Search results for: tertiary alcohols

Authors: Peninah Agaba, Monica Magadi, Bev Orton

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Uganda is one of the countries with high maternal mortality (336/100,000) where adolescents account for 24 percent of the total maternal deaths. Research shows that use of maternal health services may prevent some of these deaths and good provider attitudes attract adolescents to use the services. However, poor health provider’s attitudes discourage adolescents from seeking the services during the maternity period. This study explores the experiences of unmarried female adolescents at the health facilities during the maternity period. The study population is unmarried adolescent girls aged 10-19 years who were pregnant or had given birth within three years before the interview. This is a special interest group that requires attention throughout this period. Most of the pregnancies among unmarried adolescents are unwanted; as a result, many of them have been abused and neglected by parents and close family members including partners who deny fatherhood of the pregnancy/child. These adolescents hope to find comfort from health providers like being listened to during counseling, not abused and judged; unfortunately this is not the case always. The research was approved by the University of Hull, School of Education and Social Sciences ethics review committee, Mildmay Uganda Research Ethics Committee and Uganda National Council of Science and Technology. The study was carried out in Bushenyi and Kibale districts in Western Uganda. Fourteen in-depth interviews and seven focus group discussions were completed in the local languages and later transcribed to English language. Thematic analysis to identify the themes was done. Adolescents were aged 16-19 years, two had become pregnant before 15 years. Most had not completed secondary education; none had tertiary education and three of the 14 IDI adolescent participants wanted to get pregnant. Analysis shows varied experiences; most adolescents were abused verbally and physically by the health providers due to their young age of pregnancy, lack of essential items during this period (maternity dresses, children clothes, delivery kit) and fear of labour pains. Another cause for abuse was these adolescents coming for antenatal care with no partners yet the implementation of a policy on increasing male involvement in reproductive health in Uganda requires them to attend antenatal care with their partners and most of these unmarried adolescents have no partners to accompany them. Despite the above challenges, the study also identified the care some of these unmarried adolescents received during the maternity visits for example they were not abused, were provided with appropriate information and supported with child care. The study identified abuse and support the unmarried adolescents received during the maternity period. Efforts to provide adolescents with adequate information including what to expect during labour by providers and provision of basic needs are essential. Health providers should have trainings on client care especially how to embrace unmarried adolescents when they come to access maternity services. More so, the policy on improving male involvement in RH issues need to be considerate of unmarried adolescents who in most cases do not have the partners to go with to access maternity care.

Keywords: abuse, maternity care, Uganda, unmarried, adolescents

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Authors: Neelam Taneja, Abhishek Mewara, Ajay Kumar

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Multidrug resistant shigellae have emerged as a therapeutic challenge in India. At our 2000 bed tertiary care referral centre in Chandigarh, North India, which caters to a large population of 7 neighboring states, antibiotic resistance in Shigella is being constantly monitored. Shigellae are isolated from 3 to 5% of all stool samples. In 1990 nalidixic acid was the drug of choice as 82%, and 63% of shigellae were resistant to ampicillin and cotrimoxazole respectively. Nalidixic acid resistance emerged in 1992 and rapidly increased from 6% during 1994-98 to 86% by the turn of 21st century. In the 1990s, the WHO recommended ciprofloxacin as the drug of choice for empiric treatment of shigellosis in view of the existing high level resistance to agents like chloramphenicol, ampicillin, cotrimoxazole and nalidixic acid. First resistance to ciprofloxacin in S. flexneri at our centre appeared in 2000 and rapidly rose to 46% in 2007 (MIC>4mg/L). In between we had an outbreak of ciprofloxacin resistant S.dysenteriae serotype 1 in 2003. Therapeutic failures with ciprofloxacin occurred with both ciprofloxacin-resistant S. dysenteriae and ciprofloxacin-resistant S. flexneri. The severity of illness was more with ciprofloxacin-resistant strains. Till 2000, elsewhere in the world ciprofloxacin resistance in S. flexneri was sporadic and uncommon, though resistance to co-trimoxazole and ampicillin was common and in some areas resistance to nalidixic acid had also emerged. Fluoroquinolones due to extensive use and misuse for many other illnesses in our region are thus no longer the preferred group of drugs for managing shigellosis in India. WHO presently recommends ceftriaxone and azithromycin as alternative drugs to fluoroquinolone-resistant shigellae, however, overreliance on this group of drugs also seems to soon become questionable considering the emerging cephalosporin-resistant shigellae. We found 15.1% of S. flexneri isolates collected over a period of 9 years (2000-2009) resistant to at least one of the third-generation cephalosporins (ceftriaxone/cefotaxime). The first isolate showing ceftriaxone resistance was obtained in 2001, and we have observed an increase in number of isolates resistant to third generation cephalosporins in S. flexneri 2005 onwards. This situation has now become a therapeutic challenge in our region. The MIC values for Shigella isolates revealed a worrisome rise for ceftriaxone (MIC90:12 mg/L) and cefepime (MIC90:8 mg/L). MIC values for S. dysenteriae remained below 1 mg/L for ceftriaxone, however for cefepime, the MIC90 has raised to 4 mg/L. These infections caused by ceftriaxone-resistant S. flexneri isolates were successfully treated by azithromycin at our center. Most worrisome development in the present has been the emergence of DSA(Decreased susceptibility to azithromycin) which surfaced in 2001 and has increased from 4.3% till 2011 to 34% thereafter. We suspect plasmid-mediated resistance as we detected qnrS1-positive Shigella for the first time from the Indian subcontinent in 2 strains from 2010, indicating a relatively new appearance of this PMQR determinant among Shigella in India. This calls for a continuous and strong surveillance of antibiotic resistance across the country. The prevention of shigellosis by developing cost-effective vaccines is desirable as it will substantially reduce the morbidity associated with diarrhoea in the country

Keywords: Shigella, antimicrobial, resistance, India

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Authors: Shradha Parsekar, Suma Nair, Ajay Bailey, Binu V. S.

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Background: Concealing of cancer-related information is seen in many low-and-middle-income countries and may be associated with multiple factors. Comparatively, there is lack of information about, how breast cancers diagnosed women disclose cancer-related information to their social contacts and vice versa. To get more insights on the participant’s experience, opinions, expectations, and attitudes, a qualitative study is a suitable approach. Therefore, this study involving in-depth interviews was planned to lessen this gap. Methods: Interviews were conducted separately among breast cancer patients and their caregivers with semi-structured qualitative interview guide. Purposive and convenient sampling was being used to recruit patients and caregivers, respectively. Ethical clearance and permission from the tertiary hospital were obtained and participants were selected from the Udupi district, Karnataka, India. After obtaining a list of breast cancer diagnosed cases, participants were contacted in person and their willingness to take part in the study was taken. About 39 caregivers and 35 patients belonging to different breast cancer stages were recruited. Interviews were recorded with prior permission. Data was managed by Atlas.ti 8 software. The recordings were transcribed, translated and coded in two cycles. Most of the patients belonged to stage II and III cancer. Codes were grouped together into to whom breast cancer status was concealed to and underneath reason for the same. Main findings: followings are the codes and code families which emerged from the data. 1) Concealing the breast cancer status from social contacts other than close family members (such as extended family, neighbor and friends). Participants perceived the reasons as, a) to avoid questions which people probe (which doesn’t have answers), b) to avoid people paying courtesy visit (to inquire about the health as it is Indian culture to visit the sick person) making it inconvenient for patient and caregivers have to offer something and talk to them, c) to avoid people getting shocked (react as if cancer is different from other diseases) or getting emotional/sad, or getting fear of death d) to avoid getting negative suggestion or talking anything in front of patient as it may affect patient negatively, e) to avoid getting stigmatized, f) to avoid getting obstacle in child’s marriage. 2) Participant concealed the breast cancer status of young children as they perceived that it may a) affect studies, b) affect emotionally, c) children may get scared. 3) Concealing the breast cancer status from patients as the caregivers perceived that they have fear of a) worsening patient’s health, b) patient getting tensed, c) patient getting shocked, and d) patient getting scared. However, some participants stressed important in disclosing the cancer status to social contact/patient to make the people aware of the disease. Conclusion: The news of breast cancer spreads like electricity in the wire, therefore, patient or family avoid it for many reasons. Although, globally, due to physicians’ ethical obligations, there is an inclination towards more disclosure of cancer diagnosis and status of prognosis to the patient. However, it is an ongoing argument whether patient/social contacts should know the status especially in a country like India.

Keywords: breast cancer, concealing cancer status, India, qualitative study

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Authors: Iacopo Odoardi, Emanuele Felice, Dario D'Ingiullo

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We investigate the role of human capital in the Chinese inland-coastal inequality and how the consequences of the 2007-2008 crisis may induce China to refocus its development path on human capital. We compare panel data analyses for two periods for the richer/coastal and the relatively poor/inland provinces. Considering the rapid evolution of the Chinese economy and the changes forced by the international crisis, we wonder if these events can lead to rethinking local development paths, fostering greater attention on the diffusion of higher education. We expect that the consequences on human capital may, in turn, have consequences on the inland/coastal dualism. The focus on human capital is due to the fact that the growing differences between inland and coastal areas can be explained by the different local endowments. In this respect, human capital may play a major role and should be thoroughly investigated. To assess the extent to which human capital has an effect on economic growth, we consider a fixed-effects model where differences among the provinces are considered parametric shifts in the regression equation. Data refer to the 31 Chinese provinces for the periods 1998-2008 and 2009-2017. Our dependent variable is the annual variation of the provincial gross domestic product (GDP) at the prices of the previous year. Among our regressors, we include two proxies of advanced human capital and other known factors affecting economic development. We are aware of the problem of conceptual endogeneity of variables related to human capital with respect to GDP; we adopt an instrumental variable approach (two-stage least squares) to avoid inconsistent estimates. Our results suggest that the economic strengths that influenced the Chinese take-off and the dualism are confirmed in the first period. These results gain relevance in comparison with the second period. An evolution in local economic endowments is taking place: first, although human capital can have a positive effect on all provinces after the crisis, not all types of advanced education have a direct economic effect; second, the development path of the inland area is changing, with an evolution towards more productive sectors which can favor higher returns to human capital. New strengths (e.g., advanced education, transport infrastructures) could be useful to foster development paths of inland-coastal desirable convergence, especially by favoring the poorer provinces. Our findings suggest that in all provinces, human capital can be useful to promote convergence in growth paths, even if investments in tertiary education seem to have a negative role, most likely due to the inability to exploit the skills of highly educated workers. Furthermore, we observe important changes in the economic characteristics of the less developed internal provinces. These findings suggest an evolution towards more productive economic sectors, a greater ability to exploit both investments in fixed capital and the available infrastructures. All these aspects, if connected with the improvement in the returns to human capital (at least at the secondary level), lead us to assume a better reaction (i.e., resilience) of the less developed provinces to the crisis effects.

