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Unexpected Appearance of Ectopic Mediastinal Toxic Nodulary Thyroid Hyperplasia in a Case of Recurrent Hyperthyroidism Mine Araz Derya Çayır

Ectopic mediastinal thyroid is a rare entity. Patients are usually euthyroid and symptoms due to mediastinal
compression are cautionary to investigate intratoracic mass. We represent a female patient who had undergone subtotal
thyroidectomy 12 years ago and had recurrent hyperthyroidism following an euthyroid period. Antithyroid antibodies were
negative. Thyroid ultrasonography showed residual thyroid tissue in both sides and multiple nodules on the right side.
Thyroid scintigraphy showed a nonhomogenously increased tracer uptake on the right thyroid lobe and left lobe was
rather suppressed. Additionally, a large mass of nonhomogenously increased activity located in the mediastinum which
was totally seperate from the thyroid gland was detected. MRI images supported that the thoracic mass was an ectopic
thyroid tissue and surgical excision confirmed benign nodulary hyperplasia.
The case is intereseting in the way that the patient had a recurrent hyperthyroidism due to toxic nodular hyperplasia of
the mediastinal ectopic thyroid gland and the pathology was first realised by Technetium-99m (Tc-99m) pertechnetate
thyroid scan.

Inorganics in Nuclear Medicine A. Mushtaq  

More than 130 radionuclides are being used worldwide for therapeutic, diagnostic, and preventative purposes in the medical field. Using radionuclides, different organs can be imaged, and malfunction revealed. The most commonly used radionuclide in diagnosis by SPECT is technetium-99m (99mTc), with some 40 million procedures yearly, almost 80% of all nuclear medicine procedures in the world. The Positron Emission Tomography (PET) is sophisticated and more precise technique using isotopes, like 18F produced in a cyclotron. The synthesis and use of organic molecules and their labeling with radionuclides are currently dominating in new radiopharmaceutical development. On the other hand inorganics (60Co, 131I and 192Ir) are still playing unique role in nuclear medicine. In this article more commonly used radionuclides and their inorganic forms in nuclear medicine are described.

Evaluation of the Effectiveness of Bevacizumab Treatment in Patients with Metastatic Colorectal Cancer with PET-CT Mehmet Erdogan Aykut Recep Aktas

Purpose: To evaluate the response to therapy with PET-CT in metastatic colorectal cancer patients treated with Bevacizumab and chemotherapy.

Methods: Twenty-two patients with metastatic colorectal cancer that were treated with bevacizumab and 6 cycles of chemotherapy were evaluated by whole-body PET-CT scan before and after the treatment in accordance with the European Organization for Research and Treatment of Cancer criteria.

Results: While 31.8% of patients responded to treatment (complete response + partial response), 68.2% did not respond to treatment (stable disease + progressive disease). The mean hepatic, extra hepatic, abdomen, lung and bone metastases SUVmax values were higher after treatment in comparison to the pre-treatment values. There was an increase in SUVmax values in those who did not respond to the treatment, while a decrease was observed in those who responded to the treatment. Survival was significantly increased in all patients that responded to the treatment. The difference in terms of gender, histological subtype, histological grade, primary tumor location, presence of metastases in regional lymph nodes and liver at the time of diagnosis or the response to the treatment was not statistically significant.
Conclusions: In this study we detected metabolic response before anatomical response with PET-CT in one third of metastatic colorectal cancer patients treated with Bevacizumab and chemotherapy. This finding suggests that PET-CT may be used as a measure to follow therapy response and predict the prognosis in metastatic colorectal cancer patients.

99mTc-Ciprofloxacin Imaging: Still an Unsettled Issue? Mariano G. Portillo Andrea Mendoza Bertelli

The objective of this work consisted in the assessment of 99mTc-ciprofloxacin imaging performance as a diagnostic tool in an experimental rat model of osteomyelitis. Bone (tibia) infection was induced in adult rats by inoculation of a suspension containing S. aureus suspended in fibrin glue. In vivo studies by means of small animal imaging were conducted using a gamma camera. The study shows the correlation between 99mTc-ciprofloxacin positive images with bacterial bone count but also with histopathological findings in an osteomyelitis animal model, highlighting its potential as a tool in preclinical research and the accomplishment of 3Rs concept regarding welfare of laboratory animals. 99mTc-MDP scintigraphy, failed to show these correlations and therefore it may be proposed as a complementary method to diagnose and follow up the bone physiopathology in this animal model. Future perspectives of small animal imaging in order to potentiate osteomyelitis basic research will derive from numerous research works, and 99mTc-ciprofloxacin may still be a candidate for infectious diagnose and follow-up as demonstrated in this study.

Can SPET/CT Technique Improve the Sentinel Lymph Node Radio- Guided Research in Cutaneous Malignant Melanoma? Artor Niccoli Asabella Valentina Lavelli Valentina Lavelli

Background: the aim of the study is to define the role of SPET/CT in radio-guided sentinel lymph node surgery identification in cutaneous Malignant Melanoma (MM) and to assess if SPET/CT data can modify surgery time.
Materials and Methods: 96 patients with MM (58 men and 38 women, mean age of 44 years, range 14-71 years) were divided into two groups. 66 patients (group I) were submitted to sentinel node (SN) research by planar
lymphoscintigraphy; 30 patients (group II) performed both planar and SPET/CT lymphoscintigraphy. SN surgery identification percentage, SN anatomical site identification and surgery times were evaluated in each group.
Results: Group II presented a percentage of SN surgery identification, both globally (96.5%) and in specific sites (axilla lymph nodes 94.5%; upon clavicle lymph nodes 100%), better than group I. Furthermore surgery time was shorter in the group II (10’-20’).
Conclusions: SPET/CT allows a more accurate SN identification than planar lymphoscintigraphy, especially in axillar and upon-clavicular nodes and contributes to a correct staging of cutaneous MM. It can improve surgery success percentage and shortens surgery time, reducing also surgery team irradiation.

18F-FDG PET/CT Evaluation of Regional Cerebral Metabolic Activities in Childhood Onset Schizophrenia Ajit S Shinto K.K. Kamaleshwaran

Introduction: Functional neuro-imaging with FDG PET CT in schizophrenic patients have reported certain patterns of increased or decreased metabolism in specific areas of the brain. Frontal lobe is one of the cortical areas consistently associated with schizophrenia and the activity levels have been reported to vary with the symptomatology at presentation. Predominantly positive symptoms cause and underlying hyperfrontality and negative symptoms are associated with hypofrontality. This study aims to assess the imaging patterns in unmedicated pediatric patients with a diagnosis of schizophrenia and predominantly positive symptoms.

