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Bilateral Stress Fracture of the Femoral Neck: A Case Report

DOI: 10.31038/IJOT.2022524

 

Stress fractures of the femoral neck (sFNF) are rare and occur mostly in athletes and military personnel or in the osteoporotic elderly. The incidence rate of sFNFs has been found to be 100/100.000 person-years in a military population, while bilateral sFNFs are much rarer and not presented by an incident rate in the literature. Available literature largely focuses on athletes and military personnel [1-13] as protentional candidate for SFNF. Prospective series show that 8% of stress fractures in competitive track and field athletes are located in the femur and 5% of stress fractures in a military population are in the femoral neck. A more recent registry study found a dominance of stress fractures in younger patients (<60 years) compared to the elderly; 5.8% versus 1.1% of all femoral neck and basocervical fractures. Fullerton described the symptoms and clinical findings in 49 military recruits with sFNFs.

87% had anterior groin pain and 19% nightly pain and was preceded by a long run or march in 40% of patients. Tenderness to inguinal palpation was present in 62% of cases and 79% had pain in extremes of hip range of motion while heel percussion very rarely elicited pain [1-14].

Early diagnosis is important to prevent progression into a displaced fracture. In a series of 19 military recruits with displaced sFNFs, 6 patients developed necrosis of the femoral head despite surgery and a total of 13 patients eventually developed osteoarthritis of the hip. Other military series describes femoral head necrosis in 23.8% of patients with a displaced sFNFs during a 28 month follow up period despite surgery [15]. Primary x-rays (antero-posterior and axial) may be inconclusive and can cause a delay in diagnosis. This was evident in a study where 90% of military recruits with an MRI-confirmed sFNF had a negative plain radiograph prior to the MRI [16]. Another military study found a sensitivity of only 37% for plain radiography in detecting pelvic or hip stress fractures [7], while MR has a sensitivity of 100%.

Case Report

This case report concerns a 55-year-old female who developed bilateral sFNF sequentially with osteopenia as the only risk factor. The patient was initially referred for an evaluation at our orthopedic outpatients clinic with complaints of right-sided deep groin pain, c-shaped pain and a feeling of the hip ”giving in” for the past 10 weeks. Recent x-ray showed no fracture. An earlier x-ray of the hip and pelvis two years prior had revealed minimal arthrosis and retroversion of the acetabulum. No valgus or varus malalignment was found. Labral injury was suspected and an MRI-arthrography was ordered but failed to visualize the labrum due to extracapsular placement of contrast fluid. Surprisingly, the scan revealed minimal callus formation at the right femoral neck as a sign of a healed fracture. Due to already being healed, the right-sided sFNF was treated conservatively. The patient was admitted to the emergency department 2½ years later with identical symptoms now arising from her left hip. Plain radiographs and CT-scan of pelvis and the hip showed no fracture. MR revealed an incomplete tension-sided fissure in the femoral neck involving less than 50% of femoral neck width. The patient was in pain and signs of healing were absent on the MRI. The left sFNF was therefore treated surgically, to prevent further displacement.

The patient was postmenopausal and had a family history with disposition to osteoporosis. BMI was 28,4. Prior to the first orthopedic evaluation, 2.5 years earlier, a DEXA-scan showed osteopenia with a T-score of the spine of -2,0 and the hips of -1,9/-1,7. The patient described a normal diet with supplemental calcium and magnesium tablets but had not previously received pharmacological treatment for osteopenia. She had ceased smoking several years prior and rarely consumed alcohol. Because of the right sided sFNF, she was examined thoroughly by an endocrinologist. Blood tests showed normal levels of vitamin D and calcium and no disturbance in kidney function or thyroid and parathyroid. Indicators of auto-immune disease or myelomatosis were normal. She had a slightly elevated ALAT which was deemed unrelated. By advice from the endocrinologist the patient started yearly zoledronic acid treatment.

Between the two hip fractures, she was diagnosed with a stress fracture of the left 2nd metatarsal and low-energy fractures of a single rib and a right-sided distal radius fracture. All were treated conservatively. The right sFFN was treated conservatively because of the late clinical diagnosis.16 weeks after onset of symptoms, the patient was painless and ambulatory. She was advised against sports for another four months. The left sFFN was, on the contrary, surgically treated with 3 parallel screws on the day of admittance to the emergency department and she was allowed full weight-bearing postoperatively. The patient felt an immediate reduction in pain after surgery. After two months the patient still had a pain rating of NRS 3-4 during physical therapy but was able to walk 5 kilometers. Walking distance increased with physical therapy and she was free of pain and started jogging 6 months postoperatively (Figures 1 and 2).

fig 1

Figure 1: MRI of the right hip showing a stress fracture of the femoral neck with callus formation on the medial side. The fracture line is incomplete, and it is visible on the medial side and does not extend to the opposite cortex. A: T1 weighted TSE sequence B: T1 weighted TIRM sequence.

fig 2

Figure 2: Left hip MRI showing bone edema in the medial distal collum femoris. A: Coronal T1 weighted MRI with low signal in the affected area. B: Coronal STIR MRI with high signal. A small fissure is visible and interpreted as an incomplete fracture line.

Discussion

Treatment of undisplaced sFNFs is debated, and surgeons must weigh the risks and benefits of conservative treatment versus surgery. Conservative treatment requires a period of reduced activity and carries a risk of displacement. In a Swedish registry study on undisplaced or minimally displaced sFNF and basocervical fractures, 3 og 17 patients that were treated non-operatively would later require internal fixation due to fracture displacement. Another 3 patients received late surgical treatment for persistent pain or femoral head necrosis, which in total corresponds to 35% of patients treated surgically following a choice of primary non-operative treatment. This was higher than the overall rate of reoperation or late surgery of 28% and higher than the reoperation rate of 10% for the patients primarily treated with internal fixation for displaced or undisplaced fractures.

Osteosynthesis seems effective in preventing secondary displacement and allows for early weight bearing but carries a risk of surgical complications. Removal of implants at a second operation due to pain occurs as often as 14% in sFNFs (both displaced and undisplaced). Surgical site infection (SSI) is also a concern. Although incidence of SSI is difficult to estimate in sFNFs, extrapolation from studies including traumatic femoral neck fractures may provide an indication of the frequency of infection in stress fractures. In patients below 60 years of age with all-cause femoral neck fractures, the risk of surgical site infection in retrospective studies is 5.1% [17]. Incidence rates in traumatic versus stress fractures may differ due to differences in surrounding tissue damage from trauma and differences in patient characteristics. Furthermore, risk of avascular necrosis and non-union is not completely eliminated with internal fixation and fixation failure can occur [18]. Two relatively large retrospective MRI studies have identified prognostic fracture characteristics that may help guide the surgeon in choice of treatment.

Quinquilla et al. [19] reviewed 156 cases of sFNF in a military population and divided fractures into 4 grades based on MRI. Grades I and II had bone marrow edema of less or more than 6mm but no fracture line. Grades III and IV had fracture lines of less or more than 50% of neck width on coronal MRI. Conservative treatment of sFNFs of grades I, II and III did not result in displacement or even progression to a higher fracture grade. 3 of 21 patients with a fracture line of >50% of neck width (grade IV) were treated conservatively while the remaining 18 had surgical fixation.

There was no report of displacement in the conservatively treated fractures indicating this treatment option is viable in the military population.

Steele et al. [20] retrospectively reviewed 305 cases of sFNFs in a military population. In this cohort, patients were treated non-operatively with toe-touch-weight bearing with crutches if they had bone marrow edema or a fracture line <50% of femoral neck width on MRI and surgically if they had a fracture line of >50% of the femoral neck width. On subsequent progression on MRI at 6 weeks follow-up, conservatively treated patients would require surgery. A total of 75 (24.6%) patients required surgery and of these patients 48 had primary operations and 27 after the MRI at 6 weeks follow up. No patients who initially had edema without fracture line would later need surgery per protocol. Out of those patients with a fracture line <50% of femoral neck width, 27 of 103 (26%) progressed on follow-up MRI and were treated surgically secondarily. Effusion on primary MRI was correlated with later progression with a relative risk of 8.02 (CI 2.99-21.5; p<0.0001) and in these patients, surgery should strongly be considered. No patients with an undisplaced sFNF progressed to displacement.

In the case presented here, surgical treatment was chosen for the left side even though the fracture line was <50% of femoral neck width. Despite the retrospective studies by Steele and Quinquilla suggest similar fractures are able to heal without surgery, 26% would require surgery due to progression on follow-up MRI. Furthermore, extrapolating from young military recruits to a postmenopausal woman with repeated stress fractures is uncertain and avoiding displacement is crucial. Surgery was performed to allow immediate weight-bearing and to prevent dislocation.

Conclusion

This is a rare case of bilateral sFNFs in a middle-aged woman with and osteopenia as the only risk factor. Stress fractures of the femoral neck may have an insidious onset of symptoms and absence of trauma and the primary x-ray is often negative while MRI is gold standard. Treatment can be conservative or surgical depending on fracture pattern and patient characteristics.

References

  1. Egol KA, Koval KJ, Kummer F, Frankel VH (1998) Stress Fractures of the Femoral Neck. Clinical Orthipaedics and Related Research 348: 72-78. [crossref]
  2. Niva MH, Kiuru MJ, Haataja R, Pihlajamäki HK (2005) Fatigue injuries of the femur. Journal of Bone and Joint Surgery – Series B 87: 1385-1390. [crossref]
  3. Sundkvist J, Möller M, Rogmark C, Wolf O, Mukka S (2022) Stress fractures of the femoral neck in adults: an observational study on epidemiology, treatment, and reoperations from the Swedish Fracture Register. Acta Orthop 93: 413-416. [crossref]
  4. Kuhn KM, Riccio AI, Saldua NS, Cassidy J (2010) Acetabular retroversion in military recruits with femoral neck stress fractures. Clin Orthop Relat Res 468: 846-851. [crossref]
  5. Snyder RA, Koester MC, Dunn WR (2006) Epidemiology of stress fractures. Clin Sports Med 25: 37-52. [crossref]
  6. Pihlajamaki H, Ruohola J, Kiuru M, Visuri T (2006) Fractures in Military Recruits. J Bone Joint Surg Am 88: 1989-1997.
  7. Kiuru MJ, Pihlajamaki HK, Ahovuo JA (2003) Fatigue stress injuries of the pelvic bones and proximal femur: Evaluation with MR imaging. Eur Radiol 13: 605-611.
  8. Kiuru MJ, Pihlajamaki HK, Hietanen HJ, Ahovuo JA (2002) MR imaging, bone scintigraphy, and radiography in bone stress injuries of the pelvis and the lower extremity. Acta Radiol 43: 207-212.
  9. Pihlajamäki HK, Ruohola JP, Weckström M, Kiuru MJ, Visuri TI (2006) Long-term outcome of undisplaced fatigue fractures of the femoral neck in young male adults. Journal of Bone and Joint Surgery – Series B 88: 1574-1579. [crossref]
  10. Fullerton LRJ, Snowdy HA (1988) Femoral Neck Stress Fractures. Am J Sports Med 16(4). [crossref]
  11. May LA, Chen DC, Bui-Mansfield LT, O’Brien SD (2017) Rapid magnetic resonance imaging evaluation of femoral neck stress fractures in a U.S. active duty military population. Mil Med 182: e1619-e1625. [crossref]
  12. Matheson GO, Clement DB, Mckenzie DC, Taunton JE, Lloyd-Smith DR, et al (1987) Stress fractures in athletes: A study of 320 cases. Am J Sports Med 15: 46-58. [crossref]
  13. Neubauer T, Brand J, Lidder S, Krawany M (2016) Stress fractures of the femoral neck in runners: a review. Research in Sports Medicine 24: 185-199. [crossref]
  14. Bennell KL, Malcolm SA, Thomas SA, Wark JD, Brukner PD (1996) The incidence and distribution of stress fractures in competitive track and field athletes: A twelve-month prospective study. American Journal of Sports Medicine 24: 211-217.
  15. Lee CH, Huang GS, Chao KH, Jean JL, Wu SS (2003) Surgical treatment of displaced stress fractures of the femoral neck in military recruits: A report of 42 case. Arch Orthop Trauma Surg 123: 527-533. [crossref]
  16. May LA, Chen DC, Bui-Mansfield LT, O’Brien SD (2017) Rapid magnetic resonance imaging evaluation of femoral neck stress fractures in a U.S. active duty military population. Mil Med 182: e1619-e1625. [crossref]
  17. Slobogean GP, Sprague SA, Scott T, Bhandari M (2015) Complications following young femoral neck Injury 46: 484-491. [crossref]
  18. Sundkvist J, Möller M, Rogmark C, Wolf O, Mukka S (2022) Stress fractures of the femoral neck in adults: an observational study on epidemiology, treatment, and reoperations from the Swedish Fracture Register. Acta Orthop 93: 413-416. [crossref]
  19. Rohena-Quinquilla IR, Rohena-Quinquilla FJ, Scully WF, Evanson JRL (2018) Femoral neck stress injuries: Analysis of 156 cases in a U.S. military population and proposal of a new mri classification system. American Journal of Roentgenology 210: 601-607. [crossref]
  20. Steele CE, Cochran G, Renninger C, Deafenbaugh B, Kuhn KM (2018) Femoral neck stress fractures: MRI risk factors for progression. Journal of Bone and Joint Surgery – American Volume 100: 1496-1502. [crossref]

Forgotten Right Ventricle Entity: In PASC Patients

DOI: 10.31038/JCCP.2022523

 

World has just passed through the global pandemic of COVID-19 disease with recent reports of it resurfacing in China. Although being a disease predominantly affecting lungs the involvements of other organs like heart, brain and gut have also been seen in the acute phase. PASC (post acute SARS COVID-19) is a distinct phase of the disease seen amongst survivors from both mild and severe disease where the patients continue to suffer from symptoms of palpitations, dysnoea on exertion, chest pain and fatigue. Few studies have been done in such patients to assess ongoing cardiac involvement. Most of these patients show normal left and right ventricle Ejection fraction, normal troponin levels with non specific EKG findings of sinus tachycardia. Some of these patients are made to undergo cardiac MR to rule out COVID-19 myocarditis. Here also most of the imaging specialists and the cardiologists are focused on the left ventricle only and look for the Lake Loius criteria to establish or rule out diagnosis.

In a study by Lan et al. [1] it was shown that the right ventricle was commonly involved in COVID-19 disease and the reasons attributable were due to proximity of right ventricle with pulmonary circulation, increased after load of right ventricle due to COVID-19 lung complications, increased surface area of right ventricle free wall and direct involvement of right ventricle wall by the virus. Similarly studies by Li et al. [2] and Lee et al. [3] also showed the prognostic value of myocardial strain in COVID-19 disease and altered right ventricular strain in acute COVID-19 carried a poor prognosis. In the PASC phase the etiology of myocarditis remains elusive as is the challenge of establishing the diagnosis. Studies done by Puntmann et al. [4], Huang et al. [5] have shown the use of CMR with multiparametric mapping to diagnosis myocarditis in PASC patients. Yet in all these studies the findings for a positive diagnosis were elicited by showing changes in the left ventricle myocardium only with most of the patients showing normal Left and right ventricle size and function. Hence this entity of “forgotten right ventricle in PASC”. In a follow up study done in athletes who recovered from COVID-19 disease. Wassener et al. [6] showed strain abnormalities of left ventricle only and were silent about the changes in right ventricle even though prior studies demonstrated the common involvement of right ventricle. Only a recent study done by the author Kapoor et al. [7] where multiparametric CMR was done along with feature tracking for both left and right ventricle has shown that there is equal and severe involvement of right ventricle wall with diffuse increased signal changes on T2 maps even on the follow up of recovered COVID-19 patients. Their study showed 9.9% and 6% reduction of  systolic global circumferential shortening and 61.8% and 46.5% reduction early diastolic strain rate of the left and right ventricle respectively. They showed that the use of the above technique was valuable in not only diagnosing the condition but also staging the extent of disease which could impact the management of these patients. So in PASC patients it’s pertinent to have a detailed right ventricle evaluation and not to be taken by the forgotten right ventricle entity. Unfortunately not much emphasis is being given to the detailed right ventricle assessment apart from its size and wall motion abnormalities.

In conclusion the forgotten right ventricle entity in PASC not only eludes the patient of a diagnosis of ongoing myocarditis but also can have a long term bearing on the prognosis as these patients may finally end up in cardiomyopathy of the right ventricle. It would be therefore prudent to evaluate these patients using multiparametric cardiac MR techniques with myocardial strain evaluation rather than stopping at routine echocardiograms alone. All patients who have severe impairments need to be followed up for any progression of disease.

References

  1. Lan Y, Liu W, Zhou Y (2021) Right ventricle Damage in Covid-19: Association between Myocardial Injury and Covid-19. Frontiers in Cardiovascular Medicine 8: 606318. [crossref]
  2. Li Y, Li H, Zhu S, Xie Y, Wang B, et al. (2020) Prognostic value of right ventricular longitudinal strain in patients with COVID-19. JACC: Cardiovasc Imaging 13: 2287-2299. [crossref]
  3. Lee JW, Jeong YJ, Lee G, Lee NK, Lee HW, et al. (2017) Predictive Value of Cardiac Magnetic Reso-nance Imaging-Derived Myocardial Strain for Poor Outcomes in Patients with Acute Myocarditis. Korean J Radiol 18: 643-654. [crossref]
  4. Puntmann VO, Martin S, Shchendrygina A, Hoffmann J, Ka MM, et al. (2022) Long-term cardiac pathology in individuals with mild initial COVID-19 illness. Nature Medicine 28: 2117-2123.
  5. Huang L, Zhao P, Tang D, Zhu T, Han R, et al. (2020) Cardiac involvement in patients recovered from COVID-2019 identified using magnetic resonance imaging. JACC Cardiovasc Imaging 13: 2330-2339.
  6. Wassenaar JW, Clark DE, Dixon D, Durrett KG, Parikh A, et al. (2022) Reduced Circumferential Strain in Athletes with Prior COVID-19 Infection. Radiology: Cardiothoracic Imaging 4: e 210310.
  7. Kapoor A, Kapur A. Myocardial strain abnormalities in patients with long Covid after mild to moderate Covid-19 disease. Journal of Cardiology and Cardiovascular Research.

Crimean-Congo Hemorrhagic Fever: An Endemic Sporadic Zoonotic Viral Infection in Uganda

DOI: 10.31038/MIP.2022315

Abstract

Crimean-Congo Hemorrhagic Fever is an Arboviral zoonosis responsible for sporadic outbreaks of hemorrhagic fever in endemic areas. The control of CCHFV calls for multidisciplinary approach involving partners like WHO and OIE. Mmultidisciplinary research will allow better understanding of the epidemiology of CCHF in ticks, domestic livestock and wild animal populations, and will support the identification of human risk factors for infection and the development of better diagnostics, antiviral drugs and vaccines. Also, the identification of an animal model for testing would facilitate any further research, and allow studying host response to infection and evaluating intervention and control strategies. Finally, the role of environmental change, including climate change, needs further assessment. Support CCHF surveillance, diagnostic capacity and outbreak response activities. Reduce infection in people by raising awareness of the risk factors and educating people about the measures they can take to reduce exposure to the virus.

Keywords

Crimean-Congo hemorrhagic fever, CCHFV, Zoonosis, Seroprevalence, ELISA, Ixodid ticks, Uganda

Background and Aim

Crimean-Congo hemorrhagic fever (CCHF) is a tick-borne viral zoonotic disease caused by Crimean Congo hemorrhagic fever virus (CCHFV), a member of the genus Nairovirus in the family Bunyaviridae and order Bunyavirales. CCHF is typically asymptomatic in animals but can be highly fatal in humans approaching case fatality rate of approximately 30%. The disease is distributed in many countries of Asia, Africa, the Middle East and south-eastern Europe. As the distribution of CCHFV coincides with the distribution of its main vector, Ixodid (hard) ticks of the genus Hyalomma, both a reservoir and a vector for the CCHF virus; the spread of infected ticks into new, unaffected areas facilitates the spread of the virus. Numerous wild and domestic animals, such as cattle, goats, sheep and hares, serve as amplifying hosts for the virus. Transmission to humans occurs through contact with infected ticks or animal blood. CCHF can be transmitted from one infected human to another by contact with infectious blood or body fluids. Documented spread of CCHF has also occurred in hospitals due to improper sterilization of medical equipment, reuse of injection needles, and contamination of medical supplies. Occupational groups with an elevated risk of Crimean Congo hemorrhagic fever include farmers, shepherds, veterinarians, abattoir workers, healthcare personnel and laboratory workers, as well as anyone at elevated risk of exposure to ticks. Seasonality can result from seasonal changes in tick numbers or increased human exposure to slaughtered livestock. The case fatality rate is thought to be approximately 5-30% in most instances, although rates as high as 80% have been reported occasionally in limited outbreaks. Factors such as the availability and quality of healthcare, virus dose, route of exposure, coinfections, and possibly the viral strain, are thought to influence mortality.

A person with CCHF can have the following signs & symptoms: Sudden on-set of high fever, Headache, Back pain, Joint pain, Abdominal pain, Dizziness (feeling that you are losing your balance and about to fall), Neck pain and stiffness. The person who has been in contact with a person who has similar symptoms or animals infested with ticks, or has had a tick bite. In addition, the person can also have any of the following: Nausea, Vomiting, Diarrhoea, Sore throat, Sharp mood swings, Confusion, Bleeding, bruising or a rash After 2 or 4 days, the patient may experience sleeplessness and depression. Following a bite from an infected tick, the infection can establish in the animal with brief illness. The Crimean Congo Hemorrhagic Fever virus can then be passed on to the tick which can in turn pass the virus to human or other animals [1-5].

Uganda is divided into ten agroecological zones: Southern highlands, Southern dry lands, Lake Victoria crescent, Eastern, Mid-Northern, Lake Albert crescent, West Nile, Western highlands, South East, and Karamoja drylands. Mid-Northern: Flat terrain covered by thick Savannah grassland. Lira, Apac, Kitgum, Gulu, Pader districts. Agriculture remains the major source of livelihood in Uganda. According to the Uganda National Household Survey (UNHS) 2016/17, the bigger proportion of the working population is engaged in agriculture, forestry and fishing (65%). Among the females in the working population, 70% are engaged in agriculture compared to 58% of the males. Furthermore, 38% of persons in employment were in paid employment with a higher proportion of males (46%) compared to females (28%). The Agricultural sector accounted for the largest share of employment (36%).The agriculture sector had a total contribution to GDP at current prices of 24.9 percent in the FY 2016/17 compared to 23.7 percent in FY 2015/16. This indicated that the population at risk of CCHFV in Uganda is large.

