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TRG-High/ATM-Expressed/SIRT1-Absent Profile as Negative Prognostic Marker after Neoadjuvant Chemotherapy for Gastric Cancer

DOI: 10.31038/CST.2023822

Abstract

Gastric cancer (GC) is one of the three most deadly among cancers. Although several new drugs have been introduced for metastatic disease, the median overall survival (OS) remains 11-14 months. Perioperative chemotherapy (CT) is the current standard of care for resectable cT2-4 and/or N+ GC, and FLOT (5-fluorouracil, oxaliplatin, docetaxel) is the treatment of choice. To date, no predictive factor of response has been identified. Considering their synergism in DNA repair, ataxia telangiectasia mutated (ATM) and sirtuin-1 (SIRT1) merit investigation for prognostic stratification.

We evaluated by immunohistochemistry the expression levels of ATM and SIRT1 in the surgical specimens from 42 patients with a resectable GC or gastroesophageal junction adenocarcinoma treated with neoadjuvant CT and surgery. In the entire population, median DFS was 22.2 months (95%CI 14.9 – NR) and median OS was not reached (95%CI 26.9 – NR). DFS was significantly longer in patients achieving tumor regression grade (TRG) 2-3 compared with those achieving TRG 4-5 (median DFS not reached vs. 14.9 months; HR=0,36 CI=0,14-0,97; p=0.034), and a trend toward a better OS was also observed across the two subgroups (p=0.068). The proportion of patients who obtained a major/medium pathological regression was higher in the ATM-absent group than in the ATM-expressed group (69% vs. 50%; X-squared=6.05; p=0.1). In the overall population, OS and DFS did not have a significantly different distribution according to ATM and SIRT1 expressions. In contrast, in the TRG 4-5 subgroup, the ATM expression seems to be associated with inferior DFS (7.7 months vs. 32.1 months; p=0.055), particularly when combined with absence of SIRT1. In conclusion, TRG has been confirmed a surrogate of survival, ATM expression correlates with TRG and TRG-high/ATM-expressed/SIRT1-absent profile should be studied as a prognostic marker in prospective trials.

Keywords

Gastric cancer, Prognostic biomarker, Predictive biomarker, Epigenetic, DNA damage repair, ATM, SIRT1, TRG, DNA double-strand break

Key Points

  1. No prognostic markers are available in gastric cancer patients after neoadjuvant chemotherapy.
  2. TRG is a surrogate of survival outcomes.
  3. TRG-high/ATM-expressed/SIRT1-absent profile should be prospectively investigated as a marker for prognostic stratification.

Introduction

Gastric cancer (GC) is one of the three most deadly among cancers, and the fifth most commonly diagnosed tumor worldwide, with about 950,000 new cases per year [1]. Although several new drugs have been introduced for metastatic disease, the median overall survival (OS) remains 11-14 months [2,3]. In recent years, perioperative chemotherapy (CT) has been considered the standard of care for the vast majority of patients with resectable GC, and FLOT (5-fluorouracil, oxaliplatin, docetaxel) is the treatment of choice in patients fit for intensive CT. Doublets containing fluoropyrimidine and platinum are considered feasible for frail, comorbid or elderly patients [4-6]. To date, no reliable predictive factor of benefit from perioperative treatments has been identified and a tailored strategy is yet to be applied [7]. An appropriate patient selection for perioperative therapy is challenging, since only a few features have been associated with tumor regression and survival outcome after FLOT treatment. In the FLOT4-AIO trial, diffuse histotype has been associated with a reduced rate of pathological complete response (pCR) compared to the intestinal one (3% vs. 23%, respectively). Among the tumor-centered endpoints, pCR is currently considered of great interest as it could be a surrogate for survival outcomes [8]. Unfortunately, in resectable disease, only limited evidence is available regarding a molecular biomarker-based patient selection [7]. Although several molecular subgroups have been identified as potentially associated with a prognostic or predictive effect, stratification in prospective trials is still needed. Among the putative biomarkers of interest, microsatellite instability (MSI) seems to be the best candidate to drive treatment choice in the near future [7,9,10]. Consistent with previous evidence, a recent international meta-analysis conducted by Pietrantonio et al. confirmed MSI-high (MSI-H) status as a favorable prognostic factor in patients with resected GC. The 5-year disease-free survival (DFS) and overall survival (OS) rates were higher in patients with MSI-H GC than in those with microsatellite stable (MSS) tumor (5-year DFS: 71.8% vs. 52.3%, respectively; 5-year OS: 77.5% vs. 59.3%) [9]. In addition, the benefit from neoadjuvant CT in resectable MSI-H GC seems to be limited, and that ongoing studies are evaluating immune checkpoint inhibitors (ICIs) as neoadjuvant therapy or potentially curative strategy in patients achieving a complete clinical-pathological-molecular response [10]. Although evidence is limited, ataxia telangiectasia mutated (ATM) protein and sirtuin-1 (SIRT1) have demonstrated a deep synergism of action and could be considered for prognostic stratification, since they are involved in the repair of DNA double-strand breaks (DSB) and epigenetic regulation [11-13].

The ATM gene is located on chromosome 11 and encodes a serine/threonine protein kinase that contributes to maintaining genomic integrity transducing a DSB repair signal to effectors. ATM protein levels are decreased in GC compared to normal samples and low levels of phosphorylated ATM are associated with poor differentiation, lymph node metastasis and poor prognosis [14]. GC cells with defective ATM (expression or activity) determining homologous recombination deficiency are more sensitive to therapies that cause the accumulation of DNA DSBs [15]. In particular, in GC cell lines, ATM overexpression is associated with cisplatin-resistance and its inhibition, using the ATM inhibitor CP466722 or siRNA, induces the reversion of epithelial-to-mesenchymal transition [11]. Therefore, mediating platinum-resistance, we supposed that ATM expression could influence tumor regression in GC patients treated with platinum-based neoadjuvant CT.SIRT1 is a NAD+-dependent class-III histone deacetylase (HDAC) involved in several cell functions including DNA repair. Contributing to the identification of DNA damage sites and access of DNA repair proteins, SIRT1 has a crucial role in the epigenetic regulation of cell homeostasis by deacetylating both histone and non-histone proteins. SIRT1 acts both as tumor suppressor and tumor promoter, depending on location (nucleus vs. cytoplasm) and tissue type. DNA damage is a trigger for SIRT1 dissociation and re localization to DSB. In the SIRT1-DNA repair interplay, ATM preserves the efficient recruitment of SIRT1 to DSBs by signaling DNA damage. Simultaneously, SIRT1 stabilizes ATM at DSB sites and stimulates its autophosphorylation and activity [12,13].

The aim of this study was to investigate the prognostic role of ATM and SIRT1 expression in a cohort of patients who underwent neoadjuvant CT for resectable GC.

Materials and methods

Study Design and Population

This was a single-institution, observational, retrospective and prospective study, which enrolled patients with a resectable GC or gastroesophageal junction adenocarcinoma treated with neoadjuvant CT and surgery from September 2017 to April 2022.

Being an observational study, treatments were performed according to clinical practice and national and international guidelines, regardless of the inclusion in the study.

All patients had a histological diagnosis of GC or gastroesophageal junction adenocarcinoma and availability of tissue samples of primary tumor for translational analysis. Clinical stage was assessed in a multidisciplinary board according to the 7th edition of the International Union Against Cancer Tumour–Node–Metastasis classification [16]. A CT scan, FDG-PET scan, US-endoscopy and, wherever indicated, diagnostic laparoscopy, were routinely performed for staging. Patients with metastatic disease, squamous cell carcinoma, pure neuroendocrine carcinoma or esophageal cancer were excluded.

The primary objective was to describe the expression of ATM and SIRT1 in a cohort of patients with resectable GC who had received neoadjuvant CT. Secondary objectives included the description of clinical characteristics associated with specific patterns of expression and the identification of clinical and/or pathological characteristics that may be related to prognosis.

This study was approved by the Institutional review board of Azienda Ospedaliero-Universitaria Careggi (Comitato Etico Regionale for clinical experimentation of Toscana Region – Italy – Area Vasta Centro – 22070_BIO). Informed consent from each patient enrolled in the study was obtained.

Histopathological Evaluation and Immunohistochemical Staining

Immunohistochemistry (IHC) was performed on formalin-fixed paraffin-embedded (FFPE) tumor sections of GC, 3µm thick. Tissue sections were processed by fully automated detection and staining techniques through Discovery Ultra immunostainer (Ventana Medical Systems, AZ, USA). Slide sections were incubated with the following primary antibodies: anti-SIRT1 (#ab104833; mouse monoclonal, clone 1F3, 1:500, Abcam, Cambridge, UK) and anti-ATM (#ab32420; rabbit monoclonal, clone Y170, 1:100, Abcam, Cambridge, UK). Anti-SIRT1 signals were developed with UltraMap anti-mouse HRP, and anti-ATM with UltraMap anti-Rabbit HRP (Ventana Medical Systems, AZ, USA). The bound antibodies were visualized using Discovery ChromoMap DAB Kit (Ventana Medical Systems, AZ, USA). Finally, sections counterstaining was performed with Haematoxylin II ready-to-use; Ventana, AZ, USA). Healthy human colon for SIRT1 and testis for ATM were used as positive controls. Negative control was performed by replacing the primary antibodies with Mouse IgG1 and Rabbit IgG Isotype Control (Invitrogen). The negative and positive control sections were treated in parallel with the samples in the same run Immunohistochemical expression of SIRT1 was evaluated according to An et al. [17].

The expression score was assessed by combining staining intensity score and the positive percentages. The expression was scored as follows: <10%, 10-24%, 25-49%, 50-74%, and ≥75%. Immunohistochemical expression of ATM was evaluated according to Miller et al. [18]. The staining was evaluated based on nuclear DAB signal, and the intensity score was assessed as: 0 to 3, scaled in 0.25-point increments (0=totally negative; +/3=weak positive; ++/3=moderate positive; +++/3=strongly positive).

Statistical Analysis

Demographic and clinical data, molecular alterations, disease and treatment characteristics were analyzed using descriptive statistics. Statistical comparisons for categorical variables were performed using X2 test. Time-to-event endpoints were described by Kaplan-Mayer curves. Survival distributions for specific subgroups of patients were tested with the log-rank test. A p-value of 0.05 or lower was considered statistically significant. All the analyses were corrected for multiple testing when appropriate and challenged with comprehensive multivariate modeling.

Results

Between September 2017 and April 2022, a total of 42 patients were prospectively and retrospectively enrolled. Twenty-nine were men (69%) and 13 were women (31%) with a median age of 68 years (range 49-79). The primary tumor location was corpus-antrum in 79% of cases and gastroesophageal junction in 21%. A vast majority of the patients (90%) had an optimal performance status (ECOG PS0) at the time of the initial diagnosis. Among the most common presenting symptoms, weight loss more than or equal to 5 kg was reported in 19%. As neoadjuvant treatment, 79% (n=33) of patients had received a taxane-based triplet, while 21% (n=9) received a taxane-free doublet. Postoperative CT was administered in only 50% of cases, due to suboptimal recovery from surgery or postoperative complications, and 85% of them required a dose reduction due to toxicities. In the surgical specimens, lymph node involvement was reported in 50% (n=21) of patients and pT3-4 in 64% (n =27). Clinico-pathological characteristics are summarized in Table 1.

Table 1: Clinical and pathological characteristics of patients

Patients N (%)
Sex

Male

29 (69%)

Female

13 (31%)

Age

Median

68 (range 49-79)

Location

Corpus antrum

33 (79%)

gastroesophageal junction

9 (21%)

Baseline weight loss

No

24 (57%)

< 5Kg

10 (24%)

> 5Kg

8 (19%)

ECOG PS

0

38 (90%)

1

3 (7%)

2

1 (3%)

Type of Surgery

Ivor Lewis

7 (17%)

Partial Gastrectomy

17 (40%)

Total Gastrectomy

18 (43%)

ypN

0

21 (50%)

1

10 (24%)

2

5 (12%)

3

6 (14%)

ypT

0

0 (0%)

1

9 (21%)

2

6 (15%)

3

24 (57%)

4

3 (7%)

Intraoperative metastases

No

39 (93%)

Yes

3 (7%)

Pre-operative Treatment

Platinum-based doublet

9 (21%)

Taxane-based triplets

33 (79%)

Post-operative Treatment

Fluoropirimidine single agent

3 (7%)

Platinum-based doublet

9 (21%)

Taxane-based triplets

21 (50%)

No

9 (21%)

Grading

G1

2 (5%)

G2

23 (55%)

G3

15 (35%)

NA

2 (5%)

TRG Mandard

2

10 (24%)

3

14 (33%)

4

8 (19%)

5

8 (19%)

NA

2 (4%)

Recurrence

No

25 (60%)

Yes

17 (40%)

At the time of the analysis, 16 patients were deceased and 26 patients were still living. Disease recurrence occurred in 40% of patients (n=17). Median DFS was 22.2 months (95%CI 14.9 – NR) and median OS was not reached (95%CI 26.9 – NR). Among the other clinico-pathological factors, univariate analysis showed that weight loss at diagnosis (p=0.03), pathological nodal involvement (p=0.002) and number of neoadjuvant cycles (p=0.03) were significantly associated with DFS. In addition, ypT (p=0.05), ypN (p=0.007), number of neoadjuvant cycles (p=0.0018) and number of adjuvant cycles (p=0.008) were significantly associated with OS. The multivariate analysis confirmed the association between the number of adjuvant cycles and DFS (p=0.018) and OS (0.023) and between the number of neoadjuvant cycles and OS (p=0.042).

A histopathological review was performed by dedicated pathologists focusing on the assessment of tumor regression grade (TRG) according to Mandard. As reported in Table 1, TRG 2 was reported in 24% of cases (n=10) and TGR 3 was reported in 33,3% (n=14), while both TGR 4 and TGR 5 were described in 19% of cases (n=8). Then, we assessed whether TRG was associated with survival outcomes. Consistent with the literature, DFS was significantly longer in patients achieving TRG 2-3 compared with those achieving TRG 4-5 (median DFS not reached vs. 14.9 months; HR=0,36 CI=0,14-0,97; p=0.034) and a trend toward a better OS was also observed across the two subgroups (median OS not reached vs. 26.9 months; HR=0,39; CI=0,14-1,11; p=0.068) (Figures 1 and 2).

fig 1

Figure 1: DFS in GC patients achieving TRG 2-3 vs TRG 4-5

fig 2

Figure 2: OS in GC patients achieving TRG 2-3 vs TRG 4-5

We evaluated the expression of ATM and SIRT1 in the surgical specimens by IHC. Although optimal ATM staining cutoffs were controversial, according to Kim et al. the criteria for negative cases were set as less than 10% of cells stained as weak positive (+/3) or higher intensity, that is, more than 90% of cells showing totally negative (0) or equivocal staining (±) [15]. For example, if more than 90% of tumor cells showed equivocal (±) or negative (0) staining and less than 10% showed any positive (+, ++ or +++/3) staining, a case was defined as negative (Figure 3).

fig 3

Figure 3: Representative H&E images and IHC of ATM and SIRT-1 expression in GC specimens. Representative images of GC patient with 0 ATM score, 3 SIRT1 score, and TRG of 2 (A); representative images of GC with 3+ ATM score, 0 SIRT1 score, and TRG of 5 (B); representative images of GC with ATM and SIRT1 score 0, and TRG of 5 (C); representative images of GC with 0 ATM score, 1 SIRT1 score, and TRG of 4 (D); (Magnification ×20, inset ×40; scale bar 100 μm, 50 μm, respectively).

Accordingly, as reported in Table 2, ATM score was 0 in 16/42 cases (38%), 1+ in 16/42 (38%), 2+ in 7/42 (17%) and 3+ in 3/42 (7%).

Table 2: ATM and SIRT1 expression

Patients N (%)

ATM

0

16 (38%)

+/3

16 (38%)

++/3

7 (17%)

+++/3

3 (7%)

SIRT1

<10%

31 (74%)

10-24%

3 (7%)

25-49%

4 (10%)

50-74%

3 (7%)

≥75%

1 (2%)

SIRT1 expression was <10% in 74% of cases, 10-24% in 7%, 25-49% in 10%, 50-74% in 7% and ≥75% in 2% [12]. We then we evaluated the correlations between the expression of ATM and SIRT1 and TRG. Of note, the proportion of patients who obtained a major/medium pathological regression (TRG 2-3) was higher in the ATM-absent subgroup than in the ATM-expressed subgroup (69% vs. 50%; X-squared=6.05; p=0.1) (Figure 4).

fig 4

Figure 4: Mosaic plot including TRG and ATM as variables

In the overall population, OS and DFS did not have a significantly different distribution according to ATM and SIRT1 expressions (OS p=0.4 and p=0.2, respectively; DFS p=0.56 and p=0.81, respectively).

