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Commentary: Postoperative Pain Management Strategies in Hip Arthroscopy

DOI: 10.31038/IJAS.2021211

Abstract

Hip arthroscopy is a rapidly growing field due to its significant diagnostic and therapeutic value in treating a variety of hip disorders. Due to the lack of standardized protocol for pain management in these patients, adequate control of postoperative pain continues to be challenging. Several techniques have been employed to find a regimen that is effective at reducing postoperative pain, narcotic consumption and cost to the patient and healthcare system. The purpose of this article is to provide a review of important conclusions from the previous paper “Postoperative Pain Management Strategies in Hip Arthroscopy” and report on possible implications of the article.

Recent literature supports the use of a multi-modal approach to managing postoperative pain in patients undergoing hip arthroscopy. When a pre-and postoperative analgesic regimen is used in combination with peripheral nerve block or intraoperative anesthetic injection, patients experience less pain and postoperative narcotic consumption. Postoperative pain scores and opioid consumption are similar between the different techniques. However, postoperative complications are less in those receiving Intra-Articular (IA) injection or Local Anesthetic Infiltration (LAI) compared to peripheral nerve blocks.

Recent studies suggest that intraoperative techniques such as IA injection or LAI used in conjunction with a pre-and postoperative analgesic regimen may be the safest and most effective multi-modal strategy for reducing postoperative pain in these patients. In addition, omitting the use of peripheral nerve block may lead to decreased anesthesia procedural fees and operating room turnover time, resulting in decreased cost to the patient and increased efficiency of the facility.

Introduction

Hip arthroscopy is gaining popularity among orthopedic surgeons due to its significant diagnostic and therapeutic value in the management of common hip disorders such as Femoroacetabular Impingement (FAI), labral pathology, loose body, snapping hip, septic arthritis, synovial disorders and gluteus tendon tears. Despite the recent increased prevalence of hip arthroscopy to treat hip pathology, postoperative pain management in these patients continues to be challenging for orthopedic surgeons. Unfortunately, there is a lack of standardized protocols for postoperative pain management in hip arthroscopy, likely due to the paucity of comparative high-quality studies exploring the efficacy of different techniques.

The purpose of Postoperative Pain Management Strategies in Hip Arthroscopy [1] was to provide an up to date comprehensive review of current literature regarding postoperative pain management techniques in patients undergoing hip arthroscopy. In addition, it provides a source that orthopedic surgeons can reference to determine which hip arthroscopy pain management technique, or combination thereof, is best for their practice and patients. The purpose of this commentary is to provide a rapid review of the most important conclusions of Postoperative Pain Management Strategies in Hip Arthroscopy [1] and report on possible implications of the article.

Important Conclusions

Several recent studies have proven the effectiveness of oral medications such as acetaminophen, gabapentin and cyclobenzaprine for management of pain in patients undergoing major orthopedic surgery [2-4]. However, these drugs have not been extensively studied in patients undergoing hip arthroscopy. In contrast, Celecoxib has been extensively studied in hip arthroscopy and has proven to be an efficacious oral analgesic and nonsteroidal anti-inflammatory (NSAID) due to its high oral bioavailability, rapid absorption, and selective cyclooxygenase (COX)-2 inhibition [5]. In two randomized controlled trials, preoperative celecoxib resulted in significantly lower Visual Analogue Scale (VAS) pain scores at 1, 12 and 24 hours postoperatively compared to placebo [5,6]. In addition, patients receiving celecoxib also spent less time in the Post-Anesthesia Care Unit (PACU) compared to placebo [5,6].

There has been growing interest surrounding the use of peripheral nerve blocks such as Lumbar Plexus Block (LPB), Femoral Nerve Block (FNB) and Fascia Iliaca Block (FIB) in the management of postoperative pain in patients undergoing hip arthroscopy. Patients undergoing LPB had statistically, but not clinically significant lower VAS pain scores in the PACU compared to those with general anesthesia only, or placebo [7,8]. However, patients receiving LPB required less postoperative narcotics, anti-emetics and ketorolac than the control group [7]. Patients who receive FNB tend to require less intraoperative and postoperative narcotics compared to those who receive general anesthesia alone or placebo [9,10]. Patient reported pain scores were lower in patients receiving FNB compared to general anesthesia alone, however time in PACU was higher in those receiving FNB [10]. Importantly, patient satisfaction was higher and time to discharge was lower in patients receiving FNB compared to those who received IV morphine for pain [11]. Patients who received FIB during hip arthroscopy had fairly good overall pain scores in PACU (3.85/10) [12].

Although peripheral nerve blocks are effective at reducing postoperative pain, they are not without complication. Peripheral nerve blocks have the potential for intravascular injection, iatrogenic nerve injury, postoperative falls, infection, hematoma and rebound pain after discharge [13-15]. In addition, peripheral nerve blocks require specialized equipment and an anesthesiologist to perform them, resulting in increased cost to the patient and hospital.

When compared to FNB, local anesthetic Intra-articular (IA) injections have proven to be just as effective. Child et al. [14] reported no significant difference in patient reported pain scores at 1, 3 and 6 weeks postoperatively compared to FNB. Importantly, the occurrence of postoperative falls in the IA injection group was significantly lower (5 vs 19, p <0.001). There was also a lower rate of postoperative peripheral neuritis in the IA injection group compared to the FNB group (2 vs 26 p < 0.001). Therefore, IA injection with local anesthetic provides a valuable alternative to FNB for postoperative pain control, due to significantly less complications associated with the procedure and similar pain scores as FNB. In patients who received preoperative celecoxib with acetaminophen plus IA injection with morphine and clonidine, there was a significant reduction in postoperative narcotic consumption in PACU compared to patients who received oral analgesics only. However, pain scores were similar between the two groups and there was no significant difference in time to discharge [16]. Therefore, an IA injection with clonidine and morphine may reduce complications associated with postoperative opioid consumption such as respiratory depression and dependency, while providing adequate analgesia to patients undergoing hip arthroscopy.

Recently, Local Anesthetic Infiltration (LAI) has become popular among orthopedic surgeons as an efficacious alternative to more expensive procedures such as peripheral nerve blocks. In a study conducted by Philippi et al. [17], patients who received intraoperative LAI requested fewer rescue postoperative femoral nerve blocks compared to the non-LAI group. However, there was no significant difference in opioid consumption in PACU between the groups (p=0.740) [17]. When compared to FIB, patients who received LAI had clinically significant less pain following surgery. In addition, average morphine consumption was twice as low in the LAI group, resulting in less nausea and vomiting compared to the FIB group within 24 hours postoperatively [18]. Interestingly, when LAI was compared with IA injection, patients who received LAI required significantly more rescue medication compared to IA injection group (2.33 mg vs 0.57 mg, p = 0.036). However, VAS pain scores were not statistically different between groups at 1 and 2 hours postoperatively [19]. Therefore, LAI is an effective procedure that offers similar pain management outcomes as peripheral nerve blocks, without the risk of intravascular injection, iatrogenic nerve injury, postoperative falls and higher cost to the patient and hospital. Additionally, LAI is performed intraoperatively by the surgeon, without the need for ultrasound guidance which could decrease operating room turnover time.

Implications

The findings in recent literature support the use of a multi-modal approach to managing postoperative pain in patients undergoing hip arthroscopy. When a multi-modal approach consisting of a pre-and postoperative analgesic regimen combined with peripheral nerve block or intraoperative anesthetic injection is employed, patients experience less pain and postoperative narcotic consumption. Postoperative pain scores and opioid consumption are similar between the different techniques. However, postoperative complications are less in those receiving IA injection or LAI compared to peripheral nerve blocks. In addition, peripheral nerve blocks have the potential for intravascular injection, iatrogenic nerve injury, and require highly trained anesthesiologists resulting in higher costs associated with the procedure. IA injection and LAI are quick procedures performed intraoperatively by the orthopedic surgeon. Use of these intraoperative techniques could increase efficiency of the operating room and decrease cost to the patient and hospital by decreasing turnover time and avoiding anesthesia procedural fees. Therefore, a multi-modal approach consisting of a pre-and post-operative analgesic regimen in combination with IA injection or LAI may be the optimal strategy to manage postoperative pain and increase cost effectiveness of hip arthroscopy.

Conflict of Interest

Collin LaPorte, Michael Rahl declare no conflicts of interest. Olufemi Ayeni is part of a speaker’s bureau for Conmed, outside of the submitted work. Travis Menge reports consulting fees from Smith & Nephew, and research support/grants from Stryker, DJO, and Smith & Nephew, outside of the submitted work.

References

  1. LaPorte C, Rahl MD, Ayeni OR, Menge TJ (2019) Postoperative Pain Management Strategies in Hip Arthroscopy. Current Reviews in Musculoskeletal Medicine 12: 479-485. [crossref]
  2. Schug SA, Sidebotham DA, McGuinnety M, Thomas J, Fox L (1998) Acetaminophen as an Adjunct to Morphine by PatientControlled Analgesia in the Management of Acute Postoperative Pain. Anesthesia & Analgesia 87: 368-372. [crossref]
  3. Han C, Li X, Jiang H, Ma JX, Ma XL (2016) The use of gabapentin in the management of postoperative pain after total hip arthroplasty: a meta-analysis of randomised controlled trials. Journal of Orthopaedic Surgery and Research 11: 79. [crossref]
  4. Witenko C, Moorman-Li R, Motycka C, Duane K, Hincapie-Castillo J, et al. (2014) Considerations for the appropriate use of skeletal muscle relaxants for the management of acute low back pain. P & T: a peer-reviewed. Journal for Formulary Management 39: 427-435. [crossref]
  5. Kahlenberg CA, Patel RM, Knesek M, Tjong VK, Sonn K, et al. (2017) Efficacy of Celecoxib for Early Postoperative Pain Management in Hip Arthroscopy: A Prospective Randomized Placebo-Controlled Study. Arthroscopy: The Journal of Arthroscopic and Related Surgery 1180-1185. [crossref]
  6. Zhang Z, Zhang Z, Zhu W, et al. (2014) Efficacy of celecoxib for pain management after arthroscopic surgery of hip: a prospective randomized placebo-controlled study. European Journal of Orthopaedic Surgery & Traumatology 24: 919-923.
  7. Schroeder KM, Donnelly MJ, Anderson BM, Ford MP, Keene JS (2013) The Analgesic Impact of Preoperative Lumbar Plexus Blocks for Hip Arthroscopy. A Retrospective Review. HIP International 23: 93-98. [crossref]
  8. YaDeau JT, Tedore T, Goytizolo EA, et al. (2012) Lumbar plexus blockade reduces pain after hip arthroscopy: a prospective randomized controlled trial. Anesthesia and Analgesia 115: 968-972.
  9. Dold AP, Murnaghan L, Xing J, et al. (2014) Preoperative Femoral Nerve Block in Hip Arthroscopic Surgery: A Retrospective Review of 108 Consecutive Cases. The American Journal of Sports Medicine 144-149.
  10. Xing JG, Abdallah FW, Brull R, Oldfield S, Dold A, et al. (2015) Preoperative Femoral Nerve Block for Hip Arthroscopy: A Randomized, Triple Masked Controlled Trial. The American Journal of Sports Medicine 43: 2680-2687. [crossref]
  11. Ward JP, Albert DB, Altman R, et al. (2012) Are Femoral Nerve Blocks Effective for Early Postoperative Pain Management after Hip Arthroscopy? Arthroscopy: The Journal of Arthroscopic and Related Surgery 28: 1064-1069.
  12. Purcell RL, Nappo KE, Griffin DW, McCabe M, Anderson T, et al. (2018) Fascia iliaca blockade with the addition of liposomal bupivacaine vs. plain bupivacaine for perioperative pain management following hip arthroscopy. Knee Surgery Sports Traumatology Arthroscopy 26: 2536-2541. [crossref]
  13. Stein BE, Srikumaran U, Tan EW, Freehill MT, Wilckens JH (2012) Lower-Extremity Peripheral Nerve Blocks in the Perioperative Pain Management of Orthopaedic Patients. J Bone Joint Surg Am 94: e167. [crossref]
  14. Childs S, Pyne S, Nandra K, et al. (2017) The Effect of Intra-articular Cocktail versus Femoral Nerve Block for Patients Undergoing Hip Arthroscopy. Arthroscopy 33: 2170-2176.
  15. Louw A, Diener I, Butler DS, Puentedura EJ (2013) Preoperative Education Addressing Postoperative Pain in Total Joint Arthroplasty: Review of Content and Educational Delivery Physiother Theory Pract 29: 175-194. [crossref]
  16. Cogan CJ, Knesek M, Tjong VK, et al. (2016) Assessment of Intraoperative Intra-articular Morphine and Clonidine Injection in the Acute Postoperative Period After Hip Arthroscopy. Orthopaedic Journal of Sports Medicine 4: 2325967116631335.
  17. Philippi MT, Kahn TL, Adeyemi TF, Nair R, Kahlenberg C, et al. (2018) Extracapsular local infiltration analgesia in hip arthroscopy: a retrospective study. Journal of Hip Preservation Surgery 5: 60-65. [crossref]
  18. Garner M, MSc, Alsheemeri Z, MRCS, Sardesai, et al. (2016) A Prospective Randomized Controlled Trial Comparing the Efficacy of Fascia Iliaca Compartment Block Versus Local Anesthetic Infiltration After Hip Arthroscopic Surgery. Arthroscopy: The Journal of Arthroscopic and Related Surgery 33: 125-132.
  19. Baker JF, McGuire CM, Byrne DP, Hunter K, Eustace N, et al. (2011) Analgesic control after hip arthroscopy: a randomised, double-blinded trial comparing portal with intra-articular infiltration of bupivacaine. Hip international: the journal of Clinical and Experimental Research on Hip Pathology and Therapy 21: 373-377. [crossref]

Retrospective Google Trends Analysis to Evaluate Possible COVID-19 Outbreak Onset in Italy

DOI: 10.31038/PEP.2021212

Abstract

Background: Due to the delayed communication by Chinese authorities and International bodies, it is difficult to settle when COVID-19 pandemic has started. Italy has been the first country outside Asia to experience the spreading of SARS-CoV-2 among general population, but it is possible that some patients had already developed the infection, before the first Italian official case was confirmed at the end of February.

Methods: We have performed a specific analysis from 1st August 2019 to 29th February 2020 on Google Trends, which is a publicly available tool that compares the volume of Internet searches concerning specific queries in different areas and periods. The analysis was retrospectively extended up to 5-years in order to study the seasonality of Google Trends’ search volumes in relation to potential COVID-19 symptoms.

Results: Our analyses concerning researchers on the Internet support the evidence that the outbreak onset in Italy could be set some weeks before the first confirmed case, maybe before flights closure between Italy and China imposed at the end of January 2020.

Conclusions: Internet-acquired data might represent a preliminary real-time surveillance and alert tool for healthcare systems to plan the most appropriate responses in case of health emergency such as COVID-19 pandemic.

Keywords

COVID-19; Symptoms; Internet; Web; Searches; Google trends

Introduction

The huge amount of searches run through Google creates trends data that can be analyzed by a specific function named “Google Trends” (GT), a publicly available tool that compares the volume of Internet searches concerning specific queries in different areas and periods [1]. Individuals affected by any clinical condition frequently use search engines, such as Google, to look for terms related to their diseases, possible causes and symptoms [2]. In this view, Google Trends can provide indirect approximations of the burden and symptoms of several diseases, so that they have been used for preliminary epidemiological surveillance purposes [2]. Google Trends can integrate and lead up to traditional surveillance systems in early stage detection of seasonal or annual outbreaks of infectious (i.e. influenza, scarlet fever, HIV) and non-infectious (i.e. cancer, epilepsy) diseases, presenting specific search patterns in different parts of the world [2].

Google Trends had positively been associated with the disease prevalence in many COVID-19 studies [3]. Accordingly, researchers hypothesized that this kind of “digital epidemiology” could come up with valuable insights into the spread of viral infections. We have specifically applied this methodology to evaluate the onset of COVID-19 outbreak in Italy, the first country in Europe to experience the spreading of coronavirus SARS-COV2. Italy was also the first country to impose a nationwide lockdown since Wuhan outbreak (February, 2020). Several clinical and epidemiological studies have been presented on the prevalence of COVID-19, but it is possible that some patients had already developed the infection although it was not specifically diagnosed before the first official case, confirmed in Italy at the end of Febraury [4]. Overall, the coronavirus activity has been associated with specific seasonal patterns in relation to other viral diseases such as influenza [3]. The aim of this work was to predict, through Google Trends, the amount of searches referring to COVID-19 related symptoms in Italian population that can be inferred from Internet-based searching before the first COVID-19 confirmed case in an Italian native patient.

Materials and Methods

We have used the publicly available tool “Google Trends” to determine the amount of searches concerning COVID-19 related symptoms from March 2015 to August 2020 performed by Italian users of Google engine. Search queries were ranged simultaneously into three blocks (most common, less common and severe) as listed by WHO [5]. The search was performed in Italian language to take into account only data belonging to people living in Italy. The first block was related to ‘most common symptoms’ and included: fever (in Italian: ’febbre’), tiredness (in italian: ’spossatezza’), and dry cough (in italian: ’tossesecca’). The second block concerned ‘less common symptoms’ corresponding to: rash(in italian: ’eruzione cutanea’), taste (in italian: ’gusto’), headache (in italian: ’mal di testa’), sore throat (in italian: ’mal di gola’), smell (in italian: ’olfatto’). The third block concerning ‘severe symptoms’ included: loss of voice (in italian: ‘afasia’), chest pain (in italian: ’dolore al petto’), muscles pain (in italian: ’dolori muscolari’), shortness of breath (in italian: ’fiatocorto’) [5,6].

Google Trends tool uses a fraction of searches for a specific term (‘keyword’ or ‘search term’) and automatically standardizes the data for the total number of searches gradually presenting them as comparative search volumes (ranging from 0 to 100), in order to compare variations of different search terms across time series and queries (topics in which the word was searched) [2]. Search volumes about COVID-19 symptoms were extracted from July 2015 to August 2020. The selection of the retrospective 5-years did not represent a random selection as it is bound by the extraction limits of the GT tool. Indeed, trends for periods equal or less than 5 years, are collected by days. This method allows for greater evidence than the monthly-based analysis. Scores, recorded per each day, are based on the absolute search volume for each term and day, being related to the absolute search volume on Google on the same day. Subsequently, GT was adjusted for the annual rate variation (provided by Italian Institute for Statistics, ISTAT) for the age groups showing the highest probability to use Internet (14-74 years old). Thus, for statistical purposes, the terms were aggregated by mean estimator to assess researches concerning COVID-19 ‘most common’, ‘less common’, and ‘severe’ symptoms performed by Italian Internet users.

The study includes three statistical analyses:

  1. Main Analysis: the primary objective was to assess the amount of searches referring to COVID-19 related symptoms that can be present in Italian population before the first COVID-19 officially confirmed case in Italy;
  2. Exploratory analysis: the objective was to assess the peak of terms related to COVID-19 symptoms during the pandemic period;
  3. Adherence analysis: the objective was to assess the extent to which the Internet user’s research behavior corresponded to Google trends queries related to the COVID-19 symptoms.

Main Analysis

As main analysis, an interrupted time series analysis (ITS) was used to examine the effect of coronavirus on Google searches for terms describing symptoms potentially related to COVID-19. Google Trends data were seasonally adjusted and analyzed by using auto-regressive integrated moving average (ARIMA) modelling. The implementation of the exposition was very clear with a ban on searches of symptoms terms throughout Italy across six months from August 2019 (estimated time when the virus was circulating yet) to February 2020 (the month before the first COVID-19 confirmed case in Italy, which actually occurred at the end of February) . As “control group”, we used Internet-based searches that presented the same characteristics of the exposures during continuous period (from March 2015 to July 2019), in order to evaluate the trend changes to the breaking point (F-value test). A model stratified by calendar months was adopted to control seasonality effects. The method includes a bootstrap model by default, which runs 250 replications of the main model with randomly drawn samples. A trimmed mean F-value (10 percent removed) is reported and a boot strapped p-value was derived from it. As exploratory analysis, a generalized linear models (GLM) was adapted to assess the trend peaks of epidemics.

Exploratory Analysis

The exploratory analysis was performed to study the seasonality of Google Trends’ search volume in Italy about potential COVID-19 from August 2019 to August 2020, and evaluate possible differences in relative search volumes for ‘most common’, ‘less common’ and ‘severe’ symptoms across different months, adjusted by years and during the last year since the pandemic. According to the date of the first infected with COVID-19 in Wuhan, the month of December 2019 was considered as reference month. The results were presented as rate ratio and 95% confidence intervals (CIs). Finally, cycle plots were built to show the GLM results and their monthly trends. The vertical positions of the inserted subseries plots indicate the average searches per month. The subseries plot was made up considering monthly trends fit of the y-variable (response variable) and its confidence band; the horizontal axis shows the mean y-value over the considered time interval.

Adherence Analysis

An adherence score, stratified by symptoms’ type, was provided to describe the degree to which Internet users correctly searched terms matching the study topic. The score was computed as the total of the queries that met the study objective on the total of the queries for each type of symptoms (ex: researches related to the ‘superenalotto’ topic are considered not adhering to the objective of the study).

SAS and R studio software have been used for data processing and statistical analyses. Results have been considered statistically significant if p<0.05.

Results

The results are presented in three sub-sections (Most common symptoms, Less common symptoms, Serious symptoms). Then the main analysis and the exploratory analysis are described for each category of symptoms:

Most Common Symptoms

The ‘most common’ symptoms had a positive and significant variation in the exposure group (Internet users’ searches from 1st August 2019 to 29th February 2020) than the control group (p<0.001; F-value=1.69). The Google Trends plot of key terms from February 2018 to April 2019 versus search volumes from February 2019 to April 2020 showed how the interest was considerably higher during the COVID-19 pandemic compared to the peak of previous annual flu outbreak (Figure 2A).

The exploratory analysis (under α=0.05)–performed using as reference the month of December, 2019 adjusted by year–showed a significant increased probability from 2019 to 2020 concerning the search volumes in January 2020 (p=0.018;OR=1.67; CI=1.09-2.55), February 2020 (p=0.003;OR=1.91; CI=1.26-2.91), March 2020 (p=0.002; OR=1.96, CI=1.29-2.99), June 2020 (p=0.007; OR=1.78; CI=1.68-2.71) and July 2020(p=0.008; OR=1.75; CI=1.15-2.67), and confirmed the peak between the end of February 2020 and the beginning of March 2020 (Figure 1A).

Less Common Symptoms

The ‘less common’ symptoms showed a positive and significant variation in the exposure group (users research from 1st August 2019 to 29th February 2020) than the control group (p<0.001; F-value=1.63). The Google Trends plot of key terms from February 2018 to April 2019 versus search volumes from February 2019 to April 2020 showed how the interest was considerably higher during the COVID-19 pandemic compared to the peak of previous year flu outbreak (Figure 2B).

The exploratory analysis (under α=0.05)-performed using as reference the month of December 2019 adjusted by year-showed a significant decreasing probability from 2019 to 2020 concerning the search volumes in January 2020(p=0.005; OR=0.62; CI=0.39-1.00), April 2020 (p=0.034; OR=0.60; CI=0.37-0.96), May 2020 (p=<0.001; OR=0.38; CI=0.22-0.65), June 2020 (p=<0.001; OR=0.32, CI=0.19-0.56) and July 2020 (p=<0.001; OR=0.34; CI=0.19-0.58) and reported the peak between the end of February and the beginning of March 2020 (Figure 1B).

Severe Symptoms

The ‘severe’ symptoms showed a positive and significant variation in the exposure group (Internet users’ searches from August 2019 to February2 020) than the control group (p<0.001; F-value=0.54). The Google Trends plot of key terms from February 2018 to April 2019 versus search volumes from February 2019 to April 2020 showed how the interest was considerably higher during the COVID-19 pandemic compared to the peak of previous year flu outbreak (Figure 2C).

The exploratory analysis (under α=0.05) performed using as reference month December 2019adjusted by year, showed a significant increased probability from 2019 to 2020 concerning the search volumes in February (p=0.048; OR=1.34; CI=1.00-1.78), March 2020(p=<0.001; OR=1.82, CI=1.31-1.54) and April 2020 (p=0.018; OR=1.42; CI=1.06-1.91) and reported the peak between the end of February 2020 and the beginning of March 2020 (Figure 1C).

fig 1

Figure 1: Cycle plot by monthly average GT search for Most common symptoms (A), Less common symptoms (B) and Serious symptoms (C). *Subseries shows the spline fit of search terms in each month.

fig 2

Figure 2: Interrupted time series of GT search for Most common symptoms (A), Less common symptoms (B) and Serious symptoms (C).

Discussion

In the last decade, growing evidence has been made available that Google Trends analyses may be a reliable tool for providing estimates of awareness about many diseases and treatments, which are parallel to real-world epidemiology of diseases and drug use data. This study is the first analysis concerning web search behaviours related to the coronavirus outbreak, both in quantitative and qualitative terms, aimed at assessing the time of COVID-19 onset in Italy. Additional objective of the study was to evaluate and possibly validate the epidemiological reliability of Google Trends in different non-clinical settings, for less common, most common and severe symptoms attributable to COVID-19.

Our findings confirmed how the virus may have been spreading in Italy some weeks before the first Italian native case was officially detected. Indeed, the GT symptom terms potentially related to COVID-19 (based on 250 bootstrap simulations) increased significantly in the exposure group (searches performed from 1st August 2019 to 29th February 2020) compared to the control group (users’ trends of the 5-year time series). Moreover, Google Trends for ‘less common’ ‘and ‘most common’ symptoms presented higher significant association (F-value=1.68 and 1.63, respectively) than severe symptoms (F-value=0.58) considering the exposures as reference group (August 2019 to February 2020). The reasons of these differences could be explained by the fact that ‘common’ terms (such as ‘less’ and ‘most’) considered in this analysis represent a kind of basic noisy as they are very similar to flu-like symptoms than terms used in searches concerning severe ones (such as loss of voice, chest pain, muscles pain and shortness of breath). It is also possible that the virus was initially carried by one or more people with negligible symptoms (mostly related to ‘most common’ and ‘less common’ GT term symptoms) some weeks before the outbreak.

The exploratory analysis of the results reinforces the thesis that the virus could be present in Italy several weeks before the lockdown (March 5th 2020): the ‘less common’ symptoms are more significant in the month of December 2019 than March 2020, which appears to be the peak of the pandemic (Figure 1). As highlighted in other studies [7,8], the ‘less common’ symptoms, such as loss of taste and loss of smell, are the most frequent clinical symptoms (about 90% of cases) in COVID-19 patients. Very recently, a young football player living nearby Lodi (the city where the first official Italian native case was coming from) has been proposed as the possible first documented case, as he showed SARS-COV-2 antibodies (identified on subsequent serum analyses) and severe COVID-related symptoms requiring admission to Intensive Care Unit at the beginning of February 2020, namely three weeks before the hospital admission of the first official Italian native case.

Furthermore, the temporal distribution of web-data seems consistent with the clinical trend of the pandemic: relative search volumes for ‘less common’ (Figure 2A), ‘most common’ (Figure 2B) and ‘severe’ symptoms (Figure 2C) in the period 2019-2020 were positively associated and presented a similar monthly sinusoidal pattern as previously shown in clinical studies evaluating the COVID-19 spread in Italy [9]. This was in line with the trend of hospitalizations in Italy recorded in the same months [9]. Also the spreading of the coronavirus by number of infections in the months of June, July and August 2020 is estimated to be higher than December 2019 (Figure 1B).

Nevertheless, our study has some limitations: the main one is that search volumes of Google Trends are frequently found to be increased in case of conditions with large media coverage or, at least, during periods characterized by a higher burden of disease, so that they are gaining attractivity in surveillance studies on several epidemiologically relevant diseases [10]. This is the case, for example, of coronavirus symptoms, which were the focus of large media coverage in the last months. Another limitation could be that search trends might be produced by people other than patients with COVID-19, who are nevertheless interested about this topic. Furthermore, available data are clearly limited to Google users, and are related to the possibility to use a computer with Internet access, as well as by computer literacy and skills. Therefore, a non-representative sampling bias might have occurred due to different factors, such as age, disability, income or preferred search engine [11]. To overcome this problem, the adherence analysis confirms the consistency between the terms analyzed in the study and the topics related to Covid-19. Google Trends queries related to the terms analyzed during the exposure period were highly adherent to the objective of the study (Table 1: ‘most common’ score=91.9; ‘less common’ score=82.4; ‘severe’ score=91.9). Despite this, in some cases, search biases may be found such as in the case of fever, sore throat, headache, loss of smell or taste and loss of voice (Table 1).

Table 1: Adherence scores of Google trends queries by types and terms related to COVID-19 symptoms during the exposure period (August 2019 to February 2020).

Type

Term Query* Query Rate StudyObjective Adherence Score
Most Common

Fever

Influenza 2020 sintomi

High Yes

91,9%

Influenza 2020 durata

High Yes
Codici superenalotto la febbre del sabato sera High

No

Influenza senz afebbre 2020

High Yes
Dopo quanto tempo fa effetto la tachipirina High

Yes

Tiredness

spossatezza cause

60%

Yes

Drycough

Selentus sciroppo tosse secca

High Yes

Sedativo tossesecca

130%

Yes

Tossesecca e grassa

90% Yes
Aereosoltossesecca 70%

Yes

Sciroppo per tossesecca

60%

Yes

Less Common

Rashon skin

Eruzionecutanea o rash High

Yes

82,4%

Taste

Perditaolfatto e gusto 100%

Yes

Hedache

Mal di testa elodie

High No
Mal di testa pre ciclo High

Yes

Mal di testa tutti i giorni 160%

Yes

Tachipirina 1000

130% Yes
Svegliarsi con il mal di testa 130%

Yes

Sore throat

Nenuco mal di gola

High No
Okitask High

Yes

Rimedio naturale mal di gola

180%

Yes

Rimedi naturali per il mal di gola

110% Yes
Mal di gola e raffreddore 100%

Yes

Smell

Smell

100% Yes
Olfatto 86%

Yes

Smelltraduzione 19%

No

Perditaolfatto

8% Yes
Olfattocane 5%

Yes

Severe

Lossofspeach

Afasiasinonimo

High

No

91,9%
Afaisa primaria progressiva 200%

Yes

Afasia motoria

180%

Yes

Chestpain

Dolore in mezzo al petto

130% Yes
Dolere al petto cause 60%

Yes

Dolore petto e schiena

40%

Yes

Muscules pain

Tachipirina dolori muscolari 70%

Yes

Shortnessofbreath

Fiato corto cause

100% Yes
Fiato corto e tosse 83%

Yes

Fiato corto cuore 65%

Yes

Conclusions

This study provides additional evidence for seasonality of COVID-19 by using Google Trends. In light of our results, we have proposed a method for the right use of Google Trends to predict the pandemic’s trend. This method can serve as a baseline standard to ensure methodological understanding and reproducibility for researchers who choose to use the tool in the future for other countries or regions. In fact, a future approach could be to compare the results between countries or regions and investigate possible correlations with environmental conditions [11]. Internet-acquired data might represent a preliminary real-time surveillance tool and an alert for the care systems to plan the most appropriate resources in specific periods in case of health emergency such as epidemics or pandemics [2]. However, our results support the evidence that the beginning of the outbreak in Italy were probably seeded weeks before the first detection and possibly before the first COVID-19 patient detected and also before the flights closure between Italy and China were suspended at the end of January 2020. As a future perspective, COVID-19 related to Google Trends might be validated with external clinical data sets.

Author Contributions

Conceptualization, A.F. and P.P.; methodology, A.F.; software, A.F.; validation, P.A., P.P. and M.C.; formal analysis, A.F.; investigation, A.F.; resources, A.M.; data curation, P.P.; writing—original draft preparation, A.F and P.P.; writing—review and editing, G.I.; visualization, P.A.; supervision, A.M.; project administration, A.M.; All authors have read and agreed to the published version of the manuscript.

Funding

This research received no external funding.

Conflicts of Interest

The authors declare no conflict of interest.

