Search results for: lymph node

Authors: Christi Jackson, Chuka Onaga

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Introduction: We report a case of delayed diagnosis of extra-pulmonary INH-mono-resistant Tuberculosis (TB) in a South African patient with drug-resistant HIV. Case Presentation: A 36-year old male was initiated on 1st line (NNRTI-based) anti-retroviral therapy (ART) in September 2009 and switched to 2nd line (PI-based) ART in 2011, according to local guidelines. He was following up at the outpatient wellness unit of a public hospital, where he was diagnosed with Protease Inhibitor resistant HIV in March 2016. He had an HIV viral load (HIVVL) of 737000 copies/mL, CD4-count of 10 cells/µL and presented with complaints of productive cough, weight loss, chronic diarrhoea and a septic buttock wound. Several investigations were done on sputum, stool and pus samples but all were negative for TB. The patient was treated with antibiotics and the cough and the buttock wound improved. He was subsequently started on a 3rd-line ART regimen of Darunavir, Ritonavir, Etravirine, Raltegravir, Tenofovir and Emtricitabine in May 2016. He continued losing weight, became too weak to stand unsupported and started complaining of abdominal pain. Further investigations were done in September 2016, including a urine specimen for Line Probe Assay (LPA), which showed M. tuberculosis sensitive to Rifampicin but resistant to INH. A lymph node biopsy also showed histological confirmation of TB. Management and outcome: He was started on Rifabutin, Pyrazinamide and Ethambutol in September 2016, and Etravirine was discontinued. After 6 months on ART and 2 months on TB treatment, his HIVVL had dropped to 286 copies/mL, CD4 improved to 179 cells/µL and he showed clinical improvement. Pharmacy supply of his individualised drugs was unreliable and presented some challenges to continuity of treatment. He successfully completed his treatment in June 2017 while still maintaining virological suppression. Discussion: Several laboratory-related factors delayed the diagnosis of TB, including the unavailability of urine-lipoarabinomannan (LAM) and urine-GeneXpert (GXP) tests at this facility. Once the diagnosis was made, it presented a treatment dilemma due to the expected drug-drug interactions between his 3rd-line ART regimen and his INH-resistant TB regimen, and specialist input was required. Conclusion: TB is more difficult to diagnose in patients with severe immunosuppression, therefore additional tests like urine-LAM and urine-GXP can be helpful in expediting the diagnosis in these cases. Patients with non-standard drug regimens should always be discussed with a specialist in order to avoid potentially harmful drug-drug interactions.

Keywords: drug-resistance, HIV, line probe assay, tuberculosis

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Authors: Varun Agarwal

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Introduction: With the advent of personalized medicine, histopathological review of whole slide images (WSIs) for cancer diagnosis presents an exceedingly time-consuming, complex task. Specifically, detecting metastatic regions in WSIs of sentinel lymph node biopsies necessitates a full-scanned, holistic evaluation of the image. Thus, digital pathology, low-level image manipulation algorithms, and machine learning provide significant advancements in improving the efficiency and accuracy of WSI analysis. Using Camelyon16 data, this paper proposes a deep learning pipeline to automate and ameliorate breast cancer metastasis localization and WSI classification. Methodology: The model broadly follows five stages -region of interest detection, WSI partitioning into image tiles, convolutional neural network (CNN) image-segment classifications, probabilistic mapping of tumor localizations, and further processing for whole WSI classification. Transfer learning is applied to the task, with the implementation of Inception-ResNetV2 - an effective CNN classifier that uses residual connections to enhance feature representation, adding convolved outputs in the inception unit to the proceeding input data. Moreover, in order to augment the performance of the transfer learning CNN, a stack of convolutional denoising autoencoders (CDAE) is applied to produce embeddings that enrich image representation. Through a saliency-detection algorithm, visual training segments are generated, which are then processed through a denoising autoencoder -primarily consisting of convolutional, leaky rectified linear unit, and batch normalization layers- and subsequently a contrast-normalization function. A spatial pyramid pooling algorithm extracts the key features from the processed image, creating a viable feature map for the CNN that minimizes spatial resolution and noise. Results and Conclusion: The simplified and effective architecture of the fine-tuned transfer learning Inception-ResNetV2 network enhanced with the CDAE stack yields state of the art performance in WSI classification and tumor localization, achieving AUC scores of 0.947 and 0.753, respectively. The convolutional feature retention and compilation with the residual connections to inception units synergized with the input denoising algorithm enable the pipeline to serve as an effective, efficient tool in the histopathological review of WSIs.

Keywords: breast cancer, convolutional neural networks, metastasis mapping, whole slide images

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Authors: Ella Tyuryumina, Alexey Neznanov

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This study is an attempt to obtain reliable data on the natural history of breast cancer growth. We analyze the opportunities for using classical mathematical models (exponential and logistic tumor growth models, Gompertz and von Bertalanffy tumor growth models) to try to describe growth of the primary tumor and the secondary distant metastases of human breast cancer. The research aim is to improve predicting accuracy of breast cancer progression using an original mathematical model referred to CoMPaS and corresponding software. We are interested in: 1) modelling the whole natural history of the primary tumor and the secondary distant metastases; 2) developing adequate and precise CoMPaS which reflects relations between the primary tumor and the secondary distant metastases; 3) analyzing the CoMPaS scope of application; 4) implementing the model as a software tool. The foundation of the CoMPaS is the exponential tumor growth model, which is described by determinate nonlinear and linear equations. The CoMPaS corresponds to TNM classification. It allows to calculate different growth periods of the primary tumor and the secondary distant metastases: 1) ‘non-visible period’ for the primary tumor; 2) ‘non-visible period’ for the secondary distant metastases; 3) ‘visible period’ for the secondary distant metastases. The CoMPaS is validated on clinical data of 10-years and 15-years survival depending on the tumor stage and diameter of the primary tumor. The new predictive tool: 1) is a solid foundation to develop future studies of breast cancer growth models; 2) does not require any expensive diagnostic tests; 3) is the first predictor which makes forecast using only current patient data, the others are based on the additional statistical data. The CoMPaS model and predictive software: a) fit to clinical trials data; b) detect different growth periods of the primary tumor and the secondary distant metastases; c) make forecast of the period of the secondary distant metastases appearance; d) have higher average prediction accuracy than the other tools; e) can improve forecasts on survival of breast cancer and facilitate optimization of diagnostic tests. The following are calculated by CoMPaS: the number of doublings for ‘non-visible’ and ‘visible’ growth period of the secondary distant metastases; tumor volume doubling time (days) for ‘non-visible’ and ‘visible’ growth period of the secondary distant metastases. The CoMPaS enables, for the first time, to predict ‘whole natural history’ of the primary tumor and the secondary distant metastases growth on each stage (pT1, pT2, pT3, pT4) relying only on the primary tumor sizes. Summarizing: a) CoMPaS describes correctly the primary tumor growth of IA, IIA, IIB, IIIB (T1-4N0M0) stages without metastases in lymph nodes (N0); b) facilitates the understanding of the appearance period and inception of the secondary distant metastases.