In contrast, in the subgroup of patients with TRG 4-5, usually characterized by poor prognosis, the absence of ATM expression seemed to be a positive prognostic factor. The median DFS in patients whose tumor had TRG 4-5 and absent ATM expression was 32.1 months compared to 7.7 months in those with TRG 4-5 and positive ATM expression (p=0.055). Although not statistically significant, the median OS was numerically higher in the subgroup with ATM-absent than in the subgroup with ATM expression (55.0 months vs. 26.9 months, respectively; p=0.6) (Figures 5 and 6).

fig 5

Figure 5: DFS distribution in patients whose tumor had TRG 4-5 according to ATM expression

fig 6

Figure 6: OS distribution in patients whose tumor had TRG 4-5 according to ATM expression

Furthermore, among patients with TRG-high and ATM-expressed, those with SIRT1 <10% had a median DFS of 12.7 months, which was significantly inferior if compared with the entire population (median DFS not reached; HR=0.31; CI=0.11-0.91; p=0.024) (Figure 7).

fig 7

Figure 7: DFS distribution between TRG-high/ATM-expressed/SIRT1-absent profile vs other profiles

This difference was partially sustained by the positive prognosis of TRG-low patients. Therefore, excluding patients with TRG-low, the TRG-high/ATM-expressed/SIRT1-absent profile was associated with a trend toward a lower DFS compared with other TRG-high patients (median DFS 12.7 months vs. 32.1 months; p=0.32) (Figure 8).

fig 8

Figure 8: DFS distribution between TRG-high/ATM-expressed/SIRT1-absent profile vs TRG-high subgroup

Discussion

Since the perioperative treatments have become the standard of care for a vast majority of patients with cT2 or higher and/or nodal-positive resectable GC, the identification of new prognostic and predictive biomarkers is an urgent need. ATM expression has been extensively studied with conflicting results [19-21]. Kelmpner et al. did not show any association between ATM expression and clinico-pathological factors and any impact on prognosis from ATM profiles in a cohort of patients who were treated with first-line XELOX for advanced GC [20]. In contrast, in a study of Kim et al., a low ATM expression was associated with older age, advanced stage, MSI, and lower DFS and OS in patients who underwent radical surgery for resectable GC. In this study, the worst prognosis was exhibited by the subgroup which had low ATM expression and MSS [21]. Although the setting was similar to our study, the patient population of Kim and colleagues received upfront surgery followed by adjuvant CT in 50% of cases, while all our patients received neoadjuvant CT followed by surgery, and this may have contributed to a different ATM expression and prognosis. In our study, patients with ATM-expressed cancer after neoadjuvant CT were more frequently associated with TRG 4-5 and, consequently, had a worse prognosis. Although the real reason remains largely unknown, we can suppose that high expression of ATM, playing a crucial role in the repair of DSBs, may offer a highly efficient mechanism of repair from damages induced by CT, radiation, oxidative stress, and stochastic events [11]. As previously described, repair of DSBs involves an extensive network of signals, including a synergism between ATM and SIRT1 with epigenetic implications [11-13]. To date, the role of epigenetic alterations and changes during CT is debated. An extensive knowledge of epigenetic mechanisms underlying prognosis and treatment response could produce new promising epigenetic strategies for GC treatment [22]. SIRT1 contributes to several processes involving GC development, invasion, and metastatic spread. In preclinical studies, knockdown of SIRT1 promoted GC cell migration and invasion in vitro and metastasis in vivo. Among genes downregulated by SIRT1, ARHGAP5 has been identified as an independent prognostic marker of GC [23-25]. As previously described, SIRT1 has an ambiguous role acting both as tumor suppressor and tumor promoter [12,13]. An et al. explored the role of SIRT1 expression in chemoresistance of GC both in vitro and in vivo. They showed that SIRT1 had inhibitory activity on chemoresistance and eliminated cancer stem cell properties [17]. Several retrospective studies suggested a negative prognostic impact of SIRT1-high profile than SIRT1-low, but the prognostic role of SIRT1 expression remains unclear. In a study by Noguchi et al, patients with SIRT1-high GC had a shorter cancer-specific survival than patients with SIRT1-low GC [26,27]. Similarly, Zhang et al. showed that low SIRT1 expression was associated with better outcomes both in patients with advanced GC and in those with early-stage GC [28]. In contrast, Kang et al. reported a positive prognostic effect from SIRT1 expression in a cohort of 452 patients who received surgery for GC. In this study, SIRT1-high profile was associated with more favorable clinicopathological features, including intestinal histotype, lower grade, and lower pT and pN stage [29]. In our study, among patients with poor prognosis (TRG-high and ATM-expressed), a numerically lower DFS was observed in the SIRT1 <10% group than in the SIRT1 ≥10% group. Although statistical significance was not reached, we can speculate that a complete loss of SIRT1 expression could be associated with inhibition in reversing chemoresistance and amplification of the negative prognostic effect of ATM-high profile which efficiently repairs chemotherapy-induced DNA damage. This hypothesis is consistent with a study by An et al. [17], in which silencing of SIRT1 facilitated resistance to 5-fluorouracil and cisplatin.

Regarding limitations, our study included only patients of European origin and the comparison with studies carried out in Asia might be precluded by the geographic heterogeneity in pathological features of GC. In addition, the limited sample size could have induced us to underestimate small differences or subgroup effects. Availability of pretreatment biopsies would have contributed to a better interpretation of the results.

In conclusion, the role of ATM and SIRT1 expression in resected GC patients has not been thoroughly explored and could be of interest for the generation of hypotheses that warrant a future prospective validation in larger clinical trials. This study confirms TRG as a surrogate of survival and suggests an association between ATM expression and TRG. The TRG-high/ATM-expressed/SIRT1-absent profile tends to be associated with a poor prognosis and merits study as a stratification marker after neoadjuvant CT.

Funding

No financial funding was received.

Availability of Data and Materials

All data generated or analyzed during this study are included in this published article.

Competing Interests

The authors declare that they have no competing interests.

Abbreviations

ATM: Ataxia Telangiectasia Mutated; CT: Chemotherapy; DFS: Disease-Free Survival; FFPE: Formalin Fixed Paraffin-Embedded; FLOT: 5-Fluorouracil, Oxaliplatin, Docetaxel; GC: Gastric Cancer; HDAC: Histone Deacetylase; IHC: Immunohistochemistry; MSI: Microsatellite Instability; MSI-H: Microsatellite Instability-High; MSS: Microsatellite Stable; OS: Overall Survival; pCR: Pathological Complete Response; SIRT1: Sirtuin-1; TRG: Tumor Regression Grade

References

  1. Ferlay J, Colombet M, Soerjomataram I, et al. Estimating the global cancer incidence and mortality in 2018: GLOBOCAN sources and methods. Int J Cancer. [crossref]
  2. Roviello G, Fancelli S, Gatta Michelet MR, et al. TAS-102 in gastric cancer: Development and perspectives of a new biochemically modulated fluroropyrimidine drug combination. Crit Rev Oncol Hematol [crossref]
  3. Janjigian YY, Shitara K, Moehler M, et al. First-line nivolumab plus chemotherapy versus chemotherapy alone for advanced gastric, gastro-oesophageal junction, and oesophageal adenocarcinoma (CheckMate 649): a randomised, open-label, phase 3 trial. Lancet. [crossref]
  4. Giommoni E, Lavacchi D, Tirino G, et al. Results of the observational prospective RealFLOT study. BMC Cancer. [crossref]
  5. Al-Batran SE, Homann N, Pauligk C, et al. Perioperative chemotherapy with fluorouracil plus leucovorin, oxaliplatin, and docetaxel versus fluorouracil or capecitabine plus cisplatin and epirubicin for locally advanced, resectable gastric or gastro-oesophageal junction adenocarcinoma (FLOT4): a randomised, phase 2/3 trial. Lancet. [crossref]
  6. Nappo F, Fornaro L, Pompella L, et al. Pattern of recurrence and overall survival in esophagogastric cancer after perioperative FLOT and clinical outcomes in MSI-H population: the PROSECCO Study. J Cancer Res Clin Oncol. [crossref]
  7. Lavacchi D, Fancelli S, Buttitta E, et al. Perioperative Tailored Treatments for Gastric Cancer: Times Are Changing. Int J Mol Sci. [crossref]
  8. Al-Batran SE, Hofheinz RD, Pauligk C, et al. Histopathological regression after neoadjuvant docetaxel, oxaliplatin, fluorouracil, and leucovorin versus epirubicin, cisplatin, and fluorouracil or capecitabine in patients with resectable gastric or gastro-oesophageal junction adenocarcinoma (FLOT4-AIO): results from the phase 2 part of a multicentre, open-label, randomised phase 2/3 trial.
  9. Pietrantonio F, Miceli R, Raimondi A, et al. Individual Patient Data Meta-Analysis of the Value of Microsatellite Instability As a Biomarker in Gastric Cancer. J Clin Oncol. [crossref]
  10. Raimondi A, Palermo F, Prisciandaro M, et al. TremelImumab and Durvalumab Combination for the Non-OperatIve Management (NOM) of Microsatellite InstabiliTY (MSI)-High Resectable Gastric or Gastroesophageal Junction Cancer: The Multicentre, Single-Arm, Multi-Cohort, Phase II INFINITY Study. Cancers (Basel). 2021 Jun 7;13(11): 2839. doi: 10.3390/cancers13112839. PMID: 34200267; PMCID: PMC8201030.
  11. Choi M, Kipps T, Kurzrock R. ATM Mutations in Cancer: Therapeutic Implications. Mol Cancer Ther. 2016 Aug;15(8): 1781-91. doi: 10.1158/1535-7163.MCT-15-0945. Epub 2016 Jul 13. PMID: 27413114.
  12. Alves-Fernandes DK, Jasiulionis MG. The Role of SIRT1 on DNA Damage Response and Epigenetic Alterations in Cancer. Int J Mol Sci. [crossref]
  13. Dobbin MM, Madabhushi R, Pan L, et al. SIRT1 collaborates with ATM and HDAC1 to maintain genomic stability in neurons. Nat Neurosci. [crossref]
  14. Kang B, Guo RF, Tan XH, et al. Expression status of ataxia-telangiectasia-mutated gene correlated with prognosis in advanced gastric cancer. Mutat Res. [crossref]
  15. Kim HS, Kim MA, Hodgson D, et al. Concordance of ATM (ataxia telangiectasia mutated) immunohistochemistry between biopsy or metastatic tumor samples and primary tumors in gastric cancer patients. Pathobiology. 2013;80(3): 127-37. doi: 10.1159/000346034. Epub 2013 Jan 15. PMID: 23328638.
  16. Edge SB, Compton CC. The American Joint Committee on Cancer: the 7th edition of the AJCC cancer staging manual and the future of TNM. Ann Surg Oncol. [crossref]
  17. An Y, Wang B, Wang X, et al. SIRT1 inhibits chemoresistance and cancer stemness of gastric cancer by initiating an AMPK/FOXO3 positive feedback loop. Cell Death Dis. [crossref]
  18. Miller RM, Nworu C, McKee L, et al. Development of an Immunohistochemical Assay to Detect the Ataxia-Telangiectasia Mutated (ATM) Protein in Gastric Carcinoma. Appl Immunohistochem Mol Morphol. [crossref]
  19. Bhangoo MS, Luu HY, Kim ST, et al. Low ATM expression is associated with improved progression-free and overall survival in advanced gastric cancer patients treated with platinum-based chemotherapy [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2018; 2018 Apr 14-18; Chicago, IL. Philadelphia (PA): AACR; Cancer Res 2018;78(13 Suppl):Abstract nr 5543.
  20. Klempner SJ, Bhangoo MS, Luu HY, et al. Low ATM expression and progression-free and overall survival in advanced gastric cancer patients treated with first-line XELOX chemotherapy. J Gastrointest Oncol. [crossref]
  21. Kim JW, Im SA, Kim MA, et al. Ataxia-telangiectasia-mutated protein expression with microsatellite instability in gastric cancer as prognostic marker. Int J Cancer. [crossref]
  22. Sato H, Niimi A, Yasuhara T, et al. DNA double-strand break repair pathway regulates PD-L1 expression in cancer cells. Nat Commun. [crossref]
  23. Gigek C, Wisnieski F. Epigenetic mechanisms in gastric cancer. Epigenomics (2012) 4(3), 279–294.
  24. Canale M, Casadei-Gardini A, Ulivi P, et al. Epigenetic Mechanisms in Gastric Cancer: Potential New Therapeutic Opportunities. Int J Mol Sci. [crossref]
  25. Vaziri H, Dessain S, Eaton EN, et al. hSIR2(Sirt1) functions as an NAD-dependent p53 deacetylase. 2021. Cell 107(2): 149-59. Doi: 10.1016/S0092-8674(01)00527-X.
  26. Dong G, Wang B, An Y, et al. SIRT1 suppresses the migration and invasion of gastric cancer by regulating ARHGAP5 expression. Cell Death Dis 9, 977 (2018). https://doi.org/10.1038/s41419-018-1033-8.
  27. Noguchi A, Kikuchi K, Zheng H, et al. SIRT1 expression is associated with a poor prognosis, whereas DBC1 is associated with favorable outcomes in gastric cancer. Cancer Med. [crossref]
  28. Zhang S, Huang S, Deng C, et al. Co-ordinated overexpression of SIRT1 and STAT3 is associated with poor survival outcome in gastric cancer patients. [crossref]
  29. Kang Y, Jung WY, Lee H, et al. Expression of SIRT1 and DBC1 in Gastric Adenocarcinoma. Korean J Pathol. [crossref]

The Effects of Unprofessional Conduct in Daily Work and How We Can Correct Them

DOI: 10.31038/IJNM.2023434

 
 

Each individual selects a domain to work in, according to their intellectual capacity, preferences, and ability to perform the duties imposed by chosen areas. Attaining expertise in that field, the art of transferring knowledge in practice, skills in collaborating with colleagues, partners, customers and their families, and other community members, and building a respectful, trustful, and merciful relationship with them are fundamental factors for a successful professional and social life, ensuring societal development and public health and define professionalism. The evidence in clinical practice highlights unprofessionalism’s adverse effects on people’s health, and a proposal for corrective actions to attenuate and prevent them is necessary. Sometimes, individuals with various backgrounds were assigned to positions that did not align with their preparation, except for a medical stance. Untrained for their new role, and misunderstanding and applying it in practice has generated errors, their product defect determining dissatisfied end-users, a decrease of imports /exports of goods or services prepared for, and a decline of investment return, finally affecting practice efficiency, personal reputation, and collaborator’s health. Therefore, additional training and flexibility in a modern environment are necessary. It’s important to have versatile, creative, and optimistic individuals who embrace novelty for job improvement. Otherwise, there may be personal and social disorders during the production process and risks to people’s health. The inflexibility in public relations has a detrimental effect on professional work effectiveness, altering the emotional and social life of collaborators. The mistakes are common, but they must be quantified and their impact on the individual and community members analysed. Professionalism in dealing with intentional or unintentional errors or abuse in daily work is also required.

Research in clinical practice has shown that improper communications between business partners can hurt vulnerable individuals involved in such affairs; usually, aggressive, inappropriate words’ energy use modifies an individual’s energetic picture in motion, finally altering blood flow through the vessels and cells’ function in fragile areas. Repetitive exposure to such unsafe interactions can cause sleep disruption, depression, dyslipidaemia, hyperglycaemia, high blood pressure, and even brain haemorrhage in people at risk. Therefore, the promotion of practical communication skills for the sake of public health is mandatory. Continuous education, prompt and precise responses in clinical practice, working in a comforting atmosphere, building confidence in social interactions, cultivating positive habits, and upholding professional conduct that aligns with social norms ensure a successful career and a prosperous personal, professional, and social life.

Business continuity and development in a competitive and dominant digital world are desired; in the digital age, personal info quickly spreads, offering alternative options for collaborators if disappointed by a supplier.

Professionalism is essential for enhancing practice efficiency, promoting social progress, and improving public health. Teaching and applying it across all global industries is at the forefront of individual life quality improvement. By acting professionally, one can become an admired licensed person who receives people’s gratitude and respect from the community they serve. Attaining excellence in job performance, as an ideal, soothes the mind and heart outlook transitioning a relative and perceptible –audible and visible world.

Community and Home Based Palliative Care Services: The Key to Equitable Access to Healthcare Services

DOI: 10.31038/IDT.2023412

Abstract

Community and home based palliative care services are gaining more recognition especially now where primary health care is important for equitable access to healthcare services. Hospice Africa Uganda has exemplified the use of community and homebased care services to reach to the underprivileged populations and this approach is being adopted by a community initiative called, Lweza Community Health Program to promote primary health care. Through this approach, patients with serious illness including those with infectious diseases have been identified, initiated on treatment and are being followed up in the community. This approach has helped to bridge the divide between the rich and the poor but also helped to address other social-cultural factors which influence the health of individuals and communities. It is hoped that the community initiative will become a model for many communities in Africa to improve equitable access to healthcare services in communities.

Introduction

As a clinical discipline, palliative care relies on the collaboration of professionals, such as nurses, physicians and social workers, who have a fundamental role in running the team. Furthermore, primary care personnel – which includes family physicians, medical specialists, paediatricians, geriatricians, general practitioners, nurses from a variety of settings (home care, community care), social workers, pharmacists, physiotherapists, occupational therapists and volunteers – have a central function in this arena [1].

For communities, this requires a cooperative approach between the primary care and palliative care practitioners, both within the community and among experts in the hospital. It is these primary care professionals, who have core competencies in palliative care and access to specialist palliative care teams, who should manage the care of patients and families.

To date, most physicians in the community feel ill-prepared to deal with patients with palliative care requirements, due to their lack of training in pain and symptom management as well as the psychological issues that befall patients and their family caregivers. Thus, the most urgent need is to train physicians, nurses and social workers in the community to be able to practice basic palliation care principles [2].

One critical element that must be made available in order to support caregivers is the access to skilled homecare nursing, 24/7 [1]. Utilizing other providers, such as paramedics trained in palliative care, could fill some of the voids where round-the-clock home visits are not feasible.

Palliative care nurses have a pivotal role in community palliative care services. Not only do they treat, advise and help with ongoing treatment, they also assist in coordinating appropriate and timely care in the various institutions that are able to provide the appropriate treatment. In straight-forward situations, the palliative care nurses may simply advise the primary care physicians after consulting with a palliative care specialist. Unfortunately, the recommendations for the staffing of a palliative care team in the community are not yet applicable for the developing world. It is the profession’s obligation to ensure equitable availability of palliative care for rural and other vulnerable populations [3]. Let us not forget that the goal of palliative care is not just to improve the quality of life, but even more so to alleviate suffering for all patients with a serious illness be it an infectious disease. Thus, alleviating the suffering, be it physical or emotional, should guide us throughout the continuum of care.

The initial step in alleviating patients’ suffering is pain control. All those working in the field have experienced how unrelenting, agonizing pain impacts individuals and families and the magnitude of the hardship it engenders.

By and large, there is still very limited access to medication for moderate and severe pain in most low- and middle-income countries, worldwide. Under-treatment of severe pain is reported in more than 150 countries, accounting for about 75 percent of the world’s population, thereby creating profound global health inequity [4].

As already mentioned, in the greater part of the world there is an urgent need for basic palliative care services in the community; one important reason for this is the insufficient awareness of palliative care among primary healthcare providers as well as the extreme shortage of palliative care specialists in each region.

More recently, an innovative intervention – Project Extension for Community Healthcare Outcome – Palliative Care in Africa (ECHO-PACA) – was conducted in several sub-Saharan countries. One of the important things learned was the necessity to reach out to the primary care providers in the community and to develop a curriculum and guidelines for best practices, based on local palliative care requirements [5].

