Search results for: seismic emergency

Authors: Nuno Biga

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Artificial Intelligence (AI) has the potential to transform management into several impactful ways. It allows machines to interpret information to find patterns in big data and learn from context analysis, optimize operations, make predictions sensitive to each specific situation and support data-driven decision making. The introduction of an 'artificial brain' in organization also enables learning through complex information and data provided by those who train it, namely its users. The "Assisted-BIGAMES" version of the Accident & Emergency (A&E) simulator introduces the concept of a "Virtual Assistant" (VA) sensitive to context, that provides users useful suggestions to pursue the following operations such as: a) to relocate workstations in order to shorten travelled distances and minimize the stress of those involved; b) to identify in real time existing bottleneck(s) in the operations system so that it is possible to quickly act upon them; c) to identify resources that should be polyvalent so that the system can be more efficient; d) to identify in which specific processes it may be advantageous to establish partnership with other teams; and e) to assess possible solutions based on the suggested KPIs allowing action monitoring to guide the (re)definition of future strategies. This paper is built on the BIGAMES© simulator and presents the conceptual AI model developed and demonstrated through a pilot project (BIG-AI). Each Virtual Assisted BIGAME is a management simulator developed by the author that guides operational and strategic decision making, providing users with useful information in the form of management recommendations that make it possible to predict the actual outcome of different alternative management strategic actions. The pilot project developed incorporates results from 12 editions of the BIGAME A&E that took place between 2017 and 2022 at AESE Business School, based on the compilation of data that allows establishing causal relationships between decisions taken and results obtained. The systemic analysis and interpretation of data is powered in the Assisted-BIGAMES through a computer application called "BIGAMES Virtual Assistant" (VA) that players can use during the Game. Each participant in the VA permanently asks himself about the decisions he should make during the game to win the competition. To this end, the role of the VA of each team consists in guiding the players to be more effective in their decision making, through presenting recommendations based on AI methods. It is important to note that the VA's suggestions for action can be accepted or rejected by the managers of each team, as they gain a better understanding of the issues along time, reflect on good practice and rely on their own experience, capability and knowledge to support their own decisions. Preliminary results show that the introduction of the VA provides a faster learning of the decision-making process. The facilitator designated as “Serious Game Controller” (SGC) is responsible for supporting the players with further analysis. The recommended actions by the SGC may differ or be similar to the ones previously provided by the VA, ensuring a higher degree of robustness in decision-making. Additionally, all the information should be jointly analyzed and assessed by each player, who are expected to add “Emotional Intelligence”, an essential component absent from the machine learning process.

Keywords: artificial intelligence, gamification, key performance indicators, machine learning, management simulators, serious games, virtual assistant

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Authors: Freya Harding, Anne Gatuguta, Chi Eziefula

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Introduction Research shows the quality of experiences of pregnancy, birth, and postpartum impacts the health and well-being of the mother and baby. This is recognised by the WHO in their recommendations ‘Intrapartum care for a positive childbirth experience’. The COVID-19 pandemic saw the transformation of the NHS Maternity services to prevent the transmission of COVID-19. Physical and social isolation may have affected women’s experiences of pregnancy, birth and postpartum; especially those of healthcare. Examples of such changes made to the NHS include both the reduction in volume of face-to-face consultations and restrictions to visitor time in hospitals. One notable detriment due to these changes was the absence of a partner during certain stages of birth. The aim of this study was to explore women’s experiences of pregnancy, birth, and postnatal period during the COVID-19 pandemic in the UK. Methods We collected qualitative data from women who had given birth during the COVID-19 pandemic. In-depth, semi-structured interviews were conducted with twelve participants recruited from mother and baby groups in Southeast England. Data were audio-recorded, transcribed verbatim, and analysed thematically using both inductive and deductive approaches. Ethics permission was granted from Brighton and Sussex Medical School (ER/BSMS9A83/1). Results Interviews were conducted with 12 women who gave birth between May 2020 and February 2021. Ages of the participants ranged between 28 and 42 years, most of which were white British, with one being Asian British. All participants were heterosexual and either married or co-habiting with their partner. Five participants worked in the NHS, and all participants had professional occupations. Women felt inadequately supported both socially and medically. An appropriate sense of control over their own birthing experience was lacking. Safety mechanisms, such as in-person visits from the midwife, had no suitable alternatives in place. Serious health issues were able to “slip through the net.” Mental health conditions in some of those interviewed worsened or developed. Similarly, reduced support from partners during birth and during the immediate postpartum period at the hospital, coupled with reduced ward staffing, resulted in some traumatic experiences; particularly for women who had undergone caesarean section. However, some unexpected positive effects were reported; one example being that partners were able to spend more time with their baby due to furlough schemes and working from home. Similarly, emergency care was not felt to have been compromised. Overall, six themes emerged: (1) Self-reported traumatic experiences, (2) Challenges of caring for a baby with reduced medical and social support, (3) Unexpected benefits to the parenting experience, (4) The effects of a sudden change in medical management (5) Poor communication from healthcare professionals (6) Social change; with subthemes of support accessing medical care, the workplace, family and friends, and antenatal & baby groups. Conclusions The results indicate that the healthcare system was unable to adequately deliver maternity care to facilitate positive pregnancy, birth, and postnatal experiences during the heights of the pandemic. The poor quality of such experiences has been linked an increased risk of long-term health complications in both the mother and child.

Keywords: pregnancy, birth, postpartum, postnatal, COVID-19, maternity, social support, qualitative, pandemic

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Authors: Antonella Falanga, Armando Cartenì

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Today, an unprecedented amount of data coming from several sources, including mobile devices, sensors, tracking systems, and online platforms, characterizes our lives. The term “big data” not only refers to the quantity of data but also to the variety and speed of data generation. These data hold valuable insights that, when extracted and analyzed, facilitate informed decision-making. The 4Vs of big data - velocity, volume, variety, and value - highlight essential aspects, showcasing the rapid generation, vast quantities, diverse sources, and potential value addition of these kinds of data. This surge of information has revolutionized many sectors, such as business for improving decision-making processes, healthcare for clinical record analysis and medical research, education for enhancing teaching methodologies, agriculture for optimizing crop management, finance for risk assessment and fraud detection, media and entertainment for personalized content recommendations, emergency for a real-time response during crisis/events, and also mobility for the urban planning and for the design/management of public and private transport services. Big data's pervasive impact enhances societal aspects, elevating the quality of life, service efficiency, and problem-solving capacities. However, during this transformative era, new challenges arise, including data quality, privacy, data security, cybersecurity, interoperability, the need for advanced infrastructures, and staff training. Within the transportation sector (the one investigated in this research), applications span planning, designing, and managing systems and mobility services. Among the most common big data applications within the transport sector are, for example, real-time traffic monitoring, bus/freight vehicle route optimization, vehicle maintenance, road safety and all the autonomous and connected vehicles applications. Benefits include a reduction in travel times, road accidents and pollutant emissions. Within these issues, the proper transport demand estimation is crucial for sustainable transportation planning. Evaluating the impact of sustainable mobility policies starts with a quantitative analysis of travel demand. Achieving transportation decarbonization goals hinges on precise estimations of demand for individual transport modes. Emerging technologies, offering substantial big data at lower costs than traditional methods, play a pivotal role in this context. Starting from these considerations, this study explores the usefulness impact of big data within transport demand estimation. This research focuses on leveraging (big) data collected during the COVID-19 pandemic to estimate the evolution of the mobility demand in Italy. Estimation results reveal in the post-COVID-19 era, more than 96 million national daily trips, about 2.6 trips per capita, with a mobile population of more than 37.6 million Italian travelers per day. Overall, this research allows us to conclude that big data better enhances rational decision-making for mobility demand estimation, which is imperative for adeptly planning and allocating investments in transportation infrastructures and services.

Keywords: big data, cloud computing, decision-making, mobility demand, transportation

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Authors: Nuno Biga

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The integration of serious games with gamification in management education and training has gained significant importance in recent years as innovative strategies are sought to improve target audience engagement and learning outcomes. This research builds on the author's previous work in this field and presents a case study that evaluates the ex-post impact of a sample of applications of the BIGAMES management simulator in the training of top managers from various hospital institutions. The methodology includes evaluating the reaction of participants after each edition of BIGAMES Accident & Emergency (A&E) carried out over the last 3 years, as well as monitoring the career path of a significant sample of participants and their feedback more than a year after their experience with this simulator. Control groups will be set up, according to the type of role their members held when they took part in the BIGAMES A&E simulator: Administrators, Clinical Directors and Nursing Directors. Former participants are invited to answer a questionnaire structured for this purpose, where they are asked, among other questions, about the importance and impact that the BIGAMES A&E simulator has had on their professional activity. The research methodology also includes an exhaustive literature review, focusing on empirical studies in the field of education and training in management and business that investigate the effectiveness of gamification and serious games in improving learning, team collaboration, critical thinking, problem-solving skills and overall performance, with a focus on training contexts in the health sector. The results of the research carried out show that gamification and serious games that simulate real scenarios, such as Business Interactive Games - BIGAMES©, can significantly increase the motivation and commitment of participants, stimulating the development of transversal skills, the mobilization of group synergies and the acquisition and retention of knowledge through interactive user-centred scenarios. Individuals who participate in game-based learning series show a higher level of commitment to learning because they find these teaching methods more enjoyable and interactive. This research study aims to demonstrate that, as executive education and training programs develop to meet the current needs of managers, gamification and serious games stand out as effective means of bridging the gap between traditional teaching methods and modern educational and training requirements. To this end, this research evaluates the medium/long-term effects of gamified learning on the professional performance of participants in the BIGAMES simulator applied to healthcare. Based on the conclusions of the evaluation of the effectiveness of training using gamification and taking into account the results of the opinion poll of former A&E participants, this research study proposes an integrated approach for the transversal application of the A&E Serious Game in various educational contexts, covering top management (traditionally the target audience of BIGAMES A&E), middle and operational management in healthcare institutions (functional area heads and professionals with career development potential), as well as higher education in medicine and nursing courses. The integrated solution called “BIGAMES A&E plus”, developed as part of this research, includes the digitalization of key processes and the incorporation of AI.

