Search results for: patient autonomy

Authors: Onyebueke Godwin, Okwarafor Friday

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Introduction: Persons with HIV/AIDS disease are predisposed to mental health disorders such as depression and suicide. HIV/AIDS, being a chronic medical illness with antecedent stigmatization ostracization, leads to low mood, low self-esteem, and a tendency to kill oneself due to the burden of the disease in terms of cost and disability. The aim of one study was to examine the prevalence of depression and risk of suicide among HIV/AIDS patients compared to negative persons. Instruments: The Major Depressive Episode and Suicidality modules of the MINI-Neuropsychiatric inventory were used to screen the attendees. Report: The prevalence of depression and risk of suicide were 27.8% and 7.8%, respectively, for the HIV positive subjects, but 1208% and 2.2%, respectively, for negative subjects. Conclusion and Significance: Persons with HIV/AIDS usually present with mental health symptoms, but the attending physicians usually pay attention to physical symptoms. The symptoms of the disease or the side effects of the medication may mask the mental health disease. Recommendation: There is need to screen HIV/AIDS patents for mental health disorders during clinic visits.

Keywords: depression, HIV/AIDS, suicidality

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Authors: Nasim Nosoudi, Amir Zadeh, Hunter White, Joshua Conrad, Joon W. Shim

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De novo Malignancy has become one of the major causes of death after transplantation, so early cancer diagnosis and detection can drastically improve survival rates post-transplantation. Most previous work focuses on using artificial intelligence (AI) to predict transplant success or failure outcomes. In this work, we focused on predicting de novo malignancy after liver transplantation using AI. We chose the patients that had malignancy after liver transplantation with no history of malignancy pre-transplant. Their donors were cancer-free as well. We analyzed 254,200 patient profiles with post-transplant malignancy from the US Organ Procurement and Transplantation Network (OPTN). Several popular data mining methods were applied to the resultant dataset to build predictive models to characterize de novo malignancy after liver transplantation. Recipient's bilirubin, creatinine, weight, gender, number of days recipient was on the transplant waiting list, Epstein Barr Virus (EBV), International normalized ratio (INR), and ascites are among the most important factors affecting de novo malignancy after liver transplantation

Keywords: De novo malignancy, bilirubin, data mining, transplantation

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Authors: Yasuyuki Takahashi, Maya Yamashita, Kyoko Saito

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In general, dynamic SPECT data acquisition needs a few minutes for one rotation. Thus, the time-activity curve (TAC) derived from the dynamic SPECT is relatively coarse. In order to effectively shorten the interval, between data points, we adopted a 180-degree interpolation method. This method is already used for reconstruction of the X-ray CT data. In this study, we applied this 180-degree interpolation method to SPECT and investigated its effectiveness.To briefly describe the 180-degree interpolation method: the 180-degree data in the second half of one rotation are combined with the 180-degree data in the first half of the next rotation to generate a 360-degree data set appropriate for the time halfway between the first and second rotations. In both a phantom and a patient study, the data points from the interpolated images fell in good agreement with the data points tracking the accumulation of 99mTc activity over time for appropriate region of interest. We conclude that data derived from interpolated images improves the apparent time resolution of dynamic SPECT.

Keywords: dynamic SPECT, time resolution, 180-degree interpolation method, 99mTc-GSA.

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Authors: S. S. Patil, B. U. Janugade, S. V. Patil

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Pulsatile systems are gaining a lot of interest as they deliver the drug at the right site of action at the right time and in the right amount, thus providing spatial and temporal delivery thus increasing patient compliance. These systems are designed according to the circadian rhythm of the body. Chronotherapeutics is the discipline concerned with the delivery of drugs according to inherent activities of a disease over a certain period of time. It is becoming increasingly more evident that the specific time that patients take their medication may be even more significant than was recognized in the past. The tradition of prescribing medication at evenly spaced time intervals throughout the day, in an attempt to maintain constant drug levels throughout a 24-hour period, may be changing as researcher’s report that some medications may work better if their administration is coordinated with day-night patterns and biological rhythms. The potential benefits of chronotherapeutics have been demonstrated in the management of a number of diseases. In particular, there is a great deal of interest in how chronotherapy can particularly benefit patients suffering from allergic rhinitis, rheumatoid arthritis and related disorders, asthma, cancer, cardiovascular diseases, and peptic ulcer disease.

Keywords: pulsatile drug delivery, chronotherapeutics, circadian rhythm, asthma, chronobiology

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Authors: Peter Williams

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Mobile digital technology, in the form of smart phones, tablets, laptops and their accompanying functionality/apps etc., is becoming ever more used by people with Learning Disabilities (LD) - for entertainment, to communicate and socialize, and enjoy self-expression. Despite this, there has been very little research into the experiences of such technology by this cohort, it’s role in articulating personal identity and self-advocacy and the barriers encountered in negotiating technology in everyday life. The proposed talk describes research funded by the British Academy addressing these issues. It aims to explore: i) the experiences of people with LD in using mobile technology in their everyday lives – the benefits, in terms of entertainment, self-expression and socialising, and possible greater autonomy; and the barriers, such as accessibility or usability issues, privacy or vulnerability concerns etc. ii) how the technology, and in particular the software/apps and interfaces, can be improved to enable the greater access to entertainment, information, communication and other benefits it can offer. It is also hoped that results will inform parents, carers and other supporters regarding how they can use the technology with their charges. Rather than the project simply following the standard research procedure of gathering and analysing ‘data’ to which individual ‘research subjects’ have no access, people with Learning Disabilities (and their supporters) will help co-produce an accessible, annotated and hyperlinked living e-archive of their experiences. Involving people with LD as informants, contributors and, in effect, co-researchers will facilitate digital inclusion and empowerment. The project is working with approximately 80 adults of all ages who have ‘mild’ learning disabilities (people who are able to read basic texts and write simple sentences). A variety of methods is being used. Small groups of participants have engaged in simple discussions or storytelling about some aspect of technology (such as ‘when my phone saved me’ or ‘my digital photos’ etc.). Some individuals have been ‘interviewed’ at a PC, laptop or with a mobile device etc., and asked to demonstrate their usage and interests. Social media users have shown their Facebook pages, Pinterest uploads or other material – giving them an additional focus they have used to discuss their ‘digital’ lives. During these sessions, participants have recorded (or employed the researcher to record) their observations on to the e-archive. Parents, carers and other supporters are also being interviewed to explore their experiences of using mobile technology with the cohort, including any difficulties they have observed their charges having. The archive is supplemented with these observations. The presentation will outline the methods described above, highlighting some of the special considerations required when working inclusively with people with LD. It will describe some of the preliminary findings and demonstrate the e-archive with a commentary on the pages shown.

