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Objective Intrathecal baclofen (ITB) is an effective treatment for lower limb spasticity. In ambulatory patients with spasticity, there is a justifiable concern that ITB treatment may compromise ambulatory function by reducing the heightened muscle tone, thereby unmasking underlying muscle weakness. ITB is hence offered with reservation in ambulant patients. In this article, we review the literature surrounding the effect of ITB therapy on ambulatory function in patients with concurrent spasticity and discuss the key findings. Data sources A literature search of ProQuest Medline and EBSCO CINAHL databases was performed. Review method Inclusion criteria included (a) studies reporting the effect of ITB in adult ambulatory patients; (b) studies with an intervention of screening test trial via either bolus injections or continuous infusion tests; and (c) studies with an intervention of ITB pump implantation. Seventeen eligible studies were identified and two authors independently assessed the study quality using the risk of bias in nonrandomised studies of interventions tool (ROBINS-I). Results Seventeen studies were included, with a total of 534 participants. Most of the patients remain ambulatory after ITB treatment, accompanied by improvements in gait speed and reduction in spasticity. Conclusion ITB therapy when administered in carefully selected ambulatory patients with spasticity is not associated with loss of ambulatory function.

Aims: To evaluate the effectiveness of telemedicine in the clinical management of children living with HIV/AIDS in resource-limited settings Background: Telemedicine is an important mechanism for service delivery in health care settings, both in resource-rich and resource-poor settings. Such service delivery mechanisms have shown to be associated with virologic suppression and higher CD4 counts. These services are also associated with improved access, shorter visiting times, and higher patient satisfaction. Objective: We designed the present two-group comparison study to compare the clinical evaluation and management of children in the anti-retroviral therapy (ART) centres linked to telemedicine facility with those who are not linked to this facility in Maharashtra, India. Methods: We analysed clinical records from six ART centres in Maharashtra; of these, 250 children were in the linked ART centres and 301 were in the non-linked ART centres. The outcomes were classified according to investigations, management, and monitoring. For management, we evaluated: 1) Initiation of cotrimoxazole prophylaxis; 2) Children not initiated on ART when required; 3) ART regime after appropriate investigations; and 4) Change of regime (if immunologically indicated). For monitoring, we assessed the haematological monitoring of children on ART. Result: The mean (SD) ages of children in linked and non-linked ART centres were 10.8 (4.6) and 10.9 (4.6) years, respectively (p=0.80). After adjusting for individual and structural level variables, physical examination (OR: 2.0, 95% CI; 1.2, 3.2), screening for tuberculosis (OR: 12.9, 95% CI: 2.0, 82.9) and cotrimoxazole prophylaxis were significantly more likely in the linked centres compared with non-linked centres (OR: 1.8, 95% CI: 1.4, 2.2). A higher proportion of children eligible for ART were not initiated on treatment in the non-linked centres compared with linked centres (26% vs. 8%, p=0.06). Children were less likely to be initiated on zidovudine-based regimens without baseline haemoglobin or with baseline haemoglobin of less than 9 gm% in linked centres (OR: 0.7, 95% CI: 0.6, 0.8). Similarly, children in the linked centres were less likely to have been started on nevirapine-based regimens without baseline liver enzymes (OR: 0.8, 95% CI: 0.7, 0.9). Conclusions: Thus, the overall clinical management of Children Living with HIV/ AIDS (CLHA) was better in ART centres linked with the telemedicine initiative compared with those who were not linked. Children in the linked ART centres were more likely to have a complete baseline assessment (physical, hematological, radiological, and screening for TB); the presence of a pediatrician in the centres was helpful.