Patients and methods: 48 pediatric patients with a diagnosis of schizophrenia (all unmedicated, 38 never medicated) and 10 healthy age-matched controls were evaluated with FDG PET CT. The patients met ICD-10 and DSM-IV criteria for schizophrenia and all reported psychotic, “positive” symptoms when tested.

Results: Children with schizophrenia and positive symptoms had a pattern of diffuse hyper-metabolism involving the bilateral frontal cortices and could be demonstrated on quantification by region to occipital ratio comparison . Associated statistically significant differences were also found when comparing ratios of occipital to thalamic, striatal and temporal cortex in these patients when compared to controls.

Conclusion: Diffuse frontal hypermetabolism or hyperfrontality is observed in children with schizophrenia when there is a predominance of positive symptoms. There could be a possible disruption of cortico-striato-thalamic feedback loops causing hyperfrontality as seen in in experimentally induced models of psychosis.

Differentiating Schizophrenia from Bipolar Illness on 18 F FDG PET CT Based on white Matter Metabolism; an under-Utilised Parameter Ajit S. Shinto, K.K. Kamaleshwaran

18F-FDG PET/CT positron emission tomography studies (FDG-PET) have shown similar cortico-limbic metabolic dysregulation in bipolar disorder and schizophrenia, with hypoactive prefrontal cortex coupled with hyperactive anterior limbic areas. However, it is not clear whether white matter metabolism connecting these regions is differently affected in the two disorders. Forty eight patients with schizophrenia mean age ± S.D] 31.6 ± 7.8 and 56 patients with bipolar disorder [mean age±S.D] 46.2 ± 8.9 underwent an 18F-FDG PET/CT scan. Normalized datasets the two groups of patients were compared on a voxel-by-voxel basis using a two-sample t statistic test as implemented in SPM8, and adding age as covariate. Group differences were assessed applying a threshold of p<0.0005. White matter metabolic rates significantly differed between schizophrenia and bipolar disorder, whereas no differences were shown for cortical activity. This is the first 18F-FDG PET/CT to our best knowledge, directly comparing subjects with schizophrenia to those with bipolar disorder. It reports decreased activity in the center of large fronto-temporal and cerebellar white matter tracts in patients with schizophrenia in respect to those with bipolar disorder. This feature may characterize and differentiate the regional brain metabolism of the two illnesses.

Incidentally Detected Situs Inversus Totalis in FDG PET/CT in a Case of Gastro-esophageal Junction Carcinoma: A Case Report Koramadai Karuppusamy Kamaleshwaran Madhu Sairam

Situs inversus totalis (SIT) is a rare congenital condition in which the viscera are transposed as a mirror of normal arrangement. We present a 70-year-old man with Gastro-esophageal (GE) junction carcinoma who underwent FDG PET/CT for initial staging, in addition to hypermetabolic lesions in the GE junction, scan showed transposed heart, liver, spleen and stomach, suggestive of SIT.

Effect of Source Activity and Source Volume on Intrinsic Uniformity of SPECT Gamma Camera Mahidul Haque Prodhan Sabrina Sarah

Purpose: The quality control of the gamma camera is obligatory for the proper diagnosis of the patients. The most intensive and sensitive routine quality control of gamma camera is intrinsic uniformity. The main objective of this research work is to determine the best parameters for daily quality control testing of intrinsic uniformity for dual head Single Photon Emission Computed Tomography (SPECT) gamma camera.

Method: The integral and differential intrinsic uniformity test for both Useful Field Of View (UFOV) and Central Field Of View (CFOV) was done by placing a point source of 99mTc in front of the detectors with removed collimators to measure the effect of source activity and source volume on intrinsic uniformity.

Result:The result shows that the best intrinsic uniformity image is obtained at activity volume in the range of 0.2 – 0.7 ml in 3 ml syringe with source activity between 70 – 200 MBq since place of point source on the central axis of the detector at a distance from its face equal to five times the diameter of the useful field of view as defined by the lead mask.

Conclusion: Finally we can conclude that, the lower the intrinsic uniformity the better the imaging and diagnosis.

Ga-68 DOTATATE Accumulation in Sarcoidosis Cigdem Soydal Ozlem N Kucuk

We aimed in this case series to show Ga-68 DOTATATE uptake in relation with disease activity in sarcoidosis cases. 8 patients with previous diagnosis of sarcoidosis were included to the study. Ga-68 DOTATATE PET/CT was performed to evaluate of disease activity. Disease activity was described clinically by chest disease specialist by evaluation of lung function tests, serum ACE measurements and thorax CT. Correlation between Ga-68 DOTATATE uptake and disease activity was analyzed. Ga-68 DOTATATE PET/CT as a combination of SSR scintigraphy and anatomical imaging might be beneficial in the evaluation of active sarcoidosis.

F-18 FDG PET/CT in Tuberculosis: Non-Invasive Marker of Therapeutic Response to Antitubercular Therapy Koramadai Karuppusamy Kamaleshwaran, Ajit Sugunan Shinto Ajit Sugunan Shinto

Fluorine-18 fluorodeoxyglucose positron emission tomography/computed tomography (FDG PET/CT) imaging, an established procedure for evaluation of malignancy, also shows increased FDG uptake in inflammatory conditions like tuberculosis. We present two patients, one renal cell carcinoma, post nephrectomy on follow up, evaluated to have cervical and mediastinal nodes diagnosed as tuberculosis and another case of disseminated tuberculosis mimicking metastasis. They were started on Anti tubercular therapy (ATT). Post 2 months treatment, FDG PET/CT showed response in most of the lesions.FDG PET/CT allows an easy evaluation of early therapeutic response in patients with TB, particularly extra-pulmonary TB.

18F-FDG PET/CT in Staging and Response Evaluation of Rare Case of Non-Hodgkin's Lymphoma Involving Pericardium, Kidney and Pancreas Koramadai Karuppusamy Kamaleshwaran Sudhakar Natarajan

18F-FDG PET/CT is increasingly applied in staging and response to treatment assessment of lymphomas. Multiple isolated cases with extranodal involvement of Non hodgkins Lymphoma (NHL), detected on 18F-FDG PET/CT, have been previously reported. Here, we report a rare case of extranodal NHL involving multiple sites namely pericardium, kidney, pancreas in addition to mediastinal lymph nodes which were detected on 18F- FDG PET/CT.In the present case, involvement was accurately demonstrated, and early complete remission was documented using baseline and follow-up FDG PET/CT.

