Search results for: ER visits

Authors: N. Schneider, M. Bruchhage, M. Hartweg, G. Mutungi, J. O Regan, S. Deoni

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Observational neuroimaging studies suggest differences between breast-fed and formula-fed infants in developmental myelination, a key brain process for learning and cognitive development. However, the possible effects of a nutrient formulation on myelin development in healthy term infants in an intervention study have not been investigated. Objective was, therefore, to investigate the efficacy of a nutrient formulation with higher levels of myelin-relevant nutrients as compared to a control formulation with lower levels of the same nutrients on brain myelination and cognitive development in the first 6 months of life. The study is an ongoing randomized, controlled, double-blind, two-center, parallel-group clinical trial with a nonrandomized, non-blinded arm of exclusively breastfed infants. The current findings result from a staged statistical analysis at 6 months; the recruitment and intervention period has been completed for all participants. Follow-up visits at 12, 18 and 24 months are still ongoing. N= 81 enrolled full term, neurotypical infants of both sexes were randomized into either the investigational (N= 42) or the control group (N= 39), and N= 108 children in the breast-fed arm served as a natural reference group. The effect of a blend of docosahexaenoic acid, arachidonic acid, iron, vitamin B12, folic acid as well as sphingomyelin from a uniquely proceed whey protein concentrate enriched in alpha-lactalbumin and phospholipids in an infant nutrition product matrix was investigated. The main outcomes for the staged statistical analyses at 6 months included brain myelination measures derived from MRI. Additional outcomes were brain volume, cognitive development and safety. The full analyses set at 6 months comprised N= 66 infants. Higher levels of myelin-relevant nutrients compared to lower levels resulted in significant differences in myelin structure, volume, and rate of myelination as early as 3 and 6 months of life. The cross-sectional change of means between groups for whole-brain myelin volume was 8.4% for investigational versus control formulation (3.5% versus the breastfeeding reference) group at 3 months and increased to 36.4% for investigational versus control formulation (14.1% versus breastfeeding reference) at 6 months. No statistically significant differences were detected for early cognition scores. Safety findings were largely similar across groups. This is the first pediatric nutritional neuroimaging study demonstrating the efficacy of a myelin nutrient blend on developmental myelination in well-nourished term infants. Myelination is a critical process in learning and development. The effects were demonstrated across the brain, particularly in temporal and parietal regions, known to be functionally involved in sensory, motor and language skills. These first results add to the field of nutritional neuroscience by demonstrating early life nutrition benefits for brain architecture which may be foundational for later cognitive and behavioral outcomes. ClinicalTrials.gov Identifier: NCT03111927 (Infant Nutrition and Brain Development - Full-Text View - ClinicalTrials.gov).

Keywords: brain development, infant nutrition, MRI, myelination

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Authors: N. Rambabu, H. Gururaj, Reynold Washington, Oommen George

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Motivation: Under the USAID Strengthening Health Outcomes through Private Sector (SHOPS-TB) initiative, Karnataka Health Promotion Trust (KHPT) with technical support of Abt associates is implementing a TB prevention and care model in Karnataka State, South India. KHPT is the interface agency between the public and private sectors, and providers and the target community facilitating early TB case detection and enhancing treatment compliance through private health care providers (pHCP) engagement in RNTCP. The project coverage is 0.84 million urban poor from 663 slums in 12 districts of Karnataka. Problem Statement: India with the highest burden of global TB (26%) and two million cases annually, accounts for approximately one fifth of the global incidence. WHO estimates 300,000 people die from TB annually in India. India expanded the coverage of Directly Observed Treatment, Short-course chemotherapy (DOTS) to the entire country as early as 2006. However, the performance of RNTCP has not been uniform across states. While the national annual new smear-positive (NSP) case notification rate is 53, it is much lower at 47 in Karnataka. A third of TB patients in India reside in urban slums. Approach: Under SHOPS, KHPT actively engages with communities through key opinion leaders and community structures. Interpersonal communication, by Outreach workers through house-to-house visits and at aggregation points, is the primary method used for communication about TB and its management and to increase demand for sputum examination and DOTS. pHCP are mapped, trained and mentored by KHPT. ORWs also provide patient and family counseling on TB treatment, side effects and adherence, screen close contacts of index patients especially children under 6 years of age and screen co-morbidities including HIV, diabetes and malnutrition and risk factors including alcoholism, tobacco use, occupational hazards making appropriate accompanied or documented referrals. A treatment ‘buddy’ system for the patients involving close friends or family members, ICT-based support, DOTS Prerana (inspiration) groups of TB patients, family members and community, DOTS Mitra (friend) helpline services are also used for care and support services. Results: The intervention educated 39988 slum dwellers, referred 1731 chest symptomatics, tested 1061 patients and initiated 248 patients on anti-TB treatment within three months of intervention through continuous community engagement. Conclusions: The intervention’s potential to increase access to preferred health care providers, reduce patient and health system delays in diagnosis and initiation of treatment, improve health seeking behaviour and enhance compliance of pHCPs to standard treatment protocols is being monitored. Initial results are promising.

Keywords: DOTS, KHPT, health outcomes, public and private sector

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Authors: Shanaka Gunasekara, Maleen Jayasuriya, Nalin Harischandra, Lilantha Samaranayake, Gamini Dissanayake

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One serious facet of the worsening Human-Elephant conflict (HEC) in nations such as Sri Lanka involves elephant-train collisions. Endangered Asian elephants are maimed or killed during such accidents, which also often result in orphaned or disabled elephants, contributing to the phenomenon of lone elephants. These lone elephants are found to be more likely to attack villages and showcase aggressive behaviour, which further exacerbates the overall HEC. Furthermore, Railway Services incur significant financial losses and disruptions to services annually due to such accidents. Most elephant-train collisions occur due to a lack of adequate reaction time. This is due to the significant stopping distance requirements of trains, as the full braking force needs to be avoided to minimise the risk of derailment. Thus, poor driver visibility at sharp turns, nighttime operation, and poor weather conditions are often contributing factors to this problem. Initial investigations also indicate that most collisions occur in localised “hotspots” where elephant pathways/corridors intersect with railway tracks that border grazing land and watering holes. Taking these factors into consideration, this work proposes the leveraging of recent developments in Convolutional Neural Network (CNN) technology to detect elephants using an RGB/infrared capable camera around known hotspots along the railway track. The CNN was trained using a curated dataset of elephants collected on field visits to elephant sanctuaries and wildlife parks in Sri Lanka. With this vision-based detection system at its core, a prototype unit of an early warning system was designed and tested. This weatherised and waterproofed unit consists of a Reolink security camera which provides a wide field of view and range, an Nvidia Jetson Xavier computing unit, a rechargeable battery, and a solar panel for self-sufficient functioning. The prototype unit was designed to be a low-cost, low-power and small footprint device that can be mounted on infrastructures such as poles or trees. If an elephant is detected, an early warning message is communicated to the train driver using the GSM network. A mobile app for this purpose was also designed to ensure that the warning is clearly communicated. A centralized control station manages and communicates all information through the train station network to ensure coordination among important stakeholders. Initial results indicate that detection accuracy is sufficient under varying lighting situations, provided comprehensive training datasets that represent a wide range of challenging conditions are available. The overall hardware prototype was shown to be robust and reliable. We envision a network of such units may help contribute to reducing the problem of elephant-train collisions and has the potential to act as an important surveillance mechanism in dealing with the broader issue of human-elephant conflicts.

