Category: Body

This essay is a cardiac case study for a patient ‘John Jones’ written for the bridging module of the Paramedic Science course. A case study aims to examine complex phenomena to increase understanding of them (Yin, 2003). With this in mind, this essay will explore the location, structure and function of the heart, describe the blood flow through the heart, and examine the complications when a disruption occurs in that blood flow. It will then analyze the risk factors associated with this patient and describe a management and treatment plan from an Emergency Medical Technician (EMT) prospective.

The cardiovascular system is very complex and unique. It’s main functions are to transport oxygen and nutrients to the body’s tissues, whilst removing waste products such as carbon dioxide, urea and creatine. It is responsible for hormonal control, regulation of temperature and acts as a host defense, this is all maintained by homeostasis (Pilbery & Lethbridge, 2016). It consists of the heart, blood, arteries, veins and capillaries (Walker & Parker, 2019).

The heart is a muscular, hollow, cone-shaped organ, which sits within the mediastinum, a region within the thoracic cavity that extends from the sternum to the vertebral column. It sits medial to the lungs and posterior to the sternum. The human heart weighs between 225 and 310 grams and lies in an oblique position, with two-thirds to the left of the body’s midline (Waugh & Grant, 2018). The hearts apex is located on the midclavicular line at the level of the fifth intercostal space (Caroline, 2008).

The heart has 3 layers, all of which have different functions. The epicardium is the outer most layer of the heart wall. Its thin serous membrane secretes serous fluid to lubricate the heart, preventing friction during contractions (Siegfried, 2002). The myocardium is the middle layer of the heart, which is made of cardiac muscle tissue. It’s responsible for pumping blood around the body under involuntary control (Pilbery & Lethbridge, 2016). The endocardium is the smooth, innermost layer of the heart, made of endothelial cells, which line the chambers and valves of the heart. The smooth surface helps to prevent blood from sticking and allowing normal blood flow through the heart (Siegfried, 2002).

The heart is divided into four chambers. The right side of the heart is divided from the left side by the septum (Walker & Parker, 2019). The heart has two superior chambers, atria, which are responsible for receiving blood from the veins and two inferior chambers, ventricles, which are responsible for pumping blood into the aorta and pulmonary artery (Walker & Parker, 2019).

The atria and ventricles are divided by atrioventricular (AV) valves. The right AV valve has three cusps (tricuspid valve) and the left AV valve (mitral valve) has two cusps (Waugh & Grant, 2018). Semilunar valves are located between the right ventricle and pulmonary artery (pulmonary valve) and the left ventricle and the aorta (aortic valve). These valves prevent backflow of blood during cardiac contraction (Waugh & Grant, 2018).

Each cardiac contraction is achieved by a sequence of electrical activity, causing the muscles within the four chambers to contract. The sinoatrial node is the pacemaker of the heart, and is located at the top of the right atrium. Here impulses are initiated causing the atrial muscle to contract. The impulse travels to the atrioventricular node, through the bundle of his, down both left and right bundle branch, through the purkinje fibers, causing the ventricles to contract (Walker & Parker, 2019).

As your heart contracts, deoxygenated blood from the systemic circulation enters the right atrium through the superior and inferior vena cava. As the right atrium contracts, blood passes through the right AV valve, into the right ventricle (Caroline, 2008). The cusps of the valves have fibrous cords called chordae tendinea, which connect to the papillary muscle, which are located within the ventricles of the heart, this prevents the valves from inverting during contraction (Siegfried, 2002). As the right ventricle contracts, it closes the right AV valve and blood is forced through the pulmonary semilunar valve, into the pulmonary circulation, through the pulmonary trunk. The semilunar valve prevents back flow in to the right ventricle. The pulmonary trunk splits into the left and right pulmonary artery, where deoxygenated blood is pushed into the lungs. Interexchange of gases takes place, where the carbon dioxide is removed and oxygen is reabsorbed (Caroline, 2008). The pulmonary arteries are the only arteries within the body to carry deoxygenated blood (Pilbery & Lethbridge, 2016). Oxygenated blood is returned into the systemic circulation through the four pulmonary veins into the left atrium. Blood passes through the left AV valve and enters the left ventricle (Siegfried, 2002). The left ventricle has a much thicker myocardium wall as it comes under extreme pressure whilst pumping blood around the body. Blood exits the left ventricle via the aortic semilunar valve into the aorta (Walker & Parker, 2019). Oxygen rich blood is pumped around the body, delivering oxygen and nutrients to the body’s cells, through the arteries, arterioles and capillaries (VanPutte et al., 2016). Once the body’s tissues have received it’s oxygen and nutrients, the capillaries pick up waste products and carbon dioxide, which travel back via the venules and veins to the heart through the superior and inferior vena cava. Skeletal muscle contraction and one way valves within the veins helps to achieve venous return (Siegfried, 2002).

The heart itself requires its own blood supply in order to function and survive, this is achieved by the right and left coronary arteries (Walker & Parker, 2019). The right and left coronary arteries branch off at the base of the ascending aorta and provide blood to both sides of the heart. Most of the venous blood is collected into several small veins that join to form the coronary sinus, a large vein at the back of the heart, which empties into the right atrium (Waugh & Grant, 2018).

As described above the blood supply and functions of the heart are very complex, but vital for life. One of the major issues that disrupts the main function of the heart is when the blood flow to the hearts arteries is reduced, preventing efficient oxygen and nutrient supply. This is known as a Myocardial Infarction or Heart attack (VanPutte et al., 2016). Lack of oxygen causes part of the tissue to die. The infarction can also disrupt the conduction system of the heart. Most commonly, the cause of artery narrowing is atherosclerosis (Siegfried, 2002). Atherosclerosis is the build up of fatty deposits within the walls of the arteries, which cause them to become thick, hard and lose elasticity (Walker & Parker, 2019).

There are a number of things that can increase your likelihood of having an MI. These are known as modifiable and non-modifiable risk factors. Modifiable risk factors can be changed, whereas non-modifiable risk factors can’t, but they can be controlled and their effect reduced by lifestyle changes (Heart.org). In the case of patient John Jones, there are a number of modifiable risk factors mentioned in his past medical history and social history, which suggest he has an increased risk of suffering an MI. Such as: –

Obesity

Obesity is characterized as excessive accumulation of body fat, with a body mass index greater than 30 being deemed obese (Walker & Parker, 2019). Obesity increases cardiac workload because the heart has to work harder to pump blood to all the additional tissues. This causes enlargement of the heart. Increased pressure in the vessels results in high blood pressure (hypertension). Hypertension causes arteries to lose their elasticity, causing narrowing, which decreases blood flow to the heart (Waugh & Grant, 2018).

Ischaemic Heart Disease (IHD)

IHD is the narrowing of the coronary arteries, caused by a build up of atherosclerosis, which develop slowly over time. Eventually, the arteries become so narrow, less blood and oxygen reaches the heart muscle (British Heart Foundation, 2020). There are several risk factors that can increase the risk of developing IHD, obesity, diabetes, smoking, all of which the patient has in his history. If the plaque breaks off, the artery can become occluded, causing an MI (Pilbery & Lethbridge, 2016).

Smoking

Smoking has a considerable effect on your cardiovascular system. Chemicals found in cigarettes damage the blood vessels and cause a build up of atherosclerosis, increases your risk of MI (British Heart Foundation, 2020).

Alcohol

Mr Jones is a heavy drinker who consumes 10 units per day. This amount over a long period of time increases the risk of heart disease, by weakening the heart, affecting its ability to pump blood around the body (alcohol.org).

Diabetes

Diabetes is caused by deficiency or absence in insulin, a peptide hormone produced by the beta cells within the pancreas. Mr Jones is type ii diabetic, a very common condition on obese patients (Pilbery & Lethbridge, 2016). The body’s inability to respond to insulin leads to chronic high glucose levels, this causes damage and narrowing to the blood vessels, reducing blood flow to the heart (Walker & Parker, 2019).

Evidence shows that the best possible outcome for a patient suffering ST-Elevation myocardial infarction (STEMI) would be direct admission to the Primary Percutaneous Coronary Intervention (PPCI) department through the STEMI pathway (Brown et al., 2019). As an EMT, I do not have direct access to this pathway. Delays in getting the patient to the most appropriate care could be detrimental to the patient’s outcome. Restoring coronary blood flow as soon as possible is essential (Brown et al., 2019). Evidence states STEMI patients would benefit from the following treatment.

In my current scope of practice as an EMT, I would be wearing appropriate personal protective equipment. I would make sure that the patient receives constant reassurance because he is showing sign of anxiousness. I would use distraction techniques and make sure that I explain exactly what I am doing and why. Once I have established the patient’s condition and findings, I would administer a single does of 300 milligram aspirin as soon as possible for the patient to chew, unless there are any known allergies (National Institute for Health and Care Excellence (NICE), 2020). I would also make sure the patient has not taken aspirin prior to our arrival (Pilbery & Lethbridge, 2016).

The patient complains of pain score of 8/10. It is important to do what I can within my scope of practice, to help relieve the pain. Paracetamol is not recommended for patients suffering chest pains (Brown et al., 2019). I would be able to offer the patient entonox, as per JRCALC guidelines (book of guidelines used by ambulance personnel). Entonox is used to treat moderate to severe pains (Brown et al., 2019). I would continue to closely monitor patient’s condition carrying out further observations, checking patient’s temperature and blood glucose levels (Pilbery & Lethbridge, 2016). I would update Clinical Contact Centre of patient’s condition, asking them to let me know if Paramedic back up becomes available.

