Search results for: Total knee replacement

Authors: Ali Zaker, Zhi Chen

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Due to the concerns about the depletion of fossil fuel sources and the deteriorating environment, the attempt to investigate the production of renewable energy will play a crucial role as a potential to alleviate the dependency on mineral fuels. One particular area of interest is generation of bio-oil through sewage sludge (SS) pyrolysis. SS can be a potential candidate in contrast to other types of biomasses due to its availability and low cost. However, the presence of high molecular weight hydrocarbons and oxygenated compounds in the SS bio-oil hinders some of its fuel applications. In this context, catalytic pyrolysis is another attainable route to upgrade bio-oil quality. Among different catalysts (i.e., zeolites) studied for SS pyrolysis, activated chars (AC) are eco-friendly alternatives. The beneficial features of AC derived from SS comprise the comparatively large surface area, porosity, enriched surface functional groups and presence of a high amount of metal species that can improve the catalytic activity. Hence, a sludge-based AC catalyst was fabricated in a single-step pyrolysis reaction with NaOH as the activation agent and was compared with HZSM5 zeolite in this study. The thermal decomposition and kinetics were invested via thermogravimetric analysis (TGA) for guidance and control of pyrolysis and catalytic pyrolysis and the design of the pyrolysis setup. The results indicated that the pyrolysis and catalytic pyrolysis contain four obvious stages and the main decomposition reaction occurred in the range of 200-600 °C. Coats-Redfern method was applied in the 2nd and 3rd devolatilization stages to estimate the reaction order and activation energy (E) from the mass loss data. The average activation energy (Em) values for the reaction orders n = 1, 2 and 3 were in the range of 6.67-20.37 kJ/mol for SS; 1.51-6.87 kJ/mol for HZSM5; and 2.29-9.17 kJ/mol for AC, respectively. According to the results, AC and HZSM5 both were able to improve the reaction rate of SS pyrolysis by abridging the Em value. Moreover, to generate and examine the effect of the catalysts on the quality of bio-oil, a fixed-bed pyrolysis system was designed and implemented. The composition analysis of the produced bio-oil was carried out via gas chromatography/mass spectrometry (GC/MS). The selected SS to catalyst ratios were 1:1, 2:1 and 4:1. The optimum ratio in terms of cracking the long-chain hydrocarbons and removing oxygen-containing compounds was 1:1 for both catalysts. The upgraded bio-oils with HZSM5 and AC were in the total range of C4-C17 with around 72% in the range of C4-C9. The bio-oil from pyrolysis of SS contained 49.27% oxygenated compounds while the presence of HZSM5 and AC dropped to 7.3% and 13.02%, respectively. Meanwhile, generation of value-added chemicals such as light aromatic compounds were significantly improved in the catalytic process. Furthermore, the fabricated AC catalyst was characterized by BET, SEM-EDX, FT-IR and TGA techniques. Overall, this research demonstrated that AC is an efficient catalyst in the pyrolysis of SS and can be used as a cost-competitive catalyst in contrast to HZSM5.

Keywords: Activated char, bio-oil, catalytic pyrolysis, HZSM5, sewage sludge.

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Authors: A. Belhaj Mohamed, M. Saidi, N. Boucherb, N. Ourtani, A. Soltani, I. Bouazizi, M. Ben Jrad

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Natural hydrocarbon seepage has helped petroleum exploration as a direct indicator of gas and/or oil subsurface accumulations. Surface macro-seeps are generally an indication of a fault in an active Petroleum Seepage System belonging to a Total Petroleum System. This paper describes a case study in which multiple analytical techniques were used to identify and characterize trace petroleum-related hydrocarbons and other volatile organic compounds in groundwater samples collected from Sousse aquifer (Central Tunisia). The analytical techniques used for analyses of water samples included gas chromatography-mass spectrometry (GCMS), capillary GC with flame-ionization detection, Compound Specific Isotope Analysis, Rock Eval Pyrolysis. The objective of the study was to confirm the presence of gasoline and other petroleum products or other volatile organic pollutants in those samples in order to assess the respective implication of each of the potentially responsible parties to the contamination of the aquifer. In addition, the degree of contamination at different depths in the aquifer was also of interest. The oil and gas seeps have been investigated using biomarker and stable carbon isotope analyses to perform oil-oil and oil-source rock correlations. The seepage gases are characterized by high CH4 content, very low δ13CCH4 values (-71,9 ‰) and high C1/C1–5 ratios (0.95–1.0), light deuterium–hydrogen isotope ratios (- 198 ‰) and light δ13CC2 and δ13CCO2 values (-23,8‰ and-23,8‰ respectively) indicating a thermogenic origin with the contribution of the biogenic gas. An organic geochemistry study was carried out on the more ten oil seep samples. This study includes light hydrocarbon and biomarkers analyses (hopanes, steranes, n-alkanes, acyclic isoprenoids, and aromatic steroids) using GC and GC-MS. The studied samples show at least two distinct families, suggesting two different types of crude oil origins: the first oil seeps appears to be highly mature, showing evidence of chemical and/or biological degradation and was derived from a clay-rich source rock deposited in suboxic conditions. It has been sourced mainly by the lower Fahdene (Albian) source rocks. The second oil seeps was derived from a carbonate-rich source rock deposited in anoxic conditions, well correlated with the Bahloul (Cenomanian-Turonian) source rock.

Keywords: Biomarkers, oil and gas seeps, organic geochemistry, source rock.

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Authors: Revathi S. Rajan, Pratibha Malik, Nupur Garg, Smitha Avula, Kamini A. Rao

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This study aimed to analyse the pregnancy outcomes in patients with TPO positivity after appropriate L-Thyroxin supplementation with close surveillance. All pregnant women attending the antenatal clinic at Milann-The Fertility Center, Bangalore, India- from Aug 2013 to Oct 2014 whose booking TSH was more than 2.5 mIU/L were included along with those pregnant women with prior hypothyroidism who were TPO positive. Those with TPO positive status were vigorously managed with appropriate thyroxin supplementation and the doses were readjusted every 3 to 4 weeks until delivery. Women with recurrent pregnancy loss were also tested for TPO positivity and if tested positive, were monitored serially with TSH and fT4 levels every 3 to 4 weeks and appropriately supplemented with thyroxin when the levels fluctuated. The testing was done after an informed consent in all these women. The statistical software namely SAS 9.2, SPSS 15.0, Stata 10.1, MedCalc 9.0.1, Systat 12.0 and R environment ver.2.11.1 were used for the analysis of the data. 460 pregnant women were screened for thyroid dysfunction at booking of which 52% were hypothyroid. Majority of them (31.08%) were subclinically hypothyroid and the remaining were overt. 25% of the total no. of patients screened were TPO positive. The various pregnancy complications that were observed in the TPO positive women were gestational glucose intolerance [60%], threatened abortion [21%], midtrimester abortion [4.3%], premature rupture of membranes [4.3%], cervical funneling [4.3%] and fetal growth restriction [3.5%]. 95.6% of the patients who followed up till the end delivered beyond 30 weeks. 42.6% of these patients had previous history of recurrent abortions or adverse obstetric outcome and 21.7% of the delivered babies required NICU admission. Obstetric outcomes in our study in terms of midtrimester abortions, placental abruption, and preterm delivery improved for the better after close monitoring of the thyroid hormone [TSH and fT4] levels every 3 to 4 weeks with appropriate dose adjustment throughout pregnancy. Euthyroid women with TPO positive status enrolled in the study incidentally were those with recurrent abortions/infertility and required thyroxin supplements due to elevated Thyroid hormone (TSH, fT4) levels during the course of their pregnancy. Significant associations were found with age>30 years and Hyperhomocysteinemia [p=0.017], recurrent pregnancy loss or previous adverse obstetric outcomes [p=0.067] and APLA [p=0.029]. TPO antibody levels >600 I U/ml were significantly associated with development of gestational hypertension [p=0.041] and fetal growth restriction [p=0.082]. Euthyroid women with TPO positivity were also screened periodically to counter fluctuations of the thyroid hormone levels with appropriate thyroxin supplementation. Thus, early identification along with aggressive management of thyroid dysfunction and stratification of these patients based on their TPO status with appropriate thyroxin supplementation beginning in the first trimester will aid risk modulation and also help avert complications.

Keywords: Antinuclear antibody, Subclinical hypothyroidism, Thyroxin, TPO antibody.

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Authors: Kaushik Chaudhuri

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High Performance Work Systems (HPWS) generally give rise to positive impacts on employees by increasing their commitments in workplaces. While some argued this actually have considerable negative impacts on employees with increasing possibilities of imposing strains caused by stress and intensity of such work places. Do stressful workplaces hamper employee commitment? The author has tried to find the answer by exploring linkages between HPWS practices and its impact on employees in Japanese organizations. How negative outcomes like job intensity and workplaces and job stressors can influence different forms of employees- commitments which can be a hindrance to their performance. Design: A close ended questionnaire survey was conducted amongst 16 large, medium and small sized Japanese companies from diverse industries around Chiba, Saitama, and Ibaraki Prefectures and in Tokyo from the month of October 2008 to February 2009. Questionnaires were aimed to the non managerial employees- perceptions of HPWS practices, their behavior, working life experiences in their work places. A total of 227 samples are used for analysis in the study. Methods: Correlations, MANCOVA, SEM Path analysis using AMOS software are used for data analysis in this study. Findings: Average non-managerial perception of HPWS adoption is significantly but negatively correlated to both work place Stressors and Continuous commitment, but positively correlated to job Intensity, Affective, Occupational and Normative commitments in different workplaces at Japan. The path analysis by SEM shows significant indirect relationship between Stressors and employee Affective organizational commitment and Normative organizational commitments. Intensity also has a significant indirect effect on Occupational commitments. HPWS has an additive effect on all the outcomes variables. Limitations: The sample size in this study cannot be a representative to the entire population of non-managerial employees in Japan. There were no respondents from automobile, pharmaceuticals, finance industries. The duration of the survey coincided in a period when Japan as most of the other countries is under going recession. Biases could not be ruled out completely. We must take cautions in interpreting the results of studies as they cannot be generalized. And the path analysis cannot provide the complete causality of the inter linkages between the variables used in the study. Originality: There have been limited studies on linkages in HPWS adoptions and their impacts on employees- behaviors and commitments in Japanese workplaces. This study may provide some ingredients for further research in the fields of HRM policies and practices and their linkages on different forms of employees- commitments.

