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BACKGROUND Medical and dental education is highly dependent on the development of students’ clinical skills in addition to their theoretical knowledge. The use of logbooks to monitor the clinical procedures performed by students provides a great advantage in the educational process. Because of the pandemic, utilisation of digital logbooks may prove to be more advantageous. This study aims to investigate the effective use of online progress records and as to whether they actually decrease the chance of error compared to the traditional paper-based logbooks. METHODS In this quasi-experimental study, 139 student logbooks were studied to compare online and paper-based clinical procedures. Logbook monitoring of undergraduate dental students reported by the students themselves vs. instructors was compared. Students filled mandatory individual paper-based logbooks, reporting the number of clinical procedures performed in that year. Additionally, they filled online log- sheets, and updated them regularly. Instructors proofread and signed the paper-based students’ logbooks. Instructors also separately submitted individual online forms recording each student’s clinical procedure performed in clinical sessions. A total of 556 logbook records was collected. The mean number of procedures recorded by the students and instructors (online and paper-based) were statistically compared. RESULTS The mean number of procedures recorded in student-reported online logbooks were significantly lower than that in all other logbooks. Paper-based and online instructorreported logbook data was identical to that of student reported paper-based logbooks. CONCLUSIONS Within the scope of the study, it was concluded that online tools are an asset and may be used as a substitute for paper-based monitoring of clinical activity for instructors. However, students’ compliance updating and uploading online forms is a factor, which is a matter of concern. KEY WORDS Undergraduate Dental Logbooks, Clinical Progress Records, Monitoring Methods, Monitoring Tools, Undergraduate Dental Monitoring, Undergraduate Clinical Procedures Records

Teaching about biodiversity and its conservation could be an effective way to teach the importance of different species and human dependence on ecological support systems. This study compares the effectiveness of a digital and a paper-based dichotomous identification key for teaching pre-service teachers about plantspecies diversity. Twenty-four Slovenian teachers in pre-service training used a digital version of the key on tablet computers and twenty-nine used a paper-based version to identify woody species in the garden near their university faculty. Both keys contained the same species, identical photographs and the same sequence of steps to identify the species. The accuracy and time taken to identify the five species were measured. The participants also completed a questionnaire about the usability of the identification key. Overall, both versions of the key were equally good for determining species names. The digital version of the key was found to be more time-effective than the paper version only when multiple identification steps were required to identify species. The results confirm that those who scored better on the identification tasks have a better general opinion about the usability of the key especially students using digital version of the key. Implications for teachers using or creating identification keys are discussed in the conclusion.

In this paper, we present a system for automatic evaluation of the quality of a question paper. Question paper plays a major role in educational assessment. The quality of a question paper is crucial to fulfilling the purpose of the assessment. In many education sectors, question papers are prepared manually. A prior analysis of a question paper might help in finding the errors in the question paper, and better achieving the goals of the assessment. In this experiment, we focus on higher education in the technical domain. First, we conducted a student survey to identify the key factors that affect the quality of a question paper. The top factors we identified are question relevance, question difficulty, and time requirement. We explored the strategies to handle these factors and implemented them. We employ various concepts and techniques for the implementation. The system finally assigns a numerical quality score against these factors. The system is evaluated using a set of question papers collected from various sources. The experimental results show that the proposed system is quite promising.

In the industrialized world, increasing productivity and profitability is very important for companies as a benchmark of success in business processes. Some literature has defined the success factor of the successful application of the concept of TPM as a tool to improve the productivity performance of the company, therefore improving the productivity performance of the company becomes the main thing in improving long-term sustainable profitability for the company . In the manufacturing industry pulp and paper mills, the contribution of the highest production costs is in raw materials (Pulp and chemical raw materials), followed by energy and packaging. The energy sector occupies the top three in the cost contributor to variable costs, it is triggered because in the pulp paper industry sector, the consumption value for electrical energy and heat is very high. Therefore, success in eliminating eight major losses is a major success factor in improving the profitability of the company. To analyze the effects of elimination of eight major losses, reduction of production costs and increase in profitability can be solved by evaluating the influence of all indicators of eight major losses using PLS-SEM. The data used is operational data co-generation plant production of PT. XYZ in 2019. From the research conducted it is known that the variable Overall Plant Effectiveness (OPE) is significantly influenced by 2 (two) of the 3 (three) constituent indicators, namely Availability and Performance, both indicators affect: Productivity Improvement, Decreased Production Costs and Increased Profitability of the Company. The priority of improvement that must be done by considering the production cost performance data from the review of variable costs of energy is elimination: Loss Shutdown losses (A1), Loss Production adjustment loss (A2), Equipment failure (A3), Process failure ( A4), Normal Production (A5), and abnormal production (A6).

Allergo journal international 30(5), 155-168 (2021). doi:10.1007/s40629-021-00178-2, Published by Urban & Vogel, München

[Abstract] The accepted use of left ventricular assist device (LVAD) technology as a good alternative for the treatment of patients with advanced heart failure together with the improved survival of the LVAD-supported patients on the device and the scarcity of donor hearts has significantly increased the population of LVAD-supported patients. The expected and non-expected device-related and patient-device interaction complications impose a significant burden on the medical system exceeding the capacity of the LVAD implanting centres. The ageing of the LVAD-supported patients, mainly those supported with the 'destination therapy' indication, increases the risk for those patients to experience comorbidities common in the older population. The probability of an LVAD-supported patient presenting with medical emergency to a local emergency department, internal, or surgical ward of a non-LVAD implanting centre is increasing. The purpose of this trilogy is to supply the immediate tools needed by the non-LVAD specialized physician: ambulance clinicians, emergency ward physicians, general cardiologists, internists, anaesthesiologists, and surgeons, to comply with the medical needs of this fast-growing population of LVAD-supported patients. The different issues discussed will follow the patient's pathway from the ambulance to the emergency department and from the emergency department to the internal or surgical wards and eventually to the discharge home from the hospital back to the general practitioner. In this first part of the trilogy on the management of LVAD-supported patients for the non-LVAD specialist healthcare provider, after the introduction on the assist devices technology in general, definitions and structured approach to the assessment of the LVAD-supported patient in the ambulance and emergency department is presented including cardiopulmonary resuscitation for LVAD-supported patients.

