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Book Review ‘Teori Seni Tampak: Asas Seni Reka’

Abstract

Teori Seni Tampak: Asas Seni Reka Written by Chang Hon Woon, this book discusses the basics of art to provide a clear and comprehensive picture of the students taking Art Education subjects. All the important information that students need to know in this book. To the students concerned it is advisable to have this book in order to understand the visual art theory that is the basis of the Art Education subject. Each chapter in this book includes notes, illustrations and example works to help students understand their contents better. This book is composed of three main sections: Part A which covers the Art Elements, Part B which cover the Design Principles and Part C which include the Design Structure. The end of each chapter of this book includes exercises that reinforce understanding and sharpen the art skills among students. Art Education subjects have undergone significant changes since the KBSM approach was introduced. This new approach based on the National Education Philosophy provides the students with mentally, spiritually and physically. The Curriculum of Secondary Art Education syllabus covers all three aspects of cognitive, psychomotor and affective.

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Economic Evaluation of Effectiveness of Domestic Raw Materials | Juniper Publishers

Juniper Publishers-Open Access Journal of Mining Science & Technology

Authored by Katarína Čulková

Abstract

Raw materials provide profit for owner, state and mining company, as well as single region. Mentioned means that problem of evaluation of raw material deposits is very actual and necessary area. In developed market economies evaluation of reserved deposits is considered as one of the most complex, but also most important activities during finding and research of any deposit of raw material. According national strategy for permanently sustainable development of Slovakia position of natural environment and using of raw materials in Slovakia is not sustainable from the long-term view. From the view of social and economic impacts of mining we analyzed chosen macroeconomic indexes in mining. By this way we analyzed individual regions of Slovakia. Results of analysis shows that mining activity is characterized by technologically severity and high rate of human work, and by this way with regard to costs structure it presents important source of employment.

Keywords: Raw Material Base, Resource Policy, Economic and Social Impact, GDP, Unemployment, Export, Import

Introduction

Base of mineral raw materials provides in the frame of certain region the value that is possible to evaluate with optimal using complexly, and by this way profit for owner, state and mining company, as well as single region is created [1]. Profit for the state can be possible reasonable and rational using of deposits, as defined in legislation of raw materials using. Profit for mining organization can be profit creation during providing of its sustainability. Profit for the region is in the sense of administration creation of wealth for region´s inhabitants that is viewed through support of new working posts, support of regional taxes creation, or taxes, orientated directly to the region and availability of raw material sources that are necessary for region´s development. Owner of reserved deposits of raw materials in conditions of Slovakia is single state, but state does not have definite obligation to evaluate economically all recorded deposits of reserved raw materials [2].

Sector of mining and processing of raw materials in Slovakia is full privatized and state as owner of reserved deposits of raw materials creates in accord with available legislation space and conditions for business subjects for effective using of raw materials. Principle of freedom in business during observing of determined rules applies also in area of raw material using. It means that problems of evaluation of raw material deposits are very actual and necessary for business sector, as well as for private sector [3]. In developed market economies evaluation of reserved deposits is considered as one of the most complex, but also most import ant activities during finding and research of any deposit of raw material.

Market estimations of prices of deposits and raw material sources in Slovakia can exist only due to the Law about prices No 526/1990 Collection of Law. However, it would not be advisable to prescribe detailed pricing procedures for prices determination for a wide range of evaluation needs for all variants of real estate. Present mining practice shows that market estimations use for evaluation of non-monetary deposits to equity of the company mainly capital debts and warranty coverage.

State of The Problem

Presently raw materials are mining in all counties of Slovakia. Majority of mined raw materials are consuming at the regions of Slovakia. Raw materials, which present surplus in Slovakia, are exported to surrounding countries. Shortage of raw materials is imported to Slovakia important attention is necessary to give mainly to social and economic indexes, among which belong employment, GDP, average monthly wage, migration and criminality. Such indexes characterize changes, connected with inhabitants of the country [4]. Extraordinary important and necessary condition for state development is availability of raw materials [5]. Availability is perceived from physical and economic side. Using of own raw materials is either most economic or ignoring of such possibility could present ownership negation, which in case of raw materials is evaluated very significantly and directly by the Constitution of Slovakia.

According the Constitution SR raw material wealth must be protected and effectively used in connection to long-term needs of economic and social development of the society with regard to environmental aspects of sustainable development, beginning with geological research and using of verified stocks of raw materials. Process of raw materials using is subjected presently to legislation norms that divide deposits to two categories: reserved and non-exclusive. Non-exclusive deposits are characterized by attribute of ownership - owner of the land. Deposits reserved are part of raw materials wealth of the state an in the sense of the Constitution SR they are in ownership of the state and this ownership is unchangeable. Effectiveness of state ownership using is interpreted through rationality. Since raw materials are irrecoverable, state must care of their saving using with goal to provide protection and rational using of raw materials wealth as ownership of Slovakia, together with regarding of sustainability principles.

Raw materials wealth of Slovakia provides rather broad scale of raw materials from the view of volume and quality of stocks, proper mainly for production of products on base of non-metallic and construction materials that present economically most important group in structure of raw materials wealth of Slovakia [6]. One of the most important tasks in the future should be increasing of processing level and products finalization on base of non-metallic raw materials.

Stocks and quality of ore raw materials, as determining factor of their using, prove their decreasing economic importance in structure of raw materials wealth of the country. Similarly, domestic energetic sources (except brown coal and lignite) have due to the volume of imported commodities only small importance. Total rate of value of raw materials mining on GDP is negligible (0,5%), but this statistic data does not include value of consequently processed and adjusted commodities on mineral base that is multiply higher and it presents significant element in the economy and foreign trade of Slovakia [7].

Methodology

Due to the evaluation of present state of raw materials in Slovakia there is necessary to limit position of mining sector according classification in conditions of Slovakia. According SK NACE Rev.2, published by Statistic Office of Slovakia, official indication of mining industry is in section B - Mining and quarrying. The sector includes include mining of minerals, appearing naturally as solid minerals (coal and ores), liquid (petroleum) or gas (earth gas). In the frame of mentioned section there are divisions 05-06: mining and quarrying of fossil fuels (coal, lignite, petroleum and gas), division 07-08, including: mining and quarrying of metal ores, various minerals and stone [8].

In spite of historic tradition in mining and processing of ore raw materials, presently Slovakia does not belong among states with developed mining industry. According UN for development and business (UNCTAD) to category of states with developed mining industry belong states, in which rate of mining and processing of raw materials on GDP is higher than 25%. According national strategy for permanently sustainable development of Slovakia position of natural environment and using of raw materials in Slovakia is not sustainable from the long-term view. Present situation of raw materials base in Slovakia is characterized almost by total exhaustion of ore raw materials stocks, big stocks, but different measure of non-metaling and construction materials using, as well as total limitation by state control over mining. Influences to the country and living environment, caused by mining, are vast. Such influences present only one of the most serious environmental problems of Slovakia (Government Resolution, SR, 2001). Sector B - Mining and quarrying due to the reporting from the side of Statistical Office SR, is mentioned in the analysis as part of aggregated sector Industry in Total.

From the view of social and economic impacts of mining it is important to follow up mainly employment and wages in mining. Also, there is necessary to search development and placement of mining companies in Slovakia. By this way we analyzed individual regions of Slovakia. By the way of obtained social and economic indexes we made analysis of macro environment and analysis of mining industry. Due to the evaluation of development we followed up influence of mining industry to GDP, employment and wage (due to the extend analysis we will mention only results and conclusions of analysis).

Results

From the Table 1 there is obvious GDP development in sector Industry Total and Production remained during whole period rather stable. In last period there is gradual decline of mining activity due to the growth of input prices to mining activity process and activity, made by mining and last but not least also due to the consequences of economic crisis in Slovakia and in the world (Table 1).

All stocks of raw materials in Slovakia are divided to four groups to following stocks:

• Energetic - petroleum, coal, earth gas, uranium, lignite, anthracite, bituminous rocks,

• Ores - iron, copper, lead, zinc, antimony, mercury, silver, gold, etc.

• Non-metallic - barite, bentonite, quartz, magnesite, talc, etc.

• Construction - building stones, gravel, bricks, etc.

• Other - mineralized waters, pyrites [9].

Deployment of raw materials deposits in Slovakia is uneven. It depends mainly on geologic construction of the locality. Raw materials mined in Slovakia are determined mostly for domestic consumption. Slovakia import from abroad prevailingly petroleum, earth gas, black coal, iron ores, and raw materials for metallurgy [9]. Mining of raw materials is characterized by high rate of human work; therefore, it presents very good source of employment, but on the other hand it is less profitable. Total value of profit achieved in analyzed period 330 million EUR, which presents 0, 46% of total GDP.

From total mining in Slovakia 12, 5% belongs to fuel and energetic materials, 2, 1% to ores, 85, 4% to non-metallic materials. Production of majority of non-metallic and construction raw materials (magnesite, limestone, dolomite, gypsum, building stones, etc.) covers considerably their domestic consumption. Raw materials and products on mineral base present important element of foreign trade of Slovakia. Important element of imported mineral materials belongs mostly to fuels (petroleum, earth gas, black goal) and ores raw materials (iron ores, raw materials for aluminum metallurgy, steel and ferry-alloys). As for the materials, produced on mineral base, Slovakia exports mostly iron and steel, aluminum, ferry-alloys, magnesite, concrete, bentonite, dolomite and other products mostly from non-metallic raw materials. From seven types of registered energetic raw materials (petroleum, earth gas, brown coal, lignite, uranium ores, anthracite, and bituminous rocks only four types are industrially used - petroleum, gas, brown coal and lignite [10,11]. Economic importance of uranium ores, anthracite and bituminous rocks is negligible due to their volume and quality. Slovakia has limited stocks of energetic sources, mainly petroleum and earth gas.

Main goal of raw materials potential searching in Slovakia is geologic task in accord with analysis and evaluation of chosen ores and other raw materials from the view of their importance for Slovakian economy - possibility of their using from the view of stocks volume, their quality, possibility of replacement, structure of demand and offer, as well as identification of weaknesses and strengths (SWOT analysis) of individual types of raw materials. According evaluation of raw material potential according chosen parameters, raw materials will be identified (resp. individual deposits objects) that are strategic for Slovakian economy and that are economically perspective for further using. Results of the task should serve as frame base for decision about using of evaluated raw material sources in the future.

Export and import and its economic and social impacts

Mining and quarrying in Slovakia provides important inputs mainly for processing industry and energetics. But stocks of raw material and energetic materials are limited in Slovakia greatly. While as for the fuel and energetic and ores raw materials Slovakia is dependent on import, mining of several types of raw materials for industry and construction has positive economic importance.

Mining of brown coal and lignite covers domestic consumption approximately 80%. In the frame of energetic policy of Slovakia domestic sources of brown coal and lignite are considered as strategic raw material base, decreasing dependence on import of primary fuel and energetic materials, and as reserve in case of unpredicted situations and source of working possibilities. Due to the verified geologic stocks of petroleum and earth gas there is not possible to expect in the future considerable increasing of domestic mining volume and therefore it will be necessary to provide such commodities still by import.

Slovakia presents after Ukraine second biggest transition country of earth gas in Europe. Main attention will be orientated in the future in connection with gas market liberalization to increasing of quality of services, connected with earth gas stocking. Primary task would remain decreasing of energetic demand to level of EU countries. Regarding high production costs of mining and processing of domestic ores raw materials the mining is not profitable. Necessary ores commodities are provided by import. On the other hand, reserved deposits of non-metallic raw materials present most important group of raw materials in Slovakia.

In 2015 geological stocks of reserved deposits achieved level 16 605 mil. tones with considerable prevalence of non-metallic raw materials (12 586 mil. ton). 2015 presented year with smooth increasing of construction and non-metallic materials mining. From the long-term trend (2000-2015) there was significant decline of ores materials mining (by 95,3 %) and decrease of energetic materials mining by 50, 5%. On the other hand, growth had been recorded in mining of non-metallic materials (by 9%) and construction materials (by 49 %). In 2015 rate of energetic materials mining to stocks presented 0,16 %, ores materials presented 0,01 %, and non-metallic materials 0,09 %, construction materials - 0,62 % (Ministry of Living Environment, SR, 2016). Chosen financial indexes in Mining and quarrying is given by (Table 2).

Most important non-metallic materials from the view of export are magnesite, dolomite, stone solt, bentonite, limestone, and baryte. Magnesite industry with verified geologic stocks of magnesite and built mining and processing capacities belong to most important producent of alkaline refractory materials in the world (Ministry of Economy SR, 2004). Petroleum is mined in Slovakia mostly in deposits Gajary and Dúbrava, gasoline in eastern Slovakia (Senné, Stretava, and Ptrukša). But total consumption of the materials is covered rather by import, since rate of domestic production on consumption presents only 1% (Table 3).

Earth gas is obtained mainly from deposits in eastern Slovakia (approximately 70% of mining), remaining production is from deposits in Viedenská panva and Podunajská nížina. Production of gas from Slovakian deposits covers only approximately 3% of consumption and therefore it must be provided by import. Single producer of oil and earth gas is presently Nafta, Joint Stocks Company. Due to the volume of verified stocks of oil and earth gas this situation would be probably not changed in the future. This means permanent dependence on import. Mentioned is illustrated by data in Table 4.

Mining of brown coal is realized at deposits in Handlová, Cigeľ, Nováky (Hornonitrianske bane, a.s.) and Modrý Kameň (Baňa Dolina, a. s.). Lignite is mined at deposit Gbely (Baňa Záhorie, a. s.). Biggest domestic consumer of energetic coal and lignite presents Power plant Nováky, part of the production is consumed by Heating plant and chemical industrial plants (Chemko Strážske). Domestic mining covers consumption of brown coal at level approximately 80% (Table 5). Dependence on black coal import is permanent.

Mining of building stone moves in last years around 9 mil. tones per year and it has increasing trend. Most important producers of building stones in last period was Slovenský vodohospodársky podnik, š.p., Stredoslovenské kameňolomy, a. s., Doprastav, a. s. and Malokarpatské štrkopieskovne, a. s. Most important producers of gravel were lastly Alas Slovakia, spol. s r. o., VSH, a. s. (Betox, spol. s r. o.) and V.D.S., a. s., which provided together almost 70% of total gravel production in Slovakia (Table 7).

Development of number of companies in mining industry

During analysis of mining sector, it is appropriate to follow up number of rising and terminating mining companies in Slovakia. Table 8 illustrated total number of mining companies in individual counties. Data are obtained and available only for period 2010- 2015.

Most companies orientated to the activity of mining and quarrying were in 2014 in county Banská Bystrica. In 2015 there was recorded most companies in Bratislava county, yet 42 companies. The least companies are appearing in county Trenčín. Total number of companies in mining industry in Slovakia was in 2015 with total number 187 companies. From 2013 the number of these companies is gradually increasing. It is ideal from the view of mining, sales and new working posts increasing in mining sector. Figures 1 & 2 illustrates number of rising and terminated companies in mining and quarrying industry in Slovakia during analyzed period.

According Figure 1 we can see that in mining industry there is gradually increasing number of rising new companies and on the other hand smooth decrease is recorded for number of terminated companies, illustrated by Figure 2. It means positive situation for mining sector. By this way we can state that mining in Slovakia is still developing.

Development of employment in mining industry

Important index during analysis of the sectors is employment in mining. Average registered number of employees in mining industry for all Slovakian counties is illustrated by Table 9. The index is followed during 2010-2015.

From Table 9 there is obvious the majority of workers in mining and quarrying industry is in county Trenčín. In 2015 3 852 employees worked in the industry. It is caused by the way that mainly in this county the biggest employer is company, mining brown coal and lignite. From 2010 the least number of employees in mining were in county Nitra. Comparing of development of average number in individual sectors is given by Table 10.

We can say that in all sectors, illustrated by Table 10 average number of employed persons had decreasing tendency. From total industry the least number is employed in mining and quarrying industry, which in 2015 employed only 6 742 persons. The biggest number of employed were in industrial production [8].

