Lupine Publishers | What is beyond the Nivolumab Monotherapy approval for advanced Hepatocellular Carcinoma?

 Lupine Publishers | Journal of Oncology and Medicine

Keywords: Hepatocellular carcinoma; Immune checkpoint inhibitors; Nivolumab; FDA

Editorial

With an estimated 500,000 new cases per year, hepatocellular carcinoma (HCC) represents the third leading cause of cancer death worldwide. The incidence is rising in the west, largely due to an increasing incidence of hepatitis C virus infection [1]. The majority of HCC patients are diagnosed with disease too advanced for curative treatment. Only liver resection and liver transplantation are considered curative, with poor efficiency of other modalities such as radiofrequency ablation (RFA) and transarterial chemoembolization (TACE), although this may provide a modest prolongation in survival; however, the relapse in the majority of these patients is inevitable [2]. An array of translational research and pilot clinical trials have revealed that adoptive immunotherapy's are safe by patients with HCC, but they lack efficacy [3]. Now, we are in the new era of immunotherapy's such as immune checkpoint inhibitors and CAR-T strategies, which would bring benefit to the HCC patients.

On September 22, 2017, the Food and Drug Administration granted accelerated approval to nivolumab (OPDIVO, Bristol- Myers Squibb Co.) for the treatment of HCC in patients who have been previously treated with sorafenib. The approval was based on a 154-patient subgroup of CHECKMATE-040 (NCT 01658878), a multicenter, open-label trial conducted in patients with HCC and Child-Pugh. A cirrhosis who progressed on or were intolerant to sorafenib. Patients received nivolumab 3 mg/kg by intravenous infusion every two weeks. The confirmed overall response rate, as assessed by blinded independent central review using RECIST 1.1, was 14.3% (95% CI: 9.2, 20.8), with three complete responses and 19 partial responses. The response duration ranged from 3.2 to 38.2+ months; 91% of responders had responses lasting six months or longer and 55% had responses lasting 12 months or longer. Adverse reactions occurring in patients with HCC in CHECKMATE-040 were similar to those previously reported in product labelling, with the exception of a higher incidence of elevations in transaminases and bilirubin levels [4].

There are other immune checkpoint inhibitors that are being tested as monotherapy for efficacy and safety in HCC. Nivolumab was the first approved, but others will follow, as it has occurred in other malignancies. There is a bunch of possibilities for the treatment strategy using immune checkpoint inhibitors. Future directions point to various stages of HCC treatment, such as neo adjuvants and adjuvants after resection and ablation, combination therapy with transcatheter arterial chemoembolization, first-and second-line treatments, and all sorts of combinations with other immunotherapies, targeted molecules and novel therapies.

In the table annexed to this editorial you will find a list of ongoing clinical trials combining the immune checkpoint inhibitors with other therapies. At the top of the Table 1 are listed the trials with simultaneous blockage with anti-PD-1/PD-L1 and anti- CTLA-4 antibodies, which are expected to be promising regimens in HCC immunotherapy. The high efficacy of the combination therapy was demonstrated in malignant melanoma [5]. Simultaneous inhibition of the B7-CTLA-4 pathway by an anti-CTLA-4 antibody may increase the number of activated CD8+ T cells in lymph nodes, followed by an increase in the number of activated CD8+ T cells infiltrating the tumour tissues, thereby enhancing the antitumor effects. Their combination with molecular targeted agents (e.g., sorafenib or axitinb) also appears promising.

Table 1: Summary of ongoing trials with immune checkpoint inhibitors in HCC.

In particular, the approach combining an immune checkpoint inhibitor with an existing loco regional therapy for HCC is currently under evaluation. TACE or RFA is expected to enhance the effects of immunotherapy by inducing local inflammation, releasing gneoantigens that activate antigen presentation and immune system activation. The results of the combination therapy with anti- CTLA-4 antibody and loco regional therapy in advanced HCC have recently been published [6]. The NCT01853618 study evaluated the efficacy of adjuvant therapy with tremelimumab (anti-CTLA-4 antibody) after RFA or TACE in several, but not all, HCC nodules, with favourable outcomes, including a partial response rate of 26%, time to tumor progression of 7.4 months, and overall survival of 12.3 months.

The results of trials of the immune checkpoint inhibitor- combined strategies are awaited with high expectations by the medical community.

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Lupine Publishers | Long Term Winter Season 2017/2018 Northern Hemisophere and Their Impact over Indonesia Maritime Continent Area

 Lupine Publishers | Journal of Oceanography and Petrochemical Sciences

Short Communication

The winter season 2017/2018 could be one of the unusual condition with increasing the winter storm activities over Northern Hemisphere to affect aerodrome closed for certain airports in big city of the United States of America and Canada in Northern America Continent, it could be over European Countries and North Asian Continent. The freezing water Niagara for the first time during last 50 years could be additional condition from coolest than normal and it might longer than usual based upon public information and collecting the global climatic chart from National Climate Centers under coordination from the World Meteorological Organization. If the condition winter season 2017/2018 compared with previous condition especially in the 17 years or it could be more than that period, the winter season 2017/2018 could be worst condition and situation especially with winter storm occurrences over most northern hemisphere. Reversal condition over southern hemisphere with summer season with few day occurrences of the heat wave over Australia continent last January 2018. To assess the weather and climatic over the earth’s surface that weather and climate development came from uneven solar radiation (solar activities) received by the earth’s surface, it meant that solar radiation could consider as the main subject to asses/study the global circulation over lower atmosphere of the earth. Where we could consider solar radiation to have closed relation with solar activities in term of the sunspot and solar flare to investigate how much solar radiation/ energy emits from the center of the solar system.

In this case, the sunspot number counted every month could be used as the quantity and quality sun radiation/energy with high number of sunspot to represented large sun radiation received by the earth surface to the universe of the earth – sun system. It could also be with small number of sunspot with respect with the time especially daily, weekly, monthly, seasonally up to yearly basis to be represent less of the sun radiation received by the earth surface. From further assessment and study of the sunspot number has a relation with the weather and climate condition over the earth surface especially formation of the global air circulation both north – south between equator – north and south poles and east – west direction over the equator. High or maximum number of the sunspot on the monthly basis for 6 – 12 months duration could encourage global phenomena of the El Nino (warming sea surface temperature over equator east Pacific Ocean) and small or minimum number of the sunspot could encourage reversal El Nino in term of the La Nina. Both of the global phenomena would affect certain weather and climatic condition globally arising unusual weather and climatic pattern over the earth’s surface.

Based on the sunspot number on the monthly basis could be arranged in term of the sunspot cycle to represent from minimum number toward maximum as the peak sunspot number then to be going down toward minimum number. Now, there 24 sunspot cycles with one cycle having duration at about 11 years. It means every sunspot cycle has period between 10 – 12 years. At this period 2017/2018, sunspot cycle number 24 would be toward small number of minimum of the sunspot or minimum sun’s radiation received by the earth surface. Such that La Nina episode would active starting middle of the year 2016 up to beginning 2018. Where La Nina episode has large contribution in the developing equatorial wave of the so called Madden Julian Oscillation (MJO) which create intra seasonal weather and climatic condition over the tropical area especially over Indian Ocean Indonesia Maritime Continent and West Pacific Ocean. During MJO passing over the consecutive areas Indian Ocean – West Pacific Ocean, array of the large tower of cumulonimbus cloud would be active to support the tropical cyclone formation and other local storm. Beside the global perspective, there would be regional perspective phenomena coincide with Asian winter monsoon activities in terms of the cold surge to form the Borneo Vortex mostly over west Indonesia Maritime Continent. With having long period and cooler condition during winter season 2017/2018, the Borneo Vortex frequently forms during lack MJO activities or when MJO move eastward toward East Pacific and Atlantic Ocean.

By the frequent MJO episode of occurrence over Indonesia Maritime Continent as part the global perspective from the dynamical meteorology and oceanoanography, there was two tropical cyclones formation closer with the Java island namely tropical cyclones “ Cempaka” and “Dahlia” during period November 27th, 2017 – December 2nd, 2017 . From the operational point of view, the formation tropical cyclone Cempaka on November 2017 was closer to the coastline of southern Java island causing flash flood, no storm surge over the coast line, land slide, flooding over some areas in central and eastern Java island. Then tropical cyclone Dahlia might cause low storm surge over Sundae Strait and some coastal area over southern west Java Island and strong wind along northern coast of west and central Java Island.

The formation of the unusual Tropical cyclone would be in advance and generating over low latitudes approaching equator line. Then end of the year 2017 up to end January 2018, Indonesia Maritime Continent would suppress the cloud cover and rainfall due to the cooler than normal of the sea surface temperature Indian ocean west of Indonesia Maritime Continent. Unfortunately during February, activities of the cloud cover and rainfall would be increasing even MJO over Pacific – Atlantic Oceans.

The Cold surge would not encourage the formation the Borneo Vortex, but the convergence zone of northerly and southerly would be part from the Inter Tropical Convergence frequently occurs with more active cloud cover and rainfall. The flooding areas and landside arose including Jakarta and adjoining area frequently occurs with additional condition coolest of the environment most over Java up to lesser of Sundae Island beginning March 2018. Where these meteorological conditions are a little bit anomaly from the normal condition that peak of the rainy season coincide with cooler environment usually be in the end year – beginning next year around December – January/February. In the last that impact from long winter season over northern hemisphere would be in terms of frequently wet, cooled and windy weather, climate and environment condition especially over southern area of Indonesia Maritime Continent and also longer as usual period of the peak rainy season 2017/2018. The dynamical meteorology and oceanography would be interesting in further study if we refer with the global warming and climate change as arising environmental issue starting 1990 up to present time.