Our story describes the gradual development of community-home care services in Uganda. It tells, first-hand, of the arduous, yet successful and praiseworthy palliative care experiences owing to the endless devotion, endurance, goodwill and compassion of a dedicated physician and her nurse.

Our Personal Story

Having worked in Palliative Care for over 28 years, Dr. Anne Merriman introduced Palliative Care (PC) to Uganda through Hospice Africa Uganda (HAU), its goal being to reach “all in need of palliative care in Africa”. Hospice Africa Uganda is now a model for Palliative Care services in all of Africa. During her 40 years in Africa, Dr. Merriman has travelled through many African countries, primarily LMIC’s, and realizes that each country has its unique traditions.

Although Uganda was one of the poorest countries in Africa in the early 1990s and was just out of a long war, the people were so caring. The country had one of the lowest rates of corruption. Now, 30 years later, many things have changed. The divide between the rich and poor has increased, the population has doubled and, unfortunately, the caring spirit for each other (traditionally arising from “ubuntu”, meaning “humanity”) has declined. Those who have been blessed with greater financial wealth often have the attitude of caring only for oneself and lesser values when it comes to caring for the less fortunate. This is the situation in many African countries today.

With billions of people in the world falling under the poverty line, access to good quality health care services is becoming impossible despite the great advances in medicine. Quality, yet genuine, healthcare services are only available to the few lucky ones who can afford it. Most patients have to travel miles and miles to reach these services. The poor have been left to suffer in the hands of “quacks”. The little savings they are able to accrue goes to out-of-pocket payment for medical bills, yet the services received are often substandard and predisposes them to more ill health. It is for such reasons that the poor are now shunning hospital-based care and are seeking cheaper, friendlier and more accessible interventions in the community. Community health systems must therefore prioritize the needs of the poor.

As a Sister in charge of a gynaecology ward, Rose (the first HAU nurse, in 1993) had witnessed the unbearable suffering of patients with advanced cancer disease. Patients were in pain and some had a foul smell stemming from the fungating tumour. In such agony, doctors on ward rounds discharged these patients to go home telling them, “Nothing more can be done.” Rose wondered, what then happens to these patients when they go home in such agony? The needs of these suffering patients were as paramount then as they are today.

Rose left a promising Hospital Nursing career and, with much opposition, in 1993 joined the new Hospice Africa Uganda, travelling daily to local communities and providing professional palliative care within the homes. She was always mindful to adapt her care to the specific culture, economy and the tribe to which they belonged, while also respecting the spiritual and traditional beliefs of each family.

Although Dr. Anne had already worked in Nigeria for 10 years, the Ugandan culture was so different and there was so much to learn from Rose. So while Rose was learning from Anne, Anne was learning from Rose!

In Uganda, where 95% of those who are stricken with cancer cannot access treatment, there is an especially heavy burden on poorer families. These families are left abandoned as they watch a loved one writhing in pain, many times suffering in isolation due to the unpleasant smells that result from disease and decay. Simply attempting to attain a cancer diagnosis may throw the family into further poverty, no longer able to afford food; children stop attending school, as every penny is put toward reaching a cancer cure. The few who are able to pay for a biopsy then find that they cannot afford the cost of treatment, and are often sent home.

Community health funding is based on statistics – but are the cancer statistics realistic when they are often based on the number of biopsies and diagnoses which are unaffordable for most? When birth and death certificates are not mandatory in many parts of Africa?

By 1993, a new disease known locally as “Slim” due to a resistant fungal infection in the oesophagus which prevented eating due to pain on swallowing, was obvious wherever Dr. Anne and Rose went. This was HIV, and the pain associated with many opportunistic infections was often severe and uncontrolled. Over 30% of Uganda’s population was infected by HIV and the incidence of cancer had doubled.

What could be done to alleviate the suffering of these patients, as well as those in the community? Dr. Anne introduced the affordable formula for oral morphine for home use. With support from then the presiding Minister of Health, Dr. James Makumbi, the importation of morphine into Uganda for reconstitution in the pharmacy was endorsed. Dr. James said, “My people are suffering… you are welcome. Please come immediately.” Patients with moderate to severe pain have since been given the green liquid oral morphine, many of whom now call it the “magic” medicine as it has greatly relieved unnecessary suffering. Patients are now free of pain and “living until they die”, counting it as a true miracle. This drug has since modified pain control throughout Africa, albeit only in those countries that have overcome the myths and fears perceived by governmental officials and senior doctors who have never heard of palliative care and who equate using oral morphine with euthanasia. Beginning with only three countries in 1993, 37 African countries have been supported by HAU and are currently offering palliative care, besides 11 of them are now using the Merriman formula to reconstitute their own oral liquid morphine.

Looking at these advances, how can our medical students understand their own country’s needs, so distant from Western standards where health services reach nearly all, when they are trained in hospitals that use Western recommendations? How can international organisations, sometimes staffed by those who have never lived or worked in African countries, understand the local culture and make vital decisions affecting those communities on a daily basis? These are questions that must be considered.

In 1994, Dr. Anne, Rose and a medical student from UK studied pain in HIV and applied the treatment methods tried and proven for cancer to HIV pain management. They were careful to withdraw the pain treatment when the infection was under control. Realizing their success, they began teaching ‘pain management’ to health professionals, undergraduates and postgraduates of University Medical and Hospital Nursing schools.

Rose has now retired after 27 years in palliative care. She and her daughter, Dianah (currently a Nurse Trainer at Hospice Africa Uganda and a Lecturer at Uganda Christian University) are exemplifying the use of a community-based care approach to reach out to patients in their community by riding on the “ubuntu,” a spirit that has been in existence in Uganda for many years. The two have started a Community-Based Organization called Lweza Community Health Program (LCHP) with a vision towards a healthy, informed and productive community. The LCHP was established in April 2020, at a time when the country was under a total lock-down as a result of COVID-19 restrictions, and has registered a number of successes in its short existence. The organization has adopted some ideas from the community-based approach of HAU and tailored them to the needs of its community by strengthening Primary Healthcare to ensure that even the poorest patients can access quality medical healthcare services. This approach is destined to be a model for other areas within Uganda and, possibly, throughout Africa and beyond, but it is still in its early days.

Rose and other LCHP members have mobilized community volunteers and health workers living in the village to attend to the needs of patients. The healthcare providers work with community volunteers who go door-to-door, identifying patients in the community and offering them appropriate support.

During the home visits, the LCHP team has learnt that some patients attribute their illness to witchcraft or traditional or spiritual beliefs and, thus, do not see the benefit of modern medicine. As a result of these beliefs and the costs attached to diagnosis, some patients have not had the opportunity to get a proper diagnosis. The interface with the LCHP health worker is sometimes the first opportunity for them to consult a qualified health worker.

It was also evident that it is not only diseases that affect the health of members in Lweza community. There are a number of elements that determine the well-being of individuals, ranging from poverty, overcrowding, especially where large families are cramped into tiny dwellings without adequate facilities for privacy or protection for teenagers and women, mental illness as a result of substance abuse, child abuse, gender-based violence, which is not surprising in a traditionally male-dominated society, as well as other social problems. With all these issues and many more, where does one start? The solution was to get the backing of the community and work with the local leaders.

In 2021, Dr. Anne attended one of the medical health camps organized by Lweza Community Health Program. The camp was funded primarily by the local community and was hosted in a resident’s compound. It was a three-day camp and thirteen governmental and private health institutions provided Free services to everybody who sought them. Services included screening for; tuberculosis, heart disease, diabetes, HIV, cancers, including breast, cervix and prostate, eye problems, hepatitis B and vaccination. Other services provided were: family planning, blood donation, orthopaedic assessment, nutritional education, general counselling, legal health services, spiritual counselling and palliative care sensitization.

The camp attracted over six hundred people from not only Lweza, but also from neighbouring villages. A number of people were identified with health issues, especially hypertension, which they were not aware of previously. Those who were identified with health issues were advised on where to get health services; the LCHP team continues to guide, encourage and liaise with the health care workers in various health facilities to ensure that they get the necessary services. This has now become an annual activity for LCHP and the number of participants and service providers to the event have gradually increased. The LCHP has been contacted by other communities and has since inception been privileged to support in organizing three other community health camps in other regions of Uganda.

Dr. Anne was privileged to be the only m’sungu (white person) in the 2020 LCHP health camp. She attended the camp with a child survivor of Hospice Africa Uganda, Cathy, who had suffered a terrible tumour that, in spite of being classified histologically as non-malignant, had invaded her spine and, on several occasions, almost cost her life. Furthermore, the steep health care expenses that began to accrue six years prior, when Cathy was diagnosed at 14 years of age, had also cost the family all of their properties and personal income and caused the interruption of education for her two siblings. Despite being extremely disabled, Cathy shared a heart-rending speech in the local language to the attendees, inspiring others with her hope for her own future as well as theirs. She encouraged the attendees to embrace early screening for diseases and she touched many hearts present.

While treating diseases, LCHP members find it paramount to also address the issues that promote ill health in the community as these are major determinants to the success of any intervention. The LCHP performed a needs assessment and the main issues affecting the community identified were found to be: poor sanitation; domestic violence, child abuse/neglect, substance abuse and youth unemployment.

The LCHP, working with the local council leaders of the village, has continued to address these issues. The first undertaking was to keep the surroundings clean in order to prevent diseases that arise from poor sanitation. The community members are mobilized, sensitized and motivated through communal participation and empowered to keep their surroundings clean through bi-weekly community cleaning known locally as Bulungi Bwansi, when every person takes part in cleaning public areas and shares responsibility for maintaining a healthy and clean environment.

Some of the victims of substance abuse were identified and are now undergoing rehabilitation. A few cases of child abuse were identified and referred to legal aid services and other supportive organizations, in addition to ensuring that they are reunited with their parents.

Although there is still so much to be done to realize LCHP’s vision, the results so far are very promising. The good traditional values of the local community such as “ubuntu” are regaining ground and need to be preserved if the community health care approach is to be successful.

Local community health workers must be recognized as the experts for designing culturally appropriate community-based health care programs and should be empowered to own them.

Discussion

Palliative care is gaining ground globally and is endorsed in high-level policy commitments, however service provision, supporting policies, education and funding are incommensurate with rapidly growing needs. Uganda, along with only three other African countries (Kenya, South Africa and Zimbabwe), have reached level 4a, indicating that hospice-palliative care services reached the stage of preliminary integration into mainstream service provision [6]. Hence, Uganda has succeeded in developing a critical mass of palliative care activism in a number of locations; awareness of palliative care on the part of health professionals and local communities; the availability of morphine; the provision of a substantial number of training and education initiatives by a wide range of organizations; and the existence of a national palliative association.

In Uganda, like many developing countries, cultures have expressly prohibited informing patients of their diagnosis and prognosis at all stages of the disease (cancer, HIV) [7]. With time and training, views have been changing to the point where there is now some acceptance of idea that patients should be informed of their real condition and, accordingly, be given the opportunity to take a more active role in decisions related to their treatment planning.

The global COVID-19 pandemic was an eye opener for the increased need for palliative care services and resilient health care systems. The number of lives lost throughout the world to the coronavirus is a harsh reminder of the necessity to ensure that care, especially at the end of life, is a priority for healthcare providers, regardless of their geographical location and health system [8].

Unfortunately, inequities still remain in the provision of palliative care, both among and within countries, especially in the community. The majority of those needing palliative care, worldwide, continue to be those with non-malignant conditions. While traditionally associated with the care of people with cancer, palliative care should be available to all who need it, regardless of their diagnosis, particularly children and the elderly [9,10].

Let us reiterate that compassionate communities play an important role in access to palliative care, wherever they may be, by providing the required care, e.g. volunteer community caregivers and family members. It is especially important to understand and address the particularly gendered nature of caregiving, which falls upon women and girls in communities and families, without recompense, support or equipment, all contributing to ongoing gender inequalities [11].

In our efforts to treat individuals with cancer and to understand how to provide the best possible care to underserved populations, we must first acknowledge cultural diversity. Each culture is comprised of language, religion, social norms, history, tradition and spirituality. By recognizing each patient’s particular spiritual and cultural beliefs, and by utilizing all available approaches, we can help to improve care outcomes and, in turn, patients’ access and adherence to treatment [12].

References

  1. Henderson JD, Boyle A, Herx L, Alexiadis A, Barwich D, et al. (2019) Staffing a Specialist Palliative Care Service, a Team-Based Approach: Expert Consensus White Paper. J Palliat Med. [crossref]
  2. Silbermann M (2021) Preface: In Palliative Care for Chronic Cancer Patients in the Community: Global Approaches and Future Applications (Silbermann, M. ed.) Springer-Nature, Switzerland.
  3. Khan CP, Parver S, Lesch JK, DiGioia K, Gaglio B, et al. (2019) Comparative Clinical Effectiveness Research Focused on Community-Based Delivery of Palliative Care: Overview of the Patient-Centered Outcomes Research Institute’s Funding Initiative. J Palliat Med. [crossref]
  4. Knaul FM, Farmer PE, Krakauer EL, et al. (2018) Alleviating the access abyss in palliative care and pain relief-an imperative of universal health coverage: the Lancet Commission report. The Lancet. [crossref]
  5. Yennurajalingam S, Amos CE, Weru J, Opare-Lokko E, Arthur JA, et al. (2019) Extension for Community Healthcare Outcomes-Palliative Care in Africa Program: Improving Access to Quality Palliative Care. J Global Oncol. [crossref]
  6. Clark D, Centeno C, Clelland D, Garralda E. Lopez-Fidalgo J, et al. (2020) How are palliative care services developing worldwide to address the unmet need for care? In: Global Atlas of Palliative Care (Connor S. ed.) 2nd Edition, London, UK, pp. 45-57.
  7. Brant J, Silbermann M (2021) Global perspectives in palliative care for cancer patients. Not all countries are the same. Current Oncology Reports. [crossref]
  8. Silbermann M, Berger A (2020) The need for a universal language during the COVID-19 pandemic: Lessons learned from the Middle East Cancer Consortium (MECC) Palliative & Supportive Care. [crossref]
  9. Kebudi R, Cakir FB, Büyükkapu SB (2021) Palliative Care in high and low resource countries. Current Pediatric Reviews. [crossref]
  10. Ling J (2020) Forward in: Global Atlas of Palliative Care (Connor S., ed.) 2nd Edition, London, UK. p. 11.
  11. Morris C, Davies H (2020) What is the way forward? In: Global Atlas of Palliative Care (Connor S., ed.) 2nd Edition, London, UK, pp. 92-95.
  12. Silbermann M, Berger A. Preface in: Global Perspectives in Cancer Care: Religion, Spirituality and Cultural Diversity in Health and Healing (Silbermann M and Berger A eds.) Oxford University Press, UK (in press).

Speech-Language Therapy to Improve the Speech- Language Prosody of Clients with Autism

DOI: 10.31038/JCRM.2023624

Abstract

According to the National Autism Association, autism is a bio-neurological developmental disability that generally appears before 3 years of age. This disorder affects normal development of the brain in communication skills and cognitive function. Individuals with autism usually exhibit difficulties in verbal and non-verbal communication, social interactions, as well as leisure and play activities. These individuals may also exhibit other difficulties (e.g., allergies, asthma, sensory integration dysfunction, sleeping disorders, feeding disorders, epilepsy, sleep). “Autism is diagnosed four times more often in boys than girls.” Its prevalence is not affected by race, region, or socioeconomic status.” According to research, mortality risk among individuals with autism is twice as high as the general population, often related to accidents (e.g., drowning, and other accidents). At present, there is no cure for autism, but with early intervention and treatment, the diverse symptoms can be greatly reduced. According to Autism Parenting literature, the individual with autism may struggle with tone, speech rhythm and pitch, and the message or intention related to their words may be misunderstood (11/2/21).

Sentences with Rising Inflections (Raise Pitch at the End of the Sentence)

  1. Do you want to go? 1
  2. Do you like pie? 1
  3. Is your name Michael? 1
  4. Can you ride a bike? 1
  5. Do you have money? 1
  6. Are you going to the movies? 1
  7. Can you help me with math? 1
  8. Did you see that picture? 1
  9. Can you come over tonight? 1
  10. Do you want to go to college? 1

Sentences with Falling Inflections (Lower Pitch at the ends of Sentences)

  1. I’ll never do that again. 2
  2. She really didn’t like the food. 2
  3. I think I’ll go to the movies tonight 2
  4. I’ll never do that again. 2
  5. I’m sorry I bought that. 2
  6. I can’t come to the party next week. 2
  7. We can all enjoy the dessert. 2
  8. I do my exercises every night. 2
  9. The party was not fun. 2
  10. That story is very sad. 2

Below is a Portion of the Poem “A Little Seed” by Mabel Watts

3

Sequencing Pictures to be Described

The couple went into the restaurant.
The waiter brought the menu.
The couple chose their meal.
The waiter brought the food, and the couple ate their meal.
The waiter then brought dessert.
The couple ate the dessert and then left the restaurant.
When the client can produce the content with appropriate prosody, the clinician’s models may be removed, and the client can be presented with verbal material using role playing.

Relate a Short Familiar Story on material which is conducive to pitch variation (e.g., “The Three Bears). For older children, the content can be more mature with material conducive to pitch variation. Once the client is able to use appropriate prosody on content provided by the clinician, the client may relate an experience of his/her own, incorporating the techniques learned. A tape recorder can be used to illustrate to the client positive aspects of his content and to obtain his/her input of what may need improvement.