Materials and Methods

CCHFV is thought to infect animals with few or no clinical signs. No illnesses have been attributed to this virus in naturally infected animals. However, the disease is zoonotic. Serum samples are collected from susceptible animals. The host range includes: human, domestic and wild animals. Sera samples are tested for the presence of CCHFV-specific immunoglobulin G (IgG) antibodies using enzyme-linked immunosorbent assay (ELISA), virus isolation or detecting its nucleic acids and antigens in blood samples or tissues. Urine, saliva and other secretions and excretions may also contain nucleic acids, but the suitability of these samples for diagnosis has not been fully investigated. At autopsy, CCHFV can be found in a variety of tissues, such as liver, spleen, lung, bone marrow, kidney and brain. Clinical cases are often diagnosed with a combination of reverse transcription-polymerase chain reaction (RT-PCR) tests and serology. CCHFV strains are highly variable, and many RT-PCR tests only recognize local variants or a subset of viruses. However, tests that can detect most or all known variants, including the highly divergent AP92 strain, have also been developed. Other published assays to detect nucleic acids include microarray and macroarray-based techniques and loop-mediated isothermal amplification. In fatal cases, viral RNA tends to increase as the disease progresses. Immunohistochemistry can be used on tissues collected at autopsy. Animal inoculation into newborn or immunodeficient mice is more sensitive than cell culture, and has been used occasionally in clinical cases, though it is generally discouraged if there are alternatives. Either specific IgM or rising titers should be seen. Virus neutralization is rarely employed, due to the hazards of handling live CCHFV. Treatment is mainly supportive. Seriously ill patients require intensive care. The antiviral drug ribavirin has been used to treat CCHF infection with apparent benefit. Both oral and intravenous formulations seem to be effective.

There are no vaccines available for use in animals. Although an inactivated, mouse brain-derived vaccine against CCHF has been developed and used on a small scale in eastern Europe, there is currently no safe and effective vaccine widely available for human use. Tests on patient samples present an extreme biohazard risk and should only be conducted under maximum biological containment conditions. However, if samples have been inactivated (e.g. with virucides, gamma rays, formaldehyde, heat, etc.), they can be manipulated in a basic biosafety environment. Patients with fatal disease, as well as in patients in the first few days of illness, do not usually develop a measurable antibody response and so diagnosis in these individuals is achieved by virus or RNA detection in blood or tissue samples.

Results

A study by Nurettin et al. (2022) screened domestic animals for IgG prevalence, and compared their results with those for wild animals (14.01% vs. 9.84%, respectively) indicating that wild animals and livestock are equally important for circulating the CCHF virus in endemic areas such as seen in Turkiye. Mirembe et al. (2021), identified 14 confirmed cases (64% males) with five deaths (case-fatality rate: 36%) from 11 districts in western and central region Uganda. Of these, eight (73%) case-patients resided in Uganda’s ‘cattle corridor’. Atim et al. (2022), detected CCHFV seropositivity of 221/800 (27·6%) in humans, 612/666 (91·8%) in cattle, 413/549 (75·2%) in goats and 18/32 (56·2%) in dogs. Human seropositivity was associated with livestock farming and collecting/eating engorged ticks. In animals, seropositivity was higher in cattle versus goats, CCHFV was identified in multiple tick pools of Rhipicephalus appendiculatus. A cross sectional study was conducted to determine the prevalence of CCHF and to identify the potential risk factors associated with CCHFV seropositivity among the one-humped camel (Camelus dromedaries) in Central Sudan. A total of 361 camels selected randomly from six localities were employed in the study. Sera sampled were tested for the presence of CCHFV-specific immunoglobulin G (IgG) antibodies using enzyme-linked immunosorbent assay (ELISA). CCHFV seropositivity was recorded in 77 out of 361 animals accounting for a prevalence rate of 21.3%. The prevalence of CCHF is significantly high among camels in Khartoum State, Sudan. Age, breed, locality and tick control are considered as potential risk factors for contracting CCHF (Suliman et al., 2017). This study aimed at providing knowledge and awareness about the disease to reduce the impact on the livelihood of pastoral communities and ultimately avoid disease spread in human.

Crimean-Congo haemorrhagic fever (CCHF) is the most widespread, tick-borne viral disease affecting humans (Al-Abri et al., 2017).

References

  1. Al-Abri SS, Abaidani IA, Fazlalipour M, Mostafavi E, Leblebicioglu H, et al. (2017).Current status of Crimean-Congo haemorrhagic fever in the World Health Organization Eastern Mediterranean Region: issues, challenges, and future directions. International Journal of Infectious Diseases 58: 82-89. [crossref]
  2. Atim AS, Ashraf S, Belij-Rammerstorfer S, Ademun AR, Vudriko P, Nakayiki T, Niebel M, Tweyongyere Risk factors for Crimean-Congo Haemorrhagic Fever (CCHF) virus exposure in farming communities in Uganda. Journal of Infection (In-Press).
  3. Consultation on Crimean-Congo haemorragic fever prevention and control Stockholm, September 2008; ecdc.europa.eu
  4. Mirembe BB, Musewa A, Kadobera D, Kisaakye E, Birungi D, Eurien D, et al. (2021) Sporadic outbreaks of crimean-congo haemorrhagic fever in Uganda. PLoS Negl Trop Dis 15(3). [crossref]
  5. Nurettin C, Engin B, Sukru T, Munir A, Zati V, Aykut O.(2022). The Seroprevalence of Crimean-Congo Hemorrhagic Fever in Wild and Domestic Animals: An Epidemiological Update for Domestic Animals and First Seroevidence in Wild Animals from Turkiye. Vet Sci 9: 462 World Health Organization. Crimean-Congo haemorrhagic fever. [crossref]
  6. Suliman HM, Adam IA, Saeed SI, Abdelaziz SA, Haroun EM, et al. (2017) Crimean Congo hemorrhagic fever among the one-humped camel (Camelus dromedaries) in Central Sudan. Virology Journal 14: 147.
  7. World Health Organization. Crimean-Congo haemorrhagic fever.
fig 1

Spatial Patterning of Artefacts Using Variable Hierarchical Clustering and Bivariate Spatial Autocorrelation: A Case Study in Williston Reservoir, British Columbia

DOI: 10.31038/GEMS.2022435

Abstract

Artefacts in the Williston Reservoir, British Columbia were collected and recorded by an archaeological firm over several years. While a large and extensive dataset of the locations of these artefacts was built up, several challenges to management and interpretation of the use of the landscape are presented. This study used the Variable Clumping Method (VCM) hierarchical clustering technique to detect clusters of artefacts for each object type. These detected clusters were then used for an object-type spatial correlation analysis, using Multivariate Local Indicators of Spatial Association (LISA). The results from LISA analysis included detection of significant global and local associations between several object-type pairs. For instance, strong spatial correlation was found between Scrapers and Points, which may suggest significant use areas, such as regularly used butchering sites or campsites. While it is not possible to draw a definitive conclusion of exactly what these relationships mean in terms of landscape use, they suggest a number of interesting hypotheses of possible uses of the area in the ancient time.

Keywords

Artefacts, Archaeological materials, Hierarchical clustering, Variable clumping method, LISA

Introduction

Archaeological data is intrinsically spatial in nature, and spatial analysis can often play a key role in interpreting the distribution of archaeological materials across a landscape. This approach is particularly useful in a situation where the artefacts are scattered across the site without stratigraphic relationships or known features to provide the context. In particular, spatial patterning among the artefacts and the behavioural interpretation across the site require rigorous intrasite spatial analysis and modelling so as to deduce the kind of activities that occurred at the site [1]. A range of intrasite spatial analytical techniques have been applied to date [2], but the treatment of the spatial patterns of the artefacts and other entities occasionally presents challenges at the point of interpretation as their spatial tendency is not always correctly recognised [3]. This is mainly due to the direct application of either (1) a non-spatial statistical approach whereby all observations are treated as spatially independent in nature and that spatial randomness is warranted as the base distribution behind the spatial arrangement of the artefacts, or (2) a spatial statistical approach with the understanding that spatial dependency exists among the intrasite spatial configuration of the artefacts but the spatial patterning is often sought with respect to a predetermined set of scales informed by the specific context of the site—in other words, the spatial statistical methods are usually applied with parameters set a priori, despite that contexts may not be always available. The spatial arrangement of the artefacts found or excavated at a site is likely to have spatial dependency among them, and the scale of activities (e.g. an individual engaging in a house task, or a community taking part in a social activity) will likely vary between the types of activities and the participants involved which are difficult to calibrate without stratigraphic narratives or known features that offer the context. The objective of this study is to identify spatial associations between different types of archaeological artefacts found across an excavation site and gain knowledge on the spatial configuration and the lifestyle of the ancient community that lived in this area. To overcome the challenges stated above, this study uses two types of spatial analytical methods that can extract the hierarchical spatial structure: (1) a local variant of a spatial autocorrelation method called Multivariate Local Indicators of Spatial Association (LISA) [4], and (2) a hierarchical cluster detection method called Variable Clumping Method (VCM) [5,6]. Clustering helps to simplify a large archaeological dataset to make spatial patterns easier to discern; but they need to be arranged at suitable scales with the recognition of the multi-scale across different levels of activities. Finding clusters in the distribution of the artefacts across multiple scales would provide more natural groupings for use in the subsequent analysis. Exploration of the spatial relationships between different types of artefacts through LISA could provide us with a clue to infer activities that took place in an ancient time and could greatly enhance our understanding on how the landscape was used at the time. The study focuses on artefacts retrieved from Williston Reservoir, British Columbia, Canada.

Literature Review

Spatial Analysis in Archaeology

Spatial analysis and GIS have been used in archaeology for years, as evidenced in a study by Kintigh and Ammerman (1982) [7] which highlights the usefulness of computer-based analysis, informed by expert interpretation, for identifying meaningful patterns in archaeological data. According to Carr (1984) [1], there are two levels of archaeological spatial analysis: inferential and operational. The goals of inferential analysis are to spatially delineate the activity areas as well as to identify the tool kits of artefact types. At the operational level, the focus is placed on identifying patterns in the spatial arrangement of different artefact types, including clustering, and relationships between different artefact types. In many cases, applying inferential analysis may not be suitable. Even where the spatial relationships between artefact types can be identified, Carr (1984) [1] cautions that these do not imply an activity area and that there may be a number of other possible explanations for the observed patterns. Dynamic processes, including human activities, occurring in both space and time, have contributed to the superimposition of materials to produce static patterns [8]. For instance, artefacts may have been found clustered due to intense human activity in that location in the past, but Wood and Johnson (1978) suggest it could also result from natural processes such as water transport and sorting, or recent human activity such as farming. Deriving the nature of these processes from the static patterns can therefore be extremely difficult. Nevertheless, spatial analysis has proven as an important step to understand the nature of the archaeological deposits. A number of methods for detecting patterns in the spatial distribution of archaeological deposits have been proposed in the past and applied by a number of studies [3]. For instance, Kintigh and Ammerman (1982) [7] used the k-means cluster detection technique to iteratively split and lump points in the dataset into a user-defined maximum number of clusters and, thereby, minimise the sum of the squares of the distances between each point and its cluster centre to find the optimal solution. More generally, Carr (1984) [1] refers to a number of methods used in intrasite archaeological contexts for determining presence of clustering as well as delimiting clusters in a point dataset. These include the Nearest Neighbour Analysis [9] used for determining presence of clustering; Whallon’s Radius Approach [10] for delimiting clusters using the frequency distribution of nearest neighbour distances between point observations; and conditional spatial patterning, a multi-scale method to test for spatial patterning in an archaeological dataset [8].Other applications of these methods vary in location, site type and the scale. For instance, in a cave site in Western Belize, artefacts scattered on different surfaces, including in niches and on ledges, were mapped and recorded in a GIS to analyse the spatial arrangement of the archaeological objects [11]. They adopted a clustering method, as some artefacts were found in multiple fragments in close proximity to one another and that the uses the individual object locations for analysis would have resulted in unequal weighting. A non-hierarchical method, k-means, was used to define natural groupings of objects in space, and the resultant clusters were analysed with regard to their association with cave features. Moyes’ (2002) [11] findings suggest that clustering and comparative analysis of the morphologic cave features could provide the context and the relative analytical units for use on a broader scale.

The examples above, however, are situations where the sites and the archaeological context are well defined. Many of these methods primarily deal with “more or less intact living surfaces” [12] that may not be applicable to other archaeological situations that lack an intact or a clear definition of the site. An example of such a situation is found in Australia; similar to the Williston Reservoir case, where the archaeology consists of open sites [13]. These open sites are extensive in area size, lack stratigraphy or clear boundaries, and contain few features [13]. In essence, it is a vast expanse of a surface scattered with primarily lithic artefacts. Site boundaries are difficult to determine in this type of landscape and, for the management purposes, arbitrary rules are often used to define boundaries that are not meaningful for analysis [13]. In these situations, a site-less analysis is required; i.e. the analysis is based on individual artefacts rather than sites [13]. As a result, the first step with open sites is to identify patterns in the spatial location of artefacts; after which, attempts can be made to interpret the patterns archaeologically. Holdaway et al. (1998) [13] address these concerns through geomorphological mapping of the landscape used for understanding the patterns of surface artefact density. This step determined that the depositional surfaces had lower artefact densities, which were excluded from the subsequent analysis to avoid bias in case undiscovered artefacts were buried under the sediments. Different buffer radii were used to look at different scales, and the resultant cluster patterns of individual artefact types were then used to identify assemblages and patterns between artefact types [13]. Other studies have also explored different methods for determining the associations between artefact types. These include a variety of statistical tests based on the number of artefact in partitioned units to determine patterns of aggregation and segregation between different artefact classes [14]. In this case, the definition of the unit shape and size may impact the results of the analysis. This is known as Modifiable Areal Unit Problem (MAUP) in spatial analysis [15,16]. Hietala and Stevens (1977) [14] therefore suggest changing the partition size to determine patterns for multiple partition options. Berry et al. (1980) [17] suggest the permutation test, which can use either grid-count values or point locations, and so can avoid the problems associated with defining a grid unit size. The permutation test uses as its test statistic the “average within-class distance” (Berry et al., 1980, p. 56) [17], and thus can test for significant associations between multiple classes. These methods detect global associations between artefact classes; i.e. they assess the overall density or the tendency of clustered-ness across the study area. However, as Premo (2004) [18] points out, being able to quantify the local spatial patterns (which enables us to identify the location, the extent and the intensity of each individual cluster) is important for the understanding and interpretation of archaeological material distributions. Methods for local spatial pattern detection used by Premo (2004) [18] include local Moran’s I and local G statistics, mainly for the purpose of detecting local spatial autocorrelation. These local statistics have a great potential for multiple archaeological applications, including that of multivariate analysis for identifying the association between artefact types or material types Premo (2004) [18].

Hierarchical Clustering Methods in Spatial Analysis

With the development of data collection technology such as Global Positioning Systems (GPS), remote sensing, and vast amount of spatial data is becoming increasingly available. Yet their interpretation is not always straightforward, and dealing with the data to extract meaningful information can be difficult at times. Exploratory spatial data analysis (ESDA) offers an important first step for deriving information from large spatial datasets [19]. Cluster analysis is a spatial extension of ESDA used across a broad range of disciplines, including crime analysis, disease analysis, and archaeology [6,7,20]. Cluster detection techniques for point datasets include techniques that simply determine the presence of clustering, such as nearest neighbour indices [21], as well as techniques that identify the individual points within a cluster [6]. Early clustering techniques include the Geographical Analysis Machine [22] for identifying hot spots or areas of high intensity; while more recent techniques are designed to identify which points belong to a particular cluster—some of these techniques can be classified further into partitioning, hierarchical, and graph-based techniques [21,23]. Partitioning methods, such as k-means, group all points in the dataset into a user-defined number of groups [21]. In addition to the disadvantage of having to specify a number of groups, which can lead to bias in the analysis, partitioning techniques are unable to identify cluster shapes that are not convex [24,25]. Hierarchical methods are typically either top-down or bottom-up; for top-down methods, points are either grouped into a single cluster, then that cluster split according to some function to create two clusters, those clusters further split, and so on [26]. Bottom-up methods, such as the nearest neighbour hierarchical clustering technique use some function to group the individual points into a number of clusters, then proceed to group the primary-level clusters into secondary-level clusters and so on, until there is a single cluster. One advantage of hierarchical methods is that the user does not specify how many clusters to generate; however, user-defined criterion are required to tell the software when to stop clustering, or to define the initial clustering criteria [21,24,26]. A limitation is that each level of clustering depends on the previous level. Graph-based techniques are those that compute a graph, where the points are vertices and edges are lines connecting pairs of points, with edge lengths representing the proximity of pairs of points [26]. The minimum spanning tree (MST) and Delaunay diagram are examples of graphs used in clustering algorithms. Some cluster methods falling into this category include AMOEBA [23], AUTOCLUST [26], and VCM [5]. AMOEBA and AUTOCLUST are similar techniques based on the Delaunay Diagram. AMOEBA uses the global mean and standard deviation of all edge lengths in the graph, compared to the local mean of all edges connected to a single point, to determine a tolerance value. Edge lengths exceeding this tolerance value are removed from the graph such that the remaining connected points form the clusters. The algorithm is then reiterated to generate sub-clusters from the primary clusters, and so on until no more edges are present in the graph, producing hierarchical clusters. AMOEBA detects clusters of different density, and also non-convex clusters [23]. AUTOCLUST is like AMOEBA, but it compares local mean and standard deviation of edge lengths for a point to the average local standard deviation of all points to determine the tolerance [26]. Like AMOEBA, it succeeds in identifying clusters of different density and arbitrary shape [26]. Other similar algorithms for finding clusters have been presented by various authors [25,27].

Variable clumping method (VCM) is a hierarchical and graph-based method that uses a minimum spanning tree (MST) as the graph of edges [5]. It detects “clumps” of points at varying distances by iterating through the ordered (by length) set of edges in the MST and using each length in turn as the radius of circles centered on the points, so that a set of points within connected circles constitute a clump [5]. The use of the variable radii enables detection of clumps at multiple scales. VCM also uses Monte Carlo simulation to determine which clumps at each radius are significant, and only includes these significant clumps in the final set [5,6]. All these clustering techniques offer many advantages but they also have limitations. Selecting an appropriate clustering technique requires defining the needs of the particular analysis to determine which limitations are acceptable. While there are hierarchical clustering approaches that would serve the needs of this analysis (e.g. AMOEBA, AUTOCLUST), they are mostly unavailable as a ready-to-use software package. CrimeStat is an exception, as a freely available software package that includes a nearest neighbour hierarchical clustering routine [21]. However, preliminary tests with this routine revealed several undesirable qualities such as the need to input parameters of the minimum number of points to include in the cluster, as well as the threshold distance [21], but these parameters may be difficult to estimate in a case where no context or the extent is available. Also, after running the clustering routine on a sample dataset (a subset of the Williston artefacts dataset), some of the member points within a cluster turned out to be closer to points in another cluster, which violates the primary goal of clustering as described above. Finally, each subsequent cluster level only clustered the clusters, so that outliers from the primary-level clustering remained isolated in the secondary-level clustering and so on. These attributes made it unsuitable for this study. To overcome these challenges, this study adopts the VCM approach. While it does require a user-defined parameter, this is only needed for specifying the number of hierarchical levels to generate, which is constrained by the amount of complexity the analysis can handle (with more levels, the complexity increases). As detailed in the discussion below, it ensures that the distances between points within a cluster are minimised, through the use of natural breaks, and that any point within the cluster is closer to other points within the cluster than it is to points outside the cluster. Also, each cluster level is based on the full set of points, so outliers from the first cluster level are incorporated into higher-order clusters.

Methodology

Study Area

The study area of Williston Reservoir is located in northern British Columbia, Canada. It was created by the construction of the WAC Bennett Dam in the late 1960s, and is one of the largest reservoirs in the world [28]. Reservoir operation over the last 50 years has led to the exposure of primarily unvegetated large expanses of “beach”, made up of fine silts, clays, gravels, or sand. This area was heavily used by the First Nations peoples throughout history, and physical evidence of this use remains on the landscape in the form of exposed surface lithic artefacts and other cultural remains [29,30]. Millennia Research Limited, an archaeological consulting firm, has conducted archaeological surveys of the inundation zone of Williston Reservoir annually since 2008. The surveyed area consists of discrete beaches, which are confined and delineated by the natural boundaries, usually in the forms of large creeks or rivers. Artefacts found during these surveys were recorded using handheld Global Positioning Systems (GPS) units, with an estimated average accuracy of ±5 m. The reservoir is composed of three main “reaches”, the northernmost of which is Finlay Reach, where the majority of the archaeological work has been done. Several of the core beaches of Finlay Reach (those that are most densely populated with artefacts) form the study area for this project (Figure 1). The archaeologically surveyed portion of these beaches totals over 68 km2, in which over 6,000 artefacts have been recorded for 2009-2011 alone. The environment of the study area and the characteristics of the archaeological remains present some difficulties for the management of the archaeological resource. In British Columbia, archaeological resources are protected by law, and the provincial Archaeology Branch maintains a registry of the archaeological sites [31]. Thus, for management purposes, a site definition is required. In this environment, with vast areas covered by scatters of artefacts without clearly defined features, defining the boundaries of the archaeological site can be challenging. Furthermore, the management decisions for archaeological resources are often dependent on their significance. As highlighted by Glassow (1977) [32], significance can be difficult to define. This is even more so if the unit of analysis is unclear because the extent and the boundary of the archaeological site is ambiguous. Ideally, the unit of analysis should be extracted from non-arbitrary grouping of associated archaeological materials, yet identifying the categories for such grouping can be very difficult, because of the sheer volume of the Williston Reservoir artefact dataset, which makes visual identification of patterns impractical. There are other challenges such as the lack of stratigraphic context, defined landforms, or geomorphological features; as well as the lack of intact archaeological features. In addition, the landscape is not static, which means that new artefacts are discovered each year in areas that had been previously surveyed. All of these factors pose challenges for interpretation, analysis and management of this vast archaeological resource.

fig 1

Figure 1: Study area beaches and artefact locations

Hierarchical Clustering

VCM is a spatial analytical method for detecting statistically significant multi-level clumps [5]. Circles of a variable-sized radius are drawn around each observed point, and any connected set of circles represents a clump. Clumps have some key properties including the clump radius (r) and the clump size (k), i.e. the number of connected circles. The “variable” part of VCM comes from varying the radius, so that the clumps identified at varying radii, and thus multi-scale clumps, are identified. The clumping state at a specific radius C(r) is defined by the number of clumps of size k at radius r, or N(k|r), so that C(r) = (N(2|r), N(3|r), … , N(n|r)) [6]. Note that a clump of size one is not considered a proper clump [5]. A minimum spanning tree (MST) represents the distances between points, using the property of edge length (l), so that at radius r, any points connected by an edge with length lr form a clump. Because clumps will appear even in a random distribution of points, VCM also conducts a significance analysis to determine which clumps are significant [5,6]. A radius interval and maximum radius are specified to define a set of radii for the analysis. The set of clumping states of the observed points for this set of radii is then determined. Next, 10,000 simulations, using randomly generated point distributions and finding the MST for these point distributions, provide a frequency distribution of clumping states for the set of radii. From this distribution, using a significance level (α) of α = 0.05, the critical number for each clump size at each radius is determined from this frequency distribution. The null hypothesis (H0) states that the number of clumps of observed clump size k at a radius r will be less than or equal to the critical value for k and r. The results from the observed data are then compared to these critical values, and H0 is rejected where the observed number of clumps of size k at radius r is greater than the critical value [5,6]. A clustering method such as VCM is based on the MST of the points in the dataset. However, this study used a classification method to limit the number of distances at which to generate clusters. Individual line segments of the MST were classified by length using a natural breaks classification, to determine the distance thresholds at which each cluster level was defined. Thus, the number of classes chosen defines the number of levels in the resulting hierarchy. Figure 2 illustrates this process. In Figure 2a, the MST line segments have been classified into five classes. Note that the “Class 5” line is dashed – this is to indicate that this class is not used as a cluster level, as it would include all of the points in the dataset. Figure 2b shows the convex hulls of the resultant clusters. The process is cumulative, so that “Cluster level 2” includes all points connected by “Class 1” as well as “Class 2” line lengths.

fig 2

Figure 2: An illustrative example of hierarchical clusters; (a) classified MST lines connecting artefact point locations, (b) hierarchical clusters shown as convex hulls surrounding the original artefact point locations.