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Lupine Publishers | Proverbs and Narratives: An Inherited Knowledge System of Child Rearing and Caring in Rural Cultural Setting

 Lupine Publishers | Journal of Anthropological and Archaeological Sciences

Introduction

This paper aims to write a research proposal on ‘Archaeology of inherited wisdom: interpreting proverbs and narratives related to infants and young childcare in rural Bangladesh’. This study has investigated knowledge system of rearing and caring of infants and young children as focal point of view where their parents and relatives share the knowledge on infants and childcare from the oral literature such as proverbs and narratives to procreate infants and child. The modern biomedical and modern knowledge system spread various propagandas by stating folk wisdom as useless and irrelevant in the perspective of modern age of scientific rationality. The global cultural flows of infants and young childcare occupy almost every parts of the world through electronic media, western academicians and the medical industry as a whole. This study has basically started to its journey with the aim of interpreting proverbs and narratives as insightful thoughts of folk wisdom which are holistically applied for the procreation of infants and young children. However, this study has proposed a thoughtful design to draw research tools, systematic way of collecting primary data, the purpose and process of reviewing relevant literature, the statement of this research as an issue of investigation, the rationale of this study, the theoretical and conceptual backdrops, the systematic way of recording and the interpretation of field data in the form of ethnographic writing [1].

Background of this Study

This study has been designed through the background scenario of Bangladesh because infants and young childcare issue is a fascinating issue of investigation among the Government and Non-Government organization. They basically explain various structural and institutional processes which facilitate, constrain, and manipulate infants and young child health care. All the study implies modern biomedical and nutritional perspective that fails to interpret the local literature including proverbs and narratives which are full of insights to procreate, educate and manage knowledge on health care. Such types of knowledge are transmitted orally, and these are the experiential knowledge where proverbs and narratives are the popular forms of such oral literature of the local people. In such situation, it is imperative to record such forms of cultural knowledge or folk wisdom and in this context; this study has aimed to interpret proverbs and narratives as fundamental source of knowledge related to infants and young childcare [2].

Use of proverbs and narrative thought

Professor Wolfgang Mieder’s presentation in memory of Alan Dundes in Tartu and the title of his article in this journal The Proof of the Proverb is in the Probing points straight to my subject matter: The use of proverbs and narrative thought. Probing processes in real situations has a lot to do with molding and modifying the truthfulness of a proverb through narrative way of thinking. In more or less big questions we try to find the ways to analyze the situation in order to act or at least to react. If one focuses upon the use of proverbs or proverb-like sayings, namely on the functions of them in social interaction, one will find questions concerning the same themes as in folk narrative research in general: selective memory, reconstruction of experiences, explaining and reasoning about the past, giving instructions and warnings for the future, encouraging or amusing each other, etc. This type of research proved to be possible through a combination of social psychological approach and deep knowledge of folklore data. Rethinking of archival or ethno-methodologically collected data and new records from everyday situations made it possible to reanalyze the data and find various functions of proverbs in social interaction. The research, which was approved for a doctoral thesis in the Department of Social Psychology at the University of Helsinki, owes a great deal to folkloristic and anthropological research done among different cultures (Lauhakangas 2004). Further it has connections with the early days of psychology – namely, Wilhelm Wundt’s folk psychology (1912). This branch remained in the margin for a long time (because of the triumph of experimental psychology). But if we take W. Wundt’s thoughts under consideration now, we notice that their spirit was quite close to narrative research. The theoretical and empirical principle in the research of the functions of proverbs in social interaction was to study the common sense or everyday thinking in its cultural and social contexts. The role of language and cultural conditions was now reconsidered, after W. Wundt’s days, as a challenge to understand social interaction. In one of his introductions to proverb collections, MattiKuusi called proverbs signs of situations and emotional loadings (Kuusi 1988). He probably meant their unique linguistic properties as cultural tools of man, but this description could also be understood from the point of view of the social use of proverbs. What was their function in everyday encounters and conversations? It was not enough for a culturally orientated social psychologist to state that proverbs were a nice or tough-lived part of tradition transferred as cultural modes of thought. A general list of the functions of proverbs given even by any leading paremiologist would not be satisfying. This kind of research could be culturally valid only if it covered as many aspects as possible of any speech situations where people use proverbs [3].

Why does a proverb emerge into a speech situation?

Any social or personal context where people use proverbs in different cultures (and throughout history) could be considered equally interesting from the point of view of the above formulated general question. Accordingly, proverbs with contexts were collected for this research from other scholars around the world and not only from Finnish folklore archives and fiction. Besides, the author observed everyday situations and kept a notebook about people’s ways to use proverbs in the media. The following example shows how people even nowadays are keen to use proverbs, although they call them clichés or well-worn expressions. In a Finnish radio broadcast, editor Juha Kulmanen interviews JariLuoto, an Under Secretary of State, about population policy. The interviewer poses one of his questions in a rhetorical way: “The rich will become richer and the poor will grow poorer. This is an old phrase, but it holds good.” (cf. ‘He who has is given, he who has little is taken from’ or ‘Money is drawn to money’.) The interviewee addressed shows his agreement. The conversation continues and for a closing statement Luoto says: “It is a stock phrase but holds good: If there were no UN, we would have to invent it.” (A radio broadcast in Yle One, 24.10.2005.) For the study of contexts, a new term, ‘the proverb speech’, was formulated. It can be simply defined as a kind of speech where a proverb or a proverb-like saying is used (inner speech included). By building a many-sided classification of the functions of ‘proverb speech’ based on the material of context examples, it could also be better explained why proverbs had special linguistic structures. At least the emotional tendencies and social strategies of people to recall proverbs could be better understood. The themes of the social interaction of proverbs, in terms of their imagery, are interesting as such (see MattiKuusi’s thematic classification of proverbs in Lauhakangas 2001). But themes in proverbs seem to have a connection to the function of proverb speech as a narrative mode of thought [4].

The narrative strength of proverbs in social contexts

Proverbs are multifunctional and flexible instruments of everyday reasoning, although they may maintain solidified attitudes or traditional modes of thought of a certain culture. A proverb can be considered as a piece of advice concerning a recommended direction of action (although it is not literally a piece of advice). Proverbs are propositions loaded with hidden feelings, wishes and intentions of the speaker. They can serve as tools to cover individual opinions in public interactive situations. Like in rhetoric in general the proverbs we use in our speech (and in our inner speech, too) protect our personal attitudes by referring to the third party. They give us persuasiveness by appealing to an authority. The ability to use proverbs leans on common rules and recipes and it is a part of facilities for outlining and organizing quickly and effectively things which we experience in everyday situations. Reasoning, classifying, comparing and explaining are mechanisms by which people aim at while creating hierarchy and consistency to the contents of commonplace thinking. Using proverbs means that people can deal with their relations to each other and/or to things. People can explain to themselves what happens or what has happened, and they can give explanations to any behavior they have observed. Ready-made models make it easy to orientate in these types of situations and demands of social life, but the drawback of this is that those models, for example proverbs, guide us to see situations named by them. Thus, we are not able to see or notice the (possible) distinguishing features of them. The mundane philosophy of proverbs or proverb use deals with ethical and pragmatic questions. They are about questions how things are or how they should be; about issues how things can be recognized and what we can know about them. They are brought out in situations where people feel emotional tension and need smooth actions. They mean authorized wisdom called for when people should decide how to explain things. Proverbs are brought to conversations to make calculations of profitability: How do we influence on things or on our life? and How and when it is wise to act or let things go?

KwesiYankah (1989) wrote about a broad or wider consciousness of language and how the user of proverbs has a creative ability to utter them in a convincing way (and also an ability to convice her/himself). The proverb users have ready-made opinions about urgent questions which they seem to strengthen with suitable proverbs. But in any case, the attention of listeners focuses on creditability of the proverb mentioned. The narrative strength concentrates just on the proverb, if we examine the use of it, namely the proverb in its social context. Jokes or anecdotes are not the most critical contents of any conversation or presentation, neither is a proverb or a proverb-like expression. But anyway they may be the best remembered parts in argumentation [5].

Statement of the Problem

The problem statement of this present study draws from the background information and the gaps between the reviewing existing literatures. People in rural settings in Bangladesh from diverse socio-economic and demographic features and are still dependent on such inherited wisdom in relation to infants and child health care knowledge through sharing such experiential knowledge system. Beside this, due to global technological and modern biomedical knowledge flows, people face constrains to keep their inherited knowledge tradition on infants and childcare. However, various literatures on infants and young childcare in Bangladesh evident that people are pursued or bound to keep the touch of modern biomedical scientific knowledge system with the influences of national and global forces by public, private and tertiary initiatives of medicalization of infants and young child. In such situation, this study has aimed to find out the knowhow how people are still thinking about proverbs and narratives related to the knowledge on infants and young childcare in the rural context.

Objectives of this Study

The objective of this study has been drawn from the statement of the research problem. However, this section covers the following broad and specific objectives.

Broad objective

The broad objective of this study was to explore the architecture of inherited wisdom including proverbs and narratives related to infants and young childcare in the study area.

Specific objectives

The specific objectives of this study were;
a) To interpret the structural and functional attributes of proverbs and narratives about infants and child health care and how people think about, symbolize and distinguish proverbs and narratives on the proposed area of investigation.
b) To explore the nature of the knowledge either it covers holistic view about infants and young childcare in the study context.
c) To explain the processes and procedures of transmission of such oral knowledge related to the knowledge on infants and young childcare in the study area.
d) To identify the factors which contextualize, manipulate, and constrain such knowledge system in case of infants and young childcare in the study area.

Rationale of this Study

This study claims rationality because of a variety of embedded reasons. First of all, knowledge on infants and young childcare through sharing and transmitting proverbs and narratives which contain folk wisdom that needs to explore and record. Second, this knowledge transmitted orally and by generation to generation that covers the experiential knowledge about infants and young child care which are very cheap in availability in terms of biomedical knowledge but full of value and local wisdom and efficacy in terms of the real practitioners of such inherited knowledge system. Finally, on the academic ground, this study gives a floor to explore such knowledge system from the perspective of the generator and the user not because of the easier access of data but such type of studies are rare in anthropological academic field in Bangladesh and this study has hoped that the academic resources will be enriched by this study.

