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Barely three months into the new year and we are happy to announce a monumental milestone reached - 150 million downloads.
\n\nThis achievement solidifies IntechOpen’s place as a pioneer in Open Access publishing and the home to some of the most relevant scientific research available through Open Access.
\n\nWe are so proud to have worked with so many bright minds throughout the years who have helped us spread knowledge through the power of Open Access and we look forward to continuing to support some of the greatest thinkers of our day.
\n\nThank you for making IntechOpen your place of learning, sharing, and discovery, and here’s to 150 million more!
\n\n\n\n\n'}],latestNews:[{slug:"webinar-introduction-to-open-science-wednesday-18-may-1-pm-cest-20220518",title:"Webinar: Introduction to Open Science | Wednesday 18 May, 1 PM CEST"},{slug:"step-in-the-right-direction-intechopen-launches-a-portfolio-of-open-science-journals-20220414",title:"Step in the Right Direction: IntechOpen Launches a Portfolio of Open Science Journals"},{slug:"let-s-meet-at-london-book-fair-5-7-april-2022-olympia-london-20220321",title:"Let’s meet at London Book Fair, 5-7 April 2022, Olympia London"},{slug:"50-books-published-as-part-of-intechopen-and-knowledge-unlatched-ku-collaboration-20220316",title:"50 Books published as part of IntechOpen and Knowledge Unlatched (KU) Collaboration"},{slug:"intechopen-joins-the-united-nations-sustainable-development-goals-publishers-compact-20221702",title:"IntechOpen joins the United Nations Sustainable Development Goals Publishers Compact"},{slug:"intechopen-signs-exclusive-representation-agreement-with-lsr-libros-servicios-y-representaciones-s-a-de-c-v-20211123",title:"IntechOpen Signs Exclusive Representation Agreement with LSR Libros Servicios y Representaciones S.A. de C.V"},{slug:"intechopen-expands-partnership-with-research4life-20211110",title:"IntechOpen Expands Partnership with Research4Life"},{slug:"introducing-intechopen-book-series-a-new-publishing-format-for-oa-books-20210915",title:"Introducing IntechOpen Book Series - A New Publishing Format for OA Books"}]},book:{item:{type:"book",id:"3645",leadTitle:null,fullTitle:"Passive Microwave Components and Antennas",title:"Passive Microwave Components and Antennas",subtitle:null,reviewType:"peer-reviewed",abstract:"Modelling and computations in electromagnetics is a quite fast-growing research area. The\r\nrecent interest in this field is caused by the increased demand for designing complex microwave\r\ncomponents, modeling electromagnetic materials, and rapid increase in computational power\r\nfor calculation of complex electromagnetic problems. The first part of this book is devoted to\r\nthe advances in the analysis techniques such as method of moments, finite-difference time-\r\ndomain method, boundary perturbation theory, Fourier analysis, mode-matching method,\r\nand analysis based on circuit theory. These techniques are considered with regard to several\r\nchallenging technological applications such as those related to electrically large devices,\r\nscattering in layered structures, photonic crystals, and artificial materials.\r\nThe second part of the book deals with waveguides, transmission lines and transitions. 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From November 2000 to June 2005 he was a Metrology Engineer with the Laboratory of Metrology, Kharkiv, Ukraine. In 2004 he became a Junior Member of the Teaching Staff with the Kharkiv National University of Radio Electronics. In 2005 he joined the Technical University of Denmark, where he is currently an Assistant Professor. 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\r\n\tThis book provides information about up-to-date wind energy technologies in the context of smart grids. It starts with an introduction of wind energy characteristics and the availability prediction of wind energy in wind farms. As the wind power proportion increases in power systems, significant uncertainties and technical challenges arise to cause the concerns of the network stability and power dispatch. These bring about some latest technologies to cover the major aspects of energy integration and economic dispatch in order to meet energy demands and targets. Market tools such as pricing, gaming, bidding, and auction design as well as the “prosumer” concept will also be discussed, followed by extensive economic analysis and power dispatch optimization. Finally, cybersecurity will be studied to promote the uptake of energy Internet of Things (IoT) and also to understand electric grid security and data security.
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\r\n\tAll book chapters are produced by forward-thinking specialists in the area of renewable energy and smart grids, with detailed analysis and/or case studies. This book is intended to serve as a reference for graduate students, academics, professionals, and system operators.
Chronic pancreatitis (CP) is an inflammatory disease that causes irreversible anatomical changes and damage including infiltration of inflammatory cells, fibrotic processes and calcifications formation with destruction of the gland structure and thus affects normal nutrients digestion and absorption. The clinically early phase is characterized by pain and recurrent acute pancreatitis episodes and complications, and the late phase by exo- and/or endocrine insufficiency. In 2016, a new definition of CP was proposed, according to which CP is a fibro-inflammatory syndrome, affecting people with genetic, environmental and/or other risk factors, resulting in a persistent pathological response as a result of parenchymal injury or stress. In addition, some of the following features of advanced CP may be present in each patient: pancreatic atrophy, fibrosis, pain syndrome, ductal stricture, calcifications, pancreatic exocrine/endocrine insufficiency and dysplasia. The frequency of CP per year in the European population is 5–10/100,000. Alcohol abuse is the most observed cause. Recurrent episodes of acute pancreatitis and heredity as a contributing factor may result into CP development [1, 2, 3, 4, 5, 6, 7].
\nPain is the most frequent symptom in CP patients, leading to quality of life impairment. It pathogenesis is still poorly understood. Multimodal approach, including lifestyle changes, medical therapy, pancreatic endoscopic and surgical procedures, and other non-pharmacological options are recommended [8, 9].
\nThe pancreatic enzymes lipase, amylase, trypsin and chymotrypsin, released predominantly by the duodenal mucosa exposure of nutrients—especially lipids, are at a great importance for the macronutrient digestion. Their secretion comprises the following three phases—maximum, stable and basic secretion. Pancreatic enzymes amount and action duration depend on the caloric content maldigestion, the food type and its physical properties [1, 6, 7, 10, 11].
\nPancreatic exocrine insufficiency (PEI) due to a progressive loss of acinar cells is a functional limitation of pancreatic enzyme and bicarbonate secretion, regardless its etiology, leading to digestive process deficiency. Main pathological mechanisms in adults are (1) Insufficient pancreatic secretory capacity, (2) Decreased gland stimulation, (3) Impaired enzymes release in the duodenum. The causes are divided into primary (chronic pancreatitis, cystic fibrosis, pancreatic agenesia, congenital pancreatic hypoplasia, Shwachman-Diamond syndrome, Johanson-Blizzard syndrome, pancreatic lipomatosis or atrophy, isolated lipase or co-lipase deficiency, pancreatic carcinoma, pancreatic resection) and secondary (reduced cholecystokinin releasing, somatostatinoma or exogenous administration of somatostatin, gastrinoma, (sub) total gastrectomy, resections and Billroth II anastomosis, periampullary tumors) [11, 12, 13, 14, 15].
\nAlthough not studied in-depth, the reported prevalence of PEI in patients with CP varies widely between 40 and 94%. The onset of PEI depends on the CP etiology and is about 10–15 years (5–6 years for alcoholic CP) after initiating the pathological CP processes, which is explained by the large functional reserve capacity. Decompensation occurs when the enzyme secretion is reduced by 90–95%. However, in some patients PEI symptoms such as malnutrition and/or abdominal symptoms (diarrhea, flatulence, pain), steatorrhea, body weight loss are first appearance of the disease [1, 7, 16, 17, 18].
\nAlthough steatorrhea is a typical symptom of a severe PEI, no clinical symptom unambiguously proves or excludes PEI. Steatorrhea may be absent or caused by pancreatic duct obstruction, low duodenal pH, decreased contact time due to increased motility, small intestinal bacterial overgrowth. Fat-soluble vitamin insufficiency, protein malnutrition, increased risk of osteoporosis and fractures, life-threatening complications such as cardiovascular events are further PEI complications [2, 5, 19, 20, 21, 22].
\nAn up-to-date assessment of pancreatic exocrine function allows diagnosis of PEI, initiation of pancreatic enzyme replacement therapy (PERT) and its monitoring. Pancreatic exocrine secretion can be assessed by direct and indirect methods. Direct tests are based on determination of volume, bicarbonates and/or enzymes in the stimulated pancreatic gland by intravenous administration of hormones or their peptide analogs. These methods are invasive because duodenal intubation and a duodenal juice sample are required. Most indirect methods, which evaluate either the digestive ability of the pancreas or the pancreatic secretion by quantification of pancreatic enzymes, are non-invasive, but some require blood sampling and are then considered invasive. The clinical benefit of each method is based on diagnostic accuracy, relevance in clinical practice and cost [20, 23, 24, 25].
\nPancreatic enzyme replacement therapy is an essential part of PEI treatment. Nowadays a majority of patients with PEI might be asymptomatic, receiving none or suboptimal PERT. They are at increased risk of PEI complications and impaired quality of life. Patients’ compliance should be ensured. Periodical monitoring of PERT by nutritional assessment and BMI is mandatory with a respect to primary and secondary prophylaxis of risk factors [1, 6, 18, 26, 27, 28, 29, 30].
\nPancreatogenic diabetes or type 3c diabetes mellitus develops secondary to pancreatic disease. Recently, DM type 3c is a more recognizable entity due to new proposed criteria. It is a complex disease, further complicated by the presence of comorbidities such as maldigestion and accompanying malnutrition. Metformin is a treatment of choice. Annually screening for type 3c DM by fasting glucose levels and HbA1c is of a great importance in patients with CP regardless the grade of pathological structural changes [17, 18, 20, 31, 32].
\nMany studies are conducted to demonstrate the association between CP with tropical and hereditary etiology and DM with pancreatic cancer development. The pathogenesis of malignant transformation on the basis of CP remains unclear. Biomarkers and imaging modalities are used to distinguish inflammation form neoplasia [33, 34].
\nThe management of the miscellaneous CP complications pseudocysts, splenic vein thrombosis, duodenal and biliary obstruction, pseudoaneurysm, pancreatic calculi consists of their screening and treating [23].
\nAbdominal pain is a predominant symptom, affecting 80–90% of patients with CP. Pain significantly reduce quality of life. Pathogenesis is still poorly understood. Multifactorial mechanisms are proposed, including inflammation; duct obstruction followed by hypertension and ischemia; neuronal damage—neuropathic and dysfunctional pain due to hypersensitivity, central and spinal nociceptive neurons alterations. Alcohol and tobacco have contributing role for pain exacerbation. Pancreatic pain covers the characteristics of visceral pain—diffuse severe dull persistent pain, usually with epigastrium location and further radiation to the back, left or right hypochondria. Pain is not necessarily linked to a new acute episode and often worsens with food intake. Pain could be recurrent, during acute episodes and prolonged. Questionnaire scales could be used for pain characterization: Izbicki pain score, brief pain inventory (validated for CP), quantitative sensory testing. According to newest guidelines a multi-modal approach, including lifestyle changes, medical therapy and non-pharmacological approaches, is recommended. Alcohol and tobacco cessation should be advised in all patients. PERT could release pain in patients with ductal obstruction as oral enzymes reduce cholecystokinin levels and therefore decrease pancreatic juice secretion, leading otherwise to duct hypertension. A combination of antioxidants is useful to reduce the oxidative stress and damage. According to the published in 1986 WHO stepwise analgesic’s approach is recommended. Simple analgesics (Paracetamol, NSAIDs, Aspirin) are first-line drugs with Paracetamol being the preferable one. If no pain relief is achieved, weak opioids (Tramadol), strong opioids (Morphine, Oxycodone), gabapentinoids (Pregabalin), antidepressants or
Hormonal stimulation tests are considered to be the most sensitive and specific tests that investigate pancreatic function, including chronic pancreatitis. The test, introduced by Dreiling in 1948, is based on the physiological pancreatic stimulation by secretin with release of water and bicarbonates from the centroacinar and ductal cells. The volume of the duodenum aspiration and bicarbonate concentration are evaluated after double lumen duodenal tube insertion. Standardized ranges, which exclude pancreatic exocrine insufficiency, are: 80–130 mEq/L for peak bicarbonate concentration; 10.1–37.0 mEq/h bicarbonate output, and volume 1.5–5.7 mL/kg for volume/kg. The patient is most likely to suffer from CP if the peak bicarbonate concentration is less than 80 mEq/L. The sensitivity of the test ranges between 60 and 94% and the specificity between 67 and 95%. In a growing number of publications, the use of secretin in the course of other techniques (secretin-enhanced MRCP or endoscopic secretin testing) demonstrates the ability for evaluation of minimal structural changes in the pancreas, in contrast to standard imaging methods which fail to diagnose them [35, 36, 37, 38].
\nThe classical cholecystokinin stimulation test was developed and first used in the Mayo Clinic. The test measures the enzyme output. Cholecystokinin is given as a continuous infusion of 40 ng/kg/h, but can also be administered as a bolus. Cholecystokinin increases bile secretion in the duodenum during the first 20–40 min after administration, and as a result, the measurement of pancreatic secretion might be affected. The cholecystokinin test disadvantages are as follows: a need for simultaneous gastric and duodenal juices collection during intubation, duodenal perfusion of mannitol and polyethylene glycol solution, delayed stomach emptying, mediation of pain, symptoms of nausea and vomiting most probably due to blood–brain barrier passage [35, 39, 40, 41, 42, 43].
\nThe combined secretin-cholecystokinin stimulation testing, also called the secretin-pancreozymin test, allows the simultaneous measurement of secretion of both bicarbonate and enzyme by the pancreatic gland. However, cholecystokinin may be administered before or after secretion as long as there is no international standard for test performing and it seems to play insignificant role for diagnostic accuracy. Like the classic cholecystokinin test, it increases the secretion of bile in the duodenum [24, 35, 44].
\nAfter introducing the idea of obtaining pure pancreatic juice during ERCP in 1982, the technique was adopted and modified by the Japanese pancreatic group and the Cleveland Clinic researchers. The pancreatic fluid collected during ERCP has a higher bicarbonate concentration compared with the classic secretin test (130 mEq/L for healthy subjects and less than 105 mEq/L for CP) and is not contaminated with bile and duodenal content. The drawbacks of the method are the potential ERCP complications, the relatively short time for sample collection—15 min and the need for sedation, which can affect pancreatic secretion. Therefore, the collection of duodenal juice after secretin with or without cholecystokinin stimulation during a standard endoscopic procedure with a tube placed in the endoscope biopsy canal was developed as a comparable alternative. The peak of bicarbonate concentration and the lipolytic activity in the duodenal juice are significantly lower in patients with CP. However, experts find bicarbonate and enzyme output to be more reliable markers for exocrine pancreatic function. Due to its nature—invasiveness, labor intensity, length of procedure (endoscope placement in the duodenum for 1 h) and price, the use of endoscopic tests is limited to some specialized centers, so they are not widely used in everyday practice [24, 39, 45].
