variation

Purpose:Accurate patient positioning is crucial in radiation therapy. To fully benefit from the preciseness of proton therapy, image guided patient positioning and verification system is typically utilized in proton therapy. The purpose of this study is to evaluate the inter-observer variability of image alignment using a commercially available patient positioning and verification system in proton therapy. Methods:The VeriSuite patient positioning and verification system (MedCom GmbH, Darmstadt, Germany) provides a six degrees of freedom correction vector by registering two orthogonal x-ray images to digitally reconstructed radiograph (DRR) images that are rendered in real time from the planning computed tomography (CT) images. Six cases of various disease sites, including brain, head & neck, lung, prostate, pelvis, and bladder, were used in this study. For each case, the planning CT images and a daily orthogonal x-ray portal image pair were loaded into the VeriSuite system. The same set of x-ray images and CT images for each case were reviewed and aligned separately by each of the 10 radiation therapist, following the clinical procedure for the corresponding disease site. The resulting correction vectors were then recorded and analyzed. Results:Our study shows that the inter-observer variation (One standard deviation) in image alignment using the VeriSuite system ranged from 1.2 to 2.0 mm for translational correction and from 0.6 to 1.3 degrees for rotational correction for the six cases. The use of fiducial markers for prostate patient alignment achieved the least inter-observer variation while the bladder case produced the largest. Conclusions:Inter-observer variation in image alignment could be relatively large, depending on the complexity of patient anatomy, image alignment approach, and user experience and software limitations. Automatic registration and fiducial markers could potentially be used to align patient more accurately and consistently. To ensure adequate tumor coverage in proton therapy, inter-observer variability in patient alignment should be carefully evaluated and accounted for in patient setup uncertainty analysis and treatment planning margin determination.

Before discussing the crux of the matter, it is important to understand what “wild” signifies and the characteristics that define a wild animal. As contrasted to domesticated animals, a wild animal can be defined as an animal living freely in his natural habitat, independently of Man. These animals are only exposed to variations in the biological equilibrium, to the imperatives of their genetic program and live in a habitat that gives them the possibility of expressing it themselves. However, this definition is very narrow as there exist a number of species of wild animals that don’t live freely in their natural habitat. These animals are constrained by Man, who by creating a relationship of dependence, controls them and in turn becomes responsible for their sustenance. In such a situation, their habitat is no more their natural habitat but than which has been imposed on them by Man; such animals are said to be “held in captivity” or even “tamed”. In short, when talking about law and ethics related to wild animals, there are two things to be taken into account: wild animals that live in the wild and wild animals that live held in captivity by Man.

A survey was carried out to determine the prevalence and seasonal variations of eggs of gastrointestinal nematodes in goats in four provinces of Mozambique, from November 2016 to October 2017 in Tete and Cabo Delgado, and from November 2016 to October 2018 in Maputo and Gaza. In each province, flocks were selected from both lowlands, located within the valleys of the rivers, and uplands which are located outside the valleys. Faecal samples were collected at monthly intervals to monitor faecal egg counts fluctuations. The modified McMaster technique was used for quantitative analysis of nematode eggs and for detecting cestode eggs in faecal samples. The sedimentation technique for detecting trematode eggs in faecal samples was used. A total of 2 703 samples were examined for nematode eggs and 2 587 for trematode eggs. Faecal examination indicated that between 18% and 100% of goats sampled were infected with gastro-intestinal nematodes. The prevalence varied according to the season of the year and the ecological conditions. The highest prevalence and worm egg counts were recorded at about the peak of the rainy season. Strongyloides papillosus, Calicophoron spp., Fasciola spp. and Schistosoma mattheei eggs were also found. Moniezia expansa and Moniezia benedeni eggs were found in all the four study areas but its prevalence was low and irregular. Based on the results of this study, which showed a clear seasonal pattern, strategic anthelmintic medications to effectively control helminth infections in goats in the different ecological zones of Mozambique are suggested.