Keywords: artificial intelligence (AI), executive training, gamification, higher education, management simulators, serious games (SG), training effectiveness

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Authors: Anastasia Constantinou, Stephen Morris

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Background: The adoption of synchronous and asynchronous telemedicine modalities for primary care consultations has exponentially increased since the COVID-19 pandemic. However, there is limited understanding of how virtual consultations influence healthcare resource utilization and other quality measures including safety, timeliness, efficiency, patient and provider satisfaction, cost-effectiveness and environmental impact. Aim: Quantify the rate of follow-up visits, emergency department visits, hospitalizations, request for investigations and prescriptions and comment on the effect on different quality measures associated with different telemedicine modalities used for primary care services and primary care referrals to secondary care Design and setting: Systematic review in primary care Methods: A systematic search was carried out across three databases (Medline, PubMed and Scopus) between August and November 2023, using terms related to telemedicine, general practice, electronic referrals, follow-up, use and efficiency and supported by citation searching. This was followed by screening according to pre-defined criteria, data extraction and critical appraisal. Narrative synthesis and metanalysis of quantitative data was used to summarize findings. Results: The search identified 2230 studies; 50 studies are included in this review. There was a prevalence of asynchronous modalities in both primary care services (68%) and referrals from primary care to secondary care (83%), and most of the study participants were females (63.3%), with mean age of 48.2. The average follow-up for virtual consultations in primary care was 28.4% (eVisits: 36.8%, secure messages 18.7%, videoconference 23.5%) with no significant difference between them or F2F consultations. There was an average annual reduction of primary care visits by 0.09/patient, an increase in telephone visits by 0.20/patient, an increase in ED encounters by 0.011/patient, an increase in hospitalizations by 0.02/patient and an increase in out of hours visits by 0.019/patient. Laboratory testing was requested on average for 10.9% of telemedicine patients, imaging or procedures for 5.6% and prescriptions for 58.7% of patients. When looking at referrals to secondary care, on average 36.7% of virtual referrals required follow-up visit, with the average rate of follow-up for electronic referrals being higher than for videoconferencing (39.2% vs 23%, p=0.167). Technical failures were reported on average for 1.4% of virtual consultations to primary care. When using carbon footprint estimates, we calculate that the use of telemedicine in primary care services can potentially provide a net decrease in carbon footprint by 0.592kgCO2/patient/year. When follow-up rates are taken into account, we estimate that virtual consultations reduce carbon footprint for primary care services by 2.3 times, and for secondary care referrals by 2.2 times. No major concerns regarding quality of care, or patient satisfaction were identified. 5/7 studies that addressed cost-effectiveness, reported increased savings. Conclusions: Telemedicine provides quality, cost-effective, and environmentally sustainable care for patients in primary care with inconclusive evidence regarding the rates of subsequent healthcare utilization. The evidence is limited by heterogeneous, small-scale studies and lack of prospective comparative studies. Further research to identify the most appropriate telemedicine modality for different patient populations, clinical presentations, service provision (e.g. used to follow-up patients instead of initial diagnosis) as well as further education for patients and providers alike on how to make best use of this service is expected to improve outcomes and influence practice.

Keywords: telemedicine, healthcare utilisation, digital interventions, environmental impact, sustainable healthcare

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Authors: Jan C. Droste, Justine Burns, Nithin Narayan

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Introduction: Life-threatening detrimental effects of inappropriate adrenaline (epinephrine) administration, e.g., by giving the wrong dose, in the context of anaphylaxis management is well documented in the medical literature. Half of the fatal anaphylactic reactions in the UK are iatrogenic, and the median time to a cardio-respiratory arrest can be as short as 5 minutes. It is therefore imperative that hospital doctors of all grades have active and accurate knowledge of the correct route, site, and dosage of administration of adrenaline. Given this time constraint and the potential fatal outcome with inappropriate management of anaphylaxis, it is alarming that surveys over the last 15 years have repeatedly shown only a minority of doctors to have accurate knowledge of adrenaline administration as recommended by the UK Resuscitation Council guidelines (2008 updated 2012). This comparison of survey results of the medical workforce over several years in a small NHS District General Hospital was conducted in order to establish the effect of the employment of multiple educational methods regarding adrenaline administration in anaphylaxis in adults. Methods: Between 2010 and 2017, several education methods and tools were used to repeatedly inform the medical workforce (doctors and advanced clinical practitioners) in a single district general hospital regarding the treatment of anaphylaxis in adults. Whilst the senior staff remained largely the same cohort, junior staff had changed fully in every survey. Examples included: (i) Formal teaching -in Grand Rounds; during the junior doctors’ induction process; advanced life support courses (ii) In-situ simulation training performed by the clinical skills simulation team –several ad hoc sessions and one 3-day event in 2017 visiting 16 separate clinical areas performing an acute anaphylaxis scenario using actors- around 100 individuals from multi-disciplinary teams were involved (iii) Hospital-wide distribution of the simulation event via the Trust’s Simulation Newsletter (iv) Laminated algorithms were attached to the 'crash trolleys' (v) A short email 'alert' was sent to all medical staff 3 weeks prior to the survey detailing the emergency treatment of anaphylaxis (vi) In addition, the performance of the surveys themselves represented a teaching opportunity when gaps in knowledge could be addressed. Face to face surveys were carried out in 2010 ('pre-intervention), 2015, and 2017, in the latter two occasions including advanced clinical practitioners (ACP). All surveys consisted of convenience samples. If verbal consent to conduct the survey was obtained, the medical practitioners' answers were recorded immediately on a data collection sheet. Results: There was a sustained improvement in the knowledge of the medical workforce from 2010 to 2017: Answers improved regarding correct drug by 11% (84%, 95%, and 95%); the correct route by 20% (76%, 90%, and 96%); correct site by 40% (43%, 83%, and 83%) and the correct dose by 45% (27%, 54%, and 72%). Overall, knowledge of all components -correct drug, route, site, and dose-improved from 13% in 2010 to 62% in 2017. Conclusion: This survey comparison shows knowledge of the medical workforce regarding adrenaline administration for treatment of anaphylaxis in adults can be considerably improved by employing a variety of educational methods.

Keywords: adrenaline, anaphylaxis, epinephrine, medical education, patient safety

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Authors: Adiba Matin, Daniel Cabrera, Javiera Bellolio, Jasmine Stewart, Dana Gerberi (librarian), Nathan Cummins, Fernanda Bellolio

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OBJECTIVES: Artificial intelligence (AI) tools are becoming more prevalent in healthcare settings, particularly for diagnostic and therapeutic recommendations, with an expected surge in the incoming years. The bedside use of this technology for clinicians opens the possibility of disagreements between the recommendations from AI algorithms and clinicians’ judgment. There is a paucity in the literature analyzing nature and possible outcomes of these potential conflicts, particularly related to ethical considerations. The goal of this scoping review is to identify, analyze and classify current themes and potential strategies addressing ethical conflicts originating from the conflict between AI and human recommendations. METHODS: A protocol was written prior to the initiation of the study. Relevant literature was searched by a medical librarian for the terms of artificial intelligence, healthcare and liability, ethics, or conflict. Search was run in 2021 in Ovid Cochrane Central Register of Controlled Trials, Embase, Medline, IEEE Xplore, Scopus, and Web of Science Core Collection. Articles describing the role of AI in healthcare that mentioned conflict between humans and AI were included in the primary search. Two investigators working independently and in duplicate screened titles and abstracts and reviewed full-text of potentially eligible studies. Data was abstracted into tables and reported by themes. We followed methodological guidelines for Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR). RESULTS: Of 6846 titles and abstracts, 225 full texts were selected, and 48 articles included in this review. 23 articles were included as original research and review papers. 25 were included as editorials and commentaries with similar themes. There was a lack of consensus in the included articles on who would be held liable for mistakes incurred by following AI recommendations. It appears that there is a dichotomy of the perceived ethical consequences depending on if the negative outcome is a result of a human versus AI conflict or secondary to a deviation from standard of care. Themes identified included transparency versus opacity of recommendations, data bias, liability of outcomes, regulatory framework, and the overall scope of artificial intelligence in healthcare. A relevant issue identified was the concern by clinicians of the “black box” nature of these recommendations and the ability to judge appropriateness of AI guidance. CONCLUSION AI clinical tools are being rapidly developed and adopted, and the use of this technology will create conflicts between AI algorithms and healthcare workers with various outcomes. In turn, these conflicts may have legal, and ethical considerations. There is limited consensus about the focus of ethical and liability for outcomes originated from disagreements. This scoping review identified the importance of framing the problem in terms of conflict between standard of care or not, and informed by the themes of transparency/opacity, data bias, legal liability, absent regulatory frameworks and understanding of the technology. Finally, limited recommendations to mitigate ethical conflicts between AI and humans have been identified. Further work is necessary in this field.

Keywords: ethics, artificial intelligence, emergency medicine, review

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Authors: Festus Okotie

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Nigeria is the giant of Africa with great and diverse transport potentials yet to be fully tapped into and explored.it is the most populated nation in Africa with nearly 200 million people, the sixth largest oil producer overall and largest oil producer in Africa with proven oil and gas reserves of 37 billion barrels and 192 trillion cubic feet, over 300 square kilometers of arable land and significant deposits of largely untapped minerals. A world bank indicator which measures trading across border ranked Nigeria at 183 out of 185 countries in 2017 and although different governments in the past made efforts through different interventions such as 2007 ports reforms led by Ngozi Okonjo-Iweala, a former minister of Finance and world bank managing director also attempted to resolve some of the challenges such as infrastructure shortcomings, policy and regulatory inconsistencies, overlapping functions and duplicated roles among the different MDA’S. It is one of the fundamental structures smart nations and cities are using to improve the living conditions of its citizens and achieving sustainability. Examples of some of its benefits includes tracking high pedestrian areas, traffic patterns, railway stations, planning and scheduling bus times, it also enhances interoperability, creates alerts of transport situation and has swift capacity to share information among the different platforms and transport modes. It also offers a comprehensive approach to risk management, putting emergency procedures and response capabilities in place, identifying dangers, including vandalism or violence, fare evasion, and medical emergencies. The Nigerian transport system is urgently in need of modern infrastructures such as ITS. Smart city transport technology helps cities to function productively, while improving services for businesses and lives of is citizens. This technology has the ability to improve travel across traditional modes of transport, such as cars and buses, with immediate benefits for city dwellers and also helps in managing transport systems such as dangerous weather conditions, heavy traffic, and unsafe speeds which can result in accidents and loss of lives. Intelligent transportation systems help in traffic control such as permitting traffic lights to react to changing traffic patterns, instead of working on a fixed schedule in traffic. Intelligent transportation systems is very important in Nigeria’s transportation sector and so would require trained personnel to drive its efficiency to greater height because the purpose of introducing it is to add value and at the same time reduce motor vehicle miles and traffic congestion which is a major challenge around Tin can island and Apapa Port, a major transportation hub in Nigeria. The need for the federal government, state governments, houses of assembly to organise a national transportation workshop to begin the process of addressing the challenges in our nation’s transport sector is highly expedient and so bills that will facilitate the implementation of policies to promote intelligent transportation systems needs to be sponsored because of its potentials to create thousands of jobs for our citizens, provide farmers with better access to cities and a better living condition for Nigerians.