Keywords: HPWS, Job Intensity, Job and workplace Stressors, Continuous commitment, Affective commitment, Occupational commitment, Japan.

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Authors: E. Nemes-Nagy, E. Fogarasi, M. Croitoru, A. Nyárádi, K. Komlódi, S. Pál, A. Kovács, O. Kopácsy, R. Tripon, Z. Fazakas, C. Uzun, Z. Simon-Szabó, V. Balogh-Sămărghițan, E. Ernő Nagy, M. Szabó, M. Tilinca

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Intense oxidative stress, increased glycated hemoglobin and mineral imbalance represent risk factors for complications in diabetic patients. Cardiovascular complications are most common in these patients, including nephropathy. This study was conducted in 2015 at the Procardia Laboratory in Tîrgu Mureș, Romania on 40 type 2 diabetic adults. Routine biochemical tests were performed on the Konleab 20XTi analyzer (serum glucose, total cholesterol, LDL and HDL cholesterol, triglyceride, creatinine, urea). We also measured serum uric acid, magnesium and calcium concentration by photometric procedures, potassium, sodium and chloride by ion selective electrode, and chromium by atomic absorption spectrometry in a group of patients. Glycated hemoglobin (HbA1c) dosage was made by reflectometry. Urine analysis was performed using the HandUReader equipment. The level of oxidative stress was measured by serum malondialdehyde dosage using the thiobarbituric acid reactive substances method. MDRD (Modification of Diet in Renal Disease) formula was applied for calculation of creatinine-derived glomerular filtration rate. GraphPad InStat software was used for statistical analysis of the data. The diabetic subject included in the study presented high MDA concentrations, showing intense oxidative stress. Calcium was deficient in 5% of the patients, chromium deficiency was present in 28%. The atherogenic cholesterol fraction was elevated in 13% of the patients. Positive correlation was found between creatinine and MDRD-creatinine values (p<0.0001), 68% of the patients presented increased creatinine values. The majority of the diabetic patients had good control of their diabetes, having optimal HbA1c values, 35% of them presented fasting serum glucose over 120 mg/dl and 18% had glucosuria. Intense oxidative stress and mineral deficiencies can increase the risk of cardiovascular complications in diabetic patients in spite of their good metabolic balance. More than two third of the patients present biochemical signs of nephropathy, cystatin C dosage and microalbuminuria could reveal better the kidney disorder, but glomerular filtration rate calculation formulas are also useful for evaluation of renal function.

Keywords: Cardiovascular risk, malondialdehyde, metabolic balance, minerals, type 2 diabetes.

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Authors: Sumanta Daw, Gopal Chandra Saha

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The present study was conducted to explore the basic pulmonary functions which may generally vary according to the bio-physical characteristics including age, height, body weight, and environment etc. of the sports performers. Regular and specific training exercises also change the characteristics of an athlete’s prowess and produce a positive effect on the physiological functioning, mostly upon cardio-pulmonary efficiency and thereby improving the body mechanism. The objective of the present study was to compare the differences in cardio-respiratory functions between aquatics and track and field performers. As cardio-respiratory functions are influenced by pulse rate and blood pressure (systolic and diastolic), so both of the factors were also taken into consideration. The component selected under cardio-respiratory functions for the present study were i) FEVI/FVC ratio (forced expiratory volume divided by forced vital capacity ratio, i.e. the number represents the percentage of lung capacity to exhale in one second) ii) FVC1 (this is the amount of air which can force out of lungs in one second) and iii) FVC (forced vital capacity is the greatest total amount of air forcefully breathe out after breathing in as deeply as possible). All the three selected components of the cardio-respiratory efficiency were measured by spirometry method. Pulse rate was determined manually. The radial artery which is located on the thumb side of our wrist was used to assess the pulse rate. Blood pressure was assessed by sphygmomanometer. All the data were taken in the resting condition. 36subjects were selected for the present study out of which 18were water polo players and rest were sprinters. The age group of the subjects was considered between 18 to 23 years. In this study the obtained data inform of digital score were treated statistically to get result and draw conclusions. The Mean and Standard Deviation (SD) were used as descriptive statistics and the significant difference between the two subject groups was assessed with the help of statistical ‘t’-test. It was found from the study that all the three components i.e. FEVI/FVC ratio (p-value 0.0148 < 0.01), FVC1 (p-value 0.0010 < 0.01) and FVC (p-value 0.0067 < 0.01) differ significantly as water polo players proved to be better in terms of cardio-respiratory functions than sprinters. Thus study clearly suggests that the exercise training as well as the medium of practice arena associated with water polo players has played an important role to determine better cardio respiratory efficiency than track and field athletes. The outcome of the present study revealed that the lung function in land-based activities may not provide much impact than that of in water activities.

Keywords: Cardio-respiratory efficiency, spirometry, water polo players, sprinters.

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Authors: Mustafa M. Donma, Orkide Donma

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Vitamin deficiencies are common in obese individuals. Particularly, the status of vitamin B12 and its association with vitamin B9 (folate) and vitamin D is under investigation in recent time. Vitamin B12 is closely related to many vital processes in the body. In clinical studies, its involvement in fat metabolism draws attention from the obesity point of view. Obesity, in its advanced stages and in combination with metabolic syndrome (MetS) findings, may be a life-threatening health problem. Pediatric obesity is particularly important, because it may be a predictor of the severe chronic diseases during adulthood period of the child. Due to its role in fat metabolism, vitamin B12 deficiency may disrupt metabolic pathways of the lipid and energy metabolisms in the body. The association of low B12 levels with obesity degree may be an interesting topic to be investigated. Obesity indices may be helpful at this point. Weight- and fat-based indices are available. Of them, body mass index (BMI) is in the first group. Fat mass index (FMI), fat-free mass index (FFMI) and diagnostic obesity notation model assessment-II (D2I) index lie in the latter group. The aim of this study is to clarify possible associations between vitamin B12 status and obesity indices in pediatric population. The study comprises a total of 122 children. 32 children were included in the normal-body mass index (N-BMI) group. 46 and 44 children constitute groups with morbid obese children without MetS and with MetS, respectively. Informed consent forms and the approval of the institutional ethics committee were obtained. Tables prepared for obesity classification by World Health Organization were used. MetS criteria were defined. Anthropometric and blood pressure measurements were taken. BMI, FMI, FFMI, D2I were calculated. Routine laboratory tests were performed. Vitamin B9, B12, D concentrations were determined. Statistical evaluation of the study data was performed. Vitamin B9 and vitamin D levels were reduced in MetS group compared to children with N-BMI (p > 0.05). Significantly lower values were observed in vitamin B12 concentrations of MetS group (p < 0.01). Upon evaluation of blood pressure as well as triglyceride levels, there exist significant increases in morbid obese children. Significantly decreased concentrations of high-density lipoprotein cholesterol were observed. All of the obesity indices and insulin resistance index exhibit increasing tendency with the severity of obesity. Inverse correlations were calculated between vitamin D and insulin resistance index as well as vitamin B12 and D2I in morbid obese groups. In conclusion, a fat-based index, D2I, was the most prominent body index, which shows strong correlation with vitamin B12 concentrations in the late stage of obesity in children. A negative correlation between these two parameters was a confirmative finding related to the association between vitamin B12 and obesity degree. 

Keywords: Body mass index, children, D2I index, fat mass index, obesity.

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Authors: S. Moustafa El Shanawany, I. Labib Salem, F. Mohamed Magdy Badr El Dine, H. Tag El Deen Abd Allah

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Thermal injuries remain a global health problem and a common issue encountered in forensic pathology. They are a devastating cause of morbidity and mortality in children and adults especially in developing countries, causing permanent disfigurement, scarring and grievous hurt. Burns have always been a matter of legal concern in cases of suicidal burns, self-inflicted burns for false accusation and homicidal attempts. Assessment of burn injuries as well as rating permanent disabilities and disfigurement following thermal injuries for the benefit of compensation claims represents a challenging problem. This necessitates the development of reliable scoring systems to yield an expected likelihood of permanent disability or fatal outcome following burn injuries. The study was designed to identify the risk factors of mortality in acute burn patients and to evaluate the applicability of FLAMES (Fatality by Longevity, APACHE II score, Measured Extent of burn, and Sex) and BOBI (Belgian Outcome in Burn Injury) model scores in predicting the outcome. The study was conducted on 100 adult patients with acute burn injuries admitted to the Burn Unit of Alexandria Main University Hospital, Egypt from October 2014 to October 2015. Victims were examined after obtaining informed consent and the data were collected in specially designed sheets including demographic data, burn details and any associated inhalation injury. Each burn patient was assessed using both BOBI and FLAMES scoring systems. The results of the study show the mean age of patients was 35.54±12.32 years. Males outnumbered females (55% and 45%, respectively). Most patients were accidently burnt (95%), whereas suicidal burns accounted for the remaining 5%. Flame burn was recorded in 82% of cases. As well, 8% of patients sustained more than 60% of total burn surface area (TBSA) burns, 19% of patients needed mechanical ventilation, and 19% of burnt patients died either from wound sepsis, multi-organ failure or pulmonary embolism. The mean length of hospital stay was 24.91±25.08 days. The mean BOBI score was 1.07±1.27 and that of the FLAMES score was -4.76±2.92. The FLAMES score demonstrated an area under the receiver operating characteristic (ROC) curve of 0.95 which was significantly higher than that of the BOBI score (0.883). A statistically significant association was revealed between both predictive models and the outcome. The study concluded that both scoring systems were beneficial in predicting mortality in acutely burnt patients. However, the FLAMES score could be applied with a higher level of accuracy.

