*Supporting open minds since 2005*

Antiphospholipid Syndrome - Recent Advances in Clinical and Basic Aspects http://dx.doi.org/10.5772/intechopen.91508 Edited by Polona Žigon

#### Contributors

Pavol Holly, Peter Kubisz, Jan Stasko, Polona Žigon, Ula Štok, Snežna Sodin-Šemrl, Saša Čučnik, Kenji Tanimura, Hideto Yamada, Yuki Sasagawa, Masashi Deguchi, Noriko Arase, Hisashi Arase, John Cole, Matthew J. Woodward, Sana Somani, Adeolu Morawo, Rakhee Lalla, Adam P. Klein, Kathryn Grimes, Ariela Hoxha, Paolo Simioni

#### © The Editor(s) and the Author(s) 2022

The rights of the editor(s) and the author(s) have been asserted in accordance with the Copyright, Designs and Patents Act 1988. All rights to the book as a whole are reserved by INTECHOPEN LIMITED. The book as a whole (compilation) cannot be reproduced, distributed or used for commercial or non-commercial purposes without INTECHOPEN LIMITED's written permission. Enquiries concerning the use of the book should be directed to INTECHOPEN LIMITED rights and permissions department (permissions@intechopen.com).

Violations are liable to prosecution under the governing Copyright Law.

Individual chapters of this publication are distributed under the terms of the Creative Commons Attribution 3.0 Unported License which permits commercial use, distribution and reproduction of the individual chapters, provided the original author(s) and source publication are appropriately acknowledged. If so indicated, certain images may not be included under the Creative Commons license. In such cases users will need to obtain permission from the license holder to reproduce the material. More details and guidelines concerning content reuse and adaptation can be found at http://www.intechopen.com/copyright-policy.html.

#### Notice

Statements and opinions expressed in the chapters are these of the individual contributors and not necessarily those of the editors or publisher. No responsibility is accepted for the accuracy of information contained in the published chapters. The publisher assumes no responsibility for any damage or injury to persons or property arising out of the use of any materials, instructions, methods or ideas contained in the book.

First published in London, United Kingdom, 2022 by IntechOpen IntechOpen is the global imprint of INTECHOPEN LIMITED, registered in England and Wales, registration number: 11086078, 5 Princes Gate Court, London, SW7 2QJ, United Kingdom Printed in Croatia

British Library Cataloguing-in-Publication Data A catalogue record for this book is available from the British Library

Additional hard and PDF copies can be obtained from<EMAIL_ADDRESS>
Antiphospholipid Syndrome - Recent Advances in Clinical and Basic Aspects Edited by Polona Žigon p. cm. Print ISBN 978-1-83969-053-2 Online ISBN 978-1-83969-054-9 eBook (PDF) ISBN 978-1-83969-055-6


**3.5 The value of information**

In an era of increasingly tight budgets, it is imperative that funders in both the public and private sectors understand the value of investments in different types of information distributed across and within the germane research areas. Climate change research is a case in point; billions of dollars are being spent to improve the knowledge base for future decision-making. A study by the National Research Council [44] called for decision tools to assist in estimating "the value of new information which can help decision makers plan research programs and determine which trends to monitor to best implement a risk management strategy." Identifying the relevant decision-makers measurable priorities is critical, though, because it is their net benefit valuation protocols that produce the VOI metrics with which these calculations can be conducted. The Academy study emphasized that the application of decision theory could provide explicit descriptions of how rigorously to evaluate the appropriate value of perfect and imperfect information, much as done 30 years ago in [45–47].

On the health side of the comparison, VOI estimates need not be calibrated in monetary currency; human lives or other metric can be employed, especially if it can support aggregation across locations. This is one of the major lessons from the "risk to unique and threatened systems" Reason for Concern described in [48], even for the two areas where risks are measured in aggregates. In fact, risks of extreme (weather) events and risks to unique and threatened systems (including human communities) are areas where alternatives to financial currency are preferred.

Assuming access to decision-makers' lists of operative and quantifiable valuation metrics (including confidence in the ability to keep experienced risk below a tolerable maximum), temporal distributions of the value of enacting a re-opening strategy of a locked-down economy relative to a "stay the course" strategy could be available, for example, and the sign and magnitude of valued in differences in lives or jobs or gross domestic product or income inequality or even the likelihood of slowing progress toward an SDG could all be of interest, so, too, would be estimates of distributions of the value of improved (or depreciated) information about driving variables and/or epidemiological-socio-economic specifications.


**4. Conclusions**

In this paper, we reviewed the latest advancements in mycelium-related research and applications from academia and industry to understand the diversity of perspectives and advancements. The advantages of using mycelium-based materials in the construction industry can incentivise the birth of new protocols, consider waste as a resource, and develop new methodologies to evaluate and assess the impact of the built environment. Thus far, mycelium-based materials have been most successfully implemented at the scale of small commercial products and commodities, with a number of challenges barring the expansion of applications to architecture. Coupling a material such as MBC with appropriate computational design and digital fabrication methods, while also developing mass-production techniques and local material profile strategies, has the potential to successfully scale up architectural applications of mycelium-based materials. The challenges and research gaps we identified are cross-disciplinary in nature and will require a close collaboration on material research, integrated design methods, appropriate digital fabrication techniques, and on-site implementation strategies from microbiologists, material scientists, manufacturers, and designers alike.

**Author Contributions:** S.B. and T.D. contributed equally to this paper. Conceptualization, S.B., T.D. and J.L.; investigation, S.B., T.D. and J.L.; writing—original draft preparation, S.B., T.D. and J.L.; writing—review and editing, S.B., T.D. and J.L.; visualization, S.B., T.D. and J.L.; supervision, J.L., T.V.M., B.D. and P.B.; project administration, J.L.; funding acquisition, B.D. and P.B. All authors have read and agreed to the published version of the manuscript.

**Funding:** This research is made possible by the ETH Singapore's Future Cities Laboratory (FCL) Global Project, funded by the National Research Foundation (NRF) of Singapore. This work is a part of a collaborative research project "Urban BioCycles", with Dirk Hebel of Karlsruhe Institute of Technology and Hortense Le Ferrand of Nanyang Technological University in Singapore.

**Institutional Review Board Statement:** Not applicable.

**Informed Consent Statement:** Not applicable.

**Data Availability Statement:** Not applicable.

**Conflicts of Interest:** The authors declare no conflict of interest.


**1. Introduction**

Current research studies have been focusing on the procurement of environmentally friendly materials with the aim of resolving the problems created by materials derived from petroleum. Starch is a promising biopolymer used in the production of biocomposite materials because it is renewable, completely biodegradable, and easily available at a low cost. Starch, in the form of its thermoplastic derivate (TPS), has been revealed as an appropriate candidate to be employed as a substitute of synthetic polymers traditionally used for packaging. Starch is not a real thermoplastic polymer, but can be processed after its gelatinization by mixing it with enough water and/or plasticizers [1, 2]. In most investigations the plasticization of the material is carried out by casting a dispersion of starch with glycerol [1, 3].

TPS films are reported to have low permeability to gases, poor water vapor barrier properties, and must resist the tensions arising from their use in packaging [4].

Therefore, improving the resistance of TPS films to traction forces is a factor that must be taken into consideration for their use [5, 6]. The use of reinforcing agents in the starch matrix is an effective means of overcoming these drawbacks and several types of biodegradable reinforce‐ ments such as cellulosic fibers, whiskers, and cellulose nanofibers (CNF) have been utilized to develop new and inexpensive starch biocomposites. Cellulose is the most abundant, renewable polymer in the world; it is found in plant cell walls and it can also be synthesized by some bacteria. Its reinforcing property is remarkable [7]. Basically two types of nanoreinforcements can be obtained from cellulose: microfibrils (or CNF) and whiskers.

Improving the mechanical and water barrier properties by the addition of CNF (extracted from different botanical sources) can depend on the correct dispersion and the generation of an active nanoreinforcement/matrix interface.

This chapter provides the latest advances in green composite materials based on TPS and cellulose fibers and includes information on compositions, preparations, and the properties of "green" composite materials elaborated from TPS and cellulose fibers, with the focus on using undervalued natural resources.


**About the Editor**

#### **Hae-Young Chung**

#### **Education and Training**

#### **Professional Experiences**

College of Pharmacy, Pusan National University, Busan, Korea

## *Editorial* **Impacts of Calorie Restriction and Intermittent Fasting on Health and Diseases: Current Trends**

**Hae Young Chung 1,\*, Dae Hyun Kim 1, EunJin Bang 1 and Byung Pal Yu 2**

Received: 4 September 2020; Accepted: 14 September 2020; Published: 25 September 2020

This special issue on the effects of calorie restriction (CR) and intermittent fasting (IF) on health and diseases includes five scholarly reviews and four original articles that provide an insight into the molecular and cellular action mechanisms of epigenetically manipulated dietary paradigms.

