Monthly Archives: February 2021

fig 1

The Prognostic Value of Lymphocyte-to-Monocyte Ratio and Nutritional Index for Ovarian Cancer Patients with Normal CA125 Level

DOI: 10.31038/CST.2021611

Abstract

Background: Ovarian Cancer (OC) cases with low CA-125 concentration during routine physical examination testing are troublesome and raise false negative findings ratio. The aim of this analysis was to determine whether the Lymphocyte-To-Monocyte Ratio (LMR) and the Nutritional Index (NI) of OC patients with normal CA-125 levels had a predictive role.

Methods: This retrospective study enrolled a total of 102 OC-diagnosed patients who underwent primary cytoreductive surgery and adjuvant platinum-based chemotherapy from 2010 to 2019. Using Receiver Operating Characteristic Curves (ROC) for survival analysis, optimum cut-off values for NI and LMR were calculated. The Kaplan-Meier (KM) curve and Cox regression determined the prognostic value for Overall Survival (OS) and Progression-Free Survival (PFS).

Results: The results showed that the optimal cutoff values were 47.5 and 4.25, respectively, for NI and LMR. NI was shown to be significantly correlated with FIGO stage, Grade, the involvement of malignant ascites, and platinum response, and LMR with FIGO stage, lymph node metastasis, malignant ascites, and platinum response when the population was separated using optimized cut-off. The 5-year OS and PFS were greatly enhanced by a high NI (≧47.5). A low LMR (<4.25) was associated significantly with poor 5-year PFS and OS. Both NI and LMR were independent prognosticators for the 5-year OS in multivariate analysis.

Conclusions: In CA125-normal ovarian cancer cases, elevated NI and LMR are positive prognosticators.

Keywords

Ovarian cancer, Lymphocyte-To-Monocyte Ratio (LMR), Nutritional Index (NI), Prognosis; CA125

Introduction

One of the leading causes of cancer-related mortality in women, Ovarian Cancer (OC) accounts for 295,000 new cancer cases and 185,000 deaths worldwide annually. Among malignant gynecological tumors, the OC mortality rate is the largest, which severely endangers the health of women [1]. CA-125 is the gold standard tumor marker and has thoroughly been studied in OC [2]. For OC screening and clinical evaluation help, thirty-five kilounits/L is the cut off value of serum CA125 concentration [3]. However, during the clinical examination for OC screening, not all OC patients show perfect testing outcomes. Around 20% of women with OC have serum CA125 concentrations smaller than 35 kilounits/L [4]. Elevated false negative findings are obtained during OC screening due to these low CA125 concentration cases, which do not facilitate early diagnosis of OC.

Inflammation increases the risk and development of cancer, including initiation, promotion, malignant conversion, invasion, and metastasis [5-7]. It is considered to play an important role in tumorigenesis. Recent studies have shown a negative prognostic value of higher neutrophil-to-lymphocyte ratio and lower Lymphocyte-To-Monocyte Ratio (LMR) in OC patients, suggesting that low LMR is an independent survival prognostic factor in OC patients [8]. However, the predictive role of LMR in ovarian cancer with low CA125 concentration has not been explored.

Nutritional impairment has also been shown to have a detrimental effect on clinical outcomes [9]. At the time of diagnosis, patients with OC are also subject to starvation because of inadequate nutritional consumption due to cancer-related discomfort or psychiatric issues [10]. The prognostic Nutritional Index (NI), measured as mentioned above, could be particularly useful since both inflammation and nutritional status may serve as a surrogate marker [11]. To demonstrate the connection between postoperative complications and prognosis in patients with esophageal carcinoma [12], this index was originally examined. In this study, a low NI was seen as a poor survival predictor. However, the predictive role of NI in ovarian cancer with low CA125 concentration has not been explored.

Based on these observations, it seems urgent to determine a way to prevent false negative results due to low CA125 concentration. The objective of this research was to determine the effects of NI and LMR on OC patients with low CA125 concentration.

Materials and Methods

Patient population

The research approved by Ethics Committee of Soochow University retrospectively enrolled a total of 102 OC patients who underwent primary debulking and adjuvant paclitaxel and carboplatin chemotherapy in university hospitals between January 2010 and January 2019. Due to potential influences on laboratory test outcomes, patients with any inflammatory disorder were omitted. No neoadjuvant chemotherapy was given to the patient. Histological diagnosis were based on WHO guidelines, and an expert pathologist examined all microscope slides. Information collection of absolute lymphocyte, monocyte counts, and albumin tests using a peripheral blood sample were performed within one week prior to treatment. Clinical variables of concern, including clinicopathological attributes, such as such as, age, FIGO stage, Grade, LN metastasis, malignant ascites, CA125 level, residual mass, Histopathology types, and platinum response were collected and evaluated, as shown in Table 1.

Table 1: Clinical and pathologic characteristics according to NI or LMR in 102 patients.

Variable    

All Case

NI p value LMR

p value

<47.5

47.5 < 4.25

4.25

Age <50

51

14 37 0.774 34 17

0.635

≧50

51

15 36 31

20

FIGO stage
I/II

60

24 36 0.005* 33 27

0.025*

III/IV

42

5 37 32

10

Grade
G1/G2

58

25 33 0.003* 12 46

0.531

G3

44

4 40 14

30

Histopathology
Serous

76

55 30 0.634 50 26

0.642

Others

28

14 8 16

12

LN metastasis
No

80

26 54 0.377 50 30

0.031*

Yes

22

5 17 18

4

Malignant ascites
No

67

24 43 0.046* 35 32

0.011*

Yes

35

5 30 30

5

Residual mass
<1 cm

81

26 55 0.255 51 30

0.147

≧1 cm

21

3 18 15

6

Platinum response
Sensitive

80

28 52 0.008* 48 32

0.033*

Resistant

22

3 19 17

5

Note: FIGO, International Federation of Gynecology and Obstetrics; LN, lymph node.

By dividing the baseline total peripheral lymphocyte count (cells/mm3) by the absolute peripheral monocyte count (cells/mm3), the LMR was computed. The NI was measured as follows: 10* serum albumin baseline (g/dL) + 0.005* absolute lymphocyte baseline count (cells/mm3).

Statistical Analysis

The R software x64 (version 4.0) was used to analyze the results. To evaluate variations between proportions, the Chi-square test was used, and Kaplan-Meier analysis using the log-rank test obtained the OS and PFS curves. In evaluating hazard ratios (HR) and multivariate analysis, Cox regression analysis was used. The P-values presented are two-sided, and statistical significance was considered at P<0.05.

Results

Study Population Characteristics

The normal concentration of CA125 was described in our study as patients with a concentration equal to or below 35 U/ml. The following optimal cut-off values were identified: 4.25 for LMR (AUC = 0.748, P < 0.001) and 47.5 for PNI (AUC = 0.755, P < 0.001), as shown in Figure 1. Therefore, patients with LMR > 4.25 were referred to High-LMR and patients with NI > 47.5 were referred to High-NI. Among those 102 patients, the median age was 53 years. As previously stated, in our patients, early stage disease was more frequent than advanced disease, 60 patients had stage I to II, and 42 had stage III to IV disease. The histopathological type (76 patients) is mostly serous epithelial carcinoma. Eighty-one patients were optimally debulked with less than one cm of residual disease at primary surgery. Almost all patients are sensitive to platinum (Table 1).

fig 1

Figure 1: Receiver operating characteristic curves. Receiver operating characteristic curves for predicting the survival outcome. (A) Lymphocyte to Monocyte Ratio (LMR) (B) Nutritional Index (NI).

Relations between NI, LMR and Clinical Features

The Chi-square test was used to evaluate the association between the levels of NI, LMR and clinical characteristics (Table 1), including Age, FIGO stage, Grade, Histopathology, LN metastasis, Malignant ascites, Residual mass , and Platinum response. NI was shown to be significantly correlated with FIGO stage (P = 0.005), Grade (P = 0.003), malignant ascites (P = 0.046), and platinum response (P = 0.008), and LMR with FIGO stage (P = 0.025), lymph node metastasis (P = 0.031), malignant ascites (P = 0.011), and platinum response (P = 0.033) when the population was separated using optimized cut-off.

KM analysis found that patients in the low NI group had worse PFS (P = 0.023) and OS (P = 0.046) selected for this research than patients in the high NI group. In terms of PFS (P = 0.003) and OS (P <0.016), patients in the high LMR group had greater treatment outcomes than those in the low LMR group, as shown in Figure 2.

fig 2

Figure 2: Kaplan-Meier survival curves. Kaplan-Meier survival curves by different level of LMR and NI. (A) LMR for Overall survival. (B) LMR for Progression-free survival. (C) NI for Overall survival. (D) NI for Progression-free survival.

Prognostic Values of NI and MLR

Univariate analyses showed that interactions with FIGO stage (P < 0.001), Grade (P < 0.001), LN metastasis (P = 0.002), malignant ascites (P = 0.003), histopathology (P = 0.004), residual mass (P = 0.005), platinum reaction (P = 0.009), NI (P = 0.043) and LMR (P = 0.004) were identified in the findings obtained for PFS. Multiple cox regression analysis was used to analyze the association between survival outcomes and clinical features found in univariate analysis. A FIGO level (III-IV stage) (4.022 (1.754-9.322), P=0.001), grade III (2.640 (1.333-5.229), P=0.005), residual mass 1 cm (2.540 (1.074-5.929), P=0.005) and immune platinum reaction (3.575 (2.672-6.752), P = 0.009), a low LMR (2.640 (2.364-5.731), P = 0.005) and a low NI (1.367 (0.243-2.254), P = 0.019), as shown in Table 2.

Table 2: Univariate and multivariate analyses of PFS of patients according to clinicopathological characteristics including LMR and NI.

Variable

Univariate

Multivariate

HR (95% CI)

p value HR (95% CI)

p value

Age (≥50 vs. <50)

1.544 (0.832-2.774)

0.123
FIGO stage (III/IV vs. I/II)

8.337 (3.874-14.665)

< 0.001 4.022 (1.754-9.322)

0.001*

Grade (III vs. I/II)

6.367 (2.575-10.254)

< 0.001 2.640 (1.333-5.229)

0.005*

Histopathology (Others vs. Serous)

4.723 (3.687-7.263)

0.004 1.224 (0.875-3.354)

0.479

LN metastasis (Yes vs. No)

2.633 (1.377-5.357)

0.002 1.239 (0.994-2.995)

0.632

Malignant ascites (Yes vs. No)

3.627 (1.756-6.233)

0.018 0.994(0.383-3.411)

0.255

Residual mass (≥1 cm vs. <1 cm)

4.540 (1.383-5.929)

0.015 2.540 (1.074-5.929)

0.005*

Platinum response (Resistant vs. Sensitive)

10.367 (7.575-12.254)

0.009 3.575 (2.672-6.752)

0.009*

LMR (<4.25 vs. ≥4.25)

3.066 (1.432-6.229)

0.004 2.640 (2.364-5.731)

0.005*

NI (≥47.5 vs. <47.5)

1.795 (1.575-4.254)

0.043 1.367 (0.243-2.254)

0.019*

Note: HRs was obtained from Cox s proportional hazard model. HR, hazard ratio; CI, confidence interval; NI, neutrophil lymphocyte ratio; LMR, lymphocyte monocyte ratio; FIGO, The International Federation of Gynecology and Obstetrics; LN, lymph node.

Likewise, univariate analysis showed important relationships between the following factors and OS: FIGO stage (P < 0.001), Grade (P < 0.001), LN metastasis (P = 0.033), histopathology (P = 0.014), residual mass (P = 0.007), platinum reaction (P = 0.001), NI (P = 0.034) and LMR (P = 0.001). However, COX multivariate analysis showed only the following were independent poor prognostic factor of OS, FIGO level (III-IV stage) (6.172 (2.315-10.112), P=0.003), grade III (3.640 (2.371-6.551), P=0.015), residual mass 1 cm (3.230 (2.099-4.872), P=0.035) and immune platinum reaction (6.533 (3.232-7.992), P = 0.001), a low LMR (3.540 (2.724-6.133), P = 0.002) and a low NI (1.667(0.349-3.692), P = 0.014), as shown in Table 3.

Table 3: Univariate and multivariate analyses of OS of patients according to clinicopathological characteristcs including LMR and NI.

Variable

Univariate

Multivariate

HR (95% CI)

p value HR (95% CI)

p value

Age (≥50 vs. <50)

1.454 (0.730-2.668)

0.313
FIGO stage (III/IV vs. I/II)

9.127 (3.765-20.175)

< 0.001 6.172 (2.315-10.112)

0.003*

Grade (III vs. I/II)

7.367 (3.723-12.557)

< 0.001 3.640 (2.371-6.551)

0.015*

Histopathology (Others vs. Serous)

3.436 (2.227-8.923)

0.014 2.367 (1.445-3.674)

0.331

LN metastasis (Yes vs. No)

1.783 (1.267-4.349)

0.033 1.211 (0.749-1.995)

0.362

Malignant ascites (Yes vs. No)

4.007 (1.366-5.273)

0.147
Residual mass (≥1 cm vs. <1 cm)

4.880 (2.367-6.429)

0.007 3.230 (2.099-4.872)

0.035*

Platinum response (Resistant vs. Sensitive)

9.237 (6.945-10.322)

0.001 6.533 (3.232-7.992)

0.001*

LMR (<4.25 vs. ≥4.25)

6.014 (2.397-7.379)

0.001 3.540 (2.724-6.133)

0.002*

NI (≥47.5 vs. <47.5)

1.993 (1.235-5.641)

0.033 1.667(0.349-3.692)

0.014*

Note: HRs was obtained from Cox s proportional hazard model. HR, hazard ratio; CI, confidence interval; NI, neutrophil lymphocyte ratio; LMR, lymphocyte monocyte ratio; FIGO, The International Federation of Gynecology and Obstetrics; LN, lymph node.

Discussion

For women with OC, the high fatality risk is largely attributed to a lack of early diagnosis. There is no diagnosis for certain women until the late stage, so early diagnosis of OC is urgent. The main method used for ovarian cancer screening during physical examination is actually the concentration of serum CA125 monitoring. Furthermore, CA125 concentration can also be used to evaluate longevity following surgery in women who have been diagnosed with OC. Unfortunately, not all women with OC show high concentration of CA125. The low concentration of preoperative CA125 in OC patients was 20% [13], according to a retrospective study. It indicated that certain patients were preoperative CA125-normal OC patients and that there was a lack of effective serum biomarkers to determine the prognosis.

LMR was elevated in epithelial ovarian cancer in pretreatment and showed prognostic importance after following treatment. Immune Complexes (ICs) are formed against the antigen by the antigen and antibody, and free ICs circulating are Circulating Immune Complexes (CICs) [14]. Any medium-sized CICs, however, cannot be washed and stay in the circulatory system. Inflammatory reaction, which is a central mechanism for immune-complex diseases, could be triggered by these CICs. Daniel demonstrated the presence of CICs affecting CA125 in 2010, and proposed that CA125 CICs offer a reason for ovarian cancer with normal CA125 level [15]. LMR should be a good predictor of ovarian cancer based on both of these results.

A low PNI demonstrated a decrease in serum albumin and/or a low lymphocyte absolute count. Serum albumin is an essential component in the nutritional status and inflammatory response of the host [16]. It is often considered that the absolute lymphocyte count is a significant participant in inhibiting cancer growth by initiating a cytotoxic immune response [17]. It has been documented that low immune-nutritional status is associated with an immunosuppressed disorder that offers a favorable micro-environment for tumor relapse. That may be the reason why the bad results may be caused by this immunosuppressed syndrome in low-NI patients. Important advancement in research on immune control points in tumor immunity has made it possible to elucidate the molecular mechanism underlying the immunological resistance of tumor growth. The relation between peripheral inflammatory biomarkers and immunotherapy treatment effects appears to be uncertain. These biomarkers could serve in the future as a helpful indicator of immunotherapy in the treatment of OC.

Taken together, this current literature has demonstrated that a severely compromised immune system may be affected by starvation and lymphocytopenia. The NI cutoff value reported in previous studies was 40-60 for other cancer forms [18-20]. In our study, patients with NI < 47.5 had dramatically decreased survival when multivariate regression was corrected for other prognostic factors. Furthermore, our findings have shown that low LMR is a predictor of poor prognosis in OC patients with average levels of CA125. According to the multivariate study, patients with LMR < 4.25 had a substantial decrease in OS and PFS. Moreover, since the LMR and NI are very quickly collected, the cost-effectiveness is in line with the criteria of regular screening markers.

Any of the present study’s limitations merit attention. First, we were unable to thoroughly validate the prognostic value of LMR and NI due to the retrospective aspect of the analysis. Second, LMR is a non-specific inflammation marker, and while we omitted patients with any inflammatory disorder, the existence of other unrecognized systemic inflammatory disorders could have impaired laboratory findings. The strength of our research is that it is the first attempt to evaluate the prognostic importance of LMR and NI in OC patients with normal CA125 level.

Conclusion

In summary, our current study showed that patients with higher pretreatment LMR (≧ 4.25) showed significantly better survival than those with lower LMR (<4.25); Patients with higher NI (≧47.5) revealed pretreatment LMR and NI were also an independent prognostic factor that predicts OS and PFS.

Declarations

Ethics Approval and Consent to Participate

The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. The study protocol was approved by the Hospital Ethics Committee of the Second Affiliated Hospital of Soochow University.

References

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  15. Cramer DW, O’Rourke DJ, Vitonis AF, Matulonis UA, Dijohnson DA, et al. (2010) CA125 immune complexes in ovarian cancer patients with low CA125 concentrations. Clin Chem 56: 1889-1892. [crossref]
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fig 8

Severe COVID-19 Pneumonia is Associated with Increased Plasma Immunoglobulin G Agonist Autoantibodies Targeting the 5-Hydroxytryptamine 2A Receptor

DOI: 10.31038/EDMJ.2021511

Abstract

Aims: To test whether plasma autoantibodies targeting the 5-hydroxytryptamine 2A receptor increase in COVID-19 infection; and to characterize the pharmacologic specificity, and signaling pathway activation occurring downstream of receptor binding in mouse neuroblastoma N2A cells and cell toxicity of the autoantibodies.

Methods: Plasma obtained from nineteen, older COVID-19 patients having mild or severe infection was subjected to protein-A affinity chromatography to obtain immunoglobulin G fraction. One-fortieth dilution of the protein-A eluate was tested for binding to a linear synthetic peptide QN.18 corresponding to the second extracellular loop of the human 5-hydroxytryptamine 2A receptor. Mouse neuroblastoma N2A cells were incubated with COVID-19 IgG autoantibodies in the presence or absence of selective inhibitors of G-protein coupled receptors, signaling pathway antagonists, or a novel decoy receptor peptide.

Results: 5-hydroxytryptamine 2A receptor autoantibody binding occurred in 17 of 19 (89%) patients with acute COVID-19 infection and increased level was significantly correlated with increased severity of COVID-19 infection. The agonist autoantibodies mediated acute neurite retraction in mouse neuroblastoma cells by a mechanism involving Gq11/PLC/IP3R/Ca2+ activation and RhoA/Rho kinase pathway signaling occurring downstream of receptor binding which had pharmacologic specificity consistent with binding to the 5-HT2A receptor. A novel synthetic peptide 5-HT2AR fragment, SN..8, dose-dependently blocked autoantibody-induced neurotoxicity. The COVID-19 autoantibodies displayed acute toxicity in bovine pulmonary artery endothelial cells (stress fiber formation, contraction) and modulated proliferation in a manner consistent with known ‘biased agonism’ on the 5-HT2A receptor.

Conclusion: These data suggest that 5-HT2AR targeting autoantibodies are highly prevalent may contribute to pathophysiology in acute, severe COVID-19 infection.

Keywords

COVID-19 infection, 5-Hydroxytryptamine 2A receptor, Inflammation, Neurotoxicity

Introduction

The SARS-Cov-2 virus mediates hyper-inflammation and dysregulated immunity leading to ‘cytokine storm’ [1]. Inflammation predisposes to hypercoagulability and human autopsy studies severe COVID-19 infection demonstrated widespread microvascular occlusion in the lung, liver, kidney, heart and brain [2]. Endothelial cells harbor angiotensin converting enzyme 2 (ACE2), the cellular receptor for SARS-Cov-2 virus entry [3] and the host response (to SARS-Cov-2 virus infection) in severely-affected persons is characterized by ‘endotheliitis’ [4]. Previously, we had reported increased circulating agonist IgG autoantibodies to the 5-hydroxytryptamine 2A receptor in subsets of diabetic microvascular disease or neurodegenerative disorders [5]. The autoantibodies promoted endothelial cell apoptosis and were neurotoxic in vitro [6,7]. Since the 5-hydroxytryptamine 2A receptor is expressed on platelets, innate and adaptive immune cells [8,9] and it was reported to mediate (in part) chronic inflammation in certain animal models of autoimmunity [10-12], here we tested whether agonist 5-hydroxytryptamine 2A receptor IgG autoantibodies increase in COVID-19 infection in association with severe disease.

Patients and Methods

Patients

Total nineteen patients were either admitted to an acute medical floor or intensive care unit at the Veterans Affairs New Jersey Healthcare System (VANJHCS; East Orange, NJ) between April-June 2020 because of symptomatic COVID-19 infection or became COVID-19 PCR positive while residing on a subacute VANJHCS rehabilitation or nursing home unit. Blood was drawn for testing and validation of a new Clinical Laboratory Service, COVID-19 antibody assay. Leftover, discard plasma was provided by the Clinical Laboratory Service (Dr. Cynthia Bowman) for the purposes of this research study. The study was reviewed by the local VANJHCS Investigational Review Board and determined to be exempt from informed consent requirement. Plasma samples were stored at-20 degrees C prior to isolation of IgG autoantibodies.

Patient 1

A 73-old-man who experienced pneumonia, respiratory failure, renal failure requiring dialysis and weeks-long period of hyperinflammation (i.e. markedly elevated WBC) who died 3.5 months after admission. During his months-long hospitalization, he was not treated with any medication having antagonist activity on the 5-HT2A receptor.

Patient 2

A 62-year-old man with major depressive disorder, hypertension, HIV, cirrhosis, who experienced COVID-19 pneumonia without respiratory failure. He was treated with the selective 5-HT2A receptor antagonist mirtazapine (45 mg nightly) during a several months hospitalization for intermittent abdominal pain of unknown etiology. He was discharged in stable condition to a long-term facility.

Patient 3

An 86-year old man with prior CVA, hypertension, dementia, atrial flutter with rapid ventricular response, and congestive heart failure who experienced pneumonia and respiratory failure. The tachycardia responded to digoxin therapy. He was treated with convalescent plasma and discharged in stable condition to a subacute rehabilitation facility.

Patient 4

A 72-year-old man with prior history of cerebrovascular accident, type 2 diabetes mellitus and hypertension who experience a mild COVID-19 infection

Patient 5

A 74-year-old man with refractory hypertension, prior history of TIA , type 2 diabetes melllitus who presented with intermittent left arm weakness for 1 day. He was treated with intravenous fluids and discharged home in stable condition.

Patient 6

A 73-year old man with diabetes and dementia who experienced an asymptomatic COVID-19 infection while residing on a long-term VA nursing home unit.

Methods

Protein-A Affinity Chromatography

Protein-A chromatography was carried out as previously reported [6].

Synthetic Peptides

All peptides were synthesized at Lifetein Inc. (Hillsborough, NJ) and had > 95% purity including QN..18 (QDDSLVFKEGSCLLADDN), SN.8 (SCLLADDN), QF.7 (QDDSLVF), and VC.7 (VFKEGSC). An additional control, a scrambled sequence of SN..8 having amino acid sequence LASNDCLD, (LD..8) consisted of the same amino acids as in SN..8, but arranged in a scrambled sequence.

Enzyme Linked Immunosorbent Assay (ELISA)

An enzyme linked immunosorbent assay employed 50 microgram per milliliter concentration of QN..18, which has an amino acid sequence corresponding to the second extracellular loop region of the human 5-HT2A receptor, as the solid-phase antigen. The ELISA was performed as previously reported [5].

Mouse Neuroblastoma N2 Cells

Mouse neuroblastoma N2A cells were cultured in DMEM with 10% fetal calf serum.

N2A Mouse Neuroblastoma Cell Neurite Retraction Assay

Quantitative determination of acute neurite retraction following the addition of COVID-19 plasma autoantibodies in the presence or absence of selective antagonists was carried out as previously reported [5].

N2A Mouse Neuroblastoma Cell Survival Assay

An MTT assay was used to assess mouse neuroblastoma cell survival following exposure to COVID-19 plasma autoantibodies; and was carried out as previously reported [5].

Bovine Pulmonary Artery Endothelial Cells

Bovine pulmonary artery endothelial cells (BPAE) were obtained from Sigma Chemical Co. and they were cultured in Medium 199 with 10% fetal calf serum.

Endothelial Cell Survival Assay

BPAE cells were plated in 96-well plates and incubated for 72 hours prior to the addition of a 1:50th dilution of the protein-A eluate fraction from COVID-19 or age-matched patients without COVID-19 infection. After 48 hours incubation at 37 degrees C in a CO2 incubator, endothelial cell survival (% basal endothelial cell number) was determined using a colorimetric detection system as previously reported [6].

Chemicals

Chemicals were obtained from Sigma Chemical Co., Inc. (St Louis, MO) except YM-254890 obtained from Tocris (Mpls., MN) and SB204741 obtained from Focus Biomolecules (Plymouth Meeting, PA).

Protein Determinations

Protein assays were carried out as previously reported [5].

Statistics

Comparisons were made using unpaired Student’s t-test; and Pearson’s correlation coefficient.

Results

Clinical Characteristics and Autoantibody Prevalence

The baseline clinical characteristics in the study patients are shown in Table 1. Mean age was 67.3 ± 8.9 years. Nearly all patients had one or more co-morbidities, essential hypertension and diabetes mellitus being the most common ones (Table 1). In an enzyme linked immunosorbent assay using the second extracellular loop of the human 5-hydroxytryptamine 2A receptor as the solid phase antigen, seventeen of nineteen (89.5%) COVID-19 patients tested positive for autoantibodies having significantly increased receptor peptide binding, i.e. > 0.06 AU or higher. The mean level of binding in a 1/40th dilution of the autoantibodies in each of nineteen COVID-19 patients tested was 0.123, i.e. three-fold above background (0.04) absorbance level (Table 1).