The workforce of the medical specialty of Rehabilitation Medicine (RM) in the UK is 10 times less than the European average for the specialty of Physical and Rehabilitation Medicine (PRM). This can be explained partly by the difference in the scope of practice within the specialty between UK and other European countries. This opinion paper aims to compare the rehabilitation needs in chronic conditions and compare the scope of practice between countries within Europe and other regions of the world. The potential advantages of a broader remit specialty to improve rehabilitation care for patients across a wide range of conditions in explored. Recommendations have been put forward in the Rehabilitation Medicine Expansion Proposal (RMEP), which is likely to make the medical specialty more satisfying for the doctors working in the specialty and a more attractive career choice for those entering training in the medical specialty.

Reinforcement learning models require a choice rule for assigning probabilities to actions during learning. This chapter reviews work on a new choice rule based on an amplitude amplification algorithm originally developed in quantum computing. The basic theoretical ideas for amplitude amplification are reviewed, as well as four different simulation applications to a task with a predator learning to catch a prey in a grid world, and one application to human learning in a 4 arm bandit choice task. The applications reviewed in this chapter demonstrate that QRL can improve speed and robustness of learning compared to standard choice rules such as epsilon-greedy and softmax choice rules.

Background The Pediatric HIV Telemedicine Initiative is a video-linked delivery of expert services, designed to reach those previously unable to access expert HIV care. The present qualitative study was designed to understand the acceptability of telemedicine [TM] by patients, their caregivers and health care providers in the anti-retroviral therapy (ART) centers in Maharashtra. Methods We conducted focus group discussions with caregivers at six ART centres (three linked with TM facilities and three not linked with TM). We also conducted in-depth interviews with medical officers, counselors, and pharmacists at each centre. The data from the interviews were transcribed and translated into English for analysis. The qualitative data were analyzed using thematic framework approach. Results Children and caregivers who had participated in telemedicine consultation through video conference found the process acceptable, were comfortable communicating during these sessions, and did not have any specific problem to report. The advantages of TM were: consultation without having to travel to other cities; economic advantage; and prompt consultation. The total time spent during the process and technical difficulties during the TM sessions were some of the challenges. The medical officers had the opportunity to discuss difficult cases with the expert during the TM session. Some sessions were also considered a ’group counseling’ session, wherein several children and caregivers were able to interact and learn from each other and motivate each other. The health care providers at the three centers that did not currently have TM facilities expressed a desire to have these services at their centers as well. According to them, these facilities will help them address complicated and difficult pediatric HIV cases. Currently, they send their patients to referral centers or other hospitals. Since, many of these referral hospitals are situated in bigger cities, less than 50% of patients access care at these centers This is mostly due to the time constraints and finances (travel/stay) required for accessing these centres. Discussion TM was a feasible, acceptable, and desired approach for care of children living with HIV/AIDS. It provides support to their caregivers as well as their care providers. The ART staff from the telemedicine-linked peripheral centers were supportive of the use of TM and wanted these services to be initiated in the non-linked centers.

