To investigate the clinical effect of precise puncture and low-dose bone cement in percutaneous vertebroplasty (PVP).N = 30) and group B (N = 30). Group A has punctured to the fracture area accurately and injected with a small dose of bone cement, the group B was injected with a conventional dose of bone cement. The operation time, the amount of bone cement injection, the number of X-rays, the VAS scores, the leakage rate of bone cement, and the incidence of adjacent vertebral fractures were compared between the two groups.Sixty patients with osteoporotic vertebral compression fracture (OVCFs) who were treated with PVP in our hospital from July 2018 to June 2019. These included patients were divided into group A (P < 0.05). Patients in group A had a lower incidence of cement leakage and adjacent vertebral fracture than that in patients in group B. There was no significant difference in postoperative pain relief between the two groups.The operation time, fluoroscopic times, and bone cement volume in group A are less than that in group B (Precise puncture and injection of small doses of bone cement can reduce the number of X-ray fluoroscopy, operation time, amount of bone cement injection, reduce the rate of bone cement leakage and the incidence of adjacent vertebral fractures, which is a safe and effective surgical approach for the treatment for the aged with OVCFs. With the aging of society, the treatment of osteoporosis has become a significant issue . One of cement leakage is one of the most common complications of PVP [PVP was first performed for the treatment of a hemangioma in 1984 by Galibert and Deramond [s of PVP , 6. Alths of PVP . PVP assSixty patients with OVCFs hospitalized in the Second Affiliated Hospital of Bengbu Medical College were enrolled in this prospective study from July 2018 to June 2019, informed consent has been signed for all included patients. Seventy patients were assigned to the targeted PVP group (group A) and traditional PVP group (group B), and 30 patients in group A, 30 patients in group B.Inclusion criteria: (1) elderly patients with osteoporosis more than 60 years old, (2) single-segment thoracolumbar fractures, MRI showed fresh vertebral compression fractures, intact posterior wall of the fracture, and no symptoms of nerve injury; (3) all included patients had significant low back pain, visual analog scale (VAS) is more than 5 points.Exclusion criteria: (1) multi-segment thoracolumbar vertebral compression fracture, single vertebral compression is more than two-thirds of the original vertebral body height, (2) pathological fractures, including tumors, hemangioma, etc., (3) patients with infection in surgical area; (4) patients with spinal stenosis, coagulopathy, old fractures, incomplete vertebral posterior wall, or nerve injury symptoms.The patient is in the prone position, and the soft pillows on both sides of the front chest and the underarm cushion make the abdomen vacant to reduce the compression of the abdomen; the C-arm X-ray machine was used to observe the target vertebral body, and the upper and lower endplates are in a line. After fluoroscopy, the body surface is positioned and marked. Conventional disinfection drape, anesthesia with local infiltration of 1% lidocaine, deep into the periosteum around the pedicle. When anesthesia is sufficient, the waist is over retracted to restore the compressed vertebral body.1 OVCF is shown in Fig. The skin and subcutaneous soft tissue were cut with a scalpel at the marked location, the length of incision is about 0.5 cm. Under fluoroscopy, the core puncture needle was placed into the pedicle . Adjust the puncture needle tilt or tail tilt angle according to the fracture line area. Under the lateral fluoroscopy, it is confirmed that the puncture needle is located in the pedicle, and continues to puncture the vertebral body to the posterior one in three of the vertebral body. At this time, the fluoroscopy needle tip is located slightly inside the inner edge of the pedicle shadow. This process requires precise penetration into the fracture line area, then exits the puncture needle, and the hollow drill takes a biopsy. An injection volume of bone cement was 2 to 3 ml per segment in thoracic vertebra and 3 to 4 ml in lumbar, respectively. Stitching incision and covered with a sterile applicator, postoperative prone position for 15 min after surgery to better coagulates bone cement. Preoperative MRI film of LThe fracture reduction and puncture method are the same as those in the observation group. The puncture needle does not have to be penetrated into the fracture line area. The amount of bone cement injected is 4 to 10 ml.P < 0.05, Table There was no significant difference in the general condition of the two groups of patients Table . All patThe main cause of clinical symptoms after OVCFs is fractured trabecular micro-motion . After tLu et al. considered that the distribution of bone cement is the main factor affecting clinical efficacy . After sIn vitro mechanical tests by Belkoff et al. have shown that the infusion 2 ml of bone cement restores the strength of the vertebral body, while restoring the stiffness of the vertebral body requires at least 4 ml . Cotten Bone cement leakage is a common and severe complication of PVP. The bone cement will leak into the spinal canal and burn the nerve root and spinal cord. After the bone cement leaks, pulmonary embolism and other important organ embolisms will occur. The previous study found that injecting 7 ml of bone cement into the vertebral body, the pressure in the vertebral body can be increased by sixfolds, and an increase of pressure in the vertebral body will directly lead to leakage of bone cement . In our Huang et al. considered that adjacent vertebral fractures after PVP or PKP are a natural progression of osteoporosis , the sevReducing the amount of bone cement injected can reduce the risk of leakage . Before Clinical application experience of accurate puncture to the fracture area and injection of low-dose bone cement PVP: (1) preoperative patients need to check MRI to determine whether the diagnosis is a fresh vertebral compression fracture; (2) CT three-dimensional imaging is used to determine whether there are cracks in the upper and lower endplates of the vertebral body. Whether the posterior wall of the vertebral body is ruptured, the possibility of leakage of bone cement, the condition of the pedicle, and the angle and position of the puncture are judged in advance, and the position of the fracture line is further determined to facilitate accurate puncture into the area of the fracture line; (3) under the premise of ensuring that the puncture needle penetrates into the fracture line, the thoracic spine is injected with 2-3 ml of bone cement and the lumbar spine is injected with 3-4 ml; (4) the patient was bedridden for 6-8 h after operation.Precise puncture and injection of small doses of bone cement can reduce number of X-ray fluoroscopy, operation time, amount of bone cement injection; reduce the rate of bone cement leakage and the incidence of adjacent vertebral fractures, which is a safe and effective surgical approach for the treatment for the aged with OVCFs.


This study presents cascaded thermodynamic and environmental analyses of a high-performance academic building. Five different energy efficiency measures and operation scenarios are evaluated based on the actual measurements starting from the initial design concept. The study is to emphasize that by performing dynamical energy, exergy, exergoeconomic, and environmental analyses with increasing complexity, a better picture of building performance indicators can be obtained for both the building owners and users, helping them to decide on different investment strategies. As the first improvement, the original design is modified by the addition of a ground-air heat exchanger for pre-conditioning the incoming air to heat the ground floors. The installation of roof-top PV panels to use solar energy is considered as the third case, and the use of a trigeneration system as an energy source instead of traditional boiler systems is considered as the fourth case. The last case is the integration of all these three alternative energy modalities for the building. It is determined that the use of a trigeneration system provides a better outcome than the other scenarios for decreased energy demand, for cost reduction, and for the improved exergy efficiency and sustainability index values relative to the original baseline design scenario. Yet, an integrated approach combining all these energy generation modalities provide the best return of investment. Buildings contribute to about 35–40% to the energy used in almost all climate zones. Possible reductions of energy consumption in buildings are some of the most important strategic goals to combat the climate change ,2,3. ThiIn addition to reducing energy consumption, all possible improvements should be assessed based on their long-term economic benefits and their direct impact on occupancy comfort parameters. Only then will stakeholders be able to choose the most sustainable alternative energy technologies for new buildings or decide how to proceed with the renovation of existing ones. In this paper, we outline a cascaded thermo-economic analysis based on exergoeconomic, environmental impact and sustainability models. The present approach combines the cost of input energy, capital investment, and exergy values of input and output streams of each component in a building, and uses real data obtained at different phases of the building operation. We systematically analyze four different scenarios beyond the original design conceptualized by the architects of the building. Three of these four scenarios are based on major energy generation modalities chosen by the University and studied in detail by the researchers at the Center for Energy, Environment and Economy (CEEE/EÇEM). They include a ground heat pipe system, roof-top PV panels and the use of a trigeneration system. The last scenario corresponds to the combination all of these systems.There are several studies available in the literature which discuss similar problems based on thermodynamic principles ,12,13,14As part of improving an existing building, Jansen et al.  presenteSevilgen and Sancar  developeMartinopoulos et al.  consider2 emission, as well as the cost pollutants. We applied the methodology to five different cases mentioned above. The selected scenarios were not arbitrary, but chosen based on the improvements of an actual building constructed with contributions from a EU-FP7 grant and based on the stakeholders’  decisions. The timing of the building construction, financing of the improvements, the EU-FP7 grant to CEEE allowed a very opportune time to conduct this study based on actual construction and operation data. If it were a theoretical study, we could have considered a number of other energy efficiency measures; however, here we limit ourselves to three major improvements mentioned above and detailed next.The objective of the present article was to study the performance of an existing high-performance building with real data obtained during different phases of operation and determine the required energy generation and utilization strategies for its long term financial and sustainable operation. For this purpose, we have developed a cascaded methodology which account for energy demand, exergy demand, energy losses, exergy destructions and losses, energy cost, CO2 emission amount, and the energy costs of all of these cases are determined. The exergy efficiency and the sustainability index for each case are calculated. For this purpose, a computational tool was developed by using EES software that can allow us to estimate the benefits of any potential improvements of the building based on dynamic analysis. Finally, a number of improvements are suggested to reduce the adverse effects of the energy use of the building to the environment. In addition, we discuss how to improve the sustainability index of the building based on integrated engineering-architecture principles. The comparisons of sustainability index for different operation cases allow sustainability analysis of high-performance buildings based on