Ancient Monuments

History on the Ground

Ness of Sound, coastal battery 470m south east of

A Scheduled Monument in Lerwick South, Shetland Islands

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Latitude: 60.1334 / 60°8'0"N

Longitude: -1.1538 / 1°9'13"W

OS Eastings: 447111

OS Northings: 1139066

OS Grid: HU471390

Mapcode National: GBR R1HY.PZ4

Mapcode Global: XHFB4.DK8F

Entry Name: Ness of Sound, coastal battery 470m SE of

Scheduled Date: 28 August 2012

Source: Historic Environment Scotland

Source ID: SM13030

Schedule Class: Cultural

Category: 20th Century Military and Related: Battery

Location: Lerwick

County: Shetland Islands

Electoral Ward: Lerwick South

Traditional County: Shetland

The monument comprises the remains of a Second World War coastal defence battery, built in 1940. The two gun emplacements, battery observation post, two (of originally three) searchlight emplacements and the engine room survive as upstanding concrete buildings. Other ancillary structures survive either as upstanding buildings or are represented as concrete foundations. The battery is located 2.3 km SSW of Lerwick, overlooking the southern approach to the Bressay Sound, and lies about 10m above sea level on gently sloping ground above low cliffs.

The two gun emplacements are substantial concrete structures, of similar scale but different design. One gun emplacement (Emplacement 1) measures about 11m square and faces southeast, while Emplacement 2 is around 10m by 12m and faces just south of east. Both splay outwards towards the front and are partly sunken into the gentle slope. The battery observation post is a structure of similar size, positioned 6m west of the first emplacement. The magazine, a double-roomed subterranean structure, is located 12m to the northwest of Emplacement 1. These principal structures are connected by a network of corridors made of cast concrete and covered with corrugated iron. Other parts of the battery are located away from this cluster of buildings and include: the engine house (about 50m to the west); the reserve searchlight emplacement (90m to the SSW); Searchlight Emplacement 1 (45m to the SE, but now collapsed); Searchlight Emplacement 2 (75m to the NNE); and a reserve engine house (120m to the NW). In addition, there are the remains of other support structures, including an auxiliary building or guardhouse, 95m to the west, and the concrete footings of the accommodation camp buildings, which extend to about 70m north of the gun emplacements.

The area to be scheduled is irregular on plan and includes the remains described above and an area around them within which evidence relating to the monument's construction, use and abandonment may survive, as shown in red on the accompanying map. Towards the north end of the west boundary, the scheduled area extends up to but excludes the remains of a stone wall, while further south along the same boundary, it extends up to but excludes a post-and-wire fence. The scheduling specifically excludes the post-and-wire fences that cross the scheduled area to allow for their maintenance.

Source: Historic Environment Scotland

Statement of Scheduling

Cultural Significance

The monument's cultural significance can be expressed as follows:

Intrinsic characteristics

The main structures are built of concrete and survive in fair to good condition. The upstanding parts of the support buildings, originally of wood and metal, have been removed, but the structures are represented at foundation level by concrete bases with diagnostic features, such as the waste pipes in the ablution block. Although the main functional buildings are fortifications, they were probably completed at short notice in adverse conditions and using local materials. Both the gun and searchlight emplacements show a range of different designs that appear to reflect a development sequence as the construction progressed. Many interesting details survive, including: the main armament holdfasts; steps and fireplaces in the gun emplacements; and the concrete stand for the position finder in the battery observation post. Interesting outlying features include a small concrete-lined pit beyond the SW searchlight emplacement, which has been identified as the section observation post. The main functional structures are easy to understand and appreciate and give a vivid impression of how Lerwick was defended during the Second World War. The survival of the foundations of the accommodation camp means that the complete range of structures that formed and supported the battery is represented on this site.

Contextual characteristics

This well-preserved battery is an example of the coastal defences that were used during World War Two around the coast of the United Kingdom to defend strategic military assets or protect certain land areas. Relatively few comparable examples survive today in such good condition. The battery defended the approach to the southern end of the Bressay Sound and was an important part in the defence of Lerwick, and specifically, Lerwick harbour. It represents an important, visible and easily understood component of the military infrastructure developed around Lerwick, and is an iconic reminder of the war effort in Shetland. It conveys something of the strategy, equipment and capability of the British forces and the efforts to combat potential invasion of the United Kingdom by German forces. The battery represents part of the response to this perceived threat of imminent invasion in 1940 by the so-called 'back door' to the British Isles.

Associative characteristics

The Shetland SMR holds a schematic plan titled 'Ness of Sound, layout of battery, secret'.

This monument is of national importance because it has an inherent potential to make a significant addition to the understanding of the past, in particular the mechanism and strategy for defending strategic assets in the United Kingdom during the Second World War. It survives in fair to good condition with the majority of its functional structures intact. Differences in the gun and searchlight emplacements display the evolution of designs as the battery was being built. It is a lasting component of a wider contemporary landscape, specifically the defences that ringed Lerwick and served to protect Shetland and the northern fringes of the British Isles in 1940.

Source: Historic Environment Scotland

Friel, R, 2002 Condition report, coastal defence battery, Ness of Sound

Ness of Sound, layout of battery, secret. Plan held by Shetland SMR

Source: Historic Environment Scotland


Robbing a store with a Klingon weapon

I consider myself, unabashedly, a big Star Trek fan. Being a big fan means a lot of things. It means that I can quickly engage another Star Trek fan in a myriad of conversation about alien races and science fiction scenarios and debates about “which captain was the greatest”.

It also means that I can recognize a Klingon Bat’leth, a traditional weapon of the Klingon race:

What being a fan doesn’t mean, however, is that I take said Bat’leth and use it to rob a store:

The first robbery was reported at 1:50 a.m., at 145 N Spruce St. The clerk told police a white man in his 20s, wearing a black mask, black jacket, and blue jeans, entered the store with a weapon the clerk recognized from the Star Trek TV series.

The robber demanded money and left with an undisclosed amount.

A half hour later, police received a call from a 7-Eleven at 2407 N. Union Blvd., where a man matching the previous description entered the store with a similar weapon. He also demanded money from the store clerk. The clerk refused and the robber “transported” himself out of the store on foot.

Both clerks described the weapon as a Star Trek Klingon-type sword, called a “bat’leth.”

Neither clerk was injured in the robberies.

It especially means that I wouldn’t try to rob a store with a Bat’leth that is too small for even a child Klingon warrior to use:

Now, this is a bat’leth that you might be able to rob a store with:


info@biomedres.us   +1 (720) 414-3554

Biomedical Journal of Scientific & Technical Research

March, 2019, Volume 15, 5, pp 11662-11673

Mini Review

Mini Review

The Need to Fabricate Lower Limb Prosthetic Devices by Additive Manufacturing

Fariborz Tavangarian* and Camila Proano

Author Affiliations

Mechanical Engineering Program, School of Science, Engineering and Technology, Pennsylvania State University, Harrisburg, Middletown, PA, 17057, USA

Received: February 27, 2019 | Published: March 13, 2019

Corresponding author: Fariborz Tavangarian, Mechanical Engineering Program, School of Science, Engineering and Technology, Pennsylvania State University, Harrisburg, Middletown, PA, 17057, USA

DOI: 10.26717/BJSTR.2019.15.002772

In this study, additive manufacturing is evaluated as a means of creating custom-made lower limb prosthetic devices. Amputees greatly benefit from having a custom-made prosthetic device. Furthermore, additive manufacturing has already proven successful in increasing the accessibility to custom-made hand prostheses, but there still needs to be an evaluation of how additive manufacturing could be employed in the creation of lower limb prostheses. This mini review encompasses a brief overview of the causes of lower limb amputations, the treatment plan for amputations, and some negative impacts of a poorly designed prosthesis. Additive manufacturing technologies as a potential fabrication method, their classifications, different materials that can be used, and an array of examples of how additive manufacturing has already been successful in medical fields will be discussed.

Keywords: Additive Manufacturing; Lower Limb Prosthesis; Polymers; 3D printing

A prosthetic limb is an artificial replacement for a biological limb that may have been lost due to disease, injury, or deformation. For example, someone whose leg has been removed below the knee, a transtibial amputee, may choose to use a below-theknee prosthetic to help them regain some mobility [1]. With a prosthetic leg, he or she may be able to gain independence from a wheelchair. There are many styles of lower limb prostheses, such as running specific or the traditional design for simple walking. Each design provides its user with the movement they want and can physically handle. Figure 1 is an ottobock prosthetic leg made specifically for patients who want an active lifestyle. Around 60% of lower-limb amputees choose to use a prosthetic appendage, meaning that 30 million people worldwide require prosthetic limbs to carry out their daily activities [2]. In 2012, 1.9 million Americans were living with limb loss, a problem faced by all races. Non-whites constitute 42% of those living with limb loss [3]. In total, without including rehabilitation cost or prosthetic devices, America spends more than $8.3 billion on the health care cost of amputations [4]. Throughout their lifetime, each American amputee will pay an average of $500,000 in medical expenses. $230,000 alone can be attributed to the use of a single 5-year lower limb prosthetic device [3,5].

Figure 1: Running specific prostheses (Courtesy of Ottobock Co.).