***A page from the below book was used during therapy with the client and together, the client and the therapist, would gauge where to put the intonations. ***

SOURCE: “President George Washington” by David A. Adler 2005 A Holiday House Book

George Washington was born on February 22, 1732, in a small virginia farmhouse. Virginia was an English Colony, and the People Were Loyal to King George Ii of England. The Washingtons Grew Tobacco, Fruit, And Vegetables on their Farm. Most of the Work Was Done By African-American Slaves. When George Was Seven, He Learned To Read And Write. He Studied Arithmetic Too. It Was His Favorite Subject. He Loved To Fish, Swim, And Hunt. Most Of All He Loved To Ride His Horse. When George Was Eleven, His Father Died, And He Was Now Needed To Help His Mother On The Farm. He Also Helped With His Younger Sister And Brothers. In 1751, George Was 19 Years Old. He Joined The Virginia Army And Became Soldier. The 13 Americ An Colonies Were At War With England Because They Wanted To Be Free Of English Rule. In May 1775, Leaders Of The Colonies Met And Talked About Their Fight With The English. The Leaders Chose Washington To Lead The Fight Against England. Washington’s Army Won Battles In New York And Philadelphia. In 1778, The French Joined The Fight Against England. Washington’s Army Won The Battles In Boston And Trenton. In 1778 M, The French Joined The Fight Against England. There Were Other Battles Too. The Americans And French Beat The English, And The Americans Would Be Free Of English Rule. In September 1783, The Americans And English Agreed To End The Fighting, And A Nation Was Born. The 13 Colonies Became The First 13 States Of The United States of America. President Washington Kept The New Nation At Peace. He Led It For 8 Years Until 1797. Then He Went Home To Virginia. In December 1799, George Washington Became Ill, And He Died That Night. People Everywhere Mourned The Death Of George Washington. It Was Said That George Washington Was “First In War, First In Peace, And First In The Hearts Of His Fellow Citizens.”

Conclusion

The literature on autism confirmed a number of the characteristics displayed by the autistic client about whom the present article was written: The client is an 11-year-old male, diagnosed with autism and recommended for speech therapy, secondary to problems with prosody related to autism: He presented with an excessively slow rate of speech, which incorporated excessive pausing and lack of pitch variation. His articulation, receptive and expressive language were within normal limits for a child of his age. The plan of therapy was to improve his prosody which included appropriate speech rate, speech rhythm, and pitch variation. Therapy began with the use of phrases and then sentences with arrows on words accompanied by clinician’s models in terms of where to raise and lower his pitch appropriately. The clinician first modelled the content for the client and then had him produce the material independently. This article contains the content on which the client practiced, accompanied by indications of where to raise or lower his pitch. Once the client could read these sentences aloud with the appropriate pitch variation, he was given short poems with arrows to depict where to raise or lower his pitch. He was eventually able to read the content without a model and incorporated appropriate pitch variation, speech rate and rhythm, and pausing appropriately. It was reported that he eventually gave a talk at school (one he practiced at home) and was applauded for his presentation. Although the client made a good deal of progress, further practice will continue in terms of using appropriate prosody during spontaneous speech and other speaking activities.

Extra-Pulmonary Mycoplasma pneumoniae Infection in a Healthy 25-Year-Old Female: A Case Report

DOI: 10.31038/JCRM.2023623

Summary

Here we report a case of Mycoplasma pneumoniae (M. pneumoniae) infection in a young, previously fit and healthy female, consisting of multi-system manifestations but no pulmonary symptoms at time of presentation. M. pneumoniae was confirmed by serology testing. The patient made a full recovery after 6 weeks. Simultaneous presentation of acute hepatitis, neutropenia, thrombocytopenia, erythema multiforme, arthralgia, and vomiting is rare and to our knowledge, this is the first case report of this presentation.

Abstract

Introduction: M. pneumoniae is a respiratory pathogen, which commonly causes upper and lower respiratory infections. It primarily affects children and young adults. Respiratory symptoms are well recognised, but extrapulmonary involvement is also common. Other systems that have been implicated in the disease include: skin, mucus membranes, central and peripheral nervous systems, cardiovascular, haematological, renal, musculoskeletal systems. Here, we report a case of an otherwise healthy, young female with M. pneumonia, who presented with right upper quadrant abdominal pain.

Case presentation: A healthy 25-year-old female was referred to A&E by her general practitioner, after presenting with fever, malaise and right upper quadrant pain. M. pneumoniae was confirmed retrospectively by serology. The patient made a full recovery after a six-day course of doxycycline 100 mg.

Conclusion: M. pneumonia is a well-established cause of respiratory infections in children and young adults. A febrile illness with multisystem involvement, even in the absence of respiratory symptoms, should raise suspicion of M. pneumoniae infection in healthy, young adults. Our case illustrates the multi-system involvement of M. pneumoniae, which was initially missed, due to paucity of respiratory symptoms at presentation.

Introduction

pneumoniae is a respiratory pathogen in the class of Mollicutes, which commonly causes upper and lower respiratory tract infection. The bacterium lacks a cell wall and is the smallest self-replicating organism in nature [1-4]. M. pneumoniae is most commonly seen in children and young adults and is transmitted by cough and aerosols, with infected individuals carrying the organism in the nose, trachea and sputum [4]. It has an incubation period of 1-3 weeks and is reported to represent ~15-20% of community acquired pneumonias in adults [2,4]. In England, epidemics peak roughly every 4 years, with the highest prevalence amongst 5-14 year olds [1].

Common upper respiratory tract manifestations include a sore throat, hoarseness, fever, cough, coryza and malaise. Lower respiratory tract infections may manifest with dyspnoea, wheezing and in severe cases, respiratory failure [4].

Extra-pulmonary organ involvement, which have been implicated include cardiovascular, gastrointestinal, haematological, dermatological, renal, musculoskeletal, ocular and neurological systems [1-3]. The exact incidence of extra-pulmonary manifestations is unknown, but some reports estimate that these may occur in up to 25% of cases [1].

A systemic presentation involving several organ systems, with no pulmonary symptoms at presentation, has rarely been reported. We report a case of M. pneumoniae in a previously healthy individual, with no pulmonary symptoms at presentation, but manifested extra-pulmonary symptoms involving several organ systems. Furthermore, routine bloods demonstrated neutropenia, which is an extremely rare extra-pulmonary finding associated with M. pneumoniae.

Case Presentation

A 25 year-old female medical student was referred to A&E by her general practitioner for nausea, vomiting, fever and Right Upper Quadrant (RUQ) pain. The patient complained of a febrile illness, which started 10 days ago, with right upper quadrant pain, which started 24 hours before presentation. The patient’s symptoms initially began with severe headache, photophobia, nausea and one episode of vomiting. These settled overnight and were replaced by a fever that spiked at 40.3°C with malaise, myalgia, tiredness and nausea.

On examination, there was no cough, coryza or pharyngeal changes. Abdominal examination revealed guarding in the right upper quadrant of the abdomen, but spleen and liver were not palpable. The pain was worse on lying down and leaning to the ipsilateral side.

Past medical history included polycystic ovarian syndrome. There was no recent history of travel, vaccinations were all up to date, and to her knowledge, the patient had not been in contact with unwell individuals. The patient was taking regular ibuprofen and paracetamol for symptomatic relief.

On presentation to A&E, the patient was afebrile at 37.3°C, heart rate 97/min, respiratory rate 18/min, blood pressure 110/80 and oxygen saturation 96% on room air. She was alert and comfortable at rest. General examination revealed no pallor, icterus or lymphadenopathy. Throat examination was unremarkable and chest was clear, with equal entry on both sides.

Urine analysis showed very dark urine, with ketones 2+, trace blood and leukocytes+. The patient was treated for suspected cholecystitis with intravenous fluids, antibiotics and analgesia.

Laboratory testing on initial admission demonstrated: white blood cells 2.5 × 109/L, platelets 137 × 109/L, CRP 38 mg/L, bilirubin 14 μmol/L, ALT 83 IU/L, ALP 162 IU/L. Blood tests 3 days later demonstrated a further fall in white blood cells and platelets: white blood cells 3 × 109/L, neutrophils 0.5 × 109/L and platelets 100 × 109/L. On the other hand, hepatic enzymes rose, demonstrating: ALT 294 IU/L and ALP 197 IU/L, GGT 106 IU/L. CRP was 18 mg/L.

Liver Ultrasound Demonstrated No Stones or Cholecystitis

On day 4 of admission, the patient developed a patchy, erythematous rash on her chest, which was neither itchy nor painful. The patient complained of new-onset breathlessness, so a chest X-ray was performed. This was unremarkable. In light of a raised D-dimer and breathlessness, a CTPA was carried out. This demonstrated ground glass opacities in the right lower lobe, prominent hilar lymphadenopathy and multiple sub-centimetre axillary nodes.

A blood film demonstrated reactive lymphocytes and platelet anisocytosis, consistent with a viral infection. Viral screen was negative for HIV, Hepatitis B, Hepatitis C and Hepatitis A. It also demonstrated prior infection with CMV and EBV, but no evidence of acute infection.

A diagnosis of an unspecified viral infection was made. After 3 days, the patient was able to tolerate oral fluids. Blood tests demonstrated an increase in platelets, white blood cells and neutrophil count, with a decline in liver enzymes and CRP. The patient was discharged with a course of oral doxycycline (100 mg per day for 6 days).

Based on the clinical presentation and later serology, a diagnosis of M. pneumoniae was made retrospectively. The patient developed polyarthralgia, enthesopathy and a widespread erythematous rash, consistent with erythema multiforme. These were treated with ibuprofen and 0.1% topical mometasone cream, applied twice a day. The rash responded well to the steroid, and the arthralgia and enthesopathy resolved after 2-3 weeks. The patient made a full and uneventful recovery.

Discussion

We illustrate a case of serologically confirmed M. pneumoniae, which manifested with predominantly extra-pulmonary symptoms. To our knowledge, this is the only reported case presenting with acute hepatitis, bicytopenia (neutropenia and thrombocytopenia), erythema multiforme, arthralgia, and vomiting.

Previously reported extra-pulmonary manifestations include cardiovascular (pericarditis, endocarditis, myocarditis, cardiac thrombi), hepatic, haematological (autoimmune haemolytic anaemia, thrombocytopenic purpura, disseminated intravascular coagulation), dermatological (erythema nodosum, cutaneous vasculitis, erythema multiforme, Steven-Johnsons Syndrome), glomerulonephritis, arthritis, conjunctivitis and neurological symptoms (encephalitis, meningitis, Guillain Barre syndrome) [1-3]. These manifestations may occur before, during or after resolution of respiratory symptoms and usually fully resolve 2-3 weeks after eradication of the respiratory disease. Respiratory symptoms may be minimal or even absent [1-3].

The exact incidence of extra-pulmonary manifestations is unknown, but some reports estimate that these occur in up to 25% of cases [1].

The mechanism behind extrapulmonary involvement remains incompletely understood. Various theories have been postulated, including:

  1. direct attack from the bacterium, involving damage due to host cytokines (especially interleukin-6 and interleukin-8) and secretion of toxic molecules and proteins by the bacterium (including H2O2 and nucleases) [2,4,5]
  2. an indirect autoimmune attack by antibodies and immune complexes [2,4,5],
  3. vascular occlusion involving vasculitis and/or thrombosis [2,4,5],
  4. molecular mimicry between mycoplasma cell wall components and host tissues [2,4].
  5. It has also been suggested that some manifestations may be the result of post-infectious inflammation [4].

In vitro studies have shown that M. pneumoniae can adhere to red blood cells, which may promote dissemination of the organism into other tissues [5].

Our patient developed lymphopenia (0.3 × 109/L) and neutropenia (0.5 × 109/L), which were noted on the day of admission. Whilst haemolytic anaemia has been well documented [1-7], M. pneumoniae associated neutropenia and leukopenia remain extremely rare. To our knowledge, there are currently only 3 other published case reports of this phenomenon and no such phenomenon in an otherwise healthy, young adult.

Barge et al. [8] report a case of an 85-year-old male with exacerbation of COPD and positive serological test for M. pneumoniae. The patient developed transient agranulocytosis. Granulocyte autoantibody testing showed positive IgG and IgM autoantibodies against neutrophils. This was found to produce significant agglutination. The agranulocytosis responded well to granulocyte colony-stimulating factor and the infection was successfully treated with azithromycin. Like our patient, L. Barge et al. describe a mild thrombocytopenia relative to the neutropenia.

The main mechanisms postulated for the haematological manifestations is antibody cross reaction with red blood cells, platelets and white blood cells. The detection of antibodies in patients’ serum supports such autoimmune mechanism [8].

Chen et al. [9] report a case of a 4-year-old, who presented with upper respiratory tract infection symptoms. Serological testing demonstrated M. pneumoniae. The patient was also found to have neutropenia, thrombocytopenia and acute hepatitis. Despite normal haemoglobin on laboratory testing, erythrocyte-bound C3d was strongly positive, as was Coomb’s test. The team also found antiplatelet and antineutrophil antibodies.

Haemolytic anaemia in M. pneumoniae is thought to be due to cold agglutinins [8]. Usually IgM antibodies, these bind to the erythrocyte cell membrane at temperatures below 5°C. This leads to agglutination and haemolysis of the cell, precipitating anaemia. Our patient was not tested for these antibodies.

Thrombocytopenia associated with M. pneumoniae is thought to be due to two main mechanisms: thrombotic thrombocytopenic purpura and direct antibody effects [9]. Chen et al. report a case of M. pneumoniae associated with anti-platelet antibodies and thrombocytopenia. These antibodies were directly associated with platelets. The finding of increased megakaryocyte count in the patient’s bone marrow suggested increased peripheral platelet destruction and thus further supported an autoimmune mechanism.

To our knowledge, this is the first report of neutropenia with a systemic manifestation of M. pneumonia infection. These findings may further our understanding of the heterogenous presentation of the infection.

Our patient also developed transient transaminitis, in keeping with an acute hepatitis picture. This has been estimated to occur in 2-21% of cases [3]. Changes in hepatic enzymes are usually transient, with complete recovery after eradication of the organism. The exact pathogenesis of M. pneumoniae-induced hepatitis is still not understood, but the major mechanisms that are thought to be implicated include molecular mimicry between mycoplasma cell components and hepatic cell surface molecules and direct invasion of the liver by the pathogen [2,4]. It has been further suggested that early-onset hepatitis may be more likely due to direct mechanisms, whereas late-onset hepatitis may be more likely due to vascular injury [5].

Skin changes may be seen in 10%-25% of cases and is thought to be due to a combination of immune complex-mediated vascular injury, cell-mediated damage and autoimmune mechanisms [4,6]. Cutaneous manifestations are heterogeneous and can be confluent or confined to specific areas. Most common cutaneous presentations include maculopapular, vesicular, erythema multiforme and urticarial lesions [1-3,6]. These are generally self-limiting and associated with excellent clinical prognosis. Rarer and more serious presentations include Stevens-Johnson syndrome and toxic epidermal necrolysis [6].

The pathogenesis of cutaneous manifestations associated with M. pneumoniae is not fully understood, but some have postulated a combination of mechanisms including type III immunological hypersensitivity, immune complex deposition and immune cell infiltration, fragmentation and nuclear debris deposition [6]. Another mechanism has suggested a micro-vessel disease involving multiple thrombi and cold agglutinins [6]. M. pneumoniae has also been isolated from the cutaneous lesions, suggesting involvement of a direct mechanism [5].

The majority of M. pneumoniae-associated dermatological conditions respond to eradication of the bacterium and topical steroids. Commonly used antibiotics to treat M. pneumoniae include erythromycin, azithromycin and co-amoxiclav. All of these have been associated with cutaneous eruptions and it can therefore be difficult to determine whether the eruptions are due to the bacterium or indeed the antibiotics. Our patient developed widespread erythema multiforme, which responded well to 0.1% topical mometasone cream, applied twice a day.

Conclusion

In conclusion, we report a multi-system presentation of M. pneumoniae presenting with acute hepatitis, leukopenia, neutropenia, erythema multiforme, arthralgia, and vomiting. There was a remarkable absence of respiratory symptoms at primary presentation. M. pneumoniae is a common pathogen affecting children and young adults. It should be considered as a differential diagnosis in a febrile young patient with multisystem involvement, even in the absence of respiratory symptoms.

References

  1. Brown RJ, Nguipdop-Djomo P, Zhao H, Stanford E, Spiller OB, et al. (2016) Mycoplasma pneumoniae Epidemiology in England and Wales: A National Perspective. Frontiers in microbiology 7: 157. [crossref]
  2. Narita M (2016) Classification of Extrapulmonary Manifestations Due to Mycoplasma pneumoniae Infection on the Basis of Possible Pathogenesis. Frontiers in microbiology 7: 23. [crossref]
  3. Shin SR, Park SH, Kim JH, Ha JW, Kim YJ, et al. (2012) Clinical characteristics of patients with Mycoplasma pneumoniae-related acute hepatitis. Digestion 86: 302-308. [crossref]
  4. Sánchez-Vargas FM, Gómez-Duarte OG (2018) Mycoplasma pneumoniae-an emerging extra-pulmonary pathogen. Clinical microbiology and infection: the official publication of the European Society of Clinical Microbiology and Infectious Diseases 14: 105-117. [crossref]
  5. Poddighe D (2018) Extra-pulmonary diseases related to Mycoplasma pneumoniae in children: recent insights into the pathogenesis. Current opinion in rheumatology 30: 380-387.
  6. Greco F, Sorge A, Salvo V, Sorge G (2007) Cutaneous vasculitis associated with Mycoplasma pneumoniae infection: case report and literature review. Clinical paediatrics 46: 451-453. [crossref]
  7. Schalock PC, Dinulos JG (2009) Mycoplasma pneumoniae-induced cutaneous disease. International journal of dermatology 48: 673-681. [crossref]
  8. Barge L, Pahn G, Weber N (2018) Transient immune-mediated agranulocytosis following Mycoplasma pneumoniae infection. BMJ case reports 2018: bcr2018224537. [crossref]
  9. Chen CJ, Juan CJ, Hsu ML, Lai YS, Lin SP, Cheng SN (2004) Mycoplasma pneumoniae infection presenting as neutropenia, thrombocytopenia, and acute hepatitis in a child. Journal of Microbiology, Immunology, and Infection = Wei mian yu gan ran za zhi 37: 128-130. [crossref]

Single Point Adjustment

DOI: 10.31038/GEMS.2023544

Abstract

Single point adjustment is the special case in triangulation net adjustment where only the coordinates of one point are unknown. In practice, the coordinates of the points established for densification are calculated in the form of mixed resections. Coordinates of the point to be estimated in mixed resection; It is calculated by taking the average of the coordinates found by the method of projecting more than Intersection and Resection. This solution cannot be said to be suitable for error theory. The solution of the problem in accordance with the error theory is to make adjustment calculations as in all problems with excessive measurements. In single point adjustment, the solution becomes easier if there is no edge measure and the directions are equally weighted. In practice, a single point adjustment calculation is made on the clichés developed for this purpose. In this study, we will show how the single point adjustment can be done according to the least squares (LSQ) theory on a cliché.

