Controversies in ECMO

Controversies in ECMO Parag Gharde, Sandeep Chauhan   Controversy is defined as â€Å"Public debate about a matter which arouses conflicting opinion.† (Oxford English Dictionary) ECMO or ECLS- To start with there is controversy regarding the name itself. There are two abbreviations that we commonly come across in literature ECMO- extracorporeal membrane oxygenation ECLS- extracorporeal life support This support system is used in different clinical settings where the reversible organ dysfunction has affected the lung, the heart or both. When lung rest is needed the veno-venous ECMO system is used and for providing cardiac rest veno-arterial system is used. The term extracorporeal membrane oxygenation (ECMO) came into being when Dr. J. Donald Hill first used it successfully in a road traffic accident victim who developed acute respiratory distress syndrome after multiple blood transfusions. Since lung rest and oxygenation was the main therapeutic requirement, the life support system was named ECMO. But since this support system is now often being used in patients requiring cardiac support where the native lung is functioning well, the term ECMO is not suitable and hence the term ECLS is now in common use in clinical practice. The ECMO society itself is named as â€Å"Extracorporeal Life Support Organization-ELSO†. Therefore the reader should not get confused when they come across the terms- ECMO and ECLS, both meaning the same but to the author the term ECLS appears to be more appropriate as it can be used interchangeably whether support is required for the lung, the heart or for both. The use of the term ECMO is justified only if it is being used to support pulmonary function with the aim of giving rest to the lung. Does ELSO work? After the first successful use of ECLS in an adult, which was reported by Hill etal in 1972 (NEJM 1972; 26: 629-34.), the National Institute of Health sponsored a multicenter randomized study by Zapol etal in 1974, which showed 90% mortality in both ECLS and conventional care group. The anticipated enrolment for the study was 300 patients but the study was stopped after just 92 patients, as the death rates were similar in both the groups. This prospective randomized trial deflated the initial euphoria that was generated by the report of Hill etal. Was this supposed to be a certain miscarriage of a support system devised to deal with patients who are non-responders to conventional medical practice, even before seeing the light of the day? This study was conducted in adults with hypoxic respiratory failure and published in 1979. (JAMA 1979; 242:2193-2196). This first prospective multicenter randomized clinical trial demands a close scrutiny. During the study period a nation wide epidem ic of influenza pneumonia broke out, which might have affected the results. Though the protocol included lung rest but the inflation pressures were high compared to the present recommendation, which may have caused lung injury. VA ECLS was used rather than VV ECLS, which may be responsible for high incidence of pulmonary micro-thrombosis due to decreased pulmonary blood flow. ECMO was instituted after a mean duration of 9 days of mechanical ventilation, which in the present era has been reduced to 7 days. Morrios etal (Am J Respir Crit Care Med-1994;149(3);88) randomized 40 patients with sever ARDS to either pressure controlled inverse ratio ventilation or extracorporeal carbon dioxide removal. Survival at 30 days was not significantly different (42% in mechanical ventilation group and 33% in ECLS group). After these two randomized trials, showing failure of ECLS in the adult setup had put ECLS into disrepute despite many anecdotal mini case series and isolated case reports showing the benefits were published. The much awaited CESAR trial (Efficacy and economic assessment of Conventional ventilator support versus Extracorporeal membrane oxygenation for Severe Adult Respiratory failure), a multicenter randomized controlled trial by Peek etal was published in Lancet 2009. (Lancet. 2009:374:1351-1363.) 