Cost-Effectiveness Analysis of the Culturally Developed Diabetes Self-Management Education and Support Program among Type 2 Diabetes Mellitus Patients in Iraq.

Background: Diabetes mellitus (DM) is a chronic disease associated with a major economic burden on persons, health care systems, and countries. Diabetes self-management education and support (DSME(S)) programs are highly effective method in the management of T2DM patients. Therefore, this study aimed to determine the cost-effectiveness of the developed culturally-specific DSME(S) program regarding glycemic control, lipid profile, and body weight for Iraqi type 2 DM patients. Methods: A randomized controlled clinical trial design was used to assess the cost-effectiveness of the culturally-specific DSME(S) program from the perspective of health care providers. In the cost-effectiveness analysis (CEA), cost per patient and clinical outcomes over 6 months were compared between the intervention and control group. Incremental cost-effectiveness ratios (ICERs) were expressed as cost per unit improvement in glycosylated hemoglobin (HbA1c), fasting blood glucose (FBG), total cholesterol (TC), low-density lipoprotein-cholesterol (LDL-C), high density lipoprotein- cholesterol (HDL-C), systolic blood pressure (SBP), diastolic blood pressure (DBP), and body weight. Results: The effectiveness of most outcomes was better in the intervention group compared with the control group. The ICER per unit improvement in HbA1c, SBP, DBP, serum TC, and TG levels was <1 of the minimum CET compared with the control group, thus meeting the definition of being highly cost-effective. Conclusion: The currently developed DSME(S) was cost effective method to improve glycemic control, blood pressure, TC, and TG for T2DM patients in Iraq.

Improved Transdermal Delivery of Rabies Vaccine using Iontophoresis Coupled Microneedle Approach.

AIM: This study was aimed to develop rabies vaccine incorporated microneedle (MN) patches and evaluate the immunogenicity of prepared formulations in combination with iontophoresis. METHODS: Patches comprising of polyvinyl pyrrolidone, hyaluronic acid and polyethylene glycol 400 were engineered by vacuum micromolding technique. Physical evaluation of patches included determination of folding endurance, % swelling and morphological features. In vitro release study was performed in skin simulant agarose gel using model drug (methylene blue) loaded patches. In vitro insertion ability was assessed using stratum corneum simulant parafilm. In vivo insertion study was performed in rats. Immunogenicity was evaluated in dogs by determining immunoglobulin G (IgG) and rabies virus neutralizing antibodies (RVNA) titer. RESULTS: Patches displayed uniformly distributed microprojections with pointed tips and smooth surface, ~ 70% swelling, remained intact for ~ 200 foldings and successfully penetrated the parafilm. The area covered by model drug across agarose gel was almost double following treatment with MN-iontophoresis combination (MNdi) compared to MN alone (MNdo). Histological examination of rat skin treated with vaccine laden MN (MNvo) and MN-iontophoresis combination (MNvi) confirmed the formation of grooves in epidermis without any damage to the deep vasculature. A ~ 73% and ~ 206% increase (compared to untreated counterpart) was observed in the IgG titer of MNvo and MNvi treated dogs, respectively. The RVNA titer was increased by ~ 1.2 and ~ 2.2 times (compared to threshold value) after MNvo and MNvi treatment, respectively. CONCLUSION: MN-iontophoresis combination provided relatively potent immunogenic response over the conventional intramuscular injection, hence, can be used for administering vaccines transcutaneously.

Adverse effects associated with the use of N95 mask among health-care workers at the COVID-19 care units: A cross-sectional study in Sulaimani city, Iraq.