Keywords: inclusive research, learning disabilities, methods, technology

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Authors: Muna Jalal Ali, Essam A. Makky, Mashitah M. Yusoff

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Objectives: The aim of this study to evaluate the antimicrobial susceptibility of combined toothpaste with medicinal plants and the relations between the commercial toothpaste to its price and the patient age as well. Materials and Methods: Oral isolates of different patients aged 3 to 60 years were obtained, purified, and tested against four different ethnomedicinal plant extracts for antimicrobial activity. A total of 10 different commercial toothpastes (different brands and prices) were collected from the market, and the combined action of the medicinal plants and toothpaste was studied. Results: We found a higher bacterial population in the age group of 3–40 years than the group of 40–60 years, with approximately 44% and 32%, respectively. The combined action of ethanolic extract (alone) against oral isolates showed a synergistic effect, with 32.20, 30.50, and 25.42% for combinations A (Ci/Ca), B (Ci/Ca/P), and C (Ci/Ca/P/N), respectively. By contrast, the combined action of ethnomedicinal plants with 10 different toothpastes improved the antimicrobial sensitivity by 60, 100, and 0% for combinations A, B, and C respectively. Clinical relevance: The ethanolic extract of only combinations A and B with commercial toothpaste showed high antibacterial activity against oral isolates and the effectiveness of toothpaste is not related to the price.

Keywords: microbial evolution, oral isolates, ethnomedicinal plants, antimicrobial activity, toothpaste

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Authors: O. Maranci, A. B. Tugrul

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Scintigraphy is an imaging method of nuclear events provoked by collisions or charged current interactions with radiation. It is used for diagnostic test used in nuclear medicine via radiopharmaceuticals emitting radiation which is captured by gamma cameras to form two-dimensional images. Liver scintigraphy is widely used in nuclear medicine.Tc-99m and Cr-51 gamma radioisotopes can be used for this purpose. Cr-51 usage is more important for patients’ organ dose that has higher energy and longer half-life as compared to Tc-99m. In this study, it is aimed to determine the required dose for critical organs of patient through liver scintigraphy via Cr-51 gamma radioisotope. Experimental studies were conducted on patients even though conducting experimental studies on patients is extremely difficult for determination of critical organ doses. Torso phantom was utilized to simulate the liver scintigraphy by using 20 mini packages of Cr-51 that were placed on the organ. The radioisotope was produced by irradiation in central thimble of TRIGA MARK II Reactor at 250 KW power. As the results of the study, critical organ doses were determined and evaluated with different critic organs.

Keywords: critical organ doses, liver, scintigraphy, TRIGA Mark-II

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Authors: Md. Abu Sufian, Robiqul Islam, Imam Hossain Shajid, Mahesh Hanumanthu, Jarasree Varadarajan, Md. Sipon Miah, Mingbo Niu

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Coronary Heart Disease (CHD) remains a principal cause of global morbidity and mortality, characterized by atherosclerosis—the build-up of fatty deposits inside the arteries. The study introduces an innovative methodology that leverages cloud-based platforms like AWS Live Streaming and Artificial Intelligence (AI) to early detect and prevent CHD symptoms in web applications. By employing novel simulation processes and AI algorithms, this research aims to significantly mitigate the health and societal impacts of CHD. Methodology: This study introduces a novel simulation process alongside a multi-phased model development strategy. Initially, health-related data, including heart rate variability, blood pressure, lipid profiles, and ECG readings, were collected through user interactions with web-based applications as well as API Integration. The novel simulation process involved creating synthetic datasets that mimic early-stage CHD symptoms, allowing for the refinement and training of AI algorithms under controlled conditions without compromising patient privacy. AWS Live Streaming was utilized to capture real-time health data, which was then processed and analysed using advanced AI techniques. The novel aspect of our methodology lies in the simulation of CHD symptom progression, which provides a dynamic training environment for our AI models enhancing their predictive accuracy and robustness. Model Development: it developed a machine learning model trained on both real and simulated datasets. Incorporating a variety of algorithms including neural networks and ensemble learning model to identify early signs of CHD. The model's continuous learning mechanism allows it to evolve adapting to new data inputs and improving its predictive performance over time. Results and Findings: The deployment of our model yielded promising results. In the validation phase, it achieved an accuracy of 92% in predicting early CHD symptoms surpassing existing models. The precision and recall metrics stood at 89% and 91% respectively, indicating a high level of reliability in identifying at-risk individuals. These results underscore the effectiveness of combining live data streaming with AI in the early detection of CHD. Societal Implications: The implementation of cloud-based AI for CHD symptom detection represents a significant step forward in preventive healthcare. By facilitating early intervention, this approach has the potential to reduce the incidence of CHD-related complications, decrease healthcare costs, and improve patient outcomes. Moreover, the accessibility and scalability of cloud-based solutions democratize advanced health monitoring, making it available to a broader population. This study illustrates the transformative potential of integrating technology and healthcare, setting a new standard for the early detection and management of chronic diseases.

Keywords: coronary heart disease, cloud-based ai, machine learning, novel simulation techniques, early detection, preventive healthcare

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Authors: Dalia Almaghaslah

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Design thinking approach; empathize, define, ideate prototype, test, implement, was used to assess outpatient experiences in two hospital pharmacies in the Asir region, Saudi Arabia. Semi-structured interviews were conducted with 40 patients. The data were analyzed using thematic analysis. The findings suggested that patients were generally satisfied with pharmaceutical services provided in both pharmacies. Pharmacists were found to have enough knowledge, good attitude, and efficient communication and counselling skills. Non-pharmacy-related factors such as cultural factors (gender segregation), long waiting times, uncomfortable waiting areas, lack of electronic prescribing, number waiting system were found to have a negative impact on patients' experiences and satisfaction. Prototypes will be used to test the effects of implementing the electronic system in Al -mahal hospital and to test changing the physical layout of the waiting area in Asir hospital.