Keywords: breast cancer, exponential growth model, mathematical model, metastases in lymph nodes, primary tumor, survival

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Authors: Ahmad R. Zamani, Luigi Sanguigno, Angelo R. Maligno

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A 3D woven composite, designed for automotive applications, is studied using Abaqus Finite Element (FE) software suite. Python scripts were developed to build FE models of the woven composite in Complete Abaqus Environment (CAE). They can read TexGen or WiseTex files and automatically generate consistent meshes of the fabric and the matrix. A user menu is provided to help define parameters for the FE models, such as type and size of the elements in fabric and matrix as well as the type of matrix-fabric interaction. Node-to-node constraints were imposed to guarantee periodicity of the deformed shapes at the boundaries of the representative volume element of the composite. Tensile loads in three axes and biaxial loads in x-y directions have been applied at different Fibre Volume Fractions (FVFs). A simple damage model was implemented via an Abaqus user material (UMAT) subroutine. Existing tools for homogenization were also used, including voxel mesh generation from TexGen as well as Abaqus Micromechanics plugin. Linear relations between homogenised elastic properties and the FVFs are given. The FE models of composite exhibited balanced behaviour with respect to warp and weft directions in terms of both stiffness and strength.

Keywords: 3D woven composite (3DWC), meso-scale finite element model, homogenisation of elastic material properties, Abaqus Python scripting

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Authors: Vladimir Kulyukin, Tanwir Zaman, Sarat Kiran Andhavarapu

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Research on nutrition label use identifies four factors that impede comprehension and retention of nutrition information by consumers: label’s location on the package, presentation of information within the label, label’s surface size, and surrounding visual clutter. In this paper, a system is presented that makes nutrition label use more effective for nutrition information comprehension and retention. The system’s front end is a smartphone application. The system’s back end is a four node Linux cluster for image recognition and data storage. Image frames captured on the smartphone are sent to the back end for skewed or aligned barcode recognition. When barcodes are recognized, corresponding nutrition labels are retrieved from a cloud database and presented to the user on the smartphone’s touchscreen. Each displayed nutrition label is positioned centrally on the touchscreen with no surrounding visual clutter. Wikipedia links to important nutrition terms are embedded to improve comprehension and retention of nutrition information. Standard touch gestures (e.g., zoom in/out) available on mainstream smartphones are used to manipulate the label’s surface size. The nutrition label database currently includes 200,000 nutrition labels compiled from public web sites by a custom crawler. Stress test experiments with the node cluster are presented. Implications for proactive nutrition management and food policy are discussed.

Keywords: mobile computing, cloud computing, nutrition label use, nutrition management, barcode scanning

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Authors: Colin Smith, Linsey S Passarella

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Due to the proliferation and decentralized nature of academic publication, no widely accepted scheme exists for organizing papers by their scientific field of study (FoS) to the author’s best knowledge. While many academic journals require author provided keywords for papers, these keywords range wildly in scope and are not consistent across papers, journals, or field domains, necessitating alternative approaches to paper classification. Past attempts to perform field-of-study (FoS) classification on scientific texts have largely used a-hierarchical FoS schemas or ignored the schema’s inherently hierarchical structure, e.g. by compressing the structure into a single layer for multi-label classification. In this paper, we introduce an application of a Layered Neural Network (LNN) to the problem of performing supervised hierarchical classification of scientific fields of study (FoS) on research papers. In this approach, paper embeddings from a pretrained language model are fed into a top-down LNN. Beginning with a single neural network (NN) for the highest layer of the class hierarchy, each node uses a separate local NN to classify the subsequent subfield child node(s) for an input embedding of concatenated paper titles and abstracts. We compare our LNN-FOS method to other recent machine learning methods using the Microsoft Academic Graph (MAG) FoS hierarchy and find that the LNN-FOS offers increased classification accuracy at each FoS hierarchical level.

Keywords: hierarchical classification, layer neural network, scientific field of study, scientific taxonomy

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Authors: Pallavi Bhogaram, Xiaolong Wu, Min He, Onyedikachi Okenwa

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A transportation network is a realization of a spatial network, describing a structure which permits either vehicular movement or flow of some commodity. Examples include road networks, railways, air routes, pipelines, and many more. The transportation network plays a vital role in maintaining the vigor of the nation’s economy. Hence, ensuring the network stays resilient all the time, especially in the face of challenges such as heavy traffic loads and large scale natural disasters, is of utmost importance. In this paper, we used the Neo4j application to develop the graph. Neo4j is the world's leading open-source, NoSQL, a native graph database that implements an ACID-compliant transactional backend to applications. The Southern California network model is developed using the Neo4j application and obtained the most critical and optimal nodes and paths in the network using centrality algorithms. The edge betweenness centrality algorithm calculates the critical or optimal paths using Yen's k-shortest paths algorithm, and the node betweenness centrality algorithm calculates the amount of influence a node has over the network. The preliminary study results confirm that the Neo4j application can be a suitable tool to study the important nodes and the critical paths for the major congested metropolitan area.

Keywords: critical path, transportation network, connectivity reliability, network model, Neo4j application, edge betweenness centrality index

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Authors: El Miloudi Djelloul

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The computer network play an important position for practical implementations of the differently system. To implement a system into network above all is needed to know all the configurations, which is responsible to be a part of the system, and to give adequate information and solution in realtime. So if want to implement this system for example in the school or relevant institutions, the first step is to analyze the types of model which is needed to be configured and another important step is to organize the works in the context of devices, as a part of the general system. Often before configuration, as important point is descriptions and documentations from all the works into the respective process, and then to organize in the aspect of problem-solving. The computer network as critic infrastructure is very specific so the paper present the effectiveness solutions in the structured aspect viewed from one side, and another side is, than the paper reflect the positive aspect in the context of modeling and block schema presentations as an better alternative to solve the specific problem because of continually distortions of the system from the line of devices, programs and signals or packed collisions, which are in movement from one computer node to another nodes.