BACKGROUND: Health-care workers have to use the N95 mask as a part of the protection kit during the COVID-19 pandemic. The adverse effects of such practice are not fully elucidated. The study aims to evaluate negative impacts of N95 face masks on health-care personnel at COVID-19 care units. MATERIALS AND METHODS: One hundred and twenty-two health-care workers (aged 20-58 years) from various health-care settings in Sulaimani, Iraq, from January to August 2020, were enrolled in this prospective, cross-sectional study. The physiological variables (blood pressure, heart rate, and oxygen saturation) were recorded before putting on the N95 mask and postremoval of the mask. The incidence of adverse effects such as headache, difficulty breathing, redness, irritation, and dizziness were also reported as a number and percent at the end of the work shift. RESULTS: There was a statistically significant difference in the physiological parameters after removal of the mask compared with baseline. Only diastolic pressure was significantly lower in those working >6 h when compared to those working 1-6 h. The changes in physiological markers were poorly and nonsignificantly associated with the duration of wearing the mask. Moreover, 67.2%-70.5% of the participants complain of headaches and breathing difficulties, while 45.9%-51.6% reported signs of itching, redness, and irritation. However, health-care workers who put on the face mask >6 h showed signs of headache, breathing difficulties, and itching at the exposed areas higher than those working for 1-6 h. CONCLUSION: N95 mask negatively impacts the physiological variables of health-care providers. The adverse effects may lead to excessive exhaustion after long shifts in the intensive care unit during treatment of COVID-19 patients.

Combined Coronary Orbital Atherectomy and Intravascular Lithotripsy for the Treatment of Severely Calcified Coronary Stenoses: The First Case Series.

OBJECTIVE: Severely calcified coronary stenoses remain a significant challenge during contemporary percutaneous coronary intervention (PCI), often requiring advanced therapies to circumvent suboptimal lesion preparation and major adverse cardiac events (MACEs). Recent reports suggest combined coronary atherectomy and intravascular lithotripsy (IVL) may achieve superior preparation of severely calcified coronary stenoses during PCI. We sought to evaluate the safety and utility of combined orbital atherectomy (OA) and IVL for the modification of coronary artery calcification (CAC) prior to drug-eluting stent (DES) implantation in PCI. METHODS: We performed a retrospective review of all patients who underwent coronary OA and IVL within a single PCI procedure at our institution. The primary outcome was procedural success, defined as successful DES implantation with a residual percent diameter stenosis of <30% and Thrombolysis in Myocardial Infarction (TIMI) 3 flow following PCI without occurrence of in-hospital MACE (cardiac death, myocardial infarction, or target-vessel revascularization). MACE was additionally assessed at 30 days post intervention. RESULTS: Eight patients underwent combined coronary OA and IVL within a single PCI procedure. The mean percent diameter stenosis prior to intervention was 80.5 ± 8.3%, with a mean calcific arc of 338 ± 42°. Procedural success was achieved in 7 of 8 cases (87.5%). Both in-hospital and 30-day MACE rates were 0%. CONCLUSION: We report the safe and effective use of combined coronary OA and IVL for the preparation of severely calcified coronary stenoses during PCI. Through their distinct yet complementary mechanisms of action, the combined use of these therapies may achieve superior preparation of severely calcified coronary stenoses during PCI.

Association of cigarette and water-pipe smoking with increased visceral adiposity, glycemic intolerance and hematological derangement in Iraqi healthy smokers

Abstract The present study aims to investigate the impacts of cigarette smoking (CS) and water-pipe smoking (WPS) on the visceral adiposity index (VAI), hematological characteristics, and glycemic tolerance in Iraqi healthy smokers. A total of 528 healthy males from different locations of Baghdad city were allocated to three groups; nonsmokers (176), cigarette smokers (178), and WP smokers (174). Baseline characteristics, anthropometric and hematological markers and were reported. Glycemic control was evaluated using the glucose tolerance test. The evidence of elevated VAI, disrupted hematological markers, and impaired glucose tolerance was significantly (P<0.001) different compared with non-smokers and related to the duration of smoking. The impacts of WPS seem to be significantly greater than CS in certain parameters (hemoglobin, hematocrit, methemoglobin, and 2-hour glucose tolerance values). In conclusion, CS and WPS negatively impacted body fat distribution, glucose tolerance, and hematological markers. There is a positive association between the rate of smoking and obesity, glycemic intolerance in both groups