Sales in mining industry

In mining industry there is important to follow up also development of sales that is illustrated during analyzed period 1990- 2015 by Figure 3. Values of the index are calculated by actual exchange rate.

According Figure 3 we can state that from 1990 sales had been gradually increasing. Smooth decrease of sales was recorded in 2005, but in following years sales repeatedly increased. In 2015 sales in mining industry were around approximately level 544mil. €. From the view of sales there is important to follow up sales from raw material mining. Figure 4 shows development of raw materials mining in Slovakia during last 25 years.

During analyzed period the highest volume of mining was recorded in 2005 at level 34, 6 mil. tones. From 2005 mining of raw materials decreased in Slovakia smoothly. In 2015 Slovakia mined 29, 6 mil. tons of raw materials.

Discussion and Conclusion

Effectiveness of raw material using is changing in accord with internal and external factors. Internal factors are as follows:

I. Volume and quality of verified geologic stocks on concrete deposits,

II. Mining and geological conditions of mining,

III. Development of industrial infrastructure in surroundings of raw material occurrence and its placement of the market,

IV. Local, mostly environmental conditions,

V. Aim to realize other activities in the territory.

External factors are as follows:

i. Liberalization of market with commodities with mineral origin,

ii. Prices of similar raw materials in world markets,

iii. Availability of raw materials and possibility of their replacement from domestic source, including secondary raw materials.

Raw material policy must respect principles of social and ecologically orientated market economy during mining and processing of raw materials and to regard also saving using of natural resources. Mining activity characterized by technologically severity and high rate of human work, and by this way with regard to costs structure it presents important source of employment. In spite Slovakia is small country, it has own rich sources of raw materials. Mining is participating at GDP in Slovakia. Majority of mined raw materials is consumed in domestic market, as for example building stone, dolomite, gravel and sand. Mostly petroleum, earth gas, iron ores and black coal are imported to Slovakia. Among positive impacts of mining belong increasing average monthly wage in the sector. People automatically with increasing wage have a need to buy more and more products and services for providing of their needs, which can be met by using of raw materials.

Decrease of employment in mining can be considered as negative social and economic impact of mining activity in Slovakia. New companies purchase Technologies, by which they increase volume of mining, sales of products, and at the same time number of employees is decreasing. Further reason for employment decreasing in mining can be due to the disinterest of people to make such physically demanded job. By mining activity is influenced mostly living environment and inhabitants of the country. Mining of raw materials influences living environment mainly due to the change of relief and soil covering. Inhabitants, living in surroundings of mining works are influenced by too high dust and noise, which can cause rising of various illness. In spite of negative influence of mining there is necessary to support the sector from the side of state, since demand for raw materials in increasing by every year.

Estimation of life cycle of several stocks in Slovakia is over 200 years. Problems of raw materials using in Slovakia is fully reflecting in accord with available legislation of treatment with raw materials. Such treatment is documented through processes that are included in raw materials policy. In spite the policy is given at the level of state, it includes only general declarations that are not possible to use and realize effectively without institutional tools. In spite of mentioned the policy gives the frame that is obligatory and inspiring.

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Mini Review on Synthesis of Pyrimidinthione, Pyrimidinedione Derivatives and Their Biological Activity | Juniper Publishers

Juniper Publishers-Open Access Journal of Petrochemical Science

Authored by Nadia Ali Ahmed Elkanzi

Abstract

The chemistry of heterocycles has received amongst the chemicals prominent attention in recent years owing to its importance in the pharmaceutical sector. Organic compounds carrying pyrimidinthione, pyrimidinedione, pyridazine rings have been reported to demonstrate a wide range of pharmacological activities, which includes antibacterial, antimicrobial, antioxidant, anti-HIV and anticancer activity. These observations have been guiding for the synthesis of various derivatives of these compounds enclosing biologically active nuclei and study their pharmacological activities.

Keywords: Chalcone; Pyrimidinthione; Pyrimidinedione; Biological activities

Introduction

Over the past decade the evolution of organisms resistant to nearly all the class of antimicrobial agents has become a severe public health concern [1,2]. Heterocyclic compounds have received considerable attention owing to their synthetic and biological importance in the enhancement of the quality of human life. Among numerous heterocycles compounds that have been synthesized and evaluated for their pharmacological activities, chalcone, pyrimidinone and pyrimidinethione have played a crucial role in medicinal chemistry. It was demonstrated that the presence of reactive α, β-unsaturated keto function in chalcones was responsible for their antibacterial and antifungal activities [3].

The pyrimidinones compounds have gained interest in recent years due to their wide-ranging biological activity. These compounds displayed therapeutic applications, as anticancer [4,5], antihypertensive [6], hypoglycaemic [7], antiviral [8], anticonvulsive [9], anti-inflammatory and analgesic [10] drugs.

On the other hand, literature surveys revealed that pyrimidinethione derivatives are an important class of heterocyclic molecules possessing a wide variety of biological properties. In fact, different studies demonstrated that various compounds possessing pyrimidinethione nucleus exhibited broad range of biological activities such as antimicrobial [11-13], antioxidant and antitumor activities [14], antitubercular [15] and hypoglycemic activity [16]. The current mini review aims to focus on some synthetic procedures of pyrimidinones and pyrimidinethione derivatives to facilitate the development of new heterocyclic compounds with more efficient and promising pharmacological activities.

Result and Discussion

Pyrimidinedione derivatives were synthesized from various arylmethylene acetophenone derivatives [17]. The chalcone derivatives were prepared using substituted ketone and distinct substituted benzaldehyde through condensation reaction. Likewise, pyrimidinedione derivatives (4) were synthesized via reaction between aryl methylene derivatives and/ or chalcones with thiourea and KOH in ethanol (50ml) in microwave oven for sufficient time and under an appropriate temperature. The detailed steps used in the synthesis of the pyrimidinedione derivatives were described in the literature [18].

The pyrimidine-2-thione derivatives (4) were screened in-vitro against gram positive and gram-negative strains and were found to be less active against the gram-positive bacteria in comparison with the minimal required dose for the action against the gram-negative bacteria in most cases [17] (Figure 1) (Table 1).

Ethyl 1,5-dihydro-5-oxo-1,7-diphenyl-1,2,4-triazolo [4,3-a] pyrimidine-3-carboxylate (5) was treated with hydrazine hydrate, in refluxing ethanol to give the corresponding acid hydrazide (6) in good yield [19,20]. Acid hydrazide (6) was treated with potassium thiocyanate in refluxing methanol, in the presence of hydrochloric acid to produce1-(1,5-dihydro-5-oxo-1,7-diphenyl- 1,2,4-triazolo[4,3-a] pyrimidine-3-carbonyl) thiosemicarbazide (7). Compound (10) 3-(5-mercapto-4H-1,2,4-triazol-3-yl)-1,7- diphenyl-1,2,4-triazolo [4,3-a] pyrimidin-5-(1H)-one (10) was prepared by oxidative cyclization of compound (7) in basic medium (7% KOH) under reflux with subsequent acidification. It was found that further reflux of compound (7) with dry pyridine gave a product identified as 3- (5-amino-1,3,4-oxadiazol-2-yl)-1,7-diphenyl- 1,2,4-triazolo [4,3-a]pyrimidin-5-(1H)-one (8) (Figure 2).

On the other hand, the reaction involving the synthesis of 1,7-diphenyl-3-(5-amino-1,3,4-thiadiazol-2-yl)-1,2,4-triazolo [4,3-a] pyrimidin-5-(1H)-one (9) took place through a dehydrative cyclization by reacting compound (3) with conc. sulfuric acid. The resulting product (9) was separated as green solid, and was slightly soluble in most organic solvents (Figure 2). Acid hydrazide (6) reacted with phenyl isothiocyanate in refluxing ethanol to produce 1-(1,5-dihydro-5-oxo-1,7-diphenyl-1,2,4-triazolo[4,3-a] pyrimidine-3-carbonyl) phenylthiol semicarbazide (11).

Besides, acid hydrazide (6) was treated with phenyl isothiocyanate in refluxing ethanol to give compound (11)1-(1,5-dihydro- 5-oxo-1,7-diphenyl-1,2,4-triazolo [4,3-a] pyrimidine 3 carbonyl) phenyl thiosemicarbazide as shown in Figure 3. The latter product was subjected to intramolecular cyclization when treated with sulfuric acid, dry pyridine and KOH (5%) demonstrating a new synthetic route to produce compounds 12, 13 and 14, respectively. Subsequent treatment of compound (14) with methyl iodide in the presence of sodium ethoxide solution, yielded 3-(5-methyl thio-4-phenyl-4H-1,2,4-triazol-3-yl)-1,7-diphenyl- 1,2,4-triazolo[4,3-a]pyrimidin-5-(1H)-one (15). It is worth noting that the treatment of compound (14) or (15) with hydrazine hydrate under reflux condition produced the same product, identified as 3- (5-hydrazino-4-phenyl-4H-1,2,4-triazol-3-yl)-1,7-Diphenyl- 1,2,4-triazolo[4,3-a]pyrimidin-5(1H)-one (16) (Figure 3).

Besides, the treatment of compound (11) with phenacyl bromide in refluxing ethanol, in the presence of triethylamine, yielded 1,5-dihydro-5-oxo-1,7-dipheny-lN-(3,4-diphenyl-3H-thiazol- (2E)-ylidene-1,2,4-triazolo[4,3-a] pyrimidine-3-carbohydrazide (17) as shown in Scheme 3. Treatment of acid hydrazide (6) with carbon disulfide in ethanol, in the presence of potassium hydroxide at room temperature, resulted in the formation of potassium salt (18). The latter product reacted with ethanolic potassium hydroxide to afford 3-(5-mercapto-1,3,4-oxadiazole-2-yl)-1,7-diphenyl- 1,2,4-triazolo[4,3-a]pyrimidin-5(1H)-one (19) (Figure 3). The mechanism of formation of the corresponding ox diazole (19) was studied and discussed in previous studies [21-23]. Moreover, potassium salt (18) was subjected to treatment with hydrazine hydrate, in refluxing ethanol, the reaction yielded as 3-(5-mercapto- 4-amino-4H-1,2,4-triazol-3-yl)-1,7-diphenyl-1,2,4-triazolo[4,3-a] pyrimidin-5(1H)-one (17) (Figure 3).

Additionally, it was reported that the reaction involving the synthesis of 4-amino-1, 2, 4-triazole can took place by a simple conversion of 1, 3, 4-oxadiazole under the action of hydrazine hydrate [24,25]. Likewise, the corresponding dicarbonyl compounds including acetylacetone and ethyl acetoacetate were subjected to condensation with acid hydrazide (6) in the presence of an appropriate amount of piperidine as catalyst to give the substituted pyrazole derivatives 3-(3,5-dimethylpyrazole-1-carbonyl)-1,7-diphenyl- 1,2,4-triazolo[4,3-a]pyrimidin-5(1H)-one (20) and 3-(3-methylpyrazole-5-oxo-1-carbonyl)-1,7-diphenyl-1,2,4-triazolo[ 4,3-a]pyrimidin-5(1H)-one (21), respectively (Figure 4).

The structure of these compounds was established based on spectral and elemental analysis reported in the related literature [26-28]. Finally, condensation of acid hydrazide (6) with acid anhydrides, namely phthalic anhydride and 2, 3, 4, 5-tetrachlorophthalic anhydride, in refluxing glacial acetic acid, produced the corresponding imides (22) and (23), respectively (Figure 4). Biological studies demonstrated that these compounds exhibited antihypertensive activity [20] (Figure 5).

Conclusion

In this mini-review, we report on the efficient procedures for the synthesis of pyrimidinedione and pyrimidinethione derivatives. The experimental results showed that the prepared product displayed outstanding pharmacological activities when screened In-vitro against gram positive and gram-negative strains and could be further exploited in medicinal chemistry.

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Falls in Older Adults: How to Asses and Prevent? | Juniper Publishers

Juniper Publishers-Open Access Journal of Yoga and Physiotherapy

Authored by Natália Boneti Moreira

Opinion

Falls and its related consequences are among the major elderly’s public health worldwide problem [1-4]. Approximately 42% of elderly with 70 years or more have experienced at least one fall in the last twelve months [4]. A recent systematic review showed a higher risk-adjusted mortality in falls compared to motor vehicle collisions [3], increasing morbity and mortality in older adults [3,5,6].

Several studies have demonstrated exponential growing risk of falls with increasing age [3,7,8], not only by structural and physiological changes, but also by reduction of functionality and increasing of frailty [4,5]. Functionality is associated with elderly’s function and physical capacities, as muscle potency, walking speed and functional mobility; and social and attitudinal environmental factors affecting them [9,10], and the declines of these capacities have the potential to increase fall’s risk and the severity of falling consequences in older adults [11].

Besides the physical consequences, falls lead to psychological and cognitive changes, as social isolation, depression, fear of falling [11-13] and reduction in quality of life [11,14]. It has been concluded that combination of these factors restrict their activities of daily living, social activities and health perception, making elderly’s functionally dependent, and therefore, generating a negative social and economical impact on family, community and society [4,11,13].

In this context, it’s really important to assess the risk of falls and prevent these episodes. The multifactorial assessment identifies the risk factors for falling. The evaluation may include cognitive impairment, continence problems, falls history (involving causes and consequences, such as fear of falling and injuries), adequate use of footwear, home hazards (e.g. inadequate lightening, carpet or slippery floor, etc.), health problems that may increase their risk of falling (e.g., arterial hypertension, syncope syndrome, visual impairment, etc.), inadequate or excessive use of medication, postural instability, mobility problems and/or balance problems [15,16].

All older adults with frequent falls or with increased risk of falling should be considered for an individualized multifactorial intervention composed by strength and balance training, home hazard assessment and intervention, vision assessment and referral, medication review with modification/withdrawal and psychological aspects including risk behavior and fear of falls. These aspects can avoid the reduction of physical activity level promoting independence and improving physical, psychological and social function, providing a better quality of life for older adults [15,16].

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Notes for Clinical Use of Extra Acupoints | Juniper Publishers

Juniper Publishers-Open Access Journal of Complementary Medicine & Alternative Healthcare

Authored by Tong-zheng Hong

Abstract

Pattern identification is the key concept of the traditional Chinese Medicine theories, which unfortunately cannot apply to extra acupoints for the lack of Yin-Yang. The recent studies suggest that extra acupoints selected in combination with traditional acupoints on the traditional fourteen meridians for anesthesia in surgical operation are marking the beginning of a new chapter and indicate more and more extra acupoints will be discovered.

Keywords: Yin-Yang; Extra acupoint; Pattern identification; Traditional chinese medicine

Introduction

Extra acupoints distinguish themselves from the regular acupoints on the traditional fourteen meridians with the unique indications, actions, and the great effectiveness in acupuncture theory and treatment, even though some of extra acupoints have not been verified with scientific evidence [1].

The Yin-Yang balance is the unique concept and the dominating key of the traditional Chinese medicine (TCM) throughout the history of Chinese medicine for many centuries [1]. It is believed that this concept absolutely distinguishes TCM from the Western medicine. Based on this concept, a disease thus indicates the loss of the balance of Yin-Yang. On the other hand, this concept also serves as the foundation and the guidelines for the etiology of diseases, diagnosis, and treatments [2].

The balance of Yin and Yang can be achieved by stimulations through techniques such as acupuncture, acupressure, moxibustion, cupping, and Tui Na on acupoints. The classic and well-known protocol of Four Gates (LV 3, Yin and LI 4, Yang) used for the successful treatment of the sub-health demonstrates the application of the concept and highlights the importance of Yin-Yang balance [3].

However, extra acupoints are totally excluded from this theory simply because they have not been incorporated into the traditional fourteen meridians.