Keywords: human capital, inland-coastal inequality, Great Recession, China

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Authors: Aymen Arfaoui, Abdelkader Soumaya, Noureddine Ben Ayed

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The study region is located in the Tunisian Dorsal Backland (Central Mediterranean), which is the easternmost part of the Saharan Atlas mountain range, trending southwest-northeast. Based on our fieldwork, seismic tomography images, seismicity, and previous studies, we propose an interpretation of the relationship between the surface deformation and fault kinematics in the study area and the internal dynamic processes acting in the Central Mediterranean from the Cenozoic to the present. The subduction and dynamics of internal forces beneath the complicated Maghrebides mobile belt have an impact on the Tertiary and Quaternary tectonic regimes in the Pelagian and Atlassic foreland that is part of our study region. The left lateral reactivation of the major "Tunisian N-S Axis fault" and the development of a compressional relay between the Hammamet Korbous and Messella-Ressas faults are possibly a result of tectonic stresses due to the slab roll-back following the Africa/Eurasia convergence. After the slab segmentation and its eastward migration (5–4 Ma) and the formation of the Strait of Sicily "rift zone" further east, a transtensional tectonic regime has been installed in this area. According to seismic tomography images, the STEP fault of the "North-South Axis" at Hammamet-Korbous coincides with the western edge of the "Slab windows" of the Sicilian Channel and the eastern boundary of the positive anomalies attributed to the residual Slab of Tunisia. On the other hand, significant E-W Plio-Quaternary tectonic activity may be observed along the eastern portion of this STEP fault system in the Grombalia zone as a result of recent vertical lithospheric motion in response to the lateral slab migration eastward to Sicily Channel. According to SKS fast splitting directions, the upper mantle flow pattern beneath Tunisian Dorsal is parallel to the NE-SW to E-W orientation of the Shmin identified in the study area, similar to the Plio-Quaternary extensional orientation in the Central Mediterranean. Additionally, the removal of the lithosphere and the subsequent uplift of the sub-lithospheric mantle beneath the topographic highs of the Dorsal and its surroundings may be the cause of the dominant extensional to transtensional Quaternary regime. The occurrence of strike-slip and extensional seismic events in the Pelagian block reveals that the regional transtensional tectonic regime persists today. Finally, we believe that the geodynamic history of the study area since the Cenozoic is primarily influenced by the preexisting weak zones, the African slab detachment, and the upper mantle flow pattern in the central Mediterranean.

Keywords: Tunisia, lithospheric discontinuity (STEP fault), geodynamic evolution, Tunisian dorsal backland, strike-slip fault, seismic tomography, seismicity, central Mediterranean

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Authors: Ashima Sharma

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Human Serum Albumin (HSA)- one of the most demanded therapeutic proteins with immense biotechnological applications- is a large multidomain protein containing 17 disulfide bonds. The current source of HSA is human blood plasma which is a limited and unsafe source. Thus, there exists an indispensable need to promote non-animal derived recombinant HSA (rHSA) production. Escherichia coli is one of the most convenient hosts which had contributed to the production of more than 30% of the FDA approved recombinant pharmaceuticals. It grows rapidly and reaches high cell density using inexpensive and simple substrates. E. coli derived recombinant products have more economic potential as fermentation processes are cheaper compared to the other expression hosts. The major bottleneck in exploiting E. coli as a host for a disulfide-rich multidomain protein is the formation of aggregates of overexpressed protein. The majority of the expressed HSA forms inclusion bodies (more than 90% of the total expressed rHSA) in the E. coli cytosol. Recovery of functional rHSA from inclusion bodies is not preferred because it is difficult to obtain a large multidomain disulfide bond rich protein like rHSA in its functional native form. Purification is tedious, time-consuming, laborious and expensive. Because of such limitations, the E. coli host system was neglected for rHSA production for the past few decades despite its numerous advantages. In the present work, we have exploited the capabilities of E. coli as a host for the enhanced functional production of rHSA (~60% of the total expressed rHSA in the soluble fraction). Parameters like intracellular environment, temperature, induction type, duration of induction, cell lysis conditions etc. which play an important role in enhancing the level of production of the desired protein in its native form in vivo have been optimized. We have studied the effect of assistance of different types of exogenously employed chaperone systems on the functional expression of rHSA in the E. coli host system. Different aspects of cell growth parameters during the production of rHSA in presence and absence of molecular chaperones in E. coli have also been studied. Upon overcoming the difficulties to produce functional rHSA in E. coli, it has been possible to produce significant levels of functional protein through engineering the biological system of protein folding in the cell, the E. coli-derived rHSA has been purified to homogeneity. Its detailed physicochemical characterization has been performed by monitoring its conformational properties, secondary and tertiary structure elements, surface properties, ligand binding properties, stability issues etc. These parameters of the recombinant protein have been compared with the naturally occurring protein from the human source. The outcome of the comparison reveals that the recombinant protein resembles exactly the same as the natural one. Hence, we propose that the E. coli-derived rHSA is an ideal biosimilar for human blood plasma-derived serum albumin. Therefore, in the present study, we have introduced and promoted the E. coli- derived rHSA as an alternative to the preparation from a human source, pHSA.

Keywords: recombinant human serum albumin, Escherichia coli, biosimilar, chaperone assisted protein folding

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Authors: Shelley Jones

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Assumptions abound that education for girls will, as a matter of course, lead to their economic empowerment as women; yet. little is known about the ways in which schooling for girls, who traditionally/historically would not have had opportunities for post-primary, or perhaps even primary education – such as the participants in this study based in rural Uganda - in reality, impacts their economic situations. There is a need forlongitudinal studies in which women share experiences, understandings, and reflections of their lives that can inform our knowledge of this. In response, this paper reports on stage four of a longitudinal case study (2004-2018) focused on education and empowerment for girls and women in rural Uganda, in which 13 of the 15 participants from the original study participated. This paper understands empowerment as not simply increased opportunities (e.g., employment) but also real gains in power, freedoms that enable agentive action, and authentic and viable choices/alternatives that offer ‘exit options’ from unsatisfactory situations. As with the other stages, this study used a critical, postmodernist, global feminist ethnographic methodology, multimodal and qualitative data collection. Participants participated in interviews, focus group discussions, and a two-day workshop, which explored their understandings of how/if they understood post-primary education to have contributed to their economic empowerment. A constructivist grounded theory approach was used for data analysis to capture major themes. Findings indicate that although all participants believe that post-primary education provided them with economic opportunities they would not have had otherwise, the parameters of their economic empowerment were severely constrained by historic and extant sociocultural, economic, political, and institutional structures that continue to disempower girls and women, as well as additional financial responsibilities that they assumed to support others. Even though the participants had post-primary education, and they were able to obtain employment or operate their own businesses that they would not likely have been able to do without post-primary education, the majority of the participants’ incomes were not sufficient to elevate them financially above the extreme poverty level, especially as many were single mothers and the sole income earners in their households. Furthermore, most deemed their working conditions unsatisfactory and their positions precarious; they also experienced sexual harassment and abuse in the labour force. Additionally, employment for the participants resulted in a double work burden: long days at work, surrounded by many hours of domestic work at home (which, even if they had spousal partners, still fell almost exclusively to women). In conclusion, although the participants seem to have experienced some increase in economic empowerment, largely due to skills, knowledge, and qualifications gained at the post-primary level, numerous barriers prevented them from maximizing their capabilities and making significant gains in empowerment. There is need, in addition to providing education (primary, secondary, and tertiary) to girls, to address systemic gender inequalities that mitigate against women’s empowerment, as well as opportunities and freedom for women to come together and demand fair pay, reasonable working conditions, and benefits, freedom from gender-based harassment and assault in the workplace, as well as advocate for equal distribution of domestic work as a cultural change.

Keywords: girls' post-primary education, women's empowerment, uganda, employment

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Authors: Luiza Melo De Lima, Tito Trindade, Jose M. Oliveira

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The development of thermoplastic-based graphene nanocomposites has been of great interest not only to the scientific community but also to different industrial sectors. Due to the possible improvement of performance and weight reduction, thermoplastic nanocomposites are a great promise as a new class of materials. These nanocomposites are of relevance for the automotive industry, namely because the emission limits of CO2 emissions imposed by the European Commission (EC) regulations can be fulfilled without compromising the car’s performance but by reducing its weight. Thermoplastic polymers have some advantages over thermosetting polymers such as higher productivity, lower density, and recyclability. In the automotive industry, for example, poly(propylene) (PP) is a common thermoplastic polymer, which represents more than half of the polymeric raw material used in automotive parts. Graphene-based materials (GBM) are potential nanofillers that can improve the properties of polymer matrices at very low loading. In comparison to other composites, such as fiber-based composites, weight reduction can positively affect their processing and future applications. However, the properties and performance of GBM/polymer nanocomposites depend on the type of GBM and polymer matrix, the degree of dispersion, and especially the type of interactions between the fillers and the polymer matrix. In order to take advantage of the superior mechanical strength of GBM, strong interfacial strength between GBM and the polymer matrix is required for efficient stress transfer from GBM to the polymer. Thus, chemical compatibilizers and physicochemical modifications have been reported as important tools during the processing of these nanocomposites. In this study, PP-based nanocomposites were obtained by a simple melt blending technique, using a Brabender type mixer machine. Graphene nanoplatelets (GnPs) were applied as structural reinforcement. Two compatibilizers were used to improve the interaction between PP matrix and GnPs: PP graft maleic anhydride (PPgMA) and PPgMA modified with tertiary amine alcohol (PPgDM). The samples for tensile and Charpy impact tests were obtained by injection molding. The results suggested the GnPs presence can increase the mechanical strength of the polymer. However, it was verified that the GnPs presence can promote a decrease of impact resistance, turning the nanocomposites more fragile than neat PP. The compatibilizers’ incorporation increases the impact resistance, suggesting that the compatibilizers can enhance the adhesion between PP and GnPs. Compared to neat PP, Young’s modulus of non-compatibilized nanocomposite increase demonstrated that GnPs incorporation can promote a stiffness improvement of the polymer. This trend can be related to the several physical crosslinking points between the PP matrix and the GnPs. Furthermore, the decrease of strain at a yield of PP/GnPs, together with the enhancement of Young’s modulus, confirms that the GnPs incorporation led to an increase in stiffness but to a decrease in toughness. Moreover, the results demonstrated that incorporation of compatibilizers did not affect Young’s modulus and strain at yield results compared to non-compatibilized nanocomposite. The incorporation of these compatibilizers showed an improvement of nanocomposites’ mechanical properties compared both to those the non-compatibilized nanocomposite and to a PP sample used as reference.