fundamental thermodynamic principles.In this study, we analyze the energy and exergy flows from the beginning (energy source) to the end (building envelope) based on the real data obtained for the actual building. As the first case, we consider the original design of the building and its heating system as designed by architects and engineers (without any suggestions for improvements by the CEEE/EÇEM researchers). Then, we study four additional scenarios to determine the possible improvements of sustainable energy flow in the building. The second case involves the use of Ground Air Heat Exchanger (GAHX) that corresponds to almost 5% of heating load. The third case is the use of roof-top solar PV panels; we note that about 75% of the roof area of the building was used for solar electricity production. The fourth case is the use of a tri-generation system as an energy source instead of the current traditional boiler systems. The tri-generator actually provides the energy for the entire campus, the School of Languages (SCOLA) being one of the buildings considered in this study. Finally, we consider as the fifth case all three alternative energy additions together. Energy, exergy and exergoeconomic analyses are applied dynamically during the entire heating season to all these cases in order to make a detailed comparison between all these strategies. The energy and exergy flows, energy and exergy losses, CO2 amount, and energy demand costs of each case are quantified for the entire heating season. The cooling load analysis might be investigated in a forthcoming work.All analyses have been performed dynamically in order to have higher accuracy in the results obtained as shown in a previous study . The heaFor all calculations, we used a relatively straightforward EES software based on the guidance of IEA ECBCS Annex 49 (2011) . The govHeat transfer through the building envelop can be determined from ,31:(1)Q˙ed using .(2)Q˙v=Please note that the definitions of each symbol are given in the Nomenclature, and therefore are not repeated in the text. For the initial calculations, the solar and internal gains were not considered, although for later calculations they were included. Heating energy and exergy of the building are calculated from:FC) of the building; then the input energy and exergy are calculated as [These values of energy and exergy are considered as the output of fan coils (lated as : (5)ϕFC,Dis) have been considered as the inlet and outlet points representing the input and output energies. Therefore, the difference between input and the output values gives us the losses in pipes. Similarly, the exergy destruction is the difference between exergies at these two points [The distribution pipes (o points . The inpo points : (7)ϕDisB) uses natural gas as fuel for heating water to be distributed in the building. Hence, the input of distribution can be considered the boiler output and the input values of both energy and exergy can be estimated as [The boiler ϕBDHW) are also included in the heat-energy demand calculations. The components of the heating system need auxiliary electrical energy to be turned on. Hence, the energy demand (ED) for the first case is determined as:XD) becomes: In addition to the heating load energy, energy used for lighting, ventilation, and domestic hot water :The energy and exergy demand in 3rd case differ and were determined using the following expressions: The 4th case utilizes a trigeneration system instead of boiler, which works as a source for hot water, chilled water and electricity. In heating mode, the trigeneration system is used only for the hot water and electricity. Hence, the calculations are carried out only for the heating mode. The only energy and exergy need to be estimated before the trigeneration system is that for the natural gas energy, because only gas is used to produce energy. Therefore: sustainability index (SI), which provides a clear indication of the efficient use of resources [We also consider esources . Its valesources :(18)ηx,bspecific exergy cost’ (SPECO) method [Using these equations, the energy and exergy flows through the system components are estimated and taken as starting points for the next step, which is the exergoeconomic analysis. Several researchers used and/or illustrated the benefits of the ‘) method ,38,39. T) method  demonstrj-component.The exergoeconomic balance equation for each component of the cycle can be written as see :(20)costFinally, the relation between the cost and the exergy of any component within the heating system can be determined based on the exergetic cost coefficient  on the boiler or any component of the heating system , CO2AN is the CO2 emission during fuel firing process (0.19 kgCO2/kWh) [PWY is the annual power (kWh) that was produced by using annual consumption (CO2Y) of fuel, and NH is the annular operating time in hours [2/kWh [2 [The enviroeconomic analysis has also been considered as the emission of unburned carbon COussed in ,42 that CO2/kWh) , WYP is s [2/kWh , and the2/kWh [2 . Figure 2/kWh [2  for receThe School of Languages (SCOLA) Building was built in accordance with the master plan of the Ozyegin University campus situated in Cekmekoy district of Istanbul (north-west Turkey). The construction of the building was completed in 2014 with the partial support from the European Union 7th Frame Program New Energy Efficiency Demonstration for Buildings . The Center for Energy, Environment and Economy (CEEE) was responsible from the Turkish demonstration building at Ozyegin University . The2, whereas the net conditioned area is 15,093 m2. The building consists 6600 m2 of insulated external wall with an average U = 0.302 W/m2K, 3560 m2 of insulated roof with an average U = 0.248 W/m2K, 40% of which are underground, 1350 m2 of double glass aluminum-frame  windows (U = 1.6 W/m2K), 1500 m2 double glass curtain wall (U = 1.3 W/m2K), and 93 m2 external doors (U = 1.6 W/m2K). Moreover, it has an efficient external solar shade installed at specific sides of the building after a careful analysis of solar load [More than 1450 students, 125 instructors and 10 administrative staff have been using SCOLA since September 2014. As the user capacity of the building is very high, there are three entrances to the building. The building consists of 66 classrooms for 20 occupants, four lecture rooms for 56 persons, two lecture rooms for 90 persons, three seminar rooms, 25 study rooms, 54 offices, cafeterias, baths, hallways and various service rooms. All classes are routinely used between 08:00 to 18:00 five days a week, accept summer months. All instructor offices are to be used between 08:00 to 17:00 according to schedule of instructors. The total floor area is 17,700 mlar load . The floThe building has passed three stages of major improvements since it was built. These additions were decided by the stakeholders, i.e., by the University and the architectural firm. CEEE has influenced the process in line with the project objectives. In this paper we study only these three improvements, rather than many other energy efficiency measures considered for the building. The first was the addition of ground air heat exchanger (earth tubes). The second was addition of PV cells on the roof to exploit the solar energy and improving the building performance which plays an important role in such applications ,27. AddiThe 1st case: This case represents the original concept which involves the architectural design of the building and its original heating system. The electricity is supplied by the national network, whereas the hot water is provided by the boiler (2200 kW) that uses natural gas as fuel. This case is considered the standard/baseline to compare against the other cases (see ases see .The 2nd case: Addition of the earth-tube (earth-air heat exchanger system) for partial cooling/heating to the building ventilation system corresponds to the 2nd case. The system, installed at the eastern side of the building, covers 1200 m² of land area, it is 10 m wide, at the depth of 2 m, with 72 m long horizontal pipes, and provides 10,000 m3/h air to the building. This heat exchanger is so far the largest installed system in Turkey. The 3rd case: This case corresponds to the solar PV system installed on the building roof with a total capacity of 126 kWp. The system includes 504 Poly c-Si YL250P-26 PV modules  with 15.4% efficiency under standard test conditions . These panels occupy 75% of the entire roof of the building. Produced DC electricity is converted by six 20 kWh string inverter units from Advanced Energy . All six inverters are combined into a distribution panel and connected to the grid through automated relay on floor electricity panel.The 4th case: The most significant improvement for the building was achieved after adding a tri-generation system which simultaneously provides electricity and works as both a heating and cooling source. The tri-generator is utilized for the entire university campus, not only the SCOLA building considered in this study. The 5th case: For this final integrated case, the three additions; i.e., the air ground heat exchanger, the PV panels, and the tri-generation system are considered together. We note that the 5th case corresponds to the current operating conditions of the buildings with all alternative energy sources.2 emission. Moreover, it focuses on the development of exergy distribution, generation and storage system concept [A pre-design tool ECBCS Annex 49  is used  concept ,10,11.The energy and exergy efficiencies of the heating system were calculated based on energy and exergy balances of each component dynamically for five cases. The economic aspects of the operations were considered by applying the exergoeconomic analysis using a dynamical methodology . In addiThe monthly energy and exergy demand and the weather temperature data used for this study are shown in 2 emission.In addition to energy flow, annual exergy flows were also dynamically estimated for all cases considered for the building and its heating system at each stage. The exergy demands reductions for the 2nd and 3rd cases, relative to the 1st case, are 5% and 18%, respectively. It can be noticed that the exergy reduction is mostly due to the PV-panels (the 3rd case) which contributed significantly to the enhanced performance of a building. The 4th case helped reducing the exergy demand around 36% relative to the 1st case. The integrated 5th case is, as expected, to provide the maximum reduction in exergy consumption, by 43%. F factors; see Equations (11) and (12)) are 1.1 and 0.9, respectively, while these factors for the electricity are 3 and 1, respectively. Hence this large difference can be seen in the results presented. For the first three cases , the input energy is based on electricity and natural gas, and output is only for hot water. For the last two cases (4th and 5th case) the input energy is obtained only from natural gas. The corresponding energy, therefore, is lower than that for the first three cases. The output is the sum of electricity and hot water, which is higher than the output energies of the first three cases. For the distribution stage, in the first three cases, both the input and output energy are due to hot water; therefore, the losses are only because the reduction in water temperature within the pipes. In the last two cases the losses of this stage are higher, because that the electricity and hot water represent the input power of this stage while the output is only the hot water energy. In fan-coil/AHU component, the losses of the 2nd case are less than the corresponding value for the 4th case, as the heating load is the less.It is also important to outline the annual energy and exergy losses for system sub-components, as shown in Exergy losses (or destructions) do not differ from the energy losses, as shown in In addition to the energy and exergy flows and losses, the energy consumption cost is quantified for all five cases using a dynamic exergoeconomic analysis . The cos2 emissions by 4% and 15%, respectively. A 51% reduction can be achieved by using a trigeneration system, as shown for the 4th case. The overall system improvements corresponding to the 5th case result in 56% reduction in CO2 emissions. This improvement is significant and shows that the trigeneration system should definitely be considered for financial investment by the stakeholders.The environmental considerations of the system are outlined in The exergies corresponding to all five cases and the building components are listed in 2 emission were calculated dynamically for the entire heating season; the corresponding data are given in the (1)The consideration of the 2nd, 3rd, 4th, and 5th cases show the potential reduction the total energy demand is around 3%, 10%, 29%, and 36%, respectively, relative to the original design. These additional considerations correspond to 4%, 12%, 31%, and 37% reduction in annual cost of energy for each case, in respective order.