evaluate the effectiveness of AVS in the management of primary aldosteronism. Methods: A total of 32 patients who underwent AVS at the National Hospital of Sri Lanka from April 2021 to April 2023 were enrolled. Demographic, clinical and laboratory data were obtained retrospectively. A procedure was considered successful when adequate cannulation of both adrenal veins was demonstrated. Cortisol gradient across the adrenal vein (AV) and the peripheral vein was used to establish the success of venous cannulation. Lateralization was determined by the aldosterone gradient between the two sides. Continuous and categorical variables were summarized with mean, SD, and proportions, respectively. The mean and standard deviation of the contralateral suppression index (CSI) were estimated with an intercept-only Bayesian inference model. Results: Of the 32 patients, the average age was 52.47 +26.14 and 19 (59.4%) were males. Both AVs were successfully cannulated in 12 (37.5%). Among them, lateralization was demonstrated in 11(91.7%), and one was diagnosed as a bilateral disease. There were no total failures. Right AV cannulation was unsuccessful in 18 (56.25%), of which lateralization was demonstrated in 9 (50%), and others were inconclusive. Left AV cannulation was unsuccessful only in 2 (6.25%); one was lateralized, and the other remained inconclusive. The estimated mean of the CSI was 0.33 (89% credible interval 0.11-0.86). Seven patients underwent unilateral adrenalectomy and demonstrated significant improvement in blood pressure during follow-up. Two patients await surgery. Others were treated medically. Conclusions: Despite failure due to procedural difficulties, AVS remained useful in the management of patients with PA. Moreover, the success of the procedure needs experienced hands and advanced equipment to achieve optimal outcomes in PA.

Keywords: adrenal venous sampling, lateralization, contralateral suppression index, primary aldosteronism

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Authors: Lahoucine Zaama, Sanae Douama

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In this work, we present the results of a dosimetry study in a Moroccan radiology department . The results are compared with those of a similar study in France. Furthermore, it determines the coefficient of transmission of the lead sheets of different thicknesses depending on the voltage (KV) in a direct exposure. The objective of this study is to choose the thickness of the radiation means to determine the leaf sample sealed with the smallest percentage value radiation transmission, and that in the context of optimization. Thus the comparison among the studies is essential to consider conduct studies and research in this framework to achieve the goal of optimization.

Keywords: radiology, dosimetry, radiation, dose, transmission

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Authors: G. Lambe, D. Mansukhani, A. Shetty, S. Khodaiji, C. Rodrigues, F. Kapadia

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Introduction: Sepsis is known to cause impairment of both innate and adaptive immunity and involves an early uncontrolled inflammatory response, followed by a protracting immunosuppression phase, which includes decreased expression of cell receptors, T cell anergy and exhaustion, impaired cytokine production, which may cause high risk for secondary infections due to reduced response to antigens. Although human cytomegalovirus (CMV) is widely recognized as a serious viral pathogen in sepsis and immunocompromised patients, the incidence of CMV reactivation in patients with sepsis lacking strong evidence of immunosuppression is not well defined. Therefore, it is important to determine an association between CMV reactivation and sepsis-induced immunosuppression. Aim: To determine the association between incidence of CMV reactivation and immune modulation in sepsis-induced immunosuppression with time. Material and Methods: Ten CMV-seropositive adult patients with severe sepsis were included in this study. Blood samples were collected on Day 0, and further weekly up to 21 days. CMV load was quantified by real-time PCR using plasma. The expression of immunosuppression markers, namely, HLA-DR, PD-1, and regulatory T cells, were determined by flow cytometry using whole blood. Results: At Day 0, no CMV reactivation was observed in 6/10 patients. In these patients, the median length for reactivation was 14 days (range, 7-14 days). The remaining four patients, at Day 0, had a mean viral load of 1802+2599 copies/ml, which increased with time. At Day 21, the mean viral load for all 10 patients was 60949+179700 copies/ml, indicating that viremia increased with the length of stay in the hospital. HLA-DR expression on monocytes significantly increased from Day 0 to Day 7 (p = 0.001), following which no significant change was observed until Day 21, for all patients except 3. In these three patients, HLA-DR expression on monocytes showed a decrease at elevated viral load (>5000 copies/ml), indicating immune suppression. However, the other markers, PD-1 and regulatory T cells, did not show any significant changes. Conclusion: These preliminary findings suggest that CMV reactivation can occur in patients with severe sepsis. In fact, the viral load continued to increase with the length of stay in the hospital. Immune suppression, indicated by decreased expression of HLA-DR alone, was observed in three patients with elevated viral load.

Keywords: CMV reactivation, immune suppression, sepsis immune modulation, CMV viral load

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Authors: Arvind Aggarwal

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We have developed a comprehensive global healthcare delivery System based on information technology. It has medical consultation system where a virtual consultant can give medical consultation to the patients and Doctors at the digital medical centre after reviewing the patient’s EMR file consisting of patient’s history, investigations in the voice, images and data format. The system has the surgical operation system too, where a remote robotic consultant can conduct surgery at the robotic surgical centre. The instant speech and text translation is incorporated in the software where the patient’s speech and text (language) can be translated into the consultant’s language and vice versa. A consultant of any specialty (surgeon or Physician) based in any country can provide instant health care consultation, to any patient in any country without loss of time. Robotic surgeons based in any country in a tertiary care hospital can perform remote robotic surgery, through patient friendly telemedicine and tele-surgical centres. The patient EMR, financial data and data of all the consultants and robotic surgeons shall be stored in cloud. It is a complete comprehensive business model with healthcare medical and surgical delivery system. The whole system is self-financing and can be implemented in any country. The entire system uses paperless, filmless techniques. This eliminates the use of all consumables thereby reduces substantial cost which is incurred by consumables. The consultants receive virtual patients, in the form of EMR, thus the consultant saves time and expense to travel to the hospital to see the patients. The consultant gets electronic file ready for reporting & diagnosis. Hence time spent on the physical examination of the patient is saved, the consultant can, therefore, spend quality time in studying the EMR/virtual patient and give his instant advice. The time consumed per patient is reduced and therefore can see more number of patients, the cost of the consultation per patients is therefore reduced. The additional productivity of the consultants can be channelized to serve rural patients devoid of doctors.

Keywords: e-health, telemedicine, telecare, IT-based healthcare

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Authors: M. Strémy, P. Závacký, P. Cuninka, M. Juhás

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Main goal of this paper is to introduce our design of private cloud for storing large amount of data, especially pictures, and to provide good technological backend for data analysis based on parallel processing and business intelligence. We have tested hypervisors, cloud management tools, storage for storing all data and Hadoop to provide data analysis on unstructured data. Providing high availability, virtual network management, logical separation of projects and also rapid deployment of physical servers to our environment was also needed.

Keywords: cloud, glusterfs, hadoop, juju, kvm, maas, openstack, virtualization

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Authors: S. Adhirai Subramaniyam, Paramjit Singh

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This paper presents major issues in cloud computing. The paper describes different cloud computing deployment models and cloud service models available in the field of cloud computing. The paper then concentrates on various issues in the field. The issues such as cloud compatibility, compliance of the cloud, standardizing cloud technology, monitoring while on the cloud and cloud security are described. The paper suggests solutions for these issues and concludes that hybrid cloud infrastructure is a real boon for organizations.