CR and IF are well publicized methods for health promotion and disease prevention. An interesting aspect shared by both is that their efficacy is demonstrable without modification of any dietary ingredient. CR, also often called as restriction in dietary intake, provides dietary allocation (generally 10–50% of ad libitum feeding) to the experimental group [1]. Currently, gerontologists have acknowledged CR as the only well-founded anti-aging experimental model and the gold standard in investigating aging interventions. CR intervention delays biological aging and attenuates many age-related pathological processes, thus extending both average and maximal lifespan. Notably, CR is well-known to modulate adulthood diseases, such as atherosclerosis, diabetes, obesity, cancer, and other metabolically related disorders [2].

One unique feature of CR, first proposed as growth retardation in 1935 [3], is its well-known effect on various species, such as rats, mice, hamsters, dogs, yeast, fish, flies, monkeys, and humans [4]. Although many hypotheses for CR diverse actions have been proposed previously, at present, the precise underlying mechanisms remain to be proven. One attractive and plausible mechanism is its highly effective anti-oxidative action against oxidative stress-induced aging. The anti-aging effects of CR are likely attributable to its ability to prevent ubiquitous redox stress by maintaining a homeostatic cellular oxidative status and an antioxidative defense system that contributes to appropriate cellular signaling transductions and proper gene transcription activity [5]. One of the oxidative stress-related physiological processes is the activation of inflammation. The key pro-inflammatory molecules, IL-1β, IL-6, TNFα, iNOS, and COX-2 are all alleviated by CR during aging [6]. CR implementation leads to epigenetic alterations, such as histone modifications and methylation of promoter CpG islands, resulting in epigenetically modified markers in histones and chromatin. This established a molecular mechanism for gene transcription and expression regulation [7,8]. In this regard, lymphocyte-specific protein tyrosine kinase as a new target molecule of the CR modulatory effect was found by integrative analysis using cDNA microarray and interactome [9].

Recent progress in Omics technologies has contributed to technical improvement that allows analysis at the level of the RNA, DNA, protein, and other cellular molecules and their intricate associations during aging. Therefore, it is now feasible to both resolve and coordinate complex biological processes during aging using recent methods, such as next-generation sequencing, proteomics, lipidomics, metabolomics, and epigenomics techniques. Systems biology and Omics integration can predict CR effects, cellular signaling pathways, and action mechanisms. These technical advances made in recent years provide a much-needed database on the regulation of inflammatory process. An expanded view of the inflammatory response in aging progression dubbed as "senoinflammation",

which describes both chronic inflammation and metabolic dysregulation, was suggested in our previous work [10]. Based on previous studies, we observed that the senescence-associated secretory phenotype (SASP) comprises cytokines and chemokines, and these were notably upregulated during aging. This senoinflammatory response was reversed and downregulated by CR [11]. Moreover, metabolic signaling pathways at the cell level were also dysregulated in aging progression, and CR mimetics could reverse such effects. According to CR and Omics big data analysis, cytokines and chemokine pathways are upregulated during aging and modulated by CR [12]. CR is widely accepted as a positive and reasonable control for anti-aging intervention, which recovers disturbed metabolic pathways and decreases the pro-inflammatory SASP [11].

IF is a dietary pattern alternating between fasting and non-fasting periods. Specifically, the IF diet in a particular mouse strain extended both mean and maximal lifespans [13]. For example, loss of body weight and extension of maximal lifespan were observed in 2-, 6-, and 10-month-old C57BL/6J mice with IF implementation [14]. Furthermore, IF lowered the occurrence of diabetes and levels of fasting glucose and insulin [15]. These effects of IF are similar to those observed with CR. The beneficial results of IF on different cancers are also explained by many research groups [16]. The observations in animals indicate that, owing to dietary intake reduction, IF could effectively regulate the number of risk factors and thereby prevent chronic diseases. Such modulatory effects of IF are similar to those of CR. Although the effectiveness of IF has been reported primarily based on in vivo models, implementation of IF in humans has been proposed to prevent major risk factors for age-associated diseases [17]. Systems gerontology (i.e., the study on the overall mechanisms of complex aging progression as an integrated network of systemic interacting molecular pathways, organs, and components during aging) based on Omics technology and systems biology should facilitate unraveling of mechanisms underlying the anti-aging actions of CR and IF as well as their similarities and dissimilarities for better dietary strategies.

The growth hormone (GF)/insulin-like growth factor-1 (IGF-1) axis is an evolutionary well-conserved signaling axis, and the mechanisms underlying its effects on aging and longevity are modulated by CR in mammals [18]. Recently, Shimokawa's group confirmed that neuropeptide Y (Npy) and FoxO1, which are targets of CR, play various roles in aging and age-associated diseases depending on the nutritional intake [19]. The longevity effects of CR and suppression of IGF-1 signaling pathway are sexually heterogeneous. The beneficial effects of Npy during CR and the diverse roles for Npy in life stages are also described. These genes that mediate the effects of CR and control the aging process depend on nutritional states [19]. As described in a review by Higami's group, the mitochondrial biogenesis, following CR implementation, in white adipose tissue is regulated by peroxisome proliferator-activated receptor γ coactivator-1α (PGC-1α), a transcription cofactor regulated by sterol regulatory element-binding protein 1c (SREBP-1c), which is the principal regulator of fatty acid biosynthesis [20]. This research group has also suggested that CR mediates the increase in SREBP-1 and PGC-1α, which could occur because of downregulation of the leptin signaling axis and upregulation of fibroblast growth factor 21 (FGF21) expression in white adipose tissue [21].

Another cellular activity recently that was revealed as one of the major players in CR action is the involvement of autophagy. Autophagy is an important cellular management process that maintains an optimal cellular homeostatic condition under normal physiological and abnormal pathological states. Recent developments in CR research have proposed that the initiation of autophagy is associated with beneficial anti-aging response. CR-promoted autophagy plays a critical role under physiological states by sustaining proper homeostasis in the organism. In addition, autophagy induced by CR plays a protective role in different organs and tissues under many pathological and aging-associated conditions [22]. While CR is the most beneficial intervention to prolong lifespan and prevent aging-related diseases, its positive effects on skin aging and diseases are not yet fully understood. CR promotes anti-inflammatory and anti-oxidative responses, stem cell maintenance, and metabolic activities, and such effects contribute to the positive effects on skin aging [23]. Furthermore, widely known CR mimetics, for example, resveratrol, metformin, rapamycin, and peroxisome proliferator-activated receptor agonists, exhibit CR-like effects to inhibit or delay skin aging [23].

Fasting is known to account for physiological changes in the endocrine organs, particularly the pancreas. The study on every other day IF implementation for up to 3 months in a developing and matured healthy organism suggested that this regimen promotes β-cell dysfunction and muscle mass loss and increases fat reserves, especially in developing 30-day-old Wistar rats. More long-term studies are needed to explain the most effective IF regimen to minimize side effects [24]. In recent years, fasting-like intervention methods, such as IF and time-restricted feeding, have appeared as alternatives to CR. Lifespan responses in both CR and IF also differ significantly between males and females [25,26], leading to additional complications in explaining the molecular mechanisms of CR. A simple explanation of these in vivo studies is that a particular regimen of CR and IF may not be effective; however, they may be rather harmful possibly owing to genetic variations and sex [27]. Therefore, for implementation and practice of CR and IF in humans, it is suggested that personalized genomics and medicine should first be set in place to make the most of CR and IF [28].

In summary, we believe that this special issue provides useful information on the current research trends regarding the beneficial effects of CR and IF on longevity and health of humans. Further exploration of the effect of CR and IF on aging and age-related diseases will provide deeper insights into the interrelationships between health and diseases and enable beneficial interventions in aging mechanisms, thus aiding the development of new therapeutic approaches to improve health, diseases, and longevity.

**Author Contributions:** All authors contributed equally to the development and finalization of this Editorial. All authors have read and agreed to the published version of the manuscript.

**Funding:** This work was supported by the National Research Foundation of Korea (NRF) grant funded by the Korea government (MSIT) (2018R1A2A3075425).

**Acknowledgments:** We thank Aging Tissue Bank (Busan, Korea) for providing research information.

**Conflicts of Interest:** The authors declare no conflict of interest.

#### **References**

© 2020 by the authors. Licensee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license (http://creativecommons.org/licenses/by/4.0/).


**Statistical significance of result**

(*p* < 0.001) improvements in misdirected swallowing, cough, hoarseness, oesophageal retention, globus sensation, VAS scores, pharyngeal sling force, velopharyngeal closure and swallowing ability.


**TRENDS IN E-LEARNING**

#### **Trends in E-learning**

http://dx.doi.org/10.5772/intechopen.71183 Edited by Mahmut Sinecen

#### **Contributors**

Veeramanickam Mrm, Debnath Bhattacharyya, Tai-hoon Kim, Emerson Abraham Abraham Jackson, Moeketsi Letseka, Matsephe M. Letseka, Victor Justice Pitsoe, Vimbi Petrus Mahlangu, Shuti Steph Khumalo, Glenda H. E. Gay, Lucrecia Llerena, Nancy Rodriguez, John W. Castro, Silvia T. Acuña, Rosa Mayra Llerena, Ana Hadiana, Fatih Çağatay Baz

#### **© The Editor(s) and the Author(s) 2018**

The rights of the editor(s) and the author(s) have been asserted in accordance with the Copyright, Designs and Patents Act 1988. All rights to the book as a whole are reserved by INTECHOPEN LIMITED. The book as a whole (compilation) cannot be reproduced, distributed or used for commercial or non-commercial purposes without INTECHOPEN LIMITED's written permission. Enquiries concerning the use of the book should be directed to INTECHOPEN LIMITED rights and permissions department (permissions@intechopen.com). Violations are liable to prosecution under the governing Copyright Law.

