Search results for: Francisco Fernandes
Commenced in January 2007
Frequency: Monthly
Edition: International
Paper Count: 236

Search results for: Francisco Fernandes

206 Comparison of the Curvizigzag Incision with Transverse Stewart Incision in Women Undergoing Modified Radical Mastectomy for Carcinoma Breast

Authors: John Joseph S. Martis, Rohanchandra R. Gatty, Aaron Jose Fernandes, Rahul P. Nambiar

Abstract:

Introduction: Surgery for breast cancer is either mastectomy or breast conservation surgery. The most commonly used incision for modified radical mastectomy is the transverse Stewart incision. But this incision may have the disadvantage of causing disparity between the closure lines of superior and inferior skin flaps in mastectomy and can cause overhanging of soft tissue below and behind the axilla. The curvizigzag incision, on principle, may help in this regard and can prevent scar migration beyond the anterior axillary line. This study aims to compare the two incisions in this regard. Methods: 100 patients with cancer of breast were included in the study after satisfying inclusion and exclusion criteria. They underwent surgery at Father Muller Medical College, Mangalore, India, between November 2019 to September 2021. The patients were divided into two groups. Group A patients were subjected to modified radical mastectomy with curvizigzag incision and group B patients with transverse Stewart incision. Results: Seroma on postoperative day1, day 2 was 0% in both the groups. Seroma on postoperative day 30 was present in 14% of patients in group B. 60% of patients in group B had sag of soft tissue below and behind the axilla, and none of the patients in group A had this problem. In 64% of the patients in group B, the incision crossed the anterior axillary fold, 64% of the patients in group B had tension in the incision site while approximation of the skin flaps. Conclusion: Curvizigzag incision is statistically better with lesser complications when compared to the transverse Stewart incision for modified radical mastectomy for carcinoma breast.

Keywords: breast cancer, curvizigzag incision, transverse Stewart incision, seroma, modified radical mastectomy

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205 Mercury (Hg) Concentration in Fish Marketed in the São Luís Fish Market (MA) and Potential Exposure of Consumers

Authors: Luiz Drude de Lacerda, Kevin Luiz Cordeiro Ferrer do Carmo, Victor Lacerda Moura, Rayone Wesley Santos de Oliveira, Moisés Fernandes Bezerra

Abstract:

Fish is a food source well recognized for its health benefits. However, the consumption of fish, especially carnivorous species, is the main path of human exposure to Hg, a widely distributed pollutant on the planet and that accumulates along food chains. Studies on the impacts on public health by fish intake show existing toxic risks even when at low concentrations. This study quantifies, for the first time, the concentrations of Hg in muscle tissue of the nine most commercialized fish species in the fish market of São Luís (MA) in north Brazil and estimates the consequent human exposure through consumption. Concentrations varied according to trophic level, with the highest found in the larger carnivorous species; the Yellow hake (Cynoscion acoupa) (296.4 ± 241.2 ng/g w.w) and the Atlantic croaker (Micropogonias undulatus) (262.8 ± 89.1 ng/g w.w.), whereas the lowest concentrations were recorded in iliophagous Mullets (Mugil curema) (20.5 ± 9.6 ng/g w.w.). Significant correlations were observed between Hg concentrations and individual length in only two species: the Flaming catfish (Bagre marinus) and the Atlantic bumper (Chloroscombrus crysurus). Given the relatively uniform size of individuals of the other species and/or the small number of samples, this relationship was not found for the other species. The estimated risk coefficients, despite the relatively low concentrations of Hg, suggest that yellow hake and Whitemouth croaker (Micropogonias furnieri), fish most consumed by the local population, present some risk to human health (> 1) HQ and THQ, depending on the frequency of their consumption.

Keywords: contamination, fish, human exposure, risk assessment

Procedia PDF Downloads 76
204 Simultaneous Bilateral Patella Tendon Rupture: A Systematic Review

Authors: André Rui Coelho Fernandes, Mariana Rufino, Divakar Hamal, Amr Sousa, Emma Fossett, Kamalpreet Cheema

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Aim: A single patella tendon rupture is relatively uncommon, but a simultaneous bilateral event is a rare occurrence and has been scarcely reviewed in the literature. This review was carried out to analyse the existing literature on this event, with the aim of proposing a standardised approach to the diagnosis and management of this injury. Methods: A systematic review was conducted using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Three independent reviewers conducted searches in PubMed, OvidSP for Medline and Embase, as well as Cochrane Library using the same search strategy. From a total of 183 studies, 45 were included, i.e. 90 patellas. Results: 46 patellas had a Type 1 Rupture equating to 51%, with Type 3 being the least common, with only 7 patellas sustaining this injury. The mean Insall-Salvio ratio for each knee was 1.62 (R) and 1.60 (L) Direct Primary Repair was the most common surgical technique compared to Tendon Reconstruction, with End to End and Transosseous techniques split almost equally. Brace immobilisation was preferred over cast, with a mean start to weight-bearing of 3.23 weeks post-op. Conclusions: Bilateral patellar tendon rupture is a rare injury that should be considered in patients with knee extensor mechanism disruption. The key limitation of this study was the low number of patients encompassed by the eligible literature. There is space for a higher level of evidence study, specifically regarding surgical treatment choice and methods, as well as post-operative management, which could potentially improve the outcomes in the management of this injury.

Keywords: trauma and orthopaedic surgery, bilateral patella, tendon rupture, trauma

Procedia PDF Downloads 103
203 Study of Compatibility and Oxidation Stability of Vegetable Insulating Oils

Authors: Helena M. Wilhelm, Paulo O. Fernandes, Laís P. Dill, Kethlyn G. Moscon

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The use of vegetable oil (or natural ester) as an insulating fluid in electrical transformers is a trend that aims to contribute to environmental preservation since it is biodegradable and non-toxic. Besides, vegetable oil has high flash and combustion points, being considered a fire safety fluid. However, vegetable oil is usually less stable towards oxidation than mineral oil. Both insulating fluids, mineral and vegetable oils, need to be tested periodically according to specific standards. Oxidation stability can be determined by the induction period measured by conductivity method (Rancimat) by monitoring the effectivity of oil’s antioxidant additives, a methodology already developed for food application and biodiesel but still not standardized for insulating fluids. Besides adequate oxidation stability, fluids must be compatible with transformer's construction materials under normal operating conditions to ensure that damage to the oil and parts of the transformer does not occur. ASTM standard and Brazilian normative differ in parameters evaluated, which reveals the need to regulate tests for each oil type. The aim of this study was to assess oxidation stability and compatibility of vegetable oils to suggest the best way to assure a viable performance of vegetable oil as transformer insulating fluid. The determination of the induction period for several vegetable insulating oils from the local market by using Rancimat was carried out according to BS EN 14112 standard, at different temperatures (110, 120, and 130 °C). Also, the compatibility of vegetable oil was assessed according to ASTM and ABNT NBR standards. The main results showed that the best temperature for use in the Rancimat test is 130 °C, which allows a better observation of conductivity change. The compatibility test results presented differences between vegetable and mineral oil standards that should be taken into account in oil testing since materials compatibility and oxidation stability are essential for equipment reliability.

