**1. Introduction**

Changes to traditional land uses can be contentious, increasingly so when paired with the ongoing challenges of climate change and energy security. In Australia, land use change has a long history as management of landscapes has occupied a central position in our politics ever since re-settlement of the continent over 230 years ago ([1], p. 1). Historically, the agricultural, manufacturing, service and mining sectors have long operated alongside one another to

© 2016 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. © 2018 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

underpin the economic diversity of the nation with rural regions more specifically playing a vital part [2]. Over time, however, as power has devolved from the Federal government to the States, management of the biophysical environment—land, soils and water in particular have taken on greater significance as increased 'scarcity' created by human induced pressures, has become more widely recognised and communities have begun to demand more active responses from government to address these challenges.

in the form of civil disobedience campaigns and blockades. While these campaigns have been mostly against the placement of extractive projects in areas considered to be culturally, ecologically and agriculturally important, they also speak to a larger debate currently being waged throughout Australia [6]. This debate, seeks unproblematically to frame the future of rural places as essential nodes in an ever-expanding fossil fuelled pipeline where economic imperatives drive and surpass all other values that are not seen as being in the 'common' or 'economic good' of the nation [7, 8]. As Peck and Tickell ([9], p. 383) suggest, key to this argument is an all "pervasive metalogic" that draws on appropriate policies to justify its reasoning

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This chapter focuses on one rural region in NSW. It reports on the emergence of an unlikely alliance forming between farmers, environmentalists and concerned others in the fight to protect productive land, soil and water from unwanted land use change. Framed by de Rijke ([10], p. 41) as the advent of "agri-gas fields", the chapter considers how the socio-economic and cultural boundaries between place and matter are being contested within the different visions that exist for the region's long-term future. Beginning with an overview of strategic planning in NSW and recent changes to appeal rights, the chapter also contemplates how space is instrumentalised by government for political purposes [11] and how it can also be used by others to challenge and reframe the arena of

When the NSW State government first released its Strategic Regional Land Use Plans, they were heralded as a suite of law reforms which would address what the government itself saw as flaws in the planning process [12]. These plans were to represent the 'government's proposed framework to support growth, protect the environment and respond to competing land uses, while [also] preserving key regional values over the next 20 years " ([3], p. 8). Framed as a way to ensure that land identified as 'Strategic Agricultural Land' – i.e. – highly productive land requiring extra protection mechanisms, the government put in place what it called a 'Gateway Assessment process' [3, 4]. It also appointed a Gateway Assessment Panel of experts (GAP), who would assess the merits of 'State Significant' mining and coal seam gas

proposals on strategic agricultural land and then issue a certificate of approval [13].

application for a Gateway Certificate no matter how questionable the project [12, 14].

While the Gateway Assessment process was to mark a significant improvement on previous planning efforts in regional NSW, it did not, however, redress the imbalance between the State's perceived economic 'needs' and the social and environmental needs of specific rural regions [12]. In fact, the Strategic Regional Land Use Plans (which were later to become policy) further entrenched this imbalance by rendering it impossible for the GAP to refuse an

Under the Gateway process, the GAP is required to make an upfront assessment of the impacts of a mining/CSG proposal on agricultural activities and water sources. On what basis, however, can this assessment be undertaken if the impacts are cumulative or as of yet unknown [12, 14, 15]? Since CSG mining is still a relatively new industry in Australia, it is possible that

and effectively silence or marginalise other alternate voices.

**2. Strategic land use planning and change**

decision-making.

In an attempt to 'balance' strong economic growth with protection of agricultural lands, the New South Wales (NSW) State government in 2012 introduced strategic land use plans for the Upper Hunter and New England regions [3, 4]. While these were designed to promote 'coexistence' of diverse land uses, they also set in place long-term strategic goals which focused heavily on increasing the spatial dimensions and needs of energy industries.