\nSecretin-enhanced MRCP becomes more and more interesting as a method of visualization and morphological assessment of the pancreatic structure, as well as for quantitative assessment of various aspects of pancreatic exocrine function. The magnetic resonance technique has a number of advantages: lack of invasiveness, safety, possibility of three-dimensional reconstruction. The method is costly and is currently limited to large centers, where it is often used in combination with other tests. Its sensitivity is about 90% and is a reliable method for diagnosis of CP in an early stage. In CP, fibrous tissue gradually replaces the glandular elements in the pancreas. This process is reflected in the s-MRCP through characteristic changes in the major pancreatic duct (presence or absence of dilated main pancreatic duct >1 mm), peripheral branches (the presence or absence of dilated peripheral branches) and the volume of pancreatic secretion. The method enables the diagnosis of pancreatic divisum, pseudocysts, ductal disruption resulting from pancreatic necrosis or trauma. For the pancreatic functional evaluation a semiquantitative assessment of the duodenal filling with pancreatic juice at 10th min after secretin application is performed by the following criteria: grade 0-missing duodenal filling; grade 1-only bulbus duodeni filling; grade 2-filling up to genu inferior duodeni; grade 3-fluid filling after genu inferior duodeni. Grade 0–2 is assumed to demonstrate reduced exocrine function. During S-MRCP volume of pancreatic output is predominantly measured. That is why sphincter of Oddi spasm or obstructive lesions may lead to false CP diagnosis. Because of the technique performance and duration the sensitivity could be reduced [35, 46, 47, 48, 49, 50, 51].
\nIndirect pancreatic tests are available in clinical practice and are therefore more common. Indirect tests assess pancreatic exocrine function by quantifying pancreatic digestive ability or pancreatic enzyme levels in feces. The sensitivity and specificity of these indirect tests are variable and lower than the direct ones especially in mild and moderate PEI. From a methodological point of view, tests can be classified as oral and fecal tests.
\nIn the oral tests, the substrate is given per os along with test meal. Pancreatic enzymes hydrolyze the substrate in the duodenum, and released metabolites are absorbed from the intestine, metabolized in the liver and therefore they can be measured in serum, urine or exhaled air. Various extrapancreatic causes could limit the accuracy of oral pancreatic tests, mainly by interfering with normal digestion: reduced gastric emptying, biliary secretion and/or intestinal absorption due to intestinal disease. Impaired gastric emptying may be affected by the administration of metoclopramide or another prokinetic (cisapride, domperidone etc.) [24, 35].
\nThe first oral test for fat malabsorption assessment is based on the use of radioactive iodine 131triolein as a substrate. Modern oral tests use non-radioactive substrates the mixed triglyceride test 13C-MTG-breath test, cholesteryl 13C-octanoate, 13C-hyolein and 13C-triolein. Most commonly used and with the most optimal substrate is the only one optimized so far 13C-MTG breath test, which was introduced into clinical practice by Vantrappen et al. in 1989 and develops as a simple alternative to fecal fat quantification. The test directly measures clinically the most significant effect of exocrine pancreatic function: degradation of triglycerides. Following the already explained metabolic pathway of the labeled substrate in oral tests, 13CO2 is released and eliminated together with the exhaled air and measured by near-infrared analysis or mass spectrometry. Patients with PEI have decreased lipase activity, which can be detected by reduced elimination of 13CO2 in the exhaled air. The 13C-MTG breath test sensitivity for PEI verification is higher than 90%. The current mostly adopted and used protocol is the one developed by Domínguez-Muñoz et al. PEI is diagnosed if values are below 29%. The 13C-MTG breath test is an easy, non-invasive and accurate method of PEI diagnosis. The test is easily applicable in clinical practice and can be repeated as often as necessary. It is also used to monitor the enzyme replacement therapy [24, 52, 53, 54, 55, 56].
\nFecal tests are based on the quantification of pancreatic enzyme concentration (fecal elastase-1) or activity (chymotrypsin) in feces. Enzymes are deactivated and diluted or concentrated during the intestinal passage, which should be taken into account when interpreting the results [24, 35].
\nThe test is based on the determination of chymotrypsin activity in a single fecal sample. Fecal chymotrypsin activity lower than 3 U/g is indicative of PEI, but the sensitivity of the test is low. The test is normal in cases of mild CP and in about half of cases with moderate or severe pancreatitis. Significant disadvantages of the test are partial enzyme inactivation during gastrointestinal passage; reduced activity in patients with diarrhea. Quantitative determination of chymotrypsin in feces is an accessible way to assess patient complicity according to the taken replacement therapy as fecal chymotrypsin activity should be significantly increased if oral therapy is administered correctly [24, 35, 57].
\nThe protease elastase represents about 6% of the pancreatic enzyme secretion. Determination of Fecal Elastase-1 (FE-1) is the most common PEI screening test as the enzyme is stable during passage through the gastrointestinal tract, its levels correlate with the secreted amount of the pancreas and the direct functional assays. Even though the determination of FE-1 does not offer a significant advantage over other indirect functional tests, its easy conduction makes it a first step pancreatic function screening tool. FE-1 is determined by monoclonal or polyclonal antibodies ELISA tests. The advantage of monoclonal antibody test is its accuracy during enzyme replacement therapy intake. FE-1 concentrations below 200 μg/g feces indicate PEI, and severe PEI is considered if FE-1 is below 100 μg/g (according to some authors below 50 or even 15 μg/g). The specificity of the test is 93%. Diagnostic sensitivity varies between 54 and 63% in mild pancreatic insufficiency and reaches 82–100% in moderate and severe form. Low levels of FE-1 correlate with morphological changes in CP, objectivized by ERCP and MRCP. Determination of FE-1 is very important and useful in children at the age of 2 months with cystic fibrosis. False positive FE-1 results have been reported in the presence of diarrhea, villous atrophy or a strict vegetarian diet prior to testing [24, 35, 57, 58, 59, 60, 61, 62].
\nThe amount of released fat in the feces indirectly reflects the degree of fat digestion and thus the secretion of pancreatic lipase. The steatorrhea-based methods are divided into: qualitative (direct microscopy of Sudan III stained preparations), semiquantitative (steatocrit and semiquantitative determination by Sudan III staining) and quantitative (coefficient of fat absorption).
\nA single fecal sample is used for Sudan III staining. The methodology is based on the number and size of fat drops by high-power field (hpf). The accepted normal ranges are the presence of ≤20 fat drops sized 1–4 μm/hpf. Sudan staining has a sensitivity of up to 94% and 95% specificity for the diagnosis of abnormal fat excretion [35, 63].
\nSteatocrit is a method for semi-quantitative measurement of fats in feces, expressed as a proportion of the fat content of a single centrifuged and homogenized feces sample. The single determination of acid steatocrit (normal values below 10%) has been shown to have 100% sensitivity for steatorrhea detection and 95% specificity when compared to a 72-h quantitative fat assay [64, 65].
\nThe most reliable and recommended steatorrhea detection method is the 72-h chemical analysis using the van de Kamer method. Many technique modifications have been made so far but still the disadvantages to use large amounts of acids and bases, the manual manipulation of the analysis, the need for additional equipment and specially trained staff remain. However, Near-Infrared Reflectance Analysis (NIRA) methodology, based on the relationship between the intensity of the refractive spectrum of the fecal specimen at a specific wave length and the sample composition, is an alternative, that simplifies and aids application of the study in clinical practice [24, 66].
\nThe coefficient of fat absorption (CFA) is used for a better steatorrhea characterization. The CFA is calculated by the following equation: CFA (%) = 100 × [(mean fat value − mean fat in feces)/average fat intake]. In healthy people CFA is usually over 80%. The technique has a number of disadvantages, that reduce its everyday applicability—a standard diet containing 80–120 g of fat daily for five consecutive days, collection of entire amount of feces from the last 3 days of the diet, inconvenience during feces storing in laboratories, low specificity (any other cause of maldigestion or malabsorption can lead to abnormal fecal fat excretion) [35, 67, 68].
\nThe trypsin test is the only currently functional diagnostic test that can be performed in serum. Low concentrations of less than 20 ng/mL are specific for CP, but are only sensitive to advanced stage of disease. Levels ranged from 20 to 29 are intermediate, but in some cases may point to an early CP. The sensitivity of the method varies with mild and severe stages of the disease and is between 33 and 65% while the specificity is high. Another advantage of trypsin is that levels above 150 ng/mL are indicative of pancreatic inflammation even in the case of normal amylase and lipase levels [69].
\nMalnutrition is a major clinical consequence of PEI. Lindkvist et al. studied 114 patients with CP (EUS, MRCP), 33% suffered from PEI according to 13C-MTG breath test. Hemoglobin, albumin, prealbumin and retinol-binding protein (RBP) levels below reference limit, magnesium less than 2.05 mg/dL and HbA1C above the upper reference limit are associated with PEI. A normal panel of these serum nutritional markers excludes PEI with a high negative predictive value. In case of an abnormality, these parameters serve as a marker for initiating PERT. Their follow-up would indicate the need to adjust the dose of PERT [1, 4, 70].
\nFundamental aspects of PEI treatment, ensuring an optimal therapeutic effect, include pancreatic enzyme replacement therapy (PERT), smoking and alcohol consumption cessation, frequent small meals with a normal fats intake, fat-soluble vitamins and a systemic follow-up with respect to BMI and nutritional markers. The main aim of PEI treatment is, while compensating the lack of endogenous enzyme secretion including lipolysis, to avoid malabsorption and steatorrhea, decrease complications severity, and prevent the associated with malnutrition morbidity and mortality as well as disease progression [1, 7, 18, 20, 26, 71, 72].
\nPancreatic enzyme preparations are extracts of porcine pancreas (pancrelipase or pancreatin) with main components: lipase, amylase, trypsin and chymotrypsin. Their alternatives are bovine enzymes, lipase of mushroom origin, bacterial lipase and human lipase. The pancreatic digestive enzymes in PERT are administered orally together with the meal to ensure the mixing of pancreatin with the humus [1, 7, 11, 18, 26, 27, 71, 73, 74].
\nCurrently, the main formulations of the enzyme preparations are with immediate release, enteric-coated microspheres and minimicrospheres, enteric-coated microtablets and enteric-coated microspheres with bicarbonate buffer. The most widely used enzyme preparations are administered as acid-resistant enteric-coated minimicrospheres with a pH-related release. Currently, none of the approved enzyme supplements are specifically designed for use through percutaneous gastrostomy. In infants and patients who cannot swallow large capsules, opening the capsules in a small amount of acidic foods is an acceptable way to administer the drug [1, 2, 12, 75, 76, 77].
\nAlthough not systematically studied in clinical trials, based on recommendations from different national associations the starting dose of PERT ranges between 20,000 to 50,000 IU lipase per main course and half the dose per snacks, which corresponds to about 5–10% of the cumulative lipase activity in the duodenum after normal meal. PERT is well tolerated with no serious adverse events reported. Fibrosing colonopathy is the only serious complication associated with a high PERT dose. Cases of fibrosing colonopathy have been significantly reduced following the recommendation that PERT should not exceed 10,000 IU lipase/kg/day in patients since 1994 [6, 18, 20, 25, 78, 79, 80, 81, 82].
\nOf a great importance is to ensure patient’s compliance. If the signs or symptoms of maldigestion persist, the dose of PERT may be increased twice or three times. As e next step for optimal pH release of enzymes and to influence the precipitation of bile acids and prevent lipase degradation, proton pump inhibitors/antacids/H2 blockers/prostaglandin analogs can be added. If PERT results are still insufficient, diagnosis revision is required in respect to concomitant and/or alternative causes for maldigestion (small intestine bacterial overgrowth, biliary salt deficiency, gastric resection, therapy with certain medications (nonsteroidal anti-inflammatory drugs, antacids). Up to 40% of PEI patients with CP have concomitant small intestinal bacterial overgrowth. Import of 35 kcal/kg/day is required as protein intake of 1.0–1.5 g/kg/day is usually sufficient. Small frequent meals (4–8 times/day) are generally more tolerable than high-calorie meals due to the more effective mixing of the enzyme preparations with the humus. In the modern nutritional concept of PEI no fat restrictions are advisable to reduce the risk of weight loss and deficiency of fat-soluble vitamins. In addition, studies show that corresponding substance presence increases the half-life of the enzyme activity in small intestine [1, 5, 6, 18, 20, 25, 27, 73, 83, 84, 85, 86, 87].
\nOral, enteral and parenteral nutrition are needed in about 10–15, 5 and 1% of patients respectively, usually in case of disease complications (gastric obstruction) prior to surgery or for a short period of time in patients with advanced exocrine insufficiency [4, 20, 25, 79, 88, 89].
\nAlcohol and tobacco cessation are of a great importance as they are associated with development of pancreatic cancer, acute and chronic pancreatitis, deterioration of pancreatic exocrine function as shown by endoscopic functional tests in CP cases. Earlier development of calcified pancreatitis and diabetes mellitus are observed in patients with prolonged smoking. Physical activity and a healthy life style along with nutritional therapy should be encouraged for optimal outcome [1, 7, 20, 27, 90].
\nMost leading researchers recommend a reassessment of symptoms, BMI and serum malnutrition tests with long-term normalization of vitamin status for determining success of PEI treatment. In recent years, studies have shown widespread nutritional deficiencies (fat-soluble vitamins, prealbumin, retinol-binding protein (RBP), and magnesium) in patients with PEI with or without symptoms, which are associated with many risk factors, including malabsorption, diabetes mellitus and alcoholism. Protein markers prealbumin and RBP correlate with age, BMI, morphological changes, fat-soluble vitamins, albumin, hemoglobin, magnesium. According to the United European Gastroenterology evidence based guidelines for the diagnosis and therapy of CP (HaPanEU), PERT should be initiated in patients with PEI in the presence of clinical symptoms or nutritional deficiencies. By PERT optimization in patients with suboptimal dosage an improvement in the nutritional markers is observed [1, 7, 18, 20, 25, 26, 72, 79, 91, 92, 93, 94, 95].