The specific methodology used for the dataset in this study was to first separate the overall artefact dataset into individual datasets by beach. This was done so that the resulting clusters would reflect the distribution of artefacts on a particular beach. Some of the beaches are densely populated with artefacts, while others are more sparsely populated. As the beaches are well-defined by major landforms (creeks and rivers), it is sensible that they should be treated individually. An MST was generated for each dataset, and then classified using the Natural Breaks classification method, which is based on Jenks’ optimisation method. In essence, this clustering problem is very similar to the choropleth mapping problem discussed by Jenks (1967) [33] in that, while it may seem ideal to present every data value, or in the case of hierarchical clustering, every possible cluster level, a limited number of classes must be used in order to be able to understand and interpret the data. In that case, it is desirable that each class should contain very similar values, so that the within-class deviation is minimised.

Step 1: Select all of the primary-level cluster lines (i.e. lines that have a length less than or equal to the Class 1 breakpoint).

Step 2: Buffer the selected lines.

Step 3: Dissolve any overlapping buffer polygons.

Step 4: Spatially join the original points layer to the buffer polygons, so that they are assigned the buffer polygon ID, which becomes the “Cluster 1 ID”.

Step 5: Generate convex hulls, grouping by Cluster 1 ID.

Step 6: Repeat above steps for each cluster level, such that the each successively higher cluster level includes all line lengths smaller than the break value (i.e., each cluster includes points from lower-order clusters).

The resulting datasets included a point dataset with all of the artefacts assigned an ID value for each cluster level, as well as convex hulls of all of the clusters at each level, and a size one standard deviation ellipse for each cluster at each level.

Bivariate Autocorrelation Analysis for Object Type Relationships

Bivariate local Moran’s statistical analysis [34] is often used for describing the spatial correlation between the spatial distribution patterns of two variables; i.e. it is a local method that identifies the actual locations where significant spatial dependency was observed between the two variables. GeoDa software [35] was used to perform a multivariate LISA analysis on pairs of object types in order to determine if any statistically significant relationships exist between them locally or globally. Anselin (1995) [4] defines a LISA as any statistic that indicates the degree and significance of spatial clustering of similar values around each observation. In addition, the sum of LISA statistics for a set of observations must be proportional to a global statistic [4]. GeoDa uses the Moran’s I statistic for LISA analysis. The global Moran’s I value is an indicator of overall clustering within the dataset, while the local Moran’s I value indicates the locations of clusters [36]. A significant local association may occur that is not globally significant, or there may be patterns occurring locally that are opposite to the global trend [4]. When applied as a multivariate test of spatial correlation, the statistic compares values for one variable at a location to values for a second variable at neighbouring locations. Values are “standardised such that the mean is zero and standard deviation equals one” [33]. The standardised values at each observation location are compared to the spatially lagged, standardised values at neighbouring locations to produce a global multivariate Moran’s I [34]. The contributions of individual observations to this global value are also calculated to determine local multivariate Moran’s I statistics. These values can then be compared to the values expected under a scenario of complete spatial randomness in order to determine the significance of the relationship between the two variables, both globally and locally [34]. This is done by calculating the Moran’s I for a large number of randomised permutations, in which one of the variables is kept static, while the other is randomly reallocated amongst the observations. Running several thousand random permutations produces an indicator of how extreme, and therefore how significant, the observed values are [4]. Thus, within the GeoDa multivariate LISA analysis, it is possible to obtain both global and local indicators of significant spatial association between two different variables. For each pair of variables a pseudo-significance level for the calculated local Moran’s I statistic was determined using 9,999 randomised permutations. The results, including the local Moran’s I value for each cluster with neighbours, the spatial association type, and the significance p-value for the association, were saved to a table.

The outcome of the significance test of LISA classifies individual cluster location into four different categories:

High-High

If the LISA statistic is statistically significant, takes a positive value, and the standardised count/value of object type A is positive, then both the object type A and the object type B are significantly high.

Low-Low

If the LISA statistic is statistically significant, takes a positive value, and the standardised count/value of object type A is negative, then both the object type A and the object type B are significantly low.

Low-High

If the LISA statistic is statistically significant, takes a negative value, and the standardised count/value of object type A is negative, then the object type A is low but the object type B is high.

High-Low

If the LISA statistic is statistically significant, takes a negative values, and the standardised count/value of object type A is positive, then the object type A is high but the object type B is low.

Analysis

In the analysis, a two-tier cluster levels were used for testing the spatial patterns of artefacts at different scales. The primary-level clusters were combined into a single dataset, and the secondary-level clusters were combined into another dataset. The object types that were used in the analysis are listed in Table 1. Some object type categories had very few members to the extent that they would not sustain robust analysis and were therefore excluded from the analysis. One very large category of object types, Flake Debitage, was also excluded because these items were often recorded only cursorily, making the data for this object type unreliable for use in this analysis.

Table 1: List of object types used in the analysis, with number of clusters for each object type

Object Type

#Level 1 Clusters

#Level 2 Clusters

Macroblade

74

61

Flake Tool

321

235

Impact Fractured Point

33

32

Cody Point (also included in point category)

30

29

Biface Preform

43

38

Scraper

379

211

Point (excludes impact fractured points)

227

167

Biface

119

106

Core

85

77

Microblade core

20

20

Microblade

35

32

Spall

71

63

Battered Biface

14

14

Hammer Stone

14

11

Alberta point (also included in point category)

6

5

GeoDa was used for generating a binary spatial weights matrix, in which a distance cut-off was applied to determine whether each cluster is considered a neighbour of another polygon. Clusters falling within the distance band are counted as neighbours in the analysis, and those falling outside the distance band are not considered [35]. GeoDa automatically calculates a distance that ensures that all clusters have at least one neighbour. However, the default distance turned out to be too large to provide archaeologically meaningful results, and it was adjusted through an exploratory process to calibrate it for localised analysis that also retains sufficient neighbours for most locations. Through this process, the primary-level clusters were set with the distance threshold of 250m, and the secondary-level clusters at 500 m. The resulting weights matrix for primary-level clusters had some isolated, neighbourless locations (Figure 3a). For the secondary-level clusters, every location had at least one neighbour (Figure 3b). This second level of analysis provides a more regional view of the relationships between object types, while the first level provides a more localised view.

fig 3

Figure 3: Detected artefacts clusters (a) distribution of primary-level clusters with the omission of the neighbourless clusters, (b) distribution of secondary-level clusters.

Of the 20 different relationships between object types tested at the first cluster level, three global significant relationships were discovered, and significant local associations were present in all of the comparisons. Amongst the statistically significant global patterns which emerged from the analysis was a positive correlation between Alberta Points and Macroblades. The negative correlations observed between Impact Fractured Points and Scrapers, and Impact Fractured Points and Flake Tools were statistically significant. The secondary-level cluster analysis did not result in many global significant associations; however, a positive correlation between Scraper object types and Point object types was significant. The secondary-cluster level results provide a more regional summary of the relationships between object types. None of the significant primary-level global associations were present as global associations for secondary-level clusters. Table 2 summaries the significant local relationships for primary-level clusters by their spatial association types, and Table 3 offers the same for secondary-level clusters. The association types are perhaps the most informative with regards to the nature of the relationships, as the actual Moran’s I value is not necessarily easy to interpret on its own.

Table 2: Significant results from primary-level multivariate local Moran’s I analysis

Core Variable

Spatially Lagged Variable

#Of Clusters with significant Relationship
    High-High Low-Low Low-High

High-Low

Battered Biface Flake Tool

2

73 117

5

Battered Biface Hammer Stone

1

511 78

12

Battered Biface Scraper

1

54 150

3

Biface Flake Tool

8

71 109

29

Biface Preform Scraper

2

72 117

13

Macroblade Microblade

1

227 165

43

Microblade Microblade core

0

389 84

30

Core Flake Tool

2

74 106

20

Flake Tool Scraper

20

47 119

85

Point Scraper

13

54 130

66

Alberta Point Macroblade

3

104 178

2

Cody Point Macroblade

3

100 182

21

Impact Fractured Point Flake Tool

0

73 120

17

Impact Fractured Point Point

1

163 117

14

Impact Fractured Point Scraper

0

58 150

19

Scraper Point

11

144 103

115

Scraper Impact Fractured Point

3

182 58

240

Scraper Flake Tool

17

66 95

82

Spall Flake Tool

3

70 117

21

Spall Scraper

6

56 140

14

Table 3: Significant results from secondary-level multivariate local Moran’s I analysis

Core Variable

Spatially Lagged Variable

#Of Clusters with significant Relationship
High-High Low-Low Low-High

High-Low

Battered Biface Flake Tool

2

77 45

1

Battered Biface Hammer Stone

1

120 36

4

Battered Biface Scraper

2

51 25

1

Biface Flake Tool

2

69 42

9

Biface Preform Scraper

1

53 25

2

Macroblade Microblade

6

103 111

15

Microblade Microblade core

7

66 116

15

Core Flake Tool

2

68 43

13

Flake Tool Scraper

7

44 19

19

Point Scraper

2

47 25

12

Alberta Point Macroblade

1

119 60

0

Cody Point Macroblade

1

119 64

4

Impact Fractured Point Flake Tool

1

77 43

3

Impact Fractured Point Point

2

230 112

7

Impact Fractured Point Scraper

0

49 28

3

Scraper Point

39

185 77

51

Scraper Impact Fractured Point

0

49 28

3

Scraper Flake Tool

12

52 32

26

Spall Flake Tool

3

73 41

5

Spall Scraper

1

54 26

3

Maps of selected variable pair results display some interesting trends (Figures 4-7). For example, Figure 4a shows the association between Flake Tool and Scraper object types for primary-level clusters. While there are many High-High associations (as seen in Table 2), most of these are grouped in two locations at the north end of the study area. However, when the secondary-level cluster map for this association is compared (Figure 4b), these groupings have disappeared. Instead, new locations of High-High associations appear at this different scale. For the association between Point and Scraper (Figure 5), a similar pattern shows, with most of the High-High associations for primary-level clusters (Figure 5a) grouped in two locations at the north end of the study area. Note that the southern of these two High-High groups for Point and Scraper is in the same location as one of the Flake Tool to Scraper primary-level cluster groups. Again, these significant associations disappear at the secondary-cluster level (Figure 5b). At the first cluster level, Battered Bifaces and Hammerstones do not tend to occur together (Figure 6a), except for a single High-High cluster. At the secondary-cluster level, this High-High association has disappeared, and a new High-High association location has appeared, towards the northern portion of the study area (Figure 6b). It is interesting to note that this also occurs in the same location as one of the High-High groupings seen in both Figures 4a and 5a. Elsewhere in the reservoir, the general non-association trend between Battered Bifaces and Hammerstones holds at the secondary-cluster level. Other trends of interest include the globally significant positive correlation between Alberta Points and Macroblades. When the local associations are viewed on the map (Figure 7a), all of the High-High associations are grouped in one area, towards the center of the study area. The primary-level global negative correlation between Impact Fractured Points and Flake Tools is also visible in the local association types, as there are no High-High associations (Figure 7b). At the secondary-cluster level, the global association between Scraper and Point object types is apparent as several groups of High-High associations (Figure 7c). However, there are also several significant High-Low locations, most notably the very large group of these two association types which occurs in the northern part of the study area.

fig 4

Figure 4: Significant associations between Flake Tool and Scraper object types for (a) primary-level clusters, and (b) secondary-level clusters (insignificant associations and neighbourless clusters omitted).

fig 5

Figure 5: Significant associations between Point and Scraper object types for (a) primary-level clusters, and (b) secondary-level clusters.

fig 6

Figure 6: Significant associations between Battered Biface and Hammerstone object types for (a) primary-level clusters, and (b) secondary-level clusters.

fig 7

Figure 7: Significant associations between (a) Alberta Point and Macroblade object types for primary-level clusters, (b) Impact Fractured Point and Flake Tool object types for primary-level clusters, and (c) Scraper and Point object types for secondary-level clusters.

Discussion

Key results of the LISA analysis include the four global significant associations, between Alberta Points and Macroblades, Impact Fractured Points and Flake Tools as well as Scrapers, and Scrapers to Points. A number of interesting local patterns were also discovered, including the suggested High-High groupings seen at the same location for multiple object-pairs (Figures 4-6), and scale differences in these local patterns as highlighted by the use of two different levels of clustering. The significant relationships may have a number of explanations. The negative correlations between Impact Fractured Points and Scrapers/Flake Tools suggest that the Impact Fractured Points are hunting losses, rather than retrieved from a kill and then discarded at a campsite or butchering site. If the latter were the case, they would be expected to be found more frequently in association with Flake Tools and Scrapers, both of which object types would typically be found at camp or butchering locations. Furthermore, the Impact Fractured Point to Scraper results for secondary-level clusters. None of the clusters have a significant local High-High relationship at this level and, while not globally significant, this seems to follow the trend of the primary-level cluster results, thus implying that this relationship may persist at this scale across the site. The global relationship between Scrapers and Points at the secondary-cluster level was composed of several distinct groupings of local High-High associations. These may suggest significant use areas, such as regularly used butchering sites or campsites. However, perhaps of equal or greater interest is the area with a large grouping of High-Low significant associations, which oppose the global trend of positive correlation, suggesting that something quite different may be occurring in this particular region. The Alberta Point to Macroblade global association could indicate that these items were used contemporaneously, thus providing a possible scenario of temporal patterning. Though this association is not significant at the secondary-cluster level, even at this scale there are no clusters with high numbers of Alberta Points and low numbers of Macroblades and one second level cluster retains a significant local High-High association, suggesting that Alberta Points are not typically found far from Macroblades. Other local relationships observed have indicated some interesting trends that may have a number of explanations. The groups of High-High clusters seen in the same locations for several of the variable pairs (Figures 4-7) suggest that these are not likely to be randomly strewn artefacts but may be an indicator of some important activity areas, such as camp locations, though further research would be required to confirm this hypothesis. Hierarchical clustering has proven to be an effective tool for comparing the change in clusters over time, as well as the discovery of associations between different artefact types across multiple scales. The object type analysis revealed significant patterns in the association between different artefact types at multiple scales, and while it is not possible to draw a definitive conclusion of exactly what these relationships mean in terms of landscape use, they suggest a number of interesting hypotheses of possible uses and provide direction for further studies.

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fig 2

Impact of Temperature Rise on the Bombus Population and Their Geospatial Movements

DOI: 10.31038/GEMS.2022434

Abstract

Impact of climate change is felt across a wide range of events on earth surface, including the geospatial movements by insects. This research aims to measure the impact of rising temperature on the Bombus (Bumble bee) population. The study firstly divides an 11-year accumulation of Bombus spotting data from Oxfordshire, United Kingdom into four categories that reflect the respective stages in the Bombus life cycle. Using regression analysis, the study investigates how the temperature has influenced the bee population at each stage. Results from the regression analysis revealed that the rise in temperature is affecting the population size of the Bombus population in all stages of their life cycle, particularly at an early stage where queen bees and worker bees emerge. Spatial analysis using the mean centre and the deviational ellipse also revealed that the queen bees are migrating generally towards north-west, and are becoming increasingly dispersed, expanding continuously in the direction of north-west to south-east.

Keywords

Bombus, Temperature, Phenology, Migration, Regression analysis

Introduction

A French botanist Charles Morren first defined the term phenology as “the science of theses sort of things” in 1833 [1]. The term has since evolved and, in modern research, it is used as a reference to the seasonal natural phenomena such as the life cycles of plant, animal and insect species in relation to seasonal changes. A main indicator of seasonal change is the change in temperature. Like many countries in the world, the United Kingdom is currently experiencing rise in the temperature as an effect of global warming with an accelerated pace in the past decade, and it is likely that an over-forty degrees Celsius temperature in the summer would become a norm within this century [2]. It would mean that the summer in the UK would not be dissimilar from that of the current state of Sahara Desert [3], something we did not previously anticipate in the region north of the temperate zone [4]. This situation makes the phenological life cycles particularly volatile. Bombus bumblebees are part of the Apidae (bee) family, who are mostly known for their furry bodies and large wings. They are mostly found in the temperate climates with seventy-nine species found in Europe [5]. They play a crucial role in the pollination of crops, often filling in the gaps for those that honeybees cannot cover [6]. They live in colonies which are led by one female referred to as the ‘queen.’ The queen is the only survivor from the previous season’s colony, and she emerges out of hibernation in early spring in search of food to begin the production of her nest. The locations of these nests vary with settlings occurring under thick vegetation in areas of grassland (O’Conner et al. 2014) or rodent holes and abandoned birds’ nests in urban environments [7]. Once a habitat is established, she lays her first set of eggs which would become the first batch of worker bees. These worker bees are responsible for the maintenance and sustenance of the nest by foraging throughout the season as well as rearing the constant new broods that emerge. The timing of a worker bees’ emergence is known to be crucial as this will indicate the queen’s physiology for the rest of the season [8]. Once late summer to early autumn reaches, the queen begins to give birth to both the male and female offspring, respectively. When the males have sexually matured, they permanently exit from the nest to seek female bees from other colonies—each batch of male bees exiting a nest is referred to as ‘drones’ [9]. Shortly after the drones depart, the females begin to exit to begin mating. It is said that the mating rate is heavily influenced by the temperature with the optimum occurring at 23 degrees [9] —an indication that mating can only occur in the late season. Once the mating season is over, all but the inseminated females survive, and they go on to seek shelter to hibernate over the winter period.

To this end, the seasonal temperatures have a profound impact on the life cycle of the Bombus population from triggering their release from hibernation to egg production and mating. As temperature in the UK during the summer has shown a steady increase over the last sixty years, its impact on the wider insect phenology is of great concern. This study investigates the effect of the temperature rise on the Bombus population, as they have a key role within the pollination community and, thereby, have serious implications on the local fauna and flora [10]. In particular, this study aims to unravel how the increasing seasonal temperatures in the UK has affected the Bombus phenology by delving into the main stages of their life cycle and investigating how temperature influences the size of Bombus population. The study also investigates how the seasonal temperature changes may affect the sphere of activities of the Bombus population at each stage of their life cycle by analysing their geographical trend overtime and movement.

Literature Review

Discussion surrounding the change in bee populations has been pursued for some time. Trends in the reduction and distribution of bee populations have been documented since the 1960’s with longitudinal and long-term analysis beginning to occur in the 1980’s [11]. Some of the first indicators of climate changes were studied by investigating the spatial distribution of certain Bombus species, with some disappearing from their native lands and others migrating to different areas (Williams 1982). The potential reasons for local declines have been explored since then, and several studies have reported the loss of agricultural sites [12], reduction in the availability of preferred flora [13], parasite invasion [14], the increased presence of electromagnetic radiation [15] and, above all, rise in the temperature. The UK has seen rise in local temperatures with the summer season being affected particularly heavily. Climate models predict that, without the mitigation of greenhouse gases, the possibilities of extreme heat (beyond 40 degrees Celsius) will be common in the foreseeable future [2]. The consensus amongst the literature points towards increasing temperatures negatively impacting the Bombus population, namely due to the deficiency in flight performance and the lack of colony productivity [16-18] reported that, due to the rising temperature in the UK, the start date of summer has advanced by an average of three days per decade since 1954. As of 2007, the summer start date stood as the 7th of May: 18 days prior to that in 1954. This shift in the start date of summer implies that the exit from hibernation for Bombus species may have also advanced, as a queen’s emergence from dormancy is dictated by the temperature [19]. This assumption has been indeed recently proven by a group of researchers who studied the association between the temperature and the stages of the Bombus life cycle over a 35-year period in Central Europe [20]. They found that the rising temperatures are advancing the flight period by an average of 10-23 days. This piece of research had focused on four particular Bombus species and determined that, with an increase in temperature, both the emergence of queen bees and flight period had advanced. As mentioned earlier, the flight period begins when worker bees first exit the nest to begin foraging which continues throughout the entire summer. As the summer in the UK is advancing, this also indicates that the foraging period may not only be advancing but extending in length.

Kirbyshire and Bigg (2010) [18] also note a delay in the onset of autumn. The first frost date has generally been recorded later and later over a 50-year period, which suggests that winter is contracting on both ends. A more detailed study was also performed in the form of comparative analysis across 37 different climate models. The results showed that winter had contracted at an average rate of 2.1 days per year since 1952 and increased in temperature by 0.26 degrees every decade [21]. While findings by Guan and Yuping (2021) [21] is an aggregate across the entire northern hemisphere, it supports and develops on the study by Kirbyshire and Bigg (2010) [18]. As the Bombus mating period occurs between late summer and early autumn, the contraction of winter and the delay in the arrival of autumn may be also causing a delay in their mating period. Previous research on the association between the temperature and the Bombus lifecycle has reported varying findings. In many cases, they were studied under controlled temperatures where a set of bees were monitored over a period of time, and temperatures were artificially increased and decreased to study the optimum efficiency. These studies were aimed at identifying optimum temperatures to certain stages in a bee’s life cycle. For example, Kenna et al. (2021) [16] determined that the thermal performance of a bee is retained up to 27 degrees, suggesting that foraging activities during the summer months may be undermined if the temperature exceeds this limit. Another study showed that the queen exits hibernation between 5-9 degrees of temperature [19], suggesting that queens may emerge sooner if winter begins to become warmer. While research in the Bombus behaviour is rife, studies on the migration of or change in the spatial distribution of the Bombus population is limited. To date, most research papers have been in controlled environments, as it is difficult to monitor and assess the natural movement of bees. At the same time, there have been reports of a mass migration of bumble bees, mainly reported in the research domain of bird’s migration. The location of the new habitats of Bombus is unknown, but Fijen (2020) [22] suggests that they may be moving towards the north-east of their previous respective territories on the northern hemisphere. Research surrounding more local migrations has also been limited. One of the few exceptions was the study conducted by Williams (1982) [11] on the change of distribution in pre- and post-1960 Britain. They studied the distribution of all main British Bombus species and found that many species that were present pre-1960’s had either disappeared from the native area or had moved to neighbouring areas. They had also noted that the Bombus species have seen an overall reduction with those in more isolated areas becoming extinct. They concluded that this was due to the reduction in the favoured flora. However, in recent years, many of insect migration and related changes are being revisited and are considered to be triggered by the increase in temperature. Nevertheless, confirming the association between insect migration and temperature change is deemed quite complex, as it requires synthesis of knowledge from various domains such as meteorology, remote sensing and climatology [23]. This requirement for the combination of advanced knowledge from a variety of topics may be the reason why there is so little research studying the topic of temperature and insect migration, especially the correlation between bumble bee migration and temperature.