Keywords: graphene nanoplatelets, mechanical properties, melt blending processing, poly(propylene)-based nanocomposites

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Authors: Muhammad Waqas Baqai, Noman Shahzad, Rehman Alvi

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Communication among health care givers is the essence of quality patient care and any compromise results in errors and inefficiency leading to cumbersome outcomes. The use of smartphone among health professionals has increased tremendously. Almost every health professional carries it and majority of them uses a third party communication software called whatsApp for work related communications. It gives instant access to the person responsible for any particular query and therefore helps in efficient and timely decision making. It is also an easy way of sharing medical documents, multimedia and provides platform for consensual decision making through group discussions. However clinical communication through whatsApp has some demerits too including reduction in verbal communication, worsening professional relations, unprofessional behavior, risk of confidentiality breach and threats from cyber-attacks. On the other hand the traditional pager device being used in many health care systems is a unidirectional communication that lacks the ability to convey any information other than the number to which the receiver has to respond. Our study focused on these two widely used modalities of communication among doctors of the largest tertiary care center of Pakistan i.e. The Aga Khan University Hospital. Our aim was to note which modality is considered better and has fewer threats to medical data. Approval from ethical review committee of the institute was taken prior to conduction of this study. We submitted an online survey form to all the interns and residents working at our institute and collected their response in a month’s time. 162 submissions were recorded and analyzed using descriptive statistics. Only 20% of them were comfortable with using pagers exclusively, 52% with whatsApp and 28% with both. 65% think that whatsApp is time-saving and quicker than pager. 54% of them considered whatsApp to be causing nuisance from work related notifications in their off-work hours. 60% think that they are more likely to miss information through pager system because of the unidirectional nature. Almost all (96%) of residents and interns found whatsApp to be useful in terms of saving information for future reference. For urgent issues, majority (70%) preferred pager over whatsApp and also pager was considered more valid in terms of hospital policies and legal issues. Among major advantages of whatsApp as listed by them were; easy mass communication, sharing of clinical pictures, universal access and no need of carrying additional device. However the major drawback of using whatsApp for clinical communication that everyone shared was threat to patients’ confidentiality as clinicians usually share pictures of wounds, clinical documents etc. Lastly we asked them if they think there is a need of a separate application for instant communication dedicated to clinical communication only and 90% responded positively. Therefore, we concluded that both modalities have their merits and demerits but the greatest drawback with whatsApp is the risk of breach in patients’ confidentiality and off-work disturbance. Hence, we recommend a more secure, institute-run application for all intra hospital communications where they can share documents, pictures etc. easily under a controlled environment.

Keywords: WhatsApp, pager, clinical communication, confidentiality

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Authors: I. N. Nwafia, U. C. Ozumba, M. E. Ohanu, S. O. Ebede

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Antibiotic resistance is increasing globally and has become a major health challenge. Extended-spectrum beta-lactamase is clinically important because the ESBL gene are mostly plasmid encoded and these plasmids frequently carry genes encoding resistance to other classes of antimicrobials thereby limiting antibiotic options in the treatment of infections caused by these organisms. The specific objectives of this study were to determine the prevalence of ESBLs production in Escherichia coli, to determine the antibiotic susceptibility pattern of ESBLs producing Escherichia coli, to detect TEM, SHV and CTX-M genes and the risk factors to acquisition of ESBL producing Escherichia coli. The protocol of the study was approved by Health Research and Ethics committee of the University of Nigeria Teaching Hospital (UNTH), Enugu. It was a descriptive cross-sectional study that involved all hospitalized patients in UNTH from whose specimens Escherichia coli was isolated during the period of the study. The samples analysed were urine, wound swabs, blood and cerebrospinal fluid. These samples were cultured in 5% sheep Blood agar and MacConkey agar (Oxoid Laboratories, Cambridge UK) and incubated at 35-370C for 24 hours. Escherichia coli was identified with standard biochemical tests and confirmed using API 20E auxanogram (bioMerieux, Marcy 1'Etoile, France). The antibiotic susceptibility testing was done by disc diffusion method and interpreted according to the Clinical and Laboratory Standard Institute guideline. ESBL production was confirmed using ESBL Epsilometer test strips (Liofilchem srl, Italy). The ESBL bla genes were detected with polymerase chain reaction, after extraction of DNA with plasmid mini-prep kit (Jena Bioscience, Jena, Germany). Data analysis was with appropriate descriptive and inferential statistics. One hundred and six isolates (53.00%) out of the 200 were from urine, followed by isolates from different swabs specimens 53(26.50%) and the least number of the isolates 4(2.00) were from blood (P value = 0.096). Seventy (35.00%) out of the 200 isolates, were confirmed positive for ESBL production. Forty-two (60.00%) of the isolates were from female patients while 28(40.00%) were from male patients (P value = 0.13). Sixty-eight (97.14%) of the isolates were susceptible to imipenem while all of the isolates were resistant to ampicillin, chloramphenicol and tetracycline. From the 70 positive isolates the ESBL genes detected with polymerase chain reaction were blaCTX-M (n=26; 37.14%), blaTEM (n=7; 10.00%), blaSHV (n=2; 2.86%), blaCTX-M/TEM (n=7; 10.0%), blaCTX-M/SHV (n=14; 20.0%) and blaCTX-M/TEM/SHV (n=10; 14.29%). There was no gene detected in 4(5.71%) of the isolates. The most associated risk factors to infections caused by ESBL producing Escherichia coli was previous antibiotics use for the past 3 months followed by admission in the intensive care unit, recent surgery, and urinary catheterization. In conclusion, ESBLs was detected in 4 of every 10 Escherichia coli with the predominant gene detected being CTX-M. This knowledge will enable appropriate measures towards improvement of patient health care, antibiotic stewardship, research and infection control in the hospital.

Keywords: antimicrobial, Escherichia coli, extended spectrum beta lactamase, resistance

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Authors: Gokulan Vethanayakam, Daniel Aston

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Introduction: The ReSPECT process supports healthcare professionals when making patient-centered decisions in the event of an emergency. It has been widely adopted by the NHS in England and allows patients to express thoughts and wishes about treatments and outcomes that they consider acceptable. It includes (but is not limited to) cardiopulmonary resuscitation decisions. ReSPECT conversations should ideally occur prior to ICU admission and should be documented in the eight sections of the nationally-standardised ReSPECT form. This audit evaluated the use of ReSPECT on a busy cardiothoracic ICU in an NHS Trust where established policies advocating its use exist. Methods: This audit was a retrospective review of ReSPECT forms for a sample of high-risk patients admitted to ICU at the Royal Papworth Hospital between January 2021 and March 2022. Patients all received one of the following interventions: Veno-Venous Extra-Corporeal Membrane Oxygenation (VV-ECMO) for severe respiratory failure (retrieved via the national ECMO service); cardiac or pulmonary transplantation-related surgical procedures (including organ transplants and Ventricular Assist Device (VAD) implantation); or elective non-transplant cardiac surgery. The quality of documentation on ReSPECT forms was evaluated using national standards and a graded ranking tool devised by the authors which was used to assess narrative aspects of the forms. Quality was ranked as A (excellent) to D (poor). Results: Of 230 patients (74 VV-ECMO, 104 transplant, 52 elective non-transplant surgery), 43 (18.7%) had a ReSPECT form and only one (0.43%) patient had a ReSPECT form completed prior to ICU admission. Of the 43 forms completed, 38 (88.4%) were completed due to the commencement of End of Life (EoL) care. No non-transplant surgical patients included in the audit had a ReSPECT form. There was documentation of balance of care (section 4a), CPR status (section 4c), capacity assessment (section 5), and patient involvement in completing the form (section 6a) on all 43 forms. Of the 34 patients assessed as lacking capacity to make decisions, only 22 (64.7%) had reasons documented. Other sections were variably completed; 29 (67.4%) forms had relevant background information included to a good standard (section 2a). Clinical guidance for the patient (section 4b) was given in 25 (58.1%), of which 11 stated the rationale that underpinned it. Seven forms (16.3%) contained information in an inappropriate section. In a comparison of ReSPECT forms completed ahead of an EoL trigger with those completed when EoL care began, there was a higher number of entries in section 3 (considering patient’s values/fears) that were assessed at grades A-B in the former group (p = 0.014), suggesting higher quality. Similarly, forms from the transplant group contained higher quality information in section 3 than those from the VV-ECMO group (p = 0.0005). Conclusions: Utilisation of the ReSPECT process in high-risk patients is yet to be well-adopted in this trust. Teams who meet patients before hospital admission for transplant or high-risk surgery should be encouraged to engage with the ReSPECT process at this point in the patient's journey. VV-ECMO retrieval teams should consider ReSPECT conversations with patients’ relatives at the time of retrieval.