For example, in the Upper Hunter and New England regions alone, 11 Petroleum Exploration Licences (PELS) mainly for coal seam gas (CSG, referred to elsewhere 'as coal-bed methane') have been issued, covering a total of 461,000 ha of prime agricultural land [5] (**Figure 1**). This total does not include the minerals titles that also exist in these regions and elsewhere which cover approximately two-thirds of the State.

The increased emphasis on extractive land uses (other than those agricultural in nature) has been met with widespread opposition from farmers, local communities, environmentalists and concerned others, who over the past 5 years in particular have responded with resistance

**Figure 1.** Upper hunter and New England region PEL zones.

in the form of civil disobedience campaigns and blockades. While these campaigns have been mostly against the placement of extractive projects in areas considered to be culturally, ecologically and agriculturally important, they also speak to a larger debate currently being waged throughout Australia [6]. This debate, seeks unproblematically to frame the future of rural places as essential nodes in an ever-expanding fossil fuelled pipeline where economic imperatives drive and surpass all other values that are not seen as being in the 'common' or 'economic good' of the nation [7, 8]. As Peck and Tickell ([9], p. 383) suggest, key to this argument is an all "pervasive metalogic" that draws on appropriate policies to justify its reasoning and effectively silence or marginalise other alternate voices.

This chapter focuses on one rural region in NSW. It reports on the emergence of an unlikely alliance forming between farmers, environmentalists and concerned others in the fight to protect productive land, soil and water from unwanted land use change. Framed by de Rijke ([10], p. 41) as the advent of "agri-gas fields", the chapter considers how the socio-economic and cultural boundaries between place and matter are being contested within the different visions that exist for the region's long-term future. Beginning with an overview of strategic planning in NSW and recent changes to appeal rights, the chapter also contemplates how space is instrumentalised by government for political purposes [11] and how it can also be used by others to challenge and reframe the arena of decision-making.


**5. Conclusion**

We have demonstrated a more convenient synthesis method for colloidal CdSe quantum dots. This method does not involve quenching. This makes it easier for students to make the semiconductor nanoparticles. This synthesis method depends on different heating times for premixed CdO and Se solutions.


*4.2. Spatio-Temporal Analysis of Flood Inundation*

In order to provide support for disaster-resistant activities in the study area, it is crucial to understand the development process of flood events. Therefore, the particularly severe flood incident occurring from May to September 2020 is selected as a flood monitoring case, and the experimental results retrieved by the DBNN model on CYGNSS data are shown in Figures 9 and 10. Before the onset of the 2020 rainy season in the study area, the regions occupied by water bodies are mainly distributed in coastal areas such as Bangladesh, covering about 6.6% of the total land area. From 20 May 2020, the areas inundated by floods gradually expanded to Nepal and the northeast of India with the arrival of frequent rains. The flooded areas accounted for about 17.9% of the total area on 20 June 2020, and reached 28.7% by 20 July 2020. On 20 August 2020, the areas flooded reached their largest, covering around 34.8% of the total area. After 20 August 2020, the flooded areas gradually reduced because of the decrease in rainfalls. Observing the process of flood changes, we could find the increased area, which refers to the difference between the maximum flood area detected during the rainy season and the area of water bodies before the rainy season, accounting for 28.2% of the total study area, mainly in Nepal and the northeastern states of India. In particular, the proportion of the increased flood area in some states is calculated and summarized in Table 5, where Bihar State experienced the most severe flooding event with an increased area accounting for 89.92% of the total area, while Magway State had the smallest increased area, only covering about 5.50%.

**Table 5.** The proportion of the increased flood area to the state area.

**Figure 9.** The spatial distribution of the study area flood inundation retrieved by DBNN model on CYGNSS. The period spans from May to September 2020.

**Figure 10.** The temporal variation process of the flooded area, spanning from May to September 2020. "CYGNSS-DBNN" indicates flood inundation area retrieved by DBNN method based on CYGNSS data, while "SMAP-Threshold" denotes flood inundation area classified by threshold method based on SMAP data.