Background. The National AIDS Control Organization (NACO) of India created the Regional Pediatric Antiretroviral Therapy (ART) Center; this was subsequently upgraded to seven Pediatric Centers of Excellence (PCoEs) to strengthen the quality of treatment and care of children living with HIV/AIDS (CLHAs). In October 2013, the pediatric HIV telemedicine initiative, an e-decentralized (care provided by local healthcare providers and support provided by a central agency through telemedicine facilities) model of expert pediatric HIV care and referral services, was established as a pilot project at the Pediatric Center of Excellence for HIV Care in Maharashtra. We designed the present study to compare management, compliance to ART, and mortality in children in the ART centers linked to the PCoE through telemedicine versus those that are not linked to the PCoE. Methods. It was a retrospective cross-sectional study of secondary data from CLHAs from October 2013 through August 2015 in the ART centers to document the intermediate outcomes and to determine if the initiative has improved the quality of care for the CLHAs enrolled in the linked ART centers with nonlinked ART centers. The centers in which the telemedicine sessions were conducted regularly were called linked-regular centers and in whom it was conducted irregularly (less than the median of 12 videoconference cases), it was called a linked-irregular center. Data from 2803 children in 31 linked (1365 in irregular and 1438 in regular centers) and 2608 children in 28 nonlinked centers were analyzed. The outcomes in children in the pre-ART group (ART naïve) were (1) alive on pre-ART, (2) lost to follow-up on pre-ART, (3) death during the pre-ART period, (4) eligible but not initiated on ART, and (5) missing baseline and latest CD4 counts. The outcomes of children on ART were (1) alive on ART, (2) lost to follow-up on ART, (3) death on ART, and (4) missing baseline and latest CD4 counts. Results. We found that a higher proportion of children in the linked-regular centers (79% vs. 70%, p < 0.001 ) and linked-irregular centers (76% vs. 70%, p = 0.04 ) was alive compared with that in the nonlinked centers in the pre-ART group. In this group, the proportion of children with missing baseline CD4 counts and latest CD4 counts was significantly low in linked (regular centers) centers. In the ART group, we found that a higher proportion of children in the linked-regular centers was alive compared with that in the linked-irregular centers (77% vs. 69%, p < 0.001 ); the proportion was not significantly different in nonlinked centers (77% vs. 78%, p = 0.56 ). In this group, the proportion of missing baseline CD4 counts was significantly lower in the linked-regular centers (3% vs 13%, p p < 0.001 ) compared with that in the nonlinked centers. Furthermore, the latest CD4 counts were missing in a significantly lower proportion of children in the linked-regular centers compared with those in the linked-irregular centers (6% vs. 18%, p < 0.001 ) and nonlinked centers (6% vs. 18%, p < 0.001 ). Conclusion. Our study shows that the centers linked through telemedicine performed better in terms of patient care and treatment, with a lesser loss to follow-up and lesser deaths in CLHA. Overall, this pilot project of telemedicine for pediatric HIV has been proven to be acceptable, feasible, and effective in improving the quality of care for children living with HIV across the state of Maharashtra.

Objective The purpose of this study is to assess the utility of web-based mobile technology monitoring tool, for ensuring linkages, and tracking of HIV-exposed child until 18 months of age. Methods The ‘early infant diagnosis (EID) Follow-up System’ was designed as a tool for reminding the field level staff for follow-up of HIV-exposed babies. Using Java Swing Framework, software was developed which generates automatic advance SMS alerts regarding patient information to the Counsellor of the respective Integrated Counselling and Testing Center and district supervisor, 7 days prior to due dates. Simultaneously, system generated e-mail is sent to district program officer for monitoring and updating the line-list. Results Before the introduction of ‘EID Follow-up System’ in June 2013, only 55.9% (637/1139) of the HIV-exposed babies born were tested at 6 weeks for DNA-Polymerase Chain Reaction during April 2011–March 2012. However, after its introduction, 68.4% (1117/1631) of them were tested during April 2012–March 2013. Correspondingly, the 18 months confirmatory HIV testing in eligible babies increased from 45.6% (934/2044) to 54.7%(1118/2044) during the same period. Conclusion The replicable technology driven initiative would help in strengthening the follow-up mechanisms and reach every HIV-exposed child for EID.

Background: Snakebites are well-known medical emergencies in many parts of the world, especially in rural areas.The incidence of snakebite mortality is particularly high in South-East Asia. Rational use of snake anti-venom can substantially reduce mortality and morbidity due to snakebites. Snake bite is an important health problem in India also especially in North Kerala which has an agricultural background. There is a lack of study regarding this topic in this area. North Kerala differs from other areas in the country as hump nosed pit viper bites are more common here due to its proximity to western Ghats where it .Anti snake venom is ineffective to bites by hump nosed pit viper. Authors objectives was to assess the clinical and epidemiological profile and outcome of poisonous snake bites.Methods: Retrospective observational study done among patients with snake bite with envenomation admitted in Academy of Medical education, Pariyaram, Kannur, Kerala from January 2018 to September 2018.Results: There were 90 cases of venomous snake bite during the study period. Of these males were predominant (70%). Majority were in the age group between 20 and 40. Majority of bites occurred in the months of June and July. Bite in the extremities were more common. Nine patients were brought 1 day after the bite. Snake identified most common was Russell’s viper followed by pit viper. Majority of the systemic envenomation was hemotoxic 80 patients (85%).Conclusions: The study stress the fact that snake bite is an important problem in North Kerala. The study also shows that delay in treatment is a major risk factor for morbidity. Hump nosed pit viper bites are more common in this area.