Overview of the Development of Extra Acupoints

The meridian system is established on the experience and knowledge of the use of extra acupoints and Ashi points. Ashi (Ah Shi) points, also called painful points, were first discovered accidently in ancient China to alleviate pain and treat certain sicknesses in the daily life. Literally in Chinese, Ashi meaning “Ah yes” is coined to refer to the certain “tender spot or pathological sites” on the body with responding signal of pain for diagnosis first presented in Jing Jin Di Shi San (Thirteenth Writing: Sinew Channels) of Ling Shu. In addition, Ashi points can also serve as a treatment site as well [4].

The entire Chinese medicine systems was not established and presented until the Warring States Period (476-221 BC). Examples of extra acupoints like “tip of finger poking”, “between eyebrows”, and “stabbing the Shaoyin beneath the tongue” were mentioned in Huang Di Nei Jing (Yellow Emperor’s Inner Classic) with the locations of extra points, instead of the formal names [4].

Ashi points were not formally recognized and accepted to be incorporated into the traditional fourteen meridians. However, Extra acupoints themselves derived from Ashi points and represent the frequently used Ashi points with verified functions finally [1].

The specific names of extra points viewed as Ashi points initially were not given until the Sui Dynasty (581-618 CE) and the Tang Dynasty (618-907 CE). Up to 187 extra points were incorporated into Qian Jin Yao Fang (Thousand Ducat Formulas) by Sun Si-miao (581-682 CE) in the Tang Dynasty. Not until the Ming Dynasty were extra points formally discussed in the classic Qi Xiao Liang Fang (Wonderful Well-Tried Recipes). There were 26 extra points collected in the Chapter Extra Point in Volume 5, which marked the beginning of collecting extra points. 35 extra points were collected in Zhen Jiu Da Cheng The Systematic Classic of Acupuncture and Moxibustion); 84 extra points collected in Lei Jing Tu Yi (Illustrated Supplement to the Classic of Categories); 144 extra points collected in Zheng Jiu Ji Cheng (Compilation of Acupuncture of Moxibustion). Extra acupoints were officially separated from the traditional 14 meridians when the TCM doctors of the Tai Yi Yuan (Imperial Medical Institute) in the Qing Dynasty (1644-1911 CE) revised Yi Zong Jin Jian (Golden Mirror of Medicine) and built its own unique system [5].

Literature shows that most of the extra acupoints are not associated with a specific meridian and bear the characteristic of Yin-Yang; however, some extra acupoints like Yintang (M-HN-3), Sishencong (, M-HN-1) are located on the Governing vessel, one of the Erbai (M-UE-29) is on the PC meridian, and Taiyang (M-HN-9) is on the Sanjiao meridian [1].

Keys to Therapeutic Effects

Since diseases are understood to be a loss of balance between Yin and Yang as shown in Figure 1, good results cannot be expected without the positive consideration of Yin and Yang [1,2].

An extra acupoint may be or may not on the meridians closely associated with Yin and Yang. The typical examples to explain the importance and necessity of Yin-Yang are Five Shu-Points. As a matter of fact, each Five Shu-Point corresponds to one of the specific phases of the Five Elements, highlighting the importance of balanced Yin -Yang.

The Five Elements theory and the Yin-Yang concept unfortunately cannot apply to extra aupoints only because they are not on the traditional fourteen meridians. In other words, extra acupoints like Yintang (M-HN-3), Sishencong (M-HN-1), Erbai (MUE- 29), and Taiyang (M-HN-9) may be easier for practitioners to consider in practice with the location associated with the specific meridians bearing the characteristic of Yin-Yang as shown in Figure 1 [1].

Signs and symptoms in Traditional Chinese medicine may be totally different from those in the Western medicine and are understood to be broader. In general, TCM physicians or acupuncture practitioners usually do not follow the typical Western pathological classifications of diseases, but rather rely on the patterns individualized by the imbalance of Yin-Yang, Qi, and Blood, and body fluids in the body [1].

Patterns are unique in TCM and pattern identification plays the most critical factor for the treatment and correlates closely with the successful outcomes. However, studies by Hong [1], Zhu et al. [6], Yu SY, et al. [7], and Paraskeva, et al. [8] show extra acupoints can be used together with traditional acupoints in clinical practice but patterns were unfortunately not included in the research designs.

One of the most practical approaches in a clinical practice to acupuncture involves the use of Ashi points when the patients suffer acute pain. However, this apparent simplicity may be discarded by practitioners when it comes to the application of TCM theories to treatment based on the complex meridians and the acupoint theory.

The historical developments of extra acupoints show an extra acupoint can surely play an essential role and be used alone for the treatment, even though they do not have the corresponding phases based on the Five Elements theory. Whether or not extra points can be selected in combination with traditional acupoints in a protocol for the more effective results of the treatments deserves attention.

Discussion

The challenge acupuncture practitioners face is when it is the best time to consider extra acupoints in a protocol.

The protocol following the TCM theories can bring about the best results. Taiyang (M-HN-9), for example, can be selected for one-sided headache as GB20 when the pathogen is exterior Wind [1]. In other words, this example explains the concept of pattern (Zeng) identification based on differential diagnosis is out of doubt the key to treatment using extra acupoints.

The historical developments of extra points show that an extra point can surely play an essential role in acupuncture and be used alone or with the traditional regular acupoints for the treatment. Unfortunately, the actions and indications of extra acupoints have not be scientifically researched and verified as traditional regular acupoints.

In strategy, a practitioner may take the principle of “Least needling, best results” into consideration in practice, keeping patients from pain or worry. The goal can be achieved with the following four protocols shown in Figure 2 when it comes to the tactic.

As one of the oldest forms of the natural healing arts, acupuncture began its development and employment for anesthesia in surgical operation in the late1950’s. In a pilot study in 2015by Wang et al., 12 parents were randomized to an acupressure bead with occlusive tape covering at the Extra 3 (Yintang) point for 20 minutes. Parents in the acupressure group had significantly less anxiety at 20 minutes post-intervention compared with parents in the sham group [9].

It is true that patients and healthcare providers are usually concerned about side effects. The finding of a study on the Severity of Venipuncture Pain Among Hospitalized 6–12-Year-Old Children shows extra point Extra 3 (Yintang) in combination with P-8 (Laogong) point are recommended for its greater safety, costeffectiveness, and applicability [10].

The positive result of facial acupuncture reported by Donoyama et al. showed the protocol of BL1, GB1, ST1, ST3, ST4, ST7, SI19, CV24, Ex-HN3 (Yintang) and Ex-HN4 (Yuyao) could increase the water and oil content of the facial skin [11].

In clinic, practitioners are also concerned about if there is enough evidence-based research at present to show whether or not the use of extra acupoints alone will bring better results than the use in combination with regular acupoints. However, current studies show the extra acupoints can be effective alone, but better results of extra acupints used in combination with traditional acupoints are also reported in some researches [1].

There is no doubt that needling sensation (deqi) has been considered by many acupuncture practitioners to be a key component of a successful acupuncture treatment. However, this sensation will not occur when the needles are not insert into the acupoints accurately, which may also happen to the use of extra acupoints. In other words, locating an extra acupoint accurately is the key to the successful treatments. It is same with the development of the regular acupoints, location description may vary in different textbooks. For this issue, it is highly suggested that the use of a Moxa roll can help practitioners locate the extra acupoints accurately. The heat emitted from the Moxa roll penetrate the extra acupoint like an acupuncture needle as long as the Moxa roll pinpoints the acupoint location.

The well-known school of acupuncture characterized with extra acupoints in the world is Tung’s acupuncture, which develops and establishes the exclusive theory and protocols extremely different from the TCM. In the meantime, the new extra acupoint Gangshui discovered and used for treating subacute cough demonstrates numerous extra acupoints may remain undiscovered [1].

Looking back at the development of extra acupoints, we can expect that more and more extra acupoints in various contexts may be discovered in the future.

Both acupuncture and acupressure are used based on the acupoint stimulation to achieve the desired results of treatments. Acupuncture performed by acupuncturists to triggers a stronger stimulation on the acupoints than acupressure to activate the body’s innate healing ability. Acupressure refers to stimulating the points on the surface of the skin by pressing with the hands, fingers, elbows or feet, is basically noninvasive and can be performed by the patients themselves.

Massage on extra acupoints is feasible for healthcare. Compared with acupuncture that may cause side effects suggested by Kashefi [12], acupressure has several advantages over acupuncture and deserves recommendations for its immediate effect, safety, costfree, no side effects, and convenience to patients.

Conclusion

With new extra acupoints increasingly discovered, it is predictable that acupuncture will gain more popularity all over the world in the future because it is effective, low cost, non-surgical, and painless way to healthcare.

On the other hand, additional researches are needed to understand if extra points can outperform the traditional acupoints on the traditional fourteen meridians.

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Analysis of Safety Compliance and Accident Impacts on Lost time Performance of Small Scale Automotive Maintenance Workshops in Calabar | Juniper Publishers

Juniper Publishers-Open Access Journal of Engineering Technology

Authored by Oliver

Abstract

The objective of the present research is twofold; first to assess the level of safety compliance practices among artisans and secondly, to measure the impacts of unplanned lost time emanating from accident on time performance of small-scale auto maintenance firms. Ninety different auto-maintenance jobs executed by Automobile, Heavy duty, Generator and Panel beater auto firms between, January to December, 2016 were sampled using direct observation. Furthermore, primary data collected were analyzed using MS Excel 2013 and Minitab 17 software. Results revealed the mean performance rating of workshops on the availability and usage of personal protective equipment as 143.9 and 154.7. While 224.2 and 302.7 constitutes respective poor usage rate and non-availability of (PPE) in the respective workshops. Results further revealed 58.2% as average productive lost time rate resulting from accident occurrence. Conversely, regression analysis revealed that a unit increase of 659.2, 63.5 and 82.8 in accident, severity and lost time index, caused a decreased of -150.8 in overall productivity lost factor. With a coefficient of determination (R2) of 72.01% at p-value less than 0.005. Hence, a positive and significant relationship between accident and auto mechanics time performance exist. Therefore, sensitization of stakeholders in this sector on the usage of PPE and the need to make safety their priority as well as regular inspection for safety compliance by regulatory bodies are recommended to build customers trust and improve productivity in this sector.

Keywords: Automotive maintenance; Safety measures; Small scale; Accident index; Severity index; Lost time index; Overall productivity lost factor

Nomenclature

Aindex Accident index

Atime Actual time

No Number of observation (90)

Ptime Planned time

Sindex Severity index

Tindex Time index

ai Constant expressing weighting given to each factor, at i=1,…4

β0 Constant estimated by regression model

β1,β2,β3 Coefficients of explanatory variable

b Frequency of the occurrence

OPLF Overall Productivity Lost factor

PLTR Productive lost time rate

N Total number of occurrence

i Recordable accident within the period

w Number of workers performing maintenance

Introduction

Dhillon et al. [1], described maintenance as appropriate actions made for retaining an item/part/equipment, or restoring it to a given condition. Concisely, maintenance is undertaken to restore broken equipment’s, preserve equipment conditions and prevent their failure, which ultimately reduces production loss and downtime as well as the associated safety hazards. In Nigeria, large proportion of auto maintenance firms are classified as “small scale”. This classification owe to the fact that the sector is characterized by low capital output ratio, that is the ratio of capital level relative to output is low, [2]. SMS automotive maintenance firms are vital to human resources in the automobile industry in virtually every nation’s economy due to its significant contribution in terms of job creation. Kayemuddin & Kayumm [3], described the automotive maintenance workshop as a category of small scale industry that contributes about 8.8% to the GDP of a nation’s economy. In Nigeria, the industry records about 3billion as turnover annually to the local economy according to the regulatory body of mechanics in Nigeria, National Automobile Technicians Association (NATA) in its report “Nigeria economy and the mechanic” of October 12, 2012. Auto mechanics are involved in the repairs and maintenance of automotive facilities such as vehicles and generating plants to enhanced optimum performance when they breakdown [4]. Other task includes replacement of worn mechanical parts that can cease transmission or prove unsafe for effective operation, [5]. SMS auto maintenance firms are characterized by preventive and corrective maintenance. Preventive maintenance is defined as a series of pre-planned tasks performed on auto facility either according to manufacturer’s schedule to counteract the known causes of potential failures of the intended functions of an asset [6]. Preventive maintenance (PM) plays a vital role to mitigate if possible avoids potential stoppages and disruptions of equipment or machinery from occurring in daily operations. While corrective or breakdown maintenance, is performed when a system or machine fails. It includes repair and replacement of failed parts to create an optimal performance again. Corrective maintenance activities are, in contrast to preventive maintenance, not schedulable [7]. This makes them harder to plan and more costly to perform. However, hardly are these activities or maintenance by auto mechanics completed without hazards, thereby stimulates negative effects such as time delay, increased costs, and productivity loss. The imbalance relative to safety compliance among auto mechanics during maintenance has significantly impacted performance time and is a major concern [8,9]. Industrial safety, health and environmental management opined that in order to meet the different needs which are seen in the present day industrial environment which demands increased production, high efficiency, and cost control etc. The subject of safety, health and environment must come into play, otherwise any neglect in these aspect can prove very costly. Neglect of safety at any stage can result into disasters leading to loss of human life and production. Thus, it is imperative to evaluate the level of accident/ injuries and safety compliance in small scale auto maintenance firms and its impact on time performance.

An accident is defined as any unplanned event that result in the combination of the following consequences; physical injury, lost time case, loss of property and number of fatalities [10]. While safety measures are facilities and strategies that are put in a workplace place to prevent or reduce accident during various stages of project [11]. Accordingly, Oisamoje, and Enaruna [12] defined health and safety management as an area that is concerned with ensuring the safety, health and welfare of people engaged in work or employment. Consequently, there are several risks which expose auto mechanics to workplace accidents/ injuries in the automotive maintenance workshops. Some of these risks include exposure to chemicals, strenuous work postures, and the use of improperly specified tools and lack of safety compliance [13-15], thus, affecting their performance. However, to efficiently regulate an issue, one should satisfactorily define the problem. Bozena [16], opined that the level of accident in a particular sector like the construction industry is estimated by the labour force in the analyzed sector, the number of victims of accidents at work and the number of days lost resulting from accident at work. The Statistical Office of the European Communities (Eurostat), established specific indicators that enables any company to report their number of accident and accident index (defined as the number of accidents per 100,000 working persons). Also, the Office of Environmental Health and Safety, established specific models that enable any firm to report their recordable incident rates, lost time rates, and severity rates, so that they can be compared with other industry or group. According to OEHS, the standard base rate for the calculations is based on a rate of 200,000 labour hours. This number (200,000) equates to 100 employees, who work 40 hours per week, and who work 50 weeks per year. Using this standardized base rate, any company can calculate their rate(s) and get a percentage per 100 employees. However, one of the limitations about this approach is that none of the above indicators provides any evidence about the achieved values of productivity indices. It is therefore proposed in the current study to take productivity indices, e.g. delivery efficiency into account in accident level assessments of automotive maintenance firms. This is because unplanned idle time resulting from industrial accidents reduces real time productivity and increases delay. Downtime or lost time refers to the variation between the estimated finish and the actual finish time of tasks either resulting from ill health or injuries/accident. Lost time is an imperative issue in industries because of its relation to productivity and business profitability [17]. Evaluating the causes and impacts of accident/injuries on productivity performance in automotive maintenance workshops, has become a necessity. Because productivity rises as the number of incident related cases reduces, and the use of properly designed tools increases [18]. Hence, small scale automotive maintenance firms needs to be aware that lost time resulting from the use of improperly designed tools and lack of safety compliance as well as accident/injuries cases, whether planned or unplanned, is very costly.

