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Characterization of Teatina Coast Marine Habitats (Central Adriatic Sea) toward an Integrated Coastal Management- Juniper Publishers

Abstract

The Adriatic Sea represents a vulnerable ecosystem and need an Integrated Coastal Management to protect, conserve and manage the coastal and marine areas. This preliminary work proposes a local case study aimed to the characterization of coastal marine habitats along Teatina coast (Abruzzo, central Italy), carrying out 11 transects parallel to the coastline. Moreover, the presence of sea turtles and cetaceans has been estimated by the analysis of specimens stranded and included in the GeoCETUS database of Centro Studi Cetacei onlus. The results show that the study area has a considerable marine biodiversity and a sustainable management is urgent for preserving the habitats and associated species. As first step the Nature 2000 network should be implemented by including the marine areas in front of each terrestrial SCIs and Natural Reserves, to create some marine protected areas along Teatina coast with the aim to match the socio-economic needs of the territory and the conservation of natural habitats. Our results only represent a first step and further socio-economic analysis should be implemented to establish an integrated management plan together with the regional authorities.

Keywords: Bionomic characterization; Centro studi Cetacei onlus; Coastal environment monitoring protocol; Coastal habitats; GEOCETUS database; Marine habitats; Nature 2000 network

Introduction

In the Mediterranean Sea, the Adriatic is the most productive basin hosting endemic species and marine mammals, sea turtles, seabirds, fishes and invertebrates, and also the nursery, spawning, and foraging areas [1]. The overexploitation of resources and the increasing of human activities on the coastal areas from the fifties to the present day [2] have impacted the shallow water benthic communities modifying and impoverishing the marine habitats [3]. Moreover, the erosion processes involve both the sandy beaches and the rocky coasts losing important coastal and marine habitats and species [3]. Furthermore the description and the distribution of Adriatic benthic communities have been studied on a larger and a local scale [4-6] but the information about marine biocoenosis and biodiversity in the Teatina coast (Abruzzo, central Italy) now is poor and not exhaustive to structure management programs. In the central Adriatic Sea, the Teatina coast represents a particularly environment composed by shallow rocky cliffs generating pebble beaches alternated by sandy beaches. Along this coast there are promontories too, such as Punta Ferruccio, Ripari di Giobbe, Punta Acquabella e Punta Aderci [7]. Sandy beaches are characterized by established dunes and incipient dunes especially occur at the southern part of the Teatina coast. The marine substrates are characterized by seagrass habitat (Cymodocetum and Zosteretum), the rocky- algal reef and unvegetated sand habitats; the Posidonia oceanica seagrass beds are present only in the southern Adriatic Sea at depth greater than 20 meters [8].

The aim of our work is to improve the knowledge about marine biodiversity and EU habitats and associated species along Teatina coast (Abruzzo, central Italy) for promoting a sustainable management of such resources, as required by European Commission to implementing the marine Nature 2000 sites (EU-Pilot 83/16/ENVI case) according to the criteria identified by Annexex II and III Habitat Directive 92/43/CEE.

The study of the marine habitats was carried out through the distribution of sampling stations along 11 transects of 500 meters parallel of coastline between the municipalities of Ortona and Vasto (central Italy) from -1 to -10 meters in depth at natural rocky shores and associated ichtyofauna. In each station the sampling was carried out through visual census method (specimens/minutes), standardized by Coastal Environment Monitoring Protocol (CEM) with the cooperation of researchers, scuba divers and managers of the coastal/marine preserved areas (https://www.reefcheckmed.org/english/underwater- monitoring-protocol/). For each transect, was recorded the presence/absence, the number and frequency of specimens of guide species for marine environment [9,10]. Finally, were identified the marine habitats [11] and the Biotopes CORINE [12] and the EUNIS [13] typologies.

Data of sea turtles and cetaceans stranded along Teatina coast were collected in GIS format in the GeoCETUS website (http://geocetus.spaziogis.it/) by the Centro Studi Cetacei onlus CSC (Cetacean Study Centre-onlus), established by the Museum of Natural History of Milan in October 1985 by several researchers from the Italian Natural History Museum and other Italian scientific institutions and now responsible of the Recovery Center for sea turtles 'Luigi Cagnolaro' on Pescara, central Italy [14,15].

Discussion

Marine substrates at -7/-10 meters in depth showed well-calibrated fine and silty sand in quiet environments of Mediterranean Sea with association of seahorse grass Cymodocea nodosa (EUNIS 4.5131) referred to sandbanks (EC habitat code 1110) in continuous with estuaries (EC habitat code 1130) of the largest rivers along the Teatina coast (Sangro, Sinello) in contact with riparian woods with Salix alba and Populus alba (EC habitat code 92A0) [16,17].

The benthic populations found in sandy substrates are especially endobionts, as bivalves Tellina sp, Donax trunculus, Chamalea gallina, Cardium edule, Ensis ensis, Solen vagina, Mactra corallina, and the gasteropods Aporrhais pes-pelecani, and the echinoderms Echinocardium cordatum and Astropecten sp.

Infralittoral rock included habitats of bedrock, boulders and cobbles which occur in the shallow subtidal zone and typically support rhodophyceae communities as Corallinetum elongatae association (EUNIS A3.11) with bio-concretion on shady vertical rocks at Punta Ferruccio, Ripari di Giobbe and Punta dell'Acquabella and Punta Aderci. The Halymenia floresia association with specimens up to 15cm in length is more representative in the Punta Aderci site [18]. In the sheltered and calm waters sites other seaweeds species occurred, such as Ulva sp., Peysonnelia sp., Codium bursa, C. fragile and Dictyota dichotoma.

An important rocky habitat is Sabellaria spinulosa reef (EUNIS A3.6721) more representative along the coast with bio-concretion colonized by Mytilus galloprovincialis facies, with seaweeds, snakelocks anemone Anemonia viridis, bivaleves Ostra edulis and Gastrochaena dubia, gasteropods Trunculariopsis trunculus and Haliotis tubercolata, branching bryozoans Schizoporella errata, echinoderms Arbacia lixula, Sphaerechinus granularis and Paracentrotus lividus and crustaceans Scyllarus arctus, Palaemon elegans and Inachus sp. Moreover, a diversified icthyofauna was sampled: Parablennius gattorugine, P. rouxi, Diplodus vulgaris, D. annularis, Scorphaena porcus, Coris julis and Chromis chromis with an decreasing gradient of species number from North to South and a better status of conservation of Punta Acquabella and Ripari di Giobbe reef (Table 1).

In addition, the presence and the distribution of the cushion coral Cladocora caespitosa, the gorgoniidae Leptogorgia sarmentosa (both Least Concern for IUCN Red List), the date mussel Lithophaga lithophaga (All. IV Hab. Dir.) and the mussel Pholas dactylus (Vulnerable for IUCN Red List) were investigated and the results showed a decrease of their abundance from North to South, except to L. lithophaga with an high presence in the Punta Aderci reef up to 5-6 meters deep and in the Punta Acquabella in co-presence with few individuals of the mussel P dactylus. The gorgoniidae L. sarmentosa with four colonies (0,4 spec./min) only occurred in the Ripari di Giobbe site while cushion coral Cladocora caespitosa is especially present in the northern side of the Teatina coast with a maximum of 33 specimens (0.62 spec./min) in the Acquabella reef.

Results showed an high marine biodiversity in species and in number of specimens, especially in the northern side of the study area and a decrease in the southern part; on the contrary to the terrestrial habitats and species are mainly concentrated in the SCIs which are larger in the southern side, as on Torino di Sangro and Vasto [7,16,17].

It worth to note that a dangerous invasive species was found, the veined whelk Rapana venosa, which is homogeneously distributed along whole Teatina coast.

The CSC along the Teatina coast revealed the presence of the sea turtle Caretta caretta dead or alive and of common small cetaceans as the striped dolphin Stenella coeruleoalba and the bottlenose dolphin Tursiops truncatus, confirming the presence in the central Adriatic Sea of important nursery and feeding habitats [19], as showed in the Table 2. Furthermore, in the southern Teatina coast were stranded some rare species for a small basin like the Adriatic Sea, that is the sperm whale Physeter macrocephalus and the fin whale Balaenoptera physalus [20,21] (Table 2).

Conclusion

The Adriatic Sea represent a very vulnerable ecosystem as it is subjected to continuous pressures by the touristic, fishing, and oil activities compromising the habitats and associated species. Therefore it is necessary to protect, conserve, and manage the coastal and marine areas and their communities [22] with an Integrated Coastal Management ICZM (http://ec.europa.eu/ environment/iczm/) that involves a collaboration between the different stakeholders to manage the environmental and cultural heritage in a sustainable way. Considering the terrestrial Natura 2000 network along Teatina coast (Figure 1) and evaluating our preliminary characterization of marine habitats in the study area we suggest to implement the marine Nature 2000 network including the marine area in front of each terrestrial SCIs and Natural Reserves, to create a series of marine protected areas along Teatina coast, with the aim to match the socio-economic needs of the territory and the conservation of natural habitats. Our results only represent a first step and further socio-economic analysis should be implemented to establish an integrated management plan together with the regional authorities.

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Juniper Publishers-Open Access Journal of Environmental Sciences & Natural Resources

A Study on Sthalavrikshas in Temples of Madurai District, Tamil Nadu

Authored by Vinoth Kumar A

Abstract

India delivers rich biodiversity and it is not just the world’s twelve mega diverse countries, but also one of the eight major centers of origin and diversification of domesticated taxa. These taxa are conserved and have been considered sacred because of their cultural, religious and economic importance. In Tamil Nadu, some sacred trees are in the status of extinct, endangered, threatened, and vulnerable and vary rare habit. The sacred trees are very good examples of ex situ conservation, where a single plant is conserved and worshipped. A study of Sthalavrikshas is also known as sacred trees (or) temple trees was conducted in the temples of the Madurai district during 2016-2017. The study revealed the presence of Sthalavrikshas in 65 temples out of 100 temples studied. Totally 31 species of Sthalavriksha recorded in these 65 temples.

Keywords:Biodiversity; Conservation; Sthalavrikshas

Introduction

Sacred groves and sthalavriksha (temple tree) have been acting as a major role in the conservation of plants and animals. In the location are certain ethnic groups and residential district in India, which have been worshiping forests, trees and certain animals since time immemorial. Occurrence of sacred groves at several spaces in India, clearly defines the community’s attachment to nature. Sacred plants play a really significant role in ecology. Due to their ecological value and effective properties, sacred plants continue to be employed in the religious and social festivals of the Hindus. The five most sacred leaves of pipal, Cluster fig, white fig, banyan and mango are ubiquitously employed in making prayers and oblations. On auspicious occasions, mango leaves are attached to train and strung up on doors as a welcome banner, and leaves of purasu and banyan make workable plates and bowls during community feasts. Leaves of some other trees are also customarily offered to deities e.g., Vilvam (Bengal quince) to Lord Siva, of banana and Arjuna to Lord Ganesha, and of kontrai (Cassia fistula) to all the gods and goddesses. The red flowers of the Indian coral tree are used in the worship of Lord Vishnu and Lord Siva; of Alari (Nerium indicum) in the worship of Lord Siva and the Sun-god; of ketaki (Yucca gloriosa) in the worship of Lakshmi, and of pala or breadfruit (Artocarpus integrifolia) in the worship of Lord Vishnu. The purpose of some flowers is prohibited in worship rites like vaagai (sirisa or parrot tree/Albizia lebbeck) in the worship of Lord Ganesha and vengai (Pterocarpus marsupium) in the worship of Lord Siva. The wood of the sacred trees like vilvam, banyan, vanni, purasu and pipal is never employed as fuel, as it is believed to invite the anger of gods. But it is employed in other ways, in sacrificial rites and ceremonies. Sudhakar [1]. Sthalavriksha worship in temples is a popular exercise. Most of these temples have their own Sthalavrikshas (temple trees) and Nanthavanam (flower garden). Sacred plants provide food, shelter and nesting substratum for several species of birds and squirrels. All souls of certain species are completely protected. Sthalavriksha is a natural tree found in the temple site before construction of the temple and most temple myths (Sthalapuranas) and temple histories (Sthalavaralaru) refer to a prime deity that was first unearthed or found under the tree Gunasekaran & Balasubramanian [2]. Every temple has one plant or tree as sthalavriksham. Sthalavriksha means the tree of the locality (sthal-place; vriksha-tree). In Tamilnadu state, about sacred trees are in the status of extinct, endangered, threatened, and vulnerable and vary rare habit. Such trees are both ethno botanically or culturally important and ecological representative of the area.

Sthalavriksha or temple tree is a single plant worshipped as equal as the prime deity in the temples. In both Hinduism and Buddhism, temple tree worship holds a bigger significance. The plant, primarily worshipped are Peepal (Ficus religiosa), Neem (Azardirachta indica), Bael (Aegle marmelos), Sandalwood (Santlum album), etc. There are temples which have more than one Sthalavriksham simultaneously, whereas some temples like a Sri Kallalagar temple (Prosopis cineraria (L.) Druce and (Pterocarpus santalinus L.f.) to have different Sthalavriksham is different yugas. On that point are also examples of more than temple having the same trees as sthalavriksham (eg.) Aegle marmelos (L.) Corr.serr. and Azardirachta indica Adr. Juss. etc. Some of the important temple festivals are associated with the sthalavriksham of the temples concerned mavadi sevai of kanci Ekambareswara temple and makizhadi sevai of tiruvottiyur temple are two such festivals. Sthalavriksha mostly occurs in tree habit, in main or big temples of Tamilnadu. In some temples, it occurs in herb, shrub, grass or climber forms. Sacred trees are therefore handled as any other sacred space, and it is thus not surprising that many of the customs and ceremonies mentioned in sacred places, in general, are also observed at the sites of sacred trees. This habit shows characteristically the importance of medicinal plants in Indian System of Medicine. Medicinal parts of the Sacred Trees (Sthalavrikshas) are practiced in different forms. It is presented in the form of paste, juice, dried powder and made into tablets and juices mixed with sugar and honey to cure various diseases Amirthalingam [3].

Materials and Methods

Study Area

Historical Background: Madurai is one of the major districts of Tamilnadu State. Madurai is located along the bank of the river Vaigai. It is an ancient urban center known for its age old legacy and agile of contemporary modern lifestyle-a singular spot for worship and the Modern-day of living. Madurai is also visited by different names like “City of Jasmine” (Malligai maanagar), “Temple City” (Koil maanagar), “City that never sleeps” (Thoonga Nagaram) and “City of four junctions” (Naanmada koodal).

Location & Geographical Area: The Madurai district lies between 9° 56’ 20.7348’’ N and 78° 7’ 18.1884’’ E. It takes in an area of 3741.73 Sq. Km and is bordered on the west by Theni district, on the north by Dindigul district, on the east by Sivagangai district and along the south by Virudhunagar district. The district is empowered with a semi arid tropical climate with normal rainfall of 827.1 mm as against 923.1 mm for the state. The present study was extended out in Madurai district, Tamilnadu. 130 temples were enumerated, data gathered from the local people. Flowering twigs of trees set up within the temple premises were collected and identified taxonomically using the Floras. The tree species grown as Sthalavriksha in 65 temples in Madurai district were enumerated. The survey documented several interesting facets of tree worship. The local people, including Temple handoff, Priests, Temple Defendable and Worshipers was interacted with temple area of Madurai district that have indigenous knowledge about sacred plants of their locality and information’s were collected by group discussions and interviews with them in their local language (Tamil). Binomials of the plants with family, their local names, parts used and Medicinal uses were recorded (Figure 1).