The patient would be assisted to the Ambulance with limited movement, using a carry chair, the patient would also be assisted onto the stretcher. This will help reduce further strain on the heart. I would continue to reassure the patient, monitor patient’s vital signs, monitoring any changes to patient’s electrocardiogram (ECG), and continuously assess patient’s condition, also re assessing patient’s pain score. Defibrillator pads would be placed on the patient’s chest as two thirds of patients suffer a cardiac arrest before they reach hospital (Brown et al., 2019). I would closely monitor the patient’s oxygen levels, aiming for 94% or above. I would only administer oxygen if patient becomes hypoxaemic (Brown et al., 2019).

It is essential to undertake a time critical transfer to the nearest, most appropriate hospital, within my scope of practice. I would contact the emergency department (ED) with a pre alert using the ASHICE acronym. The patient would be driven as smoothly as possible under emergency conditions. I would continuously reassure and reassess patient’s condition on route and record patient’s details and vital signs on the patients clinical record (PCR). On arrival to the ED, I would give a full detailed handover to the receiving staff.

IHD is a serious condition caused by the build up fatty deposits within the coronary arteries, reducing blood supply to the heart. Mr Jones has many modifiable and non-modifiable risks, which have resulted in the patient suffering an MI. An adjustment to his lifestyle would help prevent a possible reoccurrence in the future.

References

1. Brown, S. N., Kumar, D. S., James, C., & Mark, J. (Eds.). (2019). JRCALC clinical guidelines 2019. Class Professional.
2. Caroline, N. L. (2008). Nancy Caroline’s emergency care in the streets (6th ed.). Jones and Barlett.
3. Pilbery, R., & Lethbridge, K. (2016). Ambulance care practice. Class Professional.
4. Siegfried, D. R. (2002). Anatomy and physiology for dummies. Wiley. VanPutte, C., Regan, J., & Russo, A. (2016). Seeley’s essentials of anatomy and physiology (9th ed.). McGraw-Hill Education.
5. Walker, R., & Parker, S. (2019). The human body book: An illustrated guide to it’s structure, function, and disorders. Dorling Kindersley.
6. Waugh A., & Grant, A. (2018). Ross and Wilson anatomy and physiology in Health and illness (13th ed.). Elsevier.

Introduction

Procrastination in time management is no stranger to the modern society. Statistics by Beswick, Rothblum & Mann, 1988; Gallagher, 1992; Rothblum, Solomon & Murakami, 1986 estimated that 40 percent to over 50 percent of students were procrastinating. ‘Procrastination arises from the Latin ‘pro,’ indicating ‘ahead, forward, either for,’ as well as ‘crastinus,’ meaning ‘future” (Klein, 1971). On that basis, procrastination actually means the postponement of a task by practice. ‘Postponing by itself is certainly not enough, since procrastination is not the only practice that has a delay aspect’ (Steel, 2002). There are other types of actions which trigger the time delay. For instance, shifting project A to a later point in time since task B is far more significant is not a procrastinating act, but instead a priority act. An action of procrastination is often a negative behavior that decreases work quality and reliability. This is a myth, and might not be valid.

Body

Character can be described as ‘the combination of traits or values that account the unique identity of an individual’ (Oxford, 2011). Many individuals are used to procrastination while others just do not. This shows that procrastination addiction is influenced by the character of an individual. One of the key procrastination reasons is the belief that this will not succeed. There’s a definition for this which is ‘Atychiphobia’, describing the fear of failure. ‘The higher the probability (real or imagined) of failure, the more likely it is that the person will feel depressed as he tackles the job. Speaking about the task provoking stress helps the procrastinator to initiate an alternative activity or diversion ‘(Aitkens, 1982). ‘Atychiphobia’ may be triggered by the procrastinator’s past history, which produced a stressful impact which causes the procrastinator to avoid those tasks and force them as late as possible to prevent the replication of the same experience. However, Schouwenburg (1992) tends to disagree by carrying out a research and finding that ‘fear of failure (Atychiphobia) and procrastination in the study as a whole are only slightly associated.’ Flett (1992) argues that the cause of procrastination should also be blamed for the ‘prescribed perfectionism.’ The justification of ‘prescribed perfectionism’ is strongly related to the fear of failure. As the performance of an individual enhances, so as well the probability of failure raises the fear of failure. There are three types of procrastination which are self-perfectionism in which we anticipate a certain level for ourselves, another perfectionism in which we set a new standard for others and socially prescribed perfectionism in which we assume others have set a standard for us. Surveys conducted out by Flett (1992) have shown that procrastination is linked only to prescribed procrastination. ‘As neuroticism (a behavioral or personality disorder not related to any known neurological or biological dysfunction) was correlated with fear of failure, it is linked with both low self-efficacy and low self-esteem’ (Ellist & Knaus, 1977). People with low self-esteem are often

ignored and therefore do not reach their full potential hence leading to an increase in failure rate. There is a growth in anxiety known as a ‘butterfly effect’ and the fear of not obtaining excellence. Many do not recognize their faith in getting the task accomplished which impacts their reactions to the job.

An individual’s mental stability may also cause procrastination. ‘Depression was connected to procrastination, also’ (Bestwick, 1988; McCown, Johnson & Petzel, 1989; Senecal, 1995). A person who is depressed is more prone to not be in the mindset to accomplish a particular task and thus inducing procrastination. According to Saddler & Sacks (1993), older students who experience low rates of depression, also experience low levels of procrastination. As student mature, the degree of maturity rises, and their ability to manage emotions improves as well. In addition, they shall also learn not to rely solely on feelings. Another mental-state related cause for procrastination is strength. According to Burka and Yuen (1983), if we are exhausted it will be more difficult to begin task. The word ‘tired’ may be described as power and strength loss. Technically speaking, executing any job without energy is impractical. A study done by Solomon and Rothblum (1984) revealed that as an origin of procrastination 23% students claimed that they did not have enough energy to start the job. And when they are tired, performing a task is frustrating and boring. And if they manage to complete it, the outcome would be low in quality. ‘One of the most interesting potential causes of procrastination is extraversion’ (Steel, 2002). Extraversion is described as being concerned with what is outside of the self. ‘Extraverts are focusing their psychic energy outward’ (Carl Jung, 1966). They’ll be charmed by the world around them. Extraverts tend to make people more creative. Unfortunately, this would be both a trigger and a method of procrastination. Energetic people will finish their mission as soon as possible and those who indulge in several tasks, on the other hand, will postpone it and procrastinate.

The act of procrastination practically speaking, affect results. This could be caused by excessive delay and shortened amount of time needed to perform tasks. Tice & Baumeister (1997) claims that, ‘whether a job is completed well before or just slightly before the deadline does not inherently affect the quality of the work.’ According to the analysis carried out by Steel (2002), the productivity of work completed by procrastinator is said to be improved upon reaching the deadline. Steel used the method of tracking the number of assignment accomplished in a day and time taken to finish it. On the other hand, the research carried out by Tice & Baumeister (1997) revealed that procrastinator has obtained lower grades than non-procrastinator in exams. The outcomes of both studies are mutually contradictory. This shows that there is not relationship between procrastination and performance. In addition, the outcome of procrastination varies among different individuals and different tasks.

In reality, some people perform better when deadlines are approaching and some people prefer to have plenty of time to complete any task. Another explanation why procrastinator could have lower grades might be that the procrastinator might have lower knowledge and less abilities than the non-procrastinator in the group has. However, Ferrari (1991) and Taylor (1979) have shown this theory to be wrong. Ferrari and Taylor maintained that there are no solid supports supporting Steel’s argument. Therefore, his point in this case is not really firm and ignored as the statement put forward by Tice & Baumeister is stronger. Procrastinator’s job will require compromises and sacrifices to reach the deadline. Tice & Baumeister’s study stands without a shadow of a doubt, and procrastination influences performance in a negative way.

In 1996 Tice and Baumeister have conducted a study on the health consequences of procrastination. The strategy they employed was to take as a study 60 student volunteers taking a course in health psychology. The due date for the assignment has been announced and they have been told that extension will be in case of submission failure. Participants were asked to fill in details on any health-care provider visit. It was concluded that ‘procrastinator may enjoy a safe, stress-free life when deadlines are far off, but when deadlines are impending they suffer more than others’ (Tice & Baumeiter, 1996). Around the start of the course, procrastinators appear to have better health, and at the end, poorer health. Students who do not procrastinate appear to have more health and emotional issues but have the job done as soon as possible. ‘There are also at least two important advantages of procrastination: reduced stress and decreased sickness’ (Tice & Baumeister, 1997). In other terms, procrastinators may not worry till last minute of their job and therefore have a calm mind and less tension. On the other hand, non-procrastinators think about their job as soon as they get the task and their mind is filled with worries and anxiety to complete the task thereby increasing their stress level and impacting their wellness. The tables are turned, as the deadline approaches. Procrastinators will experience higher levels of tension to finish the task in a rush while non-procrastinators will relax more as they have completed the task. ‘For procrastinators the overall impact of procrastination on stress is greater than for non-procrastinators’ (Tice & Baumeister, 1997). The advantages of procrastination are often balanced by the detrimental impact when the deadlines are closer. Completing a job is far more challenging when deadlines are approaching along with the raised stress levels. As a conclusion of Tice & Baumesiter’s (1997) study, procrastination act has a negative impact on the wellbeing of the procrastinator in the context of stress.