Table 1: Baseline clinical characteristics and autoantibody in the 19 Covid-19 patients

table 1

AAB-autoantibody; TIA- transient ischemic attack; AU-absorbance units

^ A 1/40th dilution of the protein-A eluate fraction of plasma was incubated with QN…18 linear synthetic peptide corresponding to second extracellular loop region of the human 5-HT2A receptor as reported [5].

Clinical Outcomes

Total ten of nineteen patients (53%) experienced pneumonia and overall 37% experienced respiratory failure. Seven patients died during the inpatient hospitalization: five patients having COVID-19 pneumonia and two patients due to a primary gastrointestinal disorder, either severe worsening of alcoholic hepatitis or from urosepsis complicated by a gastrointestinal bleed. Four of nineteen patients (21%) experienced end-stage renal disease as a manifestation of acute severe COVID-19 infection (Table 2).

Table 2: Clinical manifestation and outcome in 19 Covid-19 patients

table 2

GI-gastrointestinal; ESRD- end-stage-renal disease; Y-yes, N-no

Plasma Autoantibody Binding to 5-HT2A Receptor Peptide

Patients suffering with COVID-19 pneumonia, respiratory failure and the subset who progressed to death had highest autoantibody binding to the 5-HT2A receptor peptide (Figure 1). Respiratory failure leading to death (in two patients) was associated with mean autoantibody binding level (0.23 AU) more than 5.5-fold above background (0.04 AU) (Figure 1). COVID-19 with or without respiratory failure was associated with mean 3.25-fold increased autoantibody level compared to background (Figure 1). Persons with asymptomatic or minimally symptomatic COVID-19 infection (n=4) had much lower level of autoantibody binding, (mean 0.08 AU, Figure 1). Plasma autoantibodies in age-matched patients without COVID-19 infection (n=5) and not suffering from co-morbid vasculopathy or a neurodegenerative disorder(s) previously associated with elevated autoantibodies had no or nearly undetectable 5-HT2A receptor peptide binding (mean 0.04 AU, Figure 1).

fig 1

Figure 1: Plasma autoantibody binding to a linear synthetic 18-meric peptide QN…18 corresponding to the second extracellular loop of the human 5-hydroxytryptamine 2A receptor.

A 1/40th dilution of the protein-A eluate fraction of plasma was incubated with linear synthetic QN..18 peptide and binding was determined as previously reported [5]. ND-neurodegenerative disease; microvasc(ular) dz-disease; Asymp(tomatic).

Role of Hyperinflammation in the De novo Appearance of COVID-19, 5-HT2AR Autoantibody

A representative patient (Patient 1) who experienced multi-organ failure leading to death was a 73-year-old man who had a trajectory of white blood cell count level indicative of persistent hyperinflammation (Figure 2A). Plasma autoantibody binding to 5-HT2AR peptide was undetectable 5 days after the onset of symptoms, but (at day 35) had increased to 5.75 times higher than background level (Figure 2B). These are the first data to suggest de novo appearance of very high level of 5-HT2AR autoantibodies in association with hyperinflammation in severe COVID-19 infection.

fig 2

Figure 2: Clinical course (A) and de novo appearance of 5-HT2AR autoantibody (B) in plasma from a representative patient with severe Covid-19 pneumonia. Pt 1: A) 73-old-man who experienced pneumonia, respiratory failure, renal failure requiring dialysis and weeks-long period of hyperinflammation (i.e. markedly elevated WBC) who died 3.5 months after admission. B) Serotonin-2A receptor autoantibody binding was undetectable 6 days after hospital admission, but it had increased to 5.5-fold greater than background level approximately 1 month later (on day 36). Dashed line (A) indicates upper limit of normal WBC, or (B) lower limit of detection of 5-HT2AR peptide binding.

Pre-existing 5-HT2AR autoantibodies in patients having co-morbid neurodegenerative disease

An IgG immune response to the COVID-19 virus spike protein was reported to be present in essentially all patients tested more than 10 days after the onset of clinical symptoms, but not earlier [13]. Yet three patients who experienced only mild COVID-19 symptoms (Figure 3A) already had substantially increased level of 5-HT2AR autoantibodies (mean 3-fold above background ) in blood drawn less than 5 days after symptom onset (Figure 3B). All three patients had a co-morbid neurodegenerative disorder, (i.e. stroke, refractory hypertension or dementia) previously reported to be associated with high level of 5-HT2AR-binding autoantibodies [5]. These data are consistent with preexisting 5-HT2AR autoantibodies which may not have increased substantially after mild COVID-19 infection.

fig 3

Figure 3: White blood cell count (A) and plasma 5-HT2AR autoantibodies (B) in three representative patients with asymptomatic Covid-19 infection who had co-morbid neurodegenerative disease. A) White blood cell counts in three patients having minimally symptomatic Covid-19 infection B) Increased ‘preexisting’ 5-HT2AR autoantibody binding manifested less than 1 week after onset of Covid-19 symptoms occurred in three patients having a co-morbid neurodegenerative conditions previously associated with high autoantibody level [5].

Correlation between Baseline Risk Factors, or Inflammation and 5-HT2AR Autoantibodies

Consistent with a prior report [5] there was no significant correlation between age or body mass index and the level of 5-HT2AR autoantibody binding in plasma from nineteen COVID-19 patients tested (Figure 4A and 4B). After excluding four patients who had blood drawn for autoantibody determination < 5 days after symptom onset, white blood cell count (a marker of systemic inflammation) was significantly correlated (Pearson correlation coefficient R = 0.845; P < 0.01) with 5-HT2AR autoantibody binding (Figure 5).

fig 4

Figure 4: Lack of significant association between plasma 5-HT2AR binding autoantibodies and (A) age or body mass index (B) in 19 patients with Covid-19 infection. N=1 patient had missing data on body mass index (BMI).

fig 5

Figure 5: White blood cell count is significantly correlated with level of plasma autoantibodies to 5-HT2A receptor peptide in Covid-19 infection. Four patients were excluded from the analysis because blood drawing occurred less than 6 days after the initial onset of Covid-19 symptoms. Pearson correlation coefficient (R = 0.845; P < 0.01; N=15).

Association between Plasma 5-HT2AR Autoantibodies and COVID-19 Disease Severity

There was a gradient of increased plasma 5-HT2AR autoantibodies level for increasing severity of COVID-19 infection (Figure 6). Mean level of autoantibody binding in patients who experienced COVID-19 pneumonia, respiratory failure and death (n=5) was significantly higher (0.17 vs 0.08; P< 0.01) vs level in patients with mild or asymptomatic COVID-19 (n=4) (Figure 6). It was also significantly higher in patients who experienced COVID-19 pneumonia with or without respiratory failure (n=5) (0.13 vs 0.08; P =0.02) vs those having only mild or asymptomatic infection (n=4) (Figure 6). These data suggest a dose-response relationship may exist between level of 5-HT2AR agonist autoantibodies and severity of COVID-19 infection consistent with a possible pathophysiologic role for COVID-19 disease autoantibodies. We next examined COVID-19, plasma 5-HT2AR peptide-binding autoantibodies for toxicity in neuroblastoma or endothelial cells.

fig 6

Figure 6: Association between severity of Covid-19 infection and level of plasma autoantibody binding to 5-HT2AR peptide. **P< 0.01 respiratory failure and death vs. asymptomatic or mild Covid-19 infection. * P= 0.02 pneumonia with or without respiratory failure vs mild Covid-19 infection. Results are mean (SD) of binding in a 1/40th dilution of the protein-A eluate fraction of plasma.

Neurotoxicity Associated with COVID-19 Disease 5-HT2AR Autoantibodies: Pharmacologic Profile

In prior studies [6,7], plasma 5-HT2AR autoantibodies from patients having a neurodegenerative or microvascular disease caused acute neurite retraction and accelerated cell loss in mouse N2A neuroblastoma cells by a mechanism involving long-lasting activation of Gq/11/phospholipase C/IP3R/Ca+2 signaling, and RhoA/Rho kinase activation. Here, COVID-19 autoantibodies caused acute neurite retraction (in mouse neuroblastoma cells) which was nearly completely prevented (95%) by a 500 nanomolar concentration of the highly selective, potent 5-HT2AR antagonist M100907 (Table 3). COVID-19 autoantibody-induced neurite retraction was also significantly prevented by a similar or higher concentration of spiperone or ketanserin, antagonists that also have activity on the 5-HT2A receptor (Table 3). Specific antagonists of other classes of Gq/11-coupled G-protein coupled receptors, e.g. losartan, bosentan, prazosin, had much less (if any) protective effect on COVID-19 autoantibody-induced neurite retraction (Table 3). Taken together, the pharmacologic profile of neurotoxicity induced by COVID-19 autoantibodies is consistent with its binding to a linear synthetic peptide corresponding to the 5-HT2A receptor.

Table 3: Pharmacologic profile of Covid-19 infection autoantibody-induced neurite retraction.

Antagonist

[Conc]       GPRC % Inhibition of Covid-19 AAb Neurite Retraction
M100907 500 nM 5-HT2A/B/C

95%

Spiperone

500 nM 5-HT2A/B/C 72%
Ketanserin 5 µM 5-HT2A//B/C

70%

SB 204741

1 μM 5-HT2B  0%
Losartan 5 μM AT-1R

30%

Bosentan

5 μM ET1-R 10%
Prazosin 850 nM A1-AR

20%

Results are (mean +/- 15%) on inhibition of N2A neurite retraction in 130 nanomolar concentration of severe Covid-19 autoantibody (Pt 3) by indicated concentration of each GPCR antagonist. AT-1R- angiotensin II, type 1 receptor; ET1-R- endothelin 1 receptor; A1-AR- alpha 1 adrenergic receptor

AAb- autoantibody

Mechanism of Action of 5-HT2AR, COVID-19 Autoantibody Neurotoxicity

Co-incubation of COVID-19 autoantibodies together with a specific antagonist of Gq/11 (YM-254890), phospholipase C (U73122), inositol triphosphate receptor (2-APB) or RhoA/Rho kinase (Y27632) signaling each completely abolished acute neurite retraction by the autoantibodies (Table 4). This suggests that COVID-19 autoantibody signaling downstream of 5-HT2AR receptor binding occurs via Gq11-positively coupled to PLC/IP3R/Ca 2+ pathway activation and RhoA/Rho kinase signaling consistent with the previously reported signaling pathways involvement in 5-HT2AR peptide-binding autoantibodies from patients (without COVID-19), but having a neurodegenerative disorder or diabetic microvascular angiopathy [6,7].

Table 4: Effect of signaling pathway antagonists on Covid-19 autoantibody induced N2A neurite retraction

    Treatment

[Conc] % Covid-19 autoantibody-induced neurite retraction
YM-254890 (Gq/11 inhibitor) 1 µM

0% ± 0%

2-APB (IP3R inhibitor)

20 μM 0% ± 0%
U73122 (PLC inhibitor) 30 μM

0% ± 0%

Y27632 (ROCK inhibitor)

10 μM

0% ± 0%

Results are mean (SD) of two determinations on prevention of N2A neurite retraction in 130 nanomolar concentration of severe Covid-19 autoantibody (Patient 3) by the indicated concentration of pathway inhibitor.

Receptor Decoy Peptide Prevents Neurotoxicity from COVID-19 Autoantibodies

We next tested a receptor decoy peptide, SN..8, tentatively called ‘Sertuercept’ because it has amino acid sequence identical to an extracellular region of the serotonin 2 receptor (“Sertu”) involved in mediating long-lasting receptor activation [14] and it may function as a decoy receptor (“ercept”). Sertuercept previously demonstrated neuroprotection against toxic effects of plasma 5-HT2AR autoantibodies from patients lacking COVID-19, but having either diabetic vasculopathy or a neurodegenerative disease [5]. Here, co-incubation of COVID-19 autoantibodies together with increasing concentrations of Sertuercept dose-dependently prevented acute N2a cell neurite retraction; Sertuercept had IC50 of approximately 4 micromolar for half-maximal prevention of COVID-19 autoantibody-induced acute N2A neurite retraction (Figure 7). Ten micromolar concentration of Sertuercept afforded 87.5% protection against neurite retraction induced by a 130 nanomolar concentration of COVID-19 autoantibodies from Patient 2 (Figure 8). An identical (10 uM) concentration of scrambled peptide sequence LN..8 having the same amino acids as in Sertuercept or higher (20 uM) concentration of two peptides (e.g. QF..7 or VC..7) comprising adjacent subregions in the QN..18 sequence which comprises the second extracellular loop of the human 5-HT2A receptor did not significantly prevent COVID-19 autoantibody-induced neurite retraction (Figure 8). These data suggest that neuroprotection against COVID-19 autoantibody-induced toxicity is specific for the SN..8 peptide (Sertuercept) amino acid sequence.

fig 7

Figure 7: Dose-dependent inhibition of Covid-19 autoantibody induced N2A neuroblastoma cell neurite retraction by synthetic 5-HT2A receptor peptide fragment, SN..8. Mouse neuroblastoma N2A cells were incubated together with a 130 nanomolar concentration of autoantibody from a Covid-19 pneumonia patient (Patient 2) in the presence of the indicated concentration of 5-HT2A receptor peptide fragment SN..8. Acute neurite retraction was determined after 5 minutes as described in Methods.

fig 8

Figure 8: Specificity of 5-HT2A receptor peptide fragment SN. 8-mediated prevention of Covid-19 autoantibody induced N2A neurite retraction. *P< 0.01 compared to Covid-19 Pt 1 autoantibody (130 nM concentration) alone.

Mouse neuroblastoma N2A cells were incubated together with a 130 nanomolar concentration of autoantibody from a Covid-19 pneumonia patient in the presence of the indicated concentration of receptor peptide SN..8 or a scrambled sequence LD..8 or peptide (QN..7 or VC..7) corresponding to adjacent regions of QN..18 [5]. Acute neurite retraction was determined after 5 minutes as described in Methods.

Titer and Neurotoxicity of COVID-19, Plasma 5-HT2AR Autoantibodies

In eight patients having symptomatic COVID-19 disease, the mean titer of 5-HT2AR binding autoantibodies (determined in blood drawn on average 3.1 weeks after symptom onset) was ~ 67 nM IgG. Mean titer in two patients with either Alzheimer’s dementia or Parkinson’s disease (without COVID-19) was somewhat higher perhaps consistent with much longer duration of disease. Titer in symptomatic COVID-19 (n=8) or neurodegenerative disease (n=2) autoantibodies was significantly higher than in three uncomplicated diabetic patients without microvascular complications (Figure 9). Plasma autoantibodies from symptomatic COVID-19 disease (n=3) caused dose-dependent accelerated loss in mouse neuroblastoma cell N2a cells which significantly exceeded N2A cell loss induced by autoantibodies (tested at identical dilutions) from patients without COVID-19 infection (Figure 10).

fig 9

Figure 9: Increased titer of 5-HT2AR binding autoantibodies in plasma from eight Covid-19 patients: comparison to non-Covid patients having neurodegenerative disease or uncomplicated diabetes mellitus, ie. without vasculopathy or co-morbid neurodegeneration. *P< 0.01 vs binding in autoantibodies from uncomplicated DM diabetes mellitus, ie. without microvascular complications or neurodegenerative disorder.

Autoantibodies from Covid-19 patients, or non-Covid patients having either co-morbid neurodegenerative disorder or uncomplicated diabetes mellitus were tested for binding to QN..18 second extracellular loop of 5-HT2AR receptor peptide in ELISA. Covid-19 and non-Covid neurodegenerative disease autoantibodies displayed similarly high titer of autoantibody that exceeded binding in uncomplicated diabetes autoantibodies at each of two dilutions tested.

fig 10

Figure 10: Covid-19 autoantibodies cause dose-dependent accelerated loss in mouse neuroblastoma N2a cells compared to patients without Covid-19 infection. *P< 0.05 comparing neurotoxicity in Covid-19 protein-A eluates to nearly identical concentration of protein-A eluate from patients without Covid 19.

Pharmacologic Specificity of the COVID-19, 5-HT2A Receptor Targeting Autoantibodies

Three different antagonists having a relative order of their affinity constants (M100907< spiperone << ketanserin) on the 5-HT2AR each caused dose-dependent inhibition of COVID-19 autoantibody induced acute N2A neurite retraction (Figure 11). The IC50 for M100907 on 130 nM concentration of COVID-19 autoantibodies (Pt 2) was approximately 270 nM (Figure 11A). Spiperone and ketanserin was each tested against a lower (38 nanomolar) concentration of more highly potent, COVID-19 (Pt 3) neurodegenerative diseases autoantibody. Spiperone had an IC50 for inhibition of autoantibody-induced neurite retraction of ~ 300 nM (Figure 11B). Ketanserin had an IC50 of ~ 1.5 mM consistent with ketanserin having relatively weaker antagonism on the 5-HT2AR. Maximal concentrations of either spiperone or ketanserin afforded partial (72-77%) protection against the potent, Pt 3 COVID-19, neurodegenerative diseases autoantibodies (Figure 11B and 11C).

fig 11

Figure 11: Dose-dependent prevention of Covid-19 autoantibody-induced N2a acute neurite retraction by three different 5-HT2AR antagonists: A) M100907, B) spiperone, C) ketanserin.

A)130 nM concentration of Patient 2 plasma autoantibodies; B-C) 38 nM concentration of Patient 3 plasma autoantibodies.

Modulation of Endothelial Cell Survival by Autoantibodies in Severe COVID-19 Disease

Mean endothelial cell survival was significantly decreased (66 ± 18.5%, n=4 vs. 103.2 ± 1.8%. n=5; P =0.003) after 2 days incubation with a 1/50th dilution of the protein-A eluate from four COVID-19 plasmas compared to five age-matched patients without COVID-19 (Figure 12). Mean EC survival was significantly higher (114.5 ± 0.5%, n=2 vs. 103.2 ± 1.8%, n=5; P < 0.001) in the protein A eluates from two COVID-19 patients who had comorbid lymphoma or HIV disease compared to five patients without COVID-19 infection (Figure 10).

fig 12

Figure 12: Modulation of endothelial cell survival by plasma autoantibodies from symptomatic Covid-19 infection: comparison to age-matched patients without Covid-19 infection.

*P =0.003: Compared to EC survival in autoantibodies from patients with No Covid-19 infection.

^P < 0.001: Compared to EC survival in autoantibodies from patients with No Covid-19 infection.

Results are % endothelial cell survival in a 1/50th dilution of the protein-A eluate fraction of plasma as described in Materials and Methods. Dashed lines represent mean EC survival in each subgroup.

COVID-19 Autoantibodies Cause Endothelial Cell Stress Fiber Formation and Acute Contraction

Autoantibodies in patients having either diabetic microvascular complications [15] or a neurodegenerative disease [6,7] were previously reported to cause stress fiber formation and apoptosis in endothelial cells. In preliminary experiments, the Pt 3, COVID-19 autoantibodies (47 nanomolar concentration) caused stress fiber formation (within 5 minutes) and sustained contraction in bovine pulmonary artery endothelial cells (during 30 minutes continuous exposure). Pre-incubation with the receptor decoy peptide SN..8 (20 micromolar concentration) substantially prevented (~80-90%) endothelial cell contraction induced by (twenty-eight nanomolar concentration) of the Pt 3, COVID-19 and dementia autoantibodies (data not shown).

Discussion

Severe COVID-19 infection causes pulmonary inflammation and diffuse endothelial cell dysfunction predisposing to multi-organ failure. The present data are the first to suggest that systemic inflammation in severe COVID-19 infection can give rise to the de novo appearance of very high level of IgG autoantibodies that specifically target the 5-HT2A receptor expressed on vascular endothelial cells and on neurons. Even though acute respiratory failure may occur prior to the emergence of IgG autoantibodies (in patients who lacked preexisting autoantibodies) a significant association between antibody level and severity of COVID-19 disease suggests a possible role (for the 5-HT2AR-targeting autoantibodies) in contributing to endothelial cell damage and/or neurotoxicity underlying ongoing disease pathophysiology.

Inflammation may have driven (in part) the appearance of 5-HT2AR-targeting autoantibodies in severe COVID-19 infection consistent with a prior report of a significant association between increased peripheral inflammation and 5-HT2AR autoantibodies in patients lacking COVID-19 infection, but having either obese type 2 diabetes mellitus or traumatic brain injury [16]. Angiotensin converting-enzyme 2, the cellular receptor for SARS-Co-V2 virus is abundantly expressed on endothelial cells [3] perhaps making certain antigens expressed on endothelial cells preferential targets of humoral immunity in SARS-Co-V2 viral infection.
Endothelial cell inhibitory autoantibodies in patients having either diabetic vasculopathy or traumatic brain injury cross-reacted with heparan sulfate proteoglycan [16]. Anti-heparan sulfate proteoglycan autoantibodies occur in systemic lupus erythematosus and are thought to contribute to an increased risk of vascular thrombosis by interfering with the normal inhibitory effect of antithrombin III on thrombin [17]. Microvascular endothelial cell injury results in platelet adhesion and the 5-HT2A receptor which is expressed on platelets plays a role in platelet aggregation leading to 5-HT (serotonin) release.

Recent autopsy studies in COVID-19 patients revealed diffuse microvascular occlusions in key organs including lung, liver, heart, kidney and brain [2]. High level of 5-HT2AR-targeting autoantibodies was previously reported [5] in patients without COVID-19 infection harboring retinal artery or retinal vein microvascular occlusion. The etiology of small and large vessel thromboses occurring in severe COVID-19 infection is unknown and is likely to be multifactorial. Severe COVID-19 infection mimics aspects of systemic autoimmune disease including the presence of anti-phosphatidylserine autoantibodies implicated in causation of recurrent large vessel thrombosis e.g. anti-phospholipid syndrome [18] in systemic lupus erythematosus. For example, a recent study reported that approximately 25-50% of COVID-19 infected patients harbored either anti-phosphatidyl/prothrombin antibodies or anti-phospholipid antibodies in the circulation [19]. Viral infections, certain cancers e.g. Burkitt’s lymphoma [20] and systemic autoimmunity are all associated with an increased incidence of circulating immune complexes. The 5-HT2AR binding autoantibodies from two patients having COVID-19 infection and either co-morbid Burkitt’s lymphoma or HIV disease caused significant endothelial cell proliferation consistent with a prior report of increased cell proliferation evoked by the 5-HT2AR-targeting autoantibodies from a patient with discoid lupus erythematosus [21]. The 5-HT2A receptor is known to mediate ‘biased agonism’ such that structural differences in the agonist can direct downstream signaling toward activation of beta arrestin 2-mediated survival pathways [22].

The 5-HT2AR is not only widely expressed in vascular tissue [23], but also in the central nervous system [24]. Previously, we reported that the highly potent, endothelial cell inhibitory plasma autoantibodies in a subset of cancer fatigue patients caused excitation followed by prolonged ‘desensitization’ of synaptic input in cultured rat hippocampal pyramidal neurons [25]. Fatigue and neurologic symptoms are among the most common manifestations of ‘long haul’ COVID-19, a syndrome in which various nonspecific symptoms can persist for weeks following recovery from acute COVID-19 infection. Longer term follow up in a diverse patient population is needed to test whether 5-HT2AR-targeting IgG autoantibodies may persist for weeks or months following acute COVID-19 infection and whether persistently elevated autoantibody level or titer may correlate with a subset of persistent ‘long haul’ COVID-19 symptoms.

Recently, we reported that use (vs non-use) in hospitalized COVID-19 infection of existing FDA-approved, 5-HT2AR antagonists (to treat comorbid neuropsychiatric illness or for ICU delirium) was associated with a significant, 5-fold lower odds ratio for mortality [26]. Based on the present data, one possibility is that 5-HT2AR antagonist medications block harmful effects from agonist 5-HT2AR autoantibodies expressed at high level in most cases of severe COVID-19 infection.

In summary, nearly ninety percent of patients with COVID-19 infection, many having pneumonia and requiring hospitalization, harbored substantial titer of neurotoxic and endothelial cell toxic plasma IgG autoantibodies which bound to a linear synthetic peptide corresponding to the second extracellular domain of the 5-HT2A receptor. Binding was associated with acute neurotoxicity which could be prevented (in vitro) either with specific 5-HT2A receptor antagonists or by a serotonin 2A receptor peptide SN..8, Sertuercept, corresponding to a subregion important in mediating long-lasting 5-HT2A receptor activation [14]. Taken together, these data provide proof-of-principle that repurposing of existing FDA-approved 5-HT2AR antagonist medications or a novel decoy 5-HT2A receptor peptide (Sertuercept) might protect against harmful effects of 5-HT2A receptor agonist autoantibodies associated with COVID-19 infection.

Acknowledgement

Dr. Cynthia Bowman, Chief, Pathology and Laboratory Medicine Service, Veterans Affairs New Jersey Healthcare System (East Orange, New Jersey) for providing discard COVID-19 plasma samples used in the approved research study.

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Characterisation of Microscopic Changes in Macroscopically Unaffected Peritoneum in Women with and without Endometriosis

DOI: 10.31038/AWHC.2021413

Abstract

Study question: Is there a difference in the occurrence of occult microscopic endometriotic lesions in normal peritoneum between women with and without endometriosis and if so are there other differences in the structure of the peritoneum between these groups?

Introduction: Occult Microscopically Endometriosis (OME) was firstly described by Murphy et al. in 1986. Since then there has been more research on the topic but without finding any conclusions about the clinical significance. Therefore, OME could be a physiological phenomenon that occurs in women with and without endometriosis (EM) or it could also be an early stage of real EM lesions.

Methods: For this study, we surgically removed the macroscopically unaffected peritoenum from the left and/or right paracolic gutter from 64 women with and 22 women without EM. The tissue was then immunohistochemically stained with antibodies of an Estrogen Receptor Alpha (ERa), a Progesterone Receptor (PR), Cytokeratin, CD10, and Anti-Smooth Muscle Cell Actin (ASMA).