Keywords: local area networks, LANs, block schema presentations, computer network system, computer node, critical infrastructure packed collisions, structural control system representations, computer network, implementations, modeling structural representations, companies, computers, context, control systems, internet, software

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Authors: Armanul Hoque Shaon, Md Baizid Mahmud, Askander Nobi, Md. Raju Ahmed, Md. Jiabul Hoque

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In the Internet of Things (IoT), devices are linked to the internet through a wireless network, allowing them to collect and transmit data without the need for a human operator. Agriculture relies heavily on wireless sensors, which are a vital component of the Internet of Things (IoT). This kind of wireless sensor network monitors physical or environmental variables like temperatures, sound, vibration, pressure, or motion without relying on a central location or sink and collaboratively passes its data across the network to be analyzed. As the primary source of plant nutrients, the soil is critical to the agricultural industry's continued growth. We're excited about the prospect of developing an Internet of Things (IoT) solution. To arrange the network, the sink node collects groundwater levels and sends them to the Gateway, which centralizes the data and forwards it to the sensor nodes. The sink node gathers soil moisture data, transmits the mean to the Gateways, and then forwards it to the website for dissemination. The web server is in charge of storing and presenting the moisture in the soil data to the web application's users. Soil characteristics may be collected using a networked method that we developed to improve rice production. Paddy land is running out as the population of our nation grows. The success of this project will be dependent on the appropriate use of the existing land base.

Keywords: IoT based agriculture monitoring, intelligent irrigation, communicating network, rice production

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Authors: Mayank Mundhra, Chester Rebeiro

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Cryptocurrencies are rapidly finding wide application in areas such as Real Time Gross Settlements and Payments Systems. Ripple is a cryptocurrency that has gained prominence with banks and payment providers. It solves the Byzantine General’s Problem with its Ripple Protocol Consensus Algorithm (RPCA), where each server maintains a list of servers, called Unique Node List (UNL) that represents the network for the server, and will not collectively defraud it. The server believes that the network has come to a consensus when members of the UNL come to a consensus on a transaction. In this paper we improve Ripple to achieve better speed, security, last mile connectivity and ease of use. We implement guidelines and automated systems for building and maintaining UNLs for resilience, robustness, improved security, and efficient information propagation. We enhance the system so as to ensure that each server receives information from across the whole network rather than just from the UNL members. We also introduce the paradigm of UNL overlap as a function of information propagation and the trust a server assigns to its own UNL. Our design not only reduces vulnerabilities such as eclipse attacks, but also makes it easier to identify malicious behaviour and entities attempting to fraudulently Double Spend or stall the system. We provide experimental evidence of the benefits of our approach over the current Ripple scheme. We observe ≥ 4.97x and 98.22x in speedup and success rate for information propagation respectively, and ≥ 3.16x and 51.70x in speedup and success rate in consensus.

Keywords: Ripple, Kelips, unique node list, consensus, information propagation

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Authors: A. Peyvan, D. Li, J. Komperda, F. Mashayek

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Turbulence can be observed in a variety fluid motions in nature and industrial applications. Recent investment in high-speed aircraft and propulsion systems has revitalized fundamental research on turbulent flows. In these systems, capturing chaotic fluid structures with different length and time scales is accomplished through the Direct Numerical Simulation (DNS) approach since it accurately simulates flows down to smallest dissipative scales, i.e., Kolmogorov’s scales. The discontinuous spectral element method (DSEM) is a high-order technique that uses spectral functions for approximating the solution. The DSEM code has been developed by our research group over the course of more than two decades. Recently, the code has been improved to run large cases in the order of billions of solution points. Running big simulations requires a considerable amount of RAM. Therefore, the DSEM code must be highly parallelized and able to start on multiple computational nodes on an HPC cluster with distributed memory. However, some pre-processing procedures, such as determining global element information, creating a global face list, and assigning global partitioning and element connection information of the domain for communication, must be done sequentially with a single processing core. A separate code has been written to perform the pre-processing procedures on a local machine. It stores the minimum amount of information that is required for the DSEM code to start in parallel, extracted from the mesh file, into text files (pre-files). It packs integer type information with a Stream Binary format in pre-files that are portable between machines. The files are generated to ensure fast read performance on different file-systems, such as Lustre and General Parallel File System (GPFS). A new subroutine has been added to the DSEM code to read the startup files using parallel MPI I/O, for Lustre, in a way that each MPI rank acquires its information from the file in parallel. In case of GPFS, in each computational node, a single MPI rank reads data from the file, which is specifically generated for the computational node, and send them to other ranks on the node using point to point non-blocking MPI communication. This way, communication takes place locally on each node and signals do not cross the switches of the cluster. The read subroutine has been tested on Argonne National Laboratory’s Mira (GPFS), National Center for Supercomputing Application’s Blue Waters (Lustre), San Diego Supercomputer Center’s Comet (Lustre), and UIC’s Extreme (Lustre). The tests showed that one file per node is suited for GPFS and parallel MPI I/O is the best choice for Lustre file system. The DSEM code relies on heavily optimized linear algebra operation such as matrix-matrix and matrix-vector products for calculation of the solution in every time-step. For this, the code can either make use of its matrix math library, BLAS, Intel MKL, or ATLAS. This fact and the discontinuous nature of the method makes the DSEM code run efficiently in parallel. The results of weak scaling tests performed on Blue Waters showed a scalable and efficient performance of the code in parallel computing.

Keywords: computational fluid dynamics, direct numerical simulation, spectral element, turbulent flow

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Authors: Esra Yuksel, Dilek Duman, Levent Yeniay, Sezgin Ulukaya

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Sentinel lymph node biopsy (SLNB) is a minimal invasive technique with lower morbidity in axillary staging of breast cancer. Isosulfan blue stain is frequently used in SLNB and regarded as safe. The present case report aimed to report severe decrement in SpO2 following isosulfan blue administration, as well as skin and urine signs and inconsistency with clinical picture in a 67-year-old ,77 kg, ASA II female case that underwent SLNB under general anesthesia. Ten minutes after subcutaneous administration of 10 ml 1% isosulfan blue by the surgeons into the patient, who were hemodynamically stable, SpO2 first reduced to 87% from 99%, and then to 75% in minutes despite 100% oxygen support. Meanwhile, blood pressure and EtCO2 monitoring was unremarkable. After specifying that anesthesia device worked normally, airway pressure did not increase and the endotracheal tube has been placed accurately, the blood sample was taken from the patient for arterial gas analysis. A severe increase was thought in MetHb concentration since SpO2 persisted to be 75% although the concentration of inspired oxygen was 100%, and solution of 2500 mg ascorbic acid in 500 ml 5% Dextrose was given to the patient via intravenous route until the results of arterial blood gas were obtained. However, arterial blood gas results were as follows: pH: 7.54, PaCO2: 23.3 mmHg, PaO2: 281 mmHg, SaO2: %99, and MetHb: %2.7. Biochemical analysis revealed a blood MetHb concentration of 2%.However, since arterial blood gas parameters were good, hemodynamics of the patient was stable and methemoglobin concentration was not so high, the patient was extubated after surgery when she was relaxed, cooperated and had adequate respiration. Despite the absence of respiratory or neurological distress, SpO2 value was increased only up to 85% within 2 hours with 5 L/min oxygen support via face mask in the surgery room as the patient was extubated. At that time, the skin of particularly the upper part of her body has turned into blue, more remarkable on the face. The color of plasma of the blood taken from the patient for biochemical analysis was blue. The color of urine coming throughout the urinary catheter placed in intensive care unit was also blue. Twelve hours after 5 L/min. oxygen inhalation via a mask, the SpO2 reached to 90%. During monitoring in intensive care unit on the postoperative 1st day, facial color and urine color of the patient was still blue, SpO2 was 92%, and arterial blood gas levels were as follows: pH: 7.44, PaO2: 76.1 mmHg, PaCO2: 38.2 mmHg, SaO2: 99%, and MetHb 1%. During monitoring in clinic on the postoperative 2nd day, SpO2 was 95% without oxygen support and her facial and urine color turned into normal. The patient was discharged on the 3rd day without any problem.In conclusion, SLNB is a less invasive alternative to axillary dissection. However, false pulse oximeter reading due to pigment interference is a rare complication of this procedure. Arterial blood gas analysis should be used to confirm any fall in SpO2 reading during monitoring.