(2)The annual exergy demand can be reduced by 5%, 18%, 36%, and 43%, respectively, following the four scenarios considered beyond the original design. These values show the potential broader impact of each improvement considered.(3)2 emission can be lowered by 3%, 15%, 51%, and 56% relative to the original design by implementing the 2nd, 3rd, 4th, and 5th scenarios, respectively.The CO(4)The exergy efficiency and sustainability indexes for the case based on using tri-generation system (the fourth case) are 36% and 1.56, respectively. These values are quite high compared to those for the original case .(5)Maximum enhancement in building performance can be achieved by using a tri-generation system; the second highest impact comes from the roof-top PV panels.(6)The maximum improvements in exergy efficiency and sustainability index of the building can be achieved by considering the 4th (trigeneration) and the 5th (comprehensive) cases.(7)The dynamic analysis presented provides a clear picture of buildings performance and should be preferred over simpler static analysis.In this paper we have presented a detailed performance analyses of an existing high-performance building with five scenarios based on different alternative energy sources, including the original design, three different additions of energy systems , and the integrated design including all three systems. The building analyzed is an academic building (SCOLA) in the campus of Ozyegin University in Istanbul, Turkey. For the five cases considered the energy and exergy flows, the components losses, the energy costs, and CO


Krediet and colleagues6 also questioned the current criteria for CSH, considering them to be very sensitive, resulting in the high prevalence observed in the elderly population.6 They suggested changing to pause ≥ 6 seconds and/or lowering mean blood pressure to < 60 mmHg for more than 6 seconds, based on the fact that 6 seconds of asystole are required to cause loss of consciousness;7 that in the general population the 95th percentile for response to CSM was 7.3 seconds of asystole;6 that in clinical follow-up, patients with pauses > 6 seconds (43%) had significant recurrence of syncope compared to patients with 3-6 seconds who had only 0.7% of occurrence;8 and that in the International Study on Syncope of Uncertain Etiology 2 (ISSUE-2) the average pause in observed syncope recurrence was 9 seconds (8-18 seconds).9 Based on this new criterion, McDonald and colleagues analyzed mortality according to the current criterion and the criteria proposed by Krediet (described above) and Kerr (pause > 7.3 seconds and systolic blood pressure drop > 77 mmHg).10 In a total of 272 patients, 106 of them (38.9%) had CSH according to the standard criteria, and 141 (51.8%) and 28 (10.3%) according to the Krediet’s and Kerr’s criteria.10 They did not observe statistical difference in mortality in patients with and without CSH in a mean follow-up of 8.6 years by the standard criterion , but noted differences according to Krediet’s  and Kerr’s  criteria. After adjusting for age and gender, only CSH defined by Kerr’s criterion was associated with increased total mortality .Attempts to refine or modify the definition of positive response have been proposed to enable accuracy in the diagnosis of CSS as the cutoff value of systolic blood pressure ≤ 85 mmHg combined with symptoms suggested by Solari et al.11 observed the evolution of 502 patients undergoing CSM, with 52 patients presenting cardioinhibitory response or asystole ≥ 3 seconds. When compared to the 408 patients with physiological response (or without CSH), the authors did not observe differences in either cardiovascular or trauma-related mortality, with total mortality rates of 55.8 vs. 49.3% (p = 0.38) in patients with and without cardioinhibitory response respectively.11 Among the 52 patients with cardioinhibitory response to CSM, only 7 patients had a history of syncope and no pacemaker implantation was required in any of them. The low prevalence of patients with syncope in the study, placed as a limitation, may have further reinforced the indifference in the evolution of patients with or without cardioinhibitory CSH. These results reinforce the hypothesis of the limitation of CSH findings to clinical applicability in most of the observed cases and are in agreement with the current literature.In this issue, the study by Lacerda and colleaguesTherefore, CSH remains a matter of evaluation, with controversy since its definition, based predominantly on small, old studies with technical limitations of the time, and the heterogeneity of the methods employed in the CSM. The lack of accuracy has been pointed as a factor in the low specificity of the finding, making it difficult, and sometimes confusing the clinician, for the proper diagnosis of CSS in the investigation of syncope to be performed, which requires response to CSM according to the criteria for CSH combined with reproduction of clinical symptoms during the maneuver. The findings of the article rekindle, once again in the literature, the need for reevaluation of the current parameters described in the consensus on CSH, the bases for the correct diagnosis, appropriate treatment and prognosis of CSS in syncope.


First, two high-level controllers are designed to track the joint trajectory under two scenarios, namely known and unknown upper bounds of uncertainties. The controllers include an adaptive feedforward term based on inverse dynamics and a robust control term compensating for the uncertainties. Second, the independence of control gains from the upper bound of uncertainties and the inclusion of the joint viscous friction coefficient into the dynamic parameter vector are realised. Then, a low-level controller is designed for the task of tracking the cable tension trajectory. The system stability is analysed using the Lyapunov method. Finally, the validity and effectiveness of the proposed controllers are verified by experimenting with a three-DOF six-cable CDSM. In addition, a comparative experiment with the classical proportional–integral–derivative (PID) controller is carried out.The structure of the cable-driven serial manipulator (CDSM) is more complex than that of the cable-driven parallel manipulator (CDPM), resulting in higher model complexity and stronger structural and parametric uncertainties. These drawbacks challenge the stable trajectory-tracking control of a CDSM. To circumvent these drawbacks, this paper proposes a robust adaptive controller for an  Thus, C., m≥n+1 ,8.Currently, researchers are designing motion controllers for the fully constrained CDSM. One type of controller is based on the kinematic model of the space between the cable and the motor and uses the joint angle as feedback to form a closed-loop control ,10,11,12At present, related studies have proposed robust adaptive controllers for cable-driven parallel manipulators (CDPMs). Khosravi et al.  proposedHowever, to the best of the authors’ knowledge, no research has been conducted on robust adaptive algorithms to control the CDSM. In fact, a comparison  of the CHence, the main objective of this study is to build a theoretical system for stable tracking control of the joint position and cable tension trajectories of the CDSM, considering the uncertainties in the system model, and simultaneously remedying the present drawbacks. The controller design in this paper includes the design of a high-level controller for the tracking control of the joint position trajectory and a low-level controller for the tracking control of the cable tension trajectory. A stability analysis of the entire system with the proposed controller is also conducted. The definition of the whole system and the division of controller hierarchy will be described in detail in A robust adaptive controller for the CDSM; a stability analysis of the system as a whole, considering both high-level and low-level controllers; and a performance evaluation of the proposed controller via an experiment with a three-DOF six-cable CDSM, which is the first exploration of the adaptive robust control algorithm for CDSMs so far.System modelling for the generalised CDSM, considering the ball-screw transmission mechanism and actuator models is derived. The joint viscous friction coefficient Compared with the existing research results for CDPMs, the control gains of the high-level controller described in Theorem 2 are independent of the upper bound of uncertainties and other intermediate process parameters. This is also meaningful for the control of CDPMs.A performance comparison of two robust adaptive controllers, one with a known upper bound (combination of Theorems 1 and 3) and one without an upper bound of uncertainties (combination of Theorems 2 and 3), is developed.The main contributions of this paper are:The remainder of this paper is organised as follows. A During the movement of the CDSM, the section where the cable bends is defined as the attachment point.The section of the cable between two adjacent attachment points is defined as the cable segment.The attachment point For the cable system, the following definitions were applied:The motion equation of the generalised The symbol The following paragraphs will discuss motion control in free space. Hence, the external force is zero, i.e., operties :Property 1.The inertia matrixis symmetric and positive definite.Property 2.The dynamic model can be expressed in linear form with respect to a suitable set of dynamic parameters:wheredenotes the vector of constant dynamic parameters anddenotes the regression matrix, which is the function of joint positions, velocities and accelerations.Property 3.is a skew-symmetry matrix, i.e.,The ball-screw system converts the motor position and output torque into cable lengths and tensions. The model of the According to The system model described by Equations (1) and (8) can be regarded as a cascaded structure. Two controllers, i.e., high-level and low-level controllers, were designed to control this system. The high-level controller outs the desired input cable tensions In the following sections, on the assumption that the coupling term For the sake of clarity, the key mathematical symbols used in the controller design and their physical meanings are shown in The research object in this subsection is a high-level subsystem which ignores the coupling term The purposes of the controller for this subsystem are to design the control input The proposed control law is given byThe general solution of There are two different ways to design the estimate Another way is by describing the robust term asfound in .Therefore, the following two theorems on stability analysis for joint position trajectory tracking are formed:Theorem 1.The trajectories of the CDSM are described by the model in Equation (14) under the control law in Equations (15) and (17), the robust control law described by Equation (18), the parameter adaptive law described by Equations (19) and (16) and the following sufficient conditionglobally asymptotically converges toand, which implies convergence ofandto zero and the boundedness of.Theorem 2.The tracking error trajectories of the CDSM described by the model in Equation (14) under the control law in Equations (15) and (17), the robust control law described by Equation 21, the parameter adaptive law described by Equations (21), (16) and (22) and the following sufficient conditionis UUB, where,anddenote the-th  diagonal element of,and, respectively.Obviously, when Remark 1.For the robust control law, Equation (18) in Theorem 1 requires prior knowledge of the upper bound of uncertainties, whereas Equation (20) of Theorem 2 does not. Compared with the control gain in , which dProof of Theorem 1.Substituting Equation (15) into the dynamics model of the actuating cables and robot body described by Equation (6) givesSubtracting The property of linearity shown in Property 2 is exploited. Hence, the vector of parameter error is Consider the Lyapunov function candidate, which is given byThe time derivative of We modify Equation (28) as follows: apply Property 3, expand Substituting Equation (17), and then substituting Equation (15) into Equation (29), givesSubstituting Equation (26) into Equation (30) and then applying Equation (16) in the term If the estimate of the parameter vector is updated as in the adaptive law described by Equation (19), the representation of Equation (32) becomesConsider that, for However, the signum of Then, if It is easy to see that by satisfying the condition of Equation (23), Hence, the negative definite of the time derivative of Proof of Theorem 2.Consider the Lyapunov function candidateThis function can be bounded asBased on Equation (32), the time derivative of According to Equation (21), the following inequality can be given asSubstituting Equation (41) into Equation (40), Substituting the parameter adaptive law described by Equations (21) and (22) into Equation (42), and applying the following inequalities Q is given byIt is reasonable to assume that To ensure that Based on these conditions, Now, given Equations (47) and (39), provided the condition in Equation 24) is satisfied,  is satisxtension , in the Taken Remark 2.For the ultimate bound of the tracking error, if Theorem 1 uses Equation (18) as the robust control law, for, the joint position error trajectory will eventually converge to the sliding surface, to obtain a zero steady-state tracking error. In fact, this zero steady-state error is transient, and the trajectory will oscillate near the sliding surface with a certain amplitude. This is caused by measurement errors. This phenomenon can be eliminated by using the following new adaptive control law,wheredenotes the threshold width of. This controller cannot ensure that the error converges to zero and that the error changes within a symmetric boundary layer with a thickness ofcentered on the sliding surface, i.e., the error is UUB. The ultimate bound of Theorem 2 is, which depends on the parameters,and. The final tracking error can be reduced by lowering these parameter values, but it also reduces the system’s robustness to noise and external disturbances.Remark 3.The convergence velocity of Theorem 1 is controlled by the parameter, while that of Theorem 2 is controlled by, which is essentially controlled by the parameters,and. If these parameters were reduced, the error limitwould also be reduced directly, but the timerequired for the error trajectory to converge towould increase. That is, the convergence velocity will decrease. This can be obtained by the monotonically decreasing property of the second equation in Equation (51) in.Remark 4.In general, the ultimate bound of error and the convergence velocity of Theorems 1 and 2 can be adjusted by the corresponding parameters. Theorem 2 has many adjustable parameters and hence strong adjustability. In addition, it does not require prior knowledge of the upper bound of uncertainties of the system. However, the design of the control law in Theorem 1 is relatively simple and straightforward, with a small amount of calculation. Ifcan be obtained accurately, the accuracy of Theorem 1 using Equation (18) will be higher than that of Theorem 2.According to the above remarks, the controller should be chosen according to the actual application needs. For example, the action of positioning the charging gun in an automatic charging task requires high accuracy. Therefore, the maximum possible The tracking error of cable input tensions and its filtered tracking error are defined asDifferentiating Equation (8) givesBased on this, the dynamic extension method in  can be aCombining Equation (55) and Equation (56) givesThe following robust control law is adopted:Substituting Equation (58) into Equation (57) givesDifferentiating Equation (60) and then combining it with Equation (59) givesIt can be verified that Theorem 3.Consider the error system defined by Equation (57). The control law described by Equations (58) and (59) and the following sufficient conditions about the adjustable control gainsensure a locally exponentially stable result of the tracking errorsand, wheredenotes the infinity norm of a vector anddenotes the following defined diagonal positive-definite gain matrix.Proof of Theorem 3.Before introducing the Lyapunov candidate function, we define the auxiliary functions Using the sufficient condition of the first equation of Equation (64) gives the following inequality:The following inequality arises from the second equation in Equation (66):Let Applying Equations (66) and (67) gives the following lower and upper bounds of Using Equation (54) multiple times gives the following inequality about the time derivative of Applying the first equation of Equation (64) gives the following inequality about Hence, Equation (71) can be bounded asHere, the following inequalities about Therefore, the error Remark 5.Theorems 1 and 2 give the global asymptotic stability and UUB stability of the joint-position-tracking error, respectively. Theorem 3 gives the local exponential stability of the cable-tension-tracking error.The existence of the coupling term Lemma 1.Based on Theorem 3, the low-level subsystemis locally exponentially stable. Based on Theorem 1 or Theorem 2, the high-level subsystem ignoring the coupling term,is globally asymptotically stable or UUB. Hence, the cascaded system described by Equation (10) is asymptotically stable if its solutions are all uniformly bounded.Proof of Lemma 1.The proof is already given by  and 28]28]. □Lemma 2.Combining this lemma with Theorem 3, all solutions of the cascaded system described by Equation (10) are all uniformly bounded ,30, prov(a) The coupling termis bounded aswhereandare classfunctions.(b) There exist positive constantsand, such that forthe two Lyapunov functionsin Theorems 1 and 2, which establish the stability of, satisfyProof of Lemma 2.According to The tracking errors Therefore, there exist positive constants Theorem 4.Given the controller design described by Equations (15), (17) and (58), the robust control law described by Equation (18) and the adaptive update law described by Equation (19) or the controller design described by Equations (15), (17) and (58), the robust control law described by Equation (20) and the adaptive update law described by Equations (21) and (22), the closed-loop system Equation (10) is in asymptotically stable equilibrium at.Proof of Theorem 4.Obviously, the combination of Theorems 1 and 3 or Theorems 2 and 3 together with Lemmas 1 and 2 ensures the asymptotic stability of the equilibrium point The block diagrams of the controllers with a known upper bound and without an upper bound of uncertainties are shown in To verify the adaptability of the proposed controller to actual application scenarios, a three-DOF six-cable CDSM for an automatic charging robot of electric vehicles is used as the research object of this experiment to verify whether the controller can complete the actual task of automatic charging, as shown in Automatic charging robots for electric vehicles are a research field which has emerged in recent years ,31,32. IThe realisation of this kind of automation will free the charging workers from heavy and repetitive work. A complete automatic charging process is shown in Figure 7 in . The tasThe CDSM system was equipped with three types of sensors: motor encoders, joint encoders capable of providing accurate position measurements for the joints and load cells capable of yielding accurate cable tensions. The load cell is selected as an S-type tension and pressure sensor. To reduce the influence of the sensor’s weight on the cable tension measurement, the load cell was installed horizontally, so its weight could be supported by the upper surface of the support plate see b. A suffFor this three-DOF six-cable robot, detailed information about the Jacobian matrices The parameters of the robot and the ball-screw system are listed in To verify the effectiveness of the controllers with a known upper bound and without an upper bound of uncertainties, two sets of experiments were performed with the three-DOF six-cable CDSM system.In this experiment, a path containing a circular arc path see . In the For the position trajectory of the circular sub-path, a cubic trajectory was planned for the arc length first, which is defined as the length of the arc with extremes The trajectory of the operation space can be converted into that of the joint space by using inverse kinematics. In this experiment, the method of tracking the joint angle trajectory was adopted to ensure the trajectory of the end-effector.The parameters of the controller from the first experiment are given in The parameters of the controller from the second experiment are listed in Comparing the first and second experiments, the following results were obtained. First, the initial trajectory tracking of 0 to 1 s of the second experiment is more stable than that of the first experiment, when comparing To demonstrate the superiority of both proposed controllers with a known upper bound and without an upper bound of uncertainties over the classical PID controller, some comparison results are presented here. First, having the same experiment conditions as the previous study, the high-level controller is replaced with a well-tuned PID controller, which is commonly used in the literature for the tracking of the desired joint position. The desired and actual paths, using the three controllers, are illustrated and compared in Compared with the classical PID controller, the two proposed controllers have significant improvements according to This study proposes a robust adaptive controller for stable tracking of the joint position and cable tension trajectories in a CDSM. First, two robust adaptive controllers were designed for the task of joint position trajectory tracking in two scenarios, i.e., with known and unknown upper bounds of uncertainties, respectively. The stabilities, ultimate bounds of tracking error and convergence speeds of the two high-level controllers were compared theoretically in remarks. Compared with the adaptive controllers for a CDPM in existing research, the two controllers in this study included the joint viscous friction coefficient in their dynamic parameter vectors, which is a factor which must be considered for CDSMs’ controller design. Besides, an important advantage of the controller in Theorem 2 is that it makes the control gains independent of the upper bound of uncertainties, which is superior to existing CDPMs’ adaptive controllers. Second, for the task of cable tension tracking, this paper proposes a robust controller based on the dynamics of a ball-screw system. By using the Lyapunov method, we analysed the stability of the part of the subsystem from the cable tension to the joint position, the part of the subsystem from the motor output torque to the cable tension and the entire system. Experiments with a three-DOF six-cable CDSM demonstrated the validity and effectiveness of the designed controller. The comparison experiment with the classical PID controller verified the superiority of both proposed controllers with a known upper bound and without an upper bound of uncertainties. Further works should focus on improving the proposed controllers’ adaptability to hyper-redundant CDSMs, the link and cable numbers of which are as large as tens. This is because the hyper-redundancy will cause bulky work of the control gains’ selection when the proposed controllers are used. Moreover, the controllers proposed in this paper only consider viscous friction, although good experimental results have been obtained. However, if Coulomb friction is also taken into consideration, whether better experimental results can be obtained remains to be verified. This is also future research work.