Keywords: BOBI, Burns, FLAMES, scoring systems, outcome.

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Authors: Ernest Nweke, Enkhtuya Bavuudorj

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The harsh realities of the scandalous failure of several notable corporations in the past two decades have inextricably resulted in a surge in corporate governance studies. Nevertheless, little or no attention has been paid to corporate governance studies in Mongolian firms and much less to the comprehension of the correlation among ownership structure, corporate governance mechanisms and trend of innovative activities. Innovation is the bed rock of enterprise success. However, the funding and support for innovative activities in many firms are to a great extent determined by the incentives provided by the firm’s internal and external governance mechanisms. Mongolia is an East Asian country currently undergoing a fast-paced transition from socialist to democratic system and it is a widely held view that private ownership as against public ownership fosters innovation. Hence, following the privatization policy of Mongolian Government which has led to the transfer of the ownership of hitherto state controlled and state directed firms to private individuals and organizations, expectations are high that sufficient motivation would be provided for firm managers to engage in innovative activities. This research focuses on the relationship between ownership structure, corporate governance on one hand and the level of innovation on the hand. The paper is empirical in nature and derives data from both reliable secondary and primary sources. Secondary data for the study was in respect of ownership structure of Mongolian listed firms and innovation trend in Mongolia generally. These were analyzed using tables, charts, bars and percentages. Personal interviews and surveys were held to collect primary data. Primary data was in respect of corporate governance practices in Mongolian firms and were collected using structured questionnaire. Out of a population of three hundred and twenty (320) companies listed on the Mongolian Stock Exchange (MSE), a sample size of thirty (30) randomly selected companies was utilized for the study. Five (5) management level employees were surveyed in each selected firm giving a total of one hundred and fifty (150) respondents. Data collected were analyzed and research hypotheses tested using Chi-Square test statistic. Research results showed that corporate governance mechanisms were better and have significantly improved overtime in privately held as opposed to publicly owned firms. Consequently, the levels of innovation in privately held firms were considerably higher. It was concluded that a significant and positive relationship exists between private ownership and good corporate governance on one hand and the level of funding provided for innovative activities in Mongolian firms on the other hand.

Keywords: Corporate governance, innovation, ownership structure, stock exchange.

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Authors: Sayem Zafar, Mahmood Rahi

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Rigorous international maritime regulations are in place to limit boat and ship hydrocarbon emissions. The global sustainability goals are reducing the fuel consumption and minimizing the emissions from the ships and boats. These maritime sustainability goals have attracted a lot of research interest. Energy harvesting and storage system is designed in this study based on hybrid renewable and conventional energy systems. This energy harvesting and storage system is designed for marine applications, such as, boats and small ships. These systems can be utilized for mobile use or off-grid remote electrification. This study analyzed the use of micro power generation for boats and small ships. The energy harvesting and storage system has two distinct systems i.e. dockside shore-based system and on-board system. The shore-based system consists of a small wind turbine, photovoltaic (PV) panels, small gas turbine, hydrogen generator and high-pressure hydrogen storage tank. This dockside system is to provide easy access to the boats and small ships for supply of hydrogen. The on-board system consists of hydrogen storage tanks and fuel cells. The wind turbine and PV panels generate electricity to operate electrolyzer. A small gas turbine is used as a supplementary power system to contribute in case the hybrid renewable energy system does not provide the required energy. The electrolyzer performs the electrolysis on distilled water to produce hydrogen. The hydrogen is stored in high-pressure tanks. The hydrogen from the high-pressure tank is filled in the low-pressure tanks on-board seagoing vessels to operate the fuel cell. The boats and small ships use the hydrogen fuel cell to provide power to electric propulsion motors and for on-board auxiliary use. For shore-based system, a small wind turbine with the total length of 4.5 m and the disk diameter of 1.8 m is used. The small wind turbine dimensions make it big enough to be used to charge batteries yet small enough to be installed on the rooftops of dockside facility. The small dimensions also make the wind turbine easily transportable. In this paper, PV, sizing and solar flux are studied parametrically. System performance is evaluated under different operating and environmental conditions. The parametric study is conducted to evaluate the energy output and storage capacity of energy storage system. Results are generated for a wide range of conditions to analyze the usability of hybrid energy harvesting and storage system. This energy harvesting method significantly improves the usability and output of the renewable energy sources. It also shows that small hybrid energy systems have promising practical applications.

Keywords: Energy harvesting, fuel cell, hybrid energy system, hydrogen, wind turbine.

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Authors: Mustafa M. Donma, Orkide Donma

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Obesity is known to be associated with many clinically important diseases including metabolic syndrome (MetS). Vitamin B₁₂ plays essential roles in fat and protein metabolisms and its cooperation with vitamin B₉ is well-known. The aim of this study is to investigate the possible contributions as well as associations of these micronutrients upon obesity and MetS during childhood. A total of 128 children admitted to Namik Kemal University, Medical Faculty, Department of Pediatrics Outpatient Clinics were included into the scope of this study. The mean age±SEM of 92 morbid obese (MO) children and 36 with MetS were 118.3±3.8 months and 129.5±6.4 months, respectively (p > 0.05). The study was approved by Namık Kemal University, Medical Faculty Ethics Committee. Written informed consent forms were obtained from the parents. Demographic features and anthropometric measurements were recorded. WHO BMI-for age percentiles were used. The values above 99 percentile were defined as MO. Components of MetS [waist circumference (WC), fasting blood glucose (FBG), triacylglycerol (TRG), high density lipoprotein cholesterol (HDL-Chol), systolic pressure (SP), diastolic pressure (DP)] were determined. Routine laboratory tests were performed. Serum vitamin B₁₂ concentrations were measured using electrochemiluminescence immunoassay. Vitamin B₉ was analyzed by an immunoassay analyzer. Values for vitamin B₁₂ < 148 pmol/L, 148-221 pmol/L, > 221 pmol/L were accepted as low, borderline and normal, respectively. Vitamin B₉ levels ≤ 4 mcg/L defined deficiency state. Statistical evaluations were performed by SPSSx Version 16.0. p≤0.05 was accepted as statistical significance level. Statistically higher body mass index (BMI), WC, hip circumference (C) and neck C were calculated in MetS group compared to children with MO. No difference was noted for head C. All MetS components differed between the groups (SP, DP p < 0.001; WC, FBG, TRG p < 0.01; HDL-Chol p < 0.05). Significantly decreased vitamin B₉ and vitamin B₁₂ levels were detected (p < 0.05) in children with MetS. In both groups percentage of folate deficiency was 5.5%. No cases were below < 148 pmol/L. However, in MO group 14.3% and in MetS group 22.2% of the cases were of borderline status. In MO group B₁₂ levels were negatively correlated with BMI, WC, hip C and head C, but not with neck C. WC, hip C, head C and neck C were all negatively correlated with HDL-Chol. None of these correlations were observed in the group of children with MetS. Strong positive correlation between FBG and insulin as well as strong negative correlation between TRG and HDL-Chol detected in MO children were lost in MetS group. Deficiency state end-products of both B₉ and B₁₂ may interfere with the expected profiles of MetS components. In this study, the alterations in MetS components affected vitamin B₁₂ metabolism and also its associations with anthropometric body measurements. Further increases in vitamin B₁₂ and vitamin B₉ deficiency in MetS associated with the increased vitamin B₁₂ as well as vitamin B₉ deficiency metabolites may add to MetS parameters.

Keywords: Children, cobalamin, folate, metabolic syndrome, obesity.

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Authors: O. Adjoul, A. Feugier, K. Benfriha, A. Aoussat

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In general, issues related to design and maintenance are considered in an independent manner. However, the decisions made in these two sets influence each other. The design for maintenance is considered an opportunity to optimize the life cycle cost of a product, particularly in the nuclear or aeronautical field, where maintenance expenses represent more than 60% of life cycle costs. The design of large-scale systems starts with product architecture, a choice of components in terms of cost, reliability, weight and other attributes, corresponding to the specifications. On the other hand, the design must take into account maintenance by improving, in particular, real-time monitoring of equipment through the integration of new technologies such as connected sensors and intelligent actuators. We noticed that different approaches used in the Design For Maintenance (DFM) methods are limited to the simultaneous characterization of the reliability and maintainability of a multi-component system. This article proposes a method of DFM that assists designers to propose dynamic maintenance for multi-component industrial systems. The term "dynamic" refers to the ability to integrate available monitoring data to adapt the maintenance decision in real time. The goal is to maximize the availability of the system at a given life cycle cost. This paper presents an approach for simultaneous optimization of the design and maintenance of multi-component systems. Here the design is characterized by four decision variables for each component (reliability level, maintainability level, redundancy level, and level of monitoring data). The maintenance is characterized by two decision variables (the dates of the maintenance stops and the maintenance operations to be performed on the system during these stops). The DFM model helps the designers choose technical solutions for the large-scale industrial products. Large-scale refers to the complex multi-component industrial systems and long life-cycle, such as trains, aircraft, etc. The method is based on a two-level hybrid algorithm for simultaneous optimization of design and maintenance, using genetic algorithms. The first level is to select a design solution for a given system that considers the life cycle cost and the reliability. The second level consists of determining a dynamic and optimal maintenance plan to be deployed for a design solution. This level is based on the Maintenance Free Operating Period (MFOP) concept, which takes into account the decision criteria such as, total reliability, maintenance cost and maintenance time. Depending on the life cycle duration, the desired availability, and the desired business model (sales or rental), this tool provides visibility of overall costs and optimal product architecture.