Gingko biloba extract improves the lipid profile, inflammatory markers, leptin level and the antioxidant status of T2DM patients poorly responding to metformin: A double- blind, randomized, placebo-controlled trial

Abstract The present study aims to evaluate the effects of Ginkgo biloba (GKB) extract as "add- on" therapy with metformin on the lipid profile, inflammatory markers, leptin and the total antioxidant capacity (TAOC) of patients with type 2 diabetes mellitus (T2DM). It is a multi- center, randomized, placebo-controlled double-blinded clinical study. Sixty patients were allocated into two groups: control and treatment groups; they received orally either 120 mg starch/capsule or 120mg GKB/capsule, respectively as an adjuvant with metformin for 90 days. Blood samples were obtained at zero time and after 90 days. The blood was utilized for analysis of the lipid profile, inflammatory markers, leptin, and TAOC. The GKB extract produced a significant decrease in the levels of TG, LDL-c, and CRP, with a significant increase in HDL-c compared to baseline values. There were no significant changes reported in the placebo-treated group. It also produced a significant decrease in the concentrations of IL-6, TNF-α, and leptin compared to baseline values and placebo-treated groups with a significant increase in TAOC compared to baseline values. In conclusion, GKB extract, as an adjuvant with metformin, decreases inflammatory mediators, leptin level and improves the antioxidant status and lipid profile of T2DM patients improperly managed with metformin

Validation of newly developed culturally specific diabetes self-management education and support program for Iraqi type 2 diabetes mellitus patients.

BACKGROUND: Diabetes self-management (DSM) is the cornerstone in diabetes mellitus (DM) management. Unfortunately, the practice of DSM by Iraqi type 2 DM (T2DM) patients is poor that mainly resulted from their poor knowledge about the required DSM behaviors. This lack of knowledge may be attributed to the lack of DSM education and support (DSMES) program in Iraq. Thus, this study was conducted with aim of developing and validating a culturally specific DSMES program for Iraqi T2DM patients. MATERIALS AND METHODS: The development and validation of the DSMES program was done according to the Hilda Taba model. Content validity of the program was done by a panel of 6 health-care experts in management of Iraqi DM patients. Face validity was confirmed by conducting a pilot study for six adults with uncontrolled T2DM at the National Diabetes Center, Baghdad, Iraq. Both the experts and patients were asked to evaluate the developed program in regard to its contents, design, and supporting material (booklet). The evaluation was done by filling in a questionnaire that based on a 5-point scale. Items with a score ≥4 by <70% of the experts and patients were subjected to revision and further assessment. RESULTS: No total disagreement for any item was expressed by all participants (experts and patients). Content and face validity was ensured through obtaining a positive feedback from all participants at which all items about the program had scores of ≥4 by at least 75% of participants. CONCLUSION: The developed culturally based DSMES program is highly suitable for educating Iraqi T2DM patients.

Correlation between serum pro inflammatory cytokines and clinical scores of knee osteoarthritic patients using resveratrol as a supplementary therapy with meloxicam.

OBJECTIVE: The objective of this study was to analyze the associations between the pro-inflammatory markers with the clinical outcomes of knee osteoarthritis (OA) in patients using resveratrol as an add-on treatment with meloxicam. MATERIALS AND METHODS: This was a double-blind controlled clinical investigation, with 110 eligible patients with OA assigned randomly to receive 15 mg a day meloxicam with either resveratrol 500 mg a day or placebo for 90 days. The standard tools for assessment of pain severity and physical functions were utilized. The tumor necrosis factor-α (TNF-α), interleukin-1ß (IL-1ß), and IL-6 in the blood were evaluated. Spearman's correlation coefficient test was used to determine the significance of correlations. RESULTS: The regression analysis to determine the correlation between reductions of the inflammatory biomarkers with the amelioration of the clinical scores showed a nonsignificant weak correlation between these variables. Total clinical scores of each assessment tool that was used "Knee Injury and OA Outcome Score (KOOS) and WOMAC" displayed a weak and nonsignificant correlation with TNF-α, IL-1ß blood level. The Spearman's correlation shows a relatively nonsignificant association between IL-6 levels and KOOS, WOMAC, and Visual Analog Scale scores after incorporating resveratrol as an adjuvant with meloxicam for 90 days. CONCLUSION: A weak and nonsignificant correlation between serum biomarkers and the clinical outcomes has been suggested in patients with painful knee OA treated with meloxicam and resveratrol.

