Short Nutritional Assessment Questionnaire a
\r\n\tGlobalization does not represent a pure and generous process for humanity or other species, but rather it implies social exclusion and also provokes situations of vulnerability in groups of people, forced exclusion, and apartheid: poor job opportunities, lack of access to education, worse socio-sanitary conditions. Specifically, it can be said that social segregation entails the apartheid of social groups of different ages, genders, and ethnicities; these groups live a reality manifested through the deepening of poverty, in terms of increased vulnerability of the poor and groups with little economic, social, cultural, labor and health stability.
\r\n\r\n\tThis book aims to talk about some topics that are neglected in the discourses of academic communities and political elites. The inequality process is deeply rooted among humans and is part of many people's lives in the form of modern apartheid, gender segregation, lack of health access, and cultural gap. All those structural inequality processes are the product of the biopower perpetuated and produced in the macrosystem, exosystem, mesosystem, and microsystem. For many people from the academy, the information-consuming public, and the society in general, it is a problem to talk about these processes, since they have either lost interest or have normalized the structural and social inequity. For this reason, we see it as transcendental to explain how this situation occurs from the most internal fibers to the most evident processes, intending to make it more visible and thus expose the situation for possible solutions.
",isbn:"978-1-83768-406-9",printIsbn:"978-1-83768-405-2",pdfIsbn:"978-1-83768-407-6",doi:null,price:0,priceEur:0,priceUsd:0,slug:null,numberOfPages:0,isOpenForSubmission:!0,isSalesforceBook:!1,isNomenclature:!1,hash:"cefab077e403fd1695fb2946e7914942",bookSignature:"Ph.D. Yaroslava Robles-Bykbaev",publishedDate:null,coverURL:"https://cdn.intechopen.com/books/images_new/11473.jpg",keywords:"Wage Gap, Gender Segregation, Fundamental Human Rights, Health Access, Social Inequity Processes, Modern Apartheid, Resilience, Cultural Gaps, Globalization, Geopolitics of Social Inequality, Public Policies, Social Vulnerability",numberOfDownloads:null,numberOfWosCitations:0,numberOfCrossrefCitations:null,numberOfDimensionsCitations:null,numberOfTotalCitations:null,isAvailableForWebshopOrdering:!0,dateEndFirstStepPublish:"June 15th 2022",dateEndSecondStepPublish:"July 13th 2022",dateEndThirdStepPublish:"September 11th 2022",dateEndFourthStepPublish:"November 30th 2022",dateEndFifthStepPublish:"January 29th 2023",dateConfirmationOfParticipation:null,remainingDaysToSecondStep:"13 days",secondStepPassed:!1,areRegistrationsClosed:!1,currentStepOfPublishingProcess:2,editedByType:null,kuFlag:!1,biosketch:"Dr. Bykbaev is a member of the UNESCO Chair of Politecnica Salesiana University. She has contributed as co-author and author to approximately thirty scientific publications in the field of statistics, inclusive education, and social and cultural anthropology. These publications focus on the visibility of problems in the field of public health and focus on the creation of proposals to improve community health. Dr. Bykbaev is an active member of the NODO Ecuadorian Network of Women Scientists (REMCI).",coeditorOneBiosketch:null,coeditorTwoBiosketch:null,coeditorThreeBiosketch:null,coeditorFourBiosketch:null,coeditorFiveBiosketch:null,editors:[{id:"313341",title:"Ph.D.",name:"Yaroslava",middleName:null,surname:"Robles-Bykbaev",slug:"yaroslava-robles-bykbaev",fullName:"Yaroslava Robles-Bykbaev",profilePictureURL:"https://mts.intechopen.com/storage/users/313341/images/system/313341.jpg",biography:null,institutionString:"Politecnica Salesiana University",position:null,outsideEditionCount:0,totalCites:0,totalAuthoredChapters:"0",totalChapterViews:"0",totalEditedBooks:"0",institution:{name:"Politecnica Salesiana University",institutionURL:null,country:{name:"Ecuador"}}}],coeditorOne:null,coeditorTwo:null,coeditorThree:null,coeditorFour:null,coeditorFive:null,topics:[{id:"23",title:"Social Sciences",slug:"social-sciences"}],chapters:null,productType:{id:"1",title:"Edited Volume",chapterContentType:"chapter",authoredCaption:"Edited by"},personalPublishingAssistant:{id:"444316",firstName:"Blanka",lastName:"Gugic",middleName:null,title:"Mrs.",imageUrl:"https://mts.intechopen.com/storage/users/444316/images/20016_n.jpg",email:"blanka@intechopen.com",biography:"As an Author Service Manager, my responsibilities include monitoring and facilitating all publishing activities for authors and editors. From chapter submission and review to approval and revision, copyediting and design, until final publication, I work closely with authors and editors to ensure a simple and easy publishing process. I maintain constant and effective communication with authors, editors and reviewers, which allows for a level of personal support that enables contributors to fully commit and concentrate on the chapters they are writing, editing, or reviewing. I assist authors in the preparation of their full chapter submissions and track important deadlines and ensure they are met. I help to coordinate internal processes such as linguistic review, and monitor the technical aspects of the process. As an ASM I am also involved in the acquisition of editors. Whether that be identifying an exceptional author and proposing an editorship collaboration, or contacting researchers who would like the opportunity to work with IntechOpen, I establish and help manage author and editor acquisition and contact."}},relatedBooks:[{type:"book",id:"6926",title:"Biological Anthropology",subtitle:"Applications and Case Studies",isOpenForSubmission:!1,hash:"5bbb192dffd37a257febf4acfde73bb8",slug:"biological-anthropology-applications-and-case-studies",bookSignature:"Alessio Vovlas",coverURL:"https://cdn.intechopen.com/books/images_new/6926.jpg",editedByType:"Edited by",editors:[{id:"313084",title:"Dr.",name:"Alessio",surname:"Vovlas",slug:"alessio-vovlas",fullName:"Alessio Vovlas"}],productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"6942",title:"Global Social Work",subtitle:"Cutting Edge Issues and Critical Reflections",isOpenForSubmission:!1,hash:"222c8a66edfc7a4a6537af7565bcb3de",slug:"global-social-work-cutting-edge-issues-and-critical-reflections",bookSignature:"Bala Raju Nikku",coverURL:"https://cdn.intechopen.com/books/images_new/6942.jpg",editedByType:"Edited by",editors:[{id:"263576",title:"Dr.",name:"Bala",surname:"Nikku",slug:"bala-nikku",fullName:"Bala Nikku"}],productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"1591",title:"Infrared Spectroscopy",subtitle:"Materials Science, Engineering and Technology",isOpenForSubmission:!1,hash:"99b4b7b71a8caeb693ed762b40b017f4",slug:"infrared-spectroscopy-materials-science-engineering-and-technology",bookSignature:"Theophile Theophanides",coverURL:"https://cdn.intechopen.com/books/images_new/1591.jpg",editedByType:"Edited by",editors:[{id:"37194",title:"Dr.",name:"Theophile",surname:"Theophanides",slug:"theophile-theophanides",fullName:"Theophile Theophanides"}],productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"3161",title:"Frontiers in Guided Wave Optics and Optoelectronics",subtitle:null,isOpenForSubmission:!1,hash:"deb44e9c99f82bbce1083abea743146c",slug:"frontiers-in-guided-wave-optics-and-optoelectronics",bookSignature:"Bishnu Pal",coverURL:"https://cdn.intechopen.com/books/images_new/3161.jpg",editedByType:"Edited by",editors:[{id:"4782",title:"Prof.",name:"Bishnu",surname:"Pal",slug:"bishnu-pal",fullName:"Bishnu Pal"}],productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"3092",title:"Anopheles mosquitoes",subtitle:"New insights into malaria vectors",isOpenForSubmission:!1,hash:"c9e622485316d5e296288bf24d2b0d64",slug:"anopheles-mosquitoes-new-insights-into-malaria-vectors",bookSignature:"Sylvie Manguin",coverURL:"https://cdn.intechopen.com/books/images_new/3092.jpg",editedByType:"Edited by",editors:[{id:"50017",title:"Prof.",name:"Sylvie",surname:"Manguin",slug:"sylvie-manguin",fullName:"Sylvie Manguin"}],productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"371",title:"Abiotic Stress in Plants",subtitle:"Mechanisms and Adaptations",isOpenForSubmission:!1,hash:"588466f487e307619849d72389178a74",slug:"abiotic-stress-in-plants-mechanisms-and-adaptations",bookSignature:"Arun Shanker and B. Venkateswarlu",coverURL:"https://cdn.intechopen.com/books/images_new/371.jpg",editedByType:"Edited by",editors:[{id:"58592",title:"Dr.",name:"Arun",surname:"Shanker",slug:"arun-shanker",fullName:"Arun Shanker"}],productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"72",title:"Ionic Liquids",subtitle:"Theory, Properties, New Approaches",isOpenForSubmission:!1,hash:"d94ffa3cfa10505e3b1d676d46fcd3f5",slug:"ionic-liquids-theory-properties-new-approaches",bookSignature:"Alexander Kokorin",coverURL:"https://cdn.intechopen.com/books/images_new/72.jpg",editedByType:"Edited by",editors:[{id:"19816",title:"Prof.",name:"Alexander",surname:"Kokorin",slug:"alexander-kokorin",fullName:"Alexander Kokorin"}],productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"314",title:"Regenerative Medicine and Tissue Engineering",subtitle:"Cells and Biomaterials",isOpenForSubmission:!1,hash:"bb67e80e480c86bb8315458012d65686",slug:"regenerative-medicine-and-tissue-engineering-cells-and-biomaterials",bookSignature:"Daniel Eberli",coverURL:"https://cdn.intechopen.com/books/images_new/314.jpg",editedByType:"Edited by",editors:[{id:"6495",title:"Dr.",name:"Daniel",surname:"Eberli",slug:"daniel-eberli",fullName:"Daniel Eberli"}],productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"57",title:"Physics and Applications of Graphene",subtitle:"Experiments",isOpenForSubmission:!1,hash:"0e6622a71cf4f02f45bfdd5691e1189a",slug:"physics-and-applications-of-graphene-experiments",bookSignature:"Sergey Mikhailov",coverURL:"https://cdn.intechopen.com/books/images_new/57.jpg",editedByType:"Edited by",editors:[{id:"16042",title:"Dr.",name:"Sergey",surname:"Mikhailov",slug:"sergey-mikhailov",fullName:"Sergey Mikhailov"}],productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"1373",title:"Ionic Liquids",subtitle:"Applications and Perspectives",isOpenForSubmission:!1,hash:"5e9ae5ae9167cde4b344e499a792c41c",slug:"ionic-liquids-applications-and-perspectives",bookSignature:"Alexander Kokorin",coverURL:"https://cdn.intechopen.com/books/images_new/1373.jpg",editedByType:"Edited by",editors:[{id:"19816",title:"Prof.",name:"Alexander",surname:"Kokorin",slug:"alexander-kokorin",fullName:"Alexander Kokorin"}],productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}}]},chapter:{item:{type:"chapter",id:"48986",title:"Nutritional Support in Dysphagia",doi:"10.5772/61243",slug:"nutritional-support-in-dysphagia",body:'Dysphagia is defined as difficulty in swallowing. It is commonly caused due to neuromuscular (stroke, dementia, Parkinson’s disease, myasthenia gravis, etc.), mechanical (oral cancer, oesophageal cancer, etc.), or other causes (radiotherapy treatment, gastroesophageal reflux disease, thrush, etc.). It risks aspiration and associated bronchopulmonary infections, fluid depletion, and under nutrition. It can alter nutritional equilibrium and can affect organ function and ultimately clinical outcome. To improve clinical outcomes, it is important to screen all at risk patients in order to identify patients at nutritional risk due to dysphagia [1–4]. Most dysphagia resolves within few weeks, but in some cases it may persist. This may affect the nutritional state of the individual who is already facing an illness or injury in first instance [5, 6]. Dysphagia and accompanying malnutrition is associated with excess morbidity and increased mortality rates [7, 8]. This chapter will focus on general principles of nutritional management in any patient including patients with dysphagia.