Keywords

Intersection, Resection, Single point adjustment, Least square

Introduction

There are explanations for single point adjustment in various sources in the literature [1,2]. But the calculation methods in those sources were complex, difficult to understand, and included long calculation steps but their accuracy was also low. The method we propose here is a shorter, more understandable and more accurate method.

Intersection and Resection

Two techniques commonly employed in extending horizontal control surveys and in setting out are intersection and resection [3-8]. Intersection is a method of locating a point without actually occupying it. In Figure 1, points A and B are stations in a control network already surveyed and, in order to coordinate unknown point C which lies at the intersection of the lines from fixed A and B points, angles α and β are observed. Resection is a method of locating a point by taking angle observations from it to at least three known stations in a network . In Figure 2, in order to coordinate unknown point W can be fixed by observing angles α and β subtended at resection point W by control stations fixed D, C and L points.

fig 1

Figure 1: Intersection

fig 2

Figure 2: Resection

Solution Of Single-Point Adjustment On Clichés

Let’s now see this single point adjustment step by step on a numerical application. In order to make single point adjustment on the clichés, first chart is arranged for all direction measurements. The procedures to be done to fill the chart and clichés are summarized below in Figure 3.

fig 3

Figure 3: Numerical Example

In the triangulation network in the figure, fixed points 27, 32, 34, 39 are given with (Y, X) coordinates. The directions indicated by arrows were observed in the wax and given in the chart. Calculate the adjusted coordinates of the 133 point.

In example;

Number of measurements n=16 (number of observed directions)

Unknown number u=7 (2 coordinates + 5 orientation unknowns)

Redundancy measures f=n-u=9

– Firstly, the station point (SP), the point of target (TP), the observed directions (r) columns and the bearing angle (to) columns calculated from the coordinates are filled.

– Approximate coordinates (Yo, Xo) of the point to be estimated are required to calculate the bearing angles about the two point. For this purpose, the point to be estimated from the fixed points (Na: 32 and Nb: 39) two bearing angles.

ϕa=Zo.32 + r32-133=55.12320 + 42.40162=97.52482

ϕb=Zo.39 + r39-133=344.96144 + 36.51504=381.47648

The approximate coordinates of the point (133) to be estimated using the cliché are calculated in the cliché and written in the calculation section of the approximate coordinates in the cliché.

– Two different ways are followed to calculate the approximate value (Zo) of the oriented direction unknowns belonging to the station points. For the calculation of Zo at fixed points, only the arithmetic mean of the (to-r) differences calculated from the directions from the fixed point to the fixed point is taken. At the point to be estimated (adjusted), Zo is made by taking the arithmetic mean of the (to-r) differences to be calculated from all directions. Calculated Zo values are written in the column they belong to in the chart.

– The oriented direction column is calculated and filled as (α=r + Zo) for the directions to the points to be estimated from the fixed points and the direction observations made at the point to be estimated.

– The constant term (-∫) column is filled by computing (-∫=to – α) in units of [cc] for directed directions only.

Point adjustment on the cliché:

 – Approximate coordinate calculation section of the cliché was filled in while preparing the chart.

– The point numbers and Y, X coordinates of all fixed points are written in the edge calculation section of the cliché. The coordinate differences and lengths of ∆Yo=Yi – Yo and ∆Xo=Xi – Xo from fixed points to the point to be estimated are calculated and written in the relevant columns.

– In the section of establishment of correction equations; First, the fixed point numbers are written in order up to the double-lined line, and for the values in the p (weight) column, they are filled as p=(u-1)/u . Here u: number of target point at fixed point. The weights here are not the weights of the directions, but the p coefficients come to reduce the orientation unknown at fixed points. The direction coefficients a and b are calculated in the form of

a=63662 ∆Yo/So2                 b=-63662 ∆Xo/So2

in [cc/dm] unit by using the values in the edge calculation section of the cliché and written on the lines they belong to. After the double-lined line, the next section is filled. Again, the fixed point numbers and p weight values ​​are written as 1 this time. The pre-filled and shifted values are written under the b columns in the form of

a’=a – [a]/n             b’=b-[b]/n

– ∫ constant terms are taken from the chart and transferred to the cliché.

– In the section of establishment and solution of normal equations; Normal equation coefficients (A, B, C, D, E and F) are calculated from the values in p, a, a’, b, b’, -∫ columns in the upper part of the cliché and written in their places. Unknowns dx, dy are found and adjusted coordinates (Y, X) are calculated by adding them to approximate coordinates. In the upper part of the cliché, using dx, dy values, a.dx, b.dy, a’.dx, b’.dy columns are calculated. Go to the corrections section to the right of the vertical double-lined part of the cliché. In this section, corrections for the direction observations made from fixed points up to the double-lined are calculated from the equation v=a dx + b dy -∫, the corrections for the direction observations made from the point to be estimated point to the next section from the double-lined are from the equation v=a ‘dx + b’ dy -∫. are calculated and written in their places. The weighted sum of squares [pvv] of all corrections is calculated and replaced. As a control, the value of [pvv] is also calculated from the equation [pvv]=F + D dx + E dy. The average error of the unit measure mo, the average error of the coordinates mx, my, the point position error mp are calculated.

– Adjusted values section; The columns of point numbers viewed from the estimated point, observed direction and corrections are filled in (corrections were previously calculated). Corrections are added to the observed directions and adjusted directions are calculated so that the first gaze direction is zero. Using the adjusted coordinates of the point to be estimated, the adjusted bearing, adjusted lengths are calculated and written in the columns they belong to. In order to control the point adjustment made with cliché, the following control operations are carried out in the last calculated adjusted values section (Tables 1 and 2).

Table 1: Chart

tab 1

Table 2: Single Point Adjustments Cliché

tab 2

Control Steps

  1. The two calculated values of [pvv] must be equal within the limit of rounding errors.
  2. The sum of corrections must be zero. This total should not be greater than 0.1cc due to rounding errors.
  3. The angles between adjusted directions and the angles between adjusted bearing should be equal. The difference between the angle values calculated in two different ways should not be greater than 0.1cc.

Warning: The value of estimated point’s coordinates (133) always is exactly correct. But the value of [pvv] is different from its actual value. Because corrections are not calculated for the direction observations made from fixed points in the cliché. Therefore, the calculated values of mo, my, mx, mp are not exactly correct. The actual values that should be are: [pvv]=489.48, mo=7.38 cc, mx=0.096 dm, my=0.107 dm and mp=0.144 dm.

Conclusion

When this problem is solved in the form of mixed resection without performing point adjustment, there are differences smaller than centimetre between the coordinates of the point 133 found by mixed resection and the coordinates found by adjustment. Although this difference is easily negligible for most practical needs, it is necessary to adjustment it in studies that require high precision.

In this study, we will show how the single point adjustment can be done according to the least squares (LSQ) theory on a cliché. Moreover, with today’s advanced calculation tools, all geodetic problems can be adjusted very quickly in accordance with the error theory by means of appropriate software.

References

  1. Allan A, Hollwey J, Maynes J (1968) Practical Field Surveying and Computations, American Elsevier Publishing Co, Inc, New York.
  2. Anderson J, Mikhail E (1998) Surveying: Theory and Practice, 7th edition, WCB/McGraw-Hill, New York.
  3. Bannister A, Raymond S, Baker R (1984) Surveying, 6th edition, Longman Scientific & Technical, Essex, England.
  4. Bektas S (1992) “3D triangulation network” Turkey III. Map of technicians and Services Conference “13-16 April 1992 in Ankara.
  5. Bektaş S (1997) Space Resection, Map and Cadastre Engineering Journal, issue: 83, p.72-79, October 1997, Ankara.
  6. Bektaş S (2016) Practical Geodesy II. Edition, OMU publications, Samsun.
  7. Öztürk,E – Serbetçi M (1989) “Adjustment Calculation Volume II”, KTÜ publications, publication number: 144, page: 310, Trabzon.
  8. Uren J, Price WF (1985) Intersection and Resection. In: Surveying for Engineers. English Language Book Society student editions. Palgrave, London.

Ultrahigh-Pressure and -Temperature Mineral Inclusions in More Crustal Mineralizations: The Role of Supercritical Fluids

DOI: 10.31038/GEMS.2023543

Abstract

Supercritical fluids or melts create an essential connection between the lower mantle and upper crust. Examples demonstrate these interactions.

Examples

Sensitized by the finding of stishovite and coesite as inclusions in the Waldheim granulite in Saxony, the author found, in cooperation with his coauthors [1,2] in evolved granites and related tin-mineralizations, a couple of ultrahigh-pressure and -temperature minerals, like diamond, moissanite, stishovite, coesite, and cristobalite-XI [3]. These minerals are mostly spherical crystals with a very smooth surface. They are, as a rule, minerals entirely out of place. That means these trapped crystals have no equilibrium faces. Thomas and coauthors have interpreted these in growing crystals trapped phases as transported via fast-rising supercritical melt or fluid from the Earth’s mantle region into the crust, here granites and related mineralizations [1-3]. The crystallization velocity of the host must be very high to prevent equilibrium forms of the trapped spheres.

A careful study of the beryl-quartz veins related to the cassiterite mineralization revealed that the ordinarily tetragonal cassiterite contains a high portion of orthorhombic cassiterite [4,5]. There are isometric crystals of orthorhombic cassiterite in muscovite, water-pure topaz, or more significant remnants (cores) of orthorhombic cassiterite in the tetragonal cassiterite crystals. Also, this topaz, as well as the orthorhombic cassiterite, are of high-pressure and high-temperature origin. Supported is this statement by sub-spherical inclusion in the OH-rich topaz composed of carbonic material (graphite, moissanite, and nanodiamond), as well as spherical kumdykolite crystals [NaAlSi3O8] with carbonic material. Kumdykolite is the orthorhombic polymorph of albite formed at high temperatures followed by rapid cooling [6].

The next surprise was the finding of moissanite whiskers with nanodiamonds grown in beryl and quartz in a small hydrothermal beryl-quartz vein in the Sauberg mine of the Ehrenfriedersdorf tin district of the Erzgebirge, Germany [7]. Here the crystallization of the whiskers happens directly at the place of vein crystallization at about 720°C and pressures ≤2 kbar. Thomas [4,5] tried an explanation for this remarkable beryl-quartz-moissanite-nanodiamond paragenesis by a natural supercritical vapor-liquid-solid (VLS) mechanism and a low-pressure heteroepitaxial chemical vapor deposition process (CVD). In each case, the crystallization of moissanite at such low PT conditions is unusual and should be a challenge for further experimental studies. Supercritical phases like spherical beryl-II-moissanite intergrowing in these parageneses’ quartz show the supercritical phases’ participation in this crystallization process.

Another important point for further sophisticated studies in relationship to the unusual mineral inclusions is the chemical and physical character of the supercritical phases. Thomas [8] shows a new type of fluid inclusion that probably transported stishovite (and other mineral phases) from the lower mantle to the crust. Methane (CH4) and water are miscible at ultrahigh pressure and temperature. The transport properties of such fluid and the solubility for different elements are of particular interest because, in the crustal region, we observe a lot of extreme element enrichments in relationship to the melt-water solvus [1,2,9,10]. If we look at the whole story, we see a continuous evolution of the system of thought. Conventional physicochemical processes cannot explain this Gaussian or Lorentzian element enrichment in melt inclusions related to such solvus curves. Further studies are necessary to illuminate these complex processes in more detail.

References

  1. Thomas R, Davidson P, Rericha A, Recknagel U (2022) Discovery of stishovite in the prismatine-bearing granulite from Waldheim, Germany: A possible role of supercritical fluids of ultrahigh-pressure origin. Geosciences 12 : 1-13.
  2. Thomas R, Davidson P, Rericha A, Voznyak DK (2022) Water-Rich Melt Inclusion as “frozen” samples of the supercritical state in granites and pegmatites reveal extreme element enrichment resulting under non-equilibrium conditions. Mineralogical Journal (Ukraine), 44 : 3-15.
  3. Thomas R, Davidson P, Rericha A, Recknagel U (2023) Ultrahigh-pressure mineral inclusions in a crustal granite: Evidence for a novel transcrustal transport mechanism. Geosciences 13 : 1-13.
  4. Thomas R (2023a) Unusual cassiterite mineralization, related to the Variscan tin-mineralization of the Ehrenfriedersdorf deposit, Germany. Aspects in Mining & Mineral Science 11 : 1233-1236.
  5. Thomas R, Recknagel U, Rericha A (2023a) A moissanite-diamond-graphite paragenesis in a small beryl-quartz vein related to the Variscan tin-mineralization of the Ehrenfriedersdorf deposit, Germany (under review).
  6. Hwang SLS, Chu HTY, Sobolev NV (2010) Kumdykolite, an orthorhombic polymorph of albite, from the Kokchetav ultrahigh-pressure massif, Kazakhstan. European Journal of Mineralogy 21 : 1325-1334.
  7. Thomas R (2023b) Growth of SiC whiskers in beryl by a natural supercritical VLS process. Aspects in Mining & Mineral Science 11 : 1292-1297.
  8. Thomas R (2023c) A new fluid inclusion type in the hydrothermal-grown beryl. Geology, Earth and Marine Sciences (GEMS) accepted.
  9. Thomas R, Webster JD, Heinrich W (1999) Melt inclusions in pegmatite quartz: Complete miscibility between silicate melts and hydrous fluids. ECROFI Abstracts, Terra Nostra 99/6, 305-307.
  10. Thomas R, Davidson P, Appel, K. (2019) The enhanced element enrichment in the supercritical states of granite-pegmatite systems. Acta Geochim. 38 : 335-349.

A New Fluid Inclusion Type in Hydrothermal-Grown Beryl

DOI: 10.31038/GEMS.2023542

Abstract

The formation of a new fluid inclusion type in beryl is shown. Primarily the inclusion was composed of water-rich stishovite, which was transported from the lower mantle into the upper crust crystallization level via a supercritical fluid or melt. After trapping and phase change, the primary homogeneous inclusion split due to drastic density changes into two parts by the high beryl solubility under such conditions.

Keywords

New inclusion type, Beryl, Supercritical fluid, Stishovite, Cristobalite, Raman spectroscopy

Method

All microscopic and Raman spectrometric studies are performed with a petrographic polarization microscope with a rotating stage coupled with the RamMics R532 Raman spectrometer working in the spectral range of 0-4000 cm-1 using a 50 mW single mode 532nm laser. Details are given in Thomas et al. 2022 [1,2]. Note here that the low-frequency portion of the Raman spectrum is, according to Tuschel (2019) [3], the most efficacious for characterizing, differentiating, and screening polymorphs (here SiC) by Raman spectroscopy. Furthermore, the polarization/orientation (P/O) micro-Raman spectroscopy is complementary to micro-X-ray diffraction. According to Tuschel (2012) [4], this method should be used when X-ray analysis is not practical or possible (micro-needles and mineral globules depth in the sample volume).

Sample

The beryl-quartz sample material comes from the Sauberg mine near Ehrenfriedersdorf in the Erzgebirge region/Germany. Details are given in Thomas (2023) [5]. Noteworthy is that the synchronously grown moissanite whiskers in beryl characterize the beryl-quartz paragenesis.

Results

During the study of moissanite [SiC] whiskers simultaneously grown in a small beryl-quartz vein related to the Variscan tin deposit, Ehrenfriedersdorf/Erzgebirge, Germany, the author Thomas [5] found a new fluid inclusion type in beryl formed by a necking-of process [6]. That means both inclusions shown in Figure 1 formed from a primarily homogeneous phase, probably stishovite, trapped during the crystal growth of beryl. The density of both minerals, stishovite and cristobalite, is 4.35 vs. 2.20 g/cm3, respectively [7]. It is well known that stishovite formed at the lower crust would never be preserved over geological time at low pressure and temperature [8]. From earlier studies, Thomas and Klemm, 1997 [9] and Thomas et al. 2022 [1,2] follow a trapping temperature of 720°C at a pressure of ≤2 kbar. During cooling, the initially homogeneous inclusion separated itself into two parts by strong density contrast as a result of cooling. The upper inclusion consists of pure methane with a small cristobalite (Crs) crystal, and the lower inclusion is composed of about 65% cristobalite, 17.4% CH4, and 17.6% H2O. The solubility of beryl is at or near supercritical conditions extremely high [1,2].

FIG 1

Figure 1: Two supercritical inclusions in beryl (Brl). CH4 – methane, Fl – aqueous liquids phase. Cristobalite (Crs) in both inclusions gives in the Raman spectrum strong lines at 112.6, 229.8. 418.6, and 1072.1 cm-1, respectively. The numbers 1 to 7 in the lower inclusions show the points at which cristobalite was determined with Raman spectrometry.

The vapor phase consists exclusively of methane (CH4), and cristobalite (Crs) forms the solid phase of both inclusions. Cristobalite in the methane inclusion is stable under laser light and is metastable in the water-bearing fluid inclusion (creating quartz). With the used Raman spectrometer, in no case hydrogen using the pure rotational lines S0 (354.8 cm-1), S1 (587.4 cm-1), S2 (815.0 cm-1), and S3 (1024.9 cm-1) could be determined – see Petrov et al. 2018 [10]. Also, CO2 could not be determined. The fluid phase is almost pure water. Alkali carbonates are missing. The cristobalite was primarily water-rich stishovite or coesite, giving the supercritical fluid a minimum pressure of 7 GPa. However, if we accept the water content in the lower inclusion primary solved in the primary stishovite, according to Lin et al. (2022) [11], a pressure of about 30 GPa or more is possible (see also Thomas et al. 2022) [1,2]. Figure 2 shows a Raman spectrum of the cristobalite in the CH4-rich inclusion of Figure 1.

FIG 2

Figure 2: Raman spectrum of cristobalite, nanodiamond, and carbon in the CH4-rich inclusion of Figure 1. The Raman bands at 109.8, 228, 414.3,792, and 1070.5 cm-1 correspond to cristobalite. The 1328.5 and 1590 cm-1 bands correspond to nanodiamonds and carbon, respectively.