Background: In the recent period there is an upsurge in the incidence of fever with thrombocytopenia in the Northern Kerala. This may be due to the several emerging and re emerging infections which causes frequent epidemics in the region. Early diagnosis and meticulous management will prevent fatal out come. Studies on fever with thrombocytopenia are very few in the Northern part of Kerala.Methods: This was a descriptive study conducted at Academy of Medical Sciences Pariyaram over a period of one year from November 2015 to October 2016. The study includes 251 cases attending outpatient and inpatients units in the department of medicine. All patients with a platelet count less than 150000 was included in this study and detailed clinical and laboratory evaluation was done and assessed for the etiology and outcome.Results: Among the 251 cases, Dengue fever accounts 54.5 % of cases and 26.2% are other viral fever where the exact causative organism was not detected. Leptospirosis, malaria were also important causes of fever with thrombocytopenia. Major incidence of hemorrhagic manifestation occurred in the age group of 20 to 30 years whose platelet count was in the range of 10000 to 40000/mm3.Conclusions: In this study more than 50 % had dengue fever and in 26.2% cases an exact etiology cannot be determined. This finding highlights the fact that there may be many unidentified infection which cause fulminant thrombocytopenia and there is a need for wider screening of infection.

Background: Dengue fever is the most common arboviral disease and fifty percent of world population is at risk. Frequent outbreaks are reported from all states of our country and incidence increases every year. This case study is of 305 patients from Academy of Medical Sciences, which is a tertiary care centre and research Institute in North Kerala. The objective of this study was to study the clinical profile of dengue fever.Methods: Study was prospective observational study conducted during the epidemic for a period of one year. All the cases which fulfilled WHO criteria for diagnosis of dengue fever and those who are positive for IGM antibody detected by enzymelinked immunosorbent assay (IgM ELISA) were only included in this study.Results: There is male preponderance, and those above the age of 30 years affected more. All patients had fever. Gastrointestinal manifestation like nausea and vomiting were commonly observed symptoms. Hepatomegaly, rash and conjuctival suffusion were important physical findings, whereas splenomegaly noted only in 8.2% cases. Thrombocytopenia is noticed in 73.96%.Conclusions: The mortality is 2.6%. Hypotension and thrombocytopenia are the two important determinants of mortality. Dengue Shock syndrome and Dengue Hemorrhagic Fever were relatively less when compared to other epidemics from different regions.