In a Bombus colony, the Queen bee is a lead figure and influences every stage of their life cycle. As mentioned earlier, her role as a Queen starts when she exits hibernation in spring. Makinson et al. (2019) [24] monitored the flight movement of Queen Bee’s in the county of Hertfordshire during a two-week period in 2015 to understand what dictates her flight and direction. They had inserted transponders into artificially hibernated Queens and tracked them using a harmonic radar system which recorded their GPS co-ordinates during their journey. Their results through random walk modelling (due to an expected unpredictability of queen’s flight movement) found that Queens spent more time resting than actively flying; on average, Queens fly 3 km to find their nesting site. They also note that there is no common pattern on their dispersal and, as Queens exit hibernation, they start moving at different angles randomly. The team also went on to analyse whether the Queens’ flight and distance were affected by wind direction, wind speed or solar hours; but concluded that none of them had any influence. This indicates that these climate features are not affecting the queen’s behaviour at exit, and that rise in the temperature may still be a key influencing factor.

Pawlikowski et al. (2020) [20] studied the influence of the temperature on Bombus sightings. They recorded the mean dates of the emergence of each bee type and period: first queen, first worker, first male and the beginning of the main flight period, end of main flight period, main flight and duration of main flight and performed 8 separate regression models for each respective type and period. They discovered that there was an advance in bumble bee foraging period over a 35-year period. They also discovered that the most significant change was in the Bombus’s flight period which occurs between June and July, and that this was the part of the life cycle that was affected the most by the change in temperature. The above review suggests that, while the association between temperature change and Bombus population, their lifecycle and their geographical movement have been investigated by some, it remains largely understudied, especially with respect to their spatial distribution. This study aims to analyse how the change in temperature is affecting the phenology and the spatial distribution of the Bombus Bumble bees. Specifically, we will explore the following questions: (1) which part of the Bombus cycle is affected the most by the increasing temperatures? and (2) how does the spatial distribution of the Bombus bees change? We will address them by means of exploratory data analysis and regression modelling.

Methodology

Datasets

The study area is the entire extent of the County of Oxfordshire, United Kingdom. It is located in Central England and provides a reasonable representation on the UK’s temperature change (i.e. no extreme changes of temperature anticipated). Historic data from the weather stations are also easily accessible. The data on the average maximum temperature was taken from the UK Meteorological (Met) Office archives between the years of 2011 and 2021 (Table 1). It shows a gradual increase in temperature over the 11-year period. The study period of 2011 to 2021 was determined by the quality of data available for the bumble bee sightings.

Table 1: Average Maximum Temperature in Oxfordshire County between 2011 and 2021

Jan

Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec

2011

7 10.4 12.4 19.4 18.9 19.3 21.4 20.7 20.7 17.2 13.5

9.3

2012

9.8

7.3 14 12.6 17.7 18.9 20.5 21.8 18.4 13.4 10.1 8.6

2013

6.4 6.2 6.3 12.9 15.9 19.3 25.5 23.1 19 16.3 9.9

10

2014

9.3

9.7 12.8 15 17.1 21.5 24.9 20.8 21.1 16.8 11.5 8.7

2015

8.4 7.5 11.4 15.9 16.8 21.1 22.6 21.3 18.4 15.1 13.1

13.4

2016

9.4

9.1 10.2 12.9 18.4 20 23.3 23.5 20.9 15.1 9.4 9.6

2017

7.3 9.5 13.7 15.1 19 22.7 23.3 21.4 18.5 16.1 10.7

8.3

2018

8.9

6.4 9.1 14.2 19.9 22.8 27.4 23.4 20.4 15.6 11.7 10.2

2019

7.2 11.8 12.7 15.1 18 20.4 24.5 23.9 20.6 14.5 9.6

10.5

2020

11.4

10.5 11.4 17.8 20.4 21.6 22.5 23.5 20 14.2 11.9 8

2021

6.6 8.9 11.6 12.5 15.7 21.4 23.7 21 21.6 16.2 10.9

9.8

Bombus sightings in the Oxfordshire region between 2011 and 2021 (Table 2) was sourced from the National Biodiversity Network. It records the location where a variety of insects and animals were spotted. Data was retrieved between the years of 2011 and 2021, as data preceding 2011 was not sufficiently reliable to sustain robust analysis. While these records do not offer an exhaustive account of every spotting in the county, it provides a reasonable-sized sample of the population for analysis. It holds a total of 4130 sightings recorded throughout the 11-year period ranging across 24 different species. The data fails to categorize the individual bees, i.e. queen or worker. We note that data used for the bee spotting’s may have a degree of ‘chance sighting’ which can perhaps reduce the credibility of findings obtained through its analysis. Much of the literature studying phenology have mentioned the same issue; i.e. difficulty in finding data and hence one of the reasons this area has remained unexplored. However, bees are spotted throughout the entire county and across the year, thus implying that the entire county is being roamed for sightings. Sighting in each season is also very much in proportion with what we would expect from the bumble bees, i.e. less sighting in the winter and magnitudes more frequent in the peak of summer, then a decline in the late summer and early autumn. For this reason, we assume that the data is sufficient for investigating the relative difference in the frequency of sightings between different seasons.

Table 2: Bee Spottings in Oxfordshire County between 2011 and 2021

Jan

Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Total

2011

8 20 17 46 40 5 1

137

2012 4 19 13 17 5 8 66

2013

1 2 30 40 75 76 81 17 6 2 1

331

2014

1

4 42 67 60 136 74 63 11 3 1 462

2015

2 16 35 70 113 96 66 13 11 1

423

2016

2

14 56 34 114 101 52 28 4 1 406

2017

32 55 83 104 114 51 25 8

477

2018 26 68 105 133 133 68 36 7 1 608

2019

14 26 46 39 92 92 156 40 16 1

579

2020

2

8 44 75 131 67 67 37 45 17 15 4 531

2021

11 9 20 10 11 11 11 10 5 10 1 1

110

Total

17

14 230 466 609 1011 821 594 229 82 21 8

4130

Models

This study uses OLS regression analysis to assess the influence of seasonal temperature (Table 1) on the number of bees (Table 2). The data are grouped into four categories for separate modelling, reflecting the four different stages in the Bombus life cycle as mentioned earlier. Here are the four models:

Model A (The Queen Model)

This model takes bee sightings between 1 January and 20 April, which is when Queen Bees are expected to exit hibernation to forage and seek nesting sites. While they mainly exit between late March and early April, some sightings were recorded in earlier months.

Model B (The Worker Model)

Existing studies refer to this period as ‘foraging’ or ‘flight’. This model takes on bee sightings between 15 May and 30 July, which is when worker bees are most prevalent.

Model C (Drone and Mating Model)

This model takes bee sightings between the dates 15 August and 15 September which is when worker bees have mostly deceased. The male bees survive on average 30 days to search for a mate.

Model D (New Reign Model)

This model takes on sightings between the dates 20 September and 10 December. During this phase, the inseminated females forage and seek hibernation sites to overcome the winter.

Due to lack of information on the classification of individual bees (e.g. queen or worker), we assume that the bee sightings during the respective period when a specific type of bee is most active (e.g. a queen bee in a period specified for Model A) are of that type of bee.

Once the regression models are executed, the most significant model will undergo spatial analysis. In order to investigate the extent and direction of any geographical change of the spotting data over the 11-year period, the spatial mean centre and the directional ellipses analyses are carried out. The mean centre will give an indication as to which direction, how quickly and how far the bees are migrating or spreading. The directional ellipses will give an indication of how they are geographically distributed during each period.

Analysis

Influence of Temperature on Bombus Sightings

The result of regression analysis shows a positive correlation between temperature and Bombus sightings in all models (Figure 1), which confirms the relationship of a higher temperature and a more frequent Bombus spotting. However, the influence of temperature on the Bombus spotting was statistically significant for Model A (The queen model) and Model B (The worker model) only, with p<0.05 of t-statistic for the regression coefficient (Table 3). On the other hand, the influence of temperature in Models C and D is statistically insignificant (with p>0.05), which means that there is little influence of temperature on bee sightings. The degree of goodness-of-fit of the regression model is in the order of Model A, Model B, Model C and Model D. This is shown in the R-squared values (Table 3).

fig 1

Figure 1: Results of the Regression Models: (a) Model A (The Queen model), (b) Model B (The worker model), (c) Model C (Drone & Mating Model), (d) Model D (New Reign Model).

Table 3: Key Statistics from the Regression Models

Coef (const)

Coef (α) t P>|t| R-squared

Model A

-24.669 4.114 3.596 0.001

0.341

Model B

-127.306

9.848 2.824 0.009 0.235

Model C

-43.480 2.858 1.823 0.087

0.172

Model D

6.267

0.016 0.052 0.959

0.000

The result generally confirms findings from past research in that it is difficult to understand how temperature affects the final stages of the Bombus cycle, as the influence the end of a season has on both fauna and flora is a lot more difficult to measure than that of early season [18]. Sparks and Smithers (2002) [25] also noted a similar challenge and asserted that phenological responses to temperature change is more prevalent in the early seasons and less so later [25]. Although climatologists have stated that the onset of autumn is seemingly delayed [21], it has not been transposed sufficiently enough in the Bombus population according to the two late season models, namely, mating and new reign; which makes it difficult to delve deeper into these two life stages. The queen model’ yielded the highest goodness-of-fit value and provides the regression model of y = 4.114x – 24.669. According to this equation, Queen Bees only exit hibernation once the temperature exceeds 6 degrees. This is supported by Alford (1969) [19] who reported that hibernation exit usually occurs once temperatures reach 6-9 degrees. This equation is only credible when the average maximum temperature is between 5-23 degrees; as the model was specified and performed within this range. Once the temperature exceeds 30 degrees, bee spottings are likely to decline as intense temperatures and humidity can have a negative impact on Bee morphology, impacting their flight performance [16]. Therefore, the assumption that the rising temperature brings forward the release of Queen Bees from hibernation can be considered to hold to a certain extent. Once this degree is reached, the rise in the temperature may result in the reduction of the number of Queen Bees present. However, this is yet to be seen until we see British winters reaching temperatures beyond 30 degrees. As such, this cannot be determined – only predicted. The analysis here found that an increase in seasonal temperature has a potential to increase the emergence of Queen Bees from hibernation and increase the number of worker bees. Although, the periods of mating and new reigns also show some form of positive correlation, their degree is significantly smaller than the periods of the earlier seasons (confirmed by a statistical insignificance of the regression coefficient and the model itself).

Bombus’s Migration

This section investigates the geographical movements of Bombus over time by drawing the Mean Centre and the Deviational Ellipse for different periods. The analysis focuses on the queen bees, as the regression analysis in the previous section found out that, among the four types of bees, Queen Bees are the most sensitive to the temperature change, and therefore can be regarded as a representative of Bombus on the reaction to temperature change.

Figure 2 maps the change in the mean centres and the deviational ellipses during the four periods of life cycles between 2011 and 2021. The figure firstly shows that the mean centre has consistently moved farther to the north-west as the years have progressed, which indicates that Queen bees—and hence their colonies—have also moved in this direction. The mean centre has moved each year covering a total distance of 16.24 km north-west during this period (Table 4). Although we do not see a direct proportionality between the temperature and the distance travelled, we note that, in the years between 2014-2016 and 2017-2019, there was a temperature reduction of 0.14 degrees, and the distance moved within this time was at its smallest at 3.7 km. The years between 2011-2013 and 2014-2016 showed a movement of 7.88 km with the temperature increased 0.89 degrees. The years between 2017-2019 and 2020-2021 showed a movement of 4.66 km, in response to the temperature increase of 0.45 degrees. The deviational ellipses show how the distribution of the Queen Bees have generally become more dispersed over the years, which is reflected in the size of the directional ellipse. If the size of the ellipse in the first time period was set at 1.0, that for the second, third and the fourth is 1.3, 2.5 and 1.1, respectively. The orientations of the ellipses are between 113° to 129.9° throughout the years, meaning that the orientation of the dispersion constantly expands north-west to south-east, which broadly consistent with their movement direction.

fig 2

Figure 2: Change in the mean centre and the deviational ellipse (2011-2022)

Table 4: Mean Centre and Deviational Ellipses results

Period

Distance moved (km)

Average Max Temp. (degrees) Orientation of the ellipse (degrees)

2011-2013

  – 8.87

113.01

2014-2016

7.88

9.76 129.59

2017-2019

3.7 9.62

148.64

2020-2021

4.66

10.07

129.86

Discussion

Findings from this study suggest that the increase in the temperature has clear influence on the Bombus phenology. Results from the regression analysis show that there is an impact of rising temperature on the emergence of Bombus in all stages of their life cycle, particularly the early two stages. The regression model performed most robustly for the Queen model, indicating that she is most vulnerable to the temperature changes. Therefore, it is logical to assume that as the UK climate warms and spring continues to advance, more and more queen bees will begin to emerge sooner. If her resources are abundant upon her release and she has the ability to forage off her desired flora, her colony may also emerge sooner. On the contrary, if her early emergence means her desired flora is not available, she will go on to produce a futile colony which will unlikely survive a season. Earlier emergence can also cause an imbalance of the rest of the cycle, meaning that the proceeding stages must not function at their optimum. This will cause the extinction and reduction of many Bombus species, which has already been recorded [26]. The result of the spatial analysis shows that bumble bees are gradually moving in the north-westerly direction, which coincides with findings in some of the literature [22]. In summary, the geographical patterns of the Queen bees are: (1) moving towards north-west, (2) becoming increasingly dispersed, and (3) their spread constantly expand in the directions of north-west to south-east. Overall, there seems to be some consistency in the movement of Queen’s suggesting that there is a common form of migration going on. Unlike Makinson et al. (2019) [24] who recorded that dispersion and flight of Queens are unpredictable; our study saw a consistent pattern with a clearly specified directionality. Oxfordshire has seen a general rise in its temperature during the winter to spring months over the past eleven years. Of course, temperature increases are not demonstrated as a definitive cause behind the bee migration, but this study shows that it could be a contributing factor to a Queen’s re-location. Increasing temperatures can also assist a Queen’s metabolic process and, therefore, she would be capable of flying farther afield to nest (Kenna et al. 2021) [16], the earlier she emerges from hibernation, the more time she is afforded to search for and building a nest, leading to a further distance being flown; whilst warmer winters are tampering with a queen’s thermal limits, possibly leading to flight confusion [27]. The theories for the Queen bee’s dispersal patterns are almost endless and perhaps open up other research areas.

While these findings are implied and may fall short of proving the causation for this shift to be the change in temperature, it is worth noting that much of the literature points toward warming climates as the reason for the general insect migrations. Past research has shown butterflies have chosen to move south and grasshoppers have migrated to neighbouring regions to accommodate their climate needs [28]. If Bombus continuously begin to move northbound, it may eventually create reduction in the Bombus population in the southern region; which in turn may have an adverse impact on the wildlife biodiversity due to pollination reduction. There is also an associated risk to the migration of the Bombus population, if they continue to migrate north. As bumble bees can only survive in temperate zones, their migratory locations are limited and, therefore, they may be forced into areas which cannot accommodate their needs, thus heading towards the death of a colony. On the other hand, Roff and Fairbairn (2007) [29] note that insects which migrate into areas that are inhospitable to their liking, could trigger a genetic variation to increase their chances of living in what may have been perhaps perceived as an extreme climate in the past. If another dataset with more details on Bombus sightings was to be identified, it would be interesting to see how other climate attributes may be potentially driving this migration such as rainfall and humidity. The result of the analysis would be also more accurate, if it contained classifications of the type of Bombus bee spotted; i.e. a queen or a worker, similar to that observed by Palowkowski et al. (2020). This would have enabled us to build a more clearly defined models based on the type of bees; as opposed to dividing the regression models using seasonal dates and assuming we assign the most likely bees in that respective period; and this forms another future aspiration. Further analysis on the Queen’s emergence from hibernation can be extended by repeating this project in other countries where Bombus bees are native, as this will give insights into whether the tendencies found in this study are a global phenomenon or a more localised tendency.

Data Source

Bombus Sightings between 2011 and 2021. Source: National Biodiversity Network. Available at: National Biodiversity Network (nbn.org.uk).

Oxfordshire Temperature between 2011 and 2021. Source: Met Office. Available at: National Meteorological Archive Met Office.

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fig 1

Assessing the Association between the Types of Greenspace and Their Biodiversity

DOI: 10.31038/GEMS.2022433

Abstract

Green infrastructure refers to all manners of established green spaces that provides habitat for wildlife and ecosystem services for people. Areas with richer biodiversity is known to provide measurable benefits to the local wellbeing and the wider ecosystem, but it remains unclear if the size and the type of greenspace affect the extent of species richness. This study investigates the distribution of 92 species across green infrastructure in England to identify the variables which have the most effect on species richness. The results suggest that Forestry Commission Woodlands and Country Parks had the highest species richness, whilst Doorstep Greens and Village Greens returned the lowest species richness. ANOVA confirmed that the variation between the groups was significant. The main difference in the groups was the area, with Forestry Commission woods being on average 140 times larger than Doorstep Greens. When considering the greenspace with the highest species richness, habitats having highest mean area were woodland, managed grassland and waterfronts. These results confirm our intuition but also suggest that richer biodiversity can be only achieved in well preserved and managed woodlands and country parks occupying a sizable plot, and that regular patches of green infrastructure embedded within the urban areas do not offer high species richness.

Keywords

ANOVA, Biodiversity, Green infrastructure, Species richness, Woodlands

Introduction

Green Infrastructure (GI) is a relatively new term that is loosely defined as “a spatial structure providing benefits from nature to people [which] aims to enhance nature’s ability to deliver multiple valuable ecosystem goods and services such as clean air or water” [1]. More generally, it is a reference to established green spaces and new sites (of greenspace) that is considered to have a positive effect on our wellbeing and the wider society) [2], and they range from large areas such as agricultural land, forests, wetlands, woodlands and parks to individual street trees, private gardens, green roofs, rivers and transport corridors (UK Green Building Council 2015) [3]. Aside from the various social benefits and cultural services they offer to our society, GI has the potential to provide habitat and connectivity to wildlife. For instance, cities in the United States have seen an increase in the frequency and diversity of wildlife sightings, as more cities have invested in GI to improve their respective urban environment and achieve environmental resilience [4]. A systematic review of the literature [5] suggests that increase in biodiversity is generally considered to yield positive effect on human health. Also, GIs with greater diversity of avian species are known to evoke positive emotional responses from their visitors [6].

However, what triggers a greater range of biodiversity remains unclear. Lawton (1998) [7] once suggested that a coherent and resilient ecological network for biodiversity requires a series of larger habitat patches with good connectivity to other sites. In other words, larger areas usually hold more species present within them and the connectivity to other areas reduces the risk of localised extinctions due to changes in the local conditions. However, securing a large area of green space within and around the confined space of cities can be challenging. Also, it is unclear as to what types of green space are likely to offer high species richness. Most studies on GI and general greenspace have focused on a small sample size, or a short duration and were often unable to differentiate between greenspace type or quality. As a result, the association between the attributes of GI (the types of GI and the size in particular) and biodiversity remains understudied. Furthermore, with the predicted change in climate, a number of studies have investigated the ability of GI to alter the urban environment and alleviate the impact of climate change such as extreme temperature, rising sea levels, frequent extreme weather events and increase in the spread of diseases and pests [8-11]. Climate change is also considered to affect biodiversity with an increase in the intensity and frequency of droughts, storms and fires. For instance, the intense fires in Australia in 2019 and 2020 have increased the number of threatened species in GI and the vicinity of cities by 14% (The Royal Society 2021) [12].  Against this background, this study investigates which aspects of greenspaces would yield benefit for people and wildlife through maintaining and enhancing biodiversity.

Literature Review

Impact of Green Infrastructure on People

Green space is often considered to have a positive effect on our wider wellbeing, ranging from the reduction of post-surgery recovery time [13] to lowering cortisol levels and blood pressure [14]. However, this assertion is not conclusive, and some studies report a mixed or even negative impact of green space on our wider wellbeing. For instance, Shanahan et al. (2015) [15] systematically reviewed relevant studies and concluded that some studies reported reduced mortality and generally enhanced wellbeing, whilst some studies found no association between green space coverage and mortality, and one study even reported increase in mortality in relation to larger green space coverage. Similarly, Maas et al. (2009) [16] investigated the association between green space coverage and morbidity and other disease within a 1km window, and concluded that, the degree of urbanity of the study areas, rather than the area of green space, had stronger impact on the health outcomes. At the same time, Maas et al. (2009) also highlighted that having access to a greater green space coverage helped reduce anxiety related disorders. Others (Gong et al. 2014 [17], Coutts and Hahn, 2015) [18] report that, while accessibility of green space generally improves our health and wellbeing, the effect varies between different types of green space.

Impact of Green Infrastructure on Wildlife

The direct and indirect effects of GI on humans is wide ranging and findings in the literature are also varied. The impact of GI on wildlife, on the other hand, is more straightforward in that it provides habitat connectivity in an increasingly urbanised world [19]. Several studies have attempted to assess which aspects of GI are important for different species, and their findings vary greatly, including size, connectivity/isolation, the management regime and type of habitats present within the GI [20-22]. Birds are among the most widely studied taxa in relation to GI, because they are relatively easy to survey and their life cycles are well understood [23]. For instance, Chamberlain et al. (2007) [24] investigated bird species richness in urban parks in London and found that site area was the most important factor related to bird species richness and that, in smaller sites, the presence of a high number of adjacent gardens caused the species richness to increase. In addition to size, those areas which held rough grass or waterbodies also returned higher species richness. The authors noted that the relationship between size and species richness simply reflects the fact that larger greenspaces tend to contain a higher number of habitats, which could attract a wider range of species. Negative associations were also recorded for the presence of buildings, roads and pavements across both the species groups and the seasons. In a similar study, Zorzal et al. (2020) [20] found that the taxonomic diversity of bird species recorded across six urban greenspaces in Brazil was positively associated with greenspace area. However, when analysing the bird diversity against a proximity index, the study found that there were no correlations with maximum noise or the degree of patch isolation. They also found that species richness had a positive correlation with the heterogeneity of the habitats within each greenspace. The study was limited to a relatively small sample size as it was constrained by the number of accessible urban greenspaces available. Other studies ranged from bird populations in Sweden [22], to bumble bee populations in relation to the urban features of San Francisco [25], amphibians in New Jersey, McCarthy and Lathrop (2011), and general insect diversity in green roofs in Nova Scotia [26], most of which found richer biodiversity in GI away from urban centres, and in GI with larger area.