Keywords: audit, critical care, end of life, ICU, ReSPECT, resuscitation

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Authors: Karen Trimmer, Raelene Ward, Linda Wondunna-Foley

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Within Australian tertiary institutions, the subject of Aboriginal and Torres Strait Islander education has been a major concern for many years. Aboriginal and Torres Strait Islander teachers are significantly under-represented in Australian schools and universities. High attrition rates in teacher education and in the teaching industry have contributed to a minimal growth rate in the numbers of Aboriginal and Torres Strait Islander teachers in previous years. There was an increase of 500 Indigenous teachers between 2001 and 2008 but these numbers still only account for one percent of teaching staff in government schools who identified as Aboriginal and Torres Strait Islander Australians (Ministerial Council for Education, Early Childhood Development and Youth Affairs 2010). Aboriginal and Torres Strait Islander teachers are paramount in fostering student engagement and improving educational outcomes for Indigenous students. Increasing the numbers of Aboriginal and Torres Strait Islander teachers is also a key factor in enabling all students to develop understanding of and respect for Aboriginal and Torres Strait Islander histories, cultures, and language. An ambitious reform agenda to improve the recruitment and retention of Aboriginal and Torres Strait Islander teachers will be effective only through national collaborative action and co-investment by schools and school authorities, university schools of education, professional associations, and Indigenous leaders and community networks. Whilst the University of Southern Queensland currently attracts Indigenous students to its teacher education programs (61 students in 2013 with an average of 48 enrollments each year since 2010) there is significant attrition during pre-service training. The annual rate of exiting before graduation remains high at 22% in 2012 and was 39% for the previous two years. These participation and retention rates are consistent with other universities across Australia. Whilst aspirations for a growing number of Indigenous people to be trained as teachers is present, there is a significant loss of students during their pre-service training and within the first five years of employment as a teacher. These trends also reflect the situation where Aboriginal and Torres Strait Islander teachers are significantly under-represented, making up less than 1% of teachers in schools across Australia. Through a project conducted as part the nationally funded More Aboriginal and Torres Strait Islander Teachers Initiative (MATSITI) we aim to gain an insight into the reasons that impact Aboriginal and Torres Strait Islander student’s decisions to exit their program. Through the conduct of focus groups and interviews with two graduating cohorts of self-identified Aboriginal and Torres Strait Islander students, rich data has been gathered to gain an understanding of the barriers and enhancers to the completion of pre-service qualification and transition to teaching. Having a greater understanding of these reasons then allows the development of collaborative processes and procedures to increase retention and completion rates of new Indigenous teachers. Analysis of factors impacting on exit decisions and transitions has provided evidence to support change of practice, redesign and enhancement of relevant courses and development of policy/procedures to address identified issues.

Keywords: graduation, indigenous, pre-service teacher education, retention

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Authors: Nautiyal Ruchira, Nautiyal Hemant, Chaudhury Devnanda, Bhargava Surbhi, Chauhan Nidhi

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Introduction: South East Asian region contributes 2.5 million cases of malaria each year to the global burden of 300 to 500 million of which 76% is reported from India. Government of India launched a national program almost half a century ago, still malaria remains a major public health challenge. Pregnant women are more susceptible to severe malaria and its fetomaternal complications. Inadequate surveillance and under-reporting underestimates the problem. Aim: Present study aimed to analyze the clinical course and pattern of malaria during pregnancy and to study the feto-maternal outcome. Methodology: This is a prospective observational study carried out at Himalayan Institute of Medical Sciences – a tertiary care center in the sub-Himalayan state of Uttarakhand, Northern India. All the pregnant women with malaria and its complications were recruited in the study during 2009 to 2014 which included referred cases from the state of western Uttar Pradesh. A thorough history and clinical examination were carried out to assess maternal and fetal condition. Relevant investigations including haemogram, platelet count, LFT, RFT, and USG was done. Blood slides and rapid diagnostic tests were done to diagnose the type of malaria.The primary outcomes measured were the type of malaria infection, maternal complications associated with malaria, outcome of pregnancy and effect on the fetus. Results: 67 antenatal cases with malaria infection were studied. 71% patients were diagnosed with plasmodium vivax infection, 25% cases were plasmodium falciparum positive and in 3% cases mixed infection was found. 38(56%) patients were primigravida and 29(43%) were multiparous. Most of the patients had already received some treatment from their local doctors and presented with severe malaria with the complications. Thrombocytopenia was the commonest manifestation seen in 35(52%) patients, jaundice in 28%, severe anemia in 18%, and severe oligohydramnios in 10% and renal failure in 6% cases. Regarding pregnancy outcome there were 44 % preterm deliveries, 22% had IUFD and abortions in 6% cases.20% of newborn were low birth weight and 6% were IUGR. There was only one maternal death which occurred due to ARDS in falciparum malaria. Although Plasmodium vivax was the main parasite considering the severity of clinical presentation, all the patients received intensive care. As most of the patients had received chloroquine therapy hence they were treated with IV artesunate followed by oral artemesinin combination therapy. Other therapies in the form of packed RBC’s and platelet transfusions, dialysis and ventilator support were provided when required. Conclusion: Even in areas with annual parasite index (API) less than 2 like ours, malaria in pregnancy could be an alarming problem. Vivax malaria cannot be considered benign in pregnancy because of high incidence of morbidity. Prompt diagnosis and aggressive treatment can reduce morbidity and mortality significantly. Increased community level research, integrating ANC checkups with the distribution of insecticide-treated nets in areas of high endemicity, imparting education and awareness will strengthen the existing control strategies.

Keywords: severe malaria, pregnancy, plasmodium vivax, plasmodium falciparum

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Authors: Vasundhara Arora, Anupam Jhobta, Suresh Thakur, Sanjiv Sharma

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Aims and Objectives: Intracranial tuberculosis (TB) is one of the most devastating manifestations of TB and a challenging public health issue of considerable importance and magnitude world over. This study elaborates on the imaging spectrum of neurotuberculosis on magnetic resonance imaging (MRI) in 29 clinically suspected cases from a tertiary care hospital. Materials and Methods: The prospective hospital based evaluation of MR imaging features of neuro-tuberculosis in 29 clinically suspected cases was carried out in Department of Radio-diagnosis, Indira Gandhi Medical Hospital from July 2017 to August 2018. MR Images were obtained on a 1.5 T Magnetom Avanto machine and were analyzed to identify any abnormal meningeal enhancement or parenchymal lesions. Microbiological and Biochemical CSF analysis was performed in radio-logically suspected cases and the results were compared with the imaging data. Clinical follow up of the patients started on anti-tuberculous treatment was done to evaluate the response to treatment and clinical outcome. Results: Age range of patients in the study was between 1 year to 73 years. The mean age of presentation was 11.5 years. No significant difference in the distribution of cerebral tuberculosis was noted among the two genders. Imaging findings of neuro-tuberculosis obtained were varied and non specific ranging from lepto-meningeal enhancement, cerebritis to space occupying lesions such as tuberculomas and tubercular abscesses. Complications presenting as hydrocephalus (n= 7) and infarcts (n=9) was noted in few of these patients. 29 patients showed radiological suspicion of CNS tuberculosis with meningitis alone observed in 11 cases, tuberculomas alone were observed in 4 cases, meningitis with parenchymal tuberculomas in 11 cases. Tubercular abscess and cerebritis were observed in one case each. Tuberculous arachnoiditis was noted in one patient. Gene expert positivity was obtained in 11 out of 29 radiologically suspected patients; none of the patients showed culture positivity. Meningeal form of the disease alone showed higher positivity rate of gene Xpert (n=5) followed by combination of meningeal and parenchymal forms of disease (n=4). The parenchymal manifestation of disease alone showed least positivity rates (n= 3) with gene xpert testing. All 29 patients were started on anti tubercular treatment based on radiological suspicion of the disease with clinical improvement observed in 27 treated patients. Conclusions: In our study, higher incidence of neuro- tuberculosis was noted in paediatric population with predominance of the meningeal form of the disease. Gene Xpert positivity obtained was low due to paucibacillary nature of cerebrospinal fluid (CSF) with even lower positivity of CSF samples in parenchymal form of the manifestation. MRI showed high accuracy in detecting CNS lesions in neuro-tuberculosis. Hence, it can be concluded that MRI plays a crucial role in the diagnosis because of its inherent sensitivity and specificity and is an indispensible imaging modality. It caters to the need of early diagnosis owing to poor sensitivity of microbiological tests more so in the parenchymal manifestation of the disease.

Keywords: neurotuberculosis, tubercular abscess, tuberculoma, tuberculous meningitis

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Authors: Afolabi K. Esther, Kuye Tolulope, Babafemi, L. Olayemi, Omikunle Yemisi

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Background: Cervical cancer is a potentially preventable disease of public significance. All sexually active women are at risk of cervical cancer; however, the uptake and coverage are low in low-middle resource countries. Hence, the programme explored the feasibility of demonstrating an innovative and low-cost system approach to cervical cancer screening service delivery among reproductive-aged women in low–resource settings in Southwestern Nigeria. This was to promote the uptake and quality improvement of cervical cancer screening services. Methods: This study was an intervention project in three senatorial districts in Osun State that have primary, secondary and tertiary health facilities. The project was in three phases; Pre-intervention, Intervention, and Post-intervention. The study utilised the existing infrastructure, facilities and staff in project settings. The study population was nurse-midwives, community health workers and reproductive-aged women (30-49 years). The intervention phase entailed using innovative, culturally appropriate strategies to create awareness of cervical cancer and preventive health-seeking behaviour among women in the reproductive-aged group (30-49) years. Also, the service providers (community health workers, Nurses, and Midwives) were trained on screening methods and treatment of pre-cancerous lesions, and there was the provision of essential equipment and supplies for cervical cancer screening services at health facilities. Besides, advocacy and engagement were made with relevant stakeholders to integrate the cervical cancer screening services into related reproductive health services and greater allocation of resources. The expected results compared the pre and post-intervention using the baseline and process indicators and the effect of the intervention phase on screening coverage using a plausibility assessment design. The project lasted 12 months; visual Inspection with Acetic acid (VIA) screening for the women for six months and follow-up in 6 months for women receiving treatment. Results: The pre-intervention phase assessed baseline service delivery statistics in the previous 12 months drawn from the retrospective data collected as part of the routine monitoring and reporting systems. The uptake of cervical cancer screening services was low as the number of women screened in the previous 12 months was 156. Service personnel's competency level was fair (54%), and limited availability of essential equipment and supplies for cervical cancer screening services. At the post-intervention phase, the level of uptake had increased as the number of women screened was 1586 within six months in the study settings. This showed about a 100-%increase in the uptake of cervical cancer screening services compared with the baseline assessment. Also, the post-intervention level of competency of service delivery personnel had increased to 86.3%, which indicates quality improvement of the cervical cancer screening service delivery. Conclusion: the findings from the study have shown an effective approach to strengthening and improving cervical cancer screening service delivery in Southwestern Nigeria. Hence, the intervention promoted a positive attitude and health-seeking behaviour among the target population, significantly influencing the uptake of cervical cancer screening services.

