Barriers to Elderly Health Care in the Occupied Palestinian Territories.

This study examined different barriers to the access and utilization of primary health care services by the elderly in the occupied Palestinians territories. We collected quantitative data from a larger convenience sample of a national survey of 1299 persons in the occupied Palestinian territories (oPt) that examined the effects of Israel's colonization and its effects on health care delivery between October 2021 and February 2022. The research tool was based on the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) questionnaire. The data was obtained from 76 elderly participants with a mean age of 68.33 years standard deviation (SD = 7.09 years). The majority (75%) reported having at least one chronic health issue and having limited access to health care. They had all finished at least six years of education. The participants claimed having health insurance, while 47.4 percent reported paying for out-of-pocket expenses and medical care was a burden. Access and affordability of health care was a problem for 70 percent of participants. Older persons and their families face access to care issues created by political, geographic, and economic barriers. Poor incomes, war-like conditions, a weak health care system, and a lack of comprehensive care delivery all impact their health.

Proteomic-based stratification of intermediate-risk prostate cancer patients.

Gleason grading is an important prognostic indicator for prostate adenocarcinoma and is crucial for patient treatment decisions. However, intermediate-risk patients diagnosed in the Gleason grade group (GG) 2 and GG3 can harbour either aggressive or non-aggressive disease, resulting in under- or overtreatment of a significant number of patients. Here, we performed proteomic, differential expression, machine learning, and survival analyses for 1,348 matched tumour and benign sample runs from 278 patients. Three proteins (F5, TMEM126B, and EARS2) were identified as candidate biomarkers in patients with biochemical recurrence. Multivariate Cox regression yielded 18 proteins, from which a risk score was constructed to dichotomize prostate cancer patients into low- and high-risk groups. This 18-protein signature is prognostic for the risk of biochemical recurrence and completely independent of the intermediate GG. Our results suggest that markers generated by computational proteomic profiling have the potential for clinical applications including integration into prostate cancer management.

Creutzfeldt-Jakob disease in a post-COVID-19 patient: did SARS-CoV-2 accelerate the neurodegeneration?

Background: Creutzfeldt-Jakob disease (CJD) is a rare, fatal neurodegenerative disorder, with few months as a usual duration from onset to death. Case presentation: In this case report, a patient of Sporadic CJD (sCJD) who presented one month after severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) infection. The diagnosis of this case was established after confirming findings from clinical, neurophysiology, radiological, and laboratory features of this disease. Conclusion: Putting in mind all the updated data on the pathogenesis of CJD and the immune responses to SARS-CoV-2, we can suggest that COVID-19 can lead to accelerated pathogenesis and exaggerated manifestations of this fatal neurodegenerative disease.

Post-COVID isolated subclavian artery dissection with multiple cerebral infarctions.

Background: Coronavirus disease 2019 (COVID-19) is a pandemic disease which predominantly affects the respiratory system with high critical care mortality and morbidity, yet it also causes multiple organs dysfunction in affected patients. There is a strong evidence that it increases the susceptibility of cerebrovascular strokes in such patients. Besides this prothrombotic complication, arterial dissection can be one of its mechanisms increasing the risks of stroke. Case presentation: Herein, we report a case of spontaneous isolated subclavian artery dissection in a COVID-19 patient. Sixty-one-year-old female presented with spontaneous isolated subclavian artery dissection without any traumatic events nor history of connective tissue disorders. She had left upper limb ischemia followed by cerebellar, thalamic and occipital infarctions. Whether this patient's subclavian artery dissection was triggered by exaggerated inflammatory response or arteriopathy secondary to COVID-19 remains speculative. Conclusions: Nonetheless, arterial dissection can be one of its complications, it is essential for treating physicians to be attentive for the diversity of COVID-19 clinical manifestations.

Sinus arrest following acute lateral medullary infarction.

Lateral medullary syndrome (LMS) is an ischemic stroke of the medulla oblongata that involves the territory of the posterior inferior cerebellar artery. LMS is often missed as the cause of autonomic dysregulation in patients with recent brain stem stroke. Due to the location of the nucleus tractus solitarius (NTS), the dorsal vagal nucleus, and the nucleus ambiguous in the lateral medulla oblongata, patients with LMS occasionally have autonomic dysregulation-associated clinical manifestations. We report a case of LMS-associated autonomic dysregulation. The case presented by recurrent syncope, requiring permanent pacemaker placement. This case shows the importance of recognizing LMS as a potential cause of life-threatening arrhythmias, heart block, and symptomatic bradycardia. Extended cardiac monitoring should be considered for patients with medullary strokes.