Keywords: intelligent, transport, system, Nigeria

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Authors: Grace Scaplehorn, Muhammad Adeel Akhtar, Jane Gibson

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Background: Canoe Slalom entails the skilful navigation of a carbon composite canoe or kayak through a series of 18-25 hanging gates, strategically positioned along the course, either upstream or downstream, amidst currents of whitewater rapids in natural and man-made river settings. Athletes compete individually in timed trials, competing for the fastest course time, typically around 80 to 120 seconds. In the new discipline of Kayak Cross, descents of the course are initiated by groups of four athletes freefalling simultaneously from a starting platform situated 3m above the river. Kayak Cross athletes, in contrast to Canoe Slalom, can make physical contact with suspended gates without incurring time penalties and are required to perform a kayak roll half way down the course. The Canoe Slalom World Championships were held at Lee Valley Whitewater Centre, London, from 19th to 24th September 2023. The event comprised 299 international athletes competing for 10 World Championship titles in Canoe/Kayak Slalom events (Olympic Debut Munich 1972), and the new Kayak Cross discipline (Olympic Debut Paris 2024). The inaugural appearance of Kayak Cross at the World Championships occurred in 2017, in Pau, France. There is limited literature surrounding Kayak Cross and the incidence of athlete injuries compared to traditional Canoe Slalom, hence it was felt important to undertake this review to address the perception that the event is dangerous. Aim: The study aimed to quantify and collate data collected from athletes presenting to the event medical centre. Methods: Athletes’ details were collected at initial assessments from the start of the practice period (16th–18th September) and throughout the event. Demographics such as age, sex and nationality were recorded along with presenting complaints, treatment, medication administered and outcome. Specifically, injuries were then sub-classified into body regions. The data does not include athletes who sought medical attention from their own governing body’s medical team. Results: During the 8-day period, there were 11 individual presentations to the medical centre, 3.7% of the athlete population (n=299). The mean age was 23.9 years (n=7), 6 were male (n=10). The most common presentation was minor injury (n=9), with 6 being musculoskeletal and 3 comprising skin damage, followed by insect sting/allergy (n=1) and pain relief requests (n=1). Five presentations were event-related, all being musculoskeletal injuries; 2 shoulder/arm, 1 head/neck, 1 hand/wrist and 1 other (data was not recorded). Of these injuries, the only intervention was 2 cases of 400mg Ibuprofen, which was given to both shoulder/arm injuries. Four of the 11 presentations were pre-existing injuries, which had been exacerbated due to increased intensity of practice. Two patients were advised to return for review, with 100% compliance. There were no unplanned re-presentations, and no emergency transfers to secondary care. Both the Kayak Cross and Canoe Slalom competitions resulted in 1 new event-related athlete presentation each. Conclusion: The event resulted in a negligible incidence of presentations at the medical centre, for both Kayak Cross and Canoe Slalom. This data holds significance in informing risk assessments and medical protocols necessary for the organisation of canoe slalom events.

Keywords: canoe slalom, kayak cross, athlete injuries, event injuries

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Authors: Jelena Maletkovic

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Background: Endogenous Cushing’s syndrome is a rare disease, but iatrogenic or drug related Cushing syndrome from glucocorticoid products is commonly seen in clinical practice. With high dose and long term use of glucocorticoids, patients can develop isolated hypothalamic-pituitary-adrenal (HPA) suppression, or HPA axis suppression can be accompanied by overt iatrogenic Cushing’s syndrome. This is a rare case where severe Cushing’s syndrome developed from an unknown medication and was followed by severe and prolonged adrenal insufficiency and multiple potentially fatal complications. Case: This is a 37-year-old woman who is presented to Emergency Room (ER) with shortness of breath and chest pain. Four months prior to this presentation the patient was a generally healthy woman who was looking for improvement in her appearance and visited local Rejuvenation Clinic. After initial consultation with a nurse, she was contacted by a physician over the phone and was advised to start taking multiple injectable medications that will arrive by mail. Medications without any labels on bottles were delivered and the patient started daily intramuscular injections. Over the next two months, she noticed rounding of her face and swelling around her eyes. She gained 20 pounds, mostly abdominal fat and became extremely fatigued. Her muscles on legs were visibly decreasing in size and she felt significant muscle weakness. Unexplained bruising occurred. She started growing hair on face and developed secondary amenorrhea. New severe back pain started. She developed depression and headaches. Finally, over a few days, a number of red-purple stretch marks that were sensitive and painful appeared over her abdomen, upper part of arms and legs. She then became suspicious that these dramatic symptoms are caused by injectable medication and she discontinued injections. Over the next few days she presented to ER with low blood pressure and oxygen saturation of 75%. Studies revealed extensive pneumonia as well as multiple pulmonary emboli. Her white blood count was elevated with 32 000 and she also had acute kidney failure on admission. She was treated for sepsis and was also given stress dose steroids. Steroids were tapered over 48 hours and discontinued. After being discharged to home, on her first visit to endocrinology clinic she had undetectable ACTH of < 2pg/mL and undetectable 8am cortisol of < 0.2mcg/dL. She did not respond to an intramuscular injection of cosyntropin 250mcg and her repeated cortisol after 60 minutes was only 1mcg/dL. The patient was diagnosed with adrenal insufficiency and was started on hydrocortisone 20mg+10mg. It took close to 2 years of slow tapering for recovery of this patient’s HPA axis and resolve all the sequelae from Cushing’s syndrome. Conclusion: Misuse and abuse of glucocorticoids have been present almost since these medications were discovered. This is a rare case where not only severe Cushing’s syndrome in full clinical picture developed but also the patient suffered multiple potentially fatal complications and prolonged adrenal insufficiency. Visits to herbal, rejuvenation, esthetic, and similar clinics are becoming more and more popular and physicians need to be aware of possible non-benign nature of medications that their patients may be using.

Keywords: iatrogenic, Cushing's syndrome, adrenal crisis, steroid abuse

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Authors: Sonia Butalia, Huong Luu, Alexis Guigue, Karen J. B. Martins, Khanh Vu, Scott W. Klarenbach

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Obesity is associated with significant personal impacts on health and has a substantial economic burden on payers due to increased healthcare use. A contemporary estimate of the healthcare costs associated with obesity at the population level are lacking. This evidence may provide further rationale for weight management strategies. Methods: Adults who underwent a medical procedure between 2012 and 2019 in Alberta, Canada were categorized into the investigational cohort (had body mass index [BMI]-defined class 2 or 3 obesity based on a procedure-associated code) and the control cohort (did not have the BMI procedure-associated code); those who had bariatric surgery were excluded. Characteristics were presented and healthcare costs ($CDN) determined over a 1-year observation period (2019/2020). Logistic regression and a generalized linear model with log link and gamma distribution were used to assess total healthcare costs (comprised of hospitalizations, emergency department visits, ambulatory care visits, physician visits, and outpatient prescription drugs); potential confounders included age, sex, region of residence, and whether the medical procedure was performed within 6-months before the observation period in the partial adjustment, and also the type of procedure performed, socioeconomic status, Charlson Comorbidity Index (CCI), and seven obesity-related health conditions in the full adjustment. Cost ratios and estimated cost differences with 95% confidence intervals (CI) were reported; incremental cost differences within the adjusted models represent referent cases. Results: The investigational cohort (n=220,190) was older (mean age: 53 standard deviation [SD]±17 vs 50 SD±17 years), had more females (71% vs 57%), lived in rural areas to a greater extent (20% vs 14%), experienced a higher overall burden of disease (CCI: 0.6 SD±1.3 vs 0.3 SD±0.9), and were less socioeconomically well-off (material/social deprivation was lower [14%/14%] in the most well-off quintile vs 20%/19%) compared with controls (n=1,955,548). Unadjusted total healthcare costs were estimated to be 1.77-times (95% CI: 1.76, 1.78) higher in the investigational versus control cohort; each healthcare resource contributed to the higher cost ratio. After adjusting for potential confounders, the total healthcare cost ratio decreased, but remained higher in the investigational versus control cohort (partial adjustment: 1.57 [95% CI: 1.57, 1.58]; full adjustment: 1.21 [95% CI: 1.20, 1.21]); each healthcare resource contributed to the higher cost ratio. Among urban-dwelling 50-year old females who previously had non-operative procedures, no procedures performed within 6-months before the observation period, a social deprivation index score of 3, a CCI score of 0.32, and no history of select obesity-related health conditions, the predicted cost difference between those living with and without obesity was $386 (95% CI: $376, $397). Conclusions: If these findings hold for the Canadian population, one would expect an estimated additional $3.0 billion per year in healthcare costs nationally related to BMI-defined obesity (based on an adult obesity rate of 26% and an estimated annual incremental cost of $386 [21%]); incremental costs are higher when obesity-related health conditions are not adjusted for. Results of this study provide additional rationale for investment in interventions that are effective in preventing and treating obesity and its complications.

Keywords: administrative data, body mass index-defined obesity, healthcare cost, real world evidence

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Authors: Aishwarya Venkat, Anastasia Marshak, Ryan B. Simpson, Elena N. Naumova

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Livestock ownership is simultaneously linked to improved nutritional status through increased availability of animal-source protein, and increased risk of enteric infections through higher exposure to contaminated water sources. Agrarian and agro-pastoral households, especially those with cattle, goats, and sheep, are highly dependent on seasonally various environmental conditions, which directly impact nutrition and health. This study explores global spatiotemporally explicit evidence regarding the relationship between livestock ownership, enteric infections, and malnutrition. Seasonal and cyclical fluctuations, as well as mediating effects, are further examined to elucidate health and nutrition outcomes of individual and communal livestock ownership. The US Agency for International Development’s Demographic and Health Surveys (DHS) and the United Nations International Children's Emergency Fund’s Multi-Indicator Cluster Surveys (MICS) provide valuable sources of household-level information on anthropometry, asset ownership, and disease outcomes. These data are especially important in data-sparse regions, where surveys may only be conducted in the aftermath of emergencies. Child-level disease history, anthropometry, and household-level asset ownership information have been collected since DHS-V (2003-present) and MICS-III (2005-present). This analysis combines over 15 years of survey data from DHS and MICS to study 2,466,257 children under age five from 82 countries. Subnational (administrative level 1) measures of diarrhea prevalence, mean livestock ownership by type, mean and median anthropometric measures (height for age, weight for age, and weight for height) were investigated. Effects of several environmental, market, community, and household-level determinants were studied. Such covariates included precipitation, temperature, vegetation, the market price of staple cereals and animal source proteins, conflict events, livelihood zones, wealth indices and access to water, sanitation, hygiene, and public health services. Children aged 0 – 6 months, 6 months – 2 years, and 2 – 5 years of age were compared separately. All observations were standardized to interview day of year, and administrative units were harmonized for consistent comparisons over time. Geographically weighted regressions were constructed for each outcome and subnational unit. Preliminary results demonstrate the importance of accounting for seasonality in concurrent assessments of malnutrition and enteric infections. Household assets, including livestock, often determine the intensity of these outcomes. In many regions, livestock ownership affects seasonal fluxes in malnutrition and enteric infections, which are also directly affected by environmental and local factors. Regression analysis demonstrates the spatiotemporal variability in nutrition outcomes due to a variety of causal factors. This analysis presents a synthesis of evidence from global survey data on the interrelationship between enteric infections, malnutrition, and livestock. These results provide a starting point for locally appropriate interventions designed to address this nexus in a timely manner and simultaneously improve health, nutrition, and livelihoods.