Keywords: computer vision, deep learning, human-elephant conflict, wildlife early warning technology

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Authors: Megan Lindsey

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Background: Globalization presents international social work with both opportunities and challenges. Thus, the design of this international experience aligns with the three charges of the Commission on Global Social Work Education. An international collaborative effort between an American and Scottish University Social Work Program was based on an established University agreement. The presentation provides an overview of an international study abroad among American and Scottish Social Work students. Further, presenters will discuss the opportunities of international collaboration and the challenges of the project. First, we will discuss the process of a successful international collaboration. This discussion will include the planning, collaboration, execution of the experience, along with its application to the international field of social work. Second, we will discuss the development and implementation of participatory action research in which the student engage to enhance their learning experience. A collaborative qualitative research project was undertaken with three goals. First, students gained experience in Scottish social services, including agency visits and presentations. Second, a collaboration between American and Scottish MSW Students allowed the exchange of ideas and knowledge about services and social work education. Third, students collaborated on a qualitative research method to reflect on their social work education and the formation of their professional identity. Methods/Methodology: American and Scottish students engaged in participatory action research by using Photovoice methods while studying together in Scotland. The collaboration between faculty researchers framed a series of research questions. Both universities obtained IRB approval and trained students in Photovoice methods. The student teams used the research question and Photovoice method to discover images that represented their professional identity formation. Two Photovoice goals grounded the study's research question. First, the methods enabled the individual students to record and reflect on their professional strengths and concerns. Second, student teams promoted critical dialogue and knowledge about personal and professional issues through large and small group discussions of photographs. Results: The international participatory approach generated the ability for students to contextualize their common social work education and practice experiences. Team discussions between representatives of each country resulted in understanding professional identity formation and the processes of social work education that contribute to that identity. Students presented the photograph narration of their knowledge and understanding of international social work education and practice. Researchers then collaborated on finding common themes. The results found commonalities in the quality and depth of social work education. The themes found differences regarding how professional identity is formed. Students found great differences between their and American accreditation and certification. Conclusions: Faculty researchers’ collaboration themes sought to categorize the students’ experiences of their professional identity. While the social work education systems are similar, there are vast differences. The Scottish themes noted structures within American social work not found in the United Kingdom. The American researchers noted that Scotland, as does the United Kingdom, relies on programs, agencies, and the individual social worker to provide structure to identity formation. Other themes will be presented.

Keywords: higher education curriculum, international collaboration, social sciences, action research

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Authors: Vinti Davar

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Introduction: Childhood overweight increases the risk for certain medical and psychological conditions. Millions of school-age children worldwide are affected by serious yet easily treatable and preventable illnesses that inhibit their ability to learn. Healthier children stay in school longer, attend more regularly, learn more and become healthier and more productive adults. Schools are an important setting for nutrition education because one can reach most children, teachers and parents. These years offer a key window for shaping their lifetime habits, which have an impact on their health throughout life. Against this background, an attempt was made to impart nutrition education to school children in Haryana state of India to promote healthy food choices and assess the effectiveness of this program. Methodology: This study was completed in two phases. During the first phase, pre-intervention anthropometric and dietary survey was conducted; the teaching materials for nutrition intervention program were developed and tested; and the questionnaire was validated. In the second phase, an intervention was implemented in two schools of Kurukshetra, Haryana for six months by personal visits once a week. A total of 350 children in the age group of 6-12 years were selected. Out of these, 279 children, 153 boys and 126 girls completed the study. The subjects were divided into four groups namely: underweight, normal, overweight and obese based on body mass index-for-age categories. A power point colorful presentation to improve the quality of tiffin, snacks and meals emphasizing inclusion of all food groups especially vegetables every day and fruits at least 3-4 days per week was used. An extra 20 minutes of aerobic exercise daily was likewise organized and a healthy school environment created. Provision of clean drinking water by school authorities was ensured. Selling of soft drinks and energy-dense snacks in the school canteen as well as advertisements about soft drink and snacks on the school walls were banned. Post intervention, anthropometric indices and food selections were reassessed. Results: The results of this study reiterate the critical role of nutrition education and promotion in improving the healthier food choices by school children. It was observed that normal, overweight and obese children participating in nutrition education intervention program significantly (p≤0.05) increased their daily seasonal fruit and vegetable consumption. Fat and oil consumption was significantly reduced by overweight and obese subjects. Fast food intake was controlled by obese children. The nutrition knowledge of school children significantly improved (p≤0.05) from pre to post intervention. A highly significant increase (p≤0.00) was noted in the nutrition attitude score after intervention in all four groups. Conclusion: This study has shown that a well-planned nutrition education program could improve nutrition knowledge and promote positive changes in healthy food choices. A nutrition program inculcates wholesome eating and active life style habits in children and adolescents that could not only prevent them from chronic diseases and early death but also reduce healthcare cost and enhance the quality of life of citizens and thereby nations.

Keywords: children, eating habits healthy food, obesity, school going, fast foods

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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: Zofija Tupikovskaja-Omovie, David Tyler, Sam Dhanapala, Steve Hayes

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The UK is leading in online retail and mobile adoption. However, there is a dearth of information relating to mobile apparel retail, and developing an understanding about consumer browsing and purchase behavior in m-retail channel would provide apparel marketers, mobile website and app developers with the necessary understanding of consumers’ needs. Despite the rapid growth of mobile retail businesses, no published study has examined shopping behaviour on fashion mobile websites and apps. A mixed method approach helped to understand why fashion consumers prefer websites on mobile devices, when mobile apps are also available. The following research methods were employed: survey, eye-tracking experiments, observation, and interview with retrospective think aloud. The mobile gaze tracking device by SensoMotoric Instruments was used to understand frustrations in navigation and other issues facing consumers in mobile channel. This method helped to validate and compliment other traditional user-testing approaches in order to optimize user experience and enhance the development of mobile retail channel. The study involved eight participants - females aged 18 to 35 years old, who are existing mobile shoppers. The participants used the Topshop mobile app and website on a smart phone to complete a task according to a specified scenario leading to a purchase. The comparative study was based on: duration and time spent at different stages of the shopping journey, number of steps involved and product pages visited, search approaches used, layout and visual clues, as well as consumer perceptions and expectations. The results from the data analysis show significant differences in consumer behaviour when using a mobile app or website on a smart phone. Moreover, two types of problems were identified, namely technical issues and human errors. Having a mobile app does not guarantee success in satisfying mobile fashion consumers. The differences in the layout and visual clues seem to influence the overall shopping experience on a smart phone. The layout of search results on the website was different from the mobile app. Therefore, participants, in most cases, behaved differently on different platforms. The number of product pages visited on the mobile app was triple the number visited on the website due to a limited visibility of products in the search results. Although, the data on traffic trends held by retailers to date, including retail sector breakdowns for visits and views, data on device splits and duration, might seem a valuable source of information, it cannot explain why consumers visit many product pages, stay longer on the website or mobile app, or abandon the basket. A comprehensive list of pros and cons was developed by highlighting issues for website and mobile app, and recommendations provided. The findings suggest that fashion retailers need to be aware of actual consumers’ behaviour on the mobile channel and their expectations in order to offer a seamless shopping experience. Added to which is the challenge of retaining existing and acquiring new customers. There seem to be differences in the way fashion consumers search and shop on mobile, which need to be explored in further studies.