Keywords: compatibility, Rancimat, natural ester, vegetable oil

Procedia PDF Downloads 173
202 Holographic Visualisation of 3D Point Clouds in Real-time Measurements: A Proof of Concept Study

Authors: Henrique Fernandes, Sofia Catalucci, Richard Leach, Kapil Sugand

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Background: Holograms are 3D images formed by the interference of light beams from a laser or other coherent light source. Pepper’s ghost is a form of hologram conceptualised in the 18th century. This Holographic visualisation with metrology measuring techniques by displaying measurements taken in real-time in holographic form can assist in research and education. New structural designs such as the Plexiglass Stand and the Hologram Box can optimise the holographic experience. Method: The equipment used included: (i) Zeiss’s ATOS Core 300 optical coordinate measuring instrument that scanned real-world objects; (ii) Cloud Compare, open-source software used for point cloud processing; and (iii) Hologram Box, designed and manufactured during this research to provide the blackout environment needed to display 3D point clouds in real-time measurements in holographic format, in addition to a portability aspect to holograms. The equipment was tailored to realise the goal of displaying measurements in an innovative technique and to improve on conventional methods. Three test scans were completed before doing a holographic conversion. Results: The outcome was a precise recreation of the original object in the holographic form presented with dense point clouds and surface density features in a colour map. Conclusion: This work establishes a way to visualise data in a point cloud system. To our understanding, this is a work that has never been attempted. This achievement provides an advancement in holographic visualisation. The Hologram Box could be used as a feedback tool for measurement quality control and verification in future smart factories.

Keywords: holography, 3D scans, hologram box, metrology, point cloud

Procedia PDF Downloads 57
201 The UNESCO Management Plan for Urban Heritage Sites: A Critical Review of Olinda and Porto, in Brazil and Portugal

Authors: Francine Morales Tavares, Jose Alberto Rio Fernandes

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The expanding concept of Heritage and the increased relevance of how heritage places relate to their surroundings is associated with an important shift in public heritage policies and how they consider the development of cities and communities, with an increasingly relevant role of management. Within the current discussions, management plans, mandatory since the year 2005 in areas classified by UNESCO as World Heritage, it is a tool for the reconciliation of cultural heritage demands with the needs of multiple users of a certain area, being especially critical in the case of urban areas with intense touristic pressure. Considering the transformations of the heritage policy management model, this paper discusses the practices on the integration of cultural heritage in urban policies through indicators which were selected from resource manual 'Managing Cultural World Heritage (2013)' and analyzed two case studies: The Management Plan of the Historic Centre of Porto (Portugal) and The Management Plan for the Historic Site of Olinda (Brazil). The empirical evidence concluded that for the historic centre of Porto the increase of tourism is the main aim driver in the management plan, with positive and negative aspects on the heritage management point of view, unlike Olinda, where the plan for the development of local urban policies was identified as essential. Plans also differ in form, content and process but coincide on being unaligned with committed local political leaders’ agendas, with the consequent misunderstandings between theory and practice, planning and management, and critically missing in the field integration of urban policies. Therefore, more debate about management plans, more efficient tools and also, appropriate methodologies to correlate cultural heritage and urban public policy are still lacking.

Keywords: world heritage, management plan, planning, urban policies

Procedia PDF Downloads 123
200 Designing a Model to Increase the Flow of Circular Economy Startups Using a Systemic and Multi-Generational Approach

Authors: Luís Marques, João Rocha, Andreia Fernandes, Maria Moura, Cláudia Caseiro, Filipa Figueiredo, João Nunes

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The implementation of circularity strategies other than recycling, such as reducing the amount of raw material, as well as reusing or sharing existing products, remains marginal. The European Commission announced that the transition towards a more circular economy could lead to the net creation of about 700,000 jobs in Europe by 2030, through additional labour demand from recycling plants, repair services and other circular activities. Efforts to create new circular business models in accordance with completely circular processes, as opposed to linear ones, have increased considerably in recent years. In order to create a societal Circular Economy transition model, it is necessary to include innovative solutions, where startups play a key role. Early-stage startups based on new business models according to circular processes often face difficulties in creating enough impact. The StartUp Zero Program designs a model and approach to increase the flow of startups in the Circular Economy field, focusing on a systemic decision analysis and multi-generational approach, considering Multi-Criteria Decision Analysis to support a decision-making tool, which is also supported by the use of a combination of an Analytical Hierarchy Process and Multi-Attribute Value Theory methods. We define principles, criteria and indicators for evaluating startup prerogatives, quantifying the evaluation process in a unique result. Additionally, this entrepreneurship program spanning 16 months involved more than 2400 young people, from ages 14 to 23, in more than 200 interaction activities.

Keywords: circular economy, entrepreneurship, startups;, multi-criteria decision analysis

Procedia PDF Downloads 65
199 Tactical Urbanism and Sustainability: Tactical Experiences in the Promotion of Active Transportation

Authors: Aline Fernandes Barata, Adriana Sansão Fontes

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The overvaluation of the use of automobile has detrimentally affected the importance of pedestrians within the city and consequently its public spaces. As a way of treating contemporary urban paradigms, Tactical Urbanism aims to recover and activate spaces through fast and easily-applied actions that demonstrate the possibility of large-scale and long-term changes in cities. Tactical interventions have represented an important practice of redefining public spaces and urban mobility. The concept of Active Transportation coheres with the idea of sustainable urban mobility, characterizing the means of transportation through human propulsion, such as walking and cycling. This paper aims to debate the potential of Tactical Urbanism in promoting Active Transportation by revealing opportunities of transformation in the urban space of contemporary cities through initiatives that promote the protection and valorization of the presence of pedestrians and cyclists in cities, and that subvert the importance of motorized vehicles. In this paper, we present the character of these actions in two different ways: when they are used as tests for permanent interventions and when they have pre-defined start and end periods. Using recent initiatives to illustrate, we aim to discuss the role of small-scale actions in promoting and incentivizing a more active, healthy, sustainable and responsive urban way of life, presenting how some of them have developed through public policies. For that, we will present some examples of tactical actions that illustrate the encouragement of Active Transportation and trials to balance the urban opportunities for pedestrians and cyclists. These include temporary closure of streets, the creation of new alternatives and more comfortable areas for walking and cycling, and the subversion of uses in public spaces where the usage of cars are predominant.

