Search results for: shock waves therapy

Authors: Timea Harmath-Tánczos

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Drug-resistant epilepsy (DRE) is defined as the persistence of seizures despite at least two syndrome-adapted antiseizure drugs (ASD) used at efficacious daily doses. About a third of patients with epilepsy suffer from drug resistance. Cognitive assessment has a crucial role in the diagnosis and clinical management of epilepsy. Previous studies have addressed the clinical targets and indications for measuring neuropsychological functions; best to our knowledge, no studies have examined it in a Hungarian therapy-resistant population. To fill this gap, we investigated the Hungarian diagnostic protocol between 18 and 65 years of age. This study aimed to describe and analyze neuropsychological functions in patients with drug-resistant epilepsy and identify factors associated with neuropsychology deficits. We perform a prospective case-control study comparing neuropsychological performances in 50 adult patients and 50 healthy individuals between March 2023 and July 2023. Neuropsychological functions were examined in both patients and controls using a full set of specific tests (general performance level, motor functions, attention, executive facts., verbal and visual memory, language, and visual-spatial functions). Potential risk factors for neuropsychological deficit were assessed in the patient group using a multivariate analysis. The two groups did not differ in age, sex, dominant hand and level of education. Compared with the control group, patients with drug-resistant epilepsy showed worse performance on motor functions and visuospatial memory, sustained attention, inhibition and verbal memory. Neuropsychological deficits could therefore be systematically detected in patients with drug-resistant epilepsy in order to provide neuropsychological therapy and improve quality of life. The analysis of the classical and complex indices of the special neuropsychological tasks presented in the presentation can help in the investigation of normal and disrupted memory and executive functions in the DRE.

Keywords: drug-resistant epilepsy, Hungarian diagnostic protocol, memory, executive functions, cognitive neuropsychology

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Authors: M. B. Neace, Xin GAo

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Small entrepreneurs are ubiquitous. Regardless of location their success depends on several behavioral characteristics and several market conditions. In this concept paper, we extend this paradigm to include elements from the science of chaos. Our observations, research findings, literature search and intuition lead us to the proposition that all entrepreneurs seek increasing returns, as did the many small entrepreneurs we have interviewed over the years. There will be a few whose initial perturbations may create tsunami-like waves of increasing returns over time resulting in very large market consequences–the butterfly impact. When small entrepreneurs perturb the market-place and their initial efforts take root a series of phase-space transitions begin to occur. They sustain the stream of increasing returns by scaling up. Chaos theory contributes to our understanding of this phenomenon. Sustaining and nourishing increasing returns of small entrepreneurs as complex adaptive systems requires scaling. In this paper we focus on the most critical element of the small entrepreneur scaling process–the mindset of the owner-operator.

Keywords: entrepreneur, increasing returns, scaling, chaos

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Authors: Seyed Mohsen Jameii

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Wireless underwater sensor networks are a type of sensor networks that are located in underwater environments and linked together by acoustic waves. The application of these kinds of network includes monitoring of pollutants (chemical, biological, and nuclear), oil fields detection, prediction of the likelihood of a tsunami in coastal areas, the use of wireless sensor nodes to monitor the passing submarines, and determination of appropriate locations for anchoring ships. This paper proposes a boundary coverage algorithm for intrusion detection in underwater sensor networks. In the first phase of the proposed algorithm, optimal deployment of nodes is done in the water. In the second phase, after the employment of nodes at the proper depth, clustering is executed to reduce the exchanges of messages between the sensors. In the third phase, the algorithm of "divide and conquer" is used to save energy and increase network efficiency. The simulation results demonstrate the efficiency of the proposed algorithm.

Keywords: boundary coverage, clustering, divide and ‎conquer, underwater sensor nodes

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Authors: Aurore Cauquis, Philippe Heinrich, Mario Ricchiuto, Audrey Gailler

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In this talk, we look for an accurate time scheme to model the propagation of waves. Several numerical schemes have been developed to solve the extended weakly nonlinear weakly dispersive Boussinesq Equations. The temporal schemes used are two Lax-Wendroff schemes, second or third order accurate, two Runge-Kutta schemes of second and third order and a simplified third order accurate Lax-Wendroff scheme. Spatial derivatives are evaluated with fourth order accuracy. The numerical model is applied to two monodimensional benchmarks on a flat bottom. It is also applied to the simulation of the Algerian tsunami generated by a Mw=6 seism on the 18th March 2021. The tsunami propagation was highly dispersive and propagated across the Mediterranean Sea. We study here the effects of the order of temporal discretization on the accuracy of the results and on the time of computation.

Keywords: numerical analysis, tsunami propagation, water wave, boussinesq equations

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Authors: Marcin Dębowski, Marcin Zieliński, Mirosław Krzemieniewski

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This publication presents a reactor designed for methane fermentation of organic substrates. The design is based on rotating cellular cylinders connected to a biomass feeder and an ultrasonic generator. This allows for simultaneous mixing and partial disintegration of the biomass, as well as stimulating higher metabolic rates within the microorganisms. Such a design allows from 2-fold to 14-fold reduction of power usage when compared to conventional mixing systems. The sludge does not undergo mechanical deformation during the mixing process, which improves substrate biodegradation efficiency by 10-15%. Cavitation occurs near the surface of the rods, partially releasing the biomass and separating it from the destroyed microorganisms. Biogas is released further away from the cellular cylinder rods due to the effect of the ultrasonic waves, in addition to increased biochemical activity of the microorganisms and increased exchange of the nutrient medium with metabolic products, which results in biogas production increase by about 15%.

Keywords: methane fermentation, bioreactors, biomass, mixing system

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Authors: Aline Woine, Moïra Mikolajczak, Virginie Dardier, Isabelle Roskam