Keywords: Availability, design for maintenance, DFM, dynamic maintenance, life cycle cost, LCC, maintenance free operating period, MFOP, simultaneous optimization.

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Authors: Bülent Dilmaç, Didem Aydoğan

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Problem Statement:Rapid technological developments of the 21st century have advanced our daily lives in various ways. Particularly in education, students frequently utilize technological resources to aid their homework and to access information. listen to radio or watch television (26.9 %) and e-mails (34.2 %) [26]. Not surprisingly, the increase in the use of technologies also resulted in an increase in the use of e-mail, instant messaging, chat rooms, mobile phones, mobile phone cameras and web sites by adolescents to bully peers. As cyber bullying occurs in the cyber space, lesser access to technologies would mean lesser cyber-harm. Therefore, the frequency of technology use is a significant predictor of cyber bullying and cyber victims. Cyber bullies try to harm the victim using various media. These tools include sending derogatory texts via mobile phones, sending threatening e-mails and forwarding confidential emails to everyone on the contacts list. Another way of cyber bullying is to set up a humiliating website and invite others to post comments. In other words, cyber bullies use e-mail, chat rooms, instant messaging, pagers, mobile texts and online voting tools to humiliate and frighten others and to create a sense of helplessness. No matter what type of bullying it is, it negatively affects its victims. Children who bully exhibit more emotional inhibition and attribute themselves more negative self-statements compared to non-bullies. Students whose families are not sympathetic and who receive lower emotional support are more prone to bully their peers. Bullies have authoritarian families and do not get along well with them. The family is the place where the children-s physical, social and psychological needs are satisfied and where their personalities develop. As the use of the internet became prevalent so did parents- restrictions on their children-s internet use. However, parents are unaware of the real harm. Studies that explain the relationship between parental attitudes and cyber bullying are scarce in literature. Thus, this study aims to investigate the relationship between cyber bullying and parental attitudes in the primary school. Purpose of Study: This study aimed to investigate the relationship between cyber bullying and parental attitudes. A second aim was to determine whether parental attitudes could predict cyber bullying and if so which variables could predict it significantly. Methods:The study had a cross-sectional and relational survey model. A demographics information form, questions about cyber bullying and a Parental Attitudes Inventory were conducted with a total of 346 students (189 females and 157 males) registered at various primary schools. Data was analysed by multiple regression analysis using the software package SPSS 16.

Keywords: Cyber bullying, cyber victim, parental attitudes, primary school students.

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Authors: C. S. Mammas, A. Lazaris, A. S. Mamma-Graham, G. Kostopanagiotou, C. Lemonidou, J. Mantas, E. Patsouris

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Introduction: The process to build a better safety culture, methods of error analysis, and preventive measures, starts with an understanding of the effects when human factors engineering refer to remote microscopic diagnosis in surgery and specially in organ transplantation for the remote evaluation of the grafts. It has been estimated that even in well-organized transplant systems an average of 8% to 14% of the grafts (G) that arrive at the recipient hospitals may be considered as diseased, injured, damaged or improper for transplantation. Digital microscopy adds information on a microscopic level about the grafts in Organ Transplant (OT), and may lead to a change in their management. Such a method will reduce the possibility that a diseased G, will arrive at the recipient hospital for implantation. Aim: Ergonomics of Digital Microscopy (DM) based on virtual slides, on Telemedicine Systems (TS) for Tele-Pathological (TPE) evaluation of the grafts (G) in organ transplantation (OT). Material and Methods: By experimental simulation, the ergonomics of DM for microscopic TPE of Renal Graft (RG), Liver Graft (LG) and Pancreatic Graft (PG) tissues is analyzed. In fact, this corresponded to the ergonomics of digital microscopy for TPE in OT by applying Virtual Slide (VS) system for graft tissue image capture, for remote diagnoses of possible microscopic inflammatory and/or neoplastic lesions. Experimentation included: a. Development of an OTE-TS similar Experimental Telemedicine System (Exp.-TS), b. Simulation of the integration of TS with the VS based microscopic TPE of RG, LG and PG applying DM. Simulation of the DM based TPE was performed by 2 specialists on a total of 238 human Renal Graft (RG), 172 Liver Graft (LG) and 108 Pancreatic Graft (PG) tissues digital microscopic images for inflammatory and neoplastic lesions on four electronic spaces of the four used TS. Results: Statistical analysis of specialist‘s answers about the ability to diagnose accurately the diseased RG, LG and PG tissues on the electronic space among four TS (A,B,C,D) showed that DM on TS for TPE in OT is elaborated perfectly on the ES of a Desktop, followed by the ES of the applied Exp.-TS. Tablet and Mobile-Phone ES seem significantly risky for the application of DM in OT (p<.001). Conclusion: To make the largest reduction in errors and adverse events referring to the quality of the grafts, it will take application of human factors engineering to procurement, design, audit, and aware ness-raising activities. Consequently, it will take an investment in new training, people, and other changes to management activities for DM in OT. The simulating VS based TPE with DM of RG, LG and PG tissues after retrieval; seem feasible and reliable and dependable on the size of the electronic space of the applied TS, for remote prevention of diseased grafts from being retrieved and/or sent to the recipient hospital and for post-grafting and pre-transplant planning.

Keywords: Organ Transplantation, Tele-Pathology, Digital Microscopy, Virtual Slides.

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Authors: Ali Reza Vaezi, Naser Fakori Ivand, Fereshteh Azarifam

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Inter-rill erosion is the detachment and transfer of soil particles between the rills which occurs due to the impact of raindrops and the shear stress of shallow surface runoff. This erosion can be affected by some soil properties such as texture, amount of organic matter and stability of soil aggregates. Information on the temporal variation of inter-rill erosion during a rainfall event and the effect of soil properties on it can help develop better methods to soil conservation in the hillslopes. The importance of this study is especially grate in semi-arid regions, where the soil is weakly aggregated and vegetation cover is mostly poor. Therefore, this research was conducted to investigate the temporal variation of surface flow and inter-rill erosion and the effect of soil properties on it in some semi-arid soils. A field experiment was done in eight different soil textures under simulated rainfalls with uniform intensity. A total of twenty four plots were installed for eight study soils with three replicates in the form of a random complete block design along the land. The plots were 1.2 m (length) × 1 m (width) in dimensions which designed with a distance of 3 m from each other across the slope. Then, soil samples were purred into the plots. Rainfall simulation experiments were done using a designed portable simulator with an intensity of 60 mm per hour for 60 minutes. Runoff production and soil loss were measured during 1 hour time with 5-min intervals. Soil properties including particle size distribution, aggregate stability, bulk density, exchangeable sodium percentages (ESP) and hydraulic conductivity (Ks) were determined in the soil samples. Correlation and regression analysis was done to determine the effect of soil properties on runoff and inter-rill erosion. Results indicated that the study soils have lower both organic matter content and aggregate stability. The soils, except for coarse textured textures, are calcareous and with relatively higher ESP. Runoff production and soil loss did not occur in sand texture, which was associated with higher infiltration and drainage rates. A strong relationship was found between inter-rill erosion and surface runoff (R2 = 0.75, p < 0.01). The correlation analysis showed that surface runoff was significantly affected by some soil properties consisting of sand, silt, clay, bulk density, gravel, Ks, lime (calcium carbonate), and ESP. The soils with lower Ks such as fine-textured soils, produced higher surface runoff and more inter-rill erosion. In the soils, surface runoff production temporally increased during rainfall and finally reached a peak after about 25-35 min. Time to peak was very short (30 min) in fine-textured soils, especially clay, which was related to their lower infiltration rate.

Keywords: Erosion plot, rainfall simulator, soil properties, surface flow.