Vasculitis Diagnosed on Fluorine-18 Labelled-2-Deoxy-2-Fluoro-D-Glucose Uptake in A Patient With Fever of Unknown Origin and A History of Non Hodgkin’s Lymphoma Artor Niccoli Asabella Alessandra Di Palo

There are increasing data demonstrating the role of 18F-flourodeoxyglucose positron emission tomography with computerized tomography fusion (18F-FDG PET/CT) in the diagnosis of large vessel vasculitis, including Takayasu arteritis and giant cell arteritis. We report a case of large vessel vasculitis detected on 18F-FDG PET/CT; a 32-year-old woman with history of Non Hodgkin Lymphoma, admitted with fever of unknown origin (FUO) of 2-months duration and asthenia. To exclude FUO of malignancy, in the suspect of NHL relapse, 18F-FDG PET/CT imaging was performed. The images demonstrated significant 18F-FDG uptake in aortic arch and no signs of NHL relapse. This case report supports the role of 18F-FDG PET/CT as a useful and noninvasive tool in diagnostic evaluation of patient with FUO, both by excluding a malignant etiology and providing information about other possible causes such as inflammation, including vasculitis. 18F-FDG PET/CT is very useful in the early diagnosis of active inflammation including vasculitis and provides timely information for appropriate therapy.

Development of A New Radiogallium Porphyrin Complex as A Possible Tumor Imaging Agent Yousef Fazaeli Amir R. Jalilian

Introduction: Developing imaging agents based on novel porphyrin pharmacophores is of great interest based on interesting biological/pharmacological performance when labeled with various radionuclides.
Method: [67Ga] labeled 5,10,15,20-tetrakis (pentafluorophenyl) porphyrin ([67Ga]- TFPP) was prepared using [67Ga]GaCl3 and 5,10,15,20-tetrakis (pentafluorophenyl) porphyrin (H2TFPP) for 60 min at reflux condition followed by stability tests, partition coefficient determination as well as bio distribution tudies in wild type and tumor bearing animals using scarification and SPECT imaging.
Result: The complex was prepared with acceptable radiochemical purity (>97% ITLC, >98% HPLC, specific activity: 13-14 GBq/mmol) and stability in final formulation and human serum for 24 h. The partition coefficient was 0.69 (log P). The tumor:blood and tumor:muscle uptake ratios were 24.5 and 61.25 respectively after 48 h demonstrating significant tumor-imaging property of the tracer. Also confirmed by SPECT imaging. Conclusion: The tracer can be an interesting tumor imaging agent due to high specific uptake and rapid excretion through the urinary tract.

Fluorine-18 Fluorodeoxyglucose Positron Emission Tomography/ Computed Tomography in the Detection of Ovarian Cancer Recurrence in Patients with Elevated Serum Ca-125 Levels and Whether the Recurrence appears by Conventional Imaging Reyhan Koroglu Elgin Ozkan

Introduction: We aimed in this study to evaluate the benefit of Fluorine-18 (18F) fluorodeoxyglucose (FDG) positron emission tomography/computed tomography (PET/CT) in the detection of ovarian cancer recurrence in a selected patient group who had elevated serum Ca-125 levels and whether the recurrence appears by conventional imaging .
Material and Method: A total of 39 female patients (mean age: 59±12.3) who underwent 18F-FDG PET/CT for restaging of ovarian cancer due to of elevated serum Ca-125 levels were retrospectively included to this study. 18F-FDG PET/CT imaging have been performed for searching possible disease recurrence in 24 patients who had normal or undetermined abdominal CT or pelvic MRI (Group 1) and evaluating to extent of disease in 15 patients who had abnormal abdominal CT or pelvic MRI (Group 2). Disease recurrence was confirmed by histopathological examination of surgical procedures or clinical follow-up data for at least 6 months period .
Results: The mean period between the completion of initial treatment and 18F-FDG PET/CT was 2.6±1.4 years. In 33 of the 39 patients (82%), recurrent disease was developed during the follow-up period. Of the 33 patients with recurrent disease, 6 (18%) were confirmed by histopathological examination, while in 27 (82%) were documented by clinical follow-up. The mean Ca-125 level and the SUVmax value of group 1 were 509 U/ml (range 50.3-6544 U/ml) and 12.26±4.9 (range 0-21.7), respectively. Overall sensitivity and specificity of 18F-FDG PET/CT in group 1 were quantified as 94% and 75%, respectively. The mean Ca-125 level and mean SUVmax value of group 2 at the time of 18F-FDG PET/CT scans were calculated as 358 U/ml (range 40.6-1233U/ml) and 11.4 ± 4.53 (range 4.5-20.1), respectively. Disease recurrence of 14 (93%) patients was correctly identified by 18F-FDG PET/CT. The sensitivity of 18F-FDG PET/CT in the detection of disease recurrence of group 2 was quantified as 100%. Specificity could not quantified due to absence of TN and FP results.
Conclusions: 18F-FDG PET/CT has higher sensitivity and specificity in the detection recurrent ovarian cancer than serum Ca-125 levels and ceCT alone. The addition of 18F-FDG PET/CT to Ca-125 and ceCT improves the sensitivity of the evaluation of disease extension.

FDG PET/CT in the Evaluation of Late Manifestation of Adrenal Metastasis after Radical Nephrectomy in Patients with Renal Cell Carcinoma: A Report of Four Cases and Review of Literature Koramadai Karuppusamy Kamaleshwaran Anish Bhattacharya

Purpose: Presence of distant metastasis is a strong independent predictor of poor survival in patients with renal cell carcinoma (RCC). Positron emission tomography using F-18 fluorodeoxyglucose (FDG) has been reported to be superior to conventional anatomic imaging modalities for detecting distant metastases from RCC.
Methods: The authors report the findings of four patients who underwent FDG positron emission tomography / computed tomography (PET/CT) at varying periods after radical nephrectomy for RCC.
Results: FDG PET/CT detected increased tracer concentration in the adrenal glands in all four patients and subsequent fine needle aspiration confirmed metastatic RCC. While the adrenal was the only site of metastasis in one patient, additional metastases were detected in lymph nodes and lungs in the others.
Conclusions: RCC metastatic to the adrenal gland is usually a vascular tumour and there is an intrinsic risk of haemorrhage during CT-guided needle biopsy. This small series of cases suggests that FDG PET/CT is a useful non-invasive investigation in identifying malignant adrenal lesions in patients with RCC presenting after nephrectomy.