3'-(Phenyl alkynyl) analogs of abscisic acid: synthesis and biological activity of potent ABA antagonists.

We report here the synthesis and biological testing of 3'-(phenyl alkynyl) abscisic ABA analogs, a new class of potent ABA antagonists. These ABA analogs incorporate a rigid framework of eight carbon atoms attached at the 3'-carbon atom of ABA that prevents folding of the ABA analog-bound receptor required for ABA signalling. The two-step synthesis is based upon the optimized conversion of natural (S)-ABA to 3'-iodo ABA which can be coupled to phenyl acetylenes using Sonogashira conditions, or to styryl compounds through Suzuki chemistry. The parent 3'-(phenyl alkynyl) ABA analog 7 was obtained in 29% yield, 74% yield based on recovered starting material. In a lentil seed germination assay, compound 7 was found to have more potent activity than other known 3'-substituted ABA antagonists to date. In a structure activity study parasubstituted phenyl alkynyl analogs had comparable activity to the analog 7 while the 3'-styryl ABA 18 was only slightly less active. Analog 7 overcame ABA inhibition of germination and seedling growth in a wide range of mono and dicot plant species, including canola, lentil, soybean, rice, wheat, barley, cannabis and canary seed. 3'-(Phenyl alkynyl) ABA analogs have numerous potential practical agricultural applications including promoting ripening of crops, dormancy breaking of seeds and woody perennials, as well as promoting seed germination, and growth under stress conditions as demonstrated in this report.

The Development and Validation of Quality of Life Scale for Iraqi Patients with Type 2 Diabetes Mellitus.

BACKGROUND AND AIM: The current trend for determining the effectiveness of new treatment or services provided for diabetes mellitus (DM) patients is based on assessing the improvement in both glycemic control and the patient quality of life. Many scales have been developed to assess quality of life among DM patients, but unfortunately, no one can be considered as gold standard. Therefore, this study aimed to develop and validate a brief and specific scale to assess quality of life among Iraqi type 2 DM patients. METHODS: An extensive literature review was done using Google-Scholar and PubMed to find out scales that utilized to assess quality of life among DM patients. Four relevant scales, three diabetes specific and one general, were selected. The selected scales were carefully evaluated to find out domains that are commonly used to assess quality of life and then the items within the selected domains were reviewed to choose relevant and comprehensive items for Iraqi type 2 DM patients. Ten items were selected to formulate the quality of life scale for Iraqi DM patients (QOLSID). The content validity of QOLSID was established via an expert panel. For concurrent validity QOLSID was compared to glycosylated hemoglobin (HbA1C). For psychometric evaluation, a cross sectional study for 103 type 2 DM patients was conducted at the National Diabetes Center, Iraq. Test-retest reliability was measured by re-administering QOLSID to 20 patients 2-4 weeks later. RESULTS: The internal consistency of the QOLSID was 0.727. All items had a corrected total-item correlation above 0.2. There was a negative significant correlation between QOLSID score and the HbA1C level (-0.518, P = 0.000). A significant positive correlation was obtained after re-testing (0.967, P = 0.000). CONCLUSION: The QOLSID is a reliable and valid instrument that can be used for assessing quality of life among Iraqi type 2 DM patients.