The American Society for Parenteral and Enteral Nutrition (ASPEN) Position Paper focus is on applying the 4 ethical principles for clinician's decision-making in the use of artificially administered nutrition and hydration (AANH) for adult and pediatric patients. These basic principles are (1) autonomy, respect the patient's healthcare preferences; (2) beneficence, provide healthcare in the best interest of the patient; (3) nonmaleficence, do no harm; and (4) justice, provide all individuals a fair and appropriate distribution of healthcare resources. Preventing and resolving ethical dilemmas is addressed, with an emphasis on a collaborative, interdisciplinary approach. Optimizing early communication and promoting advance care planning, involving completion of an advance directive, including designation of a surrogate decision-maker, are encouraged. Clinicians achieve respect for autonomy when they incorporate the patient, family, community, country, geographical, and presumed cultural values and religious belief considerations into ethical decision-making for adults and children with a shared decision-making process. These discussions should be guided by the 4 ethical principles. Hospital committees and teams, limited-time trials, clinician obligation with conflicts, and forgoing of AANH are addressed. Specific patient conditions are addressed because of the concern for potential ethical issues: coma, decreased consciousness, and dementia; advanced dementia; cancer; eating disorders; and end-stage disease/terminal illness. Incorporated in the Position Paper are ethical decisions during a pandemic and a legal summary involving ethical issues. International authors presented the similarities and differences within their own country or region and compared them with the US perspective.

Human trafficking is a pandemic human rights violation with an emerging paradigm shift that reframes an issue traditionally seen through a criminal justice lens to that of a public health crisis, particularly for children. Children and adolescents who are trafficked or are at risk for trafficking should receive evidence-based, trauma-informed, and culturally responsive care from trained health care providers (HCPs). The purpose of this article was to engage and equip pediatric HCPs to respond effectively to human trafficking in the clinical setting, improving health outcomes for affected and at-risk children. Pediatric HCPs are ideally positioned to intervene and advocate for children with health disparities and vulnerability to trafficking in a broad spectrum of care settings and to optimize equitable health outcomes.

BackgroundChronic rhinosinusitis is regarded as a chronic airway disease. According to WHO recommendations, it may be a risk factor for COVID-19 patients. In most CRSwNP cases, the inflammatory changes affecting the nasal and paranasal mucous membranes are type-2 (T2) inflammation endotypes. MethodsThe current knowledge on COVID-19 and on treatment options for CRS was analyzed by a literature search in Medline, Pubmed, international guidelines, the Cochrane Library and the Internet. ResultsBased on international literature, on current recommendations by WHO and other international organizations as well as on previous experience, a panel of experts from EAACI and ARIA provided recommendations for the treatment of CRS during the COVID-19 pandemic. ConclusionIntranasal corticosteroids remain the standard treatment for CRS in patients with SARS-CoV-2 infection. Surgical treatments should be reduced to a minimum and surgery preserved for patients with local complications and for those with no other treatment options. Systemic corticosteroids should be avoided. Treatment with biologics can be continued with careful monitoring in noninfected patients and should be temporarily interrupted during the course of the COVID-19 infection.

[Abstract] The improvement in left ventricular assist device (LVAD) technology and scarcity of donor hearts have increased dramatically the population of the LVAD-supported patients and the probability of those patients to present to the emergency department with expected and non-expected device-related and patient-device interaction complications. The ageing of the LVAD-supported patients, mainly those supported with the 'destination therapy' indication, increases the risk for those patients to suffer from other co-morbidities common in the older population. In this second part of the trilogy on the management of LVAD-supported patients for the non-LVAD specialist healthcare provider, definitions and structured approach to the LVAD-supported patient presenting to the emergency department with bleeding, neurological event, pump thrombosis, chest pain, syncope, and other events are presented. The very challenging issue of declaring death in an LVAD-supported patient, as the circulation is artificially preserved by the device despite no other signs of life, is also discussed in detail.

Bone mineral abnormalities (defined as Chronic Kidney Disease Mineral Bone Disorder; CKD-MBD) are prevalent and associated with a substantial risk burden and poor prognosis in CKD population. Several lines of evidence support the notion that a large proportion of patients receiving maintenance dialysis experience a suboptimal biochemical control of CKD-MBD. Although no study has ever demonstrated conclusively that CKD-MBD control is associated with improved survival, an expanding therapeutic armamentarium is available to correct bone mineral abnormalities. In this position paper of Lombardy Nephrologists, a summary of the state of art of CKD-MBD as well as a summary of the unmet clinical needs will be provided. Furthermore, this position paper will focus on the potential and drawbacks of a new injectable calcimimetic, etelcalcetide, a drug available in Italy since few months ago.

Huge quantity of paper mill wastes are dumped at the outskirt of factory as unwanted materials. Vermicomposting is an eco-friendly technique for beneficial conversion of different biodegradable/organic wastes into useful organic manure utilizing earthworms. Solid wastes generated in paper mills contain appreciable quantity of organic matter. Attempt was made for bio-conversion of Emami paper mill wastes with different numbers of Eisenia fetida (5–30 earthworms/2 kg substrate) for studying its influence on vermi-conversing time and quality of prepared vermicompost. Vermicomposting was carried out in trays following heap method and quality of final product was determined following both chemical analysis and bioassay on wheat seedlings. Application of more earthworms up to 20 numbers per 2 kg substrate made bio-conversion quicker but further addition of earthworm, however, delayed the process as some earthworms came out of beds and died probably due to competition for food among earthworms inside beds. Ten earthworms per kg paper mill wastes–saw dust–cow dung mixture (1:0.5:0.5 weight wise) was found as optimum earthworm population for preparing quality vermicompost having more major and secondary plant nutrients. Bioassay of this manure on wheat seedlings also confirmed the analytical findings. It is confirmed that earthworm population in vermibed played vital role in faster decomposition of paper mill wastes and releasing of more nutrients, which ultimately helped in better growth of wheat seedlings. Successful demonstration of vermicomposting technique will encourage local farmers for beneficial utilization of paper mill wastes in their agriculture.

Neurogastroenterology and motility (NGM) disorders are common in childhood and are often very debilitating. Although pediatric gastroenterology fellows are expected to obtain training in the diagnosis and management of patients with these disorders, there is an ongoing concern for unmet needs and lack of exposure and standardized curriculum. In the context of tailoring training components, outcome and expressed needs of pediatric gastroenterology fellows and programs, members of the North American Society for Pediatric Gastroenterology, Hepatology and Nutrition (NASPGHAN) and American Neurogastroenterology and Motility Society (ANMS) developed guidelines for NGM training in North America in line with specific expectations and goals of training as delineated through already established entrustable professional activities (EPAs). Members of the joint task force applied their expertise to identify the components of knowledge, skills, and management, which are expected of NGM consultants. The clinical knowledge, skills and management elements of the NGM curriculum are divided into domains based on anatomic regions including esophagus, stomach, small bowel, colon and anorectum. In addition, dedicated sections on pediatric functional gastrointestinal (GI) disorders, research and collaborative approach, role of behavioral health and surgical approaches to NGM disorders and transition from pediatric to adult neurogastroenterology are included in this document. Members of the NASPGHAN-ANMS task force anticipate that this document will serve as a resource to break existing barriers to pursuing a career in NGM and provide a framework towards uniform training expectations at 3 hierarchical tiers corresponding to EPA levels.