Theoretical and conceptual framework

The structural and Functional aspects of proverbs and narratives can be interpreted on the theoretical lens of 20th century European linguistic thinkers. Ferdinand Saussurean semiology has a successful root in the study of folk elements of culture and anthropology of linguistic phenomena including language and its social and cultural contexts as well. Anthropology has a tradition to conduct ethnographic research on ‘speech and speaking’. Saussurean structural linguistic integrates two elementary parts of language including ‘langue’ (the language or tongue mainly the grammar of a language) and ‘parole’ (word or speech). Proverbial aspects of a speech community can be analyzed on the basis of the Saussurian dichotomy naming langue/parole. Proverbs in every language or speech community bear grammatical structure such as morphological, phonological and syntactic structure along with the semantic analytical principle which associates its meaning depending on the linguistic environment of the speech community. The major aim of semantic analytical principle is to excavate the meaning of the speech, words or sings and symbols.

The pragmatic analytical tools can also be applied in case of studying proverbs in rural cultural contexts. The pragmatic analysis of proverb associates threefold element including statement, evaluation and prescription. The statement includes what is coded, said or represented in the form of speech or written, the evaluation associates what is meant by the statement or the understanding the underlying meaning principles, and prescription is about what is suggested to forecast about future learning through the statement.

The semiotic analytical frame of analyzing proverb can also be put into attention to study proverbs. Park and Milica [6] have identified three manifold aspects of function of proverb these are; “ideational (language construes human experience), interpersonal (language enacts human relationship), and textual (language creates the discursive order of reality that enables the other two function”.It is cited from the writings of Grzbek (2014), ‘Semiotic and Semantic Aspects of Proverbs Study’ by Park and Milica [6] by summarizing the three interrelated semiotic categories of proverbs including ‘heterosituativity (the meaning of proverb depends on the situation of use), polysemanticity (proverbs have a manifold meaning potential) and polyfunctionality (the same proverb may serve different functions in different contexts’.

Research Methodology

Methodological Stance of this study includes the philosophical grounds of this research and the tools and techniques of data collection and interpretation. It has also been mentioned that this study will be conducted from the qualitative perspective. The epistemological grounds of anthropological research have been employed including holism, emic approach, cultural relativist perspective and the field data have been collected with the application of qualitative tools and techniques of data collection including the in-depth interview, case study, FGD, key informant interview. Hermeneutics is the main epistemological grounds that try to interpret the meaning of an event. In otherwise it is textual or literary analysis. The holistic approach of anthropological research has been employed to understand the whole pictures of people’s life including religion, economy, politics and environment. Through this approach, this study will try to find out how the religious, social, economic and ecological issues are related with proverbs and narratives in the village context of Comilla. The emic or cultural relativist approach will also be employed at the time of data collection and interpretation. Emic is an anthropological research perspective that tries to grab the native’s point of view; the explanation of various meanings and causation of these three referred folk songs in Bangladesh [7].

In-depth interview technique of field data collection has been employed to gather data. It is informal in nature to get the insights of a specific event. By employing this technique this study will collect data from the respondents who are directly or indirectly involved in such songs in the study areas. Case study is another tool of data collection which is highly practiced by anthropologists and others. Through case studies, data have been collected from the parents how they practice proverbs and narratives to procreate their infants and child care. Focused group discussion technique of data collection will be employed to get data from a group of individuals. FGD has helped to gather multiple insights from the individuals who are directly or indirectly involved in practicing proverbs and narratives related to infants and young children in the study areas [8].

Findings and Analysis

Proverbs and narratives: an inherited knowledge system of child rearing and caring in rural cultural setting

The proverbs and narratives in rural cultural setting are related to childcare and rearing are the informal form of knowledge which covers the holistic view i.e. both natural and supernatural elements to identify, distinguish and healing of the health and other mental condition of the children and the infants. The field experience claims that such form of informal knowledge through proverbs and narratives are being endangered because of the practices and the intervention of biomedical knowledge system in rural cultural settings in Bangladesh. In past, people in this rural village applied such indigenous knowledge system in case of diagnosis and healing of heath condition caused by both natural and supernatural elements. People’s Informal knowledge is transmitted orally by one generation to another which is rooted from their day to day experiences over natural and supernatural world phenomenon. Their World views and the religious scriptures are clanged together. These bear the basis of their Social and cultural life.

“DohaiSulemanBadshaer (in the name of king Suleman)” - Shimu, a respondent.
People in this study area, utter the name of king Suleman to get rid of from the bad eye of the evil spirit of ghost. The villagers have a belief in ghost, and other demons who are threatened for human beings. King Suleman is a historical legend of Islamic Religion who possessed the power of knowledge to control the ghost by his almighty Allah (Muslims believe that Allah is their creature).
The case of Shimu: the mantra of `DohaiSulemanbadsha’
Shimu’s family is comprised of six members including she herself, her husband, their three sons and only one daughter. Her son Robin is 11 years of age old caught by the ghost. After completing salad, he was sitting under a palm tree at evening. He was caught by fever in the mid night. He was started to shout and move abnormally. Seeing such situation of her boy, Shimmu’s mother-in-laws diagnosis that Shimus’s boy was caught by ghost as he was sitting under the palm tree at the dark evening (KalSondha). In such situation, both Shimu and her mother-in-laws uttered the verse “DohaiSulemmanbadshaerDohai’’. They recited again and again this verse getting relief from the ghost. But they did not get fruitful result. Then Shimu communicated with a local hujur (religious specialist) and brought water and amulet given by the hujur. Her mother-in-laws learnt from her mater to recite the verse to get rid of the evil eye of ghost spirit. They frequently recited at the dark evening and dark night even after the curing of Shimu’s boy from ghost [9].
Proverbs, narratives and myths are the basis of regulated life pattern of this villager. These cover the get rid of disease sickness and illness, to face trouble of economic and environmental crisis and other livelihood aspects. People take part in ritual like manot (arranging feast in the sacred place), Maintain same taboos during moving home and outside home. These are operated like the informal laws and rules.
Kahir Hossen, A 50 Years of old man stated that “I did not give my child the meat of duck as I Knew that duck meat creates the chance of breathing problem (hapanirog).” He further stated that I took my Children in Krishana Sagordighi (an old watery place in that village like pond) for bath while they were suffering in serious illness. People of this village believe that taking bath at this watery place cures the disease and illness. KabirHossen also provided the knowledge on infants care in the studied village by stating the followings.
“My child was experienced an irregular movement of its brain (amarbaccherbrommochandiosavabikvabelafalafikorsilo). We can observe such movement of my child’s head abnormally. For analyzing such condition, we have a myth by saying that a rat has entered into child’s head. Seeing this, we rubbed the mixture of mustard oil with water and then my child got rid of such condition.”
People also recite rhyme frequently to manage, control and entertain their infants and children. Such type of rhyme composed with linguistic vernaculars of the village setting is highly enjoyed by the infants, young children and the adults.
The sun is shining along with raining,
Fox and vixen’s marriage is happening
(Rod hocche, bristyhocche, khekhsheyalerbiyehocche). - FaruqueHossen, a 45 years old age man.
Above this rhyme bears the higher artistic value of integrating the natural elements of rain, sunshine and the behavior of the wild animal. The three incidents are not observed as regular basis and that is why such moment creates artistic value. The infants, children, adolescents and the adult people enjoy such moment as their part of entertainment in rural cultural setting. This rhyme is highly recited by the children while they are playing with their play mates.
Such type of rhyme provides mental/psychological satisfaction for the villagers of all ages, but the infants and children are highly entertained. This artistic creation has done by their effort of bridging knowledge system amongst the cultural ecology, day to day experiences, lexicography or the linguistic vernaculars what they have and put their meanings to their shared cultural meanings [10].
People of this villagers share some common ground of knowledge which roots from their existing belief system in religion, myths and legends. They are assimilated in such belief system which covers the holistic view of life including advice for maintain a sound health, statement on health, livelihood and world views, evaluation of social, cultural and material condition, and even curing of ill health condition and child procreation and rearing. The following statement covers the above addressed elements;
“If a child has been given mother’s breast feed, the child’s liver growths bigger (bacchakemayerbukerdudhkhawale tar kolizaborho hoi)” – Rina, a 45 years old age woman.
People’s knowledge and belief and the caring of infants go hand in hand. Breast feeding is very important for getting a healthy infant to child, and then to being an adult male or female. Here, Rina’s belief on child caring and her nature of evaluation on her child growth suggests that she wanted to correlate the relational bondage between the mother’s body and her child. By liver growths bigger (kolizaborho hoi), she wanted to mean the child becomes courageous. Like Rina, the other villagers think that breast feeding provides the proper nutrition for the infants. Such narratives provide the nutrient evaluation of child rearing and caring in the studied village.
People in this studied village take part in some rituals and these rituals provide the basis of their life and these are also connected with child rearing and caring. These rituals are encoded their local linguistic jargons and operated through their shared knowledge system which is transmitted orally one generation to the next. The following narratives represent one of the major ritualistic activities of the villagers;
“If a child has been given honey to its mouth, the child speaks sweetly (bacchermukhemodhudile misty kotha koi)” – Sabina, a 40 years old age woman.
Sabina learnt from her mother and adai (traditional birth attendance) that the child speaks sweetly if the child has been given at the time of birth. Not only Sabina but also her other community members share such evaluation of the ritual and the children speech behavior. Although the relationship between giving honey to the child’s mouth at the time of birth and sweet speech at the time of speaking is arbitrary. In other word, Sabina did not provide any proposition to the concrete relationship of her addressed narrative. However, either this ritual makes the child to speak sweetly or not the villagers believe such and practice as the integral part of child and infants rearing and caring in their local cultural settings [11].
People of this village also have some other ethno poetic genres like proverbs, rhyme, riddle and narratives to care about mother and infant’s health caring although they do not provide about the origin of such artistic activities such as who told first or who were the founder of such oral literature. Some of the proverbs on mother and infants caring are provided below with their meanings in the villager’s context.
“If the mother and infants eat palm fruit, they feel digestive problems (maichayekhailetal, petebadhegolmal)” – Saleha, a 49 years old age woman.
People in this studied village know that eating palm fruit is not so good for the stomach health of the both mother and infants at it creates the risk of digestive problems. Although they did not provide the medical/modern scientific reasons, they follow this connotation as an essential part of their food behavior during pregnancy, infants and childcaring, and even the adults and adolescent maintain restriction and prevention to eat palm fruits.
“Mangshokhelemangshobarhe, shakkhelemolbarhe (meat growths meat, red leaf/green leaf causes over toilet)” – Manjura, a 60 years age of old woman.
Manjura knows from her older generation about the food behavior of human especially for infants, children and the adolescent who are at the growing up stage. She believes that meat growth meats in human body although she does know how to explain it. Overeating of red leaf or other green leaf causes over toilet for infants, child and mother. Although she believes and maintains the above addressed narrative, this does not mean that she does not provide green leaf or red leaf to her grandchildren or she always suggests providing meat to them. This narrative is just a guideline to them. Another notion has been contained within the above narrative that is green leaf or red leaf causes the chances of higher toilet. In such situation, people who suffer in highly constipation (kostokathinno), they may get relief by eating green leave/red leaf.
Some other linguistic genres are also found among the villagers who play a vital role as advices, evaluation, beliefs, and taboos for regulation rural lives of either individual or collective gathering. This connotations and linguistic jargons bear the pragmatic value of rural live. These are (Table 1)