Results: OME lesions were found in five of the 86 patients (5, 81%). One of these lesions was found in a woman without EM which is 4, 5% of the control group. In the group of women with EM, there were four patients with OME lesions which is 6, 3% of the cohort, so there was no statistically significant difference between these groups. Besides the OME lesions, there were immune cells found in the tissue of 12 women with EM (18, 8% of the EM cohort) but none in the control group. These findings did not correlate with the OME lesions.

Introduction

EM is one of the most common gynecological diseases and affects approximately 10% of women of a reproductive age [1,2]. It is defined as the presence of endometrial and/or stromal cells outside the uterine cavity and is most likely to be found disseminated on the peritoneum of the pelvic cavity like in the pouch of Douglas, on the sacrouterine ligaments, in the ovaries and the ovarian fossae [3-5]. Typical symptoms are dysmenorrhea, cyclical and acyclical pelvic pain, and infertility [6]. As the intensity of symptoms does not correlate with extending of infestation it often takes several years until the diagnosis is made [7-9]. Today’s gold standard to detect peritoneal EM is by laparoscopy [10-12]. But within this technique small EM lesions may be overlooked.

As the pathogenesis of EM has not been clarified and probably cannot be described by only one theory, we were wondering which part of the OME lesions take it in. We chose to concentrate on the impact of the peritoneal fluid, which is known to have several spaces in the peritoneal cavity where it is more present. One of these spaces is the right paracolic gutter, which is why we decided to examine the difference between the right and left paracolic gutters for the occurrence of OME [13,14]. OME was first described in 1986 by Murphy et al. [15]. It is defined by the presence of endometriosis in macroscopically normal-looking tissue. Even though there have been further studies, the meaning of OME is still unclear. Firstly, it could have an important status in the pathogenesis of endometriosis. Secondly, it could also be a physiological phenomenon with no disease value. To find out more about the clinical relevance of OME we histologically examined tissue specimens derived from visually normal peritoneum of the paracolic gutters of women with and without EM to detect the possible occurrence of OME. Due to the fact, that endometriotic lesions are associated with the local inflammatory response we also investigated the occurrence of IC and angiogenesis in this tissue.

Materials and Methods

Subjects

During the period between 2013 and 2016, peritoneal biopsy samples from 64 women with visible endometriosis and 22 women without visible endometriosis were collected during laparoscopy. The institute of pathology made the diagnostic assurance by histological examination. The most common reason for the operations in women with EM was EM resection. For women without EM, it was resection of fibroids. With the knowledge of the influence the peritoneal fluid has on the distribution of EM lesions, we chose to collect tissue from the right and left paracolic gutters. The goal was to see if the distribution of OME lesions is also influenced by it. All biopsy specimens were collected in accordance with the patients and were approved by the guidelines of the ethics committee. In Table 1 you can find the clinical profiles of the two groups.

Table 1: Subjects.

With EM n (%)

Without EM n (%)

Number 64

22

Age

Mean Range

29,9 years

18-47

36,4 years

18-50

Oral Contraceptives (OC) 24 (37,5)

4 (18,2)

Menstrual cycle

Menstruation Proliferation

Secretion

No Cycle (due to OC)

Unknown

7 (10,9)

6 (9,4)

14 (21,9)

24 (37,5)

13 (20,3)

0 (0)

3 (13,64)

3 (13,64)

4 (18,18)

12 (54,54)

Coexisting diseases

Adenomyosis (AM) Myoma (UM)

Sterility

Hypothyroidism

43 (67,2)

9 (14,1)

10 (15,6)

8 (12,5)

0 (0)

12 (54,5)

1 (4,5)

4 (18,2)

Antibodies

We performed immunohistochemical studies to investigate immunoreaction of target antigens in the serial sections of biopsies using the following antibodies: PR (Progesterone receptor), ERa (Estrogen receptor alpha), CD 10 (stromal cell marker), ASMA (Anti-Smooth Muscle Cell Actin), and Cytokeratin (glandular cell marker). Non-immune mouse immunoglobulin (IgG) antibody was used as a negative control. The detailed names, dilutions, and manufacturers are given in Table 2.

Table 2: Antibodies.

Name of antibody

Dilution

Manufacturer

Ms anti- Progesteron-R Dako PgR

1:50

Dako, Denmark

Ms anti-ER-alpha 1D5

1:60

Dako, Denmark

Ms ASMA abcam 1A4

1:50

Abcam, UK

Ms anti-CD10 ab951

1:50

Dako, Denmark

Anti-Cytokeratin MNF116 Dako

1:50

Dako, Denmark

Biotin-SP-conjugated AddiniPure Rabbit Anti-Mouse IgG

1:400

Dianova, USA

Immunohistochemistry

Firstly, we prepared 2 µm thick paraffin-embedded tissue slides which were then deparaffinized in xylene and ethanol. After that, they were either treated with Target-Retrieval-Solution (pH 9) or citrate buffer (pH 6) – depending on the antigen we were planning to use on it. Subsequently, the slides were incubated with the primary antibodies for 1 hour at room temperature and then for another hour with the biotin secondary antibody (Table 2), followed by incubation with avidin–peroxidase for 30 min and finally visualized with Fast Red Chromogen System (PR, ERa, CD10, Cytokeratin) or SIGMAFAST (ASMA). Finally, the tissue sections were counterstained with Mayer’s hematoxylene, cleared in aqua dest, and mounted.

Statistical Analysis

All data were analyzed by SSPS program, using exclusively metrical variables in independent samples. All groups to be compared in the evaluation were checked for normal distribution. Subsequently, the statistical test to be used was determined. If two samples were present, the Chi-square test or the Mann-Whitney test was carried out for normally distributed and non-normally distributed samples. The t-test was not used due to the small number of cases. A value of P < 0.05 was considered to be statistically significant.

Results

The Occurrence of OME Lesions

In total, we found 5 OME lesions, which is 5, 81% of all patients. Three of these lesions contained at least one glandular cell whereas the other two lesions contained stromal cells. There was only one lesion, which contained all three parts of a typical EM lesion (glandular cells, stromal cells, and smooth muscle cells (SMC)) (Figure 1). A summary of these results can be found in Table 3. Furthermore, the clinical profiles of patients with OME are given in Table 4.

fig 1

Figure 1: OME lesion 03, which contains all three parts of an EM lesion. A: Cytokeratin; B: ASMA.

Table 3: Summary of OME lesions.

OME lesion

01

02 03 04

05

Glandular cells

Yes

Yes Yes No

No

Stromal cells

No

No Yes Yes

Yes

SMCs

Yes

Yes Yes No

No

Size in µm

88 x 30

328 x 75 310 x 312 222 x 62

337 x 140

Table 4: Clinical profiles of patients with OME.

OME lesion

01 02 03 04

05

EM

No

Yes Yes Yes

Yes

Menstrual cycle

Proliferative

Menstruation Unknown Proliferative

No Cycle

OC

No

No No No

Yes

Age (years)

45

38 45

36

25

History

UM

AM, Sterility AM AM, UM

AM

Side

Right

Right Right Right

Left

Cell type in OME

Glandular cells

Glandular cells Glandular cells Stromal cells

Stromal cells

Four of these lesions were found in the right paracolic gutter with only one on the left side while four of those lesions were also found in patients with EM with only one found in a woman of the control group. For the group of patients with EM that is a proportion of 6, 3% and for the control group, it is a proportion of 4, 5%. A statistical evaluation was carried out using the chi-square test. This calculation resulted in a p-value of 0.768 and therefore shows no statistical relevance of the probability of occurrence of OME between the two groups of patients.

The Occurrence of Immune Cells in Peritoneal Tissue

Besides the OME lesions, we also detected some groups of immune cells. These cells were seen in the immunostaining pattern of CD10. In total there were 12 patients who had such groups (containing lymphocytes and granulocytes) in their peritoneal tissue. All of these patients were in the EM group and no inflammatory signs could be found in the control group. In the group of women with EM there were 18,8% demonstrably affected by inflammation of the peritoneum. The p-value of 0.029, determined using a chi-square test, shows the statistical relevance of this result.

The Occurrence of Blood Vessels in Peritoneal Tissue

To find out if the process of neoangiogenesis takes part in the development of OME we examined all tissue specimens for blood vessels. To take into account the difference in the size of the samples, the vessel density was determined using the hot-spot method.

In women with EM we found a slightly higher density than in women without EM (1, 74 vessels per mm2 in women with EM versus 1.66 vessels per mm2 in women without EM). However, this difference is with a p-value of 0.519 determined using a Mann-Whitney U test not statistically relevant.

Discussion

There has been more research done on this topic since Murphy et al. first described the occurrence of OME lesions in 1986. Synoptically this has all but confirmed the presence of OME. However, in the study of Redwine and Yokom, it was the other way around and they found OME to be more common in women without EM. It is important to point out that this study only used a small control group consisting of 10 women, which limits the meaningfulness of it [16-22]. Nevertheless, there has not been a statistical significance in the occurrence of OME between women with and without EM in any of the studies. Table 5 shows a summary of all the studies about OME.

Table 5: Summary of results of studies about OME [16-22].

Study

Year Operation Localization of removed tissue Frequency of OME in patients with EM

Frequency of OME in patients without EM

Murphy et al.

1986

Laparotomie Cul-de-sac 25%

Redwine

1988

Laparoscopy Posterior pelvic peritoneum 0%

0%

Redwine, Yocom

1990

Laparoscopy Cul-de-sac, Sacrouterine ligaments, Broad ligaments 4,4%

10%

Nisolle et al.

1990

Laparoscopy Sacrouterine ligaments 13%

6%

Nezhat et al.

1991

Laparoscopy Peritoneum, 3-5 cm next to EM lesions 15% (clin. diagnosis) vs. 3,9% (histolog. diagnosis)

0%

Balasch et al.

1996

Laparoscopy Sacrouterine ligaments 11%

6%

Kahn et al.

2014

Laparoscopy Pouch of Douglas, Uterovesicle space, Sacrouterine ligaments 15%

6,4%

Even though there is no significant difference between the occurrence rate of OME in this study compared to Nisolle, Balasch, and Kahn, et al. there are reasons why they found a higher rate. First of all the technical possibilities were significantly improved in the last few years. Furthermore and more interestingly, we examined tissue from the paracolic gutters, which is not known to be one of the most common sites for EM. In contrast, all the other authors decided to take tissues from sites of the peritoneum where EM is very likely to find in the pelvis [6,13,23].

The Meaning of OME

There are two potential meanings of OME. Firstly, it could be an early stage of a “real” EM lesion. In that case, it would be involved in the development and eventually even in the persistence and recurrence of EM after a successful treatment. Secondly, it could also be a physiological phenomenon in which endometrial cells settle in the peritoneum but later get broken down by the immune system. In that case, it would not have anything to do with the development of a “real” EM lesion.

The first case could explain why up to 50% of patients who underwent surgical EM resection, have a recurrence of complaints and “new” EM lesions within 5 years [24,25]. The opinion of Kahn et al. that OME lesions are biologically active and have growth potential would support this theory [22].

On the other hand, the fact that the prevalence of OME in women with and without EM is almost the same suggests that OME lesions have no influence on the development of EM or only in connection with other influencing factors that have not yet been finally clarified.

Distribution of OME Lesions

The peritoneal fluid has a typical distribution in the peritoneal cavity. Due to the force of gravity, it is usually located in deeper locations such as the Pouch of Douglas. However, negative intracranial pressures during inspiration and the influence of peristalsis regularly lead to a cranial flow of the peritoneal fluid. Therefore, the fluid runs over the paracolic gutters. The majority of the peritoneal fluid runs over the right paracolic gutter, as it is deeper than the left paracolic gutter. In this way, the fluid reaches the subdiaphragmatic space on the right side and from there is directed back into the deeper areas via the inframesocolic compartment. This circulation of the PF in the peritoneal cavity results in four places where it is particularly frequent/long [13,26]. As one of these places is the right paracolic gutter, we decided to examine both of the paracolic gutters to see if there is a difference in the occurrence of OME lesions. In this study the lesions were distributed in a 4: 1 ratio (right: left) in the paracolic gutters. This result suggests that the development of the lesions is justified or at least encouraged by the influence of the peritoneal fluid, their composition, and their flow directions [13,14,27]. Therefore, one could either support Sampson’s theory or say that retrograde menstruation causes endometrial cells to enter the PF and adhere to the peritoneum as they circulate, and assume that growth factors, angiogenesis factors, and inflammatory factors contained in the PF promote the development of OME lesions [27-29].

Immune Cells

Interestingly, when comparing the specimens in the paracolic gutters of women with and without EM, it became clear that immune cells were only found in tissue samples from patients with EM. The associations of immune cells could be an expression of the inflammatory response in the context of EM and OME lesions that have been eliminated by the immune system. However, since they tended to be found more often on the left side and OME lesions as well as normal EM lesions are mainly located in the right paracolic gutter, it can be assumed that there are inflammatory processes in the entire peritoneal tissue of women with EM. A study by Scheerer et al. from 2016 also found a significantly more frequent occurrence of immune cells in the peritoneal tissue of women with endometriosis compared to women without endometriosis [30].

The question of whether the peritoneum becomes flammable through the EM, or whether the peritoneum is more likely to develop EM lesions due to its inflammatory consideration is still open. However, five women with inflammatory tissue were under the influence of OC at the time of surgery. This medication can prevent the progression of EM lesions and improve the symptoms. However, this is not the case for all patients who take OC, and often after the pills have been discontinued the symptoms recur quickly [31,32]. This could be because the peritoneum is less penetrated by EM lesions, but it is still affected by inflammatory processes and may therefore promote the formation or regrowth of regressed lesions.

Amount of Blood Vessels

The pathogenesis of EM is known to be influenced by VEGF [33]. The growth factor leads to an increased blood flow to the tissue permeated by EM and thereby promotes the progression of the lesions [34]. In this study, there was no statistically relevant difference in the vascular density between women with and without EM. Furthermore, no relevantly increased vessel density could be found in the tissue pieces in which there were OME lesions. Therefore, they did not seem to be associated with neoangiogenesis. In contrast to the samples with OME lesions, however, an increased vascular density was found in samples with immune cells, which corresponds to a typical inflammatory reaction.

Conclusion

In this study, a few cases of OME were detected in both women with and without EM. There was no significant difference in the frequency of occurrence between the two cohorts. An important significant difference in the peritoneal tissue of women with EM compared to that of women without EM was the appearance of immune cells, which were only found in women with EM. Both lymphocytes and granulocytes were found, which, however, were in no case associated with an OME lesion in this study. These tissue samples also had an increased average number of vessels, which can be easily reconciled with an inflammatory reaction. Even though this result was not significant, it does show a certain trend.

As OME occurs in both tissue samples from women with and tissue samples from women without EM, it is likely that it is a physiological phenomenon in which endometrial cells settle in the peritoneum and are subsequently cleared by the immune system. The found hormone receptor status with a predominance of PR over ER of these lesions also supports this theory.

Concerning the causality of the inflammatory changes in the peritoneal tissue of women with EM, further research is required to be able to offer patients better and long-term successful therapeutic options.

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fig 1

Is there Evidence to Suggest that Maternal Obesity Impacts Breastfeeding Prevalence? – A Review

DOI: 10.31038/AWHC.2021412

Abstract

Globally, breastfeeding and obesity have become paramount importance for mothers and infants. This paper aimed at reviewing the literature to explore the evidence that maternal obesity can have a negative impact on breastfeeding rates. A review of the literature (academic journals) was conducted between 2005 and 2019 using the PRISMA 2009 and critical appraisal approach to critically evaluate the articles and reach an evidence statement.

Concerning the research question of the study, twelve research articles were considered for review. The review found maternal obesity/overweight as independent variables (defined as Prepregnancy or postpartum Body Mass Index) and breastfeeding rate as the dependent outcome variable.

The majority of the studies showed evidence of a negative impact of obesity on breastfeeding rates. Therefore, to understand breastfeeding behavior among obese women, researchers could consider conducting more empirical studies that use well-established theories, including the theory of reasoned action. This review may help clinicians recognize patients who are less likely to breastfeed and consider targeting early intervention.

Background

It is known globally that obesity has become a widespread public health problem. For example, in Nebraska, United States of America (US), the prevalence of adult obesity is reported to be 32.8% (up from 11.3% in 1990) and is ranked the 15th highest rate of obesity in the nation [1]; in addition to, increasing prevalence of obesity in the Arab World including Jordan, Kingdom of Saudi Arabia, United Arab Emirates and others [22,23]. The degree of obesity is measured by the Body Mass Index (BMI) that calculates weight in relation to squared height. BMI between 25 -29kg/m2 is classified as overweight and 30 kg/m2 or higher as obesity [2]. The burden of disease due to obesity extends beyond conventional health consequences to include social, psychological, emotional, economic, and societal costs [3-5].

Obesity is more common among women [6]. Research has indicated that the risk of emerging a variety of non-communicable diseases, including cardiovascular diseases, diabetes, arthritis, infertility, and breast cancer, increases among obese women [7,8]. Successful breastfeeding (BF) is a relatively complex process that begins even before the birth of the baby. Studies show that the first step is the woman’s intention to breastfeed, successfully initiating BF, and then successfully maintaining that process. For optimal benefits for both baby and mother, most authorities recommend exclusive BF to continue for up to six months [9].

BF is an integral part of developing the infant’s brain and body and impacts its health as it grows [10]. Medical conditions such as childhood obesity, gastroenteritis, and type 2 diabetes are increasingly seen among children who are breastfed at lower rates [11]. BF also affects mothers’ health, where there is a decreased risk of postpartum hemorrhage and type 2 diabetes as well as other conditions such as breast, uterine, and ovarian cancers [12].

Several maternal inputs determine the success of the BF process. Medical, socioeconomic, psychosocial, and lifestyle aspects have been repeatedly cited as factors associated with BF practice [13]. Maternal obesity has emerged as yet another element that might negatively impact BF [14-19]. This phenomenon is emerging as a public health concern globally. Referring to the earlier example, in Nebraska, fewer than fifty percent of infants are BF at six months of age, and only 20% are exclusively breastfed at that age. This paper aims to review the literature to explore the evidence that maternal obesity can negatively impact BF rates. This may help clinicians recognize patients who are less likely to breastfeed and consider targeting early intervention at women who are thought to be at a higher risk. The definition of BF rates can be referred to as: “ever breastfed refers to those infants who have been put to the breast, even if only once; and exclusive breastfeeding concerns infants who have only received breast milk during a specified period of time. The cut-off points regarding the duration of exclusive-breastfeeding – 3, 4 and 6 months – are in line with past and current WHO guidelines [13,57]”.

Literature Review

Context

Globally, obesity prevalence is three times since 1975. In 2016, more than 650 million adults were classified as obese, which accounts for 13% of the world’s population; 40% of them were women, according to a 2018 report World Health Organization [20]. The cause of obesity is multiple factors, including physical activity levels, dietary patterns, medication use, food, and education [21]. The Center for Disease Control and Prevention (CDC) reported on obesity as a serious concern due to its association with reduced quality of life, poorer mental health outcomes, and the leading causes of death across the US and extending globally, including diabetes, stroke, heart disease, and cancer [21].

Within Eastern Mediterranean Region (Middle East), seven countries population (adults) were ranked among the ’20 most overweight nations’, including Kuwait (73.4%), Qatar (71.7%), Kingdom of Saudi Arabia (69.7%), Jordan (69.6%), Lebanon (67.9%), United Arab Emirates (67.8%) and Libya (66.8%) [22,23]. Reports from the International Diabetes Federation stated that there were 374,100 new cases of diabetes report in Jordan as an example and are mostly related to obesity [22]. Women suffer more from obesity, especially when they get pregnant. The World Health Organization reports that obesity is a major problem among Jordanian women, with 40% [20,27]. A Jordanian national survey in 2007 showed that obesity is most prevalent among women of reproductive age. From the research report, some of the critical factors for obesity amongst women included marriage at an early age, wealth status, parity, lack of appropriate place for women to exercise, and smoking [20,27].

It is undoubtedly known, there is a global recognition of the advantages of BF for both mothers and infants [1-3]. BF has been lately described as “personalized medicine.” For newborns, the new series published in 2016 by Lancet noted critical evidence demonstrating the notion of BF as a vital cornerstone of children’s survival, growth, health, and development, and thereby associated positively with life expectancy and prosperous future [24]. Additionally, the Lancet series highlights the economic benefits of BF. For instance, it was found that babies who were not breastfed across countries faced financial losses of over $300 billion annually due to the lowered cognitive ability levels, resulting in reduced earning capacity for these persons [24]. The World Health Organization noted the importance and benefits of exclusive breastfeeding (EBF) having more significance and positive social impact in settings of poor nutrition, poverty, and poor personal hygiene, where the baseline disease rates are higher [1,5,58]. Annually, the lives of over 800,000 children less than five years of age can be saved provided that optimal BF is administered [24,25,60].

About twenty percent of neonatal deaths may be prevented with BF initiation within the first hour after birth [7,8,58] in low-income and middle-income countries. Furthermore, the continuation and optimal BF practices have the potential of preventing at least twelve percent of all under-5 deaths [9,26,58]. Research studies have indicated that children who are exclusively breastfed are less vulnerable to developing associated childhood illnesses and fourteen times more likely to combat ill-health than those who are not breastfed [10,26,58,59]. The EBF rates prevalence is lower, and childhood mortality is higher among low-income and middle-income countries [27,58]. In Jordan and Ghana, for instance, the documented rate of infant mortality is 17 per 1000 live births and 53 per 1000 live births; while, the mortality rate of children younger than five years is 21 per 1000 live births and 31 per 1000 live births, and these death rates are moderately related to lowered prevalence of EBF practices, respectively [27,58].

Prevalence

For the first six months, postpartum, early initiation of BF and EBF are strongly endorsed [12]. Globally, the rate of BF initiation is sub-optimal [12,60]. Despite the significant developments in some World Health Organization (WHO) regions, the prevalence of EBF remains of great concern to low-and medium-income countries, as illustrated in a study using data from 66 countries [13,60]. The study reviewed the prevalence of EBF among infants younger than six months for fifteen years, from 1995 to 2010. This study revealed that most EBF among infants increased from 33% in 1995 to 39% in 2010 across developing countries [13,60]. The WHO 2009 report showed that the prevalence of EBF rate (39%) is globally low; within in low-income and medium countries, there is a 36% EBF rate [2,13,60].

In 1997 Jordan, the Demographic and Health Survey (DHS) indicated that the rate of EBF was twelve percent among babies less than six months old [27]. The prevalence of EBF fluctuated for many years in Jordan; in 2002, EBF was 26.7%, then dropped to 22% in 2007, and then had a slight increase to 23% and 26% in 2012 and 2017, respectively [27]. Several Jordanian cross-sectional studies reported suboptimal BF initiation rates ranging from 13% to 19% [27]. Eastern Mediterranean Regional (Middle East Region) data about BF and EBF are not well reported from the Arab World, and cross-sectional studies collect most data. In Saudi Arabia, the rate of initiation of BF among Saudi mothers was at 92%, as compared with the prevalence of initiation of BF as 98% in the United Arab Emirates and 57% in Qatar [28,60].

Barriers

Many factors were identified as obstacles to infant feeding traditions, proper dietary nutrition [13,58]. Some literature relates the lack of BF or even reluctance to do so to poor maternal knowledge or attitude of the mother and maternal and infant medical conditions. Several studies have identified other important factors related to health providers’ attitudes and practices and supportive policies and enabling health facility infrastructure. Several published Jordanian studies reported several adverse challenges and obstacles that influence the initiation and EBF. Of these, Dasoki et al., and Khassawneh et al., showed that Cesarean births and no endorsement of BF initiation policies were obstacles to BF [28-30]. Abuidhail [31] reported that mothers expressed that infants remained hungry after BF. Abu Shosha [32] showed that short intervals between pregnancies and physical breast problems during BF were addressed. Additionally, Khassawneh et al. [28,29] reported the place of work as another obstacle that contributed to mothers’ inability or desirability to practice BF.

Moreover, studies showed that women commonly said they did not intend to practice BF on their newborns, particularly EBF in the first six months [27-32]. Such an intention may be due to the limitations of social support and systems and the challenges posed in the workplace. In these studies, respondents shared concerns about the side effects when mothers BF, in terms of perceived pain and changes in body figure and weight [27-32]. Based on the above-given reasons for not practicing BF, women may be influenced by the knowledge, attitudes, and practices across countries. Adequate knowledge about EBF is the fundamental tool that can direct EBF practice among mothers [27-29]. Therefore, this review paper’s main objective is to review the literature to explore the evidence that maternal obesity can negatively impact BF rates.

Methods

This literature review’s search strategy involved visiting the EBSCO HOST web and Academic Search Premier, PubMed, Web of Science, CINAHL plus full text, Science Direct, EMBASE, Bio Med Central, Wiley online Library, All Health Watch and MLA International Bibliography databases. The inclusion criteria specified peer-reviewed scholarly research articles published in academic journals between 2005 and 2019, full text with references available and English. Items were excluded from the review if they did not answer the research question; if they tackled obesity in children, men, or women who had not given birth; if they were reviews of literature of any kind or if they fell outside the specified search period. A variety of keywords were used, including BF, BF behavior, BF practices, lactation, BMI, maternal, obesity, overweight, observational and cohort studies, and randomized controlled trials. A total of 2,830 articles were located. However, an assessment of these articles revealed that only eleven of them fit the criteria. Further research was carried out through exploring the South Wales University “Find it” global article search, which contributed one more article. A total of twelve research studies were finally considered for review to answer the research question. The PRISMA 2009, Hill and Spittle house, 2004 critical appraisal approach, and the Critical Appraisal Skills Program (CASP, 2013) were primarily used to critically evaluate the articles and reach an evidence statement (Figure 1) [33-35,56,61].

fig 1

Figure 1: PRISMA 2009 Flow Diagram

Results

The review considered maternal obesity/overweight as independent variables (defined as Prepregnancy or postpartum BMI) and BF rate as the dependent outcome variable. The analysis included assessing whether the studies addressed potential confounding variables that interfere in the relationship between obesity/overweight and BF rates. Besides, the PRISMA 2009 was utilized with the summary as follows: In 2006, Oddy et al. investigated the association of maternal Prepregnancy overweight and obesity with BF duration [36]. This prospective study, conducted in Western Australia, covered 1803 live-born infants and their mothers. Results indicated that, after adjusting for socioeconomic, demographic, biological, and medical factors of mothers and infants, Prepregnancy obesity and overweight had no relationship to the initiation [36]. However, they showed a significant effect on reducing BF at any period before six months; obese mothers were more likely to stop BF at two months Odds ratio (OR 1.89 [95%] CI: 1.45, 2.47) compared to normal-weight mothers (OR 1.76 [95%] CI: 1.35, 2.28) and for less than six months [36].