A scale for behavioural pain assessment is useful for the detection and determination of pain in the elderly with dementia. This study aimed to translate and evaluate the psychometric properties of Doloplus-2 in the elderly with dementia in Iran.In this methodological study, after translation and evaluating the face and content validity of Doloplus-2, 100 elderly people were selected by the convenience sampling method in Kashan, 2018–2019. Exploratory factor analysis, convergent validity, and known-groups comparison were applied to determine construct validity. Reliability was also assessed through internal consistency, equivalence, and stability methods were used. The ceiling and floor effects were also examined. Data were analyzed using the SPSS-v16 and via Mann-Whitney U test, Cronbach’s alpha, Spearman-Brown, and intraclass correlation coefficient (ICC).The scale’s content validity index was 0.95%, and the item impact of each item was above 1.5. Factor analysis identified 2 “social-functional” and “conventional subjective-objective” factors in scale that altogether were able to explain 76% of the total variance. The results revealed that P-Doloplus-2 could discriminate between the 2 groups of elderly with and without known chronic painful diseases (P < 0.0001). There was a significant positive correlation between P-Doloplus-2 and PACSLAC-II-IR scores . Cronbach’s alpha, ICC, and standard error of measurement for the scale were 0.950, 0.864, and ± 1.759, respectively. The frequency of minimum and maximum possible score of scale was less than 15%.The Persian version of Doloplus-2 can be considered as a valid and reliable scale for pain assessment in the elderly with dementia. Pain is a common problem among elderly people with dementia [1]. International studies have reported a pain prevalence of 17% to 79.5% in the elderly with dementia living in nursing homes [2]. Studies in Iran on community-dwelling elderly people reported a pain prevalence rate of 79.8%–82.4%, but no separate statistics have been reported for the elderly with dementia . Pain occurs in the elderly for a variety of reasons, such as musculoskeletal disorders, ischemia, neuropathy, or malignancies [2]; if it continues, will cause severe consequences such as depression, anxiety, social isolation, sleep disorder, sedentary behaviour, reduced quality of life [5].Despite the prevalence and significant consequences of pain in the elderly with dementia, pain in this group is often ignored and underestimated due to a variety of reasons, including addiction to analgesics, concern about the side effects of analgesics, and widely held misconceptions about the inevitability of pain among elderly people . In addition, dementia can cause memory impairment, aphasia, apraxia, and agnosia and gradually affect all functional aspects of the individual. This issue can cause a greater tendency to ignore the pain in this group [6]. On the other hand, in some patients, pain appears in the form of some symptoms like aggression, restlessness, various mood disorders, hallucinations, and delusions that can sometimes be confused with dementia symptoms due to their similarities and may lead caregivers to use antipsychotic medications. This issue is of serious concern because of the possible side effects of taking such medicines [8]. Therefore, assessment and proper detection of pain and its severity are essential in implementing effective therapy in the elderly with dementia.Regarding the subjective concept of pain, self-report is often represented as “the gold standard” in the assessment of pain . Although this method of pain assessment is often used at the onset of dementia, its use will be questioned as the disease progresses and patients lose their ability to communicate. Therefore, considering the conditions of patients with dementia, behavioural symptoms of pain should be taken into account in the evaluation of pain in this group [8]. The American Geriatrics Society (AGS) has organized and presented behavioural pain indicators in 6 different behaviours in the elderly with dementia [9]. Based on which different tools were developed for pain assessment among these patients over the past few years . In Iran, however, nonspecific pain rating scales such as a verbal descriptor scale (VDS) and faces pain scale (FPS) are used to measure pain in this group of patients . Considering the incidence of aphasia, agnosia, and other sensory-motor disorders in patients with dementia, and the nature of these scales, their use in such patients are severely restricted [8]. Haghi et al. translated and evaluated the psychometric properties of the PACSLAC-II (the pain assessment checklist for seniors with limited ability to communicate-II) as a specific tool to measure pain in patients with dementia [11]; however, this tool has many items and some relatively specialized concepts, and this feature limits its use.According to the findings of several studies conducted on pain assessment scales in the elderly with dementia, the Doloplus-2, a pain behavioural assessment scale, seems to be a useful scale in the diagnosis of pain and determination of pain severity. This scale can provide a wide range of behavioural pain indicators in dementia patients [9], can be easily used by professional caregivers [8], and its psychometric properties appear to be favourable in different communities [12–17].Doloplus-2 was developed by Wary et al. in France in 2001 [12] to assess pain in nonverbal cognitively impaired older adults [18]. This scale developed for the multidimensional assessment of pain. It consists of 3 dimensions and a total of 10 items: somatic reactions (5 items), psychomotor reactions (2 items), and psychosocial reactions (3 items). Each item is levelled with 4 behavioural descriptions representing increasing severity of pain rated from 0 to 3. Individual item scores are summed to arrive at a total score ranging from 0 to 30 scores. Score 5 indicates pain . Doloplus-2 as one of the most widely used pain assessment tools in patients with dementia have been currently translated into English, Dutch , Norwegian [14], Italian, Spanish, Portuguese [13], Japanese [15], and Chinese [16] and its psychoanalysis has been done. In all different translated versions, the desired level of psychometric properties has been verified.By searching the national and international electronic scientific databases available to the authors of the article, no study has been conducted on translation, psychometric validation, or the use of the Doloplus-2 in Iran. Given the strengths of the scale, the present study was conducted to translate the Doloplus-2 into Persian and evaluate its psychometric properties, as a pain-behavioural assessment scale, among elderly people with dementia in Iran.This methodological study focusing on translation and psychometric evaluation of the Doloplus-2 scale was conducted in 2 phases in Kashan city, Iran, during 2018-2019.At this phase, the Doloplus-2 scale was translated according to Wild et al. (2005) guideline [20]. Accordingly, in the first step (preparation), after gathering the required information about the intended scale, and getting permission from its developers by Email, translation and psychometric evaluation of the scale was performed. In the second step (forward translation), the English version of the Doloplus-2 was translated into Persian independently by 2 translators fluent in both Persian and English and familiar with health literature in the aging field. At the reconciliation step, the translated texts were reviewed in an expert panel consisting of members of the research team, and they reviewed the translations to achieve the best possible version. The Persian version of the scale approved by the expert panel, along with the original version, was given to a person with expertise in the related field and Persian literature to evaluate the scale in terms of appropriate equivalent vocabularies and grammar. Then, his points of view were reviewed by the research team, and the necessary corrections were made.In the next step (back-translation), the primary form of the translated version was back-translated into English by a person fluent in English and Persian, familiar with relevant texts and independent of the individuals involved in the forward translation process. During the back-translation review, the Persian version, the original version, and the English back-translation were reviewed by the members of the research team, and disagreements were discussed, agreed upon by both the researchers and the back-translator and final revisions were made. At the harmonization step, the revised English translated version was sent to the designers of the scale to investigate the conceptual conformity of the revised version with the original version, and they approved the conformity of the new version. In the cognitive debriefing step, 10 caregivers  were recruited to assess whether the vocabularies used in the scale are appropriate and understandable. By conducting an individual and face-to-face interview with each of the caregivers, they were asked about each of the items, words that were not understandable, and their equivalents, which they believed to be more common and comprehensible. In the review of cognitive debriefing results and finalization, the research team made the necessary adjustments to the scale with respect to the questions and ambiguities raised by the caregivers in the cognitive stage. At the proofreading and final report step, a Persian version was finally reviewed by a research team and a Persian language editor in order to resolve the grammatical and writing problems, and a primary version of the Doloplus-2 scale was prepared to investigate its psychometric properties [20].This phase was implemented in 4 steps:For face and content validity assessments, the Persian version of the Doloplus-2 scale was provided to 10 experts in different fields of neurology, geriatrics, psychiatry, psychology, and psychometrics [21]. Regarding the qualitative assessment of the scale, they were asked to comment on the comprehensibility, grammaticality, literature, scoring, components, and totality of the scale, and adequacy, clarity, and simplicity of the items [22] and accordingly, the necessary changes were made.Content validity was quantitatively assessed by calculating the content validity ratio (CVR), content validity index (CVI), and modified kappa statistic [21]. Experts were asked to rate the essentiality of each item on a 3-point Likert scale for CVR strict calculation and its relevance on a 4-point Likert scale for CVI and modified kappa statistic calculation [22]. The Lawshe table [23], Waltz and Bausell’s (1981) index [24], and Polit and Beck’s (2012) approach [25] were used to assessing the results of the CVR, CVI, and the modified kappa statistic, respectively. The S-CVI/Average was also used to calculate the total CVI [25].For quantitative face validity assessment, the same experts were asked to rate the importance of each item on a 5-point Liker scale and then, their rating scores were used to calculate item impact score. Item impact score above 1.5 was considered to be optimal . Regardless of the investigations carried out by the experts for qualitative assessment of face validity, each one of the 10 caregivers  were asked to answer each question of the questionnaire separately and express their perception about each question. Then the respondents’ perceptions were compared with the main intention of the question [26].Some statisticians believed that in factor analysis, the number of samples should be 5 to 10 times the number of tool items [27]; since the Doloplus-2 contains 10 items, the minimum number of samples needed was estimated to be 100, 10 samples for each item, in the sample size calculation formula. The inclusion criteria in this study were: having Iranian citizenship, age 60 and over, having dementia based on the neurologist diagnosis by interview and CT scan, lack of mental retardation based on the neurologist diagnosis, having hearing ability to cooperate in implementing a standard mobility protocol, satisfaction with participation in the study , no use of analgesics 6 h before the assessment, permanent residency for at least 1 month for elderly people residing in nursing homes and having qualified caregivers (taking care of elderly with dementia at home for at least 4 days per week for at least 1 month