Keywords: isosulfan blue, pulse oximetry, SLNB, methemoglobinemia

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Authors: Junaid Kameran Ahmed

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A laminated plate composite of graphite/epoxy has been analyzed dynamically in the present work by using a quadratic element (8-node diso-parametric), and by depending on 1^st order shear deformation theory, every node in this element has 6-degrees of freedom (displacement in x, y, and z axis and twist about x, y, and z axis). The dynamic analysis in the present work covered parametric studies on a composite laminated plate (square plate) to determine its effect on the natural frequency of the plate. The parametric study is represented by set of changes (plate thickness, number of layers, support conditions, layer orientation), and the plates have been simulated by using ANSYS package 12. The boundary conditions considered in this study, at all four edges of the plate, are simply supported and fixed boundary condition. The results obtained from ANSYS program show that the natural frequency for both fixed and simply supported increases with increasing the number of layers, but this increase in the natural frequency for the first five modes will be neglected after 10 layers. And it is observed that the natural frequency of a composite laminated plate will change with the change of ply orientation, the natural frequency increases and it will be at maximum with angle 45 of ply for simply supported laminated plate, and maximum natural frequency will be with cross-ply (0/90) for fixed laminated composite plate. It is also observed that the natural frequency increase is approximately doubled when the thickness is doubled.

Keywords: laminated plate, orthotropic plate, square plate, natural frequency (free vibration), composite (graphite / epoxy)

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Authors: Muntadher Sallal, Gareth Owenson, Mo Adda, Safa Shubbar

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Bitcoin is a digital currency based on a peer-to-peer network to propagate and verify transactions. Bitcoin is gaining wider adoption than any previous crypto-currency. However, the mechanism of peers randomly choosing logical neighbors without any knowledge about underlying physical topology can cause a delay overhead in information propagation, which makes the system vulnerable to double-spend attacks. Aiming at alleviating the propagation delay problem, this paper introduces proximity-aware extensions to the current Bitcoin protocol, named Master Node Based Clustering (MNBC). The ultimate purpose of the proposed protocol, that are based on how clusters are formulated and how nodes can define their membership, is to improve the information propagation delay in the Bitcoin network. In MNBC protocol, physical internet connectivity increases, as well as the number of hops between nodes, decreases through assigning nodes to be responsible for maintaining clusters based on physical internet proximity. We show, through simulations, that the proposed protocol defines better clustering structures that optimize the performance of the transaction propagation over the Bitcoin protocol. The evaluation of partition attacks in the MNBC protocol, as well as the Bitcoin network, was done in this paper. Evaluation results prove that even though the Bitcoin network is more resistant against the partitioning attack than the MNBC protocol, more resources are needed to be spent to split the network in the MNBC protocol, especially with a higher number of nodes.

Keywords: Bitcoin network, propagation delay, clustering, scalability

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Authors: Ho-Ting Wu, Kai-Wei Ke, Bo-Yu Huang, Liang-Lin Yan, Chun-Ting Lin

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With the advances in advanced technology, wireless sensor network (WSN) has become one of the most promising candidates to implement the wireless industrial internet of things (IIOT) architecture. However, the legacy IEEE 802.15.4 based WSN technology such as Zigbee system cannot meet the stringent QoS requirement of low powered, real-time, and highly reliable transmission imposed by the IIOT environment. Recently, the IEEE society developed IEEE 802.15.4e Time Slotted Channel Hopping (TSCH) access mode to serve this purpose. Furthermore, the IETF 6TiSCH working group has proposed standards to integrate IEEE 802.15.4e with IPv6 protocol smoothly to form a complete protocol stack for IIOT. In this work, we develop key network technologies for IEEE 802.15.4e based wireless IIoT architecture, focusing on practical design and system implementation. We realize the OpenWSN-based wireless IIOT system. The system architecture is divided into three main parts: web server, network manager, and sensor nodes. The web server provides user interface, allowing the user to view the status of sensor nodes and instruct sensor nodes to follow commands via user-friendly browser. The network manager is responsible for the establishment, maintenance, and management of scheduling and topology information. It executes centralized scheduling algorithm, sends the scheduling table to each node, as well as manages the sensing tasks of each device. Sensor nodes complete the assigned tasks and sends the sensed data. Furthermore, to prevent scheduling error due to packet loss, a schedule inspection mechanism is implemented to verify the correctness of the schedule table. In addition, when network topology changes, the system will act to generate a new schedule table based on the changed topology for ensuring the proper operation of the system. To enhance the system performance of such system, we further propose dynamic bandwidth allocation and distributed scheduling mechanisms. The developed distributed scheduling mechanism enables each individual sensor node to build, maintain and manage the dedicated link bandwidth with its parent and children nodes based on locally observed information by exchanging the Add/Delete commands via two processes. The first process, termed as the schedule initialization process, allows each sensor node pair to identify the available idle slots to allocate the basic dedicated transmission bandwidth. The second process, termed as the schedule adjustment process, enables each sensor node pair to adjust their allocated bandwidth dynamically according to the measured traffic loading. Such technology can sufficiently satisfy the dynamic bandwidth requirement in the frequently changing environments. Last but not least, we propose a packet retransmission scheme to enhance the system performance of the centralized scheduling algorithm when the packet delivery rate (PDR) is low. We propose a multi-frame retransmission mechanism to allow every single network node to resend each packet for at least the predefined number of times. The multi frame architecture is built according to the number of layers of the network topology. Performance results via simulation reveal that such retransmission scheme is able to provide sufficient high transmission reliability while maintaining low packet transmission latency. Therefore, the QoS requirement of IIoT can be achieved.