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Background information: Becoming a parent is said to be the happiest event one can ever experience in one’s life. This popular (and almost absolute) truth–which no reasonable and decent human being would ever dare question on pain of being singled out as a bad parent–contrasts with the nuances that reality offers. Indeed, while many parents do thrive in their parenting role, some others falter and become progressively overwhelmed by their parenting role, ineluctably caught in a spiral of exhaustion. Parental burnout (henceforth PB) sets in when parental demands (stressors) exceed parental resources. While it is now generally acknowledged that PB affects the parent’s behavior in terms of neglect and violence toward their offspring, little is known about the impact that the syndrome might have on the children’s internalized (anxious and depressive symptoms, somatic complaints, etc.) and/or externalized (irritability, violence, aggressiveness, conduct disorder, oppositional disorder, etc.) behaviors. Furthermore, at the time of writing, to our best knowledge, no research has yet tested the reverse effect, namely, that of the child's internalized and/or externalized behaviors on the onset and/or maintenance of parental burnout symptoms. Goals and hypotheses: The present pioneering research proposes to fill an important gap in the existing literature related to PB by investigating the bidirectional effect between PB and the child’s internalized and/or externalized behaviors. Relying on a cross-lagged longitudinal study with three waves of data collection (4 months apart), our study tests a transactional model with bidirectional and recursive relations between observed variables and at the three waves, as well as autoregressive paths and cross-sectional correlations. Methods: As we write this, wave-two data are being collected via Qualtrics, and we expect a final sample of about 600 participants composed of French-speaking (snowball sample) and English-speaking (Prolific sample) parents. Structural equation modeling is employed using Stata version 17. In order to retain as much statistical power as possible, we use all available data and therefore apply the maximum likelihood with a missing value (mlmv) as the method of estimation to compute the parameter estimates. To limit (in so far is possible) the shared method variance bias in the evaluation of the child’s behavior, the study relies on a multi-informant evaluation approach. Expected results: We expect our three-wave longitudinal study to show that PB symptoms (measured at T1) raise the occurrence/intensity of the child’s externalized and/or internalized behaviors (measured at T2 and T3). We further expect the child’s occurrence/intensity of externalized and/or internalized behaviors (measured at T1) to augment the risk for PB (measured at T2 and T3). Conclusion: Should our hypotheses be confirmed, our results will make an important contribution to the understanding of both PB and children’s behavioral issues, thereby opening interesting theoretical and clinical avenues.

Keywords: exhaustion, structural equation modeling, cross-lagged longitudinal study, violence and neglect, child-parent relationship

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Authors: Lina Paola Orozco Marin, Yuliet Montoya Osorio, John Bustamante Osorno

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Ischemic events can culminate in acute myocardial infarction by irreversible cardiac lesions that cannot be restored due to the limited regenerative capacity of the heart. Cell therapy seeks to replace these injured or necrotic cells by transplanting healthy and functional cells. The therapeutic alternatives proposed by tissue engineering and cardiovascular regenerative medicine are the use of biomaterials to mimic the native extracellular medium, which is full of proteins, proteoglycans, and glycoproteins. The selected biomaterials must provide structural support to the encapsulated cells to avoid their migration and death in the host tissue. In this context, the present research work focused on developing a natural thermosensitive hydrogel, its physical and chemical characterization, and the determination of its biocompatibility in vitro. The hydrogel was developed by mixing hydrolyzed bovine and porcine collagen at 2% w/v, chitosan at 2.5% w/v, and beta-glycerolphosphate at 8.5% w/w and 10.5% w/w in magnetic stirring at 4°C. Once obtained, the thermosensitivity and gelation time were determined, incubating the samples at 37°C and evaluating them through the inverted tube method. The morphological characterization of the hydrogels was carried out through scanning electron microscopy. Chemical characterization was carried out employing infrared spectroscopy. The biocompatibility was determined using the MTT cytotoxicity test according to the ISO 10993-5 standard for the hydrogel’s precursors using the fetal human ventricular cardiomyocytes cell line RL-14. The RL-14 cells were also seeded on the top of the hydrogels, and the supernatants were subculture at different periods to their observation under a bright field microscope. Four types of thermosensitive hydrogels were obtained, which differ in their composition and concentration, called A1 (chitosan/bovine collagen/beta-glycerolphosphate 8.5%w/w), A2 (chitosan/porcine collagen/beta-glycerolphosphate 8.5%), B1 (chitosan/bovine collagen/beta-glycerolphosphate 10.5%) and B2 (chitosan/porcine collagen/beta-glycerolphosphate 10.5%). A1 and A2 had a gelation time of 40 minutes, and B1 and B2 had a gelation time of 30 minutes at 37°C. Electron micrographs revealed a three-dimensional internal structure with interconnected pores for the four types of hydrogels. This facilitates the exchange of nutrients, oxygen, and the exit of metabolites, allowing to preserve a microenvironment suitable for cell proliferation. In the infrared spectra, it was possible to observe the interaction that occurs between the amides of polymeric compounds with the phosphate groups of beta-glycerolphosphate. Finally, the biocompatibility tests indicated that cells in contact with the hydrogel or with each of its precursors are not affected in their proliferation capacity for a period of 16 days. These results show the potential of the hydrogel to increase the cell survival rate in the cardiac cell therapies under investigation. Moreover, the results lay the foundations for its characterization and biological evaluation in both in vitro and in vivo models.

Keywords: cardiac cell therapy, cardiac ischemia, natural polymers, thermosensitive hydrogel

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Authors: L. Slimani, A. Bousri, A. Hamadouche, H. Ben Hamed

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The aim of this experimental and numerical study is to analyze the effects of acoustic streaming generated by 40 kHz ultrasonic waves on heat transfer in forced convection, with and without 40 PPI aluminum metal foam. Preliminary dynamic and thermal studies were done with COMSOL Multiphase, to see heat transfer enhancement degree by inserting a 40PPI metal foam (10 × 2 × 3 cm) on a heat sink, after having determined experimentally its permeability and Forchheimer's coefficient. The results obtained numerically are in accordance with those obtained experimentally, with an enhancement factor of 205% for a velocity of 0.4 m/s compared to an empty channel. The influence of 40 kHz ultrasound on heat transfer was also tested with and without metallic foam. Results show a remarkable increase in Nusselt number in an empty channel with an enhancement factor of 37,5%, while no influence of ultrasound on heat transfer in metal foam presence.

Keywords: acoustic streaming, enhancing heat transfer, laminar flow, metal foam, ultrasound

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Authors: Maha Salah Abdullah Ismail, Manal S. Ismail, Amir M. Saleh

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Reflexology treatment is a method for enhancing body relaxation. It is a widely recognized as an alternative therapy, effective for many health conditions. This study aimed to evaluate the effect of reflexology treatment on arterial blood gases among mechanically ventilated patients. A quasi-experimental (pre and post-test) research design was used. Research hypothesis was mechanically ventilated patients who will receive the reflexology treatment will have improvement in their arterial blood gases than those who will not. The current study was carried out in different Intensive Care Units at the Cairo University Hospitals. A purposeful sample of 100 adults’ mechanically ventilated patients was recruited over a period of three months of data collection. The participants were divided into two equally matched groups; (1) The study group who has received the routine care, in addition, two reflexology sessions on the feet, (2) The control group who has received only the routine care. One tool was utilized to collect data pertinent to the study; mechanically ventilated patients' data sheet that consists of demographic and medical data. Result: Majority (58% of the study group and 82% of the control group) were males, with mean age of 50.9 years in both groups. Patients who received the reflexology treatment significantly increase in the oxygen saturation pre second session (t=5.15, p=.000), immediate post sessions (t=4.4, p=.000) and post two hours (t= 4.7, p= .000). The study group was more likely to have lower PaO2 (F=5.025, p=.015), PaCo2 (F=4.952, p=.025) and higher HCo3 (F=15.211, p=.000) than the control group. Conclusion: This study results support the positive effect of reflexology treatment in improving some arterial blood gases among mechanically ventilated patients’ with the conventional therapy as in the study group there was increase in the oxygen saturation. In differences between groups there decrease PaO2, PaCo2 and increase HCo3 in the study group. Recommendation: Nurses should be trained how to demonstrate the foot reflexology among mechanically ventilated patients.