'Most nurses in the rural or remote health clinics run away from their job due to no remote allowances and poor working equipment and environment'. Health professional leaders' perception of shortages in the nursing workforce in underserved areas in Vanuatu.

INTRODUCTION: Health professional leaders are key informants working at senior levels in various health facilities in the areas of policies and planning processes, and human resources. This study explores the factors affecting the nursing shortage in Vanuatu and recommends measures and interventions to resolve the shortage. METHODS: A qualitative study was used to collect data from 12 health professional leaders using focus group discussion in three randomly selected hospitals in Vanuatu. The qualitative data were collected using a semi-structured, open-ended questionnaire and were audio-recorded. The data were translated and transcribed, and then analysed using thematic analysis. RESULTS: Four themes were identified: inadequate planning, increased population growth, nurse turnover and proposed strategies to resolve nursing shortages. Subthemes for inadequate planning were inadequate policy and human resources planning, and inadequate enrolment. Subthemes for increased population growth were demographics and burden of disease. Subthemes for nurse turnover were job dissatisfaction, absenteeism and increased medical problems. Subthemes for proposed strategies to resolve the nursing shortage were increased enrolment, infrastructure and capacity building. CONCLUSION: The present study identified key factors affecting current nursing workforce shortages and the recommended measures and interventions to resolve nursing shortages. The findings will assist policymakers to refine and develop relevant policies to address and strengthen the Vanuatu Ministry of Health nursing workforce.

A Closer Look at Precision Hard Turning of AISI4340: Multi-Objective Optimization for Simultaneous Low Surface Roughness and High Productivity.

This article reports an extended investigation into the precision hard turning of AISI 4340 alloy steel when machined by two different types of inserts: wiper nose and conventional round nose. It provides a closer look at previously published work and aims at determining the optimal process parameters for simultaneously minimizing surface roughness and maximizing productivity. In the mathematical models developed by the authors, surface roughness at different cutting speeds, depths of cut and feed rates is treated as the objective function. Three robust multi-objective techniques, (1) multi-objective genetic algorithm (MOGA), (2) multi-objective Pareto search algorithm (MOPSA) and (3) multi-objective emperor penguin colony algorithm (MOEPCA), were used to determine the optimal turning parameters when either the wiper or the conventional insert is used, and the results were experimentally validated. To investigate the practicality of the optimization algorithms, two turning scenarios were used. These were the machining of the combustion chamber of a gun barrel, first with an average roughness (Ra) of 0.4 µm and then with 0.8 µm, under conditions of high productivity. In terms of the simultaneous achievement of both high surface quality and productivity in precision hard turning of AISI 4340 alloy steel, this work illustrates that MOPSA provides the best optimal solution for the wiper insert case, and MOEPCA results are the best for the conventional insert. Furthermore, the results extracted from Pareto front plots show that the wiper insert is capable of successfully meeting both the requirements of Ra values of 0.4 µm and 0.8 µm and high productivity. However, the conventional insert could not meet the 0.4 µm Ra requirement; the recorded global minimum was Ra = 0.454 µm, which reveals the superiority of the wiper compared to the conventional insert.

Rhino-orbito-cerebral mucormycosis during the COVID-19 third wave in 2021: an Egyptian preliminary report from a single tertiary hospital.

COVID-19 is a pandemic disease which predominantly affects the respiratory system with high critical care mortality and morbidity; however, it also causes multi-organ dysfunction in a subset of patients. Although causality between COVID-19 and mucormycosis remains unclear, many factors including glucocorticoids, worsening of blood glucose control, and viral-induced lymphopenia have been attributed to cause mucormycosis in patients with COVID-19. In COVID-19 patients, especially those who need oxygen support, inflammatory and cytokine storm or usage of steroids make the immune system weak. This may pave the way for opportunistic infections including mucormycosis. We report fourteen cases of COVID-19 infection, who developed rhino-orbito-cerebral mucormycosis, during treatment. Early recognition of this life-threatening infection is the key to allow for optimal treatment and improved outcomes.

Preimaging and Postimaging of Graft and Flap in Head and Neck Reconstruction.

Head and neck reconstructive surgical techniques are complex; now the microvascular free tissue transfer is the most frequently used. The postreconstruction imaging interpretation is challenging due to the altered anatomy and flap variability. We aim to improve radiologists' knowledge with diverse methods of flap reconstruction for an accurate appreciation of their expected cross-sectional imaging appearance and early detection of tumor recurrence and other complication.