Conclusion

To conclude, procrastination does more harm than good. It is hard to avoid, because it is induced by the behavior of an individual. During the teenage stage, personality is developed and after entering adulthood it is almost difficult to alter. Parents and educators play the part of influencing an individual’s personality to avoid the habit of procrastination. Procrastination is also induced by the mental state of a person. To avoid stepping into procrastination, the person must be wise enough to regulate his or her anxiety and not let it interfere with their day-to-day work and mission.

As for the results, it has positive as well as negative effects. Negative effects therefore overpower the positive effect. The general attitude and perception that procrastination is a negative act and affects the quality of work, is true. While this argument has been confirmed, there are several special circumstances whereby procrastinators work best under stress and short time limits. As for safety, procrastinators face higher stress compared with non-procrastinators overall. To sum up, the act of procrastination is having a detrimental effect on most people and it’s hard but not impossible to stop.

Abstract

Anatomy is a field concerned with description of the body structures of living things. Gross anatomy refers to the study of the body structures that are large enough to be examined without the assistance of magnifying devices (1), those structures are as the muscles of the body. One of the essential groups of these muscles is The Adductor Group Muscles, five muscles are responsible for the adduction of the thigh, although several have additional functions. This group is part of the inner hip muscles and ranges from the lower pelvic bone to the femur and knee region so lying in between the extensor and flexor group of the thigh muscles. The hip adductors shape the surface anatomy of the medial thigh, most of them are supplied by the obturator nerve and reaches the adductors through the obturator canal.

Introduction The muscles of the body that moves the skeletal system are under voluntary control, and that are responsible of the movement, posture, and balance of the body. (2) There are five muscles of the adductor group are responsible for the adduction of the thigh (Gracillis ,Pectineus, Adductor Longus, Adductor Brevis and Adductor Magnus).They pull the thigh towards the center of the body. All except the pectineus, that is innervated by the femoral nerve and a part of the Adductor Magnus which is supplied by the Sciatic Nerve are innervated by the obturator nerve. ( 3 )

Gracilis is the most superficial the adductor group muscle. Crossing both the hip and knee joints, originates from the pubis and attaches to the tibia. It Adducts the thigh at the hip, and flexs the thigh at the knee.

Pectineus is a flat quadrangular muscle, attached above the pectineal line of the pelvic bone and descends laterally to attach to the oblique line that extendes from the lesser trochanter base to the linea aspera on the posterior surface of the proximal femur, the pectineus passes through the thigh under the inguinal ligament and makes up a part of the Femoral triangle. It adducts and reflexes the thigh at the hip joint and is supplied by the femoral nerve.

Adductor Brevis lies behind the Pectineus and Adductor Longus. It is a triangular muscle attached at its apex to the pubis body and inferiorly to the Pubic Ramus, superior to the origin of the Gracilis Muscle.Adductor Brives is attached by its base via an aponeurosis to a vertical line, it extends from lateral to the Pectineus insertion into the upper part of the liinea aspera lateral to the Adductor Longus attachment.

Adductor Longus is a flat fan shaped muscle that originates from a triangular area on the external surface of the pubis inferiorly to the pubic crest and lateral to the pubic symphysis it decends posteriolaterally to insert into the middle third of the linea aspera. The Adductor Iungus shares in the floor of the Femoral Triangle, and its medial boder mades up the medial border of the Femoral Triangle. This muscle forms the proximal posterior wall of the adductor canal too. The Adductor Longus adducts the thigh at the hip joint and medially rotates and it is supplied by the anterior division of the obturator nerve.

Adductor Brevis lies behind the Pectineus and Adductor Longus. It is a triangular muscle attached at its apex to the pubis body and inferiorly to the Pubic Ramus, superior to the origin of the Gracilis Muscle. Adductor Brives is attached by its base via an aponeurosis to a vertical line, it extends from lateral to the Pectineus insertion into the upper part of the liinea aspera lateral to the Adductor Longus attachment. It adducts the thigh and medially rotates it at the hip joint and supplied by the obturator nerve.

Adductor Magnus is the largest and deepest muscle in the medial compartment of the thigh. The muscle makes up the distal posterior Adductor Canal wall. Like the Addutor Longus and Adductor Brevis muscles. The Adductor Magnus is a triangular muscle. Its apex attached to the pelvis and its base expanted to attach to the femur on the pelvis. The part of the muscle that originates from the Ischiopubic Ramus expands laterally and inferiorly to attach to the femur. This lateral part is known as the “Adductor Part” of the Adductor Magnus. The medial part of this muscle is called the “The Hamstring Part”, originates from the ischial tuberosity and extends vertically along the thigh to insert into the adductor tubercle on the medial condyle of the head of the distal femur via a rounded tendon. It inserts into the medial suoracondylar ridge. The Adductor Magnus adducts the thigh at the hip joint and medially rotates it. The adductor part of the muscle is supplied by the obturstor nerve and the hamstring part is supplied by the tibial division of the sciatic nerve.

References

1. Contributor:The Editors of Encyclopaedia Britannica Article Title:Anatomy Website Name:Encyclopædia Britannica Publisher:Encyclopædia Britannica, inc. Date Published:September 26, 2018
2. Contributors:Robin Huw Crompton, Bernard Wood and Others Article Title: Human muscle system Website Name: Encyclopædia Britannica, inc. Date Published: April 26,2018
3. Gray’s Anatomy for Students Textbook by Adam W. M. Mitchell and Wayne Vogl Pages (581, 588, 589)
4. Anatomy of the lower limb by staff members of anatomy and embryology department, Faculty of Medicine KFS University.

Hemoglobin is a protein produced in the bone marrow that is stored in erythrocytes which carry oxygen throughout the body. The main function of erythrocytes is the transportation of oxygen to the body’s cells to enable cellular respiration to occur. 97% of the oxygen carried by the blood from the lungs is carried through hemoglobin, whilst the remaining 3% is dissolved in the plasma. Hemoglobin allows blood to move 30 to 100 times more oxygen than that dissolved in the plasma. In the lungs, hemoglobin physically bonds with oxygen due to the high levels of present oxygen within the organ.

The Structure of Hemoglobin

Hemoglobin consists of a heme molecule and a globin protein. The globin is an example of a globular protein present in a quaternary polypeptide structure. Globular proteins are multiple chains of polypeptides that are soluble in water with a spherical shape. The spherical structure of the globular proteins enables them to carry out synthesis, transportation, and metabolism within cells. Hemoglobin consists of 4 polypeptide subunits: 2 alpha chains and 2 beta chains. The genes for hemoglobin are found in chromosomes 11 and 16. DNA helicase unwinds the DNA double helix structure to enable the production of an mRNA as the first step of transcription. During the process of translation, the mRNA determines the sequence of the amino acids of the globin protein. The end result of the protein synthesis is 4 chains of proteins are produced, which can each hold one iron atom. Each iron atom binds with one molecule of oxygen. This increases the efficiency of oxygen transportation, as one hemoglobin can hold 4 oxygen particles in the area of the body for essential cellular respiration.

Protein Synthesis of Hemoglobin

The heme portion of the hemoglobin synthesis occurs in the mitochondria of the immature erythrocytes. δ-aminolevulinic acid (ALA) is formed as a result of the condensation of glycine and succinyl-CoA in the mitochondria. ALA then once produced enters the cytoplasm, in which porphobilinogen is formed through a chain of chemical reactions to hence produce coproporphyrinogen. Coproporphyrinogen re-enters the mitochondria where it undergoes additional reactions to become protoporphyrin. This then combines with an iron molecule to form heme. Globin synthesis of alpha and beta chains and their structure is given by the genes found on chromosomes 16 and 11. The 4 polypeptide globin chains are in pairs, exhibiting the formation of a tetrameric molecule in which the globin chain is covalently bonded to a heme molecule. The tetramer is an ellipsoid structure whilst being 550 nm in diameter. A normal alpha chain is composed of 141 amino acids, in comparison to a beta chain which consists of 146 amino acids.

Variations of Hemoglobin

There are 3 types of normal hemoglobin variants: hemoglobin A (HbA), hemoglobin A2 (HbA2), and fetal hemoglobin (HbF). HbA, known as adult hemoglobin, is the most common human hemoglobin tetramer. It consists of 2 alpha chains and 2 beta chains. HbA2 is a normal variant of hemoglobin A that consists of 2 alpha and 2 delta chains. HbF is the main oxygen transport protein in the human fetus during the last seven months of development in the uterus and persists in the newborn until roughly 2-4 months old. HbF consists of 2 alpha and 2 gamma chains. The level of HbF drops after 1-2 years of the child’s birth and reaches the adult level. HbF levels can become elevated in several congenital conditions. Its levels can remain the same or become increased in beta-thalassemia and sickle cell anemia.

There are 5 common hemoglobin variants: hemoglobin S (HbS), hemoglobin C (HbC), hemoglobin E (HbE), hemoglobin H (HbH), and hemoglobin Barts. Although, prior to understanding the different variants of hemoglobin, a distinguishment between signs and symptoms must be established. A sign may be defined as evidence of a condition as discovered or elicited by a practitioner while examination of the patient. However, symptoms are things that a patient complains about regards of. This is helpful in understanding why the detection of certain variants of hemoglobin is difficult as some conditions are asymptomatic. Asymptomatic is the lack of presence of symptoms of a condition in an infected individual.