Keywords: cervical cancer, screening, nigeria, health system strengthening

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Authors: Ojochenemi J. Onubi, Debbi Marais, Lorna Aucott, Friday Okonofua, Amudha Poobalan

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Background: Obesity is a worldwide epidemic with major health and economic consequences. Pregnancy is a trigger point for the development of obesity, and maternal obesity is associated with significant adverse effects in the mother and child. Nigeria is experiencing a double burden of under- and over-nutrition with rising levels of obesity particularly in women. However, there is scarcity of data on maternal obesity in Nigeria and other African countries. Aims and Objectives: This project aimed at identifying crucial components of potential interventions for maternal obesity in Nigeria. The objectives were to assess the prevalence, effects, and distribution of maternal obesity; knowledge, attitude and practice (KAP) of pregnant women and maternal healthcare providers; and identify existing interventions for maternal obesity in Nigeria. Methodology: A systematic review and meta-analysis were initially conducted to appraise the existing literature on maternal obesity in Africa. Following this, a quantitative questionnaire survey of the KAP of pregnant women and a qualitative interview study of the KAP of Health Care Workers (HCW) were conducted in seven secondary and tertiary hospitals across Nigeria. Quantitative data was analysed using SPSS statistical software, while thematic analysis was conducted for qualitative data. Results: Twenty-nine studies included in the systematic review showed significant prevalence, socio-demographic associations, and adverse effects of maternal obesity on labour, maternal, and child outcomes in Africa. The questionnaire survey of 435 mothers revealed a maternal obesity prevalence of 17.9% among mothers who registered for antenatal care in the first trimester. The mothers received nutrition information from different sources and had insufficient knowledge of their own weight category or recommended Gestational Weight Gain (GWG), causes, complications, and safe ways to manage maternal obesity. However, majority of the mothers were of the opinion that excess GWG is avoided in pregnancy and some practiced weight management (diet and exercise) during pregnancy. For the qualitative study, four main themes were identified: ‘Concerns about obesity in pregnancy’, ‘Barriers to care for obese pregnant women’, ‘Practice of care for obese pregnant women’, and ‘Improving care for obese pregnant women’. HCW expressed concerns about rising levels of maternal obesity, lack of guidelines for the management of obese pregnant women and worries about unintended consequences of antenatal interventions. ‘Barriers’ included lack of contact with obese women before pregnancy, late registration for antenatal care, and perceived maternal barriers such as socio-cultural beliefs of mothers and poverty. ‘Practice’ included anticipatory care and screening for possible complications, general nutrition education during antenatal care and interdisciplinary care for mothers with complications. HCW offered suggestions on improving care for obese women including timing, type, and settings of interventions; and the need for involvement of other stake holders in caring for obese pregnant women. Conclusions: Culturally adaptable/sensitive interventions should be developed for the management of obese pregnant women in Africa. Education and training of mothers and health care workers, and provision of guidelines are some of the components of potential interventions in Nigeria.

Keywords: Africa, maternal, obesity, pregnancy

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Authors: M. Fry, L. Fitzpatrick, Julie Considine, R. Z. Shaban, Kate Curtis

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Introduction: The vast majority of older Australians lives independently and are self-managing at home, despite a growing number living with a chronic illness that requires health intervention. Evidence shows that between 50% and 80% of people presenting to the emergency department (ED) are in pain. Australian EDs manage 7.2 million attendances every year and 1.4 million of these are people aged 65 years or more. Research shows that 28% of ED patients aged 65 years or more have Cognitive impairment (CI) associated with dementia, delirium and neurological conditions. Background: Traditional ED service delivery may not be suitable for older people who present with multiple, complex and ongoing illnesses. Likewise, ED clinical staff often perceive that their role should be focused more on immediate and potential lifethreatening illness and conditions which are episodic in nature. Therefore, the needs of older people and their family/carers may not be adequately addressed in the context of an ED presentation. Aim: We aimed to explore the utilisation and characteristics of older people presenting to four metropolitan EDs. Method: The findings being presented are part of a program of research exploring pain management practices for older persons with long bone fractures. The study was conducted across four metropolitan emergency departments of older patients (65years and over) and involved a 12-month randomised medical record audit (n=255). Results: ED presentations across four ED sites in 2012 numbered 168021, with 44778 (26.6%) patients aged 65 and over. Of the 44778 patients, the average age was 79.1 years (SD 8.54). There were more females 23932 (53.5%). The majority (26925: 85.0%) of older persons self-referred to the ED and lived independently. The majority arrived by ambulance (n=18553: 41.4%) and were allocated triage category was 3 (n=19,507:43.65%) or Triage category 4 at (n=15,389: 34.43%). The top five triage symptom presentations involved pain (n=8088; 18.25%), dyspnoea (n=4735; 10.7%), falls (n=4032; 9.1%), other (n=3984; 9.0%), cardiac (n=2987; 6.7%). The top five system based diagnostic presentations involved musculoskeletal (n=8902; 20.1%), cardiac (n=6704:15.0%), respiratory (n=4933; 11.0%), neurological (n=4909; 11.0%), gastroenterology (n=4321; 9.7%). On review of one tertiary hospital database the vital signs on average at time triage: Systolic Blood Pressure 143.6mmHg. Heart Rate 83.4 beats/minute; Respiratory Rate 18.5 breaths/ minute; Oxygen saturation 97.0% and Tympanic temperature 36.7 and Blood Glucose Level 7.4mmols/litre. The majority presented with a Glasgow Coma Score of 14 or higher. On average the older person stayed in the ED 4:56 (SD 3:28minutes).The average time to be seen was 39 minutes (SD 48 minutes). The majority of older persons were admitted (n=27562: 61.5%), did not wait for treatment (n= 8879: 0.02%) discharged home (n=16256: 36.0%). Conclusion: The vast majority of older persons are living independently, although many require admission on arrival to the ED. Many arrived in pain and with musculoskeletal injuries and or conditions. New models of care need to be considered, which may better support self-management and independent living of the older person and the National Emergency Access Targets.

Keywords: chronic, older person, aged care, emergency department

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Authors: Meenakshi Barsaul Chauhan, Aastha Chauhan, Shilpa Hurmade, Rajeev Sen, Jyotsna Sen, Monika Dalal

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Introduction: Ovarian masses are common forms of neoplasm in women and represent 2/3rd of gynaecological malignancies. A pre-operative suggestion of malignancy can guide the gynecologist to refer women with suspected pelvic mass to a gynecological oncologist for appropriate therapy and optimized treatment, which can improve survival. In the younger age group preoperative differentiation into benign or malignant pathology can decide for conservative or radical surgery. Imaging modalities have a definite role in establishing the diagnosis. By using International Ovarian Tumor Analysis (IOTA) classification with sonography, costly radiological methods like Magnetic Resonance Imaging (MRI) / computed tomography (CT) scan can be reduced, especially in developing countries like India. Thus, this study is being undertaken to evaluate the role of clinical methods and sonography for diagnosis of the nature of the ovarian tumor. Material And Methods: This prospective observational study was conducted on 40 patients presenting with ovarian masses, in the Department of Obstetrics and Gynaecology, at a tertiary care center in northern India. Functional cysts were excluded. Ultrasonography and color Doppler were performed on all the cases.IOTA rules were applied, which take into account locularity, size, presence of solid components, acoustic shadow, dopper flow etc . Magnetic Resonance Imaging (MRI) / computed tomography (CT) scans abdomen and pelvis were done in cases where sonography was inconclusive. In inoperable cases, Fine needle aspiration cytology (FNAC) was done. The histopathology report after surgery and cytology report after FNAC was correlated statistically with the pre-operative diagnosis made clinically and sonographically using IOTA rules. Statistical Analysis: Descriptive measures were analyzed by using mean and standard deviation and the Student t-test was applied and the proportion was analyzed by applying the chi-square test. Inferential measures were analyzed by sensitivity, specificity, negative predictive value, and positive predictive value. Results: Provisional diagnosis of the benign tumor was made in 16(42.5%) and of the malignant tumor was made in 24(57.5%) patients on the basis of clinical findings. With IOTA simple rules on sonography, 15(37.5%) were found to be benign, while 23 (57.5%) were found to be malignant and findings were inconclusive in 2 patients (5%). FNAC/Histopathology reported that benign ovarian tumors were 14 (35%) and 26(65%) were malignant, which was taken as the gold standard. The clinical finding alone was found to have a sensitivity of 66.6% and a specificity of 90.9%. USG alone had a sensitivity of 86% and a specificity of 80%. When clinical findings and IOTA simple rules of sonography were combined (excluding inconclusive masses), the sensitivity and specificity were 83.3% and 92.3%, respectively. While including inconclusive masses, sensitivity came out to be 91.6% and specificity was 89.2. Conclusion: IOTA's simple sonography rules are highly sensitive and specific in the prediction of ovarian malignancy and also easy to use and easily reproducible. Thus, combining clinical examination with USG will help in the better management of patients in terms of time, cost and better prognosis. This will also avoid the need for costlier modalities like CT, and MRI.