Fundamental Investigation into Tool Wear and Surface Quality in High-Speed Machining of Ti6Al4V Alloy.

This paper reports a fundamental investigation consisting of systematic trials into the response of Ti6Al4V alloy to high-speed machining using carbide inserts. It is a useful extension to work previously published, and aims at assessing the impact of the process parameters, depth of cut, cutting speed and feed rate in addition to cutting length, and their interrelations, on observed crater and flank wear and roughness of the machined surface. The results showed that abrasion was the most important flank wear mechanism at high speed. It also showed that increased cutting length accelerated crater wear more than exhibited flank wear and had considerable effect on surface roughness. In particular, crater wear increased by over 150% (on average), and flank wear increased by 40% (on average) when increasing cutting length from 40 to 120 mm. However, cutting the same length increased surface roughness by 50%, which helps explain how progression of tool wear leads to deteriorated surface quality. ANOVA was used to perform statistical analyses of the measured data and revealed that cutting length and depth of cut had the greatest effect on both crater and flank wear of the cutting tool. These results confirm that high-speed machining of Ti6Al4V alloy is a reliable process, with cutting speed identified as having a relatively small influence on the tool wear and resultant roughness of the machined surface relative to other parameters.

Empagliflozin and neohesperidin protect against methotrexate-induced renal toxicity via suppression of oxidative stress and inflammation in male rats.

Kidney injury from chemotherapy is one of the worsening problems associated with methotrexate (MTX) use. This work aims to examine the nephroprotective effects of empagliflozin (EMPA) and neohesperidin dihydrochalcone (NHD) provoked by MTX. A rat model was implemented by a single administration of MTX (20 mg/kg, i.p.). EMPA and NHD were administered in two doses (10 and 30 mg/kg, p.o.) and (40 and 80 mg/kg, p.o.), respectively for 14 consecutive days, using N-acetylcysteine (150 mg/kg, p.o.) as a reference standard. Pretreatment with EMPA and NHD showed significant attenuation in the renal function biomarkers, histopathological abrasions, and renal oxidative parameters. Also, EMPA and NHD pretreatment produced marked reductions in the expression of IL-6 and TNF-α level as proinflammatory biomarkers. Furthermore, EMPA and NHD pretreatment revealed marked decreases in the expression level of NF-ĸB, Keap1, HSP70, and caspase-3 and notable increases in Nrf2, PPARγ and HO-1 expression levels. EMPA and NHD can constrain oxidative stress liberation, inflammatory mediators proliferation, and apoptotic reactions in the renal tissue, which may be promising for further clinical applications to protect against MTX-induced renal injury or at least to reduce its adverse effects.

Breast-Gynaecological & Immuno-Oncology International Cancer Conference (BGICC) Consensus and Recommendations for the Management of Triple-Negative Breast Cancer.

Background: The management of patients with triple-negative breast cancer (TNBC) is challenging with several controversies and unmet needs. During the 12th Breast-Gynaecological & Immuno-oncology International Cancer Conference (BGICC) Egypt, 2020, a panel of 35 breast cancer experts from 13 countries voted on consensus guidelines for the clinical management of TNBC. The consensus was subsequently updated based on the most recent data evolved lately. Methods: A consensus conference approach adapted from the American Society of Clinical Oncology (ASCO) was utilized. The panellists voted anonymously on each question, and a consensus was achieved when ≥75% of voters selected an answer. The final consensus was later circulated to the panellists for critical revision of important intellectual content. Results and conclusion: These recommendations represent the available clinical evidence and expert opinion when evidence is scarce. The percentage of the consensus votes, levels of evidence and grades of recommendation are presented for each statement. The consensus covered all the aspects of TNBC management starting from defining TNBC to the management of metastatic disease and highlighted the rapidly evolving landscape in this field. Consensus was reached in 70% of the statements (35/50). In addition, areas of warranted research were identified to guide future prospective clinical trials.

RETRACTED: Empagliflozin and neohesperidin mitigate methotrexate hepatotoxicity via Nrf2/PPARγ/HO-1 signalling initiation and suppression of NF-κB/Keap1/HSP70/caspase-3 axis in rats.

This article has been retracted: please see Elsevier Policy on Article Withdrawal (http://www.elsevier.com/locate/withdrawalpolicy). This article has been retracted at the request of the Editor-in-Chief. A reader reported several mistakes in the paper including duplicated images in Figures 9 and 10, incorrect names of primer sequences and reference gene, as well as unclear description of the statistical analysis. The authors requested that a corrigendum be published, however, due to the large number of corrections applied, it cannot be concluded that these changes would not alter the conclusions of the paper. The scientific community takes a very strong view on this matter and apologies are offered to readers of the journal that this was not detected during the submission process.

