**2. Paleoseismics and paleotsunamis**

**Table 1.** lists the 17 tsunami events recorded and documented in Sweden up to now [3]. The corresponding spectrum of inferred wave heights is provided in **Figure 1** [6]. In the present chapter, five of the events will be picked out and discussed as case studies from Sweden and its surrounding seas [1].

**Table 1.** Tsunami events recorded in Sweden in association with paleoseismic events [1, 2].

**Figure 1.** Recorded tsunami heights in the Baltic (blue) and Kattegat (green) coasts of Sweden [6]. Red figures (1–5) refer to the five events here discussed with event 4 being revised in time and wave height.


*5.2. Surfactants*

Surfactants can be classified according to their electrical characteristics as ionic, nonionic, and zwitterionic. Most foods surfactants are ionic, such as esterified monoglycerides, which are mainly negatively charged and can form nanoemulsions using low or high energy. Non-ionic surfactants also can be used for both methods and have low toxicity and irritability, including compounds such as Tween® (condensate of sorbitol fatty acid esters and ethylene oxide) and Span® (a family of fatty acids sorbitan). On the other hand, zwitterionic surfactants contain two or more ionizable groups with opposite charges, and consequently, they can have a negative, positive, or neutral charge depending on the pH solution. For example, this group includes lecithin, a phospholipid widely used in foods [57,62].

One of the main aspects of an emulsion formulation is the choice of surfactant. The hydrophilic–lipophilic Balance (HLB) system was developed, which represents the balance of the size and strength of the polar and non-polar groups [62]. It demonstrates molecule properties as amphiphilic compounds using a numerical scale, assigning higher HLB values as the substance is more hydrophilic [62]. However, the HLB system only considers the properties of the surfactant itself. For this reason, the hydrophilic–lipophilic deviation (HLD) system is another approach to the behavior exhibited by surfactant– oil–water and usually more suitable in formulations [57,63]. In addition, proteins, polymers with amphiphilic properties, and combinations of polymers and surfactants can act as emulsifiers [64].

Studies have demonstrated the importance of modulating nanoemulsions composition and structure to achieve higher digestion and absorption in the gastrointestinal tract and to efficiently deliver compounds such as vitamins and nutraceuticals [54,58,65,66]. Therefore, the choice of emulsifier is of extreme importance since it can improve carotenoids bio-accessibility, for example. In a study performed by Yao et al. (2019) [65], the authors demonstrated the relationship between carotenoids bio-accessibility from spinach and co-ingesting with excipient nanoemulsions: nanoemulsions containing different ratios of medium or long-chain triglycerides in the oil phase composition decreased β-carotene bioaccessibility when the ratio of medium-chain triglycerides was increased. The findings were credited to the formed micelle's ability to hold the carotenoids in their hydrophobic domains.


**4. Tools for creating augmented reality educational applications**

There are many augmented reality applications that are specifically designed for education and are free for use for both teachers and learners. Often, teachers prefer to develop their own learning content and materials that are designed and tailored to their learners' goals.

Users can create augmented reality applications with various software platforms (many of them are free to use). There are two main approaches: using augmented reality browsers or augmented reality software development kit.

### **4.1 Augmented reality browsers**

Augmented reality browsers are applications that display virtual geolocation multimedia content upon real-world objects. Browsers access remote resources through web protocols and services, index content through media streams and support various MIME formats [16]. Augmented reality browsers offer not only opportunities for publishing content that augments the reality but also tools for developing augmented reality projects.

With browsers, the process of creating augmented reality projects is quick and easy, and no special programming skills are required since templates are used

**23**

**Figure 5.**

*Wikitude studio project.*

*The Immersive Power of Augmented Reality DOI: http://dx.doi.org/10.5772/intechopen.92361*

browser [17].

and more.

and is accessible in YouTube.

**4.2 Augmented reality software development kit**

virtual content that augments and enriches real objects.

and most of the procedures are automated. There are some limitations of created projects-recognition of only 2D images is possible and inability for interaction between users and virtual content. A major drawback of this approach is that there are no standards that allow augmented content to be interchangeable. Content created with the tools of one browser cannot be accessed through another

Popular augmented reality browsers and their project creation tools include HP Reveal (HP Reveal Studio), BlippAR (Blippar Studio and Blipp-Builder), Zappar (ZapWorks Studio and ZapWorks Designer), Wikitude (Wikitude Studio)

Different terms are used to refer to the created products (layers, channels and worlds), but the principle of action is identical-consecutive steps: (1) selection of the images-targets, which will be scanned; (2) add different types of digital content that will enrich the images; (3) review and test and (4) publish the project. After creating and publishing augmented reality projects, users (learners) must scan the images with augmented reality browser in order to visualize the digital content. **Figure 5** shows an augmented reality project created with Wikitude Studio. When scanning the image (a table with logical functions), learners can see a video material, which illustrates the results of the logical functions and their dependence on the values of the input arguments. Video material is created by Google Doodle

Augmented reality software development kits (AR SDK) have fundamental features such as image, object and location recognition, position estimation and others. Among the popular AR SDKs are ARKit, ARCore, Vuforia Engine, Wikitude AR SDK, Kudan, AR SDK, EasyAR SDK and ARToolKit. They all allow 2D image recognition and are compatible with different platforms (iOS, Android, Windows and others). Some of them provide 3D object recognition features, while others help create geolocation applications. AR SDKs can be used to create augmented reality applications for smartphones, tablets and a variety of wearable devices. This approach results in developing stand-alone applications that users use to view

## *The Immersive Power of Augmented Reality DOI: http://dx.doi.org/10.5772/intechopen.92361*

*Human 4.0 - From Biology to Cybernetic*

**4. Tools for creating augmented reality educational applications**

reality browsers or augmented reality software development kit.

There are many augmented reality applications that are specifically designed for education and are free for use for both teachers and learners. Often, teachers prefer to develop their own learning content and materials that are designed and tailored

Users can create augmented reality applications with various software platforms (many of them are free to use). There are two main approaches: using augmented

Augmented reality browsers are applications that display virtual geolocation multimedia content upon real-world objects. Browsers access remote resources through web protocols and services, index content through media streams and support various MIME formats [16]. Augmented reality browsers offer not only opportunities for publishing content that augments the reality but also tools for

With browsers, the process of creating augmented reality projects is quick and easy, and no special programming skills are required since templates are used

**22**

to their learners' goals.

**Figure 4.**

**4.1 Augmented reality browsers**

*Virtual reality tour with Google expeditions.*

developing augmented reality projects.

and most of the procedures are automated. There are some limitations of created projects-recognition of only 2D images is possible and inability for interaction between users and virtual content. A major drawback of this approach is that there are no standards that allow augmented content to be interchangeable. Content created with the tools of one browser cannot be accessed through another browser [17].

Popular augmented reality browsers and their project creation tools include HP Reveal (HP Reveal Studio), BlippAR (Blippar Studio and Blipp-Builder), Zappar (ZapWorks Studio and ZapWorks Designer), Wikitude (Wikitude Studio) and more.

Different terms are used to refer to the created products (layers, channels and worlds), but the principle of action is identical-consecutive steps: (1) selection of the images-targets, which will be scanned; (2) add different types of digital content that will enrich the images; (3) review and test and (4) publish the project. After creating and publishing augmented reality projects, users (learners) must scan the images with augmented reality browser in order to visualize the digital content.

**Figure 5** shows an augmented reality project created with Wikitude Studio. When scanning the image (a table with logical functions), learners can see a video material, which illustrates the results of the logical functions and their dependence on the values of the input arguments. Video material is created by Google Doodle and is accessible in YouTube.


**4.1 Lava flow morphology and the sources of the youngest AD2000 eruption**

Field observations have already determined that YS (**Figure 7a**) and DHG are the two large scoria cone complexes that generated significant morphologies of lava flows.

YS, The Triple Vent, preserves three distinctive scoria cones with visual successions from the observations of satellite images (**Figure 2a**-**d**). As **Figure 2a**-**d** depict, YS composes of three distinct volcanic edifices overlapping each other with a total area of 2.2 km2 . Fieldworks indicate that the highest elevation (approximately 1597 m above sea level) is observed on the top of the jointing point between the southeast one and the southwest one (**Figure 7b**). Scoria caps cover the top of the triple vent. The steepest slope is located on the southern flank of the edifice, which is nearly 47 degrees due to the welded nature of the proximal scoria and spatter beds. A breakage merges on the southwestern cone with outpouring lava flows that form a range of influxes at least 3.77 km long into the broad fluvial valley of the Halaha River. Scoria ash and lapilli formed deposits that blanketed at least 1 m thick units in an area mostly to the east of the Yanshan vents (**Figure 7c**). The Sentinel images reveal that ash plain extends about 4 km from the Yanshan volcanic complex and traces of valley accumulated ash up to 10 km from the source are likely based on the satellite image pattern. The eastern side of the Yanshan edifice is truncated and a hummocky surface can be traced about a km from the cone flank indicating an early collapse of the vent toward the east. The rafted cone fragments were subsequently covered by the ash plain (**Figure 2a, b** and **d**). Lava flows preserve a range of distinctive features of morphologies, such as


*3.3. Factors Associated with COVID-19 Vaccination among People Aged 60 Years or Older*

Nationally, 61.9% of those aged 60 years or older had completed COVID-19 vaccination by 30 November 2022 [12]. In the analysis of this subgroup, significant factors (α = 0.05) in the bivariate model negatively associated with COVID-19 vaccination, adjusting for departmental level differences, were similar to the overall analysis and included the proportion of the municipality identifying as Mayan, the proportion living in a rural residence, and the proportion experiencing poverty, but did not include the departmental-level under-five childhood mortality rate and the department's Gini coefficient (Table 4). Factors positively associated in the bivariate model were the same as in the overall analysis.