\nDeficiency of vitamins A, D, E, K correlates with the severity of steatorrhea in patients with CP and PEI, but can be caused by various mechanisms, including fat malabsorption, suboptimal nutrition, higher losses or requirements, nutrient depletion, antioxidant activity. Vitamin A, D, E and K deficiency are observed in 3, 53, 10 and 63% of patients (Sikkens et al.) with no clinical manifestations of vitamin E deficiency in up to 75% of CP patients. It has been established that the severity of CP (according to the Cambridge classification) correlates with the bone mineral density of the spine and the femoral neck. Patients with CP regardless their exocrine status have more often than expected reduced bone mineral density as shown in a recent meta-analysis: 1 in 4 patients were diagnosed with osteoporosis and 2/3 with osteopathy. Risk factors for fractures include female gender, older patients (the relative risk is higher in younger patients), smoking, alcohol consumption (60–150% greater risk than non-alcoholic CP patients), chronic inflammation, low BMI regardless of bone mineral density. The incidence of fractures after minimal trauma among CP patients is comparable and even higher than in patients with high-risk gastrointestinal diseases (Crohn’s disease, cirrhosis, celiac disease, after gastrectomy), for which guidelines for osteoporosis screening exists. The treatment of osteopathy should be carried out in accordance with up-to-date guidelines on the treatment of metabolic bone disease in the general population [2, 14, 16, 27, 28, 59, 65, 96, 97, 98, 99, 100, 101, 102, 103].
\nIn addition to bone metabolism, vitamin D is a factor in the development of pancreatic fibrosis and atrophy, cardiovascular and autoimmune diseases, type 1 and 2 diabetes mellitus, and contributes to an increased overall mortality [104, 105].
\nDue to insufficient protease secretion from the pancreas, vitamin B12 deficiency may occur. Micronutrient deficiencies have been reported as well: zinc (especially in diabetes mellitus), calcium (normal levels in patients receiving PERT), magnesium, thiamine and folic acid, riboflavin, choline, manganese, sulfur, copper and others [106, 107, 108].
\nThe assessment of fat-soluble vitamins, minerals and trace elements and bone density should be monitored 1–2 times a year [109].
\nA recent study observed increased mortality in patients with PEI. Patients who died used to have a worse nutritional status. However, an optimal PERT is essential to reduce morbidity and mortality associated with CP. Maldigestion is associated with life-threatening complications such as cardiovascular, cachexia, which are related to low plasma levels of the cardioprotective HDL, apolipoprotein (apo) A-I and lipoprotein A (2). In a recent study in patients with CP who had not received PERT, mean triglyceride levels were found to be significantly higher in patients with PEI than those without PEI. According to randomized clinical trials, mean levels of cholesterol, HDL, LDL and triglycerides in patients with CP and PEI receiving PERT have been reported in reference ranges. Based on American, European and Canadian guidelines, a complex approach, including screening systems, lipid profile, apolipoproteins, is needed to properly assess cardiovascular risk. Apolipoprotein B as part of all atherogenic or potentially atherogenic particles including LDL, VLDL, IDL, lipoprotein (a) (each particle contains 1 molecule of apo B) provides direct measurement of all atherogenic lipoprotein particles in the circulation, which makes apo B more reliable indicator of cardiovascular risk than LDL. Clinical and epidemiological studies confirm that apo B and Apo B/Apo A-I ratio are associated with a worse outcome in patients with cardiovascular diseases and are supposed to predict cardiovascular incidents more accurately than the routinely tested cholesterol, LDL, TC/HDL, non-HDL. The proposed cut-off values for Apo B/ApoA-I ratio predicting high cardiovascular risk (acute myocardial infarction) are 0.9 for men and 0.8 for women. In patients with Apo B/ApoA-I ratio higher than 0.9, higher triglyceride levels and plasma atherogenic index and lower apo E were found. A study demonstrates an increased risk of myocardial infarction using Apo B/Apo A-I ratio in patients with CP [1, 5, 7, 79, 89, 110, 111, 112, 113, 114, 115, 116, 117, 118, 119, 120, 121, 122, 123, 124, 125, 126, 127, 128, 129, 130, 131].
\nApolipoprotein A, which is the main apolipoprotein associated with HDL, has two forms—apo A-I and apo A-II. The levels of apolipoprotein A-I are strongly related to those of HDL and can serve for plasma HDL level determination. In a recent study, an impaired nutritional status with decreased prealbumin, RBP, hemoglobin, magnesium has been found to significantly relate to low apoA-I and apoA-II levels with a tendency of increased apo B/apo A-I ratio, which does not reach a significant value. Apolipoprotein C-III inhibits the lipolysis of triglyceride-rich lipoproteins and complicates their elimination from the bloodstream. High levels of apolipoprotein C-III are associated with an increased risk of cardiovascular events and atherogenesis. Lower apolipoprotein C-III levels are observed by morphological changes worsening in CP. The metabolic and inflammatory status in patients with CP can be traced with great accuracy by examining a protein panel of retinol binding protein, serum amyloid-alpha, Apo A-II, Apo A-I, Apo C-I, Apo C-II, Apo C-III and prealbumin, which are significantly more reduced than the controls (Hartmann et al.). The observed changes may be associated with underlying malnutrition/cachexia, which phenomena are known in the modulation of the synthesis of acute phase proteins in acute or chronic disease [112, 119, 127, 128, 130, 132, 133, 134, 135, 136, 137].
\nIn respect to its etiology, the diabetes mellitus (DM), which is caused by pancreatic diseases, is defined by the American Diabetes Association (ADA) and World Health Organization as pancreatogenic diabetes or Type 3c DM and is included in “other specific forms of diabetes” (ADA). About 5–10% of all diabetic patients in Western populations fulfill the criteria for pancreatogenic DM, of which circa 80% have underlying CP. The prevalence and clinical significance of DM secondary to CP has been recently underestimated. The median survival is 8.7 years after diagnosing type 3c DM. Chronic pancreatitis and DM are independent risk factors for pancreatic cancer development. While the presence of anti-insulin antibodies and clinical or biochemical data on insulin resistance are associated with type 1 and 2 DM respectively, the pathogenesis of type 3c DM is very complex. According to the recommendations of Rickels MR et al. from the Pancreas Fest 2012, the following criteria for the diagnosis of type 3c DM were proposed. Major criteria (all must be fulfilled): (1) Pancreatic exocrine insufficiency. (2) Pathological pancreas imaging (EUS, MRI, CT). (3) Lack of type 1 DM associated with the presence of autoantibodies. Minor criteria: (1) Impaired beta-cell function (HOMA-B, C-peptide/glucose ratio). (2) Lack of insulin resistance (HOMA-IR). (3) Invasive secretion disorder (GLP-1, pancreatic polypeptide). (4) Low levels of serum fat-soluble vitamins (A, D, E, K). Because of loss of glucagon response to hypoglycemia and low carbohydrate levels (malabsorption; inadequate food intake due to pain, nausea and/or chronic alcohol abuse), patients with type 3c DM may experience frequent episodes of hypoglycemia, making the glucose control challenging. The course of the disease is further complicated by the presence of comorbidities such as maldigestion and accompanying malnutrition. Metformin, which is recommend as first-line treatment for type 2 DM by ADA and EASD, has been shown to reduce the risk of pancreatic cancer by 70% and the associated mortality, making metformin suitable therapeutic option for type 3c DM patients. The associated with an increased risk of developing pancreatitis as well as numerous gastrointestinal side effects (nausea, delayed gastric emptying, weight loss) GLP-1 analogues and DPP4-inhibitors should be avoided as long as their safety and benefits are proven. Impaired incretin hormone secretion can be normalized by supplementation with pancreatic enzymes, which is reflected in improved insulin secretion and glucose tolerance during meals. Adequate oral enzyme replacement affects steatorrhea, prevents malnutrition and metabolic complications. In patients with severe malnutrition, insulin therapy is a first-line of choice because of the anabolic effect of insulin. The association of low levels of vitamin D and poor glycemic control draws attention to the need to normalize vitamin status in patients with type 3c DM. Diagnosis and monitoring of DM should be consistent with the endocrinology societies guidelines. Annually screening for type 3c DM by fasting glucose and HbA1c is of a great importance in patients with CP regardless the grade of pathological structural changes [18, 20, 25, 31, 32, 122, 138, 139, 140, 141, 142, 143].
\nSince the first report by Rocca et al. in 1987 for an increased incidence of pancreatic cancer (PC) in patients with CP, several epidemiological studies have identified that CP, mainly tropical and hereditary pancreatitis, is a major risk factor for pancreatic cancer development. Augustine et al. reported that PC is affecting 8.3% of patients with CP with a roughly 100-fold higher incidence compared to patients without tropical pancreatitis. Younger patients are affected and have a worse outcome. In hereditary CP due to multiple PRSS1 mutations the lifetime risk for PC is 40–55% by the age of 70. Possible explanations for the increased neoplastic transformation risk are the onset of CP at younger age and its long duration. Various risk factors for PC development have been described, of which smoking is the major one. In a recent study, Hao et al. (2017) suggest that age at the onset of CP (hazard ratio, 1.05) and a > 60 pack-year smoking history (hazard ratio, 11.83) are PC risk factors. CP as an inflammatory disease is associated with higher cell turnover with/without DNA damage, progressing to oncogenic mutations in K-ras, p16 and p53 promoting metaplasia and neoplastic degeneration. Another well-known PC risk factor is diabetes mellitus. Ethanol and its metabolites are supposed to activate pancreatic stellate cells over-proliferation. They play a role in tumor progression and chemotherapy resistance. Moreover, cholecystokinin receptors are abnormally over-produced. Clinical features may mimic those of CP in early stages. When symptoms such as obstructive jaundice, pain, weight loss and worsening of diabetes appear, all of which are specific for malignancy, this generally indicates that the disease is at an advanced stage. The most investigated biomarker for malignancy prediction is CA 19–9 with 96.5–100% specificity. Based on metabolic biomarkers, Mayerle et al. (2018) introduce a novel approach for differential diagnose between CP and PC with an accuracy of 90% and a negative predictive value of 99.9%. Other promising markers are plasma micro-RNAs, monoclonal antibody PAM4, CD1D, which require further investigation. For the imaging diagnosis of PC, a CT scan is the technique of choice. Endoscopic ultrasound (EUS) could detect small pancreatic tumors in CP patients at a highest sensitivity compared to the available imaging and has the potential to detect early stage PC. The most appropriate cancer treatment (surgery, chemotherapy, radiation) depends on disease proliferation, defining the cancer as resectable, locally advanced or metastatic [144, 145, 146, 147, 148, 149].
\nPancreatic pseudocysts are common complication in CP with a frequency of 20–40%. The majority of patients are with alcoholic (70–80%) or idiopathic etiology of CP (6–16%). The outcome of pseudocysts is assessed 6 weeks after acute episode occurring. In 40% of the pseudocysts there is a spontaneous resolution, another 40% of pseudocysts remain asymptomatic and in 20% of pseudocysts complications are observed (infection, rupture, bleeding, splenic vein thrombosis). Treatment is required if patients are symptomatic, if complications or obstruction of the stomach, duodenum or bile duct occur. Drainage of chronic pseudocysts may be performed by surgical, endoscopical or percutaneous approach. In asymptomatic pseudocysts with size above 5 cm, due to high possibility of complications, an endoscopical or surgical treatment is recommended. Percutaneous drainage should be avoided where possible. In chronic pseudocysts the endoscopical procedure is the treatment of choice due to lower mortality rate, improved quality of life and less length of hospitalization stay. Depending on size and localization, two endoscopic techniques are performed. A transpapillary approach should be considered in small pseudocysts with communication with the main pancreatic duct. The transmural approach (cystogastrostomy) is similar to the management of walled-off necrosis. It is more successful under echoendoscopic guidance. Double-pigtail plastic stents for at least 2 months are used for pseudocyst drainage. If a malignant genesis of the pseudocyst is suspected, surgery should follow [148, 150, 151, 152, 153, 154, 155, 156].
\nIn 1920 Hirschfeldt first reported splenic vein thrombosis (SVT) as a pancreatitis consequence. Secondary involvement of the splenic vein endothelium by a nearby inflammation, compression by a pseudocyst or enlarged retroperitoneal/pancreatic lymph nodes or initial injury could result in a splenic vein thrombosis and obstruction. The incidence of SVT in patients with CP is 1.5–41.6%. Sinistral portal hypertension and collateral development resulting in gastric and/or esophageal varices are major risk factor for bleeding. Splenomegaly is reported in 42–54% of patients. Most patients are asymptomatic. Clinical features include gastrointestinal bleeding in 12.3% of cases and abdominal pain. SVT is diagnosed primary by contrast-enhanced CT scan and/or upper endoscopy. Venous phase angiography is the gold standard confirmatory test, which could verify obstruction and collaterals routes. Based on the widely available CT scan most patients nowadays are diagnosed asymptomatic. The SVT management depends on existing symptoms including hypersplenic syndrome and history of variceal bleeding, which might require splenectomy with venous collateral outflow elimination and further variceal decompression. Gastric varices should be treated endoscopically by sclerotherapy, gastric banding [148, 157, 158, 159, 160, 161, 162].
\nThe duodenal obstruction is a rare complication in CP patients (1%) due to the anatomical relationship between the duodenum and the head of the pancreas. However, when analyzing operated patients with CP, the incidence of duodenal obstruction is higher—12%. Two types of obstruction are observed—transients during acute pancreatitis episodes and fixed by pseudocyst compression (discussed above) or fibrosclerotic process. Paraduodenal or groove pancreatitis is a rare clinic-pathological focal type of CP. The reported incidence of groove pancreatitis in resected CP patients ranges between 2.7 and 24.5%. It was first described by Becker in 1973 as a segmental pancreatitis. In 2004 Adsav and Zamboni unify the previously described terms under paraduodenal pancreatitis. The proposed pathophysiological mechanisms comprise functional/anatomical obstruction of papilla minor, Brunner’s gland hyperplasia around papilla minor, heterotopic intraduodenal pancreatic tissue or ductal variation. Two types paraduodenal pancreatitis are defined–cystic and solid. The cystic type is common with localization in the submucosa or lamina propria. The size may reach 10 cm, resulting in a bile duct obstruction. The solid type is rare and includes sheet-like and mass-like subtypes. According to several retrospective studies, the risk groups for paraduodenal pancreatitis development are middle-aged men with alcohol consumption. Acute manifestation complains include postprandial abdominal pain (90–100%), nausea and vomiting (20%), gastric outlet syndrome. Chronic manifestations are weight loss (90%) and jaundice (20%). Perforation, bleeding, malignant degeneration of heterotopic pancreas are reported rare complications. EUS and MRCP are the preferred imaging methods for diagnostic evaluation. Treatment is based on a stepwise approach: (1) conservative treatment (analgesics, infusions, PPI, PERT, enteral nutrition, somatostatin analogues); (2) endoscopic treatment; (3) surgery (Whipple procedure, pancreaticoduodenectomy, suprapapillar duodenal resection in isolated duodenal dystrophy, palliative gastrojejunostomy) [8, 148, 163, 164, 165, 166, 167, 168, 169, 170].