Keywords: cloud, cloud computing, mobile cloud computing, private cloud, public cloud, hybrid cloud, SAAS, PAAS, IAAS, cloud security

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Authors: Susanna Menis

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The context of this study revolves around the theme of consent and the construction of unlawfulness in judicial decisions. It aims to explore the formation of societal perceptions of unlawfulness within the context of consensual sexual acts leading to harmful consequences. This study investigates how judges create legal rules that reflect social solidarity and protect against violence. Specifically, the research aims to understand the justification behind criminalising consensual sexual activity when categorised under different offences. The main question addressed in this study will evaluate the way judges create legal rules that they believe reflect social solidarity and protect against violence. The study employs a historical genealogy approach as its methodology. This approach allows for tracing back the original formation of societal perspectives on unlawfulness, thus highlighting the socially constructed nature of the present understanding. The data for this study will be collected through an extensive literature review, examining historical legal cases and documents that shape the understanding of unlawfulness. This will provide a comprehensive view of how social attitudes toward private sexual relations influenced the creation of legal rules. The theoretical importance of this research lies in its contribution to socio-legal scholarship. This study adds to the existing knowledge on the topic by exploring questions of unconscious bias and its origins. The findings shed light on how and why individuals possess unconscious biases, particularly within the judicial system. In conclusion, this study investigates judicial decisions concerning consensual sexual acts and the construction of unlawfulness. By employing a historical genealogy approach, the research sheds light on how judges create legal rules that reflect social solidarity and aim to protect against violence. The theoretical importance of this study lies in its contribution to understanding unconscious bias and its origins within the judicial system. Through data collection and analysis procedures, this study aims to provide valuable insights into the formation of social attitudes towards private sexual relations and its impact on legal rulings.

Keywords: consent, sexual offences, offences against the person, legal genealogy, social construct

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Authors: Nasrin Amirrajab, Yasaman Razavi Ghahfarokhi, Zahra Tootak, Maryam Hadian, Fatemeh Abooali Shamshiri

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Urinary tract infections (UTIs) have been reported in children with nephrotic syndrome. However, the only causes for the infection reported to date are bacteria, but not many prior reported occurrences of fungi or yeast as causative organisms. Hence, the present study aimed to describe the epidemiology of urinary tract fungal infections in a tertiary care pediatric. A single-center cross-sectional study was conducted at the nephrology ward of Aboozar Pediatric Hospital between March 21, 2021, and April 28, 2022. Urine was collected aseptically from children, inoculated onto culture media, and incubated at 37 °C for 18–48 hours. Yeast was identified following standard procedures. Antifungal susceptibility testing was determined by the disk diffusion method according to the CLSI guideline. Descriptive statistics and logistical regressions were used to estimate the crude ratio with a 95% confidence interval. P-value < 0.05 was considered significant. Among 68 individuals referred to the mycology lab, the result of direct examination and culture of all patients approved for C.albicans. Of these, 38 individuals (55.8%) were male, and 30 (44.2%) were female. The patients' age ranges were between one month and an 18-year-old. In the study of infection intensity, the patients were classified into three levels such as few (73.5%), moderate (20.6%), and many (5.9%). In the present study, all the patients were sensitive to Posaconazole. Also, the eagle effect was found in Amphotericin B, Voriconazole, and Fluconazole with frequencies of 91.7%, 91.7%, and 83%, respectively. In addition, just 8.3% of isolates were resistant to Itraconazole. It has not shown resistance in other mentioned medicine. The patients showed an intermediate response to Itraconazole (91.7%), Fluconazole (17%), Voriconazole (8.3%), and Amphotericin B (8.3%). There is a high prevalence of yeast infections in children with suspected UTIs. Also, boys are more likely to get yeast infections, and the severity of the infection is higher than girls. The present study demonstrated the importance of diagnosing and selecting the appropriate drug for urinary tract fungal infections in hospitalized children.

Keywords: urinary tract infections, children, fungal infections, yeast, antifungal susceptibility

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Authors: Meidesta Pitria, Akiko Okabe

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In high-density informal settlement, extension area at the outside of the houses could primarily happen as a spatial modification response. House extension in high-density informal settlement is not only becoming a physical spatial modification that makes a blur zone between private and public but also supporting the growth and existence of informal economy and other daily activities in both individuals and communities. This research took a case study in an informal settlement named Kampung Cikini, a densely populated area in Central Jakarta. The aim of this study is to identify and clarify house extension as a strategy in dealing with urbanization in an informal settlement. By using the perspective and information from housewives, the analysis is based on the assumption that land ownership transformation and the activities in house extension area influence the different kinds of house extension’s spatial modification and local planning policy in relation with the implementation of house extension strategy. The data collection was done in four sites, two sites are located in outer-wide alley and another two sites are located in inner-narrow alley. In this research, data of 104 housewives in 86 houses were collected through representatives of housewives and local leader of each sites. The research was started from participatory mapping process, deep interview with local leader, and initiated collaboration with housewives community in having a celebration as communal event to cultivate together the issue. This study shows that land ownership, activities, and alley are indispensable in the decision of extension space making. The more permanency status of land ownership the more permanent and various extension could be implemented. However, in some blocks, the existence of origin house or first land owner also has a significant role in coordination and agreement in using and modifying extension space. In outer-wide alley, the existence of more various activities in front area of the houses is significantly related with the chance given by having wider alley, particularly for informal income generating activities. In the inner-narrow alley, limited space in front of the houses affects more negotiations in the community for having more shared spaces, even inside their private space.

Keywords: house extension, housewives, informal settlement, kampung, high density

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Authors: I. N. Nwafia, U. C. Ozumba, M. E. Ohanu, S. O. Ebede