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Effects of a Symbiotic on the Quality of Life of Elderly Patients with Breast Cancer: a Randomized Controlled Pilot Trial

DOI: 10.31038/CST.2021613

Abstract

Background: A number of studies have confirmed the beneficial effects of prebiotics and probiotics on several physical and psychological health outcomes. The present study aims to evaluate the feasibility, tolerance and preliminary results of a symbiotic, composed by oryzalose and lactobacillis plantarum on sleep quality and psycho-physical stress in a group of elderly patients affected by hormonal dependent breast cancer.

Methods: A total of 40 patients with hystologically proven breast cancer were randomly assigned to group A (intervention) or group B (placebo). Pittsburgh Sleep Quality Index (PSQI), Short Form Health Survey (SF-36) and HADS (Hospital Anxiety and Depression Scale) were submitted to all participants, provided an informed consent, at the enrolment and 6 months later.

Results: After treatment, the group A showed the highest SF-36 physical functioning and vitality score (P=0,01), the lowest bodily pain score (P=0,01) compared to the placebo control group. Group A achieved a significant improvement in the quality of life for all SF-36 domains. Moreover, the intake of symbiotic led to a significant improvement of several PSQI subscales (sleep quality, sleep disturbances, daytime dysfunction). There was a non-significant increased rate of participants classified as good sleepers. Decreased levels of anxiety and depression were observed in group A, but the difference was not significant.

Conclusion: According to our results, a combination of oryzalose and a probiotic could significantly improve both physical and psychological outcomes in a population of elderly breast cancer patients, with excellent safety profiles and optimal compliance.

Keywords

Quality of life, Psychological distress, Cancer, Microbiome, Oncobiotic

Introduction

The human microbiota is gaining more and more attention in the pathogenesis and management of several cancers, including breast cancer, within a new frame of science defined oncobiotic. As regards breast cancer, microbiome seems to be relevant for at least five reasons: the impact of dysbiosis on immune competence [1], systemic inflammation [2], hormonal milieu through the so called “estrobolome” [3-5], the emotional balance (psychobiotic) [6] and breast tissue microbial composition [7]. In fact, several studies have shown that breast tissue has a distinct microbiome with particular species enriched, and somewhat related to the gut bacteria through a gut-breast axis [8-9]. The question remains whether the microbiome plays a causal role in breast carcinogenesis or is an epiphenomenon; accordingly, probiotic treatment may be protective against the incidence of cancer and at least some of cancer related side effects [10]. The microbiome can also interfere with pharmacodynamics and efficacy of some anticancer treatment protocols, including chemotherapy and immunotherapy [11-14]. In addition, achieving benefits in terms of QoL has become increasingly important in cancer treatment, with the traditional endpoint of survival deemed insufficient as the only treatment outcome [15]. Immune dysfunction leading to inflammation is the underlying mechanism that affects the patient physically and emotionally, which also has an indirect impact on social functioning [16]. Inflammation is a hall-mark of cancer as it is associated with the microenvironment of almost all tumor sites [17]. Persistent and localized inflammation can lead to the leaking of pro-inflammatory cytokines into circulation and trigger a systemic inflammatory cascade [18]. There is a consistent relationship between increasing systemic inflammation and worsening of all QoL parameters, such as global health, physical and social functioning, fatigue, pain [19]. Increased inflammation in the central nervous system also triggers behavioural co-morbidities, including depression, anxiety, fatigue, cognitive disturbances, and neuropathic pain. In the present study, we aim to study the feasibility and tolerance of a symbiotic supplement (Superbran) composed by a prebiotic molecule (Oryzalose, a polysaccharide derived from enzymatically treated rice bran with an extract of the shiitake mushrooms), in association with Lactobacillum Plantarum, a probiotic with proven efficacy in activating the cytokine TRAIL (Tumor Necrosis Factor-Related Apoptosis Inducing Ligand), gamma-amino butyric acid (GABA) and anthocyanin in a population of elderly breast cancer patients. The secondary endpoint of this pilot randomized controlled trial is to evaluate the effects of this supplement on quality of sleep and quality of life of a sample of elderly breast cancer patients, compared to placebo. The health-related quality of life (QoL) of cancer patients includes the subjective perception of symptoms, as well as physical, emotional, social and cognitive functions, and the side effects of hormonal treatments [20].

Materials and Methods

This is a parallel, randomized, double-blind and placebo-controlled trial carried out at Fondazione Policlinico Universitario A. Gemelli IRCCS, Center for Integrative Oncology, in Rome and at International Institute of Psychoneuroendocrineimmunology (PNEI) in Milan. A total of forty (40) non-metastatic female patients, over the age of 65 (median age: 71 years, range 65-83), with histologically proven hormone-sensitive breast cancer (ER+ and/or PR+), undergoing adjuvant hormonal therapy (aromatase inhibitors) were recruited from May 2018 to December 2019. Only three (3) of total 40 patients did not finish the study due to previous comorbidities. Twenty (20) patients were randomly assigned to the intervention group (A) and twenty (20) to the placebo group (B), matched by age and performance status. Informed consent was obtained from all the patients. The eligibility criteria were as follows: histologically proven hormonal responsive breast cancer, no ongoing corticosteroids therapy due to their immunosuppressive effects, and no concomitant treatment with other immunomodulating agents, such as interferons, interleukins and monoclonal antibodies. In both arms, supplement and placebo, supplied by PneiPharma (Milan, Italy), were administered orally in a three times/day dose for six months. At the enrolment, patients were asked to collect venous blood at 0 (baseline) and 6 months later, in the morning after an overnight fast. In each blood sample, we counted lymphocytes, monocytes and some lymphocyte subpopulations, including TH lymphocytes (CD4), cytotoxic T lymphocytes (CD8), T reg (CD4+CD25+), NK cells (CD16+CD56). Data were reported as mean ± SE, and statistically analyzed by the Chiquare test, the Student’s test, and the coefficient of correlation, as appropriate. Moreover, we measured patients’ symptoms of depression and anxiety using the Hospital Anxiety and Depression Scale (HADS), including 14 items rated on a 4-point Likert-type scale (higher scores indicate more severe symptoms). The PSQI (Pittsburgh Sleep Quality Index Malay Version) is a standardized, self-administered questionnaire that evaluates retrospective sleep quality and disturbances within the past month. It includes 19 items forming seven subscales: (1) sleep quality (1 item), (2) sleep latency (2 items), (3) sleep duration (1 item), (4) sleep efficiency (3 items), (5) sleep disturbance (9 items), (6) sleep medication (1 item), and (7) daily dysfunction (2 items). The PSQI was evaluated following the original scoring system. Each component has a score ranging from 0 to 3. The scores of seven components will be added up to get a total PSQI score ranging from 0 to 21. Respondents with an overall score above 5 are classified as ‘poor sleepers’, while those with a score of 5 or below are classified as ‘good sleepers’. The SF-36 (Short Form Survery) measures 8 QOL domains which are dichotomized in physical (functioning, physical role limitations, pain, general health) and mental health (vitality, social functioning, emotional role limitations and emotional/mental health) [21]. Item scores were converted to a scale of 0–100 points; the domain scores were derived by averaging individual items within the subscale; and physical and mental health composite scores were derived by averaging the four component domains of each one. Higher values are indicative of better QOL.

All the questionnaires were administered at 0 (baseline), 3 and 6 months in all the participants.

Results

The patients both in the intervention and in the placebo group tolerated well the treatment, did not report any remarkable side effect and only three drop out was recorded. The clinical characteristics of the evaluable patients are reported in Table 1. A clear relief from asthenia was achieved by patients enrolled in the intervention group (83%).

Table 1: Subjects’ characteristics.

GROUP A

GROUP B (PLACEBO)

Age, Years, Mean (SD)

70 (65-78)

73 (67-83)

Height (m)

1.57

1.61

Weight (kg)

70,64

73,86

Improvements in QOL (SF-36) scores were reported at 3 and 6 months (Table 2), particularly in physical functioning, role limitations and pain, while the components of mental health QOL that improved more significantly were vitality and social functioning. Tables 3 and 4 report the results of groups A and B, respectively, for each domain of the SF-36.

Table 2: The SF-36 score of the 2 groups at baseline, at 3 and 6 months.

GROUP A

GROUP B

P*

SF-36 (WEEK 0)

50.3 ± 11.24

49.6 ± 9.3

 0.001

SF-36 (WEEK 12)

53.3 ± 7.03

46.5 ± 11.24

 0.001

SF-36 (WEEK 24)

55.4 ± 8.1

47.69 ± 10.8

 0.001

Table 3: SF-36 domains in group A.

SF-36

0 month 3 month

6 months

Physical functioning

40.0 [20.0; 60.0]

47.5 [43.0; 65.0]*

52.5 [45.0; 61.0]*

Physical role

25.0 [00.0; 50.0]

30.5 [02.0; 120.0]*

37.5 [00.0; 100.0]

Bodily pain

31.0 [22.0; 41.0]

38.5 [38.0; 42.0]*

41.5 [41.0; 50.0]*

General health

48.5 [22.0; 77.0]

50.0 [42.0; 72.0

52.0 [43.0; 62.0]

Vitality

27.5 [15.0; 40.0]

35.0 [30.0; 40.0]*

45.0 [40.0; 60.0]*

Social function

50.0 [25.0; 75.0]

53.5 [50.0; 65.0]

55.5 [50.0; 75.0]

Emotional role

33.3 [00.0; 66.7]

33.3 [00.0; 100.0]

33.3 [00.0; 100.0]

Mental health

60.0 [28.0; 76.0]

66.0 [48.0; 78.0]*

72.0 [55.0; 80.0]*

*Statistically significant (p=0.001).

Table 4: SF-36 domains in group B.

SF36

0 month 3 months

6 months

Physical functioning

38.0 [20.0; 60.0]

40.5 [43.0; 65.0]

40.5 [45.0; 61.0]

Physical role

27.0 [00.0; 50.0]

30.5 [02.0; 120.0]

31.5 [00.0; 100.0]

Bodily pain

29.0 [22.0; 41.0]

30.5 [38.0; 42.0]

33.5 [41.0; 50.0]

General health

50.5 [22.0; 77.0]

52.0 [42.0; 72.0]

52.0 [43.0; 62.0]

Vitality

30.5 [15.0; 40.0]

33.0 [30.0; 40.0]

34.0 [40.0; 60.0]

Social function

47.0 [25.0; 75.0]

47.5 [50.0; 65.0]

46.5 [50.0; 75.0]

Emotional role

31.3 [00.0; 66.7]

33.3 [00.0; 100.0]

32.3 [00.0; 100.0]

Mental health

58.0 [28.0; 76.0]

60.0 [48.0; 78.0]

61.0 [55.0; 80.0]

There were no significant differences between group A and group B in mean HADS-A or HADS-D scores at baseline or during follow-up. However, after three months of follow-up there was a trend towards a reduction in the mean HADS–A score in group A compared to group B, resulting in a significant difference in mean change: -0.9 (-1.8, – 0.01) in group A versus 0.5 (-0.4 to 1.4) in group B, p = 0.02. Moreover, after 6 months of follow-up the HADS-D scores remained stable in group A, but tended to increase in group B, resulting in a significant difference in the variation of score mean during this period: 0.05 (-0.8,0.9) in group A versus 1.0 (0.3 – 1.8) in group B (p = 0.03) (Table 5). Significant improvements were also observed in the PSQI score of the both study groups but in group A the difference was statistically significant (p= 0.002) (Figure 1).

Table 5: Mean HADS score in the 2 groups before and after oryzalose.

GROUP A

GROUP B

HADS-A (WEEK 0)

6.5 (5.46 to 7.4)

6.0 (6.7 to 7.5)

HADS-D (WEEK 0)

6.1 (5.4 to 6.7)

6.0 (5.5 to 6.5)

HADS-A (WEEK 12)

6.3 (5.8 to 6.8)

6.2 (6.8 to 7.6)

HADS-D (WEEK 12)

5.9 (5.3 to 6.5)

6.0 (5.8 to 6.8)

HADS-A (WEEK 24)

6.0 (5.5 to 6.5)

6.3 (6.7 to 7.3)

HADS-D (WEEK 24)

5.7 (5.3 to 6.4)

6.2 (5.6 to 6.6)

fig 1

Figure 1: Mean PSQI score in the 2 groups.

Discussion

Rice bran oryzalose exerts immunomodulating effects, which include upregulation of natural killer (NK) cell activity, increase of phagocytic cell functions, modulation of cytokines production and promotion of T and B lymphocyte proliferation [22]. The remaining components that are resistant to digestion serve as prebiotics for the gut microbiota, which induces anti-inflammatory and immunomodulatory effects and influence behavioral changes across the gut-brain axis. Among the large number of natural agents derived from plants and employed in the integrative management of cancer patients, oryzalose is extremely promising, due to its effectiveness in improving the clinical status of patients [23-26]. QoL improvements (sleep, appetite, digestion, physical activity, anxiety and pain), as well as reduced adverse effects during cancer therapy, have been reported in several studies [27-35]. Supplementating with oryzalose (400 mg/die) for three months also significantly enhanced the QoL scores of healthy elderly adults in a randomized controlled trial [36]. Clinical research on the effects of oryzalose in cancer patients is still in its early stage [37-39], and most of the trials have several limitations, unclear risks of bias, non-validated QoL measurements [40,41]. Furthermore, none of these trials attempted to rule out the impact of placebo in QoL results. The gut microbiota is achieving increasing attention as a powerful regulator of quality of life, sleep and psychological outcomes in cancer patients; moreover, microbiome composition may be modulated by diet, exercise, behaviours, xenobiotics and probiotics [42-46]. Among the most studied and widely used probiotics, Lactobacillus plantarum is an excellent candidate for supplementation, due to its resistance to many classes of antibiotics and anti-inflammatory properties [47]. In this study, we aimed at assessing the effect of the prebiotic oryzalose in association with the probiotic Lactobacillum Plantarum in the management of cancer-related side effects and quality of life of breast cancer patients undergoing hormonal therapy. Several limitations of our study require consideration. First, we carried out this study in only two academic cancer center, in a sample of patients with limited racial and ethnic diversity; therefore, our findings cannot be generalized to other more heterogeneous populations. In addition, the short-term follow-up of the enrolled patients could be considered as another limitation of the study. On of the major strenghs of the study is the advanced age of the population enrolled (over 65), who are usually excluded from clinical trials, despite being the most affected by the disease, due to the complexity of clinical issues [48]. Despite this, our drop out rate and participants compliance to the protocol were excellent, showing high profiles of safety for the compound under investigation. The results of this feasibility trial will inform the planning of a larger clinical trial for definitive conclusions.

Conclusion

This study showed an excellent compliance to the protocol of treatment and, as preliminary results, improved quality of life in terms of physical functioning, pain, vitality and psychological well-being in elderly breast cancer patients in the treatment arm compared to placebo. Further similar studies with longer follow-up periods in breast cancer patients are warranted in order to explore the impact of symbiotics and other modulators of patients’ microbiome on cancer-related symptoms and quality of life, even in elderly populations due to the high adherence and safety profile of the prebiotic and probiotic treatment.

Conflict of Interest

The authors declare they have no competing interests.

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Hypoadrenocorticism in a Kitten

DOI: 10.31038/IJVB.2021511

Abstract

This case describes how a 7-month-old, female, intact kitten was diagnosed with hypoadrenocorticism and fully recovered after treatment with fludrocortisone acetate. The cat showed signs of weight loss, severe weakness, and anorexia. Clinical findings included severe dehydration, lethargy, and moderate hypothermia. Blood examinations showed severe azotemia, hypernatremia, hypochloremia and hyperkalemia. Hypoadrenocorticism was diagnosed on the basis of low cortisol concentration during hospitalization. The cat had a full recovery after being treated with on daily dosage of fludrocortisone acetate and prednisolone; and is still well after one year. We believe this is the first case describing hypoadrenocorticism in a kitten younger than 12 months. This case demonstrates the success of fludrocortisone acetate as the treatment, using the level of cortisol concentration as an index; and that evaluating the cortisol concentration is a good method to monitor the change of hypoadrenocortism; and that hypoadrenocorticism could be reversed with a good treatment.

Keywords

Cortisol, Feline, Fludrocortisone acetate, Hypoadrenocorticism, Kitten

Introduction

Hypoadrenocorticism, also known as Addison’s disease (AD), is a severe or total deficiency of cortisone. AD is well-described in dogs. Its estimated prevalence is 0.3% to 1.1% [1] and is generally diagnosed at the age between 3 months and 14 years [2,3]. Confirmation of the AD diagnosis is often by ACTH stimulating test and its reading of the cortisol levels in blood [2,4-6]. However, testing the basal plasma cortisol level could be an easier, more reliable and less costly method than ACTH stimulating test [7]. AD is rarely reported in cats. Up to date, approximate 40 cases have been reported [8-18]. In cats, primary AD is less likely to be found, even rarer in cats younger than 12 months. The majority of patients are shorthair domestic cats [8,11,13]; and the onset age is between 1.5 to 14 years old (median 5 years old) [13]. There is no clear evidence showed the morbidity with sex, age and breeding in cats [5]. Some case reports showed that a few factors, such as corticosteroid or/and megestrol acetate withdrawal, neoplastic infiltration, immune-mediated problem, and trauma could contribute to primary or secondary AD [8,14,15,19].

Basically, an excellent outcome of AD can be achieved by using medicines, with a post-diagnosis life expectancy of up to 70 months [20]. There are two protocols to treat AD, using either the combination of methyprednisolone and DOCP or the combination of fludrocortisone acetate and prednisone/prednisolone [2,5,13]. Reports stated a consecutive treatment by using the second protocol can keep the cats alive over than one year without clinical signs [12,13,16,18]. The case aims to describe an AD occurred in a very young kitten and the good outcome after diagnosis and treatment as, based on the authors’ knowledge, no report has described AD in a kitten age under 1 year old.

Case Description

A 7 months old, female intact, and mixed breed shorthair cat was referred to a small animal clinic with a body weight of 1.6 kg and a body condition score of 3/9. The owner said the kitten showed progressive lethargy, unwilling to move, intermittent vomiting and diarrhea 3 weeks ago. The cat had no record of using exogenous steroid or mestrol acetate. After performing the physical examination (Day 0), the patient also showed clinical signs of progressive weight loss, hypothermia (36.5°C), anorexia, 10%-12% dehydration, and mucous membranes were pale and dry. Thoracic auscultation, abdomen palpation and neurological examination, blood pressure, heart rate, and respiratory rate were within normal range. The FIV/FeLV/FCoV (Speed Trio, Virbac) and the feline distemper kit (FPV Ag Test Kit, Bionote Anigen) displayed negative results.

Serum biochemistry revealed electrolyte abnormalities, severe azotaemia, and dehydration (Tables 1 and 2). Urinalysis showed isosthenuria (specific gravity 1.011), and mild proteinuria (1+). Abdominal radiography and ultrasonography returned no specific finding. Based on above findings, taking account of especially the values of electrolytes, this case could be either acute kidney injury (AKI) or AD.

On Day 0, the initial treatments included intravenous (IV) fluid therapy. The cat received 100 mL of 0.9% normal saline subcutaneously and 0.9% normal saline was administered at 120 mL/kg/day to correct the dehydration. Two mL of 10% calcium-gluconate IV and 1 IU of regular insulin SC were administered as a cardioprotective agents because of the severe hyperkalemia. To avoid hypoglycemia, 1 mL of 10% glucose was injected by IV slowly. 200 mg lanthanum carbonate was given twice daily PO for hyperphosphatemia. Eight hours later, the potassium concentration had become normal. After another injection of 1 mL of 10% glucose, the patient’s appetite, spirit started to improve at midnight, and its body temperature gradually returned to 38.4°C. On Day 1, the potassium concentration increased again. The order was the same as Day 0. On Day 2, the potassium and Inorganic phosphate returned to the normal range so cardioprotective agents and lanthanum carbonate were stopped. The kitten presented polyuria/polydipsia. The haematological results showed mild anemia. The BUN was slightly higher and the electrolytes (sodium and chloride) were slightly lower. The other biochemical values were normal. At this point, the kitten had been rescued from emergency situation.

Consequently, IV fluid was changed to 60 mL of 0.9% saline subcutaneous once daily, On Day 3, the owner asked the kitten to be discharged. We prescribed the same treatment as Day 2. One week later, on Day 10, the patient’s condition worsened again and was re-hospitalized. It showed anorexia, lethargy, and severe dehydration. Based on the previous data, we considered the possibility of a rare disease, Addisonian crisis. Haematological and biochemical findings showed mild non-regenerative anemia, severe azotemia, and electrolytes abnormal (Tables 1 and 2). The cat was administered 0.9% normal saline at 120 mL/kg/day and dosed 0.02 mg/kg fludrocortisone acetate and 0.5 mg/kg prednisolone oral once daily as mineralocorticoid and glucocorticoid supplements. On Day 15, the value of cortisol concentration (1.1 ug/dL) became lower than the reference value. On Day 26, the value of cortisol concentration came up to the normal range (2.7 ug/dL) so we decided to tapered and then stopped the oral drugs. On Day 332, the patient was spayed and its cortisol concentration was normal (2.7 ug/dL) (Table 3). The cat has been very well since its discharged a year ago.

Table 1: Serial monitoring of hematological parameters in the kitten.

Parameter

unit Day 0 Day 2 Day 8 Day15 Day21 Day 213

RI

RBC

M/μL

9.98 7.26 7.82 5.58 5.68

6.54-12.20

HCT

%

36.1 27.0 29.2 21.0 23.5 25.6

30.3-52.3

HGB

g/dL

13.3 11.4 10.3 7.6 7.7 8.8

9.8-16.2

MCV

fL

36.2 37.2 37.3 37.6 41.4 41.0

35.9-53.1

MCH

pg

13.3 15.7 13.2 13.6 13.6 14.1

11.8-17.3

MCHC

g/dL

36.8 42.2 35.3 36.2 32.8 34.4

28.1-35.8

RDW

%

29.0 24.9 29.9 25.5 33.8 22.4

15.0-27.0

RETIC

K/μL

3.0 2.9 25.8 4.5 67.6 5.6
RETIC-HGB

pg

15.7 14.8

3.0-50.0

WBC

K/μL

12.02 17.01 11.70 11.20 8.46 10.48

2.87-17.02

NEU

K/μL

9.65 12.49 10.16 7.38 4.92 5.34

1.48-10.29

LYM

K/μL

1.98 3.38 0.92 3.03 2.26 3.14

0.92-6.88

MONO

K/μL

0.31 0.29 0.54 0.33 0.70 0.25

0.05-0.57

EOS

K/μL

0.01 0.27 0.00 0.35 0.44 1.67

0.17-1.57

BASO

K/μL

0.07 0.58 0.08 0.11 0.14 0.08

0.01-0.26

PLT

K/μL

574 272 813 285 994 275

151-600

MPV

fL

18.2 17.8 16.7 16.9 16.2 17.6

11.4-21.6

RBC: Red Blood Cell; HCT: Haematocrit; HGB: Hemoglobin; MCV: Mean Cell Volume; MCH: Mean Cell Hemoglobin; MCHC: Mean Corpuscular Hemoglobin Concentration; RDW: Red Cell Distribution Width; RETIC: Reticulocyte; RETIC-HGB: Reticulocyte Hemoglobin; WBC: White Blood Cell; NEU: Neutrophil; LYM: Lymphocyte; MONO: Monocyte; EOS: Eosinophil; BASO: Basophil; PLT: Platelet; MPV: Mean Platelet Volume.

Table 2: Serial monitoring of the serum biochemistry in the kitten.

parameter

Unit initial 8 h Day 1 Day 2 Day 3 Day 10 Day 13 Day 17 Day 21 Day 22 Day 23 Day 24 Day 25 Day 26 Day 213

RI

Glucose

mg/dL

227 44 141 156 161 148 116 74-159
Total protein

g/dL

10.3 8.1 10.2 7.2 7.9 7.2 7.5 6.7 7.5 7.2

5.7-8.9

Albumin

g/dL

4.1 3.8 4.5 3.4 3.2

2.2-4.0

BUN

mg/dL

>130 62 40 110 42 37 42 30 28 26 31 41

16-36

Creatinine

mg/dL

Over 1.9 1.7 Over 1.5 1.5 2.5 1.9 1.9 2.2 1.9 3.3

0.8-2.4

ALT

U/L

13 80 22 25

12-130

ALP

U/L

17 25 18

14-111

Inorganic phosphorus

mg/dL

14.0 6.3 5.4 >16.1 6.0 5.4 6.8

3.1-7.5

Calcium

mg/dL

10.9 10.0

7.8-11.3

Potassium

mmol/L

8.1 4.7 7.1 4.4 4.3 7.5 4.3 3.5 4.4 4.1 4.4 4.1 4.0 5.3 4.7

3.5-5.8

Sodium

mmol/L

133 140 143 148 146 132 160 160 153 154 156 154 155 162 158

150-165

Sodium

/potassium

16 30 20 34 34 18 37 45 35 38 35 37 39 31 34
Chlorine

mmol/L

98 106 108 109 111 100 123 120 117 117 119 119 116 118 127

112-129

BUN: Blood Urea Nitrogen; ALT: Alanine Aminotransferase; ALKP: Alkaline Phosphatase.

Table 3: Serial monitoring of the serum cortisol concentration.

parameter

unit Day 15 Day 26 Day 332 RI
cortisol μg/dL 1.1 2.7 2.7

1.7-4.2

Discussion

We believe this is the first report case of AD in an intact kitten younger than 1 years old. A report stated that the disease all occurred in neutered adults cats over than 1 years old and the mean age was 5.8±3.7 and the range was between 1.5 and 14 [13]. Some researchers have stated that this disease can occur in 1 years old, neutered cats [10], in 3-6 years old cats [12,16,18] and in cats older than 8 years old [14,15,21,22]. Our study advances the knowledge that AD can occur in an intact kitten younger than 1 year old.

Whether to stop fludrocortisone acetate after the clinical signs have disappeared has been a controversial issue. Some researchers believe treatment of AD is lifelong because it cannot be reversed [2,12,16,18,23]. A report mentioned that a cat suffered from AD again after the treatment was changed from twice daily to once daily [12]. In fact, the decision of prescribing a consecutive treatment is based on how good the clinical signs and electrolyte are [2,18,23]. One case pointed out the cortisol concentration became to normal 40 days after the AD treatment by using prednisolone was stopped [21]. We believe to use fludrocortisone acetate could achieve the same result as the last case based on the change of the basal cortisol concentration in our case during the treatment. After Day 26, the cortisol concentration and other biochemical values have been normal. Treatment on the kitten stopped after Day 26. On Day 332, the cortisol concentration was still normal, indicating that the kitten had recovered from Addisonian crisis. The mechanism behind the kitten’s recovery from AD is unknown.

In conclusion, this is the first case which describes AD in a kitten younger than 12 months old. Secondly, the case shows that evaluating the values of cortisol concentration is a good method to monitor the change of AD. Thirdly, fludrocortisone acetate is also a good method to treat AD. And finally, AD could be reversed after a good treatment.

Acknowledgement

We thank Dr. Pingchih Teng for his kindly suggestions during we wrote this report.

References

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Experimental Studies and First Retrospective Clinical Data Suggest a Possible Benefit of CBD in COVID-19

DOI: 10.31038/JPPR.2021412

Abstract

SARS-CoV-2 damages human cells and organs by multiple mechanisms. Intriguingly, preclinical studies have demonstrated that cannabidiol (CBD) may interact in many ways with virus entry and cell stress on one hand, and with inflammatory mechanisms affecting the lung and other organs on the other. A number of very recent in vitro and in silico studies demonstrate that CBD may be able to affect a high number of different proteins that are involved in the infection process, among them the Glucose Regulated Protein 78, heme oxygenase 1 (HO1), the virus-specific protease SARS-CoV-2 Mpro and apelin. Furthermore, a number of animal studies confirmed independently the anti-inflammatory and organ protective properties of CBD. As there is still no optimal treatment known, highly purified magisterial phyto-CBD has been included to a standard therapy for COVID-19 as an adjunct anti-inflammatory drug. A retrospective analysis of data of 30 patients hospitalised for COVID-19 and who received adjuvant low dose CBD (up to 300 mg/day), show a more pronounced reduction of virus load, normalisation of lymphocyte counts and of other abnormal laboratory parameters when compared to a non-matched group of patients who did not receive CBD.

Keywords

Cannabidiol; CBD; Concomitant treatment; COVID-19; Drug repurposing; SARS-CoV-2

Introduction

Infections with SARS-CoV-2 as well as fatality rates continue to increase despite of efforts to limit the pandemic. Even with the availability of vaccines, the virus will never go away. Mutations cause variants of the virus which may have an influence on infection mechanisms and on the efficacy of vaccines. Therefore, continued research on effective and well tolerated treatments as complementary strategy is mandatory. Since the beginning of 2020, a large number of drugs and combinations have been repurposed for COVID-19. They target widely differing mechanisms related to the infection process and/or to the innate response of the human organism. Many articles have argued also an eventual role of cannabidiol (CBD) and of other cannabinoids in the infection with SARS-CoV-2, but potential inhibitory effects of CBD on virus entry and cell stress have – to the best of our knowledge – never been summarised. In addition, no treatment results have been published so far despite that pharmaceutical grade phyto-CBD received marketing authorisation in the United States already in June 2018 and in the European Community in September 2019. Furthermore, CBD is freely available since many years for magisterial prescription in Austria and Germany; in some cases it is also reimbursed by the social insurance. Based on preclinical studies which are briefly summarised below, highly purified, magisterial phyto-CBD was added to a standard treatment for patients suffering from COVID-19. Observations were compared indirectly to a cohort of patients who did not receive CBD.

