Lupine Publishers|Why to Not Rely on Nature?

 

  Lupine Publishers | Journal of Health Research and Reviews

 Abstract

Metabolism is the process your body uses to make energy from the food you eat. Food is made up of proteins, carbohydrates, and fats. Chemicals in your digestive system (enzymes) break the food parts down into sugars and acids, your body’s fuel. Your body can use this fuel right away, or it can store the energy in your body tissues. If you have a metabolic disorder, something goes wrong with this process. Dyslipidemia is main etiological factor leading to develop coronary artery disease (CAD). Allopathic drugs used in cure of hyperlipidemia, have unwanted effects, so have poor compliance. Now a day’s nutraceuticals are getting popularity due to their moderate hypolipidemic actions with fewer adverse effects. Niacin or vitamin B-3 is used as hypolipidemic agent which increases HDL-cholesterol and decreases LDL-cholesterol, VLDL, TGs by different mechanisms. But its main adverse effects are flushing due to synthesis of Prostaglandin D-2 which has vasodilatory effect causing flushing. Cardamom is herb having hypolipidemic potential if used in specific concentration for long time. In this work we did try to compare these two medicines hypolipidemic effects. Study was single blind placebo-controlled conducted at Jinnah Hospital Lahore-Pakistan from July to November 2018. Seventy-five hyperlipidemic patients were selected and divided in three groups. Their base line lipid profile was determined at laboratory of the hospital. Patients were divided in three groups. Group-1 was on placebo therapy, Group-II was on Niacin 1.5 grams daily in divided doses, and Group-III was on Cardamom 1 gram daily in three divided doses. It was two months therapeutic design. At completion of therapeutic regimen after two months we measured all patient’s lipid profile. When results were compiled and pre and post treatment values were analyzed statistically, it was observed that both drugs hypolipidemic potential is different, although both have hypolipidemic characteristic, but Niacin is the best for treating Hyperlipidemia. For statistical analysis we used SPSS version 5.0 and paired ‘t’ test was applied to understand significant changes in two tested group’s lipid profile.

Introduction

Lipid metabolism disorders, such as Gaucher disease and Tay- Sachs disease, involve lipids. Lipids are fats or fat-like substances. They include oils, fatty acids, waxes, and cholesterol. If you have one of these disorders, you may not have enough enzymes to break down lipids. Or the enzymes may not work properly, and your body can’t convert the fats into energy. They cause a harmful amount of lipids to build up in your body. Over time, that can damage your cells and tissues, especially in the brain, peripheral nervous system, liver, spleen, and bone marrow. Many of these disorders can be very serious, or sometimes even fatal. High LDL-cholesterol and low HDL-cholesterol in blood are cause of synthesis of atherosclerotic plaques which get deposited with inner endothelium of coronary arteries, leading to develop coronary artery disease (CAD) [1,2]. Hyperlipidemia either primary or secondary is challenge for scientists of 21^st century due to this disease’s complications like coronary artery disease, Hypertension, Cardiac Arrhythmias, and Myocardial Infarction [3,4]. Hyperlipidemia causes LDL particle’s oxidation, which initiate formation of atherosclerotic plaques leading to development of coronary artery disease. From this single complication of Hyperlipidemia, all major heart diseases are developed leading to morbidity and mortality due to last lethal major heart disease Ventricular Fibrillation [5-8]. Hypolipidemic drugs commonly used include Statins, nicotinic acid, bile acid binding resins and fibric acids, but all have potential for low patient compliance due to wide range of side effects [9].

Niacin increases apolipoprotein A1 levels due to anti catabolic effects resulting in higher reverse cholesterol transport. It also inhibits HDL hepatic uptake, down-regulating production of the cholesterol ester transfer protein gene. Finally, it stimulates the ABC-A1 transporter in monocytes and macrophages and upregulates peroxisome proliferator-activated receptor γ results in reverse cholesterol transport. It reduces secondary outcomes associated with atherosclerosis, such as low-density lipoprotein cholesterol, very low-density lipoprotein cholesterol, and triglycerides, but increases high density lipoprotein cholesterol [10]. Despite the importance of other cardiovascular risk factors, high HDL was associated with fewer cardiovascular events independent of LDL reduction. Other effects include anti-thrombotic and vascular inflammation, improving endothelial function [11]. To get good drug-patient compliance many health-related modern researchers have started to put their haeling potential for developing alternatives drugs used in primary or secondary Hyperlipidemia. Cardamom or in urdu ILAICHI is one of the hypolipidemic herb, widely encouraged by cardiologists to be used for prevention of atherogenesis, and coronary artery disease [12]. Cardamum’s antioxident effect is well established in many research studies on medicinal herbs. This nutraceutical contains Flavenoids and Phenolic compounds which scavenge Reactive Oxygen Species (ROS), reducing risk of developing CAD. Oral administration of cardamom extracts significantly reduced total cholesterol, highdensity lipoprotein (HDL), low-density lipoprotein, and very lowdensity lipoprotein and triglycerides in HL patients [13].

Patients & Method

Design: It was single blind placebo-controlled study conducted at GENERAL HOSPITAL Lahore from July to November 2018.

No of Patients: Seventy-five hyperlipidemic patients were selected and enrolled for the study. Written, already explained and approved consent was taken from all patients.

Inclusion Criteria: Inclusion criteria were age limit from 18 to 70 years of both gender male and female primary or secondary hyperlipidemic patients.

Exclusion Criteria: Patients suffering from any vital organ disease or their impaired functions were excluded from the study. Alcoholics, cigarette smokers and patients taking regular medicine for their any physical or mental disease were also excluded.

Grouping: Seventy-five patients were divided in three groups, comprising 25 patients in each group. Group-I was on placebo therapy. They were provided capsules containing grinded rice and mixed wheat. They were advised to take one capsule before meal, thrice daily for two months. Group-II patients were advised to take 1.5 grams of Niacin in three divided doses for the period of two months. Group-III were advised to take one-gram grinded green Cardamom powder mixed in black tea, thrice daily after each meal for the period of two months.

Methods Used: At start of study all patients’ blood pressure was recorded and kept in their personal file. Lipid profile of all patients was determined by Frei Dewald Method. Total-cholesterol, LDL-cholesterol and HDL-cholesterol were main parameters we required for further calculation of change in these parameters. All patients were advised to visit clinic fortnightly for their follow up. After two months therapy their lipid profile was measured again by same Frei Dewald Method. Blood Pressure of all participants was again measured and compiled for further statistical analysis.

Statistical Analysis: Data were expressed as the mean ± SEM and paired “t” test was applied to determine statistical significance as the difference. A probability value of <0.05 was considered as non-significant and P<0.001 was considered as highly significant change in the results when pre and post-treatment values were compared

Results

Results are shown in Table 1 with detail and all parameter’s values and changes in these parameters are self-explanatory.

Table 1: Results of pre and post treatment values, measured in mg/dl (tc, ldl-c, hdl-c) & mm of hg (sbp, dbp).

Current Statistics: (Pakistan SUN Secretariat Report 2017-18, P&D Department)

Discussion

Nutraceuticals like vitamins, and nutritional substances like fruits, vegetables, and indian spices are getting popularity in medical research regarding their therapeutic characteristics. Vitamin B-3 or niacin, and Cardamum (illaichi) are well known nutraceuticals which have been proved to have hypolipidemic potential. Metabolic syndrome is cluster of complications in lipid, protein and carbohydrate metabolism in human body. Hyperlipidemia is main fraction and part of this complication. High plasma LDL particles are prone to be oxidized leading to synthesis of atherosclerotic plaques which deposit to endothelial wall of arteries including coronary arteries (CAD). To reduce high plasma fats can prevent individual from being vulnerable for development of CAD. In our results two months therapy with Niacin decreased total and LDL cholesterol 13.1 and 6.7 % respectively. Statistically decrease in total cholesterol is highly significant while change in LDL-cholesterol is significant biostatistically. These results match with results of study conducted by Capuzzi DM et al. [14] who agree with our results. They almost saw same changes in LP (lipid profile) of primary and secondary hyperlipidemic patients.