Up to 30% of all acute hospital admissions are malnourished and this is further deepened during hospitalisation [9]. Hence, all the patients should be screened for risk of malnutrition.
There are various scoring systems available to screen a patient at nutritional risk. Screening is based on history (weight loss, etc.) and physical examination (height, weight, and body mass index (BMI)).’Malnutrition universal screening tool’ (‘MUST’) [Figure 1], rapid nutrition screen for hospitalised patients, nutrition risk index (NRI), Mini Nutritional Assessment-Short Form (MNA-SF), Short Nutritional Assessment Questionnaire (SNAQ©) (Table 1) and Nutrition Risk Screening (NRS-2002) are some of the commonly available and used composite tools in clinical practice [10–15]. An ideal screening tool should be easy to implement, accurate, reliable, inexpensive, and reproducible. NRS-2002 is the best instrument today because it is robust, simple, quick, validated, and based from an analysis of 128 controlled clinical trials. Patients with the risk criteria had a higher likelihood of a better clinical outcome from nutritional support than patients who did not fulfill the criteria [15]. NRS 2002 has also been used by nurses and dietitians in three hospitals of Denmark. Its reliability was validated by inter-observer variation between a nurse, a dietitian, and a physician with a k = 0.67. Its practicability was shown by the finding that 99% of 750 newly admitted patients could be screened [16]. Supplement 1 shows the ‘TTSH Nutrition Screening Tool’ (TTSH NST) used by the Nutrition and Dietetics department at Tan Tock Seng Hospital, Singapore. TTSH NST was developed from a cohort of younger hospitalised patients. This was later validated in a cohort of elderly patients using subjective global assessment (SGA) as a comparator. In 281 acute admissions to Tan Tock Seng Hospital with age range of 61–102 years, prevalence of malnutrition was 35% based on SGA. Risk of malnutrition as determined by TTSH NST with a cut-off of 4 had sensitivity, specificity, positive, and negative predictive values of 84%, 79%, 68%, and 90%, respectively, with area under the curve of 0.87. The optimal cut-off remained at 4 even for patients aged >85 years (AUC = 0.85). Risk of malnutrition was predictive of 6-month mortality (adjusted OR: 2.2,
\n\t\t\t\t | \n\t\t\t\n\t\t\t\t | \n\t\t
Did you lose weight intentionally? | \n\t\t\t\n\t\t |
∙ 6 Kg in past 6 months | \n\t\t\t3 | \n\t\t
∙ 3 Kg in the past month | \n\t\t\t2 | \n\t\t
Did you experience a decreased appetite over the past month? | \n\t\t\t1 | \n\t\t
Did you use supplemental drinks or tube feeding over the past month? | \n\t\t\t1 | \n\t\t
Short Nutritional Assessment Questionnaire a
a Patients who scored 0 or 1 points were classified as well-nourished and did not receive intervention. Patients who scored 2 points were classified as moderately malnourished and received nutritional intervention. Patients who scored 3 points were classified as severely malnourished and received nutritional intervention and treatment by a dietician.
Reproduced from:
Nutritional assessment is a more detailed process and is done in patients screened at risk or when metabolic or functional problems prevent a standard plan being carried out. There are few tools for evaluating the nutritional status of hospitalised patients. SGA, short nutritional assessment questionnaire, mini nutritional assessment (MNA), and corrected arm muscle area (CAMA) are tools used for nutritional assessment [18]. The assessment of nutritional status includes a nutritional history and physical examination in conjunction with appropriate laboratory studies [Figure 2]. Regurgitation, hoarse voice, coughing during or after swallowing, globus sensation, nasal regurgitation, recurrent chest infections, and frequent throat clearing symptoms may indicate dysphagia [19]. In all patients with dysphagia, a complete evaluation of the cause of dysphagia must be performed and for the purpose of this chapter we will only discuss nutrition-related assessment.
‘MUST’ flowchart
Nutritional assessment
The nutritional history should evaluate the following:
A change in the dietary pattern due to dysphagia should be ascertained.
The presence of unintentional weight loss over past six months should be ascertained. 10% or greater unintentional weight loss over the past six months is categorised as severe weight loss and is associated with a poor clinical outcome. In a study involving 3,047 patients enrolled in 12 chemotherapy protocols of Eastern Cooperative Oncology Group, Dewys WD, et al. has shown that chemotherapy response rates and median survival rates were lower in patients with weight loss [20]. The
Measurements of serum albumin, prealbumin, retinol-binding protein, transferrin, createnine height index, createnine extretion in urine and total lymphocyte count have been shown to correlate with clinical outcome. In a study involving 17 critically ill patients, Apelgren KN et al. have shown that a serum albumin <2.5 g/dL concentration is associated with an increased incidence of medical complications and death and it correctly separated 93% of patients in terms of survival prognosis [24]. Serum albumin levels are often used as a surrogate for preoperative nutritional assessment, but it is confounded by coexisting inflammation [25, 26]. Injury and inflammation decreases synthesis, increases degradation and transmembrane losses from the plasma compartment. In addition, albumin is also lost from open wounds (burns, etc.), peritonitis and through the gastrointestinal tract and/or kidneys in certain diseases. The association between hypoalbuminemia and poor clinical outcome is independent of both nutritional and inflammatory status [27]. Serum albumin is a good predictor of clinical outcomes but is a poor marker for nutritional assessment.
If a patient is identified as at risk of malnutrition, appropriate intervention should be done to improve outcomes. Nutritional pharmacology is an emerging science over the last two decades. Nutrients such as arginine, glutamine, and long chain fatty acids (both omega 3 and omega 6) have been shown to improve clinical outcomes in diverse group of patients [28]. Arginine exhibits diverse effects including wound healing, protects against ischemia-reperfusion, improves macrophage function after injury, blocks adhesion molecules, inhibits lipid peroxidation, and improves cerebral and myocardial perfusion [28]. In a double blind randomised controlled trial involving 32 malnourished patients with head and neck cancer, Buijs N et al. concluded that perioperative arginine-enriched enteral nutrition improved long term overall survival and long term disease specific survival [29]. Glutamine is the most abundant amino acid and is a fuel of neutrophils, lymphocytes, and enterocytes. Glutamine is a conditionally essential amino acid in situations of stress. A recent Cochrane review including 4,671 patients with critical illness or elective major surgery concluded that glutamine supplementation reduced the infection rate and days on mechanical ventilation in critically ill or surgical patients [30]. Long chain fatty acids are important in function of cell membranes and act as intracellular messengers.
Enteral route is physiologic and
There are various feeding formulas and selection should be based on fluid electrolyte and metabolic needs, digestion and absorption capacity, caloric and protein density of formula, physical characteristics of formula (osmolality, viscosity etc.), and cost. General purpose feeding formulas contain intact proteins and need an intact digestive and absorptive function of gastrointestinal system. Semi-elemental feeds contain free amino acids with minimal fat and are used in patients with compromised gastrointestinal function. There are also various disease-specific feeds available for patients with hepatic, renal, or pulmonary dysfunction. In addition, nutrient composition of the formulas can be altered to tailor individual patients need and such modular feeds require mixing by local pharmacy and are costly [31]. Once the feeding formula is decided and the nutritional requirement calculated, the rate and delivery of the feeding is established.
Algorithm of nutritional supplementation
Intermittent bolus feeding is convenient to administer by nasogastric or percutaneous gastric tube and is suitable in ambulatory patients. Although there are no definitive studies, bolus feeding reduces lower esophageal sphincter pressure and may increase the chance for reflux and aspiration [32]. Intermittent cyclic feeding is indicated during weaning from tube feeding to oral feeding. It can be pump-assisted or gravity-assisted and feeding cycles of varying duration of period can be planned. This feeding is advantageous when an overnight tube feed is administered and the patient continues his normal oral intake during the day. Constant feeding infusion assisted by pump or gravity is indicated in bedridden patients with critical illness. Nasal tubes are associated with discomfort, excoriation and bleeding, and anosmia. Hence, when long-term feeding is required, percutaneous gastrostomy or jejunostomy tubes should be used. In a United Kingdom study involving 1,327 patients including 1,027 patients with gastrostomy tube insertion, Kurien M et al. has demonstrated that patients who undergo gastrostomy have significantly lower mortality than those who defer the procedure (11.2% vs. 35.5% at 30 days and 41.1% vs.74.3% at 1 year, p<0.0001) [33]. The most common indication of feeding gastrostomy remains inadequate swallowing as a result of a neurological event, oropharyngeal or esophageal cancer, or facial trauma [34]. Traditionally, tube feeding is delayed until the next day after the procedure. Authors’ personal preference is to institute the feeding at the next opportunity. In a meta-analysis of six randomised controlled trials involving 467 patients, Bechtold ML et al. has shown that early feeding (defined as within 4 hrs) after percutaneous endoscopic gastrostomy placement was safe [35]. In patients with restricted mouth opening, oral cavity is inaccessible and a surgical gastrostomy needs to be created. Feeding gastrostomy is associated with the risk of aspiration and is not possible in patients with gastric outlet obstruction, gastroparesis, or gastric resection. In such patients, feeding jejunostomy is an alternative. Percutaneous feeding jejunostomy can also be inserted via the existing gastrostomy site. Percutaneous placement of feeding jejunostomy is technically difficult compared to gastrostomy. In a study involving 150 patients without a previous history of major abdominal surgery, Shike M et al. found that direct percutaneous endoscopic jejunostomy was successful in 129 procedures (86%) and aspiration occurred in 3% of patients [36]. Enteral nutrition preserves the gut integrity, reduces bacterial translocation, maintains the gut immune function, is easily administered and monitored, and cheaper compared to parenteral nutrition. However, it can also lead to complications.
Enteral nutrition causes mechanical problems with tube placement (migration, clogging etc.), metabolic problems (osmotic diarrhoea, overhydration, etc.), and is labour intensive (tube management, infusion pump device usage, etc.). In patients with tube feeding, prior to commencing feeding, a radiological confirmation of tube placement must be checked. Tube clogging could be prevented by using a wide tube, flushing the tube with water after medicine administration, minimising gastric aspirates to keep pH levels low, and using pancreatic enzymes mixed with bicarbonate [37]. Peristomal wound infections and leakage are also common problems associated with tube feeding and add to patient and family anxiety along with the nursing care burden [38]. In a Cochrane review with a pooled analysis of 1,271 patients from 12 randomised controlled trials, Lipp A et al. have shown that administration of prophylactic systemic antibiotics for percutaneous endoscopic gastrostomy tube placement reduces peristomal infection rates (OR 0.36, 95% CI: 0.26–0.50) [39]. Peristomal leakage can be reduced by appropriate fixation technique and antisecretory agents. In patients with persistent leakage, the tube should be withdrawn and replaced after few days or a new tube placed at the separate site, but no attempt should be made to control the leakage with a wider tube as it may exacerbate the leakage [40–42]. Diarrhoea remains the commonest gastrointestinal side effect of enteral tube feeding [43, 44]. Addition of fibre and probiotics has shown to reduce diarrhoea in enteral feeding. In a systematic review and meta-analysis including 51 studies, 43 randomised control trials and 1,762 subjects (1,591 patients and 171 healthy volunteers), Elia M et al. have shown that fibre supplementation was generally well tolerated and the incidence of diarrhoea reduced (OR 0.68, 95% CI: 0.48–0.96; 13 randomised control trials) [45]. In a randomised double blind placebo controlled trial involving 62 patients, Heimburger DC et al. have shown that most cases of diarrhoea in tube fed patients are caused by factors extraneous to tube feeding and lactobacillus treatment did not alter the risk of diarrhoea [46]. Patients on enteral feeding are also at risk of aspiration pneumonia. There are various strategies recommended to reduce the risk of aspiration namely head end of bed elevation, gastric residual volume measurement and postpyloric feeding. In a prospective randomized study involving 38 patients in medical and surgical intensive care units, endoscopically placed feeding jejunal tube-fed patients had a lower rate of pneumonia (nil vs. 10.5%) compared to patients fed by continuous gastric tube feeding [47]. In a literature review of 45 studies including patients with neurogenic oropharyngeal dysphagia over a period of 1978 to 1989, authors were not able to derive any meaningful conclusions with regard to superiority of postpyloric feeding due to limitations of individual studies with small sample size, inconsistent definitions of aspiration, varying feeding protocols, unspecified time frames, and heterogeneous populations [48]. Monitoring enteral nutrition involves fluid electrolyte balance, weight chart, serum electrolyte and glucose measurement, and stool charting. Refeeding syndrome is characterised by electrolyte depletion, fluid shifts, and glucose derangements that occur on reinstitution of nutrition in malnourished patients [49]. Chronically malnourished patients (e.g., patients with dysphagia) are at high risk of refeeding syndrome. In a study involving 321 patients with 92 patients at risk of refeeding hypophosphataemia, Zeki S et al. has shown that refeeding hypophosphataemia is more common in enteral-fed patients compared to parenteral nutrition [50]. Gradual introduction and progression of feeding over a few days with close monitoring of fluid and electrolytes can help in the prevention and early recognition of refeeding syndrome.