What Is Known - Endoscopy Training is becoming an integral part of Paediatric Gastroenterology Training within Europe. - There is a great degree of variation between European endoscopy training in terms of duration, content, procedural volume, assessment during and at the end of training. What Is New? - Achievement of milestones in training more accurately assesses competency compared with procedural number. - Train the trainers’ courses and educational material,such as e-learning and endoscopy simulator training improve a structuredapproachinendoscopy teaching. - Cooperation with the National Paediatric Gastroenterology, Hepatology and Nutrition Societies in Europe will facilitate dissemination, discussion and implementation of results of this position paper.

BackgroundThe EAPC White Paper addresses the issue of spiritual care education for all palliative care professionals. It is to guide health care professionals involved in teaching or training of palliative care and spiritual care; stakeholders, leaders and decision makers responsible for training and education; as well as national and local curricula development groups.MethodsEarly in 2018, preliminary draft paper was written by members of the European Association for Palliative Care (EAPC) spiritual care reference group inviting comment on the four core elements of spiritual care education as outlined by Gamondi et al. (2013) in their paper on palliative care core competencies. The preliminary draft paper was circulated to experts from the EAPC spiritual care reference group for feedback. At the second stage feedback was incorporated into a second draft paper and experts and representatives of national palliative care organizations were invited to provide feedback and suggest revisions. The final version incorporated the subsequent criticism and as a result, the Gamondi framework was explored and critically revised leading to updated suggestions for spiritual care education in palliative care.ResultsThe EAPC white paper points out the importance of spiritual care as an integral part of palliative care and suggests incorporating it accordingly into educational activities and training models in palliative care. The revised spiritual care education competencies for all palliative care providers are accompanied by the best practice models and research evidence, at the same time being sensitive towards different development stages of the palliative care services across the European region.ConclusionsBetter education can help the healthcare practitioner to avoid being distracted by their own fears, prejudices, and restraints and attend to the patient and his/her family. This EAPC white paper encourages and facilitates high quality, multi-disciplinary, academically and financially accessible spiritual care education to all palliative care staff.

Diagnostic and evidential static image, video clip, and sound multimedia are captured during routine clinical care in cardiology, dermatology, ophthalmology, pathology, physiatry, radiation oncology, radiology, endoscopic procedural specialties, and other medical disciplines. Providers typically describe the multimedia findings in contemporaneous electronic health record clinical notes or associate a textual interpretative report. Visual communication aids commonly used to connect, synthesize, and supplement multimedia and descriptive text outside medicine remain technically challenging to integrate into patient care. Such beneficial interactive elements may include hyperlinks between text, multimedia elements, alphanumeric and geometric annotations, tables, graphs, timelines, diagrams, anatomic maps, and hyperlinks to external educational references that patients or provider consumers may find valuable. This HIMSS-SIIM Enterprise Imaging Community workgroup white paper outlines the current and desired clinical future state of interactive multimedia reporting (IMR). The workgroup adopted a consensus definition of IMR as “interactive medical documentation that combines clinical images, videos, sound, imaging metadata, and/or image annotations with text, typographic emphases, tables, graphs, event timelines, anatomic maps, hyperlinks, and/or educational resources to optimize communication between medical professionals, and between medical professionals and their patients.” This white paper also serves as a precursor for future efforts toward solving technical issues impeding routine interactive multimedia report creation and ingestion into electronic health records.

A newly emerging pandemic of coronavirus disease 2019 caused by severe acute respiratory coronavirus 2 is responsible for significant morbidity and mortality worldwide The ongoing substantial research endeavor to comprehend its associated coagulopathy requires proportional progress on guidance establishment Current review of evidence and statements on management of coagulopathy and thrombotic complications related to this novel disease is expected to be a precursory formulation for prospective guideline development © 2020, Sanglah General Hospital All rights reserved

The Centers for Medicare & Medicaid Services’ Severe Sepsis and Septic Shock Early Management Bundle (SEP-1) measure has appropriately established sepsis as a national priority. However, the Infectious Diseases Society of America (IDSA and five additional endorsing societies) is concerned about SEP-1’s potential to drive antibiotic overuse because it does not account for the high rate of sepsis overdiagnosis and encourages aggressive antibiotics for all patients with possible sepsis, regardless of the certainty of diagnosis or severity of illness. IDSA is also concerned that SEP-1’s complex “time zero” definition is not evidence-based and is prone to inter-observer variation. In this position paper, IDSA outlines several recommendations aimed at reducing the risk of unintended consequences of SEP-1 while maintaining focus on its evidence-based elements. IDSA’s core recommendation is to limit SEP-1 to septic shock, for which the evidence supporting the benefit of immediate antibiotics is greatest. Prompt empiric antibiotics are often appropriate for suspected sepsis without shock, but IDSA believes there is too much heterogeneity and difficulty defining this population, uncertainty about the presence of infection, and insufficient data on the necessity of immediate antibiotics to support a mandatory treatment standard for all patients in this category. IDSA believes guidance on managing possible sepsis without shock is more appropriate for guidelines that can delineate the strengths and limitations of supporting evidence and allow clinicians discretion in applying specific recommendations to individual patients. Removing sepsis without shock from SEP-1 will mitigate the risk of unnecessary antibiotic prescribing for noninfectious syndromes, simplify data abstraction, increase measure reliability, and focus attention on the population most likely to benefit from immediate empiric broad-spectrum antibiotics.

The World One Health Congresses are biennial gatherings of approximately 1500 professionals from relevant international organisations, OIE, FAO, WHO, World Bank, leading scientific experts and researchers in the field of One Health, animal production and trade, food safety, animal health, human health and environmentology/ecology, government representatives in public health, human health, food safety, environmental health and global health security. The Congress is organized by the One Health Platform.This white paper summarizes highlights of the 5th International One Health Congress in Saskatoon, Canada, June 2018 and serves as a roadmap for the future, detailing several concrete action points to be carried out in the run-up to the 6th World One Health Congress in Edinburgh, Scotland, June 2020.