HbS is a mutation occurring on the beta chains. HbS is a primary hemoglobin in people who have sickle cell anemia. A heterozygous gene mutation of sickle cell is called sickle cell trait and is usually asymptomatic unless combined with another hemoglobin mutation. A homozygous mutation in the cell genes results in a sickle cell disease. The presence of HbS makes the red blood cells deformed, resulting in a sickle shape when exposed to a low-oxygen environment. A low-oxygen environment example includes intense exercise and sickness. Sickle cells block the small blood vessels during the time of low oxygen, causing pain and impaired circulation. The cells result in a decreased cell lifespan this is called a sickling crisis. The patient who suffers from it will usually encounter symptoms such as abdominal pains, back pain, and knee pain. In individuals with increased levels of hemoglobin F in whilst having sickle cell anemia the condition may be reduced and become milder as the affinity of hemoglobin F inhibits sickling of the red blood cells.

HbC is a mutation occurring on the beta chains, similar to that of HbS. A heterozygous mutation of a gene for HbC is the most common form of HbC. However, a homozygous gene mutation for HbC is rare and relatively mild. It usually causes a minor amount of hemolytic anemia and a mild to moderate enlargement of the spleen. Hemolytic anemia is a condition in which red blood cells are destroyed and removed from the bloodstream before their normal lifespan is over.

HbE is one of the most popular beta chain variants in the world. People who are homozygous for HbE generally have mild hemolytic anemia. The individual will possess microcytic red blood cells and mild enlargement of the spleen. A heterozygous mutation for HbE is usually asymptomatic unless is combined with another hemoglobin abnormality such as beta thalassemia trait. HbH is a type of Alpha Thalassemia caused by impaired production of alpha globins. It is composed of 4 beta chains and is produced in response to a severe shortage of alpha chain production. The tretrema of the 4 beta chains do not function normally. It has an increased affinity to oxygen, holding on to it instead of releasing it to the tissues.

Hemoglobin Barts is an abnormal type of hemoglobin that consists of 4 gamma globulins. It is produced as a result of a shortage of alpha chain production. It has an extremely high affinity for oxygen, resulting in almost no oxygen delivery to the tissues.

There are many other variants, some of which are silent, causing no symptoms or signs, while others affect the functionality and stability of the hemoglobin molecule. Examples are hemoglobin D, hemoglobin G, hemoglobin J, hemoglobin M, and hemoglobin constant spring. The most common example of silent variants is that of hemoglobin constant spring. Hemoglobin constant spring is a variant of hemoglobin in which a mutation in the alpha globin gene produces an alpha globin chain that is abnormally long. It is the most common non-deletional alpha-thalassemia mutation associated with hemoglobin H disease.

The Effect of Hemoglobin on the Human Body

The normal concentration of HbA is 15.5 grams per deciliter of blood in males. In females, the normal concentration is 14 grams per deciliter of blood. Females tend to have lower hemoglobin concentration due to their menstruation. There is a variation of the concentration of hemoglobin within populations varying from low to increased hemoglobin count.

Low hemoglobin count is called anemia and is defined as hemoglobin less than 13.5 grams per deciliter for men and less than 12 grams per deciliter for women. Anemia is caused by a variety of conditions that a person may be affected by. A mild decrease in hemoglobin count can be asymptomatic. Symptoms of low hemoglobin count are tiredness, pallor, shortness of breath, and palpitations. Untreated low hemoglobin count can be serious leading to serious problems like heart failure.

Increased hemoglobin concentration is called polycythemia and is defined as hemoglobin greater than 18.5 grams per deciliter for men and greater than 16.5 grams per deciliter for women. The types of polycythemia can be primary, which means that there is no obvious cause, and it is called polycythemia vera, or secondary to decreased oxygen concentration, such as high altitude or chronic lung conditions. High hemoglobin concentration can be as serious as low hemoglobin concentration as it can lead to blood clots due to increased blood viscosity, causing strokes and heart attacks. Polycythemia can be treated with low-dose aspirin to decrease the viscosity of the blood.

Conclusion

In conclusion, the analysis of the function of hemoglobin aims to highlight the importance of its variants’ effects on the functioning of the body. The investigation displays the importance of protein synthesis from the perspective of cellular respiration. High or low hemoglobin count contributes to serious conditions in individuals who have it. The hemoglobin molecule is constructed by a heme and a globin protein, which is synthesized separately and then combined in the mitochondria. Protein synthesis produces 2 beta chains and 2 alpha chains, which each hold an iron molecule to enable the transportation of oxygen to the body for sufficient cellular respiration to occur.

Bibliography

1. Wiwanitkit Viroj. (2008). Single Amino Acid Substitution in Important Hemoglobinopathies Does Not Disturb Molecular Function and Biological Process.
2. DAVID W. E. SMITH & M.D. (1980). The Molecular Biology of Mammalian Hemoglobin Synthesis.
3. Clancy, S. (2008). Genetic Mutation.
4. Bernard G. Forget and H. Franklin Bunn. (2013). Classification of the Disorders of Hemoglobin.
5. Richard Schweet, Hildegarde Lamform & Esther Allen. (1958). The Synthesis of Hemoglobin in a Cell-Free System.
6. Alain J. Marengo-Rowe. (2006). Structure-Function Relations of Human Hemoglobins.
7. Ou Z., Li Q., Liu W. & Sun X. (2011). Elevated Hemoglobin A2 as a Marker for β-Thalassemia Trait in Pregnant Women.
8. ‘Hemoglobin: Molecular, Genetic, and Clinical Aspects’. Bunn and Forget, Saunders, 1986.
9. UCSF Medical Center. (2018). Hemoglobin and Functions of Iron. The Regents of The University of California.

This essay will describe the structure, function, and interrelationship of one of the body’s major systems, the endocrine system, and illustrate its malfunction and associated causes, symptoms, and treatment.

A sporadic network across the body, the endocrine system, consisting of glands and organs with no physical connections, produce and secrete chemical messages called hormones. The term hormone, derived from the Greek word ‘hormao’, meaning ‘I excite’, refers to each hormone exiting or stimulating a particular part of the body or target gland. The endocrine glands comprise groups of secretory cells surrounded by an extensive network of capillaries that transport and diffuse hormones in the bloodstream to specifically targeted tissues and organs to regulate and control a wide range of bodily functions, such as respiration, metabolism, reproduction, sensory perception, movement, sexual development, and growth.

The major hormone-producing glands are the pituitary gland, situated in a hollow behind the bridge of the nose, the sella turcica, and attached to the base of the brain, which produces the hormones that cause growth and, considered the ‘master control gland’, controls other glands, including the adrenals, producing cortisol, thyroid gland, producing thyroxin, and the sex glands, ovaries, and testes. The pineal gland, producing melatonin, affects sleep and regulates the body’s circadian clock, however, this gland is not fully understood. The hypothalamus, situated on the underside of the brain, is responsible for homeostasis, regulating bodily temperature, moods, hunger, thirst, and sex drive, and dictating the discharge of hormones from other glands. The hypothalamus produces an anti-diuretic hormone to aid water reabsorption in the kidney and oxytocin, which is vital to aid breastfeeding. The parathyroid gland, producing the parathyroid hormone, controls the amount of calcium in the blood, which is vital for nerves and muscles to remain effective and bones to remain strong. The thyroid, butterfly-shaped and located in the neck, produces thyroxin, thyrocalcitonin, and triiodothyronine, hormones responsible for metabolism and heart rate digestive functions, brain function and development, muscle control, and maintenance of bones. The pancreas, found in the abdomen, controls blood sugar levels by producing insulin and glucagon. Producing hormones essential for a healthy life, the adrenal glands, triangularly shaped and found situated at the top of both kidneys, produce androgens and estrogens that control sex, aldosterone to balance the salt in the blood, and cortisol to balance sugar, proteins, carbohydrates, fats, suppress inflammation and regulates blood pressure. Catecholamines or adrenaline-type hormones such as epinephrine, also known as adrenaline, and norepinephrine, otherwise known as noradrenaline, produced by the adrenal medulla, are essential to the body’s fight or flight response. Present solely in the female body, the ovaries secrete the female sex hormones, estrogen, testosterone, and progesterone. Present only in the male body, the testes produce the male sex hormone, testosterone, and are responsible for sperm production. The kidneys, an organ with a secondary endocrine function, produce erythropoietin, a hormone responsible for the regulation of red blood cell production. Hypoxia, which can result from, for example, low blood flow, low blood volume, anemia, or lung disease, is the major stimulus for increased erythropoietin production to raise oxygen levels and restore homeostasis.

For a hormone to affect a target cell, one of two main mechanisms must take place. In the first, non-steroid action, amino acid derivative hormones such as melatonin, or peptide hormones, for example, oxytocin, cannot cross the target cell membrane freely and so bind to specific receptors on the cell surface where they cause an intercellular signaling cascade. The second type, steroid action, see lipophilic lipid and steroid hormones, pass freely through the membrane and bind to receptors inside the cell or move into the nucleus. Both hormone actions set in motion a negative feedback mechanism that persists until homeostasis is restored.