Effectiveness of Diabetes Self-Management Educational Programs For Type 2 Diabetes Mellitus Patients In Middle East Countries: A Systematic Review.

AIM: This review study aimed to determine the effectiveness and factors affecting the success of DSME programs in T2DM patients living in ME countries. METHODS: An extensive manual literature search was conducted using PubMed and Google Scholar for clinical trials assessing the effect of diabetes self-management education (DSME) for type 2 diabetes mellitus patients in Middle East countries. Information from the included studies was summarized in relation to study population, sample size, duration of follow-up, characteristics of DSME program, and follow-up time, besides in addition to parameters used in assessment, results, and conclusions. The risk of bias in the included studies was assessed using the Cochrane risk of bias tool. The effect of DSME on clinical and patient-reported outcomes was measured by calculation of the percentage of DSME studies that produce a significant improvement in these outcomes for patients in intervention group as compared to those in control group. Additionally, the effect of DSME on each clinical outcome was assessed by calculating the mean for the absolute effect of DSME on that outcome. RESULTS: Twelve studies were included in this review. Heterogeneity was found among included studies in terms of DSME program characteristics, the enrolled patients, duration of follow-up, assessment methods, and obtained outcomes. All clinical glycemic outcomes (glycosylated hemoglobin, fasting, and non-fasting blood glucose), lipid profile (total cholesterol and triglycerides), and body mass index were significantly improved for patients in intervention group as compared to those in control group in at least 60% of the included studies. All patients' reported outcomes (medication adherence, self-management behavior, knowledge, self-efficacy, health belief and quality of life) were significantly improved by the DSME program. CONCLUSION: DSME programs are highly effective in improving glycemic control, lipid profile and BMI, and modestly effective in improving BP. Thus, they can reduce the risks of developing diabetes complications. Patient diabetes knowledge, DSM behaviors, adherence to medications, self-efficacy, and quality of life can also be significantly improved by DSME.

Association of Visceral Adiposity Index, Lipid Profile, and Serum Leptin with Glucose Intolerance Risks in Iraqi Obese Patients: A Cross-sectional Study.

AIMS: The aim of this study was to evaluate the possibility of using visceral adiposity index (VAI), serum leptin, and lipid profile as indicators of impaired glucose tolerance in Iraqi obese patients. SUBJECTS AND METHODS: A cross-sectional study was performed in Iraqi obese patients of both sexes. Body mass index (BMI), waist circumference, hip circumference, triglycerides (TG), high-density lipoprotein cholesterol (HDL-C), VAI, waist-to-hip ratio (WHR), serum leptin, and 2-h glucose tolerance test (2-h GT) were determined and compared with those of healthy non-obese control group. A correlation analysis was performed to determine the strength of association between the studied markers. Data were adjusted to determine gender differences in this regard. STATISTICAL ANALYSIS: Kolmogorov-Smirnov, Shapiro-Wilk analyses, Mann-Whitney U test, and unpaired t test were used for the two-group comparisons once applicable. Pearson's and Spearman's correlation analyses were used to measure the relationship levels between the studied variables. RESULTS: A total of 144 obese patients were included; the mean age was 37.11 ± 8.2 years and 92 (63.9%) were females. Compared with non-obese subjects, the participants had significantly higher levels of BMI, WC, WHR, VAI, TG, leptin, and 2-h GTObese male subjects had significantly higher values of body weight, WC, HC, VAI, and TG compared with obese females. Elevated 2-h GT was significantly associated with VAI (r = 0.291, P = 0.0004), TG (r = 0.319, P = 0.0001), and LDL-C/HDL-C ratio (r = 0.435, P < 0.0001) in the obese patients only. CONCLUSIONS: The results provide evidence that VAI, TG, and LDL-C/HDL-C ratio can be suggested as potential markers for the risk assessment of impaired glucose tolerance in Iraqi obese patients.