Interview and Ethno Medicinal Data Collection: The ethno medicinal information was collected by interacting with the priest and people living around the temples through interview as a recorded data.

Collection of Plant: The floral parts and twigs were collected from the Sthalavriksha for Binomial name identification. Generally, the plant specimens were collected with flower and fruit. In case, if there are no flowers and fruit conditions, the plant twig with few leaves was collected for proper identification.

Result

Sthalavriksha worship in temples is an ancient religious practice in India. This study is the first attempt to survey the Sthalavrikshas of 100 temples in Madurai district. Tamilnadu, India. Of the surveyed 100 temples, there were only 68 temples in which Sthalavriksha were present. The temples found among them 12 were Lord Shiva temples, 28 were Lord Amman temples, 7 were Goddess Sakthi temples, and 7 were Lord Murugan temples, 3 were Vinayaga temples, 11 various deity temples. A total of 31 plant species belonging 20 families was recorded in the study. Most of these plants belong to Dicotyledons of angiosperms and one species belong to Monocotyledons (Borassus flabellifer L.). 30 Sthalavriksha plants were trees while one was a shrub (Tabernaemontana divaricata R.Br.ex Roem & Schult.). All the Sthalavrikshas documented in the study are given in Table 1 In Madurai district; the ancient temples were recorded for this study. The temples include Meenakshi Amman temple, Kallalagar temple, Thiruvaapudaiyar temple, Inmailum Nanmai Taruvar Temple, Puttu Sokanathar Temple etc. A total of 31 Sthalavriksha species belonging to 20 families were recorded, and Dominant families were Moraceae and Fabaceae with 4 species each, Moraceae, represented by 4 species (Ficus benghalensis L. Ficus microcarpa L.f. Ficus religiosa L. Ficus tintoria G.Forst). Fabaceae represented by 4 species (Prosopsis cineraria (L.) Druce, Pterocarpus santalinus L.f. Acacia leucophloea Wild. and Prosopsis cineraria (L.) Druce) and the other dominated families were Anacardiaceae and Mimosaceae. Each family is represented by 2 species, Mimosaceae (Albizia amara (Roxb.) Acacia nilotica (L.) Willd. ex Del.) and Anacardiaceae, includes 2 species (Lannea coromandelica (Houtt.) Merr and Mangifera indica L.) Among these Rutaceae was the dominant family represented by 16 temples followed by Moraceae represented by 6 temples and followed by Meliaceae and Rubiaceae represented by 4 temples each. The frequently occurring species was Aegle marmelos (L.) Correa recorded in 17 temples followed by Ficus benghalensis L. Druce in 6 temples and Azardirachta indica Adr. Juss and Neolamarckia cadamba (Roxb.) Bosser was recorded in 4 temples each. All the 31 species were reported to have medicinal properties. Tholkappiyavathi et al., (2013) reported that 16 temples have Sthalavrikshas while 20 such element exists in remaining temples. 9 species of Sthalavrikshas have been recorded in these 16 temples. Prabakaran et al. [4] surveyed the sthalavriksha of 106 temples in Salem, Namakkal, Karur district. They record sthalavriksha were found in 81 temples and a total 18 plant species belong to 18 genera and 14 families.Among this Caesalpiniaceae was the dominant family represented by 3 species followed by Rutaceae and Moraceae represented by 2 species each (Figure 2) .

Economically Important on Species

Most of the plants put down from sacred plants (Sthalavriksha) of Madurai district are economically significant. The medicinal plants comprise about 31 species, 29 species having timber value and 19 species were regarded for minor forest produce. Many multipurpose species have also been reported from the groves. Of these, 23 species are used as timber and medicine, 34 species as medicine and minor forest produce, 18 species as minor forest products and timber, and 10 species as timber, medicine and minor forest produce. Sukumaran et al. [5] reported 329 species belonging to 251 genera of 100 families and economically important plants such as medicinal value (194 sp.), timber value (34sp.) and minor forest product (19sp.) (Figure 3).

Quantitative Analyses of Medicinal Use

The village people have used the Sthalavriksha plants for many ills. It may be noted here that most of the sacred trees usually have great medicinal value. Traditional medicine continues to act as an important role in health maintenance. Medicinal parts of the Sacred Trees (Sthalavrikshas) are practiced in dissimilar kinds. It is presented in the form of a paste, juice, dried powder and juices mixed with sugar and honey to cure several diseases. The similar documented was made for 31 plants belong to 20 families are identified as traditional medical used species (Table 2). Gastrointestinal problems like digestive problems, diarrhea, dysentery, stomach ache and constipation were treated using specific herbal prescriptions by the local peoples same reported. Respiratory problem like cough, cold, and asthma also used medicinal plant. The plant parts, mostly reported in this regard were Leaves (29%), Bark (25%), Fruit (14), Root (12%), Flower (8%), Stem (6%), Seed (4%) and Latex (2%). Gunasekaran et al. [6] Ethnomedicinal uses of 91 Sthalavrikshas (temple trees) in Tamil Nadu, southern India, posses medicinal uses and cured various diseases like Toothache, Dysentery, Stomach ache, Diar¬rhea, etc.

Medicinal Preparations

The medicinal preparations followed by the Sthalavrikshas of Madurai district to cure a disease were based on many kinds of preparations which are as follows.

a) Decoction: A decoction was obtained by boiling the plant in water until the volume of liquid was reduced to more than ½ or ¾ of the original amount of liquid.

b) Extract: The plant material was ground with some amount of water as per the need and filtered. The filtrate was used as an extract.

c) Juice: The juice was obtained by grinding the plant material and this preparation was administered wholly (This juiciest material used for filtered or non-filtered)

d) Latex: Latex was obtained by detaching the leaf or young stem at normal region of the plants and used.

e) Paste: The paste was prepared by grinding fresh, dried material with water.

f) Powder: The powder was prepared by grinding dried material.

g) Raw: The plant material is also used in raw form, was used immediately after harvesting.

It was also likewise mentioned that the sthalavrikshas in Madurai district in Tamilnadu used the medicinal preparation mostly in the form of Paste (19%), followed by decoction (20%), juice (20%), extract (15%), Powder (9%), Raw and Latex (17%). Some of the sacred plants cure to various diseases, taken from various forms, such as Aegle marmelos species bark decoction is used to treat intermittent fever. Bark powder used for skin diseases. Leaf act as a blood purifier. Cassia fistula species taken from various forms, Leaf (paste) flower (juice) and root (extract) cured of some diseases such as skin diseases, snakebite, fever and cold. Gunasekaran et al. [6]- Ethno medicinal uses of 91 Sthalavrikshas (temple trees) in Tamil Nadu, southern India, they reported medicinal uses and taken from various formations such as juice, decoction, powder, paste, used to cure for various diseases and ailments like Diarrhea, fever, cough, cold, etc.

From the present investigation, it was noted that the Sthalavriksha plants on Madurai district of the study area used to herbal preparation made from the medicinal plants mostly used for the treatment of diarrhea (5 species: Aegle marmelos, Mangifera indica, Acacia nilotica, Morinda tinctoria, Tamarindus indica), dysentery (5 species: Acacia nilotica, Acacia leucophloea, Syzygium cumini, Tabernaemontana divaricata, Morinda tinctoria), fever (5 species: Acacia leucophloea, Aegle marmelos, Mimusops elengi, Morinda tinctoria, Neolamarckia cadamba), cough (5 species: Ailanthus excels, Acacia leucophloea, Lepisanthes tetraphylla, Prosopis cineraria, Millingtonia hortensis), skin diseases (9 species: Aegle marmelos, Azardirachta indica, Alangium salviifolium, Cassia fistula, Ficus religiosa, Millingtonia hortensis, Pongamia pinnata, Pterocarpus santalinus, Borassus flabellifer). Gunasekaran et al. [6] - Ethnomedicinal uses of 91 Sthalavrikshas (temple trees) in Tamil Nadu, southern India, they reported medicinal plants, mostly cured of fever (23 species), dysentery (13 species), asthma (10 species), rheumatism (10 species) and diarrhea (8 species). Nandkishor et al. [7] reported that the Some Sacred Trees and their Medicinal Uses from Amravati District (Maharashtra), used the medicinal plants, mostly for the treatment of fever (12 species), followed by dysentery (8 species) and diarrhea (3 species) [8-10].

Conservation Status of the Plants

The plant species Pterocarpus santalinus comes under the endangered category, all other species are of least concerned status (Table 1).

The Necessity of Security

Sthalavrikshas worshipped in plants are a means of conservation of plants. Plants in the temple gardens are cultivated and maintained and this is also a means of conservation of plants. The role of people in the conservation of plant has been an age old practice since historic period. It was concluded that the Sthalavriksha worship is an age old practice; myths, beliefs and this practice play a major role in the conservation of plants. Thus, the above results and discussion proved the relation of the human and the nature towards plant conservation. The traditional worshipping has protected many plants which have tremendous medicinal value and made them as sacred, so that with the fear of deity nobody eradicates it. So we have to protect these sacred plants for us and our next generation for better survival. On the basis of this study, we have to follow our ancestor’s belief in humanity and nature sustainability.

Conclusion

Madurai district, unitary of the ancient districts of Tamil Nadu famous for its religious culture, was studying for the sthalavriksha plants. It was noted that a total of 31 plant species was recorded. The recorded plant species belong to 20 families. Among that family of Moraceae and Fabaceae dominated together with 4 species followed by Rutaceae, Rubiaceae, Anacardiaceae and Mimosaceae family consequently represented with 2 plant species. Medicines are obtained from the Sthalavrikshas and are used in different forms. Sthalavrikshas are valued for their botanical, medicinal, environmental, religious and mythical importance. The sthalavrikshas of Tamilnadu constitute a lot of genetic resources for the conservation of species diversity. Propagation of sthalavrikshas in temples contributes to the conservation of our floral diversity. Some trees are significant for their economic use of shipbuilding or in the timber industry, some for providing homes for various animals, birds, and others for their medicinal value. In the present study, it is concluded that the religious activities are having a close relationship with plants boost up the mental health of local people of Madurai district and many of the sacred plants found in the household and temples were used for various religious cultural activities as well as for health care. These sacred plants are worshiped by the local people for getting the blessing of health and wealth by positive powers of nature. Hence the religious ceremonies, rites act as a protective factor or device for the conservation of sacred plants. So, it is the duty of the present generation to preserve and promote these aesthetic treasures to conserve biodiversity and nature, which will surely play a part in the progression of human beings. These sacred trees preserved through millennia by our ancestors as potential bio resources should be respected and conserved for the future generation. The sthalavrikshas is a mean of conservation of biodiversity.

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Metformin Reduces the Extent of Varicocele-Induced Damage in Testicular Tissue

Authored by: Erkan Erdem*

Introduction

Varicocele is an abnormal vascular dilatation of pampiniform plexus, commonly developing at puberty. Although underlying mechanisms remain poorly understood genetic background, anatomical aberrations, incompetence of venous valves, difference between the drainage of left and right testicular veins were suggested in the etiology [1]. As left spermatic vein being longer than the right vein, it is more commonly incurred to increased hydrostatic pressure and dilatation. Compression of the left renal vein between the aorta and the superior mesenteric artery may also contribute to the disturbed intravenous pressure [2].

The prevalence of varicocele varies between 15-20 % in general population and 30-40% in infertile men, and 11-19% of adolescents [3-6]. It was reported that varicocele is a progressive disease and early diagnosis and treatment in youth may enhance fertility potential [7]. Several contributing factors in the pathophysiology of varicocele have been proposed such as higher temperature of testis, the disorder of neuroendocrine system, autoimmunity, accumulation of renal and adrenal metabolites, genetic and epigenetic factors, hypoxia and oxidative stress [8-10].

Varicocele represents a chronic process within the testicle, which is linked to increased reactive oxygen species (ROS) beyond physiologic limits and, subsequently, disrupting sperm membrane fluidity, causing DNA damage and necrosis [11]. Moreover, superoxide dismutase 1, glutathione S-transferase M1 and T1 which are counteracting free superoxide radicals in cells have been reported to be decreased in men with varicocele, that may be important on disturbed sperm parameters [12]. Apoptosis of germ cells was also demonstrated in the pathogenesis of varicocele-related infertility [13]. Clinical findings suggest that surgical repair of varicocele may decrease seminal oxidative stress levels and sperm DNA fragmentation and, thus, may improve sperm quality [14]. Therefore, surgical intervention seems to be a reliable option in the treatment of varicocele-related male infertility, although some controversial reports exist.

Additionally, anti-oxidant medications such as kallikrein, L-carnitine with L-acetyl carnitine, pentoxifylline, coenzyme Q10 have been used to improve the milieu in the testis in men with varicocele [15]. Metformin is a major therapeutic agent in the treatment of type 2 diabetes mellitus as an insulin sensitizer, which decreases hepatic glucose output and increases peripheral glucose uptake. Although its action was not fully elucidated, metformin attenuated intracellular reactive oxygen species and apoptosis in aortic endothelial cells, myocardium, renal tubular cells and testicular cells [16-20].

Aim

Potential effects of metformin on varicocele-induced testicular damage have not been studied in neither humans nor in animal models. Thus, we investigated the impact of metformin on spermatogenesis, testicular integrity, and apoptotic activity in the testis of adolescent rats with experimentally-induced varicocele.

Materials and Methods

Thirty-six male adolescent Wistar rats (6-week-old) were randomly and equally divided into six experimental groups. Surgical procedures were carried out under anesthesia with intraperitoneal injection of ketamine (50 mg/kg). The experimental groups were as follows:

• (C) Control group; no surgical procedure was performed, and testis was examined after removal.

• (S) Sham group, a midline incision was performed, and testis was examined 8 weeks later.

• (V) Varicocele - only group: Experimental varicocele was induced by partial ligation of left renal vein with

Silk suture at the area medial to the insertion of the adrenal and spermatic vein into renal vein as described previously [21].

• (V+M) Varicocele + metformin group: All rats were treated with metformin (300 mg/kg per day by oral gavages) for 8 weeks following induced varicocele.

• (V/E) Varicocele + varicocelectomy group: Varicocelectomy was performed 4 weeks and the examination of the testis 8 weeks after the induction of varicocele. No medication was used.

• (V/E+M) Varicocele + varicocelectomy + metformin group: Varicocelectomy was performed 4 weeks after the induced varicocele. Metformin treatment (300 mg/kg per day by oral gavages) was initiated after the induction of varicocele and continued for 8 weeks. Left testes were examined 8 weeks after the induction of varicocele in all varicocele - induced groups. As maximum apoptotic activity initiates approximately 28 days after the induction of varicocele the procedure of varicocelectomy was performed 4 weeks after the formation of varicocele [22].

Histologic preparation and evaluation

The testicular tissue was fixed in Bouin’s solution (75% picric acid, 5% glacial acetic acid, and 25% formaldehyde) and embedded in paraffin blocks. Sections (5 μm) were formed, deparaffinized, and stained with hematoxylin and eosin. Spermatogenesis was examined in each group using Johnsen’s score (a score of 1-10 was assigned to each tubule regarding epithelial maturation) as described previously [23]. Sections were examined in a random order under a standard light microscope with 10x and 40x magnification by a blinded histologist; unaware of which group each rat belonged to. Histological grading was done by examining approximately 80 randomly selected seminiferous tubules per rat. Thus, a total of approximately 480 seminiferous tubules were scored for each group.

Histomorphometry analysis

A total of 103 randomly selected seminiferous tubules stained with hematoxylin-eosin were analyzed in each group. The presence of round spermatid stage (RSS) and primary spermatocyte stages (PSS) were assessed as described previously and compared among the groups [24].