180 patients were randomized and 90 patients were managed at the participating tertiary care centers while 90 were referred to Glenfield hospital. Five patients in the ECMO referral group died during transportation and thus the ECMO group consisted of 68 patients of which 43 survived to 6 months (63%). This study showed that survival apart from appropriate time of institution of ECLS also significantly depends on the expertise of the ECLS conducting center. There is no consensus on the optimal time for institution of ECLS. Waiting too long will result in danger of end organ dysfunction and poor outcome, while too early institution without optimizing medical therapy will expose the patient to the inherent risk of ECLS. The success in ECLS has been with neonatal acute hypoxemic respiratory failure with survival to discharge rates reaching 80%. The success story started with Bartlett etal reporting the first successful use of ECLS in a neonate in 1976. Extracorporeal carbon-dioxide removal (ECCO2R) A membrane lung is used to remove carbon dioxide in conditions of acute exacerbation of chronic obstructive pulmonary disease. A low flow is required and is perfused by femoral artery-venous shunt. Low blood flow is not adequate for performing oxygenation. Morris etal conducted a randomized control trial using this device to eliminate CO2. This trial showed no difference between ECCO2R and the conventional treatment and the study was stopped after enrolling 40 patients only. The ECCO2R arm used low flow in a group of patients with severe lung disease, which warranted higher ECMO flows. Before starting the trial, the trial team had limited experience on sheep and one patient.(Am J Respir Crit Care Med,1994:149; 295-305.) Effective CO2 clearance is achieved with blood flow as little as 10-15ml/kg/min, while oxygenation requires at least 50-60 ml/kg/min of blood flow. Nova lung (Germany) produces a membrane lung, which can be perfused using femoral arterio-venous shunt, enough blood flow for CO2 removal. ECLS Vs Ventricular assist device (VAD) Patients with failing heart and waiting for heart transplant need a bridge to transplant till the time a donor heart is available. If these patients develop acute exacerbation of cardiac dysfunction, which route should be chosen- ECLS or VAD? There are no guidelines regarding this situation. The main advantage ECLS holds over VAD is in patients with bi-ventricular dysfunction, which will require a bi-VAD. VA-ECLS on other hand can support both the ventricles along with respiratory failure and refractory pulmonary artery hypertension. The only limitation is the duration of support, which at most is 4-6 weeks. Cardiac ECLS The controversy is regarding patient selection. Though ECLS guideline clearly defines presence of a reversible condition before institution of ECLS, there are situation when it’s difficult to predict if the condition is reversible and most often the decision is surgeon dependent who may have a biased opinion regarding the true indication for instituting ECLS. This usually results in financial burden, resource and manpower wastage, bad outcome, lowers the moral of the team and loss of faith in the support system (ECLS). When is the ideal time to institute ECLS in cardiac surgical patient? Is it ideal to institute ECLS directly from CPB or to initiate it later in the intensive care unit after giving a trial? It has been shown that survival benefits were more in patients who went on ECLS directly from CPB thus avoiding the ill effects of prolonged low cardiac output state or subsequent to cardiopulmonary resuscitation (CPR) in the intensive care unit. Antegarde or retrograde ECLS Retrograde ECLS via femoral artery cannulation especially for cardiac support in a failing left ventricle is not a good option. The failing heart with this form of support has to compete with retrograde ECLS flow from the femoral artery cannula. This causes increase in LV wall stress and may even result in mitral regurgitation both of which increase left atrial (LA) pressure, thus affecting gas exchange due to pulmonary congestion. This may impair oxygenation and delivery of inadequately oxygenated blood to coronary and cerebral artery circulation will further worsen cardiac function and delay recovery. Therefore central ECLS with aortic cannulation has some advantage over peripheral ECLS, especially in case of cardiac support. But central ECLS takes time to initiate and is ideal in post cardiac surgery setup. In an emergency situation peripheral ECLS is easy to institute. Serial echocardiography needs to be done to rule out LA distention. If LA distention is present then placement o f an LA vent is necessary via percutaneous atrial septostomy. Some prefer retrograde ECLS because of the fact that 10-15% patients suffer from stroke when carotid artery was used for arterial cannulation in profound hypotension or arrest. Neck vessels are used in children up to 5-6 years and femoral access in older patients. Limb ischemia is common with femoral artery cannulation and may require additional distal limb perfusion. Is axillary artery cannulation a better option? This can provide sufficiently oxygenated blood to the upper body, which