or at least 4 shifts per week for at least 1 month in the elderly care centers). The exclusion criterion was the voluntary withdrawal of the participant or his/her caregiver/guardian from the study. Sampling was done by convenience sampling in 2 nursing homes and a private neurology clinic in Kashan from December 2018 to June 2019.After obtaining the necessary authorizations from the relevant authorities, and receiving introduction letter from the vice chancellor for research and technology of the Kashan University of Medical Sciences, the researcher referred to two nursing homes and a private neurology clinic in Kashan, to extract a list of the elderly with dementia under the supervision of these centers and contact their legal guardians. If the elderly and his/her primary caregiver were eligible and consented to participate in the study, an appointment for assessment was made with each participant’s guardian. Then, we attended the appointment for data collection.Data were collected by demographic questionnaire, the Persian-clinical dementia rating (P-CDR) [28], Doloplus-2 and PACSLAC-II-IR [11] through observation and interview with the patient and his/her caregiver and based on the patient’s record.The demographic questionnaire included 8 questions, including age, sex, marital status, education, employment status, place of residence, history of known chronic painful diseases, and name of the diseases.The Persian version of the CDR scale includes 75 questions, which should be asked from the participants and their companion in 6 areas, including memory, spatial or temporal orientation, judgment and problem solving, community affairs, home activities and leisure, and personal affairs. Each area scored on a scale from 0 to 3; the total score in the scale ranges from zero to 18. Scores of 0, 0.5–2, 2.5–4, 4.5–9, 9.5–15.5, and 16–18 are considered as normal cognitive status, suspected cognitive impairment, very mild cognitive impairment, mild cognitive impairment, moderate cognitive impairment, and severe cognitive impairment, respectively. Psychometric validation of  the Persian version of this scale was carried out by Sadeghi et al. (1390) in Iran; the experts of the field confirmed its face and content validity, and its reliability coefficient using Cronbach’s alpha was estimated 0.73 [28].The Doloplus-2 consists of a list of 10 items divided into 3 subgroups: 5 somatic reactions items , 2 psychomotor reactions items  and 3 psychosocial reactions items . Each item is scored from 0 to 3, where 0 is “absent”, and 3 is “the highest score of the behaviour”. It gives a range from 0 to 30, with higher scores indicating more pain severity. The cut-off score between ‘pain’ and ‘no pain’ was set at 5, as recommended by the scale’s developers [12]. The concurrent validity of this scale has been verified by the VDS, pain assessment in advanced dementia (PAINAD), and the PACSLAC scales [8]. Cronbach’s alpha coefficient and intraclass correlation coefficient (ICC) in different studies were reported to be 0.67–0.87 and 0.75–0.97, respectively .The original version of the PACSLAC-II scale was developed by Chan et al. (2014) to assess pain in elderly people with severe dementia [30] and translated into the Persian language by Haghi et al. (2019) [11]. The Persian version of this scale contains 30 items, each item being rated as 0 (no pain) or 1 (pain). This scale scores the pain from 0 to 30, with a higher score indicating more severe pain behaviour. Its validity has been verified by factor analysis and concurrent validity. Also, the ICC between the raters was estimated to be 0.76 [11]. In the present study, the reliability of this scale by computing the Kuder-Richardson 21 coefficient (KR21) was 0.78.The P-CDR was used to determine the severity of dementia in all the samples. The participants were examined at rest and during the standard mobility protocol presented by Husebo et al. using the pain assessment scales (Doloplus-2 and PACSLAC-II-IR) (Table 1) [31]. If the patient was not cognitively or physically able to perform the steps of the protocol, a qualified caregiver was recruited to help him/her. If either of them refused each of the steps, the participant was excluded from the study.In order to increase accuracy in completing the pain assessment scale at rest and during the mobility protocol, participants were videotaped.After data collection, construct validity was evaluated by exploratory factor analysis, known-groups validity, and convergent validity. Principal axis factoring (PAF) method with varimax rotation was used to extract data in exploratory factor analysis. Eigenvalue above 1 and the scree plot were used to determine the number of factors. The minimum load factor was estimated to be 0.52 based on Formula 1 in which “n” is the sample size [22]. Regarding the common factor loadings, the bigger factor loading was considered.Critical Value = 5.152 ÷ √(n - 2)Formula 1To compare the known-groups, the elderly with dementia were divided into 2 groups with known chronic painful diseases and the nondiseased. Then, the scores obtained for the Doloplus-2 were compared between the 2 groups. The Persian version of the Doloplus-2 and the PACSLAC-II-IR scale were completed simultaneously for all participants in the convergent validity assessment.The ceiling and floor effects of the scale were assessed [32]; so that the ceiling and floor effects were evaluated based on the relative frequency of the samples with the highest and lowest possible attainable scores, respectively.The reliability of the Persian MPS was assessed via the internal consistency, equivalence, and stability. The internal consistency of the scale was evaluated by calculating Cronbach’s alpha coefficient.For equivalence assessment, the scale was completed for 20 samples selected from the elderly of nursing homes simultaneously and independently by 2 individuals (first author of the paper and one trained caregiver), and the interrater agreement was estimated.The standard error of measurement (SEM) was also calculated to evaluate the stability of the scale [33].Data were analyzed using the SPSS software version 16. Quantitative variables were described by using central tendency and dispersion indices and categorical variables described by absolute and relative frequencies. Additionally, CVI, CVR, and modified kappa statistic were used for evaluating quantitative content validity, and quantitative face validity was analyzed using an impact score method. The Kolmogorov-Smirnov test analyzed the normality of quantitative data. The Kaiser-Meyer-Olkin (KMO) and Bartlett’s test of sphericity were used to determine the suitability of the data for factor analysis. Spearman-Brown test was used to investigate the correlation between the scores of the Persian version of Doloplus-2 with the PACSLAC-II-IR scale, Mann-Whitney U test for comparing known-groups, Cronbach’s alpha coefficient for assessing internal consistency, and ICC and the weighted kappa were used to examine the ICC.The SEM was calculated based on Formula 2, where “SD” is the standard deviation of the scores, and “r” is the Cronbach’s alpha coefficient [33]. In all the analyses, the significance level was set at P < 0.05.SEM = SD √1 - rFormula 2The draft of the Persian version of the Doloplus-2 had 10 items with a 4-point Likert scoring style (Appendix 1).In qualitative content validity assessment, minor modifications were made to the draft of the Persian version of the Doloplus-2; for example, in one of the items, the phrase of “Reduce his/her walking distance” was changed to the phrase of “Has lower mobility”. In quantitative content validity assessment, the CVR of all the scale items ranged from 0.8 to 1, which is higher than the number in the Lawshe table (0.62 for 10 experts). The CVI calculated for each item ranged from 0.8 to 1, which is higher than the minimum acceptable value based on the Waltz and Basel index (0.79). The modified kappa statistic also ranged from 0.791 to 1, which was higher than 0.74. The S-CVI/Average was estimated to be 0.95. In the qualitative face validity phase, no changes were made on the scale. In the quantitative face validity assessment, the impact score of all items was above 1.5 (3.44 to 5).A total of 127 older adults were included in the current study. Of whom, 24 cases declared (by yourself or by their guardians) that they were not willing to participate in the study, and 2 persons were not included in the study because of concomitant mental retardation; 1 person was excluded from the study due to dissatisfaction of his/her legal guardian. Finally, data of 100 samples were analyzed. The age range of the participants was from 65 to 93 years, with a mean age of 87.310 (± 8.497) years. Fifty-four percent of the participants were residing in their homes, and 27% had mild dementia (Table 2).Regarding the suitability of the scale for performing factor analysis, KMO indicated the adequacy of the number of samples (0.870); the Bartlett test also showed that the interitem correlation matrix had no problem for analysis . Factor analysis resulted in the extraction of 2 factors. The “functional-social” dimension (7 items) with an Eigenvalue of 4.386 and the “conventional subjective-objective” dimension (3 items) with an Eigenvalue of 3.228 were able to explain 43.859% and 32.283% of the total variance, respectively. These factors altogether could explain 76.142% of the total variance .In the known-groups comparison analysis, the pain intensity determined by the Persian version of the Doloplus-2 in the 2 groups with and without known chronic painful diseases were 18.270 (± 5.738) and 6.920 (± 5.589), respectively, which the results of the Mann-Whitney U test showed a significant difference (P < 0.0001).In the convergent validity analysis, the scores obtained from the Doloplus-2 and PACSLAC-II-IR scales for the studied items were 11.120 (7.865) and 11.260 (5.425), respectively. There was a significant and positive correlation between these 2 scores . Also, there was a significant positive correlation between the first and second factors of the Persian version of the Doloplus-2 with the PACSLAC-II-IR scale .As with the results of the floor and ceiling effects analyses, the relative frequencies of the minimum and maximum possible scores obtained from the Persian version of the Doloplus-2 were 2% and 0% (less than 15%), respectively.In the internal consistency analysis, the results showed that a Cronbach’s alpha coefficient for the total scale was 0.950 and for the first and second factors were 0.944 and 0.903, respectively.In the equivalence analysis for the total score of scale, the ICC coefficient between the scores of the raters was 0.864 . Also, for each item, the coefficient of agreement between the raters (weighted kappa) ranged from 0.640 to 0.919 (P < 0.0001) (Table 4).The SEM of the scale was ± 1.759.The present study aimed to translate and assess the psychometric properties of the Doloplus-2, as a behavioural pain assessment scale, in the elderly with dementia in Iran. It was found that the Persian version of the scale could determine pain severity in a range of 0 to 30 and had a desirable validity and reliability in the target population.In the translation phase of the scale, an attempt was made to maintain the maximum semantic and technical similarity of the text using the optimal translation equivalents and standard translation. If there are semantic equations, cognitive and perceptual terms in the translation process, it can be argued that this tool is consistent with the principles of cultural adaptation and is intended for the target group to understand the phrases correctly and easily [34].The results of qualitative content validity showed that the items were approved by the relevant experts in terms of intelligibility, grammar, literature, clarity, and simplicity. Also, considering the desirable values obtained from the calculation of the CVR (above 0.62), CVI (above 0.79) and modified kappa statistic (above 0.74), it can be claimed that the criteria for content validity are met in the Persian version of the scale [21].In qualitative face validity analysis, the scale items were not changed, which confirms the appropriateness of the items of the Persian version of the scale from the viewpoint of the experts and caregivers [34]. Unchanged items at this stage may be due to the use of Wild et al. (2005) guideline for the