The main method for evaluation of healing processes of the jaws in oral and maxillofacial surgery are radiological diagnostics. Quantitative description is possible by measuring the relative bone density, which puts the mean grey value of a certain area in relation to the surrounding bone tissue. In this research the intra- and interindividual variability is determined for this method and a standard operation procedure is elaborated. Therefore ten panoramic radiographs of typical surgical indications in oral a maxillofacial surgery were analyzed by three different members of the workgroup, five times each. The measurements were analyzed with descriptive and comparative statistical methods. The mean coefficient of variation was 2.972% ± 2.361%. The measurements of defect regions were more consistent (2.252% ± 1.928%) than the measurements of surrounding bone (3.691% ± 2.626%). The analysis of variance did not show a statistically significant influence of the different raters to the measurements (ANOVA, Pr>F = 0.9462). Following the standard operation procedure this method seems to be an easy, cheap and close to practice way to visualize healing process of the jaws. Especially in the mandibula, but also in the maxilla with special reconsideration of the sinus-region, it seems to be suitable.

Context: Perioperative management of morbidly obese patients undergoing bariatric surgery is challenging. Lacking standardized perioperative protocols, complication rates may be high. This retrospective study aims to quantify the incidence of significant blood pressure decreases on induction of anesthesia and intraoperative hypoxemia, before implementation of a standardized protocol designed for bariatric surgery. Design: Retrospective, observational study. Setting: A 250-bed county hospital in northern Sweden. Subjects: 219 morbidly obese patients (body mass index > 35 kg/m2) who underwent bariatric surgery between 2003 and 2008. Main outcome measures: Incidence of systolic blood pressure (SAP) falls to less than 70% of the preoperative baseline during induction of anesthesia and incidence of perioperative hypoxemia. Results: The incidence of confirmed SAP falls to below 70% of baseline at induction of anesthesia was 56.2% (n = 123/219). This incidence rose with increasing age (p < 0.001) but not with body mass index (BMI). 3.7% (n = 8/219) of cases were marked as difficult intubations. A transient period of hypoxemia was observed in 6.8% (n = 15/219) and was more common with increasing BMI (p = 0.005). Fourteen different drug combinations were used in the study population. Of those administered an induction anesthetic drug, 72.6% (n = 159/193) were given an overdose when calculated by lean body weight, but this did not correlate significantly to SAP falls (p = 0.468). Conclusion: The incidence of a significant blood pressure fall upon induction of anesthesia was common. The incidence of airway and ventilation problems were low. Overdosing of anesthetics and excessive variation in applied anesthesia methods were found.

Purpose: Adaptive planning is often needed in lung cancer proton therapy to account for geometrical variations, such as tumor shrinkage and other anatomical changes. The purpose of this study is to present our findings in adaptive radiotherapy for lung cancer using uniform scanning proton beams, including clinical workflow, adaptation strategies and considerations, and toxicities. Methods: We analyzed 165 lung patients treated using uniform scanning proton beams at our center. Quality assurance (QA) plans were generated after repeated computerized tomography (CT) scan to evaluate anatomic and dosimetric change during the course of treatment. Plan adaptation was determined mutually by physicists and physicians after QA plan evaluation, based on several clinical and practical considerations including potential clinical benefit and associated cost in plan adaption. Detailed analysis was performed for all patients with a plan adaptation, including the type of anatomy change, at which fraction the adaption was made, and the strategy for adaptation. Toxicities were compared between patients with and without plan adaptation. Results: In total, 32 adaptive plans were made for 31 patients out of 165 patients, with one patient undergoing adaptive planning twice. Anatomy changes leading to plan adaptation included tumor shrinkage (17), pleural effusion (3), patient weight loss (2), and tumor growth or other anatomy change (9). The plan adaptation occurred at the 15th fraction on average and ranged from the 1st to 31st fraction. Strategies of plan adaptation included range change only (18), re-planning with new patient-specific hardware (9), and others (5). Most toxicities were Grade 1 or 2, with dermatitis the highest toxicity rate. Conclusion: Adaptive planning is necessary in proton therapy to account for anatomy change and its effect on proton penetration depth during the course of treatment. It is important to take practical considerations into account and fully understand the limitations of plan adaptation process and tools to make wise decision on adaptive planning. USPT is a safe treatment for lung cancer patients with no Grade 4 toxicity.