Through further observation of Figures 9 and 10, it can be found that the flooded areas are mostly located in Bangladesh, Nepal, and northeast of India, which is mainly caused by three factors; i.e., the large quantities of water vapor carried by the southwest monsoons, as well as the influence of topography and water systems. In terms of topography, the region is located at the southern foothills of the Himalayas and on the windward slope of the southwest monsoons. When the southwest monsoon is blocked by the northern mountains, it is forced to lift up and form topographic rain, leading to high rainfall in the study area. In terms of the water system, rainwater from the northern foothills is usually collected in the northeast of the study area, due to the low topography and dense river networks, making the region more vulnerable to the threat of flooding.


**5. Conclusion**

*Quality of Life - Biopsychosocial Perspectives*

useful for people who are currently suffering. (6) The nurses at the sanatorium were the listeners of their life review. This book has also recorded the nursing practices. This interaction also increased the ability of the nurses to listen, empathize, understand, and deepen the relationship between them and the survivors. Through this, the nurses also got the opportunity to care for the survivors who do not have their own children. (7) The book was made by using qualitative and inductive methods in order to arrange the composition and express it in a narrative tone, therefore even elementary students can read it to learn about human rights. (8) New patients of Hansen's disease have been found only in developing countries like India, Brazil, and Indonesia. They account for about 80% of the total patients. The developed countries are not concerned about the disease. We hope that by increasing the awareness in developed countries, through the stories of the survivors, the wisdom

*(a) View of the entirety of the Ōshima Seishoen (in the background are Yashima and Takamatsu harbor); and*

and strength for solving problems in future will be shared.

**244**

**Figure 6.**

**Figure 7.**

*(b) view of Ōshima Seishoen.*

*Hansen's disease sanatoria nationwide.*

This study comprises the first report and the second report. In the first report, we describe the conceptual structure of spirituality, the relationship of spirituality and QOL, and the history of Hansen's disease. Spirituality was developed as a part of the studies relating to terminal cancer patients who must confront their own death. When our daily lives are calm and mundane, we do not notice spirituality. However, when we confront hardships of life, for example, when we are exposed to the dangers of life, we notice spirituality as an existential distress. On the other hand, the development of individuality and imperturbability by overcoming hardship is spiritual well-being. Spirituality serves as the existential foundation for human existence and is important for the relationship with "something greater than self." In common understanding, QOL is evaluated not objectively but subjectively, and not as a single dimension but as multiple dimensions. Spiritual well-being is one of multiple dimensions of QOL.

In the second report, we will show the spiritual pain and spiritual well-being of Hansen's disease survivors who have lived harsh lives via an analysis of their life review based on the findings of spirituality and QOL from the first report.

### **Acknowledgements**

This work was supported by JSPS KAKENHI Grant Number 18H03075. We would like to thank Editage (www.editage.com) for English language editing.

#### **Conflict of interest**

We have no financial relationships to disclose.

*Quality of Life - Biopsychosocial Perspectives*


**15. References**

 Patients with COPD present late with chronic respiratory symptoms and majority of early stage is asymptomatic and hence needs a high index of suspicion for diagnosis.

 Pulmonary function tests reveal airflow obstruction (ie, a forced expiratory volume in one second [FEV1]/forced vital capacity [FVC] ratio less than 0.70) which is

 The GOLD staging system is based on spirometry and is well recognized and commonly used as a guide for management. It has been criticized for underestimating the importance of the extrapulmonary effects of COPD in predicting outcome, which is

 Cessation of smoking is a central point in treatment of COPD. A short-acting inhaled bronchodilator for use on as-needed basis is a reasonable initiation therapy for early stage disease(StageIA). Addition of a long-acting inhaled bronchodilator and/or glucocorticoid should be considered to improve symptoms, improve lung function, and

 Pulmonary rehabilitation is recommended to improve symptoms, exercise capacity, and quality of life. Long-term oxygen therapy is indicated in COPD patients who have

All patients with COPD should be advised to quit smoking, educated about COPD, and

Patients who continue to have significant symptoms despite the above interventions

Extensive research is ongoing in various aspects of understanding etiopathogenesis and

Adams PF, Barnes PM, Vickerie JL.(Nov 2008) Summary health statistics for the U.S. population: National Health Interview Survey, 2007. *Vital Health Stat* 10. ;1-104. American Thoracic Society(1962): Chronic bronchitis, asthma and pulmonary emphysema.