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Antibiotic resistance is increasing globally and has become a major health challenge. Extended-spectrum beta-lactamase is clinically important because the ESBL gene are mostly plasmid encoded and these plasmids frequently carry genes encoding resistance to other classes of antimicrobials thereby limiting antibiotic options in the treatment of infections caused by these organisms. The specific objectives of this study were to determine the prevalence of ESBLs production in Escherichia coli, to determine the antibiotic susceptibility pattern of ESBLs producing Escherichia coli, to detect TEM, SHV and CTX-M genes and the risk factors to acquisition of ESBL producing Escherichia coli. The protocol of the study was approved by Health Research and Ethics committee of the University of Nigeria Teaching Hospital (UNTH), Enugu. It was a descriptive cross-sectional study that involved all hospitalized patients in UNTH from whose specimens Escherichia coli was isolated during the period of the study. The samples analysed were urine, wound swabs, blood and cerebrospinal fluid. These samples were cultured in 5% sheep Blood agar and MacConkey agar (Oxoid Laboratories, Cambridge UK) and incubated at 35-370C for 24 hours. Escherichia coli was identified with standard biochemical tests and confirmed using API 20E auxanogram (bioMerieux, Marcy 1'Etoile, France). The antibiotic susceptibility testing was done by disc diffusion method and interpreted according to the Clinical and Laboratory Standard Institute guideline. ESBL production was confirmed using ESBL Epsilometer test strips (Liofilchem srl, Italy). The ESBL bla genes were detected with polymerase chain reaction, after extraction of DNA with plasmid mini-prep kit (Jena Bioscience, Jena, Germany). Data analysis was with appropriate descriptive and inferential statistics. One hundred and six isolates (53.00%) out of the 200 were from urine, followed by isolates from different swabs specimens 53(26.50%) and the least number of the isolates 4(2.00) were from blood (P value = 0.096). Seventy (35.00%) out of the 200 isolates, were confirmed positive for ESBL production. Forty-two (60.00%) of the isolates were from female patients while 28(40.00%) were from male patients (P value = 0.13). Sixty-eight (97.14%) of the isolates were susceptible to imipenem while all of the isolates were resistant to ampicillin, chloramphenicol and tetracycline. From the 70 positive isolates the ESBL genes detected with polymerase chain reaction were blaCTX-M (n=26; 37.14%), blaTEM (n=7; 10.00%), blaSHV (n=2; 2.86%), blaCTX-M/TEM (n=7; 10.0%), blaCTX-M/SHV (n=14; 20.0%) and blaCTX-M/TEM/SHV (n=10; 14.29%). There was no gene detected in 4(5.71%) of the isolates. The most associated risk factors to infections caused by ESBL producing Escherichia coli was previous antibiotics use for the past 3 months followed by admission in the intensive care unit, recent surgery, and urinary catheterization. In conclusion, ESBLs was detected in 4 of every 10 Escherichia coli with the predominant gene detected being CTX-M. This knowledge will enable appropriate measures towards improvement of patient health care, antibiotic stewardship, research and infection control in the hospital.

Keywords: antimicrobial, Escherichia coli, extended spectrum beta lactamase, resistance

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Authors: Ersumo Tessema, Bogale Girmaye Tamrat, Mohammed Burka

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Background: Hyperthyroidism is a common thyroid disorder especially in women and characterized by increased thyroid hormone synthesis and secretion. The disorder manifests predominantly as Graves’ disease in iodine-sufficient areas and has increasing prevalence in iodine-deficient countries in patients with nodular thyroid disease and following iodine fortification. In Ethiopia, the magnitude of the disorder is unknown and, in Africa, due to scarcity of resources, its management remains suboptimal. Objective: The aim of this study was to analyze the pattern and management of patients with hyperthyroidism at the United Vision Medical Services Center, Addis Ababa between August 30, 2013, and February 1, 2018. Patients and methods: The study was a retrospective analysis of medical records of all patients with hyperthyroidism at the United Vision Private Medical Services Center, Addis Ababa. A questionnaire was filled out; the collected data entered into a computer and statistically analyzed using the SPSS package. The results were tabulated and discussed with literature review. Results: A total of 589 patients were included in this study. The median age was 40 years, and the male to female ratio was 1.0:7.9. Most patients (93%) presented with goiter and the associated features of toxic goiter except weight loss, sweating and tachycardia were uncommon. Majority of patients presented more than two years after the onset of their presenting symptoms. The most common physical finding (91%), as well as diagnosis, was toxic nodular goiter. The most frequent (83%) derangement in the thyroid function tests was a low thyroid-stimulating hormone, and the most commonly (94%) used antithyroid drug was a propylthiouracil. The most common (96%) surgical procedure in 213 patients was a near-total thyroidectomy with a postoperative course without incident in 92% of all the patients. Conclusion: The incidence and prevalence of hyperthyroidism are apparently on the increase in Addis Ababa, which may be related to the existing severe iodine-deficiency and or the salt iodation program (iodine-induced hyperthyroidism). Hyperthyroidism predominantly affects women and, in surgical services, toxic nodular goiter is more common than diffuse goiter, and the treatment of choice in experienced hands is a near-total thyroidectomy.

Keywords: Ethiopia, grave’s disease, hyperthyroidism, toxic nodular goiter

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Authors: Lokvendra S. Budania, Yogesh K Gaude, Vamsidhar Chamala

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Introduction: Congenitally corrected transposition of great arteries (CCTGA) is a complex congenital heart disease where there are both atrioventricular and ventriculoarterial discordances, usually accompanied by other cardiovascular malformations. Case Report: A 24-year-old primigravida known case of CCTGA at 37 weeks of gestation was referred to our hospital for safe delivery. Her electrocardiogram showed HR-40/pm, echocardiography showed Ejection Fraction of 65% and CCTGA. Temporary pacemaker was inserted by cardiologist in catheterization laboratory, before giving trial of labour in view of complete heart block. She was planned for normal delivery, but emergency Caesarean section was planned due to non-reassuring foetal Cardiotocography Pre-op vitals showed PR-50 bpm with temporary pacemaker, Blood pressure-110/70 mmHg, SpO2-99% on room air. Nil per oral was inadequate. Patency of two peripheral IV cannula checked and left radial arterial line secured. Epidural Anaesthesia was planned, and catheter was placed at L2-L3. Test dose was given, Anaesthesia was provided with 5ml + 5ml of 2% Lignocaine with 25 mcg Fentanyl and further 2.5Ml of 0.5% Bupivacaine was given to achieve a sensory level of T6. Cesarean section was performed and baby was delivered. Cautery was avoided during this procedure. IV Oxytocin (15U) was added to 500 mL of ringer’s lactate. Hypotension was treated with phenylephrine boluses. Patient was shifted to post-operative care unit and later to high dependency unit for monitoring. Post op vitals remained stable. Temporary pacemaker was removed after 24 hours of surgery. Her post-operative period was uneventful and discharged from hospital. Conclusion: Rare congenital cardiac disorders require detail knowledge of pathophysiology and associated comorbidities with the disease. Meticulously planned and carefully titrated neuraxial techniques will be beneficial for such cases.

Keywords: congenitally corrected transposition of great arteries, complete heart block, emergency LSCS, epidural anaesthesia

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Authors: Ammar Asma, Bouafia Nabiha, Ghammam Rim, Ezzi Olfa, Ben Cheikh Asma, Mahjoub Mohamed, Helali Radhia, Sma Nesrine, Chouchène Imed, Boussarsar Hamadi, Njah Mansour