The strong and stable nanodiamond band at 1328 cm-1 and the strong carbon band at 1590 cm-1 are conspicuous and demonstrate that at the origin of the supercritical fluid, its pressure is significantly higher than the pressure at the place of beryl crystallization. Figure 3 shows the Raman spectra of cristobalite (points 1-7) in the lower inclusion part. Here both bands corresponding to nanodiamond and carbon are entirely missing.

FIG 3

Figure 3: Raman spectra of the cristobalite at different measuring points 1-7 in Figure 1

Figure 4 shows the Raman band of pure methane in both inclusion parts. According to Vitkin et al. (2020) [12], methane is 12CH4 rich. Pruteanu et al. (2017) [13] have shown that methane and water are entirely miscible at high pressure and temperature. This condensed state at high pressure and temperature and at least the phase separation at lower PT-data dramatically influence the properties of the supercritical fluid or melt.

FIG 4

Figure 4: Both inclusion parts’ Raman methane spectrum (CH4)

Conclusion

The here-described supercritical fluid inclusion in beryl is a new type resulting from the interaction of a beryllium-bearing supercritical melt or fluid with the already present Variscan tin mineralization. The solubility of Be as bromelite [BeO] in a supercritical melt or fluid at temperatures higher than 700°C is extreme, as Thomas and Davidson (2010) [14] and Thomas et al. (2022) [1,2] demonstrated. The extreme physicochemical conditions (at a highly activated state) during the beryl crystallization from a supercritical melt or solution favored the simultaneous crystallization of moissanite [SiC] with beryl [5]. The formation of the new inclusion type shows different scenarios for the origin of beryl and simultaneously grown moissanite: ultrahigh-pressure and high-temperature conditions (1000°C and ~30 GPa) generated in the lower mantle region and low-pressure and low-temperature conditions in the upper crust (720°C, ≤2 kbar). Furthermore, the short study shows that supercritical fluids or melts are highly complex in composition and change permanently on the path between the lower mantle and upper crust. Therefore many reactions are far away from any equilibrium. Further studies are necessary to illuminate these complex processes in more detail. One point is essential: which mechanism is responsible for the extreme enrichment of, for example, beryllium? Are near beryl’s crystallization at supercritical conditions a quantum physical entanglement of Be atoms?

References

  1. Thomas R, Davidson P, Rericha A, Recknagel U (2022) Discovery of stishovite in the prismatine-bearing granulite from Waldheim, Germany: A possible role of supercritical fluids of ultrahigh-pressure origin. Geosciences 12: 1-13.
  2. Thomas R, Davidson P, Rericha A, Voznyak DK (2022) Water-rich melt inclusions as “frozen” samples of the supercritical state in granites and pegmatites reveal extreme element enrichment resulting under non-equilibrium conditions. Min. J. (Ukraine), 44, 3-15.
  3. Tuschel D (2019) Raman spectroscopy and polymorphism. Spectroscopy 34: 10-21.
  4. Tuschel D (2012) Raman crystallography, in theorie and in practice. Spectroscopy 27: 2-6.
  5. Thomas R (2023) Growth of SiC whiskers in Beryl by a natural supercritical VLS process. Aspects in Mining & Mineral Science 11: 1292-1297.
  6. Roedder E (1984) Fluid inclusions. Reviews in mineralogy. In: Ribbe PH (ed): Mineralogical Society of America 12: 644.
  7. Frondel C (1962) The System of Mineralogy. John Wiley and Sons, INC, New York and London, Vol. III Silicate Minerals, 7th Edition, 334 p.
  8. Hemley RJ, Prewitt CT, Kingma KJ (1994) High-pressure behavior of silica. Reviews in mineralogy 29: 41-81.
  9. Thomas R, Klemm W (1997) Microthermometric study of silicate melt inclusion in Variscan granites from SE Germany: Volatile contents and entrapment conditions. Journal of Petrology 38: 1753-1765.
  10. Petrov DV, Matrosov II, Sedinkin DO, Zaripov AR (2018) Raman spectra of nitrogen, carbon dioxide, and hydrogen in a methane environment. Optics and Spectroscopy 124: 8-12.
  11. Lin Y, Hu Q, Meng Y, Walter M, Mao HK (2020) Evidence for the stability of ultrahydros stishovite in Earth’s lower mantle. PNAS 117: 184-189. [crossref]
  12. Vitkin V, Polishchuk A, Chubchenko I, Popov E, Grigorenko K, at al. (2020) Raman laser spectrometer: Application to 12C/13C isotope identification in CH4 and CO2 greenhouse gases. Applied Sciences 10: 1-12.
  13. Pruteanu CG, Ackland GJ, Poon WCK, Loveday JS (2017) When immiscible become miscible -Methane in water at high pressures. Science Advances 3: 1-5.
  14. Thomas R, Davidson P (2010) Hambergite-rich melt inclusions in morganite crystals from the Muiane pegmatite, Mozambique and some remarks on the paragenesis of hambergite. Miner Petrol 100: 227-239.

Groundwater Potential Zone Mapping of Lower Omo- Gibe Watershed, Omo-Gibe Basin, Ethiopia

DOI: 10.31038/GEMS.2023541

Abstract

The demand and investigation of groundwater are occasionally increased by the ever-increasing population and abrupt climatic changes. Groundwater is currently the most important source of fresh water, and many researchers are attempting to cover all aspects of this resource in order to achieve sustainable development. This scientific and academic research and studies are attempting to present a multi-range of techniques and methods focusing on groundwater pollution, potentials, assessment, and prediction. To delineate groundwater potential (GWP) zones in the Lower Omo-Gibe Watershed, Omo-Gibe Basin, Ethiopia, an integrated strategy of remote sensing (RS), geographic information systems (GIS), and multi-criteria decision analysis (MCDA) using analytical hierarchical process (AHP) was used. For this purpose, seven GWP influencing thematic layers comprising lineament density, slope, soil, drainage density, landuse landcover, geology, elevation and rainfall map were used. Scale values for the classes and thematic layers within them were determined using Satty’s AHP and based on expert and literary judgment. The thematic layers have been integrated via their rates using weighted overlay spatial function tool of ArcGIS to provide GWP map. The distribution and extents of different potential groundwater zone are 158.05 km2 (21.59%), 35.92 km2 (4.91%), 214.77 km2 (29.34%), 220.59 km2 (30.13%), and 102.72 km2 (14.03%) for very good, good, moderate and fair zone respectively. The study’s conclusions can be used to develop a groundwater action plan that will effectively protect the study area’s considerable groundwater resources. With regard to the long-term availability of groundwater, this research will be very beneficial to water management.

Keywords

Lower Omo-Gibe watershed, Omo-Gibe Basin, AHP, GIS, GWP, MCDA

Introduction

Groundwater is a valuable natural resource, and finding the best locations for groundwater recharge, monitoring wells, water supplies, and groundwater quality depends on exploration and wise management of this resource [1]. Given the constantly rising demand for freshwater, groundwater is a crucial freshwater resource for maintaining daily life in urban and suburban areas [2]. The importance of studying groundwater potential zones is based on the quantity, quality, and contamination of groundwater. The main causes of the consistent rise in freshwater demand are population expansion, the need for irrigation in agriculture, and climate change [3]. Groundwater as a substitute supply of fresh water has received serious attention due to the dangers of surface water pollution, rapid climate change, and the likelihood of droughts [4]. In order to keep the ecological balance of the earth system, groundwater is an essential part of the hydrological cycle. By providing freshwater for drinking, agriculture, and industry, it maintains life [5]. Because it is less polluted than surface water sources, which are easily contaminated by human activities like industrial and agricultural operations, groundwater becomes a significant alternative supply of freshwater in areas with a semi-arid temperature and environment [6]. Groundwater potential maps are available in many nations of the world, assisting planners and decision-makers in the development, distribution, and management of groundwater resources [1]. Groundwater accounts for one-third of all freshwater abstractions globally [7]. In many regions of the world where water supplies are limited, groundwater is a crucial natural resource for any economic and social growth [8]. Groundwater supplies are a necessity for all economic activity, both internally and outside. However, a study that combines remote sensing and GIS data can offer a good platform for the converging analysis of massive amounts of data using very advanced cognitive process techniques for groundwater exploration. Nations like Ethiopia are seeing a rise in groundwater demand as a result of the nation’s fast urbanization, population growth, and economic development. In the area under examination, groundwater is the most often used resource for agriculture, animal husbandry, and the provision of drinking water. The Lower Omo-Gibe watershed groundwater potential zone mapping will have a significant impact on the sub-basin. Since the Lower Omo-Gibe watershed is the main source of the Omo River, mapping the underground water would improve the nation’s groundwater resources’ sustainable management. Because of this, the current study is interested in delineating the groundwater potential zones within the study area using remote sensing and GIS technology. Seven determining elements were taken into consideration for the study: slope, landuse landcover, Lineament density, Geology, Elevation, Soil texture, and Drainage density. In order to ensure sustainable management and growth of the resource, groundwater exploration has recently seen a rise in the usage of remote sensing and geographic information systems (GIS). With the development of technology, more scientists are employing remote sensing (RS) and geographic information systems (GIS) to evaluate a basin’s groundwater supplies [5]. Geophysical technology-based groundwater exploration methods are expensive and time-consuming [9]. Due of these problems, humans have been forced to use a variety of technologies that can help them research vast areas in a brief amount of time while using few resources. These techniques, which include remote sensing and GIS, have been applied to find groundwater potential zones. Exploring the groundwater potential zone in varied geological settings is made simple and rapid with this method [10-13] Several scholars have employed the RS and GIS procedures to designate groundwater potential zones all over the world [14-17]. Utilizing RS and GIS, groundwater resources can be found and explored. Geology, geomorphology, slope, soil type, rainfall, land use/land cover, lineament structures, and drainage criteria are all important factors [18,19]. Geospatial technologies offer quick and affordable ways to evaluate spatial data across a range of geoscience disciplines [20]. For long-term resource management, it is essential to be able to locate the groundwater potential zone. It aids policymakers, decision-makers, and planners in making sure the groundwater resource is safeguarded from influences on both quantity and quality. The analytical hierarchy process (AHP) is one of the approaches to multi-criteria decision-making that is most frequently used [11]. AHP can be used to demarcate groundwater potential zones since it is an easy, quick, dependable, and efficient procedure [12]. When it comes to creating sustainable groundwater policies in this district, planners and policymakers will find this research to be a useful resource.

Materials and Methods

Study Area

The Lower Omo-Gibe River Watershed is about 2345.5 km² in area and is situated in the Omo-Gibe Basin, south Ethiopia. Lower Omo-Gibe Watershed (Figure 1) mainly covers South nation and nationality region and south-west Ethiopia region. Mirab Omo, South Omo and Basketo Zones are included in this watershed. Woredas such as Maji, Salamago, South Ari, Jinka town, Boko Dawula, Hamera, Nyngatom, North Ari and Mele koza. It has a southern boundary that is formed by the contained river basin that empties into Kenya’s Lake Turkana. The Lower Omo-Gibe watershed plain is distinguished by the fact that, although being rather flat, it has various beach ridges and depressions. It was formed very recently by the subsequent movements of Lake Turkana. The Omo delta, in the south of the Basin and at the northern end of Lake Turkana has aggraded to such an extent in recent years only some 25 km2 of the lake is in Ethiopia.

fig 1

Figure 1: Location map of the study area

Methods and Data Analysis

The groundwater potential in this study was assessed using seven criteria including soil, lineament density, landuse landcover, slope, drainage density, rainfall, geology, For each criteria, thematic maps were created and utilized to assess the groundwater potential of the study area. In this study, the relationship between the variables that were utilized to forecast groundwater potential during weight calculation and the actual groundwater potential was analyzed.

Slope

In mapping groundwater potential, slope is a key factor [21]. It determines surface runoff and vertical percolation of water; hence, it affects groundwater recharge processes [22]. Slope was inversely related to infiltration [23]. Shuttle Radar Topography Missions (SRTM) 30 m resolution digital elevation model (DEM) was used to generate slope map. The slope map was classified into five classes (Figure 2) based on FAO classification standard (Sheng, 1990).

fig 2

Figure 2: Slope map

Drainage Density

Drainage density has an impact on both the availability and pollution of groundwater. Lithology has an impact on the drainage system, which is a crucial gauge of infiltration rate. Drainage density has an inverse relationship with permeability [3]. As a result, it is a crucial component in determining the groundwater potential zone obtained from DEM data.  Finding the length of the stream and dividing on to the total area of the basin as shown in the equation of Drainage Density DD=L (length/A (area) and using Archydro program [24]. The drainage-density map (Figure 3) was created by dividing themed river maps produced from a basin-wide flow accumulation (Fac) and stream definition operation [25].

fig 3

Figure 3: Drainage density map

Geology

The geologic environment has a significant influence on the existence and distribution of groundwater in any terrain [26]. One of the most crucial factors in evaluating groundwater potential zones is geomorphology, which relates to an area’s landform and terrain. It gives information on how different landform traits are distributed as well as information on numerous processes, including temperature changes, geochemical reactions, water flow, freezing and thawing, and more [27]. Geologic and Geomorphological maps created by translating length and measurement into kilometers (km), digitizing with the Arc GIS spatial analyzer application, and then saving the data as shape files. The geological structures were modified to raster file format with the corresponding presentation, and the region’s geological state was assessed. The following formula was used to compute the lineament (fault) density (LL) [28]. The geology of Lower-Omo Gibe watershed (Figure 4) characterized by tertiary extrusive and intrusive rock, tertiary, quaternary and Permian-Carboniferous.

fig 4

Figure 4: Geology map

Elevation

Elevation of the catchment ranges from 333 to 3277 m above sea level (Figure 5). High elevation was found in west and north edge of the study area and decrease toward east and south of the study area except topographically irregular and hilly areas. A higher weight is given for lower elevated zones and lower weight was assigned for highly elevated areas.

fig 5

Figure 5: Elevation map

Landuse Landcover

One of the key determining criteria to pinpoint areas with potential for groundwater recharge is the landuse and landcover map [29]. Landuse and landcover have an impact on hydrological processes such evapotranspiration, surface runoff, and infiltration. Areas with vegetation cover have high groundwater potential than built-up areas that inhibits the infiltration of water into the subsurface [30]. From land use classes, built-up area has the lowest weight compared to other classes and crop land has the highest weight [31]. Landuse landcover offers essential details on infiltration, moisture, groundwater, and surface water in addition to suggestions on groundwater requirements.  The primary coverings of the land surface by human activity or vegetation are referred to as landuse and landcover, respectively (natural or planted). The land-use type in the study area in accordance with the order of infiltration includes barren land, built up land, crop land, grass land, lichen mosses, open water, shrubs cover area, tress cover area and vegetation aquatic (Figure 6). The landuse landcover layer was obtained from the Ethiopia Sentinel2 LULC 2022. The boundaries in the layer were then visually evaluated using Landsat8 satellite images. Next, the land-use classes changed to the USGS standard classifications. Finally, the layer was entered into the GIS model after the necessary edits.

fig 6

Figure 6: Landuse landcover

Lineament Density

Lineaments are tectonic-derived linear, rectilinear, and curvilinear features that are visible in satellite photography. These lineaments typically display linearity and curvilinerities in vegetation, drainage, drainage patterns, soil tonality, relief, and tonality in soil in satellite data [32]. In particular, in the lineaments that are not filled by soil, the lineaments may operate as a channel for water to seep into the earth and migrate through the aquifer system due to linear features including fault, fractures, and geological connections between various lithologies. Since it is assumed that the rate of water infiltration increases with increasing lineament density, the lineament density (Figure 7) of a region might indirectly indicate the groundwater potential [33]. These lineaments are mapped with the help of satellite data and can be correlated with faults, fractures, joints, bedding planes and geological contacts which are useful for the groundwater potential study [34].

fig 7

Figure 7: Lineament density map

Soil

The type of soil texture present in an area has a great impact on the availability of groundwater. Highly porous soils allow easy percolation and infiltration of surface water into the subsurface, and this is ideal for a favourable groundwater potential. Soil properties influence the relationship between runoff and infiltration rates, which in turn control the degree of permeability [35]. Soil texture raster data of the Lower Omo-Gibe Watershed was obtained by HWSD (harmonized world soil database) Version 1.2 at 900 m resolution. Lower Omo-Gibe Watershed consists of five major soil textural groups (Figure 8), such as Eutric Nitosols, Eutric Cambisols, Calcaric Fluvisols, Chromic Vertisols and Haplic Yermosols. Due to their difference in infiltration and porosity, weight of soil texture is assigned on the basis of their infiltration rate.

fig 8

Figure 8: Soil map

Rainfall

The slope gradient and rainfall distribution have a direct impact on the infiltration rate and the potential for groundwater potential zones [22]. As indicated in Figure 9, the annual rainfall was categorized into five classes: very high (1410-1520 mm), high (1300-1400 mm), moderate (1180-1290 mm), low (1070-1170 mm), very low (946-1060 mm) and extremely very low (831-945 mm). Rainfall generally decreases from east to west and similar to elevation, with annual rainfall varying between 831 mm and 1520 mm.

fig 9

Figure 9: Annual rainfall map

GIS Based AHP Method

GIS Geographic Information System

A software and hardware combination is a created instrument that has been extensively employed in groundwater potential zones and assessment. A method for limiting the number of target regions for hydrogeo-physical study is provided by the combined RS and GIS analysis [36]. Following site appraisal and selection for sustainable groundwater management, site-specific ground geophysical methods like vertical electrical sounding (VES) and very low frequency electromagnetic (VLF-EM) profiling may be used. In the GIS and RS spatial analysis and modeling, thematic layers for soil, lineament density, drainage density, geomorphology, slope, and LULC are integrated. In terms of groundwater prospect, weights ranging from 1 to 4 were allocated to the classes in order of increasing.

AHP Analytical Hierarchy Process

Developing an Analytical Hierarchy Process (AHP) Model

Making a decision hierarchy is the first step in an AHP analysis. AHP divides the issue into a hierarchy. As adopted by [37] first level of the hierarchy is the goal of groundwater potential zone identification. The second level in the hierarchy indicates the parameters that used to decide the potential zone and the third level is about an alternative to select groundwater potential zone as very good, good, moderate and fair. The benefit of AHP is that it simplifies issue solving by better understanding how to break down challenges. To make sure that all requirements and potential alternatives were followed, it is also feasible to request the participation of specialists [37,38].