Therefore, finding new techniques to lower the fabrication cost seems necessary. However, it is important to note that the medical expense of an amputation is not the only financial burden faced by amputees. Other financial costs may include the loss of

Causes of Lower Limb Amputations

There are two primary sources of problems that lead to amputations. The number one cause of amputations is diabetes and its related ailments [6-8]. In 2008, 4 out of 1,000 adults with diabetes had a foot or leg amputation due to illnesses caused by diabetes [7]. The second leading reason for an amputation is traumatic injury, or a wound resulting from an external source [6-8]. Diabetes can damage the nerves of the foot and blood vessels. Additionally, it causes many secondary illnesses, such as peripheral arterial disease [6]. Diabetes patients have an increased risk of developing peripheral arterial disease if they are of advanced age, have had diabetes for a long time, or have uncontrolled hyperglycemia [9]. Some of the symptoms of peripheral arterial disease include cramping in the calf or buttocks muscles which worsens during walking [9]. Peripheral arterial disease, which affects 8-12 million Americans, hardens the patient’s veins, restricting blood flow to limbs and eventually leading to amputations [7]. Due to the nerve damage, many sufferers of diabetes do not realize their foot has been injured, has ulcers, or is infected, thus wait too long to seek medical help [6-8].

The second leading cause of amputations is traumatic injury, accounting for 30,000 patients every year. Males between 15 and 30 years old are 80% more likely to be traumatic amputees than their female counterparts. The leading causes of amputations from traumatic injury are car accidents and injuries by machines [8]. Regardless of the reason for an amputation, the need for medical devices after amputations will constantly be present. Furthermore, as more cases of diabetes are diagnosed each year, it is important to investigate new methods for creating prosthetic devices.

Prevention of Amputations

Unfortunately, accidental amputations cannot always be prevented. Workplace injuries or traffic accidents may be inevitable, but their numbers can be reduced through rules and regulations. In the workplace, safety measures such as proper protective equipment, guardrails on equipment, and workplace rules can help prevent accidents leading to amputations. Accidents that happen outside of the workplace may be harder to avoid but may be reduced through education about what kinds of accidents may lead to an amputation. On the other hand, there are methods to limit planned amputations in diabetic patients. Planned amputations are a last resort for the advanced diabetic foot. They are necessary when there is too much necrotic tissue, or there is a life-threatening infection associated with the wounds [10]. There are treatments available to manage foot ulcers before they become severe enough to require amputation. For example, debridement removes dead tissue and stimulates the regrowth of healthy tissue by keeping a healthy granular wound bed [9,11,12]. For more severe injuries it is possible to do surgical debridement, which uses a scalpel to remove dead tissue and reveal a healthy skin base [9,13]. Other methods to clean out necrotic tissue include the use of once-daily topical agents, also known as enzymatic debridement. This method is not as drastic as surgery. Similarly, mechanical debridement can be achieved with a simple tool, but unfortunately can be painful as it can also remove healthy tissue. More recently, the use of maggots, known as biological debridement, has shown promising results to remove necrotic tissue [9]. In summary, the number of diabetic amputations could be reduced through early detection and proper treatment of ulcers.

There are safety measures which can be implemented to reduce situations which may lead to accidental amputations. Accordingly, the procedures used to prevent diabetic patients from losing a limb consist of cleaning the wounds to remove dead or infected tissue. Regrettably, not all amputations can be averted. Therefore, there are established methods of proving care for an amputee.

Treatment of Transtibial Amputations

Michigan Medicine at the University of Michigan explains that the healing process for a lower limb prosthesis has multiple stages to allow gradual healing and adjustment [14]. To be fitted for a prosthetic leg a patient must go through physical evaluations and an adjustment period to living without a prosthesis. In general, healthy patients who may have suffered an amputation due to an accident will be fitted for a customized lower limb prosthesis within 4 to 6 weeks after their amputation. On the other hand, amputations caused by diabetes may be able to have a prosthesis after a 6 to 8-week period [14]. Furthermore, the process of how a patient is prepared to be fitted for a lower limb prosthesis is explained by the Brigham and Women’s Hospital Department of Rehabilitation Services [15]. There are nine stages to an amputee’s treatment plan [16].

Stage One: Preoperative: The patient is medically evaluated and educated about the procedure and the treatment process before the surgery takes place [15]. Additionally, the patient may begin a cardiopulmonary conditioning program [15,16]. The earlier the patient is evaluated and educated about the treatment process the better prepared the patient will be for the rehabilitation process [15,17].

Stage Two: Amputation Surgery/Dressing: After the surgical amputation steps are taken to ensure the patient will be able to wear a prosthetic device [15], the length of the residual limb is surgically measured, and the wound is closed. The residual limb is then reconstructed to maintain balance, and so it can support the stress caused by the prosthetic device [15,17]. With planned surgeries, it is important to try and keep the patient’s knee with the purpose of reducing energy expenditure in the future [15,18]. The more limb that is removed, the more energy that prosthetic gait demands from the lungs and the heart [15,19].

Stage Three: Acute Post-Surgical: This phase starts after the operation and ends once the patient is discharged from the hospital. The goal of this stage is to give the patients the tools for success before they can be outfitted for a prosthetic limb. Such devices include pain relief, workouts to increase muscle strength, phantom limb pain management, training on how to move without a prosthetic limb, and most importantly continued education and emotional counseling [15].

Stage Four: Pre-Prosthetic: This stage strictly prepares patients for the future use of a prosthetic device. During this phase of treatment, the patient undergoes residual limb shaping, stump shirking, skin care, and cardiovascular training [15]. Additionally, the patient works towards increasing their range of motion and continues to regain functional mobility without using a prosthesis [15]. The patient is also introduced to an Immediate Post-Operative Prosthesis which they will use to assimilate to the idea of wearing a prosthetic device [14,15,20]. This initial prosthesis is used while the limb is still healing and stabilizing [14].

Stage Five: Prosthetic Prescription/ Fabrication: To begin this stage, the wound must have healed and swelling reduced. Additionally, the stump must be mature and shaped like a cone [15,21]. Stage five aims to find a prosthetic device that will conform to the needs and the fitness condition of the patient [15]. It is interesting to note that if a patient weighs more than 330lbs, it may be difficult to find a device which can accommodate the patient’s weight [15,22]. Traditionally made prostheses are created using a casting of the residual limb with plaster and fiberglass bandages. Once the cast is dry, it is filled with a plaster slurry which will become a positive mold once the cast is destroyed [23]. The cast can then be used to create a mirror image of the stump, which will serve as the socket. The socket is latter attached to the rest of the prosthetic limb.

There are complications related to the defective fabrication of a prosthetic leg. Some of the problems associated with the construction of an inappropriate prosthesis may include [1]:

a) Vaulting, which happens when a prosthesis is too long and causes the patient to “step up” to complete a step,

b) Circumduction, in which the foot swings out while the leg is in motion,

c) Lateral trunk bending, where the patient dips his or her shoulder on the side of the prosthesis while walking.

d) Foot slap, in which the foot moves when the heel makes contact with the ground.

e) Similarly, the foot being too soft can cause other problems such as drop-off, where the knee is suddenly flexed at the end of a step, and hyperextension of the knee on the affected side.

f) Finally, a loose-fitting socket can cause the individual to piston, or move the residual limb vertically while the weight shifts between legs.

Construction of a suitable prosthesis takes into consideration the patients input along with the knowledge and skills of the prosthetist. It provides stability, balance, and comfort both during walking and standing still. Most importantly, it minimizes the energy cost and contributes to gait symmetry. To keep walking as natural as possible the first contact between the ground and the prosthesis should be made with the heel of the foot, thus transferring the weight from the heel to the center of the foot, and finally the entire foot. To begin a step, the movement should start again with the heel and finish with the toes pushing off the ground [1].

Stage Six: Prosthetic Training: During this stage, the patient aims to increase the prosthesis’ functionality and comfortable wear time. A patient will begin this stage ten or eleven weeks after their amputations. It is important to note that patients with a below-theknee amputation who use a soft dressing after amputation will have a temporary socket fabricated within six to eight weeks after their amputation surgery so they can be ready for this stage [15,20].

Stage Seven: Community Integration: During this stage, the patient resumes all recreational activities to the best of their abilities. Some activities may require some modifications. Patients are encouraged to seek emotional support and continue using the coping strategies they were taught in the past stages [15].

Stage Eight: Vocational Rehabilitation: The patients in this step return to their line of work depending on the job requirements. Due to physical demands of previous jobs, some patients may choose to have a career change. The patient’s return to work should be gradual and supplemented by professional counseling. Workload should increase over time, instead of being a sudden return to the amount of work that was appropriate before the amputation. Additionally, some training may be required to adapt to the person’s new mobility [15].

Stage Nine: Follow Up: The final stage will continue for the rest of the person’s life. This phase encompasses the lifelong use of a prosthetic device. Doctor visits should be scheduled every three months during the first 18 months, and twice a year after that [15,16]. An amputee is gradually prepared to comfortably wear their prosthesis for long periods of time. With a planned amputation, the patient starts preparing for the prosthetic device before the initial surgery takes place. The objective of the preparation is to help the patient return to a comfortable and functional life.