Effect of Different Cooling Strategies on Surface Quality and Power Consumption in Finishing End Milling of Stainless Steel 316.

In this paper, an experimental investigation into the machinability of AISI 316 alloy during finishing end milling operation under different cooling conditions and with varying process parameters is presented. Three environmental-friendly cooling strategies were utilized, namely, dry, minimal quantity lubrication (MQL) and MQL with nanoparticles (Al2O3), and the variable process parameters were cutting speed and feed rate. Power consumption and surface quality were utilized as the machining responses to characterize the process performance. Surface quality was examined by evaluating the final surface roughness and surface integrity of the machined surface. The results revealed a reduction in power consumption when MQL and MQL + Al2O3 strategies were applied compared to the dry case by averages of 4.7% and 8.6%, respectively. Besides, a considerable reduction in the surface roughness was noticed with average values of 40% and 44% for MQL and MQL + Al2O3 strategies, respectively, when compared to the dry condition. At the same time, the reduction in generated surface roughness obtained by using MQL + Al2O3 condition was marginal (5.9%) compared with using MQL condition. Moreover, the results showed that the improvement obtained in the surface quality when using MQL and MQL + Al2O3 coolants increased at higher cutting speed and feed rate, and thus, higher productivity can be achieved without deteriorating final surface quality, compared to dry conditions. From scanning electron microscope (SEM) analysis, debris, furrows, plastic deformation irregular friction marks, and bores were found in the surface texture when machining under dry conditions. A slight smoother surface with a nano-polishing effect was found in the case of MQL + Al2O3 compared to the MQL and dry cooling strategies. This proves the effectiveness of lubricant with nanoparticles in reducing the friction and thermal damages on the machined surface as the friction marks were still observed when machining with MQL comparable with the case of MQL + Al2O3.

The first BGICC consensus and recommendations for breast cancer awareness, early detection and risk reduction in low- and middle-income countries and the MENA region.

In low-middle income countries (LMICs) and the Middle East and North Africa (MENA) region, there is an unmet need to establish and improve breast cancer (BC) awareness, early diagnosis and risk reduction programs. During the 12th Breast, Gynecological & Immuno-oncology International Cancer Conference - Egypt 2020, 26 experts from 7 countries worldwide voted to establish the first consensus for BC awareness, early detection and risk reduction in LMICs/MENA region. The panel advised that there is an extreme necessity for a well-developed BC data registries and prospective clinical studies that address alternative modalities/modified BC screening programs in areas of limited resources. The most important recommendations of the panel were: (a) BC awareness campaigns should be promoted to public and all adult age groups; (b) early detection programs should combine geographically distributed mammographic facilities with clinical breast examination (CBE); (c) breast awareness should be encouraged; and (d) intensive surveillance and chemoprevention strategies should be fostered for high-risk women. The panel defined some areas for future clinical research, which included the role of CBE and breast self-examination as an alternative to radiological screening in areas of limited resources, the interval and methodology of BC surveillance in women with increased risk of BC and the use of low dose tamoxifen in BC risk reduction. In LMICs/MENA region, BC awareness and early detection campaigns should take into consideration the specific disease criteria and the socioeconomic status of the target population. The statements with no consensus reached should serve as potential catalyst for future clinical research.

Comparative Evaluation of Surface Quality, Tool Wear, and Specific Cutting Energy for Wiper and Conventional Carbide Inserts in Hard Turning of AISI 4340 Alloy Steel.

This paper presents an experimental study into the comparative response of wiper and round-nose conventional carbide inserts coated with TiCN + AL2O3 + TiN when turning an AISI 4340 steel alloy. The optimal process parameters, as identified by pre-experiments, were used for both types of inserts to determine the machined surface quality, tool wear, and specific cutting energy for different cutting lengths. The wiper inserts provided a substantial improvement in the attainable surface quality compared with the results obtained using conventional inserts under optimal cutting conditions for the entire range of the machined lengths. In addition, the conventional inserts showed a dramatic increase in roughness with an increased length of the cut, while the wiper inserts showed only a minor increase for the same length of cut. A scanning electron microscope was used to examine the wear for both types of inserts. Conventional inserts showed higher trends for both the average and maximum flank wear with cutting length compared to the wiper inserts, except for lengths of 200-400 mm, where conventional inserts showed less average flank wear. A higher accumulation of deposited chips was observed on the flank face of the wiper inserts than the conventional inserts. The experimental results demonstrated that edge chipping was the chief tool wear mechanism on the rake face for both types of insert, with more edge chipping observed in the case of the conventional inserts than the wiper inserts, with negligible evidence of crater wear in either case. The wiper inserts were shown to have a higher specific cutting energy than those detected with conventional inserts. This was attributed to (i) the irregular nose feature of the wiper inserts differing from the simpler round nose geometry of the conventional inserts and (ii) a higher tendency of chip accumulation on the wiper inserts.

