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Introduction: End-of-life care is often provided by nurses in intensive care units, and enhancing the quality of patient care largely depends on personality traits. Aim: The study aimed to investigate the associations between the attitudes and practices of intensive care nurses toward end-of-life care and their personality traits. Method: This cross-sectional study involved 201 intensive care nurses. The Ten-item Personality Inventory and the Attitudes and Behaviors Towards End-of-Life Care Scale were used. Regression analysis and the independent samples t-test were used to analyze the data. Results: The nurses' average age was 29.90 ± 4.64 years. The highest-scoring personality traits were extroverted and willing, sympathetic and warm, and reliable and self-disciplined. Age was significantly associated with agreeableness (p = 0.043). Emotional stability scores were lower for nurses in anesthesia and reanimation units compared to other units (p = 0.004). The duration of working in the intensive care unit was inversely connected with extraversion (p = 0.023). The mean overall score for attitudes and behaviors about end-of-life care was 56.29 ± 5.62. No significant correlation was found between personality traits and the Attitudes and Behaviors towards the End-of-Life Care Scale. Conclusion: Age, the type of intensive care unit, and years of experience were associated with certain personality traits among nurses. Yet, no statistically significant correlation was discovered between personality characteristics, beliefs, and practices around end-of-life care

Abstract Background Calf muscle strain injuries (CMSI), also known as “tennis leg,” are frequently observed in middle-aged and physically active people, including non-professional athletes. While magnetic resonance imaging (MRI) is frequently used to assess the extent of these injuries, the relationship between MRI findings and long-term functional outcomes in non-athletic populations remains underexplored. This study aimed to investigate the correlation between MRI-detected injury severity and functional outcomes using the Achilles Tendon Rupture Score (ATRS) and the Tegner Activity Scale (TAS). Methods A retrospective review was conducted on 78 non-athletic patients diagnosed with CMSI and were followed for an average of 25.6 ± 16.1 months. Injury severity was classified into three grades: Grade 1 (edema without architectural disruption), Grade 2 (partial muscle disruption with hematoma), and Grade 3 (complete muscle disruption or tendon detachment) based on MRI examination. The functional outcomes were assessed using the ATRS and TAS. A simple linear regression analysis was conducted to assess the impact of demographic variables and MRI findings on ATRS. Results The mean ATRS at the final follow-up was 92.9 ± 10.6, with 75.6% of patients achieving an excellent outcome. Despite the excellent ATRS scores, a notable reduction in TAS was evident from the pre-injury assessment (4.4 ± 1.2) to the final follow-up (3.8 ± 1.3; p

Abstract Background This study aimed to evaluate the predictive value of anthropometric measurements for two-stranded peroneus longus tendon (PLT) graft thickness using ultrasonography Materials and methods A prospective study was conducted on 204 healthy volunteers (102 males and 102 females) aged 18–40 years. Anthropometric measurements were recorded, including height, weight, body mass index (BMI), fibular length, calf circumference, and ankle circumference. The Tegner Activity Scale (TAS) was used to assess activity levels. PLT cross-sectional area (CSA) was measured using ultrasonography. Two-stranded PLT graft thickness was calculated using the previously reported formula by Luo et al. A thickness of less than 8 mm of PLT graft was accepted as an insufficient autograft for anterior cruciate ligament reconstruction (ACLR). Correlation and regression analyses were performed to identify predictors of two-stranded PLT graft thickness. Receiver operating characteristic (ROC) analysis was performed to establish the best threshold values. Results Males had a significantly greater PLT CSA (0.17 ± 0.03 cm2) and predicted two-stranded PLT graft thickness (8.1 ± 0.6 mm) compared with females (0.15 ± 0.03 cm2 and 7.5 ± 0.6 mm, respectively; p