After adjusting for all covariates and departmental effects in the full model, the proportions of the municipal population (1) living in a rural residence, (2) having received at least a primary school education, (3) experiencing poverty, (4) of female sex and (5) tested

for SARS-CoV-2 remained significantly associated with complete vaccination coverage (Table 4, Section "Full multivariable model"). In the simplified multivariable model (Table 4, Section "Simplified multivariable model"), when adjusting for covariates and departmental level differences, a 10% higher proportion of people experiencing poverty within a municipality was associated with 2.0% lower complete COVID-19 vaccination coverage (95% CI: −3.79–−0.28). A 10% increase in the proportion of the municipality living in a rural residence was associated with a 0.9% higher COVID-19 vaccination coverage (95% CI: 0.27–1.59); having received at least a primary school education was associated with 9.8% higher COVID-19 vaccination coverage (95% CI: 5.66–13.72); a 10% increase in the proportion of the municipality of female sex was associated with 20.6% higher COVID-19 vaccination coverage (95% CI: 6.39–34.51); and a 10% higher proportion of the municipality tested for SARS-CoV-2 infection was associated with a 3.1% higher COVID-19 vaccination coverage (95% CI: 1.90–4.37). The marginal R2 value was 0.487, and the conditional R2 value accounting for the covariates and departmental-level differences was 0.600.


**7. Actual guidelines for surgical treatment in diabetic patients**

characterized by continuous decrease of beta cell function. Absence of insulin treatment was a predictive factor for remission of diabetes after bariatric surgery. [68, 71] The insulin use was associated with lower remission rates compared with oral medication (13.5 versus

**d. Weight loss**. The amount of weight loss seems to be of major importance in the improve‐ ment of glucose control after laparoscopic adjustable gastric banding. [52] Also percentage weight loss at 1 year over 25% independently influenced remission of diabetes after gastric bypass. [69] But no correlation between normalization of fasting glucose levels and weight loss after gastric bypass and biliopancreatic diversion was observed in another study. [54] Weight changes after these former surgical procedures were not significant predictors of diabetes remission at 2 years or of normalization of glycated hemoglobin. [54] But in the Diabetes Surgery Study weight loss explains most of the benefit on glycemic control of

were predictive factors for diabetes remission whatever the procedures. [71]

**e. Initial level of C peptide:** Fasting C-peptide concentration is correlated with beta cell mass and insulin secretion. Very low C-peptide levels could be useful in identifying type 1 diabetes and latent autoimmune diabetes in adults that could have as comorbidity obesity. C-peptide levels are increased as response to insulin resistance in obese type 2 diabetes subjects and are correlated with BMI but decreased with duration of diabetes. [69] A high level of C-peptide before metabolic surgery increased the chance of a good outcome. The cut-off value of C-peptide ≥2.9ng/ml at baseline predicts the remission of diabetes after gastric bypass. [69] Also in another study the diabetes remission rates strongly correlate with the level of C-peptide: 55.3% for those with preoperative C-peptide <3ng/ml, 82% for C-peptide 3-6ng/ml, and 90.3% for C-peptide > 6ng/ml. [73] Another study showed that 90% of type 2 diabetes patients with preoperative fasting C-peptide levels over 1 nmol/l had mean A1c <6.5% after Roux-en-Y gastric bypass and 74% had complete resolution of diabetes. But none of the patients with fasting C-peptide level less than 1 nmol/l before surgery experienced diabetes remission. The authors of this study recommend fasting C-peptide levels to be measured in order to a better prediction of

**f. Type of surgical procedures** Preoperative data of patients could be of greater importance in the resolution of diabetes than the choice of bariatric surgery procedures. There are several studies that analysed the efficiency of different types of surgical procedures, reporting remission rates of 7-70% for gastric banding, 38-98% for gastric by-pass, 33-85% for sleeve gastrectomy and 52-100% for biliopancreatic diversion. [75] Weight loss and diabetes resolution were greatest for patients undergoing biliopancreatic diversion/ duodenal switch, followed by gastric bypass, and least for banding procedures. [49] The combination of these factors has an increased power in prediction of the outcomes. If a score of 1 is assigned to duration of diabetes <4years, percentage weight loss at 1 year >25%, and C-peptide ≥2.9ng/ml at baseline, a cumulative score of 2 or 3 was associated with a remission rate of 92%, and a score of 0 or 1 was associated with a remission rate of 27%. [69]

and a one year BMI under 35 kg/m2

gastric bypass. [55] A baseline BMI under 50 kg/m2

diabetes remission after surgery. [74]

53.8%). [72]

208 Treatment of Type 2 Diabetes

Obesity and type 2 diabetes mellitus are chronic, multifactorial and complex disorders with serious outcomes on health and requires multidisciplinary approach in order to improve prognostic.

Several international society have launched their guidelines, position statement and recom‐ mendations on type 2 diabetes mellitus and metabolic surgery based on growing evidences form observational, randomized controlled studies and metaanalysis. [60, 76-79] These guidelines and position statement are needed because the global prevalence of type 2 diabetes is rising dramatically as a consequence of obesity epidemic and environmental changes including high calorie food abundance and lack of physical activity. Type 2 diabetes and obesity are associated with premature morbidity and mortality and are major public health threats of the 21st century. There is increasing evidence that prognostic of patients with type 2 diabetes mellitus and obesity is dramatically improved by bariatric surgery that produces important weight loss, substantially decreases of glycated hemoglobin, improvement of lipid profile and reduces the cardiovascular risk and it even can produces remission of diabetes. [60] Bariatric surgery for severe obesity associated with diabetes mellitus is cost-effective. [60]


**Acknowledgements**

This study was carried out with the support by the Department of Biodiversity, University of Limpopo. The author acknowledges Dr. P.W. Mokwala and Mr. F. Nndwambi for providing seeds of soybean. Many thanks to Mr. L. Ramoba, F. Nukeri, S. Thosago, F.M. Masiya, R. Mudau, V.L. Makwana, L.R. Mahuluhulu, L.M. Marotola, K.K. Boshomane, M. Lutombo and T. Maleka for their technical support.


*Article* **Maintaining Normothermia in Preterm Babies during Stabilisation with an Intact Umbilical Cord**

**Alexander James Cleator, Emma Coombe, Vasiliki Alexopoulou, Laura Levingston, Kathryn Evans, Jonathan Christopher Hurst and Charles William Yoxall \***

> Liverpool Women's Hospital, Liverpool L8 7SS, UK<EMAIL_ADDRESS>(A.J.C<EMAIL_ADDRESS>(E.C<EMAIL_ADDRESS>(V.A<EMAIL_ADDRESS>(L.L<EMAIL_ADDRESS>(K.E<EMAIL_ADDRESS>(J.C.H.)

**\*** Correspondence<EMAIL_ADDRESS>
**Abstract:** Background: We had experienced an increase in admission hypothermia rates during implementation of deferred cord clamping (DCC) in our unit. Our objective was to reduce the number of babies with a gestation below 32 weeks who are hypothermic on admission, whilst practising DCC and providing delivery room cuddles (DRC). Method: A 12 month quality improvement project set, in a large Neonatal Intensive Care Unit, from January 2020 to December 2020. Monthly rates of admission hypothermia (<36.5 ◦C) for all eligible babies, were tracked prospectively. Each hypothermic baby was reviewed as part of a series of Plan, Do, Study Act (PDSA) cycles, to understand potential reasons and to develop solutions. Implementation of these solutions included the dissemination of the learning through a variety of methods. The main outcome measure was the proportion of babies who were hypothermic (<36.5 ◦C) on admission compared to the previous 12 months. Results: 130 babies with a gestation below 32 weeks were admitted during the study period. 90 babies (69.2%) had DCC and 79 babies (60%) received DRC. Compared to the preceding 12 months, the rate of hypothermia decreased from 25/109 (22.3%) to 13/130 (10%) (*p* = 0.017). Only 1 baby (0.8%) was admitted with a temperature below 36 ◦C and 12 babies (9.2%) were admitted with a temperature between 36 ◦C and 36.4 ◦C. Continued monitoring during the 3 months after the end of the project showed that the improvements were sustained with 0 cases of hypothermia in 33 consecutive admissions. Conclusions: It is possible to achieve low rates of admission hypothermia in preterm babies whilst providing DCC and DRC. Using a quality improvement approach with PDSA cycles is an effective method of changing clinical practice to improve outcomes.

**Keywords:** hypothermia; umbilical cord; preterm; resuscitation

#### **1. Introduction**

Preterm babies are particularly vulnerable to hypothermia after birth. Hypothermia is an independent risk factor for death [1,2] and a risk factor for the development of respiratory distress syndrome, intraventricular haemorrhage, late onset sepsis and severe neurodevelopmental impairment [3,4].

The benefits of Deferred Cord Clamping (DCC) at preterm birth are well documented, including a reduction in hospital mortality [5].