National Institute of Clinical Excellence (NICE) guidelines recommend that in an acute setting, if patients are unable to swallow safely or meet caloric needs orally, they should have an initial 2–4 week trial of nasogastric enteral tube feeding. Health care professionals with relevant skills and training in the diagnosis, assessment, and management of swallowing disorders should assess the prognosis and options for future nutrition support [19]. Before modifying nutritional support in a patient with dysphagia, level of alertness, need for feeding assistance, mobility, recurrent chest infections, metabolic needs, etc. should be considered [19].
In patients with short bowel or gastrointestinal intolerance, total parenteral nutrition is required. In general, parenteral nutrition should be considered if energy intake has been, or is anticipated to be, inadequate (<50% of daily requirements) for more than 7 days and enteral feeding is not feasible. Total parenteral nutrition requires labour-intensive monitoring for infection and haemodynamic stability. Metabolic complications, such as fluid overload, hypertriglyceridemia, hypercalcemia, hypoglycaemia, hyperglycaemia, and specific nutrient deficiencies, are usually caused by overzealous or inadequate nutrient administration. Catheter-related blood-borne infection is the most common life-threatening complication in patients who receive total parenteral nutrition and is commonly caused by
An interdisciplinary nutrition support team could include physicians, dieticians, pharmacists, and nurse clinicians. In a study involving 209 parenteral nutrition starts, Trujillo EB et al. have showed that non-indicated and preventable parenteral nutrition initiation, short-term (defined as less than 6 days) parenteral nutrition use and metabolic complications are less likely (34% vs. 66%, p = 0.04) when patients receive consultation by a multidisciplinary metabolic support service [54]. Nutritional support teams closely work with speech and swallowing assessment teams locally at Tan Tock Seng Hospital. In patients with non-obstructive dysphagia, videofluoroscopy swallowing study is conducted prior to determining the route of feeding. It is possible that patients may be permitted oral feeds and in addition enteral tube feeding to ensure their caloric requirements are met.
Dysphagia patients are at risk of malnutrition. Malnutrition worsens during hospitalisation. Nutritional screening and assessment are paramount to improve outcomes. There are various tools to assist in nutritional screening and assessment and it is advisable to use the locally validated tool in clinical practise. Patients with dysphagia have special needs and this need to be considered during initiation and modification of nutrition therapy. Enteral nutrition is recommended wherever feasible. Nutrition support teams and swallowing therapy experts should be involved in all patients with dysphagia who require nutrition therapy.
We are grateful to the Department of Nutrition and Dietetics, Tan Tock Seng Hospital, Singapore, for permission to publish Tan Tock Seng Hospital Nutrition Screening Tool (TTSH NST).
Glyphosate (GLYP) (or, less commonly, but still used, glyphosphate), a broad-spectrum herbicide, is one of the most used pesticides in the world [1], nearly $5 billion in sales and an annual global production about 825,800,000 kg [2]. Glyphosate is a nonselective herbicide; therefore, it is a molecule that eliminates all weeds without distinction.
\nGlyphosate [IUPAC N-(phosphonomethyl)glycine; CAS registry number 1071-83-6] is an aminophosphoric analogue of glycine and an important amino acid. It was discovered in the early 1950s by Henri Martin and was patented by Monsanto and sold as a Roundup® product for about 20 years; after 2001 (patent expiration date), free production of glyphosate was legally permitted [3, 4]. As of 2010, more than 750 glyphosate products have been on the market [5, 6]. The first important worldwide warning about the GLYP occurred in 2017: the Canadian Food Inspection Agency (CFIA) confirmed that 36.6% of the Canadian wheat samples had a high presence of GLYP (3.9% above the legal limits, which in Canada is 5 ppm) [7]. In Canada, GLYP-based products are widely used for improving the wheat ripening and drying. Such occurrence has created a big supply problem in Europe where this practice is prohibited: for instance, Italy imported large amounts of wheat to make flour for pasta from Canada (and from the United States as well).
\nGLYP inhibits the 5-enolpyruvylshikimate-3-phosphate (EPSP) enzyme produced by plants, which is involved in the synthesis of three essential amino acids such as tyrosine, tryptophan, and phenylalanine. The mechanism of action is absorption through the foliage, and to a small extent through the roots, and transport to growth points. Since this enzyme is present only in the plant kingdom, glyphosate acts only on plant organisms.
\nGLYP is a leaf herbicide (it is absorbed by the leaves of the plant), systemic (once absorbed, it passes toward the growth points, causing the death of the plant), nonselective (in fact, it is active on all plants, if not genetically modified). Glyphosate-based products are activated by the addition of a surfactant, polyoxyethylene amine (POEA), which promotes penetration through the leaf surface of plants; other additives used are sulfuric acid and phosphoric acid. Its main metabolite is aminomethylphosphonic acid (AMPA). It should be noted that a fraction of AMPA could be due to degradation processes of the detergents/surfactants rather than from glyphosate. GLYP does not penetrate deeply into the soil (maximum 20 cm) and is easily degraded by bacteria. This means that the probability that it reaches the aquifers is very low and that its presence is certainly lower than that of other dangerous pollutants.
\nThe half-life of GLYP in the soil is between 2 and 197 days, a typical half-life of 47 days has been suggested. The soil and climate conditions on the persistence of glyphosate in the soil are very important. The average half-life of GLYP in water varies from few to 91 days. The AMPA metabolite of glyphosate has been found in Swedish forest soils for up to 2 years after a glyphosate application. In this case, the persistence of AMPA has been attributed to frozen soil for most of the year. The adsorption of glyphosate into the soil, and then its release from the soil, varies according to the type of soil. GLYP is generally less persistent in water than in land, with 12–60 days persistence observed in Canadian ponds, although persistence of more than a year has been recorded in American lake sediments.
\nGLYP (Figure 1) is a weak acid commonly used in the form of salt, distributed as a powder or as a water-soluble concentrate. At room temperature, it appears as a colorless crystalline solid, is completely soluble in water, and is highly insoluble in common organic solvents such as benzene and dichloromethane. GLYP is a nonvolatile and photo-resistant molecule, and its dissolution in water generates four chemical equilibria represented by the respective acid dissociation constants (Ka). In logarithmic form, pKa acquires the following values: 2.0, 2.6, 5.6, and 10.6. This aspect makes the molecule highly polar and amphoteric [8].
\nGlyphosate [N-(phosphonomethyl)glycine; CAS number 1071-83-6].
During the reactions involving the enzymes glyphosate oxidase and glyphosate N-acetyl transferase, glyphosate can form different metabolites: the main is considered the amino-methylphosphonic acid (AMPA), whereas the others are glyoxylate, N-acetyl glyphosate, N-acetyl-AMPA, methylphosphonic acid, sarcosine, N-methyl-aminomethylphosphonic acid (MAMPA), hydroxymethylphosphonic acid, and phosphonoformic acid [9]. This behavior is important: these compounds should be considered when toxicity and environmental studies are performed for the risk assessment. Similarly, compounds used as adjuvants in commercial glyphosate formulations should be considered: for instance, polyoxyethylene amine (POEA), used as a surfactant in Roundup [10] or isopropylamine, ammonium and trimesium salts, or formulation impurities such as N-(phosphonomethyl)iminodiacetic acid and bis(phosphonomethyl)amine. This occurrence is really important because the adjuvants can modify the toxicity of pesticides based on glyphosate as active ingredient; so, the result is the need of a novel toxicological evaluation [11].
\nAll these considerations play an important role in the GLYP toxicity. The toxicity of a substance is assessed according to its median lethal dose (lethal dose, 50% – LD50), that is, the dose that causes the death of 50% of the individuals taking the test substance: Class 1, high acute toxicity, LD50 less than 50 mg per kg of live weight; Class 2, moderate toxicity, LD50 between 50 and 500; Class 3, mild toxicity, LD50 between 500 and 5000; and Class 4, harmless, LD50 of over 5000 mg. The GLYP is in Class 3, while in Class 2, we find, for example, caffeine, aspirin, and boiling chloride, and in Class 1, the vitamin D3. In Table 1, acute toxicity assessment is reported.
\n\n | High toxicity | \nModerate toxicity | \nLow toxicity | \nVery low toxicity | \n
---|---|---|---|---|
Acute oral\na\n\n | \n≤50 mg kg−1\n | \n>50–500 mg kg−1\n | \n>500–5000 mg kg−1\n | \n>5000 mg kg−1\n | \n
Inhalation\nb\n\n | \n≤0.05 mg L−1\n | \n>0.05–0.5 mg L−1\n | \n>0.5–2.0 mg L−1\n | \n>2.0 mg L−1\n | \n
Dermal\na\n\n | \n≤200 mg kg−1\n | \n>200–2000 mg kg−1\n | \n>2000–5000 mg kg−1\n | \n>5000 mg kg−1\n | \n
Primary eye irritation | \nCorrosive or corneal involvement | \nCorneal involvement (8–21 days) | \nCorneal involvement (7 days) | \nMinimal effects clearing in 24 hours | \n
Primary skin irritation | \nCorrosive | \nSevere irritation at 72 hours | \nModerate irritation at 72 hours | \nMild or slight irritation at 72 hours | \n
Relationship between GLYP levels and toxicity.
As LD50.
As lethal concentration, 50% (LC50).
Also, important is the concept of daily limit dose (expressed in milligrams per kilogram of body weight considered) definable as the maximum amount of herbicide that can be consumed daily without causing damage. Based on this concept, the glyphosate content of a food or a drink should be correctly evaluated using the milligrams of glyphosate per kilogram of body weight that can be taken per day as a unit of measurement. In this way, the European Food Safety Authority (EFSA) has set a daily limit dose of 0.5 mg kg−1 of weight per day [12].