Keywords: tactical urbanism, active transportation, sustainable mobility, non-motorized means

Procedia PDF Downloads 207
198 Design and Fabrication of Stiffness Reduced Metallic Locking Compression Plates through Topology Optimization and Additive Manufacturing

Authors: Abdulsalam A. Al-Tamimi, Chris Peach, Paulo Rui Fernandes, Paulo J. Bartolo

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Bone fixation implants currently used to treat traumatic fractured bones and to promote fracture healing are built with biocompatible metallic materials such as stainless steel, cobalt chromium and titanium and its alloys (e.g., CoCrMo and Ti6Al4V). The noticeable stiffness mismatch between current metallic implants and host bone associates with negative outcomes such as stress shielding which causes bone loss and implant loosening leading to deficient fracture treatment. This paper, part of a major research program to design the next generation of bone fixation implants, describes the combined use of three-dimensional (3D) topology optimization (TO) and additive manufacturing powder bed technology (Electron Beam Melting) to redesign and fabricate the plates based on the current standard one (i.e., locking compression plate). Topology optimization is applied with an objective function to maximize the stiffness and constraint by volume reductions (i.e., 25-75%) in order to obtain optimized implant designs with reduced stress shielding phenomenon, under different boundary conditions (i.e., tension, bending, torsion and combined loads). The stiffness of the original and optimised plates are assessed through a finite-element study. The TO results showed actual reduction in the stiffness for most of the plates due to the critical values of volume reduction. Additionally, the optimized plates fabricated using powder bed techniques proved that the integration between the TO and additive manufacturing presents the capability of producing stiff reduced plates with acceptable tolerances.

Keywords: additive manufacturing, locking compression plate, finite element, topology optimization

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197 Model of Cosserat Continuum Dispersion in a Half-Space with a Scatterer

Authors: Francisco Velez, Juan David Gomez

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Dispersion effects on the Scattering for a semicircular canyon in a micropolar continuum are analyzed, by using a computational finite element scheme. The presence of microrotational waves and the dispersive SV waves affects the propagation of elastic waves. Here, a contrast with the classic model is presented, and the dependence with the micropolar parameters is studied.

Keywords: scattering, semicircular canyon, wave dispersion, micropolar medium, FEM modeling

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196 Interorganizational Relationships in the Brazilian Milk Production Chain

Authors: Marcelo T. Okano, Oduvaldo Vendrametto, Osmildo S. Santos, Marcelo E. Fernandes, Heide Landi

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The literature on the interorganizational relationship between companies and organizations has increased in recent years, but there are still doubts about the various settings. The interorganizational networks are important in economic life, the fact facilitate the complex interdependence between transactional and cooperative organizations. A need identified in the literature is the lack of indicators to measure and identify the types of existing networks. The objective of this research is to examine the interorganizational relationships of two milk chains through indicators proposed by the theories of the four authors, characterizing them as network or not and what the benefits obtained by the chain organization. To achieve the objective of this work was carried out a survey of milk producers in two regions of the state of São Paulo. To collect the information needed for the analysis, exploratory research, qualitative nature was used. The research instrument of this work consists of a roadmap of semistructured interviews with open questions. Some of the answers were directed by the interviewer in the form of performance notes aimed at detecting the degree of importance, according to the perception of intensity to that regard. The results showed that interorganizational relationships are small and largely limited to the sale of milk or dairy cooperatives. These relationships relate only to trade relations between the owner and purchaser of milk. But when the producers are organized in associations or networks, interorganizational relationships and increase benefits for all participants in the network. The various visits and interviews in several dairy farms in the regions of São Pau-lo (indicated that the inter-relationships are small and largely limited to the sale of milk to cooperatives or dairy. These relationships refer only to trade relations between the owner and the purchaser of milk. But when the producers are organized in associations or networks, interorganizational relationships increase and bring benefits to all participants in the network.

Keywords: interorganizational networks, dairy chain, interorganizational system, São Pau-lo

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195 Technological Developments to Reduce Wind Blade Turbine Levelized Cost of Energy

Authors: Pedro Miguel Cardoso Carneiro, Ricardo André Nunes Borges, João Pedro Soares Loureiro, Hermínio Maio Graça Fernandes

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Wind energy has been exponentially growing over the last years and will allow countries to progress regarding the decarbonization objective. In parallel, the maintenance activities have also been increasing in consequence of ageing and deterioration of the wind farms. The time available for wind blade maintenance is given by the weather window that is based upon weather conditions. Most of the wind blade repair and maintenance activities require a narrow window of temperature and humidity. Due to this limitation, the current weather windows result only on approximately 35% days/year are used for maintenance, that takes place mostly during summertime. This limitation creates large economic losses in the energy production of the wind towers, since they can be inoperative or with the energy production output reduced for days or weeks due to existing damages. Another important aspect is that the maintenance costs are higher due to the high standby time and seasonality imposed on the technicians. To reduce the relevant maintenance costs of blades and energy loses some technological developments were carried out to significantly improve this reality. The focus of this activity was to develop a series of key developments to have in the near future a suspended access equipment that can operate in harsh conditions, wind rain, cold/hot environment. To this end we have identified key areas that need to be revised and require new solutions to be found; a habitat system, multi-configurable roof and floor, roof and floor interface to blade, secondary attachment solutions to the blade and to the tower. On this paper we will describe the advances produced during a national R&D project made in partnership with an end-user (Onrope) and a test center (ISQ).