Keywords: design thinking, hospital pharmacy, patient satisfaction, Saudi Arabia

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Authors: Chanpen Meenakorn

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This research aimed to examine the relationships between customer expectations and service quality management of Banpaew Hospital Samutsakorn in Thailand. The study sample consisted of 360 customers in patient unit. Data were collected using self-administered questionnaire. Descriptive statistics used were percentage, mean, and standard deviation. The analytical statistics comprised Pearson’s product moment correlation coefficient analysis. The result showed that service quality of nurses was very good with sustainable development trend. Physical evidence was at a high level, and the process and personal were rated at a high level. Additional, the study suggested that head nurse should be encouraged to improve service quality management, management training. Nurse administrators should create an appropriate nursing department climate, and provide necessary resources in the department. In addition, the nurse administrators should continuously follow up the results of customer expectations and focus on patients/customers, process management, information and knowledge management, and evaluation of service quality also.

Keywords: Banpaew Hospital, Customer Expectations, Service Provided, Samutsakorn

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Authors: Laura Mion

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Concepts of quality assurance and management are now part of the organizational culture of the Universities. Quality Assurance (QA) systems are, in large part, provided for by national regulatory dictates or supranational indications (such as, for example, at European level are, the ESG Guidelines "European Standard Guidelines"), but their specific definition, in terms of guiding principles, requirements and methodologies, are often delegated to the national evaluation agencies or to the autonomy of individual universities. For this reason, the experiences of implementation of QA systems in different countries and in different universities is an interesting source of information to understand how quality in universities is understood, pursued and verified. The literature often deals with the treatment of the experiences of implementation of QA systems in the individual areas in which the University's activity is carried out - teaching, research, third mission - but only rarely considers quality systems with a systemic and integrated approach, which allows to correlate subjects, actions, and performance in a virtuous circuit of continuous improvement. In particular, it is interesting to understand how to relate the results and uses of the QA in the triple distinction of university activities, identifying how one can cause the performance of the other as a function of an integrated whole and not as an exploit of specific activities or processes conceived in an abstractly atomistic way. The aim of the research is, therefore, to investigate which experiences of "integrated" QA systems are present on the international scene: starting from the experience of European countries that have long shared the Bologna Process for the creation of a European space for Higher Education (EHEA), but also considering experiences from emerging countries that use QA processes to develop their higher education systems to keep them up to date with international levels. The concept of "integration", in this research, is understood in a double meaning: i) between the different areas of activity, in particular between the didactic and research areas, and possibly with the so-called "third mission" "ii) the functional integration between those involved in quality assessment and management and the governance of the University. The paper will present the results of a systematic review conducted according with a method of an integrative review aimed at identifying best practices of quality assurance systems, in individual countries or individual universities, with a high level of integration. The analysis of the material thus obtained has made it possible to grasp common and transversal elements of QA system integration practices or particularly interesting elements and strengths of these experiences that can, therefore, be considered as winning aspects in a QA practice. The paper will present the method of analysis carried out, and the characteristics of the experiences identified, of which the structural elements will be highlighted (level of integration, areas considered, organizational levels included, etc.) and the elements for which these experiences can be considered as best practices.

Keywords: quality assurance, university, integration, country

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Authors: S. M. Arciniegas, D. Vargas, L. Gutierrez

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The aim of this study was to develop oral drug presentation of doxycycline hyclate that maintains longer therapeutic levels than conventional forms. A polymethacrylate and acrylic acid based matrix were used in different proportions to obtain controlled-release formulations; DOX1 (1:0.25:0.0035), DOX2 (1:2:0.0225) and DOX-C (without excipients). All were tested in vivo in healthy dogs and their serum concentrations vs. time profile was investigated after its oral administration in this species. DOX1 and DOX2 show therapeutic concentrations for 60 hours, while DOX-C only for 24 hours. The pharmacokinetics values tested were K½el, Cmax, Tmax, AUC, AUC∞, AUCt, AUMC, RT, Kel, Vdss, Clb and Frel. DOX1 does not differ significantly from DOX-C, but shows significant differences in all variables with DOX2 (p<0.05). In conclusion, DOX1 presents best pharmacokinetics for time-dependent drug and longer release time of 60 hours, thereby reducing the frequency of administration, the patient's stress, the occurrence of adverse effects and the cost of treatment.

Keywords: tetracyclines, long-acting, sustained-release, carbopol, eudragit, canine

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Authors: Supriyo Das, Elbir Jove, Ajay Singh, Sophie Corbet, Noel Carr, Martin Deetz

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Water is a critical commodity in the healthcare and medical field. The utility of medical-grade water spans from washing surgical equipment, drug preparation to the key element of life-saving therapy such as hydrotherapy and hemodialysis for patients. A properly treated medical water reduces the bioburden load and mitigates the risk of infection, ensuring patient safety. However, any compromised condition during the production of medical-grade water can create a favorable environment for microbial growth putting patient safety at high risk. Therefore, proper upstream treatment of the medical water is essential before its application in healthcare, pharma and medical space. Reverse Osmosis (RO) is one of the most preferred treatments within healthcare industries and is recommended by all International Pharmacopeias to achieve the quality level demanded by global regulatory bodies. The RO process can remove up to 99.5% of constituents from feed water sources, eliminating bacteria, proteins and particles sizes of 100 Dalton and above. The combination of RO with other downstream water treatment technologies such as Electrodeionization and Ultrafiltration meet the quality requirements of various pharmacopeia monographs to produce highly purified water or water for injection for medical use. In the reverse osmosis process, the water from a liquid with a high concentration of dissolved solids is forced to flow through an especially engineered semi-permeable membrane to the low concentration side, resulting in high-quality grade water. However, these specially engineered RO membranes need to be sanitized either chemically or at high temperatures at regular intervals to keep the bio-burden at the minimum required level. In this paper, we talk about Dupont´s FilmTec Heat Sanitizable Reverse Osmosis membrane (HSRO) for the production of medical-grade water. An HSRO element must be pre-conditioned prior to initial use by exposure to hot water (80°C-85°C) for its stable performance and to meet the manufacturer’s specifications. Without pre-conditioning, the membrane will show variations in feed pressure operations and salt rejection. The paper will discuss the critical variables of pre-conditioning steps that can affect the overall performance of the HSRO membrane and demonstrate the data to support the need for pre-conditioning of HSRO elements. Our preliminary data suggests that there can be up to 35 % reduction in flow due to initial heat treatment, which also positively affects the increase in salt rejection. The paper will go into detail about the fundamental understanding of the performance change of HSRO after the pre-conditioning step and its effect on the quality of medical water produced. The paper will also discuss another critical point, “regular hot water sanitization” of these HSRO membranes. Regular hot water sanitization (at 80°C-85°C) is necessary to keep the membrane bioburden free; however, it can negatively impact the performance of the membrane over time. We will demonstrate several data points on hot water sanitization using FilmTec HSRO elements and challenge its robustness to produce quality medical water. The last part of this paper will discuss the construction details of the FilmTec HSRO membrane and features that make it suitable to pre-condition and sanitize at high temperatures.