Furthermore, a study in Slovenia by Groot et al. (2021) [27] found that out of the 2 most prevalent urban greenspace types in Ljubljana (urban forest and managed park) there was a lower abundance of bird species within parks than urban forest, but that species richness and species composition were not affected by greenspace type. Greenspace area significantly affected the bird abundance and greenspace type influenced which species was designated as indicative of the habitat. Although there were no significant differences in bird biodiversity between urban and peri-urban areas, Ljubljana holds relatively large areas of urban forest and the impact of urbanisation (e.g. disturbance, predation) are likely to be reduced. The link between biodiversity and the provision of ecosystem services has been explored further in a literature review by Sandifer et al. (2015) [5]. In their review, papers concentrating on the effects of biodiversity on ecosystem services were considered in order to provide a body of evidence on the effects of biodiversity on human health. The review highlighted that in the most part, biodiversity assists good human health and that in studies where relationships were not found, this could be attributed to a lack of suitable data, although there is the possibility of a confounding effect of socio-economic status on human health. Most of the studies investigated had inadequate sample sizes, study durations or measured controls, or were found to be lacking in rigorous statistics; objective data; unable to differentiate between greenspace type or quality; showing evidence of long-term effects; or suffering from the suite of health data collected being too narrow. Very few studies also attempted to identify the mechanisms through which the effects of biodiversity work.

Assessing the Quality of Green Infrastructure

Many of the studies highlighted above did not account for the quality of the GI in their analyses. Quality of GI can be measured in the field, which allows for detailed surveys of local areas, but this is time-intensive and cannot be easily extrapolated across larger areas. Another way to determine quality is through the use of GIS and spatial modelling where a set of spatial criteria are captured through remote sensing and/or a composite index was used for representing the regional environmental quality [28]. The quality of GI measured with respect to their benefit to humans as well as the wildlife can be analysed by assessing the current value of different Ecosystem Services within an area. One of these tools is the Outdoor Recreational Value tool (ORVal), which seeks to estimate the number of visits a greenspace might receive and the monetary equivalent of those visits. The ORVal tool estimates the value of a GI through the application of a recreational demand model which places importance on the cost in time of visiting a greenspace, and the quality of the recreational experiences at that greenspace [29]. The quality of recreational experiences is thus considered to be based on an extensive set of variables encompassing greenspace type, size, land cover, designations, points of interests and direct connectivity with other greenspaces. These studies suggest that GI has a generally positive effect on humans and the wildlife, but there is a gap in the literature where a systematic investigation into their effect and the contributing factors towards species richness is understudied at the larger, national scale.

Context and Data

As mentioned earlier, majority of the studies carried out on evaluating the impact of green space focus on a small sample size or a specific type of greenspace. This study will investigate the relationship between the recreational value of greenspace and the number of species they hold across England. England contains an estimated 27,000 public parks, and its National Planning Policy Framework (NPPF) mandates new developments to provide more GI—in the form of safe and accessible areas of greenspace with recreational, cultural and social facilities—as these areas are considered to help mitigate climate change effects and deliver wider benefits for nature [30]. Other areas of nature reserve and conservation areas are also protected from development. Despite that, the amount of green space in urban areas has dropped from 63% to 55% between 2001 and 2018 [31]. To mitigate the loss of sites, maintaining GI of high quality and the capacity to nurture biodiversity is essential. The quality of GI can be measured in a variety of different ways, including the proximity to urban areas and types of land cover, and it is difficult to extract a single attribute as a proxy to describe each GI. The Outdoor Recreational Value (ORVal) tool mentioned earlier is a tool developed by the University of Exeter in collaboration with DEFRA. Its primary purpose is to give an estimate of the quality for people of greenspaces across the United Kingdom both in monetary terms and as an estimated number of visits. At the same time, the tool also models the interactions between the habitats present, whether the site has any legal designations or points of interest, and whether there are any shared boundaries with other greenspaces; and it is these auxiliary data that this study will exploit. Habitat areas in ORVal are derived as a combination of the 25m-grid of the 2007 Land Cover Map (LCM), Ordnance Survey Master Map data, the Priority Habitat Inventory dataset from Natural England [32] and Open Street Map data.

The estimated greenspace visits are taken from the Monitor of Engagement with the Natural Environment (MENE) survey administered by Natural England. The estimated value of each greenspace is calculated through an opportunity cost model of recreational trip choice, whilst taking into account the socio-economic factors. While both values are estimates derived from the respective surveys and cost models, they have been calibrated through empirical studies to improve their accuracy [29]. Species data is taken from the National Biodiversity Network (NBN) which provides access to arguably the most comprehensive set of aggregated biodiversity data from multiple recording schemes across England and Wales. The NBN gateway limits the maximum number of downloads to 500,000 records per species and 10 million in total. To comply with these limits, the number of species included in this study was limited to amphibians, birds, butterflies, mammals (including bats) and reptiles listed in section 41 of the Natural Environment and Rural Communities (NERC) Act 2006; namely, those of principal importance for the purpose of conserving biodiversity and are considered most likely to be accurately recorded across the whole of England. Species groups such as beetles, moths and freshwater fish were excluded due to the lack of reliability in the measurement of their recording and/or because of their irrelevance to the terrestrial habitats under study.  Some species listed in section 41 are deemed sensitive, and to avoid reporting the specific locations of these species, the NBN gateway provides the location at a reduced geographical resolution. The exact location of these species records is stored internally and only available to individuals having enhanced access, with the data provided on the public interface being generalised to a lower resolution of 1km grid. To align all analyses, location data of the species records was renumerated to 1km grids. Further data processing and cleaning were conducted on QGIS platform and with R-Studio software. The ORVal website provides a GIS shapefile detailing the boundaries of the greenspaces. Greenspace types that may not be open to the public (e.g. golf course) were removed from the data set. This left 22,698 greenspaces in the analysis. Table 1 shows the number of each greenspace type after the data processing.

Table 1: Number of each greenspace type

Greenspace Type

Number of features

Common

1283

Country Park

413

Doorstep Green

103

Forestry Commission Woods

193

Garden

331

Millenium Green

81

Nature

2844

Park

9633

Village Green

669

Wood

7166

Species records were plotted as points, and the points falling within each 1km grid square of England were aggregated to the respective grid so that the total number of records within each grid square was classified by the species’ groups. Additionally, the presence of each species was calculated within the grid squares; i.e. for each species group, the presence of species within that group was counted to give the number of unique species. The number of species records in each group is shown below (Table 2).

Table 2: Number of records for each species group

Species group

Number of records

Amphibians

98,453

Bats

77,756

Birds

2,208,575

Butterflies

687,150

Mammal

430,380

Reptiles

136,514

While different species and attribute data exhibited different patterns of distribution, a log(Y+1) transformation offered an overall best fit to bring each distribution closer to normal distribution and was therefore performed for all variables.

Analysis

The independent variables were identified through the literature as having potential correlations to species richness were plotted in scatter graphs (Figure 1). To understand the contributing factors for the biodiversity (unique number of species), this study conducted OLS regression. In other words, the OLS regression was used to determine which variables were significant in explaining the sum of unique species. Figure 2 shows the association between these variables and the number of species within greenspace. As a result, the following variables were used in the OLS regression model as the independent variables: area, wood, natural grass, managed grass, parking, urban percentage, rivers and canals, and the number of habitats. All variables were analysed using the transformed log(Y+1) data.

fig 1

Figure 1: Scatterplots of the log of unique species against variables used in OLS regression

fig 2

Figure 2: Variables affecting the number of species within greenspace

Figure 1 shows the scatterplots of the variables used in the OLS regression model against the unique species number. Whilst there is strong positive correlation between some variables, most have weak positive correlation even after transformation. The outputs of the scatterplots suggest that the analysis would be best achieved with non-parametric tests. However, due to the number of records used in the analysis, applying non-parametric tests to the entire dataset holds the risk of returning inaccurate results [33,34].

To explore the spatial concentration of these variables, the Local Indicator of Spatial Autocorrelation (LISA) was calculated in the form of local Moran’s I for each variable in the OLS regression (Figure 3). The maps clearly show that “area” size has very few hotspots or coldspots, with smaller low-low area clusters being generally around urban areas and larger high-high area clusters being generally clustered in rural areas. A large proportion of the greenspaces have no significant clustering of area, except for woodlands which show a clear contrast between the hotspots (or the areas with high concentration of woodlands surrounded by similarly high proportion of woodlands) and the remaining regions. In particular, counties with higher percentages of woodland area such as Surrey appear to be well represented in hotspot clusters in the woodland variable, with counties having typically lower woodland cover such as Suffolk and Somerset showing up as coldspots. There are areas such as Cornwall and the Lake District which have low overall woodland coverage but are both shown as having hotspot clusters, suggesting that in these counties the woodlands which are present occur in close proximity to each other rather than being dispersed across the wider county. Managed grassland habitat areas tend to be larger in urban areas whilst natural grassland habitat areas tend to be larger in rural greenspaces. Parking is again fairly sparse with large areas of no significant clustering. Whilst there appear to be some hotspots for parking in urban areas and some coldspots in rural areas, this does not hold true across the country.

fig 3

Figure 3: Local Moran’s I clusters for each log variable: area; woodland; natural grassland; managed grassland; parking; rivers and canals; number of habitats; and urban percentage.

Rivers and canals have large significant hotspots in north-west and south-west with coldspots mainly concentrated in the south and south-east. The total number of habitats shows significant hotspots mainly in urban areas, however as man-made habitats were included in the calculation for number of habitats, there is perhaps a predisposition to urban areas with significant coldspots occurring in rural areas in a similar pattern to the managed grassland variable. The urban percentage clusters appear generally as expected, although there are comparatively few high-high clusters in urban areas. Table 3 shows the results for the OLS regression of unique species counts. It illustrates the highly significant relationship for all variables with a low standard error (≤0.5162). The variables explained 76 % of the variance of the species richness. Analysis of the t-values shows that woodland area has the strongest positive relationship with unique species number, and rivers and canals showing the weakest relationship if still significant. Urban percentage was shown to have a weak negative relationship.

Table 3: Results of OLS regression

Variable

Estimate

Std error

T Value

Pr(>|t|)

(Intercept)

-2.81E-01

1.50E-02

-18.7

<2e-16

***

Area

6.33E-04

2.86E-05

22.14

<2e-16

***

Woods

5.16E-01

3.42E-03

150.83

<2e-16

***

Natural Grass

3.01E-01

7.05E-03

42.75

<2e-16

***

Managed Grass

1.94E-01

5.97E-03

32.45

<2e-16

***

Parking

4.07E-01

2.07E-02

19.71

<2e-16

***

Rivers/canals

9,49E-02

8.48E-03

11.19

<2e-16

***

Number of Habitats

3.92E-01

1.28E-02

30.68

<2e-16

***

Urban Percentage

-2.02E-01

1.49E-02

-13.69

<2e-16

***

To examine the relationship between greenspace type and species richness, a boxplot was produced (Figure 4). It highlights the difference in the number of unique species in each type of greenspace with Forestry Commission Woods and Country Parks having the highest species richness, whilst Doorstep Green and Village Green showing the lowest number of species. Woods and Nature had large variations in species richness, partly due to the frequent outliers present for these categories. An ANOVA test returned a significant result for the variation, where the sum of squares = 3184 and p = < 2.2e-16 with 1 DF.

fig 4

Figure 4: Boxplot of log +1 unique species count and greenspace type

Further analysis of the means for the lowest and highest groupings are shown in Figure 5. Unsurprisingly, both country parks and forestry commission woods have higher areas of woodland cover than doorstep green does, although country parks also have more managed grassland. Parking, built habitats, and rivers and canals were also higher in country parks than the other greenspace types investigated. Whilst it was not plotted on the graph due to the large variation in size even at a log scale and the resultant skewing of the y-axis, Forestry Commission Woods were on average approximately 140 times larger than Doorstep Greens, and average area of Country Parks were approximately 50 times larger than Doorstep Greens.

fig 5

Figure 5: Mean habitat areas by greenspace type

Discussion

Figure 3 showed that the contributing factors towards high species count (hence, high biodiversity) tend to be spatially aggregated into known species diversity hotspots such as the New Forest and Jurassic Coast, Ainsdale NNR, the Cambridge fens and the Norfolk and Suffolk coasts. The presence of hotspots mainly outside of urban area validates the use of the total unique species to determine species richness rather than using species abundance. The presence of coldspot clusters also confirms results consistent with findings from previous studies whereby species richness decreases with increasing urbanicity [25,26].  The decision to aggregate species counts by 1km2 may have affected the clustering, and a smaller grid could have given a more detailed picture of the species distributions. The large blocks of hotspots and coldspots may have been an artefact of the large data set, and analysis using smaller grid units may have resulted in more nuanced distribution of clusters.

The locations of the high-high clusters suggest that the best greenspaces for both people and wildlife mainly occur on the edges of suburbs around large urban centres, or in larger urban parks, although this may again simply be highlighting an issue with the extraction method for the species data. Analysis of the variables which make up each of the cluster grouping suggests that those greenspaces which are composed of woodlands with managed grassland are more likely to benefit wildlife. However, clusters of high species-low value greenspaces had a high mean woodland area, without a high mean managed grassland area. The large impact of woodlands on high biodiversity may also be an artefact of the species data which was used. Bird records accounted for more than 60% of the records and studies investigating the effects of landcover on bird diversity have reported a strong relationship between species richness and woodland cover [22,35]. The results of the OLS models confirm that the woodland area of a greenspace is the most important factor when predicting the number of unique species present within that greenspace. This finding reiterates the suggestion above that the heavy skew towards bird records within the original species data, and the strong relationship between bird biodiversity and woodland area, may be over-emphasising the relationship.

Further analysis of the grouped species data would be necessary to identify if the same trends are found in other species groups. The relatively low result for area in the regression model was surprising, with the estimate being ranked 5th out of the 8 variables modelled. This may be due in part to the negative multicollinearity with both natural grassland and rivers and canals. It may also be that since there are many factors that could affect each species differently, if the species groups were modelled separately then the size of each greenspace may have shown more significance in explaining species richness for generally lower mobility groups such as butterflies. The relatively high effect of parking suggests that even though attempts were made to reduce recorder bias, bias may still exist within the data as it gives the impression that an increase in parking area resulted in higher unique species counts. The variance in species richness caused by these variables is unlikely to be geographical in origin, as the geographic variation cannot be discerned at this spatial scale. The exceptions are the managed grassland and natural grassland variables, both of which broadly follow the respective distributions. A potential alternative method would have been to geographically subset the data in order to provide the local Moran’s I for each area. Also, splitting the data down into distinct geographical regions such as the south-east, south-west and so on may have provided a method to investigate how the variables behave with an adaptive bandwidth. Indeed, the effect of greenspace type on biodiversity appears to reflect their size and ruralness. Both country parks and forestry commission woods tend to be large areas of greenspace, which may explain the positive relationship between these and the number of unique species. Country parks have a set criterion for designation including a minimum area, facilities and accessibility whilst being a predominantly semi-natural landscape. Country parks should be over 10ha in size and as an increase in area typically results in an increase in the number of habitat types and thus available habitat niches, as well as reducing population isolation and disturbance [36]. As Forestry Commission Woods are the largest supply of sustainably managed timber in the UK, and commercial forestry operations require large amounts of land, Forestry Commission Woodlands are on average the largest greenspace type within the analysis.

Conclusion

This study found that green space outside the urbanised areas has a high level of species diversity than those within urban areas. Variables that contributed to high species richness were area, woodland cover, grassland cover (both managed and natural), rivers and canals, parking, number of habitats and percentage urban cover. Greenspace types with large areas (e.g. country parks and forestry commission woods) corresponded to a higher number of unique species present than those that are usually small in size (e.g. village greens and doorstep greens). Where size is not dictated by greenspace type, such as in the case of woods and commons, these result in a lower average unique species with a large number of outliers being present in the data. Potential avenues for further investigation into this topic include analysis of different species groups and comparing their findings with those from this study; and identifying similar greenspaces with similar recording effort across the country in order to test whether the differences shown in species richness during this study are geographical or an artefact of over- and under-recording. Despite these challenges, this study confirmed that richer biodiversity can be generally only achieved in well preserved and managed woodlands and country parks occupying a sizable plot, and that regular patches of green infrastructure embedded within the urban areas do not offer high species richness. This has policy implications in that, while we can explore the positive effect of having a varying extent and types of green infrastructure within urban areas, we cannot expect high biodiversity in relation to such green infrastructure.

References

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fig 7

Epidemiological and Anatomopathological Profile of Breast Cancers in Mauritania

DOI: 10.31038/AWHC.2022531

Abstract

The incidence of breast cancer in women is on the rise worldwide, including in developing countries. The objective of this study was to describe the epidemiological, clinical, and histological characteristics of breast cancer in women in Mauritania. Data were collected from 60 female patients monitored and treated at the National Hospital Center (NHC) and Military Hospital Center (MHC) in Nouakchott. The variables studied were age, parity, age at first pregnancy and menarche, place of residence, socioeconomic status, medical coverage, tumor site, Scarff Bloom and Richardson histoprognostic grade, location, Tumor Nodes Metastasis stage, molecular phenotype, and lymph node involvement. The average patient age was 48.71 ± 12.45 years, ranging from 17 to 70 years. Regarding histological types, invasive ductal carcinoma was the most frequently encountered (70% of cases). Immunohistochemical profile analysis revealed that 44% of the tumors were luminal A type, 24% were triple-negative type, and 22% were luminal B type. Our results also revealed that smoking patients had more grade III tumors, and that age was significantly correlated with disease stage (p=0.047) and molecular classification (p=0.0011). The characteristics of breast cancer in Mauritania do not differ from those in other developing countries.

Keywords

Cancer, Breast, Epidemiology, Mauritania

Introduction

Cancer is a major public health problem, and according to the World Health Organization, it is the second leading cause of death worldwide, causing 8.8 million deaths in 2015. Nearly one in six deaths worldwide are due to cancer. According to the latest WHO estimates, the number of cancer deaths is expected to continue to rise, and to exceed 11 million people per year by 2030.

Breast cancer is the most common malignant tumor type in women worldwide, and its incidence continues to increase, particularly in the 35-55 age group [1]. Mauritania ranks first in terms of breast cancer incidence and mortality among women [2]. According to some studies [3,4], this pathology is indeed the first cancer in women, although its frequency varies according to ethnicity, and it remains a major source of female mortality, as diagnoses are usually made at an advanced stage.

Several risk factors for the development of breast cancer have been recognized, including family history of breast cancer, advanced age, early puberty, late menopause, nulliparity, and obesity. However, no factor directly linked to its onset has been identified, except for the hereditary transmission of the BRCA 1 and 2 genes, which have been implicated in 5-10% of cases of breast cancer cases since Bittner’s discovery. In addition, many viruses are suspected to cause breast cancer [5]. This prospective study aimed to highlight the epidemiological, clinical, and histological characteristics of breast cancer in Mauritanian women.

Methods and Materials

This is a descriptive study of sixty patients. The study included patients newly admitted to the National Hospital Centers (NHC) and Military Hospital Centers (MHC) in Nouakchott for the treatment of breast cancer. All histologically confirmed malignant breast tumors were included in this study. The following variables were studied: age, parity, age at first pregnancy and menarche, place of residence, socioeconomic status, medical coverage, tumor site, Scarff Bloom and Richardson histoprognostic grade, location, TNM stage, molecular phenotype, and lymph node involvement. The data were collected by consulting hospitalization records, which are kept in the archives on a pre-established sheet. Data entry and analyses were performed using Microsoft Office Excel and RStudio, respectively. Correlations between certain factors, such as the grade, stage, presence or absence of metastasis, molecular classification, tobacco consumption, and patient age were analyzed in this study. In particular, the presence of a relationship between grade and tobacco consumption was investigated.

Results

Sixty patients with breast cancer were included in this study. The average age was 48.71 ± 12.45 years, ranging from 17-70 years. The average age of menarche was 12.66 ± 1.21 years, ranging from 11-16 years. The mean age at first pregnancy was 21.89 ± 3.02. The average number of births was 1.32 ± 0.60. Two of the patients were nulliparous. Overall, 43.33% were White Moors, 35% were Black Moors, 10% were Fulani, 8.33% were Wolof, and 3.33% were Soninke. A total of 53.33% of patients lived in rural areas; 71.66% of the patients were married, and 81.66% had a low socioeconomic level. A total of 56.66% of women had no social security coverage, and 11.66% of the patients were smokers. Only 5% of the patients were physically active, and 93.33% of patients had palpable nodules.

In our series, the most marked clinical tumor size according to the TNM classification was T2 (74,98%) (Figure 1). Of the tumors, 65% were stage IIA and 28.33% were stage IIB (Figure 2). The SBR grade II was the most represented in our series (73.33%) (Figure 3). The right breast alone was the most frequently affected (58.33%), followed by the left breast alone (36.66%), and bilateral location (5%).

fig 1

Figure 1: Distribution of cases by TNM classification

fig 2

Figure 2: Distribution of cases by disease stage

fig 3

Figure 3: Distribution of cases according to grade

Histological analysis showed that invasive ductal carcinoma (70% of cases) was the most frequent type (Table 1). Regarding immunohistochemical profiles, the analysis revealed that 44% of the tumors were luminal A type, 24% triple-negative type, and 22% luminal B type (Table 2). Of these patients, 51.33% had undergone chemotherapy. Local recurrence was observed in 41.66% of patients and regional recurrence in 1.66% of patients. Of these patients, 16.66% presented with metastasis. 97% of patients are alive during hospitalization (Figure 4).