Keywords: IEEE 802.15.4e, industrial internet of things (IIOT), scheduling mechanisms, wireless sensor networks (WSN)

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Authors: Mohammed Ahmed Alghamdi

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Field experiment were carried out to investigate the effect of the plant growth regulator on vegetative growth and yield components of reduced height isogenic lines of the wheat (Triticum aestivum L.) cultivar Mercia. The Field experiment compared the growth regulator response of seven isogenic lines of Mercia. Growth regulators reduced plant height significantly in all lines. Growth regulator decreased total dry matter and grain yield with greatest reduction generally for the control and Rht8 lines. Rht1 was the least affected. There were few significant effects of growth regulator on gas exchange and chlorophyll fluorescence but the trend was for greater values with growth regulator. In this field experiment, a rate of 2.0 l ha-1 applied just before the third node detectable stage under non water stressed and water stressed conditions gave slight increases in yield of up to 14% except for line Rht10 which increased significantly in non-stressed conditions. In the second glasshouse experiment, a rate of 2.5 l ha-1 applied at the start of stem elongation under 30% FC and 100% FC gave reductions in yield up to 16% for the growth regulator and 55% under water stress. In the field experiment, rates of 2.5 and 3.0 l ha-1 applied at the start of stem elongation gave reductions in yield up to 20% mainly through individual seed weight. In the final glasshouse experiment, rates of 2.5 and 3.0 l ha-1 applied at 6 leaves unfolded and 1st node detectable both reduced grain yield.

Keywords: growth regulator, irrigation, isogenic lines, yield, winter wheat

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Authors: P. Vanichkobchinda

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The Logistics Transportation techniques, Open Vehicle Routing (OVR) is an approach toward transportation cost reduction, especially for long distance pickup and delivery nodes. The outstanding characteristic of OVR is that the route starting node and ending node are not necessary the same as in typical vehicle routing problems. This advantage enables the routing to flow continuously and the vehicle does not always return to its home base. This research aims to develop a heuristic for the open vehicle routing problem with pickup and delivery under time window and loading capacity constraints to minimize the total distance. The proposed heuristic is developed based on the Insertion method, which is a simple method and suitable for the rapid calculation that allows insertion of the new additional transportation requirements along the original paths. According to the heuristic analysis, cost comparisons between the proposed heuristic and companies are using method, nearest neighbor method show that the insertion heuristic. Moreover, the proposed heuristic gave superior solutions in all types of test problems. In conclusion, the proposed heuristic can effectively and efficiently solve the open vehicle routing. The research indicates that the improvement of new transport's calculation and the open vehicle routing with "Insertion Heuristic" represent a better outcome with 34.3 percent in average. in cost savings. Moreover, the proposed heuristic gave superior solutions in all types of test problems. In conclusion, the proposed heuristic can effectively and efficiently solve the open vehicle routing.

Keywords: business competitiveness, cost reduction, SMEs, logistics transportation, VRP

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Authors: Bander Alzahrani

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Information-centric networking (ICN) using architectures such as Publish-Subscribe Internet Routing Paradigm (PSIRP) is one of the promising candidates for a future Internet, has recently been under the spotlight by the research community to investigate the possibility of redesigning the current Internet architecture to solve many issues such as routing scalability, security, and quality of services issues.. The Bloom filter-based forwarding is a source-routing approach that is used in the PSIRP architecture. This mechanism is vulnerable to brute force attacks which may lead to denial-of-service (DoS) attacks. In this work, we present a new forwarding approach that keeps the advantages of Bloom filter-based forwarding while mitigates attacks on the forwarding mechanism. In practice, we introduce a special type of forwarding nodes called Edge-FW to be placed at the edge of the network. The role of these node is to add an extra security layer by validating and inspecting packets at the edge of the network against brute-force attacks and check whether the packet contains a legitimate forwarding identifier (FId) or not. We leverage Certificateless Aggregate Signature (CLAS) scheme with a small size of 64-bit which is used to sign the FId. Hence, this signature becomes bound to a specific FId. Therefore, malicious nodes that inject packets with random FIds will be easily detected and dropped at the Edge-FW node when the signature verification fails. Our preliminary security analysis suggests that with the proposed approach, the forwarding plane is able to resist attacks such as DoS with very high probability.

Keywords: bloom filter, certificateless aggregate signature, denial-of-service, information centric network

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Authors: Hassan Parandvar, Mehrdad Farid

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In this paper, a finite element modeling is presented for large amplitude vibration of functionally graded material (FGM) plates subjected to combined random pressure and thermal load. The material properties of the plates are assumed to vary continuously in the thickness direction by a simple power law distribution in terms of the volume fractions of the constituents. The material properties depend on the temperature whose distribution along the thickness can be expressed explicitly. The von Karman large deflection strain displacement and extended Hamilton's principle are used to obtain the governing system of equations of motion in structural node degrees of freedom (DOF) using finite element method. Three-node triangular Mindlin plate element with shear correction factor is used. The nonlinear equations of motion in structural degrees of freedom are reduced by using modal reduction method. The reduced equations of motion are solved numerically by 4th order Runge-Kutta scheme. In this study, the random pressure is generated using Monte Carlo method. The modeling is verified and the nonlinear dynamic response of FGM plates is studied for various values of volume fraction and sound pressure level under different thermal loads. Snap-through type behavior of FGM plates is studied too.

Keywords: nonlinear vibration, finite element method, functionally graded material (FGM) plates, snap-through, random vibration, thermal effect

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Authors: Filippo Ranalli, Forest Flager, Martin Fischer

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This paper presents a ground structure method to optimize the topology and discrete member sizing of steel frame structures in order to minimize total installed cost, including material, fabrication and erection components. The proposed method improves upon existing cost-based ground structure methods by incorporating constructability considerations well as satisfying both strength and serviceability constraints. The architecture for the method is a bi-level Multidisciplinary Feasible (MDF) architecture in which the discrete member sizing optimization is nested within the topology optimization process. For each structural topology generated, the sizing optimization process seek to find a set of discrete member sizes that result in the lowest total installed cost while satisfying strength (member utilization) and serviceability (node deflection and story drift) criteria. To accurately assess cost, the connection details for the structure are generated automatically using accurate site-specific cost information obtained directly from fabricators and erectors. Member continuity rules are also applied to each node in the structure to improve constructability. The proposed optimization method is benchmarked against conventional weight-based ground structure optimization methods resulting in an average cost savings of up to 30% with comparable computational efficiency.