Background: Hepatic encephalopathy (HE) is a common complication of liver disease that requires intensive care management. The prevalence of HE is increasing during recent period. The most important factors of HE are alcohol consumption, chronic hepatitis, hepatotoxic drugs and unhealthy changes in life style. There were only relatively few studies from our region on the changing profile of hepatic encephalopathy under the background of life style changes. This study was conducted with the aim to detect the changing pattern of clinical profile, precipitants and to assess the prognosis of patients with hepatic encephalopathy.Methods: This was a prospective study for a period of 18 months since January 2012 at Academy of Medical Sciences, Pariyaram, Kannur, a tertiary care centre situated in the northern part of Kerala. Patients admitted in the medical and gastroenterology wards and intensive care units that fulfilled the inclusion criteria were enrolled in this study.Results: Among the 76 patients with HE, 60 were suffering from CLD and 16 due to acute liver failure. The common etiologies for HE in CLD patients were Alcoholic cirrhosis (63%), Cryptogenic cirrhosis (17%) and cirrhosis due to chronic HBV (10%) and HCV hepatitis (7%) respectively. Among the CLD patients at the start of observation majority were in Child Pugh class B and C. Based on West Haven grading most of them had Grade 2 and 3 HE. Majority with Grade 1, 2 and 3 improved where as those with Grade 4 and Grade 3 in Child Pugh class C worsened. The common precipitants of HE were GI bleed, dyselectrolemia, constipation and infections. Among these precipitants a statistically significant association for a worse outcome was present only with infection. Leptospirosis and deliberate self-harm due to ingestion of hepatotoxic rodenticide and paracetamol were the leading cause of hepatic encephalopathy in acute liver failureConclusions: In present study HE was most commonly seen in patients with alcoholic liver disease. Cryptogenic cirrhosis associated with other life style diseases was the second common condition. Among all precipitating factors infection appeared as a statistically significant factor predicting a worse outcome. Health education among alcoholic patients and life style modifications to prevent cryptogenic cirrhosis are of paramount importance in curtailing the increase in incidence of HE in this region.

An Aeroelastic study of a flight vehicle has been a subject of great interest and research. Its importance lies in the achieving better performance, safety operation (e.g. aileron reversal, flutter analysis) and related analysis in the field of aeronautics. Structural dynamics of an aircraft wing characterized by aeroelastic nature is modeled as partial differential equation. The study of these equations comes under distributed parameter system and control design of these systems is very complex as compared to lumped parameter systems defined by ordinary differential equation. In present paper we present a stabilizing state-feedback control design approach for the second order system dynamics which completely represents the heave dynamics of wing-fuselage model. This approach is presented for a class of systems when there is a continuous actuator in the spatial domain. The control methodology is designed by combining the technique of ‘Proper Orthogonal Decomposition’ (POD) and approximate dynamic programming (ADP). Nomenclature time Spatial location on beam Density of the beam material Cross-sectional area of beam Young’s modulus Area moment of inertia of the beam Coefficient of viscous damping ____________________________________________________________________________________________ 1 Ph.D. Student, Department of Mechanical & Aerospace Eng., 400W. 13 th St. Rolla, MO 65401, mk7t8@mst.edu 2 Ph.D. Student, Department of Mechanical & Aerospace Eng., 400W. 13 th St. Rolla, MO 65401, krg2d@mail.mst.edu 3 Curators' Professor of Aerospace Engineering, Department of Mechanical & Aerospace Eng., 400W. 13 St. Rolla, MO 65401, bala@mst.edu, AIAA Associate Fellow 4 Project Scientist, NASA Ames Research Center, Email: nhan.t.nguyen@nasa.gov Coefficient of Kelvin-Voigt damping Mass of rigid connection between the beams Control input function for left beam Control input function for right beam ( ) Displacement of the left beam from its initial equilibrium position at time and position ( ) Displacement of the right beam from its initial equilibrium position at time and position ( ) Continuous control on left beam ( ) Continuous control on right beam

This chapter aims to address the questions of the definition and effective management of spasticity, in order to assist the reader to recognize, assess, and treat people with this impairment. Spasticity is a physiological consequence of an insult to the brain or spinal cord, which can lead to life-threatening, disabling, and costly consequences. It is a common but not inevitable outcome of the upper motor neuron (UMN) syndrome and is characterized by muscle overactivity and high tone spasms, which, if left untreated, will lead to muscle and soft tissue contracture and limb deformity. There have been several attempts to define spasticity. The difficulty reflects the complex features of the syndrome. The most cited definition is by Lance, but does not fulfil all the clinical scenarios seen in clinical practice. The term "spasticity" in the therapeutic world covers the several other features of the UMN syndrome and, therefore, an all embracing definition is probably required as well. Rates for the prevalence of spasticity in different clinical conditions are variable. This may be due to the presence of many patients with mild spasticity, for whom little or no treatment is required for their condition. However, it is estimated that 38% of patients following stroke develop a degree of spasticity and about 19% require pharmacological treatment. Of these about one-third (5% of the total) will benefit from botulinum toxin injections for focal problems. This chapter will inform the reader about the pathophysiology of spasticity, but also includes the practicalities and principles of management, the delivery of its longer term treatments, and the utilization and measurement of relevant outcomes.