\nThe incidence of distal common bile duct obstruction in patients with advanced chronic predominantly calcific pancreatitis with frequent acute episodes ranges from 3 to 46%. Pseudocysts are considered more as a risk factor than as a cause. Patients may be asymptomatic or with various spectrum of complains and complications—pain, jaundice (transient or persistent for longer than 1 month), cholangitis and even sepsis, long-term risk of secondary biliary cirrhosis. Hyperbilirubinemia and twofold elevation of alkaline phosphatase levels for more than a month are used as reliable laboratory markers for common bile duct obstruction. CT scan provides information for the structural changes with high specificity and sensitivity. Based on the Caroli and Nora criteria, most patients with common bile duct stricture and CP are classified as type I and III. The treatment of choice depends on presence and severity and duration of symptoms; suspected malignant degeneration. To prevent progression to secondary biliary cirrhosis in patients with progressively increased alkaline phosphatase levels or persistent/with frequent relapses hyperbilirubinemia, endoscopic biliary stenting with self-expanding metal stents or multiple plastic stents or surgical procedures (pancreaticoduodenectomy, choledochojejunostomy, choledochoduodenostomy, hepaticojejunostomy) are required [148, 171, 172, 173].
\nPancreatic pseudoaneurysm as a rare life-threatening chronic pancreatitis complication occurs in 10% of patients, most often in those with pseudocysts. The pseudoaneurysm represents fibrous tissue containing hematoma and is mainly induced by enzymatic autodigestion or eroding of the nearby vessels, most frequent affecting the splenic artery. Most patients are asymptomatic, however, the first clinical manifestation might be bleeding caused by pseudoaneurysm rupture into gastrointestinal tract or other adjacent anatomic structures—peritoneal cavity, retroperitoneum, biliopancreatic ducts (hemosuccus pancreaticus). Shock and multiorgan failure further complicate the rupture. The mortality rate is about 40% and higher (90–100%) if pseudoaneurysm remains untreated. Worst outcome results have been shown in patients with pseudoaneurysm localization in the pancreas head. Angiography is the diagnostic tool of choice. Patients are nowadays treated surgical, endovascular, by angioembolization and/or by percutaneous ultrasonographically guided thrombin injection. Treatment in diagnosed asymptomatic patients is recommended [174, 175, 176, 177, 178, 179].
\nIn about 50% of patients chronic inflammation, gene predisposition and alcohol intake as a key cause change the pancreatic juice composition with pancreatic stone protein levels reduction, leading to formation of a nucleus with calcium deposition layers and later formation of a stone. The pancreatic duct stones are classified according to their number, localization and density to single or multiple calculi; stones in the pancreatic head, body and/or tail; localized in the main pancreatic duct, side-branches and/or parenchyma; radiopaque positive (the majority of cases), negative or mixed stones. The main pathological consequence is the duct obstruction with upstream dilatation, followed by ductal hypertension, which results in pain episodes, exocrine insufficiency due to reduce pancreatic juice flow into duodenum and impaired quality of life. Pancreatic duct stones are diagnosed by ERCP, CT or MRCP. However, MRCP is superior to ERCP for diagnosis as MRCP is a non-invasive alternative with no complications, providing detailed information about duct system and stone formations. Calculi removal could be performed by extracorporeal shock wave lithotripsy (ESWL), endoscopic techniques and surgery. According to the European Society of Gastrointestinal Endoscopy guidelines, first-line therapy for painful uncomplicated CP is ESWL combined or not with ERCP followed by spontaneous expulsion or endoscopic extraction of less than 3 mm fragments. However, ESWL should be performed in centers with ESWL expertise. Best results from endoscopic techniques are observed in patients with early stages of CP with infrequent pain attacks, when calculi are less than 5 mm and have head localization with upstream main pancreatic duct dilatation. Alcohol and tobacco cessation improve the long-lasting results. Endoscopic techniques include ERCP followed by pancreatic sphincterotomy; stone retrieval with a balloon, Dormia basket and/or forceps; dilatation and stent placement; mechanical lithotripsy. Endoscopy procedures together with ESWL improve the success to up to 90%. Direct visualization by pancreatoscopy followed by intraductal lithotripsy (Spyglass system) might be a future procedure of choice but today its use is limited. Surgery should be performed in patients with large or multiple calculi and strictures, after unsuccessful prior endoscopy or ESWL procedures, as well as in those with no pain relief [8, 180, 181, 182, 183].
\nWith disease progression, patients with CP report for impaired overall quality of life. Many studies are conducted to investigate the contributing factors, leading to low QoL. Pain significantly correlates with overall health status, physical and mental subscales. Researchers emphasize the role of severity in contrast to pain frequency and pathophysiology. A large study of Machiado et al., including 1024 CP patients, highlights constant pain as well as inability due to pain, smoking status and concomitant co-morbidities to worsen significantly QoL with negative influence on both physical and mental domains, leading to worsened social and family status and health resource utilization. Other assumed factors, which importance differs among the literature data, are disease duration, young age, women, tobacco and alcohol intake, underweight, pancreatic structural changes DM, PEI, prior endoscopic or surgical treatments. Psychologically conditioned disturbances (depression, anxiety etc.) are linked most often to alcohol abuse and might lead to pain manifestation and impaired QoL. A study, which enrolled non-alcoholic CP patients, significant depressive syndromes were associated with poor QoL. By the newest concepts, the quality of life assessment is an essential part of the monitoring and the outcome in patients with CP. The European Organization for Research and Treatment of Cancer (EORTC QLQ) has developed a quality of life questionnaire, containing 30 questions (EORTC QLQ-C30), including an additional question about steatorrhea. The questionnaire correlates with body weight gain and a reduced number of daily defecations related to malnutrition and maldigestion. The quality of life improved after adequate dosing in both newly diagnosed and patients receiving suboptimal PERT. Later, an additional panel of 26 questions concerning pancreatic cancer patients (PAN26) was developed. In the United European Gastroenterology evidence based guidelines for the diagnosis and therapy of CP (HaPanEU), quality of life including pain should be assessed through validated questionnaires (SF-12, SF-36, EORTC QLQ C-30, GIQLI). However, effort should be point at improvement of variable factors as psychological status, tobacco, alcohol consumption and nutritional deficiencies in respect to improve QoL and further to delay disease progression, using therapeutic education and physical rehabilitation, behavioral support and medication [6, 99, 184, 185, 186, 187, 188, 189, 190].
\nChronic pancreatitis is a progressive fibro-inflammatory syndrome, leading to abdominal pain and later to endocrine and exocrine insufficiency. Patients with CP might suffer a wide variety of complications, including pancreatic cancer, splenic vein thrombosis, pseudocysts, duodenal or biliary obstruction, pancreatic calculi, pseudoaneurysm and cardiovascular events. Proper individual up-to-date approach to diagnosis, treatment and follow-up of patients with CP are of fundamental importance to improve symptoms, detect early risk factors and reduce complications, which are associated with high mortality rate, and ensure better quality of life. Screening strategies development and their introduction into the clinical practice should be encouraged.
\nLCD stands for Liquid-Crystal Display. From the name, we know that this equipment is used as a display. Many types of electronic equipment (Laptop, Digital Voltmeter, Mobile Phone, ATM-Automatic Teller Machine, PC-Personal Computer, Compact Disk Player, Digital Thermometer, Clothe Washer, Flat TV-Television, etc.) has used this equipment to display images, Alpha Numeric information, and video. LCD is electronic equipment (display) made from liquid-crystal layers which operate if it gets varied voltage/currents which change the optical properties (light modulating properties) of this display; which causes this tool to continue or block the light through it. LCD uses its own light source known as Back Plane Light (BPL). Compared to other types of display such as CRT (Cathode Ray Tube), LED (Light Emitting Diode), plasma gas, LCD consumes smaller power, this is because it does not produce light, but this tool displays images with the principle of inhibiting or forwarding light; the changing of the optical properties of the LCD when it gets a varying voltage/current on the LCD layer and the existence of a light source (BPL) causes this equipment to display the object/character that can be seen by our eyes. At present, there are two types of LCDs known in general, namely,
Passive matrix
Active matrix
Matrix active is often referred to as AMLCD (Active Matrix LCD). Some people call AMLCD with TFT (thin-film transistor) this is due to a transistor that is useful as a large controller of the current through the intersection of pixels. With the use of transistors as controlling currents, controlling the current through intersection becomes faster which ultimately increases the refresh time of this tool which then produces subtler images compared to the LCD-passive matrix [1, 2].
The manufacture or the fabrication of AMLCD is far more complicated than the fabrication of passive matrix LCD which causes its price to be more expensive than the passive matrix LCD [2].
The Microcontroller System 51-MCS51 (Microcontroller 8051 family) can also be connected with the LCD, where the LCD is used as a display. On this occasion, we will discuss LCDs commonly used in various microcontroller applications namely LCD 2 × 16; 2 rows with 16 characters/row.
The LCD module basically consists of two units namely the LCD itself and the controller. The LCD module is mounted and pinned to the controller and then the microcontroller is connected to the LCD controller.
There are various types of LCDs commonly used in various microcontroller applications, namely 1 × 16, 2 × 16, 4 × 20 [3]. The LCD type is known by the number of lines and the number of characters per line it has. LCD with type 1 × 16 means, this LCD can only display 1 line of characters, and can only display 16 alphanumeric characters. Likewise, LCD with types 2 × 16 and 4 × 20 each has 2 and 4 consecutive lines, and the first type can only display 16 alphanumeric characters/line, while the last type is capable of displaying 20 alphanumeric characters/line. On this occasion we will only discuss the connection/the usage of the second type of LCD, type 2 × 16 (2 lines × 16 characters/line); by understanding the 2 × 16 type LCD, then you can easily read and learn the manual of other types to connect them to MCS51 [4].
Figure 1 below shows the physical appearance of this display,
2 × 16 LCD physical picture [
From Figure 1 it can be seen that the number of lines of the LCD is 2. The first line contains the words “this is a 2 × 16” while the second line contains the words “ Line LCD Display” [5].
As previously mentioned above to build the LCD module, the LCD (M1632) is mounted on and pinned to the HD44780 controller. To use the LCD module in MCS-51 the controller is connected to the MCS-51 (Figure 2) [3, 6].
Block diagram of 2 × 16 LCD module [
The LCD controller can be used for various types of LCDs with various numbers of characters per line; from 8 to 80 characters per line and the number of lines between 1 and 4 lines [4]. The controller has DISPLAY DATA RAM (DDRAM) in it with a memory map as shown in Figure 3 below [7].
2 × 16 LCD DDRAM- memory map [
From Figure 3 above we can see that the DDRAM controller should have a memory map of 104 bytes (00H to 67H = 68H = 104D), but the location that can be used is only 80 bytes 00H-27H (40 bytes) and 40H-67H (40 bytes); Note that the 28H-3FH address (24 location) is not visible.
Each place on the LCD has an address that corresponds to the address on the DDRAM on the LCD controller) see Figures 3 and 4 for more details. The DDRAM memory map on the 2 × 16 bit LCD controller that can be used for LCD with type M1632 is 00H-0FH for the first line (16 addresses) and 40H-4FH (16 addresses) for the second line (so the total address location 32 address locations), although as shown in Figure 3 DDRAM memory maps of the LCD controller basically amounted to 80 locations.
2 × 16 LCD DDRAM address [
However, the display looks just having 00H-0FH addresses for the first line and 40H-4FH addresses for the second line as shown in Figure 4 above [8].
LCD connected to this controller will adjust itself to the memory map of this DDRAM controller; each location on the LCD will take 1 DDRAM address on the controller. Because we use 2 × 16 type LCD, the first line of the LCD will take the location of the 00H-0FH addresses and the second line will take the 40H-4FH addresses of the controller DDRAM; so neither the addresses of the 10H-27H on the first line or the addresses of the 50H-67H on the second line on DDRAM is used.
To be able to display a character on the first line of the LCD, we must provide written instructions (80h + DDRAM address where our character is to be displayed on the first line) in the Instruction Register-IR and then followed by writing the ASCII code of the character or address of the character stored on the CGROM or CGRAM on the LCD controller data register, as well as to display characters in the second row we must provide written instructions (C0H + DDRAM address where our character to be displayed on the second line) in the Instructions Register-IR and then followed by writing the ASCII code or address of the character on CGROM or CGRAM on the LCD controller data register.
The characters to be displayed can be in the form of American Standard Code For Information Interchange-ASCII code, characters originating from CGROM (various characters are prepared by the controller manufacturer or producer and are permanently stored in it), and from the character generator RAM-CGRAM (special place on CGROM with the addresses 00000000B-00000111B (consecutive eight locations) prepared for storing characters specifically to be displayed by the user/custom use); the total address of the CGROM with the CGRAM address in it and allocated specially for custom use is 256D (00000000B-111111111B) locations see Figure 5 below; please do not confuse CGROM/CGRAM address with DDRAM address they are two completely different and independent memory locations. The character stored on the CGRAM address is temporary (volatile) and must be stored in it before retrieve and displayed it on the LCD; the data stored in CGRAM will disappear if the source of electrical voltage is cut off; in contrast, the characters stored in the CGROM is permanently reserved in it.