Individual chapters of this publication are distributed under the terms of the Creative Commons Attribution 3.0 Unported License which permits commercial use, distribution and reproduction of the individual chapters, provided the original author(s) and source publication are appropriately acknowledged. If so indicated, certain images may not be included under the Creative Commons license. In such cases users will need to obtain permission from the license holder to reproduce the material. More details and guidelines concerning content reuse and adaptation can be foundat http://www.intechopen.com/copyright-policy.html.

#### **Notice**

Statements and opinions expressed in the chapters are these of the individual contributors and not necessarily those of the editors or publisher. No responsibility is accepted for the accuracy of information contained in the published chapters. The publisher assumes no responsibility for any damage or injury to persons or property arising out of the use of any materials, instructions, methods or ideas contained in the book.

First published in London, United Kingdom, 2018 by IntechOpen eBook (PDF) Published by IntechOpen, 2019 IntechOpen is the global imprint of INTECHOPEN LIMITED, registered in England and Wales, registration number: 11086078, The Shard, 25th floor, 32 London Bridge Street London, SE19SG – United Kingdom Printed in Croatia

British Library Cataloguing-in-Publication Data A catalogue record for this book is available from the British Library

Additional hard and PDF copies can be obtained from<EMAIL_ADDRESS>
Trends in E-learning Edited by Mahmut Sinecen p. cm. Print ISBN 978-1-78923-542-5 Online ISBN 978-1-78923-543-2 eBook (PDF) ISBN 978-1-83881-532-5


**1. Introduction**

218 Urinary Incontinence

Ulmsten, U., Henriksson, L., Johnson, P. & Varhos, G. (1996). An ambulatory surgical

*International Urogynecology Journal*, Vol. 7, No.2, pp. (81-86), ISSN 0937-3462 Webster, G. D., Sihelnik, S. A. & Stone, A. R. (1984). Female urinary incontinence: The

*and Urodynamics*, Vol. 3, No.4, pp. (235-242), ISSN 1520-6777

procedure under local anesthesia for treatment of female urinary incontinence.

incidence, identification, and characteristics of detrusor instabiiity. *Neurourology*

The pelvic floor is a highly complex structure and plays a dual role in supporting the pelvic viscera (bladder, bowel, and uterus) and maintaining the functional integrity of these organs. Pelvic organ support is maintained by complex interactions between the levator ani muscles of the pelvic floor and connective tissues along with the urethra, vaginal wall, rectum, and normal innervation (Boreham et al., 2002; Wei and DeLancey, 2004). The pelvic floor and pelvic cavity is an integral structure and can be functionally divided into three compartments. Each compartment is not discrete and is comprised of different pelvic organs. The anterior compartment contains the urethra and bladder, the middle compartment holds the vagina and uterus, and the posterior compartment consists of the anus and rectum.

Conventionally, the pathophysiology of stress urinary incontinence at the bladder neck is caused by proximal urethral hypermobility and/or intrinsic sphincter deficiency (Schick et al., 2004). The urethra and bladder lie on the supportive or suspension layers which are composed of the pubourethral ligament, endopelvic fascia, pubucoccygeal muscle, and the anterior vaginal wall. The breakdown of these layers can attenuate the urethra and/or cause asymptomatic or symptomatic anterior vaginal wall prolapse.


**3. Results and Discussion**

The FEA model developed in the previous section was used to investigate the stress distributions resulting from different peening schemes in order to better understand how combinations of peening parameters influence residual stress distributions in thin sections. Only one-sided peening without a backing material was considered, reflecting the potential future application of in situ treatment of thin aircraft components. All simulations used a 5 mm × 5 mm square laser spot.

In general, a favorable state of residual stress for mitigating fatigue has several key characteristics. First, sufficient compression should exist at the surface and in the near-surface regions of critical areas of the component to offset fatigue-inducing tensile stresses. Second, the distribution and magnitude of the compensatory tension that arises from the LP process should not initiate a failure event when fatigue loads are applied. Third, for a line of peen spots that align with and overlay a surface scratch, such as the geometry considered in [10,12], near-surface tensile stresses transverse to the peen line should be absent to prevent premature initiation of a crack from the scratch.


**1. Introduction**

The rapid development of the textile industry has resulted to a large proportion of industrial wastewater pollution. Methylene blue (MB) dye is a most widely used dye by industries like textile, paper, rubber, plastics, leather, cosmetics, food industries and pharmaceuticals. The textile industry is classified into three main categories, namely; cellulose fibers (cotton, rayon, linen, ramie, hemp and lyocell), protein fibers (wool, angora, mohair, cashmere and silk) and synthetic fibers (polyester, nylon, spandex, acetate, acrylic, ingeo and polypropylene) [1]. The type of dyes and chemicals used in the textile industry are found to differ depending on the fabrics manufactured. Reactive dyes (remazol, procion MX and cibacron F), direct dyes (congo red, direct yellow 50 and direct brown 116), naphthol dyes (fast yellow GC, fast scarlet R and fast blue B) and indigo dyes (indigo white, tyrian purple and indigo carmine) are some of the dyes used to dye cellulose fibers [1]. The textile industry is known to be the main creator of wastewater effluents because it

consumes more water for its wet processes. Therefore, globally it is estimated that all wastewater discharge is highly populated. According to the world bank estimation, textile dyeing and finishing treatment given to a fabric generates at least 17– 20% of world's industrial wastewater [2, 3].

**2.2 Methods**

10, 20, 30, and 40 cm3

*2.2.1 Synthesis of pine-magnetite composites*

*DOI: http://dx.doi.org/10.5772/intechopen.92114*

*2.2.2 Synthesis of grafted pine magnetite composite*

was dried in a vacuum oven at 40°C.

Elmer) in the range 450–4000 cm1

**2.3 Characterization**

netite (Fe3O4 PMC).

**159**

**3. Results and discussions**

**3.1 FT-IR spectroscopy results**

A mixture of FeSO47H2O (2.1 g) and of Fe(SO4)3XH2O (3.1 g) were dissolved under inert atmosphere in 100 cm3 of double-distilled water with vigorous stirring. Thereafter, 20 cm3 of 28% ammonium hydroxide and the appropriate amount of pine powder was added. The reaction was left to run for 45 min at 80°C under constant stirring. The resulting particles, consisting of magnetite attached to the cellulose (hereafter referred to as bio-composite) were washed several times with deionized water and ethanol and dried in a vacuum oven at 60°C overnight. To

*Characterization of Grafted Acrylamide onto Pine Magnetite Composite for the Removal…*

determine the optimum conditions to achieve the desired products of the

temperatures 40, 60, 80 and 100°C and reaction times 15, 30, 45 and 60 min.

of deionised water were transferred into a three neck round bottom flask at a temperature of 42°C. The reaction was bubbled under nitrogen gas for 30 min to remove the dissolved oxygen under stirring. 10 ml of 0.5 M CAN, dissolved in 0.3 M HNO3 was slowly added to the reaction to initiate graft co-polymerization and stirring was continued for 2 h. Reaction mass was neutralised by 50% NaOH and precipitated in methanol and thereafter washed with methanol/water (90:10) several times, so that the unreacted PMC and ceric salt were removed. The final residue

biocomposites, we experimented with the following variables: volume of NH4OH 5,

1 g of pine magnetite composite (PMC), 20 ml of 1.5 M acrylicamide and 135 ml

Qualitative and fundamental identification of the functional chemical groups of grafted pine magnetite composite (GPMC) were carried out with a FTIR (Perkin-

analytical, PW3040/60 XRD; CuKα anode; *λ* = 0.154 nm) was used for particle size measurements. The size of the synthesized particles was observed using transmission electron microscope (TEM, FEI TECNAI G2 SPIRIT) at an accelerating voltage of 150 kV. TGA (Perkin-Elmer (USA) Simultaneous Thermal Analyzer 6000 instrument) was used for determining the weight loss as a function of temperature. Changes in morphology were studied using scanning electron microscopy (SEM), HRSEM Instrument Specs Model: Jeol JSM 7800F field emission scanning electron microscope run operational voltage: 5kVEDS specs Model: Thermo Fischer UltraDry EDS Detector for the graft co-polymerization and incorporation of iron oxide mag-

The FT-IR spectrum shown in **Figure 1(a)** represents the pine-Fe3O4 magnetite (PMC). The FT-IR spectrum showed some changes in band intensities, indicating the functional groups on the surface that had been modified. A compressed dOH peak at 3350 cm1 with an increase in intensity was observed. This might have been

. An X'Pert PRO X-ray diffractometer (PAN

; weight of pine powder 1.0, 1.5, 2.0, 2.5, 3.0 and 3.5 g;

Dyes often discharged in water effluents contain residues that are highly visible and undesirable even at low concentrations [4]. In addition, they are toxic due to their harmful effects on the human beings. Therefore, it is of vital importance that they are removed from water [5]. Wastewater containing dyes needs to be treated before being discharged into water bodies [6]. Various techniques including chemical oxidation, coagulation-flocculation, membrane processes and biological treatment have shown effectiveness in the removal of methylene blue from waste water [7]. The limitation most of these techniques possess is the incomplete dye removal, poor detection, requirement of expensive equipment and monitoring systems [6]. The performance of adsorption techniques have been applied due to their effectiveness since they remove the entire dye molecule, leaving no fragments in the effluent [8].

