Clinical data of the patients
\r\n\tThe eye is our window to the brain. Vision is the ability to interpret and understand the information that comes in through the eyes. The visual system utilizes brain pathways to process and understand what the eyes sense. The dynamic process of vision is to identify, interpret and understand what the eyes see.
\r\n\tAn image is a sight which has been recreated. It is an appearance which has been detached from the place and time in which it first made its appearance. Sensing is not the same as seeing. The eyes and the nervous system do the sensing, while the mind does the perceiving.
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\r\n\tMedical imaging is the process of using technology to view the human body in the interest of diagnosing, monitoring, and treating medical problems. It is especially beneficial when it comes to detecting cancer. Such a threatening disease requires very early detection to improve the chances of survival. Medical imaging is an extremely important element in medical practice in the world of today. While medical knowledge and discernment forms the basis of diagnoses and decisions, medical imaging plays a vital role in confirming any diagnosis. With scientific advancement and a continued effective use, medical imaging will continue to help with earlier detection of health issues and provide increased preventative care.
\r\n\tThis book intends to provide readers with a comprehensive overview of the latest and most advanced findings in several aspects of ophthalmic pathology, treatment and surgical strategies, ocular imaging, vision sciences, medical images and perception that focuses on the most important developments in these critically important areas. Enough has been achieved already to make it clear that these fields have enormous possibilities for improving the human health.
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Suicide has become an increasing concern as there are an estimated one million completed suicides per year worldwide. Suicide rates have increased by 60% over the last 50 years, particularly in developing countries. Suicide attempts are up to 20 times more. In 1996 more than 150,000 people committed suicide in 38 countries of the World Health Organization European Region. Suicide is currently one of the most important causes of death in Europe among young and middle-aged people, especially men. In some European Countries, in the age group 15-34, suicide ranks second among the most common causes of death. Nine of the ten countries with the highest suicide rates in the world are in the European Region [1].
In the EUROSAVE (European Review of Suicide and Violence Epidemiology) study, Finland had the highest suicide rate, while Greece had the lowest for the latest available year (1997). Greece also had the lowest undetermined deaths in 1984 and 1997 [2]. According to the Rutz and Wasserman study, increases in male adolescent suicide rates from 1979-1996 that were observed in Sweden, Ireland and Greece can partly be attributed to improved suicide statistics [3]. Botsis [4] suggests that in Greece formal statistics by the National Statistics Office are not representative of reality when they refer to reported suicides. Families avoid reporting suicide as the cause of death for religious reasons. Natural causes are reported instead.
Completed suicide rates for Greece (1960-2009) suggest a fluctuation between 2.8 and 4.0 per 100,000 for the years 1975 and 1985, respectively [1,5]. According to the table of Basic Statistics from Health for All (HFA) for the year 2006 in Greece there is a rate of 3.5 in suicides and self-inflicted injuries at all ages per 100,000. This rate is relatively stable for the years 2000-2009 (3.5-3.6) [1]. Recently, Greece began to experience the effects of the extreme financial crisis, and reports in the mass media and journals support a possible casual link between the economic crisis and suicide rates. However, scientific data concerning this matter is still controversial [5-7].
In many European countries suicidal behavior constitutes a major public and mental health problem. It is also a considerable drain of resources in both primary and secondary health care settings [8]. Furthermore, adolescent suicide and attempted suicide have been recognized as a growing health problem in the rest of the world [9]. Young people of both sexes often make repeated suicide attempts [10-12]. Deliberate self-harm is also associated with increased risk of repetition and suicide [13,14].
Several possible theories have been proposed to explain the increased risk conferred by multiple attempts. One possibility is that multiple attempts reflect persistent risk factors (e.g., a chronic or recurring psychiatric disorder or adverse psychosocial conditions). Esposito et al. [15] studied 74 single attempters (SAs) and 47 multiple attempters (MAs; ages 12-18) seen in an emergency department after a suicide attempt and found higher rates of mood disorder diagnosis among MAs. Joiner [16], suggests that multiple suicide attempts increase the risk for subsequent attempts because practice allows MAs to acquire the ability to engage in more serious suicidal behavior.
In Greece, one study in 76 suicide attempters between the ages of 9-20 years, reported an 18-fold greater frequency of psychiatric disorder, 14-fold greater frequency of other problems (relational), 9.7-fold greater frequency of smoking and 4.7-fold greater frequency of psychosocial and environmental problems [17]. A six year retrospective study of self inflicted burns with ages ranging from 18-90 years concluded that of the 1435 admissions between April 1997-April 2003, 3.69% attempted suicide by self burn. Of these, females 57%, males 43%, with a high mortality rate of 75.4%. In 43.3% there was a preexisting psychiatric disorder [18].
A study in another internal medicine clinic from November 1999 to November 2000 of 146 drug intoxications, of which male 34.2% and female 65.8%, refers that 38.3% had a history of mental illness, 31.5% were in need of psychiatric help and 42.5% had a previous suicide attempt. Mental State Examination diagnoses included depression (20.96%), psychosis (15.32%), dysthymic disorder (16.2%), anxiety disorder (22.58%) and personality disorder (8.8%) [19]. Other studies refer to substance use increasing suicidal ideation or behavior [20], rising trends in male suicides, higher rates among widowed men [21,22], and an unusual peak in the summer [23], or spring and summer [21].
A substantial amount of research indicates that self-harm by falling is a rare phenomenon, accounting for 4–7% of suicidal deaths in the developed world [24,25]. The mostet common mode of attempted suicide is drug ingestion. Completed suicides and violent suicide attempts are less common and include hanging, falls/jumps, and firearms [26]. The incidence of different methods of suicide may vary from one country to another. In the United States for instance, jumping is among the least common methods of committing suicide (less than 2% of all reported suicides in the United States for 2005), while in Hong Kong, jumping is the most common method of committing suicide, accounting for 52.1% of all reported suicide cases in 2006 and similar rates for the years prior to that [27,28]. Community samples estimate that 8–10% of all those who attempt suicide will eventually die as a result of self-harm, most of these within 5 years of the attempt depending on the diagnosis [29,30].
Patients who attempt suicide by jumping from a height usually suffer from multiple injuries. These may be of two types: deceleration type injuries and direct impact injuries [31]. The former, which are internal organ injuries, result from the tendency to displace the tissue in the direction of motion upon impact, while the movement of the body is arrested by the ground [30]. A number of studies show that most of the patients who attempt suicide by jumping suffer from serious psychiatric disorders. These patients suffer from a broad spectrum of psychiatric symptoms: schizophrenia, depression, drugs or alcohol abuse, personality disorder and manic depression [32,33].
Spinal cord injury (SCI) literature estimates suicide as being responsible for approximately 5% of deaths, though this varies greatly between populations [24-37]. Risk tends to be higher in the years immediately post-injury, but there is an increased life-time risk if an individual has ever attempted suicide or self-harm [24].
Several studies have examined the post-injury predictions for patients who survived after a suicide attempt, and various findings arise. Haenel and Jehle [38], conducted a research in Switzerland, on patients who had become paraplegic after a suicide attempt, and who had to spend a certain time in the Basel and Nottwil (canton of Lucerne) centre for paraplegics. They evaluated the records and catamnestic date of 38 patients with a mean age of 38 years, between the years of 1982-1996 and a follow up study was conducted. Catamnestic investigations performed from one month to 14 years after the suicidal attempt were based on a structured dialogue with a standardized, computerized questionnaire. The results showed that the most frequently encountered suicidal method, leading to the paraplegic lesion, was a fall from a window of a building (89,6 %). In 55% of the cases, a psychiatric disorder had been diagnosed prior to the suicide attempt, with depression, alcohol and drug dependence appearing as the most common diagnoses. Thirty-seven per cent of patients had attempted suicide at least once before and 34 % had been hospitalized for psychiatric reasons prior to the incident. The paraplegic lesions of the patients were equally distributed between thoracic, cervical and lumbar lesions. The most disturbing problem reported by patients after the paralysis was sexual impairment. Despite the limited number of cases and the rather short interval between the suicide attempt and the follow-up investigation, results seem to indicate that such patients are not likely to commit suicide on a later occasion, excluding one single case.
Anderson and Allan [24] conducted a survey in a Scottish spinal rehabilitation unit, on the demographics and patients outcome with vertebral fracture after suicide attempt. Forty-six (44 having detailed data available) patients were identified with 95% of injuries resulting from falls. Thirty-six people had pre-existing mental health problems (82%) with 15 (34%) having this diagnosis established shortly after admission. Seventy-five per cent received follow-up from mental health services. Ninety-five per cent returned to their pre-injury (or similar) residence. Length of stay and functional independence measure for the deliberate self harm group were compared with a non-deliberate self harm group. High levels of mental health and substance abuse problems were detected necessitating formal mental health assessment and follow-up. Deliberate self harm as a mechanism for injury appears to have a significant impact on length of stay in the centre only if the patient has fracture without spinal cord injuries. Immediate rehabilitation outcomes are similar to that of non-deliberate self-harm group. The authors noted in the limitations of the study that the sample size was small and a retrospective methodology concerning an accurate history and outcome was difficult. However, the particular study demonstrates that the patients benefited by their time in rehabilitation and had comparable outcomes to a non-deliberate self harm group in the short term. Despite the fact that substance and mental health problems were significant in this group, these difficulties appear to impact little on immediate rehabilitation and discharge.