Keywords: diarrhea, enteric infections, households, livestock, malnutrition, seasonality

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Authors: Jose A. Alvarez Aldegunde, Adrian Fernandez Sanchez, Matthew D. Menden, Bernardo Vila Rodriguez

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Up to five statistical pre-processings have been carried out considering the pollutant records of the stations present in Cartagena de Indias, Colombia, also taking into account the childhood asthma incidence surveys conducted in hospitals in the city by the Health Ministry of Colombia for this study. These pre-processings have consisted of different techniques such as the determination of the quality of data collection, determination of the quality of the registration network, identification and debugging of errors in data collection, completion of missing data and purified data, as well as the improvement of the time scale of records. The characterization of the quality of the data has been conducted by means of density analysis of the pollutant registration stations using ArcGis Software and through mass balance techniques, making it possible to determine inconsistencies in the records relating the registration data between stations following the linear regression. The results obtained in this process have highlighted the positive quality in the pollutant registration process. Consequently, debugging of errors has allowed us to identify certain data as statistically non-significant in the incidence and series of contamination. This data, together with certain missing records in the series recorded by the measuring stations, have been completed by statistical imputation equations. Following the application of these prior processes, the basic series of incidence data for respiratory disease and pollutant records have allowed the characterization of the influence of pollutants on respiratory diseases such as, for example, childhood asthma. This characterization has been carried out using statistical correlation methods, including visual correlation, simple linear regression correlation and spectral analysis with PAST Software which identifies maximum periodicity cycles and minimums under the formula of the Lomb periodgram. In relation to part of the results obtained, up to eleven maximums and minimums considered contemporary between the incidence records and the particles have been identified taking into account the visual comparison. The spectral analyses that have been performed on the incidence and the PM2.5 have returned a series of similar maximum periods in both registers, which are at a maximum during a period of one year and another every 25 days (0.9 and 0.07 years). The bivariate analysis has managed to characterize the variable "Daily Vehicular Flow" in the ninth position of importance of a total of 55 variables. However, the statistical correlation has not obtained a favorable result, having obtained a low value of the R2 coefficient. The series of analyses conducted has demonstrated the importance of the influence of pollutants such as PM2.5 in the development of childhood asthma in Cartagena. The quantification of the influence of the variables has been able to determine that there is a 56% probability of dependence between PM2.5 and childhood respiratory asthma in Cartagena. Considering this justification, the study could be completed through the application of the BenMap Software, throwing a series of spatial results of interpolated values of the pollutant contamination records that exceeded the established legal limits (represented by homogeneous units up to the neighborhood level) and results of the impact on the exacerbation of pediatric asthma. As a final result, an economic estimate (in Colombian Pesos) of the monthly and individual savings derived from the percentage reduction of the influence of pollutants in relation to visits to the Hospital Emergency Room due to asthma exacerbation in pediatric patients has been granted.

Keywords: Asthma Incidence, BenMap, PM2.5, Statistical Analysis

Procedia PDF Downloads 116

Authors: Chenyi Ma

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Background: The second costliest hurricane in U.S. history, Sandy landed in southern New Jersey on October 29, 2012, and struck the entire state with high winds and torrential rains. The disaster killed more than 100 people, left more than 8.5 million households without power, and damaged or destroyed more than 200,000 homes across the state. Immediately after the disaster, public policy support was provided in nine coastal counties that constituted 98% of the major and severely damaged housing units in NJ overall. The programs include Individuals and Households Assistance Program, Small Business Loan Program, National Flood Insurance Program, and the Federal Emergency Management Administration (FEMA) Public Assistance Grant Program. In the most severely affected counties, additional funding was provided through Community Development Block Grant: Reconstruction, Rehabilitation, Elevation, and Mitigation Program, and Homeowner Resettlement Program. How these policies individually and as a whole impacted housing recovery across communities with different socioeconomic and demographic profiles has not yet been studied, particularly in relation to damage levels. The concept of community social vulnerability has been widely used to explain many aspects of natural disasters. Nevertheless, how communities are vulnerable has been less fully examined. Community resilience has been conceptualized as a protective factor against negative impacts from disasters, however, how community resilience buffers the effects of vulnerability is not yet known. Because housing recovery is a dynamic social and economic process that varies according to context, this study examined the path from community vulnerability and resilience to housing recovery looking at both community characteristics and policy interventions. Sample/Methods: This retrospective longitudinal case study compared a literature-identified set of pre-disaster community characteristics, the effects of multiple public policy programs, and a set of time-variant community resilience indicators to changes in housing stock (operationally defined by percent of building permits to total occupied housing units/households) between 2010 and 2014, two years before and after Hurricane Sandy. The sample consisted of 51 municipalities in the nine counties in which between 4% and 58% of housing units suffered either major or severe damage. Structural equation modeling (SEM) was used to determine the path from vulnerability to the housing recovery, via multiple public programs, separately and as a whole, and via the community resilience indicators. The spatial analytical tool ArcGIS 10.2 was used to show the spatial relations between housing recovery patterns and community vulnerability and resilience. Findings: Holding damage levels constant, communities with higher proportions of Hispanic households had significantly lower levels of housing recovery while communities with households with an adult >age 65 had significantly higher levels of the housing recovery. The contrast was partly due to the different levels of total public support the two types of the community received. Further, while the public policy programs individually mediated the negative associations between African American and female-headed households and housing recovery, communities with larger proportions of African American, female-headed and Hispanic households were “vulnerable” to lower levels of housing recovery because they lacked sufficient public program support. Even so, higher employment rates and incomes buffered vulnerability to lower housing recovery. Because housing is the "wobbly pillar" of the welfare state, the housing needs of these particular groups should be more fully addressed by disaster policy.

Keywords: community social vulnerability, community resilience, hurricane, public policy

Procedia PDF Downloads 372

Authors: Peregrine James Dalziel, Philip Vu Tran

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Objective / Introduction: Demand for radiology services from Emergency Departments (ED) continues to increase with greater demands placed on radiology staff providing reports for the management of complex cases. Queuing theory indicates that wide variability of process time with the random nature of request arrival increases the probability of significant queues. This can lead to delays in the time-to-availability of radiology reports (TTA-RR) and potentially impaired ED patient flow. In addition, greater “cognitive workload” of greater volume may lead to reduced productivity and increased errors. We sought to quantify the potential ED flow improvements obtainable from increased radiology providers serving 3 public hospitals in Melbourne Australia. We sought to assess the potential productivity gains, quality improvement and the cost-effectiveness of increased labor inputs. Methods & Materials: The Western Health Medical Imaging Department moved from single resident coverage on weekend days 8:30 am-10:30 pm to a limited period of 2 resident coverage 1 pm-6 pm on both weekend days. The TTA-RR for weekend CT scans was calculated from the PACs database for the 8 month period symmetrically around the date of staffing change. A multivariate linear regression model was developed to isolate the improvement in TTA-RR, between the two 4-months periods. Daily and hourly scan volume at the time of each CT scan was calculated to assess the impact of varying department workload. To assess any improvement in report quality/errors a random sample of 200 studies was assessed to compare the average number of clinically significant over-read addendums to reports between the 2 periods. Cost-effectiveness was assessed by comparing the marginal cost of additional staffing against a conservative estimate of the economic benefit of improved ED patient throughput using the Australian national insurance rebate for private ED attendance as a revenue proxy. Results: The primary resident on call and the type of scan accounted for most of the explained variability in time to report availability (R2=0.29). Increasing daily volume and hourly volume was associated with increased TTA-RR (1.5m (p<0.01) and 4.8m (p<0.01) respectively per additional scan ordered within each time frame. Reports were available 25.9 minutes sooner on average in the 4 months post-implementation of double coverage (p<0.01) with additional 23.6 minutes improvement when 2 residents were on-site concomitantly (p<0.01). The aggregate average improvement in TTA-RR was 24.8 hours per weekend day This represents the increased decision-making time available to ED physicians and potential improvement in ED bed utilisation. 5% of reports from the intervention period contained clinically significant addendums vs 7% in the single resident period but this was not statistically significant (p=0.7). The marginal cost was less than the anticipated economic benefit based assuming a 50% capture of improved TTA-RR inpatient disposition and using the lowest available national insurance rebate as a proxy for economic benefit. Conclusion: TTA-RR improved significantly during the period of increased staff availability, both during the specific period of increased staffing and throughout the day. Increased labor utilisation is cost-effective compared with the potential improved productivity for ED cases requiring CT imaging.

Keywords: workflow, quality, administration, CT, staffing

Procedia PDF Downloads 112

Authors: Bassey O. Bassey

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Benchmarking has progressively become entrenched as a requisite activity for process improvement and enhancing service delivery at petroleum jetties and terminals, most especially during tanker discharge operations at the ship – shore interface, as avoidable delays result in extra operating costs, non-productive time, high demurrage payments and ultimate product scarcity. The jetty and terminal in focus had been operational for 3 and 8 years respectively, with proper operational and logistic records maintained to evaluate their progress over time in order to plan and implement modifications and review of procedures for greater technical and economic efficiency. Regular and emergency staff meetings were held on a team, departmental and company-wide basis to progressively address major challenges that were encountered during each operation. The process and outcome of the resultant collectively planned changes carried out within the past two years forms the basis of this paper, which mirrors the initiatives effected to enhance operational and maintenance excellence at the affected facilities. Operational modifications included a second cargo receipt line designated for gasoline, product loss control at jetty and shore ends, enhanced product recovery and quality control, and revival of terminal–jetty backloading operations. Logistic improvements were the incorporation of an internal logistics firm and shipping agency, fast tracking of discharge procedures for tankers, optimization of tank vessel selection process, and third party product receipt and throughput. Maintenance excellence was achieved through construction of two new lay barges and refurbishment of the existing one; revamping of existing booster pump and purchasing of a modern one as reserve capacity; extension of Phase 1 of the jetty to accommodate two vessels and construction of Phase 2 for two more vessels; regular inspection, draining, drying and replacement of cargo hoses; corrosion management program for all process facilities; and an improved, properly planned and documented maintenance culture. Safety, environmental and security compliance were enhanced by installing state-of-the-art fire fighting facilities and equipment, seawater intake line construction as backup for borehole at the terminal, remediation of the shoreline and marine structures, modern spill containment equipment, improved housekeeping and accident prevention practices, and installation of hi-technology security enhancements, among others. The end result has been observed over the past two years to include improved tanker turnaround time, higher turnover on product sales, consistent product availability, greater indigenous human capacity utilisation by way of direct hires and contracts, as well as customer loyalty. The lessons learnt from this exercise would, therefore, serve as a model to be adapted by other operators of similar facilities, contractors, academics and consultants in a bid to deliver greater sustainability and profitability of operations at the ship – shore interface to this strategic industry.

