Non-cirrhotic hyperammonemia in a newly diagnosed diabetic patient presenting in diabetic ketoacidosis

Hyperammonemia, a known cause of encephalopathy, is commonly seen in patients with liver disease. Non-cirrhotic hyperammonemia is an uncommon condition. Patients with uncontrolled diabetes can have elevated levels of ammonia. Diabetic ketoacidosis is a life threatening complication in diabetes. This is a case of a middle-aged male who presented in encephalopathy. He was found to have diabetic ketoacidosis with hyperammonemia. Encephalopathy as a result of hyperammonemia in diabetes mellitus is a rare scenario

One-step transformation of 2-oxa-3-azabicyclo[2.2.1]hept-5-ene and methyl 2,3-diazabicyclo[2.2.1]heptane-2-carboxylate to ion uptake systems

Linker generated duplexes of the title compounds- prepared from cyclopentadiene- with possibility for positioning of four oxygen in the cavity, are shown to be excellent ion uptake systems. Mass spectrometric doping studies with lithium, sodium, potassium and silver ions, show a clear preference for lithium complexation. The lithium salts of the best examples have been prepared and characterized

Exploiting Fine-Grain Concurrency Analytical Insights in Superscalar Processor Design

This dissertation develops analytical models to provide insight into various design issues associated with superscalar-type processors, i.e., the processors capable of executing multiple instructions per cycle. A survey of the existing machines and literature has been completed with a proposed classification of various approaches for exploiting fine-grain concurrency. Optimization of a single pipeline is discussed based on an analytical model. The model-predicted performance curves are found to be in close proximity to published results using simulation techniques. A model is also developed for comparing different branch strategies for single-pipeline processors in terms of their effectiveness in reducing branch delay. The additional instruction fetch traffic generated by certain branch strategies is also studied and is shown to be a useful criterion for choosing between equally well performing strategies. Next, processors with multiple pipelines are modelled to study the tradeoffs associated with deeper pipelines versus multiple pipelines. The model developed can reveal the cause of performance bottleneck: insufficient resources to exploit discovered parallelism, insufficient instruction stream parallelism, or insufficient scope of concurrency detection. The cost associated with speculative (i.e., beyond basic block) execution is examined via probability distributions that characterize the inherent parallelism in the instruction stream. The throughput prediction of the analytic model is shown, using a variety of benchmarks, to be close to the measured static throughput of the compiler output, under resource and scope constraints. Further experiments provide misprediction delay estimates for these benchmarks under scope constraints, assuming beyond-basic-block, out-of-order execution and run-time scheduling. These results were derived using traces generated by the Multiflow TRACE SCHEDULING™(*) compacting C and FORTRAN 77 compilers. A simplified extension to the model to include multiprocessors is also proposed. The extended model is used to analyze combined systems, such as superpipelined multiprocessors and superscalar multiprocessors, both with shared memory. It is shown that the number of pipelines (or processors) at which the maximum throughput is obtained is increasingly sensitive to the ratio of memory access time to network access delay, as memory access time increases. Further, as a function of inter-iteration dependency distance, optimum throughput is shown to vary nonlinearly, whereas the corresponding Optimum number of processors varies linearly. The predictions from the analytical model agree with published results based on simulations. (*)TRACE SCHEDULING is a trademark of Multiflow Computer, Inc

Health technology assessment of online eLearning for post-registration health professionals’ education