Kennedy et al. [34], conducted a retrospective review examining the admission records of 137 individuals, of mean age 32, with SCI as a result of a suicide attempt between the period 1951 to 1992. The research took place in the National Spinal Injuries Centre in Stoke Mandeville Hospital in Bucks, UK. They explored and identified the type of psychiatric condition evident around the time of injury and reviewed outcome information of this sample with specific focus on mortality, especially further evidence of deliberate self harm. The subsequent database comprised among others, cause, level and completeness of injury, height fallen, psychiatric history, psychiatric diagnosis, date of last contact, further suicide attempts, date and cause of death, date and place of discharge. Previous suicide attempts had been made by 23%. The cause of injury in 85% of cases was \'falls\'. Thirty-three people are known to have died, of whom eight (24%) committed suicide. During the period between the first and last SCI examined within this study (1951-1992) 1.6% (n=137) of the total sample of patients treated at the rehabilitation centre sustained an SCI as a result of a suicide attempt. Recommendations for further research include an adaptation of the psychological autopsy approach which would provide additional information to that which is normally available in actual suicides.
Stanford et al. [25], conducted a research to State SCI services at New South Wales, Australia to determine the incidence of acute SCI due to suicide attempt from 1970 to 2000. They examined demographics, injuries, mental illness, functional outcomes and nature of subsequent deaths of 2752 acute spinal cord injury admissions. Of these, 56 were attempted suicide (55 falls, one gun-shot wound). The median age was 30 years. Psychiatric diagnoses varied, the most common of which were personality disorder, schizophrenia, depression, chronic alcohol abuse, mood disorder and chronic substance abuse. Follow-up was available in 47 cases (84%) at an average of 8 years. Four subsequent deaths were by suicide. Community placement outcomes for survivors were good, however the subsequent death by suicide was high.
Biering et al. [35], during 1965 to 1987 examined 45 patients who were admitted to the Rehabilitation Hospital in Hornbaek, Denmark because of SCI due to suicide attempts. The median age at injury was 31 years. In 38 instances (84%), SCI was caused by jumps from buildings. 62% had previously been admitted to psychiatric hospitals, and 31% had previously attempted suicide. A follow up study was conducted in 1988-89. At follow up, 11 patients had died, 3 from suicide. Of the 34 alive at follow up, 7 had attempted suicide, and 2 reported suicidal thoughts. A 44% had had a psychiatric admission since the SCI and 56% were taking psychiatric medication.
In another research conducted by Christiansen and Jensen [39] in 2007, the incidence of repetition of suicide attempt, suicide and all deaths was examined, and the influence of psychiatric illness and socio-demographic factors on these was analysed. The study was a Danish register-based survival analysis that retrieved personal data on socio-economic, psychiatric and mortality conditions from various registers. Suicide-attempters (2.614) and non-attempters (39.210) were analysed being matched by gender, age and place of residence. The average follow-up period for suicide-attempters was 3.88 years, during which 271 of them died. By comparison, death occurred four times more often among suicide-attempters than among non-attempters. Suicide was far more common among attempters (61, 2.33%) than among non-attempters (16, 0.04%). A proportion of the attempters (31.33%) repeated their attempt within the follow-up period. The most reliable predictors for suicide and death were repetition, suicide attempt method and treatment for mental illness, while the most reliable predictors for repetition were age, gender and mental illness.
It is clear that the results of the different studies vary, but most of them agree, as Christiansen and Jensen [39] state, that individuals with a history of suicide attempts form a well-defined high-risk group for suicide, and are in need of treatment immediately after the episode. Staff attending to the physical and psychiatric needs of these patients must work together and should inform of the risk of subsequent suicidal behavior, after a first episode of attempted suicide. Furthermore, departments which are in contact with suicidal individuals need action plans to ensure that all such individuals receive proper treatment immediately after the suicide attempt. The injuries and life changing conditions following the suicide attempt, add to the existing problems of the patients, especially those with a psychiatric disorder. Further research could take a closer look at the individual factors that lead to mortality in the spinal cord injuries of the deliberate self-harm patients and perhaps suggest mechanisms to reduce mortality. It may also be profitable to examine the risk to self that all individuals bring with them into rehabilitation by merit of their past deliberate self harm or mental health history, as a way of better focused support for all of those with spinal cord injuries after rehabilitation [24].
Thirty-two patients (8 males and 24 females) that were treated for SCIs in the Athens University Orthopaedic Department, as a result of deliberate self harm, are presented. Their ages varied from 18 to 65 years, and the average age was 35 years. There were 16 singles (50%), 14 married (44%) and 2 divorced (6%) patients. Thirteen patients were employed (41%), six housewives (19%), seven unemployed (22%), three students / pupils (9%) and three with various occupations (9%). In terms of religion, 28 were Christian Orthodox (88%), one Roman Catholic (3%), one Jewish (3%), one Muslim (3%) and one (3%) with an unknown religious affiliation.
The cause of injury was a fall from a building in 29 cases (91%), a fall from a window in one case (3%), a fall from a bridge in one case (3%) and a fall inside the house in one case (3%). Concerning the level of injury, in 16 cases (50%) it was at the lumbar level, in 9 cases (28 %) at the cervical, in 5 cases (16%) at thoracic and 2 cases (6%) regarded the sacral vertebrae (Figures 1 and 2). In 20 cases (62.5%) the injury was incomplete and in 12 cases (37.5%) complete. The psychiatric diagnosis was schizophrenia in 12 patients (38%), depression in 8 patients (25%), drugs or alcohol abuse in 3 cases (9%), personality disorder in one patient (3%), bipolar disorder in one patient (3%), other psychiatric reasons in one patient (3%) and in 6 cases (19%) there was no specific diagnosis (generally marital or work related). The height of the falls ranged from 2 to 12 m and all patients landed on solid ground. Operative treatment which included laminectomies, spine instrumentation and fusion was performed in all patients.
Lateral radiograph showing a fracture of the sacrum.
Anteroposterior radiograph of the same case.
Initial clinical data of the 32 patients included in this study are shown in Table 1. At admission, ATLS guidelines were used for all patients. Associated injuries of the abdomen were present in five patients (patients 1, 4, 10 and 22). In these patients, a laparotomy was necessary for intraperitoneal bleeding, spleen and kidney injury, and mesenteric tear prior to the surgical operation for the spine fracture. Head injuries were revealed with CT scan in six patients (patients 3, 7, 8, 14, 26 and 30). In these cases craniotomy and decompression were performed first, before stabilization of the spinal fractures. Thoracic injuries (ribs fractures or sternum fracture) were present in three patients (patients 3, 5 and 28). Conservative treatment with assisted ventilation was necessary in these cases. Long bone fractures (femoral, tibial, bimalleolar, calcaneal, radial and humeral), including pelvic fractures, were treated by external fixation or closed reduction and immobilization in plaster or temporary splint. Subsequently, reduction and internal fixation, if required, were performed from 8 hours to 5 days later.
Regarding the treatment of the spinal fractures – dislocations, instrumentation devices including titanium rods, transpedicular screws, sacral bars and bone grafting were used on all patients. Patients were evaluated by a consulting psychiatrist as soon as their condition and cooperation permitted. Assessment included an interview and a complete mental status examination.
The only complications encountered were two cases of aspiration pneumonia, one of which resulted in prolonged stay on the intensive therapy unit due to difficulty weaning the patient off the ventilator. All patients were discharged from hospital approximately 6–8 weeks after the operation with a custom-made thermoplastic thoracolumbar or lumbosacral orthosis for another 8 weeks and instructions for physical therapy and rehabilitation programs. After discharge 13 patients returned to their homes and 19 to another hospital or entered residential care.