Keywords: consumer behavior, eye-tracking technology, fashion retail, mobile app, m-retail, smart phones, topshop, user experience, website

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Authors: Sum Lau, Wing Chung Cleo Lau, Wing Yan Chu, Long Ching Ip, Wan Yin Lo, Jo Long Sam Yau, Ka Ho Hui, Sze Yi Mak

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Biomedical engineering (BME) is an interdisciplinary subject where knowledge about biology and medicine is applied to novel applications, solving clinical problems. This subject is crucial for cities such as Hong Kong, where the burden on the medical system is rising due to reasons like the ageing population. Hong Kong, who is actively boosting technological advancements in recent years, sets BME, or biotechnology, as a major category, as reflected in the 2018-19 Budget, where biotechnology was one of the four pillars for development. Over the years, while resources in terms of money and space have been provided, there has been a lack of talents expressed by both the academia and industry. While exogenous factors, such as COVID, may have hindered talents from outside Hong Kong to come, endogenous factors should also be considered. In particular, since there are already a few local universities offering BME programmes, their curriculum or style of education requires to be reviewed to intensify the network of the BME community and support post-academic career development. It was observed that while undergraduate (UG) studies focus on knowledge teaching with some technical training and postgraduate (PG) programmes concentrate on upstream research, the programmes are generally confined to the academic sector and lack connections to the industry. In light of that, a “Biomedical Innovation and Outreach Programme 2022” (“B.I.O.2022”) was held to connect students and professors from academia with clinicians and engineers from the industry, serving as a comparative approach to conventional education methods (UG and PG programmes from tertiary institutions). Over 100 participants, including undergraduates, postgraduates, secondary school students, researchers, engineers, and clinicians, took part in various outreach events such as conference and site visits, all held from June to July 2022. As a case study, this programme aimed to tackle the aforementioned problems with the theme of “4Cs” (connection, communication, collaboration, and commercialisation). The effectiveness of the programme is investigated by its ability to serve as an adult and continuing education and the effectiveness of causing social change to tackle current societal challenges, with the focus on tackling the lack of talents engaging in biomedical engineering. In this study, B.I.O.2022 is found to be able to complement the traditional educational methods, particularly in terms of knowledge exchange between the academia and the industry. With enhanced communications between participants from different career stages, there were students who followed up to visit or even work with the professionals after the programme. Furthermore, connections between the academia and industry could foster the generation of new knowledge, which ultimately pointed to commercialisation, adding value to the BME industry while filling the gap in terms of human resources. With the continuation of events like B.I.O.2022, it provides a promising starting point for the development and relationship strengthening of a BME community in Hong Kong, and shows potential as an alternative way of adult education or learning with societal benefits.

Keywords: biomedical engineering, adult education for social change, comparative methods and principles, lifelong learning, faced problems, promises, challenges and pitfalls

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Authors: Prachi Buche Marathe

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Karanja Laad is a city located in the Vidarbha region in the state of Maharashtra, India. It has a huge amount of tangible and intangible heritage in the form of monuments, precincts, a group of structures, festivals and procession route, which is neglected and lost with time. Three different religions Hinduism, Islam and Jainism along with associations of being a birthplace of Swami Nrusinha Saraswati, an exponent of Datta Sampradaya sect and the British colonial layer have shaped the culture and society of the place over the period. The architecture of the town Karanja Laad has enhanced its unique historic and cultural value with a combination of all these historic layers. Karanja Laad is also a traditional trading historic town with unique hybrid architectural style and has a good potential for developing as a tourist place along with the present image of a pilgrim destination of Datta Sampradaya. The aim of the research is to prepare a conservation proposal for the historic town along with the management framework. Objectives of the research are to study the evolution of Karanja town, to identify the cultural resources along with issues of the historic core of the city, to understand Datta sampradaya, and contribution of Saint Nrusinha Saraswati in the religious sect and his association as an important personality with Karanja. The methodology of the research is site visits to the Karanja city, making field surveys for documentation and discussions and questionnaires with the residents to establish heritage and identify potential and issues within the historic core thereby establishing a case for conservation. Field surveys are conducted for town level study of land use, open spaces, occupancy, ownership, traditional commodity and community, infrastructure, streetscapes, and precinct activities during the festival and non-festival period. Building level study includes establishing various typologies like residential, institutional commercial, religious, and traditional infrastructure from the mythological references like waterbodies (kund), lake and wells. One of the main issues is that the loss of the traditional footprint as well as the traditional open spaces which are getting lost due to the new illegal encroachments and lack of guidelines for the new additions to conserve the original fabric of the structures. Traditional commodities are getting lost since there is no promotion of these skills like pottery and painting. Lavish bungalows like Kannava mansion, main temple Wada (birthplace of the saint) have a huge potential to be developed as a museum by adaptive re-use which will, in turn, attract many visitors during festivals which will boost the economy. Festival procession routes can be identified and a heritage walk can be developed so as to highlight the traditional features of the town. Overall study has resulted in establishing a heritage map with 137 heritage structures identified as potential. Conservation proposal is worked out on the town level, precinct level and building level with interventions such as developing construction guidelines for further development and establishing a heritage cell consisting architects and engineers for the upliftment of the existing rich heritage of the Karanja city.

Keywords: built heritage, conservation, Datta Sampradaya, Karanja Laad, Swami Nrusinha Saraswati, procession route

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Authors: yu-Lin Chen, Kimberly Koester, Marissa Raymond-Flesh, Anika Thapar, Jay Thapar