Keywords: arterial blood gases, foot, mechanical ventilated patient, reflexology

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Authors: Stephanie P. Nigro

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The Exhale Breath Hold (EBH) technique presents a promising approach to enhance the precision and efficacy of External Beam Radiation Therapy (EBRT) for abdominal tumours, which include liver, pancreas, kidney, and adrenal glands. These tumours are challenging to treat due to their proximity to organs at risk (OARs) and the significant motion induced by respiration and physiological variations, such as stomach filling. Respiratory motion can cause up to 40mm of displacement in abdominal organs, complicating accurate targeting. While current practices like limiting fasting help reduce motion related to digestive processes, they do not address respiratory motion. 4DCT scans are used to assess this motion, but they require extensive workflow time and expose patients to higher doses of radiation. The EBH technique, which involves holding the breath in an exhale with no air in the lungs, stabilizes internal organ motion, thereby reducing respiratory-induced motion. The primary benefit of EBH is the reduction in treatment volume sizes, specifically the Internal Target Volume (ITV) and Planning Target Volume (PTV), as demonstrated by smaller ITVs when gated in EBH. This reduction also improves the quality of 3D Cone Beam CT (CBCT) images by minimizing respiratory artifacts, facilitating soft tissue matching akin to stereotactic treatments. Patients suitable for EBH must meet criteria including the ability to hold their breath for at least 15 seconds and maintain a consistent breathing pattern. For those who do not qualify, the traditional 4DCT protocol will be used. The implementation involves an EBH planning scan and additional short EBH scans to ensure reproducibility and assist in contouring and volume expansions, with a Free Breathing (FB) scan used for setup purposes. Treatment planning on EBH scans leads to smaller PTVs, though intrafractional and interfractional breath hold variations must be accounted for in margins. The treatment decision process includes performing CBCT in EBH intervals, with careful matching and adjustment based on soft tissue and fiducial markers. Initial studies at two sites will evaluate the necessity of multiple CBCTs, assessing shifts and the benefits of initial versus mid-treatment CBCT. Considerations for successful implementation include thorough patient coaching, staff training, and verification of breath holds, despite potential disadvantages such as longer treatment times and patient exhaustion. Overall, the EBH technique offers significant improvements in the accuracy and quality of abdominal EBRT, paving the way for more effective and safer treatments for patients.

Keywords: abdominal cancers, exhale breath hold, radiation therapy, respiratory motion

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Authors: M. G. Nasuruddin, S. Ishak

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This paper deals with the traditional Malay healing ritualistic ceremony known as Main Puteri. This non-invasive intervention uses the vehicle of performance to administer the healing process. It employs the performance elements of Makyung, that is, music, movements/dance, and dramatic dialogue to heal psychosomatic maladies. There are two perspectives to this therapeutic healing process, one traditional and the other scientific. From the traditional perspective, the psychosomatic illness is attributed to the infestations/possessions by malevolent spirits. To heal such patients, these spirits must be exorcised through placating them by making offerings. From the scientific perspective, the music (sonic orders), movements (kinetic energy), and smell (olfactory) connect with the brain waves to release the chemicals that would activate the internal healing energy. Currently, in Main Puteri, the therapeutic healing ritual is no longer relevant as modern clinical medicine has proven to be more effective. Thus, Main Puteri is an anachronism in today’s technologically advanced Malaysia.

Keywords: exorcism, main puteri, shamans, therapeutic healing

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Authors: Xiaohui Wang, Zhichuan Guan, Roman Shor, Chuanbin Xu

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Early monitoring and real-time quantitative description of gas intrusion under the premise of ensuring the integrity of the drilling fluid circulation system will greatly improve the accuracy and effectiveness of deepwater gas-kick monitoring. Therefore, in order to study the propagation characteristics of ultrasonic waves in the gas-liquid two-phase flow within the marine riser, in this paper, a numerical simulation method of ultrasonic propagation in the annulus of the riser was established, and the credibility of the numerical analysis was verified by the experimental results of the established gas intrusion monitoring simulation experimental device. The numerical simulation can solve the sound field in the gas-liquid two-phase flow according to different physical models, and it is easier to realize the single factor control. The influence of each parameter on the received signal can be quantitatively investigated, and the law with practical guiding significance can be obtained.

Keywords: gas-kick detection, ultrasonic, void fraction, coda wave velocity

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Authors: Sophia Cyril Vincent

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Background: As per the Indian Census 2011, there is nearly 104 million elderly population aged above 60 years (53 million females and 51 males), and the count is expected to be 173 million by the end of 2026. Nearly 5.5% of women and 1.5% of men are living alone.1 In India, even though it is the moral duty of the children to take care of aged parents, many elders are landing in old age homes due to the social transformation factors like mushrooming of nuclear families, migration of children, cultural echoes, differences in mindset and values. Nearly 728 old age homes are seen across the country, out of which 78 old age homes with approximately 3000 inmates are seen only in Bangalore2. The existing literature shows that elderly women residing in old age homes experience the challenges like- loneliness, health issues, rejection from children, grief, death anxiety, etc, which leads to mental and physical wellbeing in numerous and tangible ways3. Hence the best and cost-effective way to improve the meaning and quality of life among elderly females is logotherapy, a type of psychotherapeutic analysis and treatment, motivating and driving force4 within the human experience to lead a decent life. Aim: The current research is aimed at studying the effectiveness of a logotherapy intervention on meaning and quality of life among elderly women of old age homes. Samples:200 women aged < 60 years and staying in the old age home for more than 1 year were randomly allocated to the control group and experimental group. Methodology: Using the Meaning in life questionnaire (MLQ)and the World health organization quality of life (WHOQOL) questionnaire, meaning and quality of life were assessed among both groups' women. Intensive Logotherapy and meaning in life program for five days were provided for the experimental group and the control group, with no treatment. Result: Under analysis. Conclusion: It is the right of the elderly woman to lead a happy and peaceful life till her death irrespective of the residing place. Hence, continuous monitoring and effective management are necessary for elderly women.