They mentioned effects of blood pressure which was nonsignificant when they analyzed pre and post treatment values in systolic and diastolic blood pressure. Our results of change in HDL cholesterol also match with results of Alam K et al. [15] who proved 11% increase in HDL-cholesterol which is highly significant change in pre, and post treatment values of the parameter mentioned. Cantarella L et al. [16] proved significant change in systolic blood pressure of hyperlipidemic patients but non-significant effects on diastolic blood pressure. Goto T et al. [17] explained cause of flushing by using Niacin in hypolipidemic doses. They recommended titration of Niacin dose to improve patient drug compliance. Kawaguchi K et al. [18] did research on Cardamom and found phenolic compounds of this herb as antioxidant. They agree with many researcher’s idea or viewpoint that phenolics work as scavenger of Reactive Oxygen Species (ROS). Mittal MK et al. [19] proved that hypolipidemic effects of any herb are not as potent as Statins or Niacin. They have encouraged researchers that active ingredients of medicinal herbs should carefully be extracted and utilized efficaciously when you could preserve all for long time. Our research study proved significant changes in total and LDL cholesterol in 24 hyperlipidemic patients, i.e. 7.2 mg/dl reduction in total cholesterol and 8.8 mg/dl decrease in LDL cholesterol. Changes in both parameters are biostatistically significant.

Almost same results were observed by Bruckert, Eric et al. [20] who again said and advised patient not totally to depend on medicinal herbs, for, it is difficult to treat the disease by monotherapy when they start to develop metabolic syndrome and its serious complications. Babu PV et al. [21] has described that too much active ingredients or chemical compounds present in herbal medicines made it (Cardamom) unpopular because unexpected effects may be observed by using large amount of grinded Cardamom. He warned individuals using large amount of drug may harm metabolic pathways of body, producing unexplained metabolites which can harm body tissues. NA Lokan et al. [22], Temokarr Y et al. [23] explained that there are remarkable number of medicinal herbs and other chemical compounds which scavenge ROS (reactive oxygen species) in human body, preventing development of CAD.

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Lupine Publishers|Malnutrition Evidence and Solutions for Pakistan

 

  Lupine Publishers | Journal of Health Research and Reviews

Malnutrition Evidence in Pakistan

Nearly one in three persons globally suffers from at least one form of malnutrition: wasting, stunting, vitamin and mineral deficiency, overweight or obesity and diet-related Non-Communicable Diseases [1]. Malnutrition is widely known as under-nutrition until and unless it is not specified. It accounts for at least half of all childhood deaths worldwide. Malnutrition is considered as fundamental cause of morbidity and mortality among the children [2,3]. It also poses a risk to children’s physical and mental development, which results in poor academic achievement. Malnutrition affects the future health and socioeconomic development of children and the dynamic prospective of the society [4,5]. In the last two decades, there has been a little reduction in the prevalence of child malnutrition in Pakistan compared to other developing countries. The prevalence of all types of malnutrition in Pakistan was found to be higher than the global threshold value. It was found that malnutrition starts at an early age and remains persistent at later stages [6].

According to the National Nutrition Survey 2011, it has been reported that 13.4 million (43%) of children under the age of five in Pakistan are moderately or severely stunted, 9.9 million (32%) are moderately or severely underweight, and 4.8 million (15.1%) children under five years of age are wasted. 50 percent of the children were anemic, and 33% were anemic from iron deficiency [7]. The contributing factors in childhood malnutrition are low birth weight, inadequate breast feeding and exclusive breastfeeding, inappropriate complementary feeding, maternal education, lack of proper knowledge of nutrition, micronutrient intake, parity, birth spacing, household socioeconomic status, food insecurity, poor sanitation, vaccination, and infectious diseases [8]. Anemia among pregnant women has increased to 52 percent. Maternal anemia is associated with reduced birth weight and increased risk of maternal mortality. Anemia rates have been worsening over the past two decades. Children who are born with intrauterine growth restriction and low birth weight have a greater risk of morbidity and mortality. These children usually continued with slow growth rate resulted in stunting, slow mental growth and remained underweight [9]. Comparison of National Nutrition Survey 2001, 2011 and PDHS 2017-18 showed that over the last 18 years there is slight improvement in few aspects of malnutrition but generally the malnutrition status among children and women is stalling or further deteriorated (Table 1).

Table 1.

Current Statistics: (Pakistan SUN Secretariat Report 2017-18, P&D Department)

Iodine deficiency among women and children has decreased (improved).
a) Anemia among children and Iron deficiency anemia among women have worsened.
b) The chronic malnutrition indicators such as Wasting and stunting among children has worsened.
c) Both women and children have showed many folds increase in the prevalence of Vitamin A deficiency.
d) Still micro-nutrient deficiencies are highly prevalent among children and women
Malnutrition has a negative impact on cognitive development, school performance and productivity. Stunting and iodine and iron deficiencies, combined with inadequate cognitive stimulation, are leading risk factors contributing to the failure of children to attain their full development potential (Figure 1). Each 1% increase in adult height is associated with a 4% increase in agricultural wages and eliminating anemia would lead to an increase of 5% to 17% in adult productivity [10].

Figure 1.

Food Security

Food security [is] a situation that exists when all people, at all times, have physical, social and economic access to sufficient, safe and nutritious food that meets their dietary needs and food preferences for an active and healthy life (defined by The Food and Agriculture Organization (FAO). Despite Pakistan’s strong agricultural base, food insecurity is widespread (Figure 2). According to The State of Food Security in Pakistan, 44 percent of households consume less than 2,350 Kcal per adult equivalent per day [11], the accepted normative standard set by Ministry of Planning Development & Reform. The food security situation showed no signs of improvement since the last food insecurity assessment conducted by the United Nations in Pakistan (WFP Report 2009), which revealed that 51% of the population was food insecure. The situation has, in fact, deteriorated further. This will have serious implications on the nutrition, growth and health of the Pakistani population [12]. Despite growing levels of food production, economic access to food remains a major challenge in Pakistan. If available food is not accessible to the population, food security cannot be achieved. A household’s access to food is a measure of its income, food distribution and the market prices of food items. Official estimates consider 29.5 percent of Pakistan’s population ‘poor’ with reference to the revised national poverty line of PKR 3,030.32 [13]. However, multidimensional poverty is estimated to affect 38.8 percent of the population when severe deprivations in education, health and living standards are considered. Poverty is most prevalent in eastern Sindh, western Balochistan and pockets of KP and Punjab [14]. The Food Consumption Score (FCS1) a proxy indicator of food security is a composite score based on dietary frequency, food frequency and relative nutrition importance of different food groups consumed at the household’s level. The recent drought assessment in Sindh revealed that overall, around 18 percent of households have ‘acceptable food consumption’, 41 percent have ‘poor consumption’ and another 41 percent have ‘borderline consumption’ [15].

Figure 2.

Key Issues Related to Food Insecurity in Pakistan

I. Access to food is a major challenge. Poverty is one of the biggest barriers to access to food. Additionally, high food cost and access to market of rural communities are major contributors.
II. Most of the households spend half (49 percent) of their monthly expenditure on food, on average, a proportion which increases among the poor.
III. Roughly half of Pakistan’s population is energy deficient, consuming fewer calories than those required for a healthy life.
IV. Dietary diversity is limited in Pakistan, especially among poor and marginalized groups who follow a fixed pattern of food intake and consume a narrow variety of nutrients. One of the resulted outcomes is micro-nutrient deficiencies.
V. Whether an individual consumes—or not—nutritious food is contingent upon a myriad of factors, ranging from the availability of certain foods, how convenient they can be turned into meals, or simply, if they meet consumers’ tastes. But above all, the high cost of food remains the most critical barrier to proper nutrition and affects the poor more than the rich. And in Pakistan, where malnutrition persists in multiple forms, the cost of nutritious food is prohibitive.
VI. The ready to use supplementary food are not available in the market and only available from limited sources on high cost.

Burden of Non-Communicable Diseases

Pakistan is facing double burden of Malnutrition as reported by National Nutrition Survey and latest data shared by Pakistan SUN Secretariat Report 2017-18, Ministry of Planning and Development. According to these reports adult overweight and obese person are 30%, mostly residing in urban locations. Among male adults obese and overweight are 27 percent and slightly more female adults 32% are obese and overweight. The major contributing factors are the dietary pattern and habits leading to inappropriate consumption of food including consumption of more energy dense foods rather than the nutrient-dense foods, and consumption of artificial foods. These malnutrition states lead to two major non-communicable diseases including Hypertension, cardiovascular diseases and Diabetes.

Solutions

Strategy for Prevention and Management of Malnutrition

It is established fact that a malnourished child will face poorer outcomes as an adult. In Pakistan, where malnutrition persists in multiple forms, improving nutrition in the early stages of life is critical to a child’s future development and health. The path toward better nutrition includes adequate maternal and childcare, access to better sanitation facilities, health services, and naturally, nutritious foods.