Abstract Background This study aimed to evaluate the effectiveness of circumferential patellar denervation in reducing anterior knee pain (AKP) and improving clinical outcomes after total knee arthroplasty (TKA) without patellar resurfacing. Materials and methods This prospective, non-randomized, observational study included patients who underwent primary TKA at our institution between August 2023 and January 2024. Patients were divided into two groups: those who received patellar denervation (PD group) and those who did not (NPD group). The primary outcome was the reduction in anterior knee pain (AKP), measured by the Visual Analog Scale (VAS). Secondary outcomes included the Kujala Knee Score, Western Ontario and McMaster Universities Arthritis Index (WOMAC), and range of motion (ROM). Assessments were conducted preoperatively and at 3 and 6 months postoperatively. Results Four patients in the PD group and five in the NPD group were excluded from the study due to failure to complete follow-up. Thus, 74 female and 16 male patients with a mean age of 67.4 ± 4.2 years were included in the final analysis. There were no significant differences between the two groups with respect to age, sex, side of surgery, height, weight, BMI, grade of patellofemoral osteoarthritis, preoperative ROM, VAS score, Kujala score, and WOMAC score (p: n.s. for all variables). No significant differences were found between the groups for VAS, Kujala, and WOMAC scores at any time point (p: n.s.). Significant improvements in these scores over time were indicated by repeated measures ANOVA (p = 0.001 for both groups). Pairwise comparisons showed significant improvements from preoperative to postoperative months three and six and from postoperative months three to six (p = 0.001 for all comparisons). Both groups experienced decreased knee ROM at third month, which returned to preoperative values at sixth month with no significant differences. No complications were observed during the study. Conclusions Circumferential patellar denervation does not provide additional benefit in reducing anterior knee pain or improving functional outcomes compared to the non-denervation approach in TKA without patellar resurfacing. Level of evidence Level III, Prospective comparative study.

Introduction Intense endurance exercise is discouraged for patients with arrhythmogenic right ventricular cardiomyopathy (ARVC), as it can increase the risk for adverse cardiac events as well as accelerate disease progression. While a sedentary lifestyle is also not advisable, there is currently no prospective data on the safety of physical activity for ARVC patients. To describe ARVC patients' average and peak ventricular arrhythmia burden – estimated from the prevalence of premature ventricular contractions (PVC) – measured during and after different exercise modalities and intensities, in context with cardiac and physiological load. Methods Twenty ARVC patients (8 f/12 m, age 48 ± 15 years, BMI 24 ± 3 kg/m2, resting PVC burden 4 ± 4%) with a heterozygous pathogenic/likely pathogenic plakophilin-2 (PKP-2) variant prospectively performed different exercises while monitored via 12-lead ECG. The order of modalities was randomized and participants were instructed to stop when surpassing perceived exertion of 15 (6-20 Borg scale). Resistance exercises included 2-min two-legged squats and single arm biceps curls (20 repetitions each) while endurance exercise included 5-min treadmill walking at comfortable speed and 3-min cycling bouts at a heart rate (HR) of 80, 100 and 120 bpm. Each activity was followed by a 10-min recovery period. Blood lactate concentration [La-] was assessed at the end of each cycling bout, with 4 mmol/L defined as a threshold to describe high-intensity exercise. Results No adverse events (including sustained ventricular tachyarrhythmia) nor premature terminations occurred. Average PVC burden during activities (including 5 min recovery) was lower for biceps curls compared with all other activities (p < 0.046), despite having the second highest level of perceived effort (13.8 ± 1.7 units). Biceps curls elicited ~20 mmHg (p < 0.001) lower peak systolic blood pressure and ~40 bpm peak lower HR (p < 0.001) compared with cycling at 120 bpm, despite similar perception of effort (12.9 ± 1.7, p = 0.818). Peak PVC burden during the different activities (highest PVC count in 1 min) ranged between 0–57% among participants and it was lower during the activities (5 ± 8%) than the subsequent 5-min recovery (8 ± 8%, p = 0.006). but no differences were detected between activities. Five patients (25%) presented [La-] that exceeded 4.0 mmol/L when cycling at 120 bpm. Discussion/Conclusion PVC burden, a marker for arrhythmogenicity, was generally higher during recovery than during exercise, with the smallest burden found during the exercise with a small muscle mass, despite high perceived exertion. Thus, such exercises might be better suited for training in ARVC patients. Generalized recommendations for a maximum HR of 120 bpm during exercise likely predispose a high number of ARVC patients to inadvertently perform high-intensity exercise, risking accelerating disease progression. Therefore, individualized exercise prescription should be recommended.