Keywords: quality of life, meaning of life, logo therapy, old age home

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Authors: Fares A. Mayia, Mahmoud A. Yamany, Mushabbab A. Asiri

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In recent years, non-invasive Focused Ultrasound (FU) has been utilized for generating bubbles (cavities) to ablate target tissue by mechanical fractionation. Intensities >10 kW/cm² are required to generate the inertial cavities. The generation, rapid growth, and collapse of these inertial cavities cause tissue fractionation and the process is called Histotripsy. The ability to fractionate tissue from outside the body has many clinical applications including the destruction of the tumor mass. The process of tissue fractionation leaves a void at the treated site, where all the affected tissue is liquefied to particles at sub-micron size. The liquefied tissue will eventually be absorbed by the body. Histotripsy is a promising non-invasive treatment modality. This paper presents a technique for generating inertial cavities at lower intensities (< 1 kW/cm²). The technique (patent pending) is based on amplitude modulation (AM), whereby a low frequency signal modulates the amplitude of a higher frequency FU wave. Cavitation threshold is lower at low frequencies; the intensity required to generate cavitation in water at 10 kHz is two orders of magnitude lower than the intensity at 1 MHz. The Amplitude Modulation technique can operate in both continuous wave (CW) and pulse wave (PW) modes, and the percentage modulation (modulation index) can be varied from 0 % (thermal effect) to 100 % (cavitation effect), thus allowing a range of ablating effects from Hyperthermia to Histotripsy. Furthermore, changing the frequency of the modulating signal allows controlling the size of the generated cavities. Results from in vitro work demonstrate the efficacy of the new technique in fractionating soft tissue and solid calcium carbonate (Chalk) material. The technique, when combined with MR or Ultrasound imaging, will present a precise treatment modality for ablating diseased tissue without affecting the surrounding healthy tissue.

Keywords: focused ultrasound therapy, histotripsy, inertial cavitation, mechanical tissue ablation

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Authors: Luthfi Assholam Solamat

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Nowadays many people do not know the soil failure pattern as an important part in planning the under structure caused by the loading occurs. This is because the soil is located under the foundation, so it cannot be seen directly. Based on this study, the idea occurs to do a study for testing the soil failure pattern, especially the type of sand soil under the foundation. The necessity of doing this to the design of building structures on the land which is the initial part of the foundation structure that met with waves/vibrations during an earthquake. If the underground structure is not strong it is feared the building thereon more vulnerable to the risk of building damage. This research focuses on the search of soil failure pattern, which the most applicable in the field with the loading periodic re-testing of a particular time with the help of the integrated video visual observations performed. The results could be useful for planning under the structure in an effort to try the upper structure is minimal risk of the earthquake.

Keywords: soil failure pattern, earthquake, under structure, sand soil testing method

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Authors: Shawna Staud, Mary Kaye Scaramucci

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Objective: Rubber cup polishing has been a traditional method of preventative therapy in dental hygiene treatment. Newer methods such as air polishing have changed the way dental hygiene care is provided, yet this technique has not been embraced by students in the program nor by practitioners in the workforce. Students entering the workforce tend to follow office protocol and are limited in confidence to introduce technologies learned in the curriculum. This project was designed to help students gain confidence in newer skills and encourage private practice settings to adopt newer technologies for patient care. Our program recently introduced air polishing earlier in the program before the rubber cup technique to determine if students would embrace the technology to become leading-edge professionals when they enter the marketplace. Methods: The class of 2022 was taught the traditional method of polishing in the first-year curriculum and air polishing in the second-year curriculum. The class of 2023 will be taught the air polishing method in the first-year curriculum and the traditional method of polishing in the second-year curriculum. Pre- and post-graduation survey data will be collected from both cohorts. Descriptive statistics and pre and post-paired t-tests with alpha set at .05 to compare pre and post-survey results will be used to assess data. Results: This study is currently in progress, with a completion date of October 2023. The class of 2022 completed the pre-graduation survey in the spring of 2022. The post-gradation survey will be sent out in October 2022. The class of 2023 cohort will be surveyed in the spring of 2023 and October 2023. Conclusion: Our hypothesis is students who are taught air polishing first will be more inclined to adopt that skill in private practice, thereby embracing newer technology and improving oral health care.

Keywords: luggage handling system at world’s largest pilgrimage center

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Authors: Nobuyuki Takemoto, Ai Koyanagi, Masanori Yasuda, Hiroshi Yamamoto

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Background: Fluorescence imaging (FI) is one of the methods to identify sentinel lymph nodes (SLNs). However, the procedure is technically complicated and requires procedural skills, as SLN biopsy must be conducted in dim light conditions. As an improved version of this method, we introduced a combined method (Combined mixed dye and fluorescence; CMF) consisting of indigo carmine blue dye and FI. The direct visualization of SLNs under shadowless surgical light conditions is facilitated by the addition of the blue dye. We compared the SLN detection rates of CMF with that of the indocyanine green (ICG) dye method (ICG-D). Methods: A total of 202 patients with stage ≤ IIA breast cancer who underwent breast conservative therapy with separate incision from January 2004 to February 2017 were reviewed. Details of the two methods are as follows: (1) ICG-D: 2ml of ICG (10mg) was used and the green-stained SLNs were resected via a 3-4cm axillary incision; (2) CMF: A combination of 1ml of ICG (5mg) and 1-3ml of indigo carmine (4-12mg) was used. Using Photodynamic Eye (PDE), a 1.5-2 cm incision was made near the point of disappearance of the fluorescence and SLNs with intermediate color of blue and green were resected. Results: There were 92 ICG-D and 110 CMF cases. CMF resulted in a significantly higher detection rate than ICG-D (96.4% vs. 83.7%; p=0.003). This difference was particularly notable in those aged ≥ 60 years (98.3% vs. 74.3%) and individuals with BMI ≥ 25kg/m2 (90.3% vs. 58.3%). Conclusion: CMF is an effective method to identify SLNs which is safe, efficient, and cost-effective. Furthermore, radiation exposure can be avoided, and it can be performed in institutes without nuclear medicine facilities. CMF achieves a high SLN identification rate, and most of this procedure is feasible under shadowless surgical light conditions. CMF can reliably perform SLN biopsy even in those aged ≥ 60 years and individuals with BMI ≥ 25 kg/m2.