is lacking with retrograde flow. The issue of limb ischemia is also addressed. The decreased pulmonary blood flow in full support VA ECLS may increase the risk of thrombus formation, in the pulmonary circulation, because of lower levels of anticoagulation. Does the type of oxygenator influence outcome? In vitro studies reported problems with Biomedicus (Medtronic, USA) pump heads. Thiara etal demonstrated improved circuit durability and reduced hemolysis when changing from Biomedicus (Minimax oxygenator) circuit to a Rotaflow (Lilliput 2 oxygenator), but failed to demonstrate survival improvement. (Perfusion, 2007;22:323-26). The earlier oxygenators were spiral wound silicone membrane oxygenator (Affinity, Avecor Cardiovascular Inc, USA), and the recent multiple hollow fibers

Cell Energetics Study Guide

Cellular Energetics Study Guide 1. Overall Metabolism a. Oxidation – a molecule LOSSES hydrogen, energy is RELEASED b. Reduction – a molecule GAINS hydrogen, energy is GAINED and stored (the more reduced a molecule is, the more energy is stored in its COVALENT BONDS) *** Always occur in a coupled pair (RED-OX)*** c. Electron Carriers i. Oxidizing Agents: are REDUCED to OXIDIZE another molecule 1. NAD+ – oxidizes glucose to 2 pyruvate in glycolysis, oxidizes pyruvate to CO2 in the Kreb’s cycle (gets reduced to NADH) 2.NADP+- oxidizes H2O to O2 during the Light Dependent Reactions of photosynthesis, final electron acceptor from chlorophyll (PSI) (gets reduced to NADPH) 3. FAD+- oxidizes NADH to NAD during glycolysis and transported to the mitochondrion (gets reduced to FADHs) ii. Reducing Agents: are OXIDIZED to REDUCE another molecule 4. NADH- reduces 2 pyruvate to 2 lactic acid in fermentation, reduces O2 during the respiratory chain (gets oxidized to NAD) *CANNOT pass through the mitochondrion* 5.NADPH- reduces CO2 to form carbohydrates (Calvin Cycle) in the Dark Reactions of photosynthesis (gets oxidized to NADP) 6. FADH2- reduces O2 during the respiratory chain (gets oxidized to FAD) *CAN pass through the mitochondrion* 2. Phosphorylation: Formation of ATP (ADP + P ATP) d. Substrate-level: direct enzymatic transfer of a phosphate to ADP * Only occurs during glycolysis when O2 is not needed to function * Only a small amount of ATP is produced this way e.Electron Transfer /Chemiosmosis: the movement of protons (H+) down a concentration gradient through ATP synthase that can HARNESS THE ENERGY OF THAT GRADIENT (proton-motive force) to bond ADP and phosphate to create ATP through oxidative phosphorylation * Occurs during the Light Dependent Reaction * 90% of ATP is produced this way 3. Photosynthesis f. Balanced Net Reaction: light 6CO2 + 6H2O C6H12O6 + 6O2 g. Light Dependent Reaction – occurs on the thylakoid lumen iii. Photol ysis – oxidation of H2O to release electrons used to return PSII to ground state iv.NADP Reduction – NADP receives an electron from PSI as it passes through electron transfer chains, reducing it to NADPH+. Electrons are passed from excited atoms that gain energy from a photon. v. ATP Synthesis – ATP is produced by chemiosmotic phosphorylation. Proton gradient (within the thylakoid interior) is made as electrons from photosystems are passed through proton pumps. h. Light Independent Reaction – occurs in the stroma vi. CO2 fixation: RuBP + CO2 2 PGA (a form that can be easily reduced).The reaction is catalyzed by RUBISCO. 7. In the presence of oxygen, RuBP + O2 Bad Sugar; process is called photorespiration. Plants overcome this by keeping a HIGH concentration of CO2. Land plants must compromise opening the stroma to maintain high CO2 concentration with loss of H2O. There are 2 additional adaptations that evolved: a. C-4 Pathway – formation of Oxaloac etate (C-4) from CO2 + PEP (C-3). Occurs in outer cells (mesophyll). Calvin cycle occurs in inner cells only (closer to supply of CO2, bundle sheath). b.CAM Pathway – like C-4, but fixation only occurs at night, when water loss is minimal. Found in desert plants, like cacti. vii. Calvin Cycle 8. PGA is reduced to PGAL using the products of the light dependent reaction, NADPH (oxidized) and ATP (provides energy) 9. One-sixth of the PGAL produced is used to create glucose for the cell to grow and repair. 10. Five-sixths of the PGAL is used to produce RuBP, completing the cycle (energy requiring). 