Aim: The aim of the study was to compare the analgesic effects of ketamine over fentanyl combined with propofol in analgesia-based elective colonoscopy with purpose of patient safety and satisfaction. Methods: This is a double-blinded prospective randomized controlled trial. Ninety patients were included and randomized to either fentanyl-propofol (Group FP, n: 30), ketamine-propofol (Group KP, n: 30) or propofol-control group (Group C, n: 30). Group FP patients received fentanyl and propofol, Group KP received ketamine and propofol and Group C, propofol. In all groups, incremental doses of propofol were used to maintain a Ramsay sedation score (RSS) of 5. Respiratory depression and hemodynamic parameters were monitored for the first minute and every 5 min during endoscopy. Fifteen minutes after the procedure, the degree of pain was assessed using a visual analog scale (VAS), the quality of recovery according to the Aldrete score (ARS), complications during and after the procedure and additional doses of propofol were recorded. Results: Mean arterial pressure (MAP) at 5 and 30 min (p < 0.05), heart rate (HR) at 15, 25 and 30 min (p < 0.05) and peripheral oxygen saturation (SpO2) at 30 min (p < 0.05) were statistically significant for Group FP. Desaturation (*p = 0.033), and weakness (*p = 0.004) was also significant for Group FP at 20, 25 and 30 min (p < 0.05). Pain was lower assessed for the Group KP according to the VAS (**p = 0.025). Conclusion: In analgesia-based colonoscopy, ketamine provides appropriate analgesia and less incidence of complications compared to fentanyl.

3 Technical RepoRT New Opportunities Offered by the ESRF to the Cultural and Natural Heritage Communities Marine Cotte,1,2 Kathleen DollMan,1 VinCent FernanDez,1 ViCtor Gonzalez,3 FreDeriK VanMeert,4,5 letizia MoniCo,6,7,4 Catherine Dejoie,1 ManFreD BurGhaMMer,1 loïC huDer,1 Stuart FiSher,1 Wout De nolF,1 iDa FazliC,1,8 hiraM CaStillo-MiChel,1 Murielle SaloMé,1 Marta GhirarDello,9 Daniela CoMelli,9 oliVier Mathon,1 anD Paul taFForeau1 1European Synchrotron Radiation Facility (ESRF), Grenoble, France 2Sorbonne Université, CNRS, Laboratoire d’Archéologie Moléculaire et Structurale (LAMS), Paris, France 3Université Paris-Saclay, ENS Paris-Saclay, CNRS, PPSM, Gif-sur-Yvette, France 4Antwerp X-ray Imaging and Spectroscopy Laboratory (AXIS) Research Group, NANOLab Centre of Excellence, University of Antwerp, Antwerp, Belgium 5Paintings Laboratory, Royal Institute for Cultural Heritage (KIK-IRPA), Brussels, Belgium 6CNR-SCITEC, Perugia, Italy 7Centre of Excellence SMAArt, University of Perugia, Perugia, Italy 8Science Department, Rijksmuseum, Amsterdam, The Netherlands 9Physics Department, Politecnico di Milano, Milano, Italy Introduction For the past 20 years, the community of heritage scientists has frequently exploited the synchrotron radiation-based techniques offered at the European Synchrotron Radiation Facility (ESRF), Grenoble, France [1]. X-ray imaging techniques (in particular, micro computedtomography, μCT) are regularly employed to probe non-destructively the inner structure of objects and materials. In paleontology, this can offer information on the functioning and evolution of organs and organisms. In addition, analytical techniques such as X-ray fluorescence (XRF), X-ray powder diffraction (XRPD), and X-ray absorption spectroscopy (XAS) are often used, alone or combined, for the chemical analysis of micro-fragments of historical manufactured materials. This can give clues about both the early days of objects (physical and chemical processes used in the production of artworks and the evolution of these skills in time and space) as well as the evolution/alteration of objects (nature of degradation products and environmental factors contributing to these degradations). The limited size of samples and their high heterogeneity often require access to micro and nano-probes. The new capabilities offered by the ESRF upgrade “EBS” (Extremely Brilliant Source), as well as instrumental developments at new and strongly refurbished beamlines, have motivated the organization of a dedicated “EBS-workshop” about cultural and natural heritage, which was held in January 2020 at the ESRF, attracting more than 150 participants, among which were 90 new ESRF users. Most of the talks were broadcast on the ESRF YouTube Channel and are still available (https:// youtube.com/playlist?list=PLsWatK2_NAmyyA0n03OMJMAKobVIvow2D). Through scientific presentations, tutorials, and discussions, the objectives of the workshop were: 1. To illustrate to expert and non-expert users the many capabilities offered by synchrotron radiation-based techniques for the study of natural and cultural heritage materials/objects; 2. To present EBS and the related instrumental developments, highlighting the ground-breaking capabilities that will be offered through the ESRF upgrade phase 2 (thanks to the new source, new beamlines, and new instruments); 3. To present and discuss the upstream and downstream challenges associated with these new instruments (e.g., access models and data analysis, data management...), which are fundamental for making the experiments a success. This was notably a very good opportunity to discuss the implementation of new beamtime access modes.