Extensive research in recent years has focused on utilizing waste materials from agricultural products (such as pine cones and others) since they are eco-friendly, cost-effective and renewable [9]. Pine cones are naturally occurring agricultural wastes widely found in a plantation in Vanderbijlpark, Gauteng, South Africa. They are of commercial importance and value which is extensively used in different industries [10]. One pine cone consists of 46.5% hemicellulose, 37.4% lignin, 18.8% cellulose and 15.4% extractives [11]. Pine cone powder has been studied extensively in the removal of heavy metal pollutants such as lead, caesium, copper nickel and arsenic from water systems. Activated carbon has been the most employed adsorbent for the removal of dyes due to its outstanding adsorption properties. However, it has limitations by being expensive and it cannot be used in large applications of wastewater treatment. The use of biomass and other microbial cultures in the removal of methylene blue has been extensively studied in recent years. Among others, carbonized organic materials, fly ashes, peat moss, recycled alum sludge, fishery residues and microorganisms such as fungus and algae [12].

The present study reports the development and characterization of grafted pine magnetite composite using grafted acrylamide (GACA) for the removal of methylene blue in wastewater. Grafting is a process of chemically or physically manipulating the surface properties of plant materials such as type and amount of functional groups, surface area and porosity by extraction of plant chemical components in order to improve its adsorptive ability. Grafting of synthetic monomers onto pure biological materials has been successfully performed, e.g., grafting of acrylonitrile onto starch [13] and methyl acrylonitrile onto cotton [14].


**Acknowledgements**

The author wishes to thank the Ministry of Health for providing the data on dog and cat bites and members of the One Health platform in Sierra Leone and the Epi unit of the Ministry of Agriculture and Forestry for their valuable contributions. Special thanks to the staff of the Njala university One Health Serology and Molecular Diagnostics laboratory for the support.


**Gendered Migration and Agroforestry in Indonesia: Livelihoods, Labor, Know-How, Networks**

**Elok Mulyoutami 1,\* , Betha Lusiana 1 and Meine van Noordwijk 1,2**

Received: 31 October 2020; Accepted: 16 December 2020; Published: 18 December 2020

**Abstract:** Migration connects land use in areas of origin with areas of new residence, impacting both through individual, gendered choices on the use of land, labor, and knowledge. Synthesizing across two case studies in Indonesia, we focus on five aspects: (i) conditions within the community of origin linked to the reason for people to venture elsewhere, temporarily or permanently; (ii) the changes in the receiving community and its environment, generally in rural areas with lower human population density; (iii) the effect of migration on land use and livelihoods in the areas of origin; (iv) the dynamics of migrants returning with different levels of success; and (v) interactions of migrants in all four aspects with government and other stakeholders of development policies. In-depth interviews and focus group discussions in the study areas showed how decisions vary with gender and age, between individuals, households, and groups of households joining after signs of success. Most of the decision making is linked to perceived poverty, natural resource and land competition, and emergencies, such as natural disasters or increased human conflicts. People returning successfully may help to rebuild the village and its agricultural and agroforestry systems and can invest in social capital (mosques, healthcare, schools).

**Keywords:** coffee; cocoa; Java; livelihoods; rural–urban; remittances; returning migrants; Sumatra; Sulawesi


*Article* **Oropharyngeal Dysphagia and Impaired Motility of the Upper Gastrointestinal Tract—Is There a Clinical Link in Neurocritical Care?**

**Paul Muhle 1,2,\*, Karen Konert 1, Sonja Suntrup-Krueger 1,2, Inga Claus 1, Bendix Labeit 1,2, Mao Ogawa 3, Tobias Warnecke 1, Rainer Wirth 4 and Rainer Dziewas 5**

**Abstract:** Patients in the neurological ICU are at risk of suffering from disorders of the upper gastrointestinal tract. Oropharyngeal dysphagia (OD) can be caused by the underlying neurological disease and/or ICU treatment itself. The latter was also identified as a risk factor for gastrointestinal dysmotility. However, its association with OD and the impact of the neurological condition is unclear. Here, we investigated a possible link between OD and gastric residual volume (GRV) in patients in the neurological ICU. In this retrospective single-center study, patients with an episode of mechanical ventilation (MV) admitted to the neurological ICU due to an acute neurological disease or acute deterioration of a chronic neurological condition from 2011–2017 were included. The patients were submitted to an endoscopic swallowing evaluation within 72 h of the completion of MV. Their GRV was assessed daily. Patients with ≥1 d of GRV ≥500 mL were compared to all the other patients. Regression analysis was performed to identify the predictors of GRV ≥500 mL/d. With respect to GRV, the groups were compared depending on their FEES scores (0–3). A total of 976 patients were included in this study. A total of 35% demonstrated a GRV of ≥500 mL/d at least once. The significant predictors of relevant GRV were age, male gender, infratentorial or hemorrhagic stroke, prolonged MV and poor swallowing function. The patients with the poorest swallowing function presented a GRV of ≥500 mL/d significantly more often than the patients who scored the best. Conclusions: Our findings indicate an association between dysphagia severity and delayed gastric emptying in critically ill neurologic patients. This may partly be due to lesions in the swallowing and gastric network.

**Keywords:** gastric residual volume; dysphagia; flexible endoscopic evaluation of swallowing; gastric emptying; intensive care; neurology; swallowing

#### **1. Introduction**

The upper gastrointestinal (GI) tract consists of the mouth, pharynx, esophagus, stomach and duodenum. To provide sufficient nutrition and fluid intake, a finely tuned interaction between the structures of the GI tract is crucial [1–4], starting with the oropharyngeal phase of swallowing. Oropharyngeal dysphagia (OD) is a key feature of different neurological diseases, such as stroke, neuromuscular and neurodegenerative disorders [5].

**Citation:** Muhle, P.; Konert, K.; Suntrup-Krueger, S.; Claus, I.; Labeit, B.; Ogawa, M.; Warnecke, T.; Wirth, R.; Dziewas, R. Oropharyngeal Dysphagia and Impaired Motility of the Upper Gastrointestinal Tract—Is There a Clinical Link in Neurocritical Care? *Nutrients* **2021**, *13*, 3879. https://doi.org/10.3390/nu13113879

Academic Editors: Dimitrios T. Karayiannis and Zafeiria Mastora

Received: 13 October 2021 Accepted: 28 October 2021 Published: 29 October 2021

**Publisher's Note:** MDPI stays neutral with regard to jurisdictional claims in published maps and institutional affiliations.

**Copyright:** © 2021 by the authors. Licensee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license (https:// creativecommons.org/licenses/by/ 4.0/).

Particularly in the context of neurocritical care, OD is associated with an increased risk of complications, such as malnutrition and aspiration pneumonia, and is also intimately linked to an overall poor prognosis [2,6,7]. The pathophysiology of OD is complex and may, according to the specific disease in question, involve damage to the central and/or peripheral levels of the swallowing network [2]. Furthermore, in the critically ill, direct trauma to the pharyngeal and laryngeal mucosa caused, for example, by endotracheal or nasogastric tubes, may worsen peripheral sensory feedback and thereby aggravate swallowing impairment [8].

GI motility is also frequently disordered in the critically ill, with up to 60% of patients having been reported to experience GI dysmotility of some form and necessitating therapeutic intervention [3,4]. GI dysmotility of the upper GI tract has significant clinical consequences, being associated with diminished provision of enteral nutrition and subsequent malnutrition, gastroesophageal reflux, and aspiration, as well as longer length of stay (LOS) in the intensive care unit (ICU) and increased mortality [9]. The pathophysiology of GI dysmotility in the critically ill is complex and, to a large extent, still unclear [4]. Interestingly, apart from the consequences of ICU treatment itself and, in particular, the GI side-effects of opioids and sedatives, alterations of hormonal pathways and impaired intrinsic modulation via enteric nerves [10], there is some evidence that dysfunction of the different parts of the nervous system may also contribute to GI dysmotility. Thus, probably because they also cause lesions to the cortical representation of the esophagus [11,12], acute strokes were shown to be related to esophageal dysmotility [13,14] and gastroesophageal reflux [15], ultimately increasing the risk of aspiration and subsequent pneumonia in affected patients [16]. In addition, patients with brain injuries have frequently been reported to present with delayed gastric emptying, resulting in gastric feeding intolerance and its sequelae [17–22].

In the present study, therefore, we investigate whether there is a correlation between OD and GI dysmotility, in particular delayed gastric emptying, in a comparatively large cohort of critically ill neurological patients requiring treatment in the ICU and mechanical ventilation (MV).