Keywords: wind turbine maintenance, cost reduction, technological innovations, wind turbine blade

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194 Risks of Traditional Practices: Chemical and Health Assessment of Bakhour

Authors: Yehya Elsayed, Sarah Dalibalta, Fareedah Alqtaishat, Ioline Gomes, Nagelle Fernandes

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Bakhour or Arabian incense is traditionally used to perfume houses, shops and clothing as part of cultural or religious practices in several Middle Eastern countries. Conventionally, Bakhour consists of a mixture of natural ingredients such as chips of agarwood (oud), musk and sandalwoods that are soaked in scented oil. Bakhour is usually burned by charcoal or by using gas or electric burners to produce the scented smoke. It is necessary to evaluate the impact of such practice on human health and environment especially that the burning of Bakhour is usually done on a regular basis and in closed areas without proper ventilation. Although significant amount of research has been reported in scientific literature on the chemical analysis of various types of incense smoke, unfortunately only very few of them focused specifically on the health impacts of Bakhour. Raw Bakhour samples, their smoke emissions and the ash residue were analyzed to assess the existence of toxic ingredients and their possible influence on health and the environment. Three brands of Bakhour samples were analyzed for the presence of harmful heavy metals and organic compounds. Thermal Desorption Gas Chromatography-Mass Spectrometry (TD-GC-MS) was used to identify organic compounds while Inductively Coupled Plasma (ICP) and Scanning Electron Microscope-Energy Dispersive X-Ray Spectrometer (SEM-EDS) were used to analyze the presence of toxic and heavy metals. Organic compounds from the smoke were collected on specific tenax and activated carbon adsorption tubes. More than 850 chemical compounds were identified. The presence of 19 carcinogens, 23 toxins and 173 irritants were confirmed. Additionally, heavy metals were detected in amounts similar to those present in cigarettes. However, it was noticed that many of the detected compounds in the smoke lacked clinical studies on their health effects which shows the need for further clinical studies to be devoted to this area of study.

Keywords: Bakhour, incense smoke, pollution, indoor environment, health risk, chemical analysis

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193 Chemical and Health Assessment of Bakhour: Risks of Traditional Practices

Authors: Yehya Elsayed, Sarah Dalibalta, Fareedah Alqtaishat, Ioline Gomes, Nagelle Fernandes

Abstract:

Bakhour, or Arabian incense, is traditionally used to perfume houses, shops and clothing as part of cultural or religious practices in several Middle Eastern countries. Conventionally, Bakhour consists of a mixture of natural ingredients such as chips of agarwood (oud), musk and sandalwoods that are soaked in scented oil. Bakhour is usually burned by charcoal or by using gas or electric burners to produce the scented smoke. It is necessary to evaluate the impact of such practice on human health and environment especially that the burning of Bakhour is usually done on a regular basis and in closed areas without proper ventilation. Although significant amount of research has been reported in scientific literature on the chemical analysis of various types of incense smoke, unfortunately, only very few of them focused specifically on the health impacts of Bakhour. Raw Bakhour samples, their smoke emissions and the ash residue were analyzed to assess the existence of toxic ingredients and their possible influence on health and the environment. Three brands of Bakhour samples were analyzed for the presence of harmful heavy metals and organic compounds. Thermal Desorption Gas Chromatography-Mass Spectrometry (TD-GC-MS) was used to identify organic compounds while Inductively Coupled Plasma (ICP) and Scanning Electron Microscope-Energy Dispersive X-Ray Spectrometer (SEM-EDS) were used to analyze the presence of toxic and heavy metals.. Organic compounds from the smoke were collected on specific tenax and activated carbon adsorption tubes. More than 850 chemical compounds were identified. The presence of 19 carcinogens, 23 toxins, and 173 irritants were confirmed. Additionally, heavy metals were detected in amounts similar to those present in cigarettes. However, it was noticed that many of the detected compounds in the smoke lacked clinical studies on their health effects which shows the need for further clinical studies to be devoted to this area of study.

Keywords: bakhour, incense smoke, pollution, indoor environment, health risk, chemical analysis

Procedia PDF Downloads 262
192 Role of Different Land Use Types on Ecosystem Services Provision in Moribane Forest Reserve - Mozambique

Authors: Francisco Domingos Francisco

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Tropical forests are key providers of many Ecosystem Services (ES), contributing to human wellbeing on a global and local scale. Communities around and within Moribane Forest Reserve (MFR), Manica Province - Mozambique, benefit from ES through the exploitation of non-wood and wood forest products. The objective was to assess the provisioning capacity of the MFR in woody forest products in species and profiles of interest to local communities in the main sources of extraction. Social data relating to the basic needs of local communities for these products were captured through an exploratory study before this one. From that study, it became known about the most collected wood species, the sources of collection, and their availability in the profiles of greatest interest to them. A field survey through 39 rectangular 50mx20m plots was conducted with 13 plots established in each of the three land-use types (LUT), namely Restricted Forest, Unrestricted Forest, and Disturbed areas. The results show that 89 species were identified, of which 28 (31.4%) are assumed to be the most used by the communities. The number of species of local interest does not vary across the LUT (p>0.05). The most used species (MUS) is distributed in 82% in Restricted Forest, 75% in Unrestricted, and also 75% in Disturbed. Most individuals of both general and MUS found in Unrestricted Forest, and Degraded areas have lower end profiles (5-7 cm), representing 0.77 and 0.26%, respectively. The profile of individuals of species of local interest varies by LUT (p<0.05), and their greatest proportion (0.51%) outside the lower end is found in Restricted Forest. There were no similarities between the LUT for the species in general (JCI <0.5) but between the MUS (JCI >0.5). Conclusion, the areas authorized for the exploitation of wood forest products in the MFR tend to reduce their ability to provide local communities with forest products in species and profiles of their interest. This reduction item is a serious threat to the biodiversity of the Restricted Forest. The study can help the academic community in future studies by replicating the methodology used for monitoring purposes or conducting studies in other similar areas, and the results may support decision-makers in designing better strategies for sustainability.