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Background: Central venous catheter associated infections (CVC-AI) are among the serious hospital-acquired infections. The aims of this study are to determine the incidence of CVC-AI, and their risk factors among patients followed in a Tunisian medical intensive care unit (ICU). Materials / Methods: A prospective cohort study conducted between September 15th, 2015 and November 15th, 2016 in an 8-bed medical ICU including all patients admitted for more than 48h. CVC-AI were defined according to CDC of ATLANTA criteria. The enrollment was based on clinical and laboratory diagnosis of CVC-AI. For all subjects, age, sex, underlying diseases, SAPS II score, ICU length of stay, exposure to CVC (number of CVC placed, site of insertion and duration catheterization) were recorded. Risk factors were analyzed by conditional stepwise logistic regression. The p-value of < 0.05 was considered significant. Results: Among 192 eligible patients, 144 patients (75%) had a central venous catheter. Twenty-eight patients (19.4%) had developed CVC-AI with density rate incidence 20.02/1000 CVC-days. Among these infections, 60.7% (n=17) were systemic CVC-AI (with negative blood culture), and 35.7% (n=10) were bloodstream CVC-AI. The mean SAPS II of patients with CVC-AI was 32.76 14.48; their mean Charlson index was 1.77 1.55, their mean duration of catheterization was 15.46 10.81 days and the mean duration of one central line was 5.8+/-3.72 days. Gram-negative bacteria was determined in 53.5 % of CVC-AI (n= 15) dominated by multi-drug resistant Acinetobacter baumani (n=7). Staphylococci were isolated in 3 CVC-AI. Fourteen (50%) patients with CVC-AI died. Univariate analysis identified men (p=0.034), the referral from another hospital department (p=0.03), tobacco (p=0.006), duration of sedation (p=0.003) and the duration of catheterization (p=0), as possible risk factors of CVC-AI. Multivariate analysis showed that independent factors of CVC-AI were, male sex; OR= 5.73, IC 95% [2; 16.46], p=0.001, Ramsay score; OR= 1.57, IC 95% [1.036; 2.38], p=0.033, and duration of catheterization; OR=1.093, IC 95% [1.035; 1.15], p=0.001. Conclusion: In a monocenter cohort, CVC-AI had a high density and is associated with poor outcome. Identifying the risk factors is necessary to find solutions for this major health problem.

Keywords: central venous catheter associated infection, intensive care unit, prospective cohort studies, risk factors

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Authors: A. Abubakar, A. Parsa, S. Walker

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Despite advances made in the diagnosis and management of drug-sensitive tuberculosis (TB) over the past decades, treatment of multidrug-resistant tuberculosis (MDR-TB) remains challenging and complex particularly in high burden countries including Nigeria. Treatment of MDR-TB is cost-prohibitive with success rate generally lower compared to drug-sensitive TB and if care is not taken it may become the dominant form of TB in future with many treatment uncertainties and substantial morbidity and mortality. Addressing these challenges requires collaborative efforts thorough sustained researches to evaluate the current treatment guidelines, particularly in high burden countries and prevent progression of resistance. To our best knowledge, there has been no research exploring the acceptability, effectiveness, and cost-effectiveness of community-based-MDR-TB treatment model in Nigeria, which is among the high burden countries. The previous similar qualitative study looks at the home-based management of MDR-TB in rural Uganda. This research aimed to explore patient’s views and acceptability of community-based-MDR-TB treatment model and to evaluate and compare the effectiveness and cost-effectiveness of community-based versus hospital-based MDR-TB treatment model of care from the Nigerian perspective. Knowledge of patient’s views and acceptability of community-based-MDR-TB treatment approach would help in designing future treatment recommendations and in health policymaking. Accordingly, knowledge of effectiveness and cost-effectiveness are part of the evidence needed to inform a decision about whether and how to scale up MDR-TB treatment, particularly in a poor resource setting with limited knowledge of TB. Mixed methods using qualitative and quantitative approach were employed. Qualitative data were obtained using in-depth semi-structured interviews with 21 MDR-TB patients in Nigeria to explore their views and acceptability of community-based MDR-TB treatment model. Qualitative data collection followed an iterative process which allowed adaptation of topic guides until data saturation. In-depth interviews were analyzed using thematic analysis. Quantitative data on treatment outcomes were obtained from medical records of MDR-TB patients to determine the effectiveness and direct and indirect costs were obtained from the patients using validated questionnaire and health system costs from the donor agencies to determine the cost-effectiveness difference between community and hospital-based model from the Nigerian perspective. Findings: Some themes have emerged from the patient’s perspectives indicating preference and high acceptability of community-based-MDR-TB treatment model by the patients and mixed feelings about the risk of MDR-TB transmission within the community due to poor infection control. The result of the modeling from the quantitative data is still on course. Community-based MDR-TB care was seen as the acceptable and most preferred model of care by the majority of the participants because of its convenience which in turn enhanced recovery, enables social interaction and offer more psychosocial benefits as well as averted productivity loss. However, there is a need to strengthen this model of care thorough enhanced strategies that ensure guidelines compliance and infection control in order to prevent the progression of resistance and curtail community transmission.

Keywords: acceptability, cost-effectiveness, multidrug-resistant TB treatment, community and hospital approach

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Authors: Koteswara Rao Pagolu, Raghava Rao Tamanam

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The present study was aimed to find out the prevalence of DD's in Visakhapatnam, one of the north coastal districts of Andhra Pradesh, India during a span of five years. A cross-sectional investigation was held at District early intervention center (DEIC), Visakhapatnam from 2016 to 2020. To identify the pattern and trend of different DD's including seasonal variations, a retrospective analysis of the health center's inpatient database for the past 5 years was done. Male and female children aged 2 months-18 years are included in the study with the prior permission of the concerned medical officer. The screening tool developed by the Ministry of health and family welfare, India, was used for the study. Among 26,423 cases, children with birth defects are 962, 2229 with deficiencies, 7516 with diseases, and 15716 with disabilities were admitted during the study period. From birth defects, congenital deafness occurred in large numbers with 22.66%, and neural tube defect observed in a small number of cases with 0.83% during the period. From the side of deficiencies, severe acute malnutrition has mostly occurred (66.80 %) and a small number of children were affected with goiter (1.70%). Among the diseases, dental carriers (67.97%) are mostly found and these cases were at peak during the years 2016 and 2019. From disabilities, children with vision impairment (20.55%) have mostly approached the center. Over the past 5 years, the admission rate of down's syndrome and congenital deafness cases showed a rising trend up to 2019 and then declined. Hearing impairment, motor delay, and learning disorder showed a steep rise and gradual decline trend, whereas severe anemia, vitamin-D deficiency, otitis media, reactive airway disease, and attention deficit hyperactivity disorder showed a declining trend. However, congenital heart diseases, dental caries, and vision impairment admission rates showed a zigzag pattern over the past 5 years. This center had inadequate diagnostic facilities related to genetic disease management. For advanced confirmation, the cases are referred to a district government hospital or private diagnostic laboratories in the city for genetic tests. Information regarding the overall burden and pattern of admissions in the health center is obtained by the review of DEIC records. Through this study, it is observed that the incidence of birth defects, as well as genetic disease burden, is high in the Visakhapatnam district. Hence there is a need for strengthening of management services for these diseases in this region.