Keywords: heat sanitizable reverse osmosis, HSRO, medical water, hemodialysis water, water for Injection, pre-conditioning, heat sanitization

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Authors: Hasan Alrashid

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The 2005 Hague Convention seeks to ensure legal certainty and predictability between parties in international business transactions. It harmonies exclusive choice of court agreements at the international level between parties to commercial transactions and to govern the recognition and enforcement of judgments resulting from proceedings based on such agreements to promote international trade and investment. Although the choice of court agreements is significant in international business transactions, the United Arab Emirates refuse to recognise it by Article 24 of the Federal Law No. 11 of 1992 of the Civil Procedure Code. A review of judicial judgments in United Arab Emirates up to the present day has revealed that several cases appeared before the Court in different states of United Arab Emirates regarding the recognition of exclusive choice of court agreements. In all the cases, the courts regarded the exclusive choice of court agreements as a direct assault on state authority and sovereignty and refused categorically to recognize choice of court agreements by refusing to stay proceedings in favor of the foreign chosen court. This has created uncertainty and unpredictability in international business transaction in the United Arab Emirates. In June 2011, the first Gulf Judicial Seminar on Cross-Frontier Legal Cooperation in Civil and Commercial Matters was held in Doha, Qatar. The Permanent Bureau of the Hague Conference attended the conference and invited the states of the Gulf Cooperation Council (GCC) namely, The United Arab Emirates, Bahrain, Saudi Arabia, Oman, Qatar and Kuwait to adopt some of the Hague Conventions, one of which was the Hague Convention on Choice of Court Agreements. One of the recommendations of the conference was that the GCC states should research ‘the benefits of predictability and legal certainty provided by the 2005 Convention on Choice of Court Agreements and its resulting advantages for cross-border trade and investment’ for possible adoption of the Hague Convention. Up to today, no further step has been taken by the any of the GCC states to adapt the Hague Convention nor did they conduct research on the benefits of predictability and legal certainty in international business transactions. This paper will argue that the approach regarding the recognition of choice of court agreements in United Arab Emirates states can be improved in order to help the parties in international business transactions avoid parallel litigation and ensure legal certainty and predictability. The focus will be the uncertainty and gaps regarding the choice of court agreements in the United Arab Emirates states. The Hague Convention on choice of court agreements and the importance of harmonisation of the rules of choice of court agreements at international level will also be discussed. Finally, The feasibility and desirability of recognizing choice of court agreements in United Arab Emirates legal system by becoming a party to the Hague Convention will be evaluated.

Keywords: choice of court agreements, party autonomy, public authority, sovereignty

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Authors: Diamant Irene, Shklarnik Batya

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In on to its widespread effects on health and economic issues, Covid-19 shook the work and employment world. Among the prominent changes during the pandemic is the work-from-home trend, complete or partial, as part of social distancing. In fact, these changes accelerated an existing tendency of work flexibility already underway before the pandemic. Technology and means of advanced communications led to a re-assessment of “place of work” as a physical space in which work takes place. Today workers can remotely carry out meetings, manage projects, work in groups, and different research studies point to the fact that this type of work has no adverse effect on productivity. However, from the worker’s perspective, despite numerous advantages associated with work from home, such as convenience, flexibility, and autonomy, various drawbacks have been identified such as loneliness, reduction of commitment, home-work boundary erosion, all risk factors relating to the quality of life and burnout. Thus, a real need has arisen in exploring differences in work-from-home experiences and understanding the relationship between psychological characteristics and the prevalence of burnout. This understanding may be of significant value to organizations considering a future hybrid work model combining in-office and remote working. Based on Hobfoll’s Theory of Conservation of Resources, we hypothesized that burnout would mainly be found among workers whose physical remoteness from the workplace threatens or hinders their ability to retain significant individual resources. In the present study, we compared fully remote and partially remote workers (hybrid work), and we examined psychological characteristics and their connection to the formation of burnout. Based on the conceptualization of Place Attachment as the cognitive-emotional bond of an individual to a meaningful place and the need to maintain closeness to it, we assumed that individuals characterized with Place Attachment to the workplace would suffer more from burnout when working from home. We also assumed that extrovert individuals, characterized by the need of social interaction at the workplace and individuals with segmentationpreference – a need for separation between different life domains, would suffer more from burnout, especially among fully remote workers relative to partially remote workers. 194 workers, of which 111 worked from home in full and 83 worked partially from home, aged 19-53, from different sectors, were tested using an online questionnaire through social media. The results of the study supported our assumptions. The repercussions of these findings are discussed, relating to future occupational experience, with an emphasis on suitable occupational adjustment according to the psychological characteristics and needs of workers.

Keywords: working from home, burnout, place attachment, extraversion, segmentation preference, Covid-19

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Authors: R. Pardo, P. Menendez, MA Gil-Olarte, S. Sanchez, E. García, R. Quintana, J. Martín