Immunohistochemical staining for cleaved caspase-3 and ImageJ analysis

Cleaved caspase-3 was used for immunohistochemical staining. Testicular tissue samples were immediately fixed in 10% neutral-buffered formalin, embedded in paraffin, and sectioned (5 μm). Sections were deparaffinized and blocked for endogenous peroxidase activity with methanol containing 3% H2O2 for 10 m. Ultra V Block (Lab vision, Freemont, CA) for 7 m at room temperature. Cleaved Caspase-3 (#9664, Cell Signaling, U.S.) was applied at a dilution of 1: 500 and incubated overnight at +4 °C in a humidified chamber for nonspecific binding. The sections were washed in phosphate-buffered saline (PBS) and incubated with biotinylated horse anti-rabbit IgG (3 mg/mL; Vector, Burlingame, CA) at a 1: 500 dilution for 1 h at room temperature.

Antibodies were detected using a VECTASTAIN avidinbiotin complex (Vector PK 4000) for 30 m at room temperature. Antibody complexes were visualized after incubation with 3,3’-diaminobenzidine tetrahydrochloride (DAB, Bio-Genex, San Ramon, CA.) and were mounted under glass coverslips in Entellan (Merck) and then evaluated under a light microscope. Immunohistochemical staining for cleaved caspase-3 was analyzed by counting 100 seminiferous tubule cross-sections in each group and expressed as the apoptotic index. In each photomicrograph, the following parameter was measured with ImageJ software: expression levels of cleaved-caspase-3 in both groups at round spermatid stage (RSS) of testes. Each of this parameter was measured 3 times for each image and the average of the 9 measurements of each sample was used for the statistical analysis. Histopathological features examined in rats with normal testis and with sham, varicocele, varicocele+ metformin in a subjective scoring (0 - not present; 1 - low grade; 2 - moderate grade; 3 - high grade; 4 - very high grade).

Statistical analysis

Histopathological findings (Johnsen’s score) were assessed by nonparametric Kruskal-Wallis test, and the mean Johnsen’s score was used in the comparison of the groups. Multiple comparisons were made using Tukey’s procedure. p<0.05 was considered statistically significant. Analysis of variance was used for statistical analysis of the apoptotic index among the groups.

Results

Assessment of spermatogenesis

Johnsen’s score was significantly lower in V group (4.14±1.25) compared to C group (9.1±0.3) or S group (9.0 ± 0.2) groups (p<0.05). V+M group had significantly higher score (6.9±0.6) than V group (p<0.05). V/E group and V/E+M group had similar Johnsen scores (8.9 ± 1.02 and 9.2 ± 0.6). These findings suggest that the administration of metformin resulted in 40.6% of improvement in spermatogenesis in rats with varicocele. However, this favorable effect was not observed when metformin was used along with varicocelectomy.

Histological and morphological changes in seminiferous tubules

Histological and morphological changes in the testes of rats were compared via hematoxylin and eosin staining and degenerated tubules (DT) were only detected in V and V+ M groups, not in C, S, V/E and V/E+M groups (Figure 1). Visual assessment of the disorganized seminiferous tubules further supported these findings as seen in Figure 2. Seminiferous tubule degeneration scores were used for quantification of data (Figure 2b). V group had significantly higher scores of RSS and PSS compared to C and S group (2.6±0.8 and 3.7±0.4; 0.2±0.4 and 0.2±0.4; 0.9±0.6 and 0.6±0.7, respectively) (p<0.05). V/E group had significantly lower RSS (0.7±0.8) and PSS (0.8±0.7) scores than V group (p<0.05). V+M group had significantly lower RSS and PSS scores (1.8±0.7 and 2.6±0.7, p<0.05) in comparison to V group, implicating beneficial effects of metformin in rats with varicocele. When compared to V/E group, V/E+M group did not exhibit any difference in RSS (0.6±0.6) and PSS (1.4±0.5) scores, suggesting the absence of additive positive effect of metformin in varicocelectomies rats.

Apoptotic activity

Apoptotic activity was assessed by using cleaved caspase 3 expressions levels, staining of cleved caspase 3 positive seminiferous tubules were shown in Figure 3a. Cleaved caspase 3 expressions were significantly higher in V group (3.5 ± 0.5) compared to C (0) and S (0.2 ± 0.4) groups. V+M group had significantly lower cleaved caspase 3 level (3.0 ± 0.7) than V group. V/E group had lower cleaved caspase-3 expression levels (1.0 ± 0.7) compared to V group. Treatment of varicoceleectomy rats with metformin (V/E+M) did not further reduce apoptotic activity in the seminiferous tubules (1.75 ± 0.43) when compared to the varicocelectomy group (V/E) (Figure 3b).

Discussion and Conclusion

The present study demonstrates that metformin can reduce the extent of testicular damage in rats with varicocele, although having no effect in rats following varicocelectomy Spermatogenesis, seminiferous tubule integrity and the degree of apoptosis were improved using metformin in the presence of varicocele although it was not as remarkable as what was obtained through varicocelectomy. A review of the literature revealed that the impact of metformin on varicocele was not investigated in humans or animal models until now.

Although it is a commonly identified abnormality not all men with varicocele present with infertility. Some intrinsic factors may render some men to become susceptible to varicocele, thus, the best candidates who benefit from varicocelectomy yet to be clarified. Since oxidative stress was shown to be important in the pathophysiology of varicocele some agents have been used to improve the milieu in the testis [1]. A number of anti-oxidant medications have been studied to relieve detrimental effects of varicocele in the testis [25]. These agents have been used either alone or as an adjuvant therapy with surgery. However, surgery remains the treatment of choice and there exists insufficient data to recommend medical therapy in men with varicocele. Barekat et al. [26] reported that administration of an antioxidant agent N-acetyl cysytein as an adjunct therapy improved semen quality following varicocelectomy [26]. Tek et al. [21] demonstrated that vascular endothelial growth factor decreased apoptosis in varicoceleinduced rats as evidenced by diminished caspase-3 positive cells [21]. Both studies showed the benefit of these as adjunct therapy following varicocelectomy. However, in the present study metformin did not enhance the effect of varicocelectomy.

Minutoli et al. [13] demonstrated that neuronal apoptosis inhibin factor and surviving expressions were significantly reduced following varicocele induction and polydeoxyribonucleotide, an agonist of adenosine A2A receptor, administration restored testicular function [13]. Several other studies detected increased germ cell apoptosis in rats with varicocele [21,22,27]. However, in another study, apoptosis was found to be decreased in germ cells in the testes of infertile men with varicocele as compared with normal men [28]. It was speculated that the fixation of testis in formaldehyde might have played a role in the different result. In the present study, cleaved caspase 3 expression was used to assess apoptotic activity and it was found that metformin reduced apoptotic activity in rats with varicocele, whereas no additional effect was observed when metformin was administered after varicocelectomy.

Metformin is commonly used in type 2 diabetes mellitus and polycystic ovarian disease as an insulin sensitizer [29]. Also, it is present in various tissues including myocardium, liver, pancreas, thyroid, adipose tissue, hypothalamus, pituitary, and male and female gonads [19,30,31]. It has been reported that metformin is mainly transported into cells by organic cation transporters as passive diffusion is limited [32]. Although the mechanism of action is not yet fully elucidated recent studies suggested that metformin acts through AMP-activated protein kinase (AMPK) pathway, inhibits the activity of the respiratory electron transport chain in mitochondria, induces epigenetic modifications which in part may explain long term effects and decreases oxidative stress and apoptotic activity [16,19, 33-35].

Male reproductive system utilizes all these metabolic pathways and is prone to be affected by metformin administration [20,36,37]. Metformin was found to stimulate lactate production which is important in the development of germ cells and show an anti-apoptotic effect in rat Sertoli cells [38]. It was also reported that metformin reduced the apoptotic cells and caspase-3 level in rat testis [20]. The findings of the present study are consistent with previous studies that metformin reduced apoptosis in testis with varicocele. Yan et al. [37] reported that metformin improved the semen parameters related to its effects on weight loss, increased testicular weight and reduced testicular cell apoptosis [37]. On the other hand, Tartarin et al. [36] reported metformin at concentration 10 times higher than therapeutic levels decreased testosterone secretion and the number of Sertoli cells in rats when it was administered during pregnancy [36]. Faure et al. [39] reduction in testicular weight and testosterone level were observed in 6-week-old chickens treated with metformin for 3 weeks [39].

Several groups demonstrated that post-operative administration of metformin can exert protective effects in male reproductive function in rat models [40]. Bosman et al. [41] demonstrated that infertile hyperinsulinaemic men could benefit from metformin treatment in combination with an enriched antioxidant diet [41]. Besides, metformin was reported to act as a protective compound when used in the media for cryopreservation of spermatozoa [30]. In conclusion, metformin reduces detrimental effects of varicocele, although no additional benefit is expected following varicocelectomy. Further studies are required to apply metformin for this indication in humans.

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Drug Delivery Development: Quality Concepts, Challenges and Prospects-Juniper Publishers

JUNIPER PUBLISHERS-OPEN ACCESS JOURNAL OF DRUG DESIGNING & DEVELOPMENT

Abstract

Quality, being a key to success in competitive market is an imperative indicator of product. It is important to recognize that quality cannot be tested into products, i.e., quality should be built in by design. The search for new drug delivery approaches and new modes of action is a rapidly developing field. Modes of drug delivery have changed in the past few decades and the future looks set to provide even more therapeutic advances. DDS can be developed to target common and rare diseases; both come with their challenges and opportunities, which are explored in this article.

Challenges in quality drug development mainly includes negligence from management, material management, quality personnel, lack of validated process, lack of equipment qualification, improper documentation, research validation specially related to novel drug delivery system. Nevertheless these challenges can be reduced to an appreciable level with the proper training, initiatives from management, continuous validation programmes and accepting novel drug delivery development considering risk assessment.

Keywords:   NDDD; Quality issues in NDDD; Drug development challenges   

Introduction

The quality in the pharmaceutical industry has become a major concern and there has been a growing awareness for the significance of the quality of the pharmaceutical products. The current concept of Good Manufacturing Practices (GMP) accentuates that the quality of pharmaceutical products must be constructed during the overall process cycle [1]. Quality is never improved in a common way. It is always improved project by project, beginning with the most significant problems [2]. The deficiency to be challenged must be clearly specified & the expected improvement can be defined in measurable terms [3]. This article examines the current status of quality related issues in development of drug delivery system with the objectives of assessing challenges and prospects.

Challenges

  Challenging molecules and challenging markets is the key factor in drug development process. "On the molecule side, the pipeline is full of molecules with bioavailability, stability, targeted delivery, controlled release, and manufacturability challenges [4,5]. The benefit to risk ratio seems far removed and in true sense there is a functional gap between the development function and technical operations in the drug companies [6]. Cost of quality involves prevention cost, appraisal cost, internal failure cost (Scrap, rework and material losses) and external failure cost (returns and recalls), which has been neglected in the development process of delivery systems [7]. Global regulatory trends are yet to be defined fully, despite the several attempts already performed specially for novel drug delivery systems like Nano medicines. The other crucial issue is scale up. Commercial manufacturing uses much larger quantities compared to supply for the laboratory-scale experiments and, therefore, is a different ball game. Raw material batch-to-batch variability needs to be understood, process capabilities evaluated, and controls demonstrated by the vendor [8-10].

Prospects

The physicochemical and biological properties of the drug substance that can influence the performance of the drug product and its manufacturability should be identified and discussed [11]. The information on excipient performance can be used, as appropriate, to justify the choice and quality attributes of the excipient and to support the justification of the drug product specification [12]. Supportive management (philosophically and financially) can bring a quality concept and develop quality culture in the employees [13]. Quality policies need to be adopted indicating the goals of organization and support system in place to achieve those goals. Responsive deviation and investigation systems that lead to timely remediation will reduce the batch to batch variations [14].

  Well-defined, designed and validated processes during entire product development life cycle can assure the product quality and reproducibility. While the rules and guidelines are quite well in place, there exists a non-uniform interpretation of these rules. An emphasis on the training of continuous manufacturing technologies, regulatory and organizational approaches is the need of hour in development of novel drug delivery system [13]. Fostering voluntary compliance by the researcher should be the focus rather than adopting more strict regulations [14]. A full scale design of experiment (Quality by Design) that begins with predefined objectives should be considered in the developmental strategy. It highlights product and process understanding and process control, based on Science-based approaches and sound methods for assessing risk [8]. This systematic approach can enhance achieving the desired quality of the product and helps in understanding manufacturing strategy. Process development studies should provide the basis for process improvement, process validation, continuous process verification (where applicable), and any process control requirements as given in Figure 1 [15].   

Discussion

A systematic process plan and plant design undertaken by management and its implementation by considering trainings and research validation as part of the program can definitely lead to a quality product. QbD is just an approach to design a robust product but a quality product can be achieved only with the agreement of ethical principles for voluntary compliance rather than just fulfilling regulatory and organizational goals.   

Conclusion

Quality drug development is not a rocket science but it's just willingness of researchers involving certain principles to be followed.

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The Relationship Between Resonance Frequency Analysis (RFA) and Insertion Torque of Dental Implants: an in Vitro Study

Abstract

Purpose: The aims of the present study are to correlate the ISQ values, registered by the Osstell ISQ system, with the insertion torque during the placement of the implant, and to assess the influence of the thread initiator on the ISQ values and on the insertion torque.

Materials and methods: 140 rough surface implants screw-shaped implants, placed in 10 bovine ribs, were assigned to Group A (using the thread initiator before the insertion of the implant) or Group B (thread initiator was not used). The implants were implantedusing a manual torque wrench so insertion torque was registered. Once the implants were in place, primary stability was measured by means of RFA with the Osstell ISQ.

Results: When the thread initiator was used (group A), the mean insertion torque was 24,36 ± 14,88 N and when the thread initiator was not used (group B) the mean insertion torque was 35,30 ± 10,51N. The mean ISQ of the thread initiator group was 69,14 ± 8,39 and of the non thread initiator group was 72,17 ± 5,76. Pearson’s correlation coefficient was 0,587 (p<0,05) for group A and 0,193 (p<0,11) for group B.

Conclusions: It seems that the fact of using or not the thread initiator have no influence in the ISQ values. However, the IT decreased when the thread initiator is employed.

Keywords: Implant stability, Insertion torque, ISQ, Osstell, osseointegration

    Introduction

Implant stability depends directly on the mechanical connection between the implant surface and the surrounding bone. Initial stability, a consequence of an immediate mechanical adaption between the implant and the bone site, depends on the density of the bone tissue (the bone quantity and quality), the surgical technique used and the congruity of the site and macrostructure of the implant [1-6]. Secondary stability is the result after the formation of woven and lamellar bone around the dental implant surface as a secondary bone contact [2,3]. Primary stability was always considered a fundamental prerequisite to acquiring osteointegration [3,7] and it is now even more important, whenever clinicians want to use immediate loading protocols [8,9]. Extensive micromotion during healing and functional loading is one likely reason for implant failure as this may result in non-physiological conditions for bone formation and remodelling [10]. The greater the primary stability, the smaller the micromotions are between implant and bone. The micromotion promotes the formation of a soft tissue capsule around the implant, and as a result implant failure may occur [11,12].

Various non-invasive stability measurement techniques (i.e. methods of percussion, radiography, resonance frequency analysis, placement resistance, reverse torque and vibration in the sonic and ultrasonic ranges) were used to measure the stability of endosseous dental implants [2,3,5,13]. One of the quantitative methods is the insertion torque (IT) [3]. The IT, was described by Johansson and Strid [14,15], is the moment of force necessary to seat the implant into the osteotomy site, and it furnishes worthy information about the quality of the local bone [1- 5,16]. The determination of the IT is done by a torque gauge incorporated within the drilling unit or with a torque wrench during the insertion of the implant [8,9]. It is an easy method, but it can be measured only once, at the time of the insertion of the implant. It is not used to monitor the stability over time.