Across the UK, in 2018 only 5.2% of babies with a gestation below 32 weeks had a documented period of DCC lasting for 60 s or more (Data from Badger System, Clevermed, UK. Personal communication, CEO, Clevermed, Edinburgh, UK). Our unit has been an early adopter of DCC. We recruited babies into studies to evaluate the practicability of using the Lifestart trolley to facilitate DCC in 2012 and 2013 [6] and enrolled babies into a randomised controlled trial of DCC from 2013 to 2015 [7]. There was some practise of DCC subsequently, but following the publication of the trial evidence showing clear benefit, we undertook a quality improvement project and increased the rate of DCC for at least 120 s

**Citation:** Cleator, A.J.; Coombe, E.; Alexopoulou, V.; Levingston, L.; Evans, K.; Hurst, J.C.; Yoxall, C.W. Maintaining Normothermia in Preterm Babies during Stabilisation with an Intact Umbilical Cord. *Children* **2022**, *9*, 75. https:// doi.org/10.3390/children9010075

Academic Editors: Simone Pratesi, David Hutchon and Anup Katheria

Received: 13 December 2021 Accepted: 29 December 2021 Published: 5 January 2022

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

**Copyright:** © 2022 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/).

to 92% of eligible babies in 2018 and 2019 [8]. During that period of implementation, we noted an increase in the rate of admission hypothermia (<36.5 ◦C) to 20% from a previous stable baseline rate of 12% (Figure 1). for at least 120 *s* to 92% of eligible babies in 2018 and 2019 [8]. During that period of implementation, we noted an increase in the rate of admission hypothermia (<36.5 °C) to 20% from a previous stable baseline rate of 12% (Figure 1).

**Figure 1.** Proportion of babies born before 32 weeks gestation with an admission temperature below 36.5 °C across time during the introduction of DCC on our unit. **Figure 1.** Proportion of babies born before 32 weeks gestation with an admission temperature below 36.5 ◦C across time during the introduction of DCC on our unit.

In addition to promoting DCC, we have also recently started providing delivery room cuddles (DRC) following stabilisation of the baby. Once the baby is stable, a brief period of physical contact with the parents takes place before transfer to the neonatal unit. This can be achieved whilst the baby is receiving respiratory support. Two recent randomised controlled trials have shown reductions in both post-partum depression and motherinfant bonding problems following DRC [9,10], although one trial [10] found lower temperatures one hour after birth in their DRC group. In addition to promoting DCC, we have also recently started providing delivery room cuddles (DRC) following stabilisation of the baby. Once the baby is stable, a brief period of physical contact with the parents takes place before transfer to the neonatal unit. This can be achieved whilst the baby is receiving respiratory support. Two recent randomised controlled trials have shown reductions in both post-partum depression and mother-infant bonding problems following DRC [9,10], although one trial [10] found lower temperatures one hour after birth in their DRC group.

The UK National Neonatal Audit Project (NNAP) standard relating to admission temperature for preterm babies states that 90% of babies born <32 weeks should have a temperature between 36.5 °C and 37.5 °C when first admitted to the Neonatal Intensive care Unit (NICU), i.e., requires avoidance of hyperthermia as well as hypothermia. The UK National Neonatal Audit Project (NNAP) standard relating to admission temperature for preterm babies states that 90% of babies born <32 weeks should have a temperature between 36.5 ◦C and 37.5 ◦C when first admitted to the Neonatal Intensive care Unit (NICU), i.e., requires avoidance of hyperthermia as well as hypothermia.

The aim of this project was to reduce the number of preterm babies who are hypothermic (temperature <36.5 °C) on admission to our neonatal unit, whilst promoting and practising DCC and DRC. In view of the NNAP standard, rates of admission hyperthermia were also measured. The aim of this project was to reduce the number of preterm babies who are hypothermic (temperature < 36.5 ◦C) on admission to our neonatal unit, whilst promoting andpractising DCC and DRC. In view of the NNAP standard, rates of admission hyperthermia were also measured.

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

We aimed to provide stabilisation at birth with at least 2 min of DCC in all babies born before 32 weeks gestation. The period of 2 min was the same as that used in the Cord Pilot trial (7). DCC is provided in our unit using the LifeStart trolley (Inspirations Healthcare, Crawley, UK) in the delivery room. This is a resuscitation platform that facilitates stabilisation of the preterm baby whilst the umbilical cord remains intact. This device has been described in detail in recent literature [6,11]. We aimed to provide stabilisation at birth with at least 2 min of DCC in all babies born before 32 weeks gestation. The period of 2 min was the same as that used in the Cord Pilot trial (7). DCC is provided in our unit using the LifeStart trolley (Inspirations Healthcare, Crawley, UK) in the delivery room. This is a resuscitation platform that facilitates stabilisation of the preterm baby whilst the umbilical cord remains intact. This device has been described in detail in recent literature [6,11].

In addition, we aimed to provide DRC for all babies once stabilised, prior to moving the baby to the NICU. Once a baby was stable, with acceptable heart rate, oxygen saturation and appropriate thermal care in place, the baby was passed to the mother for a period of physical contact lasting up to 5 min. This was not skin-to-skin care. The baby continued to receive care wrapped in a plastic bag and in contact with a self heating gel mattress (Transwarmer (Drager Medical, Hemel Hempstead, UK)) if appropriate, they were also wrapped in warmed towels and a hat was in place. This period of contact was achieved for babies who were receiving respiratory support using continuous airway pressure (CPAP) (Figure 2) and in babies who were ventilated following tracheal intubation. In some families, the period of cuddling was shared with the father and following delivery by caesarean section under general anaesthetic, the cuddle was offered to the father alone if he was present. In addition, we aimed to provide DRC for all babies once stabilised, prior to moving the baby to the NICU. Once a baby was stable, with acceptable heart rate, oxygen saturation and appropriate thermal care in place, the baby was passed to the mother for a period of physical contact lasting up to 5 min. This was not skin-to-skin care. The baby continued to receive care wrapped in a plastic bag and in contact with a self heating gel mattress (Transwarmer (Drager Medical, Hemel Hempstead, UK)) if appropriate, they were also wrapped in warmed towels and a hat was in place. This period of contact was achieved for babies who were receiving respiratory support using continuous airway pressure (CPAP) (Figure 2) and in babies who were ventilated following tracheal intubation. In some families, the period of cuddling was shared with the father and following delivery by caesarean section under general anaesthetic, the cuddle was offered to the father alone if he was present.

**Figure 2.** Simulation of a preterm baby receiving Delivery Room Cuddles whilst receiving respiratory support with nasal CPAP. **Figure 2.** Simulation of a preterm baby receiving Delivery Room Cuddles whilst receiving respiratory support with nasal CPAP.

We completed a 12-month quality improvement programme (QIP) from January 2020 to December 2020. Data were collected manually and from the electronic patient record (Badgernet full EPR, Clevermed, Edinburgh, UK) following the delivery of all babies born at less than 32 weeks' gestation. For the purposes of this project, we used the World Health Organisation definitions [2] to classify babies into 5 temperature groups; severely hypothermic (<32 °C), moderately hypothermic (32–35.9 °C), cold stress (36–36.4 °C), normothermic (36.5–37.5 °C) or hyperthermic (>37.5 °C). Axillary temperature was measured We completed a 12-month quality improvement programme (QIP) from January 2020 to December 2020. Data were collected manually and from the electronic patient record (Badgernet full EPR, Clevermed, Edinburgh, UK) following the delivery of all babies born at less than 32 weeks' gestation. For the purposes of this project, we used the World Health Organisation definitions [2] to classify babies into 5 temperature groups; severely hypothermic (<32 ◦C), moderately hypothermic (32–35.9 ◦C), cold stress (36–36.4 ◦C), normothermic (36.5–37.5 ◦C) or hyperthermic (>37.5 ◦C). Axillary temperature was measured in all babies

at all times using an electronic thermometer (Welsh Allyn Suretemp Plus, Welsh Allyn, Buckinghamshire UK).

A multidisciplinary team (MDT) was assembled consisting of neonatal consultants, trainees, nurse practitioners and neonatal nurses. The proportion of babies in each temperature group was measured monthly. A detailed review was conducted for each baby who had an admission temperature below 36.5 ◦C. The MDT met monthly and reviewed all data including the birth location, presentation at birth and mode of delivery as well as the weight and gestation of all babies who were hypothermic or hyperthermic to try to identify common associations with these outcomes. Most importantly, interviews were conducted with the staff responsible for or involved in providing the baby's care during stabilisation and transfer to gain their views on what they thought they could do differently in the future similar circumstances to prevent this outcome. Strategies to implement better thermoregulation practice were formulated by the MDT based on these data.

A series of Plan, Do, Study, Act (PDSA) cycles were performed using a standard methodology [12]. PDSA cycles are an iterative method of quality improvement that are used sequentially to change practice in order to improve outcomes. The basic structure of a PDSA cycle is:

Plan—to define what clinical practice should be to achieve the best outcome based on what we know about the subject. Decide what data are required to study the outcome (performance metric) and to establish a system of data collection.

Do—to implement best practice and collect the data prospectively.

Study—to review the data and assess performance against the metric and understand what the causes of underperformance are.

Act—to make recommendations about changes in practice to improve performance and plan the next cycle.

Not all of the PDSA cycles we undertook were synchronous. Once the project was commenced (the initial P and D phases), there was a monthly review of data (S) and new actions were taken if the MDT were able to make a new recommendation (A). Each intervention was then planned (P) and implemented (D). During some meetings new cycles could be started before a previous cycle had completed (e.g., recommendations about managing twins on the Lifestart trolley were made in June, but we needed several sets of twins to be born in order to assess the effectiveness of this, in the meantime we implemented other changes in practice). Similarly, new actions were not implemented at every monthly meeting as no new changes in practice could be recommended based on the data available at that time.