\nA tumor associated with glyphosate would be the non-Hodgkin lymphoma (NHL). In 2013, the German Federal Institute for Risk Assessment (BfR) found that “the available data are contradictory and far from convincing” in terms of the relationship between exposure to glyphosate formulations and the risk of various cancers, including the NHL [13, 14, 15, 16, 17, 18]. A meta-analysis published in 2014 identified an increased risk of NHL in workers exposed to glyphosate formulations [19, 20]. In March 2015, the International Agency for Research on Cancer (IARC) classified glyphosate “probably carcinogenic to humans” (Group 2a) based on epidemiological studies, animal studies, and in vitro studies: in particular, GLYP has been defined genotoxic through at least two mechanisms known to be associated with human carcinogens [21, 22, 23]. In contrast, EFSA concluded in November 2015 that “the substance is unlikely to be genotoxic (i.e., harmful to DNA), or pose a threat to humans.” Subsequently, EFSA itself states that while there may be formulations containing glyphosate that are carcinogenic, studies relating only to glyphosate as an active ingredient do not show this effect [24, 25]. The European Chemicals Agency (ECHA), on the basis of “the scientific evidence available at the moment,” classified GLYP, according to the CLP Regulation, as a chemical causing eye damage (H318) and being toxic to aquatic life with long-lasting effects (H411), but “the available scientific evidence did not meet the criteria in the CLP Regulation to classify glyphosate for specific target organ toxicity, or as a carcinogen, as a mutagen or for reproductive toxicity” [26]. The United States Environmental Protection Agency (US EPA) has classified glyphosate as a Group E chemical, meaning the agency has determined that there is “evidence of noncarcinogenicity to humans” [27, 28]. In any case, US EPA has established tolerances for GLYP residues in different commodities [29]. The difference of point of views depends on the fact that IARC and US EPA have analyzed different studies and applied different statistics. Further, EFSA analyses concern only the glyphosate molecule, whereas the studies considered by IARC also concern glyphosate-based products placed on the market [30].
\nThis brief analysis shows that, in any case, international pesticide regulatory agencies and scientific organizations agree that there is no evidence that GLYP as an active substance is carcinogenic to humans, only IARC has classified glyphosate as “probably carcinogenic.”
\nFinally, it should be considered an interesting hypothesis by Samsel and Seneff [31]: they propose a relationship between celiac disease and imbalances in gut bacteria generated by the known GLYP effects on them.
\nThe EFSA has renewed the authorization for GLYP, establishing the acute reference dose (ARfD) at 0.5 mg kg−1 of body weight, while the acceptable operator exposure level (AOEL) was set at 0.1 mg kg−1 body weight per day and the acceptable daily intakes (ADIs) for consumers are in line with the ARfD threshold, 0.5 mg kg−1 body weight per day.
\nThere are several exposure sources of humans to GLYP in the environment, for example, air, water, application to crops and target weeds, and food [32, 33, 34]. Solomon deeply reviewed the exposure data from the literature (PubMed and Google Scholar) and unpublished reports in different papers [35, 36]: in both papers, he reaches a similar conclusion: “In all cases, measured and estimated systemic exposures to glyphosate in humans and animals were less than the ADIs and the RfD. Based on this large dataset, these exposures represent a
This paper would like to critically revise the literature on chromatographic methods developed for analyzing GLYP and AMPA in food matrices, specifically grains (e.g., rice, wheat, soybean, and maize), honey, olive and oil, vegetables, fruit, beverages (e.g., drinking water, milk, tea, and coffee), cheese, and meat/fish products. In literature (source: Scopus database), there are 2666 papers using keywords “glyphosate” and “analysis” by the end of April 2020 and 361 using “chromatography” as third keyword.
\nStarting from the Canadian study performed in 2017, the scientific attention on GLYP has become stronger, and several papers are annually published dealing the determination of such compound, along with its main metabolite AMPA, on different agricultural and food matrices. For avoiding dispersive information due to the big amount of studies aimed to this determination, the authors have focused their attention on the main innovative analytical methods based on chromatographic methods for determining both compounds in such matrices. It is also necessary to advise the reader that different matrices could be determined with same analytical protocols, at least showing different analytical parameters (multiresidue analyses), as well as in literature are present papers dealing important toxicological studies with no analytical information.
\nBefore approaching the discussion on the different analytical methodologies developed for analyzing GLYP and AMPA in agricultural and food matrices, it should be necessary to resume some toxicological information on it along with some chemical characteristics to be taken into account for evaluating the analytical process.
\nFirst, a maximum residue level (MRL) is defined as the highest level of a pesticide residue legally tolerated in or on food or feed when pesticides are applied correctly [37]. For each product, an MRL of GLYP has been determined [38]. An example of this database is reported in Table 2.
\nProduct | \nMRL | \n
---|---|
Tangerines, clementines, oranges, and grapes | \n0.5 | \n
Lemons, grapefruits, cedars, kumquats, apples, pears, peaches, apricots, cherries, plums, almonds, hazelnuts, strawberries, and table olives | \n0.1 | \n
Oil olives | \n1 | \n
Potatoes | \n0.5 | \n
Wild mushrooms | \n50 | \n
Other vegetables | \n0.1 | \n
Baked beans | \n2 | \n
Grain peas, lupines, and lentils | \n10 | \n
Other leguminous vegetables | \n0.1 | \n
Flax seeds, rapeseed, mustard, and cotton | \n10 | \n
Sunflower and soybeans | \n20 | \n
Other oil seeds | \n0.1 | \n
Wheat and rye | \n10 | \n
Barley, oats, and sorghum | \n20 | \n
Corn | \n1 | \n
Other cereals | \n0.1 | \n
Sugar beets (roots) | \n15 | \n
Forage from meadows and pastures, and alfalfa | \n0.1 | \n
Maximum residue levels for some food products.
A preliminary important information comes from the EU Reference Laboratories for Residues of Pesticides (EURL-SRM): for all the analytical steps, it is highly recommended the use of plastic vials because there is an interaction between the pesticide and the glass surface, especially when aprotic solvents are used. These interactions greatly affect the precision and accuracy, especially at low GLYP concentration. This statement is important because it influences its stability and degradation as well. Among the different solvents, water with 10% acetonitrile is considered a good storage solvent, whereas the compound is not stable in water and methanol. At room temperature, the degradation is very low within 14 days, whereas if extract is stored in the refrigerator, it is stable over 7 months [39].
\nFinally, the authors would like to remember some definitions regarding the parameter of an analytical method. Recovery is the term used in analytical and preparative chemistry to denote the fraction of the total quantity of a substance recoverable following a chemical procedure [40]. Accuracy is the difference between the mean of some measurements and the value considered as the true or correct value for the quantity measured, whereas precision is the measurement reproducibility, that is, the dispersion around a central value. In regard to the chromatographic separation, a signal-to-noise (S/N) ratio of 3 is acceptable for determining the limit of detection (LOD), that is, the lowest amount of analyte in a sample, which can be detected, whereas a ratio of 10 for the limit of quantification (LOQ), that is, the lowest amount of analyte in a sample, which can be quantitatively determined with precision and accuracy [41, 42, 43, 44]. The S/N definition for chromatography is the ratio of the peak height relative to the middle of the noise range (S) to the difference between the maximum and minimum baseline signal values for the noise (N) [45].
\nGrain is the largest and well-studied matrix in this field. Many papers deal the glyphosate determination in cereals and legumes due to the worldwide use of such herbicide in the relative cereal crops. We must remember that, as said at the beginning, the first warning came precisely by analyzing several Canadian wheat samples and finding almost 37% of them with high presence of the pesticide. So, after this occurrence, scientific and health attention has been very high and focused on cereals in general, for example, maize corn, millet, barley, oats, rice, wheat wild rice, amaranth, and quinoa.
\nThe literature analysis for the GLYP determination in such matrix is very large; for this reason, the authors focused their attention on the main publications starting from the last deep review, that is, by Tadeo et al. [46]. The same method will be applied to the revision of the analytical methods for GLYP determination in vegetables and fruit matrices.
\nA routine control method based on extraction with water by ultrasonication was developed by Granby et al. [47] for analyzing several Danish mill products. It was one of the first studies based on green chemistry, that is, the authors used no organic solvents or chemicals except diluted solutions of NaHCO3 (as eluent) and, in some cases, H2SO4. The samples (rye or wheat in grain and flour) were subjected to online clean-up and separation by in-series system of ion chromatography (IC) and high performance liquid chromatography (HPLC) with detection by electrospray ionization mass spectrometry in the negative-ion mode. The method, investigated in the range of 0.03–0.33 mg kg−1, shows a GLYP recovery of 85%, a repeatability between 1 and 14%, a reproducibility from 4 to 16%, and a LOD of 0.02 mg kg−1 (LOQ was not reported).
\nA very interesting paper was published by Tseng et al.: they used the gas chromatography coupled with a pulsed flame photometric detector (PFPD) for a simultaneous determination of GLYP and glufosinate (DL-homoalanin-4-yl-(methyl)phosphinic acid, GLUF) along with their main metabolites including AMPA [48] after a single-step derivatization with trimethyl orthoacetate (TMOA). In particular, the authors studied the influence of the heating temperature (70–90°C) and time (90–120 min) on the AMPA and 3-(methylphosphinico)propionic acid (3-MPPA, a GLUF metabolite) derivatization. They optimized the method on soybean sprouts and rice samples and determined the different analytical parameters (recoveries 72–81, 71–86, 101–119, and 83–90%; LOD of 0.02, 0.03, 0.02, and 0.01 μg g−1; and LOQ of 0.06, 0.10, 0.06, and 0.04 μg g−1 for glyphosate, AMPA, GLUF, and 3-MPPA, respectively; RSD < 10%). On the other hand, Li et al. used fluorenylmethyl chloroformate (FMOC-Cl) as derivatizating agent followed by HPLC-MS/MS for analyzing GLYP and AMPA residues in different matrices such as rice, wheat, vegetables, fruits and tea, pig and chicken muscles, aquatic products, chestnut, and honey [49]. Further, they also used an isotope-labeled 1,2-13C15N GLYP for increasing the accuracy and the precision of the measurements at low GLYP concentration. In this way, they obtained recoveries between 80.0 and 104% and RSDs from 6.7 and 18.2% with a LOQ of 0.05 mg kg−1 for both compounds and a correlation of 0.998 in the linear range of 0.20–10 μg L−1.
\nIn 2007, Granby’s group published a paper on the (six) laboratory intercomparison for determining GLYP, chlormequat, and mepiquat (these two are plant growth regulators, also used for the growth reduction of the lowest straw part) residues in cereals [50]. GLYP was analyzed by treating the samples twice with MilliQ water by ultrasonication followed by centrifugation, filtration, clean-up on polystyrene-based reverse phase column, and separation by IC-HPLC-MS/MS, whereas the other two compounds were extracted by Ultra-Turrax and cleaned-up by SPE-C18. The results showed very different LOQs and recoveries reached by the six laboratories (0.01 and 0.3 mg kg−1 and 29 and 109% for GLY) with a good within-laboratory precision and a poor between-laboratory precision [51]. For glyphosate, the authors stated the presence of a systematic component between laboratories to be the reason of such large data variability.
\nSimple sample preparation and fast chromatographic analysis are the main features of the paper by Martins-Júnior et al. [52]. They analyzed GLYP and AMPA in soybean samples by means of liquid-liquid partition with dichloromethane and protein precipitation followed by HPLC-MS/MS determination (in positive and negative electrospray ionization, ESI, mode). This paper highlights the choice of the liquid-liquid partition and protein precipitation. Particularly, the paper evidences the importance of the second step, that is, the protein precipitation for eliminating the matrix interference: different solvents, that is, acetone, acetonitrile, and methanol, were tested, and methanol was found the best for reducing it (but it does not eliminate it). The authors took advantage of the great performance of the tandem mass spectrometry (MS/MS) and reached LODs of 0.09 and 0.1 mg kg−1 and LOQs of 0.30 and 0.34 mg kg−1 for GLYP and AMPA, respectively, with recoveries between 79.6 and 109.1% and RSD below 12.2%. Further, the authors suggested to apply this analytical protocol to other crop matrices, where GLYP is largely used, for instance, corn and cotton.