Keywords: benign, international ovarian tumor analysis classification, malignant, ovarian tumours, sonography

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Authors: Andrew Laming, John Hattie, Mark Wilson

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Nine Queensland Independent high schools provided deidentified student-matched ATAR and NAPLAN data for all 1217 ATAR graduates since 2020 who also sat NAPLAN at the school. Graduating cohorts from the nine schools contained a mean 100 ATAR graduates with previous NAPLAN data from their school. Excluded were vocational students (mean=27) and any ATAR graduates without NAPLAN data (mean=20). Based on Index of Community Socio-Educational Access (ICSEA) prediction, all schools had larger that predicted proportions of their students graduating with ATARs. There were an additional 173 students not releasing their ATARs to their school (14%), requiring this data to be inferred by schools. Gain was established by first converting each student’s strongest NAPLAN domain to a statewide percentile, then subtracting this result from final ATAR. The resulting ‘percentile shift’ was corrected for plausible ATAR participation at each NAPLAN level. Strongest NAPLAN domain had the highest correlation with ATAR (R2=0.58). RESULTS School mean NAPLAN scores fitted ICSEA closely (R2=0.97). Schools achieved a mean cohort gain of two ATAR rankings, but only 66% of students gained. This ranged from 46% of top-NAPLAN decile students gaining, rising to 75% achieving gains outside the top decile. The 54% of top-decile students whose ATAR fell short of prediction lost a mean 4.0 percentiles (or 6.2 percentiles prior to correction for regression to the mean). 71% of students in smaller schools gained, compared to 63% in larger schools. NAPLAN variability in each of the 13 ICSEA1100 cohorts was 17%, with both intra-school and inter-school variation of these values extremely low (0.3% to 1.8%). Mean ATAR change between years in each school was just 1.1 ATAR ranks. This suggests consecutive school cohorts and ICSEA-similar schools share very similar distributions and outcomes over time. Quantile analysis of the NAPLAN/ATAR revealed heteroscedasticity, but splines offered little additional benefit over simple linear regression. The NAPLAN/ATAR R2 was 0.33. DISCUSSION Standardised data like NAPLAN and ATAR offer educators a simple no-cost progression metric to analyse performance in conjunction with their internal test results. Change is expressed in percentiles, or ATAR shift per student, which is layperson intuitive. Findings may also reduce ATAR/vocational stream mismatch, reveal proportions of cohorts meeting or falling short of expectation and demonstrate by how much. Finally, ‘crashed’ ATARs well below expectation are revealed, which schools can reasonably work to minimise. The percentile shift method is neither value-add nor a growth percentile. In the absence of exit NAPLAN testing, this metric is unable to discriminate academic gain from legitimate ATAR-maximizing strategies. But by controlling for ICSEA, ATAR proportion variation and student mobility, it uncovers progression to ATAR metrics which are not currently publicly available. However achieved, ATAR maximisation is a sought-after private good. So long as standardised nationwide data is available, this analysis offers useful analytics for educators and reasonable predictivity when counselling subsequent cohorts about their ATAR prospects.  

Keywords: NAPLAN, ATAR, analytics, measurement, gain, performance, data, percentile, value-added, high school, numeracy, reading comprehension, variability, regression to the mean

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

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

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

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Authors: Zakia Hbellaq

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The Mediterranean region is considered a hotbed for climate change. Morocco is a semi-arid Mediterranean country facing water shortages and poor water quality. Its limited water resources limit the activities of various economic sectors. Most of Morocco's territory is in arid and desert areas. The potential water resources are estimated at 22 billion m3, which is equivalent to about 700 m3/inhabitant/year, and Morocco is in a state of structural water stress. Strictly speaking, the Kingdom of Morocco is one of the “very riskiest” countries, according to the World Resources Institute (WRI), which oversees the calculation of water stress risk in 167 countries. The surprising results of the Institute (WRI) rank Morocco as one of the riskiest countries in terms of water scarcity, ranking 3.89 out of 5, thus occupying the 23rd place out of a total of 167 countries, which indicates that the demand for water exceeds the available resources. Agriculture with a score of 3.89 is most affected by water stress from irrigation and places a heavy burden on the water table. Irrigation is an unavoidable technical need and has undeniable economic and social benefits given the available resources and climatic conditions. Irrigation, and therefore the agricultural sector, currently uses 86% of its water resources, while industry uses 5.5%. Although its development has undeniable economic and social benefits, it also contributes to the overfishing of most groundwater resources and the surprising decline in levels and deterioration of water quality in some aquifers. In this context, REUSE is one of the proposed solutions to reduce the water footprint of the agricultural sector and alleviate the shortage of water resources. Indeed, wastewater reuse, also known as REUSE (reuse of treated wastewater), is a step forward not only for the circular economy but also for the future, especially in the context of climate change. In particular, water reuse provides an alternative to existing water supplies and can be used to improve water security, sustainability, and resilience. However, given the introduction of organic trace pollutants or, organic micro-pollutants, the absorption of emerging contaminants, and decreasing salinity, it is possible to tackle innovative capabilities to overcome these problems and ensure food and health safety. To this end, attention will be paid to the adoption of an integrated and attractive approach, based on the reinforcement and optimization of the treatments proposed for the elimination of the organic load with particular attention to the elimination of emerging pollutants, to achieve this goal. , membrane bioreactors (MBR) as stand-alone technologies are not able to meet the requirements of WHO guidelines. They will be combined with heterogeneous Fenton processes using persulfate or hydrogen peroxide oxidants. Similarly, adsorption and filtration are applied as tertiary treatment In addition, the evaluation of crop performance in terms of yield, productivity, quality, and safety, through the optimization of Trichoderma sp strains that will be used to increase crop resistance to abiotic stresses, as well as the use of modern omics tools such as transcriptomic analysis using RNA sequencing and methylation to identify adaptive traits and associated genetic diversity that is tolerant/resistant/resilient to biotic and abiotic stresses. Hence, ensuring this approach will undoubtedly alleviate water scarcity and, likewise, increase the negative and harmful impact of wastewater irrigation on the condition of crops and the health of their consumers.

Keywords: water scarcity, food security, irrigation, agricultural water footprint, reuse, emerging contaminants

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Authors: Emilie Gout, Mathias Monnot, Olivier Boutin, Pierre Vanloot, Philippe Moulin

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Water is a precious resource. Treating industrial wastewater remains a considerable technical challenge of our century. The effluent considered for this study is landfill leachate treated by reverse osmosis (RO). Nowadays, in most developed countries, sanitary landfilling is the main method to deal with municipal solid waste. Rainwater percolates through solid waste, generating leachates mostly comprised of organic and inorganic matter. Whilst leachate ages, its composition varies, becoming more and more bio-refractory. RO is already used for landfill leachates as it generates good quality permeate. However, its mains drawback is the production of highly polluted concentrates that cannot be discharged in the environment or reused, which is an important industrial issue. It is against this background that the study of coupling RO with wet air oxidation (WAO) was set to intensify and optimize processes to meet current regulations for water discharge in the environment. WAO is widely studied for effluents containing bio-refractory compounds. Oxidation consists of a destruction reaction capable of mineralizing the recalcitrant organic fraction of pollution into carbon dioxide and water when complete. WAO process in subcritical conditions requires a high-energy consumption, but it can be autothermic in a certain range of chemical oxygen demand (COD) concentrations (10-100 g.L⁻¹). Appropriate COD concentrations are reached in landfill leachate RO concentrates. Therefore, the purpose of this work is to report the performances of mineralization during WAO on RO concentrates. The coupling of RO/WAO has shown promising results in previous works on both synthetic and real effluents in terms of organic carbon (TOC) reduction by WAO and retention by RO. Non-catalytic WAO with air as oxidizer was performed in a lab-scale stirred autoclave (1 L) on landfill leachates RO concentrates collected in different seasons in a sanitary landfill in southern France. The yield of WAO depends on operating parameters such as total pressure, temperature, and time. Compositions of the effluent are also important aspects for process intensification. An experimental design methodology was used to minimize the number of experiments whilst finding the operating conditions achieving the best pollution reduction. The simulation led to a set of 18 experiments, and the responses to highlight process efficiency are pH, conductivity, turbidity, COD, TOC, and inorganic carbon. A 70% oxygen excess was chosen for all the experiments. First experiments showed that COD and TOC abatements of at least 70% were obtained after 90 min at 300°C and 20 MPa, which attested the possibility to treat RO leachate concentrates with WAO. In order to meet French regulations and validate process intensification with industrial effluents, some continuous experiments in a bubble column are foreseen, and some further analyses will be performed, such as biological oxygen demand and study of gas composition. Meanwhile, other industrial effluents are treated to compare RO-WAO performances. These effluents, coming from pharmaceutical, petrochemical, and tertiary wastewater industries, present different specific pollutants that will provide a better comprehension of the hybrid process and prove the intensification and feasibility of the process at an industrial scale. Acknowledgments: This work has been supported by the French National Research Agency (ANR) for the Project TEMPO under the reference number ANR-19-CE04-0002-01.

Keywords: hybrid process, landfill leachates, process intensification, reverse osmosis, wet air oxidation

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Authors: Neelofar, Khursheed Alam, Jamal Ahmad

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Protein modification in diabetes mellitus may lead to early glycation products (EGPs) or amadori product as well as advanced glycation end products (AGEs). Early glycation involves the reaction of glucose with N-terminal and lysyl side chain amino groups to form Schiff’s base which undergoes rearrangements to form more stable early glycation product known as Amadori product. After Amadori, the reactions become more complicated leading to the formation of advanced glycation end products (AGEs) that interact with various AGE receptors, thereby playing an important role in the long-term complications of diabetes. Millard reaction or nonenzymatic glycation reaction accelerate in diabetes due to hyperglycation and alter serum protein’s structure, their normal functions that lead micro and macro vascular complications in diabetic patients. In this study, Human Serum Albumin (HSA) with a constant concentration was incubated with different concentrations of glucose at 370C for a week. At 4th day, Amadori product was formed that was confirmed by colorimetric method NBT assay and TBA assay which both are authenticate early glycation product. Conformational changes in native as well as all samples of Amadori albumin with different concentrations of glucose were investigated by various biophysical and biochemical techniques. Main biophysical techniques hyperchromacity, quenching of fluorescence intensity, FTIR, CD and SDS-PAGE were used. Further conformational changes were observed by biochemical assays mainly HMF formation, fructoseamine, reduction of fructoseamine with NaBH4, carbonyl content estimation, lysine and arginine residues estimation, ANS binding property and thiol group estimation. This study find structural and biochemical changes in Amadori modified HSA with normal to hyperchronic range of glucose with respect to native HSA. When glucose concentration was increased from normal to chronic range biochemical and structural changes also increased. Highest alteration in secondary and tertiary structure and conformation in glycated HSA was observed at the hyperchronic concentration (75mM) of glucose. Although it has been found that Amadori modified proteins is also involved in secondary complications of diabetes as AGEs but very few studies have been done to analyze the conformational changes in Amadori modified proteins due to early glycation. Most of the studies were found on the structural changes in Amadori protein at a particular glucose concentration but no study was found to compare the biophysical and biochemical changes in HSA due to early glycation with a range of glucose concentration at a constant incubation time. So this study provide the information about the biochemical and biophysical changes occur in Amadori modified albumin at a range of glucose normal to chronic in diabetes. Although many implicates currently in use i.e. glycaemic control, insulin treatment and other chemical therapies that can control many aspects of diabetes. However, even with intensive use of current antidiabetic agents more than 50 % of diabetic patient’s type 2 suffers poor glycaemic control and 18 % develop serious complications within six years of diagnosis. Experimental evidence related to diabetes suggests that preventing the nonenzymatic glycation of relevant proteins or blocking their biological effects might beneficially influence the evolution of vascular complications in diabetic patients or quantization of amadori adduct of HSA by authentic antibodies against HSA-EGPs can be used as marker for early detection of the initiation/progression of secondary complications of diabetes. So this research work may be helpful for the same.