Contains fulltext : 229587.pdf (Publisher’s version ) (Open Access) In Europe, lung cancer ranks third among the most common cancers, remaining the biggest killer. Since the publication of the first European Society of Radiology and European Respiratory Society joint white paper on lung cancer screening (LCS) in 2015, many new findings have been published and discussions have increased considerably. Thus, this updated expert opinion represents a narrative, non-systematic review of the evidence from LCS trials and description of the current practice of LCS as well as aspects that have not received adequate attention until now. Reaching out to the potential participants (persons at high risk), optimal communication and shared decision-making will be key starting points. Furthermore, standards for infrastructure, pathways and quality assurance are pivotal, including promoting tobacco cessation, benefits and harms, overdiagnosis, quality, minimum radiation exposure, definition of management of positive screen results and incidental findings linked to respective actions as well as cost-effectiveness. This requires a multidisciplinary team with experts from pulmonology and radiology as well as thoracic oncologists, thoracic surgeons, pathologists, family doctors, patient representatives and others. The ESR and ERS agree that Europe's health systems need to adapt to allow citizens to benefit from organised pathways, rather than unsupervised initiatives, to allow early diagnosis of lung cancer and reduce the mortality rate. Now is the time to set up and conduct demonstration programmes focusing, among other points, on methodology, standardisation, tobacco cessation, education on healthy lifestyle, cost-effectiveness and a central registry.Key Points* Pulmonologists and radiologists both have key roles in the set up of multidisciplinary LCS teams with experts from many other fields.* Pulmonologists identify people eligible for LCS, reach out to family doctors, share the decision-making process and promote tobacco cessation.* Radiologists ensure appropriate image quality, minimum dose and a standardised reading/reporting algorithm, together with a clear definition of a "positive screen".* Strict algorithms define the exact management of screen-detected nodules and incidental findings.* For LCS to be (cost-)effective, it has to target a population defined by risk prediction models.

Minimal invasive extracorporeal circulation (MiECC) systems have initiated important efforts within science and technology to further improve the biocompatibility of cardiopulmonary bypass components to minimize the adverse effects and improve end-organ protection. The Minimal invasive Extra-Corporeal Technologies international Society was founded to create an international forum for the exchange of ideas on clinical application and research of minimal invasive extracorporeal circulation technology. The present work is a consensus document developed to standardize the terminology and the definition of minimal invasive extracorporeal circulation technology as well as to provide recommendations for the clinical practice. The goal of this manuscript is to promote the use of MiECC systems into clinical practice as a multidisciplinary strategy involving cardiac surgeons, anaesthesiologists and perfusionists.

Fungi have the ability to transform organic materials into a rich and diverse set of useful products and provide distinct opportunities for tackling the urgent challenges before all humans. Fungal biotechnology can advance the transition from our petroleum-based economy into a bio-based circular economy and has the ability to sustainably produce resilient sources of food, feed, chemicals, fuels, textiles, and materials for construction, automotive and transportation industries, for furniture and beyond. Fungal biotechnology offers solutions for securing, stabilizing and enhancing the food supply for a growing human population, while simultaneously lowering greenhouse gas emissions. Fungal biotechnology has, thus, the potential to make a significant contribution to climate change mitigation and meeting the United Nation’s sustainable development goals through the rational improvement of new and established fungal cell factories. The White Paper presented here is the result of the 2nd Think Tank meeting held by the EUROFUNG consortium in Berlin in October 2019. This paper highlights discussions on current opportunities and research challenges in fungal biotechnology and aims to inform scientists, educators, the general public, industrial stakeholders and policymakers about the current fungal biotech revolution.

AimTo discuss ethical issues related to a complex study (PROFID) involving the development of a new, partly artificial intelligence-based, prediction model to enable personalised decision-making about the implantation of an implantable cardioverter defibrillator (ICD) in postmyocardial infarction patients, and a parallel non-inferiority and superiority trial to test decision-making informed by that model.MethodThe position expressed in this paper is based on an analysis of the PROFID trials using concepts from high-profile publications in the ethical literature.ResultsWe identify ethical issues related to the testing of the model in the treatment setting, and to both the superiority and the non-inferiority trial. We underline the need for ethical-empirical studies about these issues, also among patients, as a parallel to the actual trials. The number of ethics committees involved is an organisational, but also an ethical challenge.ConclusionThe PROFID trials, and probably other studies of similar scale and complexity, raise questions that deserve dedicated parallel ethics and social science research, but do not constitute a generic obstacle. A harmonisation procedure, comparable to the Voluntary Harmonization Procedure (VHP) for medication trials, could be needed for this type of trials.

Gender disparity exists in leadership roles within healthcare. While the majority of the healthcare workforce is comprised of women, significantly fewer women occupy leadership positions, particularly at executive and board levels. As the field of oncology pharmacy continues to rapidly expand and evolve, an assessment of the current state of women in oncology pharmacy leadership roles is vital to the growth and development of the profession. In the fall of 2017, the Hematology/Oncology Pharmacy Association (HOPA) hosted a summit to explore leadership issues facing women in oncology pharmacy which have the potential to affect our membership and our profession. This meeting included invited participants from across the fields of oncology and pharmacy and was part of HOPA’s strategic leadership initiative developed through the work of the HOPA Leadership Development Committee in 2016. This promotes a primary goal of HOPA, which is to support oncology pharmacists as they assume leadership roles within their practices and within healthcare to assure oncology pharmacy is integrated into cancer care. The purpose of this white paper is to (1) summarize key issues that were identified through a membership survey; (2) review ongoing efforts to address the needs of female oncology pharmacists in leadership development; (3) serve as a call to action for individuals and professional organizations to assist with and disseminate these efforts and highlight available resources, and (4) to provide practical steps to meet the needs of individuals, training programs, and institutions/employers.