Mok et al., 2008 investigated the relationship between Prepregnancy BMI of obese mothers and BF practices concerning the initiation and continuation at three months postpartum. The study covered 1432 mothers at the Centre Hospitalier Universitaire de Poitiers, France, in 2005. Obesity was significantly associated with lower BF initiation and continuation rates at one month (p ≤ 0.0001) and three months (p ≤ 0.001). An interesting finding of this study points to the psychological factors that may affect BF. Women reported feeling uncomfortable to breastfeed in public at 3 months [37].

In a cohort study, Liu et al., 2010, investigated race as a contributing factor to the negative impact of maternal obesity on the prevalence of BF. The analysis examined the relationship between maternal obesity and BF initiation and duration among women in South Carolina. This is one of the few studies which explored the effects of race in detail. A random sample of 2,840 black and 3,517 white women was drawn from a population-based Pregnancy Risk Assessment Monitoring System (PRAMS) dataset, which included women who gave birth from 2000 to 2005 [38]. The study revealed that Prepregnancy weight of white women negatively affects BF, especially in morbidly obese mothers (OR 0.63, [95%] CI: 0.42, 0.94). The study also showed that, while black obese women did not initiate BF, obesity did not affect the duration of BF when BMI was continuously measured (adjusted hazard ratio 1.03, (95%) CI: 1.01, 1.04) [38].

The association between BF initiation and maternal Prepregnancy BMI was investigated in 2013 by Thompson et al. in Florida, US. This study used a large population-based sample amounting to 1,161,949 singleton mothers who gave birth between 2004-2009. Women reported Prepregnancy weight, height measurements, and initiation of BF in the instantaneous postpartum period. The results of the study indicated that, after adjustment for the confounding variables, including race (Hispanic and other races), obese mothers were less likely to initiate BF compared to normal-weight mothers (OR: 0.84 (95%) CI: 0.83, 0.85). However, this finding did not apply to overweight mothers [39].

A population-based cohort study investigated a large sample of 22131 women delivering in four hospitals in Ontario, Canada. The findings pointed to a negative impact of obesity on BF intention and initiation. This study recruited women who had full-term live births between 2008- 2010. Study results showed that obese mothers, constituting 21% of the study sample, were less likely to plan to BF. In contrast, overweight mothers (27.7% of the sample) were likely to practice BF as normal-weight mothers. Both obese and overweight mothers were less inclined to initiate BF in hospitals and upon discharge than mothers with normal weight [OR: 0.67(0.60-0.75), 0.68 (0.62-0.76)], respectively [40].

Several elements may contribute to the negative impact of maternal BMI on BF. Some of these are related to the mother’s body shape, which hinders the infant’s physical positioning or leads to mechanical failure during suckling at the nipple [36,41]. Psychosocial factors contribute to embarrassment related to body size or shape, thus interfering with BF, mainly when practiced in public. Other factors are associated with obtaining proper health education and counseling from health professionals [36,41-43].

In the US, a national cohort study conducted by Hauff et al., 2014 found that maternal BMI did not affect BF intention and initiation. However, the duration of “ever” BF and “any” BF, as defined by the authors of overweight and obese mothers, was negatively affected by psychosocial factors. Obese women have a 29% increased risk to stop “any” BF than normal-weight mothers (adjusted hazard ratio for the cessation of BF among obese mothers 1.29 (95%) CI: 1.09-1.53). However, this did not apply to overweight mothers [44]. This longitudinal study suggested that overweight and obese mothers, in contrast to normal-weight mothers, were less confident in their ability to practice BF amongst their infants then they had initially intended. Additionally, their BF continuation was adversely influenced by social networks, friends, and relatives who had a poor BF history [44].

Keely et al., 2015 conducted in depth semi-structured interviews with a group of 28 obese women living in Scotland. The participants were recruited between 2011-2013 and represented different ethnic groups and social classes in the study area. This qualitative study aimed to identify obstacles to BF and learn more about women’s views concerning BF practices and the support provided by family, community, and health services [45]. The findings indicated that obese mothers had intentions to BF for at least 16 weeks. However, several of them failed to continue beyond a few days of initiation [45]. The rest could not continue beyond 6-10 weeks. Challenges identified as contributing to this behavior included physical, social support, and psychological factors [45]. This study’s contributions to the literature could be outlined in three themes: a lack of privacy, the impact of birth complications, and low uptake of specialist BF support [45].

A longitudinal cohort study conducted by Verret-Chalifour et al., 2015 in Quebec-Canada on a sample of 6,592 pregnant women confirmed the negative impact of high Prepregnancy BMI on BF initiation [46]. Obese mothers had a 26% increased risk of non-initiation of BF as compared to normal-weight women (relative risk 1.26 [95%] CI: 1.08- 1.46) [46].

A study from 2018 found that the incidence of self-reported BF problems was comparable across weight status groups: normal-weight and overweight. “Not enough milk” was the principal reason for providing infant milk formula [47]. Overweight women were more likely than normal-weight women to agree that infant formula was as good as breast milk [47].

Several qualitative and quantitative studies from 2019 also confirm that overweight and obese women are less likely to practice BF, have more difficulty with BF, and are strongly influenced by psychosocial factors such as poor self-efficacy and fear of negative evaluation of others based on their weight. [48-50].

Conclusion

The research question under review showed a high prevalence of maternal obesity ranging between 10-25%. The formal studies were mostly cohort, prospective, and population-based, used relatively large samples, and adjusted for most of the potential confounders. Many of the studies were carried out in developed countries, limiting the generalizability of the evidence for public health practice in different settings [51]. The majority of the studies showed evidence of a negative impact of obesity on BF rates. These data strongly suggest that although obese women may experience some additional challenges with BF initiation mechanics, perhaps a more important consideration is their perception of the opinion of the critical others in their social environment. Therefore, to understand BF behavior among obese women, we should consider conducting more empirical studies that use well-established theories, including the theory of reasoned action (TRA) [52]. TRA is a theory that is well manifested in the literature of understanding and predicting human behavior. TRA proposes that ‘intention’ is the main predictor of the behavior and response as a function of two variables: attitudes held towards behaviors, practices, ethics, and subjective norms [52]. TRA concedes humans need to be part of society. Consequently, TRA proposes that those who created an individual’s society and perceived as necessary to the individual, such as family members and friends, significantly influence an individual’s intention to perform a behavior [48]. About the reviewed literature results, it is expected that TRA will provide an excellent theoretical background to study further the effect of subjective norms on obese women’s intention to BF and to continue BF.

The reviewed literature also suggested a difference in intention and duration of obese women based on race. This difference raises the point to the need to explore the effect of culture – individuals’ collective perception of social norms, roles, and values in their environment which controls what behavior is desirable or should be circumvented to shape the intention of an obese woman towards BF [53,54]. For example, Hofstede’s studies on cultural dimensions have described two main groups for cultural differences; individualism and collectivism. Hofstede’s cultural index described individualism as independence from paying more consideration to one’s rights over one’s duties and social interaction [53,54]. On the other hand, collectivism was described as a higher degree of harmony between individuals and groups [55]. Thus, it is expected that the type of culture that obese BF women belong to will determine the degree to which they perceive others’ opinions to be essential and how it will shape their intention to breastfeed and continue for a set duration.

Another concern is a deficit of information among mothers about the importance of BF in both infants’ and mothers’ health. Given the high rates of maternal obesity and low prevalence of BF across the world, physicians and other health care providers are in an ideal position to educate patients- particularly those overweight and obese mothers or mothers-to-be on the benefits of BF and exploring with them their perceptions of factors that may be interfering with their intentions or willingness to breastfeed their infants. Attention to this issue can significantly improve the health of the people in our state for years to come.

Acknowledgments

The authors would like to acknowledge Mohammed Bin Rashid School of Government, Dubai, UAE, and the Alliance for Health Policy and Systems Research at the World Health Organization for financial support as part of the Knowledge to Policy (K2P) Center Mentorship Program [BIRD Project].

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fig 2

Homelessness and a Free Clinics Response to Emerging Infectious Disease Outbreaks: Lessons from COVID-19 Patients

DOI: 10.31038/IJNM.2020112

Abstract

Background: The first reported death among homeless persons in Miami Dade County was a 26-year-old male who presented with a fever at one of the free clinics in Homestead, Florida, and was immediately transported to the nearest public hospital in the area where he later died from COVID-19. Since that first death, other homeless persons have died from COVID-19. The purpose of this paper is to report the impact of congregant living in two homeless shelters and a free clinic’s response to COVID-19 in south Florida.

Problem: Homeless and underserved populations in South Florida are faced with medically complex needs that are partially met by onsite clinics. Unfortunately, the COVID-19 pandemic has further limited access to onsite clinic and hospital outpatient services. Therefore, follow up care and recovery support are minimal and adversely impact quality of life, resulting in a cost burden to the healthcare system.

Methods: Nasopharyngeal swabs were collected daily, Monday through Friday, from homeless persons living in and around the two shelters for 3-months, along with persons identified through contact tracing. All samples were tested for COVID-19 by reverse transcription polymerase chain reaction with results reported from the local Department of Health (DOH) laboratory.

Interventions: To decrease the spread of COVID-19, any shelter homeless person reporting symptoms or suspected of being positive for COVID-19 was assessed, tested, and separated from other residents until confirmation results were delivered. If positive, the resident was quarantined for 14-days in a single-room hotel designated for homeless persons testing positive for SARS-CoV-2, the virus that causes COVID-19.

Results: The clinic staff, assisted by the local DOH, conducted 545 coronavirus tests to 408 sheltered and unsheltered homeless persons living in and around the two shelters. Of the 545 tests performed, 56 (10%) were positive, 458 (84%) were negative, 44persons recovered from COVID-19, 4 (1%) persons died, 2 (<1%) persons were re-infected with COVID-19, 23 patients were hospitalized during the period of this study, and 108 persons were placed in quarantine, which included persons exposed during contact tracing.

Conclusion: Due to a lack of follow up, many homeless persons become super spreaders of COVID-19. Unless timely interventions using face coverings, quarantine, social distancing, and frequent hand washings are initiated, the spread of COVID-19 will continue among homeless persons resulting in greater morbidity and mortality among this population.

Keywords

Homeless, COVID-19 outbreak, Homeless shelters, Homeless clinics

Introduction

COVID-19 has taken the lives of over 1,305,189 people world-wide and greater than 244,250 in the U.S. In addition, confirmed global COVID-19 cases have reached 53,517,017 in 191 countries/regions, and in America, over 10.8 million confirmed cases [1]. As of November 14, 2020, Florida has the 3rd highest number of positive cases behind Texas and California, and reported 877,933 positive COVID-19 cases and 17,517 deaths [2]. Miami-Dade (MDC) and Broward (BC) counties lead the state in the number of positive cases and deaths, with MDC reporting 200,876 cases and 3,711 deaths, and BC reporting 95,371 cases and 1,592 deaths [1,2]. Included in the reported cases and death tolls are homeless persons adversely affected by COVID-19. The Miami Rescue Mission (MRM) provide shelter services to over 2000 homeless persons annually.

Background

The first reported death among homeless persons in MDC was a 26-year-old male who presented with a fever at one of the free clinics in Homestead, Florida, and was immediately transported to the nearest public hospital in the area where he later died from COVID-19 [3]. Homeless individuals and families are at increased risk for contracting and transmitting COVID-19, as well as other communicable diseases. Due to poor living conditions and limited access to healthcare resources, homeless people of all ages are vulnerable to acquiring COVID-19. This article will address measures taken to protect homeless men and women residing in local homeless shelters from the spread and increased morbidity and mortality associated with COVID-19 in south Florida.

History

The Miami Rescue Mission Clinic (MRMC) is a free clinic that provides primary medical services to over 11,000 homeless, destitute, uninsured, underinsured and underserved populations in south Florida annually. The MRMC has had a consistent presence in the South Florida community since 2009, addressing basic healthcare needs of homeless persons by assisting them in navigating through complex healthcare systems when additional care is needed, obtaining the necessary resources with area specialists and local hospitals, and facilitating lasting medical improvement toward empowering the patients to manage and take control of their own healthcare needs. All services including labs, medications, referred specialists and more sophisticated care arranged are provided at no cost. The MRMC is associated with the MRM, a homeless shelter, that is geographically located across the street from each other in one of the most underserved areas in South Florida, where one would find at any time of the day, homeless men and women sleeping on the sidewalks adjacent to both the MRM and the MRMC. A similar picture is seen in South Broward County (BC) at our MRM Broward Outreach Center (BOC). The MRM, Inc. is a not-for profit, 501c3 corporation that has provided meals, shelter, life-changing programs, and hope to men, women and children in need since 1922. The MRM onsite services include low demand shelter beds (24-hour – 7-days-a-week residential stay), overnight beds, three daily meals, transitional housing, case management, workforce development, life skills, health care, and stabilization services. In 2019, the MRM provided over 900,000 meals, an increase of 300,000 meals from 2018 and over 600,000 nights of safe shelter to people in need, living in MDC and BC.

COVID-19

COVID-19 is a human coronavirus frequently associated with upper respiratory tract infections (URTIs), but can also cause lower respiratory tract infections (LRTIs), such as pneumonia or bronchitis due to inflammation of the lung parenchyma [4,5]. The coronaviruses are positive-stranded ribonucleic acid (RNA) viruses named for their appearance as seen under an electron microscope, which shows elliptic virion projections of corona (crown-like spikes) from the Latin word for crown [4,6-8]. Prior to 2002, coronaviruses contributed 10% to 30% of the common colds and did not cause severe harm to humans [9,10]. However, since the outbreak of SARS-CoV in 2002 and MERS-CoV in 2012, genetic mutations of these coronaviruses resulted in severe respiratory illnesses when attached to human proteins in human respiratory tracts as well as increased mortality rates stemming from associated pulmonary and coronary emboli [9,11,12]. The World Health Organization (WHO a) issued the interim name “2019-n-CoV” on February 11, 2020, because it originated in the year 2019, the “n” indicating novel, and the “CoV” referring to coronavirus, categorizing the virus under SARS-CoV-2, later to COVID-19 [6,13]. COVID-19 is known to spread from person-to-person, between people who are in close contact with one another (less than 6 feet apart), through respiratory droplets, and touching contaminated items or inanimate surfaces [14]. It is also known that measures to prevent the spread of COVID-19, require proper hand-washing, use of personal protective equipment, social distancing of 6-feet apart, covering mouth and nose when coughing or sneezing, proper disposal of tissues, and properly cleaning frequently used surfaces with Food and Drug Administration (FDA) approved cleaning and disinfecting solutions [14,15]. Initially, due to limited personal protective equipment (PPEs) and close living conditions, the MRMC and the MRM shelters worked closely together to quickly address the Centers for Disease and Prevention (CDC) recommendations on preventing the spread of COVID-19 in our facilities [14].

The Problem

To protect MRM shelter residents from the spread of COVID-19 during the incubation period when residents were free of viral infection symptoms and viral antigen testing had not begun, MRMC staff initiated educational seminars emphasizing social distancing, frequent hand washing and importance of identifying and reporting symptoms of fever, cough, and difficulty breathing immediately to their case worker and clinic staff. The MRM also implemented strategic interventions by not allowing any new homeless admissions to either site location, spacing the beds in each dorm to at least six feet apart, providing hand sanitizers and disposable wipes to all residents, and cleaning frequently touched surfaces with FDA approved disinfectants [15]. The local health department was contacted to assist in providing antigen testing for all MRM shelter residents. Also, during the early outbreak of COVID-19 in South Florida, clinic and shelter staff closely monitored levels of transmission in MDC and BC knowing that the homeless population served has a higher risk of increased exposure and continuing disease transmission because of the large numbers of people living together.

MRM Clinic Rapid Response to COVID-19

To maintain disease surveillance and control, the MRMC and MRM staff worked twenty-four hours on-call to respond to any reported COVID-19 symptoms, with the understanding that presenting symptoms of fever, cough, shortness of breath or general malaise may be the only indication of the onset of COVID-19 [8,16]. It was equally important to initiate quarantine efforts if indicated, as we differentiated COVID-19 signs and symptoms from that of the flu virus and allergy symptoms. Understanding the incubation period for a virus helped to determine the quarantine period necessary to prevent and control viral spread [12,16]. According to the WHO, the incubation period for COVID-19 is between 2 to 10 days [7]. The main symptoms of COVID-19 are fever, tiredness, cough, and shortness of breath [8,15,16]. However, allergy symptoms are more chronic and present with sneezing, itching (eyes or skin), wheezing, post nasal drip, and coughing [16-18]. The flu virus may present with symptoms similar to COVID-19, but usually do not involve shortness of breath, except if the lower respiratory system has become involved and the condition has worsened. Common signs and symptoms of the flu virus include fever and chills, runny nose or nasal congestion, cough, occasional sore throat, myalgia, fatigue, headaches and body aches [19]. Residents reported to MRMC showing any of the symptoms listed were tested for COVID-19, and if positive, immediately quarantined in a local hotel, single person occupancy, for fourteen (14) days. At the end of the quarantine period, residents were retested for the antigen and if negative, returned to their dormitory at the MRM shelter. If a resident retested positive, the 14-day quarantine was repeated. Those residents who tested negative, but presented with symptoms were advised to stay in their dorm rooms until symptoms subsided and appropriate treatment plans were initiated. For those with more serious symptoms such as breathing difficulties, elevated temperature, and a productive cough (which can indicate pneumonia and warrant immediate medical attention) were seen by the health care provider (physician, physician assistant, or advanced practice registered nurse) via telehealth and transported by local fire and rescue services or the MRM transport van (depending upon the critical physical state of the patient) to the nearest local emergency care center for further evaluation and management. In an ongoing effort to maintain the health and well-being of the MRMC patients, the MRMC dispensed over 500 medications to homeless patients living at one of the MRM-BOC shelters over a two-month period.

Methods

First, adjustments made by the MRMC to the COVID-19 pandemic involved a rapid transition to telehealth for residential clients. Second, clinic staff provided urgent primary care to clients after local hospitals, clinics and community health centers cancelled the majority of specialty care visits, such as mental health and other critical services. Third, clinic staff provided patient medication refills delivered to the shelters to decrease emergency room utilization and a greater financial impact of existing stressed health care services due to COVID-19. Fourth, COVID testing and re-testing was initiated by the MRMC staff assisted by the local Department of Health (DOH). COVID-19 testing was conducted using nasopharyngeal swabs daily, Monday through Friday, from homeless persons living in and around the two shelters for 3-months, along with persons identified through contact tracing. COVID test results of homeless persons tested was provided by the DOH laboratory. Nasopharyngeal swabs were used because the research has shown that larger amounts of positive COVID-19 virus and viral RNA can be detected early in the disease using nasopharyngeal samples rather than throat swabs, and is independent of symptom presentation or severity [20,21]. Fifth, after clinic hours ended, clinic and shelter providers coordinated their efforts to verify priority patient needs, creating social distancing in dormitories and a single-use area in the clinic, reviewing client documentation (identifications, medical records, and symptoms) to determine the need for quarantine. Sixth, care coordination for contact tracing with local health department officials was ongoing. Seventh and ongoing was the reentry of quarantined patients back to the facility, avoiding stigmatization of previously affected individuals, and addressing the COVID deaths of clients. These action steps were taken in a rapid-fire format to reduce the spread of COVID-19 among the homeless population served. Studies have shown that viral shedding in respiratory secretions are common and can occur up to 3-days before the first clinical symptoms appear [22,23].

Interventions

The MRMC closed its clinic doors at the peak of the COVID-19 pandemic in response to mandatory shutdown orders by Florida’s Governor Rick DeSantis of non-essential businesses and orders for social distancing and face covering requirements of essential businesses for about 2-days to allow for increased purchasing of personal protective equipment (PPEs) for staff and patients and to create a social distancing design in the clinic. Following several coordinated MRMC health care and primary care providers (HCPs/PCPs) and MRM staff meetings and telehealth trainings, telehealth visits were initiated by having the on-call or on-site provider to log-in to the MRMC electronic medical record system (EMRS) and a web-video conferencing platform that is accessed by patients at each of the shelters in a designated area for private consultation. The web-video conferencing telehealth sessions allow the HCPs or PCPs and patients to connect using technology to deliver required health care services.

Telehealth

The Telehealth format allowed for synchronous (real-time telephone or live audio-video interactions with the patient using a smartphone, tablet, or computer). The caseworker/on-site medical technician was equipped with marginal medical equipment, such as temporal thermometers, digital blood pressure machines, weight scales, and oxygen saturation finger monitors. Biometric and anthropometric readings were obtained and reported by the onsite shelter medical technician while the consulting PCP conducted the remote evaluation and documented findings and planned treatments in the EMR. The MRMC PCPs conducted 397 telehealth visits over a 3-month period (June to September, 2020). Although, asynchronous (technology where messages, images, or data are collected at one point in time and interpreted or responded to later) and remote patient monitoring (direct transmission of a patient’s clinical measurements from a distance in real time or post-dated times to the PCP) are available, these two modalities were not used [24]. However, MRMC staff provided daily telephone welfare checks (362) over the same 3-month period to patients placed in quarantine at hotels or to those persons with symptoms of upper respiratory tract conditions, but tested negative or was diagnosed with other co-morbid conditions that warranted close follow-up. Because all clinic services are free, MRMC did not receive any telehealth reimbursement using the International Classification of Diseases (ICD) code – 10 99211 for office or other outpatient visits or Current Procedural Terminology (CPT) code – 99371 for telephone call by a physician to patient or for consultation or medical management or for coordinating medical management with other [25,26]. By quickly implementing Telehealth in the MRMC and making it available to homeless shelter residents, transmission of COVID-19 and other preventable diseases were mitigated, providing a safer option for HCPs, PCPs, and the patients served.

Results

The MRMC HCPs assisted by the local DOH staff, provided 545 coronavirus testing to 408 sheltered and unsheltered homeless persons living in and around the MRM and BOC persons and conducted 362 wellness telephone encounters (Table 1). Of the 545 tests performed, 56 (10%) were positive, 458 (84%) were negative, 44 persons recovered from COVID-19 (which includes individuals that tested negative and were added to the contact tracing), 4 (1%) persons died, 2 (<1%) persons were re-infected with COVID-19, 23 patients were hospitalized during the period of this study, and 108 persons were placed in quarantine, which included persons exposed during contact tracing. Ninety patients were tested at least two times during this study and one patient tested positive three times (15 Days after the first positive test and 7 days after the second positive test), The negative test for this patient came after 42 days after the first positive test.

Table 1: COVID-19 Testing Information.

Tests

N

%

N. of Tests performed Outcome

545

100.0%

Positive

56

10.3%

Negative

458

84.0%

Lab/STD

31

5.7%

Most of the individuals tested were male (83.6%, 341 Individuals), see Figure 1 and the average age of the individuals tested were 47.7 years. Regarding race and ethnicity, 74% of the patients were black and non-Hispanic (327 patients, 80%) (Table 2, Figures 2 and 3), 96% of the patients who tested positive were male and their average age was 49.3 years; 60% were black and 64% reported no Hispanic origin (Table 3), 23 patients were hospitalized and 4 died due to COVID-19. All 27 patients were male with an average age of 55.1 years (Table 4). The average age of patients who were hospitalized were 53.1 years, while the average age of the deceased patients and were on average 55.2 years old. The ages of the 4 victims who passed away ranged between 56 to 74 years of age.

fig 1

Figure 1: Demographics of Homeless Persons Tested for COVID-19 by Gender.

Table 2: Patient Demographics who were Tested for COVID-19.

Demographic Characteristics

N %
Number of Patients 408

100.0%

Age

Mean Age ± SD

47.7 ±14.6

Gender

Male 341

83.6%

Female

67 16.4%
Race and Ethnicity

Black

303 74.3%
Hispanic

3

Non-Hispanic

300
White 104

25.5%

Hispanic

78
Non-Hispanic

26

Asian

1 0.2%
Hispanic Origin

Hispanic

81 19.9%
Non-Hispanic 327

80.1%

fig 2

Figure 2: Demographics of Homeless Persons Tested for COVID-19 by Race.

fig 3

Figure 3: Demographics of Homeless Persons Tested for COVID-19 by Ethnicity.

Table 3: Patient Demographics who Tested Positive for COVID-19 at least in one test.

Demographic Characteristics

N %
Number of Patients 53

100%

Age

Mean Age ± SD

49.34 ± 12.9

Gender

Male 51

96.2%

Female

2 3.8%
Race and Ethnicity

Black

32 60.4%
Hispanic

0

Non-Hispanic

32
White 21

39.6%

Hispanic

19
Non-Hispanic

2

Hispanic Origin

Hispanic 19

35.8%

Non-Hispanic

34

64.2%

Table 4: Patient Demographics and Presenting Symptoms who were Hospitalized or Died due to COVID-19.

Demographic Characteristics

N %
Number of Patients

27

Age

Mean Age ± SD

55.15 + 10.6

Gender

Male 27

100.0%

Female

Race and Ethnicity

Black

23 85.2%
Hispanic

Among the four deaths from the homeless shelter, three were confirmed COVID-19 positive and one unconfirmed. The three confirmed COVID-19 deaths occurred within 6-days of each other. Each victim had preexisting conditions and were being treated at the MRMC prior to hospitalization for a history of diabetes mellitus, obesity and hypertension. The fourth homeless death occurred one-month following the first three deaths and was unconfirmed for COVID-19. All victims were males, three were non-Hispanic Blacks and one Hispanic. Each of the three deaths presented to the emergency room with shortness of breath, fever and cough; admitted to the intensive care unit where their conditions deteriorated rapidly; and decompensated requiring increased oxygen and later intubation.