Methodology

Primary data used in the current study were basically obtained through survey design approach with direct observation of two automotive maintenance workshops each sampled across forty-five different small scale auto firms, amounting to ninety observations. This comprises of heavy duty, automobile, generator and panel body auto firms caught across the seven layouts (Eight- Mile, Diamond Hill, Anantigha, Essien Town, Ikot Enobong, Big- Qua Town and Etta-Agbor) in Calabar metropolis where SMS auto firms are found in their large numbers. Each auto firms had a work force of at least four to six artisans performing different repairs at a duration of 8hours daily (i.e. the peak hours of industrial activities), for 6days per week, excluding Sundays, for a period of twelve months between January to December 2016. The data collected was tabulated and classified according to maintenance characteristic (i.e. initial and actual final time, actual performance, number of incident/injuries that resulted to lost days overrun cost and time, and the severity rate of incident). This was done to ensure that all variables considered were clearly defined. Furthermore, Microsoft Excel 2013 and Minitab 17 statistical tools were used for analyses of the data. Additionally, the analysis on proper usage and safe handling of tools were ranked by the measurement of the relative index ranging from (1= Excellent, 2= Very Good, 3= Poor, 4= none). Where 1 to 3 implies the level of usage or availability of tools impact, to ascertain the mean rating of each response on safety compliance in SMS auto maintenance firms.

Eqns. (2), (3), (4) and (5) defines the magnitude of lost time index, time index, time performance achieved and productive lost time rate of each project at completion [19-23].

Also, Eqn. (6) defines the Overall Productivity lost factor (OPLF) of each auto firm’s project executed.

OPLF helps to break down the reasons for productivity losses into three main factors, which include; accident index, lost time index and severity. Ideally, one fundamental area that every organization can improve upon is productive efficiency/ conformity and one of the best measures is OPLF. A possible explanation to this argument is that organizational efficiency has relevance for business profitability.

Accident index and severity for each sector was determined as expressed in Eqs. (7) and (8).

Accident index measures the productive time losses resulting from accident from a predetermined sample. And is calculated by dividing the number of incident/injuries in each sector by the total number of observation [12].

The severity index quantifies the average number of working days lost due to a worker’s involvement in minor and serious accidents [16]. Furthermore, multiple linear regression analysis in MS Excel and Minitab 7.1 statistical tools were used to establish the relation between overall productivity lost factor (OPLF) from accident index, lost time and severity index, and graphs plotted accordingly. The element of multiple regressions is expressed in equation (9).

Results and Discussion

Figure 1 present the result of common injuries/accident identified to be associated with the four selected auto firms (automobile, heavy duty, generator and panel beater workshop) which vary from superficial wounds, dislocation, burns, bruises, cuts, and backache, as evaluated using eqn (6) (Figure 1).

It is obvious from Figure 1, that superficial wounds, burns injuries, and was prevailing among panel body work auto mechanics with an average of 28.1% and 18.7%. Similarly, dislocation injuries/accident was common among heavy duty firms with an average of 44.4% been the highest. This group of auto technicians have to constantly lift heavy items which can strain their back, adopt awkward postures and may spend long hours bent over or lying on their back. Furthermore, cuts and bruises incident cases was found to be common with generator firms. A possible explanation to this finding is that most of this firms lack the basics personal protective equipment, and as such they fail to use them. For instance, auto mechanics in panel beater auto firms reported being aware of the hazards associated with their jobs when interviewed, but stated that awareness did not seem to help reduce the health problems they suffered. Additionally, the analysis on proper usage and safe handling of tools, as depicted in Figure 2 shows that about 55.1% of automotive maintenance firms, lack the ability to handle hand tools before and after each maintenance.

While about 19.2% averagely practiced safe handling of hand tools. Also an average of about 16.6% of these workshops do not even consider the handling of tools as a safety measure to be observed. Also, the proper usage of power tools was marginal with an average of 32.0%. While 28.2% didn’t make any attempt within the period under consideration. The proper usage of compressed air equipment was found to be 2.5% on the average, while 12.8% observed the safety rules of wearing safety glasses or face shield during operation to avoid metal particles into the eye. Also about 29.4% used this equipment poorly by not observing the safety rules, with unavailability of 55.1%. Also, from the result as depicted the proper usage of hydraulic/hoist equipment by auto mechanics was at an average 61.5% and 34.6 marginally applied the safety rules while using it, and 3.8% used it but never considered safety precaution at all level. Furthermore, Figure 2 reveals that only 18.5% auto mechanics appropriately used chain hoist and crane when lifting an automobile engine from the sitting. While 14.2% marginally used it well and unavailability of 67.1% on the average. This is basically found among un standardized workshops, as they lift engine manually using their hands. It was obvious from that safety practice towards equipment maintenance was lacking in most of the repair firms as majority of these mechanics fail to ensure effective cleaning of equipment/ tools before and after use. The unavailability of fire extinguisher among the auto repair firms was on the high side with an average value of 58.9%, while about 20.5% had it in their workshop, but weren’t in good condition. Except for few workshop which had it in good operational condition with an average of 6.4% and 14.1% respectively. According to survey the unavailability of goggles and face shield among auto technicians, especially panel bitters was on the high side with an average value of 70.59%, while about 22.06% had it in their workshop, but was in poor condition. From analysis the unavailability of hand gloves and safety boot among the auto firms was high with an average of 79.69% (approximately 80%).This implies that most local mechanics violate the rule of wearing safety personal protective (e.g. gloves and safety boot) equipment when working. This is because most of the local mechanics were of the opinion that protective equipment must be provided by their masters or owners of the workshops.

Also, descriptive analyses of the ninety maintenance projects of the four sectors (heavy duty, automobile, generator, and panel beater auto firms) evaluated reveals the following findings in studying time performance and lost work days, as presented in Figure 3-6 respectively.

It is clearly seen from the Figures 3-6 the need to maintain close link between time performance and lost time resulting from injuries/accident related cases. Obviously, as time performance (efficiency) reduces, lost time increases. This implies that the relationship between time performance and productivity is inversely proportional i.e. the higher the time efficiency rate, the lower the productive time losses and equally, the lower the time efficiency rates, the higher losses in productivity. Also, Table 1, further present the summary of comparative analyses of time performance and lost time rate inherent in each auto firms.

However, to determine the overall productivity lost factor (OPLF) of each auto firms, the index of accident, lost time index and severity index values were computed as depicted in Table 2. Within these auto maintenance sectors, the accident index range between 0.133, 0.111, 0.155, and 0.277 for automobile, generator, heavy duty and panel beater auto firm. This implies that panel beater autos firms recorded the highest number of injuries with an accident index of 0.277. Thus, recording lost time index of 62 and 2.48 as severity index and 42.69% as overall productivity lost factor. This is repeated for automobile, generator, and heavy duty auto firms respectively as presented in Table 2.

However, an explanation to these findings is that artisans in panel beater auto maintenance firms constantly get in contact with hot surfaces, exhaust pipes, radiator and cooling system pipes, soldering and welding operations due to the nature of maintenance practices.

Furthermore, Table 3 shows the result of the multiple liner regression model formulated to relate overall productivity lost factor with accident index, lost time and severity index as presented in eqn. (9). Table 3 indicates that the accident index has a beta coefficient ( β0) of 659.2 at a probability value of 0.000 < 0.05. Hence, it is significant. This indicates that OPLF decrease by -150.8 when accident index increases by 659.2 when all other independent variable is held constant. For every unit rise in accident index, there was a unit decrease in overall productivity lost factor.

R2 = 72.01%, R2 (adj) = 71.03%, F −Value = 73.75, P −Value = 0.000

It can then be inferred that accident index has an impacts on overall productivity lost factor. The data further revealed that severity index has a coefficient of 63.5 at a probability value of 0.036 less than 0.05. Hence, it is significant, this indicates that, for each unit increase in severity index, there is a corresponding decrease of -150.8 in overall productivity lost factor when all other independent variables are held constant. Similarly, the data further reveals that lost time has a coefficient of 82.8 at p-value 0.000<0.05. This equally indicates that an increase of 82.8 in lost time caused a reduction of -150.8 in overall productivity lost factor when all other independent variables are held constant. Coefficient of determination (R2)=72.01%. This indicates that all variations in the dependent variables are as a result of the independent variables. That is, 100% variation in overall productivity factor is as a result of changes in accident index, severity index and lost time.

Conclusion

The impacts of unplanned lost time emanating from accident/injuries on time performance of small-scale automotive maintenance firms has been evaluated using descriptive analysis and multiple linear regression technique. Descriptive analysis of ninety auto maintenance jobs executed across Automobile, Heavy duty, generator and panel beater auto firms between January to December, 2016 revealed the mean performance rating of workshops on the availability and usage of appropriate protective equipment were determined as 143.9 and 154.7 respectively while 224.2 and 302.7 constitutes respective poor usage rate and non-availability of appropriate safety equipment in the workshops. Results further revealed an average productive lost time of 58.2% resulting from accident/injuries. Conversely, regression model formulated revealed that a unit increase of 659.2, 63.5 and 82.8 in accident, severity and lost time index, caused a decreased of -150.8 in overall productivity lost factor. With a coefficient of determination (R2) of 72.01% at probability value less than 0.005. Hence, it is concluded that compliance to appropriate safety practice in this sector is very poor due to nonchalant attitude of the operators of these firms toward safety practices as well as inadequate diagnoses tools and supervision by regulatory agencies. This study could also be extended to other local artisans in the small scale industries such as auto electric technicians etc. in Nigeria to possibly identify the risks associated with non-safety compliance and the impacts of occupational accident on productivity performance. Therefore, sensitization of stakeholders in this sector on the need to make safety their priority and regular inspection of these firms for safety compliance by regulatory bodies are recommended to build customers trust and improve productivity in this sector.

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Liposome-Actuated Enzyme Systems: A Benchmark for Controlling Biomineralization | Juniper Publishers

Juniper Publishers-Open Access Journal of Material Science

Authored by Martín G Bellino

Abstract

Key to the realization of versatile nano structures are simple, efficient methods of synthesizing materials that mimic aspects of Biomineralization. Liposome-permeability that controls enzymatic reactions may provide blueprints for bio mineral design.

Keywords:Biomineralization; Enzymes; Liposomes; Enzymatic control; Membrane permeability

Opinion

Although it is difficult to overstate the importance of enzymes in biology, these famous macromolecules are also becoming more prominent in nano biotechnology. The appeal of enzymes to nano scientists is three-fold: first, it is a natural nano scale material; second, its capability to furnish high specificity and efficient chemical conversion (which is its main role in biology); and third, this ability to catalyst a large number of chemical reactions can be exploited in industrial processes, waste treatments, pharmaceutical products, and biosensors. Lipid vesicles (liposomes) are best known as the vehicles for administration of nutrients and pharmaceutical drugs, but they are also a versatile tool for nano technological purposes, because liposomes can be designed such that the lipid membranes become into well-defined nanostructures. By exploiting these exquisite nano species, liposome-based nano compartments that sequester active enzymes can be built simply by synthesizing the liposomes in presence of enzymes [1]. Current biomedical applications include, for example, the entrapment of lysozymes into liposomes in order to develop novel therapies in storage diseases [2]. In another approach, enzyme-containing vesicles have been investigated as possible micro reactor system for the decontamination of industrial wastes [1].

One challenge in fields ranging from nanotechnology to biomaterial science is the design of versatile methodologies to attain the control of enzymatic activity. Although liposomes have been used to encapsulate a wide variety of enzymes the emergent properties of systems in which enzymatic activity is controlled by surrounding liposomes have not been fully explored. Our group recently pioneered the use of designed liposomes as a robust scaffold to produce enzymatic control that does not occurs in a free enzyme system [3]. The lipid membranes of the liposomes entrapping enzymes reported by Municoy et al. are not merely static barriers between the interior and exterior environments; they are dynamic skins [3]. Properties of vesicles at the interface level, such as membrane permeability, tuned through a thermal input, allow a controlled transportation of substrates across the barrier, thereby modulating enzymatic activity externally. We used this nano-assembly to switch the reactivity of ureases through the change of the liposome permeability by means of temperature control. This synergic interplay between enzymes and liposomes that mimicking crucial aspects of cellular biochemistry such as confinement and enzymatic regulation, allows emerging bio systems capable of actively reconstructs its surface from a sacrificial mesoporous silica film to create a fully 3D silica shell on liposomes, through a self-catalyzed precipitation process. In this sense, bio mineralization is an inspiration for materials chemistry. Bio minerals are usually synthesized in aqueous media under ambient conditions, and these approaches can lead to materials with a reduced ecological footprint. Earlier attempts to create bio mineralized materials have mainly focused on homogeneous precipitation from salt solutions that are being alkalinized by the decomposition of urea catalyzed by free ureases [4]. These studies aimed to create nano/micro particle precipitates that can have important applications, such as fuel cells. In contrast, the controlled precipitation described by Municoy et al. is not primarily based in intrinsic enzymatic catalysis. Rather, theincentive for this work comes from the desire to create shellcontrolled enzymatic entities. Such entities are ubiquitous in nature, for example in micro compartment that sequesters ethanolamine metabolism in the bacterium Escherichia coli [5], where conformational flexibility encoded within shells allows selective transportation of components across the barrier. The liposome-controlled enzymatic reconstruction of a 3D interface composed of silica shells on liposomes in the system of Municoy et al. has a similarity to these functional structures within the cell. Municoy et al. showed that subtle changes in temperature have a pronounced impact on the silica precipitation, which in turn determines the morphology of their nanostructures. At high temperature, only some large shapeless particles were observed. In contrast, precipitation at lower temperature affords spherical morphologies which reflect the size and shape of the liposomes because the silica solidifies around them. Temperature was the mechanism for controlling enzymatic activity through membrane permeability and was crucial in the formation of nano structured silica. Some of the most exciting developments in material science concern the design of bio inspired synthesis methods mimicking the remarkable in vivo control of the precipitates morphology, as these features exceed the capabilities of present day in vitro materials engineering. The interplay of control of enzymatic activity and liposome membrane permeability could lead to simple routes to develop intricate bio mineralized structures such as diatoms [6]. It will be interesting to learn more about the role of these parameters in directing bio mineralization. Municoy et al. report a first step in this promising direction. It will also be exciting to explore this bio inspired approach for lantanidebased material synthesis, which would launch the production of a diversity of new functional hybrid nanostructures for advanced applications.

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Effect of Plasma Treatment on Moisture Management Properties and Drying Behavior of Polyester and Blend Fabrics for Sportswear Application | Juniper Publishers

Juniper Publishers-Open Access Journal of Fashion Technology & Textile Engineering

Authored by RV Adivarekar

Abstract

The hygienic and comfort properties of fabrics for clothing are basically determined by their electrifiability and ability to absorb moisture, i.e. the hygroscopicity and capillarity, which are quantitative characteristics of the hydrophilicity of materials. Unfortunately, the most common synthetic fibre, Polyester exhibits high electrifiability and low hydrophilicity, which makes it unsuitable for fabrication of fabrics with properties close to cellulosic fibre and significantly restricts the area of their application. However, now a days, it is more preferable in the active sportswear due to its excellent physical properties like abrasion resistance, strength etc. and low cost. The present study aims at increasing the hydrophilicity of polyester and polyester blends by combination of plasma modification and chemical treatment. Surface modification of the developed fabrics is carried out by di-electric barrier discharge plasma in presence of air and subsequently the fabrics are subjected to chemical treatment to impart hydrophilic property to make it suitable for active sportswear. The moisture management properties, drying rate and air permeability, abrasion resistance etc. of these fabrics are evaluated.

Keywords: Sportswear; Hydrophilicity; Polyester; Plasma modification; Moisture management

Abbreviations: DBD: Di-Electric Barrier Discharge; OWTC: Accumulative One-Way Transport Capacity; OMMC: Overall Moisture Management Capabilit

Introduction

Polyester fiber is one of the most widely consumed fibers (about 70%) in sportswear application but its hydrophobic properties causes discomfort to the wearer [1]. Hydrophobic nature of polyester can be a disadvantage for certain applications like moisture management properties, dyeing, finishing, detergency, etc. [2]. During sports activity, wearer perspires a lot and it is essential that the perspiration should transfer to the outer surface of the fabric from where it gets evaporated and wearer feels dry and comfortable. Physical or chemical modification of polyester to make it more hydrophilic is therefore desirable for certain performance characteristics. Surface modification of polyester for hydrophilicity can be achieved by application of adsorbing polymers on the polyester surface [3].