Nigella sativa Oil Mouth Rinse Improves Chemotherapy-Induced Oral Mucositis in Patients with Acute Myeloid Leukemia.

OBJECTIVE: The present study aims at evaluating the beneficial effect of Nigella sativa (NS) oil mouth rinse in the management of chemotherapy- (CT-) induced oral mucositis (OM) in patients with acute myeloid leukemia (AML). METHODS: Fifty-four AML patients were participated in this study and randomly allocated to either the test group or a control group. The patients of the test group received NS oil mouth rinse during 28-day CT, while the participants of the control group received a "magic mouthwash" formula. The primary outcome of this study was the incidence and severity of CT-induced OM in terms of erythema and ulcer. The secondary outcomes were the pain severity score, swallowing function, and the salivary concentrations of interleukin-6 (IL-6) and tumor necrosis factor-alpha (TNF-α). RESULTS: NS oil mouth rinse attenuated the progression of CT-induced OM compared with the control formula (AUC = 5.9 vs. 38.4, P < 0.05) and significantly decreased the erythema and ulceration scores (AUC of total OMAS = 11.4 vs. 85.9, P < 0.001) compared with the magic mouthwash formula. It also reduced the pain score and enabled all the participants of this group to consume normal food during treatment. It significantly decreased salivary IL-6 (AUC = 7376 vs. 16599, P < 0.001), while the changes of TNF-α levels were not significant (AUC = 676.9 vs. 885.2, P > 0.05). CONCLUSIONS: NS oil mouth rinse is effective in attenuating the severity of CT-induced OM and improves the pain and swallowing function in AML patients.

Advanced glycation end products (AGEs) and their soluble receptors (sRAGE) as early predictors of reno-vascular complications in patients with uncontrolled type 2 diabetes mellitus.

AIM: To evaluate the role of advanced glycation end-products (AGEs) and their soluble receptors (sRAGE) expression levels as predictors of vascular complications in uncontrolled type 2 diabetes mellitus (T2DM). METHODS: Cross-sectional study was conducted on T2DM adults of both sexes who attended the outpatient service of Al-Karak Teaching Hospital, Jordan during the period from June 2017 to August 2018. Participants were categorized in two groups according to their glycemic control and the presence of reno-vascular complications. Twenty healthy subjects were recruited as control group. Blood sample was obtained from all participants and used for the assessment of FBG, HbA1c, serum AGEs and sRAGE, serum urea and creatinine; 24 h urine was also collected for the determination of urinary albumin. RESULTS: Diabetic subjects with vascular complication had a significantly higher serum AGEs 50.3 ±â€¯13 vs. 28.9 ±â€¯8 pg/ml) and AGEs/sRAGE ratio (0.058 ±â€¯0.02 vs. 0.037 ±â€¯0.02) associated with significantly lower serum sRAGE (868.7 ±â€¯50.8 vs. 912.8 ±â€¯294.3) compared to those with no complications. Serum AGEs and sRAGE showed weak negative and non-significant association in both groups of patients. However, the AGEs/sRAGE ration was inversely and significantly associated with the urinary albumin/creatinine ratio (r = - 0.51, P = 0.009) only in DM patients with reno-vascular complications. CONCLUSION: We found an association between AGEs/sRAGE ratio and urinary albumin/serum creatinine ratio in T2DM patients with reno-vascular complications; providing evidence that serum AGEs and sRAGE can be considered as predictors of vascular complications in uncontrolled T2DM patients.

Validity and reliability of anti-diabetic medication adherence scale among patients with diabetes in Baghdad, Iraq: a pilot study.