\n\t\t\t\tPatient\n\t\t\t | \n\t\t\t\n\t\t\t\tAge/gender\n\t\t\t | \n\t\t\t\n\t\t\t\tMechanism of injury\n\t\t\t | \n\t\t\t\n\t\t\t\tNeurological deficits at admission\n\t\t\t | \n\t\t\t\n\t\t\t\tAssociated Lesion\n\t\t\t | \n\t\t\t\n\t\t\t\tSurgical treatment\n\t\t\t | \n\t\t\t\n\t\t\t\tFollow-up\n\t\t\t | \n\t\t\t\n\t\t\t\tRecovery and outcome\n\t\t\t | \n\t\t
1 | \n\t\t\t23/F | \n\t\t\tFall from building | \n\t\t\tBowel and bladderdysfunction;saddle anesthesia;incomplete L5-S1 paraplegia | \n\t\t\tL4 fracture, humeral shaft fracture | \n\t\t\tLaminectomy; titanium rods and transpedicular screws, humeral external fixation | \n\t\t\t6 years | \n\t\t\tRecovery | \n\t\t
2 | \n\t\t\t18/M | \n\t\t\tFall from building | \n\t\t\tIncomplete paraplegia | \n\t\t\tL2 fracture | \n\t\t\tLaminectomy; titanium rods and transpedicular screws | \n\t\t\t8 years | \n\t\t\tRecovery | \n\t\t
3 | \n\t\t\t34/F | \n\t\t\tFall from building | \n\t\t\tCompleteparaplegia | \n\t\t\tT9 fracture | \n\t\t\tLaminectomy; titanium rods and transpedicular screws | \n\t\t\t2 years | \n\t\t\tNone | \n\t\t
4 | \n\t\t\t42/F | \n\t\t\tFall from window | \n\t\t\tIncomplete paraplegia | \n\t\t\tL3 fracture | \n\t\t\tLaminectomy; titanium rods and transpedicular screws | \n\t\t\t18 months | \n\t\t\tRecovery | \n\t\t
5 | \n\t\t\t20/F | \n\t\t\tFall from building | \n\t\t\tCompleteparaplegia | \n\t\t\tT5 - T6 fracture, dislocation | \n\t\t\tLaminectomies; titanium rods and transpedicular screws | \n\t\t\t1 year | \n\t\t\tNone | \n\t\t
6 | \n\t\t\t48/F | \n\t\t\tFall from building | \n\t\t\tIncomplete paraplegia | \n\t\t\tL4 fracture | \n\t\t\tLaminectomy; titanium rods and transpedicular screws | \n\t\t\t5 years | \n\t\t\tRecovery | \n\t\t
7 | \n\t\t\t65/F | \n\t\t\tFall from building | \n\t\t\tIncompletetetraplegia | \n\t\t\tC2 - C3 fracture, dislocation | \n\t\t\tAnterior plating | \n\t\t\t17 months | \n\t\t\tDeath, second suicide attempt at 2 years | \n\t\t
8 | \n\t\t\t56/M | \n\t\t\tFall from building | \n\t\t\tCentral cord syndrome | \n\t\t\tC2 - C3 fracture, dislocation | \n\t\t\tAnterior plating | \n\t\t\t2 years | \n\t\t\tDeath (renal failure) | \n\t\t
9 | \n\t\t\t41/F | \n\t\t\tFall from building | \n\t\t\tIncomplete paraplegia | \n\t\t\tL4 fracture | \n\t\t\tLaminectomy; titanium rods and transpedicular screws | \n\t\t\t22 months | \n\t\t\tRecovery | \n\t\t
10 | \n\t\t\t27/F | \n\t\t\tFall from building | \n\t\t\tCompleteparaplegia | \n\t\t\tL1 fracture | \n\t\t\tLaminectomy; titanium rods and transpedicular screws | \n\t\t\t10 years | \n\t\t\tNone | \n\t\t
11 | \n\t\t\t31/F | \n\t\t\tFall from building | \n\t\t\tBowel and bladderdysfunction;saddle anesthesia;complete L4–S1paraplegia | \n\t\t\tL4 fracture | \n\t\t\tLaminectomy; titanium rods and transpedicular screws | \n\t\t\t9 years | \n\t\t\tNone | \n\t\t
12 | \n\t\t\t39/M | \n\t\t\tFall from building | \n\t\t\tComplete tetraplegia | \n\t\t\tC2 - C3 fracture, dislocation | \n\t\t\tAnteriorC2 - C3 plating | \n\t\t\t30 months | \n\t\t\tNone | \n\t\t
13 | \n\t\t\t46/F | \n\t\t\tFall from building | \n\t\t\tComplete tetraplegia | \n\t\t\tC2 - C3 fracture, dislocation | \n\t\t\tAnterior plating | \n\t\t\t25 months | \n\t\t\tNone | \n\t\t
14 | \n\t\t\t51/F | \n\t\t\tFall from building | \n\t\t\tComplete tetraplegia | \n\t\t\tC2 - C3 fracture | \n\t\t\tAnterior plating | \n\t\t\t3 years | \n\t\t\tDeath (renal failure) | \n\t\t
15 | \n\t\t\t36/M | \n\t\t\tFall from building | \n\t\t\tIncomplete tetraplegia | \n\t\t\tC7 fracture | \n\t\t\tAnterior plating | \n\t\t\t1 year | \n\t\t\tRecovery | \n\t\t
16 | \n\t\t\t19/F | \n\t\t\tFall from building | \n\t\t\tComplete tetraplegia | \n\t\t\tC2 - C3 fracture, dislocation | \n\t\t\tAnterior plating | \n\t\t\t14 months | \n\t\t\tNone | \n\t\t
17 | \n\t\t\t39/M | \n\t\t\tFall from building | \n\t\t\tIncomplete paraplegia | \n\t\t\tSacral fracture, Dennis III | \n\t\t\tTransiliac sacral bars | \n\t\t\t34 months | \n\t\t\tRecovery | \n\t\t
18 | \n\t\t\t41/F | \n\t\t\tFall from bridge | \n\t\t\tComplete tetraplegia | \n\t\t\tC2 - C3 fracture, dislocation | \n\t\t\tAnterior plating | \n\t\t\t8 years | \n\t\t\tNone | \n\t\t
19 | \n\t\t\t47/F | \n\t\t\tFall from building | \n\t\t\tIncomplete paraplegia | \n\t\t\tL4 fracture | \n\t\t\tLaminectomy; titanium rods and transpedicular screws | \n\t\t\t3 years | \n\t\t\tRecovery | \n\t\t
20 | \n\t\t\t34/F | \n\t\t\tFall from building | \n\t\t\tIncomplete paraplegia | \n\t\t\tL4 fracture | \n\t\t\tLaminectomy; titanium rods and transpedicular screws | \n\t\t\t1 year | \n\t\t\tRecovery | \n\t\t
21 | \n\t\t\t53/M | \n\t\t\tFall from building | \n\t\t\tComplete paraplegia | \n\t\t\tTransverse fracture of the sacrum with anterior displacement | \n\t\t\tlaminectomies; titanium rods and transpedicular screws; bone grafting | \n\t\t\t32 months | \n\t\t\tDeath (pneumonia) | \n\t\t
22 | \n\t\t\t38/F | \n\t\t\tFall from building | \n\t\t\tIncomplete paraplegia | \n\t\t\tL1 - L2 fracture, distal radius fracture | \n\t\t\tLaminectomies; titanium rods and transpedicular screws, cast for the distal radius fracture | \n\t\t\t23 months | \n\t\t\tRecovery | \n\t\t
23 | \n\t\t\t47/F | \n\t\t\tFall from building | \n\t\t\tBrown - Sequard syndrome | \n\t\t\tT8 fracture | \n\t\t\tLaminectomy; titanium rods and transpedicular screws | \n\t\t\t2 years | \n\t\t\tRecovery | \n\t\t
24 | \n\t\t\t41/F | \n\t\t\tFall from building | \n\t\t\tIncomplete paraplegia | \n\t\t\tL4 fracture | \n\t\t\tLaminectomy; titanium rods and transpedicular screws | \n\t\t\t4 years | \n\t\t\tRecovery | \n\t\t
25 | \n\t\t\t35/M | \n\t\t\tFall inside the house | \n\t\t\tIncomplete paraplegia | \n\t\t\tL4 fracture | \n\t\t\tLaminectomy; titanium rods and transpedicular screws | \n\t\t\t15 months | \n\t\t\tRecovery | \n\t\t
26 | \n\t\t\t36/F | \n\t\t\tFall from building | \n\t\t\tIncomplete tetraplegia | \n\t\t\tC6 - C7 fracture | \n\t\t\tAnterior plating | \n\t\t\t19 months | \n\t\t\tRecovery | \n\t\t
27 | \n\t\t\t27/F | \n\t\t\tFall from building | \n\t\t\tIncomplete paraplegia | \n\t\t\tL5 fracture | \n\t\t\tLaminectomy; titanium rods and transpedicular screws | \n\t\t\t7 years | \n\t\t\tRecovery | \n\t\t
28 | \n\t\t\t33/F | \n\t\t\tFall from building | \n\t\t\tComplete paraplegia | \n\t\t\tT9 - T10 fracture, dislocation | \n\t\t\tLaminectomies; titanium rods and transpedicular screws | \n\t\t\t2 years | \n\t\t\tNone | \n\t\t
29 | \n\t\t\t55/F | \n\t\t\tFall from building | \n\t\t\tIncomplete paraplegia | \n\t\t\tL4 fracture | \n\t\t\tLaminectomy; titanium rods and transpedicular screws | \n\t\t\t31 months | \n\t\t\tRecovery | \n\t\t
30 | \n\t\t\t50/F | \n\t\t\tFall from building | \n\t\t\tComplete paraplegia | \n\t\t\tT8 - T9 fracture, dislocation | \n\t\t\tLaminectomies; titanium rods and transpedicular screws | \n\t\t\t13 months | \n\t\t\tDeath (renal failure) | \n\t\t
31 | \n\t\t\t44/F | \n\t\t\tFall from building | \n\t\t\tIncomplete paraplegia | \n\t\t\tL3 fracture, distal radius fracture | \n\t\t\tLaminectomy; titanium rods and transpedicular screws, cast for the distal radius fracture | \n\t\t\t4 years | \n\t\t\tRecovery | \n\t\t
32 | \n\t\t\t23/M | \n\t\t\tFall from building | \n\t\t\tIncomplete paraplegia | \n\t\t\tL4 fracture | \n\t\t\tLaminectomy; titanium rods and transpedicular screws | \n\t\t\t8 years | \n\t\t\tRecovery | \n\t\t
Clinical data of the patients
The mean follow-up was 6 years (range: 12 months – 10 years). At follow-up, only 27 of the patients were available for evaluation due to the death of 5 patients 1-3 years post injury. Of the five patients one had committed suicide (patient 7) and the other four had presented medical complications [renal failure in 3 patients (patients 8, 14 and 30) and pneumonia in one (patient 21)]. Of the remaining patients, two were involved in further unsuccessful suicide attempts due to psychiatric problems, 1 to 3 years post first injury (patients 10 and 24) (Table 1). All survivors received psychiatric follow-up.