4. Cellular Respiration i. Balanced Net Reaction: C6H12O6 + 6O2 6CO2 + 6H2O j.Glycolysis – occurs in the cytoplasm. All organisms carry out this process. viii. Glucose is double phosphorylated by 2 ATP and broken up into two three carbon phosphorylated molecules called PGAL ix. Each PGAL is phosphorylated by a free phosphate and ADP to form Biphosphoglycerate (BPG) while NAD is reduced to NADH. x. Each BPG aides in Substrate Level Phosphorylation of two ADP’s to form 2 ATP’s. Water is released. The remaining 3 carbon molecule is pyruvate. k. Fermentation – when pyruvate is used to oxidize NADH to replenish NAD+.Only produces 2 ATP per glucose through glycolysis. Some organisms (anaerobic) do it exclusively. Occurs regularly in all cells, but products can build up when NAD supplied through reduction of pyruvate is not available. 2 Forms: xi. Alcoholic – produces ethanol and CO2 from reduction of pyruvate. xii. Lactic acid – produces lactic acid from the reduction of pyruvate. l. Kreb’s Cycle – NAD required to begin. Takes place in the matrix of the mitochondria or in the cytoplasm of prokaryotes. xiii. Pyruvate is oxidized to Acetyl CoA, Reduced by _______, Releases 1 NADH. iv. Acetyl CoA is added to Oxaloacetate to form Citrate. xv. Citrate is broken down releasing 2 H2O and is oxidized 4x: by NAD+ thrice an d once by FAD+. One Substrate Level phosphorylation occurs producing ATP. Oxaloacetate is the product and continues the cycle by being added to the next available acetyl CoA. m. Electron Transport and Oxidative Phosphorylation – takes place on the cristae (inner mitochondrial) membrane. xvi. NADH and FADH2, products of Glycolysis and Krebs are oxidized by Q (molecule embedded in the membrane).Electrons are passed to cytochrome and protons are pumped into the proton pumps. xvii. The protons diffuse back through ATP synthase in a process called chemiosmosis. The energy harnessed allows an oxidative phosphorylation of ATP. (3 for each NADH, 2 for each FADH2) xviii. Free protons in the matrix and the electrons accepted by E. T. C are passed to O2, which is reduced to water. Stomata Allows gas exchange; since a lot of water can be lost, plants only open stomata for photosynthesis in daylight; at night they close to reduce loss of water. **CAM plants keep their stomates closed duri ng day and open at night*** Mesophyll C-3 Plants: Calvin Cycle during day C-4 Plants: CO2 combines with 3 carbon molecule PEP to form C-4 acid CAM Plants: stores CO2 in organic compounds that are synthesized at night Bundle sheath C-4 Plants: Calvin Cycle during day CAM Plants: Calvin Cycle during day Thylakoid lumen Light dependent reactions Stroma Calvin Cycle/Light independent reactions Inner membrane E. T. C. Cytoplasm Glycolysis & Fermentaion Matrix Kreb’s Cycle Diagrams (know following structures and what takes place there)

Akhenaten Heretic and Pharaoh of New Kingdom Egypt

Akhenaten (ca. 1379–1336 BCE) was one of the last pharaohs of the 18th Dynasty of the New Kingdom Egypt, who is known for briefly establishing monotheism in the country. Akhenaten drastically revised the religious and political structure of Egypt, developed new art and architectural styles, and generally caused great chaos during the Middle Bronze Age.   Fast Facts: Akhenaten Known For: Egyptian pharaoh who briefly established monotheismAlso Called: Amenhotep IV, Amenophis IV, Ikhnaten, Osiris Neferkheprure-waenre, NapkhureyaBorn: ca. 1379 BCEParents: Amenhotep (Amenophis in Greek) III and Tiye (Tiy, Tiyi)  Died: ca. 1336 BCERuled: ca. 1353–1337 BCE, Middle Bronze Age,18th Dynasty New KingdomEducation: Several tutors, including ParenneferMonuments: Akhetaten (the capital city of Amarna), KV-55, where he was buriedSpouses: Nefertiti (1550–1295 BCE), Kiya Monkey, the Younger Lady, two of his daughtersChildren: Six daughters by Nefertiti, including Meritaten and Ankhesenpaaten; perhaps three sons by the Younger Lady, including Tutankhamun Early Life   Akhenaten was born as Amenhotep IV (in Greek Amenophis IV) in the 7th or 8th year of his fathers reign (ca. 1379 BCE). He was the second son to Amenhotep III (ruled ca. 1386 to 1350 BCE) and his primary wife Tiy. Little is known about his life as a crown prince. Brought up in the palace, he would likely have been assigned retainers to educate him. Tutors may have included the Egyptian high priest Parennefer (Wennefer); his uncle, the Heliopolitan priest Aanen; and the builder and architect known as Amenhotep son of Hapu. He was raised at the palace complex at Malqata, where he had his own apartments. Amenhotep IIIs heir was to be his eldest son, Thutmosis, but when he died unexpectedly, Amenhotep IV was made heir and at one point co-regent to his father for perhaps the last two or three years of his reign.   Early Regnal Years   Amenhotep IV likely ascended to the throne of Egypt as a teenager. There is some evidence that he took the legendary beauty Nefertiti as a consort while he was co-king, although she is not acknowledged as queen until after Amenhotep IV began his transformation. They had six daughters but no sons; the oldest, Meritaten and Ankhesenpaaten, were to become wives of their father.   