Keywords: sentinel lymph node biopsy, identification rate, indocyanine green (ICG), indigocarmine, fluorescence

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Authors: Meless Gebrie Bore, Lin Perry, Xiaoyue Xu, Andargachew Kassa, Marilyn Cruickshank

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Background: Adolescents living with HIV (ALHIV) in Ethiopia face significant health challenges, particularly related to nutrition, which is essential for optimizing antiretroviral therapy (ART) outcomes. This population is vulnerable to nutritional deficiencies due to increased energy demands and the adverse effects of HIV, alongside rapid growth and low socio-economic status. Despite advances in ART, research on nutritional care for ALHIV in Ethiopia is limited. Integrated nutritional interventions are critical for improving health outcomes, yet comprehensive guidance is lacking. This study aimed to evaluate healthcare workers' practices in ART clinics, assess the nutritional status of ALHIV, and provide recommendations for enhancing nutritional care. Method: Cross-sectional surveys were conducted, recruiting 44 healthcare professionals and 384 ALHIV across ten public hospitals in Addis Ababa and Oromia regions. Participants were selected using purposive sampling for healthcare workers and proportionate random sampling for ALHIV engaged in ART services. Data was collected using a pre-tested structured questionnaire with quantitative and qualitative components facilitated by trained healthcare workers through the Kobo Toolbox program. Results: Findings revealed that while most healthcare workers conducted basic nutritional assessments, more sensitive methods were rarely used. Only 36.4% assessed dietary intake and 27.3% evaluated food security. Nutrition counseling was limited, with only 38.6% providing such services regularly. Health Care worker participants expressed dissatisfaction with the integration of nutrition services due to a lack of training and resources. Nutritional assessments revealed that 24.2% of ALHIV were classified as thin, 21.7% as stunted, and 34.9% as malnourished based on mid-upper arm circumference, with 19.4% experiencing severe acute malnutrition. These results highlight the urgent need and opportunities to improve nutritional support tailored to ALHIV-specific needs. Conclusion and Recommendations: Study findings identified evidence of substantial nutritional deficits and critical gaps in nutritional care for ALHIV in Ethiopian ART clinics. While basic assessment and counseling were generally practiced, limited use of more sensitive methods and inadequate integration of nutrition services hindered care effectiveness. To improve health outcomes, it is essential to enhance training for healthcare workers, develop standardized nutrition guidelines, and allocate resources effectively. Conducting further research with large, diverse samples and integrating comprehensive nutritional care alongside ART services will enable better matching of the nutritional needs of this vulnerable population.

Keywords: adolescents living with HIV(ALHIV), antiretroviral therapy (ART), HIV, Ethiopia, malnutrition, nutritional support, stunting, thinness

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Authors: Fleura Shkëmbi, Sevim Mustafa, Naim Fanaj

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Hypnosis, often known as cognitive therapy, is a sort of mind-body psychotherapy. A professional and certified hypnotist or hypnotherapist guides the patient into this extreme level of focus and relaxation during the session by utilizing verbal cues, repetition, and imagery. In recent years, hypnotherapy has gained popularity in the treatment of a variety of disorders, including anxiety and particular phobias. The term "phobia" is commonly used to define fear of a certain trigger. When faced with potentially hazardous situations, the brain naturally experiences dread. While a little dread here and there may keep us safe, phobias can drastically reduce our quality of life. In summary, persons who suffer from anxiety are considered to see particular environmental situations as dangerous, but those who do not suffer from anxiety do not. Hypnosis is essential in the treatment of anxiety disorders. Hypnosis can help patients minimize their anxiety symptoms. This broad concept has aided in the development of models and therapies for anxiety disorders such as generalized anxiety disorder, panic attacks, hypochondria, and obsessional disorders. Hypnosis techniques are supposed to be attentive and mental pictures, which is conceivable; this is why they're associated with improved working memory and visuospatial abilities. In this sense, the purpose of this study is to determine how effectively specific therapeutic methods perform in treating persons with anxiety and phobias. In addition to cognitive-behavioral therapy and other therapies, the approaches emphasized the use of therapeutic hypnosis. This study looks at the use of hypnosis and related psychotherapy procedures in the treatment of anxiety disorders. Following a discussion of the evolution of hypnosis as a therapeutic tool, neurobiological research is used to demonstrate the influence of hypnosis on the change of perception in the brain. The use of hypnosis in the treatment of phobias, stressful situations, and posttraumatic stress disorder is examined, as well as similarities between the hypnotic state and dissociative reactions to trauma. Through an extensive literature evaluation, this study will introduce hypnotherapy procedures that result in more successful anxiety and phobia treatment.

Keywords: anxiety, hypnosis, hypnotherapy, phobia, technique, state

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Authors: Alireza Abdikian

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By assuming a quantum relativistic degenerate electron-positron (e-p) plasma media, the nonlinear acoustic solitary propagation in the presence of the stationary ions for neutralizing the plasma background of bounded cylindrical geometry was investigated. By using the standard reductive perturbation technique with cooperation the quantum hydrodynamics model for the e-p fluid, the spherical Kadomtsev-Petviashvili equation was derived for small but finite amplitude waves and was given the solitary wave solution for the parameters relevant for dense astrophysical objects such as white dwarf stars. By using a suitable coordinate transformation and using improved F-expansion technique, the SKP equation can be solved analytically. The numerical results reveal that the relativistic effects lead to propagate the electrostatic bell shape structures and by increasing the relativistic effects, the amplitude and the width of the e-p acoustic solitary wave will decrease.

Keywords: Electron-positron plasma, Acoustic solitary wave, Relativistic plasmas, the spherical Kadomtsev-Petviashvili equation

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Authors: Modi Alsubaie, Chris Dickens, Barnaby Dunn, Andy Gibson, Obioha Ukoumunned, Alison Evans, Rachael Vicary, Manish Gandhi, Willem Kuyken

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Background: Depression co-occurs in 20% of people with cardiovascular disorders, can persist for years and predicts worse physical health outcomes. While psychosocial treatments have been shown to effectively treat acute depression in those with comorbid cardiovascular disorders, to date there has been no evaluation of approaches aiming to prevent relapse and treat residual depression symptoms in this group. Therefore, the current study aimed to examine the feasibility and acceptability of a randomised controlled trial design evaluating an adapted version of mindfulness-based cognitive therapy (MBCT) designed specifically for people with co-morbid depression and cardiovascular disorders. Methods: A 3-arm feasibility randomised controlled trial was conducted, comparing MBCT adapted for people with cardiovascular disorders plus treatment as usual (TAU), mindfulness-based stress reduction (MBSR) plus TAU, and TAU alone. Participants completed a set of self-report measures of depression severity, anxiety, quality of life, illness perceptions, mindfulness, self-compassion and affect and had their blood pressure taken immediately before, immediately after, and three months following the intervention. Those in the adapted-MBCT arm additionally underwent a qualitative interview to gather their views about the adapted intervention. Results: 3400 potentially eligible participants were approached when attending an outpatient appointment at a cardiology clinic or via a GP letter following a case note search. 242 (7.1%) were interested in taking part, 59 (1.7%) were screened as being suitable, and 33 (<1%) were eventually randomised to the three groups. The sample was heterogeneous in terms of whether they reported current depression or had a history of depression and the time since the onset of cardiovascular disease (one to 25 years). Of 11 participants randomised to adapted MBCT seven completed the full course, levels of home mindfulness practice were high, and positive qualitative feedback about the intervention was given. Twenty-nine out of 33 participants randomised completed all the assessment measures at all three-time points. With regards to the primary outcome (depression), five out of the seven people who completed the adapted MBCT and three out of five under MBSR showed significant clinical change, while in TAU no one showed any clinical change at the three-month follow-up. Conclusions: The adapted MBCT intervention was feasible and acceptable to participants. However, aspects of the trial design were not feasible. In particular, low recruitment rates were achieved, and there was a high withdrawal rate between screening and randomisation. Moreover, the heterogeneity in the sample was high meaning the adapted intervention was unlikely to be well tailored to all participants needs. This suggests that if the decision is made to move to a definitive trial, study recruitment procedures will need to be revised to more successfully recruit a target sample that optimally matches the adapted intervention.