Preclinical Data Suggest a Potential Benefit of Cannabidiol in COVID-19

Cannabidiol (CBD) may interfere with the attack of SARS-CoV-2 on host cells by multiple mechanisms. The primary target of SARS-CoV-2 is the membrane-bound angiotensin-converting enzyme 2 receptor (ACE2), whereby the spike protein (S) functions as “door opener”. ACE2 is expressed by most cell types, although in varying densities. Recently, 13 of 22 cannabis extracts high in CBD were shown to down-regulate ACE2 receptor expression and ACE2 protein levels in artificial 3D models of oral, airway, and intestinal human tissues [1]. Theoretically, this would limit SARS-CoV-2 virus entry and disease progression. Unfortunately, pure CBD was not included in this study, and other phyto-compounds may have contributed to the effects. Co-localised with ACE2 is another enzyme, the membrane-bound transmembrane protease serine subtype 2 (TMPRSS2), known to activate in vitro and in vivo a wide range of viruses such as influenza and corona viruses including SARS-CoV-2 [2]. This enzyme is found specifically in cells of the secretory epithelium of airways, and cleaves (primes) the spike protein of SARS-CoV-2, thus facilitating fusion with the host cell. As extracts high in CBD inhibited also TMPRSS2 in the study mentioned above, this may reduce virus invasion further [1]. Apart from TMPRSS2, SARS-CoV-2 can utilise other proteases for priming as well, namely cathepsin B and L (CatB/L) and furin. As a multiplicity of cleavage mechanisms increases the efficacy of infection by SARS-CoV-2, the simultaneous inhibition of proteases used by the virus would enhance the effectiveness of a blockade of cell invasion. Once attached to the receptors, fusion with the host cell membrane occurs as next step; further viral uptake is mediated by endocytosis. Another protein, supposed to act as co-receptor to facilitate the binding of SARS-CoV-2 to the host cell, is the Glucose Regulated Protein 78 (GRP78) [3,4]. GRP78 is a highly conserved protein normally residing inside the cell where it controls the correct folding of proteins. Under stress conditions such as virus multiplication, the expression of GRP78 is considerably increased, and GRP78 is actively translocated from the endoplasmic reticulum (ER) to the cell surface where it acts as co-receptor for spike protein. Indeed, levels of GRP78 were found to be significantly increased in COVID-19 patients [5]. In an in vitro model of cadmium (Cd)-induced neuronal toxicity, a low concentration of CBD (1 µM) significantly prevented the GRP78 increase and ER stress [6]. A reduced expression of GRP78 reduces also its translocation to the cell membrane and availability as co-receptor. Another protein potentially targeted by CBD is the virus-specific protease SARS-CoV-2 Mpro, (also known as nsp5 or 3CLpro) which cleaves the continuous viral polypeptide, generating non-structural proteins. Based on in silico and in vitro molecular docking studies it was found that CBD as well as other cannabinoids bind strongly to SARS-CoV-2 Mpro, resulting in a stable conformation [7]. In this study, CBD was the most potent out of five phyto-cannabinoids (cannabidiol, cannabidiolic acid, delta-9-tetrahydrocannabinol, delta-9-tetrahydrocannabinolic acid, cannabinol), and even more potent than the reference drugs lopinavir, chloroquine and remdesivir. Intriguingly, CBD may be able to bind also to the spike protein as has been demonstrated in a recent in silico study [8]. A further peptide possibly playing more than just one role in early infection is apelin. Apelin is a natural, ubiquitous anti-inflammatory peptide with vasodilatory and positive inotropic activities; it interferes with ACE2 [9]. With viral infection, apelin levels decrease. CBD (5 mg i.p./kg b.w., every other day for three injections), almost normalised levels of apelin in a mouse model where acute respiratory distress syndrome (ARDS) was induced by intranasal administration of polyinosinic:polycytidylic acid [Poly(I:C)], a synthetic analogue of double stranded RNA. In parallel, this reduced also symptoms of ARDS. As apelin serves as well as substrate for ACE2 it may compete with the binding of viruses [10]. The final step in the life cycle of CoV is viral shedding. Viruses can egress the infected cells by many ways; for SARS-CoV-2, an unconventional mechanism via lysosomal vesicles has been proposed recently [11]. However, it is currently unknown whether this represents the only and exclusive mechanism or not. Therefore, it is worth mentioning that in two different models, bacterial- and cancer cells [12,13], CBD was able to inhibit the release of exosomes and microvesicles in vitro. Another cannabinoid, the closely related delta-9-tetrahydrocannabinol (THC) decreased extracellular vesicles in the blood of macaques infected with Simian Immunodeficiency Virus (SIV) in a pharmacological dose of 0.18 mg/kg [14]. Furthermore, reduced plasma HIV-1 RNA viral loads have been observed in HIV-infected subjects with a heavy consumption of cannabis [15]. Taking all these observations together, it may be speculated that CBD could have an influence on the formation of virus-filled lysosomes and/or on the release of extracellular vesicles, although this still needs to be investigated. It should be remembered that CBD is a highly lipophilic substance which interferes with a wide range of membrane-bound receptors, ion channels and other targets [16]. Finally, lymphopenia, particularly of T-lymphocytes, is a well known characteristic of COVID-19. As natural killer cells play an important role in the immune response to virus infections, the observation that low doses of 2.5 mg CBD i.p./kg produced a significant increase in total numbers of NK- and NKT-cells in rats is particularly noteworthy [17].

CBD Likely Protects Cells and Organs Against SARS-CoV-2 Induced Damages In Vivo

Once the virus has hijacked the cell, viral RNA is released into the cytoplasm; transcription and replication starts whereby the virus uses extensively the machinery of the host for synthesising and assembling viral proteins. As has been mentioned, the infection causes oxidative stress of the endoplasmic reticulum (ER), the site of protein synthesis. CBD significantly prevented the ER stress and GRP78 increase in an in vitro model [6]. Also induced by oxidative stress is heme oxygenase 1 (HO1), a cytoprotective enzyme regulated by the nuclear transcription factor Nrf2 of which CBD is an indirect agonist via the peroxisome proliferator-activated receptor gamma (PPARg) pathway. HO1 degrades heme, generating biliverdin/bilirubin, iron/ferritin, and carbon monoxide. It plays a critical role in the prevention of vascular inflammation and survival of endothelial cells. CBD (6 and 10 µM) increases in vitro Nrf2 and the expression of HO1, therefore mitigating the generation of ferritin [18,19]. Infections with viruses or bacteria induce the production of highly reactive oxygen species (ROS) in the mitochondria. As a result, lipid- and protein-peroxide products are formed which induce a strong inflammatory response which may end up in a cytokine release syndrome (CRS), also called “cytokine storm”, even in the absence of (further) viral replication. CBD in low to moderate concentrations has demonstrated anti-inflammatory and immune-modulating properties in many models as has been reviewed recently [20]. It is cytoprotective, reduces oxidative cell stress by ROS, and protects against the cytokine release syndrome (CRS), whereby CBD acts as antioxidant via enzymatic as well as via non-enzymatic mechanisms (as radical scavenger). It stimulates on one hand the transcription of cytoprotective proteins by activating, although weakly, the nuclear factor Nrf2, and downregulates on the other the transcription of pro-inflammatory cytokines by inhibiting NFκB [21]. Consequently, this reduces the release of inflammatory cytokines such as IL-6, TNFa and IFNg, as well as the release of LDH which is a marker of cellular damage.

Different Models Show that CBD Reduces the Inflammation of Airways and Protects Against Acute Respiratory Distress Syndrome (ARDS)

The endocannabinoid system (ECS) also plays a role in the immune-pathogenic response to viral infections. When mice were infected with respiratory syncytial virus (RSV) it was observed that the infection of airways significantly induced the expression of CB1 receptors in lung cells. Activation of CB1 receptors with JZL184, a selective indirect agonist, decreased immune cell influx and cytokine/chemokine production, and alleviated lung damage [22]. In another animal model, the “one lung-injury” model, inhibition of fatty acid amide hydrolase (FAAH) attenuated lung injury and improved ventilation [23]. Interference of CBD with FAAH indirectly increases levels of anandamide (AEA), a CB1 agonist, which may have protective effects against lung injury. This therapeutic potential of CBD for airway inflammation has been reviewed recently [24]. When ARDS was induced in mice by intranasal application of synthetic RNA, a low dose of CBD (5 mg/kg i.p., every other day for a total of three doses) downregulated the level of pro-inflammatory cytokines and improved clinical symptoms of ARDS [21]. In other murine models of lung injury, CBD (20 mg i.p./kg) reduced lipopolysaccharide (LPS)-induced acute pulmonary inflammation[25,26]. Finally, in a mouse model of allergic asthma induced with ovalbumin, CBD (5 or 10 mg i.p./kg) improved lung mechanics, and decreased collagen fibre content in the airways, as well as the inflammatory and remodelling processes[27,28]. A particularly vulnerable group are patients with pulmonary arterial hypertension. Although uncommon with COVID-19, it is worth to mention that CBD (10 mg/kg/day) was able to reduce monocrotaline-induced pulmonary arterial hypertension in two animal models [29,30]. As lung injury in COVID-19 may be increased by hypoxic ischemic brain damage, brain-protective properties of CBD are of further importance.

CBD Reduces Neuroinflammation

Meanwhile, it has been reported repeatedly that SARS-CoV-2 shows brain-neurotropism. Several animal models have demonstrated that CBD may protect from neuroinflammation. CBD (5 mg i.p./kg) daily from days 1 to 7 post-infection demonstrated anti-inflammatory effects in a viral model of multiple sclerosis [31]. Treatment of U373-MG glial cells with low concentrations of CBD (0.5 µM) can enhance the secretion of the neuroprotective neurotrophin (NTF3) and the expression of insulin-like growth factor 1- (IGF-1) genes [32]. In addition, a large number of hypoxia-ischemia models have demonstrated that low doses of CBD (between 0.1 and 5 mg/kg) significantly reduced brain damage, neonatal hypoxia-ischemia induced myelination disturbances, haemodynamic impairment and functional deficits even if CBD was applied hours to days after the hypoxic event [33]. Intriguingly, brain hypoxemia, often silent, occurs also with COVID-19, potentially inducing long lasting sequelae even after remission. Furthermore, CBD mitigates in vivo widely differing forms of cardiomyopathies as has been shown in various animal models including ischemia/reperfusion arrhythmias, myocardial infarction, autoimmune myocarditis or diabetic cardiomyopathy (reviewed recently by [34,35]). This includes also a mouse model of doxorubicin-induced cardiotoxicity [36]. In most models, very low to moderate CBD doses between 0.05 and 10 mg/kg have been used. In short, based on a number of preclinical in vitro and in vivo studies, a benefit of CBD in protecting organs and in limiting the progression and severity of COVID-19 may be expected. Hypothetically, CBD could mitigate COVID-19 on two levels, the infection of cells by SARS-CoV-2, and the protection of host cells and organs against stress and overshooting inflammation (“cytokine storm”). Based on this, we included low dose, adjuvant CBD to the standard treatment for COVID-19 in our hospital where magisterial CBD is routinely used since many years, in a number of conditions and in accordance with relevant regulations.

Methods

Patients have been referred to our hospital by their treating physicians during the second wave of the pandemic in Austria, between September and November 2020. At admission, diagnosis of SARS-CoV-2 infection or COVID-19 respectively was confirmed by real time reverse transcriptase–polymerase-chain-reaction (RT-PCR), CT or X-ray imaging and included also routine laboratory tests. For the majority of PCR-test, the cycle threshold- (ct) value was also available. Patients received immediately oxygen as required and a standard treatment consisting of dexamethason 6 mg/d for 10 days, zinc-orotate 40 mg/d and vitamin C, 500 mg/d for the duration of their stay in the hospital. Patients who were severely ill, needing intubation, unable to swallow or to cooperate have been excluded. CBD was administered orally as a supportive, anti-inflammatory treatment, starting with twice 100 mg CBD/day during the first week, followed by 300 mg/day for the next two weeks. Capsules, each containing 100 mg, have been prepared by a local pharmacy. A limited amount of CBD (magisterial phyto-CBD, purity >99.8%) has been provided, free of charge, by Trigal Pharma GmbH, Vienna, Austria. At discharge, patients received an aliquot of CBD capsules for the remaining period. The local ethics committee had consented to the use of CBD. Other treatments including antibiotics were administered as needed. Patients also continued to receive their usual medication in case of concomitant disorders. All patients with a laboratory result before discharge and at least one further test result at admission were included in the analysis. Assessment was retrospectively; a cohort of 30 patients who received CBD was compared to 24 patients who received the same standard care except CBD as unmatched control group. None of the patients had a history of SARS-CoV-2 vaccination.

Results

Patient characteristics are summarised in Table 1. Patients of the CBD-group were younger (mean age 65.6 years versus 79.5 years), and the percentage of men was higher (57% vs. 42%). Comorbidities were frequent (CBD-group: 50% versus 79% in control patients); arterial hypertension was the most frequent concomitant disorder noted with 66.7% and 68.4% respectively. Sex and age are widely accepted risk factors for the course of COVID-19, with female sex and younger age favouring a better prognosis. The mean duration between onset of disease and hospitalisation was comparable (6.6 versus 6.9 days), as was the duration of hospitalisation (8.7 vs. 9.0 days).

Table 1: Patient characteristics.

 

Patients with CBD

Patients without CBD
  Male Female All Male Female

All

N

17

13 30 10 14

24

Mean age (y)

63.8

67.8 65.57 72.6 84.43

79.5

Age range (y)

42-90

47-85 42-85 52-90 67-96

52-96

≤50 years

4

1 5

0

51-60

3

3 6 3 0

3

61-70

5

2 7 1 0

1

71-80

3

6 9 2 4

6

>80 years

2

1 3 4 10

14

Number of patients with at least one comorbidity

15

19

Disease onset to hospitalisation (d)

6.9

6.6

Duration of stay in the hospital (d)

8.7

9.0

d – days; y – years.

Among the laboratory parameters which have been reported repeatedly as markers for COVID-19, the number of lymphocytes, the level of lactate dehydrogenase (LDH), C-reactive protein (CRP), ferritin and interleukin 6 (IL-6) have been analysed more closely as they may reflect the hypothetical mechanism of CBD. Results are summarised below (Table 2) and are presented as the number of patients with an abnormal value of the respective parameter at admission, and a normal test result at discharge, out of the total number of patients with values available for analysis.

Table 2: Patients with abnormal laboratory values at admission and normal results at the last control in the hospital (n/N total).

Parameter (normal range)

All with CBD

All without CBD

PCR negative at discharge*

88.5% (23/26)

52.2% (12/23)

Lymphocytes (1.100-4.500/µl)

76.5% (13/17)

31.3% (5/16)

CRP (<0.50 mg/dl)

18.5% (5/27)

0% (0/21)

LDH (≤ 250 U/L)

30.8% (4/13)

0% (0/20)

Ferritin (30-400 ng/ml)

17.6% (3/17)

0% (0/7)

IL-6 (≤ 7pg/ml)

65.0% (13/20)

66.7% (6/9)

*Includes patients with a cycle threshold (ct)-value >30.0 (transmission considered to be unlikely); patients with a ct-value above 30.0 at admission or missing ct-values have been excluded.

As can be seen, the greatest differences concern the reduction of the infectiousness (ct-value, 88.5% vs. 52.2%), the normalisation of lymphocyte counts (76.5% vs. 31.3%), CRP-value (18.5% vs. 0%), LDH (30.8% vs. 0%) and ferritin (17.6% vs. 0%). This suggests an enhanced virus clearance, although results must be seen with caution due to the retrospective evaluation, the low number of patients and heterogeneity of groups. No adverse reactions occurred with concomitant CBD. In summary, a number of preclinical data suggest that CBD could have a broad-spectrum of beneficial properties in combating infections with SARS-CoV-2, by interfering with the attachment of SARS-viruses, reducing intracellular stress, boosting lymphocyte counts and alleviating inflammation. Preliminary observations in patients with COVID-19 could eventually support experimental results. However, our data on patients infected with SARS-CoV-2 are still very limited, and for many reasons they must be interpreted with caution. For a conclusive demonstration of the effectiveness of CBD in COVID-19, randomised controlled clinical trials would be necessary.

Author Contributions

RL: supervision, medical treatment, review,

MK: medical treatment,

SNS: medical treatment,

GN: consulting physicians, conceptualisation, writing the manuscript.

Funding

None

Competing Interests

Authors declare no potential conflict of interest.

GN acts as independent consultant.

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A Retrospective Comparison of the Modified Kakita Method and the Modified Cattel-Warren Anastomosis

DOI: 10.31038/JCRM.2020345

Abstract

Objective: This study compared the perioperative outcomes from patients who underwent pancreaticojejunostomy in pancreaticoduodenectomy via the modified Kakita method anastomosis (KMA) or the modified Cattell-Warren anastomosis (CWA).

Summary of background data: We retrospectively evaluated 43 consecutive patients who underwent pancreaticoduodenectomy between January 2006 and December 2012.

Methods: The modified CWA was exclusively performed before December 2009, and the modified KMA was exclusively performed after January 2010. To evaluate their simplicity and safety, we compared the perioperative outcomes for the patients who underwent CWA (n = 22) and the patients who underwent KMA (n = 21).

Results: Pancreatic fistula was significantly less frequent in the KMA group, compared to in the CWA group (4.8% vs. 36.3% respectively, p = 0.021). In addition, the rate of all surgical complications decreased after the introduction of KMA at our institution.

Conclusions: The results of this retrospective study appear to indicate that KMA is a simpler and safer technique, compared to CWA, for pancreaticojejunostomy in pancreaticoduodenectomy.

Keywords

Kakita method anastomosis, Pancreaticoduodenectomy, Pancreaticojejunostomy, Pancreatic fistula

Manuscript Summary

The major finding(s) from the study: Our results indicate that the modified Kakita technique provided a significantly lower frequency of pancreatic fistula, as well as non-significant reductions in other postoperative complications.

What the findings add to existing knowledge: We conclude that the modified Kakita technique may be simpler and more effective than the modified Cattel-Warren technique.

What is already known in the field: U-sutures may reduce shear forces at the fragile pancreatic parenchyma, and subsequently reduce the incidence of pancreatic fistula.

What should change as a result: We will perform the modified Kakita method anastomosis.

Introduction

The history of pancreaticojejunostomy in pancreaticoduodenectomy has been described throughout the literature, with Whipple et al. reporting the first cases of pancreaticoduodenectomy in 1935 [1]. Whipple also introduced pancreaticojejunostomy with complete one-stage reconstruction in 1946 [2]. However, in 1943, Cattell stated that pancreaticoenteric anastomosis was indispensable, and maintained that leakage of the pancreatic juice accounted for many postoperative complications and deaths among patients who underwent pancreaticoduodenectomy [3]. Therefore, Cattell recommended direct anastomosis of the pancreatic duct and jejunum in patients with a main pancreatic duct that had a sufficient diameter. However, for smaller pancreatic ducts, Cattell recommended the use of a “necrosing suture”, whereby the pancreatic duct was ligated and the cut surface of the pancreas was covered with the jejunal wall. Unfortunately, pancreaticoduodenectomy has historically had high rates of complications and operative mortality, which were often related to suture failure during pancreaticojejunostomy in pancreaticoduodenectomy. However, some high-volume institutions have reported mortality rates of <5% for pancreaticoduodenectomy [4-7], although the postoperative morbidity rates remain high, ranging from 30% to 50% [6-13].

Pancreatic fistula is a well-known complication of pancreaticoduodenectomy, with rates of 2–20% being recently reported [7-17]. To address this issue, several different anastomotic techniques have been used to minimize the incidence of pancreatic fistula [15,16]. These techniques include the modified Cattell-Warren anastomosis (CWA) 3, Peng’s method [16], Blumgart’s method [17], invaginating the pancreatic stump into the jejunal stump [18], and the modified Kakita method anastomosis (KMA) [19,20]. In this retrospective study, we compared the perioperative outcomes for pancreaticoduodenectomy among patients who underwent the CWA and KMA procedures.

Methods

Patients

Between January 2006 and December 2012, 43 consecutive patients underwent pancreaticoduodenectomy with pancreaticojejunostomy in the Department of Gastroenterological Surgery at Tomei Atugi Hospital, and were entered into our prospective database. The modified CWA method was exclusively performed before December 2009, and the modified KMA method was exclusively performed after January 2010. Using a before-after cohort design, we compared the perioperative outcomes for the CWA (n = 22) and the KMA (n = 21) groups.

Surgical Technique and Postoperative Management

All surgical procedures were performed by or under the supervision of experienced pancreatic surgeons. Most patients underwent subtotal stomach-preserving pancreaticoduodenectomy (SSpPD), which involves resection of the pyloric ring and preservation of >95% of the stomach, although some patients underwent conventional pancreaticoduodenectomy with distal gastrectomy. Reconstruction was performed using a modified Child’s technique for both SSpPD and conventional pancreaticoduodenectomy. The anastomosis was performed (in order of preference) between the jejunum and pancreas, bile duct, and stomach. Drain tubes (8-mm silicone tubes) ware placed at the ventral and dorsal sides of the pancreaticojejunostomy. Oral fluids were started at 72 h after the surgery, and oral intake was started at approximately 5 days after surgery, except in cases with postoperative complications, such as delayed gastric emptying. All abdominal drains were removed at day 7 after the surgery if the drainage fluid was clear, did not exceed 300 mL per 24 h, and contained a concentration of amylase that was <3-fold greater than the serum concentration. Second-generation cephem antibiotics were administered immediately before surgery and every 3 h during surgery, with continuation until day 3 after the surgery. In cases that contracted an infectious disease, the antibiotics were changes as necessary; octreotide was not routinely used.

The Modified KMA Technique

The pancreatic duct and jejunal mucosa were joined in an end-to-side fashion, using eight absorbable interrupted sutures (PDSII 5/0, ETHICON) via the duct-to-mucosa anastomosis. All patients who underwent KMA had a 4-Fr to 6-Fr polyvinyl catheter inserted into the main pancreatic duct for external drainage. The unique aspect of this modified KMA technique is the approximation of the pancreatic parenchyma to the jejunal seromuscular layer, using five or six non-absorbable interrupted penetrating sutures (Prolene 3/0, ETHICON) [19,20].

The Modified CWA Technique

The modified CWA was performed after a small incision was made at the antimesenteric side of the jejunal loop. Monofilament absorbable interrupted sutures (PDSII 3/0, ETHICON) were placed using an atraumatic needle, beginning at the posterior surface of the pancreas. The dorsal capsule of the pancreas was sutured to the seromuscular layer of the jejunum, and then the central portion of the anastomosis was completed as a duct-to-mucosa anastomosis, using interrupted sutures (PDSII 5/0, ETHICON). Finally, monofilament absorbable interrupted sutures (PDSII 3/0, ETHICON) were placed at the anterior surface of the pancreas [3]. All patients who underwent CWA had a 4-Fr to 6-Fr polyvinyl catheter inserted into the main pancreatic duct for external drainage.

Data Collection and Evaluation Parameters

We retrospectively reviewed our institution’s database to obtain the following case-specific information: age, sex, preoperative biliary drainage, diagnosis, medical history, preoperative laboratory findings (serum glutamic oxaloacetic transaminase, bilirubin, alkaline phosphatase, albumin, creatinine, lipase, amylase, hemoglobin, white cell count, C-reactive protein, and partial thromboplastin time), body mass index, pancreatic texture, operative time, intraoperative blood loss, number and type of postoperative local and systemic complications, and mortality. Postoperative morbidity was defined as any postoperative surgical or non-surgical complication. Postoperative pancreatic fistula (POPF) was diagnosed and graded based on the International Study Group on Pancreatic Fistula guidelines. The all-inclusive definition was a drain output of any measurable fluid volume on or after postoperative day 3, with amylase concentration of >3-fold higher than the serum amylase concentration. Three different grades of POPF (grades A, B, C) were defined according to the clinical signs of infection and/or a necessary change in the clinical management [21]. A fistula of grade B (fistula requiring any therapeutic intervention) or higher was considered clinically significant.

Statistical Analysis

Consecutive data were expressed as median (range) and were analyzed using the Mann-Whitney U test. Inter-group differences in numerical data were evaluated using the χ2 test (with Yates correction) or Fisher’s exact test when the n-value was <5. All statistical analyses were performed using Ystat2013 (Microsoft Excel), and differences with a p-value of <0.05 were considered statistically significant.

Results

Patient Characteristics

This study evaluated 22 patients who underwent CWA and 21 patients who underwent KMA; their characteristics are shown in Table 1. However, there were no significant differences in age or sex when we compared the two groups. In the CWA group, the pathological diagnoses were pancreatic cancer in 10 patients, cholangiocarcinoma in 9 patients, and intraductal papillary mucinous neoplasms in 3 patients. In the KMA group, the pathological diagnoses were pancreatic cancer in 10 patients, cholangiocarcinoma in 9 patients, and cystic intraductal papillary mucinous neoplasm in 2 patients. When we compared the two groups, no significant differences were observed for pancreatic texture (hard/soft), mean operative time, or intraoperative blood loss.

Table 1: Patient characteristics.

Modified Cattell-Warren anastomosis (n=22)

Modified Kakita method anastomosis (n=21) p-value
Age (years) 69 (56–86) 65 (32–84) 0.518
Sex (male/female) 16:06 14:07 0.92
Diagnosis

Pancreatic cancer

10 10 0.886
        IPMN* 3 2 1
        Cholangiocarcinoma 9 9 0.857
Pancreatic texture

Hard pancreas

9 10 0.892
        Soft pancreas 13 11 0.892
Duration of operation

(min)

580 520 0.345
Estimated blood loss

(mL)

978 933 0.5

IPMN: intraductal papillary mucinous neoplasm

Postoperative Complications

The types and frequencies of the postoperative complications are shown in Table 2. Pancreatic fistula occurred significantly less frequently in the KMA group, compared to in the CWA group (4.8% vs. 36.3%, p = 0.021), and one case of pancreatic fistula-related hemorrhage was observed in the CWA group. When we compared the specific incidences of pancreatic fistulas, grade B or C fistula was recognized in one case for the KMA group, compared to 7 cases for the CWA group, with latent presentation of a pancreatic fistula in one case. In the case with latent presentation of the pancreatic fistula, the drainage fluid amylase concentration was not elevated during the postoperative period, although the fistula was diagnosed via computed tomography after the drain was removed (Table 3). In addition, we observed a noticeable, although not significant, difference in the frequency of surgical complications after the introduction of KMA (23.8% after KMA vs. 45% after CWA; p = 0.242). Furthermore, the KMA group experienced fewer morbidities, although this difference was also not statistically significant (52.3% vs. 68.1%, p = 0.597). No cases of in-hospital mortality were observed for either group.

Table 2: Postoperative complication.

Modified Cattell-Warren anastomosis(n=22)

Modified Kakita method anastomosis (n=21)

p-value

Surgical complications

10 (45.4%)

5 (23.8%)

0.242

Wound infection

2 (9.0%)

3 (14.4%)

0.664

Intra-abdominal abscess

4 (18.2%)

1 (4.8%)

0.344

Chylous ascites

1 (4.5%)

1 (4.8%)

1

Anastomotic hemorrhage

1 (4.5%)

0

1

     Delayed gastric emptying

2 (9.1%)

1 (4.8%)

1

Hemorrhage of pseudoaneurysm

1 (4.5%)

0

1

Pancreatic fistula

8 (36.3%)

1 (4.8%)

0.021

Non-surgical complications

2 (9.0%)

5 (23.8%)

0.24

Enteritis

1 (4.5%)

2 (9.5%)

0.606

Deep venous thrombosis

0

1 (4.8%)

0.488

Respiratory events

0

3 (14.4%)

0.107

Catheter-associated infections

1 (4.5%)

1 (4.8%)

1

Total surgical and nonsurgical complications

12 (54.6%)

10 (47.6%)

0.649

Mortality

0

0

Table 3: Comparison of pancreatic fistula incidence for Cattell-Warren and Kakita method anastomosis.

Modified Cattell-Warren method anastomosis (n=22)

Modified Kakita anastomosis p-value (n=21)

p-value

No pancreatic fistula or

Grade A

14

20

0.0448

Grade B and Grade C

7

1

0.0448

Latent pancreatic fistula

1

0

1

Pancreatic fistula

8

1

0.0212

Comparing the Drainage Fluid Amylase Concentrations and Duration of Drain Insertion

When we compared the two groups, no significant differences were observed in the median drainage fluid amylase concentration in the CWA and KMA groups (CWA: 98 IU/L; range, 2–83,900 IU/L; KMA: 45 IU/L; range, 6–1,036 IU/L) (Figure 1). The drainage fluid amylase concentration exceeded 1,000 IU/L in 4 cases (3 cases in the CWA group and one case in the KMA group) on or after postoperative day 3. When we compared the duration of drain insertion for both groups, no significant difference in the median duration was observed (CWA: 16 days; range, 7–94 days; KMA: 14 days; range, 7–57 days) (Figure 2).

fig 1

Figure 1: Amylase concentrations in the drainage fluid for all cases.

No significant difference was observed when we compared the median amylase concentrations in the drainage fluids from the Cattell-Warren anastomosis (CWA) group (median, 98 IU/L; range, 2–83,900 IU/L) and the Kakita method anastomosis (KMA) group (median, 45 IU/L; range, 6–1,036 IU/L). P=0.088 via the Mann-Whitney U-test.

fig 2

Figure 2: Duration of drain insertion for all cases.

No significant difference was observed when we compared the median duration of drain insertion for the Cattell-Warren anastomosis (CWA) group (median, 16 days; range, 7–94 days) and the Kakita method anastomosis (KMA) group (median, 14 days; range, 7–57 days). P=0.501 via the Mann-Whitney U-test.

Discussion

The techniques that are used for reconstruction of the pancreatic stump after pancreaticoduodenectomy are closely related to the incidence of postoperative complications, mortality, and reduced quality of life. Pancreatic fistula is a well-known complication of pancreaticoduodenectomy, with rates of 2–20% being recently reported [7,8,10,12,14-17,20,22,23]. In many institutions, several different surgical procedures, such as Blumgart anastomosis, have been used to minimize the incidence of pancreatic fistula. Among these procedures, CWA is the most well-known procedure, and has been commonly used for a long period of time. In contrast, KMA is a relatively simple technique, and many surgeons in Japan perform KMA in pancreas-jejunum anastomosis. In this retrospective study, we found that KMA appeared to be a simpler and safer technique for pancreaticojejunostomy, compared to CWA. Moreover, the KMA technique significantly reduced the frequency of pancreatic fistula, with non-statistically significant reductions for other postoperative complications.

Patient age and intraoperative blood loss have been identified as perioperative risk factors for pancreatic fistula. In addition, soft pancreatic texture, pancreatic duct size, and pancreatic juice output have been reported to be predictive factors for pancreatic fistula [24,25]. In the present study, we observed similar trends within both groups, although there were no significant differences when we compared the risk and predictive factors between the two groups.

In CWA, multiple sutures are placed tangentially through the pancreatic capsule, which may create shear forces at the fragile pancreatic parenchyma. Furthermore, the knot-tying may cause the sutures to cut through the pancreas, and the use of multiple sutures is known to cause pancreatic microleakage during the knot-tying [17]. Therefore, it has been speculated that the use of too many sutures and/or too aggressive knot-tying may cause ischemia and necrosis of the pancreatic stump. In contrast, KMA uses only five or six non-absorbable interrupted penetrating sutures to approximate the pancreatic parenchyma to the jejunal seromuscular layer. Thus, this technique reduces the total number of sutures, avoids placing unnecessary shear forces on the fragile pancreatic parenchyma, and avoids some of the complicated manipulations that are required for other surgical techniques [19]. Furthermore, the KMA technique can help to reduce the risk of suture failure as a result of necrosis and ischemia.

Various previous studies have compared different anastomosis techniques, such as pancreaticojejunostomy versus pancreaticogastrostomy [25], Blumgart anastomosis versus modified CWA [17] or versus the Kakita type anastomosis [26], pancreaticojejunostomy with the invagination technique (dunking) versus duct-to-mucosa pancreaticojejunostomy [27], or binding anastomosis [28]. In addition, prospective randomized trials have compared pancreaticojejunostomy to pancreaticogastrostomy, and found that both procedures provided similar incidences of pancreatic fistula [25,29,30]. Similarly, a comparison of the invagination method and pancreatic duct jejunum anastomosis found no difference in the incidence of pancreatic fistula [6]. However, Blumgart anastomosis was associated with a lower incidence of pancreatic fistula, compared to the modified CWA (4% vs. 13%, respectively) [17] or to Kakita type anastomosis (2.5% vs. 36%, respectively) [26]. Similarly, the recessed method has been reported to provide a low incidence of pancreatic fistula [27], and Peng et al. have reported pancreatic leakage rates of 0% using a complex three-layer dunking anastomosis [29,31,32], although this procedure is technically difficult. Interestingly, the Blumgart and “dunking” invagination techniques use U-sutures [33,34], and these techniques provide relatively low complication rates. Therefore, U-sutures may reduce shear forces at the fragile pancreatic parenchyma, and subsequently reduce the incidence of pancreatic fistula. Similarly, the KMA method attempts to reduce the shear force in a manner that is similar to that performed with U-sutures.

Unfortunately, despite various techniques having been developed to manage the pancreatic remnant after pancreaticoduodenectomy, none of these techniques are associated with clearly superior outcomes. Thus, it is important to preserve the pancreatic capsule and to avoid bleeding from the pancreatic parenchyma during pancreaticojejunostomy, which can affect hemostasis in that tissue. Therefore, it is important to use surgical and suturing techniques that preserves as much of the parenchyma as possible (by not placing unnecessary shearing force on the pancreas).

This study has several limitations. First, because it is a retrospective single-center study, there are limitations regarding the generalizability of our data. In addition, over the course of 6 years, there is a possibility that the postoperative management may have changed slightly. Furthermore, it is impossible to completely exclude the potential effect of confounders (e.g., surgical standards and perioperative management), although it is unlikely that these factors strongly influenced the incidence of pancreatic fistula and suture insufficiency. Nevertheless, our results indicate that KMA was a simple and safe technique for reducing the incidence of pancreatic fistula and leakage rates after pancreaticojejunostomy.