Negation of normal or optimal hormonal range is established with negative feedback mechanisms that prevent sudden, serious changes in homeostasis. One physiological variable, core temperature, can be used to exemplify the three basic components of a system control maintaining homeostasis. The detector, nerve endings in the skin, detect a temperature decrease or increase from the normal, around thirty-seven degrees Celsius, then relay this information to the system control, the hypothalamus gland, leading to the activation of the mechanisms that control temperature, the effector. Examples of this mechanism or effector are reducing blood flow by narrowing blood vessels to prevent heat loss or, conversely, behavioral changes, such as jumping up and down to warm the body. Once the normal temperature has been re-established and the stimuli ceased, signals to the hypothalamus stop, and homeostasis is achieved.

A rare and lifelong condition, congenital hypothyroidism, is a malfunction of the endocrine system resulting from an under-developed, absent, or malfunctioning thyroid gland whereby the body cannot produce thyroxine and triiodothyronine, which are essential for brain development in infancy and typical growth in childhood and adolescence. A homeostatic level of thyroxin is also essential for the rise in sex hormones responsible for puberty. Congenital hypothyroidism, tested for in all newborns at five days old, sometimes called a ‘heal prick’ test or ‘Guthrie’ test, takes a small blood sample from the heel and is sent for analysis in a laboratory. This test also checks for eight other serious conditions: phenylketonuria, sickle cell disorders, cystic fibrosis, medium-chain acyl-CoA dehydrogenase deficiency, maple syrup urine disease, isovaleric acidemia, glutaric aciduria type one and homocystinuria. According to Great Ormond Street Hospital, “in around one in every 3500 newborns have congenital hypothyroidism”, which is less common in boys than girls, however, science is yet to discover why (GOSH, 2015). After the heel prick test, the child will undergo a nuclear medicine thyroid scan, using a small amount of radioactive iodine to obtain a picture of the thyroid to determine its function and confirm a diagnosis. Whilst most cases of congenital hypothyroidism are diagnosed very early and before any symptoms are apparent, they may present as jaundice, feeding difficulties, constipation, lethargy, cold extremities, low muscle tone, and poor growth. If diagnosis and treatment are not carried out almost immediately after birth, the child may display developmental delays, learning difficulties, and clumsiness.

Managed by a pediatric endocrinologist, treatment with the drug levothyroxine, a synthetic thyroid hormone (T4), is prescribed, with dosage calculated based on the weight of the child, and regularly assessed with blood tests to measure thyroid-stimulating hormone. The patient is prescribed levothyroxine (T4), a manufactured thyroxine substitute, as it is needed for the body to produce triiodothyronine (T3).

Summing up, the endocrine system, with its homeostatic mechanisms of a receptor, control system, and effector, maintains the stability of physiological functions such as metabolism, sensory perception, growth, respiration, body temperature, and sexual development. These homeostatic mechanisms ensure physiological equilibrium, however, if malfunctioning, as with congenital hypothyroidism, medical intervention is required.

A cell is the principal unit of a living organism. Even bacteria, which are very small, singly-living creatures, have a cellular structure. Each bacterium is a single cell. All living structures of human anatomy carry cells, and almost all functions of human physiology are executed in cells or are started by cells.

A human cell mostly comprises workable membranes that surround cytoplasm, a water-based cellular fluid hand in hand with a difference of tiny working units called organelles. A tissue is a class of cells ordered jointly for a certain purpose to shape tissues. Epithelial, nervous, muscle, and connective are the main principles types of human tissues. Epithelial tissues shelter the outside of a body, also the backing of the organs. Muscle tissues permit movements. Nervous controls electrical impulses and direct signals toward the body.While connective tissues support and protect the body. The following are found in the human body. Bones, cartilage, and blood are connective tissue. An organ is made up of two or three tissues that work hand in hand to perform a certain function. Each organ performs one or more particular functions. An organ system is a group of organs that work for hand in hand to carry out vital functions or meet the physiological demands of the body. Almost all organs contribute to more than one system.

The organism level is a high-rise level of organization. An organism is a living being that has a cellular structure and that can alone carry out all physiological roles essential for life. In multicellular organisms, as well as humans, all cells, tissues, organs, and organ systems of that work hand to hand to keep the life and health of the organism.

For example, the spine is deep in the body, the brain is deep to the skull, and muscle is deep compared to the skin, the lung is deep to the rib cage backbone. I understood that structure and function are related to the organ systems of the body during my research. From my understanding Anatomy centers on the structures that form the human body and physiology is the study of the function of organs and organ systems.

The cells in complex multicellular organisms like people are organized into tissues, groups of similar cells that work together on a specific task. Organs are groups of tissues organized that carry out a particular function and groups of organs with related functions make up the different organ systems.

From left to right: single muscle cell, multiple muscle cells forming tissue, organ are muscle tissue (bladder), organ system are kidneys, ureter, bladder, and urethra.

Cells, tissues, organs, and organ systems – structures are jointly related to function. The heart gives back its task of pushing blood throughout the body, while the lungs expand the competence in which they can take up oxygen and let go of carbon dioxide.

The human skeleton has 206 bones and the bones of the human skeleton are; the skull, shoulder, girdle, hand, chest, spine, pelvic, girdle, leg, ankle, and foot. The Joint is where two bones meet. Most are flexible permitting the bone to move.

We have Immovable (synarthrosis) examples of the bone of the skull. Slightly movable (amphiarthrosis) allows for some movement example is the spinal segments. Freely movable (diarthrosis) or synovial joints examples are hip, knee, and shoulder.

The structure in relation to its function in terms of protection. The skeleton shelters organs and brings down the chance of injury on impact. For instance, the ribs shelter the heart and lungs, cranium shelters the brain. It is the skeleton that supports our body in the right shape. It permits movement of the body. The bones shape joints and take action as a lever permitting muscles to drag on them to make a movement. Skeleton gives exterior for fitting of muscles.

Injury is damage to the body. Pulled muscles are a situation when one of your muscles straightens far away from its dimension in an unexpected way. To diagnose it, a physical examination will be asked by the doctor about the history, and also X-ray may be carried out to make sure that the bone is not broken. Knee injuries are another common injury that ranges from force to pull apart in the muscles or tissues in the knee. To diagnose a knee injury, the doctor will examine it for swelling, visible bruising, and tenderness, check also how far you can walk, pull the joint to judge division fractures. Your doctor may recommend a test like an X-ray, Computerized tomography (CT) scan can aid in diagnosing problems.

Heart disease is one of the common illnesses and happens when your heart or blood vessel is not working very well. The heart pumps blood down the body through veins and arteries. To diagnose heart diseases like Coronary heart disease, doctors will ask the medical family history, check your blood pressure and blood test to check your cholesterol, electrocardiogram (ECG), assist in reading your heart’s electrical impulses. Tiny dots and wires are placed on your chest, arms, and legs then attached to an ECG machine which accounts for the electrical impulses and copies them out on paper. A blood test can be carried out to know the level of other substances in your blood and also to know the level of injury. Stroke, another type of disease that happens when blood flow to the brain ceases, minutes without food and oxygen from your blood, damage begins to occur in the cerebrum. Treatment rests on the type of stroke, the doctor may use head CT( computed tomography) or MRI to assist diagnose the condition, and to improve observation, CTA (CT angiography) may be carried out.

The book The Survivor: An Anatomy of Life in the Death Camps by Terrence Des Pres, tells the psychological story of those who lived in death camps, during the holocaust. Terrence Des Pres shows many literary depictions of how one survived through testimonials, other fictional work and scientific research. Des Pres discuss how being a survivor is similar yet different to those of martyrs or heroes, as a survivor has no choice in which way they die. To be a survivor one must pull themselves through a challenge they did not want to be placed in in the first place. Living each day under new circumstances, circumstances that have become the new normal. This book and the material we have gone through in class has opened my eyes to see what living is really about. Yes, the class is “death and dying” and yes, we had many discussions about dying and death, but the ultimate lesson I have gained is that when you get to a point of dying or face death what truly matters is how you lived or how you will begin to live.

When looking at the qualifications it takes to write a book about the holocaust, specifically life in a death camp, many would say you had to be there to truly understand. For Des Pres, I believe, he meets a minimum qualification for writing on such a topic without actually being a survivor of a death camp. Des Pres was a professor of English literature at Colgate University, specifically teaching on holocaust literature, he also was considered a holocaust scholar, meaning he had a great depth of knowledge surrounding the holocaust it’s research, studies and literature pertaining to. These many details of Terrence Des Pres lead me to believe he was qualified to write such an impactful book without the necessary requirement of living through the tragedy. Not only did Des Pres write about this specific topic he also wrote a book relating to poetry and how it is used for survival, which shows a passion for writing on such an abstract concept such as survival.

Des Pres starts this book with the fictional accounts of survival, and how people view and understand what it is to survive. He brings in other novels that create an image for the reader to understand the difference between living and dying and surviving. Imagery used to show how one being killed after being wrongly accused seems to show that the blame did fall on them or that doing everyday task take on a whole new meaning when your world is turned upside down by a plague; giving readers some idea of what survival means in comparison to dying for a cause. The real struggle that someone who is trying to survive would go through, from the physical demands to mental torment, the fictional references help to illuminate a difficult concept of what surviving in a death camp means.

Not only are the fictional aspects important to help readers get into a survival mindset they set the stage for what Des Pres brings to light next, testimonies from survivors. Des Pres touches on how many survivors had a strong will to live solely to tell the story, to record and share their experience. Though this concept may seem minor on the survival scale, it helped many justify them living while others dead, and gave them a reason to continue their life in their new normal. Des Pres emphasizes that this concept of healing through the telling of their story and others is truly important to surviving, not a way to cope with the guilt of living over others.