Resonance frequency analysis (RFA) was introduced by Meredith in 1996 [6,17]. It is a non-invasive, reliable, and objective method where the device measures the degree of implant stability at any time during the course of implant treatment and loading [3, 5,18,19]. The technique has been demonstrated to evaluate implant stability as a function of interface stiffness [6,15,20]. Although there is some controversy about it, a recent study has demonstrated a correlation between bone density and ISQ and displacement measurements. Thus, clinical measurements of implant micromotion would be one way to identify implants at risk of failure [21]. The implant/bone interface is measured from RFA as a reaction to oscillations exerted onto the implant ⁄ bone contact, where the unit of measurement is recorded as implant stability quotient (ISQ). RFA is assessed by the instrument Osstell (Osstell AB, Göteborg, Sweden). Osstellgives the ISQ on a scale from 1 to 100. The higher the ISQ number, the higher the stability [22,23].

Clinically, ISQ values have been correlated with changes in implant stability during osseous healing. Thus, IT and ISQ values are thought to have a positive correlation. However, the correlation of higher IT torque translating into higher primary stability may not always be true because the quantity and quality of bone varies significantly among patients [4].

The aims of the present study are to correlate the ISQ values, registered by the Osstell ISQ system, with the insertion torque during the placement of the implant and to assess the influence of the thread initiator on the ISQ values and on the insertion torque.

    Material and Method

140 rough surface implants (Shot Blasting®: alumina particle sandblasting and acid passivation) screw-shaped implants (Essential® Cone, Klockner Implant System, SOADCO, Andorra) were used. All implants had a diameter of 4mm (diameter at platform level is 4,5mm), a length of 10mm and a mechanized collar height of 1,5mm. The implants were assigned to one of the following groups:

a) Group A:complete drilling sequence, following the manufacturer’s protocol and using the thread initiator before the insertion of the implant.

b) Group B:complete drilling sequence without using the thread initiator.

The implants were placed in 10 bovine ribs (bone quality type II, according to Leckholm & Zarb [24], by an experienced clinician (user and knower of the Klockner Implant System for more than 2 years), following the manufacturer’s protocol. 14 implants were place in each rib. The osteotomy was performed under abundant irrigation with sterile saline solution at 800 rpm. The implants were inserted using a manual torque wrench so that the rough/smooth interface was placed at bone crest level. The distance between the implants had to be at least 10mm in between of the centre of the implants. As the implants were place with manual torque wrench, the exactly insertion torque was registered.

Once the implants were in place, primary stability was measured by means of RFA with the Osstell ISQ, by a second experienced clinician in the use of the ISQ device. The ISQ was measured over the Smartpeg screwed directly to the implant by the specific plastic hand-screwdriver. One Smartpeg is used every 5 implants (so 10 measurements were made with each transducer). The ISQ was registered perpendicular to the Smartpeg in 2 different positions:

The ISQ is registered from the front of the rib; and

The stability is registered from the right of the rib (90º from the first measurement). At each position, the ISQ was registered once.

SPSS 19.0 software (SPSS, Chicago, IL) was used for the statistical analysis. Mean values and standard deviations and the Pearson Correlation Coefficient were calculated. The normal distribution of the values and the homogeneity of the variances were tested through a Kolmogorov-Smirnov test. The differences between the mean values were compared with the nonparametric Mann-Whitney test. Then, all the values were grouped according to the ISQ and IT registrations and the differences were compared with the non-parametric Kruskal-Wallis test.When significant differences were obtained, 95% confidence intervals were found for average and mean differences (p < 0.05).

    Results

When the thread initiator was used (group A), the mean insertion torque was 24,36 ± 14,88N and when the thread initiator was not used (group B) the mean insertion torque was 35,30 ± 10,51N. The mean ISQ of the thread initiator group was 69,14 ± 8,39 and of the non thread initiator group was 72,17 ± 5,76. Pearson’s correlation coefficient was 0,587 (p<0,05) for group A and 0,193 (p<0,11) for group B.

The mean insertion torque values according to the ISQ was studied in Table 1. Statistically significant differences were found between group A when the ISQ was < 60 and ≥ 60; between group A when the ISQ was < 60 and group B when the ISQ was ≥ 60 and between group A and B when the ISQ was <60 and when the ISQ was ≥ 60 (shown in Table as a, b, c and d). In Table 2 the insertion torque related to the ISQ divided in three groups (low, medium and high ISQ values) was showed.

The mean ISQ values related to the insertion torque are given in Table 3. Statistically significant differences were only found between group A when the IT was < 30 N and ≥ 30 N and between group A when the IT was < 30 N and group B when the IT was ≥ 30 N (shown in table as a, b). In Table 4 the ISQ values according to the insertion torque divided in three groups (low, medium and high IT) was showed.   

Discussion

This study was conducted to evaluate the correlation between the IT and the ISQ values obtained from the RFA. The bone in which the implants are place is type II, according to Leckholm & Zarb’s [24] classification. The mean ISQ in our study was 69,14 ± 8,39 for the thread initiator group and 72,7 ± 5,76 for the non thread initiator group. These results are similar to those of other trials examining the ISQ in cow ribs (also bone quality type II). In 2009, Andrés-García et al. [25] found a mean ISQ of 70,86 ± 3.4 and 70 ± 3,8 when placing two different implants (3,7 x 10mm Zimmer® Dental and 4x 10 mm Nobel Biocare®) in cow ribs with bone quality type II-III. In 2014, Romanos et al. [26] analysed the ISQ of three types of implants (two types of straight-screw type implants -one with polished collar and the other one without- and one tapered-screw type implant) placed in cow ribs, bone quality type III. The implants were Straumann, length 10 mm and diameter 3,3 mm. The mean ISQ values were 75,02 ± 3,65, 75,98 ± 3,00 and 79,83 ± 1,85, respectively. The slight differences between the results of those trials and the present one could be due to the different macro design of the implants used. The literature agrees that the most appropriate design is endosseous screw-shaped implants.

Pearson’s correlation coefficient showed that the correlation between the IT and the RFA is positive: 0,587 (p<0,05) for group A and 0,193 (p<0,11) for group B. The correlation for the group B is very low. This means that when the thread initiator was used there were more correlation in between the two variables and that when thread initiator is not used there was almost no correlation between them.

The data published about this theme is contradictory. Data presented by Turkyilmaz et al. [3] in 2006, is in contrast with the results of group B of the present study. They analysed 142 Brånemark implants and reported an Spearman correlation of 0,583 that is very far from 0,193 reported for group B, but is similar to the correlation reported for group A. The reason for this difference appears unclear, but it could be explained by the different design of the implants studied, as well as the smaller number of the sample. Kahraman et al. [2], in 2009, found a positive significant correlations between the IT and ISQ values at the surgery (r = 0,78, p < 0,001), and at the prosthesis delivery (r = 0,46, p < 0,01) when 16 Straumann Standard Plus Implants and 26 MIS Seven Implant were inserted in 13 patients. In 2010, Degidi et al. [8] also reported a positive but low correlation between IT and ISQ of 0,247 when 514 Xive Implants was inserted in 52 patients. Makari et al. [6] in 2012 showed a positive correlation between IT and ISQ at baseline (r= 0,313, p< 0,049), at 3 weeks (r = 0,472, p < 0,002), and at 6 weeks (r = 0,419, p < 0,007). In 2012, Degidi et al. [9] published another study in which IT and ISQ was evaluated in 4135 XiVE implants (Dentsply Friadent) inserted in 1045 patients. The correlation between the two variables in that study was r = 0,218 (p < 0,0001). Also in 2012 Park et al. [13],  viewed a correlation between the ISQ value and the maximum

IT value at the initial implant surgery (p < 0,01, r = 0,427); when 81 implants (Branemark with the external connection and ITI implants with internal connection) were inserted in 41 patients. They also found that Implants in the mandible showed higher ISQ values than did those in the maxilla (p < 0,01), and ISQ values were higher for the external type of implants compared to those of the internal type (p < 0,01). As the implant diameter increased, the ISQ value also increased (p < 0,01). Respect to the IT, they showed that Implants in the mandible showed higher maximum IT values than did those in the maxilla (p < 0,01), while male patients exhibited higher maximum IT values than did females (p < 0,01). Maximum IT values were higher with the external implant type compared to those of the internal type (p < 0,01).

It is also suggested that ISQ and IT values are also dependent on the system used [27,28], and self-tapping tapered implant design brings higher initial stability than parallel wall cylindrical implant systems [29]. O’Sullivan et al. [27] presented that surface geometry had a great importance, in which the design of the implant had the ability to increase the interfacial stiffness at the implant ⁄ bone interface analysed by IT and RFA analysis.

When the IT and RFA are analysed by groups, our results are in agreement with those of Degidi et al. [8]. It seemed that ISQ values were generally high or medium, while low ISQ values were quite rare. On the other hand, the distribution of IT values was much more uniform between the groups. These data suggests that RFA and IT represent two different features of primary stability, with the first indicating the resistance to bending load and the latter indicating the resistance to shear forces [8,30].

     Conclusions

The fact of using or not the thread initiator has no influence in the ISQ values. However, the IT decreased when the thread initiator is employed.

    Acknowlegement

The authors are grateful to Spanish Goverment for the CICYT MAT-2015-67183-R (MINECO/DEFDER,UE).

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Author Information :  Beibei Guo1 PubMed ID : PMID: 29645007 PubMed URL : https://www.ncbi.nlm.nih.gov/pubmed/29645007 Journal Name : Biostatistics and Biometrics Open Access Journal ISSN: 2573-2633 Full Article Link : https://juniperpublishers.com/bboaj/BBOAJ.MS.ID.555665.php Article Title : Critical Analysis of White House Anti-Drug Plan Author Information : Kenneth Blum PubMed ID : PMID: 29057394 PubMed URL : https://www.ncbi.nlm.nih.gov/pubmed/29057394 Journal Name :  Journal of Addiction & Rehabilitation Medicine ISSN: 2573-2447 Full Article Link : https://juniperpublishers.com/gjarm/GJARM.MS.ID.555568.php Article Title : Impaired Cerebral Autoregulation-A Common Neurovascular Pathway in Diabetes may Play a Critical Role in Diabetes-Related Alzheimers Disease. Author Information :  Huang J PubMed ID : PMID: 28825056 PubMed URL : https://www.ncbi.nlm.nih.gov/pubmed/28825056 Journal Name : ISSN: Full Article Link : Article Title : Opioid Prescription Drug Use and Expenditures in US Outpatient Physician Offices: Evidence from Two Nationally Representative Surveys. Author Information :  Zaina P Qureshi PubMed ID : PMID: 28845476 PubMed URL : https://www.ncbi.nlm.nih.gov/pubmed/28845476 Journal Name :   Cancer Therapy and Oncology International Journal ISSN: 2473-554X Full Article Link : https://juniperpublishers.com/ctoij/CTOIJ.MS.ID.555611.php Article Title : Psychological Well-Being and Type 2 Diabetes. Author Information :   Laura Duque-Serrano and Jeff C Huffman PubMed ID : PMID: 29276801 PubMed URL : https://www.ncbi.nlm.nih.gov/pubmed/29276801 Journal Name : Diabetes and Obesity Journals ISSN: 2476-1435 Full Article Link : https://juniperpublishers.com/crdoj/CRDOJ.MS.ID.555641.php Article Title :  The Role of Txnip in Mitophagy Dysregulation and Inflammasome Activation in Diabetic Retinopathy: A New Perspective. Author Information :  Lalit P Singh PubMed ID :  PMID: 29376145 PubMed URL : https://www.ncbi.nlm.nih.gov/pubmed/29376145 Journal Name :  Open Access Ophthalmology Journal ISSN: 2473-5477 Full Article Link : https://juniperpublishers.com/jojo/JOJO.MS.ID.555643.php Article Title : Can Diabetes Be Controlled by Lifestyle Activities? 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Juniper Publishers|  Splenic Rupture by Tubular Drain in a Patient with Necrotizing Pancreatitis

Journal of Surgery

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Abstract

Background: Severe acute pancreatitis is an acute abdominal disease that possesses a powerful systemic inflammatory response, and can progress quickly, going from the stage of local pancreatic damages to the dysfunction of several organs, with the development of multiple local and systemic complications.

Aim: In this article, a case of splenic perforation by abdominal drain will be described, as a late complication of pancreatic necrosectomy, in a patient with severe acute pancreatitis.

Methods: The information was obtained through data from medical records and photographic registers of the diagnosed methods to which the patient has been submitted, andrevision of medical literature.

Results: F.L.S, female, 54 years old, hospitalized at Health House São Lucas Hospital presenting intense abdominal pain and elevation of pancreatic enzymes. During the hospitalization, the patient developed a sepsis and a new abdominal CT scan showed necrosis covering more than 70% of the pancreas, associated with the infection of the mentioned necrosis. Following the pancreatic necrosectomy by placement of abdominal drains, the patient presented a splenic perforation by the tubular abdominal drain, resulting in the necessity to adopt conservatory measures to deal with this case.

Conclusion: Therefore, it is possible to observe that there hasn´t been any reports of splenic perforation by draining following a pancreatic necrosectomy in the medical literature consulted. Thus, this report constitutes a rare case to the present day. However, there is no way to contraindicate the frequent use of tubular draining, since this is an isolated case and there isn´t other data and there aren´t reports that analyses this topic in medical literature.

Keywords: Acute necrotizing pancreatitis; Splenic diseases; Drainage; Postoperative complications

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Introduction

Severe acute pancreatitis (SAP) is an acute abdominal disease that possesses a powerful systemic inflammatory response, and can progress quickly, going from the stage of local pancreatic damages to the dysfunction of several organs [1-4]. In most cases, acute pancreatitis (AP) is considered a mild and self-limited disease, but around 20-30% of all patients with AP develop a case of SAP, with the development of multiple local and systemic complications [5].

The complications associated with AP are divided in local and systemic. The “local” group includes pancreatic pseudocysts, fluid acute peripancreatic collections, and unconfined necrosis; not to mention splenic vein or portal vein thrombosis, colon necrosis and gastric dysfunction [6-9]. These complications must be suspected in case of persistence, or recurrence, of abdominal pain, secondary increase of serum pancreatic enzymes, organic dysfunction intensification, and/or development of clinical signs of sepsis [7-9]. The group of “systemic”, there were observations of circulatory and renal alterations, organ failure, or exacerbation of severe pre-existing comorbidities [6-9]. Such complications are responsible for slowing the patient’s hospital discharge and determine therapeutic interventions [6,8].

Necrotizing pancreatitis is the most fearful development; it is often associated with a reserved prognostic. Interventions are generally indicated to patients with a case of infected pancreatic necrosis and seldom in cases of sterile symptomatic necrosis. Traditionally, the most used approach has been open surgical necrosectomy. Nevertheless, the treatment has been evolving significantly as to using minimally invasive techniques [3,4,9]. In this article, a case of splenic perforation by abdominal drain will be described, as a late complication of pancreatic necrosectomy, in a patient with severe acute pancreatitis.