Contact Tracing, Quarantine and Reentry

Contact tracing plays a significant role in identifying positive cases, interrupting viral transmission and helps to prevent further spread of the virus. Contact tracing involves four-steps: (1) case investigation of close contacts, (2) contact tracing of exposed individuals, (3) contact support through education, information and exposure reduction, and (4) self-quarantining by staying at home and maintaining social distancing of at least 6-feet for th14-days [27]. MRMC HCPs conducted contact tracing on 108 patients. Of the 108 patients, 65 tested positive for COVID-19 and were placed in quarantine at the designated hotel. All hotel rooms used for housing positive COVID-19 patients were properly decontaminated using FDA approved disinfecting agents. Patients quarantined were required to wear face coverings when exiting the room for individual meals, when in contact with family members during the quarantine period, and when outside or in close contact with other people. Asking everyone to wear masks has helped to reduce the spread of COVID-19 by persons who may be unaware that they have the virus [16,27]. The N95 and KN95 masks are both rated to capture 95% of particles. The KN95 masks are made in China and require wearers to pass a fit test [28]. The N95 masks produced by the 3M company have stronger breathability standards. However, both the KN95 and the N95 mass filtration efficiency captures salt particles and a tested flow rate of 85L/minute [28]. Surgical masks provide approximately 63% filtration and cotton hander kerchiefs provide about 28% filtration [28]. It has been reported that “several 3M masks were able to capture over 99% of tiny 0.01-micron particles (10 times small than the coronavirus), even while on people’s face” [28].

Management and Treatment Options

Patients, staff, volunteers and visitors to the MRM or BOC experiencing any coronavirus disease were required to practice general prevention measures to include adequate rest and sleep, eating a well-balanced diet, washing hands frequently with a hand sanitizer (60% alcohol minimum) or soap and water for 20-seconds or longer, drying hands thoroughly with a clean towel or air dry, avoiding touching eyes, nose, or mouth with unwashed hands or after touching surfaces, covering mouth with a tissue or sleeve when sneezing or coughing, using a protective face covering, and calling the PCP before visiting the clinic. The HCPs were required to notify health authorities to assist with contact tracing as needed [27]. The foregoing requirements are essential for vulnerable populations and people of color who are disproportionately affected by COVID-19 because the virus is increasing at alarming rates among this group due to underlying health and economic disparities [29]. Data from the COVID-19 tracking project traces racial and ethnic data from reporting states across America and show that people of color account for 24% of COVID-19 deaths but represents only 13% of the U.S. population [30,31]. In a recent article by Washington & Cirilo [32] on vaccinating homeless persons, 76% of the participating population were members of an ethnic minority group and consisted of 117 non-Hispanic Blacks, 50 non-Hispanic Whites, 35 Hispanics, and 7 Haitians; with males (177) outnumbering females (32) in the active group. Currently the racial/ethnic make-up of MRMC patients are seen in Table 4.

To address early identification of COVID-19 in homeless shelter residents, the MRMC has partnered with a COVID-19 research and development company that is piloting a non-invasive pre-screening device, COVID PlusTM Monitor, that provides real-time subclinical markers for COVID-19 and can be worn by both children and adults [33]. The instrument is able to detect sub-clinical abnormalities associated with inflammatory markers that have shown strong correlation between COVID-19 and hyper-inflammatory states like hypercoagulation [33-35]. The COVID PlusTM is able to “allow healthcare providers to identify potentially infected patients, directing them to seek further testing and medical intervention, and avoiding the spread of infections among the general public” especially among homeless persons [33]. The device provides data within 3 to 5 minutes on abnormalities found in blood flow and other COVID-19 related complications and can track disease severity, progression, and recovery [33]. The COVID PlusTM device has been tested on over 1,000 COVID PCR positive subjects, using hundreds of biometric markers that identify patterns commonly associated with COVID-19 [33]. The goal established by the MRMC is early identification of COVID-19 among sheltered homeless persons. Once identified, actions can be taken to quickly quarantine those individuals to reduce the spread of COVID-19 among persons in congregant living facilities, such as a homeless shelter. The early identification also includes the essential workers who provide for their food, safety and shelter.

Vaccine Therapy

Nonetheless, homeless populations and racial/ethnic vulnerable groups are at-risk for contracting COVID-19 and would greatly benefit from increased accuracy in SARS-CoV-2 testing and a safe vaccine therapy. Now that Pfizer’s vaccine BNT162b2 has received emergency use authorization (EUA) from the FDA [36,37], it is critical that frontline healthcare workers, volunteering or employed by the Free Clinics, receive the COVID-19 vaccine in the first distribution. The CDC and U.S. Surgeon General encourage the continued wearing of face coverings, physical distancing, proper isolation, quarantine of infected individuals, and contact tracing to help us mitigate SARS-CoV-2 spread. Nonetheless, a safe and effective preventive vaccine is needed for healthcare workers and the general public to help create herd immunity against COVID-19 and to ultimately control this pandemic.

The MRMC currently has a vaccination program for the homeless and have vaccinated hundreds of homeless men and women with both pneumonia vaccines, PPSV23 and PCV13, quadrivalent Influenza, tetanus, diphtheria and acellular pertussis (Tdap), and Hepatitis C vaccines over the past five-years, reducing the incidence of vaccine preventable illnesses among the homeless population in MDC and BC [32]. A proven safe and effective COVID-19 vaccine could greatly reduce morbidity and mortality rates among disparate homeless populations. Homeless persons living in and around homeless shelters are among the most vulnerable, are considered high risk due to their multiple co-morbid conditions and transient characteristics, and should also be considered in the first or second round of vaccine therapy once made available to the general public.

Conclusion

Coronaviruses are respiratory diseases that infects older children and adults, including homeless men and women, more commonly than younger children [27,36]. The chances of dying from the virus is age dependent and influenced by the social determinants of health (where we live, eat and work), persons living in crowded facilities such as homeless shelters, and persons with higher comorbid conditions having worse prognoses [4,29-30]. Homeless persons and people living in poor communities with decreased access to health care and healthy foods, employment struggles, high toxic stress (allostatic loads), and factors surrounding coronaviruses, increase the risk of getting the disease and dying from the disease [29]. There were many challenges faced by homeless populations, shelters, and free clinics when the pandemic hit South Florida. The seven-step method implemented by the MRM and MRMC at the onset of Florida’s State-wide shut down may have saved more lives than the four persons that died from SARS-CoV-2. However, interventions like contact tracing and disease management were constrained due to the transient nature of the homeless population. The socio-demographics were constantly changing as individuals left the shelter and were not allowed to return during the shut-down, especially when we had minimal PPEs and test kits to protect the frontline workers and to determine positivity rates. Currently, we have an EUA approval for Pfizer’s BNT162b2 vaccine. Although frontline workers mainline employed by hospitals and long-term care facilities are receiving the vaccine first, healthcare workers assigned to provide healthcare services to the homeless must be considered as frontline workers and receive the COVID-19 vaccine. The challenges still remain to reduce hesitancy to receiving the vaccine for both healthcare workers, the general public, and homeless persons living in and around homeless shelters. More information is still needed on the safety and efficacy of the vaccine, especially when used in vulnerable populations who present with multiple co-morbid health conditions. In conclusion, homeless persons rely on health care services provided by free clinics, hospitals, and emergency rooms when they become ill. Due to the COVID-19 pandemic, the obstacles to receiving health care increased and many homeless persons with mild or undetectable symptoms are not seen by health care providers or discharged from health care facilities with minimal or no treatment. Due to a lack of follow up, many homeless persons become super spreaders of COVID-19. Unless timely interventions using face coverings, quarantine, social distancing, and frequent hand washings are initiated, the spread of COVID-19 will continue among homeless persons resulting in greater morbidity and mortality.

Acknowledgement

The authors have no conflict of interest to disclose.

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Co-occurring HIV Risk Behaviors among Males Entering Jail

DOI: 10.31038/PEP.2021211

Abstract

People going through the United States (US) criminal justice system often exhibit multiple behaviors that increase their risk of HIV infection and transmission. This paper examined the pattern of co-occurring HIV risk behaviors among male jail detainees in the US. We conducted multivariate analyses of baseline data from an HIV intervention study of ours, and found that: [1] cocaine use, heroin use and multiple sexual partners; and [2] heavy drinking and marijuana were often co-occurring among this population. From pairwise analyses, we also found that [1] heroin and IDU [2] unprotected sexes with main, with non-main, and in last sexual encounter were mostly co-occurring behaviors. Further analyses of risk behaviors and demographic characteristics of the population showed that IDU were more prevalent among middle ages (30-40) and multiple prior incarcerations, and having multiple sex partners was more prevalent among young males younger than 30 years, African American race, and those with low education. Our findings suggest that efficient interventions to reduce HIV infection in this high-risk population may have to target on these behaviors simultaneously and be demographically adapted.

Keywords

HIV risk, Co-occurring behaviors, Correctional facilities, Male jail detainees

Introduction

Over seven million people passed through the criminal justice system in the United State (US) in year 2012 [1]. Among this population, it was estimated that about 2% was infected with HIV including those unaware of their infection [2-4] — as a contrast, the prevalence among the US adult population is around 0.3% according to the US Centers for Disease Control and Prevention (CDC). The prevalence of HIV infection within jails and prisons was estimated to be about 3 to 6 times higher compared with that among non-incarcerated populations [4-8].

The reasons for this increased burden of HIV among populations in correctional settings are multi-factorial and include increased rates of substance abuse, mental illness, poverty and health disparities [9]. Persons who interact with the criminal justice system may be disenfranchised from health services in the community, such as screening programs. That makes the time of incarceration an important public health opportunity to provide HIV prevention and testing services and linkage to care [10-12].

The time period preceding incarceration has been shown to be characterized by increased substance use and risky sexual behaviors that increased exposure to HIV, viral hepatitis, and other transmitted diseases [13-18]. Release from correctional facilities might also be a time of high-risk of acquiring or spreading infections as persons re-entered their communities and resumed risk behaviors [19-21]. Thus, correctional-based HIV counseling and testing programs and prevention interventions may help to decrease their risk behaviors following release from the correctional environment and therefore reduce new HIV infections in this as well as the general population.

Although studies have documented prevalent (direct and indirect) HIV risk behaviors before entering jail (including heavy drinking, substance abuse, sexual promiscuity, and unprotected sex) [19-26] there is limited understanding of the interrelationships among these risk factors. To effectively target prevention interventions to persons at the greatest risk of HIV infection among this population, it is critically important to understand their risk profiles and quantify which risk behaviors are more likely to co-occur. In this paper, co-occurring behaviors are defined as behaviors that occur within certain time period (e.g. a 3 months window) and not necessarily always in the same episode (i.e. concurrently). This definition is consistent with the need of broader interventions on behaviors that are predictive of (not necessarily determinative of) each other and jointly place an individual at a higher risk of HIV infection.

In this paper, we conducted a secondary analysis of data from a study on HIV counseling and testing in jail [27]. Specifically, we used the baseline data of the study to investigate: 1) whether certain risk behaviors were co-occurring and to what extent, and 2) whether risk behaviors were prevalent among people with certain demographic characteristics.

Methods

Prior Study and Data

We previously conducted a two-arm randomized study [27] to assess HIV risk behaviors among males entering the Rhode Island Department of Corrections (RIDOC) jail and compared the efficacy of two methods of HIV counseling and testing (conventional versus rapid HIV testing) with respect to reducing post-release HIV risk behaviors. A total of 264 HIV-negative males met the study enrollment criteria, provided the written informed consent, were recruited within 48 hours of incarceration, and completed the study. The study was approved by the Miriam Hospital institutional review board, the Rhode Island Department of Corrections (RIDOC) Medical Research Advisory Group, and the Office for Human Research Protections of the Department of Health and Human Services. More details of the study are available elsewhere [27].

In this paper, we focused on data that were collected at the baseline of the study, including demographic information and self-reported HIV risk behaviors during 3 months prior to incarceration. The self-reported risk behaviors were collected using a written quantitative behavioral assessment survey on participant’s recent drinking, substance use behaviors (cocaine use, heroin use, marijuana use, injection of any drug) and sexual behaviors (multiple sexual partners, unprotected sex at last sexual encounter, unprotected sex with main partner, and unprotected sex with non-main partner). Because only data at the baseline prior to intervention randomization were used in this paper, we did not distinguish study participants by their study arms.

Statistical Analyses

We conducted three sets of statistical analyses, outlined as follows:

Analysis I

The co-occurrence of two risk behaviors (pair-wise analysis) was assessed using logistic regressions where one behavior (Behavior 1) was used as the dependent variable, and the other behavior (Behavior 2) as an predictor variable. The results are shown in Table 1. All regressions were adjusted for the following demographic covariates: age (categorized as <25; 25 ∼ 30; 30 ∼ 40; and > 40 years), race (Caucasian; Black; Hispanic; others), number of prior incarcerations (dichotomized at median: < 7; ≥ 7), length of incarceration as severity index of crime leading to incarceration (<2 wks; 2 wks ∼ 1/2 yr; > 1/2 yr), and education (did not finish high school; otherwise).

Table 1: Pair-wise association among risk behaviors.

table 1

(a) The table is not symmetric because the analyses are adjusted for the following covariates as predictors of Behavior 1: age, race, prior incarcerations, length of incarceration, and education.
(b) The numbers in parentheses are sample sizes.
(c) Bold indicates a p-value < 0.05 and italic < 0.10.

Pair-wise co-occurring risk behaviors were quantified using odds ratios (ORs), where an OR > 1 (OR < 1) suggests that the existence of one behavior was predictive of the existence (or absence) of the other behavior.

We used the available complete data for assessing risk behaviors, so the analysis sample size varied (range: 73-256 as in Tables 1 and 2). The overall missing data on risk behaviors were moderate (<5%), if we did not count systematic missingness as missing values (e.g. Missing sexual behaviors for those without sexual partner). Throughout, we made the missing at random (MAR) assumption [28]; that is, we assumed that with the same demographic profile, those who provided complete answers to the baseline questionnaire had engaged in similar risk behaviors as those who did not [29].

Table 2: Multivariate analyses of co-occurring risk behaviors.

table 2

(a) The table is not symmetric because the analyses are adjusted for the following demographic covariates: age, race, prior incarcerations, length of incarceration, and education.
(b) The numbers in parentheses are sample sizes.
(c) Bold indicates a p-value < 0.05 and italic < 0.10.
(d) *** “Unprotected sex at last sexual encounter” is not included as a predictor variable in the model.

Analysis II

Multiple co-occurring risk behaviors were assessed using multivariate logistic regressions where one risk behavior (Behavior 1) was used as the dependent variable and other behaviors (Behaviors 2) as predictor variables. The results are shown in Table 2. Similar to Analysis I, the co-occurring of Behavior 1 with other behaviors was characterized by ORs, which have similar interpretations except that the ORs in Table 2 are conditional ORs after accounting for all other behaviors of (Behaviors 2). Again, all analyses were adjusted for the same set of demographic characteristics as in Analysis I. When heavy drinking, cocaine, heroin, marijuana and multiple sexual partners were used as dependent variables, we excluded the risky behaviors ‘unprotected sex with main partner’ and ‘unprotected sex with non-main partner’, because they only applied to subsets of study participants with sexual partners and including them would reduce the sample size by half and reduce the analysis power. When ‘unprotected sex with main partner’ and ‘unprotected sex with non-main partner’ were used as the dependent variables, ‘unprotected sex at last sexual encounter’ was excluded from predictor variables because the later behavior strongly correlated with the former behaviors and therefore overwhelmed the associations of the former two behaviors with other risk factors. IDU was excluded from the analysis because the prevalence of injection drug use was low (overall 8%) leading to sparse data for multivariate analysis and unreliable estimates due to collinearity of heroin use and IDU [30].

Analysis III

Further, we examined the associations between HIV risk behaviors and various demographic characteristics using logistic regressions, where each risk behavior was used a dependent variable and predictor variables included: age, race, the number of prior incarcerations, length of incarceration as severity index of crime leading to incarceration, and education. The predictor variables were categorized in the same way as in Analyses I and II. The associations of each risk behaviors and certain demographic profiles were characterized by ORs.

Data were extracted and prepared using Access 2003 [31]. All analyses were conducted using the statistical program R [32]. Analysis lack of fit was assessed using Hosmer-Lemeshowtests. Statistical significance was set at a p-value < 0.05.

Results

Among the 264 male HIV-negative participants, the median age was 30 years (range 18-65); the majority was Caucasian (52% Caucasian, 22% Black, 14% Hispanic, 12% others); 51% did not finish high school; and the median number of lifetime incarcerations was 6 (range 1-200). Within the prior 3 months before incarceration, 103 (39%, data not available (NA) = 1) were heavy drinkers; 27 (10%, NA = 1) used heroin; 100 (38%, NA = 1) used cocaine; 161 (61%, NA = 1) used marijuana; and 22 (8%, NA = 1) had injected any type of drug. For the same time period, 203 (77%) had a main sexual partner and of those 170 (84%, NA = 1) never used a condom; 111 (42%) had a non-main sexual partner and of those 37 (36%, NA = 3) never used a condom; 81 (31%) had both main and non-main sexual partners; 61 (26%, NA = 4) had multiple (≥ 3) recent sexual partners; and 233 (90%, NA = 4) did not use a condom at last sexual encounter.

In Analysis I, cocaine use was found to be highly predictive of heroin use (OR = 5.21 with a 95% confidence interval (CI) of 1.8-15), IDU (OR = 6.65, CI = 1.9-23), and multiple sexual partners (OR = 2.45, CI = 1.1-5.3); see Table 1. Heroin use and IDU were mostly co-occurring, suggesting that injection might be the preferred route of heroin use. Heavy drinking and marijuana use were predictive of each other (OR = 2.88, CI = 1.6-5.3). Participants who had unprotected sex with their main and non-main sexual partner(s) were more likely to have unprotected sex at last sexual encounter (OR = 25.7, CI = 9.1-73.0 and OR = 88.6, CI = 15-200, respectively). Notably, unprotected sex with main partner and with non-main partner(s) was likely to co-occur (OR = 6.43, CI = 1.56-78.8). In terms of protective behaviors, participants who reported IDU and those with multiple sexual partners were found to be more likely to use condoms at “the last sexual encounter”, though this finding was marginally statistically insignificant (p-values = 0.08 and 0.07, respectively).

In Analysis II, we found that (1) cocaine use, heroin use, and multiple sexual partners, and (2) heavy drinking and marijuana use were mostly co-occurring (Table 2). Heavy drinking and marijuana use were highly predictive of each other (OR = 3.40, CI = 1.7-7.1). Cocaine use was predictive of heroin use (OR = 9.20, CI = 2.7-38.7) and multiple (≥ 3) sexual partnerships (OR = 2.56; CI = 1.1-6.0).

The analyses that examined the relationships between risk behaviors and demographic characteristics (Analysis III) showed that male jail detainees with age between 30-40 were more likely to abuse cocaine (OR = 8.6, CI = 3.5-23.2), heroin (OR = 4.7, CI = 1.2-23.7), and IDU (OR = 2.8, CI = 1.2-6.9). Younger males with age <30 were more likely to abuse marijuana (OR = 3.8, CI = 2.2-6.9) and had multiple sexual partners (OR = 2.1, CI = 1.2-3.8). African American were more likely to have multiple sexual partners (OR = 3.7, CI = 1.8-7.9), but less likely to engage in unprotected sex in last sexual encounter (OR = 0.3, CI = 0.1-0.6), with main partner (OR = 0.3, CI = 0.1-0.9) and non-main partner(s) (OR = 0.1, CI = 0.03-0.4). Having more than 7 prior incarcerations was predictive of heavy drinking (OR = 1.8, CI = 1.1-3.2), cocaine use (OR = 2.5, CI = 1.4-4.6), and IDU (OR = 2.9, CI = 1.1-7.7). Finishing high school was predictive of having less sexual partners (OR = 0.5, CI = 0.3-0.9) but more likely engaging in unprotected sex in last sexual encounter (OR = 3.3, CI = 1.6-7.2) and with main sexual partner (OR = 3.2, CI = 1.3-8.0).

Discussion

Our results indicate that males entering jail exhibit high rates of substance use and sexual risk behaviors that increase their risk of HIV and other infectious diseases. Our study adds to the existing literature by demonstrating high risk behaviors among incarcerated populations and by highlighting whether certain risk behaviors are more likely to be co-occurring thus compounding risk for HIV infection.

Particularly from our pairwise and multivariate analyses, we find that cocaine is co-occurring with several other risk behaviors including heroin use, injection drug use, and multiple sexual partners. Cocaine use has been reported to not only increase the probability of HIV transmission, but also the potential of poor health outcomes in those living with HIV infection [22,33-35]. Given that there is currently no pharmacotherapy based intervention for cocaine addiction as there is for opiate addiction, our study supports the need of developing behavior-based interventions for cocaine abuse that is appropriate for incarcerated populations in addition to addressing opiate use and risky sexual behaviors. Since jail incarcerations may be as short as several days, behavioral interventions such as contingency management (CM) [36-39] may provide immediate reinforcement for abstinence from cocaine use, and cognitive behavioral interventions that are paired with CM upon release may offer a bridge for continued abstinence following community re-entry [40]. However, these interventions have not been implemented among incarcerated populations [41].

The finding that unprotected sex with main partner is co-occurring with unprotected sex with non-main partner(s) is another important finding, as this suggests that some participants could be involved with concurrent sexual relationships. Concurrent sexual partnerships in incarcerated populations have been reported in several studies [42-46]. Further accounting for concurrent sexual partnerships (and social/sexual networks) in our analyses would strengthen our conclusions, but unfortunately as one limitation of this paper, collecting concurrent behaviors data is not a focus of our original study.

Heavy alcohol use and marijuana use are common substances used by this population and found to be mostly co-occurring. Previous findings with younger incarcerated men [47] suggested that prior to incarceration, the use of marijuana alone and alcohol alone increased the likelihood of multiple sexual partners (i.e. 3 or more) and when in used in combination, sexual HIV-risk behaviors and inconsistent condom use behaviors with female partners increased. Similar finding also can be found in [15,48]. Comparable to other drugs of abuse, alcohol and marijuana use can impair judgment thereby preventing safer sex behaviors, and hence remain an important domain for intervention.

This paper has several limitations. The risk behavior data were self-reported which might have introduced bias and possibly an underreporting of risk behaviors given the environment in which participants completed the questionnaire. Our findings are not generalizable to incarcerated women or the entire population, because it is known that incarcerated women have a different rate of HIV infection and other transmissible diseases compared to men. The study sample size is limited and study participants are restricted only to those at the RIDOC, which limits our analysis power to identify all co-occurring risk behaviors.

As the U.S. incarceration population continues to grow and disproportionate rates of HIV infection continue to rise among incarcerated individuals, the implications for intervention are important and imperative. Jails provide a unique opportunity for structural interventions for this high-risk population. The results of this study offer more insight into the risk behaviors of males entering the RIDOC jail, and elucidate the educational, counseling, and intervention needs of men at risk for HIV infection within the criminal justice system.

Sources of Funding Support

The research is supported by the Providence/Boston Center for AIDS Research (grant P30AI42853). Dr. Pinkston’s work is partially supported by a National Institute of Mental Health grant (5R01MH084757).

Conflicts of Interest

The authors declare that there is no conflict of interest regarding the publication of this paper.

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fig 4

Driving to Comply: Mind Genomics, Arizona, and the COVID-19 Vaccine

DOI: 10.31038/JIPC.2021111

Abstract

The paper presents a statewide study of responses to COVID-19, done in Arizona, USA, as preparation for the upcoming vaccine, promised for 2021. The objective is to determine the key messages which would engage Arizonans, and interest them in as preparation for a state-wide vaccination campaign. The process followed the Mind Genomics protocol, a protocol used to uncover how people think about the ordinary topics of their lives, done by exposing them to systematic combinations of messages, and determining which individual messages drove their ratings. The data confirmed previous North American findings, that there are two major mind-sets when it comes to COVID-19, the Pandemic Onlookers who are not involved and are engaged by one set of messages, and the Pandemic Citizens, who are involved, want to be guided by the government, and are engaged by another set of messages. These two mind-sets distribute throughout the population but can be quickly identified through a six-question, 30-second intervention, the PVI, Personal Viewpoint Identifier.

Introduction

During the past 50 years, researchers have adopted more and more structured approaches to gaining information about people, whether these people be consumers of products, clients for services, and now citizens who need government guidance in the case of emergencies. Clients of services may include individuals who are already sick and need medical help, whether from doctors, or from hospitals, as well as from pharmacists, and so forth. Indeed, it is well accepted that the customer, whether patient of a physician or patient in a hospital is due good service, at a fair price, and in a reasonable time [1-3].

The issue becomes ‘sticky’ when the client or the customer is the citizen, and the need is for guidance which has medical aspects involved, aspects which may need to be personal to be effective. For example, COVID-19 continues to suggest that bland messaging from the government about the dangers of COVID-19 appears to be effective for some individuals, but not for others. Some citizens believed the information and took precautions suggested by government spokespeople, whereas others flaunted the recommendations, frequently and with abandon.

The recent COVID-19 Pandemic has affected many states in what can only be considered a true crisis. The origin of the research reported in this paper was the effort to begin a program of understanding the mind of the Arizonan, a state, a defined entity in the United States. The objective was to find out how the Arizonan felt about the different aspects of the COVID-19 virus, to classify the citizen, not according to who the citizen is, but how the citizen thinks. The slighter longer-term goal was to use this information to drive next-steps in communication, specifically to tailor communications about protection from COVID-19 using the specific way the citizen thinks.

The study reported here represents the first effort to apply the emerging science of Mind Genomics to the citizens of an entire state, with the goal of improving communication about the pandemic, doing so during the crisis, rather than as an academic exercise AFTER the virus.