Americn Thoracic Society(1987): Standards for the diagnosis and care of patients with

American Thoracic Society(1995). Standards for the diagnosis and care of patients with chronic obstructive pulmonary disease. *Am J Respir Crit Care Med* ; 152:S77. Anthonisen NR, Connett JE, Kiley JP, et al(1994): Effects of smoking intervention and the use

ATS/ERS Task Force2004[updated 2005]: Standards for the diagnosis and management of

patients with COPD. Version 1.2. New York: ATS . Acessed from:

A statement by the committee on diagnostic standards for nontuberculous

chronic obstructive pulmonary disease (COPD) and asthma. *Am Rev Respir Dis*;

of an inhaled anticholinergic bronchodilator on the rate of decline of FEV1. *JAMA* ;

reduce the frequency of exacerbations in Stage IB disease and onwards.

influenza/pneumococcal vaccines advised as recommended.

respiratory diseases. *Am Rev Respir Dis*; 85:762-768.

pathologic process with earlier and more severe disease presentation.

Some patients present with an acute exacerbation.

incompletely reversible.

chronic hypoxemia.

**15. References**

addressed by the BODE index.

may be candidates for surgical therapy.

treatment options for COPD.

136:225-244.

272:1497-1505.

http://www.thoracic.org/go/copd.

extracellular matrix injury which heals with incomplete and disorganized repair mechanisms ultimately leading to permanent progressive airflow obstruction. Deficiency of anti-protease deficiency makes individuals particularly susceptible to this

**8**

Janice Gullick

*Australia*

**Psychosocial Dimensions of**

*Sydney Nursing School, University of Sydney*

*Concord Repatriation General Hospital*

**COPD for the Patient and Family**

This chapter will review our current understanding from the qualitative research literature on the experience of COPD for the patient and family. It will provide exemplars from the author's past research to ground these concepts within patient and family experience. Whilst research into symptom measurement, functional and biochemical measurements of lung function and pharmacological outcomes give important insights into the physiological dimensions of COPD, methodologies that explore the psychosocial dimensions are not always well understood. Research output is increasingly valued according to clearly definable 'Levels of Evidence' (National Health and Medical Research Council, 2009). This approach makes visible the rigour of processes that underpin clinical evidence and considers practices confirmed at one extreme by double-blinded, randomised, controlled trials, through to the accepted wisdom of experts in the field. Demonstrable rigour in research is particularly important when evaluating the safety and efficacy of new drugs and interventions. In this case, large sample-sizes, strict control of variables and meticulous monitoring of the research protocol to maintain objectivity means that clinicians can weigh up, with confidence, the therapeutic choices available to them. This quantitative approach to

Clinicians have sought ways to apply quantitative research methods to measure psychosocial dimensions of illness and treatments. Symptom and impact scales such as the Hospital Anxiety and Depression Scale (Zigmond et al., 1983) and the International Continence Society Sex Questionnaire (Blanker et al., 2001), are examples of instruments that can identify the presence and frequency of issues of importance to patients across the COPD population. Instruments like the SF-36 (Mahler & Mackowiak, 1995) and the Sickness Impact Profile (McDowell & Newell, 1987) allow us to determine the influence of disease and interventions on a person's quality of life. Measures of adaption to illness such as the Jalowiec Coping Scale (Jalowiec et al., 1984) quantify the behavioural and cognitive coping

These quantitative measures of psychosocial aspects of COPD are useful in their ease of applicability to large research samples. They provide an aspect of evaluation that goes beyond the purely physiological concerns of health professionals to consider the patient-

research relies on statistical methods to determine 'truth'.

strategies people use to deal with social, physical end emotional stressors.