Table 1: Case distribution according to histological groups

Histology

Adenofibroma

IC

DC

NSC

SC

MC

DC (L)

PC

DC (R)

Number

1

1

2

6

1

1

42

5

1

Frequency

1.66

1.66

3.33

10

1.66

1.66

70

8.33

1.66

IC: Invasive Carcinoma; DC: Ductal Carcinoma; NSC: Non-specific Carcinoma; SC: Sarcoma Carcinoma; MC: Mixed Carcinoma; PC: Phyllodes Carcinoma; CRC: Cribiform Carcinoma

Table 2: Distribution of biological subtypes

Phenotype

HER2+

Luminal A

Luminal B

Triple negative

RP+ RE- HER2+

RP+ RE- HER2-

Number

3

22

11

12

1

1

Frequency

6

44

22

24

2

2

fig 4

Figure 4: Patient mortality distribution. Yes: alive; No: dead

The results are shown in Figures 5-10. Patients who smoked had more grade III tumors. In addition, age was significantly correlated with disease stage (p=0.047) and molecular classification (p=0.0011).

fig 5

Figure 5: Correlation between age and grade

fig 6

Figure 6: Correlation between age and stage

fig 7

Figure 7: Correlation between age and molecular classification

fig 8

Figure 8: Correlation between age and presence of metastasis

fig 9

Figure 9: Correlation between age and tobacco consumption

fig 10

Figure 10: Histological grade according to tobacco consumption

Discussion

We enrolled 60 patients with newly diagnosed breast cancer. The 40-50 age group accounts for 36.66% of women affected by this pathology. The median age at the time of diagnosis was 48.71 years. This does conflicts with the data obtained in France (mean age: 61 years) [6], and in Algeria (average age: 50 years) [5]. The average age at menarche was 12.66 years in this study. The literature data are consistent with those of our study; we found that more than half (58.33%) of our patients had their first period at ≤12 years, and puberty before 12 years is known to increase the risk of breast cancer in adulthood through longer exposure to estrogen. The incidence of nulliparity was low in the present study. However, our patients were not multiparous and the majority (71.66%) only had one child. However, a higher number of children appeared to have a protective effect [7].

Breast cancer diagnoses often occur at a late stage, which could be due to insufficient health education and the poor socioeconomic status of the population. Of our patients, 16.66% were in a metastatic stage at the time of diagnosis. Considering these factors, it is clear that screening and awareness campaigns should be launched and strengthened to help resolved these problems. Of the patients, 93.33% discovered the disease through self-examination of a nodule. In 58.33% of cases, the tumor involved the right breast. The predominance of cancer in one breast over the other can be explained by breastfeeding habits [8]. In the literature, breast cancer is generally unilateral and rarely affects both the breasts. This was confirmed by our study, in which bilateral localization representing only 5%.

A relatively high number of young patients experience additional problems in terms of care. Indeed, several studies [9-12] have reported that breast cancer in young women tends to be more aggressive with a higher frequency of grade III SBR classification and negative estrogen receptors; in our study 20% of the patients were young (<40 years). Measurement of tumor size, both clinically and macroscopically, is an important prognostic element for therapeutic management. In our series, we noticed a slight decrease in advanced T3 and T4 forms compared to the results found in the studies by Mesmoudi [13] and Marrakech [14]. The T2 form was the most common (74.98%). The histological type was identified in all patients; invasive epithelial tumors were the most frequent, with infiltrating ductal carcinoma occurring in 70% of the cases.

Many studies have established that patients with locoregional metastases have poorer prognoses than those without lymph node involvement. Overall, ten-year survival is 70% when there is no lymph node involvement, and 25-30% in the presence of neoplastic invasion of the lymph nodes [15]. In our series, 96.66% of patients had lymph node invasion, and an average of two nodes were affected. All studies showed that metastatic risk and survival are strongly correlated with grade, regardless of the grading system used, and SBR grade III was associated with poorer prognosis than grades I and II. In the present study, grade II tumors had a predominance of 73.33%. Hormonal estrogen receptors are markers of tumor differentiation, whereas progesterone receptor positivity reflects the functionality of estrogen receptors. Hormonal receptors are prognostic factors because their expression is an indicator of good prognosis and is especially predictive of the response to hormone treatment [16]. Hormone receptors were studied in our patients, and 24% were triple negative.

Conclusion

Late diagnosis continues to worsen the prognosis for this cancer. The other findings in terms of epidemiological, clinical, and histopathological aspects were similar to those of previous studies in developing countries. Through this study, we concluded the following: 1) the rate of tumors diagnosed at a late stage remains relatively high; 2) the rate of tumors with a high histoprognostic grade and histological lymph node invasion remains significant; 3) invasive epithelial tumors are the predominate type of breast cancer. Breast cancer remains a serious pathology that is difficult to overcome, and its management remains hindered by socioeconomic conditions; therefore, a screening policy at a cost affordable to the population should be implemented and the awareness campaigns should be continued.

References

  1. Parkin DM, Whelan SL, Ferlay J, Teppo L, et al. (2002) Cancer Incidence in Five Continents: Volume VIII. Lyon: International Agency for Research on Cancer 155. [crossref]
  2. Ferlay J, Ervik M, Lam F, Colombet M, et al. (2020) Global Cancer Obser-Vatory: Cancer Today. International Agency for Research on Cancer; Lyon, France.
  3. Baba ND, Sauvaget C (2013) Le cancer en Mauritanie: résultats sur 10 ans du registre hospitalier de Nouakchott. Pan Afr Med J 14: 149. [crossref]
  4. Mohamed S (2017) Étude Épidémiologique de cancers en Mauritanie. Mémoire de Master Université de Nouakchott AL Asriya.
  5. Bouzbid S, Aouras H, Djeddi H, Yassi F (2014) Le cancer du sein chez la femme dans le département d’Annaba, Algérie. Revue d’Épidémiologie et de Santé Publique 62: S215.
  6. World Health Organization. Morocco: Incidence, Mortality and Prevalence by cancer site. Globocan 2018. Accessed 23 November 2019.
  7. Pathak DR, Speizer FE, Willet WC, Rosner B, et al. (1986) Parity and breast cancer risk: possible effect on age at diagnosis. Int J Cancer 37: 21-25. [crossref]
  8. Bonafos M, De Canelier R (1971) Cancers génitaux de la femme algérienne. Revue Afrique Noire 18: 235-240.
  9. Bakkali H, Marchal C, Lesur-Schwander J, Verhaeghe L (2003) Le cancer du sein chez la femme de 30 ans et moins. Cancer/radiothérapie 7: 153-159.
  10. Tabbane F, El May A, Hachiche M, Bahi J, et al. (1985) Breast cancer in women under 30 years of age. Breast Cancer Res Treat 6: 137-144.
  11. Althuis MD, Brogan DD, Coates RJ, Daling JR, et al. (2003) Breast cancers among very premenopausal women (United States). Cancer Causes Control 14: 151-160. [crossref]
  12. De Jesus MA, Fujita M, Kim KS, Goldson AL (2003) Retrospective analysis of breast cancer among young African American females. Breast Cancer Res Treat 78: 81-87. [crossref]
  13. Menikhar I (2017) Cancer du sein étude rétrospective à propos de 270 cas au CHU Ibn-Rochd de Casablanca. Casablanca-Maroc. Faculté de médecine et de pharmacie de Casablanca.
  14. Bouaalloucha S (2012) Le profil épidémiologique et clinique du cancer du sein chez la femme au CHU Mohammed VI de Marrakech. Marrakech- Maroc. Faculté de médecine et de pharmacie Marrakech.
  15. Galant C, Berliere M, Leconte I, Marbaix E (2010) Nouveautés dans les facteurs histopronostiques des cancers du sein. Imag. de la Femme 20: 9-17.
  16. Moise N, Hery M, Serin D, Spielmann M (2005) Cancer du sein: Compte-rendu du cours supérieur francophone de cancérologie. Saint Paul de Vence: Springer Paris. [crossref]
fig 2

Inferior Hip Dislocation during Treatment of Developmental Dislocation of Hip – A Rare Complication from Hip Abduction Splint: A Case Report and Review of Literatures

DOI: 10.31038/IJOT.2022523

Abstract

Background: DDH constitutes a group of conditions involving hip sublaxation and dislocation. It is mandatory for management of these cases to be followed by aftercare with Braces. Some complications may develop during follow-up in hip spica or hip brace.

Introduction: DDH encompasses a spectrum of diseases that includes dysplasia (a shallow or underdeveloped acetabulum), subluxation, and dislocation. These conditions are commonly seen with arthrogryposis, myelomeningocele, and Larsen’s syndrome. Cases of developmental dislocation of the hip (DDH) still occur after walking age because of Late or missed diagnosis and failed conservative treatment. Lack of follow-up leads to a lot of complications.

Case presentation: 4years old female child admitted to our hospital complaining of limbing and had neglected history of right DDH. She w managed by derotation femoral osteotomy and hip spica cast with smooth follow-up recovery. At 12 weeks an abduction hip brace was advised but follow-up last for few weeks. When returned back and during routine x-ray inferior dislocation was noticed. Patient planned for surgery and hip Spica cast. Follow-up passed smoothly for 12 months then the Spica cast replaced by Abduction hip brace. The reduction was confirmed by good x-ray.

Discussion: Bracing is an important step in follow-up treatment program of DDH. Loss of reduction as a complication may occur during follow-up regimen. Inferior hip dislocation in the hip abduction brace is a rare complication and rarely mentioned in the literatures. Avoidance of this complication can be achieved by having good orthotics in the hospital and applying the brace under supervision of the orthopedic surgeon. Immediate x-ray to check for good position of the head, and closed monitoring of the patient to detect any changes in the hip position.

Conclusion: Inferior hip subluxation in the hip brace rarely occurs as a complication during follow-up program of DDH treatment. Early recognition of this complication and reduction of the flexion angle led to a stable dislocation of the hip.

Keywords

Developmental hip dislocation, Dysplasia, Hip spica, Hip brace

Introduction

Developmental hip dysplasia (DDH) encompasses a spectrum of conditions that include dysplasia (a flat or underdeveloped acetabulum), subluxation, or dislocation. There is also a teratologic hip that is dislocated in utero and irreducible on neonatal examination. It has a pseudo-acetabulum, and is associated with neuromuscular and genetic disorders. These disorders are common in arthrogryposis, myelomeningocele, and Larsen syndrome. Cases of developmental hip dislocation (DDH) continue to occur even after walking age owing to late diagnosis or failure of conservative treatment [1]. Conservative or surgical treatment for DDH needs aftercare for braces. Lack of aftercare leads to a lot of complications related to Spica Casting – hip abduction braces (Figure 1). These complications involve compression of femoral nerve due to hyperflexion, inferior dislocation, skin detachment and the most important one is avascular necrosis of femoral head. Care of the cast or the brace should bear attention to the fully reducible hip, child not attempting to stand, close regular follow-up (every 1-2 weeks) by imaging and adjustments of the brace when necessary by the surgeon[2-3]. Pavlik Harness Failure may occur due to: Improper application and follow-up by the physician, inadequate initial reduction, failure to recognize persistent dislocation and poor parent compliance. The risk factors predispose to Pavilk harness failures include: bilateral hip dislocation, age greater than seven weeks prior to initiation of treatment with the harness and lack of Ortolani sign at initial examination.

fig 1

Figure 1: Spica Casting – hip abduction braces

Case Presentation

Four years female child presented to the orthopedic department of El-Hussein University Hospital with painless limping, limb shortening and radiographs showed a neglected right DDH. The patient was scheduled for surgery (femoral shortening with derotation osteotomy) and hip spica. Recovery was smooth and follow-up care was good. At 12 months the hip Spica was removed and the patient was advised to have an abduction hip brace. She went to a place outside the hospital and the technician applied the brace. The patient did not come back to the hospital to continue the follow-up program. After 6 weeks the child’s parents returned back to our hospital to make sure of the condition. Unfortunly plain x-ray showed strange inferior dislocation of hip (Figure 2a and 2b) and CT confirmed the diagnosis Figure 3.

fig 2

Figure 2: X-ray showing strange inferior dislocation of hip

fig 3

Figure 3: CT diagnosis

Plan of Management

The patient was scheduled for operative intervention. Closed reduction was an attempt first but failed as there was a band of elasticity feeling preventing relocation of the hip. We decided to go to open intervention.

Operative Details

We used the same incision. The operative findings revealed the femoral head was buttonholed in the capsule that preventing reduction. The capsule was release and the head was relocated easily to the acetabulum. The position was checked by C-arm and hip Spica applied for 4 weeks. The abduction hip splint was applied by the orthopedic surgeon and an immediate X-ray was done and confirmed the good reduction (Figure 4). The postoperative course was uneventful, with no early or late infection being observed. The results were evaluated according to modified McKay criteria, Severin radiological criteria, and Bucholtz – Ogden system of AVN grading after a mean follow-up for 6 months. In the last follow-up, the Clinical Evaluation patient reported no significant hip pain, and radiologically no signs of dislocation or AVN (Figure 5).

fig 4

Figure 4: X-ray of abduction hip splint

fig 5

Figure 5: Radiologically no signs of dislocation or AVN

Discussion

Bracing is considered a gold standard in treating Developmental Dysplasia of the Hip (DDH) in infants less than 6 months of age with reducible hips. A variety of braces are available that work on similar principles of limiting hip adduction and extension. The brace eliminates dislocating forces from the hamstrings, the block to reduction of the psoas and improves the muscle line of pull to stabilize the hip joint [4]. The use of excessive force or exceeding the safe zone to maintain hip position can lead to complications, such as femoral nerve palsy and avascular necrosis (AVN) [5-6]. Inferior dislocation (obturator dislocation) from the abduction brace rarely mentioned in literature. Rombouts and Kaelin [3] mention two cases of inferior dislocation but in a neonate due to the Pavlik harness. Also, they reviewed the literatures and mentioned Five cases of inferior (obturator) dislocation complicating the treatment of developmental dislocation of the hip that had been reported previously [7-10]. Only one of these cases was in a neonate [10]. Pediatric orthopedic surgeons have been aware of the problem but no one has studied it fully to declare why it happens and there were no studies to follow up and report on the final results for children with this complication. Ramsey et al. [11] emphasized that adequate hip flexion must be obtainable so that the femoral head is directed towards the triradiate cartilage. Excessive hip flexion, however, directs the metaphysis of femur to come below the triradiate cartilage and may produce an inferior (obturator) dislocation. This complication is classified as grade IIIb according to the Clavien-Dindo classification [12] (Intervention under general anesthesia). To avoid this complication we need to have good orthotics in the hospital, application of the brace should be under the supervision of the orthopedic surgeon, immediate x-ray to check for good position of the head, and closed monitoring of the patient to detect any changes in the hip. In our case and after open reduction; a hip spica cast was applied and followed for 4 weeks. After that an abduction brace was applied carefully by the surgeon and under C-arm image control to verify the proper location of the hip. The brace was gradually weaned over a period of several months [13].

Conclusion

Abduction brace can cause inferior hip dislocation during treatment of DDH. Gentle manipulation may be tried and if failed go for open reduction. Closed monitoring of the brace is mandatory. Early recognition of the complication and diminution of the angle of flexion gave a stable relocation of the hip joint.

Abbreviations

DDH: Developmental Dysplasia of Hip; AVN: Avascular Necrosis

References

  1. Gulati V, Eseonu K, Sayani J, Ismail N, Uzoigwe C, et al. (2013) Developmental dysplasia of the hip in the newborn: A systematic review. World J Orthop 4: 32-41. [crossref]
  2. Viere RG, Birch JG, Herring JA, Roach JW, Johnston CE (1990) Use of the Pavlik harness in congenital dislocation of the hip. An analysis of failures of treatment. J Bone Joint Surg Am 72: 238-244. [crossref]
  3. Rombouts JJ, Kaelin A (1992) Inferior (obturator) dislocation of the hip in neonates. A complication of treatment by Pavlik harness. J Bone Joint Surg Br 74: 708-710. [crossref]
  4. Merchant R, Singh A, Dala-Ali B (2021) Principles of Bracing in early management of Developmental Dysplasia of Hip.Indian Journal of Orthopaedics 55: 1417-1427. [crossref]
  5. Tiruveedhula M, Reading I, Clarke N (2015) Failed Pavlik harness treatment for DDH as a risk factor for avascular necrosis. Journal of Pediatric Orthopedics 35: 140-143. [crossref]
  6. Pool RD, Foster BK, Paterson DC (1986)Avascular necrosis in congenital hip dislocation. The significance of splintage. J Bone Joint Surg Br 68: 427-430. [crossref]
  7. Lloyd-Roberts GC, Swann M (1966)Pitfalls in the management of congenital dislocation of the hip.J Bone Joint Surg Br 48: 666-681. [crossref]
  8. Mubarak S, Steven G, Raymond V, Bert McKinnon, David Sutherland D (1981) Pitfalls in the Use of the Pavlik Harness for Treatment of Congenital Dysplasia, Subluxation, and Dislocation of the Hip. J Bone Joint Surg 63: 1239-1248. [crossref]
  9. Mendez AA, Keret D, MacEwen GD (1990) Obturator dislocation as a complication of closed reduction of the congenitally dislocated hip: a report of two cases.J Pediatr Orthop 10: 265-269. [crossref]
  10. Langkamer V, Clarke G, Witherow P (1991) Complications of splintage in congenital dislocation of the hip. Archives of Disease in Childhood 66: 1322-1325.
  11. Ramsey PL, Lasser S, MacEwen GD (1976) Congenital dislocation of the hip. Use of the Pavlik harness in the child during the first six months of life. J Bone Joint Surg 58: 1000-1004. [crossref]
  12. Dindo D, Demartines N, Clavien PA (2004)Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey.Ann Surg 240: 205-213.
  13. Emara K, Kersh MA, Hayyawi FA (2019) Duration of immobilization after developmental dysplasia of the hip and open reduction surgery. Int Orthop 43: 405-409. [crossref]

Lupus Pancreatitis in City Rheumatological Consultation in Bamako (Mali)

DOI: 10.31038/IJOT.2022522

Abstract

Lupus pancreatitis is a rare but potentially severe entity. It is a visceral complication of multifactorial and poorly elucidated pathogenesis. The diagnosis combines two of the three criteria: typical pain, the elevation of pancreatic enzymes above three time’s normal, and imaging. Improved prognosis depends on early diagnosis and efficient treatment. We describe the diagnostic approach and clinical features of a 19-year-old melanoderma patient.

Keywords

Pancreatitis, Systemic Lupus, Mali

Introduction

Described for the first time in 1939 by Reifeinstein et al [1], pancreatitis is a rare visceral manifestation during Systemic Lupus Erythematosus (SLE). Its incidence varies from 0.4 to 1.1 cases per 1000 lupus per year. Early diagnosis is pledge of an efficient therapy (corticosteroids and immunosuppressants) to ensure a good prognosis. We report our first observation in a melanoderma subject suffering from SLE in severe flare [2-4].

Observation

A 19-year-old girl had been followed for 45 days for SLE and chronic endoscopic gastritis. The diagnosis of SLE was based on the EULAR/ACR 2019 classification criteria (presence of antinuclear antibodies, malar rash, alopecia, synovitis, fever, leuco-neutropenia). The therapy included prednisone (10 mg/day) and azathioprine (100 mg/day). She is hospitalized in emergency for transfixing epigastric pain, abdominal pain, diarrhea, incoercible vomiting and fever. The physical examination noted patient lying in trunk’s anteflexion, feverish at 40°c, epigastric defense and distended abdomen, with much rumbling. SLE activity was very high with a SLEDAI score of 24. Biological assessment revealed inflammatory syndrome (CRP at 150 mg/L, ESR at 110 mm), amylasemia at 392 IU/L and lipasemia at 853 IU/L. Liver tests and stool examinations were normal. The chest-abdominal-pelvic CT-scan was normal. The diagnosis adopted is lupus pancreatitis after having eliminated other causes (biliary lithiasis, toxic, traumatic, drug and neoplastic). She received a bolus of methylprednisone, parenteral analgesics, isocoagulation and rehydration. She underwent a strict 48 hours diet. The evolution was favorable to 5th day hospitalization with apyrexia and pain amendment. The relay by oral corticosteroids and hydroxychloroquine was instituted.

Discussion

The occurrence of pancreatitis can complicate the evolution of connectivitis, vasculitis and granulomatosis. Pancreatic involvement during SLE is rare. Its incidence varies from 0.4 to 1.1 cases per 1000 lupus per year. It can be concomitant with other lupus disorders in 50% of cases, inaugural and revealing in 11% of cases, or a potentially serious complication. It was subsequent in our patient, which is a particularity. The pathogenesis of this pancreatitis is not well understood. It is multifactorial; difficult to separate what amounts to vasculitis, thrombosis in the context of anti-phospholipid syndrome, or iatrogenic or concomitant complications. The diagnosis is based on the association of two of the following three criteria: • Typical pain • Increased pancreatic enzymes above three times normal • Computed tomography (CT) imaging, remnography (MRI) or ultrasound [5-7]. Pancreatic pain is relieved by anteflexion of the trunk (pancreatic position) and aspirin. In our patient, epigastric pain incorrectly labelled as gastritis by digestive endoscopy could lead to mistake. The classic aspirin therapy test was not done for fear of a hypothetical gastric perforation. However, any abdominal pain syndrome and/or vomiting in a lupus context suggest lupus pancreatitis. The elevation of lipasemia is of a better diagnostic specificity because lipase is exclusively pancreatic. The elevation of protein C Reactive has an interest in prognosis but she suggested looking for infectious etiology in the patient. CT-scan has proved to be the reference examination in the diagnosis but the pancreas can be normal in 14 to 29% of cases as in our patient. The drug toxicity in this case of azathioprine and prednisone can be invoked initially acute pancreatitis [8,9]. However, the chronology of evident clinical signs in our patient minimizes iatrogenia. Many observations in the literature raise the difficulty of specifying the exact etiology of lupus pancreatitis, even autopsy studies are often non-contributory [10]. Most authors proceed by excluding other possible etiological factors and improving symptomatology with anti-inflammatory treatment to indirectly retain, responsibility for SLE. Efficient therapeutic management depends on early diagnosis for a good prognosis. Methylprednisone bolus having improved the patient, a relay with oral corticosteroids and substitution of azathioprine with synthetic antimalarials (hydroxychloroquine) was decided.

Conclusion

Most lupus pancreatitis has been described in leukoderma subjects. However, our first observation in melanoderma does not suggest any singularity. In all cases, the best prognosis depends on early diagnosis and efficient management.