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Purpose: Effectively communicating adolescent health topics to teens and their parents is crucial. This study emphasizes critically evaluating the optimal use of artificial intelligence tools (AI), which are increasingly prevalent in disseminating health information. By fostering a deeper understanding of AI voice preference in the context of health, the research aspires to have a ripple effect, enhancing the collective health literacy and decision-making capabilities of both teenagers and their parents. This study explores AI voices' potential within health learning modules for annual well-child visits. We aim to identify preferred voice characteristics and understand factors influencing perceived trustworthiness, ultimately aiming to improve health literacy and decision-making in both demographics. Methods: A cross-sectional study assessed preferences and trust perceptions of AI voices in learning modules among teens (11-18) and their parents/guardians in Northern California. The study involved the development of four distinct learning modules covering various adolescent health-related topics, including general communication, sexual and reproductive health communication, parental monitoring, and well-child check-ups. Participants were asked to evaluate eight AI voices across the modules, considering a set of six factors such as intelligibility, naturalness, prosody, social impression, trustworthiness, and overall appeal, using Likert scales ranging from 1 to 10 (the higher, the better). They were also asked to select their preferred choice of voice for each module. Descriptive statistics summarized participant demographics. Chi-square/t-tests explored differences in voice preferences between groups. Regression models identified factors impacting the perceived trustworthiness of the top-selected voice per module. Results: Data from 104 participants (teen=63; adult guardian = 41) were included in the analysis. The mean age is 14.9 for teens (54% male) and 41.9 for the parent/guardian (12% male). At the same time, similar voice quality ratings were observed across groups, and preferences varied by topic. For instance, in general communication, teens leaned towards young female voices, while parents preferred mature female tones. Interestingly, this trend reversed for parental monitoring, with teens favoring mature male voices and parents opting for mature female ones. Both groups, however, converged on mature female voices for sexual and reproductive health topics. Beyond preferences, the study delved into factors influencing perceived trustworthiness. Interestingly, social impression and sound appeal emerged as the most significant contributors across all modules, jointly explaining 71-75% of the variance in trustworthiness ratings. Conclusion: The study emphasizes the importance of catering AI voices to specific audiences and topics. Social impression and sound appeal emerged as critical factors influencing perceived trustworthiness across all modules. These findings highlight the need to tailor AI voices by age and the specific health information being delivered. Ensuring AI voices resonate with both teens and their parents can foster their engagement and trust, ultimately leading to improved health literacy and decision-making for both groups.

Keywords: artificial intelligence, trustworthiness, voice, adolescent

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Authors: Özge Çeliker Tosun, Melda Başer Secer, İsmail Düşmez, Sedat Çapar, İlkay Kozak, Melahat Aktaş, Furkan Can Şimşek, Gökhan Tosun

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Purpose: Portable innovative balance room system with digital game program; It was created to be able to be divided into small areas, such as inside the house, garden, balcony, to enable the person to enter and perform both evaluation and exercise safely, and to ensure that these results can be stored and sent to the therapist live or later when desired. The aim is to compare the effectiveness of the exercise program applied by the elderly within this system and the exercise program implemented under the supervision of a physiotherapist on balance and urinary incontinence symptoms. Materials and Methods: The study was conducted in a randomized controlled manner on 63 people with urinary incontinence (mean age: 75.5 years) at Narlıdere Nursing Home Elderly Care and Rehabilitation Center. Elderly people participating in the study were divided into 3 groups: 1. Group, an exercise program consisting of pelvic floor muscle training and OTOGA exercises, 2. Group, only pelvic floor muscle training, and 3. Group, pelvic floor muscle training and Otoga exercises in the form of a digital game program in a portable balance room system. (self-administered) for 12 weeks. Pelvic floor distress inventory (PTDE-20) and bladder diary were used to evaluate the incontinance symptoms of the cases. Pelvic floor muscle function was evaluated with superficial EMG. Berg, Fall Effectiveness Scale (FES) and Functional Status Evaluations (Chair Stand Test, Eight (8) Food Up and Go Test, Chair Sit and Reach Test, Two Minutes Step Test) were used to evaluate balance. The existence of differences between groups was analyzed using Krusskal Wallis analysis of variance, and the difference between before and after exercise was analyzed with Wilcoxon tests. Results: After treatment, PTDE-20, daily urinary incontinence and toilet visits values decreased significantly in all three groups (p < 0.001). While there was a statistically significant increase in pelvic floor muscle EMG values in the 2nd and third groups after treatment, there was no change in the other group (2nd Group PFM average EMG before-after: 5.5 (4.15-10.95) - 10.95 (8.68-13.68), P=0.05, 3 Group PFM average EMG before-after: 6.5 (4.28-11.55) - 11.75 (8.67-14.26), p=0.04). While BERG score, Chair Stand Test, Eight (8) Food Up and Go Test, and Two Minutes Step Test values increased in all groups (p<0.05), Fall Effectiveness Scale (FES) values did not change after treatment. Conclusion: Although pelvic floor muscle training combined with balance exercises reduces symptoms, it may not lead to a positive improvement in the functions of the pelvic floor muscles. For this reason, recovery lasts for a short time, and then symptoms may reoccur in the future. However, thanks to the new system, when balance exercises are combined with a game program for the pelvic floor muscles, a double effect can be achieved with a single application and both incontinence and balance problems can be treated in a safe environment where the person can do it himself. But more work needs to be done on this subject. However, thanks to the new system, a double effect can be achieved with a single application, and both incontinence and balance problems can be treated in a safe environment where the person can do it himself. But more work needs to be done on new system

Keywords: fall, urinary incontinance, balance, elderly

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Authors: M. Skibinska, A. Rajewska-Rager, M. Dmitrzak-Weglarz, N. Lepczynska, P. Sibilski, P. Kapelski, J. Pawlak, J. Twarowska-Hauser

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Introduction: Neurotrophic factors have been implicated in neuropsychiatric disorders. Brain-Derived Neurotrophic Factor (BDNF) influences neuron differentiation in development as well as synaptic plasticity and neuron survival in adulthood. BDNF is widely studied in mood disorders and has been proposed as a biomarker for depression. BDNF is synthesized as precursor protein – proBDNF. Both forms are biologically active and exert opposite effects on neurons. Aim: The aim of the study was to examine the serum levels of BDNF and proBDNF in unipolar and bipolar young patients below 24 years old during hypo/manic, depressive episodes and in remission compared to healthy control group. Methods: In a prospective 2 years follow-up study, we investigated alterations in levels of BDNF and proBDNF in 79 patients (23 males, mean age 19.08, SD 3.3 and 56 females, mean age 18.39, SD 3.28) diagnosed with mood disorders: unipolar and bipolar disorder compared with 35 healthy control subjects (7 males, mean age 20.43, SD 4.23 and 28 females, mean age 21.25, SD 2.11). Clinical characteristics including mood, comorbidity, family history, and treatment, were evaluated during control visits and clinical symptoms were rated using the Hamilton Depression Rating Scale and Young Mania Rating Scale. Serum BDNF and proBDNF concentrations were determined by Enzyme-Linked Immunosorbent Assays (ELISA) method. Serum BDNF and proBDNF levels were analysed with covariates: sex, age, age > 18 and < 18 years old, family history of affective disorders, drug-free vs. medicated status. Normality of the data was tested using Shapiro-Wilk test. Levene’s test was used to calculate homogeneity of variance. Non-parametric Tests: Mann-Whitney U test, Kruskal-Wallis ANOVA, Friedman’s ANOVA, Wilcoxon signed rank test, Spearman correlation coefficient were applied in analyses The statistical significance level was set at p < 0.05. Results: BDNF and proBDNF serum levels did not differ between patients at baseline and controls as well as comparing patients in acute episode of depression/hypo/mania at baseline and euthymia (at month 3 or 6). Comparing BDNF and proBDNF levels between patients in euthymia and control group no differences have been found. Increased BDNF level in women compared to men at baseline (p=0.01) have been observed. BDNF level at baseline was negatively correlated with depression and mania occurence at 24 month (p=0.04). BDNF level at 12 month was negatively correlated with depression and mania occurence at 12 month (p=0.01). Correlation of BDNF level with sex have been detected (p=0.01). proBDNF levels at month 3, 6 and 12 negatively correlated with disease status (p=0.02, p=0.008, p=0.009, respectively). No other correlations of BDNF and proBDNF levels with clinical and demographical variables have been detected. Discussion: Our results did not show any differences in BDNF and proBDNF levels between depression, mania, euthymia, and controls. Imbalance in BDNF/proBDNF signalling may be involved in pathogenesis of mood disorders. Further studies on larger groups are recommended. Grant was founded by National Science Center in Poland no 2011/03/D/NZ5/06146.