Keywords: mindfulness-based cognitive therapy (MBCT), depression, cardiovascular disorders, feasibility, acceptability

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Authors: M. Dagim Yoseph, M. K. Savage, A. D. Jolly, C. J. Ebinger

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Whakaari/White Island has been the most active New Zealand volcano in the 21st century, producing small phreatic and phreatomagmatic eruptions, which are hard to predict. The most recent eruption occurred in 2019, tragically claiming the lives of 22 individuals and causing numerous injuries. We employed shear-wave splitting analyses to investigate variations in anisotropy between 2018 and 2020, during quiescence, unrest, and the eruption. We examined spatial and temporal variations in 3499 shear-wave splitting and 2656 V_p/V_s ratio measurements. Comparing shear-wave splitting parameters from similar earthquake paths across different times indicates that the observed temporal changes are unlikely to result from variations in earthquake paths through media with spatial variability. Instead, these changes may stem from variations in anisotropy over time, likely caused by changes in crack alignment due to stress or varying fluid content.

Keywords: background seismic waves, fast orientations, seismic anisotropy, V_p/V_s ratio

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Authors: Flavia Oliveira de A. M. Cruz, Edison Tostes Faria, Paula Elaine D. Reis

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When the breast is submitted to radiation therapy (RT), the most common effects are pain, skin changes, mobility restrictions, local sensory alteration, and fatigue. These effects, if not managed properly, may reduce the quality of life of cancer patients and may lead to the treatment discontinuation. Therefore, promoting knowledge and guidelines for symptom management remain a high priority for patients and a challenge for health professionals, due to the need to handle side effects in a population with a life-threatening disease. Printed materials are important strategies for supporting educative activities since they help the individual to assimilate and understand the amount of information transmitted. Nurses' behavior can be systematized through the use of an educative manual, which may be effective in promoting information regarding the treatment, self-care and how to control the effects of RT at home. In view of the importance of guaranteeing the validity of the material before its use, the objective of this research was to validate the content and appearance of an educative manual for breast cancer patients undergoing RT. The Theory of Psychometrics was used for the validation process in this descriptive methodological research. A minimum agreement rate (AR) of 80% was considered to guarantee the validity of the material. The data were collected from October to December 2017, by means of two assessments tools, constructed in the form of a Likert scale, with five levels of understanding. These instruments addressed different aspects of the evaluation, in view of two different groups of participants; 17 experts in the theme area of the educative manual, and 12 women that received RT previously to treat breast cancer. The manual was titled 'Orientation Manual: radiation therapy in breast', and was focused on breast cancer patients attended at the Department of Oncology of the Brasília University Hospital (UNACON/HUB). The research project was submitted to the Research Ethics Committee at the School of Health Sciences of the University of Brasília (CAAE: 24592213.1.0000.0030). Only two items of the assessment tool for the experts, one related to the manual's ability to promote behavioral and attitude changes and the other related to the extent of its use for other health services, obtained AR < 80% and were reformulated based on the participants' suggestions and in the literature. All other items were considered appropriate and/or complete appropriate in the three blocks proposed for the experts: objectives - 89%, structure and form - 93%, and relevance - 93%; and good and/or very good in the five blocks of analysis proposed for patients: objectives - 100%, organization - 100%, writing style - 100%, appearance - 100%, and motivation. The appearance and content validation of the educative manual proposed were attended to. The educative manual was considered relevant and pertinent and may contribute to the understanding of the therapeutic process by breast cancer patients during RT, as well as support clinical practice through the nursing consultation.

Keywords: oncology nursing, nursing care, validation studies, educational technology

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Authors: Zahra R. Almansoor

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Background: Selective serotonin reuptake inhibitors (SSRI’s) and cognitive behavioural therapy (CBT) are the main treatment methods used for patients with obsessive compulsive disorder (OCD) under the National Institute of Health and Care Excellence (NICE) guidelines. Yet many patients are left with residual symptoms or remit, so several other therapeutic approaches have been explored. Objective: The objective was to systematically review the available literature regarding the treatment efficacy of current and potential approaches and diagnostic strategies. Method: First, studies were examined concerning diagnosis, prognosis, and influencing factors. Then, one reviewer conducted a systematic search of six databases using stringent search terms. Results of studies exploring the efficacy of treatment interventions were analysed and compared separately for adults and children. This review was limited to randomised controlled trials (RCT’s) conducted from 2016 onwards, and an improved Y-BOCS (Yale- Brown obsessive compulsive scale) score was the primary outcome measure. Results: Technology-based interventions including internet-based cognitive behavioural therapy (iCBT) were deemed as potentially effective. Discrepancy remains about the benefits of SSRI use past one year, but potential medication adjuncts include amantadine. Treatments such as association splitting and family and mindfulness strategies also have future potential. Conclusion: A range of potential therapies exist, either as treatment adjuncts to current interventions or as sole therapies. To further improve efficacy, it may be necessary to remodel the current NICE stepped-care model, especially regarding the potential use of lower intensity, cheaper treatments, including iCBT. Although many interventions show promise, further research is warranted to confirm this.

Keywords: family and group treatment, mindfulness strategies, novel treatment approaches, standard treatment, technology-based interventions

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Authors: Ehsan Javanmardemamgheisi, Javad Mehr, Jason Ali-Lavroff, Damien Holloway, Michael Davis

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During the last decades, a growing interest in faster and more efficient waterborne transportation has led to the development of high-speed vessels for both commercial and military applications. To satisfy this global demand, a wide variety of arrangements of high-speed crafts have been proposed by designers. Among them, high-speed catamarans have proven themselves to be a suitable Roll-on/Roll-off configuration for carrying passengers and cargo due to widely spaced demi hulls, a wide deck zone, and a high ratio of deadweight to displacement. To improve passenger comfort and crew workability and enhance the operability and performance of high-speed catamarans, mitigating the severity of motions and structural loads using Ride Control Systems (RCS) is essential.In this paper, a set of towing tank tests was conducted on a 2.5 m scaled model of a 112 m Incat Tasmania high-speed catamaran in irregular head seas to investigate the effect of different ride control algorithms including linear and nonlinear versions of the heave control, pitch control, and local control on motion responses and passenger comfort of the full-scale ship. The RCS included a centre bow-fitted T-Foil and two transom-mounted stern tabs. All the experiments were conducted at the Australian Maritime College (AMC) towing tank at a model speed of 2.89 m/s (37 knots full scale), a modal period of 1.5 sec (10 sec full scale) and two significant wave heights of 60 mm and 90 mm, representing full-scale wave heights of 2.7 m and 4 m, respectively. Spectral analyses were performed using Welch’s power spectral density method on the vertical motion time records of the catamaran model to calculate heave and pitch Response Amplitude Operators (RAOs). Then, noting that passenger discomfort arises from vertical accelerations and that the vertical accelerations vary at different longitudinal locations within the passenger cabin due to the variations in amplitude and relative phase of the pitch and heave motions, the vertical accelerations were calculated at three longitudinal locations (LCG, T-Foil, and stern tabs). Finally, frequency-weighted Root Mean Square (RMS) vertical accelerations were calculated to estimate Motion Sickness Dose Value (MSDV) of the ship based on ISO 2631-recommendations. It was demonstrated that in small seas, implementing a nonlinear pitch control algorithm reduces the peak pitch motions by 41%, the vertical accelerations at the forward location by 46%, and motion sickness at the forward position by around 20% which provides great potential for further improvement in passenger comfort, crew workability, and operability of high-speed catamarans.