ABSTRACT Background The orf virus (ORFV) is a viral pathogen that primarily causes contagious ecthyma in humans and different ruminants. The infection, which is common worldwide, causes large‐scale economic losses to animal breeders. Objective and Methods In this study, tissue samples collected from eight randomly selected goats with dermatological lesions on the teats were examined in different goat herds. B2L gene‐specific primer pairs (PP1, PP3 and PP4) were used to reveal the presence of ORFV by molecular methods and for phylogenetic analysis. Results Viral DNA was detected in four of eight tissues using the semi‐nested PCR method. In addition, the data obtained by performing sequence analyses of the amplicons with positive results were compared with the information of different ORFV isolates registered in the GenBank database. Based on the sequence analysis of the field isolates obtained in our study, it was found that the nucleotide similarities among these isolates and those from Asian countries were 100%. Furthermore, ORFV isolates collected from different species and produced in Türkiye over various periods exhibited homologous nucleotide sequences with similarities ranging from 98.1% to 98.8%. In the phylogenetic tree drawn based on the B2L genomic region, it was observed that our field isolates were classified in Group I together with other Turkish and Asian strains. Conclusion As a result, while other pathogenic agents are considered the cause of disease in goats with dermatological lesions on their mammary tissue, the ORFV should also be evaluated, and protection and control programs should be prepared accordingly.

ObjectivesAs one type of vaccine policy, the effectiveness and spillover effects of the US CDC vaccine recommendations are inadequately evaluated. This study aims to fully evaluate its impacts on male adults, in addition to children, using better data.DesignA before-after study design to examine the CDC’s 2011 HPV vaccine recommendation for men aged 11–21.Data analysisIndividual-level data included the 2010–2015 US National Health Interview Survey full sample of 7,000 male children aged 11–18, younger adults aged 19–21 and 22–25, and older adults aged 26–60. Pooled cross-sectional surveys contained individual-level vaccination, socioeconomic, and demographic information. Outcome variable is an individual HPV vaccination status, measured as individual probability of HPV vaccination. Dummy regressions were estimated by a Linear Probability Model (LPM) with fixed effects for target and non-target age groups.ResultsThe policy was significantly associated with a 14.8% (p

Abstract Purpose This study aims to evaluate the long-term outcomes of saphenous nerve (SN) injuries from hamstring tendon harvesting during ACL reconstruction, focusing on clinical results and patient satisfaction after at least two years. Additionally, it investigates the incidence, recovery patterns, and impact of these injuries on functional outcomes, daily activities, and ACL re-rupture rates immediately post-surgery and at final follow-up. Materials and methods A retrospective review was conducted on patients who had undergone ACL reconstruction with hamstring tendon grafts at a single institution between January 2015 and January 2020. The incidence of SN injuries was assessed immediately after surgery and at final follow-up. Additionally, the recovery rate and time were evaluated, and the impact of these injuries on functional outcomes was measured using the Lysholm Knee Score (LKS) and patient-reported effects on daily activities. Results Of the 159 patients analyzed, iatrogenic SN injuries were initially observed in 87 (54.7%) patients post-ACLR. By the final follow-up, paresthesia had resolved in 36 (22.6%) patients within an average of 11.1 months. Persistent SN injuries were recorded in 51 (32.1%) patients, affecting various extents of the infrapatellar branch (IPBSN) and the sartorial branch (SBSN) of the saphenous nerve. Patients with persistent SN injuries experienced a significant impact on daily activities and had lower LKS scores compared to those without injuries or with recovered injuries. Furthermore, a higher re-rupture rate was associated with persistent SN injuries. Conclusions The study finds that SN injuries during hamstring graft harvesting for ACL reconstruction are common, with a significant portion of patients experiencing persistent sensory deficits for at least two years postoperatively. These injuries are observed to adversely affect patient satisfaction and functional outcomes and to increase the re-rupture rate.

IntroductionIn recent years, high-density microelectrode arrays (HD-MEAs) have emerged as a valuable tool in preclinical research for characterizing the electrophysiology of human induced pluripotent stem-cell-derived cardiomyocytes (iPSC-CMs). HD-MEAs enable the capturing of both extracellular and intracellular signals on a large scale, while minimizing potential damage to the cell. However, despite technological advancements of HD-MEAs, there is a lack of effective data-analysis platforms that are capable of processing and analyzing the data, particularly in the context of cardiac arrhythmias and drug testing.MethodsTo address this need, we introduce CardioMEA, a comprehensive data-analysis platform designed specifically for HD-MEA data that have been obtained from iPSCCMs. CardioMEA features scalable data processing pipelines and an interactive web-based dashboard for advanced visualization and analysis. In addition to its core functionalities, CardioMEA incorporates modules designed to discern crucial electrophysiological features between diseased and healthy iPSC-CMs. Notably, CardioMEA has the unique capability to analyze both extracellular and intracellular signals, thereby facilitating customized analyses for specific research tasks.Results and discussionWe demonstrate the practical application of CardioMEA by analyzing electrophysiological signals from iPSC-CM cultures exposed to seven antiarrhythmic drugs. CardioMEA holds great potential as an intuitive, userfriendly platform for studying cardiac diseases and assessing drug effects.