Background: Medication non-adherence is a common problem among patients with diabetes. Patient-reported medication adherence scales are the most commonly used method to assess patient medication adherence, but up to today there is no specific tool for assessing medication adherence among patients with diabetes in Arab countries. This study aimed to develop and validate a new tool for assessment of adherence to antidiabetic medications among Iraqi patients with diabetes. Methods: The Iraqi Anti-Diabetic Medication Adherence Scale (IADMAS) consists of eight items. The face and content validity of the IADMAS were established via an expert panel. For convergent validity, the IADMAS was compared with the Medication Adherence Questionnaire (MAQ). For concurrent validity, the IADMAS was compared with glycosylated hemoglobin. A total of 84 patients with types 2 diabetes were recruited from a diabetes center in Baghdad, Iraq. Test-retest reliability was measured by readministering the IADMAS to the same patients 4 weeks later. Results: Only 80 patients completed the study (response rate: 95%). Reliability analysis of the IADMAS showed a Cronbach's alpha value of 0.712, whereas that of the MAQ was 0.649. All items in the IADMAS showed no significant difference in the test-retest analysis, indicating that the IADMAS has stable reliability. There was no difference in the psychometric properties of the IADMAS and the MAQ. The sensitivity and specificity of the IADMAS were higher than that of the MAQ (100% vs 87.5% and 33.9% vs 29.7%, respectively). Conclusion: The IADMAS developed in this study is a reliable and valid instrument for assessing antidiabetic medication adherence among Iraqi patients.

Healthcare personnel's experience of reporting adverse drug reactions in Baghdad city: cross-sectional study.

Background Adverse drug reactions (ADRs) are undesirable effects to drugs at doses normally used in the clinical setting for diagnosis, treatment or prophylaxis of diseases. Spontaneous ADR reporting is currently considered as a critical part of ADRs detection. Objective The study aims to assess the knowledge, attitude, and practice of healthcare providers towards adverse drug reaction reporting in public and private settings within the Baghdad area. Method We follow a quantitative cross-sectional study design, using a self-administered questionnaire to collect data from the healthcare providers regarding their reporting practice. Main outcome The outcome measures include the experiences of reporting of adverse drug reactions and the available systems, in addition to the expected benefits to clinical practice. Results Among 485 respondents, 114 were able to differentiate ADRs from side effects. About half of them (47.6%) recognized the availability of reporting systems and 43.3% knew how to report adverse drug reactions. 43.7% of the respondents mentioned that ADRs should be reported only when they are life-threatening. Among the 188 respondents who encountered ADRs, 145 reported the events to the accessible local authority. Conclusion The healthcare providers working in Baghdad healthcare institutions have a good attitude toward ADR reporting. There is a relatively below-standard reporting culture of the encountered adverse reactions. The inadequate knowledge about adverse reactions and the unavailability of reporting forms played a major role in discouraging healthcare professionals to detect and report ADRs.

Experimental investigation of tribological characteristics and emissions with nonedible sunflower oil as a biolubricant.

Plant (vegetable) oil has been evaluated as a substitute for mineral oil-based lubricants because of its natural and environmentally friendly characteristics. Availability of vegetable oil makes it a renewable source of bio-oils. Additionally, vegetable oil-based lubricants have shown potential for reducing hydrocarbon and carbon dioxide (CO2) emissions when utilized in internal combustion (IC) engines and industrial operations. In this study, sunflower oil was investigated to study its lubricant characteristics under different loads using the four-ball tribometer and the exhaust emissions were tested using a four-stroke, single-cylinder diesel engine. All experimental works conformed to American Society for Testing and Materials standard (ASTM D4172-B). Under low loads, sunflower oil showed adequate tribological characteristics (antifriction and antiwear) compared with petroleum oil samples. The results also demonstrated that the sunflower oil-based lubricant was more effective in reducing the emission levels of carbon monoxide (CO), CO2, and hydrocarbons under different test conditions. Therefore, sunflower oil has the potential to be used as lubricant of mating components.Implications: An experimental investigation of the characteristics of nonedible sunflower oil tribological behaviors and potential as a renewable source for biofluids alternative to the petroleum oils was carried out. The level of emissions of a four-stroke, single-cylinder diesel engine using sunflower oil as a biolubricant was evaluated.