Keywords: ecosystem services, land-use types, local communities, species profile, wellbeing, wood forest product

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191 Liaison Psychiatry in Baixo Alentejo, Portugal: Reality and Perspectives

Authors: Mariana Mangas, Yaroslava Martins, M. Suárez, Célia Santos, Ana Matos Pires

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Baixo Alentejo is a region of Portugal characterized by an aging population, geographic isolation, social deprivation and a lack of medical staff. It is one of the most problematic regions in regards to mental health, particularly due to the factors mentioned. The aim of this study is a presentation of liaison psychiatry in Hospital José Joaquim Fernandes; a sample of the work done, the current situation and future perspectives. The aim is to present a retrospective study of internal psychiatric emergencies from January 1st, 2016 to August 31st, 2016. Liaison psychiatry of Department of Psychiatry and Mental Health (Psychiatry Service) of ULSBA includes the following activities: internal psychiatry emergencies, HIV consultation (comprised in the general consultation) and liaison psychology (oncology and pain), consisting of a total of 111 internal psychiatry emergencies during the identified period. Gender distribution was uniform. The most prevalent age group was 71-80 years, and 66,6% of patients were 60 years old and over. The majority of the emergency observations was requested by hospital services of medicine (56,8%) and surgery (24,3%). The most frequent reasons for admission were: respiratory disease (18,0%); tumors (15.3%); other surgical and orthopedic pathology (14,5%) and stroke (11,7%). The most frequent psychiatric diagnoses were: neurotic and organic depression (24,3%); delirium (26,1%) and adjustment reaction (14,5%). Major psychiatric pathology (schizophrenia and affective disorders) was found in 10,8%. Antidepressive medication was prescribed in 37,8% patients; antipsychotics in 34,2%. In 9.9% of the cases, no psychotropic drug was prescribed, and 5,4% of patients received psychologic support. Regarding hospital discharge, 42,4% of patients were referred to the general practitioner or to the medical specialist; 22,5% to outpatient gerontopsychiatry; 17,1% to psychiatric outpatient and 14,4% deceased. A future perspective is to start liaison in areas of HIV and psycho oncology in multidisciplinary approach and to improve collaboration with colleagues of other specialties for refining psychiatric referrals.

Keywords: psychiatry, liaison, internal emergency, psychiatric referral

Procedia PDF Downloads 221
190 Fact-checking and Political Polarization in an Emerging Democracy

Authors: Eric Agyekum, Dominic Asitanga

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Ghana is widely considered asa beacon of democracy in sub-Saharan Africa. With a relatively free media, the country was ranked30thin the world and third in Africaon the 2021 Press Freedom Index. Despite the democratic gains, itis one of the most politically polarized nations in the world. Ghana’spolitical division is evident in the current hunglegislature, where each of the two dominant political parties has 137 members, with an independent member occupying the remaining one seat. Misinformation and fake newsthrive in systems with acuteideological and political differences(Imelda et al, 2021; Azzimonti&Fernandes, 2018; Spohr, 2017) and Ghana is no exception. The information disorder problem has been exacerbatedby the COVID-19 pandemic, with its attendant conspiracy theories and speculations, making it difficult for the media and fact-checking organizations to verifyall claims and flag false information. In Ghana, fact-checking agencies like Ghana Fact, Dubawa Ghana, and some mainstream news media organizations have been fact-checking political claims, COVID-19 conspiracy theories, and many others. However, it is not clear if the audience consumeand attach prominence to these fact-checked stories or even visit the websites of the fact-checking agencies to read the content. Nekmat (2020) opine that though the literature on fact-checking suggest that fact-checked stories can alter readers’ beliefs, very few studies have investigated the patronage and the potential of fact-checks to deter users from sharing false news with others, particularly on social media. In response to Nekmat, this study has been initiated to examine the perception and attitude of the audience in Ghana towards fact-checks. Anchored on the principles of the nudge theory, this study will investigate how fact-checked stories alters readers’ behavioural patterns. A survey will be conducted to collect data from sampled members of the Ghanaian society.

Keywords: fact-checking, information disorder, nudge theory, political polarization

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189 Staphylococcal Enterotoxins Play an Important Role in Clinical Signs in Bovine Mastitis

Authors: Stéfani T. A. Dantas, Laura T. S. Takume, Bruna F. Rossi, Érika R. Bonsaglia, Ivana G. Castilho, José C. F. Pantoja, Ary Fernandes Júnior, Juliano L. Gonçalves, Marcos V. Santos, Rinaldo A. Mota, Vera L. M. Rall

Abstract:

Staphylococcus aureus is one of the main pathogens causing contagious bovine mastitis, being more frequently isolated from subclinical form, although the clinical form also occurs. Clinical mastitis cause visual signs, such as swelling, fever, hardening of the mammary gland, or any change in the characteristics of the milk. Considering the subclinical type, there are no visible signs in the animal nor changes in the milk. S. aureus has many important virulence factors for the establishment of its pathogenicity in animals, such as enterotoxins, which are also responsible for foodborne poisoning. Our objective is to perform a comparative analysis between 103 isolates of S. aureus, obtained from the milk of cows with clinical mastitis and 103 more, from subclinical type, in relation to the presence of these enterotoxins and verify if their presence plays an important role in the signs of illness. We will investigate all enterotoxins described till now, such as sea-see, seg-sez, sel26, sel 27, se01, and se02 (This study was approved by the Sao Paulo State University Animal Use Ethics Committee, No. 0136/2017). For the PCR assay, we used Illustra Bacteria Mini Spin Kit for bacterial DNA. At this moment, we have already tested sea-see, seg-ser, sew, and sex, and the results have already been submitted to Fisher Exact Probability Test or Chi-square Test. Considering the isolates obtained from clinical mastitis, the most frequent enterotoxins were selw (99%), selx (78%) and selh (50.5%), and sec, see, sej, sell, selp,and ser were absent. Among the subclinics, selw (82.5%) selm (15.5%) and selx (14.6%) were the most frequent, and sea-see, seg, sei-sel, sem-ser were absent. We have already observed statistically significant differences for seb, seg, seh, sei, selo, selu, selw and selx. Other interesting results were the low number of genes in each isolate from subclinical mastitis [0 genes: 14 (13.6%); 1 gene: 55 (53.4%); 2 genes: 33 (32%) or 3: 1 (0.97%)] compared to clinical isolates [1 gene: 5 (4.9%); 2 genes: 29 (28.1%); 3 genes: 38 (36.9%); 4 genes: 14 (13.6%); 5 genes: 5 (4.9%); 6 genes: 4 (3.9%); 7 genes: 5 (4.9%); 8 genes: 2 (1.9%) and 9 genes: 1 (1%)]. Based on these results, we can conclude that enterotoxins indeed play an important role in clinical signs in cattle with mastitis.