Keywords: high-speed catamarans, ride control system, response amplitude operators, vertical accelerations, motion sickness, irregular waves, towing tank tests.

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Authors: Adel Dalilottojari, Bahman Delalat, Frances J. Harding, Michaelia P. Cockshell, Claudine S. Bonder, Nicolas H. Voelcker

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Endothelial Progenitor Cell (EPC) based therapies continue to be of interest to treat ischemic events based on their proven role to promote blood vessel formation and thus tissue re-vascularisation. Current strategies for the production of clinical-grade EPCs requires the in vitro isolation of EPCs from peripheral blood followed by cell expansion to provide sufficient quantities EPCs for cell therapy. This study aims to examine the use of different biomolecules to significantly improve the current strategy of EPC capture and expansion on collagen type I (Col I). In this study, four different biomolecules were immobilised on a surface and then investigated for their capacity to support EPC capture and proliferation. First, a cell microarray platform was fabricated by coating a glass surface with epoxy functional allyl glycidyl ether plasma polymer (AGEpp) to mediate biomolecule binding. The four candidate biomolecules tested were Col I, collagen type II (Col II), collagen type IV (Col IV) and vascular endothelial growth factor A (VEGF-A), which were arrayed on the epoxy-functionalised surface using a non-contact printer. The surrounding area between the printed biomolecules was passivated with polyethylene glycol-bisamine (A-PEG) to prevent non-specific cell attachment. EPCs were seeded onto the microarray platform and cell numbers quantified after 1 h (to determine capture) and 72 h (to determine proliferation). All of the extracellular matrix (ECM) biomolecules printed demonstrated an ability to capture EPCs within 1 h of cell seeding with Col II exhibiting the highest level of attachment when compared to the other biomolecules. Interestingly, Col IV exhibited the highest increase in EPC expansion after 72 h when compared to Col I, Col II and VEGF-A. These results provide information for significant improvement in the capture and expansion of human EPC for further application.

Keywords: biomolecules, cell microarray platform, cell therapy, endothelial progenitor cells, high throughput screening

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Authors: Muazzam A. Khan, Muhammad Wasim

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Vehicular adhoc network (VANET) Cars for network (VANET) allowing vehicles to talk to each other, which is committed to building a strong network of mobile vehicles is technical. In VANETs vehicles are equipped with special devices that can get and share info with the atmosphere and other vehicles in the network. Depending on this data security and safety of the vehicles can be enhanced. Broadcast routing is dispersion of any audio or visual medium of mass communication scattered audience distribute audio and video content, but usually using electromagnetic radiation (waves). The lack of server or fixed infrastructure media messages in VANETs plays an important role for every individual application. Broadcast Message VANETs still open research challenge and requires some effort to come to good solutions. This paper starts with a brief introduction of VANET, its applications, and the law of the message-trends in this network starts. This work provides an important and comprehensive study of reliable broadcast routing in VANET scenario.

Keywords: vehicular ad-hoc network , broadcasting, networking protocols, traffic pattern, low intensity conflict

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Authors: Celine Shi Ying Lee, Jong Jian Lee

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Background: Infectious keratitis is one of the leading causes of blindness worldwide. Prompt treatment with effective medication will control the infection early, preventing corneal scarring and visual loss. fluoroquinolones ophthalmic medication is used because of its broad-spectrum properties, potency, good intraocular penetration, and low toxicity. The study aims to evaluate the treatment outcome of corneal ulcers using Levofloxacin 1.5% ophthalmic solution (LVFX) with adjuvant oral ciprofloxacin when indicated and apply this treatment strategy in primary health care as first-line treatment. Methods: Patients with infective corneal ulcer treated in an eye center were recruited. Inclusion criteria includes Corneal infection consistent with bacterial keratitis, single or multiple small corneal ulcers. Treatment regime: LVFX hourly for the first 2 days, 2 hourly from the 3rd day, and 3 hourly on the 5th day of review. Adjuvant oral ciprofloxacin 500mg BD was administered for 5 days if there were multiple corneal ulcers or when the location of the cornea ulcer was central or paracentral. Results: 47 subjects were recruited. There were 16 (34%) males and 31 (66%) females. 40 subjects (85%) were contact lens (CL) related to corneal ulcer, and 7 subjects (15%) were non-contact lens related. 42 subjects (89%) presented with one ulcer, of which 20 of them (48%) needed adjuvant therapy. 5 subjects presented with 2 or 3 ulcers, of which 3 needed adjuvant therapy. A total of 23 subjects (49%) was given adjuvant therapy (oral ciprofloxacin 500mg BD for 5 days).21 of them (91%) were CL related. All subjects recovered fully, and the average duration of treatment was 3.7 days, with 49% of the subjects resolved on the 3rd day, 38% on the 5thday of and 13% on the 7thday. All subjects showed symptoms of relief of pain, light-sensitivity, and redness on the 3rd day with full visual recovery post-treatment. No adverse drug reactions were recorded. Conclusion: Our treatment regime demonstrated good clinical outcome as first-line treatment for corneal ulcers. A corneal ulcer is a common eye condition in Singapore, mainly due to CL wear. Pseudomonas aeruginosa is the most frequent and potentially sight-threatening pathogen involved in CL related corneal ulcer. Coagulase-negative Staphylococci, Staphylococcus aureus, and Streptococcus Pneumoniae were seen in non-CL users. All these bacteria exhibit good sensitivity rates to ciprofloxacin and levofloxacin. It is therefore logical in our study to use LVFX Eyedrops and adjuvant ciprofloxacin oral antibiotics when indicated as first line treatment for most corneal ulcers. Our study of patients, both CL related and non-CL related, have shown good clinical response and full recovery using the above treatment strategy. There was also a full restoration of visual acuity in all the patients. Eye-trained primary Healthcare practitioners can consider adopting this treatment strategy as first line treatment in patients with corneal ulcers. This is relevant during the COVID pandemic, where hospitals are overwhelmed with patients and in regions with limited access to specialist eye care. This strategy would enable early treatment with better clinical outcome.