Keywords: diabetes mellitus, glycation, albumin, amadori, biophysical and biochemical techniques

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Authors: Silvia D. Vaca, Benjamin J. Kuo, Joao Ricardo Nickenig Vissoci, Catherine A. Staton, Linda W. Xu, Michael Muhumuza, Hussein Ssenyonjo, John Mukasa, Joel Kiryabwire, Henry E. Rice, Gerald A. Grant, Michael M. Haglund

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Background: Patients with traumatic brain injury (TBI) can develop rapid neurological deterioration from swelling and intracranial hematomas, which can result in focal tissue ischemia, brain compression, and herniation. Moreover, delays in management increase the risk of secondary brain injury from hypoxemia and hypotension. Therefore, in TBI patients with subdural hematomas (SDHs) and epidural hematomas (EDHs), surgical intervention is both necessary and time sensitive. Significant delays are seen along the care continuum in low- and middle-income countries (LMICs) largely due to limited healthcare capacity to address the disproportional rates of TBI in Sub Saharan Africa (SSA). While many LMICs have subsidized systems to offset surgical costs, the burden of securing funds by the patients for medications, supplies, and CT diagnostics poses a significant challenge to timely surgical interventions. In Kampala Uganda, the challenge of obtaining timely CT scans is twofold: logistical and financial barriers. These bottlenecks contribute significantly to the care continuum delays and are associated with poor TBI outcomes. Objective: The objectives of this study are to 1) describe the temporal delays through a modified three delays model that fits the context of neurosurgical interventions for TBI patients in Kampala and 2) investigate the association between delays and mortality. Methods: Prospective data were collected for 563 TBI patients presenting to a tertiary hospital in Kampala from 1 June – 30 November 2016. Four time intervals were constructed along five time points: injury, hospital arrival, neurosurgical evaluation, CT results, and definitive surgery. Time interval differences among mild, moderate and severe TBI and their association with mortality were analyzed. Results: The mortality rate of all TBI patients presenting to MNRH was 9.6%, which ranged from 4.7% for mild and moderate TBI patients receiving surgery to 81.8% for severe TBI patients who failed to receive surgery. The duration from injury to surgery varied considerably across TBI severity with the largest gap seen between mild TBI (174 hours) and severe TBI (69 hours) patients. Further analysis revealed care continuum differences for interval 3 (neurosurgical evaluation to CT result) and 4 (CT result to surgery) between severe TBI patients (7 hours for interval 3 and 24 hours for interval 4) and mild TBI patients (19 hours for interval 3, and 96 hours for interval 4). These post-arrival delays were associated with mortality for mild (p=0.05) and moderate TBI (p=0.03) patients. Conclusions: To our knowledge, this is the first analysis using a modified 'three delays' framework to analyze the care continuum of TBI patients in Uganda from injury to surgery. We found significant associations between delays and mortality for mild and moderate TBI patients. As it currently stands, poorer outcomes were observed for these mild and moderate TBI patients who were managed non-operatively or failed to receive surgery while surgical services were shunted to more severely ill patients. While well intentioned, high mortality rates were still observed for the severe TBI patients managed surgically. These results suggest the need for future research to optimize triage practices, understand delay contributors, and improve pre-hospital logistical referral systems.

Keywords: care continuum, global neurosurgery, Kampala Uganda, LMIC, Mulago, traumatic brain injury

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Authors: Kasun P. Wijayaratna, Lauren Gardner, Taha Hossein Rashidi

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Undergraduate students entering university across the last 2 to 3 years tend to be born during the middle years of the 1990s. This generation of students has been exposed to the internet and the desire and dependency on technology since childhood. Brains develop based on environmental influences and technology has wired this generation of student to be attuned to sophisticated complex visual imagery, indicating visual forms of learning may be more effective than the traditional lecture or discussion formats. Furthermore, post-millennials perspectives on career are not focused solely on stability and income but are strongly driven by interest, entrepreneurship and innovation. Accordingly, it is important for educators to acknowledge the generational shift and tailor the delivery of learning material to meet the expectations of the students and the needs of industry. In the context of transport engineering, effectively teaching undergraduate students the basic principles of transport planning, traffic engineering and highway design is fundamental to the progression of the profession from a practice and research perspective. Recent developments in technology have transformed the discipline as practitioners and researchers move away from the traditional “pen and paper” approach to methods involving the use of computer programs and simulation. Further, enhanced accessibility of technology for students has changed the way they understand and learn material being delivered at tertiary education institutions. As a consequence, blended learning approaches, which aim to integrate face to face teaching with flexible self-paced learning resources, have become prevalent to provide scalable education that satisfies the expectations of students. This research study involved the development of a series of ‘Blended Learning’ initiatives implemented within an introductory transport planning and geometric design course, CVEN2401: Sustainable Transport and Highway Engineering, taught at the University of New South Wales, Australia. CVEN2401 was modified by conducting interactive polling exercises during lectures, including weekly online quizzes, offering a series of supplementary learning videos, and implementing a realistic design project that students needed to complete using modelling software that is widely used in practice. These activities and resources were aimed to improve the learning environment for a large class size in excess of 450 students and to ensure that practical industry valued skills were introduced. The case study compared the 2016 and 2017 student cohorts based on their performance across assessment tasks as well as their reception to the material revealed through student feedback surveys. The initiatives were well received with a number of students commenting on the ability to complete self-paced learning and an appreciation of the exposure to a realistic design project. From an educator’s perspective, blending the course made it feasible to interact and engage with students. Personalised learning opportunities were made available whilst delivering a considerable volume of complex content essential for all undergraduate Civil and Environmental Engineering students. Overall, this case study highlights the value of blended learning initiatives, especially in the context of large class size university courses.

Keywords: blended learning, highway design, teaching, transport planning

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Authors: Johanes Mandowa

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The study evaluated the status of Occupational Safety and Health Management Systems’ (OSHMSs) implementation by Mutare urban timber processing factories. A descriptive cross sectional survey method was utilized in the study. Questionnaires, interviews and direct observations were the techniques employed to extract primary data from the respondents. Secondary data was acquired from OSH encyclopedia, OSH journals, newspaper articles, internet, past research papers, African Newsletter on OSH and NSSA On-guard magazines among others. Analysis of data collected was conducted using statistical and descriptive methods. Results revealed an unpleasant low uptake rate (16%) of OSH Management Systems by Mutare urban timber processing factories. On a comparative basis, low implementation levels were more pronounced in small timber processing factories than in large factories. The low uptake rate of OSH Management Systems revealed by the study validates the Government of Zimbabwe and its social partners’ observation that the dismal Zimbabwe OSH performance was largely due to non implementation of safety systems at most workplaces. The results exhibited a relationship between availability of a SHE practitioner in Mutare urban timber processing factories and OSHMS implementation. All respondents and interviewees’ agreed that OSH Management Systems are handy in curbing occupational injuries and diseases. It emerged from the study that the top barriers to implementation of safety systems are lack of adequate financial resources, lack of top management commitment and lack of OSHMS implementation expertise. Key motivators for OSHMSs establishment were cited as provision of adequate resources (76%), strong employee involvement (64%) and strong senior management commitment and involvement (60%). Study results demonstrated that both OSHMSs implementation barriers and motivators affect all Mutare urban timber processing factories irrespective of size. The study recommends enactment of a law by Ministry of Public Service, Labour and Social Welfare in consultation with NSSA to make availability of an OSHMS and qualified SHE practitioner mandatory at every workplace. More so, the enacted law should prescribe minimum educational qualification required for one to practice as a SHE practitioner. Ministry of Public Service, Labour and Social Welfare and NSSA should also devise incentives such as reduced WCIF premiums for good OSH performance to cushion Mutare urban timber processing factories from OSHMS implementation costs. The study recommends the incorporation of an OSH module in the academic curriculums of all programmes offered at tertiary institutions so as to ensure that graduates who later end up assuming influential management positions in Mutare urban timber processing factories are abreast with the necessity of OSHMSs in preventing occupational injuries and diseases. In the quest to further boost management’s awareness on the importance of OSHMSs, NSSA and SAZ are urged by the study to conduct OSHMSs awareness breakfast meetings targeting executive management on a periodic basis. The Government of Zimbabwe through the Ministry of Public Service, Labour and Social Welfare should also engage ILO Country Office for Zimbabwe to solicit for ILO’s technical assistance so as to enhance the effectiveness of NSSA’s and SAZ’s OSHMSs promotional programmes.