Aim: The overall aim of this thesis was to undertake and report the findings of a health technology assessment (HTA) on the effectiveness, cost-effectiveness and acceptability of online and LAN-based eLearning, and blended learning, among post-registration healthcare professionals. Methods: This HTA comprised three studies. The first study was a systematic review of 93 randomised controlled trials evaluating the effectiveness of online and LAN-based eLearning on physicians' knowledge, skills, attitude and satisfaction. The second study compared the cost, cost-savings and return on investment between a blended and a face-to-face advanced cardiac life support course for physicians in Singapore. The third study was an online survey that assessed the acceptability of the technology among a sample of optometrists and opticians in Singapore and their scope of practice, primary eye care knowledge, views on extended roles in primary eye care, preferred mode of learning for continuing professional education, and referral behaviour. Results: The systematic review showed that online and LAN-based eLearning or blended learning compared with self-directed or face-to-face learning resulted in higher post-intervention knowledge scores (21 studies; small to large effect size; very poor quality); higher post-intervention skills scores (seven studies; large effect size; low quality); higher attitude scores (one study; very low quality); higher post-intervention satisfaction (four studies; large effect size; low quality); and higher post-intervention practice or behaviour changes (eight studies; large effect size; low quality) among physicians in the intervention groups. Fourteen studies compared eLearning with other forms of eLearning. Among these, four studies reported higher post-intervention knowledge scores (large effect size; very low quality) for participants in the intervention group. Unintended or adverse effects of the intervention were not reported among the included studies. Ninety-three studies (N=16,895) were included of which seventy-six studies compared ODE (including blended) vs self-directed/face-to-face learning. Overall the effect of ODE (including blended) on post-intervention knowledge, skills, attitude, satisfaction, practice or behaviour change and patient outcomes was inconsistent and ranged mostly from no difference between the groups to higher post-intervention score in the intervention group (small to large effect size, very low to low quality evidence). Twenty-one studies reported higher knowledge score (small to large effect size; very low quality) for the intervention while 20 studies reported no difference in knowledge between the groups. Seven studies reported higher skill score in the intervention (large effect size; low quality) while thirteen studies reported no difference in skill score between the groups. One study reported higher attitude score for the intervention (very low quality), while 4 studies reported no difference in attitude score between the groups. Four studies reported higher post-intervention physician satisfaction with the intervention (large effect size; low quality), while six studies reported no difference in satisfaction between the groups. Eight studies reported higher post-intervention practice or behaviour change for the ODE group (small to moderate effect size; low quality) while five studies reported no difference in practice or behaviour change between the groups. One study reported higher improvement in patient outcome, while three others reported no difference in patient outcome between the groups. None of the included studies reported any unintended/adverse effects, cost-effectiveness of the interventions. Although the review only focused on post-registration medical doctors, the technology could be used for the interprofessional education of post-registration medical doctors and other healthcare professionals. Such an initiative would encourage collaborative learning and facilitate task-shifting, which could address the problem of fragmentation in health care. Although eLearning and blended learning technology interventions have been implemented, primary studies have not assessed their cost-effectiveness. Hence, to ascertain the technology’s cost-saving potential, we used a blended advanced cardiac life support (B-ACLS) course as an exemplar and compared its cost to face-to-face advanced life support (F-ACLS) training. The analysis showed that the annual cost of F-ACLS training (USD$72,793) was 1.7 times higher than B-ACLS training (USD$43,467). The discounted total cost of training over the life of the course (5-years) was SGD $107,960 for B-ACLS and S$280,162 for F-ACLS. The cost of productivity loss accounted for 52% and 23% of the costs for F-ACLS and B-ACLS, respectively. B-ACLS yielded a 160% return on the money invested, yielding $1.60 for every dollar spent. There would be a 61% saving for course providers if they delivered a B-ACLS instead of F-ACLS course. The effectiveness component of the HTA showed that online eLearning and blended learning is as effective as traditional learning and has cost-saving potential. We also sought to determine if this technology could be used to train and equip optometrists and opticians in Singapore to take on an extended role in primary care, which would allow some simple primary eye care tasks to be shifted from ophthalmologists to optometrists and ease healthcare access issues at specialist hospital outpatient clinics. The survey of optometrists showed that the current roles of opticians and optometrists in Singapore were limited to diagnostic refraction (92%); colour vision assessment (65%); contact lens fitting and dispensing (62%) amongst others. The average self-rated primary eye care knowledge score was 8.2 ± 1.4; (score range 1-10; 1 = very poor, 10 = excellent). Average self-rated confidence scores for screening for cataract, diabetic retinopathy, chronic glaucoma and age-related macular degeneration were 2.7 ± 1.5; 3.7 ± 1.9; 4.0 ± 1.0 and 2.7 ± 1.5, respectively. Three fourths of the optometrists surveyed felt that they should undertake regular continuing professional education (CPE) to improve their primary eye care knowledge. Blended learning (eLearning and traditional face-to-face lectures) was the most preferred mode (46.8%) for CPE delivery. Conclusions: Overall, the findings from the HTA provide evidence of effectiveness, cost-saving of online eLearning and blended learning for training medical doctors and the acceptance of the technology in a local context to facilitate its wider adoption for training post-registration healthcare professionals’. These research outputs would have direct impact on the adoption of online eLearning, blended learning technologies in universities and educational institutes across the region with consequent impacts on post-registration health professionals’ education and policy. The results of learning will serve as a guide for policy makers to decide on investment in the learning technology and to learn about the associated factors, which would influence its adoption. This thesis resulted in three papers, of which one has been accepted for publication, the two other papers are under review.Thesis (Ph.D.) -- University of Adelaide, Adelaide Medical School, 201