Keywords: benchmarking, optimisation, petroleum jetty, petroleum terminal

Procedia PDF Downloads 366

Authors: Elena Parmentier, Henrik Endeman

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Introduction: Large mediastinal masses often present with diagnostic and clinical challenges due to compression of the respiratory and hemodynamic system. We present a case of a mediastinal mass with symptomatic mechanical compression of the trachea, resulting in challenging airway management. Methods: We present a case of 66-year-old male, complaining of progressive dysphagia. Initial esophagogastroscopy revealed a stenosis secondary to external compression, biopsies were inconclusive. Additional CT scan showed a large mediastinal mass of unknown origin, situated between the vertebrae and esophagus. Symptoms progressed and patient developed dyspnea and stridor. A new CT showed quick growth of the mass with compression of the trachea, subglottic to just above the carina. A tracheal covered stent was successfully placed. Endobronchial ultrasound revealed a large irregular mass without tracheal invasion, biopsies were taken. 4 days after stent placement, the patients’ condition deteriorated with worsening of stridor, dyspnea and desaturation. Migration of the tracheal stent into the right main bronchus was seen on chest X ray, with obstruction of the left main bronchus and secondary atelectasis. Different methods have been described in the literature for tracheobronchial stent removal (surgical, endoscopic, fluoroscopyguided), our first choice in this case was flexible bronchoscopy. However, this revealed tracheal compression above the migrated stent and passage of the scope occurred impossible. Patient was admitted to the ICU, high-flow nasal oxygen therapy was started and the situation stabilized, giving time for extensive assessment and preparation of the airway management approach. Close cooperation between the intensivist, pulmonologist, anesthesiologist and otorhinolaryngologist was essential. Results: In case of sudden deterioration, a protocol for emergency situations was made. Given the increased risk of additional tracheal compression after administration of neuromuscular blocking agents, an approach with awake fiberoptic intubation maintaining spontaneous ventilation was proposed. However, intubation without retrieval of the tracheal stent was found undesirable due to expected massive shunting over the left atelectatic lung. As rescue option, assistance of extracorporeal circulation was considered and perfusionist was kept on standby. The patient stayed stable and was transferred to the operating theatre. High frequency jet ventilation under general anesthesia resulted in desaturations up to 50%, making rigid bronchoscopy impossible. Subsequently an endotracheal tube size 8 could be placed successfully and the stent could be retrieved via bronchoscopy over (and with) the tube, after which the patient was reintubated. Finally, a tracheostomy (Shiley™ Tracheostomy Tube With Cuff, size 8) was placed, fiberoptic control showed a patent airway. Patient was readmitted to the ICU and could be quickly weaned of the ventilator. Pathology was positive for rhabdomyosarcoma, without indication for systemic therapy. Extensive surgery (laryngectomy, esophagectomy) was suggested, but patient refused and palliative care was started. Conclusion: Due to meticulous planning in an interdisciplinary team, we showed a successful airway management approach in this complicated case of critical airway compression secondary to a rare rhabdomyosarcoma, complicated by tracheal stent migration. Besides presenting our thoughts and considerations, we support exploring other possible approaches of this specific clinical problem.

Keywords: airway management, rhabdomyosarcoma, stent displacement, tracheal stenosis

Procedia PDF Downloads 105

Authors: Hari Krishan Sharma, Sanjay Kumar Sharma, Sushil Kumar Swar

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Inadequate transverse reinforcement is considered as the main reason for the beam column joint shear failure observed during recent earthquakes. DSP matrix consists of cement and high content of micro-silica with low water to cement ratio while the aggregates are graded quartz sand. The use of reinforcing fibres leads not only to the increase of tensile/bending strength and specific fracture energy, but also to reduction of brittleness and, consequently, to production of non-explosive ruptures. Besides, fibre-reinforced materials are more homogeneous and less sensitive to small defects and flaws. Recent works on the freeze-thaw durability (also in the presence of de-icing salts) of fibre-reinforced DSP confirm the excellent behaviour in the expected long term service life.DSP materials, including fibre-reinforced DSP and CRC (Compact Reinforced Composites) are obtained by using high quantities of super plasticizers and high volumes of micro-silica. Steel fibres with high tensile yield strength of smaller diameter and short length in different fibre volume percentage and aspect ratio tilized to improve the performance by reducing the brittleness of matrix material. In the case of High Performance Densified Small Particle Concrete (HPDSPC), concrete is dense at the micro-structure level, tensile strain would be much higher than that of the conventional SFRC, SIFCON & SIMCON. Beam-column sub-assemblages used as moment resisting constructed using HPDSPC in the joint region with varying quantities of steel fibres, fibre aspect ratio and fibre orientation in the critical section. These HPDSPC in the joint region sub-assemblages tested under cyclic/earthquake loading. Besides loading measurements, frame displacements, diagonal joint strain and rebar strain adjacent to the joint will also be measured to investigate stress-strain behaviour, load deformation characteristics, joint shear strength, failure mechanism, ductility associated parameters, stiffness and energy dissipated parameters of the beam column sub-assemblages also evaluated. Finally a design procedure for the optimum design of HPDSPC corresponding to moment, shear forces and axial forces for the reinforced concrete beam-column joint sub-assemblage proposed. The fact that the implementation of material brittleness measure in the design of RC structures can improve structural reliability by providing uniform safety margins over a wide range of structural sizes and material compositions well recognized in the structural design and research. This lead to the development of high performance concrete for the optimized combination of various structural ratios in concrete for the optimized combination of various structural properties. The structural applications of HPDSPC, because of extremely high strength, will reduce dead load significantly as compared to normal weight concrete thereby offering substantial cost saving and by providing improved seismic response, longer spans, and thinner sections, less reinforcing steel and lower foundation cost. These cost effective parameters will make this material more versatile for use in various structural applications like beam-column joints in industries, airports, parking areas, docks, harbours, and also containers for hazardous material, safety boxes and mould & tools for polymer composites and metals.

Keywords: high performance densified small particle concrete (HPDSPC), steel fibre reinforced concrete (SFRC), slurry infiltrated concrete (SIFCON), Slurry infiltrated mat concrete (SIMCON)

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Authors: Nanine Fouche

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The Cape Flats is a low-lying sand-covered expanse of approximately 460 square kilometres, situated to the southeast of the central business district of Cape Town in the Western Cape of South Africa. The aeolian sands masking this area are often loose and compressible in the upper 1m to 1.5m of the surface, and there is a general exceedance of the maximum allowable settlement in these sands. The settlement of shallow foundations on Cape Flats sands is commonly predicted using the results of in-situ tests such as the SPT or DPSH due to the difficulty of retrieving undisturbed samples for laboratory testing. Varying degrees of accuracy and reliability are associated with these methods. More recently, shear wave velocity (Vs) profiles obtained from seismic testing, such as continuous surface wave tests (CSW), are being used for settlement prediction. Such predictions have the advantage of considering non-linear stress-strain behaviour of soil and the degradation of stiffness with increasing strain. CSW tests are rarely executed in the Cape Flats, whereas SPT’s are commonly performed. For this reason, and to facilitate better settlement predictions in Cape Flats sand, equations representing shear wave velocity (Vs) as a function of SPT blow count (N60) and vertical effective stress (v’) were generated by statistical regression of site investigation data. To reveal the most appropriate method of overburden correction, analyses were performed with a separate overburden term (Pa/σ’v) as well as using stress corrected shear wave velocity and SPT blow counts (correcting Vs. and N60 to Vs1and (N1)60respectively). Shear wave velocity profiles and SPT blow count data from three sites masked by Cape Flats sands were utilised to generate 80 Vs-SPT N data pairs for analysis. Investigated terrains included sites in the suburbs of Athlone, Muizenburg, and Atlantis, all underlain by windblown deposits comprising fine and medium sand with varying fines contents. Elastic settlement analysis was also undertaken for the Cape Flats sands, using a non-linear stepwise method based on small-strain stiffness estimates, which was obtained from the best Vs-N60 model and compared to settlement estimates using the general elastic solution with stiffness profiles determined using Stroud’s (1989) and Webb’s (1969) SPT N60-E transformation models. Stroud’s method considers strain level indirectly whereasWebb’smethod does not take account of the variation in elastic modulus with strain. The expression of Vs. in terms of N60 and Pa/σv’ derived from the Atlantis data set revealed the best fit with R2 = 0.83 and a standard error of 83.5m/s. Less accurate Vs-SPT N relations associated with the combined data set is presumably the result of inversion routines used in the analysis of the CSW results showcasing significant variation in relative density and stiffness with depth. The regression analyses revealed that the inclusion of a separate overburden term in the regression of Vs and N60, produces improved fits, as opposed to the stress corrected equations in which the R2 of the regression is notably lower. It is the correction of Vs and N60 to Vs1 and (N1)60 with empirical constants ‘n’ and ‘m’ prior to regression, that introduces bias with respect to overburden pressure. When comparing settlement prediction methods, both Stroud’s method (considering strain level indirectly) and the small strain stiffness method predict higher stiffnesses for medium dense and dense profiles than Webb’s method, which takes no account of strain level in the determination of soil stiffness. Webb’s method appears to be suitable for loose sands only. The Versak software appears to underestimate differences in settlement between square and strip footings of similar width. In conclusion, settlement analysis using small-strain stiffness data from the proposed Vs-N60 model for Cape Flats sands provides a way to take account of the non-linear stress-strain behaviour of the sands when calculating settlement.

Keywords: sands, settlement prediction, continuous surface wave test, small-strain stiffness, shear wave velocity, penetration resistance

Procedia PDF Downloads 175

Authors: Merrick Lopez, Aashish Abraham, Melissa Egge, Marissa Hood, Jui Shah

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A 3 year old male with unknown medical history presented initially with encephalopathy, intubated for respiratory failure, and admitted to the pediatric intensive care unit (PICU) with refractory shock. During resuscitation in the emergency department, he was found to be in severe metabolic acidosis with a pH of 7.03 and escalated on vasopressor drips for hypotension. His initial sodium was 174. He was noted to have burn injuries to his scalp, forehead, right axilla, bilateral arm creases and lower legs. He had rhabdomyolysis (initial creatinine kinase 5,430 U/L with peak levels of 62,340 normal <335 U/L), cardiac injury (initial troponin 88 ng/L with peak at 145 ng/L, normal <15ng/L), hypernatremia (peak 174, normal 140), hypocalcemia, liver injury, acute kidney injury, and neuronal loss on magnetic resonance imaging (MRI). Soft restraints and a shock collar were found in the home. He was critically ill for 8 days, but was gradually weaned off drips, extubated, and started on feeds. Discussion Electrical injury, specifically lightning injury is an uncommon but devastating cause of injury in pediatric patients. This patient with suspected abusive use of a dog shock collar presented similar to a lightning strike. Common entrance points include the hands and head, similar to our patient with linear wounds on his forehead. When current enters, it passes through tissues with the least resistance. Nerves, blood vessels, and muscles, have high fluid and electrolyte content and are commonly affected. Exit points are extremities: our child who had circumferential burns around his arm creases and ankles. Linear burns preferentially follow areas of high sweat concentration, and are thought to be due to vaporization of water on the skin’s surface. The most common cause of death from a lightning strike is due to cardiopulmonary arrest. The massive depolarization of the myocardium can result in arrhythmias and myocardial necrosis. The patient presented in cardiogenic shock with evident cardiac damage. Electricity going through vessels can lead to vaporization of intravascular water. This can explain his severe hypernatremia. He also sustained other internal organ injuries (adrenal glands, pancreas, liver, and kidney). Electrical discharge also leads to direct skeletal muscle injury in addition to prolonged muscular spasm. Rhabdomyolysis, the acute damage of muscle, leads to release of potentially toxic components into the circulation which could lead to acute renal failure. The patient had severe rhabdomyolysis and renal injury. Early hypocalcemia has been consistently demonstrated in patients with rhabdomyolysis. This was present in the patient and led to increased vasopressor needs. Central nervous system injuries are also common which can include encephalopathy, hypoxic injury, and cerebral infarction. The patient had evidence of brain injury as seen on MRI. Conclusion Electrical injuries due to lightning strikes and abusive use of a dog shock collar are rare, but can both present in similar ways with respiratory failure, shock, hypernatremia, rhabdomyolysis, brain injury, and multiorgan damage. Although rare, it is essential for early identification and prompt management for acute and chronic complications in these children.