Communication of changes in practice to the clinical staff required to implement them is a key part of the "Do" phase of the PDSA cycle. In this study each new strategy was communicated to the staff on the unit through a variety of methods:

• Written unit policies were amended to include new changes in practice as appropriate. Some interventions also required liaison with our colleagues in other departments such as maternity and medical engineering.

The project was performed in a large women's hospital in the UK which houses a tertiary NICU. Comparisons were made with the rates of hypothermia seen on our unit in the preceding 12 months. The statistical significance of any differences were tested using Chi-squared with Yates correction. Performance data were also collected for a 3 month period following the end of the intervention period to assess the impact of interventions made in the latter part of the period. The project was approved by the Institutional Clinical Effectiveness Senate (approval date 15 November 2019, approval number QIP 0058).

### **3. Results**

130 babies less than 32 weeks' gestation were admitted to the unit between January 2020 and December 2020. The median (range) gestation was 29 (22 to 31) completed weeks. The median (range) Birth Weight was 1225 (510 to 2810) grams.

In total 90 babies (69.2%) received DCC with 69 (53%) receiving a least 2 min of DCC and 21 (16.1%) receiving between 1 and 2 min of DCC. During this period we also successfully implemented Delivery Room Cuddles (DRC) with 79 (60%) of the babies documented to have received this.

A number of thermoregulation strategies were implemented during the project during the PDSA cycles:

	- Hats for all preterm babies—We noticed that some babies who were not receiving respiratory support were not having a hat applied after birth. Subsequent routine practice included putting a hat on all babies as soon as possible.
	- An increase in the use of plastic bags to maintain normothermia from our previous gestation threshold of 30 weeks to 32 weeks.
	- An increase in the use of self heating gel mattresses to maintain normothermia from our previous gestation threshold of 28 weeks to 30 weeks.

• October 2020: For babies born in theatre, we found that the transwarmer underneath the sterile drape was often left behind when transferring the baby to the resuscitation platform. Subsequently we used two transwarmers for delivery in theatre; one was placed underneath the sterile drape that covers the LifeStart whilst the baby was receiving care with an intact umbilical cord and one was placed on the Panda resuscitation platform used for further stabilisation and transfer to the neo-

• November 2020: Breech deliveries—the data showed that several babies born by

• November 2020: Turning down the overhead heater—in babies who had a post

vaginal breech delivery were hypothermic despite the above interventions. Following a discussion with the obstetric team, we agreed to cover the body of babies born as breech deliveries with the Neohelp bag whilst waiting for the head to be deliv-

DRC temperature of >37.5 *°C*, the overhead heater was reduced to 50% power prior

natal unit.

ered.

to leaving for the neonatal unit.

**Figure 3. Figure 3.**  An example of a "Top Tips" poster used to communicate best practice to staff. An example of a "Top Tips" poster used to communicate best practice to staff.

The proportion of babies in each of the temperature groups during each month of the project is shown in Figure 4. The proportion of babies in each month that had hypothermia is shown in Figure 5. Assessing the individual impact of each of the new strategies that we introduced is difficult because of the time lag between each intervention and outcome and the non-synchronous nature of the PDSA cycles. The cumulative impact of the project is demonstrated in these charts which show a reduction in the rate of hypothermia during the latter part of the QIP period and into the following 3 months.

We have compared temperature outcomes from the babies admitted during the QIP intervention period with the 109 babies less than 32 weeks' gestation born between January 2019 and December 2019. The lower number in the 2019 cohort was a consequence of normal variation in unit activity. The distribution of babies by temperature group between the two cohorts is shown in Figure 6. *Children* **2022**, *9*, x FOR PEER REVIEW 7 of 15

> During the QIP intervention period there were no cases of severe hypothermia (<32 ◦C), only 1 baby (0.77%) was admitted with moderate hypothermia (32–35.9 ◦C) and 12 babies (9.2%) were admitted with cold stress (36–36.4 ◦C). When compared to the 2019 cohort, there has been a significant reduction in babies admitted with a temperature below 36.5 ◦C from 22.3% to 10% (*p* = 0.006). This improvement was maintained after the intervention period. The rate of hypothermia in the last 6 months of data collection (last 3 months of the QIP intervention period plus the following 3 months) was 4/73 babies (5.5%). There were no hypothermic babies in the first 3 months after the QIP intervention period. The proportion of babies in each of the temperature groups during each month of the project is shown in Figure 4. The proportion of babies in each month that had hypothermia is shown in Figure 5. Assessing the individual impact of each of the new strategies that we introduced is difficult because of the time lag between each intervention and outcome and the non-synchronous nature of the PDSA cycles. The cumulative impact of the project is demonstrated in these charts which show a reduction in the rate of hypothermia during the latter part of the QIP period and into the following 3 months.

**Figure 4.** The proportion of babies admitted in each temperature category during 2019, each month of the QIP intervention period and during the 3 month period after the QIP intervention period. Numbers on the bars are absolute numbers in each category in each month. **Figure 4.** The proportion of babies admitted in each temperature category during 2019, each month of the QIP intervention period and during the 3 month period after the QIP intervention period. Numbers on the bars are absolute numbers in each category in each month.

**Figure 5.** The percentage of babies with admission hypothermia in 2019 (black bar), during each month of the QIP intervention period (green bars) and during the 3 month period after the QIP intervention period (there were no hypothermic babies during this period). The blue line represents a 3 month rolling average. **Figure 5.** The percentage of babies with admission hypothermia in 2019 (black bar), during each month of the QIP intervention period (green bars) and during the 3 month period after the QIP intervention period (there were no hypothermic babies during this period). The blue line represents a 3 month rolling average.

We have compared temperature outcomes from the babies admitted during the QIP intervention period with the 109 babies less than 32 weeks' gestation born between January 2019 and December 2019. The lower number in the 2019 cohort was a consequence of normal variation in unit activity. The distribution of babies by temperature group between There was a slight increase in the rate of admission hyperthermia from 14.7% (20/109) in 2019 to 15.4% (20/130) in 2020, although this increase was not statistically significant (*p* = 0.88). During the 3 months after the end of the QIP intervention period 3/32 (9.4%) of babies were hyperthermic.

the two cohorts is shown in Figure 6. We were interested to understand whether the hyperthermia was due to iatrogenic warming, or due to the prevention of heat loss in already pyrexial babies. We had introduced a policy of making multiple temperature measurements at specific times during the stabilisation and transfer period during the study as described above. There were 67 babies who had paired temperature measurements on the labour ward and on admission to the neonatal unit. 55 of these were normothermic on admission and 12 were hyperthermic. Babies who were hyperthermic on admission had higher temperatures measured during their stabilisation on labour ward (Figure 7). The median (range) temperature on labour ward of the babies who were hyperthermic on admission was 37.5 ◦C (36.9 ◦C to 38.7 ◦C), compared to 36.9 ◦C (36.1 ◦C to 38.2 ◦C) in the babies who were normothermic on admission (*p* = 0.0004). All but one of the babies who were hyperthermic on admission to the neonatal unit had a temperature on labour ward above 37 ◦C.

**Figure 6.** The distribution of babies between the different temperature categories in the 2019 cohort and the 2020 cohort. **Figure 6.** The distribution of babies between the different temperature categories in the 2019 cohort and the 2020 cohort. *Children* **2022**, *9*, x FOR PEER REVIEW 10 of 15

to the neonatal unit had a temperature on labour ward above 37 °C. **Figure 7.** Temperature category at birth for babies who were normothermic on the labour ward (blue bars) and babies who were hyperthermic on the labour ward (red bars). **Figure 7.** Temperature category at birth for babies who were normothermic on the labour ward (blue bars) and babies who were hyperthermic on the labour ward (red bars).

achievable whilst still practising DCC and DRC, both of which are beneficial in the imme-

Admission hypothermia is preventable by improved care, both in the delivery room and during the transfer to the neonatal unit. Our results have demonstrated that it is pos-

The solutions that we have developed in our QIP may not be the best solutions in another environment and we recommend that other units adopt a similar approach to develop their own best solution. Our solution may provide a useful starting point however and we have included a "Step by Step guide" (Figure 8) which illustrates our learning

diate care of the newly born preterm baby.

**4. Discussion**

during this project.

#### **4. Discussion**

Admission hypothermia is preventable by improved care, both in the delivery room and during the transfer to the neonatal unit. Our results have demonstrated that it is possible to almost eradicate significant admission hypothermia in a busy NICU. This is achievable whilst still practising DCC and DRC, both of which are beneficial in the immediate care of the newly born preterm baby.

The solutions that we have developed in our QIP may not be the best solutions in another environment and we recommend that other units adopt a similar approach to develop their own best solution. Our solution may provide a useful starting point however and we have included a "Step by Step guide" (Figure 8) which illustrates our learning during this project.

Ambient temperature was not recorded systematically during our project, so we are unable to comment on its role in hypothermia in our own population. Published standards state that a temperature of 23 ◦C to 25 ◦C should be achieved for the delivery room [13].