Another essential point that Des Pres brings is the torment that happened daily in death camps. Almost everyone knows of the horrific mass murders and the details surrounding death camps, but there is also the daily living that tends to be over shadowed, the psychological torture. In Des Pres accounts of the psychological torture he brings a point in that surviving is not simply living but keeping one’s humanness as well, as this is not an easy feat when being faced with such physical and mental suffering. For example, prisoners were purposely forced into positions that caused them to defecate themselves and then punished for not obey orders, producing embarrassment and physical aguish, trying to keep one’s self in a hopeful state of mind would be almost impossible. One of the many mental game played by guards while using the prisoners own body against them, the imagery that comes from these accounts shows just how strong the will must be to be a survivor, and just how easy it would have been to give into the torment and let one’s life go. This kind of torture brings one to feel less human and is the reason why surviving is more than living, because without our humanness what are we living for. Des Pres says that prisoners needed to awake and see these horrible acts to actually choose to stay human and stay alive.

Des Pres brings into account the social factor that played a large role in how many survived. Through accounts he reviews, many helped others, keeping the humanness alive but also in hopes to end their own suffering. We cannot look at survival (for this situation) as a solo affair but one of group survival, working together to get through the unbelievable circumstances. Des Pres looks at how some believed the individual mindset was the only way one could survive this kind of extremity, contradicting his own ideas, solely to show that within certain extreme circumstances social interaction and humanness is a must for survival.

As like in class discussion we have looked at death and how different groups view the rituals surrounding it, I believe depending on the persons own circumstances how one lives, or dies can be scrutinized. For example, when looking at some Asian cultures the elderly will not handle the death of a child, as hierarchy plays such a large role in this culture. We may look at these traditions and place our own judgement on them but until we are placed in one’s circumstances, we cannot hold them to our standards. To say that this culture lacks humanness is to say that their traditions or believes are not valid. Needing to truly understand where a parent or grandparent is coming from and to know how they feel about the death of that loved one may be just as distraught and upset as any other culture, the actions may just play out differently. Then we have cultures like Buddhism that believes the body must be untouched for a period of time and allow the clear light of death to be present; many may see this as an odd tradition or disrespectful, leaving a body for days or longer. Death and dying and surviving are large pieces in our cultures and how we determine what is right and what is wrong between our culture and others is one that no one can answer. Until we are in that specific extreme circumstance, we do not know what our true feelings and or actions will be.

This book shows a great deal on insight into how dying is more than just a moment(s) in time but rather how we chose to live through that process. My thought on how Des Pres shows great relation between living and not just surviving is that many would be place in extreme circumstances and just survive, rather than keeping their humanness and truly living with the circumstances they are in. Not to say that just surviving is not a great triumph in itself. This book gave me a new outlook on living, though most of the content and stories revolve around horrific details of death camps, to not just go through each day as another day but genuinely appreciate your circumstances. Knowing that life doesn’t always make accommodations and being uncomfortable is sometimes a way of growing one’s self.

Overall, this book has brought a full circle to the concept of death and dying, with survival and living life with full human compassion. When you are looking at death, no matter the process, you almost always reflect on your life and how it was lived, I believe we should look at being humans above all else to truly feel like we survived life and what it through at us. Not only how we act individually but as a social cog, to help others and gain a better survival for us all, knowing ultimately, we are preserving the future society.

Introduction

Anatomy undoubtedly forms the basis of any medical curricula as well serves a strong component for good clinical practice. However, literature pertaining to anatomy education is increasingly reporting of a deterioration of anatomy knowledge not only among undergraduate students but also among clinical practitioners. Partly in response to these observations and due to changes in demands of medical professions, anatomy curricula have experienced a major paradigm shift from passive didactic and teacher centered approach to active, clinical based and student-centered approach. However comparative retrospective analysis of these different approaches has failed to identify a significant difference in terms of student performance. A possible explanation is that both approaches have failed to emphasize key competencies required to be known by the student. This has led to a deprivation of a strong anatomy foundation, a common observation made amongst most medical undergraduate students. The authors herewith propose a competency level based approach for teaching anatomy whereby the understanding of anatomy is allowed to evolve within the student based on pre defined competency levels. The proposed approach enables the student to develop a strong core knowledge via a teacher centered, didactic commencement and ends in a complete student centered, clinical based approach allowing for application and synthesis of new knowledge based on the already laid strong foundation.

The big picture vs details

Different approaches used in teaching anatomy, whether traditional or novel is observed to share one thing in common: the focus on detailed anatomy of a selected region. Regional anatomy taught in traditional curricula for example presents the upper limb under the main subdivisions of pectoral region, shoulder region, the arm, forearm and the hand. This approach is seen to allow the student to focus on detailed anatomy of each sub region discussed and leaves the student to amalgamate the knowledge gained so as to perceive the upper limb as a single functional unit. Careful analysis of “problem based learning” and other modern reforms to the traditional curricula is also observed to be lacking in this sense, thus leaving the challenge of amalgamation to the student.

The authors believe that the possession of a holistic understanding of anatomy is the key to successful anatomy learning. Good clinical practice requires the understanding of different anatomical entities as a single functional unit, reflecting the role in nature. Possessing detailed knowledge of regional anatomy will therefor only cater partly to the demands of the practice of anatomy in the clinical setting. The remining greater proportion thus relies on the student’s capability of self-amalgamating the acquired knowledge which woefully is not observed amongst the majority of the student population today. It is in this context that authors also argue on the threshold of such amalgamating capacities expected from undergraduate medical students.

The proposed approach for teaching anatomy is designed in such a way so as to substantially rid the student of the need of self-amalgamation. This is brought about through pre identified competency levels with each defined level designed to perceive this broader anatomical picture. Thus, at any given time it is expected that a selected student will possess a holistic understanding of a learnt functional unit appropriate of his/her competency level. The gradual course of a student through increasing competency levels will enable him/her to add required details to the broader picture whereby a deeper understanding is generated.

The evolving nature

Two major criteria (center and discipline) will be used when defining each competency level. Commencing from a teacher centered mode of deliverance the teaching methodology is gradually shifted toward the student with increasing competency level. Thus, competency level I which is identified as a complete teacher centered approach makes a gradual transit towards a fully student-centered approach on reaching competency level IV. The teaching learning methodology will also undergo a similar transition reflecting the change of center. Lectures and prosected specimen observation employed as the main teaching learning methodology at competency level I will change to student presentations and dissections when reaching the competency level IV. A simultaneous shift will also be conducted with regard to the type of anatomy taught. Commencing with core structural anatomy at competency level I, the student will course through descriptive to functional and clinical anatomy at competency level IV. Sub disciplines of histology and embryology is also expected to be presented in a similar manner with core knowledge being presented at competency level II and III and with abnormal development, histopathology and molecular basis being introduced at competency level IV. The gradual transition of the aforementioned criteria exemplifies the dynamic nature of the proposed approach when compared to traditional as well as novel teaching methods such as PBL.

Vertical integration

In the setting of basic sciences, integrated learning has proven to be effective both in terms of factual comprehension and promoting life long learning. However, studies conducted in this regard has yet to answer questions pertaining to the extend as well as exact points of such integrations. Retrospective analysis of student performance in most problem-based learning curricula which accommodates a marked degree of vertical integration has failed to identify a significant improvement in terms of student performance. In contrary to the expectations such approaches have been observed to leave students with sporadic knowledge. The authors thus present the argument that a strong core anatomy knowledge is mandatory and forms the foundation for successful vertical integration. In bringing this ideology to light, the proposed approach herewith suggests to emphasize functional and clinical anatomy learning during latter stages of competency levels, a stage where the student has already mastered his core knowledge and is ready to apply.

Structuring formative and summative assessment

While summative assessment is considered to evaluate a student’s learning progress, formative assessment can be considered as an approach to reinforce learning. Formative assessment also plays a key role in motivating the students to learn thus allowing for continuous improvement. In this perspective formative assessment can be considered to be a crucial component of a curricula and conduction of a systematic formative assessment not only is beneficial directly to the student but also allows for identification of areas to be improved within a curriculum. However, conducting a successful formative assessment demands a sensible partition of the learnt subject matter in such a way the student himself can identify his/her weaknesses and apply the experience during the next level. The competency level-based teaching approach presented herewith facilitate this process of partition enabling a successful formative assessment to be carried out.

Summative assessments are usually applied at the end of a period of instruction to measure the outcome of student learning. Such assessments ideally require a structure covering all aspects of knowledge gained over the specified time period. However, a grey area exists in defining such a structure within a traditional or a novel approach such as PBL. The competency level based approach presented herewith also facilitates the structuring process of a summative assessment via the outcome based different weightages which can be allocated to each competency level.

How do you prefer a glass of water: lukewarm or nicely chilled? An internist and a nutrition expert explain the advantages and disadvantages of the temperature of the drinking water for digestion, circulation, pain perception and calories burned.

Especially in summer on hot days you long for a sip of cold water to cool off. But that is not particularly useful, because the cold drink has to be brought up to temperature by the organism, which makes you sweat all the more. But hot water also causes beads of sweat on the forehead, because the body wants to give off the excess heat quickly. FITBOOK explains what is healthier – hot or cold water.