Adolescent suicide and attempted suicide have been recognized as a growing health problem in both Europe and the rest of the world [9]. The highest average person-based ratio of male: female suicide attempt rate was found in the age group 15-24 years (1: 1.9), the next highest in the age group 45-54 years (1: 1.7). This ratio decreases in the age group up to 55 to 1: 1.4 (range: 1:3.4 to 1:0.6) [40].
In the two Greek studies referring to attempted suicide hospitalized in internal medicine wards due to drug intoxication and self poisoning there is a definite precedence of females with the first showing a percentage of male 34.2% and female 65.8% [22], and the second a ratio of male to female of 1:1.97 in an age group of 20-30 years [23]. Other studies also report parasuicide as more common in females and younger ages [41,42]. Contrarily, in the nationwide study of 1980-1995 of suicides a mean age-standardized rate of 5.86/100,000 males to 1.89/100,000 females was demonstrated. In addition, an increase in suicide rates was reported with age for males, with rising trends in the ages of 45-54yrs and decreasing rates for females in the 15-24yrs and 75-84yrs age group. Mostly violent methods are used among men [22]. This male to female trend is confirmed in the Epirus study where a mean age-standardized suicide rate per year 4/100,000 males was reported to 1.29 females/100,000. Once again a significant rising trend was shown for male suicides in the ages 35-44yrs and 65-74yrs, while low female rates were found in the under 35yrs age group [21].
In the current study, the ratio between males to females was 1:3. Females were more likely to make a more dangerous jump that increased their mortality. Others suggest that young males tended to use more lethal methods in attempts and to repeat more often than females [29]. A previous suicide attempt is in itself the strongest predictor of future suicide and local rates of attempted suicide and regional and national suicide rates in young people, especially males, are strongly correlated [43]. There is an association between repeated suicide attempts and completed suicide, particularly in males and when a violent method has been used [44,45].
The underlying psychology of suicide is complex and unique to each individual. However, certain themes emerge from studying individuals who have attempted or completed suicides. In all age groups, depression, alcohol and drug dependence, as well as history of mental illness are known to be risk factors for suicide [46]. Twenty percent of people who attempt suicide will make another attempt within the year, and 10% ultimately succeed [26]. Injuries resulting from direct impact are mostly fractures [47]. The area over which the impact force is applied influences the severity of the fractures [48]. The smaller the area over which the patients land, the greater the load/ unit area. Patients who land on their legs tend to sustain more serious injuries than those who land on their sides.
There were two main combinations of fractures in this series. The patients with spinal fracture combined with pelvic and extremity fractures. Only three of them sustained upper extremity fractures (patients 1, 22 and 31). Twelve patients presented with pelvic or lower extremity fractures associated with upper extremity fractures. The difference between the two groups shows that fractures in the upper extremities usually exclude fractures of the spine. Upon impact, the falling body has a kinetic energy which is converted, in its major part, into fracture energy. In the first group most of the kinetic energy is dissipated to the lower extremities, pelvis and spine, causing fractures at these sites. In the second group, patients use their upper extremities in an attempt to protect themselves, possibly via more flexion at the hip level. This increased flexion converts the remaining energy into forward rotational energy of the trunk exposing the extended upper extremities to fractures. It is probable that this form of energy dissipation protects the spine from fracture.
The initial treatment should be limited to life-saving procedures and short spine and limb stabilization procedures [49]. Fractures should be treated by methods that will allow early mobilization and transfer to the psychiatric ward. Treatment by traction or spica cast is not well tolerated by these patients and interferes with their nursing care. Rigid internal fixation, whenever possible for unstable fractures, is recommended.
The results of our study and others show that most of the patients who attempt suicide by jumping suffer from serious psychiatric disorders [32,33]. These patients suffer from a broad spectrum of psychiatric symptoms: schizophrenia, depression, drugs or alcohol abuse, personality disorder and manic depression. The proportion of patients with schizophrenia is far higher than found in general suicide attempts where it is estimated to range from 5% to 10%. Sometimes they have active suicidal ideation or even a detailed suicidal plan. Thus, the treatment approach for such patients must take into account their psychiatric state. The psychiatric manifestations create subjective distress for the patient and may hinder or even prevent the medical and surgical care of the patient in some instances [50].
In this sample of patients the fact that most individuals appeared to have responded to treatment, indicated that all admissions following self-harm should have access to appropriate psychiatric treatment. The finding that three of the patients within this study, attempted suicide following SCI, suggests that a small number of the people who have attempted suicide will re-attempt. We believe that routine screening for suicide and risk assessments might highlight those who are most at risk of re-attempting suicide, thus allowing healthcare professionals to be aware of these individuals and adopt appropriate strategies to address suicidal ideation and behavior.
The prevalence of psychiatric and mental health problems illustrated in this series highlights the importance of educating staff in the care of patients with mental health problems. In view of the special needs of these individuals, services should ensure regular follow-up to prevent deterioration and monitor progress. Moreover, future clinical research should also evaluate the specific problems of people who have both SCI and a psychiatric diagnosis.
Until now it has been difficult to obtain comparable international data on suicide attempts, owing to disparities in definitions, survey designs and study methods. It has been our experience that psychiatric conditions, and especially suicide risk, should be evaluated and treated as early as possible during the orthopaedic or surgical hospitalization. Management requires both psychopharmacological therapy and psychotherapy. It has to be directed towards the achievement of symptomatic relief and, if possible, towards the remission of the primary psychiatric disorder. The management of these patients in the orthopaedic or surgical ward is difficult, because of restlessness, noncooperation of the patient and the problem of staff inexperienced in handling the psychiatric patient. When prolonged orthopaedic and rehabilitation management is necessary, it is suggested that the patient be transferred to the psychiatric hospital while continuing the necessary orthopaedic treatment.
Carbon materials can be grouped into three classifications based on their period of advancement: classical carbons, nano ones and new carbons. Cracking carbons incorporate engineered graphite squares principally utilized as anodes, carbon blacks, what are more, enacted carbons, for which creation systems were created before [1] the 1960s. During the 1960s, carbon materials not quite the same as these great carbons were designed: carbon filaments from different forerunners, including fume developed carbon filaments; pyrolytic carbons delivered by means of concoction fume testimony forms; glasslike carbons with high hardness and gas impermeability; high-thickness isotropic carbons created by isostatic squeezing; intercalation mixes with various functionalities, for example, high electrical conductivity; and precious stone like carbons as straightforward carbon sheets. These recently evolved carbon materials are grouped as new carbons [2]. Since the 1990s, different fullerenes with shut shell structure, carbon nanotubes with nanometer distances across, and graphene pieces of just a couple molecules’ thickness has stood out from nanotechnology; these are ordered as nanocarbons.
On the off chance that these carbon materials are considered from the perspective of their surface, be that as it may, they might be ordered into two gatherings: nano-textured and nano-sized carbons [3]. Most carbon materials in the new carbon classification are delegated nano-textured carbon, in light of the fact that their nano texture is controlled by means of various procedures in their creation, notwithstanding the basic control. Then again, fullerenes, carbon nanotubes, and graphene can be delegated nano-sized carbon, the shell size of fullerenes, breadth of carbon nanotubes, and thickness of graphene, drops are on the nanometer scale [4]. Carbon blacks in great carbon are made out of nano-sized particles, yet they are not typically named nanocarbons since they have different applications as a mass, not as individual nano-sized particles [5].