Table 1: The presentation and the interpretation FGD data. Source: Fieldwork: 2018.

Above this discussion represents people’s common ground of sharing of knowledge rooted from their culture where culture covers their whole aspects of life including knowledge, beliefs and evaluation of the world views having the collective organization of knowledge creation, evaluation and transitory process of sharing one generation to the next. They share such narratives and proverbs as their basis of child procreation as well as day to day interaction in rural cultural settings [12].

Concluding Remarks

From the above interpretation of the field experience, there is still some practices of people’s indigenous form of knowledge system to procreate and rearing their infants, children and mother’s who gave birth already and expected to be mother despite the dominancy of modern knowledge system. Proverbs and narratives in rural cultural settings cover the whole aspects of life including human relationship, the nature of categorizing and identifying natural and supernatural elements, the livelihood aspects etc. This form of oral literature of the people which bears the experiential knowledge of people needs to be recorded. As it is transmitted orally, this knowledge will be erased if the younger generations remain far behind their older generation. Further research, academic and institutional initiatives should be taken to record and analyze such form of knowledge system which is produced and transmitted by the locales in the form of proverbs and narratives.

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Lupine Publishers | Do You Really Want to Improve the Results of Treatment for Acute Pneumonia?

 Lupine Publishers | Journal of Anesthesia & Pain Medicine

Editorial

The question raised in the title of this letter is a natural consequence of the findings and conclusions that have been growing steadily in recent years regarding the results of treatment for acute pneumonia (АР). If you look at the publications of recent years in this field of medicine, it turns out that one of the main obstacles to progress in improving the results of treatment of this disease is the lack of appropriate methods for determining the pathogen. Thus, the lack of timely diagnostic information about the etiology of the disease excludes the possibility of targeted antibiotic therapy. In recent years, such regrets have become more and more relevant, playing the role of the main explanation for treatment failures .Continuing to narrow the unidirectional view of the problem and to pay attention only to the microbial factor as the main cause of the disease, such views are in fact another illusion, which, even in the case of its hypothetical implementation, will not make significant changes in the overall trend. This statement is easy to verify if you rely on well-known facts, and not use as arguments assumptions and guesses. First of all, it is necessary to remember the features of the initial period of clinical use of antibiotics. On the one hand, the first results showed their phenomenal effectiveness, and the greatest preference for many years was given to penicillin. On the other hand, bacteriological methods of verification of the pathogen at that time were significantly inferior in their speed and quality indicators to the methods of modern Microbiology. However, treatment of patients with AР for a long time was successfully carried out only by one penicillin and the question of the role of determining the causative agent of inflammation in those years did not have such a critical importance. I think it should be obvious to readers with medical education that such success in the use of antimicrobials in a dynamic and living biological environment could not continue indefinitely. The further course of events developed according to the so-called law of scissors, but the dynamics of these changes occurred very slowly, which made it difficult to monitor and timely assessment. On the one hand, each new generation of doctors was brought up in the spirit of priority and irreplaceability of antibiotics, gradually forming the image of a kind of panacea. One of the reflections of the new mentality was the wide spread of the principle “antibiotics alone” for the treatment of many diseases (including AP). Declaring this principle of treatment, no one was confused by the fact that the antibiotic in many patients is the only means of treatment and that the same drug is used in radically different processes. And these are indirect signs of the attitude to antibiotics as a panacea. As you know, the basic principle of antibiotics is only intended to suppress the pathogen, is not it? Other medicinal properties of these drugs do not have. All other changes that have already occurred in the focus of inflammation, and in the body in General, cannot be eliminated with the help of antibiotic therapy, no matter how powerful and long it was not. The latter task falls on individual protection and adaptation mechanisms and depends on the direction of additional assistance methods. The gradual narrowing of views on the nature of AР to the direct dependence of all sides of the disease on the type of the pathogen was accompanied by the formation of relevant normative documents recommending and prescribing the implementation of specific actions and prescriptions. Today, a specialist working on the basis of a license cannot go beyond these requirements, even if he had doubts about their effectiveness. In parallel with the deformation of the image of AР as an inflammatory process of nonspecific etiology in the lungs, there is another important process, the results of which are increasingly recorded in recent years. The symbionts of our body are also biological objects. Exposed to mortal danger, they have learned not only to survive, but also to create strains resistant to such aggression. To date, the group of resistant strains to antibiotics is already quite impressive, and its representatives are increasingly identified among the symbionts of healthy people [1]. In itself, the presence of such microflora in the body does not necessarily mean the fact of the disease, but in the case of the beginning of the last, conventional antibiotic therapy can meet with serious difficulties. In fact, we are talking about microbes that have always been found in the composition of human symbionts and that have only gained additional stability, not aggressiveness. Hardly anyone doubts the fact, that the emergence of such strains is the result of long-term and widespread use of antibiotics. In addition, the frequency of detection of such strains in a healthy population will increase as a result of continued antimicrobial therapy. At the same time, it is even theoretically impossible to stop this already started process, since such an initiative can lead to disastrous results. Therefore, it is necessary to realistically assess the current situation in bacteriology, which is not the worst option, and consider the gradual increase in the number of carriers of such strains among the healthy population as a future inevitable reality. It is known that the uncertainty of what is happening has always been one of the main prerequisites for the emergence of fears. In this regard, it is especially important to note that the author’s point of view is presented to the reader not for emotional impact, but only to develop their own rational assessments of already known facts. If for many years, the AР microbe is considered to be the main cause of the disease and the entire policy in the treatment of these patients was aimed only at suppressing this factor, the decrease in the effectiveness of treatment and the increase in the resistance of the microflora led scientists into complete confusion. In this case, modern ideas about the nature of the disease can indicate only one way out of this impasse - to speed up the process of determining the pathogen. However, the accumulated evidence shows the futility of trying to realize these hopes. Although the participation of various microorganisms in the inflammatory process of lung tissue differs significantly in its frequency, and the leaders of this list change periodically, it should be recalled that to date more than 100 microbes have already been established that can act as pathogens of AР [2]. In addition to these data, the literature on this problem always notes the fact that AР pathogens are not only bacteria, but also viruses, fungi, parasites. In this regard, it is especially advisable to pay attention to acute inflammation in the lungs, which is a consequence of a viral infection. According to the statistics of this disease, at least a third of patients in the world have the viral nature of AР [3,4]. These indicators cannot be ignored, as the continuation of the therapeutic principle of “antibiotics alone” in the AP reveals the following fact. All patients with viral etiology of the disease do not have targeted treatment, and antibiotic therapy is only an attempt to prevent the possible addition of a bacterial component. Therefore, successful treatment in such observations should be considered more as a merit of the patient’s body than as a triumph of medical efforts. At this stage, the etiology of AР is widely interpreted on the basis of the results of bacteriological studies of the microflora of the nasopharynx and oropharynx [5-7]. However, such studies require clarification of the breadth of their application, and the evaluation of their results raises logical objections. For example, it is known that bacteriological examination is usually carried out mainly in hospitalized patients. The etiology of AР in most patients undergoing outpatient treatment remains unknown. But, even among hospitalized patients, the duty of such studies refers to cases of severe forms of the disease, and positive results (including cultures of blood) are found in less than half of the cases [4,8]. However, even the interpretation of the positive results of the examination does not explain such a paradox as the presence of less virulent microflora in a number of AP observations compared with bacteriological examination of the upper respiratory tract in healthy people, when the simple presence of aggressive strains without any signs of the disease is revealed. Serological diagnosis is also not the result of studying the material directly from the area of inflammation. Allowing to identify trace reactions, this type of examination refers to indirect signs of contact of the body with a certain pathogen but is not an absolute proof of its presence at the moment directly in the inflamed organ. If we continue to discuss the role of the material in the reliability of the results, the most accurate method of determining the agent of AP, of course, is to study the content of the affected area. The possibility of practical implementation of such a study appears only in a limited group of patients with purulent pleural complications that develop at a certain stage of the process and previous treatment. However, even the results of this relatively small group of patients show that in 30 and more % of cases microflora was not detected [4,9] and there is no reasoned explanation for this fact. As a result, several hundred million AР cases are diagnosed each year in the world, but their etiology remains an open question, and the choice of antimicrobials has been and is being conducted empirically [4,8-10].