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COVID-19 is a Nightmare of 2020

DOI: 10.31038/JPPR.2021411

Introduction

According to the World Health Organization (WHO), viral illnesses maintain to emerge and constitute a critical trouble to public health. In the ultimate twenty years, numerous viral epidemics including the excessive acute respiration syndrome coronavirus (SARS-CoV) in 2002 to 2003, and H1N1 influenza in 2009, had been recorded. Most recently, the Middle East respiration syndrome coronavirus (MERS-CoV) became first diagnosed in Saudi Arabia in 2012. In a timeline that reaches the existing day, an endemic of instances with unexplained low breathing infections detected in Wuhan, the biggest metropolitan place in China’s Hubei province, became first mentioned to the WHO Country Office in China, on December 31, 2019. Published literature can hint the start of symptomatic people lower back to the start of December 2019. As they have been not able to discover the causative agent, those first instances have been categorized as “pneumonia of unknown etiology.” The Chinese Center for Disease Control and Prevention (CDC) and nearby CDCs prepared an extensive outbreak research program. The etiology of this infection became attributed to a unique virus belonging to the coronavirus (CoV) family. On February 11, 2020, the WHO Director-General, Dr. Tedros Adhanom Ghebreyesus, introduced that the disorder resulting from this new CoV changed into a “COVID-19,” that is the acronym of “coronavirus disorder 2019”. In the beyond twenty years, extra CoVs epidemics have happened [1]. SARS-CoV provoked a large-scale epidemic starting in China and regarding dozen nations with about 8000 instances and 800 deaths, and the MERS-CoV that started out in Saudi Arabia and has about 2,500 instances and 800 deaths and nonetheless reasons as sporadic instances.

This new virus appears to be very contagious and has quick unfold globally. In a assembly on January 30, 2020, in step with the International Health Regulations (IHR, 2005), the outbreak changed into declared through the WHO a Public Health Emergency of International Concern (PHEIC) because it had unfold to 18 nations with 4 nations reporting human-to-human transmission. An extra landmark happened on February 26, 2020, because the first case of the disorder, now no longer imported from China, changed into recorded withinside the United States (US). Initially, the new virus was called 2019-nCoV. Subsequently, the task of experts of the International Committee on Taxonomy of Viruses (ICTV) termed it the SARS-CoV-2 virus as it is very similar to the one that caused the SARS outbreak (SARS-CoVs). The CoVs have become the major pathogens of emerging respiratory disease outbreaks. They are a large family of single-stranded RNA viruses (+ssRNA) that can be isolated in different animal species. For reasons yet to be explained, these viruses can cross species barriers and can cause, in humans, illness ranging from the common cold to more severe diseases such as MERS and SARS. Interestingly, these latter viruses have probably originated from bats and then moving into other mammalian hosts — the Himalayan palm civet for SARS-CoV, and the dromedary camel for MERS-CoV — before jumping to humans. The dynamics of SARS-Cov-2 are currently unknown, but there is speculation that it also has an animal origin. The capability for those viruses to develop to emerge as an epidemic global appears to be a critical public fitness risk. Concerning COVID-19, the WHO raised the chance to the CoV epidemic to the “very high” level, on February 28, 2020. On March 11, because the quantity of COVID-19 instances outdoor China has expanded thirteen instances and the quantity of nations concerned has tripled with greater than 118,000 instances in 114 international locations and over 4,000 deaths, WHO declared the COVID-19 an epidemic. World governments are at paintings to set up countermeasures to stem feasible devastating effects. Health companies coordinate records flows and troubles directives and hints to exceptional mitigate the effect of the chance. At the equal time, scientists round the sector paintings tirelessly, and records approximately the transmission mechanisms, the scientific spectrum of disease, new diagnostics, and prevention and healing techniques are unexpectedly developing. Many uncertainties stay in regards to each the virus-host interplay and the evolution of the pandemic, with precise connection with the instances while it’s going to attain its peak.

At the moment, the healing techniques to address the contamination are handiest supportive, and prevention aimed toward decreasing transmission withinside the network is our first-rate weapon. Aggressive isolation measures in China have caused a modern discount of cases. In Italy, in geographic areas of the north, initially, and eventually in the course of the peninsula, political and fitness government are making high-quality efforts to include a surprise wave this is seriously trying out the fitness system. In the midst of the crisis, the authors have selected to apply the “Statpearls” platform because, in the PubMed scenario, it represents a completely unique device that can permit them to make updates in real-time. The aim, therefore, is to gather statistics and medical proof and to offer an outline of the subject so one can be constantly updated.

Etiology

CoVs are positive-stranded RNA viruses with a crown-like look beneathneath an electron microscope (coronam is the Latin time period for crown) because of the presence of spike glycoproteins at the envelope. The subfamily Orthocoronavirinae of the Coronaviridae own circle of relatives (order Nidovirales) classifies into 4 genera of CoVs: Alphacoronavirus (alphaCoV), Betacoronavirus (betaCoV), Deltacoronavirus (deltaCoV), and Gammacoronavirus (gammaCoV). Furthermore, the betaCoV genus divides into 5 sub-genera or lineages. Genomic characterization has proven that in all likelihood bats and rodents are the gene reassets of alphaCoVs and betaCoVs. On the contrary, avian species appear to symbolize the gene reassets of deltaCoVs and gammaCoVs. Members of this massive own circle of relatives of viruses can motive respiratory, enteric, hepatic, and neurological sicknesses in one-of-a-kind animal species, together with camels, cattle, cats, and bats. To date, seven humans CoVs (HCoVs) — able to infecting humans — had been diagnosed. Some of HCoVs had been diagnosed withinside the mid-1960s, whilst others had been most effective detected withinside the new millennium.

In general, estimates advise that 2% of the populace are wholesome vendors of a CoV and that those viruses are answerable for approximately 5% to 10% of acute respiration infections [2].

  • Common human CoVs: HCoV-OC43, and HCoV-HKU1 (betaCoVs of the A lineage); HCoV-229E, and HCoV-NL63 (alphaCoVs). They can motive not unusual place colds and self-restricting higher respiration infections in immunocompetent individuals. In immunocompromised topics and the elderly, decrease respiration tract infections can occur.
  • Other human CoVs: SARS-CoV, SARS-CoV-2, and MERS-CoV (betaCoVs of the B and C lineage, respectively). These motive epidemics with variable medical severity offering respiration and extra-respiration manifestations. Concerning SARS-CoV, MERS-CoV, the mortality prices are as much as 10% and 35%, respectively.

Thus, SARS-CoV-2 belongs to the betaCoVs category. It has spherical or elliptic and frequently pleomorphic form, and a diameter of about 60–one hundred forty nm. Like different CoVs, it’s far touchy to ultraviolet rays and heat [3]. In this regard, even though excessive temperature decreases the replication of any species of virus. Currently, the inactivation temperature of SARS-CoV-2 have to be properly elucidated. It appears that this virus may be inactivated at approximately 27°C. On the contrary, it is able to face up to the bloodless even beneath 0°C. Furthermore, those viruses may be successfully inactivated through lipid solvents together with ether (75%), ethanol, chlorine-containing disinfectant, peroxyacetic acid, and chloroform besides for chlorhexidine. In genetic terms, Chan [4] have demonstrated that the genome of the brand new HCoV, remoted from a cluster-affected person with abnormal pneumonia after traveling Wuhan, had 89% nucleotide identification with bat SARS-like-CoVZXC21 and 82% with that of human SARS-CoV. For this reason, the brand-new virus changed into known as SARS-CoV-2-. Its single-stranded RNA genome consists of 29891 nucleotides, encoding for 9860 amino acids. Probably, numerous SARS-CoV-2 exist. Although the SARS-CoV-2 origins aren’t totally understood, genomic analyses propose that SARS-CoV-2 in all likelihood advanced from a stress discovered in bats. The ability amplifying mammalian host, intermediate among bats and humans, is, however, now no longer known. Since the mutation withinside the authentic stress ought to have immediately brought on virulence closer to humans, it isn’t always sure that this middleman exists.

Transmission

Because the primary instances of the COVID-19 ailment had been related to direct publicity to the Huanan Seafood Wholesale Market of Wuhan, the animal-to-human transmission turned into presumed as the primary mechanism [5,6]. Nevertheless, next instances had been now no longer related to this publicity mechanism. Therefore, it turned into concluded that the virus may also be transmitted from human-to-human, and symptomatic human beings are the maximum common supply of COVID-19 unfold. Because of the opportunity of transmission earlier than symptoms, and for this reason folks that continue to be asymptomatic may want to transmit the virus, isolation is the great manner to comprise this epidemic. As with different breathing pathogens, inclusive of flu and rhinovirus, the transmission is assumed to arise via breathing droplets (particles >5-10 μm in diameter) from coughing and sneezing. Aerosol transmission is likewise viable in case of protracted publicity to accelerated aerosol concentrations in closed spaces [7]. Analysis of statistics associated with the unfold of SARS-CoV-2 in China appears to suggest that near touch among people is necessary. Of note, pre-and asymptomatic people may also make a contribution to up 80% of COVID-19 transmission. The unfold, in fact, Is mainly restricted to own circle of relatives members, healthcare professionals, and different near contacts (6 feet, 1.8 meters). Concerning the length of infection on gadgets and surfaces, a examine confirmed that SARS-CoV-2 may be determined on plastic for up to two-three days, chrome steel for up to two-three days, cardboard for up to at least one day, copper for as much as four hours. Moreover, evidently infection is better in extensive care units (ICUs) than widespread wards and SARS-Cov-2 may be determined on floors, pc mice, trash cans, and sickbed handrails in addition to in air as much as four meters from patients.

Based on facts from the primary instances in Wuhan and investigations performed through the China CDC and neighbourhood CDCs, the incubation time might be commonly inside three to 7 days (median 5.1 days, just like SARS) and up to two weeks because the longest time from contamination to signs became 12.5 days (95% CI, 9.2 to 18) [8]. This fact additionally confirmed that this novel epidemic doubled approximately each seven days, while the fundamental replica number (R0-R naught) is 2.2. In different words, on average, every affected person transmits the infection to an extra 2.2 individuals. Of note, estimations of the R0 of the SARS CoV epidemic in 2002-2003 had been about three. It has to be emphasised that these statistics is the end result of the primary reports. Thus, in addition research are had to recognize the mechanisms of transmission, the incubation instances and the scientific course, and the length of infectivity.

Epidemiology

Data furnished via way of means of the WHO Health Emergency Dashboard document 3,679,499 showed instances of COVID-19, inclusive of 254,199 deaths. Of note, 6.90 of instances had been deadly (as of 6:32 pm CEST, 7 May 2020). To date, there are instances in 215 Countries. Considering case comparison, in Europe there are 1,626,037 showed instances; Americas 1,542,829; Eastern Mediterranean 235,398; Western Pacific; South-East Asia 82,852; Africa 35,470. The maximum deadly instances had been recorded withinside the US (65,197) accompanied via way of means of UK (30,076), and Italy (29,684).

The maximum up to date supply for the epidemiology of this rising pandemic may be observed at the subsequent reasserts:

The WHO Novel Coronavirus (COVID-19) Situation Board. The Johns Hopkins Center for Systems Science and Engineering web website online for Coronavirus 
Global Cases COVID-19, which makes use of brazenly public reassets to song the unfold of the epidemic.

Pathophysiology

CoVs are enveloped, positive-stranded RNA viruses with nucleocapsid. For addressing pathogenetic mechanisms of SARS-CoV-2, its viral shape, and genome need to be considerations. In CoVs, the genomic shape is prepared in a +ssRNA of about 30 kb in length — the biggest recognised RNA viruses — and with a 5′-cap shape and 3′-poly-Atail. Starting from the viral RNA, the synthesis of polyprotein 1a/1ab (pp1a/pp1ab) withinside the host is realized. The transcription works via the replication-transcription complex (RCT) prepared in double-membrane vesicles and through the synthesis of subgenomic RNAs (sgRNAs) sequences. Of note, transcription termination takes place at transcription regulatory sequences, positioned among the so-referred to as open analyzing frames (ORFs) that paintings as templates for the manufacturing of subgenomic mRNAs. In the abnormal CoV genome, as a minimum six ORFs may be present. Among these, a frameshift among ORF1a and ORF1b courses the manufacturing of each pp1a and pp1ab polypeptides which are processed with the aid of using virally encoded chymotrypsin-like protease (3CLpro) or primary protease (Mpro), in addition to one or papain-like proteases for generating sixteen non-structural proteins (nsps) [9]. Apart from ORF1a and ORF1b, different ORFs encode for structural proteins, inclusive of spike, membrane, envelope, and nucleocapsid proteins. And accent protein chains. Different CoVs gift unique structural and accent proteins translated with the aid of using committed sgRNAs.

Pathophysiology and virulence mechanisms of CoVs, and consequently additionally of SARS-CoV-2 have hyperlinks to the feature of the nsps and structural proteins. For instance, studies underlined that nsp is capable of block the host innate immune response. Among features of structural proteins, the envelope has a essential function in virus pathogenicity because it promotes viral meeting and release. However, a lot of those features (e.g., the ones of nsp 2, and 11) have now no longer but been described. Among the structural factors of CoVs, there are the spike glycoproteins composed of subunits (S1 and S2). Homotrimers of S proteins compose the spikes at the viral surface, guiding the hyperlink to host receptors [10]. Of note, in SARS-CoV-2, the S2 subunit — containing a fusion peptide, a transmembrane area, and cytoplasmic area — is extraordinarily conserved. Thus, it can be a goal for antiviral (anti-S2) compounds. On the contrary, the spike receptor-binding area provides handiest a 40% amino acid identification with different SARS-CoVs. Other structural factors on which studies ought to always cognizance is the ORF3b that has no homology with that of SARS-CoVs and a secreted protein (encoded through ORF8), that is structurally distinct from the ones of SARS-CoV. In global gene banks including GenBank, researchers have posted numerous Sars-CoV-2 gene sequences. This gene mapping is of essential significance permitting researchers to hint the phylogenetic tree of the virus and, above all, the popularity of traces that fluctuate consistent with the mutations. According to latest research, a spike mutation, which likely befell in past due November 2019, precipitated leaping to humans. In particular, Angeletti [11] as compared the Sars-Cov-2 gene series with that of Sars-CoV. They analyzed the transmembrane helical segments withinside the ORF1ab encoded 2 (nsp2) and nsp3 and located that function 723 affords a serine in place of a glycine residue, even as the placement 1010 is occupied through proline in place of isoleucine. The count of viral mutations is fundamental for explaining capacity disorder relapses. The studies might be had to decide the structural traits of SARS-COV-2 that underlie the pathogenetic mechanisms. Compared to SARS, for example, preliminary medical information display much less more breathing involvement, despite the fact that because of the dearth of large information, it isn’t feasible to attract definitive medical information.

The pathogenic mechanism that produces pneumonia appears to be specifically complex. Clinical and preclinical studies will need to give an explanation for many factors that underlie the unique medical displays of the disease. The information to date to be had appear to signify that the viral contamination is able to generating an immoderate immune response withinside the host. In a few cases, a response takes location which as an entire is categorised a ‘cytokine storm’. The impact is significant tissue harm with dysfunctional coagulation. Just some time ago, Italian researched added the time period of MicroCLOTS [12] (microvascular COVID-19 lung vessels obstructive thromboinflammatory syndrome) for underlying the lung viral harm related to the inflammatory response and the microvascular pulmonary thrombosis. While numerous cytokines which include the tumor necrosis thing α (TNF-α), IL-1β, IL-8, IL-12, interferon-gamma inducible protein (IP10), macrophage inflammatory protein 1A (MIP1A), and monocyte chemoattractant protein 1 (MCP1) are implicated withinside the pathogenic cascade of the disease, the protagonist of this typhoon is interleukin 6 (IL-6). IL-6 is produced more often than not through activated leukocytes and acts on a big variety of cells and tissues. It is capable of sell the differentiation of B lymphocytes, promotes the boom of a few classes of cells, and inhibits the boom of others. It additionally stimulates the manufacturing of acute-section proteins and performs a vital position in thermoregulation, in bone preservation and withinside the capability of the principal worried system. Although the primary position performed through IL-6 is pro-inflammatory, it could additionally have anti-inflammatory effects [13]. In turn, IL-6increases in the course of inflammatory diseases, infections, autoimmune disorders, cardiovascular diseases, and a few forms of cancer. It is likewise implicated withinside the pathogenesis of the cytokine launch syndrome (CRS) this is an acute systemic inflammatory syndrome characterised through fever and a couple of organ dysfunction. IL-6 isn’t always the handiest protagonist at the scene. It turned into proved, for instance, that the binding of SARS-CoV-2 to the Toll-Like Receptor (TLR) induces the discharge of pro-IL-1β that is cleaved into the energetic mature IL-1β mediating lung inflammation, till fibrosis.

Histopathology

Tian [14] And others pronounced histopathological records received at the lungs of sufferers who underwent lung lobectomies for adenocarcinoma and retrospectively discovered to have had the contamination on the time of surgery. Apart from the tumors, the lungs of both ‘accidental’ instances confirmed edema and crucial proteinaceous exudates as massive protein globules. The authors additionally pronounced vascular congestion blended with inflammatory clusters of fibrinoid fabric and multinucleated massive cells and hyperplasia of pneumocytes. More recently, Zhang [15] executed a postmortem transthoracic needle lung biopsy in an affected person who died of COVID-19. Immunostaining confirmed diffuse alveolar harm and a vital alveolar expression of viral antigens. In autopsies on COVID-19 cases, the authors provided an in-depth image of the histological styles in lung and extrapulmonary tissues. This image turned into characterised through capillary congestion, necrosis of pneumocytes, hyaline membrane, interstitial edema, pneumocyte hyperplasia, and reactive atypia. Platelet-fibrin thrombi in small arterial vessels have been the expression of intravascular coagulopathy. Moreover, withinside the lung they located infiltrates expressed as macrophages in alveolar lumens and lymphocytes withinside the interstitium. In summary, much like SARS and MERS, excessive COVID-19 lung harm turned into manifested in phrases of Diffuse Alveolar Disease (DAD) with excessive capillary congestion. Again, numerous findings have been suggestive for vascular dysfunction [16], in lung and different tissues.

History and Physical

The medical spectrum of COVID-19 varies from asymptomatic or paucisymptomatic bureaucracy to medical situations characterised with the aid of using respiration failure that necessitates mechanical air flow and assist in an ICU, to multiorgan and systemic manifestations in phrases of sepsis, septic shock, and more than one organ disorder syndromes (MODS). In one of the first reviews at the disease, Huang [17] Illustrated that patients (n. 41) suffered from fever, malaise, dry cough, and dyspnea. Chest automated tomography (CT) scans confirmed pneumonia with extraordinary findings in all cases. About a 3rd of those (13, 32%) required ICU care, and there have been 6 (15%) deadly cases. The case research of Li [7] posted withinside the New England Journal of Medicine (NEJM) on January 29, 2020, encapsulates the primary 425 instances recorded in Wuhan. Data imply that the patients’ median age turned into fifty-nine years, with various 15 to 89 years. Thus, they pronounced no medical instances in kids under 15 years of age. There had been no large gender differences (56% male). On the contrary, in different reviews there’s a decrease incidence withinside the woman gender. Clinical and epidemiological facts from the Chinese CDC and concerning 72,314 case records (confirmed, suspected, diagnosed, and asymptomatic instances) had been shared withinside the Journal of the American Medical Association (JAMA) [18], offering a primary crucial instance of the epidemiologic curve of the Chinese outbreak. There had been 62% showed instances, consisting of 1% of instances that had been asymptomatic, but were laboratory-positive (viral nucleic acid test). Furthermore, the general case-fatality rate (on showed instances) became 2.3%. Of note, the deadly instances had been basically aged sufferers, mainly the ones elderly ≥ eighty years (approximately 15%), and 70 to seventy-nine years (8.0%). Approximately half (49.0%) of the crucial sufferers and laid low with pre-existing comorbidities which include cardiovascular disease, diabetes, persistent breathing disease, and oncological diseases, died. While 1% of sufferers had been elderly nine years or younger, no deadly instances passed off on this group.

The authors of the Chinese CDC file divided the medical manifestations of the sickness through there severity:

  • Mild sickness: non-pneumonia and moderate pneumonia; this passed off in 81% of cases.
  • Severe sickness: dyspnea, breathing frequency ≥ 30/min, blood oxygen saturation (SpO2) ≤ 93%, PaO2/FiO2 ratio or P/F [the ratio between the blood pressure of the oxygen (partial pressure of oxygen, PaO2) and the percentage of oxygen supplied (fraction of inspired oxygen, FiO2)] < 300> 50% inside 24 to 48 hours; this passed off in 14% of cases.
  • Critical sickness: breathing failure, septic shock, and/or a couple of organ dysfunction (MOD) or failure (MOF); this passed off in 5% of cases.

Data available from reviews and directives supplied via way of means of fitness coverage agencies, permit dividing the medical manifestations of the ailment in step with the severity of the medical pictures. The COVID-19 might also additionally gift with mild, moderate, or intense illness. Among the intense medical manifestations, there are intense pneumonia, ARDS, sepsis, and septic surprise. The medical direction of the ailment appears to are expecting a positive fashion withinside the majority of patients. In a percent nevertheless to be described of cases, after approximately per week there’s a surprising worsening of medical situations with hastily worsening respiration failure and MOD/MOF. As a reference, the standards of the severity of respiration insufficiency and the diagnostic standards of sepsis and septic surprise may be used.

Uncomplicated (Slight Illness)

These sufferers commonly gift with signs and symptoms of a higher respiration tract viral infection, together with slight fever, cough (dry), sore throat, nasal congestion, malaise, headache, muscle pain, or malaise. New lack of flavor and/or smell, diarrhea, and vomiting are commonly observed. Signs and signs and symptoms of a extra severe disease, which include dyspnea, aren’t gift.

Moderate Pneumonia

Respiratory signs and symptoms which include cough and shortness of breath (or tachypnea in children) are gift with out symptoms and symptoms of extreme pneumonia.

Severe Pneumonia

Fever is related to extreme dyspnea, breathing distress, tachypnea (> 30 breaths/min), and hypoxia (SpO2 < 90% on room air). However, the fever symptom should be interpreted cautiously as even in extreme types of the disease, it could be mild or maybe absent. Cyanosis can arise in children. In this definition, the prognosis is clinical, and radiologic imaging is used for aside from complications.

Acute Respiratory Distress Syndrome (ARDS)

The prognosis calls for scientific and ventilatory criteria. This syndrome is suggestive of a severe new-onset breathing failure or for worsening of an already diagnosed breathing picture. Different types of ARDS are outstanding primarily based totally at the diploma of hypoxia. The reference parameter is the PaO2/FiO2, or P/F ratio:

  • Mild ARDS: two hundred mmHg < PaO2/FiO2 ≤ three hundred In not-ventilated sufferers or in the ones controlled via non-invasive ventilation (NIV) via way of means of the use of tremendous end-expiratory pressure (PEEP) or a non-stop tremendous airway pressure (CPAP) ≥ five cm H2O.
  • Moderate ARDS: one hundred mmHg < PaO2/FiO2 ≤ two hundred
  • Severe ARDS: PaO2/FiO2 ≤ one hundred

When PaO2 isn’t Always Available, a Ratio SpO2/FiO2 ≤ 315 is Suggestive of ARDS

Chest imaging applied consists of chest radiograph, CT scan, or lung ultrasound demonstrating bilateral opacities (lung infiltrates > 50%), now no longer absolutely defined through effusions, lobar, or lung collapse. Although in a few cases, the scientific state of affairs and ventilator facts may be suggestive for pulmonary edema, the number one respiration starting place of the edema is confirmed after the exclusion of cardiac failure or different reasons consisting of fluid overload. Echocardiography may be useful for this purpose [19].

Sepsis

According to the International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3), sepsis represents a life-threatening organ disorder as a result of a dysregulated host reaction to suspected or demonstrated infection, with organ disorder. The scientific pics of sufferers with COVID-19 and with sepsis are specially serious, characterised through a huge variety of symptoms and symptoms and signs of multiorgan involvement. These symptoms and symptoms and signs encompass respiration manifestations inclusive of excessive dyspnea and hypoxemia, renal impairment with decreased urine output, tachycardia, altered intellectual status, and practical changes of organs expressed as laboratory statistics of hyperbilirubinemia, acidosis, excessive lactate, coagulopathy, and thrombocytopenia. The reference for the assessment of multiorgan harm and the associated prognostic importance is the Sequential Organ Failure Assessment (SOFA) rating, which predicts ICU mortality primarily based totally on lab outcomes and scientific statistics. A pediatric model of the rating has additionally acquired validation [20].

Septic Shock

In this scenario, that is related to elevated mortality, circulatory, and cellular/metabolic abnormalities including serum lactate stage more than 2 mmol/L (18 mg/dL) are present. Because sufferers commonly be afflicted by persisting hypotension in spite of quantity resuscitation, the management of vasopressors is needed to keep a median arterial pressure (MAP) ≥ 65 mmHg [20].

The Peculiar History of This New Disease

In a few sufferers, the medical records of this ailment happen with specific characteristics. It foresees that the affected person manifests specially fever, which isn’t always very conscious of antipyretics, and a nation of malaise. A dry cough is regularly associated. After 5-7 days, older sufferers with already impaired lung characteristic start to revel in shortness of breath and improved breathing rate. In extra fragile sufferers, however, dyspnea can also additionally already seem on the onset of symptoms. On the alternative hand, in more youthful topics and in people who do now no longer have primary breathing impairments or different comorbidities, dyspnea can also additionally seem later. In those sufferers experiencing worsening inflammatory-triggered lung injury, there may be a lower in oxygen saturation.

The situation is clearly notable because, for sufferers who’re paucisymptomatic and barely hypoxic, the primary healing technique is oxygen remedy. Although this approach is effective, the worsening of respiration failure can also additionally arise in a few sufferers. With the power preserved, the following step, consistent with logic, is the NIV. This remedy has a fast achievement with the aid of using growing the P/F. In a few sufferers, however, there’s a sudden, sudden worsening of scientific conditions. Patients fall apart below the operator’s eyes and require fast intubation and invasive mechanical air flow. However, after 24-48 hours the affected person may have a fast development with a boom in P/F. Operators are consequently tempted to continue with weaning. But very often, after a preliminary achievement, there’s a brand new worsening of respiration conditions, consisting of two require a brand new invasive remedy. Therefore, mechanical air flow has additionally been counselled for 1-2 weeks.

Evaluation

Most nations are making use of a few kind of scientific and epidemiologic facts to decide who ought to have trying out performed. In the US, standards were evolved for humans beneath investigation (PUI) for COVID-19. According to the U.S. CDC, maximum sufferers with showed COVID-19 have evolved fever and/or signs and symptoms of acute respiration illness (e.g., cough, trouble breathing). If someone is a PUI, it’s far advocated that practitioners at once installed area contamination manage and prevention measures. Initially, they advocate trying out for all different reassets of respiration contamination. Additionally, they advocate the usage of epidemiologic elements to help in choice making. There are epidemiologic elements that help withinside the choice on who to test. This consists of absolutely everyone who has had near touch with a affected person with laboratory-showed COVID-19 inside 14 days of symptom onset or a records of journey from affected geographic areas (currently China, Italy, Iran, Japan, and South Korea) inside 14 days of symptom onset [21,22].

Diagnosis

Molecular Test

The WHO recommends gathering specimens from each the top breathing tract (naso-and oropharyngeal samples) and decrease breathing tract along with expectorated sputum, endotracheal aspirate, or bronchoalveolar lavage. The series of BAL samples need to most effective be achieved in automatically ventilated sufferers as decrease breathing tract samples appear to stay superb for a extra prolonged period. The samples require garage at 4 tiers celsius. In the laboratory, amplification of the genetic fabric extracted from the saliva or mucus pattern is thru a opposite polymerase chain reaction (RT-PCR), which entails the synthesis of a double-stranded DNA molecule from an RNA mold. Once the genetic cloth is sufficient, the quest is for the ones quantities of the genetic code of the CoV which can be conserved. The probes used are primarily based totally at the preliminary gene series launched through the Shanghai Public Health Clinical Center & School of Public Health, Fudan University, Shanghai, China on Virological.Org, and next confirmatory assessment through extra labs. If the take a look at end result is positive, it’s miles encouraged that the take a look at is repeated for verification. In sufferers with showed COVID-19 diagnosis, the laboratory assessment ought to be repeated to assess for viral clearance previous to being launched from observation. The availability of checking out will range primarily based totally on which united states someone lives in with growing availability happening almost daily.

Serology

Despite the several antibody exams designed, so far serologic analysis has obstacles in each specificity and sensitivity. Again, outcomes from extraordinary exams vary. A CDC studies on a take a look at advanced through the United States Vaccine Research Center on the National Institutes of Health is ongoing. Of note, this takes a look at appears to have a specificity better than 99% with a sensitivity of 96%. Nevertheless, similarly studies are wanted for elucidating numerous elements of the matter. In particular:

  • If IgG antibodies will offer immunity from destiny SARS-CoV-2 infection.
  • On the protecting titer of antibodies.
  • On the period of the protection.

Serologic, however, will have a crucial position in broad-primarily based totally surveillance.

Laboratory Examinations Concerning Laboratory Examinations

  • In the early degree of the disease, an everyday or reduced general white blood mobileular rely (WBC) and a reduced lymphocyte rely may be Interestingly, lymphopenia seems to be a poor prognostic factor.
  • Increased values of liver enzymes, lactate dehydrogenase (LDH), muscle enzymes, and C-reactive protein may be
  • Unless a bacterial overlap, an everyday procalcitonin cost is found.
  • The improved neutrophil-to-lymphocyteratio (NLR), derived NLR ratio (d-NLR) [neutrophil count divided by the result of WBC count minus neutrophil count], and platelet-to-lymphocyte ratio, may be the expression of the inflammatory storm. The correction of those indices is an expression of a positive
  • Increased D-dimer
  • In essential patients, D-dimer valueis increased, blood lymphocytes decreased persistently, and laboratory changes of multiorgan imbalance (excessive amylase, coagulation disorders, etc.) are found [23].

Imaging

Chest X-ray Exam

Since the ailment manifests itself as pneumonia, radiological imaging has a essential function withinside the diagnostic process, management, and follow-up. Standard radiographic exam (X-ray) of the chest has a low sensitivity in figuring out early lung modifications and withinside the preliminary ranges of the ailment. At this stage, it may be absolutely negative. In the greater superior ranges of infection, the chest X-ray exam usually suggests bilateral multifocal alveolar opacities, which generally tend to confluence as much as the entire opacity of the lung. Pleural effusion may be associated.

Chest Computed Tomography

Given the excessive sensitivity of the technique, chest computed tomography (CT), especially excessive-decision CT (HRCT), is the technique of preference withinside the have a look at of COVID-19 pneumonia, even withinside the preliminary stages. Several non-particular HRCT findings and styles may be found. Most of those findings can also be discovered in different lung infections, including Influenza A (H1N1), CMV, SARS, MERS, streptococcus, and Chlamydia, Mycoplasma. The maximum not unusual place findings are multifocal bilateral “floor or floor glass” (GG) regions related to consolidation regions with patchy distribution, especially peripheral/subpleural and with extra involvement of the posterior areas and decrease lobes. The “loopy paving” sample may be additionally observed. This latter locating is characterised with the aid of using the presence of GG regions with superimposed interlobular septal thickening and intralobular septal thickening. It is a non-particular locating that may be detected in one-of-a-kind conditions. Other findings are the “reversed halo sign” that is a focal place of GG delimited with the aid of using a peripheral ring with consolidation, and the locating of cavitations, calcifications, lymphadenopathies, and pleural effusion.

Lung Ultrasound

Ultrasound method can permit comparing the evolution of the disease, from a focal interstitial sample up to “white lung” with proof frequently of subpleural consolidations.