Introduction: Forty-six per cent children have allergic rhinoconjunctivitis (Allergologica 2005). Working hypothesis: Ocular topical cyclosporine improves the quality of life for these patients. Material, methods, design: 2-year prospective study (2015-16), 40 patients with topical corticosteroids without improvement, followed 20 and 20 switched to corticosteroids cyclosporine 0.05%. Interview with Quality of Life Questionnaire in Children with rhinoconjunctivitis (PRQLQ) before and at the end of treatment. Mean age of 10.3 years with 60% male-40% female. Treatments were applied from January to March. There were 15 questions divided into two blocks. Children responded using a card with responses rated from zero (not bothered at all) to 6 (quite upset). Results: Before the 100% reported that, the itching was very bothersome. In the group of 40 children, 80% showed symptoms of epiphora and 60% showed symptoms of ocular inflammation. 100% complained of significant discomfort in rubbing their eyes, 30% did not like to take medications. Headaches affected 20%. 100% stated that they cannot play normally. 80% showed decreased concentration in class. Continuing with corticosteroids did not show statistically significant changes. Patients with cyclosporine improved the results by 3 points, with decreased itching, tearing, swelling, pain, eye rubbing, medication and headaches. In the 2nd questionnaire there was limited variation in the results related to fatigue, malaise, and irritability but with substantially improved balance of sleep, insomnia and concentration at school. Conclusion: Cyclosporine A is a cyclic polypeptide calcineurin inhibitor developed from the fungus Tolypocladium inflatum. The first dilution was 2% but it is currently used at a dilution of 0.05% and recent publications suggest nanosuspensions. Our study showed improvement in parameters related to symptoms, especially itching and lower improvement of psychological aspects, this achieves a better quality of life for children and more willingness to adhere to the treatment.

Objectives: The aim of this study is to compute the radiation attenuation parameters such as mass attenuation coefficient, linear attenuation coefficient, half value layer, mean free path, and effective atomic number for some selected chemotherapy drugs such as Lomustine, Cisplatin, Carmustine, and Chlorambucil in the energy range from 1 keV to 100 GeV. Materials and Methods: The mass attenuation coefficients were calculated with the help of WinXCOM program. Using the obtained mass attenuation coefficients, other parameters such as linear attenuation coefficient, half value layer, mean free path, and effective atomic number were derived. Results: It is observed that the variations of these parameters with respect to the photon energy show changes in different energy regions. According to the obtained results, Cisplatin has the highest mass attenuation coefficient, linear attenuation coefficient and effective atomic number results among the selected chemotherapy drugs. Moreover, Chlorambucil has the highest half value layer and mean free path results among the selected chemotherapy drugs. Conclusion: The results of this study are useful for applied science fields such as radiation physics, pharmacology, and medical physics. These results may be useful when the selected chemotherapy drugs are used together with radiology.

Objectives: There are variations in therapeutic regimens of different liver diseases. The accurate diagnosis ensures prompt recovery from these diseases. The present study aimed to evaluate the underlying causes of unexplained signs and symptoms associated with liver diseases through biopsies. Methods: A retrospective study was conducted in a public child care specialty of Lahore, Pakistan. The data was collected from medical records of the patients who were index hospitalized with unexplained clinical presentation of liver disease between 1st July, 2017 and 31st December, 2017. Data were analyzed by using Statistical Packages for Social Sciences (IBM SPSS Statistics for Windows, Version 21.0. Armonk, NY: IBM Corp.), and Microsoft Excel (MS Office 2010). Results: Overall, the records of 53 patients were selected for the study. Most of them were 11 to 15 years of age. The patients were presented with unexplained hepatomegaly (60.4%) and jaundice (40.7%) during index hospitalization which made them eligible for liver biopsy (LB). The findings of LB revealed that the underlying causes of liver diseases in most of the cases were metabolic (33.9%) and inflammatory disorders (22.6%). Majority of the patients were ≤4 years of age, however cryptogenic cirrhosis (39.1%) was commonly found in >10 years of age. Although most of the patients were suffering from metabolic disorders (p-value=0.07) and liver cirrhosis (p-value=0.08) but these were not statistically significant. Conclusions: LB was beneficial in evaluating the etiologies of unexplained signs and symptoms of liver diseases. It was found that glycogen storage diseases and liver cirrhosis were the most common etiologies of liver diseases among pediatric patients. But etiologies like metabolic and inflammatory diseases were insignificantly associated with gender.