Community based Primary Health Care interventions with special focus on Nutrition specific interventions for Children and Women such as

The preventive measures must focus the children under five years of age, adolescent girls and women including pregnant and lactating mothers. The first 1,000 days from the start of a woman’s pregnancy to a child’s second birthday offer a window of opportunity for preventing under nutrition and its consequences. We should target this period with support for breastfeeding, nutrition-rich foods for infants and micronutrient supplements for mother and children. These nutrition specific interventions may be effectively implemented through primary health care services by community based Marvi workers and supervisor LHVs for quality technical services. The effective strategic plan should be devised including
a) Primary Health Care interventions (community-based education of mothers, health and nutrition services for prevention of malnutrition by promoting preparation of diversified appropriate meal (age appropriate) at home).
b) Manufacturing and Provision of Ready to Use Supplementary and Therapeutic Food --- for acutely malnutrition children, pregnant and lactating women.
c) Manufacturing and Provision of Multiple Micro-nutrient supplement (including iron and folate) tablets for pregnant and lactating women and Multiple Micro-nutrient sachet for children (6 – 24 months).
Provision of antenatal care, counseling about balance diet and provision of iron-folate supplements to all pregnant women through services within villages Referral strategy for safe institutional deliveries through linkages with Public sector health facilities Promotion of breast feeding ensuring three Es including Early initiation inclusive of colostrum, Exclusive breast feeding and Extensive breast feeding for 2 years. Engage the communities in vigorous campaigns to promote breastfeeding at the local level. Prevention of stunting and wasting through promotion of Infant and young child feeding as education of mother on appropriate diet preparation and feeding based on dietary diversity. Promote local dietary recipes through cooking demonstration. Use of Positive Deviation approaches for effective behavior change and correct practices by the mothers Growth monitoring of all children under five years of age quarterly and marked on growth cards for learning of mothers for linear growth follow up of each child Provision of multiple micro-nutrient (MNN) sachet for each child of 6-24 months of age Identification of children with Severely Acute Malnutrition and Moderately Acute Malnutrition and their community based management by provision of Ready to Use Supplementary Food (RUSF --- produced locally as Acha Mum packets by Ismail industries) and Ready to Use Therapeutic Food (RUTF --- provided by Unicef) for period of at least 2 months. Additionally, encouraging mothers to feed home-made meals to the children.

Strategy for Improving Food security at Community and household level

The most energy-dense foods (cereals, oils and fats, sugars) generally had the most stable prices, showing the least inflation. These foods generally have a longer shelf life for storage and transportation. Food security and agriculture policies have emphasized energy-dense foods for the last several decades. The nutrient-dense foods such as legumes, lentils, animal source food, vegetables and fruits tend to be highly perishable, usually available on high cost, mostly not available in poor settings or unaffordable by the poor communities.

Strengthening of Regulation of Legislation on milk substitutes

There is a need to develop or where necessary strengthen legislative, regulatory and/or other effective measures to control the marketing of breast milk substitutes in order to ensure implementation of the International Code of Marketing of Breastmilk Substitutes and relevant resolutions adopted by the Health Assembly.

Food security assurance thru Food Points in rural areas

For food security, increased access to foods of good nutritional quality should be ensured in all local markets at an affordable price all year round, particularly through support to smallholder agriculture and women’s involvement. Food points /enterprises may be developed at villages levels, to ensure the availability of recommended food items at affordable cost. For establishing these food points or enterprises, a grant of 20000/- to community-based health worker may be provided. These workers may be connected to UC level wholesale shop keeper or suppliers. The system should ensure the promotion and availability of micro-nutrient fortified food such as iodized salt, wheat flour with iron, and edible oil with vitamin A &D at affordable prices within communities.In addition, to food enterprises, community cooking sites / spot may be established to prepare the nutrient-dense meals which would be available for malnourished children (at least one meal for a day) at an affordable cost. The recipes are already devised and suggested by the Unicef, Nutrition support program and HANDS PHC program. The major food items for these meals would be based on chickpeas, lentils/ legumes, rice, porridge, dairy products, eggs, edible oil (enriched with Vit A & D), and iodized salt.

Food packaging and Supply system

The food packaging and supplier agency may be formed to establish and ensure the functional food supply chain system. This agency may also play a vital role in managing and controlling the market price of the nutrient-dense and energy-dense foods. The government or concern organizations may play vital role in developing food supply chain system to ensure the availability on affordable cost of nutrient-dense foods in addition to energy-dense foods in the poor settings.

Partnership with Food industry for Ready to Use food

Additionally, strategic partnership may be developed with the food products manufacturing industries. The high energy and nutrient-dense ready to use food items may be produced by these industries on affordable cost for the treatment of acute malnourished children, pregnant and lactating women. Currently cost of treating one malnourished child by giving these ready to use food is ranged from Rs. 5500 to Rs. 10000/=.
Following food products may be produced as per demand:
i. Ready to Use Supplementary Food (RUSF) for Moderately Acute Malnutrition (MAM) Children
ii. Ready to Use Therapeutic Food (RUTF) for Severely Acute Malnutrition (SAM) Children
iii. Ready to Use Supplementary Food for pregnant and lactating women --- Mamtaa
iv. Multiple Micro-nutrient supplement sachet for children
v. Multiple Micro-nutrient supplement tablets for women

District Level Resource Centers

These resource centers may be established to serve the purpose of addressing and improving the food security issues at large scale or district level. These centers should develop strategic partnerships with agriculture institutes for technical support and oversight. These centers may perform the following tasks:
a) Support farmers by providing drought resistant and drought tolerant crops, inputs, and promotion of climate smart agriculture. Specifically, provide drought resistant seed of cereals, fodder, pulses, legumes, vegetables and shrubs plantation.
b) Introduction and up scaling of bio-saline agriculture
c) Capacity building of farmers through Farmers Field Schools (FFS), Junior Farmer Field Schools (JFFS), Farmers Business School (FBS) and Women Open Schools (WoS)
d) Introduction of drought tolerant fruit, fodder and shrubs plantations
e) Soil management through proper fertilization
f) Helping communities in applying No-till/reduced tillage systems
g) Facilitating farmers Usage of crop rotation/cropping systems
h) Strip farming as required centers
i) Establishment of community seed banks

Strategy for Reducing the Burden of Obesity and Non-Communicable Diseases

Information, Education and Communication material development: The information and education material may be used in large scale in printing form and by developing short video sessions based on healthy dietary habits and balance diet.

Halfway Healthy Spaces: The hospitals spaces such as waiting areas and OPD areas may be utilized for conducting these sessions. These may be promoted as halfway health spaces.

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Lupine Publishers|Methodical Bases of Creation of Maps for Determining the Potential Erosion Hazard of Scolon Lands of the SouthEast Part of Azerbaijan

 

  Lupine Publishers | Journal of Health Research and Reviews

Abstract

The article examines the issues soil erosion a risk traditionally rapidly growing with agriculture in tropical and semi-arid regions, which is particularly important for its long-term effects on soil productivity, removing topsoil, than soil formation processes can replace it due to natural, animal and human activities, in the example, excessive grazing, cultivation, deforestation and more mechanical farming and sustainable agriculture. Studied the spatial characteristics of grass and arable land formations, their positive impact on anti-erosion installations research. Developed methodological framework mapping of soils from the threat of erosion.

Keywords: soil Fund stability, the threat potential, formation, arable, sediment yield, etc

Introduction

Figure 1.

In recent years, the development of agriculture comes increasing, due to the increasing population in various countries. Average annual growth for the last irrigated land of the TWENTIETH centuries was over 3 million hectares. Irrigated area on the globe exceeded 220 million hectares. The total area of the Republic is 8641.5 thousand ha. Of these, 3610thousand hectares, or 43.23% of the soil of the Republic Fund places in one or another degree were subjected to erosion. Here historically formed complexes with environmental problems [1-3]. In the most precarious status of land resources, which almost everywhere in varying degrees subjected to degradation, the intensity of which depending on terrain parameters morphometric climatic and soil-plant conditions, as well as economic activity degree often reach catastrophic proportions. This contributes to the destabilization of the ecological situation in the Republic. [3,4] In Azerbaijan, in addition there is the problem of salinization of soil degradation (Figure 1).