Moisture management is one of the important property in Active sportswear fabrics with respect to thermo-physiological comfort. Therefore, it is essential to increase the hydrophilicity of polyester. In moisture management fabrics, the body perspiration is transported away from the skin to the outer surface of fabric where it can evaporate quickly in order to accomplish the consumer satisfaction of comfort [4]. To achieve such moisture management, the structural design and quality of fibers are modified so that the textile products can have good performance in absorbing, transporting, and dissipating moisture [5,6]. According to The Tai Lee Textiles Company, moisture management is related to wickability of the fabric which mainly depends upon the type of fiber and its chemical characteristics, diameter of the fiber, diameter of the yarn, yarn regularity, surface structure of the fabric, fabric construction, weave pattern, the cover factor, fabric weight etc. [7]. Das et al. [8] also described that moisture management can be enhanced through a suitable chemical treatment or coating [8].

It is evident that fiber type, yarn properties, fabric structure, finishing treatments affects the clothing comfort. The use of blended fibre combinations in sportswear has grown in the past decade as brands attempt to improve function and comfort using different fiber blends. The use of blending technologies and the chemical finishing available for sportswear will continue to provide a source of innovation for sportswear products. Therefore, the present study aims to investigate the moisture management properties and drying rate of commercial garments, and 16 knitted fabrics developed for sportswear application, composed of plasma and chemically modified polyester and polyester blend fabrics.

Materials and Methods

Materials

Polyester filament yarn (85 denier), Cotton yarn (Count 60 Ne), Lycra (20 denier), three sport fabrics were procured from specialty sportswear store. Single Layer interlock knitted fabric with lycra (Spandex) and polyester was developed. Lycra filament yarn was added to the single layer knitted polyester fabric to provide stretchability to the fabric. Similarly, Double Jersey interlocks and bi-layer interlocks knitted fabrics were also developed. Construction parameters of Single layer and double layer developed knitted fabrics are mentioned in Table 1. And construction parameters of commercial garments are mentioned in Table 2.

Plasma treatment of developed fabrics

To study the effect of plasma treatment on moisture management properties and drying behavior of knitted fabrics, a Di-electric Barrier Discharge (DBD) plasma chamber was employed for plasma treatment of polyester fabric at different duration keeping voltage and electrode spacing constant. Air was used as non-polymerizing gas for plasma treatment. Undyed microfilament polyester fabric of sample size 40cm width and 50cm length was spread between the two electrodes and then plasma treatment was carried out. The treatments were given only on one side of the fabric i.e., inner side of the garment to be worn. Table 3 indicates the details of plasma trials conducted on single layer and double layer knitted fabrics.

Application of moisture management finish

To remove the impurities like lubricants and antistatic agents, 100% polyester and Modal/Cotton, Modal/Polyester woven and knitted fabrics were scoured using 1gpl nonionic surfactant (Archroma) at 65 °C for 30min followed by rinsing, hydro extraction and drying at room temperature. These scoured fabrics were then used for moisture management finish. 30gpl Hydrophillic Softener (Archroma) which is a modified polyester copolymer based nonionic chemical; was used for finishing of polyester fabrics with 60% weight pickup. The trials were conducted using pad - dry - cure method on laboratory pad dry cure machine (R. B. Electronics and Electrical Pvt. Ltd., Mumbai); curing was carried out at 120 °C for 4min.

Results & Discussion

Moisture management properties

Fabric liquid moisture transport properties in multi dimensions, called moisture management properties significantly influence human perceptions of moisture sensation. Moisture management tester has been developed by SDL Atlas to evaluate textile moisture management properties. This method can be used to quantitatively measure liquid moisture transfer in one step in a fabric in multiple directions. Moisture spreads on both surface of the fabric and transfer from one surface to the opposite. Here ten indices are introduced to characterize the liquid moisture management properties of fabric. It measures electrical conductivity changes as a test solution migrates across the top of, through, and across the bottom of the test specimen. Factors affecting this movement include fabric water repellency, water resistance, and water absorption, and fiber and yarn wicking properties. Perspiration is mimicked with TM 195. The results obtained with this test method are based on water resistance, water repellency and water absorption characteristics of the fabric structure, including the fabric’s geometric and internal structure along with the wicking characteristics of its fibers and yarns.

Moisture management tester indices

The indices of the MMT that are used to characterize the moisture management properties of a fabric are as mentioned below:

i. Wetting time top (WTt)

ii. Wetting time bottom (WTb)

iii. Top absorption rate (MARt)

iv. Bottom absorption rate (MARb)

v. Top maximum wetted radius (MWRt)

vi. Bottom maximum wetted radius (MWRb)

vii. Top spreading speed (SSt)

viii. Bottom spreading speed (SSb)

ix. Accumulative One-Way Transport Capacity (OWTC)

x. Overall Moisture Management Capability (OMMC) [9,10].

The OWTC is the difference of accumulative moisture content between the two surfaces of fabric. The OWTC reflects the oneway liquid transport capacity from the top (inner) surface to the bottom (outer) surface of the fabric Table 4. The OMMC is an index indicating the overall capacity of the fabric to manage the transport of liquid moisture, which includes three aspects:

a. Average moisture absorption rate at the bottom surface;

b. One-way liquid transport capacity;

c. Maximum moisture spreading speed on the bottom surface [11,12].

According to AATCC Test Method 195-2009, the indices are graded and converted from value to grade based on a five point grade scale (1-5), The five grades of indices represent: 1-Poor, 2- Fair, 3- Good, 4- Very Good, 5- Excellent. Table 1 shows the range of values converted into grades.

The moisture management properties of the commercial garments and developed fabrics in grades are mentioned in Table 5.

Figure 1 indicates mean grade of accumulative one way transport index for all 3 commercial fabrics and 16 developed fabrics. In non blended fabric 100% Polyester (K1-UT and K3- UT) has fair one way transport capacity whereas Polyester/Lycra (K2-UT) blend fabric and Polyester/Cotton blend fabric (K4-UT) shows poor one-way transport capacity. Commercial garment has fair OWTC. Plasma and chemically treated Polyester (K1AK1C, K3A- K3C), Polyester/Lycra (K2A- K2C) and Polyester/ Cotton (K4A- K4C) fabric shows very good to excellent one way transport index grade indicating that these fabrics can also be effectively used for sportswear application.

Figure 2 indicates overall moisture management capability for all 3 commercial fabrics and 16 developed fabrics. 100% Polyester (K1-UT and K3-UT) has good OMMC grades. Whereas Polyester/Cotton blend fabric (K4-UT) shows poor OMMC grades and Polyester/Lycra (K2-UT) blend fabric shows fair OMMC grades. Commercial garment has fair to good OMMC properties. Plasma and chemically treated Polyester (K1A- K1C, K3A- K3C), Polyester/Lycra (K2A- K2C) fabric shows very good overall moisture management capability grade indicating that these fabrics can also be effectively used for sportswear application.

From the Table 5, it is observed that 5minute plasma treatment is optimum as giving higher one way transport index and overall moisture management capability grade in almost all the fabrics. It can be seen that OWTC grade and OMMC grades are higher for plasma pre-modified followed by chemical treated samples compared to untreated and commercial fabric samples indicating suitability of developed fabrics for effective moisture management properties required in sportswear application.

Drying rate

This drying rate test determines the drying rate of textile fabrics based on the evaporation rate at standard atmospheric conditions. This testing is based on measuring the weight of water content which is applied on the fabric for a particular time period by using a weighing balance and with drying rate software connected to it. Table 6 elaborates drying rate of 3 commercial fabrics and 16 developed fabrics. Drying rate of commercial garment is in the range of 0.29-0.38%/min.

Figure 3 shows that untreated Polyester fabric shows drying rate of 0.60 and 0.43%/min whereas Polyester/Lycra and Polyester/Cotton blend fabric shows drying rate of 0.47 and 0.43%/min respectively. From the results it is observed that after plasma and chemical treatment drying rate of Polyester, Polyester/Lycra and Polyester/Cotton blend decreases. It is found that with the increase in plasma treatment time, the drying rate (%) per minute decrease. It may be due to the more surface roughening of Polyester fabric resulting in more absorption of the hydrophilic chemicals. But even after considerable drop in drying rate of developed fabric their drying behavior are comparable with commercial garment. This indicates that plasma and chemically modified Polyester and Polyester blends show low drying rate compared to untreated fabrics but still they are suitable for sportswear application when compared with commercial garment.

Conclusion

Sportswear is a very vast and challenging field in which required functionality can be designed by suitable choice of raw materials, structure and geometry of fibers, yarns and fabrics, surface modification and garment assembly techniques. Moisture management properties like sweat absorption, sweat dissipation and faster drying are the primary desirable functions of high active sportswear which affects the comfort sensation of a player during a game. To achieve these properties, Polyester and Polyester/Lycra and Polyester/Cotton blend fabrics are treated with air plasma followed by a chemical treatment to enhance hydyophilicity. Plasma treatments help in surface roughening of Polyester. Plasma pre-modified knitted Polyester fabrics are given hydrophilic chemical treatment. The plasma treatment time of 5min followed by chemical treatment is found to give the optimum results with respect to moisture management properties and drying rate. The study indicates that after plasma and finishing with hydrophilic finishing chemical; the Polyester fabrics shows enhance moisture management properties with moderate drying arte which makes it suitable for sportswear application. These modified and light weight moisture management fabrics will be helpful to keep the sportsman free from uncomfortable clinginess and it can also improve the performance of sportsperson.

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Chronic Systemic Delusions | Juniper Publishers

Acquired brain injury

Juniper Publishers-Open Access Journal of Intellectual & Developmental Disabilities

Authored by Ronaldo Chicre Araujo

Mini Review

Systematic chronic delusions were described in detail by French and German psychiatry of the nineteenth and early twentieth centuries. These delusions are part of the pictures of psychosis characterized by permanent delusions. It must be considered that delusional ideas are not only the beliefs and conceptions by which the themes of delusional fiction are expressed, such as persecution, grandeur, jealousy, but also delirious ideas are considered ideofeffective phenomena in which delusion takes shape, such as intuitions, illusions, interpretations, hallucinations, imaginative and passionate exaltation. These delusional ideas cannot be conceived as mere errors of judgment [1]. From the classification of Kraepelin and later with the works of Bleuler, many of these delusions became part of schizophrenia. However, French psychiatry maintained the description of chronic delusions outside the schizophrenia group. Nowadays, the nosographic studies of the great classical figures of French psychiatry of the nineteenth and early twentieth centuries are increasingly giving rise to a more biological, neurological and pharmacological psychiatry.

The psychiatric clinic certainly represents one of the great endeavors of human knowledge [2]. For the diagnosis and therapeutic management, it is important to return to the classification of chronic delusional psychotic disorders proposed by the French nosography, in which chronic delusional psychoses are presented without a deficient evolution in systematized delusional psychoses (paranoia), and with a deficient evolution in schizophrenia . This work proposes to address the chronic delusions systematized that develop without progressively compromising the adaptive capacities of the individual. Systematic chronic delusions are also called paranoid psychoses, they are generally very well organized, with rich and consistent histories. They maintain over time their content and richness of detail [3].

These delusions are directly connected with the construction of the personality of the delirious and develop with coherence and clarity according to Kraepelin. They present a logical construction, from false elements, which are Clérambault’s postulates of the delirious fable. Its evolution is insidious and progressive. Interpretations, delusional perceptions, hallucinatory activities, and fabulations, which are characteristic symptoms of these delusions, are reducible to pathological beliefs. Due to their systematic form, these delusions are relatively coherent and present themselves to those who are close to the delusional many times plausibly. Therefore, their power of conviction is great and may cause others to participate actively in delirium, as induced delusions. In the group of chronic delusions systematized are classified as delusions of passion and claim.

The claim concerns procedural plaintiffs who go to court because of their conviction that they have been harmed, they feel betrayed and wronged, and can often commit a crime against their enemies; to inventors convinced that someone stole an idea from him to passionate idealists who, in defense of just cause, may commit violent acts. In the group of passionate delusions are the delirium of jealousy, in which the individual is certain that he is betrayed in his love relationship; and the erotomaniac delirium, in which the individual has the conviction that he is loved by someone. In the evolution of this delirium, three phases are considered, a phase of hope, a phase of resentment and a phase of rancor. In this last one, the individual can commit a crime against who left it.

The psychosis clinic presents different modalities. The study of paranoia allows us to apprehend the particularities of delusional propositions. To regroup the set of psychoses under the sole term of schizophrenia is the attempt to maintain an organicist reading of mental illness [4].

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Pleomorphic Adenoma Presented as Hard Palatal Mass: A Case Report | Juniper Publishers

Juniper Publishers-Open Access Journal of Otolaryngology

Authored by Lageju Nabin

Abstract

Objective: To consider one of the differential diagnoses of palatal mass as pleomorphic adenoma

Case presentation: 21-year-old female patient presented in ENT department with painless mass in right side of hard palate for 2 years which was gradually progressive and slight discomfort on tongue movement and chewing food which on examination found to be 2*2cm swelling in right hard palate with normal overlying mucosa. On radiological examination, there was heterogenous swelling with intact hard palate. With provisional diagnosis of pleomorphic adenoma, excision of mass with overlying mucosa and periosteum was done. Histopathological report confirmed the diagnosis.

Keywords: Palatal mass; Pleomorphic adenoma; Excision

Introduction

Pleomorphic adenoma is the most common salivary gland tumours accounting for 40-70% of all major and minor salivary gland tumours [1]. It is also commonest minor salivary gland benign tumours accounting 70% of all tumours [2]. Hard palate is the commonest site followed by upper lip, buccal mucosa, tongue, floor of mouth, retromolartrigone [3,4]. Common age of presentation is second decade of life [5] with slight female preference [3]. Presenting symptoms are painless slow growing mass without ulceration and surrounding inflammation which on palpation feels non-tender, firm, rubbery [6]. In this paper, we present a case of pleomorphic adenoma of minor salivary gland in hard palate who treated with wide local excision.

Case Report

21 year old female patient presented in ENT department with painless mass in right side of hard palate for 2 years which was gradually progressive and slight discomfort on tongue movement and chewing food but there was no history of ulceration, bleeding, difficulty in swallowing, breathing and swelling in neck. On examination there was single swelling in the posterior part of the right hard palate measuring 2*2cm with normal overlying mucosa which on palpation firm, non-tenderand well defined swelling (Figure 1). On radiological investigation, there was solitary heterogenous swelling in the right hard palate without calcification and bony erosion. There was scalloping of bone of hard palate due to pressure effect (Figure 2). With all this finding provisional diagnosis of pleomorphic adenoma of hard palate was made and planned for surgical excision. Surgical excision of the mass was done in total along with the overlying mucosa and taking margin from surrounding mucosa. The wound was left open to let itself heal by granulation. The per-operative findings were 2*1.5cm single well encapsulated swelling in the hard palate extending to its posterior border and on cut section it was found to be yellowish white in colour (Figure 3).

Discussion

Pleomorphic adenoma has different embryological origin. It arises from both epithelial and mesenchymal origin. They arise from intercalated and myoepithelial cells. The mass is well demarcated from surroundings by fibrous capsule [6]. Formation of the capsule is a result of fibrosis of the surrounding salivary parenchyma which is composed of the tumor and is referred to as false capsule [7]. The pleomorphic adenoma is typically a well circumscribed, encapsulated tumor. The capsule may be incomplete which is more common in minor salivary gland tumours [8]. Most of the pleomorphic adenoma occurs in major salivary glands and parotid is the commonest. It is also the commonest tumour of minor salivary glands [9]. Palate has the highest number of minor salivary glands in upper aerodigestive tract [10]. So, palate is the commonest site of minor salivary gland tumours. It is followed by lips, buccal mucosa, tongue, retromolar area, pharynx, tonsils. In palate, most common location is posterolateral aspect [11].