It ought to be finished in the first 24 hours withinside the suspect and each 24/48 hours and may be beneficial for affected person follow-up, desire of the putting of mechanical ventilation, and for indication of inclined positioning. The most important sonographic functions are:

  • Pleural traces frequently thickened, irregular, and discontinuous till it nearly seems discontinuous; subpleural lesions may be visible as small patchy consolidations or nodules.
  • B traces. They are frequently motionless, coalescent, and cascade and may waft as much as the rectangular of “White lung”.
  • They are maximum glaring withinside the posterior and bilateral fields specially withinside the decrease fields; the dynamic air bronchogram in the consolidation is a manifestation of sickness evolution.
  • Perilesional pleural effusion.
  • In summary, throughout the direction of the disease, it’s miles feasible to become aware of the primary section with focal regions of constant B traces, a section of numerical boom of the traces B as much as the white lung with small subpleural thickenings, and in addition development till proof of posterior consolidations.

Treatment/Management

There isn’t any particular antiviral remedy encouraged for COVID-19, and no vaccine is presently available. The remedy is symptomatic, and oxygen remedy represents step one for addressing breathing impairment. Non-invasive (NIV) and invasive mechanical ventilation (IMV) can be important in instances of breathing failure refractory to oxygen remedy. Again, extensive care is wanted to address complex styles of the disease. Concerning ARDS remedy, amassing understanding at the pathophysiology of lung damage, have progressively triggered clinicians to check techniques for managing breathing failure.

As Gattinoni [24] Suggested, COVID-19-caused ARDS (CARDS) isn’t always a “Typical” ARDS. This element of the sickness is of essential significance and has probable negatively affected the healing technique withinside the early tiers of the pandemic. Indeed, notwithstanding at starting of the pandemic, early IMV became postulated because the higher approach for addressing CARDS, in COVID-19 pneumonia the standard ARDS respiration mechanics offering decreased lung compliance (i.e., cappotential to stretch and enlarge lungs) can’t be found. On the contrary, in CARDS, excellent pulmonary compliance may be demonstrated. As a consequence, and in assessment to what became to start with believed, NIV will have a key function in CARDS therapy.

O2 Fast Challenge

In an affected person with a SpO2 < 93> 28-30/min, or dyspnoea, the management of oxygen through a 40% Venturi masks have to be performed. After a five to ten mins reassessment, if the scientific and instrumental photo has stepped forward the affected person keeps the remedy and undergoes a re-assessment inside 6 hours. In case of failure improvement, or new worsening, the affected person undergoes a non-invasive remedy, if now no longer contraindicated.

HFNO and Non-invasive Ventilation

In regards to HFNO or NIV, the experts’ panel, factors out that those tactics done via way of means of structures with appropriate interface becoming do now no longer create great dispersion of exhaled air, and their use may be taken into consideration at low danger of airborne transmission.

HFNO

Because this technique has a more danger of aerosolization, it need to be utilized in terrible strain rooms.

Suggested Approaches to Control HFNO

  • Indication: while it’s far hard to hold SpO2 > 92% and/or now no longer stepped forward dyspnoea thru general
  • Setting: 30-forty L/min and FiO2 50-60%; alter consistent with medical
  • Switch to NIV if the symptomatology isn’t stepped forward after 1 hour with flow > 50 L/min and FiO2>70%.
  • HFNO also can be used for CPAP breaks (among CPAP cycles) and for assisted fibreoptic tracheal intubation in seriously sick
  • Contraindication to HFNO: hypercapnic patient.
  • Non-invasive air flow and Continuous Positive Airway Pressure NIV/CPAP has a key position in coping with COVID-19-related breathing
  • Suggested methods for acting NIV/CPAP:
  • Interface: Helmet is desired for minimizing the chance of aerosolization. In the case of NIV with face mask (full-face or oronasal), the usage of expiratory valve included and non-tubes with exhalation port, and insert an antimicrobial clear out out at the expiratory valve is recommended.

Setting

  • Continuous Positive Airway Pressure (CPAP): begin with 8-10 cmH2O and FiO2 60%
  • NIV (e.g., Pressure guide ventilation, PSV): begin with PEEP five cmH2O checking the tolerance of the affected person and produce to 8-10 cmH2O, FiO2 60%, PS 8-10 cmH2O • Management: do now no longer make many adjustments withinside the first 24 hours; after as a minimum 4-6 hours, if stabilized, detach for optimum 1 hour and permit the consumption of small portions of fluids; during the night, NIV continuously.

Intubation and Protecting Mechanical Air Flow

Special precautions are vital all through intubation. The method needs to be performed through a professional operator who makes use of non-public protecting equipment (PPE) together with FFP3 or N95 masks, protecting goggles, disposable robe lengthy sleeve raincoat, disposable double socks, and gloves. If possible, fast series intubation (RSI) need to be performed. Preoxygenation (100% O2 for five minutes) need to be performedviathe non-stop wonderful airway pressure (CPAP) method. Heat and moisture exchanger (HME) need to be located among the masks and the circuit of the fan or among the masks and the air flow balloon [25].

Mechanical air flow has to be with decrease tidal volumes (four to six ml/kg expected frame weight, PBW) and decrease inspiratory pressures, accomplishing a plateau pressure (Pplat) < 28 to 30 cm H2O. PEEP ought to be as excessive as feasible to hold the using pressure (Pplat-PEEP) as little as feasible (< 14 cm H2O). Moreover, disconnections from the ventilator should be averted for stopping lack of PEEP and atelectasis. Finally, the usage of paralytics isn’t always advocated except PaO2/FiO2 < 150> 12 hours in line with day, and the usage of a conservative fluid control method for ARDS sufferers without tissue hypoperfusion (robust recommendation) are emphasized [26].

Other Therapies

Among different healing strategies, despite the fact that systemic corticosteroids for the remedy of viral pneumonia or acute breathing misery syndrome (ARDS) have been now no longer recommended, in extreme CARDS those capsules are generally used (e.g., methylprednisolone 1 mg/Kg die). Unselective or beside the point management of antibiotics ought to be avoided, despite the fact that a few facilities advocate it. Although no antiviral remedies were approved, numerous procedures were proposed inclusive of lopinavir/ritonavir (400/a hundred mg orally each 12 hours). Nevertheless, a latest randomized, controlled, open-label trial tested no advantage with lopinavir/ritonavir remedy in comparison to conventional care [27]. Preclinical research recommended that remdesivir (GS5734) — an inhibitor of RNA polymerase with in vitro pastime towards more than one RNA viruses, together with Ebola — may be powerful for each prophylaxis and remedy of HCoVs infections [28]. This drug changed into undoubtedly examined in a rhesus macaque version of MERS-CoV infection [29]. Alpha-interferon (e.g., five million gadgets through aerosol inhalation two times according to day) changed into additionally used. Chloroquine (500 mg each 12 hours), and hydroxychloroquine (two hundred mg each 12 hours) have been proposed as immunomodulatory therapy. Of note, in a non-randomized trial, Gautret [30] confirmed that hydroxychloroquine turned into appreciably related to viral load discount till viral disappearance and this impact turned into greater with the aid of using the macrolides azithromycin. In vitro and in vivo studies, indeed, have proven that macrolides may also mitigate infection and modulate the immune system [31]. In particular, those tablets may also result in the downregulation of the adhesion molecules of the molecular surface, decreasing the production of pro-inflammatory cytokines, stimulating phagocytosis with the aid of using alveolar macrophages, and inhibiting the activation and mobilization of neutrophils. However, similarly research is wanted for recommending using azithromycin, by myself or related to different tablets inclusive of hydroxychloroquine, outdoor of any bacterial overlaps [32]. Again, interest should be paid with the concomitant use of hydroxychloroquine with azithromycin because the affiliation can cause a better danger of QT c program language period prolongation and cardiac arrhythmias. Chloroquine also can set off QT prolongation. Because COVID-19 sufferers have a better prevalence of venous thromboembolism and anticoagulant remedy is related to decreased ICU mortality, it’s miles recommended that sufferers ought to obtain thrombo-prophylaxis [33]. Moreover, within side the case ofknown thrombophilia or thrombosis, complete therapeutic-depth anticoagulation (e.g., enoxaparin 1 mg/kg two times daily) is indicated.

In Italy, a wonderful research led via way of means of the Istituto Nazionale Tumori, Fondazione Pascale di Napoli is targeted on using tocilizumab similarly to conventional therapies. It is a humanized IgG1 monoclonal antibody, directed towards theIL-6 receptorand usually used withinside the remedy of rheumatoid arthritis, juvenile arthritis, massive mobileular arthritis, Castleman’s syndrome, and for handling toxicity because of immune checkpoint inhibitors. Moreover, withinside the US, a Phase 2/3, randomized, double-blind, placebo-managed have a look at on sarilumab this is some other anti-IL-6R antibody, is ongoing [34,35]. When the disorder outcomes in complicated medical images of MOD, organ characteristic assist further to respiration assist, is mandatory. Extracorporeal membrane oxygenation (ECMO) for sufferers with refractory hypoxemia regardless of lung-protecting air flow ought to advantage attention after a case-by-case analysis. It may be recommended for people with bad outcomes to susceptible role air flow.

Prevention

Preventive measures are the cutting-edge method to restrict the unfold of cases. Because an endemic will growth so long as R0 is more than 1 (COVID-19 is 2.2), manage measures need to cognizance on lowering the price to much less than 1.

Preventive techniques are centered at the isolation of sufferers and cautious contamination manage, which includes suitable measures to be followed all through the prognosis and the supply of scientific care to an inflamed patient [35]. For instance, droplet, contact, and airborne precautions need to be followed all through specimen collection, and sputum induction need to be avoided.

  • The WHO and different businesses have issued the subsequent well-known recommendations:
  • Avoid near touch with topics stricken by acute breathing
  • Wash your fingers frequently, specifically after touch with infected people or their environment.
  • Avoid unprotected touch with farm or wild animals.
  • People with signs of acute airway contamination ought to hold their distance, cowl coughs or sneezes with disposable tissues or garments and wash their fingers.
  • Strengthen, in particular, in emergency medicinal drug departments, the utility of strict hygiene measures for the prevention and manipulate of infections.
  • Individuals which might be immunocompromised ought to keep away from public gatherings.

The maximum crucial method for the populous to adopt is to often wash their fingers and use transportable hand sanitizer and keep away from touch with their face and mouth after interacting with a probable infected environment. Healthcare employees being concerned for inflamed people need to make use of touch and airborne precautions to encompass PPE inclusive of N95 or FFP3 masks, eye protection, gowns, and gloves to save you transmission of the pathogen. Meanwhile, clinical studies are developing to expand a coronavirus vaccine. In current days, China has introduced the primary animal tests, and researchers from the University of Queensland in Australia have additionally introduced that, after finishing the three-week in vitro study, they’re shifting directly to animal testing. Furthermore, withinside the U.S., the National Institute for Allergy and Infectious Diseases (NIAID) has introduced that a segment 1 trial has begun for a singular coronavirus immunization in Washington state.

Differential Diagnosis

The signs of the early ranges of the sickness are nonspecific. Differential prognosis ought to consist of the opportunity of an extensive variety of infectious and non-infectious (e.g., vasculitis, dermatomyositis) not unusual place breathing disorders.

  • Adenovirus
  • Influenza
  • Human metapneumovirus (HmPV)
  • Parainfluenza
  • Respiratory syncytial virus (RSV)
  • Rhinovirus (not unusual place cold)

For suspected cases, speedy antigen detection, and different investigations have to be followed for comparing not unusual place respiration pathogens and non-infectious conditions. The Mayo Clinic proposed a COVID-19 self-evaluation device designed for setting up a ability candidate for a COVID-19 diagnostic test (https://www.Mayoclinic.Org/covid-19-self-evaluation-device).

Prognosis

Preliminary records indicate the suggested demise charge tiers from 1% to 2% pending at the take a look at and country. The majority of the fatalities have come about in sufferers over 50 years of age. Young youngsters look like mildly inflamed however might also additionally function a vector for extra transmission.

Complications

Long time period headaches amongst survivors of contamination with SARS-CoV-2 having clinically massive COVID-19 disorder aren’t but available. The mortality prices for instances globally stay among 1% to 2%. Follow-up research will make clear the quantity of the sequelae on organ functions, which include respiratory, renal, cardiovascular, in addition to psychological/psychiatric, and associated with persistent ache problems.

Deterrence and Patient Education

b

Patients and households have to acquire coaching to:

  • Maintaining correct social distance is obligatory for stopping the unfold of the disease.
  • Strict private hygiene measures (fingers wash) are essential for the prevention and manage of this contamination.
  • Avoid near touch with topics stricken by acute breathing
  • People with signs and symptoms of acute airway contamination have to preserve their distance, cowl coughs or sneezes with disposable tissues or clothes, and wash their fingers.

Immunocompromised sufferers have to keep away from public publicity and public gatherings. If an immunocompromised man or woman ought to be in a closed area with more than one people present, along with a assembly in a small room; masks, gloves and private hygiene with antiseptic cleaning soap need to be undertaken with the aid of using the ones in near touch with the individual. In addition, earlier room cleansing with antiseptic dealers need to be undertaken and executed earlier than publicity. However, thinking about the risk worried to those individuals, publicity need to be averted except a meeting, institution event, etc. Is a real emergency.

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Sexual Imagination Potency (SIP) Test to Explore the Unconscious Sexual Life of Humans

DOI: 10.31038/PSYJ.2021314

Abstract

Despite the importance of the sexuality in the human life, most studies performed up to now have been generally limited to the only evaluation of sexual behaviour and orientation, rather than the intimate sexual feeling in terms of sexual fantasies. Some preliminary results would suggest the existence of some same sexual fancies beyond the difference occurring between homo and hetero sexuality, in particular the fantasy of androgyny. On this basis a preliminary study was planned to elaborate a sexual test carried out to investigate not only the sexual behaviour but the dimension of sexual fancies and imagination, by proposing a specific analysis that we have called Sexual Imagination Potency (SIP). The study included 150 consecutive healthy volunteers and the test was accepted in 111/150 subjects. No significant difference in SIP mean values was observed between men and women. Within the evaluated fancies, a particular importance has been shown to be played by the manner to imagine the androgyny aspect, and the pleasure for pegging. In fact, the subjects with pleasure for pegging showed significantly higher SIP mean values with respect to those, who had no pleasure for pegging. These preliminary results, which have to be confirmed in greater number of healthy subjects, seem to demonstrate the importance of the androgyny image in influencing the sexual mood by connecting hetero and homo sexual fancies in a unique imaginative psychosexual world.

Keywords

Androgyny, Heterosexuality, Homosexuality, Sexual fancies

Introduction

Imagination and desire are looked upon as major determinants of sexuality [1]. Moreover, it has to be considered that the imagination represents one of the fundamental dimensions of human cognition [2]. During the early phases of development, the close interaction of imagination and erotic desire leads to the formation of psychical representatives of experiences of satisfaction, that influence sexual and nonsexual behaviours by establishing an internalized structure of blueprints for satisfaction [3]. These blueprints can also be viewed as an important step in the development of autonomy. Sex differences can be found primarily in the function and employment of erotic fantasies [4]. Generally, men tend to use their erotic imagery to a much in the higher degree with respect to the women, as a compensation for a lack of sexual satisfaction [5]. However at present the fantasies of women have still to be better investigated and understood. Then, it has to be confirmed the lower degree of fancies in women with respect to men. Proceeding from the conceptual distinction of erotic and everyday realities, reflections on the zeitgeist of sexuality and the relationship between the sexes are put forward focussing on the ambiguity of erotic imagination and the border crossing between the two realities [6]. Based on these reflections, the potential therapeutic aspects of imagination and desire are touched upon the problems of integrating erotic reality and everyday reality in long-term male-female relationships would have to be further investigated in the clinical practices [7]. Same preliminary clinical studies carried out for many years to investigate the sexual male and female fancies, have allowed us to hypothesize that the original and primary fancy is represented by the androgyny image, which could constitute the sexual fancy, from which would depend all other human sexual fantasies, involving both men and women irrespectively of the sexual orientation, by overcoming the opposition between hetero and homo sexual fancies [8]. On this basis, we have elaborated a simple and synthetic clinical test to explore the major fancies reflecting the androgyny status, and most in general the potency of the sexual imagination, independently of the degree of sexual satisfaction and activity.

Subjects and Methods

The study included 150 consecutive healthy volunteers (M/F: 69/81) to whom the SIP test whose proposed. Test of acceptance in 111/150 (74%) subjects, without statistically significant difference between man and woman (53/69 (77%) versus 58/81 (70%)). The characteristic of subject are reported in Table 1. The subject were subdivided on the basis of six major variables, including age, profession, grade of studies, religion faith, marriage status and affective status of relatives. The SIP test, which was differentiate in relation to the sex, was consisting of five essential question, with the three type of response, with a score ranging from 0 to 2, for a total maximum values of ten points. The SIP test was reported in Table 2. Data were statistically analyzed by the Chi Square test and the Student’s T Test.

Table 1: Characteristics of subjects.

N

Acceptance

M

F

150
111 (74%)

53 (47%)
58 (52%)

Marital status

-Marriage/cohabitation

-Single/widow

-Apart/divorced

45
47
19

Occupation

-Intellectual

-Practise

 

58

53

Education
 -Low-Middle-High

33
36
42

Faith

–          Christian

–          No faith

–          Other religions

 

74

22

15

Status of relationship among parents

–          Unity

–          Separated

92
19

Age

<50

> 0

57
54

Table 2: SIP Test values in a group of healthy women and men.

N

Question Response Points
1 Do you find more excitant the common vaginal

or the anal relation?

– No opinion

the vaginal relation

the anal relation

1

2

0

2 Do you find the pegging (the woman penetrate

the man) as an excitant sexual stimulation?

– No

– I do not know 1

– yes 2

1-2**

0

3 How do you imagine the trio, with another woman or with another man? – I do not like the trio

– With another woman 1-2*

– With another man

1

2

0

4 Do you feel more cheated on if your partner had a sexual relation with a person of the same sex

or the other sex?

 – With both sexes

– with the same sex

– With the other sex

0

5 How do you imagine the androgyne human subject? Like a trans – No idea

– Like a woman with the artificial penis

1

Note: *1 for man and 2 for woman; **1 for woman and 2 for man.

Results

The evaluation of each single fancy is reported in Table 3. As reported, not significantly difference occurred between men and women in the preferential of the type of sexual relation the genital and the anal one. On the same way not significantly difference between men and women was seen in relation to the fancy of man penetration by woman, the so-called pegging. As far as trio fancy with a male and a female is concerned, male subject statistically preferred a woman as third partner (p<0.05), whereas women did not show statistically significance preference between males and females. Moreover, in relation to the psychic sufferance due to betrayal with the another partner, the percentage of pain in the presence of betrayal with a person of the same sex was respect to a betrayal with a person of the other sex was lower in women and higher in men, but none of these difference was statistically significance. Finally in the women the androgyny is imagined more significantly as a women with the strap-on, while in the men as trans (p<0.05). SIP mean values in relation to the main characteristics of healthy subjects are reported in Table 4.

Table 3: Evaluation of the single fancy expressed in percentage in men and women.

Fancy

Men=53 Women=58

Men+Women= 111

Prefered sexual relation

– Vaginal

– Anal

– no idea

 

31 (59%)

14 (26%)

8 (15%)

 

42 (72%)

7 (12%)

9 (16%)

73 (81%)

15 (16%)

23 (25%)

Love of pegging

– Yes

– No

– no idea

 

13 (25%)

15 (28%)

25 (47%)

 

10 (17%)

39 (67%)

9 (16%)

25 (23%)
64 (57%)
22 (20%)

Trio

– with men

– with women

– no love

 

10 (19%)

6 (11%)

37 (70%)*

 

13 (22%)

13 (22%)

32 (55%)

19 (17%)

50 (45%)

42 (38%)

Hurt by betrayal of the partner

– Both

– with men

– with women

 

25 (47%)

6 (11%)

 

34 (59%)

9 (15%)

15 (26%)

59 (53%)

31 (28%)

21 (19%)

Androgynous

-b no idea

– trans

– women with strap-on

 

33 (62%)

14 (27%)*

6 (11%)

 

34 (59%)

7 (12%)

17 (29%)**

67 (60%)

21 (19%)

23 (21%)

Note: * p<0.05 vs women.

**p<0.05 vs men.

In the women the androgyny is imagined more significantly as women with the strap-on, while in the men as trans.

Table 4: SIP values (X± SE) in relation to the main characteristics of men and women.

Variables

Men

Women

N. X ± SE

N. X ± SE

Sex

53 3.9 0.5

58 3.3 0.6

Age
<50

26 4.7 0.4

31 3.5 0.5

>50

27 3.9 0.5

27 3.2 0.7

Religion
Christian

32 4.3 0.5

42 3.3 0.6

No faith

13 3.9 0.4

9 3.5 0.6

Other religion

8 3.0 0.6

7 3.0 0.7

Marriage Status
Married

20 4.2 0.5

25 2.2 0.4**

Single

24 4.5 0.4

23 3.6 0.2

Separate/divorced

9 3.3 0.6

10 5.1 0.6

Study Degree
Low

16 3.9 0.4

17 3.7 0.6

Middle

17 3.5 0.5

19 3.3 0.6

High

20 4.2 0.4

22 4.0 0.5

Profession
Practical

27 3.3 0.5

26 3.1 0.4

Intellectual

26 4.2 0.4

32 4.4 0.2

Affective Status of Relatives
Unity

44 4.4 0.4

48 3.8 0.3

Separation

9 3.0 0.7

10 2.3 0.4*

Note: ** p<0.05 vs. single women, p<0.01 vs. separated women.

* p<0.05 vs. united relatives.

The only statistically significance difference were those concerning the marriage status and the professional situation. In more detail, separate and divorced women showed SIP mean values significantly higher than those found in married women. On the contrary separate or divorced men showed lower SIP mean values than the married ones, even though the difference was not significance. In addiction both women and mans with an intellectual profession showed statistically significant higher SIP values then those with a practical professional. Finally, as far as an affective status of relations, relative separation was associated with a statistically significance redaction in SIP mean values in the only women (p<0.005). Table 5 shows SIP values in relation to the man androgyny-related fancies and the difference between man and women. SIP mean values were significantly higher in subjects who referred pleasure for Pegging (PG) than in those who did not like it in the only men (p<0.001), whereas in women the difference was not statistically significance. On the same way SIP values were significantly higher in men who referred pleasure for anal relation then in those who had no pleasure for it (p<0.005), whereas no significantly difference occurred in women. On the contrary both men and women, who referred pleasure for either pegging and anal relation showed statistically significance higher SIP values than those who had no interested for both pegging and anal relation ( p<0.001).

Table 5: SIP values (X±SE) in relation to the main androgyny-related fancies.

Type of Fancies

Men

Women

N. X ± SE

N. X±SE

Pleasure for pegging
Yes

15 6.8 0.4*

10 6.9 0.8

No

25 2.3 0.3

39 3.3 0.6

Pleasure for anal relation
Yes

8 6.7 0.6**

7 4.8 0.8

No

45 2.6 0.6

51 3.9 0.3

Pleasure for both pegging and anal relation
Yes

6 7.5 0.6*

5 8.0 0.5*

NO

36 2.5 0.5

46 3.6 0.4

Pleasure for sexual trio
yes

43 4.5 0.3

26 4.9 0.6**

no

10 2.3 0.8

32 1.6 0.3

Androgyny imagination
Like transexual men

13 5.5 0.5

8 3.6 0.8

Like woman with strap-on

7 6.3 0.8

16 7.1 0.4*

No opinion

33 3.3 0.4

34 1.7 0.5

Note: * p<0.001; ** p<0.05.

The pleasure for trio was associated with higher SIP values than in those who showed no interested for trio, even though they were statistically significantly higher in the only women (p<0.005). Finally subjects who had no imagination of androgyny showed SIP values lower than those who had same imagine of androgyny. But the SIP values were statistically significant higher with respect to subject, who referred no androgyny imagine in the only women, who had the vision of androgyny like a woman with a strap-on (p<0.001), whereas no difference occurred in women who imagined the androgyny like a transgender man. The maximal SIP values occurred in both men and women, who referred pleasure for both pegging and anal relation as well as in the only women who had androgyny imagine as woman with a strap-on. Table 6 shows SIP values in subjects with pleasure for pegging and anal sexual relation or both fancies in relation to their religion. Christian men, who referred pleasure for pegging or for anal relation showed statistically significant higher SIP values than men with other religion or no religion who showed the same fancies, whereas no difference occurred in women. On the contrary both Christian man and women who had pleasure for both pegging and anal relation showed statistically significant higher SIP values than subjects with the same fancies, but who were without religion or of other religion.

Table 6: Pleasure for pegging and anal sexual coitus in relation to androgyny image in men and women.

Androgyny Image

 Women

 Men

pleasure for pegging pleasure for anal relation

pleasure for pegging pleasure for anal relation

Like transexual man

2/8 (25%)* 2/8 (25%)

6/13 (46%) 3/13 (23%)

like woman with strap-on

8/16 (50%)** 4/16 (25%)

2/7 (29%) 2/7 (29%)

no image

2/34 (7%) 4/34 (12%)

9/33 (27%) 3/33 (9%)

Note: **p<0.01 vs. women without androgyny image; *p<0.05 vs. women without androgyny image.

Discussion

Even though limited to a relatively low number of normal subjects, this preliminary study seems to suggest that the maximal sexual imagination potency is associated with the fancies related to a change in the common manner to consider the male -female relation and interpretation of male-female identity and role, such as pleasure for pegging and sexual anal relation, which could be considered as an expression of the androgyny imagine. In more detail, the sexual imagination has appeared to be negatively influenced by the separation of relatives in the only women. The marriage was also associated with an evident decline in SIP values. On the contrary, the separation, the divorce and the single life were all associated with an evident increase in the sexual imagination power. In addiction this study shows that the pleasure for pegging was associated with the higher SIP values. Moreover, the apparently higher SIP values in Christian people than in those with other religion or no religion, would demonstrated the existence of interaction between spirituality and erotic profile, by suggesting that the interpretation of the Spirit may influence the human psychosexual life. Finally, this study seems to excluded that the men may have more sexual fantasies than women.

Then further studies would be required to analyze the sexual world of women. In fact, male subjects could have more sexual fantasies with the respect to women only from a quantitative point of view, but women could express more fantasies from a qualitative point of view, even though women are generally less unconscious on their sexual dimension. Unfortunately, most studies carried out up to now on the human sexuality, has been generally limited to the only sexual behaviour and orientation, rather than to explore the dimension of the sexual unconscious fancies [9-11]. Therefore, on the basis of the results of this study obtained in a group of healthy subjects, it would be interesting to evaluate in future studies the sexual profile and fancies occurring in the main human systemic diseases, namely cancer and autoimmunity.

In conclusion, by considering the difference between males and females in relation to androgyny imagination, this preliminary study would suggest that the original sexual fancy could be constituted of the image of androgyny itself, which could connected in the same sexual imagination homo and hetero fancies. Then, the only fancy, which may integrate hetero and homosexual fancies, in a same sexual imagination and excitation, is that of the androgyny status, which would constitute the origin of the human psychosexuality.

References

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Implementation of the 1-Hour Sepsis Bundle and Evaluation of Staff Adherence: An Evidence-based Practice Quality Improvement Project

DOI: 10.31038/IJNM.2021211

Abstract

Objective: To implement an evidence-based sepsis implementation tool for nurses to use when initiating treatment for patients diagnosed with sepsis and to track time of administration of the Surviving Sepsis Campaign (SSC) 1-hour bundle interventions, mortality, and length of stay.

Design: An evidence-based practice quality improvement (EBP-QI) project.

Setting: A 38-bed observation/short stay unit within a 700-bed hospital in New York City.

Intervention: A sepsis implementation tool was created based on SSC 2018 1-hour guidelines. Sepsis champions delivered education on sepsis recognition, treatment, and management to the nurses, physicians, and other staff.

Main outcome measure: Following the practice change, audits of the sepsis implementation tool were done weekly for 5 months. A target of 85% completion for each of the bundle interventions was set.

Results: From May 8, 2019 to October 8, 2019 a total of 38 patients were diagnosed with sepsis in the emergency department or observation/short stay unit and of these 90% (n=33) had blood cultures drawn twice, 85% (n=34) had stat lactate, and 73% (n=26) had broad-spectrum antibiotics started within 1-hour. The target of 85% was met for 2 of the 3 bundle interventions.

Conclusion: The sepsis 1-hour bundle is best practice however, completion of the bundle interventions within 1-hour of sepsis diagnosis is challenging. In this EBP-QI project, the healthcare staff was successful in completing the majority of the bundle interventions within the hour. Future improvement efforts will focus on improving the initiation of antibiotics within 1-hour of sepsis diagnosis.

Introduction

In the US, sepsis, severe sepsis, and septic shock are associated with 6%, 15%, and 34% mortality rates and respective costs of $16,000, $25,000, and $38,000 per hospitalization [1]. Sepsis is a deadly and costly hospital condition that can be mitigated with early identification and initiation of lifesaving treatment. In 2004 there was a global initiative to bring together critical care and infectious disease experts in the diagnosis and management of sepsis to create the initial Surviving Sepsis Campaign (SSC) guidelines to improve awareness and outcomes of sepsis [2]. Initial guidelines included goal directed patient resuscitation during the first 6 hours after recognition, appropriate diagnostic studies to identify cause before initiating antibiotics, and early administration of antibiotics, all to be done as soon as possible within the first 24 hours. Subsequent recommendations in the following years grouped similar interventions into 6 and 3-hour bundles with the expectation that the interventions would all be completed within these shorter time frames. In 2018, the SSC developed the 1-hour sepsis bundle because the 3-hour window was associated with a significant increase in in-hospital mortality [3]. The bundle calls for lactate measures, blood cultures, antibiotics, if appropriate fluid resuscitation and vasopressors within 1-hour of sepsis recognition [3]. In 2015, The Centers for Medicare and Medicaid implemented its core bundle measure for Severe Sepsis and Septic Shock Early Management Bundle linking reimbursement to a hospitals’ ability to complete the SSC bundle interventions within 3 hours of sepsis recognition [4]. To help meet this quality measure, hospitals may benefit from initiatives aimed at improving the process of sepsis care and bundle completion within the 1 to 3-hour window. Meeting the SSC’s 1-hour implementation goal can be challenging. Historically, nurses have been responsible for initiating a sepsis protocol [5]. There are tools to facilitate timely initiation of bundle interventions [6]. The emergency room nurse sepsis screening tool significantly improved the time to bundle completion in patient’s diagnoses with severe sepsis and septic shock [7]. The nurse initiated emergency department sepsis protocol significantly reduced time to lactate measurements and antibiotic administration [8]. These tools are based on the five steps outlined in the SSC’s 2018 1-hour bundle.

Objective

The purpose of this project was to implement an evidence-based sepsis implementation tool for nurses to use when initiating treatment for patients diagnosed with sepsis and to track time of administration of the bundle elements, mortality, and length of stay.

Methods

Project Design

This EBP-QI project was completed over a 10-month period using a prospective before and after design. This consisted of a 5-month baseline period and a 5-month QI period. In the baseline period, the evidence-based sepsis implementation tool was created, and the sepsis champions delivered education on sepsis recognition, treatment, and management to the nurses, physicians, pharmacists, and other staff, and assessed sepsis knowledge. In the QI period, audits of the sepsis implementation tool were done weekly.

Setting

The Observation/Short Stay Unit (O/SSU) was the project setting. This unit is part of an 800-bed acute-care tertiary hospital in New York City that serves 37,000 patients annually. The hospital has several medical specialties (e.g. cardiology including care of vascular conditions, neurology, and oncology). The O/SSU, is considered part of the emergency department and can take up to 38 patients. O/SSU employs 71 nurses, with an average of 12-14 nurses and 2 charge nurses per shift. There are 2-3 patient care technicians per shift and 1 patient unit assistant for the day and evening shifts. The average daily census ranges from 15 to 35 patients and varies by the time of day. There is a unit nurse manager, assistant nurse manager, and a nurse manager administrative support supervisor. There is a pharmacist on the unit from 0800 to 2400. Between 0001 and 0759, pharmacists are accessible via telephone, and medications are sent via a pneumatic system. Common O/SSU diagnoses include; falls, acute coronary syndrome, transient ischemic attack, chronic obstructive pulmonary disease exacerbation, congestive heart failure, and skin, lung, and urinary infections. The average quarterly sepsis rate was 528 cases for the years 2015, 2016, 2017 and 2018, and 84% of these cases were patients with sepsis present on admission.