References

  1. Papo T, Le Tchi HD, Godeau P, Piette JC (1997) Pancreatitis and systemic diseases. Gastroenterol Clin Biol 21: 768-775. [crossref]
  2. Kefi A, Kammoun S, Jaziri F (2019) Lupus pancreatitis: a rare but potentially serious disease! Revmed 40: A105-A214.
  3. Aringer M, Costenbader K, Daikh D (2019) European League Against Rheumatism/American College of Rheumatology Classification Criteria for Systemic Lupus Erythematosus. Arthritis Rheumatol 7: 1400-1412. [crossref]
  4. Bombardier C, Gladman DD, Urowitz MB(1992) Derivation of the SLEDAI. A disease activity index for lupus patients. Arthritis & Rheumatism 35: 630-640. [crossref]
  5. Alaoui M, Ammouri W, Bourkia M (2018) Acute lupus pancreatitis: About 18 cases. Revmed 39: A23-A102.
  6. Jebali A, Gharsallah G, Klii R (2014) Acute pancreatitis and haemopagocytic syndrome during a lupic outbreak. Revmed 35S: A96-A200.
  7. Ben DB, Aydi Z, Boussema F (2012) Lupus pancreatitis: a series of 6 cases. J Afr Hepatol Gastroenterol 6: 169-174. [crossref]
  8. Agostini S, Durieux O, Mirabel T (2000) Chronic pancreatitis. Encycl Méd Chir Radiodiagnostic – Digestive System 33: 652-A-10.
  9. Bléry M, Tasu JP, Rocher L (2002) Imaging of acute pancreatitis. Encycl Méd Chir Radiodiagnostic – Digestive System 33: 651-A-10.
  10. Uchida K, Okazaki K, Konishi Y (2000) Clinical analysis of autoimmune-related pancreatitis. Am J Gastroenterol 95: 2788-94.
fig 17

The Effect of Loading of Bioactive Glass in Desensitizing Polishing Pastes on Tubular Occlusion

DOI: 10.31038/JDMR.2022611

Abstract

Objective: To determine 1) the most effective loading of the bioactive glass in a prophylactic polishing paste containing Bioactive glass particles that provides a more effective tubular occlusion and 2) the ideal application time required to achieve this objective using an in-office rotary cup with a fixed pressure and speed.

Materials and Methods: 60 dentine discs were divided equally into 15 groups treated with 0%, 5.0%, 15.0% and 25.0% bioactive glass loading respectively and Nupro® at different applications (30, 60 and 120 seconds). Dentine permeability (Percentage flow rate) of each specimen was measured using a modified Pashley hydraulic conductance model at four different time points: (1) before toothpaste application, (2) after toothpaste application, (3) after saliva immersion and (4) after an acid challenge. Data were analysed by ANOVA to determine whether there were any significant differences with the control group (Nupro®) compared to the test groups at three different time intervals (30, 60 and 120 seconds). 20 dentine discs were analysed to observe the surface tubular occlusive effect following application of the various loadings at different times using scanning electron microscope (SEM).

Results: There was an increased percentage fluid flow rate (FR) reduction with increasing bioactive glass loading (0.0%, 5.0%, 15.0%, 25.0%) compared to the control material Nupro®. The 25% bioactive glass loading was the most effective in reducing fluid flow at the various time points although there were no significant differences between the 15% and 25% glass loading. The 25.0% bioactive glass loading at 120 seconds also demonstrated effective tubular occlusion compared to the control prophylaxis paste. A comparison between the control and the various glass loadings at the various time points using SEM demonstrated increasing tubule occlusion with increasing time of application. Tubular occlusion also increased following artificial saliva immersion but decreased following an acidic challenge.

Conclusions: Increasing the bioactive glass loading resulted in a greater fluid flow rate reduction with an increase of time of applications. Overall, the most effective application was with the 25% loaded bioactive glass at 120 seconds although the application of the 15% loaded bioactive glass prophylaxis paste for 30 seconds demonstrated effective tubular occlusion and fluid flow reduction.

Keywords

Bioactive glass, Desensitising polishing pastes, Tubular occlusion, Hydraulic conductance

Introduction

According to Hench 45S5 bioactive glass was developed as a bone ceramic [1] which was also used to  improve  periodontal bone  regeneration in bony defects caused by periodontal disease-(PerioGlas®) [2].  Several investigators [3-6] have also evaluated a bioactive glass (45S5) as a desensitizing toothpaste without fluoride. More recently bioactive glass-based toothpastes have been developed for over the counter (OTC) products. These products include NovaMin® (GlaxoSmithKline [GSK]) containing fluoride and BioMinF™ (Biomin Technologies Ltd) although the surface deposits on the exposed dentine are different with. NovaMin® producing a hydroxy carbonate like apatite (HCA) layer whereas BioMinF™ provides a fluoroapatite layer, which is more resistant to an acid challenge [7]. Bioactive glass (45S5) has also been incorporated into a prophylactic polishing paste (in-office dental procedure) to remove stain and reduce dentine hypersensitivity (DH) (Nupro®). Previously there were limited published data regarding the ideal loading concentration of bioactive glass into either toothpaste or polishing paste formulations although Tie et al. [8] reported that a 5% glass loading was the ideal concentration for a toothpaste formulation. Sauro et al. [9] compared dentine permeability in vitro for both prophylactic and air-polishing procedures and concluded that a Sylc bioactive glass (Sylc™; OSspray, London, UK) was more effective in reducing dentine permeability  in both the polishing paste and air-polishing systems compared to  the controls. Milleman et al. [10] compared a Nupro® Sensodyne prophylaxis paste with Novamin® for the treatment of DH in a 4-week clinical study and concluded that the reduction in DH was statistically significantly compared to the group receiving a standard prophylaxis paste. No differences were, however detected between the two NovaMin® polishing pastes with and without fluoride. Neuhaus et al. [11] also conducted a double-blinded  randomised  clinical  trial and concluded that a 15% NovaMin® loading with and without fluoride had the same immediate DH effect for 28 days following root surface debridement (RSD). A systematic review by Zhu et al. [12] concluded that the prophylaxis paste containing 15% calcium sodium phosphosilicate was favoured over the negative control at reducing post-periodontal therapy DH (root sensitivity), although the level of evidence was categorized as “low”.

Aim

The aim(s) of the present study, therefore, was to 1) to determine the most ideal loading for a bioactive desensitising polishing paste with the most tubular occlusion and 2) to determine the effect of the application time (30s, 60s, 120s) and the effect of an acidic challenge on each of the experimental bioactive glass prophylactic polishing pastes with the percentage of loading (0%, 5%, 15%, and 25%).

Materials and Methods

This exploratory study was based on two objectives. The first part of the study was designed to choose the ideal abrasivity of the pumice that would be incorporated into prophy-paste formulations using white light profilometry has been previously described by Hussain  et al. [13]. The second part of the study evaluated selected pastes to determine their effectiveness in tubular occlusion using scanning electron microscopy (SEM) and hydraulic conductance (Fluid flow) techniques and is the focus of this paper.

Preparation of Materials

Collection of Teeth

A total of 120 extracted, caries free human premolars and molars were collected from  the  walk-in  dental  polyclinics  from  Kuwait in 2017 after obtaining verbal consent from patients for the use of their teeth in research. The teeth were stored in a small container of Listerine mouthwash (Johnson and Johnson, UK) and brought to the UK by Hamad Hussain (HFH) under QMUL guidelines UK. The teeth were transferred and stored in a 70% concentration Ethanol solution in a specimen container at room temperature within the Department of Dental Physical Sciences Unit at Mile End, London in accordance with HTA regulations.

Preparation of Mid Coronal Dentine Sections

90 non-carious human premolars, and molars were selected and prepared into dentine disc specimens of 1.2 mm thickness as described by Tie et al. [8] using an automatic precision cutting machine (Struers Accutom 5, Denmark). The dentine discs were then ground using a Kemet 4 machine (Kemet Maidstone Kent ME15 9NJ UK) followed by polishing with three different silicon carbide papers in a descending order of abrasive coarseness, starting from carbide paper grade P600, P1000 to P2500. The polishing was considered complete when the discs were polished to a thickness of 1.0 mm. The thickness of the discs was monitored constantly using a digital micrometer to avoid over polishing.

Etching of Dentine Sections

The etching of dentine discs was performed prior to using the discs for the experimental steps. This was performed by immersing the discs into 6% w/w citric acid solution for two-minutes. The discs were ultrasonicated with deionized water in an ultrasonic bath for 30 seconds to remove any residual acid using the methodology described by Tie et al. [8].

Artificial Saliva Preparation

Artificial saliva was prepared using the following constituents: 2.24 grams of KCl, 1.36 grams of KH2 PO4, 0.76 grams NaCl, 0.44 grams of CaCl2 .2H2 O, 2.2 grams of porcine Mucin and 0.2 grams of NaN3 (all Sigma-Aldrich, UK) which was mixed with 800 grams of deionized water in a 1 litre volumetric flask. The mixture was stirred using a magnetic hotplate stirrer for 30 minutes until all reagents were fully dissolved. The mixture’s pH was then adjusted to 6.5 at room temperature using a pH meter (Oakton, Netherlands) by adding 0.5 M of KOH sequentially until the desired pH was obtained. Separately, 0.5 M of KOH was previously prepared by mixing 1.40 grams of KOH (Sigma-Aldrich, UK) in 50 ml deionized water. The final mixture was made up with deionized water to 1 litre. The produced artificial saliva solution was kept in a fridge set at 5°C until required and used within 2 weeks of preparation [8].

Preparation of the Prototype Bioactive Glass Polishing Paste

The bioactive glass used in the prophy-paste formula was BioMin F which was manufactured by Cera Dynamics Ltd Stoke UK and is the same glass powder used by Biomin Technologies Limited, UK in toothpaste formulations. The composition of the Bioactive Glass is shown in Table 1. The material was stored at room temperature in a closed dry container until required.

Table 1: Composition of the Bioactive Glass used in the prophy paste

table 1

Preparation of the Prophylaxis Polishing-Paste for the Different Bioactive Glass Loading

The composition of prophy-paste components that was prepared in the laboratory was based on the components’ range of the Safety Data Sheet number 801363 of Nupro® Sensodyne® Prophylaxis Paste with Novamin® (GSK). Initially this consistency (viscosity) of this formula was poor and therefore the formula was modified as shown in Table 2. Materials were measured separately, and mixed using a metal spatula, and then stored at room temperature until required.

Table 2: Composition of both loaded and unloaded prophy-paste to produce 90 grams that was used during the main study

table 2

The final loading percentages of both the formulated Biomin prophylaxis polishing paste and pumice control are shown in Table 3.

Table 3: Loading percentages of both the formulated Biomin prophylaxis polishing prophy-paste and pumice control

table 3

Methodology

Preparation of Samples and Procedures

The experimental sample was composed of 60 teeth that were adequately prepared on the dentine discs following a specific protocol before starting the experimentation.

Scanning Electron Microscopy

15 out of 20 etched stored dentine discs were used in this study. A prophylaxis polishing-paste was applied on the discs at the different proportions of the bioactive glass (0%, 5%, 15%, 25% and, Nupro® control) and for the different times (30s, 60s, 120s) using a portable prophylaxis polishing handheld device (Table 3). Three-dentine discs were assigned for every prophylaxis polishing-paste group. Each disc was fractured into equal halves using orthodontic pliers to provide two sections. One dentine disc was used for (1) untreated control and (2) treated with a prophy-paste for 30 seconds. The second one was used for (3) treated with the same prophylaxis polishing-paste for 60 seconds and (4) treated with the same prophy-paste for 120 seconds. The third dentine disc that was halved was used for (5) treated with the same prophylaxis polishing- paste, salivary immersion, and one-minute in an acid challenge and (6) treated with the same prophylaxis polishing-paste, salivary immersion and a two-minute acid challenge. The five groups were tested using the same protocol. The same process was also used when treating the dentine discs for hydraulic conductance procedure (Table 4).

Table 4: The number of discs by percentage (%) glass loading and the time of application

table 4

Prior to the SEM analysis and visualisation, the specimens were prepared for drying, mounting, and coating. After applying the treatment to all specimens, they were placed in a vacuum desiccator to dry. Each specimen was then mounted on a metal stub using double sided carbon tape. Finally, the specimens were coated with gold-palladium using a sputter coater. After the specimens were prepared by the three above steps, they were visualised using SEM (FEI Inspect F SEM, USA) at different magnification of x1000 and 10,000. The working distance, which is the distance between the specimen and the source beam was maintained at  a fixed 10mm) for all the specimens with a working voltage at 20kV [6].

Hydraulic Conductance (FRR Values)

Based on the design developed by Outhwaite, et al. [14,15], a modified Pashley hydraulic conductance was used in the study to measure dentine permeability (Lp).

45 teeth (molar) were used for the evaluation of hydraulic conductance (Lp) following initial immersion in 6% citric acid for two minutes, teeth were divided into the test groups (1, 2 and 3). Baseline fluid flow (FR) measurements were recorded prior to the application of the test and control prophylaxis polishing pastes at  the designated timings and loadings. Following application of the designated prophylaxis polishing paste and timings the discs were rinsed in deionised water for 10 seconds and placed in the modified Pashley conductance system and FR measurements were recorded. All teeth were subsequently immersed in 10ml of artificial saliva for 30 seconds, rinsed and immersed in 30ml of 6% citric acid for one and two minutes and a final set of FR measurements were recorded. The teeth were subsequently air dried and prepared for SEM evaluation (500x, 1000x, 5000x and 10,000x magnification)

Analysis of the dentinal permeability measurement was conducted as follows [8]:

a) Percentage flow reduction after treatment with the polishing paste.
for 1

b) Percentage flow reduction after treatment with the polishing paste and immersion in artificial saliva.

for 2

c) Percentage flow reduction after treatment with polishing paste, immersion in artificial saliva and acid challenge.

for 3

where V0 = Dentine permeability at baseline (after acid etch)

V1 = Dentine permeability immediately after polishing paste application

V2 = Dentine permeability following immersion in artificial saliva

V3 = Dentine permeability following acid challenge

Statistical Analysis

Mean, standard deviation with 95% C.I.: for each variable was assessed. for the total sample used in the explorative study. A one- way ANOVA was estimated to compare flow rate, FR, means between the different loading groups at a specific time of application as well as assessing the effect of time of application for a specific loading of the bioactive glass. Bonferroni´s post-hoc test was used as a multiple comparison test, to control the propagation of a Type-I error. A two- way ANOVA with between subjects’ factors, the loading group and time of application was also used to explore the interactions and obtain the overall conclusions regarding the effect of both factors.  In view of the low numbers of disks used in this explorative study    a complementary non-parametric Brunner-Langer model was employed Distributions (not means) of FR rates were compared using an ATS-test (ANOVA-type).

Results

The permeability of the dentine tubules in  the  dentine  discs was tested and previously established as a laboratory technique to measure the fluid rate reduction using hydraulic conductance [14,15]. The reduction of the fluid flow at the three different experimental applications (FR1 after application, FR2 after immersion in saliva, FR3 after an acid challenge) on a disc at the different loading of the bioactive glass from 0.0%, 5.0%, 15.0%, to 25.0% is shown in Table 4 and Figures 1-3 respectively. The effect of application time (30s, 60s and 120s) vs. % loading, immersion in saliva, following an acid challenge was also analysed. For example, following polishing the dentine disc for one minute, there was a gradual pattern in the percentage fluid flow reduction. The pattern of the reduction did not however exist at 0% to 5% although it showed a steady increase in Lp. There was however a significant change in the pattern increasing the reduction’s flow once the glass loading was more than 15% (at 25% loading) It was clear that after applying the prophylaxis polishing-paste for a minute, the fluid flow was reduced. There was slightly more reduction after immersing the disc in artificial saliva for an hour. Whereas a two-minute acidic challenge increased the fluid flow (Table 5).

fig 1

Figure 1: Comparison of flow rates reduction by Group (application: 30 seconds)

fig 2

Figure 2: Flow rate reduction FR1 values by the loading group after paste application at time=30s

fig 3

Figure 3: Flow rate reduction values (FR2) by loading group following saliva immersion (time=30s)

Table 5: Flow rates reduction by Group (application time: 30 seconds)

table 5

Analysis of the selected loading at 30 seconds using ANOVA (p<0.001) and Bonferroni´s test can be observed in Table 5. The 25% Bioactive glass loading provided significantly more reduction than any other concentration (p<0.001). The same analytical methodology was employed throughout the study (Table 6).

Table 6: FR1 values by loading group at the time of application=30 s: results of multiple comparisons by Bonferroni´s test

table 6

FR2: After Saliva Immersion

The FR mean was 1.19 ± 0.00% if no bioactive glass was incorporated into the prophy-paste. With the 5%- glass loading the mean increased to 39.20 ± 0.09%. Higher loading levels (15% and 25%) involved new increments to 63.01% ± 0.05 and 72.99 ± 0.49%. The fluid flow reduction of the Nupro®   solution values increased to 62.55 ± 0.05%. Therefore, the optimal tubular occlusion occurred using a 25%-loading of the Bioactive glass (Figure 3).

Analysis of the selected loading following saliva immersion using ANOVA (p<0.001) and Bonferroni´s test can be observed in Table 6. There were significant differences between the groups. Loading at 25% was the most effective. Nupro® had similar values to a 15% glass loading of bioactive glass (Table 7):

Table 7: FR2 values by loading group at the time of application=30 s: results of multiple comparisons Bonferroni´s test

table 7

FR3: After an Acid Challenge

The FR mean was 0.83 ± 0.00% if no bioactive glass was incorporated into the prophy-paste. With a 5%-proportion of glass the mean increased to 36.91 ± 0.08%. At the higher loading levels (15% and 25%) the FR reduction increased to 62.44% ± 0.05 and 72.49 ± 0.05% respectively. The Nupro®  solution FR value was 61.96 ± 0.05%. Therefore, the optimal tubular occlusion took place using a 25%-loading of Bioactive glass (Figure 4).

fig 4

Figure 4: Flow rate reduction values (R3) by loading group after an acid challenge at time=30s

Analysis of the selected loading following saliva immersion using ANOVA (p<0.001) and Bonferroni´s test can be observed in Table 7. There were significant differences between the groups. Loading at 25% was the most effective.

Analysis of FR at Time of Application=60 s

The following Table 8 and Figure 5 show the basic statistics of fluid flow reduction, FR, values over the experiment period after 60s of paste application (Table 9):

Table 8: FR3 values by loading group at the time of application=30 s: results of multiple comparisons Bonferroni´s test

table 8

fig 5

Figure 5: Flow rate reduction values by loading group at the time of application=60s

FR1: After Prophy-Paste Application

The FR mean was -5.74 ± 0.02% if no bioactive glass was incorporated into the prophy-paste glass. With the 5%-loading, this reduction increased to 39.39 ± 0.09%. At the higher loading levels (15% and 25%) the FR reduction values increased to 67.53% ± 0.05 and 74.94 ± 0.04% respectively. The Nupro®  solution FR values were 63.20 ± 0.05%. The 25%-loading of bioactive glass provided the maximum tubular occlusion values (Figure 6).

fig 6

Figure 6: flow rate FR1 reduction values by loading group after paste application at time=60s

Analysis of the selected loading following saliva immersion using ANOVA (p<0.001) and Bonferroni´s test can be observed in Table 9. There were significant differences between groups. The glass loading at 25% was the most effective (Table 10).

Table 9: Comparison of the flow reduction rate vales by Group (application: 60 s)

table 9

Table 10: FR1 reduction values by loading group at the time of application=60 s: results of multiple comparisons Bonferroni´s test

table 10

FR2: After Saliva Immersion

The FR mean was 0.84 ± 0.00% if no bioactive glass was incorporated into the prophy-paste. With 5%-loading, the FR reduction values increased to 41.18 ± 0.09%. At the higher loading levels (15% and 25%) involved new increments to 70.83 ± 0.05% and 77.17 ± 0.06%. Nupro® solution involved 65.78 ± 0.05%. Again, the 25%-loading of bioactive glass was associated with an increase in tubular occlusion (Figure 7).

fig 7

Figure 7: Flow rate FR2 reduction values by loading group after saliva immersion at time=60s

Analysis of the selected loading following saliva immersion using ANOVA (p<0.001) and Bonferroni´s test can be observed in Table 10. There were significant differences between the groups. The loading at 25% of bioactive glass was the most effective (Table 11).

Table 11: FR2 reduction values by loading group at the time of application=60 s: results of multiple comparisons Bonferroni´s test

table 11

FR3: After an Acid Challenge

The FR mean value was 0.48 ± 0.00% if no bioactive glass was incorporated into the prophy-paste. With the 5%-proportion the mean reduction increased to 39.35 ± 0.09%. The higher loading levels (15% and 25%) reduction increased to 70.52 ± 0.05% and 77.02 ± 0.04% respectively. The Nupro®   solution values were 65.41 ± 0.05%. Therefore, the optimal tubular occlusion occurred using a 25%-loading of bioactive glass (Figure 8).

fig 8

Figure 8: Flow rate FR3 reduction values by loading group after an acid challenge at time=60s

Analysis of the selected loading following saliva immersion using ANOVA (p<0.001) and Bonferroni´s test can be observed in Table 11. There were significant differences between the groups. 25% Bioactive glass loading was the most effective (Table 12).

Table 12: FR3 values by loading group at time of the application=60 s: results of multiple comparisons Bonferroni´s test

table 12

Analysis of FR Values at the Time of Application=120 s

Table 13 and Figure 9 show the basic statistics of the FR reduction values over the experiment after 120s of paste application:

fig 9

Figure 9: Flow rate reduction values by loading group at the time of application=120s

Table 13: Flow rate reduction values by group (application: 120 s)

table 13

FR1: After Prophy-Paste Application

The FR mean was -9.92 ± 0.03% if no bioactive glass was incorporated into the prophy-paste. With 5%-loading, the FR reduction increased to 40.84 ± 0.09%. The higher loading levels (15% and 25%) increased the reduction to 70.54 ± 0.05% and 77.74 ± 0.04%. Nupro®  solution involved 67.30 ± 0.05%. 25%-loading was associated to the maximum power of occlusion (Figure 10).

fig 10

Figure 10: Flow rate FR1 reduction values by loading group at time of application=120s

Analysis of the selected loading following a 120 second application time using a one-way ANOVA (p<0.001) and Bonferroni´s test can be observed in Table 13. There were significant differences between the groups. Loading at 25% was the most effective.

FR2: After Saliva Immersion

FR mean was 0.36 ± 0.00% if no bioactive glass was present. With 5%-loading, the reduction of fluid flow increased to 43.08 ± 0.09%. Higher loading levels (15% and 25%) involved newer reduction increments to 73.11 ± 0.04% and 79.23 ± 0.04%. Nupro® solution involved 70.55 ± 0.05%. The 25%-loading was associated to the maximum power of occlusion (Figure 11).

fig 11

Figure 11: Flow rate FR2 reduction values by loading group after saliva immersion at time=120s

Analysis of the selected loading following saliva immersion using a one-way ANOVA (p<0.001) and Bonferroni´s test can be observed in Table 14. There were significant differences between the groups. Loading at 25% was the most effective (Table 15).

Table 14: FR1 by loading group at time of application=120 s: results of multiple comparisons Bonferroni´s test

table 14

Table 15: FR2 by loading group at time of application=120 s: results of multiple comparisons Bonferroni´s test

table 15

FR3: After an Acid Challenge

FR mean was 0.12 ± 0.00% if no bioactive glass was present. With 5%-proportion mean reduction increased to 41.43 ± 0.09%. Higher loading levels (15% and 25%) involved new reduction increments to 72.91 ± 0.04% and 79.15 ± 0.04%. Nupro® solution involved 70.31 ± 0.05%. Therefore, the optimal tubular occlusion took place using 25%-loading (Figure 12).

fig 12

Figure 12: Flow rate FR3 reduction values by loading group after an acid challenge at time=120s

Analysis of the selected loading following an acid challenge using one-way ANOVA (p<0.001) and Bonferroni´s test can be observed in Table 16. There were significant differences between groups. Loading at 25% was the most effective.