Keywords: child health screening, developmental delays, district early intervention center, genetic disease management, infrastructural facility, Visakhapatnam district

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Authors: Marjan Moradi fard, Hossein Rassi, Masoud Houshmand

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Aim: Breast cancer is one of the most common cancers affecting the morbidity and mortality of Iranian women. This disease is a result of collective alterations of oncogenes and tumor suppressor genes. Studies have produced conflicting results concerning the role of p53 codon 72 polymorphism (G>C) and miR-146a rs2910164 polymorphism (G>C) on the risk of several cancers; therefore, a research was performed to estimate the association between the p53 codon 72 polymorphism and miR-146a rs2910164 polymorphism in breast cancer. Methods and Materials: A total of 45 archival breast cancer samples from Khatam hospital and 40 healthy samples were collected. Verification of each cancer reported in a relative was sought through the pathology reports of the hospital records. Then, DNA extracted from all samples by standard methods and p53 codon 72 polymorphism genotypes and miR-146a rs2910164 polymorphism genotypes were analyzed using multiplex PCR. The tubules, mitotic activity, necrosis, polymorphism and grade of breast cancer were staged by Nottingham histological grading and immunohistochemical staining of the sections from the paraffin wax embedded tissues for the expression of ER, PR and p53 was carried out using a standard method. Finally, data analysis was performed using the 7 version of the Epi Info(TM) 2012 software and test chi-square(x2) for trend. Results: Successful DNA extraction was assessed by PCR amplification of b-actin gene (99 bp). According to the results, p53 GG genotype and miR-146a rs2910164 CC genotype was significantly associated with increased risk of breast cancer in the study population. In this study, we established that tumors of p53 GG genotype and miR-146a rs2910164 CC genotype exhibited higher mitotic activity, higher polymorphism, lower necrosis, lower tubules, higher ER- and PR-negatives and lower TP53-positives than the other genotypes. Conclusion: The present study provided preliminary evidence that a p53 GG genotype may effect breast cancer risk in the study population, interacting synergistically with miR-146a rs2910164 CC genotype. Our results demonstrate that the testing of p53 codon 72 polymorphism genotypes and miR-146a rs2910164 polymorphism genotypes in combination with clinical parameters can serve as major risk factors in the early identification of breast cancers.

Keywords: breast cancer, miR-146a rs2910164 polymorphism, p53 codon 72 polymorphism, tumors, pathology reports

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Authors: Rafiqul Hasan, A. S. M. Tanim Anwar, Mohammad Azizul Hakim

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Background: Chronic kidney disease (CKD) is a major public health problem that continues to increase in prevalence globally. The prevalence of chronic kidney disease is increasing day by day in low to middle income countries (LMICs). People living in LMICs have the highest need for renal replacement therapy (RRT) despite they have lowest access to various modalities of treatment. As continuous ambulatory peritoneal dialysis (CAPD) does not require advanced technologies, very much infrastructure, dialysis staff support, it should be an ideal form of RRT in LMICs, particularly for those living in remote areas. To authors knowledge there was scarcity of data regarding CAPD performance in remote area of Bangladesh. This study was aimed to report the characteristics and outcomes of CAPD in ESRD patients lived in least developed area of Bangladesh. Methods: This prospective study was conducted in Cox’sbazar Medical College Hospital, Cox’sbazar and Parkview hospital Ltd, Chattogram, Bangladesh. Data were collected by questionnaire from the patients of any age with end-stage renal disease (ESRD) who underwent CAPD in 2018–2021. The baseline characteristics, PD-related complication as well as patient and technique survivals were analyzed. Results: Out of 31 patients who underwent CAPD, 18 (58%) were male on the age range of 15–79 years. The mean follow-up duration was 18 months. Mortality was inversely related with the EF of echocardiography. The peritonitis rate was 0.48 episodes per patient per year. The 1, 3 and 4-year patient survival rates were 64.34% (95% CI = 52.5–81.5), 23.79% (95% CI = 17.9 – 57.4) and 3.22% (95% CI = 31.2–77.5) respectively. Conclusions: In this study, CAPD performance was poorer than usual reference. Cardiac compromised patient and inappropriate dwell might be the main contributing factors behind this scenario. The peritonitis rate was nearly similar to that of developed countries. CAPD was cost effective than HD in remote area. Some accessible measures may be taken to make CAPD a more acceptable RRT modality with improved outcomes in poor socioeconomic backgrounds.

Keywords: dialysis cost, peritoneal dialysis, peritonitis, CAPD, least developed area, remote area, Bangladesh

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Authors: Recep Kesli, Gulsah Asik, Cengiz Demir, Onur Turkyilmaz

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Objective: Stenotrophomonas maltophilia (S. maltophilia) has recently emerged as an important nosocomial microorganism. Treatment of invasive infections caused by this organism is problematic because this microorganism is usually resistant to a wide range of commonly used antimicrobials. We aimed to evaluate clinical isolates of S. maltophilia in respect to sampling sites and antimicrobial resistant. Method: During a two years period (October 2013 and September 2015) eighteen samples collected from the intensive care unit (ICU) patients hospitalized in Afyon Kocatepe University, ANS Practice and Research Hospital. Identification of the bacteria was determined by conventional methods and automated identification system-VITEK 2 (bio-Mérieux, Marcy l’toile, France). Antibacterial resistance tests were performed by Kirby Bauer disc (Oxoid, England) diffusion method following the recommendations of CLSI. Results: Eighteen S. maltophilia strains were identified as the causative agents of different infections. The main type of infection was lower respiratory tract infection (83,4 %); three patients (16,6 %) had bloodstream infection. While, none of the 18 S. maltophilia strains were found to be resistant against to trimethoprim sulfametaxasole (TMP-SXT) and levofloxacine, eight strains 66.6 % were found to be resistant against ceftazidim. Conclusion: The isolation of S.maltophilia starains resistant to TMP-SXT is vital. In order to prevent or minimize infections due to S. maltophilia such precuations should be utilized: Avoidance of inappropriate antibiotic use, prolonged implementation of foreign devices, reinforcement of hand hygiene practices and the application of appropriate infection control practices. Microbiology laboratories also may play important roles in controlling S. maltophilia infections by monitoring the prevalence, continuously, the provision of local antibiotic resistance paterns data and the performance of synergistic studies also may help to guide appropirate antimicrobial therapy choices.

Keywords: Stenotrophomonas maltophilia, trimethoprim-sulfamethoxazole, antimicrobial resistance, Stenotrophomonas spp.

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Authors: Dina Alnefaie

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This poster presents a study of a Discord private server with thirteen multilingual gamers, aiming to explore the elements that construct a multilingual online gaming community. The study focuses on the communication practices of four Saudi female and male gamers, using various data collection methods, including online observations through recorded videos and screenshots, interviews, and informal conversations for one year. The primary findings show that translanguaging was a prominent feature of their verbal and textual communication practices. Besides, these practices that mostly accompany cultural ones were used to facilitate communication and express their identities in an intercultural context.

Keywords: online community construction, perceptions, multilingualism, digital identity

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Authors: Emni Omar Daw Hussin, Pathmawathi Subramanian, Wong Li Ping

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Background: To provide quality care at the end of life, nurses should possess knowledge and skills to provide effective end-of-life care, as well as develop the attitudes and interpersonal competence to provide compassionate care. Aim: This study aimed to assess nurses’ knowledge and attitude towards end of life care and caring for terminal ill patients and to examine relationships among demographic variables and nurse’s knowledge and attitudes toward end of life care and caring for terminal ill patients. Method: a cross-sectional study was conducted at 1 tertiary hospital located in Kuala Lumpur, Malaysia. Self-administrative questionnaire was used to collect data from 553 nurses from over all departments except emergency department, operation theater and outpatient clinic. Two tools were used in this study, the Frommelt’s Attitude Toward Care of the Dying (FATCOD) Scale to assess the nurses’ attitude and End of Life Knowledge Assessment to assess the nurses’ knowledge. Result: the result of this study yielded that, the majority of participants (54.8%) and (54.4%) have less positive attitude and knowledge towards end of life care and caring for terminal ill patients respectively. As well as there is no significant relationship were found between nurses’ ethnicity, religion, and the total score of FATCOD scale; End of Life Knowledge Assessment score. On other hand there is significant relationship among nurses’ age, working experience, level of education, attending any post basic courses and the total score of both FATCOD scale and End of Life Knowledge Assessment. Conclusion: A lack of education and experience and post basic course about end of life care and palliative care may contribute to the negative attitudes and poor knowledge regarding end of life care. Providing sufficient courses about end of life care could enhance the nurses’ knowledge towards end of life care, as well as providing a reflective narrative environment in which nurses can express their personal feelings about death and dying could be a potentially effective approach. Implication for Practice: This study elaborates the need for further research to develop an effective educational programs to enhance nurses’ knowledge and to promote positive attitude towards death and dying, as well as enhance communication skills, and coping strategies.