The term sarcopenia was introduced in 1988. The original definition was a “muscle loss” of the appendicular muscle mass in the older people as measured by dual energy x‐ray absorptiometry (DXA). In 2010, the definition was altered to be low muscle mass together with low muscle function and this was agreed upon as reported in a number of consensus papers. The Society of Sarcopenia, Cachexia and Wasting Disorders supports the recommendations of more recent consensus conferences, i.e. that rapid screening, such as with the SARC‐F questionnaire, should be utilized with a formal diagnosis being made by measuring grip strength or chair stand together with DXA estimation of appendicular muscle mass (indexed for height2). Assessments of the utility of ultrasound and creatine dilution techniques are ongoing. Use of ultrasound may not be easily reproducible. Primary sarcopenia is aging associated (mediated) loss of muscle mass. Secondary sarcopenia (or disease‐related sarcopenia) has predominantly focused on loss of muscle mass without the emphasis on muscle function. Diseases that can cause muscle wasting (i.e. secondary sarcopenia) include malignant cancer, COPD, heart failure, and renal failure and others. Management of sarcopenia should consist of resistance exercise in combination with a protein intake of 1 to 1.5 g/kg/day. There is insufficient evidence that vitamin D and anabolic steroids are beneficial. These recommendations apply to both primary (age‐related) sarcopenia and secondary (disease related) sarcopenia. Secondary sarcopenia also needs appropriate treatment of the underlying disease. It is important that primary care health professionals become aware of and make the diagnosis of age‐related and disease‐related sarcopenia. It is important to address the risk factors for sarcopenia, particularly low physical activity and sedentary behavior in the general population, using a life‐long approach. There is a need for more clinical research into the appropriate measurement for muscle mass and the management of sarcopenia. Accordingly, this position statement provides recommendations on the management of sarcopenia and how to progress the knowledge and recognition of sarcopenia.

Improvements in survival among cancer patients have revealed the clinical impact of cardiotoxicity on both cardiovascular and hematological and oncological outcomes, especially when it leads to the interruption of highly effective antitumor therapies. Atrial fibrillation is a common complication in patients with active cancer and its treatment poses a major challenge. These patients have an increased thromboembolic and hemorrhagic risk but standard stroke prediction scores have not been validated in this population. The aim of this expert consensus-based document is to provide a multidisciplinary and practical approach to the prevention and treatment of atrial fibrillation in patients with active cancer. This is a position paper of the Spanish Cardio-Oncology working group and the Spanish Thrombosis working group, drafted in collaboration with experts from the Spanish Society of Cardiology, the Spanish Society of Medical Oncology, the Spanish Society of Radiation Oncology, and the Spanish Society of Hematology.

The clinical, educational, and research facets of lung transplantation have advanced significantly since the first lung transplant in 1963. The formation of the International Society for Heart and Lung Transplantation (ISHLT) and subsequent Registry has forged a precedent of collaborative teamwork that has significantly affected current lung transplantation outcomes. The Society for the Advancement of Anesthesia (SATA) is dedicated to developing educational platforms for all facets of transplant anesthesia. Additionally, we believe that the anesthetic training for lung transplantation has not kept pace with other advances in the field. As such, SATA presents for consideration these educational milestones and competencies for anesthetic fellowship training in the field of lung transplantation. The proposed milestones were designed on the framework of 6 core competencies created by the Accreditation Council on Graduate Medical Education. The milestones were identified by combining the expert opinion of our Thoracic Transplant Committee, our experience as educators, and literature review. We offer this White Paper to the anesthesiology and transplant communities as a starting point for the discussion and evolution of perioperative anesthetic care in the field of lung transplantation.

This study examined the responses of a population of brook stickleback (Culaea inconstans) exposed to pulp mill effluent at Jackfish Bay, Lake Superior, Canada, in May 2007 and May 2011. Brook stickleback were extirpated from the effluent-receiving site, presumably due to anoxia after this period. Females at the effluent-receiving site had significantly larger gonad sizes in 2007 and 2011. In 2011, effluent-exposed female gonadal development was significantly advanced when compared with reference sites; they were the second most mature when compared among three different reference sites. Analysis of 7-ethoxyresorufin-O-deethylase activity revealed that effluent-receiving site females had greater CYP1A induction in 2007 and significantly greater CYP1A induction in 2011. Effluent-receiving site males showed significantly reduced CYP1A induction in 2007 and significantly greater induction in 2011. Chemical evaluation of sediment from the receiving environment showed elevated levels of resin acids and the polycyclic aromatic hydrocarbon, retene. Higher condition factors and more mature gonads were consistent with higher winter and spring temperatures modified by effluent or by lake vs. stream environments. Overall, effects on effluent-exposed brook stickleback were not consistent with reported effects in white sucker exposed to the same effluent in previous studies. This article has been made Open Access thanks to the kind support of CAWQ/ACQE (https://www.cawq.ca).

The ever-growing urban population faces challenges of ageing infrastructure. The process for renewing the infrastructure is costly, and current practices for maintaining and repairing are often ineffective and labour intensive. Road networks, for instance, which act as the arteries of cities, suffer from reoccurring potholes (in the UK, a pothole is filled every 21 s). A more effective way of maintaining road networks is through a proactive approach, where condition assessment and intervention are conducted throughout the asset life cycle. However, there are barriers to a proactive approach, including budget constraints and the lack of effective technology for early defect detection (followed by a cheap yet effective repair). This paper puts forward an automated system, currently in development, based on cutting-edge robotic technologies to address these barriers and help achieve an effective proactive infrastructure maintenance and repair system. Technologies developed include automated condition assessment measures to detect road defects and repair technologies using a novel three-dimensional (3D) printing method to seal road cracks and potholes. Sealing small cracks by using 3D printing techniques has shown promising results by achieving superior mechanical properties.

[Abstract] The growing population of left ventricular assist device (LVAD)-supported patients increases the probability of an LVAD- supported patient hospitalized in the internal or surgical wards with certain expected device related, and patient-device interaction complication as well as with any other comorbidities requiring hospitalization. In this third part of the trilogy on the management of LVAD-supported patients for the non-LVAD specialist healthcare provider, definitions and structured approach to the hospitalized LVAD-supported patient are presented including blood pressure assessment, medical therapy of the LVAD supported patient, and challenges related to anaesthesia and non-cardiac surgical interventions. Finally, important aspects to consider when discharging an LVAD patient home and palliative and end-of-life approaches are described.

The rate of pediatric inflammatory bowel disease (IBD) has been increasing over the last decade and this increase has occurred most rapidly in the youngest children diagnosed

Cancer-related cognitive decline (CRCD) may have particularly significant consequences for older adults, impacting their functional and physical abilities, level of independence, ability to make decisions, treatment adherence, overall quality of life, and ultimately survival. In honor of Dr. Hurria's work we explore and examine multiple types of screening, assessment and non-pharmacologic treatments for CRCD. We then suggest future research and clinical practice questions to holistically appreciate the complexity of older adults with cancer's experiences and fully integrate the team-based approach to best serve this population. (C) 2019 Elsevier Ltd. All rights reserved.