Prevalence and Determinants of Smoking and Smokeless Tobacco in the Rural Population of Karnataka, India

Background: Tobacco is known as a major cause of various preventable non-communicable diseases and kills half of all its users. With a greater prevalence in the rural community compared to the urban, this global health burden is substantially malignant. This study aimed to bridge the gap in the lack of adequate statistical information pertaining to prevalence and determinants of smoking and smokeless tobacco use in the rural population of Karnataka.Subjects and Method: This randomized community interventional study was conducted in primary health center areas of Karnataka, India. A total of 4,576 persons were interviewed (2,087 males and 2,489 females). Subjects ?30 years of age and residents for a minimum of six months were included. Mentally challenged, bedridden or differently abled subjects were excluded. The study employed a validated questionnaire adapted from the WHO STEPS questionnaire concerning demographical information, behavioral, physical, and biochemical measurements. Besides tobacco, informa-tion on use of beedis, cigarettes, and smokeless tobacco products (snuff, chewing tobacco) were also elicited. Data analysis of socio-demographic characteristics (age, educational/ marital/ occupational status) was carried out only for the participants with a current smoking habit. Data were analyzed using SPSS Version 18.0.Results: The overall prevalence rate of current smoking and smokeless tobacco habit in the study population was 54.8% (95%CI= 53.40 to 56.20) and the prevalence rate of ever/past users was 39.7% (95%CI= 38.26 to 41.10). Genderwise analysis predicted a higher prevalence of males currently smoking, and among them, most were 50 to 59 years of age (43.3%), illiterate (42.7%), widowed/ separated (39.8%), unskilled (44%), and semi-skilled workers (30%).Conclusion: Both genders participate in tobacco use, prevalence of smoking was higher among men and consumption of smokeless tobacco was higher among women. Subjects aged 50-59 years, illiterate, divorced/widowed/separated and, involved in unskilled or semi-skilled labor exhibited greater prevalence of tobacco habit compared to other determinants.Keywords: noncommunicable diseases, global health, tobacco use, tobacco smoking, smokeless tobacco. Correspondence: Dinesh Rajaram, Associate Professor. Department of Community Medicine, M.S. Ramaiah Medical college and Hospital, Bengaluru 560054, Karnataka, India. Email id.: [email protected]. Mobile: +919980336893

Sastav i antimikrobno djelovanje eteričnog ulja iz plodova biljke Amomum cannicarpum

Essential oil from the fruits of Amomum cannicarpum (Wight) Bentham ex Baker (Zingiberaceae), was hydrodistilled and characterized by gas chromatography-mass spectrometry (GC-MS). The major constituents in the oil were betha-pinene (14.00%), elemol (10.45%) and alpha-cadinol (8.50%). Thirty-three (91.48%) out of forty-one constituents were identified by GC-MS and subsequent data analysis. The antimicrobial activity of the oil against Gram-positive and Gram-negative bacteria and some fungi were determined by the disc diffusion assay. The oil showed good antibacterial activity against Salmonella typhi, Pseudomonas aeruginosa and Proteus vulgaris and very good antifungal activity against Candida albicans and C. glabrata.Eterično ulje iz plodova biljke Amomum cannicarpum (Wight) Bentham ex Baker (Zingiberaceae) dobiveno je destilacijom vodenom parom, a zatim je pomoću plinske kromatografije i masene spektrometrije (GC-MS) određen njegov sastav. Najvažniji sastojci u ulju bili su -pinen (14.00%), elemol (10.45%) i -kadinol (8.50%). Ukupno je od 41 sastojka identificirano 33 sastojka (91.48%). Disk-difuzijskom metodom određeno je antimikrobno djelovanje ulja na Gram-pozitivne i Gram-negativne bakterije i neke gljivice. Dosta snažno antimikrobno djelovanje zapaženo je na bakterije Salmonella typhi, Pseudomonas aeruginosa i Proteus vulgaris ten a gljivice Candida albicans i C. glabrata