Despite the intuitive choice of antimicrobials, their use remains a very important support for the body. For most patients with AР, the suppression of an unexpected mutiny of the accompanying microflora is enough for the body to cope with inflammation in the future. However, in the most severe situations with the rapid and aggressive development of the inflammatory process, another aspect of the problem is revealed, which currently continues to be explained by the extremely high virulence of the pathogen. For example, among patients hospitalized with severe AP, mortality reaches 13-28%. Among the total number of hospitalizations with AP, septic shock is diagnosed in 30% of cases, and mortality in this group increases to 50% [4,11-13]. The statistics of these results seem, at first glance, quite understandable and logical: the more severe and aggressive the disease develops, the more difficult it is to eliminate the catastrophic violations that have arisen. However, the logic of such arguments collapses completely, if we take into account some very important, in my opinion, facts. First, if we consider shock as a septic complication of aggressive forms of AР, it is necessary to have conclusive evidence of this option, the cause of which is the penetration of pathogens into the bloodstream. However, the detection of bacteria in the blood is recorded only in 10-12% of all hospitalizations with AР without connection with the shock pattern [8,9]. That is, the latest figures reflect the frequency of diagnosis of bacteremia, which is not always accompanied by a clinic of shock. Secondly, interpretations of shock in AP as its septic variant consider this complication only from the point of view of the microflora and leave without attention such an important feature of inflammation as an individual reaction of the body to the process. It is the juxtaposition of these two causes (microorganism against microorganism) that creates the uniqueness of the manifestations of the inflammatory process even in the presence of the same pathogen. However, despite this long-known fact, the severity of AР in recent years is increasingly attributed solely to the properties of microflora. Finally, the main feature of the nature of the shock in the clinic, the AP determines, from my point of view, the undeniable fact that this intense process is the only inflammatory disease of nonspecific etiology of all known, which occurs in the vascular system of the pulmonary circulation. Rapid change of stages of the process makes it difficult to adapt the body to new conditions. In the most aggressive cases, the body gives us a clear signal of its catastrophic situation. Demonstration of shock in AP is a reflection of the body’s efforts to facilitate the work of pulmonary vessels, which could not provide the necessary blood flow and synchronous operation with a large circle of blood circulation [14]. The causes and pathogenesis of this form of shock differ significantly from other variants and require a different treatment solution. So, this form of shock has been highlighted by us in a separate section as pulmonal shock. Understanding the pathophysiology of current disorders involves eliminating the reflex effect of the source of inflammation in the lungs on pulmonary blood flow [15-18]. Instead, shock in AР is compared with its manifestations of another origin, and such patients begin to receive standard therapy in the form of intravenous injections with the addition of hormones and vasopressors [4,8,9,11,13,19-22]. Intravenous fluids increase blood flow to the pulmonary vessels and further disrupts blood circulation in the small circle, stimulating further hemodynamic changes. In parallel, the processes of exudation in the area of inflammation are stimulated. In response to such aggression, the body of many patients stops responding contrary to expectations and then begins the use of vasopressors and hormones. The result of such therapeutic efforts in pulmonal shock in patients with AР is the loss of many patients, and the frequency of pleural complications among hospitalized patients reaches 60% or more [4]. The above brief considerations, together with some known facts and figures, allow us to present only the contours of the modern problem of AР treatment and draw the attention of readers to another direction of its solution. It is important to note another fact that a non-standard approach to solving this problem has already been tested in the clinic and its results allowed us to note that early pathogenetically justified assistance with AР guarantees the prevention of a complicated course of the disease [23,24]. Therefore, the question that was raised in the title of this letter has a real basis. In order to answer this question in the affirmative, it is necessary first of all to radically reconsider the understanding of the nature of the disease and the mechanisms of its development. Without this step it is impossible to move on. Do you really want to improve the results of treatment for acute pneumonia? So, go ahead and improve!

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Lupine Publishers | Genetic Counseling and Testing for Colorectal Cancer in Young Adults: Mini-Review

 Lupine Publishers | Journal of Forensic & Genetic Sciences

Abstract

Colorectal cancer (CRC) has one of the largest proportions of familial cases. Two to 5% of all colon cancers arise in the setting of inherited syndromes, including Lynch syndrome (hereditary nonpolyposis colorectal cancer [HNPCC]), familial adenomatous polyposis (FAP), attenuated FAP, MUTYH-associated polyposis (MAP), and certain hamartomatous polyposis conditions like Peutz-Jeghers syndrome (PJS) and juvenile polyposis syndrome (JPS). All of these conditions are inherited, autosomal dominant disorders, except MAP, which is autosomal recessive [l]. Although clinical similarities do exist, each has different cancer risks, characteristic clinical features, and separate genetical etiologies. In addition to these syndromes, up to 30 % of colon cancers exhibit increased familial risk, likely related to inheritance. A number of less penetrant, but possibly more frequent susceptibility genes have been identified for this level of inheritance. Determination of predisposing genes allows for accurate risk assessment and more precise screening approaches. Examples include common polymorphisms in genes that regulate metabolism or genes that are regulated by environmental or other genetic factors.

Abbreviations: CRC: Colorectal cancer; HNPCC: Nonpolyposis Colorectal Cancer; FAP: Familial Adenomatous Polyposis; MAP: MUTYH- Associated Polyposis; JPS: Juvenile Polyposis Syndrome.

Introduction

Lynch syndrome is the result of a germline mutation in a class of hMSH2, hMLHl, hMSH6, and hPMS2. The MMR system is and insertion-deletion loops that form during DNA replication. Germline mutations in genes involved in DNA MMR (necessary for maintaining genomic stability by correcting single-base mismatches), including hMSH2 and hMLHl account for the up to 90% of Lynch syndrome cases; mutations in hMSH6 account for approximately l0% and mutations in hPMS2 are detected on rare occasions [2]. FAP (development of hundreds to thousands of colonic adenomas, beginning in early adolescence, and inevitable CRC in untreated individuals by 39 years), attenuated FAP (70% lifetime risk of CRC, an average of approximately 30 colonic adenomatous polyps), and Gardner syndrome (FAP with osteomas, epidermoid cysts, dental disorders, and/or desmoid tumors) all result from mutations in gene APC, which encodes a tumor suppressor that is part of the WNT signaling pathway.MAP is caused by biallelic mutations in MUTYH (MYH;part of the base-excision repair pathway, which is involved in defending against oxidative DNA damage) and is characterized by the presence of adenomatous polyposis of colo-rectum, and an increased risk of especially proximal colonic neoplasms, like attenuated FAP [3]. PJS and JPS are hamartomatous polyposis diseases hat are both associated with an increased risk for CRC and other malignancies. Gastrointestinal symptoms first occur in the early teenage years and include small bowel obstruction and intussusception. Mutations in STKll (LKBl) are the only known cause of PJS, whereas JPS is caused by mutations in either SMAD4 or BMPRlA [4]. Another known very rare hamartomatous condition, Cowden syndrome, arises from mutations of PTEN [5].

Identification of the genes that cause these colon cancer syndromes has led to the development of specific management guidelinesand genetic teststhat can diagnose these familial disorders. These guidelines are important, not only for the affected patient, but also for their family members. If a patient has FAP, close family members should be tested early on, usually as teenagers. This is because CRC in patients with FAP tends to arise at a very young age. If a patient has Lynch syndrome, family members can wait until they are about 20 to 25 years old to undergo genetic testing. At-risk patients can be offered genetic counseling and testing to determine whether they carry a detectable mutation for such a syndrome. If so, this information provides the clinician with valuable data about the patient's risk for other cancers, and alerts surgeon about the correct time for surgery.

Conclusion

In conclusion, genetic testing is available for most hereditary CRC syndromes and can be used to confirm suspected diagnosis, to clarify risks of extra-colonic cancers in affected individuals, and to identify relatives who are also at risk. Therefore, genetics analyses of CRC risk need to be included in mainstream clinical practice.

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Lupine Publishers | The Development Fortified Pan Bread by Increasing Its Protein Content with High Levels of Live Yeast cells Saccharomyces Cerevisiae

 Lupine Publishers | Journal of Dairy & Veterinary Sciences

Abstract

The main objective of the research is to develop pan bread nutritional value through fortification with high concentration of live yeast cells (Saccharomyces Cerevisiae). Fortified pan bread boosts the nutritional status of poor people and reduces the incidence of infertility diseases. The bread was reformulated by adding various concentrations of S. Cerevisiae at 5, 10, 15, 20 and 30g/ kg wheat flour. The bread was baked using the straight dough method. Protein, carbohydrate, moisture, fat, vitamin B complex, minerals, energy value, amino acids profile and Sensory evaluation were conducted on the fortified pan bread were evaluated. Results revealed that the carbohydrate, moisture, vitamin B complex, minerals, protein content and amino acids pattern increased with the increase in concentration of S. Cerevisiae. The sensory test showed that pan bread fortified with S. Cerevisiae concentration at 5, 10, 15 &20g/kg wheat flour were accepted by panelists, while pan bread at 30g/kg concentration was unacceptable. This study shows the potential of using high concentration of S. Cerevisiaein improving protein quality and nutritional value of pan bread consumed by economically disadvantaged communities.