Keywords: knowledge, attitude, nurse, end of life care

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Authors: Naridchaya Aberdour, Joanna Kao, Anne Miller, Timothy Shore, Richard Maher, Zhixin Liu

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Background: COVID-19 has and continues to be a strain on healthcare globally, with the number of patients requiring hospitalization exceeding the level of medical support available in many countries. As chest x-rays are the primary respiratory radiological investigation, the Radiological Assessment of Lung Edema (RALE) score was used to quantify the extent of pulmonary infection on baseline imaging. Assessment of RALE score's reproducibility and associations with clinical outcome parameters were then evaluated to determine implications for patient management and prognosis. Methods: A retrospective study was performed with the inclusion of patients testing positive for COVID-19 on nasopharyngeal swab within a single Local Health District in Sydney, Australia and baseline x-ray imaging acquired between January to June 2020. Two independent Radiologists viewed the studies and calculated the RALE scores. Clinical outcome parameters were collected and statistical analysis was performed to assess RALE score reproducibility and possible associations with clinical outcomes. Results: A total of 78 patients met inclusion criteria with the age range of 4 to 91 years old. RALE score concordance between the two independent Radiologists was excellent (interclass correlation coefficient = 0.93, 95% CI = 0.88-0.95, p<0.005). Binomial logistics regression identified a positive correlation with hospital admission (1.87 OR, 95% CI= 1.3-2.6, p<0.005), oxygen requirement (1.48 OR, 95% CI= 1.2-1.8, p<0.005) and invasive ventilation (1.2 OR, 95% CI= 1.0-1.3, p<0.005) for each 1-point increase in RALE score. For each one year increased in age, there was a negative correlation with recovery (0.05 OR, 95% CI= 0.92-1.0, p<0.01). RALE scores above three were positively associated with hospitalization (Youden Index 0.61, sensitivity 0.73, specificity 0.89) and above six were positively associated with ICU admission (Youden Index 0.67, sensitivity 0.91, specificity 0.78). Conclusion: The RALE score can be used as a surrogate to quantify the extent of COVID-19 infection and has an excellent inter-observer agreement. The RALE score could be used to prognosticate and identify patients at high risk of deterioration. Threshold values may also be applied to predict the likelihood of hospital and ICU admission.

Keywords: chest radiography, coronavirus, COVID-19, RALE score

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Authors: Ashenafi Ayele, Shewit Haftu, Tesfalem Araya

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Background: “Post-psychotic depression”, “post schizophrenic depression”, and “secondary depression” have been used to describe the occurrence of depressive symptoms during the chronic phase of schizophrenia. Post-psychotic depression is the most common cause of death due to suicide in schizophrenia patients. Overall lifetime risk for patients with schizophrenia is 50% for suicide attempts and 9-13% lifetime risk for completed suicide and also it is associated with poor prognosis and poor quality of life. Objective: To assess determinant of post psychotic depression in schizophrenia patients ACSH and Mekelle General Hospital, Tigray Ethiopia 2019. Methods: An institutional based unmatched case control study was conducted among 69 cases and 138 controls with the ratio of case to control 1 ratio 2. The sample is calculated using epi-info 3.1 to assess the determinant factors of post-psychotic depression in schizophrenia patients. The cases were schizophrenia patients who have been diagnosed at least for more than one-year stable for two months, and the controls are any patients who are diagnosed as schizophrenia patients. Study subjects were selected using a consecutive sampling technique. The Calgary depression scale for schizophrenia self-administered questionnaire was used. Before the interview, it was assessed the client’s capacity to give intended information using a scale called the University of California, San Diego Brief Assessment of Capacity to Consent (UBACC). Bivariant and multiple Logistic regression analysis was performed to determine between the independent and dependent variables. The significant independent predictor was declared at 95% confidence interval and P-value of less than 0.05. Result: Females were affected by post psychotic depression with the (AOR=2.01, 95%CI: 1.003- 4.012, P= 0.49).Patients who have mild form of positive symptom of schizophrenia affected by post psychotic depression with (AOR =4.05, 95%CI: 1.888- 8.7.8, P=0001).Patients who have minimal form of negative symptom of schizophrenia are affected by post psychotic depression with (AOR =4.23, 95%CI: 1.081-17.092, P=.038). Conclusion: In this study, sex (female) and presence of positive and negative symptoms of schizophrenia were significantly associated. It is recommended that the post psychotic depression should be assessed in every schizophrenia patient to decrease the severity of illness, and to improve patient’s quality of life.

Keywords: determinants, post-psychotic depression, Mekelle city

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Authors: Roongtiwa Chobchuen, Siriporn Mongkholthawornchai, Boonsong Hatawaikarn, Uriwan Chaichangreet, Kobkaew Thongtid, Pusda Pukdeekumjorn, Panita Limpawattana

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Background: Age-friendly nursing service system in Srinagarind Hospital has been developed continuously based on the value and cultural background of Thailand which corporates with the modified WHO’s Age friendly Primary Care Service System. It consists of 3 issues; 1) development of staff training, 2) age-friendly service and 3) appropriate physical environment. Objective: To evaluate the efficacy of Age-friendly Nursing Service System: KKU (AFNS:KKU) model and to evaluate factors associated with nursing perception with AFN:KKU. Study design: Descriptive study Setting: 31 wards that served older patients in Srinagarind Hospital Populations: Nursing staff from 11 departments (31 wards) Instrument: Age-friendly nursing care scale as perceived by hospitalized older person Procedure and statistical analysis: All participants were asked questions using age-friendly nursing care scale as perceived by hospitalized older person questionnaires. Descriptive statistics and multiple logistic regression analyses were used to analyse the outcomes. Results: There were 337 participants recruited in this study. The majority of them were women (92%) with the mean ages of 29 years and 77.45% were nurse practitioners. They had average nursing experiences of 5 years. The average scores of age-friendly nursing care scale were high and highest in the area of attitude and communication. Age, sex, educational level, duration of work among, and having experience in aging training were not associated with nursing perception where type of department was an independent factor. Nurses from department of Surgery and Orthopedic, Eye and ENT, special ward and Obstetrics and Gynecological had significant greater perception than nurses from Internal Medicine Department (p < 0.05). Conclusion: Nurses had high scores in all dimensions of age-friendly concept. The result indicates that nurses have good attitude to aging care which can lead to improve quality of care. Organization should support other domains of ageing care to achieve greater effectiveness in geriatric care.