The Republic is described as a land-hungry country, where per capita accounted for 0.2 hectares of arable land. It should also be noted that in Azerbaijan there are also lowland conditions slope crossed conditions, which requires a special approach to technologies and technical means of irrigation. Being a mountainous country, Azerbaijan is characterized by complicated natural conditions cool physiographic areas-greater and Lesser Caucasus, Kura-Arax River lowland and the Talyish mountains, strongly distinguished from each other on geological structure, climate, soil and vegetative cover, terrain slope, which range from 1 to 40 and more Highly developed in the Republic, existing in the nature of almost all types of erosion. Soil erosion is a serious problem throughout the world. Soil erosion is a serious environmental, economic and social challenges; it’s not only lead to land degradation and loss of productivity of soils, but also threatens the stability and health of the Society of universal and sustainable rural development in particular in mountain regions of the Republic (as Shamakhi, Axsu, Ismailia, Gabala, etc.) soil erosion is the removal of topsoil than soil formation processes can replace it due to natural, animal and human activities such as overgrazing, cultivation, deforestation and more mechanical farming [3- 5].

Spatial Characteristics of Herbaceous Formations and Cropland in the Objects of Study

A review of the literature devoted to soil erosion and its prevention in Azerbaijan, confirms the positive impact of antierosion herbaceous formations. A study conducted by us, under the leadership of Prof. BH. Aliyev in Terter PARADISE (2008-2010) and Shamakha OEB Institute erosion and irrigation NANA (2011- 2013) on the effect of vegetation on pastures in the runoff and sediment yield showed significant influence of runoff and sediment yield. Establishment of control factors of vegetation and water on the slopes of the motor way, Shamakhi OEB was the reduction of vegetation water cause erosion to intercept rainfall, increase water infiltration to soil fertility, interception of runoff on the soil level surface and stabilizing soils under coarse ground. [1.3] Analysis of properties of arable land in Axsu district height and slope of the terrain showed that up to 60.0% of their area is located at an altitude of more than 500 m from the sea level. On the basis of landuse maps, it was found that the main plant, grown on arable land in the region, vineyards, orchards, wheat, legumes and forage crops.

It belongs to the Group of plants that have good ohranami properties in relation to soil and besides, rather it tolerates water shortages during the growing season. Cultivation of wheat imports, together with appropriate machinery, should to a large extent, protect arable land in the region from water erosion. The selected for the analysis region of Azerbaijan, located on the Southwestern slopes of the Great Caucasus are three types of herbaceous formations: pastures, Green land -steppe. Their location depends on various factors surrounding the region Wednesday. Placing herbaceous formations, in terms of height and slope, was analyzed within the boundaries of Axsu district. In this area they occupy 24% of the total area, including: grassland-52%, green lands, almost 28% and 20% of the steppe. The most extensive high-altitude pastures have intervals, placed at an altitude of 1400 m above sea level. In high-altitude 600-70 m intervals and 700-800 m number of largest pastures, respectively 19 and 20% of the total area of the territory. Almost 50% of pastures is located on slopes with a gradient 10- 18% (6-100 ), and in the lower grades of slopes-0-6% (up to 30 ) and 6-10% (3-60 ) - 20%.

Pretty much of 7.5% is on the slopes with inclines of up to 27% (150) Green lands are located at an altitude of 1000 m above sea level. Largest area-60%, are at a height from 200 to 50 m above sea level (by 20% in areas of 200-300, 30-400 and 400 and 500 m). More than half of these grassy% 54-formations is located on slopes with a gradient 10-18% (6-100 ) and 22% with a slope of less than 6-10% (3-60 ). Steppe vegetation, often used as winter pastures, is observed in the lower altitudinal zones. In Axsu district, they are below 300 m above sea level. Almost 70% of the footprint is located below 100 meters above sea level and 98% on the gentle territories or lands with a slight slope from 0 to 6% (0-30 ). Areas covered with herbaceous vegetation formations are also dry river valleys [7]. They occupy less than one per cent of the total area to be analyzed. There are up to a height of 400 m above sea level and 95% on flat or gently sloping areas. [1.3.7] The actual problem is erosion caused by caused:

a. mismatch plant species in a mixture of perennial herbal and leguminous plants,

b. too many cattle per hectare of pasture,

c. grazing animals on too steep slopes, especially with southern exposure

d. too early onset of grazing.

Reduction of the intensity of agricultural production and, especially, the intensity of grazing animals, as well as adaptation to the conditions of grazing techniques habitats above the grassy formations will strengthen their anti-erosion value.

Methodological Framework Mapping of Soils from the Threat of Erosion

Map of the threat from surface water erosion was established on the basis of: slope, soil maps and maps of land use map slopes received as a derivative of the layer digital elevation model (SRTM 90 WGS 1984), and then the retrofit to the erosion model in their class bias. Soil map was vectorization and editorial processing. The primary material was scanned map with an average magnitude of rectified lined topographic maps (1:100 000) and classified in 5 groups of sustainability the soil leachate may run off. Land use map was also based on scanned maps vectorization Land Cover Classificationtion System-FAO [1:50 000 scale 3.5].Based on the results of the research, the following erosion and patent risk maps of the Axsu and eastern parts of the Ismayilla region created based on GIS technology, respectively, were compiled. see (Figure 2 & Figure 3) Maps a threat from erosion (potential and actual) was established on the basis of Polish methodology, given the natural conditions Azerbaijan and list of legends to soil the soil map of Azerbaijan. Map of the actual threat from erosion was established way of reduction of degrees of potential danger from erosion, with accounts of the main land use categories (forests, permanent grassland, degree and arable land). For forest land and permanent grassland, which possess a very considerable degree of functions anti erosion erosion threat reduction was at 3 units. For the steppes on the reduction unit 2 was adopted, while agricultural areas only 1 unit (Table 1). [2,3] the large change in average annual rainfall amounts Axsu area was a partition into two geographical parts: dolinnuju (South), where the average annual rainfall is within 300- 800 mm, as well as mountain-precipitation is higher 800 mm.

Table 1: Criteria for identifying threats from potential and actual surface water erosion.

Figure 2: Maps of erosion hazard of the Akshu district created using GIS.

Figure 3: Maps of the potential erosion hazard in the eastern part of the Ishmailli region district created using GIS.

In the example of Ismailia district, because of its typical hilly topography, to map the potential erosion were accepted criteria relating to mountain territories. Data on mean annual precipitation were obtained from Atlas of Azerbaijan Republic for the year 2007. [1, 3, 7] Analysis of the threat from erosion for Agsu district showed a strong effect of land use on reduction of erosion. This is the greatest mountain refers to the territories in which the significant reduction of all degrees of erosion threat, sparked the growth of the territory, not exposed erosion, more than 81% (Table 3). In the area of lowlands erosion reduction is primarily concerned with 2, 3, 4, and 5 degrees. Area, subject to erosion threat 2 degrees was reduced from 5516 HA to 412 hectares. Territory subject to erosion threat 3 and 4 degrees, only 96 ha, and 5 degrees was reduction to 0. A higher percentage of territories with 1 degree of threat from erosion in the mountainous part of the region is associated with the presence of a small amount of forests and large crops of wheat (Table 2). [1,2,6]. Residents of the area placed in regions with a significant incline of the ground, which increases the percentage of the highest degree of potential danger from erosion. Almost 48% of the analyzed of Ismailia district is threatened by erosion, 3.4 and 5 degrees (Table 3).

Table 2: The extent of the threat from surface water erosion Valley part of Agsu district.

Table 3: The extent of the threat from surface water erosion the mountain part of Axsu district.

Conclusion

A very big impact on the reduction of the intensity of surface water erosion raises some concerns about the sustainability of the advanced technologies used in the work methodology for the study area. In this regard, it would seem appropriate for field verification data, taking into account the impact of land use on washing away topsoil. Another issue not related to the influence of surface water erosion, is the development of the territory of landslides. They create a large loss for Azerbaijan’s infrastructure and may be subject to further study, including the modelling [8].