Current Design for A Lower Limb Prosthesis

When a patient loses their lower extremities, he or she may choose to use a prosthesis specific to their type of amputation. Lower limb prostheses are subdivided into categories depending on the height of the amputation. Hip disarticulations happen at the joint between the hip and the leg. Above-the-knee, amputations are called transfemoral amputations, while below-the-knee amputations are called transtibial amputations. Additionally, amputations at the ankle are called ankle disarticulations and finally, amputations at the foot are called partial foot amputations. As a reference, Figure 2 is a representation of the names and heights for lower limb amputations [2,24]. Each type of amputation requires different prosthetic devices. The parts of a below the knee prosthetic limb include the transtibial socket, the pylon, the tube adaptor, and the foot [2]. A prosthetic device for a transfemoral device is similar to one for a transtibial amputation, except that it includes an artificial knee. Figure 3 is a transfemoral prosthesis, with its socket, knee joint, pylon, ankle and foot labeled.

Figure 2: Names and heights for lower limb amputations.

Adapted with permission from [24].

Figure 3: Labeled view of a lower limb prosthesis.

When looking at the prosthetic leg from top to bottom, the first section is the socket, which is designed to have properties similar to bone. The socket distributes the person’s weight from the body to the ground. Therefore, conventional materials used for the socket are composites based on thermoset plastics mixed with other materials [2,23]. A socket is shaped like a cup to fit around the residual limb [23]. Furthermore, it is composed of three parts: the seating face, which connects the remaining limb to the prosthesis; the controlling socket area, which ensures correct motion of the leg; and the distal socket end, which transfers at most 10% of the person’s weight [1]. Figure 4 is a visual representation of the subdivision of the socket. To keep a healthy stance, the socket must maintain the muscle gluteus medius stretched, and the pelvis balanced [1]. The socket facilitates the comfort and the functionality of the prosthesis [23]. The next section of the prosthetic limb is the pylon, which is described as a hollow aluminum pipe and serves as the connection between the socket and foot. Additionally, the pylon transfers the weight from the socket to the foot. Finally, the foot connects the prosthesis with the floor and provides energy absorption. The most economical designs for the foot are the solid ankle cushion heel and the stationary attachment flexible endoskeleton foot. Patients looking for increased mobility and stability may prefer an articulated single axis foot[2].

Figure 4: Hybrid polymer socket with labeled sections (Courtesy of 5280 Prosthetics LLC).

The current design for lower limb prosthesis mimics the limb it is replacing. In the case of a transtibial prosthetic device, the socket serves as the connection between the residual limb and the device. Similarly, the pylon is the equivalent of the tibia and fibula. Furthermore, the ankle and the foot in the prosthetic device mimic the design and purpose of their biological equivalents.

Strength and Flexibility Requirements for Lower Limb Prostheses

Each different category of lower limb prosthesis requires a different strength and flexibility limits. For example, a runningspecific prosthetic limb, such as a c-shaped prosthesis has different requirements than a prosthesis designed to provide its user with slow and steady walking. Rusu et al. [26] analyzed a computeraided model of a conventional C-shape ankle prosthesis with the use of Dynamic Designer Motion Professional module (DDMP) and tabulating motion values. A simplified model of the prosthesis was utilized to test the kinematic and dynamic parameters of the prosthesis in extended and flexed positions. The importance of this experiment was that the model could also be used for Finite Element Analysis, and thus with both tests, the maker could be sure the prosthesis would be reliable. The results showed that the forces excreted would not surpass the accepted values for the materials used [26]. Their study set a precedent for how future prosthetic limbs can be evaluated before production.

Running-specific prostheses must be evaluated for their flexibility. The 2017 study conducted by Oudenhoven et al. [27] explored the relationship between the preferred step frequency of athletes and the natural frequency of the running-specific prosthesis. They investigated the influence of the rate of steps on the stiffness of the leg. The motivation behind this experiment was to resolve the uncertainty surrounding past tests about stiffness regulation and running-specific prostheses. To collect data, they had participants run comfortably, hop, and jog on a treadmill and captured their velocities. The results showed that the athletes make their whole bodies stiffer to maximize the stiffness of the prosthetic limb when running. Furthermore, it was found that amputees can modify how fast they move their legs to keep up with the desired speed but do so much better with the uninjured leg. This experiment was significant because it indicated that stiffness in the runningspecific prostheses controls running performance [27].

Before a prosthetic device is used in patients, it is evaluated through computer simulations and physical testing. The characteristics of prosthetic devices affect their performance. There is an advantage from using computer simulations before physical testing takes place. If a computer model predicts that a design will fail physical testing, then adjustments can be made before the actual physical testing takes place. Furthermore, narrowing down designs through computer simulations simplifies the amount of material wasted during physical testing. Additionally, through testing, prosthetic devices can be redesigned for better performance.

Lack of Accessibility to Prosthetic Specialist

With regards to the importance of a properly fitting prosthetic device, it is important to note that not all populations have access to trained prosthetists. According to Kumar et al. [2], there is a worldwide deficit of 40,000 trained prosthetists. Nevertheless, 18,000 new professionals will join the field in the next half-century. Unfortunately, current prosthesis wearers do not have the luxury of waiting 50 years to work with a prosthetist on designing their custom-made prostheses. Studies have shown the importance of a custom-made prosthesis for the comfort and satisfaction of the user [23,28,29]. Custom-made prostheses often fit the patient better and will, therefore, have increased comfort and performance [23]. Along with training more prosthetists, it may be important to find ways to make custom prosthetics devices more accessible to patients everywhere. One method for increasing the availability of personalized medicine is the use of additive manufacturing to create custom made items. Traditional custom-made prostheses are not always available in remote or underdeveloped locations. Therefore, additively manufactured prostheses pose a method for customization of medical devices by removing the need for laborintensive mold creations [23].

Additive manufacturing is defined as combining materials in a manner that, increases their efficiency, and diminishes the need for casts or templates [30]. To further personalize the products created through additive manufacturing, the design of medical devices is often aided by 3D imaging. Molds and templates are replaced by 3D models of the surface of scanned body parts, thus allowing for better fitting, and better working medical devices [30]. Such partnership between additive manufacturing and 3D imaging can be seen in the use of 3D scanners to create Invisalign dental aligners. Invisalign are clear aligners made of a thermoplastic material, which replaces traditional metallic braces. They allow dental patients to have a removable orthodontic treatment which can have the same effect as traditional metallic braces [31]. A good analogy for additive manufacturing is the structure of an onion. Each layer of an onion represents one layer of material laid down by the extruder head. All the layers combined make up the entire part, or in this example, the whole onion. Additive manufacturing allows for the creation of implants and prosthetics with intricate structural shapes made up of a mixture of materials [30]. Similarly, it allows for low-cost fabrication of medical devices in locations that may not have access to traditional manufacturing methods [32,33].

The lower costs can be attributed to the reduced expenses in packaging, storage, and transportation of the desired products [32]. The process for creating a custom-made prosthesis with additive manufacturing has three steps: geometry capture, device design, and device manufacture [23]. Geometry capture can be completed with a foam box, a pin-based contact digitizer, optical molding, optical scanning, or through computer tomography and magnetic resonance imaging [23]. The computer-aided methods of capturing geometry will reduce the waste created during the creation of the fiberglass and plaster cast [23].

Additive Manufacturing

Additive manufacturing is an emerging field. The Wohler’s Report explains that in 2015 the additive manufacturing market was worth $5.1 Billion USD worldwide [32,34]. The market growth over the last 27 years could be partly attributed to the increased affordability of 3D printers. For example, in America, a do-ityourself kit for fused deposition modeling can be bought for 500 dollars and a printer for under $1,000. A contributing factor to the price decrease in 3D printers is the expiration of essential patents for stereolithography, and selective laser sintering [32]. Additive manufacturing is already employed in the medical field. For example, in 2016, Van Galeen and her colleagues [35] experimented to create a new metal hip implant with built-in sensors to provide feedback on its condition. They ran into difficulties with the cassette design they included to monitor the hip implant once it was in the body. The design added unnecessary stress to the implant, which would ultimately contribute to its failure. Although there are still adjustments to be made to the prosthesis, the experiments proved that 3D printing the metal could be a gateway for faster testing and prototyping [35]. Table 1 provides some examples of areas where 3D printing is currently used in medicine [32].

Table 1: Subject areas where 3D printing is currently being used in medicine [32].

Additive Manufacturing Used for Prosthetic Devices: Additive manufacturing is not restricted to the manufacturing of implants; it can also be used for the production of prosthetic limbs such as hands. In a 2017 study conducted by Leddy et al. [36], a prosthetic finger made of composite material created using additive manufacturing, was compared to the prosthetic hands known as the Cyborg Beast, and the Bebionic v3. This experiment was conducted to validate the fabrication of composite prosthetic fingers as a viable option against current methods of production. The researchers propose a “middle of the road” option between very cheap 3D printed prostheses and professional prostheses. The hope was to influence future prosthetic designs, to create lightweight hand prosthetics that are durable, customizable, and cost-effective. Finally, by using carbon fiber, they were able to build prosthetic hands that are half as heavy as regularly printed 3D hand, and one-quarter of the weight of a machined aluminum hand with more flexible joints [36].