Keywords: bipolar disorder, Brain-Derived Neurotrophic Factor (BDNF), proBDNF, unipolar depression

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Authors: Thaminda Liyanage, Chamila Shamika Kurukulasuriya

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Introduction: Morbid obesity has been successfully treated with bariatric surgery for over 60 years. Although operative procedures have improved and associated complications have reduced substantially, surgery still carries the risk of post-operative malabsorption, malnutrition and a range of gastrointestinal disorders. Overweight by itself can impair libido in both sexes and cause erectile dysfunction in males by inducing a state of hypogonadotropic hypogonadism, proportional to the degree of obesity. Impact of weight reduction on libido and sexual activity remains controversial, however it is broadly accepted that weight loss improves sexual drive. Zinc deficiency, subsequent to malabsorption, may lead to impaired testosterone synthesis in men while excessive and/or rapid weight loss in females may result in reversible amenorrhoea leading to sub-fertility. Methods: We describe a 37 year old male, 6 years post Roux-en-Y gastric bypass surgery, who presented with erectile dysfunction, loss of libido, worsening fatigue and generalized weakness for 4 months. He also complained of constipation and frequent muscle cramps but denied having headache, vomiting or visual disturbances. Patient had lost 38 kg of body weight post gastric bypass surgery over four years {135kg (BMI 42.6 kg/m2) to 97 kg (BMI 30.6 kg/m2)} and the weight had been stable for past two years. He had no recognised co-morbidities at the time of the surgery and noted marked improvement in general wellbeing, physical fitness and psychological confident post surgery, up until four months before presentation. Clinical examination revealed dry pale skin with normal body hair distribution, no thyroid nodules or goitre, normal size testicles and normal neurological examination with no visual field defects or diplopia. He had low serum testosterone, follicular stimulating hormone (FSH), luteinizing hormone (LH), T3, T4, thyroid stimulating hormone (TSH), insulin like growth factor 1 (IGF-1) and 24-hour urine cortisol levels. Serum cortisol demonstrated an appropriate rise to ACTH stimulation test but growth hormone (GH) failed increase on insulin tolerance test. Other biochemical and haematological studies were normal, except for low zinc and folate with minimally raised liver enzymes. MRI scan of the head confirmed a solid pituitary mass with no mass effect on optic chiasm. Results: In this patient clinical, biochemical and radiological findings were consistent with anterior pituitary dysfunction. However, there were no features of raised intracranial pressure or neurological compromise. He was commenced on appropriate home replacement therapy and referred for neurosurgical evaluation. Patient reported marked improvement in his symptoms, specially libido and erectile dysfunction, on subsequent follow up visits. Conclusion: Sexual dysfunction coupled with non specific constitutional symptoms has multiple aetiologies. Clinical symptoms out of proportion to nutritional deficiencies post bariatric surgery should be thoroughly investigated. Close long term follow up is crucial for overall success.

Keywords: obesity, bariatric surgery, erectile dysfunction, loss of libido

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Authors: Igor Peraza Curiel, Suzanne Strum

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Today, when many foreign architects are receiving commissions in the United Arab Emirates, it is essential to analyze how their designs are influenced by the region's culture, environment, and building traditions. This study examines the approach to siting, geometry, construction methods, and material choices in two private homes for a family in Dubai, a project being constructed on adjacent sites by the acclaimed Spanish team of RCR Architects. Their third project in Dubai, the houses mark a turning point in their design approach to the desert. The Pritzker Prize-winning architects of RCR gained renown for building works deeply responsive to the history, landscape, and customs of their hometown in a volcanic area of the Catalonia region of Spain. Key formative projects and their entry to practice in UAE will be analyzed according to the concepts of place identity, the poetics of construction, and material imagination. The poetics of construction, a theoretical position with a long practical tradition, was revived by the British critic Kenneth Frampton. The idea of architecture as a constructional craft is related to the concepts of material imagination and place identity--phenomenological concerns with the creative engagement with local matter and topography that are at the very essence of RCR's way of designing, detailing, and making. Our study situates RCR within the challenges of building in the region, where western forms and means have largely replaced the ingenious responsiveness of indigenous architecture to the climate and material scarcity. The dwellings, iterations of the same steel and concrete vaulting system, highlight the conceptual framework of RCR's design approach to offer a study in contemporary critical regionalism. The Kama House evokes Bedouin tents, while the Alwah House takes the form of desert dunes in response to the temporality of the winds. Metal mesh screens designed to capture the shifting sands will complete the forms. The original research draws on interviews with the architects and unique documentation provided by them and collected by the authors during on-site visits. By examining the two houses in-depth, this paper foregrounds a series of timely questions: 1) What is the impact of the local climatic, cultural, and material conditions on their project in the UAE? 2) How does this work further their experiences in the region? 3) How has RCR adapted their construction techniques as their work expands beyond familiar settings? The investigation seeks to understand how the design methodology developed for more than 20 years and enmeshed in the regional milieu of their hometown can transform as the architects encounter unique characteristics and values in the Middle East. By focusing on the contemporary interpretation of Arabic geometry and elements, the houses reveal the role of geometry, tectonics, and material specificity in the realization from conceptual sketches to built form. In emphasizing the importance of regional responsiveness, the dynamics of international construction practice, and detailing this study highlights essential issues for professionals and students looking to practice in an increasingly global market.

Keywords: material imagination, regional responsiveness, place identity, poetics of construction

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Authors: Fouzia Arif, Arif S. Mohammad, Hifsa Altaf, Lubna Raees