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Lupine Publishers|Pediatric Bipolar Disorder: Diagnosis and Management

 

  Lupine Publishers | Journal of Health Research and Reviews

Introduction

Bipolar disorder in children and adolescents is characterized by recurrent episodes of elevated mood (mania or hypomania) that exceed what is expected for the child’s developmental stage and are not better accounted by other psychiatric and medical conditions. In addition, youth with bipolar disorder usually have recurrent episodes of major depression [1-3]. Identification of the illness and initiation of treatment occurs, on average, 10 years after its manifestation [4]. that is a grave problem that could be avoided if pediatricians become more aware of the warning signs of mental illness in children, to help us treat the problem early on. It’s absolutely necessary to obtain a good history from parents and caregivers, to help diagnose the child and help decide on the appropriate line of management. The child will also need proper education about his condition in a way that is easy to understand for their age. The following symptoms are suspicious of pediatric bipolar disorder:

a) Decreased need for sleep for a long period of time.

b) Increased activity, beyond what is expected for the developmental age of the child.

c) Inappropriate sexual behaviors, that occur without a history of exposure to sexual activity (eg. Abuse or videos).

d) Psychosis (eg, hallucinations and/or delusions) may be present.

Assessment

We use structured and semi-structured interviews and rating scales; as well as careful examination and observation of the child in more than one setting, after obtaining a detailed history.

Diagnosis

We use the criteria in the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) [5].

Mania

a) Grandiosity

b) Decreased need for sleep

c) More talkative than usual

d) Flights of ideas

e) Distractibility

f) Increase in goal-directed activity or psychomotor agitation

g) Excessive involvement in pleasurable activities (eg, shopping or sexual indiscretions)

Depression

a) Depressed mood most of the day, nearly every day (dysphoria).

b) Diminished pleasure in nearly all daily activities (anhedonia).

c) Insomnia or hypersomnia nearly every day.

d) Psychomotor agitation or retardation.

e) Fatigue nearly every day.

f) Inappropriate guilt nearly every day.

g) Diminished ability to think nearly every day.

h) Recurrent thoughts of death or suicidal ideations, or suicidal attempts.

Episodes of mania, hypomania and major depression can be accompanied by symptoms of the opposite polarity and are referred to as mood episodes with mixed features.

Differential Diagnosis

The main psychiatric conditions that can be difficult to differentiate from bipolar disorder in youth are:

a) Attention deficit hyperactivity disorder (ADHD).

b) Autism spectrum disorder.

c) Conduct disorder.

d) Disruptive mood dysregulation (DMDD).

e) Oppositional defiant disorder.

f) Schizophrenia.

g) Substance use disorder.

h) Unipolar depression.

The diagnosis of bipolar disorder in youth can be complex as bipolar disorder id often accompanied by comorbid disorder. The management of bipolar disorder involves:

a) Pharmacotherapy.

b) Psychotherapy.

c) Brain Synchronization Therapy (if indicated).

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Lupine Publishers|An Innovative Method for Endovascular Stabilization of Vulnerable Plaque in Coronary Arteries: An Opinion

 

  Lupine Publishers | Journal of Health Research and Reviews

Short Communication

Despite all of the available diagnostic and treatment modalities atherosclerosis remains one of the most common healthcare problems worldwide with an estimated annual mortality rate of approximately 17,5 million cases [1]. In most cases acute coronary syndrome (ACS) appears to be linked to atherosclerotic lesion associated thrombosis of a vessel [2]. In the situation, when patients come to the interventional cardiology unit with a confirmed diagnosis of ACS: myocardial infarction, a so-called culprit lesion can be identified and treated according to international guidelines. However, alongside the lesions, that are obviously causing an impairment of a blood perfusion in a certain segment of the myocardium or have already destabilized causing acute thrombosis, some other form of entity can frequently be seen. These are called non – culprit lesions. Even though their appearance in an orifice of a vessel is regarded by most surgeons as a “bad omen”, the international community is still puzzled and unsure, if these lesions are to be treated. And even if they are, the specialists cannot yet be sure, what type of an intervention is preferable. This problem arises from several premises, including the following:

I. The non – culprit vulnerable plaque destabilization is a complex phenomenon. Not only the mechanical properties and structural integrity of the plaque define the further events, but the mechanical forces [3-5], that affect the plaque and are being transduces by blood flow, a non-Newtonian fluid, whose properties might be affected in a large variety of conditions. Apparently, the hemostasis must be accessed prior to drawing the right decision in patient’s follow – up tactics. But exact parameters are yet to be determined [6].

II. The non – culprit vulnerable plaque destabilization does not always cause an ACS [7]. Some specialists imply that assessment of blood properties and structural characteristics of the plaque are not enough. Apparently, the state of a myocardium must also be assessed.

III. Not all vulnerable plaques are equal, and the risks of destabilization accompanied by MACE vary depending on the plaque localization [8]. This statement appears to be obvious. Most surgeons would have guessed this without any researches: the more approximate position in a coronary artery clearly indicates a higher chance of an unfavorable outcome. However, what might be not so apparent, the different segments of coronary arteries’ do not react to sheer-stress in a uniform manner [9]. This is almost impossible to assess in real clinical practice but is a good thing to bear in mind.

One must put a lot of effort into the diagnostic procedures, in order to understand the whole situation. Simultaneously we do not know what kind of a medication must be used in every situation. A lot of effort has been put recently into finding a preferable drug for stabilization of a vulnerable plaque. Different approaches were used. Considering the trails REVERSAL, SATURN, ASTEROID and most importantly YELLOW, the conventional statins are still a medication of choice for the most patients with vulnerable plaques. Other drugs were introduced recently, including ivabradine [10], grelin [11], canakinumab [12]. Most of these approaches are still in early development, but it is clear now, that the lack of preventive conservative treatment is a risk factor for any manipulation [13], that is to be performed upon a vulnerable plaque.

Some cardiologists imply that more aggressive invasive techniques should be prioritized. We possess only scarce data. PRAMI trial indicates, that stenting any lesion, that is even less than 50% might be beneficial [14]. The CvLPRIP trial has mostly confirmed the findings of PRAMI [15]. Interesting results were obtained by Dai et al [16] they were able to demonstrate, that routine stenting of all lesions leads to lower rates of death, secondary ACS. MACCE were lower: RR (HR) 0.35 [95% CI 0.18 – 0.69]. Additional factors listed above might contribute to drawing a right decision in different situations.

The problem with invasive procedures extends beyond that:

I. The risks of stent - thrombosis are unacceptable in endovascular plaque stabilization. This in turn requires at least using an extremely precise tool, that has only limited contact with endothelial cells, that have not yet succumbed to pathological process. Extensive damage frequently leads to neointimal hyperplasia, neoatherosclerosis and stent thrombosis. Considering all things stated, we suppose, that only truncated stents might be used for vulnerable plaque stabilization.

II. The usage of truncated stents requires a fairly good level of precision, that most devices nowadays are still unable to provide.

III. The risks of bleeding are also high, because a person is forced to take a variety of anticoagulants for a prolonged period after the procedure. The bigger the time interval, the bigger the chances of a major bleeding. Therefore, there is a question to be asked: what if the biodegradable stents, that did not legitimately receive much attention due to the known issues and inability to compete with DES in terms of conventional stenting, can be used in this situation.

IV. The risks of periprocedural myocardial infarction [17] are dependent on structural properties of the plaque. High lipid burden and large lipid core are mostly responsible for this adverse event [18]. This cannot be manipulated by the means of surgical instruments and is a single reason for carefully assessing the situation using different diagnostic techniques.

V. It is economically ineffective to create a separate device for treatment of vulnerable plaques only.

VI. Bearing in mind all the concerns stated, we decided to come up with a new device that can be used in many different fields but is also capable to satisfy all the precautions involved in vulnerable plaque endovascular stabilization. The throughout description of the basics of this over the wire stent delivery systems (SDS) construction is not however the goal of this article. All the information can be found in our patent here: US 20100070014 A1 published in 2010. The project is in early development and we do not encourage a reader to buy it. Therefore, this article is not a commercial, but a call to international specialists, that would probably find this topic interesting to discuss. The basic structure of the SDSs distal shaft is shown below (Figure 1).

Figure 1.

Such SDS works in following order. Both balloons are connected consecutively to the compressor, but radiopaque label bearing balloon is more compliant and expands in the first place allowing the precise positioning of asymmetrical truncated stent in the orifice of the vessel. By applying sufficient force, the operator can ensure that the stent is in position, meanwhile, by applying additional pressure, can start the expansion of the second stent- bearing balloon. After the implantation is complete the SDS is removed at once. We are currently developing new biodegradable stents and will test the whole system on a swine model in several months.

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Lupine Publishers| Right Versus Left-Sided Colon Cancer: Analysis of Epidemiology in Lebanese Patients

 

  Lupine Publishers | Journal of Health Research and Reviews

Abstract

Objective: Recent studies have showed that right-sided colon cancer was more aggressive than left-sided and was more common in female and older patients. We examined the incidence of colon cancer by location (right versus left sided) in one university medical center, located in Beirut, Lebanon.