**1. Introduction**


**6. Schistosomiasis**

[49, 65, 66]. The disease is highly contagious, but few people develop the disease once there is natural resistance to the bacillus [65]. This is one of the oldest diseases known to affect

There are reports of leprosy in 138 countries, with world prevalence of 0.2 cases per 10,000 inhabitants in 2015 [68]. The number of new cases in this same year was 211,973 cases, evidencing continued transmission (2.9 cases per 100,000 inhabitants). India and Brazil are

The spectrum of manifestations depends on the host's immunity and response to M. leprae, and the incubation period is long, going from 6 months to 10–20 years [65, 66]. During the course of the disease, there are "reactional states," in which the immune system reacts against the bacilli, exacerbating the clinical manifestations. The disease can be classified as paucibacillary and multibacillary, according to the number of skin lesions and bacilli found in skin smears [65, 66]. Besides affecting the skin, leprosy characterizes to cause peripheral nerve damage [65] and can complicate with systemic involvement, including nephropathy [49].

Kidney involvement in leprosy has been described for the first time a long time ago in autopsy studies and includes different types of glomerular lesions, such as epithelioid granulomas, and also Hansen's bacillus in renal parenchyma [49]. It is found in all forms of the disease but is more frequent in multibacillary forms [69, 70]. The most common leprosy-associated glomerular disease is mesangial proliferative glomerulonephritis and other histologic types are also found: acute proliferative glomerulonephritis, membranous glomerulonephritis, rapidly progressive glomerulonephritis, and others. Chronic tubulointerstitial nephritis and amyloidosis have also been described in the course of leprosy, leading to chronic kidney disease [71, 72]. The mechanics by which *M. leprae* infection leads to kidney disease are not completely understood [49], and it is probably associated with immunological phenomena. Complement reduction and immune complex deposition in glomerular basement membrane have been described [73–75]. Oxidative stress also plays a role in leprosy nephropathy. There is evidence of subclinical kidney damage even in patients with controlled infection. The levels of urinary MCP-1 are increased in leprosy patients and are associated with microalbuminuria levels and amount of bacilli of skin smears [76]. Renal tubular disturbances have also been described in leprosy, including concentration and acidification defects [77]. AKI can also occur in leprosy and seems to be associated to glomerulonephritis complications or secondary to the use of nephrotoxic drugs, mainly anti-inflammatory drugs and rifampicin, which are used in leprosy therapeutic scheme. Leprosy nephropathy seems to have changed in recent years, becoming a milder disease, characterized by micro-hematuria and mild proteinuria, which

Treatment consists of specific multi-drug therapy, reactional state treatment, prevention of disabilities, and psychosocial support. Specific therapy includes rifampicin and dapsone for paucibacillary patients (for 6 months) and rifampicin, dapsone, and clofazimine for multibacillary patients (for 12 months). Corticosteroids may be used for reactional states. Leprosyassociated end-stage kidney disease may require renal replacement therapy, which includes dialysis or transplantation, and immunosuppression for renal transplanted patients seems

humankind, with reports in the Bible [67].

36 Current Topics in Tropical Emerging Diseases and Travel Medicine

tends to recover after specific treatment [78].

not to alter the response to leprosy-specific treatment [49].

responsible for the highest majority of cases in the world [68].

Schistosomiasis is the parasitic disease caused by organisms of the genus *Schistosoma*, which affects more than 200 million people in the world and is endemic in some tropical areas of the globe [79, 80]. It is the second most frequent parasitic disease, after malaria, and is still an important infection-associated cause of death [81].