Acceptance of Prosthetics Like the Cyborg Beast in Developing Countries: A study evaluated the acceptance of 3D printed prosthetic devices in developing countries [5]. Patients in Port au Prince, Haiti, Amma, and Jordan were surveyed before and after they received 3D printed prosthetic hands which have proven to be a viable alternative to traditionally made prostheses. Figure 5 shows the offered hand prostheses to the patients in Haiti. The study revealed that the reception of 3D printed devices strongly depends on geographical location and people’s beliefs. For example, patients in Haiti may have rejected the received prosthetic devices because of the strong cultural influences of the Voudu belief system. Voudu beliefs place great emphasis on an individual’s spiritual wholeness, thus increasing the stigma of amputation. Similarly, patients in Jordan did not continue using the prosthetic devices given to them because many of the devices lack an anthropomorphic appearance.

Figure 5: 3D printed hands used in acceptance study.

The belief that “something is better than nothing” is not always true outside of western cultures. As demonstrated by Arabian’s study there is a need for improving the appearance of 3D printed prosthetic devices to make them look as anthropometric and as natural as possible. While the efforts by nonprofit organizations like eNABLE and Jordanian Royal Medical Services to provide prosthetic devices to amputees should not be undermined, it is important for prosthetic designers to understand the cultural perception in individual markets [5]. The cultural acceptance of a 3D printed device will be different when it is presented to a patient in the United States, then when it is presented to a patient in the Middle Eastern region of the world or the Caribbean [5].

Types of Additive Manufacturing: To further understand the advantages of additive manufacturing it is important to outline the four main types of additive manufacturing technologies including vat-polymerization based printing, powder-based printing, droplet-based printing, and extrusion-based printing [32]. Each technology is further broken down to a particular kind of type of printing. During vat polymerization, a layer of photocurable resin is cured by a light of a distinct wavelength [32]. The desired piece is constructed one photocurable layer at a time. Furthermore, there are three technologies included under vat polymerization: stereolithography, digital light processing or continuous direct light processing, and liquid interface production. For further information about the different types of technologies, the readers are referred to [32]. Additionally, powder-based printing works by melting powdered metals together through localized heating. Powderbased printing has four subcategories, selective laser sintering, electron beam melting, direct metal laser sintering, and selective laser melting. For further information please see [32,37,38].

Similarly, droplet-based printing works by building up each layer of the material droplet by droplet [32]. The technologies which use droplet-based printing include multijet modeling, laser-induced forward transfer, and wax deposition modeling [32,39-41]. Finally, extrusion-based printing works by extruding a thermoplastic filament through a hot nozzle [32]. The technologies included in extrusion-based printing include direct ink writing and fused deposition modeling [34,37]. Fused deposition modeling is commonly seen in home 3D printing kits. It can be used to create small plastic parts that may not be available through other manufacturing methods. Table 2 shows the classifications of 3D printing technologies. One of the advantages of 3D printing is that products can be made with composite materials of preferred characteristics. A composite material is defined as a combination of materials that is not often found in nature. In most cases, their constituent phases are chemically different and have a clear separation from one another [41]. Additive manufacturing allows for the composition of the material amalgamation to be altered to produce the required material properties. For example, carbon can be added to plastics to increase the strength of the part, or titanium can be alloyed with aluminum to create a hard yet ductile metal mixture [30,42-44].

Table 2: Classification of 3D printing technologies.

Stronger materials require larger forces to fail. Unfortunately, with increased strength also comes increased brittleness or little flexibility and resistance to impacts. On the other hand, ductile materials often lack high strength but will deform before breaking when exposed to large forces [45]. By producing composite materials, we can benefit from the desired properties of each component. Additionally, additive manufacturing allows greater control of the manufacturing processes, thus changing the material properties of parts. For example, a 2016 study conducted by Ting Guo et al. [46], demonstrated the correlation between printing parameters of poly (lactic-co-glycolic acid) and their effects on printing resolution. The study aimed to see how the inner diameter of the needle, the temperature of the material, the pressure, and the speed of printing affected 3D printed scaffolds that would be used for tissue engineering [46]. To determine the effects on printing the samples were evaluated with gel permeation chromatography to determine the molecular weight of the samples, and micro-computed tomography to characterize the samples as they were being printed.

They found that the high temperature of processing is not likely to break down the material as it is printing because a stable thermal energy is achieved. Additionally, they were able to see the relationship between needle size and the temperature needed to achieve an optimal viscosity of 0.1-10 Pa. s. Smaller needles require a lower viscosity. As the temperature of the printer increased, the viscosity of the material decreased [46]. Therefore, they concluded that high-temperature extrusion techniques would not harm the polymer during printing. Because melting temperature is mostly dependent on molecular weight, the lower printing temperatures were attributed to differences in molecular weights [46]. This finding may be relevant to future studies, as the printed scaffolds will have different mechanical and degradation properties than traditionally made structures. Due to the strict printing conditions of using a smaller needle, samples made with smaller needle sizes were more vulnerable to the material properties, than samples made with large needle sizes. On the other hand, in samples made with needles of large diameters, the fiber quality was affected by the pressure and speed of printing [46]. Plastics are not the only material which can be altered during 3D printing. There are other materials which can be used for additive manufacturing, such as metals, ceramics, and polymers. Summaries and examples of the kinds of materials that can be used for additive manufacturing are found in the following section.

Metals Used in Additive Manufacturing: There are several types of metals used for additive manufacturing. Stainless steel has two biocompatible alloys available for additive manufacturing, 304 and 316L [44]. Although the precious metals gold and platinum can also be processed through additive manufacturing, their high cost makes them unsuitable for mass production of medical devices [44]. Applications for other metals used in additive manufacturing are presented in the following section through summaries of experiments conducted with each material. Cobalt-chromium, titanium alloys, and stainless steel are commonly used in dental applications [47]. One study conducted by Alifui-Segbaya et al. [48] shows that additively manufactured cobalt chromium outperforms cast cobalt chromium in an environment with artificial saliva. Alifui-Segbaya and his team [48] aimed to see how the processing methods used in rapidly manufactured cobalt-chromium alloys would differ from the mechanical properties of cast materials. More specifically, they explored the corrosive effects of artificial saliva on a rapidly manufactured type 4 alloy, EOS SP2 (EOS GmbH, Electro Optical Systems, Germany), and a type 5 removable partial denture casting alloy, Vitallium casting alloy (Elephant Dental B.D., Netherlands).

They picked the two different alloys because they are very similar in chemical composition. For testing, the team followed the specifications under ISO 10271. Ten samples of each alloy were submerged in artificial saliva for 42 days. To compare the performance of each alloy, every few days readings were taken from an atomic absorption spectrometer to observe the amount of cobalt, chromium, and molybdenum ions released in parts per million [48]. Although Alifui-Segbaya and his team believe further research is necessary to mirror their findings, they discovered that the rapidly manufactured alloy showed lower levels of ion release than the cast material. They attributed the better performance of the type 4 alloy to its digitally controlled production method, which allowed the material to be very close to the manufacturer’s specifications. On the other hand, the type 5 cast alloy’s performance could be affected by the cooling times and melting temperatures that could not be controlled in a laboratory setting [48]. Similarly, commercially pure titanium and its alloys can be used to treat osseous defects. The properties of commercially pure titanium can be altered through its alloying elements, and through its manufacturing methods [44]. For example, when used in the alloy Ti6Al4V, commercially pure titanium is a ductile material which properties can be altered to offer high fatigue resistance, good biocompatibility, and efficiency at promoting bone growth and healing [44].

Biocompatibility meaning the material will not harm living tissue. Additionally, high strength can be achieved in Ti6Al4V additively manufactured products because their formation allows the material to form a “martensitic-like structure” [44]. A martensite-like structure refers to the crystal structure in Ti6Al4V that resembles sharp needle-like branches in a core of the material. This crystal structure provides the material with very high strength, but also with very low ductility. The structure is formed by the rapid cooling of the Ti6Al4V as the printer deposits it. Therefore, the findings of the experiment demonstrate that titanium’s strength can be increased by its manufacturing method and its ductility by the addition of alloying elements. According to Munsch [44], tantalum has similar characteristics to titanium. Therefore, it is currently used in the medical field for repairing bone defects. Stress shielding, or osteopenia, caused by the removal of normal pressure from the bone by an implant is a problem faced by patients with bone implants [49]. Porous implants made of materials such as Ti6Al4V can provide an artificial bone substitute material. The implant can promote bone ingrowth and reduction in stiffness for load-bearing applications. A study conducted by Wauthle et al. [50] used additive manufacturing to create a porous tantalum implant that simulates the structure and texture of human bones.