Keywords: cost-based structural optimization, cost-based topology and sizing, optimization, steel frame ground structure optimization, multidisciplinary optimization of steel structures

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Authors: Anthony S. Machi, Joseph Minardi

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We present a case report of left atrial myxoma diagnosed by bedside transesophageal (TEE) ultrasound. Left atrial myxoma is the most common benign cardiac tumor and can obstruct blood flow and cause valvular insufficiency. Common symptoms consist of dyspnea, pulmonary edema and other features of left heart failure in addition to thrombus release in the form of tumor fragments. The availability of bedside ultrasound equipment is essential for the quick diagnosis and treatment of various emergency conditions including cardiac neoplasms. A 48-year-old Caucasian female with a four-year history of an untreated renal mass and anemia presented to the ED with two months of sharp, intermittent, bilateral flank pain radiating into the abdomen. She also reported intermittent vomiting and constipation along with generalized body aches, night sweats, and 100-pound weight loss over last year. She had a CT in 2013 showing a 3 cm left renal mass and a second CT in April 2016 showing a 3.8 cm left renal mass along with a past medical history of diverticulosis, chronic bronchitis, dyspnea on exertion, uncontrolled hypertension, and hyperlipidemia. Her maternal family history is positive for breast cancer, hypertension, and Type II Diabetes. Her paternal family history is positive for stroke. She was a current everyday smoker with an 11 pack/year history. Alcohol and drug use were denied. Physical exam was notable for a Grade II/IV systolic murmur at the right upper sternal border, dyspnea on exertion without angina, and a tender left lower quadrant. Her vitals and labs were notable for a blood pressure of 144/96, heart rate of 96 beats per minute, pulse oximetry of 96%, hemoglobin of 7.6 g/dL, hypokalemia, hypochloremia, and multiple other abnormalities. Physicians ordered a CT to evaluate her flank pain which revealed a 7.2 x 8.9 x 10.5 cm mixed cystic/solid mass in the lower pole of the left kidney and a filling defect in the left atrium. Bedside TEE was ordered to follow up on the filling defect. TEE reported an ejection fraction of 60-65% and visualized a mobile 6 x 3 cm mass in the left atrium attached to the interatrial septum extending into the mitral valve. Cardiothoracic Surgery and Urology were consulted and confirmed a diagnosis of left atrial myxoma and clear cell renal cell carcinoma. The patient returned a week later due to worsening nausea and vomiting and underwent emergent nephrectomy, lymph node dissection, and colostomy due to a necrotic colon. Her condition declined over the next four months due to lung and brain metastases, infections, and other complications until she passed away.

Keywords: bedside ultrasound, echocardiography, emergency medicine, left atrial myxoma

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Authors: Laura Gleason, Sahithi Talasila, Lauren Banner, Ladan Afifi, Neda Nikbakht

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Primary cutaneous anaplastic large cell lymphoma (pcALCL) accounts for 9% of all cutaneous T-cell lymphomas. pcALCL is classically characterized as a solitary papulonodule that often enlarges, ulcerates, and can be locally destructive, but overall exhibits an indolent course with overall 5-year survival estimated to be 90%. Distinguishing pcALCL from systemic ALCL (sALCL) is essential as sALCL confers a poorer prognosis with average 5-year survival being 40-50%. Although extremely rare, there have been several cases of ALK-positive ALCL diagnosed on skin biopsy without evidence of systemic involvement, which poses several challenges in the classification, prognostication, treatment, and follow-up of these patients. Objectives: We present a case of cutaneous ALK-positive ALCL without evidence of systemic involvement, and a narrative review of the literature to further characterize that ALK-positive ALCL limited to the skin is a distinct variant with a unique presentation, history, and prognosis. A 30-year-old woman presented for evaluation of an erythematous-violaceous papule present on her right chest for two months. With the development of multifocal disease and persistent lymphadenopathy, a bone marrow biopsy and lymph node excisional biopsy were performed to assess for systemic disease. Both biopsies were unrevealing. The patient was counseled on pursuing systemic therapy consisting of Brentuximab, Cyclophosphamide, Doxorubicin, and Prednisone given the concern for sALCL. Apropos of the patient we searched for clinically evident, cutaneous ALK-positive ALCL cases, with and without systemic involvement, in the English literature. Risk factors, such as tumor location, number, size, ALK localization, ALK translocations, and recurrence, were evaluated in cases of cutaneous ALK-positive ALCL. The majority of patients with cutaneous ALK-positive ALCL did not progress to systemic disease. The majority of cases that progressed to systemic disease in adults had recurring skin lesions and cytoplasmic localization of ALK. ALK translocations did not influence disease progression. Mean time to disease progression was 16.7 months, and significant mortality (50%) was observed in those cases that progressed to systemic disease. Pediatric cases did not exhibit a trend similar to adult cases. In both the adult and pediatric cases, a subset of cutaneous-limited ALK-positive ALCL were treated with chemotherapy. All cases treated with chemotherapy did not progress to systemic disease. Apropos of an ALK-positive ALCL patient with clinical cutaneous limited disease in the histologic presence of systemic markers, we discussed the literature data, highlighting the crucial issues related to developing a clinical strategy to approach this rare subtype of ALCL. Physicians need to be aware of the overall spectrum of ALCL, including cutaneous limited disease, systemic disease, disease with NPM-ALK translocation, disease with ALK and EMA positivity, and disease with skin recurrence.

Keywords: anaplastic large cell lymphoma, systemic, cutaneous, anaplastic lymphoma kinase, ALK, ALCL, sALCL, pcALCL, cALCL

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Authors: Omar Nouri, Wafa Mnejja, Fatma Dhouib, Syrine Zouari, Wicem Siala, Ilhem Charfeddine, Afef Khanfir, Leila Farhat, Nejla Fourati, Jamel Daoud