Bestselling author and nutrition expert Sven-David Müller on FITBOOK: “Anyone who thinks that an ice-cold drink provides refreshment is exactly wrong. Ideally, a drink should be consumed at human body temperature, i.e. around 36 degrees. Then it does not have to be heated up or cooled down. Here one should learn from the southern peoples, because there are no ice-cold drinks for them. Desert peoples, for example, drink almost exclusively peppermint tea at body temperature. ”Compared to cold water, warm water has a number of health benefits.

Effects on muscles and nerves

Warm water is pain reliever and helps with headaches, abdominal pain and menstrual pain. Muscles and nerves are naturally relaxed. “In principle, we perceive warmth as pleasant: vessels widen, and cramps in the intestines also tend to relax in warm water. We just feel better, ”confirms the Hamburg nutritionist and diabetologist Dr. Matthias Riedl opposite FITBOOK. So instead of throwing yourself another pain reliever, you should just try it with a glass of warm water. Nevertheless, the doctor warns: “Of course, the cause of the headache and abdominal pain is important.” If the pain is severe and persistent, you should consult a doctor.

Effect on digestion

Warm water is also good for digestion and helps with constipation. Especially after or with a fatty meal, you should drink warm water, as the fats can be better dissolved and digested. ‘Warmed fats can get into the intestines in a more finely divided manner,’ says Dr. Riedel. So in the restaurant you would rather order a tea or an unconventional glass of warm water with your meal.

Effect on the circulatory system

A glass of warm water immediately after getting up not only gets the metabolism going, but also acts as a stimulant, because it increases the body temperature and thus stimulates the circulation. Instead of a morning coffee, try it with warm water.

Also interesting: an interview with extreme runner: »How I almost drowned inside in the desert

The effect of cold water on the body’s energy expenditure

Cold water, on the other hand, has another advantage: If you want to burn calories, you should drink cold water, because the body uses additional energy by bringing the water to body temperature. However, the effect is very small, because “to heat one gram of water by one degree Celsius, the body needs one calorie – not kilocalorie. This means that the body has to use energy, but this is low, ”emphasizes Dr. Riedl.

Also interesting: the 7 individual sports with the highest calorie consumption

Possible side effects of ice cold water

But cold water can also lead to undesirable side effects, warns nutrition expert Müller: “Ice-cold water can also trigger migraines. The back of the throat (palate) is particularly close to the brain, so that an ice-cold drink could trigger migraines here. ”And not only for those prone to migraines, Müller recommends drinks at body temperature – especially for people with esophageal problems (such as heartburn) or irritable bowel patients lukewarm drinks are always the right choice.

How much water does the body need?

Of course, not everyone likes warm water, but a splash of lemon or lime gives the whole thing the kick it needs. Unsweetened teas can also provide a little variety in terms of taste. And regardless of whether it is cold, lukewarm or hot water: In any case, it is good for the body’s water balance.

As a rule of thumb: 30 to 40 milliliters per kilo of body weight. If you weigh 70 kilograms, you should drink at least 2.1 liters of water a day, provided you don’t sweat too much. By the way: Drinking too much water is also not advisable. In extreme cases, this can even be dangerous. Excessive water consumption can lead to nutrient and mineral deficiencies – we have found out more about this for you here .

Chapter 1. Introduction

Though we may take for granted our brain’s ability to recognize the faces of friends, family, and acquaintances, it is actually an extraordinary gift. Designing an algorithm that can effectively scan through a series of digitized photographs or still video images of faces and detect all occurrences of a previously encountered face is a monumental task. This challenge and many others are the focus of a broad area of computer science research known as facial recognition. The discipline of facial recognition spans the subjects of graphics and artificial intelligence, and it has been the subject of decades of research and the product of significant government and corporate investment. Face recognition systems have been conducted now for almost 50 years, which makes it to be one of the researches in the area of pattern recognition & computer vision due to its numerous practical applications in the area of biometrics, Information security, access control, law enforcement, smart cards, and surveillance system.

Biometric-based techniques have emerged as the most promising option for recognizing individuals in recent years since, instead of certifying people and allowing them access to physical and virtual domains based on passwords, PINs, smart cards, plastic cards, tokens, keys and so, these methods examine an individual’s physiological and/or behavioral characteristics in order to determine and/or ascertain his/her identity. Passwords and PINs are difficult to remember and can be stolen or guessed; cards, tokens, keys, and the like can be misplaced, forgotten, or duplicated; magnetic cards can become corrupted and unclear. However, an individual’s biological traits cannot be misplaced, forgotten, stolen, or forged, however, a facial recognition system is a computer application capable of identifying a person from a digital image or video frame from a video source. The system of verifying and identifying the human face is among the few methods of biometric identification which gets the merits of a high level of accuracy and non-intrusiveness. This is because facial recognition provides details about the age, personal identity, gender, emotional state, and mood of a person. A great deal of achievements has been recorded in the area of facial recognition over the years. However, despite these achievements, facial recognition still stands as an active research area due to the changeability perceived in facial appearance as a result of illumination, expression occlusion, pose, age, and plastic surgery.

In the area of face recognition, several approaches have been proposed to address the challenges of illumination, pose, expression, aging, and disguise. However plastic surgery-based face recognition is still a lesser explored area. Thus the use of face recognition for surgical faces introduces a new challenge for designing future face recognition systems. [1]. Plastic surgery is a sophisticated operational technique that is used across the world for improving facial appearance. For instance to remove acne scars, to become white, to remove dark circles, and many more. Plastic surgery can be broadly classified in two different categories such as global plastic surgery and local plastic surgery. Global surgery changes the complete facial structure whereas in local plastic surgery certain parts of the face are changed. Recognizing a face after plastic surgery might lead to the rejection of genuine users or the acceptance of impostors. To this challenge yet much literature is not available. Very few researchers now have contributed in this field. Many researchers have shown a comparative study of different face recognition algorithms for plastic surgery. Based on the experimentation carried out but it has been concluded that face recognition algorithms such as PCA, FDA, GF, LLA, LBP, and GNN have shown a recognition rate of not more than 40% for local plastic surgery. Moreover, for global surgery, it was merely up to 10%. Among all the algorithms, the geometrical feature-based approach has proven to a great extent comparatively for local plastic surgery.

One challenge that is affecting the verification and identification of human faces using face detection algorithms is facial plastic surgery. A human face that passes through surgery alters the features to be used by these algorithms in verifying and identifying a face. When a given face undergoes surgery, criminals or evaders hide their identities and reside within the society smoothly, which means the standard of face recognition is compromised making it an issue to be dealt with using technology. Hence, in order to fort-nail these trepidations, recognition of human faces by computer algorithms had to spread its tentacles and address this issue successfully. Statistical data has shown that the use of plastic surgery to alter faces in humans is growing exponentially [1]. This is because of the improvement in technology which is making plastic surgery less painful, fast, and affordable for many within society. Furthermore, two key issues have to be considered:

• The overall speed of the system from detection to recognition should be acceptable.
• The accuracy should be high.

Problem Definition

The face recognition problem can be formulated as follows: Given an input face image and a database of face images of known individuals, how can we verify or determine the identity of the person in the input image?

Why Use the Face for Recognition

Biometric-based techniques have emerged as the most promising option for recognizing individuals in recent years since, instead of authenticating people and granting them access to physical and virtual domains based on passwords, PINs, smart cards, plastic cards, tokens, keys, and so forth, these methods examine an individual’s physiological and/or behavioral characteristics in order to determine and/or ascertain his identity. Passwords and PINs are hard to remember and can be stolen or guessed; cards, tokens, keys, and the like can be misplaced, forgotten, purloined, or duplicated; magnetic cards can become corrupted and unreadable. However, an individual’s biological traits cannot be misplaced, forgotten, stolen or forged.

Biometric-based technologies include identification based on physiological characteristics (such as the face, fingerprints, finger geometry, hand geometry, hand veins, palm, iris, retina, ear, and voice) and behavioral traits (such as gait, signature and keystroke dynamics) [1]. Face recognition appears to offer several advantages over other biometric methods, a few of which are outlined here: Almost all these technologies require some voluntary action by the user, i.e., the user needs to place his hand on a hand-rest for fingerprinting or hand geometry detection and has to stand in a fixed position in front of a camera for iris or retina identification. However, face recognition can be done passively without any explicit action or participation on the part of the user since face images can be acquired from a distance by a camera. This is particularly beneficial for security and surveillance purposes. Furthermore, data acquisition in general is fraught with problems for other biometrics: techniques that rely on hands and fingers can be rendered useless if the epidermis tissue is damaged in some way (i.e., bruised or cracked). Iris and retina identification require expensive equipment and are much too sensitive to any body motion. Voice recognition is susceptible to background noises in public places and auditory fluctuations on a phone line or tape recording. Signatures can be modified or forged. However, facial images can be easily obtained with a couple of inexpensive fixed cameras. Good face recognition algorithms and appropriate preprocessing of the images can compensate for noise and slight variations in orientation, scale, and illumination. Finally, technologies that require multiple individuals to use the same equipment to capture their biological characteristics potentially expose the user to the transmission of germs and impurities from other users. However, face recognition is totally non-intrusive and does not carry any such health risks. (Rabia, 2009).

Chapter 2. State of the Art

Face recognition is a rapidly growing area of research and innovation. Asides from much other applicability it is high in demand for security and police investigation purposes. Plastic surgery allowing criminals or evaders to hide their identities and reside in society soundly is an issue to be dealt with by the goon of technology. Hence, to overcome the challenge face recognition technology had to evolve and address this issue successfully.