Participants

Participants were patients entering the hospitals’ emergency department from May 8, 2019 to October 8, 2019 and transferred to the O/SSU and met the following SSC sepsis screening criteria. Patients with 2 or more systemic inflammatory response syndrome (SIRS) criteria or suspected infection defined as sepsis [9] or with septic shock/sepsis-3 defined as organ dysfunction with SIRS criteria (SSC).

Intervention

The evidence-based sepsis implementation tool, displayed in Figure 1, was created using SSC’s 2018 guidelines and other evidence source. The nurse immediately notifies the provider when a patient has a positive screen and initiates the sepsis implementation tool with the provider in a safety huddle at the patient’s bedside. The nurse and provider collaborate to provide the first 4 interventions within 1-hour. The nurse documents the time each intervention was completed and initials. Providers document their reasoning for not initiating fluids. The next section of the tool is for nurses to document if a critical care consult was initiated during the first hour. At the 1-hour mark, the nurse and provider re-huddle and perform the next 5 interventions (e.g. review the lab results) to determine if the patient sepsis is worsening. The provider is then required to write a sepsis note in the electronic health record that includes the patient’s presenting condition, completed interventions and subsequent plan of care.

fig 1

Figure 1: Evidence-Based Sepsis Implementation Tool.

Quality Improvement Process

We used the Revised Iowa Model of Evidence Based Practice to guide this EBP-QI project. The Iowa model uses EBP and QI processes to promote excellence in healthcare [10,11]. This project was led by three individuals with complementary areas of expertise. The project manager was a doctoral-level nursing student with expertise in sepsis recognition, treatment, and management. The physician partner has extensive leadership knowledge and has led numerous multidisciplinary quality and safety initiatives in hospitals. The academic partner has an EBP certification, clinical expertise in critical care nursing, and expertise in dissemination.

Key stakeholders were the staff nurses and healthcare providers in the O/SSU. To gain their buy in and to form a group of sepsis champions, nurses were reminded that they could submit this project for promotion through a nursing professional advancement program. This strategy resulted in four staff nurses agreeing to be sepsis champions. Physicians and physician assistants interested in sepsis management were also included in the group of champions to help guide and lead other healthcare providers. Initially pharmacists were informed of the QI project to help expedite interventions. They were added as key stakeholders during the 5-month QI period when nurses reported delays in obtaining antibiotics. Our educational strategy was multidimensional and completed over several months. During the first 2 months, we assessed baseline knowledge of sepsis recognition, treatment and management, and attitude toward sepsis care using a questionnaire (See Supplement) that was given to O/SSU nurses and healthcare providers (n=101). We held several meetings to review and discuss questionnaire answers. For the next 3 months, the project manager and sepsis champions gave updates and education as needed at monthly staff meetings, provider meetings, and in real-time in the O/SSU using an iPad. The iPad contained the sepsis checklist, a power-point presentation on sepsis from [9], the sepsis questionnaire answers, and the EBP-QI project goals and intervention description. The iPad was and was left in a central place in the O/SSU that staff could access at any time throughout the 10-month project period. The education for nurses and healthcare providers included review of sepsis recognition and diagnosis, the 1-hour bundle interventions, and the nurse’s role in management including the new sepsis implementation tool. Nurses received additional education on how to complete the sepsis implementation tool and an explanation of the buddy badge strategy to facilitate timely completion of the 1-hour bundle interventions. A badge buddy is a laminated card that attaches to an existing hospital identification badge and lists the SIRS criteria and 1-hour bundle interventions that was given to all O/SSU nurses (Figure 2).

fig 2

Figure 2: Process Map: Sepsis Algorithm 1-hour Bundle for O/SSU.

The project manager and sepsis champions held monthly group meetings throughout the 10-month project to review the project progress and address any barriers. Champions followed-up with the nurses of patients with delayed bundle interventions within a week to debrief. Monthly emails were sent to all staff with updates on audits and current status of the project including staff feedback regarding barriers to the 1-hour bundle and how to overcome them.

Evaluation Measures

Baseline knowledge of sepsis recognition, treatment and management, and attitude toward sepsis care was measured using an established questionnaire (See Supplement). Adherence was measured by how often the nurses completed the initial lactate measure, blood cultures, and antibiotic administration within the 1-hour window of the patient being diagnosed with sepsis. We set a target of 85% of cases having all interventions completed within 1-hour. Length of stay was measured as the total number of days spent in hospital and mortality was measured as death occurring in the hospital.

Data Collection and Analysis

The completed sepsis implementation tools were retrieved weekly from the O/SSU. The project manager reviewed the tools and checked the electronic health record for 1-hour bundle intervention completion times. Data on mortality and length of stay were obtained after completing chart reviews for the patients included during the QI period (n=38). These data were inputted into an Excel spreadsheet and descriptive statistics were calculated for each outcome [12].

Ethical Considerations

Differentiating Quality Improvement and Research Activities Tool was used to determine that this was a QI project. The project aim was to improve sepsis care for all patients using evidence-based recommendation and no personal health information was collected therefore it did not qualify as human subjects’ research and institutional review board was not needed. Per hospital policy, the project was reviewed and approved by the institution’s Chief Nursing Officer [13].

Actions Taken to Barriers during Baseline QI Period

Table 1 displays the barriers identified by nursing, physicians, and physician assistants during the baseline QI period. These barriers fell into the categories of staffing, factors causing delays and patient specific concerns. Actions taken include; the requirement of two nurses to initiate sepsis protocol interventions, pharmacy added as key stakeholder, nurse to notify pharmacy of patient with sepsis to expedite interventions, notification of 2nd lactate included in the EHR, IV team able to place midlines, central lines, IO kit accessible on the unit, and additional vital sign machines provided. Providers are more vigilant with screening patients prior to arrival. Questionable admissions are evaluated while in the ED by O/SSU providers.

Table 1: Staff Identified Barriers and Actions Taken During Baseline Period.

Nurses Attending Physician Physician Assistant Pharmacy Actions Taken
Staffing
Lack of staff to assist with other patients Sometimes lack of adequate nursing staff 2 Nurses are required to carry out sepsis protocol interventions
Factors causing delays
Pharmacy delays Pharmacy delays Pharmacy delays Delay in delivery of antibiotic Pharmacy added as key stakeholder, nurse to notify pharmacy of patient with sepsis
Multiple high acuity patients on the unit at once affecting timing of orders placed 2nd lactate check delays Notification of 2nd lactate requirement will be included in the EHR
Delay in patient recognition Handoff from emergency department to O/SSU inaccuracy Time to place central line /IV access IV team can place lines. New IO kit added to the unit.
Lack of equipment (Vital sign machine, IV access) Additional equipment is on the unit
A new electronic method of sepsis protocol initiation and documentation was introduced during the QI period throughout the hospital Survey sent to all staff to evaluate knowledge of electronic sepsis alert system and education on its use will be provided.
Patient specific concerns
Patients are septic prior to arrival to O/SSU Providers are more vigilant with screening patients prior to arrival. Questionable patients are evaluated in the ED.
Trying to manage patients that require aggressive fluid resuscitation and patients that can be conservatively managed with judicious fluid resuscitation
Concern for heart failure worsening with IV fluids

Results

A total of 38 patients entered the hospital’s emergency department from May 8, 2019 to October 8, 2019, transferred to the O/SSU, and had a diagnosis of sepsis. Table 1 displays the completion rates for required bundle interventions in patients diagnosed with sepsis. Blood cultures were completed within an hour on all patients. Initial lactate measures were completed within 1-hour in more than 85% of cases. In 19 of the 26 patients, broad-spectrum antibiotics were administered within 1-hour. The median hospital length of stay was 5 days and no patients died. Staff knowledge scores include a mean score of 57% (0.216) for nurses 60% (0.213) for PA’s and 61% (0.222) for MDs (Table 2).

Table 2: Completion Rates of 1-hour Sepsis Bundle Interventions after Initiating the Sepsis Implementation Tool.

May 8, 2019 to October 8, 2019
Bundle Interventions n=38
f(%)
Blood cultures x 2 (n=38) 33(100)*
Initial lactate (n=34) 29(85.29)+
Broad spectrum antibiotics (n=26) 19(73.08)a
Hospital length of stay (median, range) 5 days (1 to 76 days)
Mortality 0

*5 had blood cultures drawn before sepsis diagnosis

+4had lactate done before sepsis diagnosis

a12 had antibiotics before sepsis diagnosis

Discussion

We successfully implemented the SSC 1-hour sepsis bundle in our O/SSU. Use of the evidence-based sepsis implementation tool for nurses resulted in exceeding the 85% benchmark for initial lactate measure and blood cultures within 1-hour of the patient being diagnosed with sepsis. However, antibiotic administration within the 1-hour window was achieved 73% of the time. Several experts have proclaimed that the goal for 1-hour antibiotic administration can be unrealistic in certain circumstances and may result in unnecessary antibiotic administration for patients who are not truly septic. Talan suspect that poorer outcome rates will not increase immediately without 1-hour antibiotic therapy for many patients with sepsis. The recommendation is to focus on gaining more insight by improving diagnostic accuracy including antibiotic decision making [14]. The Infectious Disease Society of America (IDSA) withheld its support for the SSC in 2018. One of the reasons includes when and how to use antibiotic prophylaxis and duration of therapy [15]. Additionally, in a 2015 systematic review and meta-analysis authors demonstrated no significant survival benefit of administering antibiotics within 3 hours of ED triage or within 1 hour of septic shock recognition in severe sepsis and septic shock [16]. Moreover, the 1-hour bundle poses challenges to providers to send virtually every SIRS positive patient through a rapid sepsis screening which may not be feasible in certain hospital settings including the ED [17].

The median length of stay was 5 days for this quality improvement project. Studies report a decrease or no change in LOS with protocolized care. Threatt [7] reported no change in LOS after implementing the use of a Sepsis Identification Tool using SSC’s guidelines. In contrast, the median length of stay was significantly shorter in the post implementation group in a descriptive retrospective review using qSOFA [18]. Another retrospective observational study reported a decrease in the median LOS after an introduction of a new triage model for sepsis patients from 9 to 7 days [19]. The implementation of an electronic sepsis alert system in the EHR also resulted in a decrease of mean LOS for patients with sepsis from 10.1 to 8.6 days following alert introduction in a time-series study of ED patients with severe sepsis and septic shock [20]. In terms of mortality rate, there were no deaths among the patients diagnosed with sepsis during the QI period. There is conflicting data regarding the relationship between sepsis bundle adherence and mortality rates. The evidence regarding mortality rates demonstrate either no change, or a decrease in the rate. Bruce et al reported no in-hospital mortality rate differences between pre-and post-protocol implementation. Park et al performed a systematic review and meta-analysis on the effect of early goal directed therapy (EGDT) using SSC guidelines for treatment of severe sepsis and septic shock and also found no significant difference in mortality between EGDT and control groups. Another study done at a tertiary hospital in Brazil found an overall 44% lower mortality rate and shorter ICU stays for individuals who received a 3-hour bundle compared with others who did not. Moreover, Milano et al performed an observational study and found that among 4,582 patients with sepsis, the overall mortality was lower among those who received bundle-adherent care compared to those who did not.

There were several barriers we encountered during the QI period including pharmacy delays in delivery of antibiotics, delay in patient recognition, 2nd lactate check delays, and lack of adequate nursing staff (Table 1). Several previous studies report similar barriers. A study [21] found that doctors and nurses demonstrated difficulty in identifying septic patients. Results of a cross sectional descriptive study using a self-completed questionnaire given to doctors and nurses related to sepsis identification, principles, resources, skill and education demonstrated that there was a lack of adequate nursing staff, and resources to deliver interventions within the hour [22-30].

Limitations

We focused on patients who arrived through the emergency department and we sent to the O/SSU so the impact of sepsis implementation tool on clinical outcomes in other units (e.g. emergency department, intensive care) is unknown.

A new electronic method of sepsis protocol initiation and documentation was introduced during the QI period throughout the hospital. This may have contributed to an inaccuracy in the documentation of the number of actual patients presenting with sepsis on the O/SSU due to the lack of checklist or electronic use in the EHR.

It is also difficult to determine if having pharmacy as key stakeholders earlier in the project would have affected time to antibiotics. The length of the QI period may also contribute to cyclical differences affecting results. Baseline data does not adequately represent the number of patients that presented with sepsis on the O/SSU. It is difficult to determine which components of the 1-hour bundle will affect patient outcomes. Based on the results, further investigation is needed to determine if the 1-hour bundle affects mortality and LOS.

Conclusion

Utilization of the sepsis 1-hour bundle has demonstrated an increase in timely sepsis management during the QI period. An electronic form of the checklist was added to the EHR system during a new QI cycle, eliminating the need for a paper tool. Completion of the bundle interventions within 1-hour of patients presenting with sepsis is challenging. In this practice change project, the healthcare staff was successful in completing many of the bundle interventions within the hour. Future improvement efforts such as inclusion of pharmacy alert as part of the EHR tool will focus on improving the initiation of antibiotics within 1-hour of sepsis diagnosis

Funding

The authors have no funding source to proclaim.

Conflict of Interest Statement

The authors have no conflict of interest to proclaim.

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Detailed Hydrogeological and Hydrochemical Reassessment of Coastal Basins of Southwestern Nigeria

DOI: 10.31038/GEMS.2021312

Abstract

Detailed knowledge of hydrogeological and hydrochemical characteristics of coastal basins is the prime basis for improved water quality management. This review presents a detailed hydrochemical and hydrogeological reassessment of coastal basins of southwestern Nigeria. Results indicate that the Abeokuta group is the oldest Formation and comprises the Ise, Afowo, and Araromi Formations. Despite the marked spatial variability of these formations, their lithology remains relatively the same. Also crucial in this area is the deltaic Formation, which contains alluvial deposits. The Ogun and Osse-Owena Basins are the central coastal basins in western Nigeria. Though the Osse-Owena Basin has not been fully explored hydrogeologically, it is not associated with good groundwater storage, since basement complex rocks underlie it. These coastal basins were further grouped into the upper surficial aquifer system; and the intermediate aquifer system. Also found in this area is the crystalline Basement Terrain. From the hydrogeologic point of view, unweathered basement rock contains negligible groundwater; though, a significant aquiferous unit can develop within the weathered overburden and fractured bedrock. The general hydrogeological condition in the area showed that groundwater is very localized. These basins’ hydrochemistry showed groundwater is relatively good in terms of its suitability for drinking, industrial and agricultural uses. Groundwater classification based on physical parameters showed mixed results, though groundwater sources are most suitable for drinking. Due to the increasing urbanization and other forms of land use in the area, preventive measures must protect groundwater from depletion.

Keywords

The Abeokuta Group; The Ilaro Formation; The deltaic formation and alluvial deposits; Hydrogeological condition; Groundwater chemistry

Introduction

Water is an indispensable prerequisite of life deemed an economic resource rather than a social good [1-4]. Even though freshwater storage in the ecosystem remains steady, freshwater pressure such as subsurface water has experience expansion due to population increase, development, dry season farming, and household activities [1,5]. Though, the quality and quantity of this economic resource are likewise critical factors in the perspective of modern water quality management, especially in coastal areas [1,6,7]. Factors such as quality of recharge, rock weathering and mineralogical composition of the underlying rock types, land use, and climate change usually play a vital role in groundwater chemistry, affecting groundwater quality [1,8].Understanding groundwater evolution involves the hydrochemical analyses of major dissolved ions of groundwater, discovering the principal geochemical processes, and evaluating the impacts of land-use types on groundwater quality in various regions of the world [1,9,10]. Many factors such as rock-water interactions, climate changes, precipitation or dissolution of mineral species, the intensity of chemical weathering of the different rock types, groundwater resources, exchange reactions, and human activities, prolonged residence time in the aquifer and saltwater intrusion account for the variability of hydrochemistry of groundwater in coastal aquifers [1,11-14]. The hydrochemistry of coastal aquifers of southwestern Nigeria is highly variable due to variation in geological configurations and human activities. Groundwater contamination stemming from human activities, and inadequate sewage discharge is on the rise in Nigeria [15-17]. Consequently, groundwater utilized for domestic uses is problematic and hence calls for scientific scrutiny. Examining hydrochemistry and groundwater quality in coastal regions is crucial to monitor and detect groundwater contaminants sources [18-21]. Groundwater quality analysis in Abeokuta South, Nigeria by Emenike, Nnaji [17] showed that water quality parameters exhibited wide variations from location to location. Sodium, magnesium, iron (++), and EC showed the most violation of drinking water quality standards. Anthropogenetic actions are escalating threat to groundwater quality and thus call for routine monitoring of groundwater in Abeokuta. Statistical and hydrochemical modelling of groundwater quality southwestern Nigeria showed a conjunctive imprint of anthropogenic and geogenic activities influencing the increasing dissolved chemical constituents in the groundwaters [1]. Hydrochemical analysis of groundwater quality along the coastal aquifers of southwestern Nigeria revealed that the primary process influencing the hydrochemistry is saltwater invasion while mineral dissolution and rainwater infiltration play less significant roles [22]. Nitrate controls biogeochemical process over Fe, and its concentrations are above the World Health Organization’s (WHO) standard for drinking water in most water samples in the Shallow Coastal Aquifer of Eastern Dahomey Basin, Southwestern Nigeria [8]. Integrated geophysical and geochemical investigations of saline water intrusion in a coastal alluvial terrain of southwestern Nigeria by Oyeyemi, Aizebeokhai [23], showed a lateral invasion and up coning of saline water within the aquifer systems. The water is alkaline, and salinity is high with a very high electrical conductivity. The impact of anthropogenic activities over groundwater quality of a coastal aquifer in Southwestern Nigeria indicated some metals such as Cu, Fe, Mn, Al, Zn, Pb, As, Cd, Cr and H2S) were detected in only some shallow wells. However, the effects on public health are still undocumented. The drainage, geology, chemistry and associated human factors play a vital role in the extent of shallow groundwater contamination in the area [24]. Potential sources of contaminants to the groundwater such as weathering of bedrocks, leachate from septic tanks and dumpsites, runoff of materials, hardness, nutrients from agricultural lands, and chlorine pollution were identified in basement rocks of Osun State, Southwest, Nigeria [25]. Groundwater in Abeokuta Southwestern, Nigeria, is not suitable for drinking but has good irrigation quality [26]. Assessment of the risks of groundwater pollution in the coastal areas of Lagos, southwestern Nigeria, showed that the lower aquifer is mostly affected with saline water intrusion while the phreatic aquifer pollutions are both from anthropogenic and saline sources [27]. While the hydrochemistry of coastal aquifers is well researched, studies combining the hydrogeological and hydrochemical analysis of groundwater are rare. This review presents a detailed hydrogeological and hydrochemical analysis of coastal basins of southwestern Nigeria.

Geographical Setting

Southwestern Nigeria’s coastal basins constitute the Benin Embayment’s eastern portion, forming an arcuate coastal basin [28-30]. The onshore parts underlie the coastal plains of southwestern Nigeria, Benin, and Togo [31]. The Okitipupa Basement Ridge separated the Benue Trough’s embayment until the Campanian-Maastrichtian period when subsidence and marine transgression united the two basins (Figure 1). Some basement chunks that underlie the Dahomey Embayment are displaced towards the basin’s northern and southern axis and the offshore [31]. An inventory of water resources in southwestern Nigeria confirms that water supplies are generally from surface sources, such as dams and weirs in streams and rivers. Borehole and shallow-wells, tapping groundwater, are used to complement the short supply from surface water. Existing data from UNICEF-water assisted projects suggests that boreholes in southwestern Nigeria are intended to tap water from the weathered regolith or the jointed/fractured basement rock aquifers. The Coastal Basins are comprising of the Osse, Ogun and Yewa River Basins.

fig 1

Figure 1: Coastal Basins of Southwestern Nigeria. After Ola-Buraimo, Oluwajana [31].

These basins are grouped as the geological formations outcrop parallel to each other in an east-west direction and transgressing the basins in the same Coastal River Basins. The Osse River Basin is about 51400 sqkm in landmass. On the other hand, the Ogun River Basin has about occupied an area of about 88800 sqkm. The two basins are drained by many dendritic flowing streams, which empty their water into the sea. The Osse Basin is perhaps the lateral equivalent of the Benin-Owena River Basin [32]. The main drainage in the Osse-Osiomo systems is little streams and rivulets flowing straight into the sea and forming part of the Delta composite. Parallel streams with the same pattern drained the Ogun Basin, most protuberant being the Ogun, Osun, and Yewa river systems. This basin’s climate is archetypally coastal with very high rainfall, ranging from 2250 mm in the north to over 2600 mm along the coastal line. The relative humidity is very high, >80%. The mean annual temperature is about 21°C [32].

Geological Setting

The coastal basin of southwestern Nigeria is restricted to the west by the Ghana ridge, which is an extension of the Romanche Fracture Zone; and eastwards, by the Benin Hinge line, a basement escarpment which splits the Okitipupa Structure from the Niger Delta Basin and also marks the inland extension of the Chain Fracture Zone (Figure 2). The Nigeria portion of the basin spreads from Nigeria’s boundary and Benin’s Republic to the Benin Hinge Line. The stratigraphy of the sediments in the Nigerian sector of the Benin Basin is contentious. Different stratigraphic names have been suggested for the same Formation in different localities within the basin [31]. This problem can be attributed to the lack of adequate borehole reporting and satisfactory outcrops for comprehensive stratigraphic studies. As a result, the stratigraphy of the entire basin was divided into three chronostratigraphic compendia. These are (i) pre-lower Cretaceous folded sediments and (ii) Cretaceous sediments and Tertiary sediments (Figure 3).

fig 2

Figure 2: The Nigerian portion of Dahomey (Benin) Basin. After Ola-Buraimo, Oluwajana [31].

fig 3

Figure 3: A Lithologic section of Arimogija – Okeluse exposure. After Ola-Buraimo, Oluwajana [31].

In the Nigerian sector of the basin the Cretaceous sequence, as compiled from outcrop and borehole records, consists of the Abeokuta Group, further divided into three geologic units: Ise, Afowo, and Araromi Formations. Ise Formation overlies the basement complex unconformably and comprises of coarse conglomeratic sediments [33,34]. Afowo Formation is composed of transitional to marine sands and sandstone with variable but thick interbedded shales and siltstone [35,36]. Araromi is the uppermost Formation and comprises shales and siltstone with interbeds of limestone and sands. The Tertiary sediments comprise Ewekoro, Akinbo, Oshosun, Ilaro, and Benin (bare coastal sand). The Ewekoro Formation comprises fossiliferous, well-bedded limestone while Akinbo and Oshosun Formations are made up of flaggy grey and black shales [37,38]. Glauconitic rock bands and phosphatic beds define the boundary between the Ewekoro and Akinbo Formations. The Ilaro and Benin Formations are predominantly coarse sandy estuarine, deltaic, and continental beds [31].

The Abeokuta Group

The sedimentary Formation of southwestern Nigeria, otherwise known as the Eastern Dahomey Basin, extending from the Nigeria/Benin border in the west of Makun-Omi and broken in the east. The Abeokuta Group is the oldest Formation, and it comprises of main sands with intercalations of argillaceous sediments, which lie unconformably on the crystalline basement complex formation [39,40]. This group can be subdivided into three geologic units;

  • The lse Formation, which overlies the basement complex and consists of pre-drift sediments of grits and siltstones and overlain by coarse-medium grained, loose sands interbedded generally by kaolinitic clays;
  • The Afowo Formation comprises intermediate to marine sands and sandstone with variable but thick interbedded shales and siltstones. The shale to sand ratio Increase upwards with the sediment becoming highly fossiliferous. The whole arrangement represents paralic sedimentation; and
  • The Araromi Formation, which is the youngest of the stratigraphic sequence, comprises shales and siltstones with Interbeds of limestone and sands. It Is opulently fossiliferous.

The Abeokuta Formation usually has a basal conglomerate with about 1 meter thick and mostly comprises poorly rounded quartz pebbles with a silicified and ferruginous sandstone matrix or a soft gritty white clay matrix [39]. The formation outcrops where there is no conglomerate, a coarse, poorly sorted pebbly sandstone with copious white clay establishes the basal bed. The superimposing sands are coarse-grained, clayey, micaceous, and ill-sorted, suggestive short distances of transportation, or short duration of weathering and possible derivation from the granitic rocks located to the northwards. Upward stratigraphically along with the outcrop areas, the shale content increases progressively in some places, particularly around Ijebu-Ode. Close to the embayment’s eastern margin, thin beds of lignite may be present together with a high impregnation of bitumen in the sand and clays. These features are displayed in most of the eastern part of the embayment, locally referred to as Tar sand. The basal beds’ upper horizons were found in some outcrops to contain thin beds of Oolitic ironstone. The stratigraphic dating from palynological studies indicates that the ages of the lower and upper limits of the neostratotype Formation are late Albian and late Senonian. This is a characteristic species for the late Turonian-early Senonian of the Ivory Coast and was reported from Gabon’s Coniacian-Campanian. Therefore, this pollen occurrence implies a late Senonian age for the Formation’s upper layers [39].

The Ise-Afowo, Araromi, Akinbo, and Ilaro Formations

Ise and Afowo Formations are similar; thus, the two geologic units are treated together in most literature [39,41,42]. The two formations contain sand and sandstones, but the latter is interbedded by thick of shale units. Similarly, the Ise, Afowo, and Abeokuta Formations showed a similar lithologic and electric log. The uppermost beds of Abeokuta Formation which outcrop in the Ijebu-Ode, Itori, Wasimi, and Ishaga, consist mainly of fine-coarse-grained sand which is occasionally interbedded by shale, mudstone, limestone, and silt. In most recent literature the Ise and Afowo Formations are discussed as Abeokuta Formation. The Abeokuta Formation consists mainly of grits, loose sand, sandstone, kaolinitic clay, and shale. It was further characterized as usually having a basal conglomerate or a basal ferruginised sandstone [39]. The Araromi Formation overlies the Afowo Formation and has been described as the youngest Cretaceous sediment in the eastern Dahomey Basin. It is composed of fine to medium-grained sandstone at the base, overlain by shales, siltstone with interbedded limestone, marl, and lignite. This Formation is highly fossiliferous [43]. The Ewekoro Formation overlies the Araromi Formation. It is an extensive limestone body, which is traceable over a distance of about 320 km from Ghana in the west, towards the eastern margin of the Dahomey (Benin) Basin in Nigeria [44,45]. It is Palaeocene in age. Superimposing the Ewekoro Formation is the Akinbo Formation, which is mainly composed of shale and clayey sequence. The clay stones are concretionary and are largely kaolinite. The Formation’s base is defined by the presence of a glauconitic band with lenses of limestones [43]. The Akinbo Formation and consists of greenish-grey or beige clay and shale with interbeds of sandstones. The shale is thickly laminated and glauconitic. The basal beds may consist of either, sandstones, mudstones, claystones, clay-shale, or shale. The Ilaro Formation superimposes the Oshosun Formation and consists of massive, yellowish poorly, consolidated, cross-bedded sandstones. The youngest stratigraphic sequence in this basin is the Benin Formation, otherwise known as the Coastal Plain Sands and contains poorly sorted sands with layers of clay units. The sands are occasionally interbedded and show transitional to continental characteristics. The age is from Oligocene to Recent [43]. Most of the boreholes constructed in the basin are either single-screened or multiple-screened and occasionally open wells are constructed through fractured basement rocks that produce a considerable amount of water. The Depth to water level hardly exceeds 24 meters. Most aquifers in this basin are found around 40 meters below the surface. These aquifers are rarely confined, and very few boreholes tap water below 60 meters [46]. The mean yield from boreholes is ~0.4 l/s. In the crystalline basement section of the basin, a borehole depth of 40–80 m is estimated. Data from available boreholes in the southern end of Kwara State extending to Osun State, indicate the range between 25–68 meters borehole depth. The overburden thickness is also highly variable, ranging between 3–24 meters. In places around Ibadan, the overburden thickness and borehole depth are within the same range. The thickness of the overburden aquifer in the rural areas of Oyo State is correlated to the tectonic fractures rather than weathering (regolith).

Borehole yield ranging from 1–2 l/s in the basement complex section is considered suitable for installing motorized submersible pumps. Borehole yields less than 0.5 l/s are also considered good for handpumps. The recharge into the weathered aquifer is predominantly through the infiltration of rainwater. Therefore, continued yields from motorized pumps may not be workable. Midwestern Nigeria’s coastal basin’s principal aquifers occur in sandy units and overburden/superficial deposits confined by shale and clay formations. The aquifers’ thickness is highly variable with first and third horizons reaching a thickness of about 200 meters and 250 meters at Lekki headland. The second horizon is roughly 100 meters thick (Figure 4). The estimated groundwater stored in the first aquifer horizon is about 2.87 × 103 m3. The water table is mostly shallow, ranging 0.4–21 meters below the ground surface. It is estimated that annual fluctuation is less than 5 meters. The principal aquifer is within bare coastal sands, occasionally underlain by impermeable horizons of shale and clay units. Many high-yielding boreholes provide more than 30% of the water supply in Lagos and its hinterlands [46].

fig 4

Figure 4: Typical hydrogeological section of coastal basins of southwestern Nigeria. After Adelana, Vrbka [46].

The geological succession in these basins simple, forming a simple monocline against the basement outcrop northward, with a slight faulting indication. The inclines are reportedly about 1° or less southwestwards (Table 1). The Basement Complex rocks superimpose more than 50% of the Coastal basins [47-49]. The Abeokuta Formation is the oldest outcropping sedimentary formation in the Ogun and Osse River Basin. This appeared to cover the basement complex directly. The Formation is in turn superimposed by the Ewekoro, Ilaro, and Benin Formations. The is the substantial development of alluvium in the coastal areas and along the course of the major drainage systems of the Rivers Ogun and Osse.

Table 1: Hydrogeology of coastal basins of southwestern Nigeria.

table 1

After Offodile [32]

The Abeokuta Formation

This is the oldest Formation in the Ogun Basin, outwardly covering the Basement Complex. The Formation thickness ranged from 250 to 300 meters, containing arkosic sandstones and grits, tending to be carbonaceous towards the bottom. There is an increase in thickness from about 250 meters in the western sections of the basin towards the Benin border. The basal conglomerates also were encountered. One of the outcrops gave the following units in Figure 5. The Abeokuta Formation has good potential for groundwater except that the bituminous constituents associated with the sands could affect groundwater quality. This Formation is being interrelated to the Nkporo Shale, east of the River Niger. The little report is existing about the groundwater potentials of the Abeokuta Formation. Nevertheless, its proximity to the Basement Complex and its high porosity, a substantial amount of groundwater is expected to be stored above the crystalline rock layer. This condition has been confirmed at the bottom near the Basement layer, intercepted by the borehole described in the following section. This Formation is outstanding in the basin. Hydrogeologically, groundwater in the basin’s northern parts is limited to the splintered and in-situ worn portions of the rocks. The in-situ worn portion either superimposes the unweathered basement or occurs within the unweathered basement [50].

fig 5

Figure 5: Section of Abeokuta Formation. After Offodile [32].

In the former, the worn materials create phreatic aquifers typically exploited through hand-dug shallow wells, while in the later, groundwater is confined in nature and can only be accessed through boreholes. Groundwater flow is strongly influenced by topography and two common types of springs, mainly, overland and slope springs have been observed in the area. Recharge to these aquifers is primarily by infiltrating rainfall and in some places, by the outflow from adjacent surface water. The recharge areas comprise decayed and splintered rocks in which pressure heads quickly spread through local water-bearing fractures and unified voids, thereby leading to an abrupt rise in ejections in response to rain. Spring discharges in the northern parts of the basin are very common in the rainy season but terminate totally during the dry season. The area underlain by sedimentary formations is regarded as having good groundwater potential due to an aquiferous sandy layer [50].