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Authors: Mustafa M. Donma, Orkide Donma, Savas Guzel

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Iron is physiologically essential. However, it also participates in the catalysis of free radical formation reactions. Its deficiency is associated with amplified health risks. This trace element establishes some links with another physiological process related to cell death, apoptosis. Both iron deficiency and iron overload are closely associated with apoptosis. Soluble tumor necrosis factor-like weak inducer of apoptosis (sTWEAK) has the ability to trigger apoptosis and plays a dual role in the physiological versus pathological inflammatory responses of tissues. The aim of this study was to investigate the status of these parameters as well as the associations among them in children with obesity, a low-grade inflammatory state. The study was performed on groups of children with normal body mass index (N-BMI) and obesity. 43 children were included in each group. Based upon age- and sex-adjusted BMI percentile tables prepared by the World Health Organization, children whose values varied between 85 and 15 were included in N-BMI group. Children, whose BMI percentile values were between 99 and 95, comprised obese (OB) group. Institutional ethical committee approval and informed consent forms were taken prior to the study. Anthropometric measurements (weight, height, waist circumference, hip circumference, head circumference, neck circumference) and blood pressure values (systolic blood pressure and diastolic blood pressure) were recorded. Routine biochemical analyses, including serum iron, total iron binding capacity (TIBC), transferrin saturation percent (Tf Sat %) and ferritin, were performed. sTWEAK levels were determined by enzyme-linked immunosorbent assay. study data were evaluated using appropriate statistical tests performed by the statistical program SPSS. Serum iron levels were 91 ± 34 mcrg/dl and 75 ± 31 mcrg/dl in N-BMI and OB children, respectively. The corresponding values for TIBC, Tf Sat %, ferritin were 265 mcrg/dl vs. 299 mcrg/dl, 37.2 ± 19.1% vs. 26.7 ± 14.6%, and 41 ± 25 ng/ml vs 44 ± 26 ng/ml. In N-BMI and OB groups, sTWEAK concentrations were measured as 351 ng/L and 325 ng/L, respectively (p > 0.05). Correlation analysis revealed significant associations between sTWEAK levels and iron related parameters (p < 0.05) except ferritin. In conclusion, iron contributes to apoptosis. Children with iron deficiency have decreased apoptosis rate in comparison with that of healthy children. sTWEAK is an inducer of apoptosis. OB children had lower levels of both iron and sTWEAK. Low levels of sTWEAK are associated with several types of cancers and poor survival. Although iron deficiency state was not observed in this study, the correlations detected between decreased sTWEAK and decreased iron as well as Tf Sat % values were valuable findings, which point out decreased apoptosis. This may induce a proinflammatory state, potentially leading to malignancies in the future lives of OB children.

Keywords: Apoptosis, children, iron-related parameters, obesity, soluble tumor necrosis factor-like weak inducer of apoptosis.

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Authors: Y. Santosa, D. A. Rahman, C. Wulan, A. H. Mustari

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The global demand for long-tailed macaques for medical experimentation has continued to increase. Fulfillment of Indonesian export demands has been mostly from natural habitats, based on a harvesting quota. This quota has been determined according to the total catch for a given year, and not based on consideration of any demographic parameters or physical environmental factors with regard to the animal; hence threatening the sustainability of the various populations. It is therefore necessary to formulate a method for calculating a sustainable harvesting quota, based on population parameters in natural habitats. Considering the possibility of variations in habitat characteristics and population parameters, a time series observation of demographic and physical/biotic parameters, in various habitats, was performed on 13 groups of long-tailed macaques, distributed throughout the West Java, Lampung and Yogyakarta areas of Indonesia. These provinces were selected for comparison of the influence of human/tourism activities. Data on population parameters that was collected included data on life expectancy according to age class, numbers of individuals by sex and age class, and ‘ratio of infants to reproductive females’. The estimation of population growth was based on a population dynamic growth model: the Leslie matrix. The harvesting quota was calculated as being the difference between the actual population size and the MVP (minimum viable population) for each sex and age class. Observation indicated that there were variations within group size (24–106 individuals), gender (sex) ratio (1:1 to 1:1.3), life expectancy value (0.30 to 0.93), and ‘ratio of infants to reproductive females’ (0.23 to 1.56). Results of subsequent calculations showed that sustainable harvesting quotas for each studied group of long-tailed macaques, ranged from 29 to 110 individuals. An estimation model of the MVP for each age class was formulated as Log Y = 0.315 + 0.884 Log Ni (number of individual on ith age class). This study also found that life expectancy for the juvenile age class was affected by the humidity under tree stands, and dietary plants’ density at sapling, pole and tree stages (equation: Y=2.296 – 1.535 RH + 0.002 Kpcg – 0.002 Ktg – 0.001 Kphn, R2 = 89.6% with a significance value of 0.001). By contrast, for the sub-adult-adult age class, life expectancy was significantly affected by slope (equation: Y=0.377 = 0.012 Kml, R2 = 50.4%, with significance level of 0.007). The infant-toreproductive- female ratio was affected by humidity under tree stands, and dietary plant density at sapling and pole stages (equation: Y = - 1.432 + 2.172 RH – 0.004 Kpcg + 0.003 Ktg, R2 = 82.0% with significance level of 0.001). This research confirmed the importance of population parameters in determining the minimum viable population, and that MVP varied according to habitat characteristics (especially food availability). It would be difficult therefore, to formulate a general mathematical equation model for determining a harvesting quota for the species as a whole.

Keywords: Harvesting, long-tailed macaque, population, quota.

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Authors: Maha Jameal Balgoon, Gehan A. Raouf, Safaa Y. Qusti, Soad Shaker Ali

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The main cause of Alzheimer disease (AD) was believed to be mainly due to the accumulation of free radicals owing to oxidative stress (OS) in brain tissue. The mechanism of the neurotoxicity of Aluminum chloride (AlCl3) induced AD in hippocampus Albino wister rat brain tissue, the curative & the protective effects of Lipidium sativum group (LS) water extract were assessed after 8 weeks by attenuated total reflection spectroscopy ATR-IR and histologically by light microscope. ATR-IR results revealed that the membrane phospholipid undergo free radical attacks, mediated by AlCl3, primary affects the polyunsaturated fatty acids indicated by the increased of the olefinic -C=CH sub-band area around 3012 cm-1 from the curve fitting analysis. The narrowing in the half band width (HBW) of the sνCH2 sub-band around 2852 cm-1 due to Al intoxication indicates the presence of trans form fatty acids rather than gauch rotomer. The degradation of hydrocarbon chain to shorter chain length, increasing in membrane fluidity, disorder, and decreasing in lipid polarity in AlCl3 group indicated by the detected changes in certain calculated area ratios compared to the control. Administration of LS was greatly improved these parameters compared to the AlCl3 group. Al influences the Aβ aggregation and plaque formation, which in turn interferes to and disrupts the membrane structure. The results also showed a marked increase in the β-parallel and antiparallel structure, that characterize the Aβ formation in Al-induced AD hippocampal brain tissue, indicated by the detected increase in both amide I sub-bands around 1674, 1692 cm-1. This drastic increase in Aβ formation was greatly reduced in the curative and protective groups compared to the AlCl3 group and approached nearly the control values. These results supported too by the light microscope. AlCl3 group showed significant marked degenerative changes in hippocampal neurons. Most cells appeared small, shrieked and deformed. Interestingly, the administration of LS in curative and protective groups markedly decreases the amount of degenerated cells compared to the non-treated group. In addition, the intensity of congo red stained cells was decreased. Hippocampal neurons looked more/or less similar to those of control. This study showed a promising therapeutic effect of Lipidium sativum group (LS) on AD rat model that seriously overcome the signs of oxidative stress on membrane lipid and restore the protein misfolding.

Keywords: Aluminum chloride, Alzheimer’s disease, ATR-IR, Lipidium sativum.

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Authors: Mathias U. Bonet, Pericles Pilidis, Georgios Doulgeris

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A gas turbine-powered cruise Liner is scheduled to transport pilgrim passengers from Lagos-Nigeria to the Islamic port city of Jeddah in Saudi Arabia. Since the gas turbine is an air breathing machine, changes in the density and/or mass flow at the compressor inlet due to an encounter with variations in weather conditions induce negative effects on the performance of the power plant during the voyage. In practice, all deviations from the reference atmospheric conditions of 15 ^oC and 1.103 bar tend to affect the power output and other thermodynamic parameters of the gas turbine cycle. Therefore, this paper seeks to evaluate how a simple cycle marine gas turbine power plant would react under a variety of scenarios that may be encountered during a voyage as the ship sails across the Atlantic Ocean and the Mediterranean Sea before arriving at its designated port of discharge. It is also an assessment that focuses on the effect of varying aerodynamic and hydrodynamic conditions which deteriorate the efficient operation of the propulsion system due to an increase in resistance that results from some projected levels of the ship hull fouling. The investigated passenger ship is designed to run at a service speed of 22 knots and cover a distance of 5787 nautical miles. The performance evaluation consists of three separate voyages that cover a variety of weather conditions in winter, spring and summer seasons. Real-time daily temperatures and the sea states for the selected transit route were obtained and used to simulate the voyage under the aforementioned operating conditions. Changes in engine firing temperature, power output as well as the total fuel consumed per voyage including other performance variables were separately predicted under both calm and adverse weather conditions. The collated data were obtained online from the UK Meteorological Office as well as the UK Hydrographic Office websites, while adopting the Beaufort scale for determining the magnitude of sea waves resulting from rough weather situations. The simulation of the gas turbine performance and voyage analysis was effected through the use of an integrated Cranfield-University-developed computer code known as ‘Turbomatch’ and ‘Poseidon’. It is a project that is aimed at developing a method for predicting the off design behavior of the marine gas turbine when installed and operated as the main prime mover for both propulsion and powering of all other auxiliary services onboard a passenger cruise liner. Furthermore, it is a techno-economic and environmental assessment that seeks to enable the forecast of the marine gas turbine part and full load performance as it relates to the fuel requirement for a complete voyage.