translation of the scale since the cognitive debriefing of the scale is one of the stages of its completion [20]. Also, quantitative face validity assessment indicated that the item impact scores of all items were more than 1.5, which confirms the face validity of the scale. Therefore, the face validity of the Persian version of the Doloplus-2 is confirmed.Construct validity through exploratory factor analysis identified 2 factors in the Persian version of the Doloplus-2, namely “social-functional” and “conventional subjective-objective”. The social-functional dimension includes items that examine the individual and social functioning of older adults with dementia, such as sleep, mobility, and communication patterns; Whereas the conventional subjective-objective dimension refers to the most common symptoms of pain, such as physical complaints and altered facial expression. The extracted factors were more than 43% and 32%, respectively, and could explain over 76% of the total variance. These numbers, according to Wipulanusat et al. (2017), indicated excellent construct validity [35]. Therefore, the construct validity of the Persian version of the Dololplus-2 scale was confirmed. The results of the study by Neville and Ostini (2014) showed that Doloplus-2 is a single-factor scale. Also, the percentage of variance explained in their study was lower than in the present study [29]; however, unlike the present study, the data were collected by multiple raters. In a study aimed to assess the psychometric properties of the Chinese version of Doloplus-2, 3 factors were identified in the scale that was able to explain 65% of the variance of the score [16]. Regardless of the differences in the severity of dementia in the studied samples, the use of multiple raters for pain assessment in the studies can be the cause of this difference.The results of the construct validity assessment using known-groups comparison showed that the Persian version of Doloplus-2 could discriminate between the 2 groups, with and without known chronic painful diseases. Therefore, it can be noted that the scale is able to detect the pain and its severity. Convergent validity showed a strong, positive, and significant correlation between total score and the score of each subscale of the Persian version of the Doloplus-2 with the PACSLAC-II-IR scale. Many researchers believe that a correlation of 0.5 indicates strong convergent validity [22]. Some experts, however, do not consider those too high coefficients to be desirable and accordingly emphasize that both scales  are the same, and there is no need to introduce new ones. However, they acknowledge that the new scale due to its nature can be a good alternative scale [36]. Although the Persian version of the Doloplus-2 (with 10 items) has fewer items than the PACSLAC-II-IR scale (with 30 items), it covers a wide range of behavioural pain indicators; therefore, its use for accurate assessment of pain by caregivers and researchers seems to be preferable. The results of Pautex et al. (2007) study confirmed the convergent validity of the Doloplus-2 and visual analogue scale (VAS), which are in line with the results of the present study [17].The relative frequency of the minimum and maximum scores obtained from the Persian version of the Doloplus-2 were less than 15%, meaning that the scale had no ceiling and floor effects [32]. The lack of ceiling and floor effects refer to including items on the scale that represent the maximum and minimum intensity of the pain, respectively. The existence of appropriate items can confirm the content validity and stability of the scale .Cronbach’s alpha coefficient was 0.95 for the total scale and above 0.9 for each of its subscales. Given that the coefficient is higher than 0.7 [37], it can be stated that the scale has good internal consistency. Internal consistency of the Doloplus-2 has been reported in studies ranging from 0.58 to 0.87 . The reason for the difference between the results of these studies and the present study may be because of differences in the number and characteristics of the studied samples, including age, severity of dementia, residence of place, and other demographic information.The ICC of the Persian version of the Doloplus-2 was 0.864. Also, the calculated kappa coefficient for each item was between 0.640 and 0.919. Koo and Li (2016) consider the ICC of 0.6 or more as acceptable reliability [38]. Therefore, the results show that the coefficient of agreement between the raters is desirable. The coefficient of agreement between the raters was reported between 0.47 and 0.96 in similar studies . The difference between the results of these 2 studies may be due to the quality of the training provided to the raters . Because of the nature of the concepts and terms in the Doloplus-2 scale, in order to achieve the desired results, it is necessary to educate caregivers on how to complete the scale which is focused on in this study. With respect to each item, the kappa coefficients of the items were reported from 0.19 to 1.00 in similar studies . Regardless of the number of raters and the quality of training provided to raters on how to complete the scale, the method of calculating the reported kappa coefficient should also be taken into account when comparing the findings of different studies.The assessment of the absolute reliability of the Persian MPS revealed a standard error of measurement of ± 1.795, which indicates that if the scale is completed again for an individual, its score may be changed by ± 1.795. The scoring range of the Persian version of the Doloplus-2 was from 0 to 30, which is low, and thus supports the stability of the scale [22].Variation in the characteristics of the units under the study is one of the strengths of the current study. Regardless of the relatively small sample size, considering the known cases of the chronic painful disease can be considered as a limitation of this study. In future studies, it is recommended that confirmatory factor analysis be performed on the Persian version of the Doloplus-2. Also, it is recommended that a study be repeated with larger sample size and with respect to the severity of dementia.The P-Doloplus-2 scale has 10 items and can be used as a valid and reliable scale for assessment of pain in patients with dementia by caregivers and researchers; it can be used after receiving adequate training on how to complete the scale.The authors would like to express their gratitude to the developers of the original version of the scale, all the elderly participating in the study, their caregivers and families, as well as the vice-chancellor of Research and Technology of Kashan University of Medical Sciences.This research is a part of the first author’s thesis in the Master’s degree in Geriatric Nursing, which has been sponsored by the vice-chancellor of Research and Technology of Kashan University of Medical Sciences (Registration No: 9728).The authors have no conflict of interest.The written permission was obtained from Vice Chancellor for Research and Technology (Registration No: 9728) and the Ethics Committee of Kashan University of Medical Sciences (No: IR.KAUMS.NUHEPM.REC.1397.015). In addition to obtaining written informed consent from the legal guardian of the elderly with dementia (if available) or head of the center responsible for the care of the elderly , informed consent was directly obtained from the elderly by taking into account the elderly’s conditions. The reasons for recording the videotapes and the confidentiality of them and other patients’ information were explained to the elderly’s caregivers and their legal guardians and finally their consent was obtained. If the legal guardian did not have consent to take out the videotapes from the elderly residents, the videotapes would be reviewed at the elderly residence, and the relevant files would be deleted after completing the scale. All the elderly people or their guardians had the right to change your mind and leave the research at any time.


The strengthening and weakening effects of SiC particles on composite strength and ductility were studied. Al-Cu-Mg alloys matrices with three different mechanical properties were used. Their yield strength, ultimate strength, and elongation range from 90 to 379 MPa, 131 to 561 MPa, and 18% to 31%, respectively. SiC particles with sizes of 4, 8, 12, 15, 20, and 30 μm were used to reinforce these three matrices, separately, and the composites of eighteen combinations of the particle sizes and matrix strengths were manufactured. Yield strength, ultimate strength, elongation, and fracture morphology of these composites were characterized. Based on the analysis, the strengthening to weakening behavior on strength and ductility were comprehensively discussed. The critical particle size having the best ductility was obtained. The strengthening limit and match range of the particle and the matrix to achieve effective strengthening were defined as a function of the particle size and matrix strength. This work offers an important reference for optimization of mechanical properties of the particle-reinforced metal matrix composites. Particle-reinforced metal matrix composites (PRMMCs) are attractive alternatives for applications that need a combination of high specific strength, and specific stiffness and ductility, such as new energy vehicles, aircrafts, and devices in aerospace ,2,3. HowBesides developing new composites, many efforts have also been made to improve existing PRMMCs by optimizing the match of the matrix and the particle. Many particle factors can influence the composite properties. Generally, the composite strength increases with decreasing particle size ,16,17, oThe aim of this study was to provide a better understanding of the effects of reinforcement on mechanical properties and a new perspective to obtain a better combination of strength and the ductility of the PRMMCs based on SiCp/Al-Cu-Mg alloys composites. The eighteen composites combined with SiC particles of six different sizes  and Al-Cu-Mg alloys matrices of three different strengths  were manufactured. Yield strength (YS), ultimate strength (UTS), elongation (EL), and fracture morphology of these composites were measured. Based on the analyses of these data, the strengthening to weakening mechanisms and their effect on strength and ductility were discussed. The size of the particle to achieve maximum ductility for these composites was obtained. The match range of the particle size and the matrix strength to determine the effective strengthening of the composite were defined using the polynomial fitting, which could help in developing a new PRMMC in the materials selection stage.2CuMg. This can put the matrix in a more simple state where the fewest types of precipitate exist. By altering the amount of Cu and Mg and keeping the Cu:Mg mass ratio of 2.61:1, matrices with different mechanical properties were obtained. These three matrices are named L, M and H based on the level of their strength, which represent low, medium and high level of strength of the matrix. The compositions and mechanical properties of three matrices are shown in Average α-SiC particles sizes of 4.1, 7.7, 11.3, 14.8, 19.6, and 29.9 μm were used to reinforce the matrices, which cover the effective strengthening particle size and are sufficiently large to causing a weakening effect. The Al-Cu-Mg alloy, which was combined with a wide range of strength and elongation, was used as matrices. According to the Al-Cu-Mg ternary phase diagram, when the mass ratio of Cu to Mg is 2.61:1, the alloy phase is almost AlThe composite rods were shaped into a tensile specimen with a gauge length of 30 mm and subjected to uniaxial loading at a strain rate of 0.5 mm/min on an AMSLER-100-20 universal testing machine . A clip-on extensometer was used to measure the strain. The yield strength was defined as 0.2% offset yield strength. Four specimens of each composite were tested. The mechanical properties used in this work were the average values of 4 tests’ results.The metallograph was photographed using a Zeiss Axiovert 200 MAT . The fracture images were photographed using a JEOL JSM-7900F scanning electron microscope (SEM) . The EDS image was photographed by an EDS module  on SEM. The software Image Pro-Plus  was used to count the dimple size from the SEM images. Five images at a magnification of 5000× (23 μm × 13 μm) for each composite with