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Purpose and Objective: Intensity modulated radiation (IMRT) technique, associated with induction chemotherapy (IC) and/or concomitant chemotherapy (CC), is actually the recommended treatment modality for nasopharyngeal carcinomas (NPC). The aim of this study was to evaluate the therapeutic results and the patterns of relapse with this treatment protocol. Material and methods: A retrospective monocentric study of 145 patients with NPC treated between June 2016 and July 2021. All patients received IMRT with integrated simultaneous boost (SIB) of 33 daily fractions at a dose of 69.96 Gy for high-risk volume, 60 Gy for intermediate risk volume and 54 Gy for low-risk volume. The high-risk volume dose was 66.5 Gy in children. Survival analysis was performed according to the Kaplan-Meier method, and the Log-rank test was used to compare factors that may influence survival. Results: Median age was 48 years (11-80) with a sex ratio of 2.9. One hundred-twenty tumors (82.7%) were classified as stages III-IV according to the 2017 UICC TNM classification. Ten patients (6.9%) were metastatic at diagnosis. One hundred-thirty-five patient (93.1%) received IC, 104 of which (77%) were TPF-based (taxanes, cisplatin and 5 fluoro-uracil). One hundred-thirty-eight patient (95.2%) received CC, mostly cisplatin in 134 cases (97%). After a median follow-up of 50 months [22-82], 46 patients (31.7%) had a relapse: 12 (8.2%) experienced local and/or regional relapse after a median of 18 months [6-43], 29 (20%) experienced distant relapse after a median of 9 months [2-24] and 5 patients (3.4%) had both. Thirty-five patients (24.1%) died, including 5 (3.4%) from a cause other than their cancer. Three-year overall survival (OS), cancer specific survival, disease free survival, metastasis free survival and loco-regional free survival were respectively 78.1%, 81.3%, 67.8%, 74.5% and 88.1%. Anatomo-clinic factors predicting OS were age > 50 years (88.7 vs. 70.5%; p=0.004), diabetes history (81.2 vs. 66.7%; p=0.027), UICC N classification (100 vs. 95 vs. 77.5 vs. 68.8% respectively for N0, N1, N2 and N3; p=0.008), the practice of a lymph node biopsy (84.2 vs. 57%; p=0.05), and UICC TNM stages III-IV (93.8 vs. 73.6% respectively for stage I-II vs. III-IV; p=0.044). Therapeutic factors predicting OS were a number of CC courses (less than 4 courses: 65.8 vs. 86%; p=0.03, less than 5 courses: 71.5 vs. 89%; p=0.041), a weight loss > 10% during treatment (84.1 vs. 60.9%; p=0.021) and a total cumulative cisplatin dose, including IC and CC, < 380 mg/m² (64.4 vs. 87.6%; p=0.003). Radiotherapy delay and total duration did not significantly affect OS. No grade 3-4 late side effects were noted in the evaluable 127 patients (87.6%). The most common toxicity was dry mouth which was grade 2 in 47 cases (37%) and grade 1 in 55 cases (43.3%).Conclusion: IMRT for nasopharyngeal carcinoma granted a high loco-regional control rate for patients during the last five years. However, distant relapses remain frequent and conditionate the prognosis. We identified many anatomo-clinic and therapeutic prognosis factors. Therefore, high-risk patients require a more aggressive therapeutic approach, such as radiotherapy dose escalation or adding adjuvant chemotherapy.

Keywords: therapeutic results, prognostic factors, intensity-modulated radiotherapy, nasopharyngeal carcinoma

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Authors: Gunasekaran Raja, Ramkumar Jayaraman

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In this paper, we consider CCL-N (Cooperative Cross Layer Network) topology based on the cross layer (both centralized and distributed) environment to form network communities. Various performance metrics related to the IEEE 802.16 networks are discussed to design CCL-N Topology. In CCL-N topology, nodes are classified as master nodes (Master Base Station [MBS]) and serving nodes (Relay Station [RS]). Nodes communities are organized based on the networking terminologies. Based on CCL-N Topology, various simulation analyses for both transparent and non-transparent relays are tabulated and throughput efficiency is calculated. Weighted load balancing problem plays a challenging role in IEEE 802.16 network. CoTS (Concurrent Transmission Scheduling) Scheme is formulated in terms of three aspects – transmission mechanism based on identical communities, different communities and identical node communities. CoTS scheme helps in identifying the weighted load balancing problem. Based on the analytical results, modularity value is inversely proportional to that of the error value. The modularity value plays a key role in solving the CoTS problem based on hop count. The transmission mechanism for identical node community has no impact since modularity value is same for all the network groups. In this paper three aspects of communities based on the modularity value which helps in solving the problem of weighted load balancing and CoTS are discussed.

Keywords: cross layer network topology, concurrent scheduling, modularity value, network communities and weighted load balancing

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Authors: R. Sivasamy, G. Paulraj, S. Kalaimani, N.Thillaigovindan

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For profitable businesses, queues are double-edged swords and hence the pain of long wait times in a queue often frustrates customers. This paper suggests a technical way of reducing the pain of lines through a Poisson M/M1, M2/2 queueing system operated by two heterogeneous servers with an objective of minimising the mean sojourn time of customers served under the queue discipline ‘First Come First Served with an ‘m’ policy, i.e. FCFS-m policy’. Arrivals to the system form a Poisson process of rate λ and are served by two exponential servers. The service times of successive customers at server ‘j’ are independent and identically distributed (i.i.d.) random variables and each of it is exponentially distributed with rate parameter μj (j=1, 2). The primary condition for implementing the queue discipline ‘FCFS-m policy’ on these service rates μj (j=1, 2) is that either (m+1) µ2 > µ1> m µ2 or (m+1) µ1 > µ2> m µ1 must be satisfied. Further waiting customers prefer the server-1 whenever it becomes available for service, and the server-2 should be installed if and only if the queue length exceeds the value ‘m’ as a threshold. Steady-state results on queue length and waiting time distributions have been obtained. A simple way of tracing the optimal service rate μ*2 of the server-2 is illustrated in a specific numerical exercise to equalize the average queue length cost with that of the service cost. Assuming that the server-1 has to dynamically adjust the service rates as μ1 during the system size is strictly less than T=(m+2) while μ2=0, and as μ1 +μ2 where μ2>0 if the system size is more than or equal to T, corresponding steady state results of M/M1+M2/1 queues have been deduced from those of M/M1,M2/2 queues. To conclude this investigation has a viable application, results of M/M1+M2/1 queues have been used in processing of those waiting messages into a single computer node and to measure the power consumption by the node.

Keywords: two heterogeneous servers, M/M1, M2/2 queue, service cost and queue length cost, M/M1+M2/1 queue

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Authors: Bhushan Bhalgat, Suresh Singh, Phanindra Swain, Kamal Kishore Lakhera

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Carcinoma of cervix and carcinoma of vulva have been associated with common predisposing factors like human papillomavirus and smoking. Skip metastases and metachronous appearance of both these tumours have been reported. There is no case report showing synchronous appearance of these tumours in English literature. We herewith report a case report of a middle aged female patient who presented with per vaginal bleeding, and on examination, a cervical mass was palpable. Also, a proliferative growth was seen over her left vulva. Biopsy of both lesions came out to be squamous cell carcinoma and carcinoma in situ, respectively. A radical hysterectomy and bilateral pelvic and paraaortic lymph nodal dissection was performed along with left simple vulvectomy. This thereby underscores that any lesion over vulva appearing during or after treatment of cervical carcinoma should be biopsied to rule out vulvar carcinoma.