EMS personnel in the U.S. continue to be overwhelmingly Caucasian and male, with 75% being male and 85% identifying as nonminority. While the population of the United States becomes more diverse in ethnicity, religion, and race, the EMS workforce remains largely homogenous and does not reflect the diversity of the population it serves. Given the growing diversity across the country, EMS personnel will increasingly be responding to calls for service involving patients with different cultural backgrounds than their own. This growing gap between providers and the population they serve may exacerbate already existing disparities in care.

To evaluate the effect of brown-rot fungi Oligoporus placenta and earthworm Eisenia fetida on decomposition of paper mill sludge, the paper mill sludge was mixed with cow dung in 0, 25, 50, 75, and 100% proportions and changes in physicochemical quality of waste mixtures was carried out for 28 days. All waste mixtures were treated with: Setup-I (E. fetida), Setup-II (O. placenta) and, Setup-III (E. fetida + O. placenta). A decrease in total organic carbon, C/N ratio and cellulose but an increase in total kjeldhal nitrogen, total phosphorus, total potassium and pH was recorded. The paper mill sludge in 50–75% proportion in feedstock showed the better results and rate of mineralisation were in order: Setup-III > Setup-I > Setup-II. The proportion of CD has direct role in waste mineralisation. The microbial population (bacterial, fungal and actinomycetes) and earthworm biomass were also high in Setup-III, suggesting the influence of brown-rot fungi on paper mill sludge humification. Results indicate that fungal inoculate in vermicomposting was effective in decomposing cellulose-rich industrial sludge.

Both trade and production of graphic paper have decreased over the last three decades. While this general decrease can partially be attributed to increased prominence of information technology, the overall figure is devoid of context and thus of most of its meaning to global economy. In this study we aim to break this trend down across the geographical and temporal scope, across its supply-chain commodities and to find out what drives the global trade patterns. Econometric trade models focus on the trading countries and direct exports or imports but fail to consider the structural and the indirect trade relations. We take the approach of network analysis, where the emphasis is on the structure of trade and not on country-level descriptors. We focus on 1995–2017 period as within it this decrease can be observed and assess the entire graphic paper and pulp supply chain, consisting out of printing and writing paper, mechanical wood pulp, chemical wood pulp, semichemical wood pulp, pulp made from fiber other than wood, recovered paper and paperboard. We employ descriptive statistical and network analysis, grouping and role analysis, and end with an inferential logistic regression quadratic assignment procedure model. Results show that newsprint trade decline is mirrored in printing and writing paper and mechanical wood pulp. The trade network densities have remained generally stable throughout the observed period, but the topological proprieties of the individual product groups vary greatly. Although no stabile grouping of countries throughout the assessed period could be observed, role analysis shows that countries tend to trade within their continent, that European countries are at the core of the trade network, and that the structural shift of decline of the trade value is followed by increasing prominence of several Asian countries, such as China and Indonesia. The most important finding of the study is that internal trade effects such as reciprocity and transitivity are much more explanatory than classical effects used in trade models such as GDP per capita, geographical distance or forest endowment.

Ageing is one of the greatest social and economic challenges of the 21st century for European societies. According to the latest population projections, by 2070, those aged 65 years and over will rise from 19% to 29%, while the share of those aged 80 and over will increase from 5% to 13% of the total population, which will be almost as large as the youngest population (aged 0–14) in that year.1 Because older people have different healthcare requirements, often developing disabilities or multimorbidity complications, health systems will need to adapt so they can provide adequate care for longer periods while remaining financially sustainable. The estimated change in the EU’s total public expenditure on the older population (the total public expenditure includes pensions, health care, long-term care, education and unemployment benefits) will increase from 25% of GDP in 2016 by 1.7 percentage points, reaching 26.7% in 2070. This will be caused mostly by spending on health care (+0.9 percentage points) and long-term care (+1.2 percentage points); the percentages refer to the baseline scenario.2 In view of such challenges, it is of the utmost importance that hospital pharmacists’ expertise in medicine use optimisation is fully utilised along the care pathway in order to mitigate problems prevalent in the older population, such as polypharmacy and drug adherence. Therefore, the following position paper of the European Association of Hospital Pharmacists (EAHP) outlines key points for policymakers to be mindful of in shaping responses. EAHP calls on national governments and health system managers to acknowledge hospital pharmacists’ drug expertise by investing in medication reconciliation and optimisation roles in all healthcare facilities, including nursing homes, as a key part of the European level response to the increasing prevalence of polypharmacy. EAHP calls for strengthened inter-sector communication, coordination and multidisciplinary collaboration as critical approaches …

This ESC Council on Stroke/EAPCI/EBNI position paper summarizes recommendations for training of cardiologists in endovascular treatment of acute ischaemic stroke. Interventional cardiologists adequately trained to perform endovascular stroke interventions could complement stroke teams to provide the 24/7 on call duty and thus to increase timely access of stroke patients to endovascular treatment. The training requirements for interventional cardiologists to perform endovascular therapy are described in details and should be based on two main principles: (i) patient safety cannot be compromised, (ii) proper training of interventional cardiologists should be under supervision of and guaranteed by a qualified neurointerventionist and within the setting of a stroke team. Interdisciplinary cooperation based on common standards and professional consensus is the key to the quality improvement in stroke treatment.

This White Paper presents the foundational domains with examples of key aspects of competencies (knowledge, skills, and attitudes) that are intended for curriculum development and accreditation quality assessment for graduate (master’s level) education in applied health informatics. Through a deliberative process, the AMIA Accreditation Committee refined the work of a task force of the Health Informatics Accreditation Council, establishing 10 foundational domains with accompanying example statements of knowledge, skills, and attitudes that are components of competencies by which graduates from applied health informatics programs can be assessed for competence at the time of graduation. The AMIA Accreditation Committee developed the domains for application across all the subdisciplines represented by AMIA, ranging from translational bioinformatics to clinical and public health informatics, spanning the spectrum from molecular to population levels of health and biomedicine. This document will be periodically updated, as part of the responsibility of the AMIA Accreditation Committee, through continued study, education, and surveys of market trends.

China’s household paper industry saw steady growth in 2017 as the country’s economy stabilized and improved, while benefiting from increased population urbanization and consumption upgrading. On the other hand, under the circumstance of strict environmental protection and high fluctuation of external pulp price, the speed of capacity clearance is accelerating, thus driving the market share closer to the leading position. This Paper analyzes the assets and business performance of three companies, Hengan International Group Co. Ltd, Vinda International Holdings Limited and C&S Paper Co. Ltd, which are the first tier in Chinese household Paper industry. It is concluded that Hengan, as the industry leader, has a large volume and is now in a stable position. Vinda also has diversified development, but the situation is not objective. As a rising star, C&S focuses on living paper. Though it is small in size, it is growing rapidly, and has already surpassed Vinda.