CGRAM [
As mentioned above, to display a character (ASCII) you want to show on the LCD, you need to send the ASCII code to the LCD controller data register-DR. For characters from CGROM and CGRAM we only need to send the address of the character where the character is stored; unlike the character of the ASCII code, we must write the ASCII code of the character we want to display on the LCD controller data register to display it. For special characters stored on CGRAM, one must first save the special character at the CGRAM address (prepared 64 addresses, namely addresses 0–63); A special character with a size of 5 × 8 (5 columns × 8 lines) requires eight consecutive addresses to store it, so the total special characters that can be saved or stored on the CGRAM addresses are only eight (8) characters. To be able to save a special character at the first CGRAM address we must send or write 40H instruction to the Instruction Register-IR followed by writing eight consecutive bytes of the data in the Data Register-DR to save the pattern/image of a special character that you want to display on the LCD [9, 10].
We can easily connect this LCD module (LCD + controller) with MCS51, and we do not need any additional electronic equipment as the interface between MCS51 and it; This is because this LCD works with the TTL logic level voltage—Transistor-Transistor Logic.
Based on 2 × 16 LCD data sheets of the Hitachi 44780 trademark we can connect it with MCS-51 as shown in Figure 6 [11].
Connection of 2 × 16 LCD module (8 bit mode) with MCS51 [
From Figure 6 above it can be seen clearly that this display has 16 Pins that can be grouped into 4 as shown in Table 1.
Pin | Name Pin | Function |
---|---|---|
1, 2, dan 16 | VSS, VCC, GND | Power supply |
7–14 | D0-D7 | Data bus |
4, 5, and 6 | RS, R/ | Control |
3 and 15 | VEE and BPL | BPL |
Pin function of 2 × 16 LCD.
The voltage source of this display is +5 V connected to Pin 2 (VCC) and GND power supply connected to Pin 1 (VSS) and Pin 16 (GND); Pin 1 (VSS) and Pin 16 (GND) are combined together and connected to the GND of the power supply.
Pins 7–14 (8 Pins) of the display function as a channel to transmit either data or instruction with a channel width of 1 byte (D0-D7) between the display and MCS51. In Figure 6, it can be seen that each Pin connected to the data bus (D0-D7) of MCS51 in this case P0 (80h); P0.0-P0.7 MCS-51 connected to D0-D7 of the LCD.
Pins 4–6 are used to control the performance of the display. Pin 4 (Register Select-RS) is in charge of selecting one of the 2 display registers. If RS is given logic 0 then the selected register is the Instruction Register-IR, otherwise, if RS is given logic 1 then the selected register is the Data Register-DR. The implication of this selection is the meaning of the signal sent down through the data bus (D0-D7), if RS = 0, then the signal sent from the MCS-51 to the LCD is an instruction; usually used to configure the LCD, otherwise if RS = 1 then the data sent from the MCS-51 to the LCD (D0-D7) is the data (object or character) you want to display on the LCD. From Figure 6 Pin 4 (RS) is connected to Pin 16 (P3.6/
Pin 5 (R/
Pin 6 of the LCD (
Pin 3 and Pin 15 are used to regulate the brightness of the BPL (Back Plane Light). As mentioned above before the LCD operates on the principle of continuing or inhibiting the light passing through it; instead of producing light by itself. The light source comes from LED behind this LCD called BPL. Light brightness from BPL can be set by using a potentiometer or a trimpot. From Figure 6 Pin 3 (VEE) is used to regulate the brightness of BPL (by changing the current that enters BPL by using a potentiometers/a trimpot). While Pin 15 (BPL) is a Pin used for the sink of BPL LED.
Table 2 below is a summary of the function of each Pin of the 16 Pins of 2 × 16 LCD.
Pin | Name | Function |
---|---|---|
1 | VSS | GND of the source voltage. |
2 | VCC | +5 V of the source voltage. |
3 | VEE | Adjust the brightness of the BPL by using an adjustable/variable resistor (potentiometer or trimpot). |
4 | RS | Register selector on the LCD, if RS = 0 then the selected register is an instruction register (the operation to be performed is a write operation/LCD configuration if Pin 5 (R/ |
5 | (R/ | Sets the operating mode, logic 1 for reading operations and logic 0 for write operations, the information read from the LCD to μC is data, while information written to the LCD from μC can be data to be displayed or instructions used to configure the LCD. Usually, this Pin is connected to the GND of the power supply because we will never read data from the LCD but only write instructions to configure it or write data to the LCD register to be displayed. |
6 | The LCD is not active when Enable Pin is either 1 or 0 logic. The LCD will be active if there is a change from logic 1 to logic 0; information can be read or written at the time the change occurs. | |
7–14 | D0-D7 | Data/instruction transmission channel between the LCD and the μC. |
15 | BPL | Sink for LED BPL (Back Plane Light). The VCC is connected to the LED anode and the cathode is connected to the BPL. |
16 | GND | Power supply ground. This Pin is connected to the power supply ground together with Pin 1 (VSS) of the LCD. |
Summary of functions of each Pin on a 2 × 16 LCD.
Just like the microcontroller, the LCD controller must also be programmed first to operate. Programming the LCD controller is an easy thing, all we have to do is only to give the appropriate logic level to the three Pins RS, R/
2 × 16 LCD module [
The following are instructions for LCD controllers
Clear display
Clear display is an instruction that will clean the display and restore the cursor to the initial position (00h address). The format of this instruction is as follows,
RS | R/ | D7 | D6 | D5 | D4 | D3 | D2 | D1 | D0 |
---|---|---|---|---|---|---|---|---|---|
0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 1 |
Note that RS = 0 which means we choose Instruction Register-IR and R
Home cursor
This instruction serves to return the cursor to the initial position (line 0, column 0) without changing the data on DDRAM. The format to do so is shown in the table below.
RS | R/ | D7 | D6 | D5 | D4 | D3 | D2 | D1 | D0 |
---|---|---|---|---|---|---|---|---|---|
0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 1 | X |
D0(X) can be filled with either 0 or 1 (do not care) and in this case, we select X = 0. Thus, the instruction that must be written to return the cursor to the initial position on the IR is 02H [10, 13].
Entry mode set
This instruction will determine the direction of the cursor movement whether it is left or right and determines whether to shift the display or not. The format of this instruction is as follows.
RS | R/ | D7 | D6 | D5 | D4 | D3 | D2 | D1 | D0 |
---|---|---|---|---|---|---|---|---|---|
0 | 0 | 0 | 0 | 0 | 0 | 0 | 1 | I/D | S |
Please pay attention to D1 (I/D-Increment/Decrement) it is a “bit” that determines whether the cursor position goes up or down. If D1 (I/D) = 0 (decrement), the cursor position will decrease, which will shift towards the left of one column. Conversely, if D1 (I/D) = 1 (increment), the cursor position will shift to the right of one column.
Likewise, the Bit D0(S) if D0(S) = 0 then the operation is normal, the cursor shifts but the display will stay in the same place, but if D0(S) = 1 then the display will shift one column to the right if D1 = 0 (the cursor will remain in the same place/no movement. So, if we want a normal operating display and the cursor shifts to the right then the instructions, we have to give to IR is 06h and is 04h if you want to cursor shift to the left. Table 3 below summarizes the instructions given and the result of the cursor and the display movement.
Display ON/OFF
This instruction is used to ON or OFF the display, display or not display the cursor, and set the cursor to blink or not. The format of this instruction is as follows.
RS | R/ | D7 | D6 | D5 | D4 | D3 | D2 | D1 | D0 |
---|---|---|---|---|---|---|---|---|---|
0 | 0 | 0 | 0 | 0 | 0 | 1 | D | C | B |
When D2 (D-Display) = 1 then the display will be on, but if D2 = 0 then the display will be off, just like in the case of D2, D1 (C-cursor) also has the same property if D1 = 1 then the cursor will be displayed otherwise (if D1 = 0) then the cursor will not be shown. D0 (B-blink) as mentioned above is used to set the cursor to blink or not if D0 = 0 then the cursor will not blink, but if D0 = 1 then the cursor will blink.
From Table 4 it can be seen clearly that the display will be ON when the instruction is 0Ch or bigger.
Function set
Function set (set data width, number of lines, and font size) with the format of instruction as follows,
RS | R/ | D7 | D6 | D5 | D4 | D3 | D2 | D1 | D0 |
---|---|---|---|---|---|---|---|---|---|
0 | 0 | 0 | 0 | 1 | DL | N | F | X | X |
D4 (DL) ⇒ Data Length. If DL = 0, data width = 4 bits (D4-D7). If DL = 1, data width = 8 bits (D0-D7). D3 (N) ⇒ number of Line. If N = 0 number of lines = 1, if N = 1 number of lines is 2. D2 (F) = > font size. If F = 0 then the font size is 5 × 7 dot, if F = 1 then the font size is 5 × 10 dot. When data width of 4 bits is chosen, data must be sent twice.
Set CGRAM address
As mentioned earlier in Chapter 2 LCD controller, CGRAM (Character Generator RAM) is a part of CGROM (Character Generator ROM); See Figure 5 below [9]. From Figure 5 we can see that CGRAM with an address of 00000000b-00000111b (eight addresses) which is a part of CGROM is deliberately prepared by the manufacturer to be able to store custom use characters needed by the user and not be prepared by the manufacturer such characters as, battery picture, alarm picture, or other characters at the CGRAM addresses.
The format of instruction to program the CGRAM can be seen below.
RS | R/ | D7 | D6 | D5 | D4 | D3 | D2 | D1 | D0 |
---|---|---|---|---|---|---|---|---|---|
0 | 0 | 0 | 1 | CGRAM address |
It is obviously seen that we need an instruction of 40h + the location of the CGRAM address where the pattern wants to be written to the Instruction Register-IR and followed by a write of the data to the Data Register (DR); this data pattern will be stored in the CGRAM address; the CGRAM is only 6 bits in length (D0-D5), thus the number of CGRAM addresses is only 64 addresses (address 0–63) [14]. To display a custom use character we need to save the patterns (8 patterns in maximum) into the 64-byte size memory location of CGRAM (0D-63D). The first pattern to be displayed will be referred to just like a normal CGROM address but the address is 00h. To save the pattern in the CGRAM address we need to run a command (40H + the first address of the pattern saved in the CGRAM locations) to the IR and followed by eight consecutives write data to the first eight locations of the 64D locations of the CGRAM. To display the CGRAM pattern we need to run the same instruction as to display the pattern in the CGROM, thus run the write command (80H + the DDRAM address where the pattern wants to be displayed on the LCD followed by the run of the write data instruction; the data is 00h. The same steps must be taken for the rest of the pattern saved in the CGRAM addresses (8D-63D); to study how to display a custom use pattern on the LCD in-depth one can visit the following site and download the paper, http://www.arpnjournals.org/jeas/research_papers/rp_2016/jeas_1016_5086.pdf [15].
Set DDRAM address
As mentioned before (above) to display one character on the specific location of the LCD we first have to write an instruction to IR; the instruction is “80h + the location of the character to be displayed on the LCD that has the associated addresses of DDRAM” which is on the controller before it can be displayed on the LCD; see the instruction format below.
After sending the mentioned above instruction to the Instruction Register-IR we need to write the data of the character (ASCII) to display on the LCD to the Data Register; to display the character stored on the CGROM or CGRAM all we need to send is the location of the character stored on either CGROM or CGRAM instead of the code of the character. The format of the instructions to do that is as follows,
RS | R/ | D7 | D6 | D5 | D4 | D3 | D2 | D1 | D0 |
---|---|---|---|---|---|---|---|---|---|
0 | 0 | 1 | DDRAM address |
From the instruction format above we can see that the DDRAM address has a memory space of 128 locations (0000000b-1111111b) or 00H-7FH but the addresses that can be accessed only 80 locations from 00H-27H and 40H-67H each of them is 40 location memory spaces. For 2 × 16 LCD the addresses are limited to 32 locations with the first line DDRAM addresses of 00H-0FH (0D-15D) and the second line with the associated addresses range 40H-4FH (64D-79D).
Read busy flag and address
Before we can display data on the LCD, or read, change the data on the DDRAM first we must ensure the LCD module is in a not-busy state. The format to read busy Flag-BF of the LCD status is shown below,
RS | R/ | D7 | D6 | D5 | D4 | D3 | D2 | D1 | D0 |
---|---|---|---|---|---|---|---|---|---|
0 | 1 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 1 |
The results of the reading from busy flag will appear as shown in the table below.
D7 | D6 | D5 | D4 | D3 | D2 | D1 | D0 |
---|---|---|---|---|---|---|---|
BF ( | AC ( |
From the table above we can see the busy flag-BF can be read on the 7th bit (D7), while the D0-D6 bit contains the address counter (cursor position). If D7 (BF) = 0 indicates the controller is not busy, on the contrary, if D7 (BF) = 1 indicates the controller is in a busy state. For example, the program to check busy bits or busy flag-BF can be seen in a published paper in the International Journal with the following website address, https://www.sciencedirect.com/science/article/pii/s1110016817300546 [16].
To write data to DDRAM or CGRAM
The format of the instruction to write data to DDRAM or CGRAM has the same instruction format as shown below. The operation is a writing data to the Data Register-DR; RS = 1 and R/
RS | R/ | D7 | D6 | D5 | D4 | D3 | D2 | D1 | D0 |
---|---|---|---|---|---|---|---|---|---|
1 | 0 | DDRAM or CGRAM address |
Instruction format to read data from DDRAM or CGRAM has the same instruction format as shown in the table below,
RS | R/ | D7 | D6 | D5 | D4 | D3 | D2 | D1 | D0 |
---|---|---|---|---|---|---|---|---|---|
1 | 1 | DDRAM or CGRAM address |
The operation is a read operation (R/
Instruction | Cursor movement direction | Display movement direction |
---|---|---|
04h | To the left one column | Stay in the same place/no movement |
05h | Stay in the same place/no movement | Move to the right one column |
06h | To the right one column | Stay in the same place/ no movement |
07h | Stay in the same place/no movement | Move to the left one column |
Entry mode set, cursor movement, and display movement.
Instruction/command | Display | Cursor (display) | Cursor (blinking) |
---|---|---|---|
08h | OFF | NO | NOT |
09h | OFF | NO | NOT |
0Ah | OFF | NO | NOT |
0Bh | OFF | NO | NOT |
0Ch | ON | NO | NOT |
0Dh | ON | NO | NOT |
0Eh | ON | YES | NOT |
0Fh | ON | YES | YES |
Display, cursor, and blinking.