There are variations in therapeutic regimens of different liver diseases. The accurate diagnosis ensNusinersen treatment is a novel therapy for spinal muscular atrophy (SMA) type 1; consequently, the adverse reactions of the therapy, have not been well known, yet. The present study is a case report that declares a hyponatremia development after the nursinersen therapy. Since the therapy is quite new one and has limited practice, we hope that this rare complication will contribute to the scientific literature.

Several articles have been written about hyper inflated sinus structures. Never before, however, a complete overview of all possible pressure induced variations of sinus anatomy have been published. The aim of this study was to make an inventory of the most common CT signs of hyper inflated paranasal sinus structures. During a period of 2 years all CT-scans of the paranasal sinuses made in an ENT-department were studied and the most typical shapes of hyper inflated sinus structures were recorded. The authors documented 9 different anomalies of the anterior paranasal sinus complex (frontal sinus, frontal and supra-orbital recess and anterior ethmoid), 8 of the ethmoid and 1 of the sphenoidal sinus. These hyper inflated paranasal sinus structures can only be generated by high positive intranasal pressures. The nose blowing manoeuvre is the only manoeuvre that generates extremely high pressures and as such it might be the driving force in the generation of these hyper inflated paranasal structures and consequently play a role in the pathophysiology of chronic sinusitis. Pneumatisation of the sinuses starts at birth and is a lifelong process. Sometimes, however, pneumatisation can be extreme and will result in facial deformities. Pneumosinus dilatans, is such a condition, characterized by an abnormal dilatation of a paranasal sinus cavity, containing air only. Most reports describe pneumosinus dilatans of the frontal sinus, but also other sinuses can show this phenomenon: maxillary sinus and in one case a unilateral pneumosinus dilatans of nearly all sinuses (maxillary, ethmoid, and sphenoid sinus) was described. Recently Kalavagunta et al., described a less dramatic expansion of the maxillary sinus and named it “Extensive Maxillary Sinus Pneumatisation” (EMSP). They were surprised to see that EMSP has received little attention in the literature. Neuner et al., described 9 different atypical pneumatisation abnormalities of the paranasal sinus anatomy. Most of deformities of the sinus pneumatisation are growth deformities of the thick bones that make up the frame of the sinuses. Only a few articles, deal with specific deformities of thinner bone structures such as “wavy orbital floor” and “frontal cells”. Never before, however, an article was published that studied all possible deformities due to increased pressures and tried to make a classification. So the aim of this study was to make an inventory of the most obvious pressures related deformities that can be seen on CT-scans of patients with rhinosinusitis.