The definitive host is the men, where the adult parasite reproduces and eliminates its eggs, which contaminated water resources [79]. In nature, disease transmission depends on the presence of snails from the family *Planorbidae* and genus *Biomphalaria*, and the men acquire the infection when the cercariae penetrate through the skin. The presence of the parasite in the human organism is relatively harmless, and the manifestations depend on immune response to different stages of the parasite in the body [82]. The disease can manifest as an acute syndrome, also known as Katayama syndrome, which is more common among travelers or immigrants in endemic areas with no immunity to *Schistosoma* and is characterized by fever, malaise, myalgia, headache, and abdominal pain, which can last from 2 to 10 weeks [80]. Depending on the patient's immune system response, the disease can progress to the chronic forms, in which predominate the intestinal form, in the case of *S. mansoni*, *S. japonicum* and *S. mekongi* infections. Patients with poor immune regulation develop severe fibrosis and hepatosplenic disease with periportal fibrosis [80]. The species *S. haematobium*, which occurs in some parts of Africa, affects the urogenital system, manifesting mainly by hematuria [80–82]. Other symptoms described in the infection by *S. haematobium* include hematospermia and inflammation in other structures in men—epididymis, testicles, spermatic cord and prostate, and women—hypertrophic/ulcerative lesions of the vulva, vagina, and cervix [82].

Kidney involvement in schistosomiasis is described and predominates in the form of glomerulonephritis [79]. In schistosomiasis, there are circulating antigens of adult parasite, and its eggs can be found in different organs, including the kidneys [79]. Acute kidney injury (AKI) is also described, with high prevalence in endemic areas, affecting as high as more than 40% of patients with the chronic forms of the disease [79]. Schistosomal glomerulonephritis is classically associated with the hepatosplenic form and ranges from asymptomatic disease to nephrotic syndrome [79]. Renal histopathological analysis evidences immune complex deposition, with schistosomal antigens in the glomerular basement membrane, as well as the presence of schistosomal eggs and granulomas. The mechanism of these lesions includes immunological phenomena, with response directed against parasite's antigens and immune complex formation and deposition in the glomeruli [83–86]. There is also evidence of polyclonal B-lymphocytes activation [87], but it is not sufficient to induce the process of nephritis, so more recent studies suggest the participation of autoimmune mechanisms [88]. The most common pattern of glomerular disease in schistosomiasis is mesangial proliferative and membranoproliferative glomerulonephritis [89, 90]. There are deposits of IgM, IgG, and C3 [91]. Amyloidosis has also been described [79, 92] but is less frequent, although it is always a possible pattern of kidney disease in any infectious disease with chronic evolution. Schistosomal glomerulonephritis can be classified in five types: mesangial proliferative glomerulonephritis, membranoproliferative glomerulonephritis, focal and segmental glomerulosclerosis, exudative glomerulonephritis, and amyloidosis [91]. Granuloma formation in the kidney is also a possible but rare complication of schistosomiasis [92]. Tubular dysfunction also occurs in schistosomiasis, mainly urinary concentration dysfunction, which can be found in as high as 85% of patients with the hepatosplenic form in endemic areas [93]. Even in patients infected with *S. mansoni*, without clinically significant disease, there is evidence of renal inflammation, which was shown through increased urinary levels of MCP-1 [94].

Treatment is based on specific drugs, the first choice being praziquantel [80, 82], which has action against all *Schistosoma* species and provides cure rates above 80% [82]. The recommended dose is 40 mg/kg for *S. haematobium* and *S. mansoni*, and 60 mg/kg for *S. japonicum* [82].

**Table 1** summarizes the main aspects of kidney involvement in the neglected tropical diseases discussed in this chapter.

**Figure 1** illustrates the general pathophysiology of kidney involvement in tropical infectious and parasitic diseases.

**7. Conclusion**

ery is possible if adequate management is provided.