The tumour is cellular with background stroma which can be mucoid, myxoid, cartilaginous or hyaline [12]. In “cellular” type of pleomorphic adenoma the epithelial element is dominant and “myxoid” type possess myxomatous element. Typical pleomorphic adenoma is of mixed type. Different epithelial cell types are spindle, clear, squamous, basaloid, cuboidal, plasmacytoid, oncocytic, mucous and sebaceous [13]. It can occur in any age group, but common presentation is in age group of 30-60 years with slight female predominance. Usual presentation of palatal pleomorphic adenoma is painless, slow growing smooth dome shaped [11], rubbery, submucosal mass without mucosal ulceration [14]. If ulceration present, it may be due to trauma or biopsy or malignancy. Due to expansion of mass against bone, there can be cupped out bone resorption [15,16].

Diagnosis of pleomorphic adenoma is based on history, clinical examination and histopathology. Computed tomography scan is an adjuvant diagnostic aid helpful in revealing about the size and extension of the tumour to the adjacent structures and to rule out bony involvement. Confirmatory diagnosis will depend on histopathological examination. Treatment of palatal pleomorphic adenoma involves wide local excision of the tumor together with clear margins involving the periosteum and associated mucosa, followed by curettage or excision of the underlying bone if involved to avoid recurrence. Palatal periosteom is an effective barrier to spread [16]. As simple excision of this tumour has high rate of recurrence, it is best avoided [6]. If palate needs to be excised, it needs to be closed with island flaps. Prognosis of palatal pleomorphic adenoma is usually good with cure rate of 95%, does not recur after adequate surgical removal. The risk of recurrence is low for tumours of minor glands [17]. Tumors with a predominantly myxoid appearance are more susceptible to recur than those with other features. Other causes of recurrence are pseudopodia, capsular penetration, and tumour rupture [18]. The risk of malignant degeneration into carcinoma ex pleomorphic adenoma is rare, occurring only in 5% of all cases [19].

Conclusion

Pleomorphic adenoma is one of differential diagnoses of palatal mass. Excision of mass with adequate margin is the treatment of choice.

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Dendritic Cells and Regulatory T Cells Changes During ECP for Chronic GvHD in Pediatric Patients | Juniper Publishers

Juniper Publishers-Open Access Journal of Blood Research & Transfusion

Authored by Berger Massimo

Mini Review

Graft-versus-host disease (GvHD) is a leading cause of post HSCT morbidity and mortality. It is mediated by alloreactive mature donor T lymphocytes, resulting in a harmful inflammatory response and tissue injury [1]. The pathophysiology of GvHD is constituted by precise sequences of immunological events such as the activation of antigen-presenting cells (APCs), activation, differentiation and migration of T cells, and finally the development of their full effector functions [2-4]. Dendritic cells (DCs) constitute the most professional APCs, promoting alloreactivity or clonal antigen-specific T cell responses. Moreover, tolerogenic DCs may play a pivotal role in GvHD exerting an immunomodulatory or even immunosuppressive effect on T cells [5]. DCs can be divided into two major subsets, plasmacytoid DCs (pDCs) and myeloid DCs (mDCs) which have distinct functions. pDCs play a pivotal role in peripheral tolerance through the generation of regulatory T (Treg). In addition to pDCs, mDCs also promote Th2 and Th0/Tr1 responses, depending on the activation signal types [6,7].

Although corticosteroids, with potent immunosuppressive and anti-inflammatory effects, are the first-line treatment for GvHD, only 25-50% of patients respond [1,8]. Extracorporeal photopheresis (ECP) is an alternative therapeutic strategy in patients who are resistant/refractory to steroids. ECP appears to act in an immunomodulatory fashion, inducing immunotolerance in GvHD by regulatory T lymphocytes, dendritic cells, in concert with the normalization of a T lymphocyte subset.

This pilot study focuses on these two cell populations, as well as on the patients’ whole immunological pattern [9-11]. Data from eleven patients affected by chronic GVHD were included and analyzed. The median age was 9 years (range 2-18), 6 out of 11 patients were females and suffered of myeloid malignancies (4 patients), acute lymphoblastic leukemia (2 patients), neuroblastoma (1 patient), Hemophagocytic Lymphohistiocytosis (1 patient), Ewing sarcoma (1 patient), Blackfan-Diamond Anemia (1 patient).

Seven patients received an unrelated Hematopoietic Stem Cell Transplantation HSCT (3 bone marrow, 3 peripheral blood, 1 cord blood), three patients had a sibling HSCT (1 patient with 1 Ag mismatch graft, all patients had bone marrow as the stem cell source) and one patient had an phenotypic identical-HSCT). All patients suffered moderate to severe cGvHD which was resistant/refractory to steroids. All patients received ECP from January 2016 to December 2016 in our center according to previously published techniques [12]. The aim of this study was to: i) monitor peripheral blood changes after 30 days of ECP and ii) describe the immunological changes in aphaeresis samples after UVA treatment.

A sample of peripheral blood (PB), a sample of apheresis pre-UVA photoactivation (pre-PA) and a sample of photoactivated apheresis (PA) were collected at the first day of ECP and every week for the first month of treatment. Informed consent was obtained from all patients. PB, pre-PA and PA samples were characterized at day 0, 8, 15, 21, 30 of ECP treatment. The percentage obtained by cytofluorimetric analysis was used to calculate the absolute number of cells/μl based on the white blood cell (WBC) number counted using a standard hemacytometer (DASIT).

Statistical analysis was performed using NCSS for Windows. Descriptive statistics are reported as medians, continuous variable differences between groups were calculated with the Student T test. The fold change was calculated by the ratio between the difference (day 30 – day 0) /day 0. The P value below 0.05 was considered as statistically significant.

As shown in Table 1, at day 30 we observed a 0.48 change of CD3+. After 30 days of treatment there was an improvement of the CD4+/CD8+ ratio from 0.49 to 0.86 (0.75 times), that resulted in a change of CD3+CD4+ (from 234 to 384 x109/L) compared to CD3+CD8+ (from 475 to 448 x109/L). Moreover, in the same period of study, we had a change of 0.75 times of CD3-CD56+ from 272 to 478 x109/L 62 and a smaller rise of CD19+ from 214 to 256 x109/L. The naïve CD4+ and CD8+ lymphocytes rose from 4 to 39x109/L (8.75-fold change, P=0.02) and from 27 to 58x109/L (1.14-fold change) over a month while their memory counterpart fell by 0.62 and 0.55-fold. When we calculated the CD4+ and CD8+ naïve/memory ratio we found a 35- and 4-fold change (P=0.01 and 0.02). Comparing the day 0 and day 30 peripheral blood samples, we observed a high rise of 0.66 and 1.14 times for mDCs (mDC from 9 to 15 x109/L [P=0.03] and pDC from 7 to 15 x109/L [P=0.05]) respectively together with a change of Tregs (from 2.9 to 9.1 x109/L, 3.5-fold change [P=0.04]). Finally, when we analyzed the changes between pre- and post-UVA photoactivation a significant change of Treg was observed (0.35-fold change, P=0.05), while a decrease in cell number was observed for CD8+ (P=0.05) (Table 2).

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SGLT2-Inhibitor-Induced Euglycemic Diabetic Ketoacidosis in a Newly Diagnosed Type 1 Diabetes Patient | Juniper Publishers

Juniper Publishers-Open Access Journal of Endocrinology and Thyroid Research

Authored by Dina Omar

Abstract

Euglycemic Diabetic Ketoacidosis (DKA) is a medical emergency wherein the patient presents with DKA and a normal blood glucose. This can make diagnosis difficult. We report a patient with type 1 diabetes (T1D) who was prescribed the relatively new Sodium-glucose cotransporter 2 (SGLT2) inhibitor and consequently presented with euglycemic DKA.

Keywords: Euglycemic Diabetic Ketoacidosis (DKA); Sodium-Glucose Cotransporter 2 (SGLT2) Inhibitor, Type 1 Diabetes

Introduction

SGLT2 inhibitors are a relatively new class of oral hypoglycemic agents indicated for type 2 diabetes (T2D). They inhibit glucose reabsorption from urine at the proximal renal tubules by targeting SGLT2. The drugs are reported to have a relatively pronounced glucose-lowering effect with a low risk of hypoglycemia when administered as monotherapy [1]. However, when prescribed for patients with T1D, they can cause euglycemic DKA, which is DKA characterized by a normal blood glucose level at presentation.

Case Report

A 28 years old Iraqi female, known to have T2D on therapy, presented with features of DKA but with normal blood glucose (7.5mmol/L). She was diagnosed with T2D about a month before her admission to our hospital. On presentation, her Body Mass Index was 20.5kg/cm2 (Height 156cm, body weight 50kg). Family history was positive for hypothyroidism in mother, but not for diabetes in her family. She gave no history of DKA prior to this admission. At the time of diagnosis one month earlier, she had presented with a 3-week history of hyperosmolar symptoms typical of diabetes mellitus and weight loss of 7 kg. Then she had presented with a random blood glucose of 22mmol/L. Her HbA1c was 9.5%. Her physician had started her on Metformin 500 mg thrice daily. After about 2 weeks, she complained of poor glycemic control despite compliance to diet and Metformin. Glipalamide 5mg/day and dapagliflozin (10mg/day) were added after the patient refused to take insulin as recommended. Within 2 weeks of this therapy, she complained of epigastric pain for two days associated with nausea and vomiting and decreased appetite. She also complained of vaginal itching/irritation. There were no infectious diseases evidenced by chest X-ray, electrocardiogram, and urinary sediments and blood culture. Table 1 shows her laboratory findings on admission and follow up. Other investigations on follow up are presented in Table 2. Unfortunately, her initial laboratory finding at the diagnosis of T2D was not available.

Results

We stopped all her above medications. She was managed for DKA with continuous intravenous (IV) insulin and appropriate IV fluids. The patient had responded well to our management in the hospital. Her condition greatly improved after one day from admission. She was free of ketoacidosis and had resumed oral feeding with multiple daily injections of insulin (MDI). She was discharged on insulin as part 4 units thrice daily (as bolus before each meal) and insulin Glargine 4 units as basal insulin at bed time.

Discussion

SGLT2 inhibitors are a promising class of antidiabetic agents that have recently become more popular. Their main adverse effects are reported to be genital fungal infections, bacterial urinary tract infections and polyuria. Volume depletion has also been reported particularly in elderly in in patients on concurrent loop diuretics [2]. These oral antidiabetic agents can produce weight loss of about 2-3kg, secondary to the 280-320 kcal/day loss as 70-80 g of glucose is excreted in the urine [3,4]. Since patients with T2DM are usually more obese than those without diabetes, SGLT2 inhibitors may be the first choice of an oral hypoglycemic agent after metformin. However, weight loss could be a concern for patients with low body weight [3,4]. DKA is often associated with T1DM and severe hyperglycemia is a cardinal feature. Recently, there have been case reports of DKA in patients with T1DM and T2DM treated with SGLT2 inhibitors [1]. SGLT-2 inhibitor- associated DKA were also more common in patients with T1DM, rather than those with T2DM. In contrast to traditional DKA, they do not show severe hyperglycemia, and are therefore called euglycemic DKA. The absence of significant hyperglycemia in these patients made their detection and treatment delayed by physicians and patients [1]. SGLT-2 inhibitors may potentiate the generation of ketoacidosis despite achieving euglycemia through various mechanisms. Increase in glucagon in the background of an insulin deficient state, increased reabsorption of ketone with concomitant delayed clearance of ketone, shift in substrate utilization to fatty acid with concomitant increase in ketone body production, and weight loss with concomitant sarcopenia are mechanisms that could be playing complementary roles in the genesis of ketonemia. Associated dehydration, fluid loss (gastroenteritis) or poor fluid intake (vomiting) and infections, in a poor metabolic milieu, might also trigger the process of this event, making the patient ketosis prone thus precipitating a DKA with normal blood glucose levels [5]. So far, Euglycemic DKA due to SGLT2 inhibitors has been reported in patients with T1DM, and the FDA has contraindicated their routine use in such patients. Our patient also appears to have T1DM. She was later found to have positive anti GAD and anti-insulin antibodies as well as low c-peptide levels. In addition, her acute clinical presentation with DKA within one month of being diagnosed with diabetes, indicates an insulin deficient state. This case is an attestation to the FDA advice that SGLT2 inhibitors must not be routinely prescribed to patients with T1DM.

Conclusion

SGLT2 inhibitors should not be routinely used in patients with type 1 DM as add on therapy because of the adverse effect of euglycemic DKA. It poses a challenge to physicians as patients present with normal serum glucose levels and ketoacidosis may be overlooked. Despite euglycemia, ketoacidosis remains a medical emergency and must be treated quickly and appropriately [6]. Therefore, SGLT2 inhibitor should be considered as a cause in patients presenting with DKA.

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Strategies in Protein Engineering to Evolve Proteins and Mimicking Evolution in the Laboratory Scale | Juniper Publishers

Juniper Publishers-Open Access Journal of Technical & Scientific Research

Authored by Sagar Roy

Abstract

Nature has its own way of synthesizing molecules and materials with an array of bio-catalysts known as enzymes. Enzymes comprise of a combination of proteins which in turn are the building blocks of life. With just a backbone combination of Carbon, Hydrogen, Oxygen and Nitrogen, proteins can be perceived as delightfully intelligent and adaptive. Over billions of years, nature have provided a wide range of survival questions in front of these molecules and somehow, they have evolved and survived, as proved by Darwin. This adaptive nature of proteins has been exploited and successful evolution of enzymes is possible towards a desired interest on a laboratory scale using nature’s machinery. Thus, mimicking evolution on a much shorter time-scale. In this article, we address the strategies involving the idea of evolution in a laboratory directed to fulfil our chemical needs. Also, how with time, the strategies have evolved covering up the loop-holes of previous generations. The advent of polymerase chain reactions made combinatorial libraries creation easy and then screen towards a fitness test. With time we learnt, a combination of evolution with rational designing creates shorter and smarter libraries that have a strong ‘impact factor’ upon the desired goal and reduce false-positives. However, while controlling biological systems, scientists are manipulating the factories that actually make the molecules and materials into newer forms that are not natural. Nature, out-does scientists via evolution. Through survival of the fittest, evolution collects all the beneficial mutations through multiple iterated genetic diversification and screening.

Keywords: Directed evolution; Protein engineering; Combinatorial libraries; Mutagenesis; Enzymes; Promiscuous ancestral proteins; Escherichia coli metabolism; Chemical origins; Thermoanaerobacter brockii alcohol dehydrogenase; X-ray crystallographic structures

Introduction

Enzymes are thought to be highly specific biological catalysts having a very discreet range of target molecules or substrates [1, 2]. The evolution of enzymes has been occurring under different selection pressures of nature from promiscuous ancestral proteins. A genomic analysis in Escherichia coli metabolism reveals that 37% of its enzymes have a wide variety of substrate range. However, they are found to catalyze 65% of the known metabolic reactions [3]. The evolution of enzymes in response to environmental demands is the key to the overall organism’s fitness in the nature. This is manifested in the inherent promiscuity of many enzymes. Although, we are thankful to the ‘specialist’ nature of the enzyme molecule, we also do question, how much further can the ‘generalist’ nature be pushed in-vitro or in-vivo so that an enzyme can be evolved more. In the 3-D structure analysis, the active site of an enzyme is the engine, that performs the turn-over of a substrate into the product (catalytic machinery) and more specifically amino-acid residues have been identified from the X-ray crystallographic structures that are key players in the process. Textbook definition of enzymatic activity reveals that the work of the enzyme is broadly related to the binding of the substrate into the active site, followed by a possible conformation change, then the catalytic activity happening in the core of the enzyme and finally, the product leaving the enzyme-product complex. To explain the evolution of enzymatic catalytic activities, scientists have used models of chemical origins to propose the evolutionary initiation of the diversity. One such model demonstrates via chemical models and assumes key mutations in the active site that can lead towards enhanced specificities or sometimes enhanced specificities but with compromised efficiency. Then it proposes that designing a realistic trade-off constraint is possible with mutation combinations where the evolution can be directed towards both enhanced specificity and efficiency [4].