During the past decade, the increasing sophistication of marketers has moved from selling ideas to selling better lives through public messages, hopefully effective ones. The basic notion is quite simple; the more one knows about the customer with respect to the specific topic to be ‘messaged,’ the more effective the message will be. Despite the simplicity of the idea, the actual implementation is fraught with problems from beginning to end.

Marketers attempt to ‘know’ their customers, but for most topics the effort to know customers is expensive relative to the opportunity. For example, for most small items, such as shoes or dresses, or even houses, it costs much more to discover the proper messaging than the marketer is willing to pay. There emerges a culture of fast, qualitative research, if any research at all. The marketer hires a competent focus group or individual moderator, moves on with the test, and determines next steps, such as the proper words.

This paper presents the first part of an attempt to understand the mind of the Arizona citizen with respect to COVID-19, in preparation for the upcoming vaccine, promised in 2021. The objective is to understand the motivating messages which ‘reach citizens,’ not only in terms of actual messages, but themes which could be used later on to drive vaccination. The anti-vaxxer movement has gained strength over the years for various reasons, ranging from religious to conspiracy theory, as well as disbelief, and indifference [4-7].

Knowing the nature of how people respond to messages about COVID-19, and how people respond to messages about vaccination provides a way of convincing people to do what is medically appropriate.

Method

The approach presented in this paper is called mind genomics. Mindy genomics is an emerging psychological science based in experimental psychology, anthropology, sociology, consumer research, statistics, and political polling, respectively. It does not, of course, take into account the full gamut of these sciences but finds the topics and methods of the science to be relevant, and to form a good foundation for the science.

The fundament of Mind Genomics is the focus on the world of the everyday, about the decisions that we make as we confront problems and situations in our daily life. What are the criteria which convince us about the ordinary? We are not talking about the attempts to elucidate basic principles of behavior by putting people into artificial test situations, unusual experiments, watching their response and then concluding about a certain type of thinking which must be going on to result in that behavior. Rather, we are talking about responses to stated everyday situations, the pattern of the way a person thinks deduced from the way a person reacts [8].

It is important to emphasize the worldview of Mind Genomics, the world of experiment, and the history with deep roots in experimental psychology. The word ‘experiment’ is key; data which emerges from the science should be based upon experiments. The experiments, in turn, are different ways of obtaining opinions, ways emerging from the recognition that the respondent often wants to please the interviewer and be seen in a way that is today called ‘politically correct.’ This bias makes itself known in surveys when the respondent changes the criterion of the rating, based upon the specific topic of the survey question. The goal of the respondent defeats the purpose of the survey.

Mind Genomics presents these respondent-generated biases. Rather than having a person answer a survey questionnaire, item by item, the experiment puts different messages together in combinations, presents this combination or the set of combinations to a respondent, obtains a rating of the combination, and then through regression analysis at estimates the contribution of each individual element or message. The approach is simple because the messages present simple situations and issues that the respondent encounters every day. The respondent simply responds to the designed combination, from which the judgment criteria emerge by linking the individual elements or messages to the responses.

The Arizona study and the Mind Genomics protocol now follow. The protocol is illustrated by the specifics of the study.

Step 1 – Topic, Question, Answers (Messages, Elements)

The researcher must select the topic select four questions which illuminate the topic, and create four answers, in phrase form, which address each question. Table 1 shows an example of the exercise. Note that the Mind Genomics worldview is that these experiments are cartographies, mapping out the different topics of the mind. Anyone can become a Mind Genomics researcher simply by following the steps, the most important step being Step 1. It is also important to note that Mind Genomics is quick, iterative, inexpensive, building knowledge quickly, often in a matter of hours. The feature of iteration means that the questions and answers or elements shown in Table 1 need not be the final materials. One might go through four or five iterations, improving, throwing out what doesn’t ‘work’, or doesn’t convince respondents, replacing the discarded with new material, and then move on to the next iteration. In this fashion, Mind Genomics is as much a learning system as it is a scientific testing and research technology.

Table 1: The four questions and the four answers (aka messages, elements) to each question

Question A: What is the perceived risk of COVID-19?
A1 COVID-19 is spreading quickly in Arizona
A2 New strains of the virus – causing concern
A3 Government should be doing more
A4 Everyone should take care of themselves
Question B: What are my practices of masking?
B1 Stay home so I don’t have to worry about masks
B2 Masks protect me
B3 I mask up to protect older people that I love
B4 Avoid places where people aren’t wearing masks
Question C: Who do I trust for information about the virus?
C1 I trust my doctor’s advice
C2 My employer gives the best information about the virus
C3 My religious leader tells me how to stay safe
C4 I listen to my family and children about staying safe
Question D: Where do I get my news?
D1 Local Arizona media keeps me up to date
D2 Social media gives me the fastest news
D3 News from my employer is accurate
D4 My friends and family pass along the news

The reader should note that we report the results of the first experiment regarding how to understand and how to motivate Arizonans to consider the COVID-19 vaccine. The materials selected in Table 1 for questions and answers have appeared in part in other studies [9], albeit with some of the language changed, based upon previous results in other countries. It is also worth noting that the study was done overnight in Arizona, approximately four hours after the study was launched on the internet.

Step 2: Prepare the Introduction to the Respondent, and the Rating Question

The ideal format for a Mind Genomics questionnaire differs for consumer/citizen studies vs. medical/legal studies. For consumers and citizens, the objective is to understand how they react to specific messages, in terms of the degree to which the messages motivate them to do something, in this case to obtain a vaccine. In such cases, the less said the better in the introduction. The introduction just introduces the topic. The specific messages, their content, their tonality, and the mind of the respondent will drive the respondent’s rating. The rating scale is a simple 5-point Likert Scale [9].

The introduction and the rating question appear below:

This is a study to understand the effectiveness of COVID-19 messages in Arizona. You will be presented with a series of statements. Rate each set of statements using a five-point scale

How likely are you to get a COVID-19 vaccine? 1=No way 5=Yes, I absolutely agree

Step 3: Build the Test Vignettes

The respondent evaluates combinations of elements, not single elements alone. It is the set of 24 combinations, created according to an underlying experimental design, which is the mechanism by which the respondent’s underlying attitude towards a topic can be obtained and the tendency to be politically correct defeated or at least strongly stymied. The vignette, appearing as an example in Figure 1, presents a combination of elements in a manner which seems haphazard, almost created by random.

FIG 1

Figure 1: Example of a vignette.

The reality underlying the construction of the vignette is as far away from randomness as one can get with a systematic design. It is true that the combination is not written to tell a story. The objective of the vignette specifically, and Mind Genomics generally, is, figuratively, to ‘throw combinations of messages at the respondent, and see the rating.’ There is no underlying store to which the respondent can anchor, and be consistent within that anchor, and common principle. Rather, Mind Genomics is simply the response to seemingly random combinations. The respondent sits at the computer for about two-minutes, responding to 24 of these combinations, feeling that they are random, not realizing that the combinations have been systematically created. The respondent attempts to cope with the overload, but quickly relaxes into an almost automatic response, the type called System 1 by Nobel Laureate, Daniel Kahneman [11]. The respondent eventually ends up assigning the rating in an almost automatic, passive way, frustrated in the attempt to ‘game the system’ by the rapidly appearing and disappearing combinations.

There are two powerful aspects of the experimental designs used by Mind Genomics, of which the 4×4 (four questions, four answers to each question) is only an example. The first aspect is that the elements are statistically independent, viz. in a statistical sense all 16 elements are independent so that they can be used without concern in an OLS (ordinary least-squares) regression to uncover the relation between the elements and either the response or the linkage of the element to response time, the time needed to process the information and respond. The second aspect is that all the 24 vignettes used by a respondent are different from the 24 vignettes evaluated by a second response. The benefit there is that the Mind Genomics procedure covers a lot of the design space [12].

Across the set of 24 vignettes each person will encounter the same number of each of 11 different structures, albeit with different specific elements. The structure is defined as the questions which generate the elements, but not the specific elements themselves. The 11 structures comprise the six different structures for two-element vignettes, (AB AC AD BC BD CD), the four different structures for three-elements vignettes (ABC ABD ACD BCD), and the one structure of four elements (ABCD). We will see that some of these structures are, on average, stronger performers than other structures, when the data from the respondents is analyzed by structure.

Step 4: Run the Experiment and Create a Simple Topline Report (Surface Analysis)

Mind Genomics studies are run entirely on the internet, in a structure which is presented as a survey, not as an experiment. The appellation ‘experiment’ often irritates and confounds prospective respondents. The 500 respondents were members of a set of panels, used by the online study vendor, Luc.id of Louisiana. Luc.id provides populations of respondents from different geographical areas, of specific demography and activities. The panelists had to be residents of Arizona over the age of 18.

Table 2 shows the average ratings on the 5-point scale, and the average response time for each of the 11 structures. Each vignette in the study was assigned one of the 11 structures, depending upon the elements appearing, those elements dictated by the underlying experimental design. The respondent rated each vignette with the rating and the response time recorded. The response is operationally defined as the number of seconds, to the nearest tenth of second, elapsing between the appearance of the vignette and the rating.

Table 2: How average rating and average response time covary with structure of the vignette

Structure Questions

Rating

Response Time

ALL Total

3.4

3.8

AD Risk News

3.4

4.0

AB Risk Masking

3.4

4.0

ABC Risk Masking Trust

3.4

3.9

CD Trust News

3.5

3.8

BCD Masking Trust News

3.4

3.8

ACD Risk Trust News

3.4

3.8

ABCD Risk Masking Trust News

3.4

3.8

ABD Risk Masking News

3.4

3.8

AC Risk Trust

3.1

3.8

BC Masking Trust

3.4

3.7

BD Masking News

3.5

3.6

Table 2 shows a modest range in the average ratings, from a high of 3.5 to a low of 3.1). This suggests that the either the elements are seen to be equal, or there are deep differences among people in the types of elements with which they agree, but these deep differences cannot easily be seen. The differences are not emerging out the structure of the vignette, suggesting that respondents ‘graze’ for the information they need, rather than proceeding linearly through the vignette. If respondents were to proceed linearly through the text of a vignette, the vignettes with more elements would show higher response times, due to the longer times needed to read three and four elements. In contrast, the vignettes with fewer elements would show lower responses times but they do not. The data suggest that it is the nature of the information which drives the response times. The topic of ‘risk’ is the most engaging, the topic of ‘masking’ the least engaging.

One of the recurring themes in social research is that the differences in the responses may well be due to who the respondent IS. That is, there is an ongoing belief that people vote based upon who they are. Thus, much of the news reported focuses on differences between groups of people who can be easily identified, such as gender, or age-cohorts (e.g., Baby Boomers vs. Millennials vs. Generation X, etc.).

The data from this study allows us to look at the average rating and the response time from different, identifiable groups, as shown in Table 3. Table 3 shows the average age, the average rating, and the average response time, for each defined group. Table 3 also shows averages from transformed data (see Step 5 below). We see little difference in the average ratings, but we do see substantial differences in the average values of the response times, differences which make sense. Young respondents (age 18 – 29) read and rate much faster than average (2.8 seconds per vignette vs. 3.8 seconds on average), whereas old respondents (age 65+) read and rate more slowly (5.5 seconds on average).

Table 3: Average age, 5-point rating, response time (RT), and binary transformed ratings) for Total, Gender and Age, respectively

table 3

It is important to keep in mind that the differences in response time may be due both to age and to topic. We know that when the topic moves from social issues such as vaccine and COVID-19, to issues that are more ‘fun’ such as products, the response time usually diminishes, perhaps because the respondent does not have to think about the topic quite as seriously.

Step 5 – Prepare the Data for Regression Linking Elements to Responses

The underlying experimental design allows us to link the presence or absence of each element to the rating and to the response time. Yet, there is a problem with the data, one which must be solved before the analysis can proceed in a smooth manner. The problem or issue is the way one should interpret the results of a Likert Scale. From author HRM’s experience, managers commissioning the study or working with the data often ask about the meaning of the rating, such as ‘what does a 4 mean on the scale, from a practical point of view?” What the manager needs is a more black-and-white metric, one which reduces the task of interpreting the data.

Consumer researchers and public opinion pollsters are well-aware of the problems with managers interpreting the data for simple scales. Indeed, in the words of S.S. Stevens, Doyen of modern-day psychophysics, ‘one of the hardest problems in science is to go from a scale to a yes/no’ [13].

Researchers world-wide have suggested simple ways of dividing Likert Scales. For the five-point scale used today, researchers had suggested using the ratings of 5 & 4 as the key variable. Vignettes rated 5 or 4 are assigned the value of 100, vignettes rated 1, 2 or 3 are assigned the rating of 0. This is called the ‘Top2 Box,’ abbreviated here ‘Top2’. The reason is simple; The top 2 scale points (or ‘boxes’) are the ones selected.

In this spirit, we have created four new variables to use in our exploration:

Agree with the need for/goal of vaccination

Top1: Rating of 5 transformed to 100, ratings of 1, 2, 3 and 4 transformed to 0

Top 2: Rating of 5 and 4 transformed to 100, ratings of 1, 2, and 3 transformed to 0

Bot1: Rating of 1 transformed to 100, ratings of 2, 3, 4 and 5 transformed to 0

Bot 2: Rating of 1 and 2 transformed to 100, ratings of 3, 4 and 5 transformed to 0

A small random number less than 10-5 is added to each of these numbers to create some variability around the ratings. When a respondent assigns all ratings 1 & 2, or 4 & 5, respectively, regression analysis will ‘crash’ because the regression needs a bit of variation in the dependent variable, the transformed number. The transformation prevents the crash of the regression modeling but is far too small to affect the data in a meaningful way.

Step 6: Relate Elements to Ratings by OLS Regression

OLS (ordinary least-squares) regression relates the presence or absence of the 16 elements to the dependent variable. We begin with two dependent variables, the 5-point rating scale, and the response time. We add four more dependent variables, emerging from our transformation to the binary scales; Top1, Top2, Bot1, Bot2. These were defined in Step 5.

The basic equation is simple:

Dependent Variable = k0 + k1 (A1) + k2(A2) … k16(D4)

Simply stated, the dependent variable is the sum of a single base number (additive constant), and the contributions of the elements in the vignettes, these contributions being estimated by the OLS regression, and shown as k1-k16.

The value k0 is not estimated for the response time, RT, simply because it has no meaning. The value k0 is also not estimated for the 5-point scale, to give a sense of the number of rating points contributed by each element. For the other five dependent variables, k0 is the estimated value of the dependent variable in the case where all the elements in the vignette are 0, viz., absent. Such a situation, a vignette without elements, is impossible according to the underlying experimental design.

Table 4 presents the data from the Total Panel, showing only the positive coefficients. The data are incomplete, but to show all coefficients, negative values as well as 0, overwhelms the reader. The positive coefficients are those which drive the response towards the top of the scale, whether the scale be Top1 (highest possible agreement with getting a vaccine), Top2 (strong agreement with getting a vaccine), or towards the bottom of the scale, Bot1 (highest possible disagreement with getting a vaccine), or Bot2 (strong disagreement with getting a vaccine).

Table 4: How the 16 elements drive the ratings, both transformed binary ratings, original 5-point rating, and response time.

 

 

TOP1 TOP2 BOT1 BOT2 RATING

RT

Additive constant

28

53 15 28 NA

 NA

A1 COVID-19 is spreading quickly in Arizona 1.0

1.1

A2 New strains of the virus – causing concern 0.9

1.1

A3 Government should be doing more 0.9

1.0

A4 Everyone should take care of themselves

1

1.0

1.1

B1 Stay home so I don’t have to worry about masks 1 1.1

1.2

B2 Masks protect me 1.0

1.1

B3 I mask up to protect older people that I love 1 1.0

1.2

B4 Avoid places where people aren’t wearing masks 1.0

1.2

C1 I trust my doctor’s advice 1.0

1.1

C2 My employer gives the best information about the virus 1.0

1.1

C3 My religious leader tells me how to stay safe 1.0

1.1

C4 I listen to my family and children about staying safe

1

1 1.1

1.1

D1 Local Arizona media keeps me up to date 1.0

1.0

D2 Social media gives me the fastest news 1 1.0

1.0

D3 News from my employer is accurate 1 0.9

1.0

D4 My friends and family pass along the news 1 1.0 1.0

The actual interpretation of the data is left to the reader, but the Total Panel shows little in the way of patterns. The additive constant for Top1 tells us that about a quarter of the responses would be ‘5’ in the absence of the elements. Note that the additive is a theoretical, computed value, since all vignettes comprised 2-4 elements. The additive constant is a good parameter to give a sense of the ‘baseline’ level of feeling. For Top1 (strongest interest), we see an additive constant of 28, low, and in need of a ‘push’ from the elements. When we look at positive responses, 4 and 5, combined into the variable Top2, see a little over half, 53% of the responses are expected to be positive. Similarly, when we look at the negative part of the scale, about 15% of the responses are expected to be extremely negative, and a little less than twice that number (viz., 28%) are expected to be strongly or moderately negative.

Our next task is to use judgment to identify, where possible, elements with high positive coefficients for either Top1 (ideal) or Top2 (strong or moderate interest in the vaccine). Table 4 shows us no strong elements at all, a disappointing finding. From our first effort, and looking at the total panel, we find that no elements drive interest in being vaccinated. The answer may be either that we have not found that ‘magic bullet,’ or that we may have a powerful element, but it is lost in ‘noise’. We soon will see that the latter is probably the case, that there is noise in the data emerging from different groups of people, with varying, occasionally conflicting opinions.

A second look is at the response times. Do opinions of these messages engage the respondent? Engagement might be either good or bad, good when the message is a driver for vaccination, bad when the message is irrelevant, and a time waster. The model for the response time is lacking a constant. No elements engage by having the respondent focus on the element for more than 1.2 seconds.

Our first conclusion is that there is no pattern, that all the messages are irrelevant, and that the experiment was unable to uncover any element which is promising. That is, when we treat all of the respondents in the same way. We are either dealing with irrelevant elements, certainly a strong possibility in the absence of any other reasons to think otherwise, OR we are dealing with elements which push in opposite directions, cancelling each other out.

Step 7: Granular Understanding by Clustering to Uncover Mind-sets

We saw above that there are few differences among the elements in terms of those driving positive interest to get vaccinated. Some of this ‘flatness’ may emerge from the fact that people think in different ways, effectively canceling each other when they are blended together in a database which does not recognize these individual patterns.

Mind Genomics studies have uncovered the existence of different groups of ideas which go together, different mind-sets of these related ideas. It is not that people differ, but rather that the ideas they hold are of different types, even when the topic is the same. By clustering the patterns of coefficients across the individual respondents, viz., putting together people with similar patterns, Mind Genomics can identify these basically different groups of ideas. These different groups are the so-called ‘mind-sets’ [14,15].

The process of clustering is a standard statistical method. The method of k-means clustering looks at the 16 coefficients of each respondent, based upon the relation between Top2 (dependent variable) and the presence/absence of the elements. The additive constant is computed, but not used here. The clustering, based upon similarity of patterns, divides the 500 patterns into one, two, and the three groups. Each respondent is a member of only one of the groups, with two groups, or a member of one group when three groups are extracted [15].

The original analysis by clustering uses the coefficients obtained for the Top2 analysis, meaning that ratings of 4 and 5 are converted to 100, and ratings of 1-3 are converted to 0. We will remain with that clustering. For the prescription of what to feature in the messages, we will the make analysis more stringent, however. We will look at the models or equations relating the presence/absence of the 16 elements to rating 5:, How likely are you to get a COVID-19 vaccine? 1=No way 5=Yes, I absolutely agree. This is the Top1 equation, showing which elements are the strongest. Thus, we keep the clustering method the same (based on Top2), but the reportage as more stringent (use Top1 data for modeling).

Table 5 shows the positive coefficients for the Top1 model. It is clear that there are few elements which are strongly effective for each mind-set. These are the elements to select for the final messaging. The selection is far easier when the criterion is low, but the downside of the process is that the coefficients are low, albeit the most powerful. The only exception to the pattern of low coefficients emerges from mind-set MS3, the Pandemic Activist, comprising about 1/3 of the respondents.

Table 5: Strongest performing elements for vaccination, viz., highest coefficients for TOP1 (Definitely will vax)

table 5

The important consideration here is that the message be strong. Choosing a message which contributes to rating 5 (definitely will vax) is better than a message which contributes to both rating 4 and 5 (definitely/probably will vax.) The choice towards the messages which are most effective, recognizing that there can probably be at most three messages.

The final thing to keep is mind is the radically different elements which score well. These elements are clearly touching different aspects of the COVID-19 experience, suggesting quite different mind-sets among the respondents.

To get a sense of the power of a tough criterion, such as Top1, consider the same Table, but the more typical case, wherein the elements are the strong performers, but for Top2 (Definitely/Probably be vaccinated). Many of the elements are the same, but the first impression from Table 6 is a greater richness of information. That richness is certainly satisfying, but when it comes time to put the information into practice one will inevitable be confronted with the question about which of the strong performing elements is actually the ‘strongest’. That is, having a wealth of information is rewarding for the stage when one seeks understanding, but problematic when the task is to choose the one, two, or three elements from the set, and allowed only those choices.

Table 6: Strong performing elements for vaccination, viz., highest coefficients for TOP2 (Definitely will vax, probably will vax, ratings 5 and 4)

table 6

Step 8: Understand the Engagement Power of the Elements Using RT (Response Time)

Figure 2 shows the distribution of measured response times for the vignettes, independent of the structure of the vignette and the specific elements. A great many vignettes are rated faster than two seconds, most vignettes rated in fewer than five seconds. As we see below, there is very little difference in the response times linked to the different messages.

fig 2

Figure 2: Distribution of measured response times for the vignettes.

The final element-level analysis links the elements to estimated response times for the elements. The equation for response time comprises the 16 independent variables, the elements, but does not make provision for an additive constant. The rationale for leaving out the additive constant is that in the absence of any elements (again a hypothetical case) there is no expectation of any response at all.

Table 7 shows the estimated response time attributed to each element. The important thing to note is that strong performing elements in Table 5 are not necessarily those with long response times, viz., those which are engaging. Indeed, most of the response times are around 1.0 – 1.2 seconds per element, with a few shorter and a few longer. The results suggest that the respondents do not ‘whiz through’ the elements when making their ratings. They do ‘whiz through’ for other studies, especially the less serious studies having to do with brands and products. Thus, one can feel good that the respondents are actually paying attention to the information, at least in terms of taking the time to read the vignettes.

Table 7: Estimated response time for each element, by each mind-set.

table 7

Step 9: Artistic Judgment for Next Steps – Identify the Elements Which have the Greatest Staying Power

One of the ongoing issues in any messaging campaign is the probability that at some time the messages will simply ‘wear out.’ The wear out is habituation, a well-known phenomenon in psychology, wherein the stimulus fails to evoke attention as it continues to be repeated. Experimental psychology demonstrates this phenomenon in rigorous studies, such as the measuring attention reactions of cats presented with the same tone in a steady, expected, repeated, monotonous fashion. Habituation occurs in our everyday life; simply witness people who live near train tracks, and who quickly become accustomed to the noise.

How can we identify messages which have staying power, especially messages which are good to being with? One way to do this uses the actual data from the study. This time, however, the data matrix is divided into equal fourths (viz., vignettes 1-6, 7-12, 13-18, and 19-24). One takes the set of elements to be used in the proposed messaging, viz. one winning element for each mind-set. The selection of the winning element is a matter of judgment, and may involve ‘gut feelings,’ viz., intuition, which move beyond the actual data. The approach here considered only the elements doing well among the three vignettes in the Top1 metric. These were D1, A2, B4:

Local Arizona media keeps me up to date

New strains of the virus causing concern

I mask up to protect older people that I love

These three elements became the only predictors of Top1, Bot1, and RT (response time). The vignettes (fourth = 2, fourth = 3), and for the final vignettes (fourth = 4). By looking at the coefficients for each element across the four sets of evaluations, we get a sense as to whether or not the elements are ‘wearing out’.

Figure 3 suggests that repeating the messages will enhance the impact of each element in terms of driving the respond to agree to a vaccine (Top1), and for the most part will reduce the resistance (Bot1). The only exception to this general trend is element B3, which shows no loss in negativity with repetition, and perhaps even a slight increase, perhaps resentment at being reminded. The same analysis can be done for any set of messages, to determine whether the messages will change with repeated exposure. Figure 4 show the same analysis, this time for strong performing elements using their coefficients for Top1, but a combination ‘artistically’ sensed as inferior:

fig 3

Figure 3: Likely wear-out of messages for the vignette which seems ‘more artistic’. The graphs show the expected change of the coefficient for each promising element, when evaluated in sets of six vignettes each. The combination comprises D1, A2 and B3, winning elements from the three mind-sets, selected by artistic sensibility as ‘working together’.

fig 4

Figure 4: Likely wear-out of messages for the vignette which seems ‘less artistic’. The graphs show the expected change of the coefficient for each promising element, when evaluated in sets of six vignettes each. The combination comprises D1, A2 and B3, winning elements from the three mind-sets, selected by artistic sensibility as ‘working together’.

News from my employer is accurate

I listen to my family and children about staying safe

Avoid places where people aren’t wearing masks

The approach does not replicate the actual events in the world, but rather may be analogous to the process of ‘accelerated aging’ in the world of food science, with the attempt to determine the ‘shelf life’ of a product, so that the product can be pulled from the market shelves before it changes in quality and becomes significantly less palatable [17].

Step 10: Find the Mind-sets in the Population for Targeted Messaging

Ongoing patterns of results from Mind Genomics cartographies, of the type done here, albeit in many other areas, suggest that there exist clearly different mind-sets, but that these mind-sets are distributed in the population in an almost random way, at least to the outside researcher who only has data from who the respondent IS (geo-demographics), how the respondent THINKS (personas based upon large-scale segmentation), or how the person BEHAVES (either in everyday life, or in tracked shopping behavior.)

In none of the standard analysis of WHO, THINKS, or BEHAVES can we find easy covariation with the mind-sets. That is, it is quite unlikely to know how a person will think about a topic just be knowing the typical information available to the researcher. There may on occasion be some happenstance covariation that can be used, but as far as a robust system to link together mind-sets and people, there does not seem to be a recognized tool.