A systematic review of trials of deferred cord clamping found little evidence of an impact on admission temperature [5] so we did not expect to see the increase in admission hypothermia that we experienced when we implemented DCC into our practice. Further examination of the published admission temperature data from 7 trials in the systematic review however shows that, although there was little or no impact of DCC on admission temperature, the rate of hypothermia in both intervention and control groups was high. These data are summarised in Table 1. Data are reported as mean (SD) in each trial and the reported mean is below 36.7 in 5 of the 7 trials, with wide standard deviations, demonstrating that a significant proportion of the participants in both the intervention group and the control groups of these trials, were hypothermic on admission. The mean (SD) temperature on admission in our cohort was 37 (0.53) ◦C. Even in one of the trials reporting mean admission temperatures of above 36.5 ◦C [7], there were still 11.6% of babies with an admission temperature below 36 ◦C. Taken together, these observations suggest that in clinical areas where there are already moderate rates of admission hypothermia, the introduction of DCC makes little difference to these rates. Our experience, in a unit with a low rate of hypothermia, is that the introduction of DCC was associated with an increase in hypothermia.

**Table 1.** Published admission temperature data from randomized controlled trials of deferred cord clamping at preterm birth.

**Figure 8.** A Step by Step Guide to maintaining normothermia during preterm stabilisation with an intact umbilical cord, summarising all of our learning during this project. **Figure 8.** A Step by Step Guide to maintaining normothermia during preterm stabilisation with an intact umbilical cord, summarising all of our learning during this project.

Despite the significant reductions in hypothermia we achieved, we failed to achieve the NNAP standard of 90% of babies in the normothermic range during the QIP intervention period, although that was achieved in one of the subsequent 3 months (Figure 9). During the QIP intervention period, the commonest cause of failing to meet the NNAP standard was hyperthermia (*n* = 20) rather than hypothermia (*n* = 13). Our exploration of the data, presented above, shows that much, if not all, of the admission hyperthermia we saw was a consequence of prevention of heat loss in already pyrexial babies rather than iatrogenic warming. *Children* **2022**, *9*, x FOR PEER REVIEW 13 of 15

**Figure 9.** Compliance with the NNAP standard by month during 2019 (black bar), each month during the QIP intervention period (green bars) and each of the 3 months immediately after the QIP intervention period (yellow bars). The blue line represents a 3 month rolling average. **Figure 9.** Compliance with the NNAP standard by month during 2019 (black bar), each month during the QIP intervention period (green bars) and each of the 3 months immediately after the QIP intervention period (yellow bars). The blue line represents a 3 month rolling average.

Although the evidence for a causal relationship between hypothermia and adverse outcome at preterm birth is well established and accepted, the evidence relating to hyperthermia is not compelling. In fact, there is little published evidence in relation to this matter. Lyu et al. found an increased rate of a composite adverse outcome (severe neurological injury, severe retinopathy of prematurity, necrotising enterocolitis, bronchopulmonary dysplasia, and nosocomial infection) in babies with an admission temperature above 38 °C [20]. Sharma et al. also reported an increase in a composite adverse outcome (mortality or major morbidity) in babies with admission temperature >37.5 °C [21]. The Clinical Risk Indicator for Babies II score (CRIB II) [22] assigns an increased score (increased risk of mortality) to babies with an admission temperature >37.5°. We assume that this is because the dataset on which the score was developed found an increased risk of death in those babies, although this is not explicitly stated in the paper describing the development of the score. Although these studies provide some evidence of an association between hyperthermia on admission and adverse outcome in preterm babies, none of the published studies has established a causal link and it is possible that this association is due a shared aetiology with chorioamnionitis, which also has a strong association with preterm brain Although the evidence for a causal relationship between hypothermia and adverse outcome at preterm birth is well established and accepted, the evidence relating to hyperthermia is not compelling. In fact, there is little published evidence in relation to this matter. Lyu et al. found an increased rate of a composite adverse outcome (severe neurological injury, severe retinopathy of prematurity, necrotising enterocolitis, bronchopulmonary dysplasia, and nosocomial infection) in babies with an admission temperature above 38 ◦C [20]. Sharma et al. also reported an increase in a composite adverse outcome (mortality or major morbidity) in babies with admission temperature >37.5 ◦C [21]. The Clinical Risk Indicator for Babies II score (CRIB II) [22] assigns an increased score (increased risk of mortality) to babies with an admission temperature >37.5 ◦C. We assume that this is because the dataset on which the score was developed found an increased risk of death in those babies, although this is not explicitly stated in the paper describing the development of the score. Although these studies provide some evidence of an association between hyperthermia on admission and adverse outcome in preterm babies, none of the published studies has established a causal link and it is possible that this association is due a shared aetiology

injury [23,24]. The 2020 International Liaison Committee on Resuscitation recommendations for neonatal life support include a weak recommendation, based on low certainty

probably an acceptable consequence of a reduction in hypothermia. Nonetheless, we still strive to avoid hyperthermia by switching off the power supply to the overhead heather with chorioamnionitis, which also has a strong association with preterm brain injury [23,24]. The 2020 International Liaison Committee on Resuscitation recommendations for neonatal life support include a weak recommendation, based on low certainty evidence, that hyperthermia (greater than 38 ◦C) should be avoided due to the potential associated risks [13]. On this basis we believe that a small increase in hyperthermia is probably an acceptable consequence of a reduction in hypothermia. Nonetheless, we still strive to avoid hyperthermia by switching off the power supply to the overhead heather during transfer of babies with a temperature following DRC above 37 ◦C as described above.

#### **5. Conclusions**

This project highlights the importance of the perinatal MDT for driving change in a large complex organisation. Collaboration and clear communication with our obstetric, midwifery, medical engineering and estate staff colleagues were vital to facilitating the success of this project. We have used this approach previously to successfully drive change in our unit [8,25]. The team approach (rather than a top-down approach) promotes ownership of the project, generates enthusiasm and helps create a genuine desire for success.

**Author Contributions:** Conceptualization, C.W.Y.; methodology, C.W.Y.; investigation, A.J.C., E.C., V.A., L.L., K.E., J.C.H., C.W.Y.; writing—original draft preparation, A.J.C.; writing—review and editing, C.W.Y.; supervision, C.W.Y.; project administration, C.W.Y.; funding acquisition, C.W.Y. All authors have read and agreed to the published version of the manuscript.

**Funding:** This study received no external funding.

**Institutional Review Board Statement:** The project was approved by the Institutional Clinical Effectiveness Senate at Liverpool Women's Hospital (approval number QIP 0058).

**Informed Consent Statement:** Patient consent was waived as this study was performed using existing clinical data with no allocation of individuals to any intervention.

**Data Availability Statement:** The data presented in this study are available in the text and tables of this manuscript.

**Acknowledgments:** Publication costs of this study were supported by Inspiration Healthcare. Thanks to Emily Hoyle for providing the photograph in Figure 1, along with K.E.

**Conflicts of Interest:** C.W.Y. arranged for publication costs of this study to be funded by Inspiration Healthcare. The funders had no role in the design of the study; in the collection, analyses, or interpretation of data; in the writing of the manuscript, or in the decision to publish the results. There are no other conflict.

#### **References**

### *Study Protocol*


We are IntechOpen, the world's leading publisher of Open Access books Built by scientists, for scientists

4,300+

Open access books available

116,000+

International authors and editors

125M+

Downloads

151

Countries delivered to

Our authors are among the

Top 1%

most cited scientists

12.2%

Contributors from top 500 universities

Selection of our books indexed in the Book Citation Index in Web of Science™ Core Collection (BKCI)

## Interested in publishing with us? Contact<EMAIL_ADDRESS>
Numbers displayed above are based on latest data collected. For more information visit www.intechopen.com

## IntechOpen Book Series Biomedical Engineering Volume 7

Monika Elżbieta Machoy, MD, graduated with distinction from the Faculty of Medicine and Dentistry at the Pomeranian Medical University in 2009. She is currently employed as a researcher in the Department of Orthodontics at the same university. Dr. Machoy attended a one-year scholarship program at the Ernst Moritz Arndt University in Greifswald, Germany, and a threeyear internship at the Technical University in Dresden, Germany.

She has been a speaker at numerous orthodontic conferences, including the American Association of Orthodontics, the European Orthodontic Symposium, and the Polish Orthodontic Society. She conducts research focusing on the effect of orthodontic treatment on dental and periodontal tissues and the causes of pain in orthodontic patients.

**Editor of Volume 7: Monika Elżbieta Machoy** Department of Orthodontics, Pomeranian Medical University Szczecin, Poland

**Book Series Editor: Robert Koprowski** University of Silesia, Poland

### Scope of the Series

Biomedical engineering is one of the fastest growing interdisciplinary branches of science and industry. The combination of electronics and computer science with biology and medicine has resulted in improved patient diagnosis, reduced rehabilitation time and better quality of life. Nowadays, all medical imaging devices, medical instruments or new laboratory techniques are the result of the cooperation of specialists in various fields. The series of biomedical engineering books covers such areas of knowledge as chemistry, physics, electronics, medicine and biology. This series is intended for doctors, engineers and scientists involved in biomedical engineering or those wanting to start working in this field.