Cortico-Subcortical Metabolic Changes in Aging Brain: A 18F FDG PET/CT Study Agostino Chiaravalloti Paolo Abbatiello

Aim: to investigate the effects of aging on brain glucose consumption on a population of healthy subjects.
Materials and methods: 102 chemotherapy-naïve subjects (56 men, 46 women; mean age 57±16 years old; age range 20-89 years) undergoing a whole body 18F FDG PET/CT and found to be completely negative for various diseases in both PET/CT and contrast enhanced CT (performed contextually to PET/CT scan) were enrolled in the study. Age-related changes in brain 18F-FDG uptake were analysed by statistical parametric mapping (SPM8).
Results: aging is related to a reduction of brain glucose consumption in right medial frontal gyrus (BA9) and anterior cingulate cortex (BA32) and to an increased 18F-FDG uptake in right sub-cortical structures (lentiform nucleus, claustrum) and in cerebellum bilaterally.
Conclusions: The results of our study suggest that a reduced functioning of ACC and medial PFC occur in the elderly. An increased activation of the cerebellum, lentiform nucleus and claustrummay represent a compensatory mechanism, possibly involved in cognitive decline.

Correlation between Colour Duplex and Technetium-99m Thyroid Scan in Identifying the Cause of Toxic Goitre Ahmed Fathy Abdel Ghany Mohamed Amin Nassef

Introduction: Differentiation between thyroiditis induced thyrotoxicosis and Graves' disease is important for selection of proper therapy. It is often difficult to make this distinction without performing thyroid scintigraphy. Color flow Doppler sonography (CFDS) is gaining importance for the functional evaluation of the thyroid disorders. We aimed to determine the value of CFDS for the etiological diagnosis of thyrotoxicosis.
Patients and methods: Thirty patients with clinical and lab signs of hyperthyroidism (12 Graves’ disease and, 18 patients with Hashimoto’s thyroiditis) with 10 euthyroid controls were evaluated.Etiological diagnosis was carried out using standard methods. Conventional grey scale sonography was done, followed by CFDS. Doppler patterns of the glands were scored and peak systolic velocity (PSV) measurements were obtained from superior and inferior thyroid arteries. Results were correlated to isotope scanning which was used as a golden standard.
Results: Vascular patterns were significantly more prominent, and the mean PSV values were significantly higher in the Graves' Disease patients compared to the thyroiditis patients than controls. CFDS could differentiate the untreated Graves' Disease from the thyroiditis which had similar grey scale findings but higher vascular patterns and significantly higher PSV values, sensitivity = 96.6%, specificity= 96.6 %, and P>0.001
Conclusion: As an inexpensive, fast, and noninvasive imaging procedure, CFDS could be helpful in the initial clinical evaluation and may avoid scintigraphy in a substantial number of thyrotoxic patients.

The Role of 18F-Flourodeoxyglucose (18F-FDG) Positron Emission Tomography/Computed Tomography (PET/CT) in Pelvic and Paraaortic Lymph Node Staging of Uterine Cervical Cancer Cigdem Soydal Erkan Ibıs

Aim: We aimed to evaluate the sensitivity of 18F-Flourodeoxyglucose (18F-FDG) positron emission tomography/computed tomography (PET/CT) in the detection of pelvic and paraaortic lymph node metastases of uterine cervical cancer.
Material and Method: 32 female patients (mean age: 56.1±12.6) who underwent 18F-FDG PET/CT for preoperative staging of uterine cervical cancer between April 2009 and October 2013 were included to the study. Ethical committee approval was taken from Ankara University Medical Faculty Ethics Committee. All the patients had been performed trans-vaginal examination and diagnosed as uterine cervical cancer before 18F-FDG PET/CT. 18F-FDG PET/CT findings were compared with histopathological examination results. Sensitivity, specificity and accuracy of pelvic MRI and 18F-FDG PET/CT were calculated in the detection of pelvic and paraaortic lymph node metastases.
Results: 18F-FDG uptake was seen in primary cervical lesions of all the patients. Mean SUV max of primary cervical lesions was calculated as 13.6±6.6 (range: 6.7-25). In 16 (50%) patients, 18F-FDG uptake was not seen in pelvic and paraaortic lymph nodes. In the remaining patients, 18F-FDG uptake was detected in pelvic nodes in all the patients (50%) and in paraaortic nodes in 6 (18%) patients. Mean SUV max of pelvic lymph nodes were calculated as 8.4±5.2 and of paraaortic lymph nodes 12.45±6.41. 18F-FDG uptake was detected in a total of 47 lymph node stations in 16 patients. Mean SUVmax of all lymph nodes were calculated as 8.9±5.83 (range: 2.6-21.9). According to 18F-FDG PET/CT findings, disease was upstaged from I to IV in 1 (3%) patient, II to III in 2 (6%) patients, III to IV in 1 (3%) patients and I to III in 2 (6%) patients, and down staged from III to I in 1 (3%) patient, respectively. In the patient-based analysis, 18F-FDG PET/CT was TP, TN, FP and FN in 14 (%44), 14 (44%), 2 (6%) and 2 (6%) patients, respectively. Patients based sensitivity; specificity and accuracy of 18F-FDG PET/CT were calculated as 87%, 87% and 87%, respectively. In the lesion-based analysis, 18F-FDG PET/CT was TP, FP, TN and FN in 30, 7, 37 and 5 lymph node stations, respectively. Lesion based sensitivity; specificity and accuracy of 18F-FDG PET/CT were calculated as 85%, 84% and 84%, respectively.
Conclusion: 18F-FDG PET/CT is a reliable imaging tool with its high sensitivity and specificity in the pelvic and paraaortic lymph node staging of uterine cervical cancer. When performed in the preoperative staging it changes disease stage about in ¼ of patients. In combination of pelvic MRI, primary staging of primary cervical lesions and also pelvic/paraaortic lymph nodes can be done successfully.