It’s one of the techniques employed the most in MCDA approaches, as was indicated in the introduction, this concept has been developed by [39]. The AHP evaluates a collection of evaluation criteria as well as a set of alternate options before selecting the best one with the most weight [40]. It is a strategy for assessing the relative weights of the criteria, different optimization strategies for each parameter, and generating an average rating of the variations that were generated using the predetermined criteria (selection criteria identification) at a certain stage [2]. The AHP is frequently used to establish priorities utilizing expert recommendations and evaluations, reduce issue confusion and complexity, and facilitate decision-making. There should be at least two criteria and two substitutes in every study that has been examined by AHP in order to determine each factor’s weight [41]. Since these criteria were given varying degrees of importance, education and expertise are particularly important for thorough evaluation and analysis. It’s possible to employ both qualitative and quantitative criteria [42]. After using AHP within the MCDA, a decision matrix was produced in each study that was reviewed. Field experiences and literature reviews were used to weigh several parameters on a flexible scale from 1 to 5. Then using a few formulae to get the system’s normalized weight and consistency ratio (CR) (Figure 10) [38].

fig 10

Figure 10: Methodology flow chart for the present study

fig 11

Figure 11: Groundwater potential map

Result and Discussion

Landuse Landcover

Land use map of the study area (Figure 6) consists of several classes, viz., Bare area 112 km2, Built up area 143 km2, Cropland 435 km2, Grassland 268.5 km2, Lichen mosses 112 km2, Open water 97 km2, Shrubs cover areas 289 km2, Tree cover areas 667 km2 and Vegetation aquatic 222 km2 as shown in Figure 6 and Table 1. Land use is one of the important criteria for identifying groundwater potential zones. Suitable weights were given to each class and their areal extents were calculated using “Zonal Statistics” in GIS (Table 1).

Table 1: Area covered under different range of parameter of Landuse landcover

Land use class

Categories

Area (km2)

Area (%)

Bare area Poor

112

4.78

Built up area Very poor

143

6.10

Cropland Moderate

435

18.55

Grassland Good

268.5

11.45

Lichen mosses Good

112

4.78

Open water Very good

97

4.14

Shrubs cover areas Poor

289

12.32

Tree cover areas Very good

667

28.44

Vegetation aquatic Very good

222

9.46

Geology

Geology is also one of the input parameter factors in delineating the groundwater potential zones. Four different lithologies have been observed in the study area (Figure 4). Their areal extent has been determined using “Zonal Statistics” in geographic information system domain (Table 2). Geology of Lower Omo-Gibe watershed is dominated by tertiary extrusive and intrusive rock 758 (32.32%), tertiary (397 km2, 16.93%), quaternary (845 km2, 36.03%) and Permian-Carboniferous (345.5 km2, 14.73%).

Table 2: Area covered under different range of parameter of Geology

Geology class

Categories

Area km2

Area%

Tertiary extrusive and intrusive rock Very good

758

32.32

Tertiary Good

397

16.93

Quaternary Moderate

845

36.03

Permian-Carboniferous Poor

345.5

14.73

Slope

The slope of the study area has been estimated from Digital Elevation Model (DEM) data as shown in Figure 2 and Table 3. Flat or gentle slope is suitable for increasing the infiltration amount from rainfall. Otherwise, in steep slope area where the infiltration capacity is very minimum whereas runoff is maximum. From the analysis, slope ranges from 0-5 percent rise covers high area coverage which is 31.29% (734 km2), 5-10 slope categories covers 17.67% (414.5 km2), 10-15 slope  categories covers 13.69% (321 km2), 15-20 slope categories covers 9.46% (222 km2) and >20 slope categories covers 27.88% (654 km2).

Table 3: Area covered under different range of parameter of Slope

Slope categories

Categories

Area (km2)

Area (%)

0-5

Very good

734

31.29

5-10

Good

414.5

17.67

10-15

Moderate

321

13.69

15-20

Poor

222

9.46

>20

Very poor

654

27.88

Soil Type

Soil type is also one of the most determinant factors in estimating the groundwater. Ten different soil types have been observed in the study area (Figure 8). Their areal extent has been determined using “Zonal Statistics” in geographic information system domain (Table 4). Soil type of Bahir dar zuria is dominated by vertisoil with an aerial extent of 1045.19 km2 (67.78%), followed by luvisoil (284.31 km2, 18.08%), and other units together cover in the study area as indicated in Figure 8 and Table 4. Based on the hydraulic properties of the soil, the soil classes were accordingly ranked using AHP.

Table 4: Area covered under different range of parameter of soil type

Soil class

Categories

Area km2

Area%

Eutric Nitosols Moderate

450

19.19

Eutric cambisols Good

498

21.23

Calcaric fluvisols Very good

356

15.18

Chromic vertisols Very poor

782

33.34

Hapric hermosols Poor

259.5

11.06

Lineament Density

Lineaments are the natural linear feature like faults, joints and fractures, which can visualize and interpreted directly from remotely sensed data. As shown in the Table 5, lineament density class ranked as very low, low, medium, high and very high with the areal extent of 0-0.83 Km/km2, 0.84-1.66 Km/km2, 1.67-2.35 Km/km2, 2.36-2.93 Km/km2 and 2.94-3.77 Km/km2 respectively. The total area falling in different range of lineament density is given in Figure 7 and Table 5 which show that most part of the study area have very low lineament density. So very low lineament density indicates very low infiltration rate, whereas the high lineament density areas indicate high infiltration (Table 5) thus a potential zone for groundwater development.

Table 5: Area covered under different range of parameter of Lineament

Lineament density class

Categories

Area (km2)

Area (%)

0-0.83

Very low

1411

60.16

0.84-1.66

Low

322

13.73

1.67-2.35

Moderate

198

8.44

2.36-2.93

High

201.5

8.59

2.94-3.77

Very high

213

9.08

Drainage Density

Drainage density is a significant parameter for evaluating the groundwater potential zones. The areas having high drainage density have less potential for groundwater recharge, and the areas with low drainage density have a high potential for groundwater recharge. Hence, the areas having low drainage density are favorable for high groundwater potentiality. So, higher weights were assigned to the areas having low drainage density. The drainage density was classified into five categories viz. very low (0.08-091 km/km2), low (0.92-1.67 km/km2), moderate (1.68-2.74 km/km2), high (2.75-3.43 km/km2) and very high (3.44-4.22 km/km2). The highest area was under low density with 225.5 km2, followed by very low with 388 km2, moderate 510 km2, high 589 km2, and very high 633 km2 as shown in Figure 3 and Table 6.

Table 6: Area covered under different range of parameter of Slope

Drainage density class

Categories

Area (km2)

Area (%)

0.08-0.91

Very low

225.5

9.61

0.92-1.67

Low

388

16.54

1.68-2.74

Moderate

510

21.74

2.75-3.43

High

589

25.11

3.44-4.22

Very high

633

26.99

Rainfall

Rainfall is one of the most important sources of groundwater recharge through percolation in the groundwater system. The average annual rainfall in the study area is grouped into six classes namely extremely very low (831-945 mm), very low (946-1060 mm), low (1070-1170 mm), moderate (1180-1290 mm), high (1300-1400 mm) and very high (1410-1520 mm), covering the area of about 410 km2 (17.48%), 370 km2 (15.77%), 366 km2 (15.60%), 433 km2 (18.46%), 376.5 km2 (16.05%) and 390 km2 (16.63%), respectively as shown in Figure 9 and Table 7. Rainfall distribution along with the slope gradient directly affects the infiltration rate of runoff water hence, increases the possibility of groundwater potential zones.

Table 7: Area covered under different range of parameter of Rainfall

Rainfall class

Categories

Area (km2)

Area (%)

831-945

Extremely very low

410

17.48

946-1060

Very low

370

15.77

1070-1170

Low

366

15.60

1180-1290

Moderate

433

18.46

1300-1400

High

376.5

16.05

1410-1520

Very high

390

16.63

Derived Priorities (Weights) for the Parameters

The AHP method was applied in the current work to determine the weight for each data layer. One of the most widely used techniques for determining the weights of criterion in the Multi-Criteria Decision Making is AHP (MCDM) [38]. To identify the purpose, criteria, and relationship between them, the hierarchical structure of the subject being studied is created as the first stage in the AHP approach. Initially, the AHP approach involved conducting a pairwise comparison of the alternatives using specially created questions that followed the format of the standard AHP questionnaires. In this study, opinions from a range of experts were gathered regarding the potential for groundwater, including hydrologists, hydrogeologists, environmentalists, and GIS experts. The overall method is as described in the following Figure 9. The result of AHP shows that geology has the highest weight (38.39%) followed by slope, which accounts for 23.27%, drainage density 14.54%,  landuse landcover 11.40%, lineament density 7.04% and soil 5.35% of the weight given to each parameter (Tables 1 and 2). When the judgements matrix is consistent and the computed weight has been normalized by multiplying the derived weight of all parameters by 100%, it is then possible to rank the features of each parameter for the purpose of a weighted overlay. Features of each thematic layer were ranked on the basis of influence of groundwater potential within each parameter (Table 8) [38,43].

Table 8: Comparison matrix and significance weightage value of the influential factors

Factors

Geology

Lineament density

Slope

Rainfall

Soil

LULC

Drainage density

Weight

Geology

7

6

5

4

3

2

1

38%

Lineament density

7/2

6/2

5/2

4/2

3/2

2/2

1/2

19%

Slope

7/3

6/3

5/3

4/3

3/3

2/3

1/3

12%

Rainfall

7/4

6/4

5/4

4/4

3/4

2/4

1/4

10%

Soil

7/5

6/5

5/5

4/5

3/5

2/5

1/5

8%

LULC

7/6

6/6

5/6

4/6

3/6

2/6

1/6

6.6%

Drainage density

7/7

6/7 5/7

4/7

3/7

2/7

1/7

6.4%

Groundwater Potential Zone of the Watershed

To choose the best location for future groundwater development and management, it is crucial to integrate several groundwater regulating variables for discovering possible potential groundwater resources. Using the WLC of the GIS spatial analysis tool, all created thematic maps were integrated based on their weights and rates. The calculations of all the layers went into creating the GWP map. A prospective groundwater zone map was created by weighing the various theme layers and their specific features see Figure 10. The potential groundwater zone of the study area revealed five distinct zones, namely very good, good, moderate and fair. The distribution and extents of different potential groundwater zone are 158.05 km2 (21.59%), 35.92 km2 (4.91%), 214.77 km2 (29.34%), 220.59 km2 (30.13%), and 102.72 km2 (14.03%) for very good, good, moderate and fair zone respectively see Table 3. Study area have very high to high potential zone in southern, south west and central portion, while the west and eastern portion exhibits medium to low groundwater potentials. The distribution is more or less a reflection of drainage density, lineament, slope, and soil patterns in addition to geomorphic and geological elements, according to analysis of the groundwater potential map (Table 9).

Table 9: Groundwater potential zone

Groundwater Potential Zone Class

Area (sq. km)

Area in percent

Fair

432.9

18.45

Moderate

634.8

27.06

Good

954.3

40.68

Very good

323.5

13.79

Total

2345.5

100

The region appears to have a great potential for irrigation because there are large expanses of irrigable land with fertile soil available. The watershed lower areas get volcanic sediments that are moved from the watershed upper portions due to its geographic location. The area is seen as one where food security is a worry, despite having a lot of potential for irrigation agriculture due to its good soil, irrigable acreage, and high capacity for groundwater. I consequently suggest that concerted activities by the district and regional governments are required to improve the living conditions of persons who reside in the catchment. I have found in my study that the watershed may be abundant in water resources, particularly groundwater. Groundwater was found to have a high potential in nearly half of the basin. Despite the aforementioned limitation, I am confident that the results can be used to identify solutions for utilizing the local water resources and resolving the issue that the residents have been experiencing. I advise that a thorough investigation be done to determine the quantity and quality of water that is available in order to determine whether it can be used for the intended purpose. Due to the availability of substantial tracts of irrigable land with fertile soil, the area appears to have a high potential for irrigation. Due to its geographical location, the watershed lower portions receive volcanic sediments that are transferred from the watershed top portions. Despite having a lot of potential for irrigation agriculture due to its good soil, irrigable land, and high capacity for groundwater, the region is considered one of the locations where food security is a concern. In order to better the living conditions of those living in the watershed, I therefore propose that coordinated actions by the district and regional governments are needed.

Conclusion

In this study, groundwater potential zone evaluation using remote sensing, GIS, and MCDM methodologies has been successfully used and proven. The generation of thematic layers, the application of AHP to get the weights, and overlay analysis to determine the groundwater potential zone are the three steps of the process. Thematic layers were created by digitizing existing maps using a GIS and remotely sensed satellite image data. Utilizing the AHP, utility weights for the substitutes were provided. The identification of the groundwater potential zone uses an overlay analysis of multiple thematic maps and weighting. Based on remote sensing, GIS, and MCDA methodologies, four categories of groundwater potential zones have been identified in this study region. This particular study deals with the assessment of groundwater potential zones (GWPZs) using geographical information systems and remote sensing techniques in the Lower Omo-Gibe watershed, Omo-Gibe Basin, Ethiopia. The thematic layers influencing GWPZs such as geology, landuse landcover, slope, lineament density, drainage density, soil properties (soil texture, soil type), and elevation maps were getting prepared with the available data, i.e., conventional data, satellite image, and assigned individual weights along with their subclass divisions depending on literature and expertise decision. The distribution and extents of different potential groundwater zone are 158.05 km2 (21.59%), 35.92 km2 (4.91%), 214.77 km2 (29.34%), 220.59 km2 (30.13%), and 102.72 km2 (14.03%) for very good, good, moderate and fair zone respectively.

Data Availability

Data used in this research are available upon request.

Conflicts of Interest

The author declares that they have no conflicts of interest or personal relationships that could have influenced the work reported in this paper.

Acknowledgments

The authors acknowledge the Ethiopian Ministry of Water, Irrigation and Energy, and the National Metrological Agency for providing the necessary data which is helpful to accomplish this research work.