Keywords: Bread; Fortification; Nutrition; Protein Amino Acids; Yeast; Saccharomyces Cerevisae; Carbohydrate; Vitamin Supplements; Nutritional Yeast; Biomass Production; Sensorial Quality

Introduction

Bread is the main product of wheat which is manufactured commercially. Eating grain foods, like bread consumed a lot by economically disadvantaged communities. it is plays an important role in the diet by providing many nutrients, such as carbohydrate, Protein, dietary fiber, vitamins and minerals, which are vital for the health and maintenance of the body Pareyt [1]. But wheat flour which is the basic ingredient in bread is lack crucial nutrients such as essential amino acid lysine and B complex vitamins Wardlaw [2]. One way of improving the nutritional quality of pan bread is fortification with bakery yeast Saccharomyces Cerevisiaeto enhancing bread protein content Friedman & Finot [3]. Saccharomyces Cerevisiae has high nutritional value is rich in content of the proteins, vitamin B complexes and minerals such as calcium, phosphorus, manganese, magnesium, zinc and copper and has high biological value of essential and nonessential amino acids so it has several health benefits Shrinandan [4]. Saccharomyces Cerevisiae as a single cell protein is a rich source of proteins which are necessary for replacing worn out tissues or recovery after infections and contains 18 amino acids and is considered to be 55% high quality protein. It is a rich source of B vitamins which aid in lowering stress, help in metabolism, prevent cancer and ensure a healthy skin and it is low in fat and hence low in cholesterol content it maintains optimum cholesterol levels, improves blood production and also improves liver health and function Bekatorou Saccharomyces Cerevisiae also contains gluthanione, an antioxidant and beta glucan which stimulates the immune system Hong [5]. Of the 15 minerals that it contains, Saccharomyces Cerevisiae consists of chromium a trace mineral which is known as glucose tolerance factor which is essential in the prevention of diabetes, lowers blood pressure and fluctuating blood sugar Zetic [6]. Production of proteins from Saccharomyces Cerevisiae (Biomass) is advantageous, because of high protein content and short growth times, leading to rapid biomass production be propagated using cheap raw materials and easily harvested due to their bigger cell sizes and flocculation abilities so it is utilized by biscuits manufacturing companies, as vitamin supplements. It is also used in pharmaceuticals and animal feeds as a source of proteins and vitamin supplements Yamada & Sgarbieri [7]. This work aims at using increased concentration of Saccharomyces Cerevisiae biomass as live cells to be added to bread dough for the formation of high protein content of bread for promoting good health. This was performed by determining the proximate chemical composition, vitamins, minerals, amino acids profile and sensory evaluation tests of bread.

Material and Method

Starter cultures

A commercial mesophilic Saccharomyces Cerevisiae starter culture obtained from (Pakmaya instant yeast, made in Turkey by Pak Gida) was used in bread manufacture as a negative control. One selected strain MY Saccharomyces Cerevisiae from my identified yeasts isolation (my previous work in protein research department- GEBRI/ SRTA- City) was used in four treatments and positive control to improve, increasing protein and amino acids content, fortification and enhances the flavor and texture of bread. MY Saccharomyces Cerevisiae was grown in YPD medium (10g/L yeast extract; 20g/L peptone; 20g/L glucose) broth at 30-35oC for 24-48h. then centrifuged on sterilized cups at 3000rpm in 25oC for 10 min to remove broth medium, then inoculated overnight in sterilized skim milk at 30 - 35oC, then re-centrifuged to get mediumfreelive cells. The viable count of Saccharomyces Cerevisiae after incubation was 6-8×104 CFU/g by Homothito meter method.

Bread Preparation by Straight-Dough Method

The straight dough method is the easiest of the dough-making methods where all the ingredients are mixed at the same time in the mixer as described by Ayele [8] with some modification. The bread was reformulated by adding a commercial Saccharomyces Cerevisiae starter culture at 5g/kg wheat flour as a negative control, and selected strain MY Saccharomyces Cerevisiae at 5g/ kg wheat flour as positive control. Several of MY Saccharomyces Cerevisiae at concentrations of 10g/kg, 15g/kg, 20g/ kg and 30g/ kg wheat flour were prepared. Wheat flour was mixed with salt (10g/kg), sugar (30g/kg), live cell of starter culture Saccharomyces Cerevisiae (divided for negative control, positive control and other treatments) and water to make dough. Proofing of the dough was done at a standard time of 50 - 60 minutes at 30-35oC as first fermentation, then divided to five parts for positive control and treatments. More addition of Saccharomyces Cerevisiae live cells at 5, 10, 15, 25g /kg dough were added then putt in stainless pans and left for another 30 minutes as a final proofing step (second fermentation).Treatment and control baked in the electric oven at 250°C for 20min., then cooled for 2h., baked breads were packed in low-density polyethylene plastic bags and stored for three days at room temperature (24 ± 2°C).These dough mixtures and bread samples were evaluated for nutritional value and sensory evaluation.

Quality attributes evaluation

Proximate chemical composition

a) Moisture content

The sample (5g) was transferred into a Petri-dish of known weight. The weighed sample was put into an oven at 105 oC until constant weight was obtained AOAC [9]. The difference between the initial and final weight of the sample was recorded as the moisture content.

b) Determination of total carbohydrate

Determination of total carbohydrate was done using the phenol-sulfuric acid method as described by DuBois [10]. The total concentration of Carbohydrate obtained from bread samples was: Total carbohydrate (%) = (carbohydrate content from calibration curve/weight of sample) x 100.

c) Determination of crude protein

Nitrogen content was determined after digestion of about 0.5g sample by micro-Kjeldahl method and the ammonia was received in 4% boric acid according to the method of AOAC [9]. The crude protein (%) was determined by multiplying the total nitrogen by factor of 6.25.

d) Determination of fat content

Crude fat content was determined after extraction of 3.5 g sample with 50 mL diethyl ether by Soxhlet extraction method. The solvent was evaporated. The residue was recorded as crude fat content according to AOAC [9].

e) Determination of Energy value: Energy value (kcal per 100 g) was estimated using the Atwater conversion factor (Osborne & Voogt [11].

Energy (kcal per 100 g) = [9 × Lipids% + 4 × Proteins% + 4 × Carbohydrates%].

f) Determination of Vitamin B complex: The vitamin B group was extracted according to a previously described method (AOAC1990) the prepared sample was injected into the HPLC system. Quantification of vitamin B content was accomplished by comparison to vitamin B standards. Standard stock solutions for Thiamine,Riboflavin, Niacin, Pyridoxine, and Cobalamin were prepared as reported previously Aslam [12] and Ringling [13] .Chromatographic separation was achieved on a reversed phase- (RP-) HPLC column(Agilent ZORBAX Eclipse Plus C18; 250 × 4.6mm i.d., 5𝜇m) through the isocratic delivery mobile phase (A/B 33/67; A: MeOH, B: 0.023M H3PO4, pH = 3.54) at a flow rate of 0.5mL/ min. Ultraviolet (UV) absorbance was recorded at 270nm at room temperature Marzougui [14] and Rokayya [15].

g) Determination and analysis of Minerals: The mineral contents were assessed by flame atomic absorption spectrophotometer (FAAS - Analytik Jena, Germany) according to AOAC Official Method 985.35 [16] then expressed in fresh weight (mg/100g).

h) Determination of Amino Acids: Amino acids have been extracted from the wheat bread according to Knežević [17]. Each of the defatted samples was weighed (200mg) in to a glass ampoule, 5ml of 6N HCl/L was added to the ampoule, and the contents were hydrolyzed in an electric oven preset at 105°C for 22h. Oxygen was expelled in the ampoule by passing nitrogen gas in to it. Amino acid analysis was done by (SYKAM S433 Amino Acids Analyzer). The analysis was carried out with a gas flow rate of 0.5ml/min at 60°C, and the reproducibility was 3%. The amino acid composition was calculated from the areas of standards obtained from the integrator and expressed as percentages of the total protein according to Trajković [18].

i) Sensory Quality Attributes: Sensorial quality was evaluated by a10-panalists, from dept. of food science to score quality attributes of bread. Samples were scored for overall visual quality by using an interval hedonic scale, where the extremes and center of the interval were represented as follows: zero (dislike extremely, no characteristic of the product), 5 (neither like nor dislike, limit of acceptance from the consumer’s point of view), and 10 (like extremely, very characteristic of the product). The tested attributes such as texture, taste, odor, color and appearance and overall acceptance were evaluated, according to Eddy [19]. The end of shelf-life was reached when the average value of the samples was judged as unacceptable for consumption by the sensory panel.

j) Statistical analysis: All results were presented as means ± standard deviation (SD). (n =3) Values were statistically analyzed by one-way analysis of variance (ANOVA test) according to Steel [20] using SPSS 22 software package. Differences were considered significant at (P values) less than 0.05 using Duncan Multiple Range test.

Results and Discussion

Nutrient Analysis

Table 1 shows the nutrient composition of bread. An increase in nutritional yeast concentration resulted in increase in the protein content of bread. Similar results were reported by Shogran [21] Udofia [22] Noorfarahzilah [23] and Masamba [24].The nutritional yeast used to fortify bread contains high quality protein which was reflected in the fortified bread. Proposed that nutritional yeast is a rich source of protein. Therefore the consumption of nutritional yeast fortified bread means exposure to higher quantity and quality protein Goesaert [25] and Gary [26]). The nutritional yeast fortified bread had a slightly higher content of carbohydrate, moisture and B complex vitamins (Thiamine B1, Riboflavine B2, Niacin B3, Pyridoxamine B6, folic acid B9 and Cyanocobalamin B12) compared to the non-fortified bread sample. These results are in agreement with Ndife [27] and Pareyt [1]. Table 1 revealed also that the fortified bread had higher content of minerals such as (Potassium, Phosphorus, Magnesium, Calcium, Iron and Zinc) compared to the non-fortified bread sample. These results are in agreement with Nwanekezi [28]. It was also noted that lipids and Sodium content were lower in fortified bread because of the addition volume of nutritional yeast. These results are in agreement with (Mashayekh [29] Sanful [30] [Table 1].

Table 1: Means of nutritional value of fortificated bread as influenced by adding three different concentrations of active Saccharomyces Cerevisiae.

Sensory Evaluation

Color and Appearance of Bread: Data in Table 2 shows people responses to the appearances of bread samples. All the bread samples were baked using white flour and the change in color was a result of incorporation of different nutritional yeast concentrations. The darker color noticed in bread samples with higher concentrations of nutritional yeast was a result of enhanced Maillard reactions [42] between reducing sugars and proteins. Vaclavik and Christian [43] described appearance of food as the size, color, structure, transparency of turbidity and degree of wholeness or damage of the product. Structure and color are important in baked goods for example bread should have white and brown color and should have many holes uniformly spread throughout otherwise a slight drift from normal will be judged as a quality defect. Most people referred the appearance of bread sample T1 since it resembled the color of brown bread available on commercial market. This shows that many consumers prefer brown bread to white bread when considering color only. Sample T3was regarded as unacceptable by the respondents due to its dark brown color which they perceived as unattractive.