How do We Live and what is the World We Live in Like? Some Possible Neuroscientific Evaluations on the Anthropology of the Spiritual Life in the Context of the Contemporary Society Adrian Sorin Mihalache  

Numerous results from recent medical research have revealed various ways in which environment, cultural experiences or living and working conditions affect health, with significant influences on the well-being. We shall analyse some of the challenges of today's society, and some of the consequences that they may have on relating man to the others and to the world they live in, as well as on health. We shall also make a few remarks on how entertaining offers and the usual practices of the information society could influence the drives, preoccupations and spiritual practices. Lastly, we shall discuss some common practices in the field of spiritual life that recent research has brought to attention and some evidence of their beneficial influence on health and well-being.

Considerations on Medical-Patient Relationship in Psychiatry. Anthropo-Medical Implications Adin-Daniel Robe Adina Baciu

This article attempts to briefly present aspects of the doctor-patient relationship in practice cases with the unipolar affective disorder, with or without anxiety. It also presents a case study demonstrating how the approach to a friendly relationship between treating physician and depressed patient increases compliance with treatment. The subjective observations can be applied cum grano salis in other forms of depression in different disorders (post-schizophrenic depression, depression from bipolar disorder). The therapeutic experience assimilated to the imaginative level considers every person valuable because the mere fact that he/she exists, then finds what makes it unique and respects its idiosyncrasies. The volatility of the depressed patient's state of mind requires a dynamic imagination of medical knowledge and principles, as well as the sliding between the three different instances of the physician-patient relationship during admission or interaction with the patient. In the case of depression, it can be said that each instance of the disorder is unique to every patient, like fingerprints: genetics, neurodevelopment, primary and intermediate irrational beliefs are unique to the affected individual, aspects that are of great interest in medical anthropology.

Global Journal of Anthropology Research (Volume 4 Issue 2) Philosophy of Race Versus Population Genetics: Round 3 Geoffrey K Chambers  

The Social Constructionist and Biologically Realist views of human races are often presented as mutually exclusive alternatives. Surprisingly, this debate has its origin in work on blood group population genetics. A finding that the greater part of human genetic variation lies within populations, rather than between races, has led some to deny the reality of geographically limited biological clusters. An extension of this view maintains that any differences that may exist are distributed in clinal fashion along ancient human migration routes precluding reliable delineation of racial clusters.

Here I argue that new genetic data adequately demonstrate that statistically significantly differentiated human subgroups (aka biological races) do exist. Further, that the analytical methods used to reconstruct the history of these human clusters are themselves, in part, social constructs. Therefore, these two contrasting philosophical viewpoints may be seen as capable of working together. Indeed, they are a sub-element of a larger metaphysical debate regarding the reality or otherwise of race, social or biological. I conclude by stressing the importance of racial definitions as regards the collection of reliable census information, the formation of equitable social policies and better informed medical decisions, particularly those involving the prescription of pharmaceuticals.

A Preliminary Study Using Visual Assessment of Variation in Proximal Ulnar Morphology: Implications for Sex, Age, and Population Estimation A. Midori Albert Amanda L. Payne

The purpose of this preliminary study was twofold: (1) to examine the morphology of the proximal ulna by way of visual assessment (i.e., morphoscopic analysis) in order to gauge any variability between the sexes, adult ages and populations (African American and European American) and (2) to explore the possibility of utilizing a morphoscopic method in mass grave or mass disaster field settings where quantitative approaches would be prohibitive due to time and equipment constraints. The proximal ulna is an area of interest because it forms the elbow joint along with the proximal radius and distal humerus. And, whereas joints are areas of the skeleton that show sexual dimorphism as well as age-related and or biomechanical changes such as osteoarthritis, it was hypothesized that shape differences exist between females and males, and young, middle and older adult age groups, though perhaps not between populations (i.e., African American and European American), since most population differences are found in the skull and femur. This study was undertaken as well because of the paucity of information on ulnar variation of this nature in the published literature.

In this study, proximal ulnar morphology was largely characterized by a visual evaluation of torsion. A method was developed to assess this torsion, and the morphological data were collected for right and left ulnae from 64 individuals (n=128), aged 22 to 101 years, from the Robert J. Terry Skeletal Collection, Smithsonian Institution, National Museum of Natural History. Gross observations of raw data and results of certain statistical tests indicated that proximal ulnar morphology varied by sex and population; but, no clear distinctions among adult age groups could be determined. Because of small sample sizes, no definitive conclusions were drawn. Further testing on larger sample sizes is recommended. This study contributes novel information about proximal ulnar morphological variation, which, to date, has received little attention in osteological research.

Crimean Karaites and Krymchaks as Indigenous Peoples of Crimea in the Modern Conditions Borys Babin Anna Prykhodko

Objectives: This study aims to determine the qualification of the statute of two indigenous peoples residing in Crimean peninsula (Crimean Karaites and Krymchaks) in conditions of current interstate conflict.

Materials and Methods: Coherent analysis was made according to the common principles of law, norms of international human right law, to the provisions of Ukrainian and Russian legislation and to the present scientific publications devoted to the history and ethnic origin of Crimean Karaites and Krymchaks

Results: Author proved the duty of Ukraine to finish the procedure of official recognizing the Krymchaks and Karaites as the indigenous peoples (with the procedure in analogy for parliamentary Statement on Crimean Tatar People’s statute on March 20, 2014) and to adopt the Law on the Status of Indigenous Peoples fixing the prescriptions of the UN Declaration on Rights of Indigenous Peoples on the principles of subsidiarity.

Conclusion: collective political, economic, social and cultural rights of indigenous peoples must be defended despite any politic and military circumstances an situations of interstate conflict.

Coevalness and the Self-Immolating Woman: Anthropology's Objects Maja Alexandra Nazaruk  

Divergent but complementary approaches emerge out of the 80s to circumscribe anthropologists’relation to object of study with respect to translation. Concerned with intersubjective treatment of anthropology’s object, Fabian critiques the denial of coevalness as the central problematic of interdisciplinary studies in the epistemic construction of knowledge. The author’s subversion overthrows the pinnacle of human progress embodied by the West. By deploying distancing devices to demonstrate how the Other had been coined in the Western imaginary - notably, as a temporal marker of the past - Fabian emphasizes that ethnocentric visualism is pre-existing in language. At the intersection with subjective knowing in anthropology, this article provides a theoretical framework for considering Johannes Fabian’s and Gayatri Spivak’s chronopolitics. Through an analysis of synchronicity, simultaneity and contemporaneity, it especially gives attention to three issues: visualism, language and distancing device. Applied to the Hindi or Sikh tradition of suttee, the question of time is regarded as a necessary object for analysis in order to bring the Other into an equivalent plane of reference. Mired is the day when one would exist beyond the exclusionary divider between Self and Other.