Keywords: age-friendly, nursing service system, excellence model, geriatric care

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Authors: Adedayo B. Adegbaju, Carel B. Schoeman, Ilse M. Schoeman

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The unique urban contexts that emanated from the apartheid history of South Africa informed the transport landscape of the City of Johannesburg. Apartheid‘s divisive spatial planning and land use management policies promoted sprawling and separated workers from job opportunities. This was further exacerbated by poor funding of public transport and road designs that encouraged the use of private cars. However, the democratization of the country in 1994 and the hosting of the 2010 FIFA World Cup provided a new impetus to the city’s public transport-oriented urban planning inputs. At the same time, the state’s new approach to policy formulations that entails the provision of public transport as one of the tools to end years of marginalization and inequalities soon began to largely reflect in planning decisions of other spheres of government. The Rea Vaya BRT and the Gautrain were respectively implemented by the municipal and provincial governments to demonstrate strong political will and commitment to the new policy direction. While the Gautrain was implemented to facilitate elite movement within Gauteng and to crowd investments and economic growths around station nodes, the BRT was provided for previously marginalized public transport users to provide a sustainable alternative to the dominant minibus taxi. The aim of this research is to evaluate the spatial impacts of the Gautrain and Rea Vaya BRT on the City of Johannesburg and to inform future outcomes by determining the existing potentials. By using the case study approach with a focus on the BRT and fast rail in a metropolitan context, the triangulation research method, which combines various data collection methods, was used to determine the research outcomes. The use of interviews, questionnaires, field observation, and databases such as REX, Quantec, StatsSA, GCRO observatory, national and provincial household travel surveys, and the quality of life surveys provided the basis for data collection. The research concludes that the Gautrain has demonstrated that viable alternatives to the private car can be provided, with its satisfactory feedbacks from users; while some of its station nodes (Sandton, Rosebank) have shown promises of transit-oriented development, one of the project‘s key objectives. The other stations have been unable to stimulate growth due to reasons like non-implementation of their urban design frameworks and lack of public sector investment required to attract private investors. The Rea Vaya BRT continues to be expanded in spite of both its inability to induce modal change and its low ridership figures. The research identifies factors like the low peak to base ratio, pricing, and the city‘s disjointed urban fabric as some of the reasons for its below-average performance. By drawing from the highlights and limitations, the study recommends that public transport provision should be institutionally integrated across and within spheres of government. Similarly, harmonization of the funding structure, better understanding of users’ needs, and travel patterns, underlined with continuity of policy direction and objectives, will equally promote optimal outcomes.

Keywords: bus rapid transit, Gautrain, Rea Vaya, sustainable transport, spatial and transport planning, transit oriented development

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Authors: Amir E. Amirzadeh, Richard K. Strand

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Moisture-induced problems are a significant concern for building owners, architects, construction managers, and building engineers, as they can have substantial impacts on building enclosures' durability and performance. Computational analyses, such as hygrothermal and thermal analysis, can provide valuable information and demonstrate the expected relative performance of building enclosure systems but are not grounded in absolute certainty. This paper evaluates the hygrothermal performance of common enclosure systems in hospitals in cold climates. The study aims to investigate the impact of exterior wall systems on hospitals, focusing on factors such as durability, construction deficiencies, and energy performance. The study primarily examines the impact of air leakage and vapor retarding layers relative to energy consumption. While these factors have been studied in residential and commercial buildings, there is a lack of information on their impact on hospitals in a holistic context. The study integrates various research studies and professional experience in hospital building design to achieve its objective. The methodology involves surveying and observing exterior wall assemblies, reviewing common exterior wall assemblies and details used in hospital construction, performing simulations and numerical analyses of various variables, validating the model and mechanism using available data from industry and academia, visualizing the outcomes of the analysis, and developing a mechanism to demonstrate the relative performance of exterior wall systems for hospitals under specific conditions. The data sources include case studies from real-world projects and peer-reviewed articles, industry standards, and practices. This research intends to integrate and analyze the in-situ and as-designed performance and durability of building enclosure assemblies with numerical analysis. The study's primary objective is to provide a clear and precise roadmap to better visualize and comprehend the correlation between the durability and performance of common exterior wall systems used in the construction of hospitals and the energy consumption of these buildings under certain static and dynamic conditions. As the construction of new hospitals and renovation of existing ones have grown over the last few years, it is crucial to understand the effect of poor detailing or construction deficiencies on building enclosure systems' performance and durability in healthcare buildings. This study aims to assist stakeholders involved in hospital design, construction, and maintenance in selecting durable and high-performing wall systems. It highlights the importance of early design evaluation, regular quality control during the construction of hospitals, and understanding the potential impacts of improper and inconsistent maintenance and operation practices on occupants, owner, building enclosure systems, and Heating, Ventilation, and Air Conditioning (HVAC) systems, even if they are designed to meet the project requirements.

Keywords: hygrothermal analysis, building enclosure, hospitals, energy efficiency, optimization and visualization, uncertainty and decision making

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Authors: Mark Morgan, Christine Li, Shuangyu Xu, Jenny McCarty

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The National Wild and Scenic Rivers System was created by the U.S. Congress in 1968 (Public Law 90-542; 16 U.S.C. 1271 et seq.) to preserve outstanding natural, cultural, and recreational values of some U.S. rivers in a free-flowing condition for the enjoyment of present and future generations. This Act is notable for safeguarding the special character of these rivers while supporting management action that encourages public participation for co-creating river protection goals and strategies. This is not an easy task. To meet the challenges of modern ecosystem management, federal resource agencies must address many legal, environmental, economic, political, and social issues. The U.S. Forest Service manages a 44-mile section of the Eleven Point National Scenic River (EPR) in southern Missouri, mainly for outdoor recreation purposes. About half of the acreage is in private lands, while the remainder flows through the Mark Twain National Forest. Private land along the river is managed by scenic easements to ensure protection of scenic values and natural resources, without public access. A portion of the EPR lies adjacent to a 16,500-acre tract known as the Irish Wilderness. The spring-fed river has steep bluffs, deep pools, clear water, and a slow current, making it an ideal setting for outdoor enthusiasts. A 10-month visitor study was conducted at five access points along the EPR during 2019 so the US Forest Service could update their river management plan. A mail-back survey was administered to 560 on-site visitors, yielding a response rate of 53%. Although different types of visitors use the EPR, boating and fishing were the predominant forms of outdoor recreation. Some river use was from locals, but other visitors came from farther away. Formulating unbiased policies for outdoor recreation is difficult because managers must assign relative values to recreational activities and travel distance. Because policymaking is a subjective process, management decisions can affect user groups in different ways (i.e., boaters vs. fishers; proximate vs. distal visitors), as seen through a GIS analysis.