#### **2. Materials and Methods**

#### *2.1. Study Design and Setting*

This retrospective single-center investigation was conducted using the data of patients admitted to the neurological ICU of Münster University Hospital between January 2011 and December 2017. The inclusion criteria were: admittance to the neurological ICU due to an acute neurological disease, or the acute deterioration of a chronic neurological condition, an episode of MV and flexible fiberoptic endoscopic evaluation of swallowing (FEES) within 72 h of the completion of MV (either extubation or, in tracheotomized patients, the completion of weaning). The exclusion criteria were FEES ≥ 72 h after end of MV, palliative care and reduced vigilance (≤8 points on the Glasgow Coma scale), due to its impact on swallowing function. The data were derived from the clinical documentation system.

#### *2.2. Patient Characteristics and Clinical Parameters*

The epidemiological data, including sex and age, the Body Mass Index, the modified Rankin Scale (mRS) [23] on admission and discharge, the Functional Oral Intake Scale on discharge (FOIS) [24], the RASS (Richmond-Agitation-Sedation-Scale) [25] at the time of initial FEES after the completion of weaning from MV, the Acute Physiology And Chronic Health Evaluation (APACHE) II [26] on admission and discharge, the occurrence of pneumonia [27], sepsis [28] or ileus, the duration of treatment with anti-infectives and, in the case of ischemic or hemorrhagic stroke, the supra- and/or infratentorial lesion location were extracted from the patients' files. Furthermore, if the volume of enteral nutrition (EN) was reduced and/or prokinetics were administered due to high gastric residual volume (GRV), this was recorded as well.

#### *2.3. Dysphagia Assessment*

According to our in-house guidelines, all the patients were examined at their bedside in an upright position by an experienced neurologist, together with a speech-language pathologist. The FEES were assessed according to the items 'secretion management', 'spontaneous swallowing' and 'laryngeal sensibility/cough' . These items were scored, as previously described, according to the "Standardized Endoscopic Swallowing Evaluation for Tracheostomy Decannulation in Critically Ill Neurologic Patients" (SESETD) [29,30]. For this purpose and for better comparability across the patient collective, the items were similarly rated in non-tracheotomized patients as well. The item 'saliva management' was considered failed if massive pooling (not only coating) causing an impaired view of the vocal folds and/or silent penetration and/or aspiration of pooled saliva (permanently without any reaction) occurred. 'Spontaneous swallows' were considered failed if ≤2 swallows occurred during 2 min of observation. If no reaction to touch of the arytenoids with the tip of the endoscope on both sides could be elicited, the item 'laryngeal sensibility' was rated as "not passed". Deriving from these three single items with passing = 1 point and failing = 0 points, a sum score was built, reaching from 0 to 3, as previously described [30]. All the examinations were part of local routine clinical care. The FEES were carried out using a 3.1-mm-diameter flexible fiberoptic rhinolaryngoscope (11101 RP2, Karl Storz, Tuttlingen, Germany), a combined light source and camera system (rp CAM-X, rpSzene®, Rehder/Partner, Hamburg, Germany) and a Medical Panel PC (WMP-226, Wincomm Corporation, Hsinchu, Taiwan) for display and recording. The videos were produced in standard definition quality. The data acquisition and analysis were approved by the local ethics committee.

#### *2.4. Evaluation of Gastric Residual Volume*

The amount of GRV was recorded daily (6 a.m. to 6 a.m.). For this purpose, the GRV drained into a reservoir connected to the gastric tube following gravity, according to our clinical routine and as previously described [31,32]. The reservoir was connected to the nasogastric tube (NGT) every 12 h for 1 h 30 min after the conclusion of EN. If vomiting or a significant amount of GRV were detected by our nursing staff, the EN was paused for 12 h. The patients were managed in a semi-recumbent position (30–45◦) during the drainage of the GRV to prevent aspiration. Patients who had received in vivo thrombolysis and/or thrombectomy or surgery (e.g., external ventricular drainage) were kept nil-by-mouth for the first 24 h and EN was started thereafter. A GRV ≥500 mL/d on at least one day during the stay on the neurological ICU was defined as significant. This cut-off was chosen according to current recommendations and previous studies assuming this amount of GRV to be clinically relevant [31,32].

#### *2.5. Statistical Analysis*

The characteristics and clinical parameters of patients with vs. without increased GRV were compared. To test for a normal distribution of continuous variables, the Kolmogorov– Smirnov test was applied. For normally distributed data, the t-test was performed for group comparison, otherwise the Mann–Whitney U-test was used. The categorical variables were tested using the Fisher exact test in case the contingency tables included fewer than five cases and the chi2-test was used in case of a larger sample size. The significance level was set at 0.05. The significant variables in these univariate analyses were later included in a multivariate binary logistic regression analysis to identify the independent predictors of relevant GRV. The variables that were only gathered at discharge were not included. Pearson correlation was applied to test for an association between initial FEES sum score and days with significant GRV. All the analyses were performed using SPSS 26.0 (IBM, Armonk, NY, USA).

#### **3. Results**

Of the 1461 patients admitted to the neurological ICU with an episode of MV during the observational period, for further analysis, 295 had to be excluded (see patient recruitment diagram, Figure 1). Hence, 976 patients (423 females) were included in this study (Figure 1) of whom 627 (64.2%) were tracheotomized.

**Figure 1.** Recruitment flowchart; MV = mechanical ventilation; FEES = flexible endoscopic evaluation of swallowing; GRV = gastric residual volume; mL = milliliters.

The epidemiological and clinical parameters are summarized in Table 1. On the initial FEES following the conclusion of MV, 360 patients received a score of 0, indicating severe dysphagia (36.9%); 145 passed one of the three items used to evaluate swallowing function (14.9%); and 173 received a score of 2 (17.7%). A total of 297 patients passed all three items (30.4%).

**Table 1.** Epidemiological and clinical parameters and group test according to GRV.

SD = standard deviation; h = hours; d = days; LOS = length of stay; ICU = intensive care unit; GRV = gastric residual volume; GBS = Guillain-Barré syndrome; AMAN = acute motor axonal neuropathy; mRS = modified Rankin Scale; FEES = flexible endoscopic evaluation of swallowing; EN = enteral nutrition; NGT = nasogastric tube, FOIS = Functional Oral Intake Scale; † = Mann–Whitney U-test; ‡ = chi2-test; § = Fisher-exact test.

We observed a significant negative correlation between FEES score and the number of days with relevant GRV (Pearson correlation coefficient −0.125, *p* < 0.01). The number of days of GRV ≥500 mL/d according to the initial FEES score after the conclusion of MV can be seen in Figure 2.

Comparing groups without vs. with significant GRV, the latter demonstrated a longer LOS in the ICU (*p* < 0.001) and duration of MV (*p* < 0.001), suffered from hemorrhagic stroke (*p* = 0.004) and infratentorial lesions more often (*p* = 0.014), were younger (*p* < 0.001), included more males (*p* < 0.001), received a lower APACHE II on admission (*p* = 0.008), scored worse on the initial FEES after the conclusion of weaning (*p* < 0.001), including every single item of the sum score, suffered more often from pneumonia (*p* = 0.028) or sepsis (*p* = 0.004) and were discharged from the hospital with PEG or NGT significantly more often (*p* < 0.001). Multivariate logistic regression analysis (Table 2) indicated the following factors as significant independent predictors of GRV ≥500 mL/d on at least one day: dysphagia severity as evaluated by the FEES sum score (*p* = 0.010), duration of MV

(*p* = 0.004), hemorrhagic stroke (*p* = 0.042), infratentorial lesion location of stroke (*p* = 0.019), age (*p* < 0.001) and male gender (*p* = 0.018).

**Figure 2.** Days of gastric residual volume ≥500 mL/d, according to sum score on the first flexible endoscopic evaluation of swallowing (FEES) within 72 h of the conclusion of mechanical ventilation. Score 0: *n* = 360; Score 1: *n* = 146; Score 2: *n* = 173; Score 3: *n* = 297; GRV = gastric residual volume; mL = milliliters.

**Table 2.** Multivariate binary logistic regression analysis; outcome variable: GRV ≥ 500 mL/d on at least one day.

cat = categorical; LOS = length of stay; ICU = Intensive Care Unit.

#### **4. Discussion**

In this study, we assessed the relationship between the occurrence and degree of GI dysmotility and OD in ventilated patients in the neurological ICU and tried to identify predictors of GI dysmotility in this cohort. In support of our hypothesis, our first main finding was that the impairment of swallowing function diagnosed at the conclusion of MV was associated with relevant GRV as a surrogate marker of GI dysmotility. While the GI tract possesses intrinsic neural plexus that allow a certain degree of autonomy over

digestion and nutrient absorption, the central nervous system provides extrinsic input that regulates, modulates and controls these functions [33]. The small and large intestines exert comparatively independent neural control; the stomach, however, is considerably dependent on extrinsic neural inputs, particularly from the parasympathetic and sympathetic pathways connected to nuclei located in the caudal brainstem [33,34]. In line with this, relevant GRV was observed in patients with an infratentorial lesion significantly more often in our data. Recently, Rebollo et al. identified delayed connectivity between the brain and the slow electrical rhythm generated in the stomach using gastric-BOLD coupling, indicating a functional brain–gut link [35]. Within the brain, different nodes of this 'gastric network' were coupled to the gastric rhythm with different phase delays, indicating a temporal sequence of activations within this network—which, in principle, is similar to the central control of the swallowing network [36]. Interestingly, the gastric network partly comprises regions ('nodes') that are similarly found to be activated during swallowing, e.g., the primary and secondary somatosensory cortex and the supplementary motor area, as well as the insula [37–39]. Thus, the close clinical relation of both functions, in the present study may have been due to lesions that affected swallowing as well as the gastric network.