Before it can be used as a display for the MCS51 or other microprocessor or microcontroller, the LCD controller must first be configured or initialized by sending instructions to the Instruction Register-IR of the LCD controller. Before you can send instructions from the MCS51 to the LCD controller through P0 (P0.0-P0.7) we must choose the Instruction Register-IR on the LCD controller, by making RS = 0, resetting R/
The LCD configuration process is to set the number of lines to be used (1 line or 2 lines), character font size (5 × 8 dot or 5 × 10 dot), the data width used (4 bits or 8 bits), and others. In this chapter, we only discuss the initialization of the LCD controller with a data width of 8 bits and 5 × 8 dot character font size.
We will develop some subroutines for this initialization process; to make it easier to use them in the future (just by calling the needed subroutines). The subroutines to be developed includes the write instruction subroutine, the write data subroutine, and the delay subroutine.
Because the initialization process is a write operation, we name this subroutine as a write_Insli subroutine. Before we build this subroutine, let us recall the Pins connection between the LCD module and MCS-51 for this initialization process.
For the initialization process the RS Pin must be reset (RS = 0) this is because we want to access the Instruction Register- IR to provide initialization instructions/commands. RS Pin of the LCD controller is connected to P3.6 of MCS-51, for this reason, to reset this Pin (RS = 0) we can do it by running the CLR P3.6 statement.
As mentioned above initialization is a write operation, Pin R/
SETB P3.7 | ; |
CALL delay | ; call delay subroutine |
CLR P3.7 | ; |
Thus, we can build the write_Insli subroutine as shown in subroutine write_Insli below.
write_instruction | : | ||
MOV P0,r1 | ; fill P0 (D0-D7) with initialization instruction | ||
; which is in r1 | |||
CLR P3.6 | ;RS = 0 to select instruction register | ||
SETB P3.7 | ; | ||
CALL delay | ; give appropriate delay in accord | ||
; with 2 × 16 LCD datasheet | |||
CLR P3.7 | ; | ||
RET | ; return to the main program from the write_instruction subroutine |
Based on datasheets from LCD 2 × 16 and the delay time needed to be around 1000 μs [17]. For that, we can build the subroutine delay as follows,
delay: | ||
MOV r0,#0h | ; fill r0 with 0 | |
delay1: | MOV r7,#0fh | ; fill r7 with 0Fh (15 s) |
delay2: | DJNZ r7,$ | ; r7 = r7-1, if r7 is not equal to 0 jump to delay 2 |
DJNZ r0,delay1 | ; r0 = r0-1, if r0 is not equal to 0 jump to delay 1 | |
RET | ; return to the calling program or the main program |
To analyze the delay time Table 5 below can be used [18, 19],
Instructions | Number of MC-machine cycles | Time in seconds (1MC = 10−6 s) | |
---|---|---|---|
MOV r0,#00h | 1 | 10−6 s | |
delay1: | MOV r7,#0fh | 1 | 10−6 s |
delay2: | DJNZ r7, delay2 | 30 (15 × 2) | 30 × 10−6 s |
DJNZ r0, delay1 | 512 (256 × 2) | 512 × 10−6 s | |
RET | 2 | 2 × 10−6 s |
From Table 5 above it can be seen clearly that the delay time is 546 MC (546 × 10−6 s) or can be written as follows 546 μs; you can adjust the content of register r0 and r7 to obtain the recommended 1000 μs (enable cycle time) to ensure the LCD is really ready to receive the next command (not in a busy state).
To write data to the LCD is a very similar process to write instruction to the LCD (Instruction Register-IR) as shown in the write_inst subroutine; the only difference between them is the logic state of RS; instead of RS = 0 we give RS a logic 1 (RS = 1) for this process; write data to the Data Register-DR. The subroutine to write data to the Data Register-DR is called write_data as shown below,
write_data: | |||
MOV P0,r1 | ; fill in P0 (D0-D7) with the data you want to display | ||
; which is in r1 | |||
SETB P3.6 | ;RS = 1 to select data register | ||
SETB P3.7 | ; | ||
CALL delay | ; call delay subroutine to give a delay in accord | ||
; with 2 × 16. LCD datasheet | |||
CLR P3.7 | ; | ||
RET | ; return from subroutine write_instruction |
From the 2 × 16 LCD control data [20], there are some things we have to do for the initialization process, namely
D7 | D6 | D5 | D4 | D3 | D2 | D1 | D0 |
---|---|---|---|---|---|---|---|
0 | 0 | 1 | DL | N | F | X | X |
NB:
DL ⇒ Data Length. If DL = 0, data width = 4 bits (D4-D7).
If DL = 1, data width = 8 bits (D0-D7).
N ⇒ number of line. If N = 0 the number of lines is 1, if N = 1 the number of lines is 2.
F ⇒ font size. If F = 0 then the font size is 5 × 8 dot, if F = 1 then the font size is 5 × 10 dot.
If we choose the data width of 4 bits, the process of sending or receiving data or instruction must be done twice. On this occasion we only discuss the 8-bit data width (Data Length-DL) with (DL = 1), the font size 5 × 8 dot (F = 0), the number of lines 2 (N = 1), bits D1, and D0 are filled with logic 0; therefore the instruction that must be given to set the function set is 00111000B = 38H and we can use the instructions or statements below to do the function set.
MOV r1,#38h; | fill r1 with instruction (function set) 38h | |
CALL write_instruction; | CALL write_instruction |
D7 | D6 | D5 | D4 | D3 | D2 | D1 | D0 |
---|---|---|---|---|---|---|---|
0 | 0 | 0 | 0 | 0 | 1 | I/D | S |
Note Below (NB):
D1 (I/D) ⇒ Increment/decrement, if D1 (I/D) = 0 this bit will tell the controller to move the cursor to the left one column (D1 = 0) or move to right one column (D1 = 1) on condition D0(S) =0. But if D0(S) =1 the whole display (the cursor and the character or characters) will move to the left one column when D1 = 1 and to the right one column when D1 = 0; this instruction also increases or decrease the DDRAM address based on the D1 and D0 status. If D0 = 1 and D1 = 0 the DDRAM address will increase one column, but in the contrary if D0 = 1 and D1 = 1 the DDRAM address will decrease one column.
In this book, we will set S and I/D thus the instruction we send to configure the Entry Mode Set is 0000 0111b (07h). The instructions for initialization Entry Mode Set of the LCD we can use the statements below,
MOV r1,#07h; | fill r1 with instructions (entry mode set) 07h |
CALL write_instruction; | call the write_instruction subroutine |
D7 | D6 | D5 | D4 | D3 | D2 | D1 | D0 |
---|---|---|---|---|---|---|---|
0 | 0 | 0 | 0 | 1 | D | C | B |
This instruction is used to on or off the display, display or does not display the cursor, and set the cursor to blink or not.
When D2 (D-Display) = 1 then the display will be on the opposite if D2 = 0 then the display will be off, so is with the case of D1 (C-cursor) if D1 = 1 then the cursor will be displayed otherwise if D1 = 0 then the cursor will not be shown.
D0 (B-blink) as mentioned above is used to set the cursor to blink or not to blink if D0 = 0 then the cursor will not blink, but if D0 = 1 then the cursor will blink. To initialize the on /off cursor display we use the initialization of display on, cursor off, and blink off thus the instructions that must be sent to IR for it is (0Ch). The instructions used for the initialization of the display on/off cursor are shown below.
MOV r1,#0Ch; | fill r1 with instruction (display on/off cursor) 0Ch |
CALL write_instruction; | call the write_instruction subroutine |
D7 | D6 | D5 | D4 | D3 | D2 | D1 | D0 |
---|---|---|---|---|---|---|---|
0 | 0 | 0 | 0 | 0 | 0 | 0 | 1 |
Thus for the initialization process to clean the display, the instruction that must be given to IR is (01h) and can be done by running the instructions below.
MOV r1,#01h | ; fill r1 with instruction (clear display) 01h |
CALL write_instruction | ; call the write_instruction subroutine |
D7 | D6 | D5 | D4 | D3 | D2 | D1 | D0 |
---|---|---|---|---|---|---|---|
0 | 0 | 0 | 1 | S/C | R/L | X | X |
The conducted operation is based on the logic status (logic level) of both bits D3 (S/C) and D2 (R/L) as shown in the table below (Table 6) [6, 14],
The following are other commands besides the initialization command, write data, and write instructions mentioned above. These instructions or commands determine the Display Data RAM (DDRAM) address, read the status of the LCD (Busy Flag-BF), and specify the Character Generator RAM (CGRAM address).
As mentioned earlier that each location on the LCD has an address that corresponds to the address on DDRAM; See Chapter 2 LCD Controller. To display a character on the LCD you must write an instruction (80h + the address location on the LCD where the character wants to be displayed) to the Instruction Register followed by writing the data (the character code you want to display) to the Data Register-DR.
Each time we want to read or change data on certain addresses on DDRAM we must write an instruction to the Instruction Register-IR to be able to access the address before carrying out the activities mentioned above (displaying characters on the LCD, read data on certain addresses from the DDRAM, and change data at the address). The format of the instruction for it is shown as follows,
D7 | D6 | D5 | D4 | D3 | D2 | D1 | D0 |
---|---|---|---|---|---|---|---|
1 | Address of DDRAM |
From the instruction format above we can see that the instructions we have to write to the Instruction Register-IR is 80H + the DDRAM addresses where the character is to be displayed; we also have to send signals (RS = 0, R/
MOV r1,#82h | ; fill r1 with 82h (80h + 02h) |
CALL write_instruction | ; call the write_instruction subroutine |
Likewise, if we want to put the cursor in the position of the first line of column 15 (0fh) then we must provide the following instructions, [10, 13].
MOV r1,#8Fh | ; fill r1 with 8Fh (80h + 0Fh) | |
CALL write_instruction | ; call the subroutine write_instruction |
Before we display data on the LCD, or read, change data on the DDRAM first we must ensure the LCD module is in a non-busy state. Format to read busy LCD status is shown below,
D7 | D6 | D5 | D4 | D3 | D2 | D1 | D0 |
---|---|---|---|---|---|---|---|
BF ( | AC ( |
To be able to read the busy status of this LCD module we must reset RS (RS = 0), and set R/
To be able to read or write data on the CGRAM (Character Generator RAM), we must first determine the CGRAM address to be accessed. The format to access CGRAM can be seen below (RS = 0, R/
D7 | D6 | D5 | D4 | D3 | D2 | D1 | D0 |
---|---|---|---|---|---|---|---|
0 | 1 | CGRAM address |
The instructions below can be used to determine the CGRAM address (10H = 00010000B) [6, 12].
MOV r1,#01010000b | ; fill r1 with (40h + 10h = 50h) to determine the CGRAM; address |
; at address 10h | |
CALL write_instruction | ; call the write_instruction subroutine |
From the format to access the addresses of the CGRAM we can see that the address of the CGRAM which is possible to access is from 000000b to 111111b or if written in the format of the hexadecimal is 00h to 3fh and in the format of decimal is 0d to 63d, thus the total address of the CGRAM is 64 bytes.
To save one custom pattern character with a size of 5 × 8 dot (5 columns × 8 lines) it takes eight address locations on CGRAM, thus 64 locations on CGRAM can only accommodate or store eight custom patterns; 1 memory location is occupied by 1 custom pattern line. If we make a storage memory map of CGRAM we can see it as shown on the CGRAM memory map below.
Pattern no. | CGRAM address | |
---|---|---|
Hexa decimal | Decimal | |
1 | 00-07 | 0–7 |
2 | 08-0F | 8–15 |
3 | 10-17 | 16–23 |
4 | 18-1F | 24–31 |
5 | 20-27 | 32–39 |
6 | 28-2F | 40–47 |
7 | 30-37 | 48–55 |
8 | 38-3F | 56–63 |
For example, to create the character of the letter “T” then this data can be stored in eight consecutive CGRAM addresses (Table 7) [6].
Custom pattern | ||||||||
---|---|---|---|---|---|---|---|---|
1 | 8 | 4 | 2 | 1 | Hexa | Decimal | ||
Row 1 | 1F | 31 | ||||||
Row 2 | 04 | 4 | ||||||
Row 3 | 04 | 4 | ||||||
Row 4 | 04 | 4 | ||||||
Row 5 | 04 | 4 | ||||||
Row 6 | 04 | 4 | ||||||
Row 7 | 04 | 4 | ||||||
Row 8 | 04 | 4 |
Graph of the formation of a custom pattern for the letter T with a size of 5 × 8 dots [21].
And to make characters with alarm images can be seen in Table 8 below,
Custom pattern | ||||||||
---|---|---|---|---|---|---|---|---|
1 | 8 | 4 | 2 | 1 | Hexa | Decimal | ||
Line 1 | 04 | 4 | ||||||
Line 2 | 0E | 14 | ||||||
Line 3 | 0E | 14 | ||||||
Line 4 | 0E | 14 | ||||||
Line 5 | 0E | 14 | ||||||
Line 6 | 1F | 31 | ||||||
Line 7 | 04 | 4 | ||||||
Line 8 | 00 | 0 |
Graph of the formation of a custom pattern alarm image with a size of 5 × 8 dots.
If the custom pattern character size used is 5 × 10 dot then CGRAM will only be able to accommodate 6 custom pattern characters. Examples of programs to display special characters on the LCD can be seen in a published paper on the International Journal with the following website address, http://www.arpnjournals.org/jeas/research_papers/rp_ [15].
To restore the cursor to the initial position (line 0, column 0) without changing the data on DDRAM. The format to do this is as follows (RS = 0, R/
D7 | D6 | D5 | D4 | D3 | D2 | D1 | D0 |
---|---|---|---|---|---|---|---|
0 | 0 | 0 | 0 | 0 | 0 | 1 | X |
The instructions below will return the cursor to the starting position (home).
MOV r1,#02h | ; fill r1 with immediate data 02h |
CALL write_instruction | ; call the write_instruction subroutine |
As mentioned earlier, before the LCD can be used it must be initialized/configuration initially. After studying the instructions for the initialization process above, we will build a subroutine for the initialization process and call it Init_LCD. In developing this subroutine all that needs to be done is to combine the entire initialization instructions that have been discussed previously. The init_LCD subroutine can be seen as follows,
init_LCD: | |
MOV r1,#01h | ; |
CALL write_instruction | |
MOV r1,#38h | ; function set, data size of 8 bit, 2 lines, |
; font size 5 × 8 dot | |
CALL write_instruction | |
MOV r1,#0Ch | ; display ON, cursor OFF, blink OFF |
CALL write_instruction | |
MOV r1,#06h | ; entry mode set, the display will not ; move, but the cursor will ; move to the right one column |
CALL write_instruction | |
RET |
The instruction or command to display a character on the LCD is 80h. To display a character at a certain location we must add 80H with the location address on the LCD DDRAM where the character is to be displayed. For example, if we want to display a character in the first row and the second column on the LCD we must add 80h + 01h = 81h, while to display the character on the second line of column 4 then we must write 80H + 43H = C3H to the Instruction Register-IR.