Keywords: cardiogenic shock, dog shock collar, lightning strike, rhabdomyolysis

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Authors: Taikchan Lildar, Ayesha Samad, Suraj Sookhu

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Atrial fibrillation with rapid ventricular response results in the loss of atrial kick and shortened ventricular filling time, which often leads to decompensated heart failure. Pharmacologic rhythm control is the treatment of choice, and patients frequently benefit from the restoration of sinus rhythm. When pharmacologic treatment is unsuccessful or a patient declines hemodynamically, direct cardioversion is the treatment of choice. Torsades de pointes or “twisting of the points'' in French, is a rare but under-appreciated risk of cardioversion therapy and accounts for a significant number of sudden cardiac death each year. A 61-year-old female with no significant past medical history presented to the Emergency Department with worsening dyspnea. An electrocardiogram showed atrial fibrillation with rapid ventricular response, and a chest X-ray was significant for bilateral pulmonary vascular congestion. Full-dose anticoagulation and diuresis were initiated with moderate improvement in symptoms. A transthoracic echocardiogram revealed biventricular systolic dysfunction with a left ventricular ejection fraction of 30%. After consultation with an electrophysiologist, the consensus was to proceed with the restoration of sinus rhythm, which would likely improve the patient’s heart failure symptoms and possibly the ejection fraction. A transesophageal echocardiogram was negative for left atrial appendage thrombus; the patient was treated with a loading dose of amiodarone and underwent successful direct current cardioversion with 200 Joules. The patient was placed on telemetry monitoring for 24 hours and was noted to have frequent premature ventricular contractions with subsequent degeneration to torsades de pointes. The patient was found unresponsive and pulseless; cardiopulmonary resuscitation was initiated with cardioversion, and return of spontaneous circulation was achieved after four minutes to normal sinus rhythm. Post-cardiac arrest electrocardiogram showed sinus bradycardia with heart-rate corrected QT interval of 592 milliseconds. The patient continued to have frequent premature ventricular contractions and required two additional cardioversions to achieve a return of spontaneous circulation with intravenous magnesium and lidocaine. An automatic implantable cardioverter-defibrillator was subsequently implanted for secondary prevention of sudden cardiac death. The backup pacing rate of the automatic implantable cardioverter-defibrillator was set higher than usual in an attempt to prevent premature ventricular contractions-induced torsades de pointes. The patient did not have any further ventricular arrhythmias after implantation of the automatic implantable cardioverter-defibrillator. Overdrive pacing is a method utilized to treat premature ventricular contractions-induced torsades de pointes by preventing a patient’s susceptibility to R on T-wave-induced ventricular arrhythmias. Pacing at a rate of 90 beats per minute succeeded in controlling the arrhythmia without the need for traumatic cardiac defibrillation. In our patient, conversion of atrial fibrillation with rapid ventricular response to normal sinus rhythm resulted in a slower heart rate and an increased probability of premature ventricular contraction occurring on the T-wave and ensuing ventricular arrhythmia. This case highlights direct current cardioversion for atrial fibrillation with rapid ventricular response resulting in persistent ventricular arrhythmia requiring an automatic implantable cardioverter-defibrillator placement with overdrive pacing to prevent a recurrence.

Keywords: refractory atrial fibrillation, atrial fibrillation, overdrive pacing, torsades de pointes

Procedia PDF Downloads 147

Authors: Fatemeh Modirzare

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Smart interior design represents a transformative approach to creating living spaces that integrate technology seamlessly into our daily lives, enhancing comfort, convenience, and sustainability. This paper explores the concept of smart interior design, its principles, benefits, challenges, and future prospects. It also highlights various examples and applications of smart interior design to illustrate its potential in shaping the way we live and interact with our surroundings. In an increasingly digitized world, the boundaries between technology and interior design are blurring. Smart interior design, also known as intelligent or connected interior design, involves the incorporation of advanced technologies and automation systems into residential and commercial spaces. This innovative approach aims to make living environments more efficient, comfortable, and adaptable while promoting sustainability and user well-being. Smart interior design seamlessly integrates technology into the aesthetics and functionality of a space, ensuring that devices and systems do not disrupt the overall design. Sustainable materials, energy-efficient systems, and eco-friendly practices are central to smart interior design, reducing environmental impact. Spaces are designed to be adaptable, allowing for reconfiguration to suit changing needs and preferences. Smart homes and spaces offer greater comfort through features like automated climate control, adjustable lighting, and customizable ambiance. Smart interior design can significantly reduce energy consumption through optimized heating, cooling, and lighting systems. Smart interior design integrates security systems, fire detection, and emergency response mechanisms for enhanced safety. Sustainable materials, energy-efficient appliances, and waste reduction practices contribute to a greener living environment. Implementing smart interior design can be expensive, particularly when retrofitting existing spaces with smart technologies. The increased connectivity raises concerns about data privacy and cybersecurity, requiring robust measures to protect user information. Rapid advancements in technology may lead to obsolescence, necessitating updates and replacements. Users must be familiar with smart systems to fully benefit from them, requiring education and ongoing support. Residential spaces incorporate features like voice-activated assistants, automated lighting, and energy management systems. Intelligent office design enhances productivity and employee well-being through smart lighting, climate control, and meeting room booking systems. Hospitals and healthcare facilities use smart interior design for patient monitoring, wayfinding, and energy conservation. Smart retail design includes interactive displays, personalized shopping experiences, and inventory management systems. The future of smart interior design holds exciting possibilities, including AI-powered design tools that create personalized spaces based on user preferences. Smart interior design will increasingly prioritize factors that improve physical and mental health, such as air quality monitoring and mood-enhancing lighting. Smart interior design is revolutionizing the way we interact with our living and working spaces. By embracing technology, sustainability, and user-centric design principles, smart interior design offers numerous benefits, from increased comfort and convenience to energy efficiency and sustainability. Despite challenges, the future holds tremendous potential for further innovation in this field, promising a more connected, efficient, and harmonious way of living and working.

Keywords: smart interior design, home automation, sustainable living spaces, technological integration, user-centric design

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Authors: Sadaf Abbas, HimGauri Sabnis

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Introduction: Peripartum cardiomyopathy is a rare but potentially life-threatening condition that presents as heart failure during the last month of pregnancy or within five months postpartum. The incidence of postpartum cardiomyopathy ranges from 1 in 1300 to 1 in 15,000 pregnancies. Risk factors include multiparty, advanced maternal age, multiple pregnancies, pre-eclampsia, and chronic hypertension. Study: A 30-year-old Para3+0 presented to the Emergency Department of St’Marry Hospital, Isle of Wight, on the seventh day postpartum, with acute shortness of breath (SOB), chest pain, cough, and a temperature of 38 degrees. The risk factors were smoking and class II obesity (BMI of 40.62). The patient had mild pre-eclampsia in the last pregnancy and was on labetalol and aspirin during an antenatal period, which was stopped postnatally. There was also a history of pre-eclampsia and haemolysis, elevated liver enzymes, low platelets (HELLP syndrome) in previous pregnancies, which led to preterm delivery at 35 weeks in the second pregnancy, and the first baby was stillborn at 24 weeks. On assessment, there was a national early warning score (NEWS score) of 3, persistent tachycardia, and mild crepitation in the lungs. Initial investigations revealed an enlarged heart on chest X-ray, and a CT pulmonary angiogram indicated bilateral basal pulmonary congestion without pulmonary embolism, suggesting fluid overload. Laboratory results showed elevated CRP and normal troponin levels initially, which later increased, indicating myocardial involvement. Echocardiography revealed a severely dilated left ventricle with an ejection fraction (EF) of 31%, consistent with severely impaired systolic function. The cardiology team reviewed the patient and admitted to the Coronary Care Unit. As sign and symptoms were suggestive of fluid overload and congestive cardiac failure, management was done with diuretics, beta-blockers, angiotensin-converting enzyme inhibitors (ACE inhibitors), proton pump inhibitors, and supportive care. During admission, there was complications such as acute kidney injury, but then recovered well. Chest pain had resolved following the treatment. After being admitted for eight days, there was an improvement in the symptoms, and the patient was discharged home with a further plan of cardiac MRI and genetic testing due to a family history of sudden cardiac death. Regular appointment has been made with the Cardiology team to follow-up on the symptoms. Since discharge, the patient made a good recovery. A cardiac MRI was done, which showed severely impaired left ventricular function, ejection fraction (EF) of 38% with mild left ventricular dilatation, and no evidence of previous infarction. Overall appearance is of non-ischemic dilated cardiomyopathy. The main challenge at the time of admission was the non-availability of a cardiac radiology team, so the definitive diagnosis was delayed. The long-term implications include risk of recurrence, chronic heart failure, and, consequently, an effect on quality of life. Therefore, regular follow-up is critical in patient’s management. Conclusions: Peripartum cardiomyopathy is one of the cardiovascular diseases whose causes are still unknown yet and, in some cases, are uncontrolled. By raising awareness about the symptoms and management of this complication it will reduce morbidity and mortality rates and also the length of stay in the hospital.

Keywords: cardiomyopathy, cardiomegaly, pregnancy, puerperium

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Authors: Elhadi Nasr, Ibrahim Ramadan