Our second main finding was that prolonged MV was a significant predictor of impaired gastric emptying, which was in line with previous findings [40]. There are indications that positive pressure mechanical ventilation leads to splanchnic vasoconstriction and gut-hypoperfusion, which is linked with increased plasma catecholamines and proinflammatory cytokine levels, both of which are related to delayed gastric emptying [41]. Furthermore, alterations in hormone levels in the critically ill have an impact on GI motility. Lowered ghrelin levels, as well as increased levels of cholecystokinin and peptide YY, were found in the critically ill and are linked with slower gastric emptying [42,43]. Sedatives such as Propofol and the use of opioids to provide sufficient analgesia during mechanical ventilation were shown to be associated with delayed gastric emptying, as well as the use of catecholamines/vasopressors [3,40,43]. Interestingly, swallowing function has also been shown to be worse in patients with prolonged mechanical ventilation and longer ICU treatment, as well as following the use of sedatives [44], supporting the hypothesis that—at least partly—the underlying mechanisms that cause impaired swallowing function and slowed gastric motility may be similar.

The third main finding was that patients suffering from intracranial hemorrhage seem to be at a particularly high risk of slowed gastric emptying. It was previously shown that intracranial hemorrhage is a risk factor for inferior swallowing function compared to ischemic stroke in patients with and without tracheostomy [45,46]. It was proposed that besides the specific localization [47] and volume of the intracranial hemorrhage [48], this may at least partly be attributed to secondary consequences of the hemorrhage, e.g., vasospasms [49], cisternal and interventricular blood or hydrocephalus [48]. There is more evidence that increased intracranial pressure is related to delayed gastric emptying. Thus, in a study of 21 brain-injured patients requiring sedation, MV and intracranial pressure monitoring for ≥24 h, increased intracranial pressure (>20 mmHg) was associated with reduced gastric emptying, as measured by the paracetamol absorption technique, possibly due to a decreased parasympathetic tonus [18]. In a study by Kao et al., 80% of head-injury patients exhibited abnormal gastric emptying halfway through liquid meals compared to healthy age-matched control subjects [20]. Using electrogastrography, it was further shown that brain trauma or coma cause gastric dysrhythmias and intolerance to feeding, supporting the hypothesis of an altered functional brain–gut link that causes delayed gastric emptying in patients with acquired brain injury [21].

As our fourth and fifth main findings, younger age and male gender were demonstrated to be related to delayed gastric emptying. Findings on the effects of ageing in the context of gastric motor function are inconsistent. Studies in healthy as well as critically ill patients found indications of declining gastric motor function with increasing age [43,50], whereas others identified a trend towards increased gastric emptying depending on increasing age in healthy adults [51]. In the neuro-ICU setting, as mentioned above, the influence

of the intensive care treatment as well as the underlying condition causing the need for treatment may have caused the differing findings in the recent study. This can similarly be assumed for the gender differences. In general, gastric motility seems to be slower in healthy women than in healthy men [52] but there are indications that gastric motility may be less gender-specific depending on the consistency of administered boluses [53]. For a better understanding, the role of age as well as gender in the intensive care setting needs be investigated more closely.

The clinical relevance of GRV is still a matter of discussion. Generally, the intermittent measurement of GRV is a widely used practice to evaluate impaired gastric motility and feeding intolerance [4]. Several studies, including a meta-analysis, indicated that not monitoring GRV was not inferior to routine GRV measurement with regard to ICU-related infections, LOS in the ICU, length of MV and mortality. Furthermore, not monitoring GRV even improved the delivery of enteral nutrition [54–56]. These data were mainly derived from mixed cohorts. In stroke patients, who often suffer from dysphagia and impaired protective reflexes, Chen et al. observed that aspiration occurred significantly less often if GRV was monitored and the infusion rate of the EN was adjusted accordingly [57]. In our cohort of critically ill neurologic patients, relevant amounts of GRV were associated with pneumonia and sepsis. Pneumonia in the context of delayed gastric emptying in the critically ill is thought to be caused by aspiration due to gastro-esophageal reflux, which itself is a consequence of reduced esophageal sphincter tonus and increased residual volume in the stomach [4]. Dysphagia is another risk factor for pneumonia, notably as a result of aspiration [2]. Since patients with relevant GRV presented with a worse swallowing function, both disorders may foster each other. In line with this, patients with GI dysmotility presented a worse FOIS score at discharge and were more likely to be discharged with a feeding tube. Moreover, during systemic inflammation, intestinal edema deriving from capillary leakage influences GI function and cytokine release during sepsis, impedes intestinal myocyte function and inhibits enteric neuromuscular transmission [58–62].

Certain limitations to our study should be considered. First, the retrospective design may have introduced a bias into our data, which possibly include imprecise documentation of the patients' records. Second, all the patients were recruited on a single neurological ICU; hence, the transfer of findings to other environments and, in particular, to groups of patients with a different spectrum of diseases may be only be possible only to a limited extent. Third, bedside measures were previously shown to be imprecise in the identification of motility disorders [63]. While the intermittent measurement of GRV may be the most common practice through which gastric motility disorders are evaluated, indirect tests, such as the carbohydrate absorption (3-OMG), the radio-isotope breath (13CO2) or the aforementioned paracetamol absorption test, as well as gastric scintigraphy, evaluate gastric dysmotility with more precision, although they are not always applicable in the ICU setting [4]. Fourth, with regards to the impact of our findings, no long-term outcome assessment was available.

#### **5. Conclusions**

The findings in this study indicate an association between delayed gastric emptying and dysphagia severity in critically ill neurologic patients in the ICU. Beside the effects of intensive care treatment, there are indications that central lesions in the swallowing and gastric network both add to the deterioration of swallowing function as well as to the impairment of upper GI motility.

**Author Contributions:** P.M.: writing—original draft preparation, data curation, investigation K.K.: data curation, investigation; S.S.-K.: investigation, writing—original draft preparation, formal analysis; I.C.: data curation, writing—reviewing and editing; B.L.: visualization, validation, writing —reviewing and editing; M.O.: data curation, validation, writing—reviewing; T.W.: conceptualization, methodology, supervision; R.W.: methodology, writing—reviewing; R.D.: conceptualization, supervision, project administration, writing—reviewing. All authors have read and agreed to the published version of the manuscript.

**Funding:** This work was supported by the Deutsche Forschungsgemeinschaft [grant number SU 922/1–1, WO1425/6–1, DZ 78/1–1].

**Institutional Review Board Statement:** The study was conducted according to the guidelines of the Declaration of Helsinki, and approved by the Ethics Committee of the Ärztekammer Westfalen-Lippe and the Westfalian Wilhelms-University (2016-391-f-S; date: 12 August 2016).

**Informed Consent Statement:** Patient consent was waived due to the retrospective design of the study.

**Data Availability Statement:** The data presented in this study are available on request from the corresponding author. The data are not publicly available due to hospital policy.

**Conflicts of Interest:** The authors declare no conflict of interest.

#### **References**

#### *Article*


**2. Methods Used to Analyze Antibiotics**

Various methods have been developed to detect and quantify antibiotics in various types of samples. The referred methods include chromatographic, spectrophotometric, and electrochemical methods [34]. High performance liquid chromatography (HPLC) is, by far, the most extensively utilized instrumental method in pharmaceuticals analysis [35].

#### *2.1. Chromatographic Methods*

Pharmaceuticals and their metabolites have been analyzed using a variety of chromatographic methods. Such methods can be used alone or hyphenated with mass spectrometry. Mass spectrometry-based approaches, particularly liquid chromatography, coupled with tandem mass spectrometry (LC/MS/MS) can reach extraordinarily high degrees of specificity compared with immunoassay or even chromatographic detection utilizing detectors such as UV or fluorescence. The specificity and sensitivity of a chromatographic method are controlled by chromatographic conditions such as choice of mobile phase and analytical column, detector, and sample preparation [36]. For antibiotic analysis, the analytical method is selected based on the characteristics of the analyzed antibiotic, which includes solubility in water and organic solvents or acid-base properties [37].

Thin-layer chromatography (TLC) is one of the most important analytical methods used to determine the qualitative and semiquantitative levels of pharmaceuticals in various types of samples [34]. TLC is usually applied as the quick, easy, and straightforward procedure. The effective separation is determined by the sample's properties as well as the properties of the stationary and mobile phases [38]. TLC can successfully be used for preliminary screening of the pharmaceutical compounds. It is commonly employed in contemporary analysis as a separation method to determine the presence or absence of antibiotics over a predetermined concentration level [38,39]. It can also be used to evaluate and categorize pure and impure antibiotic preparations as well as assay antibiotics quantitatively in bulk or pharmaceutical preparations [40,41].