ABSTRACT Much effort has been made to uncover the cellular heterogeneities of human hearts by single-nucleus RNA sequencing. However, the cardiac transcriptional regulation networks have not been systematically described because of the limitations in detecting transcription factors. In this study, we optimized a pipeline for isolating nuclei and conducting single-nucleus RNA sequencing targeted to detect a higher number of cell signal genes and an optimal number of transcription factors. With this unbiased protocol, we characterized the cellular composition of healthy human hearts and investigated the transcriptional regulation networks involved in determining the cellular identities and functions of the main cardiac cell subtypes. Particularly in fibroblasts, a novel regulator, PKNOX2, was identified as being associated with physiological fibroblast activation in healthy hearts. To validate the roles of these transcription factors in maintaining homeostasis, we used single-nucleus RNA-sequencing analysis of transplanted failing hearts focusing on fibroblast remodelling. The trajectory analysis suggested that PKNOX2 was abnormally decreased from fibroblast activation to pathological myofibroblast formation. Both gain- and loss-of-function in vitro experiments demonstrated the inhibitory role of PKNOX2 in pathological fibrosis remodelling. Moreover, fibroblast-specific overexpression and knockout of PKNOX2 in a heart failure mouse model induced by transverse aortic constriction surgery significantly improved and aggravated myocardial fibrosis, respectively. In summary, this study established a high-quality pipeline for single-nucleus RNA-sequencing analysis of heart muscle. With this optimized protocol, we described the transcriptional regulation networks of the main cardiac cell subtypes and identified PKNOX2 as a novel regulator in suppressing fibrosis and a potential therapeutic target for future translational studies.

Background/Objectives: Epilepsy is a prevalent neurological disorder characterized by seizures that significantly impact individuals and their social environments. Given the unpredictable nature of epileptic seizures, developing automated epilepsy diagnosis systems is increasingly important. Epilepsy diagnosis traditionally relies on analyzing EEG signals, with recent deep learning methods gaining prominence due to their ability to bypass manual feature extraction. Methods: This study proposes a continuous wavelet transform-based depthwise convolutional neural network (DCNN) for epilepsy diagnosis. The 35-channel EEG signals were transformed into 35-channel images using continuous wavelet transform. These images were then concatenated horizontally and vertically into a single image (seven rows by five columns) using Python’s PIL library, which served as input for training the DCNN model. Results: The proposed model achieved impressive performance metrics on unseen test data: 95.99% accuracy, 94.27% sensitivity, 97.29% specificity, and 96.34% precision. Comparative analyses with previous studies and state-of-the-art models demonstrated the superior performance of the DCNN model and image concatenation technique. Conclusions: Unlike earlier works, this approach did not employ additional classifiers or feature selection algorithms. The developed model and image concatenation method offer a novel methodology for epilepsy diagnosis that can be extended to different datasets, potentially providing a valuable tool to support neurologists globally.

BackgroundData on the use of the wearable cardioverter defibrillator in patients suffering from inherited and congenital heart disease are limited. Consequently, evidence for guideline recommendations in this patient population is lacking.MethodsIn total 1,675 patients were included in a multicenter registry of eight European centers. In the present cohort, we included 18 patients suffering from congenital and inherited heart disease.ResultsNine patients (50%) were male with a mean age of 41.3 ± 16.4 years. Four patients suffered from hypertrophic cardiomyopathy (HCM), four patients suffered from non-compaction cardiomyopathy (NCCM), two patients were diagnosed with arrhythmogenic right ventricular cardiomyopathy (ARVC) and one patient suffered from muscular dystrophy of the limb-girdle type with cardiac involvement, secondary cardiomyopathy. Three patients presented with Brugada syndrome (BrS). One patient suffered from long-QT syndrome type 1 (LQTS1). Furthermore, two patients had congenital heart defects and one patient suffered from cardiac sarcoidosis (CS). There were no appropriate/inappropriate shocks with the WCD in this cohort. One patient had recurrent self-limiting sustained ventricular tachycardia during the wear time, but actively inhibited a shock and was hospitalized. The compliance rate in this cohort was 77.8% with a mean wear time of 45.3 ± 26.9 days with a mean follow-up time of 570 ± 734 days. 55.6% (10/18) of the patients received an ICD after WCD wear time.ConclusionsThis retrospective study of patients with inherited and congenital heart disease shows that WCD use is not beneficial in the majority of patients with inherited and congenital heart disease.