Neglected tropical diseases represent a global public health problem, affecting billions of people and requiring billions of dollars to treat and control. Authorities should have in mind that the key approach to these diseases, including kidney disease itself, is prevention, which is far from ideal, mainly in the developing world. Governments should also have in mind that the main determinant factors for the perpetuation of the neglected tropical diseases in the world in the sum of poor living conditions (lack of sanitation, potable water, piped water, garbage collection, education, domestic animal control, disease-vector control, environmental problems, lack of urbanization plans, and many others), and they have responsibility for the control of these diseases [95]. Many complications can arise from these diseases, and one of the most frequent and severe is kidney disease. The main pathophysiologic factors include immunological phenomena and hemodynamic abnormalities. Endemic diseases, such as dengue, chikungunya, and Zika virus infection, which have affected millions of people in the last few years, are having increasing evidences of kidney involvement in severe cases. In the majority of cases, kidney involvement in these diseases develops as a complication when the patient has poor or delayed access to health care. Research is being conducted to better control these diseases, including vaccine development. Concerning tropical diseases-associated kidney injury, the current "hot-topic" research is to detect this complication through novel biomarkers in order to provide an early and more specific management aiming to avoid or stop renal function loss and then prevent permanent renal insufficiency. Physicians attending patients with tropical diseases should always evaluate renal function, once renal involvement is frequent, and renal recov-

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**Figure 1.** General pathophysiology of kidney involvement in tropical infectious and parasitic diseases.

AKI: acute kidney injury; CKD: chronic kidney disease; NGAL: neutrophil gelatinase-associated lipocalin; MCP-1: monocyte chemoattractant protein-1.

**Table 1.** Kidney involvement in neglected tropical diseases.

**Figure 1.** General pathophysiology of kidney involvement in tropical infectious and parasitic diseases.


**6. Conclusions**

82 Hydrodynamics – Natural Water Bodies

Fig. 3a illustrates the pre-processing step for simulation of pollutant dispersion and demonstrates the complex geometrical configuration required to represent the turbulent flow. There are six continuous pollution sources in the cities of Macapá and Santana, from the mouth of the Matapi River (southern area) to the north of the city, the upper area of the figure. The natural flux of flows passes from the bottom (left) to top (far right, in the north and northeast). The continuous point sources of pollutants are represented by red circles along the coast, which represent the main release points of untreated pollutants into the waters in Macapá and Santana cities (Pinheiro & Cunha, 2008). The same representation

Fig. 4 shows the results of the simulations of pollutant dispersal plumes (light blue and reddish margins) during a tidal cycle. These maps show that the plumes tend to stay close to the shore. From left to right (top row) is the initial phase of a simulated low tide (approximately 7 hours). Again, from left to right (bottom row) begins the high tide phase (approximately 5.5 hours). During the tidal cycle it was possible to simulate the complex interactions between hydrodynamics and a coupled scalar (hypothetical pollutant), with an emphasis on the dynamic plumes between mainland Santana and the island of Santana. Case study 2 (Fig. 5), shows the phases of the dispersion of pollutant plumes (hypothetical tracer) in the Matapi River during a tidal cycle. The flow pattern (streamlines) changes significantly over a period of the semi-diurnal tide. Simulating the dispersal of pollutants indicates a remarkable complexity in the flow, depending on the geometry of the river

In Fig. 5, from left to right depicts changes in pollutant plumes during low tide (approximately 7 hours), during a complete semi-diurnal tidal cycle, where the natural flux

In Fig. 6, from left to right, there are three different flow fields indicated: a) velocity vectors, b) streamlines (paths of constant speeds), c) dispersion pattern of the scalar from two

Fig. 5. Lines of transient currents in the Rio Matapi: a) low tide at t = 1h, b) end of the ebb at

occur in Rio Matapi indicated by Fig 3b (Cunha, 2008).

channel and the timing of the reversal of the tidal cycle.

(hypothetical) continuous point sources of pollutants.

t = 5.5 h, c) reversal of the tide at t = 6h.

of the tide flows from top to bottom. The reverse shows the rising tide.

The main conclusions of this research are:

In the estuarine region of the Lower Amazon River, in the state of Amapá, the measurement of net discharges of large tidal rivers is only feasible with the use of devices such as ADCP to integrate hydrodynamic processes and water quality variables (biogeochemical cycle and interaction between the plume of the Amazon River and Atlantic Ocean).