Gas chromatography (GC) is a commonly used analytical technique that combines separation chromatographic stage with measurement capacity. GC employs the gas as the mobile phase and coating inside the long capillary column or, less typically, the tiny particles of a solid material packed in a column as the stationary phase. The sample in GC should be able to evaporate so that it flows with the gaseous mobile phase. The temperature gradient to which the chromatographic column is subjected is frequently utilized to speed up the elution of less volatile substances that would otherwise take a long time to elute. The detector signals for the sample's eluting components are used for quantitative and qualitative analysis [42]. GC is a useful technique for evaluating pharmaceutically relevant substances [43] and impurities [44]. Many pharmaceutical chemicals, however, cannot be gas chromatographed in their natural state and must be transformed into stable and volatile

derivatives in order to accomplish successful GC elution and separation. The derivatives are sometimes created in order to attain the appropriate sensitivity, selectivity, or specificity for a given separation [44,45].

High-performance liquid chromatography (HPLC) is a chromatographic technique that can separate a mixture of substances, and it is used in biochemistry and analytical chemistry to identify, quantify, and purify different components of the mixture [46]. HPLC employs various types of the stationary phases, and the pump that drives the mobile phase(s) and analyte through the column and detector to provide a characteristic retention time for the analyte. The retention period of an analyte varies according to the strength of its interactions with the stationary phase, solvent(s) ratio/composition utilized, and flow rate of the mobile phase [47]. HPLC has a number of advantages, including low organic solvent utilization, minimal sample volume, quick analysis, and high chromatographic resolution [48]. Apart from conventional HPLC, other sophisticated HPLC-based techniques have been widely applied for the determination of pharmaceuticals, including antibiotics in various samples. The referred methods include liquid chromatography—mass spectrometry (LC-MS) [49,50], ultra-high performance liquid chromatography-MS/MS (UHPLC-MS/MS) [51–53], and liquid chromatography linked to tandem mass spectrometry (LC-MS/MS) [54,55].

#### *2.2. Spectrophotometric Methods*

Spectrophotometric methods are based on the creation of the complex between the pharmaceutical and the reagent [12]. The intensity of the color is used to calculate pharmaceutical concentration. The complex generated by the pharmaceutical and reagent can either be charge transfer or ion-pair in nature. The charge transfer complex, also known as the electron donor-acceptor complex, transfers a fraction of electrical charge between molecules. Coulomb attraction holds oppositely charged ions together in solution in the ion-pair complex [56]. Some antibiotics have been analyzed using spectrophotometric methods including amoxicillin [40], azithromycin [41,57], tetracycline, doxycycline [58], and cefixime trihydrate [59]. They have also been used to analyze gentamicin sulfate [60], cefadroxil, ceftazidime, cefazolin sodium, cefoperazone sodium, cefaclor, cephaprin sodium, cefotaxime sodium, and cefuroxime sodium [61].


**4. Discussion**

In the present study, we demonstrated the protective effects of fenofibrate on RF/6A cells under oxidative stress. Fenofibrate inhibited ROS accumulation, mitochondrial dysfunction, and modulated the apoptosis and stress signaling pathway in oxidative stress-induced RF/6A cells.

Increasing evidence supports the idea that oxidative stress plays an important role in the pathogenesis of DR. PPAR-α is a regulator of inflammation and oxidative stress that induces the activation of antioxidant enzymes [45–47]. Evidence suggests that fenofibrate may modulate anti-oxidant pathways. For example, fenofibrate inhibits the production of ROS in streptozotocin-induced diabetic rats and reduces nephropathy development [48]. In the present study, the mRNA expression of anti-oxidant enzymes Prx, Trx1, and Trx-2 decreased in PQ-stimulated RF/6A cells, whereas the mRNA levels of these enzymes increased after fenofibrate treatment. This finding indicated that fenofibrate may induce the expression of anti-oxidant proteins and protect cells from oxidative stress. Endothelial cell apoptosis has been linked to oxidative damage through the production of 8-OHdG, nitrotyrosine, and MDA [49,50]. In the present study, the results showed that fenofibrate suppressed MDA production and protected vascular endothelial cells from lipid peroxidation. We also observed that fenofibrate suppressed 8-OHdG adduct formation but only inhibited protein oxidation at higher concentrations. Previous studies have also revealed that fenofibrate could suppress MDA production in rat models for low-density lipoprotein-induced endothelial dysfunction and Parkinson's disease [51,52]. Taken together, the results from the present study suggested that fenofibrate could induce the expression of anti-oxidant enzymes, reduce the production of ROS and decrease the generation of oxidant products, thus protecting endothelial cells from oxidative stress-induced damage.

Mitochondria are a major source of oxidative stress in DR because oxidative stress in the inner membrane leads to imbalance in the electron transport chain and generates superoxide and hydrogen peroxide, thereby damaging the membrane proteins. Furthermore, mitochondrial dysfunction activates the apoptosis-related signaling pathway [53]. Fenofibrate has been reported to decrease apoptosis in high-glucose-stimulated microvascular endothelial cells [54] and decrease the apoptotic rate of the ganglion cells in the mouse model for type 2 diabetes [55]. In the present study, we observed that fenofibrate reduced the apoptotic rate and could preserve mitochondrial function in PQ-stimulated RF/6A cells. Our findings suggested that fenofibrate could inhibit cell death and DR progression by preventing mitochondrial dysfunction.

Trxs belong to a group of small redox proteins that can be found in most cells. The anti-oxidative activity of Trxs is indispensable for cells [56]. Trxs exert most anti-oxidant properties in cells through thioredoxin peroxidase [18]. Niso-Santano et al. observed that PQ induces the phosphorylation of Ask-1 and suppress Trx expression in SH-SY5Y cells (human neuroblastoma cells) [57]. Trx-1 levels are also reduced in mycophenolic acid-induced apoptosis in pancreatic β-cells [58]. Fiuza et al. demonstrated that the protective effects of diphenyl diselenide on endothelial cells against oxidative stress are through the expression of different isoforms of Prx [59]. In our study, we found that the mRNA and protein expression of Prx, Trx-1, and Trx-2 decreased, and phosphorylated Ask-1 increased in PQ-stimulated RF/6A cells. In addition, thioredoxin-interacting protein (TRXIP) was reported to be significantly up-regulated in DR. TRXIP may interact with Trx, block its anti-oxidant activity, and then cause mitochondrial dysfunction and inflammation in DR [60,61]. The expression of Trx increased after fenofibrate treatment in our experiments. Our results were consistent with that of the study conducted by Billiet et al., in which PPAR-α activation induced Trx-1 expression [28]. The addition of PPAR-α antagonist could attenuate but not completely abolish the effects of fenofibrate, indicating that the effects of fenofibrate were not all PPAR-α dependent. In summary, our study suggested that the anti-oxidative activity and anti-apoptotic effects of fenofibrate could be attributed to the increase of Trx expression and the inhibition of Ask-1 phosphorylation.

We then investigated the effects of fenofibrate on the regulation of Trx-related signaling pathways. Trx binds to Ask-1 in the mitochondria and cytosol, thereby blocking the initiation of the cellular apoptotic process and inhibiting the activation of JNK/p38 MAP kinase [26]. In the cytosol, Ask-1 is required for the activation of JNK/p38 MAP kinases. Bcl-2 and Bcl-xl are known to regulate mitochondrial dynamics and play essential roles in anti-apoptosis; however, Bax promotes apoptosis [62,63]. JNK/p38 MAP kinase also regulates mitochondrial-mediated apoptosis [64] and facilitates the release of mitochondrial cytochrome c to the cytosol. Our study revealed that p-JNK and Bax expression were elevated in PQ-stimulated RF/6A cells and fenofibrate treatment suppressed their expression. Conversely, the expression of Bcl-2 and Bcl-xl increased after fenofibrate treatment. In mitochondria, Trx-2 inhibits Ask-1-mediated apoptosis, which in turn causes the inhibition of cytochrome c release to the cytosol [65]. Our findings showed that pretreatment of fenofibrate in PQ-stimulated cells increased Trx-2 expression, decreased the formation of p-Ask-1 and inhibited cytochrome c release. Cytochrome c release is an initiator of the main apoptotic pathway [66]. When cytochrome c is released from the mitochondria to cytosol, it binds to Apaf-1 and activates an apoptosis-related caspase cascade, consequently inducing PARP-1 cleavage leading to apoptosis [67]. We observed that fenofibrate treatment reduced the levels of cytosolic cytochrome c and the related caspase cascade in PQ-stimulated cells. In summary, our results indicated that fenofibrate could protect against oxidative stress-induced retinal/choroidal endothelial cell apoptosis by enhancing Trx-1 and Trx-2 expression, thereby suppressing Ask-1 activity, which in turn inhibits the activation of the subsequent apoptotic signaling pathways.