Climate change, which refers to the radical climatic changes that occur as a result of factors such as the release of various gases into the atmosphere, fossil fuel consumption, and industrial activities, is serious global concern. Food and water shortages, increased flooding, extreme temperatures, new epidemics, and economic losses are all threats posed by climate change. To mitigate the adverse effects of this phenomenon, some measures can be taken by all individuals. The study aims to investigate people’s attitudes toward climate change by determining their behavioral intentions with a model based on Protection Motivation Theory (PMT). The behavioral intentions of individuals to prevent climate change were analyzed with the Structural Equation Model (SEM). The source of data is a questionnaire conducted in Türkiye with 526 people over the age of 18. The results reveal that people’s threat and coping appraisals are effective in the formation of behavioral intentions to combat climate change and thus contribute significantly to protection motivation. Higher response efficiency and self-efficacy lead to higher levels of protection motivation. Threat and coping appraisal account for 65.3% of the total change in behavioral intentions.

Abstract Background Stereotactic arrhythmia radioablation (STAR) is delivered with a planning target volume (PTV) prescription dose of 25 Gy, mostly to the surrounding 75–85% isodose line. This means that the average and maximum dose received by the target is less than 35 Gy, which is the minimum threshold required to create a homogenous transmural fibrosis. Similar to catheter ablation, the primary objective of STAR should be transmural fibrosis to prevent heterogenous intracardiac conduction velocities and the occurrence of sustained ventricular arrhythmias (sVA) caused by reentry. We hypothesize that the current dose prescription used in STAR is inadequate for the long-term prevention of sVA and that a significant increase in dose is necessary to induce transmural scar formation. Objective A single arm, multi-center, phase II, dose escalation prospective clinical trial employing the i3 + 3 design is being conducted to examine the safety of a radiation dose-escalation strategy aimed at inducing transmural scar formation. The ultimate objective of this trial is to decrease the likelihood of sVA recurrence in patients at risk. Methods Patients with ischemic or non-ischemic cardiomyopathy and recurrent sVA, with an ICD and history of ≥ 1 catheter ablation for sVA will be included. This is a prospective, multicenter, one-arm, dose-escalation trial utilizing the i3 + 3 design, a modified 3 + 3 specifically created to overcome limitations in traditional dose-finding studies. A total of 15 patients will be recruited. The trial aims to escalate the ITV dose from 27.0 Gy to an ITV prescription dose-equivalent level of maximum 35.1 Gy by keeping the PTV prescription dose constant at 25 Gy while increasing the dose to the target (i.e. the VT substrate without PTV margin) by step-wise reduction of the prescribing isodose line (85% down to 65%). The primary outcome of this trial is safety measured by registered radiation associated adverse events (AE) up to 90 days after study intervention including radiation associated serious adverse events graded as at least 4 or 5 according to CTCAE v5, radiation pneumonitis or pericarditis requiring hospitalization and decrease in LVEF ≥ 10% as assessed by echocardiography or cardiac MRI at 90 days after STAR. The sample size was determined assuming an acceptable primary outcome event rate of 20%. Secondary outcomes include sVA burden at 6 months after STAR, time to first sVA recurrence, reduction in appropriate ICD therapies, the need for escalation of antiarrhythmic drugs, non-radiation associated safety and patient reported outcome measures such as SF-36 and EQ5D. Discussion DEFT-STAR is an innovative prospective phase II trial that aims to evaluate the optimal radiation dose for STAR in patients with therapy-refractory sVA. The trial has obtained IRB approval and focuses on determining the safe and effective radiation dose to be employed in the STAR procedure. Trial registration NCT05594368.