\nAs just noted above and especially using the LC-MS/MS as GLYP detection, the matrix effect is not negligible. In literature, different possibilities have been studied for reducing this artifact: for instance, sample dilution [53], injection of smaller volumes [54], the optimization of sample preparation and/or chromatographic parameters [55], or the use of expensive internal standard (IS). Ding et al. [56] developed a combination of C18 and SAX cartridge for reducing the matrix effect. After to have optimized the analytical conditions, the authors used hydrophilic interaction chromatography (HILIC)/WAX mixed-mode stationary phases for glyphosate retention and LC-MS/MS in negative ion mode for the detection. They used this methodology for analyzing soybean, corn, spicy cabbage, apple, and carrot samples. GLYP is investigated in a linear range between 0.02 and 10 mg kg−1, with a
Botero-Coy et al. explored for first the possibility to analyze GLYP in rice, maize, and soybean without derivatization step but just direct LC–MS/MS with a triple quadrupole instrument after water extraction and SPE using Oasis HLB cartridge [57]. The method has allowed to reach high correlation coefficients (<0.99) in the range of 1–250 μg L−1, recoveries between 77 and 100% with RSDs below 17%, and good LODs and LOQs (0.007–0.12 mg kg−1 and 0.1 and 2 m kg−1, respectively) for all matrices.
\nA Chinese-French scientific paper in 2018 dealt the determination of GLYP and GLUF in 136 food samples, of which 34% of samples with high (banana, apple, orange, potato, carrot, and juice) and low (biscuits or bread) water contents and 66% of animal origin samples (milk-based foods included, e.g., milk, cheese, and butter) [58]. After a solvent extraction (acidified water, methanol, and dichloromethane), the authors performed a derivatization by means of FMOC and a solid phase extraction (SPE) C18 for purifying and concentrating the extract and a HPLC-MS/MS analysis for determining the two compounds. Using these conditions, recoveries between 82 and 112%, LODs and LOQs of 1.7 and 5 μg kg−1, respectively, and RSDs below 20% for both compounds were achieved.
\nAn ion chromatography-tandem mass spectrometry-based method was developed by Adams et al. for analyzing 14 polar pesticides including GLYP in cereal and grape samples [59]. The extraction is based on quick polar pesticide (QuPPe). Although the method is interesting, not all the analytical parameters are reported except the recoveries for cereals (specifically, oat flour) ranging between 85 and 104%.
\nA simple method based on acidified methanol solution extraction followed by centrifugation and filtration and LC-MS/MS analysis was developed by Santilio et al. for analyzing GLYP in rice and maize [60]. The authors highlighted the importance of using GLYP isotope labeled in the matrix effect reduction. LODs of 2 μg kg−1 for rice and 4 μg kg−1 for maize and a LOQ of 10 μg kg−1 for both matrices were reached in a linearity range of 0.01–1.5 mg kg−1 (
Finally, Herrera López et al. set up a multiresidue analysis for determining 14 highly polar pesticides (parents and metabolites) in 352 samples including oat and soya beans, lettuce, grapes, and oranges [61]. After a solvent extraction step, a LC system coupled with a hybrid quadrupole/linear ion trap mass spectrometer system (with ESI source) (LC-ESI-QTRAP-MS) was used for reaching high analytical performances: linearity range between 0.01 and 10 mg kg−1 with
The scientific attention on GLYP contamination in this food class is on the rise recently. Only few papers are available on such matrices. In fact, if the GLYP behavior in the aquatic environment is studied since many years [62, 63, 64], poor information is presented on its presence in foods.
\nStarting from the paper by Botero-Coy et al. [57], Chiesa et al. developed a method based on IC coupled to high resolution mass spectrometry (IC-HRMS) for determining GLYP, GLUF, and AMPA in different foods of animal origin without a derivatization step [65]. The authors focused their attention on the matrix, particularly on the lipid composition, which is the major interfering group because co-extracted with the analytes. The main contribution of this study was to identify the best extraction solvent: among different assays, the best solution is 30% of methanol and 70% of acidified water (1% formic acid). Thirty samples among fish (bass), bovine muscle, and organic honey were analyzed. The detector, an orbitrap quipped with heated electrospray ionization (HESI) source, allowed to reach very low LOQs (4.26–5.38 ng g−1, 6.25–6.47 ng g−1, and 4.30–9.26 ng g−1 for fish, bovine, and honey, respectively), good recoveries (96.9, 76.1, and 97.0%, respectively), RSDs <13.1%, and good correlation coefficients (
Actually, in literature, there are other few papers showing the determination of GLYP and AMPA in muscle meat (bovine, cow, pig, and chicken), but the LODs are higher (50 ng g−1) [49, 66, 67], whereas the only paper on fish does not report any information on LOQ [68].
\nA communication dealing with the determination of GLYP and GLUF in animal feeds shows linearity more than 0.999, instrumental detection limits (IDLs) of 8.3 μg kg−1 and 1.1 μg kg−1, respectively, accuracy between 102 and 112%, and precision below 6% in both matrices [69].
\nFinally, about the GLYP determination in cheese or, basically, in milk-based foods, the authors just discussed above the only paper present in the literature [58]. Please note that the milk as beverage will be discussed in other section.
\nSome papers dealing with the GLYP determination in such food matrices are just discussed previously [46, 49, 56, 58, 61]: here the attention is focused on papers showing novelty or improvements in the analytical methodology or large studies on the herbicide content. The first interesting paper is dated in 1992: Tanaka and coauthors developed a very easy method employing routinely available instrumentation, that is, HPLC with a fluorescence detection [70]. The analytical parameters are quite weak (recoveries >68% and >88% for GLYP and AMPA, respectively, and LOD 0.05 ppm for both), but it is to be appreciated the use of common equipment. In 1996, two papers investigated the GLYP presence in green lentils, fresh beans [71], and carrot [72]. The first paper introduced a post-column reaction, a denitrozation, for obtaining a N-nitroso-GP (NGP) derivate to be analyzed by HPLC coupled with thermal energy analyzer (TEA), that is, a chemiluminescence detector. Over vegetables, the authors also analyzed beverages (water and beer) and cereals (rice flour, corn, barley, and rye). They obtained recoveries between 83 and 97% for vegetables, 70–100% for beverages, and 67–100% for cereals with LODs ranging between 0.005 and 1 μg g−1. On the other hand, the second paper presents a GC analysis coupled with flame photometric detection (FPD) for analyzing GLY, AMPA, and GLU. The use of instrumentation commonly present in each laboratory is to be appreciated also in this case. The three compounds were derivatized with N-isopropoxycarbonyl (isoPOC) for obtaining the relative isoPOC methyl ester derivatives: 0.5–1 μL of this solution wax injected in the GC-FPD. The authors determined the LODs (12, 8, and 20 pg injected for GLY, AMPA, and GLU, respectively), the recoveries (91–104, 94–104, and 91–100%, respectively), and the correlation coefficients (
Hooijschuur and coauthors explored the possibility to use the microcolumn liquid chromatography with FPD detection (μLC-FPD) and compared these results with those obtained by capillary electrophoresis (CE) with FPD (CE-FPD) [73]. They used a silica column (25 cm × 320 μm ID, 450 μm OD) with 5 μm LiChrosorb RP-1 bonded silica. Although CE-FPD was faster than μLC-FPD, this is more sensitive for the GLYP and AMPA analysis: LODs are 15 and 7.5 ng mL−1, respectively, versus LOD of 1.0 μg mL−1 for both compounds by CE-FPD. Grey et al. applied the LC-ESI/MS analysis after the derivatization with FMOC-Cl of GLYP and AMPA [74]. They evaluated the use of isotope-labeled compounds: their conclusions were positive in the GLYP determination (LODs 0.11 μg g−1 and 0.06 μg L−1 for lettuce and water samples, respectively), whereas they did not find any contribution for the accurate AMPA analysis (LODs 0.53 μg g−1 and 0.3 μg L−1, respectively). Finally, the recoveries increased from 23.2 to 98.4% for GLYP and from 33.8 to 99.4% using the isotope dilution mass spectrometry (IDMS)-based glyphosate analytical method. Finally, Takahashi et al. determined GLYP and GLUF in cabbage, Chinese cabbage, carrot, onion, strawberry, lemon, kiwi fruit, over soybean, corn, and brown rice after derivation with FMOC-Cl and analysis by HPLC with fluorescence detection [75]. Another interesting paper came from Japan in 2004: Watanabe set up a rapid method for determining GLYP, GLUF, and 3-MPPA in vegetables (cucumber and spinach) and fruits (apple, mandarin, and orange) using an anion exchange resin and elution with acetic acid, followed by derivatization with trimethyl orthoacetate and clean-up on SPE Florisil cartridge and GC-FPD analysis [76]. The method allows to reach LODs of 0.01, 0.01, and 0.005 μg g−1 and recoveries of 83.5–89.8, 77.9–92.2, and 75.0–87.2% for GLYP, GLUF, and 3-MPPA, respectively.
\nA Chinese group proposed an original method for determining GLYP in apple samples [77]: after clean-up with SPE-C18, a derivatization step was performed using 4-chloro-3,5-dinitrobenzotrifluoride (CNBF). The quantification occurred by reverse ion-pair liquid chromatography using cetyltrimethylammonium bromide (CTAB) as ion-pair reagent. The strengths of the method are the formation of a stable derivative (5% degradation after 7 storage days at room temperature) and the easy pretreatment procedure. LOD of 0.01 μg g−1, recoveries from 86.0 to 99.5%, and RSDs from 1.43 to 6.32 were achieved applying this method to apple samples.
\nRembisz and coauthors started from a different idea: GLYP (as well GLU) is an aminophosphonic acid, analogous of the amino acid. So, they proposed a derivatization with phenyl isothiocyanate (PITC) for obtaining phenylthiocarbamyl derivatives (PTC derivatives): a thin-layer chromatography (TLC) with iodine-azide detection allowed to detect such compounds in parsley and lettuce samples [78]. The method was sensitive, accurate, and inexpensive showing recoveries between 95 and 104%, LODs 0.99–4 μg per spot, LOQs 1.78–8.45 μg per spot, and RSDs <7.7 for both compounds.
\nA fast routine analysis was developed by Boušová et al. for routinely determining the polar pesticides, including GLYP, AMPA, GLUF, and 3-MPPA, in lettuce, orange, and flour samples [79]. The coupling of ion chromatography to a triple quadrupole mass spectrometer allowed the authors to reach very good LODs and LOQs (1–10 μg kg−1 and 10–20 μg kg−1), recoveries ranging between 71 and 116% according to the matrix, and RSD < 18%. Rajski et al. implemented this procedure using an orbitrap detector and validating the method for aubergine, zucchini, cabbage, orange, and watermelon samples [80], achieving good recoveries (70–120%) and LOQ (0.01 mg kg−1) for GLY, AMPA, and GLU. Melton et al. still used the ion chromatography but coupled with the tandem mass spectrometry (IC-MS/MS) for determining highly polar pesticides (including GLY, AMPA, and GLU) in 288 samples of melon, peas without pods, and pineapple [81]. Finally, a paper by Savini et al. worth to be mentioned: the authors used the UHPLC coupled with a orbitrap detector for analyzing GLPY, AMPA, GLUF, and other polar pesticides in 98 samples (83 processed fruits and vegetables and 15 infant foods) [82]. Using the developed method, the authors obtained LOQ of 0.003 mg kg−1 for all three compounds, recoveries 75–113% in all matrices, RSDs below 18.5%, and a
Two papers dealt with the determination of GLYP in olives and olive oil [83, 84]. Both papers deal the difficulty of analyzing such matrices, and there is strong matrix effect. In the first paper, two different methods were developed, that is, UHPLC-TOFMS and UHPLC-MS/MS using HILIC separation: in this way, the authors reached LOQ of 0.3 μg kg−1 and 0.1 μg kg−1, respectively, and recoveries between 57.2 and 117.6% with a linearity >0.99 and an RSD < 3.9%. The two different LOQs were calculated using time-of-flight mass spectrometry (TOFMS) and triple quadrupole instruments: as expected, the MS/MS shows lower quantifiable levels. The second paper presented a green fast-analytical method based on vortexing (1 min with acidified water) and centrifugation (10 min at 3700 rpm) and extract injection in UHPLC–MS/MS for determining GLYP, AMPA, and GLUF in different olive oils, that is, extra virgin olive oil, virgin olive oil, olive pomace oil, and soy oil. Particularly, the paper reported the determination with no internal standards nor matrix-matched calibration. The authors tested the linearity in the concentration range of 5–250 μg L−1: they fixed LOQs at 5 μg kg−1 for AMPA and at 10 μg kg−1 for GLYP and GLUF and determined recoveries between 81.4 and 119.4% with intra and inter-day precision lower than 19%.