Keywords: mastitis, S. aureus, PCR, staphylococcal enterotoxin

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188 San Francisco Public Utilities Commission Headquarters "The Greenest Urban Building in the United States"

Authors: Charu Sharma

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San Francisco Public Utilities Commission’s Headquarters was listed in the 2013-American Institute of Architects Committee of the Environment (AIA COTE) Top Ten Green Projects. This 13-story, 277,000-square-foot building, housing more than 900 of the agency’s employees was completed in June 2012. It was designed to achieve LEED Platinum Certification and boasts a plethora of green features to significantly reduce the use of energy and water consumption, and provide a healthy office work environment with high interior air quality and natural daylight. Key sustainability features include on-site clean energy generation through renewable photovoltaic and wind sources providing $118 million in energy cost savings over 75 years; 45 percent daylight harvesting; and the consumption of 55 percent less energy and a 32 percent less electricity demand from the main power grid. It uses 60 percent less water usage than an average 13-story office building as most of that water will be recycled for non-potable uses at the site, running through a system of underground tanks and artificial wetlands that cleans and clarifies whatever is flushed down toilets or washed down drains. This is one of the first buildings in the nation with treatment of gray and black water. The building utilizes an innovative structural system with post tensioned cores that will provide the highest asset preservation for the building. In addition, the building uses a “green” concrete mixture that releases less carbon gases. As a public utility commission this building has set a good example for resource conservation-the building is expected to be cheaper to operate and maintain as time goes on and will have saved rate-payers $500 million in energy and water savings. Within the anticipated 100-year lifespan of the building, our ratepayers will save approximately $3.7 billion through the combination of rental savings, energy efficiencies, and asset ownership.

Keywords: energy efficiency, sustainability, resource conservation, asset ownership, rental savings

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187 Proposal for a Framework for Teaching Entrepreneurship and Innovation Using the Methods and Current Methodologies

Authors: Marcelo T. Okano, Jaqueline C. Bueno, Oduvaldo Vendrametto, Osmildo S. Santos, Marcelo E. Fernandes, Heide Landi

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Developing countries are increasingly finding that entrepreneurship and innovation are the ways to speed up their developments and initiate or encourage technological development. The educational institutions such as universities, colleges and colleges of technology, has two main roles in this process, to guide and train entrepreneurs and provide technological knowledge and encourage innovation. Thus there was completing the triple helix model of innovation with universities, government and industry. But the teaching of entrepreneurship and innovation can not be only the traditional model, with blackboard, chalk and classroom. The new methods and methodologies such as Canvas, elevator pitching, design thinking, etc. require students to get involved and to experience the simulations of business, expressing their ideas and discussing them. The objective of this research project is to identify the main methods and methodologies used for the teaching of entrepreneurship and innovation, to propose a framework, test it and make a case study. To achieve the objective of this research, firstly was a survey of the literature on the entrepreneurship and innovation, business modeling, business planning, Canvas business model, design thinking and other subjects about the themes. Secondly, we developed the framework for teaching entrepreneurship and innovation based on bibliographic research. Thirdly, we tested the framework in a higher education class IT management for a semester. Finally, we detail the results in the case study in a course of IT management. As important results we improve the level of understanding and business administration students, allowing them to manage own affairs. Methods such as canvas and business plan helped students to plan and shape the ideas and business. Pitching for entrepreneurs and investors in the market brought a reality for students. The prototype allowed the company groups develop their projects. The proposed framework allows entrepreneurship education and innovation can leave the classroom, bring the reality of business roundtables to university relying on investors and real entrepreneurs.

Keywords: entrepreneurship, innovation, Canvas, traditional model

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186 A Model for Operating Rooms Scheduling

Authors: Jose Francisco Ferreira Ribeiro, Alexandre Bevilacqua Leoneti, Andre Lucirton Costa

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This paper presents a mathematical model in binary variables 0/1 to make the assignment of surgical procedures to the operating rooms in a hospital. The proposed mathematical model is based on the generalized assignment problem, which maximizes the sum of preferences for the use of the operating rooms by doctors, respecting the time available in each room. The corresponding program was written in Visual Basic of Microsoft Excel, and tested to schedule surgeries at St. Lydia Hospital in Ribeirao Preto, Brazil.

Keywords: generalized assignment problem, logistics, optimization, scheduling

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185 PWM Harmonic Injection and Frequency-Modulated Triangular Carrier to Improve the Lives of the Transformers

Authors: Mario J. Meco-Gutierrez, Francisco Perez-Hidalgo, Juan R. Heredia-Larrubia, Antonio Ruiz-Gonzalez, Francisco Vargas-Merino

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More and more applications power inverters connected to transformers, for example, the connection facilities to the power grid renewable generation. It is well known that the quality of signal power inverters it is not a pure sine. The harmonic content produced negative effects, one of which is the heating of electrical machines and therefore, affects the life of the machines. The decrease of life of transformers can be calculated by Arrhenius or Montsinger equation. Analyzing this expression any (long-term) decrease of a transformer temperature for 6º C - 7º C means doubles its life-expectancy. Methodologies: This work presents the technique of pulse width modulation (PWM) with an injection of harmonic and triangular frequency carrier modulated in frequency. This technique is used to improve the quality of the output voltage signal of the power inverters controlled PWM. The proposed technique increases in the fundamental term and a significant reduction in low order harmonics with the same commutations per time that control sine PWM. To achieve this, the modulating wave is compared to a triangular carrier with variable frequency over the period of the modulator. Therefore, it is, advantageous for the modulating signal to have a large amount of sinusoidal “information” in the areas of greater sampling. A triangular signal with a frequency that varies over the modulator’s period is used as a carrier, for obtaining more samples in the area with the greatest slope. A power inverter controlled by PWM proposed technique is connected to a transformer. Results: In order to verify the derived thermal parameters under different operation conditions, another ambient and loading scenario is involved for a further verification, which was sampled from the same power transformer. Temperatures of different parts of the transformer will be exposed for each PWM control technique analyzed. An assessment of the temperature be done with different techniques PWM control and hence the life of the transformer is calculated for each technique. Conclusion: This paper analyzes such as transformer heating produced by this technique and compared with other forms of PWM control. In it can be seen as a reduction the harmonic content produces less heat transformer and therefore, an increase in the life of the transformer.

Keywords: heating, power-inverter, PWM, transformer

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184 Design of a New Vegetable Snack

Authors: Patricia Calvo, Francisco M. Sánchez, María J. Rodríguez

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Nowadays, food intake is becoming more irregular due to changes in family organization and lifestyle. Snacking is part of the day-to-day lives of people, however, most of the snacks have a high saturated fat, salt and refined sugar content; these dietary factors are believed to have negative health consequences. For this reason, there has been an increase in consumer demand for healthy, natural and convenient foods, so the development of a significant portion of new products focuses on improving the nutritional value of food snacks through modification its nutritional composition. In this paper, a new product made from vegetables has been designed. This new product would be an ideal food format to include ingredients with positive health benefits.