On the Assessment of Surface Quality and Productivity Aspects in Precision Hard Turning of AISI 4340 Steel Alloy: Relative Performance of Wiper vs. Conventional Inserts.

This article reports an experimental assessment of surface quality generated in the precision turning of AISI 4340 steel alloy using conventional round and wiper nose inserts for different cutting conditions. A three-factor (each at 4 levels) full factorial design of experiment was followed for feed rate, cutting speed, and depth of cut, with resulting machined surface quality characterized by resulting average roughness (Ra). The results show that, for the provided range of cutting conditions, lower surface roughness values were obtained using wiper inserts compared with conventional inserts, indicating a superior performance. When including the type of insert as a qualitative factor, ANOVA revealed that the type of insert was most important in determining surface roughness and material removal rate, with feed rate as the second most significant, followed by the interaction of feed rate and type of insert. It was found that using wiper inserts allowed simultaneous increases in feed rate, cutting speed, and depth of cut, while providing better surface quality of lower Ra, compared to the global minimum value that could be achieved using the conventional insert. These findings show that wiper inserts produce better surface quality and a material removal rate up to ten times higher than that obtained with conventional inserts. This clearly indicates the tremendous advantages of high surface quality and productivity that wiper inserts can offer when compared with the conventional round nose type in precision hard turning of AISI 4340 alloy steel.

Multi-Response Optimization in High-Speed Machining of Ti-6Al-4V Using TOPSIS-Fuzzy Integrated Approach.

Titanium alloys are widely used in various applications including biomedicine, aerospace, marine, energy, and chemical industries because of their superior characteristics such as high hot strength and hardness, low density, and superior fracture toughness and corrosion resistance. However, there are different challenges when machining titanium alloys because of the high heat generated during cutting processes which adversely affects the product quality and process performance in general. Thus, optimization of the machining conditions while machining such alloys is necessary. In this work, an experimental investigation into the influence of different cutting parameters (i.e., depth of cut, cutting length, feed rate, and cutting speed) on surface roughness (Rz), flank wear (VB), power consumption as well as the material removal rate (MRR) during high-speed turning of Ti-6Al-4V alloy is presented and discussed. In addition, a backpropagation neural network (BPNN) along with the technique for order of preference by similarity to ideal solution (TOPSIS)-fuzzy integrated approach was employed to model and optimize the overall cutting performance. It should be stated that the predicted values for all machining outputs demonstrated excellent agreement with the experimental values at the selected optimal solution. In addition, the selected optimal solution did not provide the best performance for each measured output, but it achieved a balance among all studied responses.

Towards Optimization of Surface Roughness and Productivity Aspects during High-Speed Machining of Ti-6Al-4V.

Nowadays, titanium alloys are achieving a significant interest in the field of aerospace, biomedical, automobile industries especially due to their extremely high strength to weight ratio, corrosive resistance, and ability to withstand higher temperatures. However, titanium alloys are well known for their higher chemical reactive and low thermal conductive nature which, in turn, makes it more difficult to machine especially at high cutting speeds. Hence, optimization of high-speed machining responses of Ti-6Al-4V has been investigated in the present study using a hybrid approach of multi-objective optimization based on ratio analysis (MOORA) integrated with regression and particle swarm approach (PSO). This optimization approach is employed to offer a balance between achieving better surface quality with maintaining an acceptable material removal rate level. The position of global best suggested by the hybrid optimization approach was: Cutting speed 194 m/min, depth of cut of 0.1 mm, feed rate of 0.15 mm/rev, and cutting length of 120 mm. It should be stated that this solution strikes a balance between achieving lower surface roughness in terms of Ra and Rq, with reaching the highest possible material removal rate. Finally, an investigation of the tool wear mechanisms for three studied cases (i.e., surface roughness based, productivity-based, optimized case) is presented to discuss the effectiveness of each scenario from the tool wear perspective.