Sunulan çalışmada solunum yolu hastalığı belirtileri gösteren koyunlarda genel fiziksel ve özel klinik muayene bulgularının, tam kan sayımı sonuçlarının ve nazofarengial sürüntü örneklerinin incelenmesi amaçlandı. Çalışmada solunum yolu hastalığı şikâyeti bulunan bir İvesi koyun sürüsünde (n:62) alt solunum yolu hastalığı belirtileri tespit edilen 18 adet dişi koyun kullanıldı. Hasta koyunların yaş kayıtları tutuldu, genel fiziksel muayeneleri gerçekleştirildi. Özel klinik muayene parametrelerinin her biri kendi içinde skorlandı. Hasta koyunlar akciğer oskultasyon skor sonuçlarına göre “Hafif Hasta (n:11)” ve “Orta Hasta (n:7)” şeklinde iki gruba ayrıldı. Hasta hayvanlar da dahil bütün koyunlardan antikoagülantlı ve antikoagülantsız kan örnekleri alındı. Antikoagülantlı kan örneklerinden tam kan sayımı yapıldı. Hasta (n:18) ve sağlıklı (n:6) koyunlardan mikrobiyolojik ve virolojik analizler için steril swap ile nazofarengial sürüntü örnekleri alındı. Kan (n:62) ve nazofarengial sürüntü (n:24) örneklerinden Bovine herpesvirus tip 1, Respiratorik sinsityal virus (RSV), Parainfluenza 3 (PI-3) ve Pestivirus varlığına yönelik analizler gerçekleştirildi. Hafif hasta ve orta hasta koyunlar karşılaştırıldığında, yaş, dakikadaki kalp atım sayısı, klinik durum gözlem skoru, MCH Pg, MCHC g/dL verilerinde gruplar arasında anlamlı farklılık (P

Introduction Patients suffering from arrhythmogenic right ventricular cardiomyopathy (ARVC) should avoid intense endurance exercise to reduce the risk of adverse cardiac events and disease progression. On the other hand, an active lifestyle might be preferable to a sedentary one, which also brings a host of complications. Evidence for safe levels of physical activity in ARVC, however, is scarce. This is study aimed to describe the ventricular arrhythmia burden - estimated as the prevalence of premature ventricular contractions (PVC) - of different exercise modalities and intensities on ARVC patients. Methods The pilot analysis includes four (1F, 33 ± 12 yrs, BMI 24 ± 4 kg/m2) ARVC patients harboring a pathogenic plakophilin-2 variant and carrying an implantable cardioverter-defibrillator performed different exercises while monitored via 12-lead ECG. The order of modalities was randomized and participants instructed to stop when surpassing perceived exertion of 15 on the Borg 6-20 scale. Resistance exercises included two-legged squats and single arm biceps curls (each with 20 repetitions and 2 min duration) while endurance exercise included 5 min of treadmill walking, 3 min cycling bouts at heart rate (HR) of 80, 100 and 120 bpm as well as cycling at 120 bpm with 2 additional min of active cool down. Blood lactate concentration was assessed at the end of the cycling bouts. Results No adverse cardiac event were noted and no exercise was terminated for medical reasons. During walking HR was 76 ± 8 bpm, whereas PVC burden was 11 ± 6% (range 4-18%). Cycling at 82 ± 4 bpm induced a PVC burden of 7 ± 5% (range 3- 14%), which increased to 13 ± 8% (range 3- 21%) at 93 ± 2 bpm and further to 16 ± 16% (range 7-37%) at 105 ± 3 bpm. In all three modalities the PVC burden was higher in the first 3 min of recovery than during the activity itself. Adding a 2 min active cool down increased the PVC burden to 25 ± 16% (range 6-45%). 2-legged squats performed at 101 ± 15 bpm had a PVC burden of 9 ± 12%, which increased to 19 ± 14% at recovery. One arm biceps curls at 75 ± 13 bpm had a PVC burden of 4 ± 3% during the activity and 9 ± 5% during recovery. Perception of effort varied widely when cycling at 80 bpm (range 6-12) or 100 bpm (range 8-14), but less so at 120 bpm (range 13-15). Blood lactate concentration when cycling at 120 bpm ranged between 2.2 and 3.5 mmol/L, typically associated with exercise in the “heavy” intensity domain. Discussion/Conclusion ARVC patients present a high, intensity-dependent PVC burden during exercise and short-term recovery. However, we observed widely different PVC burdens and perceived exertion at a given HR during different exercise modalities, which calls for personalized recommendations on physical activity. Exercises with small muscle mass seem to minimize the PVC burden and training the different muscles separately could be an interesting avenue to maintain physical fitness in ARVC patients.