Keywords:

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Authors: Lee Boudreau, Ash Kumar Khaitu, Laura A. S. MacDonald

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In April 2015, a magnitude 7.8 earthquake struck Nepal, killing, injuring, and displacing thousands of people. The earthquake also damaged water and sanitation service networks, leading to a high risk of diarrheal disease and the associated negative health impacts. In response to the disaster, the Environment and Public Health Organization (ENPHO), a Kathmandu-based non-governmental organization, worked with the Centre for Affordable Water and Sanitation Technology (CAWST), a Canadian education, training and consulting organization, to develop two training programs to educate volunteers on water, sanitation, and hygiene (WASH) needs. The first training program was intended for acute response, with the second focusing on longer term recovery. A key focus was to equip the volunteers with the knowledge and skills to formulate useful WASH advice in the unanticipated circumstances they would encounter when working in affected areas. Within the first two weeks of the disaster, a two-day acute response training was developed, which focused on enabling volunteers to educate those affected by the disaster about local WASH issues, their link to health, and their increased importance immediately following emergency situations. Between March and October 2015, a total of 19 training events took place, with over 470 volunteers trained. The trained volunteers distributed hygiene kits and liquid chlorine for household water treatment. They also facilitated health messaging and WASH awareness activities in affected communities. A three-day recovery phase training was also developed and has been delivered to volunteers in Nepal since October 2015. This training focused on WASH issues during the recovery and reconstruction phases. The interventions and recommendations in the recovery phase training focus on long-term WASH solutions, and so form a link between emergency relief strategies and long-term development goals. ENPHO has trained 226 volunteers during the recovery phase, with training ongoing as of April 2016. In the aftermath of the earthquake, ENPHO found that its existing pool of volunteers were more than willing to help those in their communities who were more in need. By training these and new volunteers, ENPHO was able to reach many more communities in the immediate aftermath of the disaster; together they reached 11 of the 14 earthquake-affected districts. The collaboration between ENPHO and CAWST in developing the training materials was a highly collaborative and iterative process, which enabled the training materials to be developed within a short response time. By training volunteers on basic WASH topics during both the immediate response and the recovery phase, ENPHO and CAWST have been able to link immediate emergency relief to long-term developmental goals. While the recovery phase training continues in Nepal, CAWST is planning to decontextualize the training used in both phases so that it can be applied to other emergency situations in the future. The training materials will become part of the open content materials available on CAWST’s WASH Resources website.

Keywords: Water and sanitation, emergency response, education and training, building resilience.

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Authors: Areej Azhar, Peter Duncan, David Edgar

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Due to a high unemployment rate among local people and a high reliance on expatriate workers, the governments in the Gulf Co-operation Council (GCC) countries have been implementing programmes of localisation (replacing foreign workers with GCC nationals). These programmes have been successful in the public sector but much less so in the private sector. However, there are now insufficient jobs for locals in the public sector and the onus to provide employment has fallen on the private sector. This paper is concerned with a study, which is a work in progress (certain elements are complete but not the whole study), investigating the effective implementation of localisation policies in four- and five-star hotels in the Kingdom of Saudi Arabia (KSA) and the United Arab Emirates (UAE). The purpose of the paper is to identify the research gap, and to present the need for the research. Further, it will explain how this research was conducted. Studies of localisation in the GCC countries are under-represented in scholarly literature. Currently, the hotel sectors in KSA and UAE play an important part in the countries’ economies. However, the total proportion of Saudis working in the hotel sector in KSA is slightly under 8%, and in the UAE, the hotel sector remains highly reliant on expatriates. There is therefore a need for research on strategies to enhance the implementation of the localisation policies in general and in the hotel sector in particular. Further, despite the importance of the hotel sector to their economies, there remains a dearth of research into the implementation of localisation policies in this sector. Indeed, as far as the researchers are aware, there is no study examining localisation in the hotel sector in KSA, and few in the UAE. This represents a considerable research gap. Regarding how the research was carried out, a multiple case study strategy was used. The four- and five-star hotel sector in KSA is one of the cases, while the four- and five-star hotel sector in the UAE is the other case. Four- and five-star hotels in KSA and the UAE were chosen as these countries have the longest established localisation policies of all the GCC states and there are more hotels of these classifications in these countries than in any of the other Gulf countries. A literature review was carried out to underpin the research. The empirical data were gathered in three phases. In order to gain a pre-understanding of the issues pertaining to the research context, Phase I involved eight unstructured interviews with officials from the Saudi Commission for Tourism and Antiquities (three interviewees); the Saudi Human Resources Development Fund (one); the Abu Dhabi Tourism and Culture Authority (three); and the Abu Dhabi Development Fund (one).

In Phase II, a questionnaire was administered to 24 managers and 24 employees in four- and five-star hotels in each country to obtain their beliefs, attitudes, opinions, preferences and practices concerning localisation. Unstructured interviews were carried out in Phase III with six managers in each country in order to allow them to express opinions that may not have been explored in sufficient depth in the questionnaire. The interviews in Phases I and III were analysed using thematic analysis and SPSS will be used to analyse the questionnaire data. It is recommended that future research be undertaken on a larger scale, with a larger sample taken from all over KSA and the UAE rather than from only four cities (i.e., Riyadh and Jeddah in KSA and Abu Dhabi and Sharjah in the UAE), as was the case in this research.

Keywords: KSA, UAE, localisation, hotels, Human Resource Management.

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Authors: P. M. Natarajan, Shambhu Kallolikar, S. Ganesh

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By size and volume of water, Ganges River basin is the biggest among the fourteen major river basins in India. By Hindu’s faith, it is the main ‘holy river’ in this nation. But, of late, the pollution load, both domestic and industrial sources are deteriorating the surface and groundwater as well as land resources and hence the environment of the Ganges River basin is under threat. Seeing this scenario, the Indian government began to reclaim this river by two Ganges Action Plans I and II since 1986 by spending Rs. 2,747.52 crores ($457.92 million). But the result was no improvement in the water quality of the river and groundwater and environment even after almost three decades of reclamation, and hence now the New Indian Government is taking extra care to rejuvenate this river and allotted Rs. 2,037 cores ($339.50 million) in 2014 and Rs. 20,000 crores ($3,333.33 million) in 2015. The reasons for the poor water quality and stinking environment even after three decades of reclamation of the river are either no treatment/partial treatment of the sewage. Hence, now the authors are suggesting a tertiary level treatment standard of sewages of all sources and origins of the Ganges River basin and recycling the entire treated water for nondomestic uses. At 20million litres per day (MLD) capacity of each sewage treatment plant (STP), this basin needs about 2020 plants to treat the entire sewage load. Cost of the STPs is Rs. 3,43,400 million ($5,723.33 million) and the annual maintenance cost is Rs. 15,352 million ($255.87 million). The advantages of the proposed exercise are: we can produce a volume of 1,769.52 million m³ of biogas. Since biogas is energy, can be used as a fuel, for any heating purpose, such as cooking. It can also be used in a gas engine to convert the energy in the gas into electricity and heat. It is possible to generate about 3,539.04 million kilowatt electricity per annum from the biogas generated in the process of wastewater treatment in Ganges basin. The income generation from electricity works out to Rs 10,617.12million ($176.95million). This power can be used to bridge the supply and demand gap of energy in the power hungry villages where 300million people are without electricity in India even today, and to run these STPs as well. The 664.18 million tonnes of sludge generated by the treatment plants per annum can be used in agriculture as manure with suitable amendments. By arresting the pollution load the 187.42 cubic kilometer (km³) of groundwater potential of the Ganges River basin could be protected from deterioration. Since we can recycle the sewage for non-domestic purposes, about 14.75km³ of fresh water per annum can be conserved for future use. The total value of the water saving per annum is Rs.22,11,916million ($36,865.27million) and each citizen of Ganges River basin can save Rs. 4,423.83/ ($73.73) per annum and Rs. 12.12 ($0.202) per day by recycling the treated water for nondomestic uses. Further the environment of this basin could be kept clean by arresting the foul smell as well as the 3% of greenhouse gages emission from the stinking waterways and land. These are the ways to reclaim the waterways of Ganges River basin from deterioration.

Keywords: Holy Ganges River, lifeline of India, wastewater treatment and management, making Ganges permanently holy.

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Authors: Natasha Bhate

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Contraception is important in helping to reduce maternal and infant mortality rates by allowing women to control the number and spacing in-between their children. It also reduces the need for unsafe abortions. Women worldwide use contraception; however, the contraceptive prevalence rate is still relatively low in Central American countries like Guatemala. There is also an unmet need for contraception in Guatemala, which is more significant in rural, indigenous women due to barriers preventing contraceptive use. The study objective was to investigate and analyse the current barriers women face, in Guatemala, Panajachel and the surrounding areas, in using contraception, with a view of identifying ways to overcome these barriers. This included exploring the contraceptive barriers women believe exist and the influence of males in contraceptive decision making. The study took place at a charity in Panajachel, Guatemala, and had a cross-sectional, qualitative design to allow an in-depth understanding of information gathered. This particular study design was also chosen to help inform the charity with qualitative research analysis, in view of their intent to create a local reproductive health programme. A semi-structured interview design, including photo facilitation to improve cross-cultural communication, with interpreter assistance, was utilized. A pilot interview was initially conducted with small improvements required. Participants were recruited through purposive and convenience sampling. The study host at the charity acted as a gatekeeper; participants were identified through attendance of the charity’s women’s-initiative programme workshops. 20 participants were selected and agreed to study participation with two not attending; a total of 18 participants were interviewed in June 2017. Interviews were audio-recorded and data were stored on encrypted memory sticks. Framework analysis was used to analyse the data using NVivo11 software. The University of Leeds granted ethical approval for the research. Religion, language, the community, and fear of sickness were examples of existing contraceptive barrier themes recognized by many participants. The influence of men was also an important barrier identified, with themes of machismo and abuse preventing contraceptive use in some women. Women from more rural areas were believed to still face barriers which some participants did not encounter anymore, such as distance and affordability of contraceptives. Participants believed that informative workshops in various settings were an ideal method of overcoming existing contraceptive barriers and allowing women to be more empowered. The involvement of men in such workshops was also deemed important by participants to help reduce their negative influence in contraceptive usage. Overall, four recommendations following this study were made, including contraceptive educational courses, a gender equality campaign, couple-focused contraceptive workshops, and further qualitative research to gain a better insight into men’s opinions regarding women using contraception.