Carbon, a basic chemical substance containing 6 as atomic number with 6 electrons tend to occupy s and p orbitals. It can able to undergo hybridization through three different forms such as sp/sp2 or sp3 means. Recent inventions of compact structured carbon materials such as fullerene [6], graphene [7], and carbon nanotubes [8] have envisaged prompt enquiries into this emerging field. Various physical properties of carbon nanotubes were mostly derived from base material (graphene). Such graphene involves the dense packing arrangement of carbon atoms in a regular sp2 pattern bonded to honeycomb based atomic scale structure and especially this pattern is most suitable as a primary structure for other sp2 materials [9]. Based on theoretical judgment, this CNT is explicitly distinct in the cylinder form fabricated of swirled up graphene thick sheet, which can delineate itself to single or multiple well. The single well nanotubes were known as single walled carbon tubes which were investigated during 1993 whereas multi-walled ones were found during 1991 itself [10].
CNTs have outstanding mechanical, thermal, electrical, and optical properties that are being used exclusively or in mix to deliver keen sensors or on the other hand multifunctional materials [11, 12]. They have high angle proportions that are perfect for long and persistent detecting. Their high surface region, for example, can be misused for storing materials to make half breed useful materials or functionalized to make cathodes for an assortment of uses [13]. CNTs are additionally known to display ballistic conductivity because of insignificant electron dispersing in their 1D structure with mean free-ways of the request of several microns [14, 15].
Mechanical strain may cause reproducible changes in the electrical properties of CNT filaments, making it conceivable to misuse them as electromechanical sensors [16, 17]. The partner changes incorporate inductance, capacitance, and obstruction which can be associated to the strain. Of incredible significance is that CNT filaments are receptive to elastic, compressive, flexural, and torsional strain [18].
The working standards of sensors produced using a CNT plainly visible get together incorporate difference in their electrical resistivity or obstruction because of mechanical strain known as piezoresistivity, change of their inductance and capacitance because of mechanical strain, change of their electrical resistivity because of variety in temperature known as thermoresistivity [19], change of their electrical obstruction because of variety in an attractive field known as magnetoresistance [20], and change in their electrical opposition with change of their mechanical thunderous recurrence because of variety of temperature, weight, mass, and strain [11]. The adjustment in conductance or obstruction is substantially more predominant than other variety in electrical properties. This is somewhat in light of the fact that charge transporters are handily isolated under simultaneous deformation prompting an expansion in obstruction. For extremely little strains, the total deformation has demonstrated to be flexible and the conductive system is completely recouped when the strain is evacuated, prompting an abatement in opposition [21]. Thus, the presented chapter highlights the synthesis details, associated properties and current applications of carbon nanotubes.
There are many methods to synthesize CNTs, but these three methods are most important and commonly used methods. They are as follows.
Chemical vapor deposition (CVD): CVD is a technique in which the vaporized reactants react chemically and forms a nanomaterial product that is deposited on the substrate Figure 1.
CVD method.
Sources for carbon: The precursor for carbon nanotubes are hydrocarbon gases such as acetylene, ethylene, methane, etc. [22].
Substrate used: Substrates are materials on which the CNTS are grown. The commonly used substrates in CVD method are zeolite, silica, silicon plate coated with iron particles, etc.
Catalyst used: To produce single-walled carbon nanotubes metal catalyst nanoparticles such as iron, cobalt, nickel, molybdenum, iron-molybdenum alloys, etc. are used.
Sources for CVD used: Based on the heating source, the CVD can be:
Thermal activated CVD which is heated by IR radiation, RF heater, etc.
Photo assisted CVD which is heated by Arc lamps, CO2 laser, Argon ion laser, Nd:YAG laser, etc.
Plasma assisted CVD which is heated by microwave radiation, etc.
Conditions maintained: The following conditions are maintained inside the furnace.
Temperature: 500–900°C.
Inert gas atmosphere: Argon gas.
CNTs are synthesized by thermal CVD method by using hydrocarbon gas as carbon source. In this method, a quartz tube is placed inside a furnace maintained at high temperature (500–900°C) heated by RF heater. A crucible containing the substrate coated with catalyst nanoparticles is placed inside quartz tube filled with inert gas such as argon gas. The hydrocarbon gas (carbon source) is pumped into the quartz tube which undergoes pyrolysis reaction and forms vapor carbon atoms. These carbon atoms bind to the substrate and join to eachother by Vanderwaal force of attraction and grow as multi-walled carbon nanotubes (MWCNTs) on the substrate [23]. To synthesize single-walled carbon nanotubes catalyst nanoparticles of Fe, Co, Ni are used. The obtained CNTs are further purified to get the pure form of CNTs.
Carbon nanotubes are synthesized by electric arc discharge method which is also called Plasma Arcing method.
Electrodes: Pure graphite rods (both positive and negative electrode). The positive electrode is adjustable from outside to maintain the gap between the two electrodes.
Diameter of electrodes: 5–20 μm.
Gap between electrodes: 1 mm.
Current: 50–120 amperes.
Voltage: 20–25 V.
Inert gas pressure: 100–500 torr (No CNT formed below 100 torr). Inert gas is used for cooling and condensation of atoms to form the CNTs. Inert gas determines the structure of carbons to be present in CNTS. Commonly used inert gas is helium gas.
Temperature: 3000–3500°C.
Reactor: It contains a quartz chamber which is connected to vacuum pump and a diffusion pump to inert gas supply. Initially the chamber is made vacuum by the vacuum pump and then the chamber is filled with helium gas by the diffusion pump [24].
In this method, a potential of 20–25 V is applied across the pure graphite electrodes separated by 1 mm distance and maintained at 500 torr pressure of flowing helium gas filled inside the quartz chamber Figure 2. When the electrodes are made to strike each other under these conditions it produces an electric arc. The energy produced in the arc is transferred to the anode which ionizes the carbon atoms of pure graphite anode and produces C+ ions and forms plasma (Plasma is atoms or molecules in vapor state at high temperature). These positively charged carbon ions moves towards cathode, gets reduced and deposited and grow as CNTs on the cathode. As the CNTs grow, the length of the anode decreases, but the electrodes are adjusted and always maintain a gap of 1 mm between the two electrodes. If proper cooling of electrodes are achieved uniform deposition of CNTs are formed on the cathode which is achieved by inert gas maintained at proper pressure [25]. By this method multi-walled carbon nanotubes are synthesized and to synthesize single-walled carbon nanotubes catalyst nanoparticles of Fe, Co, and Ni are incorporated in the central portion of the positive electrode. The obtained CNTs are further purified to get the pure form of CNTs.
Electric arc method.
Physical vapor deposition (PVD): PVD is a technique by which a material can be vaporized into gaseous form and then deposited on the surface of a substrate.
Target source: The most common carbon source target used is solid graphite which is irradiated by laser source and vaporized into vapor carbon atoms.
Laser source: Laser source used for vaporization of target material into target vapor atoms can be continuous laser source such as CO2 laser or pulsed laser source such as Nd:YAG laser (Neodymium doped Yttrium Aluminum Garnet, Nd:Y3Al5O12) .
Substrate used: The substrate used in this method is the water cooled copper collector on which the vaporized carbon atoms deposit and grow as CNTs.
Inert gas atmosphere: Argon gas is commonly used as inert gas which flows at a constant flow rate towards the water cooled copper collector.
Laser Ablation method is a Physical Vapor Deposition method in which graphite target is vaporized by laser source Figure 3. In this method the graphite target is placed at the center of quartz chamber filled with argon gas and maintained at 1200°C. The graphite target is vaporized by either continuous laser source or pulsed laser source. The vaporized target atoms (carbon) are sweeped toward cooled copper collector by the flow of argon gas. The carbon atoms are deposited and grown as CNTs on cooled copper collector. In case of continuous laser beam, the carbon atoms are continuously vaporized whereas in case of pulsed laser beam the amount of CNTs produced can be monitored as each shot of pulsed laser beam is directly proportional to the amount of carbon atoms vaporized [26]. By this method multi-walled carbon nanotubes are synthesized and to synthesize single-walled carbon nanotubes catalyst nanoparticles of Fe, Co, Ni are used. The obtained CNTs are further purified to get the pure form of CNTs.
Laser ablation method—schematic representation.
Pulsed Laser deposition is a thin film deposition technique in which the target material is vaporized by pulsed laser beam and vaporized target atoms are made to deposit on substrates Figure 4. The furnace contains a target at bottom and substrate mounted on the top. A pulsed laser beam from Nd:YAG laser source is made to strike the target to produce vaporized target atoms called the plume (plume is vaporized atoms at high temperature) [27]. The plume moves towards the substrate and it is deposited and grown as CNTs. Each shot of laser is directly related to the amount of material ablated, thus deposition rate can be controlled and calibrated.