A pandemic caused by the coronavirus affects all aspects of life of an individual and a society as a whole. It is not only a question of the medical profession, but also of other areas, and especially the need for fundamental human rights. The measures adopted by state bodies are primarily aimed at protecting human health, but the effects and implications they cause limit other rights, so it raises the question of their adequacy. The basic and most important question is how to access health care in such conditions. Therefore, the main aim of the paper is to try to answer the question through PESTEL (P-Political, E-Economic, S-Social, T-Technological, E-Environmental, L-Legal) analysis of the healthcare system of the local community of Pale. Thirty factors of PESTEL analysis were quantified by using the Improved Fuzzy Stepwise Weight Assessment Ratio Analysis (IMF SWARA) method. The results obtained through the total of 70 formed models show that the current state of the observed local community is marked by social and legal factors. This analysis should present a diagnostic test of the current situation and provide a good basis for future actions.

A search is performed for delayed and nonpointing photons originating from the displaced decay of a neutral long-lived particle (LLP). The analysis uses the full Run 2 data set of proton-proton collisions delivered by the LHC at a center-of-mass energy of $\sqrt{s}=13$ TeV between 2015 and 2018 and recorded by the ATLAS detector, corresponding to an integrated luminosity of 139 fb$^{-1}$. The capabilities of the ATLAS electromagnetic calorimeter are exploited to precisely measure the arrival times and trajectories of photons. The results are interpreted in a scenario where the LLPs are pair-produced in exotic decays of the 125 GeV Higgs boson, and each LLP subsequently decays into a photon and a particle that escapes direct detection, giving rise to missing transverse momentum. No significant excess is observed above the expectation due to Standard Model background processes. The results are used to set upper limits on the branching ratio of the exotic decay of the Higgs boson. A model-independent limit is also set on the production of photons with large values of displacement and time delay.

Out of all benign tumors of the ceruminous glands, syringocystadenoma papilliferum is the rarest and represents only 2% of cases. It is an extremely rare benign tumor that originates from modified apocrine sweat glands. The aim of this paper was to present, according to our findings, the 18th case of syringocystadenoma papilliferum in the external auditory canal, with a detailed review of its clinical, radiological and histomorphological characteristics. A 59-year-old man reported to our clinic due to a 5×5 mm papillomatous growth at the entrance to the right external auditory canal. Histopathology indicated, after an excisional biopsy, that it was a syringocystadenoma papilliferum. The resection lines were free of tumor tissue, and the patient has no signs of tumor recurrence. Although rare, it should be considered as a differential diagnosis of lesions in this region. Complete excision is mandatory in order to avoid recurrence and potential malignant alteration.

Due to higher requirements for achieving sustainable development goals, current challenging sociopolitical climate and internationalization, business models remain problematic, resulting in a more complex global competition among firms and the need for sustainability incorporation. Throughout this study, a conceptual model based on the systematic literature review was applied as the methodology, with the study's purpose to propose the new Model of Continuous Enterprise Sustainability, which is designed to facilitate and enhance enterprise management in today's demanding and complex business environment by providing concise steps for effectively incorporating sustainability into day‐to‐day business activities. Five essential components, through their interconnectedness, form the Model of Continuous Enterprise Sustainability, which smooth the path of sustainable management in a dynamic environment, which are as follows: (1) situational factors, (2) creating factors/processes, (3) triple‐sustainable results, (4) organizational results, and (5) continuous stakeholder communication, optimization, innovation and learning. This conceptual model contributes in the first line to advancement and detail explanation of how to achieve sustainable human, financial and natural resources management within enterprises. In addition to directions for sustainable internal resources management, this model also involves clarification how to strategically manage with external resources and prime stakeholders in order to integrate meaningful sustainability matters in firm's business core and create continuously greater value for firm and its prime interested parties.