The present study demonstrates the vermistabilization of paper mill wastewater sludge (PMS) spiked with cow dung (CD) employing indigenous epigeic earthworm Perionyx excavatus Perrier. A total of six treatments were prepared along with a positive control (PC) and negative control (NC). Twenty earthworms were released into each treatment including PC and NC without earthworms. The different proportions viz., T1 (CD – 100%), T2 (PMS:CD – 1:3), T3 (PMS:CD – 1:2), T4 (PMS:CD – 1:1), T5 (PMS:CD – 3:1), T6 (PMS:CD – 2:1), PC (PMS – 100%) and NC (PMS – 100%) and changes in chemical parameters and microbial properties were recorded during the course of 60 days. Vermistabilization caused a significant decrease in the level of heavy metals: Cd (2.9–27.8%), Cu (0.22–42.3%), Pb (1.3–56.3%) and Cr (0.8–46.2%). The bioconcentration factor (BCFs) was also calculated and great amount of heavy metals accumulated in their body (mg kg−1) that ranged from 0.31 ± 0.003–0.45 ± 0.007 for Cd, 0.12 ± 0.005–0.24 ± 0.003 for Cu, 0.15 ± 0.005–0.31 ± 0.006 for Pb and 0.29 ± 0.007–0.56 ± 0.001 mg kg−1 for Cr, accumulation of heavy metals are in the order: Cr > Cd > Pb > Cu. The physicochemical parameters of earthworm treated substrate such as electrical conductivity, total nitrogen, total phosphorus and total potassium were significantly increased; whereas, pH, total organic carbon, C:N ratio (carbon: nitrogen) and C:P ratio (carbon: phosphorus) were reduced after 60 days of vermistabilization. The vermistabilized materials also had a higher population of bacteria (98.90 ± 0.30 CFU × 106 g−1), fungi (43.75 ± 0.55 CFU × 103 g−1) and actinomycetes (67.65 ± 0.45 CFU × 105 g−1) than initial mixtures. Moreover, several histopathological changes were observed in earthworm tissues viz., disintegration of cells, irregular surface of epidermis, cellular debris, irregular cellular compartmentation, and oval-shaped nucleus. Higher level of histopathological abnormalities was recorded in PC (PMS-100%) while none were detected in lower concentrations of PMS. Furthermore, the study concludes that the paper mill sludge in a mixture of cow dung (1:1 ratio) can be a useful proposition for utilizing this hazardous waste through the adoption of vermitechnology.

Objective The aims of this study were to understand the status quo of authors, collaborations between institutions, research hotspots, and research frontiers of fund-sponsored clinical nursing papers and to provide a reference for Chinese scholars to conduct clinical nursing studies in the future. Methods The visualization software CiteSpace was used to analyze fund-sponsored clinical nursing papers published between 2012 and 2016 in 12 core journals of nursing. Results In the clinical nursing field, there are many cooperative author groups; however, the collaborations between institutions are not close and exist mainly within the same province or city. High-frequency keywords have revealed the four clinical nursing research hotspots of population, diseases, nursing intervention, and others. Chinese medicine nursing, prevention, treatment and nursing, and new technology-aided nursing of ventilator-associated pneumonia are the study frontiers of clinical nursing. Conclusions Clinical nursing studies are rich in content and cover a wide range of areas, and their hotspots and frontiers are closely related to the requirements of clinical nursing. Collaborations across regions, provinces, and cities are not adequate; there is an urgent need to strengthen the cross-regional exchanges and collaborations to promote the further development of clinical nursing.

Mobile learning has been increased in past years and has attracted the interests of academicians and educators in the past many years especially in higher education. The mobile-based online test is the buzzing in the current pandemic time. Institutions need to use online learning as a powerful tool for conducting exams and assess the students effectively. Integrating technology in education can be advantageous for universities and help engage better results for students. Therefore, it is important to understand each student their capacities and create a different test based on the required difficulty. Students should be graded based on their capabilities. The purpose of the research study is to develop the progressive model with the calibration of difficulty level according to the student capacity. To achieve the goal, a test of 20 python questions was conducted on 120 students with each question having difficulty given by 8 field experts. To verify the model, 5 categories were formed with different difficulty levels which in turn gave satisfactory results. To find a relation between the initial difficulty and the calculative difficulty based on the student response, a correlation test was conducted. After careful analysis of the question difficulty and student responses, it was observed that both are highly dependent on each other wherein the difficulty level of any question can be calculated using incorrect answers. The correlation coefficient obtained between them was 0.9833. Upon collecting the difficulty of the questions and student responses, respective grading could be done using the stated formula. Later on, the progressive model was simulated with five different cases (Best case, above-average case, below average case, the average case, worst case). The model outperformed in all the cases with appropriate difficulty levels. Online Tests have ushered a revolution in the assessment of students but yet they tend to be unpopular in India as the evaluation based on pen-paper approach is preferred. The main reasons for this are difficult to grade everyone at the same level, susceptible to cheating, and transition to open books. Using our study, universities can identify obstacles, and prepare an appropriate result-driven plan of action for implementing the mobile-based online test and make easy migration from paper-based test to online test.

Percutaneous therapeutic options for an increasing variety of structural heart diseases (SHD) have grown dramatically. Within this context of continuous expansion of devices and procedures, there has been increased demand for physicians with specific knowledge, skills, and advanced training in multimodality cardiac imaging. As a consequence, a new subspecialty of ‘Interventional Imaging’ for SHD interventions and a new dedicated professional figure, the ‘Interventional Imager’ with specific competencies has emerged. The interventional imager is an integral part of the heart team and plays a central role in decision-making throughout the patient pathway, including the appropriateness and feasibility of a procedure, pre-procedural planning, intra-procedural guidance, and post-procedural follow-up. However, inherent challenges exist to develop a training programme for SHD imaging that differs from traditional cardiovascular imaging pathways. The purpose of this document is to provide the standard requirements for the training in SHD imaging, as well as a starting point for an official certification process for SHD interventional imager.

BACKGROUND Examination has always been an important part of the total educational process. Examinations are designed and administered at different stages of education and their results are used for various purposes like improvement in learning, grading and classification of students, selection for admission to higher classes or for scholarship, certification and for providing guidance for future, etc., Importance of educational progress in learning lesions in future life of student and lessons learned in life. Examinations are only for human persons not for animals and trees, important in Learning in feature.