Keywords: healthy, pepper, dried, carotenes, polyphenols

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183 DEMs: A Multivariate Comparison Approach

Authors: Juan Francisco Reinoso Gordo, Francisco Javier Ariza-López, José Rodríguez Avi, Domingo Barrera Rosillo

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The evaluation of the quality of a data product is based on the comparison of the product with a reference of greater accuracy. In the case of MDE data products, quality assessment usually focuses on positional accuracy and few studies consider other terrain characteristics, such as slope and orientation. The proposal that is made consists of evaluating the similarity of two DEMs (a product and a reference), through the joint analysis of the distribution functions of the variables of interest, for example, elevations, slopes and orientations. This is a multivariable approach that focuses on distribution functions, not on single parameters such as mean values or dispersions (e.g. root mean squared error or variance). This is considered to be a more holistic approach. The use of the Kolmogorov-Smirnov test is proposed due to its non-parametric nature, since the distributions of the variables of interest cannot always be adequately modeled by parametric models (e.g. the Normal distribution model). In addition, its application to the multivariate case is carried out jointly by means of a single test on the convolution of the distribution functions of the variables considered, which avoids the use of corrections such as Bonferroni when several statistics hypothesis tests are carried out together. In this work, two DEM products have been considered, DEM02 with a resolution of 2x2 meters and DEM05 with a resolution of 5x5 meters, both generated by the National Geographic Institute of Spain. DEM02 is considered as the reference and DEM05 as the product to be evaluated. In addition, the slope and aspect derived models have been calculated by GIS operations on the two DEM datasets. Through sample simulation processes, the adequate behavior of the Kolmogorov-Smirnov statistical test has been verified when the null hypothesis is true, which allows calibrating the value of the statistic for the desired significance value (e.g. 5%). Once the process has been calibrated, the same process can be applied to compare the similarity of different DEM data sets (e.g. the DEM05 versus the DEM02). In summary, an innovative alternative for the comparison of DEM data sets based on a multinomial non-parametric perspective has been proposed by means of a single Kolmogorov-Smirnov test. This new approach could be extended to other DEM features of interest (e.g. curvature, etc.) and to more than three variables

Keywords: data quality, DEM, kolmogorov-smirnov test, multivariate DEM comparison

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182 Congenital Sublingual Dermoid Cyst with Cutaneous Fistula

Authors: Rafael Ricieri, Rogerio Barros, Francisco Clovis

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Objective– The Objective of this is study is to report a rare case of dermoid cyst, with a sublingual location and cutaneous fistula in a 4 year-old child.Methods: This study is a case report. The main study instrument was the medical record and the radiological and intraoperative image bank. Results: Infants with congenital cervical lesions eventually need tomography for diagnostic elucidation, and health services should be structured to perform sedation and thin tomographic sections in order to reduce morbidity.

Keywords: congenital, sublingual dermoid cyst, fistula, pediatric surgery, head and kneck surgery

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181 Perspectives and Challenges a Functional Bread With Yeast Extract to Improve Human Diet

Authors: Cláudia Patrocínio, Beatriz Fernandes, Ana Filipa Pires

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Background: Mirror therapy (MT) is used to improve motor function after stroke. During MT, a mirror is placed between the two upper limbs (UL), thus reflecting movements of the non- affected side as if it were the affected side. Objectives: The aim of this review is to analyze the evidence on the effec.tiveness of MT in the recovery of UL function in population with post chronic stroke. Methods: The literature search was carried out in PubMed, ISI Web of Science, and PEDro database. Inclusion criteria: a) studies that include individuals diagnosed with stroke for at least 6 months; b) intervention with MT in UL or comparing it with other interventions; c) articles published until 2023; d) articles published in English or Portuguese; e) randomized controlled studies. Exclusion criteria: a) animal studies; b) studies that do not provide a detailed description of the intervention; c) Studies using central electrical stimulation. The methodological quality of the included studies was assessed using the Physiotherapy Evidence Database (PEDro) scale. Studies with < 4 on PEDro scale were excluded. Eighteen studies met all the inclusion criteria. Main results and conclusions: The quality of the studies varies between 5 and 8. One article compared muscular strength training (MST) with MT vs without MT and four articles compared the use of MT vs conventional therapy (CT), one study compared extracorporeal shock therapy (EST) with and without MT and another study compared functional electrical stimulation (FES), MT and biofeedback, three studies compared MT with Mesh Glove (MG) or Sham Therapy, five articles compared performing bimanual exercises with and without MT and three studies compared MT with virtual reality (VR) or robot training (RT). The assessment of changes in function and structure (International Classification of Functioning, Disability and Health parameter) was carried out, in each article, mainly using the Fugl Meyer Assessment-Upper Limb scale, activity and participation (International Classification of Functioning, Disability and Health parameter) were evaluated using different scales, in each study. The positive results were seen in these parameters, globally. Results suggest that MT is more effective than other therapies in motor recovery and function of the affected UL, than these techniques alone, although the results have been modest in most of the included studies. There is also a more significant improvement in the distal movements of the affected hand than in the rest of the UL.

Keywords: physical therapy, mirror therapy, chronic stroke, upper limb, hemiplegia

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180 Localization of Radioactive Sources with a Mobile Radiation Detection System using Profit Functions

Authors: Luís Miguel Cabeça Marques, Alberto Manuel Martinho Vale, José Pedro Miragaia Trancoso Vaz, Ana Sofia Baptista Fernandes, Rui Alexandre de Barros Coito, Tiago Miguel Prates da Costa

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The detection and localization of hidden radioactive sources are of significant importance in countering the illicit traffic of Special Nuclear Materials and other radioactive sources and materials. Radiation portal monitors are commonly used at airports, seaports, and international land borders for inspecting cargo and vehicles. However, these equipment can be expensive and are not available at all checkpoints. Consequently, the localization of SNM and other radioactive sources often relies on handheld equipment, which can be time-consuming. The current study presents the advantages of real-time analysis of gamma-ray count rate data from a mobile radiation detection system based on simulated data and field tests. The incorporation of profit functions and decision criteria to optimize the detection system's path significantly enhances the radiation field information and reduces survey time during cargo inspection. For source position estimation, a maximum likelihood estimation algorithm is employed, and confidence intervals are derived using the Fisher information. The study also explores the impact of uncertainties, baselines, and thresholds on the performance of the profit function. The proposed detection system, utilizing a plastic scintillator with silicon photomultiplier sensors, boasts several benefits, including cost-effectiveness, high geometric efficiency, compactness, and lightweight design. This versatility allows for seamless integration into any mobile platform, be it air, land, maritime, or hybrid, and it can also serve as a handheld device. Furthermore, integration of the detection system into drones, particularly multirotors, and its affordability enable the automation of source search and substantial reduction in survey time, particularly when deploying a fleet of drones. While the primary focus is on inspecting maritime container cargo, the methodologies explored in this research can be applied to the inspection of other infrastructures, such as nuclear facilities or vehicles.