Introduction Various side effects and complications in the perioperative period can occur with the use of hyperbaric lidocaine and bupivacaine. Goal Comparative presentation of the occurrence of side effects and complications of hyperbaric lidocaine and bupivacaine during spinal anesthesia in our patients. Methods The study was retrospective and included 178 patients of both sexes. Patients were divided into two groups. In Group I (n-98) hyperbaric lidocaine 5% was used for spinal block. Group II (n-80) was divided into 2 subgroups, A- where hyperbaric Markain 0.5% was used (n-51), and B (n-29) where hyperbaric Sensorkain 0.75% was used. In the study, we analyzed gender, age, block onset, and complications. Results There were 98 patients in Group I, 79 males and 19 females. There were 80 patients in Group II, 69 males and 11 females. The mean age of patients in Group I was 44.96 and in Group II 48.16 years. There was no statistically significant difference in the age of patients in both groups p> 0.05 (p = 0.2321). The occurrence of spinal block occurred significantly faster in Group I compared to group II (p <0.0001), and in subgroup B faster than in subgroup A (p <0.005). The clinical occurrence of complications and side effects during spinal anesthesia is somewhat more common in spinal block with 5% lidocaine. Conclusion The compared incidence of adverse perioperative clinical effects and complications after administration of hyperbaric lidocaine and bupivacaine in spinal anesthesia was not statistically significant.

Introduction Healthcare utilisation requires knowing one’s entitlements and how to access them (navigation) and having access to grievance redressal when entitlements are denied. To ensure citizen access to and use of health insurance entitlements, the Health Insurance Fund established an initiative called the Protector of Patients’ Health Insurance Entitlements (PPHIE). PPHIEs are supposed to provide patient navigation and grievance redressal services. This paper explores to what extent this initiative meets its objectives and is used by the elderly in rural areas. Methods This study employed a mixed methods approach. We conducted in-depth interviews with elderly patients in rural areas, PPHIEs, health providers and health insurance managers (N=39), as well as focus groups (N=5) and a household survey (N=715) with elderly rural patients. Qualitative data were analysed using content analysis, and the household survey results were analysed using descriptive statistics. Results The majority of elderly patients were not aware of the PPHIE initiative and instead received patient navigation support from their healthcare providers. The PPHIE programme was poorly publicised among the population. Although PPHIEs had a mandate to pursue grievance redressal they rarely did so, and their role in the system was more symbolic than functional. Conclusion While healthcare providers have (by default) filled the navigation role left by inactive PPHIEs, the grievance redressal role remains unfilled. Information about health insurance entitlements and access to grievance redressal must be provided through visible, accessible and efficient mechanisms that should be continuously monitored and improved.

This study aimed to examine the impact of personality on glycemic regulation in adult patients with type 1 diabetes mellitus (T1DM). The study group consisted of subjects with T1DM, who were ≥ 18 years of age. The study was conducted in two phases: At baseline, subjects completed the Croatian version of the International Personality Item Pool scale (IPIP50s) and a questionnaire designed to gather socioeconomic data, duration of diabetes, presence of chronic complications, presence of cardiovascular risk factors, frequency, and type of pre-existing hypoglycemic episodes per week. Blood and urine samples were collected and body mass index (BMI) was calculated. Each participant was provided with the intermittently scanned glucose monitoring system (isCGM) Freestyle Libre. During the second visit (3 months from the start of the trial), glycemic parameters were collected from the reports generated from the Freestyle Libre system. Estimated glycated hemoglobin (HbA1c) values were significantly lower after three months compared to baseline HbA1c (Wilcoxon test, p < 0.001). An inverse correlation between the number of daily scans and degree of extraversion among subjects was observed, e.g., higher degrees of extraversion resulted in lower numbers of daily scans, while lower degrees of extraversion, i.e., introvertedness, resulted in higher numbers of daily scans (Rho = −0.238 p = 0.009). There was a positive correlation between emotional stability and time spent in hypoglycemia (Rho = 0.214; p = 0.02). In addition, a shorter duration of diabetes was associated with higher percentages of TIR and vice versa (p = 0.02). Investigating personality traits can be a useful tool for identifying patients predisposed to hypoglycemia and lower scanning frequency. Patients with a longer history of T1DM require closer follow-up and should be re-educated when necessary.