he presence of bifid mandibu¬lar canals is an unusual but not rare occurrence. The mandibular canal containing the inferior alveolar artery, vein, and nerve, originates from the mandibular foramen and terminates at mental foramen [1-4]. In radiology, mandibular canal’s appearance has been described as “a radiolucent dark ribbon between two white lines”[5]. White and Pharoah defined it as “dark linear shadow with thin radiopaque superior and inferior borders cast by the lamella of bone that bounds the canal” [6]. Understanding of its anatomic variations is very important due to its clinical implications in various oral and maxillofacial treatments like removal of wisdom teeth [7], mandibular implant placement [8], in bilateral sagittal split osteotomy procedures and during fixation of mandibular fractures. Presence of bifid or multiple mandibular canals forces the clinician to change the treatment plan. Ignoring this variation can cause several complications intra or postoperatively or even result in failure of treatment. For instance a bifid canal if ignored during surgical removal of third molar or dental implant placement can cause prolonged pain even after administering local anesthesia and also severe bleeding if the accessory canal is encroached [2]. Bifid mandibular canals may originate from the mandibular foramen independently or might bifurcate from a single canal during its course inside the mandible [8]. Bifid mandibular canals have been by classified by multiple authors according to anatomical location and configuration, on panoramic radiographs and computerized tomography. According to Carter and Keen [1], inferior alveolar nerve can be arranged as- Type I: single large bony canal, Type II: canal is lower down in the mandible and Type III: canal separates posteriorly into two large branches. Nortje, et al. [9] gave patterns of duplication as- Type I: duplicate canals from a single mandibular foramen which can be of same size/ lower canal smaller/ upper canal smaller. Type II: short upper canal up to the second molar areas. Type III: two canals from separate foramina, joining at molar area and Type IV: supplemental canals joining the main canals in the retromolar areas. This report describes a case of a bilateral Bifid Mandibular Canal suspected by a panoramic radiograph and confirmed by a CBCT prior to a dental treatment.

Age estimations process is not standardized worldwide. However, there is a wide agreement about the most suitable methods currently available. Up until now, the procedure of creating expert reports and to implement quality assurance in age estimation are variable. Aim: The aim of this paper was to examine expert age estimation reports from around the world and identify the similarities and shortcomings present, which will help in providing recommendations to improve the reporting to reach standardization in expert age estimation reports. Methods and Material: A questionnaire was developed to explore whether there is a universal consensus in writing age estimation reports. Countries participated in the survey were: Afghanistan, Australia, France, Indonesia, Italy, New Zealand, Norway, Paraguay, Saudi Arabia, Spain, Switzerland, United Arab Emirates, United Kingdom, and the United States of America. Areas investigated by the survey included: Information about the individual in question and the entity requesting the assessment, if age interval is given along with if statistics were described in the report, if population reference data are used and reported and finally if the format of the report is standardized within each country. Results: The results of this survey suggest that there is a high degree of individual variation in age estimation reports, sometimes even within the same country. While the majority of participants report the main findings, some important information is still missing. The statistical information remains extremely varied. Conclusion: Although a resolution is not obvious, it is hoped that this study will promote further research and discussion on reporting age estimation. International guidelines on quality assurance in age estimation reports are urgently needed. Information to be reported should be specified on an international level and the exact report format to be used could be left to the national societies.

Venous Thromboembolism (VTE) is a multifactorial disease that is influenced by individual genetic background and various environmental factors, high altitude (HA) being the one. HA exposure may cause release of several damage associated molecular patterns (DAMPs), which act as ligand for various immune receptors. Previous studies on western population involving SNPs analysis of TLRs demonstrated that TLRs are involved in development and progression of several cardiovascular diseases. But, no such study has been done in Indian population in context of HA exposure. TLRs, being receptors play a significant role in manifestation and elimination of diseases by recognition of specific ligands and downstream signal transduction therefore; the genetic variation in TLRs could be implicated for imparting varying response of individuals to discrete diseases. Therefore, in accordance with it, in present study changes in protein structures of TLR2 and TLR4 due to presence of SNP were accessed by in-silico tools to observe whether the mutation has effect on protein structure and integrity which further influencing its function. The results showed that SNP harbouring protein has decreased functional pockets, thus may be protective for disease. Taking this lead further to genotypic level, first time association between Toll-like receptor genes polymorphism and risk of high altitude induced venous thrombosis is analyzed in Indian population by PCR RFLP method. Though the result showed initial trend that TLR2 and TLR9 SNP are monomrphic in distribution and for TLR4 there was no significant difference in distribution of SNP between healthy and HA-DVT group, these SNPs have potential to be used as susceptibility markers if studied in large population size. 