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Methods

The information was obtained through data from medical records and photographic registers of the diagnosed methods to which the patient has been submitted. Having completed the revision of medical literature concerning this topic, through thorough research on the Pubmed/Medline, Scielo, Embase, Scopus and Web of Science databases using the description: “necrotizing pancreatitis”, “spleen perforation by tubular drain”, “splenic complications in acute pancreatitis”, “surgical management in necrotizing pancreatitis”. Also, having analyzed published articles in the period between the years 2000 and 2015, written in English, Spanish and Portuguese, we did not find any case of splenic perforation by tubular drain following pancreatic sequestrectomy, or even something similar to this, in all medical literature. Consequently, we can infer that this is a unique case.

Blood investigations including thyroid profile were within normal range. FNAC was done from both the swellings and it was reported as follicular neoplasm. CECT neck showed ill-defined lesion with calcification (5.1 x 4.0 x 3.6 cms in size) is seen in right lobe of thyroid (Figure 2). Medially the lesion was abutting thyroid cartilage without osseous erosion. Lesion was having ill-defined interface with adjacent strap muscle and causing left lateral displacement of trachea. Posteriorly the lesion is abutting vertebral body of corresponding cervical vertebra w/o osseous erosion. Laterally the lesion is seen abutting carotid vessels and internal jugular vein with slight postero - lateral displacement. Another morphologically similar soft tissue lesion with necrotic areas and calcification (5.4 x 5 x 5.1 cms in size) is seen lateral to lesion described in right lobe of thyroid (Figure 3). No retrosternal extension of right thyroid lesion was present.

Indirect laryngoscopy showed bilaterally mobile vocal cords. Patient was optimized for surgery and total thyroidectomy with right selective neck dissection (supraomohyoid level I, II and III lymph nodes) was done (Figures 4 & 5). Both right and left recurrent laryngeal nerves were preserved. 3 parathyroid glands were identified and were preserved.Intraoperative and immediate postoperative period was uneventful with post op T - sign monitoring and serial total calcium & phosphorus remained within normal range. No immediate or late postoperative complications were noted. Stitch line was healthy & patient was discharged in satisfactory condition on 4th post operative day. Final Histopathology report came out to be follicular variant of papillary carcinoma thyroid with lymph node invasion. Patient was enrolled for postoperative radioactive iodine therapy. He is now asymptomatic with completely normal biochemical profile.

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Results

Case Report

Patient F.L.S, 54 years old, female, admitted to the Health House São Lucas Hospital, Natal/RN-Brazil, presenting high intensity abdominal pain on the upper quadrant, with irradiation on the dorsal region, associated with distension, nausea and vomiting. The patient denied having fever, any sort of bleeding or urinary abnormalities. Patient described an instance of evacuation with softened feces. She also made daily use of 50mg captopril for arterial hypertension control. The laboratory exams displayed an increase in amylase and lipase, both over 3 times the superior limit of normality. Hence, the patient was diagnosed with severe acute pancreatitis (classified by the Ranson criteria and the tomography index). After her admission in the hospital, the patient was submitted early enteral nutrition through jejunal nasoenteral catheters, as this is protocol when dealing with cases of SAP.

Following the stabilization of the patient’s clinical condition and around 48h after the diagnosis of the SAP, a CT scan was conducted, which evidenced a grade D acute pancreatitis on the Balthazar classification. Having passed 6 days, a new CT scan displayed an evolution to a grade E (AP). In face of this, the patient remained hospitalized receiving clinic treatment (enteral nutrition, analgesics and venal hydration). On her 20th day of hospitalization, her clinical condition worsened, with the development of diffused abdominal pain, distension, fever, diarrhea and severe edema in inferior limbs. In this occasion, the laboratory exams showed alteration that suggested sepsis. Because of this, a new CT scan was conducted (with contrast), which revealed signs of a SAP, with more than 70% of pancreatic parenchyma, and two perinecrotic collections which may have suggested an infection; not to mention bilateral pleural effusion.

As a result of the patient’s clinical condition, she was submitted to surgical treatment, which consisted in a pancreatic sequestrectomy with the placement of silicon 20F tubular (Blake drains), in retrocavity of the epiploon, with the intention to continuously irrigate and wash this area. After the proceeding, the patient was transferred to the Intensive Care Unit (ICU), where she remained for 24h and following this, she was moved to the infirmary. Following the surgical proceeding, she remained in continuous irrigation of the pancreas through three drains, via a pressure regime, resulting in an improvement of her clinical condition. Despite the improvement, shortly after one of the washing proceedings, she developed a bacteremia, and there was an observation of a mucocutaneous paleness, fever with shivering and hypotension; resulting in the initiation of an antibiotic therapy.

She developed a progressive improvement, which led to the decision of substituting the enteral diet (offered by the jejunal nasoenteric catheter) with a liquid oral diet test. However, after a few more days of treatment, drainage of enteric content was observed by one of the drains. Therefore, we decided to conduct an upper digestive endoscopy, which evidenced a duodenum-pancreatic fistula. Following this, the enteral diet was suspended, and we initiated a total parenteral nutrition associated with treatment with hyperbaric therapy, culminating in the fistula’s spontaneous closure around 28 days after the start of the treatment of this complication.

The patient remained hospitalized receiving a conservatory treatment associated with hyperbaric oxygen therapy, showing satisfactory and continuous improvement of her condition and a progressive reduction of the abdominal drain debit, with an improvement of the drained secretion aspect; regardless of showing mild pain on the left upper quadrant and occasional fever (she was receiving antibiotic therapy). She occasionally displayed sudden secretion elimination with a dark maroon color in the abdominal drain of the collecting bag along with a mild and transitory hypotension. The patient was, therefore, submitted to a new total abdomen CT scan (Figures 1 & 2), with the observation of an abdominal drain where its extremities were in the inferior spleen region, not to mention peripheral splenic hypotransparent areas; which may be related to infarct regions. Because of this, the patient was diagnosed with transfixing lesion of the spleen by the tubular drain.

In the complication treatment, a conservatory measure was chosen, removing the tubular drain on the 5th day after the diagnosis, along with splenic arteriography with the objective of embolization, in case of bleeding. However, there was no bleeding. Following this approach, there was an improvement of the clinic and laboratorial parameters, with the spontaneous output of the abdominal drain. The hospital discharge occurred after 197 days of hospitalization, and the patient did not present any residual symptoms.

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Discussion

The pancreatitis can appear in varied degrees, from a simple form to a more complicated one; and it can also affect other tissues. According to the Atlanta Revision Classification, the AP can be classified in types and degrees of the disease’s severity [6,8].

Regarding the types, it is divided in edematous interstitial and necrotizing. The edematous interstitial pancreatitis constitutes 80% to 90% of patients with AP. It is a milder form where there isn´t a necrosis of the pancreatic parenchyma or peripancreatic parenchyma in image exams, and has a quick resolution. The necrotizing pancreatitis is defined by the presence of necrosis of the pancreatic parenchyma or of the peripancreatic tissues. It is the most aggressive type of AP, associated to the reserved prognostic [6,8]. This brings some possible complications in its development, such as: infection, bleeding, alteration of the pancreatic duct and formation of stenosis, and compartmental abdominal syndrome [3,4,9].

Three degrees of classification of the disease’s gravity are observed: mild acute, moderated and severe pancreatitis. This classification is based on the presence or absence of the persistent organic failure-verified through the Modified Marshall Score - and local or systemic complications [6,8,10,11]. In the mild degree, there isn’t any organic failure or local and systemic complications, and generally this is settled within a few days to a week [6,8]. The moderated form is associated to transitory organic failure (with a score ≤ 2 in the Marshall Score in one or more organ systems for less than 48 hours) and/or local complications or exacerbations of pre-existing comorbidities, and in general this resolves in a slower manner, and may require interventions and increases the hospitalization time [6,8].

In the severe form, organic failure occurs in a persistent manner (with a score ≥2 in the Marshall Score in one or more organic systems for more than 48h), which forces the patient to remain hospitalized and some form of intervention [6,8]. Systemic complications include splanchnic venous thrombosis, compartmental abdominal syndrome, pseudoaneurysm, acute respiratory distress syndrome and exacerbation of subjacent comorbidities, as a reference of the coronary arterial and chronic pulmonary disease [12]. Most of the severe complications occur within 48h after the start of the symptoms. The Ranson criteria can identify several factors which, if positive, can predict a bad prognostic [13].

It’s important to remember that the necrotic fluids and tissues may become secondarily infected, resulting in systemic inflammatory response syndrome and sepsis [12]. The most important matter in the management of pancreatic necrosis and peripancreatic necrosis intervention is the adequate moment to do surgery [3,9]. At first, the conservative treatment for necrotizing pancreatitis should be the first to be executed [14]. The interventions to drain and/or debride the necrotic tissue are divided in open surgery (transperitoneal laparotomy or retroperitoneal approach with an incision in flank) and minimally invasive (percutaneous proceedings, laparoscopic, retroperitoneal, transmural endoscopy or combined approach) [3,9].

With regards to the adequate moment, it’s essential to emphasize that the debridement of the pancreatic necrosisless than three weeks of clinical evolution increases the risk of bleeding and other adverse events [3,9,14]. Moreover, postpone the intervention allows the separations between necrosis and viable tissue, in a way that if the necrosectomy is executed, the chance of removal of the viable tissue is minimized, allowing a better endocrine and exocrine prognostic [3,9,15,16]. In most cases, the sterile acute necrosis doesn’t require early intervention (only if there are signs of sepsis). It´s only required in a more advanced stage and in the presence of the symptoms (abdominal pain or mechanic bowel obstruction) [3,9,17]. The goal will be to control the infection, through the removal of the necrotic tissue and draining of the inflammatory exudates [18].

The pancreatic necrosis (PN) becomes infected in most cases when it covers more than 50% of the organ. The diagnostic is given especially when the patients are submitted to CT with contrast, in periods longer than seven days, simplifying the discovery of the necrosis. In case of doubt with regards to infectious condition, a fine needle aspiration (FNA) guided by CT must be executed, followed by Gram staining and microbiologic culture. This method is considered the gold standard of diagnosis [19]. In our case, the puncture was not performed, since there was strong clinical evidence and suggestive CT image of infection in pancreatic tissue.

In case of confirmed infection of pancreatic necrosis, there may be the need for early intervention, aiming to control the infection with the removal of necrotic tissue and preserving the remaining pancreatic tissue [20]. The approach should be done with systemic antibiotics and surgical intervention, such as the laparotomy with pancreatic debridement, accompanied by debridement and washing the peripancreatic tissue [3,9,17,18]. After the procedure, the abdomen can be kept in peritoneostomy or be closed and maintained in continuous washing system through calibrous drains [19].

Due to the absence of similar cases in the literature, there is no established cause or frequency of complication of sequestrectomy with abdominal drain in severe acute pancreatitis [20]. Regarding to pancreatic fistulae, are in an abnormal communication between two tissues. They usually arise when there is injury to the main pancreatic duct or one of its branchs [21,22], commonly as complications of procedures as necrosectomy or endoscopic drainage. They are reported mainly posttraumatic pancreatitis, being evidenced by around 2 to 7 days post-trauma observation of serous drainage with increased amylase level (1000-30000u/mL) [23].

There are also reported cases of non-traumatic fistulas resulting from non-surgical treatment of pancreatitis, but mainly as the outcome of a pseudocyst. These fistulas allow more often communication with stomach (one third of the cases), followed by colon and duodenum [24]. Most enteric fistulas by pseudocyst that form in the upper gastrointestinal tract can be treated conservatively and has relatively good prognosis. However fistulas formed in the colon rarely exhibit spontaneous healing and tend to have fatal complications [24].

In the case of infected necrosis, fistulas and bleeding, the treatment must be surgical, and one of the techniques used is the sequestrectomy with drainage per tubular drain [25].

The splenic complications are rare events during the course of acute pancreatitis and have various descriptions, including pseudocyst, subcapsular hematoma, spleen infarction, spleen internal hemorrhage and spleen rupture [26]. Subcapsular hematoma, pseudocysts and ruptured spleen are more common in chronic pancreatitis [26], while splenic infarcts and spleen internal bleeding tend to be more frequent in acute pancreatitis [27]. However no traumatic splenic lesions in acute pancreatitis scenario are rare [28]. To this present date no other splenic injury by tubular drain has been reported.

Visceral perforation, especially perforation of hollow viscera is a known complication of pancreatic necrosectomy; however, this is reported in medical literature as an immediate complication of the procedure. There are no data in the medical literature showing the splenic drilling as a late complication of pancreatic surgical debridement, as well as any relationship between the use of tubular drain with such complication [29].

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Conclusion

Severe acute pancreatitis is a difficult condition to handle, featuring a variety of local and systemic complications, such as acute pseudocyst, pancreatic abscess, net collections, fistulas (pancreaticoenteric and pancreaticopleural), abdominal compartment syndrome, systemic inflammatory response syndrome (SIRS), acute renal failure and pancreatic necrosis, as described in the literature. The complication reported in this case, as previously mentioned, has never been reported in the medical literature as post sequestrectomy pancreatic complication. Thus, despite being a potentially serious complication, we chose to manage the case through a non-invasive therapy with the support of interventional radiology. This approach resulted in a reduction in hospitalization time, reduced likelihood of complications, and consequently optimized time of patient recovery.

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Embolic Stroke and Nephrotic Syndrome: A Case Report and Literature Review

Authored by  X Michelle Androulakis

Abstract

Nephrotic syndrome (NS) is less commonly associated with arterial thrombosis than venous thrombosis. We report a case of a 43-year- oldwomanwho presented with an acute embolic stroke confirmed on MRI, about 3 months after the diagnosis of NS. The standard stroke evaluations did not show evidence ofcardiac source of embolism, large vessel atherosclerosis or any primary hypercoagulable disorders. Laboratory tests revealed impaired renal function and extremely high nephrotic range proteinuria and a renal biopsy showed primary membranous glomerulonephropathy. Subsequently, she was discharged on anticoagulation and responded well to the treatment. This case illustrates the importance of considering hypercoagulable evaluation due to nephrotic syndrome as a potential cause of embolic stroke, and the initiation of anticoagulation therapy in a timely manner. We also present a literature review on the association between nephrotic syndrome and acute stroke.

Keywords: Stroke; Nephrotic syndrome; Hypercoagulable state; Arterial thrombosis

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Introduction

It has been shown that patients with nephrotic syndrome (NS) are prone to thrombo-embolic phenomena [1, 2]. The risk of thrombo embolism is increased during the first 6 months of the onset of NS3. In adults with NS, arterial thrombo embolic events are not as well characterized and less commonly reported than venous thrombo embolism [4]. Acute ischemic stroke is a rare complication of NS [5,6,7] and this link has not been widely reported in the literature.

Although the exact pathogenesis of cerebral infarction is not clearly understood, it has been postulated that a hyper coagulable state in NS may play an important role in ischemic stroke [3,8]. Few studies have suggested that hyper coagulability in NS is associated with the steroid and diuretic administration [9]. Although there are case reports of NS and stroke [7,10-16], we report this case to illustrate the importance of considering hypercoagulability from NS as a potential cause of embolic stroke, and to initiate anticoagulation treatment if appropriate. Additionally, we performed an extensive literature search for NS and association with ischemic stroke.

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Case Report

A 43-year-old, left-handed, woman presented with sudden onset of left sided weakness and word finding difficulty three months after the diagnosis of NS. Her other pertinent medical history included COPD, hypertension and was a smoker, with no significant family history for coagulation disorders. NS with membranous glomerulonephropathy was confirmed with biopsy during this admission. Medication history at the time of presentation included cyclophosphamide, prednisone, spironolactone, Lasix, Lisinopril and metoprolol. Her vitals were stable at presentation and general physical examination was benign. Her neurologic examwas significant for mild anomia and left sided weakness. Her laboratory tests showed significant proteinuria, mild hyperlipidemia and the standard hypercoagulable workup was normal. Other laboratory values are as detailed in Table 1.