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Introduction : Within oncoplastic breast techniques there is increased interest in immediate partial breast reconstruction. The volume resected is greater than that of conventional conservative techniques. Central tumours of the breast have classically been treated with a mastectomy with regard to oncological safety and cosmetic secondary effects after wide central resection of the nipple and breast tissue beneath. Oncological results for central quadrantectomy have a recurrence level, disease- free period and survival identical to mastectomy. Grissoti flap is an oncoplastic surgical technique that allows the surgeon to perform a safe central quadrantectomy with excellent cosmetic results. Material and methods: The Grissoti flap is a glandular cutaneous advancement rotation flap that can fill the defect in the central portion of the excised breast. If the inferior border is affected by tumour and further surgery is decided upon at the Multidisciplinary Team Meeting, it will be necessary to perform a mastectomy. All patients with a Grisotti flap undergoing surgery since 2009 were reviewed obtaining the following data: age, hystopathological diagnosis, size, operating time, volume of tissue resected, postoperative admission time, re-excisions due to positive margins affected by tumour, wound dehiscence, complications and recurrence. Analysis and results of sentinel node biopsy were also obtained. Results: 12 patients underwent surgery between 2009-2015. The mean age was 54 years (34-67) . All had a preoperative diagnosis of ductal infiltrative carcinoma of less than 2 cm,. Diagnosis was made with Ultrasound, Mamography or both . Magnetic resonance was used in 5 cases. No patients had preoperative positive axilla after ultrasound exploration. Mean operating time was 104 minutes (84-130). Postoperative stay was 24 hours. Mean volume resected was 159 cc (70-286). In one patient the surgical border was affected by tumour and a further procedure with resection of the affected border was performed as ambulatory surgery. The sentinel node biopsy was positive for micrometastasis in only two cases. In one case lymphadenectomy was performed in 2009. In the other, treated in 2015, no lymphadenectomy was performed as the patient had a favourable histopathological prognosis and the multidisciplinary team meeting agreed that lymphadenectomy was not required. No recurrence has been diagnosed in any of the patients who underwent surgery and they are all disease free at present. Conclusions: Conservative surgery for retroareolar central tumours of the breast results in good local control of the disease with free surgical borders, including resection of the nipple areola complex and pectoral major muscle fascia. Reconstructive surgery with the inferior Grissoti flap adequately fills the defect after central quadrantectomy with creation of a new cutaneous disc where a new nipple areola complex is reconstructed with a local flap or micropigmentation. This avoids the need for contralateral symmetrization. Sentinel Node biopsy can be performed without added morbidity. When feasible, the Grissoti flap will avoid skin-sparing mastectomy for central breast tumours that will require the use of an expander, prosthesis or myocutaneous flap, with all the complications of a more complex operation.

Keywords: Grisotti flap, oncoplastic surgery, central tumours, breast

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Authors: Dina Farran, Mark Ashworth, Fiona Gaughran

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Atrial fibrillation (AF), the most prevalent cardiac arrhythmia, is associated with an increased risk of stroke, contributing to heart failure and death. In this project, we aim to improve patient safety by screening for stroke risk among people with AF and co-morbid mental illness. To do so, we started by conducting a systematic review and meta-analysis on prevalence, management, and outcomes of AF in people with Serious Mental Illness (SMI) versus the general population. We then evaluated oral anticoagulation (OAC) prescription trends in people with AF and co-morbid SMI in King’s College Hospital. We also evaluated the association between mental illness severity and OAC prescription in eligible patients in South London and Maudsley (SLaM) NHS Foundation Trust. Next, we implemented an electronic clinical decision support system (eCDSS) consisting of a visual prompt on patient electronic Personal Health Records to screen for AF-related stroke risk in three Mental Health of Older Adults wards at SLaM. Finally, we assessed the feasibility and acceptability of the eCDSS by qualitatively investigating clinicians’ perspectives of the potential usefulness of the eCDSS (pre-intervention) and their experiences and their views regarding its impact on clinicians and patients (post-intervention). The systematic review showed that people with SMI had low reported rates of AF. AF patients with SMI were less likely to receive OAC than the general population. When receiving warfarin, people with SMI, particularly bipolar disorder, experienced poor anticoagulation control compared to the general population. Meta-analysis showed that SMI was not significantly associated with an increased risk of stroke or major bleeding when adjusting for underlying risk factors. The main findings of the first observational study were that among AF patients having a high stroke risk, those with co-morbid SMI were less likely than non-SMI to be prescribed any OAC, particularly warfarin. After 2019, there was no significant difference between the two groups. In the second observational study, patients with AF and co-morbid SMI were less likely to be prescribed any OAC compared to those with dementia, substance use disorders, or common mental disorders, adjusting for age, sex, stroke, and bleeding risk scores. Among AF patients with co-morbid SMI, warfarin was less likely to be prescribed to those having alcohol or substance dependency, serious self-injury, hallucinations or delusions, and activities of daily living impairment. In the intervention, clinicians were asked to confirm the presence of AF, clinically assess stroke and bleeding risks, record risk scores in clinical notes, and refer patients at high risk of stroke to OAC clinics. Clinicians reported many potential benefits for the eCDSS, including improving clinical effectiveness, better identification of patients at risk, safer and more comprehensive care, consistency in decision making and saving time. Identified potential risks included rigidity in decision-making, overreliance, reduced critical thinking, false positive recommendations, annoyance, and increased workload. This study presents a unique opportunity to quantify AF patients with mental illness who are at high risk of severe outcomes using electronic health records. This has the potential to improve health outcomes and, therefore patients' quality of life.

Keywords: atrial fibrillation, stroke, mental health conditions, electronic clinical decision support systems

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Authors: Nwamaka Patricia Ibeme, Musa Zakari

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E-learning is made more effective because; it is enable student to students to easily interact, share, and collaborate across time and space with the help of e-governance platform. Zoom and the Microsoft classroom team can invite students from all around the world to join a conversation on a certain subject simultaneously. E-governance may be able to work on problem solving skills, as well as brainstorming and developing ideas. As a result of the shared experiences and knowledge, students are able to express themselves and reflect on their own learning." For students, e-governance facilities provide greater opportunity for students to build critical (higher order) thinking abilities through constructive learning methods. Students' critical thinking abilities may improve with more time spent in an online classroom. Students' inventiveness can be enhanced through the use of computer-based instruction. Discover multimedia tools and produce products in the styles that are easily available through games, Compact Disks, and television. The use of e-learning has increased both teaching and learning quality by combining student autonomy, capacity, and creativity over time in developed countries." Teachers are catalysts for the integration of technology through Information and Communication Technology, and e-learning supports teaching by simplifying access to course content." Creating an Information and Communication Technology class will be much easier if educational institutions provide teachers with the assistance, equipment, and resources they need. The study adopted survey research design. The populations of the study are Students and staff. The study adopted a simple random sampling technique to select a representative population. Both primary and secondary method of data collection was used to obtain the data. A chi-square statistical technique was used to analyze. Finding from the study revealed that e-learning has increase accesses to universities educational by public servants in Nigeria. Public servants in Nigeria have utilized e-learning and Online Distance Learning (ODL) programme to into various degree programmes. Finding also shows that E-learning plays an important role in teaching because it is oriented toward the use of information and communication technologies that have become a part of the everyday life and day-to-day business. E-learning contributes to traditional teaching methods and provides many advantages to society and citizens. The study recommends that the e-learning tools and internet facilities should be upgrade to foster any network challenges in the online facilitation and lecture delivery system.