Keywords: plastic scintillators, profit functions, path planning, gamma-ray detection, source localization, mobile radiation detection system, security scenario

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179 The Effect of Outliers on the Economic and Social Survey on Income and Living Conditions

Authors: Encarnación Álvarez, Rosa M. García-Fernández, Francisco J. Blanco-Encomienda, Juan F. Muñoz

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The European Union Survey on Income and Living Conditions (EU-SILC) is a popular survey which provides information on income, poverty, social exclusion and living conditions of households and individuals in the European Union. The EUSILC contains variables which may contain outliers. The presence of outliers can have an impact on the measures and indicators used by the EU-SILC. In this paper, we used data sets from various countries to analyze the presence of outliers. In addition, we obtain some indicators after removing these outliers, and a comparison between both situations can be observed. Finally, some conclusions are obtained.

Keywords: poverty line, headcount index, risk of poverty, skewness coefficient

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178 Neuro-Epigenetic Changes on Diabetes Induced-Synaptic Fidelity in Brain

Authors: Valencia Fernandes, Dharmendra Kumar Khatri, Shashi Bala Singh

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Background and Aim: Epigenetics are the inaudible signatures of several pathological processes in the brain. This study understands the influence of DNA methylation, a major epigenetic modification, in the prefrontal cortex and hippocampus of the diabetic brain and its notable effect on the cellular chaperones and synaptic proteins. Method: Chronic high fat diet and STZ-induced diabetic mice were studied for cognitive dysfunction, and global DNA methylation, as well as DNA methyltransferase (DNMT) activity, were assessed. Further, the cellular chaperones and synaptic proteins were examined using DNMT inhibitor, 5-aza-2′-deoxycytidine (5-aza-dC)-via intracerebroventricular injection. Moreover, % methylation of these synaptic proteins were also studied so as to correlate its epigenetic involvement. Computationally, its interaction with the DNMT enzyme were also studied using bioinformatic tools. Histological studies for morphological alterations and neuronal degeneration were also studied. Neurogenesis, a characteristic marker for new learning and memory formation, was also assessed via the BrdU staining. Finally, the most important behavioral studies, including the Morris water maze, Y maze, passive avoidance, and Novel object recognition test, were performed to study its cognitive functions. Results: Altered global DNA methylation and increased levels of DNMTs within the nucleus were confirmed in the cortex and hippocampus of the diseased mice, suggesting hypermethylation at a genetic level. Treatment with AzadC, a global DNA demethylating agent, ameliorated the protein and gene expression of the cellular chaperones and synaptic fidelity. Furthermore, the methylation analysis profile showed hypermethylation of the hsf1 protein, a master regulator for chaperones and thus, confirmed the epigenetic involvement in the diseased brain. Morphological improvements and decreased neurodegeneration, along with enhanced neurogenesis in the treatment group, suggest that epigenetic modulations do participate in learning and memory. This is supported by the improved behavioral test battery seen in the treatment group. Conclusion: DNA methylation could possibly accord in dysregulating the memory-associated proteins at chronic stages in type 2 diabetes. This could suggest a substantial contribution to the underlying pathophysiology of several metabolic syndromes like insulin resistance, obesity and also participate in transitioning this damage centrally, such as cognitive dysfunction.

Keywords: epigenetics, cognition, chaperones, DNA methylation

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177 One Year Follow up of Head and Neck Paragangliomas: A Single Center Experience

Authors: Cecilia Moreira, Rita Paiva, Daniela Macedo, Leonor Ribeiro, Isabel Fernandes, Luis Costa

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Background: Head and neck paragangliomas are a rare group of tumors with a large spectrum of clinical manifestations. The approach to evaluate and treat these lesions has evolved over the last years. Surgery was the standard for the approach of these patients, but nowadays new techniques of imaging and radiation therapy changed that paradigm. Despite advances in treating, the growth potential and clinical outcome of individual cases remain largely unpredictable. Objectives: Characterization of our institutional experience with clinical management of these tumors. Methods: This was a cross-sectional study of patients followed in our institution between 01 January and 31 December 2017 with paragangliomas of the head and neck and cranial base. Data on tumor location, catecholamine levels, and specific imaging modalities employed in diagnostic workup, treatment modality, tumor control and recurrence, complications of treatment and hereditary status were collected and summarized. Results: A total of four female patients were followed between 01 January and 31 December 2017 in our institution. The mean age of our cohort was 53 (± 16.1) years. The primary locations were at the level of the tympanic jug (n=2, 50%) and carotid body (n=2, 50%), and only one of the tumors of the carotid body presented pulmonary metastasis at the time of diagnosis. None of the lesions were catecholamine-secreting. Two patients underwent genetic testing, with no mutations identified. The initial clinical presentation was variable highlighting the decrease of visual acuity and headache as symptoms present in all patients. In one of the cases, loss of all teeth of the lower jaw was the presenting symptomatology. Observation with serial imaging, surgical extirpation, radiation, and stereotactic radiosurgery were employed as treatment approaches according to anatomical location and resectability of lesions. As post-therapeutic sequels the persistence of tinnitus and disabling pain stands out, presenting one of the patients neuralgia of the glossopharyngeal. Currently, all patients are under regular surveillance with a median follow up of 10 months. Conclusion: Ultimately, clinical management of these tumors remains challenging owing to heterogeneity in clinical presentation, the existence of multiple treatment alternatives, and potential to cause serious detriment to critical functions and consequently interference with the quality of life of the patients.

Keywords: clinical outcomes, head and neck, management, paragangliomas

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