Further work up included an MRI which revealed bi hemispheric regions of diffusion restriction, consistent with acute infarcts (Figure 1). Her cardiac work up was essentially normal. Vascular imaging of the brain was obtained with a CT angiogram which showed a left MCA occlusion at the M3- M4 segments, without evidence of any proximal large artery atherosclerosis. Given the bihemispheric infarcts, an underlying embolic source was likely. After an exhaustive cardiac work up did not reveal any source of cardio embolism, the possibility of hypercoagulability with significant proteinuria due to NS was considered the likely etiology, and anticoagulation was initiated.

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Literature Review

Systematic searches of peer-reviewed, published, research papers indexed in PubMed, EMBASE, and Science Direct from inception until Nov. 2016 were undertaken using key search terms related to ‘Nephrotic Syndrome', ‘ischemic stroke', and ‘infarction'. We identified 30 reported cases of acute ischemic strokes with NS after eliminating 10 cases with nephropathy related to DM. The age at the presentation ranged from 14 -73 years with a mean age of 40.7, and standard deviation 15.7 years. 70% of the cases (21/30) were male. Among 30 there were only 5 cases without a biopsy-proven diagnosis of NS, most of the cases (8/30) were membranous disease. The other cases were associated with Memberano proliferative Glomerulo nephritis, minimal change disease, IgA nephropathy, IgM nephropathy, Focal Segmental Glomerulo sclerosis and nodular glomerulopathy (Table 2). These infarcts have been described in various vascular distributions.

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Discussion

In this case of acute embolic stroke in the setting of NS (primary membranous glomerulopathy) with a normal coagulation profile, the initial differential diagnoses for the etiology of the embolic infarcts werecardioembolism, atherombolism and a primary hypercoagulable state. The work up for these, as outlined in the case were negative. Our standard hypercoagulable panel was normal in this case, butthis maybe confounded by the concomitant use of steroids. Other clotting factors that are not included in the standard hypercoagulable panel may be affected due to large amounts of urinary protein loss [17]. Marsh et al reported a similar case of stroke in NS with normal coagulation profile except for activated free protein S level [5]. As Fibrinogen is an acute phase reactant and has been associated with elevations in acute stroke with uncertain prognostic value, the fibrinogen level was not checked in our case. [18,19] Increased fibrinogen levels after vascular event is associated with recurrence of stroke and MI [20]. As the likelihood of hypercoagulability secondary to NS was high on the differential, she was discharged on anticoagulation and high intensity statin. She has remained stable since then, with no further vascular events.

Thrombosis is a major complication of NS. Although both arterial and venous thromboses occur, arterial thrombosis is rare and has been described in the femoral arteries commonly [7], but not in cerebral vasculature. Venous thrombosis is more common in the adult patient population while arterial thrombosis is more common in the pediatric patient population [4]. Primary hypercoagulable states like congenital or hereditary deficiencies of protein C, protein S and antithrombin-IIIare relatively rare inherited conditions that lead to endothelial dysfunction [21].

Secondary hypercoagulable states can be associated with underlying conditions such as pregnancy, malignancy, NS or oral contraceptive use [21]. Hypercoagulable states result from the imbalance between the pro-coagulant and anticoagulant factors. The primary glomerular defect in NS results in leakage of high amount of high molecular weight protein, which consist many hemostatic regulatory proteins [22,23]. The overall hypoproteinemia is compensated by increased hepatic synthesis of high molecular weight clotting factors V, VII, VIII and X [24,25]. Increased urinary excretion of natural anticoagulant protein S, anti-thrombin III [26,27] has been reported.

Taken together, the net hemostatic balance is shifted towards a pro-coagulable state. As steroids may increase the concentration of anti-thrombin III and factor VIII [10], the levels of these clotting factors can be normal in NS patients taking steroids. Furthermore, diuretics can also lead to hypercoagulability due to hypovolemia and hemoconcentration. NS is also associated with thrombocytosis and platelet hyperaggregability [25]. In addition, immunologically mediated glomerular damage triggers extrinsic coagulation pathway and thus hypercoagulability [28]. Our review of current literature suggests that most of the acute stroke cases in NS are amongst young, predominantly male patients, and have relatively fewer other vascular risk factors. Hypercoagulable panels were not consistently abnormal, which is indicative of the limitations of current standard laboratory testing for this type of patients.

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Conclusion

In patients with cryptogenic ischemic stroke with concomitant nephrotic syndrome, anticoagulation for the secondary prevention of stroke and other thrombo-embolic events should be considered. Future prospective or randomized trials are needed to evaluate the link between NS and acute stroke as well as efficacy of anticoagulation therapy.

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Effects of Dredging Operations on Fishing Sites in the Niger Delta Basin Nigeria- Juniper Publishers

Abstract

The study examines the ecological and economic implications of dredging activities on fishing sites in the Niger Delta area of Nigeria. Data from secondary sources were empirically analysed and results show that dredging operations have significant effect on fishing sites. These are revealed by the magnitude of ecological and economic implications to the region, which is reflected by the level of economic value of damage caused by dredging in the area, the number of fishing sites and farm lands affected by the dredging operations. The study concludes that even though dredging is imperative for the economic survival of the area, there is need for routine studies to be conducted prior to the operations so as to ensure that dredging activities are executed in the most environmentally friendly manner in accordance to international best practices in order to mitigate ecological imbalance in the basin.

Keywords: Ecology; Economics; Dredging; Fishing; Niger delta; Basin

Introduction

The area politically known as the Niger delta is situated within the south-south, partly south-East and South-West regions of Nigeria. It extends over 70,000km2 and accounts for about 7.5% of Nigeria's land mass. Historically, the Niger delta consists of the present day Bayelsa, Delta and Rivers states, and recently Abia, Akwa-Ibom, Cross Rivers, Edo, Imo and Ondo states (Wikipedia, 2017). Geographically, the Niger delta is the delta of Niger River at the Gulf of Guinea on the Atlantic Ocean in Nigeria. Remarkably, the Niger delta is a coastal region of global environmental and economic importance, being one of the largest mangrove forests in the world, Africa's largest and the world's third largest delta (Wikipedia, 2017).

In furtherance, it is described as the most extensive fresh water swamp forests with a mosaic of diverse and sensitive ecosystems which transverse four vegetations zones in west and central Africa.

The major economic and occupational activities of the Niger Delta people include fishing, farming, hunting and palm oil production. Those residing in the coastal area are preoccupied with fishing while the upland inhabitants are pre-occupied with farming and palm oil production. This pre supposes that any human activity that poses an imbalance to the ecosystem of the area, may invariably affect the economic well being of the inhabitants. Dredging is one of such activities. L0kkeborg [1] posits that dredging is often carried out to create access for oil exploration, marine transportation and water borne commerce. The discovery of oil in the 50's have increased dredging and associated activities in the area, and thus supports the assertion of Akegbejo- Samsons [2] that dredging in sensitive ecosystems may have serious impacts if not well managed because of the dredged materials and their disposal.

Hence this study attempts to bridge these research gaps by the examination of the extent of ecological and economic effect of dredging and the fishing sites and farms in the Niger delta area of Nigeria.

Objectives

The specific objectives of this study include:

I. To examine the extent to which dredging activities affect fishing sites in the Nigeria Delta

II. To evaluate the extent to which dredging activities affect farming in the Niger Delta.

III. To determine the level of significance of the area dredged in respect of economic loss arising from dredging activities in the Niger Delta.

Research questions

The following questions are asked in order to proffer solutions to the problem of this study.

I. To what extent does dredge activities affect fishing sites and ecosystem of the Niger Delta?

II. To what extent does dredging activities affect farming and ecosystem of the Niger Delta?

III. Is the area dredged significant to economic loss arising from dredging activities in the Niger Delta?

Hypotheses

The tentative answers to the research questions asked in this study include:

I. Ho1: Dredging activities have no significant effect on the fishing sites and ecology of the Niger Delta.

II. Ho2: dredging activities have no significant effect on farming and ecology of the Niger Delta.

III. Ho3: The area dredged is not significant to economic loss arising from dredging activities in the Niger Delta.

Review of related literature

Dredging in sensitive environments as conveyed by Ade [3], Ohimain et al., Enger & Bradley [4]; and Edy & Ukpong [5] is often accompanied by ecological impacts including damage to Flora and Fauna; alteration of coastal topography and hydrology as well as impairment of water quality. They further agree that dredging virtually affects all components of the environment including zooplankton, phytoplankton, benthic invertebrates and the vegetation at large. In addition, it has been revealed that dredging and associated operations result to widespread hydrological changes resulting to coastal retreat. Hence, dredging may disrupt the dynamic interrelationship between environmental components and socio- economic functions of the coastal areas which may disrupt the ecological equilibrium.

The problems associated with dredging in respect of the environment are revealed in the works of Bray et al. [6] which affirms that dredging causes environmental changes, especially anthropogenic impacts on landscape that causes the accumulation of sediments in depositional sites in lakes, rivers and estuaries. Ehrlich & Anne [7] assert that dredged up pollutants dumped at designated locations increase the chance of contaminants straying into such areas that were initially free from contaminants. These contaminants which may be acidic in nature spread out to adjacent farms thereby affecting crop yields. On the other hand, the studies of Mercaldo- Allen & Goldberg [8] and L0kkeborg [1] further confirms that dredging affects fish species, as it is revealed that fish species in the un- dredged locations were found to be generally in a better condition than those in the dredged locations.

In summary, the effects of dredging on aquatic organisms have been a source of environmental concern for decades as it affects not only the mortality of fish and shell fish entrained during the dredging process but the adjourning farm lands and crop yields. Supportively, Ashton-Jones [9] concludes that dredging and associated activities could disrupt fisheries and may as well damage spawning grounds which result to serious impacts on vital fishery resources and invariably the fishing industry at large.

Materials and Methods

Data for this research was solely collated from secondary sources, particularly from the Shell bulletin and the publications of the Niger Delta Development Commission (NDDC). The data were subjected to econometric methods of multiple linear regression analysis in order to determine the empirical relationship that may exist among the variables defined as follows:

1. ADG = Area dredged in square kilometres (km2), a proxy for dredging activities in the Niger Delta.

2. ECV = Economic Value of damage caused by dredging activities in the Niger Delta, in millions of naira (Nm); a proxy for the economic effects of dredging activities.

3. FSS = Fishing sites affected by dredging activities in the Niger Delta, a proxy for the effect on the fishing industry.

4. FLD = The number of farm lands affected by dredging activities in the Niger Delta, a proxy for the ecological effect on the area.

5. μ = The disturbance variable denoted as Error term.

While ECV is the dependent variable, ADG, FSS and FLD represent the independent variables respectively.

Data Presentation

Source: Compiled from shell Bulletins and NDDC Publications.

Table 4.1 shows the annual statistics of the area dredged, the economic value of damage arising from dredging activities, the number of farms affected by dredging activities in the Niger Delta area of Nigeria.

Data analysis

Table 4.2 shows the correlations of the dependent variable and independent variables. The correlation matrix reveals that positive correlation exists between the Economic values of damage arising from dredging activities and the Area dredged as well as the Fishing sites and farm lands affected by dredging in the Niger Delta.

Source: SPSS V.20 Software.

Table 4.3 describes the variables entered/ removed for the analysis. It describes the dependent and independent variables as removed and entered respectively.

a. Dependent Variable: ECV

b. All requested variables entered.

Source: Software Output.

Table 4.4 shows the characteristics of the model as summarized. It reveals a model with a coefficient of determination R2 value of 0.804 which implies that the regression line gives a good fit to the observed data, since this line explains 80.4% of the total variation of the ECV values around their mean. Therefore, the remaining 19.6% of the total variation in the dependent variable, ECV is un accounted for by the regression line and is attributed to the factors included in the disturbance variable denoted as Error term, .The Durbin- Watson value of 2.505 reveals that there is no autocorrelation in the relationship.

a. Predictors: (Constant), FLD, FSS, ADG

b. Dependent Variable: ECV

Source: Software Output

Table 4.5 shows the Analysis of variance (ANOVA) for the variables. The F ratio indicates the effect of the independent variables on the model. The value of 5.481 is greater than 1 and therefore is an indication that there is no sampling error. At 0.067 level of significance, we can infer that out of 93.3 cases the difference between the mean is not by chance but genuine, as indicated in the table.

a. Dependent Variable: ECV

b. Predictors: (Constant), FLD, FSS, ADG Source: Software Output.

Table 4.6 shows the coefficients of the model and reveals their degree of statistical significance of the independent variables to the dependent variable. The t- test reveals that Area dredged, ADG is not significant in the model with a value of 0 which is less than 2 since it falls within the acceptance region; hence we accept the null hypothesis that the area dredged has no significant effect on the economic value of damage from dredging. The Fishing sites and Farmlands affected by dredging activities are significant in the model with t- test values of 2.334 and 1.968 respectively as they fall within the critical region. Hence we reject the null hypotheses that dredging activities has no significant effect on the fishing sites and that dredging activities has no significant effect on farmlands in the Niger delta. The model is mathematically formulated as: ECV = 39104641.66 + 4.815ADG + 119994FSS + 163048FLD.

a. Dependent Variable: ECV

Source: Software output.

Discussion

Prior to the discovery of crude oil in commercial quantities in the 50s in the Niger Delta, the people relied on their serene marine environment for sustenance. They made their living from exploitation of the waters, land and tropical as well as mangrove vegetations adjacent to their homes. They had strong attachment to their environment. However, the economic activities of the people were soon distorted as a result of environmental degradation occasioned by oil exploration and pollution as well as increased marine transportation and dredging activities. These activities have seemingly made life difficult for the coastal and riverside inhabitants of the Niger Delta.

In the light of the above, the salient issues addressed in this study were:

A. The examination that dredging activities affect fishing sites in the Niger Delta

B. The evaluation that dredging activities affect farming in the Niger Delta; and

C. The determination that the area dredged has no significant effect on the economic value of damage from dredging in the Niger Delta.

The results in Table 4.5 reveals that the Fishing sites and Farmlands affected by dredging activities are significant in the model with t- test values of 2.334 and 1.968 respectively as they fall within the critical region. These answers the first and second objectives of this study and the corresponding research questions which led to the rejection of the null hypotheses that dredging activities has no significant effect on the fishing sites and that dredging activities has no significant effect on farmlands in the Niger delta. Therefore, the results of the analysis reveal significant effects of dredging activities on both fishing sites and farmlands in the Niger Delta. This is strongly supported by the works of Bray et al. [6] and Mercaldo- Allen & Goldberg [8] that respectively posit that dredging causes environmental changes and increased contaminants.

The third research question of this study tends to be answered by the outcome of the analysis as shown in Table 4.5 which indicates that the Area dredged, ADG is not significant in the model with a value of 0 which is less than 2 as it fell within the acceptance region. This led to the acceptance of the null hypothesis that the area dredged has no significant effect on the economic value of damage from dredging. This result is contradicted by the work of Houton et al. [10] who reported that dredging has significant effect on the mangrove area. More so, the studies of Lokkeborg [1]; Lenihan & Peterson [11] further confirms that dredging affects fish species, as it is revealed that fish species in the un- dredged locations were found to be generally in a better condition than those in the dredged locations [12].

Conclusion

This study concludes that dredging activities have significant effect on fishing sites and farmlands in the Niger Delta as indicated by the positive correlation between the economic values of damage from dredging and the fishing sites and farmlands affected. It is also concluded that the area dredged have no significant effect on the economic value of damage from dredging. Finally, the study concludes that even though dredging is imperative for the economic survival of the area, there is need for routine studies to be conducted prior to the operations so as to ensure that dredging activities are executed in the most environmentally friendly manner in accordance to international best practices so as to mitigate ecological imbalances in the basin.