Metric Methods of Skeletal Sex Determination using the Arm Bones of Two British Medieval Populations S. Martin C. Eliopoulos

Several studies have stated the importance of devising population-specific metric methods for sex determination. The long bones of the arm have been previously reported as having a high reliability. This paper explores the degree of sexual dimorphism in adult arm bones displayed in two Medieval British populations, one urban and one rural. The urban Gloucester population sample consists of 45 individuals (19 female and 26 male) and the rural Poulton sample of 27 individuals (13 female and 14 male) and were selected from collections housed at Liverpool John Moores University. Measurements of the proximal and distal epiphyses along with maximum length were used on the humerus, radius and ulna. These populations showed sexual dimorphism in every measurement taken. Discriminant function analysis found that all arm bones had very high discriminant accuracies in both populations reaching 91.2% (Gloucester radii) and 95.5% (Poulton radii). It was found that some of the values were significantly different between the populations supporting the necessity for population-specific metric standards..

Family Health History and Mate Selection: A Qualitative Study of Chinese Americans’ Views Lei-Shih Chen Qian Ji

Frequent and better use of family health history (FHH) may affect individuals’ reproductive decision-making. Yet, its impacts on mate selection are unclear, given that selecting partners for dating or marriage often comes before pregnancy, and the attitudes and decisions for having children and selecting mates are somewhat different. As Chinese Americans are understudied in FHH-related research, we carried out the first qualitative study (to the best of our knowledge) to examine whether or not knowing someone’s FHH influences dating or marriage decisions among this fast-growing ethnic minority group in the United States. In a community-based setting, we conducted in-depth interviews with 49 Chinese Americans. Interviews were audio recorded, transcribed, and analyzed using a content-analysis approach. Our findings revealed that about one-third of participants believed that FHH does not matter in their choice of mate, love is more imperative than FHH, and using FHH for mate selection is against God’s will. Nevertheless, nearly half of participants perceived a number of negative impacts that FHH might have on dating or marriage. These negative thoughts were attributed to fears of (1) certain unacceptable, FHH-related, severe, chronic, or infectious diseases; (2) the potential of passing diseases to the next generation; and (3) the burden of taking care of the sick partners and the inability of the sick partners to care for participants’ offspring. This study contributes to existing literature in FHH-related studies. Health education efforts are needed to educate Chinese Americans in order to improve their FHH knowledge, reduce unnecessary fears, and promote informed decision-making in mate selection.

Measurements of Head Circumference, Near Interpupillary Distance and Distant Interpupillary Distance of Ikwerre School Children in Nigeria G.S. Oladipo F.C. Akpuaka

The study aimed at determining standard values for head circumference, near interpupillary distance and distant (far) interpupillary distance of Ikwerre school children between the ages of 3-18 years. The measurements of head circumference, near interpupillary distance and distant (far) interpupillary distance were obtained from a randomly selected sample size of one thousand, five hundred and twenty-three (1523) children comprising seven hundred and sixty-four (764) males and seven hundred and fifty-nine (759) females. The mean values for male subjects (10.45±4.61 years) were found to be 52.42±2.22cm for head circumference, 5.76±0.45cm for near interpupillary distance and 6.38±0.45cm for distant interpupillary distance. The mean values for female subjects (11.00±4.62years) were found to be 51.95±2.18cm for head circumference, 5.72±0.47cm for near interpupillary distance and 6.34±0.48cm for distant interpupillary distant. Also mean values were obtained for different ages. Statistical analysis using z-test showed that males had significantly higher values than the females in head circumference measurement (p<0.05) but no significant difference was found in near and distant interpupillary distance (p>0.05).The knowledge of these values are important because normal values of head circumferences, near interpupillary distance and distant interpupillary distant are useful parameters in the evaluation and treatment of congenital or post traumatic deformities of the cephalic and facial regions.

Foot Length and Preference: Implication in Footwear Design A.S. Alabi G.S. Oladipo

Introduction: The foot bears great anatomical function and therefore needs to be protected. The design and engineering of footwear for diverse population is subject to accurate anthropometric data provided for the population.

Aims and Objectives: The present study therefore evaluates foot length difference in relation to foot preference and their implication in footwear design.

Methods: A total of 1154 adult Nigerians comprising of 577 males and 577 females were included in the study. Direct linear measurements of the left and right foot length were measured using a metric tape. Foot preference (RT, LF or both) and longer foot (RT, LT or EQ) were also determined. Data were analyzed using SPSS (IBM®Armonk, New York, USA) and Minitab V17 (Minitab® Inc. State College, Pennsylvania) statistical software. Paired-sample t-test was used to evaluate symmetry; student t-test was used to compare sex differences while Chi square analysis was used to evaluate the association of foot preference with sex, side and longer foot. Confidence level was set at 95%; as P-values ≤0.05 were considered significant.

Results: The mean (S.D) of the right and left foot length (RFL and LFL) of male was 270.20±13.25mm and 270.46±12.94mm while female was 248.90±12.07mm and 249.52±11.81mm respectively. The population RFL and LFL was 259.55±16.56mm and 259.99±16.22mm. The paired sample t-test showed significant symmetric differences in RFL and LFL for females (P=0.033) and total population (P=0.011) but not males (P=0.168). Males displayed significantly higher mean values than the females (P<0.001). Results of the Chi-square analysis showed that, when sex was related to foot preference, the right foot was observed to be dominant for both males (88%) and females (87%), while dual-footedness presented least (2.4% males and 1.7% females). However, there was no observed association of sex and the foot preference neither was there any proportionality difference (P>0.05) but there was association between sex and foot-length difference (P<0.01), with more females having a longer left and right foot while more males had relatively equal foot length. Conclusion:This study suggests the avoidance of assumption of equal foot length; hence, length difference must be considered when constructing footwear for the Nigerian population, most especially for the females, as the study observed bilateral asymmetry in foot length.