\nDuring the past few years, the important question has emerged about GLYP contamination in natural honey samples. Different papers have been published dealing this issue. Some of them have already been discussed previously [49, 65].
\nA first interesting paper dealing with such of matrix was this of Karise and coauthors [85]. They set up a multiresidue method for analyzing GLYP along with other 47 pesticides in 33 honey samples collected from beehives of Estonia. The paper was focused on the detection of the pesticide concentration and the relative maximum residue levels and the possible impact of the agriculture on the product. In any case, the authors largely used the analytical methodology based on using QuEChERS (acronym of Quick, Easy, Cheap, Effective, Rugged and Safe) extraction methodology followed by detection using GC-MS and ultra-high-performance liquid chromatography-MS/MS (UHPLC-MS/MS): the method shows recovery between 78 and 115%, repeatability from 3.0 to 16%, LOQ for GLYP of 0.050 mg kg−1 (and 0.010 mg kg−1 for the other pesticides), and correlation coefficients >0.990 for all compounds.
\nIn 2018, Zoller et al. found GLYP at very low levels in 15 of 16 honey samples analyzed; in addition, they also analyzed pulses (tofu and soy sauce), breakfast cereals (corn flakes and pops), durum wheat, pastry and snacks (crisps, etc.), bread, flour and baking mixtures, and beverages (beer, wine, milk, fruit juices, and mineral water) for a total of 243 samples [86]. The authors applied a well-tested analytical method based on solvent extraction with methanol and LC-MS/MS analysis for determining GLYP and AMPA (LODs 0.2–0.4 and 0.5–1 μg kg−1, respectively; LOQs 0.5–1 and 1–2.5 μg kg−1; recoveries 92–103 and 92–115%; RSDs <9.5 and <13.9%). Further, in this paper, the authors assessed a dietary risk of each food for a child of 15 kg body weight and for an adult of 60 kg body weight. The first findings of this work were that the GLYP maximum residue levels did not exceed more than the legally tolerated ones (0.1 mg kg−1 for plant products and 0.05 mg kg−1 for animal products). So, the scores reported by authors for the risk assessment highlighted a low exposure only for the pulses (5% of the acceptable daily intake, ADI, and acute reference dose, ARfD), whereas in all the other cases, honey samples included, the exposure to GLYP is less than 1% of the ADI/ARfD, meaning there is no any human health issue in all samples. Further, the authors, simulating a daily ingestion of the different investigated foods, estimated the probable GLYP content in urine. They found levels in agreement with those found by other authors in German [3, 17] and Swiss [87] populations, whereas some differences could be expected in AMPA concentration comparison [17].
\nA pilot study for monitoring GLYP and AMPA in 32 honey samples was set up by Pareja et al. based on IC coupled to a Q-Orbitrap accurate high-resolution mass spectrometry [88]. It is still confirmed that the use of IC simplifies the polar pesticide determination, whereas the use of an orbitrap detector allows to reach a GLYP LOQ of 5 μg kg−1 (20 μg kg−1 for AMPA), less than the allowed EU MRL (50 μg kg−1) and recoveries ranging between 80 and 110% with RSDs <20% in the linearity range of 5–500 μg kg−1.
\nStill in 2019, a Canadian group developed an easy method for analyzing GLYP, AMPA, and GLUF at low μg kg−1 levels based on both the derivatization with FMOC-Cl in acetonitrile solution and online SPE(C18)-LC-MS/MS analysis [89] and the use of isotopically labeled internal standards (as just evidenced previously). In particular, for all the investigated compounds, the authors obtained accuracies ranging between 95.2 and 105.3% (intraday precision 1.6–7.2%) and LOQ 1 μg kg−1. By this method, 200 honey samples were analyzed: GLYP was found in 196 samples at maximum level of 49.8 μg kg−1 with a 95th percentile of 14.2 μg kg−1, evidencing no risks for the consumers. Further, the authors performed a survey between their data with others from worldwide studies (the United States, Estonia, Switzerland, some just cited in this review) [85, 86, 90, 91, 92].
\nA 2020 paper evaluated the exposure risk of bees and humans to GLYP and AMPA residues in three different bee matrices, that is, beebread, wax, and paired samples of wax/honey collected from 379 Belgian apiaries using an analytical method based on clean-up on SPE-C18 followed by derivatization step with FMOC-Cl and HPLC-ESI-MS/MS analysis [93]. LOD and LOQ of 1 ng g−1 and 10 ng g−1, respectively, were achieved for both compounds in all matrices with recoveries ranging between 72.2 and 112.9% and RSDs from 0.1 to 4.5%. The authors stated that the GLYP levels were below the EU regulation in all samples. In any case, they suggest particular attention because recent studies deal the effects of GLYP [94] and AMPA [95] below the allowed concentrations.
\nThis last matrix is really important considering the large use of beverages in the daily dietary intake. Beverages such as water, beer, milk, and fruit juices are under strict attention by the different national authorities. For instance, in 2019, a study by Cook of the CalPIRG Education Fund (available at https://uspirg.org/sites/pirg/files/reports/WEB_CAP_Glyphosate-pesticide-beer-and-wine_REPORT_022619.pdf?_ga=2.33097086.1581849178.1551185850-857148262.1551185850) reported that 19 of wine (5) and beer (14) brands contained GLYP at levels ranging between 4.8 and 51.4 ppb. Several papers have been published in recent years, some of which have already been mentioned in this review [49, 58, 71, 73, 86].
\nThe first interesting paper by Hao et al. describes a method for analyzing GLYP, AMPA, and GLUF in drinking water, surface water, and groundwater samples [96], that is, a LC-MS/MS method with reversed-phase and weak anion-exchange mixed-mode Acclaim® WAX-1 column. Good analytical parameters were obtained: LODs of 1.5, 3.9, and 1.7 μg L−1 for GLYP, AMPA, and GLUF, respectively; LOQs of 4.5, 11.6, and 5.3 μg L−1; and recoveries between 62 and 102%. The main aspect is the analysis by direct injection of aqueous samples without derivatization or clean-up procedures with the risk of artifacts.
\nIn 2015, a Chinese group developed a procedure for analyzing GLYP and GLUF in tea samples by means of FMOC-Cl derivatization and UPLC–MS/MS analysis [97]. The method shows good linearity (
Two papers published in 2015 reported the GLYP, AMPA, and GLUF determination in milk and milk-based products. Ehling and Reddy carried out a derivatization with FMOC-Cl followed by means of LC-MS/MS in different nutritional milk matrices such as cow’s milk, human breast milk, soy milk, and whole milk powder [98]. This study is important because the reported analytical method does not require any analytical treatment such as clean-up, evaporation, or concentration; so, the possible artifact formation is drastically reduced. Further, the importance of the use of a triple-quadrupole mass spectrometry is still confirmed in terms of selectivity and fragment analysis. This occurrence gives good analytical parameters:
Steinborn et al. reported of a survey on the GLYP content in 114 breast milk samples collected in Bavaria and Lower Saxony, Germany, by comparing the data obtained by LC-MS/MS and GC-MS/MS analyses [100]. The two analyses required (a) an ultrafiltration and chromatography on an anion exchange column for LC–MS/MS and (b) a clean-up step on a cation exchange column and derivatization with trifluoroacetic acid anhydride (TFAA) and heptafluorobutanol (HFB) for the GC–MS/MS. The authors deeply investigated the difference between the chromatograms obtained with the two methods, especially for evaluating parameters such as precision, accuracy, LOD, and LOQ . Basically, GC–MS/MS allowed to reach instrumental detection limit (IDL) lower than that found in LC–MS/MS (0.02 vs. 0.5 ng mL−1), but they detected an interference on a GLYP peak, which they did not manage to identify (all reagents, ultrapure water, all components were tested). Therefore, they fixed the LOQ at 1 ng mL−1, the same concentration determined by LC–MS/MS (whose LOD is 0.5 ng mL−1). The recoveries ranged between 83 and 128% with RSD < 17% for LC–MS/MS and between 71 and 102% with RSD < 13% for GC–MS/MS. Resuming, the GC–MS/MS is powerful at lower concentrations, but it simultaneously gives more bias than LC–MS/MS; both methods manage to investigate concentration above 1 ng mL−1 with high precision and accuracy.
\nTwo papers investigated the GLYP and AMPA content in human milk and urine samples. In the first, a high-throughput LC–MS/MS method using stable isotope labeled internal standard and clean-up with methylene chloride allowed to reach very low LODs (0.92 and 1.2 for GLYP and AMPA in human milk samples and 0.023 and 0.033 μg mL−1 in human urine samples) and LOQs (10 μg mL−1 for both in breast human milk samples and 0.1 μg mL−1 in human urine samples), high recoveries (GLYP ranging between 92 and 107% in both matrices, AMPA between 89 and 107%) with low RSDs (<7.4 and <11.6% in human milk and urine samples, respectively) [101]. The authors also studied the matrix stability over a storage in 5°C (refrigerator) and at –20°C (freezer): in the first case, the recoveries were acceptable also after 24 hours, whereas in the second case, they were good also after 3 months. On the other hand, the second paper investigated the presence of GLYP and AMPA in milk (41 samples) and urine (40 samples) from healthy lactating women from Russia and the United States [102]. The authors used the same analytical procedure as reported above (i.e., LC-MS/MS, the use of stable isotope labeled internal standard and two fragments, such as precursor and product ion transitions, for the quantification) for the analysis, that is, the same analytical parameters. The results showed GLYP and AMPA in milk samples at levels below the LODs, whereas at low concentrations (<LOD and 1.93 μg mL−1 and <LOD and 1.33 μg mL−1, respectively, in urine samples). The authors extrapolated the maximum intake of milk containing 1 μg mL−1 of GLYP for a 5-kg infant: their conclusions were that the expected levels should be 12,000 times lower than the health concern.
\nThe presence of MRLs for GLYP in barley, wheat, rye, and hops is regulated by EU Regulation (EC) No. 396/2005 (i.e., 20, 10, and 0.1 mg kg−1) [37, 38]. These are the raw agricultural commodities for beer beverage. Jansons et al. (2018) analyzed 100 beer samples from 24 different producers and distributors in Latvia with LC–MS/MS method (
Over these papers, it should be underlined two other paper dealing the GLYP determination in river water and soil samples. This particular occurrence regards the analytical protocol used by authors. In the first paper, Kudzin et al. developed a procedure based on derivatization with TEA-trifluoroacetic anhydride (TFAA)-trimethyl orthoacetate reagent and analyses by GC-CI(or EI)/MS (LOD 2.5–5.0 pmol) and GC-flame ionization detection (GC-FID; LOD 30–80 pmol, recovery 97%) [104]. In the second paper, Hu et al. investigated the performance of a method based on GC with nitrogen-phosphorus detector (GC-NPD): they estimated a LOD of 9 × 10−12 g and a LOQ of 0.01 mg kg–1 in samples, recoveries between 84.4 and 94.0%, and RSDs between 8.1 and 13.7% [105]. These two papers deserve to be mentioned for having introduced the possibility to analyze GLYP by two very easy, cheap, and worldwide available detectors such as FID and NPD.