A colorimetric polydiacetylene (PDA) paper strip sensor that can specifically recognize Bacillus thuringiensis (BT) HD-73 spores is described in this work. The target-specific aptamer was combined with PDA, and the aptamer-conjugated PDA vesicles were then coated on polyvinylidene fluoride (PVDF) paper strips by a simple solvent evaporation method. The PDA-aptamer paper strips can be used to detect the target without any pre-treatment. Using the paper strip, the presence of BT spores is directly observable by the naked eye based on the unique blue-to-red color transition of the PDA. Quantitative studies using the paper strip were also carried out by analyzing the color transitions of the PDA. The specificity of this PDA sensor was verified with a high concentration of Escherichia coli, and no discernable change was observed. The observable color change in the paper strip occurs in less than 1 h, and the limit of detection is 3 &times, 107 CFU/mL, much below the level harmful to humans. The PDA-based paper sensor, developed in this work, does not require a separate power or detection device, making the sensor strip highly transportable and suitable for spore analysis anytime and anywhere. Moreover, this paper sensor platform is easily fabricated, can be adapted to other targets, is highly portable, and is highly specific for the detection of BT spores.

Asthma prevalence in Italy is on the rise and is estimated to be over 6% of the general population. The diagnosis of asthma can be challenging and elusive, especially in children and the last two decades has brought evidences that asthma is not a single disease but consists of various phenotypes. Symptoms can be underestimated by the patient or underreported to the clinician and physical signs can be scanty. Usual objective measures, like spirometry, are necessary but sometimes not significant. Despite proper treatment asthma can be a very severe condition (even leading to death) however new drugs have recently become available which can be very effective in its control. Since asthma is currently thought to be caused by inflammation, a direct measure of the latter can be of paramount importance. For this purpose, the measurement of Fractional Exhaled Nitric Oxide (FENO) has been used since the early years of the current century as a non-invasive, easy-to-assess tool useful for diagnosing and managing asthma. This SIP-IRS/SIAAIC Position Paper is a narrative review which summarizes the evidence behind the usefulness of FENO in the diagnosis, management and phenotypization of asthma.

Using standardized tests such as paper-based TOEFL with three subtests for classroom assessment is restricted by the length of the test, which is usually longer than the class duration. Therefore, it is significant to be able to predict other subtests by conducting only one subtest. Therefore, the current study aimed to calculate prediction coefficients, enabling teachers to predict scores in paper-based TOEFL by conducting only one subtest. The data to create the prediction models were obtained from 2,030 scores of Institutional TOEFL, i.e. paper-based TOEFL without writing subtest. The prediction coefficient was calculated by using linear regression analysis. The result shows that the listening comprehension sub-score predicts the TOEFL score more accurately (MSE of 520) than other sub-scores (MSE of 553 and 587). The intercept for listening comprehension sub-score was 373.07, 357.14 for structure & written expression, and 364.19 for reading comprehension. In addition, the slope for each sub-score was 4.07, 5.96, and 4.63, respectively. Therefore, a listening test should be used in predicting the overall TOEFL scores for an accurate prediction.

Light-reflecting characteristics play a crucial role in optically rewritable liquid crystal display (electronic paper). By using a special optimizer software, light-reflecting characteristics of the twisted nematic cell were calculated. The achieved values of the normalized reflection coefficients range within ∼ 0.03 - 0.43, which is comparable or better than other commercial technologies. The calculated contrast ratio of the device is 10 : 1. A 2D image, which can be displayed on the electronic paper was obtained. Comparison of the simulated background color and contrast ratio is very similar with the results, which were obtained in experimental cells of other studies. Our calculations indicate that angular dependence of the reflectance coefficient is almost uniform within a wide range of viewing angles.

This study explored the relationship between syntactic complexity and rhetorical functions and the relationship between syntactic complexity and level of move/step realization in learner-generated research paper introductions. We created a corpus of 79 introductions written by undergraduate L2 students at intermediate to high-intermediate levels. We annotated the introductions for moves and steps, measured their syntactic complexity at the global, clausal, and phrasal levels, and rated their level of move/step realization across four levels (no, low, intermediate, and high). We conducted one-way MANOVA, one-way ANOVA, Pearson correlation, and stepwise multiple linear regression analyses. We found sentences realizing Reviewing items of previous research function to be significantly longer than other steps in Move1 and to contain significantly more clausal and phrasal complexity features. Sentences performing Claiming centrality function also demonstrated significantly more phrasal complexity features as measured by complex nominals per clause. We also found a higher level of phrasal complexity in introductions with a higher level of move/step realization, which can be attributed to introductions including Step1 and Step3, rather than containing all steps. Our findings imply that there is value in developing explicit instructions on how to use complex structures in performing rhetorical steps in research paper introductions. © 2021 Elsevier Ltd

Valorisation involves conversion of toxic compounds into value added products. The present study has tried to evaluate the potential of vermicomposting in management of different types of toxic paper mill wastes such as primary waste (VCP) and secondary waste (VCS) using Eisenia fetida for 60 days. The procedure was performed using sundried samples of paper mill wastes, cow dung and straw in different trial sets using different ratios. The study had revealed that the trial sets (VCP1 and VCS1) using ratio of paper mill waste: Cow dung: Straw (5:4:1) were effective in maintaining physiochemical parameters and different population attributes of earthworm. The present study had also demonstrated the enzymatic enrichment of vermicompost in terms of 19 enzymes such as α-Glucosidase, lipase, leucine aminopeptidase etc. in maintenance of C/N ratio of the compost. A significant reduction of heavy metals were noticed in vermicomposting of primary waste (VCP1) as Zn (40%) ​> ​Pb (36%) ​> ​Cr (28%) ​> ​Cu (25%) and secondary waste (VCS1) as Zn (44%) ​> ​Pb (41%) ​> ​Cu (19%) ​> ​Cr (13%). Such reduction of heavy metal was highly correlated with the reduction of C/N ratio of the vermicompost. The process of bioremediation was further manifested through the regular monitoring of bioaccumulation factor (BAF) among earthworm population in vermicomposting of primary waste (VCP1) as Zn (0.40) ​> ​Cu (0.23) ​> ​Cr (0.18) ​> ​Pb (0.11) and secondary waste (VCS1) as Zn (0.47) ​> ​Cu (0.25) ​> ​Cr (0.21) ​> ​Pb (0.14). Therefore, the study concludes that the ratio of paper mill waste, cow dung and straw (5:4:1) can be an efficient formulation in qualitative enrichment of different toxic organic paper mill wastes through vermicomposting.