The Progression of Craniofacial Growth and Development: An Anthropological Study Applicable to the Forensic and Identity Sciences A. Midori Albert Charissa L. Wright

The purpose of this study is to provide a description of the progression of craniofacial growth and development from infancy through adulthood. Whereas much of the diverse published literature provides information specific to separate dimensions and or components of the craniofacial skeleton, unique to particular populations, our aim, through compiling these disparate findings, was to capture and convey the overall appearance of the craniofacial complex at various ages. This was accomplished through an intensive review and amalgamation of the published literature, mostly from the recent five years, which addresses various aspects of craniofacial growth and development. Key findings suggest that at birth, craniofacial bones have attained approximately 45% of their total growth.

Most rapid growth is complete by age 7 with facial development largely complete (82 to 92%) by age 5. Specific sexual dimorphism (shape differences in females and males) begins to appear around age 9.Final size maturity is attained between 13 and 15 years in females and 17 and 25 years in males. Although technically craniofacial growth is continuous, after 20 years of age the rate of growth appears insignificant. These findings, and this integrated anthropological research approach provides essential information for individuals working at the frontier of forensic science technologies inclusive of age progression, age regression, and facial identification.

Women’s Sexuality: the Safavid Legacy Faegheh Shirazi  

Literature from the Safavid era suggests that issues of female fertility, sterility, and sexuality were controlled by a well-entrenched patriarchy. Muslim women placed trust in the learned hakim or male “healers”- believing that they were following religious doctrine established by the Prophet himself. Consequently, women who could neither read nor interpret the Qu`ran deferred to the hakim, participating in elaborate ritualistic practices to promote fertility and to win their husbands’ affection. Some would suggest that this collective dependency on and submission to patriarchal control–sealed during the Safavid era–springs from a historical trinity comprised of the Prophet Mohammad, his son-in-law Imam Ali ibn Abi Talib, and Majlesi, the 16th century Shi`i alim.

The Development of Physical Activities in the French West Africa Territories Yaya Koné  

This socio-historical approach of physical activity and sport focuses on Mali, Southern Burkina Faso and Northern Ivory Coast. We interest both to the representations of body and sport phenomenon. Numerous cultural and historical factors throw light on the situation of physical education in Sahel (religion, ethnicity, settlement). The beginning of sport in western Africa is placed under the control of France. The indigenous were forbidden to do sport, but later with the World War I, French authorities have seen in teaching of physical education a great way to strengthen the Army. Then, the physical activities appear as useful and subversive practices. The African national sports emerge during 1950 decade, mainly in track and field and football.

The Austronesian Diaspora: A Synthetic Total Evidence Model Geoffrey K. Chambers and Hisham A. Edinur

This is an evidence-based account of a remarkable, but perhaps somewhat underestimated, series of human population movements lasting continuously for around 5000 years. Information has been collected from a wide variety of studies across a range of disciplines and subjected to critical examination. The emergent picture is presented as a Synthetic Total Evidence Model which traces the Austronesian Diaspora from Taiwan via a genes, language and culture trail to Island Southeast Asia. From there two distinct branches are shown to lead one across the Pacific and another through Malaysia and Indonesia then on to Madagascar. Along the way there are many confounding episodes of admixture, language shifts and cultural assimilation. The Pacific branch is shown to contain two distinct groups known as Polynesians and Melanesians with similar, but still individually characteristic, genepools. Despite all these complexities, the evidence does build to a single unified multi-dimensional picture.

State Mediation of Qāt Consumption in Yemen: The Political Socialization of the National Polity Serge D. Elie  

Yemen is probably unique in the world, as it is a country in which the consumption of a commodity (qāt) – that is considered a drug, and an illegal one, elsewhere – structures the functioning of its social order, and regulates the quotidian existence of its population. This article explains how a plant became the singular object of commodity fetishism on a national scale, and how its mode of consumption came to instantiate a state-enabled social panopticon. It presents a comprehensive narrative that situates the endemic cultural practice of qāt consumption in Yemen within a historical continuum that spans nearly a century of qāt mediated state-society relations. In adopting a historically embedded explanation of this practice, the article provides a corrective to the intrinsically mistaken nature of the ahistorical interpretive framework of metropolitan travelling theories used by most social scientists – especially anthropologists – studying the qāt phenomenon in Yemen. Accordingly, the article retraces the historical trajectory of the gradual sedimentation of the qāt chewing practice into an inexorable state-qāt-society nexus as the constitutive matrix of Yemen’s national polity. The article elucidates how qāt consumption was used by the Yemeni state in the political socialization of citizens as part of its polity formation strategy. This is done through a reconstructed genealogy of the state mediation of qāt consumption informed simultaneously by a historical anthropology, a cultural sociology and a political economy of the multiple factors and ensemble of processes that contributed to the societal hegemony of this practice. The article offers a panoramic analysis that integrates the social, cultural, political, economic and institutional ramifications of qāt fetishism through a narrative of four historical conjunctures which illustrate the shifts in state policy vis-à-vis qāt and the capillary effects throughout Yemeni society. The article concludes with a summation of the current configuration of state-society relations in which qāt emblematizes a national social currency, and offers a brief menu of the challenges to be confronted in addressing the multiple dilemmas of Yemen’s endemic qāt chewing culture.

Dr Oscar Amoëdo y Valdes (1863-1945), Founding Father of Forensic Odontology Xavier Riaud  

Oscar Amoëdo y Valdes was born in Mantazas, a
village near Havana in Cuba, on November 10th 1863.
Early in his teenage years, he started practising
dentistry in Ricardo Gordon’s dental office, a local
dental surgeon1. The latter encouraged the young man
to further his training at Dr Florencio Cancio Zamora’s
Central Academy of dentists in Havana. He graduated
with the highest honours. The student sollicited the
dean of the university of the Cuban capital city in
October 1884 in order to take the diploma of dental
surgeon that he passed at the age of 21 years old.
Inquisitive about all subjects, Oscar decided to enroll at
the New York Dental College in the USA, where he
graduated in 1888. Then, he returned to Cuba. There,
he had an independent practice until 1889. He
attended the first dental congress in Paris. Following
this symposium where he was largely acclaimed, he
settled in Paris and enrolled at the Faculty of Medicine.
In 1897, he was asked to identify a body which was
supposed to be that of Louis XVII from his teeth. After
the examination of the teeth, he undoubtedly concluded
that it was not the dead son of the beheaded king.