Keywords: corneal ulcer, levofloxacin hydrate, treatment strategy, ciprofloxacin

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Authors: Anita Bajpai, Sarah Duan, Ashlee Erskine, Shehzein Khan, Raymond Kramer

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Introduction: This research focuses on exploring the beneficial effects if any, of Vitamin-D in reducing the need for supplemental oxygen among hospitalized COVID-19 patients. Two questions are investigated – Q1)Doeshaving a healthy level of baselineVitamin-D 25-OH (≥ 30ng/ml) help,andQ2) does administering Vitamin-D therapy after-the-factduring inpatient hospitalization help? Methods/Study Design: This is a comprehensive, retrospective, observational study of all inpatients at RUHS from March through December 2020 who tested positive for COVID-19 based on real-time reverse transcriptase–polymerase chain reaction assay of nasal and pharyngeal swabs and rapid assay antigen test. To address Q1, we looked atall N1=182 patients whose baseline plasma Vitamin-D 25-OH was known and who needed supplemental oxygen. Of this, a total of 121 patients had a healthy Vitamin-D level of ≥30 ng/mlwhile the remaining 61 patients had low or borderline (≤ 29.9ng/ml)level. Similarly, for Q2, we looked at a total of N2=893 patients who were given supplemental oxygen, of which713 were not given Vitamin-D and 180 were given Vitamin-D therapy. The numerical value of the maximum amount of oxygen flow rate(dependent variable) administered was recorded for each patient. The mean values and associated standard deviations for each group were calculated. Thesetwo sets of independent data served as the basis for independent, two-sample t-Test statistical analysis. To be accommodative of any reasonable benefitof Vitamin-D, ap-value of 0.10(α< 10%) was set as the cutoff point for statistical significance. Results: Given the large sample sizes, the calculated statistical power for both our studies exceeded the customary norm of 80% or better (β< 0.2). For Q1, the mean value for maximumoxygen flow rate for the group with healthybaseline level of Vitamin-D was 8.6 L/min vs.12.6L/min for those with low or borderline levels, yielding a p-value of 0.07 (p < 0.10) with the conclusion that those with a healthy level of baseline Vitamin-D needed statistically significant lower levels of supplemental oxygen. ForQ2, the mean value for a maximum oxygen flow rate for those not administered Vitamin-Dwas 12.5 L/min vs.12.8L/min for those given Vitamin-D, yielding a p-valueof 0.87 (p > 0.10). We thereforeconcludedthat there was no statistically significant difference in the use of oxygen therapy between those who were or were not administered Vitamin-D after-the-fact in the hospital. Discussion/Conclusion: We found that patients who had healthy levels of Vitamin-D at baseline needed statistically significant lower levels of supplemental oxygen. Vitamin-D is well documented, including in a recent article in the Lancet, for its anti-inflammatory role as an adjuvant in the regulation of cytokines and immune cells. Interestingly, we found no statistically significant advantage for giving Vitamin-D to hospitalized patients. It may be a case of “too little too late”. A randomized clinical trial reported in JAMA also did not find any reduction in hospital stay of patients given Vitamin-D. Such conclusions come with a caveat that any delayed marginal benefits may not have materialized promptly in the presence of a significant inflammatory condition. Since Vitamin-D is a low-cost, low-risk option, it may still be useful on an inpatient basis until more definitive findings are established.

Keywords: COVID-19, vitamin-D, supplemental oxygen, vitamin-D in primary care

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Authors: Amirah Azzeri, Fatiha H. Shabaruddin, Scott A. McDonald, Rosmawati Mohamed, Maznah Dahlui

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Objective: A scaled-up treatment cascade with direct-acting antiviral (DAA) therapy is necessary to achieve global WHO targets for hepatitis C virus (HCV) elimination in Malaysia. Recently, limited access to Sofosbuvir/Daclatasvir (SOF/DAC) is available through compulsory licensing, with future access to Sofosbuvir/Velpatasvir (SOF/VEL) expected through voluntary licensing due to recent agreements. SOF/VEL has superior clinical outcomes, particularly for cirrhotic stages, but has higher drug acquisition costs compared to SOF/DAC. It has been proposed that a stratified treatment cascade might be the most cost-efficient approach for Malaysia whereby all HCV patients are treated with SOF/DAC except for patients with cirrhosis who are treated with SOF/VEL. This study aimed to conduct a five-year budget impact analysis from the provider perspective of the proposed stratified treatment cascade for HCV treatment in Malaysia. Method: A disease progression model that was developed based on model-predicted HCV epidemiology data in Malaysia was used for the analysis, where all HCV patients in scenario A were treated with SOF/DAC for all disease stages while in scenario B, SOF/DAC was used only for non-cirrhotic patients and SOF/VEL was used for the cirrhotic patients. The model projections estimated the annual numbers of patients in care and the numbers of patients to be initiated on DAA treatment nationally. Healthcare costs associated with DAA therapy and disease stage monitoring was included to estimate the downstream cost implications. For scenario B, the estimated treatment uptake of SOF/VEL for cirrhotic patients were 25%, 50%, 75%, 100% and 100% for 2018, 2019, 2020, 2021 and 2022 respectively. Healthcare costs were estimated based on standard clinical pathways for DAA treatment described in recent guidelines. All costs were reported in US dollars (conversion rate US$1=RM4.09, the price year 2018). Scenario analysis was conducted for 5% and 10% reduction of SOF/VEL acquisition cost anticipated from the competitive market pricing of generic DAA in Malaysia. Results: The stratified treatment cascade with SOF/VEL in Scenario B was found to be cost-saving compared to Scenario A. A substantial portion of the cost reduction was due to the costs associated with DAA therapy which resulted in USD 40 thousand (year 1) to USD 443 thousand (year 5) savings annually, with cumulative savings of USD 1.1 million after 5 years. Cost reductions for disease stage monitoring were seen in year three onwards which resulted in cumulative savings of USD 1.1 thousand. Scenario analysis estimated cumulative savings of USD 1.24 to USD 1.35 million when the acquisition cost of SOF/VEL was reduced. Conclusion: A stratified treatment cascade with SOF/VEL was expected to be cost-saving and can results in a budget impact reduction in overall healthcare expenditure in Malaysia compared to treatment with SOF/DAC. The better clinical efficacy with SOF/VEL is expected to halt patients’ HCV disease progression and may reduce downstream costs of treating advanced disease stages. The findings of this analysis may be useful to inform healthcare policies for HCV treatment in Malaysia.

Keywords: Malaysia, direct acting antiviral, compulsory licensing, voluntary licensing

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