We investigated the production conditions and optoelectrical properties of thin film material consisting of regularly ordered core/shell Ge/Al and Ge/Si3N4/Al quantum dots (QDs) in an alumina matrix. The materials were produced by self–assembled growth achieved by means of multilayer magnetron sputtering deposition. We demonstrated the successful fabrication of well-ordered 3D lattices of Ge/Al and Ge/Si3N4/Al core/shell quantum dots with a body-centred tetragonal arrangement within the Al2O3 matrix. The addition of shells to the Ge core enables a strong tuning of the optical and electrical properties of the material. An Al shell induces a bandgap shift toward smaller energies, and, in addition, it prevents Ge oxidation. The addition of a thin Si3N4 shell induces huge changes in the material spectral response, i.e., in the number of extracted excitons produced by a single photon. It increases both the absolute value and the width of the spectral response. For the best sample, we achieved an enhancement of over 250% of the produced number of excitons in the measured energy range. The observed changes are, as it seems, the consequence of the large tensile strain in Ge QDs which is induced by the Si3N4 shell addition and which is measured to be about 3% for the most strained QDs. The tensile strain causes activation of the direct bandgap of germanium, which has a very strong effect on the spectral response of the material.

Background: Medical professionals (doctors and other medical staff) in the field of healthcare everyday must make calculated decisions which have important consequences, impacting patients on the individual level, local (community), national or global level. Healthcare professionals must at times make these choices with limited information, resources, and knowledge, and yet is is expected that these decisions are highly calculated and accurate. It is important to familiarise oneself with the exact definitions regarding medical decision making. Objective: The aim of this study was to describe application of the most important rules to help decision makers to be good or excellent decision makers in medical practice at every level of health care system. Methods: The author used descriptive method of explanation teoretical and practical issues regarding application of od decision making processes in the praxis, based on searchied scientific literature about this topic deposited in online databases. Results and Discussion: The author of this paper discussed about important topics: a) the importance of medical decision in emergency situations; b) the varies of decision making with solving problems by medical professionals; c) the limitations when it comes to medical decison making; and d) what doctors need to follow regarding decision making in the praxis. Two factors that have influenced to the decision process: a) degree of uncertainty about future events; b) usefulness of outcomes in any particular case. The clinical decision problem analysis process demands: a) explicit formalization of a decision making problem or the description of the medical problem decision with a registration of all possible actions which have to be undertaken and registration of all the possible so determined outcomes. b) construction of the decision tree which presents all described actions and outcomes with predictions of the probabilities and the choice of the most optimal action based on the probability outcome and its use. Doing this allows us to delve deeper into more intricate options present within medical decision making. Simple put, a decision is a choice between two options. The person or entity conducting that decision is the decision maker. The exact definition is “Under the decision should imply some specific action which is selected from several variables or which satisfies the expectation that is previously set”.Many different factors and individuals may be involved in medical decision making, with varying consequences, according to different players and settings. Conclusion: A vital component of medical decision making is evaluation. Decision makers must concisely evaluate situations, in order to make better choices. For example, when examining a health care system, their decisions should consider the following questions, such as, what is the health status of the given population? What economic resources are at the disposal of our patients, and government? How effective is the current healthcare model that is already in place? Does the existing social system pay enough attention to the healthcare protection? Does the organisation structure of the healthcare system satisfy? Are the existing practice and the healthcare technologies secure, effective, and suitable? Are the planning, programming, determination and the choice of priority the adequate to the needs of people? How are the monitoring and evaluation of healthcare system quality organised? These are a few examples of evaluation in medical decision making.

Abstract Background falls and fall-related injuries are common in older adults, have negative effects on functional independence and quality of life and are associated with increased morbidity, mortality and health related costs. Current guidelines are inconsistent, with no up-to-date, globally applicable ones present. Objectives to create a set of evidence- and expert consensus-based falls prevention and management recommendations applicable to older adults for use by healthcare and other professionals that consider: (i) a person-centred approach that includes the perspectives of older adults with lived experience, caregivers and other stakeholders; (ii) gaps in previous guidelines; (iii) recent developments in e-health and (iv) implementation across locations with limited access to resources such as low- and middle-income countries. Methods a steering committee and a worldwide multidisciplinary group of experts and stakeholders, including older adults, were assembled. Geriatrics and gerontological societies were represented. Using a modified Delphi process, recommendations from 11 topic-specific working groups (WGs), 10 ad-hoc WGs and a WG dealing with the perspectives of older adults were reviewed and refined. The final recommendations were determined by voting. Recommendations all older adults should be advised on falls prevention and physical activity. Opportunistic case finding for falls risk is recommended for community-dwelling older adults. Those considered at high risk should be offered a comprehensive multifactorial falls risk assessment with a view to co-design and implement personalised multidomain interventions. Other recommendations cover details of assessment and intervention components and combinations, and recommendations for specific settings and populations. Conclusions the core set of recommendations provided will require flexible implementation strategies that consider both local context and resources.