However, the success of boreholes in this basin is highly variable, and it could be credited to inferior drilling methods, or the frequent occurrence of the clayey matrix, which extends to seal the pores and reduce the absorptivity. The successful boreholes were reported from Aiyetoro and Ijebu Ode. Also, specific capacity ranging from 63 to 17550 list/hr/m (1300 gift) have been measured. Successful boreholes were also reported from Iboro, Imushin, and Ishaga as depicted below. In the eastern parts, within the Osse Basin, the Abeokuta Formation appears to thicken in Agenebode and Auchi’s higher regions, where the groundwater table is deep (120-300 meters). The low water table recorded is thought to be due to the aquifer’s high porosity, as typified in by the Kerri-Kerri Formation, in the Upper Benue Basin Nanka Sands of the Anambra Basin [32]. Some drilled boreholes in the Abeokuta Basin are shown in Figure 6. Figure 7 illustrates some successful boreholes in Abeokuta Formation. The GSN. BH. No. 2436 is located at Meko. The lies unconformably showed unconformity. It has a total depth of 57.9 meters. Although it penetrates the Basement Complex, yields are relatively low (1620 lits/hr (0.45 lits/sec)—the GSN. BH. No. 2612 was located at Igbogila. The borehole penetrates a Basement Complex section and has a total depth of 70.5 meters. Yield is relatively high (28350 lits/hr), or 7.87 lits/sec. it has a specific capacity of about 390.8 lits/hr—the GSN. BH. No. 2438 is located at Aiyetoro. The borehole penetrated a Basement Complex formation and showed unconformity. The total depth is about 55.9 meters. Yield is relatively low (2340 lit/hr), or 0.65 lits/sec (Offodile, 2002). Figure 7 further illustrates some boreholes penetrating the Abeokuta Formation. The GSN. BH. No. 2433 reached a depth of 48 meters below the ground level. This borehole’s actual location is unknown, but it is believed to penetrate the Abeokuta Formation. The borehole produced a yield of about 3600 lits/hr and had a specific capacity of 11880 lit/hr/m (Offodile, 2002). The GSN. BH. No. 2435 is located at Ishaga. It penetrated the basement complex (BC) and had a total depth of 75 meters. It had a yield of 31050 lits/hr. It also had a specific capacity of 3192.75 lit/hr/m [32]. The lithology is mainly sandy (Figure 7) – the GSN. BH. No. 2597 is located at Ijebu Ode about 46 km NE of the town. The borehole penetrated the BC and reached a depth of 54.6 meters. The yield obtained from this well is comparatively low (10800 lits/hr), with a specific capacity of 935.5 lits/hr/m. The last borehole in Figure 6 (GSN. BH. No. 1807), also lies unconformably on the BC. The well reached a depth of 72.8 meters and produced a yield of 13500 lits/hr, with a specific capacity of 4039.2 lit/hr/m [32]. Generally, boreholes penetrating the Abeokuta Formation has a higher proportion of sands.

fig 6

Figure 6: Lithological sections of boreholes in Abeokuta Formation. After Offodile [32].

fig 7

Figure 7: The lithology of boreholes in Abeokuta Formation. After Offodile [32].

The Ilaro Formation

The Ilaro Formation is comprised of fine to medium-grained which are reasonably well sorted. The Formation lies conformably on the Oshoshun Formation (Lower-Middle Eocene) and locally unconformably underneath the Benin Formation -Oligocene-Pleistocene [51-53]. The Ilaro Formation is typically Middle to Upper Eocene in age. The estimated thickness of this Formation is about 70 meters and displays rapid lateral facies changes. This can affect aquifer quality [54]. Hydrogeologically, not much information exists on the Ilaro Formation, though it is reported to be transitional to, and in part equivalent to the Ameki Formation. Given the Ilaro Formation’s geological physiognomies, its equivalent lateral part could be a good aquifer that can yield a substantial amount of water. However, GSN. BH. No. 2611 in Ilaro had reached a depth of 57 meters and gave a low yield of 2975 lits/hr and a specific capacity of 1023 lits/hr/m [32]. The lithology of this borehole is illustrated in Figure 8.

fig 8

Figure 8: The lithology of the borehole in Ilaro. After Offodile [32].

The Benin Formation

The Benin Formation (Miocene-Recent) consists of thick bodies of ferruginous and white sands. The Formation lies conformably on Ilaro Formation. Friable, poorly sorted with intercalation of shale, clay, and sandy clay with lignite [55]. The Benin aquifer is an important reservoir of groundwater. It is well developed in the Osse Basin and underlies more than 50% of its sedimentary section. The Benin aquifer is underlain by the sandstones of and shales of the upper Ilaro Formation, consists of a sequence of predominant continental sands and some lenses of shales and clays proved to be up to 107.7 meters thick in the area. The cross-section of the Benin Basin is further illustrated below. The Benin Aquifer gives very high yields of up to 4500 lits/hr (10000 g/hr) in most parts of the outcrop area.

The water table is relatively shallow, ranging between 20 to 25 meters. The water quality is also good. By this Formation, the land area underlain extends from Ado-Odo, Ilaro, Ikeja, and Mushin, passing through Okitipupa of Ogun Basin, into a broad area Benin-Ugheli-Agbo province of Osse Basin, in Edo and Delta States [32]. The lithology of boreholes from the Benin formation is illustrated in Figure 8. The GSN. BH. No. 2608 is located at Ikeja, had a total depth of 99 meters. The yield from this borehole is comparatively high (55350 lits/hr) [32]. Figure 9 illustrates the lithology of Benin formation [56].

fig 9

Figure 9: Hydrogeologic Cross-section of the Benin Basin. After Oteri and Ayeni [56].

Figure 10 shows the specific capacity of this borehole is 9,220 lits/hr/m. This well penetrates the Benin Formation. The GSN. BH. No. 927 is located in Otta. The well had a depth of 243 meters. The remaining lithologies were not accessed. Yield from this borehole was estimated to be 22500 lits/hr in GSN. BH. No. 2599, located at Mushin penetrates a similar sequence, attained a depth of 108.6 meters. This well gave a yield of 32850 lits/hr (9 lits/sec). The specific capacity was 1930.5 lits/hr/m. This prolific yield is typical of the Benin Formation across the southwestern river basins of Nigeria. The Benin Formation is also very important in the Osse Owena Basin, where it is the primary groundwater source [32].

fig 10

Figure 10: The lithology of the borehole in Ikeja and Otta. After Offodile [32].

The Deltaic Formation and Alluvial Deposits

This Formation contains alluvial deposits associated with Lagos’ coastal areas and the Osse Basin areas connecting to the Niger Delta Basin [57-59]. The hydrogeological conditions in areas were explained in studies on the Niger Delta Basin. Be sufficient to mention that the sandstone beds are limited in thickness and usually variable in the lateral extent. Furthermore, these aquifers have been exposed to saline water intrusion due to overdevelopment and seawater invasions. Correspondingly, the limitations in thickness and extent of the aquifers significantly reduce the boreholes’ specific capacity. The groundwater condition varies swiftly across the basins. In the Lagos region areas where the Formation appears to be least developed and has been polluted, the underlying Benin Formation provides a ready supply to the groundwater demand in the basin [32]. These comprise the Yewa, Ogun, and Oshun river networks’ vast basins, presenting a general alluvial development with considerable groundwater potential. The available drilling records have not distinguished this Formation. However, a 49275 lits/hr yield from GSN. BH. No. 2610 at Ibefun. The borehole was just 28.5 meters deep and had a specific capacity of 9234 lits/hr/m. This presents an excellent yield and underlines the high potential of these river basins’ alluvial deposits. The hydrogeology of these basins is similar to that of the Niger Delta Basin, discussed in the previous chapter.

Hydrogeological Condition in Coastal Basins of Southwestern Nigeria

The Ogun River Basin

The Ogun River Basin is one of the significant coastal basins located in southwestern Nigeria [60-62]. The basin is situated between latitudes 6° 26′ N and 9° 10’N and longitudes 2° 28’E and 4° 8 ‘E (Figure 11). About 98% of the basin area falls within Nigeria and the remaining 2% in the Benin Republic. The basin covers an of about 23,000 sqkm. The topography is generally low, with the gradient in the north-south direction. The Basin is drained by the Ogun River which had its source from the Iran hills at an elevation of about 530 meters above sea level. The river flows southwards over a distance of about 480 km before it discharges into the Lagos lagoon. The main tributaries of the Ogun River are the Ofiki and Opeki Rivers. Two seasons are distinguishable in the Ogun River Basin; a dry season from November to March and a wet season between April and October. The mean annual rainfall ranged from 900 mm in the northern parts to 2000 mm in the south. The total annual potential evapotranspiration ranged from 1600 and 1900 mm [63]. Hydrogeologically, very little is known about the Ogun Basin since the basin is often discussed in southwestern Nigeria’s coastal basins. However, Offodile [32], compiled data on borehole on borehole depths summarized in Table 2. There is not much reporting of hydrogeological physiognomies of the individual boreholes from western Nigeria’s coastal basins. Most of the boreholes in this basin penetrate the Pre Cambrian-Basement Complex. Yields from these boreholes are poorly known. However, GSN. BH. No. 2614 in Ewekoro gave an artesian flow of 90-135 lits/hr obtained near the borehole base. Similarly, GSN. BH. No. 1583 at Itori gave artesian flow at 81 meters. The estimated yield was 450 lits/hr and a specific capacity of 92.7 m 45000 lits/hr/m. Although, these two boreholes produced a substantial amount of water, a more detailed study on the hydrogeology Ogun Basin is required for further evaluation.

fig 11

Figure 11: Ogun-Osun River Basins and the Adjacent Basins. After Oke, Martins [63].

Table 2: Borehole information from Ogun Basin.

S/no.

Borehole Locality (Abeokuta Formation)

GSN. BH. No. Total Depth (m) Depth to First Water (m) Final Depth to Water (m) Yield (lits/hr) Draw Down (m) Specific Capacity (lits/hr/m)

Remarks

1

Aiyetoro 2

2438 63 31.2 31.2 2340 15

Pre Cambrian-45.9-63 m

2

Aiyetoro 2

2439 53.7 20.7 20.7 18900 3.6 5250

Pre Cambrian-45.9-63 m

3

Ijebu Ife

1808 57 42 39.9 10655 10.6 1035
4

Ijebu Ode

2620

Abandoned Pre Cambrian-Very shallow

5

Ijebu Ode

2597 69.9 46.2 46.2 10800 11.4 945

Pre Cambrian-54.6-69.6 m

6

Ijebu Ode

2598 54

Abandoned Pre Cambrian-18.3-54 m

7

Imushin

1807 87 55.8 52.8 13500 3.3 4080

Pre Cambrian-72.9-87 m

8

Imushin

2616 75.9 51.9 35100 1.8 19500

Pre Cambrian-65.4-75 m

9

Ishage

2435 75 29.1 19.8 31050 9.6 3225

Pre Cambrian-67.8-75 m

10

Meko

2436 57.9 42.3 42.3 1620 10.5

Pre Cambrian-54.6-57.9 m

(a)                 Borehole Locality (Fugar Area)
11

Agenebodo

2604 127.2 105.9 105.9

Not tested

12

Fugar

1136 69.3

Abandoned

13

Fugar

1179 157.5 129.6 4500

14

Fugar

2603 157.8 129.6 129.6

Not tested

15

Ogbona

2613 213 183.3

Not tested

(b)                 Borehole Locality (Ewekoro Formation)
16

Ewekoro

2614 90 58500

Artesian flow 90-135 lits/hr Obtained near the bottom of the hole

17

Iboro2

2433 48 13.5 10.2 36000 3 1200

18

Labour

2434 33.6 32850 3 10950

19

Ifon2

2602 79.5 64.5 61.8 12600 2.1 6000

20

Igbogila2

2612 70.5 11.4 10.2 28350 11.7 2415

21

Itori

1583 96

Artesian flow at 81 m, 450 lits/hr; at 92.7 m 45000 lits

22

Yemoji

1590 348

(c)                 Borehole Locality (Ibeshe Area)
23

Ibeshe2

2437 121.2 57.5 57.9 10.26 9.3 1095

24

Ilaro

2611 132.9 17.4 20.4 26.55 22.5 1170

(d)                 Borehole Locality (Imo Shale)
25

Sabon Gida

2601 121.2 41.4 13.05 51 255

Artesian flow 900 to 1350 lits/hr

After Offodile [32]

The Osse Owena Basin

Also known as the Benin-Owena, River Basin occurs in Edo-State. The basin is situated within the Western Littoral Hydrological Area HA-6, one of the eight hydrological areas into which Nigeria is subdivided. The gauge station at which the hydrometric measurements were made is located at Osse River at Iguoriahki [64-66]. Hydrogeologically, this basin has not been well explored. Earlier, Offodile [32] summarised borehole information on this basin. Base on the borehole information presented in Table 3, it is clear that this basin has not been fully explored hydrogeologically.

Table 3: Borehole information from Osse Owena Basin.

Borehole Locality (Ameki Formation)

GSN. BH. No.

Total Depth (m) Depth to First Water (m) Final Depth to Water (m) Yield (lits/hr) Draw Down (m) Specific Capacity (lits/hr/m)

Remarks

1 Asaba

72

27.6 23.1 8325

2 Asaba

72

22.5 25.5 9450 3 31

3 Asaba

67.5

16.5 17.4 18000

4 Asaba

45.6

25.2 22.2 95850 3 31950

5 Asaba2

44.7

26.4 24 95850 4.2 22815

6 Isse-Uku

112.5

102.5

Abandoned

7 Isse-Uku

120

Abandoned

8 Iuue

241.5

Abandoned

9 Ogwashi-Uku

89.7

Abandoned

10 Uburu

114

108.5

Abandoned

Borehole Locality (Benin Formation)
11 Abafon

45.6

41.4 16.67

12 Ado Odo

96

I1 45000 2.7 9990

13 Ado Odo

14 Agbon

63

45 40500

15 Agbon

75 7.5 45000 4.5

16 Agbon

75 7.5 45000 32.13

17 Benin City

110.4 56.4 29.25 27.55

Borehole Locality (Ameki Formation)
18 Benin City

61.8 15 67500 2.1

19

Ethiope

34.5 10.5 49500 1.8

20 Sapele

37.5 4.8 31500

21 Sapele

37.5

No Data

22 Sapele

37.5 5.1 27000

23 Sapele

No Data

After Offodile [32]

The Osun River Basin

The Osun basin is drained by the Osun River system which rises from Oke-Mesi ridge, about 5 km North of Effon Alaiye along the Oshun and Ekiti States border and flows North through the Itawure gap to latitude 7° 53′ before winding its way westwards through Oshogbo and Ede and Southwards to enter Lagos lagoon about 8 km east of Epe [63,67]. A considerable part of the basin is underlain by rocks of the Precambrian Basement Complex, most of which are very ancient. This Basement Complex rocks showed significant variations in grain size and mineral composition [63]. The rocks are quartz gneisses and schist consisting essential of quartz with small amounts of white micaceous minerals. Even though the outcrops are visible, large areas are overlain by layers of laterite soil formed by weathering and decomposing the parent rock material. The minerals’ origin has been dealt with based on heavy mineral studies along the river basin. Moreover, the sedimentary rocks of Cretaceous and Tertiary deposits are found in the southern sector of the basin [63]. Generally, in coastal basins of southwestern Nigeria, groundwater is contained in four principal aquifers [56]:

  • The first is the shallow aquifer, which contained the Recent Sediments along the Atlantic Sea coast and river valleys. It is used for minimal private domestic supplies through dug wells and shallow boreholes.
  • The second and third aquifers are in the Coastal Plains Sands Formation. They are exploited through hand-dug shallow wells in some areas, shallow – and profound – boreholes. These aquifers provide considerable amounts of water for water supplies. This is the principal aquifer exploited, particularly in Lagos and its environs.
  • The fourth aquifer is the deep and highly productive Abeokuta formation, which was discussed in previous sections.

A few boreholes located mostly in Ikeja industrial area in Lagos only extract water from the fourth aquifer. The water from this aquifer is hot with temperatures as high as 80°C recorded in a few boreholes. This aquifer is undergoing massive development in adjoining Ogun State when encountered at shallower depths of between 300 and 550 meters. Figure 12 is a north-south geologic cross-section showing various Formations in the sedimentary basin. In Figure 12, a hydrogeologic cross-section from west to east along the coast shows both the lithologic and water-quality variations in the Coastal Plains Sands and Recent Sediments [56].

fig 12

Figure 12: Hydrogeological cross-section of coastal basins along with Lagos State. After Oteri and Ayeni [56].

The delineation of shallow aquifers in the coastal plain sands of Okitipupa Area, Southwestern Nigeria, revealed two central aquifer units within the Okitipupa Area, Southwestern Nigeria [56]:

  • The upper/surficial aquifer system, which occurs at depths ranging from 5.8 m (around Agbabu) to 61.5 m (around Ikoya), and with materials of higher average resistivity (504.7 Ωm), suggestive of gravelly/coarse to medium-grained sand; and
  • The intermediate aquifer system, characterized by depth range of 32.1-127.5 m, average resistivity of 296.8 Ωm, typical of medium-grained sand saturated with water.

The highly resistive, impermeable materials overlying the aquifer units around Ajagba, Aiyesan, Agbetu, Ilutitun, Igbotako, and Erinj suggests that the aquifer units are less vulnerable to near-surface contaminants than in Agbabu, Igbisin, Ugbo, and Aboto where less resistive materials overlie aquifers. However, this indicates that the aquifer cannot be recharged in these areas. The geoelectric sequence suggests subsurface geology characterized by the alternation of sands/gravel, clay/shale, and sandstone occurring at varying depths with variable thicknesses. The sand and gravel layers constitute the aquifer units [56]. The aquifer units’ geoelectric parameters were determined by interpreting the sounding curves, assisted by the distinctive resistivity contrasts between the discrete geoelectric layers.

The upper and lower aquifer horizons work are referred to as the surficial (upper) and intermediate (lower) aquifers. In a different study by Adepelumi, Ako [68], which delineates saltwater intrusion into the freshwater aquifer of Lekki Peninsula, Lagos, Nigeria, the study delineates four distinct resistivity zones viz:

  • The unconsolidated dry sand having resistivity values ranging between 125 and 1,028 Xm represents the first layer;
  • The fresh water-saturated soil having resistivity values which correspond to 32–256 Xm is the second layer;
  • The third layer is interpreted as the mixing (transition) zone of fresh with brackish groundwater. The resistivity of this layer ranges from 4 to 32 Xm; and
  • Layer four is characterized by resistivities values generally below 4 Xm reflecting an aquifer possibly containing brine. The rock matrix, salinity, and water saturation are the major factors controlling the Formation’s resistivity. Furthermore, this study illustrates that saline water intrusion into the aquifers can be accurately mapped using the surface DC resistivity method.

The Crystalline Basement Terrain

The Basement Complex terrains of South-western Nigeria are underlain by Precambrian basement rocks, which comprise crystalline igneous and metamorphic rocks mostly granite/porphyritic granite, granite-gneiss, quartz-schist, migmatite as well as Augen-gneiss, Pegmatite intrusions and variably Migmatized Biotite-hornblende Gneiss [28,69,70]. Descriptions on the field and petrographic/mineralogical characteristics of the different rock types are subject to various works. Textural and compositional attributes are wide-ranging. Directional fabrics such as foliation, lineation, and lamination are often developed in the Gneisses, Schists, Quartzites, and Tectonized rocks [71]. From the hydrogeologic perspective, unweathered basement rock contains negligible groundwater; however, the significant aquiferous unit can develop within the weathered overburden and fractured bedrock. It is this weathered and fractured zone, which forms potential groundwater zones. However, several factors that usually contribute to the weathering and development of fracture systems in the basement rocks can be summarized as follows [71]: (i) Presence and stress components of fractures; as conduit zones, hydro-geomorphological conditions that dictate the influence of weathering agents; (ii) Hydro-climatic/temperature regimes that dictate chemical weathering pace; and (iii) Mineral contents of the rock which affect the degree of weathering/overburden thickness.

The availability of groundwater in Pre Cambrian-Basement of southwestern Nigeria depends not only on the geology but also on the complex interactions of the various hydroclimatic and geomorphologic factors [72,73]. Accordingly, several methods have been established to locate favourable sites for groundwater resources extraction within basement rocks. These include remote sensing geophysical methods and geomorphological studies [71]. Assessment of previous studies on groundwater in the crystalline basement terrain of southwestern Nigeria discovered that the hydrogeological setting of the terrain is characterized by weathered saprolite units with varied thickness over the different bedrock units, Porphyritic Granites, Granite-gneiss, Migmatite, Pegmatite, and Quartz-schist settings. Such a setting suggests the influence of rock types and mineralogy on the extent of fracturing and weathering. Consequently, groundwater occurrences in the study area are in localized, disconnected phreatic regolith aquifers, practically under unconfined to semi-confined conditions. Nonetheless, groundwater in the study area can be categorized under two central units: area with highly weathered and fractured bedrock units and poorly weathered/sparsely fractured bedrock units [71]. In an area with deeply weathered regolith and highly fractured zones, groundwater occurrences usually depend on the thickness of the water-bearing rock; this rock can be gravelly and fractured with possible quartz veins within the deep weathered zone of between 10 m to 30 m. These are characteristic of areas underlain in the study area by weathered crystalline and metamorphic rocks such as schist/quartz-schist, fractured granite-gneiss, and porphyritic granites as well as Augen gneiss with vertical fracture zones. These are generally characterized by moderate to high yield of about 75 m3/day and up to >150 m3/day. The borehole depth usually varies from 20 to 60 m, while the saturated thickness varies from 20 to 35 m below the ground surface [71]. In areas where the weathered zone is thin or absent, groundwater is usually tricky due to widely spaced fractures and the weathered zone’s localized zone/pockets. In the study area, these are characteristic of areas underlain by crystalline and metamorphic rocks, especially migmatite and variably Migmatized gneiss characterized by thin/shallow overburden unit of usually less than 10 meters in thickness and low yield of generally less than 75 m3/day. In such a setting also, the borehole depth varies from 20 to 30 m while saturated thickness varies from 8 to 20 m below the ground surface [71]. Nonetheless, towards the base of the weathered zone at the interface with the fresh bedrock, the permeability is usually high, allowing water to move freely due to the low proportion of clayey materials. However, deep-seated fractures are vital in such situations and can sometimes provide appreciable water supplies, mainly when tectonically controlled. Wells or boreholes that penetrate this horizon can usually provide sufficient water to sustain even hand-dug wells. Due to the complex interactions of the various factors affecting weathering in a typical basement complex setting like the study area, the groundwater potential zone distribution can be erratic and may not be present in some locations [71]. The analysis that involved characterization of weathered overburden revealed estimated overburden thickness using geoelectrical VES surveys from 3.8 to 50 meters with a mean value of about 20 meters as dictated by bedrock types. These values are within the range of values obtained for similar Basement Complex terrains of Africa. Furthermore, it was observed that areas with thin/shallow overburden coincided mostly with areas underlain by variably Migmatized gneiss complex, while the area with thicker overburden unit coincided with area mainly underlain by schist. However, the quartzite/quartz-schist setting coincided with areas of moderate to shallow overburden thickness [71]. In a nutshell, the varied thickness and the weathered overburden units’ isolated pockets also confirm the localized nature of weathered basement aquifers under the crystalline basement setting. The implication of this lies in the fact that there is the need for careful characterization and delineation of areas of possible fracturing and deep weathering as an aquiferous zone in respect of groundwater developments in Basement Complex settings of the study area. Therefore, the present study addresses the aspect of characterization of the groundwater potential using integrated GIS, RS, and MCDA techniques in conjunction with conventional hydrological and hydrogeological data [71]. Although the hydrogeology of southwestern Nigeria’s coastal basins is well described in the literature, a comprehensive description of its hydrochemistry has been lacking. The following section presents a synthesis of physicochemical physiognomies of groundwater in the basin.

Groundwater Chemistry

Physical Chemistry

Figures 13-15 present a summary of groundwater’s physical and chemical parameters in southwestern Nigeria’s coastal basins. Evaluation of pH concentration from 210 locations showed that pH ranged from 3.9 to 10.2 with a mean pH value of 7.4. Generally drinking water having pH < 7 is measured as acidic, and pH > 7 is considered basic. The normal range for pH in surface water systems is 6.5 to 8.5 and for groundwater aquifers 6 to 8.5 [74-76]. Unlike the Niger Delta Basin, groundwater in coastal basins of southwestern Nigeria is slightly alkaline. Alkalinity is a degree of the water’s capacity to resists a change in pH that would tend to make the water more acidic. The measurement of alkalinity and pH is needed to determine the water’s corrosivity [77-80]. The pH of clean water is 7 at 25°C, but when exposed to the atmosphere’s carbon dioxide, this equilibrium results in a pH of approximately 5.2. Because of the association of pH with atmospheric gasses and temperature, it is strongly recommended that the water is tested as soon as possible. The water’s pH is not a measure of the acidic or basic solution’s strength and alone does not provide a full picture of the characteristics or limitations with the water supply. In general, groundwater sources with low pH (< 6.5) could be acidic, soft, and corrosive. Therefore, the water could leach metal ions such as iron, manganese, copper, lead, zinc from the aquifer, plumbing fixtures, and piping. Consequently, groundwater with low pH could contain elevated levels of toxic metals, cause premature damage to metal piping, and have associated aesthetic problems such as a metallic or sour taste, laundry staining, and the characteristic blue-green staining of sinks and drains [81-83].

Groundwater sources having pH > 8.5 could indicate that the water is hard [84-86]. Hard water does not pose a health risk but can cause aesthetic problems. These problems include:

  • Formation of a ‘scale’ or precipitate on piping and fixtures causing water pressures and the interior diameter of piping to decrease;
  • Causes an alkali taste to the water and can make coffee taste bitter;
  • Formation of a scale or deposit on dishes, utensils, and laundry basins;
  • Difficulty in getting soaps and detergents to foam and Formation of insoluble precipitates on clothing, etc.; and Decreases efficiency of electric water heaters.

The temperature ranged from 22.7 to 30.5°C, with a mean value of 27.5°C. The causes for the temperature rise in aquifers are numerous, and these are directly linked to the continuing structural developments and the existing uses at the earth’s surface. These influences can be direct or indirect. The direct influences on the groundwater temperature include all heat inputs to the groundwater through the sewage network, district-heat pipes, power lines, and sources connected with groundwater heat use and storage [87-89]. The indirect influences on groundwater temperature processes are linked with urbanization-related changes in the heat balance in the near-surface atmosphere. The most important factors are:

  • The disturbance of the water balance due to a high degree of surface imperviousness;
  • The change of soil characteristics caused by an aggregation of structures (differences in the near-surface heat input and heat capacity);
  • Changes in the irradiance balance by changes in the atmospheric composition; and
  • Anthropogenic heat generation (domestic heating, industry, and transport).

The differences mentioned above cause changes in the heat balance by comparison with the areas surrounding the city. The city heats itself slowly, stores more heat overall, and passes it on again slowly to the surrounding areas, i.e., it can generally be considered an enormous heat storage unit [90,91]. Over the long term, this process increases the annual mean air and soil temperatures. The long-term warming of the near-surface soil also leads to a heating of the groundwater. Since the temperature affects the physical qualities and the groundwater’s chemical and biological nature, deterioration of groundwater quality and an impairment of the groundwater fauna may result from high temperatures [92-94]. The concentration of EC was synthesized from 177 locations from the basins. Conductivity values ranged from 31.9 to 1643 µS/cm with a mean value of 526.47 µS/cm. Electrical conductivity is widely used for monitoring the mixing of fresh and saline water, for separating stream hydrographs, and for geophysical mapping of contaminated groundwater [95,96]. Distilled water should typically have an EC of less than 0.3 µS/cm. For groundwater, EC values greater than 500 µS cm-1 indicate that the water may be polluted, although values as high as 2000 µS/cm may be acceptable for irrigation water [97,98]. In Europe, the EC of drinking water should be no more than 2500 µS/cm; water with a higher TDS may have water quality problems and be unpleasant to drink [99-101]. Synthesis of hardness from 211 locations revealed that hardness ranged from 11 to 3215 mg/l with a mean value of 467.05 mg/l. Initially, water hardness was understood to be the capacity of water to precipitate soap. Hard water does not allow soap to form as many suds. Water high in hardness is detrimental to plumbing and will reduce the life of water heaters. Water softeners will typically reduce hardness to below 10 mg/l. However, they replace the calcium and magnesium metals with sodium which is undesirable for low salt intake diets [102-104]. Water softener companies often discuss hardness in ‘Grains per Gallon’ instead of the standard units mg/l. To convert hardness from mg/L to grains per gallon, multiply mg/l by 17. Thus, 525 mg/l is equal to 31 gram/gallon. Salinity ranged from 0.08 to 1109 mg/l with a mean value of 178.90 mg/l. There is a substantial reporting on salinity in coastal basins of southwestern Nigeria. All-natural water holds some salt level, and in groundwater, the concentration can naturally vary from fresh to saltier-than-seawater. While small amounts of salt are vital for life, high levels can limit groundwater use and affect ecosystems that depend on groundwater. Small quantities of salt are deposited on the landscape every time it rains. Evaporation and plant transpiration remove water from the landscape but leave the salt behind. It concentrates salt over time. Evaporation can also directly increase groundwater salinity in areas where groundwater is close to the surface. Old groundwater can also become saltier as it passes through aquifers and picks up salts from dissolved minerals.

Although salt in the southwestern Nigeria landscape’s coastal aquifers is natural, groundwater and salt movement’s salinity into groundwater-dependent ecosystems can be increased by human activities. Increases in groundwater salinity can be caused by:

  • Increased groundwater recharge because of irrigation, which mobilizes salts naturally accumulated in the soil (irrigation salinity);
  • Increased groundwater recharge because of land clearing, bringing groundwater near the land surface, causing evaporation from the soil surface and salt accumulation (dryland salinity);
  • Leaking pipes, over-watering of gardens, and runoff from compacted surfaces can raise groundwater levels and concentrate salts in urban areas, which can lead to salt damage on buildings and roads (urban salinity);
  • Over-pumping near the coast, which can cause seawater to seep into replenishing water levels.