Social Network and Social Support among Elderly Asian Immigrants in the United States Xuewei Chen Divya Talwar

The immigrant populations in the U.S., especially elderly Asian immigrants, have increased significantly in recent years. With limited English proficiency and health literacy, elderly Asian immigrants are a vulnerable minority group with poor health outcomes, inadequate use of healthcare services, high healthcare costs, and mistrust on the U.S. healthcare system. Receiving support from social ties helps them to better utilize available resources within and beyond their community. The purpose of this paper is to systematically review the current social support and social network studies among elderly Asian immigrants. Our findings indicate that they receive emotional support from spouses, friends and neighbors, instrumental support from adult children (e.g. financial help), appraisal support from religious members (e.g. suggestion/feedback), and information support from ethnic communities. However, they have limited social ties and receive inadequate social support. Therefore, helping them expanding their social networks and operating social skills are effective for improving their well-being

Sexual Dimorphism of the Fovea Capitis Femoris in a Medieval Population from Gloucester, England Natalie Murton Matteo Borrini

Attempts to develop new methods of sex determination in forensic anthropology are constantly being made by researchers in the field. This paper investigates the potential of using an index of the fovea capitis femoris shape as a method of sex determination. The currently held belief is that variation within the fovea capitis is purely idiosyncratic. The study was carried out on a sample of 19 males and 19 females from the Gloucester skeletal collection housed at Liverpool John Moores University. Measurements of the maximum fovea capitis height and breadth were taken from both the left and right femora and converted into an index. It was found that while there was no significant difference in dimensions alone, there was a significant difference in index values between males and females for both the left (t(34) = 4.294, p < 0.001) and right (t(32) = 3.046. p = 0.05) fovea capitis. This method was found to have 78.1% accuracy in determining the sex of an individual. Therefore, we may now be able to state that variation of the fovea capitis is sexually dimorphic and not exclusively idiosyncratic as first thought

Drug Consumption in Romania: Anthropological and Medical Aspects Adina Baciu*  

Abstract: Objectives: These include the presentation of: the main causes of drug use; the influence of polydrug use on
the physical condition and body mass index; the importance of understanding the consequences of medical,
psychological and social consequences of illicit drug use in prevention.
Materials and methods: The transversal study was carried out in 2015 in Bucharest on a group of 44 drug users (31
male, 13 female). Volunteer subjects were aged between 19 and 43 years old (mean age, 31.27±5.81 years). A
questionnaire with 46 items was used for this study and 8 items are related to this particular paper, referring to drug use,
ways of administrating it and to the linkage between illegal and legal drugs, and also to the physical condition of the
participants to the study. The quantitative results were analysed using SPSS version 19 and Excel.
Results: Of this sample, 43.2% of the subjects had started using drugs out of curiosity, 38.6% because of the
environment (entourage), 4.5% for entertainment (fun), 4.5% because of family, school or work related issues and 2.4%
because of social affirmation desire. Used more drugs 47.7% of the participants, 36.4% only heroin, 6.8% used only new
psychoactive substances (“legal drugs” or “ethnobotanics”, the commercial name of new psychoactive substances),
4.5% only marijuana and 2.3% methadone. 75% of consumers used drugs by injection (parenteral or intravenous),
15.9% smoked the drugs (pulmonary) and 6.8% use both ways of administration. 18.2% of the respondents did not
associate the consumption of illegal drugs with legal drugs, while the rest did make the association (with alcohol-9.1%,
cigarettes-27.3% and coffee-2.3%. Combined drug use with alcohol and smoking 29.5% of the subjects and 81.8%
noticed that after drug use their physical condition deteriorates. Consumers from the study noticed a deterioration in their
physical condition after 2 (13.6%) – 3 (27.3%) years, after 1 year (11.4%) and after few month (6.8%). 53.85% of women
and 19.36% of men are underweight.
Conclusions: This study shows that the polydrug use was prevalent among consumers. It was found that the polydrug
use had negative effects on health, causing psychological disorders (cognitive, emotional and behavioural), and
degradation of physical and nutritional status, after a shorter or longer period of time. Knowing the effects of medical,
psychological (cognitive, emotional and behavioural) and social aspects of illicit drug use among young people is
essential to prevention.


Integrating e-procurement in hospitals’ supply chain units has made it possible to conduct procurement practices effectively as compared to the manual methods of recording procurement and general conducting of procurement functions. However, the performance of hospitals in delivering high quality of services has reduced due to lack of an e-procurement system in some hospitals. The purpose of the study was to determine the effect of e-tendering on organizational performance. The study adopted the use of diffusion of innovation theory. The study employed a descriptive survey of 5 hospitals. The sample size was 367 respondents. Questionnaires were the main types of data collection tools. The data collected was then coded and entered into the Statistical Package for Social Sciences (SPSS) Version 22. The study used both quantitative and qualitative data. Data was then presented in tables of frequencies and percentages. The study findings indicated that e-tendering has increased competitiveness in the tendering bid for the hospital; The result on inferential analysis was that e-tendering had a β = 0.369; P <0.005. The study findings will be of great significance to Uasin Gishu County Hospitals as it was deemed to shed light on how e-procurement practices can enhance performance. The study recommended the e-tendering to be adopted for all hospitals to enhance performance. The study also forms a basis for further research in the area of procuremen

A Study on Body Mass Index and Prevalence of Chronic Energy Deficiency among Adult Kharwar Tribes of India Ajeet Jaiswal  

Abstract: The Health and nutritional status of an individual depends on the food he eats. Man needs a wide range of
nutrients to lead a healthy and active life and these are derived through the diet they consume daily. Good nutrition is a
basic component of health. This paper deals with the utility of various anthropometric cut-off points in the evaluation of
nutritional & health status. The Kharwar is one of the Adavasi groups of Uttar Pradesh and Bihar. “They are
contemporary of Mundari speaking Indian tribes” and “racially they belong to Proto-Australoids” and “linguistically to
Dravidian group”. The traditional economic activities of the Kharwar have been agriculture and other wage earning
labour. The objective of the present study is to investigate the nutritional status of adult Kharwar tribal. This crosssectional
study was undertaken to determine the prevalence of under nutrition using body mass index (BMI) among
individuals of 18 years and above. A total of 151 (75 males and 76 females) adults from the different villages of
Varanasi- Mirzapur District were measured. The result revealed that prevalence of under nutrition (age and sex
combined) among Kharwar was 26.5 %. The sex specific rates were 33.3 % and 19.4 % among females and males,
respectively. There was a highly significant sex difference in Chronic Energy Deficiency (CED) prevalence based on
BMI. Kharwar adults were experiencing serious situation, especially the women and oldest were experiencing the most
serious situation with respect to their health and nutritional status.

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