Wauthle and his research team [50] examined selective laser sintering as a manufacturing method to produce pure tantalum implants with desired mechanical properties and highly porous surfaces. Selective laser sintering is a type of 3D printing where a laser cures one layer of resin at a time. Then a platform lifts the cured layers out of the way, allowing a new uncured layer of resin is allowed to flow under the cured layer. The laser cures the newest layer of the resin, and the process continues until the entire part is created [32]. Static and dynamic fatigue testing was conducted on a specimen shaped like a rat’ femur defect. It was concluded that selective laser sintering technology could be used to produce fine porous tantalum structures with a yield strength of 12.7Mpa and an elastic modulus of 1.22Gpa, values within the range of human cancellous bone. The results showed 50% of bone ingrowth into the bone defect, meaning that the implant was osteoconductive. In conclusion, they proved that tantalum implants produced through selective laser sintering are a possible alternative to current methods of implant production [51].

Although magnesium and its alloys are biocompatible materials, they still need further research to overcome the restrictions caused by its material properties [44]. In 2015, Matena et al. [51] conducted a comparison between titanium and magnesium implants produced by selective laser melting method. Due to its release of gasses, magnesium and its alloys need a polymer coating to be safely used in bone grafting [51]. In this experiment, Matena’s research team used a coating made of polycaprolactone (PLC) on the porous structure of bone implants produced by selective laser melting. The researchers aimed to provide an alternative to Ti6Al4V implants. Selective laser melting of magnesium and its alloys requires wetting solidified material with the liquid magnesium from the laser radiation. This process causes the surface of the parts to have no oxygen solubility, therefore exposing them to corrosion. The PLC coating could provide magnesium with increased corrosion resistance, therefore making it safe for bone tissue engineering applications [51]. Tissue engineering is defined as the use of 3D scaffolds with porous structures used to promote bone growth and regeneration. Additive manufacturing can provide a platform for combining metals or polymers in the production process.

Polymers Used for Additive Manufacturing: A polymer is made up of long repeating chains of organic elements, called monomers. Polymers are subdivided into two categories: thermosets and thermoplastics. Thermosets are those polymers that once they have been set through a chemical reaction will degrade when heated. Therefore, they are not suitable for additive manufacturing. On the other hand, thermoplastics are semi crystalline polymers which can be heated without degradation, allowing them to be manipulated during their cooling process. This behavior allows thermoplastics to be recycled [48]. Polyaryletherketones are a kind of thermoplastic polymers which have been used in orthopedic and spinal implants. They are a thermoplastic material with high levels of strength, temperature stability, and chemical resistance [44]. According to Munsch [44], polyamide is one of the most widely used synthetic materials used for selective laser sintering, a process in which polymer powders are heated and fused into the wanted 3D design [35]. The consolidation of polymers still needs further research to understand how more polymers could be used for additive manufacturing [47]. In an experiment conducted by Bai et al. [52], laser-sintered Polyamide 13 (PA12) was compared with a mixture of carbon nanotubes added to Polyamide 12 (PA12- CNT). The carbon nanotubes were added with the hope of creating a material that could meet mechanical, thermal, and electrical requirements of specific applications.

The results of the experiment demonstrated that there was no significant change in the morphology of PA12 as compared to PA12-CNT. The near-spherical structure of both materials allows them to be continuously used for laser sintering. Similarly, carbon nanotubes were evenly spread throughout the PA 12 matrix. The balanced spreading of the carbon nanotubes ensures that the PA12- CNT would have better properties than PA12. Therefore, the carbon nanotubes created more favorable conditions for laser sintering by increasing the thermal conductivity of PA12 by an average of 14.2%. Furthermore, the shrinking of the material as it cools was reduced from 7.9% in PA12 to 3.7% in the PA12-CNT samples. Finally, PA12-CNT increased the tensile modulus of PA12 by 44.5% and the tensile strength by 7.0% [52]. Similarly, polycaprolactone is a biodegradable polymer that can also be used for selective laser sintering [44]. Mazzoli et al. [53] experimented in 2015 with polycaprolactone scaffolds manufactured through selective laser sintering for bone and cartilage repair. The polymer was printed into a cylindrical structure with interconnected holes that would allow cell growth. The study showed that PCL scaffolding created through selective laser sintering was a viable option for tissue engineering applications because it provided an environment that fostered cell growth [53].

Polylactides are also biocompatible materials and safely degrade within the body (bioresorbable) [44]. Some of the advantages of working with polylactides like polylactic acid (PLA) are that they can be made from renewable resources, and they have high strength and rigidity. Unfortunately, PLA is also brittle, meaning it has low flexibility and resistance to impacts [44]. In 2016, Chen et al. [30,54] conducted a study to strengthen PLA with carbon nanotubes introduced into the polymer through graphene oxide. The researchers investigated the printing of a composite made of thermoplastic polyurethane, polylactic acid, and graphene oxide, for its compatibility in tissue scaffolding. Specifically, they studied the mechanical and thermal properties and the effects of the printing orientation. For the mechanical properties, they conducted tensile and compression tests on printed cubes. To examine the consequences of printing direction, they performed tensile and compression tests on the other samples, which were placed in standing and lying positions. Finally, they tested to see how graphene oxide affects the growth of cells around the materials. Their method of 3D printing allowed them to improve thermal stability, understand the effects of printing orientation, and see how the addition of graphene oxide can affect cellular growth. This experiment furthers the understanding of what could be used for tissue engineering scaffolds [31].

Similarly, a study discussed earlier by Tin Guo et al. [46] also aimed to understand the effectiveness of a 3D printed scaffold for tissue engineering. A correlation between the presence of methyl side groups in lactic acid and the rate of water absorption in the material was noted. The scaffolds with a lower ratio of lactic acid to glycolic acid had a greater water absorption capability [46]. Similarly, the presence of an acid end cap in the molecular structure of the material decreased the hydrophobicity and accelerated the degradation of the material [46]. Therefore, poly (lactic-co-glycol acid) with a high ratio of lactic acid to glycolic acid combined with an ester end cap can be used to create 3D printed scaffolds suitable for cartilage regeneration because it has mechanical properties similar to human cartilage and a slow rate of degradation [46].

Strengthening of Polymers Through Carbon: As demonstrated by the studies summarized above, polymer materials can be reinforced through the addition of carbon nanotubes [30,44,46]. Many studies have been conducted to test the validity of polymer strengthening through carbon nanotubes [30,55]. The experiment conducted by Xinhua et al. [54] in 2016 supplements the studies mentioned above by evaluating the impact of carbon fiber embedded in 3D printed structures. The study evaluated structures made with polylactic acid and continuous carbon fibers. The influence of carbon fibers on the mechanical properties of 3D printed structures as well as the biodegradability of the material was evaluated. Without reinforcements, 3D printed structures made of polymers are sometimes too weak for certain applications. Polyacrylonitrile with continuous carbon fibers mixed with E-44 epoxy resin and a low molecular polyamide adhesive was used to create the testing samples. Samples were fabricated by printing one layer of the polymer and using the adhesive and the resin to bind the carbon fibers to the printed layer.

Uniaxial tension tests and three-point bending tests were conducted to evaluate the strength and strain of the specimens. They found that adding carbon fibers to the structure of polyacrylonitrile increased their strength. These findings were in good agreement with previous studies that showed carbon fibers were a good indicator of when the polymer had been tested past its yield point [54]. Finally, the researchers evaluated their results with the real-world application of a 3D printed prosthetic hand [54]. Similarly, a study was conducted to assess the effectiveness of welding 3D printed carbon nanotube polymer composites by applying heat directly at the point of welding between the nanotube and the surface of the 3D printed polymer [55]. In the past, the carbon filament was bonded to the 3D printed structure by heating the entire polymer past its critical sintering temperature [55]. The process created a problem because uniform heating of the 3D printing structure would cause the structure to deform, and lack of heat creates a weak bond between the carbon nanotube and the polymer [55]. A trouser tear test was performed to check the strength of the weld between the nanotube and the polymer. The test allowed the researchers to estimate the fracture strength of a 3D printed layer weld line when it is pulled in two opposing horizontal directions. The fracture strength of the welded parts increased by 275% as compared with a regularly printed part [55]. Additionally, the welded parts were not deformed by the welding process. Therefore, the welding process effectively increases the bonds between printed layers without distorting the shape of the parts [55].

In summary, there have been in-vitro advantages to using additively manufactured products were traditionally made products were used. The benefits come from the ability to manipulate the constituents of the material, and the increased manufacturing controls that are available with additive manufacturing.

In conclusion, there is an ever-present need to provide amputees with custom-made prosthetic devices. In some regions of the world, there is a lack of accessibility to trained professionals who could provide patients with quality custom-made prosthetic devices. The need for increased accessibility to hand prostheses is currently being addressed through additively manufacturing prosthetic hands and finger. Therefore, it is important to evaluate the possibility of using the materials found in an at home 3D printer kit to create an acceptable lower limb prosthesis. Furthermore, the advantage of using additive manufacturing to create medical devices previously made by traditional methods such as casting show promising results in the area of prosthetics. Such benefits include the increased control over material composition and manufacturing techniques. There is still further evaluation needed with regards to the use of 3D printed lower limb prosthetics. It is hoped that removing the need for labor-intensive mold creation for lower limb prostheses can be bypassed through the use of computer models and 3D scanning combined with 3D printing. Therefore, creating custom-made lower limb prosthetic devices available to a wider audience.