Groundwater salinity can also be reduced at times, such as when rapid recharge from flooding flushes out or dilutes salty groundwater. Broadscale changes in groundwater salinity occur very slowly, over decades or longer. Therefore, groundwater salinity is usually monitored rarely except where human impacts are of concern. Measurements on Turbidity, TSS, and Alkalinity were not much in the coastal basins of southwestern Nigeria. Turbidity ranged from 0.86 to 26.34 mg/l, with a mean value of 8.06 mg/l. This estimate was based on two studies (Figure 13f). Therefore, more reporting on turbidity is required in the basin. There is currently little information regarding turbidity in groundwater, and the cause is not fully understood. The common assumption is that groundwater turbidity indicates a fast transport pathway connecting potentially contaminated surface water with the aquifer. Studies found no relationship between turbidity and microbiology, although Chalk sources appear more susceptible to E. coli than other aquifers [105]. The occurrence of turbidity tends to be site-specific with a variety of causes. Mitigation measures in groundwater might include variable speed pumps, automatic pumping to waste, blending, or engineered solutions. Discussion on TSS was based on one study (Figure 13g). Total suspended solids ranged from 153 to 1109 mg/l with a mean value of 472.67 mg/l. Total Suspended Solids (TSS), also known as non-filterable residue, are those solids (minerals and organic material) that remain trapped on a 1.2 µm filter. Suspended solids can enter groundwater through runoff from industrial, urban, or agricultural areas [106]. Elevated TSS can reduce water clarity, degrade habitats, clog fish gills, decrease photosynthetic activity, and cause an increase in water temperature. TSS has no drinking water standard; drinking water with high TSS concentration can increase people’s severity with liver diseases. Similarly, there is not much reporting on alkalinity from these basins. Alkalinity ranged from 0.3 to 1.5 mg/l, with a mean concentration of 0.67 mg/l (Figure 13h). Alkalinity is not a chemical in water, but, instead, it is a property of water-dependent on the presence of certain chemicals in the water, such as bicarbonates, carbonates, and hydroxides. Groundwater aquifers with high alkalinity will experience less of a change in its acidity, such as acidic water, such as acid rain or an acid spill, introduced into the water body [107-109]. In a surface water body, such as a lake, the water’s alkalinity comes mostly from the lake’s rocks and land. Precipitation falls in the lake’s watershed, and most of the water entering the lake comes from runoff over the landscape. If the landscape is in an area containing rocks such as limestone, then the runoff picks up chemicals such as calcium carbonate (CaCO3), which raises the water’s pH and alkalinity. In areas where the geology contains large amounts of granite, lakes will have lower alkalinity. A pond in a suburban area, even in a granite-heavy area, as in some parts on the coastal basins (e.g., Lagos and its environs), could have high alkalinity due to runoff from home lawns where limestone has been applied. However, studies are required for further evaluation. Studies on dissolved oxygen from coastal basins of southwestern Nigeria are quite small in number. Ayolabi, Folorunso [110]’s integrated geophysical and geochemical methods for environmental assessment of the municipal dumpsite system in Lagos revealed DO ranging between 4 to 4.4 mg/l with a mean value of 4.1 mg/l. Similarly, Awomeso, Taiwo [111]’s study on the pollution of a waterbody by textile industry effluents in Lagos, Nigeria showed that COD concentration varies with distance from the discharge point. The concentration of was 890 mg/l at 0 meters, 600 mg/l at 50 meters, 214 mg/l at 100 meters, 1703 at 150 meters, 1172 ta 200 meters, 10 mg/l at 250 meters, 1693 mg/l at 300 meters, 860 mg/l at 350 meters, 1901 mg/l at 400 meters and 10 mg/l at 450 meters respectively. Omale and Longe [112]’s, assessment of the impact of abattoir effluents on River Illo, Ota, Nigeria showed that BOD ranged from 140 to 670 mg/l with a mean value of 333.33 mg/l. Most of the studies reporting BOD came from surface water bodies. Groundwater is yet to be fully explored in southwestern Nigeria’s coastal basins, based on these parameters. Dissolved oxygen significantly affects groundwater quality by regulating the valence state of trace metals and constraining dissolved organic species’ bacterial metabolism [113-115]. Consequently, the measurement of dissolved oxygen concentration should be considered vital in most water quality researches. Measurements of dissolved oxygen have been often ignored in groundwater monitoring. Oxygen has regularly been assumed absent below the water table; O2 measurements are not mandated by drinking water standards. Regular organic debris and organic waste derived from wastewater treatment plants, failing septic systems, and agricultural and urban runoff act as food sources for water-borne bacteria. Bacteria decompose these organic constituents using DO, consequently reducing the DO present for aquatic organisms. Chemical oxygen demand does not discriminate between biologically available and inert organic matter, and it is a measure of the total quantity of oxygen required to oxidize all organic material into carbon dioxide and water [116-119]. The COD values are always greater than BOD values, but COD measurements can be made in a few hours while BOD measurements take five days. Since parameters play a significant role in groundwater quality, it is recommended that such parameters are measured throughout the coastal basin of southwestern Nigeria. Figure 14 presents the groundwater classification based on pH, Hardness, Conductivity, and TDS. Based on pH 50.95% of groundwater sources in coastal basins of southwestern Nigeria fall in neutral class, 35.24% fall in acidic class, and 13.80% fall in alkaline class. Conversely, total hardness is also varying in the basin. About 43.37% of groundwater sources fall in soft class, 24.29% fall in intermediate class, 23.72% fall in hard class, and 9.60% fall in the very hard-water class. About 67.80% of groundwater sources have conductivity below 750 µS/cm, and 32.24% have EC values between 750 to 2250 µS/cm. Low TDS levels further show the low conductivity of groundwater sources in the basin. About 62.55% groundwater sources have TDS below 500 mg/l, 27.96% have TDS concentration between 500 to 1000 mg/l, 9.00% have TDS level between 1000 to 3000 mg/l and 0.47% have TDS above 3000 mg/l. This variability is further illustrated in Figure 14d.

fig 13

Figure 13: Hydrogeological cross-section of coastal basins along with Lagos State.

fig 14

Figure 14: Groundwater classification (a) pH, (b) Total hardness, (c) Conductivity and (d) TDS.

Cation Chemistry

Understanding the chemical physiognomies of groundwater is essential as a result of their contrasting sources. As soon as their concentration is above the suggested reference guidelines, these prerequisites may render groundwater unusable. Chemical essentials including Ca, Mg, Cu, Cd, B, Al, K, PO4, SO4 As, and Cl, for instance, are primarily derived from rocks. Nonetheless, elements like NO3 and SO4 are derived mainly from anthropogenic sources [118,119]. Understanding the derivation and absorption level of these chemical elements in groundwater is needed for effective groundwater management. Generally, there is little reporting on Al, NH4, and southwestern Nigeria’s coastal basins. For instance, Ayolabi, Folorunso [110]’s analysis of the municipal dumpsite system in Lagos showed Al ranged from 0.001 to 1.641 mg/l with a mean value of 0.29 mg/l.

Longe and Enekwechi [120] investigated potential groundwater impacts, and the influence of local hydrogeology on natural attenuation of leachate at a municipal landfill from Olusosun landfill showed that NH4 ranged from 0.14 to 1.5 mg/l with an average value of 0.41 mg/l. A review of the level of arsenic in potable water sources in Nigeria and their potential health impacts by Izah and Srivastav [121]’s analysis showed that arsenic concentration in western Nigeria ranged from 0.00 to 0.38 mg/l at Ibadan, 0.00 to 0.05 mg/l in Odeda region, 0.03 to 0.47 mg/l at Ijebu land and 0.01 to 0.70 mg/l at Igun-ijesha. People are exposed to elevated levels of inorganic arsenic through drinking contaminated water, using contaminated water in food preparation and irrigation of food crops, industrial processes, eating contaminated food and smoking tobacco. Long-term exposure to inorganic arsenic, mainly through drinking water and food, can lead to chronic arsenic poisoning. Skin lesions and skin cancer are the most characteristic effects. The SON has recommended 0.2 mg/l as a maximum permissible limit in drinking water. Aluminium is an excellent metal in the earth’s crust and is regularly found in the form of silicates such as feldspar. The oxide of Al known as bauxite provides a suitable source of uncontaminated ore. Aluminium can be selectively leached from rock and soil to enter groundwater aquifer. Aluminium is known to exist in groundwater in concentrations ranging from 0.1 ppm to 8.0 ppm. Al can be present as Aluminum Hydroxide, a residual from the municipal feeding of aluminium (Aluminum Sulfate), or as Sodium Aluminate from clarification or precipitation softening. It has been known to cause deposits in cooling systems and contributes to the boiler scale. Aluminium may precipitate at normal drinking water pH levels and accumulate as a white gelatinous deposit. Aluminium is controlled in drinking water with a recommended Secondary Maximum Contaminant Level (SMCL). SMCL’s are used when the taste, odour, or appearance of water may be adversely affected. In this case, the WHO [122] established that an Al concentration above 0.1–0.2 mg/l might impact colour but recognize that level may not be appropriate for all water supplies. The Nigerian Standard for Drinking Water Quality (NSDWQ) has recommended 0.2 mg/l as a maximum permissible limit because of potential neuro-degenerative disorders associated with high Al concentrations in water. The natural levels of NH4 in groundwater and surface water are usually below 0.2 mg/litre. Anaerobic groundwaters may contain up to 3 mg/l. Leached effluents from the concentrated rearing of farm animals can give rise to much higher levels in groundwater. Ammonia pollution can also rise from cement mortar pipe linings. Ammonia is an indicator of possible bacterial, sewage, and animal waste effluence. Contact from environmental sources is insignificant in comparison with the endogenous synthesis of NH4. Toxicological effects are observed only at exposures above about 200 mg/kg of body weight. Ammonia in drinking water is not of immediate health significance, and consequently, no health-based guideline value is proposed by SON. There are few studies on Barium concentration in groundwater from coastal basins of southwestern Nigeria. Odukoya and Abimbola [123]’s assessment of contamination of surface and groundwater within and around two dumpsites in Lagos revealed that Ba concentrations ranged from 40 to 100 mg/l with a mean value of 49 mg/l within and around abandoned dumpsite. Barium also ranged from <0.001 to 80 mg/l with a mean value of 56 mg/l within and around active dumpsite. Barium is available as a trace element in both igneous and sedimentary rocks. Even though it is not found free, it occurs in several compounds, most commonly barium sulfate (or barite) and, to a lesser extent, barium carbonate (or witherite). Barium goes into the environment naturally via the weathering of rocks and minerals. Anthropogenic releases are primarily connected with industrial processes. The over-all population is exposed to Ba through the ingestion of drinking water and foods, usually at low levels. Figure 15a presents a synthesis of Ca from groundwater from coastal basins of southwestern Nigeria. Calcium ranged from 1.49 to 1460 mg/l with a mean value of 56.78 mg/l. Calcium in drinking water is beneficial, but it is important to note that calcium is a significant constituent of hardness. Based on SON guidelines, Ca is not limited to drinking water. Based on the results of the WHO meeting of experts held in Rome, Italy, in 2003 to discuss nutrients in drinking water [124], the assembly focused its attention on Ca and Mg, for which, next to F, a sign of health benefits accompanied by their existence in drinking water is robust. The Ca’s insufficient consumption has been accompanied by increased risks of osteoporosis, nephrolithiasis (kidney stones), colorectal cancer, hypertension and stroke, coronary artery disease, insulin resistance, and obesity. Most of these disorders have treatments but no cures. Due to a lack of convincing evidence for Ca’s role as a single influential element about these diseases, estimates of the Ca requirement have been made based on bone health outcomes to improve bone mineral density. Calcium is exclusive among nutrients because the body’s reserve is also functional: increasing bone mass is correlated to a decrease in fracture risk. There relatively high Ca level in these basins could be beneficial to the health of the people living there. Figure 15b presents a synthesis of Mg from groundwater in coastal basins of southwestern Nigeria. Evaluation of Mg from 183 sites across these basins showed that Ca ranged from 0 to 108 mg/l with a mean value of 12.26 mg/l. Based on the NSDWQ [125] reference guidelines, 0.2 mg/l was suggested as the maximum permissible Mg concentration in drinking water. The relatively high Ca and Mg recorded in these basins have resulted in the hard water as 56.63% of groundwater in these basins is either moderately hard, hard, or very hard. Numerous epidemiologic researches carried out during recent years have established an inverse relationship between water hardness and death from cardiovascular disease. Many recommendations leave been offered concerning, the causal agent for the association between death from cardiovascular disease and water hardness. Two standards have been debated: a toxic effect brought by the contamination of lead or cadmium or a shielding effect from Ca or Mg’s water content. What is vital is to limit the concentrations of these elements in drinking water. Figure 15c presents a synthesis of Mn from groundwater across the coastal basins of southwestern Nigeria. Manganese ranged from <0.001 to 108 mg/l with a mean concentration of 10.05 mg/l. The SON has recommended 0.2 mg/l Mn as the maximum permissible limit in drinking water due to the neurological disorder associated with water ingestions having a high Mn level [125]. Manganese has recently come under inspection in drinking water due to its possible toxicity and its impairment to water distribution networks. Manganese is rarely found alone in groundwater. It is often found in iron-bearing waters but is rarer than iron. Chemically it can be measured as a close relative of iron since it occurs in much the same iron forms. When manganese is available in groundwater, it is as annoying as iron, perhaps even more. At low concentrations, it produces incredibly objectionable stains on everything with which it comes in contact. Evaluation of K from 207 sites (Figure 15d), in the coastal basin of southwestern Nigeria, showed that K ranged from <0.001 to 341.7 mg/l with a mean value of 24.77 mg/l. Potassium is an essential electrolyte, which is a mineral required by the body to function correctly. Potassium is especially vital for nerves and muscles, including the heart. While K is central to human health, too much ingestion of K can be just as harmful as, or worse than, not getting enough. Usually, kidneys keep a healthy balance of K by flushing excess potassium out of the body. However, for many reasons, the level of potassium in the blood can be too high. This is called Hyperkalemia, or high potassium. The NSDWQ [125], issued no guidelines on K levels in drinking water. Figure 15e presents a synthesis of Na from groundwater across the coastal basins of southwestern Nigeria. Sodium concentration from 152 sites showed that Na ranged from <90.001 to 483.42 mg/l with a mean value of 38.02 mg/l. There is an increasing call to use K in combination with Na to treat and soften drinking water. However, this would cause the level of K in drinking water to increase. The WHO found that the level of K found in drinking water would present no health concerns for healthy adults; though, for specific populations with comprised renal functions, such as infants or individuals suffering from specific diseases, there is the likelihood of adverse health effects. Sodium is not measured to be toxic. The human body requires Na to maintain blood pressure, control fluid levels, and normal nerve and muscle function. However, there are no health-based criteria for Na in drinking water. Only a small amount of the Na we ingest practically comes from water. As a substitute, the standard for Na is based on taste. The mean Na concentration in these basins is below [125] recommended value (200 mg/l).

Quality assessment of groundwater in the vicinity of dumpsites in Ifo and Lagos, Southwestern Nigeria by Majolagbe, Kasali [126], showed that Cd concentration was below the detection limit at Ifo, whereas, mean Cd concentration was 0.005 in Lagos. In the same vein, groundwater quality assessment in a typical rural settlement (Igbora, Oyo state,) in southwest Nigeria by Adekunle, Adetunji [127], showed Cd concentration varies with distance from dumpsites. The Mean Cd concentration was 0.78 mg/l at 50 meters, 0.30 mg/l at 100 meters, 0.32 mg/l at 150 meters, and 0.30 mg/l at 200 meters away from during the dry season. Cadmium concentration was 0.34 mg/l at 50 meters, 0.32 mg/l at 100 meters, 0.30 mg/l at 150 mg/l and 0.24 mg/l at 200 meters away from dumpsite during wet season. Ayolabi, Folorunso [110]’s assessment of the municipal dumpsite system in Lagos indicated that Cd ranged from <0.001 to 0.025 mg/l. There are many studies on Cd in these basins, but the underline reasons for higher Cd in groundwater need to be understood. Many studies have been carried out to decode relationships between geological environment, potable/drinking water, and diseases as they were considered to have caused suffering due to diseases among people. Chronic anaemia can be caused by protracted exposure to drink water polluted with Cd. The Cd’s accumulation is established in the kidney under such conditions, resulting in cancer and cardiovascular diseases. The NSDWQ [125] has limit Cd concentration in drinking water to be 0.003 mg/l. Cadmium is restrained in drinking water because of its toxic effects on the kidney. Assessment of groundwater fluoride and dental fluorosis in Southwestern Nigeria by Gbadebo [128], revealed that groundwater samples from Abeokuta Metropolis (i.e., basement complex terrain) had F concentrations in the range of 0.65 to 1.20 mg/l. These values were lower than the F contents in the groundwater samples from Ewekoro peri-urban and Lagos metropolis where the values ranged between 1.10 to 1.45 and 0.15 and 2.20 mg/l, respectively. The F concentrations in nearly all locations were generally above the WHO recommended 0.6 mg/l. The study also revealed that the F distribution of groundwater samples from the different geological terrain was more dependent on pH and TDS than on temperature. The result of the analyzed social-demographic characteristics of the residents indicated that the adults (between the age of 20 and >40 years) showed dental decay than the adolescent (<20 years). This indicates an incidence of dental fluorosis by the high fluoride content in the populace’s drinking water. Conversely, evaluation of groundwater contamination in Ibadan, South-West Nigeria by Egbinola and Amanambu [129], revealed that F concentration is above the recommended limits in 13% and 100% the dry and wet season samples. The occurrence of F in groundwater has become one of the most significant toxicological environmental hazards worldwide. Fluoride in groundwater is due to the weathering and leaching of fluoride-bearing minerals from rocks and sediments. When consumed in small quantities (<0.5 mg/l), F is advantageous in promoting dental health by reducing dental caries, but higher concentrations (>1.5 mg/l) may cause fluorosis [130]. It is projected that about 200 million people, from among 25 nations the world over, may suffer from fluorosis and the causes have been attributed to fluoride pollution in groundwater including Nigeria. High F concentration in groundwater is expected from sodium bicarbonate-type water, which is calcium deficient. The alkalinity of water also mobilises fluoride from fluorite (CaF2) [131-133]. Exposure to F in humans is related to:

i. Fluoride concentration in drinking water

ii. Duration of consumption; and

iii. The climate of the area. In hotter climates where water consumption is more significant, exposure doses of fluoride (F) need to be modified based on mean F intake.

Many cost-effective and straightforward measures for water defluoridation methods are already known. Nonetheless, the benefits of such methods have not reached the affected rural population due to limitations. Consequently, there is a need to develop workable plans to provide fluoride-safe drinking water to rural communities [130]. There are few studies reporting lead in groundwater from coastal basins of southwestern Nigeria. An assessment of drinking water quality using the Water Quality Index in Ado-Ekiti and environs, by Olowe, Oluyege [134], showed that Pb ranged from <0.001-7.0 mg/l with a mean value of 1.94 mg/l. The quality assessment of groundwater in the vicinity of dumpsites in Ifo and Lagos, Southwestern Nigeria by Majolagbe, Kasali [126], showed that Pb concentrations at Ifo were below the detection limit. The Pb level at Lagos was 0.003 mg/l, and this value is below NSDWQ [125], reference guidelines. The primary reason for restraining Pb in groundwater is that Pb is associated with cancer, interfering with Vitamin D metabolism, affects mental development in infants, and is toxic to central and peripheral nervous systems.

Studies on Mercury are few in coastal basins of southwestern Nigeria. The geostatistical exploration of the dataset assessing the heavy metal contamination in Ewekoro limestone, Southwestern Nigeria by Oyeyemi, Aizebeokhai [135], showed that Hg ranged from 0.002 to 0.38 mg/kg with an average value of 0.12 mg/kg. The absence of Hg reporting groundwater in these basins at the time of this study revealed a possible research gap in groundwater quality in southwestern Nigeria’s coastal basins. Mercury is a scarce element in the Earth’s crust, having an average crustal abundance by mass of only 0.08 parts per million (ppm). Typical Hg sources comprise volcanoes, geologic deposits of Hg, volatilization from the ocean, and some geothermal springs. Nearly half of all Hg released to the environment is natural in origin. About 5,000 tons of Hg is released to the environment per year due to anthropogenic activities worldwide. The NSDWQ [125] has recommended 0.001 mg/l of Hg as the maximum permissible limit for Hg in drinking water due to its health effects on the kidney and central nervous system [125].

Figure 15f presents a synthesis of Ni from groundwater in coastal basins of southwestern Nigeria. Ni ranged from <0.001 to 9.2 mg/l with a mean concentration value of 1.84 mg/l. The NSDWQ [125], set 0.02 mg/l as the maximum permissible limit of Ni in drinking water, because of possible carcinogenicity. The risk of developing cancer from the ingestion of Ni contaminated water is high in western Nigeria since the average Ni (1.84 mg/l) is very much higher than the NSDWQ [125] reference guidelines. Nickel absorptions in groundwater hang on the soil use, pH, and depth of sampling. The mean concentration in groundwater in the coastal basins of western Nigeria is 1.84 mg/l. This value is very much high. Acid rain raises the mobility of Ni in the soil and thus might increase Ni concentrations in groundwater. In groundwater with a pH below 6.2, Ni concentrations up to 0.098 mg/l have been measured. The acidic composition of groundwater sources (35.24%) perhaps is responsible for high Ni levels in the basins. Table 4 shows silica concentrations in groundwater from Abeokuta. Silica varied markedly between the studied locations. The range was higher at Ikereku 12.5-16.4 mg/l [136]. Silica in groundwater has become an exciting element to hydrogeologists as an index to aquifers’ general lithology. Groundwater travelling slowly in the subsurface will approach chemical equilibrium with minerals present in the aquifers. Under average temperature and pressure, mean silica concentrations in groundwater vary from low values of about 7 mg/l in carbonate aquifers to about 85 mg/l in aquifers containing unaltered rhyolitic ash. Groundwater from unweathered or slightly weathered basaltic aquifers generally ranges from 25 to 75 mg/l and has a mean silica value of ~45 mg/l.

Table 4: Silica concentrations in groundwater from Abeokuta.

S/No Location

No. of Sample

SiO2 (mg/l) S/No. Cont. Location Cont. No. of Sample Cont.

SiO2 (mg/l) Cont.

L1 Itoko

3

7.5-8.5 L25 Saje 6

6.9-8.2

L2 Erube

3

6.2-8.0 L26 Aregba 5

7.5-9.0

L3 Olumo

2

18.5-19.3 L27 Ikija 4

1.3-1.5

L4 Ijaye

2

8.7-10.5 L28 Ikereku 2

2.4-2.6

L5 Ago-Ika

2

4.6-5.4 L29 Efon 3

2.5-3.0

L6 Adatan

2

1.8-2.3 L30 Bode Olude 5

6.0-6.4

L7 Ake

2

2.0-4.3 L31 Housing Estate 5

6.5-6.8

L8 Ijemo

2

2.7-4.0 L32 Iberekodo 2

2.4-2.6

L9 Idomapa

2

3.6-6.3 L33 Lafiaji 2

7.9-8.2

L10 Ikija

2

4.0-6.0 L34 Ita Elega 7

3.9-4.5

L11 Kemta

2

4.0-4.9 L35 Mokola 3

2.0-2.5

L12 Itesi

2

2.3-2.6 L36 Adigbe 2

1.0-1.7

L13 Okejigbo

2

1.9-2.3 L37 Amolaso 2

3.3-3.9

L14 Oke Lantoro

2

0.5-1.8 L38 Ibara HE 5

3.8-4.7

L15 Ilugun

2

3.1-3.9 L39 Ijeja 5

1.2-2.6

L16 Itoku

2

1.4-1.6 L40 Isabo 4

2.1-2.5

L17 Iporo Ake

2

2.4-2.6 L41 Ita-Eko/Ita Iyalode 3

0.5-4.6

L18 Ijeun

2

8.5-9.0 L42 Kuto 5

2.0-3.6

L19 Sapon

2

3.1-4.7 L43 NEPA/NUD 7

1.2-1.6

L20

Lantoro

2 3.5-4.0 L44 Oke-Sokori 3

1.2-1.7

L21 Olorunsogo

2

3.2-3.5 L45 Oke-Ilewo 2

1.3-4.7

L22 Ikereku

2

12.5-16.4 L46 Onikolobo 2

1.4-2.6

L23 Ago Oko

2

5.5-6.5 L47 Quarry Rd 2

1.2-2.5

L24 Asero

6

9.0-13.6

After Offodile [32]

Hypothetically, if the water were in chemical equilibrium and if the thermodynamic properties and amounts of all minerals present were known, then the exact silica concentrations of water in the subsurface might be predicted. However, many reactions involving silicate minerals are sluggish, and equilibrium cannot be assumed, mostly in highly permeable basaltic aquifers. Moreover, the types and distribution of minerals may be quite varied and hard to determine in most aquifers. Notwithstanding these complicating factors, field data indicate that silica values for any given aquifer lithology are moderately uniform.

There are many studies on copper in coastal basins of southwestern Nigeria (Figure 15g). The concentrations of Cu ranged from 0.01 to 19.6 mg/l with a mean value of 2.86 mg/l. Dissolved Cu in groundwater can occasionally impart a light blue or blue-green colour and an unfriendly metallic, acrimonious taste to drinking water. Metallic Cu is soft, yielding, and an excellent thermal and electrical conductor. Groundwater analysis revealed high electrical conductivity, it may indicate high Cu concentrations, mainly if other ions, including Fe, Zn, Mn showed a lower concentration. Copper concentration is limited in drinking water since excessive ingestion (>1.0 mg/l), is associated with the gastrointestinal disorder [125]. Figure 15h presents a synthesis of Fe concentrations in groundwater from coastal basins of southwestern Nigeria. The Fe’s concentration was highly variable and ranged from 0 to 2.95 mg/l with a mean value of 0.31 mg/l. Fe in groundwater is a direct result of its natural availability in underground rock formations and precipitation water that infiltrates through these formations as the recharge water moves through the rocks some of the iron dissolves and accumulates in aquifers which serve as a source for groundwater. Since the earth’s underground rock formations contain about 5% iron, it is common to find iron in many geographical areas worldwide. Iron is naturally found in three significant forms and is rarely found in concentrations greater than 10 mg/l [137]. The degree to which Fe and Mn dissolve in groundwater hinge on the amount of oxygen in the water and, to a lesser extent, upon its degree of acidity, i.e., its pH. For instance, iron can occur in two forms: as Fe(++) and as Fe (+++). When the DO level is greater than 1-2 mg/l, iron occurs as Fe3+, while at lower DO levels, the iron occurs as Fe(++). Even though Fe(++) is very soluble, Fe(+++) will not dissolve substantially. Therefore, if the groundwater is oxygen-deprived, iron (and Mn) will dissolve more readily, especially if the water’s pH is on the acidic side. The DO content is decreased with an increased aquifer depth, mainly if the aquifer contains organic matter (OM). The OM decomposition depletes the oxygen in the water, and the iron dissolves as Fe(++) [138,139]. Under these circumstances, the dissolved iron often goes with dissolved manganese or hydrogen sulfide (rotten egg smell). When this water is pumped to the surface, the dissolved iron reacts with the oxygen in the atmosphere, changes to Fe(+++) (i.e., is oxidized), and forms rust-coloured iron minerals. Dissolved manganese may form blackish particulates in the water and cause similar coloured stains on fixtures. The mean Fe concentration is with the [125] reference guidelines, even though high Fe ingestion in drinking water is not associated with any health hazard. Figure 15i presents a synthesis of Zn concentration in groundwater from the coastal basins of southwestern Nigeria. The concentration of Zn ranged from 0 to 45.9 mg/l with a mean value of 3.65 mg/l. The Nigerian standard has set 3.0 mg/l as a maximum permissible limit of Zn in drinking water. Mean Zn (3.65 mg/l) is above the SON limits. Zinc is an indispensable nutrient needed for good health. Too little Zn in the diet is associated with adverse health effects such as loss of appetite, decreased sense of taste and smell, lowered ability to fight off infections, slow growth, slow wound healing, and skin sores. Eating or drinking too much Zn in a short period can lead to adverse health effects, such as stomach cramps, nausea, and vomiting. Eating large amounts of Zn for more extended periods may cause anaemia, nervous system disorders, damage to the pancreas, and lowered required cholesterol levels. There is no evidence that zinc causes cancer in humans.

fig 15

Figure 15: Cation chemistry (a) Ca, (b) Mg, (c) Mn, (d) K, (e) Na. (f) Ni, (g) Cu, (h) Fe, and (i) Zn.

Anion Chemistry

Evaluation of HCO3 concentrations from 119 locations in coastal basins of southwestern Nigeria revealed that HCO3 ranged from 3.6 to 456.28 mg/l with a mean value of 116.98 mg/l (Figure 16a). There are no reference guidelines set up by NSDWQ [125]. Studies on CO3 were not accessed at the time of this study. The two ions are essential to water quality parameters because when CO3 and HC03 are joint with Ca and Mg, they form carbonate hardness. However, if soil concentrates on drying solution, it advances as CaCO3 or MgCO3. Ca and Mg decrease Na concentration levels and the SAR index rise, initiating an alkalizing effect and elevated pH levels. When groundwater analysis shows elevated pH levels, it may indicate the high content of carbonate and bicarbonate ions. Figure 16b presents a synthesis of Cl concentrations in the coastal basin of southwestern Nigeria. Evaluation of Zn in groundwater from 203 sites across the basin revealed that it ranged from 0.12 to 387 mg/l with a mean concentration value of 47.15 mg/l. The NSDWQ [125], has set 250 mg/l as the maximum permissible allowable drinking water limit. Chloride is one of the most common anions found in tap water. Chloride generally combines with Ca, Mg or Na to form various salts: for example, sodium chloride (NaCl) is formed when Cl and Na combine. Chloride occurs naturally in groundwater but is found in high concentrations where seawater and run-off from road salts can make their way into groundwater aquifers. Although Cl is harmless at low levels, groundwater sources having high in NaCl can harm plants if used for gardening or irrigation and give drinking water an unpleasant taste. Over time, NaCl’s high corrosivity will also damage the water system, appliances, and water heaters, causing toxic metals. Nitrate ranged from <0.001 to 50.6 mg/l with a mean value of 8.81 mg/l. There are very few studies on NO2 in coastal basins of southwestern Nigeria (Figure 16c). Akinbile and Yusoff [140]’s environmental impact of leachate pollution on groundwater supplies in Akure, Nigeria, showed that NO2 ranged from 0.7 to 0.9 mg/l with an average value of 0.8 mg/l. The impact of pit latrines on groundwater quality of Fokoslum, Ibadan, Southwestern Nigeria [141], showed that NO2 concentrations vary with pits’ distance. The mean NO2 concentration was 0.12 mg/l at 10.9 meters, 0.05 mg/l at 11.8 meters, 0.12 mg/l at 13.1 meters, 0.21 mg/l at 16.3 meters, 0.22 mg/l at 13.3 meters, 0.19 mg/l at 17.9 meters, 0.23 mg/l at 9.4 meters and 6.1 mg/l at 6.1 meters, respectively. The NO2 from these sites was below the NSDWQ [125] reference limits.

Figure 16d presents a synthesis of PO4 in groundwater from coastal basins of western Nigeria. The PO4 ranged from 0 to 3.5 mg/l with a mean value of 0.65 mg/l. High PO4 in drinking water is not associated with any severe health risks. The presence of PO4 in groundwater is an indicator of anthropogenic pollution since PO4 is mainly derived from organic wastes. The significance of PO4 is mostly linked to eutrophication of surface water bodies. High PO4 and NO3 in water, help plant and algal growths, leading to a variation of diurnal dissolved oxygen, blooms, and littoral slimes [142]. Figure 16e presents a synthesis of SO4 concentrations in groundwater from coastal basins of southwestern Nigeria. The Concentration of SO4 ranged from <0.001 to 1855 mg/l with a mean value of 52.01 mg/l. The NSDWQ [125], has set 100 mg/l as the maximum allowable limit of SO4 in drinking water, even though there is no health risk associated with high ingestion of SO4 drinking water. However, high concentrations of SO4 in drinking water can cause diarrhoea in humans, especially infants. However, adults usually become adapted to high SO4 concentrations after a few days [143].

fig 16

Figure 16: The anion chemistry (a) HCO3, (b) Cl, (c) NO3, (d) PO4, and (e) SO4.

Conclusion

The literature is unanimous about the importance of understanding the hydrogeology and hydrochemistry of groundwater in coastal basins of southwestern Nigeria. Based on the reviewed works, the following remarks can be made:

i. In southwestern Nigeria’s coastal basins, the Abeokuta group is the oldest formation in the area. This group comprised of the Ise, Afowo, and Araromi Formations. Other formations in the basin include the Akinbo and Ilaro formations. Despite the marked spatial variability of these formations, their lithology remains relatively the same.

ii. Also found in this area is the deltaic formation, which contains alluvial deposits. The Ogun Basin is the central coastal basin in western Nigeria, followed by the Osse-Owena Basin. The later has not been fully explored hydrogeologically. The Osun Basin, drained by the Osun River, covers most Osun and Ekiti States parts. This basin is not associated with good groundwater storage, since basement complex rocks underlie it.

iii. These coastal basins were further grouped into the upper surficial aquifer system; and the intermediate aquifer system. Also found in this area is the crystalline Basement Terrain. From the hydrogeologic point of view, unweathered basement rock contains negligible groundwater; though, a significant aquiferous unit can develop within the weathered overburden and fractured bedrock. The general groundwater condition in the area showed that groundwater is very localized.

iv. Groundwater classification based on physical parameters showed mixed results, though groundwater sources are most suitable for drinking.

These basins’ hydrochemistry showed groundwater is relatively good in terms of its suitability for drinking, industrial and agricultural uses. Owing to the increasing urbanization in the area, reasonable measures are required to protect groundwater from overexploitation and pollution.

Acknowledgement

Federal University Birnin kebbi supported this review. Thanks to all anonymous contributors.

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