Contents

**Section 1**

**Section 2**

*by Monika Elżbieta Machoy*

**Preface III**

Introduction **1**

**Chapter 1 3**

Clinical Computing in Dentistry **9**

**Chapter 2 11**

**Chapter 3 31**

**Chapter 4 55**

**Chapter 5 73**

*by Aswini Kumar Kar, Prabhu Yuvaraj, Mirna Garhnayak, Shruti Vishal Dev, Purna Chandra Mishra, Tapan Kumar Patro, Loknath Garhnayak, Sonali Perti*

Introductory Chapter: Computer Vision in Dentistry

Intelligent Assisting Tools for Endodontic Treatment

*by Csaba Dobo-Nagy and Balazs Benyo*

*by Ji-Man Park and June-Sung Shim*

Clinical Computing in Dentistry

*and Nabagata Ganchoudhury*

Optical Impression in Restorative Dentistry

Role of Computer Technology in Changing Smile

*by Swapnil B. Shankargouda, Preena Sidhu and Sonica Miyyapuram*

## Contents

Preface

Imaging, both two- and three-dimensional, is one of the basic foundations for success in dental work. There are many possibilities in the area of imaging and a variety

As the basis for imaging in dentistry is already digital visualization, it can be used in various devices, including computer tomographs, cameras compatible with systems for creating virtual prosthetic projects, intraoral cameras, and 3D face scanners. All these devices work independently of each other to produce digital images of the patient's mouth, but they can also be used together and thus fully exploit the

of equipment that is at least partially available in every office or laboratory.

The currently available technical and technological imaging techniques have opened up numerous possibilities for creating visualizations useful for dentists and technicians. It is now no longer difficult to obtain a three-dimensional image of a patient's face and profile, which is used, among other reasons, to visualize changes in appearance after prosthodontic or orthodontic treatment. The same is true of obtaining detailed scans of the area to be treated; scanning provides an exact map of the working field, allowing for the planning and implementation of even very difficult dental procedures. Equally available are three-dimensional images of the patient's skull, on the basis of which it is possible to accurately estimate the possibilities of dental implantation. These images help the dentist to plan the depth of implant placement and the angle at which the implants will be inserted into

**Monika Machoy, MD**

Szczecin, Poland

Department of Orthodontics, Pomeranian Medical University,

potential of devices with software adapted to 3D imaging.

the bone.


**3. Methods**

The authors chose to implement a qualitative inquiry design for this study because it best fit the purposes of the research questions and the nature of the study [25]. This study is situational in its contextual emphasis on the public school environment of one sizable district in Abu Dhabi; personalistic in relying on the examination of participating principal supervisors' unique perspectives; and interpretive in its core essence. The qualitative methods employed by the researchers benefited them throughout the research process in similar ways to those outlined by Merriam and Tisdell: "in understanding how people interpret their experiences, how they construct their worlds, and what meaning they attribute to their experiences" ([26] p. 6). In the context of the present research, qualitative research methods helped them grasp principal supervisors' interpretations of their supervision and the meaning they gleaned from it.

Another characteristic of qualitative inquiry that contributed to the purposes of this study was its usefulness as an investigatory tool [27]. Through the use of qualitative inquiry, it was possible to continuously look into concepts and themes in order to discover the best explanations for the phenomena [28]. Qualitative research is allegedly superior to other forms of research in its ability to procure rich information about the phenomenon under study as well as recognize, investigate, and characterize its parameters [29]. A case study was chosen as a research method for this study. The case study is regarded by many, including Yin, as "one of the most challenging of all social science endeavors" ([30] p. 3). However, this technique fits with the goals and purposes of this study. Yin laid out the following definition for the case study: "an empirical inquiry that investigates a contemporary phenomenon (the case) in depth and within its real-life context, especially when the boundaries between phenomenon and context may not be clearly evident" ([30] p. 16).

In order to understand the duties of principal supervisors, the difficulties they encounter, and the ideal circumstances they require to improve their long-term leadership performance, the researchers conducted interviews as a primary means of gathering data. Three male and three female principal supervisors (six total) agreed to participate in semi-structured, in-person interviews. An overview of the characteristics of the principal supervisors is provided in **Table 1**, including gender, years of experience, assigned school level, and the number of principals assigned to them. Principal supervisors in the Al-Ain district had between 2 and 7 years of experience managing principals. Additionally, the principal supervisors oversaw a cluster of schools within their assigned level and were tasked with managing and evaluating a number of principals.

### **3.1 Interviewing participants**

According to Seidman, interviews are conducted to comprehend the experiences of others, not to test theories [31]. Kvale underlined the goal of qualitative interviewing as a tool to explain central themes in each participant's universe [32]. However, in the process of gathering data through interviews, it is critical that the interviewer has a genuine interest in those whom they interview. That genuine interest should not be a simple statement at the beginning of an interview, but rather an interwoven part of the full interview process. In order to accomplish this, the interviewer must remove themselves from the spotlight and focus exclusively on the interviewee [31].

*The Roles, Challenges, and Needs of Principal Supervisors: A Case Study DOI: http://dx.doi.org/10.5772/intechopen.108834*

#### **Table 1.**

*Overview of principal supervisors (all names are pseudonyms).*

The researchers of this study conducted face-to-face interviews with each of the principal supervisors who participated. Each interview was approximately 2 hours in length, and the primary objective was to glean information about principal supervisors' perspectives on their experiences while serving as supervisors to school principals. As Kvale recommended, the researchers of the present study came to the interviews prepared with a thorough familiarity with the literature on the topic [32]. Delving into the research about a phenomenon greatly reduces uncertainty before an interview and helps interviewers refine their question sets to include those that are most impactful.

All of the interviews in this study were semi-structured to maintain an easy flow of conversation with some leeway to adjust the course of the interview while remaining focused on the topic at hand. Semi-structured interviews give the interviewer freedom to propose additional questions that might supplement or supplant those that have already been decided upon, which provides a chance to examine a specific case more thoroughly [33]. Following the semi-structured format allowed the principal supervisors who were interviewed to be more creative in their responses and feel at liberty to elaborate on closely related topics that might prove beneficial to the comprehensiveness of the data.  The researchers planned the timing and location of each interview to accommodate the schedules of each principal supervisor. The researchers briefly introduced themselves and explained the interview's purpose and objectives before the interview began. They used an IC recorder to electronically record each interview, which they later transcribed verbatim. They instructed the interviewees to choose the language they felt most at ease using to articulate their ideas and insights.

The researchers used a thematic analysis to find, examine, and describe the themes within the datasets collected from the interview transcripts [34]. Thematic analysis is used to organize qualitative data, untangle the twisted webs of data, and produce emerging themes to appropriately interpret them [35]. The thematic analysis made it possible for the authors to fully achieve the study's purpose and respond to the research questions. Before beginning the data analysis procedure, however, the researchers familiarized themselves with the information by reading each transcript numerous times to fully grasp them. Then, from the transcripts of each interview, they created numerous codes that highlighted the patterns and discrepancies between the stories and experiences. The codes were then meticulously organized into

appropriate categories with verbal examples from participants and quotes from the interviews for verification and corroboration.


**3.2 Making earth orbit an accessible extension of human life**

Like the time revolution that the Concorde provided to cross the Atlantic in the early age of the supersonic civilian flights, a similar revolution could be perceived to go through a certain altitude (stratospheric/sub-orbital, von Karman line, orbital) to fasten travel across opposite sides of Earth. The psychological importance of such a commodity on the human civilization is non-negligeable. Technology mainline acceptance, incremental reliability, robustness, reducing prices, adoption of a way of doing things. In brief, internalization, as a global society, of the extended boundary layer of human daily life. To permit this, the evolving technology should provide extensions of tried and tested means of transport, already widely accepted by all: from an airplane to a spaceplane, there is nearly no psychological barrier when someone climbs in what may look like an airplane, even if it goes much further up, it still may look like what is known to be strongly reliable: an airplane.

Access to LEO by humans on a regular airplane was a long-time revolution to come to fruition. Eventually, evolutions of the 1959 Dyna-Soar [11], the Virgin Galactic Space Ship One [12], the Scaled Composites Model 339 SpaceShipTwo (Scaled Composite, 2010) and the SpaceShipThree released in April 2021 have evolved the spaceplane

**Figure 3.** *Boeing X20 dyna-soar (1959), virgin galactic StarShipTwo (2010) & three (2021).*

*Access to Space, Access to the Moon – Two Sides of the Same Coin? DOI: http://dx.doi.org/10.5772/intechopen.105175*

#### **Figure 4.**

*Operational diagram of Dawn mk-II Aurora single-stage loop to LEO [14].*

concept to reduce the cost of oblation protection to much less than the initial design by using the *feather fall* concept (thus the articulated and elongated winglets) that generates a stable high-drag shape for atmospheric re-entry (**Figure 3**). The SpaceShip planes have three flight controls, depending on the in-atmosphere flight being subsonic (manual control) or supersonic (electric) or space (RCS). This space plane launches from larger airplanes (Scaled Composites Model 318 & 348) with a standard runway though longer and larger [13] compared with the Dyna-Soar which was designed smaller and to be launched on top of a rocket.

And yet, closing the single-stage spaceplane surface-LEO-surface loop might just come from New Zealand, where the New Zealand Civil Aviation Authority (CAA) has granted Dawn Aeronautical [14] an Unmanned Aircraft Operator Certificate to fly a suborbital spaceplane from a conventional airport [15]. Dawn aerospace is developing a spaceplane drone (Dawn Mk-II Aurora at this stage of development) in the initial aim at providing a single step to space delivery for smallsat and cubesattype EO platforms in LEO, with a view to scale the spaceplane design with payload requirements onboard the next iteration, the Mk-III, an 18 metric tons spaceplane. Take-off and landing can be done (**Figure 4**) from any standard runway in the world, permitting government and private companies to have at hand the launching platform and insert the payload directly in their premises. In all, spaceplanes, whether airborne launched/runway landing (Virgin Galactic) or runway take-off/ landing (Dawn Aerospace) is decreasing vastly costs to LEO for both passengers and freight. But the most important part is the *ubiquity of launching geolocations* that they address, vastly reducing some of the most common risks and costs to space payloads. Also, bringing spaceplanes one step closer to be visible to all in daily life, a critical part of society adoption of the extended space dimension these carry within.