Mini Review

The Need to Fabricate Lower Limb Prosthetic Devices by Additive Manufacturing

Fariborz Tavangarian* and Camila Proano

Author Affiliations

DOI: 10.26717/BJSTR.2019.15.002772


UPDATE 1-World Bank says goal of ending extreme poverty by 2030 unlikely to be met

(Adds quotes from chief economist)

By Andrea Shalal

WASHINGTON, Oct 5 (Reuters) - Shocks related to the COVID-19 pandemic and the war in Ukraine mean the world is unlikely to meet a longstanding goal of ending extreme poverty by 2030, the World Bank said in a new report released on Wednesday.

The COVID-19 pandemic marked a historic turning point after decades of poverty reduction, the report said, with 71 million more people living in extreme poverty in 2020.

That meant 719 million people - or about 9.3% of the world's population - were living on just $2.15 a day, and the ongoing war, reduced growth in China and higher food and energy prices threatened to further stall efforts to reduce poverty, it said.

Barring sharp growth gains, an estimated 574 million people, or about 7% of the world's population, would still be subsisting at that same income level by 2030, mostly in Africa, it said.

World Bank President David Malpass said the new Poverty and Shared Prosperity report showed the grim outlook facing tens of million of people, and called for major policy changes to boost growth and help jumpstart efforts to eradicate poverty.

"Progress in reducing extreme poverty has essentially halted in tandem with subdued global economic growth," he said in a statement, blaming inflation, currency depreciations and broader overlapping crises for the rise in extreme poverty.

Indermit Gill, the World Bank's chief economist, said failure to reduce poverty in developing countries would have profound implications for the world's broader ability to combat climate change and could unleash large new flows of migrants.

It would also limit growth in advanced economies, since extreme poverty rates would prevent these often heavily populated developing countries from becoming bigger consumers of goods on the global market.

"If you care about prosperity in advanced economies, sooner or later you want these countries to have large markets, countries like India, countries like China," he said. "You also want these countries to grow so they actually start to become sources of demand and not just supply."

To change course, the World Bank said countries should boost cooperation, avoid broad subsidies, focus on long-term growth and adopt measures such as property taxes and carbon taxes that could help raise revenue without hurting the poorest people.

It said poverty reduction had already slowed in the five years leading up to the pandemic, and the poorest people clearly bore its steepest costs. The poorest 40% of people saw average income losses of 4% during the pandemic, twice the losses experienced by the wealthiest 20%, the World Bank said.

Government spending and emergency support helped avert even bigger increases in poverty rates, the report showed, but the economic recovery had been uneven, with developing economies with fewer resources spending less and achieving less.

Extreme poverty was now concentrated in sub-Saharan Africa, which has a poverty rate of about 35% and accounts for 60% of all people in extreme poverty, the report said. (Reporting by Andrea Shalal; Editing by Kim Coghill and Paul Simao)


Q. Do you also provide any funding facility and at what cost?
A.  No, we don’t provide funding from our side, but we do have tie-ups with financial institutions. However, the financing will be at the sole discretion of the funding institution and the rate of interest applicable would be determined by the agency only.

Q. I currently own a school, but I am interested in turning it into a DALIMSS Sunbeam School so that I may benefit from your brand, system
A.  Absolutely, if you are interested in converting an operating school into DALIMSS Sunbeam, simply fill out the Questionnaire to get started.

Q. Does our Trust/Society need any experience in the education field?
A.  No prior experience is required as our training and support Programmes will provide you with all that you need to run your school.

Q. Is it necessary that the school be run by a society or can it be run by an individual?
A.  The school has to be run under a non-profit trust (minimum 2 members) or society (minimum 7 members).

Q. Are there any other hidden costs?
A.   Absolutely not, we have transparent policies and there is no hidden cost.

Q. Is it possible to start with a low investment? We are considering a low investment initially and wish to expand slowly based on
A.  No, the reason being that if you don’t invest properly upfront, people will return disappointed and later no matter how much you spend on advertising , people will not change their perception easily. Hence it is important that when you launch the branch you create the hype and then live up to the people's expectation as they come to visit the DALIMSS Sunbeam branch. However you can construct the school in phases, but whatever is constructed should be up to DALIMSS Sunbeam Standards.

Q. Why is there large cost variation?
A.   Each potential location is different and has different characteristics. Land size, dimensions, location, economic status of the area, density of population, can individually or together affect the cost of opening a school. The exact amount of investment will be decided after a market study of the paying potential of the local area and what other schools are offering and charging.

Q. How much construction will we be doing initially?
A.  The maximum construction depends on the local laws. We shall aim to maximize our constructed area to build more facilities and accommodate more children. Initially we shall go in for construction of 30,000 sq ft of area which should accommodate 500-600 children and should be adequate for 2 years. Then construction of further phases can be done every 2 years.

Q. What will be our investment and the cost of construction?
A.   Initially the cost of construction can ranges from 800 onwards Rs per sq ft (including furniture and interiors) depending on the fee that is being targeted in the school. We should be able to secure bank funding for a majority of this amount. Hence to start a school you need the land and some working capital.

Q. What would be the investment amount?
A.   The initial investment amount is decided after studying the potential of the area - the number of students the school is targeting and the fee structure that can be expected. Based on this we do a reverse calculation to arrive at an investment amount. In addition, a certain amount has to be invested in advertising and as working capital for the first couple of years.

Q. Can the investment be made in phases? How?
A.  The investment in infrastructure is made at the time of construction and the remaining investment is required as working capital for the first couple of years. The construction will be in phases and further investment will occur as these phases advance.

Franchise License Fee
. Any minimum amount to be paid annually?
A.   Yes, There is a fixed License fee to be paid every year in the month of April.

Q. Is the royalty payable on revenues or on net income? What is the frequency of payments?
A.   Royalty is to be paid on revenue and is paid to DALIMSS Sunbeam Educomp Limited and is settled quarterly.

Q. What Sign-up fee/ Set-up fee do we have to pay in the beginning? Is it refundable?
A.   The Franchise sign-up fee is Rs 50,000 and initial set-up fee is Rs 1.5 Lacs. This amount is payable at the time of signing the agreement and is strictly non-refundable.

Q. When is the license fee to be paid to you?
A.  The first year’s license fee is to be paid at the time of signing of agreement along with one time sign-up fee & Set-up fee, how-ever in subsequent years’ license fee is to be paid at the beginning of the academic session i.e. in the month of April;

Q. Is it compulsory that the land should be owned or rented?
A.   No, you may lease it. The lease has to be irrevocable and for minimum 35 years.

Q. In city land is expensive and scarce how far we can go out of city?
A.   The thumb rule is that the further you go from the city, the larger the area should be as you are competing with schools in the city. Hence your disadvantage in terms of location should be compensated with more land and therefore more facilities

Q. How much space is required and of what kind? -Residential, Agricultural, Institutional or Commercial?
A.   Any amount of space will do as, long as it is allowed by the local civic authorities or conversion is permitted

Q. Would you help in locating a suitable place to start the school?
A.   Yes, once the agreement is signed, a site selection professional will work with you, as well as with local brokers or developers to evaluate sites in your market and help identify a proper location for your new school.

Q. What is an ideal location for a DALIMSS Sunbeam school? What is the criterion for approval of location?
A.   The branch can be situated at any good location where students have easy access to the school. There are various criteria like land size, accessibility, visibility, neighborhood, lease rental to be paid (if leased), competition etc.

Starting the School
Q. what will happen during this period?
A.   Several major tasks are orchestrated in parallel. You obtain the furniture, attend your training program and obtain other educational equipment. At the same time, pre-marketing is conducted in your area using various forms of advertising media. At the same time you shall be making preparations for the implementation of the Marketing Plan designed by our marketing staff for your school. We manage this process with checklists and active support in order to get you started as soon as possible.

Q. Till what class will we start in the first year?
A.   Initially we shall admit children up to class 5th and year by year progress to class 12th. To admit children to class 9th -one must have affiliation to a school board and the process takes 2-3 years and we keep 1 year as a buffer incase of any administrative delays.

Q. How long will it take to open a school?
A.   It depends upon the quality and condition of the existing infrastructure. Accordingly, it may take from 2 months - 12 months.

Q. Does a school require a license? How can I get the recognition from CBSE board?
A.   The school will require recognition from the state government and affiliation from CBSE. We shall guide you through the process.

Q. What board will be affiliating to (ICSE or CBSE or IB or IGCSE)?
A.  The school shall be affiliated to CBSE board.

Q. Will you help me to construct the building?
A.  The construction of the school will be as per the specifications of our architect.

Q. How much does training cost?
A.   The cost of the initial training is included within the License Fee. The only items not covered are your own travel, accommodation and food expenses. Further training may be chargeable.

Q. How will I learn to run my school?
A.   In addition to the manuals, we have created a training programme and give you hands-on experience that will teach you to run your school. We will also host an annual conference, which will bring associates together to discuss opportunities to improve skills and share best practices. It will allow us to communicate with all our branches about various school issues and operational improvements.