Keywords: E-governance, E-learning, online distance learning, university education public servants, Nigeria

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Authors: Aref Zribi, Sonia Ben Nasr, Sana Fendri, Mahdi Balti, Abderazzek Haddaoui

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Background: Despite their benefit, Endocrine therapies (ET) are known to have substantial adverse events (AEs) such as hot flashes, mood disorders and osteoarticular pain. ET induced alopecia(EIA) is less frequently noted by patients and is less reported in the literature. The aim of our study was to report ET alopecia characteristics and their influence on patient and treatment observance. Method: We conducted a retrospective study including luminal BC patients treated in the oncology department of the military hospital of Tunis between January 2015 and December 2020. Patients treated with previous chemotherapy-inducing alopecia were excluded. Results: 145 female patients were included. The median age was 59 years. EIA was reported in 44% of cases. Alopecia was attributed to aromatase inhibitors in 53% and tamoxifen in 21%. Severity was grade 1 in 80% and grade 2 in the remaining cases. ET discontinuation because of alopecia was noted in 6.5 % of patients. Moderate improvement of alopecia was observed with topical minoxidil and Thallium metallicum 9CH homeopathy during ET in 60% of patients. Conclusions: EIA is frequent in BC patients and should be considered to improve treatment observance and patients’ quality of life.

Keywords: endocrine therapy, alopecia, breast cancer, Tunisia

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Authors: Taher Eid Shaaban Ahmed Mousa

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Non-Alcoholic fatty liver disease (NAFLD) is a major cause of multiple liver disorders, which strongly linked to a poor lifestyle. This study aiming to elucidate the exercise program’s effectiveness on hepatic fat mobilization among nonalcoholic fatty liver patients. Subjects: A purposive sample of 150 adult male & female patients. Setting: National institute of liver out patient's clinics of Menoufia University. Tools: three tools I: An interviewing structured questionnaire, II: International Physical Activity Questionnaire, III: compliance assessment sheet. Results: There was statistically significant difference pre and post exercise program regarding total body weight, physical activity level and compliance that prevent new fat development with resolution of existing one. Conclusion: regular exercise is the best implemented approach as an initial step for the prevention, treatment and management of NAFLD. Recommendation: It is highly important to unravel the mechanism and dose by which each exercise specifically resolve various stages of liver diseases.

Keywords: exercise program, hebatic fat mobilization, nonalcoholic fatty liver patients, sport science

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Authors: Tanya Beran, Michelle Drefs, Ghazwan Altabbaa, Nouf Al Harbi, Noof Al Baz, Elizabeth Oddone Paolucci

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Although research shows that interprofessional practice has desirable effects on patient care, its implementation can present challenges to its team members. In particular, they may feel pressured to agree with or conform to other members who share information that is contrary to their own understanding. Obtaining evidence of this phenomenon is challenging, as team members may underreport their conformity behaviors due to reasons such as social desirability. In this paper, a series of studies are reviewed in which several approaches to assessing conformity in the health care professions are tested. Simulations, questionnaires, and behavior checklists were developed to measure conformity behaviors. Insights from these studies show that a significant proportion of people conform either in the presence or absence of others, express a variety of verbal and nonverbal behaviors when considering whether to conform to others, may shift between conforming and moments later not conforming (and vice versa), and may not accurately report whether they conformed. A new method of measuring conformity using the implicit bias test is also discussed. People at all levels in the healthcare system are encouraged to develop both formal and informal.

Keywords: conformity, decision-making, inter-professional teams, simulation

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Authors: Junjun Chen, Yingxiu Li

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The occupational well-being of school principals has played a vital role in the pursuit of individual and school wellness and success. However, principals’ well-being worldwide is under increasing threat because of the challenging and complex nature of their work and growing demands for school standardisation and accountability. Pressure is particularly acute in the post-pandemicfuture as principals attempt to deal with the impact of the pandemic on top of more regular demands. This is particularly true in Hong Kong, as school principals are increasingly wedged between unparalleled political, social, and academic responsibilities. Recognizing the semantic breadth of well-being, scholars have not determined a single, mutually agreeable definition but agreed that the concept of well-being has multiple dimensions across various disciplines. The multidimensional approach promises more precise assessments of the relationships between well-being and other concepts than the ‘affect-only’ approach or other single domains for capturing the essence of principal well-being. The multiple-dimension well-being concept is adopted in this project to understand principal well-being in this study. This study aimed to understand the situation of principal well-being and its influential drivers with a sample of 670 principals from Hong Kong and Mainland China. An online survey was sent to the participants after the breakout of COVID-19 by the researchers. All participants were well informed about the purposes and procedure of the project and the confidentiality of the data prior to filling in the questionnaire. Confirmatory factor analysis and structural equation modelling performed with Mplus were employed to deal with the dataset. The data analysis procedure involved the following three steps. First, the descriptive statistics (e.g., mean and standard deviation) were calculated. Second, confirmatory factor analysis (CFA) was used to trim principal well-being measurement performed with maximum likelihood estimation. Third, structural equation modelling (SEM) was employed to test the influential factors of principal well-being. The results of this study indicated that the overall of principal well-being were above the average mean score. The highest ranking in this study given by the principals was to their psychological and social well-being (M = 5.21). This was followed by spiritual (M = 5.14; SD = .77), cognitive (M = 5.14; SD = .77), emotional (M = 4.96; SD = .79), and physical well-being (M = 3.15; SD = .73). Participants ranked their physical well-being the lowest. Moreover, professional autonomy, supervisor and collegial support, school physical conditions, professional networking, and social media have showed a significant impact on principal well-being. The findings of this study will potentially enhance not only principal well-being, but also the functioning of an individual principal and a school without sacrificing principal well-being for quality education in the process. This will eventually move one step forward for a new future - a wellness society advocated by OECD. Importantly, well-being is an inside job that begins with choosing to have wellness, whilst supports to become a wellness principal are also imperative.