Plastic surgery is a process of alteration or reconstruction of facial defects or improving the aspects like cleaning off the birthmarks, and pockmarks and adjusting the disfiguring defects. Although facial surgery is advantageous for some it can be misused by some who have indulged in some kind of crime and wants to conceal his/her identity. Many countries have incorporated facial data into the electronic passport with fingerprint information and iris information for security reasons. However, due to plastic surgery facial texture, shape and countenance can be altered and the security becomes unapt [9]. In all types of plastic surgery, there is one common thing that is all are gone through some kind of facial modification and diverge from the original. Plastic surgery is broadly divided into two types of classification.

A. Depend on the area of impact

Based on the percentage of surgical procedures, the classification of surgery is done. It depends on the modification of features and the degree of modification. Plastic surgery derived under this type of classification is of the following types:

1. Local surgery: This kind of surgery is used for correcting the skin texture, removing birthmarks, and correcting anomalies, aging effects, and accidental marks. Local surgery is also known as disease-correcting plastic surgery. It changes only some regions of face locally instead of the entire region globally.
2. Global surgery: This kind of surgery can be performed to alter facial texture entirely. This is also known as complete facelift surgery. In the situation of lethal flame and bruise, this type of surgery is mostly suggested.

B. Depend on the surgical approach

It is based on the process of surgery in which the person can do some kind of surgery according to need. Following are plastic surgery based on the surgical procedure.

• Eyelid surgery: It is basically used to correct defects and abnormalities of the eyelids. It remakes the eyelids which are overlapped the region of the eyebrow and upper chop area.
• Nose surgery: It is primarily used for modifying or reshaping of the nose. It is mainly preferred for decorative purposes like changing the shape of the nose according to the mouth to look good.
• Ear surgery: It is used for correcting the abnormality of Pima or ear. It can be used for decorative purposes or functional purposes.
• Lip augmentation: This is mainly used for beautifying purposes. It basically magnifies the form of the lips for better facial appearances.
• Skin peeling: Skin peeling is a global surgery and by using laser technology it regenerates the whole face or removes wrinkles. Using this type of surgery, the face gets changed entirely and gives the younger look [12].

Face recognition is a process of verifying or identifying a person from a video frame or image. A face recognition system is beneficial in the area of security mostly. The mirror points on the face on opposite sides of the central axis, pupillary separation, and some other basic features are mostly used for verifying the identity of a person. And then there are certain features that cannot be altered even after plastic surgery like the shape of the zygomatic bone, nodal points on the face, and the pupillary distance [8].

In 2010 Singh et al. observed the six existing face recognition algorithms and have shown that the performances of these algorithms are downgrading on the plastic surgery database [7]. The correlativeness between faces before and after plastic surgery was studied comprehensively by K. R. Singh et al. (2011). In that, they can classify the facial image using near set theory [1]. In 2011, Lakshiprabha et al. present an approach for face recognition using Gabor and LBP for feature extraction on the face region and eye region and achieved better accuracies [2]. Aruni Singh et al. done the contrast of various face verifying approaches on a dummy dataset of faces and they have shown the critical analysis of various algorithms on the same sets of data (2012) [3]. Face recognition presents a challenging problem in the field of image analysis and computer vision, and as such has received a great deal of attention over the last few years because of its many applications in various domains. Face recognition techniques can be broadly divided into three categories based on the face data acquisition methodology: methods that operate on intensity images; those that deal with video sequences; and those that require other sensory data such as 3D information or infra-red imagery.

Chapter 3. Aim of the Research

The main aim of the research work is to fully explore those challenges attached to facial recognition after plastic surgery and find out the possible solution.

Objectives of the Research

• To identify the reasons behind the lower rate of recognition when plastic surgery is performed on a given face and possible solutions.
• To develop an algorithm that will increase the recognition rate in facial recognition after plastic surgery.
• To highlight the area of feature research in facial recognition after plastic surgery.

The approach of the Research

The approach of Pankaj Dadure in 2018, will be studied and modified, the approach uses Local Binary Pattern(LBP) and Principal Component Analysis(PCA). Possibly when little modification is done in his work the recognition rate can be improved.

Research Methodology

In the proposed approach, LBP combined features the given pixel of LBP pattern is outlined as an ordered set of binary comparisons and using the following equation resulting value can be obtained [10][11]. Extracted from the face and periocular region to perform well and PCA algorithm is used for dimension reduction. Using a Euclidean distance classification is done. Features extracted from the face region are compared first and then features extracted from the periocular region are compared.

A. Data collection and preprocessing

For the recognition of face images, a plastic surgery database would be used [7]. In the plastic surgery database, it contains 1800 face images, 900 images are non-surgery face images and 900 are surgery face images. The images of faces have some noise and irregularities. So that the preprocessing operations like extracted features. So, here PCA is used to reduce the dimensionality. The extracted features are decumbent to noise. Using PCA, this problem can be minimized. The PCA algorithm has the following step:

1. Assemble a training set of images (M number of face images)
2. Resampled all the images to common pixel resolution

B. Local binary pattern

Local binary pattern (LBP) provides an efficient way for texture description. LBP is faster as compared to any other feature extraction algorithm. It is a non-parametric approach and very demanding in the domain of machine vision and image processing [8][9]. Consider a 3*3 pixel with (pC , qc) intensity value be Ic and local texture as L = l(t0, t1, t2, t3, t4, t5, t6, t7) where tn (n=0,1,2,3,4,5,6,7) corresponds to the grey values of the eight encompassing pixels. These encompassing pixels are threshold with the middle value tc as l(r(t0 – tc), – – – – – r(t7 – tc)) and therefore the r(x) is outlined.

Feature extraction using LBP

C. Principle component analysis (PCA)

PCA is used for feature extraction and reduces the dimensionality of the images. Which transfigure a number of associated pixel values into a number of disassociated pixel values called as Eigenfaces. It also calculates an optimized and compact description of the dataset. Sometimes the extracted features are large in size which leads to a memory problem, computation problem, and many more. PCA procedure is as follows.

1. Assemble a training set of images (M number of face images)
2. Resampled all the images to common pixel resolution R*C
3. Individual image is converted to a single vector or single row which contains R*C elements. i.e. [R1 R2 R3 – – – – – – RC]
4. The training set is then accumulated into a single matrix S which consists of M column. i.e.
5. Calculate mean image m using the following formula.
6. Subtract mean m from matrix T and from that matrix A (centroid image matrix) is obtained.
7. Calculate surrogate matrix S and covariance matrix C. Where C = A* A| and S = A| * A
8. Calculate eigenvalues and eigenvectors of surrogate matrix S.
9. Calculate eigenvalues and eigenvectors of the covariance matrix with the help of eigenvalues of S using the following formula. Vc = A * Vs and Uc = A * Us. Where Vc and Uc are eigenvectors and eigenvalues of the covariance matrix and Vs and Us are eigenvectors and eigenvalues of the surrogate matrix.
10. An eigenvector of the covariance matrix is eigenfaces.

D. Periocular region

The periocular region includes the iris, eyes, eyelids, eyelashes, and part of the eyebrows. Recognition using periocular biometrics is an emerging research area Eyelids, lateral canthus, medial canthus, lid folds, and surrounding area of the eyes are known as the periocular region and these points consider as discriminant in nature. There is no separate database is present for the periocular region. So that can be obtained from face images by cropping the periocular region. There are three different ways to perform periocular biometrics is overlapping, non-overlapping, and strip [2]. Using the periocular region a significant accuracy is obtained for face recognition.

Chapter 4. Current Work and Preliminary Results

The literature for the work was carried out, the plastic surgery database was obtained from IIIT New Delhi India. Now the research work is at the replication stage.

Chapter 5. Work Plan and Implications

Inline quantum of the work a time frame was allocated to each activity within which it will be executed step by step which is represented in the chart below.

Figure 1 Activity chart for the Work

Step 1 (Information gathering stage)

This will be the initial stage of the research, it involves gathering enough materials such as journals, write-ups, conference papers, review articles, textbooks, lecture notes, etc. that will enable the literature of the research work to have a solid foundation and to have deep inside of the work dataset gathering inclusive.

Step 2 (Replication stage)

At this stage the previous work by Pankaj Dadure., will be studied and the algorithm for the work will be replicated. The result of the work will be used to identify the shortcomings, however, facts will be established based on the result obtained. My research work will be carried out based on the limitations of the replicated result. A seminar paper will be presented.

Step 3 (Experimental stage)

This is where the work be done it will involve enhancing the algorithm of Pankaj Dadure., which will eliminate the drawback of the existing work and facts will be devoid on the result by comparing it side by side i.e the enhanced algorithm will run side by side with the replicated algorithm so that result will be compared. Another seminar paper will be presented.

Step 4 (Analysis stage)

At this stage, the two results will be analyzed and by so doing a good summary and conclusion could be derived based on the facts established from the results. However on the bases of analysis, the work it will show what has been added to the former work and the contributions to knowledge. Another seminar paper will be presented.

Chapter 6. Conclusions

The Conclusions would be restated based on the objectives of the work project, a recap of the research approach would also be stated, and clarified in a few words indicating my findings, why it is scientifically valuable to find it out would be answered, and on what basis would the work expect to evaluate the validity of the results.