Our study has some limitations. It is an in vitro analysis, and the protective effects of fenofibrate and the underlying mechanisms need to be demonstrated with animal models. However, two large randomized controlled trials (FIELD and ACCORD study) have shown significant benefits of fenofibrate in patients with DR. Our results supported the assertion that fenofibrate can slow the progression of DR by modulating apoptosis- and stress-related signaling pathways.


**Interference Alignment for UWB-MIMO Communication Systems**

Mohamed El-Hadidy, Mohammed El-Absi, Yoke Leen Sit, Markus Kock, Thomas Zwick, Holger Blume and Thomas Kaiser

Additional information is available at the end of the chapter

http://dx.doi.org/10.5772/55083


**9. Importance of antimicrobial stewardship programs, outcomes, and new regulatory mandate from the Joint Commission (7 CDC elements)**

According to the World Health Organization (WHO), "Antimicrobial resistance threatens the effective prevention and treatment of an ever-increasing range of infections caused by bacteria, parasites, viruses, and fungi." The Centers for Disease Control and Prevention (CDC) has identified that 20–50% of all antibiotics prescribed in the U.S. acute care hospitals are either inappropriate or unnecessary. The CDC has also stated that "Antibiotics are among the most commonly prescribed medications in nursing homes. Up to 70% of long-term care facilities' residents receive an antibiotic every year [76]."

White House held the antibiotic stewardship program in June, 2015, in which the Joint Commission participated along with more than 150 major healthcare organizations and other relevant organizations for helping to implement changes over the next 5 years to decrease the rate of emergence of antibiotic-resistant bacteria, to help detect the resistant strains, help preserve the efficacy of existing antibiotics, and also more importantly regulate to prevent the spread of resistant infections [76].

The Joint Commission has also developed the antimicrobial stewardship standard for hospitals, critical access hospitals, nursing care centers, ambulatory care organizations, and Official Publication of Joint Commission Requirements New Antimicrobial Stewardship Standard Applicable to Hospitals and Critical Access Hospitals Effective January 1, 2017 Medication Management (MM) Standard MM.09.01.01 The critical access hospital has an antimicrobial stewardship program based on current scientific literature.

**1**. Leaders establish antimicrobial stewardship as an organizational priority. (*See also* LD.01.03.01, EP 5) **Note:** *Examples of leadership commitment to an antimicrobial stewardship program are as follows:*

activity against imipenem-resistant *A. baumannii* and MDR *A. baumannii* clinical isolates [75]. Combinations of minocycline plus meropenem and minocycline plus colistin were found to be synergistic *in vitro* against XDR *A. baumannii*. The package insert (PI) has an initial dose of 200 mg, with subsequent doses of 100 mg administered over 60 min every 12 h. Minocycline is very lipophilic compared to other tetracyclines. It has a very unique pharmacokinetic/phar-

a) Peak concentrations following 200-mg load (mean) = 4.18 μg/mL (range, 2.52–6.63 μg/mL).

c) These achievable peak and trough serum concentrations with standard human doses of minocycline intravenous exceed the mutant prevention concentration of 1 μg/mL, which

e) The mean concentration of minocycline in lung parenchyma has been reported to be 378%

g) Renal dysfunction does not appear to alter the maximum serum concentrations of mino

h) Bactericidal activity in combination with carbapenems or colistin against *A. baumannii*.

**9. Importance of antimicrobial stewardship programs, outcomes, and new regulatory mandate from the Joint Commission (7 CDC elements)**

According to the World Health Organization (WHO), "Antimicrobial resistance threatens the effective prevention and treatment of an ever-increasing range of infections caused by bacteria, parasites, viruses, and fungi." The Centers for Disease Control and Prevention (CDC) has identified that 20–50% of all antibiotics prescribed in the U.S. acute care hospitals are either inappropriate or unnecessary. The CDC has also stated that "Antibiotics are among the most commonly prescribed medications in nursing homes. Up to 70% of long-term care facilities'

White House held the antibiotic stewardship program in June, 2015, in which the Joint Commission participated along with more than 150 major healthcare organizations and other relevant organizations for helping to implement changes over the next 5 years to decrease the rate of emergence of antibiotic-resistant bacteria, to help detect the resistant strains, help preserve the efficacy of existing antibiotics, and also more importantly regulate to prevent the

The Joint Commission has also developed the antimicrobial stewardship standard for hospitals, critical access hospitals, nursing care centers, ambulatory care organizations, and

b) Trough concentration of (1.4–1.8 μg/mL) with 100-mg dosing every 12 h.

macodynamic profile (PK/PD) [67]:

92 Contemporary Topics of Pneumonia

has been reported with *Acinetobacter*.

residents receive an antibiotic every year [76]."

spread of resistant infections [76].

d) Half-life of 15–23 h.

of that in plasma.

cycline.

f) Urinary excretion 11%.

**3**. The critical access hospital educates patients, and their families as needed, regarding the appropriate use of antimicrobial medications, including antibiotics. (For more information on patient education, refer to Standard PC.02.03.01)

**Note:** *An example of an educational tool that can be used for patients and families includes the Centers for Disease Control and Prevention's Get Smart document, "Viruses or Bacteria— What's got you sick? At https://www.cdc.gov/antibiotic-use/ community/pdfs/Viruses-or-Bacteria-Factsheet-Eng.pdf*

**2**. The critical access hospital educates staff and licensed independent practitioners involved in antimicrobial ordering, dispensing, administration, and monitoring about antimicrobial resistance and antimicrobial stewardship practices. Education occurs upon hire or granting of initial privileges and periodically thereafter, based on organizational need

**4**. The critical access hospital has an antimicrobial stewardship

multidisciplinary team that includes the following members, when available in the setting:

**Note 1:** *Part-time or consultant staff are acceptable as members of the antimicrobial stewardship multidisciplinary team*

**Note 2:** *Telehealth staffs are acceptable as members of the antimicrobial stewardship multidisciplinary team*

#### **5. The critical access hospital's antimicrobial stewardship program includes the following CDC core elements:**

**Note:** *These core elements were cited from the Centers for Disease Control and Prevention's Core Elements of Hospital Antibiotic Stewardship Programs (https://www.cdc.gov/antibiotic-use/healthcare/pdfs/core-elements.pdf)*

**6**. The critical access hospital's antimicrobial stewardship program uses organization-approved multidisciplinary protocols (for example, policies and procedures). **Note:** *Examples of protocols are as follows:*

**8**. The critical access hospital takes action on improvement opportunities identified in its antimicrobial stewardship program. (*See also* MM.08.01.01, EP 6)

Adopted from https://www.jointcommission.org/assets/1/6/New\_Antimicrobial\_Stewardship\_Standard.pdf.

**Table 6.** The New Joint Commission antimicrobial stewardship standard: MM.09.01.01.

office-based surgery practices in standard with the following governmental and professional organizations: Centers for Medicare & Medicaid Services (CMS), the CDC, and the Society for Healthcare Epidemiology of America (SHEA) (**Table 6**).


**2. Materials and Methods**

#### *2.1. Viruses, Cell Lines, Antibodies and Reagents*

The clinical isolate PF-25013-18 (PF13) and the molecular clones of ZIKV (BR15MC and MR766MC) have been previously described [20,21]. Vero cells (ATCC, CCL-81) and HEK 293T (CRL-3216) were cultured at 37 ◦C under a 5% CO2 atmosphere in MEM medium (PAN Biotech, Aidenbach, Germany), supplemented with 5% or 10% heat-inactivated fetal bovine serum (FBS) (PAN Biotech, Aidenbach, Germany). A549-Dual ™ cells (InvivoGen, Toulouse, France, a549d-nfis) designated hereafter as A549 cells were maintained in MEM medium supplemented with 10% heat-inactivated FBS. A549 cells were maintained in growth medium supplemented with 10 μg.mL−1 blasticidin and 100 μg.mL−1 zeocin (InvivoGen, Toulouse, France).

To detect the ZIKV envelope E protein (ZIKV-E), we used the mouse anti-pan flavivirus envelope E protein mAb 4G2 produced by RD Biotech or the rabbit anti-ZIKV-E-DIII that was kindly provided by Dr. Valerie Choumet (Institut Pasteur). The rabbit anti-BAX (#2772) and anti-active caspase 3 (#9664) antibodies and the mouse anti-cytc 6H2.B4 (#12963) were purchased from Cell Signalling Technology (Ozyme, Saint-Cyr-l'École, France). The mouse anti-BAX clone 2D2 was from Invitrogen (Thermofisher, Les Ulis, France). The anti-mitochondria antibody MTC02-3298 was from Abcam (Cambridge, UK). Donkey anti-mouse Alexa Fluor 488 and anti-rabbit Alexa Fluor 594 IgG antibodies were from Invitrogen (Thermofisher, Les Ulis, France). Horseradish peroxidase-conjugated anti-rabbit (ab97051) and anti-mouse (ab6789) antibodies were purchased from Abcam (Cambridge, UK).

All reagents were from Sigma Aldrich (Humeau, La Chapelle-Sur-Erdre, France) except when indicated. ABT-737 (ab141336) was purchased from Abcam (Cambridge, UK).