This chapter aims to address the questions of the definition and effective management of spasticity, in order to assist the reader to recognize, assess, and treat people with this impairment. Spasticity is a physiological consequence of an insult to the brain or spinal cord, which can lead to life-threatening, disabling, and costly consequences. It is a common but not inevitable outcome of the upper motor neuron (UMN) syndrome and is characterized by muscle overactivity and high tone spasms, which, if left untreated, will lead to muscle and soft tissue contracture and limb deformity. There have been several attempts to define spasticity. The difficulty reflects the complex features of the syndrome. The most cited definition is by Lance, but does not fulfil all the clinical scenarios seen in clinical practice. The term "spasticity" in the therapeutic world covers the several other features of the UMN syndrome and, therefore, an all embracing definition is probably required as well. Rates for the prevalence of spasticity in different clinical conditions are variable. This may be due to the presence of many patients with mild spasticity, for whom little or no treatment is required for their condition. However, it is estimated that 38% of patients following stroke develop a degree of spasticity and about 19% require pharmacological treatment. Of these about one-third (5% of the total) will benefit from botulinum toxin injections for focal problems. This chapter will inform the reader about the pathophysiology of spasticity, but also includes the practicalities and principles of management, the delivery of its longer term treatments, and the utilization and measurement of relevant outcomes.

Background Maternal death reviews have been utilized in several countries as a means of identifying social and health care quality issues affecting maternal survival. From 2005 to 2009, a standardized community-based maternal death inquiry and response initiative was implemented in eight Indian states with the aim of addressing critical maternal health policy objectives. However, state-specific contextual factors strongly influenced the effort's success. This paper examines the impact and implications of the contextual factors. Methods We identified community, public health systems and governance related contextual factors thought to affect the implementation, utilization and up-scaling of the death inquiry process. Then, according to selected indicators, we documented the contextual factors' presence and their impact on the process' success in helping meet critical maternal health policy objectives in four districts of Rajasthan, Madhya Pradesh and West Bengal. Based on this assessment, we propose an optimal model for conducting community-based maternal death inquiries in India and similar settings. Results The death inquiry process led to increases in maternal death notification and investigation whether civil society or government took charge of these tasks, stimulated sharing of the findings in multiple settings and contributed to the development of numerous evidence-based local, district and statewide maternal health interventions. NGO inputs were essential where communities, public health systems and governance were weak and boosted effectiveness in stronger settings. Public health systems participation was enabled by responsive and accountable governance. Communities participated most successfully through India's established local governance Panchayat Raj Institutions. In one instance this led to the development of a multi-faceted intervention well-integrated at multiple levels. Conclusions The impact of several contextual factors on the death inquiry process could be discerned, and suggested an optimal implementation model. District and state government must mandate and support the process, while the district health office should provide overall coordination, manage the death inquiry data as part of its routine surveillance programme, and organize a highly participatory means, preferably within an existing structure, of sharing the findings with the community and developing evidence-based maternal health interventions. NGO assistance and the support of a development partner may be needed, particularly in locales with weaker communities, public health systems or governance.

The approach presented in this paper aims toward resolving producibility problems, in the design stage of an electronic circuit assembly. A brief discussion of the three main assembly processes—component placement, soldering and inspection—is followed by an investigation of the design parameters that affect these processes. A methodology for assigning producibility codes for components, with respect to their location and orientation on the board, is devised for enhanced soldering and inspection. Assembly process plans are recommended as a function of the component package styles and board configuration. Finally, a flowchart is presented for placement, utilizing the producibility codes, component area constraints and assembly process plans.