\nThis long
In any case, the fear for the future is that the refinement of analytical methods increasingly leads to alarmist attitudes based on the discovery of very low quantities of GLYP, which is possible for a very wide range of products, even extremely toxic, without forgetting that in nature the zero residue does not exist.
\nThe authors would like to thank Giuseppe Ianiri for his help in the database revision and data analysis.
\nThe authors declare no conflict of interest.
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All published Book Chapters are licensed under a Creative Commons Attribution 3.0 Unported License. Monographs are licensed under the Creative Commons Attribution-NonCommercial 4.0 International (CC BY-NC 4.0) license granted to all others. Our Copyright Policy aims to guarantee that original material is published while at the same time giving significant freedom to our Authors. IntechOpen upholds a flexible Copyright Policy meaning that there is no copyright transfer to the publisher and Authors hold exclusive copyright to their work.
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She is now a lecturer at the University of Witwatersrand, South Africa, and a principal researcher at the Health Economics and Epidemiology Research Office (HE2RO), South Africa. Dr. Moolla holds a Ph.D. in Psychology with her research being focused on mental health and resilience. In her professional work capacity, her research has further expanded into the fields of early childhood development, mental health, the HIV and TB care cascades, as well as COVID. 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He is currently the Director of the Postgraduate Program in Implantology of the Bioface/UCAM/PgO (Montevideo, Uruguay), Director of the Cathedra of Biotechnology of the Catholic University of Murcia (Murcia, Spain), an Extraordinary Full Professor of the Catholic University of Murcia (Murcia, Spain) as well as the Director of the private center of research Biotecnos – Technology and Science (Montevideo, Uruguay). Applied biomaterials, cellular and molecular biology, and dental implants are among his research interests. He has published several original papers in renowned journals. In addition, he is also a Collaborating Professor in several Postgraduate programs at different universities all over the world.",institutionString:null,institution:{name:"Universidad Católica San Antonio de Murcia",country:{name:"Spain"}}},{id:"342152",title:"Dr.",name:"Santo",middleName:null,surname:"Grace Umesh",slug:"santo-grace-umesh",fullName:"Santo Grace Umesh",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/342152/images/16311_n.jpg",biography:null,institutionString:null,institution:{name:"SRM Dental College",country:{name:"India"}}},{id:"333647",title:"Dr.",name:"Shreya",middleName:null,surname:"Kishore",slug:"shreya-kishore",fullName:"Shreya Kishore",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/333647/images/14701_n.jpg",biography:"Dr. Shreya Kishore completed her Bachelor in Dental Surgery in Chettinad Dental College and Research Institute, Chennai, and her Master of Dental Surgery (Orthodontics) in Saveetha Dental College, Chennai. She is also Invisalign certified. She’s working as a Senior Lecturer in the Department of Orthodontics, SRM Dental College since November 2019. She is actively involved in teaching orthodontics to the undergraduates and the postgraduates. Her clinical research topics include new orthodontic brackets, fixed appliances and TADs. She’s published 4 articles in well renowned indexed journals and has a published patency of her own. Her private practice is currently limited to orthodontics and works as a consultant in various clinics.",institutionString:null,institution:{name:"SRM Dental College",country:{name:"India"}}},{id:"323731",title:"Prof.",name:"Deepak M.",middleName:"Macchindra",surname:"Vikhe",slug:"deepak-m.-vikhe",fullName:"Deepak M. Vikhe",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/323731/images/13613_n.jpg",biography:"Dr Deepak M.Vikhe .\n\n\t\n\tDr Deepak M.Vikhe , completed his Masters & PhD in Prosthodontics from Rural Dental College, Loni securing third rank in the Pravara Institute of Medical Sciences Deemed University. He was awarded Dr.G.C.DAS Memorial Award for Research on Implants at 39th IPS conference Dubai (U A E).He has two patents under his name. He has received Dr.Saraswati medal award for best research for implant study in 2017.He has received Fully funded scholarship to Spain ,university of Santiago de Compostela. He has completed fellowship in Implantlogy from Noble Biocare. \nHe has attended various conferences and CDE programmes and has national publications to his credit. His field of interest is in Implant supported prosthesis. Presently he is working as a associate professor in the Dept of Prosthodontics, Rural Dental College, Loni and maintains a successful private practice specialising in Implantology at Rahata.\n\nEmail: drdeepak_mvikhe@yahoo.com..................",institutionString:null,institution:{name:"Pravara Institute of Medical Sciences",country:{name:"India"}}},{id:"204110",title:"Dr.",name:"Ahmed A.",middleName:null,surname:"Madfa",slug:"ahmed-a.-madfa",fullName:"Ahmed A. Madfa",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/204110/images/system/204110.jpg",biography:"Dr. Madfa is currently Associate Professor of Endodontics at Thamar University and a visiting lecturer at Sana'a University and University of Sciences and Technology. He has more than 6 years of experience in teaching. His research interests include root canal morphology, functionally graded concept, dental biomaterials, epidemiology and dental education, biomimetic restoration, finite element analysis and endodontic regeneration. Dr. Madfa has numerous international publications, full articles, two patents, a book and a book chapter. Furthermore, he won 14 international scientific awards. Furthermore, he is involved in many academic activities ranging from editorial board member, reviewer for many international journals and postgraduate students' supervisor. Besides, I deliver many courses and training workshops at various scientific events. Dr. Madfa also regularly attends international conferences and holds administrative positions (Deputy Dean of the Faculty for Students’ & Academic Affairs and Deputy Head of Research Unit).",institutionString:"Thamar University",institution:null},{id:"210472",title:"Dr.",name:"Nermin",middleName:"Mohammed Ahmed",surname:"Yussif",slug:"nermin-yussif",fullName:"Nermin Yussif",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/210472/images/system/210472.jpg",biography:"Dr. Nermin Mohammed Ahmed Yussif is working at the Faculty of dentistry, University for October university for modern sciences and arts (MSA). Her areas of expertise include: periodontology, dental laserology, oral implantology, periodontal plastic surgeries, oral mesotherapy, nutrition, dental pharmacology. She is an editor and reviewer in numerous international journals.",institutionString:"MSA University",institution:null},{id:"204606",title:"Dr.",name:"Serdar",middleName:null,surname:"Gözler",slug:"serdar-gozler",fullName:"Serdar Gözler",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/204606/images/system/204606.jpeg",biography:"Dr. Serdar Gözler has completed his undergraduate studies at the Marmara University Faculty of Dentistry in 1978, followed by an assistantship in the Prosthesis Department of Dicle University Faculty of Dentistry. Starting his PhD work on non-resilient overdentures with Assoc. Prof. Hüsnü Yavuzyılmaz, he continued his studies with Prof. Dr. Gürbüz Öztürk of Istanbul University Faculty of Dentistry Department of Prosthodontics, this time on Gnatology. He attended training programs on occlusion, neurology, neurophysiology, EMG, radiology and biostatistics. In 1982, he presented his PhD thesis \\Gerber and Lauritzen Occlusion Analysis Techniques: Diagnosis Values,\\ at Istanbul University School of Dentistry, Department of Prosthodontics. As he was also working with Prof. Senih Çalıkkocaoğlu on The Physiology of Chewing at the same time, Gözler has written a chapter in Çalıkkocaoğlu\\'s book \\Complete Prostheses\\ entitled \\The Place of Neuromuscular Mechanism in Prosthetic Dentistry.\\ The book was published five times since by the Istanbul University Publications. Having presented in various conferences about occlusion analysis until 1998, Dr. Gözler has also decided to use the T-Scan II occlusion analysis method. Having been personally trained by Dr. Robert Kerstein on this method, Dr. Gözler has been lecturing on the T-Scan Occlusion Analysis Method in conferences both in Turkey and abroad. Dr. Gözler has various articles and presentations on Digital Occlusion Analysis methods. He is now Head of the TMD Clinic at Prosthodontic Department of Faculty of Dentistry , Istanbul Aydın University , Turkey.",institutionString:"Istanbul Aydin University",institution:{name:"Istanbul Aydın University",country:{name:"Turkey"}}},{id:"240870",title:"Ph.D.",name:"Alaa Eddin Omar",middleName:null,surname:"Al Ostwani",slug:"alaa-eddin-omar-al-ostwani",fullName:"Alaa Eddin Omar Al Ostwani",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/240870/images/system/240870.jpeg",biography:"Dr. Al Ostwani Alaa Eddin Omar received his Master in dentistry from Damascus University in 2010, and his Ph.D. in Pediatric Dentistry from Damascus University in 2014. Dr. Al Ostwani is an assistant professor and faculty member at IUST University since 2014. \nDuring his academic experience, he has received several awards including the scientific research award from the Union of Arab Universities, the Syrian gold medal and the international gold medal for invention and creativity. Dr. Al Ostwani is a Member of the International Association of Dental Traumatology and the Syrian Society for Research and Preventive Dentistry since 2017. He is also a Member of the Reviewer Board of International Journal of Dental Medicine (IJDM), and the Indian Journal of Conservative and Endodontics since 2016.",institutionString:"International University for Science and Technology.",institution:{name:"Islamic University of Science and Technology",country:{name:"India"}}},{id:"42847",title:"Dr.",name:"Belma",middleName:null,surname:"Işik Aslan",slug:"belma-isik-aslan",fullName:"Belma Işik Aslan",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/42847/images/system/42847.jpg",biography:"Dr. Belma IşIk Aslan was born in 1976 in Ankara-TURKEY. After graduating from TED Ankara College in 1994, she attended to Gazi University, Faculty of Dentistry in Ankara. She completed her PhD in orthodontic education at Gazi University between 1999-2005. Dr. Işık Aslan stayed at the Providence Hospital Craniofacial Institude and Reconstructive Surgery in Michigan, USA for three months as an observer. She worked as a specialist doctor at Gazi University, Dentistry Faculty, Department of Orthodontics between 2005-2014. She was appointed as associate professor in January, 2014 and as professor in 2021. Dr. Işık Aslan still works as an instructor at the same faculty. She has published a total of 35 articles, 10 book chapters, 39 conference proceedings both internationally and nationally. Also she was the academic editor of the international book 'Current Advances in Orthodontics'. She is a member of the Turkish Orthodontic Society and Turkish Cleft Lip and Palate Society. She is married and has 2 children. Her knowledge of English is at an advanced level.",institutionString:"Gazi University Dentistry Faculty Department of Orthodontics",institution:null},{id:"178412",title:"Associate Prof.",name:"Guhan",middleName:null,surname:"Dergin",slug:"guhan-dergin",fullName:"Guhan Dergin",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/178412/images/6954_n.jpg",biography:"Assoc. Prof. Dr. Gühan Dergin was born in 1973 in Izmit. He graduated from Marmara University Faculty of Dentistry in 1999. He completed his specialty of OMFS surgery in Marmara University Faculty of Dentistry and obtained his PhD degree in 2006. In 2005, he was invited as a visiting doctor in the Oral and Maxillofacial Surgery Department of the University of North Carolina, USA, where he went on a scholarship. Dr. Dergin still