Keywords: well-being, school principals, quantitative, influential factors

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Authors: Yong Seong Kim, Seongbin Hong, So Hun Kim, Moonsuk Nam

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Background: Patients who undergo thyroidectomy due to thyroid cancer often complain weight gain, although they are on suppressive thyroid hormone treatment. The aim of this study is to know whether thyroid cancer patients gain the weight after thyroidectomy and weight change is dependent on estrogen state or use of rhTSH. Material and Method: We performed a retrospective chart review of subjects receiving medical care at an academic medical center. Two hundred two patients who underwent total thyroidectomy were included. As a control group, patients with thyroid nodule and euthyroidism were matched for age, gender, menopausal status. The weight changes occurring over first one year and thyroid function were assessed. Results: Mean age was 51±12 years and patients was composed with 38% of premenopausal, 15 % perimenopausal women, 37% of postmenopausal women and 20% of men. Patients with thyroid cancer gained 2.2 kg during the first year. It’ was not significantly different with control. However, weigh change in perimenopausal and post menopausal women gained more weight than control (P <0.05). Age, baseline body weight and weight gain were not correlated. Discussion: Patient who had undergone thyroidectomy gained more weight than their control, especially in peri- and postmenopausal women. Patients in this age should be monitored for their weight carefully.

Keywords: weight gain, thyroidectomy, thyroid cancer, weight chance

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Authors: R. V. Dahibhate, A. B. Deoghare, P. M. Padole

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Maintaining natural integrity of biosystem is paramount significant for orthopedic surgeon while performing surgery. Restoration is challenging task to rehabilitate trauma patient. Drilling is an inevitable procedure to fix implants. The task leads to rise in temperature at the contact site which intends to thermal necrosis. A precise monitoring can avoid thermal necrosis. To accomplish it, data acquiring instrument is integrated with the drill bit. To contemplate it, electronic feedback system is developed. It not only measures temperature without any physical contact in between measuring device and target but also visualizes the site and monitors correct movement of tool path. In the current research work an infrared thermometer data acquisition system is used which monitors variation in temperature at the drilling site and a camera captured movement of drill bit advancement. The result is presented in graphical form which represents variations in temperature, drill rotation and time. A feedback system helps in keeping drill speed in threshold limit.

Keywords: thermal necrosis, infrared thermometer, drilling tool, feedback system

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Authors: Briohny H. Spencer, Russ Chess-Williams, Catherine McDermott, Shailendra Anoopkumar-Dukie, David Christie

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Background: Prostate cancer is the second most common cancer diagnosed in men worldwide and the most prevalent in Australian men. In 2015, it was estimated that approximately 18,000 new cases of prostate cancer were diagnosed in Australia. Currently, for localised disease, androgen depravation therapy (ADT) and radiotherapy are a major part of the curative management of prostate cancer. ADT acts to reduce the levels of circulating androgens, primarily testosterone and the locally produced androgen, dihydrotestosterone (DHT), or by preventing the subsequent activation of the androgen receptor. Thus, the growth of the cancerous cells can be reduced or ceased. Radiation techniques such as brachytherapy (radiation delivered directly to the prostate by transperineal implant) or external beam radiation therapy (exposure to a sufficient dose of radiation aimed at eradicating malignant cells) are also common techniques used in the treatment of this condition. Radiotherapy (RT) has significant limitations, including reduced effectiveness in treating malignant cells present in hypoxic microenvironments leading to radio-resistance and poor clinical outcomes and also the significant side effects for the patients. Alpha1-adrenoceptor antagonists are used for many prostate cancer patients to control lower urinary tract symptoms, due to the progression of the disease itself or may arise as an adverse effect of the radiotherapy treatment. In Australia, a significant number (not a majority) of patients receive a α1-ADR antagonist and four drugs are available including prazosin, terazosin, alfuzosin and tamsulosin. There is currently limited published data on the effects of α1-ADR antagonists during radiotherapy, but it suggests these medications may improve patient outcomes by enhancing the effect of radiotherapy. Aim: To determine the impact of α1-ADR antagonists treatments on time to biochemical relapse following radiotherapy. Methods: A retrospective study of male patients receiving radiotherapy for biopsy-proven localised prostate cancer was undertaken to compare cancer outcomes for drug-naïve patients and those receiving α1-ADR antagonist treatments. Ethical approval for the collection of data at Genesis CancerCare QLD was obtained and biochemical relapse (defined by a PSA rise of >2ng/mL above the nadir) was recorded in months. Rates of biochemical relapse, prostate specific antigen doubling time (PSADT) and Kaplan-Meier survival curves were also compared. Treatment groups were those receiving α1-ADR antagonists treatment before or concurrent with their radiotherapy. Data was statistically analysed using One-way ANOVA and results expressed as mean ± standard deviation. Major findings: The mean time to biochemical relapse for tamsulosin, prazosin, alfuzosin and controls were 45.3±17.4 (n=36), 41.5±19.6 (n=11), 29.3±6.02 (n=6) and 36.5±17.6 (n=16) months respectively. Tamsulosin, prazosin but not alfuzosin delayed time to biochemical relapse although the differences were not statistically significant. Conclusion: Preliminary data for the prior and/or concurrent use of tamsulosin and prazosin showed a positive trend in delaying time to biochemical relapse although no statistical significance was shown. Larger clinical studies are indicated and with thousands of patient records yet to be analysed, it may determine if there is a significant effect of these drugs on control of prostate cancer.

Keywords: alpha1-adrenoceptor antagonists, biochemical relapse, prostate cancer, radiotherapy

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Authors: Abdelmaguid Ramzy, Mohamed Bahaa

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Introduction: The effects of ovarian endometrioma on fertility outcomes with IVF have been always related to poor outcomes. Objective: To evaluate the effect of unilateral unoperated ovarian endometrioma < 2cm on the number of developing follicles and compare them with the contralateral ovary as a control. Design: Retrospective case control study. Setting: KasrEl-Aini IVF center. Patient(s): We studied 32 women with unilateral endometrioma who underwent their first IVF cycle. Methods: 32 Patients aged between 20-35 years selected for IVF who were diagnosed with one unilateral endometrioma (diameter <2 cm) and who did not undergo previous ovarian surgery were retrospectively identified. The number of follicles > 17 mm during folliculometry on the day of HCG trigger in the ovary that contained endometrioma were compared with those from the contralateral ovary. They were all hyperstimulated using long protocol with (225-300 IU) gonadotrophins. Primary outcome: The number of follicles > 17 mm during folliculometry on the day of HCG trigger. Result(s): The mean ± SD age, Day 3 serum FSH and LH were 27± 3.7 years, 5.8 ± 1.6 IU/ml and 4.5 ± 1.7 IU/ml respectively. There was no significant difference in the number of follicles > 17 mm on the day of HCG trigger in the ovary that contained endometrioma (4.4 ±2.5) and in the opposite ovary (4.5 ± 2.8) (P= 0.48). Conclusion: The presence of ovarian endometrioma in a controlled ovarian hyperstimulation cycle for IVF treatment is not associated with a reduced number of follicles > 17 mm during folliculometry on the day of HCG trigger.