To improve the characteristics of an enzyme structural bioinformatics has been extensively used and with de-novo approaches enzymes have designed for enhanced specificity and functionality. Evolution has been a brute force that pushes the enzymes to evolve and then select the survivors based on their functionality. From Figure 1 it is evident that the evolution not only results in various changes in chemistry and substrates but are also supplemented with rarer gain or loss in the function in the form of moonlighting and pseudoenzymes respectively [5]. Due to the innate promiscuity, many enzymes do show off-target activity even when the natural selection pressure ceases to exist over evolutionary time. At that point of saturation, further catalytic/specificity changes do not improve the fitness in its highly conserved active site. The phenomenon was demonstrated by -lactam antibiotic resistance in bacterial populations over many generations. The promiscuity can also vary between orthologous enzymes which originate from the same family [5-7]. An approach of rational design relying on somewhat of a thorough knowledge of the protein structure that exists for many years is called directed evolution [8,9]. It is a popular technique that has been used to evolve a particular enzyme towards a user-defined goal. The ‘user defined’ goals narrows down the chances to produce the false-positives in comparison to natural selections. Also, this gives an opportunity to mimic natural evolution in a laboratory pilot scale operation. The limitations of this technique however is, screening may be needed for enormous random mutagenesis libraries which in-turn needs a robust high-throughput assay. A combinatorial approach has also been implied to create ‘focused’ libraries that will concentrate on regions of the enzyme active site that has been predicted by rational design to produce beneficial mutations and reduce the number of mutants to screen by a significant number. However, it must also be mentioned that our understanding of the link between the genetic sequence and function lags well behind our desire for designing new enzymes. Which makes predictions of performance-enhancing mutations, extremely challenging.

In the early 90s the most user-defined properties that were targeted for evolution included thermostability, nonnative substrates or activity in harsh organic solvents and after rounds of screening it was sometimes revealed that beneficial mutations could be nowhere near the active site of the enzyme [5,6]. Hence, it would be a hitting a deadended loop to just look for the key in the active site of the enzyme. The power of a combinatorial library is enormous. With a stable high-throughput assay it is possible to analyze millions of mutant proteins in one day. In some other cases however, the number can be less than a few hundred per day. So, development of smarter libraries is very important in this aspect. Using site-directed mutagenesis and site-directed saturation mutagenesis techniques, identification and construction of a ‘mutable landscape’ has been done in case of cytochrome P450 evolution [10-12]. This has been proved to be a very effective technique recently to tackle the very important challenge of the sequence-function relationship in case of directed evolution. The libraries thus generated on mutability landscapes can be used to engineer any fitness trait of user-defined interest [6,7,13]. We are entering into an era where the ‘user-defined’ interest has changed a lot. The demand for synthetic compounds has been growing and ‘green synthesis’ has been one of the most valued tools in the 21st century that uses enzymes as biocatalysts and minimizes the production of non-degradable bye-products and pollutants. So, directed evolution of stereo- or regio-selective enzymes that can behave as biocatalysts in asymmetric transformations is of particular interests to bio-organic chemists. Towards this goal, raised the need to develop the small and smart libraries. And hence forth different strategies including triple-code saturation mutagenesis (TCSM) at multiresidue sites of the Thermoanaerobacter brockii alcohol dehydrogenase by using distinct reduced amino acid alphabets and with requirement minimal screening have been recently reported [13-15]. So not only the physical labor has been greatly reduced, but also chances of false-postive results and codon-degeneracy can be minimized under this protocol [13].

Discussion

To push the promiscuous nature inherent in enzymes has been what scientists been brain-storming over the decades. The further challenges are to create enzymes for reactions that will let them solve problems that neither synthetic organic chemistry nor biological chemistry can address. Being macromolecular catalysts, it would be easier for enzymes to stabilize transition-states which otherwise would be inaccessible to chemical small molecule catalysts as they would likely compete with other lower-energy reaction pathways. Such was reported from cytochrome P450 from Labrenzia arregata [16]. Strategies and efforts are currently being invested to design enzymes with artificial cofactors as well. However, designed enzymes are yet to have the sophistication of nature’s products and struggles remain with other co-factors and prosthetic groups that are currently being addressed.

Conclusion

Over time, nature has been the best template to mankind. In our case, it has been the best chemistry teacher, solving the very challenges of existence of life over billions of years through a range of astonishing conditions. This has been possible only at the molecular level because of the enzymes which act as the fundamental bio-molecules. These systems are good models for a sustainable chemical industry or energy industry that uses renewable natural resources and recycles almost all of it without causing significant damage to the environment. It is not far where we stand today that DNA programmable organisms can produce many of our desired chemical needs.

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Impact of Acute Kidney Injury on the Survival of Subjects Receiving Noninvasive Ventilation | Juniper Publishers

Juniper Publishers-Open Access Journal of Pulmonary & Respiratory Sciences

Authored by César Cinesi Gómez

Abstract

Objective: the main objective was to determine the presence of acute kidney injury (AKI) and the 90-day survival of subjects with acute respiratory failure (ARF) receiving noninvasive ventilation (NIV) in the Emergency Department (ED)

Method: We performed a prospective observational study. AKI was defined as the growth of level of creatinin between the one made in the ED, which had to be 1.5 times higher than the “basal value” (within the previous 3 months). Subjects were contacted by telephone at hospital discharge and at 30, 60 and 90 days after the initiation of NIV.

Result: We analyzed 174 cases: 30(17.3%)subjects with AKI and 144(82.7%)subjects no-AKI. Fifty-three percent of the subjects (16 subjects)with AKI died versus twenty percent (30 subjects)with no-AKI (RR 3.276; CI 95%: 1.74-6.16. P<.001) Cox regression analysis showed the following to be statistically significant: subjects with AKI (HR 2.808; CI95%: 1.497-5.291. P=.001), mean blood pressure (HR 0.969; CI95%: 0. 926-0.994. P=.044)and age (HR 1.039; CI 95%: 1.007-1.71. P=.015).

Conclusion: The presence of AKI is an independent factor of mortality in subjects with ARF requiring NIV in the ED.

Abbreviations: ARF: Acute Respiratory Failure; ED: Emergency Department; IMV: Invasive Mechanical Ventilation; NIV: Non Invasive Ventilation; COPD: Chronic Obstructive Pulmonary Disease; APE: Acute Pulmonary Edema; AKI: kidney Injury; AKIN: Acute Kidney Injury Network; IPAP: Inspiratory Positive Airway Pressure

Introduction

The management of acute respiratory failure (ARF)in the Emergency Department (ED)is evolving from classical invasive mechanical ventilation (IMV)with endotracheal intubation to the "more recent” noninvasive ventilation (NIV)[1]. From almost the beginning of the implementation of the latter technique EDs were considered as fundamental strategic areas since early initiation of NIV reduces patient mortality [2]. Exacerbations of chronic obstructive pulmonary disease (COPD)and acute pulmonary edema (APE)are the two most frequent diseases in the ED [1]. Factors associated with failure of NIV and lower patient survival include a low level of consciousness, high respiratory rate, pH values less than 7.25, high scores in severity scales(APACHE, SOFA)or hemodynamic instability [2,3-7]. On adding IMV to these prognostic, it is observable a worsening in the kidney function, which leads to a higher mortality [8-10]. The evaluation of renal function consolidates acute kidney injury (AKI)which is based on the RIFLE [11] and Acute Kidney Injury Network (AKIN)criteria [12]. These criteria present two fundamental points: the first is a dynamic study of renal function according to changes over time, and the second is a grading of AKI depending on the relative decline in renal function. Both scales adequately determine the prognosis of the patient [14-17]. However, studies on factors associated with NIV do not evaluate in depth the relationship between the renal function and the survival of these subjects [2-5,14]. Therefore, the aim of the present study is to determine the survival of subjects receiving NIV and the presence of AKI in the ED.

Methods we performed a prospective observational study carried out in the ED of the Hospital General Universitario Reina Sofia of Murcia (Spain)which attends a population of 202,000 inhabitants, with 92,297 emergencies having been attended in 2014. The study began on November 10, 2012 and finished on June 28, 2014. Patient recruitment was dynamic and consecutively included all the subjects attended in the ED. The inclusion criteria for these subjects were:

a. Aged above 18 years.

b. ARF defined by pO2/FiO2<300.

c. NIV during the ED visit.

d. A diagnosis in ED that were of APE or COPD exacerbation.

The diagnosis for APE was base on clinical’s foundings made by the ED’s physician with a chest radiography compatible with APE. The COPD exacerbation is defined as a worsening of the patient’s respiratory symptoms that is beyond normal day-to- day variations in subjects with known COPD.

A patient with a serum creatinine value carried out in the last 3 months. The exclusion criteria were: requirement for a lifesaving or emergency intervention, the necessity IMV before beginning with NIV and subjects receiving hemodialysis. The study followed the prevailing laws and regulation and was approved by the Ethical Committee of Clinical Investigation of our hospital. All the participants of the study provided informed consent. Confidentiality of all personal data was managed according to the Spanish Organic Law 15/1999, of 13 December on the protection of personal data. The main objective of the study was to determine the mortality at 90 days after the initiation of NIV and the presence of AKI. We determined serum creatinine (mg/dl) levels at admission to the ED. To define the "basal value” we had to use the last measurement of serum creatinine made to the patient. This measurement had a deadline of three months. AKI was defined as the growth of level of creatinine between the one made in the ED, which had to be 1.5 times higher than the “basal value”. The subjects that were discharged were telephoned at 30, 60 and 90 days after the initiation of NIV. The study included secondary objectives were the mortality rate during hospitalization, admission to the intensive care unit (ICU), mortality at 30 and 60 after the initiation of NIV and mortality according diagnosis(APE, COPD exacerbation). Mortality was also taken into account according to the AKIN criteria [13]. NIV was the administration of continuos positive airway pressure (CPAP) or Bilevel positive airway pressure (BiPAP) applied through a interface. All subjects were continuously monitored. The ventilators used for NIV were either BiPAP model ST or Trilogy 202 (Respironics; Murrysville, PA). The initial ventilator.

Settings are as follows:

I. BiPAP Mode: Inspiratory Positive Airway Pressure (IPAP) between 10-16cm H2O and an Expiratory Positive Airway Pressure (EPAP) of 4cm H2O. After, the pressure (increasing the pressure support in 2 cm H2O each time) was adjusted to achieve an expiratory mean tidal volume of at least 5 ml/kg.

II. CPAP Mode: EPAP of 5cm H2O, increasing the pressure to 10-15 cm H2O. The IBM SPSS Statistics v-21 was used for the statistical analyses. Categorical variables were expressed as absolute values and percentages. Continuous values were expressed as mean, standard deviation and median. In addition, the type of distribution was determined using the Kolmogorov- Smirnov test. Differences between categorical variables were evaluated using the Chi square and continuous variables were analyzed with the Student’s T test if the distribution was normal or the Mann-Whitney U test if otherwise. The relative risks were calculated with their 95% confidence intervals (CI 95%). To determine associations between the continuous variables and the different groups the ANOVA or Kruskall-Wallis test was used. To discriminate the confounding power of the variables, Cox regression analysis was used performing univariate analysis of the statistically significant variables (not only regarding AKI, but also the mortality) and including the subjects with AKI. Kaplan- Meier analysis was performed for survival analysis, and the curves were compared using the Log rank test. A p value < 0.05 was considered significant.

Results

ARF: Acute Respiratory Failure.

NIV: Noninvasive Ventilation.

COPD: Chronic Obstructive Pulmonary Disease.

APE: Acute Pulmonary Edema.

AKI: Acute Kidney Injury.

A total of 291 cases were included, 52(17.8%) of which were excluded for lacking serum creatinine determinations in the previous 3 months, 61(20.9%) presented a different diagnosis exacerbation of COPD or APE, in 2(0.68%) cases data were lacking and 2(0.68%) were less than 18 years of age. Thus, 174 cases (59.7% of the subjects) were finally analyzed (Figure 1). One hundred forty-four subjects (82.7%) didn’t have Acute Kidney Injury (no-AKI), while 30 subjects (17.2%) developed an Acute Kidney Injury (AKI).Table 1 shows the basal characteristics of the subjects comparing those with AKI with subjects with no-AKI. Of the 174 subjects studied, 45(25.9%) died within 90 days of ED discharge. Among subjects with AKI the mortality at 90 days was 53.3% (16 subjects) compared to 20.1% (29 subjects) in those with no-AKI (RR 3.276; CI 95%:1.74- 6.16.P<.001). The global in-hospital mortality was 14.3% (25 subjects), 30.0% with AKI vs 11.1% no-AKI (RR 2.554; CI 95%:1.32-4.92.P=0,007). Tables 2 & 3 show the data related to mortality. Urea, serum creatinine, creatinine clearance and previous serum creatinine values showed no statistically significant relationship with 90-day mortality, with P values of .133, .269, 0118 and .527, respectively. However, the difference in serum creatinine levels (1.14±0.89 vs. 0.28±0.51 mg/dl; P=.024) were found to be related to mortality at 90 days. Regarding the in-hospital mortality, a significative statiscal difference was found as regards the serum creatinine (1.76±0.93 vs. 1.37±0.68 mg/dl; P=0.014) and the difference in serum creatinine levels (0.57±0.91 vs. 0.21±0.35 mg/dl; P=.039).

* Continuous values are presented as mean ± SD (median)

† p-value to contrast both groups.

‡ Any type of domiciliary noninvasive ventilator

S Inspiratory oxygen fraction.

‖ Creatinine obtained from analyses in the last three months.

¶In the lowest line the percentage amoung the group are shown.

AKI: Acute Kidney Injury.

NIV: Noninvasive Ventilation.

COPD: Chronic Obstructive Pulmonary Dissease.

SOFA: Sequential Organ Failure Assessment.

* AKI: Acute Kidney Injury.

† p-value to contrast both groups..

‡ ICU: Intensive Care Unit

S The number of event is shown/ total amount within the diagnosis.

‖ COPD: Chronic Obstructive Pulmonary Diseases.

With regard to the remaining variables studied, among the categorical variables none of them showed a significative statiscal relationship with 90-day and in-hospital mortality. To the contrary, of the variables the following were statistically significant: aged (75.27±11.4 vs 80.40±10.4 years. P=.004), mean blood pressure (100.7±22. vs 91.3±21.4 mmHg. P=.010), pro BNP (4627.0±6299.5 vs 7244.1±9264.3 pg/ml. P=.040); procalcitonin 0.48±4.4 ng/dl vs 0.59±1.5 ng/dl. P=.001)and SOFA score (3.5±1.1 vs 4.6±1.7. P=.023) No relationship was observed between the presence of AKI and the probability of admission to the intensive care unit (ICUj, with ICU admission of 8.3% in subjects with no-AKI, in opposition to a 6.7% in subjects with AKI (RR: 0.816; CI 95%: 0.21-3.07; P=.760)(Table 2). The Kaplan-Meier curves (Figure 2) showed a greater mortality in subjects with AKI on comparing no-AKIN (P<.001) Cox regression analysis showed statistical significance in the presence of AKI (HR 2.808; CI 95%: 1.49-5.29; P=.001), mean blood pressure (HR 0.969; CI 95%: 0.926-0.994; P=.015)and age (HR 1.039; CI 95%: 1.007-1.071; P=.015) (Table 4).

*P < .001. AKI: Acute Kidney Injury.

*HR: Hazard Ratio.

CI: Confidence interval.

AKI: Acute Kidney Injury.