Pulsed laser ablation method—Schematic representation.
The synthesized CNTs can be separated from the amorphous carbon, carbon nanoparticles, residual catalyst and other impurities by various methods. The conventional methods of purification are not very successful but methods like gas phase, liquid phase and intercalation methods show good results.
Gas phase purification of CNTs: In this method the CNTs are subjected to a high temperature oxidation followed by repeated extractions with nitric acid and hydrochloric acid. This procedure makes the synthesized CNTs purer and high stability with fewer amounts of residual catalyst and other non CNTs forms.
Liquid phase purification of CNTs: A series of steps are followed in the liquid phase purification of synthesized CNTs. They are:
Preliminary filtration to remove bulk graphite particles.
Dissolution in both organic solvents and concentrated acids to remove the fullerenes and catalyst, respectively.
Centrifugal separation of CNTs (Solid part) from the solution (containing impurities).
Microfiltration.
Chromatography to isolate multi-walled carbon nanotubes, single-walled carbon nanotubes, etc.
Intercalation purification of CNTs: In this method the nanoparticle impurities present are oxidized by metallic copper which acts as oxidation catalyst formed from the reduction of copper chloride added during the process. This process introduces intercalate residues and damage CNTs during oxidation process.
There are numerous mechanisms available to build up structures occluded with various characteristics. The sp2 nature of carbon hybridization constructs a layered pattern of arrangement with weaker plane bonding of Vander Waals forces at the outside and strong forces at inner plane bounds. Few numbers of concentric cylinders were equipped with regular spacing of interlayers that are located around central hollow section and demonstrated as multi walled CNTs Figure 5. In general, the real time spacing of MWCNTs contain interlayer spacing in range of 0.35–0.40 nm. The inner diameter of multi-walled CNTs can even range from 0.40 nm to few nanometers [28]. Outer diameter can exist up to 25 nm. The tips on both sides were closed and protruding ends were capped using dome shaped half width fullerene molecules. Axial molecules can exist up to few centimeters. The primary function of half width fullerene molecules is to aid in shutting down the tubes at both the ends. Whereas SWCNT can exist up to 4 nm. Length is up to micrometer range. Such arrangement is organized in a hexagon shape so as to develop a crystal [29].
Graphene to CNT.
Based on wrapping mechanism, three different forms of SWCNTs include chiral, armchair, and zigzag pattern. The single walled structure is primarily characterized by a set of indices (n and m) which describes the vector mechanism of chiral and absolutely it impinges an impact on electrical tendency of both nanotubes Figure 6. As a general predict, when n = m, these nanotubes are known as armchair ones and if m = 0, they are said to be zigzag and for other range as chiral pattern [30].
Different forms of SWCNTs.
The vector value of chiral mechanism can be determined using C = na1 + ma2, where a1 and a2 represent the base vectors of graphite cell and also used to evaluate the tube radius and moreover this vector function also estimates the rolling direction of graphene sheet. Hence, the radius of carbon nanotube can be estimated using.
where a takes the lattice parameter in graphite sheet.
Whenever n − m = 3 times of any value, it indicates the carbon nanotube to be metallic or extremely conducting nature and if it is not so, it can be semi-metallic type or a semi-conductor. At most of the times, armchair type can be referred as metallic one whereas all other forms can be denoted as a semi-conductor. Various involved parameters and vector representations [31] can provide an impinging impact on structure of CNT as follows.
chiral vector = na1 + na2> > (n,m)
Translational vector, T = t1a1 + t2a2 > > (t1, t2)
Chiral vector length, L = a(n2 + n.m + m2)1/2 a is constant of lattice parameter.
angle of chiral vector = (2n + m)/2*(n2 + n.m + m2)1/2
radius = L/2∏
Rotation angle, ᴪ = 2∏/N
vector of symmetry, R = pa1 + qa2
Such MWCNTs can be developed via two distinct models such as Russian doll and Parchment type model. If the diameter of outer CNT exceeds the inner tube, such a model is prescribed as Russian type model whereas, wrapping of a single graphite sheet to many a fold around itself constitutes the simple Parchment model. Both multi walled and single walled CNTs possess similar properties. Due to multi-layered arrangement of multi walled nanotubes, the outer portion not only cover the inner tubes from certain chemical reactions when contaminate with ambient substances but also exhibit greater tensile characteristics, which would be a drawback of single walled CNTs [32].
Owing to the presence of sp2 bonds available betwixt indigenous carbon atoms, CNTs possess higher tensile property compared to steel as well as Kevlar. such a bond exhibits more strength rather than sp3 bonding of diamond. Hence, SWCNTs possess maximum tensile property which may be nearly 100 times as that of steel [33].
An amazing feature of CNTs is its elasticity. Under maximum force and high pressure by exposing it to greater compressive forces along axial direction, it can even bend, kink, twist and ultimately buckle without causing any damage to CNT. Thus nanocarbon tubes can retain its original geometric structure. But sometimes, elasticity tends to cope up with a limit and hence under the influence of stronger physical pressure forces, it can even undergo a temporary deformation to form the nanotube shape. Few defects may weaken its structure which includes the atomic defects or else rearrangement developed on the carbon bonds.
The elasticity property for both single walled and multi walled CNTs is examined by the term known as modulus of elasticity or elastic modulus. Such property of multi-walled CNTs can be analyzed using transmission electron microscopy (TEM). Using such an apparatus, the researchers examine and investigate the molecular vibrations owing to thermal forces created at both edges of tubes [34].
As the atomic bond strength is high, CNTs not only withstand elevated temperature levels but also act as excellent thermal conductors. Hence under vacuum atmospheric pressure ranges, they are able to withstand 2900°C and nearly 800°C at normal pressure conditions. But the prevailing tube temperature and ambient environment may have an impact on thermal conductivity of carbon nanotubes [35]. The prescribed physical properties were outlined in Table 1.
Physical properties | Parameter | Range | References |
---|---|---|---|
Structure during equilibrium | Mean diameter | 1.3–1.5 nm | [31] |
Density | Zig zag (16,0) | 1.33 g/cm3 | [30] |
Armchair (10,9) | 1.32 g/cm3 | [30] | |
Chiral (12,5) | 1.41 g/cm3 | [32] | |
Lattice parameter | Zig zag (16,0) | 16.53 nm | [32] |
Chiral (12,5) | 16.53 nm | [33] | |
Arm chair (10,9) | 16.55 nm | [32] | |
Interlayer distance | Zig zag | 3.40 Å | [33] |
Chiral | 3.38 Å | [33] | |
Arm chair | 3.37 Å | [34] | |
Elastic nature | Young’s modulus | 1.0–1.27 TPa | [35] |
Tensile strength | About 100 GPa | [35] | |
Thermal property | Mean free path | Around 100 nm | [36] |
Thermal conductivity | Around 2000 W/m-K | [37] | |
Electrical behavior | Current density | 1015 A/m2 | [38] |
Conductance | 13.0 (K.Ohms)−1 | [38] |
Physical properties of CNTs.
Various types of indigenous single walled CNTs obtained using chemical vapor deposition technique onto a supporting chemical agent are mostly of semi-conducting nature (I type). Such nanotube type depicts the impact of field transistor (FET) nature at atmospheric conditions and these have been recently attaining greater interest and also achieved extensive exploration towards their application as nanoelectronic materials indulging logic circuit devices and electronic transistors. Such growing CNTs are seemed to be p-type containing doped holes with absolute hole depletion and reduced conductance values (100 kΩ to 1 MΩ) in specific to positive logic gate voltages. in the present context, it has been demonstrated that adsorption of molecular oxygen onto the CNTs is a contributing factor do drive the hole doping effect of SWCNTs. Oxygen removal can even lead to mere existence of semi-conducting nature. Instead, day by day investigations on CNTs reveals that the electrical properties of such carbon nanotubes are much sensitive to chemical doping impacts and charge transfer mechanism in spite of exhibiting extreme robustness [36].
The II type CNTs developed by CVD technique appears to be quasi metallic consisting smaller band gaps in the order of 10 meV. Such CNTs are not sensitive compared to semi-conducting type due to their electrostatic doping mechanism through gate potentials but exhibit a mere conductance dip occluded with that of smaller band gap. These CNTs origin towards a class of non-armchair single walled CNTs and band origin may be due to shift of sp2 to sp3 orbital hybridization which occurs prominently by the existence of non-flat hexagonal nature of tube walls. Quasi metallic types exhibit enhanced electrical conductivity at low temperature levels when subjected to temperature dependent experimental studies [37].