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Let’s Talk and Grow Together: A Bidirectional Communication between Granulosa- and Oocyte Derived Factors in the Ovary

Abstract

Reproduction, one of the most active and appealing area of research for endocrinologists and reproductive biologists since many a years, has several faces that remains to be unmasked in terms of its regulatory aspects. Available information on the regulation of oocyte development and maturational competence are gaping and needs elucidation to achieve utmost quality of eggs, a major area of concern. The notion of the somatic follicular cells providing an appropriate microenvironment for the development of oocyte throughout its journey has been replaced with the current perception of a complex yet regulated cross-talk between the granulosa-and oocyte-derived factors to orchestrate follicle development. Interestingly, actions of FSH and LH are mediated or modulated by these locally produced non-steroidal peptide factors from the follicular layer and the oocyte itself (insulin-like growth factors (IGFs), epidermal growth factor (EGF) family members, TGFβ super family members etc.), forming an intimate regulatory network within the ovarian follicles. Present article will provide a deeper insight into the need and underlying mechanisms of action of these growth factors in the intraovarian network to sustain a healthy oocyte.

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Psychiatric Rehabilitation Programs for Peoples with Disabilities: Literature Review-Juniper Publishers

Juniper Publishers- Journal of Yoga and Physiotherapy

Abstract

Hereditary factors and stigma in disabled people increase the possibilities of unemployment, environmental factors including adverse life experiences and psychiatric problems.Studies have shown that psychiatric problems in disabled people are five times higher than other people in the community. For this reason, besides treatment programs rehabilitation programs that enable psychiatric strengthening are needed to reintegrate disabled people into society and to enable them live their lives on their own or with minimum support. Psychiatric rehabilitation programs were revised through this mini-literature review and it is seen that the programs improved problem solving skills in disabled people, increased perceptions of family communication and social support, increased self esteem and decreased anxiety and depression symptoms.

Keywords:   Disability; Disabled person; Psychiatric rehabilitation; Psychoeducation; Evidencebased practices

Introduction

Disability is a phenomenon which is characterized by difficulties in adapting to social life and meeting the needs of daily life because of the loss, by birth or later for any reason, of physical, mental, spiritual, sensory and social skills at various grades and it needs support services such as prevention, care, rehabilitation and counseling [1]. Prenatal, at birth and postnatal causes play a role in the occurrence of disability. It is classified in seven groups as mental, physical, sight, hearing, language and speech, disability due to persistent diseases, and spiritual emotional disability [2]. According to World Health Organization (WHO) 2011 disability data, the rate of disability is accepted as 10% for developed countries and 15.6% for developing countries and it is estimated that 750 million to 1 billion people are disabled worldwide [3]. Disability rates have reached significant numbers all over the world and have recently been a serious issue to raise awareness on. In disabled people; the risk of biological disposition, unsuccessful experiences in social life, stigma perception and the occurrence of the psychiatric problems that are based upon stress effects originating from the individuals in family or in the environment are five times higher than the other individuals in the society [4]. Therefore, besides treatment programs rehabilitation programs that enable psychiatric strengthening are needed to reintegrate disabled people into society and to enable them live their lives on their own or with minimum support. Psychiatric rehabilitation is a comprehensive, coordinated and long-term treatment that is practiced to meet the mental and social needs of individuals with persistent symptoms and functional impairment [5]. In disabled individuals who are treated as private/different groups; this process progresses according to different and group specific needs because they have different problems than usual patients [4,5]. With this mini-literature compilation, it is aimed to review the "psychiatric rehabilitation programs" for disabled people which are a special group.

Methods

Search methodology

The study was carried out by retrospective scanning in the databases of the relevant publications. Studies, between January- March 2017, were scanned via Istanbul University internet access network, with the keywords "psychiatric rehabilitation", "physical handicap", "physical disability", "mental/intellectual handicap-disability-retarded", "deaf", "deafness", "hearing impaired", "visually handicap-disability", "speech and language disability"; in the databases of Ulakbim, Turkish Psychiatry Index, Google Academic, Pubmed, CINAHL, and Cochrane. The thesis studies done on the subject and the leaflets presented in the congresses were not included in the scope of the study.

Selection of studies

The following criteria were taken into consideration in the selection of the articles to be included in the study;

The practiced psycho-rehabilitation program is towards disabled people,

Being a research article that can be reachable as a full text,

Language of the publication is either Turkish or English,

Being original and quantitative,

Published in a national/international refereed journal between 2000 and 2017.

In the summarization of the data; a valid and reliable guideline for systematic reviews "A checklist of items that should be taken into account in the reporting of systematic compilation or meta-analysis studies" (Preferred reporting items for systematic reviews and meta-analyses statement -PRISMA-) was taken into account.

Results

When the psychiatric rehabilitation programs for disabled people were examined in the mentioned databases, a total of 7413 studies were reached. When studies were analyzed via the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) scheme by considering the inclusion criteria, 14 studies (Table 1) were considered appropriate and included. When studies are examined, it is seen that there are various cognitive, behavioral and socially supporting programs towards disabled people. Out of 14 studies examined, 7 of them are programs towards children and teenagers with autism, cerebral palsy and sight-disability, 1 of them towards elderly people with sight-disability, 6 of them towards adults with multiple sclerosis, physical or sight disability. In studies examined, it is seen that "Virtual Reality Therapy" (Table 2) practiced on children with cerebral palsy increases spiritual adaptation, "Picture Exchange Communication System (PECS)" practiced on children with autism provides a progress in social communication skills, "Communication-based Intervention Program" practiced on children with both autism and lack of verbal communication makes a significant difference in starting the conversation and "Interpersonal Communication Skills Psycho-Education Program" and "Structured Experience of Group Process" practiced on teenagers with sight disability are effective on increasing the empathetic tendencies and communication skills of teenagers.

In consequence of psychoeducation program practiced on elderly individuals with visual impairment, it is seen that depression and symptoms of anxiety reduce, "Healing Pathways" program practiced on physically disabled women with depression diagnosis decreases the points of depression and reduces its symptoms, "Development Programs of Self Esteem" increases the points of self esteem level significantly. Besides, with the development of technology, as a result of practicing telepsychiatry and telehealthprograms which have been often used recently on physically disabled people, it is seen that breakoff phenomenon and depressive symptoms are reduced in people.

Conclusion

With this mini-literature review, the psychiatric rehabilitation programs were revised and it was seen that the programs improved problem solving skills in disabled people, increased perceptions of family communication, social support, self esteem and decreased mood problems such as anxiety and depression. Besides programs examined, teaching daily life skills, assisted living and employment programs, sensory integration therapies, social skills education, behavioral change (regulation) education and spiritual education of the family towards disabled individuals exist and they are practiced.

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Enzybiotics, A New Class of Enzyme Antimicrobials Targeted against Multidrug–Resistant Superbugs-Juniper Publishers

JUNIPER PUBLISHERS-OPEN ACCESS JOURNAL OF DRUG DESIGNING & DEVELOPMENT

Summary

Gut microbiota with 2X1012 bacterial populations is essential for synthesis of vitamins, coenzymes and many other biomolecules in human and animal. But high dose of antibiotics destructed (since 1928) such bacteria in the alimentary tract posing a threat to extinct of human life. As a result signalling from human and bacteria orchestrated to build a defence to protect symbiotic relations saving both life forms. Bacteria synthesized hundreds of new genes (MDR Genes) to destroy antibiotics in different modes of actions. G-20 leaders and scientists have vowed a strong action plans (as assembled recently in Germany) to abolish the horror of superbugs which are claiming millions of death worldwide. Enzymes as therapeutic antibiotics has taken as emerging new antimicrobials derived from bacteriophages as well as bacteria like Staphylococcus sp., Streptococcus sp. and Histeria monocytogenes. Simply, autolysins, lysozymes, lysins and bacteriocins are great enzybiotics. Genetically modified enzybiotic (GMEnzy) has now a new field of enzyme antibiotic production using molecular biology and genetic engineering principles to overcome the antibiotic resistance. GMEnzy database has built for researchers and is available at http:// biotechlab.fudan.edu.cn/database/gmenzy/.   

Introduction

The term enzibiotic was coined from two words, enzyme and antibiotic and usually refers as the bacteriophage enzymes that attack the cell wall of bacteria with lyses [1]. However, enzybiotic present in bacteria, bacteria infected phages and in body fluids like tears, saliva and animal mucous [2]. Antibiotics had used 80 years with success to eradicate pathogenic bacteria like Escherichia, Klebsiella, Salmonella, Mycobacterium, Pseudomonas and Vibrio species. However, last two decades gradual increase of clinical isolates had shown with >95% now ampicillin and amoxicillin resistant which was controlled by synthesis of new derivatives of penicillin like cephalosporin and carbapenem drugs [3]. In 2009 NDM-1 Escherichia coli was found however, resistant to all class of penicillins including Beta-lactamase inhibitors like cavulinate and sulbactam but avibactam [4]. Skin infections by MRSA Staphylococcus aureus, PDR nosocomial infections by Pseudomonas aeroginosa and XDR tuberculosis by Mycobacterium tuberculosis are now serious threat to human and alternative approaches should be needed to overcome such crisis [5]. MDR genes (blaTEM, amp, blaNDM, blaOXA, sul1/2, catB3, aacA4, aacC2, aph, aad, dhfr, arr3,strA/B,etc) and drug efflux genes (tetA, acrAB-TolC, mexAB-oprM, mcr, macAB, norA, mdtA etc.) are wide spread in conjugative plasmids and chromosomes of superbugs which are also found in rain, sea and river water posing a threat to global peoples [6].

Thus a new field of science is enzybiotics which is under clinical trial in many research foundations. If enzybiotic is injected into patient with success then all physicians believe that such single enzyme or chimera enzyme would be most useful in superbug cure [7]. It is to save gut microbiota that provide life saving coenzymes involved in glycosysis, TCA cycle and ATP generation [5].   

Result

Some important enzybiotics are:

(a) Lysins. PlyG is Phage-y amidase which can destroy Bacillus anthracis (Figure 1) [8].

(b) Bacteriocins. Lysostaphin is Streptococcus simulans enzyme that acts as endopeptidase on Staphylococcus aureus and many Streptococcei sp. (Figure 2) [9].

(c) Autolysins. S. equidermis autolysin enzyme lyses β (1-  >4) glycoside bong between N-acetyl glucosamine and N-acetyl  muraminic acid of many bacteria (Figure 3) [10].

(d) Lysozymes. Egg white lysozyme is muramidase that destroy peptidoglycans and very effective against Gram (+) bacteria [11].

The lysins are 453-473aa long extracellular enzymes and have been sequenced from Streptococcus suis, Streptococcus agalactiae and others (protein ids. WP_061713285, WP_043026720, WP_070043600) with 50-150 mutations among themselves [12,13]. The multispecies bacteriocin (protein id. WP_013103375) has only 54% amino acid similarities to the Leuconostoc sp. Bacteriocin secretory protein (protein id. WP_030058663) but further pharmacological data are lacking. Autolysins are also much diverged as S. aureus enzyme (protein id. AAA99982; accession no. L41499) has only 60% homology with 8% gap to other autolysin enzymes (protein id. BAD83399) [14]. Genetically recombinant Lysins have great potential in curing MDR-bacteria [15-18]. P2neumococcal LytA autolysin, a potent therapeutic agent in peritonitis-sepsis caused by highly beta-lactamase resistant Streptococcus pneumonia [19,20].   

Discussion

Enzybiotics is an emerging field of medicinal science with many molecular approaches have undertaken which have patent litigations and many data are hidden from GenBank database now [13]. It also has combined with phage therapy technologies targeting both Gram (+) and Gram (-) bacterial pathogenesis originating from MDR genes of superbugs [10]. We believe as MDR genes are created both from human and bacteria symbiosis, it will be there with gut microbiota [5]. So to eliminate the pathogenic bacteria alternative to antibiotics will be forthcoming like gene medicines (antisense, Casper-Cas, SiRNA, miRNA, ribozyme) and nanodrug-carriers [21]. Thus enzybiotic is in good place in molecular medicine and its success is ahead. Novel chimerical endolysins with broad antimicrobial activity against methicillin-resistant Staphylococcus aureus was reported [16,22]. About 1144 enzybiotics along with 216 natural resources (heterogeneous phyto-antibiotics) have been listed in GMEnzy database [2,13,23,24].

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Juniper Publishers Indexing Sites List All journals may be registered in the ICI World of Journals database. The database gathers information on international scientific journals which is divided into sections: general information, contents of individual issues, detailed bibliography (references) for every publication, as well as full texts of publications in the form of attached files (optional). Within the ICI World of Journals database, each editorial office may access, free of charge, the IT system which allows you to manage your journal's passport: updating journal’s information, presenting main fields of activity and sharing the publications with almost 200 thousand users from all over the world. The idea behind the ICI World of Journals database is to create a place where scientific journals from all over the world would undergo verification for ‘predatory journals’ practices by scientific community. 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SIS focuses on: citation indexing, citation analysis, and maintains citation databases covering thousands of academic journals. SIS Provides Quantitative And Qualitative Tool For Ranking, Evaluating And Categorizing The Journals For Academic Evaluation And Excellence. This Factor Is Used For Evaluating The Prestige Of Journals. The Evaluation Is Carried Out By Considering The Factors Like Paper Originality, Citation, Editorial Quality, and Regularity & International Presence. We Perform The In-Depth Analysis Method. The Acceptance And Rejection Rates Of Journals Can Be A Determining Factor. Low Acceptance Rate, High Rejection Rate Journals Are Considered The Best And Most Prestigious Journals As The Acceptance Criteria Is Of High Quality Standard. Many Journals And Societies Have Web Pages That Give Publication Data And Style Requirements And Often Includes Acceptance/Rejection Rates. 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[juniperpublishers-dentistry]

Community Consultation of Families with Young Children about a New dental Service Centre in Southeast London- Juniper Publishers

Abstract

Objectives: To engage families with young children and empower them to inform service provision; explore the views and expectations of families with young children in West Norwood area of how dental services may be best provided at the West Norwood Health and Leisure Centre (WNHLC); explore barriers to dental care, uptake and use of dental services.

Research design: Cross-sectional questionnaire survey

Participants: 1,016 parents/guardians with children aged seven and under.

Main outcome measure: Willingness to access the dental service.

Results:An overall response rate of 24% (246/1016) was achieved. The majority (72%, n=178) were unaware of the dental services at the Centre. Lack of convenient appointment times (43%, n=106) was the most common barrier to accessing dental care reported by families. Approximately 48% of parents indicated their willingness to bring their children to the WNHLC, the majority of them were NHS users (75%, n=89, OR=1) who attended the dentist occasionally (65%, n=77, OR=4.8, p<0.01). Essential facilitating factors were friendly dental care providers (81%, n=203), ease of getting appointments (76%, n=186) and suitable opening hours (74%, n=183).

Conclusion: The results of this study signified the need of collaboration with local settings to increase awareness about its dental services. The uptake of service would depend upon factors such as its opening hours, ease of getting appointments, having a patient-friendly dental team. The results of the study will inform future dental service provision at the Centre in the light of NICE guidelines (NICE, 2008).