Q. Will DALIMSS Sunbeam provide qualified teachers? What would be the salary and remunerations of the staff?
A.   The quality of staff will have a great impact on the quality of education offered in the school. Hence it is crucial that we personally supervise the recruitment process to attract the best possible talent. The teachers and other staff have to be recruited at a local level and we do assist the franchisee at the time of recruitment and training of staff. The number of staff members will be decided keeping in mind the response to the admissions. Their salary will be governed by the market , but in no case will it be less than government/CBSE scales.

Q. Can I offer additional services at the school location such as sports coaching, tuitions and hobby classes?
A.   Some of these are wonderful "value-added" services. If you have the space in your location for these services and you are licensed to provide them or you would like to employ or contract with people who are licensed to provide these services, you may go ahead with our permission. We reserve the right to approve any proposed additional services and require all applicable licenses, should we grant approval

Q. What is our working?
A.   You will be responsible for the day to day administrative responsibilities of running the school.

Q. How much involvement will I need to commit to the school, as a franchisee?
A.  Most of the day-to-day communication can be directly between the school principal and us. However, as with any other organization, you will need to recruit & manage your staff, monitor the financials and look after some administration work as well.

Q. Does DALIMSS Sunbeam provide the books, study material, uniform, etc., or do we have to organize the material locally?
A.   Yes, DALIMSS Sunbeam provides the books, uniform, study material like worksheets etc. and you don’t have to procure the things locally. We will have our own suppliers and you have to buy the prescribed books and uniforms from them. For other school requirements, we have a recommended list of suppliers, but you are free to have local suppliers if they work out to be cheaper, provided the quality is up to the mark and approved by us.

Q. Can I get a loan for this project?
A.   Yes, you should be able to secure funding – subject to eligibility

Q. How many students can the school expect?
A.   We do not provide any projections or authorize anyone else to provide this information, because this number can fluctuate a lot. Your school strength will depend on a number of factors, such as geography, competition, investment, site location, size, your local market, your advertising & promotional efforts, your working acumen, current economic conditions and how well you run your school according to the specified Standard Operating Procedures and many other factors. Because of these variables, there is a wide range in the number of students you might expect.

Q. How much will it cost per month to run such a school?
A.   The amount can be devised from calculating teachers’ salaries, salaries of other staff members such as Principal, Administration, Accounts, Security Guards, Drivers, Attendants etc., Electricity Bills, Telephone Bills, Property Tax, Maintenance of Building, Marketing & Advertisement Expenses.

Q. What fee will be charged from the parents?
A.   Our school fee structure consists of the Registration Fee, Admission Fee, Annual Charges, and Monthly Fee. We do not have a fixed fee structure as the cost structure (population, paying capacity, salaries, real estate costs, local market conditions, running expenses, cost structures, amount of investment done) vary between city to city and within cities as well. Similarly on the revenue side, the paying potential is different for different areas. So, we fix the fee in consultation with the franchisee keeping in mind all the above factors. The right fee can be set with a combination of our experience and your local knowledge.

Q. How long is the term of a Franchise Agreement?
A.   The agreement will be for 12 years renewable mutually after that.

Do you grant exclusive territories?
A.   We believe our model is robust enough to be able to operate successfully in a wide variety of locations and demographics, it would be near impossible to create a set of one-size fits all restrictions that would be fair to both our associates and to us. For example, one city might be able to easily accommodate 5 schools in a 10 km radius, while another suburban town could accommodate 2 schools and yet another area might only be able to accommodate a single school over 3 or 4 towns. It is critical that both our associates and we have the freedom to grow intelligently and respectfully and make decisions based on information provided on a case-by-case basis. Because of all of this, we believe the fairest way to approve a new branch is to assess each location as it is proposed to us, based on a variety of factors and approve locations that we believe will allow for maximum opportunity for success. It is our goal to sell territories that are large enough for you to realize your full growth potential, but not so large that potential students are not served adequately. However, we do give you an exclusive radius of 5 kms within which we shall not open another DALIMSS Sunbeam branch.

Q. Can I start more than one franchise?
A.   Yes, you can start more than one franchise but we would advise you to start the second about 6 months after the first one, as you should be giving your full efforts to kick-start the first one.

Q. Do you offer a master franchise or something or you just have unit franchise?
A.   Yes we do give unit as well as master franchisee.


Tips For Reading the Different Betting Styles of Opponents

Learn to read the different betting styles of opponents. This can help you determine who you should fold to. If you’re playing with friends, don’t reveal what kind of holding you have. This will make it more difficult for them to read your poker hand. You can also avoid giving any advice to them as it goes against poker rules. Instead, play every hand individually. Here are some tips for reading the different poker styles of opponents:

Each betting interval begins with one player placing a bet. After each player has placed their bet, they must raise or match the last bet. After each player places their bets, they must raise the amount of chips they have in the pot, if they do not, they lose their chips. In other words, it’s not possible to raise your bet if no one has bet before you. The last thing you want is to lose a large portion of your hand!

Before betting, you should analyze your table and determine which possible hands other players have. For example, if all 4 cards on the table are spades, then you’ll have a “flush” – five cards from the same house. Likewise, if the cards on the table make a winning hand, you should fold. You should also try to determine whether you have any other good hand, or if you’re merely making a bad one.


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Year to date (YTD): What is it and how to calculate it

Written by

Last editedMay 20212 min read

How can you analyse business trends before the fiscal year has ended? A year to date, or YTD, comparison is useful for this and many other purposes. Here’s what you need to know about the year to date meaning, and how it’s used in accounting.

What does year to date mean?

Year to date (YTD) is a term covering the period between the beginning of the year and the present. It can apply to either calendar or fiscal years. Your fiscal year might not necessarily begin on 1st January but no matter the dates, YTD covers the first day of the year in question up until the day of calculation.

How is year to date used?

We’ve now discussed the year to date meaning, but why is it useful in business? YTD information might be used to look at a company’s earnings, net pay, or investment returns, even though you don’t have the full years’ worth of data just yet. Management can ask for the YTD details as a quick check-up on the company’s interim financial health, rather than waiting until the end of the year.

It’s also useful for comparison purposes. You can compare current YTD financial details to historical statements covering the same period, such as the first financial quarter of the year. One thing to keep in mind, whether you’re analysing trends or measuring performance, is that different companies might have different fiscal year starting dates. If you compare YTD information between two companies with different fiscal years, the analysis will be skewed.

Year to date example

Here’s a quick example to illustrate how year to date is used to calculate a YTD revenue. Imagine that Company XYZ uses the calendar year for its financial statements, meaning it begins on the 1st of January. Today is the 31st of March, and so far, Company XYZ has recorded the following monthly revenues.

  • January: $5,000,000

  • February: $2,500,000

  • March: $2,500,000

You simply add the revenue from all three months together to determine that the YTD revenue is $10,000,000. Company XYZ can then compare this figure to the first three months of any other fiscal year for a quick comparison.

How to calculate year to date

The best year to date calculator will depend on how you’re using this concept. The example above looks at YTD revenue, which is the sum of all revenues between the first and last date of the period in question.

YTD returns

Another common application of YTD is in calculating profit made by any investment from the first date of the current year. This is called the YTD return, and it’s used by investors to assess portfolio performance. A year to date calculator for return on investment uses the following equation:

YTD ROI = (Current Investment Value – First Day of Year Value) / First Day of Year Value

Multiply the result by 100, and you’ll have a percentage for YTD comparison.

YTD earnings

Like YTD revenue, you can calculate an individual’s year to date earnings by adding together all pay received from the first date of the fiscal year up until today. This typically includes income tax payments as well as national insurance withholdings and benefits.

For independent contractors, you can use the following formula:

YTD Earnings = Revenue – Expenses

Add years to date in Excel

If you’re using Excel to keep track of your business’s finances, you should use the DATE function. You can add years to date in Excel by using the following formula:

DATE (YEAR(date)+years,MONTH(date),DAY(date))

Whether you’re calculating returns on your investment, keeping track of company earnings, or analysing any other financial figures, year to date is a useful measurement to keep in mind.

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What Does It Mean To See Someone In Your Dream?

What Does It Mean To See Someone In Your Dream
The following are some common interpretations of dreams that might help you understand why certain persons keep showing up in your dreams: Dreams are one of the most fascinating aspects of the human experience. They take place when we are asleep and can provide us with a lot of useful information.

They can be an indication that there is something going on in our life that is not being addressed, which is the case in certain circumstances. It’s possible that if you dream about someone, your ideas and feelings about them are being reflected in your subconscious. Having said that, it’s also possible that it’s a sign or symbol of something else that plays a significant role in your life.

It might be challenging to decipher exactly what a dream means, but typically, it is illustrative of the aspects of our waking lives that we are having the greatest difficulty coping with. It’s also possible that it’s a sign of things that are going through our minds when we’re awake.

Dreams may be about anything, even things that have never been in the real world or that we have never seen or experienced. While you have a dream about a certain person, the dream is typically a representation of how you feel about that person when you are awake. It’s possible that your dream is trying to urge you to pay attention to a certain individual when you’re awake.

It’s possible that your subconscious is trying to piece together information about something, but it requires the assistance of your conscious mind to do it. You should also make a note of any themes that keep coming up since they may provide you with some insight into what is going on in your life.

See also:  How To Forget A Bad Dream?

What does it mean when you dream about looking for someone?