Keywords: occupational safety health management system, national social security authority, standard association of Zimbabwe, Mutare urban timber processing factories, ministry of public service, labour and social welfare

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Authors: Fahrur Rozi, Daniswara Krisna Prabatha, Latief Zulfikar Chusaini

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Amidst the backdrop of Pertamina Plaju Refinery, which stands as the oldest and historically less technologically advanced among Pertamina's refineries, lies a unique challenge. Originally integrating facilities established by Shell in 1904 and Stanvac (originally Standard Oil) in 1926, the primary challenge at Plaju Refinery does not solely revolve around complexity; instead, it lies in ensuring reliability, considering its operational history of over a century. After centuries of existence, Plaju Refinery has never undergone a comprehensive major turnaround encompassing all its units. The usual practice involves partial turnarounds that are sequentially conducted across its primary, secondary, and tertiary units (utilities and offsite). However, a significant shift is on the horizon. In the Q-IV of 2023, the refinery embarks on its first-ever major turnaround since its establishment. This decision was driven by the alignment of maintenance timelines across various units. Plaju Refinery's major turnaround was scheduled for October-November 2023, spanning 45 calendar days, with the objective of enhancing the operational reliability of all refinery units. The extensive job list for this turnaround encompasses 1583 tasks across 18 units/areas, involving approximately 9000 contracted workers. In this context, the Strategy of Simultaneous Operations (SIMOPS) execution emerges as a pivotal tool to optimize time efficiency and ensure safety. A Hazard Effect Management Process (HEMP) has been employed to assess the risk ratings of each task within the turnaround. Out of the tasks assessed, 22 are deemed high-risk and necessitate mitigation. The SIMOPS approach serves as a preventive measure against potential incidents. It is noteworthy that every turnaround period at Pertamina Plaju Refinery involves SIMOPS-related tasks. In this context, enhancing the implementation strategy of "Simultaneous Operations (SIMOPS)" becomes imperative to minimize the occurrence of incidents. At least four improvements have been introduced in the enhancement process for the major turnaround at Refinery Plaju. The first improvement involves conducting systematic risk assessment and potential hazard mitigation studies for SIMOPS tasks before task execution, as opposed to the previous on-site approach. The second improvement includes the completion of SIMOPS Job Mitigation and Work Matrices Sheets, which was often neglected in the past. The third improvement emphasizes comprehensive awareness to workers/contractors regarding potential hazards and mitigation strategies for SIMOPS tasks before and during the major turnaround. The final improvement is the introduction of a daily program for inspecting and observing work in progress for SIMOPS tasks. Prior to these improvements, there was no established program for monitoring ongoing activities related to SIMOPS tasks during the turnaround. This study elucidates the steps taken to enhance SIMOPS within Pertamina, drawing from the experiences of Plaju Refinery as a guide. A real actual case study will be provided from our experience in the operational unit. In conclusion, these efforts are essential for the success of the first-ever major turnaround at Plaju Refinery, with the SIMOPS strategy serving as a central component. Based on these experiences, enhancements have been made to Pertamina's official Internal Guidelines for Executing SIMOPS Risk Mitigation, benefiting all Pertamina units.

Keywords: process safety management, turn around, oil refinery, risk assessment

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Authors: Narottam Puri, Gurvinder Kaur

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Background: The National Accreditation Board for Hospitals & Healthcare Providers (NABH) is India’s apex standard setting accrediting body in health care which evaluates and accredits healthcare organizations. NABH requires accredited organizations to become reaccredited every three years. It is often though that once the initial accreditation is complete, the foundation is set and reaccreditation is a much simpler process. Fortis Hospital, Shalimar Bagh, a part of the Fortis Healthcare group is a 262 bed, multi-specialty tertiary care hospital. The hospital was successfully accredited in the year 2012. On completion of its first cycle, the hospital underwent a reaccreditation assessment in the year 2015. This paper aims to gain a better understanding of the challenges that accredited hospitals face when preparing for a renewal of their accreditations. Methods: The study was conducted using a cross-sectional mixed methods approach; semi-structured interviews were conducted with senior leadership team and staff members including doctors and nurses. Documents collated by the QA team while preparing for the re-assessment like the data on quality indicators: the method of collection, analysis, trending, continual incremental improvements made over time, minutes of the meetings, amendments made to the existing policies and new policies drafted was reviewed to understand the challenges. Results: The senior leadership had a concern about the cost of accreditation and its impact on the quality of health care services considering the staff effort and time consumed it. The management was however in favor of continuing with the accreditation since it offered competitive advantage, strengthened community confidence besides better pay rates from the payors. The clinicians regarded it as an increased non-clinical workload. Doctors felt accountable within a professional framework, to themselves, the patient and family, their peers and to their profession; but not to accreditation bodies and raised concerns on how the quality indicators were measured. The departmental leaders had a positive perception of accreditation. They agreed that it ensured high standards of care and improved management of their functional areas. However, they were reluctant in sparing people for the QA activities due to staffing issues. With staff turnover, a lot of work was lost as sticky knowledge and had to be redone. Listing the continual quality improvement initiatives over the last 3 years was a challenge in itself. Conclusion: The success of any quality assurance reaccreditation program depends almost entirely on the commitment and interest of the administrators, nurses, paramedical staff, and clinicians. The leader of the Quality Movement is critical in propelling and building momentum. Leaders need to recognize skepticism and resistance and consider ways in which staff can become positively engaged. Involvement of all the functional owners is the start point towards building ownership and accountability for standards compliance. Creativity plays a very valuable role. Communication by Mail Series, WhatsApp groups, Quizzes, Events, and any and every form helps. Leaders must be able to generate interest and commitment without burdening clinical and administrative staff with an activity they neither understand nor believe in.

Keywords: NABH, reaccreditation, quality assurance, quality indicators

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Authors: Aryati Yashadhana, Ted Fields Jnr., Wendy Fernando, Kelvin Brown, Godfrey Blitner, Francis Hayes, Ruby Stanley, Brian Donnelly, Bridgette Jerrard, Anthea Burnett, Anthony B. Zwi

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Indigenous Australians experience some of the worst health outcomes globally, with life expectancy being significantly poorer than those of non-Indigenous Australians. This is largely attributed to preventable diseases such as diabetes (prevalence 39% in Indigenous Australian adults > 55 years), which is attributed to a raised risk of diabetic visual impairment and cataract among Indigenous adults. Our study aims to explore the interface between structural and sociocultural determinants and human agency, in order to understand how they impact (1) accessibility of eye health and chronic disease services and (2) the potential for Indigenous patients to achieve positive clinical eye health outcomes. We used Participatory Action Research methods, and aimed to privilege the voices of Indigenous people through community collaboration. Semi-structured interviews (n=82) and patient focus groups (n=8) were conducted by Indigenous Community-Based Researchers (CBRs) with diabetic Indigenous adults (> 40 years) in four remote communities in Australia. Interviews (n=25) and focus groups (n=4) with primary health care clinicians in each community were also conducted. Data were audio recorded, transcribed verbatim, and analysed thematically using grounded theory, comparative analysis and Nvivo 10. Preliminary analysis occurred in tandem with data collection to determine theoretical saturation. The principal investigator (AY) led analysis sessions with CBRs, fostering cultural and contextual appropriateness to interpreting responses, knowledge exchange and capacity building. Identified themes were conceptualised into three spheres of influence: structural (health services, government), sociocultural (Indigenous cultural values, distrust of the health system, ongoing effects of colonialism and dispossession) and individual (health beliefs/perceptions, patient phenomenology). Permeating these spheres of influence were three core determinants: economic disadvantage, health literacy/education, and cultural marginalisation. These core determinants affected accessibility of services, and the potential for patients to achieve positive clinical outcomes at every level of care (primary, secondary, tertiary). Our findings highlight the clinical realities of institutionalised and structural inequities, illustrated through the lived experiences of Indigenous patients and primary care clinicians in the four sampled communities. The complex determinants surrounding inequity in health for Indigenous Australians, are entrenched through a longstanding experience of cultural discrimination and ostracism. Secure and long term funding of Aboriginal Community Controlled Health Services will be valuable, but are insufficient to address issues of inequity. Rather, working collaboratively with communities to build trust, and identify needs and solutions at the grassroots level, while leveraging community voices to drive change at the systemic/policy level are recommended.

Keywords: indigenous, Australia, culture, public health, eye health, diabetes, social determinants of health, sociology, anthropology, health equity, aboriginal and Torres strait islander, primary care

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Authors: Kakali Roy, Sahana P. Raju, Subhra Dhar, Sandipan Dhar

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Introduction: Xeroderma pigmentosa (XP) is a rare inherited (autosomal recessive) disease resulting from impairment in DNA repair that involves recognition and repair of ultraviolet radiation (UVR) induced DNA damage in the nucleotide excision repair pathway. Which results in increased photosensitivity, UVR induced damage to skin and eye, increased susceptibility of skin and ocular cancer, and progressive neurodegeneration in some patients. XP is present worldwide, with higher incidence in areas having frequent consanguinity. Being extremely rare, there is limited literature on XP and associated complications. Here, the clinico-pathological experience (spectrum of clinical presentation, histopathological findings of malignant skin lesions, and progression) of managing 8 cases of XP is presented. Methodology: A retrospective study was conducted in a pediatric tertiary care hospital in eastern India during a ten-year period from 2013 to 2022. A clinical diagnosis was made based on severe sun burn or premature photo-aging and/or onset of cutaneous malignancies at early age (1st decade) in background of consanguinity and autosomal recessive inheritance pattern in family. Results: The mean age of presentation was 1.2 years (range of 7month-3years), while three children presented during their infancy. Male to female ratio was 5:3, and all were born of consanguineous marriage. They presented with dermatological manifestations (100%) followed by ophthalmic (75%) and/or neurological symptoms (25%). Patients had normal skin at birth but soon developed extreme sensitivity to UVR in the form of exaggerated sun tanning, burning, and blistering on minimal sun exposure, followed by abnormal skin pigmentation like freckles and lentiginosis. Subsequently, over time there was progressive xerosis, atrophy, wrinkling, and poikiloderma. Six patients had varied degree of ocular involvement, while three of them had severe manifestation, including madarosis, tylosis, ectropion, Lagopthalmos, Pthysis bulbi, clouding and scarring of the cornea with complete or partial loss of vision, and ophthalmic malignancies. 50% (n=4) cases had skin and ocular pre-malignant (actinic keratosis) and malignant lesions, including melanoma and non melanoma skin cancer (NMSC) like squamous cell carcinoma (SCC) and basal cell carcinoma (BCC) in their early childhood. One patient had simultaneous occurrence of multiple malignancies together (SCC, BCC, and melanoma). Subnormal intelligence was noticed as neurological feature, and none had sensory neural hearing loss, microcephaly, neuroregression, or neurdeficit. All the patients had been being managed by a multidisciplinary team of pediatricians, dermatologists, ophthalmologists, neurologists and psychiatrists. Conclusion: Although till date there is no complete cure for XP and the disease is ultimately fatal. But increased awareness, early diagnosis followed by persistent vigorous protection from UVR, and regular screening for early detection of malignancies along with psychological support can drastically improve patients’ quality of life and life expectancy. Further research is required on formulating optimal management of XP, specifically the role and possibilities of gene therapy in XP.

Keywords: childhood malignancies, dermato-pathological findings, eastern India, Xeroderma pigmentosa

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