Keywords: endometrioma, folliculometry, hyperstimulation, fertility

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Authors: Alyona Gencheva

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The most common way to study diagnostic results is using specialized programs at a stationary workplace. Magnetic Resonance Imaging is presented in a two-dimensional (2D) format, and Computed Tomography sometimes looks like a three-dimensional (3D) model that can be interacted with. The main idea of the research is to compare ways of displaying diagnostic results in virtual reality that can help a surgeon during or before an operation in augmented reality. During the experiment, the medical staff examined liver vessels in the abdominal area and heart boundaries. The search time and detection accuracy were measured on black-and-white and coloured scans. Usability testing in virtual reality shows convenient ways of interaction like hand input, voice activation, displaying risk to the patient, and the required number of scans. The results of the experiment will be used in the new C# program based on Magic Leap technology.

Keywords: augmented reality, computed tomography, magic leap, magnetic resonance imaging, usability testing, VTE risk

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Authors: Alessandro Marano

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Aim: The author describes the aesthetic modification using orthognathic surgery and closed rhinoplasty. Methods: Series of case study. After orthognathic surgery we can observe a dramatical change of aesthetic especially in the mid-face and nose projection. The advancement of maxillary bone through Le Fort I osteotomy will change the nasal tip projection and lips roundness; combining orthognathic surgery with closed approach rhinoplasty will manage both function and aesthetic of all mid face district. Results: Combining Le Fort I osteotomy with closed approach rhinoplasty resulted in good objective results with high patient satisfaction. Le Fort I osteotomy will increase projection of mid face and the closed approach rhinoplasty will modify the nasal shape to be more harmonic with the new maxillary district. The scars are not visible because hidden inside the mouth and nose. Conclusions: The orthognathic surgery combined with closed approach rhinoplasty are very effective for changing the aesthetic of the mid face. The results illustrate the difference between the use of orthognathic surgery only and to use it in association of closed approach rhinoplasty. Using both will allow to obtain a long lasting and pleasing results.

Keywords: orthognathic, rhinoplasty, aesthetic, face

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Authors: M. Mousavi-Daramoroudi, H. Yousefnia, F. Abbasi-Davani, S. Zolghadri

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Dosimetry is an indispensable and precious factor in patient treatment planning to minimize the absorbed dose in vital tissues. In this study, compartmental model was used in order to estimate the human absorbed dose of ¹⁷⁷Lu-DOTATOC from the biodistribution data in wild type rats. For this purpose, ¹⁷⁷Lu-DOTATOC was prepared under optimized conditions and its biodistribution was studied in male Syrian rats up to 168 h. Compartmental model was applied to mathematical description of the drug behaviour in tissue at different times. Dosimetric estimation of the complex was performed using radiation absorbed dose assessment resource (RADAR). The biodistribution data showed high accumulation in the adrenal and pancreas as the major expression sites for somatostatin receptor (SSTR). While kidneys as the major route of excretion receive 0.037 mSv/MBq, pancreas and adrenal also obtain 0.039 and 0.028 mSv/MBq. Due to the usage of this method, the points of accumulated activity data were enhanced, and further information of tissues uptake was collected that it will be followed by high (or improved) precision in dosimetric calculations.

Keywords: compartmental modeling, human absorbed dose, ¹⁷⁷Lu-DOTATOC, Syrian rats

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Authors: Devin Doos, Ashley Hughes, Trang Pham, Paul Barach, Rami Ahmed

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Over 115,000 Health Care Workers (HCWs) have died from COVID-19, and millions have been infected while caring for patients. HCWs have filed thousands of safety complaints surrounding safety concerns due to Personal Protective Equipment (PPE) shortages, which included concerns around inadequate and PPE reuse. Protocols for donning and doffing PPE remain ambiguous, lacking an evidence-base, and often result in wide deviations in practice. PPE donning and doffing protocol deviations commonly result in self-contamination but have not been thoroughly addressed. No evidence-driven protocols provide guidance on protecting HCW during periods of PPE reuse. Objective: The aim of this study was to examine safety-related threats and risks to Health Care Workers (HCWs) due to the reuse of PPE among Emergency Department personnel. Method: We conducted a prospective observational study to examine the risks of reusing PPE. First, ED personnel were asked to don and doff PPE in a simulation lab. Each participant was asked to don and doff PPE five times, according to the maximum reuse recommendation set by the Centers for Disease Control and Prevention (CDC). Each participant was videorecorded; video recordings were reviewed and coded independently by at least 2 of the 3trained coders for safety behaviors and riskiness of actions. A third coder was brought in when the agreement between the 2 coders could not be reached. Agreement between coders was high (81.9%), and all disagreements (100%) were resolved via consensus. A bowtie risk assessment chart was constructed analyzing the factors that contribute to increased risks HCW are faced with due to PPE use and reuse. Agreement amongst content experts in the field of Emergency Medicine, Human Factors, and Anesthesiology was used to select aspects of health care that both contribute and mitigate risks associated with PPE reuse. Findings: Twenty-eight clinician participants completed five rounds of donning/doffing PPE, yielding 140 PPE donning/doffing sequences. Two emerging threats were associated with behaviors in donning, doffing, and re-using PPE: (i) direct exposure to contaminant, and (ii) transmission/spread of contaminant. Protective behaviors included: hand hygiene, not touching the patient-facing surface of PPE, and ensuring a proper fit and closure of all PPE materials. 100% of participants (n= 28) deviated from the CDC recommended order, and most participants (92.85%, n=26) self-contaminated at least once during reuse. Other frequent errors included failure to tie all ties on the PPE (92.85%, n=26) and failure to wash hands after a contamination event occurred (39.28%, n=11). Conclusions: There is wide variation and regular errors in how HCW don and doffPPE while including in reusing PPE that led to self-contamination. Some errors were deemed “recoverable”, such as hand washing after touching a patient-facing surface to remove the contaminant. Other errors, such as using a contaminated mask and accidentally spreading to the neck and face, can lead to compound risks that are unique to repeated PPE use. A more comprehensive understanding of the contributing threats to HCW safety and complete approach to mitigating underlying risks, including visualizing with risk management toolsmay, aid future PPE designand workflow and space solutions.

Keywords: bowtie analysis, health care, PPE reuse, risk management

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