Discussion

This is the first prospective study to evaluate the association between worsening in renal function and the mortality of subjects with severe ARF. The severity of both hypoxemic and hypercapnic ARF is related to the need for NIV. The results of the present study indicate a lower survival among subjects with worsening in renal function compared to basal values and the greater the renal failure the worse the survival. The strength of our study lays in the use of the initial serum creatinine value compared with a reasonable recent basal determination. Therefore, the prognostic value of renal function may be determined at the time of initiating NIV. In the present study we demonstrate that the presence of renal failure triples the probability of death. The importance of this study is that it suggests that AKI has a previously unappreciated relationship among the prognostic factors of subjects receiving NIV.

The classical study on prognostic factors by Confalonieri et al. [8] did not include either the presence of renal failure or measurements of renal function such as serum creatinine or urea. Indeed, serum bicarbonate values reflecting acid-base equilibrium are often not included [1,3,7-9]. This study even proposed a prognostic scale including the APACHE. Thus, a greater mortality is observed with values >29 in the APACHE scale. In our trial, we have used the SOFA scale in order to predict the mortality. As it was expected, taking into account the reference literature, the mortality in subjects with high SOFA was higher mortality. However, when the multivariate analysis was carried out, the SOFA scale disappeared from the model because of the presence of AKI. As the APACHE, SAPS II and SOFA scales included the kidney function, it is likely that the worsening of the kidney function is an independent variable and very important in the mortality of subjects undergoing a NIV. A recent study by Pacilli et al. [3] reported 18.2% of moderate or severe renal failure in COPD subjects with hypercapnic ARF requiring NIV. This value is closer to that observed in our study in which the mean age of the subjects was also over 75 years.

However, although this study determined the success of NIV as discharge to a hospital ward from the respiratory ICU, they observed 28.6% vs. 14.9% of moderate or severe renal failure in subjects with technique failure. Although only almost statistically significant (P=.069j, this result is similar to our results. The present study has the advantage of being prospective and having renal function as its principal objective. However, on analyzing the relationship between serum creatinine levels and mortality, again no differences were found, except for the in-hospital mortality where it could be found. This corroborates the argument that acute worsening in renal function is a fundamental factor for prognosis, being stronger than punctual measurement of renal function [14,18-19]. Therefore, in cases in which basal serum creatinine levels are not available, the use of serum creatinine can help the emergency physician to come to a decision. With respect to IMV the study by Nim et al. [19] reported that subjects with an increase in serum creatinine levels above 0.3 mg/dl within 24 hours and basal serum creatinine levels ≤1.4 mg/dl carried an in-hospital mortality of 56%. The mortality in the group without an increase in basal serum creatinine was 36%. Although the mortality rates in our study were not as high, our results support the results of this group since the mortality rate tripled in our study (30% in the group with AKI and 11% in subjects without). The “low” mortality rate in our study is probably due to its having been performed in subjects with NIV, because the IMV behaves as independent factor of mortality in subjects with AKI [10]. This proves that the kidney function is a determinant factor in the prognosis made to subjects with ARF undergoing mechanical ventilation, both invasive and non invasive. Our trial wasn’t designed to monitorizated the creatinin’s levels after the initiation of NIV. Hence, the weight of the NIV as factor in the development of AKI is unknown nowadays. Therefore, more researches are needed. As mentioned previously, bicarbonate levels are often not included as a prognostic factor of NIV, but have a low predictive power [5].

However, studies describing a relationship have observed that high levels of bicarbonate (greater than 25 mmol/L) carry a better prognosis [3,4]. We did not find a relationship between serum bicarbonate levels and mortality but we did observe lower levels in the presence of AKI. Traditionally, the pH has been given a very important factor to prognosis. Therefore, the lower the pH, the worst the prognosis [6,7]. However, in our trial as well as in others [1], a relationship between and the prognosis was not observed. Similary, the same can be said for the pCO2. The classical hypothesis was that a higher level of pCO2 led to a lower pH and, therefore, a worse prognosis [7-8]. Moreover, our study as well don’t prove this. Hence, there has to be another important factor that influenciates in the pH as well as in the prognosis. One explanation for the behave of the pH, pCO2 and HCO3-, may be that subjects with mainly hypercapnic ARF require an increase in serum bicarbonate to compensate for the associated acidosis. If these subjects presented AKI they would not be able to increase bicarbonate levels and consequently their pH levels would be lower. Since AKI carries a higher mortality this would explain the association between the higher mortality, low pH levels and not high serum bicarbonate levels as described in previous studies [1-6].

The main limitation of the present study is the different use of the AKIN criteria. These criteria are based on changes in serum creatinine or diuresis once the patient has been admitted. However, we evaluated the changes between serum creatinine levels at admission and within the previous 3 months. These “recent” serum creatinine levels were chosen with the aim of detecting subjects with AKI earlier since strict use of the AKIN criteria leads to a delay during which these time-dependent pathologies may worsen. The second limitation of the study is the cutoff of 3 months for creatinine levels. This time point was selected with the aim of having relatively “recent” values to carry out the study. Notwithstanding, in almost 20% of the cases the previous serum creatinine levels were not available. The last limitation is the relative small number of subjects with AKI. This fact is made worse in subjects classificated as AKIN 2 and AKIN 3. Therefore, it is fundamental for the research of more studies that valorate the behave in the changes in the kidney function in subjects undergoing NIV. Strangely enough subjects with AKI do not possess a higher possibility of being in ICU admission. Once more, the kidney function is the forgotten one in subjects undergoing a NIV. This study is just the first step. It is clear that the way we deal with AKI subjects has to change. The best path is yet to be discovered. In conclusion, the presence of AKI measured according to the AKIN criteria is an independent factor of mortality in subjects with ARF requiring NIV in the ED.

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Severity of Hip Displacement in Relation to Subtypes and Motor Function in Cerebral Palsy- Role of Hip Surveillance | Juniper Publishers

Juniper Publishers-Open Access Journal of Orthopedics and Rheumatology

Authored by Kunju PAM

Abstract

Background: Hip dislocation in children with cerebral palsy (CP) is a common and often over looked problem by the treating pediatricians. Though it can be diagnosed early by using radiographs, knowledge about the standardized methodology and need for periodic surveillance is lacking among primary care pediatricians. Hip surveillance by X-ray pelvis can identify early hip dislocation and it is shown that early intervention may prevent the need for surgery [1].

Methods: The study was done in a tertiary care hospital as a onetime radiological evaluation of children with CP between the age group of 4-9 yrs. One hundred and one children with CP formed our study population.Clinical evaluation for details regarding CP type and assessment of motor ability by gross motor function classification system (GMFCS) was done. A hip X-ray was done for calculation of, migration index for establishing or ruling out hip displacement. Migration percentage (MP) in relation to CP subtypes and GMFCS grades were done.

Results: There were 48 boys and 53 girls (mean age 4.80 years). 12 children were Gross Motor Function Classification System (GMFCS) level 5, while 26 were GMFCS level 4. Out of 36 hemiplegic CP only one had MP > 40. out of 6 children with spastic quadriplegia, 5 (83%) had MP > 40%. Spastic diplegic and choreoathetotic subtypes showed MP >40% in 9 out of 43 and 7 out of 16 respectively.According to the gross motor function classification system, GMFCS level I had no child with MP > 40%. Whereas 50% of children in GMFCS level IV and V had MP > 40% compared to only 4.76% in GMFCS I and II put together.

Conclusion: All the children in this study did not undergo a hip X-ray prior to this study. 22 out of 101 children had severe degree of hip displacement. The maximum number of hip displacements was seen in children with spastic quadriplegia; Spastic diplegic and choreoathetotic subtypes showed intermediate risk of hip displacement and hemiplegia had very low risk. According to the gross motor function classification system,GMFCS level I had no child with MP > 40%. Whereas 50% of children in GMFCS level IV and V had MP > 40%. The study showed the relationship between the CP subtypes and the severity of the motor involvement. It also emphasized the need for early hip surveillance.

Keywords: Hip dislocation; Cerebral palsy; Lateral Displacement; Hip surveillance

Introduction

In children with spastic cerebral palsy reduced activity of the hip abductor muscles in comparison to the spastic adductors leads to diminished growth of the greater trochanter of femur results in pathologic deformities of the hips-femoral anteversion and coxa valga antetorsa [2]. If untreated, dislocation of the hip typically occurs at age 2–7 years with a maximum at the age of 6 years. The incidence of hip displacement in cerebral palsy is related to the severity of involvement; varying from 1% in children with spastic hemiplegia, up to 75% in those with spastic quadriplegia [2,3]. So periodic evaluation of hip function is essential for early intervention and preventive measures.

Hip surveillance is defined as: “The process of monitoring and identifying the critical early indicators of hip displacement” [4].Hip displacement refers to the displacement of the femoral head laterally out of the acetabulum and is measured using a migration percentage (MP). Hip subluxation refers to hip displacement where the femoral head is partially displaced from under the acetabulum while hip dislocation refers to hip displacement where the femoral head is completely displaced from under the acetabulumn [5,6].Hip surveillance is important, to prevent morbidity of spastic hip disease-The aim of the management in children with spastic hip displacement is to maintain flexible, well-located and painless hips with a symmetrical range of movement. The key to achieving this goal is early identification and intervention.

Periodic hip surveillance also helps to reduce the need for extensive surgical procedures which is highly specialized area of orthopedics which may not be available in every center. So primary care pediatrician has a role for hip surveillance and timely referral.

Patients and Methods

The study was done in a pediatric neurology department of a tertiary care hospital as a onetime radiological evaluation of children with CP between the age group of 4-9 yrs prior to the referral to orthopedics. One hundred and one children between the age group of 4-9 yrs. with the diagnosis of CP formed our study population.A pediatric neurologist and physiotherapist in the department examined the children and completed an assessment form. Clinical evaluation for details regarding CP subtype and assessment of motor ability by gross motor function classification system (GMFCS) [6] was done. Winters, Gage, Hicks (WGH) gait type was determined, in addition to inquiring regarding pain during history taking. Orthopedic consultations done whenever required.

Radiographic Examination

Decision for referral for surgery depends on the degree of displacement of the femoral head and acetabular dysplasia. The migration percentages as described by Reimers and the acetabular index described by Hilgenreiner are the conventional measurements of displacement of the hip and acetabular dysplasia in young children with cerebral palsy.Radiographic assessment consists of measurement of migration percentage (MP) from a supine AP pelvis radiograph with standardized positioning [7] (Figure 1). Reimers Hip Migration Percentage is the percentage of body width of femoral capital epiphysis displaced out of the acetabulum (which falls lateral to perkins line) [8].Measurement of migration percentage of femoral head was done as given in the (Figure 2).

In the adult or older child, where the triradiate cartilages are fused and therefore inapparent, the inferior margin of the pelvic teardrop is used instead.The acetabular angle using Hilgenreiner’s line should be less than 28°at birth. The angle should become progressively shallower with age and should measure less than 22° at and beyond 1 year of age.

Present study an anteroposterior (AP) pelvic radiograph at the time of first visit was done. Any decrease in the range of movement at the hip or presence of scoliosis was a definite indication for further detailed radiological examination & immediate referral. In the present study 101 children were assessed between 4 and 9 years of age. Children with MP > 33% and > 40% were compared in relation to those with MP below these limits. Migration percentage (MP) in relation to CP subtypes and GMFCS grades were done.

Results

There were 48 boys and 53 girls (mean age 4.80 years). Distribution of Cerebral Palsy sub types were as follows. Hemiplegic 36 (35.64%), Quadriplegic 6(5.94%), Diplegic 43(42.57%) and Choreo athetotic 16(15%). 12 children were Gross Motor Function Classification System (GMFCS) level 5, while 26 were GMFCS level 4. Results of hip displacement by radiography as measured by MP in relation to CP subtypes and motor severity are presented in (Tables 1&2) and (Figure 3).

Only one child out of 36 children with spastic hemiplegia developed MP > 40%. The maximum number of hip displacements was seen in children with spastic quadriplegia, where 5 of 6 children (83%) had MP > 40%. Spastic diplegic and choreoathetotic subtypes showed intermediate risk of hip displacement (9 out of 43 and 7 out of 16 respectively had MP >40%). In the present study onset of hip displacement could not be assessed as hip surveillance was not done in a periodic basis. Figure 4 shows x-ray hip of 4-year-old with very minimal displacement (MP 33.33%) and Figure 4 shows severe hip displacement in an 8-year-old child.

According to the gross motor function classification system, GMFCS level I had no child with MP > 40%. Whereas 50% of children in GMFCS level IV and V had MP > 40% compared to only 4.76% in GMFCS I and II put together.

Discussion

The natural history of spastic hip disease of CP is progressive lateral displacement of the hip secondary to spasticity and muscle imbalance in the major muscle groups around the hip. Displacement may progress to severe subluxation, secondary acetabular dysplasia, deformity of the femoral head, dislocation and painful degenerative arthritis [4,5]. The long-term effects of dislocation of the hip can be disastrous for individual patients leading to pain and loss of the ability to sit comfortably in up to 50% of cases [6]. Other problems include difficulty with perineal care and personal hygiene, pelvic obliquity and scoliosis, poor sitting balance and loss of the ability to stand and walk [7-11].

A hip is usually considered to be subluxed,if the migration is equal to or greater than 33%. Reimers [17] found that among normal, the 90th gentile for migration percentage at four years was 10% with spontaneous migration of less than 1% per year. An unstable migration percentage is when progression is greater than or equal to 10% over 1 year [12-16]. Present study has shown that even a single radiological evaluation could identify hip displacement in children after the age of 4 yrs. Majority of (5 out of 6) quadriplegic CP, had severe type of hip displacement compared to hemiplegic CP (1 out of 36). Compared to other bilateral types of CP diplegia had lower rate of hip displacement (9 out of 43). This may be because of the less motor function impairment. So GMFCS may be a better predictor for early prediction of hip structural impairment. It is seen that there is direct correlation between the GMFCs class and severe hip displacement. According to the gross motor function classification system, GMFCS level I had no child with MP > 40%. Whereas 50% of children in GMFCS level IV and V had MP > 40% compared to only 4.76% in GMFCS I and II put together.

Subtyping of CP may have a role in predicting occurrence of severe hip displacement as shown by the almost complete occurrence in quadriplegic CP. However, a mere clinical examination and subtyping will not help in identifying severe hip disease in other type of CP. So, a systematic analysis of GMFCS is required for intensified screening of hip dysfunction. Moreover, as described in various guide lines periodic hip surveillance is mandatory for better ambulation and avoidance of surgery. This can be attained by early intervention measures. Figure 4 itself shows the importance of early surveillance. AACPDM - (American Academy for Cerebral Palsy and developmental medicine) recommends following schedule of hip surveillance (Table 3).

Conclusion

Need for hip evaluation in children with CP is emphasized by this study. All the children in this study did not undergo a hip Xray prior to the study. 22 out of 101 children had severe degree of hip displacement. The maximum number of hip displacements was seen in children with spastic quadriplegia and hemiplegia had very low risk. According to the gross motor function classification system, GMFCS level I had no child with MP > 40%. Whereas 50% of children in GMFCS level IV and V had MP > 40 %. The study showed the relationship between the CP subtypes and the severity of the motor involvement in producing hip displacement. Referral to an orthopedic surgeon with experience in treating hip displacement in children with CP is recommended when there is presence of hip pain on history and/or physical examination. Periodic hip surveillance is mandatory for early detection of hip displacement. When the migration percentage is greater than 30% and/or there is less than 30 degrees of hip abduction with or without other findings, referral to an orthopedic surgeon is recommended [1,17].

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Severity of Hip Displacement in Relation to Subtypes and Motor Function in Cerebral Palsy- Role of Hip Surveillance | Juniper Publishers

Juniper Publishers-Open Access Journal of Orthopedics and Rheumatology

Authored by Kunju PAM

Abstract

Keywords: Hip dislocation; Cerebral palsy; Lateral Displacement; Hip surveillance

Introduction

Patients and Methods

Radiographic Examination

Results

Discussion

Conclusion

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