Even quantum interfering impacts were also being observed: (1) phonon acts as the basic scattering mechanism existing in single walled CNTs at ambient conditions and (2) excellent levels of ohmic frequency contacts can be proliferated in the nanotubes with a probability of adequate transmission T = 1 and 3 electron transfer is explicitly phase coherent along with ballistic ability in CNTs at even low temperature levels. This also suggest a lengthy mean distance for ballistic electron transfer in super quality CVD developed SWCNTs [39].
Schematic pattern of growth has been extensively used to obtain suspended CNTs in single wall across certain trenches along with normal nanotubes which may be electrically wired up with relative easiness. By manipulating a suspended CNT using an AFM probe while measuring its electrical conductivity, the impact of mechanical deformation on electrical characteristics of CNT can be judged. The wide scope of CNTs based on nanoelectro-mechanic (NEM) devices are invented to explore twisting pattern of single nanowires, pure stretching levels and also due to their high frequency characteristics of resonance measurements. Operated NEMs switches and accessible memory devices have also been envisioned in nearby future. Powerful control and deterministic mode of synthesis of CNT will further explore exciting opportunities and greater possibilities of finding novel nanomaterials and other devices [38].
SWCNTs are mostly inert in nature. The covalent attachment agglomerated the molecular species with fully bonded sp2 hybridization onto sidewalls of CNT proves to be complex. The adsorbed molecules onto CNTs through the development of non-covalent forces has evidently turned to be facile and consequently lead to possible effects on their physical properties and also with their potential applications. Desorption of orientation molecules from single walled tubes can be achieved by heating the nanotubes to higher temperature levels [40].
Similarly, illumination of UV light at low photon intensity forces a drastic molecular desorption rate from SWCNTs at even ambient conditions whereas, wavelength governing measurements predict that photo-desorption process may occur due to sudden excitation of electrons occluded in the nanotubes and perhaps it is a non-thermal process. The excitation of electrons in specific by ∏ plasmons included in SWCNTs due to UV light results in electron/hole pair formation which occur through Landau damping. The studies portray that surface and photochemistry problems are much predominant to exhibit properties and to create molecular nano surface wires that possess ultrahigh surface distribution with each and every atom accommodating onto the surface. Therefore, surface science study can be evaluated at single wire level itself by incorporating both chemical and electrical properties of CNTs as thin probes [41].
Carbon nanotubes have helpful assimilation, photoluminescence (fluorescence), and Raman spectroscopy properties. Spectroscopic strategies offer the chance of speedy and non-dangerous portrayal of moderately a lot of carbon nanotubes. There is a solid interest for such portrayal from the mechanical perspective: various parameters of nanotube union can be changed, purposefully or accidentally, to modify the nanotube quality. As demonstrated as follows, optical assimilation, photoluminescence, and Raman spectroscopies permit brisk and solid portrayal of this “nanotube quality” as far as non-rounded carbon content, structure (chirality) of the delivered nanotubes, and auxiliary imperfections. These highlights decide about some other properties, for example, optical, mechanical, and electrical properties [42].
Carbon nanotubes are novel “one-dimensional frameworks” which can be imagined as moved single sheets of graphite (or all the more accurately graphene). This rolling should be possible at various points and ebbs and flows bringing about various nanotube properties. The width normally fluctuates in the range 0.4–40 nm (i.e., “just” ~100 times), yet the length can shift ~100,000,000,000 times, from 0.14 nm to 55.5 cm [43]. The nanotube perspective proportion, or the length-to-breadth proportion, can be as high as 132,000,000:1 [44] which is unmatched by some other material. Thusly, all the properties of the carbon nanotubes comparative with those of common semiconductors are incredibly anisotropic (directionally reliant) and tunable.
While mechanical, electrical, and electrochemical (supercapacitor) properties of the carbon nanotubes are entrenched and have quick applications, the down to earth utilization of optical properties is yet muddled. The previously mentioned tunability of properties is conceivably helpful in optics and photonics. Specifically, light-discharging diodes (LEDs) and photograph detectors dependent on a solitary nanotube have been created in the lab. Their exceptional element is not the effectiveness, which is yet moderately low, however the limited selectivity in the frequency of discharge and recognition of light and the chance of its adjusting through the nanotube structure. What’s more, bolometer and optoelectronic memory gadgets have been acknowledged on groups of single-walled carbon nanotubes [45].
Crystallographic absconds additionally influence the cylinder’s electrical properties. A typical outcome is brought down conductivity through the flawed space of the cylinder. An imperfection in easy chair type tubes (which can lead power) can make the encompassing area become semiconducting, and single monatomic opening incite attractive properties.
The characteristic properties ascertained to CNTs are really enthusiastic. in the last decades, many research studies have proposed potential uses of CNTs and also have remarkably portrayed promising applications when such newly developed materials are joined together with typical scientific products, for example, nanorods production using such CNTs as reactive template materials.
Applications of CNTs encompass major fields and various disciplines, which include nanotechnology, medicine, construction, manufacturing, electronics, peripheral hardware, software and so on Figure 7. The mentioned applications can be considered: actuators, composites with maximum strength, energy storage as well as energy conversion equipment, media for H2 storage, nanosensors and probes, electronic instruments and process catalysis. Anyway the forthcoming sections will highlight detailed applications of CNTs in biomedical field. There are three parameters which may act as barriers before using CNTs in the fields of biotechnology and biomedical based industry. These barriers have to be overcome: toxicity, pharmacology and functionalization perspectives of CNTs [46].
CNT applications in biomedical field.
The most prominent barrier is toxic nature of CNTs. In general, the coexistence of maximum surface area rendered by CNT along with the intrinsic toxic nature of nano surface can become most important for the harmful impacts of aggregated nanoparticles. The toxic nature of CNTs can be influenced by the particle size of designed nanotubes. If the particles are less than a size of 100 nm, they are able to exhibit definite harmful effects such as enhanced potential hazard to the liver, lung, protein structure modification, escape from usual phagocytic powerful attacks, activation of immunological and inflammatory responses, and explicit redistribution strategy from their spot of tube deposition [47].
Another predominant barrier with CNT is the pharmacokinetics and bio-distribution of aggregated nanoparticles which are in-turn influenced by distinct physicochemical attributes such as size, shape, aggregation capacity, chemical composition, solubility of surface and effective fictionalization. Previously made studies have demonstrated that CNTs of water soluble nature are much more biocompatible with the inbuilt human body fluids and also do not show any toxic ill-effects or abnormal mortality [48].
The most notable disadvantage of CNTs is the lack of aqueous solubility when exposed to any media and in order to eradicate such a problem, surface modification is introduced on the carbon nanotubes, that is, stable fictionalization of surface with suitable hydrophilic substituents and reaction chemistries which can improve both aqueous solubility as well as biocompatibility of CNT [49].
Nanomaterials portray their chosen probability and thrusted promise in the field of regenerative medicine due to their extraneous physical/chemical properties. In general, the rejected implant materials which may be the cause for post administration implant pain and in order to avoid such rejection, nanotubes were attached to amino acids and to proteins, thereby achieved a promising development. Both the single and multi-walled forms can be effectively utilized as implants which may be either artificial joints or else other implant materials without any kind of host rejection output response. Perhaps, due to its unique material properties such as maximum tensile strength, these can effectively act as implant materials for bone substitutes and if suitably filled with calcium, such implants can be shaped or arranged within the bone structure [50, 51].
It has also been invented that proliferation and cellular adhesion can increase with the availability of SW and MW carbon nanotube composites and hence, these can be essentially integrated into natural nanomaterials and synthetic type materials to fabricate suitable nanocomposites. The specific type of CNT accustomed to artificial implants was represented in Table 2.
Type of CNT | Background materials | Properties | References |
---|---|---|---|
SWCNT impregnated | Chitosan type | Enhancement in cell morphology and growth | [50] |
SWCNT (pore type) | Membrane of polycarbonates | Increase cytoskeletal extensions | [51] |
SWCNT | Sodium alginate | Elevate proliferation | [51] |
MWCNT | Collagen type | Enhancement in cellular adhesion | [52] |
MWCNT | Poly-acrylic acid type | Improves cellular discrimination | [53] |
Nature of CNT in artificial implants application.
The scope of tissue engineering lies in the substitution of damaged tissue using biological alternatives that can possibly replace/repair original and normal function. The recent advances in the emerging fields of material science have been promisingly supported in the growth of tissue engineering and regenerative medicine [54].
CNTs can be recommended for use in the field of tissue engineering under four different perspectives. They are cell tracking/labeling, sensing cellular nature and mechanism, augmenting the mechanism and enhancing the tissue matrices. Cell tracking/labeling is the specific capacity to identify implanted cell structures and to record the noteworthy improvement of tissue growth in vivo as well noninvasively [52]. Labeling of transferred cells by implants not only permits the evaluation of engineered tissue viability but also promotes a deep understanding of migration, bio-distribution, movement pathways and relocation of implanted cells. The non-invasive techniques nowadays become more familiar than traditional techniques such as cytometry owing to more time consumption and practical challenges associated with handling of usage. Hence, CNTs can be more feasible as contrast imaging agents for optical resolution, magnetic resonance behavior and also for radio tracer simulating models [54].