References

  1. Verma N, Pate RK (2021) Delineation of groundwater potential zones in lower Rihand River Basin, India using geospatial techniques and AHP, Egypt J Remote Sens Sp Sci 24: 559-570.
  2. Sulaiman WH, Karimi H, Mustafa YT (2021) A GIS-based AHP Method for Groundwater Potential Zone Assessment : A Review. 2: 86-92.
  3. Mahato R, Bushi D, Nimasow G, Nimasow OD, Joshi RC (2022) AHP and GIS-based Delineation of Groundwater Potential of Papum Pare District of Arunachal Pradesh, India. J Geol Soc India 98: 102-112.
  4. Shabani M, Masoumi Z, Rezaei A (2022) Assessment of groundwater potential using multi-criteria decision analysis and geoelectrical surveying. Geo-Spatial Inf Sci.
  5. Barua S, Mukhopadhyay BP, Bera A (2021) Integrated assessment of groundwater potential zone under agricultural dominated areas in the western part of Dakshin Dinajpur district, West Bengal, India. Arab J Geosci 14.
  6. Ifediegwu SL (2022) Assessment of groundwater potential zones using GIS and AHP techniques: a case study of the Lafia district, Nasarawa State, Nigeria. Appl Water Sci 12: 1-17.
  7. Abirami C, Annadurai (2016) Identification of Groundwater Potential Zones on GIS based Multi-Criteria Technique – A Case Study Erode District. Int J Eng Res Technol 4: 1-6.
  8. Said S, Anees M (2020) Remote sensing and gis based assessment of groundwater potential zones in amu campus using ahp approach. Ecol Environ Conserv 26: S6-S11.
  9. Arefayne Shishaye H, Abdi S (2015) Groundwater Exploration for Water Well Site Locations Using Geophysical Survey Methods. J Waste Water Treat Anal 07.
  10. Mengistu TD, Chang SW, Kim IH, Kim MG, Chung IM (2022) Determination of Potential Aquifer Recharge Zones Using Geospatial Techniques for Proxy Data of Gilgel Gibe Catchment, Ethiopia. Water (Switzerland) 14.
  11. Legesse Kura A, Abrar H, Esayas Dube E, Likisa Beyene D (2021) AHP based analysis of groundwater potential in the western escarpment of the Ethiopian rift valley. Geol Ecol Landscapes.
  12. Sajil Kumar PJ, Elango L, Schneider M (2022) GIS and AHP Based Groundwater Potential Zones Delineation in Chennai River Basin (CRB), India. Sustain14.
  13. Hussein AA, Govindu V, Nigusse AGM (2017) Evaluation of groundwater potential using geospatial techniques. Appl Water Sci 7: 2447-2461.
  14. Ouchar Mahamat Hijazi AD, MorabitiK, Rahimi A, Amellah O, Fadil O (2021) Delineating of groundwater potential zones based on remote sensing, GIS and analytical hierarchical process: a case of Waddai, eastern Chad. GeoJournal 86.
  15. Doke A (2019) Delineation of the Groundwater Potential Using Remote Sensing and GIS: A Case Study of Ulhas Basin, Maharashtra, India. Arch Photogramm Cartogr Remote Sens 31: 49-64.
  16. Arulbalaji P, Padmalal D, Sreelash K (2019) GIS and AHP Techniques Based Delineation of Groundwater Potential Zones: a case study from Southern Western Ghats, India. Sci Rep 9: 1-17.
  17. Castillo JLU, Cruz DAM, Leal JAR, Vargas JT, Tapia SAR, et al. (2022) Delineation of Groundwater Potential Zones (GWPZs) in a Semi-Arid Basin through Remote Sensing, GIS, and AHP Approaches. Water (Switzerland) 14.
  18. Kaewdum N, Chotpantarat S (2021) Mapping Potential Zones for Groundwater Recharge Using a GIS Technique in the Lower Khwae Hanuman Sub-Basin Area, Prachin Buri Province, Thailand. Front Earth Sci 9: 1-16.
  19. Jothimani M, Abebe A, Duraisamy R (2021) Groundwater potential zones identification in Arba Minch town, Rift Valley, Ethiopia, using geospatial and AHP tools. IOP Conf Ser Earth Environ Sci 822.
  20. Biswas S, Mukhopadhyay BP, Bera A (2020) Delineating groundwater potential zones of agriculture dominated landscapes using GIS based AHP techniques: a case study from Uttar Dinajpur district, West Bengal. Environ Earth Sci 79.
  21. Biswas A, et al. (2012) Hydrogeochemical contrast between brown and grey sand aquifers in shallow depth of Bengal Basin: Consequences for sustainable drinking water supply. Sci Total Environ 431: 402-412.
  22. Kumar T, Gautam AK, Kumar T (2014) Appraising the accuracy of GIS-based Multi-criteria decision making technique for delineation of Groundwater potential zones. Water Resour Manag 28: 4449-4466.
  23. Rahmati O, Nazari Samani A, Mahdavi M, Pourghasemi HR, Zeinivand H (2015) Groundwater potential mapping at Kurdistan region of Iran using analytic hierarchy process and GIS. Arab J Geosci 8: 7059-7071.
  24. Yihunie D, Halefom A (2020) Investigation of groundwater potential zone using Geospatial Technology in Bahir Dar Zuria District, Amhara, Ethiopia. An Int Sci J 146: 274-289.
  25. Çelik R (2019) Evaluation of Groundwater Potential by GIS-Based Multicriteria Decision Making as a Spatial Prediction Tool: Case Study in the Tigris River Batman-Hasankeyf Sub-Basin, Turkey. Water 11.
  26. Yeh HF, Cheng YS, Lin HL, Lee CH (2016) Mapping groundwater recharge potential zone using a GIS approach in Hualian River, Taiwan. Sustain Environ Res 26: 33-43.
  27. Thapa R, Gupta S, Guin S, Kaur H (2017) Assessment of groundwater potential zones using multi-influencing factor (MIF) and GIS: a case study from Birbhum district, West Bengal. Appl Water Sci 7: 4117-4131.
  28. Mandal U, et al. (2016) Delineation of Groundwater Potential Zones of Coastal Groundwater Basin Using Multi-Criteria Decision Making Technique. Water Resour Manag 30: 4293-4310.
  29. Gadrani L, Lominadze G, Tsitsagi M (2018) F assessment of landuse/landcover (LULC) change of Tbilisi and surrounding area using remote sensing (RS) and GIS. Ann Agrar Sci 16: 163-169.
  30. Adewumi AJ, Anifowose YB (2017) Hydrogeologic characterization of Owo and its environs using remote sensing and GIS. Appl Water Sci 7: 2987-3000.
  31. Dahiphale P, Kasal y, Madane D (2020) European Journal of Molecular & Clinical Medicine Groundwater Potential Zones Identification Using Geographical Information System. 07.
  32. Selvam S, Magesh NS, Sivasubramanian P, Soundranayagam JP, Manimaran G, et al. (2014) Deciphering of groundwater potential zones in Tuticorin, Tamil Nadu, using remote sensing and GIS techniques. J Geol Soc India 84: 597-608.
  33. Magesh NS, Chandrasekar N, Soundranayagam JP (2012) Delineation of groundwater potential zones in Theni district, Tamil Nadu, using remote sensing, GIS and MIF techniques. Geosci Front 3: 189-196.
  34. Jhariya DC, Kumar T, Gobinath M, Diwan P, Kishore N (2016) Assessment of groundwater potential zone using remote sensing, GIS and multi criteria decision analysis techniques. J Geol Soc India 88: 481-492.
  35. Kudamnya E, Andongma W (2017) Predictive Mapping for Groundwater within Sokoto Basin, North Western Nigeria. J Geogr Environ Earth Sci Int 10: 1-14.
  36. Ndatuwong LG, Yadav GS (2014) Integration of Hydrogeological Factors for Identification of Groundwater Potential Zones Using Remote Sensing and GIS Techniques. J Geosci Geomatics 2: 11-16.
  37. Mu E, Pereyra-Rojas M (2017) Group Decision-Making in AHP.
  38. Patidar N, Mohseni U, Pathan AI, Agnihotri PG (2022) Groundwater Potential Zone Mapping Using an Integrated Approach of GIS-Based AHP-TOPSIS in Ujjain District, Madhya Pradesh, India. Water Conserv Sci Eng 7: 267-282.
  39. Saaty TL (1984) 285 R. Avenhaus et al. (eds.), pg: 285-286.
  40. Leake C, Malczewski J (2000) GIS and Multicriteria Decision Analysis. J Oper Res Soc 51.
  41. Greene R, Devillers R, Luther JE, Eddy BG (2011) GIS-Based Multiple-Criteria Decision Analysis. 6: 412-432.
  42. Triantaphyllou E, Sánchez A (1997) A Sensitivity Analysis Approach for Some Deterministic Multi‐Criteria Decision‐Making Methods. Decis Sci 28: 151-194.
  43. Doke AB, Zolekar RB, Patel H, Das S (2021) Geospatial mapping of groundwater potential zones using multi-criteria decision-making AHP approach in a hardrock basaltic terrain in India. Ecol Indic 127.

Improving Traumatic Brain Injury Outcomes: Early Identification and Management of Paroxysmal Sympathetic Hyperactivity

DOI: 10.31038/IJNM.2023433

Introduction

There is a high incidence of excessive sympathetic outflow activity in many traumatic brain injury (TBI) patients [1]. Symptoms consist of hyperthermia, sweating, arterial hypertension, tachycardia, tachypnea, and extremity motor dystonic posturing, often in response to stimuli [1-3]. The lack of clear definition or terminology of the symptomatology of this syndrome has caused under diagnosis despite its high incidence in severe traumatic brain injury, morbidity and mortality and the increased healthcare and societal costs associated with traumatic brain injured patients [1]. The absence of a unified diagnostic criterion has severely hindered the ability to advance medical treatments. Finally, in 2014, a consensus expert group came together, 60 years after the first described written case, to establish a rigorous conceptual definition and diagnostic criteria [1-3]. The term Paroxysmal Sympathetic Hyperactivity (PSH) was introduced by a consensus group in 2014 and has become the unified term or acknowledged definition of these abnormal symptoms in TBI patients. The identified criteria and assessment tool, known as the Paroxysmal Sympathetic Hyperactivity Assessment Measure (PSH-AM) was developed and can be useful in assisting healthcare professionals in the diagnosis and medical management of TBI patients [3]. The PSH-AM is broken into two components the Diagnostic Likelihood Tool (DLT) and Clinical Feature Scale (CFS).

Currently, within a large teaching community level one trauma center, in the south side of Chicago, there is a perceived lack of implementation of evidence into practice in the surgical trauma intensive care unit. Most nurses working in the surgical trauma intensive care unit (STICU) admit that TBI patients are difficult to take care of given the complex pathophysiological nature of their injury or injuries. The trauma multidisciplinary team’s data has also seen an increase in TBI readmission to the intensive care unit related to PSH symptoms and medication administration. It was identified that an educational quality improvement project was needed to improve care provided to our TBI patients, specifically, patients showing signs and symptoms of PSH, in the STICU. By providing education to healthcare professionals about the current literature, pathophysiology, pharmacological management, and newly acknowledged PSH-AM tool, healthcare professionals can deliver evidence-based care. The belief is that PSH will be recognized and treated earlier to prevent worsening brain injury and unfavorable outcomes in this patient population.

Literature Review

Literature was reviewed and obtained after using the search engines of CINHAL, MEDLINE, and PubMed. The search strategy and keywords that were used consisted of full-text, English, an adult population (>18 years of age), paroxysmal sympathetic hyperactivity (PSH), autonomic dysregulation, sympathetic storm, dysautonomia, traumatic brain injury (TBI), and acquired or acute brain injury ABI). Four main research articles were evaluated and synthesized for evidence about PSH in TBI patients. Mathew et al. [4] have acknowledged in the literature that most studies have a wide range of incidental findings of PSH in TBI patients ranging from 8% to 33%. All articles identified the most common symptoms of PSH as tachycardia, tachypnea, hypertension, hyperthermia, diaphoresis, and extremity motor posturing. The studies recognized that symptoms could occur within the first five days of admission and may last more than two months. Symptom management is vital throughout all transitional phases in the acute care setting of these patients. All studies evaluated for evidence identified the significance of clinical symptomatology of PSH and that the PSH-AM tool had clinical usage in assisting healthcare providers in identifying symptoms of PSH for adequate diagnosis and prompt treatment management. Most literature notes that greater than 80% of the paroxysmal episodes in TBI or acquired brain injury patients are related to allodynic responses to noxious and non-noxious stimuli like suctioning, pressure sensations, and noise to name a few [5]. Identifying patient triggers or stimuli is beneficial in the overall care management of PSH patients. The studies also addressed the impact PSH had on length of hospital stay and worsening outcomes. Samuel el al. [2] in their study, assumed clinical assessment as the gold standard, while utilizing the PSH-AM tool yielded a sensitivity of 94% (identifying who has PSH) and specificity of 35% (ruling out who does not have PSH). The other studies discussed how the PSH-AM tool correlated with adequate diagnosis when used appropriately. The literature reviewed on PSH in TBI patients will provide imperative information regarding best practice management of the syndrome and allow for the development of a unit-specific educational seminar for quality improvement on TBI care and outcomes.

Project Methods

The project’s purpose is to improve the bedside care of TBI injury patients in the STICU by preventing secondary brain injury through early identification and management of PSH. The STICU setting was selected for this quality initiative because of the amount of TBIs this unit acquires, the high acuity this patient population poses, and the increased awareness of the identified educational needs of the healthcare professionals working in this unit. The internal review board for the institution was consulted, but no further approval was needed from the review board since this was deemed a quality improvement project. Key stakeholders were identified early and included the trauma director, attending physician leadership, nursing management, nursing educator, and the STICU’s pharmacist. The gatekeeper and overseer of the project was the trauma director and another surgical trauma attending colleague who assisted with creating urgency of PSH knowledge amongst residents and other physician colleagues. The nursing unit management and the unit nurse educator helped with sending out emails regarding the educational project presentation, empowering nurses, and obtained presentation equipment technologies. Lastly, the STICU’s pharmacist assisted with the pharmacological knowledge of the medications associated with the syndrome. Project objectives and outcomes were discussed in detail with all key members prior to the project’s roll-out to healthcare providers working in the STICU setting.

Evaluation of Outcomes and Limitations

The evaluation process consisted post-tests scores after a provided education seminar. One of these seminars was particularly for the eight attending surgical intensivists, who are also trauma surgeons on the unit. Their educational needs centered around the symptoms of PSH and the evidenced based pharmacological management therapies. The rest of the seminars were geared towards nursing staff, residents, and nurse practitioners working in the unit. These population educational needs centered more in depth with the history, pathophysiology, interventions and management. A total of 36 nurses, three NPs, and four attending physicians completed the seminar, the pre-post-tests, and evaluation process. This quality improvement project did have a few limitations. A required calculated sample size of 62 participants was not achieved. This was due to several factors, including high acuity of the patients in the intensive care setting, work and staffing schedules, timing of seminar sessions, a physician lacking the perceived need of the education and the presenter being sick with COVID-19 for 10 days (about 1 and a half weeks). During the implementation of education, there were technological issues with signing online to obtain the PowerPoint presentation and the connection capabilities of computer and monitoring screens in some seminar sessions. At times, the PowerPoint was viewed via laptop computer with a few nurses huddled around. Lastly, the evaluation process and chart review were completed by the project content expert who also created the educational presentation. The pre and post-test evaluation’s goal was to obtain an improvement in test scores. The goal was an increase in scores by more than twenty percent for knowledge attainment through statistical measures. Pre-test score average was 3.9 out of 6 questions with an overall score of 65% and the post-test average was 5.5 out of 6 questions with an overall score of 92% of all participants. The outcome for knowledge attainment was achieved statistically post-test with an overall score of greater than 85%. Eight patients were chart reviewed for PSH, after sustaining a TBI, utilizing the two constructs of the Paroxysmal Sympathetic Hyperactivity Assessment Measure (PSH-AM). Five patients were identified early, and treatment started at the time of symptom onset, while three patients were noted to have missed symptoms with treatment started one to three days post spike in temperature and documented symptoms. Propranolol was still noted as the attending physician’s first preference in patient management; however, oxycodone was more widely being applied early and utilized with post weaning of Fentanyl drips for PSH patients experiencing prominent symptoms identified by the PSH-AM and clinical presentation. Prior to this educational presentation, little was known regarding the current literature on the topic of PSH by many of the healthcare providers involved in the seminar sessions. Post-presentation, there were small improvements noted after chart review of the first 6 months of project implementation within the surgical trauma ICU. Most patient symptomatology only lasted, on average, two to three weeks, and by the time of discharge, some of the PSH medications were able to be weaned off. Key takeaways were noted with the post presentation presenter evaluation form. The acknowledged significances of this project included the following: the information presented was important for bedside practice, the presentation was concise, objectives noted, the pathophysiology of the syndrome and the rationale to early identification and management was presented clearly, the overall outcomes were summarized, and the continuous need for increased monitoring and bedside care for TBI patients who may develop PSH was identified by all healthcare providers. This continuous quality improvement project will continue onward in the surgical trauma ICU with the medical management and care of TBI patients, specifically patients at considerable risk of acquiring PSH. The PowerPoint presentation and three evidence-based articles on the topic will be posted on the surgical trauma ICU nursing and resident websites for educational review. Secondary brain injury in TBI patients will continue to decline as health care providers realize the importance of early identification and management of this syndrome.

Impact on Practice

There was an immediate impact with the healthcare team’s early recognition of the signs and symptoms of PSH in our TBI patient population. The t-test scores identified greater than 20% increase in average scores. The earlier identification of symptoms allowed for appropriate medication management of this syndrome and prevented worsening outcomes. Nursing care was further adjusted to prevent provocation of PSH symptoms and to meet patient and family care needs. The predicted long-term impact will include utilizing the information provided in this educational quality improvement project to identify PSH symptomatology, earlier pharmacological management, meeting quality outcomes for this population within the acute care setting and limiting and preventing secondary brain injury in the healthcare system’s TBI population. Ongoing educational implementation will be impactful in the long term. The STICU nursing website will provide a resource for nursing staff. The website will include the project’s educational PowerPoint and three main articles reviewed on PSH. Continued excitement and reinforcement measures at the bedside from the surgical trauma healthcare team regarding TBI management will be key in meeting quality outcomes for this highly unique patient population [6-13].

Conclusion

In conclusion, the data gathered from this quality improvement project indicates that knowledge attainment can be achieved by presenting new evidence on TBI care management and engaging educational seminars in the ICU setting. The most current evidence was disseminated and transitioned into practice, immediately. Further educational seminars should be provided to nurses and new healthcare professionals caring for traumatic brain injury patients by the surgical trauma team. The Likert evaluation tool allowed for suggestions and improvements in the visual presentation and the delivery method of key information in the presenter’s PowerPoint. Key stakeholders and leadership partners need to continue to maintain urgency in early identification and management of PSH in TBI patients to prevent worsening outcomes in this population. Further research and evidence are needed with the utilization of the PSH-AM tool in acute care practice. A TBI management protocol would be beneficial in acute care settings including the management of PSH and prevention of secondary brain injury in the TBI patient population.

References

  1. Meyfroidt G, Baguley I, Menon D (2017) Paroxysmal sympathetic hyperactivity: the storm after acute brain injury. The Lancet Neurology 16: 721-729. [crossref]
  2. Samuel S, Lee M, Brown RJ, Choi HA, Baguley IJ (2018) Incidence of paroxysmal sympathetic hyperactivity following traumatic brain injury using assessment tools. Brain Injury 32: 1115-1121. [crossref]
  3. Zheng R, Lei Z, Yang R, Huang G, Zhang G (2020) Identification and management of paroxysmal sympathetic hyperactivity after traumatic brain injury. Frontiers in Neurology 11: 1-14. [crossref]
  4. Mathew MJ, Deepika A, Shukla D, Devi BI, Ramesh VJ (2016) Paroxysmal sympathetic hyperactivity in severe traumatic brain injury. Acta Neurochirurgica, 158: 2047-2052. [crossref]
  5. Thomas A, Greenwald B (2019) Paroxysmal sympathetic hyperactivity and clinical considerations for patient with acquired brain injury. American Journal of Physical Medicine & Rehabilitation 98: 65-72. [crossref]
  6. Abdelmalik AP, Draghic N, Ling FS, Geoffrey (2018) Management of moderate to severe traumatic brain injury. Transfusion 59: 1529-1538. [crossref]
  7. Dang D, Dearholt, S, Bissett K, Ascenzi J, Whalen M (2022) Johns Hopkins evidence-based practice for nurses and healthcare professionals: model and guidelines. 4th ed. Indianapolis, IN: Sigma Theta Tau International.
  8. Ding H, Liao L, Zheng X, Wang Q, Liu Z, et al. (2021) B-Blockers in traumatic brain injury: A systematic review and meta-analysis. Journal of Trauma and Acute Care Surgery 90: 1077-1085. [crossref]
  9. Jafari AA, Shah M, Mirmoeeni S, Hassani SM, Nazari S, et al. (2021). Paroxysmal sympathetic hyperactivity during traumatic brain injury. Clinical Neurology and Neurosurgery 212: 1-6. [crossref]
  10. Khalid SM, Yang LG, Mcguire LJ, Robinson JM, Foreman B, et al. (2019) Autonomic dysfunction following traumatic brain injury: translational insights. Neurosurgical Focus 47: E8 1-8. [crossref]
  11. Nguembu SMM, Endalle G, Dokponou H, Dada EO, et al. (2021) Paroxysmal sympathetic hyperactivity in moderate-to-severe traumatic brain injury and the role of beta-blockers: A scoping review. Emergency Medicine International 1-6.[crossref]
  12. Shald AE, Reeder J, Finnick M, Patel I, Evans K, et al. (2020) Pharmacological treatment for paroxysmal sympathetic hyperactivity. Critical Care Nurse 40: e9-e16. [crossref]
  13. van Eijck M, Sprenger M, Oldenbeuving A, de Vries J, Schoonman G, et al. (2019) The use of PSH-AM in patients with diffuse axonal injury and autonomic dysregulation: A cohort study and review. Journal of Critical Care 49: 110-117. [crossref]