Taste of Bread:b Taste was the main attribute in rating of the samples since addition of the nutritional yeast had an effect of changing the taste of the bread. Tepper and Ulrich [44] defined taste as a combination of five major tastes: salty; sweet; sour; bitter and umami. Taste is detected by taste buds at the tips, sides and back of the tongue and the sensitivity to a particular taste depends on the concentration of the substance responsible for the taste. The responses to the taste of different bread samples are shown in Table 2 the respondents liked the taste of sample T1 most largely because it had the taste of what they already perceive as normal and fresh bread taste. Samples T2 and T3 had low scores due to the cheese like taste of the nutritional yeast which was appealing to most respondents who originally prefer cheese. Bread sampleT4 was regarded as unacceptable for human consumption as a result of a bitter aftertaste experienced by the consumers.

Table 2: Means of sensory score values of bread as influenced by adding four different concentrations of active yeast.

Values are means of three determinations ± standard deviation (n = 3). Values in the same row are not statistically different (p<0.05).
(Negative Control) = Reformulated by adding a commercial Saccharomyces Cerevisiae starter culture in the range 5g / kg wheat flour
(Positive Control) = Reformulated by adding selected isolated strain MY Saccharomyces Cerevisiae in the range 5g / kg wheat flour
(Treatment 1) = Reformulated by adding selected isolated strain MY Saccharomyces Cerevisiae in the range 10g / kg wheat flour
(Treatment 2) = Reformulated by adding selected isolated strain MY Saccharomyces Cerevisiae in the range 15g /kg wheat flour
(Treatment 3) = Reformulated by adding selected isolated strain MY Saccharomyces Cerevisiae in the range 20g /kg wheat flour
(Treatment 4) = Reformulated by adding selected isolated strain MY Saccharomyces Cerevisiae in the range 30g /kg wheat flour

Flavor of Bread: Flavor is one of the major sensory properties which are decisive in acceptance and selection. Vaclavik and Christian [43] defined flavor as a combination of smell and taste which is largely subjective. Table 2 shows consumer responses to bread flavor of different nutritional yeast concentration. As the level of nutritional yeast increased, the typical flavor associated with bread decreased. The respondents accepted flavor of bread samples T1, T2 and T3 but rejected bread samples T4 as a result of strong yeast smell. Consumers are more likely to accept products that they are familiar with. Any deviation in flavor is deemed as quality defect.

Bread Texture: Texture refers to those qualities of food that can be felt with fingers, tongue, palate or teeth Murano [34]. The texture of bread samples is shown in Table 2. The respondents found the texture of samples T1, T2 and T3 as highly acceptable. Sample T4was regarded as unacceptable in terms of texture due to the high amounts of moisture in the bread samples which resulted in a lumpy crumb structure instead of an open texture.

Amino acids Analysis: The results of Table 3 the qualitative analysis showed the variability in the amino acid composition in the examined wheat genotype. For all analyzed cultivars have been identified 18 different amino acids. These results suggest that wheat flour and non-fortified bread protein is deficient in certain essential amino acids, such as lysine, tryptophan, threonine, methionine and histidine. Wheat protein is rich in glutamic acid and proline, which are the dominating non- essential amino acids. Paterson [35] also reported the deficiency of lysine, tryptophan and methionine in wheat protein; likewise Khan [36] reported that lysine is the limiting essential amino acid in wheat grain protein. In contrast fortified bread treatments showed highly increase in certain essential and non- essential amino acids. At the same time it should be noted that the lysine has been higher increase value in fortified bread treatments which is in agreement with the experience of Yalçın [37] who used a similar technique with fortified bread. According to the results of the analysis the most present amino acids in the examined wheat flour were glutamic acid, glycine, sarcosine, valine, norvaline and tryptophan. It is well known, that glutamic acid and glycine are principal amino acids in all cereal protein fractions. Likewise Sejian [38] and Knezevic [39] found that increase in the protein content of wheat grain showed differences among wheat genotypes. Considering that amino acid composition of wheat flour proteins is genetically determined, it mean that changes of amino-acid composition is possible realize through changes of backing proceed. Similar results were reported by Paterson [35] there was a significant loss of lysine when dough is baked into bread. Ahmad & Hussain [40] and Jensen [41] also reported negative relation between the protein and lysine content of wheat (Table 3).

Table 3: Means of Amino acids concentration value of wheat flour and fortificated wheat bread as influenced by adding three different concentrations of active Saccharomyces Cerevisiae as (mg/gm).

Values are means of three determinations ± standard deviation (n = 3). Values in the same row are not statistically different (p<0.05).
(Negative Control)= Reformulated by adding a commercial Saccharomyces Cerevisiae starter culture in the range 5g / kg wheat flour
(Postive Control)= Reformulated by adding selected isoleted strain MY Saccharomyces Cerevisiae in the range 5g / kg wheat flour
(Treatment 1)= Reformulated by adding selected isoleted strain MY Saccharomyces Cerevisiae in the range 10g / kg wheat flour
(Treatment 2)= Reformulated by adding selected isoleted strain MY Saccharomyces Cerevisiae in the range 15g / kg wheat flour
(Treatment 3)= Reformulated by adding selected isoleted strain MY Saccharomyces Cerevisiae in the range 20g / kg wheat flour

Conclusion

The protein content spatially essential amino acids content of the homemade bread was improved through nutritional yeast fortification. The carbohydrate, B complex vitamins and minerals content of the fortified bread were improved. The flavor and taste greatly influenced consumer acceptance of the product. Addition of artificial flavorings to mask the strong flavor of the nutritional yeast could help improve the taste and consumer acceptability of the fortified bread. For increasing of amino acid content as well composition of free essential amino acids in grain of wheat we need to increase our knowledge about mechanisms of the control grain protein accumulation at the molecular, biochemical and physiological levels. Also, for improving nutritional value are necessary to select wheat genotypes in terms of essential amino acids content and higher protein content.

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Lupine Publishers | Features of Rheumatic Disease Management while Pregnancy

 Lupine Publishers | Journal of Gynaecology and Women's Healthcare

Abstract

Rheumatism is a systemic inflammatory disease of connective tissue and joints with a predominantly affected heart. Children and young people are ill mostly: women are 3 times more likely than men. Therefore, the problem of rheumatism in pregnant women is quite common.

Keywords: Rheumatism; Pregnancy; Orthopedist

Etiology & Pathogenesis

The main etiological factor in acute forms of the disease is betahemolytic streptococcus of group A [1]. In patients with prolonged and continuously recurrent forms of rheumatic heart disease, the association of the disease with streptococcus often fails to be established. In such cases, the defeat of the heart, which fully meets all the main criteria for rheumatism, apparently has a different nature - allergic (not related to streptococcus or, in general, infectious antigens), infectious-toxic, viral. Speaking of rheumatism, it is implied that the process involves the musculoskeletal system and the cardiovascular system [2]. Given this fact, it becomes extremely clear that pregnancy with such extra genital pathology should proceed under the compulsory supervision of not only the obstetrician-gynecologist, but also the rheumatologist. According to statistical data, pregnancy itself rarely leads to the development of an unpleasant phenomenon of the future mother, such as rheumatism.

Usually, women already suffer from this ailment, only during pregnancy the disease worsens in 20% of women and causes many pregnant women to seek medical help [3]. The development of rheumatism is observed in the first months of pregnancy, when there is a weakening of immunity and the body as a whole. This indicates that the body is not able to withstand various diseases, which are mostly infectious. Births also play a significant role in the development of extra genital pathology. After all, it is well known that after giving birth, the body is significantly weakened and loses ability to fight against many diseases, including rheumatism. It takes sufficient time for the body to recover and the woman to return to her former strength. The most unpleasant thing is that if rheumatism worsens at the initial stage of pregnancy, it can lead to an interruption of the process, because any acute inflammation occurring in the body requires mandatory medical intervention and the admission of certain groups of drugs [4]. How rheumatism is manifested and how can it happen in pregnant women? Most often it is caused by beta-hemolytic streptococcus group A.

The development of the rheumatic pathological process consists of several stages:

a) a disease with sore throat, pharyngitis, scarlet fever, or other ENT infection of streptococcal nature;

b) In response to the penetration of β-hemolytic streptococcus, the immune system produces specific antibodies - the so-called “antibodies”. C-reactive proteins;

c) In the presence of a genetic predisposition to rheumatism, C-reactive proteins begin to attack their connective tissue cells (similar antigens exist on their surface, as in hemolytic streptococcus);

d) An autoimmune inflammatory process develops in the affected area - most often in the joints, myocardium, endocardium, vessels, etc. [5,6].

The provoking factors of exacerbation of rheumatism during pregnancy are [7]:

a) Hypothermia;

b) Physiological Reduction of Immunity in early Pregnancy;

c) Bacterial and Viral Infections;

d) Stress;

e) Malnutrition;

f) Exacerbation of Existing Chronic Diseases;

g) Excessive Exposure to the sun.

Speaking about the symptoms of the disease, it should be borne in mind that they are in some ways similar to those with streptococcal angina and are characterized by [8,9]:

a) general weakness;

b) the appearance of pain in the heart;

c) often minor physical exertion can provoke shortness of breath, rapid heart rate;

d) loss of appetite;

e) Joint pain, especially on days when the weather is changing noticeably; increase in temperature.

Due to the fact that during pregnancy many corticosteroid hormones are produced that have anti-inflammatory effect, the signs of exacerbation of rheumatism are blurred and not pronounced. With a heart form of rheumatism, pain in the heart is more pronounced. As a rule, the joint form is combined with the heart. It all starts with pain in the large joints. In this case, the pain passes from one group of joints to another. The cutaneous form is manifested in the appearance of characteristic pink rings on the skin, which eventually pass Rheumatism of pregnant women can lead to a condition like late toxicosis. With the exacerbation of rheumatism, there is often an acute shortage of oxygen, which can lead to placental vasculitis, changes in the placenta, intrauterine hypoxia and hypotrophy. Given the possible complications, those pregnant women who are at risk are kept under close supervision throughout the process, right up to the birth itself. If a woman has suffered several exacerbations of rheumatism, she should definitely mention this at the first visit to the doctor of a woman’s consultation. As a preventive measure, you must take care of acute infectious diseases, and if they arise, immediately go to a doctor who will prescribe an effective treatment. In addition, antirheumatic therapy is performed in pregnant women who have undergone angina or catarrh of the upper respiratory tract.