The program below is an example of a program to display character A on the second line of column 4 (C3H) [21].
Org 0h | ||
CALL init_LCD | ; initialization of the LCD | |
Start: | ||
MOV r1,#C3h | ; fill r1 with C3h, put the character | |
; on row 2 column 4 of the LCD | ||
CALL write_instruction | ; call write_instruction | |
MOV r1,#’A’ | ; fill r1 with ‘A’ the character | |
; to be displayed on the LCD | ||
CALL write_data | ; call write_data | |
SJMP $ | ; halt or stop |
The paper that can be used as a learning media for reading a 4 × 4 keypad and displaying the results of typing characters on the LCD can be seen at the following site address, http://www.arpnjournals.org/jeas/research_papers/rp_2018/jeas_0418_7024.pdf [22].
To display more than one character is almost the same as to display a single character. The program below is an example of a program to display seven characters “MANDATE” in the first line of the first column (80h) [21, 23].
Org 0h | ||
CALL init_LCD | ; LCD initialization | |
start: | ||
MOV r1,#80h | ; fill r1 with 80h, put the character | |
; on LCD row 0, column 0 | ||
CALL write_instruction | ; call write_instruction | |
MOV r1,#’M’ | ; fill r1 with ‘M’ the character | |
; to be displayed on the LCD | ||
CALL write_data | ; call write_data | |
MOV r1,#’A’ | ; fill r1 with ‘A’ the character | |
; to be displayed on the LCD | ||
CALL write_data | ; call write_data | |
MOV r1,#’N’ | ; fill r1 with ‘N’ the character | |
; to be displayed on the LCD | ||
CALL write_data | ; call write_data | |
MOV r1,#’D’ | ; fill r1 with ‘D’ the character | |
; to be displayed on the LCD | ||
CALL write_data | ; call write_data | |
MOV r1,#’A’ | ; fill r1 with ‘A’ the character | |
; to be displayed on the LCD | ||
CALL write_data | ; call write_data | |
MOV r1,#’T’ | ; fill r1 with ‘T’ the character | |
; to be displayed on the LCD | ||
CALL write_data | ; call write_data | |
MOV r1,#’E’ | ; fill r1 with ‘E’ the character | |
; to be displayed on the LCD | ||
CALL write_data | ; call write_data | |
SJMP $ | ; halt or stop |
Figure 8 below shows a 4 bit mode 2 × 16 LCD module. Unlike the LCD in 8 bit mode in 4-bit mode only used 6 Pins as the LCD interface to other equipment (a microcontroller, a microprocessor, or a computer), 4 bidirectional data bus (D4-D7) (Pin 11-Pin 14), and 2 control signal RS (Pin 4) and E (Pin 6) [6, 24].
4 bit mode 2 × 16 LCD module [
Data channels (Pin 7–Pin 10) D0-D3 are not used and connected to the ground of the power supply. Note the Pin (R/
The advantage of using LCD in 4-bit mode compared to 8-bit mode is the number of Pins used as interfaces with microprocessors, microcontrollers, or computers is lesser, but also it has some shortcomings in programming; more complicated (data transmission must be done twice, the first is the high nibble data (D4-D7) then followed by sending low nibble (D0-D3) through D4-D7 data bus. Because the channels used are only 4 bits (D4-D7), a shift operation must be carried out to shift data from low nibble to high nibble (D4-D7) or swap instruction that exchanges between high nibble and low nibble.
LCD is an alternative display to the Light Emitting Diode-LED and seven segment display which are commonly used in various microcomputer and microcontroller applications or projects. LCDs are available in various sizes; size is usually based on the number of rows and columns. LCD is basically a module consisting of a display and controller. The controller is a microcontroller that has two types of memory (the DDRAM and the CGROM with CGRAM resides in it; CGROM is a non-volatile memory but not the CGRAM, it is a volatile memory) and two registers (the instruction register and the data register) in it. The LCD modules that are commonly used are LCD with a size of 2 × 16; has two lines and each line can display 16 characters.
The memory in the controller can be divided into two, the Display Data RAM-DDRAM, and Character Generator ROM-CGROM. DDRAM is a RAM memory (volatile memory) each address on the DDRAM has a corresponding address to each location on the LCD; where the character will be displayed. LCD with a size of 2 × 16, the first line has the DDRAM addresses corresponding to the LCD addresses of 00h-0Fh, while the second line has a DDRAM address corresponding to the LCD addresses of 40h-4Fh.
CGROM is a non-volatile memory where various characters are permanently stored in it by the manufacturer, see Figure 5 to be displayed on the LCD by sending the address where the character is stored in the CGROM of the LCD controller; The command (80h + column in the first line where the character is to be displayed) is written to the LCD controller’s instruction register.
To display the character on the second line, command C0h + column on the second line where the character is to be displayed in the LCD controller instruction register. The LCD controller manufacturer has also prepared a special location 00h-07h on the CGROM is a place to store special characters that are not provided by the LCD controller manufacturer. This special character is built by the user by sending a 40h command to the instruction register and sending the next eight bytes (the graph of the constructed character) to the data register eight times in sequence.
LCD can be operated in two modes, namely eight-bit mode and four-bit mode. In the eight-bit mode, the eight data busses of the LCD controller are connected to the data bus of the microcontroller used to communicate between the two. In 4-bit mode, only four channels of the 8-bit width data bus of both LCD controllers and microcontrollers are used, namely D7-D4; taken from the data bus of the LCD controller, D3-D0 is not used and is connected to the power supply ground (GND). The eight-bit mode does use more wires than the four-bit mode, but is simpler in programming; the four-bit mode requires fewer wires but is more complicated to program and requires sending instructions and data twice.
In order to use the LCD module, it must be programmed first. By programming it, we can display the characters we want to display on the LCD. To enable it to display the characters, the LCD must first be configured/initialized first. Initialization is a process where we tell the LCD controller to display the characters on the LCD in the mode we want; font type, shift the cursor or the display to the left or to the right direction, blinking cursor or not, characters are displayed on the desired LCD row and column and so on. Basically, LCD programming consists of two operations, namely read and write operations; write or read the instructions to or from the instruction registers-IR or write the data to the data registers-DR. The write operations are used more than the read operation. The read operation is usually used to find out whether the LCD is busy or not (by reading the LCD controller’s busy flag-BF); if the LCD is in a busy state, sending or reading the instructions/data to or from it will be useless. If you have connected Pin (R/
Explain the reasons for the widespread use of LCDs in the market today and mention equipment that uses LCDs as their display.
What is the real difference between active matrix LCD and passive matrix LCD?
Explain how the LCD works; associated with the term light modulating properties.
What is the light source of the LCD to operate and explain how it works?
Name the main parts of the LCD module.
Name and explain the types of memory owned by the LCD.
What does the term “initialization” mean?
What steps should be taken in carrying out write operations on the LCD module?
What steps should be taken in carrying out the read operation on the LCD module?
State the steps that must be taken in displaying the characters stored in the CGROM onto the LCD.
Plan to develop a program to display the character in the first row and 9th column [21, 25, 26].
State the steps to store a special character at address 4 (05h) of the CGRAM.
Draw a block diagram and explain the advantages and disadvantages of using LCD in four-bit and eight-bit modes.
By using the ASM-51build a program to display the character “A” in the second row and fourth column on the LCD [6, 25, 26].
From question no. 12 above, state the steps to be taken to display the special characters that have been stored at address 5 (05h) CGRAM on the LCD [6, 25, 26].
By using the ASM-51 build a program to display your name on the first line; the first letter of your name appears in the first column [6, 25, 26].
From problem no. 16 above plan and develop a program to display your name and shift it to the right one character each shift to the end of the first line and reappear in the first row and first column continuously [6, 25, 26].
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Fifty-two articles were reviewed; however, 14 of them were not been included in the study. As a result, 38 articles were examined. Level of education, field of education, and material types of AR used in education and reported educational advantages of AR have been investigated. All articles are categorized according to target groups, which are early childhood education, primary education, secondary education, high school education, graduate education, and others. AR technology has been mostly carried out in primary and graduate education. “Science education” is the most explored field of education. Mobile applications and marker-based materials on paper have been mostly preferred. 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Research continuously innovates to develop efficient and cheap methods to sustain clean water for developing countries. Developing nations are a broad term that includes countries that are less industrialised and have lower per capita income levels than developed countries. This chapter will discuss clean water for drinking water purposes. Pollution concerns of water in developing countries will be categorised in terms of physical, chemical and biological pollutants such as turbidity, organic matter and bacteria. Natural and anthropogenic pollution concerns linking with seasonal factors will be outlined. The multi-barrier approach to drinking water treatment will be discussed. Abstraction points used will be researched. Water treatment systems, medium- to small-scale approaches, will be discussed. The processes involved in removing the contaminants including physical processes such as sedimentation, filtration such as slow-sand filtration, coagulation and flocculation, and disinfectant processes such as chlorination will be reviewed. Other important methods including solar disinfection, hybrid filtration methods and arsenic removal technologies using innovative solid phase materials will be included in this chapter. Rainwater harvesting technologies are reviewed. Safe storage options for treated water are outlined. Challenges of water treatment in rural and urban areas will be outlined.",book:{id:"6682",slug:"the-relevance-of-hygiene-to-health-in-developing-countries",title:"The Relevance of Hygiene to Health in Developing Countries",fullTitle:"The Relevance of Hygiene to Health in Developing Countries"},signatures:"Josephine Treacy",authors:[{id:"238173",title:"Dr.",name:"Josephine",middleName:null,surname:"Treacy",slug:"josephine-treacy",fullName:"Josephine Treacy"}]}],mostDownloadedChaptersLast30Days:[{id:"58890",title:"Philosophy and Paradigm of Scientific Research",slug:"philosophy-and-paradigm-of-scientific-research",totalDownloads:13759,totalCrossrefCites:9,totalDimensionsCites:17,abstract:"Before carrying out the empirical analysis of the role of management culture in corporate social responsibility, identification of the philosophical approach and the paradigm on which the research carried out is based is necessary. Therefore, this chapter deals with the philosophical systems and paradigms of scientific research, the epistemology, evaluating understanding and application of various theories and practices used in the scientific research. The key components of the scientific research paradigm are highlighted. 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Likewise, they exist in all schools. The school is inserted in a space where the conflict manifests itself daily and assumes relevance, being the result of the multiple interpersonal relationships that occur in the school context. Thus, conflict is part of school life, which implies that teachers must have the skills to manage conflict constructively. Recognizing the diversity of school conflicts, this chapter aimed to present its causes, highlighting the main ones in the classroom, in the teacher-student relationship. It is important to conflict face and resolve it with skills to manage it properly and constructively, establishing cooperative relationships, and producing integrative solutions. Harmony and appreciation should coexist in a classroom environment and conflict should not interfere, negatively, in the teaching and learning process. This bibliography review underscore the need for during the teachers’ initial training the conflict management skills development.",book:{id:"7827",slug:null,title:"Interpersonal Relationships",fullTitle:"Interpersonal Relationships"},signatures:"Sabina Valente, Abílio Afonso Lourenço and Zsolt Németh",authors:null},{id:"52475",title:"Teenage Pregnancies: A Worldwide Social and Medical Problem",slug:"teenage-pregnancies-a-worldwide-social-and-medical-problem",totalDownloads:8225,totalCrossrefCites:6,totalDimensionsCites:8,abstract:"Teenage pregnancies and teenage motherhood are a cause for concern worldwide. From a historical point of view, teenage pregnancies are nothing new. For much of human history, it was absolutely common that girls married during their late adolescence and experienced first birth during their second decade of life. This kind of reproductive behavior was socially desired and considered as normal. Nowadays, however, the prevention of teenage pregnancies and teenage motherhood is a priority for public health in nearly all developed and increasingly in developing countries. For a long time, teenage pregnancies were associated with severe medical problems; however, most of data supporting this viewpoint have been collected some decades ago and reflect mainly the situation of per se socially disadvantaged teenage mothers. According to more recent studies, teenage pregnancies are not per se risky ones. A clear risk group are extremely young teenage mothers (younger than 15 years) who are confronted with various medical risks, such as preeclampsia, preterm labor, and small for gestational age newborns but also marked social disadvantage, such as poverty, unemployment, low educational level, and single parenting. In the present study, the prevalence and outcome of teenage pregnancies in Austria are focused on.",book:{id:"5392",slug:"an-analysis-of-contemporary-social-welfare-issues",title:"An Analysis of Contemporary Social Welfare Issues",fullTitle:"An Analysis of Contemporary Social Welfare Issues"},signatures:"Sylvia Kirchengast",authors:[{id:"188289",title:"Prof.",name:"Sylvia",middleName:null,surname:"Kirchengast",slug:"sylvia-kirchengast",fullName:"Sylvia Kirchengast"}]},{id:"58060",title:"Pedagogy of the Twenty-First Century: Innovative Teaching Methods",slug:"pedagogy-of-the-twenty-first-century-innovative-teaching-methods",totalDownloads:8743,totalCrossrefCites:15,totalDimensionsCites:21,abstract:"In the twenty-first century, significant changes are occurring related to new scientific discoveries, informatization, globalization, the development of astronautics, robotics, and artificial intelligence. This century is called the age of digital technologies and knowledge. How is the school changing in the new century? How does learning theory change? Currently, you can hear a lot of criticism that the classroom has not changed significantly compared to the last century or even like two centuries ago. Do the teachers succeed in modern changes? The purpose of the chapter is to summarize the current changes in didactics for the use of innovative teaching methods and study the understanding of changes by teachers. In this chapter, we consider four areas: the expansion of the subject of pedagogy, environmental approach to teaching, the digital generation and the changes taking place, and innovation in teaching. The theory of education, figuratively speaking, has two levels. At the macro-level, in the “education-society” relationship, decentralization and diversification, internationalization of education, and the introduction of digital technologies occur. 