Methods: We collected the data of patients with colon cancer diagnosed between the years of 2011 and 2016 in Geitawi University Hospital, comparing the epidemiology of cases with right versus left sided colon cancer; concerning the following variables: age, sex, RAS status and the stage according to the American Joint Commission of Cancer AJCC.

Results: 96 patients were included, 61% had left-sided, 36% had right-sided, 1.5% had cancer in the transverse colon and 1.5% had synchronous left and right sided colon cancer. Patients with transverse and both right and left sided colon cancer were excluded from the study. We examined the incidence in patients under the age of 50; in whom screening is not recommended, versus patients over the age of 50; in whom screening is recommended. Patients with left-sided colon cancer were more common, more likely to be younger, to be males and to be diagnosed with a more advanced stage. In patients under the age of 50, 20% had cancer in the right and 80% had left-sided colon cancer.

Conclusion: Patients with right-sided were less common, predominantly males, older and with less aggressive stage than patients with left-sided colon cancer in a sub-group of Lebanese population.

Keywords: Colon Cancer; Right Sided; Left Sided; Epidemiology

Introduction

Colorectal cancer is one of the most commonly diagnosed cancers worldwide with over 1.2 million new cases and 608,700 deaths estimated to occur annually [1]. Colorectal cancer (CRC) is the second leading cause ofcancer-related deaths for both men and women in the United States, with 147,000 new occurrences and 50,000 deaths in 2009 [2]. Over the past years, the distinction between right-sided and left-sided colon cancer has been brought into consideration, regarding epidemiology, clinical presentation, pathology, and genetic mutations [3] Bufill in 1990 was the first to propose this, knowing that there are a number of differences between the sides of the bowel, for example the embryological beginnings; with the right bowel arising from the midgut and the left side from the hindgut, in addition to the difference in the vascular supply of each side [4].Epidemiological studies have demonstrated a gender and age relationship with a higher incidence of right colon cancer (RCC) in women and elderly people. Therefore, it has been suggested to consider colo-rectal cancer as three distinct tumor entities: right colon cancer (RCC), left colon cancer (LCC) and rectal cancer [5]. Right-sided colon cancers tend to be bulky, exophytic, polypoid lesions growing into the colon lumen and causing anemia. However, left-sided colon cancers tend to be infiltrating, constricting lesions en-circling the colorectal lumen and causing obstruction [6]. The idea of personalized medicine was introduced to the treatment of metastatic colorectal cancer (mCRC) when KRAS codon 12/13 mutations were identified as negative predictors of anti-EGFR-antibody (EGFR-mAB) treatment [7]. While there are many publications worldwide regarding this difference, it’s the first time in Lebanon we approach this issue. We studied patients with colon cancer admitted to Geitawi University Medical Center in an interval of 6 years (Figure 1).

Figure 1: The different entity of colon cancer Right Colon (ascending colon + hepatic flexure) Transverse Colon Left Colon (splenic flexure + descending colon + sigmoid).

Methods

Data selection

The data was detected from the archive of data base in Geitawi University Medical Center in Beirut. Patients selected were those diagnosed with colon cancer between the year of 2011 and 2016. The data selected included: patients age, tumor location, tumor stage and RAS status in stage 4 colon cancer.

Patient selection

All patients who were diagnosed with primary adenocarcinoma of the colon in Geitawi hospital from 2011 to 2016 were included in the study,96 patients were identified, 22 patients were excluded either because the location of the cancer was not exactly identified or because the workup and management was continued outside the hospital, also 2 patients were excluded because the Cancer was located in the transverse or synchronous side right and left colon. Inclusion criteria were as follows:

a) All patients diagnosed with colon cancer between 2011 and 2016

Exclusion criteria were as follows:

b) Transverse colon cancer

c) Synchronous left and right sided colon cancer

d) Patients continued the care out of the hospital

e) Patient without exactly primary location of colon cancer

Figure 2: Data collection and sidedness of colon cancer

After considering the above criteria, the patient pool consisted of 72 patients. They were distributed into two groups according to the colonic tumor site: 45 cases were found to be LCC and 27 were RCC. We collected the information considering the age, sex, stage according to AJCC American Joint Committee on Cancer and RAS status because Ras mutation was identified as a negative predictor of anti-EGFR-antibody (EGFR-mAB) treatment in each group. Then we divided the patients according to the age into two groups, one included patients < 50 years of age and the other included patients≥ 50 years (Figure 2).

Result

Out of the 72 patients, two thirds 62.5% had LCC, 37.7% were right-sided, 57% were males, 43.5% were females, and the mean age of the patients upon diagnoses was 65 years (Table1). In the Left-sided subgroup, the mean age was 62.5 years, 53% were males, 47% were females, and according to the AJCC staging system; 49% had tumor with stage 4 upon presentation and 51% had tumor with stage less than 4.The RAS status was found to be wild in 30% and mutated in 61% of cases, knowing that the mutation was not done in 9% of patients.In the right-sided subgroup, the mean age was 68 years, 63% were males and 37% were females. Moreover, according to the AJCC staging system, 37% had stage 4 tumor upon presentation and 63% had tumor with stage less than 4. The RAS was wild in 20% and mutated in 30% of patients. The mutation was not tested in 50% of patients, of whom 75% did not test because they decided to receive palliative treatment only. With respect to the two groups divided according to age <50 and ≥50 years (Table 2), 13.9% of the total number of patients were under the age of 50. In the latter subgroup, 80% had LCC, 40% were males, 60% were females, and the mean age was 41 years. Moreover 40% were with stage 4 tumor and 60% had tumor with stage < 4 upon diagnosis. Regarding the subgroup including patients ≥ 50 years, 59.7% LCC, 59.7% were males and 40.3% were females. The mean age was 69 years, 46.8% were with stage 4 tumor and 53.2% had tumor in stage < 4 upon diagnosis (Figure 3) (Tables 1-2).

Figure 3: Epidemiologic differences between the 2-age group.

Table 1: Epidemiologic differences between right-sided and left-sided colon cancer.

Table 2: Epidemiologic differences between the 2-age group.

With respect to patients with right-sided colon cancer, 2 patients had stage 4 tumor with wild type RAS, both treated with EGFR targeted therapy. One patient passed away after progression in his disease status and the other one didn’t respond to first line treatment.

Discussion

Patients with RCC were, overall, older, more often of female gender, and had more advanced AJCC stages than patients with LCC [1]. Differences in clinical presentation, epidemiology, and tumor biology between right and left-sided colon cancer have long been reported in the literature [2-6]. This study retrospectively collected the data from the archive of Geitawi University Medical Center and showed that patients with LCC were more often of female gender and had more advanced AJCC stages than patients with RCC. There were more patients <50 years with LCC than with RCC, and the progression of the tumor was less aggressive compared to patients≥ 50 years. Our study showed that RCC is less aggressive than LCC and this result, despite the small number of patients included in our study, is in contradiction with the results published in the studies mentioned above, which may let us question the role of ethnicity and geographic factors in this issue. Thus, additional studies should be done to confirm this hypothesis. The retrospective analysis of RAS mutation status in patients with colon cancer of stage 4 showed that RAS was mutated in patients with LCC more than those with RCC. The last study of CALGB/SWOG 80405 (Alliance) showed that patients who received cetuximab and had left-sided tumor had a median overall survival (OS) of 36 months versus 16.7 months for patients with right-sided tumor. While patients who received bevacizumab had an overall survival of 31.4 months for those with left-sided tumor versus 24.2 months for those with right-sided tumor [8,9]. These findings played a role in changing the guidelines by limiting the use of cetuximab to patients with LCC only. Also, in our study 2 patients with RCC RAS wild type were treated with EGFR targeted therapy and both demonstrated progressive disease. These data concur with the above study and may lead us to restrict ordering RAS mutation studies to patients with RCC only, perhaps reducing the financial burden. Our study’s limitations were the small number of patients included with data collected from only one center, and it didn’t report overall survival or progression free survival.

Conclusion

The patients with right-sided colon cancer were more commonly males, older and had less aggressive tumor than patients with left-sided colon cancer, contrasting with the studies published internationally. Moreover, patients under the age of 50 were more often females, had LCC more than RCC, and the progression of the tumor was less aggressive than in patients above the age of 50 years.