One of the prominent applications of CNTs in the study of tissue engineering is its ability to bio-distribution measurement and also it can be systematically varied using radiotracers applicable to gamma scintigraphy. The proper design of engineered tissue structures enhances and promotes monitoring of cellular physiology that includes protein/metabolite secretion rate, enzyme and other cofactor interactions, cellular growth/mechanism and molecules/ions transport. Novel nanosensors will be effectively utilized in such a way to determine continuous monitoring associated towards the working performance of engineered tissues.
Numerous and popular features involved in the structure of CNTs envisage them to become key elements for nanosensing devices owing to its maximum surface area and DNA or protein immobilizing capacity along with electrical properties [53].
Moreover, these carbon nanotubes possess distinctive electronic structures make the invention of redox active proteins and also amino acids thereby rendering the cell monitoring activity in engineered tissue patterns. In another research, MWNTs were combined with that of platinum micro nanoparticles and also able to identify thiols such as prescribed amino acids which include glutathione and L-cysteine observations in rat.
The cell matrix predominates its function in tissue engineering. Even though, PLA and PLGA have been utilized for tissue engineering, they tend to adopt the inbuilt mechanical strength and cannot be just functionalized pertaining to controversial version of synthetic polymer compounds. Hence, CNTs have potential applications as tissue scaffolds and able to ascertain the structural reinforcement. The only demerit of CNTs is such that they are not biodegradable. When CNTs are dissolved in certain quantity of polymeric substance, rapid enhancement in mechanical strength has been promptly noted. If these MWNTs combine with chitosan material it may lead to advancement in properties whereas SWNT on blending with natural collagen improves the cell growth of smooth muscles [43].
Nanodevices have been investigated that has the effective potential to generate new techniques in cancer treatment, diagnosis as well as detection. The geometric structures of these nanomaterials may be very small (< 100 nm) such that the body will evacuate it rapidly so as to become more efficient either through detection or by imaging and thereby enter the damaged cells and organelles inside the body to have interaction with DNA or protein molecules. The possible detection of cervical cancer causing cells among human beings can be improved by carrying out modification on the graphene electrode using peptide form of nanotube folic acid [55].
As large quantity of cancer types is truly asymptotic throughout their initial stage and also due to absence of specific morphologic modifications among most of the neoplastic disorders in preliminary stage, possibly traditional cancer imaging and clinical methods such as X-ray, CT scan and even MRI scan does not require any kind of spatial resolution for such disease detection in initial stages. Imaging analysis using single walled CNTs have been explored for the past few decades. Coupling of radioisotopes with single walled CNTs along with imaging techniques based on radio nucleotides can progress advancement in tissue sensitivity, penetration as well as nano medium spatial resolution.
Many sophisticated protein biomarkers are available which are often overexpressed in the interior of cancer cells and they offer an entry mark for preliminary diagnosis, maintaining surveillance, prognosis, curative surgery techniques, advancement in disease monitoring therapy and finally detecting therapeutic response. Special categories of tumor biomarkers have been tremendously applied and also conceivably utilized in diagnosis and treatment of hepatocellular carcinoma, pancreatic, colorectal cancer, prostate cancer, ovarian tumor on epithelial cells which includes CA19-9 (carbohydrate antigen), carcinoembryonic antigen (CEA), alpha fetoprotein (AFP), human chorionic gonadotropin (hCG), carcinoma antigen 125 (CA125) and specific antigen to prostate (PSA) [27].
There are various interim obstacles associated with conventional application and administration of chemo-therapic agents which includes system toxicity, lack of proper sensitivity/selectivity, minimum solubility, poor cellular distribution, lagging of certain clinical procedures, and inefficiency of specific drugs to overcome the cellular barriers for achieving the treatment of multidrug resistive cancer disease. Scientists and research experts have conceptualized various drug handling/delivery systems to combat these terrific issues using silica nanomaterials, quantum dots, polymeric materials, dendrimers, liposomes, emulsions, micelles and even molecular conjugates [56, 57].
As discussed above Table 3, CNTs possess specific features such as ultrapure/maximum surface distribution, which essentially provoke them to act as a promising tool for drug delivery, nucleic acids and peptides. The selective drug or desired gene can be effectively coupled with tips and walls of carbon nanotubes and can easily trace out specific cancer causing receptors that are available on the cell structure and thereby such CNTs can even over cross the cell membrane of mammals through the mechanism of endocytosis or other plausible procedures. Thus, it can recognize the therapeutic drugs/genes much more reliably and safely in the affected cells that are reluctantly inaccessible during previous procedures.
Nucleic acid/drug-CNT type | Cell/tissue | Properties |
---|---|---|
Doxorubicin—SWCNT | Colon cancer | Efficient take up of cancer causing cells and then transfers to nucleus |
Radionuclide-SWCNT | Burkitt lymphocytes | Targeted tumor both in vitro/in vivo |
siRNA-SWCNT | Human neuro cells | Improves the working of siRNA assisted gastrin peptide receptor |
Toxic siRNA—MWCNT | Human lung system | Inhibits discrete tumor growth |
Cisplatin—SWCNT | Neuro Carcinoma | Tumor development—drastic recession |
Paclitaxel—SWCNT | Breast cancer | Improved efficacy in treatment with minimal effects |
Release of drugs from CNTs.
Recent discoveries of research experts paved the way to invent novel and efficient single walled CNT based drug delivery tool for targeting tumor which comprises of targeting ligands for tumor, drugs for anticancer treatment and also functionalized single walled CNTs. If such system has an interaction with cancer causing cells, it can provoke the receptor assisted endocytosis by identifying specific receptors to cancer cells onto the affected cell surface and perhaps specifically and efficiently release the active chemotherapeutic agents [58]. The release of drugs using CNTs were highlighted in Table 3.
In cardiology field, the CNTs are used for artificial valves to heart blocks, pacemakers, etc. These CNTs may be involved either as individual or in combined form to synthesize smart sensors and various multi-functional materials. They possess maximum aspect ratios that make the CNT to be extremely ideal for operating longer duration and of course continuous sensing. Their greater surface distribution shall be definitely exploited for providing material deposition in order to generate hybrid variety of functional materials or better functionalized to formulate different electrodes for certain applications [59].
CNTs are much prone to promote its ballistic conductivity which may occur owing to minimum scattering of electrons in their one dimensional solid structure containing mean free paths in the measurable range of tens to microns. The exerted mechanical stress/strain can even aid few reproducible changes acquainted with the electrical properties involved in CNT fibers, thereby felicitating it extremely viable to act as electro mechanical sensor devices. The occluded changes are noted as capacitance, inductance and electric resistance which can be directly correlated to the impact of strain Figure 8. Moreover, such CNTs are hugely responsive to compressive, flexural, tensile /torsional strain [60, 61].
Nanosensor schematic representation.
The working mechanism of sensors derived from a simple CNT macroscopic assembly inculcate the change of their electrical resistance or resistivity resulting from mechanical strain is said to be piezo-resistivity, change of its inductance/capacitance via mechanical strain, variation of its electrical resistivity with a plausible variation with temperature is said to be thermo resistivity and a magnetoresistance may result due to variation in electrical resistance which may be due to varying magnetic field is known as magnetoresistance [62].
Even electrical resistance change can occur owing to variation in mechanical resonance frequency thereby resulting change in temperature, mass, pressure and strain. In contrast, the simultaneous change in electrical conductance/resistance is most predominant than any other mild variation accustomed in electrical properties. This happens partially due to selective and simple separation of charge carriers under the influence of temporary/permanent deformation which may lead to certain elevation in resistance. For every minute strain effects, the deformation is shown to be extremely elastic and the electrically conductive mechanism can be completely withdrawn due to its associated strain removal and thereby leads to a deduction in resistance [63]. However, plastic deformation has been proved to be much different. Though the resistance approaches zero due to strain removal and hence hysteresis curve has been fully observed. The various sensors involved with such CNT fiber yawns were strain type, pressure sensor devices, chemical sensors, and even mass sensors.
Nanomaterials provide an enriched knowledge on distinct probability and also definitely sound well in biomedical regenerative therapy for its uniqueness owing to its excellent physical as well as chemical properties. Thus, CNT both in modified and purified type have a definite potential of establishing promising applications in wide sectors of scientific fields. Perhaps, the prompt impregnation of other substituents in carbon nanoforms would confirm its strong perspective for their enhancing biomedical applications and in general medicine. Still then, there exist questions on unsolved issues whereas proximate homogeneity of the selected nanomaterial contains extensive distribution of nanotubes radius, unlike its geometric structures, classification of nanotubes, trace inclusion of residual elements, and a marked sensitivity to different species and other toxic gases.
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