Keywords: carcinoma of cervix, carcinoma of vulva, synchronous tumours, gynecological oncology

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Authors: Mohammed A. Abutalib

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Papillary thyroid carcinoma (PTC) accounts for the most common type of thyroid cancer, a well-differentiated type. PTC is featured by biologically low-grade and less aggressive tumors with a survival rate of 10 years in most of the diagnosed cases. PTC can be presented with the involvement of cervical lymph nodes in about 50% of the patients, yet the distant spread is very uncommon. Herein, we discussed an early 50-year-old male patient with a history of PTC that presented to the emergency department complaining of shortness of breath and a radiological finding of hydrothorax. Cytologic examination, together with immune-histochemical staining and molecular studies of pleural effusion aspiration, concluded the definitive diagnosis of metastatic papillary thyroid carcinoma in the pleural space. PTC seldom causes metastatic niches in the pleural space, and this is a rare clinical presentation; nevertheless, a differential diagnosis of thyroid metastasis needs to be excluded.

Keywords: thyroid cancer, malignant pleural effusion, cytology aspiration, papillary thyroid carcinoma

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Authors: Wenjun Hou, Marek Perkowski

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The Traveling Salesman problem is famous in computing and graph theory. In short, it asks for the Hamiltonian cycle of the least total weight in a given graph with N nodes. All variations on this problem, such as those with K-bounded-degree nodes, are classified as NP-complete in classical computing. Although several papers propose theoretical high-level designs of quantum algorithms for the Traveling Salesman Problem, no quantum circuit implementation of these algorithms has been created up to our best knowledge. In contrast to previous papers, the goal of this paper is not to optimize some abstract complexity measures based on the number of oracle iterations, but to be able to evaluate the real circuit and time costs of the quantum computer. Using the emerging quantum programming language Q# developed by Microsoft, which runs quantum circuits in a quantum computer simulation, an implementation of the bounded-degree problem and its respective quantum circuit were created. To apply Grover’s algorithm to this problem, a quantum oracle was designed, evaluating the cost of a particular set of edges in the graph as well as its validity as a Hamiltonian cycle. Repeating the Grover algorithm with an oracle that finds successively lower cost each time allows to transform the decision problem to an optimization problem, finding the minimum cost of Hamiltonian cycles. N log₂ K qubits are put into an equiprobablistic superposition by applying the Hadamard gate on each qubit. Within these N log₂ K qubits, the method uses an encoding in which every node is mapped to a set of its encoded edges. The oracle consists of several blocks of circuits: a custom-written edge weight adder, node index calculator, uniqueness checker, and comparator, which were all created using only quantum Toffoli gates, including its special forms, which are Feynman and Pauli X. The oracle begins by using the edge encodings specified by the qubits to calculate each node that this path visits and adding up the edge weights along the way. Next, the oracle uses the calculated nodes from the previous step and check that all the nodes are unique. Finally, the oracle checks that the calculated cost is less than the previously-calculated cost. By performing the oracle an optimal number of times, a correct answer can be generated with very high probability. The oracle of the Grover Algorithm is modified using the recalculated minimum cost value, and this procedure is repeated until the cost cannot be further reduced. This algorithm and circuit design have been verified, using several datasets, to generate correct outputs.

Keywords: quantum computing, quantum circuit optimization, quantum algorithms, hybrid quantum algorithms, quantum programming, Grover’s algorithm, traveling salesman problem, bounded-degree TSP, minimal cost, Q# language

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Authors: Fakhrosadat Sajjadian

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In the USA, about 5% of women diagnosed with breast cancer annually are affected by Inflammatory Breast Cancer (IBC), which is a highly aggressive type of Locally Advanced Breast Cancer (LABC). It is a type of LABC that is clinically and pathologically different, known for its rapid growth, invasiveness, and ability to promote the growth of blood vessels. Almost all women are found to have lymph nodes affected upon diagnosis, while around 36% show obvious distant metastases. Even with the latest improvements in multimodality therapies, the outlook for patients with IBC remains bleak, as the average disease-free survival time is less than 2.5 years. Recent research on the genetic factors responsible for the IBC phenotype has resulted in the discovery of genes that play a role in the advancement of this illness. The development of primary human cell lines and animal models has assisted in this research. These advancements offer new possibilities for future actions in identifying and treating IBC.

Keywords: breast cancer, inflammation, diagnosis, IBC, LABC

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Authors: Amenah Dhannoon, Ciaran Martin Hurley, Laura Wrafter, Podraic J. Regan

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Introduction: The COVID-19 pandemic continues to present unprecedented challenges for healthcare systems. This has resulted in the pragmatic shift in the practice of plastic surgery units worldwide. During this period, many units reported a significant fall in urgent melanoma referrals, leading to patients presenting with advanced disease requiring more extensive surgery and inferior outcomes. Our objective was to evaluate our unit's experience with both non-invasive and invasive melanoma during the COVID-19 pandemic and characterize our experience and contrast it to that experienced by our neighbors in the UK, mainland Europe and North America. Methods: a retrospective chart review was performed on all patients diagnosed with invasive and non-invasive cutaneous melanoma between March to December of 2019 (control) compared to 2020 (COVID-19 pandemic) in a single plastic surgery unit in Ireland. Patient demographics, referral source, surgical procedures, tumour characteristics, radiological findings, oncological therapies and follow-up were recorded. All data were anonymized and stored in Microsoft Excel. Results: A total of 589 patients were included in the study. Of these, 314 (53%) with invasive melanoma, compared to 275 (47%) with the non-invasive disease. Overall, more patients were diagnosed with both invasive and non-invasive melanoma in 2020 than in 2019 (p<0.05). However, significantly longer waiting times in 2020 (64 days) compared to 2019 (28 days) (p<0.05), with the majority of the referral being from GP in 2019 (83%) compared to 61% in 2020. Positive sentinel lymph node were higher in 2019 at 56% (n=28) compared to 24% (n=22) in 2020. There was no statistically significant difference in the tutor characteristics or metastasis status. Discussion: While other countries have noticed a fall in the melanoma diagnosis. Our units experienced a higher number of disease diagnoses. This can be due to multiple reasons. In Ireland, the government reached an early agreement with the private sector to continue elective surgery on an urgent basis in private hospitals. This allowed access to local anesthetic procedures and local skin cancer cases were triaged to non-COVID-19 provider centers. Our unit also adapted a fast, effective and minimal patient contact strategy for triaging skin cancer based on telemedicine. Thirdly, a skin cancer nurse specialist maintained patient follow-ups and triaging a dedicated email service. Finally, our plastic surgery service continued to maintain a virtual complex skin cancer multidisciplinary team meeting during the pandemic, ensuring local clinical governance has adhered to each clinical case. Conclusion: Our study highlights that with the prompt efficient restructuring of services, we could reserve successful management of skin cancer even in the most devastating times. It is important to reflect on the success during the pandemic and emphasize the importance of preparation for a potentially difficult future

Keywords: malignant melanoma, skin cancer, COVID-19, triage

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