continues his academic career as an associate professor in Marmara University Faculty of Dentistry. He has many articles in international and national scientific journals and chapters in books.",institutionString:null,institution:{name:"Marmara University",country:{name:"Turkey"}}},{id:"178414",title:"Prof.",name:"Yusuf",middleName:null,surname:"Emes",slug:"yusuf-emes",fullName:"Yusuf Emes",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/178414/images/6953_n.jpg",biography:"Born in Istanbul in 1974, Dr. Emes graduated from Istanbul University Faculty of Dentistry in 1997 and completed his PhD degree in Istanbul University faculty of Dentistry Department of Oral and Maxillofacial Surgery in 2005. He has papers published in international and national scientific journals, including research articles on implantology, oroantral fistulas, odontogenic cysts, and temporomandibular disorders. Dr. Emes is currently working as a full-time academic staff in Istanbul University faculty of Dentistry Department of Oral and Maxillofacial Surgery.",institutionString:null,institution:{name:"Istanbul University",country:{name:"Turkey"}}},{id:"192229",title:"Ph.D.",name:"Ana Luiza",middleName:null,surname:"De Carvalho Felippini",slug:"ana-luiza-de-carvalho-felippini",fullName:"Ana Luiza De Carvalho Felippini",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/192229/images/system/192229.jpg",biography:null,institutionString:"University of São Paulo",institution:{name:"University of Sao Paulo",country:{name:"Brazil"}}},{id:"256851",title:"Prof.",name:"Ayşe",middleName:null,surname:"Gülşen",slug:"ayse-gulsen",fullName:"Ayşe Gülşen",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/256851/images/9696_n.jpg",biography:"Dr. Ayşe Gülşen graduated in 1990 from Faculty of Dentistry, University of Ankara and did a postgraduate program at University of Gazi. \nShe worked as an observer and research assistant in Craniofacial Surgery Departments in New York, Providence Hospital in Michigan and Chang Gung Memorial Hospital in Taiwan. \nShe works as Craniofacial Orthodontist in Department of Aesthetic, Plastic and Reconstructive Surgery, Faculty of Medicine, University of Gazi, Ankara Turkey since 2004.",institutionString:"Univeristy of Gazi",institution:null},{id:"255366",title:"Prof.",name:"Tosun",middleName:null,surname:"Tosun",slug:"tosun-tosun",fullName:"Tosun Tosun",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/255366/images/7347_n.jpg",biography:"Graduated at the Faculty of Dentistry, University of Istanbul, Turkey in 1989;\nVisitor Assistant at the University of Padua, Italy and Branemark Osseointegration Center of Treviso, Italy between 1993-94;\nPhD thesis on oral implantology in University of Istanbul and was awarded the academic title “Dr.med.dent.”, 1997;\nHe was awarded the academic title “Doç.Dr.” (Associated Professor) in 2003;\nProficiency in Botulinum Toxin Applications, Reading-UK in 2009;\nMastership, RWTH Certificate in Laser Therapy in Dentistry, AALZ-Aachen University, Germany 2009-11;\nMaster of Science (MSc) in Laser Dentistry, University of Genoa, Italy 2013-14.\n\nDr.Tosun worked as Research Assistant in the Department of Oral Implantology, Faculty of Dentistry, University of Istanbul between 1990-2002. \nHe worked part-time as Consultant surgeon in Harvard Medical International Hospitals and John Hopkins Medicine, Istanbul between years 2007-09.\u2028He was contract Professor in the Department of Surgical and Diagnostic Sciences (DI.S.C.), Medical School, University of Genova, Italy between years 2011-16. \nSince 2015 he is visiting Professor at Medical School, University of Plovdiv, Bulgaria. \nCurrently he is Associated Prof.Dr. at the Dental School, Oral Surgery Dept., Istanbul Aydin University and since 2003 he works in his own private clinic in Istanbul, Turkey.\u2028\nDr.Tosun is reviewer in journal ‘Laser in Medical Sciences’, reviewer in journal ‘Folia Medica\\', a Fellow of the International Team for Implantology, Clinical Lecturer of DGZI German Association of Oral Implantology, Expert Lecturer of Laser&Health Academy, Country Representative of World Federation for Laser Dentistry, member of European Federation of Periodontology, member of Academy of Laser Dentistry. Dr.Tosun presents papers in international and national congresses and has scientific publications in international and national journals. He speaks english, spanish, italian and french.",institutionString:null,institution:{name:"Istanbul Aydın University",country:{name:"Turkey"}}},{id:"171887",title:"Prof.",name:"Zühre",middleName:null,surname:"Akarslan",slug:"zuhre-akarslan",fullName:"Zühre Akarslan",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/171887/images/system/171887.jpg",biography:"Zühre Akarslan was born in 1977 in Cyprus. She graduated from Gazi University Faculty of Dentistry, Ankara, Turkey in 2000. \r\nLater she received her Ph.D. degree from the Oral Diagnosis and Radiology Department; which was recently renamed as Oral and Dentomaxillofacial Radiology, from the same university. \r\nShe is working as a full-time Associate Professor and is a lecturer and an academic researcher. \r\nHer expertise areas are dental caries, cancer, dental fear and anxiety, gag reflex in dentistry, oral medicine, and dentomaxillofacial radiology.",institutionString:"Gazi University",institution:{name:"Gazi University",country:{name:"Turkey"}}},{id:"256417",title:"Associate Prof.",name:"Sanaz",middleName:null,surname:"Sadry",slug:"sanaz-sadry",fullName:"Sanaz Sadry",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/256417/images/8106_n.jpg",biography:null,institutionString:null,institution:null},{id:"272237",title:"Dr.",name:"Pinar",middleName:"Kiymet",surname:"Karataban",slug:"pinar-karataban",fullName:"Pinar Karataban",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/272237/images/8911_n.png",biography:"Assist.Prof.Dr.Pınar Kıymet Karataban, DDS PhD \n\nDr.Pınar Kıymet Karataban was born in Istanbul in 1975. After her graduation from Marmara University Faculty of Dentistry in 1998 she started her PhD in Paediatric Dentistry focused on children with special needs; mainly children with Cerebral Palsy. She finished her pHD thesis entitled \\'Investigation of occlusion via cast analysis and evaluation of dental caries prevalance, periodontal status and muscle dysfunctions in children with cerebral palsy” in 2008. She got her Assist. Proffessor degree in Istanbul Aydın University Paediatric Dentistry Department in 2015-2018. ın 2019 she started her new career in Bahcesehir University, Istanbul as Head of Department of Pediatric Dentistry. In 2020 she was accepted to BAU International University, Batumi as Professor of Pediatric Dentistry. She’s a lecturer in the same university meanwhile working part-time in private practice in Ege Dental Studio (https://www.egedisklinigi.com/) a multidisciplinary dental clinic in Istanbul. Her main interests are paleodontology, ancient and contemporary dentistry, oral microbiology, cerebral palsy and special care dentistry. She has national and international publications, scientific reports and is a member of IAPO (International Association for Paleodontology), IADH (International Association of Disability and Oral Health) and EAPD (European Association of Pediatric Dentistry).",institutionString:null,institution:null},{id:"202198",title:"Dr.",name:"Buket",middleName:null,surname:"Aybar",slug:"buket-aybar",fullName:"Buket Aybar",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/202198/images/6955_n.jpg",biography:"Buket Aybar, DDS, PhD, was born in 1971. She graduated from Istanbul University, Faculty of Dentistry, in 1992 and completed her PhD degree on Oral and Maxillofacial Surgery in Istanbul University in 1997.\nDr. Aybar is currently a full-time professor in Istanbul University, Faculty of Dentistry Department of Oral and Maxillofacial Surgery. She has teaching responsibilities in graduate and postgraduate programs. Her clinical practice includes mainly dentoalveolar surgery.\nHer topics of interest are biomaterials science and cell culture studies. She has many articles in international and national scientific journals and chapters in books; she also has participated in several scientific projects supported by Istanbul University Research fund.",institutionString:null,institution:null},{id:"260116",title:"Dr.",name:"Mehmet",middleName:null,surname:"Yaltirik",slug:"mehmet-yaltirik",fullName:"Mehmet Yaltirik",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/260116/images/7413_n.jpg",biography:"Birth Date 25.09.1965\r\nBirth Place Adana- Turkey\r\nSex Male\r\nMarrial Status Bachelor\r\nDriving License Acquired\r\nMother Tongue Turkish\r\n\r\nAddress:\r\nWork:University of Istanbul,Faculty of Dentistry, Department of Oral Surgery and Oral Medicine 34093 Capa,Istanbul- TURKIYE",institutionString:null,institution:null},{id:"172009",title:"Dr.",name:"Fatma Deniz",middleName:null,surname:"Uzuner",slug:"fatma-deniz-uzuner",fullName:"Fatma Deniz Uzuner",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/172009/images/7122_n.jpg",biography:"Dr. Deniz Uzuner was born in 1969 in Kocaeli-TURKEY. After graduating from TED Ankara College in 1986, she attended the Hacettepe University, Faculty of Dentistry in Ankara. \nIn 1993 she attended the Gazi University, Faculty of Dentistry, Department of Orthodontics for her PhD education. After finishing the PhD education, she worked as orthodontist in Ankara Dental Hospital under the Turkish Government, Ministry of Health and in a special Orthodontic Clinic till 2011. Between 2011 and 2016, Dr. Deniz Uzuner worked as a specialist in the Department of Orthodontics, Faculty of Dentistry, Gazi University in Ankara/Turkey. In 2016, she was appointed associate professor. Dr. Deniz Uzuner has authored 23 Journal Papers, 3 Book Chapters and has had 39 oral/poster presentations. She is a member of the Turkish Orthodontic Society. Her knowledge of English is at an advanced level.",institutionString:null,institution:null},{id:"332914",title:"Dr.",name:"Muhammad Saad",middleName:null,surname:"Shaikh",slug:"muhammad-saad-shaikh",fullName:"Muhammad Saad Shaikh",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"Jinnah Sindh Medical University",country:{name:"Pakistan"}}},{id:"315775",title:"Dr.",name:"Feng",middleName:null,surname:"Luo",slug:"feng-luo",fullName:"Feng Luo",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"Sichuan University",country:{name:"China"}}},{id:"423519",title:"Dr.",name:"Sizakele",middleName:null,surname:"Ngwenya",slug:"sizakele-ngwenya",fullName:"Sizakele Ngwenya",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"University of the Witwatersrand",country:{name:"South Africa"}}},{id:"419270",title:"Dr.",name:"Ann",middleName:null,surname:"Chianchitlert",slug:"ann-chianchitlert",fullName:"Ann Chianchitlert",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"Walailak University",country:{name:"Thailand"}}},{id:"419271",title:"Dr.",name:"Diane",middleName:null,surname:"Selvido",slug:"diane-selvido",fullName:"Diane Selvido",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"Walailak University",country:{name:"Thailand"}}},{id:"419272",title:"Dr.",name:"Irin",middleName:null,surname:"Sirisoontorn",slug:"irin-sirisoontorn",fullName:"Irin Sirisoontorn",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"Walailak University",country:{name:"Thailand"}}},{id:"355660",title:"Dr.",name:"Anitha",middleName:null,surname:"Mani",slug:"anitha-mani",fullName:"Anitha Mani",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"SRM Dental College",country:{name:"India"}}},{id:"355612",title:"Dr.",name:"Janani",middleName:null,surname:"Karthikeyan",slug:"janani-karthikeyan",fullName:"Janani Karthikeyan",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"SRM Dental College",country:{name:"India"}}},{id:"334400",title:"Dr.",name:"Suvetha",middleName:null,surname:"Siva",slug:"suvetha-siva",fullName:"Suvetha Siva",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"SRM Dental College",country:{name:"India"}}}]}},subseries:{item:{id:"20",type:"subseries",title:"Animal Nutrition",keywords:"Sustainable Animal Diets, Carbon Footprint, Meta Analyses",scope:"An essential part of animal production is nutrition. 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