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Biostratigraphical analyses of well sections from the Maragh Low in the Eastern Sirt Basin has allowed high resolution correlations to be undertaken. Full integration of this data with available palaeoenvironmental, lithological, gravity, seismic, aeromagnetic, igneous, radiometric and wireline log information and a geochemical analysis of source rock quality and distribution has led to a more detailed understanding of the geological and the structural history of this area. Pre Sirt Unconformity two superimposed rifting cycles have been identified. The oldest is represented by the Amal Group of sediments and is of Late Carboniferous, Kasimovian / Gzelian to Middle Triassic, Anisian age. Unconformably overlying is a younger rift cycle which is represented the Sarir Group of sediments and is of Early Cretaceous, late Neocomian to Aptian in age. Overlying the Sirt Unconformity is the marine Late Cretaceous section. An assessment of pyrolysis results and a palynofacies analysis has allowed hydrocarbon source facies and quality to be determined. There are a number of hydrocarbon source rock horizons in the Maragh Low, these are sometimes vertically stacked and they are of fair to excellent quality. The oldest identified source rock is the Triassic Shale, this unit is unconformably overlain by sandstones belonging to the Sarir Group and conformably overlies a Triassic Siltstone unit. Palynological dating of the Triassic Shale unit indicates a Middle Triassic, Anisian age. The Triassic Shale is interpreted to have been deposited in a lacustrine palaeoenvironment. This particularly is evidenced by the dark, fine grained, organic rich nature of the sediment and is supported by palynofacies analysis and by the recovery of fish fossils. Geochemical analysis of the Triassic Shale indicates total organic carbon varying between 1.37 and 3.53. S2 pyrolysate yields vary between 2.15 mg/g and 6.61 mg/g and hydrogen indices vary between 156.91 and 278.91. The source quality of the Triassic Shale varies from being of fair to very good / rich. Linked to thermal maturity it is now a very good source for light oil and gas. It was once a very good to rich oil source. The Early Barremian Shale was also deposited in a lacustrine palaeoenvironment. Recovered palynomorphs indicate an Early Cretaceous, late Neocomian to early Barremian age. The Early Barremian Shale is conformably underlain and overlain by sandstone units belonging to the Sarir Group of sediments which are also of Early Cretaceous age. Geochemical analysis of the Early Barremian Shale indicates that it is a good oil source and was originally very good. Total organic carbon varies between 3.59% and 7%. S2 varies between 6.30 mg/g and 10.39 mg/g and the hydrogen indices vary between 148.4 and 175.5. A Late Barremian Shale unit of this age has also been identified in the central Maragh Low. Geochemical analyses indicate that total organic carbon varies between 1.05 and 2.38%, S2 pyrolysate between 1.6 and 5.34 mg/g and the hydrogen index between 152.4 and 224.4. It is a good oil source rock which is now mature. In addition to the non marine hydrocarbon source rocks pre Sirt Unconformity, three formations in the overlying Late Cretaceous section also provide hydrocarbon quality source rocks. Interbedded shales within the Rachmat Formation of Late Cretaceous, early Campanian age have total organic carbon ranging between, 0.7 and 1.47%, S2 pyrolysate varying between 1.37 and 4.00 mg/g and hydrogen indices varying between 195.7 and 272.1. The indication is that this unit would provide a fair gas source to a good oil source. Geochemical analyses of the overlying Tagrifet Limestone indicate that total organic carbon varies between 0.26% and 1.01%. S2 pyrolysate varies between 1.21 and 2.16 mg/g and hydrogen indices vary between 195.7 and 465.4. For the overlying Sirt Shale Formation of Late Cretaceous, late Campanian age, total organic carbon varies between 1.04% and 1.51%, S2 pyrolysate varies between 4.65 mg/g and 6.99 mg/g and the hydrogen indices vary between 151 and 462.9. The study has proven that both the Sirt Shale Formation and the Tagrifet Limestone are good to very good and rich sources for oil in the Maragh Low. High resolution biostratigraphical interpretations have been integrated and calibrated with thermal maturity determinations (Vitrinite Reflectance (%Ro), Spore Colour Index (SCI) and Tmax (ºC) and the determined present day geothermal gradient of 25ºC / Km for the Maragh Low. Interpretation of generated basin modelling profiles allows a detailed prediction of timing of maturation development of these source horizons and leads to a determination of amounts of missing section at major unconformities. From the results the top of the oil window (0.72% Ro) is picked as high as 10,700’ and the base of the oil window (1.35% Ro) assuming a linear trend and by projection is picked as low as 18,000’ in the Maragh Low. For the Triassic Shale the early phase of oil generation was in the Late Palaeocene / Early to Middle Eocene and the main phase of oil generation was in the Middle to Late Eocene. The Early Barremian Shale reached the main phase of oil generation in the Early Oligocene with late generation being reached in the Middle Miocene. For the Rakb Group section (Rachmat Formation, Tagrifet Limestone and Sirt Shale Formation) the early phase of oil generation started in the Late Eocene with the main phase of generation being between the Early Oligocene and the Early Miocene. From studying maturity profiles and from regional considerations it can be predicted that up to 500’ of sediment may have been deposited and eroded by the Sirt Unconformity in the central Maragh Low while up to 2000’ of sediment may have been deposited and then eroded to the south of the trough.

Keywords: Geochemical analysis of the source rocks from wells in Eastern Sirt Basin.

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Authors: Kuldeep Rawat, Michael O'Shea, Maureen McGough

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The paper will discuss a National Institute of Justice (NIJ) funded project to provide cost-effective aviation technologies and research to support counter-poaching operations related to endangered, protected, and/or regulated wildlife. The goal of this project is to provide cost-effective aviation technology and research support to Kenya Wildlife Service (KWS) in their counter-poaching efforts. In pursuit of this goal, Elizabeth City State University (ECSU) is assisting the National Institute of Justice (NIJ) in enhancing the Kenya Wildlife Service’s aviation technology and related capacity to meet its counter-poaching mission. Poaching, at its core, is systemic as poachers go to the most extreme lengths to kill high target species such as elephant and rhino. These high target wildlife species live in underdeveloped or impoverished nations, where poachers find fewer barriers to their operations. In Kenya, with fifty-nine (59) parks and reserves, spread over an area of 225,830 square miles (584,897 square kilometers) adequate surveillance on the ground is next to impossible. Cost-effective aviation surveillance technologies, based on a comprehensive needs assessment and operational evaluation, are needed to curb poaching and effectively prevent wildlife trafficking. As one of the premier law enforcement Air Wings in East Africa, KWS plays a crucial role in Kenya, not only in counter-poaching and wildlife conservation efforts, but in aerial surveillance, counterterrorism and national security efforts as well. While the Air Wing has done, a remarkable job conducting aerial patrols with limited resources, additional aircraft and upgraded technology should significantly advance the Air Wing’s ability to achieve its wildlife protection mission. The project includes: (i) Needs Assessment of the KWS Air Wing, to include the identification of resources, current and prospective capacity, operational challenges and priority goals for expansion, (ii) Acquisition of Low-Cost Aviation Technology to meet priority needs, and (iii) Operational Evaluation of technology performance, with a focus on implementation and effectiveness. The Needs Assessment reflects the priorities identified through two site visits to the KWS Air Wing in Nairobi, Kenya, as well as field visits to multiple national parks receiving aerial support and interviewing/surveying KWS Air wing pilots and leadership. Needs Assessment identified some immediate technology needs that includes, GPS with upgrades, including weather application, Night flying capabilities, to include runway lights and night vision technology, Cameras and surveillance equipment, Flight tracking system and/or Emergency Position Indicating Radio Beacon, Lightweight ballistic-resistant body armor, and medical equipment, to include a customized stretcher and standard medical evacuation equipment. Results of this assessment, along with significant input from the KWS Air Wing, will guide the second phase of this project: technology acquisition. Acquired technology will then be evaluated in the field, with a focus on implementation and effectiveness. Results will ultimately be translated for any rural or tribal law enforcement agencies with comparable aerial surveillance missions and operational environments, and jurisdictional challenges, seeking to implement low-cost aviation technology. Results from Needs Assessment phase, including survey results and our ongoing technology acquisition and baseline operational evaluation will be discussed in the paper.

Keywords: aerial surveillance mission, aviation technology, counter-poaching, wildlife protection

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Authors: Aidan Ryan, Nahima Miah, Sahaj Kaur, Imogen Sutherland, Mohamed Saleh

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Pulmonary symptoms are a common presentation to the emergency department. Due to a lack of understanding of the underlying pathophysiology, chronic liver disease is not often considered a cause of dyspnea. We present three patients who were admitted with significant respiratory distress secondary to hepatopulmonary syndrome, portopulmonary hypertension, and hepatic hydrothorax. The first is a 27-year-old male with a 6-month history of progressive dyspnea. The patient developed a severe type 1 respiratory failure with a PaO₂ of 6.3kPa and was escalated to critical care, where he was managed with non-invasive ventilation to maintain oxygen saturation. He had an agitated saline contrast echocardiogram, which showed the presence of a possible shunt. A CT angiogram revealed significant liver cirrhosis, portal hypertension, and large para esophageal varices. Ultrasound of the abdomen showed coarse liver echo patter and enlarged spleen. Along with these imaging findings, his biochemistry demonstrated impaired synthetic liver function with an elevated international normalized ratio (INR) of 1.4 and hypoalbuminaemia of 28g/L. The patient was then transferred to a tertiary center for further management. Further investigations confirmed a shunt of 56%, and liver biopsy confirmed cirrhosis suggestive of alpha-1-antitripsyin deficiency. The findings were consistent with a diagnosis of hepatopulmonary syndrome, and the patient is awaiting a liver transplant. The second patient is a 56-year-old male with a 12-month history of worsening dyspnoea, jaundice, confusion. His medical history included liver cirrhosis, portal hypertension, and grade 1 oesophageal varices secondary to significant alcohol excess. On admission, he developed a type 1 respiratory failure with PaO₂ of 6.8kPa requiring 10L of oxygen. CT pulmonary angiogram was negative for pulmonary embolism but showed evidence of chronic pulmonary hypertension, liver cirrhosis, and portal hypertension. An echocardiogram revealed a grossly dilated right heart with reduced function, pulmonary and tricuspid regurgitation, and pulmonary artery pressures estimated at 78mmHg. His biochemical markers showed impaired synthetic liver function with an INR of 3.2, albumin of 29g/L, along with raised bilirubin of 148mg/dL. During his long admission, he was managed with diuretics with little improvement. After three weeks, he was diagnosed with portopulmonary hypertension and was commenced on terlipressin. This resulted in successfully weaning off oxygen, and he was discharged home. The third patient is a 61-year-old male who presented to the local ambulatory care unit for therapeutic paracentesis on a background of decompensated liver cirrhosis. On presenting, he complained of a 2-day history of worsening dyspnoea and a productive cough. Chest x-ray showed a large pleural effusion, increasing in size over the previous eight months, and his abdomen was visibly distended with ascitic fluid. Unfortunately, the patient deteriorated, developing a larger effusion along with an increase in oxygen demand, and passed away. Without underlying cardiorespiratory disease, in the presence of a persistent pleural effusion with underlying decompensated cirrhosis, he was diagnosed with hepatic hydrothorax. While each presented with dyspnoea, the cause and underlying pathophysiology differ significantly from case to case. By describing these complications, we hope to improve awareness and aid prompt and accurate diagnosis, vital for improving outcomes.

Keywords: dyspnea, hepatic hydrothorax, hepatopulmonary syndrome, portopulmonary syndrome

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Authors: E Tambo, O. O. Olalubi, E. C. Ugwu, J. Y. Ngogang

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Despite the World Health Organization (WHO) declaration of international health emergency concern, the status quo of responses and efforts to stem the worst-recorded Ebola epidemic Ebola outbreak is still precariously inadequate in most of the affected in West. Mining natural resources have been shown to play a key role in both motivating and fuelling ethnic, civil and armed conflicts that have plagued a number of African countries over the last decade. Revenues from the exploitation of natural resources are not only used in sustaining the national economy but also armies, personal enrichment and building political support. Little is documented on the mining and ecological impact on the emergence and geographical distribution of Ebola in Africa over time and space. We aimed to provide a better understanding of the interconnectedness among issues of mining natural, resource management, mining conflict and post-conflict on Ebola outbreak and how wealth generated from abundant natural resources could be better managed in promoting research and development towards strengthening environmental, socioeconomic and health systems sustainability on Ebola outbreak and other emerging diseases surveillance and responses systems prevention and control, early warning alert, durable peace and sustainable development rather than to fuel conflicts, resurgence and emerging diseases epidemics in the perspective of community and national/regional approach. Our results showed the first assessment of systematic impact of all major minerals conflict events diffusion over space and time and mining activities on nine Ebola genesis and geo-distribution in affected countries across Africa. We demonstrate how, where and when mining activities in Africa increase ecological degradation, conflicts at the local level and then spreads violence across territory and time by enhancing the financial capacities of fighting groups/ethnics and diseases onset. In addition, led process of developing minimum standards for natural resource governance; improving governmental and civil society capacity for natural resource management, including the strengthening of monitoring and enforcement mechanisms; understanding the post-mining and conflicts community or national reconstruction and rehabilitation programmes in strengthening or developing community health systems and regulatory mechanisms. In addition the quest for the control over these resources and illegal mining across the landscape forest incursion provided increase environmental and ecological instability and displacement and disequilibrium, therefore affecting the intensity and duration of mining and conflict/wars and episode of Ebola outbreaks over time and space. We highlight the key findings and lessons learnt in promoting country or community-led process in transforming natural resource wealth from a peace liability to a peace asset. The imperative necessity for advocacy and through facilitating intergovernmental deliberations on critical issues and challenges affecting Africa community transforming exploitation of natural resources from a peace liability to outbreak prevention and control. The vital role of mining in increasing government revenues and expenditures, equitable distribution of wealth and health to all stakeholders, in particular local communities requires coordination, cooperative leadership and partnership in fostering sustainable developmental initiatives from mining context to outbreak and other infectious diseases surveillance responses systems in prevention and control, and judicious resource management.