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Introduction: The term "disability", refers to any condition that impedes the completion of daily tasks using traditional methods. In developing countries like Pakistan, disable population is usually excluded from the mainstream. In squatter settlements the situation is more critical. Sultanabad is one of the squatter settlements of Karachi. Purpose of case study is to improve the health of disabled children’s, and create awareness among the parents and community. Through a household visit, Shiraz, a young disabled boy of 15.5 years old was identified. Her mother articulated that her son was living normally and happily with his parents two years back. When he was 13 years old and student of class 8th, both his legs were traumatized in a Railway Train Accident while playing cricket. He got both femoral shaft fractured severely. He was taken to Jinnah Post Graduate Medical Centre (JPMC) where his left leg was amputated at above knee level and right leg was opened & fixed by reduction internally, luckily bone healed moderately with the passage of time. Methods: In Squatter settlements of Karachi Sultanabad, a survey was conducted in two sectors. Disability screening questionnaire was developed, collaboration with community through household visits, outreach sessions 23cases of disabled were identified who were socialized through sports, Musical program and get-together was organized with stockholder for creating awareness among community and parent’s. Collaboration was established with different NGOs, Government, stakeholders and community support for establishment of Physiotherapy Center. During home visit it was identified that Shiraz was on bed since last 1 year, his family could not afforded cost of physiotherapist and medical consultation due to poverty. Parents counseling was done mentioning that Shiraz needed to take treatment. After motivation his parents agreed for treatment. He was consulted by an orthopedic surgeon in AKUH, Who referred to DMC University of Health Science for rehabilitation service. There he was assessed and referred for Community Based Physiotherapy Centre Sultanabad. Physiotherapist visited home along with Coordinator for Special children and assessed him regularly, planned Physiotherapy treatment for abdominal, high muscles strutting exercise foot muscles strengthening exercise, knee mobilization weight bearing from partial to full weight gradually, also strengthen exercise were given for residual limb as the boy was dependent on it. He was also provided by an artificial leg and training was done. Result: Shiraz is now fully mobile, he can walk independently even out of home, functional ability progress improved and dependency factors reduced. It was difficult but not impossible. We all have sympathy but if we have empathy then we can rehabilitate the community in a better way. His parents are very happy and also the community is surprised to see him in such better condition. Conclusion: Combined efforts of physiotherapist, Coordinator of special children, community and parents made a drastic change in Shiraz’s case by continuously motivating him for better outcome. He is going to school regularly without support. Since he belongs to a poor family he faces financial constraints for education and clinical follow ups regularly.

Keywords: femoral shaft fracture, trauma, orthopedic surgeon, physiotherapy treatment

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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: 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

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Authors: Bridget J. Kenny, Elizabeth Hoban, Jo Williams

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Adolescent pregnancy presents a significant public health challenge for Cambodia. Despite declines in the overall fertility rate, the adolescent fertility rate is increasing. Adolescent pregnancy is particularly problematic in the Northeast provinces of Ratanak Kiri and Mondul Kiri where 34 percent of girls aged between 15 and 19 have begun childbearing; this is almost three times Cambodia’s national average of 12 percent. Language, cultural and geographic barriers have restricted qualitative exploration of the sexual and reproductive health (SRH) challenges that face indigenous adolescents in Northeast Cambodia. The current study sought to address this gap by exploring the SRH practices of adolescent mothers from indigenous populations in Ratanak Kiri Province. Twenty-two adolescent mothers, aged between 15 and 19, were recruited from seven indigenous villages in Ratanak Kiri Province and asked to participate in a combined body mapping exercise and semi-structured interview. Participants were given a large piece of paper (59.4 x 84.1 cm) with the outline of a female body and asked to draw the female reproductive organs onto the ‘body map’. Participants were encouraged to explain what they had drawn with the purpose of evoking conversation about their reproductive bodies. Adolescent mothers were then invited to participate in a semi-structured interview to further expand on topics of SRH. The qualitative approach offered an excellent avenue to explore the unique SRH challenges that face indigenous adolescents in rural Cambodia. In particular, the use of visual data collection methods reduced the language and cultural barriers that have previously restricted or prevented qualitative exploration of this population group. Thematic analysis yielded six major themes: (1) understanding of the female reproductive body, (2) contraceptive knowledge, (3) contraceptive use, (4) barriers to contraceptive use, (5) sexual practices, (6) contact with healthcare facilities. Participants could name several modern contraceptive methods and knew where they could access family planning services. However, adolescent mothers explained that they gained this knowledge during antenatal care visits and consequently participants had limited SRH knowledge, including contraceptive awareness, at the time of sexual initiation. Fear of the perceived side effects of modern contraception, including infertility, provided an additional barrier to contraceptive use for indigenous adolescents. Participants did not cite cost or geographic isolation as barriers to accessing SRH services. Child marriage and early sexual initiation were also identified as important factors contributing to the high prevalence of adolescent pregnancy in this population group. The findings support the Ministry of Education, Youth and Sports' (MoEYS) recent introduction of SRH education into the primary and secondary school curriculum but suggest indigenous girls in rural Cambodia require additional sources of SRH information. Results indicate adolescent girls’ first point of contact with healthcare facilities occurs after they become pregnant. Promotion of an effective continuum of care by increasing access to healthcare services during the pre-pregnancy period is suggested as a means of providing adolescents girls with an additional avenue to acquire SRH information.

Keywords: adolescent pregnancy, contraceptive use, family planning, sexual and reproductive health

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Authors: Tristance Kee

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With the unprecedented increase in elderly population globally, it is critical to search for new sustainable housing and urban development alternatives to traditional housing options. This research examines concepts of elderly migration pattern in the context of a high density city in Hong Kong to Mainland China. The research objectives are to: 1) explore the relationships between soon-to-be-old elderly and their intentions to move to Mainland upon retirement and their demographic characteristics; and 2) What are the desired amenities, locational factors and activities that are expected in the soon-to-be-old generation’s retirement housing environment? Primary data was collected through questionnaire survey conducted using random sampling method with respondents aged between 45-64 years old. The face-to-face survey was completed by 500 respondents. The survey was divided into four sections. The first section focused on respondent’s demographic information such as gender, age, education attainment, monthly income, housing tenure type and their visits to Mainland China. The second section focused on their retirement plans in terms of intended retirement age, prospective retirement funding and retirement housing options. The third section focused on the respondent’s attitudes toward retiring in Mainland for housing. It asked about their intentions to migrate retire into Mainland and incentives to retire in Hong Kong. The fourth section focused on respondent’s ideal housing environment including preferred housing amenities, desired living environment and retirement activities. The dependent variable in this study was ‘respondent’s consideration to move to Mainland China upon retirement’. Eight primary independent variables were integrated into the study to identify the correlations between them and retirement migration plan. The independent variables include: gender, age, marital status, monthly income, present housing tenure type, property ownership in Hong Kong, relationship with Mainland and the frequency of visiting Mainland China. In addition to the above independent variables, respondents were asked to indicate their retirement plans (retirement age, funding sources and retirement housing options), incentives to migrate to retire (choices included: property ownership, family relations, cost of living, living environment, medical facilities, government welfare benefits, etc.), perceived ideal retirement life qualities including desired amenities (sports, medical and leisure facilities etc.), desired locational qualities (green open space, convenient transport options and accessibility to urban settings etc.) and desired retirement activities (home-based leisure, elderly friendly sports, cultural activities, child care, social activities, etc.). The finding shows correlations between the used independent variables and consideration to migrate for housing options. The two independent variables indicated a possible correlation were gender and the frequency of visiting Mainland at present. When considering the increasing property prices across the border and strong social relationships, potential retirement migration is a very subjective decision that could vary from person to person. This research adds knowledge to housing research and migration study. Although the research is based in Mainland, most of the characteristics identified including better medical services, government welfare and sound urban amenities are shared qualities for all sustainable urban development and housing strategies.