ÖZ: Bu çalışmanın amacı, özellikle en son sürümüyle gelen yenilikler çerçevesinde, ISO 9001:2015 Kalite Yönetim Sisteminin (KYS) KOBİ’lerde ne derece etkin uygulandığını araştırmak ve sistemin uygulanmasına yönelik zorlukları ortaya koymaktır. Çalışmada, Kayseri’de faaliyet gösteren 22 KOBİ’de ISO 9001:2015 KYS uygulamaları incelenerek, standarttaki yeni kavram ve konulara uyum sağlama durumları, karşılaştıkları uygunsuzluklar ve uygulamada yaşadıkları zorluklar özelinde değerlendirmeler yapılmıştır 1 . Bu kapsamda, araştırmanın güvenirliğini doğrulayacak şekilde verileri toplamak için, önceden tanımlı bir görüşme protokolü izlenerek görüşmeler gerçekleştirilmiştir. Yarı yapılandırılmış soru formu aracılığı ile elde edilen nitel veriler, tanımlayıcı istatistikler ve içerik analizi yöntemi ile bulgulara dönüştürülmüştür. Çalışmada KOBİ’lerin ISO 9001:2015 standardının şartlarına uyumu açısından firma ölçeğine göre farklılaşan uygulamalar görülmüştür. KOBİ’lerin büyüklüğü arttıkça ISO 9001 standardında yapılan değişikliklere verilen tepkiler olumlu karşılanmış ve uygulamaların etkinliği artmıştır. Daha çok kalite yönetim sisteminde süreç yaklaşımının uygulanması, liderlik ve taahhüt, yetkinlik, farkındalık, iç denetim ve risk ve fırsatları belirleme ile ilgili uygunsuzlukların yaşandığı gözlenmiştir. KOBİ’lerde standardın uygulanmasını zorlaştıran faktörler arasında, ISO 9001 standardındaki kavramların kişilerce farklı yorumlanabilmesi, çok fazla dokümantasyon gerektirmesi, çalışanların standardın önemini bilmemesi, motivasyon eksikliği, standart ile ilgili eğitimlerin yetersizliği ilk sıralarda yer almıştır. Çalışma, KOBİ yöneticilerine, uygulayıcılara ve araştırmacılara ISO 9001:2015 KYS şartlarının uygulanmasına ilişkin önemli sonuçlar sunmaktadır. ABSTRACT: The purpose of this study is to investigate how effectively the ISO 9001:2015 Quality Management System is implemented in SMEs within the framework of the updates (e.g., risk based thinking) that came with its latest version and to reveal the challenges for the implementation of the system. In the study, it was also aimed to explain why SMEs need a quality management system and to develop suggestions for improvements that can be made to increase the success of the implementation. In the study, ISO 9001:2015 Quality Management System applications were examined in 22 SMEs operating in Kayseri province, and their adaptation to the new concepts and issues in the standard, the nonconformities and the difficulties they encountered in practice were evaluated. In this context, interviews were conducted accordance with a predefined interview protocol to collect data, thereby validating the reliability of the research. Qualitative data collected via a semi-structured questionnaire were transformed into findings with descriptive statistics and content analysis. In this study, on the basis of new concepts and themes introduced with the ISO 9001:2015 version, especially such new themes as "business planning and strategic direction", "process risk", "product and service risk", "risk associated with the control of externally provided process, product and service" were examined in detail through PDCA cycle and identified the extent to which these themes were applied in SMEs with evidences. In terms of adaptation of SMEs to these changes, different practices were observed according to firm scale. As the size of SMEs increased, the reactions to the changes in the ISO 9001 standard were welcomed and the effiency of the implementation increased. It was observed that there were nonconformities in the implementation of the process approach in the quality management system, leadership and commitment, competence, awareness, internal audit and determining risks and opportunities. The challenges experienced by SMEs in applying and maintaining the standard were determined as follows: Different interpretation of the concepts in the ISO 9001 standard by individuals, too much documentation, lack of awareness for the importance of the standard, lack of motivation, and inadequacy of Standard training. The study provides important findings for SME managers, practitioners, and researchers interested in implementing ISO 9001:2015 QMS requirements.