Table 8 shows the distribution of the three mind-sets by gender, by age, and by ethnicity. It is clear from Table 8 that simply finding the mind-set will be difficult in the population. The next best thing is to use set of messages woven together to incorporate the essence of one message for each mind-set, as Figure 3 suggests.

Table 8: The distribution of respondents by mind-set, gender, age, and ethnicity. The numbers in the body of the table are the actual number of respondents who classified themselves at the start of the Mind Genomics experiment, in the self-profiling questionnaire

 

Total

MS1 MS2

MS3

Total

494

181 169

144

Male

192

65 62

65

Female

302

116 107

79

Age 18-29

160

62 51

47

Age 30-49

181

63 60

58

Age 50-64

79

30 28

21

Age 65+

74

26 30

18

Caucasian

322

120 118

84

Latinx

85

30 27

28

Other

81

30 21

30

The fact that mind-sets can so easily emerge from data, and be found at any level of granularity desired, and virtually for any topic, in as a fast as one hour, suggests that a new way of thinking is needed to use the mind-set segments. It is no longer sufficient to spend days, weeks, or months cogitating over the application of mind-set segmentation when the actual results had been obtained in a matter of hours.

During the past four years authors Gere and Moskowitz have worked on algorithms to classify the respondent as a member of a mind-set, recognizing that the algorithm should be quick to develop, easy to implement, and inexpensive. The algorithm also must minimize the ability of a respondent to ‘game the system,’ by guessing what the interviewer wants to hear.

The approach developed emerges out of the actual experiment and data set used to create the mind-sets in the first place. This first step ensures that the elements used to assign a new person to a mind-set are relevant to the topic, moving away from the potential error-propagating step of searching for other language that can be used for assigning the respondent to the mind-set. This first is close in, and immediate. As soon as the mind-sets are determined so is the performance of each element for each mind-set.

The second step uses a Monte Carlo system to introduce noise, and then assign respondents to the mind-set in the present of the noise.

The third step aggregates the data and generates the decision rule which is most resistive to the introduced ‘noise’ and correctly types of the mind-sets in the presence of the noise.

The resulting approach is called the PVI, the personal viewpoint identifier. The set-up is done according to a Microsoft Excel template (Table 9). The template requires the researcher to provide specific information about the mind-sets (viz., name, feedback), as well as an optional video or landing page corresponding to the mind-set, right after the respondent is assigned to one of the mind-sets. At the bottom of Table 9 is the summary data from the mind-sets, used by the PVI to create the actual calculation table.

Table 9: Template for the creation of the PVI (personal viewpoint identifier).

table 9

Once the input in Table 9 has been processed to create the PVI, the result comes back in a link. The respondent who clicks on the link is led to the PVI on the web. Figure 5 shows the introductory page, which introduces the respondent to the reason for the short study, obtains permission, and obtains background data. Figure 6 shows the set of questions, comprising background questions (not part of the classification algorithm), and six questions answered by one of two answers. These six questions are the PVI. Each respondent sees the six questions in a different order. The data are stored in a database for further work, and the results sent back to the respondent either in a detailed form, or just an email with mind-set membership, and something about the mind-set to which the respondent belongs (Figure 7).

fig 6

Figure 5: The orientation page for the PVI. The link (as of January, 2021) is: https://www.pvi360.com/TypingToolPage.aspx?projectid=1270&userid=2

fig 6, 6

Figure 6: The questions about one’s concerns, and the six questions for the PVI.

fig 7

Figure 7: Feedback page for insertion into the database. The respondent receives a simple email showing the three mind-sets, viz., their names and the feedback, as well as the mind-set to which the respondent belongs. This example is from a person in Mind-Set 1, the Pandemic Observer.

Discussion and Conclusions

The study reported here typifies what, in the emerging science of Mind Genomics, is called cartography, for want of a better word. The cartography is not designed to test hypotheses, in the traditional view of some scientists [18]. There are no working hypotheses to falsify. The cartography, as the word connotes, explores the topic, and maps its detailed features. Here the features are the words. As we begin to create cartographies, there are usually several sequential cartographies or iterations. At the start we need not know whether the questions are the correct ones, and certainly whether the answers are correct or event relevant. Yet, we do the experiment, we put a ‘stake in the ground,’ discover what works and embellish it, discard what does not work, and then add new material for the next iteration [19].

Although this might not seem to be the most elegant way of creating a database, it certainly is the quickest, and in fact allows the database to create to be created by all sorts of people, whether these are professionals in the healthcare world, patients, doctors, or hospital administrators, or even relatives of those who are patients. The notion is not to get it right, because there is no ‘right’ – at least not at the start. Rather, the notion is that through responses to descriptions, the vignettes, the underlying patterns will emerge, in the way the underlying structure emerges from the many pictures taken by the MRI and reassemble the structure after the fact through a computer program.

A key benefit of Mind Genomics is its availability to anyone, expert or amateur alike, and the possibility that the discoveries may be made by virtually anyone. A dedicated analyst working with dozens of transcripts of interviews lasting an hour or two about the topic might emerge with similar findings, but not as crisp, nor as data rich. In contrast, the novice but avid researcher, can do an iteration overnight, following the templated approach of Mind Genomics. The templated approach forces the research to focus on the messages, do the experiment, obtain the data, and face the bare facts, specifically how the messages drive the response. The data are archival, the learning is incremental and expansive, and the result resides in a searchable data warehouse, ready for reanalysis to provide new insights. The information can be searched for words, for meanings, and for new correlations, done, at virtually any time after the study, and by virtually anyone. These data from the first study on COVID-19 in Arizona give a sense of the potential.

Practical Conclusions – Driving Vaccination in Arizona

The focus of this paper is both on method and on results. Both are important during this period of the COVID-19 pandemic. The rationale of showing what can be done in one day is not so much to provide a perfect answer or write a perfect paper, as it is to show a revolutionary change in what could be learned in a short time at a low cost. Cost, time, and the power to iterate to a better answer are important for the obvious reasons; costs of medical treatment and of medicines are increasing, making prevention increasing attractive. The more that we can learn about people ‘in the moment’ with respect to issues which emerge, the more likely it will be that we can communicate more effectively with people. This communication includes providing the necessary information and the suggestions, both tailored to the mind-set of the person, and perhaps both more convincing, more motivating. It is no simple thing to motivate people. The faster and easier it becomes to learn the necessary facts and words, ideally in ‘real time,’ the more likely it we be that people will be guided gently, through words, to live healthier lives, and to take better care of themselves. The cost of the medical interventions might be lower.

The data here suggest that it is vital to consider the different mind-sets of respondents. In light of the speed, ease of analysis, and low cost, as well as a tool to determine the mind-set of the respondent, the prudent action would be to do one to three or four Mind Genomics cartographies, as done here, eliminating the poor performing elements, and building upon the elements which look like they work. Table 6 shows the dramatic increase in performance of elements, and the clearly different mind-sets. Several more cartographies, each last no more than a day, should build a new set of ‘Table 6’s’ with increasingly strong performing elements. It is unlikely that there is a single ‘magic bullet,’ for all mind-sets, but there are clearly a number of strong elements for each mind-set.

Acknowledgments

Attila Gere thanks the support of Premium Postdoctoral Research Program of the Hungarian Academy of Sciences.

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fig 2

Development and Testing: Cervical Cancer Prevention Questionnaire Based on Theory of Planned Behavior in Chile

DOI: 10.31038/AWHC.2021411

Abstract

The purpose of this study was to developmentally and psychometrically validate the cervical cancer prevention questionnaire (CPCC-16) based on Theory of Planned Behavior in Chilean women. The patient sample was 967 women. Confirmatory factor analysis was used to evaluate factor structure, Cronbach’s alpha for internal consistency and t-test for criteria validity. The development and validation of the questionnaire resulted in six factors with 16 items, demonstrating a bi-factorial structure. Cronbach’s alpha was higher than 80 in the questionnaire and its factors. To generate a valid and reliable questionnaire that measures, under a theory of behavior, more than one preventive behavior in cervical cancer is an important advancement that fills a gap in nursing research.

Keywords

Cervical cancer, Prevention, Instrument development

Precis: The CPCC-16 questionnaire is a validated and reliable instrument, with 16 items distributed in a bi-factorial structure, useful for clinical and research area.

Call Outs: Behaviors are the principal causes of deaths from cancer, and thus, a reliable and validated questionnaire is necessary to measure these behaviors (before method).

The validated and reliable questionnaire will be useful to measure cervical cancer preventive behaviors as a whole, but it will also be useful to identify theory constructs (after method).

The new questionnaire will be useful to measure more than one preventive behavior in cervical cancer; therefore, it fills a gap in clinical and research area (after discussion).

Introduction

Theory of Planned Behavior (TPB) has been a framework to explain and predict behaviors [1], and its ability as a framework intervention has been supported by previous studies [2-4]. TPB postulates that the motivations of people to change are based on their perceptions of norms, attitudes, and control over behaviors, and each of these factors can either increase or decrease the intention to change their behavior. The intention to change behavior is directly related to behavioral change [5,6]. Cervical Cancer (CC) prevention has been one topic that has been studied under this theory [7-11].

There are two methods to stop CC: to prevent its pre-cancer and to identify and treat the cancer before it becomes a true cancer [12,13]. The first method includes behaviors, including the use of condoms during sex, limiting the number of sexual partners, not smoking and obtaining the Human Papilloma Virus (HPV) vaccine; the second method includes having regular screenings [13,14]. The CC prevention questionnaire (CPCC-16) was developed based on TPB to measure CC preventative behaviors.

Background

Even where screening is widely available and methods to prevent CC are known, there is an important barrier in adopting these methods by women. Thus, understanding the factors that affect preventive behavior remains an important issue.

TPB has been previously used by several studies to understand how cervical cancer preventive behaviors are carried out, and the intent to perform the behavior is explained [8,15,16]. The main behaviors studied are those related to the detection of CC, such as adherence to the HPV [8,11,17] tests [7,10,15,18,19]. Some studies have described the use of TBP and HPV vaccination intentions [16,20]. The use of condoms has been studied; however, these studies are not always related to CC prevention and are mainly examined in an adolescent population [21,22]. To the best of our knowledge, there have been no previous studies using questionnaires to measure more than one preventive behavior using TPB as a framework.

Regarding the psychometric properties of the questionnaires used in CC prevention, the reliability and/or validity of the instruments has not always been reported [10,11,16,20,21], or they have been incompletely reported [7-9,17,19]. Research on TPB with other behaviors indicates the same problem [2,3,23]. The author and creator of TPB [1] supports these findings, describing the measures of the theory constructs as fallible with respect to reliability and construct validity, and thus, it is difficult to test the theory.

With regard to TBP as a framework, the literature indicates that the most important theory construct studied has been intention [24] and that some research studies have only partially studied the TBP components [15].

Behaviors are the principal causes of deaths from cancer, and infections such as HPV are responsible for up to 25% of cancer cases in low and middle-income countries [25]. If the solid foundation of TBP and the relevance to prevent CC worldwide are considered, then a questionnaire that is reliable and valid, which permits the ability to simultaneously measure more than one CC preventive behavior and to test the four-principal construct of TPB, may be useful in different countries and contexts. Thus, it is useful to have a CC prevention questionnaire based on TBP.

The purpose of this study was to develop and psychometrically validate a new questionnaire based on Theory Planned Behavior (TPB) with relation to Cervical Cancer (CC) prevention (known as the CPCC-16 questionnaire).

Method

This study is a part of a larger cross-sectional study about Social Determinants related to the adherence to CC screening (FONDECYT #11130626); this article focuses on the development and testing of one of the questionnaires used in the project, which was performed in two phases: scale development and psychometric evaluation.

Sample/Participants

This research study was performed on a total of 967 Chilean females, between 25 to 64 years old, under Chilean national public health care coverage (known as FONASA); these participants attended four primary health care centers in the Servicio de Salud Metropolitano Sur-Oriente (Southeast Metropolitan Public Health Service) in Santiago, Chile. The sample size was calculated according to the larger study aims considering an effect size of 0.1, power analysis of 80%, 15 latent variables and 40 observed, and a significance level of 95%. The sample was obtained according to the recommendations related to the questionnaire validation [26-28]. The exclusion criteria included having had a hysterectomy and CC disease. Females who had agreed to participate were randomly selected and recruited by telephone between March 2014 and October 2015.

Scale Development

The questionnaire was developed based on TPB and according to Icek Ajzen’s recommendations [29]. The first step was to define the behavior; therefore, four behaviors were included: annual gynecological check, updated Papanicolaou test (Pap), condom use on sexual relations and having a single partner (at the same time). Behaviors related to the HPV vaccine or HPV screenings were not considered because they are not available in the public health care system where the study was performed. Figure 1 shows the construct and preventive behaviors considered in the questionnaire. The second step was defining the population; females between 25 to 64 years old were selected because they are the target group for cervical cancer screening and prevention interventions in Chile. The third step was formulating items; they were developed to assess the major constructs of TPB for each preventive behavior selected in the first step: attitude, subjective norm, perceived behavioral control, and intention. The items were given feedback from content experts and then pilot tested on ten females from the target population. The questionnaire was developed in the Spanish language and back-translated for this article.

fig 1

Figure 1: Theory of Planned Behavior Constructs and Cervical Cancer Preventive Behaviors considered in the Original Questionnaire.

Psychometric Evaluation

Construct validity was performed by Confirmatory Factor Analysis (CFA), and reliability was assessed using ordinal Cronbach’s alpha. Three models were adjusted: one model with the four TBP constructs, the second with a bifactorial model considering the four TBP constructs and the four CC prevention behaviors, and the last model considered the four constructs from TBP; four behaviors but three of them were grouped in one factor. Diagonally Weighted Least Squares (DWLS) were used to estimate the models because the variables were measured using the four-point ordinal scale. The fit model was evaluated using normed chi-squared (chi-squared/degree of freedom) with two comparative fit indices: Comparative Fit Index (CFI) and Tucker-Lewis Index (TLI); Root Mean Square Error of Approximation (RMSEA) was used as parsimonious fit indices. We considered CFI and TLI values >0.95, with RMSEA <0.05 as good; CFI and TLI values between 0.90-0.95 and RMSEA between 0.05-0.08 were acceptable; and CFI and TLI values <0.90 or RMSEA >0.08 were unacceptable. The statistical significance of each item as it is related to the factor, as well as whether an item shared a common conceptual meaning with the factor, was also considered. The PAP test and gynecological check status were used as external criteria to validate the questionnaire. The scores of each factors of the questionnaire were calculated by regression method, using standardized variables and the factor scores between women with adherence to CC screening and without adherence or with annual gynecological check and without it were compared using t-Student test for independent samples. Data were analyzed using R Statistical Program and the lavaan package.

Instrument

The proposed instrument (Appendix 1) consisted of 16 items related to CC prevention behaviors, which were divided into 4 dimensions according to the TPB constructs: attitudes (4 items), subjective norms (4 items), perceived behaviors control (4 items), and intentions (4 items). Each item was evaluated using a Likert scale of four alternatives (strongly agree/very good=1 to strongly disagree/very bad=4). Such a scale is used to force directionality of a response (de Vellis, 200 [30]) in a population where culture (Hispanic) tends to avoid conflict, resulting in a frequent selection of neutral alternatives (Antshel, 2002 [31]).

Ethical Considerations

This study was approved by the University of the Principal Investigator and by the health care service to which the women belonged. Written informed consent was obtained by all of the participants. All of the questions that the women had about CC were answered after the interview.

Results

The mean age of the participants was 43.37 ± 10.77 years, with the mean educational level being 10.97 ± 3.4 years. The CC preventive behaviors of the women are shown in Table 1.

Table 1: Characteristics of the women (n=967).

Characteristic

Value

Annual Gynecological Check, n (%)

537 (55.5)

Pap test in the last three years, n (%)

740 (76.5)

Have a partner, n (%)

766 (79.2)

Number of partners, mean ± SD (range)

2.69 ± 2.73 (1 to 40)

Use of Condom, n (%)

Always

65 (6.7)
Almost always

85 (8.8)

Never always

102 (10.5)
Never

715 (73.2)

Three models were calculated to achieve the best fit with the data (Table 2). The first model considered the proposed questionnaire with four factors, but the goodness of fit was not good (TLI <0.9 and RMSEA=0.231); the modified indices suggested the inclusions of correlations between the items with similar wording; and the correlations between intention and subjective norms (r=0.863) and intention and perceived behaviors control (r=0.939) were too high.

Table 2: Fit Statistics for the three models calculated (n=967).

Factor Model

x2/df

CFI TLI

RMSEA (CI 95%)

Four Factor

52.75

0.909 0.888

0.231 (0.226-0.237)

Eight Factor (bifactorial)

1.77

0.999 0.998

0.028 (0.020-0.036)

Six Factor (bifactorial)

1.94

0.999 0.998

0.031 (0.024-0.038)

These results suggested the consideration of second-order models, which explain the high correlations between factors, but this approach did not resolve the problem related to the correlations between preventive behavioral items. Thus, a bifactorial model was tested as a plausible alternative; one side with four factors related to TPB and the other side with four factors related to CC preventive behaviors were considered; the four factors within each side were correlated but not between the sides. The second model showed a good fit but with two high correlations: one of the correlations between an annual gynecological check and single partner (r=0.839) and the other between an annual gynecological check and updated PAP test (r=0.98). Thus, the decision was to place the correlations together into one factor. This model good fits the data, thus indicating a bi-factor structure with six factors, four of which were the TPB components and the other two were CC preventive behaviors. The results of external criteria validly of the questionnaire are in Table 3.

Table 3: External criterion validity through comparison between groups for Papanicolaou test and Gynecological check.

Factor

Papanicolaou Test in the last three years

Anual Gynecological Check

Yes

No   Yes No  
Mean (SD) Mean (SD) P value (a) Mean (SD) Mean (SD)

P value (a)

1. Cervical cancer preventive behaviors

-0.06 (0.39)

-0.16 (0.41) <0.001 -0.05 (0.38) -0.12 (0.41)

0.004

2. Condom use as cervical cancer prevention

-0.03 (0.63)

-0.05 (0.63) 0.631 -0.03 (0.64) -0.04 (0.63)

0.876

3. Attitude to cervical cancer prevention

-0.00 (-35)

-0.05 (0.38) .045 -0.02 (0.35) -0.01 (0.36)

.738

4. Perceived norm

-0.01 (0.40)

-0.11.46 .002 -0.02 (0.42 -0.06 (0.42)

.152

5. Perceived behaviors control

-0.00 (0.43)

-0.29 (0.65) <0.001 .03 (0.39) -0.19 (0.60)

<0.001

6. Intention

-0.01 (0.26)

-0.11 (0.30) <0.001 -0.00 (0.25) -0.07 (0.30)

<0.001

(a) T-Student was used to compare group values.

The new questionnaire (Appendix 1) called CPCC-16 (Conductas Preventivas en Cáncer Cérvicouterino-16 items/ Preventive Behaviors on Cervical Cancer -16 items) consisted of 16 items, which were distributed into six factors. The complete standardized parameters of the bifactorial model are shown in Figure 2. According to the bifactorial structure, each item corresponds to two factors. A summary of the CPCC-16 bifactorial model with factors, number of items and Cronbach’s alpha are shown in Table 4.

fig 2

Figure 2: Complete Standardized Parameters for the Bifactor Model of CPCC-16 (n=967).

Table 4: Name of factor, items and Cronbach’s alpha (n=967).

Factor

No of items

Cronbach’s alpha

1. Cervical cancer preventive behaviors

12 items

0.95

2. Condom use as cervical cancer prevention

4 items

0.93

3. Attitude to cervical cancer prevention

4 items

0.81

4. Perceived norm

4 items

0.87

5. Perceived behaviors control

4 items

0.81

6. Intention

4 items

0.86

CPCC-16 Questionnaire

0.94

Discussion

The first considerations to note are how the structure of the original questionnaire, without varying the number of items, was shown throughout the analysis. The initial questionnaire was created considering the underpinning of TPB constructs, where four factors were proposed. However, a questionnaire where only the theory constructs are considered was unacceptable, and thus, it was necessary to include the behavioral dimensions. However, although the second tested model with eight factors has good fit, it should not be considered a final model because it has two dimensions highly correlated (Pap test and Gynecological check). Thus, the result was a model with six dimensions in which all of the factors loading were significant, although some of the factors exhibited values lower than 0.4.

The final questionnaire was very consistent with another underpinning construct, that was not considered from the beginning (CC preventive behaviors). This result allows us to extend its usefulness, not only to test the TPB but also to analyze and explain CC preventive behaviors using this theoretical model.

The criteria validity shows that the final questionnaire is useful to associate the TPB constructs with the behaviors. The women with different CC screening or gynecological check behaviors did not show differences in condom factor scores; explanations could be because the condom use is not associated with cervical cancer prevention [32,33], or because the use of condom could be overestimated in the sample since it is an expected social behavior.

There are many contexts where the new questionnaire could be useful and where the TBP has demonstrated its utility: to assess the acceptability of preventive behaviors as a whole among the target group of women currently engaged in preventive programs [8,11], to evaluate the evolution of the intention across time [8,17], to evaluate the strategies of cervical cancer prevention programs [8,11,20] and to determine the factors that influence the behaviors [7,9,10,15,18,20]. CC remains a relevant problem, particularly in underdeveloped countries and ethnic minorities in developed countries [10]. Thus, instruments related to the prevention of CC could be very useful in many contexts. Theoretically based models of behaviors are also useful and necessary for the development of effective interventions [2,9,16,34].

A second consideration, related to the results, is why three preventive behaviors proposed in the initial questionnaire were collapsed into 1 factor, CC preventive behaviors (annual gynecological check, updated PAP test and to have a single partner). The second model tested demonstrated that each of the four behaviors proposed as a factor, but the results suggested other structures. This finding could be explained by it being necessary to consider who participated in the behavior and who decided it Therefore, CC preventive behavior factor focuses on behaviors in which the decision is primarily or only related with females, and the condom use factor indicates a behavior in which consensus is required between a woman and her partner.

Other explanations to account for the second consideration and indirectly related to the previous consideration could be that the CC preventive factor included behaviors that are not clearly associated with sexual life, and thus, it is not necessary to have an active sexual life. This is in contrast to the second factor where having sexual intercourse is the principal focus. The association between HPV and CC is one of the strongest described [13], but the relationship between sexual behaviors and CC risk has not been previously recognized by the women [35]. The use of a condom as CC preventive behavior was described in only 5.6% of the women [32], and in a Chilean study [33], only 27.6% of the women described sexual intercourse as a risk factor of CC. Thus, these reasons could explain the way that the preventive behaviors were grouped.

Related to factor loading of the items, there are only two items (items 3D and 4D), which have values less than 0.3, that could indicate that both items may be explained by the condom use factor rather than the intention and perceived behavioral control factors. To the best of our knowledge, there are no studies in which the results fit into a bifactorial model for preventive behaviors and TBP. This may be due to the focus of the research study on only one behavior and not as a group. There are many diseases that can be prevented by practicing some behavior, and the TPB is a solid theory that can help with its understanding. Thus, the CPCC-16 could be considered an example of how more than one behavior could be studied under a bifactorial structure under this theory.

One limitation of this research is that the new questionnaire did not include all of the CC preventive behaviors recognized in the literature, so it could be useful to develop a new version by adding these behaviors. However, it is important to consider that to include other behaviors; the questionnaire could require that the age range of the population be broader where the questionnaire will be used, because preventive behaviors, such as HPV vaccination, are targeted at a younger population where the decision does not often depend on them alone.

Conclusion

The new questionnaire is a contribution to the measurement of preventive behaviors in cervical cancer, enabling its use in research and a clinical setting. The use of TPB as a framework of this questionnaire and the structure shown by the questionnaire are important contributions to advance the cervical cancer arena because the new questionnaire will not only be useful to measure cervical cancer preventive behaviors as a whole but also identify the theory constructs. To have a valid and reliable questionnaire that measures, under a theory of behavior, more than one preventive behavior in cervical cancer is an important advance because it fills a gap in clinical and research area.

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Appendix 1

Instructions: The following phrases are some ideas about behaviors. Mark your level of agreement with a cross for each phrase. There are no right or wrong answers, so if you are not sure about some questions or do not know an answer, feel free to answer with what you think.

1. How do you evaluate each of the following behaviors:

Very good

Good Bad

Very Bad

1.A Have a gynecological check (with a nurse midwife or gynecologist) annually
1.B Take the PAP test when appropriate.
1.C Have a single sexual partner (at the same time)
1.D Use condoms in (all) sexual relationships.
2. Most people who are important to me would agree to:

Strongly Agree

Agree Disagree

Strongly Disagree

2.A Have a gynecological check (with a nurse midwife or gynecologist) every year
2.B Take the PAP test when appropriate.
2.C Have a single sexual partner (at the same time)
2.D Use condoms in (all) sexual relationships.
3. I am confident that I can:

Strongly Agree

Agree Disagree

Strongly Disagree

3.A Have a gynecological check (with a nurse midwife or gynecologist) every year
3.B Take PAP when appropriate.
3.C Have a single sexual partner (at the same time)
3.D Use condoms in (all) sexual relationships.
4. In the future I want to:

Strongly Agree

Agree Disagree

Strongly Disagree

4.A Have a gynecological check (with a nurse midwife or gynecologist) every year
4.B Take PAP when appropriate.
4.C Have a single sexual partner (at the same time)
4.D Use condoms in (all) sexual relationships.

Application of Drainage Position Ventilation and Real- Time Bedside Monitoring in Mechanical Ventilation of Patients Infected with nCov-19

Abstract

At present, the new coronavirus has spread to more than 200 countries and regions around the world. Up to now, no specific antiviral drugs are proved effective in defeating the new coronavirus, some measures, such as postural drainage ventilation, real-time bedside pulmonary ultrasound and chest electrical impedance monitoring may provide some new ideas for mechanical ventilation patients infected with new coronavirus.

Keywords

New coronavirus, ARDS, Mechanical ventilation, Bioelectrical impedance tomography, Pulmonary ultrasound

Etiology and Pathogenesis

The novel coronavirus (2019-nCoV) belongs to the beta genus of coronavirus, the S protein of the new coronavirus binds to the angiotensin-converting enzyme 2 (ACE2) receptor of human alveolar type II epithelial cells, and then enters into the cell to replicate and spread through respiratory droplets and contact [1].