matrices M and H and magnification of 2000× (61 μm × 34 μm) for a composite with the L matrix were used to count the dimple size, and the results in this paper are the average values of 5 images’ results. At least 100 dimples for composites with matrices M and H and 70 dimples for composites with matrix L were measured.The YS, UTS, EL, and true stress–true strain curves obtained from the uniaxial tensile testing are shown in The variation trend in the EL was found to be more complex compared to that of the strength. When the particle size was smaller than 12 μm, the values of EL increased with increasing particle size. However, the EL values decreased with the increasing particle size when particle size exceeded 12 μm. This indicated that different factors dominate the variation in EL in different size range of the particle.Typical metallographs of composites with the H matrix are shown in The distribution of elements is shown as EDS mapping in The fracture surfaces of all composites were observed and photographed by SEM. To simplify the presentation of the results, the fracture morphologies of nine typical composites are shown in In the composites with a low-strength matrix, the fracture surface was composed of large size dimples a–c. The When high-strength matrices were used, the dimple size significantly decreased, and the number of broken particles increased. On the fracture surface of M-4 and H-4, a few cracked particles were found  can be considered the representative of the particle-strengthening ability. The normalized YSc and UTSc are shown in A polynomial is used to fit the relationship of normalized strength with the matrix strength and the particle size:The elongation of the composite increased with the increasing particle size when the particle size was smaller than 12 μm. After the particle size increased up to 12 μm, the elongation of the composite began to decrease with increasing particle size. The particle size has a critical size in a composite to obtain the maximum elongation value. When a composite with a small particle deforms, the strong resistance of the particle to the dislocation movement limits the matrix deformation into small regions where the tiny cavities are generated . In the (1)The strengthening ability of the particle decreases with increasing particle size as well as the matrix strength, and has a strengthening limit. When the particle size exceeds the limit, the effect of the particle changes from strengthening to weakening.(2)The strengthening ability and its limit were defined as a function of the particle size and the matrix strength using polynomial fitting.(3)The elongation of the composite increases with the increasing particle size when the particle size is smaller than the critical size. The main factor in this stage is the resistance of the particle to the matrix deformation. When particle size is larger than the critical size, the composite elongation decreases with the increasing particle size due to the early fracture caused by particle cracking.In this study, the effects of the particle on the strength and ductility of SiC particle- reinforced Al-Cu-Mg alloys matrix composites were investigated. Yield strength, ultimate strength, elongation, and fracture morphology of composites with eighteen combinations were characterized. The dimple sizes on the fracture surface were also counted from the fracture surface images. Based on the analysis of these results, the following conclusions can be drawn:


In this paper, we developed an isolation system for A549 human lung carcinoma cells as an effective factor for the early diagnosis of lung cancer. A microfluidic immunomagnetic method was used, in which the combination of immunomagnetic separation and a microfluidic system allowed for increased isolation efficiency with uncomplicated manipulation. In the microfluidic immunomagnetic strategy, A549 cells were combined with aptamer-conjugated carboxylated magnetic beads and then collected in a specified region by applying a magnetic field. The results were recorded using a fluorescence microscope, and the captured targets were then quantified. The isolation efficiency of A549 cells is up to 77.8%. This paper developed a simple working procedure, which is less time consuming, high-throughput, and trustworthy for the isolation of A549 cells. This procedure can be a useful reference method for the development of an effective diagnosis and treatment method for lung cancer in the future. In recent decades, cancer has been a significant problem in society and the leading cause of human death worldwide. Among the types of cancer, lung cancer accounts for 12.9% of new cases and 19.4% of deaths in total and is consistently leading among common cancers in terms of incidence and mortality . TherefoSeveral cellular isolation and detection approaches, including electrochemical detection , chemiluThe IMS method is based on a combination of the interaction of cell membrane antigen-specific antibodies and magnetic force. The nano- and microsized magnetic particles used in the IMS method are usually made from superparamagnetic particles covered with a layer of different chemical groups on the surface . The uniAptamers are short, single-stranded oligonucleotides or peptide molecules; the tertiary structure formation enables the aptamer to bind various targets such as small molecules, bacterial, proteins, and cells. An in vitro process known as Systematic Evolution of Ligands by Exponential enrichment (SELEX) is used for the synthesis of aptamers with high binding affinity and specificity . Due to In this study, we implemented the microfluidic immunomagnetic method for the isolation of A549 human lung carcinoma cell line. A novel procedure for the efficient and specific association between the A549 cells to the magnetic beads was performed, and then these targets were isolated in a simple structure channel. Carboxylated magnetic beads were coupled to DNA aptamers based on the covalent coupling between carboxylic groups on the bead surface and the DNA aptamer to form immunomagnetic beads. The resultant immunomagnetic beads were anchored on the cell surface because of the specific interaction between the DNA aptamer and target molecule on the cell surface. Then, the microfluidic channel with an external magnetic field was used for the isolation of the functionalized A549 cells A. The re2), EDC, and NHS were obtained from Sigma-Aldrich . The modification strategy of DNA aptamer on the 3′ end aims to resist nuclease degradation as well as increase the stability of the aptamer [The carboxylated-magnetic beads are superparamagnetic particles with a mean particle diameter of 1.36 μm, concentration of 8.15 mg-Fe/mL, and ligand density of 0.2 mM that were purchased from MagQu Co., Ltd. . The DNA aptamer , acetone, alcohol, and deionized water and dried by nitrogen gas flow. The negative SU-8 photoresist was spin-coated onto the cleaned silicon wafer at 500 rpm for 20 s and 1000 rpm for 35 s to form an SU-8 resist layer with 50 μm thickness. This wafer was then soft-baked at 65 °C for 30 min and 95 °C for 45 min on a programmable hot plate. The wafer was cooled, covered with a microchannel pattern-designed mask (channel width of 1 mm), and exposed under UV light at an exposure dose of 200 mJ/cm2 for 95 s. The wafer was then baked again at 65 °C for 15 min and 95 °C for 23 min to complete the polymerization. The master mold was developed by MicroChem’s SU-8 developer, washed with isopropyl alcohol, then hard-baked, and stored for subsequent experiments.For the fabrication of a master mold based on the photolithography technique, a silicon wafer was sequentially cleaned with piranha solution mcducessed as :(2)Fm=VcCarboxylated magnetic beads  were cleaned three times with PBS washing buffer solution , and the results were recorded through a fluorescence microscope . The microfluidic channel was also filled with the washing buffer solution for 30 min before injecting the experiment sample to minimize surface absorption. The experimental setup is shown in N-(3-Dimethylaminopropyl)-N′-ethylcarbodiimide hydrochloride (EDC)/N-hydroxysuccinimide (NHS) solution was used in the experiment to prepare amine-reactive esters derived from carboxylate groups to react with the amino group of the DNA aptamer. Although NHS is not required for the carbodiimide reaction, the presence of NHS as a catalyst enhances coupling efficiency considerably. The NHS esters were hydrolyzed over time; thus, we investigated the optimal time for activation reaction with the EDC/NHS solution. Results showed that a duration of 30 min for the given reagent concentrations is ideal for the subsequent modification step of the aptamers. The process of binding between the magnetic beads and A549 cells is illustrated in The functionalization of aptamers or antibodies on a carboxylated magnetic bead was carried out based on intermediate carbodiimide reaction, which has been widely implemented in many previous studies and showed high stability as well and strong binding capacity ,21. N- placed on a glass substrate with pool diameter and height of 4.5 and 6.5 mm, respectively, to assess the effectiveness of the modification of the immunomagnetic beads and their ability to bind to the cell surface. An amount of 100 μL of the sample experiment was prepared by the incubation of the mixture of Calcein green AM-stained A549 cells and Calcein red-orange-stained HeLa cells to form the immunomagnetic beads as mentioned. The concentrations of the A549 cells and HeLa cells are both 1 × 10the well A. The imIn addition, the fluorescence and conventional images of the HeLa cells and labeled A549 cells were also recorded and investigated. 5 cells/mL was prepared. A flow rate of 10 μL/min was used in our study. The experiment was then carried out in accordance with the setup that was mentioned. Magnetic field was generated by applying two magnets on the center of each side of the PDMS chambers. The intensity distribution of the magnetic field was also calculated via the ANSYS Emag software , whereas the HeLa cells were swept along the fluidic flow and washed away to the outlet of the microchannel. An amount of 1 mL of the experiment sample with a cell concentration of 1 × 10software . The mod uniform B. FigureFlow rate investigation was performed by injecting the prepared sample into the microfluidic system and isolating the target at different flow rates . After isolation, the number of captured A549 cells was measured by calculating the amount of A549 cells at the output via ImageJ software. The experiment was repeated 5 times for each flow rate; the average value was recorded for drawing the graphs. The cell capture efficiency was defined as in Equation (4):5 cells/mL (3 × 105 cells) was isolated. Most of the target circulating tumor cells (CTCs) were isolated in the system, of which 71.3% of isolated target CTCs were isolated in the first half of the area of the system, while 76.9% of non-target CTCs were collected at the latter half of the area. The isolating efficiency of the system in our current study is comparable to the published report in literature; moreover, the proposed system has the advantages of being easy to manufacture, low cost, as well as simple in operation and integration.k et al. , 3 mL ofIn summary, we successfully developed an isolation system for human lung carcinoma cell line (A549) based on the microfluidic immunomagnetic method. This system has a simple working procedure, is less time consuming, has high throughput, and is trustworthy. The isolation efficiency for A549 cells is up to 77.8%. The effective binding of the magnetic beads on the surface of A549 cells opens up many possible applications for the future detection of A549 cells. The development of a new microfluidic channel structure for the collection and detection of A549 cells is feasible herein. The main purpose of this study is to demonstrate the feasibility and efficiency of this approach. Detailed analysis of the experimental parameters, such as the concentration of cells, the composition of the sample or the buffer solution, and the size of magnetic beads as well as the number of aptamers binding on the surfaces of beads, could be conducted in future work. Therefore, we expect that this study will be seen as a useful reference method for the development of an effective diagnosis and treatment method for lung cancer in the future.