Keywords: Outreach; Skill-Mix; Access; Barriers; Communication; Dental services; NHS

    Introduction

Access to dental services is a major policy and public concern in the UK, which is considered as “one of the contributing factors for improvement of oral health”[1,2]. Differences in oral health and oral health service utilization exist at all levels for various reasons ranging from psychosocial characteristic of individuals to regional deprivation [3,4] (Nuttall, Freeman, Beavan-Seymour, Hill). It is evident from local studies in England that there is inequity in access in deprived areas of London [5,6,7].

The borough of Lambeth is the fifth most socially and economically deprived borough in London and distinctive in terms of its young and dynamic population, ethnic diversity and a highly mobile population (Census Information Scheme, 2012 &Trust for London and New Policy Institute, 2010-2014). The oral health needs among pre-school children in local children’s centers are high [8]. Despite availability of free dental services to children and more equitable dental services for adults through the National Health Service in the UK, health service data reveals lower access rates in Lambeth than London and England [9,10].

Numerous attempts to address inequity in access to dental services by reorienting dental services to ameliorate oral health inequalities [11]. The WNHLC is one of the initiatives of the local authorities in partnership with the NHS to improve health and wellbeing of the residents in the West Norwood area of south Lambeth (West Norwood News, 2009). The dental service at the WNHLC provided as a part of King’s outreach programme, is perceived as an opportunity that will serve the local community by providing primary dental care in holistic way

The high need for dental service and low level of service uptake, as in the West Norwood area, reflects a poor ‘fit’ between the patient and health care system [12]. Community engagement in planning, development and management of health related activities that affect them have been a strategic recommendation. There is evidence that engaging communities in service design and delivery empowers them and strengthens community cohesion making health policy initiatives more sustainable (NICE, 2008). Therefore we set out to assess the families’ perceptions of barriers in accessing dental services and the factors that would motivate them to bring their children more often, thus enabling prevention as well as treatment services [10].

The aim of the project was to explore the views of families with young children in order to ascertain their expectations of how dental services may be best provided at the WNHLC, with a view to informing the structure and delivery of dental services at this site.

    Methods

Chemicals

Ethical approval was granted by King’s College London Research and Ethics Committee (Ref number BDM/12/13- 77).Based on the local data, children below seven years were included in the sample [8]. Initially, seven primary schools and four children’s centres in the West Norwood area from Lambeth’s Local Authority website [10] within a radius of one mile from the WNHLC were approached and invited to participate in the study. Five primary schools and one children’s centre participated and distributed questionnaires to 1,016 parents and guardians of children aged five to seven years.

An initial approach with the gatekeepers was made through a written invitation and promotion was undertaken through posters and newsletters. The parents/guardians were given the questionnaire with an information sheet by the class teachers in an anonymous envelope. The information sheet contained detailed information about the study and emphasized voluntary and anonymous participation. Attempts were made to enhance the response rate by approaching the schools via reminder letters, emails and phone calls and pens were given as an incentive and extra questionnaires were kept in each school (Dillman, Smyth, Christian, 2008).

A two-page questionnaire was derived from validated questions from the Child’s Dental Health Survey 2003 [3]. Questions on quality of dental care and barriers were derived from the local surveys [8,13]. The questionnaire consisted of mainly close-ended questions that derived information about the awareness of the Centre and its dental service, socio-demographic features, dental service usage, barriers, preferences, etc. The final open-ended question requested any suggestions for the dental service at the Centre. Only 246 parents/guardians returned completed surveys to their respective class teachers. However, this number was considered adequate since a calculated sample size with 80% power at 5% level of significance was 84 to test the proportion of parents/guardians willing to bring their children, using the chi square test. A multivariate regression analysis was used to assess factors independently associated with willingness to bring children to the centre. The regression model was adjusted for variables such as the awareness of the WNHLC and its dental service, child’s and respondents’ attendance pattern, child’s and respondents’ type of dental care, influence of dental students on the respondents’ decision to avail the service. Quantitative data was analysed using SPSS software whilst responses to open question were analysed using simple thematic framework methodology.

Results

Response

Out of the eleven institutions targeted, five primary schools and one children’s centre agreed to participate in our survey. A response rate of 24% (range 17% to 80% at school level) was achieved.

Socio-demographic characteristics as reported by the respondents

The majority of parents (92%, n=225) and children (54%, n=133) were female. The average age of child was six years ranging from one to nine years? The presence of siblings was identified by 32 respondents (12%). In terms of ethnicity, a majority of the parents identified their children as White (53%, n=131) followed by Black (21%, n=52) and multiple/mixed (20%, n=49), Asian (5%, n=11) and other (1%, n=3) ethnic groups. Here in after, respondents will be referred to as parents.

Reported dental attendance patterns and type of dental care received

In response to questions about dental attendance patterns, it was reported that 47% parents (n=116) and 64% of their children (n=158) attended a dentist regularly. A further 31% parents (n=76) and 25% children (n=61) reported occasionally, while 20% parents (n=50) and 11% children (n=27) were reported as attending only when in trouble. There was a significant association between child and parental attendance patterns (p<0.001).

When asked about the type of dental service used, out of 246 parents, 71% parents indicated that they received NHS care (n=174) that was either paid for (40%, n=99) or free (31%, n=75). On the other hand, a slightly higher proportion of 79% children (n=193) were reported as being provided NHS dental care. Furthermore, 17% parents (n=41) utilized private dental care out of them 40% (n=16) reported utilizing NHS dental care for their children. A notable proportion of 13% children (n=32) were reported as utilizing private dental care

Reported awareness about west norwood centre and its dental service

With regards to the awareness of WNHLC, 51% parents (n=125) were aware about the Centre while the majority (73%, n=178) had no perception about its dental service as reported.

Of the 125 parents who were aware of the centre, 52% (n=65) had no knowledge of its dental wing.

Willingness to bring child to the west norwood centre’s dental service and influence of supervised dental students on decision to bring their child

Overall, 48% (n=119) of parents indicated a willingness to bring their child to the centre whilst 36% (n=89) were unsure about the Centre or required more information. Of the 119 parents who reported that they would bring their child, the dominant ethnic groups were White (46%, n=55), Black (27%, n=32) and of mixed ethnicity (19%, n=23). The results suggested that among those who showed willingness to bring their child, 75% (n=89) of parents and a higher proportion of 82% children (n=97) were NHS users. There was significant association between the child’s ethnicity (p<0.01), child’s dental attendance (p<0.05) and parental dental attendance (p<0.001) and their willingness to visit the Centre with Whites, parents and children attending occasionally or only in trouble identifying that they were more likely to use the service. Less than half of the parents (44%, n=107) indicated that the provision of dental treatment by dental students at the centre would not influence their decision to visit the Centre as shown in Table 1.

Reported reasons for delay to access dental care for children

The lack of convenient appointment time was the most important barrier to take their children to the dentist reported by the parents (43%, n=106). A significant association was found between lack of convenient appointment time and willingness of parents to bring their child to the Centre (p<0.01) with the parents most willing to bring their child to the centre reporting the lack of convenient appointment time as a barrier to care.

Figure 1 displays responses to what are the important features of a quality dental service for children. The six key features showed agreement, having a friendly dental care provider being the most important issue. Parents were asked about their preferred time to visit a dentist. The majority of the parents indicated that after school followed by weekends and school holidays are the most appropriate times for their children to visit a dentist. The parents were asked to choose from a range of options on how, and where, the Centre’s dental service could best promoted the two families in the area who do not have a dentist. The vast majority of the parents endorsed advertisement at the schools (87%, n=214) followed by GPs (74%, n=183) and children’s centres (63%, n=154) as shown in Figure 2.

Parental suggestions

A final question was an open question regarding anything else the respondents would like to suggest as to how the dental service at the West Norwood Health and Leisure Centre could best serve the local families. This accounted to 25% (n=61) of the total responses.

Maxwell’s dimensions of quality, has been widely used to evaluate and assess the quality of health services [14]. The comments and suggestions of parents were in line with Maxwell’s dimensions. Of all the dimensions of quality, ‘accessibility’ was predominately evident in the responses. The most repeated theme that emerged in accessibility were opening hours, ease of getting appointments, online registration, and special provision for children with learning disability, advertisement to increase awareness about the availability of the service in Norwood. In relation to ‘relevance’ of the dental service, there was a standard suggestion for the centre to emphasize on preventative services and oral health awareness through schools and children’s centres via seminars, workshops, lectures, etc. ‘Acceptability’ mainly was apparent in terms of accepting supervised dental students as the primary dental care provider. Areas of concerns regarding supervised dental students emerged as duration of treatment, experience in handling children, and change of provider in every visit, maturity level and confidence linked to anxiety of respondents. There was a clear demand for transparency of personnel including need of trained and experienced supervisors along with a sufficient workforce through means of dental auxiliaries. Comments in relation to ‘equity’ were raised in relation to acceptance of adults at an affordable rate. The parents recommended use of patient-friendly aids such as online booking system, text reminders to increase the ‘effectiveness’ of the dental service. Adequacy of staff was highlighted as an important criterion to increase the ‘efficiency’ of services.

    Discussion

The latest report on Children and Young People’s Health (2014) recommends improvement in oral health outcomes and reduction in oral health inequalities by putting families with young children at the heart of commissioning [10]. This study gave an opportunity to understand the nature of the service users in terms of socio-demographic characteristics, their barriers in accessing dental care and the potential areas that need to be considered in service design and capacity building at the new centre.

In this study, the majority of the respondents were females. The gender profile of the children in the study sample was identical to Lambeth’s general children population with 51% female and 48% male (Lambeth First 2011). In terms of ethnicity, the sample showed similar characteristics to the Lambeth population with the maximum number of respondents classifying themselves as ‘white’ followed by ‘black’ and ‘multiple’ ethnic groups. The willingness to use the new centre showed variations with respect to ethnicity, respondents classifying themselves as ‘white’ being more willing to use the dental service at the new centre.

The majority of the parents and their children were users of the NHS dental care, which were similar to the results from the national survey. Additionally, similarity in results to the national surveys was evident in terms of dental attendance patterns; the majority of the parents and their children reported visiting their dentists for regular check-ups (Morris et al. 2006; Office for National Statistics 2011). This finding may be a result of response bias as a questionnaire approach may have filtered out the ones who are less likely to visit a dentist or respond to a survey because evidence suggests that Lambeth has low uptake of dental care [6, 8-10]. There could also be two other possibilities in that the questionnaire attracted pro-active parents or the parents genuinely attend the dentist regularly as reported (Benett 2013).

Parental and child’s attendance patterns were seen to be strongly associated with each other which is similar to findings from the national survey (Morris et al. 2006). As reported by other studies, in this population the parental perception of dental need predicted their dental attendance [15,16]. This study also showed that there was an association between parents’ attendance pattern and their willingness to bring their child to the new centre’s dental service. Those being nonregular attenders reported they were more likely to use the dental service at the centre. This may have an positive impact on reducing oral health inequalities as evidence shows that oral health and associated problems are associated with attendance pattern [17] (Richards & Ameen 2002).

This study showed that, according to their parents, the majority of children were reported to have had no recent dental problem. These findings do not necessarily suggest absence of dental problems but may be a result of ‘social desirability’ or lack of awareness of the child’s oral health as highlighted in previous studies [13] (Sjöström & Holst 2002).

A significant relation between the age of the child and the time since the last dental visit was observed, which was more pronounced in the 5-7 age groups. Various reasons may contribute to this finding. One may be that decay in deciduous molars is more common in this age group as highlighted in other studies (Levine, Pitts, Nugent 2002; Milsom, Blinkhorn, Tickle 2008).

In terms of barriers to access to dental care for their children, the study highlighted that lack of convenient appointment times was the most common difficulty faced by the parents. In addition, parents being busy, failure to find a dentist followed by fear of cost were also found to hinder the use of dental service. These findings confirm results from previous researches done in the area [5,8,13,18]. In response to the most convenient time to bring their children, there was a definite preference of having appointments after school, at weekends and during school holidays. Finally, in terms of defining a quality dental practice for children, it was found that a child-friendly dental care provider with ease of getting appointments and suitable opening hours are important factors that need to be considered, which are in parallel to previous research evidence [19,20].

With regards to dental care being provided by dental students, there was a mixed response with less than half of the parents approving the concept, which was similar to the findings of another recent local study [19]. Suggestions in terms of necessity of mandatory supervision of the students along with issues linked to the experience and level of expertise were made.

The barriers as well as preferences suggested by the parents are key features that need to be considered while planning the service delivery at the new centre. An area that will need to be clarified is the discrepancy between preferred time for appointments and the working hours of the dental students. Traditionally dental students have provided care during normal 9-5 office hours, Monday to Friday. It should also be born in mind that after school is not always the best time to treat children as they may be tired after a day at school. However, Saturday opening may also be a consideration as the health and wellbeing centre will be open seven days a week (Swider & Valukas 2004).

Furthermore, awareness of the centre and its dental services was relatively low. However, it may be suggested that this study might have had the positive effect of raising awareness of the dental service at the centre amongst the parents who had no previous knowledge of it. There is a need to initiate collaboration between the Centre and the local settings such as schools, general practitioners (GPs) and children’s centres in order to promote the centre.

There were a number of limitations encountered during the study. Feedback from the ethics committee suggested that ‘any identifiable information (e.g. post code) should not be considered in the survey to protect anonymity’. Indeed the previous study in West Norwood found that taking the post code information from participants did not benefit the overall study [19]. It should be born in mind however that it is recognised that socio-economic disparities are evident in oral health and related issues and any bias in this area would not be detectable. The study design initially included a qualitative approach using interviews/focus groups that would have been ideal to explore the views and expectations of families with young children but the schools found it difficult to implement them (Ritchie, Lewis, Nicholls, Ormston, 2013). The cross sectional self-administered questionnaire approach featured a response rate of 24%, which varied between schools. The fairly low response rate may introduce ‘non-responder’ bias and could be a result of the lack of knowledge of the proposed service (Berg 2005). Despite attempts to engage with the schools and children’s centres and increase response rates by displaying posters and putting up a note in the school newsletter as well as a pen as incentive (Dillman et al. 2008; Edwards, et al. 2002), the engagement of parents and guardians through the schools was questionable.

Response bias was minimised by formatting the questionnaires as suggested by William (2003) that included non-leading, non-ambiguous simple and short questions, the page-layout and clarity of the questionnaire. It has been suggested that respondents often answer according to the social norms prevailing rather than the factual situation and hence social desirability might be a factor that may bias the results of questionnaire surveys (Sjöström & Holst 2002). Also, the study had a majority of females and it has been observed in national data that women are more likely to report accessing dental care than men (Office for National Statistics 2011). However, the semi-structured questionnaire design had many advantages and produced 246 responses that gave an opportunity to explore various areas. It also provided the parents, an opportunity to provide anonymously suggestions for future dental service provision.

This research was one of its kind in informing future actions to ensure that West Norwood Health and Leisure Centre’s Dental Service, serves the local population and maximises the acceptability and utilisation of the service by catering services with service user involvement. The ‘White Paper (2010)’ in their slogan (No decision about me, without me) mentions that the consumers of services should be the heart of everything and in charge of decision-making about their care. Perhaps, if the suggestions were implemented, measuring the outcomes could add to the predictability of such a contemporary approach.

    Conclusion

The study suggests that the awareness of parents/guardians using the West Norwood Dental Services would increase if the Centre promotes itself and collaborates with schools and children’s centres and GPs. The results of the study show that uptake of dental service would depend upon factors such as opening hours, ease of getting appointments especially after school and weekends, having a friendly dental team in a child friendly dental setting. This study provided evidence that parents of young children whose patterns of dental attendance are less than ideal may be more interested in attending the centre. The results of the study will inform dental service provision at the West Norwood Health and Leisure Centre, although implementing the findings may be challenging and will require inter-sectorial co-operation.

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