During his first regnal year, Amenhotep IV ruled from Thebes, the traditional seat of power in Egypt, and remained there for five years, calling it the southern Heliopolis, the first great seat of Re. His father had built his authority on the basis of being a divine representative of Re, the Egyptian sun god. Amenhotep IV continued that practice, but his attention was focused primarily on his connection to Re-Horakhty (Horus of the two horizons or God of the East), an aspect of Re.   The Egyptian pharaoh Akhenaten (18th dynasty) and his family on the balcony of his palace. The pharaoh submits gifts from the sun to the priest Ai and his wife. Wood engraving, published in 1879. ZU_09 / Getty Images Changes to Come: The First Jubilee   Beginning with the first dynasty of the Old Kingdom, pharaohs held sed festivals, over-the-top parties of eating, drinking, and dancing that were jubilees of kingly renewal. Neighboring kings in the Mediterranean were invited, as were nobles and the general populace. Normally, but by no means always, kings held their first jubilee after they had ruled 30 years. Amenhotep III celebrated three, beginning with his 30th year as pharaoh. Amenhotep IV broke with tradition and held his first sed festival in his second or third year as pharaoh.   To prepare for the jubilee, Amenhotep IV began building a huge number of temples, including several near the ancient temple of Karnak. There were so many temples required that Amenhotep IVs architects invented a new building style to speed things up, using smaller blocks (talatats). The largest temple Amenhotep IV built at Karnak was Gemetpaaten (the Aten is Found), built perhaps as early as the second year of his reign. It had several royal greater-than-lifesized statues made in a new art style, located north of the temple of Amun, and near a mudbrick palace for the king. Amenhoteps jubilee didnt celebrate Amun, Ptah, Thoth, or Osiris; there was only one god represented: Re, the sun god. Further, Res representation—a falcon-headed god—disappeared to be replaced by a new form called Aten, a solar disc extending rays of light ending in curved hands bearing gifts to the king and queen.   Art and Imagery Akhenaten and Nefertiti worship the Aten, Tall al-Amarnah (Amarna, Tell el-Amarna), necropolis, detail of stele, relief. G Sioen / De Agostini Picture Library / Getty Images The first changes in the artistic representation of the king and Nefertiti began early in his reign. At first, the figures are modeled true to life in a way never seen in Egyptian art before. Later, the faces of both he and Nefertiti are drawn down, their limbs thin and elongated and their bodies bloated.   Scholars have debated the reasons for this peculiar almost other-worldly representations, but perhaps the figures represent Akhenatens notions of the infusion of light brought from the solar disk into the bodies of the king and queen. Certainly the 35-year-old skeleton found in Akhenatens tomb KV-55 does not have the physical deformities illustrated in Akhenatens depictions.  Ã‚   True Revolution   The fourth temple built at Karnak in the 4th year of his reign, called Hutbenben the Temple of the benben stone, is the earliest example of the revolutionary style of the new pharaoh. On its walls were pictured the transformation of Amenophis III to the godly sphere, and the renaming of his son from  Amenophis (the god Amun is content) to Akhenaten (he who is effective on the Atens behalf.   Akhnaten soon relocated with 20,000 people to a new capital city, named Akhetaten (and known to archaeologists as Amarna), while it was still under construction. The new city would be dedicated to Aten and built far from the capitals of Thebes and Memphis.   Ruins of Pharaoh Akhenatons capital Tell el-Amarna (Akhetaten). New Kingdom, 18th Dynasty. G. Sioen / Getty Images The temples there had gateways to keep out the masses, hundreds of altars open to the air and no roofs over the sanctuary—visiting dignitaries complained about having to stand in the sun for a long time. In one of the surrounding walls was cut the Window of Appearances, where Akhenaten and Nefertiti could be seen by his people.   The religious beliefs espoused by Akhenaten are not described anywhere, except that the god is far away, radiant, untouchable. Aten created and fashioned the cosmos, authorized life, created people and languages and light and dark. Akhenaten attempted to abolish most of the complex mythology of the solar cycle—no longer was it a nightly struggle against the forces of evil, nor were there explanations for the existence of sorrow and evil in the world.   