Keywords: elderly migration, housing alternative, soon-to-be-old, sustainable environment

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Authors: Ashley L. Freeman, Jessica D. Watkins

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TeleEmergency Medicine (TeleEM) is an innovative approach leveraging virtual technology to deliver specialized emergency medical care across diverse healthcare settings, including internal acute care and critical access hospitals, remote patient monitoring, and nurse triage escalation, in addition to external emergency departments, skilled nursing facilities, and community health centers. TeleEM represents a significant advancement in the delivery of emergency medical care, providing healthcare professionals the capability to deliver expertise that closely mirrors in-person emergency medicine, exceeding geographical boundaries. Through qualitative research, the extension of timely, high-quality care has proven to address the critical needs of patients in remote and underserved areas. TeleEM’s service design allows for the expansion of existing services and the establishment of new ones in diverse geographic locations. This ensures that healthcare institutions can readily scale and adapt services to evolving community requirements by leveraging on-demand (non-scheduled) telemedicine visits through the deployment of multiple video solutions. In terms of financial management, TeleEM currently employs billing suppression and subscription models to enhance accessibility for a wide range of healthcare facilities. Plans are in motion to transition to a billing system routing charges through a third-party vendor, further enhancing financial management flexibility. To address state licensure concerns, a patient location verification process has been integrated through legal counsel and compliance authorities' guidance. The TeleEM workflow is designed to terminate if the patient is not physically located within licensed regions at the time of the virtual connection, alleviating legal uncertainties. A distinctive and pivotal feature of TeleEM is the introduction of the TeleEmergency Medicine Care Team Assistant (TeleCTA) role. TeleCTAs collaborate closely with TeleEM Physicians, leading to enhanced service activation, streamlined coordination, and workflow and data efficiencies. In the last year, more than 800 TeleEM sessions have been conducted, of which 680 were initiated by internal acute care and critical access hospitals, as evidenced by quantitative research. Without this service, many of these cases would have necessitated patient transfers. Barriers to success were examined through thorough medical record review and data analysis, which identified inaccuracies in documentation leading to activation delays, limitations in billing capabilities, and data distortion, as well as the intricacies of managing varying workflows and device setups. TeleEM represents a transformative advancement in emergency medical care that nurtures collaboration and innovation. Not only has advanced the delivery of emergency medicine care virtual technology through focus group participation with key stakeholders, rigorous attention to legal and financial considerations, and the implementation of robust documentation tools and the TeleCTA role, but it’s also set the stage for overcoming geographic limitations. TeleEM assumes a notable position in the field of telemedicine by enhancing patient outcomes and expanding access to emergency medical care while mitigating licensure risks and ensuring compliant billing.

Keywords: emergency medicine, TeleEM, rural healthcare, telemedicine

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Authors: Pradipta Chandra, Titas Bhattacharjee, Bhaskar Bhowmick

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The foundation of economy in India is primarily based on agriculture while this is the most neglected in the rural setting. More significantly, household women take part in agriculture with higher involvement. However, because of lower education of women they have limited access towards financial decisions, land ownership and technology but they have vital role towards the individual family level. There are limited studies on the institution-wise training barriers with the focus of gender disparity. The main purpose of this paper is to find out the factors of institution-wise training (non-formal education) barriers in technology transfer with the focus of participation of rural women in agriculture. For this study primary and secondary data were collected in the line of qualitative and quantitative approach. Qualitative data were collected by several field visits in the adjacent areas of Seva-Bharati, Seva Bharati Krishi Vigyan Kendra through semi-structured questionnaires. In the next level detailed field surveys were conducted with close-ended questionnaires scored on the seven-point Likert scale. Sample size was considered as 162. During the data collection the focus was to include women although some biasness from the end of respondents and interviewer might exist due to dissimilarity in observation, views etc. In addition to that the heterogeneity of sample is not very high although female participation is more than fifty percent. Data were analyzed using Exploratory Factor Analysis (EFA) technique with the outcome of three significant factors of training barriers in technology adoption by farmers: (a) Failure of technology transfer training (TTT) comprehension interprets that the technology takers, i.e., farmers can’t understand the technology either language barrier or way of demonstration exhibited by the experts/ trainers. (b) Failure of TTT customization, articulates that the training for individual farmer, gender crop or season-wise is not tailored. (c) Failure of TTT generalization conveys that absence of common training methods for individual trainers for specific crops is more prominent at the community level. The central finding is that the technology transfer training method can’t fulfill the need of the farmers under an economically challenged area. The impact of such study is very high in the area of dry lateritic and resource crunch area of Jangalmahal under Paschim Medinipur district, West Bengal and areas with similar socio-economy. Towards the policy level decision this research may help in framing digital agriculture for implementation of the appropriate information technology for the farming community, effective and timely investment by the government with the selection of beneficiary, formation of farmers club/ farm science club etc. The most important research implication of this study lies upon the contribution towards the knowledge diffusion mechanism of the agricultural sector in India. Farmers may overcome the barriers to achieve higher productivity through adoption of modern farm practices. Corporates will be interested in agro-sector through investment under corporate social responsibility (CSR). The research will help in framing public or industry policy and land use pattern. Consequently, a huge mass of rural farm-women will be empowered and farmer community will be benefitted.

Keywords: dry lateritic zone, institutional barriers, technology transfer in India, farm-women participation

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Authors: Aparajita Bhattacharya, Mousumi Dutta, Zakir Husain, Dionne Sequeira, Asima Mukhopadhyay

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Background: Tata Medical Centre (TMC), Kolkata is a major cancer referral centre in Eastern India and neighbouring countries providing state of the art facilities; however, it is a non-profit organisation with patients requiring to pay at subsidised rates. Although a system for social assessment and applying for governmental/ non-governmental (NGO) funds is in place, access is challenging. Amongst gynaecological cancers (GC), ovarian cancer (OC) is associated with the highest treatment cost; majority of which is required at the beginning when complex surgery is performed and funding arrangements cannot be made in time. We therefore appointed a dedicated Medical Social Worker (MSW) in 2016, supported by NGO for GC patients in order to assist patients/family members to access/avail these funds more readily and assist in economic evaluation for both direct and opportunity costs. Objectives: To reflect on our experience and challenges in collecting data on economic evaluation of cancer patients and compare success rates in achieving fund mobilization after introduction of MSW. Methods: A Retrospective survey. Patients with OC and their relatives were seen by the MSW during the initial outpatients department visit and followed though till discharge from the hospital and during follow-up visits. Assistance was provided in preparing the essential documents/paperwork/contacts for the funding agencies including both governmental (Chief-Minister/Prime-Minister/President) and NGO sources. In addition, a detailed questionnaire was filled up for economic assessment of direct/opportunity costs during the entire treatment and 12 months follow up period which forms a part of the study called HEPTROC (Health economic evaluation of primary treatment for ovarian cancer) developed in collaboration with economics departments of Universities. Results: In 2015, 102 patients were operated for OC; only 16 patients (15.68 %) had availed funding of a total sum of INR 1640000 through the hospital system for social assessment. Following challenges were faced by majority of the relatives: 1. Gathering important documents/proper contact details for governmental funding bodies and difficulty in following up the current status 3. Late arrival of funds. In contrast in 2016, 104 OC patients underwent surgery; the direct cost of treatment was significantly higher (median, INR 300000- 400000) compared to other GCs (n=274). 98/104 (94.23%) OC patients could be helped to apply for funds and 90/104(86.56%) patients received funding amounting to a total of INR 10897000. There has been a tenfold increase in funds mobilized in 2016 after the introduction of dedicated MSW in GC. So far, in 2017 (till June), 46/54(85.18%) OC patients applied for funds and 37/54(68.51%) patients have received funding. In a qualitative survey, all patients appreciated the role of the MSW who subsequently became the key worker for patient follow up and the chief portal for patient reported outcome monitoring. Data collection quality for the HEPTROC study was improved when questionnaires were administered by the MSW compared to researchers. Conclusion: Introduction of cancer specific MSW can expedite the availability of funds required for cancer patients and it can positively impact on patient satisfaction and outcome reporting. The economic assessment will influence fund allocation and decision for policymaking in ovarian cancer. Acknowledgement: Jivdaya Foundation Dallas, Texas.