The outbreaks and resurgence: The disease which reportedly began in the Chinese city Wuhan in November-December 2019, soon spread to various parts of the world, and was named and declared a pandemic disease by WHO. While the European countries were recovering from the epidemic, the disease took hold in the USA, the South American countries, Arabian countries, and South Asian countries, predominantly affecting Brazil, Peru, Iran, and India. Presently, many European countries are witnessing a resurgence and recurrent outbreaks of COVID-19. Spread and evolving new insights: Whereas there is workplace-related infection rise as people are returning to their offices, in other places the outbreaks are related to the people crowding and meeting care-freely and trying to resort back to their earlier way of life. The reopening of the educational facilities across the continents may make matters worse. Impact on health and healthcare: Most cases of COVID-19 infections go unnoticed and are followed by self-recovery. But what may appear good from the clinical perspective, appears to complicate epidemiological efforts to contain the outbreak. With the evolving information about the disease, there seem to be certain possible outcomes such as control and containment, or the persistence of the disease as global endemic accompanied with outbreaks and resurgent episodes. Gnetic factors linked to disease severity: With the COVID-19 pandemic, not all infected patients develop a severe respiratory illness. Further, there is a large variation in disease severity, which may be due to the genetic factors underlying the variable response to the virus. It is becoming clear that apart from the advanced age and pre-existing conditions, certain genetic constituent factors render some patients more vulnerable to the more severe forms of the diseases. Integration of virus into human genome: A significant part of the human genome is derived from viruses especially the RNA viruses. In fact, about 8 percent of the human genome is made up of endogenous retroviruses (ERVs), which are viral gene sequences that have become a permanent part of the human lineage after they infected our ancient ancestors. With this background, a novel concept emerging that if COVID-19 persists for several generations, its genetic material is projected to be integrated or assimilated into human genome. The involved mechanisms are conceptualized through the transposons or transposable elements of the SARS-CoV-2.

Introduction: SARS-CoV-2 life cycle: The disease which reportedly began in Chinese city Wuhan in November-December 2019 manifesting as severe respiratory illness, soon spread to various parts of the world, and was named COVID-19, and declared a pandemic by WHO. The life cycle of SARS-CoV-2 begins with membrane fusion mediated by Spike (S) protein binding to the ACE2 receptors. Following viral entry and release of genome into the host cell cytoplasm there occurs replication and transcription to generate viral structural and non-structural proteins. Finally, VLPs are produced and the mature virions are released from the host cell. Immunogenicity of the spike protein: The S protein is considered the main antigenic component among structural proteins of SARS-CoV-2 and responsible for inducing the host immune response. The neutralising antibodies (nAbs) targeting the S protein are produced and may confer a protective immunity against the viral infection. Further, the role of the S protein in infectivity also makes it an important tool for diagnostic antigen-based testing and vaccine development. The S-specific antibodies, memory B and circulating TFH cells are consistently elicited following SARS-CoV-2 infection, and COVID-19 vaccine shots in clinical trials. The emerging SARS-CoV-2 variants: The early genomic variations in SARS-CoV-2 have gone almost unnoticed having lacked an impact on disease transmission or its clinical course. Some of the recently discovered mutations, however, have impact on transmissibility, infectivity, or immune response. One such mutation is the D614G variant, which has increased in prevalence to currently become the dominant variant world-over. Another, relatively new variant, named VUI-202012/01 or B.1.1.7 has acquired 17 genomic alterations and carries the risk of enhanced infectivity. Further, its potential impact on vaccine efficacy is a worrisome issue. Conclusion: THE UNMET CHALLENGES: COVID-19 as a disease and SARS-CoV-2 as its causative organism, continue to remain an enigma. While we continue to explore the agent factors, disease transmission dynamics, pathogenesis and clinical spectrum of the disease, and therapeutic modalities, the grievous nature of the disease has led to emergency authorizations for COVID-19 vaccines in various countries. Further, the virus may continue to persist and afflict for years to come, as future course of the disease is linked to certain unknown factors like effects of seasonality on virus transmission and unpredictable nature of immune response to the disease.