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Lupine Publishers| Impact and Challenges of Electronic Services and Devices on Medical Laboratory Practice; A Study in the Central Region of Ghana

 

  Lupine Publishers | Journal of Health Research and Reviews

 

Abstract

Background: The introduction of electronic services and devices has led to rapid and dramatic innovation and development in the laboratory environment. However, despite the numerous achievements and contributions in the health sector, laboratory practice continues to encounter certain difficulties in the use of electronic services and devices.

Objective: This study examined the challenges medical laboratory personnel face in the use of electronic services and devices, and its impact on the attitude of medical laboratory personnel.

Methods: A total of 62 medical laboratory personnel were conveniently selected from 8 hospitals within the Central region of Ghana. A questionnaire on Electronic Medical Laboratory Personnel Services for Efficient Health Delivery Services in Ghana was used to collect data for the study. Data collected were screened, coded and entered into computer software, and analysed using the Statistical Package for Social Sciences (SPSS version 21) for Windows.

Results: Findings revealed that the supply of electronic device accessories such as reagent was a challenge as only 37.1% of the respondents agreed it was easy. About 15% responded that maintenance/servicing of electronic device was easy. Majority showed positive attitude towards the operation of electronic device understanding principle under which electronic devices work. A higher proportion of the respondents agreed to the fact that results produced by electronic device are reliable, with average duration of producing being minutes indicating a better turnaround time. The use of electronic services and devices in the medical laboratory has had a positive impact on the attitude of some medical laboratory personnel.

Conclusion: Maintenance and repair works on electronic devices by maintenance/service team have to be prompt and regular. Workshops and training should be organized on use of electronic services and devices on regular basis for medical laboratory personnel so they could be abreast with current trends in their usage.

Keywords: Electronic Services and Devices; Laboratory, Medical Laboratory Personnel

Introduction

The use of medical laboratory tests to detect, diagnose, monitor and treat disease keeps on increasing day by day. The results produced by medical laboratory tests are used by physicians to make decisions regarding a patient’s medical condition. Some sources estimate that 70-80% of decisions made by physicians are directly dependent on medical laboratory values [1]. According to contribution to modern medicine by laboratories has been recognized as something more than the addition of another resource to medical science and is now being regarded as the seat of modern medicine, where physicians account for what they observe in their patients. As stated by [2], the emergence of sophisticated automated laboratory machines with complex procedures and the laboratories that housed them coincided with the worldwide political, industrial and philosophical revolutions. These have transformed our world which was dominated by religion and aristocracy into those dominated by the industrial, commercial and professional classes. Years after years, laboratories and their heads were met with opposition especially those clinicians who did not understand their work and saw their profession as a threat to science. However, as they continuously practice this profession, lay people and many health practitioners saw the introduction of medicine in the laboratory as a removal of medical knowledge from the realm of common experience to that of evidence based. Recently, with the introduction of electronic services and devices, the laboratory environment has experienced rapid and dramatic innovation and development [1]. There has been a significant increase in the variety and nature of medical laboratory investigations and services. This is due to technology and it is expected to continue. This has made laboratory technology according to [1] the forefront of medical advances. Testing techniques to diagnose or screen for a particular condition are now available before effective treatment. According to [3], advance in medical laboratory technology involving new tests, automated equipment and testing technique has resulted in a more efficient laboratory testing [4]. As stated by [5], information technology has also influenced the transfer of data by decreasing the time it takes to request for and receive test results and also by creating opportunities for research on large datasets. The integration of electronic services into medical laboratory practice may be affected by policies related to training of personnel, attitude of personnel, coverage and finally payment of services. Ghana was celebrated in 2013 for hosting five out of the nine state owned ISO laboratories in West Africa. Besides these ISO laboratories, there are numerous laboratories spread along the length and breadth of the country which function in hospitals, clinics just like strategically positioned private laboratories [6]. All these achievements are through the efforts of the scientists and the introduction of modern technology. However, despite the numerous achievements and contributions in the health sector in disease diagnosis, prevention, managements and prognosis, laboratory practice continues to encounter certain difficulties in the use of electronic services and devices. Therefore, this study examined the challenges medical laboratory personnel face in the use of electronic services and device and its impact on the attitude of medical laboratory personnel in the Central Region of Ghana.

Materials and Methods

Research Design and Site

A cross-sectional study with quantitative approach was conducted in the Central Region of Ghana. The Central Region is one of the ten administrative regions of Ghana. It is renowned for its many elite higher education institutions and an economy based on an abundance of tourist sites. There are seventeen districts in the region with each district having a health directorate and a district hospital and many health centers. There are also some mission and private hospitals in the region. The region has a regional hospital and a teaching hospital which attend to referral cases from the district hospitals and other health facilities. All these health facilities have medical laboratories which are in full operation with different categories of medical laboratory personnel performing various functions. The district, municipal, teaching, mission and some private hospitals have laboratories which make use of electronic services and devices in the running of patient sample. The laboratories included Cape Coast teaching hospital, Winneba and Swedru Municipal Hospitals and Kasoa District Hospital. The mission and private laboratories selected were Apam Catholic Hospital, St. Joos Hospital, MDS Lancet and Sanford Hospital.

Population

The target population for this study was all medical laboratory personnel in the central region who make use of electronic services and devices in their daily practice.

Sampling Procedure

Convenience sampling method was used to choose the sample. Convenience sampling according to Dörnyei (2007), is a type of non-probability or non-random sampling where members of the target population that meet certain practical criteria such as easy accessibility, geographical proximity, availability at a given time, or the willingness to participate are included for the purpose of the study. The researcher adapted convenience sampling method for this study because it was assumed that most of the staff from these laboratories either had a degree or an HND and were licensed and certified by the Allied Health Council of Ghana to use electronic services and devices. It was also assumed that personnel were also easy to reach and were readily available. It was assumed that convenience method placed primary emphasis on generalizability, thus ensuring that the knowledge gained was representative of the population from which the sample was drawn.

Sample Size

In this study, a sample of 62 medical laboratory personnel were conveniently selected from Cape Coast Teaching Hospital, Winneba and Swedru Municipal Hospitals, Kasoa District Hospital, Apam Catholic Hospital, St. Joos Hospital, MDS Lancet and Sanford Hospital. Out of the 62 laboratory personnel that were sampled, 6 came from medical laboratories in the teaching hospital, 14 from laboratories in municipal hospitals, 13 from district hospital laboratories, 14 from mission hospital laboratories and the remaining 15 from private medical laboratories. These laboratories were used because it was observed that they have the highest number of laboratory personnel who use electronic services and devices in the region.

Research Instrument

A questionnaire on Electronic Medical Laboratory Personnel Services for Efficient Health Delivery Services in Ghana was used to collect data for the study. A questionnaire: Electronic Medical Laboratory Personnel Services for Efficient Health Delivery Services in Ghana (Appendix A) was developed by the researcher based on extensive literature review on areas related to medical laboratory practice and electronic services. These areas included challenges medical laboratory personnel face in the use of electronic services and devices in the laboratory, impact of electronic services on the attitude of laboratory personnel, some unique skill that must be acquired in using electronic devices in the laboratory and finally measures to be put in place to ensure effective use of electronic services in the laboratory. A pool of 39 items was created using the content of areas reviewed as a guide. The items consisted of both positive and negative statements to avoid respondents’ answers being skewed toward the positive respond’s options. The questionnaire had open and close ended items.

Pilot Test

In this study, Electronic Medical Laboratory Personnel Services for Efficient Health Delivery Services in Ghana instrument was piloted with 5 medical laboratory personnel from the Baptist Hospital in Winneba to validate the effectiveness of the instrument, and the value of the questions to elicit the right information to answer the primary research questions. This preceded the main observation to correct any problems with the instrumentation or other elements in the data collection technique.

Validity of Instrument

Face validity of the questionnaire items for this study was determined by both Lecturers and colleague students to ensure there were no redundant and ambiguous items. All reviewers’ comments and suggestions were collected, analysed and considered. The final draft instrument contained four parts. The first part sought information on personnel biological and educational characteristics such as gender and age. The second and third part of the questionnaire sought information on some of the challenge’s medical laboratory personnel face in the use of electronic devices in the laboratory and the impact of electronic services on the attitude of laboratory personnel. The final part sought to identify some of the unique skill that must be acquired in using electronic devices in the laboratory and to find some of the measures to be put in place to ensure effective use of electronic services and devices in the laboratory.