Relevant hydrodynamic parameters such as velocity profiles, stress and identification of background turbulent flow velocity components need to be determined with the aid of modern equipment whose operation must be efficient and economic for hydrometric quantification in complex estuarine environments.

Bathymetric analyses, at the scales of interest, have been a difficult hurdle to overcome because of the intricate system of channels in the Amazon River.

The logistics required for experimental studies in large rivers is a major obstacle that has inhibited research interest in this poorly studied area.

A major challenge to be overcome in systematic studies of water quality parameters is the generation of local physical parameters, such as rating curves, rates of sedimentation and resuspension of sediments, etc, which are a fundamental input for complex numerical models of water quality.

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The modelling of water quality in the Amazon estuary is complex due to the absence and / or inadequacy of data describing different physical characteristics. The drainage system imposes enormous difficulties in this area. An example is the absence of long-term time series to obtain necessary parameters and coefficients to build numerical models.

Hydrodynamic simulations of flow and dispersion of pollutant plumes released into the environment are difficult to implement, and require calibration and verification with local data that are not always available.

Existing techniques in numerical modelling can become strong allies in informing public policy and the management of regional water resources.

Among the parameters of interest from numerical models, the generation of 3D computational meshes is potentially the most important source of novel information.

The development of local expertise constitutes one of the biggest challenges in the area, since the best and most efficient option for development of experimental studies in hydrodynamics and computer simulation, is the formation of local human resources. The main advantages are lower operating costs for complex experimental campaigns.

The implementation of a database accessible to the interested user would also be an important technological challenge for the systematic studies of the hydrodynamics and water quality at this region. Thus, would be possible to improve our understanding about the ecosystem functioning and to evaluate the complexity of the Amazon estuary and the role of carbon cycle in these environments.


**5. Diagnosis of PH**

The existence of sophisticated monitoring in this particular group of patients is deemed necessary because early diagnosis and prompt institution of therapy for acute PH is required in order to prevent right ventricular failure.

Diagnosis is aided by awareness of existing preoperative risk factors, such as valvular pathology or intracardiac shunts that are associated with PH. The development of acute PH will result in clinical signs of relatively rapid onset relating to the development of tricuspid regurgitation: prominent central venous atrioventricular pulsatile pressure waveforms, right-sided heart failure and a holosystolic murmur at the lower border of the sternum that increases in intensity during inspiration.

Pulmonary artery pressure catheterization and transesophageal echocardiography (TOE) constitute a valid monitoring tool for early detection of acute PH.

Pulmonary artery pressure catheterization will demonstrate elevated right atrial pressure, right ventricular end-diastolic pressure and pulmonary artery pressure with normal or low pulmonary wedge pressures. In the case of right ventricular dysfunction without pulmonary vasoconstriction, the pulmonary artery pressure may also be normal. Hemodynamic parameters calculated and derived by thermodilution will reflect elevated PVR and a reduction in right ventricular stroke work index and right ventricular stroke work index / central venous pressure relationship and a reduction in cardiac output or right ventricular ejection fraction.

TOE is an invaluable tool in the diagnosis of PH and right ventricular dysfunction, demonstrating both right ventricular volume and pressure overload. The two- dimension mode provides a subjective view of the increased ratio of right ventricle-to- left ventricle chamber size, paradoxical septal bulging, and deterioration in right ventricular function as seen on five-chamber and 4-chamber long axis views (Figure 1).

Color flow mapping will often reveal pulmonary and tricuspid regurgitation. The use of continuous wave Doppler across the regurgitant tricuspid valve allows quantification of the

Fig. 1. Severe tricuspid regurgitation and enlargement of the right ventricle caused by severe pulmonary hypertension

pressure gradient across the valve and thereby an estimation of the pulmonary artery pressure.

Also TOE has been proved to be a useful tool in the continuous assessment of the results of the applied therapeutic strategy.