Clinical Manifestation

Fever, dry cough and fatigue are the main symptoms of the people infected with novel coronavirus. Critically ill patients usually have dyspnea and (or) hypoxemia one week after the onset of the disease. Some patients can rapidly progress to acute respiratory distress syndrome, septic shock, uncorrectable metabolic acidosis, coagulation dysfunction and multiple organ failure [1].

Chest Imaging

Chest radiographs showed multiple small patch shadows and interstitial changes in the lungs, especially in the lateral pulmonary zone in the early stage of the patients infected with new coronavirus. Then it developed into multiple ground glass shadows and infiltration shadows in both lungs, and in severe cases, lung consolidation could occur [1-3].

Pulmonary Pathophysiology

Lung pathology showed focal hemorrhage and necrosis, marked proliferation of the type II alveolar epithelial cells in the lung tissue. Serous, fibrin exudates, and hyaline membrane formation were seen in the alveolar cavity; it could also be observed that the alveolar septal vascular congestion and edema, and some alveolar exudates organization and pulmonary interstitial fibrosis. Part of the bronchial mucosa epithelium was shed; mucus and mucus emboli could be seen in the bronchial lumen. A small number of alveoli were over-inflated, the alveolar septum was broken or the cysts were formed [4].

Thus, critically ill patients infected with new coronavirus may present abnormal pathophysiological changes such as obstructive ventilation disorder, lung gas exchange disorder, imbalanced ventilation blood flow ratio, and increased shunt.

Antiviral Therapy

During the emergency clinical trial of antiviral drugs, a number of randomized, double-blind, antiviral-placebo controlled studies have been carried out, but no antiviral drugs proved effective in treating the new coronavirus infection.

Mechanical Ventilation

Early and appropriate invasive mechanical ventilation is an important treatment for critically ill patients. In general, when PaO2/FiO2 is less than 150 mmHg, the effect of high flow oxygen therapy or noninvasive ventilation is not good, endotracheal intubation should be considered in time for invasive mechanical ventilation in severe and critical ill cases [2]. The strategies of lung protective mechanical ventilation and lung recruitment are implemented. If there is no contraindication, it is suggested to implement prone position ventilation at the same time. Prone position ventilation can improve oxygenation in patients with ARDS by increasing functional residual volume, improving ventilation/blood flow ratio (V/Q), reducing shunt (Qs/Qt), improving diaphragmatic movement and promoting secretion excretion. In the airway management, posture drainage and sputum suction by bronchoscope should be adopted to promote the sputum drainage and lung rehabilitation [2].

Lung Protective Mechanical Ventilation Strategy

The individualized strategy of mechanical ventilation is to adopt the most suitable methods or parameters in ventilation mode, lung recruitment, tidal volume, PEEP and mechanical ventilation posture for patients according to their different pathophysiological conditions, so as to achieve the best treatment effect. At present, low tidal volume, high PEEP, lung recruitment and prone position ventilation are widely used in patients infected with new coronavirus [2]. The characteristics of severe new coronavirus cases, such as inflammatory serous and fibrin exudate, exudate organization, pulmonary fibrosis, alveolar septum destruction, atelectasis and pulmonary bullae, coexist in the patients’ lung [4]. Large tidal volume is not suitable for patients infected with new coronavirus due to the potential mechanical ventilation lung injury [2]. The selection of PEEP should be guided by the best pulmonary mechanics, the reduction of pulmonary shunt, the improvement of oxygenation and the function of stable circulation, while the effect of pulmonary recruitment should be examined by CT, MRI, bioelectrical impedance tomography (EIT) and ultrasound imaging. In the process of lung recruitment, there is the possibility of lung over inflation and the original pulmonary injury aggravation, and the effect on the hemodynamics should be concerned at the same time. The optimal method, opportunity and parameters of lung recruitment have not been determined, but it is necessary to judge the potential of pulmonary reinflation under real-time bedside EIT and ultrasound pulmonary monitoring.

The Advantage of Real Time Bedside Monitoring of EIT and Ultrasound

The goal-oriented mechanical ventilation is to adjust the mechanical ventilation strategy in time with the aim of imaging, respiratory and oxygen dynamics monitoring, blood gas examination, the function of circulatory system and the condition of other organs [2]. Blood oxygen saturation, blood gas, hemodynamics and respiratory mechanics are still routine and convenient monitoring methods of mechanical ventilation. Traditional lung images, such as X-ray, CT, MRI, certainly have the characteristics of clear images and easy analysis and diagnosis, but they are complicated to operate under the special circumstances of isolation and transportation of patients infected with new coronavirus. The chest electrical impedance tomography cannot provide clear image, but it is convenient to operate and can be continuously imaged [5]. Ultrasound lung images also have unique advantages in the diagnosis of pneumonia and the effect of ventilation [6]. These two methods can be real-time bedside monitoring, which are simple and practical to guide lung recruitment, to diagnose pneumonia, and to evaluate the mechanical ventilation effectiveness. In addition, while monitoring respiratory mechanics and oxygenation parameters during mechanical ventilation, we should pay close attention to the corresponding changes in the circulatory system and make timely adjustments.

Electrical Impedance Tomography

Electrical Impedance Tomography (EIT) is to use the impedance changes of living organisms or biological tissues, biological organs, and biological cells under the action of a safe current below the excitability threshold to obtain the organism internal resistance rate of distribution and changing images through image reconstruction [5,7]. The resistivity of different tissues or the same tissue under different physiological and pathological conditions is different. The periodic changes of air and blood flow in the lungs together determine the changes in the electrical impedance of the chest. The advantage of EIT lies in the use of the rich physiological and pathological information carried by bio-impedance to obtain damage-free functional imaging and medical image monitoring. Chest X-rays and CT are widely used in the diagnosis of lung infections. But they cannot monitor lung lesions in real time, cannot measure lung ventilation status, and most importantly cannot be used in patients with severe pneumonia and respiratory failure who cannot easily access these examination, so their application are limited. Lung EIT, as a brand new medical imaging technology, which is different from traditional imaging technology and conventional lung function monitoring, has outstanding features such as injury-free, portable, low-cost, functional imaging, and image monitoring. EIT can real-time dynamic monitor the pulmonary ventilation and blood flow distribution, evaluate the effectiveness of clinical treatment methods such as mechanical ventilation by measuring electrical resistance under different ventilation conditions [5,7].

At present, the commonly used methods to monitor the effectiveness of lung recruitment strategy and the suitability of PEEP include arterial blood gas analysis, peripheral oxygen saturation, pulmonary and chest maximum compliance, static pressure volume curve and so on, but these methods cannot meet the requirements of dynamic monitoring of regional lung perfusion. A number of studies have showed that in mechanical ventilation patients with ARDS, EIT has been used to accurately measure the whole lung and regional lung ventilation distribution, to show the influence of PEEP changes on alveolar expansion and collapse by gradually increasing and decreasing PEEP level, and in the end to obtain the optimal value of PEEP, which improves the ratio of ventilation and blood flow (V/Q), and plays an important role in individulized lung protective ventilation strategy [5,7].

Pulmonary Ultrasound

Bedside lung ultrasound can be used for the diagnosis and differential diagnosis of various lung diseases by using a low-frequency convex probe of 3 to 5 MHz and a high-frequency linear probe of 8 to 12 MHz [8]. Normal lung ultrasound images include bat sign, lung sliding sign, and A-line. Pathological images mainly include abnormal pleural lines, pulmonary consolidation, interstitial syndrome, fragmentation sign, dynamic bronchial signs, pleural effusion and so on [9].

With the development of ultrasound technology, pulmonary ultrasound is gradually found to be of great value in diagnosing acute respiratory distress syndrome, pulmonary edema, pneumonia, pneumothorax, pulmonary embolism and so on [6,10,11]. It can be used to monitor the changes in lung ventilation, to guide clinical fluid management and evaluate prognosis, especially in patients with severe diseases. Since chest X-rays and CT examinations are unsuitable for rapid diagnosis of critical diseases due to the shortages of inconvenient carrying, radiation exposition, poor reproducibility, position limitations, and high costs, and compared with chest CT, bedside lung ultrasound has advantages of non-invasive, dynamic and repeatable observation of patients with lung disease.

The Advantage of Drainage Position Ventilation

At present, prone position mechanical ventilation is widely used in patients infected with new coronavirus, which may be helpful to the drainage of pulmonary inflammation and the reduction of pulmonary shunt volume [2]. So far, no effective antiviral drugs have been found in defeating new coronavirus, so drainage becomes an important treatment for pulmonary inflammatory lesions. Because of inflammatory lesions in different parts of the lung, prone position ventilation is not suitable for all patients, and it may be more beneficial to adopt drainage position mechanical ventilation combined with tracheal suction with the infected side of lung lesions upper side. For example, the lateral and head-down position mechanical ventilation with the inflammatory lung upper side according to the characteristics of pulmonary imaging of some patients infected with new coronavirus. The lateral prone position can be tried to improve the inflammatory side lung ventilation, reduce pulmonary shunt, increase blood reflux and improve hemodynamics. However, it is important to avoid excessive head down, which increases abdominal pressure on the chest cavity.

In summary, based on the autopsy, clinical manifestations, lung pathological characteristics and present treatment of the patients infected with the new coronavirus, this article describes some possible improvement measures for the mechanical ventilation strategy. We believe that postural drainage ventilation, real-time bedside pulmonary ultrasound and chest electrical impedance monitoring will improve the clinical treatment of critical patients based on the previous guidelines for ARDS treatment. These methods provide some new ideas for clinical treatment and need to be used and verified in future clinical work.

References

  1. Guan WJ, Ni ZY, Hu Y, Liang WH, Ou CQ, et al. (2020) Clinical characteristics of coronavirus disease 2019 in China. N Engl J Med.
  2. Lingzhong Meng, Haibo Qiu, Li Wan, Yuhang Ai, Zhanggang Xue, et al. (2020) Intubation and Ventilation amid the COVID-19 Outbreak: Wuhan’s Experience. Anesthesiology 132: 1317-1332. [crossref]
  3. Huang C, Wang Y, Li X, Ren L, Zhao J, et al. (2020) Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China. Lancet 395: 497-506.
  4. Qin Liu, Rongshuai wang, Guoqiang Qu, Yunyun wang, Pan Liu, et al. (2020) Gross Observation Report on the Autopsy of a nCov-2019 Pneumonia Death. Journal of Forensic Medicine (Chinese) 36: 21-23. [crossref]
  5. Hsu CF, Cheng JS, Lin WC, Cheng KS, Lin SH, et al. (2016) Electrical impedance tomography monitoring in acute respiratory distress syndrome patients with mechanical ventilation during prolonged positive end-expiratory pressure adjustments [J]. J Formos Med Assoc 115: 195-202. [crossref]
  6. Staub LJ, Mazzali Biscaro RR, Kaszubowski E, Maurici R (2019) Lung ultrasound for the emergency diagnosis of pneumonia, acute heart failure, and exacerbations of chronic obstructive pulmonary disease / asthma in adults: a systematic review and meta-analysis. J Emerg Med 56: 53-69. [crossref]
  7. Heines SJH, Strauch U, Van de Poll MCG, Paul MHJR, Dennis CJJB (2018) Clinical implementation of electric impedance tomography in the treatment of ARDS: a single centre experience [J]. J Clin Monit Comput. [crossref]
  8. Rouby JJ, Arbelot C, Gao YZ, Zhang M, Lv J, et al. (2018) APECHO Study Group. Training for lung ultrasound score measurement in critically ill patients. Am J Respir Crit Care Med 198: 398-401. [crossref]
  9. Lichtenstein DA (2015) BLUE-protocol and FALLS-protocol: two applications of lung ultrasound in the critically ill. Chest 147: 1659-1670.
  10. Chavez MA, Shams N, Ellington LE, Naithani N, Gilman RH, et al. (2014) Lung ultrasound for the diagnosis of pneumonia in adults: a systematic review and meta-analysis. Respir Res 15: 50. [crossref]
  11. Long L, Zhao HT, Zhang ZY, Wang GY, Zhao HL (2017) Lung ultrasound for the diagnosis of pneumonia in adults: a meta-analysis. Medicine (Baltimore) 96: e5713. [crossref]

Self-Recovery of Pancreatic Beta Cell’s Insulin Secretion Based on 10+ Years Annualized Data of Food, Exercise, Weight, and Glucose Using GHMethod: Math-Physical Medicine (No. 339)

Abstract

The author was inspired from reading two recently published medical papers regarding pancreatic beta cells insulin secretion or diabetes reversal via weight reduction. The weight reduction is directly related to the patient’s lifestyle improvement through diet and exercise. He has published six medical papers on beta cells based on different stages in observations of his continuous glucose improvements; therefore, in this article, he will investigate food ingredients, meal portions, weight, and glucose improvement based on his 10+ years of collected big data.

Here is the summary of his findings:

  1. His successful weight reduction, from 220 lbs. in 2010 to 171 lbs. in 2020, comes from his food portion reduction and exercise increase.
  2. His lower carbs/sugar intake amount, from 40 grams in 2010 to 12 grams in 2020, is resulted from his learned food nutrition knowledge and meal portion reduction, from 150% in 2010 to 67% in 2020.
  3. His weight reduction contributes to his FPG reduction, from 220 mg/dL in 2010 to 104 mg/dL in 2020. His carbs/sugar control and increased walking steps, from 2,000 steps in 2010 to ~16,000 steps in 202, have contributed to his PPG reduction, from 300 mg/dL in 2010 to 109 mg/dL in 2020. When both FPG and PPG are reduced, his daily glucose is decreased as well, from 280 mg/dL in 2010 to 108 mg/dL in 2020.
  4. His damaged beta cell’s insulin production and functionality, most likely, have been repaired about 16% for the past 6 years or 27% in the past 10 years at a self-repair rate of 2.7% per year.

The conclusion from this paper is a 2.7% annual beta cells self-repair rate which is similar to his previously published papers regarding his range of pancreatic beta cells self-recovery of insulin secretion with an annual rate between 2.3% to 3.2%.

To date, the author has written seven papers discussing his pancreatic beta cell’s self-recovery of insulin secretion. In his first six papers [1-7], he used several different “cutting angles” or “analysis approaches” to delve deeper into this complex biomedical subject and achieved consistent results within the range of 2.3% to 3.2% of annual self-recovery rate.

He used a quantitative approach with precision to discover and reconfirm his pancreatic beta cell’s health state by linking it backwards step-by-step with his collected data of glucose, weight, diet, and exercise. He has produced another dataset for a self-repair rate of 2.7% which is located right in the middle between 2.3% and 3.2% from his previous findings.

In his opinion, type 2 diabetes (T2D) is no longer a non-reversible or non-curable disease. Diabetes is not only “controllable” but it is also “self-repairable”, even though at a rather slow rate. He would like to share his research findings and his persistent efforts from the past decade with his medical research colleagues and to provide encouragement to motivate other T2D patients like himself to reverse their diabetes conditions.

Introduction

The author was inspired from reading two recently published medical papers regarding pancreatic beta cells insulin secretion or diabetes reversal via weight reduction. The weight reduction is directly related to the patient’s lifestyle improvement through diet and exercise. He has published six medical papers on beta cells based on different stages in observations of his continuous glucose improvements; therefore, in this article, he will investigate food ingredients, meal portions, weight, and glucose improvement based on his 10+ years of collected big data.

Methods

Background

To learn more about his developed GH-Method: math-physical medicine (MPM) research methodology, readers can review his article, Biomedical research methodology based on GH-Method: math-physical medicine (No. 54 and No. 310), in Reference [1] to understand his MPM analysis method.

Diabetes History

In 1995, the author was diagnosed with severe type 2 diabetes (T2D). His daily average glucose reached 280 mg/dL with a peak glucose at 398 mg/dL and his HbA1C was at 10% in 2010. Since 2005, he has suffered many kinds of diabetes complications, including five cardiac episodes (without having a stroke), foot ulcer, renal complications, bladder infection, diabetic retinopathy, and hypothyroidism.

As of 9/30/2020, his daily average glucose is approximately 106 mg/dL and HbA1C at 6.1%. It should be mentioned that he started to reduce the dosage of his three different diabetes medications (maximum dosages) in early 2013 and finally stop taking them on 12/8/2015. In other words, his glucose record since 2016 to the present is totally “medication-free”.

Beginning on 1/1/2012, he started to collect his weight value in the early morning and his glucose values four times a day: FPG x1 in the early morning and PPG x3 at two hours after the first bite of each meal. Since 1/1/2014, he also started to collect his carbs/sugar amount in grams and post-meal walking steps. Prior to these two dates, especially during the period of 2010 to 2012, the manually collected biomarkers and lifestyle details were scattered and unorganized. Therefore, those annualized data from 2010 to 2012 or 2014 were guesstimated values with his best effort. It should be further mentioned that on 1/1/2013, he began to reduce his dosages of three diabetes educations step by step. By 1/1/2015, he was only taking 500 mg of Metformin for controlling his diabetes conditions. Finally, he completely ceased taking Metformin on 12/8/2015; therefore, since 1/1/2016, his body has been completely free of any diabetes medications.

Other Research Results

Recently, a Danish medical research team has published an article on JAMA which emphasizes a strengthen lifestyle program can reverse” T2D. This program includes a weekly exercise (5-6 times and 30-60 minutes each time), daily walking more than 10,000 steps using smart phone to keep a record, personalized diet and nutritional guidance by healthcare professionals, etc. The observed results from this Danish report are patientsoverall HbA1C reduction of 0.31%, and their diabetes medication dosage reduction from 73% to 26%.

DiRECT research report from UK also indicated that an aggressive weight reduction program can induce improvement on diabetes conditions. This UK program includes low-calories diet for 3-5 months with 825-853 K-calories per day, plus daily walking of 15,000 steps per day. The observed results from this UK report are patientsoverall HbA1C reduction of 0.9%, weight reduction of 10 kg (or 22 lbs.), and reduced diabetes medication dosage as well.

The Author’s Approach

Inspired by the results from the two European studies and based on his own collected big data over the past 10+ years, from 2010 to 2020, he decided to conduct a similar research on his own. He has separated his 10+ years data into two periods. The first period of 5 years, from 2010 to 2014, with partially collected and partially guesstimated data under different degrees of medication influence, and the second period of 6 years, from 2015 to 2020, with a complete set of collected raw data stored in software and severs without any medication influence.

His trend of thoughts include a sequence from cause to consequence as listed below from top to bottom:

  • Food and meal’s portion %
  • K-calories per day
  • Weight (lbs.)
  • FPG (mg/dL)
  • Carbs/sugar intake (grams)
  • Walking
  • PPG (mg/dL)
  • Daily glucose (mg/dL)

He has further conducted nine calculations of correlation coefficient based on the above parameters to examine the degree of connections between any 2 elements of these total 8 parameters. It should be mentioned that the correlation coefficients can only be done between two data sets, or two curves.

More importantly, in addition to examining the raw data, he also placing an emphasis on the annual change rate percentage, its trend, and their comparisons of these 8 parameters.

Results

Figure 1 shows his background data table which includes his calculated annual averages of the 8 parameters plus proteins, fat, and daily K-calories, based on his daily data collected during 2010 to 2020.

fig 1

Figure 1: Background data table.

Figure 2 depicts the annual change rate percentage of his food (meal portion %, K-calories, and carbs/sugar) and his weight. In this figure, meal portion and weight have similar change rates which means the less he eats, the lighter his weight. Also, carbs/sugar amount and K-calories have similar change rates which means the less his K-calories, the less his carbs/sugar intake amount.

fig 2

Figure 2: Annual change rates of Weight and Food (meal portion, K-calories, and carbs/sugar).

Figure 3 illustrates the similar trend of annual data of his weight and three food components (meal portion, K-calories, and carbs/sugar amount).

fig 3

Figure 3: Annual change rates of Weight and Food (meal portion, K-calories, and carbs/sugar).

Exercise is a missing component from this figure which is also essential on weight reduction. The more he eats, the higher intake amounts of his K-calories and his carbs/sugar as well. During the past decade on his effort for weight reduction, he has focused on reducing both of his meal portion percentage and carb/sugar intake amount. As a result, he was able to reduce his weight from 220 lbs (100 kg) and his average glucose from 280 mg/dL in 2010 to 171 lbs. (78 kg) and 106 mg/dL in 2020 (without any medication).

Figure 4 reflects the annual change rate percentage of his daily glucose, weight and carbs/sugar amount. In this figure, the change rates of his glucose and weight are remarkably similar, almost a mirror image, which indicates the lower his weight, the lower his glucose. This finding matches the two European studies and the common knowledge possessed by healthcare professionals. The reason for the obviously mismatched change rates between carbs/sugar and glucose or weight is due to the missing component of exercise which is equally important on glucose reduction.

fig 4

Figure 4: Annual change rates of Weight, Glucose, and Carbs/sugar.

Figure 5 focuses exclusively on the relationships among data of glucose, carbs/sugar, and exercise. The positive correlation coefficient between glucose and carbs/sugar is expressed by these two similar moving trends. On the other hand, the negative correlation coefficient between glucose and exercise (walking) is expressed by these two opposite moving trends.

fig 5

Figure 5: Annual data of Weight, Glucose, and Carbs/sugar.

Figures 6-8 collectively collective together to show the 9 sets of calculated correlation coefficients among those 8 listed elements in above section of Methods. A better illustration of these three figures can be found in a table, where all of the calculated correlations are above 90%, which means they are highly connected to each other (Figure 9). Even the correlation of -89% between glucose and walking exercise is also extremely high in a negative manner.

fig 6

Figure 6: Correlation coefficients among Weight, K-calories, meal portion.

fig 7

Figure 7: Correlation coefficients among Weight, Glucose, Carbs/sugar.

fig 8

Figure 8: Correlation coefficients among PPG, Carb/sugar, Walking, FPG, Weight.

fig 9

Figure 9: A combined data table of 9 correlation coefficients among 8 elements.

Figure 10 reveals the detailed annual change rates of 8 elements for a 10+ year period from 2010 to 2020. It should be pointed out that his average change rates within 6 years from 2015 through 2020 are 2.7% per year for both FPG and PPG, and 3.4% for daily glucose. This conclusion is similar to his six previously published papers regarding his pancreatic beta cell’s self-recovery rate of insulin secretion. Most likely, his beta cells insulin production and functionality have been repaired about 16% during the past 6 years or 27% during the past 10 years at a self-repair rate of 2.7% per year.

fig 10

Figure 10: A combined data table of annual change rates of 7 elements, especially glucose change rates of 2.7%.

Here is the summary of his findings:

  1. His successful weight reduction, from 220 lbs. in 2010 to 171 lbs. in 2020, comes from his food portion reduction and exercise increase.
  2. His lower carbs/sugar intake amount, from 40 grams in 2010 to 12 grams in 2020, is resulted from his learned food nutrition knowledge and meal portion reduction, from 150% in 2010 to 67% in 2020.
  3. His weight reduction contributes to his FPG reduction, from 220 mg/dL in 2010 to 104 mg/dL in 2020. His carbs/sugar control and increased walking steps, from 2,000 steps in 2010 to ~16,000 steps in 202, have contributed to his PPG reduction, from 300 mg/dL in 2010 to 109 mg/dL in 2020. When both FPG and PPG are reduced, his daily glucose is decreased as well, from 280 mg/dL in 2010 to 108 mg/dL in 2020.
  4. His damaged beta cell’s insulin production and functionality, most likely, have been repaired about 16% for the past 6 years or 27% in the past 10 years at a self-repair rate of 2.7% per year.

Summary

To date, the author has written seven papers discussing his pancreatic beta cell’s self-recovery of insulin secretion. In his first six papers [2-7], he used several different “cutting angles” or “analysis approaches” to delve deeper into this complex biomedical subject and achieved consistent results within the range of 2.3% to 3.2% of annual self-recovery rate.

He used a quantitative approach with precision to discover and reconfirm his pancreatic beta cell’s health state by linking it backwards step-by-step with his collected data of glucose, weight, diet, and exercise. He has produced another dataset for a self-repair rate of 2.7% which is located right in the middle between 2.3% and 3.2% from his previous findings.

In his opinion, type 2 diabetes (T2D) is no longer a non-reversible or non-curable disease. Diabetes is not only “controllable” but it is also “self-repairable”, even though at a rather slow rate. He would like to share his research findings and his persistent efforts from the past decade with his medical research colleagues and to provide encouragement to motivate other T2D patients like himself to reverse their diabetes conditions.

References

  1. Hsu, Gerald C. eclaireMD Foundation, USA. “GH-Method: Methodology of math-physical medicine, No. 54 and No. 310.”
  2. Hsu, Gerald C. eclaireMD Foundation, USA. “Changes in relative health state of pancreas beta cells over eleven years using GH-Method: math-physical medicine (No. 112).”
  3. Hsu, Gerald C. eclaireMD Foundation, USA. “Probable partial recovery of pancreatic beta cells insulin regeneration using annualized fasting plasma glucose via GH-Method: math-physical medicine (No. 133).”
  4. Hsu, Gerald C. eclaireMD Foundation, USA. “Probable partial self-recovery of pancreatic beta cells using calculations of annualized fasting plasma glucose using GH-Method: math-physical medicine (No. 138).”
  5. Hsu, Gerald C. eclaireMD Foundation, USA. “Guesstimate probable partial self-recovery of pancreatic beta cells using calculations of annualized glucose data using GH-Method: math-physical medicine (No. 139).”
  6. Hsu, Gerald C. eclaireMD Foundation, USA. “Relationship between metabolism and risk of cardiovascular disease and stroke, risk of chronic kidney disease, and probability of pancreatic beta cells self-recovery using GH-Method: Math-Physical Medicine (No. 259).”
  7. Hsu, Gerald C. eclaireMD Foundation, USA. “Self-recovery of pancreatic beta cell’s insulin secretion based on annualized fasting plasma glucose, baseline postprandial plasma glucose, and baseline daily glucose data using GH-Method: math-physical medicine (No. 297).”