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This research covers a wide context of working with people, so the researchers raised a task not only to gain confidence in the respondents’ eyes, to receive reliable data, but also to ensure the transparency of the science. This chapter discusses the theoretical and practical topics of research, after evaluation of which ethical principles of organization and conducting the research are presented. There is a detailed description of how and what ethical principles were followed on the different stages of the research.",book:{id:"5791",slug:"management-culture-and-corporate-social-responsibility",title:"Management Culture and Corporate Social Responsibility",fullTitle:"Management Culture and Corporate Social Responsibility"},signatures:"Pranas Žukauskas, Jolita Vveinhardt and Regina Andriukaitienė",authors:[{id:"179629",title:"Prof.",name:"Jolita",middleName:null,surname:"Vveinhardt",slug:"jolita-vveinhardt",fullName:"Jolita Vveinhardt"}]}],onlineFirstChaptersFilter:{topicId:"23",limit:6,offset:0},onlineFirstChaptersCollection:[{id:"82394",title:"Learning by Doing Active Social Learning",slug:"learning-by-doing-active-social-learning",totalDownloads:2,totalDimensionsCites:0,doi:"10.5772/intechopen.105523",abstract:"Project-based learning and future-based pedagogy are important and effective tools for teaching and learning in the twenty-first century. They are especially suited to instilling social activism among students, which is extremely valuable in today’s multicultural society. This study examined the impact of such learning among Arab and Jewish students and teachers in Israel. Following a collaborative program on social activism, in which students from different sectors worked together via digital platforms and face-to-face encounters, the impact of the program and its pedagogical tools were examined. The program, called Living in a Multicultural Society, reflects the mosaic of different people and communities, living side by side yet separated by religion, culture, and language. Through this program, students who may not have otherwise met worked together to learn, research, and create. This study was conducted using the mixed-method approach, whereby the qualitative data were gathered via interviews, and the quantitative data were collected through questionnaires. The findings show that this project-based learning program led to significant encounters, understandings, and co-operations between different sectors, and to meaningful end-products relating to social activism. This study enhances the concept that significant pedagogical processes increase students’ motivation, in-depth learning, and outcomes.",book:{id:"11481",title:"Active Learning - Research and Practice",coverURL:"https://cdn.intechopen.com/books/images_new/11481.jpg"},signatures:"Anat Raviv"},{id:"81785",title:"Social Distancing Disbanding Learner Groupings: A Case on Language Development",slug:"social-distancing-disbanding-learner-groupings-a-case-on-language-development",totalDownloads:8,totalDimensionsCites:0,doi:"10.5772/intechopen.104893",abstract:"Information sharing is a fundamental aspect in learning an unfamiliar, yet, an additional language, with specific regards to reading comprehension. Language teachers are faced with a task to monitor development, performance, and effectiveness in learner reading proficiencies. This chapter aims to measure if disbanding learner groupings as per the social distancing protocols brought about by COVID-19 restrictions has any impact on language enhancement. Henceforth, there are limited suggestions by literature in relation to disbanding learner groupings, yet improved reading proficiency is one of the crucial language aspects to be mastered for one to be a successful scholar. Nonetheless, this chapter aims to provide teaching strategies applied by English language teachers to necessitate transmitted learning in accordance with information sharing as learners are dependent on one another for language enhancement, thus leading to academic achievement.",book:{id:"10912",title:"Psychosocial, Educational, and Economic Impacts of COVID-19",coverURL:"https://cdn.intechopen.com/books/images_new/10912.jpg"},signatures:"Bulelwa Makena and Thandiswa Mpiti"},{id:"82173",title:"Integral Ecology and Spiritual Dialogues",slug:"integral-ecology-and-spiritual-dialogues",totalDownloads:7,totalDimensionsCites:0,doi:"10.5772/intechopen.105126",abstract:"The essay has as its starting point, a brief awareness of the accelerated degradation and depletion of Planet Earth and the incompetent or insensitive economies toward the scandalous increase of social inequalities and situations of human waste in the world. Next, come some core points of the Church’s Social Teaching under Pope Francis, highlighting integral ecology and dialogue, as well as some relevant aspects in the debate of global ethical standards and new perceptions of the paths of spirituality. With this broad framework, the central focus of the text synthesizes a proposal for a concept of promoting justice considered coherent and operative within this context, emphasizing the relevance of spiritual dialogues as a transforming practice within the complexity that questions and challenges us. Even without directly addressing the concept of sustainability, by focusing on integral ecology and spiritual dialogues, the essay’s main horizon is to suggest paths to sustainable societies.",book:{id:"11429",title:"Sustainability, Ecology, and Religions of the World",coverURL:"https://cdn.intechopen.com/books/images_new/11429.jpg"},signatures:"José Ivo Follmann"},{id:"82295",title:"Religious Self and Sustainability Ideation: Islamic Perspective and Indonesian Context",slug:"religious-self-and-sustainability-ideation-islamic-perspective-and-indonesian-context",totalDownloads:3,totalDimensionsCites:0,doi:"10.5772/intechopen.105127",abstract:"This chapter describes the role of the religious self in relation to sustainability ideation. The religious self that can foster sustainability ideation is the genuine religious self. The process is to realize the duty of humans as a caliphate and learn the science of God’s creation as part of human obedience to God. The traditional perspective of religiosity that separates the science of religion from the general science, and considers the general science has nothing to do with religiosity, needs to be retheorized. Retheorization is necessary. Thinking about religiosity provides the opportunity to a Muslim who studies the natural sciences and other sciences to carry out the human duties as caliph, namely guarding the earth.",book:{id:"11429",title:"Sustainability, Ecology, and Religions of the World",coverURL:"https://cdn.intechopen.com/books/images_new/11429.jpg"},signatures:"Retno Hanggarani Ninin and Noer Fauzi Rachman"},{id:"82310",title:"Knowledge of Intergenerational Contact to Combat Ageism towards Older People",slug:"knowledge-of-intergenerational-contact-to-combat-ageism-towards-older-people",totalDownloads:8,totalDimensionsCites:0,doi:"10.5772/intechopen.105592",abstract:"Among the multi-dimensional social aspects of aging, intergenerational contacts and relationships between older and younger people will be the focus of this chapter. Underpinned by a study that sought to address and reduce ageism, this chapter discusses the respective roles of direct and indirect intergenerational contacts and their associations with the attitude and prosocial behavior of younger people towards older people. This chapter aims to provide initial evidence about the related processes, mechanisms and relationships involving the older individuals and young people in our society. Valuable insights and synergistic efforts will be provided in how the governments, schools, private and community groups, and the media will all have an integral part to play in applying the knowledge of intergenerational contact to combat ageism towards older people. Future research is needed to better integrate the processes, mechanisms and changing relationships between generations to serve the aging population of Hong Kong.",book:{id:"11479",title:"Social Aspects of Ageing - Selected Challenges, Analyses, and Solutions",coverURL:"https://cdn.intechopen.com/books/images_new/11479.jpg"},signatures:"Alice Nga Lai Kwong"},{id:"82239",title:"Impact of Dialogic Argumentation Pedagogy on Grade 8 students’ Epistemic Knowledge of Science",slug:"impact-of-dialogic-argumentation-pedagogy-on-grade-8-students-epistemic-knowledge-of-science",totalDownloads:25,totalDimensionsCites:0,doi:"10.5772/intechopen.104536",abstract:"This study explores the effect of dialogic argumentation on grade 8 students’ epistemic knowledge of science in physics. A quasi-experimental design was employed to compare experimental (239) and control (240) groups’ epistemic knowledge of science. A pre-intervention and post-intervention physics reasoning test was administered, and small group classroom discussions were also video recorded. Physics teachers in the intervention group had trained for three days about dialogic argumentation and Talking Physics Students Activities manual was also distributed and used in this yearlong intervention. Mann-Whitney U test results indicated that the post-test scores of grade 8 students in the argumentation lessons significantly increased in their level of epistemic knowledge compared to the non-argumentation groups, z =−4.509, p = .000, and r = .21, but not in the pre-test scores, z =−1.038 and p = .299. However, both pre- and post-test scores of both groups were relatively low. The intervention groups showed significant improvements in the quality of their argumentation on the ASAC scale, z = 2.111, p = .035, and r = .56, but not the control groups, z = 1.068 and p = .285. The study found evidence that argumentation-based lessons improved both the epistemic knowledge and the quality of dialogic argumentations of grade 8 students and that students’ level of epistemic knowledge and the quality of their dialogic argumentations were strongly correlated.",book:{id:"11279",title:"Advances in Research in STEM Education",coverURL:"https://cdn.intechopen.com/books/images_new/11279.jpg"},signatures:"Getachew Tarekegn, Jonathan Osborne and Mesfin Tadesse"}],onlineFirstChaptersTotal:144},preDownload:{success:null,errors:{}},subscriptionForm:{success:null,errors:{}},aboutIntechopen:{},privacyPolicy:{},peerReviewing:{},howOpenAccessPublishingWithIntechopenWorks:{},sponsorshipBooks:{sponsorshipBooks:[],offset:0,limit:8,total:null},allSeries:{pteSeriesList:[{id:"14",title:"Artificial Intelligence",numberOfPublishedBooks:9,numberOfPublishedChapters:89,numberOfOpenTopics:6,numberOfUpcomingTopics:0,issn:"2633-1403",doi:"10.5772/intechopen.79920",isOpenForSubmission:!0},{id:"7",title:"Biomedical Engineering",numberOfPublishedBooks:12,numberOfPublishedChapters:104,numberOfOpenTopics:3,numberOfUpcomingTopics:0,issn:"2631-5343",doi:"10.5772/intechopen.71985",isOpenForSubmission:!0}],lsSeriesList:[{id:"11",title:"Biochemistry",numberOfPublishedBooks:32,numberOfPublishedChapters:317,numberOfOpenTopics:4,numberOfUpcomingTopics:0,issn:"2632-0983",doi:"10.5772/intechopen.72877",isOpenForSubmission:!0},{id:"25",title:"Environmental Sciences",numberOfPublishedBooks:1,numberOfPublishedChapters:12,numberOfOpenTopics:4,numberOfUpcomingTopics:0,issn:"2754-6713",doi:"10.5772/intechopen.100362",isOpenForSubmission:!0},{id:"10",title:"Physiology",numberOfPublishedBooks:11,numberOfPublishedChapters:141,numberOfOpenTopics:4,numberOfUpcomingTopics:0,issn:"2631-8261",doi:"10.5772/intechopen.72796",isOpenForSubmission:!0}],hsSeriesList:[{id:"3",title:"Dentistry",numberOfPublishedBooks:8,numberOfPublishedChapters:129,numberOfOpenTopics:2,numberOfUpcomingTopics:0,issn:"2631-6218",doi:"10.5772/intechopen.71199",isOpenForSubmission:!0},{id:"6",title:"Infectious Diseases",numberOfPublishedBooks:13,numberOfPublishedChapters:113,numberOfOpenTopics:3,numberOfUpcomingTopics:1,issn:"2631-6188",doi:"10.5772/intechopen.71852",isOpenForSubmission:!0},{id:"13",title:"Veterinary Medicine and Science",numberOfPublishedBooks:11,numberOfPublishedChapters:105,numberOfOpenTopics:3,numberOfUpcomingTopics:0,issn:"2632-0517",doi:"10.5772/intechopen.73681",isOpenForSubmission:!0}],sshSeriesList:[{id:"22",title:"Business, Management and Economics",numberOfPublishedBooks:1,numberOfPublishedChapters:19,numberOfOpenTopics:2,numberOfUpcomingTopics:1,issn:"2753-894X",doi:"10.5772/intechopen.100359",isOpenForSubmission:!0},{id:"23",title:"Education and Human Development",numberOfPublishedBooks:0,numberOfPublishedChapters:5,numberOfOpenTopics:1,numberOfUpcomingTopics:1,issn:null,doi:"10.5772/intechopen.100360",isOpenForSubmission:!0},{id:"24",title:"Sustainable Development",numberOfPublishedBooks:0,numberOfPublishedChapters:15,numberOfOpenTopics:5,numberOfUpcomingTopics:0,issn:null,doi:"10.5772/intechopen.100361",isOpenForSubmission:!0}],testimonialsList:[{id:"13",text:"The collaboration with and support of the technical staff of IntechOpen is fantastic. 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Her qualifications are: a specialist in Dental Imaging and Radiology, Master in Dentistry (Periodontics) from the University of São Paulo (FORP-USP, Ribeirão Preto, SP), and Doctor (Ph.D.) in Dentistry (Stomatology Clinic) from Hospital São Lucas of the Pontifical Catholic University of Rio Grande do Sul (HSL-PUCRS, Porto Alegre, RS). She held a postdoctoral internship at the Federal University from Jequitinhonha and Mucuri Valleys (UFVJM, Diamantina, MG). She is currently a member of the Brazilian Society for Dental Research (SBPqO) and the Brazilian Society of Stomatology and Pathology (SOBEP). Dr. Marinho's experience in Dentistry mainly covers the following subjects: oral diagnosis, oral radiology; oral medicine; lesions and oral infections; oral pathology, laser therapy and epidemiological studies.",institutionString:null,institution:{name:"State University of Paraíba",institutionURL:null,country:{name:"Brazil"}}},editorTwo:null,editorThree:null,series:{id:"3",title:"Dentistry",doi:"10.5772/intechopen.71199",issn:"2631-6218"},editorialBoard:[{id:"267724",title:"Dr.",name:"Febronia",middleName:null,surname:"Kahabuka",slug:"febronia-kahabuka",fullName:"Febronia Kahabuka",profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0030O00002bRZpJQAW/Profile_Picture_2022-06-27T12:00:42.JPG",institutionString:null,institution:null}]},onlineFirstChapters:{paginationCount:20,paginationItems:[{id:"80964",title:"Upper Airway Expansion in Disabled Children",doi:"10.5772/intechopen.102830",signatures:"David Andrade, Joana Andrade, Maria-João Palha, Cristina Areias, Paula Macedo, Ana Norton, Miguel Palha, Lurdes Morais, Dóris Rocha Ruiz and Sônia Groisman",slug:"upper-airway-expansion-in-disabled-children",totalDownloads:35,totalCrossrefCites:0,totalDimensionsCites:0,authors:null,book:{title:"Oral Health Care - An Important Issue of the Modern Society",coverURL:"https://cdn.intechopen.com/books/images_new/10827.jpg",subseries:{id:"1",title:"Oral Health"}}},{id:"80839",title:"Herbs and Oral Health",doi:"10.5772/intechopen.103715",signatures:"Zuhair S. 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