Keywords: mining, mining conflicts, mines, ecological, Ebola, outbreak, mining companies, miners, impact

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Authors: Juliet Sorensen, Anna Maitland

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Introduction: Characterized by lack of water and sanitation, food insecurity, and low access to hospitals and clinics, informal urban settlements in Lagos, Nigeria have very poor health outcomes. With little education and a general inability to demand basic rights, these communities are often disempowered and isolated from understanding, claiming, or owning their health needs. Utilizing community-based participatory research characterized by interdisciplinary, cross-cultural partnerships, evidence-based assessments, and both primary and secondary source research, a holistic health education and advocacy program was developed in Lagos to address health barriers for targeted communities. This includes a first of its kind guide formulated to teach community-based health educators how to transmit health information to low-literacy Nigerian audiences while supporting behavior change models and social support mechanisms. This paper discusses the interdisciplinary contributions to developing a health education program while also looking at the need for greater beneficiary ownership and implementation of health justice and access. Methods: In March 2016, an interdisciplinary group of medical, legal, and business graduate students and faculty from Northwestern University conduced a Health Needs Assessment (HNA) in Lagos with a partner and a local non-governmental organization. The HNA revealed that members of informal urban communities in Lagos were lacking basic health literacy, but desired to remedy this lacuna. Further, the HNA revealed that even where the government mandates specific services, many vulnerable populations are unable to access these services. The HNA concluded that a program focused on education, advocacy, and organizing around anatomy, maternal and sexual health, infectious disease and malaria, HIV/AIDS, emergency care, and water and sanitation would respond to stated needs while also building capacity in communities to address health barriers. Results: Based on the HNA, including both primary and secondary source research on integrated health education approaches and behavior change models and responsive, adaptive material development, a holistic program was developed for the Lagos partners and first implemented in November 2016. This program trained community-nominated health educators in adult, low-literacy, knowledge exchange approaches, utilizing information identified by communities as a priority. After a second training in March 2017, these educators will teach community-based groups and will support and facilitate behavior change models and peer-support methods around basic issues like hand washing and disease transmission. They will be supported by community paralegals who will help ensure that newly trained community groups can act on education around access, such as receiving free vaccinations, maternal health care, and HIV/AIDS medicines. Materials will continue to be updated as needs and issues arise, with a focus on identifying best practices around health improvements that can be shared across these partner communities. Conclusion: These materials are the first of their kind, and address a void of health information and understanding pervasive in informal-urban Lagos communities. Initial feedback indicates high levels of commitment and interest, as well as investment by communities in these materials, largely because they are responsive, targeted, and build community capacity. This methodology is an important step in dignity-based health justice solutions, albeit in the process of refinement.

Keywords: community health educators, interdisciplinary and cross cultural partnerships, health justice and access, Nigeria

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Authors: Chusit Apirumanekul, Chayanis Krittasudthacheewa, Ratchapat Ratanavaraha, Yanyong Inmuong

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Rapid economic development in the Lower Mekong region is leading to changes in water quantity and quality. Changes in land- and forest-use, infrastructure development, increasing urbanization, migration patterns and climate risks are increasing demands for water, within various sectors, placing pressure on scarce water resources. Appropriate policies, strategies, and planning are urgently needed for improved water resource management. Over the last decade, Thailand has experienced more frequent and intense drought situations, affecting the level of water storage in reservoirs along with insufficient water allocation for agriculture during the dry season. The Huay Saibat River Basin, one of the well-known water-scarce areas in the northeastern region of Thailand, is experiencing ongoing water scarcity that affects both farming livelihoods and household consumption. Drought management in Thailand mainly focuses on emergency responses, rather than advance preparation and mitigation for long-term solutions. Despite many efforts from local authorities to mitigate the drought situation, there is yet no long-term comprehensive water management strategy, that integrates climate risks alongside other uncertainties. This paper assesses the application in the Huay Saibat River Basin, of the Robust Decision Support framework, to explore the feasibility of multiple drought management policies; including a shift in cropping season, in crop changes, in infrastructural operations and in the use of groundwater, under a wide range of uncertainties, including climate and land-use change. A series of consultative meetings were organized with relevant agencies and experts at the local level, to understand and explore plausible water resources strategies and identify thresholds to evaluate the performance of those strategies. Three different climate conditions were identified (dry, normal and wet). Other non-climatic factors influencing water allocation were further identified, including changes from sugarcane to rubber, delaying rice planting, increasing natural retention storage and using groundwater to supply demands for household consumption and small-scale gardening. Water allocation and water use in various sectors, such as in agriculture, domestic, industry and the environment, were estimated by utilising the Water Evaluation And Planning (WEAP) system, under various scenarios developed from the combination of climatic and non-climatic factors mentioned earlier. Water coverage (i.e. percentage of water demand being successfully supplied) was defined as a threshold for water resource strategy assessment. Thresholds for different sectors (agriculture, domestic, industry, and environment) were specified during multi-stakeholder engagements. Plausible water strategies (e.g. increasing natural retention storage, change of crop type and use of groundwater as an alternative source) were evaluated based on specified thresholds in 4 sectors (agriculture, domestic, industry, and environment) under 3 climate conditions. 'Business as usual' was evaluated for comparison. The strategies considered robust, emerge when performance is assessed as successful, under a wide range of uncertainties across the river basin. Without adopting any strategy, the water scarcity situation is likely to escalate in the future. Among the strategies identified, the use of groundwater as an alternative source was considered a potential option in combating water scarcity for the basin. Further studies are needed to explore the feasibility for groundwater use as a potential sustainable source.

Keywords: climate change, robust decision support, scenarios, water resources management

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Authors: Reham K. Sebaih, Afaf I. Shehata , Awatif A. Hindi, Tarek Gheith, Amal A. Hazzani Anas Al-Orjan

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Staphylococci spp are ubiquitous gram-positive bacteria is often associated with infections, especially nosocomial infections, and antibiotic resistanceStudy pathogenic bacteria and its use as a tool in the technology of Nano biology and molecular genetics research of the latest research trends of modern characterization and definition of different multiresistant of bacteria including Staphylococci. The Staphylococci are widespread all over the world and particularly in Saudi Arabia The present work study was conducted to evaluate the effect of five different types of nanoparticles (biosynthesized zinc oxide, Spherical and rod of each silver and gold nanoparticles) and their antibacterial impact on the Staphylococcus species. Ninety-six isolates of Staphylococcus species. Staphylococcus aureus, Staphylococcus epidermidis, MRSA were collected from different sources during the period between March 2011G to June 2011G. All isolates were isolated from inpatients and outpatients departments at Royal Commission Hospital in Yanbu Industrial, Saudi Arabia. High percentage isolation from males(55%) than females (45%). Staphylococcus epidermidis from males was (47%), (28%), and(25%). For Staphylococcus aureus and Methicillin-resistant Staphylococcus aureus (MRSA. Isolates from females were Staphylococcus aureus with higher percent of (47%), (30%), and (23%) for MRSA, Staphylococcus epidermidis. Staphylococcus aureus from wound swab were the highest percent (51.42%) followed by vaginal swab (25.71%). Staphylococcus epidermidis were founded with higher percentage in blood (37.14%) and wound swab (34.21%) respectively related to other. The highest percentage of methicillin-resistant Staphylococcus aureus (MRSA)(80.77%) were isolated from wound swab, while those from nostrils were (19.23%). Staphylococcus species were isolates in highest percentage from hospital Emergency department with Staphylococcus aureus (59.37%), Methicillin-resistant Staphylococcus aureus (MRSA) (28.13%)and Staphylococcus epidermidis (12.5%) respectively. Evaluate the antibacterial property of Zinc oxide, Silver, and Gold nanoparticles as an alternative to conventional antibacterial agents Staphylococci isolates from hospital sources we screened them. Gold and Silver rods Nanoparticles to be sensitive to all isolates of Staphylococcus species. Zinc oxide Nanoparticles gave sensitivity impact range(52%) and (48%). The Gold and Silver spherical nanoparticles did not showed any effect on Staphylococci species. Zinc Oxide Nanoparticles gave bactericidal impact (25%) and bacteriostatic impact (75%) for of Staphylococci species. Detecting the association of nanoparticles with Staphylococci isolates imaging by scanning electron microscope (SEM) of some bacteriostatic isolates for Zinc Oxide nanoparticles on Staphylococcus aureus, Staphylococcus epidermidis and Methicillin resistant Staphylococcus aureus(MRSA), showed some Overlapping Bacterial cells with lower their number and appearing some appendages with deformities in external shape. Molecular analysis was applied by Multiplex polymerase chain reaction (PCR) used for the identification of genes within Staphylococcal pathogens. A multiplex polymerase chain reaction (PCR) method has been developed using six primer pairs to detect different genes using 50bp and 100bp DNA ladder marker. The range of Molecular gene typing ranging between 93 bp to 326 bp for Staphylococcus aureus and Methicillin resistant Staphylococcus aureus by TSST-1,mecA,femA and eta, while the bands border were from 546 bp to 682 bp for Staphylococcus epidermidis using icaAB and atlE. Sixteen isolation of Staphylococcus aureus and Methicillin resistant Staphylococcus aureus were positive for the femA gene at 132bp,this allowed the using of this gene as an internal positive control, fifteen isolates of Staphylococcus aureus and Methicillin resistant Staphylococcus aureus were positive for mecA gene at163bp.This gene was responsible for antibiotic resistant Methicillin, Two isolates of Staphylococcus aureus and Methicillin resistant Staphylococcus aureus were positive for the TSST-1 gene at326bp which is responsible for toxic shock syndrome in some Staphylococcus species, None were positive for eta gene at 102bpto that was responsible for Exfoliative toxins. Six isolates of Staphylococcus epidermidis were positive for atlE gene at 682 bp which is responsible for the initial adherence, three isolates of Staphylococcus epidermidis were positive for icaAB gene at 546bp that are responsible for mediates the formation of the biofilm. In conclusion, this study demonstrates the ability of the detection of the genes to discriminate between infecting Staphylococcus strains and considered biological tests, they may potentiate the clinical criteria used for the diagnosis of septicemia or catheter-related infections.

Keywords: multiplex polymerase chain reaction, toxic shock syndrome, Staphylococcus aureus, nosocomial infections

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