Reliability of Instruments

Data from the pilot test was used to determine the reliability of research questionnaire. Item analysis was at the point carried out to identify items whose removal would enhance the internal consistency of the instrument.

Data Collection Procedure

Ethical approval was obtained from the Kwame Nkrumah University of Science and Technology (KNUST) ethical committee to medical laboratories whose personnel were part of the target population. The structured questionnaire was administered on the medical laboratory personnel at different times when they were working. The laboratories accessed included Cape Coast Regional and Teaching Hospital, Winneba and Swedru Municipal Hospitals and Kasoa District Hospital. The mission and private laboratories were Apam Catholic Hospital, St. Joos Hospital, MDS Lancet and Sanford Hospital. All the personnel who used electronic services and devices in these laboratories were eligible to participate in the study, but only those who gave their consents constituted the sample. The respondents were briefed on the intended research and their confidentiality assured as their names were not required. The questionnaire was then administered on the personnel from the selected laboratories.

Data Analysis

Data collected were screened, coded and entered into computer software. The analysis was done using the Statistical Package for Social Sciences (SPSS version 21) for Windows. Using this software, descriptive statistics function was used to determine the mean scores and standard deviations. These responses were converted into percentages for easy understanding and interpretation.

Results

Table 1 shows the general characteristics of study participants. Most of the respondents were males (61%) with 39% females. The dominant age group was 20-30 years (54.8%) followed by age group of 31-40 years (33.9%). Six of the respondents representing 9.7% work in the Teaching hospital, 14(22.6%) work in Municipal hospital with 13 (21%) of respondents working in District hospital. Most (66%) of the respondents were medical laboratory scientist thus degree holders with only one (2%) of the respondents being a laboratory assistant thus certificate holder. Also, 13 (21%) were technicians (diploma holders), and 7 (11%) had other qualifications. Table 2 shows the mean scores of responses for challenges personnel face. Majority (66.1%) of the respondents showed positive attitude towards the operation of electronic device as less challenging (M=2.6613, SD=0.47713). The table also revealed that 48.4% (30) of the respondents had positive attitude towards understanding principle under which electronic devices work (M=2.4839, SD=0.50382). However, the supply of electronic device accessories such as reagent was observed to be a challenge and only 37.1% (23) of the respondents agreed that it was easy. A little over a quarter 27.4% (17) of the respondents out of the total number of respondents agreed that calibration of electronic device was easy, and therefore revealed negative response. Less than a quarter 14.5% (9) of the respondents out of the total number of respondents agreed that maintenance/servicing of electronic device was easy. This indicate that a significant number of the respondents have challenges in using electronic device when there is the need to either maintain or service them. With the documentation of result by electronic equipment as a challenge, most of the respondents, 71% (44) of the sample scored 3 with a mean of 2.6452 and standard deviation of 0.6031. This indicates that documentation of results was not a challenge when it comes to the use of electronic device.

Table 1: General characteristics of study participants.

Table 2: The respondents’ responses on challenges faced by personnel.

From Figure 1, almost all the respondents agreed to the fact that results produced by electronic device are reliable as indicated by 93.5% (58) out of the total sample. Only 6.5% (4) of the respondents said results produced by electronic equipment are not reliable. The average duration most of these electronic devices produce result is in minutes as given by the respondents (77.4%, 48). Again, 6.5% (4) of the respondents however said the equipment produce results in hours. Finally, 16.1% (10) of the respondents said electronic equipment produced results in seconds (Figure 2). Table 3 presents mean score, standard deviation and percent frequencies on the respondents ‘attitude in the use of electronic services’ attitude scale. The mean scores of the respondent’s ranges between 3.3871 and 4.7097 while the standard deviations range between 0.45762 and 1.42983. Most of the mean scores items were above 4 (i.e. high agreement of the respondents) such as; “the use of these electronic device is helpful” with a mean score of 4.6774; “I work faster with these electronic device” had a mean score of 4.7097 and “electronic devices are user friendly” had a mean score of 4.3548. Percentages of most of the items were also very high in agreement. However, in two of the items thus “I have difficulty in working when these electronic devices break down’’ and “I have alternative means of working when these electronic devices break down”, percentage of the respondents who disagreed were 32.2% and 25.8% respectively. This indicates a number of the respondents were not in agreement to the development of positive attitude towards medical laboratory practice.

Figure 1: The respondents’ responses on the reliability of electronic service/device.

Figure 2: The respondents’ responses on the duration electronic devices produce result.

Table 3: The respondents’ responses on the impact of modern technology.

Discussion

This study examined the challenges medical laboratory personnel face in the use of electronic services and devices and its impact on the attitude of medical laboratory personnel. Majority of the respondents in this study showed positive attitude towards the operation of electronic devices understanding principle under which electronic devices work. However, the supply of electronic device accessories such as reagent was a major challenge. This is in line with the work of [4], which reported that the use of modern technology in the laboratory demanded high capital cost in terms of instrument installation and maintenance. According to his study, the status of international market may affect the supply of reagents and spare parts of equipment. Finally, the availability of maintenance of instruments and supply of reagent kits is limited to ‘big’ cities and not available in remote areas. A little over a quarter (27.4%) of our respondents agreed that calibration of electronic devices was easy, and therefore revealed negative response, with about 15% responding that maintenance/servicing of electronic device was easy. This indicates that a significant number of the respondents have challenges in using electronic device when there is the need to either maintain or service them. With the documentation of result by electronic equipment as a challenge, most of the respondents scored 3 with a mean of 2.6452 and standard deviation of 0.6031. This indicates that documentation of results was not a challenge when it comes to the use of electronic devices. It is in this direction that the study sought to identify some of the challenge’s medical laboratory personnel face in the use of electronic service and device and put in measures to help address these challenges. A higher proportion of the respondents agreed to the fact that results produced by electronic devices are reliable, with average duration of production being minutes indicating a better turnaround time. The study also revealed that the use of electronic device in the medical laboratory has had a positive impact on the attitude of some medical laboratory personnel. The mean score for most of the sub-scale was above 4 indicating positive attitudes. The implication is that some medical laboratory personnel have acquired some positive attitudes toward the practice of their profession after the introduction of electronic service and device in medical laboratories.

This is not surprising, since most of the laboratories are now moving from the manual way of practicing to the use of electronic services. The above findings are in line with [7], who confirmed technology makes use of laboratory equipment more user friendly, and also give better control of the entire process affecting the attitude of personnel positively. Again, [8] also reported that other benefits of electronic services in medical laboratories in relation to attitude of personnel include; decrease in the turnaround time (TAT) for the investigations. According to Markin and [9], in order to obtain high throughput, proper documentation, efficacy and accuracy with minimum expenditure of reagents in limited time and space, use of technology in the medical laboratory becomes very important. However, the use of electronic services and device in the laboratory also had some negative impact on the attitude of personnel. The mean score for two of the sub-scale was below 4 indicating negative attitudes. [4] reiterated that in cases of breakdown or if the equipment is out of order, alternative arrangements are very costly, and personnel often do not care leaving patients stranded. This was similar to the findings in our study, thus often alternative means of working when modern technology equipment break down are not there.In summary, the introduction of the electronic services has helped develop positive attitude in some medical laboratory personnel towards the practice of their profession[10].

Conclusion

Medical laboratory personnel had challenges with the supply of electronic device accessories such as reagent, calibration and maintenance/servicing of electronic device [11]. This requires immediate attention by authorities and other stake holders including the Ministry of Health and its agencies to address these challenges. Some personnel have developed positive attitude towards their work in the medical laboratory due to the introduction of electronic services and devices with each of the personnel receiving training before the use of electronic devices [12].

Recommendations

Based on the findings of the study, the following recommendations are made:

Reliable suppliers of electronic medical laboratory device and accessory must be engaged by hospital management such that supply of accessories such as reagent and others could be done quarterly. This must be done in order to avoid shortage in supply since most hospitals have policies which allow procurements to be done quarterly. Medical laboratory training institutions could collaborate with electronic medical laboratories for their students to have attachment and training on electronic medical laboratory services such that before the student’s complete school they are adequately prepared for electronic services in the various medical laboratories. The ministry of health must encourage all medical laboratories in Ghana to use electronic services since its use will have a positive impact on the attitude of personnel towards the practice of their profession. There must be workshops and refresher courses for medical laboratory personnel on the use of electronic services and devices by the Allied Health Professions Council of Ghana on regular basis so personnel could abreast themselves with current trends in the use of electronic services and devices in medical laboratories.

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