At this point, we, as a people, reach the very close to Earth external boundary and orbital space. A vastly non-negligeable step in itself to appreciate the civilizational expansion as a daily happening. As with all progresses and development, many steps are intertwined, as it is in these years, both sub-orbital, orbital and the next part to be focussed on. That part is one step further, more difficult, more careful, in terms of engineering, more complex to survive as a human without increasing amount of assistance. Further away, yet also orbitally intertwined with us.


**5. Sialidosis**

Sialidosis (MIM#256550) is a LSD caused by the inherited deficiency of the lysosomal enzyme alpha-N-acetyl-neuraminidase-1 (NEU1), which cleaves the terminal sialic acid residues of several oliogosaccharides and polypeptides.

Therefore, the deficiency of NEU1 leads to the accumulation of sialic acid (Nacetylneuraminic acid) covalently linked to oligosaccharides and/or glycoproteins. This aspect distinguishes sialidoses from sialurias, in which the neuraminidase activity is normal or elevated with a storage and excretion of 'free' sialic acid, rather than 'bound' forms.

#### **5.1 Clinical aspects**

A systematic classification of Sialidosis has been provided by Lowden and O'Brien in 1979, who divided them in two main clinical variants: Type I, the milder form of the disease, which lacks the physical changes (normosomatic) and Type II, a more severe form with an earlier onset, which can be subdivided in 2 different phenotypes: congenital/neonatal and juvenile forms.

Patients affected with type I sialidosis, (normomorphic or 'cherry-red-spot, myoclonus syndrome'), generally manifest first clinical signs during school-age period or early adulthood. Progressive reduction of visual acuity, red-green and night blindness, bilateral cherry-red spots, punctate corneal opacity and nistagmus, are prominent symptoms. Ocular involvement is accompanied or followed by the appearance of motor impairment, with walking difficulties and myoclonus. Same cases may present seizures. In contrast with type II forms, these patients generally do not present dysmorphisms or bone dysplasia and they have a normal intelligence. Survival is usually long.

Type II congenital sialidosis may manifest in utero with foetal hydrops or foetal ascites while the neonatal form is characterised by diffused edema, hepatosplenomegaly, ascites and Hurler's like clinical signs: facial dysmorphisms, umbilical and inguinal hernias, short trunk with a prominent sternum, kyphosis, and dysostosis multiplex (Froissart et al., 2005). Severe dysmrphisms (coarse facies, pectus carinatum, short trunk, exaggerated toracic kyphosis, and wadding gait) as well as growth delay characterize also infantile phenotypes, cherry-red spot, corneal opacity, hearing loss, progressive neurodegeneration and cognitive deterioration with myoclonic seizures. Skeletal imaging shows dysostosis multiplex with vertebral abnormalities and generalized osteoporosis. Renal involvement, nephrosialidosis, may be present in some patients with proteinuria evolving to nephrotic syndrome (Okada et al., 1983).

Juvenile onset is charactrized by less pronounced dysmorphic signs with muscular hypotonia and hypotrophy, ataxia, and myoclonic seizures. Cherry-red spots and corneal opacities are constantly present, as well as hearing loss. Pyramidal syndrome with cerebellar anomalies and peripheral neuropaty have been described. Mental retardation is costant. Survival rarely exceed the second, third decade of life (Winter et al., 1980; Caciotti et al., 2009; Canafoglia et al., 2011).


**4. Monitoring strategies: The importance of reliable analysis as controlling guidance**

Monitoring of the corn chain in northern Paraná showed that 81 % (n = 435, crop 2003) and 98.8 % (n = 435, crop 2004) of corn was safe for human consumption, in regard to fumonisin. The decreasing trend in fumonisin contamination, when compared to previous studies [8, 9, 12], could suggest a conscious monitoring procedure at the quality control level, in accordance with the strict guidelines imposed by importing countries.

The main approaches in corn phytosanitary control involve pesticides and agricultural practices with an emphasis on tillage and crop rotation. Efforts have been focused on novel fungicides for *Fusarium* sp. control to maximize grain yield [51, 52]; however, several studies have shown that fungicide application can increase mycotoxin levels [53, 54]. The recom‐ mended dose of fludioxonil + metalaxyl-M (2.5 + 1.0 %) was insufficient to inhibit *F. verticillioides* growth *in vitro*, but it increased FB1 production from 3.5-fold to 12.5-fold (2.58 μg mL-1 when compared with 0.72 μg mL-1 in control), with an alteration in mycelial morphology [55, 56]. A scanning electron microscopy analysis showed that the fungicide caused the inhibition of hyphal growth and defects of hyphae, such as excessive septa‐ tion, cell wall disruption, and withered hyphae, and extracellular material around the hyphae was rarely observed (Figure 3) [57].

Therefore, efforts to reduce mycotoxin levels should be focused on sustainable production. In uninterrupted planting in tropical regions, non-drastic management of cropping systems using culture rotation in no-tillage areas under different fertilizations emphasizing nitrogen rate, and low cost organic waste remain concerns in the protection of grain and soil conserva‐ tion [58, 59, 60, 28].

**Figure 3.** Electron micrographs of *F. verticillioides* 103 F mycelia cultured in defined liquid media in the absence (con‐ trol) and presence (treatment) of fludioxonil + metalaxyl - M at the dose recommended by the manufacturer (1.5 μL mL-1) showing the fibrillar extracellular material present in the control cultures (A and C) and withered hyphae and disruption of cell walls in the treatments (B and D).

The effect of conventional and no-tillage cropping systems in corn cultivated in summer following either oats or fallow in winter on natural fumonisin levels (2006 and 2007 growing seasons) has been assessed [60]. No-till corn following oats showed stronger fumonisin contamination patterns than the other treatments (2006 season, *P* < 0.05). Although no-till could be advantageous from a soil conservation standpoint, it may enhance fumonisin contamination in the tropics, contrasting another report [61] that there was no significant difference between conventional and no-till in fumonisin in monoculture corn in Northern Italy. When the nitrogen fertilizer rates (0 to 90.0 kg ha-1 N) on fumonisin contamination was evaluated, higher fumonisin levels were detected in plots with lower N (≤ 22.5 kg ha-1) than ≥ 45.0 kg ha-1 N, indicating a negative correlation between fumonisin and N rates [60]. Both N stress due to deficiency and excessive rates can increase the FB1 level in corn [62].

The nitrogen-fixing potential of *Azospirillum* sp. in the rhizosphere can increase yields, reduce costs and improve the nutritional quality of corn kernels. An experiment was conducted matching the inoculums of the *Azospirillum brasilense* Ab-V5 and Ab-V6 strains in corn seeds with N doses in Northern and Central-Southern Paraná in the 2010/2011 and 2011/2012 seasons [63]. Although the seed inoculation associated with N doses showed non-significant effects on fungal count, the inoculum treated plots showed lower fumonisin levels (p < 0.05) than the non-treated plots, indicating favourable trend towards agricultural practices with inoculants. Fumonisins were detected in 90 % of samples in 2010/2011 (mean, 0.62 μg g-1) and 97.5 % in 2011/2012 (mean, 4.34 μg g-1) in the northern region, whereas its occurrence was 45 % in 2010/2011 (mean, 0.14 μg g-1) and 100 % in 2011/2012 (mean, 2.67 μg g-1) in central-southern Paraná.

The use of landfill leachate in agricultural soils as fertilizers has been suggested as an alternative for the disposal of this effluent; however, heavy metals may be a limiting factor [63]. The application of increasing doses of leachate (0 to 130.8 m3 ha-1) increased the yield, protein content, lipid and ash in corn grain, but no effect was observed on fumonisin reduction, which occurred in all samples, with 31.2 of samples with levels over the maximum tolerable limit in Brazilian guidelines (5.0 μg g-1). An increasing trend in lead content was also observed in the 2009/2010 seasons, and in sodium (2011/2012 seasons) when the leachate rate was increased [63].

The management of plant density (60 to 105 thousand plants/ha) with N doses (0 to 240 kg ha-1) showed no effect on corn fungal count, but there was an increasing trend in fumonisin levels when plant density was increased. Total fumonisins (FB1 + FB2) were detected in corn grain at levels ranging from non-detectable to 7.80 μg g-1 (mean, 1.50 μg g-1) in the 2009/2010 season, while it was non-detectable to 23.36 μg g-1 (mean, 1.72 μg g-1) in the 2010/2011 season [63].

Efforts also should be focused on the safety and quality of the wheat chain, one of major universal components in food. Although 90 % of the national crop is centred in southern Brazil, domestic consumption still depends on importation [1, 2]. Table 3 shows that natural contam‐ ination of DON in wheat was non-equally distributed among different crops and was de‐ pendent on local and climatic conditions (the impact of agricultural management practices was evaluated in 2010 and 2011 seasons). Environmental conditions can shift the metabolic route of *Fusarium graminearum*, changing the fusariotoxin profile in grains, ex., leading to an increase of acetylated analogues of DON [64, 65]. Although such acetylated trichothecenes are consid‐ ered less toxic than DON, a rapid deacetylation can take place in the digestive tract of mam‐ mals, turning into it to DON [66]. DON of the group B has been regarded as a unique trichothecene in wheat products under current Brazilian guidelines [41], although studies have indicated that group B trichothecenes, such as nivalenol (NIV) and acetylated analogues (3 acetyl-DON and 15-acetyl-DON), should be included [17].