We have all, at some time in our lives, experienced incredibly strange dreams that have left us wondering what on earth they could possibly signify. For example, you have a dream in which you are seeking for someone or searching for them. Because of the variety of meanings that may be attached to this scenario, the person who is experiencing this type of dream should investigate and choose for themselves which interpretation is most applicable to the circumstances of his or her waking life.

  • Dreams have always been something of a mystery to the human race.
  • Why do we dream? Is there any relevance to the things that appear to us in our dreams? Are there any connections to the world that we actually live in? These are some of the topics that therapists, psychoanalysts, and dream analysts have mulled over and discussed at length on several occasions.

According to Sigmund Freud, our dreams are actually the repressed urges and impulses that we are unable to express in our real life because we are expected to conform to the norms of society and live by the ‘rules.’ In other words, our dreams are our unconscious way of expressing what we are unable to say out loud.

However, at some point in the future, these impulses will remain buried deep inside our subconscious mind and will emerge in our dreams in the garb of something else entirely. Therefore, if a person is able to correctly interpret their dreams, they will be able to know their genuine selves and be able to listen to the voice that comes from inside themselves.

One school of thought contends that if you are looking for someone, it indicates that something important to you in your everyday life is absent, and that you are making an effort to locate it. It’s possible that the “thing” that’s lacking in your life is love, serenity, riches, happiness, spiritual enlightenment, a way out of any issue that you are in, or any of a number of other things.

  1. In a nutshell, the object of your search may be something physical, something mental, something emotional, or even something spiritual.
  2. Conduct an assessment of the connections you now have and the circumstances you find yourself in.
  3. It is possible that if you do this, you will be able to discover a correlation between this dream and your everyday life.
See also:  What Do Dogs Dream About When They Twitch?

If at some point in the future you are able to make a connection and figure out what it is you truly want out of life, then you should begin working toward achieving that goal. If you dream that you are searching for a familiar person, it may be a sign that you are anxious about the future of your connection with that person in particular and that you are anticipating it will come to an end.

This interpretation of dreams comes from another school of thought. It’s possible that the dream is attempting to tell you that you’re trying to reestablish the closeness and connection that you previously had with that person, or that you wish to do so. One possible interpretation is that you seek to adopt or nurture the characteristics and abilities of the person who appears in your dreams in order to become more like them.

You wish to possess the same qualities as that person, particularly strength, individualism, and independence, if that person is strong and independent. If this individual is a good friend, it is likely that you have longed for the kind of relationship and intimacy that you share with this person at some point in your life.

  • If this individual is your significant other, then it’s possible that you’re yearning for love and closeness in your relationship.
  • How well you feel connected to yourself, your feelings, your ideas, and your inner voice is the most important factor to consider while attempting to decipher the meaning of your dreams.
See also:  Why Do I Dream About My Ex Years Later?

In conclusion, if you have had this dream more than once and you are unable to determine the meaning behind it yourself, you should talk to a therapist or a dream analyst about it. These specialists are able to assist interpret your dreams and also show you methods in which you may employ them for the purpose of improving not just your life but also your relationships.

What does it mean when you see different people in dreams?

1. You See a Member of Your Family in Your Dream – If you dream that you see a member of your family, this often reflects one of your personality traits. It is possible that if a member of your immediate family is involved in a serious accident or emergency scenario that this is a sign that you have not completely utilized all aspects of your personality yet.


Perspectives | Diaspora

Why would an Albanian support Giorgia Meloni?

By - 13.10.2022

Muslims celebrating an Islamophobe, immigrants celebrating a xenophobe.

On September 25, 2022, Italians went to the polls and, with 26.3% of the vote, Giorgia Meloni’s Brothers of Italy party won. It is a landmark result. Not only will she likely be Italy’s first female prime minister, it is also the first time since World War II that an Italian party with roots in the fascist movement won a plurality and will have the mandate to form a government.

When the results of the polls came in, I started to see some posts from Albanian diaspora in Italy and some prominent Muslim personalities in Kosovo celebrating her win on social media. As a Kosovar Albanian who has lived most of my life in Italy, I was confused.

Why would a Muslim in Kosovo, presumably sensitive to European chauvinism towards Islam, celebrate a politician who flirts so openly with Islamophobia?

Why would an Albanian in Italy, so many of whom experienced extreme racism and xenophobia when they arrived in the 1990s and after, celebrate a politician who rails against immigrants and wants to block future migration into the country?

The first case is a little easier to wrap my head around. If you can look past the Islamophobia and ethnic chauvinism, Meloni’s conservative worldview — with its emphasis on the importance of “traditional” families, values and identity — has a lot in common with the conservatism of some members of Kosovo’s Islamic community (and others in Kosovo without any particular religiosity, for that matter).

Despite changes in the past decades, the classical idea of the family is still central in Kosovar society. The purpose of life? Get married and have children (and better make it a boy, male children are still seen as so much more of a blessing than girls that sex-based selective abortions are not unheard of in Kosovo).

Patriarchal ideas about separate societal roles for men and women still reign. Men are supposedly natural decision-makers, breadwinners, the ones who take a role in public life (or just lounge about at cafes). Women, however, are caretakers — better that they have babies, cook and focus on domestic issues. Of course, this supposed ideal is all too often a cover for robbing women of their property rights and treating them like unpaid maids.

Though there are plenty of areligious or nominally religious people who live by these patriarchal codes, it seems that the more eager someone is to assert themselves as a religious authority in Kosovo, the more likely they are to operate on these principles, principles that fit in well with the staples of Meloni’s politics, which stress exactly these ideas about “natural” and “traditional” families.

Why would a Muslim in Kosovo celebrate a politician who flirts so openly with Islamophobia?

One specific thing that appears to draw some Kosovars to Meloni is her defense of “tradition” and the way she presents herself and her values as supposedly a victim of what she calls the “LGBT lobby.” Intolerance towards LGBTQ+ individuals being present and vocal in the public sphere is something Meloni and conservative Muslims in Kosovo are in complete accord over.

But it’s frankly stunning that a mutual intolerance for LGBTQ+ people and superficial speeches about family and identity could be enough to get some of these Kosovar Muslims to overlook Meloni’s position on Islam. She’s been quoted as saying that the religion is “against our freedoms.” In 2016 she declared that “all terrorists are Muslim” and on the campaign trail in 2018 she called for a “no to the Islamization of Italy.”

And comically, for a woman who demands a return to traditional family values, Meloni has a daughter with a man to whom she is not married, an act that’s socially acceptable only due to the progressive changes that she presents herself as the victim of. It’s unclear if the people enthusiastically sharing her speeches are aware of this.

For the Albanian diaspora in Italy celebrating Meloni’s win, things are a little more complicated.

One aspect of this support is connected to Albania’s political history. Hoxha’s communist dictatorship still weighs heavily on the nation’s psyche. Some Albanians at home or abroad see leftist politics as forever tainted and unfairly equate them with Hoxha’s regime. For someone with those politics and that political experience living in Italy, Meloni’s Brothers of Italy, which has its roots in rabid anti-communism, would have an appeal.

But how can someone who came to Italy as an immigrant, often risking their life on a dangerous boat passage and living for years as the target of racists and scapegoated as the source of the country’s ills, forget all that and support someone who’s built their political career as an outspoken xenophobe?

Most Albanians came to Italy with empty pockets fleeing worsening conditions in Albania and Kosovo throughout the 1990s. The men were stereotyped across Italy as rapists or thieves, the women as prostitutes. Such conditions are bound to create inferiority complexes.

You see the ongoing results of these inferiority complexes among many Albanians in Italy today, particularly in the attempt to fully integrate and assimilate, to cast off markers of Albanianness. You see it in the way some take on an Italian name to avoid job discrimination, or how for some, finding an Italian partner is seen as a way to upgrade their social status.

After years of living in Italy, the type of Albanian who celebrates Meloni’s win sees an opportunity. Since they’ve arrived, there has been an increase in immigrants from the Middle East and Africa towards whom Meloni and her supporters have even greater animosity than towards Albanian immigrants. Instead of taking the often humbling experience of immigration as a lesson to be in solidarity with others facing discrimination or humiliation, the Albanians in Italy who support Meloni have a chance to align with the dominant side this time, to position themselves as better than the recent migrants.

The whole thing reminds me of a sketch from Turkish-German comedian Kaya Yanar in which he recounts a complaint from his father, who had moved to Germany 40 years prior:

“‘There are so many Turks in Germany.’

Dad, what do you mean? You are also a Turk!

‘I am a different Turk.'”

After decades of labor in often underpaid work, struggling to learn a new language and adapt to a new culture, what better way to assert that you are at home in your new country than to reject newcomers in the way that you were rejected when you were a newcomer? That, sadly, is what some of my fellow Albanians in Italy have decided is the best way to become a true Italian.

We don’t have numbers on Albanians’ support for or feelings towards Meloni. The posts I saw were shared by individuals, and these individuals do not represent an entire community. But the messages in the posts do represent pernicious ideas that find a home among some in the community — a sad reminder of a lack of solidarity. Those who have been the targets of Islamophobia or xenophobia would do well to remember it and to never side with the perpetrator.

Feature image: K2.0.