Introduction - the perennial pandemic: It is being increasingly realised that the COVID-19 may have become the new reality associated with human existence world over and the mankind may have to live with it for years or even decades. Further, the grievous nature of the disease is evolving further with the genomic changes in the virus in form of mutations and evolution of variants, with enhanced infectivity and probably virulence. There are serious challenges posed by the SARS-CoV-2 virus and COVID-19 as the disease. COVID-19 as acute and chronic disease: On exposure to the SARS-CoV-2 virus, not all patients develop a disease. Further, for those who develop the disease, there is a large variation in disease severity. The known factors including the constituent factors and several still unknown factors influence the disease manifestations, its course, and later the convalescent phase as well. In fact, substantial continuing morbidity after resolution of the infection indicates persisting multisystem effects of COVID-19. The ‘long COVID-19’ or ‘long haulers’: The patients who continue to suffer with persisting symptoms have been described as long haulers and the clinical condition has been called post-COVID-19 or ‘long COVID-19’. The diagnosis should be entertained if various symptoms and signs linger well beyond the period of convalescence in COVID-19. With the chronicity, there occur inflammatory changes and damage in various organs, and the extent of organ damage determines the long-term effects. Management of ‘long COVID’ syndrome: The ‘long COVID’ syndrome has multi-system involvement, variable presentation, and unpredictable course. Following clinical and investigational assessment, the patients should be managed as per clinical manifestations, extent of organ damage and associated complications. The findings from various studies indicate that preventing further organ damage in ‘long COVID’ is crucial. The long COVID’s prognostic challenges: As apparent, the ‘long COVID’ afflictions are more common than realized earlier. The symptoms can escalate in patients with co-morbid conditions. The persistent symptoms among COVID-19 survivors pose new challenges to the healthcare providers and may be suitably managed with a combination of pharmacological and non-pharmacological treatments, and holistic healthcare. 

Background: Recent years have seen chaos in the neonatology use of antibiotics with diverse opinions and recommendations in international guidelines and societies. This has created great uncertainty in which cases to use, for how long, and which tests apply to make these decisions. We conducted a retrospective cohort study about the use of antibiotics in the EpicLatino neonatal units and a Latin American network database, after noting these variations in the 2019 report. Methods: For the year 2019 using the EpicLatino database, we included cases (only first admission) ≤ 32 weeks gestational age at birth, excluding one unit that did not accept to participate. The number of cases and days receiving antibiotics were recorded as well as the progression for each unit. Inappropriate use of antibiotics was defined as greater than 3 days in patients with negative cultures (blood/CSF cultures) excluding: major malformations, urinary tract infections, necrotizing enterocolitis (NEC) and cases with suspected chorioamnionitis in the mother (the latter two only during the course of diagnosis of NEC or chorioamnionitis). Results: A total of 6,543 days of antibiotics were observed, 49.5% of cases had at least one positive blood/CSF culture. A total of 595 days of antibiotics without justification were found in 72 courses in 61 cases: 19.4% had no diagnosis of infection in the database, 9.7% did not document any culture throughout their stay, and 51,4% obtained only one blood/CSF culture during their entire stay. In the 58 cases with diagnosis of infection: 41% were clinical sepsis and a diagnosis of pneumonia with a poor positive culture correlation was found. Furthermore, 74% of the unit’s didn´t use pneumonia as a justification to use antibiotics. Other diagnosis found: Conjunctivitis, NEC 1A and rotavirus NEC. Conclusion: Although the method of reviewing the use of antibiotics in a database has a number of limitations, especially the cause that motivated the use of antibiotics and other tools used for diagnosis of infections, the notable differences between units is striking. Although it is difficult to make recommendations to all units, it is important to control infections in some units and in others to reduce the excessive use of antibiotics, especially with diagnosis of pneumonia in neonates and negative blood/CSF cultures.