**Figure 3.** Electron micrographs of *F. verticillioides* 103 F mycelia cultured in defined liquid media in the absence (con‐ trol) and presence (treatment) of fludioxonil + metalaxyl - M at the dose recommended by the manufacturer (1.5 μL mL-1) showing the fibrillar extracellular material present in the control cultures (A and C) and withered hyphae and

The effect of conventional and no-tillage cropping systems in corn cultivated in summer following either oats or fallow in winter on natural fumonisin levels (2006 and 2007 growing seasons) has been assessed [60]. No-till corn following oats showed stronger fumonisin contamination patterns than the other treatments (2006 season, *P* < 0.05). Although no-till could be advantageous from a soil conservation standpoint, it may enhance fumonisin contamination in the tropics, contrasting another report [61] that there was no significant difference between conventional and no-till in fumonisin in monoculture corn in Northern Italy. When the nitrogen fertilizer rates (0 to 90.0 kg ha-1 N) on fumonisin contamination was evaluated, higher fumonisin levels were detected in plots with lower N (≤ 22.5 kg ha-1) than ≥ 45.0 kg ha-1 N, indicating a negative correlation between fumonisin and N rates [60]. Both N stress due to

The nitrogen-fixing potential of *Azospirillum* sp. in the rhizosphere can increase yields, reduce costs and improve the nutritional quality of corn kernels. An experiment was conducted matching the inoculums of the *Azospirillum brasilense* Ab-V5 and Ab-V6 strains in corn seeds

deficiency and excessive rates can increase the FB1 level in corn [62].

disruption of cell walls in the treatments (B and D).

150 Food Production and Industry

In addition, lactic bacteria of the *Lactobacillus plantarum* group have shown versatile profiles concerning genes that can code for special functions such as biodegradation, absorption, and adherence to different surfaces in the vast natural microbiota in food niches [69, 68]. Lactic acid bacteria strains can be isolated from multiple wheat sources (grains, germ, bran, and flour) and have been tested against *F. graminearum* strain IAPAR 2218 (Figure 4). All tested strains demonstrated some DON-reducing potential, and the non-viable autoclaved *L. plantarum* cells (71.19 %) showed a higher effectiveness in DON reduction than viable cells (16.41 %). The probable mechanism of reduction would be the adsorption by cell walls [69, 70]. Lactic acid bacteria can also degrade a range of low molecular weight compounds, carrier compound families, and influx and efflux facilitators and mycotoxin degrading enzymes have been detected [71].

**Figure 4.** Effect of lactic acid bacteria isolated from different wheat sources (grains, germ, bran, flour) against *F. grami‐ nearum* strain IAPAR 2218. Inhibition Halo scale: (-): no inhibition; (+):1 to 5 mm; (++): 6 to 10 mm; (+++): 11 to 15 mm; and (++++): >15 mm.

Another use of naturally occurring microorganisms in the biocontrol/biodegradation of undesired natural toxins has been assessed for the reduction of cyanobacteria in drinking water. The potential of microcystin (MC) biodegradation has been tested in the following microorganisms: *Sphingosinicella microcystinivorans* (B9) isolated of the Lago Tsukui, Kanaga‐ wa-Japan; water kefir (mixture of lactic and acetic bacteria and yeast) (P4); *L. acidophilus* La-5 (P5); and yeast isolated of sugarcane (L5). The strain B9 degraded 99 % of MCs, while the strains P4, P5 and L5 degraded 44, 43 and 54 % of total MCs, respectively, after 96 h (Figure 5).

Strain B9 (*S. microcystinivorans*) showed the highest MCs degradation capacity and has been evaluated for its anti-cyanobacterial activity against 5 cyanobacteria strains, *Microcystis* sp. (C1), *Microcystis* sp. (C2), *Anabaena ucrainica* (C3), *Phormidium tenue* (C4), and *Synechocystis*(C5). After 96 h, the inhibition percentages (cellular counts) against cyanobacteria strains ranged from 41.4 to 79.3 %, while the inhibition percentages (concerning chlorophyll-a) ranged from 34.4 to 68.9 %.

probable mechanism of reduction would be the adsorption by cell walls [69, 70]. Lactic acid bacteria can also degrade a range of low molecular weight compounds, carrier compound families, and influx and efflux facilitators and mycotoxin degrading enzymes have been

**Figure 4.** Effect of lactic acid bacteria isolated from different wheat sources (grains, germ, bran, flour) against *F. grami‐ nearum* strain IAPAR 2218. Inhibition Halo scale: (-): no inhibition; (+):1 to 5 mm; (++): 6 to 10 mm; (+++): 11 to 15 mm;

Another use of naturally occurring microorganisms in the biocontrol/biodegradation of undesired natural toxins has been assessed for the reduction of cyanobacteria in drinking water. The potential of microcystin (MC) biodegradation has been tested in the following microorganisms: *Sphingosinicella microcystinivorans* (B9) isolated of the Lago Tsukui, Kanaga‐ wa-Japan; water kefir (mixture of lactic and acetic bacteria and yeast) (P4); *L. acidophilus* La-5 (P5); and yeast isolated of sugarcane (L5). The strain B9 degraded 99 % of MCs, while the strains P4, P5 and L5 degraded 44, 43 and 54 % of total MCs, respectively, after 96 h (Figure 5).

Strain B9 (*S. microcystinivorans*) showed the highest MCs degradation capacity and has been evaluated for its anti-cyanobacterial activity against 5 cyanobacteria strains, *Microcystis* sp. (C1), *Microcystis* sp. (C2), *Anabaena ucrainica* (C3), *Phormidium tenue* (C4), and *Synechocystis*(C5). After 96 h, the inhibition percentages (cellular counts) against cyanobacteria strains ranged from 41.4 to 79.3 %, while the inhibition percentages (concerning chlorophyll-a) ranged from

detected [71].

152 Food Production and Industry

and (++++): >15 mm.

34.4 to 68.9 %.

**Figure 5.** Biodegradation of microcystin by *Sphingosinicella microcystinivorans* (strain B9), water kefir (P4), *Lactobacillus acidophilus* La-5 (P5) and yeast (L5).

In summary, adequate agricultural practices based on crop rotation, fertilization, soil biodi‐ versity, resistant crops, and post-harvest management could reduce mycotoxin contamination in field. Further long-term strategies encouraging no-tillage cultivation, and the maintenance of riparian forests in extensive agricultural land would be goals to maintain water quality; and the sustainable production of nutrient-rich high-quality products would still be possible.


**Conflict of interest**

this strategy, the authors obtained 31% of mutation efficiency [74]. This team targeted two other genes of the diatom using this technology and obtained from 25 to 63% of mutation level [74]. Adaptability of the CRISPR/Cas9 system has been demonstrated in other diatoms like *Thalassiosira pseudonana* [75] as well as in the heterokont, *Nannochloropsis oceanica* in order to knock out the nitrate reductase activity [76]. In conclusion, CRISPR/cas9 system is a promising technology to generate genome-modified organisms in microalgae. **Table 1** compares this system with the other nuclease systems cited above in terms of their technical characteristics

The study of mutants impaired in a glycosidase or a glycosyltransferase implied in the *N*-glycan pathway is of great interest. Indeed, the synthesis of oligosaccharides is a sequential process. Inactivation of an enzyme usually results in the accumulation of its *N*-glycan substrate which enables the step-by-step dissection of the entire pathway. Moreover, mutant phenotyping of the glycosylation pathway allows to investigate to which extent the protein *N*-glycan processing is required for normal growth and development. An indexed and mapped mutant library has been created in *C. reinhardtii* by single random insertional mutagenesis of gene cassettes in 2016 [79]. This library already envisioned to study the function of genes encoding putative glycosyltransferases, glycosidases or even putative translocators in microalgae and to confirm

The production of biopharmaceuticals in microalgae currently requires a better understanding of the *N*-glycosylation pathway mechanism and regulation. Such information can be gained by the use of mutant libraries like the one recently developed for *C. reinhardtii*. Indeed, characterization of each individual mutants will allow an understanding of a specific step of the *N*-glycan processing, and mutant cells could represent interesting cell lines for the pro-

Once these pathways would be completely deciphered in the microalgae model intended to be used for the production of biopharmaceuticals, the humanization of the *N*-glycosylation pathway could be initiated using designed engineered nucleases strategies recently developed in microalgae. We can now consider that transformed microalgae by these innovative new genomic tools will constitute in a near future one of the most suitable green cell factories

The authors are indebted to all coworkers and students at the Glyco-MEV laboratory who are currently contributing to the microalgae research project or did so in the past. They are also

and highlights their advantages and disadvantages.

their physiological role from reverse genetic studies.

duction of biopharmaceuticals bearing a chosen *N*-glycan profiling.

for the production of humanized biopharmaceuticals.

**3.2. Mutant libraries**

186 Microalgal Biotechnology

**4. Conclusion**

**Acknowledgements**

The authors have declared no conflict of interest.