Keywords: economic evaluation, funding, medical social worker, ovarian cancer

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Authors: Robert E. Kenney, Efrain Antunez, Samuel Nodal, Ameer Malik, Richard B. Aguilar

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Physician burnout has gained much attention during the COVID pandemic. After-hours workload, HCC coding, HEDIS metrics, and clinical documentation negatively impact career satisfaction. These and other influences have increased the rate of physicians leaving the workforce. In addition, roughly 1% of the entire physician workforce will be retiring earlier than expected based on pre-pandemic trends. The two Medical Specialties with the highest rates of burnout are Family Medicine and Primary Care. With a predicted shortage of primary care physicians looming, the need to address physician burnout is crucial. Commonly reported issues leading to clinician burnout are clerical documentation requirements, increased time working on Electronic Health Records (EHR) after hours, and a decrease in work-life balance. Clinicians experiencing burnout with physical and emotional exhaustion are at an increased likelihood of providing lower quality and less efficient patient care. This may include a lack of suitable clinical documentation, medication reconciliation, clinical assessment, and treatment plans. While the annual baseline turnover rates of physicians hover around 6-7%, the COVID pandemic profoundly disrupted the delivery of healthcare. A report found that 43% of physicians switched jobs during the initial two years of the COVID pandemic (2020 and 2021), tripling the expected average annual rate to 21.5 %/yr. During this same time, an average of 4% and 1.5% of physicians retired or left the workforce for a non-clinical career, respectively. The report notes that 35.2% made career changes for a better work-life balance and another 35% reported the reason as being unhappy with their administration’s response to the pandemic. A physician-led primary care-focused health organization, Cano Health (CH), based out of Florida, sought to preemptively address this problem by implementing several supportive measures. Working with >120 clinics and >280 PCPs from Miami to Tampa and Orlando, managing nearly 120,000 Medicare Advantage lives, CH implemented a number of changes to assist with the clinician’s workload. Supportive services such as after hour and home visits by APRNs, in-clinic care managers, and patient educators were implemented. In 2021, assistive Artificial Intelligence Software (AIS) was integrated into the EHR platform. This AIS converts free text within PDF files into a usable (copy-paste) format facilitating documentation. The software also systematically and chronologically organizes clinical data, including labs, medical records, consultations, diagnostic images, medications, etc., into an easy-to-use organ system or chronic disease state format. This reduced the excess time and documentation burden required to meet payor and CMS guidelines. A clinician Documentation Support team was employed to improve the billing/coding performance. The effects of these newly designed workflow interventions were measured via analysis of clinician turnover from CH’s hiring and termination reporting software. CH’s annualized average clinician turnover rate in 2020 and 2021 were 17.7% and 12.6%, respectively. This represents a 30% relative reduction in turnover rate compared to the reported national average of 21.5%. Retirement rates during both years were 0.1%, demonstrating a relative reduction of >95% compared to the national average (4%). This model successfully promoted the retention of clinicians in a Value-Based Care setting.

Keywords: clinician burnout, COVID-19, value-based care, burnout, clinician retirement

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Authors: Krishna Raj Regmi

Abstract:

A “Climate change adaptation and disaster risk management for sustainable agriculture” project was implemented in Nepal, a Himalayan country during 2008 to 2013 sponsored jointly by Food and Agriculture Organization (FAO) and United Nations Development Programme (UNDP), Nepal. The paper is based on the results and findings of this joint pilot project. The climate change events such as increased intensity of erratic rains in short spells, trend of prolonged drought, gradual rise in temperature in the higher elevations and occurrence of cold and hot waves in Terai (lower plains) has led to flash floods, massive erosion in the hills particularly in Churia range and drying of water sources. These recurring natural and climate-induced disasters are causing heavy damages through sedimentation and inundation of agricultural lands, crops, livestock, infrastructures and rural settlements in the downstream plains and thus reducing agriculture productivity and food security in the country. About 65% of the cultivated land in Nepal is rainfed with drought-prone characteristics and stabilization of agricultural production and productivity in these tracts will be possible through adoption of rainfed and drought-tolerant technologies as well as efficient soil-water management by the local communities. The adaptation and mitigation technologies and options identified by the project for soil erosion, flash floods and landslide control are on-farm watershed management, sloping land agriculture technologies (SALT), agro-forestry practices, agri-silvi-pastoral management, hedge-row contour planting, bio-engineering along slopes and river banks, plantation of multi-purpose trees and management of degraded waste land including sandy river-bed flood plains. The stress tolerant technologies with respect to drought, floods and temperature stress for efficient utilization of nutrient, soil, water and other resources for increased productivity are adoption of stress tolerant crop varieties and breeds of animals, indigenous proven technologies, mixed and inter-cropping systems, system of rice/wheat intensification (SRI), direct rice seeding, double transplanting of rice, off-season vegetable production and regular management of nurseries, orchards and animal sheds. The alternate energy use options and resource conservation practices for use by local communities are installation of bio-gas plants and clean stoves (Chulla range) for mitigation of green house gas (GHG) emissions, use of organic manures and bio-pesticides, jatropha cultivation, green manuring in rice fields and minimum/zero tillage practices for marshy lands. The efficient water management practices for increasing productivity of crops and livestock are use of micro-irrigation practices, construction of water conservation and water harvesting ponds, use of overhead water tanks and Thai jars for rain water harvesting and rehabilitation of on-farm irrigation systems. Initiation of some works on community-based early warning system, strengthening of met stations and disaster database management has made genuine efforts in providing disaster-tailored early warning, meteorological and insurance services to the local communities. Contingent planning is recommended to develop coping strategies and capacities of local communities to adopt necessary changes in the cropping patterns and practices in relation to adverse climatic and disaster risk conditions. At the end, adoption of awareness raising and capacity development activities (technical and institutional) and networking on climate-induced disaster and risks through training, visits and knowledge sharing workshops, dissemination of technical know-how and technologies, conduct of farmers' field schools, development of extension materials and their displays are being promoted. However, there is still need of strong coordination and linkage between agriculture, environment, forestry, meteorology, irrigation, climate-induced pro-active disaster preparedness and research at the ministry, department and district level for up-scaling, implementation and institutionalization of climate change and disaster risk management activities and adaptation mitigation options in agriculture for sustainable livelihoods of the communities.

Keywords: climate change adaptation, disaster risk management, soil-water management practices, sustainable agriculture

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