Table 16: FR3 by loading group at time of application=120 s: results of multiple comparisons Bonferroni´s test

table 16

Analysis of FR at Loading=0%

Table 17 highlights the basic statistics of FR over the experiment following 0%-bioactive glass paste application:

Table 17: Flow rate reduction values by time of application (0% loading)

table 17

FR1: After Prophy-Paste Application

The FR1 mean was -5.05 ± 0.02% within discs treated for 30s, -5.74 ± 0.02% in discs treated 60s and, finally, -9.92 ± 0.03% for the longest duration 120s (Table 16).

Analysis of the time of application at the time of loading (0%) using one-way ANOVA (p<0.001) and Bonferroni´s test indicated that there were significant differences between times, with the time of application at 30s being the most effective option.

FR2: After Saliva Immersion

The FR2 mean was 1.19 ± 0.00% within discs treated for 30s, 0.84 ± 0.00% in discs treated 60s and, finally, 0.36 ± 0.00% for the longest duration 120s (Table 16). Analysis of the time of application at the time of loading (0%) using one-way ANOVA (p<0.001) and Bonferroni´s test indicated that there were significant differences between times, with the time of application at 30s being the most effective option.

FR3: After an Acid Challenge

The FR3 mean was 0.83 ± 0.00% within discs treated for 30s, 0.48 ± 0.00% in discs treated 60s and, finally, 0.12 ± 0.00% for the longest duration 120s (Table 16). Analysis of the time of application at the time of loading (0%) using one-way ANOVA (p<0.001) and Bonferroni´s test indicated that there were significant differences between times, with the time of application at 30s being the most effective option.

Analysis of FR at Loading=5%

Table 18 provides the basics statistics of FR reduction values over the experiment following a 5%-bioactive glass paste application:

FR1: After Prophy-Paste Application

The FR1 mean was 37.77 ± 0.08% within discs treated for 30s, 39.39 ± 0.09% in discs treated 60s and, finally, 40.84 ± 0.09% for the longest duration 120s (Table 17). Analysis of the time of application at the time of loading (5%) using one-way ANOVA (p<0.001) and Bonferroni´s test indicated that there were significant differences between times, with the time of application at 120s being the most effective option.

FR2: After Saliva Immersion

The FR2 mean was 39.20 ± 0.09% within discs treated for 30s, 41.18 ± 0.09% in discs treated 60s and, finally, 43.08 ± 0.09% for the longest duration 120s (Table 17). Analysis of the time of application at the time of loading (5%) using one-way ANOVA (p<0.001) and Bonferroni´s test indicated that there were significant differences between times, with the time of application at 120s being the most effective option.

FR3: After an Acid Challenge

The FR3 mean was 36.91 ± 0.08% within discs treated for 30s, 39.35 ± 0.09% in discs treated 60s and, finally, 41.43 ± 0.09% for the longest duration 120s (Table 17). Analysis of the time of application at the time of loading (5%) using one-way ANOVA (p<0.001) and Bonferroni´s test indicated that there were significant differences between times, with the time of application at 120s being the most effective option.

Analysis of FR at Loading=15%

Table 19 provides the basics statistics of FR over the experiment after 15%-bioactive glass paste application:

Table 19: Flow rates reduction values by time of application (15% loading)

table 19

FR1: After Prophy-Paste Application

The FR1 mean was 60.86 ± 0.05% within discs treated for 30s, 67.53 ± 0.05% in discs treated 60s and, finally, 70.54 ± 0.05% for the longest duration 120s (Table 18). Analysis of the time of application at the time of loading (15%) using one-way ANOVA (p<0.001) and Bonferroni´s test indicated that there were significant differences between times, with the time of application at 120s being the most effective option.

Table 18: Flow rate reduction values by time of application (5% loading)

table 18

FR2: After Saliva Immersion

The FR2 mean was 63.01 ± 0.05% within discs treated for 30s, 70.83 ± 0.05% in discs treated 60s and, finally, 73.11 ± 0.04% for the longest duration 120s (Table 18). Analysis of the time of application at the time of loading (15%) using one-way ANOVA (p<0.001) and Bonferroni´s test indicated that there were significant differences between times, with the time of application at 120s being the most effective option.

FR3: After an Acid Challenge

The FR3 mean was 62.44 ± 0.05% within discs treated for 30s, 70.52 ± 0.05% in discs treated 60s and, finally, 72.91 ± 0.04% for the longest duration 120s (Table 18). Analysis of the time of application at the time of loading (15%) using one-way ANOVA (p<0.001) and Bonferroni´s test indicated that there were significant differences between times, with the time of application at 120s being the most effective option.

Analysis of FR at Loading=25%

Table 20 provides the basics statistics of FR over the experiment after 25%-bioactive glass paste application:

Table 20: Flow rates reduction values by time of application 25% loading

table 20

FR1: After Prophy-Paste Application

FR mean was 70.68 ± 0.05% within discs treated for 30s, 74.94 ± 0.04% in discs treated 60s and, finally, 77.74 ± 0.04% for the longest duration 120s (Table 19). Analysis of the time of application at the time of loading (25%) using one-way ANOVA (p<0.001) and Bonferroni´s test indicated that there were significant differences between times, with the time of application at 120s being the most effective option.

FR2: After Saliva Immersion

FR mean was 72.99 ± 0.49% within discs treated for 30s, 77.17 ± 0.06% in discs treated 60s and, finally, 79.23 ± 0.04% for the longest duration 120s (Table 19). Analysis of the time of application at the time of loading (25%) using one-way ANOVA (p<0.001) and Bonferroni´s test indicated that there were significant differences between times, with the time of application at 120s being the most effective option.

FR3: After Acid Challenge

The FR3 mean was 72.49 ± 0.05% within discs treated for 30s, 77.02 ± 0.04% in discs treated 60s and, finally, 79.15 ± 0.04% for the longest duration 120s (Table 19). Analysis of the time of application at the time of loading (25%) using one-way ANOVA (p<0.001) and Bonferroni´s test indicated that there were significant differences between times, with the time of application at 120s being the most effective option.

Analysis of FR at Nupro® Group

Table 21 provides the basics statistics of FR over the experiment following the Nupro® paste application:

FR1: After Prophy-Paste Application

The FR1 mean was 57.11 ± 0.05% within discs treated for 30s, 63.20 ± 0.05% in discs treated 60s and, finally, 67.30 ± 0.05% for the longest duration 120s (Table 20). Analysis of the time of application at the time of loading (Nupro®) using one-way ANOVA (p<0.001) and Bonferroni´s test indicated that there were significant differences between times, with the time of application at 120s being the most effective option.

FR2: After Saliva Immersion

The FR2 mean was 62.55 ± 0.05% within discs treated for 30s, 65.78 ± 0.05% in discs treated 60s and, finally, 70.55 ± 0.05% for the longest duration 120s (Table 20). Analysis of the time of application at the time of loading (Nupro®) using one-way ANOVA (p<0.001) and Bonferroni´s test indicated that there were significant differences between times, with the time of application at 120s being the most effective option.

FR3: After an Acid Challenge

The FR3 mean was 61.96 ± 0.05% within discs treated for 30s, 65.41 ± 0.05% in discs treated 60s and, finally, 70.31 ± 0.05% for the longest duration 120s (Table 20). Analysis of the time of application at the time of loading (Nupro®) using one-way ANOVA (p<0.001) and Bonferroni´s test indicated that there were significant differences between times, with the time of application at 120s being the most effective option.

Analysis of FR by Both Loading and Time of Application

The analysis of the results would indicate that 1) the higher the bioactive glass loading resulted in a greater potential to occlude the tubules and 2) the longer time of application resulted in a greater potential to occlude the tubules.

Data as displayed in Figures 12-14 (FR 1-3) were used to determine whether the benefits of a high glass loading was similar for all conditions at the time of application and whether the benefit of a longer time of application was similar for all glass loading conditions. A more general statistical model was estimated to assess the interaction between both factors. The results indicated that for all flow rate reductions (FR1-3) by loading group and time of application (F-test of 2-way ANOVA.) clearly demonstrated that differences between the time of application were significant for any loading (Figure 14). This model concludes that differences are even more apparent as the glass loading was increased (p<0.001, interaction) (Figure 15).

fig 13

Figure 13: Flow rate FR2 reduction values by loading group and time of application

fig 14

Figure 14: Flow rate FR3 reduction values by loading group and time of application

fig 15

Figure 15: The relative effects from the Brunner-Langer model of the different prophy-paste loading through the three treatment FR1, FR2 and FR3 and different times 30, 60 and 120 seconds

The relative effects from the Brunner-Langer model of the different prophy-paste loading through the three treatment regimens (FR1, FR2 and FR3) and the different application times (30, 60 and 120 seconds) was also analyzed (Figure 16).

fig 16

Figure 16: Summarizes the results regarding both 15% loaded glass and Nupro® groups through the three treatment modalities FR1, FR2 and FR3 at three different times (30, 60 and 120 seconds).

This above figure demonstrates that the magnitude of the FR to the different elements (paste, saliva, acid) depends specifically in the % loading and time of application. There was a high inter-correlation involving all factors included in the analysis. In other words, the higher the bioactive glass loading was, the higher the positive effect of polishing a longer time. Alternatively, for longer times of application, the slope of the increment of FR rate is higher, that is an increment of loading involves a higher impact. For example, a 15% loaded bioactive glass showed the best effect when applied to samples for 30 seconds.

The results of the model confirmed that the pattern of FR changes depends specifically on the conditions of both loading and time of application.

Comparison between the 15%-Glass Loading and the Nupro® Polishing Paste

This comparison is important since these two products share    the same proportion of glass but are manufactured differently. For example, the 15% Bioglas loading is an experimental paste whereas the Nupro® paste is an established commercial product. Table 21 and Figure 16 compares the results between the 15% glass loading and Nupro® group at different times (30s, 60s and 120s) (Table 22).

Table 21: Flow rates reduction values by time of application (Nupro® group)

table 21

Table 22: Comparison between the 15% glass loading and Nupro® group at different times (30 s, 60 s and 120 s)

table 22

Comparison of the FR rates by loading group (15% vs. Nupro®) at different times of application: using a 2-sample t-test indicated that there were significant differences for every comparison apart from the 30s application. The results of the analysis suggested that a 15%-glass loading was better (higher FR reduction value) than the Nupro® paste (for each time and phase) (Figure 17).

fig 17

Figure 17: a-e Comparison of different prophylaxis polishing-pastes assessed in the study; 0%, 5%, 15%, 25% loaded glass and a Nupro® control at 10,000x magnification

Scanning Electron Microscope (SEM).

The surface morphologies of each dentine disc were evaluated under the scanning electron microscopy at x1000 (1k) and x10000 (10k) magnifications at different stages of treatment. For viewing the occlusal characteristic of dentine tubules, the discs were mounted flat on the stub. Each dentine disc was viewed after (1) acid etching as a control, (2) 30 seconds of a prophy-paste application, (3) 60 seconds after a prophy-paste application, (4) 120 seconds after a prophy paste application, (5) 1-minute of an acid challenge after 1-hour of salivary immersion and (6) 2-minutes of an acid challenge after 1-hour of salivary immersion.

Effect of a 0%, 5%, 15%, 25% and a Nupro® control) loading of prophylaxis polishing-paste:

In the control group where the dentine disc was etched for 2 minutes with citric acid no tubular occlusion was evident and the  open dentinal tubules were observed. Immediately after 30 seconds of applying a prophylaxis polishing-paste of 0% loading, the surface had some particles on the outer surface as well as inside the dentinal tubules, although the dentinal tubules were open. Increasing the time to 1-minue and 2 minutes with the same loading in different tooth samples, more particles were deposited over the surface of the disc, but the dentinal tubules could still be observed. When the discs were challenged in an acidic environment for one-minute and two-minutes after the discs were treated for 60 seconds and immersed for an hour in artificial saliva, there were fewer scattered particles on the dentine surface compared to the previously treated disc for a minute. Furthermore, more dentinal tubules were visualised after two-minutes of an acidic challenge (Figure 17a). Increasing the application time of 5.0% loaded prophy-paste from 30 seconds, 60 seconds to 120 seconds resulted in more scattered particles over the dentinal surface with fewer open dentinal tubules were at the 2-minutes of prophy-paste application interval. By way of comparison following increasing the time in an acidic challenge solution after 1 minute of prophy-paste treatment resulted in fewer scattered particles over the dentine surface although there were more opened dentinal tubules observed (Figure 17b). It appeared there was a pattern established when increasing the application time, since more occluded dentinal tubules were observed. After treating the sample for 30 seconds when applying the 15% loaded prophy-paste, more scattered particles and some obvious signs of angular shaped particles which appeared to be bioactive glass were noted. Once the application time increased to 60 seconds and 120 seconds, more glass particles were observed and the whole disc surface was covered with a dense layer of the material. Once the disc was placed in citric acid for 1-minute and 2-minutes, the dense layer was washed away although the prophylaxis polishing- paste material was observed inside the dentinal tubules (Figure 17c). By increasing the loading of the bioactive glass and application time, more occluded dentinal tubules were observed. After 30 seconds of application of a 25% loading, a dense layer covering the external surface of the sample was observed. No differences were noticed when applying the 25% loaded bioactive glass at 1-minue and 2-minutes. When the sample was placed as part of an acidic challenge for 1-minute, the dense layer of the material was noticed. Once the acidic challenge time increased to 2-minutes however, the orifices of the blocked dentinal tubules were observed (Figure 17d). The Nupro® control followed the same pattern as the 15% loaded prophy-paste where a dense layer was observed after 1-minute of application. When exposed to an acidic challenge, it was evident that the dense layer formed at the external surface was affected in a similar manner to the 15% loaded prophy-paste when applied after 2-minutes (Figure 17e).

Discussion

Bioactive glass has been previously used as an active ingredient in a desensitizing prophy-paste to treat DH by blocking dentinal tubules [3-6]. The use of bioactive glass products has been reported for its effectiveness in blocking dentinal tubules in a desensitising toothpaste in reducing DH [3-6] as well as an active ingredient in prophylaxis polishing pastes. Although Bioactive glass products have been incorporated in both toothpaste and prophylactic polishing pastes [12] there appears to be limited data regarding the actual percentage of the loading of Bioactive glass for a desensitizing prophylactic polishing paste as well as the time requirement for use in an in-office application. Neuhaus et al. [11] conducted a double-blinded randomised clinical trial and concluded that a 15% NovaMin® loading with and without fluoride had the same immediate DH effect for 28 days following root surface debridement (RSD). For this reason, fluoride was not incorporated into the prophy-paste formulation, however Brauer et al. [16] suggested that incorporating fluoride into dental materials bioglass formulations would be beneficial since the formed fluoroapatite layer may improve in withstanding an acidic challenge.

The effectiveness of the different loading of bioactive glass at 0.0%, 5.0%, 15%, 25% and Nupro® from Sensodyne® from Densply was investigated in the present study. Nupro® was used in the study as it was commercially available as a prophy-paste and as such was used as a control when comparing the various loading of bioactive glass in novel prophy-paste preparations in its effect on fluid flow and tubular occlusion. The other issue to be evaluated in the present study was to choose the ideal time of paste application as there was available data evidenced in the published literature. In the present study three different application times namely 30 seconds, 60 seconds and 120 seconds were selected. Due to the limited number of extracted teeth available for this study it was not possible to investigate other higher percentage loading of bioactive glass or different times and this could therefore be part of a future study. There were numerous limitations and difficulties, however when using these two techniques. Firstly, the individual tooth has unique characteristics when comparing the dentine tubules within a mid-coronal section of dentine (dentine disc). There was also a problem with source of the teeth as the age, tooth pathology and collection procedures as well as regional variations and differences with the tooth itself [17,18] which may account in turn to the regional variation in fluid flow through dentine [10]. These factors however, made standardization of the dentine discs difficult to achieve. To overcome this issue or at least minimise these effects Mordan et al. [19] developed methodology to standardize the evaluation of the dentine disc by limiting the area of evaluation to the centre of each disc and sectioning the disc into a test and control section for comparison.

Dentine Permeability Evaluation

The results of the first treatment phase which included applying the different loading of bioactive glass in prophy-pastes for different times showed a reduction in dentine permeability except for the 0% bioactive glass loading. There was however some occlusion of the dentinal tubules in the cross-section samples using SEM. According to Gillam et al. [6], this may be due to the presence of silica in a polishing paste, or toothpaste, it may also be possible for the extra- fine pumice to play a role in blocking the dentinal tubules. Although these effects were insignificant when comparing the hydraulic conductance measurements. The results also indicated that increasing the application time influenced both tubular occlusion and flow rate (FR).

When applying the 5% glass loading of bioactive glass at 30 seconds, the fluid flow was reduced by 37.77%. As the glass loading increased to 15% the fluid flow was reduced to 60.87%. When comparing the 15% glass loading with Nupro®, Nupro® showed less fluid flow reduction (57.11%). At the 25% glass loading a 70% flow rate, FR, reduction was noted. A similar pattern was noticed when applying the different glass loading of the prophy paste at different times namely 60 seconds and 120 seconds where the highest reduction of 77.7% of fluid flow occurred at 120 seconds when using the 25% loading of bioactive glass. Furthermore, when comparing Nupro® with the 15% loading, the 15% loading showed a fluid flow reduction at the three different time applications. Moreover, the benefit of a longer application time (60-120s) was evident at the 15%-loading compared to a shorter application time (30s) (Figure 16).

Immediately after the prophylaxis polishing paste application, the same specimens were immersed in artificial saliva for an hour. Reduction of fluid flow in all specimens was statistically significant (Figure 4.38). The optimum occlusion was noticed with the 25% loading with a 120 second application time (Figure 16). There was a slight increase in tubular occlusion at the 0% loading which suggested some effects of the artificial saliva as previously indicated above.

The final treatment involved challenging the specimens in a 6% citric acid solution for two minutes after the prophy-paste application with the dentine disc placed in the hydraulic conductance  cell.  Citric acid was used in the present study due to its weak acidity that resembled fruit juices freely commercially available and consumed orally on a regular basis by consumers. Citric acid has an erosive effect unlike the neutralising effect of saliva and will remove the precipitated layer opening the dentinal tubules thereby increasing the flow rate within the tubules. The FR values of all groups were reduced following the immersion in an acid solution although the 25% bioactive glass loading appeared to withstand the effects of this challenge better than the other groups showing the least amount of opening dentinal tubules when compared with the rest of the groups (Figure 15).

When the Brunner-Langer model applied to verify the relative effect magnitude of FR to the different elements (paste, saliva, acid) depending specifically on the loading and time of application. There was a high inter-correlation involving all factors included in the analysis. In conclusion, the greater bioactive glass loading together with an increased application time, the greater the effect on tubular occlusion and flow rate. On the other hand, the 15% loaded bioactive glass showed the best effect when applied on samples for 30 seconds (Figure 16). One of the main issues, however, to consider when discussing the results was the low sample size used in the present study and for future studies a larger sample size is recommended.

SEM Analysis

SEM was used to magnify and amplify the specimens under magnification of x1000 and x10,000. The images were grouped together for comparison purposes. These were first etched with 6% citric acid to remove the smear layer which opened the dentinal tubules as observed in the control groups. All the specimens with the different bioactive glass loading and application times together with the Nupro® control were analysed using SEM (Figure 17a-e).

All groups with the different loading of bioactive glass 0%, 5%, 15%, 25% and Nupro® produced a precipitated layer on the dentine disc surface. The specimens of 0% prophy-paste of bio-active glass at 30, 60 and 120 seconds showed some occlusion of the dentinal tubules that was possibly due to the 5% of the silica used in the patent composition of the prophy-paste. Also, the extra-fine pumice which is a highly vesicular silica was used in the ingredient, its particle size was smaller than the dentinal tubules which may induce some tubular occlusion. On increasing the loading of bioactive glass in the other groups from 5% to 25%, more precipitation and blocking of the dentinal tubules was observed particularly at the higher glass loading. The 5% loading had a lower density of the precipitation layer, and the dentinal tubules were partially blocked. The 15% loading however showed a much higher coverage of the dentinal tubules with great reduction in its size. At the 25% loading, no dentinal tubules were observed, and the whole surface of the specimen was covered with a dense precipitation layer (Figures 17a-e). When comparing the Nupro® prophy-paste used as a control with the other loading bioactive glass prophy paste groups, the 15% and 25% loaded SEMs showed a superior effect on occluding the dentinal tubules (Figure 17c-e). Increasing the time from 30 seconds, 60 seconds to 120 seconds had an impact on the tubular occlusion. These results would suggest that using a higher loading of bioactive glass together with increasing the application time would have a major effect on the degree of tubular occlusion. It was evident from the study that the 25% bioactive glass and 2 minutes application time was the most ideal formulation for a prophy-paste an observation that was also supported by the reductions in FR in the hydraulic conductance experiment. By way of comparison there was little evidence of tubular occlusion in the 0% loading prophy-paste at 30 seconds. The samples were then immersed in saliva for an hour prior to an acidic challenge with 6% citric acid for one minute and two minutes following a one- minute application with the different loading of bioactive glass and Nupro® as a control. When the specimens were immersed in saliva and then challenged in 6% citric acid for one minute, no further effect on tubular occlusion was observed due to the density of the precipitated layer on the dentine surface particularly in the high loading groups (15%, 25%) and the Nupro® control. On the other hand, challenging the specimens for two minutes showed a slight reduction effect on tubular occlusion although this effect varied between the groups.

The same effect was observed in the 0% and 5% loading of bioactive specimens with the removal of some of the surface deposit exposing the dentinal tubule orifices (opening) as compared with the 15%, 25% loading and Nupro® groups. The resistance of the surface precipitation following an acidic challenge can be explained by the formation of a fluoro-apatite layer which is more resistant to an acidic challenge rather than a hydroxy-carbonated layer formed by the Nupro® control.

Conclusions

Increasing the bioactive glass loading resulted in a greater fluid flow rate reduction with an increase of time of applications. Overall, the most effective application was with the 25% loaded bioactive glass at 120 seconds although the application of the 15% loaded bioactive glass prophylaxis paste for 30 seconds demonstrated effective tubular occlusion and fluid flow reduction. The incorporation of bioactive glass into a prophylactic-polishing paste may be advantageous in reducing DH following both non-surgical and surgical periodontal treatment in that it may be an effective tubular occludent. Clinical studies however should be conducted to evaluate whether incorporated a novel bioactive glass at the recommended loadings from this in vitro study would be an effective desensitizing agent in the treatment of DH.

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