Keywords: Barrier, contraception, machismo, religion.

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Authors: Liliia N. Butymova, Vladimir Ya Modorskii

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To ensure the gas transmittal GCU's efficient operation, leakages through the labyrinth packings (LP) should be minimized. Leakages can be minimized by decreasing the LP gap, which in turn depends on thermal processes and possible rotor vibrations and is designed to ensure absence of mechanical contact. Vibration mitigation allows to minimize the LP gap. It is advantageous to research influence of processes in the dynamic gas-structure system on LP vibrations. This paper considers influence of rotor vibrations on LP gas dynamics and influence of the latter on the rotor structure within the FSI unidirectional dynamical coupled problem. Dependences of nonstationary parameters of gas-dynamic process in LP on rotor vibrations under various gas speeds and pressures, shaft rotation speeds and vibration amplitudes, and working medium features were studied. The programmed multi-processor ANSYS CFX was chosen as a numerical computation tool. The problem was solved using PNRPU high-capacity computer complex. Deformed shaft vibrations are replaced with an unyielding profile that moves in the fixed annulus "up-and-down" according to set harmonic rule. This solves a nonstationary gas-dynamic problem and determines time dependence of total gas-dynamic force value influencing the shaft. Pressure increase from 0.1 to 10 MPa causes growth of gas-dynamic force oscillation amplitude and frequency. The phase shift angle between gas-dynamic force oscillations and those of shaft displacement decreases from 3π/4 to π/2. Damping constant has maximum value under 1 MPa pressure in the gap. Increase of shaft oscillation frequency from 50 to 150 Hz under P=10 MPa causes growth of gas-dynamic force oscillation amplitude. Damping constant has maximum value at 50 Hz equaling 1.012. Increase of shaft vibration amplitude from 20 to 80 µm under P=10 MPa causes the rise of gas-dynamic force amplitude up to 20 times. Damping constant increases from 0.092 to 0.251. Calculations for various working substances (methane, perfect gas, air at 25 ˚С) prove the minimum gas-dynamic force persistent oscillating amplitude under P=0.1 MPa being observed in methane, and maximum in the air. Frequency remains almost unchanged and the phase shift in the air changes from 3π/4 to π/2. Calculations for various working substances (methane, perfect gas, air at 25 ˚С) prove the maximum gas-dynamic force oscillating amplitude under P=10 MPa being observed in methane, and minimum in the air. Air demonstrates surging. Increase of leakage speed from 0 to 20 m/s through LP under P=0.1 MPa causes the gas-dynamic force oscillating amplitude to decrease by 3 orders and oscillation frequency and the phase shift to increase 2 times and stabilize. Increase of leakage speed from 0 to 20 m/s in LP under P=1 MPa causes gas-dynamic force oscillating amplitude to decrease by almost 4 orders. The phase shift angle increases from π/72 to π/2. Oscillations become persistent. Flow rate proved to influence greatly on pressure oscillations amplitude and a phase shift angle. Work medium influence depends on operation conditions. At pressure growth, vibrations are mostly affected in methane (of working substances list considered), and at pressure decrease, in the air at 25 ˚С.

Keywords: Aeroelasticity, labyrinth packings, oscillation phase shift, vibration.

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Authors: Mustafa M. Donma, Orkide Donma

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Obesity is a low-grade inflammatory state. Childhood obesity is a multisystem disease, which is associated with a number of complications as well as potentially negative consequences. Gender is an important universal risk factor for many diseases. Hematological indices differ significantly by gender. This should be considered during the evaluation of obese children. The aim of this study is to detect hematologic indices that differ by gender in morbid obese (MO) children. A total of 134 MO children took part in this study. The parents filled an informed consent form and the approval from the Ethics Committee of Namik Kemal University was obtained. Subjects were divided into two groups based on their genders (64 females aged 10.2±3.1 years and 70 males aged 9.8±2.2 years; p ≥ 0.05). Waist-to-hip as well as head-to-neck ratios and body mass index (BMI) values were calculated. The children, whose WHO BMI-for age and sex percentile values were > 99 percentile, were defined as MO. Hematological parameters [haemoglobin, hematocrit, erythrocyte count, mean corpuscular volume, mean corpuscular haemoglobin, mean corpuscular haemoglobin concentration, red blood cell distribution width, leukocyte count, neutrophil %, lymphocyte %, monocyte %, eosinophil %, basophil %, platelet count, platelet distribution width, mean platelet volume] were determined by the automatic hematology analyzer. SPSS was used for statistical analyses. P ≤ 0.05 was the degree for statistical significance. The groups included children having mean±SD value of BMI as 26.9±3.4 kg/m² for males and 27.7±4.4 kg/m² for females (p ≥ 0.05). There was no significant difference between ages of females and males (p ≥ 0.05). Males had significantly increased waist-to-hip ratios (0.95±0.08 vs 0.91±0.08; p=0.005) and mean corpuscular hemoglobin concentration values (33.6±0.92 vs 33.1±0.83; p=0.001) compared to those of females. Significantly elevated neutrophil (4.69±1.59 vs 4.02±1.42; p=0.011) and neutrophil-to-lymphocyte ratios (1.70±0.71 vs 1.39±0.48; p=0.004) were detected in females. There was no statistically significant difference between groups in terms of C-reactive protein values (p ≥ 0.05). Adipose tissue plays important roles during the development of obesity and associated diseases such as metabolic syndrom and cardiovascular diseases (CVDs). These diseases may cause changes in complete blood cell count parameters. These alterations are even more important during childhood. Significant gender effects on the changes of neutrophils, one of the white blood cell subsets, were observed. The findings of the study demonstrate the importance of considering gender in clinical studies. The males and females may have distinct leukocyte-trafficking profiles in inflammation. Female children had more circulating neutrophils, which may be the indicator of an increased risk of CVDs, than male children within this age range during the late stage of obesity. In recent years, females represent about half of deaths from CVDs; therefore, our findings may be the indicator of the increasing tendency of this risk in females starting from childhood.

Keywords: Children, gender, morbid obesity, neutrophil-to-lymphocyte ratio.

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Authors: Antonis Skouloudis, Georgios Deligiannakis, Panagiotis Vouros, Konstantinos Evangelinos, Ioannis Nikolaou

Abstract:

On November 15th, 2017, a catastrophic flash flood devastated the city of Mandra in Central Greece, resulting in 24 fatalities and extensive damages to the built environment and infrastructure. It was Greece’s deadliest and most destructive flood event for the past 40 years. In this paper, we examine the consequences of this event to small and medium-sized enterprises (SMEs) operating in Mandra during the flood event, which were affected by the floodwaters to varying extents. In this context, we conducted semi-structured interviews with business owners-managers of 45 SMEs located in flood inundated areas and are still active nowadays, based on an interview guide that spanned 27 topics. The topics pertained to the disaster experience of the business and business owners-managers, knowledge and attitudes towards climate change and extreme weather, aspects of disaster preparedness and related assistance needs. Our findings reveal that the vast majority of the affected businesses experienced heavy damages in equipment and infrastructure or total destruction, which resulted in business interruption from several weeks up to several months. Assistance from relatives or friends helped for the damage repairs and business recovery, while state compensations were deemed insufficient compared to the extent of the damages. Most interviewees pinpoint flooding as one of the most critical risks, and many connect it with the climate crisis. However, they are either not willing or unable to apply property-level prevention measures in their businesses due to cost considerations or complex and cumbersome bureaucratic processes. In all cases, the business owners are fully aware of the flood hazard implications, and since the recovery from the event, they have engaged in basic mitigation measures and contingency plans in case of future flood events. Such plans include insurance contracts whenever possible (as the vast majority of the affected SMEs were uninsured at the time of the 2017 event) as well as simple relocations of critical equipment within their property. The study offers fruitful insights on latent drivers and barriers of SMEs’ resilience capacity to flash flooding. In this respect, findings such as ours, highlighting tensions that underpin behavioural responses and experiences, can feed into: a) bottom-up approaches for devising actionable and practical guidelines, manuals and/or standards on business preparedness to flooding, and, ultimately, b) policy-making for an enabling environment towards a flood-resilient SME sector.

Keywords: Flash flood, small and medium-sized enterprises, organisational resilience capacity, disaster preparedness, qualitative study.