Diagnosis of rheumatism in pregnancy

Recognize and determine rheumatism in a pregnant woman can only a doctor after the examination and analysis. Diagnosing rheumatism is important in the first trimester. Because of the dangers that rheumatism causes (especially if there is heart failure and heart defects), it may be asked about the need for abortion. The diagnosis of rheumatic carditis is based on ECG (electrocardiogram), ultrasound of the heart [10]. It is necessary to consider those cases when a number of pregnant women do not suspect about the presence of rheumatism. To identify extra genital pathology, laboratory (diagnostic) studies are mandatory. Speaking about the complex of diagnostic examination, we mean the delivery of a blood test, as well as ultrasound, an echocardiogram of the heart. These indicators can give accurate information about whether a pregnant woman suffers from rheumatism or not.

Particular attention is paid to increasing the heart rate. In pregnant women suffering from a disease such as rheumatism, the heart rate has a more pronounced picture than the usual (healthy). Nevertheless, it should not be forgotten that in most cases this picture may indicate more about the development of insufficiency in pregnant blood circulation, rather than the development of rheumatism. Therefore, several methods are used to obtain more accurate and reliable information about the work of the heart. In this case, an important role in the diagnosis is played by ECG (electrocardiogram) indicators, such as: increase / flattening / broadening of the P-Q interval; serration of the tooth P; QRS complex changes; slight or, conversely, a significant decrease in the ST segment and T wave. In addition to the results of ECG and ultrasound of the heart, blood tests are used to diagnose rheumatism. Practice shows that rheumatism, especially if there is a tendency to exacerbate it, leads to an increase in ESR (sedimentation rate erythrocytes) to 35-50 mm / h. When conducting a biochemical blood test in pregnancy, the main indicators are [11]:

a) C-reactive protein;

b) Hexose;

c) Ceruloplasmin;

d) Seromucoid;

e) Hydroxyproline;

f) A2-globulin.

As for the indicator, such as fibrinogen, which is determined by the blood test, it is not given special attention, since it is always elevated in pregnant women and does not indicate an increase in rheumatism. Another issue is the identification of those pregnancy periods in which one can expect activation of the rheumatic process. Almost all authors agree that the most frequent exacerbation of rheumatism occurs in the first trimester of pregnancy. The second vulnerable period is postpartum; sometimes an exacerbation occurs at a gestational age of 28-32 weeks, so it is reasonable to conduct an anti-relapse treatment in these periods and especially in the first 3 months of pregnancy and immediately after delivery. It should be noted that the risk of exacerbation is not limited only to the postpartum period. These people may come several months after the birth, demanding special monitoring of this contingent of women for a longer time (at least, up to 6-12 months).

Many pregnant women are wondering: why should the survey be conducted at an early stage, that is, in the first months and even weeks of pregnancy? The fact is that pregnant women with rheumatism require serious treatment, especially if it is a question of exacerbating it. If the treatment is serious enough, that is, the expectant mother should take strong drugs, then the process should be suspended. That is, in this case, it will be about the termination of pregnancy. There is nothing comforting in this, of course, not, as most of the pregnant women fall into depression and understand that they do not promise birth in the near future. However, such an approach to solving the problem is most appropriate, since rheumatism has the ability to negatively affect the development and formation of the baby’s future. To avoid any consequences, doctors are advised to terminate the pregnancy, undergo a full course of treatment and only then think about re-conception of the child. Exacerbation of the rheumatic process during pregnancy, and even more so if a woman becomes pregnant with an active rheumatic process, is fraught with the possibility of a number of complications of pregnancy. Thus, according to the materials of the authors [12], with an active rheumatic process, deviations from the normal course of pregnancy are observed one and a half times more often than with the inactive and pathological births - more than twofold.

Our observations confirm these data: premature termination of pregnancy, late toxicosis, threatening fetal asphyxia, premature discharge of amniotic fluid was more frequent. Of particular note is the late toxicosis, which in patients with rheumatism often occurs atypically, at a “normal” level of arterial pressure against the background of impaired blood circulation, caused by activation of the rheumatic process. If you recognize the allergic nature of late toxicosis, you can understand why it often occurs with rheumatism. In the case if rheumatism in pregnant women is mild, that is, there is no exacerbation, and the issue of termination of pregnancy is closed. However, the future mother in any case is under the supervision of her attending physician before the birth begins. This is necessary to ensure the safety of both the pregnant woman herself and her future baby. She is recommended to undergo at least two procedures in the hospital mode for the entire period of pregnancy.

Complications

What is the risk of rheumatism in pregnancy?

In the early stages of aggravation of rheumatism can cause miscarriage or defects in the formation of the fetus. In the second and third trimester, exacerbation of rheumatism can lead to the following complications and consequences [13]: damage to the blood vessels of the placenta causes hypoxia, hypotrophy and intrauterine fetal death;.

a) Edema and pulmonary infarction; Thrombophlebitis;

b) Rheumatic carditis of the future mother becomes the cause of fetal hypoxia, which entails various violations of its intrauterine development

c) Severe fetal malformations;

d) Premature separation of amniotic fluid;

e) Threat of premature termination of pregnancy; late toxicosis (gestosis);

f) Threat of fetal asphyxia;

g) Decomposition, threatening the life of a pregnant woman.

Due to active rheumatic endocarditic, in some cases sudden death may occur during childbirth or soon after (Table 1).

Table 1: Possible complications of rheumatism during pregnancy.

Treatment

What to do in case of an exacerbation of rheumatism and how to cure it during pregnancy?

A. Treatment of pregnant women will depend on the following factors:

a) The degree of the disease;

b) Clinical form of rheumatism;

c) Individual characteristics;

d) Condition of the heart muscle, valvular heart apparatus

e) Results of the survey;

f) Presence of other diseases;

g) The course of the pregnancy process.

To treat rheumatism during pregnancy is necessary, as dangerous complications threatening the life of the future mother and her child can develop.

B. There are several important rules in treatment [14]

a) At detection of foci of infection or expressed activity of pathological processes (2nd or 3rd degree of rheumatism) antibacterial therapy is shown, including the use of drugs from the penicillin group and its synthetic derivatives.

b) In the first 10 weeks of gestation, the use of aspirin is contraindicated because of teratogenic effects. Do not take it before birth, because it has hypo coagulant properties and increases the risk of bleeding.

c) In severe toxicosis, analgin cannot be used because it can cause difficulties in removing the fluid from the body. NSAIDs are also contraindicated, and corticosteroids are resolved only after the end of the first trimester, when antirheumatic therapy does not help.

Timely begun therapy in most cases saves the life of the mother and the future baby. In the therapy of any disease, the spirit mood is important. Often, pregnant women become depressed after learning about rheumatism and its consequences. This is extremely untrue. It is necessary to assess together with the doctor all possible outcomes of the pathology and make the right choice. When there is a real threat to the baby and his mother, it makes sense to interrupt the pregnancy in order to undergo a full course of treatment and start planning a re-conception. In the absence of a significant threat, you should follow all the doctor’s recommendations and adjust to the best. This will help the body to regain strength and coupled with competent therapy to stop the progression of the disease.

C. What can the patient do?: The occurrence of the above symptoms should be alerted, you should immediately contact a therapist or rheumatologist. It is better to carry out the treatment even before the onset of pregnancy, since medications negatively affect the intrauterine development of the baby. In case of rheumatism it is advisable to be treated at least twice during the pregnancy period in a hospital. It is necessary to comply with bed rest during the exacerbation stage, to fully eat and fulfill all the prescriptions of the doctor.

D. What does the doctor do?: After examination, the doctor prescribes antibiotics, drugs with hyposensitizing and antiinflammatory action, sedatives, vitamin remedies, etc. It is also important to monitor the condition of the baby. If future mothers are late, you should visit your gynecologist regularly and listen to the fetal heartbeat.

Prevention

A. Is it possible to prevent the onset of rheumatism or its aggravation during pregnancy?

a) the risk can be minimized if one adheres to the following principles: beware of acute infectious catarrhal diseases - avoid public places during epidemics;

b) timely treatment of tonsillitis, pharyngitis, otitis, sinusitis - foci of streptococcal infection;

c) conduct hygiene of the oral cavity - treat tooth decay, periodontal disease, gingivitis, candidiasis of the oral mucosa;

d) do not overcool and do not undergo excessive sun exposure; maintain immunity;

e) Ensure that the diet contains all the necessary vitamins and microelements, the need for which is increased during pregnancy.

B. The likelihood of developing rheumatism or exacerbations during childbearing can be minimized by performing the following preventive measures [15]

a) it is necessary to beware of catarrhal diseases: avoid crowded public places during epidemics, take a complex of vitamins and minerals for pregnant women;

b) timely treatment of foci of streptococcal infection - pharyngitis, tonsillitis, sinusitis and otitis;

c) maintain oral hygiene: brush your teeth daily and treat dental diseases - dental caries, periodontal disease, candidiasis and gingivitis;

d) Do not overcool and avoid long exposure to direct sunlight.

It is necessary to eat fully, walk more, avoid overstrain of muscles, agitation and stress. It is useful to do morning exercises and go swimming. Rheumatism in most pregnant women often occurs before the onset of conception. The period of bearing of the baby aggravates its course, causing a vivid clinic of the disease. This refers to the first months when the body adapts to a new status, and the immune system weakens [16]. As a result, control of the disease is lost, and its symptoms are aggravated, which is a significant threat to the baby and his mother. To reduce the likelihood of all risks to a minimum, it is strongly recommended that you plan your pregnancy and take timely therapy for rheumatism. In this case, you can successfully take a future child and become a mother.

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