As a replacement for a 2,000-year-old tradition, Akhenatens religion lacked some important underpinnings, in particular, an afterlife. Instead of having a detailed pathway for people to follow, shepherded by Osiris, people could only hope to be reawakened in the morning, to bask in the suns rays. Extremism on the Nile Akhenatens revolution became ugly as time progressed. He demanded more and more temples to be built as rapidly as possible—the South Cemetery at Amarna contains the remains of children whose bones show evidence of hard physical labor. He demoted the Theban gods (Amun, Mut, and Khonsu), had their temples dismantled, and killed or sent away the priests. By the 12th year of his reign, Nefertiti disappeared—some scholars believe she became the new co-king, Ankhheperure Neferneferuaten. The next year, two of their daughters died, and his mother Queen Tiy died in the 14th year. Egypt suffered a devastating military loss, losing its territories in Syria. And the same year, Akhenaten became a true fanatic.   Ignoring the foreign political losses, Akhenaten instead sent out his agents bearing chisels and orders to destroy all carved references to Amun and Mut, even if they were carved on granite stele many stories above the ground, even if they were small hand-held personal items, even if they were used to spell Amenhotep IIIs name. A total eclipse occurred on May 14, 1338 BCE, and it lasted for over six minutes, which must have seemed an omen of displeasure from the kings chosen parent. Death and Legacy After a brutal reign of 17 years, Akhenaten died and his successor—who may have been Nefertiti—immediately but slowly began dismantling the physical elements of Akhenatens religion. His son Tutankhamun (ruled ca. 1334–1325, a child of the consort known as the Younger Wife) and the earliest 19th dynasty pharaohs led by Horemheb (ruled ca. 1392–1292 BCE) continued to tear down the temples, chisel out Akhenatens name, and bring back the old traditional forms of belief. Although there is no recorded dissension or push back from the people while the king lived, once he was gone, everything was disassembled. Sources and Further Reading Cooney, Kara. When Women Ruled the World, Six Queens of Egypt. Washington DC: National Geographic Partners, 2018. Print.Kemp, Barry J., et al. Life, Death and Beyond in Akhenatens Egypt: Excavating the South Tombs Cemetery at Amarna. Antiquity 87.335 (2013): 64–78. Print.Redford, Donald B. Akhenaten: New Theories and Old Facts. Bulletin of the American Schools of Oriental Research 369 (2013): 9–34. Print.Reeves, Nicholas. Akhenaten: Egypts False Prophet. Thames and Hudson, 2019. Print.Rose, Mark. Whos in Tomb 55? Archaeology 55.2 (2002): 22–27. Print.Shaw, Ian, ed. The Oxford History of Ancient Egypt. Oxford: Oxford University Press, 2003. Print.Strouhal, Eugen. Biological Age of Skeletonized Mummy from Tomb KV 55 at Thebes. Anthropologie 48.2 (2010): 97–112. Print.

Informative Speech Reference Of Music By Gretel Herrera

Informative Speech Outline in reference to Music by Gretel Herrera General Purpose: To Inform Specific Purpose: At the end of my speech, the audience we will learn the importance of music in our lives and the benefits associated with listen to music to our health and development of our brain. Thesis: Music is an important and rewarding part of our lives and is essential to the development of a child’s brain and to keep a healthy body. I. Introduction A. Attention Getter: Today I am going to talk about music. We can say that all people around the world listen music because it is part of our everyday lives. During my whole life I have ever met any person who said they do not like music. Many people do not realize the importance and benefits of listen to music. Do you really think that the only way that music benefits our life is to relax after an stressful day? B. Thesis: Since the beginning of civilization man has heard music, he has played music using the simplest to the most complex instruments that exist nowadays. Every day of our lives we listen to music, when we are staying in our home, when we are driving in our car, when we want to relax, when we go to a party, when we take a shower, music is always part of our lives. The music has on us the power to affect our mood. Music stimulates brain cells, reduces stress and is also used to cure sick people and has therapeutic powers. Music should be considered an essential element of human being life. C. Credibility