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Authors: Mustafa M. Donma, Orkide Donma

Abstract:

Childhood obesity is an important clinical problem, because it may lead to chronic diseases during the adulthood period of the individual. Obesity is a metabolic disease associated with low-grade inflammation. The liver occurs at the center of metabolic pathways. Adropin, fibroblast growth factor-21 (FGF-21) and fetuin A are hepatokines. Due to the immense participation of the liver in glucose metabolism, these liver derived factors may be associated with insulin resistance (IR), which is a phenomenon discussed within the scope of obesity problems. The aim of this study is to determine the concentrations of adropin, FGF-21 and fetuin A in childhood obesity, to point out possible differences between the obesity groups and to investigate possible associations among these three hepatokines in obese and morbid obese children. A total of 132 children were included in the study. Two obese groups were constituted. The groups were matched in terms of mean±SD values of ages. Body mass index values of the obese and morbid obese groups were 25.0±3.5 kg/m2 and 29.8±5.7 kg/m2, respectively. Anthropometric measurements including waist circumference, hip circumference, head circumference, and neck circumference were recorded. Informed consent forms were taken from the parents of the participants and the Ethics Committee of the institution approved the study protocol. Blood samples were obtained after an overnight fasting. Routine biochemical tests including glucose- and lipid-related parameters were performed. Concentrations of the hepatokines (adropin, FGF-21, fetuin A) were determined by enzyme-linked immunosorbent assay. Insulin resistance indices such as homeostasis model assessment for IR (HOMA-IR), alanine transaminase-to aspartate transaminase ratio (ALT/AST), diagnostic obesity notation model assessment laboratory index, diagnostic obesity notation model assessment metabolic syndrome index as well as obesity indices such as diagnostic obesity notation model assessment-II index, and fat mass index were calculated using the previously derived formulas. Statistical evaluation of the study data as well as findings of the study were performed by SPSS for Windows. Statistical difference was accepted significant when p < 0.05. Statistically significant differences were found for insulin, triglyceride, high density lipoprotein cholesterol levels of the groups. A significant increase was observed for FGF-21 concentrations in the morbid obese group. Higher adropin and fetuin A concentrations were observed in the same group in comparison with the values detected in the obese group (p > 0.05). There was no statistically significant difference between the ALT/AST values of the groups. In all of the remaining IR and obesity indices, significantly increased values were calculated for morbid obese children. Significant correlations were detected between HOMA-IR and each of the hepatokines. The highest one was the association with fetuin A (r = 0.373, p = 0.001). In conclusion, increased levels observed in adropin, FGF-21 and fetuin A have shown that these hepatokines possess increasing potential going from the obese to morbid obese state. Out of the correlations found with IR index, the most affected hepatokine was fetuin A, the parameter possibly used as the indicator of the advanced obesity stage.

Keywords: adropin, fetuin A, fibroblast growth factor-21, insulin resistance, pediatric obesity

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Authors: A. Appe, B. Poluparthi, L. Kasivajjula, U. Mv, S. Bagadi, P. Modi, A. Singh, H. Gunupudi, S. Troiano, J. Paul, J. Stovall, J. Yamamoto

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The necessity of data-driven decisions in healthcare strategy formulation is rapidly increasing. A reliable framework which helps identify factors impacting a healthcare provider facility or a hospital (from here on termed as facility) market share is of key importance. This pilot study aims at developing a data-driven machine learning-regression framework which aids strategists in formulating key decisions to improve the facility’s market share which in turn impacts in improving the quality of healthcare services. The US (United States) healthcare business is chosen for the study, and the data spanning 60 key facilities in Washington State and about 3 years of historical data are considered. In the current analysis, market share is termed as the ratio of the facility’s encounters to the total encounters among the group of potential competitor facilities. The current study proposes a two-pronged approach of competitor identification and regression approach to evaluate and predict market share, respectively. Leveraged model agnostic technique, SHAP (SHapley Additive exPlanations), to quantify the relative importance of features impacting the market share. Typical techniques in literature to quantify the degree of competitiveness among facilities use an empirical method to calculate a competitive factor to interpret the severity of competition. The proposed method identifies a pool of competitors, develops Directed Acyclic Graphs (DAGs) and feature level word vectors, and evaluates the key connected components at the facility level. This technique is robust since it is data-driven, which minimizes the bias from empirical techniques. The DAGs factor in partial correlations at various segregations and key demographics of facilities along with a placeholder to factor in various business rules (for e.g., quantifying the patient exchanges, provider references, and sister facilities). Identified are the multiple groups of competitors among facilities. Leveraging the competitors' identified developed and fine-tuned Random Forest Regression model to predict the market share. To identify key drivers of market share at an overall level, permutation feature importance of the attributes was calculated. For relative quantification of features at a facility level, incorporated SHAP, a model agnostic explainer. This helped to identify and rank the attributes at each facility which impacts the market share. This approach proposes an amalgamation of the two popular and efficient modeling practices, viz., machine learning with graphs and tree-based regression techniques to reduce the bias. With these, we helped to drive strategic business decisions.

Keywords: Competition, DAGs, hospital, healthcare, machine learning, market share, random forest, SHAP.

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Authors: Orkide Donma, Mustafa M. Donma

Abstract:

Childhood obesity, which may lead to increased risk for heart diseases in children as well as adults, is one of the most important health problems throughout the world. Prevalences of morbid obesity and metabolic syndrome (MetS) are being increased during childhood age group. MetS is a cluster of metabolic and vascular abnormalities including hypercoagulability and an increased risk of cardiovascular diseases (CVDs). There are also some relations between some components of MetS and leukocytes. The aim of this study is to investigate complete blood cell count parameters that differ between morbidly obese boys and girls with MetS diagnosis. A total of 117 morbid obese children with MetS consulted to Department of Pediatrics in Faculty of Medicine Hospital at Namik Kemal University were included into the scope of the study. The study population was classified based upon their genders (60 girls and 57 boys). Their heights and weights were measured and body mass index (BMI) values were calculated. WHO BMI-for age and sex percentiles were used. The values above 99 percentile were defined as morbid obesity. Anthropometric measurements were performed. Waist-to-hip and head-to-neck ratios as well as homeostatic model assessment of insulin resistance (HOMA-IR) were calculated. Components of MetS (central obesity, glucose intolerance, high blood pressure, high triacylglycerol levels, low levels of high density lipoprotein cholesterol) were determined. Hematological variables were measured. Statistical analyses were performed using SPSS. The degree for statistical significance was p ≤ 0.05. There was no statistically significant difference between the ages (11.2±2.6 years vs 11.2±3.0 years) and BMIs (28.6±5.2 kg/m² vs 29.3±5.2 kg/m²) of boys and girls (p ≥ 0.05), respectively. Significantly increased waist-to-hip ratios were obtained for boys (0.94±0.08 vs 0.91±0.06; p=0.023). Significantly elevated values of hemoglobin (13.55±0.98 vs 13.06±0.82; p=0.004), mean corpuscular hemoglobin concentration (33.79±0.91 vs 33.21±1.14; p=0.003), eosinophils (0.300±0.253 vs 0.196±0.197; p=0.014), and platelet (347.1±81.7 vs 319.0±65.9; p=0.042) were detected for boys. There was no statistically significant difference between the groups in terms of neutrophil/lymphocyte ratios as well as HOMA-IR values (p ≥ 0.05). Statistically significant gender-based differences were found for hemoglobin as well as mean corpuscular hemoglobin concentration and hence, separate reference intervals for two genders should be considered for these parameters. Eosinophils may contribute to the development of thrombus in acute coronary syndrome. Eosinophils are also known to make an important contribution to mechanisms related to thrombosis pathogenesis in acute myocardial infarction. Increased platelet activity is observed in patients with MetS and these individuals are more susceptible to CVDs. In our study, elevated platelets described as dominant contributors to hypercoagulability and elevated eosinophil counts suggested to be related to the development of CVDs observed in boys may be the early indicators of the future cardiometabolic complications in this gender.

Keywords: Children, complete blood count, gender, metabolic syndrome.

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Authors: Milada Krejci, Martin Hill, Vaclav Hosek, Dobroslava Jandova, Jiri Kajzar, Pavel Blaha

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The paper declares effects of exercise intervention of the research project “Basic research of balance changes in seniors”, granted by the Czech Science Foundation. The objective of the presented study is to define predictors, which influence bio-psycho-social consequences and effects of balance ability in senior 65 years old and above. We focused on the Fall-Efficacy Scale changes evaluation in seniors. Comprehensive hypothesis of the project declares, that motion uncertainty (dyskinesia) can negatively affect the well-being of a senior in bio-psycho-social context. In total, random selection and testing of 100 seniors (30 males, 70 females) from Prague and Central Bohemian region was provided. The sample was divided by stratified random selection into experimental and control groups, who underwent input and output testing. For diagnostics the methods of Medical Anamnesis, Functional anthropological examinations, Tinetti Balance Assessment Tool, SF-36 Health Survey, Anamnestic comparative self-assessment scale were used. Intervention method called "Life in Balance" based on yoga techniques was applied in four-week cycle. Results of multivariate regression were verified by repeated measures ANOVA: subject factor, phase of intervention (between-subject factor), body fluid (within-subject factor) and phase of intervention × body fluid interaction). ANOVA was performed with a repetition involving the factors of subjects, experimental/control group, phase of intervention (independent variable), and x phase interaction followed by Bonferroni multiple comparison assays with a test strength of at least 0.8 on the probability level p < 0.05. In the paper results of the first-year investigation of the three years running project are analysed. Results of balance tests confirmed no significant difference between females and males in pre-test. Significant improvements in balance and walking ability were observed in experimental group in females comparing to males (F = 128.4, p < 0.001). In the females control group, there was no significant change in post- test, while in the female experimental group positive changes in posture and spine flexibility in post-tests were found. It seems that females even in senior age react better to incentives of intervention in balance and spine flexibility. On the base of results analyses, we can declare the significant improvement in social balance markers after intervention in the experimental group (F = 10.5, p < 0.001). In average, seniors are used to take four drugs daily. Number of drugs can contribute to allergy symptoms and balance problems. It can be concluded that static balance and walking ability of seniors according Tinetti Balance scale correlate significantly with psychic and social monitored markers.

Keywords: Exercises, balance, seniors 65+, health, mental and social balance.

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