Geosynthetics used in landfills provides a technical and economic advantages over traditional clay liners. It may create stability issue and even lead to landfill failure due to its low interface or internal shear strength if improperly designed and/or constructed. The most common failure mechanism in geosynthetic-lined landfills is transitional failure involving waste and bottom liner (deep-seated failure) or only final cover system (shallow failure). Shear strengths of geosynthetic-geosynthetic and geosynthetic-soil have a wide range of variations. Shear strengths of interface from literature may be used in preliminary design. For final design, site-specific interface shear strengths shall be used. Internal shear strengths of unreinforced geosynthetic clay liner (GCL) are less than those of reinforced GCLs. Unreinforced GCLs are not recommended for slopes steeper than 1:10 (1 Vertical and 10 Horizontal). Peak shear strength of interface and internal GCLs can be used in bottom liner; residual shear strength of interface and internal GCLs shall be used for geosynthetic placed along the slopes. Site-specific shear strengths of waste are recommended to be used in the design. Landfill failure could be triggered by static loadings including excessive leachate, pore pressure above the bottom liners, gas pressure, and excessive wetness of the geomembrane-GCL, and earthquake loading. The factor of safety of 1.5 is recommended for static loading and 1.0 for earthquake loading. A higher factor of safety is recommended if a failure could have a catastrophic effect on human health or the environment, and if large uncertainty exists in input parameters to calculate the factors of safety. The main objective of this review article is to provide a comprehensive knowledge of slope failure mechanisms, causes, and probable remedies in one place.

Background: NSU is generally caused by right cerebral hemisphere lesions with a preeminent localization on the frontoparietal lobe. Aim: To assess the correlation between the typology and the brain lesion site and the consensual consent modality of body image modification after an integrated rehabilitative and neuropsychological treatment. Setting: A rehabilitation institute for the treatment of neurological gait disorders and neuropsichological failures. methods: Patients recruited were divided according to the brain lesion site into 3 groups (IG = ischemic group = 5 patients; HG = hemorrhagic group = 4 patients; IG + HG = ischemic + hemorrhagic group = 3 patients) based on CT brain performed in the post-acute phase. At time T0, the patients recruited underwent a systematic review of their current neuroradiological profile (location delineation and type of brain injury) compared with a consensual framing of the neuromotor and neuropsychological profile acquired at the time of taking charge in the ward. At time T1 and after the drafting and implementation of the rehabilitation treatment plan foreseen in the study (1 to 4 months after T0), the patients in our sample underwent a re-evaluation of their neuromotor and neuropsychological profile with controls of the same outcome parameters considered at time T0. Results: A parametrically but not statistically significant modification of the results obtained was observed by measuring the MI ULl, MI LLl and TCT scales in the group with hemorrhagic brain injury; the analysis of variance did not show any statistical significance in the relationship between the type of stroke (ischemic, hemorrhagic or both) and the motor impairment passing from time T0 to time T1. The analysis of variance did not reveal a statistically or parametrically significant relationship between the type (ischemic, hemorrhagic and ischemic + hemorrhagic) of cerebral stroke and the variations of the neuropsychological profile. The T-Student test showed statistically significant changes in the importance of the lesion site in defining the degree of motor disability. In particular, we observed, about the presence of frontal lobe lesions, a statistically significant variation passing from the T0 time to the T1 time for the following motor scales in 9 of 12 recruited patients: MI LLl (26.4 vs. 62, with p < 0.05), TCT (43.6 vs. 80.6, with p < 0.01 for equal variance assumed and p < 0.05 for equal variance not assumed), FAC (0.8 vs. 2.3 with p < 0,01 for equal variance assumed and p < 0.05 for equal variance not assumed). Conclusion: We have confirmed the importance of the anatomical-dysfunctional correlation as a key concept from which to start in any neurorehabilitative treatment approach. Our work has highlighted the basic role of the right frontal lobe in the programming and execution of the gesture and its kinesthetic control as regards the left lower limb and the trunk.