Keywords: activity selection, forest recreation, policy, travel distance

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Authors: Zahra Hamidi

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Promoting cycling, as an affordable environmentally friendly mode of transport to replace private car use has been central to sustainable transport policies. Cycling is faster than walking and combined with public transport has the potential to extend the opportunities that people can access. In other words, cycling, besides direct positive health impacts, can improve people mobility and ultimately their quality of life. Transport literature well supports the close relationship between mobility, quality of life, and, well being. At the same time inequity in the distribution of access and mobility has been associated with the key aspects of injustice and social exclusion. The pattern of social exclusion and inequality in access are also often related to population characteristics such as age, gender, income, health, and ethnic background. Therefore, while investing in transport infrastructure it is important to consider the equity of provided access for different population groups. This paper proposes a method to evaluate the equity of cycling in a city from Rawls egalitarian perspective. Since this perspective is concerned with the difference between individuals and social groups, this method combines accessibility measures and Theil index of inequality that allows capturing the inequalities ‘within’ and ‘between’ groups. The paper specifically focuses on two population characteristics as gender and ethnic background. Following Rawls equity principles, this paper measures accessibility by bikes to a selection of urban activities that can be linked to the concept of the social primary goods. Moreover, as growing number of cities around the world have launched bike-sharing systems (BSS) this paper incorporates both private and public bikes networks in the estimation of accessibility levels. Additionally, the typology of bike lanes (separated from or shared with roads), the presence of a bike sharing system in the network, as well as bike facilities (e.g. parking racks) have been included in the developed accessibility measures. Application of this proposed method to a real case study, the city of Malmö, Sweden, shows its effectiveness and efficiency. Although the accessibility levels were estimated only based on gender and ethnic background characteristics of the population, the author suggests that the analysis can be applied to other contexts and further developed using other properties, such as age, income, or health.

Keywords: accessibility, cycling, equity, gender

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Authors: Vasundhara Arora, Anupam Jhobta, Suresh Thakur, Sanjiv Sharma

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Aims and Objectives: Intracranial tuberculosis (TB) is one of the most devastating manifestations of TB and a challenging public health issue of considerable importance and magnitude world over. This study elaborates on the imaging spectrum of neurotuberculosis on magnetic resonance imaging (MRI) in 29 clinically suspected cases from a tertiary care hospital. Materials and Methods: The prospective hospital based evaluation of MR imaging features of neuro-tuberculosis in 29 clinically suspected cases was carried out in Department of Radio-diagnosis, Indira Gandhi Medical Hospital from July 2017 to August 2018. MR Images were obtained on a 1.5 T Magnetom Avanto machine and were analyzed to identify any abnormal meningeal enhancement or parenchymal lesions. Microbiological and Biochemical CSF analysis was performed in radio-logically suspected cases and the results were compared with the imaging data. Clinical follow up of the patients started on anti-tuberculous treatment was done to evaluate the response to treatment and clinical outcome. Results: Age range of patients in the study was between 1 year to 73 years. The mean age of presentation was 11.5 years. No significant difference in the distribution of cerebral tuberculosis was noted among the two genders. Imaging findings of neuro-tuberculosis obtained were varied and non specific ranging from lepto-meningeal enhancement, cerebritis to space occupying lesions such as tuberculomas and tubercular abscesses. Complications presenting as hydrocephalus (n= 7) and infarcts (n=9) was noted in few of these patients. 29 patients showed radiological suspicion of CNS tuberculosis with meningitis alone observed in 11 cases, tuberculomas alone were observed in 4 cases, meningitis with parenchymal tuberculomas in 11 cases. Tubercular abscess and cerebritis were observed in one case each. Tuberculous arachnoiditis was noted in one patient. Gene expert positivity was obtained in 11 out of 29 radiologically suspected patients; none of the patients showed culture positivity. Meningeal form of the disease alone showed higher positivity rate of gene Xpert (n=5) followed by combination of meningeal and parenchymal forms of disease (n=4). The parenchymal manifestation of disease alone showed least positivity rates (n= 3) with gene xpert testing. All 29 patients were started on anti tubercular treatment based on radiological suspicion of the disease with clinical improvement observed in 27 treated patients. Conclusions: In our study, higher incidence of neuro- tuberculosis was noted in paediatric population with predominance of the meningeal form of the disease. Gene Xpert positivity obtained was low due to paucibacillary nature of cerebrospinal fluid (CSF) with even lower positivity of CSF samples in parenchymal form of the manifestation. MRI showed high accuracy in detecting CNS lesions in neuro-tuberculosis. Hence, it can be concluded that MRI plays a crucial role in the diagnosis because of its inherent sensitivity and specificity and is an indispensible imaging modality. It caters to the need of early diagnosis owing to poor sensitivity of microbiological tests more so in the parenchymal manifestation of the disease.

Keywords: neurotuberculosis, tubercular abscess, tuberculoma, tuberculous meningitis

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Authors: Mardiana Madjid, Nurpudji Astuti Taslim, Suryani As'ad, Haerani Rasyid, Agussalim Bukhari

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The high level of Urine Urea Nitrogen (UUN) indicates hypercatabolism occurs in hospitalized patients. High levels of Total Lymphocyte Count (TLC) indicates the immune system condition, adequate wound healing, and limit complication. Adequate dietary intake affects to decrease of hypercatabolism status in treated patient’s hospitals. Nitrogen Balance (NB) is simply the difference between nitrogen (N₂) intake and output. If more N₂ intake than output, then positive NB or anabolic will occur. This study aims to evaluate the effect of dietary intake in influencing balance nitrogen and total lymphocyte count. Method: A total of 43 patients admitted to a Wahidin Sudirohusodo Hospital between 2018 and 2019 for 10 days' treats are included. The inclusion criteria were patients who were treated for 10 days and receives food from the hospital orally. Patients did not experience gastrointestinal disorders such as vomiting and diarrhea and experience impair kidney function and liver function and expressed approval to participate in this study. During hospitalization, food intake, UUN, albumin serum, balance nitrogen, and TLC was assessed twice on day 1 and day 10. There is no Physician Clinical Nutritional intervention to correct food intake. UUN is 24 hours of urine collected on the second day after admission and the tenth day. Statistical analysis uses SPSS 24 with observational cohort methods. Result: The Forty-three participants completed the follow-up (27 men and 18 women). The age of fewer than 4 years is 22 people, 45 to 60 years is 16 people, and over 60 years is 4 people. The result of the study on day 1 obtained SGA score A, SGA score B, SGA score C are 8, 32, 3 until day 10 are 8, 31, 4, respectively. According to 24h dietary recalls, the energy intake during observation was from 522.5 ± 400.4 to 1011.9 ± 545.1 kcal/day P < 0.05, protein intake from 20.07 ± 17.2 to 40.3 ± 27.3 g/day P < 0.05, carbohydrates from 92.5 ± 71.6 to 184.8 ± 87.4 g/day, and fat from 5.5 ± 3.86 to 13.9 ± 13.9 g/day. The UUN during the observation was from 6.6 ± 7.3 to 5.5 ± 3.9 g/day, TLC decreased from 1622.9 ± 897.2 to 1319.9 ± 636.3/mm³ value target 1800/mm³, albumin serum from 3.07 ± 0.76 to 2.9 ± 0.57 g/day, and BN from -7.5 ± 7.2 to -3.1 ± 4.86. Conclusion: The high level of UUN needs to correct adequate dietary intake to improve NB and TLC status on hospitalized patients.

Keywords: adequate dietary intake, balance nitrogen, total lymphocyte count, urine urea nitrogen

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